How should I manage a burn (first aid, fluid resuscitation with the Parkland formula, analgesia, tetanus prophylaxis, wound care, and follow‑up) based on the total body surface area (TBSA)?

Burn Management Based on Total Body Surface Area (TBSA)

Immediate First Aid (All Burns)

Cool the burn with clean running water for 5-20 minutes immediately after injury to limit tissue damage and reduce pain. 1, 2

• Apply cooling only to burns <20% TBSA in adults or <10% TBSA in children to avoid hypothermia risk 1, 2
• Monitor children under 4 years closely for signs of hypothermia (shivering, visible coldness) during cooling 1, 2
• Never apply ice directly, as this causes additional tissue damage 1, 3
• Remove all jewelry and constrictive items before swelling occurs 2

Triage and Referral Criteria

Adults Requiring Burn Center Transfer:

• TBSA >10% (some sources suggest >20% for specialized care) 1, 2
• Deep burns >5% TBSA 1, 2
• Burns to face, hands, feet, perineum, or flexures 1, 2
• Age >75 with comorbidities 2
• Any electrical or chemical burns 1
• Inhalation injury 2

Children Requiring Burn Center Transfer:

• TBSA >10% 1, 2
• Deep burns >5% TBSA 1, 2
• Age <1 year 1, 2
• Burns to function-sensitive areas 1, 2
• Any electrical or chemical burns 1

Immediate Specialist Referral (Regardless of Size):

• Any partial-thickness or full-thickness hand burns 1
• All genital burns, even if superficial 2

Fluid Resuscitation Protocol

Initial Bolus (First Hour):

Administer 20 mL/kg of balanced crystalloid solution (Ringer's Lactate preferred) within the first hour for adults with TBSA ≥15% and children with TBSA ≥10%. 4

• Use Ringer's Lactate as first-line balanced crystalloid solution to reduce risk of hyperchloremia and acute kidney injury compared to 0.9% NaCl 4
• Obtain IV access in unburned areas when possible; use intraosseous route if IV access cannot be rapidly obtained 4

Ongoing Resuscitation (Parkland Formula):

Calculate total 24-hour fluid requirement using the Parkland formula: 2-4 mL/kg × %TBSA (typically 4 mL/kg × %TBSA). 4, 5

• Give half the calculated volume in the first 8 hours post-burn 5
• Give the remaining half over the next 16 hours 5
• Titrate fluids strictly to urine output (target 0.5-1 mL/kg/hour) rather than blindly following formulas to avoid "fluid creep." 5
• Consider albumin administration after the first 6 hours for TBSA >30% to maintain serum albumin >30 g/L 5

Critical Pitfall:

• Do not use hydroxyethyl starches for fluid resuscitation, as they are contraindicated by the European Medicines Agency in severe burns 5

Analgesia Protocol

Use multimodal analgesia with all medications titrated based on validated pain assessment scales. 4, 2

Mild to Moderate Pain:

• Administer oral acetaminophen or NSAIDs 1, 2

Severe Pain:

• Consider short-acting opioids or titrated intravenous ketamine 4, 1, 2
• Ketamine can be combined with other analgesics for severe burn-induced pain 4, 2
• Pre-medicate 30-60 minutes before dressing changes 1
• Titrate carefully due to burn-induced inflammation, capillary leakage, and hypovolemia that increase risk of adverse effects 4

Non-Pharmacological Adjuncts:

• Combine non-pharmacological techniques (cooling, covering with petrolatum) with analgesic drugs for dressings when patient is stable 4, 1

Tetanus Prophylaxis

Provide tetanus prophylaxis according to standard wound management protocols, as burns are tetanus-prone wounds. 6, 7, 8

• For actively immunized patients, administer a booster injection of tetanus toxoid 8
• For unimmunized or inadequately immunized patients, provide both tetanus toxoid and tetanus immune globulin 7, 8
• Careful wound cleaning and debridement of necrotic tissue are the most important aspects of local tetanus prophylaxis 6, 8

Wound Care Based on Burn Depth

Superficial (First-Degree) Burns:

• After cooling, apply petrolatum or petrolatum-based ointment 1, 2
• Cover with clean, non-adherent dressing 1, 2
• These burns can be managed outpatient with proper follow-up 1

Partial-Thickness (Second-Degree) Burns:

• Clean wound with tap water, isotonic saline, or antiseptic solution (e.g., chlorhexidine 1:5000) 1, 2
• Gently debride loose tissue; for tense blisters, perform sterile puncture leaving blister roof intact as biological dressing 1
• Apply petrolatum-based ointment over entire burn surface 1
• Cover with non-adherent dressing (Mepitel, Telfa, Xeroform) 1, 2
• Add secondary foam or absorbent dressing to collect exudate 1
• Re-evaluate dressings daily ideally 2

Full-Thickness (Third-Degree) Burns:

• Cover with clean, dry, non-adherent dressing while awaiting medical care 2
• All full-thickness burns require immediate medical attention and burn center care 2
• Early excision and skin grafting is the standard treatment once resuscitation is established 5

Critical Pitfalls in Wound Care:

• Avoid prolonged use of silver sulfadiazine on superficial burns, as it delays healing and increases infection risk 1, 2
• Do not apply butter, oil, or other home remedies 1, 2
• Do not use topical antibiotics as first-line prophylaxis; reserve only for infected wounds 1, 2
• Do not give prophylactic systemic antibiotics in the absence of documented infection 5
• When applying dressings on limbs, prevent tourniquet effect and monitor distal perfusion 2

Follow-Up and Post-Healing Management

Outpatient Burns (TBSA <10% in adults, <10% in children without high-risk features):

• Appropriate for outpatient management with proper wound care, pain control, and close follow-up 1
• Re-evaluate wounds daily or as clinically indicated 2

Signs Requiring Immediate Medical Attention:

• Clinical deterioration or expansion of burn area 1
• Presence of subepidermal pus or signs of infection 1
• Delayed wound healing 1
• Very painful burns 2

Post-Healing Care:

• For healed burns with hypopigmentation, dryness, or itching, apply petrolatum-based ointment with hydrocortisone 1% cream 1
• Continue daily until symptoms resolve 1
• Avoid prolonged potent steroids, as they can cause further hypopigmentation 1
• Repigmentation depends on burn depth; superficial burns repigment better 1

Special Considerations for Severe Burns (TBSA >40%)

Contact a burn specialist immediately to guide initial management and arrange direct transfer, as every hour matters for survival. 5

• Do not delay transfer while attempting wound care interventions 5
• Continue fluid resuscitation during transfer, titrating to urine output 5
• Initiate enteral nutrition within 12 hours after burn injury once at burn center 5
• Escharotomy should be performed only at a burn center for circumferential burns causing airway compromise, ventilation issues, intra-abdominal hypertension, or circulatory impairment within 48 hours 4