Evaluation
PRIMARY SURVEY AND MANAGEMENT
Assess the ABCDEs (Airway, Breathing, Circulation, Disability, neurologic deficit and gross deformity, and Exposure/Environmental control) of resuscitation.
Burns - Initial Management_Management 1Airway
Assess whether the airway is compromised or is at risk of compromise. Inhalation of hot gases will result in a burn above the vocal cords, and the burn will become edematous over the next few hours, especially after fluid resuscitation has begun. In small children, the small airway diameter is vulnerable to any narrowing. Direct inspection of the oropharynx should be done by an anesthesiologist. Intubate if there is concern about the patency of the airway, symptomatic inhalation injury, or any thermal injury to the face, mouth, or oropharynx.
Indications for Intubation
Intubation is indicated in the following: Erythema or swelling of the oropharynx on direct visualization; change in voice, with hoarseness or harsh cough; stridor, tachypnea, or dyspnea; burns >20-25% BSA; pulmonary toilet; extensive and deep facial burns; difficulty swallowing; and decreased level of consciousness where airway protective reflexes are impaired.
Breathing
Assess the lung status by bilateral auscultation, and respiratory rate and depth determination. Breathing problems are those that affect the respiratory system below the vocal cords. The effect of circulating inflammatory mediators can reduce lung compliance in the absence of overt inhalational injury. All burn patients should receive 100% oxygen through a humidified non-rebreathing mask.
Causes of Compromised Breathing
Mechanical Restriction to Breathing
Deep second-degree and third-degree circumferential burns of the chest can limit chest expansion and ventilation. This may require escharotomy; thus, refer for surgical consult.
Blast Injury
Penetrating blast injury may cause pneumothorax. The blast itself may cause lung contusions and alveolar trauma that may lead to acute respiratory distress syndrome (ARDS).
Smoke Inhalation
The products of combustion act as irritants to the lungs, which may cause bronchospasms, inflammation, and increased sputum formation. The ciliary action of pneumocytes is impaired in inhalation injury, and atelectasis and/or pneumonia may follow. Noninvasive management, such as nebulization and positive pressure ventilation with positive end-expiratory pressure (PEEP), may be attempted.
Carboxyhemoglobin (HbCO)
All patients with large burns and/or closed-space burns should be assumed to have carbon monoxide (CO) poisoning until otherwise proven. Blood gas analysis may reveal metabolic acidosis and decreased partial pressure of oxygen (PaO2). CO poisoning may be mild (<20% HbCO), moderate (20-40% HbCO), or severe (40-60% HbCO). Delivery of 100% oxygen counteracts the effects of CO and enhances its clearance. Oxygen therapy should be continued until the metabolic acidosis is resolved.
Circulation
Patients requiring intravenous (IV) resuscitation include children with burns >10% BSA (those with 30% BSA burns need central venous access); all with inhalational injury for control of fluid intake; and all high-tension and electrical injuries to ensure forced alkaline diuresis and to prevent myoglobinuric renal failure. IV assessment should be established using large-bore needles, preferably on the unburnt area. Consider giving 20 mL/kg boluses of lactated Ringer’s solution or normal saline if there is an inadequate pulse or the child is hemodynamically compromised.
The Parkland formula is used to compute the total fluid to be given in the first 24 hours post-burn. Give 2 mL lactated Ringer’s solution/kg per % BSA burn. Administer ½ of calculated volume over the first 8 hours and the other ½ of calculated volume over the next 16 hours. Lactated Ringer’s solution is the preferred resuscitation and maintenance fluid in most burn centers because it helps prevent hyperchloremic metabolic acidosis. For children weighing <20 kg, maintenance fluids should include 5% dextrose to reduce the risk of hypoglycemia.
Urine output must be monitored in all patients requiring IV fluids. Adequate urine output is 1-2 mL/kg/hr in children and 0.5-1 mL/kg/hr in adolescents. Total target urine output is increased to 1-2 mL/kg/hr for electrical burns due to the risk of high myoglobin levels. Titrate infused IV fluid based on the child’s response to therapy, such as an adequate urine output, normal pulses, and normal blood pressure (BP).
Extremities must be assessed for any deep or full-thickness circumferential burn, as these may occlude perfusion to distal extremities. Peripheral circulation must be checked with a Doppler. There is an increased risk for compartment syndrome to develop during fluid resuscitation as burned tissue loses the ability to stretch. A decreased perfusion due to circumferential burn warrants referral to surgery for early escharotomy and debridement.
Disability, Neurologic Deficit and Gross Deformity
Identify any serious injuries or gross deformities. Assess the patient’s level of consciousness using the AVPU method: Alert, responds to Verbal stimuli, responds only to Painful stimuli, and is Unresponsive. Neurologic status must be briefly assessed by evaluating level of consciousness using the Glasgow coma scale. A Glasgow coma score of 8 warrants intubation. Cerebral injury may be caused by hypoxia from smoke inhalation or hypovolemia from fluid loss.
Signs of increased intracranial pressure (ICP) and progressive neurologic deterioration must be treated immediately. Hyperventilate the patient using a bag-valve mask to lower PaCO₂ to promote cerebral vasoconstriction. Use Mannitol cautiously because it promotes osmotic diuresis, which may exacerbate hypovolemia. Consult with neurosurgery for co-management if there is a persistent increase in ICP.
Exposure/Environmental Control
All smoldering clothing or clothing saturated with hot liquid should be cut away to facilitate an exam. Children easily become hypothermic, so they should be warmed with radiant warmers or heated blankets and IV fluid as soon as possible. Cleanse the area with warm saline or mild soap and water. Cover the burned area with a clean dry sheet and apply cold wet compresses to small injuries. Do not use cold compress dressings on large burn surface areas (>15% BSA) as this will decrease body temperature.
In chemical injury, brush off any remaining chemical if powdered or solid, then use copious irrigation or wash the affected area with water. Call poison control for the neutralizing agent to treat chemical ingestion. If burn is caused by hot tar, use mineral oil to remove the tar. Debride open wounds and necrotic tissue. Unruptured blisters should be left intact and dressed.
SECONDARY SURVEY AND MANAGEMENT
Secondary survey includes a head-to-toe exam of the patient to determine any concomitant injuries. Evaluate for associated injuries, common if the child fell from a height during the burn incident, and injuries to the spine, bones, and thoracic or intra-abdominal organs may occur. The child should be placed on cervical spine precautions until these injuries are ruled out. Ventricular tachycardia and fibrillation are common when burns result from high-electric-voltage injury. Children with burns >15% BSA should not be given anything per orem and require insertion of a nasogastric tube to prevent aspiration. Insertion of a Foley catheter is mandatory to monitor urine output in patients requiring IV resuscitation. Pain control can be managed initially with intramuscular (IM) or IV analgesics. Elevate affected extremities to reduce edema and pain.
Principles of Therapy
The primary goal of burn wound management is to restore both the appearance and function of the affected area. The main objective of burn wound care is rapid wound closure. Superficial burns often heal with cleansing, debridement, and local care, whereas deep burns require early surgical excision and skin grafting to speed recovery. Local burn wound care focuses on protecting the wound surface and maintaining an optimal level of moisture, neither too dry nor too wet, to prevent desiccation or maceration. The goal is to support burn wound healing, limit wound progression, minimize patient discomfort, and safeguard the surrounding skin and tissues. Initial management of burn injuries focuses on stabilizing the patient through resuscitation, precisely assessing the extent of the burn, promptly closing the wound, and actively preventing sepsis.
Optimal local burn wound care relies on gentle cleansing and careful debridement to reduce the risk of infection and avoid additional injury to the wound bed. Strategies to reduce the risk of infection include strict infection-control practices, the use of topical antimicrobial agents, and timely burn wound debridement or excision when indicated. Performing early tangential excision and skin grafting has been demonstrated to reduce mortality and morbidity, as well as enhance overall outcomes. The use of advanced wound dressings in burn care has been shown to promote faster healing and increase patient adherence to treatment. The selection and the use of burn dressings and topical agents should be guided by the burn’s depth and extent, specific wound features (eg contamination, infection, or exudate), and the patient’s allergy history.
Nonpharmacological
Initial Therapy
Burns - Initial Management_Management 2Stop the burning process by applying cold water on the burned area and removing smoldering clothing or clothing saturated with hot liquid or chemicals. Wash the burned skin with cool running water for 20 minutes. Make sure to remove any debris, clothing, jewelry, etc. from the affected area. Keep the patient warm to avoid hypothermia; wrap the patient in clean sheets.
Blisters
Leave small blisters (<6 mm) intact in partial-thickness burns. Remove thin walls of large blisters (>6 mm), especially near joints and those more likely to rupture spontaneously. Removing the extra wall will allow direct application of moist or wet dressings on the affected area. Blisters that persist for several weeks without resorption suggest an underlying deep partial-thickness or full-thickness burn and warrant referral to a burn center or a burn-experienced surgeon.
Maintenance Treatments
Oral rehydration schemes may be considered in patients whose access to fluid resuscitation is only oral. Salt-containing fluids (eg rice water with salt, oral rehydration solution, and Lassi) may be given in small amounts so that the equivalent amount is 10% BSA.
Emollients and Skin Protectives
Lipid-rich topical treatments (eg, lotions, moisturizers, and aloe vera) are also recommended for healing lesions. The lipid contents of these treatments help accelerate repair of damaged skin. Superficial burns may be effectively treated with lotion and cream.
Patient/Parent/Guardian Education
Advise the parents or guardians on home wound care. Clean burns at home at least twice daily with soap and water to remove leftover creams from previous applications, and change dressings at least once daily. Apply topical antibiotics and give oral pain medications.
The aim of preventive education is the continuing reduction in the number of serious burn injuries. Educate parents on how to prevent fires, use smoke detectors, discourage cigarette smoking, control hot water thermostats, and learn to use fire, matches, and lighters to prevent injury. Educate parents and caregivers in preventive burn injury measures. Roll, not run, if clothing catches fire, or wrap in a blanket. Practice escape procedures during a fire incident. Crawl beneath smoke if caught indoors during a fire. Use flame-retardant clothing and toys.
Educate parents and caregivers on emergency treatments prior to seeking medical consultation. For thermal burns, cool the burn injuries with cold water or a cold compress. Avoid ice or ice water, especially for large burns, because it will cause hypothermia. Leave burn blisters intact and do not apply any ointment, oil, or spray to the burned area. For chemical burns, irrigate the affected skin or eyes with tap water. If the chemical is in powder form, wipe off the powder from affected skin. Remove contaminated clothing. Cover the burn area loosely with a dry clean cloth. For electrical burns, unplug the device that caused the burn injury; do not touch the child in contact with the electric current until you turn off the circuit breaker. Determine if the child is breathing and initiate cardiopulmonary resuscitation (CPR) if necessary. Cover the burned area with a sterile gauze bandage or clean bedsheet and keep the child warm. Do not give the child anything to eat or drink. Advise close follow-up.
Pharmacological therapy
Burns - Initial Management_Management 3Analgesics
Pain control in children is done with the use of Paracetamol for outpatients and opioid analgesics (Morphine) for admitted patients. Opioids are still the analgesic of choice for moderate to severe pain in pediatric patients. Non-opioid analgesics (Paracetamol and Ibuprofen) are used for pediatric patients for minor pains or as an adjunct to opioid analgesics for severe pain. Topical anesthetics (eg Lidocaine-Prilocaine cream) can help reduce procedural pain when debriding minor (partial-thickness burns <25 cm²) in the emergency room or outpatient setting. Analgesics should initially be given on a scheduled, around-the-clock basis with additional “rescue” doses provided before dressing changes or periods of increased physical activity.
Antimicrobial Agents
Superficial burns typically do not require antimicrobial treatment, but in more extensive burns, topical antimicrobials may be used to prevent bacterial colonization while maintaining a moist environment that supports wound healing.
Skin Antiseptics
Burns - Initial Management_Management 4Disinfectants may be used to prevent colonization of bacteria within wound beds, but further studies are needed. Examples of skin antiseptics are Povidone-Iodine solution, Chlorhexidine, and superoxide water. Scrubbing of burn wounds with antiseptics is not recommended.
Topical Antibiotics
Topical antibiotics are effective against most burn pathogens. Prophylactic parenteral antibiotics are not indicated in the initial management of burn wounds.
Sulfonamides
Sulfonamides are bacteriostatic, broad-spectrum antibiotics that interfere with the folic acid synthesis of susceptible organisms. Examples are silver sulfadiazine and sulfathiazole silver. Silver sulfadiazine is the recommended topical antibiotic for burn wounds. This is not to be used on infants <2 months of age.
Dressings
Burns - Initial Management_Management 5Appropriate dressing depends upon burn degree, location, and wound exudate. Dressings absorb drainage, increase healing time, decrease pain, and help control bacterial growth in burns. These also provides protection and isolation of wounds from the environment. Occlusion dressing is preferred for patients with superficial partial-thickness burns and donor sites of split-thickness skin grafts. For burns with minimal to moderate exudate, polyurethane, hydrocolloids, and hydrogels are recommended. Foams and alginates are preferred for partial-thickness burns with moderate-high exudate. Application of dressings directly to large blisters is beneficial.
Burn wounds heal best in a moist environment, which can be provided by the application of dressings. A closed dressing is recommended for raw areas and deep partial-thickness and full-thickness burns. Closed dressing techniques are often recommended to reduce cross-contamination by pathogens (eg methicillin-resistant Staphylococcus aureus [MRSA]), which can lead to burn wound infections, delayed healing, and graft failure.
A high-quality burn dressing typically demonstrates the following characteristics: Supports autolytic debridement of non-viable tissue; provides protection against infection and environmental contamination or trauma; maintains a moist wound environment while absorbing or wicking away excess exudate; minimizes evaporative fluid loss; is non-adherent to safeguard fragile skin; conforms easily to body contours and the wound bed; assists with splinting or immobilization when needed; has an acceptable and reassuring appearance; is simple to apply and remove; causes minimal to no pain during application, wear, or removal; and is cost-effective, considering product price, required frequency of dressing changes, and the time needed from healthcare professionals. Gauze alone should be avoided unless no alternatives exist (eg in disaster settings or when topical antimicrobials are unavailable), as dry gauze encourages scab formation that will typically separate naturally during re-epithelialization.
Please see Wound Care Disease Management Chart for further information.
Biologic Dressing
Biologic dressing uses amniotic fetal membranes as wound dressing. An example of a biologic dressing is an allogenic amnion. This is an option for burns with intact vesicles when modern dressing options cannot be applied. The snip-open technique, coated with topical antibiotic and covered with bulky dressing is recommended. Biologic dressing has shown to be an effective protective dressing in partial-thickness burn wounds. This reduces the need for frequent dressing changes, reduces pain, helps prevent infection, and supports healing.
Honey Dressing
Honey dressing is primarily utilized as a preparatory step before additional surgical interventions such as split-thickness or full-thickness skin grafts. Rehydrate the wound bed, support autolytic debridement, and provide antimicrobial activity. Honey demonstrates antibacterial properties due to factors like its high osmolarity, acidic pH, hydrogen peroxide production, and the presence of other yet-to-be-identified compounds. Honey is effective against a range of bacteria, including antibiotic-resistant organisms such as MRSA and Pseudomonas sp. This is useful in managing difficult-to-heal chronic wounds (eg burns, leg ulcers, surgical wounds).
Synthetic Dressing
Synthetic dressing has shown to be an effective protective dressing in superficial partial-thickness burn wounds. Examples of synthetic dressings are hydrocolloid dressings, collagen/silicone-coated nylon threads, and silver-containing dressings. Studies show that use of synthetic dressing causes less pain, increases healing time, has better patient compliance, and is cheaper as compared to other types of dressings. Synthetic dressing reduces the need for frequent dressing changes, helps prevent infection, and supports healing.
Hydrocolloid dressings are recommended for small-area partial-thickness burns and in the final stages of healing of small burn wounds. These absorb fluid and support autolytic debridement. Silver-containing dressings (eg Acticoat, Aquacel Ag) consist of a urethane film embedded with elemental silver that provides sustained silver release into the wound and are used for small, medium, and large surface burns. These offers stronger antimicrobial activity and longer-lasting effects, allowing dressing changes to be reduced to about once weekly depending on exudate levels.
| Dressing Guideline for Burn Wounds | |
|---|---|
| First-degree burn (eg sunburn) |
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| Second-degree burn |
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| Deep partial-thickness and higher degree of burn injury |
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Reference: Ministry of Health Malaysia. Wound care manual – 2nd ed. Putrajaya: Ministry of Health Malaysia. 2023:81-82
Wound Cleansing
Wound cleansing involves removing debris, bacteria, and any leftover materials from previous dressings from both the wound surface and the adjacent skin. This can be carried out using skin disinfectants or with mild soap and water. Chlorhexidine is an effective cleansing solution for burn wounds. Chlorhexidine gluconate is a long-acting antimicrobial skin cleanser and is commonly used with gauze for superficial partial-thickness burn coverage, and its use does not impede wound re-epithelialization.
Debriding Agents
Enzymatic and proteolytic debriding agents have been used to speed debridement of deeper or indeterminate-depth surgical burn wounds while preserving viable dermis. Examples of debriding agents are collagenase derivatives, various fruit enzyme derivatives (eg Papain/urea derivatives), and Bromelain derivatives. Anacaulase, a bromelain-derived enzyme, has been approved in the United States, the European Union, and several other international markets for treating small- to moderate-sized intermediate and deep dermal burn wounds.
Vaccine
Examples of vaccines are tetanus toxoid and tetanus immune globulin. Tetanus immunization is recommended for patients with more than first-degree burn and burns >10% BSA. These should be considered for patients who received tetanus toxoid and immunoglobulin >10 years ago and those whose immune status is uncertain. Tetanus immune globulin should also be administered to patients who have not completed their primary immunization series.
Surgery
Wound excision is required for deep burns (eg deep partial-thickness, full-thickness, and deeper injuries) and must be followed by graft or flap coverage. Excision of full-thickness eschar removes the biological and bacterial burden, reducing morbidity and mortality while enhancing the effectiveness of wound dressings, biologic grafts, semibiologic substitutes, and definitive coverage.
Debridement
Debridement of sloughed or necrotic skin, including ruptured blisters, should be performed before applying a dressing, since these remnants can raise infection risk and reduce the effectiveness of topical antimicrobial contact with the burn wound. Ruptured blisters should be fully debrided, meaning the entire blister and all loose skin are removed so that no necrotic epidermis remains.
Escharotomy
Escharotomy is commonly required for deep partial- and full-thickness burns, especially when burn size exceeds 20% TBSA. This may be performed immediately, particularly for circumferential burns, or later as progressive edema develops during fluid resuscitation. This is performed to relieve pressure within the subcutaneous tissues to prevent secondary ischemia. Deep burn injuries require the removal of the eschar to create a viable wound bed for autografting, reduce the risk of burn wound sepsis, and facilitate simpler dressing changes. For deep partial- or full-thickness burns requiring escharotomy, the incisions and any exposed tendon, bone, or muscle should be kept moist with saline-soaked gauze to prevent tissue desiccation. Emergency escharotomy may become necessary when circumferential partial- or full-thickness burns cause major functional impairment (eg restricted chest wall expansion with respiratory compromise or compartment syndrome in the abdomen or limbs), as these complications typically worsen during the first 24 hours with progressive swelling and edema.
Temporary Burn Wound Coverage
Biologic Graft Materials
Biologic graft materials are used for temporary burn wound coverage (eg allografts, xenografts, and human amniotic membrane) to support healing and can serve as a bridge to definitive wound coverage. This can be applied to clean burn wounds to prevent desiccation, promote re-epithelialization, and naturally separate once healing is complete, offering particular benefit in children by avoiding repeated painful dressing changes.
Semibiologic Skin Substitutes
Semibiologic skin substitutes are temporary biosynthetic dressings designed to reduce dressing change frequency and support healing, with their semipermeable structure allowing wound exudate to be absorbed by the outer bulky dressing. Examples are semibiologic skin substitutes are Biobrane, Hyalomatrix, NovoSorb/Polynovo, PermeaDerm, Primatrix, StrataGraft, and Suprathel. The choice of a skin substitute depends on the wound’s appearance, the desired clinical outcome, clinician experience, product availability, cost, and cultural considerations, particularly for porcine-derived options. Semibiologic skin substitutes have been shown to shorten healing time, decrease pain medication needs, lessen hospital stays, and improve pain relief during dressing changes. These are used to cover donor sites and to manage large-surface-area burns, including those involving the hands, feet, and joints, and it may also serve as a temporary dressing over full-thickness excisions in staged procedures prior to definitive skin grafting.
Biobrane is a bilaminate dressing composed of a thin semipermeable silicone layer bonded to a nylon mesh coated with type I porcine collagen, which promotes fibrin deposition and adherence. This is not inherently antimicrobial, but its porous structure permits absorption of topical agents and exudate, and its flexibility, elasticity, and transparency make it a versatile option for wound management. Hyalomatrix is a synthetic non-woven pad made from a benzyl ester of hyaluronic acid that functions as a biodegradable scaffold for cellular and capillary ingrowth and is also reported to have free-radical-scavenging and antioxidant properties. NovoSorb/PolyNovo is a bilayer polyurethane foam composed of a biodegradable matrix, a bonding layer, and a perforated sealing membrane, functioning as a scaffold for fibrovascular ingrowth to optimize the wound bed in deeper burns or excised wounds prior to subsequent skin grafting. PermeaDerm is a dual-layer biosynthetic skin substitute similar to Biobrane, featuring an outer transparent, flexible silicone-nylon layer coated with aloe vera to mimic the epidermis and an inner porous porcine gelatin-collagen matrix intended for partial-thickness wounds and donor sites. Primatrix is a type II collagen dermal scaffold derived from fetal bovine dermis and approved for full-thickness excisional wound beds and has shown promise as a potential option for managing deeper partial-thickness burn wounds. StrataGraft is a bioengineered allogeneic, cellularized skin substitute composed of a stratified epidermal layer supported by normal human dermal fibroblasts embedded within a collagen gel matrix. Suprathel is placed on the wound after debridement, then covered with fatty gauze and a secondary cotton gauze layer, and both the Suprathel and fatty gauze remain in place until healing is complete, naturally separating once re-epithelialization occurs.
Skin Grafts
Skin grafts are a management option for coverage of second- or third-degree burns. Autografts consist of split- or full-thickness skin taken from healthy, uninjured donor sites and transplanted to the burn wound. Split-thickness grafts are preferred for burns with large affected areas and less donor skin or donor sites. Self-regenerating ability allows this type of graft to be re-harvested once healing is complete. Full-thickness grafts are better aesthetically but with limited availability of donor sites and vascularity.
Please see Wound Care Disease Management Chart for further information.