Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

suitable for outpatient care

1st line – wound cleaning and topical antibiotic prophylaxis

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ACUTE
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suitable for outpatient care
1st line – 

wound cleaning and topical antibiotic prophylaxis

Patients with smaller burns who have adequate support at home can generally be managed in the outpatient setting. Wounds of the face, ears, hands, genitals, and feet have a functional and cosmetic importance out of proportion to their wound size. In such cases, early specialty evaluation may be prudent. Most burns selected for outpatient management are superficial and heal within 2 weeks. If this is not the case, patients may benefit from specialty evaluation.

Clean burn wounds with lukewarm tap water and a bland soap.

​Systemic antibiotic prophylaxis is not routinely recommended as prior studies demonstrated no compelling benefit.[46]

Superficial burns can be treated with viscous antibacterial ointments containing low concentrations of various antibiotics, although supportive data is weak. Silver is an excellent antiseptic and is used in burn wound care in several forms, including silver sulfadiazine cream, aqueous silver nitrate solution, and dressings containing nanocrystalline silver.[50] Topical silver sulfadiazine is commonly used, as it is painless on application and has a broad spectrum of antibacterial activity, although some in vitro evidence suggests it may slow epithelialization to a modest degree and some guidelines advise against its use.[37][49][51][52]​ 

Treat deeper ear burns with mafenide, as it is the only agent that penetrates relatively avascular cartilage. This is important as infection of the cartilaginous skeleton of the external ear can cause significant deformity.

Primary options

silver sulfadiazine topical: (1%) apply to the affected area(s) once or twice daily

OR

mafenide topical: (8.5%) apply to affected area(s) once or twice daily

Consider – tetanus immunization

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ACUTE
|
suitable for outpatient care
Consider – 

tetanus immunization

Treatment recommended for SOME patients in selected patient group

Indicated in patients with no current immunization.

Consider – opioid analgesic

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ACUTE
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suitable for outpatient care
Consider – 

opioid analgesic

Treatment recommended for SOME patients in selected patient group

Many patients will have significant anxiety and pain with wound inspection and cleansing.

Some will benefit from an oral opioid given 30 to 60 minutes prior to a planned dressing change.

Primary options

morphine sulfate: 10-30 mg orally (immediate-release) every 4 hours when required initially, titrate dose according to response

Plus – antibiotics ± surgical debridement

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ACUTE
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suitable for outpatient care
|
with suspected wound infection
Plus – 

antibiotics ± surgical debridement

Treatment recommended for ALL patients in selected patient group

Regular monitoring of burn wounds allows for the early recognition of infection. Once infection has been identified, it requires aggressive management, which may include admission, intravenous antibiotics, observation, and surgical debridement if wounds are deep.

Burn wound cellulitis responds readily to antibiotics in most cases.

Burn impetigo is usually associated with Staphylococcus aureus and Streptococcus pyogenes and is particularly common in burns of the scalp. Treatment requires wound cleansing, which often mandates shaving of nearby hair-bearing areas, and grafting of full-thickness areas.

Follow local protocols for selection of antibiotic and appropriate dosing.

Primary options

cefadroxil: 1 g orally/day given in 1-2 divided doses

requires inpatient care

1st line – assessment for admission to a burn center

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ACUTE
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requires inpatient care
1st line – 

assessment for admission to a burn center

Patients who cannot take fluid by mouth, need burn resuscitation, potentially have inhalation injury, or cannot be managed in the outpatient setting should be admitted for inpatient care. Where possible, consult with a specialist burns center and arrange transfer as appropriate.

Some patients initially managed in the clinic setting will subsequently require admission. Reasons prompting admission include: increased pain and anxiety; inability to keep scheduled appointments; delayed healing; signs of infection; and wounds that appear deeper than initially estimated (burn depth is commonly underestimated during the first days after injury).

Serious burns are most effectively managed in organized programs focused on burn care. The American Burn Association (ABA) states that the following burn injuries should be referred to a burn center: partial-thickness burns of >10% total body surface area (TBSA); burns that involve the face, hands, feet, genitalia, perineum, or major joints; third-degree burns in any age group; electrical burns, including lightning injury; chemical burns; inhalation injury; burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality; burned children in hospitals without qualified personnel or equipment for the care of children; burn injury in patients who will require special social, emotional, or rehabilitative intervention; and patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.[41]

An expert consensus panel has proposed updating and extending the original ABA referral criteria to include the following additional referral criteria/considerations:[42] full-thickness burns ≥ 5% TBSA burned; children and older adults (>55 years of age, who may benefit from referral to a burn center to access the multidisciplinary team resources, even when TBSA burned is less than 10%); smaller burns should be followed up in burn center outpatient settings as soon as possible after injury, and preferably within a week; consider telemedicine consultations as an alternative to immediate transfer or outpatient referral for selected patients.

Internationally, burn center transfer criteria vary and may depend on local resources and/or configuration of specialist burn services.[43]

Consider – fluid resuscitation

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ACUTE
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requires inpatient care
Consider – 

fluid resuscitation

Treatment recommended for SOME patients in selected patient group

If burns involve >20% of the body surface, reduced capillary integrity becomes clinically important, with a resulting need for fluid resuscitation (usually given as crystalloid solutions). Capillary integrity is typically restored at approximately 24 hours. Any of the several burn formulas available may be used to initiate resuscitation but none can be assumed to be accurate in an individual patient. Bedside titration of infusions, based on physiologic endpoints, is important.

The Parkland formula is often used and suggests 4 mL/kg/% burn over the first 24 hours, half in the first 8 hours, generally as lactated Ringer solution. The evidence for choice of crystalloid fluids for critically ill patients in general is conflicting, with very little good data specific to burn resuscitation.[63][66][67][68]

The Modified Brooke formula suggests 2 mL/kg/% burn, half of the total fluid requirement is given in the first 8 hours, and the other half is given in the next 16 hours.[24]​ The rate of fluid administration is adjusted based on the patient's urine output. The goal is to maintain an hourly urine output of 30-50 mL for a 70 kg adult. During the second 24 hours, 0.33 to 0.5 mL/kg/% TBSA burned of colloid plus D5W is given to maintain urine output.[65]

The American Burn Association (ABA) Clinical Practice Guideline (CPG) recommends 2 mL/kg/% TBSA burn rate for initial fluid resuscitation in adults with burns ≥20% TBSA, in order to reduce resuscitation fluid volumes.[64]

Young children should receive 5% dextrose in lactated Ringer solution at a maintenance rate to ensure they do not develop hypoglycemia.

Even patients with massive burns can have a good outcome if managed in a comprehensive burn program. Fluid resuscitation becomes increasingly challenging as burn size increases. War-time experience has added to our understanding of the resuscitation needs of the very severely injured.[74]

The role of colloid remains controversial. Very little relevant data exist. Many clinicians advise inclusion of colloid (generally albumin) in burn resuscitation when burns are large to reduce anasarca (severe, generalized interstitial fluid accumulation) despite evidence to the contrary from a meta-analysis and conflicting recommendations from some guidelines.[69][70][71]​​

ABA CPG advises to consider giving albumin in burn patients with ≥20% TBSA in the first 24 hours of burn resuscitation to improve urinary output and to reduce the total volume of resuscitation fluids.[64]​ The strength of this recommendation is greater for patients with larger burns and weaker for patients with smaller burns. It also suggests in situations where albumin is part of the general resuscitation plan, versus in an acute rescue situation, that it is preferable to start the albumin after the first 12 hours.[64]

Solutions containing hydroxyethyl starch (HES) are not recommended due to their increased risk of adverse outcomes including kidney injury and death, particularly in critically ill patients, and their use has been suspended in Europe.[24][63][72][73]

Consider – supplemental oxygen and supportive care

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ACUTE
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requires inpatient care
Consider – 

supplemental oxygen and supportive care

Treatment recommended for SOME patients in selected patient group

Patients with airway involvement or major burns generally require intubation and mechanical ventilation, although intubation should be done selectively.[25][60]​​[61]​​ Carbon monoxide intoxication is best treated acutely by ventilation with 100% oxygen, but can be associated with delayed neurologic sequelae. Hyperbaric oxygen treatment is appropriate in selected stable patients with serious exposures, but it is not indicated for routine wound healing.[62]

Wound healing requires adequate nutritional support. General needs are debated and individual needs vary, but in general 25-40 kcal//kg/day, depending on the extent and severity of injuries, is a reasonable starting estimate of caloric needs for most patients. More refined calculations can be achieved with other equations, such as the Harris-Benedict equation, or needs can be measured using indirect calorimetry. A reasonable protein target is 1.5 to 2 grams/kg/day, and trace element and vitamin needs should also be met.

Nutritional needs in most patients can be effectively provided by the enteral route. In occasional very ill patients, parenteral nutrition can be safely administered with good effect.[90]

Wound dressing frequency and type vary substantially between burn centers and the individual needs of patients. In general, when eschar exists, agents with a broad antibacterial spectrum and penetration are advisable. In superficial burns or postoperative wounds, prevention of desiccation is particularly important. In the presence of skin grafts, graft stability is an essential consideration. Within these general principles, the variety of possibilities and practices is vast, and a single best practice cannot be defined. Familiarity with a program of care leads to optimal results.

Burn patients experience exaggerated heat loss from their wounds and should be managed in settings where environmental heating is available.

Consider – tetanus immunization

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ACUTE
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requires inpatient care
Consider – 

tetanus immunization

Treatment recommended for SOME patients in selected patient group

Indicated in patients with no current immunization.

Update tetanus immunization in patients with wounds deeper than a superficial partial-thickness burn.

Consider – surgery

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ACUTE
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requires inpatient care
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

In patients with severe burns, identification and removal of large areas of full-thickness burn is required, before wound sepsis and systemic inflammation develop. This should be done using staged hemostatic and minimally ablative techniques.[79] Near- or completely circumferential burns should be identified for special monitoring and possible escharotomy.[24][25] If involving the torso, such wounds can interfere with ventilation or even contribute to intra-abdominal hypertension. When they involve an extremity, limb-threatening ischemia may occur 12 to 24 hours after the injury. Escharotomy can decompress such problems. The procedure can be done with coagulating electrocautery. When performing escharotomy it is important not to damage uninjured skin or superficial neurovascular structures. Anesthesia or sedation is generally required in children.

Ideally, close wounds with autograft. Temporary wound membranes can be useful in patients with large wounds. This strategy changes the natural history of the injury from inevitable systemic sepsis and inflammation to a more controlled wound-closure situation.

Amniotic membrane can be an accessible and effective temporary membrane, but blood-borne infectious disease screening remains a concern and should be considered.[80]

Definitive wound closure is achieved by replacing any temporary membranes with autograft and closing small complex wounds, such as on the hands and face. When donor sites are severely limited, this phase may take many weeks.

The role of antibiotic prophylaxis during acute burn surgery remains unclear.

Consider – deep venous thrombosis (DVT) prophylaxis

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ACUTE
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requires inpatient care
Consider – 

deep venous thrombosis (DVT) prophylaxis

Treatment recommended for SOME patients in selected patient group

DVT is a risk in all injured patients. There are few studies of this in burn patients to support a specific approach. Each unit should develop its own policy for monitoring, prophylaxis, and treatment.[82]

Consider – intravenous opioid plus benzodiazepine ± nonpharmacologic therapy

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ACUTE
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requires inpatient care
Consider – 

intravenous opioid plus benzodiazepine ± nonpharmacologic therapy

Treatment recommended for SOME patients in selected patient group

Attention to pain and anxiety are essential in all phases of care. This is usually done by infusion of opioids and benzodiazepines (e.g., morphine and midazolam).

Each unit should establish their own protocol and dosing regimens. A typical initial dosing of infusion is shown below.

Even during resuscitation, it is important to ensure attention is paid to patient comfort. Pain and anxiety can have adverse physiologic and emotional consequences.[75] Nonpharmacologic therapies, such as music therapy, can be useful in selected patients. Virtual reality is an innovative, new, nonpharmacologic, noninvasive analgesic technique. Although only few studies are available, positive initial experiences have been reported and a systematic review found it to be an effective adjunct for treatment of pain during wound dressing changes and physical therapy.[88][89] Successful early pain control can enhance important aspects of long-term outcome.[76] The psychosocial needs of the patient should be considered during and following hospitalization and rehabilitation.[24]

Primary options

morphine sulfate: consult specialist for guidance on dose

and

midazolam: consult specialist for guidance on dose

Plus – antibiotics ± surgical excision

Back
ACUTE
|
requires inpatient care
|
with suspected wound infection
Plus – 

antibiotics ± surgical excision

Treatment recommended for ALL patients in selected patient group

Regular monitoring of burn wounds allows for the early recognition of infection. Once infection has been identified, it requires aggressive management, which may include intravenous antibiotics, observation, and surgical excision if wounds are deep.

Burn wound cellulitis responds readily to antistaphylococcal antibiotics such as a first-generation cephalosporin (e.g. cefadroxil ) in most cases. If resistant species are suspected or documented by culture and sensitivity, appropriate antibiotics should be prescribed. If MRSA is suspected or documented by culture, it is reasonable to begin treatment with vancomycin.

Burn impetigo is usually associated with Staphylococcus aureus and Streptococcus pyogenes and is particularly common in burns of the scalp. Treatment requires wound cleansing, which often mandates shaving of nearby hair-bearing areas, and grafting of full-thickness areas.

Open burn-related surgical wound infections are treated with debridement of necrotic and infected material with delayed wound closure.

Invasive burn wound infection is a serious problem, usually addressed by excision and treatment with systemic antibiotics (e.g., penicillin) or a first-generation cephalosporin (e.g., cefadroxil). Antibiotics are supportive in the management of burn wound infection.

Follow local protocols for selection of antibiotic and appropriate dosing.

Primary options

penicillin G sodium: 4 million units intramuscularly/intravenously every 4 hours, maximum 24 million units/day

OR

cefadroxil: 1 g orally/day given in 1-2 divided doses

Secondary options

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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