After airway management has been addressed, the priority in burn patients is fluid resuscitation. Although there is controversy on the subject of resuscitation formulas, the Parkland formula is widely used. This formula calls for an isotonic crystalloid solution (such as Lactated Ringers) to be given at 4 mL/kg/% BSA over a 24-hour period. Half of this fluid volume is given over the first 8 hours, and the second half is given over the next 16 hours. BSA can be calculated using the Lund and Browder diagram (Fig. 137-3), with only second- and third-degree burns factoring into fluid resuscitation. Pediatric patients should be started on maintenance IV fluids in addition to resuscitation fluids and adjustments made to fluid rates in order to maintain urine output of 1–2 mL/kg/h for children and 0.5–1 mL/kg/h for adolescents and adults.
Tetanus immunization should be administered to all patients without a complete immunizations series or who have not had a tetanus booster within 5 years.
Pain management is an important consideration in burn management. Burns, especially partial-thickness burns, can be extremely painful. Opioid analgesia is often required, preferably given intravenously because of fluid shifts and absorption irregularities from the oral and intramuscular routes. Morphine is the most commonly used analgesic, with a starting dose of 0.1 mg/kg IV.7
Initial wound care in the emergency department should consist of covering the burns with a dry, sterile sheet. The burn surface can be cleaned with a sterile saline solution, and debridement may be performed on devitalized tissue. Sterile saline-soaked dressings may be applied to small burns, but should be avoided in large burns because of the risk of developing hypothermia. Antiseptic solutions such as povidone–iodine and topical antibiotics should be avoided in patients who are being transferred to a burn center until the primary service has had the opportunity to evaluate the wounds.
Minor burns can be managed on an outpatient basis. These burns should be cleaned with sterile saline solution. Ruptured blisters and devitalized tissue should be debrided. The management of intact blisters remains controversial; large, painful, or hemorrhagic blisters should be debrided but smaller blisters can be left intact.8 Topical antibiotics are routine in outpatient burn care. One percent silver sulfadiazine cream is most commonly used, although it should be avoided in facial burns due to the risk of tissue hypopigmentation. Bacitracin ointment is an alternative agent for the face or small burns. Do not apply topical antibiotics if transferring to a burn center or another hospital pending discussion with accepting pediatric or burn surgeon due to need for visualization of the burn, varying opinions on topical treatment choices, or possibility of skin grafts. Sterile gauze dressings should be applied over topical antibiotic ointment or cream and changed once or twice daily.
There are several popular commercially available products for treatment of burns including silver-containing antimicrobial dressings made of carboxymethylcellulose fibers. These newer synthetic alternatives are often used for outpatient burn management in children. Designed to act as a “second skin,” these dressings do not require frequent changes and have been associated with improved patient compliance and outcomes.9,10
All burn patients should be reevaluated at 24–48 hours to ensure proper wound healing and to examine for signs of infection. Oral pain medication may be required before dressing changes.