TOPIC 45: Thermal Burns – Evaluate and manage a patient with thermal burns

MOCA-PBR – 2025 Edition TOPIC 45: Thermal Burns – Evaluate and manage a patient with thermal burns

OFFICIAL ABP TOPIC: 

Evaluate and manage a patient with thermal burns

BACKGROUND

Thermal burns are a common cause of injury in children, with the majority occurring due to scalds from hot liquids or contact with hot objects. Accurate assessment of burn severity and prompt management are crucial to minimize morbidity and mortality.

BURN CLASSIFICATION

Burn severity is determined by the depth and extent of the injury. The depth of a burn is classified as superficial (epidermal), superficial partial-thickness, deep partial-thickness, or full-thickness. The extent of a burn is expressed as the percentage of total body surface area (TBSA) involved. While the rule of nines can be useful for rapidly estimating the extent of a burn in adolescents, the Lund and Browder chart is a more accurate way to assess burns across age groups.

DEPTH OF BURN 

APPEARANCE 

SENSATION 

HEALING TIME 

Superficial (Epidermal) 

Dry, red, blanches with pressure 

Painful 

3 to 6 days 

Superficial Partial-Thickness 

Blisters, red, weeping, blanches with pressure 

Painful to temperature, air, and touch 

7 to 21 days 

Deep Partial-Thickness 

Blisters, wet or dry, variable color (cheesy white to red), may have sluggish or absent blanching 

Painful to pressure 

>21 days, usually requires surgical treatment 

Full-Thickness 

Waxy white to gray to black, dry, no blanching 

Deep pressure only 

Rarely heals without surgical treatment 

INITIAL EVALUATION AND MANAGEMENT OF THERMAL BURNS

  1. Assess and stabilize airway, breathing, and circulation (ABCs).
  2. Remove clothing, jewelry, and any smoldering or scalding materials.
  3. Cover the burn with a clean, dry sheet or blanket to prevent hypothermia.
  4. Obtain a detailed history of the burn injury, including mechanism, time of injury, and any associated injuries or illnesses.
  5. Perform a thorough physical examination, focusing on burn depth, extent, and location. Determine burn severity and estimate % TBSA affected.
  6. Provide pain management with oral or intravenous analgesics as needed.
  7. Initiate fluid resuscitation for burns >10% TBSA using the Parkland formula:
    • 4 mL/kg/% TBSA of Lactated Ringer’s solution over the first 24 hours (half given in the first 8 hours, and half in the next 16 hours).
  8. Consider transferring the patient to a burn centerfor:
    • Partial-thickness burns >10% TBSA.
    • Burns to the face, hands, feet, genitalia, perineum, or major joints.
    • Full-thickness burns (any size).
    • Burn injuries with special long-term social, emotional, or rehabilitative needs.
    • Suspected intentional injury.
  9. Minor burns (<10% TBSA partial-thickness burns) can be managed in an outpatient setting with proper wound care and follow-up. Arrange for follow-up within 24-48 hours for reassessment and dressing changes.

EVALUATION FOR ASSOCIATED INJURIES

TRAUMA

Evaluate for associated traumatic injuries, especially in cases of explosions, motor vehicle crashes, or falls.

INTENTIONAL INJURY

Consider the possibility of abuse or neglect, particularly in cases with inconsistent history or suspicious burn patterns (e.g., imprint of a hot object with clear margins and uniform depth, well-demarcated high-water mark on lower legs).

WOUND MANAGEMENT OF THERMAL BURNS

  1. Cool small, partial-thickness burns <%5 TBSA with room-temperature water or cooled wet gauze, NOT ice.
  2. Clean the burn wound with mild soap and water or chlorhexidine solution.
  3. Debride loose, nonviable tissue and ruptured blisters.
  4. For non-superficial burns, apply topical antimicrobial agents and dress the wound with non-adherent gauze. Commonly used topical agents include silver sulfadiazine, bacitracin, and silver-containing dressings. The choice of agent depends on the burn’s location, size, and depth, as well as patient factors such as allergies and comorbidities.
  5. Elevate the affected extremity to minimize edema.
  6. Update tetanus prophylaxis as needed (see table below).
  7. Monitor for signs of infection and compartment syndrome.

ADMINISTRATION OF TETANUS VACCINATION/IMMUNE GLOBULIN

PREVIOUS DOSES OF TETANUS 

CLEAN AND MINOR WOUNDS

ALL OTHER WOUNDS

<3 doses or unknown

Tetanus toxoid-containing vaccine

Tetanus vaccine and tetanus immune globulin

≥3 doses

Tetanus vaccine if last dose ≥10 years ago

Tetanus vaccine if last dose ≥5 years ago

LONG-TERM MANAGEMENT

  • Monitor for the development of hypertrophic scars or contractures, which may require surgical intervention or rehabilitation.
  • Address psychosocial concerns and provide support for the patient and family throughout the recovery process.
  • Encourage the use of pressure garments and silicone gel sheets to minimize scarring.
  • Advise on sun protection to prevent hyperpigmentation of healing skin.

REFERENCES

https://publications.aap.org/pediatricsinreview/article/34/9/395/34806/Initial-Assessment-and-Management-of-Thermal-Burnhttps://www.uptodate.com/contents/moderate-and-severe-thermal-burns-in-children-emergency-managementhttps://www.uptodate.com/contents/treatment-of-minor-thermal-burns

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