BURN INJURIES
- Executive Summary
This guideline provides standardized, evidence-based recommendations for the recognition and management of Burn.
1-) Burn injury First aid
Recommendation 1: (First Aid Education)
We recommend educating both the public and first responders is essential for enhancing awareness and ensuring optimal first responder performance.
· Strength of recommendation: Strong
Recommendation 2: (First Aid Safety)
We recommend that first responder must ensure the removal of the individual from all potential hazards, including heat or flame, live electrical sources, and chemicals. It is essential that the responder prioritises the safety of themselves, the patient, and any bystanders.
· Strength of recommendation: Strong
Recommendation 3: (Cooling Burns)
We recommend in the event of heat or flame injuries, to cool the burn wound with clean, running water at a temperature that is comfortable for the patient for 15–20 minutes, ideally within three hours of the injury. Following the cooling process, the individual should be kept warm, and primary medical attention should be sought promptly.
· Strength of recommendation: Strong
Recommendation 4: (Chemical Injuries)
We recommend in case of chemical injuries, the first responder should promptly remove and safely dispose of all contaminated clothing and materials, followed by thorough irrigation with water for up to 45 minutes. Additionally, it is important to identify the chemical agent involved and adhere to established protocols specific to that substance, if applicable.
· Strength of recommendation: Strong
Recommendation 5: (Electrical Injuries)
We recommend when providing first aid for electrical injuries, it is essential to prioritise safety by deactivating the electrical source or isolating the victim using a nonconductive material. Initiate cardiopulmonary resuscitation (CPR) if required, and subsequently manage burns by applying appropriate cooling measures.
· Strength of recommendation: Strong
2-) Resuscitation in Burn Patient
a-) Fluid resuscitation in burn patient:
Recommendation 6: Indication to start Iv fluids:
We recommend Initiating intravenous fluid resuscitation with salt‑containing solutions in:
-Adults with burns involving ≥20% of total body surface area (TBSA), or earlier if there are clinical signs of shock or significant comorbidities.
-Children with burns involving ≥10% TBSA.
· Strength of recommendation: Strong
Recommendation 7: Timing
We recommend initiating intravenous fluid resuscitation as early as possible, ideally within 2 hours of injury, for all patients who meet the TBSA thresholds (≥20% in adults, ≥10% in children). Do not delay resuscitation until arrival at a burn center—start at the first point of care once criteria are met.
· Strength of recommendation: Strong
Recommendation 8: Initial Fluid Type:
We recommend using a balanced crystalloid solution, such as Lactated Ringer’s (LR) or acetated Ringer’s, as the primary fluid for initial burn resuscitation. Avoid using normal saline as the sole resuscitation fluid due to the risk of hyperchloremic metabolic acidosis.
· Strength of recommendation: Strong
Recommendation 9: Initial 24-hour Volume:
We recommend using a validated formula (such as the Parkland formula) to estimate the initial 24-hour fluid requirement but emphasize that this is only a starting point. The calculated volume should be adjusted frequently based on urine output and clinical endpoints, not given as a fixed amount.
· Strength of recommendation: Strong
Recommendation 10: Titration Targets:
We recommend adjusting fluid administration based on physiological endpoints, primarily urine output, rather than relying solely on calculated formula volumes. Continuous reassessment is essential to avoid both under- and over-resuscitation.
· Strength of recommendation: Strong
b-) Inhalation burn:
Recommendation11: Clinical Indicators for Airway Burns
We recommend using clinical indicators, such as injury circumstances (closed-space exposure, inhalation of hot vapour/liquid) and physical findings (soot in mouth, singed nasal hairs, facial burns), rather than using invasive diagnostic tools (e.g., laryngoscopy, bronchoscopy), as findings that suggest airway burns.
· Strength of recommendation: Strong
Recommendation 12: Radiographic Monitoring
We recommend perform serial plain chest radiography in the acute period for the early diagnosis of respiratory disorders.
· Strength of recommendation: Strong
Recommendation 13: Early Preventive Intubation
We suggest performing early preventive intubation if inhalation injury is suspected and airway oedema is likely.
· Strength of recommendation: Conditional
c-) Pain management and sedation in burn patients.
Recommendation14: Pain Assessment
We recommend that the adequacy of pain control be routinely assessed using standardized scoring systems. Whenever possible, self-report measures should be utilized as the preferred method of pain assessment. In situations where patients are unable to self-report such as young children or individuals with impaired mental status validated behavioural pain assessment scales should be employed to ensure accurate and effective pain management.
Inhalation injury can cause rapid and progressive airway oedema, making delayed intubation difficult or impossible once swelling develops. Early (preventive) endotracheal intubation ensures a secure airway before obstruction occurs, reducing the risk of respiratory failure and mortality.
Although not all patients with suspected inhalation injury will require intubation, the potential harm from a lost airway outweighs the risks of early intervention when airway oedema is likely. Therefore, early intubation is conditionally recommended in such cases.
· Strength of recommendation: Strong
Recommendation 15: Multimodal analgesia
We recommend that analgesia should be used as an
essential component in the management of burn patients. A multimodal approach
is preferred, combining agents with different mechanisms of action; however,
single-agent therapy may be appropriate in selected cases.
Recommended options include opioids and non-opioid agents such as acetaminophen
(paracetamol), nonsteroidal anti-inflammatory drugs (NSAIDs), ketamine,
dexmedetomidine, gabapentin, and pregabalin.
· Strength of recommendation: Strong
Recommendation 16: Assessment of agitation before sedation
We recommend timely identification and treatment of any underlying causes of agitation including pain, delirium, hypoxemia, hypoglycaemia, and hypotension before sedative administration.
· Strength of recommendation: Strong
d-) Sedation During Tracheal Intubation in Burn Patients
Recommendation 17: Multimodal Sedation Strategy Egyptian National Burn Guidelines
We recommend that sedation during tracheal intubation in burn patients be guided by a multimodal strategy that prioritizes patient safety, minimizes adverse effects, and supports optimal outcomes. This approach should be tailored to the clinical condition, burn severity, and ICU status of each patient.
· Strength of recommendation: Strong
e-) Recommendation regarding antibiotic administration / tetanus vaccination:
Recommendation 18: Systemic Antibiotic Administration
We advise against use uniform systemic administration of antibiotics except in immunocompromised patients with contaminated wounds.
Routine preventive systemic antibiotic administration is not currently recommended due to insufficient evidence supporting its effectiveness. However, in patients with contaminated wounds, immunocompromised individuals (such as those with diabetes), children, and perioperative patients, targeted antibiotic prophylaxis may be considered. In such cases, the selection of antibiotics should be guided by local microbial patterns, facility-specific characteristics, and wound culture results.
· Strength of recommendation: Conditional
Recommendation 19: Tetanus Prophylaxis
We recommend the administration of tetanus toxoid (TT) or human tetanus immunoglobulin (TIG) for contaminated burns
It is recommended to manage contaminated burns in the same manner as other wounds. Although no clear national guideline exists in Egypt regarding anti-tetanus treatment for burn patients, the committee reached a strong consensus on its necessity, given the potentially fatal nature of tetanus and existing recommendations supporting prophylaxis for contaminated burns. Clinically, it is often difficult to clearly differentiate between “tetanus-prone” and “non-tetanus-prone” wounds, as tetanus can develop even from minor injuries such as small scratches, burns involving less than 1% TBSA, or sometimes without any apparent wound. Therefore, administration of tetanus toxoid (Tt) or tetanus immune globulin (TIG) is recommended for patients with incomplete or uncertain primary immunization, and for those with contaminated burns occurring more than 5–10 years after their last vaccination, depending on the level of wound contamination.
· Strength of recommendation: Strong
3- Burn Wound care management
Recommendation
20: - Blister Management
We suggest intact blisters should generally be left undisturbed, while large, tense, or contaminated blisters may require aspiration or deroofing
Strength of recommendation: conditional
Recommendation 22: -Use of Antimicrobial Ointments for Superficial Burns
We consider the use of topical antimicrobial ointments (e.g., bacitracin, polymyxin B, mupirocin) for small, superficial burns, particularly on sensitive areas such as the face.
Strength of recommendation: Conditional
Recommendation 23: - Dressing Technique Selection
We consider starting with conventional dressings (e.g., gauze with antimicrobial ointment) for heavily exudative or contaminated wounds, then transitioning to advanced or biologic occlusive dressings based on wound characteristics and healing progression. Closed dressing techniques are preferred over open techniques for most wounds.
Strength of recommendation: good practise statement
Recommendation 24: Management of raw burnt areas for deep partial-thickness and full-thickness burns.
We recommend immediate or early burn wound excision (within 24–72 hours) over conservative care for deep partial-thickness and full-thickness burns.
Strength of recommendation: strong
Recommendation 25: -Duration and Frequency of Dressing Changes
We recommend minimizing the frequency of dressing changes and maintaining long-lasting occlusive dressings whenever possible.
Strength of recommendation: Strong
4- Referral Guidelines for Burn Injuries
Recommendation 26: -Referral Based on Burn Size
We advise referring patients to a designated burn center if they have:
Partial-thickness burns >10% TBSA (any age), or
Full-thickness burns of any size.
· Strength of recommendation: good practice statement
Recommendation 27: -Referral Based on Anatomic Location:
· Strength of recommendation: good practice statement
Recommendation 28: -Referral Based on Mechanism of Injury:
We recommend referral to designated burn center for:
- Electrical burns (including lightning)
- Chemical burns
- Suspected or confirmed inhalation injury
· Strength of recommendation: good practice statement
Recommendation 29: - Referral Based on Patient Factors:
We advise referral to a designated burn center for:
ü Burns in patients with significant comorbidities (e.g., diabetes, cardiac disease, immunosuppression)
ü Burns with concomitant trauma where burns pose the greatest risk
ü Children in facilities without paediatric burn expertise
· Strength of recommendation: good practice statement
Recommendation 30: -Referral and Transfer Arrangements:
We suggest the referring facility establish communication with the receiving burn center prior to transfer, confirm bed availability, and provide comprehensive patient information. A structured handover and safe transport with adequate monitoring and personnel are essential for optimal continuity of care.
· Strength of recommendation: good practice statement