Guidelines for Management of Second‑Degree Burns

Initial Cooling and Temperature Control

Immediate cooling of second‑degree burns with running water for 20–40 minutes when the total body surface area (TBSA) burned is < 20 % in adults or < 10 % in children (and no shock) markedly reduces the need for skin grafting (P < 0.001) and limits burn depth progression【1】【4】.
Running water should be used; prolonged use of external cooling devices is discouraged because of the risk of hypothermia【4】.
Cooling also provides effective analgesia during the acute phase【1】【2】【3】.

Analgesia must be titrated using validated comfort‑pain scales【2】【3】.
Short‑acting opioids combined with ketamine are the preferred pharmacologic agents for burn‑related pain【1】【2】【3】.
Intravenous ketamine, when titrated, can be combined with other analgesics for severe pain【2】.
Inhaled nitrous oxide is useful when intravenous access is unavailable【1】【3】.
General anesthesia is an effective option for highly painful procedures or debridement【1】【3】.
Non‑pharmacologic techniques such as virtual reality and hypnosis can lower pain intensity and patient anxiety【1】【2】【3】.

Prior to dressing, wounds should be cleansed with running water, isotonic saline, or an appropriate antiseptic solution【1】【2】【3】.
Wound care should be performed in a clean environment and often requires deep analgesia or general anesthesia【1】【2】【3】.
Wound care is secondary to adequate resuscitation and should be delayed until resuscitation is well established【1】【2】【3】.
Consultation with a burn‑care specialist is recommended to determine the optimal dressing type and whether blisters should be deroofed or excised【1】【2】【3】.
No single dressing type has proven superiority; however, silver sulfadiazine should be avoided in superficial second‑degree burns because it prolongs healing when used long‑term【1】【2】【3】.
Antiseptic dressings are appropriate for large or contaminated burns【1】【2】【3】.
Topical antibiotics are not first‑line therapy and should be reserved for infected wounds only【1】【4】.
Greasy dressings (e.g., petroleum‑based) may improve pain control【1】【2】【3】.
Choice of dressing depends on TBSA burned, local wound appearance, and the patient’s overall condition【1】【2】【3】.

When applying dressings to limbs, care must be taken to avoid a tourniquet effect【4】.
For circumferential dressings, distal perfusion should be continuously monitored【4】.
Dressings should be reassessed at least daily【4】.
Simple dressings (sterile gauze, non‑adherent interfaces) may be used in the pre‑hospital setting but must not delay resuscitation efforts【4】.

Adults with significant TBSA burns and children with ≥ 10 % TBSA burns should receive an initial crystalloid bolus of 20 mL kg⁻¹ within the first hour【5】【6】【7】.
Balanced crystalloid solutions (e.g., Ringer’s lactate) are the preferred fluid type【5】【6】【7】.
Intravenous access should be obtained as rapidly as possible, preferably in unburned skin areas【5】【6】【7】.
If rapid IV access is not feasible, intra‑osseous infusion is recommended【5】【6】【7】.

Routine prophylactic antibiotics are not indicated for burn patients; systemic antibiotics should be reserved for confirmed infected wounds【4】.

Do not use external cooling devices for prolonged periods during hospital transport, as this may cause hypothermia【4】.
Do not delay resuscitation to perform wound care; prioritize fluid management and hemodynamic stabilization【1】【2】【3】.
Analgesic medications must be carefully titrated to avoid complications such as hypovolemia, exaggerated inflammatory response, and hypermetabolism【2】【3】.