Outpatient management of burns – includes patient handout on burn prevention and treatment tips – Practical Therapeutics
Wayne F. Peate
The United States has the highest incidence of burns in the industrialized world. In this country, the risk of accidental death from burns is second only to the risk of death from motor vehicle accidents.’ Each year, one of every 100 Americans, or approximately 2.5 million people, seek medical attention for burns. Of these, 100,000 will be hospitalized and 12,000 will die.(2) About 440,000 children are treated each year for burn injuries. Preschoolers have the highest age-specific incidence of burns (mostly scalds from hot liquids) and account for 47 percent of deaths in residential fires.(3)
Inhalation injury can result in cardiopulmonary failure and is the leading cause of burn fatalities. 4,5 burn injuries can cause fluid, electrolyte and metabolic derangements, as well as cosmetic and functional deficits. Burn injuries are also a predisposing factor in the development of sepsis.
Most burns are minor, occur at home and can be adequately managed in an outpatient setting. Management involves accurate assessment of burn severity, control of pain, appropriate debridement and infection chemoprophylaxis. In some cases, referral for surgery is necessary. In all burns, treatment is directed at restoring function and achieving acceptable cosmetic results.
Successful outpatient management of burns may require an evaluation of the patient’s personal situation. With a child, the physician may need to determine whether the patient’s parents can be relied on to change dressings and provide other appropriate wound care. With an adult, the physician may need to find out whether the patient’s work situation can be modified to avoid wound contact with moisture. Patients in less than optimal circumstances may require close follow-up.
Types of Burn Injury
Management decisions may be based, in part, on an understanding of the type of burn injury (Table 1). For example, excessive exposure to sunlight causes superficial burns that may blister in 12 to 24 hours. Electrical injuries may initially appear superficial, with deeper tissue damage becoming apparent days later. Flash burns from the ignition of flammable materials such as propane usually cause second degree or partial-thickness burns. Scalds, the most common type of burn occurring in the home, may cause third-degree or full-thickness burns, but the redness caused by hemoglobin fixed in burned tissue may create the appearance of only a deep partial-thickness burn.
Burns can cause pathophysiologic changes in multiple organ systems, including the skin, lungs, eyes, mucous membranes, gastrointestinal tract and kidneys.
Burn damage to the protective surface of the skin results in fluid loss by evaporation. Inflammatory responses cause leakage and sequestration of extracellular fluid in the burn wound. Extracellular fluid, a serous exudate composed of plasma, leukocytes and fibrin, often forms blisters or a yellow sticky eschar in second degree burns. Beginning about 48 hours after a second-degree burn, a new network of blood vessels is created. This neovascularity is important for successful reepithelialization or grafts.
Microorganisms proliferate rapidly in the burn environment. Initially, the microflora is gram-positive, reflecting the normal skin flora, but gram-negative organisms predominate by the fifth day. Less severe burns may evolve into deeper burns due to infection-related tissue destruction.
Severe burns may cause hypertrophic scarring and flexion contracture as a result of myofibroblast proliferation and contraction.(6) Burns with devitalized dermis are particularly susceptible to this type of scarring.
Evaluation for Treatment
One of the first steps in burn management is to determine whether the patient requires hospital admission and/or surgical referral. The decision as to whether a burn can be managed on an outpatient basis is based on the answers to two questions: First, how did the burn occur? Second, what is the severity (extent and depth) of the burn?
Abusive acts are responsible for 16. 0 to 19.5 percent of burn injuries in children.(18) Clues to child abuse include the presence of more than two burn sites, a demarcated pattern of burns (e.g., stocking-glove” distribution) and burns in varying stages of healing. Examination of prior medical records and consultation with local child protective service agencies may increase the suspicion of child abuse. Social and legal considerations make it appropriate to admit patients with burns due to suspected child abuse.
Electrical burns from domestic house current (110 to 220 volts) can precipitate immediate ventricular arrhythmias. Higher-voltage burns can cause deep tissue damage that may not be detected during the initial examination. Therefore, patients with electrical burns from a current of 220 volts or greater usually require surgical referral or hospitalization for observation.
Occupational history is critical. For example, burns from exposures to low concentrations of hydrofluoric acid (the most common burns in the semiconductor industry) are initially painless; however, severe tissue necrosis may become evident several days later. Hospitalization of patients with burns from concentrated hydrofluoric acid is often required.
Burn severity is a function of how much surface area the burn wound involves and how deep the burn damage is. Total burn area can be determined by using the classic “rule of nines” originally established by Lund and Browder.(9) In adults, the percentage of surface area of most major body parts is a multiple of nine. However, surface area varies with age (Figure 1). In general, the surface area of the palm is equal to 1 percent of the patient’s total body surface area.
Burns are also classified according to depth (Figure 2 and Table 2). Determining the depth of tissue damage is often difficult, since the depth of destruction may vary within the same burn. In addition, depth of damage may be misleading. For example, blisters (a classic sign of second-degree or partial-thickness burns) can sometimes overlie small full-thickness burns.
The same thermal exposure may cause different depths of injury, depending on the body part affected. For example, a given thermal exposure may cause a first degree burn on the palm, but a more serious injury, with tendon damage, on the thinner-skinned dorsum of the hand.(10)
Sophisticated equipment, such as electronic optical scanners (which measure hemoglobin absorption), doppler devices (which measure capillary blood flow), fiberoptic perfusion fluorometers and ultrasound scanners, have been studied in the evaluation of burn depth and can be useful in determining whether skin grafting is needed.
Hospital admission is advised for adults with partial-thickness burns involving 15 percent of the total body surface area and for children with partial-thickness burns involving 10 percent of the total body surface area. Admission or surgical referral is also recommended for patients of all ages who have deep partial-thickness or full-thickness burns covering 3 percent or more of the total body surface area.(13) Several authorities are even more cautious and recommend one-day admission for patients of all ages who have partial thickness burns on 5 percent or more of the total body surface area, who have any full-thickness burns (since these burns often require early excision and grafting) or who have any of the conditions listed in Table 3.(14,15)
Admission is required for patients with circumferential full-thickness burns of the extremity, because decompressive escharotomy is often needed. (36) Excision and grafting are of ten used to prevent the scarring and contracture that may occur if deep partial-thickness burns are allowed to heal spontaneously. (17,18) Patients with infected burns should also be admitted.(19)
Burns complicated by inhalation injury are associated with substantially increased mortality rates. Such patients generally require admission. Inhalation injury occurs in 30 percent of persons with major burns and is the most frequent cause of death following burns. Even patients with minor burns may have inhalation injury and may require admission. The physician should ask about coughing, wheezing, or difficulty breathing or swallowing and should examine the patient for facial burns, hair loss, sooty mucus and laryngeal edema.
With inhalation injury, initial chest radiographs, arterial blood gas measurements and the physical examination can be helpful, but in many cases the results may be normal. Even the results of bronchoscopy may be unremarkable. Xenon lung scans can confirm the diagnosis, but if injury is suspected, high-flow oxygen should be administered, and mechanical ventilation may be required.(20)
Outpatient Treatment of Burns
Once it has been determined that outpatient treatment without surgical referral is appropriate for a burn injury, the physician can begin treatment. Basic principles of outpatient burn management are summarized by the five “C’s”: cut, cool, clean, chemoprophylaxis and cover. An algorithm for outpatient burn management is given in Figure 3.
Hot, burned or chemical-laden clothing (or chemicals still on the patient) should be removed immediately. If clothing is not easily removed, the physician should cut away nonadherent material. In such cases, surgical removal of clothing directly attached to the burn is accomplished later
Mineral oil or “orange” solvent (a mineral oil and organic solvent mixture available from dental supply houses) removes substances such as tar. Both are safer than ether and more effective than mechanic’s soap. Before use, orange solvent or mineral oil should be mixed with cool water.
Cooling decreases postburn hyperthermia and pain, and it increases impaired circulation for up to three hours after a burn injury.” To avoid iatrogenic ice injury or hypothermia, only moderately cooled (12’C [53.6’F), sterile, saline-soaked gauze should be used and, if necessary, the patient should be warmed with a blanket.(21,22)
Before a burn is cleaned, local, digital or regional anesthesia may be necessary. burns should be cleaned with standard agents such as a chlorhexidine gluconate (Hibiclens) solution or a half-strength povidone iodine (Betadine) solution. The burn area should be rinsed thoroughly. Embedded materials and chemicals are best removed by copious irrigation with a large gauge syringe or a Water-pik device.(23)
Second- and third-degree burns require debriderment of devitalized tissue with aseptic technique. Whirlpool debridement is better tolerated by patients and is often preferred to manual debridement. The yellow eschar from second-degree burns should be left in place, because removal is painful and causes bleeding.
Blisters should be removed if they are broken or if they are suspected of covering a full-thickness burn. Many experts in burn management also recommend removing intact blisters, particularly if they are cloudy or likely to break (e.g., if they are over a joint).
Evacuation of intact blisters is controversial. Some argue that blisters provide a barrier against Staphylococcus aureus.(24) However, Rockwell and Ehrlich,(25) as well as other unroofing proponents, have established that blister fluid is an effective culture medium for microorganisms, escalates the local inflammatory response, hampers leukocyte function and impairs the postburn fibrinolytic process. Needle aspiration of blisters is not an appropriate compromise since any purported protection from the blister will be lost.
Chemoprophylaxis with topical antibiotics is used for all second- and thirddegree burns until wound closure occurs. Silver sulfadiazine (SSD, Silvadene), an antibacterial cream with both gram-positive and gram-negative activity, provides reasonable wound penetration. The cream is easy and painless to apply, wash off and reapply. Silver sulfadiazine also softens tissue, thereby maintaining joint movement and facilitating eschar debridement. However, silver sulfadiazine should not be used around the eyes and mouth, in persons with hypersensitivity to sulfonamides, or in pregnant women, nursing mothers and infants less than two months of age (because of the risk of sulfonamide kernicterus).
Povidone iodine penetrates wounds better than silver sulfadiazine. However, povidone iodine is less well tolerated because it causes pain. Furthermore, iodine toughens and dries the eschar and diminishes joint mobility. Other topical agents, such as mafenide acetate (Sulfamylon) and silver nitrate solution, should not be used in the outpatient setting. Recent developments may soon affect ambulatory burn care. For example, chlorhexidine hydrochloride has been found to be effective in cases of bacterial resistance to sulfonamide antibiotics.(6) Accelerated reepithelialization of wounds may be achieved with the use of topical epidermal human growth factor, (26,27) and new synthetic skin (Biobrane or DMAC/DMSO) impregnated with antimicrobials may be particularly useful in burn therapy.(28) Systemic antibiotics should be reserved for patients with proven burn infections or for burned patients undergoing surgery. If infection is suspected, full-thickness biopsy is preferred,(20) with early excision and subsequent grafting being the treatment of choice.(6)
Covering a burn with a dressing helps keep the wound dry and protects it from microorganisms andother contaminants. A dressing can also provide proper positioning, especially for hand burns.
Patients with first-degree burns can be released after being advised to use skin lubricants and to return if blisters appear. No wound dressing is needed.
Partial-thickness burns and full-thickness burns require dressings. A sterile tongue depressor or glove can be used to cover the burn with a 2-mm layer of silver sulfadiazine. Next, an occlusive nonadherent petrolatum-impregnated dressing or another nonadherent dressing such as Telfa is then applied over the silver sulfadiazine. The area is then wrapped with gauze, and circulation is checked before the patient is released.
Burns of the hand or arm require special dressings. Each finger should be dressed individually by applying gauze in a spiral, starting with the fingertip and moving into the hand (distal to proximal). To allow metacarpophalangeal joint movement, the hand is dressed separately from the fingers. The palm should be well padded and the interphalangeal joints maintained in mild extension. Tape is used to hold the gauze in place. (10) The hand and wrist should be in the “functional position” (i.e., wrist in 30 degrees of extension, metacarpophalangeal joints in 60 degrees of flexion and interphalangeal joints in as much extension as tolerated).(23) Edema can be decreased by elevating the burned extremity above the level of the heart.
Extensive sunburn with constitutional symptoms responds to oral prednisone, 20 mg per day for three days. Topical steroids are minimally effective. Anesthetic sprays, which are sometimes used to treat sunburn pain, should be avoided because they may sensitize the skin to “caine” anesthetics.
Oral analgesics, such as acetaminophen with codeine, are usually adequate for outpatient treatment of burn pain. Occasionally, meperidine (Demerol) or other narcotics may be needed to provide pain relief. Antihistamines may control the itching that can persist for weeks during burn healing.
Since burns are prone to tetanus infection, standard recommendations for tetanus immunization should be followed. Immigrants, the very young and the elderly are the population groups at high risk for inadequate immunization against tetanus.
The physician should teach the patient and/or caregiver how to check the burn wound, how often to check it and how to avoid iatrogenic complications, such as impaired circulation due to overly tight wrapping of elastic bandages. Patients should bathe daily and should wash off the old silver sulfadiazine completely. Use of a whirlpool should be considered for patients with large burns. Silver sulfadiazine should be applied once or twice daily. At home, adult patients do not need dressings on small burns during the day, but they should apply dressings at bedtime, when leaving the house or before performing household chores.
Second-degree burns, especially those of the hand, should initially be checked daily. Less frequent checks are sometimes appropriate if the patient is reliable.
In children, the discomfort associated with dressing changes can be reduced by using bismuth-impregnated petrolatum material (Xeroform), which is left in place, checked daily and rewrapped with gauze. A disadvantage of this technique is the greater potential for infection.30,31
Patients should be advised to watch for signs or symptoms of impaired circulation from an overly tight dressing (i. e., numbness, tingling, change in skin coloration). They should also be alert to signs of problems with the underlying wound (i.e., fever, chills, swollen glands, vomiting). Patients need to avoid overly hot showers or mechanical trauma to the healing burn. They also should be informed that burned skin is sun-sensitive for up to a year.(32)
The physician should anticipate questions about scarring and pigment changes. Scarring can occur even in superficial to moderately deep partial-thickness burns and should be expected in deep partial thickness burns and full-thickness burns. As noted previously, excision and grafting often yield superior cosmetic results in deep partial-thickness and full-thickness burns.(33)
Sunburn, the most common burn, can be prevented by using sunscreens, wearing protective clothing and staying out of the sun during the hours of strongest exposure to ultraviolet-B radiation (10 a.m. to 4 p.m.). The majority of burns occur at home, and most fatal burns result from house fires that occur at night during sleep. Smoke detectors can decrease the risk of death due to house fire. Evidence indicates that the decrease in fire-related deaths in recent years is directly related to the increased installation of home smoke detectors and the improvement in emergency medical services.(34)
The author thanks Dennis Driscoll, a registered physical therapist, of Tucson Physical Therapy, for providing five years of daily guidance regarding burn therapy.
Figure 1 adapted from Lund C, Browder N. The estimate of areas of burns. Surg Gynecol Obstet 1944;79:352-8.
A patient information handout on burn prevention and management is provided on the following pages.
1. Accident facts 1983. Chicago: National Safety
2. Department of Health Education and Welfare reports of the epidemiology and surveillance of injuries. Atlanta: Centers for Disease Control, 1982;DHEW publication no. HSM 7310001.
3. McLoughlin E, McGuire A. The causes, cost, and prevention of childhood burn injuries. Am J Dis Child 1990; 144:677-83.
4. Heimbach DM, Waeckerle JF. Inhalation injuries. Ann Emerg Med 1988;17:1316-20.
5 .Harvey JS, Watkins GM, Sherman RT. Emergent burn care. South Med J 1984;77:204-14.
6. Demling RH. Burns. N Engl J Med 1985;313: 1389-98.
7. Rosenberg NM, Marino D. Frequency of suspected abuse/neglect in burn patients. Pediatr Emerg Care 1989;5:219-21.
8. Guzzetta P, Randolph J. Burns in children: 1982. Pediatr Rev 1983; 4:271-8.
9. Lund C, Browder N. The estimate of areas of burns. Surg Gynecol Obstet 1944;79:352-8.
10. Howell JW. Management of the acutely burned hand for the nonspecialized clinician. Phys Ther 1989;69:1077-90.
11. Wisnicki JL, Sato RM, Baxter CR. Current concepts in burn care. Ann Plast Surg 1986; 16:242-9.
12. Heimbach DM, Afromowitz MA, Engrav LH, Marvin JA, Perry B. Burn depth estimation man or machine. J Trauma 1984;24:373-8.
13. Joint Committee of the American Burn Association and the American College of Surgeons Committee on Trauma. Assessment and initial care of burn patients. Chicago: American College of Surgeons, 1986.
14. Amy BK McManus WF, Goodwin CW, Mason A Jr, Pruitt BA Jr. Thermal injury in the pregnant patient. Surg Gynecol Obstet 1985; 161:209-12.
15. La Ferla GA, Fyfe AH, Drainer IK. Minor burn injuries in children: inpatient versus outpatient treatment? Ann Roy Coll Surg Engl 1983;65:394-5.
16. Waymack JP, Pruitt BA Jr. Burn wound care. Adv Surg 1990;23:261-89.
17. Deitch EA. The management of burns. N Engl J Med 1990;323:1249-53.
18. Engrav LH, Heimbach DM, Reus JL, Harnar Tj, Marvin JA. Early excision and grafting vs. nonoperative treatment of burns of indeterminant depth: a randomized prospective study. J Trauma 1983;23:1001-4.
19. Pruitt BA Jr. The diagnosis and treatment of infection in the burn patient. Burns Incl Thermal Inj 1984;11:79-91.
20. Cahalane M, Demling RH. Early respiratory abnormalities from smoke inhalation. JAMA 1984;251:771-3.
21. Pushkar NS, Sandorminsky BP. Cold treatment of burns. Burns Incl Thermal Inj 1982;9: 101-10.
22. Purdue GF, Layton TR, Copeland CE. Cold injury complicating burn therapy. J Trauma 1985;25:167-8.
23. Carter PR. Common hand injuries and infections: a practical approach to early treatment. Philadelphia: W.B. Saunders Co., 1983:195-7.
24. Swain AH, Azadian BS, Wakeley Cj, Shakespeare PG. Management of blisters in minor burns. Br Med J [Clin Res] 1987;295:181.
25. Rockwell WB, Ehrlich HP. Should burn blister fluid be evacuated? J Burn Care Rehabil 1990;11:93-5.
26. Brown GL, Schultz G, Brightwell JR, et al. Epidermal growth factor enhances epithelialization. Surg Forum 1984;35:565-7.
27. Brown GL, Nanney LB, Griffen J, et al. Enhancement of wound healing by topical treatment with epidermal growth factor. N Engl J Med 1989;321:76-9.
28. Zachary L, Heggers JP, Robson MC, Leach A, Ko F, Berta M. The use of topical antimicrobials combined with Biobrane in burn wound infections. J Trauma 1982;22:833-6.
29. Cruse CK Daniels S. Minor burns: treatment using a new drug delivery system with silver sulfadiazine. South Med J 1989;82:1135-7.
30. Cockington RA. Ambulatory management of burns in children. Burns 1989; 15:271-3.
31. Schonfeld N. Outpatient management of burns in children. Pediatr Emerg Care 1990;6:249-53.
32. Heimbach D, Engrav LH, Marvin J. Minor burns: guidelines for successful outpatient management. Postgrad Med 1981;62(5):22-6,28-32.
33. Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic burn scars: analysis of variables. J Trauma 1983;23:895-8.
34. Karter Mj Jr. Fire loss in the United States during 1982. Fire J 1983; 77:44-60.
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