Introduction
Treatment of minor outpatient burns and the referral of major burns is an important
aspect of emergency medicine. The essence of successful management of burn injuries is
effective triage, timely assessment, and appropriate resuscitation.
Evaluation
Important historical information that must be obtained from a burn
patient includes the following points:
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The causative agent (thermal, electrical, chemical, radiant).
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The time and extent of exposure.
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The patients medical status (trauma, illnesses, allergies).
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The time, location (open space vs. closed space), and extent of injury sustained. Also
determine the tetanus status, alcohol and drug use, and what first aid treatment was
provided.
Defining the
Burn
Significant physical findings in burn injuries are related to depth and extent of
the burn.
First-degree burns are the equivalent of a bad sunburn and are characterized by
pain and redness. Within a few days the outer layer of injured cells peel away from the
totally healed subjacent skin with no residual scarring.
Second-degree burns are usually quite sensitive, both to touch and to exposure, are
moist with exudate, and are prone to blister formation. With proper care such wounds may
heal spontaneously, though healing may require 2 to 3 weeks.
Third-degree burns are less painful, often anesthetic, and skin is dead, white or
charred, with a dry surface. Restoration of the integrity of the skin can be accomplished
only by grafting skin from non-burned areas of the body.
Extent and size of burns are easily determine by the rule of 9's, using charts
available or by comparison with the patient's palmar surface area, which represents
roughly 1 percent of the total body surface.
Outpatient vs. Inpatient Treatment
The important differential diagnosis in burn injuries is burn severity and extent
which determines whether the burn patient can be treated as an outpatient, or requires
admission to a general hospital or a burn unit. Most deep second and almost all third
degree burns should be admitted. This is especially true if the burn; involves a smoke
inhalation (respiratory injury), involves more than 20 percent skin surface, or involves
critical anatomical areas such as hands, face, feet, genitalia, perineum, and major
joints. Electrical and chemical burns regardless of size are deceptive in depth and nearly
always require hospitalization.
Smaller burns which appear to be partial thickness in depth may be treated as an
outpatient provided the patient can obtain frequent follow-up examination, his or her
dressing changes and medications are appropriately monitored, and the symptoms and
findings are not deteriorating under treatment.
Management
All major burns (greater then 20 percent full or partial thickness) require
appropriate advanced trauma life support (ATLS) protocol with emphasis on airway and fluid
resuscitation and transfer to a burn center. The more common smaller partial thickness
burns may be treated as outpatient after thorough washing with surgical soap (Hibiclens or pHisoHex) and
application of a sterile non-adherent dressing such as Xeroform or Adaptic gauze covered
by a sterile bandage. Further management requires protection from the environment with
application clean dressing and bandages, daily, or twice daily along with cleaning with a
mild soap until the burn has healed. Topical antimicrobials (i.e., Silvadene)
or systemic antibiotics should not
be applied to these burns unless there are specific indication for these drugs (i.e.,
signs of infection). Blisters or bullae that are small and intact need not be opened or
removed unless they impede pint motion or show signs of infection. Superficial small size
burns about the face can be treated open (without dressing) by daily cleaning and
application of Bacitracin ointment.
Tetanus prophylaxis
and analgesics should be used as
indicated.
When to refer
Should during the outpatient treatment of smaller burns, the wounds show signs of
infection or the burn fails to heal within 2 weeks, the patient should be referred for
hospitalization and more extensive treatment. Patients with major burns that meet the
American Burn Association (ABA) criteria for burn center referral should be assessed,
stabilized, and immediately transferred to a burn center. This requires
physician-to-physician contact to assure the patient's needs are met throughout every
aspect of the transfer. In the military system, burn center referral can be obtained
through the Army Institute of Surgical Research (Brook Army Medical Center Burn Unit); by
telephone request 24 hours per day to the duty physician (512)-221-2943, DSN: 471-2943, or
(512) 222-2876.
References
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Advances in Burn Care, Clinic in Plastic Surgery, 1986,13:1, W. B. Saunders
Am. Burn Life Support Provider's Manual, 1990, Nebraska Burn Institute, Artz, Moncrief
and Pruit, 1979.
Burn, A Team Approach, W. B. Saunders, William F. McManus, M.D., Colonel, MC, USA,
Personal Communication Wiener and Barrett, 1986, Trauma Management, chapter 5, W. B.
Saunders
Originally written by CAPT Robert F. Brewer, MC, USN, Department of Plastic
Surgery, Naval Medical Center Portsmouth. Reviewed by CAPT Patrick W. Lappert, MC, USN,
Head, Department of Plastic Surgery, Naval Medical Center Portsmouth, VA (1999).
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