You are in: eMedicine Specialties > Dermatology > ENVIRONMENTAL Thermal BurnsArticle Last Updated: Feb 27, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School Robert L Sheridan is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons Editors: Marjan Garmyn, MD, PhD, Professor, Faculty of Medicine, Katholieke Universiteit Leuven, Belgium; Chair and Adjunct Head, Department of Dermatology, University of Leuven, Belgium; Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA; Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: burn wound infection, burn wound cellulitis, evaluation of the burn wound, evaluation of the burn patient, burn wound management, burn wound medications, burn wound management, face burns, hand burns INTRODUCTIONSection 2 of 11
  Evaluation and management of small burns is a routine part of the outpatient practice of most dermatologists; therefore, an ability to accurately evaluate and to properly care for these injuries is essential. Although outcomes for individuals with burns have dramatically improved over the past 20 years, burns still cause substantial morbidity and mortality. Proper evaluation and management, coupled with appropriate early specialty referral, are very helpful in minimizing suffering and optimizing results. Patient Education: For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education article Thermal (Heat or Fire) Burns. EVALUATION OF THE BURN PATIENTSection 3 of 11
Before management of the burn wound can begin, the burn patient must first be properly and completely evaluated. Oftentimes, this effort is brief, particularly in patients with small, uncomplicated wounds. In patients with larger burns, evaluation of the wound itself is often of secondary importance. As described by the American College of Surgeons Committee on Trauma, evaluation of the burn patient is organized into a primary survey and a secondary survey. Primary survey Burn patients should be systematically evaluated by using the methodology of the American College of Surgeons Advanced Trauma Life Support Course. This evaluation is described by the primary survey, with its emphasis on airway support, gas exchange, and circulatory stability. The airway is first evaluated; this area is of particular importance in burn patients. Early recognition of impending airway compromise, followed by prompt intubation, can be lifesaving. Appropriate vascular access is obtained, and monitoring devices are placed. A systematic trauma secondary survey is then completed, including any indicated radiographic and laboratory studies. Secondary survey Following a primary survey, burn patients should undergo a burn-specific secondary survey. This survey should include a determination of the mechanism of injury, an evaluation for the presence of inhalation injury and carbon monoxide intoxication, an examination for corneal burns, a consideration of the possibility of abuse, and a detailed assessment of the burn wound. Eliciting a detailed history upon the first evaluation and transmitting this information with the patient to the next level of care are particularly important. Inhalation injury is diagnosed by a history of a closed-space exposure and the presence of soot in the nares and the mouth. Carbon monoxide intoxication is suspected in individuals injured in structural fires, particularly if they are obtunded, knowing that carboxyhemoglobin levels can be misleading in individuals ventilated with oxygen. Individuals with facial burns should undergo a careful examination of the cornea prior to the development of lid swelling, which can compromise the examination. After evaluation of the burn wound, fluid resuscitation is begun. At this point, decisions concerning outpatient or inpatient management or transfer to a burn center are ideally made (see Image 1). EVALUATION OF THE BURN WOUNDSection 4 of 11
The burn wound itself should be carefully examined only after the patient has been fully evaluated and stable hemodynamics and gas exchange have been ensured. Burn wounds should initially be evaluated for extent, depth, and circumferential components. Decisions regarding the type of monitoring, wound care, hospitalization, or transfer are made based on this information. Extent of the burn An accurate estimate of the size of the burn is important in treatment and transfer decisions. The size or extent of the burn can be estimated in a number of ways. Perhaps, the most accurate method is the age-specific chart based on the Lund-Browder diagram that compensates for the changes in body proportions with growth. One such chart is illustrated in Image 2. The burn is drawn on a cartoon figure, and an associated age-specific table is used to calculate the body surface area involved. An alternative method in adults is to use the rule of nines. This method is less accurate in children because their body proportions are different from those of adults. For areas of irregular or nonconfluent burns, the palmar surface of the patient's hand can be used. The area of the palm represents 0.5% of the body surface over a wide range of ages. Depth of the burn Burns are routinely underestimated in depth on initial examination because estimating the depth of the burn can be difficult. Devitalized tissue may appear viable for some time after injury, and, often, some degree of progressive microvascular thrombosis is present around the periphery of the wounds. As a consequence, the appearance of the wound changes over the days following injury. Serial examination of burn wounds can be useful. The depth of the burn is classified as first, second, third, or fourth degree. First-degree burns are usually red, dry, and painful. They are often deeper than they appear, sloughing the next day. Second-degree burns are often red, wet, and very painful. Their depths vary enormously, as do their ability to heal and their propensity to form hypertrophic scars (see Image 3). Third-degree burns are generally leathery, dry, insensate, and waxy. These wounds do not heal (see Image 4). Burn blisters (see Image 5) can overlie both second- and third-degree burns. Although controversy continues over how to manage burn blisters, intact blisters greatly help with pain control. If infection occurs, these blisters should be debrided. Fourth-degree burns involve the underlying subcutaneous tissue, tendon, or bone. Even for an experienced examiner, accurately determining the depth of the burn during the early examination is commonly difficult. As a general rule, burns are usually underestimated in depth on initial examination. Circumferential or near-circumferential burn wounds should be noted because they may cause progressive extremity ischemia or they may interfere with ventilation as swelling of the burn wound increases. In such situations, timely escharotomy is essential. BURN WOUND INFECTIONSection 5 of 11
The ability to diagnose an infection of the burn wound is important. A clinically focused set of burn wound infection definitions has recently been published (see Image 6). Two burn wound infections are seen with some regularity by clinicians outside a burn center environment: burn wound cellulitis and invasive burn wound infection. Burn wound cellulitis (see Image 7) usually manifests as progressive erythema, swelling, and pain in the uninjured skin around a wound. These findings are usually seen in the first few days after burning, and they are usually caused by Streptococcus pyogenes. The infection can progress rapidly, but it is generally sensitive to penicillin. Burn wounds should be frequently inspected so that any infection is identified early. This consideration is especially important in outpatient burn care. Someone must inspect the wounds managed in the outpatient environment so that infections are promptly detected. Errors in the initial depth assessment are routine. Infections occur and must be treated in a timely manner. A wound monitoring plan is an essential part of burn care. BURN WOUND MANAGEMENTSection 6 of 11
Most burns are small and appropriately managed in an outpatient setting. Outpatient burn management can be taxing, and, when poorly managed, it causes unnecessary suffering and compromised long-term results. In some situations, outpatient management is best coordinated with the burn unit's team of doctors, nurses, and therapists because their expertise may facilitate attaining optimal outpatient results. However, most small burns are well-managed by community-based providers with burn center consultation as needed. Selection for outpatient care Several factors are relevant to a decision regarding the location of burn care. No question of airway compromise should be present. The wound must be small enough so that fluid resuscitation is unnecessary (this factor generally precludes outpatient care of burns over 10-15% of the body surface). The patient must be capable of the oral intake of an adequate amount of fluid. Generally, serious burns on the face, the ears, the hands, the genitals, or the feet should be initially managed in an inpatient setting. The patient and his or her family must be able to comply with an outpatient care plan. An adult caregiver must be present with a child managed in an outpatient setting. A family member or a visiting nurse must be available to perform necessary wound cleansing, inspection, and dressing applications because most patients cannot do this themselves. The family must have adequate transportation to return for clinic visits and unexpected emergency visits. If abuse is suspected, outpatient management is contraindicated. If on initial examination surgery is clearly needed for a full-thickness wound area, the patient should be promptly admitted for surgery. Despite all of these qualifications, most patients with small burns can be successfully managed in an outpatient setting. Outpatient wound care strategies The components of outpatient burn care include (1) patient and family teaching, (2) wound cleansing, (3) choice of topical or membrane dressing, (4) pain control, (5) early return instructions, (6) follow-up clinic visits, and (7) long-term follow-up. Wound cleansing and dressing techniques must be taught to whomever will be doing the dressing changes. Documenting this teaching is ideal. Exactly which of many medications or membranes should be placed on burn wounds is continually debated, but certain basic principles apply to all situations. The wound should be gently cleaned of debris and exudate on a regular basis. This cleaning usually requires the daily removal of accumulated exudate and topical medications. The small superficial burns managed in this setting present a low risk of infection, so clean, rather than sterile, technique is reasonable. Patients may clean the burn with lukewarm tap water and a bland soap. Soaking the dressings in lukewarm tap water may decrease the pain associated with their removal. The wound is gently cleansed with gauze or a clean washcloth, inspected for any sign of infection, patted dry with a clean towel, and redressed. Both the patient and the family should be instructed to return promptly if erythema, swelling, increased tenderness, odor, and/or drainage are noticed, so that infections can be promptly managed. The frequency of wound cleansing and dressing change is debated, but most small burns are adequately managed with a daily cleansing and dressing change. Any wound dressing, whether it is a topical medication or a wound membrane, should provide 4 benefits: (1) prevention of wound desiccation, (2) control of pain, (3) reduction of wound colonization and infection, and (4) prevention of added trauma to the wound. Most topical medications in outpatient use have a viscous carrier that prevents wound desiccation and a more or less broad antibacterial spectrum that reduces wound colonization. The addition of a gauze wrap minimizes the soiling of clothing and unburned skin and protects the wound from the external environment. A large number of excellent agents are available. Superficial facial burns are commonly treated with a clear, viscous, antibacterial ointment. Wounds around the eyes can be treated with heavy topical ophthalmic antibiotic ointments. Deep burns on the external ear should be treated with mafenide acetate because it penetrates the eschar and prevents purulent infection of the cartilage. Any wound care strategy that addresses these principles is appropriate. Control of pain in the outpatient setting can be difficult, and if pain and anxiety cannot be adequately managed at home, then hospitalization is appropriate. In most patients, an oral narcotic medication given 30-60 minutes prior to a planned dressing change provides adequate pain control. Because most dressings are occlusive, pain control in between dressing changes tends to be adequately managed in most patients without narcotics. Specific conditions that mandate an early return should be detailed. Particularly important are pain and anxiety associated with wound care to the degree that wound care is compromised, which are signs of an infection or a wound that appears deeper than appreciated at the time of the initial examination. Wound care instructions should be reviewed with caregivers. Inpatient management The plan of management of patients with large burns that require inpatient care is usually determined by the physiology of the burn injury. Management strategies for these patients are beyond the scope of this article, but they generally require a coordinated approach that involves a specialized team, fluid management, and surveillance for infection. Hospitalization is divided into 4 general phases: (1) initial evaluation and resuscitation, (2) initial wound excision and biologic closure, (3) definitive wound closure, and (4) rehabilitation and reconstruction. MEDICATIONS AND MEMBRANESSection 7 of 11
The choice of which medication or what membrane is placed on a wound is a never-ending source of discussion. Fortunately, as long as physicians carefully monitor wounds, keep them clean, prevent desiccation, and properly manage secondary infection, most medications and membranes work well. The range of available topical medications is vast, including simple petrolatum, various antibiotic-containing ointments and aqueous solutions, and debriding enzymes. A partial list of available topical medications and their characteristics is provided in Image 9. When properly used by experienced providers in a burn care program that includes wound evaluation, regular cleansing, and monitoring, they all can be effectively used. Wound membranes are different from medications and dressings because they provide transient physiologic wound closure. This effect implies that wound membranes have a degree of protection from mechanical trauma, vapor transmission characteristics similar to that of skin, and a physical barrier to bacteria. These membranes facilitate a moist wound environment with a low bacterial density. They are commonly placed on clean superficial wounds while awaiting epithelialization. These membranes are all more or less occlusive; therefore, they must be used with caution if wounds are not clearly clean and superficial. If an occlusive membrane is placed over devitalized tissue, submembrane purulence can occur, with subsequent local and systemic sepsis. A large number of such membranes are available, some of which are listed in Image 9. WOUNDS IN SPECIAL AREASSection 8 of 11
The face, the ears, the hands, the genitals, and the feet have functional and cosmetic significance that far exceeds their size and physiologic importance. The surface area involved is such that burn sepsis from these sources rarely threatens life, and a studied approach to these wounds is usually possible. Face burns Especially in adolescents and adults, the deep sweat and sebaceous glands in the central part of the face make it likely that most second-degree burns will heal well with adequate topical wound care. Many reasonable management options are available, including topical silver sulfadiazine or bland ointments. Burns around the eyes can be dressed with topical ophthalmic antibiotic ointments. If grafting is a possibility, thick donor skin with optimal color match should be reserved for facial resurfacing. The most important point in the early management of deeply burned ears is prevention of auricular chondritis. This condition is a serious complication in which the cartilage becomes infected and quickly liquefies. This complication can be minimized by twice-daily cleansing and application of topical mafenide acetate, which penetrates the eschar. Subsequent management of the ear is based on the depth of the injury. Deep corneal burns are obvious on physical examination, with the cornea appearing cloudy. More subtle injuries can be detected only with topical fluorescein application. After facial edema resolves, lid retraction may occur, with variable degrees of exposure of the globe or ectropion. When lid retraction is relatively mild, no intervention is required beyond ocular lubricants. If keratitis occurs, early lid release is advised. Amniotic membrane grafting has been used. Hand burns Hand burns assume a high priority from the onset of care. During the first 24-48 hours, adequate blood flow must be ensured. The consistency, the temperature, and the presence of pulsatile flow detectable by Doppler ultrasonography in the digital pulp should be regularly monitored. If any question exists, escharotomy or fasciotomy should be performed. The hands should be splinted in a position of function: the metatarsophalangeal joints at 70-90°, the interphalangeal joints in extension, the first web space open, and the wrist at 20° of extension. The hands should be elevated to minimize edema, and a therapist should perform range of motion exercises twice daily. Deep dermal and full-thickness burns should undergo early excision and sheet autograft closure. Hand therapy should be continued throughout the healing period, halted only in the few days immediately after grafting. If this therapy is not completed, long-term suboptimal function results (see Image10). CONCLUSIONSSection 9 of 11
Burn care is a regular, if not frequent, part of the practice of many dermatologists. If a careful initial evaluation is made, complex or larger wounds are referred for specialty care, the basic principles of management are applied, and the response to therapy is regularly monitored, most burn wounds heal with acceptable functional and cosmetic results. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
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