Ambulatory Management of Burns
Minor burns comprise approximately 95 percent of burn injuries treated by physicians. Most of these burns can be managed on an outpatient basis. An algorithm to assist in identifying patients suitable for ambulatory management is provided in Figure. Management of Burns
A systematic approach to the ambulatory management of burns is conceptualized by the six "Cs": clothing, cooling, cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief). Clothing. Any clothing that is hot or burned should be removed immediately from the patient’s body. Clothing that has been exposed to chemicals should also be removed to avoid exposing the skin to continued burn insult. If clothing does not remove easily, nonadherent material should be cut away, with adherent clothing left for removal in the cleaning phase. Cooling. Ideally, burns should be cooled immediately after they occur. Although most tissue has already cooled by the time patients with burns present to a physician, further cooling during the first several hours after injury effectively decreases burn pain. Sterile saline-soaked gauze, moderately cooled to around 12°C (53.6°F), can be applied to the burned tissues. Ice application should be avoided. Because of the risk of hyperthermia, caution should be exercised in cooling extensive burns (i.e., those with a TBSA of more than 10 percent). ¾ Ruptured blisters from a burn may be unroofed, but intact blisters should not be needle aspirated because of the increased risk of infection.
Cleaning. Cleaning a burn wound is critical but can cause excruciating pain. It is therefore important to establish local or regional anesthesia before the wound is cleaned. Anesthesia should not be applied topically to a burn or injected directly into the wound. Although disinfectants (e.g., chlorhexidine gluconate solution, povidone-iodine solution are often employed to clean burn wounds, their use is discouraged because these agents can actually inhibit the healing process. There is growing support for washing burns with mild soap and tap water. Once a burn wound has been cleaned, it should be thoroughly rinsed. Tar residues should never be debrided; instead, they can be removed with a mixture of cool water and mineral oil. Applying copious amounts of polymyxin; bacitracin zinc ointment (Polysporin) over several days should emulsify and remove residual tar. Embedded bits of clothing or other materials should be removed by copious irrigation using a large-gauge syringe. To minimize infection, necrotic tissue from partial- and full-thickness burns should be removed manually or with whirlpool debridement. The latter method tends to be better tolerated by patients. The yellow eschar characteristic of partial-thickness burns need not be removed. Ruptured blisters should be removed. Many experts recommend unroofing blisters if they contain cloudy fluid or are likely to rupture imminently (e.g., blisters located over joints). The management of clean, intact blisters is controversial. Intact blisters should never be aspirated with a needle because of the increased risk of infection. The persistence of blisters for several weeks, with no signs of resorption, typically indicates the presence of an underlying deep partial- or full-thickness burn. Chemoprophylaxis. Tetanus immunization should be updated in patients with wounds deeper than a superficial partial-thickness burn. Diagnosing infection in patients with burns is challenging. Burns elicit inflammation, which results in mild erythema, edema, pain and tenderness. If these signs occur in conjunction with lymphangitis, fever, malaise and anorexia, or if they increase over a baseline level, infection should be suspected. Infection can involve the depth and extent of a burn, converting a superficial partial-thickness burn into a deep partial-thickness burn or even a full-thickness burn. An infected burn is also more susceptible to blood invasion and sepsis. Because of these risks, all suspected burn infections warrant aggressive management, including hospital admission and parenteral antibiotic therapy. Some authors contend that all infected burns require surgical referral with consideration of full-thickness skin biopsy to confirm the presence of infection and identify the causative organism. Full-thickness skin grafting after excision should also be considered.
Superficial burns do not require infection prophylaxis, but all other burns should receive topical prophylaxis. Classically, silver sulfadiazine cream is used to prevent burn infections. This agent should never be used on the face or in patients with sulfonamide hypersensitivity. Because of the risk of sulfonamide kernicterus, silver sulfadiazine should not be used in pregnant women, newborns or nursing mothers with infants younger than two months of age.
Bacitracin is an alternative topical prophylactic antibiotic. This agent should always be used around mucous membranes.
Alternatives to topical antibiotics include biologic dressings (pigskin, human allograft) and bismuth-impregnated petroleum gauze or Biobrane dressings. The advantage of these dressings is that they are applied only once. As a result, patients are spared the pain that typically accompanies dressing changes. Biologic dressings are associated with lower infection rates and faster healing rates than silver sulfadiazine. However, these dressings are expensive, difficult to apply and not always readily available. If used, biologic dressings should be applied within the first six hours after the burn is sustained. The initial application may loosen by the following day, necessitating reapplication. Thereafter, these dressings gradually peel off as skin epithelializes underneath them. Early separation of the dressing from the skin indicates the presence of a deeper wound (requiring surgical treatment) or an infection. Bismuth-impregnated petroleum gauze and Biobrane dressings appear to be advantageous treatments and are acceptable for use in young children with superficial partial-thickness burns. Both of these dressings are applied as a single layer over the burn and are then covered with a bulky dressing. The bulky dressing should be changed every other day, typically in a physician’s office, with close assessment of the wound for signs of infection. Covering. Dogmatic recommendations regarding the type and duration of dressing cannot be made because of the paucity of studies on the subject. Covering burns serves a number of purposes. Dressings provide anesthetic relief, act as a barrier against infection and keep the wound dry by absorbing drainage. The types of coverings differ, depending on the depth of a burn and its location. Superficial burns do not require wound dressings. Use of a simple skin lubricant (e.g., aloe vera cream) is sufficient, and patients should be instructed to see their physician if any blisters develop. All partial- and full-thickness burns should be covered with sterile dressings. A fine mesh gauze should be applied after the burn has been cleaned and a thin layer of topical antibiotic has been applied. Circulatory impairment is minimized by applying this nonadherent dressing in successive strips, rather than wrapping it around the wound. The dressing is held in place with a tubular net bandage or lightly applied gauze wraps. Tubular net bandages come in a variety of sizes. This bandage is excellent for use on extremities, and it can be modified to fit the trunk of a younger child. Recommended frequencies for dressing changes range from twice daily to once a week. Dressings should be changed whenever they become soaked with excessive exudate or other fluids. At each dressing change, the topical antibiotic should be removed as completely as possible using gentle washings. Scrubbing and sharp debridement are not necessary. Comforting. Analgesics should be given around the clock to control "background" pain. Acetaminophen and nonsteroidal anti-inflammatory drugs (alone or in combination with opioids) are often appropriate for use in patients with small burn wounds. Aspirin products should be avoided because of platelet inhibition and the risk for bleeding. Patients with burns often require a "rescue" medication (e.g., acetaminophen with codeine or a stronger narcotic ) before dressing changes and during increased physical activity. Narcotic medications can be used in children as well as adults.