• Size, depth, and location of burn
• Patient’s age, comorbidities, and functional state
• Concern for abuse or neglect
• Home support including assistance in wound care and transportation
Burn Center referral criteria
Burn injuries that should be referred to a burn center include: |
1. Partial thickness burns greater than 10% total body surface area (TBSA) |
2. Burns that involve face, hands, feet, genitalia, perineum, or major joints |
3. Third-degree burns in any age group |
4. Electrical burns, including lightning injury |
5. Chemical burns |
6. Inhalation injury |
7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality |
8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols |
9. Burned children in hospitals without qualified personnel or equipment for the care of children |
10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention |
Comorbidities including cardiac disease, COPD, chronic kidney disease, dementia or psychological impairment, diabetes mellitus, and/or infirmity may complicate initial outpatient care. It may be necessary to admit these patients initially until a more in-depth assessment of their overall medical condition and home support system can be completed. Nevertheless, if the medical conditions are controlled and the patients’ home support is acceptable or can be arranged, patients with comorbidities are excellent candidates for outpatient management.
Children are excellent candidates for outpatient care. One must ascertain the comfort of the family with outpatient care. The majority of parents clearly prefer outpatient care due to the decrease in family disruption. The child also often has less psychological stress in the home environment. However, dressing changes in children may require multiple caregivers, and the injured child who cannot return for dressing care may require admission.
Nonthermal injuries can also be treated on an outpatient basis. Low voltage household current (110–220 V) electrical injuries usually result in minor tissue damage. However, they may be associated with a syncopal event due to a concurrent dysrhythmia. Patients without syncope and with normal screening EKG may be treated as an outpatient without concern for subsequent cardiac complication. Patients with high voltage injuries (<1000 V), syncope, or EKG changes should be admitted for serial exams and telemetry.
Chemical burns involving less than 15% total body surface area may also be treated on an outpatient basis depending on the depth and location of the burn. Ocular involvement must be ruled out with an appropriate history and examination. Following appropriate lavage of the wound, an outpatient dressing may be applied. However, conversion to a deeper depth is common and patients selected for outpatient therapy must be able to return within 24–48 h for a repeat examination. Patients exposed to toxic chemicals such as hydrofluoric or chromic acid require admission.
Review of the patient’s social situation is an essential component of the evaluation for outpatient care. Children and geriatric patients must have a safe home environment. There can be no suspicion of abuse or psychological conditions impairing the patient’s safety. Family or friends must be available to support the patient who often has impairments in mobility and use of his limbs following a burn injury. Finally, there must be transportation available for return clinic visits. It is often necessary to admit a patient for a short period of time while the social support system is evaluated.
33.2.1 Initial Wound Management
The recommended immediate treatment of minor thermal burns is cool running water. Avoid the use of ice or ice water [4]. Cleaning the wound with a mild antibacterial soap and water is recommended. Careful debridement of ruptured blisters and other devitalized tissue should be performed. The patient’s tetanus vaccination status must be assessed and tetanus toxoid administered if appropriate.
The management of intact blisters is controversial [5]. Blisters arise usually in the setting of superficial partial thickness injury by leakage of fluid from heat injured vessels deep in the zone of coagulation. Release of plasma protein and skin degradation products into the blister osmotically draws yet more fluid causing enlargement of a blister over a period of time.
Acceptable practices for managing blisters include leaving them intact, aspirating blister fluid and leaving the devitalized epidermis intact or unroofing the devitalized epidermis [6]. Clinicians who believe that the blisters should remain intact state that the blister indicates a superficial burn that will spontaneously heal in a few weeks. The intact blister creates its own biologic dressing, thereby keeping the wound clean, moist, and protected. The wound is protected from air making it less painful. Leaving burned blisters intact also reduces bacteria colonization of the wound. Burn blister fluid may stimulate the wound healing process since it contains multiple growth factors.
The case for debriding blisters is supported by studies that demonstrate that blister fluid depresses immune function by impairing neutrophil function. Inflammation is enhanced by the presence of metabolites of arachidonic acid in the blister fluid. Blister fluid may also provide a culture medium growth of any bacteria that enters that space.
The majority of evidence supports leaving blisters intact. Large blisters with thin walls should be debrided as they will likely rupture on their own, and it is beneficial from an infection standpoint to apply a dressing directly to the wound bed. Thicker blisters that interfere with proper range of motion of a joint should be aspirated leaving the blistered skin to protect to cover the wound. If the blister remains intact and the wound is a superficial partial thickness burn, spontaneous re-absorption of the fluid will begin within 1 week.
Intermediate and deep second degree burns may convert to full-thickness injury over 24–48 h. The outpatient management of these deeper partial thickness burns require repeat evaluation at 48–72 h. Patients unable to return within that time period may require admission.
33.2.2 Topical Burn Care and Dressings
Commonly used topical agents for burn wounds
Agent | Description | Action | Advantages | Disadvantages |
|---|---|---|---|---|
Silver sulfadiazine (SSD) | Nontoxic salt of silver sulfadiazine in water-based cream | Binds to bacterial cell membranes and interferes with DNA synthesis | Painless Wide-spectrum antimicrobial action against gram-positive and gram-negative organisms Long shelf life Delays eschar separation to a lesser degree than do many other topical drugs Used for deep partial and full-thickness wounds | Delays healing Stains tissue Contraindicated in sulfa allergy, pregnant women, newborns, and nursing mothers |
Mafenide acetate (Sulfamylon) | Soft white, non-staining cream, water-based topical cream | Bacteriostatic action against many gram-negative and gram-positive organisms | Effective against pseudomonas Penetrates thick eschar Used for deep burns and exposed cartilage | Can be painful on application May delay healing or cause metabolic acidosis |
Bacitracin | Topical cream | Narrow antimicrobial coverage | Inexpensive Painless Can be used on face or near mucous membranes | Requires frequent dressing changes May cause urticaria, burning Does not penetrate eschar |
Mupirocin (Bactroban) | Topical antibacterial cream | Bacteriostatic at low concentrations and bactericidal at high concentrations | Good gram-positive antimicrobial coverage Painless Can be used on face Active against most strains of methicillin-resistant S. aureus | Expensive Requires frequent dressing changes |
Hydrocolloid (Duoderm) | Hydrophilic absorptive Dressing | Has a triple hydrocolloid matrix with a viral and bacterial barrier Forms a hydrophilic gel which facilitates autolytic debridement | Less pain Shorter time to wound closure than SSD Decrease dressing change and pain Inexpensive Keep underlying tissue moist | Cannot be used with large exuding wounds |
Impregnated nonadherent gauze (Xeroform, Vaseline gauze, Adaptic) | Semi-occlusive Nonabsorptive dressing | Provides a nonadherent barrier over the burn Used for partial thickness burns Maintains a moist environment deodorizing agent Clings and conforms to all body contours | No antimicrobial activity | |
Silicone (Mepitel) | Nonabsorptive dressing | Conforms to shape of wound and allows for drainage of exudate to secondary bandage | Expensive Painless Decrease dressing changes Highly transparent May be left in place for 14 days Protect skin from additional trauma | No antimicrobial activity Expensive |
Silver-impregnated dressing | ||||
Aquacel Ag | Nylon, silver-impregnated, antimicrobial, absorbent dressing | The silver in the dressing kills wound bacteria | Broad-spectrum antimicrobial coverage decreases dressing changes Reduces pain Decreases use of pain medications Faster wound closure than with standard therapies Decrease total cost compared with SSD | Aquacel Ag is not compatible with oil-based products, such as petrolatum |
Mepilex Ag | Absorptive silicone dressing | Antimicrobial foam dressing that absorbs exudate and maintains a moist wound environment | Decrease pain Effects up to 7 days Nonadhering to the moist wound bed Easy application | Do not use during MRI Do not use with hypochloride solutions or hydrogen peroxide Expensive |
Acticoat | Nonabsorptive dressing | Delivers low concentrations of silver when moisten with sterile water | Broad-spectrum antimicrobial coverage Nonadherent Reduces pain Decreases dressing changes | Expensive May dry out and adhere to wound Do not use with oil-based products |
Collagenase (Santyl) | Enzymatic debriding ointment | Removes nonliving tissue without harming granulation tissue May be used with barrier dressing | Do not use dressings containing silver (Ag) or iodine (I 2 ) No antimicrobial activity |
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