Burn Management


• 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





Table 33.2

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



Excerpted from Guidelines for the Operation of Burn Centers (pp. 79–86), Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons



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


The goal of topical burn care and dressings are to minimize pain, decrease the risk of infection, promote wound healing, minimize cosmetic deformity, and preserve function. Burn wounds heal best in a moist but not wet environment that promotes epithelialization and prevents cellular dehydration. This can best be accomplished by applying either a topical agent or an occlusive dressing to minimize fluid loss. There are a large number of excellent agents available, and all of them can be effectively employed when properly used by an experienced burn care provider (Table 33.3).


Table 33.3

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


Digests collagen in necrotic tissue


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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Nov 4, 2020 | Posted by in Aesthetic plastic surgery | Comments Off on Burn Management
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