Burns are optimally treated upon thorough assessment. Assessment entails evaluating cause, depth, area, complications, and associated medical conditions. With complete assessment, burn victims will be treated effectively. Causes of burns can be thermal, electrical, chemical, or radiation. Depth of burns can be first degree, second degree, third degree, or fourth degree. Complications can include topical and systemic infections, skin necrosis, pain, scarring, immobility, and psychological disability such depression and anxiety.
Multiple burn etiologies or causes are possible. Thermal burns result from direct external heat contact such as hot liquid, fire, or heating pad. Electrical burns result from electrical currents that can cause small but deep injuries or even great amount of damage. Chemical burns result from acid or alkali base contact. Radiation burns result from nuclear exposure. The most common cause is thermal type.
Depending on the severity and type of exposure, the burn depth and area can alter. For example, first, second, third, or fourth degree burns exist. A first degree burn results in no blisters affecting only the epidermis classified as superficial and healing after 3-5 days. Second degree burns involve either upper or deeper dermal layers, range from painful to non painful experiences, and about 2-3 week heal time. Third degree burns require surgical intervention for healing, with full thickness or entire dermis and lack of pain. Fourth degree burns require surgical invention, lack blisters or pain, appear charred black involving entire dermis, fat, muscle, and bone.
Just as extensive as depth can be, so can the affected area. Area is classified as body surface area involved. Various methods exist for determining surface area. The simplest method is the palmar method. It is best used for small surface area burns as compared to medium to large size burns. Typically, small burns are classified as < 15% of body area and large burns are > 85% of body area. The Wallace rule of nines is a surface area burn assessment tool only in adults dividing the body into 9% areas. It is most useful for medium-large burns. Lund and Browder chart estimates total body surface area burn percentage in adults and children. BurnMed is more accurate and convenient as compared to other methods discussed and thus is used frequently, especially in healthcare setting.
Healthcare professionals manage burns with non-pharmacological and pharmacological agents and procedures. Considerations for burn management include immediate needs, burn cooling, burn covering, pain management, immunizations, outpatient management, cleansing and debridement, dressing types, dressing selections, infection control, itching, scarring, depression, and burn prevention.
Immediately, burn cooling, covering, pain control, and immunizations are necessary. Upon the burn, jewelry and clothing should be removed. The burn can be cooled by using cool running water or equal parts of non-refrigerated and refrigerated saline. Covering the burn assists in preventing infections, drying out, and body temperature maintenance. Pain is controlled with acetaminophen, ibuprofen, and opoids depending on severity. Immunizations entail tetanus and tetanus immunoglobulin based on frequency.
Once inpatient burns are managed, outpatient treatments begin. This involves infection and pain management as well as dressing selections and cleansing needs. Cleansing is completed with warm soapy water. Blisters are to remain intact and often covered. In covering, adequate dressing is necessary, depending on wound discharge and type. For example, there are nonadherent, dry gauze, hydrocolloid, polyurethane, hydrogels, silicano-coated. Non-adherent dressings are Telfa and Xeroform used as primary dressings. Dry gauze is secondary dressing for oozing wounds or burns. Hydrocolloid is Duoderm and used as a primary dressing for moderate oozing wounds or burns. Polyurethane films are Tegaderm used as a primary dressing for mildly oozing wounds or burns. Hydrogels are Nu-Gel, INtrasite, Solugel and used for severly oozing wounds or burns. Alginate, hydrofiber, or anti-microbial for infected and severely oozing burns.
Selecting the dressings depend on a variety of burn characterisitics. For example, burn depth and location play a significant role in dressing usage. Superficial burns are typically not covered as anti-biotics are not necessary and topical pain agents may precipitate irritation. Partial-thickness burns often result in drainage or exudate (oozing), requiring absorbent dressings such as hydrocolloids. Depending on the exudate amount, either polyurethane for lower drainage or hydrofiber for moderate to high amounts are used. In conditions of sloughing skin, hydrogels or hydrocolloids are useful. Burns of the face, head, and neck are challenging to cover and thus dressings are not used.
Despite burn coverage, pain and infection management are essential. Severity of burns result in various pain relievers such as acetaminophen, ibuprofen, and opoids. The deeper burns are less painful then superficial due to lack of nerve ending involvement. Infections are treated best within 48 hour assessment of drainage color, amount, and consistency along with systemic signs and symptoms of redness, swelling, and fever, resulting in either topical or by mouth anti-biotics with coverage of gram + early and gram – late.
Once the acute management is resolved, other considerations such as skin care, scaring, and psychological issues are addressed. Itching is common in 80-100% of burn victims. It represents healing. Oatmeal baths, compression stockings, cetirizine, loratidine, diphenhydramine, hydroxyzine ,etc. are used to treat the itching and promote healing. Scaring is a common complication to burns. Initially, the scar appears red, inflamed, and raised. However, after 4-6 weeks, depending on severity, the scar is flat, uncolored. Depression results from scaring often or loss of function. The statistic is 23% of burn victims have depression. These complications are treated with common aloe vera, onion extract or Mederma, selective serotonin reuptake inhibitors and/or tri-cyclic anti-depressants.
Treatment can be avoided if preventative burn techniques are practiced. For example, fire safety, patient education, and sunburn prevention. Smoke alarms in each room with monthly checks. Sunburn lotions of 30 SPF with application every 2-3 hours. These measures can delay or prevent burns.
In conclusion, burns are unique. They differ in cause, extent, and depth. Depending on these characteristics determines the skin care and treatment procedures. Providing optimal care reduces complications such as scars, itching, and psychological conditions. Refer to healthcare professional with any questions, concerns, or suggestions.
Pharm D, BCPS, BCACP, CDE, MSMTM