Burn Management

Aka: Burn Management

1. See Also
   1. Burn Evaluation
2. Management: Home interventions for patients prior to presentation
   1. Do not break Blisters
   2. Do not apply any topical medications to burn site prior to evaluation
   3. Immediately remove any items that may cause further injury
   4. Consider placing the wound site under cool Running water for 20 minutes (minor Burn Injury only)
      1. May reduce Burn Injury depth and allow for faster healing with less scar
      2. Benefits may be limited to the following one hour
   5. Do not immerse the burn in ice water
      1. Risks further injury and Hypothermia
3. Management: General Pointers
   1. Use Narcotics intravenously (avoid intramuscular use)
      1. Administer adequate analgesia to allow for assessment, cleaning and dressing of wounds
   2. Avoid antibiotics until infection occurs
   3. Do not cover burns with Silvadene if transporting
      1. Obscures lesions for primary burn team
      2. Burn team will apply Silvadene after their evaluation
   4. Administer tetanus vaccination
4. Management: Initial
   1. Trauma Primary Survey
      1. Assess airway Inhalation injury
         1. Assess airway edema (intubate if suspect unstable airway)
         2. Arterial Blood Gas (ABG)
         3. Carboxyhemoglobin
            1. Dive Chamber indicated for level >40
      2. Cover injured areas after evaluation to prevent overall body heat loss
   2. Trauma Secondary Survey
      1. Assign Burn Injury grading and surface area involved
      2. Assess other injuries
      3. Evaluate for signs of intentional injury (e.g. abuse)
   3. Assess Fluid status
      1. Urine Output minimums
         1. Adult: 30-50 cc per hour
         2. Child: 1 cc/kg per hour
      2. Intravenous requirements for insensible loss
         1. Administer 2-4 ml Ringers Lactate per kg per %BSA
         2. Divide rehydration over 24 hours
            1. Give 50% over first 8 hours since burn
            2. Give second 50% over next 16 hours
5. Management: Wound Care
   1. Avoid scrubbing the wound with antiseptics (e.g. Betadine, Peridex, Hibiclens)
   2. Use sterile water to clean the wound and eliminate debris
   3. Blisters
      1. Small Blisters (<6 mm) should be left intact
      2. Debride roofs of large Blisters with thin walls
         1. Allows dressings to be applied to wound directly
      3. Debride roofs of Blisters overlying joints
         1. Allows for normal joint movement
6. Management: Topical agents
   1. Goal is to maintain moist healing environment and prevent infection
   2. Avoid Topical Corticosteroids
   3. Topicals for superficial burns (first degree)
      1. Aquaphor
      2. Bacitracin ointment
      3. Honey
      4. Aloe vera (may reduce pain)
      5. Topical NSAID (e.g. Diclofenac Gel, may reduce pain)
   4. Topicals for partial thickness burns
      1. Topical Antibiotics
         1. Bacitracin
         2. Bactroban
         3. Mafenide acetate (Sulfamylon)
            1. Used for deep burns even if eschar present
         4. Silvadene (SSD)
            1. Contraindicated in sulfa allergy, G6PD, pregnancy and Lactation and newborns
            2. New Occlusive Dressings may offer faster healing, less pain and lower cost (e.g. Aquacel Ag)
      2. Absorptive Dressings
         1. Aquacel Ag
            1. Less pain and healing time as well as less frequent dressing changes
            2. Lower total cost than Silvadene
            3. Broad spectrum antibacterial coverage
         2. Hydrocolloid Dressings (Duoderm, urgotul)
            1. Less pain and healing time, but this dressing has an odor and obscures visualization of the wound site
      3. Nonabsorptive dressings
         1. Nonadherent gauze (e.g. Vaseline Gauze)
            1. Inexpensive dressing used for superficial burns; lacks antibacterial coverage
         2. Silicone (Mepitel)
            1. Expensive dressing that allows wound seepage to pass through to overlying bandage
         3. Silver Impregnated dressing (e.g. Acticoat)
            1. Expensive non-adherent dressing that has broad spectrum antibacterial coverage
      4. Miscellaneous dressings
         1. Biocomposite (e.g. Biobrane)
            1. Efficacy limited to superficial burns and is expensive
         2. Bioactive skin substitute (e.g. Trancyte)
            1. Expensive, but less pain and healing time and allows visualization of burn through the dressing
7. Management: Infection
   1. Causes
      1. Staphylococcus aureus
      2. Streptococcus Pyogenes
      3. Pseudomonas aeruginosa
      4. Acinetobacter species
      5. Klebsiella species
   2. Precautions
      1. Signs of Iinfection may be difficult to distinguish from the original burn inflammation
      2. Infections at burn sites may progress rapidly
   3. Management
      1. Direct antibiotics coverage to Gram Negatives and Gram Positives based on local Antibiotic Resistance
8. Management: Criteria for transfer or referral to burn center
   1. Partial thickness burns involving more than 10% of total body surface area
      1. Immediate transfer if partial thickness burn involving 20% BSA (10% if age under 10 or over 50 years old)
   2. Third degree (full thickness) burns
      1. Immediate transfer if third degree burn >5% of total body surface area
   3. Any burns of high risk areas
      1. Face, eyes or ears
      2. Hands or Feet
      3. Genitals or perineum
   4. Electrical Burns
   5. Inhalation injury
   6. Chemical burns
   7. Burn Injury with associated trauma (e.g. Fractures)
9. Management: Burn-related symptoms
   1. Pruritus
      1. Cetirizine (Zyrtec)
      2. Doxepin topically
   2. Pain
      1. Narcotic Analgesics
      2. Gabapentin (Neurontin) or Pregabalin (Lyrica)
10. References
    1. Cuttle (2009) Burns 35(6): 768-75
    2. Grunwald (2008) Plast Reconstr Surg 121(5): 311e-9e
    3. Hettiaratchy (2004) BMJ 328(7452): 1366-8
    4. Lloyd (2012) Am Fam Physician 85(1): 25-32
    5. Roberts (2003) Emerg Med News 25(3): 28-31
    6. Sheridan (2005) Emerg Care 21(7): 449-56