Are You Confident of the Diagnosis?

What you should be alert for in the history

The history of a thermal burn is usually quite clear and does not require further laboratroy or radiologic studies for diagnosis. However, in regards to patients that are unable to provide a detailed history, whether due to altered mental status, cognitive disability, language barrier or other reason, special care should be taken to obtain a history through ancillary sources and a thorough physical examination should be performed. Thermal burns may be the first clue of physical abuse in pediatric, geriatric and handicapped populations. Other diagnoses to consider in special populations include occupational exposures and chemical/ radiologic warfare.

Characteristic findings on physical examination

Typical examination findings vary greatly in regard to the location, depth and surface area involved (Figure 1). First-degree burns are commonly caused by UV radiation (ie, sunbathing) or minor flash burns and are typically seen in combination with second- and third-degree burns. They involve only the epidermis and are typically described as pink, painful, soft and dry or with small blisters and heal within 2 to 3 days .

Figure 1.

Note the linearity of a grease burn, indicative of first- and focal second-degree burn.

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Second-degree burns are partial thickness burns that extend through the epidermis and into the dermis. Hot liquids and flashes of flame commonly cause superficial second-degree burns. They are described as pink to red in color and painful with variably sized ruptured bullae and edematous skin with a copious exudate with healing times of 5 to 21 days. Deep second-degree burns are associated with longer contact times and higher temperatures than more superficial burns. They are described as dark red to mottled yellow-white in color with smaller bullae, moist edematous skin and decreased sensation to pinprick and heal in 3 to 6 weeks.

Third-degree burns are full thickness burns that extend through the epidermis and dermis and as such are typically not painful. They are associated with flame injuries and immersion in hot water. They are described as pearly white or charred in color, anesthetic, dry, inelastic and leathery and further require skin grafting for healing.

Who is at Risk for Developing this Disease?

National study of emergency department visits for burn injuries (1993-2004):

-59% male, 41% female

-Ethnicity: 77% Caucasian, 20% African-American, 3% other

-22% occurred ages 20 to 29 years, 12% ages less than 10 years

American Burn Association’s National Burn Repository; 2010 Report. Acute Burn Admissions 2008-9:

-70% male; 30% female

-Ethnicity: 63% Caucasian, 17% African-American, 14% Hispanic, 6% other

-Mean age, 32

-Children less than 5 years old, 17%; most common are scald injuries

-Adults greater than 60 years old, 12%

-66% of burns occurred at home

-66% of burns were non-work-related accidents

What is the Cause of the Disease?

National study of emergency department visits for burn injuries (1993-2004):

-48% partial thickness, 29% unspecified, 15% superficial, 7% full thickness

-23% work related, 59% non-work related, 19% unspecified

-37% upper extremity, 20% unspecified, 16% head and neck, 14% lower extremity, 9% multiple sites, 4% trunk

American Burn Association’s National Burn Repository 2010 Report. Acute Burn Admissions 2008-9:

-Fire/flame, 42%

-Scald, 31%

-Contact with hot object, 9%

-Electrical, 4%

-Chemical, 3%

Systemic Implications and Complications

Systemic implications and complication associated with thermal injuries can be thought of either as those that require immediate attention with a high likelihood of hospitalization while others are delayed and are commonly evaluated and managed in an outpatient setting.

Inpatient complications

-Infection/ Shock/ Sepsis/ Pain/ Death: specialty inpatient hospitalization/ treatment. Many infections are possible, but pseudomonas can be seen as particularly problematic.

-Inhalational injury: airway intubation

-Circumferential burns/ compartment syndrome: General Surgery consult for liberal fasciotomies

Outpatient complications

-Psychological complaints: referral to mental health

-Anhidrosis: negative sweat (NaCl) test and lack of sweat glands confirmed by punch biopsy of the skin; referral to burn specialist for counseling and possible laser therapy

-Pruritus: no specific workup; management detailed below

-Poor cosmetic outcome/ hypertrophic scar/ keloid formation (rare)/ joint contracture (late complication): referral to burn specialist

-Heterotopic ossification: consider computed tomography (CT) scan vs bone scan to diagnosis, referral to bone specialist

-Marjolin’s ulcer: high index of suspicion for non-healing ulcer diagnosed by biopsy and/ or referral to dermatology

Treatment Options

Every burn and every subsequent scar is as unique as we are as a population. However, before focused burn care takes place, a decision should be made as to whether the patient will be treated as an inpatient or outpatient as this will guide much of the treatment. Characteristics of thermal burns requiring inpatient care services are described below. If any of the criteria below are met, prompt referral to a specialized burn center is ideal. If one is not available, consultation with any number of inpatient medical and surgical specialties may be required.

Inpatient (burn center) referral guidelines

– Burns that involve the face, hands, feet, genitalia, perineum, or major joints

– Third-degree burns in any age group

– Inhalational injury

– Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality

– Any patients with burns and concomitant trauma (eg, 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’s condition may be stabilized initially in a trauma center before transfer to a burn center. Physician judgement will be necessary in such a situation and should be in concert with the regional medical control plan and triage protocols.

– Burned children in a hospital without qualified personnel or equipment for the care of children

– Burn injury in patients who will require special social, emotional or rehabilitative intervention

Initial management options for outpatient burn care

– Immediate cooling: only effective within the first 30 minutes post-burn and most effective within the first 2 minutes; ice is contraindicated

– Wound care: gentle cleaning with a sponge/soft fabric is effective for removing bacteria and particulate matter

– Blisters: no strong evidence on management; however, one may consider the following. If a blister is likely to spontaneously rupture, debridement in the physician’s office may be advisable as to provide better wound care and decrease chances of complications such as infection.

Blister size

<6mm: leave intact–unlikely to rupture spontaneously depending on location

>6mm: should be debrided–likely to rupture spontaneously

Blister type

-Thin walled: consider debriding as spontaneous rupture more likely

-Thick walled: may leave intact as spontaneous rupture unlikely

Infection-prone strategies

-Blisters should be debrided if underlying tissue is nonviable

-Blisters should be debrided to assist with more accurate determination of burn depth

-Blisters may be debrided to remove fluid that may cause local immune suppression

Wound-healing strategies

-Blisters should be debrided if underlying tissue in nonviable

-A moist wound bed should be maintained for partial thickness wounds

-A moist wound bed may be accomplished by using a variety of dressings (see chart below)

Consider functional and aesthetic outcomes

-Blisters should be debrided if they limit patient functionality

-Blisters should be debrided to aid in faster healing and potentially less scarring

Optimization of patient comfort

-Small blisters may be left intact as a natural form of pain control

-Using dressing that requires fewer changes should be considered

-Strive for ease: Consider simple management techniques to aid in patient compliance

-Cost-effectiveness: While some newer wound dressings have a higher cost up front, often the total cost is less as they require less overall maintenance and care.

Pain management: Narcotics are the mainstay, benzodiazepines may be needed as adjunct, NSAIDs/ acetaminophen for some outpatient settings may be appropriate. If unfamiliar with chronic pain and burn sequelae, a pain management consult should be obtained.

Pruritus: cooling, anti-histamines, local anesthetics, colloidal oatmeal baths, capsaicin, laser treatments, compression garments, dapsone, ondansetron, gabapentin, massage, transcutaneous electrical nerve stimulation (TENS), psychological support, referral to dermatology

Poor wound healing: debridement, grafting, hyperbaric oxygen therapy

Poor cosmetic outcome (texture/ color): laser therapy, referral to plastic/ reconstructive surgeon and/or dermatology

Hypertrophic/ keloidal scarring: keloid injection, laser therapy, excision and/ or repeat grafting or flaps

Folliculitis: laser hair removal, oral antibiotics

Wound dressings

Burn wounds dressed with hydrogels, silicon-coated dressings, biosynthetic dressings and antimicrobial dressings heal more rapidly than those dressed with silver sulphadiazine- or chlorhexidine-impregnated gauze dressings. Pain, but not infection risk, seems to reduce with the use of intervention dressings as compared with silver sulphadiazine or chlorhexidine dressings. See Table 1.

Table 1.
Time to complete wound healing Patient perception/satisfaction Level of pain Number of dressing changes Adverse effects Incidence of infection
Hydrocolloid dressing vs
1. Chlorhexidine- impregnated paraffin gauze dressing (3 trials, 236 people) No significant difference Preferred hydrocolloid dressing No significant difference Conflicting data Pain, rash No significant difference
2. Chlorhexidine- impregnated paraffin gauze dressing/silver sulphadiazine cream (1 trial, 30 people) No significant difference Hydrocolloid dressings easier to change No significant difference Fewer than hydrocolloid dressings None reported No infections reported
3. Silver sulphadiazine cream (1 trial, 42 people) Faster with hydrocolloid dressing Hydrocolloid dressings easier to change Less with hydrocolloid dressings Fewer than hydrocolloid dressings No comment No comment
Polyurethane film dressing vs
1. Paraffin gauze dressing (1 trial, 55 people) No significant difference No significant difference No significant difference No comment Follicular exanthema, itching in polyurethane film group No significant difference
2. Chlorhexidine- impregnated paraffin gauze dressing (1 trial, 51 people) Faster with polyurethane film dressing No comment Less with polyurethane film dressing No comment No comment No significant difference
Hydrogel dressings vs
1. “Usual care” (2 trials, 155 people) Faster with hydrogel dressing No comment Less with hydrogel dressing Fewer with hydrogel dressings No significant difference No significant difference
Silicon-coated nylon dressing vs
1. Silver sulphadiazine cream (2 trials, 142 people) Faster with silicon-coated nylon dressing No comment Less with silicon-coated nylon dressing Fewer with silicon-coated nylon dressing Moderate to severe eschar formation noted with silver sulphadiazine; Fever of unknown origin & rash in 3 children treated with silicon-coated nylon dressing No significant difference
Biosynthetic skin substitute dressings
1. Biobrane vs silver sulphadiazine cream (4 trials, 209 people) Faster with Biobrane dressing No comment Less with Biobrane dressing No comment No comment No significant difference
2. Biobrane vs hydrocolloid dressing (1 trial, 72 people) No significant difference No comment No significant difference No comment No comment No comment
3. Transcyte vs silver sulphadiazine cream (2 trials, 69 wound sites) Faster with Transcyte dressing No comment Less with Transcyte dressing Fewer with Transyte dressing No comment Multiple cases of cellulitis in silver sulphadiazine group, none in biosynthetic group
4. Mixed biosynthetic dressing regimes (1 trial, 33 people) Transcyte<Biobrane<silver sulphadiazine cream No comment Transcyte/Biobrane<silver sulphadiazine cream Transcyte<Biobrane<silver sulphadiazine cream No comment No comment
Antimicrobial-releasing biosyntethic dressing
1. Hydron vs silver sulphadiazine cream (3 trials, 95 people) Faster with Hydron dressing Conflicting data Less with Hydron dressing Fewer with Hydron dressing No comment No significant difference
2. Silver impregnated dressing vs silver sulphadiazine cream (3 trials, 162 people) Faster with silver impregnated dressing No comment Less with silver impregnated dressing No comment No comment No significant difference
Fiber dressings
1. Calcium alginate vs silver sulphadiazine cream (1 trial, 59 people) No significant difference No comment No significant difference No significant difference No comment No comment
2. Hydrogel fiber vs silver sulphadiazine cream (1 trial, 47 people) No significant difference No comment Less with hydrogel fiber dressing Fewer with hydrogel fiber dressing No comment No significant difference

Optimal Therapeutic Approach for this Disease

Outpatient burn therapy

Minor burns should be cleansed with a mild surgical detergent disinfectant, debrided (based on factors in treatment options section), and dressed. The use of occlusive dressings is optional and depends on the location of the burn and the patient’s desire. In years past the standard of care was to apply silver sulphadiazine cream under occlusion and change as needed though usually every 3 days.

However, there is much ongoing research into newer intervention dressings noted in the Table. Some of these newer dressings have advantages over one another, however, there is likely no single dressing appropriate for every situation. Many of these newer dressings are expensive and may not be available and thus the inclusive nature of the Table.

In most cases, patients and family can be educated on home wound care and dressing changes. Frequent follow-ups can insure appropriate wound care and prevention of any consequences. The larger and deeper the burn, the more follow-up is necessary. Follow-up with a skin care/ burn specialist should be considered if complications are noted.

Patient Management

Patient management is naturally dictated by the degree of injury. If inpatient hospitalization is required, a comprehensive management plan is typically required and led by a burn specialist at a specialized burn center. However, outpatient treatment can easily be initiated by the primary care manager, urgent care center, or emergency room.

Early focus should be on pain control and wound care. Patients with first-degree and superficial second-degree burns will require at least some type of follow-up. Patients and family members should be educated on wound care and the signs and symptoms of infection to look out for including increasing signs of inflammation (calor, rubor, dolor, tumor). Additionally, patients should be counselled on the possibility of scarring and poor cosmetic outcome.

Referral to the appropriate authorities should be done if abuse is suspected. 4281

Unusual Clinical Scenarios to Consider in Patient Management

A wide array of complications can occur within significant body surface area burns. These are managed in a burn center, and this chapter is not meant to address those issues.

Depending on the etiology of the burn, complications may arise. Lightening strikes may alter neurologic function in addition to the burns, and a neurology consult should be obtained. One must also look for the exit wound. This should also be considered in high-voltage accidents.

What is the Evidence?

Barillo , D, Goodwin , C. ” Dermatologist and the burn center”. Dermatol Clinics . vol. 17. 1997. pp. 161-75. (Review article that any dermatologist who sees patients in the burn unit should have available.)

Fagenholz , P, Sheridan , R, Harris , S, Pelletier , A, Camargo , C. ” National study of emergency department vistis for burn injuries. 1993-2004″. J Burn Care Res . vol. 28. 2007. pp. 681-90. (Current epidemiology for emergency room burn visits.)

“2010 National Burn Repository: Report of Data from 2000-2009”. (Current epidemiology data for burns requiring hospital admission.)

Beachkofsky , T, Henning , J, Hivnor , C. ” Induction of de novo hair regeneration in scars following fractionated carbon dioxide laser therapy in 3 patients”. Dermatol Surg . vol. 37. 2011. pp. 1-4. (New research using laser therapy for complications of burns.)

Bell , P, Gabriel , V. ” Evidence based review for the treatment of post-burn pruritus”. J Burn Care Res . vol. 30. 2009. pp. 55-61. (Thorough review of the management of post-burn pruritus.)

“Resources for optimal care of the injured patient”. 2006. pp. 79-86. (Guidelines for the referral to and management of a burn center.)

Ahrenholz , D, Cope , N, Dimick , A, Gamelli , R, Gillespie , R, Kagan , R. “Practice guidelines for burn care”. J Burn Care Rehab. 2001;April. pp. 1S-69S. (Original guidelines published by J Burn Care Rehab in 2001 offering the most comprehensive single-source document for burn care.)

Bartlett , N, Yuan , J, Holland , A, Harvey , J, Martin , H, Hei , E. “Opitmal duration of cooling for an acute scald contact burn injury in a porcine model”. J Burn Care Res . vol. 29. 2008. pp. 828-34. (Study to determine the impact of cooling after a burn injury.)

Sargent , R. ” Management of blisters in the partial-thickness burn: An integrative research review”. J Burn Care Res . vol. 27. 2006. pp. 66-81. (Guide to the management of post-burn blisters.)

Engrav , L, Garner , W, Tredget , E. ” Hypertrophic scar, wound contraction and hyper-hypopigmentation”. J Burn Care Res . vol. 28. 2007. pp. 593-7. (Research and guidelines for post-burn complications.)

Faucher , L, Furukawa , K. ” Practice guidelines for the management of pain”. J Burn Care Res . vol. 27. 2006. pp. 659-68. (Thorough review and guidelines for the pain management in burn patients.)

Wasiak , J, Cleland , H, Campbell , F. ” Dressings for superficial and partial thickness burns”. The Cochrane Library . vol. 10. 2010. pp. 1-51. (Thorough review that the chart in the chapter tries to summarize. The definitive source for evidence-based look at the different types of dressings.)