Learning Objectives: After reading this article, the physician should be able to:
1. Recall the principles of outpatient burn care, including the use of topical preparations.
2. Outline the proper method of dressing a burn wound and the technique of debridement.
3. Describe appropriate follow-up care of the ambulatory burn victim.
Burns of less than 15 percent body surface area in adults (10% in children) can usually be handled on an outpatient basis unless the injury involves the feet, hands, face, or genitalia. A quick way to measure the extent of the burn is to use the patient's outstretched palm as roughly equal to one percent surface area.
The immediate use of cool tap water, not ice water or ice, not only provides immediate pain relief, but augments the healing process if used within the first few minutes. I recommend the immediate use of enough parenteral narcotics to make patients comfortable before extensive examination, debridement, or dressing application. Special problems and poor outcomes are frequent in seemingly minor burns to the feet, and a liberal admission policy is advocated for these specialized burns.
Although little has changed in the science of minor burn therapy over the past 20 years, many clinicians are uncomfortable with tackling all but the most minor burns. Treatment myths still abound, unproven dogma is promulgated, and the same mistakes are still made. This month's column continues the review of the proper approach to outpatient burn management with an emphasis on the specifics of follow-up, the use of burn dressings, antibiotics, and the age-old question of what to do with blisters.
Outpatient Management of the Burn Patient Shuck JM Surg Clin of NA 1978;58(6):1107
This article is almost 25 years old, but it reviews treatment principles that are still apropos for today's management. However, this article does contain some recommendations (e.g., unproven dogma) that are suspect. Almost two million burn patients are treated in the U.S. as outpatients each year. Most continuing care is given in emergency departments or doctors' offices, and an elaborate facility (a specialized burn clinic) is not required for the majority of cases. Ideally, physical therapy, whirlpool facilities, and occupational therapists should be available as part of the support treatment plan. It is noted that most burn clinics only meet twice a week, and this frequency of return visits works well in most cases.
Many patients with burn injuries that could theoretically be treated as outpatients are admitted because of social reasons, because the burn involves a special area of the body, or because there is a need to teach wound care to family members. The author categorically states that there are no unnecessary admissions for patients with burns, and emphasizes that injuries to the eyelids, neck, hands, feet, and genitalia qualify as special circumstances. To obtain good results with these injuries, admission is often necessary even though the percent of burn is small. It also is emphasized that when patients are first seen, anxiety and pain relief are major issues requiring attention. The author suggests parenteral meperidine or morphine in combination with diazepam. It's important to obtain proper analgesia before the wound is dressed.
The author also recommends shaving hair around a burn wound. After analgesia is obtained, the wound is washed with a mild antiseptic soap. It is recommended that blisters not be initially debrided, even if they have ruptured, because the skin functions as a biological dressing. Tetanus prophylaxis is routine. Because invasive bacterial infection is not a problem in the vast majority of outpatient burns, systemic antibiotics are not prescribed routinely.
The author recommends not using an occlusive dressing for burns of the neck and face. It is noted that topical agents are not usually necessary for facial burns because infection in this area is rare, and any occlusive dressing on the face and neck runs the risk of skin maceration. Because of the excellent blood supply to the face, and the difficulty in applying an adequate dressing, the open method is recommended on all facial burns. The patient should wash his face twice a day with a mild soap.
The most acceptable method for the routine outpatient treatment of most small burns is the use of occlusive dressings. Although many physicians have strong personal opinions and recommend a variety of topical agents to use under the dressing, there are no hard data supporting the use of one preparation over another. For most burns, the author uses only a dry fine mesh gauze (without creams or ointments) covered with absorbent gauze. If a topical antimicrobial is desired, silver sulfadiazine is generally accepted as the standard burn cream.
Gentamycin cream is not recommended because it may promote the growth of Pseudomonas. Combination ointments containing polymyxin bacitracin and neomycin also are adequate to use under burn dressings. Heavy petrolatum and other thick ointments are discouraged because they may encourage skin maceration. It is noted that many topical antibiotics are probably ineffective against bacteria once they have been under a dressing for a number of hours. The author emphasizes the use of bulky dry absorbent gauze sponges to soak up any drainage. Dry occlusive dressings should be changed twice a week. Because superficial burns heal within two weeks, most patients do not require long-term follow-up.
Comment: This article is still timely, although it does contain some questionable recommendations. I would specifically disagree with the concept of shaving hair and the ritual of washing a burn with any special soap on the first visit.
I am continually amazed that physicians have such dogmatic yet unproven approaches to the outpatient treatment of minor burns. If you have numerous options for almost anything in medicine, it usually means that it really doesn't matter what you do. Individuals have their own rigid therapies (usually taught to them by someone else who was just as dogmatic), and vehemently cling to treatment axioms that have no basis in fact. As long as common sense rules are followed, it actually matters very little what cream is used, what dressing is applied, what you do with blisters, or how often the patient is seen in follow-up. Like treating a URI, no matter what witchcraft is practiced on the partial thickness outpatient burn, the outcome is generally satisfactory.
Some important caveats concerning follow-up should be emphasized. If you plan to follow your own patients, don't neglect the physical therapists, occupational therapists, and whirlpool debridement when appropriate. For some reason, emergency physicians hardly ever use these ancillary modalities, yet even a few visits to physical therapy can make your life easier, make the patient feel important, and make a tremendous difference in the final outcome of some burns. There is no reason why the emergency physician cannot work in conjunction with the same therapists who treat patients from the burn clinic, making the famous burn specialist look good.
But there seems to be an unwritten rule that these helpful additions to therapy are somehow the private property of the burn clinic. Our physical therapy department is only too happy to do most of the laborious work with outpatient burns, with only occasional physician involvement. Those guys know what they are doing, from debridement to fancy dressings to spotting potential problems.
The ED (with its 24-hour access to care and fast tracks) is the ideal place to follow minor burns, yet many emergency physicians shy away from this type of short-term care. With emergency department follow-up, the patient's burn is not relegated to care on Tuesdays and Thursdays between 9 and 11 a.m. in the burn clinic. If sutures can be removed in the ED, it follows that burns can be debrided and dressings can be changed.
It is very important to become adept at dressing a burn. Although in the long run the exact makeup of the dressing is largely inconsequential, one should adhere to certain underlying principles. An improper dressing can turn a minor burn into a problematic one. The most important property of a burn dressing is its ability to absorb and control fluids oozing from the wound. Because a burn dressing should be designed to create an environment that allows wound healing, fluid should not pool between the dressing and the skin. Material that best meets this critical criteria is plain gauze. The gauze dressing should be fluffy and thick enough to absorb all drainage. I prefer to use multiple fluffed-up 4x4 pads, covered with Kling or Kerlix, avoiding elastic bandages or excessive tape. I see no reason to use sterile gauze pads to cover gobs of Silvadene or to cover a burn that has intact skin.
If the fingers or toes are included in the dressing, it's best to lay 4x4s generously between the digits to avoid skin to skin contact. Individual digits must be separated with dressing material. Many authors suggest placing porous fine mesh gauze (such as Adaptic) against the burn surface before covering it with gauze. I generally find this an unnecessary expense, and have not had the problem of dressings sticking to the burn surface when antibiotic creams are used. If fact, if the gauze gets a little sticky, changing the dressing helps debride dead skin.
Home dressing changes are totally acceptable in most cases, but some patients or their parents or spouse simply can't deal with a burn. The squeamish caretaker is no help in the long run, so evaluate each situation individually. Parents tend to avoid painful dressing changes in their children because they do not want to be the ones to hurt their child. If I opt for home dressing changes, I give the patient a supply of gauze dressings that will only last them to the next scheduled visit. These items are very expensive and not covered by insurance. Some patients skimp on dressings if they have to buy them or leave soppy dressings in place for too long. The next time you are in CVS or RiteAid, check out the cost of 4x4 gauze pads. I see no reason why gauze pads have to be sterile, especially when a thick layer of Silvadene is applied. If you give expensive dressings to indigent patients, it serves as an incentive for them to return for follow-up.
I usually suggest that the first dressing change be done in the hospital or clinic. This gives a medical person the chance to re-evaluate the wound, and ward off potential problems. Even the most experienced burn specialist cannot totally grade the depth or the extent of a burn on day one.
The frequency of dressing changes depends on individual wounds (particularly the amount of fluid ooze) and the individual who has the wound. Some patients do well at home, and others just can't get it together to change a burn dressing. There is little proof that changing a burn dressing twice a day is any better than once a day, and clearly some burn dressings need to be changed only every three to four days. As a guideline, I advise daily dressing changes if a burn cream is used, and every three to four days with a dry dressing. Burn healing is a dynamic process, so I prefer to evaluate the need or frequency of dressing changes at the first 24- to 36-hour follow-up visit. Reliable patients probably only need a physician recheck every five to seven days.
Because invasive bacterial infection is not a problem in most outpatient burns, systemic antibiotics are not prescribed routinely
The author of this paper changes dressings every Tuesday and Thursday, but you should note that he does not use creams, only nonadherent mesh gauze and dry gauze rolls. Finally, don't forget to be generous with intravenous narcotics prior to a painful dressing change. For the first few dressing changes at home or in the hospital, at least have the patient take a few Percocet tablets one hour before the anticipated activity.
Burn Creams and Ointments
There is a universal misconception among patients and physicians that all burns, even first-degree burns no worse than sunburn, should be covered with an expensive antibiotic cream. It's a billion-dollar industry, and all patients expect some magic topical potion. Most of the time, however, burn topicals are only part of the show business of medicine. Do something fancy and expensive, especially when a magic doctor-prescribed elixir is involved, and the patient is happy. Few patients will accept a simple gauze dressing on their burns, especially if they have the dreaded burn blisters.
I shared the mystique until I closely read the literature, and learned that science does not support any topical for minor burns, and, in fact, many burn specialists do not routinely recommend creams under outpatient occlusive dressings. Burn topicals were designed to prevent burn wound sepsis in burn units, not to treat a superficial second-degree burns from hot water. These preparations are usually recommended for inpatients when dressings can be changed twice a day. Although topicals do present a soothing and nonadherent layer over a burn, the benefit of their routine use in minor outpatient burns has not been documented. I have yet to see a patient with a burn leave our emergency department without some sort of burn ointment. The wonders of the placebo still pervade our practice.
Silver sulfadiazine (Silvadene) seems to be the current topical of choice. This nonirritating, water soluble broad spectrum antibiotic cream has become the standard in outpatient burn care. It is often avoided on the face, although I could find no scientific reason for this. Our burn specialists prefer instead to use Neosporin ointment on the face, but this appears to be only because of the cosmetics of a thick white cream. Because neomycin can sensitize skin, I don't use it, and but prefer plain bacitracin ointment.
I have heard contentions that Silvadene causes hypopigmentation or burns the eyes, but the manufacturer denies this. Silvadene does not damage tissue, and does not burn when applied. The antibacterial effectiveness of any topical agent under the occlusive dressing is probably very short-lived (12 to 24 hours), possibly due to properties of the proteinaceous exudates from burns. When wounds are treated on an inpatient basis, twice-daily application of the antibacterial agents is recommended because of this phenomenon. However, daily changes are more the norm. The manufacturer of Silvadene states that its cream is effective for 24 hours under an occlusive dressing.
An old but interesting prospective study on outpatient burns appears in the Journal of Trauma (1976;16:191) by Hunter and Chang. This study pertains to the microbial flora present in outpatient second-degree burns, the efficacy of various types of dressings, and the advantage of topical antibiotics. It is one of the few studies that prospectively addresses these issues. Fifty consecutive outpatients were treated with one of two commonly used dressings, either nitrofurazone (Furacin) ointment or light petroleum mesh gauze (Adaptic) without antibacterial activity.
The wounds treated with the antibiotic ointment healed in 17 days, and the petrolatum gauze-treated burns healed in 18.9 days (no significant difference in overall healing rates). The wounds were not sterile, but the significance of culturing organisms under the burn dressing was not obvious. The value of any topical antibacterial agent in outpatient burns remains unproven to this day. Another study of interest by Webber et al (JACEP 1977;6:486) failed to show an advantage of silver sulfadiazine over povidone-iodine or nitrofurazone.
Minor burns just don't get infected except under unusual circumstances. The rate of infection in outpatient thermal burns is less than five percent. Because creams are so ingrained in clinical practice and are a safe and soothing treatment, I doubt if any patient will ever leave our emergency department without the ritual topical antimicrobial preparation. I personally use an occlusive dressing with a topical cream on outpatient burns, and advise the patient to change the dressing daily.
Although twice a day may be more scientific, this is very difficult for most patients. Patients are generally afraid to touch any wound, let alone a burn wound. My approach is to have the patient remove the gauze, get in the bath tub or shower, and wash off all the burn cream, using a gentle stream of water and soft gauze or cotton. I use Silvadene because it is water soluble, and does not have to be scraped off. I could find no data supporting the omnipresent recommendation to “wash the area with a mild soap and water,” but I see no harm with a gentle wash with Ivory, Dove, or castile soap.
The area is then dried, a thin layer of cream is reapplied using a sterile tongue blade (the patient is given a supply), and fluffed-up gauze is placed over the burn and secured with a gauze wrap. If a nonadherent porous mesh gauze is used, I don't use topicals. The Adaptic can be covered with a dry gauze wrap, and this needs to be changed only every three to five days, depending on fluid accumulation. This dry dressing may be preferred for those who have difficulty with home dressing changes.
Probably the best reason for using the topicals is that the patient will pay attention to the wound, perform a minor debridement with the dressing change, and give it a good daily cleaning. Running out of fancy creams and dressings, especially if they are free from the hospital, also tends to make patients more compliant with follow-up.
There is no indication to routinely prescribe systemic antibiotics to patients with outpatient burns. When used for possible infected burns, the antibiotic of choice is penicillin (or erythromycin) to cover streptococcal infections. Although it's common knowledge that infection is rare, a study by Boss (J Trauma 1985;25:224) evaluated systemic antibiotics in minor outpatient burns. The choice was usually penicillin, although erythromycin, dicloxacillin, and cephalsporins also were used. Infection rates were comparable in the antibiotic-treated group and the nontreated group (3.8% and 3.1% respectively). The authors concluded that the routine use of prophylactic systemic antibiotics is not warranted. Prophylactic antibiotic use always brings up the concept of selecting out resistant organisms, particularly pseudomonas.
It may be difficult to differentiate the healing process from true burn cellulitis at three to five days post-burn. Many patients with five to 10 percent burn areas will develop a fever as part of the natural healing process, so this is not helpful, nor does the CBC diagnose infection. Tender erythema spreading out from the burn site often signifies cellulitis. When in doubt, it's reasonable to err on the side of giving antibiotics. The main concern is not sepsis, of course, but that local infection increases the depth of the injury.
Whether to remove blisters in outpatient burns is an age-old controversy. Currently, most authors believe that blisters should be left intact for at least a few days. The good news is that you can do whatever you want with blisters; it simply doesn't matter in the long run.
Those who favor blister removal contend that blister fluid is an ideal culture medium and therefore represents a risk for infection. This is clearly not the case, and rarely, if ever, do intact blisters become infected. If fact, there is good experimental evidence that blisters prevent capillary stasis and retard skin necrosis at the burn injury site (Ann Surg 1974;180:98).
There is no question that retention of blisters aids in the control of pain, and I view a blister as the ideal burn dressing. A happy patient with an intact blister turns into someone screaming in agony within a few seconds after blister removal. In my opinion, even large intact blisters should definitely be left alone for three to five days. Some authors even prefer to leave the skin from ruptured blisters as a biological dressing until they rupture or leak on their own. Although blisters larger than the size of a quarter will eventually need to be debrided, I could find no scientific evidence favoring early vs. late removal. Blisters over joints tend to rupture early. Intact blisters do not interfere with early motion, but a recently debrided hand quickly becomes immobile from pain when the blisters are removed. Once a definite cellulitis has occurred (a rare event), all blisters and dead skin should probably be removed.
The management of blisters in minor wounds has not, however, been the subject of much scientific investigation. Swain (Brit Med J 1987;295:181) did compare bacterial colonization rates in patients with thermal burns of the arm and legs, in whom the blisters were left intact, aspirated, or deroofed. Bacterial colonization occurred in 14 percent of patients in whom blisters were left intact, compared with 70 percent in who blisters were aspirated and 70 percent in whom the lesions were deroofed. I see no rationale for sticking a needle into an intact blister to drain it. Current consensus is that intact blisters prevent pain and dehydration, promote healing, and allow motion, and therefore should be left alone until they rupture spontaneously or healing is well underway. It should be noted, however, that a full thickness burn may be brewing beneath a blister.
Necrotic or obviously sluffed skin should definitely be removed. Some authors prefer the tedious removal of skin with forceps and scissors. I prefer to give appropriate intravenous analgesia (usually Fentanyl), and turn an elaborate 20-minute task into a simple 30-second procedure by using a dry gauze pad and just pulling off the skin in one quick motion. This may hurt bit more than using forceps and scissors, but it gets the job done in a few seconds. I suggest an aggressive debridement on the first try because most patients won't readily give you a second chance. One reason to delay blister removal for a few days is that a more mature burn better defines the areas of nonviable skin, decreasing the number of times it has to be debrided.
Although some authors recommend shaving the area around the burn, I could find no data that supports this practice. I recommend that the hair be left intact in patients who have minor burns.
Authors generally fail to mention the need for adequate analgesia in outpatients. Burns hurt, and patients require narcotics for the first few days. You won't make an addict out of any patient with a painful burn by giving him a prescription for narcotics for the first few days. Patients should be advised specifically about elevating the injured part. Hand or foot burns that are admitted should have their elevation begin in the ED. Burns generally swell even under the best of circumstances, and an arm or leg is guaranteed to become edematous if left dependent. Edema clearly influences the healing process, and is a detriment to rapid recovery. Patients with burns to the face should be advised to sleep with the head of the bed elevated.
No discussion on minor burn care would be complete without a discussion of the use of honey as a topical therapy. For centuries, raw honey has been used as a burn and wound dressing, and its use is actually supported by data. It's not very exotic, and not made by an international pharmaceutical company, so I doubt if the establishment will ever champion its use. However, I'm determined to start using it.
Any comment from honey users in the readership would be appreciated. Lusby et al (J Wound Ostomy Continence Nurs 2002;29:295) make a case for honey as a potent agent to augment healing of many types of wounds, citing proven antibacterial action and beneficial effects on wound healing. Honey may possess antiinflammatory activity, and it stimulates the immune system. One study demonstrated that honey was actually better than Silvadene for superficial burns (Burns 1998;24:157), providing better antiinflammatory, antibacterial, and wound healing properties. I assume honey could be used the same way Silvadene or bacitracin is now used.
The same patients who cover their wounds with butter simply love vitamin E creams and aloe vera. Aloe gel may permit faster healing of burn wounds (Plast Reconstr Surg 1988;81:386) so I suggest it when patients need nothing special, yet want something advised by a doctor for their minor burns. I could find no advocates for vitamin E. One might intuit that high-potency topical steroids ameliorate injury and speed recovery of burns. This is simply not the case, and steroid creams are not used on burned tissue (Acad Emerg Med 2002;9:977).