During the past 50 years, advances in burn management, such as resuscitation, early excision and grafting, and surgical critical care, have dramatically improved survival from severe burn injury. 1,2 Burn prevention and fire safety measures have also reduced the incidence of severe burn injury to the extent that most health care professionals in burn centers are more likely to manage small burns than large, deep burns. 3 The major focus of burn care has changed from survival issues to such issues as early return to work and cost-effective treatment. 4
Not all burns require care in a specialized burn center. Skin and wound care professionals are often called on to manage less-severe burns in both outpatient and inpatient settings. This article outlines the continuum of care for 1 type of burn— partial-thickness burn wounds.
TYPES OF BURN WOUNDS
Burn wounds have numerous causes:
- thermal—residential fires, automobile accidents, playing with matches, improper handling of firecrackers, scalds caused by kitchen or bathroom accidents
- chemical—contact, ingestion, inhalation, or injection of acids, alkalis, or vesicants
- electrical—contact with faulty electrical wiring, electrical cords, or high-voltage power lines
- friction or abrasion
- ultraviolet radiation—sunburn.
In burn injury, these injuring agents denature all cellular protein. Some cells die because of traumatic or ischemic necrosis. Denaturation also disrupts collagen cross-links in connective tissue. This results in abnormal osmotic and hydrostatic pressure gradients, which force intravascular fluid into interstitial spaces. Cellular injury triggers the release of inflammation mediators, further contributing to local or systemic increases in capillary permeability.
Burn wounds are classified by depth: superficial, partial-thickness, full-thickness, 5–7 or subdermal. 8 The depth of injury is diagnosed by the anatomic thickness of the skin involved, based on clinical observation. 5–8
Superficial burns affect only the epidermis of the skin. They are usually caused by ultraviolet radiation from the sun. Although the epidermis anatomically lacks a direct blood supply, this wound type still becomes erythematous. Coloration is due to irritation of the vascular plexus that project upward into the epidermal-dermal junction from the underlying dermis. 8
In a true superficial burn, no blisters are present and the surface is dry. 7,8 Pain, in the form of tenderness to touch, is usually delayed for several hours after sun exposure. Edema may be present, especially around the eyes when the face has been exposed. The area will heal itself without evidence of scarring, usually in 3 to 5 days. 7,8
Superficial partial-thickness burns
Superficial partial-thickness burns extend through the epidermis downward into the papillary, or superficial, layer of the dermis. 6–8 These wounds become erythematous because the dermal tissue has become inflamed. When pressure is applied to the reddened area, the area will blanch but demonstrate a brisk or rapid capillary refill upon release of the pressure, a hallmark of the superficial partial-thickness burn. 5,7,8
Thin-walled, fluid-filled blisters will develop within minutes of the injury. As these blisters break, the exposed nerve endings transmit the senses of superficial pain, light touch, and temperature, 5–8 making these wounds extremely painful. The wound will be moist because the characteristic waterproofing of the epidermis has been lost, allowing body fluid to leak on the wound surface. Due to dermal vascular network involvement in this type of injury, moderate edema is usually present.
Deep partial-thickness burns
Deep partial-thickness burns extend downward into the reticular, or deeper, layer of the dermis and present as mixed red or waxy white. 8 Areas of redness will continue to blanch when pressure is applied, but capillary refill may be absent or may be sluggish when pressure is released. Blisters are usually absent; however, the exposed surface of the wound is wet or moist, similar to superficial partial-thickness burns. Edema is marked and sensation is altered in areas of a deep partial-thickness burn.
Full-thickness and subdermal burns
Full-thickness and subdermal burns affect every body system and organ. A full-thickness burn extends through the epidermis and dermis and into the subcutaneous tissue layer. A subdermal burn damages muscle, bone, and interstitial tissue. Within hours, fluid and protein shift from capillary to interstitial space, causing edema. An immediate immunologic response to injury makes wound sepsis a potential threat. An increase in metabolic rate after a burn injury mandates aggressive nutritional support.
A plan of care for managing a burn injury cannot be developed and implemented until the severity of the burn is known. This involves estimating the extent of the burn injury and the wound depth.
Extent of burn injury
Estimating the extent of burn injury is the first component of estimating burn injury severity. This can be calculated by at least 3 different methods.
- Rule of Nines—The Rule of Nines 9 divides the surface area of the body into areas of 9% or multiples of 9% equal to 18% (Figure 1). When all body areas of 9% are summed, 1% remains, which is assigned to the genitalia and perineum.
- The Rule of Nines is a convenient and rapid method of estimating the extent of body surface area burned. It is less than accurate, however, for children. For patients younger than 15, a more precise method of burn size estimation must be used.
- Lund and Browder Chart—The second, more accurate, method of measuring the extent of total body burn utilizes the Lund and Browder Chart, 10 which subdivides body areas into segments and assigns a proportionate percentage of body surface to each area based on age (see Estimating the Extent of Burn Wounds). Rather than being viewed as a whole, the lower extremity is divided into foot, leg, and thigh areas. The head of a newborn baby is proportionately much larger than any other area of the body. As a child grows, the lower extremities assume more body surface area; the head becomes relatively smaller compared with the rest of the body.
- Palmar surface—The third method of estimating burn injury extent uses the size of the patient’s hand, assuming the palmar surface of the hand is roughly 1% of the total body surface. Visualizing the patient’s hand covering the burn wound approximates the amount of body surface involved, especially if the burn areas are scattered. In actuality, the palm alone more accurately represents 0.5% of the body’s total surface area. 11
Regardless of the calculation method used, it should be noted that estimation of burn surface area is subjective, with a wide margin of discrepancy. 12
Clinical assessment of depth
The second component of the estimation of burn injury severity is the determination of the depth of skin injury. In the past, burn wounds were described by degrees—from first- to fourth-degree. 5–8 Because this nomenclature can be confusing, it is more accurate to refer to burn wound depth by the anatomic thickness of the skin involved. 5–8
Correct clinical diagnosis of burn injury depth is easy in cases of superficial burns, in which only erythema without blisters is seen. Desiccated, leathery, insensate full-thickness and subdermal burns are also easy to define. However, partial-thickness burns can be more difficult to accurately classify.
Partial-thickness burns are generally classified as superficial or deep. Superficial partial-thickness burns are blistered; however, they still have good capillary refill and are pink and sensate to pinprick. Deep partial-thickness burns may appear waxy and have poor capillary refill; sensation to pinprick is equivocal.
For more information on clinical characteristics of burn wounds used to help determine depth, see Classification of Burn Wound Depth.
Surgeons correctly diagnosis burn depth approximately two-thirds of the time. 13 Correct diagnosis often depends on the surgeon’s experience and the timing of diagnosis. Different techniques have been used to improve the early diagnosis of burns with indeterminate depth. Indocyanine green fluorescence was attempted in the early 1990s, for example, but did not reach widespread acceptance. 14,15 Histologic assessment of the wound with punch biopsy can identify occluded blood vessels within the dermis and can be used to estimate burn depth 16; however, it is an invasive technique.
The application of laser Doppler technology to the management of partial-thickness burns is a major advancement in burn care. Laser Doppler probes can be placed on a burn to monitor microvascular blood flow in the dermis; newer laser Doppler scanners can examine larger areas in a short period. Many studies confirm improvement in the diagnosis of partial-thickness burns with this technology. The accuracy of burn depth diagnosis can range from 90% to 97% using laser Doppler technology, compared with about 66% using clinical examination alone. 17–19 Use of this technology is limited, however, because the scanners that can examine large burn areas are relatively expensive.
The depth of the burn wound will determine how it should be treated. A superficial wound can be cared for in the primary care provider’s office; partial-thickness burns can be cared for in the primary care provider’s office, another outpatient facility, acute care hospital, or a burn center; and full-thickness and subdermal burns should be cared for in a burn center.
As mentioned earlier, not all partial-thickness burns require specialized care in a burn center. The American Burn Association (ABA) has well-defined criteria for patient transfer to a burn center (see Burn Center Referral Criteria). Patients who fall outside of the ABA criteria may be managed by other wound care professionals.
Two areas of concern regarding patients with minor burns deserve special consideration. First, these patients may occasionally have significant psychologic problems and should be questioned about such symptoms as anxiety, sleep disturbance, and flashbacks. 20 Second, elderly patients may require close monitoring because they may develop problems with functional range of motion in a short period.
Because of the variety of products available, making decisions about nonsurgical treatment of partial-thickness burns is no longer a simple process. Data from some randomized trials are available, but in their absence, practitioners must make decisions based on clinical and empirical evidence.
Products can be classified as (1) topical antibiotics, (2) biologic dressings, and (3) nonbiologic dressings. Research examining the use of growth factors and enzymatic debridement in burn care is also under way.
Following is a discussion of the types of products available.
Local wound care
A previous report discussed the benefits and alternatives of blister management. 21 With the exception of small blisters on glabrous palmar skin, blisters should be removed to allow adequate examination and treatment of a partial-thickness wound. Tetanus prophylaxis should be administered because, although rare, fatal tetanus may occur, even after a small partial-thickness burn. 22
Some partial-thickness burns may convert to full-thickness burns during the first few days after injury. Adequate fluid resuscitation is important to maintain skin perfusion and to help prevent conversion. 23 Nonsteroidal agents have also shown positive effects on local burn wounds, reducing inflammation and edema and increasing blood flow. 24 However, these effects have not been conclusively shown to prevent conversion of partial-thickness burns. 25
Application of negative pressure wound therapy (Vacuum Assisted Closure [V.A.C.]; Kinetic Concepts, Inc, San Antonio, TX) may prevent the progression of partial-thickness burns. In a swine model, decreased burn depth was noted on partial-thickness burns that had received negative pressure wound therapy within 6 hours. 26 However, only anecdotal reports of negative pressure wound therapy in partial-thickness burns exist. Although not a widely used treatment modality for partial-thickness burns, negative pressure wound therapy may become more prevalent in the future.
Topical antibiotics represent a major advancement in burn care, making burn wound sepsis no longer the major cause of death for these patients. Most burn patients die of pulmonary complications subsequent to the institution of topical antibiotics and early operative intervention. 27
Silver sulfadiazine (Silvadene; King Pharmaceuticals, Inc, Bristol, TN) is the most common topical antibiotic used in burn care. Most studies utilizing biologic and nonbiologic dressings are compared with silver sulfadiazine, indicating that silver sulfadiazine represents the standard treatment in many institutions.
In general, silver sulfadiazine is a good choice for deep partial-thickness burns because it may allow the wound to heal without the need for a skin graft. Care must be taken in selecting a dressing, however; inappropriate coverage of burn wounds with semiocclusive dressings has led to high infection rates and can cause complications such as toxic shock syndrome. 28,29
One disadvantage is that silver sulfadiazine has been shown to delay partial-thickness burn healing, probably by delaying separation of burn eschar. Donor site reepithelialization is not affected by silver sulfadiazine. 30
Silver sulfadiazine is relatively contraindicated in patients with sulfa allergies, although many of these patients who cannot tolerate oral sulfonamides can tolerate topical silver sulfadiazine.
Mafenide acetate solution (Sulfamylon; Bertek Pharmaceuticals, Morgantown, WV) provides broad-spectrum coverage of bacteria and some fungal species. 31,32 At the authors’ institution, mafenide acetate solution is used for partial-thickness burns that are resistant to silver sulfadiazine and in conjunction with gauze to help debride eschar. A 5% solution is used, usually with twice-a-day dressing changes; dressings are remoistened once in between dressing changes.
A major disadvantage is the high cost of mafenide acetate solution, which may be offset if purchased in large quantities. The solution is isotonic and painless to apply; however, mafenide HCl cream is hyperosmolar and can be painful when applied to larger areas. Mafenide HCl cream can be used on the ears, where it can penetrate eschar to prevent chondritis. Mafenide is contraindicated for patients with metabolic acidosis.
An ointment containing polymyxin B sulfate and bacitracin zinc (Polysporin; Pfizer, Morris Plains, NJ) is clean and useful for partial-thickness facial burns. A thin layer is applied twice daily; it is completely removed before reapplication. This ointment is contraindicated in patients who develop an allergic rash or who had an allergy to it in the past.
Acetic acid (¼% solution) has been used in burn care. However, it has shown poor antibacterial effects in a recent in vitro study 33 and is not generally effective.
A topical antibiotic gauze dressing coated with silver (Acticoat; Smith & Nephew Inc, Largo, FL) can be left on a wound for up to 7 days. This dressing may also be used over meshed skin grafts, and it appears to increase reepithelialization between the interstices of meshed grafts. 34 Because of the long wear time, this dressing may be appropriate for outpatients who will not be seen for several days. It also eliminates patient manipulation of the wound. The dressing should be moistened to activate it if there is minimal wound exudate.
Biologic dressings serve several functions, including closing a wound to contamination and reducing pain and fluid loss. 35 Theoretically, biologic products may deliver growth factors to a wound as well.
Traditional products, such as xenograft and allograft, are still widely used in burn care. Although allograft is generally used with full-thickness burns, it has compared favorably in studies with silver sulfadiazine in partial-thickness burns, almost doubling the number of patients healed at 21 days (76% versus 40%). 36,37 Similar results have been seen when xenograft was used on partial-thickness burns. 38 Xenograft may adhere to the film of partial-thickness burns and facilitate eschar debridement. Human amnion has been suggested for use as a biologic burn dressing, especially in developing countries. 39
Biosynthetic products have been widely used in burn care. Closure of wounds with these dressings may lead to faster healing, less pain, and less scarring. They are used until the wound is healed, usually in 10 to 14 days, then the dressing peels off.
A biosynthetic wound dressing sheet (Biobrane; Bertek Pharmaceuticals, Morgantown, WV) has been used extensively and compares favorably with silver sulfadiazine in treating superficial partial-thickness burns. 40 However, improper use of this biosynthetic dressing in deep partial-thickness burns has led to a high infection rate. 41 The dressing can enclose dead tissue in the wound, providing a medium for bacterial overgrowth and invasive wound infection. A human fibroblast-derived temporary skin substitute (TransCyte; Smith & Nephew, Largo, FL) has also been used on middermal burns after debridement and showed faster healing with less pain in 2 prospective trials. 42,43
Closure of superficial burns can be safely performed with nonbiologic dressings. Nonbiologic wound coverage provides a moist wound environment and allows more rapid epithelialization. Compared with topical antibiotics, wound coverage can lead to fewer dressing changes and less pain and anxiety for the patients. Nonbiologic products generally cost less than biologically engineered skin substitutes.
A contact layer dressing (Mepitel; Mölnlycke Health Care, Newtown, PA) has compared favorably in superficial scald burns, with lower cost, faster healing, and less pain. 44 Likewise, a hydrocolloid (DuoDERM; ConvaTec, Skillman, NJ) has shown similar results in small, superficial burns. 45,46
A petrolatum gauze (Xeroform; Kendall Healthcare, Mansfield, MA) can be used to cover large areas of superficial burns. If petrolatum gauze does not adhere, the wound is likely deeper than suspected and should be treated with topical antibiotics or surgery.
Superficial partial-thickness burns can be treated with a variety of products, all of which are highly successful if the burn is not too deep. Even simple products, such as honey, work well in superficial partial-thickness burns. 47
Early debridement of burn eschar is beneficial to wound healing. Steed ‘et al’48 demonstrated the effect of debridement alone on wound healing of patients with diabetic foot ulcers and found that routine debridement leads to faster wound healing. This is probably due to the reduction of protease, which degrades growth factor activity within the wound. Although this was not a study of burn wounds, the data suggest that debridement is the key to healing.
Topical debridement products include collagenase and papain. In a multicenter trial, collagenase ointment (Santyl; Smith & Nephew, Largo, FL) was shown to have a faster healing time than silver sulfadiazine ointment. 49,50 However, it is difficult to establish whether collagenase increased healing time or if silver sulfadiazine delayed healing time by delaying the separation of debris.
Papain, available in several enzymatic debriding agents (such as Accuzyme; HEALTHPOINT, Fort Worth, TX), has been used to debride partial-thickness burns. 51,52 However, no controlled studies examining their effectiveness are available.
Despite theoretical advantage, enzymatic debridement results have been highly variable for both chronic wounds and burn wounds.
There has been great interest in the use of peptide growth factors to stimulate wound healing, but relatively few studies have demonstrated the use of growth factors in burns. Growth factors, such as epidermal growth factor (EGF) and tumor necrosis factor (TNF), are found in significant quantities in partial-thickness donor sites. Platelet-derived growth factor (PDGF) is not detectable in donor-site fluid, 53 but has been demonstrated in partial-thickness blister fluid. 54 PDGF was studied in a swine model, but it did not show an increase in reepithelialization. 55 EGF has been shown to improve healing time in partialthickness injuries 56,57; however, it is not commercially available.
Deep partial-thickness burns that are sensate but do not blanch well are usually treated with topical antibiotics. This type of wound is clinically followed daily. The progression of the wound normally follows 1 of 2 pathways: (1) exudative filmy eschar to epithelial buds from skin appendages to reepithelization, or (2) filmy eschar followed by granulation.
The presence of granulation tissue is usually associated with hypertrophic scarring, and large areas usually require grafting for wound closure. These pathways may take 7 to 14 days to delineate whether surgery will be required.
Most partial-thickness burns will heal by reepithelialization from dermal skin appendages within 1 to 2 weeks. Wounds that do not show healing in this time may require surgery. Deitch et al 58 demonstrated hypertrophic scarring in 78% of patients who had deep partial-thickness burns that took longer than 3 weeks to heal. Subsequent studies confirmed fewer hypertrophic scars, shorter hospital stays, and fewer costs with early excision and grafting. 59,60 It is reasonable, therefore, to perform excision and grafting of burns that will not be significantly healed in 3 weeks. Long-term outcome studies in patients with face and neck burns continue to reinforce this concept. 61
Another determinant for surgery depends more on wound location than size. An area, such as the abdomen, that has laxity in the adjacent skin might heal by wound contraction even if the area is as large as 300 cm2 to 400 cm2. However, an area of 10 cm2 located on the face, hands, or digits could produce significant deformity.
Surgical treatment of partial-thickness burns is divided into 2 steps: excision and grafting. Tangential excision to preserve any viable remaining dermis and the blood supply of the subdermal plexus is performed by either dermatome debridement or the Goulian-Weck knife. Techniques that limit blood loss with tangential excision include topical thrombin 62 and tourniquets. 63 The role of epinephrine 64 is somewhat controversial and deserves further study.
Because the end point of excision is based on a healthy, bleeding, viable wound bed, it is sometimes difficult to determine if adequate tangential excision has been performed when tourniquets are used. Meticulous hemostasis is required, especially if nonmeshed sheet grafts are used.
If meshed grafts are used, the keratinocytes migrate between the interstices of the graft. Widely meshed areas generally have a poorer, fishnet appearance. In many institutions, more patients are being grafted with sheet grafts or narrow meshed grafts than with meshed grafts. Sheet grafts are always used on the face and hands due to the cosmetic improvement.
Hypertrophic scarring is a potential complication of partial-thickness burn wounds. It can be minimized with appropriate surgical and nonsurgical management. Matsumura et al 65 suggest that the occurrence of hypertrophic scars may be more related to the specific areas of the body that contain cones of skin. This theory may explain why certain areas of the body, such as the shoulder and presternal area, are more prone to hypertrophic scarring than the forehead.
Pressure garment therapy is still used in many burn centers to aid in the management of hypertrophic scarring. Requiring extensive attention by physical and occupational therapists, pressure garments must also be replaced every 3 to 4 months to remain effective. In addition, patient compliance is not easily attained, and patients may wear the garments inappropriately. These factors may explain why the only prospective trial on pressure garments failed to demonstrate a difference in scarring with pressure garment therapy. 66 In a prospective randomized comparison, a tubed compression gauze (Tubigrip; ConvaTec, Skillman, NJ) was compared with a pressure garment (Jobst garment; BSN Jobst, Inc, Charlotte, NC) with equal results, less cost, and more patient compliance. 67
Massage therapy with cocoa butter (30 minutes, twice a week for 5 weeks) reduced pain, itching, and anxiety compared with control patients in a study by Field et al. 68,69
Hypertrophic scarring and pigmentation changes are the 2 main areas of concern in partial-thickness burn healing. Treatment with pressure garments and tubed compression gauze (Tubigrip) require constant patient education and reinforcement, as well as monitoring by physical and occupational therapists. Otherwise, compliance is compromised.
Scar massage techniques with a moisturizing cream should be reinforced as well, usually recommended for 10 minutes, 3 times a day. There is a lack of consensus among burn centers as to the best product to use. A survey of 86 burn center respondents (57%) identified 21 different moisturizing creams (R Richard, unpublished data). A trend was noted related to burn center geography; however, most creams were recommended based on ability to moisturize (Figure 2). Many moisturizing products are available, with the main active ingredients of the creams including petroleum (30%), lanolin (27%), and glycerine (14%). Silicone gel sheets may also be beneficial, probably increasing the surface temperature of the scar that, in turn, increases collagenase activity. 70
Thermal injury also stimulates melanocytes, causing hyperpigmentation of healed partial-thickness burns after sun exposure. Sun protection is an important part of the patient education process after a burn injury and should include sunscreen with a rating of SPF 15.
If hyperpigmentation does occur, it can be treated with hydroquinone cream or laser treatments. Bowes et al 71 showed pigmented hypertrophic scars improved significantly when treated with either a pulsed dye or Q-switched YAG laser, showing a Vancouver Scar Scale measurement of 38%, compared with a 14% improvement in controls.
Hypopigmentation is more difficult to treat, especially in the African American population, and dermal tattooing generally leads to poor results. However, excellent results have been seen in small case series using dermabrasion or CO2 laser ablation and epidermal grafts. 72–74 Most patients prefer to live with or cover-up the hypopigmentation rather than accept the risks of another surgery and donor sites.
The diagnosis and treatment of partial-thickness burns is a challenging part of wound care. Superficial burns can be treated with a variety of products with good success. Indeterminate or deep partial-thickness burns that fail to heal in 3 weeks should be excised and grafted. Efforts to treat partial-thickness burns should be directed toward cost-effective care that promotes good outcomes with less scarring and maintenance of the patient’s range of motion.
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BURN CENTER REFERRAL CRITERIA
A burn center may treat adults, children, or both. Burn injuries that should be referred to a burn center include:
- partial-thickness burns greater than 10% of total body surface area
- burns that involve the face, hands, feet, genitalia, perineum, or major joints
- full-thickness burns in any age-group
- electrical burns, including lightning injury
- chemical burns
- inhalation injury
- burn injury in patients with preexisting medical disorders that could complicate treatment, prolong recovery, or affect mortality
- burn injury in any patient with 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.
- burn injury in children being treated in hospitals without qualified personnel or equipment for the care of children
- burn injury in patients who require special social, emotional, or long-term rehabilitative intervention.
Source: Resources for Optimal Care of the Injured Patient, Chapter 14: Committee on Trauma, American College of Surgeons, 1999.