Treatment of minor outpatient burns and the referral of major burns is an important aspect of emergency medicine. The essence of successful management of burn injuries is effective triage, timely assessment, and appropriate resuscitation.

Important historical information that must be obtained from a burn patient includes the following points:

• The causative agent (thermal, electrical, chemical, radiant).

• The time and extent of exposure.

• The patients medical status (trauma, illnesses, allergies).

• The time, location (open space vs. closed space), and extent of injury sustained. Also determine the tetanus status, alcohol and drug use, and what first aid treatment was provided.

Significant physical findings in burn injuries are related to depth and extent of the burn.

First-degree burns are the equivalent of a bad sunburn and are characterized by pain and redness. Within a few days the outer layer of injured cells peel away from the totally healed subjacent skin with no residual scarring.

Second-degree burns are usually quite sensitive, both to touch and to exposure, are moist with exudate, and are prone to blister formation. With proper care such wounds may heal spontaneously, though healing may require 2 to 3 weeks.

Third-degree burns are less painful, often anesthetic, and skin is dead, white or charred, with a dry surface. Restoration of the integrity of the skin can be accomplished only by grafting skin from non-burned areas of the body.

All major burns (greater then 20 percent full or partial thickness) require appropriate advanced trauma life support (ATLS) protocol with emphasis on airway and fluid resuscitation and transfer to a burn center. The more common smaller partial thickness burns may be treated as outpatient after thorough washing with surgical soap (Hibiclens or pHisoHex) and application of a sterile non-adherent dressing such as Xeroform or Adaptic gauze covered by a sterile bandage. Further management requires protection from the environment with application clean dressing and bandages, daily, or twice daily along with cleaning with a mild soap until the burn has healed. Topical antimicrobials (i.e., Silvadene) or systemic antibiotics should not be applied to these burns unless there are specific indication for these drugs (i.e., signs of infection). Blisters or bullae that are small and intact need not be opened or removed unless they impede pint motion or show signs of infection. Superficial small size burns about the face can be treated open (without dressing) by daily cleaning and application of Bacitracin ointment. Tetanus prophylaxis and analgesics should be used as indicated.

Should during the outpatient treatment of smaller burns, the wounds show signs of infection or the burn fails to heal within 2 weeks, the patient should be referred for hospitalization and more extensive treatment. Patients with major burns that meet the American Burn Association (ABA) criteria for burn center referral should be assessed, stabilized, and immediately transferred to a burn center. This requires physician-to-physician contact to assure the patient's needs are met throughout every aspect of the transfer. In the military system, burn center referral can be obtained through the Army Institute of Surgical Research (Brook Army Medical Center Burn Unit); by telephone request 24 hours per day to the duty physician (512)-221-2943, DSN: 471-2943, or (512) 222-2876.

References

1. Advances in Burn Care, Clinic in Plastic Surgery, 1986,13:1, W. B. Saunders

2. Am. Burn Life Support Provider's Manual, 1990, Nebraska Burn Institute, Artz, Moncrief and Pruit, 1979.

3. Burn, A Team Approach, W. B. Saunders, William F. McManus, M.D., Colonel, MC, USA, Personal Communication Wiener and Barrett, 1986, Trauma Management, chapter 5, W. B. Saunders