SECTION IV: INITIAL WOUND MANAGEMENT

Wound assessment as to size, depth and location is necessary before the correct treatment can be initiated.  Treatment is in large part based on depth.

However, it is important to recognize which burns should be immediately referred to a burn center as only minimal initial care is needed for those patients who are to be transferred.

The American Burn Association (ABA) has identified those injuries that should be treated in a specialized burn center.  Patients with these burns should be treated in a specialized burn facility after initial assessment and treatment at an appropriate hospital emergency department.  Sometimes major burns are directly to a burn center from scene if the center is within a safe transport time.

A.  Superficial Second Degree (Partial Thickness Burn)

This depth of burn is at low risk for infection unless grossly contaminated.  Initial cleansing should include removal of dirt, broken blisters and dead epidermis.  Large blisters can be debrided off if using a temporary skin substitute or left intact for a few days.  Often blisters get larger with time and impede movement at which time they should be removed.  Topical antibiotics are not needed, especially cream based agents such as silver sulfadiazine as these agents impede healing and are only used if infection risk is high.

Definition:  Second-degree burns are defined as those burns in which the entire epidermis and variable portions of the dermis layer are heat destroyed.  A superficial second-degree (partial thickness) burn is characterized by heat injury to the upper third of the dermis leaving a good blood supply.

Cause:  Usually hot water.

Appearance:   The micro vessels perfusing this area are injured resulting in the leakage of large amounts of plasma, which in turn lifts off the heat-destroyed epidermis, causing blister formation.  The blisters will continue to increase in size in the post-burn period as well and protein breakdown occurs.  A light pink, wet appearing very painful wound is seen as blisters are disrupted.  Frequently, the epidermis does not lift off the dermis for 12 to 24 hours and what appears initially to be a first degree is actually a second degree burn.

Outcome: 

Healing Rate:  Despite  loss of the entire basal layer of the epidermis, a burn of this depth will heal in seven to fourteen days if non-infected due to repopulation of the epithelial cells that are also present in skin appendages, anchored deep in the dermis.  Minimal to no scarring is expected to occur.  There is a relatively small zone of injury and conversion is uncommon except at extreme of age or chronically ill.  Most antibiotic creams will slow the healing rate.

Treatment:

1. Clean, remove small blisters; apply grease gauze and soft gauze dressing (occlusion, absorbent dressing, changed daily).

2. On face, perineum, apply bacitracin or neomycin ointment, applying several times a day.

3. Excellent alternative is the use of a synthetic adhesive dressing which seals the wound and decreases pain.

4. Use a water-soluble topical antibiotic if the wound is grossly contaminated or if one is unsure if the wound is superficial or deep.

5. Prophylactic systemic antibiotics are not needed.

Hot Water (Superficial Dermal Burn)

B.  Mid-Partial Thickness Burn

It is not necessary to distinguish a superficial from a mid-dermal burn on initial assessment as initial management is basically the same.

Definition:  A mid second degree extends to the mid portion of the dermis.  Longer exposure to hot liquids (5-10 seconds) or flash flames (not direct contact of flames with skin) are the most common causes.

Cause:  Brief exposure to flames or flash explosion: hot water in infant or elderly.

Appearance: The burn surface may have blisters but is more red, less wet and only moderately painful.

Outcome: These burns usually heal in about two to four weeks.  The exception is the very young and elderly where the dermis is thin and dept of burn is invariable deeper.  However, there is a large zone of injury and risk of conversion.  If a burn heals in two weeks, then minimal to no scarring is expected.  With healing time beyond three weeks scarring will occur, the degree being greater in dark skinned individuals.

Treatment: 

1.  In patients six years to 60 years, without diabetes, chronic illness, etc., treatment is grease gauze and occlusive dressing.  A topical antibiotic ointment such as bacitracin can also be used daily. The depth can be underestimated and a switch to an antibiotic cream may be needed if the wound appears deeper on the first dressing change because of risks of infection.

2.  In very young, and very old patients, or those with chronic illness, contaminated wounds or perineal wounds, the traditional choice is a topical antibiotic.  First choice is silver sulfadiazine or a silver dressing with closed dressing technique.

3. New Approach: (a temporary skin substitute) which could increase healing and decrease conversion.

MID-DERMAL BURN (HOT GREASE)

MID-DERMAL BURN (HOT GREASE)

c) Deep Partial Thickness (Deep Second Degree) Burn

A deep dermal burn has not only compromised blood flow but also a layer of adhered dead dermis.  The combination increases the risk for infection.  A topical antibiotic is required to prevent infection until the area is excised and grafted.  Spontaneous healing typically leads to significant scarring.  Often, there are patches of deep and less deep burn together.  Unless the more superficial burn is covered with a skin substitute, the whole area is often treated with a topical agent.  Ointments such as Bacitracin do not adequately penetrate the eschar of a deep burn so a silver release dressing or cream is required.

Prophylactic systemic antibiotics are not needed.  Do not apply a cream on to the wound if the patient is to be transferred immediately to a burn center as it interferes with a wound assessment.

Definition: A deep partial thickness or deep second-degree burn extends well into the dermal layer and fewer viable epidermal cells remain.  Therefore, re-epithelialization is extremely slow, sometimes requiring months.  Grafting is often the preferred treatment for long-term function.

Appearance:  In these patients, blister formation does not characteristically occur because the dead tissue layer is sufficiently thick and adherent to underlying viable dermis that it does not readily lift off the surface.  The wound surface may be red and dry in appearance with white areas in deeper parts (dry since fewer blood vessels are patent).  There is a marked decrease in blood flow making the wound very prone to conversion to a deeper injury and to infection.  It is often not possible to distinguish a deep partial from a full thickness burn by initial appearance.  Frequently the wound is a mixed second and third degree.  Direct contact with flames is a common cause.  Most chemical burns are also deep.  The appearance of the deep dermal burn changes dramatically over the next several days as the area of dermal necrosis along with surface coagulated protein turns the wound a white to yellow color.  The amount of surface coagulum is accentuated with the use of a topical antibiotic, making the deep second degree burn difficult to differentiate from a third degree burn.  The presence of some pain can assist in the diagnosis because pain is usually absent in a full thickness injury.  Fluid losses and the metabolic effects of deep dermal burns are basically the same as that seen with the third degree burn. 

Outcome:  A deep dermal burn will require 4-10 weeks or longer to heal.  Since the new epidermis is very thin and not adhered well to dermis (no rete pegs), wound breakdown is common.  Excision and grafting is the preferred treatment.  Dense scarring is usually seen if the wound is allowed to heal primarily.

Treatment:  After initial cleaning and removal of dirt and loose dead tissue, a topical antibiotic is required. A silver based dressing or cream is the first choice.

E) Chemical Burns

Sect. III Sect. V