8. Burns to High Risk Areas

Face Burns Foot Burns Perineal Burns Hand Burns Ear Burn
Burns to high risk areas are defined as those which have a high risk of complications and potential disability both functional and cosmetic. These burns should usually be managed in a burn care facility.

 

Face Superficial burns of the face are best managed with a gentle wash, followed by application of a thin layer of bacitracin to keep the wound from drying as well as to maintain control of the predominantly gram-positive organisms on the face.  Skin substitutes can also be used.  Deeper burns will require a topical antibiotic cream with better eschar penetration.  Silver sulfadiazine or silver dressing is the first choice.  This agent can be applied without dressings or on a layer of fine mesh gauze which prevents the cream from running into the eyes, nares, and mouth.

 

Eyes Burns to the eyes must always be considered with a facial burn.  Superficial corneal burns should be managed like any corneal abrasion.  Ophthalmic antibiotic ointment is indicated.  An eye patch is then applied.  Artificial tears every several hours will be required if the tear ducts are involved.  Burns to the eyelids are managed in a similar fashion.

 

Ears Superficial burns to the ears can be managed like those to the face.  However, external pressure should not be applied to the injured helix.  The cartilage is already poorly vascularized and any compression will potentiate further injury.  No pillows or any external pressure are allowed.  In addition, the topical agent, silver sulfadiazine) or mafenide, must be applied multiple times a day, especially if any cartilage is exposed.  Mafenide is the agent of choice for deep burns with a thick eschar.  Chondritis is a major complication that requires an extensive (several weeks) course of systemic antibodies.  Chondritis invariably leads to loss of cartilage and permanent deformity.  Pseudomonas is the most common pathogen.

 

Hands Escharotomies on the hand and fingers must be considered with deep circumferential burn.  Superficial burns of the hands can be effectively managed using Xeroform gauze with a thin layer of bacitracin followed by a soft gauze dressing.  Temporary skin substitutes are also ideal and markedly decrease pain and improve motion.  Topical antibiotics are necessary for deeper burns.  Fingers should be wrapped separately to avoid any impairment.  Hands must be elevated for the first 24 to 48 hours to minimize edema. Movement must be encouraged during the healing process.

 

Feet Burned feet must also be elevated initially.  A compression wrap over a bulky dressing can be used when walking.  Blood supply to the feet is not as good as that to face and hands, and therefore, better topical antibiotic coverage, e.g. silver antibiotic, is usually needed except in the superficial burn.  Because of the difficulty of function and of self-cleaning, foot burns of any significance should be admitted at least for the initial 24 to 48 hours until home care can be arranged.

 

Perineum Superficial burns can be managed open with an antibiotic grease-based ointment that has a broad-spectrum coverage, such as Neosporin.  Hospitalization is usually necessary, at least initially, for observation of urinary obstruction secondary to edema.  Deeper burns by definition require admission with two to three times daily application of topical antibiotic cream, usually silver sulfadiazine.  Open technique or closed dressing, with a loose diaper dressing,  can be used.