ERIC D. MORGAN, MAJ, MC, USA, Eisenhower Army Medical Center, Fort Gordon,
Georgia
SCOTT C. BLEDSOE, CPT, MC, USA, Weed Army Community Hospital, Fort Irwin,
California
JANE BARKER, CPT, MC, USA, Moncrief Army Community Hospital, Fort Jackson,
South Carolina
Am Fam Physician. 2000 Nov 1;62(9):2015-2026.
Burns often happen unexpectedly and have the potential to cause death, lifelong
disfigurement and dysfunction. A critical part of burn management is assessing
the depth and extent of injury. Burns are now commonly classified as superficial,
superficial partial thickness, deep partial thickness and full thickness. A
systematic approach to burn care focuses on the six Cs: clothing, cooling,
cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief). The
American Burn Association has established criteria for determining which
patients can be managed as outpatients and which require hospital admission or
referral to a burn center. Follow-up care is important to assess patients for
infection, healing and ability to provide proper wound care. Complications of
burns include slow healing, scar formation and contracture. Early surgical referral
can often help prevent or lessen scarring and contractures. Family physicians
should be alert for psychologic problems related to long-term disability or
disfigurement from burn injuries.
DEPTH OF A BURN
The traditional classification of burns as first, second or third degree is being
replaced by the designations of superficial (Figure 1), superficial partial thickness
(Figure 2), deep partial thickness (Figure 3) and full thickness (Figure 4).2 Burn
depth has an impact on healing time, the need for hospitalization and surgical
intervention, and the potential for scar development. Although accurate
classification is not always possible initially, the causes and physical
characteristics of burns are helpful in categorizing their depth (Table 1).24
FIGURE 1.
Superficial burns on the trunk and right arm of a young child. Typically, these are
red burns that blanch with pressure.
View Large
FIGURE 2.
Superficial partial-thickness burn on a man's right knee. Blistering wounds that
blanch with pressure are characteristic of superficial partial-thickness burns.
These wounds are also typically moist and weeping.
View Large
FIGURE 3.
Deep partial-thickness burns on the trunk and extremities of a young child. These
burns are typified by easily unroofed blisters that have a waxy appearance and
do not blanch with pressure.
View Large
FIGURE 4.
Full-thickness burn on a woman's left flank. Burn areas of this type are
characteristically insensate and waxy white or leathery gray in color.
View Large
TABLE 1 Classification of Burns Based on Depth
View Table
Differentiating a deep partial-thickness burn from a full-thickness burn can be
quite difficult initially.2,5,6 Revisions of burn-depth estimations are often
necessary in the first 24 to 72 hours5 and may be required through the first two
or three weeks.2 For instance, although a full-thickness burn typically has a white
or charred appearance, it can be red after a scald injury. It is also possible to
have a full-thickness burn underneath a blister, which is usually a characteristic
feature of a partial-thickness burn.3 Furthermore, thin skin sustains deeper burn
injuries than may be suggested by the initial appearance of the wound.5 Thin
skin is common on the volar surface of the arms and on the medial thigh,
perineum and ears. All skin can be presumed to be thin in children younger than
five years and in adults older than 55 years.5 It is best to assume that there are
no shallow burns in these age groups.7
EXTENT OF A BURN
The extent of a burn is expressed as the total percentage of body surface area
(TBSA) affected by the injury. Accurate estimation of the TBSA of a burn is
essential to guide management.
Multiple methods have been developed to estimate the TBSA of burns. These
methods are not used for superficial burns. The best known method, the rule of
nines, is appropriate for use in all adults and when a quick assessment is
needed for a child.2
More accurate methods are required for definitive estimation of the extent of
burns in children. The Lund and Browder method covers all age groups and is
considered the most accurate method to use in pediatric patients (Figure 5).2,8
FIGURE 5.
Modified Lund and Browder chart for estimating the area of burns. This approach
is considered the most accurate for use in pediatric patients. The figures can be
colored in with red for full-thickness burns and blue for partial-thickness burns.
(2nd = second-degree burn; 3rd = third-degree burn; TBSA = total percentage of
body surface area)
Adapted with permission from Mertens DM, Jenkins ME, Warden GD. Outpatient
burn management. Nurs Clin North Am 1997;32:34364, and Lund C, Browder N.
The estimation of areas of burns. Surg Gynecol Obstet 1944;79:3528.
View Large
The surface area of a patient's palm can also be used to estimate the extent of
small or patchy burns. Classically, the palm has been considered to represent 1
percent of the TBSA.2,6 However, a recent study demonstrated that the palm
more accurately represents 0.4 percent of the TBSA, and the entire hand
represents 0.8 percent of the TBSA.9
TABLE 2 American Burn Association's Grading System for Burn Severity and
Disposition of Patients
View Table
Pulmonary insufficiency is responsible for more than 75 percent of fire-related
deaths.1 Because of the possibility of progressive edema, patients with
suspected inhalation injury should be observed for at least 12 to 24 hours.6,11
Historical or physical findings that raise concern about inhalation injury include
coughing, wheezing, dyspnea, facial burns, sooty mucus and laryngeal edema.4
Patients at risk for inhalation injury should also be checked for carbon monoxide
poisoning. An arterial carboxyhemoglobin level of greater than 10 percent tends
to indicate carbon monoxide exposure. Hyperbaric oxygen is the treatment.13
Hospital admission is necessary for patients who have circumferential partialthickness or full-thickness burns, patients who have burn injury and are
considered to be predisposed to infection (e.g., those with diabetes), and
patients who have sustained a high-voltage electrical injury.14 Cardiac
arrhythmias can occur up to 72 hours after high-voltage electrical injury.15
Nonspecific changes in ST-T waves are the most common abnormalities noted on
electrocardiograms (ECGs) obtained subsequent to electrical injuries.
Observation is warranted until the ECG becomes normal.6
Referral to a burn unit is indicated for patients who meet the criteria for major
burns as defined by the ABA (Table 2).6,10 Included are patients who manifest
inhalation injury or have burn marks from high-voltage electrical injury.14
AMBULATORY TREATMENT
Minor burns comprise approximately 95 percent of burn injuries treated by
physicians in the United States.2 Most of these burns can be managed on an
outpatient basis. An algorithm to assist in identifying patients suitable for
ambulatory management is provided in Figure 6.4
Management of Burns
Figure 6.
Algorithm for the management of patients with burns.
Adapted from Peate WF. Outpatient management of burns. Am Fam Physician
1992;45:1326.
View Large
A systematic approach to the ambulatory management of burns is
conceptualized by the six Cs: clothing, cooling, cleaning, chemoprophylaxis,
covering and comforting (i.e., pain relief).4
Clothing. Any clothing that is hot or burned should be removed immediately from
the patient's body. Clothing that has been exposed to chemicals should also be
removed to avoid exposing the skin to continued burn insult. If clothing does not
remove easily, nonadherent material should be cut away, with adherent clothing
left for removal in the cleaning phase.
Cooling. Ideally, burns should be cooled immediately after they occur. Although
most tissue has already cooled by the time patients with burns present to a
physician, further cooling during the first several hours after injury effectively
decreases burn pain.6 Sterile saline-soaked gauze, moderately cooled to around
12C (53.6F), can be applied to the burned tissues.17 Ice application should be
avoided.6,18 Because of the risk of hyperthermia, caution should be exercised in
cooling extensive burns (i.e., those with a TBSA of more than 10 percent).19
Cleaning. Cleaning a burn wound is critical but can cause excruciating pain. It is
therefore important to establish local or regional anesthesia before the wound is
cleaned. Anesthesia should not be applied topically to a burn or injected directly
into the wound.6
Tar and asphalt residues should never be debrided5; instead, they can be
removed with a mixture of cool water and mineral oil.4 Applying copious
amounts of polymyxin Bbacitracin zinc ointment (Polysporin) over several days
should emulsify and remove residual tar.15 Embedded bits of clothing or other
materials should be removed by copious irrigation using a large-gauge syringe.4
To minimize infection, necrotic tissue from partial- and full-thickness burns should
be removed manually or with whirlpool debridement. The latter method tends to
be better tolerated by patients. The yellow eschar characteristic of partialthickness burns need not be removed.4
Infection can involve the depth and extent of a burn, converting a superficial
partial-thickness burn into a deep partial-thickness burn or even a full-thickness
burn. An infected burn is also more susceptible to blood invasion and sepsis.
Because of these risks, all suspected burn infections warrant aggressive
management, including hospital admission and parenteral antibiotic therapy.15
Some authors contend that all infected burns require surgical referral with
consideration of full-thickness skin biopsy to confirm the presence of infection
and identify the causative organism.4 Full-thickness skin grafting after excision
should also be considered.24
Superficial burns do not require infection prophylaxis, but all other burns should
receive topical prophylaxis. Classically, silver sulfadiazine cream (Silvadene) is
used to prevent burn infections. This agent should never be used on the face or
in patients with sulfonamide hypersensitivity. Because of the risk of sulfonamide
kernicterus, silver sulfadiazine should not be used in pregnant women, newborns
or nursing mothers with infants younger than two months of age.4
Biologic dressings are associated with lower infection rates and faster healing
rates than silver sulfadiazine. However, these dressings are expensive, difficult to
apply and not always readily available.14 If used, biologic dressings should be
applied within the first six hours after the burn is sustained. The initial
application may loosen by the following day, necessitating reapplication.
Thereafter, these dressings gradually peel off as skin epithelializes underneath
them. Early separation of the dressing from the skin indicates the presence of a
deeper wound (requiring surgical treatment) or an infection.5
Superficial burns do not require wound dressings. Use of a simple skin lubricant
(e.g., aloe vera cream) is sufficient, and patients should be instructed to see their
physician if any blisters develop.
All partial- and full-thickness burns should be covered with sterile dressings. A
fine mesh gauze (e.g., Telfa) should be applied after the burn has been cleaned
and a thin layer of topical antibiotic has been applied. Circulatory impairment is
minimized by applying this nonadherent dressing in successive strips, rather
than wrapping it around the wound.16 The dressing is held in place with a
tubular net bandage or lightly applied gauze wraps. Tubular net bandages come
in a variety of sizes. This bandage is excellent for use on extremities, and it can
be modified to fit the trunk of a younger child.
Recommended frequencies for dressing changes range from twice daily to once a
week.6 Dressings should be changed whenever they become soaked with
excessive exudate or other fluids.5 At each dressing change, the topical
antibiotic should be removed as completely as possible using gentle washings.
Scrubbing and sharp debridement are not necessary.5
A patient's worst pain score should be less than 5 (on a scale of zero to 10).
Scores of 5 or higher interfere with sleep, activity and mood.28
FOLLOW-UP INTERVALS
Patients with burns who are being managed as outpatients should be seen again
on the day after injury. At this visit, the level of pain can be assessed, pain
medication can be adjusted if necessary, and competence in managing dressing
changes can be assessed. Subsequent follow-up can then be performed on a
weekly basis until wound epithelialization occurs. However, if pain control is
insufficient or there are concerns about the ability of a patient or family members
to provide proper wound care, the patient should be seen on a daily basis until
complete epithelialization occurs.2,6
After epithelialization has occurred, patients are seen every four to six weeks to
assess for evidence of hypertrophic scar formation and to monitor coping
mechanisms.
ROLE OF SURGERY
Surgical excision and skin grafting beginning less than 72 hours after injury is
beneficial and is indicated for nonscald full-thickness burns in children and in
adults younger than 30 years of age.30,34 All other patients with suspected fullthickness burns should be observed for eight to 10 days, as nothing is lost by
delaying surgical excision.5 It is also best to wait two weeks before assessing the
need for surgery in children with hot-water scald burns because overly
aggressive excision and skin grafting in this group has resulted in worse
outcomes.35 Full-thickness burns less than 2 cm wide can be allowed to heal by
contracture as long as they are in nonfunctional, noncosmetic areas and the skin
is not thin (e.g., the ankle).21
The Authors
ERIC D. MORGAN, MAJ, MC, USA, is residency director for the Department of
Family and Community Medicine at Eisenhower Army Medical Center, Fort
Gordon, Ga. He received his medical degree from Loma Linda (Calif.) University
School of Medicine and completed a family practice residency at Tripler Army
Medical Center, Honolulu. He also earned a master of public health degree from
the University of Washington, Seattle, and completed a faculty development
fellowship at Madigan Army Medical Center, Fort Lewis, Wash.
SCOTT C. BLEDSOE, CPT, MC, USA, is a staff physician at the Family Practice
Clinic, Weed Army Community Hospital, Fort Irwin, Calif. He graduated from
Kirksville (Mo.) College of Osteopathic Medicine and recently completed a family
practice residency at Eisenhower Army Medical Center.
JANE BARKER, CPT, MC, USA, is a staff family physician at the Family Health
Center, Moncrief Army Community Hospital, Fort Jackson, S.C. She graduated
from Kirksville College of Osteopathic Medicine and recently completed a family
practice residency at Eisenhower Army Medical Center.
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of the
Army Medical Department or the Army Service at large.
This article is dedicated to Elisabeth Morgan, the daughter of Dr. Eric D. Morgan.
Elisabeth sustained a severe scald injury shortly after her first birthday. Although
Elisabeth's skin permanently reflects the tragedy of the accident and has forever
sensitized her physician father to the horror of burns, her tenacity, vitality and
joy for life are a testament to the ability of the human will and personality to be
more flexible and forgiving than the sometimes fragile bodies in which we live.
REFERENCES
1. Brigham PA, McLoughlin E. Burn incidence and medical care use in the United
States: estimates, trends, and data sources. J Burn Care Rehabil. 1996;17:95
107.
2. Mertens DM, Jenkins ME, Warden GD. Outpatient burn management. Nurs Clin
North Am. 1997;32:34364.
3. Clayton MC, Solem LD. No ice, no butter. Advice on management of burns for
primary care physicians. Postgrad Med. 1995;97(5):1515,15960,165.
6. Hartford CE. Care of outpatient burns. In: Herndon DN, ed. Total burn care.
Philadelphia: Saunders, 1996:7180.
9. Perry RJ, Moore CA, Morgan DB, Plummer DL. Determining the approximate
area of a burn: an inconsistency investigated and re-evaluated. BMJ.
1996;312:1338.
10. Hospital and prehospital resources for optimal care of patients with burn
injury: guidelines for development and operation of burn centers. American Burn
Association. J Burn Care Rehabil. 1990;11:98104.
12. Lull RJ, Tatum JL, Sugerman HJ, Hartshorne MF, Boll DA, Kaplan KA.
Radionuclide evaluation of lung trauma. Semin Nucl Med. 1983;13:2237.
13. Heimbach DM, Waeckerle JF. Inhalation injuries. Ann Emerg Med.
1988;17:131620.
15. Waitzman AA, Neligan PC. How to manage burns in primary care. Can Fam
Physician. 1993;39:2394400.
17. Pushkar NS, Sandorminsky BP. Cold treatment of burns. Burns Incl Therm Inj.
1982;9:10110.
18. Allwood JS. The primary care management of burns. Nurse Pract.
1995;20:74,779,83 passim.
19. Purdue GF, Layton TR, Copeland CE. Cold injury complicating burn therapy. J
Trauma. 1985;25:1678.
20. Hill MG, Bowen CC. The treatment of minor burns in rural Alabama
emergency departments. J Emerg Nurs. 1996;22:5706.
21. Greenhalgh DG. The healing of burn wounds. Dermatol Nurs. 1996;8:1323.
22. Rockwell WB, Ehrlich HP. Should burn blister fluid be evacuated? J Burn Care
Rehabil. 1990;11:935.
23. Karyoute SM, Badran IZ. Tetanus following a burn injury. Burns Incl Therm Inj.
1988;14:2413.
25. Ou LF, Lee SY, Chen YC, Yang RS, Tang YW. Use of Biobrane in pediatric scald
burnsexperience in 106 children. Burns. 1998;24:4953.
26. Ulmer JF. Burn pain management: a guideline-based approach. J Burn Care
Rehabil. 1998;19:1519.
27. Parsons L. Office management of minor burns. Lippincotts Prim Care Pract.
1997;1:409.
28. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain
Inventory. Ann Acad Med Singapore. 1994;23:12938.
29. Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic burn
scars: analysis of variables. J Trauma. 1983;23:8958.
30. Muller MJ, Herndon DN. The challenge of burns. Lancet. 1994;343:21620.
31. Carr-Collins JA. Pressure techniques for the prevention of hypertrophic scar.
Clin Plast Surg. 1992;19:73343.
32. Ahn ST, Monafo WW, Mustoe TA. Topical silicone gel for the prevention and
treatment of hypertrophic scar. Arch Surg. 1991;126:499504.
33. Quinn KJ. Silicone gel in scar treatment. Burns Incl Therm Inj.
1987;13(suppl):S3340.
34. Herndon DN, Barrow RE, Rutan RL, Rutan TC, Desai MH, Abston S. A
comparison of conservative versus early excision therapies in severely burned
patients. Ann Surg. 1989;209:54752.
35. Desai MH, Rutan RL, Herndon DN. Conservative treatment of scald burns is
superior to early excision. J Burn Care Rehabil. 1991;12:4824.
ERIC D. MORGAN, MAJ, MC, Amerika Serikat, Eisenhower Army Medical Center,
Fort Gordon, Georgia
SCOTT C. Bledsoe, CPT, MC, Amerika Serikat, Weed Rumah Sakit Komunitas
Angkatan Darat, Fort Irwin, California
JANE BARKER, CPT, MC, Amerika Serikat, Moncrief Rumah Sakit Komunitas
Angkatan Darat, Fort Jackson, Carolina Selatan
Am Fam Physician. 1 November 2000; 62 (9): 2015-2026.
Lihat terkait handout informasi pasien tentang merawat luka bakar dan
mencegah luka bakar, yang ditulis oleh penulis artikel ini.
Luka bakar sering terjadi tiba-tiba dan memiliki potensi untuk menyebabkan
kematian, cacat seumur hidup dan disfungsi. Sebuah bagian penting dari
manajemen luka bakar yang menilai kedalaman dan luasnya cedera. Luka bakar
sekarang umum diklasifikasikan sebagai dangkal, ketebalan parsial superfisial,
ketebalan parsial yang mendalam dan ketebalan penuh. Suatu pendekatan
sistematis untuk membakar perawatan berfokus pada enam "Cs": pakaian,
pendinginan, membersihkan, kemoprofilaksis, meliputi dan menghibur (yaitu,
penghilang rasa sakit). Asosiasi Bakar Amerika telah membentuk kriteria untuk
menentukan pasien mana yang dapat dikelola sebagai pasien rawat jalan dan
yang memerlukan perawatan di rumah sakit atau rujukan ke pusat luka bakar.
Perawatan Tindak lanjut penting untuk menilai pasien untuk infeksi,
penyembuhan dan kemampuan untuk memberikan perawatan luka yang tepat.
Komplikasi luka bakar termasuk penyembuhan lambat, pembentukan parut dan
kontraktur. Rujukan bedah dini sering dapat membantu mencegah atau
mengurangi jaringan parut dan kontraktur. Dokter keluarga harus waspada untuk
masalah psikologi yang berhubungan dengan cacat jangka panjang atau cacat
dari luka bakar.
Luka bakar dapat menghancurkan luka yang mengakibatkan kematian atau luka
seumur hidup, cacat dan disfungsi. Luka bakar adalah penyebab utama ketiga
kematian karena kecelakaan di Amerika Serikat (setelah insiden yang melibatkan
kendaraan bermotor dan senjata api). Setiap tahun, lebih dari 1 juta orang di
negeri ini mencari perawatan medis untuk luka bakar. Lebih dari 95 persen
pasien tersebut dapat dikelola pada basis.1,2 ambulatory
KEDALAMAN A BURN
Klasifikasi tradisional luka bakar sebagai pertama, tingkat kedua atau ketiga
digantikan oleh sebutan dangkal (Gambar 1), ketebalan parsial superfisial
(Gambar 2), ketebalan dalam parsial (Gambar 3) dan ketebalan penuh (Gambar
4) .2 Bakar mendalam memiliki dampak pada waktu penyembuhan, kebutuhan
untuk rawat inap dan intervensi bedah, dan potensi untuk pengembangan bekas
luka. Meskipun klasifikasi akurat tidak selalu mungkin awalnya, penyebab dan
karakteristik fisik dari luka bakar sangat membantu dalam mengkategorikan
kedalaman (Tabel 1) 0,2-4
Gambar 1.
Luka bakar superfisial pada batang dan lengan kanan dari anak muda. Biasanya,
ini adalah luka bakar merah yang memutihkan dengan tekanan.
Lihat besar
Gambar 2.
Superficial partial-thickness membakar lutut kanan pria. Terik luka yang
memutihkan dengan tekanan merupakan karakteristik dangkal parsial-ketebalan
luka bakar. Luka ini juga biasanya lembab dan menangis.
Lihat besar
GAMBAR 3.
Dalam parsial-ketebalan luka bakar pada batang dan ekstremitas dari anak
muda. Luka bakar ini ditandai oleh lepuh mudah unroofed yang memiliki
penampilan lilin dan tidak pucat dengan tekanan.
Lihat besar
GAMBAR 4.
Full-ketebalan membakar sayap kiri wanita. Membakar area jenis ini berwarna
abu-abu putih atau kasar khas mati rasa dan lilin dalam warna.
Lihat besar
Tabel 1 Klasifikasi Burns Berdasarkan Kedalaman
Lihat Tabel
Membedakan luka bakar parsial-ketebalan yang mendalam dari luka bakar
ketebalan penuh dapat cukup sulit Revisi initially.2,5,6 burn mendalam estimasi
sering diperlukan dalam pertama 24 sampai 72 hours5 dan mungkin diperlukan
melalui dua pertama atau tiga minggu.2 misalnya, meskipun full-thickness burn
biasanya memiliki penampilan putih atau hangus, dapat merah setelah cedera
melepuh. Hal ini juga memungkinkan untuk memiliki luka bakar full-thickness
bawah melepuh, yang biasanya fitur karakteristik dari burn.3 parsial-ketebalan
Selanjutnya, kulit tipis menopang luka bakar lebih dari mungkin disarankan oleh
penampilan awal wound.5 yang kulit tipis adalah umum pada permukaan volar
lengan dan paha medial, perineum dan telinga. Semua kulit dapat dianggap
untuk menjadi kurus pada anak-anak berumur di bawah lima tahun dan pada
orang dewasa yang lebih tua dari 55 tahun.5 Cara terbaik adalah dengan
mengasumsikan bahwa tidak ada luka bakar dangkal ini usia groups.7
LUAS A BURN
Luasnya luka bakar dinyatakan sebagai persentase total luas permukaan tubuh
(TBSA) terkena cedera. Estimasi akurat dari TBSA dari luka bakar sangat penting
untuk membimbing manajemen.
Metode yang lebih akurat diperlukan untuk estimasi definitif tingkat luka bakar
pada anak-anak. The Lund dan Browder metode mencakup semua kelompok usia
dan dianggap sebagai metode yang paling akurat untuk digunakan pada pasien
anak (Gambar 5) .2,8
GAMBAR 5.
Modifikasi Lund dan Browder grafik untuk memperkirakan area luka bakar.
Pendekatan ini dianggap paling akurat untuk digunakan pada pasien anak.
Angka-angka dapat diwarnai dengan merah untuk full-thickness luka bakar dan
biru untuk parsial-ketebalan luka bakar. (2 = tingkat dua luka bakar, 3 = tingkat
tiga bakar; TBSA = persentase total luas permukaan tubuh)
Diadaptasi dengan izin dari Mertens DM, Jenkins ME, Warden GD. Rawat Jalan
membakar manajemen. Nurs Clin Utara Am 1997; 32: 343-64, dan Lund C,
Browder N. Estimasi daerah luka bakar. Surg Gynecol Obstet 1944; 79: 352-8.
Lihat besar
Luas permukaan telapak tangan pasien juga dapat digunakan untuk
memperkirakan luas luka bakar kecil atau tambal sulam. Secara klasik, sawit
telah dianggap mewakili 1 persen dari TBSA.2,6 Namun, penelitian terbaru
menunjukkan bahwa telapak tangan lebih akurat mewakili 0,4 persen dari TBSA,
dan seluruh tangan mewakili 0,8 persen dari TBSA.9 yang
Pasien dianggap memiliki luka bakar moderat berdasarkan sistem penilaian yang
dikembangkan oleh American Association Bakar (ABA) harus diakui untuk hidrasi
intravena dan perawatan bedah luka mereka (Tabel 2) .6,10 Karena kesulitan
awal dalam membedakan partial- dalam ketebalan luka bakar dari full-thickness
luka bakar, dokter keluarga harus mempertimbangkan mendapatkan konsultasi
bedah untuk apa yang tampaknya menjadi luka bakar parsial-ketebalan yang
mendalam yang mempengaruhi lebih dari 3 persen TBSA.4
TABEL 2 Amerika Bakar Sistem Grading Association untuk Bakar Keparahan dan
Disposisi dari Pasien
Lihat Tabel
Insufisiensi paru bertanggung jawab untuk lebih dari 75 persen dari deaths.1
terkait dengan kebakaran Karena kemungkinan edema progresif, pasien dengan
dugaan cedera inhalasi harus diamati selama setidaknya 12 sampai 24
hours.6,11 temuan sejarah atau fisik yang meningkatkan kekhawatiran tentang
cedera inhalasi termasuk batuk, mengi, dyspnea, luka bakar wajah, lendir jelaga
dan laring edema.4
Pasien yang beresiko untuk cedera inhalasi juga harus diperiksa untuk keracunan
karbon monoksida. Tingkat karboksihemoglobin arteri lebih besar dari 10 persen
cenderung menunjukkan paparan karbon monoksida. Oksigen hiperbarik adalah
treatment.13 yang
Anak-anak dengan luka bakar harus dirawat di rumah sakit setiap kali pelecehan
anak dicurigai. Dari 9 sampai 11 persen luka bakar pada anak-anak adalah
cedera nonaccidental, dengan kejadian puncak pada 13-24 bulan age.16 luka
bakar Immersion adalah luka bakar klasik dalam pelecehan anak, tetapi
pelecehan harus dicurigai dengan cedera melepuh, terutama jika ada demarkasi
yang tajam antara tanda kulit atau percikan terbakar dan normal
penyalahgunaan anak absent.6 juga harus diduga kuat pada anak-anak dengan
luka bakar sugestif rokok atau panas besi injuries.6
Rujukan ke unit luka bakar diindikasikan untuk pasien yang memenuhi kriteria
untuk luka bakar besar seperti yang didefinisikan oleh ABA (Tabel 2) .6,10
Termasuk pasien yang memanifestasikan cedera inhalasi atau membakar tanda
dari tegangan tinggi listrik injury.14
PENGOBATAN ambulatory
Luka bakar ringan terdiri sekitar 95 persen dari luka bakar dirawat oleh dokter di
Amerika States.2 Sebagian besar luka bakar ini dapat dikelola secara rawat jalan.
Sebuah algoritma untuk membantu dalam mengidentifikasi pasien cocok untuk
manajemen rawat disediakan pada Gambar 6.4
Manajemen Burns
Gambar 6.
Algoritma untuk pengelolaan pasien dengan luka bakar.
Diadaptasi dari Peate WF. Manajemen Rawat Jalan luka bakar. Am Fam Physician
1992; 45: 1326.
Lihat besar
Suatu pendekatan sistematis terhadap manajemen rawat luka bakar yang
dikonsep oleh enam "Cs": pakaian, pendinginan, membersihkan, kemoprofilaksis,
meliputi dan menghibur (yaitu, penghilang rasa sakit) .4
Pakaian. Setiap pakaian yang panas atau terbakar harus segera dihapus dari
tubuh pasien. Pakaian yang telah terkena bahan kimia juga harus dihapus untuk
menghindari mengekspos kulit untuk terus membakar penghinaan. Jika pakaian
tidak menghapus dengan mudah, bahan nonadherent harus dipotong, dengan
pakaian patuh tersisa untuk dihapus dalam tahap pembersihan.
Pendingin. Idealnya, luka bakar harus didinginkan segera setelah mereka terjadi.
Meskipun sebagian besar jaringan telah didinginkan oleh pasien dengan luka
bakar saat hadir untuk dokter, pendinginan lebih lanjut selama beberapa jam
pertama setelah cedera efektif menurunkan bakar pain.6 steril saline-direndam
kasa, cukup didinginkan sampai sekitar 12 C (53,6 F) , dapat diterapkan untuk
dibakar tissues.17 aplikasi Ice harus avoided.6,18 Karena risiko hipertermia, hatihati harus dilakukan dalam pendingin luka bakar yang luas (yaitu, orang-orang
dengan TBSA lebih dari 10 persen) .19
Tar dan aspal residu tidak boleh debrided5; sebaliknya, mereka dapat dihapus
dengan campuran air dingin dan oil.4 mineral Menerapkan jumlah berlebihan
polimiksin B-bacitracin zinc salep (Polysporin) selama beberapa hari harus emulsi
dan menghapus sisa bit tar.15 Tertanam pakaian atau bahan lainnya harus
dihapus oleh irigasi berlebihan menggunakan syringe.4 besar-gauge
Lepuh pecah harus dihapus. Banyak ahli merekomendasikan lecet unroofing jika
mereka berisi cairan keruh atau cenderung pecah waktu dekat (misalnya, lepuh
yang terletak di atas sendi) .15,22 Manajemen bersih, lepuh utuh kontroversial.
Lepuh utuh tidak boleh disedot dengan jarum karena peningkatan risiko
infection.3,15,22 Bertahannya lepuh selama beberapa minggu, tanpa tandatanda resorpsi, biasanya menunjukkan adanya suatu partial- mendalam yang
mendasari atau full-thickness burn.6
Mendiagnosis infeksi pada pasien dengan luka bakar menantang. Luka bakar
menimbulkan peradangan, yang menghasilkan ringan eritema, edema, rasa sakit
dan nyeri. Jika tanda-tanda ini terjadi bersamaan dengan lymphangitis, demam,
malaise dan anoreksia, atau jika mereka meningkat dari tingkat dasar, infeksi
harus suspected.6
Luka bakar superfisial tidak memerlukan profilaksis infeksi, tetapi semua luka
bakar lainnya harus menerima profilaksis topikal. Secara klasik, silver
sulfadiazine krim (Silvadene) digunakan untuk mencegah infeksi luka bakar.
Agen ini tidak boleh digunakan pada wajah atau pada pasien dengan
sulfonamide hipersensitivitas. Karena risiko sulfonamide kernikterus, sulfadiazine
perak tidak boleh digunakan dalam hamil wanita, bayi baru lahir atau ibu
menyusui dengan bayi yang lebih muda dari dua bulan age.4
Bacitracin adalah antibiotik profilaksis topikal alternatif. Agen ini harus selalu
digunakan sekitar selaput lendir. Karena penurunan biaya, beberapa penulis
mendukung menggunakan bacitracin daripada sulfadiazin perak untuk setiap
dangkal parsial-ketebalan burn.3 ada studi yang membandingkan khasiat dari
bacitracin dan sulfadiazine perak tersebut belum dipublikasikan.
Alternatif untuk antibiotik topikal juga pembalutan biologis (kulit babi, allograft
manusia) dan bismuth-diresapi minyak kasa atau dressing Biobrane. Keuntungan
dari dressing ini adalah bahwa mereka diterapkan hanya sekali. Akibatnya,
pasien terhindar dari rasa sakit yang biasanya menyertai perubahan rias.
Dressing biologis berhubungan dengan tingkat infeksi yang lebih rendah dan
tingkat penyembuhan lebih cepat dari sulfadiazin perak. Namun, dressing ini
mahal, sulit untuk menerapkan dan tidak selalu mudah available.14 Jika
digunakan, dressing biologis harus diterapkan dalam enam jam pertama setelah
luka bakar berkelanjutan. Penerapan awal dapat melonggarkan pada hari
berikutnya, yang memerlukan reapplication. Setelah itu, dressing ini secara
bertahap melepas sebagai kulit epithelializes bawah mereka. Pemisahan awal
saus dari kulit menunjukkan adanya luka yang lebih dalam (memerlukan
perawatan bedah) atau infection.5
Semua partial- dan full-thickness luka bakar harus ditutup dengan perban steril.
Sebuah kasa fine mesh (misalnya, Telfa) harus diterapkan setelah luka bakar
telah dibersihkan dan lapisan tipis antibiotik topikal telah diterapkan. Penurunan
sirkulasi diminimalkan dengan menerapkan berpakaian nonadherent ini di strip
berturut-turut, daripada membungkusnya sekitar wound.16 Dressing diadakan di
tempat dengan balutan bersih tubular atau ringan diterapkan wraps kasa. Perban
bersih Tubular datang dalam berbagai ukuran. Perban ini sangat baik untuk
digunakan pada ekstremitas, dan dapat dimodifikasi agar sesuai dengan bagasi
anak muda.
Frekuensi yang disarankan untuk perubahan rias berkisar dari dua kali sehari
untuk sekali dressing week.6 harus diubah setiap kali mereka menjadi basah
dengan eksudat yang berlebihan atau fluids.5 lainnya Pada setiap perubahan
rias, antibiotik topikal harus dihapus selengkap mungkin menggunakan
pembasuhan lembut. Scrubbing dan debridement tajam tidak diperlukan.5
Skor nyeri terburuk Seorang pasien harus kurang dari 5 (pada skala nol sampai
10). Skor dari 5 atau lebih tinggi mengganggu tidur, aktivitas dan mood.28
Jika epitelisasi luka belum dimulai setelah dua minggu atau jika evaluasi
berikutnya mengungkapkan adanya sebuah full-thickness membakar lebih dari 2
cm, pasien harus dirujuk ke dokter bedah dengan keahlian dalam membakar
care.2,6,15 kecil terbuat dr batu baiduri pulau epitel seluruh luka menunjukkan
epitelisasi, dengan luka biasanya penyembuhan sepenuhnya dalam tujuh sampai
10 days.6
Setelah epitelisasi telah terjadi, pasien terlihat setiap empat sampai enam
minggu untuk menilai bukti pembentukan bekas luka hipertrofik dan memantau
mekanisme koping.
Kontraktur Scar menyebabkan cacat dan cacat. Jika terdeteksi dini, contracture
dapat diobati dengan sisipan silikon dan tekanan. Jika contracture lebih maju,
belat statis terus menerus dipakai ditambahkan untuk menjaga peregangan
berkelanjutan. Setelah berbagai gerak tercapai, belat dapat dikurangi dengan
penggunaan malam hari sampai bekas luka sepenuhnya matang. Intervensi
bedah harus dipertimbangkan jika contracture tidak sepenuhnya reduced.31
PERAN BEDAH
Eksisi bedah dan cangkok kulit mulai kurang dari 72 jam setelah cedera yang
bermanfaat dan diindikasikan untuk nonscald full-thickness luka bakar pada
anak-anak dan pada orang dewasa yang lebih muda dari 30 tahun age.30,34
Semua pasien lain yang diduga penuh luka bakar harus diamati selama delapan
sampai 10 hari, karena tidak ada yang hilang dengan menunda excision.5 bedah
Hal ini juga yang terbaik untuk menunggu dua minggu sebelum menilai
kebutuhan untuk operasi pada anak-anak dengan air panas melepuh luka bakar
karena eksisi terlalu agresif dan cangkok kulit di grup ini telah menghasilkan di
lebih buruk outcomes.35 Full-ketebalan luka bakar kurang dari 2 cm lebar dapat
diizinkan untuk sembuh dengan kontraktur selama mereka berada di
nonfungsional, daerah noncosmetic dan kulit tidak tipis (misalnya, pergelangan
kaki) .21
Gatal adalah masalah umum selama proses penyembuhan. Pruritus sering dipicu
atau diperburuk oleh lingkungan ekstrim (terutama panas), aktivitas fisik dan
stress.6 gatal biasanya berkurang secara bertahap dan akhirnya berhenti setelah
healing.6 luka lengkap Sampai saat itu, sejumlah langkah dapat digunakan untuk
mengendalikan gatal. Antihistamin sistemik biasanya mencoba pertama, dengan
diphenhydramine (Benadryl) digunakan siproheptadin paling frequently.5,6
(Periactin) dan hydroxyzine (Atarax) adalah ukuran lokal alternatives.6 termasuk
bikarbonat soda mandi dan pelembab lotions.5 Banyak pasien lebih memilih
untuk memakai longgar , lembut, kapas clothing.6
Penulis
ERIC D. MORGAN, MAJ, MC, Amerika Serikat, adalah direktur residensi untuk
Departemen Keluarga dan Pengobatan Masyarakat di Eisenhower Army Medical
Center, Fort Gordon, Ga. Ia menerima gelar dokter dari Loma Linda (California.)
University School of Medicine dan menyelesaikan residensi praktek keluarga di
Tripler Army Medical Center, Honolulu. Dia juga meraih gelar master kesehatan
masyarakat dari University of Washington, Seattle, dan menyelesaikan beasiswa
pengembangan fakultas di Madigan Army Medical Center, Fort Lewis, Wash.
SCOTT C. Bledsoe, CPT, MC, Amerika Serikat, adalah seorang dokter staf di
Praktek Klinik Keluarga, Weed Rumah Sakit Komunitas Angkatan Darat, Fort Irwin,
California. Ia lulus dari Kirksville (Mo) College of Osteopathic Medicine dan baru
saja menyelesaikan latihan residensi keluarga di Eisenhower Army Medical
Center.
JANE BARKER, CPT, MC, Amerika Serikat, adalah seorang dokter keluarga staf di
Puskesmas Keluarga, Rumah Sakit Komunitas Moncrief Angkatan Darat, Fort
Jackson, SC Dia lulus dari College of Osteopathic Kirksville Kedokteran dan baru
saja menyelesaikan residensi praktek keluarga di Eisenhower Army Medical
Center.
Foto-foto dalam angka 1 sampai 4 yang disediakan oleh Steve Bracci dari Joseph
M. Masih Burn Center di Rumah Sakit Dokter, Augusta, Ga.
REFERENSI
1 Brigham PA, McLoughlin E. Membakar kejadian dan penggunaan perawatan
medis di Amerika Serikat: perkiraan, tren, dan sumber data. J Bakar Perawatan
Rehabil. 1996; 17: 95-107.
2 Mertens DM, Jenkins ME, Warden GD. Rawat Jalan membakar manajemen. Nurs
Clin Utara Am. 1997; 32: 343-64.
3 Clayton MC, Solem LD. Tidak ada es, tidak ada mentega. Rekomendasi
pengelolaan luka bakar untuk dokter perawatan primer. Pascasarjana Med. 1995;
97 (5): 151-5,159-60,165.
4. Peate WF. Manajemen Rawat Jalan luka bakar. Am Fam Physician. 1992; 45:
1321-1330.
5. Baxter CR. Manajemen luka bakar. Dermatol Clin. 1993; 11: 709-14.
6 Hartford CE. Perawatan rawat jalan luka bakar. In: Herndon DN, ed. Jumlah
perawatan luka bakar. Philadelphia: Saunders, 1996: 71-80.
8 Lund C, Browder N. Estimasi daerah luka bakar. Surg Gynecol Obstet. 1944; 79:
352-8.
9. Perry RJ, Moore CA, Morgan DB, Plummer DL. Menentukan taksiran luas luka
bakar: inkonsistensi diselidiki dan re-evaluasi. BMJ. 1996; 312: 1338.
10 Rumah Sakit dan sumber daya pra-rumah sakit untuk perawatan optimal
pasien dengan luka bakar: pedoman untuk pengembangan dan pengoperasian
pusat luka bakar. Amerika Bakar Association. J Bakar Perawatan Rehabil. 1990;
11: 98-104.
11. Monafo WW. Manajemen awal luka bakar. N Engl J Med. 1996; 335: 1581-6.
12. Lull RJ, Tatum JL, Sugerman HJ, Hartshorne MF, Boll DA, Kaplan KA. Evaluasi
radionuklida dari trauma paru. Semin Nucl Med. 1983; 13: 223-7.
13. Heimbach DM, Waeckerle JF. Terhirup cedera. Ann Emerg Med. 1988; 17:
1316-1320.
14. Schonfeld N. manajemen Rawat Jalan luka bakar pada anak-anak. Pediatr Pgl
Care. 1990; 6: 249-53.
15. Waitzman AA, Neligan PC. Bagaimana mengelola luka bakar dalam
perawatan primer. Bisa fam Dokter. 1993; 39: 2394-400.
17. Pushkar NS, Sandorminsky BP. Pengobatan dingin luka bakar. Termasuk luka
bakar Therm Inj. 1982; 9: 101-10.
18. Allwood JS. Manajemen perawatan primer luka bakar. Perawat Pract. 1995;
20: 74,77-9,83 passim.
19 Purdue GF, Layton TR, Copeland CE. Cedera Dingin komplikasi terapi luka
bakar. J Trauma. 1985; 25: 167-8.
20. Bukit MG, Bowen CC. Pengobatan luka bakar ringan di bagian gawat darurat
Alabama pedesaan. J Emerg Nurs. 1996; 22: 570-6.
21. Greenhalgh DG. Penyembuhan luka bakar. Dermatol Nurs. 1996; 8: 13-23.
22. Rockwell WB, Ehrlich HP. Harus membakar cairan blister dievakuasi? J Bakar
Perawatan Rehabil. 1990; 11: 93-5.
23. Karyoute SM, Badran IZ. Tetanus setelah luka bakar. Termasuk luka bakar
Therm Inj. 1988; 14: 241-3.
25. Ou LF, Lee SY, Chen YC, Yang RS, Tang YW. Penggunaan Biobrane pada anak
melepuh luka bakar-pengalaman dalam 106 anak-anak. Burns. 1998; 24: 49-53.
27. Parsons L. Kantor manajemen luka bakar ringan. Lippincotts Prim Perawatan
Pract. 1997; 1: 40-9.
28 Cleeland CS, Ryan KM. Penilaian nyeri: penggunaan global dari Brief Nyeri
Persediaan. Ann Acad Med Singapura. 1994; 23: 129-38.
29. Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic bekas
luka bakar: analisis variabel. J Trauma. 1983; 23: 895-8.
30. Muller MJ, Herndon DN. Tantangan luka bakar. Lancet. 1994; 343: 216-20.
31. Carr-Collins JA. Teknik tekanan untuk pencegahan parut hipertrofik. Clin Plast
Surg. 1992; 19: 733-43.
32. Ahn ST, Monafo WW, Mustoe TA. Gel silikon topikal untuk pencegahan dan
pengobatan bekas luka hipertrofik. Arch Surg. 1991; 126: 499-504.
33. Quinn KJ. Gel silikon dalam pengobatan bekas luka. Termasuk luka bakar
Therm Inj. 1987; 13 (suppl): S33-40.
34. Herndon DN, Barrow RE, Rutan RL, Rutan TC, Desai MH, Abston S.
Perbandingan konservatif dibandingkan terapi eksisi awal luka bakar parah
pasien. Ann Surg. 1989; 209: 547-52.
35. Desai MH, Rutan RL, Herndon DN. Pengobatan konservatif dari melepuh luka
bakar lebih unggul eksisi awal. J Bakar Perawatan Rehabil. 1991; 12: 482-4.
ERIC D. MORGAN, MAJ, MC, USA, Eisenhower Army Medical Center, Fort Gordon,
Georgia
SCOTT C. BLEDSOE, CPT, MC, USA, Weed Army Community Hospital, Fort Irwin,
California
JANE BARKER, CPT, MC, USA, Moncrief Army Community Hospital, Fort Jackson,
South Carolina
Am Fam Physician.2000 Nov 1;62(9):2015-2026.
Burns often happen unexpectedly and have the potential to cause death, lifelong
disfigurement and dysfunction. A critical part of burn management is assessing
the depth and extent of injury. Burns are now commonly classified as superficial,
superficial partial thickness, deep partial thickness and full thickness. A
systematic approach to burn care focuses on the six Cs: clothing, cooling,
cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief). The
American Burn Association has established criteria for determining which
patients can be managed as outpatients and which require hospital admission or
referral to a burn center. Follow-up care is important to assess patients for
infection, healing and ability to provide proper wound care. Complications of
burns include slow healing, scar formation and contracture. Early surgical referral
can often help prevent or lessen scarring and contractures. Family physicians
should be alert for psychologic problems related to long-term disability or
disfigurement from burn injuries.
DEPTH OF A BURN
The traditional classification of burns as first, second or third degree is being
replaced by the designations of superficial (Figure 1), superficial partial thickness
(Figure 2), deep partial thickness (Figure 3) and full thickness (Figure 4).2 Burn
depth has an impact on healing time, the need for hospitalization and surgical
intervention, and the potential for scar development. Although accurate
classification is not always possible initially, the causes and physical
characteristics of burns are helpful in categorizing their depth (Table 1).24
Gambar 1.
Superficial burns on the trunk and right arm of a young child. Typically, these are
red burns that blanch with pressure.
Lihat besar
FIGURE 2.
Superficial partial-thickness burn on a man's right knee. Blistering wounds that
blanch with pressure are characteristic of superficial partial-thickness burns.
These wounds are also typically moist and weeping.
Lihat besar
FIGURE 3.
Deep partial-thickness burns on the trunk and extremities of a young child. These
burns are typified by easily unroofed blisters that have a waxy appearance and
do not blanch with pressure.
Lihat besar
FIGURE 4.
Full-thickness burn on a woman's left flank. Burn areas of this type are
characteristically insensate and waxy white or leathery gray in color.
Lihat besar
TABLE 1 Classification of Burns Based on Depth
Lihat Tabel
Differentiating a deep partial-thickness burn from a full-thickness burn can be
quite difficult initially.2,5,6 Revisions of burn-depth estimations are often
necessary in the first 24 to 72 hours5 and may be required through the first two
or three weeks.2 For instance, although a full-thickness burn typically has a white
or charred appearance, it can be red after a scald injury. It is also possible to
have a full-thickness burn underneath a blister, which is usually a characteristic
feature of a partial-thickness burn.3 Furthermore, thin skin sustains deeper burn
injuries than may be suggested by the initial appearance of the wound.5 Thin
skin is common on the volar surface of the arms and on the medial thigh,
perineum and ears. All skin can be presumed to be thin in children younger than
five years and in adults older than 55 years.5 It is best to assume that there are
no shallow burns in these age groups.7
EXTENT OF A BURN
The extent of a burn is expressed as the total percentage of body surface area
(TBSA) affected by the injury. Accurate estimation of the TBSA of a burn is
essential to guide management.
Multiple methods have been developed to estimate the TBSA of burns. These
methods are not used for superficial burns. The best known method, the rule of
nines, is appropriate for use in all adults and when a quick assessment is
needed for a child.2
More accurate methods are required for definitive estimation of the extent of
burns in children. The Lund and Browder method covers all age groups and is
considered the most accurate method to use in pediatric patients (Figure 5).2,8
FIGURE 5.
Modified Lund and Browder chart for estimating the area of burns. This approach
is considered the most accurate for use in pediatric patients. The figures can be
colored in with red for full-thickness burns and blue for partial-thickness burns.
TABLE 2 American Burn Association's Grading System for Burn Severity and
Disposition of Patients
Lihat Tabel
Pulmonary insufficiency is responsible for more than 75 percent of fire-related
deaths.1 Because of the possibility of progressive edema, patients with
suspected inhalation injury should be observed for at least 12 to 24 hours.6,11
Historical or physical findings that raise concern about inhalation injury include
coughing, wheezing, dyspnea, facial burns, sooty mucus and laryngeal edema.4
Patients at risk for inhalation injury should also be checked for carbon monoxide
poisoning. An arterial carboxyhemoglobin level of greater than 10 percent tends
to indicate carbon monoxide exposure. Hyperbaric oxygen is the treatment.13
Hospital admission is necessary for patients who have circumferential partialthickness or full-thickness burns, patients who have burn injury and are
considered to be predisposed to infection (e.g., those with diabetes), and
patients who have sustained a high-voltage electrical injury.14 Cardiac
arrhythmias can occur up to 72 hours after high-voltage electrical injury.15
Nonspecific changes in ST-T waves are the most common abnormalities noted on
electrocardiograms (ECGs) obtained subsequent to electrical injuries.
Observation is warranted until the ECG becomes normal.6
Referral to a burn unit is indicated for patients who meet the criteria for major
burns as defined by the ABA (Table 2).6,10 Included are patients who manifest
inhalation injury or have burn marks from high-voltage electrical injury.14
AMBULATORY TREATMENT
Minor burns comprise approximately 95 percent of burn injuries treated by
physicians in the United States.2 Most of these burns can be managed on an
outpatient basis. An algorithm to assist in identifying patients suitable for
ambulatory management is provided in Figure 6.4
Management of Burns
Gambar 6.
Algorithm for the management of patients with burns.
Adapted from Peate WF. Outpatient management of burns. Am Fam Physician
1992;45:1326.
Lihat besar
Clothing. Any clothing that is hot or burned should be removed immediately from
the patient's body. Clothing that has been exposed to chemicals should also be
removed to avoid exposing the skin to continued burn insult. If clothing does not
remove easily, nonadherent material should be cut away, with adherent clothing
left for removal in the cleaning phase.
Tar and asphalt residues should never be debrided5; instead, they can be
removed with a mixture of cool water and mineral oil.4 Applying copious
amounts of polymyxin Bbacitracin zinc ointment (Polysporin) over several days
should emulsify and remove residual tar.15 Embedded bits of clothing or other
materials should be removed by copious irrigation using a large-gauge syringe.4
To minimize infection, necrotic tissue from partial- and full-thickness burns should
be removed manually or with whirlpool debridement. The latter method tends to
be better tolerated by patients. The yellow eschar characteristic of partialthickness burns need not be removed.4
Infection can involve the depth and extent of a burn, converting a superficial
partial-thickness burn into a deep partial-thickness burn or even a full-thickness
burn. An infected burn is also more susceptible to blood invasion and sepsis.
Because of these risks, all suspected burn infections warrant aggressive
management, including hospital admission and parenteral antibiotic therapy.15
Some authors contend that all infected burns require surgical referral with
consideration of full-thickness skin biopsy to confirm the presence of infection
and identify the causative organism.4 Full-thickness skin grafting after excision
should also be considered.24
Superficial burns do not require infection prophylaxis, but all other burns should
receive topical prophylaxis. Classically, silver sulfadiazine cream (Silvadene) is
used to prevent burn infections. This agent should never be used on the face or
in patients with sulfonamide hypersensitivity. Because of the risk of sulfonamide
kernicterus, silver sulfadiazine should not be used in pregnant women, newborns
or nursing mothers with infants younger than two months of age.4
Biologic dressings are associated with lower infection rates and faster healing
rates than silver sulfadiazine. However, these dressings are expensive, difficult to
apply and not always readily available.14 If used, biologic dressings should be
applied within the first six hours after the burn is sustained. The initial
application may loosen by the following day, necessitating reapplication.
Thereafter, these dressings gradually peel off as skin epithelializes underneath
them. Early separation of the dressing from the skin indicates the presence of a
deeper wound (requiring surgical treatment) or an infection.5
Superficial burns do not require wound dressings. Use of a simple skin lubricant
(e.g., aloe vera cream) is sufficient, and patients should be instructed to see their
physician if any blisters develop.
All partial- and full-thickness burns should be covered with sterile dressings. A
fine mesh gauze (e.g., Telfa) should be applied after the burn has been cleaned
and a thin layer of topical antibiotic has been applied. Circulatory impairment is
minimized by applying this nonadherent dressing in successive strips, rather
than wrapping it around the wound.16 The dressing is held in place with a
tubular net bandage or lightly applied gauze wraps. Tubular net bandages come
in a variety of sizes. This bandage is excellent for use on extremities, and it can
be modified to fit the trunk of a younger child.
Recommended frequencies for dressing changes range from twice daily to once a
week.6 Dressings should be changed whenever they become soaked with
excessive exudate or other fluids.5 At each dressing change, the topical
antibiotic should be removed as completely as possible using gentle washings.
Scrubbing and sharp debridement are not necessary.5
A patient's worst pain score should be less than 5 (on a scale of zero to 10).
Scores of 5 or higher interfere with sleep, activity and mood.28
FOLLOW-UP INTERVALS
Patients with burns who are being managed as outpatients should be seen again
on the day after injury. At this visit, the level of pain can be assessed, pain
medication can be adjusted if necessary, and competence in managing dressing
changes can be assessed. Subsequent follow-up can then be performed on a
weekly basis until wound epithelialization occurs. However, if pain control is
insufficient or there are concerns about the ability of a patient or family members
to provide proper wound care, the patient should be seen on a daily basis until
complete epithelialization occurs.2,6
After epithelialization has occurred, patients are seen every four to six weeks to
assess for evidence of hypertrophic scar formation and to monitor coping
mechanisms.
ROLE OF SURGERY
Surgical excision and skin grafting beginning less than 72 hours after injury is
beneficial and is indicated for nonscald full-thickness burns in children and in
adults younger than 30 years of age.30,34 All other patients with suspected fullthickness burns should be observed for eight to 10 days, as nothing is lost by
delaying surgical excision.5 It is also best to wait two weeks before assessing the
need for surgery in children with hot-water scald burns because overly
aggressive excision and skin grafting in this group has resulted in worse
outcomes.35 Full-thickness burns less than 2 cm wide can be allowed to heal by
contracture as long as they are in nonfunctional, noncosmetic areas and the skin
is not thin (e.g., the ankle).21
of soda baths and moisturizing lotions.5 Many patients prefer to wear loose, soft,
cotton clothing.6
The Authors
ERIC D. MORGAN, MAJ, MC, USA, is residency director for the Department of
Family and Community Medicine at Eisenhower Army Medical Center, Fort
Gordon, Ga. He received his medical degree from Loma Linda (Calif.) University
School of Medicine and completed a family practice residency at Tripler Army
Medical Center, Honolulu. He also earned a master of public health degree from
the University of Washington, Seattle, and completed a faculty development
fellowship at Madigan Army Medical Center, Fort Lewis, Wash.
SCOTT C. BLEDSOE, CPT, MC, USA, is a staff physician at the Family Practice
Clinic, Weed Army Community Hospital, Fort Irwin, Calif. He graduated from
Kirksville (Mo.) College of Osteopathic Medicine and recently completed a family
practice residency at Eisenhower Army Medical Center.
JANE BARKER, CPT, MC, USA, is a staff family physician at the Family Health
Center, Moncrief Army Community Hospital, Fort Jackson, S.C. She graduated
from Kirksville College of Osteopathic Medicine and recently completed a family
practice residency at Eisenhower Army Medical Center.
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of the
Army Medical Department or the Army Service at large.
This article is dedicated to Elisabeth Morgan, the daughter of Dr. Eric D. Morgan.
Elisabeth sustained a severe scald injury shortly after her first birthday. Although
Elisabeth's skin permanently reflects the tragedy of the accident and has forever
sensitized her physician father to the horror of burns, her tenacity, vitality and
joy for life are a testament to the ability of the human will and personality to be
more flexible and forgiving than the sometimes fragile bodies in which we live.
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