Burn Care Procedures: Wound Evaluation

WOUND EVALUATION
C H A P T E R 3 8
Emergency clinicians should be aware that the depth of a burn
wound cannot always be determined accurately on clinical
Burn Care Procedures grounds alone at initial evaluation and that burn injury is a
dynamic process that may change over time, particularly during
Anthony S. Mazzeo the 24 to 48 hours after the burning process has been arrested.
It is common, for example, for a seemingly minor or superficial
burn to appear deeper on the second or third return visit (Fig.
38.1). This phenomenon is not a continuation of the burning
process that can be altered by clinician intervention but is
Testimates
wo million people suffer a burn-related injury every year
in the United States. The American Burn Association (ABA)
that almost 500,000 of these patients received medical
considered to be a pathophysiologic event related to tissue
edema, dermal ischemia, or desiccation.6
evaluation and treatment in 2014 and approximately 40,000

required hospitalization.1 According to the 2014 National Burn
Estimating Burn Depth
Repository,2 patients who suffer burn injuries are predominately The depth of a burn has historically been classified by degree.7
male (69%), and their mean age is 32 years old. Children First degree involves the epidermis only, second-degree (or
younger than 5 years account for 19% of burns, and patients partial-thickness) burns extend into the dermis, and third-degree
older than 60 years account for an additional 13%. Seventy-four (or full-thickness) burns destroy the entire skin. An additional
percent of all burns involve less than 10% of the total body fourth degree is sometimes used to describe injuries to the
surface area (TBSA). Nearly 80% of all burns are caused by underlying muscle, tendon, or bone (Fig. 38.2).
flame or fire or by scalds, with scald injury occurring most in First-degree burns involve the epidermis only (Fig. 38.3A).
children younger than 5 years. The skin is reddened but is intact and not blistered. This
Overall, the incidence of burn injury has declined in recent injury ranges from mildly irritating or even pruritic to exquisitely
decades and advances in medical care have improved the painful. Minor edema may be noted. Causes include ultraviolet
morbidity and mortality of burn patients.2,3 Enhancements in light (as in sunburn) and brief thermal “flash” burns. First-
resuscitation, surgical and anesthetic techniques, intensive care, degree burns may blister within 24 to 36 hours, and the patient
infection control, nutrition, and metabolic support have all should be warned about this possibility. Frequently, the epi-
contributed to dramatic improvements in the survival, preserva- dermis may flake or peel within 5 to 10 days. Healing occurs
tion of body function, physical appearance, and emotional spontaneously, usually without scarring.
outcomes of patients with this injury. The initial care provided Second-degree burns involve the epidermis and extend into
to burn patients by emergency medical providers can improve the dermis to include the sweat glands and hair follicles.
outcomes by preventing the conversion of superficial burns to Superficial second-degree burns involve only the papillary
deep burns requiring surgery and by improving the long-term dermis (see Fig. 38.3B). These burns are pink, moist, and
functional and cosmetic outcomes of the affected tissues. extremely painful. Blisters are common and the skin may slough.
The classification of burns is based on three criteria4: depth The burn blanches with pressure, and mild to moderate edema
of skin injury, percentage of TBSA involved, and source of is common. Hair follicles often remain intact. Superficial
injury (thermal, chemical, electrical, or radiation). The serious- second-degree burns are the most common burns seen in the
ness of a burn injury is determined by the characteristics and emergency department (ED). The usual causes are scalds,
temperature of the burning agent, the duration of exposure, contact with hot objects, or exposure to chemicals. Barring
the location of the injury, the presence of associated injuries, infection or repeated trauma, these burns heal spontaneously
and the age and general health of the victim (Table 38.1). and without scarring in approximately 2 weeks. These areas
The ABA defines minor burns as uncomplicated partial- may be sensitive to sunburn, windburn, and skin irritation for
thickness burns involving less than 5% TBSA in children months after the original injury has healed.
(<10 years old) or the elderly (>50 years old), less than 10% Deep second-degree burns involve the reticular dermis and
TBSA in adults, or full-thickness burns less than 2% TBSA.5 appear mottled white or pink (see Fig. 38.3C). There is obvious
Moderate or major burns include injuries that involve a greater edema and sloughing of the skin, and any blisters are usually
TBSA, as well as burns in areas of specialized function, such ruptured. Blanching is absent. These burns are not generally
as the face, hands, feet, and perineum. More serious burns painful initially and may have decreased sensation, but pressure
also include those caused by a high-voltage electrical injury may be perceived. Within a few days, however, these burns
or those with associated inhalation injuries or other major can become exquisitely painful. This type of burn may be
trauma. converted to a full-thickness injury by further trauma or
Throughout the course of history, clinicians have experi- infection.
mented with burn therapies to relieve pain and promote healing. Third-degree burns result from complete loss of the dermis
Many treatment regimens and home remedies have been and may extend into subcutaneous (SQ) tissue (see Fig. 38.3D).
successful, largely because minor burns generally do well with These burns usually appear dry, pearly white, or charred. They
a modicum of intervention and commonsense wound care. are initially painless, with a leathery texture. Circumferential
Although little has changed in the care of minor ambulatory third-degree burns on an extremity or the torso cause a loss
burns over the past 3 decades, treatment of major burns has of elasticity that may impair the circulation or ventilation and
significantly improved, including the development of sophis- necessitate an escharotomy.
ticated burn centers, increased knowledge of burn wound Fourth-degree burns extend deeply into SQ tissue,
physiology, and prevention of infection. muscle, fascia, or bone (see Fig. 38.3E). These burns are
774
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TABLE 38.1 Characteristics of Burns, by Depth
CLASSIFICATION TIME TO COMPLETE
OF BURN ETIOLOGY APPEARANCE SENSATION HEALING SCARRING
First Degree
Superficial Sunburn, other Dry, red Present 3–7 days No
epidermal UV exposure Blanches with pressure May be quite
layers Short flash flame painful
burns
Second Degree
Varying depth, blisters, or bullae formation
Dermal appendages spared (e.g., sweat glands, hair follicles)
Includes entire epidermis and some portion of the dermis
Superficial Water scald Blisters, peeling skin Painful 7–21 days Unusual if no infection
partial thickness Longer flash burn Blanches with pressure Exposure to and proper follow-up
Skin red and moist air and Pigment change may
under blisters temperature be seen
painful Burned area may be
sensitive to frostbite,
windburn, and sunburn
for many months
Itching may be
problematic for weeks
after healing
Deep partial Flame Variable color Pressure only >21 days Severe; risk for
thickness Water immersion Wet or waxy dry, does contracture
Oil, grease, hot not blanch
foods (e.g., soup) Blisters easily
removed, skin peeling
off
Third Degree
Loss of all skin Flame, steam, oil Leathery appearance, Deep pressure Never heals Very severe, high risk
elements, grease white or charred, dry, only Requires for contracture
thrombosis and Immersion, scald inelastic; blanching grafting
coagulation of Caustic chemical, with pressure
vessels high voltage May be present under
blisters
UV, Ultraviolet.
Modified after Clayton MC, Solem LD: No ice, no butter: advice on management of burns for primary care physicians, Postgrad Med 97:151, 1995; Morgan ED, Bledsoe
SC, Barker J: Ambulatory management of burns, Am Fam Physician 62:2015, 2000.
A B C
Figure 38.1 It may be difficult to accurately assess the depth or severity of a burn on the first visit.
A, This full-thickness burn will not heal without a skin graft. B, This blistered hot water burn
is probably second degree, but full-thickness burns can develop under blisters. C, At 2 weeks, a
second-degree burn and a small area of third-degree burn (arrows).
776 SECTION VI Soft Tissue Procedures
First degree
Epidermis
Superficial
second degree
Dermis
Deep
second degree
Figure 38.2 Depths of a burn. First-degree burns are confined to the

epidermis. Second-degree burns extend into the dermis (dermal burns). Subcutaneous fat
Third-degree burns are full thickness through the epidermis and dermis. Third degree
Fourth-degree burns involve injury to underlying tissue structures such
as muscle, tendons, and bone. (From Townsend CM, Beauchamp RD, Muscle
Evers BM, et al., editors: Sabiston textbook of surgery, ed 19, St. Louis, Fourth degree
2012, Saunders.)
A B
C D
Figure 38.3 Depth of thermal injury. A, Patient with sunburn on

the lower extremity (a superficial or first-degree burn with associated
blisters on the anterior tibial surface). B, Partial-thickness injury of
the hand (superficial second-degree burn). C, Partial-thickness injury
extending beyond the subcutaneous layers (deep second-degree burn).
D, Full-thickness (third-degree) burn. E, Full-thickness injury with
extensive tissue loss (fourth-degree burn). (From Davis PJ, Cladis FP,
Motoyama EK, editors: Smith’s anesthesia for infants and children, ed 8, E
St. Louis, 2011, Mosby.)
CHAPTER 38 Burn Care Procedures 777
TABLE 38.2 American Burn Association’s Grading System for Burn Severity and Disposition of Patientsa
Type of Burn
Minor Moderate Major
Criteria <10% TBSA burn in adult 10%–20% TBSA burn in adult >20% TBSA burn in adult
<5% TBSA burn in young or old 5%–10% TBSA burn in young or old >10% TBSA burn in young or old
<2% full-thickness burn 2%–5% full-thickness burn >5% full-thickness burn
High-voltage injury High-voltage burn
Suspected inhalation injury Known inhalation injury
Circumferential burn Any significant burn involving the
Concomitant medical problem face, eyes, ears, hands, feet,
predisposing the patient to infection genitalia, or joints
(e.g., diabetes, sickle cell disease) Significant associated injuries (e.g.,
fracture, other major trauma)
Disposition Outpatient management Hospital admission vs. higher-level, Consider referral to a burn centerb
structured outpatient care
a
Burn, partial-thickness or full-thickness burn, unless specified; young, patient younger than 10 years; adult, patient 10 to 50 years of age; old, patient older than 50 years.
b
Decision to refer to a burn center is according to physician judgment on a case-by-case basis. The above list are guidelines set by the ABA for consideration for referral.
TBSA, Total body surface area (percentage) affected by the injury.
Adapted with permission from 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 11:98, 1990; with additional information from Hartford CE: Care of outpatient burns. In Herndon DN, editor: Total burn care,
Philadelphia, 1996, Saunders p 71.
characteristically caused by contact with molten metal, flame, the emergency provider to accurately estimate the burn size.
or high-voltage electricity. Note that first-degree burns do not count in the calculation
A more practical method of classifying burns is to describe of total burn surface area when utilizing fluid resuscitation
them as either superficial or deep because this approach defines formulas. Overestimating the burn size is a common error,
both treatment and prognosis. In general, first- and second- especially in children. Several formulas are available to estimate
degree burns are considered partial-thickness burns, whereas TBSA in burn patients. In 1944, Lund and Browder published
third- and fourth-degree burns are full-thickness burns. As the now famous Lund-Browder chart (Fig. 38.4).9,10 In their
such, superficial burns involve the papillary dermis, with its landmark paper, they used direct measurements and body
rich vascular plexus, and the epidermis, which permits spontane- surface area formulas to produce a chart that clinicians can
ous healing by reepithelialization from the dermal appendages, use to estimate %TBSA. Burn centers typically utilize the
including hair follicles, sebaceous glands, and sweat glands. Lund-Browder chart for estimating burn size.11 The initial
This usually occurs within 2 weeks with minimal scarring. Lund-Browder chart was developed from human anatomic
Superficial burns appear wet, pink, and blistered and blanch studies derived from 11 adults (3 women and 8 men) and
with pressure. They are painful. Deep burns involve the reticular produced a unisex chart. A 2004 study involving 60 volunteers
dermis and SQ fat and generally lack sufficient epithelial determined that the Lund-Browder chart significantly under-
appendages for spontaneous healing. If healing does occur, it estimates the size of chest burns in large-breasted women.
will occur slowly and produce unstable skin, hypertrophic The investigators developed a table that incorporates a cor-
scarring, and contracture. Deep burns are best treated by rection using brassiere cup size.12
excision and skin grafting. The initial appearance of deep burns The simplest method for estimating TBSA in adults is the
ranges from cherry red, mottled, white, and nonblanching to “rule of nines.” This formula was developed in the late 1940s
leathery, charred, brown, and insensate (Table 38.2). by Pulaski and Tennison, who observed that the percentage
Although bedside evaluation of very superficial or deep of each body segment was approximately a multiple of nine
wounds presents little diagnostic difficulty, clinical assessment (Fig. 38.5).13 Similar formulas for children adjust estimates for
of a mid-dermal or “indeterminate” burn is accurate only their disproportionately large head surface area. However, in
approximately two-thirds of the time.8 Even though it is useful a study of obese patients it was determined that this formula
to initially characterize the extent of the burn, it must be noted underestimates %TBSA of the legs and torso and overestimates
that the early appearance of a burn wound may not accurately %TBSA of the arms and head. The authors suggested replacing
reflect the true extent of the soft tissue injury. Reexamination the “rule of nines” with a “rule of fives” for obese patients
and follow-up are critical because burn wounds may change heavier than 80 kg.
during the 24 to 72 hours following injury. Indeterminate burns The size of a burn can also be estimated by using the patient’s
may eventually heal spontaneously, or they may convert to deeper hand as representing approximately 1% TBSA. With this
wounds requiring excision and skin grafting (see Fig. 38.1). method, the hand is a rectangle. However, two studies using
planimetry have determined that the hand actually represents
from 0.5% to 0.78% of a patient’s TBSA.14
Estimating Burn Size Regardless of the method used, it is important for the
Calculating burn size is necessary to determine treatment plan, emergency provider to take time to quantify the %TBSA
fluid requirements, and aids in prognosis. It is important for as accurately as possible. It should be reemphasized that
Entire head and neck (9%)

(front and back)
31/2 31/2
Entire chest and Entire back and
abdomen (18%) 1
1 buttocks (18%)
13
Entire arm (9%) 2 13 2 2 2 Entire arm (9%)
(front and back) (front and back)
11/2 5 11/2 11/2 11/2 A A
21/2 21/2
11/4
1 11/4 11/4
11/4
43/4 43/4 43/4 43/4
13
2 13 2 2 2
11/2 5 11/2 11/2 11/2

Entire leg (18%) Entire leg (18%) 21/2 21/2
(front and back) (front and back) 1
31/4 31/4 31/4 31/4 B B 1
11/4 B B 11/4 11/4 1 /4
C C C C
13/4 13/4 13/4 13/4 13/4 13/4 13/4 13/4
See chart for A, B, and C

A according to age
AGE Birth–1 yr 1–4 yr 5–9 yr 10–14 yr 15 yr Adult

Head 19 17 13 11 9 7
Neck 2
Ant trunk 13
Post trunk 13
R buttock 21/2
L buttock 21/2
Genitalia 1
R U arm 4
L U arm 4
R L arm 3
L L arm 3
R hand 21/2 61/2 8 81/2 9 91/2
L hand 21/2 61/2 8 81/2 9 91/2
R thigh 51/2 5 51/2 6 61/2 7
L thigh 51/2 5 51/2 6 61/2 7
R leg 5
L leg 5
R foot 31/2
L foot 31/2
B BODY AREA
Figure 38.4 Lund-Browder charts. A, The Lund-Browder charts are somewhat more accurate than
the rule of nines in estimating the total body surface area (TBSA) burned. B, Proportion of TBSA
of individual areas according to age. When compared with adults, children have larger heads and
smaller legs. Other areas are relatively equivalent throughout life. The rule of nines is not accurate
in determining the percentage of TBSA burned in children.
fluid recommendations based on %TBSA DO NOT include 2. Zone of stasis: injured tissue in which blood flow is impaired.
first-degree burns in the %TBSA, rather they are based Desiccation, infection, or mechanical trauma may lead to
on %TBSA of second- and third- (and fourth-) degree burns. cell death.
Including first-degree burns in the calculation of %TBSA 3. Zone of hyperemia: minimally injured, inflamed tissue that
results in an overestimate of the total burned areas, and is a forms the border of the wound. The hyperemia usually
common error. resolves within 7 to 10 days but may be mistaken for
cellulitis.
Histologically, full-thickness burns are characterized by conflu-
HISTOPATHOLOGY OF BURNS ent vascular thrombosis involving arterioles, venules, and
capillaries. Edema secondary to loss of microvascular integrity
One thermal wound theory describes three zones of injury in results not only from the effects of direct thermal injury but
burns (Fig. 38.6)15: also from the release of vasoactive mediators. The increase in
1. Zone of coagulation: dead, avascular tissue that must be vascular permeability is linked to activation of complement
débrided. and release of histamine. Histamine increases catalytic activity
9
OUTPATIENT VERSUS INPATIENT CARE
One of the first steps in minor burn care is to select patients
for whom outpatient care is appropriate. For patients determined
18 to require inpatient care, the decision to admit or transfer the
FRONT
patient depends on the burn care capabilities of the initial
18 treating facility. Guidelines set forth by the ABA17 regarding
BACK criteria for referral to a burn center are listed hereafter. Burn
9 9
injuries that should be considered for referral to a burn center
1 18
include the following:
1. Partial thickness burns greater than 10% TBSA
18 18 18
2. Burns involving the face, hands, feet, genitalia, perineum,
FRONT or major joints
9 9 3. Third-degree burns in any age group
4. Electrical burns, including lightning injury
1 5. Chemical burns
14 14 6. Inhalation injury
7. Burn injury in patients with preexisting medical disorders
that could complicate management, prolong recovery, or
affect mortality
Figure 38.5 The “rule of nines.” The rule of nines is a rough estimate 8. Any patient with burns and concomitant trauma in which
of the total body surface area (TBSA) burned. Note that adults and the burn injury poses the greatest risk for morbidity or
children are different. This formula frequently overestimates the extent mortality after emergency or surgical stabilization of the
of a burn in clinical practice. As a rough guide, the area covered by traumatic injuries. In such cases if the trauma poses the
the individual’s palm is approximately 1.25% TBSA. See Fig. 38.4 for greatest immediate risk, the patient’s condition may be
a more accurate method of determining TBSA burned in children. stabilized initially in a trauma center before transfer to a
burn center. Physician judgment will be necessary in such
situations and should be in concert with the regional
Epidermis medical control plan and triage protocols.
Zone of 9. Burned children in hospitals without qualified personnel
coagulation
or equipment for the care of children
10. Burn injury in patients who will require special social,
emotional, or rehabilitative intervention
Zone of Note, the previously-mentioned guidelines are not absolute
stasis
clinical mandates and clinical judgment and patient charac-
Dermis teristics may allow certain patients listed in these categories
Zone of to be treated appropriately without transfer to a burn center.18
hyperemia If in doubt, the decision to admit a patient with an acute burn
injury is rarely inappropriate. Candidates who can be considered
Figure 38.6 Zones of injury after a burn. The zone of coagulation
for outpatient treatment are generally adults and children
is the portion that is irreversibly injured. The zones of stasis and meeting the ABA criteria for minor burn criteria. Burns usually
hyperemia are defined in response to the injury. (From Townsend better managed initially on an inpatient basis are large or deep
CM, Beauchamp RD, Evers BM, et al., editors: Sabiston textbook of burns involving the hands, face, feet, neck, or perineum; burns
surgery, ed 19, St. Louis, 2012, Saunders.) resulting from abuse or attempted suicide; burns occurring in
association with other trauma or inhalation injuries; and
chemical or electrical burns.
of the enzyme xanthine oxidase, with resultant production of Patients who are at risk for poor outcomes with even minor
hydrogen peroxide and hydroxyl radicals. These by-products burns include patients with concomitant medical problems
increase the damage to dermal vascular endothelial cells and such as diabetes mellitus, peripheral vascular disease, congestive
result in progressive vascular permeability.16 heart failure, and end-stage renal disease; patients taking steroids
The cellular debris and denatured proteins of the eschar or other immunosuppressive agents; patients who are very
provide a milieu that supports the proliferation of microorgan- young or very old; those who are mentally impaired or have
isms. The devitalized tissue (eschar) sloughs spontaneously, drug and alcohol dependency; homeless persons; those who
usually as a result of the proteolytic effect of bacterial enzymes. are malnourished; and patients without a sufficient home support
The greater the degree of wound bacteriostasis, the greater system. Whereas very minor burns in these patients may still
the delay in sloughing. be treated appropriately in the outpatient setting, inpatient
Partial-thickness burns result in incomplete vascular treatment might be necessary in these circumstances even
thrombosis, usually limited to the upper dermis. The dermal though the burn might be considered “minor” by ABA criteria.
circulation is restored gradually, generally over a period of Other admission considerations include pain control, the ability
several days, thus resulting in a significant interval of relative to return for follow-up care, the degree of incapacity, the ability
ischemia. The eschar in deep partial-thickness burns is thinner to receive wound care at home, and the overall social situation;
than in a full-thickness burn and sloughs as a result of reepi- all should influence the final decision of whether admission
thelialization rather than bacterial proteolysis. or transfer is warranted.19
BOX 38.1 General Approach to Blisters With

Minor Burnsa
IF TREATED LESS THAN 48 HOURS AFTER THE BURN

1. Leave all intact blisters alone.
2. If blisters have ruptured, treat them as dead skin and débride
them completely.
3. Needle aspiration of blisters is not advised.
ON FOLLOW-UP OR MORE THAN 48 TO 72 HOURS AFTER

THE BURN
1. Débride large (>6 cm in diameter) intact blisters and all
blisters that have ruptured. Large, firm blisters on the palms
and soles may be left intact longer. Do not aspirate blisters.
2. Do not débride small or spotty blisters until they break or
Figure 38.7 This patient suffered from circumferential third-degree
until 5 to 7 days after the burn.
burns on the arm, and compartment syndrome developed. Escharotomy
was required.
FIVE TO 7 DAYS AFTER THE BURN
1. Débride all blisters completely.
a
All blisters and burned skin are débrided in the presence of infection. Note: Multiple whenever the injuries are of indeterminate depth, affect a
approaches to blisters are acceptable, and practice varies considerably. large area, or are deep and require surgical excision or if
Note: Intact blisters provide significant pain relief. Be prepared for an there are systemic manifestations of chemical toxicity or
exacerbation of pain immediately after débridement. Prophylactic analgesia is
when the chemical responsible for injury requires a specific
recommended.
antidote. Swelling from deep circumferential burns may
constrict the chest or limbs and result in compartment
syndrome. Such burns should be monitored frequently to
Additional guidelines that can guide emergency providers determine the potential need for escharotomy or fasciotomy
in determining the need for admission following an acute burn (Fig. 38.7). Whenever the patient’s condition prevents a
injury include the following: reliable clinical examination, direct measurement of compart-
1. Patients requiring intravenous (IV) access. Following a burn ment pressures can provide an objective measurement of
there is an immediate capillary leak of plasma-like fluid intracompartmental pressure and assist in the decision to
that can last for 18 to 24 hours. In burns involving greater perform these surgical procedures (see Chapter 54). Adult
than 20% TBSA, the leak occurs in both burned and and pediatric patients with extensive burn injuries that
nonburned tissues. If not replaced, this fluid loss can lead require fluid resuscitation with large volumes of crystalloid
to hypovolemic shock and renal failure. IV fluid resuscitation should be monitored closely for the development of
is indicated for all patients with second- and third-degree abdominal compartment syndrome.20 Patients with mechani-
burns greater than 10% TBSA, in patients younger than cal burns involving large areas of skin loss or with significant
10 or older than 50 years, and for burns greater than 20% frostbite injuries are often admitted for specialized wound
TBSA in all other age groups. care and parenteral pain management. Patients with certain
2. Anticipated surgery. Deep burns are best treated by early electrical injuries may require admission for cardiac monitor-
surgical excision and skin grafting. This permits faster wound ing, specialized wound care, or IV fluids.
healing, provides more stable skin, and reduces contractures.
Hospital admission facilitates wound care and preparation
for surgery.
3. Respiratory problems. Patients with respiratory distress requir- PROCEDURE
ing oxygen therapy and those suspected of inhaling toxic
fumes or vapors should be admitted for observation or
Emergency Treatment
intubation and for mechanical ventilation (Box 38.1). Direct Home or field treatment and ED care overlap. Initial treatment
bronchoscopic evaluation of the airway may assist in the of a thermal injury begins immediately following the burn. If
evaluation and diagnosis of tracheobronchitis or pneumonitis safe to do so, patients should be rapidly removed from the
from a smoke inhalation injury. source of injury. Flames are extinguished by smothering the
4. Need for special nursing care. Specialized wound care, dressings, fire with a blanket, jacket, or equivalent item; by dousing
and nursing care are often required for burns involving the the fire with water; or by using a chemical fire extinguisher.
face, hands, feet, perineum, and genitalia and may best be Most chemical injuries are best treated by irrigating the affected
treated on an inpatient basis if outpatient care is not feasible area with copious quantities of clean water. Patients with
or ideal based on the case specifics. Patients unable to care electrical injuries are removed from contact with the electrical
for themselves or those lacking family and friends able to source as soon as it is safe to do so.
assist them may also require admission. Cooling is most beneficial for small burns if started within 3
5. Special burn injuries. Chemical injuries are often more severe minutes of injury and possibly of additional benefit if continued
than the initial examination would suggest. Unlike thermal for the first few hours after the burn. Doing so has been shown
burns, tissue destruction may continue many hours after to reduce pain significantly and can limit tissue damage by
injury. Patients with chemical injuries should be admitted decreasing thromboxane production. When cooling a burn
BOX 38.2 ABA ABLS Initial Fluid

Recommendations for Burn Patients
in First 24 Hours
1. Lactated Ringer’s (LR) is the fluid of choice.

2. Estimate %TBSA (count second and third degree only)
3. Obtain actual body weight in kilograms.
4. Utilize appropriate formula as detailed below:
• Adults with Thermal and Chemical Burns:
2 mL LR × patient’s body weight in kg × %TBSA
Figure 38.8 To cool a burn that cannot easily be immersed in water, (second and third degree only)
cover the area with unfolded gauze pads that have been soaked in • Children 14 years or younger and body weight of
room-temperature saline. Continue to frequently soak the gauze with less than 40 kg
cool saline or tap water drawn up in a syringe. Adding a few ice chips 3 mL LR × child’s weight in kg × %TBSA (second
to the liquid is helpful, but do not cover the burn with ice. Towels are and third degree only)-add normal maintenance fluid to
generally too bulky for this procedure. Narcotics are the best way to
the fluid requirements, consider including dextrose in
control pain in any burn, and should be used liberally.
maintenance fluids for infants and young children who
may rapidly deplete glycogen stores, particularly for
wound, it is important to avoid hypothermia or freezing of those 2 years and younger.97
tissue because this may deepen the injury.21 At home or in the • Adult patients with High Voltage Electrical Injuries
field, room-temperature or cold tap water irrigation, immersion, If there is evidence of deep tissue injury or red pigments in
or compresses (20°C to 25°C) will provide some pain relief urine use:
without the risk of further injuring burned tissues and inducing 4 mL LR × patient’s body weight in kg × %TBSA
hypothermia, which can occur with iced solutions (Fig. 38.8).22,23 (second and third degree only)
Placing ice on a burn should not be done. Sterile dressings are 5. Infuse half of the calculated 24-hour fluid needs in the first
not required for field treatment; a moist towel or nonadherent 8 hours following the burn. Infuse the second half of the
sheet may be used. Nonmentholated shaving cream makes 24-hour fluid needs in the next 16 hours (hours 9–24)
an excellent temporary covering for out-of-hospital use if a 6. Increase or decrease the fluid rate based on the patient’s
dressing is not available.24 Home remedies, such as butter or urine output (and pigment). Adjust fluids to maintain urine
Vaseline, are best avoided but are probably benign.25 Remove output at 0.5 mL/kg per hr in adults and 1 mL/kg per hr in
jewelry and gross debris in the field if possible. children.
ABA, American Burn Association; ABLS, advanced burn life support; TBSA, total
body surface area.
Initial Care of Major Burns
Major burns require the specialized resources of a burn center.
In such cases, emergency providers should initiate the resuscita- (under age 14 and weight less than 40 kg), the ABLS advises
tion, consult the burn center for referral, and transfer the a total of 3 mL LR × body weight in kilograms × % second- and
patient as soon as practically possible. Initial resuscitation should third-degree burns in the first 24 hours. It should be noted
follow standardized trauma protocols, including a primary and that 24 hours starts at the time of the burn and not the time
secondary survey, and provide immediate interventions directed medical care begins. After the total amount is calculated, fluids
at airway management, breathing, and cardiovascular support, should be administered as a constant infusion rather than by
as needed. IV catheters can be inserted initially through burned bolus administration. Half of the calculated fluid requirement
skin when unburned sites are unavailable. Early IV access should be given in the first 8 hours and the remaining half
permits the administration of resuscitative fluids, medications, provided over the following 16 hours (Box 38.2). Lastly, these
and parenteral narcotics to relieve the pain. Patients with burns fluid quantities are guidelines and urine output monitoring
exceeding 20% TBSA should receive IV fluid resuscitation with will assist in adjusting the rate or volume to meet the target
lactated Ringer’s (LR) solution based on various available formulas. outputs of 0.5 mL/kg per hour for adults and 1 mL/kg per
LR solution is preferred because large saline infusions will hour for children weighing under 40 kg. According to the
produce hyperchloremic acidosis. One need not use bolus ABA, Foley catheter placement is advised in major burns to
fluid resuscitation as fluids are lost via capillary leak and via accurately monitor urine output.
the raw skin, and significant fluid loss does not occur within More recently, the US Army Institute of Surgical Research
the first hour. has advocated a simpler formula for estimating hourly fluid
Historically, the Parkland or Brooke formulas have been requirements in burn patients. This simpler formula may be
used to estimate fluid needs. It should be noted that the 2011 more useful for prehospital providers or ED resuscitation (Box
Advanced Burn Life Support (ABLS) Manual specifies that 38.3). The formulas estimate hourly fluid requirements and
research has shown that the Parkland formula’s 4 mg/kg × must be adjusted up or down to achieve a urine output of 0.5
%TBSA formula commonly results in excessive edema formation to 1.0 mL/hr. Insertion of a Foley catheter is usually necessary
and over-resuscitation.11 Whether this is because first-degree to accurately measure hourly urine output.
burns may have been erroneously included in the %TBSA or Patients exposed to carbon monoxide should have carboxy-
other reasons is unclear. For adults the ABLS advises a total hemoglobin levels measured and empirically receive 100%
of 2 mL LR × body weight in kilograms × % second- and oxygen. The duration of oxygen administration will depend
third-degree burns in the first 24 hours. For pediatric patients on the level and symptoms of the individual patient, but often
BOX 38.3 Simplified ED Burn Fluid Resuscitation: BOX 38.4 Baux Score and Modified Baux Score
the Rule of 10 to Predict Mortality in Burn Injury
1. Estimate burn size (%TBSA) to the nearest 10. Original Baux Score: % Mortality = Age + %TBSA
2. %TBSA × 10 = initial fluid rate in mL/hr (for adult patients Modified Baux Score: % Mortality = Age + %TBSA +
weighing 40 to 80 kg). 17*(Inhalation Injury, Yes=1, No=0)
3. For every 10 kg above 80 kg, increase the rate by 100 mL/hr.
ED, Emergency department; TBSA, total body surface area.
From Chung KK, Salinas J, Renz EM, et al: Simple derivation of the initial fluid
rate for the resuscitation of severely burned adult combat casualties: in silico
validation of the rule of 10, J Trauma 69:S49–S54, 2010.
require 6 hours or more. Once considered a traditional empirical

treatment, there is no evidence-based proven benefit from
hyperbaric oxygen therapy for carbon monoxide poisoning. A
Cochrane review (http://www.summaries.cochrane.org/
CD002042) concluded that there is insufficient evidence to Plot of the observed mortality versus the group midpoint computed
support the use of hyperbaric oxygen for the treatment of within 10 groups of the revised Baux score.
patients with carbon monoxide poisoning. The Cochrane review From Baux S: Contribution a l’Etude du traitment local des brulures
of published trials found conflicting, potentially biased, and thermigues etendues, Paris, 1961, These; Osler, et al: Simplified estimates and
generally weak evidence regarding the usefulness of hyperbaric probability of death after burn injuries: extending and updating the Baux score,
J Trauma Inj Crit Care 68(3):690–697, 2010.
oxygen for the prevention of neurologic injury. Per an evidence-
based analysis, existing randomized trials do not establish
whether the administration of hyperbaric oxygen to patients
with carbon monoxide poisoning reduces the incidence of transfer to a burn center or before surgical consultation, remove
adverse neurologic outcomes. Because there may still be any wet cooling dressings that may have been applied initially
advocates of hyperbaric oxygen therapy, consultation with a and cover the wounds with dry gauze dressings.
local hyperbaric center is reasonable in certain cases, but it is
not standard that this intervention be routinely implemented.
Critically ill and pregnant patients are still often offered
Initial Care of Minor Burns
hyperbaric treatment, but controversy over the efficacy and Prompt cooling of the burned part is an almost instinctive
safety persists even for these subgroups. response and is one of the oldest recorded burn treatments,
Cyanide is released from mattress fires and burning of uphol- having been recommended by Galen (AD 129–199) and Rhazes
stery. Patients suspected of having been exposed to significant (AD 852–923).6 In the ED, room-temperature or cold tap water
levels of cyanide and manifesting symptoms should receive irrigation, immersion, or compresses (20°C to 25°C) are optimal
hydroxocobalamin (Cyanokit [Meridian Medical Technologies, in obtaining pain relief and providing some measure of protec-
Inc., Columbia, MD]). If not available, the Cyanide Antidote tion for burned tissues without the problems of hypothermia
Package may be used despite lack of proven benefit of this that iced solutions can cause.10,12 If not done before ED
traditional cyanide therapy. It is reasonable to empirically treatment, immediate cold water immersion may still have
administer hydroxocobalamin or the sodium thiosulfate portion some ability to limit the extent of a burn and will provide
of the cyanide kit to burn victims in coma or to those exhibiting significant pain relief. It is acceptable to add a few ice chips
metabolic (lactic) acidosis after smoke exposure. to the water, but packing the wound in ice must be avoided.
In addition to the logical increased mortality with larger All involved clothing and jewelry (such as rings), along with
areas of TBSA involved, the mortality of patients with burns any gross debris, should be removed from the burned area.
is also increased when concomitant inhalation is present. The Chemical burns involving the skin or eyes require prolonged
Baux Score was developed a half-century ago by Professor tap water irrigation. The burn should otherwise be covered
Serge Baux to estimate the mortality of burns.26 This score was with a moist, sterile dressing. In the ED and prehospital phase,
updated in 2010 using data from the National Burn Registry to appropriate analgesics, usually narcotics, are the best way to
include the effect of inhalation injury to mortality (Box 38.4).27 control pain and should not be forgotten in the initial phase
In short, the original Baux score became outdated because of burn care. The burned area may be immersed immediately
advances in care of the burn victim which has improved the in room-temperature water or covered with gauze pads soaked
mortality of patients. The modified Baux score is now more in room-temperature water or saline (see Fig. 38.8). The gauze
accurate for modern burn survival rates. may be kept cool and moist to provide continued pain relief;
Burn patients have an impaired ability to regulate their core the patient will let the clinician know when additional cooling
body temperature and will quickly become hypothermic if is desired. Many clinicians use sterile saline for cooling, but
untreated. Core temperature should be measured frequently, it has no proven benefit over tap water, even when the skin is
and active and passive warming strategies should be imple- broken. It is acceptable to add ice chips to water or saline to
mented to prevent hypothermia from developing. This can lower the temperature. As stated previously, immersion of
include minimizing exposure by covering patients with sheets burned tissue in ice or ice water should be avoided because
and blankets, warming IV fluids, warming the room, or applying ice immersion increases pain and risks frostbite injury or
radiant or convective warming systems. In anticipation of systemic hypothermia.
to remove only grossly devitalized tissue. Additional débride-

BOX 38.5 Advantages of Prompt Burn Cooling
ment of the wound can take place, if needed, during sub-
sequent follow-up visits when the wound has matured.
Limit extent of thermal damage 3. Consider applying a layer of antibiotic cream or ointment
Reduction or cessation of pain such as 1% silver sulfadiazine (Silvadene [Pfizer Inc., New
Elimination of local hyperthermia York, NY]) or bacitracin directly to the wound (see Fig.
Inhibition of postburn tissue destruction 38.10D).
Decreased edema 4. Apply fine-mesh gauze or commercial nonadherent gauze
Reduced metabolism and toxin production such as Adaptic or petrolatum gauze impregnated with 3%
bismuth tribromophenate (Xeroform [DeRoyal, Powell,
TN]) to the burn wound.
The potential benefits of burn cooling are listed in Box 5. Cover and pad the wound with loose gauze fluffs. If fingers
38.5. Because most patients with minor burns seek medical and toes are involved, pad the web spaces and the digits
attention after initial self-instituted prehospital cooling, it is individually and separate them with strips of gauze (see
unlikely that the clinician can favorably affect the burned tissue Figs. 38.9D and 38.10E and F). Wrap the entire dressing
with any intervention in the ED. With the exception of pain snugly (but not tightly) with an absorbent, slightly elastic
relief and removal of debris, the primary benefits of burn cooling material such as Kerlix (Medtronic, Minneapolis, MN).
are probably experienced only if the burn is cooled promptly, 6. Instruct the patient to elevate the affected limb to prevent
within the first 3 minutes after injury, thus making home care swelling, which may cause delayed burn conversion or wound
important.28,29 Minor burns are considered tetanus prone, and infection.
tetanus toxoid should be administered if patients are unsure
of their tetanus immunization status or when it has been more Open Burn Care
than 10 years since the last immunization. Nonimmunized Following cleansing of the wound with chlorhexidine soap
patients should receive tetanus toxoid and immunization with and débridement of blisters and any loose skin, wounds that
subsequent boosters in accordance with current guidelines. are not amenable to a dressing, such as those on the face, can
be managed initially by the application of a bland topical
antibiotic such as bacitracin. The wound can be washed two
Outpatient Care of Minor Burns or three times per day, followed by reapplication of the topical
Minor burns are generally those that will heal spontaneously agent. This is the preferred method for managing burns on
and do not require surgery or specialized wound care. These the face and neck.
wounds are not associated with immunosuppression or hyper-
metabolism, nor are they highly susceptible to infection, a Burn Dressings
quality associated with larger burns.30,31 Treated conservatively, Biologic Dressings
most minor burns will heal without significant scarring. Many Biologic dressings are natural tissues, including skin that consists
complications seen with minor burns are thought to result of collagen sheets containing elastin and lipid. They are not
from overtreatment rather than undertreatment. Examples routinely used in the emergency care of minor wounds and
include the use of dry dressings that can adhere to newly are primarily treatment options in burn centers. The benefits
forming skin and secondary infections from the overzealous of biologic dressings include a reduction in surface bacterial
use of topical or systemic antibiotics. colonization, diminished fluid and heat loss, avoidance of further
The most important characteristic of a dressing is that it wound contamination, and prevention of damage to newly
controls fluids within the wound. Burn dressings that keep the developed granulation tissue. Examples of biologic dressings
surface of the wound moist and avoid pooling of fluids will include cadaveric human skin and commercially available porcine
speed healing.32 The best material for this purpose is a generous xenograft or collagen sheets.
amount of simple dry gauze applied over a nonadherent dressing
or topical preparation. The outer layer of dressing should be Synthetic Dressings
porous to permit evaporation of water from the absorbent Synthetic dressings are manufactured in various forms. Film-
dressing material. Some clinicians prefer to eschew a nonadher- type dressings have a homogeneous structure and are usually
ent portion of the dressing so that subsequent dressing removal polymers. Because these dressings are nonpermeable, problems
aids in minor débridement. Wound preparation and basic with retention of wound exudates have occurred. Some second-
bandaging should include the following steps (Fig. 38.9): generation dressings have been developed to address these
1. Cleanse the burned area gently with a clean cloth or gauze problems. These products include Tegaderm (3M Medical,
and a mild antibacterial wound cleaner such as chlorhexidine, St. Paul, MN), Vigilon (Bard Medical, Covington, GA),
and irrigate the wound with saline or water. It is not necessary DuoDERM (ConvaTec, Bridgewater, NJ), Biobrane (Smith
to shave the hair in or around the wound. There is no & Nephew), Op-Site (Smith & Nephew, Inc., Andover, MA),
benefit to vigorously washing a minor wound with strong Acticoat (Smith & Nephew), Aquacel products (ConvaTec,
antiseptic preparations (such as povidone-iodine [Betadine, Greensboro, NC), and TransCyte (Advanced Tissue Sciences,
Purdue Products L.P., Stamford, CT] and others).31 La Jolla, CA).32-33a These preparations have theoretical benefits
2. Although some authors recommend leaving blisters intact, under certain circumstances, but are not proven to have superior
most sources advise that providers débride blisters and performance over simple gauze dressings for minor outpatient
sloughed skin initially by peeling the devitalized skin from burns. These products are most often used by burn centers
the wound (Fig. 38.10A–C). Blisters can be opened with and have little applicability for minor burns in patients dis-
scissors and forceps. If necessary, provide analgesia for any charged from the ED. For patients admitted or transferred to
painful débridement. On the initial débridement, attempt a burn center, simple gauze dressings are appropriate. Some
A B
C D
Figure 38.9 Outpatient burn dressing of the hand. Patients with serious hand burns should be admitted
to the hospital, but minor burns can be treated in the outpatient setting. A, After the application
of an antibiotic ointment or a dry, nonadherent dressing, separate the fingers with fluffs in the web
spaces and B, enclose the entire hand in a position of function (here with the help of a roll of Kerlix).
C, If the wrist is involved, a removable plaster splint may be applied over the dressing. D, The result
of a minor burn involving the hand when the fingers were not wrapped individually. Initially, there
were only a few blisters, but this patient now has second-degree skin loss because of an improper
burn dressing that caused maceration of normal skin between the fingers. Not only were the fingers
incorrectly wrapped together in one gauze wrap, but the first wound check was also incorrectly
scheduled in 6 days, too long for the first wound inspection of a hand burn.
burn centers prefer that topical agents not be applied before procedures such as débridement and dressing changes are
transfer so that the full extent of the burn can be assessed planned. We prefer to use IV opioids (occasionally supplemented
immediately. with a short-acting benzodiazepine such as midazolam) for all
painful procedures. For complicated débridement or dressing
Specific Clinical Issues in Minor Burn Care changes adequate analgesia is a minimum requirement with
Analgesia some patients requiring procedural sedation (see Chapter 33).
Pain is a critical feature of any burn injury. Relief of pain by Regional or nerve block anesthesia is an excellent alterna-
the appropriate and judicious use of narcotic analgesics is of tive when practical, and if feasible, nitrous oxide analgesia
the utmost importance in the initial care of all burn patients. may be used. Ketamine may also be a reasonable alternative.
Prehospital narcotics are very appropriate when standard Oral opioids may be inadequate for the initial treatment of
contraindications do not exist. Analgesia should be provided significant pain but can be used for continued outpatient
before extensive examination or débridement is performed. analgesia. Local anesthetics may be injected in small quanti-
Inadequate analgesia is probably the most common ED error ties when appropriate, such as for the débridement of a deep
in the treatment of burn injuries, especially when burns occur ulcer or other small burn. Topical analgesics have no role in
in children. Parenteral narcotic analgesics have been erroneously burn care. A properly designed dressing will do much toward
relegated to pain control only for major burns, but it is suggested preventing further discomfort after release home; however,
that narcotics be generously administered in the initial treatment home burn care and dressing changes may be quite painful.
of even minor painful burns. For this reason, an adequate supply of an oral opioid analgesic
Parenteral opioids (e.g., fentanyl, 1 to 2 µg/kg, or morphine, should be provided, and responsibility in analgesic use should
0.1 to 0.2 mg/kg) are usually required, especially if painful be encouraged.
Dry 4 × 4
gauze
A B
C D
E F
Figure 38.10 Débridement and dressing of a blistering burn. A, Exactly when to débride burn blisters
is controversial and probably of no consequence to the final outcome (see text), although blisters
often thin after the first 24–48 hours and are therefore easier to débride at that time. Eventually,
however, all dead tissue must be removed. B and C, The easiest and quickest way to débride blisters
is to grasp the dead loose skin with dry 4- × 4-inch gauze and pull it off quickly rather than with slow
meticulous instrument techniques. Provide analgesia that is appropriate for the clinical condition.
D, Apply an appropriate ointment to the denuded tissue. (Silvadene [Pfizer] is shown here, but
bacitracin can also be used.) E and F, The débridement itself is not especially painful, but when
the underlying tissue is exposed, pain increases. Hence, dress the burn quickly after débridement.
Pruritus the acute treatment phase. Despite the limited literature on

Postburn pruritus is one of the most common and distressing the treatment of postburn pruritus, available therapies include
complications of burn injury and is estimated to affect 87% oral antihistamines, topical antihistamines, and topical moistur-
of burns.34 It typically develops in the subacute phase and is izers. The use of topical therapies should be withheld until
therefore not a common issue for the emergency provider in sufficient wound healing has occurred.
Edema wound healing.36 Although the procedure is of unproven value,

Minor burns lead to immediate inflammation mediated by the many clinicians routinely use antibiotic creams or ointments
release of histamine and bradykinins, which cause localized on even the most minor burns. Most patients expect some
derangements in vascular permeability with resultant burn type of topical concoction, so a discussion of their use—or
wound edema. This edema may be harmful in several ways. nonuse—is prudent.
First, the increase in interstitial fluid increases the diffusion Topical antimicrobials were designed for the prevention
distance of oxygen from capillaries to cells and thereby increases and care of burn wound sepsis or wound infection, primarily
hypoxia in an already ischemic wound. Second, the edema in hospitalized patients with major burns, and there is no
may produce untoward hemodynamic effects by a purely convincing evidence that their use alters the course of first-
mechanical mechanism: compression of vessels in muscular degree burns and superficial partial-thickness injuries. As noted,
compartments. Third, edema has been associated with the the burn dressing is the key factor in minimizing complications
inactivation of streptococcicidal skin fatty acids, thus predispos- in all burns. Nonetheless, topical antimicrobials are often
ing the patient to burn cellulitis.35,36 soothing to minor burns, and their daily use prompts the patient
Successful management of burn edema hinges on immobiliza- to look at the wound, assess healing, perform prescribed dressing
tion and elevation. Most patients are unfamiliar with the medical changes, or otherwise become personally involved in the care.
definition of elevation and are not aware or convinced of its Keep in mind that if a topical antimicrobial is used, its effective-
value. Patient education in this regard is critical; however, ness is decreased in the presence of proteinaceous exudate,
certain burns (e.g., burns in dependent body areas) are prone thus necessitating regular dressing changes if the antimicrobial
to edema despite everyone’s best intentions. It is for this reason benefit of topical therapy is to be realized. In reality, once-daily
that lower extremity burns in general and foot burns in particular dressing changes are most practical and are commonly pre-
are prone to problems. Major burns of the hand should be scribed, and no data indicate that this regimen is inferior to
elevated while the patient is still in the ED. This is most readily more frequent dressing changes.
accomplished by hanging the injured hand from an IV pole All full-thickness burns should receive topical antimicrobial
with a stockinette to support the bandaged hand (Fig. 38.11). therapy because the eschar and burn exudate are potentially
good bacterial culture media and deep escharotic or subescha-
Use of Topical Preparations and Antimicrobials rotic infections may not be easily detected until further damage
Minor burns result in insignificant impairment of normal host is done. All deep partial-thickness injuries likewise benefit from
immunologic defenses, and burn wound infection is not usually the application of a topical antimicrobial. As stated, this
a significant problem. Topical antimicrobials are often used; intervention can await definitive therapy in a burn unit.
however, some believe that these agents may actually impair Criteria for choosing a specific topical agent include its’ in
vitro and clinical efficacy, toxicity (absorption), superinfection
rate, ease and flexibility of use, cost, patient acceptance, and
side effects. It is important to note that no firm scientific data
convincingly support the use of any specific topical antimicrobial
for minor outpatient burns.
Specific Topical Agents

Silver Sulfadiazine (Silvadene, Pfizer). This poorly soluble
compound is synthesized by reacting silver nitrate with sodium
sulfadiazine. It is the most commonly used topical agent for
outpatients, and it is well tolerated by most patients (Fig.
38.12A; also see Fig. 38.10D). It has virtually no systemic
effects and moderate eschar penetration, and it is painless on
application. Although silver sulfadiazine is commonly used,
its popularity is waning. It must be applied daily and the thick
white cream can be difficult to remove. There are no well
designed studies confirming improved burn healing or a reduced
rate of infection with silver sulfadiazine. It may impede reepi-
thelialization and should be stopped when this occurs. Hence,
many burn specialists prefer plain bacitracin ointment as the
topical of choice because of its cost, equal efficacy, and good
patient acceptance.
Silver sulfadiazine is available as a “micronized” mixture
with a water-soluble white cream base in a 1% concentration
that provides 30 mEq/L of elemental silver. It does not stain
clothes, is not irritating to mucous membranes, and washes
off with water. It may be used on the face, but such use may
be cosmetically undesirable for open treatment. It should not
be used near the eyes. Its broad gram-positive and gram-negative
Figure 38.11 Begin elevation of a burned hand in the emergency antimicrobial spectrum includes β-hemolytic streptococci,
department. After a hand dressing is applied, suspend the arm from Staphylococcus aureus and Staphylococcus epidermidis, Pseudomonas
an intravenous pole with stockinette. A plaster or fiberglass splint spp., Proteus spp., Klebsiella spp., Enterobacteriaceae, Escherichia
may also be incorporated into the dressing. coli, Candida albicans, and possibly herpesvirus hominis.
BROAD-SPECTRUM ANTIBIOTIC OINTMENTS. Many

nonprescription topical antimicrobials are used for minor burn
therapy despite a paucity of data attesting to specific benefits.
Included are bacitracin zinc ointment, polymyxin B–bacitracin
(Polysporin, Johnson & Johnson, New Brunswick, NJ). These
are all soothing, cosmetically acceptable for open treatment
(such as on the face), and effective antiseptics under burn
dressings. Some researchers caution against agents containing
neomycin because of a potential for sensitization (see Fig.
38.12B). Though commonly applied by patients without adverse
effects, we advise against the use of topicals that contain
neomycin (Neosporin, Johnson & Johnson) because of the
potential for contact dermatitis. The authors suggest plain
bacitracin or Polysporin ointment as the routine topical agents
for most burns, although Silvadene is a very acceptable, albeit
more expensive alternative.
A
ALOE VERA CREAM. Aloe vera cream is commercially available
in a 50% or higher concentration with a preservative. It exhibits
antibacterial activity against at least four common burn wound
pathogens: Pseudomonas aeruginosa, Enterobacter aerogenes, S.
aureus, and Klebsiella pneumoniae. Heck and coworkers and
others37,38 compared a commercial aloe vera cream with silver
sulfadiazine in 18 patients with minor burns. Healing times
were found to be similar, and there was no increase in wound
colonization in the aloe vera group in comparison to patients
treated with silver sulfadiazine. Other authors have promulgated
the use of aloe gel preparations for minor burns.38 Aloe vera
cream is an acceptable, inexpensive option for open or dressed
outpatient care of minor burns.
B
HONEY. Honey has long been advocated as an inexpensive
Figure 38.12 A, The most popular topical burn preparation is Silvadene and effective topical treatment for minor outpatient burns.
(Pfizer) cream. Though commonly used on minor burns, it probably The physicochemical properties of honey (osmotic effect, pH)
has little beneficial effect on healing, and minor burns rarely become give this substance the antibacterial and antiinflammatory
infected. Nonetheless, Silvadene is a standard intervention that at
properties that support its use. It may be superior to silver
least causes the patient to look at the burn and become involved in
dressing changes. B, Some clinicians suggest inexpensive neomycin-free sulfadiazine with regard to minor burn wound healing. Honey
topical antibiotic ointments, such as bacitracin or bacitracin-polymyxin is not widely used, but it has been promulgated as a safe,
B sulfate (Polysporin, Johnson & Johnson) for all outpatient burns. effective, and inexpensive dressing for the outpatient manage-
They are commonly used on face and neck burns. These are preferred ment of burn wounds.39–41
because contact dermatitis can occur from the neomycin portion of
some topical agents, as depicted in the photograph. CORTICOSTEROIDS. High-potency topical steroid prepara-
tions have no beneficial effects on the rate of healing or limita-
tion of scarring of thermal burns. Though probably not harmful
One downside of silver sulfadiazine is that it often interacts in most cases, their use is not supported.42
with wound exudate to form a pseudomembrane (pseudoeschar)
over partial-thickness injuries. This pseudomembrane is often
difficult and painful to remove. Removing the pseudomem- FOLLOW-UP CARE OF MINOR BURNS
brane is necessary to monitor the wound state and facilitate
reepitheliazation. The specifics of outpatient follow-up of minor burns are
Except for term pregnancy and in newborns (i.e., because controversial and often based on clinician preference and
of possible induction of kernicterus), there are no absolute personal bias rather than on firm scientific data. Follow-up
contraindications to the use of silver sulfadiazine. Allergy and should be individualized for each patient and should be based
irritation are unusual, although there is potential cross-sensitivity on the reliability of the patient, the extent of the injury, the
between silver sulfadiazine and other sulfonamides. frequency and complexity of dressing changes, and the amount
of discomfort anticipated during a dressing change. Depending
Other Topical Preparations. Mafenide acetate (Sulfamylon, on the characteristics of the patient and the resources available
Mylan Institutional Inc., Rockford, IL), gentamicin, povidone- to them as an outpatient follow-up plans may include primary
iodine, and silver nitrate are products that have been replaced care physician rechecks, follow-up at wound care center, home
with newer topicals, but they are mentioned for historical health visits by wound care team, or even return to an ED or
interest. These products are not typically used in modern burn “fast-track” setting. Outpatient physical therapy departments
therapy, although they are generally acceptable alternatives or wound care centers often have excellent facilities to monitor
for specific indications. outpatient burns with clinician oversight.
BOX 38.6 How to Change a Burn Dressing at

Home: Patient Instructions
Antibiotic ointment Sterile tongue blade
1. Take pain medicine 1 2 hour before dressing change if you
find dressing changes to be painful.
2. If the burn is on the hand, foot, or other areas that are
difficult to reach, have someone help you.
3. Have all materials available. Gloves may be worn.
Kerlix
4. Remove the dressing and rinse off all burn cream or
ointment with tap water, under a shower, or in the bathtub.
The area can be gently washed with mild soap and a clean
cloth or gauze pads.
5. Look at the burn and assess the healing, blistering, and
Tape amount of swelling. Note any signs of infection.
Sterile gauze 6. Gently exercise the area through range of motion.
7. Apply the burn ointment with a sterile tongue blade.
8. Cover the cream with fluffed-up gauze.
Figure 38.13 Providing patients with burn dressing material on
9. Wrap the area in bulky gauze.
discharge encourages proper home care. Dispensing only limited
supplies of the items may enhance compliance with follow-up visits. 10. Repeat this dressing change daily.
If a topical antibiotic agent is used, the dressing should be Norwalk, CT), Vaseline Intensive Care Lotion (Chesebrough
changed daily with removal and reapplication of the topical Ponds, Inc., Greenwich, CT), or other readily available over-
preparation. The wound should be rechecked by a clinician the-counter skin care moisturizing lotions. Natural skin
after 2 to 3 days and periodically thereafter, depending on lubrication mechanisms usually return by 6 to 8 weeks.30
wound size, compliance, healing, and other social issues. If a Excessive sun exposure should be avoided during wound
dry dressing is chosen, follow-up every 3 to 5 days is usually maturation because this may lead to hyperpigmentation. When
adequate. The purpose of any burn dressing changes or home the patient is outdoors, sun avoidance strategies should be
care regimen is defeated if the patient cannot afford the material used, or at the very least, a commercially available sunblock
or is not instructed in the specifics of burn care. Many EDs should be applied. Exposure of the recently healed burned
supply burn dressing material on patient release. A complete area to otherwise minor trauma (chemicals, heat, sun) may
pack includes antibiotic ointment or cream, gauze pads (fluffs), result in an exaggerated skin response. Pruritus is common
an absorbent gauze roll, a sterile tongue blade to apply the and may be treated with oral antihistamines or a topical
cream, and tape (Fig. 38.13). Providing limited supplies of the moisturizing cream.
items necessary for dressing changes may enhance compliance
with follow-up if the patient has to return for additional supplies.
Writing a prescription and merely stating that the dressing
Outpatient Physical Therapy for Burn Care
should be changed daily may not be sufficient. When the hospital’s outpatient physical therapy department
Daily home care can be performed by the patient with help or wound care center is equipped to treat minor burns, it is
from a family member or visiting nurse (Box 38.6). The dressing prudent to consider this option as a means of longitudinal
may be removed each day and the burn area gently washed follow-up. Many centers make available daily or periodic burn
with a clean cloth or a gauze pad, tap water, and a bland soap. treatment consisting of dressing changes, whirlpool débride-
Sterile saline and expensive prescription soaps are not required. ment, and range-of-motion exercises. An additional advantage
A tub or shower is an ideal place to gently wash off burn cream. is that medically trained personnel evaluate the burn daily,
The affected area may be put through a gentle range of motion thereby decreasing clinician visits and enabling identification
during dressing changes. After the burn is cleaned, the patient of problems before serious complications develop. Similar
inspects it in the hope that complications can be recognized services are available in many areas where providers visit the
and prompt further follow-up. After complete removal of the patient in their home to perform wound/burn care.
old cream, a new layer is applied with a sterile tongue blade
and covered with absorbent gauze.
If the undermost fine-mesh gauze of a dry dressing is dry
Burn Wound Healing
and the coagulum is sealed to the gauze, the patient should Burn wound healing differs from healing of other soft tissue
allow the dressing to remain and simply reapply the overlying wounds.4 The duration is variable but is often proportional to
gauze dressing. If the wound is moist and macerated, the burn depth. Within 1 to 3 weeks and following the initial
fine-mesh gauze should be removed and the wound cleaned inflammatory response, neovascularization of the burn occurs
and re-dressed. The patient should be instructed to not remove and is accompanied by fibroblast migration. Collagen production
dry adherent fine-mesh gauze from the underlying crust. When begins but it is often deposited randomly, thereby leading to
epithelialization is complete, the crust will separate, and the scar formation. Reepithelialization follows collagen deposition.
gauze can be removed at that time. The persistence of necrotic tissue and eschar in the wound
In the postacute phase, dryness in healing skin may be will impede all aspects of healing. The extent of scar formation
treated with mild emollients such as Nivea (Beiersdorf, Inc., is related directly to healing time. Wound healing that occurs
in fewer than 16 days often results in decreased scar formation.4

Proper wound débridement is also associated with faster wound
healing and minimizes scar formation.
Healing of superficial burns occurs by reepithelialization
from the wound edge and from residual dermal elements
containing epithelial cells. This process generally requires 10
to 14 days. After healing, the initial epithelial layer is often
fragile and is easily reinjured. The application of bland, lanolin-
containing creams for 4 to 8 weeks after initial healing may
reduce dryness and cracking of the healing wound.
Deep burns lack residual dermal elements within the wound
and heal by reepithelialization from the wound edge. Healing
is slow and often unsatisfactory; it frequently takes longer than
3 weeks, and an unstable epithelium is produced that is prone A
to hypertrophic scarring and contractures. This is a particular
problem in burns that extend across joints and limit motion.
Burns that take longer than 2 to 3 weeks to heal are also prone
to infection, which may be reduced by using topical antimi-
crobial agents. Deep wounds should be referred for surgical
consultation and generally require early excision, grafting, and
physical therapy.
SPECIAL MINOR BURN

CARE CIRCUMSTANCES B
Blisters Figure 38.14 It is difficult to do anything wrong with minor burn

blisters, and many regimens are acceptable. Blister aspiration is not
Management of blisters in minor burns is controversial. In supported. Eventually, however, any unroofed blisters will have to be
reality, there is little one can do wrong when it comes to débrided. A, An expeditious and relatively painless way to débride a
a clinical approach to blisters in minor burns (Fig. 38.14). burn is to use a dry gauze pad to grasp the dead skin and B, peel it
Management arguments are generally theoretical or based off. Meticulous instrument débridement is often time-consuming and
on local tradition; the ultimate outcome of a minor burn is stressful to the patient. Be aware that pain occurs when air comes
rarely determined by how one treats blisters. Intact blisters in contact with the débrided skin, and prophylactic analgesia should
therefore be provided. Large burns can be débrided under procedural
do offer some pain control and a physiologic dressing that
sedation.
rarely becomes infected; however, most large blisters spon-
taneously rupture after 3 to 5 days and eventually require
débridement. When the integrity of the blister is breached,
the fluid becomes a potential culture medium. Clinical choices
Minor Burn Infections
for blister management include débridement (immediate and Prophylactic systemic antibiotics are not warranted in the
delayed) or simply leaving the blister intact. In general, rup- routine treatment of outpatient burns. It may be difficult to
tured blisters should be débrided. Needle aspiration of blisters separate the erythema of the injury or healing process from
should NOT be performed as this may increase the risk of cellulitis, but minor burns rarely become infected, with infection
infection. rates being well under 5%.46 There are bacteria on the skin
Some studies suggest that intact burn blisters may allow at all times; normal skin usually harbors nonvirulent pathogens
reversal of capillary stasis and less tissue necrosis.4 Madden such as S. epidermidis and diphtheroids. Therefore, all burns
and colleagues43 showed that burn exudate (as contained within are contaminated but not necessarily infected. Because thermal
intact blisters) is beneficial in stimulating epidermal cell trauma results in coagulative necrosis, burn wounds contain
proliferation. a variable amount of necrotic tissue which, if infected, acts
Swain and associates44 demonstrated that the density of much as an undrained abscess and prevents access of antibiotics
wound colonization with microorganisms was much lower in and host defense factors.
minor burns with blisters left intact. They also found that The microbial flora of outpatient burns varies with time
37% of patients with aspirated blisters (not recommended) after the burn. Shortly after injury, the burn becomes colonized
experienced a reduction in pain versus none of those whose with gram-positive bacteria such as S. aureus and S. epidermidis.
blisters were unroofed. Other investigators believe that After this period there is a gradual shift toward inclusion of
undressed wounds with débrided blisters are subject to additional gram-negative organisms, 80% of which originate from the
necrosis secondary to desiccation, which can convert a partial- patient’s own gastrointestinal tract.6 Common organisms seen
thickness burn to a full-thickness injury.5 Finally, intact blisters on days 1 to 3 include S. epidermidis, β-hemolytic streptococci,
clearly provide some pain relief, as evidenced by the sudden Bacillus subtilis, S. aureus, enterococci, Mima polymorpha,
increase in pain immediately after débridement. Increased pain Enterobacter spp., Acinetobacter spp., and C. albicans. One week
should be anticipated and analgesia offered as appropriate when after the burn these organisms may be seen along with E. coli,
débridement is necessary. We suggest the steps listed in Fig. P. aeruginosa, Serratia marcescens, K. pneumoniae, and Proteus
38.10 as a general approach to burn blisters.4,5,43–45 vulgaris.
Anaerobic colonization of burn wounds is rare unless there

is excessive devitalized tissue, as occurs with a high-voltage
electrical injury.47 For this reason, routine anaerobic cultures
are generally unnecessary in an assessment of infective organisms
that produce minor infections.
A healing burn may produce leukocytosis and a mild fever
in the absence of infection, especially in children. Early (days
1 to 5) burn infections are generally caused by gram-positive
cocci, especially β-hemolytic streptococci. Streptococcal cellulitis
is characterized by marked spreading erythema extending
outward from the wound margins. Despite the plethora of
organisms and the presence of some gram-negative pathogens
in superficial burn cultures, standard gram-positive cellulitis
coverage is appropriate initial therapy in most cases.
Effective topical treatment at the time of initial burn care
and subsequent dressing changes is meant to delay bacterial
colonization, maintain the bacterial density of wounds at low
levels, and produce a less diverse wound flora. Because out-
patient management of burns should be attempted only when
the risk for infection is minimal, the use of systemic antibiotics
is unnecessary for minor burns, even in the setting of delayed
treatment, diabetes, and steroid use.46 Unnecessary antibiotic A
use may select for resistant organisms. Antibiotics in the
management of minor burns have been recommended for
patients undergoing an autograft procedure.49 There are no
data on the use of antibiotics as prophylaxis for patients with
burns in the setting of valvular heart disease.
In minor burn care, wound cultures are not required or
recommended. It is useless, for example, to culture blister fluid
in a patient who arrives for emergency care immediately after
a thermal injury. Cultures are necessary only when overt
infection develops, especially when it occurs when a topical
or systemic antibiotic is being used. Cultures may also be
of benefit when the infected wound is old, when hygiene
is poor, or when there are preexisting abrasions nearby.50 B
Although they may adequately reflect wound flora, falsely sterile
Figure 38.15 Burns of the feet are special burns that require careful
cultures are relatively frequent. In general, superficial cultures evaluation and an individualized treatment plan, even if the burn
do not reflect deep burn flora and provide no quantitative surface area is relatively small. It is difficult for many patients to
information. provide ideal burn care at home when the feet are involved. A, It is
Sterile wound biopsy for culture is most satisfactory for the tempting to initially treat a seemingly minor superficial second-degree
assessment of intraescharotic, subescharotic, or invasive infec- foot burn in an outpatient setting, but the patient’s compliance and
tions and allows quantification of bacterial flora. social situation must be ideal for a successful outcome. Unless home
health care, a wound care center, or other similar arrangements are
available to the patient, hospitalization may be most prudent until
Foot Burns these arrangements can be solidified. B, Example of a foot burn that
is a potential disaster, in this case because of late treatment of a
Despite their relatively small surface area, foot burns tend to
diabetic patient.
heal poorly, usually because of excessive edema; therefore, they
are generally considered major burns. Foot burns are the most
common burn category to fail outpatient therapy, and subse-
quently require admission and inpatient care (Fig. 38.15). minimizes edema. For these reasons, initial admission should
Zachary and coworkers51 reported on a series of 104 patients be considered for all but the most minor of foot burns. Close
with foot burns. In no patient admitted on the day of injury outpatient follow-up wound checks are required for those foot
did burn cellulitis develop; in contrast, 27% of delayed- burns that are most appropriate for outpatient care.
admission patients had cellulitis. Their study also noted a higher
incidence of hypertrophic scarring with the need for skin
grafting in the delayed-admission group. Overall, fewer days
Hand Burns
of hospitalization were required for the initially admitted group. Because of its functional significance, burns involving the hand
Specific problems in the care of foot burns include pain, can result in significant functional loss even when the TBSA
wound drainage, difficulty changing dressings without help, burned is small. Losing the use of one or both hands can
inability of even motivated patients to comply with the require- become seriously disabling and affect the patient’s activities of
ments for elevation, and prolonged convalescence. The benefits daily living regardless of whether the cause of the loss is a
of hospital admission include splinting, intensive local burn burn dressing, the late onset of scar contractures, or loss as a
care, physical therapy, and bed rest with elevation, which result of amputation.52
As with other burns, the depth and extent of the burn

determine the severity of the injury. The entire surface of one
Facial Burns
hand represents only 2.5% TBSA, yet even small burns can Facial burns commonly result from unexpected ignition flash
cause a disproportionate loss of function. Deep partial- or burns (e.g., from a stove, oven, or charcoal grill) or from car
full-thickness hand burns, even if quite small, often warrant radiator accidents (Fig. 38.17A and B).55,56 Facial burns from
referral for early excision and grafting to limit scarring and these sources usually do well, but singeing of facial hair, sig-
maintain function. The skin on the dorsum of the hand is nificant edema, and pain often result. However, facial burns
thinner than that on the palm and is more susceptible to burn from these causes may produce airway problems and might
injury so it must remain flexible to allow finger motion. Any require skin grafting. Singed nasal hairs or any sign of significant
exposed tendon or bone, such as may be seen with an electrical heat exposure to the face should prompt an evaluation of airway
burn, constitutes a true fourth-degree injury, and either flap injury, which may result in airway compromise at a time later
closure or amputation is required to heal the wound. than the initial incident (see Fig. 38.17C).
Many of the issues complicating outpatient management Concurrent globe or corneal injury is quite rare because
of foot burns are relevant to the care of hand burns. After of protective blinking reflexes. If the eye is burned, it is usually
initial burn cooling, the wound should be gently cleansed with in the setting of a life-threatening concomitant burn injury.57
mild soap. Any loose skin or ruptured blisters should be gently Burns involving the eyelids can cause significant scarring.
débrided, rinsed, patted dry, and covered with a topical anti- Fluorescein staining and slit-lamp examination should be
microbial agent and a nonadherent, bulky gauze dressing. The performed to confirm or exclude the diagnosis of corneal injury
fingers should be carefully separated and bandaged individually. (Fig. 38.18). Treatment of a corneal injury can involve irrigation,
Small, intact blisters that do not interfere with hand function topical ophthalmic antibiotics, and consideration of eye patching
should be left intact to serve as a biologic dressing. Elevation versus protective soft contact lens (see Chapter 62). Referral
of the hand is very important in the first few days after a burn to an ophthalmologist is usually prudent. Facial burns are
injury to minimize edema. Deep partial- or full-thickness burns otherwise treated in the usual fashion and with an open (no
on the dorsum of the hand should be splinted53,54 after bandaging dressing) technique. Patients are instructed to wash their face
to avoid the development of contractures or a boutonnière two or three times a day with a mild soap and then apply a
deformity. thin layer of antibiotic ointment, such as bacitracin zinc. Car
Hospital admission or burn center referral should be radiator burns result from the combination of a hot liquid and
considered for all significant hand burns, particularly full- steam burn (see Fig. 38.17B). Antifreeze exposure to skin does
thickness injuries and circumferential burns involving the digits not produce a caustic injury, nor is it systemically absorbed.
(Fig. 38.16). If outpatient treatment is appropriate, the patient Neck burns are treated similarly.
should have appropriate follow-up, must be given comprehensive A flash burn in a patient smoking cigarettes while using
instructions, and should have the resources available to perform nasal oxygen causes a facial burn that is not uncommonly seen
daily dressing changes and range-of-motion exercises of the in the ED (see Fig. 38.17D). These burns may involve the
fingers and wrist during these dressing changes. An initial nose and lips, may have melted plastic particles on the skin or
follow-up visit should occur in 48 to 72 hours, but the patient in the nose, and can be quite painful. Although such patients
should be encouraged to return if burn cellulitis, worsening generally do well, facial burns can make the continued use
pain, fever, or lymphangitis develops. Ideally, the patient should of nasal cannula oxygen problematic until healing takes
be seen twice in the first week after injury and then, if clinically place. Though not generally an inhalation burn issue, careful
appropriate may be reduced to once a week until the burn is evaluation of the upper airways and assessment of lung
healed. function are prudent. Many patients using oxygen are relatively
immunocompromised. They may not be able to tolerate even
minor physical insults and have fragile conditions that require
careful evaluation, short-term observation in some cases, and
close follow-up for delayed healing and infection. Hospitaliza-
tion for burn care and general supportive measures may be
prudent for all but minor burns in this patient population.
Minor burns can be treated on an outpatient basis in an open
fashion with topical ointments, such as bacitracin.
All patients with head or neck burns should be evaluated
carefully for a concomitant inhalation injury. Such patients
may have direct evidence of injury, such as oral burns, blisters,
soot, or hyperemia and a history of being in an enclosed space,
or have indirect evidence, such as dyspnea, wheezing, arterial
hypoxemia, or an elevated carboxyhemoglobin level. The
definitive diagnostic test for inhalation injury is fiberoptic
bronchoscopy.58 Flash ignition burns involving the face do
not pose a problem with carbon monoxide poisoning, and
although inhalation injuries generally do not occur with minor
flash ignition burns, airway management should remain a
consideration.
Figure 38.16 This badly burned hand requires referral to a surgeon or Inpatient care should be considered for all patients with
burn center and should not be definitively handled in the emergency significant facial burns. Outpatient pain control may be difficult
department. Note the very tight ring (arrow). in those with facial burns, the degree of edema may be difficult
A B
C D
Figure 38.17 A, Flash burns on the face from lighting a gas stove. These burns are painful and may
cause edema, but they usually do well. Note the singed facial hair. The eyes are usually protected by
rapid reflex blinking, and carbon monoxide poisoning and pulmonary burns are not an issue. Most
can be handled in the outpatient setting with bacitracin ointment and no dressing. Pain control
may be problematic unless opioids are prescribed. B, Facial and neck burns when a radiator cap was
removed and the victim was sprayed with steam and hot antifreeze. C, This patient has a severe facial
burn with smoke inhalation, as evidenced by soot in the pharynx and singed nasal hairs. Tracheal
intubation is in the near future for this patient. D, A flash burn in a patient who was smoking a
cigarette while using nasal oxygen.
to predict, and home care can be problematic. There are no

universally agreed standards for admission versus outpatient
treatment of facial burns.
Corneal contact burns, as from accidental contact with a
curling iron, are often manifested rather dramatically as opaci-
fied, “heaped-up” corneal epithelium (see Fig. 38.18). Despite
their appearance, the end result is usually excellent. Treatment
is the same as for a corneal abrasion.59
Abuse of Children and Elderly Individuals

Recognition of the possibility of deliberate abuse by burning
in the pediatric and geriatric populations is essential. In addition,
children younger than 2 years have a thinner dermis and a less
well-developed immune system than adults do. Elderly patients
Figure 38.18 A thermal burn of the cornea. Note the opacified, (>65 years) likewise tolerate burns poorly. These two populations
“heaped-up” appearance of the epithelium. (From Kanski JJ, editor: are the most prone to abuse, often by family members (Fig.
Clinical diagnosis in ophthalmology, St. Louis, 2006, Mosby.) 38.19). For these reasons, both these groups of patients often
require inpatient care.23
A B
C D
Figure 38.19 Burns can be a manifestation of child abuse, spouse abuse, or abuse of the elderly.
A, Abuse burns from contact with a hot metal grate as a result of a child allegedly falling. B, This
burn was the result of spouse abuse caused by throwing hot soup during an argument. Domestic
abuse is often denied initially, but the delayed arrival at the hospital was a clue. C, Burns of the face
and neck are common when a toddler pulls hot liquid from a stove. This case was never proved to
be child abuse, but burns in young children are often due to abuse, especially if they are in atypical
places. Although the body surface area of this burn is relatively small, the patient’s age and the burn’s
location, coupled with the possibility of child abuse, require that this child be hospitalized. D, This
infant received a severe blistering sunburn at the beach despite being in the shade most of the day.
Reflection of sunlight from the sand and water can injure the delicate skin of an infant, who should
have sunscreen applied. E, Self-inflicted cigarette burns in a psychiatric patient.
The majority of abused children are 18 to 36 months old,

and for unknown reasons, the majority are male.36 Immersion
burns are a common type of abuse and are characterized by
circumferential, sharply demarcated burns on the hands, feet,
buttocks, and perineum. Cigarette burns and burns from hot
objects such as irons should be obvious. Contact burns on
“nonexploring” parts of the child also warrant suspicion. A
delay in seeking treatment may be a tip-off that a burn resulted
from abuse. In older populations, the presence of confirmed
self-inflicted burns such as cigarette burns suggests psychiatric
disease (see Fig. 38.19E).
Burns in Pregnancy
There is little information in the literature concerning the
special problems of pregnant burn victims. Ying-bei and Ying-
jie60 reported on 24 pregnant burn patients representing a
wide range of burn severity. Complications of the burn injuries
included abortion and premature labor, although all patients
in this series with burns covering less than 20% TBSA did
well and delivered living full-term babies.
Because the resistance of pregnant women to infection A
is lower than that of nonpregnant women, control of burn
wound infection is paramount. Gestational age appears to
have no direct bearing on prognosis. Silver sulfadiazine cream
should be avoided near term because of the potential for
kernicterus.
SPECIFIC BURNING AGENTS

B
Hot Tar Burns
Figure 38.20 A, There is no compelling reason to remove all tar
Asphalt is a product of the residues of coal tar and is commonly on the first visit. Physical removal of cooled tar usually results in
used in roofing and road repair. It is kept heated to approxi- avulsion of the underlying skin. Skin that is obviously loose should be
mately 450°F. When spilled onto the skin, the tar cools relatively débrided, but adherent tar is best liquefied with an emulsifying agent.
rapidly, but the retained heat is sufficient to produce a partial- Neomycin cream, not ointment, is a suggested emulsifier, but others
thickness burn. Fortunately, full-thickness burns are unusual. are acceptable (see text). Final removal may be delayed for several
Cooled tar is nonirritating and does not promote infection. days to permit loosening of the tar. Frequent dressing changes and
application of an emulsifying agent can be performed by the patient
When cooled tar is physically removed, the adherent skin is
to remove the tar over a period of a few days. B, This extremity was
usually avulsed (Fig. 38.20). Careless removal of the tar may covered with an emulsifying agent and with gauze, and the residual
inflict further damage on burned tissues. Agents such as alcohol, tar was washed off easily 36 hours later.
acetone, kerosene, or gasoline have been used to remove the
tar, but these are flammable and may cause additional skin
damage or a toxic response secondary to absorption.
There is no great need to meticulously remove all tar at
the first visit. Obviously devitalized skin can be débrided, but tar and asphalt. Because De-Solv-It is itself a petroleum-based
adherent tar should be emulsified or dissolved rather than solvent, it should be applied only briefly, and the operator
manually removed (Fig. 38.21). Polyoxyethylene sorbitan (Tween should wear gloves and protective eyewear during application.
80 [Sigma-Aldrich Corp., St. Louis, MO] or polysorbate 80) It should be used only for external exposure to tar or asphalt.
is the water-soluble, nontoxic, emulsifying agent found in After removal, the skin should be cleansed gently and dressed
Neosporin and several other topical antibiotic creams. Note appropriately.
that the cream formulations, not the ointments, contain the Many clinicians instead prefer to emulsify the majority of
most useful tar dissolvers. The creams contain a complex mixture tar on an outpatient basis. A generous layer of polysorbate-based
of ethers, esters, and sorbitol anhydrides that possess excellent ointment can be applied under a bulky absorbent gauze dressing.
hydrophilic and lyophilic characteristics when used as nonionic, The patient is then released home, and the residual tar is
surface-active emulsifying agents. With persistence, most tar easily washed off after 24 to 36 hours (see Fig. 38.20B).
can be removed (emulsified) on the initial visit, although this Several dressing changes may be required. Once the residual
may be unnecessary as previously detailed. tar is removed, the wound is treated as any other burn (see
Another household product (De-Solv-It [Orange-Sol Blend- Fig. 38.21).
ing and Packaging, Inc., Chandler, AZ] multiuse solvent) also Shur-Clens (ConvaTec), a nontoxic, nonionic detergent,
appears logical for topical ED use.50,61 De-Solv-It has a surface- also works well for tar burn wound cleansing, as do mineral
active moiety that wets the chemical’s surface and emulsifies oil, petrolatum, and Medi-Sol (Orange-Sol), a petroleum-citrus
A B
Figure 38.21 A, Tar stuck to the face can B, be emulsified with various agents and a lot of patience
and persistence. Fortunately, tar burns are not usually full-thickness burns.
BOX 38.7 Commonly Used Acids and Alkalis Immediate flushing with water is recommended for all
chemical burns, with the exception of those caused by alkali
metals. Flushing serves to cleanse the wound of unreacted
ACIDS ALKALIS
surface chemical, dilute the chemical already in contact with
Picric Sodium hydroxide
tissue, and restore lost tissue water. Leonard and colleagues63
Tungstic Ammonium hydroxide
clearly demonstrated that patients receiving immediate copious
Sulfosalicylic Lithium hydroxide
water irrigation for chemical burns had less full-thickness burn
Tannic Barium hydroxide
injury and a 50% or greater reduction in hospital stay. Flushing
Trichloroacetic Calcium hydroxide
should be thorough and may require at least 30 minutes (or
Cresylic Sodium hypochlorite
as much as 2 hours) for maximal benefit, depending on the
Acetic
nature of the chemical.
Formic
Sulfuric
Acid and Alkali Burns
Hydrochloric
Chemical burns cause progressive tissue damage until the
Hydrofluoric
chemical is inactivated or removed. Acids damage tissue by
Chromic
coagulation necrosis, a process that limits the depth of penetra-
tion into tissue. Alkalis react with lipids in skin and result in
liquefaction necrosis. This process permits penetration of the
chemical into tissues until neutralized. Thus, exposure to alkali
product. Butter-soaked gauze has been suggested as an emulsifier is more likely to produce deep tissue wounds. Skin exposed
of tar. to caustic substances should be decontaminated aggressively
until neutralized and the resulting wounds considered deep
until demonstrated otherwise.
Chemical Burns Desiccant acids, such as sulfuric acid, create an exothermic
Chemical burns generally occur in the workplace, and the reaction with tissue water and can cause both chemical and
offending substance is usually well known. More than 25,000 thermal injury. With extensive immersion injuries, acids may
chemicals currently in use are capable of burning the skin or be absorbed systemically, thereby leading to systemic acidosis
mucous membranes. Commonly used chemical agents capable and coagulation abnormalities.
of producing skin burns are shown in Box 38.7. Chemical burns may be excruciatingly painful for long
Injury is caused by a chemical reaction rather than a thermal periods. Discomfort can be out of proportion to what one
burn.62 Reactions are classified as oxidizing, reducing, corrosive, might expect from the perceived depth or extent of the burn.
desiccant, vesicant, or protoplasmic poisoning. The injury to When caring for a chemical burn, the emergency care team
skin continues until the chemical agent is physically removed should remove all potentially contaminated clothing. Any dry
or exhausts its inherent destructive capacity. The degree of (anhydrous) chemical should first be brushed off the patient’s
injury is based on the strength, concentration, and quantity skin. The involved skin should then be irrigated with large
of the chemical; duration of contact; location of contact; extent amounts of water under low pressure. Any remaining particulate
of tissue penetration; and mechanism of action. matter should be carefully débrided during irrigation.
Strong alkali burns may require irrigation for 1 to 2 hours

before tissue pH returns to normal. Some recommend that if
the burn continues to feel “slippery” or tissue pH has not
returned to normal after extensive irrigation, chemical neu-
tralization may be helpful.64,65 Given that any heat of neutraliza-
tion will be carried away with the irrigation solution,66 prompt
irrigation with a dilute acid (e.g., vinegar, or 2% acetic acid)
may hasten neutralization and patient comfort.
Contact Burns From Wet Cement

The major constituent of Portland cement, an alkaline substance,
is calcium oxide (64%), combined with oxides of silicon,
aluminum, magnesium, sulfur, iron, and potassium. There is
considerable variability in the calcium oxide content of different
grades of cement, with concrete having less and fine-textured
masonry cement having more.63 The addition of water exo- A
thermically converts the calcium oxide to calcium hydroxide
(Ca[OH]2), a strongly corrosive alkali with a pH of 11 to 13.
As the cement hardens, the calcium hydroxide reacts with
ambient carbon dioxide and becomes inactive.
Both the heat and the Ca(OH)2 produced in this exothermic
reaction can result in significant burns. Because of its low
solubility and consequent low ionic strength, long exposure
to Ca(OH)2 is required to produce injury. This usually occurs
when workers spill concrete into their boots or kneel in it for
a prolonged period. The burn wound and the resultant protein
denaturation of tissues produce a thick, tenacious, ulcerated
eschar. Concrete burns are insidious and progressive. What
may appear initially as a patchy, superficial burn might in several
days become a full-thickness injury requiring excision and skin
grafting.67 The pain associated with these burns is often severe
and more intense than the appearance of the wound might
suggest (Fig. 38.22). Interestingly, many workers are not warned B
of the dangers of prolonged contact with cement, and because
the initial contact with cement is usually painless, exposure Figure 38.22 Alkali burns from wet cement develop insidiously, are
may not be realized until the damage is done. extremely painful, and are frequently full-thickness injuries. They are
Treatment is as follows. Remove any loose particulate cement most common A, on the feet when cement leaks over the top of the
boots or B, from kneeling in wet cement while working. The alkali
or lime, usually by brushing off, remove contaminated clothing,
can penetrate clothing.
and irrigate the wound copiously with tap water (the pH of
the effluent is tested and irrigation continued if the effluent
is still alkaline). Apply compresses of dilute acetic acid (vinegar)
to neutralize the remaining alkali and provide relief of pain
after irrigation. Apply antibiotic ointment to the eschar during
the early postburn period.
Sutilains ointment (Travase, Flint Pharmaceuticals, Deerfield,
IL) is often recommended because it contains proteolytic
enzymes that help speed eschar separation, but any common
topical burn preparation is acceptable. The depth of burns
from wet cement can be difficult to assess in the first several
days. If it becomes apparent that the burns are full-thickness
burns, early excision and skin grafting are recommended.
Cement burns should be differentiated from cement der-
matitis, which is far more common. The latter is a contact
sensitivity reaction, probably from the chromates present in
cement. The contact dermatitis can initially be treated as a
superficial partial-thickness burn.
Air Bag Keratitis and Thermal Burns

Safety legislation has mandated increased use of air bags to
protect automobile occupants in the event of collision. Burns
from air bags can be thermal, friction, or chemical (Fig. 38.23).
The automobile air bag is a rubberized nylon bag that inflates Figure 38.23 A burn on the forearm from a first-generation air bag
on spark ignition of sodium azide to yield nitrogen gas, ash, can be a combination of friction and chemicals. They are usually minor.
and a small amount of sodium hydroxide. Within seconds, the Full-strength polyethylene glycol (PG 300 or 400) is more
superheated air is vented, and this can produce a thermal burn effective than water alone in removing phenolic compounds
if it contacts an extremity, the face, or the upper part of the and should be obtained and used after water irrigation has
torso.7,68,69 If the air bag ruptures, the alkaline contents of the begun. Polyethylene glycol is nontoxic and nonirritating and
bag are dispersed as a fine, black powder that usually causes may be used anywhere on the body. When immediately avail-
no problems unless the eyes are exposed. Patients with eye able, polyethylene glycol can be used to remove the surface
exposure exhibit clinical evidence of a chemical keratocon- chemical before water irrigation (and chemical dilution) is
junctivitis, including photophobia, tearing, redness, and begun.
decreased visual acuity. Tear pH is usually elevated, and there
may be particulate matter in the fornices.70 Hydrofluoric Acid Injury
The severity of an ocular alkaline burn is related to the Hydrofluoric acid (HFA) is one of the strongest inorganic
duration of exposure and the concentration and pH of the acids known; it has been widely used since its ability to dissolve
chemical. For this reason, prompt, copious irrigation of silica was discovered in the late 17th century.73 Currently, HFA
the eyes with frequent assessment of tear pH is essential to is used in masonry restoration, glass etching, and semiconductor
prevent or minimize the injury (see Chapter 62). A rising pH manufacturing; for control of fermentation in breweries; and
suggests that trapped particulate matter is releasing additional in the production of plastics and fluorocarbons. It is also used
chemical. Corneal edema and conjunctival blanching are signs as a catalyst in petroleum alkylating units. It is available in
of serious injury and can necessitate immediate ophthalmologic industry as a liquid in varying concentrations up to 70%. It is
consultation. also readily sold in home improvement and hardware stores.
Significant concentrations of HFA are present in many home
Hydrocarbon Burns rust removal products, aluminum brighteners, automobile wheel
Hydrocarbons are capable of causing severe contact injury by cleaners, and heavy-duty cleaners in concentrations of less
virtue of their irritant, fat-dissolving, and dehydrating properties. than 10%. Despite its ability to cause serious burns, unregulated
Cutaneous absorption may cause even more dangerous systemic and poorly labeled HFA products are recklessly used on a
effects. Gasoline, the usual agent involved, is a complex mixture regular basis in the home and in small businesses. The public
of C4 to C11 alkane hydrocarbons and benzene; the hydrocarbons and many clinicians are generally unaware of the potential
appear to be the major toxic agent. Lead poisoning caused by problems with this acid (Fig. 38.24).
either absorption through intact skin or burns from exposure Although HFA is quite corrosive, the hydrogen ion plays
to leaded gasoline have been reported previously but are cur- a relatively insignificant role in the pathophysiology of the
rently quite rare because unleaded gasoline has virtually replaced burn injury. The accompanying fluoride ion is a protoplasmic
the leaded version for most purposes.71 poison that causes liquefaction necrosis and is notorious for
The depth of injury is related to the duration of exposure and its ability to penetrate tissues and cause delayed pain and deep
the concentration of the chemical agent. Gasoline immersion tissue injury. This acid can penetrate through fingernails and
injuries resemble scald burns and are usually partial thickness.72 cause nail bed injury. With home products, the unwary user
Occasionally, gasoline-injured skin exhibits a pinkish brown does not realize that the substance is caustic until the skin
discoloration, possibly related to dye additives. A common (usually the hands and fingers) is exposed for a few minutes
source of gasoline exposure is motor vehicle collisions in which to hours, at which time the burning begins and becomes
a comatose patient has been lying in a pool of gasoline. progressively worse. At this point the damage is done and the
The lungs are the usual site of systemic absorption and are absorbed HFA cannot be washed off. With higher-strength
often the only major route of excretion. The resultant high industrial products, symptoms are almost immediate.
pulmonary concentrations may lead to pulmonary hemorrhage, The initial corrosive burn is due to free hydrogen ions;
atelectasis, and acute respiratory distress syndrome. To treat secondary chemical burning is due to tissue penetration of
hydrocarbon burns, remove contaminated clothing, administer fluoride ions. Fluoride is capable of binding cellular calcium,
prolonged irrigation or soaking of the contaminated skin, which results in cell death and liquefaction necrosis. The ionic
débride significant burns caused by lead-containing gasoline shifts that result, particularly shifts of potassium, are believed
(to reduce systemic lead absorption), and apply topical antibiotic to be responsible for the severe pain associated with HFA
ointments. burns.
In high concentrations, the fluoride ions may penetrate to
Phenol Injury bone and produce demineralization. Exposure of skin to
Phenol is a highly reactive aromatic acid alcohol that acts as concentrated HFA involving as little as 2.5% TBSA can lead
a corrosive. Carbolic acid, an earlier term for phenol, was to systemic hypocalcemia and death from intractable cardiac
noted to have antiseptic properties and was used as such by arrhythmias; it has been calculated that exposure to 7 mL of
Joseph Lister in performing the first antiseptic surgery. Hex- anhydrous HFA (HFA gas) is capable of binding all the free
ylresorcinol, a phenol derivative, is in current use as a bactericidal calcium in a 70-kg adult.74,75 Hyperkalemia and hypomagnesemia
agent. Phenols, in strong concentrations, cause considerable can also develop. If the hands are exposed, the acid characteristi-
eschar formation, but skin absorption also occurs and can result cally penetrates the fingernails and injures the nail bed and
in systemic effects such as central nervous system depression, cuticle area. As with most caustics, the pain is generally out
hypotension, hemolysis, pulmonary edema, and death. Interest- of proportion to the apparent external physical injury. HFA
ingly, phenol acts differently from other acids in that it pen- burns produce variable areas of blanching and erythema, but
etrates deeper in a dilute solution than in a more concentrated blisters or skin sloughing are rarely seen initially. Skin necrosis
form.62 Therefore, irrigation with water is suboptimal for phenol and cutaneous hemorrhage may be noted in a few days.
burns, but, because water is commonly and readily available, Immediate treatment should begin with copious irrigation
it is frequently used for irrigation. with water. Another approach is to wash the area with a solution
the fingers and hands. Completely re-dress the wound and

reapply the paste every 6 hours for the first 24 hours. As with
most topical treatments of HFA burns, calcium gluconate is
only minimally effective in relieving pain, and its value is
probably overestimated in the literature.
A digital or regional nerve block with long-acting bupivacaine
is an excellent way to provide prolonged pain relief if the hands
are involved, but this does nothing to ameliorate the injury.
In most cases, oral opioids are required. If bullae or vesicles
have formed, they should be débrided to decrease the amount
of fluoride present, and the wound should then be treated as
A any partial-thickness burn. Burns with HFA of less than 10%
strength will heal spontaneously, usually without significant
tissue loss, but pain and sensitivity of the fingertips may persist
for 7 to 10 days. In addition, the fingernails may become loose.
The presence of significant skin injury or intense pain implies
penetration of the skin by fluoride ions. This scenario is
particularly common with exposure to HFA solutions in
concentrations of 20% or greater, but tissue injury can occur
with prolonged exposure to less concentrated products.
Initial treatment of a more concentrated exposure begins
as described earlier and includes immediate débridement of
necrotic tissue to remove as much fluoride ion as possible.76
After débridement, inject a 10% solution of calcium gluconate
(note: avoid calcium chloride for tissue injections) intradermally
and subcuticularly with a 30-gauge needle about the exposed
area, using approximately 0.5 mL per square centimeter of
burn. Pain relief should be almost immediate if this therapy
is adequate. Because the degree of pain is a measure of the
effectiveness of treatment, the use of anesthetics, especially by
local infiltration, may be deleted if the burn is on the arm or
leg. HFA can penetrate fingernails without damaging them.
Soft tissue can be injected without prior anesthesia, but if the
fingertips or nail beds are involved, they may be injected after
a digital nerve block has been performed (Fig. 38.25). Before
anesthesia and injection of calcium, the patient can outline
B
the affected areas with a pen to ensure accurate injection of
Figure 38.24 A, Initially, this very painful hydrofluoric acid burn of the antidote (see Fig. 38.25C). Although some investigators
the thenar and hypothenar eminence appeared minimal. B, Despite recommend that the fingernails be removed routinely, we
infiltration with calcium gluconate, a deep burn developed 3 days later. strongly advise against this unless the nails are very loose or
there is obvious necrosis of the nail bed. Fingers are best
injected with a 25- or 27-gauge needle (a tuberculin syringe
works well).65 Nails frequently become loose in a few days,
of iced magnesium sulfate (Epsom salts) or a 1 : 500 solution but they often return to normal and do not require removal,
of a quaternary ammonium compound such as benzalkonium particularly when lower-concentration nonindustrial products
chloride (Zephiran, Sanofi-Synthelabo Inc., New York, NY) are involved.
or benzethonium chloride (Hyamine 1622, Sigma-Aldrich). Although infiltration of calcium gluconate is somewhat
Magnesium and calcium salts form an insoluble complex with effective, the technique has certain limitations. Injections are
fluoride ions, thus preventing further tissue diffusion. Though painful, and the calcium gluconate solution itself causes a
frequently recommended, topical preparations are often inef- burning sensation. Because of the volume restrictions, not
fective in limiting injury or controlling pain. enough calcium may be delivered to bind all the free fluoride
If there is no or only minimal visible evidence of skin injury ions present. For example, 0.5 mL of 10% calcium gluconate
and minimal pain, the burn may be dressed with topical calcium contains 4.2 mg (0.235 mEq) of elemental calcium, which will
gluconate paste. This is not commercially available in the neutralize only 0.025 mL of 20% HFA.
United States but is easily compounded in the pharmacy by Several authorities have advocated intraarterial calcium
mixing 3.5 to 7 g of pulverized calcium gluconate with 5 oz infusions in the treatment of serious HFA burns of the extremi-
of a water-soluble lubricant such as K-Y jelly. This will form ties.77,78 Though very effective, this technique is not recom-
a thick paste with a calcium gluconate concentration of 2.5% mended for burns secondary to dilute HFA (i.e., concentrations
to 5.0%. Some have suggested dimethyl sulfoxide as a vehicle <10%) because the morbidity is usually quite mild. When
to aid in skin penetration of the calcium. Plastic wrap (e.g., using this technique, 10 mL of 10% calcium gluconate is diluted
Saran Wrap, SC Johnson, Racine, WI) is used over a standard in 50 mL of a 5% dextrose and water solution. The dilute
dry burn dressing to cover the calcium paste on the limbs. A solution is administered by slow infusion into an arterial
vinyl or rubber glove filled with the paste can be used to cover catheter. It is unclear which artery best delivers the calcium
A B
C D
Figure 38.25 A, Hydrofluoric acid (HFA) burns of the fingertips are extremely painful despite
minimal clinical findings; initially only hyperemia and minor ecchymosis are apparent. HFL can
penetrate the intact fingernail and produce a significant injury to the nail bed. B, The area of burn
can be injected with calcium gluconate minimally diluted with plain lidocaine. Using a small-gauge
needle, generously infiltrate the entire area of the burn. C, Before performing digital block anesthesia
to painlessly infiltrate the fingertips with calcium gluconate, ask the patient to outline the painful
areas with a felt-tipped marker to ensure accurate placement of the antidote. In the treatment of
HFA burns, topical therapy is often ineffective. Calcium gluconate may be injected subcutaneously
with a 25- to 27-gauge needle into the nail bed via the fat pad under a digital nerve block. Do not
remove fingernails routinely if burns are mild, such as those seen with household products containing
less than a 10% concentration of the acid. Intraarterial calcium infusions are often quite successful
in relieving pain and limiting necrosis. D, Combine the calcium gluconate with a small amount of
lidocaine for injection.
to injured tissues. If only the radial three digits are involved, ED. Such patients require hospitalization or burn center referral
probably only the radial artery needs to be cannulated. Oth- for further evaluation and observation.
erwise, a percutaneous catheter is inserted into the brachial Advantages of the intraarterial method are elimination of
artery. However, some investigators have advocated use of the the need for painful SQ injections and avoidance of the volume
radial artery in all cases, and because the arterial supply of the limitations of the SQ route while providing substantially more
hand is interconnected, this may be a reasonable recommenda- calcium to neutralize the fluoride. Disadvantages of intraarterial
tion.79 The radial artery is usually more easily cannulated than calcium therapy include the possibility of local arterial spasm
the brachial artery. When arterial access has been accomplished, (which can be treated with vasodilators such as phentolamine
the solution is infused slowly over a 4-hour period. At this or removal of the catheter), local arterial injury or thrombus,
point the catheter is left in place and the patient is observed. and the long duration of treatment required.
If pain returns at any time over the next 4 hours, the infusion Infusing calcium into the general venous circulation is of no
is repeated. If the patient is pain free over the 4-hour observation benefit for HFA burns. Some authors have advocated the use
period, the burn is dressed and the patient is released home. of regional IV calcium gluconate, similar to the method used
This technique may be initiated in the ED, but many clinicians with the Bier block for regional anesthesia (see Chapter 32).80
are reluctant to cannulate an artery and infuse calcium in the Case reports have noted variable success, but this technique
has neither been well studied nor rigorously compared with Hemodialysis, peritoneal dialysis, or exchange transfusion may
other options. This method would be useful only for upper be indicated.
extremity burns. To perform regional calcium therapy, place an
IV catheter in the dorsum of the hand on the involved extremity. Phosphorus Burns
Partially exsanguinate the arm by elevation, wrapping with an White phosphorus is a translucent, waxy substance that ignites
elastic bandage, or both. Apply a Bier block tourniquet or a spontaneously on contact with air. For this reason, it is usually
heavy-duty blood pressure cuff to the burn and inflate it to 20 stored under water. It is used primarily in fireworks, insecticides,
to 30 mm Hg above the systolic pressure to stop blood flow to rodenticides, and military weapons.
and from the arm. Because slow deflation of a regular blood Phosphorus causes both thermal burns from the flaming
pressure cuff may thwart success of the procedure, using this pieces and acid burns from the oxidation of phosphorus to
specialized tourniquet is recommended. Then, dilute 10 mL phosphoric acid. The burns classically emit a white vapor with
of 10% calcium gluconate with 30 to 40 mL of saline, and a characteristic garlic odor.84
infuse the solution into the venous catheter. Keep the solution Treat these burns first by immersion in water. Débride any
in the arm by keeping the tourniquet on for 20 to 30 minutes. gross debris. Wash the wound with a 1% copper sulfate solution,
Some patients cannot tolerate arm ischemia for this period, which reacts with the residual phosphorus to form copper
thus limiting the effectiveness of this procedure. Theoretically, phosphate. Copper phosphate appears as black granules, which
the calcium diffuses out of the venous system and into the allow for easy débridement. After débridement, remove the
injured tissues. After 20 to 30 minutes, deflate the cuff to residual copper with a thorough water rinse, dress the wound,
restore normal circulation to the extremity. It may require and treat it as any other burn.
10 to 20 minutes after deflation of the tourniquet before the
patient experiences relief of pain. This procedure is safe, but Elemental Alkali Metal Burns
its efficacy is variable. The commonly encountered alkali metals (sodium, lithium,
HFA burns involving the eye are potentially devastating and potassium) are highly reactive with water and with water
injuries that deserve special mention. Ophthalmologist referral vapor in the air and produce their respective hydroxides with
is mandatory. Ocular exposure to liquid or gaseous HFA will liberation of hydrogen gas. Therefore, water should never be
result in severe pain, tearing, conjunctival inflammation, and used for extinguishing or débriding the metal. A class D fire
corneal opacification or erosion. Complications include extinguisher or plain sand may be used to smother the fire,
decreased visual acuity, globe perforation, uveitis, glaucoma, followed by the application of mineral oil or cooking oil to
conjunctival scarring, lid deformities, and keratitis sicca. Optimal isolate the metal from water and allow safe débridement. Then,
therapy for ocular HFA burns, other than initial irrigation, is treat the burn as an alkali burn.
unknown. Irrigation may be performed with water, isotonic Magnesium burns in a less intense fashion but otherwise
saline, or magnesium chloride.81 We advise copious saline acts as other alkali metals do. These burns may be particularly
irrigation. Topical antibiotics and cycloplegics, along with light injurious, however, because if all the metallic debris is not
pressure patching, are also recommended. The use of topical removed, the small ulcers that form will slowly enlarge until
steroids has been advocated by some to lessen corneal fibroblast they become quite extensive.
formation, but other attempted therapies such as subconjunctival The initial topical treatment of unusual chemical burns is
injections of calcium gluconate and ocular irrigation with outlined in Table 38.3.
quaternary ammonium compounds have been associated with
additional injury.82
Electrical Burns
Chromic Acid Injury Electrical burn wounds occur when energy traveling through
Chromium compounds are used extensively in industry, mainly the body across a potential difference is converted to heat.
in metallic electroplating. Chromic acid is commonly used in This energy has the ability to destroy deep tissues, including
concentrated solutions containing up to 25% sulfuric acid. It muscles, tendons, and nerves (Fig. 38.26). In addition, electrical
causes sufficient skin damage to allow absorption of the toxic injuries can arise from the arc produced when electricity passes
chromium ion if intensive irrigation is not undertaken imme- through the air and from flames caused by the ignition of
diately. Heated (60°C to 80°C) chromic acid makes the problem clothing. Electrical injuries from high-voltage or high-current
of chromium absorption much worse. sources (> 1000 V and > 5000 mA) are more likely to result
Dichromate salts containing hexavalent chromium are the in deep soft tissue damage, whereas low voltage or low current
most readily absorbed and the most toxic because they can (< 1000 V and 5 to 60 mA) causes less soft tissue damage but
cross cell membranes. The mortality rate from these burns is is more likely to result in cardiac arrhythmias.85
very high if the burn exceeds 10% TBSA. Chromium absorption
leads to diarrhea, gastrointestinal bleeding, hemolysis, hepatic
and renal damage, coma, encephalopathy, seizures, and dis-
TEN and SJS
seminated intravascular coagulation. Toxic epidermal necrolysis (TEN) and Stevens-Johnson
To treat, immediately excise the burned tissues to lessen syndrome (SJS) are severe blistering diseases. They are primarily
the total body dichromate burden. Wash wounds with a 1% associated with the intake of medications that cause apoptosis
sodium phosphate or sulfate solution and dress them with of keratinocytes, which results in the separation of large areas
bandages soaked in 5% sodium thiosulfate solution. These of skin at the dermal-epidermal junction and produces the
actions reduce the hexavalent chromium ion to the less well appearance of a scald. More than 200 medications have been
absorbed trivalent form.83 associated with this condition, although infections and immu-
Institute chelation therapy with ethylenediaminetetraacetic nizations have also been associated. A major factor in improving
acid (EDTA) and give IV sodium thiosulfate and ascorbic acid. outcomes has been high-quality intensive support and trained
TABLE 38.3 Chemical Burn Treatment

WATER LAVAGE CHROMIC ACID TANNIC ACID
Potassium Tannic acid
permanganate
Cantharides Sulfosalicylic acid
Lyes (hydroxide Trichloroacetic
salts) acid
Clorox Cresylic acid
Dichromate salts Acetic acid
Picric acid Formic acid
Calcium salt Oxalic acid

injection Hydrofluoric acid
Oil immersion Sodium metal Figure 38.27 Stevens-Johnson syndrome (SJS). Purpuric macules
White phosphorus became bullous. Note the inflammation of the conjunctivae and lips.
Mustard gas By definition, in SJS the lesions occupy less than 10% of total body
surface area (TBSA). (From Paller AS, Mancini AJ, editors: Hurwitz
Avoid water Sodium metal clinical pediatric dermatology, ed 4, St. Louis, 2011, Saunders.)
lavage Potassium metal
Lithium metal
incidence of 0.4 to 1.2 and 1.2 to 6.0 per million persons,
Specific Sodium metal Excision respectively, and are more common in females and the elderly.86
approaches Lyes (hydroxide Weak acid lavage Patients at risk are those who are severely immunocompromised
salts) (vinegar) (e.g., human immunodeficiency virus [HIV] infection, lym-
Hydrofluoric acid Calcium gluconate phoma). Death occurs on average in every third patient
injection with TEN. More than 200 drugs, including antibiotics (par-
ticularly sulfonamides), nonsteroidal antiinflammatory drugs,
White phosphorus Copper sulfate
and anticonvulsants, have been implicated.
solution
Various theories exist to explain the precise sequence of
molecular and cellular events responsible for the development
of TEN. The 1- to 3-week interval between the onset of TEN
and the commencement of drug therapy favors an immune
etiology. Cytotoxic T cells are seen in cutaneous lesions, and
it is hypothesized that necrolysis is due to their recognition
of complexes between drug metabolites and major histocompat-
ibility complex class I molecules on the surface of keratinocytes.
Exfoliation is due to the death of keratinocytes via apoptosis,
and data suggest that the latter is mediated by interaction of
the death receptors, transmembrane proteins, Fas, and its ligand
FasL. This activates the proteolytic cascade (caspases), which
leads to cellular disintegration.87 Evidence has shown upregula-
tion of FasL in patients with TEN.
Clinical Features
TEN and SJS are usually characterized by fever, corneal irrita-
tion, and painful swallowing (representing oral mucocutaneous
Figure 38.26 Electrical burn. The patient experienced a contact burn
involvement). These symptoms can precede the rash by 1 to 3
across the dorsa of the toes from an exposed electrical wire. (From days. In more than 99% of patients, erythema and erosions of
Davis PJ, Cladis FP, Motoyama EK, editors: Smith’s anesthesia for the buccal, ocular, and genital mucosa develop and are painful.
infants and children, ed 8, St Louis, 2011, Mosby.) Diagnosis may require skin biopsy as the condition might be
difficult to clinically differentiate from other conditions such
as staphylococcal scalded skin syndrome or other dermatologic
nursing care with expertise in wounds. Thus these disorders emergencies. The epithelium of the respiratory tract is involved
are ideally suited to treatment at burn centers. in 25% of cases of TEN, and gastrointestinal lesions can occur.
The distinction between TEN and SJS is one of extent, The skin lesions first appear as erythematous, dusky red, or
with lesions occupying less than 10% TBSA qualifying as SJS purpuric macules, irregular in size and shape, that tend to
(Fig. 38.27) and lesions involving greater than 30% TBSA coalesce. Nikolsky’s sign (blistering following pressure with
being called TEN (Fig. 38.28); when the extent of involvement the finger) may be evident. A gray appearance of the macule
lies between 10% and 30%, an intermediary term is coined, heralds necrosis of the epidermis, which soon separates from
SJS-TEN overlap. These disorders are rare with an annual the dermis and leaves a raw painful area. Wound infections
A B C
Figure 38.28 Toxic epidermal necrolysis. A, Detachment of large sheets of necrolytic epidermis
(>30% total body surface area) led to extensive areas of denuded skin. A few intact bullae are still
present. B, Hemorrhagic crusts with mucosal involvement. C, Epidermal detachment of the palmar
skin. (From Bolognia JL, Jorizzo JL, Rapini RP, editors: Dermatology, ed 3, St. Louis, 2012, Saunders.)
(S. aureus and P. aeruginosa) and fluid and electrolyte loss

TABLE 38.4 Scorten Score for Predicted Mortality
often follow. Death is mainly due to sepsis, acute respiratory
in TENa
distress syndrome, and multiorgan failure. Reepithelialization
and healing of wounds can occur within 3 weeks but may be RISK FACTOR 0 1
prolonged. There are, however, late sequelae such as scarring
Age <40 years ≥40 years
and pigmentary abnormalities, as well as serious ophthalmic
complications (e.g., symblepharon, conjunctival synechiae, Malignancy No Yes
entropion), which can range from sicca syndrome to blindness.
Heart rate <120 ≥120
Management Serum BUN (mg/dL) <27 >27
Initial management of TEN requires immediate discontinuation
of all medications, including antibiotics, if there are no signs %BSA involved <10% >10%
of infection. Supportive care is similar to that required in the
treatment of thermal burns. Depending on the body surface Serum bicarbonate (mEq/L) ≤20 <20
area involved patients may require the resources of a Burn Serum glucose (mg/dL) <250 >250
Center that has dermatology consultants available. Medical
attention is paid to correction of fluid and electrolyte abnormali- NUMBER OF RISK FACTORS MORTALITY RATE
ties, renal insufficiency, nutrition, and sepsis. Involvement of
0–1 3.2%
respiratory mucosa may warrant intubation and ventilation.
The wounds are carefully débrided and a biopsy specimen is 2 12.1%
taken to confirm the diagnosis. Regular hydrotherapy and
topical antimicrobials are used to decrease infection. Silvadene 3 35.3%
and mafenide are best avoided because they may be implicated 4 58.3%
in causing the disorder, but alternative dressings include the
various silver products (e.g., Acticoat, Smith & Nephew), as 5 or more 90%
well as bacitracin and Xeroform (DeRoyal). Synthetic dressings
a
such as Biobrane (Smith & Nephew) and biologic materials, Scorten Scale as reported in article by Bastuji-Garin S, Fouchard N, Bertocchi
M, et al: SCORTEN: a severity-of-illness score for toxic epidermal necrolysis,
including allograft, have all been used with various success.88 J Invest Dermatol 115(2):149–153, 2000.
Regular examination by an ophthalmologist is also recom-
mended. The eyelids should be cleansed daily and followed
with a daily application of antibiotic ointment. Attention to oral
hygiene is also mandatory because oral lesions are common. against Fas that can block the binding of Fas with FasL, but
Several case reports and uncontrolled series suggest the utility of recently granulysin has been identified as the most important
specific therapies for the treatment of TEN/SJS; however, thus of known mediators for SJS & TEN.90 Importantly, subsequent
far there are no strong evidence-based standards to promote research has not demonstrated a significant mortality advantage
any particular therapy. Studies have included cyclosporine, for patients using either high- or low-dose IVIG compared
cyclophosphamide, IVIG, plasmapheresis, and N-acetylcysteine, with patients treated with supportive care only, so IVIG is not
but these therapies are not established as standard of care. The currently established as standard of care therapy.
use of systemic corticosteroids remains controversial, and they Mortality of TEN approaches 30% on average, depending
may even increase mortality. Promising results were shown on stage of diagnosis at presentation, supportive measures,
with the use of IV immunoglobulins that contain antibodies age, and comorbidities. A modified scoring system for patients
A B
Figure 38.29 Frostbite. Initial management includes rapid rewarming in a water bath (temperature
of 40°C to 42°C) for 15 to 30 minutes. Hemorrhagic blisters should be left intact; white or clear
blisters may be débrided. Avoidance of refreezing is imperative.
with TEN has been published by Bastuji-Garin and colleagues exposure of more than 100 rad causes acute radiation syndrome
that predicts the mortality of these patients91 (Table 38.4). within hours of exposure. This is characterized acutely by
Although rarely useful for the emergency provider, this scoring nausea, vomiting, diarrhea, fever, fatigue, and headache. The
system and predicted mortality may aid in the collaborative symptoms may resolve transiently during a latent period
decision to hospitalize at a non-burn center or arrange for only to recur as hematopoietic, gastrointestinal, or vascular
transfer to a burn center. complications.93,94
Frostbite
EMERGENCY ESCHAROTOMY
Frostbite is the result of exposure to low environmental
temperatures (Fig. 38.29). The formation of ice crystals within Full-thickness burns result in an eschar that is inelastic and
extracellular fluid causes direct cellular injury and cellular may become restrictive and result in compartment syndrome.
dehydration through transmembrane osmotic shifts. In addition, Intracellular and interstitial edema can develop and progress,
a secondary vascular effect of cooling leads to endothelial both because of fluid resuscitation and as a direct result of
damage and progressive dermal ischemia.92 transcapillary extravasation of fluid from the thermal injury. As
Initial management of acute frostbite should entail deter- the soft tissues become edematous and pressure rises under the
mination of the core temperature and a full physical examina- unyielding eschar, first venous and then lymphatic, capillary, and
tion. The frostbitten part should be rapidly rewarmed in a ultimately arterial flow to the underlying and distal unburned
water bath (temperature of 40°C to 42°C) with adequate tissue may be compromised. Full-thickness and extensive partial-
analgesia for 15 to 30 minutes. Treatment of deep injury consists thickness circumferential extremity burns are most likely to
of elevation of the injured part to control edema, adequate impede peripheral blood flow. Circumferential chest burns
analgesia, splinting, and the application of topical antibiotics. may restrict chest wall movement and impair ventilation, and
Traditionally, white blisters are débrided. They generally circumferential neck burns may result in tracheal obstruction.
represent superficial injury, and débridement is thought to be In such cases, immediate escharotomy may be indicated.
beneficial because it helps in the removal of thromboxane A2 On occasion, because of high-volume fluid resuscitation,
and prostaglandin F2α. Hemorrhagic blisters, however, are said noncircumferential and deep partial-thickness burns require
to represent deeper injury and are best left intact to protect surgical decompression to prevent the complications of nerve
tissues against desiccation. The use of antithromboxane drugs or muscle damage. Once signs and symptoms of vascular
such as aspirin or ibuprofen has been shown to be useful, as impairment are present, the clinician must act quickly to prevent
has the application of aloe vera. The avoidance of refreezing tissue hypoxia and cellular death. This pathophysiology may
is critical to reduce complications. Patients should be educated be manifested within a time frame that requires an emergency
on this important precaution. Premature amputation should clinician to intervene. Clinical assessment of tight compartments
be avoided but may be necessary for definitive closure. Long- may be aided by measurements such as capillary refill, Doppler
term consequences include a predilection for future frostbite, signals, pulse oximetry, and direct measurement of compartment
vasospastic syndromes, and cold hypersensitivity. pressures. Escharotomy, when required, is usually performed
within the first 2 to 6 hours of a burn injury. The need for
non–burn specialists to identify the need for and perform an
Radiation Burns adequate escharotomy is illustrated by the report of Brown
Accidents involving ionizing radiation are not common, but and associates,95 who found that 44% of pediatric burn cases
when they occur, the clinical findings may range from erythema were inadequately decompressed before arrival at a referral
to charring of the superficial layers of skin. Whole-body burn unit.
It is not standard of care that emergency clinicians be skilled

in emergency escharotomy, nor can it be expected that this
procedure will be done in the ED. The technique is described
here for circumstances when escharotomy must be performed
by a non–burn specialist.
Indications
The indications for escharotomy are based on clinical examina-
tion, compartment pressure, or both. A high index of suspicion
and a low threshold for intervention are essential for a successful
outcome. Skin temperature and palpation of pulses are unreliable
and imprecise indicators of the adequacy of circulation because
of peripheral vasoconstriction and local edema. A patient with
A
circulatory embarrassment significant enough to warrant
escharotomy may complain of deep aching pain, progressive
loss of sensation, or paresthesias, but these parameters are
difficult to quantitate in a severely burned, sedated, or mechani-
cally ventilated patient. However, motor activity and peripheral
pulses may remain intact despite severe underlying muscle
ischemia. In the series by Brown and associates,95 peripheral
pulses were present in 74% of the limbs that required decom-
pression. Muscle compartments with pressures in excess of
30 mm Hg should be decompressed. Measurements should
be taken before and after escharotomy to ensure adequate
decompression.
In a patient with absent distal arterial flow (as determined
with a Doppler ultrasonic flow meter) but otherwise adequate B
blood pressure, immediate escharotomy is indicated. Bardakjian
Figure 38.30 Escharotomy. A, Patients with deep, nearly circumferential
and coworkers96 suggested that an oxygen saturation below
or circumferential chest wall burns may require escharotomy to facilitate
95% in the distal end of the extremity as demonstrated by ventilation. If performed properly, escharotomy of the torso will
pulse oximetry (in the absence of systemic hypoxia) is also a markedly enhance compliance. B, Properly performed escharotomy
reliable indicator of the need for emergency escharotomy. will result in immediate improvement in extremity blood flow. (From
Vincent JL, Abraham E, Moore FA, et al., editors: Textbook of critical
care, ed 6, St. Louis, 2011, Saunders.)
Technique of Escharotomy
Because full-thickness burns are insensate to pain and involve
coagulation of superficial vessels, no anesthesia is needed.
Patients with deep partial-thickness burns may still possess
pain sensation, and escharotomy may be performed with local
anesthesia or systemic analgesia. A properly executed escha-
rotomy releases the eschar to the depth of SQ fat only. This
results in minimal bleeding, which can be controlled with local
pressure or electrocautery. These incisions, even though life
or limb saving, represent potential sources of infection for the
burn patient and should be treated as part of the burn wound.
The wounds should be loosely packed with sterile gauze
impregnated with an appropriate topical antimicrobial such
as silver sulfadiazine cream. Fasciotomy, which involves a deeper
incision, may be needed for thermal or electrical burns.
Limbs
Under sterile conditions, incise the lateral and medial aspects
of the involved extremity with a scalpel or electrocautery 1 cm
proximal to the burned area and 1 cm distal to the involved
area of constricting burn (Fig. 38.30). Carry the incision through
the full thickness of skin only and this should result in immediate
separation of the constricting eschar to expose SQ fat. Because
joints are areas of tight skin adherence and potential vascular Figure 38.31 Preferred sites for escharotomy incisions. Dotted lines
impingement, incisions should cross these structures (Fig. indicate the escharotomy sites. Bold lines indicate areas where caution
38.31). Take care to avoid vital structures, such as the ulnar is required because vascular structures and nerves may be damaged
nerve at the elbow, the radial nerve at the wrist, the superficial by escharotomy incisions. (From Davis JH, Drucker WR, Foster RS,
peroneal nerve near the fibular head, and the posterior tibial et al: Clinical surgery, St. Louis, 1987, Mosby.)
artery at the ankle. In circumferential burns of the feet, if

escharotomy is indicated, extend the incision to the great toe
Complications
medially and the little toe laterally. In circumferential burns Complications of escharotomy include bleeding, infection, and
of the hands in which escharotomy is indicated, extend the damage to underlying structures. Complications of inadequate
incisions to the thenar and hypothenar aspects of the hands decompression include muscle necrosis, nerve injury (such as
(see Figs. 38.30 and 38.31). Softening of the compartment, footdrop), and even amputation of the limb. Systemic complica-
improved distal tissue perfusion, return of sensation, Doppler tions of inadequate decompression include myoglobinuria and
flow signal strength, and oximetry values indicate adequate renal failure, hyperkalemia, and metabolic acidosis.
release.96
Chest CONCLUSION
Full-thickness circumferential chest or upper abdominal burns
may impair respiration. Nearly all these patients are expected Patients with circumferential or nearly circumferential burns
to be intubated and mechanically ventilated. Evidence of the should be evaluated for the risk of developing compartment
need to release the eschar is increased airway pressure or an syndrome and deep tissue ischemia. Emergency clinicians should
inability to ventilate. Escharotomy of the chest wall should not hesitate to perform an escharotomy before transfer of the
extend from the clavicle to the costal margin in the anterior patient to a burn center if there is evidence of reduced limb
axillary line bilaterally, while avoiding breast tissue in females. perfusion or impaired ventilation.
This may be joined by transverse incisions to result in a
chevron-shaped subcostal incision (see Fig. 38.30).
ACKNOWLEDGMENTS
Neck
Neck escharotomy should be performed laterally and posteriorly The significant contributions of Courtney A. Bethel, MD,
to avoid the carotid and jugular vessels. Leigh Ann Price, MD, and Kevin B. Gerold, MD, to earlier
editions remain appreciated.
Penis
Penile escharotomy is performed midlaterally to avoid the
REFERENCES ARE AVAILABLE AT www.expertconsult.com
dorsal vein.
CHAPTER 38 Burn Care Procedures 805.e1
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Burn Care Procedures: Wound Evaluation

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WOUND EVALUATION

evaluation and treatment in 2014 and approximately 40,000

Varying depth, blisters, or bullae formation

Dermal appendages spared (e.g., sweat glands, hair follicles)

Includes entire epidermis and some portion of the dermis

Figure 38.2 Depths of a burn. First-degree burns are confined to the

Figure 38.3 Depth of thermal injury. A, Patient with sunburn on

Entire head and neck (9%)

11/2 5 11/2 11/2 11/2

13/4 13/4 13/4 13/4 13/4 13/4 13/4 13/4

See chart for A, B, and C

AGE Birth–1 yr 1–4 yr 5–9 yr 10–14 yr 15 yr Adult

BOX 38.1 General Approach to Blisters With

IF TREATED LESS THAN 48 HOURS AFTER THE BURN

ON FOLLOW-UP OR MORE THAN 48 TO 72 HOURS AFTER

BOX 38.2 ABA ABLS Initial Fluid

1. Lactated Ringer’s (LR) is the fluid of choice.

require 6 hours or more. Once considered a traditional empirical

to remove only grossly devitalized tissue. Additional débride-

Pruritus the acute treatment phase. Despite the limited literature on

Edema wound healing.36 Although the procedure is of unproven value,

Specific Topical Agents

BROAD-SPECTRUM ANTIBIOTIC OINTMENTS. Many

BOX 38.6 How to Change a Burn Dressing at

in fewer than 16 days often results in decreased scar formation.4

SPECIAL MINOR BURN

Blisters Figure 38.14 It is difficult to do anything wrong with minor burn

Anaerobic colonization of burn wounds is rare unless there

As with other burns, the depth and extent of the burn

to predict, and home care can be problematic. There are no

Abuse of Children and Elderly Individuals

The majority of abused children are 18 to 36 months old,

SPECIFIC BURNING AGENTS

Strong alkali burns may require irrigation for 1 to 2 hours

Contact Burns From Wet Cement

Air Bag Keratitis and Thermal Burns

the fingers and hands. Completely re-dress the wound and

TABLE 38.3 Chemical Burn Treatment

Calcium salt Oxalic acid

(S. aureus and P. aeruginosa) and fluid and electrolyte loss

It is not standard of care that emergency clinicians be skilled

artery at the ankle. In circumferential burns of the feet, if

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