Minor Burns

Second-degree burn of the hand
https://en.wikipedia.org/wiki/Burn

Classification of Burns

1. First Degree-Also known as superficial burns. They only involve the epidermis with swelling, redness, and pain. Blanches with pressure. Doesn't blister and heals quickly without scarring. Healing time is 3-6 days. Ex: Sunburns
2. Second Degree –Also known as partial-thickness burns. They involve the entire epidermis and portions of the dermis. They are characterized as either superficial or deep.
   1. Superficial Partial-Thickness Burns: Forms blisters within 24 hours. Painful, red, and blanch upon pressure. Painful to temperature and air. Healing takes 7 to 21 days. Scarring is unusual.
   2. Deep Partial-Thickness Burns: These damage hair follicles and glandular tissue. Painful to pressure only. Always blisters and easily unroofed. They do not blanch with pressure. Healing takes more than 21 days to heal and they tend to cause hypertrophic scarring. A deep partial thickness burn that fails to heal in 21 days is functionally and cosmetically similar to a third degree burn.
3. Third Degree- Also known as full thickness burns. These affect the entire epidermis and dermis. The nerves endings are destroyed and so usually there is no pain. The skin is dry and inelastic and does not blanch with pressure. Color can vary from waxy-white to black. Because of the inability to epithelialize, grafting is necessary.
4. Fourth Degree- potentially life threatening burn that extends into the underlying tissue such as fascia, muscle, and/or bone.

Minor burns

Partial thickness burn that are <10 % of the total surface body area (TSBA) in patients between 10-50 years old,  or <5% of TSBA in patients <10 yrs or >50 yrs old, or a full thickness burn that is <2% of TSBA in any patient without other injuries. These are generally treated as outpatient.

Epidemiology

Burns in children are mainly occur during early life from birth to 4 years of age:

• 2/3 scalding burns such as spilling hot liquids from microwaves
• 1/5 contact with hot surfaces like stoves
• 2/15 open flame burns

Scalding burns are a result of temperature and time and it is a curvilinear and asymptotic relationship. The same burn will be caused after:

• 10 minutes with liquid at 120F
• 30 seconds of liquid that is 131F
•   5 seconds of liquid at 140F
• 1 second of liquid at 160F

Burn Classification

https://en.wikipedia.org/wiki/Burn

Burn severity is determined through, among other things, the size of the skin affected. The image shows the makeup of different body parts, to help assess burn size. OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013
https://en.wikipedia.org/wiki/Burn

Management for Burns

1. Assess the patient status:  airway, breathing, circulation, IV acess
2. Assess the burn: how deep is it and how much of the body does it cover? A sheet can be placed on burns during this time
3. Cleaning: Mild soap and water should be used for most burns with burns caused by tar needing petroleum based solution to melt the tar away after cooling with water.  Any skin that is loose can be debrided with mechanical brushing or scrubbing techniques 
4. Cooling: You want to limit inflammation and pain by using cool water, cool saline soaked gauze or a large sheet in the case of a large wound. Care should be maintained to not allow for hypothermia or worsening of the wound by cooling quickly, with ice on large wounds, and with other chemical that could worsen the burn and the skin base.
5. Pain Control- Acetaminophen usually helpful but may need to use opiates such as codeine. 
   

   Type of Pain	ICU (NPO)	ICU (taking diet)	Ward (large wound)	Ward (small wound)
   Background	Continuous IV morphine	Scheduled oxycodone or methadone	Scheduled acetaminophen, ibuprofen or oxycodone	Scheduled acetaminophen or ibuprofen
   Procedural	Morphine IV or fentanyl IV	Transmucosal fentanyl or hydromorphone	Transmucosal fentanyl or hydromorphone	Acetaminophen with codeine or oxycodone
   Breakthrough	Morphine IV	Oxycodone	Codeine, acetaminophen or oxycodone
   Discharge Pain drugs			Acetaminophen with codeine or acetaminophen	Acetaminophen with codeine or acetaminophen

    

6. Check immunization status and update tetanus if necessary.
7. Debridement of Bulla- there are some differences of opinion regarding breaking of blisters.
   
   1. Some suggest leaving intact because the blister acts as a barrier to infection and others debride all blisters. 
   2. Most agree that after blister ruptures necrotic skin should be removed.
8. Application of Antibiotics- suggest use of ointments. Should always be used to prevent infection in any non-superficial burns.
   
   1. Mucopiricin- good Streptococcal and Staphylococcal coverage.
   2. Neosporin/ Bacitracin
   3. Silvadene- has good gram negative coverage and gram negative infections predominate in the second week after the burn. Disadvantage is because it is difficult to see the burn under the Silvadene. 
9. Dressing- should use a non-adherent dressing and is usually applied after the application of antibiotic ointments.
   
   1. Superficial burns do not require dressing.
   2. Basic dressing includes a first layer of non-adherent gauze (ex. adaptic) then a second layer of fluffed dry gauze, and an outer layer of elastic gauze (ex. Kerlix)
   3. May want to inspect the wound frequently but not necessarily take off the entire dressing. Can inspect for warmth, redness, and drainage without removing all the layers.
   4. Dressing should be changed when they are soaked.
10. Pruritus- Itching is a common problem in the healing process and systemic antihistamines are often used (ex. diphenhydramine)
11. Follow up- Look for signs of infection, scarring, and contracture. There should be a follow up visit the day after injury to adjust pain medications, assess dressing change competence, and possibly to debride the wound. Thereafter, follow up visit can be done on a weekly basis or until epithelialization is complete.
    
    1. When to refer: Patients with minor burns should be referred to a surgeon with expertise in burn care if epithelialization has not begun after two weeks or if further evaluations shows full-thickness burn greater than 2 cm. Referral should also occur if there are such wound complications as infection or the development of necrotic tissue.

Special Circumstances: Nonaccidental Burns

• 10-20% of burns in children are inflicted but most are more extensive and sever, requiring hospitalization

• Patterns to recognize:  Triangle of iron, parellel lines of radiator, submersion of buttocks, thigh, feet into water, cigarette burns

•  Full skin and body evaluation should be performed for each child. Care should be noted when injury pattern and story do not match.

Reference

1. American Burn Association White Paper. Surgical management of the burn wound and use of skin substitutes. Copyright 2009. www.ameriburn.org. (Accessed on September 19, 2010).
2. American Burn Association: burn incidence fact sheet www.ameriburn.org (Accessed on September 19, 2010)
3. Baxter, CR. Management of burn wounds. Dermatol Clin 1993; 11:709.
4. Hartford, CE. Care of outpatient burns. In: Total Burn Care, Herndon, D (Ed), WB Saunders, Philadelphia 1996. p.71.
5. Hansbrough JF and Hansbrough W. Pediatric Burns. Pediatrics in Review. 1999; 20:117-124.
6. Heimbach, D, Mann, R, Engrav, L. Evaluation of the burn wound. Management decisions. In: Total Burn Care, Herndon, D (Ed), WB Saunders, Philadelphia 1996. p.81.
7. Hill, MG, Bowen, CC. The treatment of minor burns in rural Alabama emergency departments. J Emerg Nurs 1996; 22:570.
8. Mertens, DM, Jenkins, ME, Warden, GD. Outpatient burn management. Nurs Clin North Am 1997; 32:343.
9. Schiller, William. Burn Management in Children. Pediatric Annals August, 1996.
10. Rodgers Gail Reducing the toll of childhood Burns. Contemporary Pediatrics April 2000