Burns: Treatment

Burn patients require specialized care and support. The American Burn Association estimates the level of care required for burns according to the location, depth, and percentage of total body surface area (TBSA) affected.  

The types of burn cases that should be referred to a burn unit include:²

• Partial–thickness burns covering more than 10% TBSA.
• Burns involving the face, hands, feet, genitalia, perineum, or major joints.
• Full–thickness burns.
• Electrical burns.
• Chemical burns.
• Inhalation injuries.
• Patients with preexisting medical disorders that could complicate management or recovery.
• Patients with concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. 
• Patients who will require special social, emotional, or long–term rehabilitative intervention.

 Immediate care can be lifesaving. Before burns are treated, the burning agent must be prevented from inflicting further damage. Materials such as melted synthetic shirts, hot tar, or chemicals should be immediately removed, or, in some cases, chemically inactivated (eg, hydrofluoric acid).

Burns should be thoroughly cleaned (under local anesthesia if necessary) to prevent infection, and sterile dressings should be applied. Tetanus vaccination and analgesics may be administered as needed.

Partial–Thickness Burns

Superficial minor burns should be immersed immediately in cool water if possible, or a cool moist cloth can be applied until pain subsides. Very cold water and ice should not be used, as these may damage skin. Once a minor burn is completely cooled, a fragrance–free lotion or moisturizer can be applied to prevent drying. Additional topical treatments may also be helpful. Aloe vera gel may achieve more rapid healing, compared with petroleum jelly.³

Blisters should be left intact only if they are smaller than 2 cm. Inflammatory cytokines delay healing in larger blisters. Dead skin, broken blisters, and blisters larger than 2 cm should be debrided and cleaned regularly to prevent infection.

Partial–thickness burns are the hardest to evaluate. Depending on the depth, these burns can be treated with Bacitracin ointment, collagenase ointment, silvadene cream, artificial membranes, or surgery. In general, the best cosmesis will result from conservative care.

Elevation of the burned area above heart level aids healing. Physical and occupational therapy may be needed to prevent joint immobility caused by scarring from moderate burns.

Full–Thickness Burns

Surgery is usually required for full–thickness burns; debridement with skin grafting is indicated when muscle, tendon, and bone are affected.

During the first hours after a major burn, massive capillary leakage may result in profound shock if not treated. Most burn surgeons begin fluid resuscitation using the Parkland Formula. Burns can be better assessed if they are not covered with cream. Therefore, major burns are best dressed with dry gauze only, before transferring the patient to a burn unit. 

Large doses of narcotics and anxiolytics may be required to keep the patient comfortable. Often, promotility agents, stool softeners, or cathartics are needed to maintain bowel function. An insulin drip may be necessary to prevent hyperglycemia.

Also, beta–blockade with propanolol and anabolic steroid support with oxandrolone can decrease muscle wasting and weight loss due to hypermetabolism.⁴

In addition, an escharotomy (which involves cutting through burned tissue until healthy tissue is reached) may be needed to allow chest expansion or to release fluid buildup that can cause loss of blood flow to limbs in circumferential burns.

Inhalation Injuries

Inhalation burns are identified by the following triad:

• The patient was in an enclosed space with the fire.
• Carbonaceous sputum and singed oropharynx are present.
• Elevated carboxyhemoglobin is detected by arterial blood gas analysis.

 Inhalation injuries are frequently accompanied by carbon monoxide poisoning and require hospitalization. Other substances in smoke that can cause breathing problems include benzenes, aldehydes, ammonia, acrolein, nitrogen oxide, and hydrogen cyanide produced by burning wool and plastics.

Superheated steam or gas causes airway edema or bronchospasm resembling an asthmatic attack. In time, this can lead to acute respiratory distress syndrome (ARDS), which is often lethal.

Chemical Burns

With chemical burns, it is imperative to identify the source, ascertain whether the agent has been ingested through inhalation or swallowing, and determine the duration of contact. Health care workers must observe universal precautions to avoid exposure.

Most chemical burns can be treated with copious water irrigation. However, chemicals can complicate care through metabolic derangement and respiratory failure. Forced emesis can further injure the esophagus and lungs.

A burn center or poison control center can provide useful information on treatment of chemical burns.

Electrical Burns

Any electrical injury requires a call to a burn center. Electrical injuries damage multiple organs, including the nervous, cardiovascular, visual, and musculoskeletal systems. Two different types of electrical injuries are caused by direct and alternating current. 

The most common direct current electrical injury is lightning, which is nearly always fatal. When the patient survives, trauma injuries from muscle contractures and from the patient being thrown are common. Urinalysis or serum creatine phosphokinase (CPK) can help rule out myoglobinuria or rhabdomyelinolysis. 

Injuries from alternating current arise from domestic or industrial wiring and can be classified as low or high voltage (>1,000 volts). The entire body is subjected to its effects, with no entrance and exit points.

Any electrical skin burns should be regarded solely as contact points. Contact points are often full–thickness burns that need referral to a burn center. Most of the damage is underneath the skin, as the current courses through muscles, nerves, blood vessels, and the periostium. For example, patients may lose most of their forearm musculature, despite an initial clinical exam showing only a small palmar contact point. Compartment syndromes are common and must be treated aggressively. Urinalysis or serum CPK measurement should be performed, and referral to a burn center is strongly advised.