In the United States (US), over 1 million burn injuries occur each year. The most common burn injuries are the result of scalds from hot liquid and flame burns. Approximately 80% of these burns occur in the home and 70% of them occur in males. Burns in children younger than 5 years of age account for 20% of yearly burn injuries (Evans, 2016). Managing minor burns in the home fine but burns that cover large surface areas or significant burns that damage deep tissue should be evaluated and treated by a healthcare professional.
Thermal burns include exposure to flame, scald from hot liquids and contact with hot surfaces. The degree or temperature and the length of time of contact determine the severity of the burn.
Electrical burns are classified by category, high voltage, low voltage, lighting strikes and electric arc without passage current through the body. Most electrical burns are work-related and high voltage, usually occurring in men. Injuries in children are most often low voltage occurring in the home and related to home appliances, frayed electrical cords or placement of objects in an electrical outlet. Electrical injuries can cause cardiac arrhythmias which result in death.
Chemical burns generally progress after contact as the chemical continues to destroy healthy tissue. The severity of the burn is determined by:
It is difficult to determine the extent of damage initially. It may appear superficial at first but the chemical continues to breakdown the skin, often effecting much deeper levels. Tissue damage begins with contact and continues until the agent is removed from the skin by irrigation.
As in flame injuries, inhalation of chemicals and toxic material can cause lower airway damage. Chemical inhalation causes sloughing of the lining, secretion of mucus, inflammation, collapsing of the small air sacs in the lungs and obstruction of the airway.
This is based on the depth of the wound, the number of cells damaged. The degree of burns has changed from first, second, third and fourth degree to:
Wound care management is planned based on the location, severity, and depth of the injury. The patient should be medicated for pain prior to any treatment of burn wounds. Factors that play a role in the plan of care are:
Hydrotherapy can be used for debridement, tub immersion or shower. If the wound involves a joint, this is the best time to provide range of motion (ROM) exercises.
Topical antimicrobial agents are typically used in deep burns that are not excised or closed surgically to keep the risk of infection low. These antimicrobial agents are not usually indicated for superficial wounds or donor sites of skin or meshed skin grafts. The most commonly used antimicrobial for burns is silver sulfadiazine. This agent does not cause pain with application and requires a prescription.
Antimicrobial dressing with silver (Ag) may be used. Mepilex Border Ag Antimicrobial Foam Dressing is a good choice for high draining burn wounds. It protects the surrounding skin from excess moisture or drainage from the wound and does not cause pain with application or removal.
One option for superficial burns is Hydrofera Blue. It manages wound drainage, helps remove debris from the wound and helps to manage bacterial growth within the wound bed. Calcium alginate dressing such as Algisite, can be used on superficial and partial-thickness wounds but cannot be used on deep-partial-thickness or full-thickness burns. Algisite is available with silver as well. Burns that affect the epidermis (superficial) only may be dressed with a transparent film dressing such as Tegaderm or Opsite and left in place for 5-7 days.
Topical ointments for minor burns include Bacitracin or Neosporin. These ointments can be applied multiple times a day and are perfect for burns on the face or perineal areas. They provide a moist environment for healing while offering antimicrobial properties.
Cellular or tissue-based products are used as a temporary skin substitute in partial-thickness burns. This product will help maintain an infection free wound. The nerves in the wound are covered which helps decrease pain. They also reduce frequency of dressing changes, also helping to minimize pain. Extracellular matrix scaffolding or skin replacement promotes rapid skin production which decreases scar formation. Skin grafting is the best choice if the burn victim has undamaged skin available. If not, Allograft is skin harvested from donors. Xenograft is a split-thickness pigskin and is used n partial-thickness burns that do not require skin grafting.
Severe burn injuries require a multidisciplinary approach to management. Burn victims need support on many levels. Pain and anxiety create stress which can delay wound healing. Along with medications to help manage pain and anxiety, non-medication measures are quite helpful. These include:
Children suffering burn injuries have special needs but include the same physical support adults require. Children may suffer from separation anxiety while hospitalized. They develop fear of treatments because of repeated painful procedures and dressing changes. Their developmental stages ay regress secondary to these fears. Behavioral changes such as anger, anxiety and agitation are more common in children. Family should be present with the child during treatments and wound care. It is recommended a parent be present during the recovery phase in the hospital setting, offering support and comfort. Post-traumatic stress disorder (PTSD) is not uncommon the child with burn injuries. Treatment of PTSD should be started at the earliest signs for best outcomes.
Author Profile: Christine Kijek, Registered Colorectal Nurse
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