Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Office Treatment of Minor Burns Joseph A. Moylan To cite this article: Joseph A. Moylan (1976) Office Treatment of Minor Burns, Postgraduate Medicine, 59:3, 189-195, DOI: 10.1080/00325481.1976.11714309 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714309
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 23 August 2017, At: 18:05
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
• Burns that can be effectively treated in the office, emergency department, or industrial clinic are, in the adult, second-degree partial-thickness skin injuries involving 15% or less of the body surface or third-degree full-thickness injuries involving less than 3% of the body surface. In children under l 0 years of age, a second-degree burn should not exceed l 0% of the body surface. Exceptions to these criteria for both adults and children include ocular and full-thickness band burns, for which shortlerm hospitalization may be necessary. Second- and third-degree burns involving larger surface areas require hospitalization either in a community hospital or in a burn trauma center, depending on local facilities. Aùeaament for Inhalation lnjury
traumatic injuries OFFICE TREATMENT OF MINOR BURNS Joseph A. Moylan, MD Duke University Medical Center Durham, North Carolina
While minor burns are not lite threatening, they may result in significant morbidity, such as loss of function, prolonged healing time, and scarring. Proper office care is mandatory if such complications are to be prevented.
During the initial evaluation, the circumstances of the burn injury should be carefully elicited to rule out the presence of inhalation injury. Pulmonary damage frequent! y occurs when smoke is inhaled during closed-space accidents and may be found even in patients with minor surface burns. 1 A history of wheezing or production of sooty sputum following the burn indicates possible inhalation injury. Diagnostic findings on physical examination include intraoral and nasal airway burns, hoarsenes~. raies, and wheezing. When inhalation injury is suspected, fiberoptic bronchoscopy performed in the emergency department with the patient under topical anesthesia pro vides a definitive diagnosis. 2 Since the mortality rate following inhalation injury is extremely high, ali patients with such injuries should be hospitalized, regardless of the size and depth of cutaneous burns. Burn Evaluation
The depth of the burn injury can be estimated from certain clinical signs. A second-degree, partial-thickness burn is erythematous, has weeping blisters, and is painful to pinprick when evaluated within the first few hours after injury. A thirddegree, full-thickness injury has necrosis of capillaries and nerve endings and is white or charred, dry, and anesthetic to touch . .,.. One of a series of articles coordinated by Dr. Allan J. Ryan of the University of Wisconsin. Madison.
Vol. 59 • No. 3 • Man:h 1978 • POSTGRADUATE MEDICINE
189
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
Figure 1. Single layer of fine-mesh petrolatum gauze is placed over superficial burn of dorsum of hand and fourth and fifth fingers. Care is taken to separate injured fingers.
Figure 2. Fluffed-up squares of gauze (4x4-inch) provide excellent absorbent material for intermediate portion of burn dressing.
table 1. steps in minor burn therapy 1. 2. 3. 4. 5. 6.
Control pain Wash burn with water and bland soap Dress bum Provide tetanus prophylaxis Begin program of physical therapy Control hypertrophie scarring
The extent of the burn can be calculated using the rule of nines, in which body surface is divided into areas of 9% or multiples of 9%. Th us, each upper extremity is 9% of total body surface; the head and neck are 9%; the lower extremities, the anterior torso, and the posterior torso are 18% each. The
190
genitalia are 1%. A convenient way to evaluate small irregular burns is to use the palm of the hand, which represents 1% of body surface area, as a ruler. Initial Treatment
An organized stepwise approach to minor burn therapy assures optimal results (table 1). For minor burns caused by chemical agents, initial treatment is directed at neutralization and dilution of the chemical solution, since the amount of burn damage is proportion al to the concentration of the agent and its duration of contact with the skin. The damaged area should be copiously irrigated
POSTQRADUATE MEDICINE • March 1976 • Vol. 59 • No. 3
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
Figure 3. Stockinette is used for strong outer layer of burn dressing.
Figure 4. ln dressing burns of distal portion of extremlty, tips of fingers or toes are left exposed to allow continuous monitoring of digital circulation.
with tap water, which is an effective, readily available neutralizing and diluting agent. Time spent searching for a specifie neutralizer may permit deeper cutaneous damage. A major consideration in the initial trealment of ali min or burns is control of pain. Use of wet towels soaked in ice water or submersion of the burned area in cold soapy water alleviates the pain. A narcotic administered parenterally may be necessary to facilitate wound cleansing in apprehensive patients, however. Long-term pain control following cleaning and dressing of the· burn can be accomplished by use of aspirin or propoxyphene hydrochloride.
Vol. 59 • No. 3 • Match 1978 • POSTGRADUATE MEDICM
Thorough cleansing is essential to promote early healing, and bland soap and water are the best agents to use. (Alcohol solutions or antiseptics often cause pain and may further damage the injured epithelium.) The wound should be gently scrubbed with gauze bandages or a sterile washcloth to remove foreign bodies and dirt. A scrub brush may be needed if dirt has been ground in. Ali devitalized tissue should be carefully removed with scissors and forceps, care being taken not to damage viable tissues. In generaf, ali blisters should be ruptured and the epithelium removed. Protein-rich blister fluid makes an excellent bacterial cul-
191
traumatic injuries - - - - - - - - - - - - - - - - - - - - ture medium, and bacterial proliferation may lead to local cellulitis and further tissue destruction. As many as 5% of people harbor Staphylococcus coagulase-positive organisms in skin pores. These organisms cancontaminate fluid in unbroken blisters.
Joseph A. Moylan Dr. Moylan is associate professor, department of surgery, and chief, trauma service, Duke University Medical Center, Durham, North Carolina. ·
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
Dressing the Burn
Covering minor burns with dressings is the most satisfactory way to treat them in the office. Second-degree burns exposed to air sting a great deal, and patients find covered wounds more comfortable. The dressing also helps to keep the wound clean. Burns in areas that are difficult to dress, such as the perineum or face, may be left exposed. The dressing should co ver the en tire wound and should be absorbent, comfortable, and easily removed. The layer adjacent to the burned skin should be nonadherent and hypoallergenic; either simple petrolatum ga uze (figure 1) or Adaptic dressing serves this purpose. Next, a bulky layer of material such as gauze packs (figure 2) will absorb any exudate and prevent soiling of the bandage. The outer layer of the dressing is composed of stockinette (figure 3) or Kling bandage. It is important not to apply any layer too tightly, as circulatory insufficiency may resuit. With burns on the band or foot, tips of fingers or toes should be left exposed so that circulation can be monitored (figure 4). The finished dressing should be taped in place to prevent its coming loose, especially in active children. Infection Prevention
Ali individuals with minor burns, especially if these are third-degree burns or are significantly contaminated, should receive adequate tetanus prophylaxis. This should take the form of tetanus toxoid for patients who have been previously immunized and human antitetanus serum for patients who have no history of immunization. Frank tetanus bas been documented in patients with burn injuries of insignificant size. 3 Adequate cleansing and débridement of minor burns minimize the risk of other infection, including streptococcal cellulitis. Sys-
Vol. 59 • No. 3 • March 1978 • POSTGRADUATE MEDICINE
ternie antibiotic therapy is thus not indicated initially for outpatients. 4 Routine topical use of antibacterial agents bas not been found to be of value in the treatment of minor burns. Follow-up Therapy
The patient with minor burns should be advised to return in 48 hours for reexamination unless fever, chills, lymphangitis, or other signs of infection çlevelop, in which case the individual should return immediately. Parents of infants treated as outpatients should be warned that dehydration may develop if sufficient fluids are not given to the child during the frrst day after injury or if vomiting occurs, and that immediate consultation is indicated if such is the case. After 48 hours, the outer bandage and fluff dressing are removed and the petrolatum gauze is observed. If the gauze is clean and adherent, a fresh dressing and bandage are applied over it and the patient is told to return in five days. At that time, exposure is usually possible without discomfort. If exudate or pus is present under the ga uze, the complete dressing is gently removed to prevent pain or damage to the thin, viable epithelium. If the presence of localized infection is suspected, a culture should be made. If the culture is positive, oral antibiotic therapy should be started, the wound redressed, and the patient told to return at frequent intervals for observation. If signs of systemic infection or ascending lymphangitis are present, hospitalization is required. Maintenance of Function
Extremities with minor burns should be maintained in a functional position during the
193
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
traumatic injuries - - - - - - - - - - - - - - - - - - - - - closed phase of therapy. With the hands, in particular, attention should be paid to maintaining dorsiflexion at the wrist and palmar flexion at the metacarpophalangeal joints, and to separating the fingers and maintaining ali web spaces, especially between the thumb and index finger. If the extremity is kept elevated constantly during the first 24 to 36 hours after injury, edema will be minimized. When exposure is possible, passive and then active range-of-motion exercises should be started. Submerging the burned extremity in warm water for brief periods three times daily facilitates motion. It must be stressed to the patient that the amount of function recovered is directly proportional to the amount of patient cooperation. Exercise programs of patients with injuries involving most of the hand surface should be supervised by a physical therapist, at first on a daily basis and then less often as the situation dietates. Close supervision should help to minimize the poor results which have been noted even in individuals with partialthiekness burns. Use of statie splints during sleep has been shown to be valuable in maintaining function. Burns over joints or in cosmetieally important areas should be observed for two to three months, as hypertrophie scarring may develop. Use of continuo us pressure appliances, such as elastic bandages or elastie ex!remity
readysource
TREATMENT OF MINOR BURNS
BOOKS
DO
The Treatment of Burns (ed 2) (Artz, Moncrief) Philadelphia. WB Saunders Co. 1969
support materials, over the hypertrophie areas has been effective in preventing progression of scarring. Summary
Second-degree, partial-thickness burns involving 15% or less of the body surface in the adult (or 10% in the child under age 10) or third-degree, full-thickness burns involving less than 3% of the body surface can generally be treated on an outpatient basis. Inhalation injury must be ruled out immediately, since the associated mortality is high. Thorough cleansing and débridement of the wound must be carried out, and the burn should then be dressed. Tetanus prophylaxis must be given. Care should be taken to maintain function, especially in the hands; as soon as the burn can be uncovered, range-of-motion exercises should be started. • Address reprint requests to Joseph A. Moy lan, MD, Department of Surgery, PO Box 3043, Duke University Medical Center, Durham, NC 27710.
References 1. Pruitt BA Jr, Moy lan JA Jr: Current management of thermal burns. Adv Surg 6:237-288, 1972 2. Moylan JA, Adib K. Birnbaum M: Fiberoptic bronchoscopy following thermal injury. Surg Gynecol Obstet 140:541, 1975 3. Larkin JM. Moylan JA Jr: Tetanus following a minor burn. J Trauma 15:546-548, 1975 4. Moy lan JA Jr: Current burn therapy. Wis Med J 73:S 123126, 1974
0
D
Thorsell) Source: Lakes Area Regional Medical Program. lnc, 2929 Main St, Buffalo. NY 14214 Cost: $10
AUDIOVISUALS
Burn Wound Management (Bennett) Source: ACS/Ciinitapes, 55 E Erie St, Chicago, IL 60611 Cost: $6.50
Treatment of Burns ln a Communlty Hospital (31 :30-min tape, 39 slides, 3-page handout) (Cloutier.
For details on how to use ReadySoun::e. see page 153
Burns and Thelr Treatment (ed 2) (Muir, Barclay) Chicago, Year Book Medical Publishers, lnc, 1974
Vol. 59 • No. 3 • March 1976 • POSTGRADUATE MEDICttE
195
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Office Treatment of Minor Burns Joseph A. Moylan To cite this article: Joseph A. Moylan (1976) Office Treatment of Minor Burns, Postgraduate Medicine, 59:3, 189-195, DOI: 10.1080/00325481.1976.11714309 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714309
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 23 August 2017, At: 18:05
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
• Burns that can be effectively treated in the office, emergency department, or industrial clinic are, in the adult, second-degree partial-thickness skin injuries involving 15% or less of the body surface or third-degree full-thickness injuries involving less than 3% of the body surface. In children under l 0 years of age, a second-degree burn should not exceed l 0% of the body surface. Exceptions to these criteria for both adults and children include ocular and full-thickness band burns, for which shortlerm hospitalization may be necessary. Second- and third-degree burns involving larger surface areas require hospitalization either in a community hospital or in a burn trauma center, depending on local facilities. Aùeaament for Inhalation lnjury
traumatic injuries OFFICE TREATMENT OF MINOR BURNS Joseph A. Moylan, MD Duke University Medical Center Durham, North Carolina
While minor burns are not lite threatening, they may result in significant morbidity, such as loss of function, prolonged healing time, and scarring. Proper office care is mandatory if such complications are to be prevented.
During the initial evaluation, the circumstances of the burn injury should be carefully elicited to rule out the presence of inhalation injury. Pulmonary damage frequent! y occurs when smoke is inhaled during closed-space accidents and may be found even in patients with minor surface burns. 1 A history of wheezing or production of sooty sputum following the burn indicates possible inhalation injury. Diagnostic findings on physical examination include intraoral and nasal airway burns, hoarsenes~. raies, and wheezing. When inhalation injury is suspected, fiberoptic bronchoscopy performed in the emergency department with the patient under topical anesthesia pro vides a definitive diagnosis. 2 Since the mortality rate following inhalation injury is extremely high, ali patients with such injuries should be hospitalized, regardless of the size and depth of cutaneous burns. Burn Evaluation
The depth of the burn injury can be estimated from certain clinical signs. A second-degree, partial-thickness burn is erythematous, has weeping blisters, and is painful to pinprick when evaluated within the first few hours after injury. A thirddegree, full-thickness injury has necrosis of capillaries and nerve endings and is white or charred, dry, and anesthetic to touch . .,.. One of a series of articles coordinated by Dr. Allan J. Ryan of the University of Wisconsin. Madison.
Vol. 59 • No. 3 • Man:h 1978 • POSTGRADUATE MEDICINE
189
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
Figure 1. Single layer of fine-mesh petrolatum gauze is placed over superficial burn of dorsum of hand and fourth and fifth fingers. Care is taken to separate injured fingers.
Figure 2. Fluffed-up squares of gauze (4x4-inch) provide excellent absorbent material for intermediate portion of burn dressing.
table 1. steps in minor burn therapy 1. 2. 3. 4. 5. 6.
Control pain Wash burn with water and bland soap Dress bum Provide tetanus prophylaxis Begin program of physical therapy Control hypertrophie scarring
The extent of the burn can be calculated using the rule of nines, in which body surface is divided into areas of 9% or multiples of 9%. Th us, each upper extremity is 9% of total body surface; the head and neck are 9%; the lower extremities, the anterior torso, and the posterior torso are 18% each. The
190
genitalia are 1%. A convenient way to evaluate small irregular burns is to use the palm of the hand, which represents 1% of body surface area, as a ruler. Initial Treatment
An organized stepwise approach to minor burn therapy assures optimal results (table 1). For minor burns caused by chemical agents, initial treatment is directed at neutralization and dilution of the chemical solution, since the amount of burn damage is proportion al to the concentration of the agent and its duration of contact with the skin. The damaged area should be copiously irrigated
POSTQRADUATE MEDICINE • March 1976 • Vol. 59 • No. 3
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
Figure 3. Stockinette is used for strong outer layer of burn dressing.
Figure 4. ln dressing burns of distal portion of extremlty, tips of fingers or toes are left exposed to allow continuous monitoring of digital circulation.
with tap water, which is an effective, readily available neutralizing and diluting agent. Time spent searching for a specifie neutralizer may permit deeper cutaneous damage. A major consideration in the initial trealment of ali min or burns is control of pain. Use of wet towels soaked in ice water or submersion of the burned area in cold soapy water alleviates the pain. A narcotic administered parenterally may be necessary to facilitate wound cleansing in apprehensive patients, however. Long-term pain control following cleaning and dressing of the· burn can be accomplished by use of aspirin or propoxyphene hydrochloride.
Vol. 59 • No. 3 • Match 1978 • POSTGRADUATE MEDICM
Thorough cleansing is essential to promote early healing, and bland soap and water are the best agents to use. (Alcohol solutions or antiseptics often cause pain and may further damage the injured epithelium.) The wound should be gently scrubbed with gauze bandages or a sterile washcloth to remove foreign bodies and dirt. A scrub brush may be needed if dirt has been ground in. Ali devitalized tissue should be carefully removed with scissors and forceps, care being taken not to damage viable tissues. In generaf, ali blisters should be ruptured and the epithelium removed. Protein-rich blister fluid makes an excellent bacterial cul-
191
traumatic injuries - - - - - - - - - - - - - - - - - - - - ture medium, and bacterial proliferation may lead to local cellulitis and further tissue destruction. As many as 5% of people harbor Staphylococcus coagulase-positive organisms in skin pores. These organisms cancontaminate fluid in unbroken blisters.
Joseph A. Moylan Dr. Moylan is associate professor, department of surgery, and chief, trauma service, Duke University Medical Center, Durham, North Carolina. ·
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
Dressing the Burn
Covering minor burns with dressings is the most satisfactory way to treat them in the office. Second-degree burns exposed to air sting a great deal, and patients find covered wounds more comfortable. The dressing also helps to keep the wound clean. Burns in areas that are difficult to dress, such as the perineum or face, may be left exposed. The dressing should co ver the en tire wound and should be absorbent, comfortable, and easily removed. The layer adjacent to the burned skin should be nonadherent and hypoallergenic; either simple petrolatum ga uze (figure 1) or Adaptic dressing serves this purpose. Next, a bulky layer of material such as gauze packs (figure 2) will absorb any exudate and prevent soiling of the bandage. The outer layer of the dressing is composed of stockinette (figure 3) or Kling bandage. It is important not to apply any layer too tightly, as circulatory insufficiency may resuit. With burns on the band or foot, tips of fingers or toes should be left exposed so that circulation can be monitored (figure 4). The finished dressing should be taped in place to prevent its coming loose, especially in active children. Infection Prevention
Ali individuals with minor burns, especially if these are third-degree burns or are significantly contaminated, should receive adequate tetanus prophylaxis. This should take the form of tetanus toxoid for patients who have been previously immunized and human antitetanus serum for patients who have no history of immunization. Frank tetanus bas been documented in patients with burn injuries of insignificant size. 3 Adequate cleansing and débridement of minor burns minimize the risk of other infection, including streptococcal cellulitis. Sys-
Vol. 59 • No. 3 • March 1978 • POSTGRADUATE MEDICINE
ternie antibiotic therapy is thus not indicated initially for outpatients. 4 Routine topical use of antibacterial agents bas not been found to be of value in the treatment of minor burns. Follow-up Therapy
The patient with minor burns should be advised to return in 48 hours for reexamination unless fever, chills, lymphangitis, or other signs of infection çlevelop, in which case the individual should return immediately. Parents of infants treated as outpatients should be warned that dehydration may develop if sufficient fluids are not given to the child during the frrst day after injury or if vomiting occurs, and that immediate consultation is indicated if such is the case. After 48 hours, the outer bandage and fluff dressing are removed and the petrolatum gauze is observed. If the gauze is clean and adherent, a fresh dressing and bandage are applied over it and the patient is told to return in five days. At that time, exposure is usually possible without discomfort. If exudate or pus is present under the ga uze, the complete dressing is gently removed to prevent pain or damage to the thin, viable epithelium. If the presence of localized infection is suspected, a culture should be made. If the culture is positive, oral antibiotic therapy should be started, the wound redressed, and the patient told to return at frequent intervals for observation. If signs of systemic infection or ascending lymphangitis are present, hospitalization is required. Maintenance of Function
Extremities with minor burns should be maintained in a functional position during the
193
Downloaded by [Australian Catholic University] at 18:05 23 August 2017
traumatic injuries - - - - - - - - - - - - - - - - - - - - - closed phase of therapy. With the hands, in particular, attention should be paid to maintaining dorsiflexion at the wrist and palmar flexion at the metacarpophalangeal joints, and to separating the fingers and maintaining ali web spaces, especially between the thumb and index finger. If the extremity is kept elevated constantly during the first 24 to 36 hours after injury, edema will be minimized. When exposure is possible, passive and then active range-of-motion exercises should be started. Submerging the burned extremity in warm water for brief periods three times daily facilitates motion. It must be stressed to the patient that the amount of function recovered is directly proportional to the amount of patient cooperation. Exercise programs of patients with injuries involving most of the hand surface should be supervised by a physical therapist, at first on a daily basis and then less often as the situation dietates. Close supervision should help to minimize the poor results which have been noted even in individuals with partialthiekness burns. Use of statie splints during sleep has been shown to be valuable in maintaining function. Burns over joints or in cosmetieally important areas should be observed for two to three months, as hypertrophie scarring may develop. Use of continuo us pressure appliances, such as elastic bandages or elastie ex!remity
readysource
TREATMENT OF MINOR BURNS
BOOKS
DO
The Treatment of Burns (ed 2) (Artz, Moncrief) Philadelphia. WB Saunders Co. 1969
support materials, over the hypertrophie areas has been effective in preventing progression of scarring. Summary
Second-degree, partial-thickness burns involving 15% or less of the body surface in the adult (or 10% in the child under age 10) or third-degree, full-thickness burns involving less than 3% of the body surface can generally be treated on an outpatient basis. Inhalation injury must be ruled out immediately, since the associated mortality is high. Thorough cleansing and débridement of the wound must be carried out, and the burn should then be dressed. Tetanus prophylaxis must be given. Care should be taken to maintain function, especially in the hands; as soon as the burn can be uncovered, range-of-motion exercises should be started. • Address reprint requests to Joseph A. Moy lan, MD, Department of Surgery, PO Box 3043, Duke University Medical Center, Durham, NC 27710.
References 1. Pruitt BA Jr, Moy lan JA Jr: Current management of thermal burns. Adv Surg 6:237-288, 1972 2. Moylan JA, Adib K. Birnbaum M: Fiberoptic bronchoscopy following thermal injury. Surg Gynecol Obstet 140:541, 1975 3. Larkin JM. Moylan JA Jr: Tetanus following a minor burn. J Trauma 15:546-548, 1975 4. Moy lan JA Jr: Current burn therapy. Wis Med J 73:S 123126, 1974
0
D
Thorsell) Source: Lakes Area Regional Medical Program. lnc, 2929 Main St, Buffalo. NY 14214 Cost: $10
AUDIOVISUALS
Burn Wound Management (Bennett) Source: ACS/Ciinitapes, 55 E Erie St, Chicago, IL 60611 Cost: $6.50
Treatment of Burns ln a Communlty Hospital (31 :30-min tape, 39 slides, 3-page handout) (Cloutier.
For details on how to use ReadySoun::e. see page 153
Burns and Thelr Treatment (ed 2) (Muir, Barclay) Chicago, Year Book Medical Publishers, lnc, 1974
Vol. 59 • No. 3 • March 1976 • POSTGRADUATE MEDICttE
195
