Answer
Components of outpatient burn care include the following: [11]
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Patient and family education
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Wound cleansing
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Choice of topical or membrane dressing [39]
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Pain control
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Early return instructions
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Follow-up clinic visits
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Long-term follow-up care
Wound cleansing and dressing techniques must be taught to the person who changes the dressings. Ideally, document this instruction.
The choice of the many medications or membranes to place on burn wounds remains unclear, but certain basic principles apply to all situations. Gently clean the wound of debris and exudate on a regular basis. This usually requires daily removal of accumulated exudate and topical medications. Small superficial burns managed in this setting present a low risk of infection, thus, a clean rather than sterile technique is reasonable. Patients may clean the burn with lukewarm tap water and mild soap.
Soaking dressings in lukewarm tap water may decrease the pain associated with their removal. Gently cleanse the wound with a gauze or clean washcloth, inspect for signs of infection, pat dry with a clean towel, and re-dress the patient. To manage infections promptly, teaching the patient and family to return promptly if they notice erythema, swelling, increased tenderness, odor, or drainage is important. The frequency of wound cleansing and dressing change is debated, but most small burns are managed adequately with daily cleansing and dressing.
Wound dressing, whether one is using topical medication or a wound membrane, should provide 4 benefits, including (1) prevention of wound desiccation, (2) control of pain, (3) reduction of wound colonization and infection, and (4) prevention of added trauma to the wound. [40] Most topical dressings for outpatient use have a viscous carrier that prevents wound desiccation and a broader antibacterial spectrum that reduces wound colonization. The addition of a gauze wrap minimizes soiling of both clothing and unburned skin and protects the wound from the external environment. A large number of excellent agents are available.
Superficial facial burns are commonly treated with a clear, viscous antibacterial ointment. Wounds around the eyes can be treated with heavy topical ophthalmic antibiotic ointments. [19] Treat deep burns of the external ear with mafenide acetate because it penetrates the eschar and prevents purulent infection of the cartilage. Appropriate wound care strategies address these principles.
Pain control in the outpatient setting can be difficult, and if pain and anxiety cannot be adequately managed at home, then hospitalization is appropriate. For most patients, an oral narcotic medication administered 30-60 minutes prior to a planned dressing change provides adequate pain control. Because most dressings are occlusive, pain control between dressing changes tends to be managed adequately without narcotics in most patients. Elaborate specific conditions may mandate an early return to the hospital. Particularly important are (1) pain and anxiety associated with wound care to the degree that wound care is compromised, (2) signs of infection, or (3) a wound that appears deeper than appreciated during the initial examination. Review wound care instructions with caregivers.
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Initial evaluation and management of the burn patient. Burn size is best estimated using a chart that corrects for changes in body proportion with aging.
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Initial evaluation and management of the burn patient. Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and tendency to result in hypertrophic scar formation vary enormously.
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Initial evaluation and management of the burn patient. Third-degree burns are usually leathery in consistency, dry, and insensate. These wounds do not heal.
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Initial evaluation and management of the burn patient. Management of burn blisters is controversial. Burn blisters occasionally obscure the presence of full-thickness wounds.
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Initial evaluation and management of the burn patient. Burn wound cellulitis manifests with increasing erythema, swelling, and pain in uninjured skin around the periphery of a wound.
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Initial evaluation and management of the burn patient. Invasive burn wound infection implies that bacteria or fungi are proliferating in eschar and invading underlying viable tissues. These wounds display a change in color, new drainage, and often a foul odor. These infections are life-threatening.
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Initial evaluation and management of the burn patient. If hand positioning and therapy are ignored while overlying burns heal, poor long-term function may result.
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Initial evaluation and management of the burn patient. Estimating the burn area in an adult patient.
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Initial evaluation and management of the burn patient. Estimating the burn area in a child.
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Initial evaluation and management of the burn patient. Escharotomy incisions.
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Partial-thickness burn.
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A 2-year-old child with a scald burn to the hand.
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Proper functional positioning for splinting of serious hand burns is the metacarpophalangeal joints are at 70-90° of flexion, the interphalangeal joints are in extension, the wrist is at 20° of extension, and the first web space is open.
