The traditional classification of burns as first, second or third degree is being replaced by the designations of superficial, superficial partial thickness, deep partial thickness, and full thickness. Burn depth has an impact on healing time, the need for hospitalization, surgical intervention, and the potential for scar development. Although accurate classification is not always possible initially, the causes and physical characteristics of burns are helpful in categorizing their depth (Hettiaratchy, 2004).

“Few areas in medicine are fraught with as much mysticism, personal bias, and unscientific dogma as the care of the minor burn wound.”—Roberts and Hedges, 2009

1. When (if ever) do you open blisters in acute burns?

Although there are many strong feelings about the answer to this question amongst emergency physicians and burn specialists, there is a paucity of in vivo evidence related to this subject. Most of the debate circles around articles from lab models and from clinical studies done generations ago. Based on the best, currently available evidence, blisters should generally be left intact, to reduce the risk of infection. Occasionally it is necessary to intervene for functional purposes. Aspiration is generally considered less painful than unroofing (Shaw, 2006).

In one study (a controlled study of 202 patients with partial thickness burns), the infection rate was lower in patients with intact blisters, compared to patients who underwent needle aspiration or de-roofing. However, aspiration significantly reduced pain in 37% of patients with partial thickness burns, compared with 0% in the de-roofing group. This study was not randomized, and was not blinded (Swain, 1987).

A review of the literature by Flanagan and Graham concluded that small blisters should initially be left intact, but then concluded that as a general rule blisters should be debrided (see how conflicted this literature is?) (2001). Some commentators determine the length of time to leave blisters intact by age and location, such as blisters on the palm of the hand and sole of the foot in children should be left intact for 48 hours (Morgan, 2000).  Roberts and Hedges, however, recommend that blisters should be left intact on the initial visit (Fifth edition).

Morgan, et al., recommend that only ruptured blisters should be debrided. If blisters contain cloudy fluid or are likely to rupture imminently they should be unroofed. They recommend that intact blisters not be ruptured because of the increased risk of infection. When a blister persists for several weeks, it typically indicates the presence of an underlying deep partial or full thickness burn (Morgan, 2000). These patients should have close follow up. Tar and asphalt should not be debrided. Cool water, mineral oil, and polymyxin-B or bacitracin can emulsify and remove tar. Clothing or other materials should be removed using standard irrigation techniques.

Dead skin of open blisters should be removed, but the yellow eschar of partial-thickness burns need not be removed (Benson, 2006). Most burn blisters will rupture spontaneously if they are not aspirated. At this time all non-adherent devitalized tissue needs to be debrided.  If a patient with a blister from a burn returns a second time to the emergency department, this blister and tissue should be debrided, especially if it appears infected (Roberts and Hedges, 2009). They recommend using a large 10 X 10 cm gauze pad to rub over the blister, and to avoid long meticulous procedures with scissors or other instruments.

It appears there is currently no right or wrong answer to this question. Our practice is to approach this on a case-by-case basis, and to consider location. A large blister on the hand is likely to be very uncomfortable, and aspirating or unroofing may provide relief. However, a blister on the forearm may not bother the patient and removal of the epidermis may be more painful and increase the risk of infection.

2. When do you transfer patients directly to a burn center versus outpatient follow up? How do you arrange that follow up and for when (i.e., do you call the burn place and make a time? Is it for the next day, a week, etc.?)?

There are multiple algorithms on how to determine disposition for an acute burn. The National Burn Care review has divided burns into complex burns (those that require specialist intervention) and non-complex burns (those that do not require immediate admission to a specialist unit), and recommends contacting your nearest burn center with any questions regarding the complexity level of a burn.

A burn injury is more likely to be complex if it is associated with: extremes of age (younger than 5 or over 60); burns to the face, hands, perineum, feet (partial or full thickness); any area of flexure (especially the neck or axilla); circumferential partial or full thickness burn of limb, torso or neck; chemical burn > 5% of total body surface area; exposure to ionizing radiation; high pressure steam injury; high tension electrical injury; hydrofluoric acid burn >1% of total body surface area; suspicion of non-accidental injury; or partial of full thickness burn > 5% total body surface area in children and >10% of total body surface area in adults. Patients with coexisting serious medical conditions (cardiac history, immunosuppression, pregnancy, renal insufficiency) should also be referred to a burn center (Hettiaratchy, 2004).

The American Burn Association has produced a table to assist with disposition.

American Burn Association’s Grading System for Burn Severity and Disposition of Patients

	Type of burn
	Minor	Moderate	Major
Criteria:	< 10 percent TBSA burn in adult < 5 percent TBSA burn in young or old < 2 percent full-thickness burn	10 to 20 percent TBSA burn in adult5 to 10 percent TBSA burn in young or old2 to 5 percent full-thickness burn High-voltage injury Suspected inhalation injury Circumferential burn Concomitant medical problem predisposing the patient to infection (e.g., diabetes, sickle cell disease)	> 20 percent TBSA burn in adult> 10 percent TBSA burn in young or old> 5 percent full-thickness burn High-voltage burn Known inhalation injury Any significant burn to face, eyes, ears, genitalia or joints Significant associated injuries (e.g., fracture, other major trauma)
Disposition:	Outpatient management	Hospital admission	Referral to burn center

Burn = partial-thickness or full-thickness burn, unless specified; TBSA = total percentage of body surface area affected by the injury; young = patient younger than 10 years of age; adult = patient 10 to 50 years of age; old = patient older than 50 years of age (Herndon, 2007)

Burn Center Referral Criteria excerpted from the American Burn Association:

1. Partial thickness burns greater than 10% of total body surface area (TBSA).

2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.

3. Third degree burns in any age group.

4. Electrical burns, including lightning injury.

5. Chemical burns.

6. Inhalation injury.

7. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality.

8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.

9. Burned children in hospitals without qualified personnel or equipment for the care of children.

10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

(Committee on Trauma, American College of Surgeons, 2006)

It is essential to note that, at least in the United States, burn center beds are at a premium, with decreases in the number of available beds and funding in recent decades. Burn surgeons may refuse transfers simply because there are not enough of these specialty beds. This is not unreasonable for many burns. Most burns generally require daily dressing changes, debridement, pain control, and hydration. Within the community of burn surgeons there is increasing discussion about the necessity of the current number of transfers to a burn center, with one series finding that only 31% of transferred patients required surgical intervention (Vercruysse, 2011). Telemedicine and photos taken by mobile phones may allow better assessment of necessity of a transfer to a burn unit by a burn specialist (Shokrollahi, 2007).

Superficial burns usually do not need specialist follow up. However, for extensive superficial burns consider follow up with a primary care physician within 3 to 5 days. Superficial partial thickness and deep partial thickness burns should be seen within 3-5 days if they do not meet criteria for admission. Deep thickness burns and partial thickness burns to the hands and face should be seen within 48 hours if they do not require admission. Full thickness burns that do not meet admission criteria, unless less than 2 cm, should be seen by a burn specialist within 3-5 days (Waitzman, 1993). Full-thickness burns less than 2 cm wide can be allowed to heal by contracture as long as they are in non-functional, non-cosmetic areas and the skin is not thin (e.g., the ankle) (Morgan, 2000).

3. What topical medications should you put on burns, and which ones do you avoid?

Superficial burns: Patients should be instructed to keep the wound clean and apply moisturizer. They do not require topical antibiotic ointment; the wound will heal regardless. Patients should use non-perfumed moisturizing cream (e.g., Vaseline Intensive Care, Eucerin, Nivea, mineral oil, or cocoa butter) until natural lubricating mechanisms return. High lanolin content lotions, thick waxes, and ointments should be avoided.  Sun block should be used continuously upwards of one to two years until healed completely (Morgan, 2000).

Partial thickness burns: Topical antimicrobials are soothing for minor burns. By prescribing daily use of topical antimicrobials, the patient is reminded  to look at the wound, perform dressing changes, and become involved in his or her care. It is imperative that patients know that the antimicrobials should be wiped away completely during dressing changes before new ointment is applied. Once daily dressing changes are practical. There is no data to indicate that this is inferior to more frequent changes (Roberts and Hedges, 2009).  The most common agent used for superficial partial thickness burns, as well as more severe burns, is silver sulfadiazine (SSD or Silvadene), applied twice daily. This penetrates the burn eschar, and has broad antimicrobial coverage. Bacitracin is another option in patients with sulfa allergy or hypersensitivity. No study has compared the two agents, however, bacitracin is less expensive. Patients may have allergic reactions to the sulfa portion of SSD. It is irritating to mucous membranes. SSD is contraindicated during pregnancy and in infants younger than 2 months of age. It has been shown in some studies to delay wound healing, decrease leukocyte chemotaxis, and cause transient leukopenia (Waitzman, 1993). SSD has wide gram positive and gram negative antimicrobial coverage (including Pseudomonas and MRSA). Its use is not necessary for superficial partial thickness burns, because these burns rarely become infected, but becomes more important in deep partial thickness and full thickness burns because the eschar and debris forms a culture media ripe for bacteria (Roberts and Hedges, 2009).

Full thickness burns:

Initial management is identical to deep partial thickness burns, but with early referral to an experienced burn surgeon if the patient does not require admission otherwise. In partial and full thickness burns, a sterile dressing with fine mesh gauze (Telfa) should be used once the burn is cleaned and has a layer of topical antibiotic cream. Non-adherent dressing should be applied in successive strips, rather than wrapped around the wound. A tubular net bandage or lightly applied gauze wrap can be used over the non-adherent dressing (Morgan, 2000)

Burns to the face, however, are treated differently. They become very edematous after 24 hours. They should not be treated with SSD (there are reports of permanent skin discoloration) or dressed initially. They should be treated with twice daily washings and polymyxin B ointment (Waitzman, 1993).

Topical anesthetics such as Lidocaine should not be injected into a burned area. Regional anesthesia is preferred. Disinfectants such as chlorhexidine are often employed to clean burns, but their use should be discouraged as they can inhibit healing. The consensus in the burn literature supports washing burns with mild soap and tap water and/or copious irrigation with tap water (Morgan, 2000).

4.  Is there any guidance for fluid resuscitation in patients who are more complicated (renal failure, CHF) than the Parkland formula?

There is a paucity of information in the literature regarding resuscitation in patients who cannot tolerate large volume fluid resuscitation in the initial period after a burn. A review article from 1990 suggests monitoring CVP in patients with CHF, elderly patients, or those with renal insufficiency (Robertson, 1990).  Regardless of previous medical history, there is a systemic capillary leak, which increases with injury size, within hours after a serious burn, requiring large volume resuscitation (Sheridan, 2002). All patients with a severe burn should have a catheter placed and urine output recorded and followed closely (Hettiaratchy, 2004).

Commonly used formulas such as Parkland and Brooke try to estimate and predict the volume requirements, but do not tailor fluid resuscitation to individual patient needs. Resuscitation end points such as urine output and hypoxia should be reassessed frequently (Sheridan, 2002).  It is very important to decrease fluid administration after 18-24 hours, as capillary integrity has generally returned by this point. Excess administration of fluid at this time is associated with morbidity. Urine output is a helpful adjunct in most patients.

It may be difficult to balance the acute fluid needs against over-resuscitation in the early period. For instance, the type of CHF and degree of renal insufficiency matter in the early resuscitation period. It is important to take into account the high prevalence of primary lung injury in acutely burned patients. Unfortunately, there is almost no room for error in the volume given to these patients. In the critically ill burn patient (i.e., ventilated), the standard measures of preload such as CVP and wedge pressure are not useful measurements due to decreased pulmonary compliance, hypoxia, and increased PEEP. Here, there is no clear method that has yet proven superior in determining where a patient is on their Starling curve. These types of patients have a high likelihood of requiring renal replacement therapy during their ICU stay.

In the emergency department, patients should still receive high fluid volume, but not to the point where they are developing pulmonary edema. Resuscitation can be started with the Parkland formula and then slowed if any subtle signs of respiratory compromise arise. The patient populations with major burns requiring large volume fluid resuscitation, especially those with complicating medical conditions, of course belong in a burn center.

Our thanks to Brian Lin of UCSF and Jordan Bonomo of the University of Cincinnati for their expert opinions used in compiling the above.