Outpatient burns: prevention and care

Most burn injuries can be managed on an outpatient basis by primary care physicians. Prevention efforts can significantly lower the incidence of burns, especially in children. Burns should be managed in the same manner as any other trauma, including a primary and secondary survey. Superficial burns can be treated with topical application of lotions, honey, aloe vera, or antibiotic ointment. Partial-thickness burns should be treated with a topical antimicrobial agent or an absorptive occlusive dressing to help reduce pain, promote healing,and prevent wound desiccation. Topical silver sulfadiazine is the standard treatment; however, newer occlusive dressings can provide faster healing and are often more cost-effective. Physicians must reevaluate patients frequently after a burn injury and be aware of the indications for referral to a burn specialist.     

The management of non-complex burns within the community

Superficial burns and superficial partial-thickness burns can be managed at home or on an outpatient basis. More severe injuries should be referred for specialist treatment at a burns unit. If a superficial partial-thickness burn does not show signs of healing after 10 days, the patient should be referred to the local burns and plastic surgery service as the injury may be infected or deeper than had originally been suspected.     

Efficacy of mupirocin in methicillin-resistant Staphylococcus aureus burn wound infection.

Methicillin-resistant Staphylococcus aureus strains (MRSA) have become increasingly prevalent as nosocomial pathogens, especially in burn wounds. MRSA constituted 38% of all S. aureus isolates in our 25-bed burns unit despite the utilization of a combination of 1% silver sulfadiazine and 0.2% chlorhexidine as topical therapy. Mupirocin, a new antibiotic, has proved in vitro and in vivo to be highly effective in the treatment of MRSA infections. A prospective clinical trial with mupirocin ointment in MRSA burn wound infection was untertaken. Forty-five children with 59 discrete burn wounds and from whom MRSA were isolated were treated with 2% mupirocin ointment under occlusive dressings, applied twice daily for 5 days. The average burned area treated was 8% (range, 2 to 20%) of the total body surface area. The burn wounds were assessed clinically and bacteriologically daily. Mupirocin eliminated MRSA in all 59 wounds treated, with the maximum therapeutic response seen within 4 days. In three wounds, gram-negative organisms persisted after 5 days of topical therapy. Treatment was well tolerated by all children. We recommend that mupirocin in its present polyethylene glycol base should be used only on a selective basis, when current prophylactic topical therapy has failed to control MRSA infection in burns of less than 20% of the total body surface area, and that it should be applied only for a limited period of 5 days. The safety and the efficacy of mupirocin in burns exceeding 20% of the total body surface area need to be established.     

Pediatric upper extremity burns: outcomes of emergency department triage and outpatient management.

Pediatric upper extremity burns are common. Though current American Burn Association guidelines recommend burn unit referral for burns involving the hands or major joints, many minor injuries are treated in the emergency department (ED) or outpatient setting. Despite the large number of burn patients managed by primary care providers, no large studies have been performed to assess effectiveness. A retrospective 5-year review of the epidemiology and outcomes associated with pediatric upper extremity burns treated at an urban ED was performed. Two hundred sixty-nine patients were identified. The mechanism of burn, percentage of total body surface area (%TBSA) affected, plastic surgery consultations (for wound management recommendations and additional treatment), complications, and surgical interventions were examined. Mechanisms of burn included direct contact (47%), scald (29%), flame (12%), electrical (10%), and friction or chemical (1.5%). Fifty percent of patients suffered from burns over less than 1% TBSA; close to 95% had burns on less than 5% TBSA. Seventy-five percent of patients had second-degree burns, 21% had first-degree burns, and 2% had third-degree burns. Forty patients (15%) had a plastic surgery consult. Seven patients (3%) required skin grafting. Complications occurred in five (2%) patients and included two cases of hypertrophic scarring; two patients with flexor contractures, one case of compartment syndrome requiring fasciotomy, and one late infection. These results suggest that although significant burns are usually cared for in specialized burn centers, the majority of childhood burns to the upper extremity are relatively minor and often treated in the primary care setting. Most patients had small areas of injury and healed without complications. Contact burns are an ever-increasing proportion of childhood burns and should be seemingly preventable. Education to parents and primary care physicians should be reemphasized. It appears that minor upper extremity burns treated by our urban ED staff are handled appropriately and result in favorable outcomes.     

Comparison of purified olive oil and silver sulfadiazine in the treatment of partial thickness porcine burns

Introduction

Burns are widespread in the developed world, and expensive burn dressings are not universally available. Most burn patients suffer from a partial thickness burn that can be treated conservatively. Nevertheless, the ideal dressing for the burn wound has not been identified. We performed an animal experiment to compare the healing of partial thickness burns treated with silver sulfadiazine (SSD) and olive oil.

Methods

A randomized controlled animal experiment was conducted on 3 anesthetized domestic pigs in which 51 partial thickness burns were created using a metal bar heated to 400°C and applied to the dorsum of the animals for 20 seconds. The burns were treated every other day with SSD cream (n = 16), purified olive oil (n = 20), or no topical therapy at all (n = 15). Assessment of wound healing was done by drawing and scanning the margins of the wound at the endpoint of the experiment. The remaining open wound area was then calculated using Scion Image version beta 4.0.2 (Scion, Frederick, Md), and the results were analyzed using a 1-way ANOVA test.

Results

Burns treated with SSD healed faster than control burns (P < .05). There were no differences in the healing rates of wounds treated with olive oil versus controls or SSD. There were no wound infections in any of the 3 study groups.

Conclusions

Treatment of partial thickness burns with purified olive oil did not result in faster healing when compared with SSD or dry gauze in a porcine model.     

复方磺胺嘧啶锌涂膜与磺胺嘧啶银霜治疗小儿Ⅱ度烧伤创面的比较研究

目的：观察复方磺胺嘧啶锌涂膜治疗小儿Ⅱ度烧伤创面的疗效和安全性，探讨其在小儿烧伤治疗中的应用价值。方法：133例患儿随机分为复方磺胺嘧啶锌涂膜组70例（甲组）和磺胺嘧啶银霜组63例（乙组），比较两组患儿创面愈合时间、愈合率、药物抗感染效果及不良反应。结果：甲组创面愈合时间较乙组提前（P〈0．05），细菌检出率甲组小于乙组（P〈0．05）。用药后甲组未见加深现象，乙组出现加深现象，两组均无其他不良反应。结论：复方磺胺嘧啶锌涂膜治疗小儿烧伤安全、有效，可促进创面愈合，尤其适用于小儿Ⅱ度创面的治疗。     

Comparison of complications during rehabilitation between conservative and early surgical management in thermal burns involving the feet of children and adolescents

To evaluate the long-term sequelae of early surgical management compared with conservative therapy, a retrospective review from January 1976 to December 1984 was undertaken. Through inspection of burn diagrams, 395 patients were identified with burns involving the foot. From 1976 through 1980, 109 patients were managed in a conservative fashion with topical antimicrobial therapy and delayed debridement and grafting; 36 of these patients with severe burns were managed with skeletal suspension. Between 1981 and 1984, 136 patients were treated with earlier surgical debridement and grafting; during this period, skeletal suspension was rarely used. No statistical difference was found in mortality, amputations, incidence of open wounds, development of contractures, or number of patients requiring reconstructive procedures between conservative and early excision therapy except in those children treated with skeletal suspension. Thus in burns involving the feet in children, early excision and grafting does not alter the resultant morbidity compared with conservative burn management.     

Ambulatory management of burns

Burns often happen unexpectedly and have the potential to cause death, lifelong disfigurement and dysfunction. A critical part of burn management is assessing the depth and extent of injury. Burns are now commonly classified as superficial, superficial partial thickness, deep partial thickness and full thickness. A systematic approach to burn care focuses on the six "Cs": clothing, cooling, cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief). The American Burn Association has established criteria for determining which patients can be managed as outpatients and which require hospital admission or referral to a burn center. Follow-up care is important to assess patients for infection, healing and ability to provide proper wound care. Complications of burns include slow healing, scar formation and contracture. Early surgical referral can often help prevent or lessen scarring and contractures. Family physicians should be alert for psychologic problems related to long-term disability or disfigurement from burn injuries.     

Severe multiple extensive postburn contractures: a simultaneous approach with total scar tissue excision and resurfacing with dermal regeneration template.

Deep partial or full-thickness burns if untreated, neglected, or managed conservatively can develop dysfunctional scar contractures with severe deformities and significant reduction in patient's activities of daily life. These burn sequelae can require multistage procedures to restore anatomy and function. These include single scar release, use of skin grafts, skin expansion, regional or free musculocutaneous or fasciocutaneous flaps to achieve adequate functional improvement. The use of dermal regeneration template (Integra), initially used in primary burns reconstruction, has been already described and compared in single scar contracture-releasing procedures, but to our knowledge, it has not been used in the simultaneous releasing of multiple severe extensive postburn contractures. A simultaneous approach with total scar tissue excision and resurfacing with Integra may reduce the number of operations and the prolonged time period of treatment required by conventional procedures of multistage scar contracture release. A 7-year-old girl, who developed severe postburn scar contractures involving the right upper limb, right axilla, neck, and face after healing of a deep 16% total body surface area burn injury, was treated with this approach. Restoration of anatomy and function, with significant improvement in the range of movement of the involved regions, was achieved in a relatively short period of time (15 weeks) with limited donor-site morbidity and preservation of donor areas for possible future procedures. Total scar tissue excision and resurfacing with Integra should be considered as a valid option in case of simultaneous management of severe multiple extensive scar contractures.     

Biobrane improves wound healing in burned children without increased risk of infection

A synthetic bilaminar membrane used as a skin substitute (Biobrane) has been shown to decrease pain and hospitalization in superficial second-degree burns. Despite these benefits, it has not been utilized universally, particularly in young children, due to a perceived increase in related infections. We propose that when this synthetic membrane is applied to superficial scald burns <25% of the total body surface area (TBSA), decreased healing times are expected without increased risk of infection. Between 1994-1999, 89 children treated within 48 h after receiving superficial partial thickness scald burns covering 5-25% TBSA with no indication of infection were seen at our hospital. Forty-one were assigned randomly to receive treatment with the skin substitute Biobrane and 48 to receive conservative treatment with topical antimicrobials and dressing changes. Comparisons of treatment were made between groups for length of hospitalization, wound healing times, and infectious complications. Children treated with Biobrane or topical antimicrobials were similar in age, race, sex, %TBSA burned, and location of burn. Those receiving Biobrane had shorter hospitalizations and healing times, which was significant for both infants and toddlers and older children. Treatment groups were not different in the use of systemic antibiotics or readmissions for infectious complications. Biobrane was removed in 5.9% of cases for non-adherence. The application of Biobrane within 48 h of superficial burns provides for shorter hospitalizations and faster healing times in children of all ages without increased risk of infection.     

Comparative evaluation of zinc sulfadiazine and silver sulfadiazine in burn wound infection

One percent silver sulfadiazine has been commonly used as a topical antimicrobial agent after a burn injury. Incidence of burn wound colonization by Staphylococcus aureus in patients treated with silver sulfadiazine has spurred research for other agents. A topical preparation that contains zinc and sulfadiazine (Zad-G) was evaluated for in vitro antibacterial spectrum and in vivo efficacy. Muscle biopsy specimens of rats treated with Zad-G appear to have fewer colonies of S. aureus than groups treated with silver sulfadiazine. Topical therapy with Zad-G for patients with burns was comfortable, reduced wound infection, and was comparable to therapy with silver sulfadiazine. A topical Zad-G preparation that contains zinc sulfadiazine appears to be an effective alternative to silver sulfadiazine in the treatment of burn wounds.     

Chitosan preparations for wounds and burns: antimicrobial and wound-healing effects

Since its discovery approximately 200 years ago, chitosan, as a cationic natural polymer, has been widely used as a topical dressing in wound management owing to its hemostatic, stimulation of healing, antimicrobial, nontoxic, biocompatible and biodegradable properties. This article covers the antimicrobial and wound-healing effects of chitosan, as well as its derivatives and complexes, and its use as a vehicle to deliver biopharmaceuticals, antimicrobials and growth factors into tissue. Studies covering applications of chitosan in wounds and burns can be classified into in vitro, animal and clinical studies. Chitosan preparations are classified into native chitosan, chitosan formulations, complexes and derivatives with other substances. Chitosan can be used to prevent or treat wound and burn infections not only because of its intrinsic antimicrobial properties, but also by virtue of its ability to deliver extrinsic antimicrobial agents to wounds and burns. It can also be used as a slow-release drug-delivery vehicle for growth factors to improve wound healing. The large number of publications in this area suggests that chitosan will continue to be an important agent in the management of wounds and burns.     

Chitosan preparations for wounds and burns: antimicrobial and wound-healing effects

Since its discovery approximately 200 years ago, chitosan, as a cationic natural polymer, has been widely used as a topical dressing in wound management owing to its hemostatic, stimulation of healing, antimicrobial, nontoxic, biocompatible and biodegradable properties. This article covers the antimicrobial and wound-healing effects of chitosan, as well as its derivatives and complexes, and its use as a vehicle to deliver biopharmaceuticals, antimicrobials and growth factors into tissue. Studies covering applications of chitosan in wounds and burns can be classified into in vitro, animal and clinical studies. Chitosan preparations are classified into native chitosan, chitosan formulations, complexes and derivatives with other substances. Chitosan can be used to prevent or treat wound and burn infections not only because of its intrinsic antimicrobial properties, but also by virtue of its ability to deliver extrinsic antimicrobial agents to wounds and burns. It can also be used as a slow-release drug-delivery vehicle for growth factors to improve wound healing. The large number of publications in this area suggests that chitosan will continue to be an important agent in the management of wounds and burns.     

The assessment and management of burns

Each year many people seek medical advice or hospital treatment for burn or scald injuries. There is limited data on the number of burns patients seen in primary care, however a recent national survey suggested that there are 250,000 presentations of burn injuries to primary care teams in the UK per year (National Burn Care Review, 2001). This article discusses the nursing management of burns in the community, outlining the initial assessment of the burns patient in terms of trauma management, and focusing primarily on those patients with non-complex burns. A full patient assessment incorporates the patient's general condition, the type, cause, depth and extent of the burn and the effects on the individual patient. Good patient management is an essential element of care and the focus of this is the management of pain, prevention of infection, provision of evidence based wound care and onward referrals as appropriate. However not all patients can be managed solely in the community and the nurse needs to know when to refer and to whom to refer. The article outlines the recommendations from the National Burn Care Review in terms of patient referral.     

Lack of agreement between gross visual and histological assessment of burn reepithelialization in a porcine burn model

One of the most important and earliest measures of burn healing is wound reepithelialization. Reepithelialization is a vital determinant of wound infection and scarring. Reepithelialization is generally based on gross visual assessment; however, histological assessment remains the criterion standard. We hypothesized that there would be poor agreement (r < .4) between gross visual and histological assessments of burn reepithelialization in a porcine model. The study design was prospective observational using three anesthetized female pigs (20-25 kg). Forty-eight 2.5- × 2.5-cm burns were created on the flanks of pig's using an aluminum bar (150 g) preheated to 80°C for 20 seconds. Burns were treated with an occlusive or antimicrobial dressing and photographed at day 10 for determination of gross percentage reepithelialization in a 1-cm diameter circle in the center of the burn by two experienced clinicians masked to each other's measurements. A 10-mm full-thickness punch biopsy was taken from the center of the burns and evaluated by a board-certified dermatopathologist masked to clinical assessments. One clinician and the dermatopathologist repeated the assessments 1 month apart. The outcome was percentage wound reepithelialization at 10 days. The criterion standard was the histological assessment. Intraobserver and interobserver agreements were calculated with Pearson's correlation coefficients. A coefficient less than .4 was considered poor. Sixteen burns were created on each of three animals. Six wounds were excluded because of the presence of a thick eschar covering the burn, making the gross determination of reepithelialization impossible. Intraobserver agreement for histological reepithelialization was 0.96 (P < .001). Intraobserver agreement for gross visual assessment of reepithelialization was 0.75 (P < .001). Interobserver agreement for gross visual assessment of reepithelialization was 0.60 (P < .001). The agreement between gross visual and histological assessment of burn reepithelialization was -0.25. Although there was a good interobserver agreement for gross visual assessments, there was a poor agreement between gross visual and histological assessments of burn reepithelialization. Care should be used when determining burn reepithelialization based on gross visual assessments alone.     

Preliminary experience with cultured epidermal autograft in a community hospital burn unit.

Initial experience with cultured epidermal autograft (CEA) in a community hospital burn unit is described. Five applications of CEA to three patients (mean burn size, 59% total body surface area) were made. Final graft "take" of CEA ranged from 10% to 80%. Healed CEA is cosmetically superior to meshed autograft and appears to form less hypertrophic scar tissue. CEA is more sensitive to infection than meshed autograft. A review of the literature concerning topical antibiotic use with CEA is included. This experience with CEA demonstrates that large burns can be successfully managed with this modality in a community hospital burn unit setting.     

Topical chemotherapy for the treatment of burns

A burn is a tissue lesion which provokes different alterations that vary from topical erythema to total destruction of the structures affected. A burn always produces an alteration in the skin, a lesion in the corneal strata is sufficient to cause the skin to lose its capacity to act as a barrier. The objective the treatment for a burn has is to produce epithelization as soon as possible in order to prevent infection and to reduce functional and esthetic aftereffects. Infection is the main cause of death due to burns due to the growth of endogenous flora or due to external contamination. The use of topical chemotherapy is fundamental to prevent infections when there are deep and superficial burns or extensive intermediary burns. Centella asiatica extract has proven to be efficient in helping, maintaining and regularizing cicatrisation of skin affected by burns. Its usage combined with an antibiotic agent such as neomycin covers the bacterial spectrum for gram-positive or -negative microorganisms, guaranteeing an anti-infectious efficiency for this extract.     

Treating minor burns. Ice, grease, or what?

Minor burns are common but require early and appropriate care to avoid infection and scarring. Damage can be arrested by immersing the burn in cold water as soon as possible. The goals of care are then to remove dead tissue and protect viable tissue during healing. Very superficial burns require only application of an emollient to limit inflammation and pain and prevent desiccation. Partial-thickness burns that are clean and superficial may benefit from use of a biosynthetic bilaminar membrane dressing, which forms a skin substitute while protecting the wound. A patient with an infected wound or one on a primary area (hands, feet, face, or perineum) may have to be hospitalized to ensure proper care.     

Nongenital warts: classification and treatment options

Common, plantar and flat warts are the primary classes of nongenital warts. Although spontaneous remission does occur, all warts should be treated to avoid spreading. Common warts often develop in the periungual region of the fingers. This type of wart generally can be removed with cryotherapy, topical application of salicylic acid or occlusive taping. Plantar warts are found over pressure points of the heel or metatarsal heads. They are also treated with cryotherapy or salicylic acid. Flat warts are commonly seen on the dorsum of the hands or on the face. These warts are best treated with topical retinoids. Immunotherapies are being developed.     

The present status of research in burn toxins

Modern intensive care combined with current improvements in the specific, systemic and local therapy of burns has delayed the mortal effects of severe burns. Nor has there been any significant improvement in this mortality during the last decade.The occurrence of uncontrollable infection and sepsis due to gram-negative bacteria or fungi as the basic cause of death was not a satisfactory explanation. So, progress should only be expected from a new concept in burn treatment. This new concept should be to view the burn disease as being caused by toxic factors induced by thermal injury to the skin. Electron-microscope studies in mice and rats have revealed similar mitochondrial alterations in hepatocytes after either a sublethal controlled burn injury or an intraperiotoneal application of an equivalent dose, of a cutaneous burn toxin. The intraperitoneal injection of different amounts of the burn toxin indicated, that the extent of the mitochondrial changes correlated directly with the dose of toxin. Investigations of liver metabolism suggested an inhibition of the oxygenation chain. The incubation of isolated liver cells together with the burn toxin demonstrated by scanning electron microscopy a direct cytotoxic effect of the burn toxin. In animal tests the pathogenic effect of the burn toxin could be prevented by treatment with an antitoxic IgG generated in sheep.The fatal sepsis of severely burned patients is the consequence of a decreased host defence against infections, which is caused by a primary and general toxic alteration of the whole organism. One important aspect of treatment should therefore be the elimination of burn toxins. To achieve this management should include primary excision of the burns, local application of nonabsorbable protein-complex-binding substances and specific passive immuno-therapy with an antitoxic IgG.