University of Utah Health Services Center

University of Utah Health Services Center
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=Emergency Care for Burn Victims =

==Emergency Care Overview ==

The intent of these pages is to provide you with information for the basic emergency care required within the first 24 hours after a burn injury. Patients with serious burn injuries should be referred to a burn center according to the Referral Criteria established by the American Burn Association.

In order to determine the seriousness of a particular burn injury there are two areas of concern: The depth of the injury and the extent, or how much of the person is burned. This is very important information in terms of deciding how to treat the patient and determining morbidity and mortality.

We will begin by first reviewing the depth of burn injury. We will start with first degree burns. The most obvious example of a first degree burn is the sunburn. First degree burns involve only the epidermis, which is the superficial layer of the skin. Locally, there is tenderness and redness of the skin but the most important thing to remember about first degree burns is that they don’t make you very sick. You may get a fever or a chill but most people can go home and resuscitate themselves with oral fluids. People with first degree burns do not need to be hospitalized or resuscitated. The wounds will heal on their own without scarring in about 4 to 5 days. The main thing to remember about treating first degree burns is treat the symptoms. Make the patient feel better. The exception for the care of patients with first degree burns, are the very old or very young patients, for they can become seriously ill even from small first degree burns. The reason for this is due to their increased sensitivity to fluid loss and dehydration.

This diagram of the skin is intended to show you that the epidermis is the most superficial layer of the skin This is the only layer that is damaged in a first degree burn. The dermis which is considerably thicker, contains most of the important structures of the skin. When the dermis is involved in the burn injury, the risk for complications is much greater.

==Burns by Degree ==


This is a picture of a child with a combination of a first degree burn with some areas of second degree superficial burns. The areas of first degree may blister after a couple of days. The areas that have already blistered are second degree burns. The most reliable guide to determine if a burn is first versus second is blistering. Second degree burns blister immediately.

Most blisters should be removed. You will notice that the skin is very thin and friable. It won’t maintain its integrity. If you leave the blister in place it will eventually break down and the fluid will leak out and stick to dressings. Debride all blisters except intact blisters on the palm of the hand where there is thicker skin. These injuries should heal within two weeks time, if kept clean and free of infection and have adequate nutritional and hydration support.

The type of burn that can give the most trouble, in regards to diagnosis, are the second degree burns. Second degree burns can be very variable in degree from very superficial, almost like a first degree burn, to very deep, almost like a third degree burn. Typically the wounds have a very moist appearance.

The epidermis has been lifted off the underlying tissue by the fluid which accumulates following the burn injury. They are the most painful burn injury because the nerve endings are preserved with second degree burns where as they are destroyed with third degree burns. The single best criteria to determine second versus third degree is if the burn is extremely painful.


The other type of second degree burns is the deep second degree burn which can be much more difficult to treat because they don’t heal as well. They can scar significantly because of the extended healing time. These burns need to be treated like third degree burns which means the will require surgery for skin grafting for optimal functional and cosmetic results.

Deep partial thickness burns have a waxy, white appearance which looks much like a third degree burn. The surface appears to be more dry and is much less painful than a superficial partial thickness burn.

Most of this diagram is taken up by the dermis which is much thicker than the epidermis and contains several structures that are very important physiologically. Notice the large blood vessels within the deep part of the dermis. These supply the skin with blood. These remain intact with second degree burns and that is why the injury may take on a bright red appearance. The nerve endings are also located deeply within the dermis, which explains why second degree burns tend to hurt as much as they do.

Notice on the diagram, the skin appendage lining the hair follicle or a sweat gland. This tubular structure is made up of epidermis. The epidermis penetrates deeply into the dermis. It is from these skin appendages that healing takes place. The superficial tissues which have been destroyed by the burn will fall off and intact epidermis will well up over the surface of this tissue and recover it with new skin. Because of these skin appendages this burn may heal in about 30 days, but very deep partial thickness burns shouldn’t be permitted to heal because of their tendency to scar.

This is a picture of an elderly women with deep second degree hand burns on post burn day number 24. Eventually the left hand was grafted, where as the right hand was allowed to heal on its own.

These are the same hands after all wounds have healed. Notice the significant scar formation on the right hand; the hand wound that was allowed to heal on it’s own.

This is how a deep partial thickness burn may look if allowed to heal without surgical intervention. The scars take on a very thick and rubbery texture and the function of the hands and arms will be poor due to the loss of range of motion. Scar tissue is quite unstable. The epidermis which covers a scar is not a good quality. Even months after this hand has healed, when the person starts using their hand areas of epidermis may tear off. Then they’ll have to go back into dressings. This will compromise the potential of doing any kind of heavy work. Skin grafting a wound like this will achieve a better end result, both functionally and cosmetically.

This is a good example of a third degree burn because it shows you that they can be any color. They can be red, white, or brown. Notice the very dry appearance. This wound is not swelling, appears to have sucked down, is dry and tightening. These wounds do not heal because all of the skin elements are destroyed and there is no potential for epidermal growth. The exception is in very small wounds, approximately 5 cm, which can heal from the outside edges in.

In third degree burn injuries all of the structures in the dermis are destroyed. The deep blood vessels in the depth of the dermis have coagulated, therefore there is no blood supply to the tissue. The nerve endings have been completely destroyed, these burns do not hurt. The epidermal appendages have been destroyed, therefore these burns will not heal.

The entire depth of the dermis is made up of collagen which is a structural protein and has elastic fibers as well. These structures are cooked into position therefore there is a loss of elasticity. The skin tends to be dry and contracted and very rigid.

==Extent of Injury ==

An easy way to determine the extent of a burn injury is by using a tool called the rule of nines. You simply divide the body up into sections which equal nine. For instance each arm is nine percent, each leg is two nines which equals eighteen. There are two limitations to this tool. One is that this is not how people get burned. For example, a typical burn injury may involve a hand, part of the lower arm, a spot on the abdomen and 25% of the back. One good rule to remember is that the area of the palm of the patient’s hand is equal to one percent. But remember it’s the patient’s hand not your hand. The other limitation with the rule of nines is that it is not the same for children.

Kids have relatively big heads and relatively small legs compared to adults. Therefore when a little kid pulls cups of hot coffee onto themselves (a very typical cause of injury) they may have a much more severe injury than an adult with a similar type of injury. Therefore, the infant will require more treatment as a result.

The Land and Browder chart is another tool that has been in use for a long time. This tool divides the body up into much smaller areas and also gives you the sizes that are associated with different aged patients. When we first see a burn victim, we completely debride all of the burn tissue, then we draw the burned areas on the diagram. We use blue for second degree and red for third degree burns. Then you add up all of the areas and the total gives an accurate size of burn injury. The two points two remember when you are estimating the size of the injury are:

Debride all of the blisters first before you estimate the size, and
First degree burns do not count.
As you can see by this chart the survival of a particular patient relies heavily on the size of the burn. These are statistics from our own burn center but they are very similar to statistics published nationally. As you can see, for groups two and three, which are young adults, survival can be very good even with very large burns. Even a patient with a 70% burn has a 50% chance of survival. For very young people and very old people those figures are considerably different. The survival rates of the very old or very young person with a much smaller burn, are very poor. Therefore the age of the patient is also very important when determining the severity of the injury.

Patients with serious burn injuries should be referred to a burn center according to the Referral Criteria established by the American Burn Association.

Now you know everything you need to know about the depth of burn injuries, the extent of burn injuries and when you should consider referring a burn patient to a burn center. Now we need to talk about the actual treatment of the burn patient.

==Management of the Burn Victim at the Scene ==

For the health care providers who are in the front line, the firefighters, the EMT’s, the first thing to remember is to Stop the Burning Process! This may sound trivial but believe it or not burn victims, wrapped in blankets, have been brought into the emergency room still smoldering. Also if you try to put supplemental oxygen on someone who is still on fire you can make the fire explode.

For flame burns, smother the fire with water or a blanket. The health care providers in the field can limit the extent of the injury. Make sure the fire is out and remove burned clothing.

For scald injuries cool the area with water immediately, within 30 seconds of the injury. If you cool a scald injury with water later than 30 seconds, you will have no effect on the extent of injury. After cooling the burn, keep the patient warm and dry.

For chemical burns wash the burn with copious amounts of water. Rather than trying to remember specific chemicals and their neutralization just remember to flush every chemical injury with huge amounts of water. Many of these chemicals will produce more heat if you put only a small amount of water on them, so it is very important to remember that you must flush with copious amounts of water in order to dilute the effects of the chemical. The most dramatic example are alkaline or acid burns to the eye. You must flush the eye out immediately, because if you wait until the victim can be transported to the emergency room, it will be too late, the damage will be done.

Tar, asphalt and melted plastics are treated a little differently because the material can be very difficult to remove. These materials can retain heat for a very long period of time. If you have a patient with a tar burn cool the tar off and leave it in place. These can be removed in most local emergency rooms with chemicals. It can be very difficult to remove, the materials can be very sticky and more damage and pain may be inflicted if removed improperly. One other thing to remember is, when you have a situation like the man in the picture, is to assure an adequate airway.

Most people killed in America by electricity are killed by low voltage current. These victims don’t die of their burn injuries, they die from cardiac dysrhythmias, usually ventricular fibrillation. At the scene of an accident, if someone is down, make sure they are not still in contact with the electrical current before you touch them or you can become part of the accident as well. Many of these people are resusitatable, with only a few minutes of CPR or maybe a counter shock will restart the heart.

With high voltage current, the skin resistance is lowered and the victim can get profound injuries from the electricity. Electricity does not travel over the surface of the skin, because the surface tension of the skin is very high. The current tends to enter the body through a relatively small opening, travels deep through the body then exits through a small opening.

This is a typical entrance wound to the hand. This man grabbed a high voltage wire and received the shock through the base of the thumb. This is what the wound looked like in the emergency room.

This is what it looked like after debridement. You can see extensive damage of all of the muscles of the thumb and extending down into the forearm. You can see where a fasciotomy was required to release the pressure.

This is an exit wound, which does not appear to be very significant, but this man’s foot had to be amputated because of the extensive muscle necrosis.

Electrical shock may result in unconsciousness, convulsions, loss of memory and orthopedic injuries. Spine fractures may result from tetanic contractions of muscles induced by high voltage current. The victim must have spinal stabilization and cervical collars placed.

After the source of the burn has been eliminated, treat the patient, not the burn! Do not focus on the burn. You can have a very large burn and you won’t die within the first hour from your burn injury, but you may die from an obstructed airway in just a few minutes. You can die from a ruptured spleen or you can die from a fractured pelvis, those are the types of injuries that require immediate attention.

Remember the burn patient is a multiple trauma patient. Just like with any other trauma patient you begin with airway, breathing and circulation!

Statistically, people are far more likely to die from an inhalation injury than from burn wounds. Historically, in catastrophes involving fires in large public buildings, most of the people who died did not die from burn injuries. They died from carbon monoxide poisoning and inhalation injury. If you respond to fires with victims, that should be the primary concern.

This is the kind of injury that obviously will require endotrachial intubation. This man has extensive facial burns, upper airway injury and an inhalation injury. He will require intubation not only for oxygenation but also for airway protection.

There are mainly three types of airway injuries:

*-Carbon monoxide poisoning
*Inhalation injury above the glottis
*Inhalation below the glottis
Any victim, burned in a closed area, like a house fire, should be presumed to have an inhalation injury until proven otherwise.
The most common type of airway injury is carbon monoxide poisoning, which may often present with very few symptoms. Carbon monoxide is a byproduct of incomplete combustion of fuels. Carbon monoxide has a 200 times greater affinity for hemoglobin than oxygen. As carbon monoxide binds to the hemoglobin molecule, it prevents the red blood cell from transporting oxygen. As the levels of carboxyhemoglobin increase the patient may develop myocardial and cerebral hypoxia. The most common signs are central nervous system complications: confusion, loss of memory and headache. Anyone unconscious at the scene of a fire should be presumed to have a carbon monoxide injury. The only way to treat a carbon monoxide accident is with immediate application of high flow oxygen at the scene of the fire.

The injuries above the glottis are quite common due to the capacity of the nasopharynx to dissipate heat to the nose, throat and mouth. The resulting thermal injury can cause edema which can present within minutes to hours. These are the types of injuries that can progress to airway obstructions. Those are the people that need to be intubated to protect their airway.

Inhalation injuries of the lungs or injuries below the glottis, may be clinically asymptomatic for the first 48 hours. These people could have normal arterial blood gas levels, a normal chest X-ray, but the next day they get into respiratory distress. These people need to be intubated and treated like someone who has adult respiratory distress (ARDS). When you suspect an inhalation injury, these patients must be watched very closely.

==Care of those with evidence of inhalation injuries ==

Associated injuries are very common with burn injuries. Explosions are common in fires; people jump out of burning buildings; people get burned in automobile accidents. Remember that an unconscious patient is unconscious for a reason other than the burn injury.

This little girl was admitted to the burn center not because of her burn injuries but because of her black eye. This is an absolute indication for referral to the child protection agency. Child abuse is a prevalent problem in infants and children and should be considered in the assessment of every burned child.

The water line pattern may be an indication of abuse if the pattern does not match the story of how the child was burned.

The principles for trauma care are the same for burn victims. If you need to start IV’s through burned tissue you can, but you must not tape them in place because the tape will not stick, instead, suture the IV’s in place. You can splint fractures that also involve burns, but you must remember to check circulation which may be at risk after splinting due to swelling. Don’t be so intimidated by the burn wound that you don’t treat the associated trauma.

Keep burn victims warm, they can get hypothermic very quickly. When you loose the outer surface of your skin you lose the ability to regulate your own body temperature. Keep them dry . If you put fluid on them it will cause heat to be evaporated. Do not give a burn victim anything to drink or eat for the first 24 hours. There is a great potential for burn victims to vomit. All pain medication should be given intravenously. Intramuscular medications are not adequately absorbed in the early period following a burn. Titrate intravenous narcotics to achieve pain control.

Please send the initial patient history along with the patient. By the time they arrive at a burn center there is the possibility that they will be intubated and/or sedated. Communication will be difficult at best. Any information that can be sent with the patient will be very helpful in treating the patient.

==Treatment of the Burn Victim ==

Now it is time to start treating the burn wound. This part of the information is left towards the middle for a good reason. You don’t want to start treating the burn wound until you have:

*Stopped the burning process
*Assessed Airway, Breathing and Circulation
*Evaluated the extent and depth of the burn
*Assessed the criteria for referral to a burn center
*Have observed for and treated associated injuries.

Fluid replacement is the prime object of initial burn treatment. When someone gets burned, to put it very simply, their capillaries begin to leak. Instead of sticking together, keeping blood inside of the vessel, the endothelial cells separate and become very porous. Huge amounts of fluid pour out into the tissue. In small burns this fluid accumulates only in the burned areas but in very large burns fluid can accumulate everywhere in the body. These patients can develop a significant amount of edema at the expense of your vascular volume. The blood volume goes down as you become more edematous, or rather, they develop hypovolemic shock.

Who gets resuscitated? Any burn greater than 10%, but this is dependent on the age and health of the patient. For instance if you are treating a healthy 20 year old with a 15 % burn, they can probably resuscitate themselves with oral fluids but nonetheless, they should be observed to make sure they take in enough fluids, is not vomiting and that they produce a satisfactory amount of urine. Anyone with an inhalation injury, associated trauma or electrical injury gets fluid resuscitation. When in doubt, over treat. Make sure they get through the first 24 hours.

There are many formulas for fluid resuscitation. These are not aimed at treating burn shock because burn shock will reverse itself. The goal in resuscitation is to maintain the volume of the patient during the period of hypovolemia. The formula that we use at the Burn Center is the Parklund Formula. It is a good formula for two reasons:

It calls for a large amount of fluid
It is easy to remember.
Please remember that the resuscitation time is calculated from the time of the burn injury. If a person gets burned at 1:00 A.M. and resuscitation is delayed until 8:00 A.M. that person is 7 hours behind. You will need to increase the rate of the fluid to catch up, in order to get back on schedule.

The criteria to judge whether or not fluid resuscitation is adequate is measured by urine volume.

Why do we use lactated ringers? Because lactated ringers is most like normal extracellular fluid. If you must give a couple liters of normal saline to a burn patient, you will not harm them but remember that normal saline contains a large amount of chloride. If you give very much chloride to a burn patient there is a potential for metabolic acidosis. Fluid which contains dextrose is not used for two reasons:

*Does not contain any electrolytes,
*There is potentially a large amount of adrenaline in the bloodstream which makes these patients glucose intolerant. Their blood glucose levels will increase which will cause their urine output to increase, therefore they will not be getting resuscitated appropriately.
Perfusing the kidneys is one of the goals of therapy. If the kidneys are perfused adequately, the patient will make enough urine. If the patient does not make enough urine they are not getting enough fluid. Even if you are following the Parklund Formula guidelines correctly, some people require more fluid. Turn the rate of the IV fluid up, DO NOT GIVE DIURETICS!

Patients with electrical injuries or very deep tissue damage may have myoglobin in their urine, therefore they will require double the urine output to flush the kidneys of the large myoglobin cells. The amount of fluid resuscitation required is difficult to assess because you can’t go by the size of the burn. If the urine is very dark, such as in the picture, increase the rate of the intravenous fluids to maintain a urine output of 100 cc/hr.

All of these criteria are important, but this doesn’t help you very much if you are in the field. If there is only one criteria which you can assess, it must be urine output.

The complications of edema get worse as resuscitation proceeds. Any major burn of an extremity of the torso tends to swell very tightly. This is because the skin in third degree burns become very rigid and hard. Elasticity is drastically compromised. As you pour fluid into these patients during resuscitation, the extremity or torso will swell and the burns become tighter and tighter. This tightness can become so great that the circulation may become compromised. This happens over several hours. The patient may loose peripheral pulses, motor function and nerve function in the extremity. The extremity can become cyanotic. Instead of surface pain, the patient may start complaining of a deep, throbbing pain. This can be difficult to evaluate in the field. The best way to evaluate this complication is by watching extremities closely for tightness, loss of pulses and complaints of numbness and tingling.

The procedure of choice is an escharotomy. What we have done in this man’s arm is to cut through the burned tissue with a scalpel medially and laterally to ensure restoration of pulses. Notice how far apart the edges are. We did not remove any tissue. The skin simply spreads apart as a result of the tension and tightness caused by the swelling. Initially, even a badly burned extremity will feel soft. The complications of edema occur only after several hours.

The complications of edema may also effect the ability of the chest to expand. Ventilation is mechanical. The chest needs to be able to expand during breathing. When this occurs an escharotomy may be performed to the chest in the shape of a square. It is important to connect all sides by incision.

This is a picture of a man with escharotomies to the upper legs and fasciotomies to the lower legs.

Initially there will be very little bleeding, but after the extremity becomes perfused, the potential for bleeding becomes great, therefore the wounds must be dressed appropriately with bulky dressings and pressure wraps.

We are not advocating that this be done in the field. There is the potential for blood loss, severe hypotension, contamination of the wound and damage to the nerves.

The other complication from edema is swelling of the airway. This young boy got burned while sniffing gasoline. He has a very deep burn to the face which is difficult to appreciate in this photo. This picture was taken immediately after admission and shortly after the burn injury.

This is that same boy, just one hour later. The facial swelling that occurs in these injuries is very profound. That is about as far as the mouth can be opened. His eyes are completely swollen shut. If you feel his face you would appreciate that all of the skin in the face and neck is swollen very tight. If this boy had not been intubated prior to swelling, it would have been impossible to intubate him at this point because the swelling also occurs on the inside. The tongue swells, the pharyngeal tissue swells, and if you look down his throat with a laryngeal scope you would not be able to see the chords. He would have died from loss of airway. When in doubt , intubate before transport. If you intubate a patient who does not need it, the tube can always be pulled, but if you fail to intubate a patient who does need it, the patient will die.

==Review of the Emergency Care ==

*Stop the burning process
*Stabilize ABC’s
*Observe and treat associate injuries
*Begin fluid resuscitation
*Referral Criteria
*Treatment of Minor Burns”,”utf-8″
“516”,”International Society for Burn Injuries

==Care of Out Patient Burns ==
Denise Tompkins, RN, MBA, Boston, Massachusetts; Lidia Aparecida Rossi RN, DNS, Associate
Professor – Department of General and Specialized Nursing at Ribeirão Preto College of Nursing
University of São Paulo, Brazil, WHO Collaborating Center for Nursing Research Development; Nursing
Committee of the International Society for Burn Injuries

==Introduction ==
Out patient care of burns is appropriate for patients with small partial thickness burns who also have a supportive home environment. The cosmetic outcome of most small second degree burns if healed in 2 weeks time is good. In general, children with less than 10% BSA (body surface area) partial thickness burns and adults with less than 15% BSA partial thickness burns can usually be safely treated as outpatients, unless unsuitable home conditions prevail. In order to quickly determine the BSA of an outpatient burn, use the “rule of palms.” The palm of the patient (child or adult) will equal approximately 1% BSA. Always make sure that the history of the injury matches the clinical picture you see. This is particularly critical with children as you always want to rule out child neglect or abuse as a contributing factor to the injury; and also to make sure that in the case of flame burns, there is no possibility of smoke inhalation and airway impairment. The objectives of out patient burn care are:
• To achieve wound healing without loss of work or school
• To minimize any permanent impairment or scarring.

Criteria to determine eligibility for out patient care should include:
• Less than 10% BSA partial thickness burns in children and elderly and less than 15% BSA partial thickness burns in adults.
• Reasonable state of good health with minimal underlying medical problems.
• Adequate airway.
• Ability to drink adequate amounts of fluids.
• No circumferential burns.
• No additional trauma.
• No chemical burns.
• Minimal involvement of face, hands, genitalia and joints.
• No evidence of abuse or neglect.
• Patient and family demonstrate ability to carry out plan of care.

==Laboratory Recommendations ==
• For burns less than 10% body surface area (BSA), obtain CBC (complete blood count), electrolytes, serum glucose, BUN (blood urea nitrogen) and creatinine.
• Always check a Carboxy-hemoglobin if inhalation injury is suspected or in burn occurred in an enclosed space to ensure airway adequacy.
• A skeletal survey is recommended when trauma is apparent or suspected.
• Take an electrocardiogram (EKG) if there is a history of high tension electrical injury or known history of heart disease.

==Treatment ==
;Emergency Care
• Stop the burning process. Remove all clothing, including diapers in the case of babies, and any plastic coverings that may retain heat and cause a deeper injury.
• Rinse the affected area with cool water for at least 15 minutes.
• If a chemical involved, check with poison control center for best neutralizing agent and repeat washing process until all chemical is removed.
• Tetanus prophylaxis is indicated only when immunizations not up to date (in the case of children) or for adults if last tetanus immunization was more than 10 years ago.

;Non-Emergent Care
• Clean wound with soap and water.
• Leave blisters intact; only debride devitalized tissue after blister has burst. Debridement should only be done by the health care professional in the clinic and not left to the patient or family to do at home.
• For burns on trunk and extremities: Apply 1% silver sulfadiazine, mafenide acetate or povidone iodine cream for all partial thickness burns and secure with a clean bandage. Teach family or significant other “clean” technique. Instruct to change dressing once to twice daily, depending on
your assessment of the wound and the families’ ability (technically and economically) to do it. Be sure to instruct them to wash wound and remove all residual cream before applying new cream. Bathtub and /or shower may be appropriate. Elevate injured area as needed and as possible.
• For facial burns, apply neomycin, bacitracin, polysporin or some similar agent. Instruct patient and family to protect affected area from sun exposure.
• For electrical cord injury to mouth, use neomycin ointment three times a day. Teach patient/ family to gently rinse area after eating. Instruct patient/family to pinch affected area if bleeding occurs and go immediately to nearest Emergency Room. This is a complication that may occur when the eschar separates and detaches from the surface, usually 14 to 21 days after injury.
• Set up schedule to see patient frequently in outpatient clinic to monitor wound and progress in healing.
• Provide pain relief for dressing changes with acetaminophen. Make sure patient/ family know to take medicine approximately ½ hour before dressing change and before return clinic appointment.
• Once burn wound is healed, teach patient/ family to use emollient cream to lubricate and protect skin as well as to decrease itching. Instruct to protect healed areas from sun exposure with clothing and sun block for at least one year after healing

;Special considerations for Infection Control
• Teach clean technique for wound care and dressings and be sure to give written instructions for the family to refer to.
• Emphasize the importance of hand washing before and after caring for the patient and most importantly when performing wound care.
• Instruct the family to clean the bathroom, especially the bathtub or shower stall before and after they have been used with a strong disinfectant like household bleach.
• Teach the family signs and symptoms of infection to look for including: fever, increased redness and/or warmth around the wound, increased pain, increased swelling or tenderness and any increased odor or drainage from the wound site. Be sure they have the clinic telephone number to report any of these findings.

==Pain Management ==
Management of pain and anxiety is very important. As previously mentioned, make sure the patient receives pain medicine ½ hour before dressing changes and wound care and also before return clinic appointments. Using the Brief Pain Inventory (Cleeland), the patient’s worst pain score should be
less than 5, on a scale of zero to 10. Pain score of 5 or higher interferes with sleep, activity and mood. Accordingly, make sure the patient also receives pain medicine if needed before bedtime to make sure there is no interference with sleep. Be sure the patient and family knows that pain will decrease as the wound heals and that they should expect decreasing levels of pain. If pain increases, that is reason to call the clinic for earlier follow up. Also teach complementary alternative measures for minimization of pain such as distraction and music.

==When to Refer/ Admit ==
• Burn is greater than 10% BSA
• Suspected or actual respiratory burn
• Electrical burn, high tension wire accident
• Full thickness (third degree burn) of an area larger than 3 inches in diameter
• Burn is to area of body where dressings are difficult to apply, i.e. face perineum.
• In the case of a child, suspected abuse or neglect
• Inadequate home situation to mange proper treatment of wound.

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