Urgent Care Management of Patients With Thermal Burns

Table of Contents

 

About This Course

Although some burn injuries will require transport to the ED or a burn center, many thermal burns can be treated in urgent care. Priorities for management of thermal burns in the urgent care setting include ruling out severe burn injury and/or inhalation injury, and providing fluid resuscitation (if needed), wound care, and pain control. In some cases, referral to specialized burn care may be needed to improve long-term outcomes. This article reviews thermal burn classification and evidence-based treatment strategies. In this issue, you will learn:

How to classify burns and quickly estimate the total body surface area affected.

The most effective dressings and topical therapies for burns.

When unroofing and/or debridement of burn blisters is indicated.

Evidence-based recommendations for pain control, including for sunburn.

The quality of evidence for nontraditional wound care strategies such as aloe vera, honey, or hyperbaric oxygen therapy.

The physical examination findings that raise concern for nonaccidental burn injuries in pediatric patients.

The indications for transfer or referral to a burn center.

1. About This Course
2. Case Presentations
3. Introduction
4. Etiology and Pathophysiology
5. Differential Diagnosis
6. Urgent Care Evaluation
   1. History
   2. Physical Examination
7. Diagnostic Studies
   1. Laboratory Testing
   2. Imaging
      1. Chest X-Ray
8. Treatment
   1. Cooling
   2. Intravenous Fluid Resuscitation
   3. Wound Care
      1. Unroofing, Debridement, and Surgical Excision
      2. Escharotomy
   4. Antibiotics
   5. Pain Control
   6. Tetanus Prophylaxis
9. Managing Sunburns
10. Controversies and Cutting Edge
    1. Wound Care Controversies
11. Disposition
12. KidBits: Nonaccidental Burn Injuries in Pediatric Patients
13. Risk Management Pitfalls for Management of Burn Patients in Urgent Care
14. Summary
15. Time- and Cost-Effective Strategies
16. Critical Appraisal of the Literature
17. Case Conclusions
18. Clinical Pathway for Management of Burns in Urgent Care
19. References

Case Presentations

A 35-year-old woman who works as a chef presents to UC after burning her right hand on a cooking surface…

• Her vital signs are normal and her hand is blistered over half of the palmar surface.
• You have the patient immerse the burn in cool running water and order pain medication and a tetanus booster.
• As you leave her room, you try to recall whether she should be referred to a burn center and whether there are any evidence-based guidelines to help you select a dressing…

A 20-year-old man presents with a complaint of severe sunburn...

• He states that he returned from spring break in Florida the previous day and complains of painful sunburn to his upper torso, shoulders, and arms. He had been on the beach for 3 straight days prior to traveling back to college and admits that he forgot to apply sunblock on his second day of fun in the sun.
• His vital signs are normal, but he appears uncomfortable, with intense erythema across the upper back and chest, shoulders, and arms. There is blistering in some discrete areas of the shoulders and upper back.
• The patient phoned his mother for advice prior to the visit, and she recommended that he go to UC for a “shot of steroids and a prednisone prescription.” You wonder if the suggested management is appropriate…

A 3-year-old boy is brought in by his mother for scald burns to his feet…

• The mother says that yesterday the child picked up a bowl of hot soup and accidentally spilled its contents.
• The boy appears fussy and has symmetric, well-demarcated, full-thickness burns to both feet from the ankles down.
• His vital signs are: temperature, 37°C (98.6°F); heart rate, 120 beats/min; respiratory rate, 22 breaths/min; and oxygen saturation, 98% on room air.
• You are concerned about the delay in seeking care and wonder whether this might be more than an accidental burn…

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Introduction

The American Burn Association (ABA) reports that nearly half a million people suffer thermal burns each year in the United States.¹ According to World Health Organization estimates, as many as 265,000 people worldwide die annually from thermal burns.² The economic burden of thermal burn injury is also substantial: In the United States in 2000, the annual direct-care cost of treating pediatric burns alone was $211 million.² This does not take into account the economic impact of rehabilitation and long-term disability. Although efforts to prevent thermal burns through regulation and public health initiatives have reduced the incidence in developed countries, burn injuries still account for approximately 0.5% of annual emergency department (ED) visits in the United States.³ This issue of Evidence-Based Urgent Care reviews the guidelines on assessment of burns, the latest evidence on burn wound care, pain control, and the criteria for referral to specialized care.

Clinical Pathway for Management of Burns in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. American Burn Association. Burn Incidence Fact Sheet. 2016. Accessed June 10, 2022. (Website fact sheet)

2. World Health Organization. Burns. World Health Organization; 2018. Accessed June 10, 2022. (WHO website fact sheet)

3. United States Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables. Accessed June 10, 2022. (Government survey database)

5. * Rae L, Fidler P, Gibran N. The physiologic basis of burn shock and the need for aggressive fluid resuscitation. Crit Care Clin. 2016;32(4):491-505. (Review) DOI: 10.1016/j.ccc.2016.06.001

14. * Aziz Z, Abu SF, Chong NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012;38(3):307-318. (Systematic review; 14 randomized controlled trials, 877 participants) DOI: 10.1016/j.burns.2011.09.020

35. * Magnette J, Kienzler JL, Alekxandrova I, et al. The efficacy and safety of low-dose diclofenac sodium 0.1% gel for the symptomatic relief of pain and erythema associated with superficial natural sunburn. Eur J Dermatol. 2004;14(4):238-246. (Randomized double-blind single-center trial; 172 patients) PMID: 15319157

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Keywords: burn, thermal burn, superficial, first-degree burn, partial-thickness burn, second-degree burn, deep partial-thickness burn, full-thickness burn, third-degree burn, cooling, total body surface area, TBSA, silver sulfadiazine, escharotomy, scald, nonaccidental trauma, intentional injury, sunburn, topical NSAIDs, aloe vera, honey, referral criteria, burn center