New strategies offer help for burn wounds
Caregivers may overlook resources
Recent years have brought marvelous advances in burn wound care and an increase in the number of medical centers that specialize in treating burn wound patients. With this issue, Wound Care begins a series on burn wound care with an overview of the field. Subsequent articles will provide information on different kinds of burns and provide detailed information on the latest treatments.
Burn injuries result in more than 500,000 emergency room visits and about 50,000 hospital admissions every year in the United States. Of those patients who cannot be discharged following outpatient treatment at the initial medical facility, about 20,000 are admitted directly or by referral to hospitals with specialized burn units.1
Many innovative burn wound treatment techniques have been developed in the past few years. For instance, there are multiple surgeries now available in the reconstructive phase, such as z-plasty, a procedure performed to resolve contractures of the skin in which a surgeon makes a z-shaped incision. The incision releases skin from different directions and increases mobility. Another modality is tissue expanders, large balloons that are inserted under the skin. Saline solution is injected into the balloons. Once the tissue has expanded to the point where there’s good coverage, the expanders come out, the scar is excised, the two sides of the wound are joined, and the patient no longer has a scar. There also are steroid injections for keloided areas to help smooth them out and pressure garments patients can wear to keep scarring to a minimum.
But not all health care professionals are well-versed in the basics of burn wound care, not to mention diagnosis and initial treatment.
Despite the abundance of advances in burn treatments, burn injuries are sometimes not even recognized as such by medical personnel, let alone given appropriate treatment. Shannon Nelson, RN, has worked as a burn care specialist for 14 years. She ran a burn center in Georgia for two years and is now with the Grossman Burn Center at Sherman Oaks (CA) Hospital. Nelson says electrical burns are a good example of poor recognition.
"A man came into our outpatient clinic because his hand tingled, and he just didn’t feel right," Nelson explains. "He’d taken 220 volts into his hand, and had the tiniest little speck on one of his fingers, just a little black dot. He’d gone to a hospital emergency room and been told, That’s just soot, it’ll go away.’ By the time the damage from the electrical current was done, he lost his arm above the elbow because the burn had completely killed all the nerves and muscle. Over a three- to four-day period, you could see the wound begin to break down."
Nelson points out that electrical burns are just as dynamic as flame burns. "You can track the path of the current. You can see the tissue damage continue on up. A lot of times, with what looks like a little tiny burn, you have to surgically open the wound up down to the muscle to control swelling and protect circulation. With electrical burns, what appears minute can in fact be devastating.
"Had this patient come to us first, we would have admitted him and begun immediate fluid resuscitation to keep everything flushed out," she adds. "We admit any patient who takes current for 24 hours, because anytime you take current, you can affect the heart. Any electrical burn victim needs to be admitted to a telemetry unit and put on a cardiac monitor for 24 hours." Nelson points out that electrical injuries can incur damage to the kidneys, too, which can cause the patient to spill myoglobin.
Electrical burn victims need frequent nerve and circulation checks. The medical caregiver must identify where sensation starts and stops. "If there’s any swelling at all, they’ll lose some of the dull sensation," says Nelson. "If the patient can’t feel a sharp sensation, it’s a third-degree burn. A lot of times there’s also internal swelling. The patient can develop compartment syndrome. If you’ve got a third-degree burn that goes around the wrist or hand, the skin no longer has any elasticity and doesn’t stretch. As the body swells from the burn and from fluid hydration, the swelling has nowhere to go but internally, where it compresses nerves and circulation. If you start to compress, say, the radial nerve or the ulnar nerve, you can lose function and can actually lose part of the hand."
Burn wounds can be put into four categories:
• thermal wounds, which include flame burns, flash burns, contact burns like hot tar and molten plastics, and all burning substances that adhere to the skin;
• scald wounds, including hot water and immersions;
• electrical wounds from AC and DC current and lightning strikes;
• chemical wounds, which come most commonly from hydrofluoric and hydrochloric acid or wet cement.
Wet cement is a good example of a burn wound source that Nelson says often goes unrecognized. Construction workers and weekend warriors pouring cement for a patio who get down on their hands and knees to smooth out wet cement can get up with second- and third-degree burns to those areas from a lye-based cement.
Here are the American Burn Association’s and the American Burn Foundation’s criteria for burn unit referral:
1. Partial-thickness burns greater than 10% of total body surface.
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 patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk or 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 occur 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 require special social, emotional, or long-term rehabilitative intervention.