Injuries secondary to burns represent a significant and prevalent form of injury with major morbidity and mortality. Prevention must still be in the forefront of burn management. There has been an increase in the prevalence of a shift to ambulatory or Emergency Department care for burn patients.1-3 Scald burns make up the majority in children younger than 5 years of age with the balance shifting to flame burns in older children. The rates of hospitalization for burns appear to be decreasing.4 The annual cost for burn hospitalizations exceeds $200 million per year.4
Child abuse must be considered in all pediatric burn patients. Abuse should be suspected in younger patients presenting with burns that are in a bilateral and symmetrical distribution (e.g., a stocking and glove distribution), patterned burns (e.g., a hot grate), or burns on the dorsum of the hands; in cases of delayed medical care; or when there are inconsistent histories.
The Emergency Physician must be familiar with the initial management of burns, the treatment of burns, and the indications for transfer to a regional burn center. This chapter is limited to minor burn management of the skin as an outpatient. It will not cover airway burns, significant burns, fluid and electrolyte management, associated poisoning (e.g., carbon monoxide and cyanide), and inhalation burns.
ANATOMY AND PATHOPHYSIOLOGY
The skin is the largest organ of the body. It consists of the epidermal, dermal, and subcutaneous layers (Figure 115-1). The epidermis is the outer layer of stratified squamous epithelium, whereas the dermis is a dense bed of vascular connective tissue. The skin acts as a physical barrier, a sensory organ, and a thermoregulatory organ. The body reacts to a burn with local and systemic responses.
Cross section of the skin.
There are three zones of tissue response described after an acute thermal injury.5 The zone of coagulation occurs at the point of maximum damage. Tissue proteins coagulate and lead to irreversible tissue loss. The next zone is labeled the zone of stasis and is characterized by decreased tissue perfusion. This tissue may be salvaged or completely lost if not properly treated. Surrounding the zone of stasis is a zone of hyperemia. This area sees an increase in tissue perfusion. Tissue in this zone should recover unless there are severe systemic insults (e.g., profound hypotension or sepsis). Severe and major burns can involve a systemic response (e.g., cardiovascular, respiratory, metabolic, and immunologic derangements). Systemic involvement is generally not seen unless a burn is greater than 20% of body surface area (BSA).6
Burns are classified by depth, size, and total body surface area (TBSA) involved.7,8 A superficial or first-degree burn is characterized by dry, blanching, and erythematous skin. This is ...