Burn Care in an Outpatient Setting

Transcription

1 Burn Care in an Outpatient Setting

2 Abstract There are more than 1 million burn injuries in the United States each year resulting in over 45,000 hospital admissions and 4,500 deaths. 1 Statistics have shown that a majority of the hospital admissions are for minor burns that could otherwise be treated in an outpatient setting. 1 As the United States becomes increasingly focused on pay for performance initiatives, proper referral to burn centers will becomes imperative. 16 New silver dressings such as Aquacel Ag and Acticoat have made management of burns less painful with the need for fewer dressing changes and decreased occurrences of infection. A prospective, randomized controlled trial comparing SSD to Aquacel Ag time-to-wound closure was significantly shorter in the Aquacel Ag group with a mean of 10 days versus a mean of 13 days (P < 0.002). 15 In a meta-analysis comparing Acticoat to SSD, patients in the later group had a significantly lower rate of infections, (P < 0.001) and a significant reduction in pain in the Acticoat group (P < ). In addition, both Aquacel Ag and Acticoat were more cost affective than SSD. 12,15 It is crucial that primary care providers have a comprehensive understanding of minor burn care. This knowledge, coupled with new dressings and strict guidelines for burn center referral, allow for adequate and cost effective outpatient management of minor burns.

3 Introduction There are more than 1 million burn injuries in the United States each year resulting in over 45,000 hospital admissions and 4,500 deaths. 1 Major burns require expert care and a multi-disciplinary approach that includes laborious wound care, vigorous infection control, intricate surgical management, demanding nutritional and metabolic support, and expansive physical and occupational therapy after discharge. This was the stimulus behind the development of specialized burn centers, which are associated with a decrease in burn mortality in the past 30 years. 2 However, even with this decrease in mortality, the nation has seen an increase in burn center admissions 2. What s more surprising, is that a majority of this increase stems from patients with minor burns of <5% of their total body surface area (TBSA) 1. This increase is due, in part, to burn centers expanding their expertise to include complex non-burn patients, but it is also likely due to a reduced comfort level and competency in the management of minor burns 2. Data from the American Burn Association shows the average daily cost of hospital charges for burns in 2006 was $4546 $ This data, coupled with an increase in hospital admissions for burns that could otherwise be managed in an outpatient setting, shows this is an area of unnecessary healthcare costs. Thus, it is crucial for primary care providers to have a comprehensive understanding of minor burn care so they can feel confident about treating patients in an outpatient setting when necessary. I. Pathophysiology of Burns A burn is an injury that occurs as a result of exposure to chemicals, heat or electricity. The primary injury is at the center of the burn and referred to as the zone of coagulation 3.

4 This area has irreversible tissue loss secondary to the coagulation of proteins and lack of vascular supply and will appear black or dark brown 3. Surrounding the central necrosis is an area of ischemia called the zone of stasis, which is characterized by a whitish appearance, decreased capillary refill and injured cells 4. This area is the most susceptible and needs to be watch carefully during treatment. It will invariably result in necrosis, termed wound conversion, if the ischemia is not reversed, or if there is additional insult to the burn such as infection or hypoperfusion 4. The outermost area of the burn is called the zone of hyperemia, which is characterized by vasodilation, capillary permeability and inflammation 4. This area has a reddish appearance and will most likely recover unless systemic sepsis or prolonged hypoperfusion occur 3. Although burns can be localized to small areas the resulting insult to heat-injured capillaries has the potential to cause a generalized fluid shift. After the initial insult, the complement and clotting systems are activated which stimulates a systemic release of inflammatory mediators. These mediators stimulate increased capillary permeability, which results in the transudation of large amounts of fluid and protein into the interstitial space 1. This fluid shift causes edema secondary to third spacing. Uncontrolled edema will lead to decreased circulation and result in further damage to hypersensitive tissue, consequently placing the burn at higher risk for wound conversion 4. Initial management of fluids is a high priority in burn victims because losses peak at 6-8 hours and should resolve by hours 4. However, further injury can occur with reperfusion when toxins are released after tissue perfusion is restored 1. Furthermore, systemic effects occur with larger burns and cause cardiovascular, respiratory, metabolic and immunologic changes. Therefore, proper

5 evaluation of burns, and consequently proper referrals, can prevent additional injury and unnecessary costs. II. Evaluation of Burn Patients Surveying the Patient The general survey should be conducted similar to a trauma and include the basics for airway, breathing and circulation. It should also include a quick head-to-toe survey of associated injuries 6. The edema that results from facial and neck burns are two common etiologies of airway compromise. Trouble breathing can be secondary to flame burns, which cause inhalation injury. Inhalation injury should be considered with burns sustained in a confined space, soot around the nares, singed nasal nares, burnt sputum, hoarseness, stridor, symptoms of respiratory distress or a carboxyhemoglobin level >10% 9. Circumferential burns around the trunk or an extremity can compromise circulation and breathing 6. These are examples of burns that meet the American Burn Association transfer criteria; the full criteria are listed in Table 1. After the initial survey, a second more burn-specific survey is conducted. Specifics such as determining the mechanism of injury, duration of contact and closed space exposure can all aid in accurately diagnosing burn depth 6. Special attention should also be given to lack of a specific mechanism of injury or a delayed presentation because these could be signs of abuse 3. After obtaining accurate historical data and determining wound depth and extent, as described below, decisions about transferring to a burn center or outpatient care can be made.

6 Classification with associated mechanisms of injury The clinical examination remains the most common technique for determining burn depth 1. The first step at managing burn patients is to determine burn depth, which can be accomplished by appreciating the common characteristics that classify each level of burns. First-degree burns involve only part of the epidermis. They are diffusely red, dry and painful, but will not blister. The most common first-degree burn is a heat radiation burn from sun exposure 2. Second-degree burns involve the entire epidermis and part of the dermis. They are further classified into superficial partial-thickness or deep partial-thickness burns depending on their depth. Superficial partial-thickness burns are wet, form blisters and blanche when pressure is applied indicating that the dermal circulation is intact 1. In contrast, deep partial-thickness burns are wet and form blisters, but do not blanche with pressure because dermal circulation has been destroyed 1. Both types are associated with severe pain, however deep partialthickness burns are also associated with significant scarring 1. Two common causes of superficial partial-thickness burns are scald and flash injuries. A scald burn is caused by contact with hot liquid and a flash burn is the result of quick exposure to a burning gas 2. A common cause of deep partial-thickness burns is a flame injury, which results after clothes catch on fire due to exposure to house fires or a barbecue 2. Contact burns are also very common and can result in either superficial or deep burns depending on the exposure time. Contact burns are usually superficial, however, prolonged contact can result in devastating third-degree burns 2. A third-degree burn is characterized by a complete loss of the epidermis and dermis. They appear white, thick brown or tan and have a leathery texture 1. They are less painful than second degree burns because of the extensive

7 damage to the nerves. These are also associated with significant scarring. To minimize the occurrence of wound conversion, any burn that is difficult to distinguish between seconddegree and third-degree should be treated as the former until correct classification can be determined. Fourth-degree burns are life-threatening burns that extend through the dermis to underlying tissue such as muscle, fascia or bones 5. These occur less frequently, but are usually associated with electrical injuries. Electrical burns cause extensive damage and early exploratory surgery is often necessary to uncover the true extent of this damage. Consequently, these burns should always be referred to a burn center. For the remainder of this article, focus will be on the outpatient treatment of first-degree and superficial seconddegree burns, excluding chemical or electrical burns. Total body surface area estimates Once depth is determined, it is important to carefully note the extent of the burn. On average, burns are over-estimated by up to 100% by referring practitioners 1. Accurate estimation is accomplished by following the Lund-Browder chart or the Rule of Nines. The Lund-Browder chart is the most accurate way to determine TBSA because it takes into account growth and age of the patient 5. A second, more widely known method is the Rule of Nines, which assigns eighteen percent each to the anterior trunk and posterior trunk, nine percent to each extremity, nine percent to the head and one percent to the genitals. 5,6 The comparable Rule of Nines for children and adults is listed in chart 1.

8 A useful, although less accurate, way to measure irregular or non-concurrent burn surface area is by assuming the patient s hand accounts for 1% TBSA 6. It is important to note that, according to the American Burn Association, a minor burn is a first or second-degree burn involving less than 5% TBSA 3. However, this does not include burns involving the face, ears, eyes, perineum or joints. Criteria for minor burns also exclude patients with significant co-morbidities such as renal failure or diabetes 1. Of special note are circumferential burns, these may cut of blood supply to an extremity and thus necessitate special care. Burns that are greater than 5% TBSA and fit the above description should always be referred to an emergency room or burn center. Minor burns, however, can be managed in an outpatient setting. III. Management of Burn Patients Selection for Outpatient Care: The estimate of 1 million burn injuries per year with 45,000 hospitalizations due to burns indicates that most of burns are minor. The American Burn Association (ABA) defines minor burns as second-degree burns affecting less than 10% TBSA in persons years old or second-degree burns affecting less than 5% TBSA in children under 10 and adults over 50 years old 3,5,6,7. Partial thickness burns are considered minor and can be successfully treated with outpatient management 1,6, In general, patients selected for outpatient management should have <10% TBSA with burn depths not exceeding superficial partial thickness. There should be no associated injuries or additional medical conditions that cause decreased circulation or an increased risk for infection. For example, any patient with diabetes, renal failure, heart disease, respiratory

9 disease, vascular disease, morbid obesity, immunocompromised or chronic substance use should be referred to a burn center for management 8. Special care must also be paid to elderly patients because thinner skin may lead to deeper burns 8. The location of the burn is also important in selecting for outpatient management. Burns to the face, trunk and extremities should be carefully managed for edema and injury to the airway, breathing or circulation. In addition, burns to the perineum may cause urethral obstruction and necessitate an indwelling catheter 8. Despite these restrictions, most burns are minor and can be adequately managed in the outpatient setting. Initial Management of Burn Wounds The most important first step in the management of burn wounds is cooling the burn 1. Cooling the burns with cool tap water for 10 minutes has been shown to decrease pain, the depth and extent of the burn, scarring, the need for surgical intervention and mortality 1,5. However, utilizing ice or ice water can lead to increase tissue injury, thus their use should be avoided 1. A second important step is managing blisters. They occur when the epidermis separates from the dermis during the inflammatory stage of a burn injury 9. A study of 14 human volunteers in which partial thickness burns were created showed that blisters left intact healed faster than blisters that were de-roofed 10. Several studies have shown that by creating a moist environment wounds heal faster, thus leaving blisters intact creates this environment naturally. This idea was further supported by a study in 1994 that discovered Calmodulin, a protein in burn fluid that acts as a growth factor for keratinocytes and is therefore beneficial for healing 9. Thus, it is suggested to keep small blisters intact unless signs of infection

10 develop. However, if shearing forces are likely to be an issue, such as blisters over a joint, it is better aspirate the fluid using a needle but leave the blister intact 9. If the blisters have not reabsorbed after 72 hours then they can be debrided using aseptic technique 9. Dressing Options for Outpatient Management Most superficial burns heal well under any dressing, however some have been proven more efficacious for antimicrobial properties, minimized pain and cost. For first-degree burns aloe vera has been proven efficacious because it stimulates cooling and collagen production 11. Collagen is the main component of the extracellular matrix that provides strength and integrity to the dermis 11. One study compared aloe vera cream to silver sulphadiazine (SSD) in the treatment of second-degree burns and found that aloe vera had faster healing times, 16 days in comparison to 19 days with SSD (P < ) 11. However, aloe vera has fewer antimicrobial properties than SSD, which is why silver dressings have been the standard of care for many decades 12. Second-degree burns are one of the most frequently occurring injuries and those involving mixed depths are probably the most common 13. Managing these burns and preventing wound conversion is consequently more difficult, thus its suggested to utilize a dressing that has strong antimicrobial properties along with fast healing times. SSD is an older silver dressing that is effective in preventing infection but is quickly inactivated by the wound environment, thus requires dressing changes twice daily 12. Frequent dressing changes have been associated with delayed healing times, increased pain and increased cost 12. In a study performed by Lee and Moon, SSD was found to significantly decrease breaking strength of skin (P < 0.004) and was found to inhibit the regeneration of fibroblasts and

11 collagen, consequently impairing healing 14. These negative effects have stimulated the production of newer silver dressings such as Aquacel Ag and Acticoat. Aquacel Ag has sodium carboxymethyl-cellulose impregnanted into absorbant hydrofibers that form a gel once placed onto a burn wound, stimulating a moist healing environment 13. The dressing is made to vertically wick bacteria from the wound and continuously release silver into the wound for up to 14 days 13. Aquacel Ag has a broad range of antimicrobial activity that includes Methicillin Resistant Staphylococcus aureus, Vancomycin Resistant Enterococcus, Pseudomonas aeruginosa, Enterobacter, Escherichia coli, Serratia marcesceus and Candida albicans 13. This same trial showed a significant decrease in pain with dressing changes and found that 82% of care providers said the dressing was easy to apply. Perhaps the most important benefit to Aquacel Ag is that the dressing loses adherence if infection occurs or if the wound undergoes secondary deepening 13, thus making it a very good option for difficult to assess burns. During a prospective, randomized controlled trial comparing SSD to Aquacel Ag time-towound closure was significantly shorter in the Aquacel Ag group with a mean of 10 days versus a mean of 13 days (P < 0.002) 15. In addition, pain score at day 1 was 4.1 in the Aquacel Ag group in comparison to 6.1 in the SSD group (P < 0.002) and total cost of treatment was $52 $29 for the Aquacel Ag group versus $93 $36 for the SSD group 15. Both the lower pain score and lower cost is due to a decreased frequency of dressing changes with Aquacel Ag. Acticoat contains nancrystalline silver which continues to release silver ions into the burn wound when moistened with water 20. Acticoat has antimicrobial activity against gram

12 positive, gram negative, Vancomycin Resistant enterococci, and Methicillin Resistant Staphylococcus aureus 20. In a meta-analysis comparing Acticoat to SSD, patients in the later group had a significantly lower rate of infections, (P < 0.001) and a significant reduction in pain in the Acticoat group (P < ). In addition, the average cost was $946 per patient for the Acticoat group and $1533 per patient for the SSD group 12. Outpatient Management Techniques The major components of outpatient management include teaching proper wound inspection, cleansing and dressing techniques, pain control, clearly defined follow-up visits, and long-term follow-up for scar management 6. Teaching proper wound inspection includes a thorough description of each type of burn and includes how to watch for wound conversion from a superficial partial thickness burn to a deep partial thickness burn. This is important because early surgical intervention of a deep partial thickness burn will result in proper healing with less scarring 5. Wound cleansing is done with lukewarm tap water and a bland soap 6. The burn should be gently cleaned with a clean washcloth or gauze and inspected for signs of infection such as erythema, swelling, increased tenderness, lymphangitis (red streaks extending from wound to armpit, elbow or groin), odor or drainage 6. Prior to dressing changes mild pain should be controlled with non-steroidal antiinflammatory or acetaminophen and moderate pain should be controlled with oral narcotics 1. If dressings are adherent to the burn they should be soaked in water until they are easily removed. Once the burn is properly cleaned and inspected, the dressing should be placed as

13 per the manufacturers instructions. If dressings are meant to be placed for 5-7 days then these should be wrapped in gauze that is changed daily, otherwise a full dressing change should occur daily. In addition, documentation of all teaching should be included in patient s chart 6. Follow-up visits should occur at least twice weekly and daily if the burn is a superficial second-degree burn to watch for wound conversion 6. During the visits wounds should be cleaned and re-evaluated. Wound care instructions should also be reviewed with the patient or patient s caregivers 6. Most superficial burns should heal within two weeks and thus should be reevaluated for surgical intervention if they are not healed within this time 1, 5,6. IV. Complications of Burn Wounds Complications of superficial burns include infection, cellulitis, invasive wound sepsis and hypertrophic scarring. Signs and symptoms of infection include redness, swelling, increased tenderness, lymphangitis, odor or drainage. Cellulitis should be considered if a burn wound presents with increasing redness, pain and swelling in the uninjured skin around the burn 6. Invasive wound sepsis is from rapid proliferation of bacteria in burn eschar that infects underlying viable tissue 6. This will present with odor, drainage and a change in color of the wound 6. Both cellulitis and wound sepsis can be accompanied by fever and systemic toxicity 6. Hypertrophic scarring occurs more frequently with deeper burns, however must still be watched for with superficial burns. They present with raised lesions that are very inflamed, painful and pruritic 5. The change to hypertrophic scarring is somewhat linked to the time of reepithelization, thus it is an important consideration when choosing dressings because decreased time to healing may indirectly reduce hypertrophic scarring 5.

14 V. Conclusions In conclusion, a vast majority of burns are superficial and thus can be managed in an outpatient setting. It is important to obtain the skills to accurately diagnose burn depth and extent so patients are not transferred to burn centers when it is unnecessary to do so. Proper referral to burn centers has become especially important as the United States becomes increasingly focused on pay-for performance initiative. 16 By utilizing new silver dressings, complications of small burns can be minimized and successful outpatient management can occur. It is important to thoroughly teach patients and care providers how to adequately manage burn wounds and this should be documented in the patient s chart. Patients should be seen regularly for two weeks and if at this time the wound has not healed then they should be referred to a burn center for a surgical consult. This article has attempted to outline the basic guidelines for outpatient management of superficial burns. By following these guidelines, successful outpatient management can occur and an area of excessive healthcare costs can be minimized.

15 References 1. Singer AJ, Brebbia J, Soroff HH. Management of local burn wounds in the ED. American Journal of Emergency Medicine. 2007; 25: Kastenmeier A, Farakas I, Cochran A, et al. The Evolution of Resource Utilization in Regional Burn Centers. Journal of Burn Care and Research. 2010; 31(1): Hettiaratchy S, Dziewulski P. ABCs of Burns: Pathophysiology and types of burns. Burn Medical Journal. 2004; 328: Doherty GM. Current Medical Diagnosis and Treatment, Surgery. 13 th ed. Ann Arbor, MI. The McGraw-Hill Companies, Electronic. 5. Hermans MHE. A general overview of burn care. International Wound Journal. 2005; 2(3): Sheridan R. Outpatient Burn Care in the Emergency Department. Pediatric Emergency Care. 2005; 21(7): Carter JE, Neff LP, Hokmes JH. Adherence to Burn Center Referral Criteria: Are Patient s Appropriately Being Referred? Journal of Burn Care & Research. 2010; 31: Moss LS. Outpatient management of the burn patient. Critical Care Nursing Clinics of North America. 2004; 16: dukamp A. Deroofing minor burn blisters- what s the evidence? Accident and Emergency Nursing. 2001; 9: Gimbel NS, Kapetansky DI, Weissman F, Pinkus HKB. A study of epithelization in blistered burns. AMA Arch Surg. 1957; 74(5):

16 11. Khorasani G, Hosseinimehr SJ, Azadmakht M et al. Aloe versus Silver Sulfaciazine Creams for Second-Degree Burns: a Randomized Controlled Study. Surgery Today. 2009; 39: Gravante G, Caruso R, Sorge R, et al. Nanocrystalline Silver: A Systematic Review of Randomized Trials Conducted on Burn Patients and an Evidence-Based Assessment of Potential Advantages Over Older Silver Formulations. Annals of Plastic Surgery. 2009; 63(2): Caruso DM, Foster KN, Hermans MHE, et al. Aquacel Ag in the Management of Partial Thickness Burns: Results of a Clinical Trial. Journal of Burn Care Rehabilitation. 2004; 25: Cho Lee AR, Moon HK. Effect of Topically Applied Silver Sulfadiazine on Fibroblast Cell Proliferation and Biomechanical Properties of the Wound. Archibes of Pharmacal Research. 2003; 26(10): Muangman P, Pundee C, Opasanon S, et al. A prospective, randomized trial of silver containing hydrofiber dressing versus 1% silver sulfadiazine for the treatment of partial thickness burns. International Wound Journal. 2010; 7: Carter JE, Neff LP, Holmes JH. Adherence to Burn Center Referral Criteria: Are Patients Appropriately Being Referred? Journal of Burn Care Research. 2010; 31:

17 Table 1: American Burn Association Transfer Criteria 1. Partial thickness burns > 10% TBSA 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints 3. Third and fourth degree burns 4. Electrical burns (including lightening) 5. Inhalation injury 6. Chemical burns 7. Burn injury in patients with preexisting medical conditions that could complicate management, prolong recovery or affect mortality 8. Burn patients with concomitant trauma in which the burn poses the greatest risk of morbidity or mortality. If trauma poses the greatest risk, then stabilize first. 9. Hospitals/Clinics without qualified equipment and personnel for the care of children 10. Burn patients who require special social, emotional, or rehabilitative intervention Chart 1: Child TBSA Adult TBSA Head 18% 9% Upper extremity 10% 9% Anterior Trunk 16% 18% Posterior Trunk 16% 18% Lower Extremity 14% 18% Genitals 1% 1%

18 Table 2: Selection Criteria for Outpatient Management 6 1. No airway compromise or inhalation injury 2. TBSA <10% so IV fluid resuscitation is not necessary 3. Patient must be able to take in adequate fluids by mouth 4. No burns to the face, ears, hands, genitals or feet 5. Patient must have resources to support outpatient management 6. Family member or visiting nurse must be able to adequately perform wound cleansing, inspection and dressing changes 7. Patient must have reliable transportation to and from clinic to maintain follow-up visits 8. Any suspicion of abuse must be admitted 9. If wound conversion occurs then prompt admission should be able to occur 10. Patient does not fulfill ABA transfer criteria

19 References 1. Singer AJ, Brebbia J, Soroff HH. Management of local burn wounds in the ED. American Journal of Emergency Medicine. 2007; 25: Kastenmeier A, Farakas I, Cochran A, et al. The Evolution of Resource Utilization in Regional Burn Centers. Journal of Burn Care and Research. 2010; 31(1): Hettiaratchy S, Dziewulski P. ABCs of Burns: Pathophysiology and types of burns. Burn Medical Journal. 2004; 328: Doherty GM. Current Medical Diagnosis and Treatment, Surgery. 13 th ed. Ann Arbor, MI. The McGraw-Hill Companies, Electronic. 5. Hermans MHE. A general overview of burn care. International Wound Journal. 2005; 2(3): Sheridan R. Outpatient Burn Care in the Emergency Department. Pediatric Emergency Care. 2005; 21(7): Carter JE, Neff LP, Hokmes JH. Adherence to Burn Center Referral Criteria: Are Patient s Appropriately Being Referred? Journal of Burn Care & Research. 2010; 31: Moss LS. Outpatient management of the burn patient. Critical Care Nursing Clinics of North America. 2004; 16: dukamp A. Deroofing minor burn blisters- what s the evidence? Accident and Emergency Nursing. 2001; 9: Gimbel NS, Kapetansky DI, Weissman F, Pinkus HKB. A study of epithelization in blistered burns. AMA Arch Surg. 1957; 74(5):

20 11. Khorasani G, Hosseinimehr SJ, Azadmakht M et al. Aloe versus Silver Sulfaciazine Creams for Second-Degree Burns: a Randomized Controlled Study. Surgery Today. 2009; 39: Gravante G, Caruso R, Sorge R, et al. Nanocrystalline Silver: A Systematic Review of Randomized Trials Conducted on Burn Patients and an Evidence-Based Assessment of Potential Advantages Over Older Silver Formulations. Annals of Plastic Surgery. 2009; 63(2): Caruso DM, Foster KN, Hermans MHE, et al. Aquacel Ag in the Management of Partial Thickness Burns: Results of a Clinical Trial. Journal of Burn Care Rehabilitation. 2004; 25: Cho Lee AR, Moon HK. Effect of Topically Applied Silver Sulfadiazine on Fibroblast Cell Proliferation and Biomechanical Properties of the Wound. Archibes of Pharmacal Research. 2003; 26(10): Muangman P, Pundee C, Opasanon S, et al. A prospective, randomized trial of silver containing hydrofiber dressing versus 1% silver sulfadiazine for the treatment of partial thickness burns. International Wound Journal. 2010; 7: Carter JE, Neff LP, Holmes JH. Adherence to Burn Center Referral Criteria: Are Patients Appropriately Being Referred? Journal of Burn Care Research. 2010; 31: