Burn treatment protocol starts with six C's.
The six C's of burn care include clothing, cooling, cleaning, chemoprophylaxis, covering, and comforting, said Ms. Mendez-Eastman, a wound care nurse at Nebraska Medical Center in Omaha. Once the wound has been fully assessed and the ABCs--airway, breathing, and circulation--are stabilized, start with the first C: clothing.
* Clothing. Any clothing that is hot or burned should be removed right away. If the clothing does not remove easily, however, any nonadhering pieces should be cut away.
* Cooling. To cool the burn, use a saline-moistened gauze--never use ice. Think about the possibility of hyperthermia for patients that present with a total body surface area burn greater than 10%.
* Cleaning. "Cleaning a burn wound is critical, but it can cause excruciating pain," Ms. Mendez-Eastman said. Topical anesthesia should not be applied directly to the burn's surface because of the different vascular effects it may have. But the patient can be treated systemically for pain.
Ms. Mendez-Eastman said that in cleaning burn wounds, she and her colleagues typically use products such as Hibiclens and Betadine. "But, quite frankly, an antibacterial soap such as Dial soap and tap water work very well and are less expensive," she said. Just be sure to rinse the burn very thoroughly after cleansing. Any ruptured blisters should be removed. Don't attempt to aspirate intact blisters because this may introduce bacteria.
* Chemoprophylaxis. Chemoprophylaxis should include a tetanus immunization or update for patients with burns deeper than a superficial partial-thickness burn. Superficial burns don't necessarily require infection prophylaxis, but all other burns should get topical infection measures.
At Nebraska Medical Center, patients often are treated topically with silver sulfadiazine cream. Sulfamylon can also be used, though not on the face because of pigmentation changes; nor should it be used in pregnant women, nursing mothers, or newborns. Bacitracin is an inexpensive antimicrobial agent that can be used as an alternative to silver dressings and creams.
* Covering. Covering of burns serves a number of purposes. Covering can provide some anesthetic relief, provide some barrier against infection, and absorb drainage, Ms. Mendez-Eastman said.
Initially, all partial- and full-thickness burns should be covered with a sterile dressing, following a thin layer of topical antibiotic. Try not to wrap the burn circumferentially; the inflammatory process and edema can create a strangulation effect. Instead, try a tubular net bandage.
Burn dressings fall into several categories: absorbent; nonadherent; occlusive/semiocclusive; and adherent (temporary skin substitutes, such as Biobrane).
Absorbent dressings wick wound exudates away from the wound surface. The accumulation of wound fluid can delay healing. Acute and infected wounds generally drain more than chronic wounds. Nonadherent dressings are designed not to stick to the wound. These dressings may incorporate petrolatum or have a silicone (or other synthetic material) layer. There are a variety of petrolatum-impregnated gauzes, such as Xeroform, that can be used for minimal depth burns.
In most cases, occlusive or semiocclusive dressings protect the burn from the outer environment but still allow airflow. This is an important factor when anaerobic contamination may be present in the wound. Adherent dressings are used to close the wound, adhering to the wound bed in a way that acts as an artificial skin. Adherents decrease drainage but still maintain a moist healing environment. However, it is important that the wound is clean of eschar or devitalized tissue. Firm adhesion is crucial. Biologic dressings, such as pigskin or human allograft, can be used for deeper burns.
* Comforting. In comforting patients, always consider their pain, she advised. Burns and the treatment of burns can be very painful. Avoid aspirin-based products because of their platelet inhibition and the risk of bleeding. Give pain medications before dressing changes and as patients increase their physical activity.
RELATED ARTICLE: Classification Key In Burn Care
Burn treatment relies on first fully assessing and correctly classifying the wound, Ms. Mendez-Eastman said.
Burn classification is largely based on the degree of tissue damage. Superficial burns are commonly referred to as first degree. These burns can appear pink or red and are dry. "There is generally not an opening in the outer layer of the skin," she said. Swelling can occur as well.
In the United States, partial-thickness burns--where the dermis is not entirely destroyed--are split into two classifications. On assessment, blisters are very common with superficial partial-thickness burns, but in many cases the blisters have popped by the time patients present. With deep partial-thickness burns (also known as second degree), the epidermis and most of the dermis are destroyed; some of the reticular dermis will remain. The skin may be dry or slightly moist. These burns are very painful.
Full-thickness burns include third- and fourth-degree burns. With third-degree burns, both the epidermis and dermis are completely destroyed. The skin will appear dry and leathery. The burn may be several different colors, but it will not blanch when pressed. The area that has been destroyed by the burn is insensate to touch.
"That doesn't mean the area will not be painful. The surrounding area--due to inflammation--is likely going to be painful," she said. Fourth-degree burns involve damage to subcutaneous fat, muscle, or bone and have a very charred appearance.
It can be difficult to tell the difference between a partial-thickness and full-thickness burn on inspection. A measurement of the depth of damage is not necessarily useful. "You have to look at the area that has been destroyed by the burn," she said.
Burns consist of several zones. In the zone of coagulation, the tissue is dead. In the zone of stasis, the choice of treatment can influence the outcome for the tissue in this area. In general, tissue within the zone of hyperemia will heal regardless, she said.
BY KERRI WACHTER