Burn wounds: The degree determines the protocol
May 1, 1999 4 minutes read
Burn wounds: The degree determines the protocol
Determining extent of burn wound isn’t always easy
Knowing the degree of a burn wound is essential for correct wound treatment, but sometimes there are different degrees of burning within the same wound. Mastering the burn degree descriptions will help wound caregivers recognize a mixed-degree burn.
Steven E. Wolf, MD, assistant professor in the department of surgery at the University of Texas Medical Branch in Galveston and staff surgeon at Shriners’ Burns Hospital, describes a first-degree burn as a sunburn, limited to the epidermis, that will blanch when the skin is pressed. "It’s painful, but the epithelium will not denude and the burn is not at risk for infection. First-degree burns can be treated with topical salves, with or without aloe vera, and with a non steroidal anti-inflammatory drug such as ibuprofen.
"Second-degree burns by definition include the epidermis and some degree of the dermis," Wolf says, "and both can be called dermal burns." There are two types of second-degree burns: superficial, which involves only the top of the dermis, and deep second-degree, or full-thickness burns. Clinically, the latter present with blistering and wounds that are wet and very painful. Usually these will heal in seven to 10 days; they are at risk of infection and should be treated with topical antimicrobials such as Silvadene. According to Wolf, deep second-degree burns are still sensate; however, they have an eschar and need to be debrided and treated with topical antimicrobials. Most also require excision and grafting. Partially because they have some keratinocytes remaining in the hair follicles, deep second-degree burns can heal within two to four weeks.
Burn degrees influenced by age
Because skin becomes thinner as people age, the degree of heat that would create a superficial second-degree burn in a young adult can easily cause a deep second- or even a third-degree burn in an elderly person. Also, as Shannon Nelson, RN, of the Grossman Burn Center at Sherman Oaks (CA) Hospital observes, patients often experience mixed degrees of burning. "A first-degree burn with a little bit of second can easily become infected," she says, "and patients often pick at burn wounds, which creates secondary infections."
Third-degree burns extend through both the dermis and epidermis. Most if not all of these will require excision and grafting. According to Nelson, there are three kinds of grafts: xenograft (pigskin), which is widely used in burn centers; homograft, which is cadaver tissue; and autograft, which uses the patient’s own unburned skin. "Later, when the patient has healed sufficiently to have a tissue bed, grafts such as neonatal foreskin, Dermagraft TC, and Integra can be used," Nelson says. She prefers Integra, especially in fasciotomies, in which flaying the skin open all the way to muscle leaves a crater. "My experience is that Integra seems to fill this better than other products."
Patients often don’t realize the seriousness of third-degree burn wounds because there is no pain. Nelson says, "No pain is the one thing you don’t ever want to hear, because if the wound isn’t hurting, the nerve endings have been destroyed. We had a patient with a tar burn who was transferred to our burn unit from another hospital where personnel wanted to give him medication for pain. He was walking around with third-degree burns on his hands and face, saying, Don’t bother, it doesn’t hurt.’ They didn’t understand that tar comes out of the pot at 550 degrees [F]. They were treating it with topical cleansing. Since the patient said he wasn’t having any pain, they figured he was OK and that in a couple of days he’d be healed and go home."
Francis V. Winski, MD, assistant professor of surgery at New York Medical College in Valhalla and attending staff member of the university’s burn center, notes that while burn care unit physicians can see 300 to 400 patients per year, other physicians may not see that many during their entire careers. "We see a large number of patients at the office who really don’t end up requiring admission to the burn center because they were seen and treated by someone with sufficient experience in burn injuries."
Winski says he likes to start all burn wounds with Silvadene dressing, which is usually well-tolerated and easy to apply. "I know a lot of people make a big deal about how to do it," Winski says, "but it just takes a lot of common sense. When you’re going to do your dressing, get everything that you’re going to need. Then, wash your hands thoroughly, remove the dressing, and wash the burned area with soap and water on a sterile gauze pad. In the burn center, everybody will put on sterile gloves and gowns so there’s no cross-contamination. If you’re caring for someone in their home, either clean gloves or sterile gloves would be fine. Gently wash and dry the area, then apply the dressing. If the burn area is small, it doesn’t necessarily need to be a sterile environment, it just needs to be a clean environment." Winski warns against using, or allowing anyone else to use, a gel pack dressing. Though paramedics are often instructed to use gel packs, "all they [gel packs] do is make a mess out of things," Winski says. "They make it very hard to get the wound cleaned."
Wolf also uses Silvadene, which does not have a protein as its active molecule. He notes that the problem to date with effectively using topically delivered growth factors on burn wounds is that there are so many protease enzymes active on a burn wound site that the growth factor isn’t there long enough to work well. "Growth factors are dependent upon binding to a receptor and causing the cells there to do something," he says, "and a lot of times the delivery system is inadequate." Regarding the use of pressure garments for burn injuries, Wolf notes that "some studies have shown pressure garments have benefit in reducing or improving the appearance and functionality of scars; other studies have shown no benefit. The jury’s really still out."
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