eMedicine Specialties > Emergency Medicine > Environmental
Burns, Thermal: Follow-up
Updated: Oct 29, 2008
Follow-up
Further Outpatient Care
- Many children may qualify for outpatient treatment for their burns. Although no official guidelines exist, many studies have shown that, if the patient does not meet the criteria for inpatient admission and does meet the below criteria, then they may be treated on an outpatient basis.8,11,12
- There must be no question of airway compromise or inhalational injury.
- Wound must be less than 10% of body surface area so that fluid resuscitation is unnecessary.
- Child must be able to take in adequate fluid by mouth to make up for losses.
- Serious burns of the face, ears, hands, genitals, or feet or those with circumferential burns should generally be admitted. Superficial burns on the hands may be treated as outpatients if the patient has good follow-up care.
- The family must have the resources to support an outpatient care plan.
- An adult caregiver should be able to stay with a child who may not be able to attend day care or school.
- A family member or visiting nurse must be able to properly perform wound cleansing, inspection, and dressing changes.
- Family must have transportation to clinic and emergency visits.
- Any suspicion of abuse precludes outpatient care.
- If surgery for a full-thickness wound will be needed, prompt admission is generally indicated.
- Patients discharged should be followed up the following day, preferably with a burn specialist, to access the adequacy of the dressing changes and pain management.
- Patients and their families will need guidelines and conditions that mandate return. These can be as simple as anxiety over dressing changes for the parents to signs and symptoms of infection such as cellulitis or sepsis.
- If patients are being treated as outpatients and wound epithelialization has not begun after 2 weeks or if subsequent evaluations reveal a full-thickness burn greater than 2 cm, then the patient should be referred to a burn surgeon.8
Transfer
- The American Burn Association has established the following criteria for referring patients to a burn center:
- Any partial-thickness burn greater than 20% TBSA in a patient of any age or greater than 10% TBSA in children younger than 10 years or adults older than 50 years
- Third-degree burns covering over 5% TBSA
- Second-degree or third-degree burns involving critical areas (eg, hands, feet, face, perineum, genitalia, major joints)
- Burns with associated inhalation injury
- Electrical or lightning burns
- Severe burns complicated by coexisting trauma: If traumatic injuries pose a higher risk to the patient than the burn injuries, the patient may need to be sent first to a trauma center.
- Preexisting disease that could complicate management of the burn injury
- Chemical burns with threat of cosmetic or functional compromise
- Circumferential burns on the extremities or the chest
- Children with severe burns (These patients should be sent to a facility that has personnel and equipment to care for children with burns.)
- Children may be transferred between burn centers if the one they were originally brought to are not qualified or do not have the equipment for the care of children.
- Any cases where abuse may be suspected as the cause of the burn or if the patient may require long-term rehabilitative support
- Prior to transfer, referring physician needs to accomplish the following:
- Respiratory support
- If the patient is at risk for airway compromise or deterioration, perform intubation prior to transfer.
- Support with 100% oxygen.
- Stabilize circulatory status by fluid resuscitation.
- Administer Ringer solution at the rate indicated by the Parkland formula or at that rate adjusted for clinical status (eg, urine output).
- Ensure adequate vascular access for fluid resuscitation and administration of analgesics, if necessary.
- Give transporting personnel orders defining rate and amount of analgesics that can be administered during transport.
- Respiratory support
- Care of the burn wound
- Cover patients being transferred with a dry sheet.
- Transport crews should exercise care to prevent the patient from becoming hypothermic.
- Use of saline-soaked dressings increases risk of hypothermia.
- Application of antimicrobial creams may delay transfer, and these agents must be removed once the patient arrives at the burn center.
- Physician-to-physician contact prior to transfer is essential. The accepting physician at the burn center can provide advice in caring for the burn patient and often can assist in arranging transfer. Documentation of what already has been performed for the patient and of any findings should accompany the patient to the burn center.
Complications
Complications of burns include the following:
- Scarring
- Cosmetic deformity
- Burn wound sepsis
- Acute respiratory distress syndrome (ARDS)
- Sepsis
- Death
- Contractures (especially in children, as the scar tissue cannot expand to keep pace with the growth of the child)
Prognosis
- The prognosis varies from excellent to poor depending on the severity of the burn.
Patient Education
- Prevention is the best tool in the management of burn injuries. Campaigns stressing the use of smoke detectors and the adoption of laws mandating their use have decreased the mortality rate from burns significantly in North America. Additional materials useful for teaching burn prevention may be obtained from the American Burn Association.
- The development of flame retardant sleepwear and the famous program "Stop, Drop, and Roll" have prevented numerous fire-related injuries.
- Parents should create specific escape plans, discuss and practice them with their children in case quick escape from house emergencies is necessary.
- Children should not be allowed to play with lighters or fireworks.
- EPs should work with their local fire service to develop burn prevention programs as part of the fire service's fire prevention strategies.
- Discussions with patients who have sustained burn injuries should attempt to determine how the injury was sustained and what steps can be taken to prevent recurrence. As part of discussions with parents regarding risks in the home, EPs should ask parents if the water heater is set to 49°C (120°F). If parents do not know, encourage them to find out and have it adjusted if necessary. Simple interventions like this can have significant impact upon the lives of many.
- For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education articles Thermal (Heat or Fire) Burns and Sunburn.
Miscellaneous
Medicolegal Pitfalls
- Failure to consider abuse as the cause of burns in children
- Failure to recognize potential for airway involvement, even when classic signs of airway burns are absent
- Signs of toxic inhalation may not be apparent for several hours after exposure, and the patient may deteriorate very rapidly.
- Failure to involve burn specialists in the care of burns, including minor ones that involve critical areas (eg, hand, face, feet, genitalia)
- Development of scars in these areas can have significant cosmetic and functional consequences.
Special Concerns
- Take a proactive approach in the community by discussing burn injury and burn prevention with organizations such as local media, school officials, and adult care center.
- Take the opportunity to remind the community about the dangers of fireworks, malfunctioning smoke detectors, and home water heater temperature (must be set below 120°F).
The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Jerome FX Naradzay, MD, and Roy Alson, MD, PhD, to the development and writing of this article.
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Further Reading
Keywords
burns, thermal burns, thermal injury, heat burn, scalds, burn injury, burn treatment, contact burns, firework burns, fire deaths
