Part III: Initial management of the minor wound

Continuing our discussion on burn management, here is a review of some controversial points in management of the acute burn wound injury.  The focus of this post is on the steps of cooling, cleansing, and blister management.  A detailed discussion of dressings for burn wounds will follow in a future post.  The management below is best suited for burns appropriate for outpatient management: that is, burns that are partial thickness involving less than 10% total body surface area.

Cooling

From the Global Evidence Mapping Initiative, Australasian Cochrane Center.

From the Global Evidence Mapping Initiative, Australasian Cochrane Center.

This is an often forgotten first step during early presentation.  It’s as simple as it sounds: just run cool running tap water over the injured area for 20 minutes. Cooling is not just anecdotally effective, it’s a class IIa recommendation from the American Heart Association.  Potential benefits of cooling include pain relief, reduced depth of injury, and even reduced need for grafting, & lower mortality. It is most effective if performed immediately, but may be of benefit even 1-3 hours after an injury.

Cleansing & Pain Management

To cleanse burn wounds, gentle irrigation with mild soap and water is adequate.  The key point to remember here is that this is probably the most painful step for the patient in initial wound evaluation.  Don’t be shy about liberal use of IV morphine in these patients.

Many adjunctive agents have been studies for burn wound care, including acetaminophen, NSAIDs, gabapentin, clonidine, benzodiazapines, IV lidocaine…but there is limited data to support these agents for acute burn pain management. Emerging evidence suggests ketamine may be a safe/effective alternaitve for burn pain management.  I’ve found low dose ketamine works great for this and other types of refractory pain management, and this is no secret among emergency physicians.

What to do with those pesky burn blisters?

Superficial partial thickness burns often form bullae and blisters within hours of injury. The optimal management of these blisters has been a topic of heated debate in the clinical and basic research burn community for decades.  This has left us in the emergency department, who manage these patients in real time, in a bit of a quandary when it comes to deciding what to do for these patients.

IMG_1680

Options for burn blister management include: (a) leaving them alone; (b) unroofing and debriding them; and (c) aspiration of the serous blister fluid while leaving the injured epidermal blister “roof” intact to act as a sort of biologic bandage.

There is no shortage of opinion from experienced emergency physicians regarding which of these options constitutes best management.  But, these opinions are generally rooted in anecdote-based and vehemence-based medicine, rather than thorough knowledge of the medical evidence.

I’ll preface by saying that I am not going to give you the right answer in this post.  That’s because, as of February 2015, there is no right answer to give.

Basic science research has looked at what is actually inside of these burn fluid blisters, and that has been the basis of most traditional recommendations regarding what to do about burn blisters. Unfortunately, the data from these studies is conflicting, revealing the presence of both pro- and anti-inflammatory mediators within the milieu.

In terms of clinical research: There is one very small study looking at burn wound healing in blistered wounds, published in the Archives of Surgery back in 1957 (so not very up to date) that seemed to show better healing if the blisters were left intact.

On a practical note, burn blister fluid may act as a “biologic” dressing, protecting the underlying wound bed and the newly forming epidermis.  The AHA’s 2010 first aid recommendation is to leave blisters intact (Class IIa, LOE B).

On the other hand, burn blister fluid can impair topical antibiotic penetration, which can be detrimental to wound healing.  And, if a blister spontaneously and only partially opens up, this can lead to a portal of entry for bacteria and a mighty tasty broth for its growth.

A burn blister potential worth debriding,

A burn blister potential worth debriding,

My personal feeling: location matters. For example, a tense bullae like this on the thenar eminence is likely to be pretty uncomfortable for the patient. This is one I would more likely aspirate/unroof simply as a comfort measure.

Burn blisters...what to do?

How long would you spend debriding these blisters, if there is no proof it helps?

In contrast: are you going to spend all shift debriding, or even aspirating, the bullae in a patient like the one pictured here, if there is no evidence it helps?  Sounds like an exercise in futility to me.  These are blisters I may be more likely to leave alone.  I might consider aspirating the largest of these blisters in the center, but probably wouldn’t take it farther than that.

Final Housekeeping Points

Make sure the patient has an up to date tetanus vaccination, as burns are considered to be tetanus-prone wounds.  Make sure any rings or jewelry.  Do this early, as rings can act like tourniquets around a digit as it swells.  Other jewelry can potentially become adherent to the wound bed so it is best to remove it early.

Aside from this, you have a wound bed that is clean and prepared for dressing. In Part IV, we’ll discuss burn wound dressings for the outpatient, minor burn wound.

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