Ambulatory Management of Burns

ERIC D. MORGAN, MAJ, MC, USA, Eisenhower Army Medical Center, Fort Gordon,
Georgia
SCOTT C. BLEDSOE, CPT, MC, USA, Weed Army Community Hospital, Fort Irwin,
California
JANE BARKER, CPT, MC, USA, Moncrief Army Community Hospital, Fort Jackson,
South Carolina
Am Fam Physician. 2000 Nov 1;62(9):2015-2026.

See related patient information handouts on taking care of burns and

preventing burns, written by the authors of this article.

Burns often happen unexpectedly and have the potential to cause death, lifelong
disfigurement and dysfunction. A critical part of burn management is assessing
the depth and extent of injury. Burns are now commonly classified as superficial,
superficial partial thickness, deep partial thickness and full thickness. A
systematic approach to burn care focuses on the six Cs: clothing, cooling,
cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief). The
American Burn Association has established criteria for determining which
patients can be managed as outpatients and which require hospital admission or
referral to a burn center. Follow-up care is important to assess patients for
infection, healing and ability to provide proper wound care. Complications of
burns include slow healing, scar formation and contracture. Early surgical referral
can often help prevent or lessen scarring and contractures. Family physicians
should be alert for psychologic problems related to long-term disability or
disfigurement from burn injuries.

Burns can be devastating injuries that result in death or lifelong scarring,

disfigurement and dysfunction. Burn injuries are the third leading cause of
accidental death in the United States (after incidents involving motor vehicles
and firearms). Each year, more than 1 million persons in this country seek
medical care for burns. More than 95 percent of these patients can be managed
on an ambulatory basis.1,2

Ambulatory management of burns is divided into acute treatment and follow-up

care. Acute management includes measures to minimize further damage to
patients presenting with recently sustained burns, identifying patients requiring

hospitalization and implementing measures to promote healing, prevent infection

and relieve pain. During follow-up care, the focus shifts to limiting disfigurement
from scarring and dysfunction from contractures. Although most patients with
burns can be managed by family physicians, some require surgical referral for
skin grafting and scar rehabilitation.

Acute Management of Burns

It is of paramount importance to determine whether a patient with a burn injury
should be hospitalized for hydration and burn care or whether ambulatory
management appears feasible. Classification of burns as minor, moderate or
major facilitates hospitalization decisions. Proper burn classification requires
accurate determination of the depth and extent of the wound(s), as well as
consideration of critical issues such as skin thickness, burn location and
comorbid conditions.

DEPTH OF A BURN
The traditional classification of burns as first, second or third degree is being
replaced by the designations of superficial (Figure 1), superficial partial thickness
(Figure 2), deep partial thickness (Figure 3) and full thickness (Figure 4).2 Burn
depth has an impact on healing time, the need for hospitalization and surgical
intervention, and the potential for scar development. Although accurate
classification is not always possible initially, the causes and physical
characteristics of burns are helpful in categorizing their depth (Table 1).24

FIGURE 1.
Superficial burns on the trunk and right arm of a young child. Typically, these are
red burns that blanch with pressure.
View Large

FIGURE 2.
Superficial partial-thickness burn on a man's right knee. Blistering wounds that
blanch with pressure are characteristic of superficial partial-thickness burns.
These wounds are also typically moist and weeping.
View Large

FIGURE 3.
Deep partial-thickness burns on the trunk and extremities of a young child. These
burns are typified by easily unroofed blisters that have a waxy appearance and
do not blanch with pressure.
View Large

FIGURE 4.
Full-thickness burn on a woman's left flank. Burn areas of this type are
characteristically insensate and waxy white or leathery gray in color.
View Large
TABLE 1 Classification of Burns Based on Depth
View Table
Differentiating a deep partial-thickness burn from a full-thickness burn can be
quite difficult initially.2,5,6 Revisions of burn-depth estimations are often
necessary in the first 24 to 72 hours5 and may be required through the first two
or three weeks.2 For instance, although a full-thickness burn typically has a white
or charred appearance, it can be red after a scald injury. It is also possible to
have a full-thickness burn underneath a blister, which is usually a characteristic
feature of a partial-thickness burn.3 Furthermore, thin skin sustains deeper burn
injuries than may be suggested by the initial appearance of the wound.5 Thin
skin is common on the volar surface of the arms and on the medial thigh,
perineum and ears. All skin can be presumed to be thin in children younger than
five years and in adults older than 55 years.5 It is best to assume that there are
no shallow burns in these age groups.7

EXTENT OF A BURN
The extent of a burn is expressed as the total percentage of body surface area
(TBSA) affected by the injury. Accurate estimation of the TBSA of a burn is
essential to guide management.

Multiple methods have been developed to estimate the TBSA of burns. These
methods are not used for superficial burns. The best known method, the rule of
nines, is appropriate for use in all adults and when a quick assessment is
needed for a child.2

More accurate methods are required for definitive estimation of the extent of
burns in children. The Lund and Browder method covers all age groups and is
considered the most accurate method to use in pediatric patients (Figure 5).2,8

Chart for Estimating Area of Burns

FIGURE 5.
Modified Lund and Browder chart for estimating the area of burns. This approach
is considered the most accurate for use in pediatric patients. The figures can be
colored in with red for full-thickness burns and blue for partial-thickness burns.
(2nd = second-degree burn; 3rd = third-degree burn; TBSA = total percentage of
body surface area)
Adapted with permission from Mertens DM, Jenkins ME, Warden GD. Outpatient
burn management. Nurs Clin North Am 1997;32:34364, and Lund C, Browder N.
The estimation of areas of burns. Surg Gynecol Obstet 1944;79:3528.
View Large
The surface area of a patient's palm can also be used to estimate the extent of
small or patchy burns. Classically, the palm has been considered to represent 1
percent of the TBSA.2,6 However, a recent study demonstrated that the palm
more accurately represents 0.4 percent of the TBSA, and the entire hand
represents 0.8 percent of the TBSA.9

INPATIENT TREATMENT AND BURN UNIT REFERRAL

Patients considered to have moderate burns based on the grading system
developed by the American Burn Association (ABA) should be admitted for
intravenous hydration and surgical care of their wounds (Table 2).6,10 Because
of the initial difficulties in differentiating deep partial-thickness burns from fullthickness burns, family physicians should strongly consider obtaining a surgical
consultation for what appears to be a deep partial-thickness burn affecting more
than 3 percent TBSA.4

TABLE 2 American Burn Association's Grading System for Burn Severity and
Disposition of Patients
View Table
Pulmonary insufficiency is responsible for more than 75 percent of fire-related
deaths.1 Because of the possibility of progressive edema, patients with
suspected inhalation injury should be observed for at least 12 to 24 hours.6,11

Historical or physical findings that raise concern about inhalation injury include
coughing, wheezing, dyspnea, facial burns, sooty mucus and laryngeal edema.4

Fiberoptic bronchoscopy or xenon ventilation-perfusion scanning results in more

frequent and earlier diagnosis of inhalation injury.12 One of these examinations
should be performed if the diagnosis of inhalation injury is in doubt.11

Patients at risk for inhalation injury should also be checked for carbon monoxide
poisoning. An arterial carboxyhemoglobin level of greater than 10 percent tends
to indicate carbon monoxide exposure. Hyperbaric oxygen is the treatment.13

Hospital admission is necessary for patients who have circumferential partialthickness or full-thickness burns, patients who have burn injury and are
considered to be predisposed to infection (e.g., those with diabetes), and
patients who have sustained a high-voltage electrical injury.14 Cardiac
arrhythmias can occur up to 72 hours after high-voltage electrical injury.15
Nonspecific changes in ST-T waves are the most common abnormalities noted on
electrocardiograms (ECGs) obtained subsequent to electrical injuries.
Observation is warranted until the ECG becomes normal.6

Children with burns should be admitted to a hospital whenever child abuse is

suspected. From 9 to 11 percent of burns in children are nonaccidental injuries,
with a peak incidence at 13 to 24 months of age.16 Immersion scalds are classic
burn injuries in child abuse, but abuse should be suspected with any scald injury,
especially if there is sharp demarcation between burned and normal skin or
splash marks are absent.6 Child abuse should also be strongly suspected in
children with burns suggestive of cigarette or hot-iron injuries.6

Referral to a burn unit is indicated for patients who meet the criteria for major
burns as defined by the ABA (Table 2).6,10 Included are patients who manifest
inhalation injury or have burn marks from high-voltage electrical injury.14

AMBULATORY TREATMENT
Minor burns comprise approximately 95 percent of burn injuries treated by
physicians in the United States.2 Most of these burns can be managed on an
outpatient basis. An algorithm to assist in identifying patients suitable for
ambulatory management is provided in Figure 6.4

Management of Burns

Figure 6.
Algorithm for the management of patients with burns.
Adapted from Peate WF. Outpatient management of burns. Am Fam Physician
1992;45:1326.
View Large
A systematic approach to the ambulatory management of burns is
conceptualized by the six Cs: clothing, cooling, cleaning, chemoprophylaxis,
covering and comforting (i.e., pain relief).4

Clothing. Any clothing that is hot or burned should be removed immediately from
the patient's body. Clothing that has been exposed to chemicals should also be
removed to avoid exposing the skin to continued burn insult. If clothing does not
remove easily, nonadherent material should be cut away, with adherent clothing
left for removal in the cleaning phase.

Cooling. Ideally, burns should be cooled immediately after they occur. Although
most tissue has already cooled by the time patients with burns present to a
physician, further cooling during the first several hours after injury effectively
decreases burn pain.6 Sterile saline-soaked gauze, moderately cooled to around
12C (53.6F), can be applied to the burned tissues.17 Ice application should be
avoided.6,18 Because of the risk of hyperthermia, caution should be exercised in
cooling extensive burns (i.e., those with a TBSA of more than 10 percent).19

Cleaning. Cleaning a burn wound is critical but can cause excruciating pain. It is
therefore important to establish local or regional anesthesia before the wound is
cleaned. Anesthesia should not be applied topically to a burn or injected directly
into the wound.6

Although disinfectants (e.g., chlorhexidine gluconate solution [Hibiclens],

povidone-iodine solution [Betadine]) are often employed to clean burn wounds,
their use is discouraged because these agents can actually inhibit the healing
process.5 There is growing support for washing burns with mild soap and tap
water.2,5,15,20,21 Once a burn wound has been cleaned, it should be thoroughly
rinsed.

Tar and asphalt residues should never be debrided5; instead, they can be
removed with a mixture of cool water and mineral oil.4 Applying copious
amounts of polymyxin Bbacitracin zinc ointment (Polysporin) over several days
should emulsify and remove residual tar.15 Embedded bits of clothing or other
materials should be removed by copious irrigation using a large-gauge syringe.4

To minimize infection, necrotic tissue from partial- and full-thickness burns should
be removed manually or with whirlpool debridement. The latter method tends to
be better tolerated by patients. The yellow eschar characteristic of partialthickness burns need not be removed.4

Ruptured blisters should be removed. Many experts recommend unroofing

blisters if they contain cloudy fluid or are likely to rupture imminently (e.g.,
blisters located over joints).15,22 The management of clean, intact blisters is
controversial. Intact blisters should never be aspirated with a needle because of
the increased risk of infection.3,15,22 The persistence of blisters for several
weeks, with no signs of resorption, typically indicates the presence of an
underlying deep partial- or full-thickness burn.6

Chemoprophylaxis. Tetanus immunization should be updated in patients with

wounds deeper than a superficial partial-thickness burn.23

Diagnosing infection in patients with burns is challenging. Burns elicit

inflammation, which results in mild erythema, edema, pain and tenderness. If
these signs occur in conjunction with lymphangitis, fever, malaise and anorexia,
or if they increase over a baseline level, infection should be suspected.6

Infection can involve the depth and extent of a burn, converting a superficial
partial-thickness burn into a deep partial-thickness burn or even a full-thickness
burn. An infected burn is also more susceptible to blood invasion and sepsis.
Because of these risks, all suspected burn infections warrant aggressive
management, including hospital admission and parenteral antibiotic therapy.15
Some authors contend that all infected burns require surgical referral with
consideration of full-thickness skin biopsy to confirm the presence of infection
and identify the causative organism.4 Full-thickness skin grafting after excision
should also be considered.24

Superficial burns do not require infection prophylaxis, but all other burns should
receive topical prophylaxis. Classically, silver sulfadiazine cream (Silvadene) is

used to prevent burn infections. This agent should never be used on the face or
in patients with sulfonamide hypersensitivity. Because of the risk of sulfonamide
kernicterus, silver sulfadiazine should not be used in pregnant women, newborns
or nursing mothers with infants younger than two months of age.4

Bacitracin is an alternative topical prophylactic antibiotic. This agent should

always be used around mucous membranes. Because of the decreased cost,
several authors favor using bacitracin rather than silver sulfadiazine for any
superficial partial-thickness burn.3 No studies comparing the efficacies of
bacitracin and silver sulfadiazine have yet been published.

Alternatives to topical antibiotics include biologic dressings (pigskin, human

allograft) and bismuth-impregnated petroleum gauze or Biobrane dressings. The
advantage of these dressings is that they are applied only once. As a result,
patients are spared the pain that typically accompanies dressing changes.

Biologic dressings are associated with lower infection rates and faster healing
rates than silver sulfadiazine. However, these dressings are expensive, difficult to
apply and not always readily available.14 If used, biologic dressings should be
applied within the first six hours after the burn is sustained. The initial
application may loosen by the following day, necessitating reapplication.
Thereafter, these dressings gradually peel off as skin epithelializes underneath
them. Early separation of the dressing from the skin indicates the presence of a
deeper wound (requiring surgical treatment) or an infection.5

Bismuth-impregnated petroleum gauze and Biobrane dressings appear to be

advantageous treatments and are acceptable for use in young children with
superficial partial-thickness burns.14,25 Both of these dressings are applied as a
single layer over the burn and are then covered with a bulky dressing. The bulky
dressing should be changed every other day, typically in a physician's office, with
close assessment of the wound for signs of infection.

Covering. Dogmatic recommendations regarding the type and duration of

dressing cannot be made because of the paucity of studies on the subject.6
Covering burns serves a number of purposes. Dressings provide anesthetic relief,
act as a barrier against infection and keep the wound dry by absorbing drainage.
The types of coverings differ, depending on the depth of a burn and its location.

Superficial burns do not require wound dressings. Use of a simple skin lubricant
(e.g., aloe vera cream) is sufficient, and patients should be instructed to see their
physician if any blisters develop.

All partial- and full-thickness burns should be covered with sterile dressings. A
fine mesh gauze (e.g., Telfa) should be applied after the burn has been cleaned
and a thin layer of topical antibiotic has been applied. Circulatory impairment is
minimized by applying this nonadherent dressing in successive strips, rather
than wrapping it around the wound.16 The dressing is held in place with a
tubular net bandage or lightly applied gauze wraps. Tubular net bandages come
in a variety of sizes. This bandage is excellent for use on extremities, and it can
be modified to fit the trunk of a younger child.

Recommended frequencies for dressing changes range from twice daily to once a
week.6 Dressings should be changed whenever they become soaked with
excessive exudate or other fluids.5 At each dressing change, the topical
antibiotic should be removed as completely as possible using gentle washings.
Scrubbing and sharp debridement are not necessary.5

Comforting. Analgesics should be given around the clock to control background

pain. Acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (alone
or in combination with opioids) are often appropriate for use in patients with
small burn wounds.26 Aspirin products should be avoided because of platelet
inhibition and the risk for bleeding.

Patients with burns often require a rescue medication (e.g., acetaminophen

with codeine [Tylenol W Codeine] or a stronger narcotic [e.g., morphine]) before
dressing changes and during increased physical activity.26 Narcotic medications
can be used in children as well as adults.14,16,27

A patient's worst pain score should be less than 5 (on a scale of zero to 10).
Scores of 5 or higher interfere with sleep, activity and mood.28

Follow-Up Care for Burns

Follow-up care involves surveying patients with burns for signs of infection,
scarring and contracture. To minimize further damage, infection is best managed
in a hospital. Scarring and contractures connote long-term disfigurement and
disability, both of which are indications for specialized care.

FOLLOW-UP INTERVALS
Patients with burns who are being managed as outpatients should be seen again
on the day after injury. At this visit, the level of pain can be assessed, pain
medication can be adjusted if necessary, and competence in managing dressing
changes can be assessed. Subsequent follow-up can then be performed on a
weekly basis until wound epithelialization occurs. However, if pain control is
insufficient or there are concerns about the ability of a patient or family members
to provide proper wound care, the patient should be seen on a daily basis until
complete epithelialization occurs.2,6

If wound epithelialization has not begun after two weeks or if subsequent

evaluations reveal the presence of a full-thickness burn more than 2 cm in
diameter, the patient should be referred to a surgeon with expertise in burn
care.2,6,15 Tiny opalescent islands of epithelium throughout the wound indicate
epithelialization, with the wound typically healing completely in seven to 10
days.6

After epithelialization has occurred, patients are seen every four to six weeks to
assess for evidence of hypertrophic scar formation and to monitor coping
mechanisms.

HYPERTROPHIC SCARRING AND CONTRACTURES

It has been said that time heals all wounds. This is not necessarily the case
with burns. Although the threat of infection and the magnitude of pain diminish
with time, the prospects for long-term scarring and disability often become more
apparent. Hypertrophic scarring is thought to be inevitable when epithelialization
takes longer than two weeks in blacks and young children, or longer than three
weeks in all other patients.29

Application of pressure to burn wounds is generally recommended to minimize

hypertrophic scarring, although optimal pressure and duration have not yet been
determined in controlled trials.30 A variety of techniques are used, but all are
complex and costly. Therefore, family physicians often refer patients at risk for
scarring to a burn specialist. Because pressure prevents scars but does not treat
them once they develop, referral should be initiated promptly at the first sign of
hypertrophic scarring or if a wound misses certain epithelialization milestones
(Table 3).31

TABLE 3 Wound Epithelialization Milestones

View Table
Although pressure does little to remodel existing hypertrophic scars, the
application of silicone gel sheeting has been found to significantly reduce
established scars as late as 12 years after injury.31 A two-month trial of the
continual use of silicon gel sheeting on established scars distinguishes
responders from nonresponders.32 Side effects of pruritus and rash can be
minimized by washing the scar and applying silicon gel daily.33

Scar contractures result in disfigurement and disability. If detected early, a

contracture can be treated with silicone inserts and pressure. If the contracture is
more developed, a continuously worn static splint is added to maintain sustained
stretch. Once full range of motion is achieved, splinting can be reduced to
nighttime use until the scar fully matures. Surgical intervention should be
considered if the contracture is not completely reduced.31

ROLE OF SURGERY
Surgical excision and skin grafting beginning less than 72 hours after injury is
beneficial and is indicated for nonscald full-thickness burns in children and in
adults younger than 30 years of age.30,34 All other patients with suspected fullthickness burns should be observed for eight to 10 days, as nothing is lost by
delaying surgical excision.5 It is also best to wait two weeks before assessing the
need for surgery in children with hot-water scald burns because overly
aggressive excision and skin grafting in this group has resulted in worse
outcomes.35 Full-thickness burns less than 2 cm wide can be allowed to heal by
contracture as long as they are in nonfunctional, noncosmetic areas and the skin
is not thin (e.g., the ankle).21

COPING WITH THE INJURY

After epithelialization occurs, no further dressing changes are required. However,
patients should be instructed to use a non-perfumed moisturizing cream (e.g.,
Vaseline Intensive Care, Eucerin, Nivea, mineral oil or cocoa butter)6 until natural
lubricating mechanisms return.2 Use of preparations with a high lanolin content,
thick waxes and ointments should be avoided.5 In addition, a sun block with a
skin protection factor greater than 15 should be used to prevent
hyperpigmentation until the wound loses its pink and red coloring.2 Depending
on the depth of injury, it usually takes six months to two years for a burn wound
to heal completely.5

Itching is a common problem during the healing process. Pruritus is often

triggered or worsened by environmental extremes (especially heat), physical
activity and stress.6 The itching usually diminishes gradually and eventually
stops after complete wound healing.6 Until then, a number of measures can be
employed to control itching. Systemic antihistamines are usually tried first, with
diphenhydramine (Benadryl) used most frequently.5,6 Cyproheptadine (Periactin)
and hydroxyzine (Atarax) are alternatives.6 Local measures include bicarbonate
of soda baths and moisturizing lotions.5 Many patients prefer to wear loose, soft,
cotton clothing.6

In addition to helping patients cope with long-term physical discomfort, family

physicians should be alert for psychologic issues. Patients who have sustained
burns are at increased risk for anxiety, depression and post-traumatic stress
disorder. Family dynamics can also change dramatically. Family members may be
stricken with guilt, and patients are susceptible to dependency issues because of
the additional help required for daily activities while healing is occurring. If a
psychologic issue is noticed, appropriate treatment should be implemented.27

The Authors
ERIC D. MORGAN, MAJ, MC, USA, is residency director for the Department of
Family and Community Medicine at Eisenhower Army Medical Center, Fort
Gordon, Ga. He received his medical degree from Loma Linda (Calif.) University
School of Medicine and completed a family practice residency at Tripler Army
Medical Center, Honolulu. He also earned a master of public health degree from
the University of Washington, Seattle, and completed a faculty development
fellowship at Madigan Army Medical Center, Fort Lewis, Wash.

SCOTT C. BLEDSOE, CPT, MC, USA, is a staff physician at the Family Practice
Clinic, Weed Army Community Hospital, Fort Irwin, Calif. He graduated from
Kirksville (Mo.) College of Osteopathic Medicine and recently completed a family
practice residency at Eisenhower Army Medical Center.

JANE BARKER, CPT, MC, USA, is a staff family physician at the Family Health
Center, Moncrief Army Community Hospital, Fort Jackson, S.C. She graduated
from Kirksville College of Osteopathic Medicine and recently completed a family
practice residency at Eisenhower Army Medical Center.

Address correspondence to Eric D. Morgan, MAJ, MC, USA, Residency Director,

Department of Family and Community Medicine, Eisenhower Army Medical

Center, Fort Gordon, GA 30905-5650 (e-mail address:

Eric.Morgan@se.amedd.army.mil). Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of the
Army Medical Department or the Army Service at large.

The photographs in figures 1 through 4 were provided by Steve Bracci of the

Joseph M. Still Burn Center at Doctors Hospital, Augusta, Ga.

This article is dedicated to Elisabeth Morgan, the daughter of Dr. Eric D. Morgan.
Elisabeth sustained a severe scald injury shortly after her first birthday. Although
Elisabeth's skin permanently reflects the tragedy of the accident and has forever
sensitized her physician father to the horror of burns, her tenacity, vitality and
joy for life are a testament to the ability of the human will and personality to be
more flexible and forgiving than the sometimes fragile bodies in which we live.

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Members of various medical faculties develop articles for Practical

Therapeutics. This article is one in a series coordinated by the Department of
Family and Community Medicine at Eisenhower Army Medical Center, Fort
Gordon, Ga. Guest editor of the series is Ted D. Epperly, COL, MC, USA

Manajemen Ambulatory Burns

ERIC D. MORGAN, MAJ, MC, Amerika Serikat, Eisenhower Army Medical Center,
Fort Gordon, Georgia
SCOTT C. Bledsoe, CPT, MC, Amerika Serikat, Weed Rumah Sakit Komunitas
Angkatan Darat, Fort Irwin, California
JANE BARKER, CPT, MC, Amerika Serikat, Moncrief Rumah Sakit Komunitas
Angkatan Darat, Fort Jackson, Carolina Selatan
Am Fam Physician. 1 November 2000; 62 (9): 2015-2026.

Lihat terkait handout informasi pasien tentang merawat luka bakar dan
mencegah luka bakar, yang ditulis oleh penulis artikel ini.

Luka bakar sering terjadi tiba-tiba dan memiliki potensi untuk menyebabkan
kematian, cacat seumur hidup dan disfungsi. Sebuah bagian penting dari
manajemen luka bakar yang menilai kedalaman dan luasnya cedera. Luka bakar
sekarang umum diklasifikasikan sebagai dangkal, ketebalan parsial superfisial,
ketebalan parsial yang mendalam dan ketebalan penuh. Suatu pendekatan
sistematis untuk membakar perawatan berfokus pada enam "Cs": pakaian,
pendinginan, membersihkan, kemoprofilaksis, meliputi dan menghibur (yaitu,
penghilang rasa sakit). Asosiasi Bakar Amerika telah membentuk kriteria untuk
menentukan pasien mana yang dapat dikelola sebagai pasien rawat jalan dan
yang memerlukan perawatan di rumah sakit atau rujukan ke pusat luka bakar.
Perawatan Tindak lanjut penting untuk menilai pasien untuk infeksi,
penyembuhan dan kemampuan untuk memberikan perawatan luka yang tepat.
Komplikasi luka bakar termasuk penyembuhan lambat, pembentukan parut dan
kontraktur. Rujukan bedah dini sering dapat membantu mencegah atau
mengurangi jaringan parut dan kontraktur. Dokter keluarga harus waspada untuk
masalah psikologi yang berhubungan dengan cacat jangka panjang atau cacat
dari luka bakar.

Luka bakar dapat menghancurkan luka yang mengakibatkan kematian atau luka
seumur hidup, cacat dan disfungsi. Luka bakar adalah penyebab utama ketiga
kematian karena kecelakaan di Amerika Serikat (setelah insiden yang melibatkan
kendaraan bermotor dan senjata api). Setiap tahun, lebih dari 1 juta orang di
negeri ini mencari perawatan medis untuk luka bakar. Lebih dari 95 persen
pasien tersebut dapat dikelola pada basis.1,2 ambulatory

Manajemen Ambulatory luka bakar dibagi menjadi pengobatan akut dan

perawatan tindak lanjut. Manajemen akut mencakup langkah-langkah untuk
meminimalkan kerusakan lebih lanjut untuk pasien dengan luka bakar baru-baru
ini berkelanjutan, mengidentifikasi pasien yang membutuhkan rawat inap dan
menerapkan langkah-langkah untuk mempromosikan penyembuhan, mencegah
infeksi dan mengurangi rasa sakit. Selama tindak lanjut perawatan, fokus
bergeser ke membatasi cacat dari jaringan parut dan disfungsi dari kontraktur.
Meskipun sebagian besar pasien dengan luka bakar dapat dikelola oleh dokter
keluarga, beberapa memerlukan rujukan bedah untuk pencangkokan kulit dan
rehabilitasi bekas luka.

Manajemen akut Burns

Hal ini sangat penting untuk menentukan apakah pasien dengan luka bakar
harus dirawat di rumah sakit untuk hidrasi dan membakar perawatan atau
apakah manajemen ambulatory muncul layak. Klasifikasi luka bakar karena
keputusan memfasilitasi rawat inap kecil, sedang atau besar. Proper klasifikasi
luka bakar memerlukan penentuan akurat kedalaman dan luasnya luka (s), serta
pertimbangan isu penting seperti ketebalan kulit, membakar lokasi dan
komorbiditas kondisi.

KEDALAMAN A BURN
Klasifikasi tradisional luka bakar sebagai pertama, tingkat kedua atau ketiga
digantikan oleh sebutan dangkal (Gambar 1), ketebalan parsial superfisial
(Gambar 2), ketebalan dalam parsial (Gambar 3) dan ketebalan penuh (Gambar
4) .2 Bakar mendalam memiliki dampak pada waktu penyembuhan, kebutuhan
untuk rawat inap dan intervensi bedah, dan potensi untuk pengembangan bekas
luka. Meskipun klasifikasi akurat tidak selalu mungkin awalnya, penyebab dan
karakteristik fisik dari luka bakar sangat membantu dalam mengkategorikan
kedalaman (Tabel 1) 0,2-4

Gambar 1.
Luka bakar superfisial pada batang dan lengan kanan dari anak muda. Biasanya,
ini adalah luka bakar merah yang memutihkan dengan tekanan.
Lihat besar

Gambar 2.
Superficial partial-thickness membakar lutut kanan pria. Terik luka yang
memutihkan dengan tekanan merupakan karakteristik dangkal parsial-ketebalan
luka bakar. Luka ini juga biasanya lembab dan menangis.
Lihat besar

GAMBAR 3.
Dalam parsial-ketebalan luka bakar pada batang dan ekstremitas dari anak
muda. Luka bakar ini ditandai oleh lepuh mudah unroofed yang memiliki
penampilan lilin dan tidak pucat dengan tekanan.
Lihat besar

GAMBAR 4.
Full-ketebalan membakar sayap kiri wanita. Membakar area jenis ini berwarna
abu-abu putih atau kasar khas mati rasa dan lilin dalam warna.
Lihat besar
Tabel 1 Klasifikasi Burns Berdasarkan Kedalaman
Lihat Tabel
Membedakan luka bakar parsial-ketebalan yang mendalam dari luka bakar
ketebalan penuh dapat cukup sulit Revisi initially.2,5,6 burn mendalam estimasi
sering diperlukan dalam pertama 24 sampai 72 hours5 dan mungkin diperlukan
melalui dua pertama atau tiga minggu.2 misalnya, meskipun full-thickness burn
biasanya memiliki penampilan putih atau hangus, dapat merah setelah cedera
melepuh. Hal ini juga memungkinkan untuk memiliki luka bakar full-thickness
bawah melepuh, yang biasanya fitur karakteristik dari burn.3 parsial-ketebalan
Selanjutnya, kulit tipis menopang luka bakar lebih dari mungkin disarankan oleh
penampilan awal wound.5 yang kulit tipis adalah umum pada permukaan volar
lengan dan paha medial, perineum dan telinga. Semua kulit dapat dianggap
untuk menjadi kurus pada anak-anak berumur di bawah lima tahun dan pada
orang dewasa yang lebih tua dari 55 tahun.5 Cara terbaik adalah dengan
mengasumsikan bahwa tidak ada luka bakar dangkal ini usia groups.7

LUAS A BURN
Luasnya luka bakar dinyatakan sebagai persentase total luas permukaan tubuh
(TBSA) terkena cedera. Estimasi akurat dari TBSA dari luka bakar sangat penting
untuk membimbing manajemen.

Beberapa metode telah dikembangkan untuk memperkirakan TBSA luka bakar.

Metode ini tidak digunakan untuk luka bakar dangkal. Metode yang paling
terkenal, "aturan sembilan," cocok untuk digunakan di semua orang dewasa dan
ketika penilaian cepat diperlukan untuk child.2 sebuah

Metode yang lebih akurat diperlukan untuk estimasi definitif tingkat luka bakar
pada anak-anak. The Lund dan Browder metode mencakup semua kelompok usia
dan dianggap sebagai metode yang paling akurat untuk digunakan pada pasien
anak (Gambar 5) .2,8

Bagan Perkiraan Area di Burns

GAMBAR 5.
Modifikasi Lund dan Browder grafik untuk memperkirakan area luka bakar.
Pendekatan ini dianggap paling akurat untuk digunakan pada pasien anak.
Angka-angka dapat diwarnai dengan merah untuk full-thickness luka bakar dan
biru untuk parsial-ketebalan luka bakar. (2 = tingkat dua luka bakar, 3 = tingkat
tiga bakar; TBSA = persentase total luas permukaan tubuh)
Diadaptasi dengan izin dari Mertens DM, Jenkins ME, Warden GD. Rawat Jalan
membakar manajemen. Nurs Clin Utara Am 1997; 32: 343-64, dan Lund C,
Browder N. Estimasi daerah luka bakar. Surg Gynecol Obstet 1944; 79: 352-8.
Lihat besar
Luas permukaan telapak tangan pasien juga dapat digunakan untuk
memperkirakan luas luka bakar kecil atau tambal sulam. Secara klasik, sawit
telah dianggap mewakili 1 persen dari TBSA.2,6 Namun, penelitian terbaru
menunjukkan bahwa telapak tangan lebih akurat mewakili 0,4 persen dari TBSA,
dan seluruh tangan mewakili 0,8 persen dari TBSA.9 yang

RAWAT INAP PENGOBATAN DAN BURN UNIT RUJUKAN

Pasien dianggap memiliki luka bakar moderat berdasarkan sistem penilaian yang
dikembangkan oleh American Association Bakar (ABA) harus diakui untuk hidrasi
intravena dan perawatan bedah luka mereka (Tabel 2) .6,10 Karena kesulitan
awal dalam membedakan partial- dalam ketebalan luka bakar dari full-thickness
luka bakar, dokter keluarga harus mempertimbangkan mendapatkan konsultasi
bedah untuk apa yang tampaknya menjadi luka bakar parsial-ketebalan yang
mendalam yang mempengaruhi lebih dari 3 persen TBSA.4

TABEL 2 Amerika Bakar Sistem Grading Association untuk Bakar Keparahan dan
Disposisi dari Pasien
Lihat Tabel
Insufisiensi paru bertanggung jawab untuk lebih dari 75 persen dari deaths.1
terkait dengan kebakaran Karena kemungkinan edema progresif, pasien dengan
dugaan cedera inhalasi harus diamati selama setidaknya 12 sampai 24
hours.6,11 temuan sejarah atau fisik yang meningkatkan kekhawatiran tentang
cedera inhalasi termasuk batuk, mengi, dyspnea, luka bakar wajah, lendir jelaga
dan laring edema.4

Fiberoptik bronkoskopi atau xenon ventilasi-perfusi pemindaian hasil diagnosis

lebih sering dan sebelumnya inhalasi injury.12 Salah satu pemeriksaan ini harus
dilakukan jika diagnosis cedera inhalasi dalam doubt.11

Pasien yang beresiko untuk cedera inhalasi juga harus diperiksa untuk keracunan
karbon monoksida. Tingkat karboksihemoglobin arteri lebih besar dari 10 persen
cenderung menunjukkan paparan karbon monoksida. Oksigen hiperbarik adalah
treatment.13 yang

Rumah sakit diperlukan untuk pasien yang memiliki keliling parsial-ketebalan

atau full-thickness luka bakar, pasien yang memiliki luka bakar dan dianggap
cenderung untuk infeksi (misalnya, orang-orang dengan diabetes), dan pasien
yang telah menderita cedera listrik tegangan tinggi .14 aritmia jantung dapat
terjadi sampai 72 jam setelah tegangan tinggi listrik injury.15 perubahan
nonspesifik dalam gelombang ST-T kelainan yang paling umum dicatat pada
electrocardiograms (EKG) yang diperoleh setelah cedera listrik. Pengamatan
dijamin sampai EKG menjadi normal.6

Anak-anak dengan luka bakar harus dirawat di rumah sakit setiap kali pelecehan
anak dicurigai. Dari 9 sampai 11 persen luka bakar pada anak-anak adalah
cedera nonaccidental, dengan kejadian puncak pada 13-24 bulan age.16 luka

bakar Immersion adalah luka bakar klasik dalam pelecehan anak, tetapi
pelecehan harus dicurigai dengan cedera melepuh, terutama jika ada demarkasi
yang tajam antara tanda kulit atau percikan terbakar dan normal
penyalahgunaan anak absent.6 juga harus diduga kuat pada anak-anak dengan
luka bakar sugestif rokok atau panas besi injuries.6

Rujukan ke unit luka bakar diindikasikan untuk pasien yang memenuhi kriteria
untuk luka bakar besar seperti yang didefinisikan oleh ABA (Tabel 2) .6,10
Termasuk pasien yang memanifestasikan cedera inhalasi atau membakar tanda
dari tegangan tinggi listrik injury.14

PENGOBATAN ambulatory
Luka bakar ringan terdiri sekitar 95 persen dari luka bakar dirawat oleh dokter di
Amerika States.2 Sebagian besar luka bakar ini dapat dikelola secara rawat jalan.
Sebuah algoritma untuk membantu dalam mengidentifikasi pasien cocok untuk
manajemen rawat disediakan pada Gambar 6.4

Manajemen Burns

Gambar 6.
Algoritma untuk pengelolaan pasien dengan luka bakar.
Diadaptasi dari Peate WF. Manajemen Rawat Jalan luka bakar. Am Fam Physician
1992; 45: 1326.
Lihat besar
Suatu pendekatan sistematis terhadap manajemen rawat luka bakar yang
dikonsep oleh enam "Cs": pakaian, pendinginan, membersihkan, kemoprofilaksis,
meliputi dan menghibur (yaitu, penghilang rasa sakit) .4

Pakaian. Setiap pakaian yang panas atau terbakar harus segera dihapus dari
tubuh pasien. Pakaian yang telah terkena bahan kimia juga harus dihapus untuk
menghindari mengekspos kulit untuk terus membakar penghinaan. Jika pakaian
tidak menghapus dengan mudah, bahan nonadherent harus dipotong, dengan
pakaian patuh tersisa untuk dihapus dalam tahap pembersihan.

Pendingin. Idealnya, luka bakar harus didinginkan segera setelah mereka terjadi.
Meskipun sebagian besar jaringan telah didinginkan oleh pasien dengan luka

bakar saat hadir untuk dokter, pendinginan lebih lanjut selama beberapa jam
pertama setelah cedera efektif menurunkan bakar pain.6 steril saline-direndam
kasa, cukup didinginkan sampai sekitar 12 C (53,6 F) , dapat diterapkan untuk
dibakar tissues.17 aplikasi Ice harus avoided.6,18 Karena risiko hipertermia, hatihati harus dilakukan dalam pendingin luka bakar yang luas (yaitu, orang-orang
dengan TBSA lebih dari 10 persen) .19

Membersihkan. Membersihkan luka bakar sangat penting tetapi dapat

menyebabkan sakit luar biasa. Hal itu penting untuk membangun anestesi lokal
atau regional sebelum luka dibersihkan. Anestesi tidak boleh dioleskan pada luka
bakar atau disuntikkan langsung ke dalam wound.6

Meskipun desinfektan (misalnya, chlorhexidine glukonat solusi [Hibiclens], solusi

povidone-iodine [Betadine]) sering digunakan untuk membersihkan luka bakar,
penggunaan tidak dianjurkan karena agen ini benar-benar dapat menghambat
penyembuhan process.5 Ada dukungan yang berkembang untuk mencuci luka
bakar dengan sabun ringan dan tekan water.2,5,15,20,21 Setelah luka bakar
telah dibersihkan, harus dibilas secara.

Tar dan aspal residu tidak boleh debrided5; sebaliknya, mereka dapat dihapus
dengan campuran air dingin dan oil.4 mineral Menerapkan jumlah berlebihan
polimiksin B-bacitracin zinc salep (Polysporin) selama beberapa hari harus emulsi
dan menghapus sisa bit tar.15 Tertanam pakaian atau bahan lainnya harus
dihapus oleh irigasi berlebihan menggunakan syringe.4 besar-gauge

Untuk meminimalkan infeksi, jaringan nekrotik dari partial- dan full-thickness

luka bakar harus dihapus secara manual atau dengan pusaran air debridement.
Metode terakhir cenderung lebih baik ditoleransi oleh pasien. Karakteristik
eschar kuning parsial-ketebalan luka bakar tidak perlu removed.4

Lepuh pecah harus dihapus. Banyak ahli merekomendasikan lecet unroofing jika
mereka berisi cairan keruh atau cenderung pecah waktu dekat (misalnya, lepuh
yang terletak di atas sendi) .15,22 Manajemen bersih, lepuh utuh kontroversial.
Lepuh utuh tidak boleh disedot dengan jarum karena peningkatan risiko
infection.3,15,22 Bertahannya lepuh selama beberapa minggu, tanpa tandatanda resorpsi, biasanya menunjukkan adanya suatu partial- mendalam yang
mendasari atau full-thickness burn.6

Kemoprofilaksis. Imunisasi tetanus harus diperbarui pada pasien dengan luka

lebih dalam dari burn.23 parsial-ketebalan dangkal

Mendiagnosis infeksi pada pasien dengan luka bakar menantang. Luka bakar
menimbulkan peradangan, yang menghasilkan ringan eritema, edema, rasa sakit
dan nyeri. Jika tanda-tanda ini terjadi bersamaan dengan lymphangitis, demam,
malaise dan anoreksia, atau jika mereka meningkat dari tingkat dasar, infeksi
harus suspected.6

Infeksi dapat melibatkan kedalaman dan luasnya luka bakar, mengkonversi

parsial-ketebalan dangkal membakar ke luka bakar parsial-ketebalan dalam atau
bahkan luka bakar ketebalan penuh. Sebuah luka bakar yang terinfeksi juga lebih
rentan terhadap invasi darah dan sepsis. Karena risiko ini, semua infeksi luka
bakar diduga menjamin manajemen yang agresif, termasuk rawat inap dan
antibiotik parenteral therapy.15 Beberapa penulis berpendapat bahwa semua
luka bakar yang terinfeksi memerlukan rujukan bedah dengan pertimbangan
biopsi kulit full-thickness untuk mengkonfirmasi adanya infeksi dan
mengidentifikasi penyebab yang organism.4 kulit Full-ketebalan mencangkok
setelah eksisi juga harus considered.24

Luka bakar superfisial tidak memerlukan profilaksis infeksi, tetapi semua luka
bakar lainnya harus menerima profilaksis topikal. Secara klasik, silver
sulfadiazine krim (Silvadene) digunakan untuk mencegah infeksi luka bakar.
Agen ini tidak boleh digunakan pada wajah atau pada pasien dengan
sulfonamide hipersensitivitas. Karena risiko sulfonamide kernikterus, sulfadiazine
perak tidak boleh digunakan dalam hamil wanita, bayi baru lahir atau ibu
menyusui dengan bayi yang lebih muda dari dua bulan age.4

Bacitracin adalah antibiotik profilaksis topikal alternatif. Agen ini harus selalu
digunakan sekitar selaput lendir. Karena penurunan biaya, beberapa penulis
mendukung menggunakan bacitracin daripada sulfadiazin perak untuk setiap
dangkal parsial-ketebalan burn.3 ada studi yang membandingkan khasiat dari
bacitracin dan sulfadiazine perak tersebut belum dipublikasikan.

Alternatif untuk antibiotik topikal juga pembalutan biologis (kulit babi, allograft
manusia) dan bismuth-diresapi minyak kasa atau dressing Biobrane. Keuntungan
dari dressing ini adalah bahwa mereka diterapkan hanya sekali. Akibatnya,
pasien terhindar dari rasa sakit yang biasanya menyertai perubahan rias.

Dressing biologis berhubungan dengan tingkat infeksi yang lebih rendah dan
tingkat penyembuhan lebih cepat dari sulfadiazin perak. Namun, dressing ini
mahal, sulit untuk menerapkan dan tidak selalu mudah available.14 Jika
digunakan, dressing biologis harus diterapkan dalam enam jam pertama setelah
luka bakar berkelanjutan. Penerapan awal dapat melonggarkan pada hari
berikutnya, yang memerlukan reapplication. Setelah itu, dressing ini secara
bertahap melepas sebagai kulit epithelializes bawah mereka. Pemisahan awal
saus dari kulit menunjukkan adanya luka yang lebih dalam (memerlukan
perawatan bedah) atau infection.5

Bismuth-diresapi minyak kasa dan Biobrane dressing tampaknya perawatan

menguntungkan dan dapat diterima untuk digunakan pada anak-anak dengan
dangkal parsial-ketebalan burns.14,25 Kedua dressing ini diterapkan sebagai
lapisan tunggal atas luka bakar dan kemudian ditutup dengan ganti besar. The
saus besar harus berubah setiap hari, biasanya di kantor dokter, dengan
penilaian penutupan luka tanda-tanda infeksi.

Meliputi. Rekomendasi Dogmatis mengenai jenis dan durasi berpakaian tidak

dapat dibuat karena kurangnya studi tentang subject.6 Meliputi luka bakar
melayani beberapa tujuan. Dressing memberikan bantuan anestesi, bertindak
sebagai penghalang terhadap infeksi dan menjaga luka kering dengan menyerap
drainase. Jenis-jenis penutup berbeda, tergantung pada kedalaman luka bakar
dan lokasinya.

Luka bakar superfisial tidak memerlukan pembalut luka. Penggunaan pelumas

kulit sederhana (misalnya, lidah buaya krim) sudah cukup, dan pasien harus
diinstruksikan untuk melihat dokter mereka jika ada lecet berkembang.

Semua partial- dan full-thickness luka bakar harus ditutup dengan perban steril.
Sebuah kasa fine mesh (misalnya, Telfa) harus diterapkan setelah luka bakar
telah dibersihkan dan lapisan tipis antibiotik topikal telah diterapkan. Penurunan
sirkulasi diminimalkan dengan menerapkan berpakaian nonadherent ini di strip
berturut-turut, daripada membungkusnya sekitar wound.16 Dressing diadakan di
tempat dengan balutan bersih tubular atau ringan diterapkan wraps kasa. Perban
bersih Tubular datang dalam berbagai ukuran. Perban ini sangat baik untuk
digunakan pada ekstremitas, dan dapat dimodifikasi agar sesuai dengan bagasi
anak muda.

Frekuensi yang disarankan untuk perubahan rias berkisar dari dua kali sehari
untuk sekali dressing week.6 harus diubah setiap kali mereka menjadi basah

dengan eksudat yang berlebihan atau fluids.5 lainnya Pada setiap perubahan
rias, antibiotik topikal harus dihapus selengkap mungkin menggunakan
pembasuhan lembut. Scrubbing dan debridement tajam tidak diperlukan.5

Menghibur. Analgesik harus diberikan sekitar jam untuk mengendalikan "latar

belakang" sakit. Acetaminophen (Tylenol) dan obat anti-inflamasi nonsteroid
(sendiri atau dalam kombinasi dengan opioid) sering sesuai untuk digunakan
pada pasien dengan luka bakar kecil wounds.26 produk Aspirin harus dihindari
karena penghambatan platelet dan risiko perdarahan.

Pasien dengan luka bakar sering membutuhkan "rescue" obat (misalnya,

asetaminofen dengan kodein [Tylenol W Codeine] atau narkotika yang lebih kuat
[misalnya, morfin]) sebelum perubahan berpakaian dan selama peningkatan
activity.26 fisik obat Narkotika dapat digunakan pada anak-anak juga sebagai
adults.14,16,27

Skor nyeri terburuk Seorang pasien harus kurang dari 5 (pada skala nol sampai
10). Skor dari 5 atau lebih tinggi mengganggu tidur, aktivitas dan mood.28

Follow-Up Perawatan Burns

Perawatan tindak lanjut survei melibatkan pasien dengan luka bakar tanda-tanda
infeksi, jaringan parut dan kontraktur. Untuk meminimalkan kerusakan lebih
lanjut, infeksi terbaik dikelola di rumah sakit. Jaringan parut dan kontraktur
berkonotasi cacat jangka panjang dan cacat, yang keduanya indikasi untuk
perawatan khusus.

TINDAK LANJUT INTERVAL

Pasien dengan luka bakar yang dikelola sebagai pasien rawat jalan harus dilihat
lagi pada hari setelah cedera. Pada kunjungan ini, tingkat rasa sakit dapat dinilai,
obat penghilang rasa sakit dapat disesuaikan jika perlu, dan kompetensi dalam
mengelola perubahan rias dapat dinilai. Selanjutnya tindak lanjut kemudian
dapat dilakukan secara mingguan sampai epitelisasi luka terjadi. Namun, jika
kontrol nyeri tidak mencukupi atau ada kekhawatiran tentang kemampuan
pasien atau anggota keluarga untuk memberikan perawatan luka yang tepat,
pasien harus dilihat setiap hari sampai selesai epitelisasi occurs.2,6

Jika epitelisasi luka belum dimulai setelah dua minggu atau jika evaluasi
berikutnya mengungkapkan adanya sebuah full-thickness membakar lebih dari 2

cm, pasien harus dirujuk ke dokter bedah dengan keahlian dalam membakar
care.2,6,15 kecil terbuat dr batu baiduri pulau epitel seluruh luka menunjukkan
epitelisasi, dengan luka biasanya penyembuhan sepenuhnya dalam tujuh sampai
10 days.6

Setelah epitelisasi telah terjadi, pasien terlihat setiap empat sampai enam
minggu untuk menilai bukti pembentukan bekas luka hipertrofik dan memantau
mekanisme koping.

Jaringan parut hipertrofik dan kontraktur

Telah dikatakan bahwa "waktu menyembuhkan semua luka." Ini tidak selalu
terjadi dengan luka bakar. Meskipun ancaman infeksi dan besarnya rasa sakit
berkurang dengan waktu, prospek jaringan parut jangka panjang dan cacat
sering menjadi lebih jelas. Jaringan parut Hypertrophic dianggap tak terhindarkan
ketika epitelisasi memakan waktu lebih dari dua minggu pada orang kulit hitam
dan anak-anak, atau lebih dari tiga minggu di semua patients.29 lain

Penerapan tekanan untuk membakar luka umumnya direkomendasikan untuk

meminimalkan jaringan parut hipertrofik, meskipun tekanan yang optimal dan
durasi belum ditentukan dikendalikan trials.30 Berbagai teknik digunakan, tetapi
semua itu rumit dan mahal. Oleh karena itu, dokter keluarga sering merujuk
pasien pada risiko jaringan parut ke spesialis luka bakar. Karena tekanan
mencegah bekas luka tetapi tidak memperlakukan mereka setelah mereka
mengembangkan, rujukan harus dimulai segera pada tanda pertama dari
jaringan parut hipertrofik atau jika luka merindukan tonggak epitelisasi tertentu
(Tabel 3) .31

TABEL 3 Luka epitelisasi Milestones

Lihat Tabel
Meskipun tekanan tidak sedikit untuk merombak yang sudah ada bekas luka
hipertrofik, aplikasi terpal silikon gel telah terbukti secara signifikan mengurangi
bekas luka ditetapkan hingga akhir 12 tahun setelah injury.31 Sebuah uji coba
dua bulan penggunaan terus-menerus terpal gel silikon pada didirikan bekas luka
Yang membedakan responden dari efek samping nonresponders.32 pruritus dan
ruam dapat diminimalkan dengan mencuci bekas luka dan menerapkan daily.33
gel silikon

Kontraktur Scar menyebabkan cacat dan cacat. Jika terdeteksi dini, contracture
dapat diobati dengan sisipan silikon dan tekanan. Jika contracture lebih maju,
belat statis terus menerus dipakai ditambahkan untuk menjaga peregangan
berkelanjutan. Setelah berbagai gerak tercapai, belat dapat dikurangi dengan
penggunaan malam hari sampai bekas luka sepenuhnya matang. Intervensi
bedah harus dipertimbangkan jika contracture tidak sepenuhnya reduced.31

PERAN BEDAH
Eksisi bedah dan cangkok kulit mulai kurang dari 72 jam setelah cedera yang
bermanfaat dan diindikasikan untuk nonscald full-thickness luka bakar pada
anak-anak dan pada orang dewasa yang lebih muda dari 30 tahun age.30,34
Semua pasien lain yang diduga penuh luka bakar harus diamati selama delapan
sampai 10 hari, karena tidak ada yang hilang dengan menunda excision.5 bedah
Hal ini juga yang terbaik untuk menunggu dua minggu sebelum menilai
kebutuhan untuk operasi pada anak-anak dengan air panas melepuh luka bakar
karena eksisi terlalu agresif dan cangkok kulit di grup ini telah menghasilkan di
lebih buruk outcomes.35 Full-ketebalan luka bakar kurang dari 2 cm lebar dapat
diizinkan untuk sembuh dengan kontraktur selama mereka berada di
nonfungsional, daerah noncosmetic dan kulit tidak tipis (misalnya, pergelangan
kaki) .21

MENGATASI CEDERA YANG

Setelah epitelisasi terjadi, tidak ada perubahan ganti lebih lanjut diperlukan.
Namun, pasien harus diinstruksikan untuk menggunakan krim pelembab nonwangi (misalnya, Vaseline Intensive Care, Eucerin, Nivea, minyak mineral atau
cocoa butter) 6 sampai mekanisme pelumas alami return.2 Penggunaan olahan
dengan konten lanolin tinggi, lilin tebal dan salep harus avoided.5 Selain itu, sun
block dengan faktor perlindungan kulit lebih besar dari 15 harus digunakan untuk
mencegah hiperpigmentasi sampai luka kehilangan merah muda dan merah
coloring.2 Tergantung pada kedalaman cedera, biasanya memakan waktu enam
bulan dua tahun untuk luka bakar luka untuk menyembuhkan completely.5

Gatal adalah masalah umum selama proses penyembuhan. Pruritus sering dipicu
atau diperburuk oleh lingkungan ekstrim (terutama panas), aktivitas fisik dan
stress.6 gatal biasanya berkurang secara bertahap dan akhirnya berhenti setelah
healing.6 luka lengkap Sampai saat itu, sejumlah langkah dapat digunakan untuk
mengendalikan gatal. Antihistamin sistemik biasanya mencoba pertama, dengan
diphenhydramine (Benadryl) digunakan siproheptadin paling frequently.5,6
(Periactin) dan hydroxyzine (Atarax) adalah ukuran lokal alternatives.6 termasuk
bikarbonat soda mandi dan pelembab lotions.5 Banyak pasien lebih memilih
untuk memakai longgar , lembut, kapas clothing.6

Selain membantu pasien mengatasi ketidaknyamanan fisik jangka panjang,

dokter keluarga harus waspada untuk masalah psikologis. Pasien yang telah
menderita luka bakar akan meningkatkan risiko untuk kegelisahan, depresi dan
gangguan stres pasca-trauma. Dinamika keluarga juga dapat berubah secara
dramatis. Anggota keluarga dapat terserang rasa bersalah, dan pasien rentan
terhadap ketergantungan masalah karena bantuan tambahan yang dibutuhkan
untuk kegiatan sehari-hari sementara penyembuhan terjadi. Jika masalah
psikologis adalah melihat, perawatan yang tepat harus implemented.27

Penulis
ERIC D. MORGAN, MAJ, MC, Amerika Serikat, adalah direktur residensi untuk
Departemen Keluarga dan Pengobatan Masyarakat di Eisenhower Army Medical
Center, Fort Gordon, Ga. Ia menerima gelar dokter dari Loma Linda (California.)
University School of Medicine dan menyelesaikan residensi praktek keluarga di
Tripler Army Medical Center, Honolulu. Dia juga meraih gelar master kesehatan
masyarakat dari University of Washington, Seattle, dan menyelesaikan beasiswa
pengembangan fakultas di Madigan Army Medical Center, Fort Lewis, Wash.

SCOTT C. Bledsoe, CPT, MC, Amerika Serikat, adalah seorang dokter staf di
Praktek Klinik Keluarga, Weed Rumah Sakit Komunitas Angkatan Darat, Fort Irwin,
California. Ia lulus dari Kirksville (Mo) College of Osteopathic Medicine dan baru
saja menyelesaikan latihan residensi keluarga di Eisenhower Army Medical
Center.

JANE BARKER, CPT, MC, Amerika Serikat, adalah seorang dokter keluarga staf di
Puskesmas Keluarga, Rumah Sakit Komunitas Moncrief Angkatan Darat, Fort
Jackson, SC Dia lulus dari College of Osteopathic Kirksville Kedokteran dan baru
saja menyelesaikan residensi praktek keluarga di Eisenhower Army Medical
Center.

Alamat korespondensi Eric D. Morgan, MAJ, MC, Amerika Serikat, Residency

Direktur, Departemen Keluarga dan Kedokteran Komunitas, Eisenhower Army
Medical Center, Fort Gordon, GA alamat 30905-5650 (e-mail:
Eric.Morgan@se.amedd. army.mil). Cetak ulang tidak tersedia dari penulis.

Pendapat dan pernyataan yang terkandung adalah pandangan pribadi penulis

dan tidak dapat dianggap sebagai resmi atau mencerminkan pandangan Medis
Departemen Angkatan Darat atau Angkatan Darat Layanan pada umumnya.

Foto-foto dalam angka 1 sampai 4 yang disediakan oleh Steve Bracci dari Joseph
M. Masih Burn Center di Rumah Sakit Dokter, Augusta, Ga.

Artikel ini didedikasikan untuk Elisabeth Morgan, putri Dr Eric D. Morgan.

Elisabeth mengalami cedera parah melepuh lama setelah ulang tahun
pertamanya. Meskipun kulit Elisabeth permanen mencerminkan tragedi
kecelakaan dan telah selamanya peka ayah dokternya dengan kengerian luka
bakar, keuletan nya, vitalitas dan sukacita bagi kehidupan adalah bukti
kemampuan kehendak manusia dan kepribadian untuk menjadi lebih fleksibel
dan pemaaf daripada badan kadang-kadang rapuh di mana kita hidup.

REFERENSI
1 Brigham PA, McLoughlin E. Membakar kejadian dan penggunaan perawatan
medis di Amerika Serikat: perkiraan, tren, dan sumber data. J Bakar Perawatan
Rehabil. 1996; 17: 95-107.

2 Mertens DM, Jenkins ME, Warden GD. Rawat Jalan membakar manajemen. Nurs
Clin Utara Am. 1997; 32: 343-64.

3 Clayton MC, Solem LD. Tidak ada es, tidak ada mentega. Rekomendasi
pengelolaan luka bakar untuk dokter perawatan primer. Pascasarjana Med. 1995;
97 (5): 151-5,159-60,165.

4. Peate WF. Manajemen Rawat Jalan luka bakar. Am Fam Physician. 1992; 45:
1321-1330.

5. Baxter CR. Manajemen luka bakar. Dermatol Clin. 1993; 11: 709-14.

6 Hartford CE. Perawatan rawat jalan luka bakar. In: Herndon DN, ed. Jumlah
perawatan luka bakar. Philadelphia: Saunders, 1996: 71-80.

7 Heimbach D, Mann R, Engrav L. Evaluasi luka bakar. Keputusan manajemen. In:

Herndon DN, ed. Jumlah perawatan luka bakar. Philadelphia: Saunders, 1996: 817.

8 Lund C, Browder N. Estimasi daerah luka bakar. Surg Gynecol Obstet. 1944; 79:
352-8.

9. Perry RJ, Moore CA, Morgan DB, Plummer DL. Menentukan taksiran luas luka
bakar: inkonsistensi diselidiki dan re-evaluasi. BMJ. 1996; 312: 1338.

10 Rumah Sakit dan sumber daya pra-rumah sakit untuk perawatan optimal
pasien dengan luka bakar: pedoman untuk pengembangan dan pengoperasian
pusat luka bakar. Amerika Bakar Association. J Bakar Perawatan Rehabil. 1990;
11: 98-104.

11. Monafo WW. Manajemen awal luka bakar. N Engl J Med. 1996; 335: 1581-6.

12. Lull RJ, Tatum JL, Sugerman HJ, Hartshorne MF, Boll DA, Kaplan KA. Evaluasi
radionuklida dari trauma paru. Semin Nucl Med. 1983; 13: 223-7.

13. Heimbach DM, Waeckerle JF. Terhirup cedera. Ann Emerg Med. 1988; 17:
1316-1320.

14. Schonfeld N. manajemen Rawat Jalan luka bakar pada anak-anak. Pediatr Pgl
Care. 1990; 6: 249-53.

15. Waitzman AA, Neligan PC. Bagaimana mengelola luka bakar dalam
perawatan primer. Bisa fam Dokter. 1993; 39: 2394-400.

16. Martinez S. manajemen Ambulatory luka bakar pada anak-anak. J Kesehatan

Pediatr. 1992; 6: 32-7.

17. Pushkar NS, Sandorminsky BP. Pengobatan dingin luka bakar. Termasuk luka
bakar Therm Inj. 1982; 9: 101-10.

18. Allwood JS. Manajemen perawatan primer luka bakar. Perawat Pract. 1995;
20: 74,77-9,83 passim.

19 Purdue GF, Layton TR, Copeland CE. Cedera Dingin komplikasi terapi luka
bakar. J Trauma. 1985; 25: 167-8.

20. Bukit MG, Bowen CC. Pengobatan luka bakar ringan di bagian gawat darurat
Alabama pedesaan. J Emerg Nurs. 1996; 22: 570-6.

21. Greenhalgh DG. Penyembuhan luka bakar. Dermatol Nurs. 1996; 8: 13-23.

22. Rockwell WB, Ehrlich HP. Harus membakar cairan blister dievakuasi? J Bakar
Perawatan Rehabil. 1990; 11: 93-5.

23. Karyoute SM, Badran IZ. Tetanus setelah luka bakar. Termasuk luka bakar
Therm Inj. 1988; 14: 241-3.

24. Demling RH. Burns. N Engl J Med. 1985; 313: 1389-1398.

25. Ou LF, Lee SY, Chen YC, Yang RS, Tang YW. Penggunaan Biobrane pada anak
melepuh luka bakar-pengalaman dalam 106 anak-anak. Burns. 1998; 24: 49-53.

26. Ulmer JF. Membakar manajemen nyeri: pendekatan berbasis pedoman. J

Bakar Perawatan Rehabil. 1998; 19: 151-9.

27. Parsons L. Kantor manajemen luka bakar ringan. Lippincotts Prim Perawatan
Pract. 1997; 1: 40-9.

28 Cleeland CS, Ryan KM. Penilaian nyeri: penggunaan global dari Brief Nyeri
Persediaan. Ann Acad Med Singapura. 1994; 23: 129-38.

29. Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic bekas
luka bakar: analisis variabel. J Trauma. 1983; 23: 895-8.

30. Muller MJ, Herndon DN. Tantangan luka bakar. Lancet. 1994; 343: 216-20.

31. Carr-Collins JA. Teknik tekanan untuk pencegahan parut hipertrofik. Clin Plast
Surg. 1992; 19: 733-43.

32. Ahn ST, Monafo WW, Mustoe TA. Gel silikon topikal untuk pencegahan dan
pengobatan bekas luka hipertrofik. Arch Surg. 1991; 126: 499-504.

33. Quinn KJ. Gel silikon dalam pengobatan bekas luka. Termasuk luka bakar
Therm Inj. 1987; 13 (suppl): S33-40.

34. Herndon DN, Barrow RE, Rutan RL, Rutan TC, Desai MH, Abston S.
Perbandingan konservatif dibandingkan terapi eksisi awal luka bakar parah
pasien. Ann Surg. 1989; 209: 547-52.

35. Desai MH, Rutan RL, Herndon DN. Pengobatan konservatif dari melepuh luka
bakar lebih unggul eksisi awal. J Bakar Perawatan Rehabil. 1991; 12: 482-4.

Members of various medical faculties develop articles for Practical

Therapeutics. This article is one in a series coordinated by the Department of
Family and Community Medicine at Eisenhower Army Medical Center, Fort
Gordon, Ga. Guest editor of the series is Ted D. Epperly, COL, MC, USA
Ambulatory Management of Burns

ERIC D. MORGAN, MAJ, MC, USA, Eisenhower Army Medical Center, Fort Gordon,
Georgia
SCOTT C. BLEDSOE, CPT, MC, USA, Weed Army Community Hospital, Fort Irwin,
California
JANE BARKER, CPT, MC, USA, Moncrief Army Community Hospital, Fort Jackson,
South Carolina
Am Fam Physician.2000 Nov 1;62(9):2015-2026.

See related patient information handouts on taking care of burns and

preventing burns, written by the authors of this article.

Burns often happen unexpectedly and have the potential to cause death, lifelong
disfigurement and dysfunction. A critical part of burn management is assessing
the depth and extent of injury. Burns are now commonly classified as superficial,
superficial partial thickness, deep partial thickness and full thickness. A
systematic approach to burn care focuses on the six Cs: clothing, cooling,
cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief). The
American Burn Association has established criteria for determining which
patients can be managed as outpatients and which require hospital admission or
referral to a burn center. Follow-up care is important to assess patients for
infection, healing and ability to provide proper wound care. Complications of
burns include slow healing, scar formation and contracture. Early surgical referral
can often help prevent or lessen scarring and contractures. Family physicians
should be alert for psychologic problems related to long-term disability or
disfigurement from burn injuries.

Burns can be devastating injuries that result in death or lifelong scarring,

disfigurement and dysfunction. Burn injuries are the third leading cause of
accidental death in the United States (after incidents involving motor vehicles
and firearms). Each year, more than 1 million persons in this country seek
medical care for burns. More than 95 percent of these patients can be managed
on an ambulatory basis.1,2

Ambulatory management of burns is divided into acute treatment and follow-up

care. Acute management includes measures to minimize further damage to
patients presenting with recently sustained burns, identifying patients requiring
hospitalization and implementing measures to promote healing, prevent infection
and relieve pain. During follow-up care, the focus shifts to limiting disfigurement
from scarring and dysfunction from contractures. Although most patients with
burns can be managed by family physicians, some require surgical referral for
skin grafting and scar rehabilitation.

Acute Management of Burns

It is of paramount importance to determine whether a patient with a burn injury
should be hospitalized for hydration and burn care or whether ambulatory
management appears feasible. Classification of burns as minor, moderate or
major facilitates hospitalization decisions. Proper burn classification requires

accurate determination of the depth and extent of the wound(s), as well as

consideration of critical issues such as skin thickness, burn location and
comorbid conditions.

DEPTH OF A BURN
The traditional classification of burns as first, second or third degree is being
replaced by the designations of superficial (Figure 1), superficial partial thickness
(Figure 2), deep partial thickness (Figure 3) and full thickness (Figure 4).2 Burn
depth has an impact on healing time, the need for hospitalization and surgical
intervention, and the potential for scar development. Although accurate
classification is not always possible initially, the causes and physical
characteristics of burns are helpful in categorizing their depth (Table 1).24

Gambar 1.
Superficial burns on the trunk and right arm of a young child. Typically, these are
red burns that blanch with pressure.
Lihat besar

FIGURE 2.
Superficial partial-thickness burn on a man's right knee. Blistering wounds that
blanch with pressure are characteristic of superficial partial-thickness burns.
These wounds are also typically moist and weeping.
Lihat besar

FIGURE 3.
Deep partial-thickness burns on the trunk and extremities of a young child. These
burns are typified by easily unroofed blisters that have a waxy appearance and
do not blanch with pressure.
Lihat besar

FIGURE 4.
Full-thickness burn on a woman's left flank. Burn areas of this type are
characteristically insensate and waxy white or leathery gray in color.

Lihat besar
TABLE 1 Classification of Burns Based on Depth
Lihat Tabel
Differentiating a deep partial-thickness burn from a full-thickness burn can be
quite difficult initially.2,5,6 Revisions of burn-depth estimations are often
necessary in the first 24 to 72 hours5 and may be required through the first two
or three weeks.2 For instance, although a full-thickness burn typically has a white
or charred appearance, it can be red after a scald injury. It is also possible to
have a full-thickness burn underneath a blister, which is usually a characteristic
feature of a partial-thickness burn.3 Furthermore, thin skin sustains deeper burn
injuries than may be suggested by the initial appearance of the wound.5 Thin
skin is common on the volar surface of the arms and on the medial thigh,
perineum and ears. All skin can be presumed to be thin in children younger than
five years and in adults older than 55 years.5 It is best to assume that there are
no shallow burns in these age groups.7

EXTENT OF A BURN
The extent of a burn is expressed as the total percentage of body surface area
(TBSA) affected by the injury. Accurate estimation of the TBSA of a burn is
essential to guide management.

Multiple methods have been developed to estimate the TBSA of burns. These
methods are not used for superficial burns. The best known method, the rule of
nines, is appropriate for use in all adults and when a quick assessment is
needed for a child.2

More accurate methods are required for definitive estimation of the extent of
burns in children. The Lund and Browder method covers all age groups and is
considered the most accurate method to use in pediatric patients (Figure 5).2,8

Chart for Estimating Area of Burns

FIGURE 5.
Modified Lund and Browder chart for estimating the area of burns. This approach
is considered the most accurate for use in pediatric patients. The figures can be
colored in with red for full-thickness burns and blue for partial-thickness burns.

(2nd = second-degree burn; 3rd = third-degree burn; TBSA = total percentage of

body surface area)
Adapted with permission from Mertens DM, Jenkins ME, Warden GD. Outpatient
burn management. Nurs Clin North Am 1997;32:34364, and Lund C, Browder N.
The estimation of areas of burns. Surg Gynecol Obstet 1944;79:3528.
Lihat besar
The surface area of a patient's palm can also be used to estimate the extent of
small or patchy burns. Classically, the palm has been considered to represent 1
percent of the TBSA.2,6 However, a recent study demonstrated that the palm
more accurately represents 0.4 percent of the TBSA, and the entire hand
represents 0.8 percent of the TBSA.9

INPATIENT TREATMENT AND BURN UNIT REFERRAL

Patients considered to have moderate burns based on the grading system
developed by the American Burn Association (ABA) should be admitted for
intravenous hydration and surgical care of their wounds (Table 2).6,10 Because
of the initial difficulties in differentiating deep partial-thickness burns from fullthickness burns, family physicians should strongly consider obtaining a surgical
consultation for what appears to be a deep partial-thickness burn affecting more
than 3 percent TBSA.4

TABLE 2 American Burn Association's Grading System for Burn Severity and
Disposition of Patients
Lihat Tabel
Pulmonary insufficiency is responsible for more than 75 percent of fire-related
deaths.1 Because of the possibility of progressive edema, patients with
suspected inhalation injury should be observed for at least 12 to 24 hours.6,11
Historical or physical findings that raise concern about inhalation injury include
coughing, wheezing, dyspnea, facial burns, sooty mucus and laryngeal edema.4

Fiberoptic bronchoscopy or xenon ventilation-perfusion scanning results in more

frequent and earlier diagnosis of inhalation injury.12 One of these examinations
should be performed if the diagnosis of inhalation injury is in doubt.11

Patients at risk for inhalation injury should also be checked for carbon monoxide
poisoning. An arterial carboxyhemoglobin level of greater than 10 percent tends
to indicate carbon monoxide exposure. Hyperbaric oxygen is the treatment.13

Hospital admission is necessary for patients who have circumferential partialthickness or full-thickness burns, patients who have burn injury and are
considered to be predisposed to infection (e.g., those with diabetes), and
patients who have sustained a high-voltage electrical injury.14 Cardiac
arrhythmias can occur up to 72 hours after high-voltage electrical injury.15
Nonspecific changes in ST-T waves are the most common abnormalities noted on
electrocardiograms (ECGs) obtained subsequent to electrical injuries.
Observation is warranted until the ECG becomes normal.6

Children with burns should be admitted to a hospital whenever child abuse is

suspected. From 9 to 11 percent of burns in children are nonaccidental injuries,
with a peak incidence at 13 to 24 months of age.16 Immersion scalds are classic
burn injuries in child abuse, but abuse should be suspected with any scald injury,
especially if there is sharp demarcation between burned and normal skin or
splash marks are absent.6 Child abuse should also be strongly suspected in
children with burns suggestive of cigarette or hot-iron injuries.6

Referral to a burn unit is indicated for patients who meet the criteria for major
burns as defined by the ABA (Table 2).6,10 Included are patients who manifest
inhalation injury or have burn marks from high-voltage electrical injury.14

AMBULATORY TREATMENT
Minor burns comprise approximately 95 percent of burn injuries treated by
physicians in the United States.2 Most of these burns can be managed on an
outpatient basis. An algorithm to assist in identifying patients suitable for
ambulatory management is provided in Figure 6.4

Management of Burns

Gambar 6.
Algorithm for the management of patients with burns.
Adapted from Peate WF. Outpatient management of burns. Am Fam Physician
1992;45:1326.
Lihat besar

A systematic approach to the ambulatory management of burns is

conceptualized by the six Cs: clothing, cooling, cleaning, chemoprophylaxis,
covering and comforting (i.e., pain relief).4

Clothing. Any clothing that is hot or burned should be removed immediately from
the patient's body. Clothing that has been exposed to chemicals should also be
removed to avoid exposing the skin to continued burn insult. If clothing does not
remove easily, nonadherent material should be cut away, with adherent clothing
left for removal in the cleaning phase.

Pendingin.Ideally, burns should be cooled immediately after they occur.Although

most tissue has already cooled by the time patients with burns present to a
physician, further cooling during the first several hours after injury effectively
decreases burn pain.6 Sterile saline-soaked gauze, moderately cooled to around
12C (53.6F), can be applied to the burned tissues.17 Ice application should be
avoided.6,18 Because of the risk of hyperthermia, caution should be exercised in
cooling extensive burns (i.e., those with a TBSA of more than 10 percent).19

Membersihkan.Cleaning a burn wound is critical but can cause excruciating

pain.It is therefore important to establish local or regional anesthesia before the
wound is cleaned.Anesthesia should not be applied topically to a burn or injected
directly into the wound.6

Although disinfectants (e.g., chlorhexidine gluconate solution [Hibiclens],

povidone-iodine solution [Betadine]) are often employed to clean burn wounds,
their use is discouraged because these agents can actually inhibit the healing
process.5 There is growing support for washing burns with mild soap and tap
water.2,5,15,20,21 Once a burn wound has been cleaned, it should be thoroughly
rinsed.

Tar and asphalt residues should never be debrided5; instead, they can be
removed with a mixture of cool water and mineral oil.4 Applying copious
amounts of polymyxin Bbacitracin zinc ointment (Polysporin) over several days
should emulsify and remove residual tar.15 Embedded bits of clothing or other
materials should be removed by copious irrigation using a large-gauge syringe.4

To minimize infection, necrotic tissue from partial- and full-thickness burns should
be removed manually or with whirlpool debridement. The latter method tends to

be better tolerated by patients. The yellow eschar characteristic of partialthickness burns need not be removed.4

Ruptured blisters should be removed. Many experts recommend unroofing

blisters if they contain cloudy fluid or are likely to rupture imminently (e.g.,
blisters located over joints).15,22 The management of clean, intact blisters is
controversial. Intact blisters should never be aspirated with a needle because of
the increased risk of infection.3,15,22 The persistence of blisters for several
weeks, with no signs of resorption, typically indicates the presence of an
underlying deep partial- or full-thickness burn.6

Chemoprophylaxis. Tetanus immunization should be updated in patients with

wounds deeper than a superficial partial-thickness burn.23

Diagnosing infection in patients with burns is challenging. Burns elicit

inflammation, which results in mild erythema, edema, pain and tenderness. If
these signs occur in conjunction with lymphangitis, fever, malaise and anorexia,
or if they increase over a baseline level, infection should be suspected.6

Infection can involve the depth and extent of a burn, converting a superficial
partial-thickness burn into a deep partial-thickness burn or even a full-thickness
burn. An infected burn is also more susceptible to blood invasion and sepsis.
Because of these risks, all suspected burn infections warrant aggressive
management, including hospital admission and parenteral antibiotic therapy.15
Some authors contend that all infected burns require surgical referral with
consideration of full-thickness skin biopsy to confirm the presence of infection
and identify the causative organism.4 Full-thickness skin grafting after excision
should also be considered.24

Superficial burns do not require infection prophylaxis, but all other burns should
receive topical prophylaxis. Classically, silver sulfadiazine cream (Silvadene) is
used to prevent burn infections. This agent should never be used on the face or
in patients with sulfonamide hypersensitivity. Because of the risk of sulfonamide
kernicterus, silver sulfadiazine should not be used in pregnant women, newborns
or nursing mothers with infants younger than two months of age.4

Bacitracin is an alternative topical prophylactic antibiotic. This agent should

always be used around mucous membranes. Because of the decreased cost,
several authors favor using bacitracin rather than silver sulfadiazine for any

superficial partial-thickness burn.3 No studies comparing the efficacies of

bacitracin and silver sulfadiazine have yet been published.

Alternatives to topical antibiotics include biologic dressings (pigskin, human

allograft) and bismuth-impregnated petroleum gauze or Biobrane dressings. The
advantage of these dressings is that they are applied only once. As a result,
patients are spared the pain that typically accompanies dressing changes.

Biologic dressings are associated with lower infection rates and faster healing
rates than silver sulfadiazine. However, these dressings are expensive, difficult to
apply and not always readily available.14 If used, biologic dressings should be
applied within the first six hours after the burn is sustained. The initial
application may loosen by the following day, necessitating reapplication.
Thereafter, these dressings gradually peel off as skin epithelializes underneath
them. Early separation of the dressing from the skin indicates the presence of a
deeper wound (requiring surgical treatment) or an infection.5

Bismuth-impregnated petroleum gauze and Biobrane dressings appear to be

advantageous treatments and are acceptable for use in young children with
superficial partial-thickness burns.14,25 Both of these dressings are applied as a
single layer over the burn and are then covered with a bulky dressing. The bulky
dressing should be changed every other day, typically in a physician's office, with
close assessment of the wound for signs of infection.

Covering. Dogmatic recommendations regarding the type and duration of

dressing cannot be made because of the paucity of studies on the subject.6
Covering burns serves a number of purposes. Dressings provide anesthetic relief,
act as a barrier against infection and keep the wound dry by absorbing drainage.
The types of coverings differ, depending on the depth of a burn and its location.

Superficial burns do not require wound dressings. Use of a simple skin lubricant
(e.g., aloe vera cream) is sufficient, and patients should be instructed to see their
physician if any blisters develop.

All partial- and full-thickness burns should be covered with sterile dressings. A
fine mesh gauze (e.g., Telfa) should be applied after the burn has been cleaned
and a thin layer of topical antibiotic has been applied. Circulatory impairment is
minimized by applying this nonadherent dressing in successive strips, rather
than wrapping it around the wound.16 The dressing is held in place with a

tubular net bandage or lightly applied gauze wraps. Tubular net bandages come
in a variety of sizes. This bandage is excellent for use on extremities, and it can
be modified to fit the trunk of a younger child.

Recommended frequencies for dressing changes range from twice daily to once a
week.6 Dressings should be changed whenever they become soaked with
excessive exudate or other fluids.5 At each dressing change, the topical
antibiotic should be removed as completely as possible using gentle washings.
Scrubbing and sharp debridement are not necessary.5

Comforting. Analgesics should be given around the clock to control background

pain. Acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (alone
or in combination with opioids) are often appropriate for use in patients with
small burn wounds.26 Aspirin products should be avoided because of platelet
inhibition and the risk for bleeding.

Patients with burns often require a rescue medication (e.g., acetaminophen

with codeine [Tylenol W Codeine] or a stronger narcotic [e.g., morphine]) before
dressing changes and during increased physical activity.26 Narcotic medications
can be used in children as well as adults.14,16,27

A patient's worst pain score should be less than 5 (on a scale of zero to 10).
Scores of 5 or higher interfere with sleep, activity and mood.28

Follow-Up Care for Burns

Follow-up care involves surveying patients with burns for signs of infection,
scarring and contracture. To minimize further damage, infection is best managed
in a hospital. Scarring and contractures connote long-term disfigurement and
disability, both of which are indications for specialized care.

FOLLOW-UP INTERVALS
Patients with burns who are being managed as outpatients should be seen again
on the day after injury. At this visit, the level of pain can be assessed, pain
medication can be adjusted if necessary, and competence in managing dressing
changes can be assessed. Subsequent follow-up can then be performed on a
weekly basis until wound epithelialization occurs. However, if pain control is
insufficient or there are concerns about the ability of a patient or family members

to provide proper wound care, the patient should be seen on a daily basis until
complete epithelialization occurs.2,6

If wound epithelialization has not begun after two weeks or if subsequent

evaluations reveal the presence of a full-thickness burn more than 2 cm in
diameter, the patient should be referred to a surgeon with expertise in burn
care.2,6,15 Tiny opalescent islands of epithelium throughout the wound indicate
epithelialization, with the wound typically healing completely in seven to 10
days.6

After epithelialization has occurred, patients are seen every four to six weeks to
assess for evidence of hypertrophic scar formation and to monitor coping
mechanisms.

HYPERTROPHIC SCARRING AND CONTRACTURES

It has been said that time heals all wounds. This is not necessarily the case
with burns. Although the threat of infection and the magnitude of pain diminish
with time, the prospects for long-term scarring and disability often become more
apparent. Hypertrophic scarring is thought to be inevitable when epithelialization
takes longer than two weeks in blacks and young children, or longer than three
weeks in all other patients.29

Application of pressure to burn wounds is generally recommended to minimize

hypertrophic scarring, although optimal pressure and duration have not yet been
determined in controlled trials.30 A variety of techniques are used, but all are
complex and costly. Therefore, family physicians often refer patients at risk for
scarring to a burn specialist. Because pressure prevents scars but does not treat
them once they develop, referral should be initiated promptly at the first sign of
hypertrophic scarring or if a wound misses certain epithelialization milestones
(Table 3).31

TABLE 3 Wound Epithelialization Milestones

Lihat Tabel
Although pressure does little to remodel existing hypertrophic scars, the
application of silicone gel sheeting has been found to significantly reduce
established scars as late as 12 years after injury.31 A two-month trial of the
continual use of silicon gel sheeting on established scars distinguishes

responders from nonresponders.32 Side effects of pruritus and rash can be

minimized by washing the scar and applying silicon gel daily.33

Scar contractures result in disfigurement and disability. If detected early, a

contracture can be treated with silicone inserts and pressure. If the contracture is
more developed, a continuously worn static splint is added to maintain sustained
stretch. Once full range of motion is achieved, splinting can be reduced to
nighttime use until the scar fully matures. Surgical intervention should be
considered if the contracture is not completely reduced.31

ROLE OF SURGERY
Surgical excision and skin grafting beginning less than 72 hours after injury is
beneficial and is indicated for nonscald full-thickness burns in children and in
adults younger than 30 years of age.30,34 All other patients with suspected fullthickness burns should be observed for eight to 10 days, as nothing is lost by
delaying surgical excision.5 It is also best to wait two weeks before assessing the
need for surgery in children with hot-water scald burns because overly
aggressive excision and skin grafting in this group has resulted in worse
outcomes.35 Full-thickness burns less than 2 cm wide can be allowed to heal by
contracture as long as they are in nonfunctional, noncosmetic areas and the skin
is not thin (e.g., the ankle).21

COPING WITH THE INJURY

After epithelialization occurs, no further dressing changes are required. However,
patients should be instructed to use a non-perfumed moisturizing cream (e.g.,
Vaseline Intensive Care, Eucerin, Nivea, mineral oil or cocoa butter)6 until natural
lubricating mechanisms return.2 Use of preparations with a high lanolin content,
thick waxes and ointments should be avoided.5 In addition, a sun block with a
skin protection factor greater than 15 should be used to prevent
hyperpigmentation until the wound loses its pink and red coloring.2 Depending
on the depth of injury, it usually takes six months to two years for a burn wound
to heal completely.5

Itching is a common problem during the healing process. Pruritus is often

triggered or worsened by environmental extremes (especially heat), physical
activity and stress.6 The itching usually diminishes gradually and eventually
stops after complete wound healing.6 Until then, a number of measures can be
employed to control itching. Systemic antihistamines are usually tried first, with
diphenhydramine (Benadryl) used most frequently.5,6 Cyproheptadine (Periactin)
and hydroxyzine (Atarax) are alternatives.6 Local measures include bicarbonate

of soda baths and moisturizing lotions.5 Many patients prefer to wear loose, soft,
cotton clothing.6

In addition to helping patients cope with long-term physical discomfort, family

physicians should be alert for psychologic issues. Patients who have sustained
burns are at increased risk for anxiety, depression and post-traumatic stress
disorder. Family dynamics can also change dramatically. Family members may be
stricken with guilt, and patients are susceptible to dependency issues because of
the additional help required for daily activities while healing is occurring. If a
psychologic issue is noticed, appropriate treatment should be implemented.27

The Authors
ERIC D. MORGAN, MAJ, MC, USA, is residency director for the Department of
Family and Community Medicine at Eisenhower Army Medical Center, Fort
Gordon, Ga. He received his medical degree from Loma Linda (Calif.) University
School of Medicine and completed a family practice residency at Tripler Army
Medical Center, Honolulu. He also earned a master of public health degree from
the University of Washington, Seattle, and completed a faculty development
fellowship at Madigan Army Medical Center, Fort Lewis, Wash.

SCOTT C. BLEDSOE, CPT, MC, USA, is a staff physician at the Family Practice
Clinic, Weed Army Community Hospital, Fort Irwin, Calif. He graduated from
Kirksville (Mo.) College of Osteopathic Medicine and recently completed a family
practice residency at Eisenhower Army Medical Center.

JANE BARKER, CPT, MC, USA, is a staff family physician at the Family Health
Center, Moncrief Army Community Hospital, Fort Jackson, S.C. She graduated
from Kirksville College of Osteopathic Medicine and recently completed a family
practice residency at Eisenhower Army Medical Center.

Address correspondence to Eric D. Morgan, MAJ, MC, USA, Residency Director,

Department of Family and Community Medicine, Eisenhower Army Medical
Center, Fort Gordon, GA 30905-5650 (e-mail address:
Eric.Morgan@se.amedd.army.mil). Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of the
Army Medical Department or the Army Service at large.

The photographs in figures 1 through 4 were provided by Steve Bracci of the

Joseph M. Still Burn Center at Doctors Hospital, Augusta, Ga.

This article is dedicated to Elisabeth Morgan, the daughter of Dr. Eric D. Morgan.
Elisabeth sustained a severe scald injury shortly after her first birthday. Although
Elisabeth's skin permanently reflects the tragedy of the accident and has forever
sensitized her physician father to the horror of burns, her tenacity, vitality and
joy for life are a testament to the ability of the human will and personality to be
more flexible and forgiving than the sometimes fragile bodies in which we live.

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Members of various medical faculties develop articles for Practical

Therapeutics. This article is one in a series coordinated by the Department of
Family and Community Medicine at Eisenhower Army Medical Center, Fort
Gordon, Ga. Guest editor of the series is Ted D. Epperly, COL, MC, USA