General Medical Officer (GMO) Manual: Clinical Section
Burns
Department of the Navy
Bureau of Medicine and Surgery
Peer Review Status: Internally Peer Reviewed
(1) Introduction
Treatment of minor outpatient burns and the referral of major burns is an important aspect of emergency medicine.
The essence of successful management of burn injuries is effective triage, timely assessment, and appropriate
resuscitation.
(2) Evaluation
Important historical information that must be obtained from a burn patient includes the following points:
(a) The causative agent (thermal, electrical, chemical, radiant).
(b) The time and extent of exposure.
(c) The patients medical status (trauma, illnesses, allergies).
(d) The time, location (open space vs. closed space), and extent of injury sustained. Also determine the
tetanus status, alcohol and drug use, and what first aid treatment was provided.
(3) Defining the Burn
Significant physical findings in burn injuries are related to depth
and extent of the burn. First-degree burns are the equivalent of a
bad sunburn and are characterized by pain and redness. Within a
few days the outer layer of injured cells peel away from the
totally healed subjacent skin with no residual scarring. Seconddegree burns are usually quite sensitive, both to touch and to
exposure, are moist with exudate, and are prone to blister
formation. With proper care such wounds may heal
spontaneously, though healing may require 2 to 3 weeks. Thirddegree burns are less painful, often anesthetic, and skin is dead,
white or charred, with a dry surface. Restoration of the integrity
of the skin can be accomplished only by grafting skin from nonburned areas of the body. Extent and size of burns are easily
determine by the rule of 9's, using charts available or by
comparison with the patient's palmar surface area, which
represents roughly 1 percent of the total body surface.
(4) Outpatient vs. Inpatient Treatment
The important differential diagnosis in burn injuries is burn severity and extent which determines whether the burn
patient can be treated as an outpatient, or requires admission to a general hospital or a burn unit. Most deep second
and almost all third degree burns should be admitted. This is especially true if the burn; involves a smoke inhalation
(respiratory injury), involves more than 20 percent skin surface, or involves critical anatomical areas such as hands,
face, feet, genitalia, perineum, and major joints. Electrical and chemical burns regardless of size are deceptive in
depth and nearly always require hospitalization.
Smaller burns which appear to be partial thickness in depth may be treated as an outpatient provided the patient can
obtain frequent follow-up examination, his or her dressing changes and medications are appropriately monitored, and
the symptoms and findings are not deteriorating under treatment.
(5) Management
All major burns (greater then 20 percent full or partial thickness) require appropriate advanced trauma life support
(ATLS) protocol with emphasis on airway and fluid resuscitation and transfer to a burn center. The more common
smaller partial thickness burns may be treated as outpatient after thorough washing with surgical soap (Hibiclens or
Phisohex) and application of a sterile non-adherent dressing such as Xeroform or Adaptic gauze covered by a sterile
bandage. Further management requires protection from the environment with application clean dressing and
bandages, daily, or twice daily along with cleaning with a mild soap until the burn has healed. Topical antimicrobials
(i.e., Silvadene) systemic antibiotics should not be applied to these burns unless there are specific indication for these
drugs (i.e., signs of infection). Blisters or bullae that are small and intact need not be opened or removed unless they
impede pint motion or show signs of infection. Superficial small size burns about the face can be treated open
(without dressing) by daily cleaning and application of Bacitracin ointment. Tetanus prophylaxis and analgesics
should be used as indicated.
(6) When to refer
Should during the outpatient treatment of smaller burns, the wounds show signs of infection or the burn fails to heal
within 2 weeks, the patient should be referred for hospitalization and more extensive treatment. Patients with major
burns that meet the American Burn Association (ABA) criteria for burn center referral should be assessed, stabilized,
and immediately transferred to a burn center. This requires physician-to-physician contact to assure the patient's
needs are met throughout every aspect of the transfer. In the military system, burn center referral can be obtained
through the Army Institute of Surgical Research (Brook Army Medical Center Burn Unit); by telephone request 24
hours per day to the duty physician (512)-221-2943, DSN: 471-2943, or (512) 222-2876.
References
(a) Advances in Burn Care, Clinic in Plastic Surgery, 1986,13:1, W. B. Saunders
(b) Am. Burn Life Support Provider's Manual, 1990, Nebraska Burn Institute, Artz, Moncrief and Pruit,
1979.
(c) Burn, A Team Approach, W. B. Saunders, William F. McManus, M.D., Colonel, MC, USA, Personal
Communication Wiener and Barrett, 1986, Trauma Management, chapter 5, W. B. Saunders
Originally written by CAPT Robert F. Brewer, MC, USN, Department of Plastic Surgery, Naval Medical Center
Portsmouth. Reviewed by CAPT Patrick W. Lappert, MC, USN, Head, Department of Plastic Surgery, Naval
Medical Center Portsmouth, VA (1999).