Written by: Mitch Blenden, MD (NUEM ‘24) Edited by: Vytas Karalius, MD, MPH, MA (NUEM ‘22) Expert Commentary by: Matt Levine, MD
Expert Commentary
Dr. Blenden and Dr. Karalius provided an excellent handy, high-yield, quick reference of thermal burn considerations in the ED. There are some nuances of thermal burn care that I’d like to provide further commentary:
A pitfall is underestimating the severity of the burn when the patient presents within a few hours of the event. Burn appearance evolves over 24-48 hours. What initially appears as erythematous skin can be covered in bullae the next day. Consider a repeat examination in 24-48 hours, or at least discuss with the patient the possibility that this may occur and what to do if it does. Otherwise, if you initially diagnosed the patient with superficial burns and provided only instructions for superficial burns, which require little treatment or follow-up, the patient can be set up for a worse outcome when these burns subsequently declare themselves to be partial thickness.
For years, most non-facial burns were sent home with instructions to use silver sulfadiazine (AKA Silvadene) cream. This would require teaching of how to apply and remove it. The cream needs to be removed daily before applying a new coat (I always sent the patient home with tongue blades to scrape it off). The benefits of this are that it debrides some nonviable tissue when the cream is removed and provides a moist antimicrobial barrier. The down sides are that removal can be painful and some patients have difficulty performing this procedure, which requires teaching. Silver sulfadiazine can also cause skin staining. There is scant evidence recommending one topical antimicrobial over another. For these reasons, practice (including mine) has evolved in many places to simply prescribe whatever antibiotic ointment is on hand for ease of use and less painful and technically challenging application.
Another controversy is whether to debride blisters and bullae or leave them intact. This is another area without definitive evidence and practice is often guided by gestalt, local custom, or prior teachings. On one hand, intact bullae can be thought of as “sterile” coverings and may be less painful than dermal layers exposed to air and friction. On the other hand, when bullae rupture, the patient is left with dead skin which can be a nidus for infection. My practice has been to leave small blisters intact and debride large bullae if it seems like they will soon rupture and leave the patient with hanging skin fragments. If the patient has reliable follow up burn care then I may choose a less aggressive approach in debriding. Other clinicians are likely to give alternate approaches so ask your attendings what they do in these scenarios so you can develop a practice pattern that makes sense to you.
Matthew Levine, MD
Associate Professor of Emergency Medicine
Department of Emergency Medicine
Northwestern Memorial Hospital
How To Cite This Post:
[Peer-Reviewed, Web Publication] Blenden, M. Karalius, V. (2021, Oct 18). Managing Minor Thermal Burns in the ED. [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/managing-minor-thermal-burns
