This resource discusses triage and care of burns in the clinical and home setting.

The skin is the largest organ of the body. It protects the body from infection, controls fluid loss, helps maintain body temperature, enables sensing of the environment, and plays a part in determining identity. The skin is composed of 2 layers - the epidermis, which is the outermost layer, and the dermis. Beneath the dermis lies the subcutaneous fat layer that holds the dermis to other body tissues and organs. The dermis contains, among other things, hair follicles, sweat glands, and nerve endings. This is why burns are typically very painful.

When the skin comes into contact with a temperature source significant enough to cause cell damage, a burn injury will result. The depth of the burn wound will depend on the duration of contact, the temperature of the heat source, and the thickness of the skin. Because children have a thinner dermis, they are at an increased risk of thermal injury at lower temperatures. Exposure to a temperature of 140°F (a common setting for home water heaters) can cause a third-degree burn in as little as 3-5 seconds.

First-degree (superficial) burns affect only the epidermis (outer layer) of skin. The burn site is red, painful, dry, and with no blisters or delayed blisters. Mild sunburn is an example. They will heal without treatment.

Second-degree (partial-thickness) burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, moist, blistered (tense, fluid-filled, and may be swollen and very painful. They usually will heal in 10-14 days.

• Deep second-degree burns involve the first and second layer of skin. The burns appear dry, waxy, white, or dull colored. They are less painful than milder second-degree burns and take more than 10 days to heal.

Third-degree (full-thickness) burns destroy the epidermis and dermis and may go into the subcutaneous tissue. The burn site may appear dry and leathery with tight swelling. The burns are relatively painless.

In general, third-degree (full-thickness) burns require emergency care. Second-degree (partial-thickness) burns require immediate care if they occur on the face, hands, face, feet, or genitals or over a major joint or large area of the body. Otherwise, home care is typically adequate for first-degree (superficial thickness) and second-degree burns.

The American Burn Association (ABA) recommends referral to a burn center that provides pediatric burn care for the following:

• Partial-thickness burns greater than 10% of Total Body Surface Area (TBSA)
• Full-thickness burns (but use clinical judgment in those less than 2% of TBSA)
• Burns on the face, hands, face, feet, genitals/perineum, or over a major joint
• Electrical, chemical, or inhalation burns
• Patients with complicating factors, such as underlying medical fragility, more extensive trauma (e.g., fracture - although may need to be stabilized in a trauma center first)
• Patients with extensive social, emotional, or rehabilitation needs - burn centers often provide multidisciplinary support, including social work. [Moss: 2010]

Scattered or splashed burn size can be estimated using the full size of the child’s palm including fingers as approximately 1% of their TBSA. [Moss: 2010]

The medical home clinician can offer the following home-care advice for minor burns or follow these steps if the child with minor burns presents at the primary care clinic:

• Cool the burned area with cool (not cold) water or cool compresses for a few minutes initially. Do not continue to cool or ice it after that.
• Remove jewelry or tight items before the affected area swells.
• There is lack of consensus on whether or not to break blisters. If blisters break or you debride them, wash gently with water and soap, then apply antibiotic ointment (unless the child gets a rash due to the ointment).
• Apply an ointment containing aloe or another moisturizer when the burn has cooled. Over-the-counter antibiotic ointment or petrolatum ointment is also acceptable.
• Wrap the burn loosely in sterile gauze; superficial burns do not require covering. Do not wrap in occlusive dressings like plastic wrap. Using a non-stick gauze such as a petrolatum ointment-penetrated gauze as the first layer over the ointment makes it easier to change the dressing.
• If using a dressing with adhesive borders, consider shaving the hair adjacent to the wound site for ease of removing adhesive dressings.
• Keep the burned area elevated above the heart initially to help not only with pain and swelling but also to encourage full range-of-motion activities right away. This helps reduce edema and promotes healing.
• Give a pain reliever, such as ibuprofen or acetaminophen, if needed.
• Wash the burn and re-dress the wound twice daily while it heals.
• Home care is appropriate if there is adequate pain control, the family is able to help the child wash the area twice daily and change dressings, and the child can perform full range of motion activities or therapies and adequate oral intake and hydration.

For burns that are significant but do not require emergency care or burn center referral, there are a few additional considerations for the primary care clinician.

• Ensure updated tetanus vaccine as appropriate.
• Blistering burns are considered sterile for the first 24 hours, and the fluid does not need to be cultured. Experts do not advise prescribing systemic antibiotics to prevent wound infections. Counsel families to watch for infection and return for evaluation if concerned.
• There are differences in expert opinion on how to manage blisters and debridement. See [Moss: 2010] for more details.
• Evaluate range of motion as burned skin contracts. Counsel families on continuing range of motion exercises at home. Consider referral to physical therapy.
• Short-term hospitalization may be indicated if pain control is inadequate, such as for large superficial burns.
• Consider surgical referral for burns that are not healing within 2 weeks and not fully healed in 4 weeks.
• Remain vigilant for secondary problems such as itching, infection, sleep disturbance, or depression (including parents who may feel guilty about the injury). Be mindful of the cost of specialized dressings.
• Prevent sunburn of scar tissue by advising liberal use of sunblock for up to the year and a half that it takes for a scar to mature. [Moss: 2010]

After a child has been treated in the emergency room or burn center, wound care and pain management may continue at home or in the primary care setting. This includes information about pain management and wound dressing changes for burns that have previously been evaluated and managed in a medical setting.

Pain Management for Follow-Up Burn Care
Prior to performing wound care for burns, give some form of analgesia if indicated. Oral medication should be taken 30-45 minutes prior to changing the dressing. Pain will gradually decrease when dressings or skin grafts cover the wounds or healing has occurred. Keeping the burn elevated and maintaining normal activity will also decrease pain and swelling in addition to promoting healing.

Follow-Up Wound Care for Burns
Good wound care promotes healing and prevents infection. There are numerous topical agents and types of dressing to choose from. The dressing type depends on each patient’s wounds and their individual needs; therefore, dressing change recommendations vary. See below for discussion of different dressings.

Regardless of product type, the basic principles of wound management are the same.

• Prepare the new dressings prior to the wound change. This will decrease the time the open skin is exposed to air and will help decrease the pain.
• Prior to performing the dressing change, the care provider’s hands should be washed with soap and water.
• Gently remove old dressings. Saline can help loosen old dressings for less painful removal.
• Gently wash wounds with mild soap and water. The goal is to remove loose skin and old ointment in addition to any wound drainage. This exposes healthy tissue and helps to control bacteria. If washing multiple wounds, a separate washcloth should be used for each body part to avoid the spread of bacteria from one wound to another. For example, 1 washcloth should be used for the leg and another for the arm. Forceful scrubbing may injure the new skin buds. A gentle, but firm pressure is best.
• After washing, gently pat the wounds dry.
• Prior to application of the new dressings, the care provider should wash their hands again with soap and water.

Heat loss can occur with large burns
For large burns, keep the child from becoming cold during the dressing change; body heat can be lost quickly.

Wash face and neck burns at least 2 times daily
Face and neck burns should be washed at least 2 times a day removing all old ointment and any loose skin. Apply Bacitracin ointment to all open areas. If this ointment rubs off during the day, instruct the caregiver to reapply Bacitracin as often as needed to keep wounds moist.

Watch for signs of infection
While a low-grade fever is normal with burn injuries, healing of burn wounds can be complicated by infection. Swelling of the burned area is normal. Warning signs of infection include increased redness, swelling and/or warmth in the normal skin surrounding a burn, increased pain, and fever.

Managing itching skin that is healing
Healed skin may have a dry, scaly appearance and be very itchy. Itching is a normal part of the healing process. Scratching the new skin may result in new open wounds. Keeping the skin moisturized is often an effective way of managing itching. Use of oral antihistamines can be considered.

Diet is important
When a body is burned, it requires increased calories and fluids to heal. A healthy nutritious and well-balanced diet, especially including foods high in protein, will improve wound healing.

Psychological toll of burns
Burns are one of the most psychologically devastating injuries to patients and their families, and recovery may take a long time. There are several burn support groups and programs available to positively facilitate the recovery process.

Turn down water heater temperature
Exposure to a temperature of 140°F (a common setting for home water heaters) can cause a third-degree burn in children in as little as 3-5 seconds. Primary care clinicians should advise families to set their water heater at a max of 120°F.

The frequency of wound care will depend on the topical agent or dressing type ordered by the physician. Common dressings used for burns include: [Dai: 2010]

• Silver sulfadiazine dressing (SSD) (e.g., Thermazene or Silvadene) covered with a minimal amount of gauze: Home Care: change twice daily. Because burns are at risk for developing infection, antibiotics may be used to prevent infection. The SSD has been considered the “gold standard” for burn care as it has good antibiotic properties, although some resistance has developed. Be aware that silver nitrate is not optimal for treatment of burns and should generally be avoided.
• Bacitracin covered by a non-stick gauze such as Adaptic (B & A). Home Care: change once daily. The Bacitracin is an example of an over-the-counter topical antibiotic used to prevent infection. It is a good option for patients who have a sulfa allergy so have to avoid the silver sulfadiazine dressings.
• Mepilex AG gray foam covered with a minimal amount of gauze and netting. NOT ADVISED FOR HOME DRESSING CHANGES. Changed at least weekly at the burn center or primary care clinic. This type of dressing takes advantage of the antibiotic properties of silver and can be cut to fit the patient’s needs and can be used on partial thickness burns. Consider this for children who would benefit from less frequent changes.

The information below contains examples of the most common burn dressing types with patient instructions for care. It is adapted with permission from the University of Utah Health Care Burn Center.

Silver Sulfadiazine Dressing (Thermazene or Silvadene):

Your burn has been dressed in Silver Sulfadiazine. This is to be changed 2 times a day. This is very important to promote healing and prevent infection.

Follow these guidelines as your Primary Care Provider has instructed you:

• Wash the burn with mild soap, water, and a washcloth, removing all old ointment and any loose skin.
• Blot dry.
• Apply a thick coat of Silver Sulfadiazine (like icing on a cake) and cover with a minimal amount of gauze netting. Silver Sulfadiazine tends to work better when some air can get through the dressing.

Bacitracin and Adaptic (B & A):

Your burn has been dressed in Bacitracin with non-stick gauze. This dressing is changed once a day. This is very important to promote healing and prevent infection.

Follow these guidelines as the Primary Care Physician has instructed you:

• Wash the burn with mild soap, water, and a washcloth, removing all old ointment and any loose skin.
• Blot dry.
• Apply a very thin coating of ointment only to the open areas.
• Place the non-stick gauze over the ointment. Do not overlap excessively.
• Cover with minimal amount of gauze followed by netting.

Mepilex AG:

Your burn has been dressed in Mepilex Ag. This dressing is NOT to be changed until your next clinic visit. Follow these guidelines as the Primary Care Physician has instructed you:

• Keep dressing clean, dry, and intact. If dressing becomes wet, please contact the Burn Clinic. You may change the outer gauze wrap and netting if there is excessive drainage or it becomes dirty. Do NOT remove gray foam.

Face and Neck Burns:

Face and neck burns should be washed at least 2 times a day, removing all old ointment and any loose skin. Apply Bacitracin ointment to all open areas. If this ointment is rubbed off during the day, reapply Bacitracin as often as needed to keep wounds moist.