Thermal Burns

This post, inspired by a smiling patient with a sub 1st degree, coffee burn that found me in an ER. There are bad burns and everything else. The above injury fit the latter. Here are what we use in ERs to separate wheat from chaff:

Red Flags:

• Blistering
• White with no sensation in the middle (suggesting deep with burnt nerves)
• Circumferential (around an arm, leg, neck, chest, etc)
• Over a joint
• Face, hands, genitals involved
• Uncontrolled pain
• Older burn with signs of infection
• Comorbidities like diabetes
• Kids (We look extra close for abuse.)
• Elderly (We try to ID ongoing hazards at home.)
• Concurrent inhalation injury (singed nose hairs, wheezing, facial soot)
• Indoor fire with carbon monoxide or cyanide exposure
• “I was hit by lightning and you can see the entrance wound. The exit wound blew off my shoe. And I’m not sure how long I was unconscious.”

Happy Words

• Localized injury that doesn’t inhibit movement
• “I spilled coffee on myself. Doesn’t really hurt but just thought I’d get it checked.”
• “This is a worker’s comp injury. I’m fine.”

Rule of thumb: If you’re wondering whether or not to call Pre-R, you’re very likely going to be fine. People with clinically significant burns don’t spend a lot of time Googling urgent cares or scanning Yelp reviews. Serious burns are some of the most painful and horrendous injuries you can imagine and most lead to 911.

If you do find an ER, here’s what to expect… First off, we’ll try to help your pain. This will probably be done with narcotics like morphine, but NSAIDs like Toradol or ibuprofen can be quite helpful too. We’ll try to cool your injury as well, sometimes by running it under cool water. Some burns may need cleaning, for example those splashed by acid or hot tar.

Few ERs have a product called Water-Jel, but I’m a big fan. If you work in a setting where burns are possible, you may want to have some on hand. It certainly beats butter, mayo, crisco and other home remedies that some folks apply.

Blister debridement is something else we’ll attempt once pain is controlled. This means we’ll try to cut away any dead or hanging tissue to limit infection. Sometimes we’ll leave intact blisters to form a “physiologic dressing,” but for blisters over joints, we’ll generally remove the dead skin and cover with bacitracin and non stick dressings. Silvadene is popular for severe burns, but beware for those with sulfa allergy.

For the worst burns we also hyper hydrate with IV fluids, because burns are like holes in a boat. It’s amazing how much fluid can be lost through weeping burns in the first few days. (For med students here, Google “Parkland Formula.”) Urine output is our main guide for hydration.
And expect a tetanus booster.

Pre-R rarely gets burn related calls. However, I suspect we could have saved my coffee burn patient $500-1000 bucks. Actually, nah… He was workers comp.

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