Outpatient burn care

Introduction

Epidemiology

Burns are one of the most frequently-occurring types of injuries. Estimates place the number of burn victims in the United States at 1.25 million annually, 40,000 of which require inpatient treatment at a hospital [1]. Other sources write that the US has 700,000 burn victims annually, with 35,000 hospital visits. Both sources show that the percentage of victims with severe injuries requiring inpatient care is around 5%. The figures are similar in Germany. With a total of 350,000 burn victims and 15,000 inpatient cases, the ratio here is 4.3% [2].

Accident causes

The most frequent cause of all injuries from scald burns and burns resulting from contact with flames and hot objects are accidents around the home. The number of such injuries which occur in the workplace has dropped significantly. In this context, most injuries occur in the food service industry as a result of scald burns and contact burns [3].

Care structures

The care structures in highly-developed industrialized nations are, to a large extent, the same. Patients

Marc G. Jeschke et al. (eds.), Handbook of Burns

are offered both outpatient as well as inpatient treatment. In Germany, hospitals’ emergency departments and doctors in private practice are the first point of contact for burn victims. In addition to correctly assessing and evaluating the wound, this is where the patients’ further course of treatment is determined.

The goal of the following chapters is to explain the indications for inpatient burn treatment as well identify the most important care principles. If, in the course of providing inpatient care, complications such as an infection or delayed wound healing should arise, the approach to inpatient treatment must but reconsidered and the patient must be submitted to a specialized burn care facility. In the cooperation between specialized outpatient and inpatient care structures, this is the only way to achieve ideal treatment results for the patient while simultaneously cutting healthcare costs [4].

Indications for inpatient treatment

Upon receiving a patient with a burn injury, the physician first treating the patient at a hospital’s emergency department or in their own practice must determine whether an indication for inpatient treatment exists. In doing so, the physician must initially determine whether the indication for transferring the patient to a specialized center for severe burn

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treatment exists as set forth in the guidelines published by the German Association of Burn Medicine (Deutsche Gesellschaft für Verbrennungsmedizin). These indications (Table 1) must be adhered to in order to begin providing the patient with burn treatment in a timely and professional manner. In addition to the indications set forth in these guidelines which govern whether a patient must be transferred to a specialized burn care center, other indications exist which determine whether a patient should be provided inpatient treatment and forgo outpatient care [5]. The following chapters discuss in detail the most important criteria for making this determination in a professional manner. These include the patient’s age, the depth of the burn, the surface area of the body which has been burned, as well as special burn cases. In this context, correctly evaluating the depth of the burn plays a crucial role. In particular, superficial second degree burns represent an area of conservative treatment. In special cases, they are suitable for outpatient care [6].

In this context, physicians must pursue the following goals:

An optimal functional and aesthetic result for the patient when receiving treatment outside of specialized centers

Palliation of physical and mental discomfort

Adequate follow-up care

Changing the treatment regimen in a timely fashion should complications arise

Patient age

The elderly above the age of 70 as well as small children are particularly at risk for injuries from burns. The group of patients between 5 and 20 years of age has the best prospects for recovery, as this group’s 50% mortality rate now applies to cases where 94.5% of the body’s surface area is burned [7]. In contrast, patients over 70 have a 50% mortality rate in cases where burns cover 29.5% of their body [8]. This agerelated risk is also reflected in the aforementioned guidelines governing indications for transferring patients to specialized burn centers. Patients under the age of 8 as well as those over the age of 60 require special care, which includes hospitalization in spe-

cialized centers. Patients above the age of 60 particularly exhibit a slowed biological wound healing process. This must be taken into consideration when making the necessary plans for outpatient treatment. Similarly, small children and the elderly also often have thinner skin [9].

Age represents an important factor for deciding whether a person requires conservative outpatient treatment or inpatient care.

Total burned body surface area (TBSA)

Ultimately, the extent of the surface of the body affected is the deciding factor which determines whether a person can be offered outpatient treatment. When making this estimation, Wallace’s wellknown “Rule of Nines” as well as the “Rule of Palms”, which is particularly suited for estimating the size of smaller injuries, are both used. This rule states that the surface of the patient’s palm represents 1% of their body surface area. When initially evaluating a patient’s burns, one must always estimate the size of the affected area [10].

Depending on the location of the burns, patients with superficial burns covering up to 10% of the body can be given outpatient treatment. The location of the burn is extremely important, however. A completely burned hand or a 1% burn in the face, covering large joints, in the genital area, or near the feet is enough to cause numerous complications, and such burns can heal badly. In such a case, inpatient treatment for patients with smaller wounds in these areas must be considered, and the patients should be transferred to a specialized center pursuant to the aforementioned guidelines [11].

Depth of the burn

Under conservative treatment, individual superficial burns heal with a positive aesthetic and functional result within a maximum period of three weeks. The different burn depths from first to third degree have already been explained in one of this book’s earlier chapters. It is important to note that when dealing with second-degree (partial-thickness) burns, one must differentiate between superficial and deep par- tial-thickness burns. Similar to third-degree burns, deep partial-thickness burns usually also require

Fig. 1. Shows a significantly reddened superficial partialthickness burn

surgery, which means that outpatient treatment is not suitable for patients with such burns [12].

In order to differentiate between the two types of wounds outside of a specialized environment, the following rule can be applied:

Second-degree burns are moist, painful, associated with the formation of blisters and have a coloration from white to pink or red, while thirddegree burns are dry, painless, and have a coloration running from grey-white to brown. Superficial partial-thickness burns exhibit significant capillary regrowth, which means that the skin’s dermal plexus has survived and is enlarged similar to an inflammation. This capillary regrowth is one of the most important signs used to differentiate between superficial and deep partial-thickness burns. At this point however, we must once again refer to the special locations which can also complicate superficial burns, and as such to these zones (see indications for transfer to a burn center). Physicians should select inpatient treatment for those affected by these cases [13,14].

Pre-existing conditions

The burn victim’s pre-existing health condition has both an influence on the healing process as well as on the results which can be expected. Burn patients in reduced states of consciousness, with neurological diseases with paresthesia, as well as those with mental health illnesses should receive inpatient

Fig. 2 Shows a deep partial-thickness burn, which from its outward appearance looks similar to a third-degree burn

treatment. The same applies to those taking sedative medications and/or drugs and alcohol [15].

When it comes to internal diseases the focus is on renal insufficiency as well as cardiovascular disorders such as cardiac defects, arrhythmia, high blood pressure and also pulmonary diseases. In addition, this also includes diseases that have an effect on wound healing, such as diabetes mellitus, chronic alcoholism and chronic steroid use. Furthermore, this also includes autoimmune disorders and malignant tumors [16].

When determining a patient’s medical history, these individual diseases must be analyzed and their impact on the entire burned area as well as the patient’s overall condition must be estimated. A person can only receive inpatient treatment after a reliable estimation and risk analysis has been carried out. Frequently analyzing such a patient’s overall health condition may also be necessary during the course of providing inpatient treatment.

Accompanying injuries

The most frequent injury accompanying burns is damage to the pulmonary system as a result of smoke and carbon monoxide. This is known as inhalation trauma and can always occur alongside burns from flames. In this case, the physician providing initial treatment must determine whether the patient has suffered a smoke inhalation injury, and if so, the ex-

tent of the damage [17]. An examination of the patient using auscultation as well as a blood gas analysis are obligatory. Carbon monoxide poisoning can particularly cause the patient to appear disoriented, tired, or exhibit signs of other psychological or mental impairments. Determining the level of carbon monoxide in the patient’s blood is also necessary. It is not enough to simply measure the oxygenation of the patient’s hemoglobin.

If there is reason to suspect that the patient’s upper respiratory tract has been injured through heat or a relevant smoke inhalation injury, they must receive inpatient treatment, and if they only exhibit signs of inhalation trauma, they should at least be kept in the hospital for observation [18].

An additional point of interest are accident-re- lated accompanying injuries. The physician providing initial treatment must always search for additional injuries that may have been caused by falling, jumping from significant heights or trauma caused by the force of explosions. If findings are inconclusive or the mechanics of the accident require it, this case also requires clarification by a team specialized in dealing with such trauma [19].

Special injuries

Finally, one must respond to special types of injuries which are also known to lead to complications during the wound healing process, and as a result, require the injured person to receive inpatient care. This includes electrical burns, chemical burns, as well as self-inflicted injuries or those caused by third parties [20].

Electricity

In day-to-day life, we usually deal with high-voltage electricity of over 1,000 volts or regular household electricity which has between 110 and 220 volts. While injuries from high-voltage electricity or electric arcs can cause significant tissue damage, contact with household electricity often causes heart conditions from arrhythmia to ventricular fibrillation [21].

Since the electrical resistance of the skin is relatively high, the electrical current often looks for other paths through the body. It flows under the skin through neurovascular bundles as well as muscles