11.03 Partial Thickness (Second-Degree) Burns and Tar Burns

agk’s Library of Common Simple Emergencies

Presentation

Small, (<6% total body surface) partial thickness (second degree) burns can occur in a variety of ways. Spilled or splattered hot water and grease are among the most common causes, along with hot objects, explosive fumes, and burning (volatile) liquids. The patient will complain of excruciating pain and the burn will appear erythematous with vesicle formation. Some of these vesicles or bullae, may have ruptured prior to the patient’s arrival, while others may not develop for 24 hours. Tar burns are special in that tar adheres aggressively to the burned skin.

What to do:

To stop the pain, immediately cover the burned area with sterile towels that have first been soaked in iced normal saline or an iced povidone-iodine solution. Continue irrigating the burn with the iced solution for the next 20-30 minutes or until the patient can remain comfortable without the cold compresses.
Provide the patient wrth any necessary tetanus prophylaxis and pain medication, (e.g., Percodan, Demerol).
Examine the patient for any associated injuries and check the airway and pulmonary status of any patient with significant facial burns.
When the pain has subsided, gently cleanse the burn with povidone-iodine scrub and rinse this off with normal saline.
If the vesicles are not perforated, have a relatively thick wall, and are on a hairless surface such as the palm of the hand, they should be left intact. With small burns such as these, patients can be sent home to continue cold compresses for comfort. Otherwise, these vesicles should be protected from future rupture with a bulky sterile dressing.
Open vesicles or bullae, large, thin-walled vesicles that are prone to rupture, or vesicles occurring on hairy surfaces that are prone to infection, should be completely debrided. Using fine scissors and forceps, you can easily strip away any loose epithelium from the burn. (With tar burns, debridement should be accomplished in the same manner, removing the tar along with the loose epithelium. Tar adhering to normal epithelium can be left in place, acting as a sterile dressing in itself.) Rinse off any remaining debris with normal saline and cover all the open areas with an oil emulsion gauze (e.g., Adaptic) followed by silver sulfadiazene (Silvadene) cream and a bulky absorbent sterile dressing. The first dressing change should be scheduled in 2 days.
Small burns and facial burns can often be treated with an open technique of using Silvadene cream only. Patients are instructed to wash the burn 4 times each day, followed by reapplication of the Silvadene cream. Patients can be reassured that unless there are complications (such as infection) they do not have to worry about scarring.

What not to do:

Do not use ice-containing compresses which might increase tissue damage. Compresses soaked in iced saline should be avoided on large burns (greater than 15% total body surface) because they may lead to problems with hypothermia. When pain cannot be controlled with compresses use strong parenteral analgesics such as morphine sulfate. Do not confuse partial thickness burns with full thickness burns. Full thickness burns have no sensory function or skin appendages such as hair follicles remaining, do not form vesicles, and may have evidence of thrombosed vessels. If areas of full thickness burn are present or suspected, seek surgical consultation because these areas will not grow new skin and may later require skin grafting.
Do not discharge patientw with suspected resipratory burns or extensive burns of the hands or genitalia. These patients require special inpatient observation and management.
Do not use caustic solvents in an attempt to remove tar from burns. It is unnecessary, painful, and will cause further tissue destruction.

Discussion

Simple partial thickness burns will do well with nothing more than clensing, debridement, and a sterile dressing. All other therapy, therefore, should be directed at making the patient more comfortable. Silvadene cream is not always necessary, but it is soothing and may reduce the risk of infection. When it is possible to leave vesicles intact, the patient will have a shorter period of disability and will require fewer dressing changes and follow up visits. If the wound must be debrided, the closed dressing techique may be more convenient and less of a mess than the open technique of washings and cream applications.

Some physicans believe it is important to remove all traces of tar from a burn. Removal can be accomplished relatively easily by using a petroleum of petroleum-based antibiotic ointment such as Bacitracin, which will dissolve the tar. Others have found the citrus and petroleum distillate industrial cleanser, De-Solv-It, very effective as well as non-toxic and non-irritating.

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