General Burn Care. Introduction. Overview of burn injury

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1 By: Kate Pape PharmD, BCPS Clinical Pharmacy Specialist, University of Iowa Hospitals and Clinics Assistant Professor (Clinical), University of Iowa College of Pharmacy Kate Pape is currently a Clinical Pharmacy Specialist at the University of Iowa Hospitals and Clinics and Assistant Professor (Clinical) for the University of Iowa College of Pharmacy in Iowa City, Iowa. Her clinical practice site includes the University of Iowa Burn Treatment Center, where she works daily as part of a multidisciplinary team for the treatment of burn patients. Dr. Pape reports no actual or potential conflicts of interest in relation to this continuing pharmacy education activity. This CPE activity reviews the different types and causes of burns, including thermal, electrical, and chemical burns. Pharmacy technicians will learn the various pharmacologic treatments used for the burn itself, as well as common complications and the treatment of those associated complications, including topical antimicrobials and medications for pain control. Upon completion of this activity, Pharmacy Technicians will be able to: 1. Describe the different types of burn injury and classify its severity based on size and depth 2. Compare the available topical antimicrobial treatments used for the treatment of burn injuries 3. Summarize the potential complications that can occur in a burn injury 4. Recognize the challenges of drug dosing that can occur in patients with a burn injury due to their hypermetabolic state 5. Discuss options for providing patient education in the prevention of burn injury CPE Information: UAN #: H01-T CEUs/Hours: 1 contact hour (0.1 CEU) Target Audience: Pharmacy Technicians Activity Type: Knowledge-based Initial Release Date: 1/1/2015 Planned Expiration Date: 1/1/2018 The Collaborative Education Institute is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity has been developed specifically for pharmacy technicians and is one of 10 activities in the TEAM series. General Burn Care Introduction Every year, over 450,000 individuals suffer a burn injury that requires treatment, with 40,000 of those requiring admission to the hospital. 1 Burns affect all ages and can be caused by a variety of mechanisms, from flames to hot liquids to chemicals.. Treatment of burns has evolved over the years, leading to increased survival among patients. However, many complications can still occur, with infections being the leading complication in patients. 1 Drug dosing can also be complicated, as large burns cause a hypermetabolic state in patients, and there are limited data of dosing specific medications in this population. The key to burn treatment is prevention, and there are many ways patients can be educated to prevent burn injuries in their homes and workplaces. Overview of burn injury The skin consists of two layers, the epidermis and dermis, with the epidermis being the outermost layer and provides protection from the environment to the underlying tissues. The dermis contains many cellular and structural components, including collagen, elastic fibers, fibroblasts, sweat glands, sebaceous glands and pigment-producing cells. Burn injury occurs when there is damage to the skin and its underlying tissues following exposure to heat, chemicals, electricity, or radiation. Over 450,000 individuals suffer a burn injury every year that requires treatment, with 40,000 individuals requiring admission to the hospital. 1 According to the American Burn Association (ABA) National Burn Repository, the most common cause of burn injury is due to fire/flame (43%), followed by scald (34%), contact with hot object (9%), electrical (4%) and chemical (3%). 2 The severity of a burn injury depends on the size and depth of the injury. Burn injury depth is determined subjectively using commonly observed clinical features (Table 1). 3 First-degree burns typically only involve the epidermal layer of the skin. Clinical features of a first-degree burn include painful, red skin that is dry and does not have any blister formation. A common example of a first-degree burn is a sunburn. First-degree burns typically heal within seven days, and treatment includes moisturizers such as aloe to provide comfort. 3 Second-degree, or partial-thickness, burns involve both the epidermis and dermis, while not involving the deepest parts of the dermis. Common clinical features include blistering of the skin that is very painful to touch. The wounds blanch with pressure, indicating that there is good perfusion to the dermis with capillary refill. These wounds heal within two to four weeks. 3 Healing time and degree of scarring depend on the depth of injury. Third-degree, or full-thickness, burns extend through the entire dermis. These wounds are often painless as the nerve endings have been destroyed. The skin will have a pale, leathery appearance that does not blanch with pressure. Fullthickness burns will not heal spontaneously, and they will require surgical excision and skin grafting TEAM SERIES 1

2 The Use of Over-The-Counter Drugs During Pregnancy Fourth-degree burns extend past the dermis into the subcutaneous fat, muscle and bone. They may appear dry, black and charred. These wounds may require amputation, depending on the location of injury. 3 The ABA has set forth criteria for when a patient should be referred to a verified burn treatment center (Table 2). Burn centers are specially equipped with personnel and resources that are able to accommodate patients who may be considered high-risk or with extensive injuries. These include patients with full-thickness wounds that will require surgery, patients with other underlying medical issues, pediatric and elderly patients and burn injuries that resulted from chemicals, electricity, or with additional trauma. Smaller wounds and those who are only first-degree or superficial second-degree wounds may be managed locally or as outpatients. The ABA defines minor burns that can be treated as an outpatient as those that are isolated and do not involve the hands, face, feet, or perineum and it should not cross any joints or be circumferential. 3 Burn wound treatment Initial treatment of the burn begins with removing the offending agent to stop the burning process. If the injury involves a flame, the patient should stop, drop and roll until the fire is out. Burned clothing should be removed immediately. Chemical burns require extensive irrigation with water to ensure all remaining chemical is removed from the skin. Injuries caused by flame or hot liquids, such as scald burns, should be irrigated with cool water. Patients should be immediately transferred to the emergency department to evaluate injuries. In the emergency department, patients will be assessed for the size and severity of their burn injuries. Burn size is estimated by calculating the body surface area (BSA) burned. Patients with larger burns (generally over 10-20% total BSA burned) will require fluid resuscitation to maintain perfusion to the organs and tissues. Larger burns are associated with an inflammatory response that can result in intravascular volume depletion, elevated systemic vascular resistance and decreased cardiac output. 4 Initiating fluid resuscitation immediately has been a cornerstone of modern burn care and has improved patient survival. 4 There are several fluid resuscitation formulas available to calculate estimated fluid needs, but there is no current gold standard formula. One commonly used formula is the Parkland formula. The Parkland formula is 4 ml/kg/%bsa burned, with the first half given over the first eight hours, followed by the remainder given over the following 16 hours. During the first 24 hours, it is important to closely monitor patients with frequent assessment of vital signs, other signs of perfusion and urine output, as every patient will respond differently and may require further adjustment of his or her resuscitation to maintain perfusion. Patients with suspected smoke inhalation injury also require immediate evaluation in the emergency department. Treatment for inhalational injury includes 100% oxygen, and patients may require intubation and mechanical ventilation. 3 Hyperbaric oxygen may be necessary to treat carbon monoxide poisoning. There is a high rate of ventilatorassociated pneumonia in patients with inhalational injury, although there is no role of administering prophylactic antibiotics as they may increase actual infection rates. 4 After patients have been evaluated and stabilized, attention should turn to cleaning the burn wound with mild soap and water. Blisters may be left intact or drained, with those that are small and on non-mobile areas left intact. 3 Patients tetanus immunization status should also be evaluated, as all burn wounds are considered tetanus-prone. Tetanus toxoid and/or immunoglobulin should be administered if indicated. 3 Often times, burn wounds are contaminated with bacteria and other microorganisms, which can lead to infection and sepsis if left to colonize. Topical antimicrobials are commonly used in the treatments of burn wounds rather than prophylactic systemic antibiotics. Unlike systemic antibiotics, they are able to control microbial contamination on the wound surface. 5 A variety of agents are available (Table 3). Bacitracin Bacitracin ointment is available as both a singular agent and in triple antibiotic ointment (neomycin, polymyxin B and bacitracin zinc). Bacitracin is active against most gram-positive organisms, but not gram-negative organisms. Advantages of using bacitracin include its smoothness upon application and no staining of the skin so it can be applied to facial burns. Bacitracin is most effective for superficial wounds rather than deeper wounds, such as those that are full-thickness, as it does not effectively penetrate thick eschar. Mafenide Mafenide acetate (MA) is available as both a 5% solution and cream. It prevents bacterial growth through the inhibition of nucleotide synthesis. MA has a broad spectrum of activity, and it is bacteriostatic against both gram-negative and grampositive organisms, including Pseudomonas aeruginosa. 5,6 MA is rapidly absorbed, making it effective in wounds with full thickness eschar or those with established infections. Adverse reactions include pain on administration, which is more likely in wounds with nerve endings still intact. 7 The cream also tends to be more painful on administration compared to the solution. Metabolic acidosis is also known to occur with MA administration, and therefore should be used with caution in patients with known renal dysfunction. 8 MA is contraindicated in patients who have a known hypersensitivity to MA, but it is unknown whether there is cross sensitivity to patients who have a known sensitivity to other sulfonamides. 7 Mupirocin Mupirocin is available as both a 2% cream and 2% ointment. Mupirocin is limited to covering mostly grampositive bacteria, but it has the added advantage of being able to treat methicillin-resistant Staphylococcus aureus (MRSA). 6 Mupirocin is generally well tolerated with few adverse reactions TEAM SERIES 2

3 Silver sulfadiazine Silver sulfadiazine (SSD) is bactericidal on contact with the cell wall, suppressing bacterial growth. 9 SSD is a broad-spectrum antimicrobial, covering both gram-positive and gram-negative bacteria, including Pseudomonas aeruginosa. 10 It does not have coverage against MRSA, but it does cover some Candida species. Toxic adverse effects that can occur with SSD administration include allergy, hemolysis in glucose-6-dehyddrogenase deficiency and methemoglobinemia. 10 Staining of the skin may also occur; therefore it is not recommended to administer on burns to the face. Patients with a history of an allergy to sulfa drugs may react to SSD, therefore careful attention should be noted. It may be advisable to do patch testing with the SSD before applying it to a large area, or consideration of using another agent without a sulfonamide component may be warranted. 9 SSD is also contraindicated in pregnant women approaching or at term, premature infants, or infants under the age of two months. 10 Silver impregnated dressings There are several options of silver impregnated dressings. Some of the available options are Acticoat, Aquacel-Ag and Mepilex Ag. 11 Advantages to using these types of dressings are that they can be left in place for anywhere from three days (Acticoat ) to up to two weeks (Aquacel- Ag ). They are ideal for partial-thickness wounds, especially those in patients who may have additional stress and pain with frequent dressing changes. However, because the wounds may not be evaluated daily due to the dressing staying in place, early signs of infection may be missed. A recent meta-analysis indicated that silver impregnated dressings may promote faster wound healing than SSD. 12 However, it is important to note that many of the studies that were included in this review were of poor quality, industry sponsored, and not published in peer-reviewed journals. While these dressings do have a place in practice, SSD should be recommended as first-line therapy unless clinically indicated. Complications of burn injury Although there have been a variety of advances in the treatment of burn patients, there are still many complicating factors that can play an important role in the patient s recovery. Patients with larger injuries may go into a hypermetabolic state, which can lead to doubling of their normal resting energy expenditure, 4 which also increases their overall daily caloric and protein needs. This hypermetabolic state can also complicate drug dosing, as all steps of drug delivery are affected, from absorption, to distribution, metabolism, and finally excretion of the drug. Drug binding may also be altered, as both albumin and total protein concentrations are decreased in the burn patient. There are limited data on how to optimize drug dosing in burn patients, as they tend to be excluded from many studies because of their hypermetabolic state. The clinician must take into account both the pharmacokinetic properties of the drug as well as the individual patient, considering both potential toxicities and the effect on the overall outcome. Infections are also a common complication in the burn patient, with pneumonia and cellulitis being the most common infections diagnosed. 2 Pneumonia is frequently encountered in patients with a smoke inhalation injury. Judicious wound care and dressings can help prevent infections at the site of the burn. There is no role for prophylactic systemic antibiotics in the burn patient to prevent infection. Drug dosing of antibiotics may be complicated. Not only does the clinician need to consider the hypermetabolic state of the patient, but consideration to the emergence of bacterial resistance should be noted as well. Pain management is another important facet in the treatment of the burn patient, and adequate pain control may be complicated. Superficial partial-thickness, or seconddegree, burns tend to be the most painful for patients. 3 Pain control is typically achieved with opioid analgesics, such as morphine, acetaminophen, and non-steroidal antiinflammatory drugs. Anxiolytic agents, such as midazolam or lorazepam, may be necessary for painful dressing changes. Patient education for burn prevention There are a variety of ways the pharmacy technician can become involved with educating patients and community members on how to prevent burn injuries. Education on scald injuries prevention can be very beneficial, considering that more than one-third of all burn injuries every year are due to hot liquids. 1 Most of these burns occur in the home, with injuries occurring most commonly in the kitchen or bathroom. Behavioral and environmental changes within the home can help prevent scald injuries. The kitchen should have a kid-safe zone that is out of the traffic path of the stove and sink. Use back burners on the stove with the pot handles turned back, and use caution when removing hot liquids from the microwave. Tap water scald burns are often more severe than cooking-related scald burns, and the ABA has made recommendations to help increase safety within the home. 13 Elderly patients are just as much at risk as young children. The home water heater thermostat should be set to 120 degrees Fahrenheit. Anti-scald or tempering devices can be installed to stop or interrupt the flow of water when the temperature reaches a pre-determined level. Children should be constantly supervised if they are able to reach faucets themselves or need assistance removing themselves from the hot water. Patients who may be weak or unsteady should have grab bars, shower seats, or non-slip flooring installed in their tubs or showers. According to the National Fire Protection Association, three out of five home fire deaths resulted from fires in properties without working smoke detectors. 14 Every bedroom in the home should have a working smoke detector, as well as outside each sleeping area and on every level of the home TEAM SERIES 3

4 Smoke detectors should be tested monthly and be replaced every ten years. Campfires and fire pits also serve as a fire danger. According to the ABA, 70% of all campfire burns are the result of hot embers rather than the flames themselves. Fire pits can retain heat for up to 12 hours after being extinguished at temperatures hot enough to cause a severe burn. 15 An accelerant, such as gasoline, should never be used to start a fire. Children should be educated on campfire safety, including keeping a safe distance of at least four feet away from the fire. Patients should also be educated on sun protection and potential drug reactions due to photosensitivity. Photoinduced drug eruptions (PIDE) can occur after exposure to a medication and either ultraviolet or visible radiation. 16 The most commonly offending drugs are listed in Table 4. Primary prevention of PIDE includes sun avoidance and protection, such as sunscreen and protective clothing. If a PIDE occurs, treatment may include removing the offending agent and systemic or topical corticosteroids. 16 Conclusion Burn wound injuries can require complex treatment, as well as the complications that can develop. Advances over the last few decades have greatly improved survival for patients. Prevention is key, and patients should be educated on improvements and modifications that can be made in their homes and lifestyles to prevent devastating injuries. Table 1. Overview of Burn Classification 3 Burn Depth Clinical Presentation Treatment First degree (Superficial) Second degree (Partial-thickness) Third degree (Full-thickness) Fourth degree Red, painful, blanches with pressure Pink, blisters, most painful, blanches with pressure Dry, leathery, white/brown, painless, does not blanch with pressure Dry, black, charred, painless Moisturizing lotions, soothing lotions, aloe; burns heal spontaneously without scarring within 7 days Silver sulfadiazine, bacitracin, silver-impregnated dressings; burns heal spontaneously within 2 (superficial) to 4 (deep) weeks; scarring depends on length of time to heal Silver sulfadiazine, require surgical excision and skin grafting to heal Silver sulfadiazine, surgical excision and skin grafting; may require amputation Table 2. Criteria for Transfer to a Burn Center 1 Second and third degree burns >10% BSA Second and third degree burns with serious threat of functional or cosmetic impairment involving the face, hands, feet, genitalia, perineum, and major joints All patients with full-thickness burns Electrical burns, including lightning injury Chemical burns Inhalational injury Burn injury patients with preexisting medical conditions that could complicate management, prolong recovery, or affect mortality All patients with burns and concomitant trauma Transfers from hospitals without qualified personnel or equipment for the care of children Burn injuries that will require special social, emotional, or long term rehabilitation intervention BSA = body surface area Pharmacy 2015 TEAM SERIES Series 4 4

5 Table 3. Topical Antimicrobials Agent Antimicrobial Coverage Advantages Potential Adverse Effects Bacitracin Mafenide Gram-positive bacteria Gram-positive and gramnegative bacteria; some anaerobic bacteria; yeast Soothing, no pain associated with application Can penetrate deeper wounds Not appropriate for deeper burn wounds Pain on application, can cause metabolic acidosis Mupirocin Gram-positive bacteria; MRSA MRSA coverage Limited bacterial coverage Silver sulfadiazine Silver impregnated dressings Gram-positive and gram-negative bacteria; Pseudomonas, yeast Gram-positive and gramnegative bacteria; yeast MRSA = methicillin-resistant Staphylococcus aureus Soothing, no pain associated with application Can be left on for 3 to 7 days depending on dressing Can build up with repeated application, may cause a decrease in white blood cell count Cannot assess burn wound daily for infection Table 4. Selected Medications Implicated in Photo-induced Drug Eruptions 15 Class Antidepressants Antimicrobials Antipsychotics Chemotherapeutic Agents Diuretics Nonsteroidal Anti-inflammatory Drugs Retinoids Drug Citalopram Escitalopram Fluoxetine Paroxetine Sertraline Ciprofloxacin Doxycycline Moxifloxacin Levofloxacin Tetracycline Voriconazole Chlorpromazine Clozapine Olanzapine Thioridazine Fluorouracil Hydroxyurea Furosemide Hydrochlorothiazide Naproxen Piroxicam Isotretinoin Pharmacy 2015 TEAM SERIES Series 5 5

6 REFERENCES: 1. Burn Incidence and Treatment in the US: 2013 Fact Sheet, American Burn Association. Available at Accessed October 9, National Burn Repository Annual Report: 2014, American Burn Association. Available at Accessed October 2, Schwartz LR, Balakrishnan C. Chapter 210. Thermal Burns. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill Latenser BA. Critical care of the burn patient: The first 48 hours. Crit Care Med 2009;37: Neely AN, Gardner J, Durkee P, Warden GD, Greenhalgh DG, Gallagher JJ, Herndon DN, Tompkins RG, Kagan RJ. Are topical antimicrobials effective against bacteria that are highly resistant to systemic antibiotics? J Burn Care Res 2009;30: Glasser JS, Guymon CH, Mende K, Wolf SE, Hospenthal DR, Murray CK. Activity of topical antimicrobial agents against multidrug-resistant bacteria recovered from burn patients. Burns 2010;36: Sulfamylon [package insert]. Rockford, IL: Mylan Institutional Inc.; White MG, Asch MJ. Acid-base effects of topical mafenide acetate in the burned patient. N Engl J Med 1971;284: Fuller FW. The side effects of silver sulfadiazine. J Burn Care Res 2009;30: SSD (1% Silver sulfadiazine cream) [package insert]. Telangana, India: Dr. Reddy s Laboratory; Aziz Z, Abu SF, Chong NJ. A systemic review of silvercontaining dressings and topical silver agents (used with dressings) for burn wounds. Burns 2012;38: Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns (Review). Cochrane Database Syst Rev 2013, Issue Scald Prevention Press Release: American Burn Association. Available at Accessed October 9, Home Fires. National Fire Protection Association. Available at Accessed October 9, Smoke Alarms in U.S. Home Fires. National Fire Protection Association. Available at Accessed October 5, Campfire Safety: Cool the Coals. American Burn Association. Available at Accessed October 9, Drucker AM, Rosen CF. Drug-induced photosensitivity. Drug Saf 2011;34 (10): TEAM SERIES 6

7 POST ASSESSMENT QUESTIONS: 1. First-degree burns are typically painless and have a white, leathery appearance. 2. Mupirocin can be used to treat suspected methicillinresistant Staphylococcus aureus (MRSA) infections. 3 The temperature of a home water heater should be set no higher than: A. 120 degrees Fahrenheit B. 130 degrees Fahrenheit C. 140 degrees Fahrenheit D. 150 degrees Fahrenheit 4. Adverse reactions to mafenide acetate cream include pain on administration and metabolic acidosis. 8. Third- and fourth-degree burns will require surgical excision and skin grafting to heal. 9. Patients who present with a burn wound injury should be assessed for the following immunization status: A. Influenza B. Pneumococcal C. Shingles D. Tetanus 10. Bacitracin is the preferred agent for treating burns to the face, as it is both soothing upon administration and does not cause staining like silver-containing products can. 5. Smoke detectors should be replaced every: A. 1 year B. 5 years C. 10 years D. 20 years 6. When dosing medications in burn patients, both the pharmacokinetic properties of the drug and the patient s clinical status must be considered. 7. Patients with burn injuries should be started on prophylactic systemic antibiotics to prevent infection of their burn wound. CPE Instructions: 1. Go to click on Technician tab 2. Scroll down to Pharmacy TEAM Series 2015 and click on Register and Log-In (if this is your first time in CEI s website you will need to set up a quick profile by clicking New To CEI ) 3. Click on the box to select the TEAM Series 2015 and click Register 4. On the Payment Transaction Page, scroll down to Pay With An Access Code and type in the access code given to you by your association and click Continue 5. You can now start the TEAM Series right away by clicking Click Here to Go to Activity. Scroll down to activity and all 10 TEAM articles are within your profile! 6. Whenever you want to go back in and complete a TEAM Series activity, go to Log-In, and click on your Profile. Any questions, please contact Cindy Smith at csmith@gotocei.org or TEAM SERIES 67