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Thursday, January 7, 2010

Management of 2nd degree superficial burns- (2nd degree burns)

Dear burn surgeon,
My daughter has a burn with hot soup on the hand with a lot of ugly looking blisters. Am worried as it’s quite painful. How will it heal and will it leave a scar?
Magaret p

Thank you very much for your question. You have not sent me a photograph, so I shall put up a representative one to explain things better. For a better understanding of this topic also read the blog topic: degree of burns.
The photograph shows a burn of the right hand with hot water (called scald burns). There are some areas of redness which represent a 1st degree burn. There is a large blister on the dorsum of the hand. It is tense and full of serous fluid. This is a good sign as it implies a second degree superficial burn and not a deep burn. There are no areas of deep burns seen on this hand and it probably looks similar to your daughter’s burn.

Well don’t panic!

Blisters are a good sign as they imply a superficial burn. The epidermis just separates from the dermis and only the uppermost part of the dermis is burnt. So this should heal easily by God’s grace.

Pain is also a good sign in early burns. Why? Well pain perception occurs because we have nerve endings in the dermis which pick up the pain sensations from the mediators released due to the burn. If these nerve endings are also burnt as occurs in a deep burn, then the pain will be less or even absent and though we may like it , its implies a deep burn and that we may need surgery to heal the wound!!

Should we break or puncture the blister?

That’s a good question. Blister fluid makes the skin tense and induces pain mechanically. When you puncture the blister and release the fluid this mechanism of pain is removed.
Again, blister fluid contains a lot of chemical substances which are detrimental to the wound healing process and promotes pain. In small blister I would advice that the blister be puncture and the fluid drained out. There is no need to de-roof the blister as the dead skin serves as a biological dressing. However in large areas, the dead skin will serve as a source of infection and should be removed totally during the dressing process.

What happens if we remove the blister skin?
Lot of patients as well as parents are very concerned and worried when you tell them that the blister skin will be removed as they feel that it will expose the muscle or bone below.

Don’t worry; the only thing it exposes is the dermis below. The picture on the right shows a hand burns which had large blister which was removed and the dermis or deeper layer of the skin is exposed. The wound is clean and is clearly a second degree superficial burn which is then dressed as described below.

Does this need a burn professional to take care of the wound?

Definitely! This wound needs daily or sometimes alternate day dressing depending on the condition of the wound which need to be evaluated regularly. All procedures should be done in a sterile manner by a burn professional to prevent any infection. Further signs of infection of the wound are picked up by burn professionals easily.

What type of dressing?
Well the nurse will first clean the wound with sterile saline solution and remove any loose debris. Then a layer of sterile Vaseline gauze or sofratulle may be applied, so that the dressing does not stick to the wound the next time it is opened. An antibacterial ointment or silver sulphadiazine or other burn creams available in your place will work and can be applied over this and then covered by gauze padding and a crepe bandage. There is no need to go in for expensive dressing materials or ointments for a burn of this kind.
If there is too much pain, a local anesthetic cream such as lignocaine gel can be applied before the start of dressing.

How often should we change the dressing?
Well, for a superficial burn of this kind, wound dressings can be changed every 2nd or 3rd day depending on the follow up. If the wound appears soggy or there is too much discharge, change the dressing more frequently.

Should antibiotics be given for this case?
Antibiotics in general are not prescribed routinely for burn patients the first time they are seen. I would not advice any antibiotic in this case. However in case the patient is diabetic or the wound begins to show signs of infection on follow up or if the patient is immunocompromised, one may need to start antibiotics depending on the merits of each case. That’s why you need a burn professional to follow up these cases.

When do we expect this wound to heal?
Well, healing should occur in about two week’s time. Burns take their time to heal and we have to be patient!! The patient has to be patient !!!

How can we spend this time off from work?
On a lighter note:
You could take time off from work and do the following ;
Relax, forget the burn :)
Think about the past and the years passed by- did your life benefit anyone around you?
Plan for the future
Spend time with your kids- for once they will seem happy
Spend quality time with your wife
Make the house a home- though you spend one third of your life sleeping and half of it at work
Call your friends, relatives and mom and dad - tell them for once you miss them and how much you love them. Last and most important of all- get closer to God (that includes the atheist).

What else needs to be done?
Besides dressing the wound, one needs analgesics for the pain:
Any of the regular analgesics like ibuprofen, paracetamol, diclofenac sodium etc can be helpful depending on your pain tolerance.

You should elevate your hand as much as possible- this will help to reduce the edema (swelling that results with all burn wounds). You could use a pillow while sleeping -under the hand :) or use a sling to keep the hand elevated while awake.

Encourage your daughter to use her hand and let her play around – this will help in preventing any stiffness and will work as a sort of physiotherapy!!
So relax, and I wish your daughter a quick recovery.Will send you some flowers from mom's garden.

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