AUTHOR INFORMATION

Section 1 of 12

Authored by Jerome FX Naradzay, MD, FACEP, Emergency Services Medical Director, Department of Emergency Medicine, Maria Parham Medical Center

Coauthored by Roy Alson, MD, PhD, FACEP, FAAEM, Associate Medical Director, North Carolina Baptist AirCare; Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine

Jerome FX Naradzay, MD, FACEP, is a member of the following medical societies: American College of Emergency Physicians, and Society for Academic Emergency Medicine

Edited by Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jon Mark Hirshon, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School

Author's Email:	Jerome FX Naradzay, MD, FACEP
Editor's Email:	Debra Slapper, MD

eMedicine Journal, November 15 2006, VOLUME 7, Number 11

INTRODUCTION

Section 2 of 12

Background: Burn injuries account for an estimated 700,000 annual emergency department (ED) visits per year. Of these, 45,000 require hospitalizations. Approximately half of these patients are hospitalized at one of the 125 specialized burn treatment centers.

Most burns are not life threatening, but each burn causes a significant amount of pain for the patient, and some degree of psychological trauma to all those involved. From the patient's perspective, even superficial burns carry a risk of scar formation. At temperatures greater than 120°F, it only takes 3 seconds to burn a child’s skin severely enough to require surgery. Rapid evaluation by the emergency physician (EP) is essential to address pain management, mitigate the psychological impact of the burn, and identify intentional burns. Following initial intervention, providing appropriate follow-up, even for the most minor burns, is imperative.

To effectively evaluate, treat, and, ultimately, prevent burns, understanding the different methods of categorizing burns is helpful. The general categories include life-threatening versus non–life-threatening, accidental versus intentional, recreational versus occupational, and domestic (home or residence) versus industrial.

Identifying the type of burn is essential because unique interventions are required. Type of burns are as follows: thermal burns, chemical burns, and radiation burns. Thermal burns can be further classified according to skin depth and percentage of total body area burned. Additional descriptions for thermal burns include contact, flame, heat, and scalding.

Because emergency intervention, specialist referral, and prognosis must be considered during the EP’s evaluation, including an accurate description of the burn location, such as ophthalmic, hand, face, inhalation, soles, or perineum, is essential. The topic of this article is thermal burns; however, remember that burns can be caused by chemical agents, ionizing radiation, electromagnetic radiation, and electric current.

Pathophysiology: The skin is the largest organ of the body. While not very active metabolically, the skin serves multiple functions essential to the survival of the organism, including the following:

• Thermal regulation and prevention of fluid loss by evaporation

• Hermetic barrier against infection

• Contains sensory receptors that provide information about environment

Major burns compromise these functions.

The skin is divided into 3 layers, as follows:

• Epidermis: This is the outermost layer composed of cornified epithelial cells. Outer surface cells die and are sloughed off as newer cells divide at the stratum germinativum.

• Dermis: This is the middle layer composed of primarily connective tissue. It contains capillaries that nourish the skin, nerve endings, and hair follicles.

• Hypodermis: This is a layer of adipose and connective tissue between the skin and underlying tissues.

Frequency:

• In the US: Nearly 1 million Americans seek ED treatment of burns each year. According to data provided by the American Burn Association, the incidence of burn injuries in the United States has declined from 2 million annual injuries estimated from 1957-1961.

  According to 2003 data from the US Fire Administration (USFA, an entity of the Department of Homeland Security and the Federal Emergency Management Agency [FEMA]), between 1994 and 2003, an average of 4,060 Americans lost their lives, and another 22,650 were injured annually as the result of fire. Not included in this data are the deaths attributed to fire caused by the terrorist events of September 11, 2001. In 2003, the United States had one of the highest fire death rates reported in the industrialized world at 13.5 deaths per million population. A slight increase from 12.9 deaths per million population reported in 2001 (USFA, 2003).

  Slightly different findings were released by the World Fire Statistics in 2002. They reported that the fire-related death rate in the United States was 1.86 deaths per 100,000 (18.6 per million) in the year 2000. For comparison, fire-related death rates per 100,000 were higher in Finland and Hungary at 2.02 and 2.88, respectively.

  States with the higher death rates in 2001 were in Arkansas (37 per million), Mississippi (30 per million), and Delaware (30 per million). The states with the lowest rates were Colorado (5.4 per million), Hawaii (4.1 per million), and Utah (3.1 per million) (USFA, 2003).

  According to the USFA in 2003, 3,925 civilians lost their lives as the result of fire, 18,125 civilian injuries occurred as the result of fire, and 111 firefighters were killed in duty-related incidents.

• Internationally: The incidence of burn injuries varies from country to country, typically peaking during the country's holiday period.

  In 2000, the World Fire Statistics Centre released fire-related death data by country (from lowest to highest number of deaths per 100,000 person) from 1995-1997 (World Fire Statistics Centre, 2000).

  • Singapore - 0.20 (1996-1997)

  • Switzerland - 0.43 (1994-1996)

  • Spain - 0.60 (1995-1997)

  • Netherlands - 0.68 (1994-1996)

  • Australia - 0.71

  • Austria - 0.79

  • Italy - 0.82 (1993-1995)

  • Germany - 0.98

  • France - 1.01

  • New Zealand - 1.10

  • Czech Republic - 1.23

  • Belgium - 1.24 (1992-1994)

  • UK - 1.29

  • Sweden - 1.38

  • Greece - 1.43

  • Canada - 1.46

  • Slovenia - 1.51

  • Norway - 1.56

  • Poland - 1.56

  • Denmark - 1.71

  • Japan - 1.74

  • Finland - 2.02

  • Hungary - 2.88

  In the United Kingdom, more than 47 fire-related injuries occur every day.

  In Greece, the estimated annual incidence of childhood firework injuries treated in EDs is 7 injuries per 100,000 children per year. Seventy percent of injuries occur in children aged 10-14 years. Boys sustain self-inflicted accidental injuries; girls are injured as bystanders. A sharp peak of firework injuries occurs in the spring when the Greek Orthodox Easter is celebrated.

  Interesting data from Northern Ireland allows a comparison of burn incidence before and after the enactment of firework legislation. In the prelegislation series, the mean number of patients admitted annually was 0.38 per 100,000, while in the postlegislation series, the mean was 0.43 per 100,000. The authors concluded that legislation did not significantly affect the incidence of burns. Also in Northern Ireland, blast injuries to the hand account for more than 50% of injuries in this series.

  In Bergen, Norway, the incidence of burns was 17 cases per 10,000 inhabitants. Fewer than 10% occur in individuals older than 60 years. More than a third occur in children younger than 15 years. Burns were more common in males than in females, and the burns were likely to be flame and firework burns. Interestingly, females were more likely to experience scald burns.

Mortality/Morbidity: The number of deaths from fires and burns has declined since the 1960s for several reasons. Improved burn care (ie, quality burn centers, recognition, and effective management of burn shock) has reduced the number of deaths in the early postburn period. Improved wound management and antibiotics have decreased deaths from burn wound infection.

The greatest factor in the reduction of burn-related deaths is the use of smoke detectors. In the United States, most people killed in house fires die from smoke inhalation rather than from burns (see Smoke Inhalation and Toxicity, Carbon Monoxide).

Race:

• African American children are more than 3 times as likely to die in a fire than white children.

• Native American children are more than 2 times as likely to die in a fire than white children.

Age: Minor burns are more common in younger adults, often as a result of cooking or occupational exposures. Teenaged males are at increased risk of injury from fireworks; scald injuries are more common in young children. Most scald injuries in young children result from improper setting of domestic hot water heaters and spillage of cooking pots or beverages. Both types of injuries are easily prevented.

• Infants and children: Most children aged 4 years and younger who are hospitalized for burn-related injuries suffer from scald burns (65%) or contact burns (20%).
  • Most scald burns to children, especially small children aged 6 months to 2 years, are caused by hot foods or liquids spilled in the kitchen or other areas where food is prepared and served.
    

  • Water heater temperature must be set lower than 120°F. Within 3 seconds, a child's skin can be burned severely enough to require surgery when they are scalded with water temperature greater than 120°F.
    

  • The EP must consider intentional injury when burn patterns, such as soles, palms, and pinpoint “cigarette ash” burns, are identified. Children aged 4 years and younger and children with disabilities are at the greatest risk of burn-related death and injury, especially scald and contact burns.

• Adolescents and children younger than 14 years: The leading cause of residential fire-related death and injury among children aged 9 years and younger is due to carelessness. Fires kill more than 600 children aged 14 years and younger each year and injure approximately 47,000 other children. Approximately 88,000 children aged 14 years and younger were treated at hospital EDs for burn-related injuries; 62,500 were thermal burns and 25,500 were scald burns. The most common causes of product-related thermal burn injuries among children aged 14 years and younger are hair curlers, curling irons, room heaters, ovens and ranges, irons, gasoline, and fireworks.

CLINICAL

Section 3 of 12

History: The EP must consider the type of burn (thermal, chemical, radiation) and the location during early burn management. Once it has been determined that the burn is a thermal burn, the EP must add to the description: contact (with source name), scald (with fluid or gas type), heat, and flame. Systemic injury, duration, intentional versus accidental, and location of the burn must all be considered during the critical early burn period.

Other important points for the EP to determine include the patient's tetanus immunization status as well as the components of the history outlined by the mnemonic AMPLE, as follows:

• A - Allergies

• M - Medications (eg, over-the-counter medications, aspirin)

• P - Past medical history/previous illness

• L - Last meal or beverage consumed

• E - Events preceding injury/history of present illness

History should also include the following:

• Medical personnel must consider abuse as a cause of burns in all children. As many as 10% of abuse cases involve burns (see Pediatrics, Child Abuse).

• Components of the history that should raise suspicion of abuse include the following:

• Multiple stories of how injury was sustained

• Injury attributed to a sibling

• Injury claimed to be unwitnessed

• Injury incompatible with developmental level of the child

• Characteristics of the burn that should raise suspicion of abuse include the following:

• Pattern burns that suggest contact with an object

• Cigarette burns

• Stocking, glove, or circumferential burns

• Burns to genitalia or perineum

• It is the obligation of all healthcare personnel to contact appropriate law enforcement and protective services if they suspect the burn was intentional.

• Medical personnel must be aware that burns resulting from abuse or neglect may also be seen in the geriatric population.

Physical: Thermal, chemical, and radiation constitute the large classes of burn types. Each can be further broken down, with each subsection directing the EP to provide more specific treatment.

The most common type of burns are thermal burns. Soft tissue is burned when it is exposed to temperatures above 115º F (46°C). The extent of damage depends on surface temperature and contact duration. A thermal burn causes coagulation of soft tissue. As soft tissue temperature increases, capillary permeability increases, fluid loss occurs, and plasma viscosity increases with resultant microthrombi formation. Fluid loss can lead to hypovolemia and shock, depending on the amount of loss and response to resuscitation.

Burns cause an increased metabolic rate and energy metabolism. How the individual responds to the increased energy demands will dictate recovery.

• Burn depth is described as first, second, or third degree. (See Causes for more information.)

• First-degree burns involve only the epidermis.

• Tissue blanches with pressure.

• Tissue is erythematous and often painful.

• Tissue damage is minimal.

• Sunburn is a classic example of this type of burn (see Sunburn for more details and management).

• Second-degree burns are also referred to as partial-thickness burns.
  • Epidermis and portions of the dermis are involved.

  • Adnexal structures (eg, sweat glands, hair follicles) are often involved, but enough of these structures are preserved for function, and the epithelium lining them can proliferate and allow for regrowth of skin.

  • The burned area characteristically has blisters and is very painful.

  • If deep second-degree burns are not cared for properly, edema, which accompanies the injury, and decreased blood flow in the tissue can result in conversion to full-thickness burn.

• Third-degree burns are also referred to as full-thickness burns (see Image 1).
  • These burns are characterized by charring of skin or a translucent white color, with coagulated vessels visible below.

  • The area is insensate, but the patient complains of pain, which is usually a result of surrounding second-degree burns.

  • As all of the skin tissue and structures are destroyed, healing is very slow. Third-degree burns are often associated with extensive scarring because epithelial cells from the skin appendages are not present to repopulate the area.

• Burn extent

• The more body surface area (BSA) involved in a burn, the greater the morbidity and mortality rates and the difficulty in management. EMS personnel tend to overestimate the extent of the burn, while ED personnel tend to underestimate it.

• An individual's palmar surface represents 1% of the BSA. A simple method to estimate burn extent is to use the patient's palmar surface to measure the burned area. Burn extent is calculated only on individuals with second-degree or third-degree burns.

• Another quick method is to use the Rule of Nines to estimate the extent of burn injury (see Image 2). The head represents a greater portion of body mass in children than it does in adults. Lund and Browder first described a method for compensating for the differences, and the Lund and Browder Chart is used to calculate BSA in children (see Image 3). If the chart is unavailable, estimate BSA by the Rule of Nines and adjust for age as follows:
  • In children younger than 1 year, the head is 18% of BSA and each leg is 14% of BSA. The torso and arms represent the same percentages as in adults.

  • For each year older than 1 year, add 0.5% to each leg and decrease percentage for the head by 1% until adult values are reached.

• On the basis of burn extent and depth, EPs can determine the severity of burn injury and whether the patient requires transfer to a burn center. The American Burn Association has developed criteria for burn center admission, as follows:

• Full-thickness (third-degree) burns over 5% BSA

• Partial-thickness (second-degree) burns over 10% BSA

• Any full-thickness or partial-thickness burn involving critical areas (eg, face, hands, feet, genitals, perineum, skin over any major joint), as these have significant risk for functional and cosmetic problems

• Circumferential burns of the thorax or extremities

• Significant chemical injury, electrical burns, lightning injury, coexisting major trauma, or presence of significant preexisting medical conditions

• Presence of inhalation injury

Causes:

• Flame burns

• Contact with open flame causes direct injury to tissue.

• Flame may ignite clothing. While natural fibers tend to burn, synthetic fibers may melt or ignite, adding a contact burn component to the injury.

• Contact burns

• Contact burns result from direct contact with a hot object.

• Burn injury is confined to the point of contact.

• Examples are burns from cigarettes and tools (eg, soldering irons, cooking appliances).

• Scalds

• Scalds result from contact with hot liquids (see Image 4).

• The more viscous the liquid and the longer the contact with the skin, the greater the damage.

• Accidental scalds often show a pattern of splashing, with burns separated by patches of uninjured skin.

• In contrast, intentional scalds often involve the entire extremity, appearing in a circumferential pattern with a line that marks the liquid surface.

• Steam burns

• Steam burns most often occur in industrial accidents or result from automobile radiator accidents.

• These burns produce extensive injury from the high heat-carrying capacity of steam and the dispersion of pressurized steam and liquid.

• Steam inhalation can actually cause thermal injury to the distal airways of the lung.

• Gas burns

• Inhalation of hot gas normally does not injure distal airways, as the heat-exchange capacity of the upper airway is excellent.

• In this situation, the upper airway is at risk for thermal injury and subsequent occlusion due to edema.

• Distal airway injury is more likely to be due to the direct effects of the products of combustion on the mucosa and alveoli.

• Electrical burns

• Electrical burns produce heat injury by passing through tissue.

• Ignition of clothing may produce some flame burn, but most of the injury is deep in the skin (see Electrical Injuries).

• Flash burns

• Flash burns are a subset of flame burns and are a result of rapid ignition of a flammable gas or liquid.

• The body parts involved are those exposed to the agent when it ignites.

• Areas covered by clothing are usually spared.

• The face may be involved, but if this type of injury takes place outside, then the risk for inhalation injury is low. A careful examination of the airway is indicated.

• A classic example of this type of injury occurs when a person pours gasoline on a trash or leaf fire to increase the flame and is burned by the subsequent fireball.

• Tar burns (see Emergency Department Care)

DIFFERENTIALS

Section 4 of 12

Burns, Chemical
Burns, Ocular
Electrical Injuries
Hydrofluoric Acid Burns
Smoke Inhalation
Sunburn

WORKUP

Section 5 of 12

Lab Studies:

• Severe burns (ie, third-degree burns) require a complete laboratory workup, including the following:

• CBC

• Chemistry profile

• Arterial blood gases with carboxyhemoglobin

• Coagulation profile

• Urine analysis

• Type and screen

• Creatine phosphokinase (CPK) and urine myoglobin (in electrical injuries)

Imaging Studies:

• Chest radiography

• Obtain a chest radiograph in all patients whose history or physical examination suggests the possibility of inhalation injury and in those who require intubation to manage the airway.

• The initial chest radiograph rarely shows significant findings of smoke inhalation.

• Other plain radiography: On the basis of history and physical findings, obtain other plain radiographs if indicated to identify other associated traumatic injuries.

• CT scanning: On the basis of history and physical findings, obtain CT scans if indicated to identify other associated traumatic injuries.

Other Tests:

• Perform fiberoptic bronchoscopy for any patient suspected of having an inhalation burn.

TREATMENT

Section 6 of 12

Prehospital Care:

• The immediate goal is to remove the person from the source of the burn. This must be accomplished without endangering rescue personnel.

• Following extrication, initial care of the burn victim should follow the basic principles of trauma resuscitation.
  • Burn victims rarely expire immediately from burn injury.

  • Immediate death is the result of coexisting trauma or airway compromise.

  • Perform a rapid primary survey to assess the status of the patient's airway, breathing, and circulation. Immediately correct any problems found.

  • Remove constricting clothing and jewelry to prevent these items from exerting a tourniquetlike effect following the development of burn edema.

• During airway assessment, give careful attention to signs of inhalation injury. Findings such as carbonaceous sputum, singed facial or nasal hairs, facial burns, oropharyngeal edema, changes in the voice, or altered mental status suggest the possibility of inhalation injury. Assume inhalation injury in any person whose history suggests being confined in a fire environment. Secure the airway by endotracheal intubation, as necessary. Deliver high-flow supplemental oxygen via mask or endotracheal tube (see Smoke Inhalation and Toxicity, Carbon Monoxide).

• Concurrently, the EP must stop the burning process. Remove charred clothing and cool tissues with saline or clean water. Once the burn has been cooled, place the patient in dry, sterile sheets. Prolonged irrigation with cool fluids or leaving the victim in wet sheets will not improve the burn and greatly increases the risk of hypothermia.

• After more life-threatening issues have been addressed, cool minor burns with running tap water and dress them.

Emergency Department Care:

• After the airway is stabilized, assess the extent and depth of the burn injury, as outlined above.

• Airway edema can develop rapidly in a burn victim who has inhaled toxic products of combustion or heated gases. Consider intubation early in those patients who show signs of such inhalation (eg, singed nasal hairs, facial burns, oral burns, sooty sputum, respiratory difficulty manifested by stridor or wheezes). Fiberoptic laryngoscopy or bronchoscopy can be helpful in assessing the extent of airway involvement.

• Maintain a high index of suspicion for airway injury and a low threshold for intubation because intubation may be extremely difficult once edema forms.

• Establish intravenous access and begin fluid resuscitation. Begin two large-bore peripheral lines and administer crystalloids. With the loss of the vapor barrier provided by intact skin, burn victims have large insensible fluid losses. Fluid needs for burn victims in the acute phase can be calculated using the Parkland formula, as follows:

• (4 cm³ of crystalloid) X (% BSA burn) X (body weight in kg)

• Example: A man who weighs 70 kg and has a 30% BSA burn would require (30) X (70 kg) X (4 cm³/kg) = 8400 cm³ in the first 24 hours.

• One half of the calculated fluid requirement is administered in the first 8 hours, and the balance is given over the remaining 16 hours. Thus, fluids would be given at 525 cm³/h for the first 8 hours, then at 262.5 cm³/h for the remaining 16 hours.

• Monitor typical markers of fluid status (eg, urine output) and adjust fluids accordingly. Placement of a Foley catheter simplifies monitoring of hourly urine output. Urine output should be maintained at 0.5 cm³/kg/h.

• This formula does not predict fluid resuscitation needs in electrical injuries accurately, and the presence of coexisting trauma may increase fluid volumes needed for resuscitation.

• For children, an alternative formula to calculate fluid needs is the Galveston formula, which is based on BSA rather than body weight. Although many pediatric burn centers believe it is more accurate than the Parkland formula, it is more time-consuming to calculate.

• Lactated Ringer (LR) solution is used at 5000 cm³/m² X % BSA burn plus 2000 cm³/m²/24 h of maintenance. One half of the total fluid is given in the first 8 hours, with the balance given over the next 16 hours.

• Maintain urine output in children at 1 cm³/kg/h.

• Treatment of tar burns
  • The boiling point of asphalt and roofing tar are 140°C and 232°C, respectively. Tar cools rapidly to between 93-104°C as soon as it leaves the heat source. Most likely the tar is cool by the time the patient arrives in the ED. Avoid the temptation to allow the tar to cool. The tar should be actively cooled to terminate thermal damage. The tar and burned skin should be liberally washed with room temperature saline or water if it is not already cool to the touch.

  • Once the tar is firm, it should be picked, peeled, and debrided from the underlying tissue. Some degree of autodebridement will occur. Debriding is a balance between removing the foreign body (tar) and exposing the injured skin for evaluation and treatment.

  • If the skin has a light coat of tar and the patient does not complain about the underlying skin or surrounding tissue, leaving the asymptomatic tar in place may be acceptable.

  • Tar that is part of an obvious burn, blister, or tissue loss should be removed.

  • Tar on the conjunctiva should be removed by an ophthalmologist.

  • Applying ointments, such as polymicrobial antibiotic ointment, petroleum jelly, or mineral oil, can facilitate tar removal. Organic solvents, such as acetone or gasoline, must be not be used to remove the tar.

  • Common household agents, such as mayonnaise, butter, sunflower seed oil, and baby oil, have been promoted to remove tar. Organic, nonsterile agents are easy to acquire and are available in large quantities, but they carry the risk of promoting wound infection or allergic reaction. Bacterial or fungal growth can occur if the tar is not completely removed and the organic agent is not completely rinsed off.

• When circumferential full-thickness burns involving the extremities or the chest are present, escharotomy may be necessary. The eschar is tough and rigid. As edema forms in the injured extremity following the burn, the eschar restricts outward expansion of the tissue. As a result, interstitial pressure rises to the point that vascular flow is compromised. In short, the eschar behaves like a tourniquet. Incising the eschar allows return of flow and prevents further ischemic injury.
  • Perform escharotomy along the lateral aspect of the extremity. Use of an electrocautery simplifies the procedure and can reduce the amount of bleeding.

  • The incision should go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound.

  • If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior axillary lines, and across the top of the chest, freeing up the anterior chest wall.

• Most burns seen in the ED are minor. The key point in managing these wounds is to be sure that the patient receives adequate follow-up care. Cool the burn area with towels moistened with cool sterile saline. Avoid immersion in ice baths.

• Burns of areas such as the face are best treated by an open technique. Wash the burn area, debride any open blisters, and cover wounds with topical antibiotics (eg, Neosporin, Bacitracin).

• Cleanse other areas with minor burns. A debate exists as to whether intact blisters should be debrided; the intact skin serves as a hermetic barrier, although the blister fluid can serve as an excellent medium for bacterial growth. Another argument for debridement is that removal of the blister roof allows topical agents to reach burn tissue.

• Debride open blisters. Blisters that are intact but are located in areas that have a high likelihood of rupture may be sharply debrided to prevent the blister fluid from being aspirated. Wounds should then be treated with a topical antibiotic and dressed. Discharge the patient with explicit instructions on how to clean and dress the wound, and arrange follow-up care for evaluation of the wound.

• Remember to check tetanus status of all patients and to administer tetanus immunization (Td) as appropriate.

Consultations:

• Refer patients with critical burns to a regional burn center for further management. Burns involving critical areas, if not referred to a burn center, should be evaluated by a burn surgeon or a plastic surgeon.

• Admit patients whose history suggests the possibility of inhalation injury for observation.

MEDICATION

Section 7 of 12

Pain management and topical medication application are two therapeutic interventions for burns.

Of the two, rapid and effective pain reduction is central to burn patient care. The EP must recognize that for the patient in pain every minute without treatment is another minute with pain. Treat the patient's pain quickly and effectively.

With few exceptions, the EP should not hesitate to insert an IV line, preferably in a nonburned area, and provide IV analgesic.

IV administration is ideal for the acute treatment of patients who require immediate pain relief. The pain level can be reduced or aborted almost immediately, and additional medication can be provided quickly. The IV line can be used for fluid therapy, adjunctive medications, and blood sample collection.

The time for oral pain medication to take effect is too long for the patient who is suffering from a fresh burn. Oral medication is more suitable for patients who will be discharged to home.

The EP should resist the propensity of emergency staff to apply topical burn ointment as the first intervention. Except for EMLA cream or lidocaine ointment, topical thermal burn ointments and gels address microbial growth on the burned tissue; they do not address the pain, per se.

If the patient has a burn that requires the patient to be transferred to a burn center, it may be better not to apply any ointment at all. Treatment should be limited to removing the source of the thermal burn, debriding contaminated tissue, and covering the burned area with a nonadhesive cover (petroleum-based gauze) then a sterile, dry towel or sheet.

The emergency medical director should work with the emergency nursing director to establish thermal burn evaluation and treatment protocols including standing orders. If the nursing or triage staff can identify a thermal burn, estimate the degree, depth, and associated injuries (airway) then protocols and policies can be put into place so that the triage nurse can initiate pain intervention therapy. Regardless of the burn severity, standing orders to provide pain relief for the burned patient should be in place.

A prudent emergency medical director should collaborate with commonly used burn centers. The sending and receiving facilities should have protocols for analgesic treatment, IV access, and burn dressing. Preapproved protocols and arrangements provide a seamless transfer of care for the burned patient.

Drug Category: Analgesics -- Opiates provide rapid pain relief. Opiates can be titrated to achieve the desired comfort level for each patient. Opiates side effects can be reversed quickly.

Drug Name	Morphine sulfate (Duramorph, Astramorph, MS Contin) -- DOC for burn pain treatment because of the reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Morphine sulfate administered IV can be dosed in a number of ways and is commonly titrated until desired effect is obtained.
Adult Dose	Initial IV, IM, or SC: 0.1-0.2 mg/kg; avoid IM and SC injections in burn patients Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h (2 mg is a good starting dose in patients who may be hypovolemic)
Pediatric Dose	Neonates: 0.05-0.2 mg/kg/dose IV q4h Children: 0.1-0.2 mg/kg/dose IV q2-4h
Contraindications	Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
Interactions	Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Avoid in respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate Physicians must be aware of a National Patient Safety Goal (NPSG): Do not abbreviate morphine sulfate "MS" or "MSO4" (always write clearly "morphine sulfate" to avoid confusion with other drugs); similar "forbidden" abbreviations under the NPSG guidelines include avoiding "SC" or "SQ" for subcutaneous injections (the provider must write legibly: "subcutaneously")

Drug Name	Meperidine (Demerol) -- Narcotic analgesic with actions similar to those of other opiates. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Adult Dose	25-75 mg PO/IV/IM/SC q3-4h prn
Pediatric Dose	1-1.8 mg/kg (0.5-0.8 mg/lb) PO/IV/IM/SC q3-4h prn; not to exceed adult dose
Contraindications	Documented hypersensitivity; concurrent MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant anticipated
Interactions	Cimetidine and protease inhibitors may increase toxicity; hydantoins may decrease effects
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in patients with head injuries because meperidine may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution postoperatively and with history of pulmonary disease (suppresses cough reflex); substantially increased dose levels, because of tolerance, may aggravate or cause seizures even if no prior history of convulsive disorders; monitor closely for meperidine-induced seizure activity if prior seizure history; caution in patients with a creatinine clearance <50 mL/min; avoid multiple injections in short time, particularly in patients >65 y

Drug Name	Hydrocodone bitartrate and acetaminophen (Vicodin ES) -- Drug combination indicated for relief of moderate to severe pain.
Adult Dose	1-2 tab or cap PO q4-6h prn for pain
Pediatric Dose	<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen or 5 mg of hydrocodone bitartrate/dose >12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose
Contraindications	Documented hypersensitivity; elevated intracranial pressure
Interactions	Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Drug Name	Hydromorphone (Dilaudid) -- A hydrogenated ketone of morphine. Hydromorphone is a narcotic analgesic. Analgesic action of parenterally administered Dilaudid is apparent within 15 min and usually remains in effect for > 5 h.
Adult Dose	1-2 mg IV q2-4h
Pediatric Dose	Not recommended
Contraindications	Documented hypersensitivity; obstetrical analgesia; increased intracranial pressure; respiratory depression; ulcerative colitis; Crohn disease; abdominal cramping and distention
Interactions	Hydantoins may decrease effects; phenothiazines, CNS depressants, and tricyclic antidepressants may increase toxicity
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Pregnancy category D in prolonged use or high doses at term; caution in patients with head injuries because may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution postoperatively and with history of pulmonary disease (suppresses cough reflex); increased dosing levels, because of tolerance, may aggravate or cause seizures (even without prior history); adjust dose in renal insufficiency (do not use in severe renal dysfunction); normeperidine metabolite accumulation may induce CNS toxicity; monitor closely for morphine-induced seizure activity if prior seizure history

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs) -- These agents are used most commonly for relief of mild pain. Although effects of NSAIDs in treatment of pain tend to be patient specific, ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

These agents will not provide rapid relief of other agents and, except for ketorolac, must be administered to patients that do not have oral intake restrictions.

Drug Name	Ibuprofen (Ibuprin, Advil, Motrin) -- Treatment of mild pain, if no contraindications. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in inhibition of prostaglandin synthesis.
Adult Dose	200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric Dose	6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions	Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants; may increase risk of methotrexate toxicity; may increase phenytoin levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (monitor PT and bleeding)

Drug Name	Flurbiprofen (Ansaid) -- Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase, causing inhibition of prostaglandin biosynthesis that may, in turn, result in analgesic and anti-inflammatory activities.
Adult Dose	200-300 mg/d PO divided bid/qid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants; may increase risk of methotrexate toxicity; may increase phenytoin levels
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; caution in coagulation abnormalities or during anticoagulant therapy (monitor PT and bleeding); acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, or renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Name	Ketoprofen (Oruvail, Orudis, Actron) -- Used for relief of mild to moderately severe pain and inflammation. Initially administer small dosages to patients with a small body size, elderly persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	3 months to 14 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants; may increase risk of methotrexate toxicity; may increase phenytoin levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (monitor PT and bleeding)

Drug Name	Naproxen (Anaprox, Naprelan, Naprosyn) -- Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in decrease in prostaglandin synthesis.
Adult Dose	500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO q6-8h; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants; may increase risk of methotrexate toxicity; may increase phenytoin levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in coagulation abnormalities or during anticoagulant therapy (monitor PT and bleeding); acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Name	Ketoralac (Toradol) -- Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.
Adult Dose	30 mg IV/IM q6h; not to exceed 120 mg/d 10 mg PO q4-6h; not to exceed 40 mg/d Combined duration of PO/IV/IM not to exceed 5 d
Pediatric Dose	Not established; recommended dose is 0.4-1 mg/kg IM once
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if leukopenia, granulocytopenia, or thrombocytopenia persists

Drug Category: Topical antibiotics -- Prophylaxis is given topically to patients with burns.

Drug Name	Neomycin and polymyxin B (Neosporin) -- Used to treat minor infections. Inhibits bacterial protein synthesis and, thus, bacterial growth. Polymyxin B disrupts bacterial cytoplasmic membrane, permitting leak of intracellular constituents, causing inhibition of bacterial growth.
Adult Dose	Apply 1-4 times/d to affected areas
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Extended use can lead to resistant infections and thinning or atrophy of skin

Drug Name	Silver sulfadiazine (Silvadene) -- Although expensive, Silvadene has antipseudomonal properties in addition to coverage for most gram-positive organisms. Avoid facial use. Useful in prevention of infections from second- or third-degree burns. Has bactericidal activity against many gram-positive and gram-negative bacteria, as well as yeast.
Adult Dose	Apply using sterile technique to affected areas bid; wash burn prior to application to remove previously applied agent
Pediatric Dose	>2 years: Administer as in adults
Contraindications	Documented hypersensitivity; neonates and infants <2 y
Interactions	Reduces effect of proteolytic enzymes
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in G-6-PD deficiency and renal insufficiency

FOLLOW-UP

Section 8 of 12

Transfer:

• The American Burn Association has established the following criteria for referring patients to a burn center:
  • Second-degree burns covering over 10% total BSA (TBSA)

  • Third-degree burns covering over 5% TBSA

  • Second-degree or third-degree burns involving critical areas (eg, hands, feet, face, perineum, genitalia, major joints)

  • Burns with associated inhalation injury

  • Electrical or lightning burns

  • Severe burns complicated by coexisting trauma. If traumatic injuries pose a higher risk to the patient than the burn injuries, the patient may need to be sent first to a trauma center.

  • Preexisting disease that could complicate management of the burn injury

  • Chemical burns with threat of cosmetic or functional compromise

  • Circumferential burns on the extremities or the chest

  • Children with severe burns (These patients should be sent to a facility that has personnel and equipment to care for children with burns.)

• Prior to transfer, referring physician needs to accomplish the following:

• Respiratory support
  • If the patient is at risk for airway compromise or deterioration, perform intubation prior to transfer.

  • Support with 100% oxygen.

  • Stabilize circulatory status by fluid resuscitation.

  • Administer Ringer solution at the rate indicated by the Parkland formula or at that rate adjusted for clinical status (eg, urine output).

  • Ensure adequate vascular access for fluid resuscitation and administration of analgesics, if necessary.

  • Give transporting personnel orders defining rate and amount of analgesics that can be administered during transport.

• Care of the burn wound
  • Cover patients being transferred with a dry sheet.

  • Transport crews should exercise care to prevent the patient from becoming hypothermic.

  • Use of saline-soaked dressings increases risk of hypothermia.

  • Application of antimicrobial creams may delay transfer, and these agents must be removed once the patient arrives at the burn center.

• Physician-to-physician contact prior to transfer is essential. The accepting physician at the burn center can provide advice in caring for the burn patient and often can assist in arranging transfer. Documentation of what already has been performed for the patient and of any findings should accompany the patient to the burn center.

Complications:

• Scarring

• Cosmetic deformity

• Burn wound sepsis

• Adult respiratory distress syndrome (ARDS)

• Sepsis

• Death

Prognosis:

• The prognosis varies from excellent to poor depending on the severity of the burn.

Patient Education:

• Prevention is the best tool in the management of burn injuries. Campaigns stressing the use of smoke detectors and the adoption of laws mandating their use have decreased the mortality rate from burns significantly in North America. Additional materials useful for teaching burn prevention may be obtained from the American Burn Association.

• EPs should work with their local fire service to develop burn prevention programs as part of the fire service's fire prevention strategies.

• Discussions with patients who have sustained burn injuries should attempt to determine how the injury was sustained and what steps can be taken to prevent recurrence. As part of discussions with parents regarding risks in the home, EPs should ask parents if the water heater is set to 49°C (120°F). If parents do not know, encourage them to find out and have it adjusted if necessary. Simple interventions like this can have significant impact upon the lives of many.

• For excellent patient education resources, visit eMedicine’s Burns Center. Also, see eMedicine’s patient education articles Thermal (Heat or Fire) Burns and Sunburn.

MISCELLANEOUS

Section 9 of 12

Medical/Legal Pitfalls:

• Failure to consider abuse as the cause of burns in children can lead to litigation.

• Failure to involve burn specialists in the care of burns, including minor ones that involve critical areas (eg, hand, face, feet, genitalia), can lead to litigation. Development of scars in these areas can have significant cosmetic and functional consequences.

• Failure to recognize potential for airway involvement, even when classic signs of airway burns are absent, can lead to litigation. Signs of toxic inhalation may not be apparent for several hours after exposure, and the patient may deteriorate very rapidly.

Special Concerns:

• Take a proactive approach in the community by discussing burn injury and burn prevention with organizations such as local media, school officials, and adult care center.

• Take the opportunity to remind the community about the dangers of fireworks, malfunctioning smoke detectors, and home water heater temperature (must be set below 120°F).

TEST QUESTIONS

Section 10 of 12

CME Question 1: Early death from severe burn injury as a result of a house fire usually is caused by which of the following?

A: Hypovolemic shock resulting from loss of fluid from the burn wound
B: Septic shock resulting from infection of the burn wound
C: Respiratory failure from inhalation of toxic products of combustion, such as carbon monoxide
D: Associated traumatic injuries
E: None of the above

The correct answer is C: While major burns have the potential to cause loss of large fluid volumes following the destruction of the vapor barrier provided by the skin, development of clinical shock takes several hours. Most individuals who die in house fires in North America die from inhalation injuries. Aggressive management of the airway, especially in those who show signs of respiratory difficulty, who have a history of being confined in proximity to fire, or who have signs such as facial burns, can reduce the risk of death greatly.

CME Question 2: Transfer to a burn unit is indicated for which of the following patients?

A: A 5-year-old boy who fell into a campfire and acquired full-thickness burns to both legs below the knees
B: A 68-year-old man who has chronic obstructive pulmonary disease (COPD) and is well known to the ED was pulled from his fully involved trailer by the fire department (He has burns to the chest and abdomen resulting from his shirt being ignited by a cigarette and the flames fed by his home oxygen.)
C: A 27-year-old man who contacted a 220-volt power line at work (He has partial-thickness burns to his left arm and shoulder.)
D: All of the above indicate transfer to a burn unit.
E: None of the above indicate transfer to a burn unit.

The correct answer is D: On the basis of recommendations by the American Burn Association, each of these cases has one or more factors that are indicators for transfer to a burn unit. The 5-year-old boy has full-thickness burns covering over 5% total body surface area and feet. The 68-year-old man should be transferred because of his age, underlying disease, and high risk of inhalation injury. The 27-year-old man has associated electrical injury.

Pearl Question 1 (T/F): An escharotomy incision should be performed if needed in cases of thermal burns but only superficially.

The correct answer is False: Escharotomy incisions, made along the lateral aspects of the limb or in a box over the anterior chest, should go completely through the eschar (ie, through the dermis) and just into the subcutaneous fat.

Pearl Question 2 (T/F): Fluid needs for the first 24 hours for a 20-year-old woman (50 kg) with burns to the back of both legs and her back can be calculated. All of the burns are deep partial- or full-thickness burns.

The correct answer is True: Using the Rule of Nines, each leg is 18%. Half of each leg is involved: 2 X 9% = 18%. The back of the torso is 18%. Therefore, the total body surface area (TBSA) involved is 36%. Remember to include only second-degree or deeper burns in the calculation. Using the Parkland formula, the patient`s fluid requirement can be calculated as follows: 4 cm³/kg X (50 kg) X (36) = 7200 cm³ in the first 24 hours. Half of this is administered in the first 8 hours (beginning at the time of burn, not the time of arrival in the ED). Thus, the rate of fluid infusion should be 450 cm³/h for the first 8 hours, and then 225 cm³/h for the next 16 hours.

Pearl Question 3 (T/F): Fluids used in initial resuscitation of burn victims should contain colloids.

The correct answer is False: While colloid solutions have higher oncotic pressures and, thus, allow less leakage of fluids into the tissue spaces, an increased leak of protein has been shown in the early postburn period. Thus, colloids are no more effective than crystalloids in initial resuscitation of patients with burns.

Pearl Question 4 (T/F): Hot tar should be left on the skin until it cools down.

The correct answer is False: The tar should be actively cooled to terminate thermal damage. Tar can be peeled, picked, or debrided from injured skin and soft tissues once it has hardened. Polymicrobial antibiotic ointment, mineral oil, or petroleum jelly can be used to soften the tar. Organic agents, such as mayonnaise, butter, sunflower seed oil, or baby oil can be effective when removing tar. However, they must be rinsed or removed completely from occlusive sites beneath the tar that remains attached to the skin. Organic solvents, such as acetone or gasoline, can damage tissues and should be avoided.

PICTURES

Section 11 of 12

Caption: Picture 1. Partial- and full-thickness burns from a structure fire. Note facial involvement.
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Caption: Picture 2. Rule of nines for calculating burn area.
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Caption: Picture 3. Lund and Browder chart illustrating the method for calculating the percentage of body surface area affected by burns in children.
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Caption: Picture 4. Child with burns from a scald. Hot soup was spilled when the child grabbed the handle of a pot. Note the full-thickness burn to left upper part of the chest. Edema of the lips and blisters on the face and nose indicate second-degree burns of the face.
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Caption: Picture 5. Escharotomy to release the chest wall and allow for ventilation of the patient.
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BIBLIOGRAPHY

Section 12 of 12

• ABA: Burn Incidence and Treatment in the US: 2000 Fact Sheet [American Burn Association Web site]. [Full Text].
• Children's Hospital Boston: Fire Safety and Burns - Injury Statistics and Incidence Rates [Children's Hospital Boston Web site]. Accessed April 22, 2005. [Full Text].
• Edlich RF, Moghtader JC, Rosen P, et al, eds: Thermal burns. In: Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis: Mosby; 1998:941-953.
• Fogarty BJ, Gordon DJ: Firework related injury and legislation: the epidemiology of firework injuries and the effect of legislation in Northern Ireland. Burns 1999 Feb; 25(1): 53-6[Medline].
• Hove LM, Lindtjorn B: Epidemiology of burns in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg 1999 Jun; 33(2): 225-9[Medline].
• Jones D, Lee W, Rea S, et al: Firework injuries presenting to a national burn's unit. Ir Med J 2004 Sep; 97(8): 244-5[Medline].
• Juma A: Bitumen burns and the use of baby oil. Burns 1994 Aug; 20(4): 363-4[Medline].
• Monafo WW: Initial management of burns. N Engl J Med 1996 Nov 21; 335(21): 1581-6[Medline].
• Monafo WW, Freedman B: Topical therapy for burns. Surg Clin North Am 1987 Feb; 67(1): 133-45[Medline].
• Schwartz LR, Tintinalli JE, et al, eds: Thermal burns. In: Emergency Medicine: A Comprehensive Study Guide. 4th ed. Minneapolis: McGraw Hill: 1996:893-898.
• Shea PC, Fannon P: Mayonnaise and hot tar burns. J Med Assoc Ga 1981 Sep; 70(9): 659-60[Medline].
• Stratta RJ, Saffle JR, Kravitz M, Warden GD: Management of tar and asphalt injuries. Am J Surg 1983 Dec; 146(6): 766-9[Medline].
• Türegün M, Oztürk S, Selmanpakoglu N: Sunflower oil in the treatment of hot tar burns. Burns 1997 Aug; 23(5): 442-5[Medline].
• Tiernan E, Harris A: Butter in the initial treatment of hot tar burns. Burns 1993 Oct; 19(5): 437-8[Medline].
• US Fire Administration: QuickStats: The Overall Fire Picture - 2003 [US Fire Administration Web site]. 2003. [Full Text].
• Vassilia K, Eleni P, Dimitrios T: Firework-related childhood injuries in Greece: a national problem. Burns 2004 Mar; 30(2): 151-3[Medline].
• Wald DA: Burn management: Systematic patient evaluation, fluid resuscitation and wound management. Emergency Medicine Reports 1998; 19: 45-52.
• Wibbenmeyer LA, Amelon MJ, Torner JC, et al: Population-based assessment of burn injury in southern Iowa: identification of children and young-adult at-risk groups and behaviors. J Burn Care Rehabil 2003 Jul-Aug; 24(4): 192-202[Medline].
• World Fire Statistics Centre: Population Comparisons for Fire Deaths (1995-1997). October 2000 [The Geneva Association Web site]. [Full Text].

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