TL;DR
- Purpose: Firework burns can look minor at first and progress significantly within 48 hours. If you’re working this weekend, this is your quick-reference guide to burn depth, referral criteria, and what’s actually happening in that wound before it declares itself.
- First question to ask: Does this burn involve the hands, feet, face, genitalia, or a major joint, regardless of how small or superficial it looks?
- Don’t miss:
- Dorsal hand burns: thin skin and superficial tendons mean these progress to full thickness faster than a palm burn of the same size
- Burns over a joint: even small partial thickness burns here need referral because of contracture risk during healing
- Periorbital burns: need same-day ophtho referral
- Suspected blast or chemical component (black powder, metal salts): x-ray before closure if there’s any chance of embedded debris
- Management: Silver sulfadiazine is out. Most centers now use Xeroform, Mepilex Ag, or a non-adherent dressing with topical antibiotic ointment.
- The rule: Re-evaluate at 24 to 48 hours, and utilize your local burn center for consults.
- In the app: We added images of burn depth types to Blox so you can compare what you’re looking at mid-visit.
- Free resource: American Burn Association’s Find a Burn Center directory
Did you know sparklers burn at around 1,200°F? For reference, that’s literally hotter than lava. Throw in a couple of alcoholic beverages, a late night, or a child, and they can cause serious injuries quickly.
July 3rd into the 4th is its own little burn season. If you’re working this weekend, you’re likely going to see at least one injury related to this. Here are a few things to remember.
“Zone of Stasis”
The trouble with burns is that they can look benign at first. There’s something called the “zone of stasis”, which is the area surrounding the initial burn where blood flow is compromised but not yet dead. We say that the burn hasn’t “fully declared itself”. Over the next 24 to 48 hours, that tissue either recovers or it doesn’t, depending on the person’s overall health, perfusion, infection, and how you initially manage the wound. What may look like a straightforward, partial thickness burn on day one can progress to a deeper full thickness by day three. Your burn patients need regular follow-up, and you need to counsel them that a one-time dressing change isn’t going to cut it.
Dorsal Hand Burns
Dorsal hand burns are often under-triaged and under-treated. The skin here is thin with tendons right under the surface, so these can progress to full thickness burns much faster than a palm burn of the same size would. You can’t treat them the same.
Burn Unit Referral Criteria
Here’s where I want you to have a low threshold for referral. Call your nearest burn center for:
- Full thickness burns of any size
- Partial thickness burns over 10% TBSA
- Burns involving the hands, feet, face, genitalia, or major joints (contracture risk is the major concern here)
- Circumferential burns, regardless of depth
- Any burn with suspected inhalation injury or significant associated trauma
- Electrical or chemical burns layered on top of the thermal injury (more common with fireworks than you’d expect)
What if the Nearest Burn Center Is Two Hours Away?
Not everyone lives close to a burn center. If your patient meets referral criteria and the nearest one is two hours away with no reliable way for your patient to get there, you’ll have to get creative with management and follow-up. A few things that you can do:
- Call the nearest burn center first. Most will do a phone consult and a lot of borderline cases can be managed locally with their guidance. Send photos (securely) if you can.
- If transport is the actual barrier (no car, no gas money, kids without childcare), communicate that to the burn center. A lot of centers can help coordinate transport for confirmed transfers.
You can find the nearest verified burn center through the American Burn Association’s directory.
A Few More Pearls Before the Weekend
Silver sulfadiazine has fallen out of favor by a lot of burn providers. It can form a pseudoeschar that makes it hard to reassess the wound and tends to slow healing compared to newer options. Most burn centers are using Xeroform, Mepilex Ag, or a simple non-adherent dressing with topical antibiotic ointment instead.
Any periorbital burn needs a same-day ophtho referral.
If you’re seeing a burn from a mortar or anything bigger than a sparkler, think blast injury on top of the thermal one. You need to get an X-ray before closure if there’s any chance of embedded debris.
Identifying burn depth is one of the harder skills to keep sharp when you’re not seeing burns every week. We added images of the different burn types to Blox — pull it up mid-visit and compare what you’re looking at.