Treatment of the Burn Patient in Primary Care

NOVEMBER 2010
Treatment of the Burn Patient
in Primary Care
C M E
CATEGORY 1
1 Credit
ANCC/AACN
2.5 Contact Hours
Lee S. Moss, MS, APRN, NP-C, CWS & Nurse Practitioner & Department of Surgery & University Health Care Burn Center &
Salt Lake City, Utah
The author has disclosed that he has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.
All staff and faculty, including spouses/partners (if any), in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in,
any commercial companies pertaining to this educational activity.
This continuing educational activity will expire for physicians on November 30, 2011.
This article is adapted from the August 2010 issue of The Nurse Practitioner. Moss LE. Treatment of the burn patient in primary care. 2010;35(8):24-31.
PURPOSE:
To enhance the learner’s competence in treating burn patients in primary care.
TARGET AUDIENCE:
This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.
OBJECTIVES:
After participating in this educational activity, the participant should be better able to:
1. Use correct burn classifications for documentation and for making patient referrals to burn units.
2. Construct treatment regimens for burn patients.
3. Apply burn care knowledge to patient education scenarios.
ADV SKIN WOUND CARE 2010;23:517-24; quiz 525-6.
mean age of 32 years; about 17% were younger than 5 years,
and 12% were 60 years or older.2 The majority of burn patients have minor wounds and may be treated on an outpatient
basis.3
By reading this article, clinicians will be better able to assess
burn injuries, including the depth, severity, extent, and location
of the burn, and select the appropriate burn wound care treatment, including pain management, dressings, rehabilitation, and
scar management.
A
ccording to the American Burn Association (ABA) 2007
Fact Sheet, approximately 500,000 burn-injured patients
receive medical treatment at hospital emergency departments and outpatient clinics, urgent care centers, and private healthcare provider offices. Approximately 40,000 of these
are admitted to hospitals.1 Data from the 2010 ABA National
Burn Repository Report state that 71% of burn patients had
burn sizes of less than 10% total body surface area (TBSA).2
Approximately 70% of these burn patients were male, with a
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ADVANCES IN SKIN & WOUND CARE & NOVEMBER 2010
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ASSESSMENT
Figure 1.
A thorough history should be obtained, including the time and
etiology of the burn injury, to help determine whether there is
concomitant trauma (such as electrical injury causing cardiac
dysrhythmias, closed-space injury causing smoke inhalation,
or an explosion, fall, or crash causing orthopedic injuries). In
addition, the medical, surgical, family, and social history should
be obtained to identify comorbid medical conditions (such as
diabetes, immunocompromise, heart, respiratory, vascular and
kidney disease, substance abuse, or obesity), which may complicate the patient’s recovery. Infants, toddlers, and older adults
have a higher risk of morbidity and mortality. Infants and small
children have a larger surface area than do adults (larger heads
and smaller legs) causing increased evaporative losses and decreased body temperature compared with adults. As with older
adults, infants also have a thinner dermis causing deeper burn
wounds.3–7 Burns resulting from abuse or neglect in patients of
any age are not uncommon, and if suspected, they should be
thoroughly investigated, and authorities notified according to
state law.3–6,8
CLASSIFICATION OF BURNS BY DEPTH OF INJURY
Source: Anatomical Chart Company. Atlas of Pathophysiology. 3rd ed. Philadelphia, PA:
Wolters Kluwer/Lippincott Williams 2010:385.
less painful than superficial second-degree burns. They frequently take 2 to 4 weeks to heal and often with significant
scarring.
& Full-thickness burns involve all of the epidermis and dermis.
They are dry, have a leather-like texture due to destroyed collagen, are variable in color depending on the causative agent,
are insensate due to destruction of sensory nerve endings,
and unless they are very small, do not heal spontaneously. They
also may extend beyond the skin to subcutaneous fat, tendon, muscle, or bone and may require amputation or complex
reconstruction.3–5,7–9
Many burn wounds are a mixture of burn depth, so patients
with full-thickness burns frequently also have painful partialthickness burns and need treatment for pain as well.
BURN SEVERITY
Burn severity depends on the depth, extent, and location of the
burn injury. The ABA considers the following to be minor burns:
& superficial-thickness burns.
& partial-thickness burns less than 15% of TBSA in people 10
to 50 years old.
& partial-thickness burns less than 10% of TBSA in children
younger than 10 years and adults older than 50 years.
& full-thickness burns less than 2% of TBSA in all populations.3,9
DEPTH
The depth of a burn wound depends on the temperature and
the duration of contact with the injuring agent, as well as the
thickness of the skin and blood supply to the injured area8
(Figure 1). Burn depth is described as follows, going from the
most superficial to the deepest:
& Superficial burns involve only the epidermis. They are red,
dry, and painful, blanch, and are tender to palpation. The
injured epidermis sloughs within a few days. They require only
symptomatic care and usually heal within 1 week without
scarring.
& Superficial partial-thickness burns involve all of the epidermis
and the superficial dermis. They are red, moist, and very painful. There is blister formation, and the burns usually heal with
minimal scarring in 10 to 14 days.
& Deep partial-thickness burns involve all of the epidermis
and most of the dermis. They are generally paler, dryer, and
ADVANCES IN SKIN & WOUND CARE & VOL. 23 NO. 11
EXTENT
Burn extent is given as a percentage of the TBSA burned. Two
common methods of estimating the extent of a burn injury
include the Rule of Nines and the Lund and Browder methods
(Figure 2). The Rule of Nines is commonly used in the prehospital setting because it is easy to remember and use. It
divides the adult body into anatomical regions of 9% or a
multiple of 9%. Infants and small children have larger heads
and smaller legs than adults, and so the rule is modified for
them by doubling the size of the head from 9% to 18% and
decreasing each leg from 18% to 14% (Figure 3). Also, the rule
does not work well with scattered small burns (such as splash
burns from spilled hot liquids). To correct for this, the patient’s
palm including the fingers, which represent approximately 1%
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later by hypertrophic scarring.3,5,8 Consider a consultation with or
referral to a Burn Center based on the ABA Burn Center Referral
Criteria (Table 1).
of the patient’s TBSA, can be used to estimate small scattered
burns.
The Lund and Browder method uses narrower age ranges and
divides the body into smaller anatomical regions to account for
changes in surface area with age.3–5,7–9
BURN WOUND CARE
The acute phase of burn care lasts from the time of injury until
the burn wounds are closed. Most burn wounds are painful. The
most painful are superficial partial-thickness burns because
the sensory nerve endings are intact and working but exposed
because of the loss of the epidermis. Burn pain is intense initially,
during debridement and dressing changes, but usually moderates once dressings are applied, protecting the nerve endings.
Pain increases again with activity, especially physical therapy.
Most patients require analgesics and will need opioid-based
analgesics for wound care, physical therapy, and sleep. If possible, make sure the patient has been premedicated for pain
LOCATION
The location of the burn wound may cause additional complications initially or during the healing process, such as edema,
causing pharyngeal obstruction necessitating endotracheal intubation. Facial edema may prevent eyes from opening, impeding
vision and circumferential limb burns, and subsequent edema
may lead to vascular compromise necessitating an escharotomy.
Burns to the perineum may cause urethral obstruction necessitating an indwelling urinary catheter, whereas burns over joints
immediately affect the range of motion, which may be exacerbated
Figure 2.
ESTIMATING THE EXTENT OF BURNS
Source: Anatomical Chart Company. Atlas of Pathophysiology. 3rd ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams 2010:385.
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ADVANCES IN SKIN & WOUND CARE & NOVEMBER 2010
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pairing neutrophil and lymphocyte function and increases
inflammation. The devitalized tissue and fluid are also mediums
for bacterial growth and possible infection.10
Researchers in support of leaving blisters intact state that an
intact blister usually indicates a superficial burn that will heal
spontaneously within a few weeks.10 The intact blister creates its
own dressing, thereby keeping the wound clean, moist, and
protected. The wound is protected from the air, manipulation,
and contamination because of dressing changes; thus, there is
less pain and less need for analgesics. With fewer dressings, the
cost of supplies is decreased. Some practitioners prefer to debride
blisters that are already broken, fragile, and imminently going to
break or are crossing joints, thus interfering with function. These
practitioners leave other blisters intact unless pain caused by
pressure from the blister is intolerable or preventing active range
of motion.3,4,7,9–11
Figure 3.
RULE OF NINES FOR INFANTS AND YOUNG CHILDREN
Table 1.
BURN CENTER REFERRAL CRITERIA
The ABA has identified the following injuries as those
requiring referral to a burn center. A burn unit may treat
adults, children, or both.
Burn injuries that should be referred to a burn unit include
the following:
(1) Partial-thickness burns greater than 10% of TBSA.
(2) Burns that involve the face, hands, feet, genitalia,
perineum, or major joints.
(3) Full-thickness burns in any age group.
(4) Electrical burns, including lightning injury.
(5) Chemical burns.
(6) Inhalation injury.
(7) Burn injury in patients with preexisting medical
disorders that could complicate management, prolong
recovery, or affect mortality.
(8) Any patient with burns and concomitant trauma (such
as fractures) in which the burn injury poses the greatest
risk of morbidity or mortality. In such cases, if the trauma
poses the greater immediate risk, the patient may be
initially stabilized in a trauma center before being
transferred to a burn unit. Physician judgment will be
necessary in such situations and should be in concert
with the regional medical control plan and triage
protocols.
(9) Burned children in hospitals without qualified
personnel or equipment for the care of children.
(10) Burn injury in patients who will require special social,
emotional, and/or long-term rehabilitative intervention.
before manipulating the wounds, but be aware that anything less
than anesthesia will not eliminate burn pain.3–7,10,11
The patient’s tetanus vaccination status should be assessed and
updated if needed.3,7,8 Superficial burns are not open wounds and
do not require dressings. They may be treated symptomatically
with moisturizers, cool compresses, and analgesics. Large superficial burns may require short-term hospitalization for pain control. Wound care should begin with gentle cleansing of the burn
wounds with a bland soap and water or wound cleanser. Remember that the burn wound is initially sterile, and the goal is to
remove devitalized skin, dirt, and debris while minimizing pain
and additional trauma to the burn wound.3–5
Two frequently asked questions are whether to debride intact
blisters and whether burn wounds should be shaved, clipped, or
left alone. The literature regarding both issues is mixed. With
regard to blisters, recommendations range from leaving blisters
intact until the underlying skin heals, needle aspirating them
leaving the dead skin in place, to debriding them immediately.
The case for debriding blisters is supported by studies that demonstrate that blister fluid depresses immune function by imADVANCES IN SKIN & WOUND CARE & VOL. 23 NO. 11
Source: Advanced Burn Life Support Course Provider Manual. 2007:76. Used with
permission.
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use of occlusive dressings as they do not allow absorption or
drainage of exudates and lead to skin maceration and an
anaerobic environment.
Deep partial-thickness burns with adherent exudates, fullthickness burns, or cellulitic wounds can be treated with silver
sulfadiazine 1%. It has a broader spectrum of antimicrobial
activity and better penetration of necrotic tissue than
bacitracin.10,12 Silver sulfadiazine 1% inhibits wound epithelialization and should be discontinued once exudates and eschar
have separated from the wound, leaving a clean wound bed,
which is then treated as a superficial partial-thickness burn.10
Silver sulfadiazine 1% is a sulfa drug and should not be used
on patients with sulfonamide allergies.10 It should also not be
used on pregnant or nursing women or on infants younger than
2 months.10
The open-dressing method for face, head, and neck burns
is effective because contamination is unlikely. A thin film of
bacitracin ointment applied to these wounds works well because
it stays in place.10 Because most people do not like having their
face covered, silver sulfadiazine 1% may be used without a
dressing to cover the face; however, the drug runs off as it warms
and mixes with serum and turns gray to black when exposed to
light because of silver nitrate. Dressings applied over burned
joints should facilitate range of motion, and fingers should be
wrapped individually.3–5,7,9–11
For patients with limited financial resources, alternative dressings to keep ointments on wounds include light cotton gloves
and snug-fitting T-shirts, undergarments, socks, or other items
that can be purchased at discount stores in multipacks, washed,
and reused until the burn wounds heal.
Diapers work well for buttock and perineal burns in infants,
young children, and adults with incontinence.3
A variety of burn care products are available. Although many
claim to provide the fastest healing time at the lowest cost,
clinicians must evaluate the claims and the research to decide
what will work best for individual patients.3,9
Alternative dressings for superficial partial-thickness burn
wounds without adherent exudates or eschar include alginates, hydrofibers, or foam dressings that absorb exudates,
maintain a moist environment, and require fewer dressing
changes, thus decreasing pain and anxiety for patients. Many
of these products have silver in them, which is used as an
antimicrobial.3–5,7
An alternative treatment for deep partial-thickness burns
is an enzymatic debrider that chemically debrides devitalized tissue without harming healthy tissue and may speed
healing, decrease the likelihood of a surgical procedure, or
may be used when surgery is not an option. Once the wound
bed is clear of debris, another dressing may be used.
Those in support of shaving or clipping hair from the burn
wound say that the risk of infection is decreased by making
it easier to debride dead tissue and keep the wound clean.
Shaving the hair exposes the burn, making it easier to evaluate the depth and extent of the burn. The pain of subsequent wound care is decreased because devitalized tissue and
exudates wash off easier as they are not anchored in place by
intact hair.3,11 Other practitioners believe that shaving the
hair from minor burn wounds can cause additional trauma.3
Some prefer to shave most burn wounds to expose their
depth and extent especially on scalps, and most importantly
on infants and toddlers whose hair may hide a moderate or
major burn that should not be treated in a primary care
setting.3,8,11
Immediately following the burn and for up to 24 hours after
injury, the burn wound is essentially sterile. Systemic antibiotics are no longer prescribed to prevent burn wound infections, and burn wounds should not be routinely cultured in
the primary care setting.10 Burned limbs should be elevated
above the level of the patient’s heart when not being actively
exercised to decrease edema and pain.10 Burned skin contracts
and so range of motion of all affected areas should begin
with the first visit. This may necessitate referral to a physical
therapist.3,4
BURN WOUND DRESSINGS
The burn wound dressing should keep the wound moist and
clean, promote optimal function of affected joints, protect
the wound from additional trauma, and provide for patient
comfort. There are quite a variety of dressing types available
to treat burn wounds on an outpatient basis, and there
are several ways to accomplish the goals above. They vary
widely in complexity and cost. In the primary care environment, simple and inexpensive will work best for the patient
and the provider.3,5,9
Superficial burns do not require topical antimicrobials. Moisturizers should be used for dry skin and comfort, as well as
sunblock as a moisturizer when the hypopigmented skin is
exposed to the sun until it is back to its baseline color.
Superficial partial-thickness burns without adherent exudates
or eschar can be treated with a topical antimicrobial ointment,
such as bacitracin, other over-the-counter antimicrobials, or
vitamins A and D ointment. They are inexpensive and easy to
use. Bacitracin has activity against Gram-positive bacteria. On
occasion, it may cause contact dermatitis causing additional
skin breakdown, especially after long-term use.10 The ointment
should be covered with a nonadhering layer then dry gauze and
may be secured with flexible elastic netting and changed 1 to 2
times per day, depending on the amount of drainage. Avoid the
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PATIENT EDUCATION
caregivers should be informed that scarring is a normal process, but the amount of scar formation is variable. The deeper
the burn wound, the more scar tissue will form. Scar tissue
replaces normal skin in deep partial- and full-thickness burn
wounds. Scar tissue formation is also genetic and unique,
so only time will tell how much scar tissue will develop. Frequently, patients and families consider any difference in skin
color as scarring, although this may not truly be scar tissue.
Healed burns that remain hyperemic or hypopigmented are
sensitive to UV light, are more easily sunburned, and may
become permanently hyperpigmented. This can usually be
prevented by protecting this skin from UV radiation using
sunblock and proper clothing until the skin returns to its
The patient and caregivers should be instructed in burn
wound care and range-of-motion exercises and provided with
oral and written instructions, with demonstrations if possible. Also, pain management, signs and symptoms of infection, and information about wound healing, scar formation
and maturation, and expected outcomes should be discussed
(Table 2).
REHABILITATION AND SCAR MANAGEMENT
The rehabilitation phase of burn care lasts from burn wound
closure until scar maturation. The most frequent question patients and families ask is about scarring. Patients and their
Table 2.
PATIENT EDUCATION: WOUND AND BURN CARE INSTRUCTIONS
Listed below are the basic principles of wound care regarding your burn injury:
(1) SILVER SULFADIAZINE DRESSING: Your burn has been dressed in silver sulfadiazine. This is to be changed 2 times a day.
This is very important to promote healing and prevent infection. Follow these guidelines as the healthcare practitioner has instructed
you:
(a) Wash the burn with mild soap, water, and a washcloth, removing all old ointment and any loose skin.
(b) Blot dry.
(c) Apply a thick coat of silver sulfadiazine (like icing on a cake) and cover with a minimal amount of gauze netting. Silver
sulfadiazine tends to work better when some air can get through the dressing.
(2) BACITRACIN AND DRESSING: Your burn has been dressed in bacitracin with a nonadhering dressing. This dressing is
changed 2 times a day. This is very important to promote healing and prevent infection.
Follow these guidelines as the healthcare practitioner has instructed you:
(a) Wash the burn with mild soap, water, and a washcloth. Be sure to remove all old ointment and any loose skin.
(b) Blot dry.
(c) Apply a very thin coating of ointment only on the open areas.
(d ) Place a sheet of the nonadhering dressing over the ointment. Do not overlap excessively.
(e) Cover with minimal amount of gauze followed by netting.
(3) MOISTURIZER AND SUNBLOCK should be applied on all areas. Healed skin is pink and shiny with no drainage. Apply as
needed throughout the day. If in water, sunblock should be applied every 30 minutes.
(4) FACE AND NECK BURNS: Face and neck burns should be washed at least 2 times a day, removing all old ointment and any
loose skin. Apply bacitracin ointment on all open areas. If this ointment is rubbed off during the course of the day, reapply
bacitracin as often as needed to keep wounds moist.
(5) INFECTION: A low-grade fever associated with burn injuries is normal. Cellulitis, however, is a localized infection of the burn
wound and would benefit from simple treatment. If there is redness spreading out from the burn wound and the surrounding skin is
warm and swollen, you should contact the healthcare practitioner immediately.
(6) BATHING: A daily bath is helpful in wound management. Shampoo and other chemicals involved in bathing will not
contaminate your burn injury. Immediately before getting out of the tub, wash your wounds as described above.
(7) DIET: Fluid intake is very important. Increasing your normal fluid intake with juices and drinks high in protein and calories will
help speed healing. Be sure to eat well-balanced, nutritious meals.
(8) ACTIVITY: Maintaining function of a burned extremity decreases pain and swelling as well as promotes healing. Therefore,
normal activity is encouraged except when otherwise instructed by the healthcare practitioner.
(9) PAIN CONTROL: Dressing changes are often very painful, and medication cannot take all the pain away. It may be helpful for
you to take your pain medication 30 minutes before doing the dressing change. Please ask for medication refills at your
appointment or call 48 hours before you finish your prescription.
Source: University Health Care Burn Center, Salt Lake City, Utah. Used with permission.
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PREVENTION
baseline color. Patients with burns to the face or joints may
need physical therapy to maintain their range of motion, regain their strength and endurance, control hypertrophic scarring, and prevent scar contractures.
Common complaints that must be addressed during the
rehabilitation phase include itching; pain and discomfort
associated with exercise, pressure, and positioning; and sleep
disturbances. Itching can be especially troubling and difficult to treat. It is frequently treated with moisturizers and
antihistamines with inconsistent results. Pain at this stage
of healing is usually managed with a nonsteroidal antiinflammatory drug. Some patients develop postinjury nerve
pain, which is similar to diabetic neuropathy and may be
treated in a similar fashion. Sleep disturbances may be due
to poor sleep hygiene, pain, itching, anxiety, or other psychological problems (ie, depression or posttraumatic stress
disorder), which may require additional medication or
counseling.3,9,10
The ability to treat burn patients and obtain successful outcomes
is very important, but it is always better to prevent burn injuries
than to treat them. Primary care providers are in a unique position to offer burn prevention education to their patients and
families. In the same way that teaching is provided with routine
visits regarding diet, exercise, smoking cessation, and other
health promotion topics, burn prevention should be discussed
with each encounter related to the age and developmental level
of the patient.6 Burn prevention resources are available on the
ABA Web site, http://www.ameriburn.org.
SUMMARY
Managing burn injuries is one of the many challenges of wound
care. After reading this article, clinicians should be better able to
assess burn injuries, including the depth, severity, extent, and
location of the burn, and select the appropriate burn wound care
treatment, including pain management, dressings, rehabilitation, and scar management for patients of all ages.
FOLLOW-UP
Follow-up visits range from daily to weekly during the acute
phase, depending on the severity of the burn injury, medical
history, and social factors including significant others who
can assist the patient with burn care and activities of daily
living. Other factors include financial resources and the
patient’s living arrangements, such as whether it is a clean
environment with functioning utilities (electricity and running water), pain management, and the type of burn
dressing used.
If burn wounds are not clearly healing in 2 weeks or are not
fully healed by 4 weeks after the injury, the burn may be deeper
than previously assessed and may require surgical intervention. These wounds are also more likely to develop hypertrophic scar tissue and require scar management, especially
over joints that could hinder their function. These patients
should be considered for referral to a burn clinic for further
evaluation and treatment. Patients should be advised to
contact their primary care provider with any concerns including inadequate pain management, signs or symptoms of
infection, or any problems with their wound care. Although
most burn wounds are ‘‘healed’’ within a month, burn patients
in the rehabilitation phase should be monitored intermittently
until their wounds are mature (approximately 1 year), as evidenced by skin that is soft, supple, and back to baseline color,
to evaluate and manage any hypertrophic scarring or scar
contractures that may develop. Families of patients burned as
children should understand that even after burn wounds are
fully mature, scar contractures can develop until the patient
stops growing.3,5–7
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PRACTICE PEARLS
Tips for using wound care dressings and alternatives for
burn patients include the following:
& The open-dressing method for face, head, and neck
burns is effective because contamination is unlikely.
& Dressings applied over burned joints should facilitate
range of motion, and fingers should be wrapped
individually.
& Alternative dressings to keep ointments on wounds
include light cotton gloves, snug-fitting T-shirts,
undergarments, and socks.
& Diapers work well for buttock and perineal burns in
infants, young children, and adults with incontinence.
& Alternative dressings for superficial partial-thickness
burn wounds without adherent exudates or eschar
include alginates, hydrofibers, or foam dressings that
absorb exudates, maintain a moist environment, and
require fewer dressing changes.
REFERENCES
1. Burn incidence and treatment in the US: 2007 fact sheet. http://www.ameriburn.org/
resources_factsheet.php?PHPSESSID=8a6e2691d223caf3cba21f775c8fe2f6. Last accessed September 2, 2010.
2. National Burn Repository 2010 Report dataset version 6.0 http://www.ameriburn.org/
2010NBRAnnualReport.pdf. Last accessed September 2, 2010.
3. Moss LS. Outpatient management of the burn patient. Crit Care Nurs Clin North Am
2004;16(1):109-17.
4. Grunwald TB, Garner WL. Acute burns. Plast Reconstr Surg 2008;121:311e-9e.
5. Sheridan RL. Outpatient burn care in the emergency department. Pediatr Emerg Care
2005;21:449-56.
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ADVANCES IN SKIN & WOUND CARE & NOVEMBER 2010
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
6. Ewings EL, Pollack J. Pediatric upper extremity burns: outcomes of emergency department triage and outpatient management. J Burn Care Res 2008;29(1):77-81.
7. Gomez R, Cancio LC. Management of burn wounds in the emergency department.
Emerg Med Clin North Am 2007;25(1):135-46.
8. ABLS Advisory Committee. Advanced Burn Life Support Providers Manual. Chicago, IL:
American Burn Association; 2005:14-22, 42-5, 70-6.
9. Hermans MH. A general overview of burn care. Int Wound J 2005;2:206-20.
10. Hartford CE, Kealey GP. Care of outpatient burns. In: Herndon DN, Jones JH, eds. Total
Burn Care. Philadelphia, PA: WB Saunders; 2007:67-80.
11. Nowlin A. The delicate business of burn care. RN 2006;69(1):52-4,56-7.
12. Drug Information Online. Silver sulfadiazine (topical). http://www.drugs.com/mmx/
silver-sulfadiazine.html. Last accessed September 2, 2010.
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&
& Take the test, recording your answers in the test answers section (Section B)
of the CE enrollment form. Each question has only one correct answer.
ADVANCES IN SKIN & WOUND CARE & VOL. 23 NO. 11
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524
Nurses: If you take two or more tests in any nursing journal published by
LWW and send in your CE enrollment forms together by mail, you may
deduct $0.95 from the price of each test. We offer special discounts for
as few as six tests and institutional bulk discounts for multiple tests. Call
1-800-787-8985 for more information.
WWW.WOUNDCAREJOURNAL.COM
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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