A 4-year-old male accidentally tipped over hot butter while making homemade popcorn. The extent of injury is seen in this picture.
What is the next best step in management?
A. Aspirate the blister
B. Unroof the blister
C. Wash with gentle soap and water
D. Wash with gentle soap and water then apply silver sulfadiazine
E. X-ray the hand
Correct answer:
C. Wash with gentle soap and water
This patient is presenting with <1% TBSA oil burn. It should be treated as a standard thermal burn. By its appearance it is likely a deep partial-thickness burn. Referral to a burn center is indicated since it is on the hand (he will need physical therapy to ensure full range of motion as the healing skin tightens) and because he is a child (if pediatric burn services are not available where he presented).
Incorrect answer choices:
Blisters that are tense may be unroofed/debrided (Choice B) or aspirated (Choice A) to allow a controlled resolution of the blister. It is debatable which is better. This blister is not tense and should therefore be left alone. The argument can be made that it should be unroofed to see the extent of damage, but based on mechanism and appearance, it is highly unlikely to be a full-thickness burn.
Silver sulfadiazine (Choice D) is associated with worsened outcomes compared to other dressings including biosynthetic dressings, silver-containing dressing, and silicon-coated dressings when applied to partial-thickness burns and is no longer recommended unless the burn is full-thickness (previously classified as a 3rd degree burn).
Without a history of trauma, an X-ray (Choice E) would be especially low yield in this patient and expose the patient to unnecessary radiation.
References
Fairbrother H, Long M, Haines E. Optimizing Emergency Management to Reduce Morbidity and Mortality in Pediatric Burn Patients. EB Medicine. June 30, 2020. Accessed September 20, 2022. https://www.ebmedicine.net/topics/trauma/pediatric-burns (full free access for residents)
Singer A and Lee C. Chapter 56. Thermal Burns. In: Walls RM, Hockberger RS, Gausche-Hill M, et al. <em>Rosen’s Emergency Medicine: Concepts and Clinical Practice</em>. 9th ed. Philadelphia: Elsevier; 2018.
Wasiak J, Cleland H, Campbell F, et al: Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev 2013
