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J. B. Starr et al.
2 7. Lirk P, Picardi S, Hollmann MW.Local anaesthetics: 10 essentials.
Eur J Anaesthesiol. 2014;31(11):575–85. https://doi.org/10.1097/
EJA.0000000000000137.
28. Picardi S, Cartellieri S, Groves D, et al. Local anestheticinduced inhibition of human neutrophil priming: the influence
of structure, lipophilicity, and charge. Reg Anesth Pain Med.
2013;38(1):9–15. https://doi.org/10.1097/AAP.0b013e31827a3cbe.
29. Anderson TA, Fuzaylov G.Perioperative anesthesia management
of the burn patient. Surg Clin North Am. 2014;94(4):851–61.
S0039-6109(14)00071-1.
30. Town CJ, Johnson J, Van Zundert A, Strand H. Exploring
the role of regional anesthesia in the treatment of the burninjured patient: a narrative review of current literature.
Clin J Pain. 2019;35(4):368–74. https://doi.org/10.1097/
AJP.0000000000000680.
31. Krediet AC, Moayeri N, van Geffen GJ, et al. Different
approaches to ultrasound-guided thoracic paravertebral block:
an illustrated review. Anesthesiology. 2015;123(2):459–74. https://
doi.org/10.1097/ALN.0000000000000747.
32. Ueshima H, Otake H.Continuous erector spinae plane block
for pain management of an extensive burn. Am J Emerg Med.
2018;36(11):2130.e1–2. S0735-6757(18)30571-0.
33. Cordts T, Horter J, Vogelpohl J, Kremer T, Kneser U, Hernekamp
JF. Enzymatic debridement for the treatment of severely
burned upper extremities—early single center experiences.
BMC Dermatol. 2016;16(1):8–2. https://doi.org/10.1186/
s12895- 016- 0045- 2.
34. Shteynberg A, Riina LH, Glickman LT, Meringolo JN, Simpson
RL.Ultrasound guided lateral femoral cutaneous nerve (LFCN)
block: safe and simple anesthesia for harvesting skin grafts.
Burns. 2013;39(1):146–9. S0305-4179(12)00059-9.
35. Shank ES, Martyn JA, Donelan MB, Perrone A, Firth PG, Driscoll
DN.Ultrasound-guided regional anesthesia for pediatric burn
reconstructive surgery: a prospective study. J Burn Care Res.
2016;37(3):213. https://doi.org/10.1097/BCR.0000000000000174.
36. Cuignet O, Pirson J, Boughrouph J, Duville D.The efficacy of
continuous fascia iliaca compartment block for pain management
in burn patients undergoing skin grafting procedures. Anesth
Analg. 2004;98(4):1077–81, table of contents. https://doi.
org/10.1213/01.ane.0000105863.04140.ae.
3 7. Cassell EJ.Diagnosing suffering: a perspective. Ann Intern Med.
1999;131(7):531–4. 199910050-00009.
Chapter 15. Pain Management inBurn Patients
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
333
38. Fordyce WE. Behavioural science and chronic pain.
Postgrad Med J. 1984;60(710):865–8. https://doi.org/10.1136/
pgmj.60.710.865.
39. Kim DE, Pruskowski KA, Ainsworth CR, Linsenbardt HR,
Rizzo JA, Cancio LC. A review of adjunctive therapies for
burn injury pain during the opioid crisis. J Burn Care Res.
2019;40(6):983–95. https://doi.org/10.1093/jbcr/irz111.
40. Romanowski KS, Carson J, Pape K, et al. American burn
association guidelines on the management of acute pain in the
adult burn patient: a review of the literature, a compilation of
expert opinion, and next steps. J Burn Care Res. 2020;41(6):1129–
51. raa119.
41. Najafi Ghezeljeh T, Mohades Ardebili F, Rafii F, Haghani
H. The effects of music intervention on background pain and
anxiety in burn patients: randomized controlled clinical trial.
J Burn Care Res. 2016;37(4):226–34. https://doi.org/10.1097/
BCR.0000000000000266.
42. Hsu KC, Chen LF, Hsiep PH. Effect of music intervention on
burn patients’ pain and anxiety during dressing changes. Burns.
2016;42(8):1789–96. S0305-4179(16)30131-0.
43. Zhang XH, Gao XX, Wu WW, Yu JA.Impact of orally administered
tramadol combined with self-selected music on adult outpatients
with burns undergoing dressing change: a randomized controlled
trial. Burns. 2020;46(4):850–9. S0305-4179(19)30513-3.
44. Tan X, Yowler CJ, Super DM, Fratianne RB. The efficacy of
music therapy protocols for decreasing pain, anxiety, and muscle
tension levels during burn dressing changes: a prospective
randomized crossover trial. J Burn Care Res. 2010;31(4):590–7.
https://doi.org/10.1097/BCR.0b013e3181e4d71b.
45. Li J, Zhou L, Wang Y. The effects of music intervention
on burn patients during treatment procedures: a systematic
review and meta-analysis of randomized controlled trials.
BMC Complement Altern Med. 2017;17(1):158–4. https://doi.
org/10.1186/s12906- 017- 1669- 4.
46. Scapin S, Echevarría-Guanilo ME, Boeira Fuculo Junior
PR, Gonçalves N, Rocha PK, Coimbra R. Virtual reality in
the treatment of burn patients: a systematic review. Burns.
2018;44(6):1403–16. S0305-4179(17)30602-2.
4 7. Bermo MS, Patterson D, Sharar SR, Hoffman H, Lewis DH.Virtual
reality to relieve pain in burn patients undergoing imaging and
treatment. Top Magn Reson Imaging. 2020;29(4):203–8. https://
doi.org/10.1097/RMR.0000000000000248.
334
J. B. Starr et al.
48. Voon K, Silberstein I, Eranki A, Phillips M, Wood FM, Edgar
DW. Xbox kinect™ based rehabilitation as a feasible adjunct
for minor upper limb burns rehabilitation: a pilot RCT.Burns.
2016;42(8):1797–804. S0305-4179(16)30178-4.
49. Najafi Ghezeljeh T, Mohades Ardebili F, Rafii F. The effects
of massage and music on pain, anxiety and relaxation in
burn patients: randomized controlled clinical trial. Burns.
2017;43(5):1034–43. S0305-4179(17)30023-2.
50. Choi J, Lee JA, Alimoradi Z, Lee MS. Aromatherapy for
the relief of symptoms in burn patients: a systematic review
of randomized controlled trials. Burns. 2018;44(6):1395–402.
S0305-4179(17)30563-6.
51. Cuignet O, Pirlot A, Ortiz S, Rose T. The effects of
electroacupuncture on analgesia and peripheral sensory
thresholds in patients with burn scar pain. Burns. 2015;41(6):1298–
305. S0305-4179(15)00062-5.
52. Jafarizadeh H, Lotfi M, Ajoudani F, Kiani A, Alinejad V.Hypnosis
for reduction of background pain and pain anxiety in men with
burns: a blinded, randomised, placebo-controlled study. Burns.
2018;44(1):108–17. S0305-4179(17)30348-0.
53. Chester SJ, Tyack Z, De Young A, etal. Efficacy of hypnosis on
pain, wound-healing, anxiety, and stress in children with acute burn
injuries: a randomized controlled trial. Pain. 2018;159(9):1790–
801. https://doi.org/10.1097/j.pain.0000000000001276.
54. Wiechman Askay S, Patterson DR, Sharar SR, Mason S,
Faber B. Pain management in patients with burn injuries.
Int Rev Psychiatry. 2009;21(6):522–30. https://doi.
org/10.3109/09540260903343844.
Chapter 16
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Outpatient Burn Care
BarclayT.Stewart andNicoleS.Gibran
Introduction
The vast majority of the 11 million people globally who sustain burn injuries that require medical attention each year
have small burns that can be safely and effectively managed
in the outpatient setting (see Chap. 1) [1]. However, careful
care planning and organization are required to achieve excellent outcomes. Outpatient burn care involves emergency
units, primary and wound care clinics, mental health clinics,
physiotherapy programs, and interdisciplinary burn centers.
Each of these environments plays a vital role in the care of
individuals who sustained smaller burn injuries and follow-up
care of patients living with larger burn injuries after hospital
discharge.
B. T. Stewart (*)
Division of Trauma, Burn and Critical Care Surgery, UW Medicine
Regional Burn Center, University of Washington, Harborview
Medical Center, Seattle, WA, USA
e-mail: barclays@uw.edu
N. S. Gibran
Washington Research Foundation, Seattle, WA, USA
University of Washington, Seattle, WA, USA
e-mail: nicoleg@uw.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_16
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B. T. Stewart and N. S. Gibran
Burn clinics within regional burn centers are interdisciplinary and provide comprehensive wound management,
burn therapy, psychological treatment, functional activities,
social support, and vocational rehabilitation. Given that most
people in the world live far from an interdisciplinary burn
center where these resources are available, coordinating
community-based care is a core function of a regional burn
center. Telemedicine now plays an important role as a triage,
education, and care delivery platform [2–4].
Burn injuries, even small ones, can be devastating and lead
to scarring, pain, itch, disfigurement, dysfunction, and distress.
People living with even small burn injuries experience anxiety, depression, pain interference, acute stress symptoms, and
difficulty with re-integration that can manifest in many ways
and be subtle even to experienced burn care providers.
Therefore, systematic screening of patients to detect concerning signs, symptoms, and impairments using patient-reported
outcome (PRO) measures can identify those patients who
need specialized care. Similarly, PRO measures can be used
to track patient recovery over time, evaluate the effectiveness
of care, and identify service delivery gaps.
Value ofInterdisciplinary Outpatient
BurnCare
Integrated, interdisciplinary outpatient care within a burn
center can ensure quality care, reduce hospital lengths of stay,
bolster inpatient care capacity, and reduce overall costs of
care [1, 5, 6]. By concentrating burn-injured patients to a
high-volume center, patients and healthcare systems benefit
coupling patient volume and care quality through concentrating infrastructure, expertise, and resources [7, 8]. However,
regional burn centers should also plan and organize outpatient burn care with collaborating outpatient therapy and
mental health care providers within their catchment areas to
facilitate encounters that are easier for patients and their support system in certain circumstances.
Chapter 16. Outpatient Burn Care
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337
The multiple and complex sequelae of burn injuries can
often be anticipated by experienced, interdisciplinary burn
care teams. These sequelae include physical and psychosocial
complications, poor community integration, and inability to
return to work or school. When risk factors are recognized
early, these sequelae can often be prevented or reduced with
a combination of interdisciplinary management and follow up coordination. However, reports from survivors have demonstrated that the clinical manifestations of these sequelae
vary from patient to patient, can be subtle, and are often
challenging to manage as an outpatient without dedicated
burn care providers, nurses, therapists, psychologists, and
vocational rehabilitation counselors [9].
Patients benefit from concentrated services. The burden of
multiple outpatient care visits can be significantly reduced
when all necessary interdisciplinary services (i.e., burn surgeons, nurses, therapists, mental health professionals, vocational rehabilitation specialists, physiatrists, social workers)
are provided in a single encounter. Patients often prefer
expert burn care delivered during interdisciplinary encounters and often by providers with whom they are familiar.
Therefore, the added time and monetary costs associated
with travel to regional centers often are sometimes valued
greater than less organized or experienced burn care closer to
home. Given the growing capacity for telemedicine, reducing
travel-related burdens on patients and ensuring access to
interdisciplinary burn care services no longer need to be competing interests.
Telemedicine (e.g., phone consultation, videoconference,
use of photos to inform remote care) is technically feasible,
and cost-effective for all burn care-related disciplines in the
outpatient setting, including psychology and burn therapy
(see Chap. 18) [10]. Telemedicine can play an important triage
tool to identify patients who might benefit from in-person
burn expert consultation and those who would be better
served by care within their communities, avoiding unnecessary transfers [2, 11, 12]. Additionally, telemedicine review of
patients and wounds at a burn center can be used to guide
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B. T. Stewart and N. S. Gibran
care by non-burn providers and serve to increase communitybased burn care capacity over time [2, 10, 12]. Among the
bright spots of the COVID-19 pandemic include increased
use and acceptance of telemedicine. Telemedicine, when
planned and organized within a burn center, is not associated
with lower patient satisfaction or decreased wound and scar
assessment fidelity compared with in-person care [3, 13].
Detailed guidelines produced by American Telemedicine
Association for teleburn care can be found at american-
telemed.org [14].
Although the costs of developing and maintaining integrated, interdisciplinary regional outpatient burn care are
high, they are markedly lower than the costs associated with
longer hospital stays, delays in diagnosis of outpatient complications (e.g., wound infections, range of motion impairment), and unplanned hospital readmissions [1]. Therefore,
maintenance of regional, interdisciplinary burn centers, and
increasing community-based care partnerships in a hub and
spoke model can mitigate costs and improve local capacity
for outpatient burn care [15].
Identifying Patients Who Are Appropriate
forOutpatient Burn Care
Selecting patients with an acute burn injury who can achieve
an excellent outcome without hospitalization is the first and
most critical step in outpatient burn care. Four sets of factors
determine whether or not a patient is appropriate for outpatient management:
1. Injury factors—size, depth, and location of injury, pain
2. Patient factors—age, comorbidities, functional status
3. Social factors—social support, concern for abuse or
neglect, access to clean wound care environment and
transportation
4. Local burn care capacity and interdisciplinary burn center
outreach
Chapter 16. Outpatient Burn Care
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Generally speaking, patients must have injuries that do not
require inpatient care (e.g., no need for fluid resuscitation,
complex wound care, or advanced pain management; no
advanced comorbidities), the resources to manage their injuries and daily needs at home (e.g., clean wound care environment, social support), and ability to access burn care services
when needed [16].
Commonly considered patient and injury characteristics
that should prompt consultation with a burn center and possible inpatient management are listed in Table16.1. Although
these criteria were developed for well-resourced health systems, they can be used to inform decisions and protocols
regarding appropriateness of outpatient care in any setting.
T . Criteria for burn center referral adapted from American
Burn Association Burn Center referral criteria
Example criteria for referral to an interdisciplinary burn center
Partial thickness burns ≥20% Total Body Surface Area (TBSA)
in patients aged 10–50years old
Partial thickness burns ≥10% TBSA in children aged 10 or
adults aged 50years old
Full-thickness burns ≥5% TBSA in patients of any age
Patients with partial or full-thickness burns of the hands, feet,
face, eyes, ears, perineum, and/or major joints
Patients with high-voltage electrical injuries, including lightning
injuries
Patients with significant burns from caustic chemicals
Patients with burns complicated by multiple trauma
Patients with burns who sustained inhalation injury
Patients with comorbidities that could complicate management,
recovery, or mortality risk (e.g., substance use)
Burn injury in patients who will require special social,
emotional and/or long-term rehabilitative support
Suspected child abuse
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B. T. Stewart and N. S. Gibran
Regardless of setting and resource availability, it may be necessary to hospitalize a patient briefly until a more in-depth
assessment of their injury, functional status, social support
system, and access to transportation can be completed to
facilitate successful outpatient care.
Thorough assessment of psychosocial comorbidities and
social support is a key component of the decision-making
process that may lead to proceeding with outpatient care.
Patients must have a safe environment to live in, e.g., home,
transitional housing, medical respite at a shelter. There can be
no suspicion of abuse, neglect, or psychological conditions
that may jeopardize the patient’s safety or possibility to
achieve a good outcome. Family and/or friends must be available to support the patient, particularly those who need assistance with mobility, wound care, and/or transportation.
Special Injury Considerations
Patients with combined burns and other trauma require a
thorough evaluation at a trauma center. The combination of
these injuries results in high risk of complications and mortality, even for smaller burn injuries. As an example, a retrospective analysis of the National Trauma Data Bank
determined that the non-burn trauma exerts a negligible
increase in the risk of a poor outcome; however, increase in
the burn size, even for small burns, results in a stepwise
increase in the rate of poor outcomes for patients with these
combined injuries [17].
About one-third of burn patients sustain one or more
types of inhalation injury (i.e., upper airway heat injury, tracheobronchial steam or chemical injury, parenchymal smoke
irritant injury, and systemic toxicity—carbon monoxide, cyanide, as examples). Patients with a history of injury within an
enclosed space or associated with exposure to heat, smoke, or
chemicals and supporting clinical signs and symptoms should
be managed at a burn center.
Chapter 16. Outpatient Burn Care
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Although electrical and chemical injuries generally warrant consultation with a burn center, patients with smaller
injuries can usually be managed as outpatients (see Chap. 13).
Low-voltage household current (110–220 volts) electrical
injuries typically cause only minor tissue damage. Patients
who do not experience syncope and who have normal screening electrocardiogram (ECG) may be treated as outpatients
without concern for subsequent cardiac events. However,
anticipatory guidance is sometimes needed. As example, a
toddler who chews on a live wire and sustains an injury to the
oral commissure is at risk of delayed labial artery bleeding,
particularly as the scab lifts off. Parents or caregivers should
be educated about this risk and how to manage it by pinching
the corner of the mouth and presenting to an emergency
department.
Small chemical injuries can also be treated in the outpatient setting depending on the type of chemical, ability to
perform decontamination, and location of the injury (see
Chap. 14). Certain chemicals, such as powder alkalis and
hydrofluoric acid, require serial decontamination and treatment that is often best suited for the inpatient setting. For
those who can achieve adequate decontamination by brushing off dry powders and thorough irrigation of injuries until a
normal skin pH is achieved, an outpatient plan can be created. Given that wound depth progression is common with
chemical injuries, patients must be closely followed for infection, contracture, and need for surgical care.
Inpatient toOutpatient Transitions
Patients who require inpatient management for their injury
and are nearing hospital discharge should be prioritized for
follow-up at a burn center, particularly those with large burns
or other significant injuries. The transition between inpatient
and outpatient care is a vulnerable time for patients and their
families, often characterized by competing feelings of joy to
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