11.03 Partial Thickness (2nd-Degree) Burns; Tar Burns
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agk's Library of Common Simple Emergencies

Presentation
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Small, (<6% total body surface) partial thick- 
ness (second degree) burns can occur in a 
variety of ways. Spilled or splattered hot 
water and grease are among the most common 
causes, along with hot objects, explosive 
fumes, and burning (volatile) liquids. The 
patient will complain of excruciating pain and 
the burn will appear erythematous with vesicle 
formation. Some of these vesicles or bullae, 
may have ruptured prior to the patient's 
arrival, while others may not develop for 24 
hours. Tar burns are special in that tar 
adheres aggressively to the burned skin.

What to do:
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- To stop the pain, immediately cover the 
    burned area with sterile towels that have 
    first been soaked in iced normal saline or 
    an iced povidone-iodine solution. Continue 
    irrigating the burn with the iced solution 
    for the next 20-30 minutes or until the 
    patient can remain comfortable without the 
    cold compresses.
- Provide the patient wrth any necessary 
    tetanus prophylaxis and pain medication, 
    (e.g., Percodan, Demerol).
- Examine the patient for any associated 
    injuries and check the airway and pulmonary 
    status of any patient with significant 
    facial burns.
- When the pain has subsided, gently cleanse 
    the burn with povidone-iodine scrub and 
    rinse this off with normal saline.
- If the vesicles are not perforated, have a 
    relatively thick wall, and are on a 
    hairless surface such as the palm of the 
    hand, they should be left intact. With 
    small burns such as these, patients can be 
    sent home to continue cold compresses for 
    comfort. Otherwise, these vesicles should 
    be protected from future rupture with a 
    bulky sterile dressing.
- Open vesicles or bullae, large, thin-walled 
    vesicles that are prone to rupture, or 
    vesicles occurring on hairy surfaces that 
    are prone to infection, should be complete- 
    ly debrided. Using fine scissors and 
    forceps, you can easily strip away any 
    loose epithelium from the burn. (With tar 
    burns, debridement should be accomplished 
    in the same manner, removing the tar along 
    with the loose epithelium. Tar adhering to 
    normal epithelium can be left in place, 
    acting as a sterile dressing in itself.) 
    Rinse off any remaining debris with normal 
    saline and cover all the open areas with an 
    oil emulsion gauze (e.g., Adaptic) followed 
    by silver sulfadiazene (Silvadene) cream 
    and a bulky absorbent sterile dressing. The 
    first dressing change should be scheduled 
    in 2 days.
- Small burns and facial burns can often be 
    treated with an open technique of using 
    Silvadene cream only. Patients are 
    instructed to wash the burn 4 times each 
    day, followed by reapplication of the 
    Silvadene cream. Patients can be reassured 
    that unless there are complications (such 
    as infection) they do not have to worry 
    about scarring.

What not to do:
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- Do not use ice-containing compresses which 
    might increase tissue damage. Compresses 
    soaked in iced saline should be avoided on 
    large burns (greater than 15% total body 
    surface) because they may lead to problems 
    with hypothermia. When pain cannot be 
    controlled with compresses use strong 
    parenteral analgesics such as morphine 
    sulfate. Do not confuse partial thickness 
    burns with full thickness burns. Full 
    thickness burns have no sensory function or 
    skin appendages such as hair follicles 
    remaining, do not form vesicles, and may 
    have evidence of thrombosed vessels. If 
    areas of full thickness burn are present or 
    suspected, seek surgical consultation 
    because these areas will not grow new skin 
    and may later require skin grafting.
- Do not discharge patients with suspected 
    resipratory burns or extensive burns of the 
    hands or genitalia. These patients require 
    special inpatient observation and 
    management.
- Do not use caustic solvents in an attempt to 
    remove tar from burns. It is unnecessary, 
    painful, and will cause further tissue 
    destruction.

Discussion
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Simple partial thickness burns will do well 
with nothing more than cleansing, debridement, 
and a sterile dressing. All other therapy, 
therefore, should be directed at making the 
patient more comfortable. Silvadene cream is 
not always necessary, but it is soothing and 
may reduce the risk of infection. When it is 
possible to leave vesicles intact, the patient 
will have a shorter period of disability and 
will require fewer dressing changes and follow 
up visits. If the wound must be debrided, the 
closed dressing techique may be more convenient 
and less of a mess than the open technique of 
washings and cream applications.

Some physicans believe it is important to 
remove all traces of tar from a burn. Removal 
can be accomplished relatively easily by using 
a petroleum of petroleum-based antibiotic 
ointment such as Bacitracin, which will 
dissolve the tar. Others have found the citrus 
and petroleum distillate industrial cleanser, 
De-Solv-It, very effective as well as non-toxic 
and non-irritating.

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