Dr Duhe and I had a case last night, very straightforward. A kid burned the top of his foot with some hot water. He had some blistering over his MTP joints causing him pain. Dr Duhe wanted to send him home with pain control, I had always been taught that the blisters need to be debrided. I’m the attending, so I won and the blisters were debrided (Dr Duhe used the scissors in the suture kit and cut the dead skin overlying the blister), Silvadene was applied, the foot was bandaged and the kid was sent on his way.
This of course brought about a debate of whether burn blisters need to be debrided or not. I did a PubMed search and the first source I found that looked useful was a consensus statement from the American Burn Association, released in 2012. They stated: “Among the most direct and effective interventions for reduction of risks from cutaneous burns is removal of the burn eschar. Devitalized skin is a rich medium for microbial growth, and also is known to promote inflammation by release of cytokines and growth factors from injured or lysed skin cells. Consequently, practices for care of burn wounds have favored early and complete removal of the burn eschar.” So I thought, “cool, I win!”, except that I’m not sure that a blister is an eschar so I’m not really sure that they are advocated for popping the blister and removing the dead tissue. So the lit search continued.
To make a long story short, I ended up finding an EM Practice article that gave a class IIa recommendation to leave the blister intact. Hmm, I lose. Then, I went to Wikipedia, the ultimate source for all medical information. They state “it is not clear” what to do with intact blisters. So we both win. Then they recommend AGAINST using Silvadene! Now my world has been turned upside down. I will need to investigate this recommendation against Silvadene next.
So, at the end of the day, there is no clear answer as to what to do with intact burn blisters. Do whatever you want. Probably leaving them intact and applying a dressing is the quickest and easiest thing to do. But the real overriding message here is not everything that you are learning on-the-job is necessarily the right thing to do. I was taught that debriding a burn blister was, without question, the right thing to do. This was from a pediatric surgeon that used to run the burn unit at Children’s. Not that he’s wrong, but it’s important to know that a doctor’s opinion is not the same as fact, and new evidence is emerging all of the time, so you have to stay on top of your stuff. You have to be curious and research things on your own and form your own informed opinion. When I work with you guys, I try to make sure you are aware of certain things that you do that are “Sinai-Grace”-ish and not necessarily how things are done at other hospitals. More than a few of you have been on the receiving end of my rants against routinely ordering a BNP on patients with CHF. There are a lot of ways to practice medicine, and you need to form your own opinions based on a myriad of information thrown at you. Look things up, ask questions, and try to picture how you will handle certain patients and situations because in a few short years (or months), it’s all up to you!