Burns

Background

  • Burn is an injury caused by thermal, chemical, electrical or radiation energy
    • A scald is a burn caused by contact with a hot liquid or steam
  • ~250,000 patients are treated for burns in the UK each year; ~0.1% of these patients will die of burns injury
  • Burns can be classified by
    • Depth
      • Superficial epidermal (previously 1st degree)
        • Red and painful
        • Cap refill blanches and refills quickly
      • Partial thickness (superficial dermal; previously 2nd degree)
        • Pale pink, painful, blistered
        • Cap refill blanches and refills slowly
      • Partial thickness (deep dermal; previously 2nd degree)
        • Typically white but may have patches of non-blanching erythema; reduced sensation
        • Cap refill does not blanch
      • Full thickness (previously 3rd degree)
        • White/brown/black in colour, no blisters, no pain
    • Extent
      • Wallace’s rule of 9’s (each 9%)
        • Head and neck; arm ; anterior leg; posterior leg; anterior chest; posterior chest; anterior abdomen; posterior abdomen
      • Roughly a palm is 1% (although this loses accuracy in burns >15%
      • A Lund and Browder chart is useful (more accurate), particularly in children where body surface proportions differ dramatically from adults
    • Severity
      • Minor
        • Simple erythema or superficial epidermal burns anywhere
        • Superficial dermal burns in a fit 5-60 year old <5% of total body surface area
      • Major
        • Any deep or full thickness burns (or superficial dermal burns >5% of TBSA)

Management

  • Immediate first aid
    • Check area; ABCDE if appropriate
    • If caused by heat:
      • Remove the patient from source (if flames, extinguish by appropriate method); remove clothing/jewellery UNLESS stuck to skin (do not remove anything stuck to skin)
      • Irrigate the burn with cool/tepid water within 20 mins and for 10-30 minutes.
      • Cover the burn with cling film (layers not wrapping) (avoid wet dressings/cream)
      • Offer pain relief, elevate the body part if oedema is present
    • If caused by electricity:
      • Switch off source/remove person from source using a non-conducting material e.g. wood (NB Only if low voltage e.g. household mains; NOT high voltage e.g. supply station)
      • Arrange immediate transfer to A&E (ABCDE as required)
    • If caused by chemicals:
      • Determine the causative agent; remove any affected clothing/brush down the skin (if powder/dry form)
      • Copiously irrigate with cool/tepid water for at least an hour
      • Do NOT attempt to neutralise any chemical (can cause reactive heat generation and further damage)
      • Arrange immediate transfer to A&E
  • Examination/Assesment
    • Ask about mechanism of burn
    • Try and gauge depth and extent of burn, as well as type
      • Use Wallace’s rule of Lund and Browder chart
      • Flash/sun burns are usually superficial epidermal; Scalds are usually superficial epidermal or dermal; Flame or contact burns are commonly deep dermal or full thickness
      • Ask about pain and look at the appearance of the skin (peeling/blistering etc)
    • Consider the possibility of non-accidental injury (pattern of burn)
    • Assess any associated injury e.g. inhalation injury
    • Ask about co-existent medical problems, immunocompromise or pregnancy
  • Consider Referral
    • Major burns
    • Circumferential burns (i.e. encircle a limb)
    • Superficial dermal burns >3% of TBSA in adults and >2% in children; or any superficial dermal burns of the face, hands, feet, perineum, genitalia, flexures (e.g. neck)
    • Associated infection
    • Children <5 and adults >60 (superficial dermal)
    • If wound has not healed within 14 days
  • Non-adhesive dressings are preferred e.g. paraffin gauze
    • Consider TB prophylaxis and/or antibiotic use if there is a risk of TB or infection
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