Burns

Remember — Life support — DRS ABC then treat the burn

Do not

  • Do not use ice, ice packs, or refrigerated water — can cause more damage
  • Do not wash chemicals over unaffected skin/eye or let water collect in shoes
  • Do not try to remove clothing if stuck to burn
  • Do not wrap plastic around limbs — will become tight if they keep swelling
  • Do not cover face or chemical burns with plastic wrap — use damp cloth or non-stick dressing
  • Do not use any creams or medicated dressings until after burns unit consult

Do first

Stop the burning process

  • If person on fire — stop-drop-cover-and-roll
  • If scalds or liquid chemicals — remove any wet clothing
  • If chemical burns
    • Brush powder or solid chemicals from skin (use gloves), remove contaminated clothing
    • If eye involved — immediately wash eye while double everting eyelid. Lie person on side with affected eye lowermost to protect good eye

Cool the burn

  • Cool burned area with cool water (aim for 15°C) — up to 3 hours after burn
  • Thermal burns ​— continue cooling if providing pain relief
    • Run or pour cool water over burn (best)
    • OR if no suitable water available — wrap burn in towels/cloths soaked in water or normal saline, change towels/cloths as needed
    • OR submerge in water. Change water as needed
  • Alkali burns ​— pour water over burn for 2 hours or until burning pain stops
  • Acid burns ​— pour water over burn for 1 hour or until burning pain stops

Once cooling has started

  • Remove clothing — do not try to remove if stuck to burn
  • Remove anything else that might get tight with swelling (eg watch, rings)
  • Keep rest of person warm
  • If skin loss more than 10% ​— risk of hypothermia from cooling
    • Risk highest for babies and small children
  • Continue assessment while cooling the burn

Ask

  • When did burn happen
  • What caused burn and how long was it in contact with person
    • Thermal, chemical, electrical (including lightning)​
  • Where did it happen (eg in closed room, out in camp)
  • What has already been done

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Immunisation status — tetanus
  • Head-to-toe check — with attention to
    • Lungs — hoarseness or stridor (noisy breathing), coughing black dust/soot, face burn — person may suddenly get worse and their airway will need to be protected, usually need intubation
    • Other injuries ​apart from burns
    • Pulses ​and capillary refill ​distal to injury (eg toes, fingers)

Work out area of burn

  • Measure area that is blistered or deeper ​burn — do not include area that is just red (simple erythema)
  • Count number of ‘palm areas’ that are ​burnt — person’s own palm is about 1% of their body area
  • Check again a couple of hours after first assessment unless burn has been dressed

Work out depth of burn — Table 2.5

  • Difference important for deciding how to treat burn
  • Always check again a couple of hours after first assessment unless burn has been dressed

Table 2.5   Working out depth of a burn

Photograph wound

  • Take digital photo of uncovered burn (with consent) if possible. Send by phone text message, email, web camera, videoconference for medical/burns unit consult
    • Phone first and they will tell you how to do this
  • If unable to photograph the burn — use numbered body charts 

Do

  • Decide if major or minor burn, manage accordingly 

Management of major burns

  • Send major (serious) burns to hospital urgently — usually to burns unit
  • Urgent medical consult — will work out fluids and pain relief
    • Person with major burns needs large amounts of fluids very early on
    • May also need direct burns unit consult

Do

  • Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD — 88–92%
    • If inhalation burns — give high concentration
  • Put in IV cannula, largest possible, 2 if you can — try for unburnt skin
  • Give IV fluids — see Working out fluids needed
  • Keep person warm — person with major burns cannot control their temperature
  • Give pain relief — best given IV/intraosseous. Use morphine in small doses
  • Put in nasogastric tube, especially for child to avoid vomiting, aspiration
  • Elevate burnt limb — keep in raised position
  • If burns to 10% or more of body or extensive burns to perineal area — put in indwelling urinary catheter, measure urine hourly
  • Medical consult if urine output less than
    • 1mL/kg/hr for child less than 30kg
    • 0.5–1mL/kg/hr for child weighing 30kg or more
    • 0.5mL/kg/hr for adult OR 1mL/kg/hr if electrical burn
  • If not done earlier, take digital photo of uncovered burn — send for medical/burns unit consult
  • Medical/burns unit consult before applying first dressing if possible
  • Cover major burns with plastic cling wrap laid lengthways or blueys plastic side to skin THEN clean towels. Change every 4 hours until sent to hospital
  • If delay in sending to hospital or long travel time
    • Remove plastic wrap
    • Put on soft paraffin, non-medicated dressing, combine dressing, loose bandage

Working out fluids needed

Be careful with airway burns — give less fluid until you get advice and airway is secure

  • Medical/burns unit consult about fluid resuscitation
    • Fluid formula only a guide to fluid needs
    • Record accurately — time fluids started, amount given. Send in with person
    • If delay in sending to hospital — medical/burns unit consult to change fluids according to clinical response (eg urine output, pulse rate)
  • Work out amount of fluid needed for first 24 hours — start from when person was burnt, not when you first saw them
    • Give half in first 8 hours
    • THEN give rest in next 16 hours
    • THEN maintenance fluid in next 24 hours  
  • Use Modified Parkland Formula for
    • Over 20% TBSA in adults
    • Over 10% TBSA in children
    • 3mL Hartmann’s solution x weight (kg) x % total body surface area burnt (TBSA) = volume (mL) in 24 hours
  • For children (under 16 years) in addition give maintenance fluid normal saline with 5% glucose (4mL/kg/hour for the first 10kg + 2 mL/kg/hour for next 10kg + 1mL/kg/hr thereafter)

Example — working out fluids needed

  • Child aged 8 years weighing 24kg with burns to 30% of their body, burnt at 0900hrs, arrives at clinic at 1130hrs

Replacement fluids

  • Total = 3mL x 24(kg) x 30(%) = 2160mL over 24 hours
    • 1080mL to be given by 1700hrs — 8hrs after burn occurred
    • If starting fluids at 1200hrs (30mins after arrival) then 1080mL needs to be given over the next 5hrs = 1080mL/5hrs = 216mL/hr
  • Half in next 16 hours = 1080mL/16hrs = 67.5mL/hr

PLUS maintenance fluids for a child (under 16 years)

  • 64mL/hr

Management of minor burns
  • Minor burns may still need consult with burns unit or hospitalisation — medical consult for advice

Do

  • Early treatment to prevent or reduce swelling can prevent chronic problems
    • Gentle compression — use woven short stretch crepe bandage
    • Start with ¼ overlap closest to torso and increase to ¾ overlap as bandage is wound down the limb
    • Elevate body part above heart when at rest
  • Active muscle contraction and movement is very important — helps remove swelling
  • Reassure person that moving will help healing, will not harm burn or wound

Remember: Good early management is important for good healing. Always get help if not sure

Burns being managed in the community

Be alert for sudden onset severe sepsis in young children with small burns — can present 2–4 days after burn.Advise carer to return to clinic if child seems unwell

Burns at risk of infection if

  • Caused by dirty/contaminated materials, friction, flames, chemicals
  • Rolled in dirt to put out flames OR burns first cooled in dirty water
  • Happened more than 12 hours before you saw person
  • In area with lots of bacteria (eg armpit, umbilicus)

Check

  • Depth of burn
  • Risk of infection
  • Immunisation status — tetanus

Do

  • Clean with mild soap and water. Do not use skin disinfectant
  • Clip body hair from burn wound and 2.5cm around it — not eyebrows
  • Dry carefully around burn, but not the burn itself. Let burn air dry
  • Give pain relief
  • Remove blisters, loose or burned skin
  • Dress and review as below

Superficial burns — skin intact

  • Use simple moisturising cream several times a day

Superficial burns — blistered OR partial thickness burns — clean

  • If oozing (usual for first 3 days) put on hydrocolloid dressing
    • Change within 2 days
  • If no ooze or when ooze has stopped — use
    • Protective dressing such as island dressing
    • OR adhesive foam
    • OR hydrocolloid dressing left intact for 7 days, when little or no ooze

Partial thickness burns at risk of infection OR full thickness burns smaller than a 20 cent piece

  • Use anti-bacterial, silver-foam dressing held in place with non-woven dressing
  • Leave in place for up to 5 days, change if saturated

Healed burn wounds that need added protection

  • If healed — moisturiser only
  • If area may be rubbed (under friction) or knocked and fragile — continue dressing as previous

Burns care after hospitalisation

  • Follow hospital discharge advice — especially for dressings and compression garments
  • Person may need emotional support
  • Watch for signs of infection
  • Advise person/carer 
    • Wash daily and check skin integrity — look for breaks, blisters, hardness or tightness. Advise clinic if any changes/concerns
    • Massage area with water-based moisturiser up to 3 times a day
    • Return to daily activities and do exercises advised by hospital. These help to build muscle and strength, improve movement and reduce swelling and stiffness
    • Protect burn area from sun and injury

Infected burns

  • Infection likely if
    • Pain and swelling worse after 2 days
    • Not healing in 1 week
    • Burn smelly, pussy, surrounded by red/hot area
    • Person has a fever

Do

  • Medical consult
  • Swab burn area for MC&S
  • Dress as partial thickness burns at risk of infection
  • Check swab result, give antibiotic according to sensitivities