Burns and Their

Management
By CJ Lau
28 Oct 2009
What causes burns

 Dry heat (fire)

 Wet heat (steam or hot liquids)

 Radiation, heated objects, friction

 Sun, chemicals, electricity

- Thermal burns are the most common kind of

burns
- Occurs when flames, hot metals, scalding liquids,
or steam come into contact with skin
Symptoms
 Blisters
 Pain (the degree of pain is not related to the
severity of the burns as most serious burns
can be painless)
 Peeling skin
 Redness, swelling
 Shock (symptoms include pale and clammy
skin, weakness, bluish of lips and fingernails
and drop in alertness )
Assessment
 Burns patient has the same priorities as all other
trauma patients.
 Assess:
1. Airway
2. Breathing: beware of rapid airway compromise
3. Circulation: fluid replacement
4. Disability: compartment syndrome
5. Exposure: percentage area of burn
Essential Management Points
 Stop the burning
 Determine the percentage area of burn (Rule of
9’s)
 Good IV access and early fluid replacement
 Severity of burn is determined by:
1. Burned surface area
2. Depth of burn
Rule of 9’s
 Commonly used to estimate the burn surface area in adults
 The body is divided into anatomical region that represents 9% (or
multiply of 9%) of the total surface body area
 The outstretched palm and fingers approximates to 1% of the
body surface area
 If the burned area is small, assess how many time your hand
covers the area
 Morbidity and mortality rises with increasing burned surface area
 Also rises with increasing age, so even small burns may be fatal
in elderly people
Children
 Rule of 9’s is imprecise for estimating the
burned surface area in infant and children
 Infant or young child’s head and lower
extremities represent different proportions of
surface areas than in adults
 Burns greater than 15% in an adult and
greater than 10% in a child, or any burn
occurring in the very young or elderly are
serious.
 Depth of burn
 It is important to estimate the depth of burn to assess its severity and to
plan for future wound care. Burns can be divided into 3 types.
Depth of burns Characteristics Cause Healing

First degree burn Erythema sunburn Three to six days without

1) superficial Pain scarring
-involves only epidermis Absence of blister

Second degree burn Red or mottled Contact with hot liquids 7-21days

(partial thickness) Flash burns Scarringis unusual

-involves epidermis and Usually forms blisters Pigment changes may
superficial portions of dermis occur

Third degree burn Dark and leatherly Fire Scarring

is severe
(full thickness) Dry and inelastic Electricity or lightning Spontaneous healing is not

-extend through and destroy painless Prolonged exposure to hot possible

dermis liquids or objects
- Considered serious
Superficial burn
Partial thickness burn
Full thickness burn
Serious burn requiring hospitalization
 Greater than 15% burns in adult
 Greater than 10% burns in children
 Any burn in the elderly or very young
 Any full thickness burn
 Burns of special regions: face, hands, feet,
perineum
 Circumferential burns
 Inhalation injury
 Associated trauma or significant pre-burn
illness: eg.diabetes
Wound care/first aid
 Drench the burn thoroughly with cool water (not ice) to
prevent further damage and remove all burned
clothing
 If the burn area is limited, immerse the site in cool
water for 30 minutes to reduce pain and oedema
 If the area is large, after it has been doused with cool
water, apply clean wraps about the burned area to
prevent systemic heat loss and hypothermia
 Hypothermia is a particular risk in young children
 First 6 hours following injury are critical, transport the
patient with severe burns to hospital as soon as
possible.
Initial treatment
 Consists mainly of cooling, simple cleansing and
appropriate dressing
 Cleaning- burn wound should be cleaned, but use of
disinfectant is discouraged as it can inhibit healing.
Growing support for washing the wound using mild
soap and water.
 Debridement- Sloughed or necrotic skin including
ruptured blisters, is debrided. Extensive debridement
is generally not required immediately and may be
deferred until the initial follow up visit.
 Blisters- ruptured blisters should be removed, but
management of clean intact blisters is controversial.
Needle aspiration should never be performed, as it
increases risk of infection.
Treatment
 Pain management- for small burn injuries, paracetamol and
NSAIDs, alone or in combination with opiods are often
appropriate. Patients with sustained burns and significant pain
should be treated with IV narcotics.
 Elevation of foot and hand burns above the level of the heart can
reduce pain and swelling for several days following the injury
 Pruritus is common and can be treated with systemic
antihistamines or moisturizing lotions
 Tetanus immune globulin should be given to patient who have
not received a complete immunization, particularly for any burns
deeper than than superficial thickness.
 Dressing- superficial burns do not require dressings. Partial and
full thickness burns should be dressed.
Dressings
Basic dressing
 For emergency treatment, a basic gauze dressing provides
good burn coverage.
 It is placed after the application of topical antibiotic and
consists of a first layer of nonadherent gauze placed over the
burn, a second layer of fluffed dry gauze, and an outer layer
of elastic gauze.
Biologic and synthetic dressings
 Generally not used in the emergency department

 Should be applied within first 6 hours after injury

 Can be used to treat partial thickness burns

 May reduce pain, help prevent infection and promote healing

 More difficult to apply, expensive, and not readily available

Dressings
 Bismuth impregnated petroleum gauze & biosynthetic dressing-
appears advantageous for young children and adults with
superficial partial thickness burn. Both are applied as a single
layer over the burn and then covered with an external bulking
dressing (to absorb wound exudate).
 Dressing change- range from twice weekly to weekly. Best to
change dressings whenever they become soaked with excessive
exudates or other fluids.
Management of Infection
 All suspected burn infections warrant
aggressive management including admission
and parenteral antibiotics
 Burn infections can extend the depth and
extent of a burn, converting a superficial
partial-thickness into deep partial thickness or
full thickness burn.
 Many authors recommend full thickness skin
biopsy for any hospitalized patient due to the
risk of infection with resistant organisms.
Scarring
 The depth of the burn and the surface involved influence the
duration of healing phase. Without infection, superficial burn
heals rapidly.
 Burns scars undergo maturation, at first being red & raised. They
frequently become hypertrophic and form keloids. They soften,
flattened and fade with time, but the process is unpredictable and
takes time.
 Silicon can significantly reduce scar hypertrophy scars as late as
twelve years after injury.
 Burn scars on the face lead to cosmetic deformity, ectropion and
contractures about the lips.
 Consider specialized care for these patients as skin grafting is
often not sufficient to correct facial deformity.
References
 WHO Management of Burns
 Bethel, CA, and Krisanda, TJ. Burn care procedures. In: Clinical
Procedures in Emergency Medicine. 4th ed, Roberts, JR,
Hedges, JR (Eds), Saunders, Philadelphia 2004. p.749.
 Karyoute, SM, Badran, IZ. Tetanus following a burn injury. Burns
Incl Therm Inj 1988; 14:241.
 Burn pain- A Unique Challenge, International Association for the
study of pain, Vol IX, Issue 1, March 2001
 Church, D, Elsayed, S, Reid, O et.al. Burn Wound Infections,
Clinical Microbiology Reviews, Vol 9, No.2, April 2006, page 403-
434
 Gang, RK, Bang, RL, Sanyal, SC, et al. Pseudomonas
aeruginosa septicaemia in burns. Burns 1999; 25:611.
 Up to date