Burns - Assessment and Management

1. Burns - Assessment and Management
 A burn is an injury caused by thermal, chemical, electrical, or radiation energy.
 Most burns heal without any problems but complete healing in terms of cosmetic outcome
is often dependent on appropriate care, especially within the first few days after the burn.
Most simple burns can be managed in primary care but complex burns and all major burns
warrant a specialist and skilled multidisciplinary approach for a successful clinical outcome.
Risk factors
 Highest rates are seen in children under the age of 5 and the elderly
over the age of 75.
 About 50% of burns and scalds occur in the kitchen.
Assess:
 Airway
 Breathing: beware of inhalation and rapid airway
 compromise
 Circulation: fluid replacement
 Disability: compartment syndrome
 Exposure: percentage area of burn.
Essential management points:
 Stop the burning
 ABCDE
 Determine the percentage area of burn (Rule of 9’s)
 Good IV access and early fluid replacement.
The severity of the burn is determined by:
 Burned surface area
 Depth of burn
 Other considerations.
 Rule of 9’s
Rule of 9s’ is used to determine the total percentage
of area burned, for each major section of the body.
In some cases, the burns may cover more than
In such cases, burns are measured by using the palm
of the casualty as a reference point for 1% of the body.

2.  TYPES OF BURNS
1. Thermal: exposure to flame or a hot object
2. Chemical: exposure to acid, alkali or organic substances
3. Electrical: result from the conversion of electrical energy into heat. Extent of injury depends
on the type of current, the pathway of flow, local tissue resistance, and duration of contact
4. Radiation: result from radiant energy being transferred to the body resulting in production of
cellular toxins
Types of Burn Injury
Thermal Flash - Explosions ofnatural gas,propane,gasoline and other flammable
liquids. Intense heatfor a very brief period of time. Clothing is protective unless it
ignites.
Flame - Exposure to prolonged,intense heat. House fires,improper use offlammable
liquids,automobile accidents,ignited clothing from stoves/heaters.
Scalds - Burns caused by hot liquids. Water, oil, grease,tar, oil.Water at 140 degrees
F, creates a deep burn in 3 seconds,butat 156 degrees Fwill cause the same injuryin 1
second. (Coffee is 180 degrees Fjustbrewed). Circumferential burns should raise
suspicion ofnon-accidental trauma. Tar needs to be removed either with an adhesive
remover solution or petroleum based dressings.
Contact - Resultfrom hot metals,plastics,glass or coals.Can be very deep.
Chemical Caused by strong acids or alkali substances. They continue to cause damage until the
agentis inactivated. Alkali substances usuallycause more severe injurysince they react
with the lipids in the skin.
Electrical Caused by either AC or DC current. Current follows the path of leastresistance and
causes injuryin areas other than the contact/entry site. They cannotbe judged from the
external injury alone. High voltage > 1,000 volts, low voltage < 1,000 volts and
lightening. Electrical burns are thermal burns from very high heat.
Radiological Caused by alpha,beta or gamma radiation. They may need to have some type of
decontamination done to stop the injury.

3. Burn Classification
Determining burn depth is important. Things to consider are temperature, mechanism, duration of
contact, blood flow to skin, and anatomic location. Epidermal depth varies with body surface, which
can offer varying degrees of thermal protection. Older adults and young children also have thinner
skin.
 First degree:
- Includes only the outer layer of skin, the epidermis
- Skin is usually red and very painful
- Equivalent to superficial sunburn without blisters
- Dry in appearance
- Healing occurs in 3-5 days, injured epithelium peels away from the healthy skin
- Hospitalization is for pain control and maybe fluid imbalance
 Second degree (classified as partial or full thickness).
 Partial thickness
- Blisters can be present
- Involve the entire epidermis and upper layers of the dermis
- Wound will be pink, red in color, painful and wet appearing
- Wound will blanch when pressure is applied
- Should heal in several weeks (10-21 days) without grafting, scarring is usually minimal
 Full thickness
- Can be red or white in appearance, but will appear dry.
- Involves the destruction of the entire epidermis and most of the dermis
- Sensation can be present, but diminished
- Blanching is sluggish or absent
- Full thickness will most likely need excision & skin grafting to heal
 Third degree:
- All layers of the skin is destroyed
- Extend into the subcutaneous tissues
- Areas can appear, black or white and will be dry
- Can appear leathery in texture
- Will not blanch when pressure is applied

4. First Second
(Superficial or Deep)
Third (Full Thickness)
Depth (how
deep the burn
is)
Epithelium Epithelium and top aspects
of the dermis
Epithelium and dermis
How the wound
looks
No blisters;drypink Moist, oozing blisters;
Moist, white, pink, to red
Leathery, dry, no elasticity;
charred appearance
Causes Sunburn,scald,flash
flame
Scalds,flash burns,
chemicals
Contact with flame,hot surface,
hot liquids,chemical,electric
Level of Pain
(sensation)
Painful,tender, and
sore
Very painful Very little pain,or no pain
Healing Time Two to five days;
peeling
Superficial:five to 21 days.
Deep:21-35 days
Small areas maytake months to
heal;large areas need grafting.
Scarring No scarring;may
have discoloration
Minimal to no scarring;
may have discoloration
Scarring present
Symptoms
 Blisters
 Pain (The degree of pain is not related to the severity of the burn, as the most
serious burns can be painless.)
 Peeling skin
 Red skin
 Shock (Symptoms of shock include pale and clammy skin, weakness, bluish lips
and fingernails, and a drop in alertness.)
 Swelling
 White or charred skin

5. First Aid
 If the patient arrives at the health facility without first aid having been given,
drench the burn thoroughly with cool water to prevent further damage and
remove all burned clothing.
 If the burn area is limited, immerse the site in cold water for 30 minutes to
reduce pain and oedema and to minimize tissue damage.
 If the area of the burn is large, after it has been doused with cool water, apply
clean wraps about the burned area (or the whole patient) 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 a hospital as soon as possible.
Initial treatment
 Initially, burns are sterile. Focus the treatment on speedy healing and
prevention of infection.
 In all cases, administer tetanus prophylaxis.
 Except in very small burns, debride all bullae. Excise adherent necrotic (dead)
tissue initially and debride all necrotic tissue over the first several days.
 After debridement, gently cleanse the burn with 0.25% (2.5 g/litre)
chlorhexidine solution, 0.1% (1 g/litre) cetrimide solution, or another mild
waterbased antiseptic.
 Do not use alcohol-based solutions.
 Gentle scrubbing will remove the loose necrotic tissue. Apply a thin layer of
antibiotic cream (silver sulfadiazine).
 Dress the burn with petroleum gauze and dry gauze thick enough to prevent
seepage to the outer layers.
DO NOT
 Do NOT apply ointment, butter, ice, medications, cream, oil spray, or any
household remedy to a severe burn.
 Do NOT breathe, blow, or cough on the burn.
 Do NOT disturb blistered or dead skin.
 Do NOT remove clothing that is stuck to the skin.
 Do NOT give the person anything by mouth, if there is a severe burn.
 Do NOT immerse a severe burn in cold water. This can cause shock.
 Do NOT place a pillow under the person's head if there is an airways burn. This
can close the airways.

6. When to Contact a Medical Professional
if:
 The burn is extensive (the size of your palm or larger).
 The burn is severe (third degree).
 You aren't sure how serious it is.
 The burn is caused by chemicals or electricity.
 The person shows signs of shock.
 The person inhaled smoke.
 Physical abuse is the known or suspected cause of the burn.
There are other symptoms associated with the burns:
 Call a doctor if your pain is still present after 48 hours.
 Call immediately if signs of infection develop. These signs include increased pain,
redness, swelling, drainage or pus from the burn, swollen lymph nodes, red streaks
spreading from the burn, or fever.
 Also call immediately if there are signs of dehydration: thirst, dry skin, dizziness,
lightheadedness, or decreased urination. Children, elderly, and anyone with a weakened
immune system (for example, HIV) should be seen right away.
Prognosis
 Will depend on depth of burn and the body surface area affected.
 Superficial burns usually heal within two weeks without surgery.
 Risk factors for death include age over 60 years, more than 40% of body surface
area affected and inhalation injury.
 Death may result from severe extensive burns or electric shock.
Nutrition
 Patient’s energy and protein requirements will be extremely high due to the
catabolism of trauma, heat loss, infection and demands of tissue regeneration.
If necessary, feed the patient through a nasogastric tube to ensure an
adequate energy intake (up to 6000 kcal a day).
 Anaemia and malnutrition prevent burn wound healing and result in failure of
skin grafts. Eggs and peanut oil and locally available supplements are good.

7. Prevention
To help prevent burns:
 Install smoke alarms in your home. Check and change batteries regularly.
 Teach children about fire safety and the hazards of matches and fireworks.
 Keep children from climbing on top of a stove or grabbing hot items like irons and
oven doors.
 Turn pot handles toward the back of the stove so that children can't grab them and
they can't be accidentally knocked over.
 Place fire extinguishers in key locations at home, work, and school.
 Remove electrical cords from floors and keep them out of reach.
 Know about and practice fire escape routes at home, work, and school.
 Set temperature of water heater at 120 degrees or less.