Minor burns

Jasmina, a five-year-old girl, is brought in by her mother after a Sunday afternoon barbecue.  Having had very little for breakfast, she became very excited when the burgers came out and reached out to grab one from the grill, sustaining a minor burn to her hand.

Bottom line

Simple first aid is often forgotten, and cold running water for at least 20 minutes may be effective up to 3 hours after the burn.

Grading the severity of a burn can be tough.  It is easy for experts to get it right in retrospect

Follow local guidelines regarding wound management (de-roofing blisters) and dressing choice.

Don’t forget tetanus prophylaxis in non-immunised children.

Although not mentioned in this article, always ask yourself if the burn could be a sign of non-accidental injury.

What immediate first aid does she need?

Grandma may suggest using butter, turmeric or Tiger Balm, but the most important thing to do is…To hold the hand under cool running water for at least 20 minutes. If this has not been done prior to presentation and the patient is seen within 3 hours, then this should be done in the emergency department. If they don’t have access to cold running water, then immersion in cool water may be of some benefit.

Victoria Ambulance, and a number of first aid kits, use Burnaid®. This is a hydrocolloid dressing impregnated with melaleuca oil. It helps keep the burn moist, is easy to take down so everyone can take a look at the burn, and, most importantly, it smells nice.

What burns should be referred to the burns centre?

Other than large area burns and inhalation injuries, the following should be discussed with your local experts…”

• Burns to special areas, e.g. face, hands, feet or perineum
• Full-thickness burns > 5% TBSA
• Electrical burns
• Chemical burns
• Circumferential burns of the limbs or chest
• Burns as a result of suspected non-accidental injury

How do we grade minor burns?

Nobody understands first-, second-, and third-degree burns, so what approach can we use? Grading the depth of burn is notoriously difficult. We should all be able to distinguish between a superficial epidermal burn and a charred full-thickness burn, but there is some room for error in the middle ground. Often, grading varies depending on who is doing it and when. Tincture of time helps differentiate a mid-dermal burn from a deeper dermal one.

Remember, too, that most burns are heterogeneous and contain multiple components. Remember to measure, check capillary refill and sensation.

How are you going to clean them?

Once the patient is adequately analgesed, remove any adherent clothing and pre-hospital creams and unguents to properly assess the burn. Intranasal fentanyl or diamorphine can make this process much less distressing. One of the main aims of cleaning the burn is to prevent bacterial infection, which can delay healing.

Most burn services recommend shaving the surrounding skin because of colonisation of nearby hair follicles. Limb, trunk or torso burns should be cleaned with 0.1% aqueous chlorhexidine or normal saline.

There is some controversy as to whether blisters should be left intact or de-roofed. Those in favour of de-roofing suggest it is impossible to gauge the depth of the burn without seeing the base. Those against suggest that the sterile blister fluid acts as a cushion against shear trauma to the healing skin and keeps things moist. As always, be guided by local policies.

In Victoria, the regional burns service recommends removing blisters using a sterile technique.

How are you going to dress the minor burns?

Once again, local policy often trumps evidence, but some type of dressing often depends on the depth of burn. The ideal dressing should be non-adherent, highly absorbent and have some antimicrobial properties. Non-Adherent dressings make it easier to re-examine the burn without causing undue distress to the child.  Burns with blistering also need to be able to absorb exudate unless the patient wants to wear it on their clothes.

Superficial/epidermal – these often require nothing more than aloe vera and a stern word

Superficial dermal (partial) – these often need something to soak up the exudate, such as a foam or paraffin gauze, or a more flexible silicone-based dressing, e.g. Mepilex

Mid-dermal to deep dermal – these wounds are often heavily contaminated, and the majority of burn units now favour silver-based dressing such as Acticoat©. In the past, we used silver sulphadiazine (SSD) cream, but it tended to stick to the wound, necessitating more frequent dressing changes and impairing healing.

The silver-impregnated dressing acts as an antibacterial, but dries out readily and requires water (not saline) to activate it. Once the silver dressing has been applied, a second layer of moist gauze should be applied over the top, followed by crepe. After 24 hours or so, the dressing should auto-activate as the burn exudate keeps the dressing moist. There is no evidence that prophylactic antibiotics reduce the incidence of infection.   Evidence for the use of silver impregnated dressings in superficial dermal burns is lacking, and given their high relative cost, there is a move to using them only for the deeper burns.

How do you look after them?

Parents need to know what to expect to lessen the chance of an unplanned revisit. All but the most superficial of burns should be followed up, either in a specialist burns or plastics clinic or at planned intervals in the emergency room. In this era of smartphones, parents can take a picture of the healing burn at each visit in case they are seen by a different healthcare professional.

A burn often looks very dramatic when it first occurs, which makes it hard to judge its depth. It is easy to make mistakes, and if the wound does not appear to be healing within the expected time frame, the patient should be promptly referred to the burns service for consideration of grafting. Burn skin may be a different colour to surrounding skin, may be hyperalgesic for a period of time and is much more likely to burn if exposed to the sun. Blisters may form, but they should be dealt with by healthcare professionals at the next visit rather than risk infection.

Outcome

Jasmina had some erythema to her palm and immediate blistering to her fingertips, which was incredibly painful.  It was determined that the burn involved a mixture of epidermal and superficial dermal layers. As the burns affected the finger tips of a young child, the case was discussed with the local burns service, who advised individual paraffin gauze dressings.  They arranged to see Jasmina in their next clinic.

Acknowledgements: Thanks to Cameron Keating SET2 Registrar Plastics & Reconstructive Surgery & Prof Roy Kimble

References

Aziz Z, Abu SF, Chong NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012 May;38(3):307-18

The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia – https://www.vicburns.org.au/ – (accessed 29/07/2013)

Guthrie,K, Minor Burns in the Emergency Department – www.lifeinthefastlane.com (accessed 29/07/2013)

Selig HF, Lumenta DB, Giretzlehner M, Jeschke MG, Upton D, Kamolz LP. The properties of an “ideal” burn wound dressing–what do we need in daily clinical practice? Results of a worldwide online survey among burn care specialists. Burns. 2012 Nov;38(7):960-6

Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2013 Mar 28

Wu C, Tan AL, Maze DA, Holland AJ. Instant hot noodles: do they need to burn? Burns. 2013 Mar;39(2):363-8