Jasmina, a five 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 burning her hand.
- 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 with regard to wound management (de-roofing blisters) and dressing choice.
- Don’t forget tetanus prophylaxis in non-immunized 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 should be done at home BEFORE coming to the ED?
Whilst grandmothers may advocate using butter, turmeric or Tiger balm 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®, a hydrocolloid dressing impregnated with melaleuca oil as their primary dressing. 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 a regional 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 burns?
As nobody understands first, second and third degree burns what approach can we use?Grading depth of burn is notoriously difficult. We should all be able to pick the superficial epidermal burn or the charred full thickness burn but there is some room for error in the middle ground. Often the grade of a burn will vary depending on who is doing it and when. Often the tincture of time helps differentiate a mid dermal burn from a deeper dermal burn.
Remember, too, that the majority of burns are heterogenous and contain a number of different components. This handy, dandy table, adapted from the Victoria Burns specialists should help. Remember to measure, check capillary refill and check sensation.
How are you going to clean the burns?
Once the patient is adequately analgesed you might consider removing any adherent clothing or pre-hospital creams and unguents so you can properly assess the burn. Intranasal fentanyl or diamorphine may make this process much less distressing. One of the main aims of cleaning the burn is to prevent bacterial infection hat would delay healing.
Most burns services recommend shaving the hair of the surrounding skin because of colonisation of the hair follicles. Limb, trunk or torso burns should be cleaned with 0.1% aqueous chlorhexidine or normal saline.
There is a great deal of 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 visualising it. Those against suggest that the blister fluid, being sterile, acts as a cushion against shear trauma for the healing skin as well as keeping the environment moist. As always be guided by local policies.
In Victoria the regional burns service recommends removal of the blisters using a sterile technique.
How are you going to dress the burns?
Once again local policy often trumps evidence but some type of dressing depends often on 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 a degree of blistering also need to be able to soak up the 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 burns units now favour silver based dressing such as Acticoat©. In the past silver sulphadiazine (SSD) cream was used but this tended to stick to the wound necessitating more frequent dressing changes thus 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 then 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.
What should the family be told about aftercare of the burn?
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 and that does make it hard to judge depth. It is easy to make mistakes and if it looks like the wound is not healing within the expected time frame then 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.
Jasmina had some erythema to her palm and immediate blistering to her fingertips, that was incredibly painful. It was decided that the burn was a mixture of epidermal and superficial dermal. 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
The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia – https://www.vicburns.org.au/ – (accessed 29/07/2013)
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