Minor burns 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 with regard to wound management (de-roofing blisters – see BBA Burn Blister Management document link in references) and dressing choice (see LSEBN Initial Management of Burn Wounds guideline link in the references).
- 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 injured area 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 running water, then immersion in cool water may be of some benefit. If they don’t have access to running water, then application of cool wet soaks can also be used – apply as a wet compress every five minutes over total of a 20 minute block. Placing a child into a bath of cold water can make them very cold very quickly – always be mindful of and monitor for impending hypothermia.
What burns should be referred to a regional burns centre?
The suggested minimum threshold for referral into specialised UK burn care services:
- All burns ≥2% TBSA in children
- All full thickness burns
- All circumferential burns
- Any burn not healed in 2 weeks
- Any burn with suspicion of non-accidental injury should be referred to a Burn Unit/Centre for expert assessment within 24 hours
In addition, the following factors should prompt a discussion with a Consultant in a specialised burn care service and consideration given to referral:
- All burns to hands, feet, face, perineum or genitalia
- Any chemical, electrical or friction burn
- Any cold injury
- Any unwell/febrile child with a burn
- Any concerns regarding burn injuries and co-morbidities that may affect treatment or healing of the burn
If the above criteria/threshold is not met then continue with local care and dressings as required.
If burn wound changes in appearance / signs of infection or there are concerns regarding healing then discuss with a specialised burn service.
If there is any suspicion of toxic shock syndrome then refer early (fever, lethargy, vomiting, diarrhoea).
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 superficial partial thickness burn from a deep dermal burn.
Remember, too, that the majority of burns are heterogenous and contain a number of different components. This handy, dandy table, 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 that 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.
BBA guidance is always to deroof the blisters.
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.
Watch Professor Fiona Wood, AM, one of the worlds leading burns surgeons talk at DFTB17. In this talk, she talks about the past, the present and the future of burns care whilst championing the roles of women in medicine and surgery. As a mother of six children, she reminds us all that there is nothing that cannot be achieved if you ask for it.
The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia– https://www.vicburns.org.au/ – (accessed 07/07/2021)
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
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
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
British Burn Association. BBA Clinical Practice Guideline for Management of Burn Blisters. 2018. https://www.britishburnassociation.org/wp-content/uploads/2017/06/BBA-Burn-Blister-Management-Guideline-20.6.18.pdf (accessed 28/6/2021)
British Burn Association. First Aid Clinical Practice Guidelines. 2018. https://www.britishburnassociation.org/wp-content/uploads/2017/06/BBA-First-Aid-Guideline-24.9.18.pdf (accessed 28/6/2021)
National Network for Burn Care. National Burn Care Referral Guidance. 2012. https://www.britishburnassociation.org/wp-content/uploads/2018/02/National-Burn-Care-Referral-Guidance-2012.pdf (accessed 28/6/2021)
London and South East of England Burn Network. Initial Management of Burn Wounds. 2018. https://www.lsebn.nhs.uk/website/X13911/files/LSEBN%20Initial%20management%20of%20burns.pdf (accessed 28/6/2021)
London and South East of England Burn Network. Post Burn Care. 2015. https://www.lsebn.nhs.uk/website/X13911/files/LSEBN%20Post%20Burn%20Care.pdf (accessed 28/6/21)