Key questions specific to burns

• Burn mechanism and timing​

• First aid - how and how long

• Any other injuries

• Dressings (especially old wounds)

• Tetanus immunity

• Co-morbidities and regular medications

Flame

Chemical

Electrical

Special types

• Cement​

• Bitumen

• Phosphorus

• Hydrofluoric acid

Quantified in total body surface area (% TBSA)

The greater the surface area of the body injured, the greater the mortality rate

"Rule of Nines"

• divides the body sirface into areas of 9% or multiples of 9%, with the exception of perineum is estimated at 1%

• inaccurate in children

Patient's palmar surface is approximately 1% TBSA

Lund and Browder chart

• Age adjusted estimation of % TBSA​

• More accurate in children because it takes into account their larger head to lower limbs % TBSA ratios

• Can be tedious to utilise under pressure

Skin consists of epidermis and dermis

The dermis contains reservoirs of epithelial cells under the control of growth factors that will undergo mitosis and can produce an epithelial lining, a process called epithelialisation

Classification systems for burns depth (superficial to deep):

• Epidermal, superficial dermal, mid dermal, deep dermal, full thickness​

• Superficial, superficial partial thickness, deep partial thickness, full thickness

• First degree, second degree, third degree, fourth degree

Epidermal burns​

• Burn to stratified layers of epidermis

• Healing occurs by regeneration of the epidermis from the basal layer

• Hyperaemia due to production of infllamatory mediators

• Quite painful

• Heal quickly - within 7 days

• No cosmetic blemish

• Not included in estimations of %TBSA

Superficial dermal burns​

• Burn to epidermis and the superficial part of the dermis (papillary dermis)​

• Blistering

• Once blister deroofed, papillary dermis appears pink to white

• Extremely painful due to exposed nerves

• Should heal spontaneously by epithelialisation wihtin 14 days

• Leaves colour match defect, no scarring

Mid-dermal burns​

• Dark pink

• Sluggish cap refill

• Number of surviving epithelial cells capable of re-epithelialisation is less​

• Spontaneous burn wound healing does not always occur

Deep dermal burns​

• Blotchy red reticular dermis​

• Destruction of dermal vascular plexus and dermal nerve endings

• Does not heal spontaneouslyby epithelialisation

Full thickness burns​

• Dense white, waxy or charred appearance​

• Sensory nerves destroyed - loss of sensation

• May have leathery appearance of eschar

• Does not heal spontaneouslyby epithelialisation

Nationally agreed referral guidelines by the National Network for Burn Care and endorsed by the British Burn Association​ (see images)

Preparation for transfer:

• Respiratory​

  • All patients with major injuries should be given high flow oxygen at 15 L/min​

  • Consider need for endotracheal intubation before transfer

  • Infraglottic less likely to be problem during transfer

• Circulatory system​

  • 2 wide bore cannulae or other routes of access​

  • Commence fluid resuscitation (see Burns Resus)

• Burn wound​

  • Washed with chlorhexadine 0.1%​ solution or 0.9% NaCl and then covered with cling film or by a clean dry sheet

  • More formal dressing if transfer is significantly delayed

  • Check dressings protocol with local burns centre

• Pain relief​​

  • IV opioid analgesia given according to patient response​

  • Consider in relation with co-morbidities

• Gastro-intestinal system​

  • NG tube regularly aspirated and on free drai​nage for adults burns ≥20% and paediatric burns ≥10% TBSA

Document findings of the primary and secondary survey and care given​​

If there is no bed available within the local network the National Burn Bed Bureau (telephone no 01384214476) will be able to identify beds elsewhere in the UK​​