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Management of Burns in the Community

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Management of Burns in the Community Clinical REVIEW Clinical REVIEW Management of burns in the community Burn injuries pose a significant burden to the NHS with 250,000 patients presenting annually to primary care teams and a further 175,000 presenting to A&E (National Burn Care Review, 2001). The large majority of these patients are managed in the community by healthcare professionals who may have limited experience or lack formal training in burn management. The purpose of this article is to highlight key principles in managing burns in the community from the provision of first aid to rehabilitation, as well as guidelines for referral to a specialist burns unit. Kshemendra Senarath-Yapa, Stuart Enoch formal training in burns management. adults (although burns of this nature This disparate group includes not only are not suitable for management in KEY WORDS GPs but more frequently practice and the community). Burns district nurses. The purpose of this article Community care is to outline some of the key principles The importance of this common in burns management in the community approach lies in the detection of Burns dressings including initial assessment and first aid, associated non-burn injuries that may Wounds classification of mechanisms of burn injury, pose a more immediate threat to life and assessment of burn depth, estimation of require urgent medical attention. The aim total body surface area (TBSA) burnt, and of first aid should be to stop the burning the types of dressings that may be used. process, cool the burn, provide pain relief It also aims to highlight the criteria for and cover the burn (Hudspith and Rayatt, urn injuries range from the most referral to specialist burns units as set out 2004). Key steps include: severe, requiring high levels by the National Burn Care Review, thus 8 Removing the victim from the source Bof intensive care and multiple providing a plan for the management of of the burn without endangering the surgeries, to the most trivial, for which burns in the community. rescuers. This may involve turning self-treatment may suffice. Almost all off electricity in the case of electrical of us will experience a burn injury in Initial assessment burns our lifetime, even if only in a minor The immediate steps taken during an 8 Assisting the victim to ‘drop and roll’ form such as from fleeting contact initial encounter with a burn victim can if their clothing is alight with a hot surface or a minor scald be life-saving. After initial first aid, the 8 Removing all clothing as soon as from a hot drink. Burn injuries pose a assessment of all burn patients should be possible — unless adherent to considerable burden to the NHS with followed by a primary survey according underlying skin (which may be the 250,000 patients presenting to primary to advanced trauma life support case with nylon clothes) care teams, and a further 175,000 guidelines (British Burn Association, 8 Cool the burn with cool/tepid patients presenting to A&E annually in 2008). This includes: running water for at least 20 minutes the UK. Fortunately, only 10% of those 8 A Airway maintenance with cervical (Yuan et al, 2007). It has been presenting to A&E need admission spine control observed in animal studies that the (National Burn Care Review, 2001). 8 B Breathing and ventilation heat transferred during a thermal A significant number of minor burns 8 C Circulation and haemorrhage injury will continue to dissipate and are managed in the community by a control deepen the burn wound unless diverse group of healthcare professionals 8 D Disability — neurological status cooled. Ideally this water should with varying degrees of experience or 8 E Exposure and environmental be at about 15ºC. Very cold or icy control water can cause vasoconstriction Kshemendra Senarath-Yapa is Speciality Registrar in Burns 8 F Fluid resuscitation proportional to and worsen tissue ischaemia and and Plastic Surgery Royal Preston Hospital, Stuart Enoch is burn size which is recommended for thus paradoxically deepen the burn Speciality Registrar in Burns and Plastic Surgery, Royal burns >10% in children and >15% wound (Sawadal et al, 1997). In the Preston Hospital total body surface area (TBSA) in case of chemical burns, copious 38 Wounds UK, 2009, Vol 5, No 2 Review5(2)Enochrh.indd 38 11/6/09 15:25:09 Clinical REVIEW Clinical PRACTICEClinical DEVELOPMENT REVIEW amounts of water should be used to wash away the agent Table 1 8 Cover the burn preferably with Aetiological factors for burn injuries and their specific features polyvinyl chloride film (cling-film) or a sterile cotton sheet. Covering the burn in this way provides pain relief by covering the exposed Burn type Key points and features nerve endings and prevents external Thermal injury noxious agents contaminating the Flame burn 8 Common from various causes including house fire wound. Cling-film has the added 8 Accelerants such as lighter fluid and petrol are contributing factors often found advantage of being non-adherent and among teenagers transparent, thus enabling subsequent 8 Can be of any depth and is usually a mix of different depths assessment of the burn. Do not use Scald 8 About 60% of ‘burns’ in children are scalds constrictive circumferential dressings 8 Important aetiological factors include hot water from bath, kettle or that may compromise circulation hot drink 8 Do not use topical creams or agents such as silver sulfadiazine as these Contact burn 8 Often present in children as small percentage burns over the hands, face may affect subsequent assessment of or extremities burn depth in the specialist unit. 8 Sources include radiator (Figure 1), glass front of gas fires and irons 8 Can cause full-thickness burns in those unable to extricate themselves, such as the elderly, post-convulsion or individuals incapacitated by drugs and alcohol Flash burn 8 Usually caused from ignition of a volatile substance or from an unexpected ball of fire (such as when pouring petrol over a barbeque fire) 8 Commonly results in superficial flame burn usually to the face, neck and upper limbs Electrical injury Low voltage 8 From domestic electrical supplies <240volts 8 Inspect for entry and exit wounds 8 Usually small area burns in the extremities Figure 1. A full-thickness contact burn from a 8 ECG to rule out arrhythmias and hospital admission may be required so that radiator. This type of burn may require excision the patient can be monitored for the first 24 hours and skin grafting if it fails to heal with conservative High voltage 8 From power cables (>1,000 volts), industrial accidents or lightening strikes treatment. 8 Can lead to significant systemic injuries 8 Will need hospital admission to rule out cardiac, renal and skeletal muscle damage Chemical injury Acids 8 Usually painful 8 Hydrofluoric, sulphuric and hydrochloric acid are the common agents 8 Testing for pH is useful 8 Copious lavage with or without a specific antidote is essential Alkali 8 Onset of pain may be delayed 8 Examples include household cleaning agents, bleaches and cement 8 Testing for pH is useful 8 Mostly lead to deeper burns 8 Copious lavage (for up to 24 hours) with or without a specific antidote is essential Organic 8 Bitumen (or tarmac) burns (Figure 2) compounds 8 Treatment involves early cooling with water and removal of bitumen (agents Figure 2. Bitumen burn in the cheek from a road such as citrus and petroleum distillate, sunflower oil or butter may surfacing accident. Bitumen is a mixture of organic be used) liquids that are highly viscous, sticky and entirely 8 Chemical debridement using kerosene, gasoline, acetone or alcohol may cause soluble in carbon disulphide. This type of burn local irritation or toxicity and should be avoided may occur in individuals working in road surfacing, roofing and waterproofing industry. Immediate removal of the bitumen is essential. Wounds UK, 2009, Vol 5, No 2 39 Review5(2)Enochrh.indd 39 11/6/09 15:25:10 Clinical REVIEW Clinical REVIEW Taking a history The importance of taking a thorough Table 2 history from the burn victim cannot Features of different burn depths be overemphasised. Elucidation of the exact mechanism of injury, the duration of exposure to the injurious agent, details of any fi rst aid delivered and Burn type Appearance Blisters Capillary Sensation Treatment an understanding of any other salient refi ll points of the burn history will facilitate Epidermal Red and None Brisk Painful Heals with referral to specialist secondary or (epithelial) glistening conservative tertiary services, enable risk assessment treatment and thereby help to assess whether Superfi cial dermal Pale pink Yes Brisk Usually Usually heals with the patient can be managed in the (superfi cial partial painful conservative community. Young children and the thickness) treatment elderly are at a higher risk of sustaining Deep dermal (deep Dry, May be Absent Dull Although can heal burn injuries since factors such as partial thickness) blotchy present absent spontaneously may physical impairment, poor mobility and cherry require surgical and inability to extricate themselves red intervention in from danger act as contributing factors. certain instances When assessing burns in children and the elderly, it is imperative to consider Full thickness Dry, white None Absent Absent Seldom heals the possibility of non-accidental injury or black. with conservative even if the extent of burns may Eschar may treatment. Usually appear trivial. Delays in presentation, be present requires surgical inconsistent history, incongruity between intervention history and clinical fi ndings, an unusual pattern of injury, and a history of previous similar incidents are all possible indicators (Andronicus et al, 1998) and and the resulting scarring (superfi cial may often be mixed and the depth of a should alert the examining healthcare burns that heal with conservative burn wound can progress over 24–48 professional to initiate appropriate treatment will cause considerably less hours.
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