Clinical REVIEW Clinical REVIEW Management of in the community

Burn 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 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 classification of mechanisms of burn , 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 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 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

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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.

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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 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. Progression may be hastened if action according to local policy. scarring than a full-thickness burn the initial management was inadequate that requires surgical excision with or (British Burn Association, 2008), or in Mechanism of burn injuries without a skin graft). Dermal burns the presence of infection. Reassessment Identifying the exact mechanism of burn can be further classifi ed as superfi cial of the wound should be undertaken injury in the history is useful as particular dermal (also called superfi cial partial at 24–48 hours if the initial assessment patterns of injury and burn depths can thickness) and deep dermal (also called was considered to be unsatisfactory be predicted from this aspect of the deep partial thickness). The various burn or the depth deemed uncertain. In the history alone. Table 1 summarises some depths are illustrated in Figure 3. Table 2 common and important aetiological highlights some of the essential clinical Superfi cial Superfi cial Deep Full factors for burn injuries. Thermal injury is characteristics of burns of different dermal dermal thickness the most common form. depths (Enoch et al, 2009) and some clinical examples of burns of different Assessment of burn depth aetiologies and depths are represented Assessment of burn depth is important in Figures 4, 5 and 6. not just because it affects the choice of dressing, but also because burn depth It can indeed be challenging during can determine whether a wound will the fi rst consultation to accurately heal without surgical intervention. It assess burn depth on inspection and by is also a determinant of the severity clinical examination. In fact, a comparison of residual scarring. Burns are broadly of experienced surgeons showed classifi ed as epidermal (superfi cial), concurrence rates as low as 60% (La Hei dermal or full-thickness, corresponding et al, 2006). Therefore, modalities such to the level of involvement of the skin as laser Doppler imaging, transcutaneous and underlying tissues. This classifi cation videomicroscopy and infrared

takes into account the amount of skin thermography have been developed, Subcutaneous Dermis Epidermis and skin appendages affected, and although none are in routine clinical use. Figure 3. Illustration of depth of burns in relation thereby the ability of the wound to heal Furthermore, burn depth in a given area to layers of the skin.

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8 Palm as one percent: the patient’s palm and fingers make up about 1% of TBSA which is a useful tool in obtaining a quick estimate. Although this is a relatively crude method, it is useful in estimating small or large burns (<15% or >85% TBSA). In large burns, the burnt area can be quickly calculated by estimating the Figure 4. Hot water scald to the back of a child area of uninjured skin and subtracting demonstrating some erythema, superficial areas it from 100. (epidermal) and superficial/deep dermal areas (with blisters). These blisters need to be ‘de-roofed’ to Who should be referred to a specialist unit? accurately assess the burn depth before it can be Having made the initial assessments, decided if the areas can be treated conservatively. administered first aid, taken a good history and assessed severity of the burn in terms of depth and TBSA burnt, a decision should be made as to whether referral or transfer to a specialist burns unit is needed. The National Burn Care Review (2001) has issued referral guidelines to Figure 7. Wallace’s ‘Rule of Nines’. In adults, this is help in this decision-making process (Table a useful tool — 18% each for chest, back and legs 3). Put simply, burns can be classified into apiece, 9% each for head and arms apiece and 1% complex and non-complex. Burns <5% for the perineum. It is quick to apply and easily TBSA that are superficial or superficial remembered, although there may be a tendency to dermal in depth are non-complex and Figure 5. A scald to the knee mostly involving the overestimate the area by about 3%. can be managed in the community superficial dermis, thus demonstrating a pale pink (provided there are no associated burnt. This is a common error when surface. This type of scald will usually heal with injuries or comorbidities). The other estimating TBSA burns in referrals made appropriate conservative treatment. situation in which a burn patient might to the specialist burns units. Including be managed in the community is when erythema results in overestimation of they are recovering from a complex burn the area burnt leading to patients being and are discharged from hospital. The inappropriately referred for unnecessary management of such patients will not be investigations, given excessive fluid discussed in this article. resuscitation (with its own associated risks) and being unnecessarily referred Although the guidelines highlight the to burns units. Only the de-epithelialised types of burn injury that can lead to a areas should be included in the TBSA complex clinical course, they are not burn calculations. There are three intended to be rigidly prescriptive. If in commonly used methods to estimate doubt it is always best to seek guidance Figure 6. A flame burn over the anterior aspect of the TBSA burnt: from the specialist burns unit. In addition the knee demonstrating different depths. The middle 8 Wallace’s ‘Rule of Nines’ (Figure 7) to the types of burns listed in Table 3, of the burn is full thickness (dry, pale white and (Wallace, 1951) is easy to remember the following patients should also be no blisters), the superomedial aspect is mid/deep and can be used to make a quick considered for referral to a burns unit or dermal (dry and blotchy), and the periphery may estimate but tends to overestimate burns clinic: be superficial or deep dermal (note the blisters). the area of the burn by about 3% 8 Any burn wound that remains The depth of the burn at the periphery can be (Watchel et al, 2000). It is more unhealed 14 days post-injury assessed accurately only after the blisters have been useful for adults. 8 Infected burn wound with de-roofed. 8 The Lund Browder Chart (Figure 8) surrounding cellulitis or (Lund and Browder, 1944) is more systemic spread case of mixed depth wounds, the choice accurate than ‘Rule of Nines’ since 8 Patients (usually children) manifesting of dressing should be guided by the it takes the patient’s age and body evidence of toxic shock syndrome predominant burn depth in a given area. proportions into consideration. It (pyrexia, rashes, vomiting and/or is thus useful across all age groups diarrhoea), or toxic shock-like illness Estimation of a burn surface area (Watchel et al, 2000), particularly (pyrexia, rash or general malaise) Areas with only erythema should not children. However, the specific chart 8 Patients who develop problematic be included in the calculation of TBSA is required to make the calculations. scarring that causes pain, discomfort,

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Table 3 8 National Burn Injury guidelines for referral to a burns unit

All complex injuries should be referred. A complex burn injury comprises and is likely to be associated with: 8 Extremes of age (<5 or >60 years) 8 Site of injury — face, hands, or perineum. Any flexural surface such as neck, axilla, front of elbow or back of the knee. Circumferential dermal burns, or full- thickness burn of the limb, torso or neck 8 Inhalation injury* 8 Mechanism of injury Chemical burns >5% TBSA Hydrofluoric acid burns >1% TBSA Exposure to ionising radiation High pressure steam injury High tension electrical injury Suspected non-accidental injury** 8 Large size Paediatric (<16 years old) >5% TBSA Adult (≥16 years) >10% TBSA 8 Co-existing conditions 8 Serious medical conditions (e.g. immunosuppression) 8 Pregnancy 8 Associated injuries (fractures, or crush injuries)

* Suspect inhalation injury if: 8 Burns occurred in enclosed space (e.g. a house fire) Figure 8: . This method takes into account the vicissitudes of body surface area with 8 Smoke during incident age (and growth) and thus has the advantage of being useful for all ages and being particularly useful for 8 Blast, explosion and detonation children. The chart also divides the limb areas into smaller components and is thus more accurate than the 8 Patient is unconscious Wallace ‘Rule of Nines’. 8 Facial burns or singed hairs 8 Soot in airway possible, since the rapid development of Specialists has issued guidelines stating that 8 Hoarseness of voice or stridor post-burn oedema can lead to serious the burn should be washed thoroughly 8 Tachypnoea life-threatening airway obstruction. It is with soap and water or mild antibacterial 8 Decreased Glasgow Coma Scale rating also essential to recognise the signs of wash such as diluted chlorhexidine before inhalation injury as these patients may applying dressings (Alsbjörn et al, 2007). ** Suspect non-accidental injury in a vulnerable require management in an intensive care Although there is some controversy individual such as a child or older person if the presentation is delayed, the pattern of injury setting even in the absence of significant regarding the management of blisters is unusual, the history is inconsistent, there is cutaneous burns. Inhalation injury must (Uchinuma et al, 1998), it is widely discrepancy between history and clinical findings, there be suspected whenever burn injuries accepted that all blisters apart from those are multiple injuries, and/or old scars are noted in take place in an enclosed space or <1cm should be de-roofed (Hudspith unusual anatomical locations explosions, or if the patient manifests any et al, 2004). In addition to enabling more of the features listed in Table 3. accurate assessment of burn depth, de- roofing the removes dead tissue functional impairment or cosmetic Management of minor burns that can subsequently act as a medium for dissatisfaction. Cleaning the burn and debridement of burn debris bacteria. There is no role for the routine with soap and water use of antibiotics. All facial and neck burns should A new burn is essentially sterile and be referred to a specialist unit and management is directed at keeping it that Dressings reviewed by an anaesthetist as early as way. The European Working Party of Burns There is a huge assortment of dressings

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Table 4 Examples of different dressings that can be used in a burn

Dressing type Examples Use Low adherent Jelonet® (Smith and Nephew), Superficial or superficial dermal burns dressings Paratulle, Tulle Gras, with minimum exudate Figure 9. Biobrane®, a biological dressing, has been Atrauman® (Hartmann), Mepilex®, applied over areas of superficial dermal burn Mepitel® NA dressing (Mölnlycke) and the edges of the dressing stapled. Note the Semi-permeable Opsite® Flexigrid, Opsite® Plus (Smith Superficial or superficial dermal burns translucency of Biobrane. films and Nephew), Tegaderm® (3M) with minimum exudate Allows visual checks and may be left in available for the management of burn place for 2–3 days wounds and as result the task of choosing Should not be used in infected or heavily an appropriate dressing for a particular exuding burns clinical problem can, at first sight, appear Hydrocolloids Comfeel®, Comfeel® Plus (Coloplast), Superficial dermal or small area deep daunting. There is, however, little evidence DuoDERM® Extra Thin (ConvaTec), dermal burns in ‘difficult areas’ such as to suggest that one dressing is superior Granuflex® (ConvaTec) digits, heel, elbow, sacrum to another. Therefore, an understanding Absorbent and conformable of the few key aspects (Table 4) is more important than in-depth knowledge Hydrofibers Aquacel® (ConvaTec), Versiva® Superficial dermal burns about individual dressings. Although (ConvaTec) Can be used in moderately traditionally wet to dry gauze was used exuding wounds to dress wounds, in the past two decades Hydrogels Aquaform® (Unomedical), Intrasite® Useful in small area deep dermal burns it has been widely accepted that it is the Gel (Smith and Nephew) with slough maintenance of a moist environment Alginate Kaltostat® (ConvaTec) Used to dress skin graft donor sites that is key for optimal . ® ® For this reason, plain gauze is not widely Foam/ Allevyn Adhesive, Allevyn Lite Superficial or superficial dermal burns ® ® used (Hudspith et al, 2004). Simple non- Hydrocellular Island, Allevyn Thin, Allevyn Plus with minimum exudate adhesive dressing such as a soft silicone Adhesive (Smith and Nephew), Provides a degree of cushioning and may ® (such as Mepitel® [Mölnlycke, Goteburg]) Biatain Adhesive (Coloplast) be left in place 2–3 days padded by gauze is effective in most Antimicrobials Acticoat, Actisorb® Silver 200 Superficial dermal or small area deep superficial and superficial dermal burns. (Johnson and Johnson), Aquacel® Ag dermal burns with moderate exudate Other non-adhesive dressings such as (ConvaTec), Inadine® (Johnson and and/or evidence of local infection Jelonet® (Smith & Nephew, Hull), which Johnson) consists of dressing gauze impregnated with paraffin, can also be considered.

Secondary dressings can be placed All of these factors necessitate that trap moisture in the wound. Any over this first layer and might include a earlier dressing changes and re- overlying exudate on the wound after gauze pad, wool and crepe. In the limbs, examination of the wound. removal of the dressing should be wiped applying the wool and crepe in a ‘figure- away before reassessment of burn of-eight’ fashion and securing with tape In the hospital setting and in children depth. Flamazine® (Smith & Nephew, will prevent any unwarranted movement in particular, biological dressings such Hull), a hydrophilic cream containing of the dressings and resultant shear as Biobrane® (Smith & Nephew, Hull), silver sulfadiazine, is the most widely forces being applied to the burn wound. which consists of porcine collagen, are used topical cream in burn wounds and The dressing should be examined at 48 being increasingly used for superficial should be reserved for deep dermal hours in order to re-assess the depth of dermal burns as they have been shown burns. The silver ions act as a broad the burn and should be changed if there to control pain well and allow wound spectrum antimicrobial agent and are is considerable soakage. After this first inspection without disturbance of particularly useful in the treatment change, the dressings can be left intact the dressing due to its translucency and prevention of colonisation with for 3–5 days at a time, as long as there is: (Whittaker et al, 2008) (Figure 9). Small Gram negative organisms such as 8 No prior soakage of dressings areas of superficial dermal burns can also pseudomonas. It is also excellent at 8 No significant malodour be managed with hydrocolloid dressings keeping the wound well hydrated and 8 No pain such as Granuflex® and the thinner is soothing and painless on application. 8 No evidence of infection. DuoDERM® (both ConvaTec, Ickenham) It should, however, be reserved in the

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first instance for deep dermal burns, as psychological well-being of the patient. Uchinuma E, Kognei Y, Shioya N, Yoshizato early use in superficial burns can make Psychological and social factors play an K (1988) Biological evaluation of burn blister subsequent assessment of depth difficult important role in the patient pathway fluid. Ann Plast Surg 20: 225–30 due to staining of the wound which can from initial injury to the process Wallace AB (1951) The exposure and make it appear deeper. When Flamazine of recovery and rehabilitation. It is treatment of burns. Lancet 1(6653): 501–4 is used, it should be changed on therefore vital that the expertise of a Watchel TL, Berry CC, Watchel EE, Frank alternate days until any eschar has lifted psychologist is sought when needed. HA (2000) The inter-rater reliability of and epithelialisation has commenced. Likewise, an assessment of home estimating the size of burns from various circumstances and activities of daily burn area chart drawings. Burns 26: 156–70 Emerging therapies in burn living will not only aid return to normal Yuan J, Wu C, Holland AJA, Harvey JG, management include the use of artificial life but may, in some cases, prevent Martin HCO, La Hei ER, Arbuckle S, Godfrey further injury. As with all complex C (2007) Assessment of cooling on an acute skin substitutes produced through tissue scald burn injury in a porcine model. J Burn engineering techniques and the use of health problems a multidisciplinary team Care Res 28: 514–20 various growth factors to modulate approach is needed in the management Whittaker IS, Prowse S, Potokar TS (2008) A different phases of the healing process. of patients with burns. WUK critical evaluation of the use of Biobrane as Some of the tissue engineered skin a biologic skin substitute: a versatile tool for substitutes (AlloDerm® [Biohorizons, Acknowledgements the plastic and reconstructive surgeon. Ann Alabama] and Integra® [Integra, NJ]) are Thanks to Matthew Briggs, Medical Plast Surg 60: 333–7 particularly useful in large area burns where Photography and Illustrations Department, the availability of donor skin might be Royal Preston Hospital for Figure 3 and to limited. However, the cost, patient selection Helen Caruthers, Medical Photography and Illustrations Department, University Hospital of and the meticulous skill/technique required South Manchester, Wythenshawe for Figure 7. in the application of these products Key points precludes their use outside specialist burn units. There is insufficient evidence References 8 When managing burns, at present for the routine use of growth appropriate first aid and initial factors, or for the role of gene therapy or Alsbjörn B, Gilbert P, Hartmann B, Kazmierski M, Monstery S, Palao R, Roberto management according to ATLS stem cell therapy in burn wounds. MA, Van Trier A, Voinchet V (2007) principles is essential and it is Guideline for the management of partial also important to be aware of After the wounds have healed thickness burns in a general hospital or associated injuries. Once healed, burn wounds often leave community setting — recommendations of a an area that is dry, sensitive, pruritic European working party. Burns 33: 155–60 8 A good history and accurate (itchy) and prone to pigmentation Andronicus M, Oates RK, Peat J, Spalding changes (hypo or hyper) after sun S, Martin H (1998) Non-accidental burns in estimation of the total body exposure. Therefore, it is important to children. Burns 24: 552–8 surface area is vital to the immediate and onward advise applying moisturising cream to British Burn Association (2008) Emergency the areas regularly and protect them management of severe burns course manual, management in the community from direct sunlight; a high factor sun UK version. Wythenshawe Hospital, as well as for an appropriate and Manchester block for up to 12 months may be safe referral to a specialist unit. indicated. Physiotherapy is required in Enoch S, Roshan A, Shah M (2009) 8 burns involving anatomical areas such Emergency and early management of burns Early cleaning and debridement and scalds. Br Med J 338: 937–41 as neck, axilla, elbow, wrist, ankle and of burn debris aids healing and digits since these areas are prone to Hudspith J, Rayatt S (2004) First aid and is essential for estimation of treatment of minor burns. Br Med J 328: burn depth. excessive scarring and that 1487–9 may cause functional limitation. Patients 8 with these injuries should be referred La Hei ER, Holland AJA, Martin HCO (2006) Aim for a well-hydrated wound Laser Doppler imaging of paediatric burns: when choosing dressings. to the physiotherapists as soon as burn wound outcome can be predicted possible. Problematic scarring can also independent of clinical examination. Burns 8 Always solicit advice from the be minimised with the use of pressure 32: 550–3 garments and silicone therapy, and specialist burns unit if there is Lund C, Browder N (1944) The estimation of any doubt. therefore referral to the occupational areas of burns. Surg Gynecol Obstet 79: 352–8 therapist should be made if necessary. National Burn Care Review (2001) Standards 8 Burn injuries may represent a and strategy for burn care. A Review of Care in highly complex clinical problem Management of a patient with burns the British Isles. NBCR, London goes beyond the management of the and are best managed with a Sawadal Y, Urushidate S, Yotsuyanagil T, multidisciplinary approach. wound. A burn injury that might seem Ishita K (1997) Is prolonged and excessive trivial to the healthcare professional cooling of a scalded wound effective? Burns can have a devastating impact on the 23: 55–8

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