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Information

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JussiValtonen

Burn Injuries

Essentials

  • First aid
    • Extinguish the flames.
    • Cool.
  • Initial treatment
    • Cover with clean, dry bandage, cling film or paraffin gauze dressing.
    • In case of extensive injury, follow the ABCD(E) trauma protocol Prehospital Emergency Care.
    • Prevent hypothermia.
  • Assessment of burn injuries
    • Extent
    • Depth
    • Location
  • The choice of place of treatment depends on the extent, depth, location and mechanism of the burn injuries, as well as on certain patient-related factors.
    • Small, superficial burns can be treated in outpatient care (for more detail, see Treatment of minor burns and Where to treat?).
  • Find out about local organization of care and appropriate place of treatment of severe burns, which often are treated in specialized burn care centres.
    • The burn care centre may prefer that photographs are taken of the patient's injuries before consultation, as far as possible. Find out about their instructions.

First aid and initial treatment at the site of the accident

  • First aid
    • Stopping the burning
      • Extinguish the flames.
      • Remove clothes that are burned or contain other cause of injury.
      • In case of electrical injury, break contact between the patient and the current source Electrical Injuries.
    • Cooling
      • Cool the burn area by flushing it with running water at about +20 degrees Celsius for about 10-15 minutes; do not use ice or ice water for cooling. Cooling is useful for 3 hours after injury.
      • In case of injuries caused by acids or bases, the area should primarily be rinsed with running water for at least 30 minutes to neutralize the chemical agent. Do not hesitate to consult a burn centre.
      • Avoid hypothermia, particularly if the patient is a small child.
      • Protect yourself.
  • Initial treatment
    • Extensive injuries: always follow the ABCD(E) trauma protocol.
    • For transportation, cover burn wounds with clean, dry bandage or paraffin gauze dressing.
      • Burn areas swell, so do not use circular bandaging.
    • During transportation, burn areas should be kept elevated.
    • Reassure the patient.
    • In case of extensive injuries or suspected respiratory burns, administer 15 litres/minute of oxygen through a reservoir mask.
    • Avoid hypothermia.

Estimating the extent of burn injury

  • Various aids can be used to estimate the extent of burn injury. What is most important is that the estimation is logical.
    • Small-area injuries
      • The 1% rule: the patient's palm with fingers held together corresponds to about 1% of the patient's total body surface area (in both children and adults).
    • More extensive injuries
      • The rule of 9s: the patient's total body surface area is divided into areas representing 9% or its multiples (see Table T1). In children, body proportions change with age.
    • Special forms/figures for assessing the injuries may be available from the local burn care centre.

Estimating the extent of burns (rule of 9s)

AreaAdult %1-year-old child %
Palm11
Head919
Upper limb99.5
Upper body3632
Lower limb1815

Estimating the depth of burn injury

  • Burns can be divided into various degrees of depth using either verbal or numeric definitions.
    • Epidermal (1st degree)
      • Not included in the total body surface area burned (TBSA%)
      • Erythematous
      • No blisters
      • Capillary refill present (= the affected skin blanches when pressed and regains its red colour immediately when the pressure is released)
      • Sense of touch intact
    • Superficial dermal (2nd degree (2a))
      • Pink and moist
      • Blisters
      • Capillary refill present
      • Sense of touch intact
      • Painful
    • Mid-dermal (2nd degree (2b))
      • Deeper pink colour
      • Blisters
      • Capillary refill present but slower
      • Sense of touch intact/impaired
    • Deep dermal (2nd degree (2c))
      • Brick-red, patchy red, light
      • Dry wound surface
      • Possibly blisters
      • No capillary refill
      • Sense of touch lost
    • Full-thickness (3rd degree)
      • White, charred
      • Wound surface waxy/leathery
      • No blisters
      • No capillary refill
      • No sense of touch
  • Monitoring
    • As burns continue to deepen with time, they should be reassessed 2-3 days after the injury.
      • Infection may also deepen the burn injury.
    • Burns healing with conservative treatment
      • Superficial dermal burns heal within 2-3 weeks.
        • Burns should be checked again 2-3 weeks after the injury if they have not healed, were deeper than estimated or have become deeper due to an infection, for instance.
    • Injuries requiring surgical management
      • As deeper burns will not heal in 2-3 weeks and often require surgical management, a surgeon should be consulted concerning possible surgical treatment.
    • Special cases
      • In burns from high-voltage electricity or hot air (sauna), the skin finding may be misleading.
        • Tissues underneath the skin may be primarily necrotic (high-voltage injuries) or the injury may become gradually deeper due to thrombosis (particularly in hot-air injuries).
        • In high-voltage injuries, in particular, keep in mind the possibility of compartment syndrome.
      • Injuries caused by flames are usually deep.

Where to treat?

  • The information in this chapter is based on the organization of burn care in Finland. Division of responsibilities may vary between countries. Find out about locally relevant policies.
  • Outpatient care
    • Initial assessment and monitoring of small-area and superficial burns unless the patient requires inpatient care due to pain, for example.
  • Inpatient care at a primary care hospital or district hospital
    • Treatment of small-area and superficial burns if the patient cannot cope at home due to pain, for example.
  • Major secondary care hospital
    • Burns affecting less than 10% of the body surface area in adults
  • University hospital (tertiary care hospital)
    • Burns covering less than 20% of body surface area in adults or less than 10% in children
  • A specialized burn centre should be consulted if:
    • there are deep burns covering more than 10% of total body surface area in adults or more than 5% in children
    • there are burns covering more than 20% of total body surface area in adults or more than 10% in children
    • there are burns involving the face, hands, feet, perineum or joint area or circular limb injuries
    • the patient has many underlying diseases
    • the patient is pregnant or
    • the patient is a small child or an elderly person of advanced age.
  • A burn centre can be consulted whenever the lines of treatment are unclear; consultation does not necessarily mean referring the patient to the burn centre.

Treatment of minor burns Honey as a Topical Treatment for Wounds

  • First aid
    • See First aid and initial treatment at the site of the accident.
  • Initial treatment in the first treating unit
    • Always give analgesics, as necessary; superficial dermal injuries, in particular, are painful.
    • Remove necrotic tissue, burn residues and dirt from the skin, and clean the wound with soap and water, for instance.
      • Large and distended blisters can be debrided by puncturing and de-roofing. Smaller blisters may be left intact and removed at a later stage.
    • After assessment, the burn should be covered with a paraffin or silicone dressing or with a foam dressing containing silver.
      • The dressing should be covered with sufficient absorbent secondary dressing, since the wound will ooze copious amounts of exudate over the next 48 hours; the secondary dressing can be changed at home, as necessary.
    • Apply bandage so as to preserve function.
      • For hands, for example, try to bandage the fingers separately.
      • Encourage mobilization.
    • Antimicrobial prophylaxis is not indicated in the treatment of minor burns.
  • Monitoring
    • 2−3 days after injury
      • Instruct the patient to take analgesics at home before the checkup, and give additional analgesics, as necessary.
      • If the injury is superficial, continue conservative treatment for 2-3 weeks.
        • Choose bandages that need to be changed as seldom as possible.'
      • In deeper injuries, consult a surgeon about the need for surgical treatment.
    • 2−3 weeks after injury
      • If the injury has healed, instruct the patient to apply non-medicated emollient ointment and to protect the skin from UV radiation from the sun.
        • As scarring can occur even after superficial burns (particularly in children), instruct the patient/relative to contact you if there are signs of scar formation.
        • Any pigment changes will resolve in some patients within about 2 years from the injury.
      • If the injury has not healed, was deeper than originally estimated or has become deeper due to infection, for instance, consult a surgeon for possible need for surgical treatment.

First aid and initial treatment of severe burns

  • Patients with burns are trauma patients, who should be treated according to trauma protocols Prehospital Emergency Care.
    • ABCD(E)
      • (A) Airway: support the cervical spine, check and clear both the mouth and the throat, keep the airway patent manually, insert a pharyngeal airway or intubate, as necessary.
      • (B) Breathing: expose the chest, check respiratory excursions, breath sounds (symmetry and respiratory rate), pulse oximetry; administer oxygen at 15 l/min. through a reservoir mask.
      • (C) Circulation: exclude external and internal haemorrhage, check the pulse status and capillary reaction both centrally and peripherally, check blood pressure and heart rate, and insert two large-bore intravenous cannulas, preferably through unburned skin.
      • (D) Disability: check the pupils and assess the level of consciousness using either the GCS (Glasgow Coma Scale) or the AVPU method (Alert, responds to Vocal stimuli, responds to Painful stimuli or Unresponsive to all stimuli).
      • (E) Exposure: keep the patient warm, assess burns (extent and depth) and check for other external signs of injury.
    • Prevent shock and fluid deficit.
      • Fluid replacement should be commenced if the burn covers more than 15% of the body surface area in an adult and more than 5-10% in a child.
      • Infusion should be started with Ringer's solution.
      • Assessment of initial fluid replacement in patients (adults or children) with burns should be done using the Parkland Formula: 4 ml × burn percentage × patient's weight. Half of the amount should be administered within the first 8 hours and the rest within the following 16 hours.
        • For fluid replacement in children weighing less than 30 kg, do not hesitate to consult either an emergency physician, a paediatrician or a burn centre.
      • A urinary catheter should be placed to follow the response to fluid administration.
        • The aim for adults is 0.5 ml/kg/h and for children 1.0 ml/kg/h.
    • Administer analgesics, as necessary.
      • For example, 4-6 mg morphine i.v. or s.c., for children 0.05-0.1 mg/kg.
    • Prevent hypothermia.
    • Reassure the patient.
    • Wounds
      • For transportation, cover the wounds either with dry, clean bandage or with cling film (do not use circular bandaging for limbs), if the transportation time is less than 8 hours. If the transportation time exceeds 8 hours, use foam dressings with silver.
    • Keep the burned areas elevated during transport.
    • Always consult a burn centre.