Burns

Classification of Burns

Burns can be classified according to the body surface area that is involved:

• Minor Burns involve 10% TBSA or less
• Moderate Burns involve 11% to 20 of TBSA
• Major Burns involve 20% to 60% of TBSA
• Severe Burns involve >60% of TBSA

Types of Burns

There are 4 main types of burns that occur:

• Thermal
• Chemical
• Electrical
• Radiological

Classification of depth of burn injury

Burns are also classified according to the depth of injury:

• Superficial — involves the epithelium: burns appear pink, red, painful, and generally take 7-10 days to heal. Sunburn is the classic example.
• Partial thickness — involves the epidermis and some dermis: appears mottled pink, painful, hairs intact, and generally take 2-3 weeks to heal. Scarring may occur, particularly if healing is delayed and skin grafts may be required.
  • Superficial dermal – darker pink, sluggish capillary refill
  • Deep dermal – mottled, fixed staining, no capillary refill
• Full thickness — extends through the skin to deeper structures: appears black or white (eschar), leathery, produces no response to pain, and hairs are absent. Skin grafts are required.

Pathophysiology of burn injuries

The local response to a burn injury is described as consisting of three zones:

1. Zone of coagulative necrosis results from the direct thermal injury at time of exposure.
2. Zone of stasis borders the site of coagulation necrosis, there is a prominent inflammatory response and vascular reactivity that reduces blood flow. This reduction in flow occurs for the first 24-48 hours after the burn occurs.
3. Zone of hyperaemia is the outermost area of the burn injury and is characterised by intense yet reversible vasodilatation and increased blood flow.

Thermal injuries trigger an intense local and systemic inflammatory response, with increased capillary permeability causing fluids and proteins to leak from the vascular space. This leakage can lead to oedema and hypovolaemia in extensive burns.

Burns Management

The Four Main Aims of Burns Treatment:

1. Protection from the Environment: Prevent infection by maintaining a sterile environment and using appropriate dressings.
2. Temperature Control: Avoid hypothermia by maintaining normal body temperature, especially in extensive burns.
3. Fluid Control: Prevent dehydration through appropriate fluid resuscitation.
4. Energy Control: Ensure increased caloric intake to meet the metabolic demands of burn healing.

First Aid:

• Cool Running Water: Apply cool running water (2-15°C) for 20 minutes as soon as possible, effective up to 3 hours post-burn.
  • as been shown to significantly reduce soft tissue damage, hastens wound re-epithelialisation and reduces scaring.
• Avoid Ice: Ice can cause further thermal damage.
• Avoid Alternative Therapies: Butter and other home remedies are ineffective and potentially harmful.
• Burnaid® Dressings: Use with caution; effective for cooling but not for preventing infection and may cause dermatitis.

Cleaning Burns:

• Infection Risk: Burns have a high risk of infection due to epidermal damage.
• All burns that are contaminated, or have been de-roofed or debrided, should be thoroughly irrigated.
• Irrigation: Use tap water or saline for irrigation of contaminated or debrided burns.

Blister Management:

• Controversy: Limited evidence, practices vary.
• Leave Alone:
  • Leave the blisters alone?
    • pros — they provides an barrier for the burn site against infection.
    • cons — the underly damage to the epithelium cannot be visualised and the serous fluid in the blister may be impairing healing to the burn. The blister may impair joint functionality.
  • De-roof and Debride:
    • Many specialists now recommend de-roofing and debriding the blister, so the underlying wound bed can be assessed and managed accordingly, and so that any non-adherent de-vitalised tissue is debrided.
• Follow Local Guidelines: Seek specialist advice if unsure.

Dressings:

• Choosing the appropriate dressing for burns can be challenging due to the wide range of options and limited evidence supporting the superiority of one over another.
• Partial-thickness burns usually heal within 10-12 days with proper wound care.
• Superficial burns:
  • Typically do not require dressings.
  • Heal well with good first aid and emollient creams (e.g., sorbolene).
• Partial-thickness and full-thickness burns:
  • Require dressings to promote healing.

Types of dressings for burns:

• Hydrocolloid dressings
• Silicone nylon dressings
• Antimicrobial dressings
• Polyurethane film
• Biosynthetic dressings
• Silver Sulphadiazine (SSD) creams:
  • Previously used for burns, but effectiveness is now questioned.
  • Studies show little evidence that SSD creams reduce bacterial infections.
  • Commonly cause local hypersensitivity reactions.
  • Require daily removal and reapplication, making them inconvenient and costly.
  • Modern burn care protocols have largely shifted away from SSD creams in favor of hydrocolloid and silver-impregnated dressings.
  • A survey by Johnson et al. (2007) revealed a decline in the use of SSD creams due to these issues.

Types of Burn Dressings

Foam Dressing (Mepilex® Ag):

• Contains Silver: Acts as a strong antibacterial/antimicrobial agent and promotes healing.
• Dry Dressing: Needs to be kept dry.
• Duration: Can be left on for 3 to 5 days.
• Moisturising Gel: Doctor or nurse may apply a moisturising gel under the dressing to keep it moist and further promote healing.

Foil Dressing (Acticoat® 3):

• Contains Silver: Prevents infection and promotes healing.
• Moist Dressing: Needs to be kept moist with tap water every 4 to 6 hours.
• Duration: Can be left on for 3 days.
• Requires a secondary occlusive dressing (e.g., Duoderm®) to maintain moisture.
• Importance of Moisture: Failure to keep the dressing moist may cause damage to the burn, delay healing, deepen the burn, or cause scarring.

Cream Dressing (Flamazine®):

• Contains Sulphur and Silver: Prevents infection and promotes healing.
• Dry Dressing: Needs to be kept dry and changed daily.
• Changing Frequency: If unable to change the dressing yourself, see your local doctor or healthcare professional.
• Daily Changes: Failure to change the dressing every 1 to 2 days may cause damage, infection, delay healing, deepen the burn, or cause scarring.
• Absorbent Dressing: Usually dressed with an absorbent dressing on top of the cream to contain the Flamazine® and held in place with white tape.

Analgesia:

• Pain Management: Superficial and partial thickness burns are painful.
  • Use paracetamol and NSAIDs for minor burns.
  • IV opioids may be needed for severe pain.

Antibiotics:

• Not for Prophylaxis: Not recommended for minor burns.
• Signs of Infection: Take wound swabs and guide antibiotic use based on results.

Tetanus: Determine tetanus status and provide ADT booster if needed.

Follow-Up:

• Early Follow-Up: Arrange follow-up 48-72 hours post-injury as burns may look worse after 2-3 days.
• Prolonged Healing: Refer to a burns unit if healing takes longer than 12-14 days to prevent scar formation.

Referral Criteria:

• Burns involving the face, hands, feet, genitalia, perineum, or major joints.
• Full-thickness burns or burns >10% TBSA in children or >20% TBSA in adults.
• Electrical or chemical burns.
• Suspected inhalation injury.
• Circumferential Burns
• Complex medical history
• Suspect NAI
• Very young < 1 year
• Not healed within 10 days, significant infection or scarring

Patient Education:

• Wound Care at Home:
  • Instruct on proper wound cleaning and dressing changes.
  • Infection Signs: Seek early medical review if:
    • Pain that is out of proportion to your initial level
    • Redness developing around the burn
    • New swelling in or around the burn
    • Fevers above 37.5ºC
  • Advise keeping the burn clean and dry, avoiding scratching or breaking blisters.
  • Avoid Tight Clothing: Wear loose-fitting clothing to avoid pressure on the burn area.
  • Encourage gentle range-of-motion exercises to prevent contractures, especially for burns over joints.
• Itch Management for Burns
  • Healing Sign: Itchiness indicates that your burn is healing.
  • Avoid Scratching or Rubbing: Scratching or rubbing the burn can delay healing.
  • Cold Pack: Pressing down on the area with a cold pack may reduce itchiness.
  • Antihistamines: Over-the-counter antihistamines can help manage symptoms. Consult your pharmacist for advice.
  • Moisturiser: If the itchy area does not have a dressing, applying extra moisturiser can help relieve the itch.
• Scar
  • Healing Time: Burns that heal within 7 to 14 days generally do not scar.
  • Keloid Scars: Some people may develop keloid scars, which are thicker and raised. Consult your doctor or nurse for advice and treatment options.
  • Skin Discolouration: After healing, skin discolouration can persist for up to 12 months. This is normal.
    • Moisturiser: Use a non-perfumed hypoallergenic moisturiser to prevent dryness.
    • Sun Protection: Avoid sun exposure to prevent prolonged or permanent discolouration. Use SPF 30+ sunscreen and wear protective clothing.
• Showering
  • can shower at home, use a soap-free wash, warm water, and a soft cloth to gently cleanse the area.
• Swimming
  • Do not swim in pools or the ocean if burn is not completely healed to avoid the risk of infection.
• Sun Protection:
  • Advise using sunscreen and protective clothing to prevent hyperpigmentation of healed burn areas.
• Psychological Support:
  • Recognize the potential psychological impact of burns and refer for counseling if needed.
  • Provide support and resources for coping with visible scars or functional limitations.

Medico-legal Pitfalls

• Failure to suspect that non-accidental injury could be the cause of burns in children
• Not referring minor burns that are taking long time to heal, placing the patient at risk of scarring and psychosocial impairment.
• Burns will always look worse the next day, early follow up will detect changes in the severity of the burn.

when to suspect Non-accidental injury in burns in children:

• Inconsistent or vague explanation:
  • The story provided does not match the severity, type, or pattern of the burn.
  • There is a delay in seeking medical attention without a reasonable explanation.
  • The explanation given for the injury changes over time or differs between caregivers.
• Pattern of the burn:
  • Burns with clear demarcation lines, suggesting intentional scalding (e.g., “stocking” or “glove” patterns on hands and feet, consistent with immersion).
  • Symmetrical or patterned burns, which may suggest the use of an object (e.g., iron, cigarette).
  • Burns in protected areas not typically exposed to accidental injury (e.g., buttocks, back, or genital region).
  • Circumferential burns around limbs or torso.
• Age and developmental stage of the child:
  • The injury does not align with the child’s developmental abilities (e.g., an infant too young to pull down a hot object).
• Multiple injuries or burn types:
  • The presence of multiple burns or injuries at different stages of healing, indicating possible previous trauma or repetitive harm.
  • Burns in combination with other signs of physical abuse (e.g., bruises, fractures).
• Burns in unusual locations:
  • Burns on areas of the body that are less likely to be accidentally injured (e.g., back, buttocks, perineum).
• Absence of splash marks:
  • Immersion burns, such as those from scalding, may lack splash marks, suggesting the child was held or forced into hot liquid.
• Caregiver behavior:
  • Caregivers may display unusual or inappropriate reactions, such as indifference, anger, or reluctance to provide details about the injury.
  • The child shows fear or withdrawal in the presence of the caregiver.
• History of previous injuries:
  • A pattern of recurrent injuries, particularly in a child with frequent visits to healthcare providers, should raise concern about possible abuse.