Burns and Scalds

 

Burns and scalds are damage to the skin caused by heat. Both are treated in the same way. A burn is caused by dry heat, for example, by an iron or fire. A scald is caused by something wet, such as hot water or steam. Burns may also be caused by chemicals and electricity. Burns / scalds can be very painful and may cause red or peeling skin, blisters, swelling, or white or charred skin.  The amount of pain felt is not always related to how serious the burn is.  A serious burn may be relatively painless

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Differential diagnosis

The differential diagnosis of burns and scalds includes:

  • Blistering skin disease (e.g. Stevens–Johnson syndrome, staphylococcal scalded skin syndrome, or toxic epidermal necrolysis)
  • Skin infection (e.g. cellulitis)
  • Skin necrosis (e.g. caused by pressure)

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Assessment of severity

Thorough assessment of the burn should include:

  • The type of burn (for example flame, scald, electrical, or chemical)
  • The depth and extent of the burn, and therefore the severity
  • The risk of inhalation injury (singed nasal hair, black carbon in the sputum, or carbon in the oropharynx).
  • Any coexisting medical conditions (for example cardiac, respiratory, or hepatic disease; diabetes; pregnancy; or immunocompromised state)
  • Any predisposing factors which may require further investigation or treatment (for example a burn resulting from a fit or faint)
  • The possibility of a non-accidental injury
  • The person's social circumstances
  • The need for referral

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Using the Rule of Nines, the extent of the burn, in terms of total body surface area, can be calculated from the area affected:

Rule of Nines Burns Chart (Adults)

Rules of Nines Burns Chart (Children)

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The depth of a burn can be determined using the following classification table:

Burn Depth Classification Table

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Management of minor burns and scalds

Managing epidermal burns:

  1. Advise the person of measures to provide symptomatic relief, for example:
    1. Take a cool bath or shower
    2. Apply topical emollients
    3. Apply cold compresses
    4. Take simple analgesia (e.g. paracetamol or ibuprofen)
  2. Advise the person to maintain adequate hydration
  3. Consider referral if there are signs or symptoms of heat exhaustion or heat stroke such as:
    1. High body temperature
    2. Fatigue, weakness, dizziness, fainting
    3. Nausea or vomiting
    4. Rapid pulse
    5. Headache, muscle cramps, myalgia
    6. Strange behaviour, irritability, agitation
    7. Impaired judgement, confusion, disorientation, hallucinations
  4. Advise the person to return if blisters develop
    1. If blisters have developed, manage as a superficial dermal burn

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Managing superficial dermal burn:

  1. Ensure that:
    1. Appropriate first aid has been given
    2. The burn has been adequately assessed
    3. The burn is suitable for management in primary care and does not require referral
  2. Clean the wound with sodium chloride 0.9% or lukewarm tap water. Gently remove any remaining loose/dead tissue using forceps
  3. Leave blisters intact wherever possible to reduce the risk of infection
    1. Consider aspirating large blisters and blisters that are likely to burst or are in an awkward position. Use an aseptic technique
    2. Seek specialist advice regarding the management of any blister that lasts longer than 2 weeks
  4. Dress the wound:
    1. Cover the wound with a non-adherent dressing such as paraffin gauze, silicone-coated nylon dressing, polyurethane film, or hydrocolloid dressing. Apply a secondary non-fibrous absorbent dressing such as a dressing pad, and secure well with a light-weight conforming bandage or tubular gauze bandage
    2. Consider using a hydrogel dressing if the wound is sloughy or if there is necrotic tissue that cannot be removed by cleansing
    3. Do not use antimicrobial-impregnated dressings; antimicrobial creams such as silver sulfadiazine (Flamazine®); or other creams or ointments
    4. Consult your local formulary for choice of dressings
  5. Offer pain relief
    1. Paracetamol or ibuprofen is usually adequate
    2. Consider adding codeine for more severe pain
  6. Assess the need for tetanus prophylaxis
  7. Do not prescribe systemic or topical prophylactic antibiotics
  8. Once the wound has healed, advise the person to:
    1. Massage the area 2–3 times a day with an emollient such as emulsifying ointment (aqueous cream in not recommended)
    2. Protect from the sun (with high factor sunblock or clothing) to prevent hyperpigmentation

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Reviewing a superficial dermal burn:

  1. Check the dressing after 24 hours to ensure that it is still in place, and that there is not excessive exudate. Check there are no signs of infection
    1. This may be done by the patient or their carer if appropriate
  2. Reassess the wound and change the dressing after 48 hours if needed
  3. Subsequently, change dressings every 3–5 days (depending on type of dressing, amount of exudate, and rate of healing)
  4. Continue dressing the wound until it is healed
  5. Advise the person to seek advice immediately if the wound becomes painful or smelly, the dressing becomes soaked with exudate, or they develop a fever
  6. Seek specialist advice for any minor burn that has not healed within 2 weeks

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Management of infected minor burns and scalds

  1. Suspect infection if the wound becomes increasingly uncomfortable, painful, or smelly; if cellulitis is observed; or if the person develops a fever
  2. Clean the wound with 0.9% sodium chloride or lukewarm tap water
    1. If infection is suspected, take a swab from the burn wound and start empirical antibiotic treatment:
    2. Prescribe flucloxacillin first-line
    3. For people who are allergic to penicillin, prescribe erythromycin. Clarithromycin can be used for people who are known not to tolerate erythromycin
    4. Prescribe doses high enough to ensure adequate tissue penetration
    5. Prescribe 7 days of antibiotic treatment initially. If symptoms have not fully resolved after 7 days, consider continuing the antibiotic for up to a further 7 days
  3. Offer adequate pain relief — paracetamol or ibuprofen, plus codeine for more severe pain
  4. Assess the need for tetanus prophylaxis
  5. If there is poor, or no, clinical response to empirical antibiotics, change the antibiotic according to the results from the swab

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When to refer

Minor burns should largely be managed in primary care, however consider referral if there are signs or symptoms of heat exhaustion or heat stroke such as:

  • High body temperature
  • Fatigue, weakness, dizziness, fainting
  • Nausea or vomiting
  • Rapid pulse
  • Headache, muscle cramps, myalgia
  • Strange behaviour, irritability, agitation
  • Impaired judgement, confusion, disorientation, hallucinations

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Using the Rule of Nines, the extent of the burn, in terms of total body surface area, can be calculated from the area affected:

Rule of Nines Burns Chart (Adults)

Rules of Nines Burns Chart (Children)

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The depth of a burn can be determined using the following classification table:

Burn Depth Classification Table

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

 

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