The correct management of burn injuries is vital if we are to minimise the pain, scarring and psychosocial impairment suffered by many victims.
Burn injuries pose a considerable burden to the NHS, with 250,000 patients presenting to primary care teams and a further 175,000 patients presenting to A&E annually in the UK. In Europe as a whole, almost 2 million people suffer from burns annually. Therefore it is feasible that most practising nurses will encounter a patient with a burn at some point in their working lives.
The ability to manage burn patients appropriately is important and this article hopes to identify the key principles of burn management including first aid, classification of burn depth, estimation of total body surface area burned (TBSA) and the type of wound management to adopt. In addition, the aftercare and ongoing prevention and treatment of scarring is essential to promoting well- being in the individual. The patient with burns presents a difficult challenge to most health care personnel. In addition to the serious nature of the injury, we must consider the patient’s discomfort, the distress of the patient and their relatives, the loss of income and the compromise of their future employment, and their uncertainty about the future.1
The aim of first aid should be to stop the burning process, cool the burn, provide pain relief and cover the injury.2
Yuan et al (2007) advocate cooling the burn with running cool/tepid water for at least 20 minutes.3 This is said to decrease pain from damaged nerve endings, decrease immediate cell death due to hot temperatures, decrease the inflammatory response, prevent vasoconstriction and decrease or prevent oedema formation.4 The suggested temperature is 15°C to prevent possible hypothermia; ice should never be used as this will promote vasoconstriction and potentially deepen the burn.4 Chemical burns are the obvious exception and should be irrigated with copious amounts of water.5 Some recent work has also demonstrated that even if there is a delay in applying appropriate first aid, then application of water even up to 3 hours post injury will have a beneficial effect.4
Once the wound is cooled then it should be wrapped in a clean covering. Cling film (plasticised polyvinyl chloride) is the covering of choice as it excludes air and bacteria and renders burns painless.6 It also allows the wound to be viewed for assessment without having to be removed, it does not shed fibres into the wound, and is easily removed without causing further trauma. It is important to lay the film on the patient, not wrap the area, as swelling may lead to constriction. Avoid using wet dressings as heat loss during transfer can be considerable.7
Mechanism of Injury
Identifying the exact mechanism of burn injury in the history is really important in determining a management plan. Table 1 summarises some common burn mechanisms.
Assessment of Depth
The interpretation of burn depth is different throughout the world; the USA, Europe and the UK all have their own assessment criteria and they should not be used interchangeably. A useful classification system is displayed in Table 2.
Clinical Assessment of Burn Depth
Assessment entails obtaining a detailed history of the accident from the patient, relatives or firemen. When contact burns are involved, a history of temperature of the object and exposure time are again relevant. Accurately assessing the depth of a burn can be more difficult than estimating its extent. The temperature or strength of the burning agent and the duration of contact determines the depth of the burn.8 The depth of burn is determined by the thickness of the skin and the amount of heat transferred to the skin. Skin thickness depends on the age of the patient (an infant’s dermis is only a quarter the thickness of an adult’s) and the anatomical location. For example a hot cup of coffee split on an adult may only cause a superficial dermal burn whereas the same cup may cause a deep dermal injury in a child.8,9
Assessment of Total Body Surface Area
Assessment of Total Body Surface Area (TBSA) is usually carried out using the Wallace Rule of Nines (see Figure 2).10 This is quick and simple to use tool, which breaks the body up into multiples of nine. Wallace's Rule of Nines provides a quick approximation of the area of skin burnt.
This gives a very quick estimation, but it has often been criticised as leading to overestimation. However, it is easy to use and is recommended for pre-hospital and A&E Departments to use.11
The Rule of Nines is inaccurate in children due to the relative disproportion of body parts; their hips and legs are smaller, and heads, necks and shoulders are larger. For children and for small burns, an alternative method is to estimate the extent of the burn by comparison with the area of the patient's hand. The area of the fingers and palm roughly equates to a 1% total body surface area burn.12 Another tool, which can be used, is the Lund and Browder Chart,13 which breaks the body down into smaller sections and is deemed to be more accurate (see Figure 4). It takes into account the changes in proportion of the limbs and head in children. This is deemed to be more accurate and therefore is used throughout most burn centres in the UK, Europe and USA.
Management of Minor Burns
Cleansing and Debridement
The aim of treatment for the first few days following a burn is to reduce the risk of infection and to prevent progressive extension of burn depth. This is achieved by the application of sterile dressings to act as a physical barrier and the creation of a moist environment, which has been shown to enhance the healing process. However, it must be remembered that these conditions are also ideal for bacterial growth. Thus it is important to use strict aseptic technique when applying dressings and to change the dressings if they become soaked in exudate.
In the first 48 hours the wound is in a dynamic state. A burn that was initially assessed to be superficial may progress to a deeper wound over a few days. The wound should initially be washed with soap and water and then all dead skin and blisters debrided.14
Richard and Johnson (2002) suggest that debridement of burn blisters aids in accurate wound depth identification by allowing direct visualization of the wound bed.15 Traditionally, blisters are thought to occur in only superficial or superficial dermal wounds, and typically they do signify the presence of a more superficial partial thickness burn, but they can occur over deeper injuries.10
Non-viable tissue on the burn wound can provide a rich medium on which bacteria can feed and thrive, and puts the patient at risk of both local and systemic infection.16.Therefore it might be recommended that the blister is removed before it bursts, to clear the wound of non-viable tissue and decrease the likelihood of infection. Function is one of the main aims of burn wound management, therefore, debridement of blisters and application of appropriate dressings increases the likelihood that the patient can return to normal daily activities.11.Intact blisters over joints may impede activity which in turn may lead to burn contracture during healing.
Debridement of burn wounds can be carried out relatively painlessly with the correct skill and tools. Fine scissors should be used and it is often better carried out on the day of injury before plasma can glue the skin in place, an incision should be made into the blister and the fluid should be drained and the dead or devitalised tissue carefully cut away up to (but not including) the margin of sensate tissue. Once the blister is debrided, full assessment of the wound can take place.
The achievement of early, sound, durable burn wound healing is one of the fundamental aims of burn care in order to minimise subsequent morbidity and mortality. However, it must be remembered that all patients with burns are individuals. There is no standard way to treat a burn and treatment must be tailored to suit the needs and requirements of both the patient and the burn wound.
Antimicrobial dressings are the mainstay of burn wound management, as gram-positive organisms such as staphylococcus and streptococcus colonise the wound surface during the first post-burn week. The goal of burn wound treatment is not to sterilize the wound but to control bacterial load and decrease the likelihood of burn wound infection.17
Dressings should maintain a moist wound environment to aid healing. Burns are often thought of as wet wounds, but whilst minor burns might be wet for the first 24 hours or following debridement, they are in fact drier than most wounds. This can often lead to inappropriate application of dressings, e.g. Melolin-type dressings or low adherent with gauze, which leads to drying out and death of viable dermal appendages. This will make the burn go deeper and contribute to scar formation. For this reason, Flamazine is often the mainstay of minor burn wound management.
Dressings should also be capable or providing an effective barrier to the environment to reduce the risk of infection, fit well and contour to the wound to support pain relief and be easy to apply and remove to prevent additional trauma and pain to the wound.14
Scar management relates to the physical and aesthetic componentsas well as the emotional and psychosocial implications of scarring.
Hypertrophic scarringresults from the build up of excess collagenfibres during wound healing and the reorientation of those fibresin non-uniform patterns. This leads to hot red, thickened scars that are painful and itchy. Keloid scarring is rare in burns. Hypertrophic scars will regress with time but this can take over 2 years.
Scarring is influenced by many factors:
- Extraneous factors: first aid, adequacy of fluid resuscitation,positioning in hospital, surgical intervention, wound and dressingmanagement.
- Patient-related factors: degree of compliance with rehabilitationprogramme, degree of motivation, age, pregnancy,skin pigmentation.
First-line management in terms of scar prevention is massage and moisturisation. Because of the altered functions of the skin after a burn, patients must be shown how to massage and moisturise the affected site, using small circular motions up to three times a day for a period of at least ten minutes each time.18 Patients must also be made aware that they need to protect themselvesfrom the sun for up to two years and that they will need tokeep their skin protected and covered with sun screen (and appropriateclothing). Failure to do so can lead to dark patches of skin forming, which can be unsightly and distressing to patients.
If massage alone does not lead to a flat, soft supple scar, then the next intervention is usually silicone gel. The mechanism of action is still not fully understood, but application of silicone gel sheeting seems to improve the redness, itching, texture and thickness of the scars.19 Silicone comes in a number of presentations including sheets, gels and sprays which are easily applied by the patient. Treatment should be continued for a minimum of 3 months and often considerably longer.
If this does not bring about improvement in the scar, then the patient should be referred on for specialist scar treatments. These include:
- Pressure garments: applying pressure to a burn is thought to reduce scarring byhastening scar maturation and encouraging reorientation of collagen fibres into uniform, parallel patterns as opposed to the whorled pattern seen in untreated scars. The garments need to be made to measure and are worn 23 out of 24 hours for a period of 12 months or longer.
- Steroid Injection: intralesional injections reduce fibroblast proliferation, collagen synthesis and glycosaminoglycan synthesis and suppress inflammatory mediators. Injections take place every 4- 6 weeks for up to 6 months. Response rate varies but usually range from 50–100%.20
- Camouflage: this is used to try and disguise the scar. The make-up is long-lasting, remaining in place all day, and can tolerate swimming whilst in situ. Patients are taught to apply the make-up themselves and it is available on prescription.
Management of the patient with burns goes beyond the management of the wound. The resulting scar can have a devastating effect on the individual so knowing when to refer on for specialist care is imperative. Most burn services have ready access to trained psychologists as well as a whole range of multidisciplinary team members who can promote function, activities of daily living and offer specialist scar input. Referral to a burn service should not be based on the wound alone, but rather on the overall need for the patient to access the larger multidisciplinary team.
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