ABC of Burns
ABC of Burns
ABC of Burns
Introduction
Shehan Hettiaratchy, Peter Dziewulski
Most burns are due to flame injuries. Burns due to scalds are
the next most common. The most infrequent burns are those 15-64 years old
caused by electrocution and chemical injuries. The type of
burns suffered is related to the type of patient injured. It is
therefore useful to break down burn aetiology by patient Causes of burns (left) and incidence of burns by age (right)
Further reading
x Wilkinson E. The epidemiology of burns in secondary care, in a x Fire kills. You can prevent it. www.firekills.gov.uk
population of 2.6 million people. Burns 1998;24:139-43 x Herndon D. Total burn care. 2nd ed. London: WB Saunders, 2002
x Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, x National Community Fire Safety Centre Toolbox.
Tompkins RG. Objective estimates of the probability of death from www.firesafetytoolbox.org.uk
burn injuries. N Engl J Med 1998;338:362-6 x Liao C-C, Rossignol AM. Landmarks in burn prevention. Burns
2000;26:422-34
Local response
The three zones of a burn were described by Jackson in 1947.
Zone of coagulation—This occurs at the point of maximum
damage. In this zone there is irreversible tissue loss due to
coagulation of the constituent proteins.
Zone of stasis—The surrounding zone of stasis is Clinical image of burn zones. There is central necrosis,
surrounded by the zones of stasis and of hyperaemia
characterised by decreased tissue perfusion. The tissue in this
zone is potentially salvageable. The main aim of burns
resuscitation is to increase tissue perfusion here and prevent
any damage becoming irreversible. Additional insults—such as
prolonged hypotension, infection, or oedema—can convert this
Zone of Zone of
zone into an area of complete tissue loss. coagulation stasis
Zone of hyperaemia—In this outermost zone tissue perfusion is
increased. The tissue here will invariably recover unless there is Zone of
Epidermis hyperaemia
severe sepsis or prolonged hypoperfusion.
Dermis
These three zones of a burn are three dimensional, and loss
of tissue in the zone of stasis will lead to the wound deepening
Adequate Inadequate
as well as widening. resuscitation Zone of resuscitation
coagulation
Systemic response
The release of cytokines and other inflammatory mediators at
the site of injury has a systemic effect once the burn reaches
30% of total body surface area.
Cardiovascular changes—Capillary permeability is increased,
leading to loss of intravascular proteins and fluids into the Zone of stasis preserved Zone of stasis lost
Immunological
Mechanisms of injury Reduced immune
response
Thermal injuries
Scalds—About 70% of burns in children are caused by scalds.
They also often occur in elderly people. The common
mechanisms are spilling hot drinks or liquids or being exposed Systemic changes that occur after a burn injury
Electrical injuries
Some 3-4% of burn unit admissions are caused by electrocution True high tension injury Flash injury
Chemical injuries
Chemical injuries are usually as a result of industrial accidents
but may occur with household chemical products. These burns
tend to be deep, as the corrosive agent continues to cause
coagulative necrosis until completely removed. Alkalis tend to
penetrate deeper and cause worse burns than acids. Cement is a
common cause of alkali burns.
Certain industrial agents may require specific treatments in
addition to standard first aid. Hydrofluoric acid, widely used for
glass etching and in the manufacture of circuit boards, is one of
the more common culprits. It causes a continuing, penetrating Chemical burn due to spillage of sulphuric acid
The ABC of burns is edited by Shehan Hettiaratchy; Remo Papini, “Doughnut sign” in a child with immersion scalds. An
consultant and clinical lead in burns, West Midlands Regional Burn area of spared skin is surrounded by burnt tissue. The
Unit, Selly Oak University Hospital, Birmingham; and Peter tissue has been spared as it was in direct contact with
Dziewulski. The series will be published as a book in the autumn. the bath and protected from the water. This burn
pattern suggests non{accidental injury
Competing interests: See first article for series editors’ details.
BMJ 2004;328:1427–9
First aid
The aims of first aid should be to stop the burning process, cool
the burn, provide pain relief, and cover the burn.
Stop the burning process—The heat source should be removed.
Flames should be doused with water or smothered with a
blanket or by rolling the victim on the ground. Rescuers should
take care to avoid burn injury to themselves. Clothing can retain
heat, even in a scald burn, and should be removed as soon as
A superficial scald suitable for management in primary care
possible. Adherent material, such as nylon clothing, should be
left on. Tar burns should be cooled with water, but the tar itself
should not be removed. In the case of electrical burns the victim
should be disconnected from the source of electricity before
first aid is attempted.
Benefits of cooling burn injuries with water
Cooling the burn—Active cooling removes heat and prevents
x Stops burning process x Reduces pain
progression of the burn. This is effective if performed within
x Minimises oedema x Cleanses wound
20 minutes of the injury. Immersion or irrigation with running
tepid water (15°C) should be continued for up to 20 minutes.
This also removes noxious agents and reduces pain, and may
reduce oedema by stabilising mast cells and histamine release.
Iced water should not be used as intense vasoconstriction can
cause burn progression. Cooling large areas of skin can lead to Cling film for dressing burn wounds
hypothermia, especially in children. Chemical burns should be x Essentially sterile
irrigated with copious amounts of water. x Lay on wound—Do not wrap around
Analgesia—Exposed nerve endings will cause pain. Cooling x Non-adherent
x Pliable
and simply covering the exposed burn will reduce the pain. x Transparent for inspection
Opioids may be required initially to control pain, but once first
aid measures have been effective non-steroidal
anti-inflammatory drugs such as ibuprofen or co-dydramol
taken orally will suffice.
Covering the burn—Dressings should cover the burn area
and keep the patient warm. Polyvinyl chloride film (cling film)
is an ideal first aid cover. The commercially available roll is
essentially sterile as long as the first few centimetres are
discarded. This dressing is pliable, non-adherent, impermeable,
acts as a barrier, and is transparent for inspection. It is
important to lay this on the wound rather than wrapping the
burn. This is especially important on limbs, as later swelling
may lead to constriction. A blanket laid over the top will keep
the patient warm. If cling film is not available then any clean
cotton sheet (preferably sterile) can be used. Hand burns can
be covered with a clear plastic bag so as not to restrict mobility.
Avoid using wet dressings, as heat loss during transfer to
hospital can be considerable.
Use of topical creams should be avoided at this stage as
these may interfere with subsequent assessment of the burn.
Cooling gels such as Burnshield are often used by paramedics.
These are useful in cooling the burn and relieving pain in the Burnshield is a cooling gel used to cover burn and
initial stages. reduce pain
Dressings
Many different dressings are in use, with little or no data to
support any individual approach. We favour covering the clean
burn with a simple gauze dressing impregnated with paraffin
(Jelonet). Avoid using topical creams as these will interfere with
subsequent assessment of the burn. Apply a gauze pad over the
dressing, followed by several layers of absorbent cotton wool. A
firm crepe bandage applied in a figure of eight manner and
secured with plenty of adhesive tape (Elastoplast) will prevent
slippage of the dressing and shearing of the wound.
An elastic net dressing (Netelast) is useful for securing
awkward areas such as the head and neck and chest. Limb
burns should be elevated for the duration of treatment.
Dressing changes
The practice of subsequent dressing changes is varied. Ideally
the dressing should be checked at 24 hours. The burn wound
itself should be reassessed at 48 hours and the dressings
changed, as they are likely to be soaked through. At this stage
the depth of burn should be apparent, and topical agents such
as Flamazine can be used.
Superficial scald burn on side of neck (top left) is cleaned and then a
Depending on how healing is progressing, dressing changes layer of Jelonet applied over it (top right). Gauze square dressings on top
thereafter should be every three to five days. If the Jelonet of the Jelonet (bottom left) are held in place with a Netelast type of
dressing has become adherent, it should be left in place to avoid dressing (bottom right)
damage to delicate healing epithelium. If Flamazine is used it
should be changed on alternate days. The dressing should be Dressing changes for burns
changed immediately if the wound becomes painful or smelly
x Use aseptic technique
or the dressing becomes soaked (“strike through”).
x First change after 48 hours, and every 3-5 days
Any burn that has not healed within two weeks should be thereafter
seen by a burn surgeon. x Criteria for early dressing change:
Excessive “strike through” of fluid from wound
Specialist dressings Smelly wound
Contaminated or soiled dressings
Many specialist dressings are available, some developed for Slipped dressings
specific cases, but most designed for their ease of use. The Signs of infection (such as fever)
following are among the more widely used.
B—Breathing
All burn patients should receive 100% oxygen through a
humidified non-rebreathing mask on presentation. Breathing Carbonaceous particles
staining a patient’s face after
problems are considered to be those that affect the respiratory
a burn in an enclosed space.
system below the vocal cords. There are several ways that a burn This suggests there is
injury can compromise respiration. inhalational injury
Airway Yes
C—Circulation
Compromised or at Intubate
Intravenous access should be established with two large bore risk of compromise?
cannulas preferably placed through unburnt tissue. This is an No
opportunity to take blood for checking full blood count, urea
Yes
and electrolytes, blood group, and clotting screen. Peripheral Breathing Cause:
Compromised? Mechanical Escharotomies
circulation must be checked. Any deep or full thickness Carboxyhaemoglobin Intubate and ventilate
circumferential extremity burn can act as a tourniquet, No
Smoke inhalation Nebulisers
especially once oedema develops after fluid resuscitation. This Circulation Non-invasive ventilation
Compromised perfusion Invasive ventilation
may not occur until some hours after the burn. If there is any to an extremity? Blast injury Invasive ventilation
suspicion of decreased perfusion due to circumferential burn, Chest drains
No Yes
the tissue must be released with escharotomies (see next article).
Profound hypovolaemia is not the normal initial response
to a burn. If a patient is hypotensive then it is may be due to Escharotomies
F—Fluid resuscitation
Investigations for major burns*
The resuscitation regimen should be determined and begun.
This is based on the estimation of the burn area, and the General
x Full blood count, packed cell volume, urea and electrolyte
detailed calculation is covered in the next article. A urinary
concentration, clotting screen
catheter is mandatory in all adults with injuries covering > 20% x Blood group, and save or crossmatch serum
of total body surface area to monitor urine output. Children’s
Electrical injuries
urine output can be monitored with external catchment devices x 12 lead electrocardiography
or by weighing nappies provided the injury is < 20% of total x Cardiac enzymes (for high tension injuries)
body area. In children the interosseous route can be used for Inhalational injuries
fluid administration if intravenous access cannot be obtained, x Chest x ray
but should be replaced by intravenous lines as soon as possible. x Arterial blood gas analysis
Can be useful in any burn, as the base excess is predictive of the
Analgesia amount of fluid resuscitation required
Superficial burns can be extremely painful. All patients with Helpful for determining success of fluid resuscitation and essential
large burns should receive intravenous morphine at a dose with inhalational injuries or exposure to carbon monoxide
appropriate to body weight. This can be easily titrated against *Any concomitant trauma will have its own investigations
pain and respiratory depression. The need for further doses
should be assessed within 30 minutes.
Investigations
The amount of investigations will vary with the type of burn. Indications for referral to a burns unit
All complex injuries should be referred
A burn injury is more likely to be complex if associated with:
Secondary survey x Extremes of age—under 5 or over 60 years
At the end of the primary survey and the start of emergency x Site of injury
Face, hands, or perineum
management, a secondary survey should be performed. This is
Feet (dermal or full thickness loss)
a head to toe examination to look for any concomitant injuries. Any flexure, particularly the neck or axilla
Circumferential dermal or full thickness burn of limb, torso, or neck
x Inhalational injury
Dressing the wound Any substantial injury, excluding pure carbon monoxide poisoning
Once the surface area and depth of a burn have been estimated, x Mechanism of injury
Chemical injury > 5% of total body surface area
the burn wound should be washed and any loose skin removed.
Exposure to ionising radiation
Blisters should be deroofed for ease of dressing, except for High pressure steam injury
palmar blisters (painful), unless these are large enough to High tension electrical injury
restrict movement. The burn should then be dressed. Hydrofluoric acid burn >1% of total body surface area
For an acute burn which will be referred to a burn centre, Suspicion of non-accidental injury
cling film is an ideal dressing as it protects the wound, reduces x Large size (dermal or full thickness loss)
Paediatric ( < 16 years old) > 5% of total body surface area
heat and evaporative losses, and does not alter the wound
Adult ( ≥ 16 years) > 10% of total body surface area
appearance. This will permit accurate evaluation by the burn x Coexisting conditions
team later. Flamazine should not be used on a burn that is to be Any serious medical conditions (cardiac dysfunction,
referred immediately, since it makes assessment of depth more immunosuppression, pregnancy)
difficult. Any associated injuries (fractures, head injuries, crush injuries)
included. This may take a few hours to fade, so some Right arm Left arm
= 9% = 9%
overestimation is inevitable if the burn is estimated acutely.
Head = 18%
Palmar surface—The surface area of a patient’s palm (including (front and back)
Back
fingers) is roughly 0.8% of total body surface area. Palmar surface = 18%
are can be used to estimate relatively small burns ( < 15% of total Chest = 18%
Perineum
surface area) or very large burns ( > 85%, when unburnt skin is = 1% Right arm Left arm
counted). For medium sized burns, it is inaccurate. = 9% = 9%
Resuscitation regimens 1
1
Fluid losses from the injury must be replaced to maintain
homoeostasis. There is no ideal resuscitation regimen, and 13 13
2 2 2 2
many are in use. All the fluid formulas are only guidelines, and
their success relies on adjusting the amount of resuscitation
fluid against monitored physiological parameters. The main 11/2 11/2 11/2 11/2
aim of resuscitation is to maintain tissue perfusion to the zone 1
2 /2 2 /2 1
11/2 1 11/2 11/2 11/2
of stasis and so prevent the burn deepening. This is not easy, as
too little fluid will cause hypoperfusion whereas too much will B B B B
lead to oedema that will cause tissue hypoxia. %
The greatest amount of fluid loss in burn patients is in the REGION PTL FTL
first 24 hours after injury. For the first eight to 12 hours, there is Head
a general shift of fluid from the intravascular to interstitial fluid C C Neck C C
compartments. This means that any fluid given during this time Ant. trunk
will rapidly leave the intravascular compartment. Colloids have Post. trunk
no advantage over crystalloids in maintaining circulatory 13/4 13/4 Right arm 13/4 13/4
volume. Fast fluid boluses probably have little benefit, as a rapid Left arm
rise in intravascular hydrostatic pressure will just drive more Buttocks
fluid out of the circulation. However, much protein is lost Genitalia
Right leg
through the burn wound, so there is a need to replace this
Left leg
oncotic loss. Some resuscitation regimens introduce colloid
Total burn
after the first eight hours, when the loss of fluid from the
intravascular space is decreasing.
AREA Age 0 1 5 10 15 Adult
Burns covering more than 15% of total body surface area in
A = 1/2 OF HEAD 91/2 81/2 61/2 51/2 41/2 31/2
adults and more than 10% in children warrant formal
B = 1/2 OF ONE THIGH 23/4 31/4 4 41/2 41/2 43/4
resuscitation. Again these are guidelines, and experienced staff
C = 1/2 OF ONE LOWER LEG 21/2 21/2 23/4 3 31/4 31/2
can exercise some discretion either way. The most commonly
used resuscitation formula is the Parkland formula, a pure
crystalloid formula. It has the advantage of being easy to Lund and Browder chart
the deeper layers of the dermis but not through the entire
dermis.
Diagram of the different burn depths
Estimation of burn depth
Assessing burn depth can be difficult. The patient’s history will
give clues to the expected depth: a flash burn is likely to be
superficial, whereas a burn from a flame that was not rapidly
extinguished will probably be deep. On direct examination,
there are four elements that should be assessed—bleeding on
needle prick, sensation, appearance, and blanching to pressure.
Bleeding—Test bleeding with a 21 gauge needle. Brisk
bleeding on superficial pricking indicates the burn is superficial
or superficial dermal. Delayed bleeding on a deeper prick
suggests a deep dermal burn, while no bleeding suggests a full
thickness burn.
Sensation—Test sensation with a needle also. Pain equates
with a superficial or superficial dermal burn, non-painful
sensation equates with deep dermal injury, while full thickness Full thickness burn in a black patient. In a white patient with extensive
injuries are insensate. However, this test is often inaccurate as burns, such full thickness burns can easily be mistaken for unburnt skin
oedema also blunts sensation.
Appearance and blanching—Assessing burn depth by Assessment of burn depth
appearance is often difficult as burns may be covered with soot
or dirt. Blisters should be de-roofed to assess the base. Capillary Burn type
refill should be assessed by pressing with a sterile cotton bud Superficial Deep Full
Superficial dermal dermal thickness
(such as a bacteriology swab).
Bleeding on Brisk Brisk Delayed None
x A red, moist wound that obviously blanches and then rapidly
pin prick
refills is superficial
Sensation Painful Painful Dull None
x A pale, dry but blanching wound that regains its colour
Appearance Red, Dry, whiter Cherry red Dry, white,
slowly is superficial dermal glistening leathery
x Deep dermal injuries have a mottled cherry red colour that
Blanching to Yes, brisk Yes, slow No No
does not blanch (fixed capillary staining). The blood is fixed pressure return return
within damaged capillaries in the deep dermal plexus
x A dry, leathery or waxy, hard wound that does not blanch is
full thickness. With extensive burns, full thickness burns can
often be mistaken for unburnt skin in appearance. Key points
Most burns are a mixture of different depths. Assessment of x Accurate assessment of burn area is crucial to calculate
depth is important for planning treatment, as more superficial resuscitation formula
burns tend to heal spontaneously whereas deeper burns need x Resuscitation formulas are only guidelines—monitor the patient
surgical intervention, but is not necessary for calculating x Discuss resuscitation with a burns unit
x Be aware of the need for escharotomies
resuscitation formulas. Therefore, in acute situations lengthy
x Burn depth is difficult to estimate and changes with resuscitation
depth assessment is inappropriate. A burn is a dynamic wound,
and its depth will change depending on the effectiveness of
resuscitation. Initial estimates need to be reviewed later.
Shehan Hettiaratchy is specialist registrar in plastic and reconstructive Further information
surgery, Pan-Thames Training Scheme, London; Remo Papini is x Clarke J. Burns. Br Med Bull 1999;55:885-94
consultant and clinical lead in burns, West Midlands Regional Burn x Herndon D. Total burn care. 2nd ed. London: WB Saunders, 2002
Unit, Selly Oak University Hospital, Birmingham. x Kao CC, Garner WL. Acute burns. Plast Reconstr Surg 2000;105:
2482{93
The ABC of burns is edited by Shehan Hettiaratchy; Remo Papini; x Yowler CJ, Fratianne RB. The current status of burn resuscitation.
and Peter Dziewulski, consultant burns and plastic surgeon, St
Clin Plast Surg 2000;1:1-9
Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital,
x Collis N, Smith G, Fenton OM. Accuracy of burn size estimation
Chelmsford. The series will be published as a book in the autumn.
and subsequent fluid resuscitation prior to arrival at the Yorkshire
Competing interests: RP has been reimbursed by Johnson & Johnson, Regional Burns Unit. A three year retrospective study. Burns 1999;
manufacturer of Integra, and Smith & Nephew, manufacturer of Acticoat 25: 345-51
and TransCyte, for attending symposiums on burn care.
x Burnsurgery.org (see www.burnsurgery.org)
BMJ 2004;329:101–3
Treatment
Flame injury showing all burn depths
Epidermal burns
By definition these affect only the epidermis and are typified by
sunburn. Blistering may occur but is not common. Supportive
therapy is usually all that is required, with regular analgesia and
intravenous fluids for extensive injuries. Healing occurs rapidly,
within a week, by regeneration from undamaged keratinocytes
within skin adnexae.
Timing of surgery
Ideally, all wounds should have epithelial cover within three
weeks to minimise scarring, but in practice the decision whether Thick and thin split skin grafts
to refer a patient must be made by day 10 to achieve this.
The burn eschar is shaved tangentially or excised to deep
fascia. From the surgical viewpoint, the best time to graft burns
is within five days of injury to minimise blood loss, and injuries
that are obviously deep at presentation must be referred early.
With major burns, treatment is skewed towards preservation
of life or limb, and large areas of deep burn must be excised
before the burnt tissue triggers multiple organ failure or
becomes infected. In such cases more superficial burns may be
treated with dressings until healing occurs late or fresh skin
donor sites become available.
The ideal covering is split skin autograft from unburnt areas.
Thickness is usually tailored to the depth of excision to obtain
good cosmesis, although thinner grafts are thought to contract
Meshed graft
more. Donor sites should ideally be harvested adjacent to the
injury to improve colour match, and sheet graft is preferred to
improve the cosmetic result.
If donor sites are sparse, however, or the wound bed is likely
to bleed profusely (because excision is carried out late, for
instance) then the graft is perforated with a mesher to allow
expansion. Although this improves graft “take” where the
wound bed is bleeding after tangential excision, the mesh
pattern is permanent and unsightly. Unmeshed sheet graft is
used on hands and faces, and over any future site for
intravenous central lines and tracheostomies to obtain rapid
cover. Where unburnt split skin donor sites are in very short
supply, there are two possible solutions:
x Rotation of donor sites is practised, and unexcised burn
covered with antimicrobial creams
x The excised wound is resurfaced with a temporary covering
until donor sites have regenerated and can be re-harvested.
Examples of a temporary covering are cadaveric allograft
from an unrelated donor, xenograft (such as pigskin), synthetic
products, and cultured epithelial autograft. Development of Persistent mesh pattern in patient whose extensive
synthetic products (such as Integra dermal regeneration burns were covered with meshed skin grafts
Major burns
These include injuries covering more than 20% of the total
body surface area, and represent a real challenge to burn
Top: Deep dermal
surgeons. Survival depends on accurate assessment and prompt injury from bath scald.
resuscitation initially, as well as on patients’ premorbid Bottom: Six weeks after
conditions and associated injuries such as smoke inhalation. tangential excision and
grafting with 3:1 mesh
Subsequently, constant attention to wound cleanliness and to
and cultured epithelial
nutritional, respiratory, cardiovascular, and renal support is autograft in suspension.
necessary. Relentless but carefully timed removal of burnt tissue Note biopsy site for cell
and replacement with definitive wound cover is the key to survival culture on buttock
and return to function. Such injuries are best managed in large
centres where the necessary expertise is concentrated. Early
excision and grafting have been shown to reduce pain, shorten
hospital stay, and accelerate return to normal function in
moderate injuries. It is more difficult to show that this approach
improves survival in massive injuries because these are
uncommon and many factors other than surgery play a part.
Most major centres treating burns believe early aggressive
excision is the treatment of choice, and advances in intensive care
and the development of skin substitutes have facilitated this.
Summary
x Full thickness injuries have no regenerative elements left.
Unless they are very small they will take weeks to heal and
Major burn in elderly patient
undergo severe contraction. They should be referred for
surgery as early as possible.
x Deep dermal injuries are unlikely to heal within three weeks.
Depth assessed (appearance, bleeding, capillary refill, sensation)
The incidence of unsightly hypertrophic scarring rises from
33% to 78% if healing is delayed from three to six weeks.
Therefore these injuries should also be excised and grafted Superficial Superficial Deep partial Full
within the first 5-10 days. (epidermal) partial thickness thickness thickness
x Superficial wounds should heal by regeneration within two
weeks. They should be cleaned, dressed, and reviewed on Dress with tulle Dress with tulle Obvious deep Yes
alternate days to optimise the wound healing environment. Any gras and gauze if gras and gauze, dermal injury?
extensive until reassess at
burn not healed within two weeks should be referred for healed (usually 48 hours Requires surgery,
assessment. within 1 week) No preferably within
5 days, unless
x Clean wounds can be dressed with a non-adherent primary Likely to heal <1 cm2 in area in a
dressing such as tulle gras or Mepitel and an absorbent within 2-3 weeks? Dress with tulle non-essential area
secondary dressing such as gauze or Gamgee Tissue. gras and gauze,
reassess at 48 hours Signs of improvement
Antimicrobial agents are added where infection is likely
or healing?
(perineum, feet) or heavy colonisation is evident on the Yes No
Remo Papini is consultant and clinical lead in burns, West Midlands Low exudate? High exudate? No Yes
Regional Burn Unit, Selly Oak University Hospital, Birmingham.
May be suitable for Contaminated Requires surgery - Re-dress and review
The ABC of burns is edited by Shehan Hettiaratchy, specialist Hypafix; wash or signs refer to burns unit every 2 days
registrar in plastic and reconstructive surgery, Pan-Thames Training dressing daily and of infection?
Scheme, London; Remo Papini; and Peter Dziewulski, consultant take off with
burns and plastic surgeon, St Andrews Centre for Plastic Surgery and oil in 1 week Unhealed at
Burns, Broomfield Hospital, Chelmsford. The series will be published 2 weeks?
as a book in the autumn. No Yes
Competing interests: RP has been reimbursed by Johnson & Johnson, Continue with tulle gras or Bactigras Apply antimicrobials (such as silver
manufacturer of Integra, and Smith & Nephew, manufacturer of Acticoat and review every 2 days until healed sulfadiazine cream, antibiotics) Need to refer
and TransCyte, for attending symposia on burn care.
BMJ 2004;329:158–60 Algorithm for assessing depth of burn wounds and suggested treatment
Airway burns
The term “inhalational injury” has been used to describe the
aspiration of toxic products of combustion, but also more
generally any pulmonary insult associated with a burn injury. Patient with burns in intensive care unit. Note the bilateral slings raising the
Patients with cutaneous burns are two to three times more likely burnt hands, air fluidised mattress, warm air heater, haemofiltration, and
ventilator
to die if they also have lower airway burns. Death may be a
direct result of lung injury but is usually due to the systemic
consequences of such injury. It may be impossible to distinguish
lung injury caused at the time of the burn directly to the lungs Warning signs of airway burns
by a burn from injury due to the systemic consequences of the Suspect airway burn if:
burn. x Burns occurred in an enclosed space
Diagnosis of lower airway burns is largely based on the x Stridor, hoarseness, or cough
x Burns to face, lips, mouth, pharynx, or nasal mucosa
patient’s history and clinical examination. Clinicians should
x Soot in sputum, nose, or mouth
have a high index of suspicion of airway burns in patients with x Dyspnoea, decreased level of consciousness, or confusion
one or more of the warning signs. Special investigations will x Hypoxaemia (low pulse oximetry saturation or arterial oxygen
support clinical suspicion. However, severity of injury or tension) or increased carbon monoxide levels ( > 2%)
prediction of outcome is not aided by additional tests. Onset of symptoms may be delayed
The pathophysiology of airway burns is highly variable,
depending on the environment of the burn and the incomplete
products of combustion. The clinical manifestations are often
delayed for the first few hours but are usually apparent by 24 Mechanisms of pulmonary insult after lower airway burns
hours. Airway debris—including secretions, mucosal slough, and x Mucosal inflammation x Ciliary paralysis
smoke residue—can seriously compromise pulmonary function. x Mucosal burn x Reduced surfactant
There is no specific treatment for airway burns other than x Bronchorrhoea x Obstruction by debris
ensuring adequate oxygenation and minimising iatrogenic lung x Bronchospasm x Systemic inflammatory response
insult. Prophylactic corticosteroids or antibiotics have no role in
treatment.
Control of the airway, by endotracheal intubation, is
essential before transporting any patient with suspected airway
burn. Rapid fluid administration, with inevitable formation of
oedema, may lead to life threatening airway compromise if
control of the airway is delayed. Endotracheal intubation before
oedema formation is far safer and simpler. Oxygen (100%)
should be given until the risk of carbon monoxide toxicity has
been excluded, since high concentrations of oxygen will clear
carbon monoxide from the body more rapidly than
atmospheric concentrations. Importantly, carbon monoxide
toxicity may result in a falsely elevated pulse oximetry
saturation.
Airway burns are associated with a substantially increased
requirement for fluid resuscitation. Reducing the fluid volume
administered, to avoid fluid accumulation in the lung, results in
a worse outcome. Invasive monitoring may be required to guide
fluid administration, especially with failure to respond to
increasing volumes of fluid. Adequate oxygen delivery to all the
tissues of the body is essential to prevent multi-organ failure. Bronchoscopy image showing mucosal inflammation
Pathogenesis
Sites of potential infection in a burns patient
The burn injury destroys surface microbes except for Gram
positive organisms located in the depths of the sweat glands or
hair follicles. Without prophylactic use of topical antimicrobial
agents, the wound becomes colonised with large numbers of
Gram positive organisms within 48 hours. Gram negative
bacteria appear from three to 21 days after the injury. Invasive
fungal infection is seen later.
The microbiology reflects the hospital environment and
varies from centre to centre. In general there has been a change
in the main infective organisms over time from haemolytic
streptococci to resistant Gram negative organisms including
pseudomonas, resistant Gram positive organisms, and fungi.
Burns reconstruction
Juan P Barret
Patient-surgeon relationship
The relationship between a burns patients and a reconstructive
burn surgeon is normally long lasting, often continuing for a
lifetime. Patients not only require a surgeon’s professional
expertise, but also time, a good dose of optimism, and
compassion.
The initial meeting is one of the most important events. The
patient presents a set of problems, and the reconstructive surgeon
has to evaluate these and the patient’s motivation for surgery and
psychological status. We have to remember, though, that the
patient will also evaluate the surgeon’s attitude and conduct.
Although deformities or chief complaints will often be
apparent and ready for surgery, it is preferable to have further
visits before surgery, to allow new queries to be addressed and
unhurried preparation for surgery. Photographic workup is
extremely important to assist in definitive preoperative
planning and for documentation.
Patients need frequent reassurance. A reconstructive
surgeon needs to know a patient’s fears and feelings as the
reconstructive plan goes on. A burn reconstruction project
commonly requires more than 10 operations and many clinic
visits over a long period before a final assessment is made. In
the case of a small child, this may take more than 18 years.
Patients’ feelings and impressions must be addressed
continuously, and any trouble, minor disappointment, or
depression detected early and treated as needed.
Surgical procedures
Burn reconstructive surgery has advanced in recent decades,
though not as dramatically as in other areas of plastic surgery.
For many years, burn reconstructive surgery comprised Incisional release of a severe neck contracture. Scar releases leave substantial
tissue losses that require extensive skin autografting. Although scar release
incisional or excisional releases of scars and skin autografting.
is still the first choice for some difficult contractures, flap reconstruction and
Nowadays, however, the first approach that should be mobilisation of adjacent tissues should be attempted to decrease the size of
considered is use of local or regional flaps. These provide new the defect to be grafted
Further reading
x Herndon DN, ed. Total burn care. 2nd ed. London: WB Saunders, 2002 x Barret JP, Herndon DN. Color atlas of burn care. London: WB
x Engrav LH, Donelan MB. Operative techniques in plastic and Saunders, 2001
reconstructive surgery. Face burns: acute care and reconstruction. London: x Brou JA, Robson MC, McCauley RL. Inventory of potential
WB Saunders, 1997 reconstructive needs in the patient with burns. J Burn Care Rehabil
x Achauer BM. Burn reconstruction. New York: Thiene, 1991 1989;10:555-60
Pain control
In order to achieve desired outcomes and movement habits,
ensuring adequate pain control is important. The aim of
analgesic drugs should be to develop a good baseline pain
control to allow functional movement and activities of daily
living to occur at any time during the day. The use of combined
analgesics such as paracetamol, non-steroidal anti-inflammatory
drugs, tramadol, and slow release narcotics reduces the need for
increasing doses of narcotics for breakthrough pain. Codeine
should be avoided if possible because of its negative effects on
gut motility. Other pain control methods that may be helpful
include transcutaneous electrical nerve stimulation (TENS).
Inhalational injury
Aggressive, prophylactic chest treatment should start on
suspicion of an inhalational injury. If there is a history of burn Functional use of a positive expiratory pressure device
in a closed space or the patient has a reduced level of to improve breathing mechanics (top) and practising
consciousness then frequent, short treatments should begin on activities of daily living to exercise a burnt limb
(bottom)
admission. Treatment should be aimed at removing lung
secretions (oedema), normalising breathing mechanics, and
preventing complications such as pneumonia.
Initial treatment should include:
x Normalisation of breathing mechanics—such as using a
positive expiratory pressure device, intermittent positive
pressure breathing, sitting out of bed, positioning
x Improving the depth of breathing and collateral alveolar
ventilation—such as by ambulation or, when that is not possible,
a tilt table, facilitation techniques, inspiratory holds.
Oedema management
Strengthening exercise for a patient who had sustained a high tension
Oedema removal should be encouraged from admission. The
electrical flash burn to the right upper limb and right lateral trunk.
only body system that can actively remove excess fluid and Rehabilitation to restore function focuses on upper limb strength and trunk
debris from the interstitium is the lymphatic system. Oedema core stability
Scar management
Scar management relates to the physical and aesthetic
components as well as the emotional and psychosocial
implications of scarring.
Hypertrophic scarring results from the build up of excess
collagen fibres during wound healing and the reorientation of
those fibres in non-uniform patterns.
Keloid scarring differs from hypertrophic scarring in that it
extends beyond the boundary of the initial injury. It is more
common in people with pigmented skin than in white people.
Scarring is influenced by many factors:
x Extraneous factors—First aid, adequacy of fluid resuscitation,
positioning in hospital, surgical intervention, wound and Example of hypertrophic scarring
dressing management
x Patient related factors—Degree of compliance with
rehabilitation programme, degree of motivation, age,
pregnancy, skin pigmentation.
Management techniques
Pressure garments are the primary intervention in scar
management. Applying pressure to a burn is thought to reduce
scarring by hastening scar maturation and encouraging
reorientation of collagen fibres into uniform, parallel patterns
as opposed to the whorled pattern seen in untreated scars.
Garments need to be tailored to patients’ requirements and
are often influenced by the type of surgery completed. Patients
should generally be measured for garments at five to seven days
after grafting surgery, and these should be fitted as soon as they
are available. A pressure garment lasts for about three months;
after that time it is helpful to re-measure patients frequently to
accommodate the changing dimensions of the scar.
If people have moderate to severe burns around the neck or
face, an acrylic face mask must be considered. This provides
conforming pressure over the face and neck. Material masks Acrylic face mask providing conforming pressure over
can also be made for patients to wear at night. burns to the face and neck
Outpatient follow up
A burns unit team should offer outpatients regular and
comprehensive follow up reviews. The type of follow up
required obviously depends on the severity of the burn, but in
terms of movement and function, patients require regular
monitoring and updating of their prescribed exercise regimen
and home activity programme.
Therapists who do not regularly treat burns patients require
experienced support to achieve the expected outcomes. This
should include written, verbal, and visual communications as
well as monitoring of management plans.
Conclusion
The rehabilitation of burns patients is a continuum of active
therapy. There should be no delineation between an “acute
phase” and a “rehabilitation phase”—instead, therapy needs to
start from the day of admission (and before if possible).
Education is of paramount importance to encourage patients to
accept responsibility for their rehabilitation. A consistent
approach from all members of the multidisciplinary team
facilitates ongoing education and rehabilitation.
Pain control
Both procedural and background pain can be challenging for
patients and staff. Some patients report that procedural pain is
easier to cope with because of its transient nature, whereas with
background pain there is no clear end in sight. It is important
to conduct a thorough pain assessment in order to determine
which type of pain is the greatest problem.
A pain treatment plan that provides pharmacological and
non-pharmacological approaches should be established. Opioid
agonists are the most commonly used analgesics. Long acting
opiates are used for background pain, and short acting opiates
are used for painful procedures such as wound care. It is crucial
that drugs for background pain are provided on a fixed dose
schedule to maintain control of the pain. Opioid analgesics may
be supplemented with other drugs, including inhaled nitrous
oxide and anxiolytics. Lorazepam has recently been found to
lessen burn pain, largely by treating acute anxiety.
Non-pharmacological pain control techniques include
cognitive{behaviour therapy and hypnosis. These have been
shown to be effective in treating procedural pain. One exciting
new distraction technique is virtual reality. Since attentional
focus is limited and a person cannot attend to more than one
stimulus at a time, virtual reality creates a realistic environment
for patients to absorb themselves in during painful procedures, A patient’s attention is taken up with “SnowWorld” via a water-friendly
thus taking focus away from the discomfort. virtual reality helmet during wound care in the hydrotub
Problems in management
Burn management in developing countries is riddled with
difficulties. Lack of government initiative and low literacy rates
preclude effective prevention programmes. Many uneducated
households are fraught with superstition, taboos, weird religious
rituals, and faith in alternative systems of “medicine,” which
complicates management.
Most burn centres are situated in large cities and are
inadequate for the high incidence of injuries. Resuscitation is
often delayed as patients have to travel long distances and
transport facilities are poor. Many burn centres are also plagued
with lack of resources, lack of operating time, and shortage of
blood. Often there are no dedicated burn surgeons, and general
surgeons without formal training are involved in burn care.
Burn nursing is also not a recognised concept. These conditions
Unsupervised use of fireworks by children during
make excisional surgery impossible for a large percentage of festivals such as Diwali increases the incidence of burns
patients. There is generally no coordination between district during the festival period
hospitals and tertiary burn centres.
Strategies for effective burn care in developing countries Burn management problems in developing
The approach to burn management has to be radically different countries
from that in Western countries.
x High incidence of burns
x Lack of prevention programmes
Prevention programmes x Inadequate burn care facilities
Prevention programmes should be directed at behavioural and x Lack of resources
x Lack of trained staff
environmental changes which can be easily adopted into
x Poor infrastructure and coordination
lifestyle. The programmes need to be executed with patience, x Social problems
persistence, and precision, targeting high risk groups.
Further treatment
Initial care is in the line of ABC of resuscitation. An adequate
airway and respiration must be ensured. All patients except
Rajeev B Ahuja is head of department and Sameek Bhattacharya is
those with minor burns must receive fluid resuscitation based
specialist in the Department of Burns, Plastic, Maxillofacial, and
on a simple formula. Wounds should be covered with a sterile Microvascular Surgery, Lok Nayak Hospital and associated Maulana
sheet until they are dressed. Dressings should be simple, with Azad Medical College, New Delhi, India.
only antimicrobial pads and Gamgee Tissue. Effort should be The ABC of burns is edited by Shehan Hettiaratchy, specialist
made to detect and treat associated injuries. registrar in plastic and reconstructive surgery, Pan-Thames Training
Secondary triage may also be done at this time. If necessary, Scheme, London; Remo Papini, consultant and clinical lead in burns,
seriously injured patients can be sent to centres of higher West Midlands Regional Burn Unit, Selly Oak University Hospital,
Birmingham; and Peter Dziewulski, consultant burns and plastic
level while less serious patients who reach the tertiary centres surgeon, St Andrew’s Centre for Plastic Surgery and Burns,
are referred back to primary care centres. The success of Broomfield Hospital, Chelmsford. The series will be published as a
such a plan lies in accurate triage at every level, so that all book in the autumn.
centres are used optimally and best possible treatment is Competing interests: See first article for series editors’ details.
delivered to all according to the severity of injury, with
minimum delay. BMJ 2004;329:447–9
At the age of 18, I thought I had the best summer job possible,
working outside at the local marina, with the prospect of going
to college in a few months to become a nurse. In an instant
everything changed. While moving a boat on a trailer, a group
of us sustained electrical injuries when the mast hit a high
tension power line. I found myself fighting for my life in a burns
centre and mourning the loss of a friend. The physical healing
was gruelling and at times overwhelming for me and my family,
and the medical team was a great support for me. However, this
article focuses on the problems I faced once I left the hospital,
two and a half months later, because that was toughest part of
my journey.
My comments are both personal and from the perspective
of having been a burn nurse for over 13 years. It is a shared
story of healing the emotional scars of burn injuries because I
have learnt so much from others. One such person is Barbara
Kammerer Quayle, a fellow burn survivor and colleague I met
after I became a burn nurse. She taught me how healthcare
professionals could make a difference for survivors struggling
to regain a place in their family and society. Many of the
strategies I discuss are her life’s work and are used with her
permission. For some burn survivors these strategies are natural
responses, but for others they have to be learnt and practised.
Faulty assumptions
In his book The Body Image Workbook Thomas Cash states that it
is flawed thinking to assume that, simply because they notice
you, people will dislike you: “friendliness, kindness, and
conversational skills” are “more influential than whatever might
be different about your looks.” Instead, the truth is that “you are
the one noticing what you don’t like about your appearance.”
Other people usually do not care because they are thinking
about other things.
In the first months after my burn injury, I wore clothing to
hide my injuries and continually looked to see if people were
“looking” at me. People staring and seeing my scars became the
focus of my attention, and I felt uncomfortable in social settings.
I spent much of my energy worrying what others thought. Many
burn survivors have reported the same behaviour.
Cash also points out that “first impressions don’t always last”
and “our initial reactions to someone’s appearance are not
frozen forever in our minds.” A person may focus on a burn
survivor’s appearance initially. I consider this pretty normal.
When I meet another burn survivor for the first time, I often
take a few minutes to “get used to” the new and unique skin
patterns I am seeing. After we have established a relationship,
however, the burns become less important, and personal traits
such as intelligence, humour, integrity, and sensitivity are the
most defining characteristics. Often I forget exactly where a
person’s burns are located—which side of the face, which hand,
etc. By strengthening our social skills, we can overcome the
challenge of looking “different.”
So what do I do?
Barbara Quayle has developed some simple strategies to help
those with physical differences respond in a positive way to
questions and staring. By practising these strategies, many burn
survivors have become more comfortable in social settings.
These techniques are easily taught to patients before discharge
from hospital, and they should be part of the care plan for all
burn survivors.
“STEPS”
If you find yourself being stared at, Barbara suggests standing
up straight, looking directly into the person’s eyes, smiling, and,
with a friendly tone of voice, saying “Hi, how are you doing?” or
“Hi, how’s it going?” or even “Hi, great day, isn’t it?” Looking at