BURNS (MINOR)

Introduction

Minor burns are a very common presentation to Emergency Departments and local clinics.

There is not an exact definition as to what constitutes a “minor” burn (as opposed to a
moderate or severe one), however in general terms a minor burn may be considered to have to
following characteristics:

● Are not extensive: arbitrarily this could be defined as <10 %, (10-20 % moderate,
>20% major)

● Do not require fluid resuscitation

● Are superficial (epidermal or superficial dermal) and not deep (mid-deep dermal or full
thickness)

● Do not involve “special” areas such as: Hands, Soles, Face, Perineum, Over joints,
Airway.

● Do not involve major secondary toxic or chemical complications, (e.g., bitumen or HFl
burns)

● Do not require special considerations, (e.g., electrical, radiation, chemical)

● There are no associated major comorbidities which would adversely affect the ongoing
management of the patient.

● The patient is not elderly or very young (extremes of age).

Minor burns can usually be treated in the Emergency Department, and the patient can then be
discharged home following follow-up arrangements.

There is substantial interregional variation in definitive dressings used for minor burns.

Clinical Assessment

As discussed in the Burns Introduction CPD Activity

Management

1. Immediate first aid:

● Immediate cooling of burns is an effective and safe method of reducing the

severity of tissue damage and relieving pain.

Current recommendations suggest that the best method is cool running water
(for up to 20 minutes).
 ● In the absence of a source of continuing running water, immersion in cool
water or wrapping in clean wet towels are good alternatives.

● Direct exposure to ice or ice water may cause harm (by tissue freezing) so is
not recommended. Ice needs to be first wrapped in a towel, then used as a
cooling agent.

● Excessively prolonged cooling to large burn areas should be avoided because of

the risk of the development of significant hypothermia, especially in the elderly
and the very young.

2. Analgesia:

Oral or parenteral analgesia is given, as clinically indicated.

Often simple oral analgesia is sufficient, however just because a burn is (medically)
“minor”, does not mean that it cannot be exceptionally painful!

Analgesia options include:

For mild to moderate pain:

● Paracetamol 1g orally 4 hourly prn (to a maximum dose of 4g per 24-hour

period)

If the oral and rectal routes are contraindicated, paracetamol can be given IV 1g
6 hourly

With or without:

● Oxycodone immediate release 5 to 10mg orally 4 to 6 hourly prn

For severe pain:

Morphine 2.5 to 5mg IV as an initial dose, then titrated to effect every 5 to 10 minutes
with further incremental doses of 2.5 to 5mg IV

In elderly patients or those with cardiorespiratory compromise, an initial morphine dose

of less than 2.5mg IV and incremental doses of 0.5 to 1mg should be considered.

Patients should be reassessed to determine if the dose has been effective or if there are
any adverse effects (especially sedation).

If morphine is contraindicated, consider fentanyl at 25 to 50 micrograms IV as initial

equivalent dose.

Intranasal fentanyl is a useful option for children

Dressings and debridement:

Useful further options include:

● Nitrous oxide
 ● Ketamine

In very distressed children or those with intellectual disability, ketamine may be

required to adequately assess and treat a burn.

3. Shave hair in and around the wound to about a 2 cm radius.

4. Wound debridement:

● Remove any foreign materials

● Remove any loose and non-viable skin / tissue with sterile scissors

5. Wound care:

Normal Saline or 0.1% aqueous Chlorhexidine irrigation:

● The wound should be irrigated to clear any foreign material or tissue debris.
This can be done with sterile saline or with aqueous chlorhexidine solution

Blistering:

● As a general rule blisters should be left intact to reduce the risk of infection.
The epithelium forms a biological protective barrier against infection to the
underlying wound.

● Larger blisters (>2.5 cm) or those overlying joints or where there will be
functional problems can be aspirated with a sterile needle.

● If the blister needs to be removed, then aspiration is better than “de-roofing” the
blister, (epidermal debridement), which causes more pain and patient distress.

● As the burn wound acutely evolves, wound review, especially in the early
stages, is required. Most blisters if not aspirated will eventually rupture, and it is
at this point that basic wound management principles dictate that all non-
adherent devitalized tissue is debrided.
 Typical appearance of a blister seen in superficial dermal burns

6. Initial primary Dressings:

See separate activity for facial burns considerations.

Burnshield:

Burnshield is useful for the immediate management of burns injury in the Emergency
Department for the purpose of analgesia. It is best used for the initial few hours of
analgesia rather than the ongoing management of the burn and has several advantages
over wet sterile saline dressings.

It is not suitable as a longer-term dressing, and it not generally used in children

with more extensive burns.

There is substantial interregional variation in definitive dressings used for minor

burns, but in general terms:

Epidermal burns:

● Soothing gels, such as Vaseline may be used.

Superficial dermal burns:

● Paraffin gauzes (e.g., jelonet tulle gras or if contaminated, bactigras)

OR

● Alginates

OR

● Silver preparations if the burn is contaminated or very extensive, Consideration

should also be given to the size of the burn even if only superficial dermal. The
risk of infection increases as the burn size increases. Therefore, silver dressings
should be considered for minor superficial burns with greater surface size.

Mid dermal/ deep dermal/ full thickness burns:

These should generally have a silver preparation dressing:

Silver Dressings options include:

● Silver sulfadiazine (SSD) cream:

● Acticoat (3 day or 7-day dressings are available)

7. Initial secondary layer dressings:

 Epidermal burns:

Purely epidermal burns do not require any secondary dressings.

Superficial dermal burns/ Mid dermal/ deep dermal/ full thickness burns:

Significant amounts of exudate can be produced in first 72 hours

● Absorbent secondary dressings such as gauze should be considered to manage

this excess exudate.

● Melolin ((non-absorbent film side to the wound)) can then be used to stop
exudate sticking to the outer most dressing.

8. Secure the primary/ secondary dressings with an outer holding dressing such as crepe
bandage, tubinet or tubigrip.

9. Tetanus immunoprophylaxis:

● Provide as clinically indicated

Disposition

Once treatment is completed in the ED, most patients will be able to be discharged and
followed up as outpatients.

A plastics or specialist burns unit consultation needs to be considered in cases of burns to any
of the “special areas” or those that are failing to heal (> 2 weeks - although it is preferable to
try and predict the need for plastics consult before this period, where possible).

Review may be by the local GP or in some cases, hospital review may be required, or more
appropriate in a specialized Dressings Clinic or Plastic Surgical Clinic or Specialist Burns
clinic depending on local expertise and practice.

Short admissions may be required in some cases such as:

● The elderly or very young

● Those with significant comorbidities whereby they would find difficulty in coping at
home.

● Those requiring specialist consultation/ review (e.g., Plastic Surgical Unit)

● Those with significant ongoing analgesia requirements.

 BURNS FACIAL

Introduction

Facial burns can be acutely life-threatening when there is significant associated airway burns
and inhalational injury.

Survivors can be left with devastating cosmetic scarring.

Fortunately, most facial burns encountered will be minor, but treatment will still present
special challenges and these burns are treated differently to minor burns in other areas of the
body.

Superficial burns of the face are best managed using an open method.

Pathophysiology

The most significant complication of facial / neck burns will be:

● Cosmetic damage

● Ocular damage

● Airway compromise

● Inhalational pulmonary injury

Superficial burns (epidermal and superficial dermal) of the face will usually take around 7 -10
days to heal.

Clinical assessment

The most critical initial assessment will be that of:

● The airway

● The potential for inhalational injury.

Severe full thickness facial and neck burns in a 12-year-old boy. Early intubation will be
required before life-threatening airway oedema occurs, (8x8 VAQ CD, AM Kelly et. al).

Investigation

There are no specific investigations required for facial burns unless there is a suspicion of
significant associated inhalational injury.

In these cases, the following should be considered:

1. ABGs

2. CO levels

● This can be done by co-oximetry, on the ABGs.

3. CXR

Management

1. Immediate assessment and management of any airway compromise will be the

priority.

● There should be close and repeated observation of any patient with the
potential for airway or inhalational injury.

● Patients with significant facial/neck/airway burns should be intubated

early, before airway compromise occurs.

2. First aid:

Water:

● Initial management is by simple running cold water where this is possible, or

sponging with cool water, which will provide initial pain relief, and help limit
burn damage.

Hydrogels:

● Hydrogel sheets (Burnshield or Burnaid) are cross-linked polymer gels in

sheet form. These are useful for initial first aid in providing pain relief.

3. Analgesia:

● Give analgesia as clinically indicated

● This may range from simple oral analgesia to parenteral opioid analgesia.

4. Initial wound management:

The wound needs to be kept moist, free of infection and comfortable. Facial dressings
are problematic, and an open method of management is preferred.
 Hair:

● Hair and its follicles harbour bacteria that can slow healing and predispose
to infection.

● Therefore, it is important to shave facial hair to the reduce microbial load.

● A disposable razor or clippers can be used to trim facial and scalp hair,
which should be removed from at least 2.5cm around the burn.

Chloramphenicol (eye) ointment:

● Superficial burns of the face are best managed using an open method.

● Where the burn is predominantly superficial dermal, topical antimicrobials such

as Chloramphenicol (eye) ointment or Tetracycline Eye Ointment (TEO)
should be applied twice or up to four times daily to the broken areas on the face
and neck as a thin layer.

This method of wound care uses antimicrobial agents twice a day to

minimize bacterial proliferation and fungal colonisation.

Topical antimicrobials should only be used for short times until healing is
progressing and the wound is clean.

Gel preparations:

● Gel based products, such as Vaseline (or other liquid paraffins) can be used
between these times to keep the face wound moist and comfortable.

● This can be applied as often as two hourly to minimize crusting.

5. Later management:

Cleansing:

● It is important to wash the burn with mild soap and/or running water to
remove any residue and allow the skin to breathe prior to reapplication of any
creams.

● Using a clean flannel may assist with removal of debris and residual
creams.

● This process can be as often as two hourly and washing frequency decreases as
exudate decreases.

Moisturisers:

● Once the wound has been epithelised, non-perfumed, hypoallergenic,

moisturisers, (e.g., unperfumed sorbolene) may be used until complete
healing has occurred.
6. Psychological support:

● This will also be an important consideration when significant facial

scarring has occurred.

Disposition

Facial burns should be reviewed within two to three days after initial management.

Facial burns are best reviewed by dedicated specialized burns or plastic surgical units.

Burns Unit referral:

Burns deeper than superficial dermal will require referral to a plastic surgeon or specialist
burns surgeon.