Burns - Assessment

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Indications

Cutaneous burns

Contraindications (absolute in bold)

First aid incomplete

Alternatives

Nil

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Pain

Infection

Procedural hygiene

Standard precautions

Standard aseptic non-touch technique

PPE: sterile gloves

Area

Any treatment space appropriate to injury severity

Staff

Procedural clinician

Equipment

Gauze squares

Saline or chlorhexidine gluconate 0.2%

Positioning

Position of patient comfort

Medication

Consider oral medication 30-60 minutes prior to procedure (e.g.1g paracetamol, 400mg ibuprofen, 5mg oxycodone)

Consider intranasal fentanyl 1.5mcg/kg

Consider morphine IV 5-10mg or 0.1mg/kg repeated as required

Consider inhaled nitrous oxide

Assessing burns is often painful and requires pain relief

Sequence (estimating burn depth)

Assess the acute burn for the following features:

Colour: superficial burns are red, deep burns are variable, full-thickness burns are white or charred

Pain: superficial burns are painful, reducing to zero pain for dermal to full thickness burns

Exudate: epidermal burns are dry, dermal thickness are moist under blisters, full-thickness burns are dry

Blisters: blisters indicate at least dermal thickness burns (thicker walled blisters are deeper)

Sensation: pin-prick sensation is present for superficial burns, reducing to zero sensation for full thickness burns

Epidermal detachment: present in dermal burns with slight skin friction (Nikolsky sign)

Capillary refill: rapid for superficial burns, reducing with depth (no colour change on palpation for deep burns)

Photography: recommended to accompany all burns referrals

Sequence (estimate total body surface area of burn)

Epidermal burns (erythema only) are not included in the estimation

Age >10: use the Wallace rule of nines to estimate the total body surface area affected

Age <10: use the Paediatric Rule or Nines to estimate the total body surface area affected

At any age, the surface area of the patient’s palm and fingers is approximately 1% of total body surface area

These tools are available online:

www.vicburns.org.au/burn-assessment-overview/burn-tbsa

www.aci.health.nsw.gov.au/resources/burn-injury

Post-procedure care

Complete burns first aid and dressing, which includes (see separate guideline):

First aid, wound bed preparation, dressing

Consideration of burn centre referral

Consideration of tetanus toxoid

Ongoing pain relief

General burns advice

Arranging ongoing care and reassessment

Document assessment

Tips

Deep burns may be present under blisters (particularly hot oil burns)

Burns under blisters cannot be assessed without debriding the blister (see separate guideline on burns blisters)

Take care estimating total burn surface area, as this is often overestimated, impacting management

Discussion

Depending on the depth of tissue damage burn are classified as either:

Epidermal

Superficial dermal thickness

Mid-dermal thickness

Deep dermal thickness

Full-thickness

The extent and speed of capillary refill is the most useful clinical method to assess burn depth. Epidermal burns and superficial dermal burns are hyperaemic with intact capillaries and appear red with brisk capillary refill. Mid-dermal damage affects capillaries slowing capillary refill. Deep dermal injury causes extensive destruction of the dermal vascular plexus and may appear either pale (from vascular destruction) or very deep red (due to the extravasation of red blood cells from the damaged vessels). Such deep dermal injury will exhibit no colour change when pressure is applied and no or sluggish capillary refill. Full-thickness burns will often appear white with complete destruction of dermis and vascular plexus.

Intermediate burn depths are difficult to diagnosis accurately in the first few days following injury, with even experienced clinicians only correct two-thirds of the time. These wounds evolve and may deepen over 48 hours.

Wound reassessment of these burn wounds within 48 hours is essential and may be required repeatedly.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

ACI State-wide Burn Injury Service

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australia and New Zealand Burns Association. Resources. n.d. Available from https://anzba.org.au/resources/

Victorian Adult Burns Service at the Alfred. Burns management guidelines. Melbourne: Victorian Adult Burns Service; various dates. Available from: https://www.vicburns.org.au/burn-assessment-overview/burn-pathophysiology/

European Burns Association. European practice guidelines for burns care. Barcelona: European Burns Association; 2017. 147 pp. EBA – Guidelines – Version 4 2017. Available from: https://www.euroburn.org/wp-content/uploads/EBA-Guidelines-Version-4-2017.pdf

NSW Agency for Clinical Innovation. Burn patient management. 4th ed. Sydney: ACI; 2019. 36pp. Available from: https://www.aci.health.nsw.gov.au/networks/burn-injury/resources

NSW Agency for Clinical Innovation. Burn patient management: summary of evidence. 4th ed. Sydney: ACI; 2018. 19pp. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0016/250009/Burns-summary-of-evidence.pdf.

NSW Agency for Clinical Innovation. Minor burn management. 4th ed. Sydney: ACI; 2017 [updated 2019]. 10pp. Available from: https://www.aci.health.nsw.gov.au/networks/burn-injury/resources

Sydney Children’s Hospital Network. Burns management practice guideline. Sydney: SCHN; 2019. 58pp. Guideline 2006-8142 v6. Available from: https://www.schn.health.nsw.gov.au/_policies/pdf/2006-8142.pdf

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

eTG complete. Melbourne: Therapeutic Guidelines; 2019 Jan. Minor burns (retrieved 2019). Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=minor-burns

Harshman J, Roy M, Cartotto R. Emergency care of the burn patient before the burn center: a systematic review and meta-analysis. J Burn Care Res. 2019;40(2):166-188. doi:10.1093/jbcr/iry060

Singh V, Devgan L, Bhat S, Milner SM. The pathogenesis of burn wound conversion. Ann Plast Surg. 2007;59(1):109-115. doi:10.1097/01.sap.0000252065.90759.e6

Johnson RM, Richard R. Partial-thickness burns: identification and management. Adv Skin Wound Care. 2003;16(4):178-189. doi:10.1097/00129334-200307000-00010

Jaskille AD, Shupp JW, Jordan MH, Jeng JC. Critical review of burn depth assessment techniques: Part I. Historical review. J Burn Care Res. 2009;30(6):937-947. doi:10.1097/BCR.0b013e3181c07f21

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