Burns (minor) Nurse Management Guidelines

Red Flag Exclusion Criteria

  • Child at risk of significant harm

  • Suspected non-accidental injury

  • Unplanned repeat ED presentation

  • Infant ≤ 12 months

  • High risk mechanism of injury

    • Confined space

    • Electrical injury

    • Chemical burn

    • Flash burn

    • Lightning strike

    • Airway and / or facial burns

    • Concomitant trauma

  • Stridor, sore throat, hoarse voice, sooty sputum

  • Burns to hands, feet, perineum, genitalia, over major joints or circumferential

  • Singed facial hair, eyebrows, eyelashes or nasal hair

  • Partial or full thickness burns in an adult ≥ 10% body surface area

  • Partial or full thickness burns in a paediatric ≥ 5% body surface area

  • Pregnancy with cutaneous burns

  • Significant co-morbidity

  • Immune suppression

  • History of workplace injury

  • Yellow or Red Zones observations or additional criteria outlined in the NSW Health Standard Observation charts

Additional observations

Additional history

  1. Establish mechanism of injury
    • How was the burn sustained
    • Date and time of burn

  2. First-aid treatment initiated prior to ED presentation
    • What was done

    • How long was it done for

    • Was clothing and / or jewellery removed

  3. Tetanus immunisation status

Management principles

  1. Jewellery (rings / watches etc.) must be removed from affected limb (cut jewellery if required)

  2. Limb should be elevated

  3. Continue or commence first-aid measures: cool burn with cool running water (not cold / ice) for at least 20 minutes. Cooling can be effective up to 3 hours after injury

  • DO NOT APPLY ICE TO BURNS EITHER DIRECTLY OR INDIRECTLY

  1. Provide analgesia as required according to pain scale. Refer to Pain (any cause) NMG

  2. For an epidermal burn only (e.g. minor sun burn), a suitable skin moisturiser (e.g. sorbolene cream) will usually suffice for treatment

  3. For mid-dermal, deep dermal or full thickness burns, consult with a medical officer and NSW Specialist Burns Unit prior to applying any cream or ointment

  4. Consider photographing burn injury after obtaining appropriate patient consent (see ACI State-wide Burn Injury Service Burn Patient Management 2014 p. 22)

  5. Cover burn with appropriate dressing as guided by ACI State-wide Burn Injury Service Minor Burn Management p. 9

  6. Consider consultation with a NSW Specialist Burns Unit for advice

  7. Document assessment finding, interventions and outcomes

References / further resources

  1. ACI Minor Burn Management: ACI State-wide Burn Injury Service Agency for Clinical Innovation, Sydney

  2. ACI (2014) Clinical Practice Guidelines: Burn Patient Management: ACI Statewide Burn Injury Service Agency for Clinical Innovation, Sydney

Contact Details for NSW Specialist Burns Units

Children’s Hospital Westmead (paediatric patients):

  • +61 2 9845 1850 (business hours)

  • +61 2 9845 1114 (after hours)

Concord Repatriation General Hospital (adult patients):

  • +61 2 9767 7775 (business hours)

  • +61 2 9767 7776 (after hours)

Royal North Shore Hospital (adult patients):

  • +61 2 9463 2111 (business hours)

  • +61 2 9926 7111 (after hours)

© Agency for Clinical Innovation 2021

Feedback