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Abstract
Burns are a common injury in the UK. Most burns are limited in size and
depth and are therefore suitable for management in the community.
Primary care and non-specialist clinicians need to understand initial
assessment of the burn and when referral to a specialist burns unit is
indicated. Successful treatment of minor burns and ongoing care of
severe burns in the community requires careful selection of dressings
to support wound healing and achieve optimal outcomes for patients.
Authors
Martyn Butcher
Independent tissue viability and wound care consultant, Devon.
Correspondence to: m.butcher_woundcare@hotmail.com
Beverley Swales
Burns educator in Yorkshire and Humber.
Keywords
Burns, burns injuries, dressings, wound care
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Initial assessment
The skin is an effective, self-repairing barrier,
which provides protection from the external
environment. Burns range from those that are
minor and can be managed in the primary care
setting or even self-treated, to those that are severe,
significantly compromising the integrity and
protective function of the skin and necessitating
high levels of intensive care and multiple surgeries.
It is estimated that more than 250,000 people will
experience a burn in the UK each year, with 175,000
individuals attending an emergency department;
of these, 13,000 people will require hospitalisation
(Hettiaratchy and Dziewulski 2004a). However,
the number of people experiencing a burn may be
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Mechanism of injury
The mechanism of injury may provide clues
about the potential severity of the burn. A burn
can arise from many sources such as exposure to
heat, chemicals, friction, electricity and radiation.
Burns resulting from radiation are rare, with the
exception of ultraviolet light (sunburn) (Rawlins
2011). Generally, the higher the temperature of
the heat source and the longer the exposure, the
greater the damage to the skin and underlying
structures (Williams 2009). Damage may also
occur at temperatures as low as 48C, although
this may require exposure for five minutes (Rawlins
2011). Scald injuries are dependent on temperature,
volume and duration of the contact. The degree of
skin damage is related to the thickness of the skin
(Hermans 2005). Hot oil causes deeper burns than
water owing to its high temperature oil boils at
about 300C and water boils at 100C.
Burns resulting from exposure to flames
tend to cause deep damage because of the high
temperature involved, which is often in excess of
1,000C (Babrauskas 2006). Similarly, electrical
burns are likely to cause full-thickness injuries
(damage to all skin structures); heat is generated
as the electrical current passes through the tissue,
causing coagulation and cell death. The higher
the amperage the greater the damage (Sances et al
1981). This type of burn usually produces an entry
and exit point wound and may result in widespread
areas of damage within the affected tissues and
secondary injuries such as cardiac arrhythmias
(Senarath-Yapa and Enoch 2009).
With chemical burns, more than one reaction
may take place at the same time. Exposure of skin
proteins to some chemicals will incite an exothermic
reaction generating high levels of local heat (as
with phosphorus burns), and corrosive agents such
as acids and alkalis cause coagulative necrosis of
the tissues (Hettiaratchy and Dziewulski 2004b).
However, some chemicals, for example hydrofluoric
acid, produce a chemical reaction that may cause
local or systemic electrolyte imbalance, resulting
in local or systemic toxicity (Hettiaratchy and
Dziewulski 2004b). Even innocuous chemicals, such
as cement, can produce burns that may progress to
full-thickness skin loss if contact is maintained and
treatment is not administered (Dowsett 2002).
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Location of injury
The location and distribution of a burn can have a
significant effect on the patients ability to self-care,
particularly if the hands, feet or face are burned,
as well as long-term recovery and rehabilitation
(National Network for Burn Care (NNBC) 2012).
This may have a bearing on treatment and referral
to secondary or tertiary care environments. The
distribution of a burn may also raise questions
about the events surrounding the injury, and
may provoke suspicion of non-accidental injury
(Dubowitz and Bennett 2007, McGarry and
Simpson 2009).
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Full-thickness burns
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During
initial burns assessment patients who
present in the primary care setting. Following
presentation and assessment, the patient will
either be considered suitable for management
in the primary care setting or will need to be
referred or transferred to a specialist burns care
unit (NNBC 2012).
During
early (acute) burns treatment patients
considered suitable for management in the
primary care setting. Dressings that can provide
an appropriate environment to encourage healing
should be selected. Because the characteristics of
a burn wound can change over time, for example
exudate levels fall after 24-72 hours, it is necessary
to re-evaluate dressing selection.
During
post-stabilisation burns treatment
patients who have been assessed and/or
initially treated in a specialist burns unit and are
considered suitable for continuing management
in the primary care setting. These patients will
include those for whom healing of superficial
and partial-thickness burns is anticipated and
those who have deeper burns requiring
long-term wound management because existing
comorbidities mean they are not considered
suitable for reconstructive surgery (NNBC 2012).
Following
burns surgery patients who have
been discharged from a specialist burns unit
following reconstruction of a burn wound. These
patients may need dressings to manage skin graft
sites, skin graft donor wounds and possibly small
areas of non-healed burns.
BOX 1
National burns care referral guidance
Referral to a specialist burns unit should be made for:
Burns equal to or greater than 2% total body surface area (TBSA)
in children and 3% TBSA in adults.
All full-thickness burns.
All circumferential burns.
Any burn not healed in two weeks.
Any burn where there is suspicion of non-accidental injury (should be
referred for expert assessment within 24 hours).
The following factors should prompt a discussion with a consultant
in a specialist burns unit and consideration given to referral:
All burns to hands, feet, face, perineum or genitalia.
Any chemical, electrical or friction burn.
Any cold injury.
Any unwell or febrile child with a burn.
Any concerns regarding burn injuries and comorbidities that may
affect treatment or healing of the burn.
If the burn changes in appearance or there are concerns about healing,
then advice should be sought from a specialist burns care service. If there
is any suspicion of toxic shock syndrome, early referral is recommended.
(National Network for Burn Care 2012)
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Conclusion
Recognising the need to refer patients to a
specialist burns unit when necessary is essential.
However, burns are common and many can be
managed appropriately in the primary care setting.
Comprehensive and frequent wound assessment is
a prerequisite of optimal management. There is a
wide variety of dressings suitable for treating the
non-complex burn and it is the responsibility of the
clinician to select the dressing that best meets the
patients needs NS
Conflict of interest
This article was supported by Mlnlycke
Health Care
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