Chapter 31. Burns
The following information should be sought in all cases of burn injury:
• Time of the burn
• Burning agent
• Is the patient complaining of pain?
• Has the patient jumped or been involved in an explosion?
• Was the patient in a confined space?
• Has the patient lost consciousness at any time?
• A brief medical history, drug and allergy history (AMPLE)
• Tetanus status of the patient.
Simple erythema is a superficial burn with no skin loss, e.g. sunburn. The skin is red and tender; this heals in 5–10 days with no scarring.
Superficial partial-thickness burn
Blisters are thin-walled and the burn is extremely painful. The skin is red and moist with a granular appearance and the germinal layer is not penetrated; an example is a scald from boiling water. Healing takes 10–20 days and there is minimal scarring.
Deep partial-thickness burn
A deep partial-thickness burn can be produced, e.g. by boiling fat; it is deeper than the superficial partial-thickness burn and the blisters are thick-walled. The underlying skin is granular and white in appearance, with pinpoint red mottling; sensation may be dulled. Healing is by migration of epithelial cells from the edge of the wound or skin adnexa, which takes 25–60 days.
Deep full-thickness burn
Full-thickness burns are caused by prolonged contact with the burning agent or dry heat. The appearance is white, leathery or charred. Although the areas of full-thickness burn are painless, the depth of the burn is usually shallower around its margins and these areas will be painful. This burn affects the full thickness of the skin and may extend further into fat, muscle or bone; it does not heal. Treatment includes tangential excision and either skin graft or free flap repair, depending on the depth.
Types of burn
• Wet heat
• Dry heat
• Flash burns
• Chemical burns
• Electrical burns
• Radiation burns.
Extent of burn
It is important to assess the extent of the burn accurately. Methods include:
• The Lund and Browder chart (Figure 31.1) – this is more appropriate for in hospital use
|Figure 31.1 |
• The rule of nines for adults (Figure 31.2)
|Figure 31.2 |
• The rule of fives for children and infants (Figure 31.2)
• Using the approximation that the patient’s hand (flat with the fingers together) is equal to 1% of the patient’s body surface area
• Serial halving. Ask ‘Does the patient have 100% burns?’ If not, ‘Does the patient have 50% burns?’ and so on until an estimation is reached that reflects total body surface area burnt (excluding erythema).
As the time of exposure to the burning agent is increased, the severity of the burn increases
Burn sites with a poor prognosis are:
• Hands and feet
Facial burns are often associated with an inhalation injury
If there is a circumferential burn to the neck this can cause airway obstruction. Circumferential burns to the limbs produce constriction, causing oedema and distal ischaemia. A circumferential burn to the chest can lead to respiratory failure.