The current ATLS guidelines recommend that all deep-partial and full-thickness burns larger than 20% total body surface area (TBSA) are considered major burns that require resuscitation, while some other sources suggest a lower cut off of 15%.
The American Burn Association (ABA) has developed a useful classification system for burns, designating them as being either minor, moderate or major based primarily upon the depth and size of the burn.
Partial-thickness burns less than 10% TBSA in adults and less than 5% TBSA in children or older adults. Full-thickness burns must be less than 2% TBSA to qualify as a minor burn. These burns can usually be managed in the outpatient setting.
Partial-thickness burns less of 10-20% TBSA in adults or 5%-10% TBSA in children or the elderly. Full-thickness burns must of 2-5% TBSA are considered to be moderate burns. The moderate burns category also includes special types of burns regardless of the TBSA affected, including high-voltage injuries, suspected inhalational injury, circumferential injuries, and burns in patients who are immunosuppressed or predisposed to infection (e.g. sickle-cell disease, diabetes, cancer, immunosuppressive drugs). These patients are generally admitted to the hospital for their management but do not require initial fluid resuscitation.
Partial-thickness or full-thickness burns greater than 20% TBSA in adults or greater than 10% TBSA in children and the elderly. High-voltage burns, confirmed inhalational injury, significant burns to the face, eyes, ears, genitalia, or joints, and anyone with significant associated injuries such as a fracture or major trauma are also considered to be major burns. These patients usually require initial resuscitation and should be referred to a specialist burn centre.
Managing minor burns
Minor burns that do not require admission to hospital or referral to a specialist burns centre should be managed meticulously in the outpatient setting in order to minimise scarring, reduce risks of complications, and ensure the best possible cosmetic outcome. The three main aspects of minor burns management are:
- Initial first aid measures
- Cleaning of the burn
- Dressing of the burn
Initial first aid measures
The initial first measure should be to cool the burn by running the area under cool running water (2-15°C) for approximately 20 minutes. This process reduces soft tissue damage, encourages re-epithelialisation of the wound and reduces scarring. This should be undertaken as soon as possible but is an effective measure for up to 3 hours after the burn occurred.
Cleaning of the burn
Burns are at a high risk of subsequent infection due to damage to the epidermis removing the skins natural protective barrier to micro-organisms. All debris and contaminants should be removed by thoroughly irrigating the affected area with normal saline. Tap water is a suitable alternative and can also be used to irrigate the wound.
Blister management is somewhat controversial with some specialists advising that they are left intact and some recommending de-roofing and debridement. The blister provides a barrier to infection but also limits visualisation of the epithelium. The serous fluid within the blister may also impairing burn healing. Local guidelines should be followed, and specialist advice from a burn unit is advised.
Dressing of the burn
Many minor burns can be left open without a dressing applied. These should be managed with the use of topical emollient creams only (e.g. sorbelene). Partial-thickness and full-thickness burns generally require dressing to aid healing. Full-thickness burns will require excision and grafting unless they are less than 1 cm in diameter. Grafting is required within three weeks in order to minimise scarring.
For those burns that require dressings, there are a wide variety of different burns dressings available, and it is advised that local guidelines and protocols are followed. Commonly used dressings include hydrocolloid, silicon nylon, antimicrobial, polyurethane film and biosynthetic dressings. With appropriate wound management partial-thickness burns heal within around 10-12 days.
Other aspects of management
Other aspects of the management of minor burns include the following:
- Analgesia – unlike full-thickness burns, superficial and partial-thickness burns can be very painful as nociceptors are intact. Initially, intravenous analgesia with opiates may be necessary. Subsequently, management with simple oral analgesia, such as paracetamol and ibuprofen, is usually sufficient.
- Antibiotics – antibiotics should be reserved for the treatment of infection only and not used prophylactically. Initial first aid measures and the use of sterile dressings reduce the risk of infection considerably.
- Tetanus – tetanus status should be evaluated, and vaccination may be necessary
Referral to a specialist burns centre
Local referral guidelines should be followed and if there is concern about any burn a discussion with the specialist burns centre is advised. All complex injuries should be referred, including the following:
- Burns in patients under 5 years or over 60 years of age
- All burns on the face, hands, perineum, any flexure (including neck or axilla)
- All circumferential dermal burns or a full-thickness burn of the limb, torso or neck
- Inhalation injury
- Chemical burns affecting over 5% total body surface area burned (over 1% for hydrofluoric acid burns)
- Exposure to ionising radiation
- High-pressure steam injury
- High-tension electrical injury
- Suspected non-accidental injury in a child
- Patients with co-existing conditions, e.g. serious medical conditions (such cardiac dysfunction, diabetes, cancer or immunosuppression) pregnancy or associated fractures, head injury or crush injuries
- Burns affecting a large TBSA:
- Aged under 16 years: over 5% total body surface area burned
- Aged 16 years or older: over 10% total body surface area burned.
This will vary according to the patient’s location, access to a specialised burns clinic and the frequency of dressing changes required. In most cases, early follow up at 48-72 hours after the injury should be arranged. Any burn taking longer than 12-14 days to heal should be referred to a specialist burns centre for further assessment.
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