to reducing the depth of the burn , |
delaying optimal care . Many burns |
||||
BFAT is also very effective as an anal- |
units now encourage submission of |
||||
gesic . Laboratory animal studies and |
digital photographic images at the |
||||
detailed correlation of the outcome of |
time of contact to assist in accurate |
||||
burn injuries in children with optimal |
determination of TBSA so that cor- |
||||
BFAT have consistently demonstrated the superior efficacy of cold running |
rect advice can be given . Determination of burn depth |
||||
water over other forms of first aid |
is often more difficult in children |
||||
in promptly reducing the tempera- |
than in adults because of the for- |
||||
ture of the burnt area and helping to |
mer ’ s thinner skin , their inconsistent |
||||
reduce the need for skin grafting . 6 |
response to burn injury and differ- |
||||
While logically , BFAT should be |
ences in the appearance of the skin |
||||
used as soon as possible after the |
at different ages . The traditional |
||||
injury has occurred , experimental |
classification of burn injury based |
||||
and clinical evidence has demon- |
on degrees has long been replaced |
||||
strated its value up to three hours after injury . 7 Thus , if the patient presents to a GP within three hours of |
by the more practical , clinically focussed descriptions of whether the burn will heal within 7-10 days |
||||
a burn injury and has not had opti- |
( superficial ) or will not ( deep ). The |
||||
mal first aid , immediately provide |
likelihood of the depth of the burn |
||||
this in the practice . If cold running |
can be estimated based on the MOI : |
||||
water is not available , other forms |
sunburn ( see figure 6 ) tends to be |
||||
of cooling — such as a damp cloth or |
superficial , scalds are mixed depth |
||||
towel , cold water or saline spray — |
and flame or hot exhaust burns are |
||||
help ; however , these are not nearly |
deep to full thickness . |
||||
as effective and should be replaced |
On inspection , superficial burns |
||||
by cold running water as soon as this |
( of which the classic example is sun- |
||||
can be accessed . Do not use ice as |
burn ) typically exhibit marked ery- |
||||
this may cause frostbite and is more |
thema and cause significant pain . |
||||
likely to deepen the burn by causing |
The presence of any blisters indi- |
||||
vasoconstriction . |
cates at least an extension to the |
||||
In the uncommon scenario of a |
superficial dermis . Deep burns may |
||||
chemical burn injury , after taking appropriate personal precautions , brush away any dry powder and start irrigation with cold running water . An amazing variety of home remedies , ranging from butter to shoe polish , have been used to treat acute burn wounds with no scientific evidence to support their use and some |
Treatment and referral depend on percentage TBSA burnt and burn depth . |
||||
evidence to suggest they might |
enhance burn wound progression |
range from full-thickness to mid- to |
||||
|
and increase the risk of infection .
ASSESSMENT
IN any patient with a burn injury , there are two key pieces of information that will be crucial in determining the appropriate treatment
|
Figure 1 . Classical paediatric scald burn on day four post-injury . Note the typical distribution of the burn from a hot drink that has been pulled . This involves the face , neck , chest and upper abdomen . These burns are generally mixed depth , ranging from superficial to deep partial thickness . |
deep dermal burns . Full-thickness burns have a pale , waxy appearance and often associated charring . These are not painful because the nerve endings in the skin have been destroyed . Deep dermal burns are characterised by a mottled coloura- |
|||
and need for referral to a burns unit . |
tion , blanch and are painful on pres- |
||||
First , how much of the patient has |
sure . Most burns are mixed , with |
||||
been burnt ( percentage TBSA ), and |
careful clinical examination crit- |
||||
second , how deep is the burn ? Both |
ical to estimating burn depth and |
||||
require observational skills and some |
assisting in predicting burn wound |
||||
clinical acumen . Time spent examin- |
healing . Even experienced burn cli- |
||||
ing the patient to calculate the TBSA |
nicians have reported accuracy rates |
||||
and estimate the depth is generally |
that vary between 50 % and 70 %. 1 , 8 |
||||
well spent and will greatly assist in |
A wide variety of additional tech- |
||||
determining optimal management . |
nologies have therefore been studied |
||||
Calculating the TBSA in children |
to assist in predicting burn wound |
||||
is more difficult than in adults as |
healing potential , ranging from ther- |
||||
their body proportions change with |
mal imaging to multiple skin biop- |
||||
age . In infants , the head and neck |
sies subject to detailed histological |
||||
represent a much larger proportion |
analysis . Laser doppler imaging is |
||||
of the TBSA ( 18 % as opposed to 9 %) |
currently the only device approved |
||||
compared with an adult , with the |
by the US Food and Drug Adminis- |
||||
smaller lower limbs accounting for |
tration for the assessment of burn |
||||
the deficit . With each year of age , 1 % |
injuries , with an accuracy of up to |
||||
is taken from the head and neck and added to the growing lower limbs until the child reaches adult body |
96 % compared with clinician assessment alone . 8 Given the cost and size of the device , such technology is |
||||
proportions . This system , termed the |
currently confined to burns units . |
||||
‘ rule of nines ’ ( see figure 5 ), has been |
Future research using AI may enable |
||||
shown to be the most accurate and |
improved diagnosis based on photo- |
||||
simplest to use in conjunction with |
graphic images . |
||||
the child ’ s age and inspection of the |
Armed with an assessment of |
||||
burnt areas . |
burn area and depth , GPs are then be |
||||
Several apps can assist in calculation of the TBSA . These incorporate additional functionality once the patient ’ s age and weight have been added to facilitate the calculation of any IV fluids required . Alternatively , burns charts are readily available online or can be supplied by any |
Figure 2 . Acute contact burn of the hand , three hours post-injury . Note the blistering of the palms and the palmar aspects of thumb , indicating the burn is at least superficial dermal in depth . These burns are typically very painful . |
able to perform appropriate primary care and determine which patients need referral and which can be safely managed outside a burns unit .
INITIAL MEDICAL TREATMENT
ANY burn injury is a form of trauma
|
|||
state burns units . |
as any advice given relating to the |
of unnecessary or excessive IV flu- |
require transfer and admission to |
and should be initially managed |
|
Despite these aids , calculation |
need for resuscitation and admission |
ids , tissue oedema ( with deepening |
a burns unit . Similarly , underesti- |
as such , with the standard trauma |
|
of burn TBSA remains problematic , |
will only be as accurate as the data |
of the burn wound as a result ) and |
mate of the TBSA may lead to delays |
sequence ( see box 1 ). |
|
with over- and underestimates com- |
provided . Overestimates may lead to |
inappropriate allocation of scarce |
in resuscitation — again , potentially |
Resuscitation fluids should be |
|
mon . This has clinical implications |