Depth of burns
Texture: Dry
Complications: None
Superficial Partial Thickness (2nd degree)
Texture: Moist
Texture: Leathery
Healing time: Months or incomplete
Source - https://www.tes.com/lessons/biv0S-
NCbEId0g/burns
Layers involved:
Texture: Dry
As can be see above, as well as the management of pain, you must also consider the risk of local
and systemic infection as well as the issue of fluid loss:
At temperatures above 44oc, proteins begin to break down causing cell damage (2). This
damages reduces the skin’s natural ability to prevent water loss through evaporation, and
ability to control body temperature (3) as such large area burns present secondary
complications of potential hypothermia. The last thing anyone would suspect with a heat
related injury!
Continued cellular breakdown causes cells to leak fluid out of the cells into the intracellular
spaces resulting in localised swelling.
Further inflammatory responses causes blood vessels to dilate, become porous and release
further fluid into intracellular spaces. (4) It is this shift in fluids which presents life
threatening conditions; in burns over 30% body surface area (5) this inflammatory response
can lead to sequelae* such as hyponatremia (low sodium levels), hyperkalaemia(high
potassium levels) and hypovolaemic shock and eventually death.
Coverage of Burn
Thermal burns (flame, contact, scalds) account for the majority of burns presented at A&E in the
UK (8). A meta-review of burns treatments conducted in 2010 provides comprehensive
guidance to the treatment of thermal burns(9).
Cold running water 2oc-15oc: Water temperatures below 15oc are most effective in
relieving pain and promoting wound healing. Water temperature should be limited to 2oc,
especially in large are burns, to reduce hypothermia.
Treatment should be maintained for at least 20 minutes for optimum effect. Beyond 20
minutes analgesia should be used for pain relief.
Treatment should be started a soon as possible. There is little benefit in wound healing if
cold running water is applied beyond 3 hours of the initial injury.
Burns should be covered with a non-fibrous, non stick dressing. Cling film is ideal in a
prehospital setting being relatively sterile and airtight. This reduces the chance of infection
and maintains a moist environment to aid wound healing (10-13). The cling film should be
applied loosely.
Do not use ice. Ice does not improve pain or wound healing compared to cold running
water but can cause tissue damage.
Do not use lotions or cremes. There is no better treatment than cold running
water. Antiseptic creams may have marginal benefit on minor burns. The determining
factor in wound healing is the clinical treatment at hospital rather than the first aid treatment
pre-hospital. Furthermore, oils and cremes present a barrier to the wound which will need
to be removed should medical treatment need to be applied in hospital. Neither the casualty
nor the nurse will appreciate your efforts when they are scrubbing the wound to remove the
product which has been applied.
Hydrogel Dressings
Several hydrogel dressings are available for the treatment of burns. These include “Water
Jel”, “Burnshield” and The residue of these water-based dressings are more easily removed
that oils or greases. They typically contain a small amount of aloe vera and are designed to
increase evaporative cooling. There is little evidence to their efficacy (9, 10) however they
are reported to soothe the burn; their effects are attributed to their anti-inflammatory,
antibacterial and antifungal properties. Hydrogel dressings have two important benefits is an
industrial or remote environment.
2. Hydrogel face dressings are more tolerable than 20 minutes of running water to a
facial injury.
Because of the evaporative cooling, hydrogel dressings should be limited to burns of >20%
TBSA in adults or >10% TBSA in children. (9)
Blisters serve a function; fluid leaking from damaged cells is retained under the
epidermis. This creates a protective environment for wound healing. Over time the fluid is
reabsorbed or the blister will burst in due course. The argument for not popping blisters is
that it interrupts the natural healing mechanism and increases the risk of infection.
The argument for popping blisters is that the increased fluid pressure within the blister can
increase pain and reduce joint mobility.
Our rational is this: If it is going to pop, pop it. If it is not going to pop, leave it. For
example, a blister the palm of a hand or heal of a foot is going to pop because these are high-
wear areas of the body, subject to rubbing and impact. It is safe to pop the blister in a
controlled, sterile manner and dress it appropriately than let it pop naturally, within a dirty
sock for example, where the risk of infection is greater. If it is not likely to pop due to
impact or damage, leave it. (14)
Hospitalization
The World Health Organization (15) provides the following guidance for determining hospital
referral for the treatment and management of serious burns.
Because of the complexities associated with the assessment and management of burns, we would
advocate referral to hospital if there is any concern.
References:
4. Brunicardi, Charles (2010). "Chapter 8: Burns". Schwartz's principles of surgery (9th ed.).
New York: McGraw-Hill, Medical Pub. Division.
6. Wachtel TL, Berry CC, et al. (March 2000). "The inter-rater reliability of estimating the size
of burns from various burn area chart drawings". Burns. 26 (2): 156–170.
7. Wachtel TL, Berry CC, et al. (March 2000). "The inter-rater reliability of estimating the size
of burns from various burn area chart drawings". Burns. 26 (2): 156–170.
9. Cuttle L & Kimble RM(2010) “First aid treatment of burn injuries”. Wound Practice and
Research. 18(1): 6-13
10. Tiong, W.H. (2012) “Emergency Burn Care in Practice: From first contact to operating
theatre” Burns – Prevention, Causes and Treatment. McLaughlin ES, Paterson AO (Ed.)
11. Hettiaratchy, S. and Dziewulski, P. (2004a) ABC of burns: introduction. British Medical
Journal 328(7452), 1366-1368
12. Settle, J.A.D. (Ed.) (1996) Principles and practice of burns management. Edinburgh:
Churchill Livingstone.
13. NZGG (2007) Management of burns and scalds in primary care. New Zealand Guidelines
Group. www.health.govt.nz
14. Shaw, J. & Dibble, C. (2006) "Management of burns blisters". Emergency Medicine
Journal. 23(8), 648–649.
15. World Health Organization (2007) “Management of Burns” WHO Surgical Care at the
District Hospital. WHO.