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Burns - Acute Management

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  • See also

    Burns - Post Acute Care and Dressings

    Key Points

    1. Burn injuries should be managed as a Trauma case requiring primary and secondary survey
    2. Accurate Total Body Surface Area (TBSA) estimation is essential for fluid resuscitation decision making. TBSA does not include epidermal burns
    3. Ensure adequate analgesia to facilitate assessment and patient comfort
    4. Appropriately consented photographs of the burn are very helpful for assessment and monitoring

    Background

    Specific features in children with burns

    • Children have thinner skin than adults, predisposing them to a deeper burn for any given temperature
    • Assessment of burn depth is difficult, especially early post injury
    • Young children are at risk of hypothermia, especially during initial cooling of the burn

    Burns are described as epidermal, dermal (superficial/mid/deep) and full thickness

    Assessment

    History of burn

    • Time of injury
    • Mechanism of injury, including circumstance for specific pattern of burn
      • Scald: estimated temperature and nature of the liquid
      • Contact: estimated temperature and nature of the surface
      • Friction
      • Flame / explosion: product that burned/exploded, location (enclosed vs. open space); duration of exposure, inhalation injury
      • Electrical: voltage, type of current (AC or DC), duration of contact
      • Chemical: type of product
      • Cold: direct contact with cold surface or exposure (frostbite)
      • Radiant: sunburn
    • First aid
      • Time started (was it within 3 hours and maintained)
      • Agents used
      • If clothes and jewellery were removed
      • Decontamination method (for chemical exposure)
    • Consider co-existing non-burn injuries
    • Consider non-accidental injury or vulnerable child
    • Tetanus status

    Examination and initial management

    Like all traumas paediatric burn assessments require a primary and secondary survey with the initial aim of identifying and managing immediate life threats: do not get distracted by the burn injury.

    Airway

    • Signs of airway burn/inhalation injury: stridor, hoarseness, black sputum, respiratory distress, singed nasal hairs or facial swelling
    • Sign of oropharyngeal burn: soot in mouth, intraoral oedema and erythema
    • Significant neck burn
    • If above present, consider early intubation
    • If suspicion of airway burns or carbon monoxide intoxication apply high flow oxygen
    • Protect the cervical spine with immobilisation if there is associated trauma

    Breathing

    • Full thickness and/or circumferential chest burns may require escharotomy to permit chest expansion

    Circulation

    • If early shock is present, consider causes other than the burn
    • IV fluid resuscitation as required
    • IV or IO access (preferably 2 points of access)
    • For circumferential burns check peripheral perfusion and need for escharotomy

    Disability

    • If altered conscious state, consider airway support
    • Assess neurovascular status if limb involved

    Exposure - burn assessment and initial management

    • Assessment of burn depth
      • Burns are dynamic wounds, it is difficult to accurately estimate the true depth and extent of the wound in the first 48-72 hours
      • Do NOT include area with epidermal burn (erythema only)

    Classification

    Depth

    Colour

    Blisters

    Capillary Refill

    Sensation

    SUPERFICIAL

    Epidermal

    Red

    No

    Brisk

    Present

    Superficial  Dermal

    Pale Pink

    Present

    Brisk

    Painful

               Mid   Dermal

    Dark Pink

    Present

    Sluggish

    +/-

    DEEP

             Deep   Dermal

    Blotchy Red

    +/-

    Absent

    Absent

    Full Thickness

    White

    No

    Absent

    Absent

    Assessment of TBSA

      • Expose whole body - remove clothing and log roll to visualise posterior surfaces
      • Use Lund & Browder Chart

        Burns - Access the extent and depth of the burn

      • The palmar surface of the child’s hand (including fingers) represents approximately 1% TBSA and can be used to approximate TBSA

        Burns - the palmar surface

    • First aid
      • Remove jewellery and clothing in contact with burn source
      • Cool affected area as soon as possible (within 3 hours from time of burn) for 20 minutes with cool running water
        • If unavailable, other options include: frequently changed cold water compresses, immersion in a basin, irrigation via an open giving set
        • Never apply ice and avoid use of hydrogel burn products
      • Cover burn with plastic cling film lengthways along the burn (do not wrap circumferentially)
        • Do not apply plastic cling film to face (use paraffin ointment)
        • Do not apply plastic cling film to a chemical burn
      • Discuss chemical burn decontamination with Poisons Information (Tel: 131126)
      • Appropriately consented photos of burns prior to dressings are useful for ongoing management
    • Prevent hypothermia
      • Remove wet clothes/dressings after initial cooling
      • Try to keep child otherwise warm
      • Cover the wound and the child after assessment
      • When possible, warm intravenous fluids and the room

    Fluid management in burns ≥10% TBSA

    • The Modified Parkland Formula provides a guide to resuscitation fluids to compensate for excess fluid losses in the first 24 hours after burn 
    • Calculate requirements from time of the burn, not time of presentation
    • Calculate resuscitation fluid requirements using Modified Parkland Formula (see below)
    • Hartmann’s Solution is the fluid of choice - if unavailable, use 0.9% sodium chloride
    • Insert urinary catheter for strict fluid balance
    • Keep nil by mouth and consider nasogastric tube - gastric ileus is a potential complication 
    • Prescribe intravenous maintenance fluids (see Intravenous fluids) until tolerating adequate oral/enteral intake


      Modified Parkland Formula


      Patients with delayed fluid resuscitation, electrical conduction injury and inhalation injury have higher fluid requirements. Discuss with specialist team

      Analgesia

      • Especially during cooling, dressing and mobilisation. See Acute Pain Management
      • Appropriate initial choices include intranasal fentanyl or IV morphine

      Initial investigations

      Major burn (≥10% TBSA)

      Haemoglobin, electrolytes, BGL, group and hold, VBG

      Multi trauma

      See Primary and Secondary survey 

      Suspected inhalation injury

      ABG for carbon monoxide

      Electrical burn

      ECG

      Burn wound management

      FACADE = First aid, Analgesia, Clean, Assess, Dress, Elevate

      General burn management             

      • Limit debridement to wiping away clearly loose/blistered skin
      • De-roof blisters with moist gauze or forceps and scissors if >5mm or crossing joints. See blister management
      • Clean burn wound and surrounding surface with saline or water
      • Reassess burn, take photos with appropriate consent
      • Apply appropriate occlusive non-adherent dressing. If these products are not available, refer to local Burns service for alternative options
      • If there is anticipated delay or time until definitive care, consider use of multiple layer BactigrasTM

      Location

      Depth

      Dressing

      Facial and perineal burns

      Epidermal or superficial dermal

      Apply white soft paraffin twice daily after cleaning face
      Chloramphenicol ointment to eye and ear burns
      Perineal burns are at risk of contamination – after bowel action, area should be cleaned with soapy solution; consider catheterisation

      Mid or deep dermal

      Consider silver-impregnated dressing (discuss with Burns service)

      Other body regions

      Epidermal

      May not require dressing
      Consider covering with protective, low-adherent dressing (e.g. MepitelTM, MelolinTM, BactrigrasTM) for comfort

      Mid or deep dermal

      Dressing product used depends on the expected duration required before removal or wound review

       Consider consultation with local paediatric team when

      • Suspected non-accidental injury, self-inflicted burns or assault
      • Multiple co-morbidities
      • Concern regarding ability to care for burns at home

      Consider transfer when

      Child requiring care beyond the comfort level of the hospital
      Following burns:

      • >10% TBSA
      • All full thickness
      • Special areas: face, ears, eyes, neck, hands, feet, genitalia, perineum or a major joint, even if <10%
      • Circumferential
      • Chemical
      • Electrical
      • Associated with trauma and/or spinal cord injury
      • All inhalation/airway
      • Children <12 months

      For emergency advice and paediatric or neonatal ICU transfers, see  Retrieval Services

      Special considerations

      Type of burn

      Consideration

      Circumferential deep burn (deep dermal or full thickness)

      Neurovascular compromise
      Elevate part of limb distal to burn
      Monitor colour, capillary refill time, temperature
      Escharotomy may be required

      Head and neck burns

      Nurse head up to reduce swelling and oedema

      Ocular burns (See Acute eye injuries in children)

      Signs include blepharospasm, tearing, conjunctivitis
      All facial burns should have assessment with fluorescein 2% eye drops to assess for corneal damage
      Treat with copious irrigation using 0.9% sodium chloride with topical anaesthetic in eye (unaffected eye upwards)

      • Up to 1 hour with acidic contamination or until pain stops
      • Up to 2 hours with alkaline contamination or until pain stops

      Topical chloramphenicol to prevent secondary infection
      Urgent paediatric ophthalmology review

      Limb burns

      Elevate the limb
      Monitor perfusion distal to burn

      Suspicion of associated Carbon monoxide (CO) poisoning, Cyanide poisoning

      Liaise early with Paediatric Burn Unit, Intensive Care and Poisons Information (Tel: 131126)

      Electrical injuries

      Liaise early with Paediatric Burn Service and Intensive Care
      Inspect for entrance/exit wounds
      Consider spinal precautions
      Risk of dysrhythmias - consider 24 hours ECG monitoring
      Monitor for elevated CK, urine haemoglobin and haemochromogen

      Chemical burns

      • Personal protective equipment for first aid givers should be worn (gloves, mask, gown, eye protection)
      • Remove contaminated clothing
      • Brush powdered agent off skin
      • Areas in contact with chemical should be irrigated with cool water
      • Irrigate to floor with appropriate drainage so contaminated water does not cause further injury

      Tetanus prone wounds

      Parent information

      Burns – medical treatment
      Burns – prevention and first aid
      Burns – rehabilitation

      Additional notes

      See individual State Burns and Trauma clinical information and mobile phone applications

      Last updated June 2020

    • Reference List

      1. Australian and New Zealand Burn Association Ltd (ANZBA) (2019).   Emergency Management of Severe Burns course manual (version 18).  (c) Copyright, Australian and New Zealand Burn Association.  Produced with permission.
      2. NSW Burns Transfer guidelines
        https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns-Transfer-Guidelines.pdf
      3. Queensland Paediatric burns Guideline: https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/guidelines/gdl-paediatric-burns.pdf
      4. South Australia Women’s and Children’s hospital Paediatric Burns Service guidelines http://www.wch.sa.gov.au/services/az/divisions/psurg/burns/documents/WCHN_paediatric_burns_service_guidelines_july-2018.pdf
      5. Trauma Victoria Paediatric Burns guideline file:///C:/Users/caseyv/Downloads/Burns%20guideline_V2%2016102017%20update%20poster%20201118.pdf