Key learning points
- Many small burns can be appropriately managed in the community, as long as sensible precautions of appropriate follow-up and diligent care are in place.
- All thermal burns must be given first aid: 20 minutes of cool water to help reduce the inflammatory process.
- Burn wounds change over the first few days and will need to be reviewed again by you or a doctor.
- All burns failing to heal within two weeks need to be referred on to the appropriate medical team.
Currently the World Health Organisation (WHO estimates that globally 180,000 deaths are caused annually by burns1. Around 1% of the population in the UK each year are affected in some way by a burn2. More than 75% of burns accidents in the UK occur at home2.
Patients do not always seek medical attention or delay in doing so, often trying to self-manage. Subsequently they may present to a pharmacy to assist with their care. Managing simple burns and being able to recognise those that need further medical treatment or monitoring is an important skill. This is a guide for management of simple burns.
Different types of burn
A burn is an injury to the skin caused by heat, electricity, radiation, friction or chemicals. This can affect all or just some of the layers of the skin.
The depth of burn injury describes the anatomical extent of tissue injury and is divided into partial and full thickness skin loss, with partial thickness burns being divided into superficial and deep types.
This classification quantifies the amount of tissue damage into anatomical terms.
- Erythema (first degree burns). Involves the epidermis only, usually with no blistering although desquamation (skin peeling) can occur later on. Heals quickly without scarring.
- Partial thickness (second degree burns). Involves the epidermis and a varying portion of the dermis.
- Superficial if sparing of significant proportion of hair follicles, sebaceous and sweat glands and substantial portion of dermis. These heal within 14 days with a low risk of scarring.
- Deep if there is destruction of large proportion of hair follicles, sebaceous and substantial portion of dermis. Takes over three weeks to heal and has a high risk of scarring.
- Full thickness (third degree burns). The of epidermis, dermis and all adnexal structures are destroyed. In general these will not heal without surgical intervention.
Only involve the epidermis. This is described as erythema, due to the release of inflammatory mediators following an injury causing hyperaemia, such as sunburn. Epidermal burns are often very painful, usually healing quickly and no blisters are present.
Moisturise regularly, especially with aloe vera lotion as it has some anti-inflammatory properties.
Superficial partial thickness burns:
Pale pink or red in appearance, the top layer of skin has been lost with blister formation. These injuries are very painful and tender to touch. The capillary refill time is brisk again. These heal within 14 to 21 days with a low incidence of scarring.
The actual depth of the burn is difficult to assess in the presence of blisters. Large blisters should referred on for medical attention. Small blisters can be left intact, the area cleaned and dressed with a non-adherent dressing and a secondary absorbent dressing to soak up any exudate. These should be reassessed at 24 to 48 hours to evaluate any burn depth progression. Burn wounds not healed by 14 days should have medical review.
Recognising deeper burns:
The defining signs are:
- mottled red, pale in colour or, if really deep, a white leathery appearance.
- reduced or absent sensation (again indicative of a deeper burn affecting the nerve endings).
- Delayed or absent capillary refill time with or without thrombosed vessels.
Any of these signs mean that the patient should be referred on or encouraged to seek medical attention. Deep partial thickness burns taking longer than three weeks to heal spontaneously have a high risk of unsightly and or disabling scarring.
If there is a small, full thickness burn smaller than a 10 pence piece in size, this is potentially manageable with dressings in the community, as these can be left to heal by secondary intention. Ensure there is a low threshold for onward referral for deeper injury.
What burns can be managed in the community?
The two types of burns seen and managed in the community will be a combination of epidermal and small superficial partial thickness burns. Patients with anything more severe should be advised to seek medical attention.
Initial burn management
- Remove clothing or jewellery covering the burn.
- First aid is crucial; the aim is to reduce the inflammatory process. It is recommended that 20 minutes of cool/tepid water is applied for thermal burns, which helps mediate the inflammation and subsequently prevents extension of the burn. This still shows benefit up to three hours following the injury.
- It is important to note that there are different burn gels available. These can be helpful with pain, though these should not be used instead of the initial first aid treatment.
- Assess the patient’s tetanus status, especially if it is a contaminated wound. It is important as they may require a booster or immediate protection with immunoglobulins. Check the NICE and WHO websites for guidance around this; here is a good flow chart.
- Leave any blisters intact, clean with saline or water.
- Provide simple analgesia for pain relief.
- If the patient is going straight to hospital, wrap the burn in cling film. Otherwise use a non-adherent dressing.
- The patient needs to have a wound check at 48 hours.
Check for signs of infection (redness, increasing pain, feeling unwell) and maintain adequate hydration. If referring to a doctor it is important to apply a simple non-adherent dressing. Silver dressings affect the appearance of the wound and make it difficult to assess. They can also stain clothing.
These are key features that warrant seeking a doctor’s advice; assume a low threshold.
- Burns greater than 1% in adults and any burns in small children (this does not include epidermal burns). The percentage burn is calculated by the area of the patient’s whole hand being equivalent to 1%.
- Failure to heal within two weeks.
- Specialised area burns (including hands, feet, face, perineum).
- Circumferential burns.
- Chemical burns.
- Electrical burns.
- Where you have concerns surrounding the mechanism of injury or un-witnessed injuries, especially in children or vulnerable adults.
Routine antibiotics are not recommended for burns. It’s important to bear in mind that patient can develop infection and subsequently sepsis from a burn.
If you have any concerns, contact the burns services in your area directly for telephone advice.
Emergency measures: toxic shock syndrome
This is a rare life threatening condition. Children are more at risk, following even a small burn. Symptoms include:
- a temperature greater than 38°C
- general unwellness
- low blood pressure
- decreased urine output
The child or adult must be sent straight to hospital. Call 999 if necessary.
Potential neglect or abuse
Consider this when the injury is un-witnessed:
- The stated mechanism of injury does not fit burn pattern.
- There is delayed presentation, especially in children or the elderly.
- Repeated small or simple burns – a frequent attender.
- Burns in a child that cannot walk or crawl.
- Intimate body burns.
- Concerns about the parent/child relationship when giving advice.
- You must consider the risk or possibility that the injury may have been caused by self-harm; this may require referral to mental health or social care services. Sometimes a self-harm injury can precede a suicide attempt.
- WHO website on burns www.who.org
- EMSB (Emergency Management of Severe Burns) course manual,
- London and South East Burns Network website: www.lsebn.nhs.uk
- Nice guidance on Tetanus
Justine Sullivan is a registrar in plastic surgery at the Burns & Plastic Surgery Unit, Broomfield Hospital, Chelmsford. Essex. Consultants Mr D Barnes and Mr P Dziewulski are co-authors.