Ten Top Tips
Clinical Update TEN TOP TIPS Management of burn wounds
Other: • All burns with other injury • All burns with significant comorbidity or pregnancy
• All infected burns • Any other case that causes concern, discuss with local burn service.
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RECOGNISE THE IMPORTANCE OF FOLLOW-UP
Burns are dynamic wounds and can deepen in the first 72 hours, as demonstrated in seminal work by Jackson.[32]
This is especially
true of the partial thickness and deep dermal burns, where the tissue has the potential to heal or alternatively to progress to full thickness depth.[29]
There are number of local
(e.g. increased inflammation and impaired blood flow), systemic (e.g. hypovolaemia), and environmental (e.g. inappropriate wound management) factors that can lead to burn wound progression.[32] Due to the dynamic nature of burn wounds, a
follow-up review within 48 hours of the original injury is advised.[28]
At this stage, the true depth
of the burn should be apparent. Analgesic requirements should be
reviewed. As the burn wound heals, the nerve regeneration may cause an increase in wound pain and, therefore, an increase in analgesic requirements.[33]
further thermal damage or pigmentation changes to the affected area.[28]
• Scar management by way of pressure garments or silicone to alleviate physical discomfort and functional limitation.
• Psychological support to deal with trauma of burn injury and living with disfigurement.
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NON-ACCIDENTAL BURN INJURIES
Non-accidental burn injuries can present in any patient, but a high level of suspicion should be maintained by the clinician when assessing burns in small children[35]
[Figure 2], older
people, and vulnerable adult patients. Consider non-accidental injury if:
• The mechanism or pattern of injury described does not match the injury sustained.
• There is a delay in presentation. • There is inconsistency in history. • There are signs of other trauma. • There are certain patterns of injury (cigarette marks or bilateral “sock” or “shoe” scalds).
• Well-defined demarcation lines/ lack of splash marks.
Adults are also at risk of non-accidental Patients’ experience
of poor pain management can lead to non- concordance with therapy and heightened anxiety regarding dressing changes, which will delay healing and, as a result, increase the likelihood of scarring. The review should include assessment of the
appropriateness of the dressing. A good burns dressing, as suggested by Alsbjorn et al,[26]
supported by Selig et al, should:[34] • Maintain a moist wound environment • Be non-adherent, absorbent, and maintain close contact with the wound
• Be easy to apply and remove • Be painless on application and removal • Protect against infection Any burn wound not healed within 2 weeks should be referred to a specialist burns service for review.[25] Post-burn wound care is essential to burns management and involves: • Daily application of skin moisturiser for dry, flaky skin. This helps the often present pruritus.[26]
• Protection of healed areas from the sun with use of sun block for 6–12 months to prevent
and
injury, especially the elderly and other vulnerable people. Carers and clinicians should take a few minutes to really look at the injury and ask themselves if the injury matches the story. Where it does not, this can alert them to the possibility of potential neglect or abuse. Figure 3 shows a patient who was hoisted into
a bath. Carers stated that the patient screamed as soon as her skin touched the water. However, the buttocks have been fully submerged and the white waxy appearance and deeper cherry red areas to the buttocks and thighs suggest deeper and longer submersion.
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CLINICAL CONSIDERATIONS FOR SPECIFIC BURN TYPES
Electrical burns
• An electrocution injury can cause deep cutaneous burns, cardiac arrhythmias, limb loss, and serious systemic effects.[35]
• Domestic (low) versus industrial (high) voltage injury: • Low voltage electrical injuries will cause localised, deep burns and may initiate arrhythmias. • High voltage injury will cause severe tissue damage, penetrating through fat, muscle, and bone. Resulting muscle
Wounds International Vol 5 | Issue 1 | ©Wounds International 2014 |
www.woundsinternational.com REFERENCES cont.
21. Yapa A, Enoch S (2009) Management of burns in the community. Wounds UK 5(2): 38–48
22. Ong YS et al (2006) Meta-analysis of early excision in burns. Burns 32(2): 145–50
23. National Network for Burn Care (2012) National Burn Care Referral Guidance (1st edn). NNBC, London
24. Todd M (2011) Compression bandaging: types and skills used in practical application. Br J Nurs 20(11): 681–7
25. London and South East Burn Network (2010) Adult burn referral guidelines. LSEBN, London
26. Alsbjörn B et al (2007) Guidelines for the management of partial-thickness burns in a general hospital or community setting--recommendations of a European working party. Burns 33(2): 155–60
27. Hermans MH (2005) A general overview of burn care. Int Wound J 2(3): 206–20
28. Hudspith J, Rayatt S (2004) First aid and treatment of minor burns. BMJ 328(7454): 1487–9
29. Evers LH et al (2010) The biology of burn injury. Exp Dermatol 19(9): 777–83
30. Edgar D, Brereton M (2004) Rehabilitation after burn injury. BMJ 329(7461): 343–5
31. Saffle JR et al (2009) Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma 67(2): 358–65
“ Non-accidental burn injuries can present in any patient, but a high level of suspicion should be maintained by the clinician when assessing burns in small children, older people, and vulnerable adult patients.”
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