Burns and Scalds

Introduction | Classification | Clinical Presentation | Diagnosis | Management and Treatment | Prevention | When to Refer | References

Introduction

Burns and scalds are injuries to the skin caused by heat. Burns are usually caused by dry heat, such as fire, hot objects, or electricity, while scalds are caused by wet heat, such as hot liquids or steam. These injuries can range from minor to life-threatening, depending on the depth and extent of skin damage. Prompt and appropriate management is crucial to minimise complications and promote healing.

Classification

Burns and scalds are classified based on the depth of skin damage:

• Superficial (First-Degree) Burns: Affect only the epidermis, causing redness, pain, and swelling without blistering. These burns usually heal within a week without scarring.
• Partial-Thickness (Second-Degree) Burns: Extend into the dermis and are further classified into superficial and deep partial-thickness burns:
  • Superficial Partial-Thickness: Involve the upper dermis, with red, blistered, and very painful skin. Healing typically occurs within 2-3 weeks, often without scarring.
  • Deep Partial-Thickness: Extend deeper into the dermis, with pale, mottled, or white areas and reduced pain due to nerve damage. Healing can take more than 3 weeks, often resulting in scarring.
• Full-Thickness (Third-Degree) Burns: Destroy both the epidermis and dermis, extending into subcutaneous tissue. The skin may appear white, brown, or black, and the area is typically painless due to nerve destruction. These burns require surgical intervention and are prone to significant scarring and contractures.

Clinical Presentation

The clinical features of burns and scalds vary depending on the depth and extent of the injury:

• Superficial Burns: Red, painful, and dry skin without blisters. The affected area is sensitive to touch.
• Partial-Thickness Burns: Blistering, swelling, and intense pain. The skin may be moist and red with a mottled appearance.
• Full-Thickness Burns: The skin appears charred, white, or leathery. There is little or no pain due to nerve damage, and the area may be surrounded by less severe burns that are painful.
• Systemic Symptoms: Larger burns, especially those covering significant body surface areas, may lead to systemic symptoms such as shock, dehydration, and hypothermia.

Diagnosis

The diagnosis of burns and scalds is primarily clinical, based on the history of the injury and physical examination:

• History: Assess the cause of the burn (e.g., flame, scald, chemical), duration of exposure, and any pre-existing medical conditions. Determine if the burn occurred in a confined space, which may suggest inhalation injury.
• Physical Examination: Evaluate the burn depth, extent (using the Rule of Nines or Lund and Browder chart), and the presence of any complications, such as infection or inhalation injury.
• Investigations: In severe burns, consider laboratory tests such as full blood count (FBC), urea and electrolytes, and blood gases to assess for dehydration, electrolyte imbalances, and metabolic acidosis.

Management and Treatment

The management of burns and scalds varies based on the severity and location of the injury:

1. First Aid

• Cool the Burn: Immediately cool the burn with running cool (not cold) water for at least 20 minutes to reduce pain and tissue damage. Avoid using ice or very cold water.
• Protect the Burn: Cover the burn with a sterile, non-adhesive dressing or clean cloth. Do not apply creams, oils, or other substances unless directed by a healthcare provider.
• Remove Constrictive Items: Carefully remove any clothing, jewellery, or belts near the burn area before swelling occurs.

2. Pain Management

• Analgesics: Administer appropriate pain relief, such as paracetamol or ibuprofen. For more severe pain, opioids may be required.

3. Wound Care

• Cleansing: Gently clean the burn area with mild antiseptic solution or saline.
• Dressings: Apply a non-stick, sterile dressing to protect the burn and prevent infection. For partial-thickness burns, consider using hydrocolloid or antimicrobial dressings.
• Blisters: Leave intact blisters alone; if a blister is large or likely to burst, it may be drained and dressed by a healthcare provider.

4. Topical Treatments

• Moisturisers: Once the burn has healed, emollients can be used to keep the skin hydrated and reduce itching.

5. Fluid Management

• Fluid Resuscitation: In patients with burns covering more than 15-20% of total body surface area, intravenous fluid resuscitation is required to prevent shock. The Parkland formula (4 mL/kg/% TBSA) is often used to guide fluid replacement in the first 24 hours.

6. Infection Prevention

• Antibiotics: Systemic antibiotics are not routinely used but may be indicated if there is evidence of infection, such as cellulitis or sepsis.
• Tetanus Prophylaxis: Ensure that tetanus immunisation is up to date, especially in cases of deeper burns.

7. Rehabilitation

• Physical Therapy: Early mobilisation and physical therapy are important to prevent contractures and maintain range of motion, particularly in burns involving joints.
• Scar Management: Pressure garments, silicone gel sheets, and massage may help reduce hypertrophic scarring and keloid formation.
• Psychological Support: Burns can have a significant psychological impact, especially in cases involving visible scarring. Referral for psychological support or counselling may be beneficial.

8. Surgical Management

• Debridement: Surgical removal of necrotic tissue may be necessary in deep burns to prevent infection and promote healing.
• Skin Grafting: In full-thickness burns, skin grafting may be required to cover large areas of damaged skin and improve healing.

Prevention

Prevention strategies focus on reducing the risk of burns and scalds, particularly in vulnerable populations such as children and the elderly:

• Safe Cooking Practices: Use stove guards, keep hot liquids out of reach of children, and never leave cooking unattended.
• Water Temperature: Set water heaters to no higher than 48°C (120°F) to prevent scalds.
• Fire Safety: Install smoke detectors, use fireguards, and have an emergency plan in place for fire evacuation.
• Sun Protection: Use sunscreen and protective clothing to prevent sunburn.

When to Refer

Referral to a specialist burns unit or emergency department may be necessary in the following situations:

• Large Burns: Burns covering more than 10% of total body surface area in adults or 5% in children.
• Full-Thickness Burns: Any full-thickness burn, particularly those involving critical areas such as the face, hands, feet, genitalia, or major joints.
• Inhalation Injury: Signs of respiratory distress or burns sustained in an enclosed space, suggesting possible inhalation injury.
• Chemical or Electrical Burns: These require specialised management and are more likely to cause deeper tissue damage.
• Non-Healing Burns: Burns that do not show signs of healing after 2 weeks or are complicated by infection.

References

1. British Burn Association (2024) National Standards for Burn Care. Available at: https://www.britishburnassociation.org (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Burns and Scalds: Assessment and Management. Available at: https://www.nice.org.uk/guidance/ng66 (Accessed: 26 August 2024).
3. British National Formulary (2024) Topical and Systemic Treatments for Burns. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).