Burns

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Read the full CAHS clinical disclaimer.

Aim

To guide staff with the assessment and management of burns.

Background

Burns are a leading cause of injury in children
All patients with burns requiring admission must be discussed with the Burns Registrar who will discuss with the Burns Consultant.

Assessment

Assessing an acute burn can be difficult for clinicians and the appearance can change during the first 72 hours.⁷
Clinical photography can facilitate communication and assessment of injury. Use of the Medical Information Communication Exchange (MICE) application can be used for photographs and facilitate review.
- In cases where there is suspicion of a Child Protection issue the PCH Medical Illustration Department should be engaged for clinical photography.
Photographic consent must be obtained and documented.
All injury presentations (including burns) in children under 2 years must have an Early Childhood Injury Proforma completed (MR301.3) (internal WA Health only)

History

Time and place the burn occurred
Type of burn: scald (most common), contact, flame, electrical, chemical (the substance causing the burn, duration of contact), radiation or friction
First aid done at the scene
Any further treatment prior to arrival in hospital
Other injuries
Immunisation: tetanus

Examination

Total Body Surface Area (TBSA)

Use the Burns Body Surface Area Sheet.
Do not include areas of erythema
Note: the palmar surface of the child’s hand = 1% BSA as a rough estimate

Depth - see Burns depth assessment table

Superficial: only involve the epidermis
Partial: involve whole epidermis and part of the dermis – can be divided into superficial (papillary layer of the dermis) and deep (reticular layer of the dermis).
Full thickness: involve epidermis and entire dermis.

Distribution

Note the pattern of the burns
Consider non-accidental injury (NAI) if history inconsistent with the examination findings, delay in presentation, other concerning injuries e.g. unusual / unexplained bruises.

Specific information

Burns in special areas (e.g. face, neck, hands, feet, perineum)
Assess for inhalation burns: singed nasal / eyebrow hairs, swelling of mouth / face, stridor, hoarse voice, cough, respiratory distress, any facial, oral or neck burns, black sputum.
Circumferential or almost circumferential burn areas.

Management

Resuscitation

Assess for other injuries (depending on mechanism) – refer to Trauma - Serious injury
Airway: consider early intubation for inhalation burns, remember C-spine precautions in trauma.
Breathing: always give oxygen in severe or inhalation burns.
Circulation: If signs of shock, resuscitate with sodium chloride 0.9%, 10-20 mL/kg bolus. Reassess after first fluid bolus and repeat as required.
Consult Intravenous Fluid Therapy.

First aid

Stop the burning process
Cool the burn with cool running water for 20 minutes. Do NOT use ice
Remove clothing and nappy, taking care not to rip any adhered skin. Cut around adhered clothing if required
Remove jewellery
Keep the patient normothermic 36-37°C
First aid is effective for 3 hours from the time of burn injury.⁷
If outside hospital, do not apply any burns gels - burns can be covered with Acticoat^® for transfer. Do not use Fixomull^®.

Analgesia

Review analgesia given prior to arrival
Intranasal fentanyl should be the 1st line analgesia
If IV cannula already in situ, IV morphine can be given
Oral analgesia: paracetamol, ibuprofen, oxycodone
Be aware NSAID use in burns may be associated with risk of necrotising fasciitis^5,6
Consult Burns - Analgesia and dosing.

Assess for concurrent injuries

Perform a head to toe examination for concurrent injuries – consider the possibility of NAI.
Whilst conducting survey take note of estimated BSA % and document on the chart.

Further management

Minor burn or burn with elevated concerns

Discuss with Emergency Department Senior Doctor and Burns Registrar / Consultant to consider admission for:

Special area burns (e.g. face, neck, hand, feet, perineum)
Full thickness burns
Suspicion of NAI

Wound care

Consult Burns - Dressing and ensure adequate analgesia is provided.

Major burn or burns of high concern

Consult with Burns Registrar/Consultant for inpatient admission:

5% TBSA or greater
Full thickness
Inhalation burns.
Facial burns
Other special burn areas e.g. neck, hands, feet, perineum
Concurrent injury or co-morbidities.
Circumferential burns (potential need for escharotomy).
Chemical and electrical burns
Infected burns.
Infants
Suspicion of NAI.

Rehydration and maintenance

Consult the following guidelines:

Wound care while waiting for transfer to PCH Burns Service

Ensure adequate analgesia is provided
Refer to Burns - Dressing.
Elevate the burnt area
Apply loose dressings over Acticoat^® that allow access to the peripheries for neurovascular observations
Regular neurovascular observations.

Medications

Consult Burns - Analgesia and dosing

Arrange follow up or admission with PCH Burns Service

Discuss with Emergency Department Senior Doctor and Burns Registrar
Consider admission when burns meet the above ‘Major Burn or Burns of High Concern’ criteria
All burn patients should be followed up by the PCH Burns Service.
Patients suitable for follow up in the PCH Burns Outpatient Clinic (Clinic J) should be discussed with the on-call Burns Registrar, referred to the Burns Walk-in Clinic and an e-Referral sent.

Bibliography

AMH Children’s Dosing Companion (July 2021) Australian Medicines Handbook Pty Ltd
Textbook of Paediatric Emergency Medicine 3rd Edition Cameron P, Browne GJ, Mitra B, et al (2018) Publisher: Elesevier Edition updated
Nelson Textbook of Pediatrics: 21st Edition Robert M. Kliegman, St Geme JW, Blum MJ et al. 2020 Publisher: Elsevier
McWilliams TL, Twigg D, Hendricks J, et al (2019) The Implementation of an infection control bundle within a Total Care Burns Unit. Burns 47 (2021), 569-571
Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal anti-inflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine. 2003 Jul;82(4):225-235.
Zerr, D., Rubens, C. NSAIDS and Necrotizing Fasciitis, The Pediatric Infectious Disease Journal: August 1999 - Volume 18 - Issue 8 - p 724-725
Children’s Health Queensland Hospital and Health Service, Management of a paediatric burn patient. Updated: February 2021, Cited 2 Nov 2021. Available from: Management of a paediatric burn patient (health.qld.gov.au)

Endorsed by:	Co-Director, Surgical Services	Date:	Nov 2021
		Amendment date:	Dec 2023
		Review date:	Nov 2024

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