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 PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of burns.

Background 

  • Burns are a leading cause of injury in children.

Risk

Failure to refer to this guideline may result in inadequate assessment and management in the child with a burn injury.

Assessment

  • Assessing an acute burn can be difficult for clinicians and the appearance can change during the first 48 hours.

History

  • Time burn occurred
  • Type of burn: thermal (most common), electrical, chemical (the substance causing the burn, duration of contact)
  • First aid done at the scene
  • Any further treatment prior to arrival in hospital
  • Other injuries
  • Immunisation status: especially tetanus

Examination

Percentage Body Surface Area (BSA)

Depth

  • 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 pattern of 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.

Management

Resuscitation

  • Airway: consider early intubation for inhalation burns, remember C-spine precautions in trauma.
  • Breathing: always give oxygen in severe or inhalation burns.
  • Circulation: treat shock with boluses of 0.9% saline, 20mL/kg then reassess. 
  • Consult Intravenous Therapy.

First aid 

  • Stop the burning process
  • Cool the burn with cold running water for 20 minutes. Do not use ice
  • Remove clothing, taking care not to rip any adhered skin. Cut around adhered clothing if required
  • Remove jewellery
  • Keep the patient normothermic 36-37°C
  • If outside hospital, do not apply any burns gels - burns can be covered with plastic cling wrap for transfer. Do not use Fixomull.

Analgesia

  • Check what has been 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
  • Consult Burns - Medication

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 to consider admission for:

  • Special area burns (e.g. face, neck, hand, feet, perineum)
  • Suspicion of NAI
  • Full thickness burns
  • Chemical / electrical burns
  • Circumferential burns (partial or full thickness)

Take photos and when available call Medical Illustrations on 6456 0357.

  • Photographic consent form must be used.

Wound care

Arrange follow up or admission

  • Discuss with Emergency department senior doctor and / or Burns registrar

Major burn or burns of high concern

Consult with Burns registrar / consultant for admission:

  • 5% or greater
  • Full thickness
  • Inhalation burns
  • Concurrent injury or co-morbidities
  • Infected burns
  • Circumferential (potential need for escharotomy).

Rehydration and maintenance

Consult the following guidelines:

Wound Care 

  • Elevate burnt area
  • Regular neurovascular observations
  • Consult burns dressings.

Medications

  • Consult burns medications

Admission criteria

As above, consider admission when:
  • Special area burns (e.g. face, neck, hand, feet, perineum)
  • Suspicion of NAI, other concurrent injuries
  • Full thickness burns
  • Chemical / electrical burns
  • Circumferential burns (partial or full thickness – potential need for escharotomy)
  • 5% or greater BSA
  • Inhalation burns
  • Infected burns.

Bibliography

  1. AMH Children’s Dosing Companion (2015) Australian Medicines Handbook Pty Ltd
  2. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
  3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 


Endorsed by: Director, Emergency Department  Date:  Feb 2018


 Review date:   Feb 2021


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