Acute Management of Burn and Scald Injuries in Adults

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Published: 22 March 2021

Between 2013 and 2014, 5,430 Australians were admitted to hospital for burn injuries, with 16% of these cases being considered a high threat to life (AIHW 2016).

Being able to appropriately manage burns and scalds is essential for all healthcare professionals, particularly those involved in emergency and prehospital care, and those working with older adults.

What are Burns and Scalds?

A burn is an injury wherein the skin tissue or eye is partially or completely damaged by heat, cold, electricity, chemicals, gas, friction, bitumen or radiation (WHO 2018; ANZCOR 2016; Vic Burns 2017).

A scald is a burn injury caused by a wet agent such as hot water or steam (NHS 2018).

Burns and scalds can vary in severity from minor to a potentially fatal emergency, depending on their size and depth (Healthdirect 2019).

What are the Most Common Causes of Burns?

  • Hot water
  • Heaters
  • Oven doors and stove tops
  • Frying pans
  • The sun
  • Hair straightener irons
  • Fireplaces
  • Hot water bottles
  • Candle wax
  • Hot drinks.

(St John 2019)

Types of Burns and Scalds

  • Thermal burns and scalds are caused by external heat sources such as flames, hot metals, hot liquids and steam that increase the temperature of the skin tissue, leading to the death or charring of cells. Thermal burns may occur through direct contact or inhalation.
  • Electrical burns are caused by contact with an alternating or direct electrical current. They include lightning strikes.
  • Radiation burns are caused by exposure to ultraviolet radiation (i.e. sunburn), lasers, nuclear radiation, x-rays or other types of radiation.
  • Chemical burns occur when the skin and/or eyes come into contact with hazardous substances.

(Stanford Health Care 2017; ANZCOR 2016)

Acute management will depend on the type of burn being treated.

Burns in Older Adults

Burns in older adults are more complex to manage. This is because:

  • Superficial burns are less common, as older adults have thinner skin
  • Comorbidities such as diabetes, vascular disease and immune conditions may complicate and delay healing
  • The injury may indicate a broader health issue related to frailty and safety.

(Vic Burns 2016)

For these reasons, burns in older adults require more frequent assessment (Vic Burns 2016).

Burn and Scald Classification

Acute Management of Burn and Scald Injuries skin layers diagram

Burns and scalds are classified into one of five categories depending on their depth. They are:

Category Depth Description Treatment Image
Epidermal Superficial
  • Damage to the epidermis only
  • Skin is intact
  • No blisters
  • Skin redness
  • Capillary refill is brisk
  • May require moisturiser or protective dressing
  • Generally heals on its own within 3 to 7 days

(www.vicburns.org.au The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia)

Superficial dermal Partial thickness
  • Damage to the epidermis and upper layer of the dermis
  • Skin appears pink
  • Blisters may be present
  • Capillary refill is brisk under blisters
  • Minimal dressing required
  • Generally heals within 7 to 10 days

(www.vicburns.org.au The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia)

Mid dermal Partial thickness
  • Damage to the epidermis and middle of the dermis
  • Skin appears dark pink
  • Capillary refill is sluggish
  • Deeper areas may require surgery
  • Generally heals within 14 days

(www.vicburns.org.au The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia)

Deep dermal Partial thickness
  • Damage to the epidermis and deeper layers of the dermis (but not through the entire dermis)
  • Skin appears blotchy, red and/or white
  • Capillary refill is sluggish to absent
  • Usually requires surgery and referral to a specialist unit

(www.vicburns.org.au The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia)

Full thickness Full thickness
  • Damage to the epidermis and entirety of the dermis, and sometimes damage to the underlying tissue as well
  • Skin may appear white, waxy, cherry red, brown or black
  • Capillary refill is absent
  • Minimal pain may be experienced due to destroyed nerve endings
  • Usually requires surgery, long-term scar management and referral to a specialist unit

(www.vicburns.org.au The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia)

(ACI 2020; Victorian Adult Burns Service 2012; Better Health Channel 2020)

What is a Significant Burn?

According to ANZCOR, significant burns are those that:

  • Affect more than 10% of the total body surface area (TBSA)
  • Affect the face, hands, feet, genitalia, perineum or major joints
  • Are full thickness burns that affect more than 5% of the TBSA
  • Are electrical or chemical burns
  • Are associated with inhalation injury
  • Affect the circumference of the limbs or chest
  • Are experienced by very young (infants or children) or very old patients/residents
  • Are experienced by patients/residents with comorbidities that may cause complicate treatment, extend recovery time or increase the risk of death
  • Are associated with trauma.

(ANZCOR 2016)

What is Total Body Surface Area?

Acute Management of Burn and Scald Injurie rule of nines diagram

The extent of a burn injury is measured in terms of total body surface area (TBSA). TBSA is calculated using the Rule of Nines, wherein the body is divided into several areas, each representing a multiple of nine (except for the perineum, which is 1%). When all of the areas are added together, they equal 100% of the TBSA (ACI 2020).

For example, a burn that affects the entirety of a patient/resident’s left arm would be equal to 9% of their TBSA.

Note: Children have different body surface area proportions and therefore use the paediatric rule of nines, which differs depending on the child’s age (ACI 2020).

Acute Management of Burns and Scalds

Note: The following management steps apply to burns and scalds that are significant as defined by ANZCOR (see above).

General Management of Burns and Scalds

  1. Ensure that the patient/resident, rescuers and bystanders are safe.
  2. Don appropriate protection before entering a burning or toxic atmosphere.
  3. Stop active burning by:
    • Stop, Drop, Cover and Roll
    • Smothering flames with a blanket.
  4. Move the patient/resident away from the source of the burning and to a safe environment as soon as possible.
  5. Assess the patient/resident’s airway and breathing.
  6. Assess for any other injuries.
  7. Administer oxygen if the patient/resident has smoke inhalation or a facial injury (only if appropriately trained to do so).
  8. Call for an ambulance.

Specific management steps will depend on what kind of burn the patient/resident is experiencing.

Thermal Burns

  1. Immediately cool the burn with cold running water (between 8 and 25°C, ideally 15°C). Do this for 20 minutes.
  2. Remove any rings, watches, jewellery or other items from the injured area, making sure not to cause further tissue damage when doing so.
  3. Remove any wet non-adherent clothing (as clothes soaked with hot liquids retain heat).
  4. Use a loose, light non-stick dressing such as plastic cling film to cover the injury. The dressing should be clean, dry and free of lint if possible.
  5. The patient/resident may be at risk of hypothermia. Cover unburnt areas and ensure you keep the patient/resident warm.
  6. Elevate burnt limbs to reduce swelling if possible.

DO NOT:

  • Peel off clothing that is stuck to the patient/resident’s skin
  • Peel off burning substances
  • Use ice or ice-cold water to cool the burn - this may cause further tissue damage
  • Break any blisters
  • Use any lotions, ointments, creams or powders (except for hydrogel).

Bitumen Burns

  1. Immediately cool the burn with cold running water (between 8 and 25°C, ideally 15°C). Do this for 20 minutes.
  2. Flush any eye burns out with water. Do not remove any bitumen in the eyes.
  3. Only remove bitumen that is not stuck to the skin.
  4. Remove any rings, watches, jewellery or other items from the injured area, making sure not to cause further tissue damage when doing so.
  5. The patient/resident may be at risk of hypothermia. Cover unburnt areas and ensure you keep the patient/resident warm.

DO NOT:

  • Peel off any bitumen that is stuck to the patient/resident’s skin
  • Peel off clothing that is stuck to bitumen.

Inhalation Burns

Inhalation burns may be caused by gases such as ammonia, formaldehyde, chloramines, chlorine, nitrogen dioxide and phosgene.

Always assume inhalation burn if the patient/resident:

  • Has burns to their face, nose hair, eyebrows or eyelashes
  • Has carbon deposits in their nose or mouth.

Other potential indications of inhalation burn are:

  • Coughing up black particles in sputum
  • Hoarse voice
  • Breathing difficulties
  • The patient/resident having been trapped in an enclosed area with hot or toxic gas, steam or fumes from a fire or chemicals.

The acute management steps for inhalation burns are:

  1. Move the patient/resident to fresh air.
  2. Assess and manage the patient/resident’s airway (Read: Adult Basic Life Support (BLS) Using DRSABCD).
  3. Administer oxygen (only if appropriately trained to do so).
  4. Call for an ambulance.

Note: Breathing, talking or standing up do not necessarily indicate stability. Delayed pulmonary inflammation may occur up to 24 hours after inhalation.

Electrical Burns

  1. If possible, isolate or turn off the power supply without touching the patient/resident.
  2. Commence CPR (Read: Adult Basic Life Support (BLS) Using DRSABCD).
  3. If safe to do so, cool the burn with cold running water. Do this for 20 minutes.
  4. Administer oxygen (only if appropriately trained to do so).
  5. Call for an ambulance.

Radiation Burns

  1. Cover the injury with a clean, dry dressing.

Chemical Burns

Note that the aim of managing a chemical burn is to dilute the agent rather than cool the injury.

  1. Don appropriate PPE. Do not make contact with the chemical or any contaminated objects.
  2. Move the patient/resident to safety.
  3. Remove the chemical along with any contaminated clothes or jewellery from the patient/resident as soon as possible. Powdered chemicals should be brushed off the skin.
  4. Immediately cool the burn with cold running water. Do this for one hour or until stinging has stopped. Avoid spreading the chemical to unaffected areas when doing this.
  5. Apply a non-adherent dressing to the injury (even if there is no visible burn mark).
  6. If the chemical has entered the patient/resident’s eye:
    • Open the affected eye and flush thoroughly with water as long as tolerated.
    • If only one eye is injured, the patient/resident’s head should be positioned with the affected eye facing down (so that the chemical does not spread to the other eye).
    • Refer the patient for immediate care.
  7. Check instructions on the chemical container for specific treatment advice.
  8. Check Safety Data Sheets (SDS) for specific treatment advice.
  9. Call the Poisons Information Centre on 131 126 for more treatment advice.

DO NOT:

Neutralise acid or alkali burns (this increases heat generation and may increase damage) Apply cling wrap or hydrogel dressings to chemical burns.

(ANZCOR 2016; ACI 2020; Vic Burns 2017)

Practical Tips for Assessing Burns and Scalds

  • Erythema (epidermal burns that resemble minor sunburns) should not be included in the TBSA calculation.
  • Redness does not always indicate an epidermal burn. Capillary return and pain are a better measure of burn severity.
  • Some deeper burns can be covered by an attached epidermis, disguising the true extent of the injury. Check whether the epidermis is attached when assessing a burn.
  • Ask your colleagues for help if you are unsure in any way.

(Vic Burns 2016)

Complications of Burns and Scalds

Burns and scalds may lead to further complications such as:

  • Hypovolaemic shock due to fluid loss
  • Lung injury from smoke inhalation
  • Hypothermia, as burnt skin impairs temperature regulation
  • Heat exhaustion or heatstroke
  • Loss of consciousness
  • Cardiac and/or respiratory distress
  • Wound infection, including sepsis in rare cases
  • Tissue scarring
  • Psychological distress caused by the incident.

(Better Health Channel 2020; NHS 2018)

Preventing Burns and Scalds

Read: Fire Safety in Your Client’s Home

Tips for preventing burns to yourself or your patients/residents include:

  • Being cautious when microwaving food and drinks and checking the temperature before serving
  • Limiting water temperatures to a maximum of 50°C in bathrooms
  • Ensuing that nobody smokes near beds or other flammable materials - outside is safest
  • Ensuring that hot water bottles and heat packs are never used in bed
  • Covering unused electrical outlets and keeping electrical cords out of the way
  • Ensuring that all smoke detectors work and have regular batteries changes
  • Donning appropriate PPE if working with chemicals.

(ACI 2012; Mayo Clinic 2020)

Additional Resources


References

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Ausmed’s Editorial team is committed to providing high-quality and thoroughly researched content to our readers, free of any commercial bias or conflict of interest. All articles are developed in consultation with healthcare professionals and peer reviewed where necessary, undergoing a yearly review to ensure all healthcare information is kept up to date. See Educator Profile