Practice

ABC of wound healing This is the seventh in a series of 12 articles

Burns
Alex Benson, William A Dickson, Dean E Boyce

About 250 000 people are burnt each year in the United
Aetiology of burn injuries (percentage)
Kingdom. Of these, almost 112 000 attend an accident and
emergency department and about 210 die of their injuries. At Adults Paediatric
x Flame (48) x Scalds (60)
least 250 000 others attend their general practitioner for
x Scalds* (33) x Flame (25)
treatment of their injury. A burn results in loss of epidermal x Contact (8) x Contact (10)
integrity of the skin; this article discusses the aetiology and x Electrical (5) x Electrical (2)
management of various types of burn injury. x Chemical (3) x Chemical (2)
x Friction (2) x Sunburn (1)
x Sunburn (1)

Mechanisms of burn Adapted from UK manual for “Emergency Management of

Severe Burns” course. See “protocol” box next page
*Oil and water.
Thermal injury
Flame—Accelerants such as petrol, lighter fluid, or natural
gas are often involved. The depth of flame burn is typically full
or partial thickness.
Scald—60% of burns in children are from scalds.
Non-accidental injury is rare but should be considered if there
are delays in presentation, inconsistencies in history, or an
unusual pattern of injury.
Contact—Contact burns often present as small burns on
extremities, but they can be serious in those not able to remove
themselves from the source of injury, such as elderly people,
children, disabled people, and those incapacitated by drugs,
alcohol, fit, or faint.
Flash—Flash burns are usually to the face and upper limbs
and are caused by an explosive ignition of a volatile substance.
They are often due to use of accelerants to light a fire or gas
explosions.

Electrical injury
Low voltage—The energy imparted from 240 V usually gives Clockwise from top left: Full thickness flame burn to the right arm,
a deep burn in the form of a small entry and exit wound. Such torso, and face and neck (not shown); “pull over” scald (hot tea) to a
burns are commonly seen on the hands. If alternating current toddler; flash burn and erythema to face (note sparing of skin creases);
crosses the myocardium, arrhythmias may arise. If the full thickness contact burn (patient was alcoholic and fell unconscious
against a portable heater)
electrocardiogram is normal and there is no history of loss of
consciousness, admission to hospital for cardiac monitoring is
not required.
High voltage—High tension burns occur with an injury
resulting from 1000 V or more. These catastrophic injuries
result in extensive tissue damage. Rhabdomyolysis and renal
failure may occur.
Flash—An arc of high tension current from a high voltage
power source may cause injury, without the current traversing
the body. Heat can damage exposed skin, and clothing may Low voltage (240 V) electrical
ignite. burns to the finger pulps

Chemical injury
Acids—Acids cause coagulative necrosis, denature proteins,
and are usually painful. Hydrofluoric acid penetrates tissues
deeply and can cause fatal systemic toxicity even in small burns.
Immediate copious lavage and treatment with topical calcium
gluconate gel is essential. Systemic calcium may be required as
hydrofluoric acid sequesters calcium with the burn.
Alkalis—Common household alkalis such as bleaches,
cleaning agents, and cement give a liquefactive necrosis. They
have the potential to penetrate tissues deeper than most acids
as further injury occurs as cells dehydrate and collagen and
Left: Cement burns to the dorsum of the toe. These burns may initially be
protein are denatured. Often the onset of pain is delayed, thus deemed superficial; persistence of the alkali within the skin can cause a
postponing first aid and allowing more tissue damage. progressive full thickness burn. Right: Full thickness caustic soda burn

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Burn assessment
The severity of burn injuries is related to the depth of skin
involvement and the percentage of total body surface area
involved.
In the United Kingdom burns are classified as partial
thickness or full thickness, as these terms correspond to the
level of burn injury and the likelihood of healing without
surgical intervention.
Partial thickness burns are further categorised as superficial
or deep dermal. Superficial burns usually heal without surgery,
but deeper burns are likely to require excision and skin grafts.
Burn depth can progress without adequate first aid and
treatment such as appropriate fluid resuscitation and dressings.
Burn depth can be worsened by the presence of infection.
Superadded infection may lead to an increase in burn depth.

Classification of burn depth

A Lund and Browder chart is useful in assessing the extent of
Superficial burns burn injury (the relative proportions of body areas differ in
These usually heal within 14 days and leave minimal scarring. children)
Burn erythema may be described as skin redness and pain.
Erythema is not included in the assessment of the percentage of
total body surface area. With superficial dermal burns the outer
part of the dermis is injured; these burns characteristically have
blisters and are very painful.
Deep burns
These take a prolonged time to heal and do so with severe
scarring. All but the smallest areas of full thickness burn require
surgical intervention. In deep dermal burns the skin has fixed
capillary staining and has blotchy cherry red appearance. It
does not blanch with pressure and is typically insensate. Full Top: Superficial dermal scald
(top). Bottom: Burn injury of
thickness burns have a leathery white or charred black
different depths (FT= full
appearance (eschar). In people with dark skin, parameters other thickness; DD = deep dermal;
than skin colour may need to be used. SD = superficial dermal)

Indicators of depth of burn injury

Burn type Skin colour Blisters Capillary refill Sensation Pinprick Healing
Epidermal Red Absent Brisk Painful Bleeds Yes
Superficial dermal Pale pink Present (small) Brisk Painful Bleeds Yes
Mid-dermal Dark pink Present Slow May be painful Bleeds Usually
Deep dermal Dry blotchy red May be present Absent No pain No bleeding No
Full thickness Dry white/black Absent Absent No pain No bleeding No

Management of burn injuries

First aid
The “drop and roll” procedure: get the person to drop
The person should be removed from the burning source
to the ground then help them to roll over to extinguish
without endangering the rescuers. If clothing is alight, follow the flames from burning clothing (the use of a wet
the “drop and roll” procedure. When electricity is involved, blanket may help)
power should be turned off before administering first aid.
The burn should be cooled (or the toxin diluted) with
lukewarm running water for at least 20 minutes. This period
should be increased in those with chemical injury. Ice or very Protocol for managing burn injuries*
cold water should be avoided, as blood flow to the affected area A = Airway and cervical spine control
will be reduced, and hypothermia induced, particularly in B = Breathing and ventilation
infants and elderly people. C = Circulation and haemorrhage control
Patients are assessed and their treatment priorities D = Disability
established on the basis of the severity of their injuries The E = Exposure and environmental control
history of events leading to the burn will also alert those F = Fluid resuscitation
treating the patient to the risks of coexisting injury. Inhalation *According to guidelines advocated in the course “Emergency Management of
injury is potentially life threatening when burns have been Severe Burns,” run by the British Burn Association
(www.britishburnassociation.co.uk)
sustained in enclosed areas.

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 Practice

Simple analgesia or opiates should be used. Covering the

All burns are susceptible to infection. Silver based
burn and cooling with water will also provide some pain relief.
products have traditionally been used to treat burns,
Dressings including silver sulfadiazine (Flamazine) and silver
sulfadiazine plus cerous nitrate (Flammacerium)—the
Polyvinyl chloride sheeting (“clingfilm”) or sterile cotton
latter available only on a named patient basis in the UK.
sheeting may be used initially. These are simple to use and allow However, the use of these preparations makes
wound inspection so that definitive assessment can be subsequent assessment difficult. Ideally, they should not
performed. Sterile burn cooling gels are also available. be applied without discussion with the burns team
Minor burn injury
Debridement
Burn debris should be removed with mild soap and water, Criteria for referral to a burns centre
sterile saline, or a topical antiseptic solution before dressings are x Associated airway injury
applied. The dead skin of open blisters should be removed, and x Partial thickness burns < 5% of total body surface area in a child
large or friable blisters should also be “deroofed” (the outer x Partial thickness burns < 10% of total body surface area in an adult
layer removed). Small blisters may be left intact. Antibiotics are x < 1% full thickness burn
x Partial or full thickness burns to face, perineum, external genitalia,
not routinely prescribed in minor burns. The tetanus status of
feet and hands, and over joints
the patient should be checked. x Circumferential injury
x Chemical and electrical burns
Dressings x Extremes of age
In the simple, clean, partial thickness burn, dressings such as x Non-accidental injury
x Comorbidity
paraffin gauze (for example, Jelonet), chlorhexidine x Non-healed burn three weeks after injury
impregnated gauze (Bactigras), or similar dressings such as soft
silicone (Mepitel) or soft polymer (Urgotul) can be used with an
overlying gauze pad. Hydrocolloid dressings are particularly
good for use on hands and other small areas of superficial or Repeated review of the burn wound and multiple
partial thickness burns, although they leave a “skim” of exudate dressing changes are unnecessary. A change of
that needs to be removed to allow appropriate assessment of dressings and wound review after 48 hours is usual.
the wound. In bigger burns, several layers of dressing are usually Further changes are guided by the rate of healing, but
required to absorb exudate and to prevent shear or friction of are generally needed at intervals of two to three days.
the skin. More frequent change of dressing is needed if there is a
Dressings such as alginate adhere to the wound and should high volume of exudate or evidence of infection
be reviewed after 24 hours. At this point only the secondary
dressing immediately overlying the alginate needs to be
replaced. Once the wound is healed, the alginate separates off.
If there is excessive exudate or a full thickness burn, the
dressing fails to stick, indicating the necessity for further
assessment. These properties also make alginate dressings
useful for donor sites after skin graft harvest.

Major burn injury

A major burn should be managed according to the guidelines
advocated in the British Burn Association’s Emergency
Management of Severe Burns course. Transfer of these patients
needs careful planning and communication with the burns
team. In a patient with multiple injuries, the most obvious injury
may be their burn, but careful assessment and treatment of
other injuries is vital before burn management. All patients with
facial burns or suspected of having inhaled smoke or hot gases
should be assessed by an anaesthetist before being transferred
to a specialist unit , as early intubation may be required. Escharotomies to the chest to allow respiratory expansion
Deep or full thickness burns make the skin inelastic and act
like a tourniquet. They should be released by escharotomy to
prevent respiratory embarrassment (of the chest and abdomen)
Fluid resuscitation guide based on Parkland formula
or vascular compromise of the limbs. This may need to be done
before transfer to a specialist unit. Calculations are guidelines only and refer to fluid required from the
Fluid resuscitation is indicated after a serious burn ( ≥ 10% time of burn injury, not the time of presentation. Volumes refer to
fluid resuscitation for the first 24 hours: half is given in the first 8
of total body surface area in children and ≥ 15% in adults). The hours, and half over the subsequent 16 hours
British Burn Association recommends the use of the Parkland
formula, but intravenous fluids should also be guided by the Resuscitation formula for adults
x 3-4 ml Hartmann’s solution/kg body weight/% total body surface
patient’s response to resuscitation.
area
Surgical debridement of the major burn is influenced by the
fitness of the patient to undergo a procedure and the depth and Resuscitation formula for children
x 3-4 ml Hartmann’s solution/kg body weight/% total body surface
location of the burn. Excision of the burn may be required.
area, plus maintenance fluids (4% glucose in 0.25N saline or 0.2N
Reconstruction is often done with split skin grafts taken from saline)
the patient in single or multiple stages. This may be combined

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Practice

with cadaveric skin if the patient has insufficient donor skin.

Artificial skin substitutes are being increasingly used with good
results (see a later article in this series). Several layers of
dressings are used to minimise shear at the site of skin grafting.
These should not be too tight as swelling often occurs after a
burn injury.
Once a burn has healed, the area should be regularly
moisturised and protected from the sun by sunblock cream or
clothing. Physiotherapy may be required to prevent burn
contractures.

Further reading and resources Top: Full thickness

burns of the abdomen
x Herndon D. Total burn care. 2nd ed. London: Saunders, 2002.
have been excised and
x National Burn Care Review. National burn injury referral
closed with split
guidelines. In: Standards and strategy for burn care. London: NBCR, thickness skin grafts.
2001:68-9. Bottom: Artificial skin
x Burnsurgery.org (a website designed to be a comprehensive substitute used to cover
educational tool for burn care professionals worldwide) full thickness burn
www.burnsurgery.org

Alex Benson is specialist registrar in plastic surgery in the Mersey Prevention of burns is key: the main improvement in
Regional Plastic Surgery Unit, Whiston Hospital, Liverpool. William
reduction of burns in the UK over the past 40 years has
A Dickson is consultant burns and plastic surgeon and Dean E Boyce
is consultant hand and plastic surgeon in the Welsh Centre for Burns been the introduction of legislation to reduce the
and Plastic Surgery, Morriston Hospital, Swansea. flammability of clothing, furniture, and fireworks and
of proper labelling of inflammable materials
The ABC of wound healing is edited by Joseph E Grey
([email protected]), consultant physician,
University Hospital of Wales, Cardiff and Vale NHS Trust, Cardiff, and
honorary consultant in wound healing at the Wound Healing
Research Unit, Cardiff University, and by Keith G Harding, director of Competing interests: For series editors’ competing interests, see the first
the Wound Healing Research Unit, Cardiff University, and professor article in this series.
of rehabilitation medicine (wound healing) at Cardiff and Vale NHS
Trust. The series will be published as a book in summer 2006. BMJ 2006;332:649–52

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