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CHAPTER8 Burns first aid
Steps ofburns first aid
• SAFE approach
• Stop the burning process
• Cool and manage the burn wound
SAFE approach
The British Burns Association has adopted the SAFE approach acronym
standing for:
• Shout or call for HELP
• Assess the scene for dangers to rescuers or patients
• Free from danger
• Evaluate the casualty
As the rst responders to burn injuries may be non- professional bystanders
at the trauma scene, it is important that any individuals administering burns
rst aid do so in a systematic way. The initial steps of rst aid should focus
on ensuring that the patient and the rst aider are safe and that help is
sought early on. Lack of education and understanding, language barriers,
and fear may all delay presentation. First aid education should therefore
highlight the need to seek medical attention earlier rather than later in burn
injuries.
Stop theburning process
Once the initial evaluation of the scene is complete and the rst- aider is
deemed safe, the priority is to halt the burning process and limit the extent of the injury to the patient. These steps should be carried out without
hindering later assessment and management of the burn by application of
inappropriate dressings and cleaning materials. The patient must be removed from the burning source and the burning process stopped as soon
as possible. In ame burns it is advisable that the patient is prevented from
running as this creates a fanning eect on the ames and may make the
situation worse. In addition, the patient should be laid at on the ground
facing upwards to reduce the risk of ames involving the head and neck.
Burnt clothing should be removed (unless stuck to the wounds) and jewellery taken o as this may later lead to constriction of swollen body parts.
Removed clothing should be kept with the patient for later evaluation by
the hospital burns team.
Cool and manage theburn wound
Cooling theburn wound
When the burning process has been stopped, it is important that the burnt
area is cooled to minimise further tissue damage.
The use of clean, cool water for this purpose has the greatest evidence
in the literature. Multiple studies have supported previous circumstantial
evidence that immediate application of cold water (15°C) for 20 minutes
to a burn injury gives the optimal result in terms of later re- epithelialization
and scar result.
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STEPS OFBURNS FIRST AID
Cold water also has the additional proven benets to the burnt area.
• Decrease mortality
• Pain relief
• Decreases cell damage
• Decrease skin temperature to below dangerous level
• Decreases cell metabolism in hypoxic tissue for greater cell survival
• Stabilizes vasculature
• Reduces oedema
• Improves wound healing and scar formation
• Decreases inammatory response
It is therefore recommended that rst aiders ensure that burns are irrigated
with cold running water for 20 minutes.
Ice is not recommended as this may also create a thermal injury.
If this initial irrigation has not been performed, there is patchy evidence
that later irrigation up to 3 hours post burn may still provide benet. Various
dierent agents for initial burns lavage and cooling have come and gone out
of fashion over time and in dierent cultures.
There is little or no evidence for the benets of anything other than cold
water for initial rst aid management of burns and indeed the use of substances such as oils or toothpaste can even hinder later assessment of the
injuries by medical professionals.
In order to stop the burning process in chemical burns, more lengthy
periods of irrigation are often required. However, exposure of some powders and other chemicals such as carbolic acid or phenol to water can
worsen the injury by creating an exothermic reaction. This complicates
matters generally so specic information about the causative agent should
be taken with the patient to hospital with them if possible.
Managing theburn wound
Once the burn has been irrigated, it is important to cover the burn with
a temporary dressing. This maintains the uncontaminated microenvironment by preventing bacterial exposure to the burn and also improves patient comfort. Clinglm is the most widely used and appropriate temporary
dressing, except in chemical burns where it may in fact worsen the injury. An
alternative is a clean cool damp cloth.
It is advisable that smaller pieces of Clinglm are placed on a wound rather than circumferentially wrapped as there is a theoretical risk of constriction with the latter. Once the burn is covered it is important to keep
the patient warm by minimizing exposure. The patient should be covered
and the protected burn wrapped for this purpose. Children and the elderly
are at particular risk of hypothermia so this is of particular importance in
these groups.
A useful mnemonic to aid in education of these basic rst aid steps
is STOP
• Strip hot clothes and jewellery
• Turn on cold tap (never use ice)— run burn under cold water for 10
minutes. Keep the rest of the patient warm.
• Organise medical assistance (999/ A&E/ GP)
• Protect burn with cling lm or clean cloth (do not use dressings, uy
cloth, creams or lotions)
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CHAPTER8 Burns first aid
Initial management bymedical personnel
In the community setting, the majority of burns will rst come into medical
contact with either paramedic services or the patients’ GP.
The key aspects of this phase of pre- hospital care are
• Basic ATLS assessment if appropriate
• Assessment of burns severity/ size/ depth
• Resuscitation IV uids in large burns
• Analgesia
• History
• Early transport for denitive management
It is important that medical personnel have a good basic understanding
of burns management for dealing with such patients. Recent surveys of
healthcare workers have shown that health care workers in general have
a limited understanding of the basics of burns care. First- aid courses with
a particular focus on burns improves this basic knowledge and this should
therefore be mandatory for all healthcare workers.
Basic ATLS
When a burnt patient is rst assessed by paramedic or other medical service it is important that the mechanism of the burn is considered, and if
appropriate, an ATLS ABCDE (Airways/ C- spine, Breathing, Circulation,
Disability, Environment) approach adopted. Any rst aid steps not carried
out by those rst attending the patient should also be carried out if appropriate. Burns often have associated injuries, particularly if they are in the
context of a house re or motor accident, among other causes. In patients
with suspected concomitant injuries, the airway should be secured, and if
appropriate, the cervical spine immobilized.
In large burns and in those suspected of having inhalational injuries (for
example ame burns in an enclosed space) it is essential that high ow
oxygen is given via a non- rebreathing mask as soon as possible.
Assessment ofburns severity/ size/ depth
Estimation of burn size is essential to decide if IV uids are required.
There are several methods for calculation of burn percentage including
• The Wallace rule of nines
• The “half burnt/ half not” approach (which is only generally used in
pre- hospital care).
• The patients palm size (1% TBSA)
• Chart- based methods
Resuscitation IV uids inlarge burns
If it is felt that the burn is greater than 10% TBSA in children or 15% in
adults then cannulation should be carried out at the scene and warmed IV
uid started.
Hartmann’s uid is the recommended uid choice. Ideally the uid requirements should be calculated based on the Parkland formula, however,
this is almost always not appropriate at the scene as the calculations will
delay proceedings.
In the elderly and those with a signicant cardiac history or known left
ventricular failure, care should be taken not to over hydrate these patients.
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INITIAL MANAGEMENT BYMEDICAL PERSONNEL
Analgesia
It is also important to consider pain in acute burns, which may be considerable in some cases, particularly more supercial burns.
If the patient is cannulated, IV morphine may be given and titrated to
eect, accompanied by an antiemetic.
In children, intranasal diamorphine is a suitable alternative.
Inhaled nitrous oxide may also be given but should only be used when
morphine is not suitable or unavailable.
History
A concise history should be taken from the patients regarding the time and
mechanism of the burn, whether the burn was in a conned space, past
medical history, medications and allergies and time of the patient last ate or
drank (as per ATLS guidelines).
It should also be noted, it is important to consider the possibility of nonaccidental injury in all children and the elderly presenting with unusual patterns of injury or delay in presentation.
Early transport fordenitive management
Once the patient is initially stabilized the patient should be delivered or
transferred to either the nearest A&E or if possible, the nearest burns unit.
This will depend on local protocols. Initial assessment should always aim to
minimise on- scene time and deliver the patient to the appropriate medical
services as soon as possible. Communication with the receiving department
should be by the standard approach used nationally (age, sex, injury, ABC
problems, treatment, and estimated time of arrival). Ensure that the cooling
of the wound does not result in over- cooling of the patient.
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CHAPTER8 Burns first aid
Conclusion
Pre- hospital care consists of two major components:
• Basic rst aid
• Later assessment and initial management by out of hospital medical
services including paramedics, GPs and nurse practitioners
It is common that burns are not appropriately treated because of poor
knowledge of basic burns care by non- medically trained individuals who
are usually rst on the scene after a burn has occurred. Asolution to this
problem is adoption of a simple and standard approach to burns rst aid
education programmes as the initial management of a burn may substantially inuence the nal outcome in patients with burns.
The above text summarizes the current approach to pre- hospital management and highlights the requirement for widespread education to optimize this initial phase of management in these patients.
Further reading
Greaves I, Hodgetts TJ, Porter K. (ed.) Basic life support. In Emergency care a textbook for para-
medics, WB Saunders 1997; pp. 17– 26.
British Burns Association rst aid position statement. Available from
British Burns Association Pre- hospital Approach to Burns Patient Management: http:// www.
britishburnassociation.org/ pre- hospital- care
IHCD. Ambulance service basic training. Bristol:IHCD 1991.
IHCD. Ambulance service paramedic training. 3. Bristol:IHCD 1994.
Mlcak RP, Bualo MP, Jimenez CJ. Pre hospital management, transportation and emergency care. In
Herndon D (ed.) Total burn care, 4th edn. NewYork:Elsevier 2013.
National Association of Emergency Medical Technicians. Pre- hospital trauma life support manual
1994. Clinton, MS:NAEMT, 1994.
Weekes R. Scene approach, assessment and safety. In Greaves I, Porter K (eds) Pre- hospital
medicine. The principles and practice of immediate care, London:Arnold, 1999; pp. 273– 9.
Wallace HJ, O’Neill TB, Wood FM, etal. Determinants of burn rst aid knowledge:cross- sectional
study. Burns 39:1162– 9.
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Chapter9
67
Assessment ofburn
surface area
Initial assessment 68
Assessment of TBSA 70
Newer techniques 74
Further reading 75
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CHAPTER9 Assessment ofburn surface area
Initial assessment
Early, accurate assessment of the extent of a burn injury is central to successful resuscitation, and inuences the mortality of burns patients. Two key
elements must be assessed:
• The percentage of the total body surface area (%TBSA) burned
• The depth of burn
Remember, the TBSA burned is directly correlated with the risk of death.
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INITIAL ASSESSMENT
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CHAPTER9 Assessment ofburn surface area
Assessment ofTBSA
There are a number of methods that allow the clinician to rapidly assess the
area of burn. Clinicians must NOT include simple erythema in the assessment. If in doubt, gently wipe a suspicious area of burn with clean gauze,
if the surface easily sloughs away it is indeed burned and must be included
in TBSA. This is in contrast to areas of simple erythema that resemble sunburn and which should not be incorporated into TBSA estimations.
The palm ofthe hand is 1% (that ofthe patient, not
theclinician)
This is most useful for assessing relatively small burns (<10% TBSA) that
may be patchy such as scald injury in a child. It becomes less accurate in
assessing large areas of burn injury.
Wallace rule ofnines
This method divides the body into sections of 9%, or multiples thereof
(see Table 9.1).
This technique is best suited for larger burns in adult patients. The proportions are altered in children where the head comprises a relatively higher
surface area (and the limbs less so) and thus can lead to an inaccurate assessment of burn size.
Lund and Browder chart
This current “gold standard” of TBSA assessment was devised in 1940, and
is similar to the Wallace rule of nines with further renement. In particular,
paediatric patients are more reliably assessed with clearly tabulated guides
to age related changes in surface area (see Fig. 9.1).
In a large burn, it may be simpler to estimate the unburned area and subtract it from 100%.
Estimation ofhand surface area, and small burns
The hand is a common site of burn injury, and the area involved varies considerably. Asimple method of estimation is to express the area involved in
terms of the patient’s thumbprint area (T)(Table 9.2), which can also be
used to estimate small burns (<1% TBSA) elsewhere in the body.
• Calculation of % surface area=number of thumbprints ÷ 30
• One thumbprint (T)=1/ 30th of 1%=0.033% TBSA
• 3T burn=0.1% TBSA
Table9.1 Rule ofnines
Area % TBSA
Head 9
Each upper limb 9
Each lower limb 18
Front of trunk 18
Back of trunk 18
Perineum 1
% Total body surface area burn
½4
¼3
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ASSESSMENT OFTBSA
(do not include erythema)
Lund and browder)
1
13
22
1½
1½
AREA Age 01 51015 Adult
A-1½ OF HEAD
B-1½ OF ONE HEAD
1
CC
1½
1½
BB
REGION
Head
Neck
Ant. trunk
Post. trunk
Right arm
1¾ 1¾1¾ 1¾
Left arm
Buttocks
Genitalia
Right leg
Left leg
Total burn
9½ 8½ 6½ 5½ 4½ 3½
2¾ 3¼44½4
2½ 2½ 2¾ 33
1½
1½
%
PTL FTL
71
1½
1½
¾
½C-½ OF ONE LOWER LEG
Fig.9.1 Lund and Browder Chart.
Reproduced from Smith J, Greaves I, Porter KM (eds). Oxford desk reference:major trauma, Figure22.7,
Copyright © Oxford University Press 2007, with permission from Oxford University Press.
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