Art & science burns supplement sponsored by Mlnlycke Health Care

Assessment and management

of patients with burns
Butcher M, Swales B (2012) Assessment and management of patients with burns.
Nursing Standard. 27, 2, 50-56. Date of acceptance: July 24 2012.

Abstract
Burns are a common injury in the UK. Most burns are limited in size and
depth and are therefore suitable for management in the community.
Primary care and non-specialist clinicians need to understand initial
assessment of the burn and when referral to a specialist burns unit is
indicated. Successful treatment of minor burns and ongoing care of
severe burns in the community requires careful selection of dressings
to support wound healing and achieve optimal outcomes for patients.

Authors
Martyn Butcher
Independent tissue viability and wound care consultant, Devon.
Correspondence to: m.butcher_woundcare@hotmail.com
Beverley Swales
Burns educator in Yorkshire and Humber.

Keywords
Burns, burns injuries, dressings, wound care

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greater as some individuals will self-treat the injury

and do not seek medical advice (Hermans 2005).
Even in relatively minor burns, infection, pain
and scarring can be problematic, and may have
long-term effects on patients physical and
psychological wellbeing (Rockwell et al 1989,
Wiechman-Askay and Patterson 2008). It is
essential that clinicians are aware of how burns can
be managed successfully, who should be responsible
for this care, and how interventions can affect
healing and patient outcomes. For most clinicians,
initial contact with the person who has a burn will
be in the healthcare setting and first aid may already
have been carried out at the scene of the accident.
Following first-aid measures, assessment of the
patient with a burn should include the A, B, C, D,
E, F approach (Hettiaratchy and Papini 2004):
A
 airway maintenance with cervical
spine control.
B
 breathing and ventilation.
C
 circulation and haemorrhage control.
D
 disability, neurological status.
E
 exposure and environmental control.
F
 fluid resuscitation proportional to burn size.
This approach aims to identify other injuries or
complications that may pose a more immediate
threat to the person than the burn itself, such as
a cardiac or cerebral vascular event or major
trauma (Senarath-Yapa and Enoch 2009).

Initial assessment
The skin is an effective, self-repairing barrier,
which provides protection from the external
environment. Burns range from those that are
minor and can be managed in the primary care
setting or even self-treated, to those that are severe,
significantly compromising the integrity and
protective function of the skin and necessitating
high levels of intensive care and multiple surgeries.
It is estimated that more than 250,000 people will
experience a burn in the UK each year, with 175,000
individuals attending an emergency department;
of these, 13,000 people will require hospitalisation
(Hettiaratchy and Dziewulski 2004a). However,
the number of people experiencing a burn may be
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It is vital to make an initial assessment of the burn

to ensure appropriate management. This involves
obtaining the patients medical history, examining
the burn and identifying details surrounding the
incident. The mechanism of injury, duration of
exposure to the causative agent and delivery of
any first aid must be ascertained. Comprehensive
assessment will help to determine a management
strategy and whether referral to a specialist burns
unit is necessary.
Older and younger people are at particular
risk of experiencing a burn as a result of physical
impairment, reduced mobility, inability to extricate
themselves from danger and high-risk decision

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making (Senarath-Yapa and Enoch 2009). It is

important that the clinician is aware of signs and
symptoms that may indicate that the burn could
be the result of a deliberate act. If in doubt, the
clinician should initiate appropriate action promptly
according to local policy. This might include child
protection or vulnerable adult procedures.

Mechanism of injury
The mechanism of injury may provide clues
about the potential severity of the burn. A burn
can arise from many sources such as exposure to
heat, chemicals, friction, electricity and radiation.
Burns resulting from radiation are rare, with the
exception of ultraviolet light (sunburn) (Rawlins
2011). Generally, the higher the temperature of
the heat source and the longer the exposure, the
greater the damage to the skin and underlying
structures (Williams 2009). Damage may also
occur at temperatures as low as 48C, although
this may require exposure for five minutes (Rawlins
2011). Scald injuries are dependent on temperature,
volume and duration of the contact. The degree of
skin damage is related to the thickness of the skin
(Hermans 2005). Hot oil causes deeper burns than
water owing to its high temperature oil boils at
about 300C and water boils at 100C.
Burns resulting from exposure to flames
tend to cause deep damage because of the high
temperature involved, which is often in excess of
1,000C (Babrauskas 2006). Similarly, electrical
burns are likely to cause full-thickness injuries
(damage to all skin structures); heat is generated
as the electrical current passes through the tissue,
causing coagulation and cell death. The higher
the amperage the greater the damage (Sances et al
1981). This type of burn usually produces an entry
and exit point wound and may result in widespread
areas of damage within the affected tissues and
secondary injuries such as cardiac arrhythmias
(Senarath-Yapa and Enoch 2009).
With chemical burns, more than one reaction
may take place at the same time. Exposure of skin
proteins to some chemicals will incite an exothermic
reaction generating high levels of local heat (as
with phosphorus burns), and corrosive agents such
as acids and alkalis cause coagulative necrosis of
the tissues (Hettiaratchy and Dziewulski 2004b).
However, some chemicals, for example hydrofluoric
acid, produce a chemical reaction that may cause
local or systemic electrolyte imbalance, resulting
in local or systemic toxicity (Hettiaratchy and
Dziewulski 2004b). Even innocuous chemicals, such
as cement, can produce burns that may progress to
full-thickness skin loss if contact is maintained and
treatment is not administered (Dowsett 2002).

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Location of injury
The location and distribution of a burn can have a
significant effect on the patients ability to self-care,
particularly if the hands, feet or face are burned,
as well as long-term recovery and rehabilitation
(National Network for Burn Care (NNBC) 2012).
This may have a bearing on treatment and referral
to secondary or tertiary care environments. The
distribution of a burn may also raise questions
about the events surrounding the injury, and
may provoke suspicion of non-accidental injury
(Dubowitz and Bennett 2007, McGarry and
Simpson 2009).

Estimation of burn surface area

The size of a burn is directly related to systemic
effect the larger the burn, the more severe its
effects are on fluid loss and the efficiency of the
circulatory system. This makes burn size a key
factor in deciding the best clinical environmentin
which to manager the patient. Accurate estimation
of the extent of the burn, described as a percentage
of the total body surface area (TBSA) affected,
is essential. Areas of erythema should not be
included in the estimate as this does not affect
capillary permeability and therefore does not
increase fluid loss from the circulatory system.
Three methods are commonly used to assess the
percentage of TBSA involved:
Wallaces

Rule of Nines (Wallace 1951) divides
the body into areas each representing 9% TBSA
(or multiples of 9%) to estimate the area of
the burn. This system is easy to remember and
can be used to make a quick calculation of the
surface area involved in the injury, but it has
been found to overestimate the area of the burn
by about 3% (Wachtel et al 2000). Wallaces
Rule of Nines is rarely used in paediatric burns
as child body proportions change with age.
The
 Lund and Browder Chart (Lund and
Browder 1944) divides the body into areas, each
of which has a percentage TBSA value, but these
are smaller than those used in Wallaces Rule of
Nines. However, key areas such as the legs and
head are given different values depending on the
age of the individual. This makes the Lund and
Browder chart more accurate than Wallaces
Rule of Nines, particularly in estimating
paediatric burns (Wachtel et al 2000).
The
 palmar surface measurement or 1%
hand rule uses the patients hand with fingers
extended, but closed together, to correspond with
approximately 0.8-1% of the individuals TBSA.
Patient hand size is used to compare the size of the
burn. This method is useful in small or scattered
burns (up to 15% TBSA affected) or in estimating
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Art & science burns supplement sponsored by Mlnlycke Health Care

large burns (more than 85% TBSA affected)
when unburned skin is measured and the figure
subtracted from 100% (Williams 2009).

Assessment of burn depth

Burn depth has major implications for wound
management. In recent years, a variety of terms
have been used to describe burn depth.

Epidermal or superficial burns

These burns involve the epidermis only and are red in

appearance much like sunburn. They do not blister
and have normal or brisk capillary refill and normal
sensation. They heal rapidly and are not included in
any estimation of burn area used to determine fluid
resuscitation because the capillaries of the skin in this
area are still patent (Rawlins 2011).

Superficial dermal or superficial

partial-thickness burns

In a superficial dermal burn, damage occurs to the

epidermis and papillary dermis. These injuries are
pale pink in appearance, blistering is common and
capillary refill is normal. Burns of this nature are
particularly painful as nerve endings are exposed.
The lower regenerative layers of the epidermal
tissues survive, therefore these burns usually heal
within seven to ten days in adults and five to seven
days in children, without scar formation, provided
that the patient is given appropriate supportive
therapy. This may include fluid resuscitation,
analgesia, a moist wound healing environment and
protection from bacterial infection (Papini 2004).

Deep dermal burns

Deep dermal burns extend into the reticular dermis

and are typically blotchy red in appearance with
variable sensation. Blanching of the burnt area
with finger pressure may not produce a blanching
response as a result of damage to the capillary
network within the skin (Rawlins 2011). The
epidermis and most of the dermis is destroyed and
healing depends on epidermal migration from the
peri-burn area. Burns of this nature can take a long
time to heal and may result in marked scarring
and changes to skin pigmentation (Cubison et al
2006). Previously, this type of wound was treated
conservatively with moist antimicrobial creams and
dressings. However, following the results of trials
(Engrav et al 1983), it is now common to treat these
wounds with early intervention surgical methods
such as excision and skin grafting (Atiyeh et al 2005).

Full-thickness burns

Damage extending through all the skin structures

is described as a full-thickness burn. These burns
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may appear white and waxy (typically scalds)

or charred (typically flame) (Papini 2004).
Full-thickness burns may also extend to
underlying structures such as subcutaneous
tissue, muscle or bone. The wound will be
insensate, but the patient may experience pain
from surrounding tissues (Judkins and Clark
2010). Large full-thickness burns are unable
to heal without surgical excision and repair;
however, small isolated burns, particularly in
patients unable to tolerate surgery, may be treated
conservatively with dressings (Edwards 2010).
As many injuries are of mixed depth, even the
most experienced clinician may find initial
assessment challenging (La Hei et al 2006).
Jackson (1953) referred to the burn injury being
constructed of three concentric zones:
Zone

of coagulation contains blood vessels
that have thrombosed and the skin is dead.
This tissue is unsalvageable.
Zone

of stasis contains tissue with a static
blood flow. Effective first-aid measures
(such as cooling, maintenance of adequate
fluid balance, prevention of infection and good
wound care involving a moist wound healing
environment) may result in tissue recovery.
Zone

of hyperaemia contains red, inflamed
tissue caused by the inflammatory response.
Wound conversion refers to a dynamic process
whereby the zone of stasis progresses to tissue
necrosis, with subsequent increase in wound size
and depth (Jackson 1953). Conversion is more
likely to occur in a mid to deep dermal injury as
a result of local or systemic factors. For example,
impaired blood flow, increased inflammation,
wound desiccation, build-up of surface exudate
and mechanical trauma increase the local
effect. Systemic factors include septicaemia,
hypovolaemia, excess catabolism or chronic illness
(Demling and DeSanti 2004).
Environmental hazards can also lead to
conversion of a burn (Demling and DeSanti
2004), including inappropriate management and
post-burn wound care (Butcher 2011). Therefore,
reassessment of the injury should be undertaken
at 24-48 hours and an appropriate plan of care
should be formulated with a focus on dressing
choice (Hermans 1992).

Referral to a specialist burns unit

The patient with a burn may need to be referred
or transferred to a specialist burns unit. Those with
extensive burns are likely to present to the emergency
department. Those presenting in the primary care
setting should be transferred immediately to hospital
or directly to a burns unit. Traditionally, burns were

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categorised as complex or non-complex according to

wound size and depth (National Burn Care Review
(NBCR) 2001). Partial or full-thickness burns
covering more than 5% TBSA were described as
complex, and superficial or partial-thickness burns
covering less than 5% TBSA were described as
non-complex (Fowler 1999). However, these
descriptions may not be appropriate as even small
localised burns (less than 0.5% TBSA) can pose
significant challenges to clinicians if the burn is
full-thickness and involves areas such as the face,
hands or genitals. Complexity is now determined by
a combination of factors, including (NBCR 2001):
Potential

systemic effect of the injury on the
individual and subsequent degree of medical
support required to ensure survival.
Need

for surgical intervention to correct
immediate burn complications, such as limb
ischaemia secondary to circumferential damage,
or later to assist tissue reconstruction and repair.
Social

factors such as the patients ability to
self-care.
Investigation

and patient protection for those
suspected of experiencing non-accidental injury.
Psychiatric

assessment if self-harm is suspected.
National guidance outlines when referral to a
specialist burns unit is necessary or when expert
advice on patient management should be sought
(NNBC 2012) (Box 1).

Management of burns in primary care

For individuals who do not require hospitalisation
or who, following inpatient stabilisation, are
considered suitable for management in the primary
care setting, topical treatment of the burn is essential.
On initial presentation, the burn should be washed
with a warm soap and water or sodium chloride
solution before applying dressings (Alsbjrn et al
2007). Some patients will present with burn blisters
and, despite some controversy (Swain et al 1987,
Uchinuma et al 1988), it is accepted that blisters less
than 1cm in diameter can be left intact, while all
others should be de-roofed and dressed (Dowsett
2002, Hudspith and Rayatt 2004, Sargent 2006).
This enables more accurate assessment of burn depth
and removes dead tissue that can act as a growth
medium for bacteria (Sargent 2006).
Dressings should provide an optimum
environment to assist wound healing with
minimal scarring, or temporary protection until
reconstruction is undertaken (Butcher 2011). Topical
burns management depends on the anticipated
method of wound repair and where the patient is in
the treatment pathway. For the clinician in primary
care there are four key points in this pathway where
dressing choices need to be considered:

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During

initial burns assessment patients who
present in the primary care setting. Following
presentation and assessment, the patient will
either be considered suitable for management
in the primary care setting or will need to be
referred or transferred to a specialist burns care
unit (NNBC 2012).
During

early (acute) burns treatment patients
considered suitable for management in the
primary care setting. Dressings that can provide
an appropriate environment to encourage healing
should be selected. Because the characteristics of
a burn wound can change over time, for example
exudate levels fall after 24-72 hours, it is necessary
to re-evaluate dressing selection.
During

post-stabilisation burns treatment
patients who have been assessed and/or
initially treated in a specialist burns unit and are
considered suitable for continuing management
in the primary care setting. These patients will
include those for whom healing of superficial
and partial-thickness burns is anticipated and
those who have deeper burns requiring
long-term wound management because existing
comorbidities mean they are not considered
suitable for reconstructive surgery (NNBC 2012).
Following

burns surgery patients who have
been discharged from a specialist burns unit
following reconstruction of a burn wound. These
patients may need dressings to manage skin graft
sites, skin graft donor wounds and possibly small
areas of non-healed burns.

BOX 1
National burns care referral guidance
Referral to a specialist burns unit should be made for:
Burns equal to or greater than 2% total body surface area (TBSA)
in children and 3% TBSA in adults.
All full-thickness burns.
All circumferential burns.
Any burn not healed in two weeks.
Any burn where there is suspicion of non-accidental injury (should be
referred for expert assessment within 24 hours).
The following factors should prompt a discussion with a consultant
in a specialist burns unit and consideration given to referral:
All burns to hands, feet, face, perineum or genitalia.
Any chemical, electrical or friction burn.
Any cold injury.
Any unwell or febrile child with a burn.
Any concerns regarding burn injuries and comorbidities that may
affect treatment or healing of the burn.
If the burn changes in appearance or there are concerns about healing,
then advice should be sought from a specialist burns care service. If there
is any suspicion of toxic shock syndrome, early referral is recommended.
(National Network for Burn Care 2012)

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When transfer of a patient to a specialist burns
unit is required, a temporary dressing will protect
the burn, reduce the risk of contamination and
pain, and prevent adherence of the wound to
clothing and/or blankets (Edwards 2001). Cling
film (polyvinyl chloride film) provides an ideal
temporary dressing as it is easily available, pliable,
non-adherent and transparent (Hudspith and
Rayatt 2004). In addition, it does not shed fibres,
which could adhere to the wound. Cling film
should be laid over the burn and not wrapped
around the limb as this may have a tourniquet
effect if swelling occurs. Burns to the hand are best
covered in clear, clean plastic bags (Hudspith and
Rayatt 2004).
For burns that are managed in the community,
there are several issues to consider when choosing
an appropriate dressing. Edwards (2001) stated
that dressings should maintain a moist wound
environment to aid autolysis of damaged tissue,
promote migration of epithelial cells, prevent
desiccation of exposed dermis and keep exposed
nerve endings moist, thereby reducing pain and
risk of wound conversion.
Management of exudate is also a key
consideration. The burn wound leaks significant
amounts of serous fluid in the 24-72 hours
following injury as capillary permeability
increases and epidermal tissue is lost (Hermans
2005). Exudate rapidly soaks through dressings
providing a portal for bacterial contamination,
and leads to evaporative moisture and heat loss.
In an international consensus survey of burns care
experts, Selig et al (2012) identified that absorbency
is a prime function of the ideal dressing.
Control of bacteria in the wound is also
important (Edwards 2001). Bacterial colonisation
of the wound occurs rapidly (Norman 2003) as
organisms from surrounding unburned skin and
the environment enter the wound, which with its
moist, protein-rich surface provides ideal conditions
for bacterial proliferation. Compromised host
defences, caused by changes to wound vascularity
and reduced immune status following the burn
(Kao and Garner 2000), increase the risk of wound
infection, which may further damage tissues and
lead to sepsis (Williams 2002).
For many patients, particularly those who
are immunocompromised, the use of topical
antimicrobial dressings may be indicated (World
Union of Wound Healing Societies 2008). This
is supported by Selig et al (2012) who found
that antimicrobial properties scored highly as a
component of the ideal burns dressing. However,
where burns are small, contamination of the
wound is avoided and the patient is healthy, this
may be less important.
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Pain is a feature of most burns. This is made

worse by exposed pain receptors on or close to the
surface of the wound, localised inflammation and
burns oedema. The use of inappropriate dressings,
which adhere to the burn or cause trauma to the
surrounding skin, will increase pain (Judkins and
Clark 2010). The importance of using non-adherent
dressings has been identified (Selig et al 2012).
Factors such as ease of application and removal,
product durability and the ability of the patient
to self-treat and maintain independence with
the dressing in situ are important. The dressing
selected should also ideally be available to the
community care team on the Drug Tariff. Initially,
the burn will require frequent dressing changes
to assess the wound and permit removal of soiled
dressing material. Senarath-Yapa and Enoch
(2009) suggested that once the depth of the burn
is confirmed dressings may be left in situ for three
to five days as long as there is no strike-through
(leakage) of exudate, significant malodour, pain
or evidence of infection.
When managing the post-surgery (skin graft
and donor site) wound and deep dermal or
full-thickness burns, a systematic approach to
wound healing and dressing selection may be
appropriate. This approach has been used in
the development of tools such as Wound Bed
Preparation (Schultz et al 2003, Jones 2004),
Applied Wound Management (Gray et al 2005)
and TIME (Dowsett and Ayello 2004). The
key principles underlying these tools involve
appropriate use of debridement to remove necrotic
tissue, control of bacteria in the wound (bioburden)
to avoid infection, management of moisture
and prevention of trauma to the wound and
surrounding skin.

Potential dressing options

Superficial and partial-thickness burns were
previously dressed using paraffin-impregnated
gauze (tulle gras). Tulle gras is cheap and easy to
apply, however dressing adherence, trauma and
pain on removal have been identified (Fowler and
Dempsey 1998), capillary and epithelial in-growth
is common (Fowler and Dempsey 1998) and the
product cannot absorb wound exudate.
Edwards (2001) discussed the use of biological
dressings for the treatment of burns. These products,
which are constructed from processed human or
animal tissue, are used in some specialist burns units.
However, these dressings are not widely available
in the community setting. Instead, the clinician will
need to use products listed on the Drug Tariff.
As an alternative to tulle gras, several wound
contact layers have been found to be effective in

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managing burns, and subsequent skin grafts and

donor wounds (White 2005, 2008, Fowler 2006,
Rippon et al 2007, 2008, Davies and Rippon 2008,
Tan et al 2009). These dressings use a flexible mesh
covered with a non-adherent silicone adhesive. They
do not adhere to the wound and can be removed
easily and painlessly. This adhesive material is also
used as a wound interface layer in many foam and
film dressings (White 2005, Edwards 2011).
If antimicrobial activity is not required
in dressings used on superficial and
partial-thickness burns, semi-permeable film
dressings and hydrocolloid dressings can be
used to provide protection and a moist wound
environment (Dowsett 2002, Senarath-Yapa and
Enoch 2009). These dressings are self-adhesive
so they are relatively easy to apply and stay in
place. However, they have limited absorbency
and tend to be reserved for small, localised
burns or low-exuding wounds. With high
moisture-handling capabilities, alginate
and hydrofibre dressings may be effective in
managing partial-thickness burns (Edwards 2001,
Dowsett 2002, Hermans 2005, Fowler 2006).
Historically, silver has been used as one of the
principal antimicrobial agents in treating burns
and preventing infection (Klasen 2000). The
use of silver sulfadiazine 1% cream as a topical
antimicrobial agent is common in the management
of these injuries (Edwards 2002, 2009). However,
as Butcher (2011) identified, there are limitations to
its use. In large burns, the cream adds extra weight
to the dressing which, when soaked with exudate,
restricts movement. The cream also needs to be
reapplied every 24-36 hours to remain effective;
this is expensive and time-consuming, removal
and reapplication of the cream can be painful
and repeated application can cause development
of a discoloured film of cream and exudate over

the burn, which can make visualisation and

assessment of the wound bed difficult. In addition,
antimicrobial dressings may not be needed to treat
uncomplicated burns (Butcher 2011).
The addition of silver-based antimicrobial
components to many wound products such as
alginate and hydrofibre dressings has resulted
in an increase in their use in burns management
(Hermans 1998, 2007, Caruso et al 2004).
However, these are primary dressings and
therefore require a secondary product such as
a film, hydrocolloid or adhesive foam dressing
to keep them in place. This increases the cost of
treatment and makes application of the dressing
more difficult and time-consuming.
Foam dressings (with or without silver-based
antimicrobial components) allow control of
moisture and exudate (Butcher 2011). They are
available in a wide range of sizes and can be cut
to fit body contours. Dressings containing active
silver elements can provide effective antimicrobial
action (Chadwick et al 2009).

Conclusion
Recognising the need to refer patients to a
specialist burns unit when necessary is essential.
However, burns are common and many can be
managed appropriately in the primary care setting.
Comprehensive and frequent wound assessment is
a prerequisite of optimal management. There is a
wide variety of dressings suitable for treating the
non-complex burn and it is the responsibility of the
clinician to select the dressing that best meets the
patients needs NS
Conflict of interest
This article was supported by Mlnlycke
Health Care

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