Burns

Description

Emergency Treatment

Medicine Treatment

Referral

---

ICD-10 code: T30.0-3/T31.0-9 + (Y34.99)

DESCRIPTION

Burns lead to skin and soft tissue injury and may be caused by:

• heat, e.g. open flame, hot liquids, hot steam
• chemical compounds
• physical agents, (e.g. electrical/lightning) or
• radiation.

The extent and depth may vary from superficial (epidermis) to full-thickness burns of the skin and underlying tissues.
Initially, burns are usually sterile.

Table 21.8: Assessment of burns

Depth of burn wound	Surface/ colour	Pain sensation/ healing
Superficial or epidermal	Dry, minor blisters, erythema	- Painful - Heals within 7 days
Partial thickness superficial or superficial dermal	Blisters, moist	- Painful - Heals within 10–14 days
Partial thickness deep or deep dermal	Moist white or yellow slough, red mottled	- Less painful - Heals within a month or more  - Generally needs surgical debridement and skin graft
Full thickness (complete loss of skin)	Dry, charred whitish, brown or black	- Painless, firm to touch - Healing by contraction of the margins - Generally needs surgical debridement and skin graft

EMERGENCY TREATMENT

Follow the 7C’s:

• Clothing: remove non-sticking clothing especially if hot or smouldering or constrictive (e.g. rings).
• Cool: with tap water for 30 minutes.
• Clean: with chlorhexidine.
• Cover: with a non-adherent dressing.
• Comfort: provide pain relief.
• Carbon dioxide poisoning: consider if enclosed fire, decreased LOC, disorientation.
• Consider inhalation injury if: carbonaceous (black-coloured) sputum, shortness of breath, perioral burns, hoarse voice, stridor. Discuss with referral centre as early intubation may be needed.

Table 21.9: Estimated body surface area (BSA) percentages

Click on the image to enlarge.

Figure 21.6: Calculating body surface area for management of burns
* Source: Karpelowsky JS, Wallis L, Madaree A, Rode H; South African Burn Society. South African Burn Society burn stabilisation protocol. S Afr Med J. 2007. Aug;97(8):574-7. https://www.ncbi.nlm.nih.gov/pubmed/17966146

Click on the image to enlarge.

MEDICINE TREATMENT

Fluid replacement

Burns ≤ 10% Total Body Surface Area (TBSA):

Oral fluids.

Burns > 10% of TBSA:

• IV fluid for resuscitation, replacement, and maintenance.

---

Note:
IV fluid replacement is very important in large burns. However, if unable to obtain IV access, give fluids orally or via NGT and transfer urgently.

---

Calculation of fluid replacement

Fluids in adults:

If shocked, see: Shock.

First 24 hours:

• Sodium chloride 0.9%, IV.
  • Calculate total fluid requirement in 24 hours: Total % burn x weight (kg) x 4 mL.
  • Give half this volume in the first 8 hours.
  • Administer remaining fluid volume in next 16 hours.

---

Note:
If urine output is not adequate, increase fluids for the next hour by 50%. Continue at a higher rate until urine output is adequate, then resume normal calculated rate.

---

Fluids in children:

---

Note:
Avoid circumferential taping when securing infusion lines, as oedema under the eschar may decrease the venous return.

---

Table 21.10: Replacement fluids for burns >10% BSA in children

Click on the image to enlarge.

Click on the image to enlarge.

Pain:

Children

• Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See dosing table.

Adults

• Paracetamol, oral, 500mg -1 g 4–6 hourly when required (to a maximum of 4 g in 24 hours)
  • Maximum dose: 15 mg/kg/dose.

Severe pain:

See: Chronic non-cancer pain.

Wound cleansing:

Clean the burn wound gently.
Sodium chloride 0.9% or clean water.

Burn dressing:

Keep the wound clean and dress with sterile dressings.

For patients requiring referral

• If within 12 hours, transfer patient wrapped in clean dry sheet and blankets.
• If delayed by >12 hours, paraffin gauze dressing and dry gauze on top.
• For full thickness and extensive burns cover with a paraffin gauze occlusive dressing. Cover the dressing with plastic wrap (e.g. cling film).

LoE:IVb

For patients not requiring transfer (burns that can be treated at home)

• Paraffin gauze dressing.

If infected burn

• Povidone-iodine 5%, cream, applied daily.

LoE:IIIb⁴⁰

Tetanus prophylaxis:

ICD-10 code: Z23.5

If not vaccinated within the last 5 years

• Tetanus toxoid (TT), IM, 0.5 mL.

See: Animal bites or Human bites, for detailed indications and management principles.

REFERRAL

• All children <1 year of age.
• All children >5% in children 1–2 years of age.
• Full thickness burns of any size in any age group.
• Partial thickness burns >10% TBSA.
• Burns of special areas – face, hands, feet, genitalia, perineum and major joints.
• Electrical burns, including lightning injury.
• Severe chemical burns.
• Inhalation injury – fire or scald injury.
• Circumferential burns of the limbs or chest.
• Burn injury in a patient with pre-existing medical disorders which could complicate management, prolong recovery or affect mortality.
• Any patient with burns and concomitant trauma.
• Suspected child abuse.
• Burns exceeding the capabilities of the referring centre.
• Septic burn wounds.
• Consider rehabilitation services for reducing the risk of contractures and disfigurement.

Click here for the pdf.

Click here for the Burn Dressings Scoping Review PHC/Adults October.

Click here for the NEMLC Recommendations for medicine amendments (2020-4 review cycle).

---

Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.1_October 2024

Chapter 21: Emergencies and Injuries