• Electrical

  • Search for entry and exit sites. Assess ECG rhythm. The extent of burn damage in electrical burns is often impossible to assess fully at the time of injury

• Thermal

  • The skin contact time and temperature of the source determine the depth of the burn. Scalds with boiling water are frequently of short duration as the water flows off the skin rapidly. Record the type of clothing (e.g. wool retains the hot water). Those resulting from hot fat and other liquids that remain on the skin may cause significantly deeper and more serious burns. Also the time to cold water and removal of clothing is of significant impact.

• Chemical

  • It is vital to note the nature of the chemical. Alkalis in particular may cause deep, penetrating burns, sometimes with little initial discomfort. Certain chemicals such as phenol or hydrofluoric acid can cause poisoning by absorption through the skin and therefore must be irrigated with COPIOUS amounts of water for a minimum of 20 minutes (this should be continued until definitive care is available if patient condition and water supply allows)

If safe to do so, stop the burning process:

• Remove from the burn source.

• Brush off dry chemical.

Assess <C>ABCD

If any of the following TIME-CRITICAL features present:

• major <C>ABCD problems

• airway burns (soot or oedema around the mouth and nose)

• history of hot air or gas inhalation; these patients may initially appear well but can deteriorate very rapidly and need complex airway intervention

• respiratory distress

• evidence of circumferential (completely encircling) burns of the chest, neck, limb

• significant facial burns

if present:

• Start correcting A and B and undertake a TIME-CRITICAL transfer to nearest appropriate hospital according to local care pathways.

• Continue patient management en-route.

• Provide an alert/information call.

Signs/Increased Risk of Airway Burns

• Facial or neck burns.

• Soot in the nasal and oral cavities.

• Coughing up blackened sputum.

• Cough and hoarseness.

• Difficulty with breathing and swallowing.

• Blistering around the mouth and tongue.

• Scorched hair, eyebrows or facial hair.

• Stridor or altered breath sounds such as wheezing.

• Loss of consciousness.

• Fires/blasts in enclosed spaces.

• Remember that a burn injury may be preceded by a medical condition causing a collapse (e.g. elderly patient with a stroke collapsing against a radiator).

• Burns can be very painful, give pain relief.

Specifically Assess

• Airway patency as early intervention may be required with inhalational burns; if intubation is impossible, needle cricothyroidotomy is the management of choice.

• Waveform capnography should be used whenever intubation is performed.

• Breathing for rate, depth and any breathing difficulty (refer to Airway and Breathing Management).

• Evidence of trauma – for neck and back trauma, refer to Spinal Injury and Spinal Cord Injury.

• Co-existing or precipitating medical conditions.

Oxygen

• Administer supplemental oxygen via a non-rebreathing mask – SpO2 readings may be false due to carboxyhaemoglobin.

Cool/Irrigate the Burn

• Irrigate with copious amounts of water as soon as is practicable; this can still be effective up to 3 hours after the injury. Irrigate the burn for a maximum of 20 minutes, except for chemical burns (acid, alkalis and other corrosive substances) where the irrigation can be continued up to 1 hour.

• Cut off burning or smouldering clothing, providing it is not adhering to the skin.

• Remove any constricting jewellery, including rings.

• DO NOT use ice or ice water, as this can worsen the burn injury and exaggerate hypothermia.

• Use saline if no other irrigant available.

• Gel-based dressings may be used but water treatment is preferred.

• Alkali burns require prolonged irrigation – continue until definitive care.

Assess Burn Size

• Rule of Nines or Lund and Browder Chart.

• Patient's palmar surface, including adducted fingers.

• Consider obesity and large breasts when estimating burn size.

Dress the Burn

• Use small sheets of clingfilm – do not wrap around limbs but layer the film.

• In the absence of clingfilm, use a clean cotton sheet.

• Elevate the affected area if possible, to reduce the risk of oedema.

• NB Do not apply creams, ointments, wet gauze or non-adherent dressings; they interfere with the assessment process.

Fluid Resuscitation

• Large burns (>10% in children and >15% in adults) require intravenous fluids

• If IV access is required, obtain on a non-affected limb where possible.

Wheezing

• If the patient is wheezing as a result of smoke inhalation:

• Administer nebulised salbutamol 6–8 litres of O2 per minute.

Transfer to Further Care

• The following patients should be conveyed to the nearest Emergency Department (ED), from where transfer to a regional burns unit may be arranged, if necessary, or transfer in accordance with local referral pathways:

• Any full-thickness burns.

• Deep dermal burns affecting more than 5% of TBSA in adults, and all deep dermal burns in children.

• All chemical and electrical burns (including lightning injuries).

• Any high-pressure steam injury.

• Any burn associated with suspected non-accidental injury, regardless of the complexity.

• Burns affecting the face, hands, feet, genitalia perineum or any flexural surface such as the neck, axilla, elbow or knee.

• Circumferential deep dermal burns.

• Burns associated with suspected inhalation injury.

• Burns associated with co-morbidities that may affect wound healing or increase the risk of complications.

• Burns associated with significant other injuries.

• Burns associated with sepsis.

• People who may require admission due to social circumstances or inadequate pain control.

• Complete documentation.

Alkali Burns to the Skin and Eye(s)

• When irrigating the eyes, ensure that the fluid runs away from the contralateral eye to avoid contamination.

• Irrigate with water and continue en-route to hospital – it may take hours of irrigation to neutralise the alkali. This also applies to eyes, which require copious and continual irrigation, ideally with water or saline in the absence of a water source.

Acid/Chemical Burns to the Skin and Eye(s)

• When irrigating the eyes, ensure that the fluid runs away from the contralateral eye to avoid contamination.

• Irrigate copiously, ideally with water or otherwise with saline if no water source available.

• NB Specific treatment agents may be available in industrial settings with on-site medical/first aid.

Chemical Burns

• DO NOT wrap in clingfilm.

• NB Do not attempt to neutralise chemicals, as additional heat will be generated, which may increase tissue damage.

Circumferential Burns

• Encircling completely a limb or digit. Full thickness burns may be ‘limb threatening’, and require early in-hospital incision/release of the burn area along the length of the burnt area of the limb (surgical escharotomy).

Corrosive Substances

• Following a significant increase in the frequency of serious criminal assaults using acids and corrosive substances, the National Ambulance Resilience Unit (NARU) has advised:

Personal Safety

• Make a dynamic risk assessment and ensure your own safety.

• Exercise extreme caution if there appear to be multiple patients or an ongoing attack.

• Ensure accurate updates are provided to ensure awareness of the severity of the incident, so this can be escalated if necessary.

• Activate specialist resources early where there appear to be multiple patients or extensive contamination.

• Wear eye protection and double-glove nitrile gloves.

• Protect any exposed skin by wearing a jacket to provide a barrier.

• Do not carry out sniff tests on contaminants or containers.

• If attacked, use hands to protect face; skin may blister and scar, but corrosives in the eyes may cause irreversible loss of vision.

• Corrosive vapours should be considered in terms of ventilation from around any contaminants.

Patient Management

• Irrigate freely with clean water for 20 minutes; this includes utilisation of the fire brigade if required.

• If a shower is available, use this with a mild soap which can be used safely on skin.

• Try to ensure any run-off does not come into contact with other uncontaminated parts of the body.

• Early and thorough irrigation of the face and eyes is important to reduce the risk of long-term damage.

• Eye irrigation can be achieved by using a bag of saline, giving set (maximum half open) and washing with a gentle stream.

• Contaminated clothing should be cut off whenever possible and left on scene. Do not pull contaminated clothing over the head or remove clothing that is adhering to the skin.

• Contaminated jewellery should be removed, rinsed and placed in a bag or wrapped to avoid skin contact and then handed back to the patient.

• If possible, get the patient to do as much as possible with directions; this may not always be possible but will greatly reduce the exposure to the first responders.

• Do not apply any form of dressing or gel until the burn has been adequately irrigated.

• Minimise on-scene duration for patients with large burns or burns on the face, eyes or hands.