Initial management:

First Aid

 Cool the area with running water for 20 minutes but avoid hypothermia (useful up to 3
hours after burn).
 Do not apply ice or ice slushDo not apply gel burn products as a first aid measure.
 Burns to the eyes require early copious irrigation with normal saline or water.
 Irrigate chemical burns with copious volumes of water.
 Plastic (cling) wrap useful after cooling (limits evaporation and heat loss).
 Cold water compresses (changed frequently) can be used for localised burns, but
should not be used on extensive areas as can cause hypothermia.

Pain relief

 Immediate oral analgesia should be provided - paracetamol and oral opiates should
be used.
 Fentanyl (intranasal) - 1.5 mcg/kg.
 In addition, parenteral opiates may be effective: Morphine (IV) - 0.1 mg/kg given in
titrated boluses.
 Inhaled nitrous oxide can be useful for dressing applications initially with appropriate
analgesia.
 Ongoing oral analgesia
 See Analgesia & Sedation guidelines

Assessment:
Airway and breathing

 Assess for presence of stridor, hoarseness, black sputum or respiratory distress,

singed nasal hairs or facial swelling.
 Oropharyngeal burns and significant neck burns usually require immediate intubation
even if the airway is not yet compromised; consult anaesthetics/ICU/PETS early.
 Immobilise cervical spine if associated trauma.

Circulation

 Early hypovolaemia is rarely related to the burn injury and other sources of bleeding
should be sought.
 For circumferential burns, check for signs of circulatory obstruction and the need for
an escharotomy; elevate the limb.
 For electrical burns, take 12 lead ECG. High voltage limb burns may require early
fasciotomy.


Estimation of Surface Area

  Use a Burn diagram (LUND-BROWDER) to accurately calculate the area burnt; do
not count skin with isolated erythema.
 As a rough measure, the child's palm represents 1% Body Surface Area (BSA)
 BSA involvement determines need for fluid resuscitation and admission, as opposed
to dressings and potential outpatient management (see below)
 Burns depth assessment is very difficult and unreliable in acute settings, and for
practical purposes, the identification of deep burns is most important.

Depth Cause Surface/colour

Superficial Sun, flash, minor scald Dry, minor blisters, erythema,

brisk capillary return

Partial thickness- Scald Moist, reddened with broken

superficial
 (superficial dermal) blisters, brisk capillary return

Partial thickness- deep
 (deep Scald, minor flame contact Moist white slough, red mottled,
sluggish capillary return
dermal)

Full thickness Flame, severe scald or flame Dry, charred whitish. Absent
contact capillary return

Acute Management:
Management of Major burns >10% BSA

Airway and Breathing

 For signs of airway burn or lung injury, arrange intubation as soon as possible and
before airway swelling occurs.

Fluids

 If > 10% of body surface involved, commence Burns fluid resuscitation and calculate
fluid requirements from the time of injury. Preferably insert IV line through uninvolved
skin.
 Insert urinary catheter if burn > 15% SA or if significant perineal burn.
 Insert NGT if > 15% deep partial thickness or full thickness burns; start feeding within
6-18 hrs
Investigations

 Hb, electrolytes, blood glucose, blood group and hold.

 Carboxyhaemoglobin levels (if fire in confined space).

Document the following:

 Time of burn
 Extent - Burn diagram
 Depth
 First aid
 Tetanus status

Management of minor burns (isolated, <10% BSA)

 Analgesia; children may require opiates before assessment and initial dressings.
 Immobilisation with sling and splinting is suggested for upper limb burns.
 Check Tetanus status.
 Closed dressings are recommended for partial thickness burns. The wound exudate
determines the number of dressing changes.
 The depth of a partial thickness burn may only be declared after 7-10 days.
 Evidence regarding the management of blisters is limited:

 May have protective function, and reduce pain if left intact for a few days.
 If small, not near a joint and not obstructing the dressing, should be left intact.
 In children, small blisters may require debridement as they cover a greater
relative surface area.
 Large blisters should be deroofed to allow for accurate assessment of the
wound base
 If overlying a joint, de-roof as may limit function.
 De-roof if a silver dressing is used.
 De-roof if blister fluid becomes opaque (suggests infection).

RCH Burns Dressings

Superficial burns with erythema only:

 Can be treated by exposure. In infants who show a tendency to blister or scratch, a

protective, low-adherent dressing (eg. Mepitel™ + Melolin™) with crepe bandage
may be helpful.
Partial thickness burns

 Cleanse the burn and surrounding surface with saline and pat dry. If treatment is
delayed or wound is dirty, use aqueous chlorhexidine 0.1% then saline.
 For small, superficial partial thickness burns, a low adherent dressing (eg. Mepitel™
+ Melolin™) then crepe bandage or adhesive paper.
 For more extensive or deeper partial thickness burns, a low-adherent silver dressing
(eg. Acticoat™ or Acticoat 7™) should be applied.

Facial burns

 Superficial burns only require Vaseline™ to be applied twice daily, whereas partial
thickness burns may need silver dressings. Good education regarding care of the
burn is essential - see handout Burns on the face
 For more details and advice regarding specific area burns, please see RCH Burns
unit Clinical Information
*Although references are made to specific products in this guideline, it is possible that other
products may be suitable to use in their place. Seek advice from the Product Information,
treating physician or dressings specialist.

Consider consultation with local paediatric team:

 Concern regarding non-accidental injury

 Multiple co-morbidities
 Concern regarding social situation or dressing compliance

When to consider transfer to tertiary centre:

The following circumstances should prompt discussion with the Burns Service at RCH (on-
call surgical registrar via RCH switchboard). They may suggest transfer, local review, or
review in the RCH Burns Clinic.

 Partial thickness (superficial) burns with a surface area greater than 10%, except
very superficial burns.
 All full thickness burns, except those that are extremely small.
 All burns to face, ears, eyes, hands, feet, genitalia, perineum or a major joint, even if
less than 5-10%.
 Circumferential burns.
 Chemical burns.
 Electrical burns (including lightning). Extensive tissue damage can occur to
underlying structures.
 Burns associated with significant fractures or other major injury.
 All inhalation burns.
 Burns in children under the age of 12 months.
 Small burns in patients with social problems, including children at risk.
 Child requiring care beyond the comfort level of the hospital, or advice regarding
appropriate dressings or disposition.

Transfer of patients from other hospitals for assessment

 If time from burn to arrival at burns centre is <6 hours and the burn is clean:

 Wash with saline, cover with plastic cling wrap for transfer (do not wrap
circumferentially), allowing for easy assessment at the burns centre without
undue discomfort from removal of dressings.

 If transfer is likely >6 hours or burn is dirty:

 Dirty or charred burns should be washed with aqueous chlorhexidine 0.1% and
dressed with Acticoat™ (or SSD cream if the former unavailable).
  Clean burns should be dressed with a low-adherent dressing - (eg Mepitel™).

For advice or ICU level transfer ring the Sick Child Hotline: (03) 9345 7007
Follow up:

 Burns are dynamic injuries and can evolve over time. A follow up review should occur
within 3 days of initial presentation to reassess depth, monitor healing and determine
ongoing management.
 If burn depth is unclear after 3 - 5 days, referral to a burns team is warranted.
 Urgent review for increased pain, redness, swelling, fever, chills or rash.
 Burn injuries which are slow to heal (eg poor progression at 5-7 days) should be
referred for outpatient review by a burns team.
 If a superficial burn has not healed in 7 - 10 days, it has either become infected or is
deeper than anticipated.