Burns - For Clinicians
Referral Criteria for Adult Burn Unit
The suggested minimum threshold for referral into specialised burn care services can be summarised as:
- All burns ≥3% in adults (Over 16 yrs)
- All full thickness burns
- All burns to hands, feet, face, neck, perineum or genitalia
- All circumferential burns
- Any chemical or electrical burn
- Any cold injury
- Any burn where there is a suspicion of non-accidental injury or neglect
- Any burn with concomitant medical illness, which may influence healing e.g. diabetes, paraplegia
- Any burn with concomitant trauma e.g. inhalation
- Any burn with concomitant psychiatric illness
- Any burn not healed in 2 weeks
- Any unwell/febrile patient with a burn
- If burn wound changes in appearance / signs of infection or there are concerns regarding healing
- Any other burn that the referring department is not happy about or confident to manage
If the above criteria/threshold is not met then continue with local care and dressings as required. Burn injuries >25% TBSA + inhalation injury or >40% TBSA without will be referred and transferred to the local burn centre (Swansea).
If there is any doubt, please discuss the case with a senior member of the burns team. For urgent referrals telephone Southmead Hospital Switchboard: 0117 9505050
If you are able to send photographs of the patient, please send and discuss by email Burns@nbt.nhs.uk
Adult Burn Guidelines - Management of the Burn Wound – First Aid
- Stop the Burning Process
- Cool the Burn Wound
Stop the Burning Process:
- Remove patient from the source of injury.
- If on fire STOP, DROP, COVER face & ROLL
- Remove hot, scalding or charred clothing.
- Avoid self harm during above steps.
Cool the Burn Wound
- Cool burn with cold running tap water for at least 20 minutes
- Ideal water temperature for cooling is 15°C, range 8°C to 25°C
- Cooling is effective up to 3 hrs after injury
- Keep the remaining areas dry and warm to avoid hypothermia. If patient’s body temperature falls below 35°C - stop cooling.
- Ice should not be used as it causes vasoconstriction and hypothermia. Ice can also cause burning when placed directly against the skin.
- Duration of running water should be at least 20 minutes unless other factors prevent this (eg. large burn causing rapid heat loss, hypothermia, and multiple traumas).
- Wet towels / pads are not efficient at cooling the burn as they do not cool the wound adequately. They should not be used unless there is no water readily available i.e. in transit to medical care. If required use 2 moistened towels/pads and alternate at 30 second intervals.
- Remove any jewellery or constrictive clothing as soon as possible.
Seek Medical Advice
For urgent referrals or if there is any doubt please discuss the case with a senior member of the burns medical team via Southmead Hospital Switchboard: 0117 9505050
For all burn wound injury and wound management advice please contact:
- Adult burns unit, Gate 33a, level 2 telephone: 0117 4143100 or 0117 4143102
- Acute Burns Clinic telephone: 0117 4144005
- Karen Highway Adult Burns Specialist Nurse Bleep 1380
- Burns SHO on-call bleep 1311 or via switchboard.
For transfers to the Burns Unit, remove all jewellery cover burn injury with cling film or clean dry sheet if evacuation is to occur quickly. Do not apply any creams or ointments. Be aware not too wrap the cling film too tight as this can cause a tourniquet effect if applied circumferentially and additionally restrict limb movement. Only if transfer is to be significantly delayed then the burn wound should be washed with chlorhexidine solution 0.1% or normal saline then more formal dressings should be applied. This should only be after liaison with the receiving burn service. If applicable, then simple application of non-adherent film, tulle/jelonet/gauze dressings to the burn wounds and wrap secondary dressings of gauze and crepes bandages loosely too allow for potential excess swelling. Elevate limbs if applicable. Keep patient warm (blanket, space blanket).
Remove contaminated clothing (store in a protective container for disposal later) and dry chemicals. Copious irrigation is required with tepid running water or saline as appropriate. Continued prolonged irrigation is required for all chemical burns for one hour or more until the patient’s chemical burning sensation has ceased/neutralised even if pH test strip is normal. Neutral = 7 or until transfer if appropriate. Bitumen and alkali burns require irrigation with water for an even longer period than other chemical burns. Hydrofluoric acid burns require neutralisation with calcium gluconate. Please discuss management with on-call burns team. Chemical eye injuries require copious water irrigation. Diphoterine is very helpful. Refer to ophthalmologist. Please bring chemical agent if available or provide details of the chemical agent. Contact the National Poisons Help line for advice.
Relevant history may include loss of consciousness or cardiac symptoms such as chest pain or palpitations. A twelve-lead ECG should be undertaken. Cardiac monitoring is required within the first 24 hours period for significant injuries. Please discuss any episode further with the on-call burns team. Please note that all significant electrical injuries should be admitted to a burns service for definitive treatment.
Clean with saline and apply soft paraffin to raw areas Apply soft paraffin to lips, clean eyes with saline, refer to ophthalmologist if required and apply eye drops or ointment as appropriate e.g. chloramphenicol ointment. Exclude injury-using fluorescein. Consider airway assessment and monitor for airway swelling, anaesthetic review if any concerns and discuss with on-call burns team.
Blisters (Burns only)
Small ones of 1 cm or less may be left intact, however, large ones and blister over joints will need to be de-roofed and dead skin trimmed away. Redress with non-adhesive dressings such as Mepitel, Adaptic Touch or hydrocolloid to small superficial wounds only. Do not wrap hydrocolloid dressings circumferentially around fingers but place in longitudinal strips.
Clean with saline, tepid tap water or shower patient (if applicable and stable). If wounds are contaminated with dirt particles or infection suspected then warmed diluted 0.1% chlorhexidine solution (Savlon) should be used.
After Wound Assessment
Apply suitable low adherent dressing e.g. paraffin gauze (if daily dressings) or hydrocolloid dressing (if wound is superficial with low exudate). If paraffin gauze is used, a secondary dressing of gauze and bandage is required. Hydrocolloids can be used without a secondary dressing where there is little exudate (can be useful for fingers to facilitate movement). If transferring a hand burn this can be temporarily placed in plastic bags to facilitate movement and comfort, depending on the extent of the burn. If delayed transfer or not transferring to the burns unit then hand burns and individual fingers will need to be redressed with a non-adhesive dressing such as Metipel or Adaptic Touch No ointment is used in bag. Do not use Flamazine or Flammercerium until seen by the burns surgeon, as these should not be used if the depth of the burn is unclear, as it will mask the appearance of the depth.
All patient’s tetanus status should be checked and revised protocol applied.