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The assessment and classification of non-complex burns injuries

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A burn or scald, however minor, is painful and distressing. Patients with non-complex injuries may find that their quality of life is affected by pain, wound dressings and fear of disfigurement, as is the case, albeit for a shorter period of time, with more complex injuries.

Abstract

VOL: 99, ISSUE: 25, PAGE NO: 46

Ann Fowler, BSc, DSPN, RCN, is clinical nurse specialist, Centre for Plastic Reconstructive and Burns Surgery, Mount Vernon Hospital, West Hertfordshire Hospitals NHS Trust

A burn or scald, however minor, is painful and distressing. Patients with non-complex injuries may find that their quality of life is affected by pain, wound dressings and fear of disfigurement, as is the case, albeit for a shorter period of time, with more complex injuries.

The care of patients with non-complex (minor) burn injuries is usually nurse-led, and services should be aimed at: preventing or reducing the risk of infection and providing pain relief, topical wound care and good patient education.

Patients with superficial burns can be managed as outpatients in A&E departments, minor injuries clinics, walk-in centres and GP surgeries rather than at specialist centres. This article will focus on the clinical assessment of the burn injury and provide details of referral criteria proposed by the National Burn Care Review Committee (NBCRC) in 2001.

Assessment of severity of injury

The primary assessment of the severity of a burn is based on clinical observations and personal history taken from the patient. It involves estimating the following:

- The extent of body surface involved - the total body surface area affected (TBSA);

- The depth of tissue damage (see Box 1).

Assessing total body surface area

The total area of the burn is significant as the skin acts as a barrier to the environment - without it patients are at risk of infection and loss of body fluid. Burns that cover more than 15 per cent of TBSA in adults, or more than 10 per cent in children or people over 70, can lead to shock and will require hospital treatment with intravenous fluid replacement and intensive burns care.

TBSA has been calculated using various formulas. That most familiar to British medical and nursing staff is the so-called rule of nines, where the body is divided into sections divisible by nine (Kyle and Wallace, 1951). This is most often used with adults. Lund and Browder (1944) provide a formula that can be used with children. This is considered more accurate and allows for the differences in children’s body sizes.

A simple rule of thumb when assessing TBSA is to consider the palm of the patient’s hand with closed fingers as being roughly one per cent of TBSA. This is useful for assessing small burns or in emergency situations. It is also a useful measure for those less familiar with other assessment formulas. When making an estimate of TBSA, however, it should be remembered that simple erythema (reddening of the skin) is not be included in such estimates.

Assessment of depth

The ability of skin to repair itself following injury depends on the depth of the burn.

- Superficial partial-thickness burns involve the epidermis and papillae only, producing red serum-filled blisters; the skin blanches easily on pressure. The burn is very painful and sensitive to touch, as well as exposure to air. Healing occurs in 10-14 days with virtually no scarring.

- Deep partial-thickness or deep dermal burns involve loss of the epidermis and varying depths of the dermis. The burn may appear pink and white, and may or may not blanch on pressure (depending on the extent of tissue damage). The patient will experience varying degrees of pain; in a pin-prick test the patient cannot usually discriminate the sharp point of the needle to the blunt end. Where hair follicles are still visible, epithelial cells will be present (as will sweat glands), which can result in regeneration of tissue; healing can occur within 14 days. Deep partial-thickness burns can heal if protected from infection but scarring occurs and they may take up to five or six weeks to re-epithelialise.

- Full-thickness injury refers to the loss of epidermis and dermis. This type of injury requires skin grafting.

Non-complex burns

Non-complex burns, which were previously described as minor burns, can be classified as covering no more than five per cent of TBSA and as being no deeper than superficial partial thickness. They can be expected to heal spontaneously without grafting in 10 days to three weeks. If there is any doubt about the nature, severity or significance of the injury, the assessing staff should consult their local burns and plastic surgery service.

Definition of non-complex burns - Non-complex burns vary, but are usually defined by the following:

- The burn covers less than five per cent of TBSA;

- There is obvious superficial erythema (redness) on any part of the body;

- It is a superficial partial thickness (SPT) burn affecting less than five per cent of TBSA in a fit, healthy individual aged between five and 60 years;

- An adult with a burn affecting five to 10 per cent of TBSA that does not require a skin graft;

- Deep burns (other than electrical) less than 2.5cm in diameter on the trunk, arm or leg;

- Children with a burn affecting less than one per cent of TBSA.

It is important to remember that other medical or social conditions, such as coexisting respiratory or cardiac disease, can necessitate the patient being admitted into specialist care (a burns or plastic surgery unit). Admissions criteria are not based purely on the size and depth of the burn, and careful assessment of the patient is required.

Toxic shock syndrome is a very rare and serious, sometimes fatal, complication of burns (including non-complex burns) in children. If there are any concerns or doubts about a burns injury received by a child, the individual should be referred to a plastic surgery unit on the day of the incident.

Complex burns

National burn injury referral guidelines provide criteria for treatment of burns in a burns care unit (NBCRC, 2001). A burn injury is likely to be classified as complex if any of the following apply:

- The patient is aged under five years or over 60 years;

- The injury is a dermal or full-thickness burn in a child under 16 years and involves more than five per cent TBSA, or more than 10 per cent in the case of an adult;

- The burn involves the key ‘special’ sites - the face, hands, perineum or the feet;

- The burn involves any flexures, especially the neck or axilla areas;

- The injury is a circumferential dermal or full-thickness burn of the limbs, torso or neck;

- The trauma is an inhalation injury;

- The injury involves any of these factors: chemical burns greater than five per cent of TBSA; ionising radiation; high-pressure steam; high-tension electrical burns; hydrofluoric acid of more than one per cent TBSA; suspicion of non-accidental injury.

A burn injury is also deemed complex if it occurs alongside conditions such as cardiac or respiratory problems, immunological conditions, pregnancy or when patients have associated injuries, such as fractures, head, crush or penetrating injuries.

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