The assessment and classification of non-complex burns injuries
Fowler A. Nursing Times. 2003; 99(25): 46-47.
- A burn or scald, however minor, is distressing and painful. Patients with non-complex injuries may find that their lives are affected by pain, wound dressings and fear of disfigurement just like more complex burns injuries.
- Before a burns injury can be referred for treatment it must be fully assessed and classified.
- To provide practical guidelines for the assessment and classification of burns. Provides details of the referral criteria proposed by the National Burn Care Review Committee (NBCRC) in 2001. Precedes guidelines on management of superficial burns and superficial partial-thickness burns.
- The care of patients with non-complex burns 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 out-patients in A&E departments, minor injury clinics, walk in centres and GP surgeries rather than at specialist centres.
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 total body surface area (TBSA) affected.
- The depth of tissue damage (see box 1).
Assessment of 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 > 15% of TBSA in adults or > 10% 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. The most familiar to UK medical staff is the rule of nines, where the adult body is divided into nine sections.
- A more accurate formula for children has been developed which allows for differences in children’s body sizes (Lund and Browder, 1944).
- A simple rule of thumb when assessing TBSA is to consider the palm of the patient’s hand with closed fingers as being roughly 1% of TBSA. This can be useful for assessing small burns or emergencies.
- When making an assessment of TBSA it should be remembered that simple erythema should not be included.
Assessment of depth
- The ability of skin to repair itself after injury depends on wound depth.
- Superficial and partial-thickness burns involve the epidermis and papillae only, producing red, serum filled blisters with the skin blanching easily on pressure. The burn is very painful and sensitive to touch and exposure to air. Healing occurs in 10-14 days with virtually no scarring.
- Deep partial-thickness burns 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 discern the sharp point of the needle from the blunt end.
- Where hair follicles are present epithelial cells will be present (as will sweat glands), which can result in regeneration of tissue. Healing can occur in 10-14 days. Deep partial-thickness burns can heal if protected from infection, but scarring will occur and they may take up to 5 or 6 weeks to re-epithelialise.
- Full thickness injury refers to the loss of epidermis and dermis. This type of injury requires skin grafting.
- Non-complex or minor burns can be classified as covering no > 5% of TBSA in a fit, healthy individual aged 5-60 and no deeper than superficial partial-thickness.
- An adult with a burn affecting 5-10% of TBSA that does not require a skin graft.
- There is obvious superficial erythema present.
- Deep burns (other than electrical) < 2.5cm in diameter on the trunk, arms or leg.
- Children with a burn affecting < 1% of TBSA.
- They can be expected to heal spontaneously between 10 days – 3 weeks.
- If there is any doubt about the nature, severity or significance of the injury then staff should consult with their local burns or plastic surgery service.
- Other medical or social conditions, such as co-existing respiratory or cardiac disease, can mean the patient needs to be admitted into specialist care (burns or plastic surgery unit).
- Toxic shock syndrome is a very rare, sometimes fatal, complication of burns, including non-complex burns in children. If there are any concerns about a burns injury suffered by a child they should be referred to a plastic surgery unit on the day of the incident.
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 classed as complex if any of the following apply:
- The patient is aged < 5 or > 60.
- The injury is a dermal or full-thickness burn in a child aged < 15 and involves > 5% TBSA or > 10% in the case of an adult.
- The burn involves key, special sites – face, hands, perineum or 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 > 5% of TBSA, ionising radiation, high pressure steam, high tension electrical burns, hydrofluoric acid of > 1% TBSA, suspicion of non-accidental burns.
- 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.
(Insert box 1 – Characteristics of a burn wound, p.47)