Every year in Victoria, around 5,000 presentations to emergency departments are related to burns.2 Emergency department presentations, hospital admissions and deaths have remained stable, though rates of burns remain high in males, children and older people.
A burn is a complex trauma that requires multidisciplinary care and ongoing therapy. Burns can range from minor to severe and may be thermal, electrical or chemical. Burn injuries can have a devastating impact on both the patient and family, resulting in both physical and psychological scarring.
Full personal protective equipment (PPE) for health professionals must be worn throughout treatment to ensure the safety of care providers.
Burn assessment can be challenging in the pre-hospital setting especially in regard to determining burn depth when burns may not have fully evolved. Once the patient has reached the designated health service, accurate early identification of the burn depth and percentage of total body surface area (TBSA) will guide definitive treatment.

Deep thermal burn
Image used with permission from the Alfred Hospital

Thermal burns

A heat induced, or thermal, burn occurs when the skin comes into contact with a source of heat such as a fire, a hot surface, scalding liquid or heated objects. Thermal burns are the most common type of burn and affect roughly 1% of the population per year.3
There is a greater risk of inhalation injury with flame burns in an enclosed space than with scalds to the neck and face for example. Any suspected inhalation injury should be managed promptly with a thorough assessment of airway stability.

Electrical burn to the axilla
Image used with permission from the Alfred Hospital

Electrical burns

Electrical injuries are classified as low voltage(< 1,000 volts) or high voltage(> 1,000 volts)4 however arc flash or arc explosion should also be treated as a high voltage injury presentation. A thorough history of the incident is crucial to understanding the degree of injury. The size of the entry or exit wound does not necessarily correlate with the amount of deep-tissue damage that may have occurred. The route through which the current has flowed is most important. Conduction of electrical current through the mediastinum may cause myocardial damage and associated local tissue destruction. Arrhythmias may occur immediately and up to 24 hours post injury,3 therefore continuous electrocardiogram (ECG) monitoring is required in all electrical burns patients who have an ECG abnormality.
For these injuries, initial management is the same as for thermal burns. Adequate fluid resuscitation is important, as in all severe burns. This is especially important in electrical burns due to the destruction of deep-tissue regions and the possibility of developing rhabdomyolysis.

Chemical burn - Cement
Image used with permission from the Alfred Hospital

Chemical burns

Chemicals will continue to cause damage while on the skin. Dry chemicals should be brushed off. The main goal in initial treatment is decontamination; remove all contact of the chemical from clothing and thoroughly irrigate the burns. Damage to tissue will continue to occur until the agent is weakened by dilution or inactivated with a specific neutralising agent. The amount of damage to tissue is directly related to the strength and volume of the agent, as well as the manner and duration of contact with the skin, the extent of penetration and the mechanism of action. Similarly, a thorough history of the exposure must be established to ascertain possible damage.5


Severe burns

A severe burn injury requiring immediate transfer to a MTS includes any burn greater than 20% TBSA, high-voltage electrical injury burns and any inhalation burns. A patient who has suffered a severe burn injury should be assessed and managed as a major trauma patient; polytrauma may co-exist, especially when there is a significant mechanism of injury. All patients with severe burns must receive a rapid and systematic primary and secondary survey. The main goal is to ensure optimum resuscitation in the emergency setting as well as activation of the retrieval network, with timely transfer to an appropriate burns facility. For non-severe burns injuries, refer to the Victorian state burns clinical practice guidelines for management and to ascertain whether a non-immediate transfer to a specialist facility is required.

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