Clinical Review ABC of burns

Management of burn injuries of various depths

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7458.158 (Published 15 July 2004) Cite this as: BMJ 2004;329:158
  1. Remo Papini

    Introduction

    Accurate assessment of burn depth on admission is important in making decisions about dressings and surgery. However, the burn wound is a dynamic living environment that will alter depending on both intrinsic factors (such as release of inflammatory mediators, bacterial proliferation) and extrinsic factors (such as dehydration, systemic hypotension, cooling). It is therefore important to review the wound at regular intervals until healing.

    Optimum treatment of the wound reduces morbidity and, in larger injuries, mortality. It also shortens the time for healing and return to normal function and reduces the need for secondary reconstruction.

    When epithelialisation is delayed beyond three weeks, the incidence of hypertrophic scarring rises. Hypertrophic scars occur in 60% of burnt children aged under 5 years. Early grafting of those burns that have not healed at three weeks has been shown to improve the result, but because of delays in the referral process, all injuries, which show no sign of healing by 10 days, should be referred for assessment.


    Embedded Image

    Flame injury showing all burn depths

    Treatment

    Epidermal burns

    By definition these affect only the epidermis and are typified by sunburn. Blistering may occur but is not common. Supportive therapy is usually all that is required, with regular analgesia and intravenous fluids for extensive injuries. Healing occurs rapidly, within a week, by regeneration from undamaged keratinocytes within skin adnexae.

    Superficial partial thickness burns

    These affect the upper dermis and the epidermis. Blistering is common. The exposed superficial nerves make these injuries painful.

    Healing is expected within two weeks by regeneration of epidermis from keratinocytes within sweat glands and hair follicles. The rate of regeneration depends on the density of these skin adnexae: thin hairless skin (inner arm, eyelids, etc) heals more slowly than thick or hairy skin (back, scalp, and face). Progression to a deeper burn is unlikely but can occur if the wound dries …

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