Chantelle: We’ll get this webinar underway. Welcome to the latest instalment of our Rural Health webinar series. This webinar is: How deep is that burn: Assessment and management of minor burns for Rural GPs, which will be presented by Dr Carl Lisec who's a general and burn surgeon at the Royal Brisbane and Women's Hospital. He is also a Conjoint Academic Coordinator for the University of Queensland, a board member for the Australian and New Zealand Burn Association, a Queensland Trauma Committee Member and an AUSMAT surgical team member.
RACGP would like to start with an Acknowledgement of Country. RACGP would like to acknowledge the traditional owners of the land on which this event is being broadcast and we pay our respects to their elders past, present and emerging.
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I will now hand over to our presenter, Dr Carl Lisec.
Dr Carl Lisec: Thanks Chantelle. It's my pleasure to be here tonight and thank you very much for the invitation. Tonight we're going to cover these things and hopefully that's been sent out prior to tonight's presentation. But the main thing that I want everyone to get out of tonight is how to assess burn depth – I think that's going to be one of the focuses of tonight's presentation.
And this is how you do it. I'm going to start off by saying you need two things to start to estimate the depth of the burn: mechanism and you need to look at the colour of the burn. So, as always, we start off by taking a history and mechanism is really, really important for burns because it allows you to tell the likely depth of a burn. And once you've gone through a few examples (as we will do tonight) hopefully you'll get to see that there are certain mechanisms that are always deep burns and we worry about, and there are more benign mechanisms, which we’ll go through. And then the second thing is the colour – you need to look at the colour of the burn. You can forget about all those other things like capillary refill and sensation and feeling the burn (how thick it is), you know, you don't really need any of those things. All you need to do is look at the burn and it's either going to be pink, red, or white – they’re the three colours that you need to remember in burn wound assessment. Pink is good, pale is bad, and red is somewhere in between. And we're going to go through that in more detail.
First of all, with the history, there are some mechanisms that when they happen I think to myself, well that's probably going to be fine – the patient's not going to need a skin graft, they're going to heal within the prerequisite two week mark (which we aim for), and they're unlikely to need transfer to a burns unit or to even be seen in the burns clinic. So sunburn is a fairly benign thing. Similarly most of the hot water scalds in adults we see are usually benign. Children, however, it's a different story – if children have a hot water scald, if they pull tea or coffee off the counter or, you know, the saucepan full of hot soup or whatever, with children scalds are usually bad. But it's different in adults because adults have a good reaction time, they get good first aid usually, and they've got thicker skin.
If you have a very brief contact with something hot – I mean you can brush up against something that's really, really hot but if it's very brief contact, then it's unlikely to cause significant burn injury. Gas ignition flash burns, you know people lighting barbecues, LPG cylinders that sort of thing, you know, it might produce a significant burn but the flash is so quick that they're very rarely deeper than superficial partial thickness. Most steam and radiator burns are similar – you know, when you open the car bonnet and you open the radiator and you get a steam burn, most of them are fine as well.
When you're taking a history, these are the things you're thinking about – you're thinking of what temperature it is (and we're dealing with thermal burns here), what temperature is the agent causing the burn and how long was it in contact with the skin? The burn depth is going to be a function of those two things. So you can actually get burned by something at 44-45 degrees if you hold it on the skin long enough – but that would need, you know, quite a few minutes in order to produce a burn. So always think about temperature and time when you're looking at taking a history with the burn.
So these are some examples of significant mechanisms. So when I hear this sort of story, this sort of mechanism, I automatically think the patient is going to need to come to the burns clinic, they might need a skin graft, they are probably going to be in hospital and they’re probably going to take a long time to heal. So whenever someone's clothes catch on fire that's usually bad. If you have a scald and there's hot liquid and you struggle to get your clothes off or if the patient's got poor reaction times such as an elderly patient in a nursing home with dementia or Alzheimer's etcetera then they’re going to be deep. Any burn involving petrochemicals are usually deep. I've got a few examples of pictures coming up soon but any of those burns usually are deep and they usually need a skin graft – you have to be lucky not to require surgery for that. If you have a diabetic foot burn, most of the time they take weeks and weeks, sometimes months, to heal and we see two sorts of common patterns of injury with diabetic feet – in the summertime they walk on hot pavement or sand or bitumen and they burn their feet because of that peripheral neuropathy, and in winter it's usually from sitting in front of a fire or a heater and they don't feel their feet burning. So because of the time where they don't feel their feet burning, it's usually a deep injury. Hot oil is different from water because obviously it's a hotter temperature, higher temperature and particularly if the oil is on fire, once the oil reaches its flash point, it's usually several hundred degrees. So hot oil on fire is usually bad – it usually needs a skin graft. Contact burns from exhaust engine parts, you know exhaust from a motorcycle, they're usually bad because the patient is usually pinned under the motorcycle for a period of time. Most of the chemical burns we see (the most common ones we see are oven cleaner contact and also concreters when they get lime or concrete down in their boots and they don't notice it until the end of the day when they take their boots off and they've got full thickness alkaloid burns to their calves). And these are some other common ones – electrical arc from car batteries (that's more common than you think – if you touch your wedding ring or a ring on your finger to the battery, it can arc and because it's electrical it's usually a deep burn) and then lastly all the self-harm burns that we see, you know, they're obviously doing it with intent to cause a lot of harm so most of the time they're quite deep.
Now the list I've provided so far is all the sort of common burns that we see in the adult burns unit – and I should have qualified at the start of my talk that I'm going to be predominantly talking about adult burns but a lot of what I saying also applies to paediatric burns, but these are the common ones we see in the adult population.
Before we get to some pictures (and I've got lots of pictures tonight and it's, you know, a lot about pattern recognition for telling the depth of the burn), before we get to that, I thought you know, no burn talk is complete without talking about the layers of the skin. I'm sure you all know, we've got two layers – epidermis and dermis – and the thickness of the epidermis and dermis varies throughout the body and with age. For example, we've got very thick dermis on our back, whereas the dermis on our eyelids is very, very thin. An area of the body where the epidermis is quite thick is actually on the soles of the feet and the palms of the hand – that specialised skin or glabrous skin, when you get a blister on that part of the body you might notice that the blister is very thick and that's because the epidermis is thick.
And just in another diagrammatic form, this is just to remind everyone that this is what happens when you have a blister – the epidermis lifts off the underlying dermis and fluid accumulates between those two layers. So as soon as you see a blister, by definition, you have a partial thickness burn there has been an injury to the dermal component of the skin, the dermis. As soon as the dermis is injured, then you get a blister forming. And the blister can be intact, it can be tense, it can be flaccid and kind of loosely applied to the underlying dermis, or it can be wiped off completely. It doesn't matter how it presents, the fact that there's a blister present means that it's a partial thickness burn at the very least.
In terms of the nomenclature, you've probably all heard of first, second and third degree. This is the current nomenclature endorsed by the Australian and New Zealand Burn Association. We talk about epidermal burns, which are burns just limited to the epidermis. And the classic example of an epidermal burn will be sunburn, you know, just mild sunburn, so sunburn where you don't have a blistering sunburn. With sunburn there is simple erythema, you know, it's painful for a few days and then it gets better with moisturiser.
Then next, as we go deeper down, these are the partial thickness burns. So you have superficial, mid, and deep dermal and these are the three colours that I alluded to at the beginning of the talk – pink, red and white. As you go down through the layers of the dermis the burn gets paler. So pink is good, pale is bad, and then red is somewhere in between.
And then, last of all, full thickness burns are obviously all the way through the skin down into the fat or underlying tissue. They're usually pretty obvious to tell when it's a full thickness burn (but, again, I've got pictures coming up).
So just to clarify, again, pink, red, white. These are the colours that you need to remember when you're assessing burn depth. And the reason I've tried to simplify it like this is that in this day and age we get most of our burn referrals through telemedicine, some form of telemedicine, and reliably every time with every referral I get two things – I get the history of what happened to the patient and I get a nice colour photograph of the burn. And I guess I've become good at picking burn depth over the years because these are the only two things that I'm provided with on telehealth, but I think anyone can use this this technique of estimating burn depth because there's only three colours to remember and it's very simple.
So, here we go – I've got lots and lots of photos. This is the biggest blister I could find on our email system (I hope you enjoy it). So this is a partial thickness burn – why do I say that – because there's a blister. So I know that there's been an injury to the dermis, the epidermis is lifted off, and there's fluid collecting between the epidermis and the dermis. Now if I told you this patient had a splash with hot oil from a pan (it wasn't on fire, but it was pretty hot) but they had really, really good first aid and then they came to the emergency department. Now the mechanism would suggest that it's a deep burn because, you know, it's hot oil and we know that hot oil is probably worse than hot water. But the next thing we need to do is to look at the colour of the burn and I like showing this picture because we cannot see the colour of the burn yet because the epidermis is in the way. When you are assessing the burn depth in terms of colour you need to look at the dermis. So, for this burn, we deroofed it partially and now we can see the underlying dermis and hopefully you can all agree that the underlying dermis is nice and pink. So this is a superficial dermal burn and this will heal within sort of 7 to 10 days probably if it's looked after. It won't need surgery and it probably won't scar. The point of this slide is that we need to look at the underlying dermis. If you want to try and judge the depth of the burn you need to see the dermis. Now, I'm not saying that we have to deroof all blisters or removal blisters (and I'm going to mention blister management specifically later in the talk) but in looking order to determine the depth you have to see the dermis – that's the point.
Every burn, no matter who it is or where it is, should heal within two weeks. If a burn heels within two weeks, then the patient is very unlikely to have hypertrophic scarring or contractures or any long-term functional or cosmetic impairment as a result of the burn. Some people, some burn centres, will push that out to three weeks, but we are a little bit more aggressive at the unit that I work in and we prefer two weeks. So this might come in handy one day because if you're seeing a burn and it's 12 days old and it's, you know, it's still a raw wound and it's still healing and the patient hasn't been discussed with the burns unit then they probably should be referred because time is ticking. We want all burns to heal within two weeks – that's the sort of magical number to remember.
Next I'd like to just go through the various depths of burn and I've got some pictures demonstrating each one. And I know this talk tonight is going to be recorded so if you forget it, you can bring it up again and just go through it – but just remember pink, red and white as we go along. Before we get to the partial thickness burns, we're going to talk about epidermal burns.
I won't spend too much time on this because everyone can pick simple erythema. There's no blistering. This is from a scald – hot water down over the back of the head. No blistering, simple erythema. It's going to heal. It's just like sunburn. And even if a burn like this is on the hand or in a special area or if it crosses a joint (any of the typical, you know, burn unit referral criteria that you know about) if it's simple erythema, you don't necessarily have to discuss it with a burns because we're really only interested in the partial thickness burns and the full thickness burns. Having said that, if you're worried or if this is a big area or if you just want to advice then we're more than happy to take your referral.
So with epidermal burns, there's no blisters. Just as an aside, with epidermal burns, we don't count them in surface area calculations – when we're dealing with a major burn, simple erythema is ignored. We only count the blistered areas – so the partial thickness areas and the full thickness areas.
All right. Next is superficial dermal burns. So these are the burns that are pink. This young girl works at Maccas. She put her hand straight into the hot oil in the deep fryer but pulled it out straight away and got excellent first aid. And you might think well based on the mechanism that's going to be deep but you need to take, you know, both things into account – mechanism and colour. So this, I hope you'll agree, is a nice pink looking wound. It's a little bit blurry this photo so I hope it comes through on your screens, but hopefully you can also appreciate the blistering that's there. So just at the proximal extent of the burn on the forearm, there's a little intact blister and there's some also some blisters around the MCP joints on the back of the hand and the hand is quite swollen and puffy as well.
This is what it looked like a few days later, day 5. And, again, sorry about the blurry photos (the rest of my photos are pretty good) but you can see the blistered skin coming off now and it's nice and pink underneath. So this is a superficial partial thickness burn.
This is another superficial partial thickness burn. This guy was lighting a fire and using petrol, got a little bit too close, petrol ignited and he got a flash burn to his calf. And although I said petrol burns are bad, this is probably the luckiest guy in the world right now. So he's managed to get a partial thickness burn and it's not too deep. It's nice and pink. You can also appreciate that it’s moist – we've got the reflection from the lights in the room. So pink and moist burns, they’re superficial partial thickness. The blister has come off completely or it's crumbled up into the left hand side of the wound there – you can see it all crumpled up there and there's also a bit of soot and dirt and carbonaceous stuff around which will need cleaning up. So hopefully that's pretty straightforward – pink is a superficial dermal burn.
As you move down into the dermis, where you get an injury lower down in the dermis now, around the halfway mark, we call that a mid-dermal burn and these are red. Characteristically, beefy red, sort of fire engine cherry red. And this is the sort of appearance you might have seen before – so a synthetic dress caught on fire and stuck to the back of her calf when she walked too close to a campfire, young girl, 25. And this is on day one, you know, day zero when it happened. This is a good demonstration of a mixture of burn depths. It would be lovely if burns were the same depth throughout and it would make management a whole lot easier, but you can see there's a mixture of depths here. At the top there's a pink area, there's a pink rim of tissue – that is a superficial partial thickness burn. But the vast majority of this burn is red – so it's mid-dermal. And then you've got those three little islands of discoloured dermis that is eschar and that is deep dermal or full thickness areas.
You might be asking why mid-dermal burns go red. I think it has something to do with the dermal plexus within the skin. So once you start injuring the mid and the deep dermal plexus of the skin you get blood leaking out of the capillaries and the red blood cells, the haemoglobin pigment, stains the skin and it's often that cherry red colour. So whenever you see a burn that's red like this you automatically should think that it's a mid-dermal burn.
Just to show you that, you know, burns heal at different rates, this is a week later, same girl. You can see the pink area at the top which was a superficial partial thickness burn has now healed – it's got a shiny dry layer on top of it now, which is actually new epithelium. Whereas all of the beefy sort of red areas are still healing at day 7. So the mid-dermal burns will take a little bit longer to heal. And that makes sense – I mean the deeper the burn the longer it's going to take to heal. And then those three little spots of perhaps full thickness burn, they're going to take the longest to heal.
When burns heal they do so by epithelial cells growing from the sides of the wound and also from within skin adnexal structures like sweat glands and hair follicles. They grow out from those structures and they populate the surface of the burn wound. And it's our job to provide a nice moist wound healing environment for that re-epithelialization to occur.
Another example of a mid-dermal burn. You can see again that cherry red colour. Again this is a young male pouring petrol on a fire. We see a lot of that particularly in Queensland. This is one of the most common presentations in that sort of age demographic. And you can appreciate hopefully the red, kind of cherry red, stippling that occurs and that is again a mid-dermal burn. There are areas, like the last case, of deeper burn – so that brown, sort of green, discoloured area – it would be potentially deep dermal or full thickness burn.
So pink is good, superficial. Red is in the middle, mid-dermal. And next we'll talk about deep dermal burns, and these are pale white. Whenever you see a burn that is pale white, you should be thinking deep dermal.
So again, another petrol flame burn whilst trying to start a fire and got a little bit too close. So the surface of this burn appears pale and hopefully you can appreciate that it also appears quite dry – that's in distinction to, you know, the first few photos that I showed you where you've got a nice pink moist dermis. This is kind of dry and it's pale, it's white. So this is a deep dermal burn. This will need surgery. This will need a skin graft because it's deep dermal. It's probably not going to heal within two weeks.
This is a contact burn. This young girl got her wrist caught between the motorcycle exhaust and a tyre. So it's a contact burn and, again, this is a nice the demonstration of the different depths of the burns. Around the edges it's nice and pink, towards the centre it's red and mid dermal, and right in the centre there it's pale white so it's a deep dermal burn – that could actually be full thickness in the middle and you'd have to, you know, consider also the mechanism. I'd want to know how long her wrist was caught between the exhaust and the tyre – you know, if she was stuck there for two or three minutes and her skin was sizzling then that's probably going to be full thickness, whereas if it's just a brief contact and she managed to get free then it could still be just deep dermal (pale from deep dermal).
And the last partial thickness example I've got to show you is another deep dermal burn. Hopefully you can appreciate here on the skin of the thumb, the back of the thumb, it's quite pale white, you know, it's almost completely white. So too is the index finger particularly around the MCP joint. The back of the middle finger on the proximal phalanx, that's also white and deep, whereas the fourth finger and the fifth finger (the fifth finger particularly), you can see that's nice and pink. So the fourth and the fifth fingers are probably superficial partial thickness, whereas the thumb, the index finger and the middle finger plus the web space there, that's deep dermal.
Now, there are a lot of cooking analogies – it’s fitting that this guy's a chef. Why does the dermis turn white? Well, I think it's because of a few reasons. Number one, the dermis is mainly composed of protein – so collagen, elastin and when you heat up protein, it denatures, and in cooking analogies it’s is like cooking an egg. So when you heat up an egg the white goes from translucent to opaque – the same thing happens in the dermis. The other reason I think the dermis appears pale is because now you've completely destroyed the dermal plexus in the skin or most of the dermal plexus so the skin or the dermis does don't have a good blood supply – so it appears pale.
So pink, red and white. Pink is good. Pale is bad. And red is somewhere in between. What happens in patients with pigmented skin, darker skin, different skin types? We just have to remember that all of the melanocytes are in the basal layer of the epidermis as well as some of the skin appendages so that when you get a blister most of the melanocytes come away with the blister.
This is a young Indigenous girl who just had a scald on her wrist. You can see it's a partial thickness burn because there's a blister. The blister has crumpled up in the corner there and along with it comes all of the melanocytes. In the dermis you can hopefully appreciate some little brown dots – they’re hair follicles with little rests of melanocytes within them. Now her pigment will probably come back but one of the big problems we face with darker skin colours is varied return of that pigmentation – so they can end up with pale patches, hypopigmentation, or sometimes the opposite can happen, that burn wound can become hyperpigmented and changes in pigment of very hard to treat long term.
If we follow this girl up, on day one (so this is the next day) suddenly it appears quite pale. If I go back to the first picture, it's nice and pink and moist. I hope you agree on day one it looks quite pale and this is because we've been using flamazine as a dressing. This is not a pale wound. This is something called pseudo-eschar and you may have come across this before if you have used flamazine as a burn dressing. We are big on flamazine in Queensland – we recommended it a lot for our burns. Some of the other states and territories are not a big fan of flemazine – they prefer other silver-based dressings. But if you do use flemazine this is sometimes what you get you get, a pseudo-eschar.
This is another day later and you can hopefully appreciate that dermis isn’t pale. What you have is a layer of flamazine and protein sitting on top of the wound. And hopefully you can see that appearance. If you get some forceps and gradually kind of lift away it will actually come away quite easily and it will be pink underneath. So that's what a pseudo-eschar from flamazine looks like.
Now, we've been talking a lot about burn depth. I've said that it would be lovely if burns were all the same depth throughout. It would also be lovely if burns stayed the same depth over time. All too often though a burn looks good on day one and then by day three it's full thickness. Why does this happen? Well, there's lots of reasons – poor first aid, delays in presentation, swelling or edema of the affected limb (is the enemy of healing, so we really have to be quite strict with elevation and edema control), if the burn becomes infected the burn is likely to deepen, and then there are things that are out of our control. These are the patient comorbidities that they come with. So if you've got diabetic, microvascular disease or peripheral arterial disease or a patient smokes or they’re immunosuppressed in some way then the burns might look pink on day one, but by day two or three they often look worse.
Just to give you a little idea of what a burn wound infection looks like. If you are looking at a burn and you suspect infection, what you're actually looking for is cellulitis away from the burn in the normal unburned skin. So you need to be looking away from the burn and it's the typical appearance of cellulitis anywhere else. So you have redness, heat, swelling lymphangitis, lymphadenopathy, and systemic signs. If you have an infected burn I think it's always good to seek advice from your local burns unit. We have a very low threshold to admit patients to hospital, particularly if they're going to be non-compliant at home or if they're systemically unwell in any way. We treat them with rest and elevation, we give them antibiotics directed against gram-positive organisms, but in older burns and burns in the perineum or proximal thighs we always consider gram negative organisms (and the one that is the most common would be pseudomonas). You can take swabs for culture as you do usually for wounds, infected wounds. And I think in terms of dressings we prefer, I prefer and our unit prefers, daily dressings because it allows you and the patient to monitor the cellulitis, you can clean the wound daily with chlorhexidine, and because you're doing a daily wound dressing flamazine is what we recommend in Queensland, but as I said before, you might get some different advice from other units you speak to.
I just wanted to quickly mention full thickness burns. I mentioned at the start, these are usually pretty obvious. This guy tried to remove his police tracking device with a blowtorch and came in several days later after being on the run with a, you know, infected full thickness burn. This guy ended up having a free flap after being debrided by the plastics team at a different hospital.
This is a hot molten metal slag. If you’re thinking about temperature and time, this guy works at a metal works and a bit of slag went down into the boot. It was very brief contact, but the molten metal is 1200 degrees celsius. So it doesn't matter how brief the contact is, it's going to cause a full thickness burn. And that's full thickness – you can see it’s contracted, that'll be insensate, it won't have any capillary refill. Not that you have to test for those things – you can just see from the appearance of it.
This is a classic motorcycle exhaust burn. So this young girl was trapped under the motorcycle for 10 minutes – the motorcycle was too heavy for her to lift off. So her calf would have been sizzling away. You know from that story, you know from the mechanism, that it's going to be full thickness, 1) because of the time and 2) because of the hot temperature of those exhaust parts.
This is an example of a diabetic foot burn that we see. He was wearing shoes but was standing too close to a campfire and didn't feel his feet burning because of his peripheral neuropathy. So when you see black and you see different colours of purple and mottling, that's going to be full thickness. And there's the top of his foot.
This is a chemical burn. I wanted to show an example of a chemical burn. This young male was riding home with some oven cleaner tucked into his jacket pocket which leaked (the container he was using leaked out). You can appreciate that it's quite dry. It doesn't have the typical blistering appearance that you see with thermal turns and that's because the alkali has just kind of eaten through the epidermis and the dermis and you can see in the centre of it particularly it's discoloured. You might be able to appreciate thrombosed vessels in the skin, those little purple kind of dark lines throughout it. That's full thickness based on the mechanism.
All right, so we're going to move on. That was the assessment of the burn. We spent most of the time talking about that because I think that was probably the most important thing that I wanted to get out of tonight's presentation. So now we're going to talk a little bit about managing the burn wound. We're going to start with talking about the management of blisters.
You basically can do anything you want with a blister. It doesn't really matter. These are the options: you can leave it alone, you can deroof it, or you can aspirate it and leave the blister intact. There's pros and cons to doing all three. As a general rule, we like to leave blisters alone. We're not very aggressive with removing blisters. That might be different with children's burns or in different burn units, but here in Queensland and the adult units, we just tend to leave it alone. We think the blister is a good kind of biological dressing and it's also a good analgesic to have. Once you take the blister off, the pain levels go through the roof. We only treat blisters if they're causing problems with moving the hand, particularly the small joints in the hand. So with that hot oil burn I showed you at the start, we would have to do something about this blister because this patient is not going to be able to do physiotherapy properly with such a tense blister. So we'd always do something about blisters on the hands. But, in general, we kind of just leave blisters to do whatever in other parts of the body.
This is what it looks like if you leave a blister on for too long. The blister fluid will get infected. You know, it's turned green with something. So this is 13 days old and once you deroof that you can see it's mostly healed underneath. So there are times when you would deroof a blister and, you know, 13 days down the track, I definitely would deroof that blister, but early on I would only treat blisters if they were causing problems with physiotherapy, particularly on the hand.
So, the initial management of minor burns. Depending on the unit, the state and territory that you're in, you'll get probably different advice and we'll go through specific dressing advice in a second. First of all, don't forget first aid. We have to stop the burning process, cool the burn – and it's 20 minutes of cool running water – and you can do that within the first three hours. So if they turn up and they see you and the burn happened two hours ago, theoretically first aid will still be effective for the next hour. So get them in the shower, get them under a tap and do 20 minutes of cool running water and then cover the burn with a dressing or cling-wrap afterwards.
I won't go into detail about the burns unit referral criteria because that's pretty well known and it's pretty well published in different textbooks and it's on the ANZBA website, but I will say that, you know, even if a burn doesn't meet this criteria, if you're concerned or if you just want advice then any of the burn units across Australia and New Zealand would be happy to take your referral.
So with dressings, there are a million burns dressings out there and ANZBA has tried to simplify things by making this little brochure (it's available on their website) and getting, you know, 17 or 18 burn units in Australia and New Zealand to agree on addressing regime is almost impossible. So this is kind of an even ground attempt at making sense of all the dressings that are out there. If I could just go through this this card with you. For epidermal burns we don't need to put a dressing on – they just need moisturiser (just like regular sunburn), they can shower, probably keep out of the sun because it's going to be sensitive, and no real specific follow-up, particularly from the burns unit point of view (we don't really need to see these sort of referrals coming to the burns unit, however, if you're worried you can always ask).
For the superficial dermal burns, so these are the ones that are pink, as I said before we want to provide a moist wound environment. So we want to use paraffin based gauze dressings. Gauze to sort of wick away the fluid because burns are messy and paraffin to kind of seal it and keep it all moist. We don't necessarily need to use antimicrobial dressings with pink burns, however I would consider using them if you've got high risk wounds – so if you've got contaminated wounds or high-risk patients (so diabetics etc.).
And for everything else, so mid-dermal, deep dermal, and full thickness burns, we recommend silver-based dressings. And you can use any silver based dressing you want – acticoat, mepilex Ag, flamazine, as long as you're using that dressing correctly. So flamazine is a daily dressing – don't leave it on for a week. Acticoat you have to keep wet – if it dries out then it's no good. Mepilex Ag you have to keep dry. So it doesn't matter what dressing you use (you should be using an antibacterial dressing for the mid-dermal, deep dermal and full thickness burns), as long as you're using the dressing correctly.
If you dress a wound and things are going all right, we try and get it to heal within two weeks. And this is kind of where the line is – somewhere halfway down the dermis, most superficial dermal burns and a lot of mid dermal burns will follow that rule and will heal in two weeks. Everything deeper than mid-dermal burns, if you're seeing a red burn or a pale white deep thermal burn or a full thickness burn, they're probably going to take longer to heal and you probably should discuss that with a burns unit.
This is what happens when you get comorbidities or sub optimal conditions. Suddenly, all of the pink burns, all of the superficial dermal burns take longer than two weeks to heal. So if you've got a patient with comorbidities or there is, you know, any other problem, even if they've got a pink superficial dermal burn you probably need to discuss it with us.
And last of all, just in the last sort of five minutes or so, I just wanted to go through different areas of the body with some tips and suggestions on how to look after things.
So, first of all, facial burns. When someone has a burn to the face don't forget to check their visual acuity and we usually recommend doing a fluoroscein stain to check for any corneal injury. Patients usually close their eyes when there's a flash or flame or something like that, but you just can't miss a corneal injury. Always keep in mind obviously the potential for an inhalation injury – any burn above the clavicles has the potential to cause an inhalation injury We never use flamazine on the face, particularly around the eyes because it's toxic. So to dress the face, you know, no dressing stays on the face, so all we do is we apply soft white paraffin and sometimes we use chlorsig and we keep the burn wound moist until it heals. And in men we have to shave the beard every single day, so what we recommend is get a fresh razor, just a disposable razor, lots of shaving cream, it will be a little bit painful, but it's not as bad as you think and if you don't shave the beard you will be at risk of getting folliculitis and that can be difficult to treat.
For burns on the hands, you know, this is a special area – it's one of the referral criteria for a burns unit. So you might want to discuss it with your local burns team. As I said before, get rid of any blisters – either aspirate them or deroof them, particularly if they're causing problems with the movement of the joints. Physiotherapy is important – it starts from the day of the burn. So the patient needs to do range of motion exercises. Elevation helps reduce swelling. And this is a nice dressing – all the fingers are dressed individually to allow for physiotherapy to continue. Try and avoid do doing a mitten kind of dressing because that won't help with their movement.
Genital and perineal burns are messy and difficult to look after. General principles are that toileting should continue as normal. If they've got vulva burns or burns on the glands and there's difficulty urinating then they might need a catheter but we tend to try and avoid that where we can. They're messy so every time you go to the toilet the patient needs to shower or bathe and then reapply the dressing. And flamazine really comes into its own in this area. We make flamazine underpants in inverted commas because, you know, we just get a nappy or a diaper or something disposable and we smear it with flamazine and we put it on and we just tell the patient that's going to be messy until it heals. Fortunately most genital and perineal burns heal quite quickly.
Lower limb bones are a big problem. Whenever you see a burn on a lower limb this should be a red flag, particularly older people with comorbidities. The lower limb burns are at higher risk of infection than any other part of the body and I think this is because of the tendency of the lower limbs to become swollen and edematous and that, you know, the distance from the heart, the further away the circulation is, the poorer it is, so poor circulation and swelling is a recipe for infection. So we always have a very low threshold to admit these patients for bed rest and elevation. And if there is infection we start antibiotics early. And edema control, you know, apart from elevation, a good idea is to provide the patient with some outer sort of light compression using, you know, one or two layers of tubigrip. But the patient, you know, if they can't be trusted, if you’re worried about compliance, get them admitted to hospital and refer them to a burns unit.
And then we have contaminated burns last of all. So patients will often jump into a creek or roll around in the dirt to put out the fire and these wounds are also probably more prone to infection because of the contamination. You have to get off all of the contamination – you have to get off the bits of grass and dirt and whatever else is sitting on the wound. We use an aqueous chlorhexidine solution to do that. Remove all the foreign material and, you know, if you're doing this in your office or in your emergency department, then they might need a bit of sedation to do this, but it's best to get all of the contamination off. And when you've got a contaminated burn this is where I like to do a daily dressing because I know that the wound is at risk of infection and I want to keep a close eye on that. So flamazine is a great dressing for contaminated burns like this.
So that brings me to the end of the presentation. I've left about 15 minutes or so for questions. So I'm happy to take any as they come. Thank you very much.
Chantelle: Okay, thanks for that. So we have had a few questions come through, some of which you have actually answered as you've gone through. One question though is: I would like to know the referral pathway for minor burn injuries in Tasmania
Dr Carl Lisec: That’s a good question. So each burns unit will have a specific way of handling their referrals. In Queensland we have an email system and I don't know specifically what Tasmania has because everyone's different and there are 18 burn units around the country. But you might have to get in contact with the actual burns unit and just find out how they will receive their referrals. The other thing to say is they sometimes change from time to time. So I'm not up to speed with what Tasmania is doing at the moment. I imagine you'll send an email and a photo. But then I think you can't just stop there. You have to call the burns registrar on call to make sure that they receive that email and referral.
Chantelle: Great. Well, the next question we've got: Is it true, are burns usually worse at about day three before getting better?
Dr Carl Lisec: Yeah, there's some truth to that. So when you see a burn on day one, you know, it might look pink. It might be superficial, partial thickness. As I said, the burns often progress over several days and we often give burns time to declare themselves. I've admitted a patient just the other day – it was a flame petrol burn. It all looked pink to begin with but we are keeping him in hospital (it's a fifteen percent burn so he can't go home anyway, it's too big) but we are keeping him in hospital so that we ensure that it's going to heal. And on day three for this particular patient, it actually still looked quite good. So yeah, you're right. I think burns do look a little bit worse by about day three or four or five and then, if they're going to heal, they tend to turn the corner and heal after that.
Chantelle: Great. Next we have: What to do in the case of ice burn?
Dr Carl Lisec: Um, it's funny you mentioned that. We had a guy come back from Japan just last week. He was intoxicated and thought it would be a good idea to punch his way through some snow. So he was punching, punching, punching. He got some sort of blunt trauma to his fists, but also some frostbite from the cold. So with ice burns and frostbite in general, first aid is actually warming. It's not cool water, it's actually treating it with warm water. So you can just place the hand or whatever body part just in a warm water bath or a warm shower and you kind of want to slowly warm that up. Otherwise, when you're left with the wound at the end of the first aid and the warming, you just treat it like any other burn, like any other thermal burn. So, you know, if you think it's deep it might need some antimicrobial dressings. It’s not going to look like a hot thermal burn – it will have a different appearance. Frostbite has a different appearance – it’s often purple because there's sort of vascular micro thrombosis happening so they often look sort of purple and motley so it's a bit different. But I think you've got an ice burn / frostbite, if you’re concerned that would probably be warrant discussion with the burns unit.
Chantelle: Okay, next we've got: You say to change flamazine daily. Are there any dressings you can leave on for a week?
Dr Carl Lisec: Yes. So I mentioned two other silver based dressings. One is acticoat. You can get acticoat 3 or acticoat 7. The 7 is supposed to last up to a week. If you're going to use active coat, please just keep it wet. If it dries out then it turns into cardboard and it's very abrasive on the surface of the wound and the burn will get deeper. It'll be okay, you'll think you're doing the right thing, you’ve put acticoat on, but if the patient doesn't keep it wet the burn will get deeper. So that's one. The other one is a product called mepilex Ag. It's a soft sort of foam pad impregnated with silver. The manufacturers of mepilex Ag say that it can also last up to sort of five to seven days. But I would be cautious if leaving any dressing on the burn for a week. In my experience, after four or five days, burns become kind of like a smelly mess. I would much rather change them every 2-3 days and keep them clean and have a shower rather than leaving on a dressing for that period of time. Even though the manufacturers say you can leave it on for a week, in my experience, it's a smelly mess after a few days.
Chantelle: Next: What about cryotherapy for burns or blisters?
Dr Carl Lisec: Umm Burns caused by cryotherapy or…
Chantelle: Sorry… burns caused by cryotherapy.
Dr Carl Lisec: Yeah similar lines along, you know, when we talked about the frostbite sort of ice injuries. You probably want to warm the area – you could use a warm compress or you can do warm immersion. Immersion has been shown to be more effective at warming an area than you know topical compresses. But, yeah, same thing.
Chantelle: Which antibiotics would you normally use?
Dr Carl Lisec: It varies by state to state. So in Queensland our go-to antibiotic would be flucloxacillin and quite high dose. We use two grams QID intravenously. If we're treating with oral antibiotics, then you could use the same thing flucloxacillin either 250 or 500 milligrams QID, but you could also use cephalexin and that would be another appropriate antibiotic. Staphylococcus and streptococcus are the most common organisms in the first few days, and if a burn is going to get infected it'll do so around day three or four. If your burn is infected and it's a week or ten days down the track, the burn wound is different – it gets colonised by a lot of gram-negative bacteria after a week. So you've got to be thinking that to broaden your antibiotic choice if you've got a delayed sort of burn wound infection. And usually if that's the case they will need hospitalization and intravenous antibiotics.
Chantelle: Can you please tell us about the pain management during dressing and also dealing with contaminated wounds.
Dr Carl Lisec: Yeah. So with pain management, I'm going to leave that up to you. You can use whatever you like. I find, personally, that ketamine works really well – ketamine plus or minus midazolam if you want to do intravenous sedation. If you're not going to do intravenous sedation, then entonox, just inhaled entonox, will work fine. If you're going to do a procedure without intravenous sedation or analgesia, if you want to use entonox you can also supplement that just with some oral analgesia and we would use endone, panadol, neurofen together. And for the anxiety component, you could also use like a small dose of lorazepam (two milligrams or something like that), but it's completely up to you and it's whatever, you know, you're comfortable with using. Entonox is a good thing to have just in your clinical rooms. Most people do okay with that if it’s a small burn. And contaminated burns – yeah, you might need some analgesia to clean them but always get all the stuff off the wound, get all the grass off, wash it with aqueous chlorhexidine, and I would suggest a daily dressing so you can keep an eye on it.
Chantelle: Next we have a question about: How accessible are burns units to telemedicine and with rural areas.
Dr Carl Lisec: Very accessible if you're talking about just still images, if you want to send a photo. The video link that is exists in Queensland Health isn't great. You know, we don't get good quality video and it's very hard for us to tell the depth of the burn based on a poor video link when there’s not the resolution. You know, if you've got a smart phone or a camera which takes very good quality images like the ones I showed you tonight, that's far more beneficial to us when we are assessing a burn wound. So, it is accessible (certainly in our unit). We prefer the email referrals. We get around 300 emails a month at the Royal Brisbane and Women's Hospital for Adult Burns. So it's very popular and it's a very efficient way of dealing with a large volume of referrals. And if you've ever used an email referral service, hopefully you find it, you know, useful on your end, too.
Chantelle: Next we've got a question that seems to be about burns to the hands. Should we refer to a physiotherapist on day one or just advise a patient to perform simple finger and hand movements?
Dr Carl Lisec: If you've got access to a physiotherapist, I think that's probably beneficial. Having said that though, some physiotherapists aren't used to dealing with burn injuries so they can always call the burn physiotherapist for some advice. On our website (and I can't speak for other units), but if you google burns unit RBWH and navigate to our home page we actually have a link to patient handouts, including physiotherapy handouts and our physio team have developed exercise patient information sheets for every part of the body including the hand. You can download them as a PDF, you can print them out and give to patients, and it goes through all of the range of motion exercises. So, yes, absolutely physio is really important.
Chantelle: We’ve got another question about: Do we use body surface area calculation to determine referral as well as the thickness, and if so what percentage would be requiring referral?
Dr Carl Lisec: Yeah, so anything over sort of 10% in children and sort of 15-20% in adults should result in a burn unit referral. Having said that, if you've got a 9% burn in a child you are probably going to refer that on, so you just have to take that with a grain of salt. You know, the published burns unit referral criteria, they've had to draw a line in the sand somewhere, but ultimately the referral is at your discretion. If you're worried, if you've got a big burn, if you're not really sure how to manage it, we would prefer to hear about that earlier rather than later (things could have been done a little bit differently). So the percentage wise yeah about 10% in kids, 15-20% in adults. And in terms of the thickness, the depth of the burn, I think, you know, no blisters (epidermal burns) we don't need to hear about but as soon as you've got a partial thickness burn (so pink, red or white dermis), a blistering burn, or full thickness burns, consider calling us, particularly if the patient has comorbidities (you know, they're at the extremes of age and they're really old or really young or there's anything else going on), we can always just give dressing advice and also follow up advice as well. Hope that answers that question great.
Chantelle: Great. Well, we are essentially out of time. Were there any last messages you wanted to leave our participants with?
Dr Carl Lisec: From my point of view, hopefully, you've all got something out of tonight. I want you all to remember pink, red, and white – you need to look at the colour of the burn to determine the depth of it and also consider the mechanism carefully. If you have any concerns, always call your burns unit.
Chantelle: Okay, great. Well, thank you Dr Lisec and thank you to all for our attendees for joining us this evening. Just a reminder to complete the evaluation form that will pop up in a new window in a moment once the webinar session closes. It'll take no more than a minute to complete and certificates of attendance will become available on your CPD statements within the next few days, but for any non RACGP members who would like a certificate of attendance please email firstname.lastname@example.org. So thank you again Dr Lisec.
Dr Carl Lisec: Thanks for having me.
Chantelle: Good night everyone.