Wound management

• Immediate closure with sutures/clips/Steri-Strips/glue
• This is only used if there is negligible skin loss, the wound is clean with no foreign bodies, <12 hours old (<24 hours for face wounds), and the edges come together easily without tension

• Wound cleaned thoroughly, then dressed and left open for 48 hours
• The wound is then reviewed for signs of infection, swelling and bleeding
• If these are absent and the wound edges can be opposed without tension, the wound is sutured closed
• This is used for contaminated wounds, contused/bruised wounds, infected wounds, or wounds >12 hours old
• Antimicrobial dressings and prophylactic antibiotics should also be used for contaminated/infected wound

• Allow wound to close by itself, i.e. by granulation, epithelialisation and scarring
• This is used for wounds with tissue loss preventing edge approximation, chronic ulcers and partial-thickness burns

• For significant skin loss (including most full-thickness burns)

Initial assessment

• Test sensation, blanching and check tetanus status
• Determine the % body surface area involved using rule of 9’s (head 9%, arm 9%, leg 18%, trunk front 18%, trunk back 18%), palmar surface (patient’s palm and fingers = 0.8%) or a Lund and Browder chart (more accurate, especially in children)

Classes of burns

Initial management for all major burns should begin with an ABCDE  approach

• Airway burns: call anaesthetist and intubate patient as soon as possible
• Breathing: give all patients 100% oxygen through a humidified non-rebreather mask; nebulisers for smoke inhalation
• Circulation: site 2 large bore cannulas and commence IV fluid resuscitation
• Disability: check responsiveness, give strong analgesia
• Exposure: examine entire skin and look for other injuries
  • Large area burns: cover with sterile sheets or cling film until specialist review
  • Minor burns: immerse in cool water for 30 minutes (or cover with cool sterile saline soaked towels)

Further management of partial-thickness burns

• Use systemic (never topical) analgesia if required
• Cleanse with soap and water, then thoroughly rinse
• Scrub off any necrotic tissue
• Dress simple low-exudate burns with multiple layers of low-adherent impregnated tulle gauze. Cover this with a sterile non-adherent absorbent pad dressing and secure with bandages or dressing fixing tape.
• Review in 48 hours to look for signs of infection
• Re-dress every 2 days

Blisters

• Leave intact unless they are open/contaminated (fully debride) or are large/prevent dressing (sterile aspiration)

Burns requiring specialist opinion/admission

• Full thickness burns (need skin graft)
• >10-15% body surface area or if elderly/significant comorbidities (risk of significant fluid loss)
• Hands (put in bag with paraffin and keep moving)
• Face (use Vaseline); genitalia/perineum (admit as difficult to dress)
• Burns over major joints; chemical (‘irrigate, irrigate, irrigate!’)
• Electrical (spare skin); inhalation injuries (airway risk)
• Circumferential burns (risk of compartment syndrome)

• X-ray if any possibility foreign body
• If wound is deep and contaminated, it needs wide debridement in theatre
• If not, use simple debridement and irrigation
• Follow-up is required

• Cat and human bites are worst
• High risk of tendon injury and joint contamination leading to risk of septic arthritis
• Most require aggressive surgical management, often followed by delayed primary closure/healing by secondary intention
• Give antibiotics for 5 days

• Gunshot wounds are usually treated with thorough debridement and delayed primary suture
• Facial injuries should ideally be sutured by a plastic surgeon– use fine sutures and remove after 2-5 days
• Crushed tissues need to be elevated for 7-10 days to reduce swelling prior to closure (risk of compartment syndrome)

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