The toddler tugging a tablecloth and a scalding bowl of noodles spilling in their lap.
Or the bloke in his back garden who decides to throw some accelerant onto a smouldering rubbish fire and gets hit with a flash burn.
Deborah Murray and Jackie Beaumont are burn clinical nurse specialists at the National Burn Centre at Middlemore Hospital whose daily work is work to treat the aftermath of such accidents. Approximately half of their patients are children. The majority of those are heartbreakingly under two years old.
The pair says with children, scalding is the most common burn injury, including spilt hot drinks and baths. With adults, it is flames and explosions.
While the National Burn Centre’s staff see much of the nation’s most horrific burn wounds, they also work with the more common, smaller burn wounds from their local region. These include the kind more likely to first present at their local general practice than an emergency department.
“These smaller wounds are still complex in their own right,” says Murray. “There is still some uncertainty (amongst health professionals in the community) over how to manage them and at what point to ask for help or refer them to a burns unit.”
The pair is keen to share some take home messages with nurses in the community from general practices to rest homes. Firstly and most importantly, to encourage prevention of burns; secondly, to share some first aid tips for burn injuries; and lastly, a call to assess the patient, not just the burn, and be conservative in referring on quite simple burns in patients with compromised healing ability.
Out of the frying pan …
Most of us have seen those Fire Service ads on the telly, but Beaumont says this doesn’t stop people leave their cooking unattended. Unfortunately, the pair sees the consequences.
“They are cooking with oil in a pan and leave for just a few minutes. The oil starts to smoke and catches fire,” says Beaumont. “They come back and their first instinct is not to put out the fire but to lift the pan and take it outside. You can imagine getting hold of a flaming hot pan – the handle is hot and the flames can reach up to a metre. So they invariably drop that pan, which then spills hot oil over them, and if the flames catch hold of their clothes, too …”
Beaumont says they would always encourage people to put the flames out, either with a fire blanket (if available) or a wet tea-towel.
Then there is the backyard cook cleaning off their barbecue grill with methylated spirits. They open the lid to double check it’s working … and get hit with a flash burn.
It is a case of accidents will happen, but some are more preventable than others. The risk of other accidents – particularly tragic ones involving inquisitive and active toddlers – can be reduced by advising people to turn down their hot water cylinder so the temperature is a maximum of 55 degrees C at the tap. Extra vigilance with hot drinks, boiling kettles, and pots and pans will also reduce burns (see links to SafeKids Aotearoa guide below).
Old wives tales still hold
When it comes to first aid in the home for burns, Murray and Beaumont are very aware that old wives tales are still resorted to rather than the simplest and best remedy – tepid running water.
“We try to get the message out there (about running water), but there are lots of other things that people use,” says Beaumont. “Like they put toothpaste on burns because they think it’s cooling.”
Or they use ice to cool the burn. “Which is getting the theory right but the wrong product as ice can cause a burn itself as it is too cold. It can add to the injury rather than help it.”
Then there are people who use butter and other products like flour or eggs.
The pair says a great deal of research has been put into what is the optimal cooling method for a burn, and the general consensus internationally is 20 minutes of cool running water.
If that ‘first’ first aid is done right, damage to the skin can be minimised. For some patients, that means they don’t actually need to have a skin graft to repair their burn.
The temperature to aim for is basically what comes out of your cold-water tap. But with the very young or very old, there is a risk of the burn victim getting hypothermia, so Murray suggests keeping the rest of their body warm, or if it is a large burn area, the temperature of the shower can be turned up until it is lukewarm.
The pair urges people not to be reluctant to call an ambulance – particularly if it is a child with a burn as 20 minutes under running water can be a very long time with a distressed child.
Three-hour window of opportunity
So what should a nurse do if a child is brought into their general practice or a medical clinic an hour or so after a minor burn incident with flour on the child’s wound?
Murray says the great thing about the running water first aid process is that it is still useful up to three hours after a burn injury.
“There is a three-hour window of opportunity to actually cool the burn. Obviously, the quicker this is done, the more effective it is.
“But if a practice nurse is at work and a mum comes in with a child who has burnt their arm, and the mum has put butter on it, you can still start the cooling process.”
First, though, get the butter off, because as an oily, greasy product, it actually retains the heat in the burn. Likewise, flour and eggs also retain heat, says Murray.
“So give lots of pain relief and lots of assurance and wash any products off, then start the first aid cooling of 20 minutes under running water.”
If the patient is finding the running water soothing or relieving – more often the case for adults than children – it is not unsafe to go over the 20 minutes. It is better to go too long than too short.
Clothing over the burn needs to be removed, but this follows the running water and should also follow appropriate pain relief.
The pair says a general practice usually quickly identifies if a fresh burn wound is beyond their capacity and refers the patient on to their local ED – particularly the very young and the very old.
Murray and Beaumont also point nurses towards the National Burns Service website (see details in box), which outlines first aid and initial assessment of burns, plus guidance on referral pathways and burns wound management.
For wounds that can be managed in the community the National Burns Service wound management guideline (see website link in box) recommends dressing the wound with an antimicrobial or specialist dressing for the first few days before changing to a moist wound healing product, if possible.
Assess patient’s ability to heal, not just size of burn
While some burns and patients are obvious candidates for an ambulance or immediate referral to ED, some other seemingly minor burns can end up being much more complex than they first appear.
Beaumont and Murray are keen to stress that the complexity of managing a burn wound can be as much about the patient’s ability to heal as it is about the size and appearance of the burn.
If a frail rest home resident tips a hot cup of tea all over themselves, the impact may be much more than for a healthy young adult.
“You need to be mindful that burns (of the frail resident) have the potential to be quite deep – as children and elderly have thin, delicate, and very fragile skin. It doesn’t have to be really super-duper hot water to cause a deep burn. They can easily sustain a full thickness burn.”
A nurse caring for an elderly burn victim needs to be extra vigilant with the cooling first aid and more ready to consider referral.
People can also be vulnerable to delayed healing of what appear to be simple burns because of underlying health issues such as diabetes or cardiovascular disease, or if they are on medication that restricts the blood flow to their fingers or toes.
“You need to look at your patient holistically rather than just focusing on the burn,” says Beaumont. “It is very easy to focus on the burn because it’s visual and right in front of your eyes, but you need to look at the patient as a whole and the factors that may affect their healing.”
An example could be a diabetic putting a hot water bottle on their cold feet overnight and waking up in the morning with a nasty contact burn because their diabetes made them insensitive and vulnerable to being burnt from the still-intact hot water bottle. Wheat bags can be another culprit. Murray says people with chronic conditions can present at their general practice with such burns, which may appear as just a simple blister, but once burst, they are slow to heal. Sometimes the patient may have tried to manage the burn at home by applying an ointment and only present when the burn is infected.
“These are significant burn injuries because although they are small, they are on a patient who is vulnerable, so those sorts of patients should really be referred on to a plastic surgical unit for assessment.”
The pair says a rule of thumb for referral to a burns or plastic surgery unit is basically how long a burn wound takes to heal, with the threshold for referral being when the wound is unable to heal within three weeks of the initial injury.
If a practice or community nurse is monitoring a wound – preferably seen every two or three days – that is looking unlikely to heal within that timeframe, then the patient should be referred on for further assessment and follow-up.
The pair says the aim is not only a good cosmetic outcome for the patient but also a good functional outcome.
“We don’t want any unattractive scarring of a patient if we can avoid it,” says Murray.
Delayed healing of burns – particularly over hands, elbows, shoulders, feet, and other joints – increases the risks of scars that cause contractures (skin that is hard, rigid, and tightened over the joint, thereby reducing its mobility).
“So say you have a burn across the top of your foot and it takes weeks and weeks to heal. Basically, you can end up with your toes being pulled up, which makes it harder to walk or keep your balance,” says Beaumont.
“We’d rather people referred earlier rather than later,” concludes the pair.
It goes without saying, that burn prevention efforts see fewer burns ever happening in the first place.
Children’s burns: the sad facts
- On average, six children each year die from burn injuries in New Zealand.
- Every day a child is burned severely enough to be admitted into hospital.
- Burns are a leading cause of injury for young children.
- Of the severe burns to one- and two-year-olds admitted to hospital, over half are caused by spilt hot drinks (tea and coffee) and other liquids.
Source: SafeKids Aotearoa, Starship Children’s Health
Brief First Aid for Burns*
- Run tepid water over burn injury for 20 minutes (between 8–25 degrees C, aiming for 15 degrees C).
- Running water still effective in reducing tissue injury within the first three hours from burn occurring.
- Give adequate pain relief.
- Keep patient warm.
- Remove clothing and jewellery.
- Can loosely cover wound with cling film as temporary transport dressing for up to eight hours after burn (inside surface of film against wound).
- Elevate burned limbs to manage swelling.
- Consider tetanus booster.
*Source: Summary of First Aid Management of Wounds from National Burn Service Initial Assessment – Guideline (2013). See website link below.
- National Burns Service: Website includes National Burn Service Initial Assessment – Guideline (2013) for health professionals: www.nationalburnservice.co.nz
- NZ Fire Service: Useful tips on preventing fires within the home: www.fire.org.nz/Fire-Safety/Fire-Safety-Advice/Pages/Inside-your-home.html
- Get Firewise: NZ Fire Service safety education resources for children and young people: www.getfirewise.org.nz
- SafeKids Aotearoa: The child injury prevention services of Starship Children’s Health. Good tips on preventing burn injuries, including the ‘Fancy a cuppa’ flier and setting your hot water temperature to 50–55 degrees C at the tap: www.safekids.org.nz.