I have found that this works well for burns.

1. At initial presentation disturb as little as possible. Get a good idea of thickness where you can, but don't go overboard with 
trying to find the numb pieces. Do /not/ deroof blisters. I was very surprised to hear my local burns unit advocating this, as it 
exposes a large area of skin to a dressing which can be painful and the dead skin acts as a dressing just fine. However, tense 
bullae should be drained by slicing with a blade. Analgesia, digital photo.

2. Refer to your burns unit according to your agreed protocol. Dress with clingfilm draped loosely over the affected area.

3. If treating locally, drizzle the wound with paraffin oil. On the face do nothing else and send the patient home with the oil to be 
applied whenever the skin feels tight.

4. For all other burns, dress with a /double/ layer of jelonet. No flamazine, no antibacterials by mouth and no impregnated gauzes. 
Give advice, particularly reminding parents of toddlers about good hydration and to watch for dry nappies. Spend a few 
moments counselling parents who are often deeply traumatised, even by what appears to you to be a trivial burn. Don't forget to 
think about NAIs.

5. Bring the patient back for senior review the /next/ day. No exceptions, apart from superficial burn/primary erythema less than 2 
cm in diameter in an adult.

6. At review, it will be much easier to assess depths. Beware of the patient still in pain at this point; the burn should be virtually 
painless. Slice any bullae that have arisen overnight. A full thickness burn on the hand or face should probably go for specialist 
review whatever, but small ones elsewhere (less than 2cm or so in any dimension) can be left to decompose on their own. 
Redress with the same dressing and leave alone for a week, unless the dressing strikes through, when it should be replaced. This 
can be done in the community for most superficial burns. Have particular vigilance for any burn on the ankle or forefoot; the skin 
over here is prone to infection.

Using this regime, the incidence of infection is close to zero, and the incidence of sticking is also very low indeed.

Flamazine is reserved for neglected superficial burns that have become infected. Ignore the Old Wives tale about facial skin 
tattooing; the discoloration is transient. If this dressing is used, the wound should be inspected every other day at least. 

If the wound has developed exudate some progress may be made with mechanical debridement with scalpel or simply wiping 
with gauze. However, I have found considerable success with a thickly applied layer of a mixture of Varidase and Intrasite. Half is 
applied at the first visit and then covered with a bandage. The next day this is washed off and the other half applied for 48 hours. 
After this, the wound will be clean. Duoderm is a good dressing at this point until the base of the wound is covered with 
granulation tissue and then you can return to jelonet. Both tend to cause overgranulation, and I suspect (but can't think of a way 
of proving) that it results from localised hypoxia from the dressing.

I'm a bit jetlagged still so I've probably forgotten something vital. Oh, I have tried a couple of Tea Tree oil dressings. Looked 
silly, but gave tremendous pain relief in the acute phase.

Best wishes,


Rowley Cottingham

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