BURNS MANAGEMENT CHW - Agency for Clinical Innovation · PDF fileGuideline No: 0/C/06:8142-01:03 Guideline: Burns Management - CHW This document reflects what is currently regarded

Guideline No: 0/C/06:8142-01:03 Guideline: Burns Management - CHW

This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to each individual presentation. Approved by: SCHN Policy, Procedure and Guideline Committee Original endorsed by CHW SMG 2004 Date Effective: 1st June 2013 Review Period: 3 years Team Leader: Burns Nurse Practitioner Area/Dept: Outpatient Department

Date of Publishing: 27 May 2013 1:44 PM Date of Printing: Page 1 of 29 K:\CHW P&P\ePolicy\May 13\Burns Management - CHW.docx This Guideline may be varied, withdrawn or replaced at any time.

BURNS MANAGEMENT - CHW PRACTICE GUIDELINE ©

DOCUMENT SUMMARY/KEY POINTS

• Immediate assessment and treatment of burn injury, including first aid management

• Burn Wound management. Dressing application of:

o BactigrasTM

o ActicoatTM

o MepilexTM Range

o Biobrane

• Analgesia for procedures

CHANGE SUMMARY

• Due for mandatory review: no major changes.

• Updated version of wound products for use with Burns

READ ACKNOWLEDGEMENT

• All clinical staff involved in burns management involving first aid, major burns or minor burns should read and acknowledge the document.



TABLE OF CONTENTS 1 Anatomy and Physiology of the Skin ........................................................................ 4 2 Assessment of the Burn Wound ................................................................................ 6 2.1 Definitions ...................................................................................................................... 6

Major Burns ......................................................................................................................... 6 Minor Burns ......................................................................................................................... 6 Emergency Burns Assessment Form .................................................................................. 6

3 General Management .................................................................................................. 7 3.1 Airway ............................................................................................................................ 7 3.2 First Aid Management ................................................................................................... 7 3.3 Fluid Replacement - calculated by weight and size of the burn .................................... 8 3.4 Urine Output .................................................................................................................. 8 3.5 Electrolytes and FBC ..................................................................................................... 8 3.6 Observations ................................................................................................................. 8 3.7 Pain Management ......................................................................................................... 8 3.8 Circumferential Burn ...................................................................................................... 9 3.9 Head Burn ..................................................................................................................... 9 3.10 Immunisation ................................................................................................................. 9 3.11 Eye Care ........................................................................................................................ 9 3.12 Diet and Nutrition ........................................................................................................... 9 4 Minor Burn Management ............................................................................................ 9 4.1 Baseline Information ...................................................................................................... 9 4.2 Surface Area Assessment ........................................................................................... 10 4.3 Pain Management ....................................................................................................... 10 4.4 Dressing ...................................................................................................................... 10 4.5 Discharge .................................................................................................................... 10 5 Routine Bath and Dressings .................................................................................... 10 5.1 Removal of Dressing ................................................................................................... 11 5.2 Preparation for the Bath or a Sponge .......................................................................... 11 5.3 Pre – Medications used for Baths ................................................................................ 11 5.4 Burn Blister Management ............................................................................................ 11

Management ...................................................................................................................... 12 5.5 Bathing Procedure ....................................................................................................... 13 5.6 Dressing Procedure ..................................................................................................... 14 5.7 Infection Control – Cleaning the Bath Area ................................................................. 15 6 Dressing Specialised Areas ..................................................................................... 15 6.1 Face, Head, Neck ........................................................................................................ 15 6.2 Ears ............................................................................................................................. 16 6.3 Arms ............................................................................................................................ 16 6.4 Hands & Fingers .......................................................................................................... 16 6.5 Trunk ........................................................................................................................... 17 6.6 Legs ............................................................................................................................. 17 6.7 Feet ............................................................................................................................. 17 6.8 Perineum ..................................................................................................................... 17



7 Dressing Materials ..................................................................................................... 18 7.1 Types of Dressing Used .............................................................................................. 18 7.2 Acticoat™ and Acticoat7™ Use .................................................................................. 19 7.3 Mepilex Range, including Mepliex Ag+ and Mepliex Lite ........................................... 21 7.4 Bactigras™ .................................................................................................................. 22 7.5 Biobrane ...................................................................................................................... 23

Application Technique ....................................................................................................... 23 Nursing Management ........................................................................................................ 23

7.6 FlammazineTM Use ...................................................................................................... 26 8 Post Burn Wound Healing Care ............................................................................... 26 9 Burns and Plastic Surgery Treatment Centre and other Burn personnel Contact Details .................................................................................................................................... 27 10 Websites ..................................................................................................................... 28 11 References ................................................................................................................. 29



1 Anatomy and Physiology of the Skin

The skin, also referred to as the Integumentary System, is the largest organ of the body, with a surface area of 1-2 metres. It is also the heaviest organ of the body; average adults have 4 – 7kg of skin.

The functions of the skin include:

• protecting against infections

• protecting underlying organs

• detecting stimuli including heat, pain, touch and relays to nervous system

• maintaining the body’s thermoregulation

• excreting excess salts, water and urea, but protects excess loss

• vitamin D production

• wound self-healing capabilities

• lubrication by own oil glands

Picture 1: Structure of the skin

Skin structure consists of several layers, the uppermost being the epidermis and dermis, beneath which are the subcutaneous fat, muscle and skeletal layers. The epidermis is the first barrier for protection of foreign substance invasion. Keratinocytes are the principle cells of the epidermis, gradually migrating to the surface and sloughed off in ‘desquamations’. In the epidermis keratin is flexible, but is thicker, stiffer and harder in the finger and toe nails. Hair is also made up of keratin.



The epidermis is comprised of five layers:

• stratum corneum

• stratum lucidium

• stratum granulosum

• stratum spinosum

• stratum germinativum

The dermis controls thermoregulation and supports the vascular network. Hair follicles, nerve fibres, sweat glands and nails are located in the dermis layer and protrude through the epidermis. The dermis contains mostly fibroblasts which secrete collagen and elastin. Immune cells defend against foreign substances that have come through the epidermis.

The dermis consists of two layers

• papillary dermis • reticular layer

The subcutaneous fat cells insulate the body against the cold. When the body overheats the small blood vessels carry warm blood near the surface for cooling.

Alterations to the skin affect the overall wellbeing of the individual.

Picture 2: Burn Skin Depth

See: http://www.skinhealing.com/2_2_skinburnsscars.shtml

Burn Depth

Superficial

Superficial Partial Thickness

Deep Partial Thickness

Full Thickness

http://www.skinhealing.com/2_2_skinburnsscars.shtml



2 Assessment of the Burn Wound

It is important to ensure that burns are appropriately assessed and managed in order to promote the wellbeing of the child. Importance should also be placed on the enhancement of the natural healing process of wounds, which should be free of infection.

2.1 Definitions

Major Burns

These are burns, which require admission to a specialised burns referral unit such as The Children’s Hospital at Westmead (CHW).

• A burn is classified as major if: o it involves greater than 10% body surface area o there is any respiratory involvement o there is greater than 5% full thickness skin loss o any priority areas are involved, i.e. face/neck, hands, feet, perineum, major joints. o any circumferential burn o there are suspicions about how the injury occurred o it is caused by electricity

Acute period: first 24 – 48 hours - may be longer in severe burns.

Minor Burns

These are burns, which can be managed in outlying hospitals/medical centres, or via the Burns and Plastic Surgery Treatment Centre (BPTC) at CHW.

• A minor burn is generally defined as: o less than 10% body surface area o no full thickness skin loss o no history of inhalation o not caused by electricity o no suspicious circumstances o no adverse social circumstances to outpatient management

Emergency Burns Assessment Form

For assistance in assessing a burn injury and severity of the injury please see the Burns Assessment and Initial Management form available on the CHW intranet: http://chw.schn.health.nsw.gov.au/o/forms/burns_unit/burns_assessment_and_inital_management.pdf

Special Considerations:

• If the child requires admission, Emergency Department staff must liaise with Burns Unit staff prior to sending child to the unit.

• If the child requires a follow up appointment to be reviewed in the Burns and Plastic Surgery Treatment Centre, please contact the BPTC or Clubbe ward to make

http://chw.schn.health.nsw.gov.au/o/forms/burns_unit/burns_assessment_and_inital_management.pdf



appointment, do not bring the child back to the Emergency Department unless there is no available appointments (See Section 9).

• Child Protection Unit (CPU) involvement required for all suspected non-accidental injuries.

3 General Management

3.1 Airway Priority is given to possible respiratory involvement. Children burnt in an enclosed space, eg. house fire or car, are at most risk. The Medical Officer regarding possible airway involvement obtains a detailed history. The child is observed closely for stridor, hoarseness, oedema of the face, neck or chest, increased respiratory effort, presence of soot in the nostrils or mouth, carbonaceous sputum. Report any of the above to the Medical Officer (MO). Medical Officer may order baseline chest x-ray, blood gases and carboxyhaemoglobin and will make a decision regarding need for intubation.

3.2 First Aid Management 1. Separate from heat source

o Remove clothing from burn areas (clothing traps heat and prevents effective cooling). If clothing is adherent to the skin do not peel it off.

o If the burn is chemical in nature the burning agent should be flushed off with a continuous stream of water.

o Flushing is particularly important in chemical burns to the cornea/eyes.

2. Cool the area

o Local cooling is effective if used in the first 3 hours post burn injury.

o Cool water should be applied for 20-30 minutes post burn. Running water is best; children who have no potential or actual systemic compromise may be taken to the bathroom for cooling.

o As the burns are locally sterilised by the heat in the first instance. Ordinary tap water is suitable.

o Spraying water is also effective. Hand driven spray bottles are available in the Emergency Department. Ensure that the bottles have not been used for any other purpose (i.e., contain cleaning fluids).

o Combines soaked in water are the least effective and require continuous renewal in cool water.

o Do not cool the whole child as this will precipitate hypothermia. Keep unburned parts of the child wrapped/clothed and increase the ambient temperature (e.g., turn on the heat lamps in the resuscitation bay).



o Do not use ice packs or water cooler than 12 degrees Celsius. Vasoconstriction due to the cold extends the burn wound and makes it worse.

o Cooling should be completed before the patient leaves the Emergency Department for a ward admission. Transfer with cooling continuing may produce worse hypothermia.

o After cooling, cover the burnt area until the patient is assessed. o A simple non-stick dressing is suitable. o Face areas can be left undressed.

3.3 Fluid Replacement - calculated by weight and size of the burn All children are weighed on admission for accurate calculation of IV fluids and medications. Burns involving greater than 10% body surface area require insertion of an Intravenous (IV) cannula. If the child has burns to 10-15% body surface area and is drinking adequately, the decision for IV replacement may be postponed. The Medical Officer will make the decision for IV replacement. Burns greater than 15% body surface area generally requires fluid replacement according to the protocol detailed in the CHW Handbook (2004). This includes insertion of a nasogastric tube for enteral feeding.

Strict fluid balance is essential.

3.4 Urine Output Insertion of a urinary catheter with hourly urine measures is recommended for all burns greater than 15% body surface area and or when the perineum is involved. The urine output needs to be monitored carefully as it is an important indicator of hydration status. Desired hourly output = 1mL/kg/hr. When assessing adequacy of output, it is advisable to consider output over several hours.

3.5 Electrolytes and FBC Are routinely taken by the Medical Officer on admission and monitored closely during the acute resuscitation phase.

3.6 Observations Most children with major burns have a disturbance in thermoregulation, often for a considerable length of time. High temperatures are managed with paracetamol, sponging and fanning 4th hourly.

3.7 Pain Management Opioids given intravenously are the drugs of choice during the acute period. A morphine infusion is frequently used. Pain management follows the involvement with the Acute Pain Service Team in CHW. These may include oral and IV analgesics. Refer to Procedural Sedation (Paediatric Ward, Clinic and Imaging Areas) Practice Guideline – Sedation for Burns Baths & Dressing Changes at CHW (Section 8.4) for analgesia and sedation pre-medication dosages and guidelines.

http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2011-9017.pdf#page=25



3.8 Circumferential Burn Full thickness and deep partial thickness burns act as a tourniquet compromising distal tissue. Limbs should be elevated and hourly circulation observations monitored. It may be necessary to use a Doppler to adequately detect pulses. The medical staff will assess the need for surgical decompression (i.e. escharotomy or fasciotomy) and perform them if indicated.

3.9 Head Burn Burns involving the head require shaving of hair so that an adequate assessment can be made. Careful examination of the scalp is required to ensure correct % BSA evaluated and treated. Children with burns to the head/face should be nursed with the head of the bed elevated to about 30° to help reduce oedema during the resuscitation phase.

3.10 Immunisation Immunisation status should be checked on admission and tetanus prophylaxis given if indicated.

3.11 Eye Care Reflex generally prevents direct eye injury but oedema from burns to eyelids and the periorbital area rapidly results in the eyes closing. Prophylactic eye washes with normal saline to remove grit and a chloramphenicol (Chlorsig) eye ointment should be administered as soon as possible. An eye consult is recommended to exclude more serious damage. Parents and the child should be warned that the eyes might close.

3.12 Diet and Nutrition Burn/wound patients require adequate nutrition to aid in the body’s healing process. Foods high in protein have been shown to be most beneficial for skin healing. These include cheese, milk, yoghurt, custard, baked beans, fish, meat, etc. Encourage your child to eat and drink as many of these foods as possible.

4 Minor Burn Management

4.1 Baseline Information It is important to obtain baseline information for subsequent comparison.

• Temperature, pulse, respiration on presentation to Emergency.

• An accurate bare weight must be recorded for: o calculation of pain relief medication o baseline for monitoring weight loss

• Obtain clear history of how and when the burn occurred, first aid given and how long, clothes removed, etc.



4.2 Surface Area Assessment It is important to accurately assess surface area involved and possible depth of burn. The most experienced medical officer available should assess the patient. Following initial assessment by the medical officer in Emergency, surface area/depth are charted on burns chart, and after consideration of other factors outlined above, a decision is made regarding the need for either admission or outpatient management.

4.3 Pain Management The IV route is preferred, but as most children with minor burns do not require IV therapy, an oral opioid can provide initial pain relief. Thereafter, paracetamol and oral morphine is recommended. These are generally prescribed by the Burns anaesthetic fellow. For further information refer to Procedural Sedation (Paediatric Ward, Clinic and Imaging Areas) Practice Guideline – Sedation for Burns Baths & Dressing Changes at CHW (Section 8.4) for analgesia and sedation pre-medication dosages and guidelines.

4.4 Dressing A decision will be made by the burn fellow, nurse practitioner or Registrar on call for Burns for the day regarding appropriate dressing selection. The Burns Clinical Nurse Consultant is available for consultation regarding dressings and will attend ED and other areas of the hospital for consultation page 7240 (This is only during business hours).

4.5 Discharge • Parents are instructed to leave the dressing intact and keep it clean.

• Paracetamol 4th hourly is recommended for pain relief. This will also help with temperature control.

• A normal well-balanced diet high in protein is recommended with encouragement of extra fluid for the first few days following the injury.

• Follow-up is arranged as ordered by the burns team, this is organised with the BPTC for times, medication required and fasting times.

• Parents are informed that they need to contact the BPTC or the burns ward should their child develop persistent high temperatures, the dressing becomes wet/dirty, or the bandages become dislodged.

5 Routine Bath and Dressings

Ensure the bathing of burns patients is performed as quickly and safely as possible minimising pain, anxiety, hypothermia and infection.

Performing a complex procedure such as a burns bath and dressing requires skills that are mastered through instruction and practice. The procedure is usually a traumatic one for all concerned and should ideally be attended by experienced staff in an environment geared to meeting the needs of the child, parents and nursing staff. Staff in Clubbe Ward, (Burns Unit),





are available to provide assistance where necessary in cases where staff are not familiar with the procedure. Careful planning is required to ensure that the procedure is performed as quickly and thoroughly as possible minimising pain, anxiety and potential side effects such as hypothermia.

Prior to attending to bath and dressings all areas in the bath and treatment rooms must be adequately cleaned (see Cleaning the Bath Area procedure below).

5.1 Removal of Dressing The aim of this procedure is to remove soiled dressings using a technique that:

• Does not damage the healing burn wound.

• Is as least traumatic as possible to all concerned.

• Does not contaminate “clean” areas with dirty dressings.

Dressings may be removed wherever it is most practical to do so; in the bathroom, or in the bath.

5.2 Preparation for the Bath or a Sponge The child and parents should be given adequate explanation of the procedure. Parents wear a clean gown. Older patients are involved, wherever possible, in deciding the timing of the bath as this gives them a sense of control.

For all burns procedures analgesia is given beforehand allowing time for it to take effect. The drug of choice is determined on an individual basis and may include an opiate such as morphine, with paracetamol. Midazolam may also be used for its dissociative, anxiolytic and sedative qualities. Trimeprazine tartrate can be useful in children where there is excessive itch, but should not be used in conjunction with midazolam. Inhaled nitrous oxide mixture is often used during dressing removal and reapplication in some cases (see protocol).

Oral morphine and paracetamol pre medication for burn procedures is most effective when given one (1) hour prior to the procedure. However, if there are time constraints this may be reduced slightly. Oral midazolam is most effective when given 15-30 minutes prior to procedure.

5.3 Pre – Medications used for Baths Procedural Sedation (Paediatric Ward, Clinic and Imaging Areas) Practice Guideline – Sedation for Burns Baths & Dressing Changes at CHW (Section 8.4) for analgesia and sedation pre-medication dosages and guidelines.

5.4 Burn Blister Management Blister management is dependent on the history of the burn, place of injury (e.g. finger, limb, and flank), how quickly the blister developed and the wound bed itself.

There is no consensus between burn professionals world-wide on what to do with the blister. The argument for keeping a blister intact is based on the idea that the intact blister provides a natural biologically protective cover. However you cannot assess the wound bed base when this occurs.

http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2011-9017.pdf




Those that are advocates for debriding the wound bed base this argument on the notion that it decreases wound infection and complications.

The management for burn blisters should consider six broad categories infection, healing rate. Functional movement and aesthetic outcome, patient comfort, ease of dressing care and cost efficiency.11 This should also take into account the best practice at the referring burn centre.

Here at The Children’s Hospital at Westmead, for burn blister management we support the use of debriding the blister and removal of the blister head. This allows for wound bed visualisation, appropriate dressing application, and correct splinting and alignment. With the use of pre-medications issues surrounding pain management can be overcome.

Management

1. Clean the wound

2. Snip the blister head and drain fluid

3. Trim around the edges of the blister to remove the devitalised tissue. By trimming you are decreasing the amount of pain associated with the procedure, or provide a firm wipe of the area to remove the devitalised tissue.

4. Dress with appropriate wound dressing depending on depth of injury to the wound bed.

Step A. Prior to removal of blisters. Snip and drain blister. Then trim around the edge of blister. (Picture 3)

Step B. After removal of blisters, you can visualise the wound bed and now the dressing product will be able to penetrate the wound bed. (Picture 4)



5.5 Bathing Procedure Notes:

o A clean gown and gloves are worn.

o Outer bandages are removed either by unwrapping the bandages or cutting them.

o Soiled dressings are then removed and discarded (as per CHW Waste Management Policy) into a bin taking care not to contaminate the floor etc. It is normal procedure to only remove those dressings that are easily removed. If dressings are adhered to the wound they should be soaked off in the bath or by sponging to minimise trauma.

Equipment:

o Gloves (non-sterile for removal of dressings)

o Clean gown

o Daylee (disposable wash cloths)

o Sterile scissors (if required)

o Nitrous oxide circuit, filter and mask (if required)

o Yankauer sucker and suction

o Bath towels

o Radio/CD Toys

Procedure:

1. Experienced staff should attend to the bath wherever possible. They are to wash their hands.

2. Heat lights are used when applicable.

3. The procedure should be done as quickly and efficiently as possible to decrease pain, anxiety and complications such as heat loss.

4. Adequate analgesia is essential. Nitrous oxide is often used along with other medications as needed.

5. For a small bath 400mL chlorhexidine gluconate 5% is added to a bath approx. 70mm deep, for a large bath 640mL chlorhexidine gluconate 5% is added to a bath approx. 100mm deep. For sponge/bowl wash use 28mL chlorhexidine gluconate 5% is added a large bowl approximately half full.

6. Bathing/washing aims to decrease the number of contaminating organisms by removing old dressings and exudate. Soaking adherent dressings reduces the risk of trauma to the healing wound.

7. The overhead heat lights are turned on. Due to the disruption in thermoregulation patients may become hypothermic.

8. Once dressings have been removed, the burnt areas are washed with Daylee handtowels using enough pressure to remove all exudate, slough and loose skin.



9. Washing should cease if excess bleeding or pain occurs.

10. Scissors are not routinely used except for minor trimming or removal of blisters.

11. Tapes, music, overhead pictures and presence of parents and/or child life therapy are useful diversional techniques. Provision of diversional therapy helps decrease pain and anxiety.

12. The physiotherapist utilises the bath time to assess the burnt areas without dressings and provide therapy as needed.

13. Bath time provides an opportunity for active and passive exercises as the warm water helps to relax the child. The doctor may wish to be present to review the burn, and the parents and child should be given explanations regarding the appearance of the burn and evidence of healing.

14. Bath time provides opportunities to monitor wound healing and educate the parents and child.

5.6 Dressing Procedure Equipment:

o Clean gown

o Sterile dressing sheet

o Sterile gloves

o Appropriate dressing (see dressing guidelines)

o Clean drawsheet for bench

o Sterile scissors

o Clean bandages and tape

It is important to maintain an ASEPTIC technique at all times. Ensure gloves are changed between bath and dressing!

After the bath the staff member should weigh the child and record the weight. Place child on dressing table.

Procedure:

1. Wound swabs are used to assess for infection and evaluate treatment options as necessary.

2. Photographs are also taken to allow for monitoring of the wound bed and to use as education for the parents. Consent needs to be obtained by filling the photograph consent form.

3. A Laser Doppler Scan (LDI) may also be attended. This scan does not harm the child, and is conducted to help further assessment of the burn wound. This scan is usually conducted up to 72 hours post burn. This scan can only be conducted in Clubbe ward. Again consent for the scan is required and is obtained on the photograph consent form.



4. Open a new sterile dressing sheet aseptically onto the dressing trolley. Place r, sterile scissors and appropriate dressing onto dressing sheet.

5. Wash hands.

6. Don sterile gloves and proceed with dressing (see individual dressing uses below)

7. Post procedure pain relief may be required for some patients. Page medical staff if excessive pain is noted through procedure.

5.7 Infection Control – Cleaning the Bath Area • At the completion of each bath the surrounding bench area is cleaned thoroughly to

decrease risk of contamination.

• Wash hands and don disposable gloves to protect against contamination and the irritant effect of the cleansing agent. Goggles are available to protect staff eyes and should be worn as necessary.

• Remove all debris from the bath, including particles in the strainer and chains. Spray the bath well with a hose.

• Apply cleaning solution/bleach to all areas including pillow, plug, strainer and chains. With a Daylee spread the solution all over the bath, plug, chain and pillow.

• Difficult stains are removed using an abrasive powder. This is usually done by the ward assistant/cleaner when they clean the bath at the end of each day.

• The dressing room table, scales and trolley are wiped thoroughly with large alcohol wipes (Isowipes). A clean drawsheet is placed on the dressing table in preparation for the next bath. Gloves are disposed of and cleaning solutions placed in the high cupboard out of children’s reach.

• If the child is colonised with a multi-resistant organism such as MRSA all excess equipment and dressings are removed to decrease the risk of cross infection.

6 Dressing Specialised Areas

• Brown Leukoplast applied to crepe or Hypafix directly onto unburnt skin is used to fasten the bandages.

• Clips may be dangerous to young children.

• Safety pins should never be used to secure bandages.

• Consult individual surgeon or specialist clinicians regarding treatment of blisters.

6.1 Face, Head, Neck Burns which extend to the scalp require shaving of the hair so that the extent of the burn can be assessed and the appropriate dressing applied. The necessity for this procedure should be discussed with the parents as sometimes religious beliefs preclude cutting of the hair



under normal circumstances, and may cause great distress for parents if they do not understand the rationale.

Open wounds on the face have paraffin applied regularly to prevent them drying out.

Burnwound dressings can be used on the face. Select dressings that conforms to the contours of the face. Webril can then be applied over the primary dressing and a bandage used if necessary to secure the dressing. If BactigrasTM alone is used, at least a double layer should be applied and the dressing secured with Webril and a bandage. BactigrasTM should not stick to the wound when the dressing is taken down. To prevent this happening especially if there is exudate three or four layers should be used. Tracheostomy tape may be used to secure a naso-gastric tube when adhesive tape is unsuitable due to burns around the nose.

A suitable primary dressing, such as ActicoatTM covered by Mesorb, Webril and Hypafix or the Mepliex range and hyparfix can be used on burnt necks. The dressing is best applied as a "collar" and it is often useful to hold the dressing in place by use of a Jobst or foam collar if oedema is not excessive.

6.2 Ears The area behind the ear should be padded to avoid burnt surfaces coming into contact with each other and the area incorporated into the head dressing if appropriate. BactigrasTM or Jelonet are the dressings of choice on ears.

Doughnuts made of Mepliex can be made to fit around the ear to help prevent pressure on the ear. To protect the helix (cartilage) of the ear, the ear must lie in a natural position and the padding must be high enough so that any pressure from the bandaging is borne by the padding.

6.3 Arms It may be necessary to elevate the arms, especially in the acute period to reduce oedema. Bandage from the fingers upward.

6.4 Hands & Fingers If the fingers are swollen, it is usual practice to dress each finger separately by applying a dressing such as BactigrasTM and covering with Webril. The whole hand is then bandaged as shown in FIG.1. A splint is then applied over the dressing to maintain the hand in a neutral but functional position as shown in FIG.2. When no Physiotherapist or Occupational Therapist is available to make the splints, nursing staff can use a temporary plaster backslab.

NB: It is important to separate burnt surfaces. Once oedema has subsided, the fingers can be individually bandaged using 2.5cm (1") conforming elastic gauze (see Picture 5). The palm must be bandaged with a 5cm conforming elastic gauze bandage or a crepe bandage as the narrow bandage causes oedema to form between the strands. These bandages also allow better mobility.

• When circulation observations have to be performed the fingers should be dressed to just below the fingernails. A flap dressing of BactigrasTM and Webril can be placed over the fingertips.



• If a Doppler has to be used a BactigrasTM dressing can be used around the base of the thumb.

Figure 1 Figure 2 Picture 5

(Refer SBIS Website for more information)

6.5 Trunk It is useful when bandaging the upper trunk to start by anchoring the dressing on an arm. It is important to bandage "away from" yourself going over the shoulders as this technique encourages correct posture. Figure of 8 dressings over the shoulder should be avoided as this makes the axilla area bulky and difficult to mobilise.

6.6 Legs If the upper thigh is involved, the outer bandage should incorporate the waist to avoid slippage.

Legs should be bandaged straight and splints may be necessary. When bandaging legs, start from the toes and move upwards. Incorporate the feet, even if they are not burnt to avoid oedema formation.

6.7 Feet The web spaces between the toes should be separated but it is often difficult to bandage toes separately due to their size. A large supportive dressing allows for mobilisation and helps keep the toes in a normal position.

6.8 Perineum Males: If the penis and/or scrotum are burnt, apply a BactigrasTM dressing using double layers and cover with Webril. A scrotal support may be necessary.

Females: Dressing the female perineum is more difficult but the type of dressing is the same as for males. The bandages from the abdomen and upper thighs can be adapted to keep the dressing in place.

For children still in nappies, strips of BactigrasTM can be cut to size and placed in the nappy. Children with perineal burns are generally catheterised to decrease pain and allow for the area to be kept as clean as possible.

http://www.health.nsw.gov.au/gmct/burninjury/guidelines.html



7 Dressing Materials

Effective burn wound management requires the selection of the most suitable dressing and application technique to promote the healing of wounds, prevent infection and minimise painful procedures.

7.1 Types of Dressing Used There are an ever-increasing number of dressings that can be used on burn wounds. Below is a list and description of the current dressing used in the burns unit at CHW. For instructions on how to use these dressings, please refer to each individual dressing in Section 7.2 – 7.6.

Acticoat™ and Acticoat7™

Nanocrystalline silver impregnated antimicrobial barrier dressings, release silver directly onto the wound bed reducing the risk of colonisation and acts as a barrier to bacteria whilst maintaining a moist wound environment. The dressing is kept moist to ensure continued release of silver crystals into the wound bed. Used in the initial stages of burn wound. Available in ActicoatTM for 3 day application or Acticoat7TM for 7 day application, in sheets of different sizes.

Biobrane™

Biobrane® is a biosynthetic wound dressing constructed of a silicone film with a nylon fabric partially embedded into the film. The wound contact layer of the nylon fabric has been chemically bound (coated) with collagen. Blood & serous fluid clot in the nylon matrix thereby firmly adhering the dressing to the wound until epithelialisation occurs.16

Biobrane® is a temporary skin substitute. It is a flexible product. It has been shown to reduce pain and reduce healing times when compared with traditional treatments.16

Clinical Usage at CHW

The 2 main uses for Biobrane® in the acute management of burn injuries at CHW are:

1. A definitive dressing for superficial-mid dermal burns. Application of Biobrane® should take place within the first 24-48 hours post burn injury following initial wound debridement.

Avoid the application of Biobrane® to facial burns around / below the mouth & chin (especially in toddlers).

2. To provide a temporary wound coverage following surgical debridement of a deep dermal – full thickness burn. In this instance all eschar must be removed. Biobrane® will not adhere to dead tissue and any remaining necrotic tissue may cause infection.16 The Biobrane® will be left insitu until skin grafting occurs.

Mepilex Product Range

These dressings consist of a polyurethane foam pad, an outer backing film, and a non-adherent silicone based wound contact layer. Available in different sizes and thicknesses to accommodate different levels of wound exudate.and application use. Mepilex Ag+ contains silver particles in the foam layer. As the foam absorbs wound exudate, silver ions are released within the foam providing an antimicrobial barrier,



thus reducing the risk of wound colonisation. Mepilex Ag provides a moist burn wound healing environment and is appropriate for use onsuperficial to mid dermal burns. It should not be used on deep dermal or full thickness burn wounds. May be used in the initial acute stage, or post use of Acticoat. May be left intact for 5- 7 days dependent upon the level of wound exudate. Mepliex is a plain polyurethane foam pad with a silicone based wound contact layer. It is primarily used to dress new donor site wounds following harvesting of skin for skin grafting. This product is the same thickness as Mepliex Ag+ however it does not contain silver particles. It has no antimicrobial cover. It can be left intact for 5-7 days. Strikethrough of exudate should be monitored in the post-operative period. Mepliex Lite is a thinner version of Mepliex.It has no antimicrobial cover. It is primarilyused for protection of newly healed fragile skin,It is also useful on fingers and toes, as healing progresses, due to its thin size and conformability. Mepliex Lite may beleft intact for 3-5 days.

Bactigras™

BactigrasTM contains soft paraffin and chlorhexidine 0.5%. It provides bacterial coverage as non-stick antiseptic gauze and may be left intact for 2 days over an acute burn, or up to 5 days over a skin graft.days. Short term Burn wound dressing. May be applied after initial assessment in CHW ED where debridement +/- Laser Doppler Imaging scan (LDI) and application of Acticoat is planned for the following day. Preferred dressing prior to theatres for ease of removal. Available in different sized sheets, or rolls.

Flammazine™(SSD)

Contains silver sulphadiazine 1% Effective antibacterial wound coverage. Must be changed 24hrs after each application to reduce exudate accumulation. Primary use is on infected burn wounds that require a daily dressing. Available in 100g tubes or 500g pots.

Hypafix™

Self-adhesive fabric tape with one way stretch. Removed easily with De-Solve-It or olive oil. Used to secure grafts or external dressings. Available in different sized rolls.

Sorbolene

An appropriate moisturiser such as Glycerin 10% and Sorbolene cream is used on all areas once they have healed and are no longer moist. Suggest to parents that it should be applied four to five times daily as this aids in maintenance of the skin's elasticity.

Paraffin

Soft white paraffinused topically on exposed facial burns to keep the wound areas moist. Frequent reapplication required to ensure a moist wound bed is maintained.

7.2 Acticoat™ and Acticoat7™ Use Acticoat™ and Acticoat7™ can be used in the following situations after consultation with the surgeon/registrar or experienced burns staff: • Partial to full thickness burns with moderate exudate. • Burns of indeterminable depth in the initial stages of injury.



Picture 6

Procedure:

1. Wash the burn in Chlorhexidine Gluconate 5% and water (see 5.5 for dilution details), and dry. Remove any dead tissue and debride blisters to ensure a clean wound bed.

2. Select the appropriate size and type of Acticoat™ or Acticoat7™. Acticoat™ or Acticoat7™ may contract on the wound site so there should be about a 2-5cm overlap around the wound site. This varies with the size of the child and the site of the wound.

3. Moisten the Acticoat™ or Acticoat7™ with sterile water as this activates the Nanocrystalline silver in the dressing.

4. DO NOT USE SALINE as this can cause adverse effects on the Acticoat™. Sterile water ONLY to be used to moisten Acticoat™.

5. Place the Acticoat™ or Acticoat7™ on the wound. Make sure all the burned areas are covered with Acticoat™ or Acticoat7™ and there is suitable overlap. Acticoat™ or Acticoat7™ can be applied over itself.

6. Moisten Mesorb™, or similar secondary dressing, with sterile water. Apply moist Mesorb™ (white side down) over the ActicoatTM or Acticoat7TM; making sure that the ActicoatTM or Acticoat7TM is well covered.

7. Cover with a layer of cling wrap, or Tegaderm depending on the size of the area to be covered. This helps to maintain the moisture content of the dressings and avoids evaporate loss. Then seal edges with Hypafix. Do not apply cling film or Tegaderm circumferentially around non-burnt limbs or torsos.

8. Apply a suitable dressing such as Webril and crepe. Hypafix is most appropriate for any areas where the dressings are at risk of slippage.

9. Leave intact until further review; can remain intact for approximately 3 days if using ActicoatTM or 7 days if using Acticoat7TM.

Care must be taken not to tightly wrap primary or secondary dressings circumferentially around the burns.



7.3 Mepilex Range, including Mepliex Ag+ and Mepliex Lite Mepilex Ag+ can be used in the following situations after consultation with the surgeon/registrar or experienced burns staff:

• Superficial to mid dermal burns with moderate exudate (Mepilex Ag)

• Burns of indeterminable depth in the initial stages of injury.(Mepilex Ag)

• Donor sites (Mepilex)

• Grafted areas and for protection of newly healed burn wounds (Mepilex Lite)

Picture 7

Procedure:


2. Select the appropriate size of Mepilex allowing for slippage so there should be about a 2-5cm overlap around the wound site. This varies with the size of the child and the site of the wound.

3. Peel away outer plastic backing of Mepilex and apply tacky side to wound bed.

4. Apply Hypafix to the surrounding edges of the wound dressing

5. Apply a suitable secondary dressing such as Webril and crepe.

6. Leave intact until further review; can remain intact for approximately 5-7 days.

7. Instruct parents to keep the dressing dry.



7.4 Bactigras™ • All burns types from superficial to full thickness when alternate dressings are

contraindicated.

• Grafted areas, immediately post-op and in the healing stages.

• Burns to specialised areas such as face, hands, perineum where alternate dressings may be difficult.

• Packing for escharotomy sites.

• Jelonet is used on patients who have a Chlorhexidine allergy.

Procedure:


2. Select the appropriate size and type of BactigrasTM. It is important to cover the whole area, on and slightly around the wound site, to allow for movement. The dressing varies with the size of the child and the site of the wound.

3. In the initial stages of injury it is necessary to apply at least two layers of BactigrasTM to the wound bed. For areas with very high exudate such as the face it is necessary to apply 3-4 layers to ensure the underlying tissue is not damage on removal.

4. As the wound heals less dressing is required as the healing skin becomes clogged with excess moisture. A single layer should be used on open areas only at this stage.

5. Healed areas of skin need moisturising with Sorbelene (or appropriate moisturiser); a small amount is rubbed in until absorbed.

6. Apply a suitable external dressing such as Webril and crepe. These outer dressings must not come in contact with the wound as they may adhere and cause trauma on removal.

7. Leave intact until further review; can remain intact for 1-3 days depending on the wound and the need for further review.

Care must be taken not to tightly wrap primary dressings circumferentially around the burns.



7.5 Biobrane

Application Technique

1. Burn wound debridement generally takes place in CHW operating theatres (manual / Versajet / surgical). Haemostasis must be achieved prior to application of Biobrane®1. Manual debridement may also take place in Clubbe Ward or the BPTC

2. Swab burn wound surfaces prior to application.

3. Biobrane® is applied under slight tension (stretch) and is placed dull side down with the nylon fabric layer in contact with the wound surface.16,17 Ensure that there are no wrinkles across the surface of the Biobrane®. See Pictures 8 and 9.

4. Biobrane® may be secured in place with thin strips of Hypafix. Skin glue or steri-strips may be used to secure the edges of Biobrane® applied over facial burns.

Picture 8 Picture 9

Nursing Management Torso & Limbs

• When Biobrane® is applied to burns over limbs and areas on the torso it is covered with routine Acticoat / Acticoat 7 dressings.

• Each surgeon will determine the exact length of time in which dressings are to remain intact. Check post-operative orders for instructions.

• At the first dressing change post application, the main aim is to check for adherence of the Biobrane® layer to the wound surface.

• Once adherence is achieved, the method used to secure the Biobrane® may be removed (Hypafix / Steri-strips / sutures) and the Biobrane® trimmed back to the edge of the burn wound. See Pictures 10, 11 and 12.



Picture 10 Picture 11

Picture 12

• Once adhered, the burn areas covered with Biobrane® can be washed / bathed as per standard protocol.

• If there are any areas of non-adherence of Biobrane® with fluid collection underneath, or any areas of purulent collection seek Medical review of the patient. Pockets of fluid may require aspiration, or entire sheets of Biobrane® may require removal if infection is present.3

The Face

• When Biobrane® is applied to facial burns it may be nursed open to the air. Secondary dressings are generally not required. If infants, toddlers or younger children start to pull at the Biobrane® dressing, appropriate areas may be covered with a routine head dressing and bandage. Within the first 24-48 hours post application serous ooze may seep through the small perforations in the Biobrane®.2

• Children with Biobrane® insitu over the face should have daily face care attended to.

• As re-epithelialisation occurs, the Biobrane® will spontaneously separate from the skin surface. During this process of separation, use a fine pair of Iris scissors to trim back



any edges of Biobrane® that have lifted. See Pictures 13 and 14. Once the Biobrane® is well adhered the face can be washed with normal saline or water. Exposed healed areas can then be moisturised with sorbelene lotion. Continue to apply soft white paraffin to any raw, moist areas that have not yet epithelialised.


• If a wound swab (pre-application of Biobrane®) results in a positive growth, the outer dressings should be taken down to the Biobrane® layer in the affected areas and observations made for the following:

o If the Biobrane® is adhered to the wound and no fluid accumulation or purulent exudate is present, re-dress with Acticoat. Continue to monitor patient for signs of infection (temperature / wound odour / exudate).

o If the Biobrane® is loose and there is purulent exudate underneath +/- signs of infection, (see Pictures 15 and 16) remove purulent non-adherent areas of Biobrane®, take a wound swab, clean wound surface with dilute antiseptic solution (Chlorhexidine gluconate) and apply antimicrobial dressing.




7.6 FlammazineTM Use FlammazineTM is an antibacterial cream containing Silver Sulphadiazine (SSD) It can be used on all burn types, especially in the initial burn stages, after consultation with the surgeon/registrar or experienced burns staff.

Procedure

1. If possible pre prepare FlammazineTM impregnated sterile disposable wash cloths (Daylees™) prior to bath/wash. This is done by opening a sterile trolley cover onto a clean surface, opening enough sterile Daylees™ for the size of the wound, and spreading a generous amount of FlammazineTM cream onto the Daylee™ until it is well covered.


3. Cut the dressing to size, allowing an overlap of 2.5-5cm around the wound. The dressing varies with the size of the child and the site of the wound.

4. Apply the FlammazineTM directly to the burn wound. Make sure all the burned areas are covered with FlammazineTM and there is suitable overlap. FlammazineTM can be applied over itself.

5. Cover with an appropriate secondary dressing such as Webril and a crepe bandage.

6. Leave intact until further review; can remain intact for 1-2 days depending on the wound and the need for further review.

Care must be taken not to tightly wrap primary dressings circumferentially around the burns.

8 Post Burn Wound Healing Care

• Physiotherapists are involved in most wound care from initial visit, and for months or years afterwards. The physiotherapists utilise splints and exercise regimes to ensure that full range of movements are maintained. These need to be attended as instructed to ensure the child has the best opportunity of returning to full movement in the affected areas.

• The child may be given pressure garments to reduce the amount of scarring. These garments are to be worn at all times except for bathing/showering times. Whilst one garment is being worn, the other is being washed to be worn the following day. The garments come with care instructions, please read these prior to washing. They need to be hand washed daily with a liquid detergent and hung to dry in the shade.

• Other forms of scar management may also be used. These include softening products like Silicone and Duoderm.



• Protect from the sun, even if it is cloudy, as the new skin is very fragile and susceptible to sunburn and damage. Apply a high SPF sunscreen for sensitive skin to all skin. Always wear a hat.

• Pimples can occur due to damage to the sweat glands, this is normal. If the area breaks open protect area with a non-stick dressing as you would any other open area. Always ensure sorbelene is properly absorbed, as this may also be the cause.

• Wounds can be very itchy, keep a close watch on your child to ensure they are not scratching away the newly healed skin. Give antihistamines such as Vallergan (Trimeprazine Tartrate) as required. More frequent moisturising may also be effective.

9 Burns and Plastic Surgery Treatment Centre and other Burn personnel Contact Details

The Burns and Plastics Treatment Centre (BPTC) is the Burns and associated plastic patients outpatient Nurse Practitioner led service. It provides burn care to those patients that do not require an inpatient bed, but still require wound care, or links with the burns multidisciplinary team. Operation hours are Monday – Friday 7:30 to 1600 hrs. Appointments are required to attend the clinic. Appointments can be made throughout business hours by direct phone number of 51850 and after hours to Clubbe ward nursing staff on 51114. When making appointments please remind parents that they need to arrive one hour prior to the appointment time so that their child can be assessed and given any appropriate analgesia prior to a procedure. For some children they will require fasting prior to the procedure, so fasting times are 4hours for solids and fluids (including water or apple juice).

It is also advisable where possible to send photos of the burn wounds via email to the Kidsburns Digital email clinic. This allows the team to have a better idea about the wound and can help in assisting with pre- meds and ongoing needs. The email address is [email protected]

• Burns Fellow – pg 6440

• Burns Nurse Practitioner – pg 7038

• Burns Clinical Nurse Consultant – pg 7240

• Burns and Plastic Surgery Treatment Centre – 9845 1850 (Business Hours)

• Clubbe Ward – 9845 1114

• Digital Email Clinic – [email protected]

• NSW Statewide Burn Injury Service – www.health.nsw.gov.au/gmct/burninjury

mailto:[email protected]

mailto:[email protected]

http://www.health.nsw.gov.au/gmct/burninjury



10 Websites

• NSW Statewide Burn Injury Service: http://www.aci.health.nsw.gov.au/networks/burn-injury

• Australian New Zealand Burn Association: http://www.anzba.org.au

• Journal of Burn Care & Research: www.burncareresearch.com

• International Society for Burn Injuries: http://www.worldburn.org

• Annals of Burns and Fire Disasters: http://www.medbc.com/annals/

• Management Guidelines for People with Burn Injury: www.health.nsw.gov.au/public-health/burns/burnsmgt.pdf

• Resident Orientation Manual - Acute Burn Management: www.totalburncare.com/orientation_acute_burn_mgmt.htm

• Skin Healing: http://www.skinhealing.com

Skin Information

• http://www.skinhealing.com/3_1_burntreatments.shtml

• http://www.essentialdayspa.com/Skin_Anathomy_and_Physiology.htm

• http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/skinlsn/skini.htm

• http://www.nurse-prescriber.co.uk/education/anatomy/anatomy2.htm

• http://reference.allrefer.com/encyclopedia/S/skin.html

• http://www.swiss-creations.com/sc-14story.htm#The%20Human%20Skin

http://www.aci.health.nsw.gov.au/networks/burn-injury

http://www.aci.health.nsw.gov.au/networks/burn-injury

http://www.anzba.org.au/

http://www.burncareresearch.com/

http://www.worldburn.org/

http://www.medbc.com/annals/

http://www.health.nsw.gov.au/public-health/burns/burnsmgt.pdf

http://www.health.nsw.gov.au/public-health/burns/burnsmgt.pdf

http://www.totalburncare.com/orientation_acute_burn_mgmt.htm

http://www.skinhealing.com/

http://www.skinhealing.com/3_1_burntreatments.shtml

http://www.essentialdayspa.com/Skin_Anathomy_and_Physiology.htm

http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/skinlsn/skini.htm

http://www.nurse-prescriber.co.uk/education/anatomy/anatomy2.htm

http://reference.allrefer.com/encyclopedia/S/skin.html

http://www.swiss-creations.com/sc-14story.htm#The%20Human%20Skin



11 References

1. Australian & New Zealand Burn Association. 2012, Emergency Management of Severe Burns (EMSB), Course Manual (13th Ed.).

2. Bartlett, N, Yuan ,J, Holland, A, Harvey, J, Martin, H, La Hei, E, Arbuckle ,S & Godfrey, C,2008, Optimal Duration of Cooling for an Acute Scald Contact Burn Injury in a Porcine Model, Journal of Burns Care & Research, 29 (5) pp828-834.

3. Benson, A, Dickson, W & Boyce, D 2006, Burns, British medical Journal, vol. 332, no. 7542, pp. 649-652.

4. Chi, K. and Garner, W. 2002, ‘Acute burns’. Plastic and Reconstructive Surgery, vol.105, no.7, pp.2482-2493.

5. Demling R.H and DeSanti L (2001). The Rate of Epithelialization across Meshed Skin Grafts Increases with Exposure to Silver, Burns, vol. 28, pp.264-266.

6. Dunn, K, & Edward- Jones, V. 2004, The role of acticoat with nanocrystalline silver in the management of burns, Burns, vol. 30, pp. S1-9.

7. Holland, A, Ward, D & Farrell, B 2007 The influence of burn wound dressings on laser Doppler imaging assessment of a standardized cutaneous injury model, Journal of Burn Care & Research, vol. 28, no. 6, pp- 871-878.

8. NSW Statewide Burn Injury Service: Clinical Practice Guidelines, 2010 NSW Health (available via SBIS website http://www.health.nsw.gov.au/gmct/burninjury).

9. Reed, J.L. & Pomerantz, W.J. 2005, ‘Emergency management of pediatric burns’, Pediatric Emergency Care, vol. 21, no.2, pp.118-129.

10. Sakuta, S, West, S, McBride, C, & Taylor, R, 2008, Incorrect acticoat application causing iatrogenic injury to a child with a palmer burn, Emergency medicine Australasia vol. 20, no.2, pp. 183-184

11. Sargent, R, 2006, Management of Blisters in the Partial-thickness burn: An integrative Research Review, Journal of Burn Care and Research 27(1) pp66-81.

12. The Children’s Hospital, Westmead. Handbook (2004). 13. Tredget E.E, Shankowsky H.A, Groeneveld A and Burrell R.E (1998). A Matched- Pair, Randomized

Study Evaluating the Efficiacy and Safety of Acticoat Silver- Coated Dressing for the Treatment of Burn Wounds. Journal of Burn Care and Rehabilitation 19(6) 531-537.

14. Wright J.B, Lam K and Burrell R.E 1998, ‘Wound management in an era of increasing bacterial antibiotic resistance: a role for topical silver treatment’. American Journal of Infection Control, vol.26, pp. 572-577.

15. Yin H.Q, Langford K and Burrell R.E (1999). Comparative Evaluation of the Antimicrobial Activity of ACTICOAT Antimicrobial Barrier Dressing. Journal of Burn Care and Rehabilitation, Vol 20, no 3, pp 195-199

16. Smith & Nephew Product Information 17. Solanki N, Nowak K, Mackie I, Greenwood J. Using Biobrane: Techniques to Make Life Easier, ePlasty

Vol 10 Dec 2010 18. Lang E, Eiberg C, Brandis M, Stark G. Biobrane in the Treatment of Burn and Scald Injuries in Children,

Annuls of Plastic Surgery 2005, 55(5): 485-489 19. Mandal A. Paediatric partial thickness scald burns – is Biobrane the best treatment available? Int Wound

J 2007 Mar; 4(1):15-9 20. Lai S, Barrow R, Wolf S, Chinkes D, Hart D, Heggers J, Herndon D. Biobrane improves wound healing in

burned children without increased risk of infection. Shock 2000 Sep;14(3):314-8 21. Greenwood J. A Randomised Prospective Study of the Treatment of Superficial Partial Thickness

Burrns: AWBAT-S Versus Biobrane ePlasty Vol 11 Feb 2011

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