MUHC guide to handling burns

7/23/2019 MUHC guide to handling burns

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The Managementof Burn Traumain Children and Teens

A G U I D E F O R P A R E N T SA N D F A M I L I E S


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Having a child in the hospital with a burn injury can be a traumatic experience. This booklet

has been designed to provide you with information on what to expect throughout the different

phases of your childs hospitalization, treatment and recovery. We hope it answers many of your

questions.

THE BURN TRAUMA TEAM: A FAMILY CENTERED APPROACH

Family-centered care is based on the belief that the family is a childs primary source of strength and

support. Healthcare professionals are the experts on health and disease. Parents are the experts on

their child and they can offer essential information to enhance their childs health care. A successful

partnership between healthcare providers and families is based on mutual trust, respect and

responsibility.The Montreal Childrens Hospital Patient and Family Centered Care Policy

The Management of Burn Traumain Children and Teens



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There is a story behind every scar.

We never expect that our life will change in an instant.

We are in a state of panic, we are unsure of how to

react and we do not know what to expect. When I

was burned, I was immediately sent to the Montreal

Childrens Hospital Trauma Centre. Upon my arrival,

there were many staff members waiting and ready to

take care of me. Initially, I was afraid because I didnt

know what was going to happen, however the care

I received during my hospital stay was exceptional.

Without the support of the team of nurses, doctors,

surgeons and my family, I would have never overcome

this event. Thanks to them, I had a reason to smile

everyday despite all the pain I was enduring.

Today, I am in a body that has undergone many plastic

surgeries. The exceptional work of the entire team

was so wonderful for which I have so many memories.

The entire team made my hospital stay positive,

moving and unforgettable.

Thank you to the Montreal Childrens! Vronique

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CONTENTREVIEW

Mirko S. GilardinoM.D, MSc, FRCSC,FACS

Board-CertifiedPlastic Surgeonrecognized by boththe Canadian Societyof Plastic Surgeonsand the AmericanBoard of PlasticSurgery

Montreal ChildrensHospital, MUHC

WRITTEN BY

Diane RichardBSc. RN

Trauma CoordinatorBurn Trauma Program


EDITED BY

Debbie FriedmanBSc. pht. M. Mgmt.

Trauma Director

Director Canadian

Hospitals InjuryReporting andPrevention Program


Assistant Professor,Department ofPediatrics, Facultyof Medicine, McGillUniversity

Amanda Fitzgerald

TraumaAdministrativeProcedures Specialist


OTHERCONTRIBUTORS

Angeliki SouranisSocial Worker

Anne-Marie Hurteau

AudiologistCaroline RicherSpeech and LanguagePathologist

Doreen ShallaSpiritual CareProfessional

Helen MagdalinosChild Life Specialist

Jessica NoletPhysiotherapist

Justine Noiseux Social Worker

Katrine DoucetSpeech and LanguagePathologist

Line ParentOccupational

TherapistLise GagnonChild Life Specialist

Rachel BoisjoliPsychologist


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SPECIALACKNOWLEDGEMENTS

We wish to thank the QuebecFirefighters Foundation for MajorBurn Victims for their financialsupport of this publication.

Our extreme gratitude is alsoextended to the families who sograciously allowed us to use theirphotographs in this publication:mile, Cathy and Patrice Couillard,Ivy and Isabelle Maheu andVronique Potvin.

A NOTETO THE READER

The information you are about to read is intended for the family of a child oradolescent who has sustained a burn trauma. It is our objective to enhance yourunderstanding of pediatric and adolescent burn care management. Informationregarding the spectrum of burn trauma care and the role of the differentspecialists will be discussed.

Issues related to burn classification, recovery stages, rehabilitation, returninghome, school re-integration and outcome are covered in the booklet you areabout to read.

We hope that as burn trauma victims and families living through the experienceyou will find that the information will respond to your questions and assist youthrough the stages of recovery and facilitate your return home. Families play a keyrole in assisting the patient to achieve their maximum potential.

The content of this booklet is reflective of the experience and expertise ofthe Burn Trauma Program of the Montreal Childrens Hospital Trauma Centreof the McGill University Health Centre.

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Blisters and Open Areas . . . . . . . . . . . 34Discoloration . . . . . . . . . . . . . . . . . . 34

Sun Sensitivity. . . . . . . . . . . . . . . . . 35

Swimming . . . . . . . . . . . . . . . . . . . . 35

Diet . . . . . . . . . . . . . . . . . . . . . . . . . 35

Medication . . . . . . . . . . . . . . . . . . . . 35

Returning to School . . . . . . . . . . . . . 36

HOW TO CHANGE A DRESSING . . . . . 38

Equipment. . . . . . . . . . . . . . . . . . . . 38

Instructions for Changing a Dressing . 38Individualized Instructions . . . . . . . . 39

YOUR SPLINT: WEAR AND CARE . . . . 40

Splint Care. . . . . . . . . . . . . . . . . . . . 40

Precautions . . . . . . . . . . . . . . . . . . . 40

When to Wear your Splint . . . . . . . . . 40

Individualized Instructions . . . . . . . . 41

HOW TO USE A SILICONE

GEL SHEET . . . . . . . . . . . . . . . . . . . . 42

Recommendations . . . . . . . . . . . . . . 42

REFERENCES . . . . . . . . . . . . . . . . . . 44

USEFUL LINKS. . . . . . . . . . . . . . . . . 44

Wound Healing . . . . . . . . . . . . . . . . . 21Scars. . . . . . . . . . . . . . . . . . . . . . . . 21

Positioning and Splinting. . . . . . . . . . 23

Pain Management . . . . . . . . . . . . . . . 24

Nutrition . . . . . . . . . . . . . . . . . . . . . 25

Psychological and Social Impact. . . . . 25

Discharge Planning. . . . . . . . . . . . . . 26

THE REHABILITATION PHASE. . . . . . 28

Minimizing Scars after a Burn . . . . . . 28

Preventing ContracturesFollowing a Burn . . . . . . . . . . . . . . . . 30

CARING FOR YOUR BURNAT HOME

IMPORTANT RECOMMENDATIONS. . 32

Dressing Change and/or Irrigation . . . 32

Compressive Garments and Splints. . . 33

Exercises . . . . . . . . . . . . . . . . . . . . . 33

Skin Care . . . . . . . . . . . . . . . . . . . . . 33

Scar Massage . . . . . . . . . . . . . . . . . . 33

Precautions . . . . . . . . . . . . . . . . . . . 34

Itching . . . . . . . . . . . . . . . . . . . . . . . 34

CONTENTS

THE MONTREAL CHILDRENS

HOSPITAL BURN TRAUMA PROGRAM .6

The MCH Trauma Burn Team. . . . . . . . . .6

UNDERSTANDINGTHE BURN INJURY

THE SKIN . . . . . . . . . . . . . . . . . . 12

DETERMINING THE SEVERITY OF

A BURN. . . . . . . . . . . . . . . . . . . . . . 12

Burn Location . . . . . . . . . . . . . . . . . . 14

Burn Size . . . . . . . . . . . . . . . . . . . . . 14

Burn Depth. . . . . . . . . . . . . . . . . . . . 14

DURING YOUR HOSPITALSTAY

THE EMERGENT PHASE . . . . . . . . . . . 16

THE ACUTE PHASE. . . . . . . . . . . . . . 17

Wound Care. . . . . . . . . . . . . . . . . . . 19

The Management of Burn Traumain Children and Teens



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THE MCH TRAUMA BURN TEAM

Acute Pain Service A team of anesthetists andnurses who specialize in pain managementare consulted to work collaboratively withthe Burn Trauma Team in order to effectivelymanage pain following a burn trauma.

Audiologist An Audiologist is consulted if thepatients burn has affected the ear, hearingor the ability to communicate. Audiologistsevaluate hearing and provide treatment as

needed at the bedside or in the AudiologyDepartment.

Burn Trauma Coordinator A member of theinterprofessional team who coordinatesthe care of the patient which includesensuring communication and collaborationwithin the interprofessional team. The BurnTrauma Coordinator also helps to ensure asmooth transition from hospitalization toa rehabilitation centre or discharge home.

THE MONTREAL CHILDRENS

HOSPITAL BURN TRAUMAPROGRAM

The Montreal Childrens Hospital Burn TraumaProgram specializes in emergency care, criticalcare, early rehabilitation, and ambulatorymanagement for all types and severities of burntrauma. Caring for a burn patient and supportingthe family requires a team approach. Burn TraumaSpecialists provide the patient with medical,surgical, nursing, rehabilitation and psychosocialcare.

The patient- and family-centered team approachand involvement of Trauma Specialists beginsin the Emergency Department and continuesthrough the critical care phases to earlyrehabilitation, recovery phases and through

transfer to a rehabilitation centre, communityresource or discharge home.

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The Child Life Specialist provides distractionand relaxation techniques during wound careand other medical procedures. Teaching dolls,medical play and expressive therapy all helpmake procedures less traumatic.

The Child Life Specialist offers supportthrough the stages of recovery, the returnhome and during school reintegration asneeded. Sibling support is also offeredas appropriate.

Clinical Nutritionist A specialist who assesses

and makes recommendations regardingthe nutritional requirements needed topromote optimal wound healing. The ClinicalNutritionist works collaboratively withthe patient and family in order to promotehealthy eating habits during hospitalizationthat can be continued at home upondischarge post burn injury.

The Burn Trauma Coordinator ensures thatfamily needs are met and will follow themregularly throughout the different stagesof recovery.

Child Life Specialist A specialist who providessupport to children, teens and theirfamilies during hospitalization. Throughdevelopmentally appropriate activities,the Child Life Specialist helps patients adjustto the hospital setting, reduce stress andpromote positive coping mechanisms.

Children are frequently overwhelmed duringan unplanned hospitalization. Followinga burn trauma, children have particularemotional and psychological needs thatdiffer from those of other patients. Thegoal of the Child Life Specialist is to helpthe patient regain a sense of control byexpressing feelings, exploring body image

and understanding treatments. Throughplay, the Child Life Specialist helps to restorefunctional skills.


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and others to prevent contractures. Someinterventions include: splinting, positioning,passive and active range of motion exercises.

Physiotherapist Evaluates the patients abilityto move his/her body and to perform dailyactivities. The Physiotherapists goal is toprevent scar contracture, restore normalrange of motion (ROM) of the involved jointsand to assist the patient in achieving theirhighest level of function. The Physiotherapistconcentrates on gross motor function

which includes: gait training, stairs, balance,coordination, strengthening and improvingcardiovascular endurance. Recommendationsfor equipment are made as needed.

Plastic Surgeon A surgical specialist whoseexpertise encompasses all areas of burntrauma care.

Critical Care Physician A physician whospecializes in caring for critically ill patientsin the Pediatric Intensive Care Unit.

Emergentologist A specialist who treatspatients with acute illnesses or injuriesrequiring immediate medical attention inthe Emergency Department.

General Surgeon A physician who specializes inthe treatment of patients with acute injuriessuch as a burn trauma.

Nurse A member of the interprofessionalteam who assesses, plans, implements andevaluates the care of the patient.

Occupational Therapist A therapist whofacilitates the patient in maintainingindependence when performing dailyactivities. Interventions may includetherapeutic activities to improve mobility

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facilitate communication between thepatient/family and the treating team. TheSocial Worker will also provide travel andaccommodation needs assessment as well asfacilitate arrangements for parents requiring

time off work. They will continuously monitorthe individual psychosocial needs of the patientand family throughout the hospital stay.

Speech and Language Pathologist A Speechand Language Pathologist is involved withpatients who have sustained inhalation

burn injuries. These patients often havedifficulty communicating due to injury tothe vocal tract and/or vocal folds. The Speechand Language Pathologist may be involvedwhen a patient is intubated and alert. TheSpeech and Language Pathologist helps thepatient establish a personalized method ofnon-verbal communication, for example,

through the use of a communication book.

Plastic Surgery Resident A physician who isbeing trained in plastic surgery followingcompletion of medical school.

Psychologist The Psychologist supports thepatient by helping them regain an optimallevel of functioning. Victims of burn traumaoccasionally experience psychologicalsymptoms that can impair social functioningin school or at home. Some may experiencenightmares, flashbacks or avoidance, all ofwhich may be difficult to manage. Treatment

is recommended when symptoms affect thefunctioning of the child or influence behavior.Furthermore, emotional issues such as lowself-esteem may require a more targetedtreatment plan.

Social Worker The Social Worker providesemotional and practical support to the patient

and family throughout hospitalization andfollowing discharge by offering a varietyof coping methods. The Social Worker will


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Spiritual Care Professional A professional whohas received specialized training. They offersupport and coping strategies to the patientand their family during a period of illnessor hospitalization. Spiritual Care Services is

available 24 hours a day, 7 days a week.

Other specialists may be consulted as indicated.

Once the patient is extubated, the Speechand Language Pathologist assesses speechand voice to avoid risk of further damage tothe vocal folds. Healthy vocal hygiene habitsare explained and reinforced.

Over time, the Speech and LanguagePathologists recommendations will evolveand may include:

Avoid whispering

Avoid forcing the voice

Discourage staff and family membersfrom asking the child to raise his/hervoice

Promote the use of alternativecommunication methods

Encourage voice use only when vocalquality is deemed adequate

Drink more water (if medically possible)

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Understandingthe Burn Injury THE SKIN

DETERMINING THE SEVERITYOF A BURN


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THE SKIN

Normal skin consists of two main layers: theepidermis and the dermis. The epidermis is theouter layer of the skin and acts as the first line of

defence to the environment. The dermis containsglands, hair follicle roots and capillaries.

The skin serves as a physical barrier against theenvironment. Specific functions include:

Protective agent against infection

Protects against body fluid loss preventingdehydration

Controls body temperature

Excretes some waste products

Receives sensory stimuli

Produces vitamin D

These essential functions are reduced witha partial thickness burn, and eliminated with

a full thickness burn.

DETERMININGTHE SEVERITY OF A BURN

The overall severity of a burn is determined bya variety of factors. Depth, size and location are

all considered when evaluating the severity of aburn. Knowing the severity will help determineand predict the healing process as well as thelikehood of complications.

Hospitalization following a burn trauma isbased on:

Burn location Burn size

Burn depth

UnderstandingtheBurnInjury

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BURN DEPTH EXPLANATION

Deep second-degree burn

Deep partial thickness

Damage to the epidermisand the deeper dermis

Less moist, red to white,very painful

May require surgeryand grafting

Third-degree burn

Full thickness

Entire thickness of skindestroyed (into fat)

Dry, varies in color(white, black, red or brown)

Usually not painful

Requires surgery and grafting

First-degree burn

Dry, red and painful(sunburn)

Limited to the outer layer(epidermis) of skin

Superficialsecond-degree burn

Damage to the epidermisand part of the dermis

Moist, red and blisters

Usually very painful

Heals independentlyand does not usually scarif healed within 2 weeks


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UnderstandingtheBurnInjury

A

B

14

16 16 16 16

14 14

15

25 25

1515 15

14

C C C C

B B

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1

13 132 2 2 2

B

A

BURN LOCATION

Burns affecting the face, eyes, hands,genitals, feet, and those that encircle thelimbs and/or torso, as well as burns over

joint areas, require special attention.

BURN SIZE

Burn size is expressed as a percentage of thetotal body area affected by the burn.

BURN DEPTH

Burn depth is classified as either first,

second or third degree.

BURN SIZE PERCENTAGE DIAGRAM

YEARS

SURFACE 0 1 5 10 15

A =of head 9 8 6 5 4

B =of thigh 2 3 4 4 4

C =of leg 2 2 2 3 3

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DuringYour Hospital Stay THE EMERGENT PHASE

THE ACUTE PHASE

THE REHABILI TATION PHASE


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There are different phases involved in

burn care. Burn severity will determine

the length of each recovery stage.

Trauma care is unique to each patients

specific condition and individualized

needs.

THE EMERGENT PHASE

The emergent phase refers to the first few dayspost-burn. The severity of the injury sustained isdetermined. Urgent care is provided; intravenoustherapyand wound care are started. During thisphase, vital signs are monitored and all fluidstaken in and eliminated are recorded. Observationis ongoing for signs of potential complications.

Stabilization occurs during the emergent periodand includes the following:

Airway/Breathing Smoke inhalation cancause swelling of the airway. The patient mayneed a tube inserted to help with breathingand to give the lungs an opportunity toheal. The tube is connected to a ventilatorthat pushes air in and out of the lungs. Thepatient is given medication to keep themsedated and more comfortable.

Hydration Burns cause body fluid loss.Intravenous lines are inserted to ensure

that the patient remains hydrated. A Foleycatheteris inserted into the bladder tomonitor fluid levels (output) and is also usedto keep peri-anal burns clean.

DuringYourHospitalStay

Intravenous therapy Infusion of specialized fluidsand medication directly into a vein.

Foley catheter Flexible tube inserted into thebladder used to drain urine.

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THE ACUTE PHASE

The acute phase begins and remains until allfull-thickness wounds are covered by skin grafts.The objectives during this period include:

Removal of dead tissue (eschar) and coveringthe wounds with skin grafts (if required)

Providing adequate nutrition

Preventing complications

Preventing contractures

Meeting the individualized and evolvingemotional needs of the patient and family

For a burn wound to heal, the wound(s) need tobe cleaned regularly, which may involve daily,bi-weekly or weekly cleansing. Wound care canbe done in the Operating Room, Treatment Roomor at the bedside depending on specific needs.The size of the burn, the treatment required andthe patients condition will determine where the

Feeding tube (NG or NJ) A small tubeinserted through the nose or mouth thatextends into the stomach. A feeding tubeis inserted when the patient is intubated orhas insufficient caloric intake. Burn patients

require additional calories and protein inorder to heal.

Initial debridement and dressing Oncestabilized, wounds are cleaned and a burndressing is applied. The patient is theneither transferred to the Pediatric IntensiveCare Unit (PICU) or to the Surgical/Trauma

Unit. The location is based on specific carerequirements.

Contractures Tightening of the skin followinga second or third degree burn.

Many other tubes, lines and equipment

may be used throughout your childs

treatment, each of which has an

important function in the care process.

Do not hesitate to ask questions aboutequipment and its purpose.


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Otherwise, this aspect of care can beperformed by a Nurse, Physiotherapist orOccupational Therapist on the unit during adressing change.

Escharotomies The dead skin and tissue ona burn is called eschar. A burn that surroundsa body part may cause the area to swelland tighten, subsequently impairing bloodflow to the area. When this occurs, PlasticSurgeons make an incision in the burned areain order to relieve the pressure.

Grafting Deeper burns rarely heal on their

own therefore requiring a skin graft. A skingraft is a very thin piece of skin that is takenfrom an area of the body unaffected by theburn and then used to cover the burn. Thesite from which the graft is removed willheal on its own in approximately 10-14 daysand can be used again for future grafting.The most common areas used as a donor

site include the legs, back and buttocks;less frequently used are the chest and arms.

dressing change will be done. When medicallypermitted, some patients choose to remain intheir hospital room for treatment while othersprefer to have their treatments done in the unitsTreatment Room. Having treatments done in

the Treatment Room may help preserve the safefeeling of the hospital room.

WOUND CARE

Wound care may include wound cleaning,debridement, grafting, escharotomies anddressing changes:

Wound cleaning The first step involvedin wound care is to clean the burned skin.Warm water and gauze is used to removedead tissue. This step is essential to woundhealing and for preventing infection.

Debridement Occasionally surgicalequipment is needed to remove dead skin. If

wounds are deep, debridement is performedby a Plastic Surgeon in the operating room.


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be present during the procedure and mayinclude: Plastic Surgeon, Plastic SurgeryResident, Trauma Coordinator, Nurses,Physiotherapist, Occupational Therapist,Child Life Specialist and a Patient Care

Attendant.The Burn Trauma Team works efficiently sothat wounds are not exposed for extendedperiods of time. The team will wear gowns,masks and gloves as necessary to diminishthe risk of infection. You too may be requiredto wear these items. The Child Life Specialist

will provide distraction and coping techniquesthroughout the procedure.

A variety of dressing types are used to coverthe donor site. Skin grafting is performed byPlastic Surgeons in the Operating Room. Thereare two types of skin grafts: sheetand mesh.

Dressing changes This procedure maycause pain. Prior to the dressing change,a nurse or doctor will give the patientmedication to help control pain and diminishanxiety. A variety of Trauma Specialists will

Donor site Area of the body from which skin is takenand used to cover areas affected by the burn.

Sheet skin graft Thin layer of skin used in its

entirety to cover a burn. Mesh skin graft Thin layer of skin modified by

medical equipment permitting it to stretch and covera large area affected by the burn.Meshed graft


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Parents are an integral part of the team and are therefore encouraged to accompany their child during procedures.

Your presence will reassure and comfort your child. At this time, you will also have the opportunity to see the evolution

of the healing burn.

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All grafts are immobilized to preventmovement and promote healing.

The first dressing change is done at approxi-mately five days post surgery. Dressings areworn until all wounds have healed.

WOUND HEALING

Varies depending on the size and depth of theburn, individual healing ability, nutrition andinfection. This stage can often be a challengingtime for the patient and family. An update ofthe treatment plan will be discussed regularly

with you.

SCARS

Depth of the wound, healing time, complicationsand treatment will affect scarring. Some patientsscar more profoundly than others thereforemaking it more difficult to predict how much

scarring a patient will have. Once the woundheals, the scar will typically be red in appearanceand is referred to as an immature scar.

The bandages/dressings are removed and allwounds are cleaned to remove dead tissueand exudates. The wounds are then assessedby the Plastic Surgeon who will determinewhen the next dressing change will take place

or if surgery is required.The Physiotherapist and OccupationalTherapist will assess range of motionandfunction, perform exercises and determineif splintsare required. The wounds are thencovered with a silver dressing or ointmentdepending on the size and area of the body

affected by the burn. The frequency ofdressing changes varies and can range fromdaily to weekly.

Exudates Refers to the fluid that leaks froman open wound.

Range of motion Full movement of a joint,

range of flexion and extension. Splint A rigid material made of either

plaster or plastic used to support and/or immobilizea limb.


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From about three months to two years post burnthe scar will likely become paler, flatter and softerand is referred to as a mature scar.

Deep second-degree and third-degree burns can

continue to produce scar tissue up to two yearsfollowing the injury. At this point in time, somescars will gradually improve while others maybecome permanent. The Plastic Surgeon willprovide you with information concerning scarring.Surgical procedures that can be done at a latertime to improve the appearance of permanentscars may also be discussed.

Scar massage Scar tissue may stick to theunderlying muscles, tendons, blood vessels,nerves and bones. Massage can prevent this fromoccurring and helps to maintain the flexibilityof the scar tissue. Scar massage involves rubbingand moving the skin and underlying tissue ina firm manner.

Scars may feel sensitive or hurt when touched;regular massage can help control this andeventually the area will become less sensitive.It is recommended to use an unscentedmoisturizing cream during scar massage. Once

the burn wounds are healed the OccupationalTherapist will teach you the proper techniquesused in scar massage.


Mature scar

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Positioning and splinting

is essential to the rehabilitation

process.

POSITIONING AND SPLINTING

It is essential for the rehabilitation process tobegin immediately following hospitalizationand continue through discharge. Both the

Physiotherapist and Occupational Therapistclosely monitor and oversee this aspect ofburn care. They will assess the patients needfor splinting and positioning. An individualizedprogram will be developed which will includerange of motion exercises and stretching toensure all joints are loose and functional. Properpositioning is essential for optimal healing and

to prevent contractures. If the joints are notstretched regularly and positioned properlythey eventually become tight and difficultto straighten. This will have a direct impacton function, rehabilitation potential and thepatients ability to perform daily activities.


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PAIN MANAGEMENT

Children with burn injuries experience pain. Theintensity will vary according to the degree of burnand individual tolerance levels. Pain medication

is given orally or through an IV before proceduresand therapy sessions as well as on a regularbasis. The objective is to maintain optimal levelsof comfort.

Some parents express concern regarding theregular use of pain medication and addiction.It is rare for children to develop an addiction topain medication because they are given smallquantities for only a short period of time.

Trauma Specialists will ask your child (agepermitting) to rate their pain using a pain scale.This tool helps the nurses determine whenand how much pain medication to give your childin order to ensure comfort.

The Child Life Specialist will also help your childcontrol pain using various coping techniques.Education and preparation helps manageanxiety surrounding procedures and treatments.The Child Life Specialist will teach your childto identify comforting ways to reduce anxiety.If you have questions about pain medication,

you are encouraged to speak with your childsTrauma Coordinator, Nurse, Doctor or the PainManagement Team.

A PAIN SCALE


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Burn injury patients often lack an appetite. Familymembers and nursing staff should be patient,supportive and encourage the patient to eat.Nourishing snacks or supplements are oftenprovided between regular meals.

Vitamin supplements can also be given asneeded. The Clinical Nutritionist will developan optimal diet based on your childs individualneeds.

PSYCHOLOGICAL AND SOCIAL IMPACT

We are committed to meeting the individualpsychological needs of the patient and familythroughout burn treatment and recovery.To facilitate this process we encourage parentsand caregivers to collaborate with the teamwhen developing individualized care plans.These plans are designed to meet the childsmedical, rehabilitation and psychological needs

as well as the familys needs throughout thedifferent phases of recovery.

NUTRITION

The nutritional needs of burn injury patientsdiffer from those of healthy individuals. Thebody requires a lot of energy to heal therefore

it needs more calories, protein and vitamins.The nutritional support required will depend on:

The patients pre-burn nutritional status

The total body surface area (TBSA) affectedby the burn and the degree of burn

The patients nutritional intake duringhospitalization

The well-nourished patient with a minor burninjury will not require additional nutritionalsupport beyond that of a regular diet. This ofcourse relies on the patient maintaining theirusual nutritional intake. Given the amount ofenergy required throughout the healing process,a moderate burn injury patient with goodpre-burn nutrition, as well as a major burn willrequire a high caloric and protein diet.


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hospital stay. This is a difficult time for your child;love, support and providing clear expectationsare beneficial.

DISCHARGE PLANNING

Upon admission to the hospital, the Burn TraumaCoordinator and other team members will begindiscussing and planning your childs dischargewith you. Some burn patients will be dischargedhome, while others may require a stay in arehabilitation centre before returning home.The team will also determine when your child is

ready to be discharged from the hospital from amedical, nursing and rehabilitation perspective.The severity of the burn injury and rehabilitationneeds will be the determining factors as towhether or not your child will be transferred toa rehabilitation centre for a period of in-patientor out-patient care. Alternatively, your child maygo home with out-patient follow-up care at

the Montreal Childrens Hospital Trauma Centre.Services may also be organized through yourcommunity CLSC.

Children will often experience a variety ofemotions following a burn trauma as well as duringan unplanned hospital stay. Children with burninjuries may also experience changes in behaviorand emotion. It is common for children to feel pain,

stress, anxiety, anger, guilt, isolation, and to reportlow self-esteem and loneliness. Common reactionsto these emotions are aggression, nightmares andeven developmental regression in younger children(i.e. bed wetting or thumb sucking).

Your childs sense of body image may also beaffected depending on their age. The way in

which a child perceives themselves following aburn injury is an important concern. The MCHPsychosocial Team, consisting of a Social Worker,Child Life Specialist, Psychologist and SpiritualCare, will address these and other concerns thatyou may have about your child. Professionalcounseling is available if there are other aspectsof your childs behavior which concern you.

It is important to maintain a structured andconsistent approach similar to the one at homeregarding your childs discipline during the


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We are committed to meeting the individual psychological needs of the patient and family throughout the different

phases of burn treatment and recovery.


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THE REHABILITATION

PHASE

The rehabilitation phase involves resuming dailyactivities and helping your child to reach their

functional potential. Patients and families oftenreport that the period following discharge ischallenging. In fact, many patients and familieshave expressed that the first 18 months followingdischarge from hospital are often more difficultfor the patient than the hospital stay itself.

The rehabilitation goals at this time include:

maintaining and increasing range of motionof joints, muscle strengthening, increasingfunctional activities, scar management,reconstructive surgery (if needed) and emotionaland psychological support.

MINIMIZING SCARS AFTER A BURN

Compressive garmentsare used to reducescarring. Children with deep burns are required towear compressive garments. For optimal results,

the garments must be worn 23 hours per dayfor up to two years following the burn injury andcan only be removed while bathing. You will needto have at least two sets of compressive garmentsso that one can be worn at all times even duringlaundering.

Hypertrophic scars Hypertrophic scars are achallenging complication of burn injuries. Tissueformation is often excessive and can result inthick and swollen scars. Typically, hypertrophicscars develop once deep burns have healed. It isimportant to note that the burn healing processcontinues within the deeper layers of the skineven though the surface has healed.

Compressive garment Form-fitting clothes wornover burned areas to help minimize scarring.

DuringYour

HospitalStay

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There are different methods used to help preventand reduce hypertrophic scarring which include:

Compressive garments

Gel sheet

Scar massage Injections

Surgical incision

The Plastic Surgeon, Occupational Therapist andTrauma Coordinator will discuss available options.

Gel sheet Specialized sheet made of siliconeused under the compressive garments to help reducescarring.

PREVENTING CONTRACTURES

Wear a splint

Perform range of motion exercises Promote independence in function

Compressive garments


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PREVENTING CONTRACTURESFOLLOWING A BURN

A contracture is a serious complication of aburn injury. Contractures develop when a burn

scar matures, thickens and tightens preventingor limiting movement. If your child develops acontracture, they will not be able to mobilize thescarred area normally.

Have your child perform normal daily activities asmuch as possible. Movement that occurs duringthese daily activities such as eating, brushingteeth and hair as well as getting dressed will helpkeep the scar area stretched. It is important toencourage your child to continue doing theseactivities despite the fact that they may findthem challenging.

DuringYour

HospitalStay

Rehabilitation following a burn trauma

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Caringfor Your Burnat Home IMPORTANT

RECOMMENDATIONSTO FOLLOW


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Once your child is ready to return home, youwill receive instructions that will help you carefor them. An individualized plan will be discussedand written instructions will be provided.

Your individualized discharge plan will includemedication requirements, dietary needs,suggested daily activities, return to schoolintegration plan, home care supplies andequipment, wound care instructions as wellas information on potential complications.Follow-up appointments will be arranged andgiven to you at the time of discharge.

Returning home after a burn injury involves anadjustment period for both the child and family.You will likely experience a variety of feelings andemotions which are normal and to be expectedfollowing a burn injury. You may feel afraid,anxious, or uneasy about leaving the hospital andabout your childs appearance and how others will

react. The Trauma Specialists who were involved inyour childs care will remain available as a resourceupon discharge home.

IMPORTANT

RECOMMENDATIONS

DRESSING CHANGE AND/OR IRRIGATION

Your child may have healing burned areas stillrequiring dressing changes and/or irrigation afterdischarge. The dressing change will either be doneat the hospital, local CLSC or at home. You willbe given specific instructions on how to changeand/or irrigate the dressing if needed followingdischarge. Refer to the guidelines at the end ofthe booklet for additional details. The frequency

of dressing changes may vary and you willtherefore be provided with a schedule. It is bestto give your child the prescribed pain medication30 minutes before the dressing change begins.

CaringforYourBurnatHome

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COMPRESSIVE GARMENTS AND SPLINTS

Your child may be required to wear compressivegarments and splints in order to:

Manage scars

Prevent contractures Decrease itchiness

Compressive garments should be hand washedusing a mild soap, rinsed well, patted gently ona towel, and finally hung out to dry. Do not usebleach products or put the compressive garmentin the dryer as this will damage the garment.

Garments should be changed approximately everythree months. Make sure to contact the Occupa-tional Therapist if the garment becomes too looseor if other changes to the garment concern you.

EXERCISES

It is essential to ensure that your child performsthe daily recommended exercises provided by theBurn Team. The Physiotherapist and OccupationalTherapist will provide you with a written sheet ofexercises prior to your discharge home.

SKIN CARE

Healed wounds, skin grafts, donor sites andscars all need regular moisturizing to preventdryness, cracking and discomfort. Newly healedskin is unable to lubricate itself in the same wayundamaged skin can.

Unscented lotions/creams should be appliedgently to the area then gradually progress toa massage

Moisturizing should be done two to threetimes per day or more if the skin is very dry

It is extremely important that the skin is

cleaned each day as the build-up of creamcan cause skin irritation

SCAR MASSAGE

Once the wound is fully healed begin scarmassage.

Massage the scar two to three times a day

for five to 10 minutes at a time


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If itching is intolerable and prevents yourchild from sleeping, contact the PlasticSurgeon who may then prescribe medicationto reduce itching

BLISTERS AND OPEN AREASMay develop in newly healed skin and may formafter minor hits, scrapes or scratches. Can alsobe caused by friction from tight clothing, as wellas from not wearing compressive garments ornot wearing them properly. With time, the skintoughens and blistering is less frequent. It maybe necessary to apply a small dressing until thewound heals.

DISCOLORATION

Once burn healing has begun you may notice thatyour childs skin is a different color in comparisonto the skin on the rest of their body. This isexpected and is part of the normal healing process.

It may appear light, deep pink or brownish incolor. The extent of discoloration varies with eachindividual depending on their natural skin tone.

Continue scar massage until the scar hasmatured. A mature scar appears pale, flatand/or soft

Moisturize the mature scar regularly

PRECAUTIONS Do not massage open wounds

If the scar becomes sore, blisters, reopens ora rash develops, stop massaging and contactthe Occupational Therapist or the TraumaCoordinator

ITCHINGBurn injured areas and donor sites may bevery itchy for a prolonged period of time. Thiscan be very uncomfortable especially at night.The following are some tips that may help easethe discomfort:

Dress your child in loose, light-weight clothing

Compressive garments should be worn all day Use an unscented body lotion or cream to

moisturize healed wounds


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SWIMMING

If burn injury wounds are fully closed and healedyour child is permitted to swim in a pool, lakeor ocean. However, it is important to note thatchlorine tends to dry out burn scars. Make sureto rinse the body well after swimming andremember to apply extra moisturizing cream onthe scar.

DIET

It is important that your child maintain awell-balanced and nutritious diet at home as

the healing process continues. The ClinicalNutritionist will provide you with informationregarding your childs caloric needs at home andmake suggestions on how you can fulfill them.

MEDICATION

Your child may be discharged home with several

different medications. A nurse will review howand when to take these medications, what theyare used for and discuss any possible side effects.

In superficial and/or some second-degree burns,the skins natural color may return within severalmonths. Other areas may take much longer andsome discoloration can be permanent in burns ofgreater depth.

SUN SENSITIVITY

Newly healed skin and donor sites are extremelysensitive to sun exposure. The area tends tosunburn quickly especially within the first yearfollowing a burn injury.

Limit sun exposure as much as possible

Protect the skin by wearing light clothing tocover the areas affected by the burn

Wear a large hat if the face and neck wereburned

Apply a high factor sun screen with both UVAand UVB protection

It is important to remember that pressuregarments do not protect the skin from sunburn.


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RETURNING TO SCHOOL

Returning to school can be a challenging timefor children and teens who have sustained a burninjury. Nonetheless, it is beneficial for them toreturn to their academic and social activities assoon as they can. To help with this transition,a member of the Psychosocial Team can go toyour childs school ahead of time to help prepareclassmates and teachers for your childs return.

This often helps students understand burntrauma and to recognize what their classmatehas experienced. It also provides an excellentopportunity to discuss burn trauma prevention.If you feel that any of the above would facilitateyour childs school reintegration, contact the BurnTrauma Coordinator.


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THE TRAUMA PROGRAM IS HERE FOR YOU

Contact the MCH Burn Trauma Program if your child experiences any of the following: Fever

Increase in wound pain

Wound odor

Bleeding from the wound between

dressing changes

Increased swelling to the burn injured

part of the body

The Trauma Specialists remain available to you and your child upon discharge.

ALTERNATIVE CARE MODULE NURSE

Monday to Friday 8a.m. to 6p.m.

514-412-4 4 0 0, extension 23535

BURN TRAUMA PROGRAM


514-412-4 4 0 0, extension 23310

SURGICAL/TRAUMA UNIT 7C1

AVAILABLE AT ALL TIMES

514-412-4 4 0 0, extension 22433

PLASTIC SURGERY CLINIC


514-412-4 4 0 0, extension 23206


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CaringforYourBurnatHome HOW TO CHANGE A DRESSING

Ensure that you have all the supplies you need set up neatly and that the area is clean.

EQUIPMENT

Sterile water Sterile gauze

Gauze bandage (e.g. Kerlix)

Tape

Cream, ointment or prescribed dressing

INSTRUCTIONS FOR CHANGING

A DRESSING

1. Wash your hands with warm waterand soap

2. Remove the old dressing (s)

3. Discard the old dressing (s) in a smallplastic bag

4. Wash your hands again

5. Gently clean the wound. Always remove

cream/ointment residue before applyinga new dressing

6. Gently pat the area dry with a gauze

7. Apply the cream, ointment or dressingto the wound

8. Wrap the dressing with the gauze bandage.Begin wrapping at the point furthest

away from the heart. For example, if theleg is burned, wrap from the ankle up tothe knee

9. Tape the wrap in place

10 . Clean equipment

11. Wash your hands

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INDIVIDUALIZED INSTRUCTIONS


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CaringforYourBurnatHome YOUR SPLINT: WEAR AND CARE

SPLINT CARE

Clean the splint using lukewarm water andmild soap. Do not use hot water because

it may alter the shape of the splint A brush may be used to clean your splint

Thoroughly dry your skin and splintcarefully after cleaning

Do not leave your splint near a heat source(heater, oven, window) as it can alter theshape

If your splint breaks or its shape isaltered, contact the Occupational TherapyDepartment. Do not try to modify or repairthe splint. It might change the fit, affectthe skin or damage the splint

After swimming, ensure the splint isdry on the inside and reapply it to dry,

clean skin

PRECAUTIONS

Observe for signs of redness, rash orblisters. A pressure point may be causing

skin damage or an allergic rash may havedeveloped to the material

Note any signs of discomfort and/ornumbness to the affected limb

If either of the above develops contact theOccupational Therapy Department and stopwearing the splint

WHEN TO WEAR YOUR SPLINT

During the day

At night and during rest periods

Remove splint every hours

Splint can be removed for exercises

Splint can be removed for skin care

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The splint prescribed by your doctorwas custom designed and is an important

part of treatment. If you have questions

or concerns regarding its fit, applicationand/or schedule, please contact the

Occupational Therapy Department at514-412-4407.

INDIVIDUALIZED INSTRUCTIONS


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RECOMMENDATIONS

Apply the adhesive side to clean, dry skin

Wash the sheet twice daily with mild,

non-oily soap and reapply to clean, dryskin. If there is a substantial heat exposureor physical activity it should be cleanedmore frequently

Do not use paper towels to dry the siliconesheet as it may adhere to the surface

The silicone sheet should be applied for

a minimum period of 12 hours (preferably24 hours) per day

The silicone sheet should be used for amaximum of:- 4 hours for the first application- 8 hours the following day

Increase wearing time to 24 hours a day

Once the silicone sheet begins todeteriorate, it should be changed. Sheetstypically last three 3-4 weeks

If skin irritation, softening, skin breakdownor rash develops, call the Occupational

Therapy Department and stop wearing thesilicone sheet

HOW TO USE A SILICONE GEL SHEET

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You will meet with the MCH TraumaBurn Program members on a regular basis.

Your questions and concerns are important tous. We encourage you to write down questions,concerns and/or suggestions that you wish

to discuss with the team at a later time.


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REFERENCES

The American Burn Association

Burnsurgery.org

The Montreal Childrens HospitalBurn Trauma Protocol

USEFUL LINKS

About face

aboutface.ca

Association des grands brls F.L.A.M.www.assdesgrandsbrulesflam.ca

Canadian Burn Survivors Community

www.canadianburnsurvivors.ca

Entraide grands brls

www.entraidegb.org/home_en.htm

Fondation des pompiers du Qubec

pour les grands brls

fondationdespompiers.ca

The Montreal Childrens Hospital

Trauma Centre

thechildren.com/trauma/en/

Phoenix Society for Burn Survivors

www.phoenix-society.org

Documents

MUHC guide to handling burns