burn wound management

Clinical Practice

Guidelines

BURN WOUND MANAGEMENT

FIRST WRITTEN 24/08/2006 REVISED 20/08/2008

NSW Severe Burn Injury Service Website: http://www.health.nsw.gov.au/gmct/burninjury

Concord Repatriation General Hospital Royal North Shore Hospital The Children’s Hospital at Westmead Hospital Rd, Concord 9767 5000 Pacific Hwy, St Leonards 9926 7111 Hawkesbury Rd, Westmead 9845 000

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

Contents: Page Number

1. Contributors 3 2. Introduction 4 3. Definitions of Burns 5 4. Anatomy and Physiology of the Skin 6

Structure of Skin 6 5. Pathophysiology of Burn Injuries: Local and systemic 8

Injury Zones of the Burn Wound 8 Management of the Burn Wound - First Aid 9 Emergency Assessment and Management of Severe Burns 11 Surface Area Assessment 14 Pain Management 15 Initial Assessment of the Burn Wound Depth 17 Burn Skin Depth 17 Assessment Of The Burn Wound 18 Capillary Refill 18 Recognising Burns 19

6. On Presentation of Burn Patient to ED - Flowchart 21 7. Burns Unit Admission Criteria 22 8. Burn Wound Management 23

Burn Wound Healing: Concepts & Principles 23 Cleansing and Debriding Burn Wound 24 Minor Burn Management (see link) 25 Digital Photograph of Burn Wound 26 Selecting an Appropriate Dressing 27 Wound Care Product Selection 28

- Silver 28 - Gauze (moist) 30 - Film & Hydrocolloid 31 - Foam 32 - Absorbent 33 - Skin Substitute 34 - Silicone 35 - Other Dressings 36 - Moisturiser 37 - Retention/Fixation 38 - Suppliers 38

Dressing Procedure 39 - Dressing Specialised Areas 39

Specific Dressing Application 41 - Omiderm 41 - Acticoat 41 - Mepilex 41 - Bactigras 42 - Aquacel Ag 42

8.9 Dressing Fixation Application 43 - Coban 43 - Hypafix/Mefix/Fixamul 43

9. Skin Grafting Management 44 Harvesting Donor Skin 45 Debriding Graft Site 46 Skin Graft Management in OT 48

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10. Donor Site Management 50 Harvesting Donor Skin in OT 52 Donor Site Management in OT 54 Initial Inspection 55 Dressing Removal 56

11. The Multidisciplinary Team 57 12. References 58 13. Websites 59

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Contributors:

Siobhan Connolly Burn Prevention/Education Officer NSW Severe Burn Injury Service Megan Brady Clinical Nurse Specialist (CNS) – Burns Concord Repatriation General Hospital Peter Campbell Clinical Nurse Consultant (CNC) – Burns/Plastics Royal North Shore Hospital Jan Darke Clinical Nurse Consultant (CNC) – Burns/Plastics Royal North Shore Hospital Diane Elfleet Nurse Unit Manager (NUM) – Burns/Plastics Royal North Shore Hospital Rae Johnson Clinical Nurse Consultant (CNC) – Burns Concord Repatriation General Hospital Nicole Klingstrom Clinical Nurse Educator – Burns The Children’s Hospital at Westmead Deborah Maze Nursing Clinical Coordinator – Burns The Children’s Hospital at Westmead Chris Parker Nurse Unit Manager (NUM) – Burns/Plastics Concord Repatriation General Hospital Dorothy Roberts Clinical Nurse Specialist (CNS) – Burns Concord Repatriation General Hospital Sue Taggart Clinical Nurse Consultant (CNC) - Burns Support / ICU Concord Repatriation General Hospital Kelly Waddell Transitional Nurse Practitioner - Burns

The Children’s Hospital at Westmead Anne Darton Program Manager NSW Severe Burn Injury Service Prof Peter Maitz Burn and Reconstructive Surgeon Concord Repatriation General Hospital Members of the Multidisciplinary Team of the NSW Severe Burn Injury Service (from Royal North Shore Hospital, Concord Repatriation General Hospital and The Children’s Hospital at Westmead)

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Introduction

The following guidelines were developed by specialist staff working within the NSW Severe Burn Injury Service (SBIS) from the tertiary Burns Units at The Children’s Hospital at Westmead, Royal North Shore Hospital and Concord Repatriation General Hospital. They were designed for use by staff working in these Burn Units to guide practice, not to replace clinical judgement. Burn Units provide specialist, multidisciplinary care in the management of burn injuries due to the continued reinforcement of treatment modalities, which is not readily available in outlying areas. Burn care involves high expense for wound management materials, staffing, equipment and long term scar management products. There are generally also long term issues arising from the initial trauma, resultant scars and the ongoing effects these have on the patient and their family. It is acknowledged that primary care or follow up management of burn injuries may occur outside of specialist units, particularly for patients with a minor burn. These guidelines are designed as a practical guide to complement relevant clinical knowledge and the care and management techniques required for effective patient management. Clinicians working outside a specialist burn unit are encouraged to liaise closely with their colleagues within the specialist units for advice and support in burn patient management. Due to the dynamic nature of burn wounds and the large number of available wound management products it is not possible to state emphatically which product is superior for each wound, however suggestions of possible dressings for different wound types are included in this document, along with application advice. This document will be reviewed on a yearly basis at present, and updated as required with current information at that time.

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Burn Injury Definitions A burn injury is defined as damage to the skin caused by heat, radiation, friction or chemicals. The injuries sustained are generally classified as:

• Chemical – direct contact with chemicals • Contact – direct contact with hot objects • Electrical – direct contact with an electrical current • Flame – direct contact with open flame or fire • Flash – exposure to the energy produced by explosive material • Friction – rapid movement of a surface against the skin eg treadmill, MBA, etc • Radiation – exposure to solar energy, radiotherapy, laser or IPL • Radiant Heat – heat radiating from heaters, open fire places, etc • Scald – hot liquids such as hot water and steam, hot fats, oils and foods

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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 4-7 kg of skind. The functions of the skin include:

o Temperature regulation o Sensory interface o Immune response o Protection from bacterial invasion o Control of fluid loss o Metabolic function o Psycho-social function

Structure of 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 ‘desquamation’c. In the epidermis keratin is flexible, but is thicker, stiffer and harder in the finger and toe nails. Hair is also made up of keratind.

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The epidermis is comprised of five layersb,c

o stratum corneum o stratum lucidium o stratum granulosum o stratum spinosum o 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 12. 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 layersc

o papillary dermis o 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.

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Pathophysiology of Burn Injuries: Local and Systemic Injury Zones of the Burn Wound9

Jackson Burn Wound Model

Zone of Coagulation (Necrosis)

Zone of Stasis (Damage)

Zone of Hyperaemia (Survival)

Epidermis

Dermis

Subcutaneous Layer

• Burns consist of three zones of damage: the zone of coagulation, the zone of stasis and the

zone of hyperaemia.9 • The zone of coagulation, or necrosis, is the central area of a burn injury where there is the

greatest amount of damage. First aid measures do not alter the extent of injury in this area. • The zone of stasis, also referred to as the zone of ischaemia or damage, lies outside the zone

of coagulation. Adequate first aid measures can have a beneficial affect on this zone. • The outer layer is the zone of hyperaemia, or survival. In burns greater than 20% TBSA the

whole body becomes the zone of hyperaemia. This zone does not generally have any long term effects, usually resolving after seven to ten days.8,10

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Pathophysiology of Burn Injuries: Local and Systemic Management of the Burn Wound - First Aid

Aim: • Stop the Burning Process • Cool the Burn Wound 1. Stop the Burning Process • Remove patient from the source of injury. • If on fire STOP, DROP, COVER face & ROLL • Remove hot, scalding or charred clothing. • Avoid self harm during above steps.

2. Cool the Burn Wound • Cool burn with cold running tap water for at least 20 minutes • Ideal water temperature for cooling is 15°C, range 8°C to 25°C • Cooling effective up to 3 hrs after injury • Keep the remaining areas dry and warm to avoid hypothermia. If patient’s body temperature

falls below 35°C - stop cooling. NB

o Ice should not be used as it causes vasoconstriction and hypothermia. Ice can also cause burning when placed directly against the skin.

o Duration of running water should be at least 20 minutes unless other factors prevent this (eg. large burn causing rapid heat loss, hypothermia, and multiple traumas).

o Wet towels / pads are not efficient at cooling the burn as they heat up quickly. They should not be used unless there is no water readily available ie in transit to medical care. If required use 2 moistened towels / pads and alternate at 2 minute intervals.

o Remove any jewellery or constrictive clothing as soon as possible.

3. Seek medical advice • Dial “000” (Triple Zero) for any burn over 10% of the body for adults, 5% of the body for

children, or when there are assosciated trauma or concerns. • Visit local doctor if burn larger than 20c piece with blisters, or if any concerns about burns. Plastic cling wrap is an appropriate simple dressing for transfering patients with burn injuries to a specialist burns unit. It protects against colonisation and excess fluid and heat loss.

4. On arrival at Hospital • Place the person on a clean dry sheet and keep them warm. • Keep the burn covered with plastic cling wrap or a clean sheet when not being assessed. • Elevate burnt limbs. • Small burns may require continuous application of water to reduce pain (eg spray pack). • Chemical burns require copious amounts of water, and prolonged period of irrigation. A

shower is preferable. Identify the chemical involved. If the chemical is a powder first brush off excess, then irrigate.

• Eye burns require an eye stream (saline) or an IV bag of saline attached to a giving set and placed over the open eye to flush it adequately

NB The application of timely and effective first aid measures such as cold running water for 20

minutes given within the first three hours after injury can have a beneficial affect on the zone

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of stasis by stopping the burning process and assisting in cell survival (see below). Conversely the lack of effective first aid can lead to an increased chance of further tissue necrosis as the zone of stasis can progress to coagulation.

Effectiveness of First Aid

With First Aid No First Aid

Outcomes: The burning process is stopped and the burn wound is cooled.

For further information see NSW Severe Burn Injury Service Transfer Guidelines12

http://www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_012.pdf

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Pathophysiology of Burn Injuries: Local and Systemic Emergency Assessment and Management of Severe Burns1

Aim: Immediate life threatening conditions are identified and emergency management commenced.

Primary Survey

A. Airway maintenance with cervical spine control • Inspect the airway for foreign material/oedema. If the patient is unable to respond to verbal

commands open the airway with a chin lift and jaw thrust; stabilize neck for suspected C Spine injury.

• Keep movement of the cervical spine to a minimum and never hyperflex or hyperextend the head or neck.

• Insert Guedells airway if airway patency is compromised. Think about early intubation. B. Breathing and Ventilation • Expose the chest and ensure that chest expansion is adequate and bilaterally equal – beware

circumferential deep dermal or full thickness chest burns – is escharotomy required? • Administer 100% oxygen. • Ventilate via a bag and mask or intubate the patient if necessary. • Examine for carbon monoxide poisoning – non burnt skin may by cherry pink in colour in a

non-breathing patient • Monitor respiratory rate – beware if rate <10 or > 20 per minute.

C. Circulation with Haemorrhage Control • Monitor the peripheral pulse for rate, strength (strong, weak) and rhythm, • Apply capillary blanching test (centrally and peripherally to burnt and non-burnt areas) –

normal return is two seconds. Longer indicates hypovolaemia or need for escharotomy on that limb; check another limb.

• Inspect for any obvious bleeding – stop with direct pressure. D. Disability: Neurological Status • Establish level of consciousness:

A - Alert V - Response to Vocal stimuli P - Responds to Painful stimuli U - Unresponsive

• Examine pupil response to light for briskness and equality. • Be alert for restlessness and decreased levels of consciousness – hypoxaemia, shock, alcohol,

drugs and analgesia influence levels of consciousness.

E. Exposure with Environmental Control • Remove all clothing and jewellery. • Keep patient warm • Roll and remove wet sheets and examine posterior surfaces for burns and other injuries.

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F. Fluids Resuscitation • Fluid Resuscitation will be required for a patient that has sustained a burn >10% for children,

>15% for adults. • Estimate burn area using Rule of Nines. For smaller burns the palmar surface (including

fingers) of the patient’s hand (represent 1% TBSA) can be used to calculate the %TBSA burnt.

• Insert 2 large bore, peripheral IV lines preferably through unburned tissue. • Collect bloods simultaneously for essential base line bloods - FBC/EUC/ LFT. /Group &

hold/Coags. Others to consider – Drug/alcohol screen/Amylase/Carboxyhaemoglobin • Obtain patients body weight in kgs. • Commence resuscitation fluids, IV Hartmann’s at an initial rate of the Parkland Formula but

adjust according to urine output:

4mls x kgs x % TBSA burnt = IV fluid mls to be given in 24hrs following the injury Give ½ of this fluid in the first 8hrs from the time of injury

Give a ½ of this fluid in the following 16hrs

• Children less than 30kg require maintenance fluids in addition to resuscitation fluids. • Insert an IDC for all burns >15% and attach hourly urine bag. IV Hartmann’s is adjusted

each hour according to the previous hour’s urine output. REMEMBER: The infusion rate is guided by the urine output, not by formula.

The urine output should be maintained at a rate Adult 0.5 – 1 ml / kg / hr

Children 0.5 – 2ml / kg / hr – * aim for 1 ml/kg/hr*

• If urine output <0.5mls/kg/hr increase IV fluids by 1/3 of current IV fluid amount. If urine output >1ml/hr for adults or >2ml/kg/hr for children decrease IV fluids by 1/3 of current IV fluid amount (see fluid balance chart on following page).

Eg: Last hrs urine = 20mls, received 1200mls/hr, increase IV to 1600mls/hr

Last hrs urine = 100mls, received 1600mls/hr, decrease IV to 1065mls.

• More IV fluids are required: 1. When pigmenturia (dark red, black urine) is evident. Pigmenturia occurs when the

person has endured thermal damage to muscle eg electrical injury. Mannitol may be ordered if pigmenturia evident.

2. Inhalation Injury. 3. Delayed resuscitation.

• ECG, pulse, blood pressure, respiratory rate, pulse oximetry or arterial blood gas analysis as appropriate.

Nutrition • Insert nasogastric/ nasoduodenal tube for larger burns (>20% TBSA in adults; >15% TBSA

in children) or if associated injuries. See SBIS Nutrition & Dietetics Guidelines. Pain Relief • Give morphine (or other appropriate analgesia) slowly, intravenously and in small

increments according to pain score and sedation scale (see Page 18).

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Secondary Survey

History A - Allergies M - Medications P - Past Illnesses L - Last Meal E - Events/Environment related to injury

Mechanism of Injury

Burn • Gather information from the patient or others the following:

o Date and time of burn injury, date and time of first presentation. o Source of injury and length of contact time. o Clothing worn. o Activities at time of burn injury. o Adequacy of first aid.

Head to Toe Assessment • Record and document • Swab all burn wounds and send to microbiology. • Reassess A, B, C, D, E, and F.

Circulation: If the patient has a circumferential full thickness burn it will impede circulation and or ventilation (if burn around chest). • Contact the Burns Registrar at a specialist burns unit. • Elevate the effected limb above the heart line. • Commence a circulation chart. • Escharotomy may be necessary to relieve pressure if circulation is compromised.

Psychosocial Care • Document next of kin and telephone number. • Inform and provide support to family. • Obtain relevant psychosocial information during assessment and document. • Contact relevant Social Worker, Psychologist or Psychiatrist

Re-evaluate • Give tetanus prophylaxis if required • Note urine colour for pigmenturia • Laboratory investigations:

o Haemoglobin/haematocrit o Urea/creatinine o Electrolytes o Urine microscopy o Arterial blood gases o Electrocardiogram

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Pathophysiology of Burn Injuries: Local and Systemic

Surface Area Assessment

Rule of Nines a

Palmar Method

Adult

Child

For every year of life after 12 months take 1% from the head and add ½% to each leg,

until the age of 10 years when adult proportions

• Palm and fingers of the patient = 1% TBSA

• Useful for small and scattered burns

• Can be used for subtraction e.g. full arm burnt except for hand-sized area = 8% TBSA

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Pain Management Aim: • To reduce pain levels that are unacceptable to the patient • To minimise the risk of excessive or inadequate analgesia Assessment • How much pain does the patient have? Utilise the Visual Analogue Scale (VAS) at regular

intervals every 3-5 minutes, document. • How much analgesia has the patient been given prior to arrival? • Ask the patient if they use illicit drugs and alcohol. • Weigh patient so that analgesic amounts are adequate.

Acute Management • Give small increments of IV narcotic. A standard stat dose of IV morphine is 2.5 - 10 mg for

adults and 0.1 - 0.2 mg/kg of body weight for children. • The dose should be titrated against the patient’s response, including the respiratory rate. • A narcotic infusion can be commenced once the initial treatments have stabilised the patient. • Burn procedures may require analgesia 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. Oral midazolam may also be used for its dissociative, anxiolytic and sedative qualities. Antihistamines can be useful in patients 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).

• Tapes, music and overhead pictures are useful diversional/distraction techniques. For children a play therapist can also assist with procedures. Provision of diversion/distraction therapy helps decrease pain and anxiety.

• Anti-emetics may be necessary when narcotics are given. • Aperients to be administered when narcotics given to avoid constipation. • Oral analgesia may be administered to patients with minor burns. • Follow general hospital/institutional Pain Management Guidelines. The 3 Stages of Pain Relief7,16

1. Background a. Pain experienced, when at rest, in burned areas and treatment areas, e.g. donor site. b. Constant and dull in nature. c. Best treated with constant serum opioid levels, e.g. acute phase, continuous narcotic

infusion or slow released oral opioid as pain levels decrease. 2. Breakthrough

a. Rapid onset of pain and often short in duration. b. Occurs whilst attending to simple activities such as walking or changing position in

bed. c. Relieved by quick release oral opioids and for patients with IV access, PCA or

bolus doses. 3. Procedural Pain

a. High levels of intense pain for duration of procedure, e.g. wound dressing changes and physiotherapy.

b. Requires higher more potent doses of opioid administration.

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c. Can also utilise adjuncts such as diversion/distraction (see above)

Special Considerations: Narcotic IMI’s should not be administered as peripheral shut down occurs in burns > 10%. Absorption of the drug will not take place so pain relief will not be achieved. As circulation improves an overdose of the opiate may occur.

Outcome: Pain is kept at an acceptable level



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Initial Assessment of the Burn Wound Depth

Aim: • To determine the depth of the burn wound. • Epidermal, superficial dermal (superficial partial), mid-dermal (partial), deep dermal/(deep

partial), and full thickness are terms to describe the depth of burn injury.

To determine the depth of the injury several aspects should be investigated • Clinical examination of the burn, including capillary refill • Source and mechanism of the injury, including heat level, chemical concentration, and

contact time with source. • First aid. Prompt first aid will reduce further destruction of the zone of stasis. • Age of the patient • Pre existing disease or medical condition

Burn Skin Depth

Assessment of The Burn Wound

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

Epidermal

Superficial Dermal Mid Dermal Deep Dermal

Full Thickness

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Assessment of the Burn Wound

Depth Colour Blisters Capillary Refill Healing Scarring

Epidermal Red No Brisk 1-2 sec

Within 7 days None

Superficial Dermal (Superficial Partial)

Red / Pale Pink Small Brisk 1-2 sec

Within 14 days None Slight colour

mismatch Mid-Dermal

(Partial) Dark Pink Present Sluggish

>2 sec 2-3 weeks

Grafting may be required

Yes (if healing >3wks)

Deep Dermal (Deep Partial)

Blotchy Red / White +/- Sluggish >2 sec / Absent

Grafting required Yes

Full Thickness White / Brown / Black (charred) / Deep Red

No Absent Grafting required Yes

Sources: Modified from EMSB Course Manual, p461; Partial Thickness Burns – Current Concepts as to Pathogenesis and Treatment, p21. (Jan Darke CNC RNSH)

Capillary Refill Pictures by Rae Johnson CNC CRGH

If there is a blister lift small area of skin. Apply pressure to wound bed and observe for capillary refill, replace skin as biological dressing if acceptable refill time.

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Recognising Burn Depths Epidermal Burn Superficial Dermal Burn Mid Dermal Burn (Superficial Partial Thickness) (Mid Partial Thickness)

• Faint erythema not included in % TBSA

• Heal spontaneously within 3-7 days with protective dressing

• Blanch to pressure • Should heal within 7-10

days with minimal dressing requirements

• Heterogeneous, variable depths

• Should heal within 14 days • Deeper areas may need

surgical intervention

Deep Dermal Burn Full Thickness Burn (Deep Partial Thickness)

• Heterogeneous, variable depths

• Generally need surgical intervention

• Refer to specialist unit

• Outer skin, and some underlying tissue dead • Present as white, brown, black • Surgical intervention and long-term scar management

required • Refer to specialist unit

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• The wound appearance will change over a period of time, especially during the first 7 days following injury.

This patient suffered a scald burn. Notice the changing appearance of the wound over just a few

days.

Day1 Day 2 Day 5

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On Presentation of Burn Patient to ED

Perform Primary & Secondary Surveys

Obtain Clear History of Burn Injury • Mechanism of Injury, How and When burnt • Any First Aid (what, how long?). Continue

cooling if within 3 hours of burn • Were clothes removed?

Give Appropriate Pain Relief

Assess % TBSA (total body surface area) using Rule of Nines

Does it meet referral criteria?

• Partial/full thickness burns in adults >10% TBSA. • Partial/full thickness burns in children >5% TBSA. • Any priority areas are involved, i.e. face/neck, hands, feet,

perineum, genitalia and major joints. • Caused by chemical or electricity, including lightning. • Any circumferential burn. • Burns with concomitant trauma or pre-existing medical condition. • Burns with associated inhalation injury. • Suspected non-accidental injury. • Pregnancy with cutaneous burns.

YES NO

Refer to appropriate Burn Unit: • Royal North Shore Hospital

Ph: (02) 9926 8940 (Burn Unit) Ph: (02) 9926 7988 (Ambulatory Care)

• Concord Repatriation General Hospital Ph: (02) 9767 7776 (Burn Unit) Ph: (02) 9767 7775 (Ambulatory Care)

• The Children’s Hospital at Westmead (all paediatrics <16yrs) Ph: (02) 9845 1114 (Burn Unit) Ph: (02) 9845 1850 (Ambulatory Care)

Minor Burn: Can be managed in outlying hospitals and clinics, (see Minor Burn Management booklet) • Assess burn wound • Apply appropriate dressing • Arrange follow-up dressing and

review • Prescribe pain relief as required • Contact Burn Unit for any

questions or for further review

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Burns Unit Admission Criteria DEFINITIONS 1. Severe burns These are burns, which require referral to a specialised tertiary burns unit (see SBIS Transfer Guidelines12). These units include adults units at Royal North Shore Hospital and Concord Repatriation General Hospital, and the paediatric unit at The Children’s Hospital at Westmead. A burn is classified as severe if:

a. it involves partial/full thickness burns in adults >10% TBSA (total body surface area). b. it involves partial/full thickness burns in children >5% TBSA. c. any priority areas are involved, i.e. face/neck, hands, feet, perineum, genitalia and major

joints. d. it is caused by chemical or electricity, including lightning. e. the burn is circumferential. f. there are burns with concomitant trauma or pre-existing medical condition. g. there are burns with associated inhalation injury. h. the injury is suspected to be non-accidental. i. there is pregnancy with cutaneous burns.

Acute period - first 24-48 hours - may be longer in severe burns. NSW Burn Units will admit patients who address the criteria for a major burn. They will also admit patients who have major skin loss due to trauma or disease, or require post burn reconstructive surgery. Additionally Burns Units will admit patients requiring pain management, physical or psychosocial support. Special Considerations: • Burn Unit staff are available for consultation on any burn patient as required. See Page 24

for digital photograph information • If the patient requires admission, Emergency Department staff must liaise with Burns Unit

staff prior to sending the patient to the unit. • Patients with respiratory involvement and/or large %TBSA are generally nursed in Intensive

Care until they can be cared for in the ward setting. • Child Protection Unit (CPU) involvement required for all suspected non-accidental injuries

in children. Psychiatry involvement required for adult suspected non-accidental injuries. 2. Minor Burns A minor burn does not meet any of the above criteria for referral to specialist burn unit and there are no adverse physical or social circumstances to outpatient management. These are burns which can be managed in outlying hospitals/medical centres, or via the ambulatory care units within the referral hospitals named above. It is recommended that there is at least some discussion with burn unit to aid planning for appropriate management



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Burn Wound Management

Burn Wound Healing Principles and Concepts Principles To promote wound healing and ease patient discomfort observe the following principles: • Ensure adequate perfusion • Minimise bacterial contamination • Minimize negative effects of inflammation • Provide optimal wound environment • Promote adequate nutrition and fluid management • Provide adequate pain management • Promoting re-epithelialisation • Provide pressure management Concepts To ensure the above principles are observed utilise the following concepts for burn wound management: • Cleansing – wound surface should be free of slough, exudate, haematoma and creams • Debridement – removal of loose, devitalised tissue and non-surgical removal of eschar • Dressing

o choose appropriate primary dressing to maintain optimal moisture level and promote wound healing

o Exudate management - appropriate absorbency level of dressing must be considered on application

o consider pain and trauma on dressing removal, consider long-term dressing wherever possible, aim for prevention of trauma on dressing removal

o application - protect against alteration to distal perfusion due to constrictive dressings, protect against wound bed colonisation

• Pressure – to minimise the effects of scarring

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Burn Patient Dressing Decision-Making Tree

Patient with Burns

Adequate First Aid

Yes No

Mechanism – flame, electrical, hot oil. Or extended exposure to heat source?

Mechanism – flame, electrical, hot oil Or extended exposure to heat source?

Yes Yes

No Yes

Probable superficial burn. Dress with film, silicone or hydrocolloid dressing and review in 7-10 days

Capillary refill <2 secs?

Probable deeper burn. Dress with silver or antimicrobial dressing and review in 3 days

No No

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Burn Wound Management Cleansing and Debriding the Burn Wound

Aim: • Remove exudate and creams • Debride devitalised and loose tissue • Prevent damaging the healing burn wound. • Minimise bacterial contamination • Minimise psychological trauma to all concerned. • Reassess the wound 1. Pain Management • Adequate analgesia (refer to pain management guidelines) • For specific pharmacological and non pharmacological pain management strateges see page

15. Older children and adult patients are involved, wherever possible, in the procedure as this gives them a sense of control.

2. Preparation • The patient should be given adequate explanation of the procedure. • Prepare environment and equipment eg warm environment. The patient with an acute burn

wound should be washed and dried within 30 minutes or less, if possible. Longer sessions may cause heat loss, pain, stress and sodium loss (water is hypotonic). Keep the bathroom well heated.

3. Cleansing • The wound is cleansed gently to remove loose devitalised tissue, exudate and old dressings

or creams. • Wash with soft combines or sterile handtowels (Daylees) in diluted approved solution such

as Chlorhexidine Gluconate (diluted in water 1:2000), or pre-impregnated Chlorhexidine sponges or saline. Use cloth for unburnt parts of the body to maintain hygiene.

• Dry the patient well, as moisture left behind may macerate the burn and provide an ideal environment for bacterial contamination.

4. Exudate Management13

• There will be high exudate from the wound in the first 72hrs post injury • Appropriate dressing will be required to manage exudate level • Maintain optimal moisture balance http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

Special Considerations • Assess and monitor for possible hypersensitivity or allergic responses to products • Burns to scalp and excessively hairy areas should be shaved to allow initial assessment and

ongoing wound management, thus preventing folliculitis. Ideally this should extend 2-5cm past the boundary of the burn to ensure full visualisation and prevent hair impeding skin regeneration.. The necessity for this procedure should be discussed with the patients as sometimes religious beliefs preclude cutting of the hair under normal circumstances, and may cause great distress if they do not understand the rationale.

• Burn wounds are an excellent medium for bacterial contamination, colonisation and localised infection which may spread, resulting in systemic infection (reference – international wound journal).

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http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

• Prophylactic antibiotics are not routinely given to burn patients as they do not reduce the risk of infection. Antibiotics are only given to patients with known infections and are prescribed to sensitivities, consultation with Infectious Diseases is strongly recommended.

• In the initial post-burn stage the patient may experience febrile periods. These do not necessarily indicate infection, although they should be monitored. Febrile episodes are often related to the release of large amounts of pyrogens resulting from the initial injury13

Flowchart displaying Exudate management sourced from http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

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Flowchart displaying Exudate management sourced from http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

Outcome: The burn wound is visibly clean.

Minor Burns see Minor Burn Management document http://www.health.nsw.gov.au/gmct/burninjury/docs/minor_burn_management.pdf

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http://www.health.nsw.gov.au/gmct/burninjury/docs/minor_burn_management.pdf


Digital Photograph of the Burn Wound

Aim: • Allow ease of communication between Burn Units and external hospitals or health care

facilities • Assist with monitoring of wounds progress • Minimises prolonged or multiple exposure of patients • Reduces issue of infection control by reducing attending staff numbers 1. Preparation • The patient should be given adequate explanation of the procedure and sign a consent prior

to any photographs being taken. • Taking of photos should not delay the dressing procedure for extended periods due to the

risk of hypothermia and trauma to the patient. • Turn off overhead heat light whilst taking photographs as they can lead to discolouration. • Consider colouring. Dark skin on stark white background can give illusion of greater severity

of burn. Very pale skin on white background will not give enough contrast. • Aim for neutral colour background such as green sterile sheet. 2. Procedure • Patient should be made comfortable on clean dry sheet. • Take a photo of the patient’s hospital sticker for identification. • If patient has extensive burns take global photograph to show where burn occurs on body. • For small burns lay a measure rule next to the wound to display wound size. • Consider patient’s dignity especially if burns around perineum or genitalia. Use small cloth

to cover non-involved areas.

Tips: ° Take numerous pictures, with and without flash if necessary, extras can be deleted

when downloading. ° Label photos stating anatomical position and orientation

3. Storage • To preserve confidentiality all images must be stored in a limited access area, such as

password protected. • For ease of access to appropriate images each should be stored in an easily recognisable

pattern such as under medical record number and date taken. 4. Emailing pictures It is possible to email digital photographs of burn wound to burn units. Contact must be made between referring and accepting medical/nursing staff. Photographs must be taken in accordance with above guidelines and must be accompanied by injury history and consent. Outcome: The burn wound is photographed.

Page 29 of 63

Page 30 of 63

Burn Wound Management Selecting an Appropriate Dressing

What Dressing Dressing Options Dressing Product Dressing Application

• Film (eg Omiderm)

• Silicone • Vaseline

Gauze • Silver • Hydrocolloid

• Apply to moist wound bed • Allow 2-5 cm overlap • Cover with absorbent secondary

dressing eg Lyofoam • Review in 7-10 days, remove

secondary dressing • Leave intact until healed, trimming

edges as required

• Silicone (eg Mepilex Lite)

• Film • Vaseline

Gauze • Silver • Hydrocolloid

• Apply to clean wound bed • Cover with fixation/retention

dressing • Change 3-4 days depending on level

of exudate

• Hydrocolloid (eg Comfeel)

• Film • Silicone • Vaseline

Gauze • Silver

• Apply to clean wound bed • Change 3-4 days depending on level

of exudate

• Vaseline Gauze (eg Bactigras)

• Film • Silicone • Silver • Hydrocolloid

• Apply directly to wound • 2 layers for acute wounds, 1 layer

for almost healed wounds • Cover with appropriate secondary

dressing • Change every 1-3 days

• Silver (eg Acticoat)

• Vaseline Gauze

• Hydrocolloid

• Wet Acticoat with H20; drain and apply blue side down

• Insert irrigation system for Acticoat7• Moistened secondary dressing to

optimise desired moisture level • Replace 3-4 days (Acticoat) or 7

days (Acticoat 7)

• Silver (eg Silvazine)

• Vaseline Gauze

• Hydrocolloid

• Apply generous amount to sterile handtowel to ease application

• Cover with secondary dressing • Not recommended for most burns

due to changes to wound appearance and frequency of required dressing changes – daily

Burn Wound Management Wound Care Product Selection Aim: To choose the most suitable wound care product to reduce infection, promote wound healing, and minimize scarring. SILVER

Wound Care Product What?

Function Why?

Indications When?

Application How?

Note / Precautions

Acticoat/Acticoat 7 • 2 layered/3 layered

nanocrystalline Ag coated mesh with inner rayon layer.

• Silver ions released with greater surface area + increased solubility

• Broad spectrum antimicrobial protection

• Decreases exudate formation

• Decreases eschar autolysis

• Partial to full thickness • Grafts & donor sites • Infected wounds • Over Biobrane &

Integra • TENS & SJS

• Moisten Acticoat with H20; remove excess and apply blue side down

• Moistened secondary dressing to optimise desired moisture level

• Replace 3-4 days (Acticoat) or 7 days (Acticoat 7)

• Initial stinging on application – provide prophylactic pain relief

• Temporary skin staining • Maintain normothermia –

use warm blankets.

AtraumanAg • Coarsely woven water-

repellent polyamide textille coated with metallic silver


• Low cytotoxicity

• Partial to full thickness • Grafts & donor sites • Moderately infected

wounds • TENS & SJS

• Apply directly to wound • Cover with appropriate secondary

dressing • Leave intact up to 7 days,

dependent on the wound

• Do not use with paraffin dressing

Aquacel Ag • Sodium

carboxymethycellulose (CMC) & 1.2% ionic Ag in fibrous material



• Facilitates debridement


• Absorbs exudate

• Partial to deep partial thickness burn

• Moderately exuding wound

• Moderate bacterial load

• • Exudate level indicates frequency of dressing change

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Silvazine (SSD) • Silver Sulphadiazine 1%

and Chlorhexidine Gluconate 0.2%.

• Reduces infection • Enhances healing

• Partial to full thickness • Infected wounds

• Apply generous amount to sterile handtowel to ease application

• Apply to wound • Cover with secondary dressing

• Change daily, remove old cream

• Contraindicated during first trimester of pregnancy

Contreet H • Sodium

carboxymethycellulose (CMC) & 1.2% ionic silver wafer



• Facillitates debridement


• Low to moderate exudating wounds

• Partial thickness burns • Donor sites • Infected wounds.

• No secondary dressing • Change if leaking or when exudate

is at edge of dressing. • Can remain intact up to 7 days. • Overlap dressing 1.5 cm from

wound perimeter.

• Not evaluated for pregnancy or on children. Consult with RMO prior to application.

• To be removed if radiation, ultrasonic, diathermy or microwaves treatment applied.

Contreet • Polyurethane Foam

wound dressing with silver. 1.2% ionic silver.



• Absorbs exudate • Decreases

exudate formation

• Partial thickness burns • Donor sites • Highly exudating

wounds

• Overlap dressing so that that it is 2cm from edge of wound

• Change if leaking or when exudate is at edge of dressing.

• Can remain intact 7 days • Retention dressing

• Has not been evaluated during pregnancy or on children. Consult with RMO prior to application.

• To be removed if radiation, ultrasonic, diathermy or microwaves treatment applied.

Wound Care Product

What? Function

Why? Indications

When? Application

How? Note / Precautions

Flammcerium NB Only to be used by burn units under order by a treating burn specialist

• Creates dry inactive wound

• Decreases bacterial load

• Burns Specialist to decide application.

• Early application • Consult with RMO for

repeat application at 48 hrs

• Apply to body pad or combine dressing then onto wound

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GAUZE (moist) Wound Care Product

What? Function

Why? Indications

When? Application


Bactigras • Chlorhexidine

impregnated vas gauze

• Non adherent antiseptic dressing

• Partial thickness wounds

• Apply directly to wound • 2 layers for acute wounds, 1

layer for almost healed wounds • Cover with appropriate

secondary dressing • Change every 1-3 days

Jelonet, Adaptic, Curity • Petrolatum/Vaseline

impregnated gauze

• Non adherent conservative dressing

• Clean Partial thickness wounds.

• As above

Xeroform • Mesh gauze

impregnated with 3% Xeroform (Bismuth Tribomophophenate)

• Non adherent • Partial thickness wounds

• Light exudating wounds

• Secondary dressing to optimise desired moisture level

Page 33 of 63

FILM & HYDOCOLLOID Wound Care Product

What? Function

Why? Indications

When? Application


Omiderm • Synthetic clear

hydrophilic non-adherent semi permeable membrane.

• Barrier to contaminants

• Allows moisture to be released from the wound bed into an absorbent outer dressing

• Superficial to mid-dermal burns.

• SJS • Donor sites

• Apply to moist wound bed • Allow 2-5 cm overlap • Cover with absorbent secondary

dressing eg Lyofoam • Review after 7-10 days, remove

secondary dressing, trim from healed areas.

• Remains intact until healed

• Do not use if any infection

Tegaderm • Adhesive, conformable

film dressing

• Barrier to contaminants

• Small isolated wounds • Some blisters

• Apply directly to wound • No secondary dressing required

• Only use when surrounding tissue not compromised

Comfeel • Hydrocolloids contain

carboxymethylcellulose (CMC).

• Hydrocolloid wafer • Hydrocolloid paste

• CMC combines with exudate to aid autolysis of devitalised tissue.

• Provides moist wound environment

• Absorbs exudate.

• Devitalised tissue, sloughy wounds

• Low to moderately exudating wounds

• Allow 2cm margin around wound. • Can remain intact 2-3 days • Wafers up to 5 days if no signs

infection.

Duoderm • Hydrocolloid wafer

• Provides moist wound environment

• Absorbs exudate. • Assists scar

management in healed wounds

• Exudating wounds • Scars

• Apply directly to area • No secondary dressing required

• Only use when surrounding tissue not compromised

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FOAMWound Care Product

What? Function

Why? Indications

When? Application


Lyofoam • Two layer polyurethane

foam

• Absorb exudate from wound bed

• Pads areas such as behind ears to protect delicate tissues.

• Secondary dressing over Omiderm

• Apply shiny side down, over primary dressing

• N/A

Mepilex Transfer • Hydrophilic polyurethane

foam with soft silicone layer

• Absorb exudate from wound bed and transfers to outer dressing


• Apply to clean wound bed • Cover with absorbent secondary

dressing

• Avoid use on infected wounds

Mepilex Lite • Hydrophilic polyurethane

foam with soft silicone layer and waterproof outer layer



• Apply to clean wound bed • Cover with fixation/retention

dressing


Mepilex Border • Hydrophilic polyurethane

foam with soft silicone layer and adhesive external layer and border



• Apply to clean wound bed • No need for secondary dressing


Biatain • Foam dressing

• Highly absorbent foam that absorbs exudate

• Highly exudating wounds

• Retention dressing to secure • Change when exudate approaches 2

cm from the edge of the dressing

• Remove if radiation, ultrasonic, diathermy or microwaves treatment.

Allevyn • Non-adherent

hydrocellular foam


• Exudating wounds • Granulation

• Use as primary or secondary dressing, white side down

• Retention dressing to secure • Change when exudate approaches 2

cm from the edge of the dressing

• Avoid use with oxidising agents

Page 35 of 63

ABSORBENT Wound Care Product

What? Function

Why? Indications

When? Application


Exudry • Non-adherent, highly

absorbent, permeable dressing.

• Absorbs high exudate

• Protects against shearing

• Over primary dressing • Apply appropriate primary dressing

• Then apply outer absorbent dressing

Mesorb • Sterile absorbent pad

• Absorbs exudate • As above • As above

Webril • Cotton wool bandage

• Protective • As above • As above • May adhere if inappropriate primary dressing

Telfa, Melolite • Non-adherent,

absorbent wound dressing pad

• Non-adherent • As above • As above

Combine • Absorbent pad

• Absorbs exudate • As above • As above • May adhere if inappropriate primary dressing

Kaltostat, Algisite, Algoderm • Calcium sodium

alginate wound dressing

• Absorbent dressing • Moist wound

environment • Haemostatic

• Donor sites • Granulating wounds • Excessively bleeding

wounds

• Apply directly to wound • Replace when exudate no longer absorbed or infection evident.

• Donor site leave intact at least 10 days

Page 36 of 63

SKIN / DERMAL SUBSTITUTES Wound Care Product

What? Function

Why? Indications

When? Application


Cultured Epithelial Autograft (CEA) / Keratinocyte Spray Only used in specialist Burn Unit

• Assists with skin closure

• Reduces need for extensive donor skin harvesting

• Burns Medical Specialist will indicate application

• Excised full thickness and deep partial thickness burns.

• Used in conjunction with autograft

• Only used in specialist Burn Unit

Biobrane • Biosynthetic dressing

made up of collagen coated nylon bonded to silicone.

• Temporary skin cover

• Decreases risk of infection

• Reduces evaporative water loss.

• If limited donor skin available or loss

• Applied over debrided wound bed

• Generally in theatres

• Appropriate secondary dressing • Granulation may incorporate Biobrane into regenerating skin layer

Integra • Bovine tendon

collagen and glycosaminoglycan cross linked fibres with a silastic top layer.

• Dermal replacement. The matrix layer allows the infiltration of fibroblasts, macrophages, lymphocytes and capillaries to generate the new dermis.

• Surgical indication and application by Burns Medical Specialist

• Full thickness burns over a flexor joints

•

• Burn debrided, Integra applied, 3 weeks silastic layer peeled off and SSG applied.

• Acticoat applied over Integra • Area immobilised and splint

applied. • If Integra lifting consult with

RMO, remove affected Integra, cleans gently (saline) and apply Acticoat.

• No paraffin, moisturisers, Silvazine dressings or water as this will lift Integra.

• Not to be applied to people with known sensitivities to collagen, silastic.

Page 37 of 63

SILICONE (use in consultation by specialist therapists)Wound Care Product

What? Function

Why? Indications

When? Application


Mepitel

• Transparent, open mesh,

polyamide net, coated

with soft silicone layer

• Non stick dressing

• Exudate moves vertically

• Painful open granulating wounds

• Partial thickness burns • Skin tears

• Can be left intact 2 – 3 days if exudate minimal

• Secondary dressing to optimise desired moisture level

• Do not apply if sensitive to silicone.

Cica Care

• Silicone sheet • Scar softening • Reduces effects of scar • Apply to affected area as instructed

by therapist • Strict initial usage regime

to assess sensitivity • Avoid if allergic to

silicone Mepiform

• Silicone sheet • Scar softening • Reduces effects of scar • Apply to affected area as instructed

by therapist • Can be used up to 23 hours/day

• Avoid if allergic to silicone

Page 38 of 63

OTHERWound Care Product

What? Function

Why? Indications

When? Application


Surfasoft • Woven polyamide

transparent dressing.

• Reduces friction rub over graft allowing it to ‘take’.

• Exudate able to pass through dressing

• Easy to view graft.

• Applied in the OT over meshed grafts.

•

• Surfasoft applied wet (sterile normal saline)

• Leave intact 5 days unless infection evident.

• Apply olive oil prior to day of removal (day 4 usually).

• Peel off gently. If adhered reapply oil.

Solosite, Intrasite, Purilon • Hydrogels

• Re-hydrate wounds and absorbs some exudate into the gel.

• Dry, necrotic • Low exudating • Cavity wounds.

• Apply directly onto wound, cover with Tegaderm

• Apply onto Lyofoam Bactigras, Kerlix or Exudry

Saline Dressings • Draws exudate away from wound

• Granulating wounds • Sloughy wounds

• Bactigras, saline soaked Kerlix, Webril or body pad

• TDS or re-irrigating TDS.

• Do not allow dressing to dry out or it will adhere to wound

Iodine Betadine

• Anti microbial agent • Wounds infected with gram +ve & -ve bacteria, spores, fungi, viruses and proteus.

• Dab onto wound • Avoid use if sensitive to iodine, or thyroid condition.

• Iodine toxicity may occur, consult RMO prior to application

Hydrocortisone Cream eg Betnovate, Diprosone

• Reduces blood flow to hypergranulated wound

• Hypergranulating wounds

• Apply direct to wound or to dressing

• Change daily • Short term usage only

Silver Nitrate Cauterizing agent

• Cauterises hypergranulated wound

• Hypergranulating wounds

• Apply direct to affected area • Single application, can be repeated if necessary

Bepanthen Antiseptic cream

• Antiseptic with moisturising capabilities

• Superficial burns • Newly healed partial

thickness burns

• Apply thin film to wound • For hand burns cover with

cotton glove

• Do not apply too thick layer • Do not use longer than 7

days

Page 39 of 63

http://en.wikipedia.org/wiki/Cauterization

MOISTURISER Wound Care Product

What? Function

Why? Indications

When? Application


Dermaveen Bath and Shower oil • Oatmeal based oil

• Helps to remove and clean devitalised tissue and exudate when massaged onto wounds.

• Can relieve pruritus

• Epithelialised, dry skin • Folliculitis

• Massage onto wounds and healed areas.

• Wash with warm water and pat dry.

• Do not apply if known sensitivities to oatmeal.

Paraffin • Prevents wound from drying out

• Face / lips • Superficial and Partial

thickness burns

• Apply layer to affected area, do not rub in

Lacrilube • Prevents wound from drying out

• Burns around the eye • As Above

Lanolin • Moisturiser • Burnt Lips • dry, healing wounds

• As Above

Sorbolene • Sorbolene + 10%

Glycerin

• Can be used as a moisturiser or ‘soap’

• Dry, healing exudating and devitalised tissue

• Massage small amount into required areas of healing wound.

Dermaveen • Oatmeal based

moisturiser

• Rehydrates new epithelium, may relieve pruritus

• Epithelialised wounds • Grafts and donor sites

• Massage onto healing wound • Do not apply if known sensitivities to oatmeal.

Page 40 of 63

Page 41 of 63

RETENTION / FIXATION Wound Care Product

What? Function

Why? Indications

When? Application


Hypafix, Fixamul, Mefix • Adhesive non

woven fabric

• Stabilises primary and secondary dressings

• Protects epidermis whilst healing and initially after epithelialisation

• Superficial partial thickness (skin intact)

• Stabilising external dressing layer

• Remove 7 – 10 days when epithelialised.

• Removed easily with De-Solve-It (immediate) or olive oil (takes 30-60mins).

• DO NOT use on open areas as primary dressing

• Do not apply to people who may have delayed healing or fragile skin (eg the elderly).

Tubigrip • Tubular pressure

bandage 67%cotton and 30% rayon.

• Tissue support • Pressure to healing and

epithelialised wounds.

• Healing or epithelialised wounds

• Measuring tapes to be used to decide appropriate size and pressure.

• Utilise rings for application.

• Avoid application to upper arms and upper thighs, as soft tissue damage may occur.

• Remove if painful/tingling Coban • Self adherent wrap

bandage

• Stabilises primary and secondary dressings

• Pressure to wounds.

• Healing or epithelialised wounds

• Adheres to itself but not the skin

• Apply with gentle stretch only

• Do not apply with full stretch as this may impair blood flow to peripheries

SUPPLIERS Company Products Website Smith & Nephew Acticoat, Silvazine, Bactigras, Jelonet, Allevyn, Exudry,

Melolite, Algisite, Cica Care, Solosite, Intrasite, Hypafix http://wound.smith-nephew.com/au/node.asp?NodeId=3820

Molnlycke Mepilex Transfer, Mepilex Lite, Mepilex Border. Mepitel, Mepiform, Mefix, Lyofoam, Tubigrip

http://www.molnlycke.com/item.asp?id=39328&lang=2&si=336

Convatec Aquacel Ag, Duoderm, Kaltostat http://www.convatec.comTyco Curity, Mesorb, Webril, Telfa, Surfasoft www.tycohealthcare.com.auTechnology for Life Omiderm 3M Tegaderm, Coban www.3m.com/intl/auColoplast Comfeel Wafer, Comfeel Paste, Biatain www.coloplast.com.auAaxis Pacific Lyofoam www.aaxispacific.com.au Hartman AtraumanAg www.hartmann-online.com.auMylan Laboratories Biobrane www.mylan.comSSL Tubigrip www.sslaustralia.com.au

http://wound.smith-nephew.com/au/node.asp?NodeId=3820

http://www.molnlycke.com/item.asp?id=39328&lang=2&si=336

http://www.convatec.com/

http://www.tycohealthcare.com.au/

http://www.3m.com/intl/au

http://www.coloplast.com.au/

http://www.aaxispacific.com.au/

http://www.hartmann-online.com.au/

http://www.mylan.com/

http://www.sslaustralia.com.au/


Dressing Procedure

Aim: • To apply most appropriate dressing using correct technique • To apply dressing in timely manner to avoid hypothermia, excess pain or trauma • To maintain an aseptic technique at all times • Healed areas of skin need moisturising with appropriate moisturiser; a small amount is

rubbed in until absorbed. • Secondary dressings must not come in contact with the wound as they may adhere and

cause trauma on removal. NB • Care must be taken not to tightly wrap primary dressings circumferentially around the

burns. • Post procedure pain relief may be required for some patients. • Occlusive dressings should not be applied to infected wounds DRESSING SPECIALISED AREAS Specialised areas include face, head, neck, ears, hands, perineum and genitals. These areas require the application of complex dressings which should only be carried out by experienced clinicians. If attending these types of dressings in areas other than a burn unit please seek advise from Burns Unit staff and access resources available on SBIS website. 1. Face, Head, Neck • Tracheostomy tape may be used to secure a naso-gastric tube when adhesive tape is

unsuitable due to burns around the nose. 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. • Bactigras or Jelonet are often the dressings of choice on ears. • Doughnuts made of a soft foam such as Lyofoam 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.

3. Hands & Fingers • In the first 24-48 hours if the fingers are swollen, it is sometimes recommended to dress

each finger separately by applying an appropriate primary dressing. The whole hand is then bandaged as shown in FIG.1. This method inhibits normal functioning and mobility and should only be used when necessitated.

Page 42 of 63

• At all other times, and once oedema has subsided, the fingers should be individually bandaged as shown in Fig.2. These bandages allow better mobility and enhance functional ability.

FIG.1. FIG.2.

4. 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. Foam padding (i.e. Lyofoam, Allevyn) can be used to protect burnt soles. 5. Perineum • Males: If the penis and/or scrotum are burnt, apply appropriate primary dressing with

outer supportive dressings. 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. • Children: When still in nappies, dressings such as Bactigras can be cut to size and placed in

the nappy. • Patients with perineal burns are generally catheterised to decrease pain and allow for the

area to be kept as clean as possible.

Tips:

• It is important to separate burnt surfaces • When bandaging start distally and work proximally, from feet or hands. It may be

necessary to incorporate feet or hands, even if they are not burnt to avoid oedema formation.

• Elevate the arms and legs, especially in the acute period to reduce oedema. • Legs should be bandaged straight and splints may be necessary.

Page 43 of 63


Specific Dressing Application

Omiderm application

Clean wound bed, moisten if

required

Apply Omiderm with 2-5 cm

overlap

Fix with retention dressing

Cover with absorbent

secondary dressing

Mepilex Application

Clean wound bed

Apply directly to wound surface

Acticoat Application

Clean wound bed

Moisten Acticoat with water NOT

saline

Apply to wound, either side down

Apply moistened secondary dressing

and stabilise as above

Page 44 of 63

AquacelAG Application

Clean wound bed

Apply to wound

Leave intact

Bactigras Application

Clean wound bed

Apply Bactigras. 2 laye ist

wounds

Appropriate external dressings rs for mo

Problem dressings

Issue und. SecPrimary dressing slipped off wo ondary dressing stuck causing

Use appropriate fixation dressing over primary and secondary dressings

trauma Solution

Page 45 of 63


Dressing Fixation Application Coban Application

Start at base of

hand working with a slight

stretch

Then work from tips of fingers in a

spiral covering half of the

previous coban

Anchor to coban on hand

Place pieces through

webspaces of each finger to

separate

Hypafix/Mefix/Fixamul Application

Can be used on many areas of the body to fix dressing in place

NB This is not a primary dressing and must not be used on areas of skin loss

Tubular Bandage Application

Cut to length, then cut slit for

thumb

Put onto aplicator

Apply to area Remove wrinkles

Page 46 of 63

Problem Fixation Dressings

Issue Swelling, pressure areas and reduced blood flow in peripheries

Solution Remove wrinkles in tubigrip and incorporate feet and hands even if not burnt to prevent

pressure areas and swelling

Issue Dressing falls off

quickly Solution

Use appropriate fixation dressing

Issue Patient unable to move hand

adequately Solution

Wrap fingers individually

Issue Tape applied over pressure

dressing can lead to pressure areas

Solution Use appropriate fixation

dressing

Page 47 of 63

Skin Graft Management Definition A skin graft is a common surgical procedure in which the ‘graft’, a thin shaving of skin harvested from the epidermal and papillary dermal tissue, is used to provide cover to replace a defect elsewhere in the body. For coverage of areas where there is:

a. burn b. lesion removed c. skin tear with muscle defect d. trauma etc

Wounds with skin loss affecting the deep dermal, subcutaneous and muscular tissue require a skin graft to assist with healing. For example burn wounds considered deep partial to full thickness (see Figure 1) would require a skin graft to facilitate healing.

Assessment of The Burn Wound

Figure 1. Burn skin depth diagram


Epidermal

Superficial Dermal Mid Dermal Deep Dermal

Full Thickness

Page 48 of 63


Skin Graft Management Skin Grafting in OT Harvesting donor skin The required skin is removed (see page 50 for further information regarding donor sites)

Figure 2. Taking donor skin with dermatone. Once the skin has been harvested it is laid flat with the moist side facing upwards ready for application onto the graft site. If the area to cover is large the donor skin is meshed using a meshing tool or blade. This involves tiny slits being made throughout the skin so that when stretched the skin can cover a larger surface area.

Figure 3. Donor skin ready for application

Page 49 of 63

Debriding graft site Prior to grafting the wound bed is cleaned and dead tissue or ‘eschar’ is removed. The area is debrided to a bleeding wound bed to encourage optimum graft survival. Debridement may be carried out in numerous ways including cutting away dead tissue using a surgical blade or a waterjet tool such as the Versajet. The debridement method can be related to the available equipment or the depth of the burn wound. A small or linear burn can be excised and primarily closed

Debrided burn wound bed

Excision and primary closure

Figure 4. Debrided wound bed ready for graft application Skin application The donor skin is applied to the graft site, making sure that all areas are suitable covered.

Page 50 of 63

Figure 5. Applying donor skin The graft skin is attached using staples, sutures, surgical glue or an adhesive dressing such as Hypafix, depending on graft site requirements and the surgeon’s preference.

Figure 6. Graft insitu Skin is generally applied in the operating theatre after the donor skin has been taken. However, sometimes more skin is taken from the donor site than is applied during the operation. This skin can be laid on the patient’s wounds in the ward area if the burn wound is not sufficiently covered following surgery. When applying the skin the ‘shiny’ side should be placed face down onto the wound surface using a sterile technique. Skin should be stabilised using an adhesive dressing such as Hypafix or Steri strips. Care and management needs to be carried out as with any skin graft following this procedure.

Page 51 of 63

Skin Graft Management Skin Graft Management in OT Dressing Procedure

Aim: • To allow the skin graft to heal through the bodies own process of re-epithelialisation • To apply most appropriate dressing using correct technique • To apply dressing in timely manner to avoid hypothermia, excess pain or trauma • To maintain an aseptic technique at all times Procedure: • Once skin has been applied to graft site appropriate fixation is applied, eg staples, sutures,

adhesive dressing • When the graft has been fixed in place the graft site is dressed with an appropriate dressing

such as a vaseline gauze or silicone dressing (see Selecting an Appropriate Dressing). • Ensure area is cleaned using a sterile technique. • Ensure any build up of blood/fluid under graft has been evacuated to reduce risk of graft

failure. • Apply the primary dressing directly to the graft site. The primary dressing should have a 2-

5cm overlap and border. It is important to cover the whole area, on and slightly around the wound site, to allow for movement.

• Apply a suitable dry absorbent secondary dressing such as a foam or pad dressing. • Secondary dressings must not come in contact with the graft site as they may adhere and

cause trauma on removal. • Use a fixation dressing such as an adhesive tape to secure the dressing. NB • Care must be taken not to tightly wrap primary dressings circumferentially around the

burns.

Page 52 of 63

Skin Graft Management

Dressing removal

Aim: • Observe skin graft progress • Provide appropriate management for level of healing Taking graft site down at day 3 to 7 post-op. • Skin grafts should be fully taken down and assessed within this time frame unless otherwise

advised by the Plastics Team, Surgical team or CNC/NP Burns/Plastics. • Remove dressing, taking care not to pull off graft in the process • Graft is reviewed by appropriate clinical staff and wound management plan is formulated.

Dressing application: • Graft site dressed utilizing principles discussed in burn wound management guideline. • If graft is healed, discuss scar management with therapist and apply appropriate pressure

dressing or garment. • If graft is unhealed but present dress with vaseline gauze or silicone dressing and appropriate

secondary dressing. • If graft is lost assess for causative factors such as infection or friction and treat accordingly.

o For infection swab wound and send for culture. Clean wound bed thoroughly and apply silver or other antimicrobial dressing and secondary dressing.

o For graft loss due to friction apply appropriate primary and secondary dressings and ensure friction does not continue to occur. If friction is caused by patient itching arrange for appropriate antihistamine. If friction is caused by proximity to other body surface dress well with protective and padded dressing.

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Donor Site Management11

Definition A donor site is the area where epidermal and papillary dermal tissue is harvested to provide cover to replace a defect elsewhere in the body. For coverage of areas where there is:

a. burn b. lesion removed c. skin tear with muscle defect d. trauma etc

Tissue used for

donor site Figure 1. Cross Section of Skin Donor Sites Common donor site areas include the thighs, buttocks and scalp as these areas are not readily visible and can provide large strips of donor skin. However donor sites are often taken from an area of the body closest in colour match for the graft site. If available skin is limited almost any area on the body can be used.

Figure 1. Common Sites for Skin Harvesting

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Donor Site Management

Harvesting the Donor Skin in OT The required skin is removed with an electronic surgical cutting tool called a dermatone. The dermatome has multiple depth settings and can take a very thin shaving of skin. Figure 2. Dermatone The selected area is prepared using Betadine and sterile drapes.

Figure 3. Area prepared for donor site

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The skin is stretched to allow even pressure on all areas of skin harvested, thus providing an even piece of donor skin

Figure 4. Taking donor skin with dermatone. Once the skin is harvested the donor site is left as a bleeding wound bed.

Figure 5. Fresh donor site

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Donor Site Management in OT Dressing Procedure Aim: • To allow the donor tissue to heal through the bodies own process of re-epithelialisation • To apply most appropriate dressing using correct technique • To apply dressing in timely manner to avoid hypothermia, excess pain or trauma • To maintain an aseptic technique at all times Figure 6. Dressing being applied to a donor site 1. Procedure: • Once donor skin has been harvested, adrenaline soaks are placed on the bleeding wound to

assist with coagulation. • When the bleeding has ceased the donor site is dressed with an appropriate dressing such

as a Calcium Alginate, Silicone dressing or Omiderm (see Selecting an Appropriate Dressing).

• Apply the dressing directly to the donor site wound. The primary dressing should have a 2-5cm overlap and border. It is important to cover the whole area, on and slightly around the wound site, to allow for movement.

• A suitable dry absorbent secondary dressing such as Mesorb or Lyofoam will be applied • Secondary dressings must not come in contact with the donor site as they may adhere and

cause trauma on removal. • A fixation dressing such as an adhesive tape will be used to secure the dressing. NB • Care must be taken not to tightly wrap primary dressings circumferentially around the

burns.

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Initial Inspection Aim: • Observe donor site wound progress at 24-48 hours • Provide effective donor site management and problem solving Procedure • Assess pain and provide analgesia as necessary. Reassess periodically during procedure • Observe for:

o Bleeding o Offensive Smell o Exudate Strike-through onto secondary dressing. o Wet Primary dressing o Increased pain o Limb Swelling

• If the primary dressing is dry and clean – leave intact and provide a secondary retentive and absorptive dressing.

• Ensure dressing is kept clean and dry (i.e. cover during showering with a plastic bag).

Figure 7. Exudating & bleeding donor site. Managing complications • If any of the previously mentioned signs or symptoms are noted, the area must be cleaned

thoroughly with Normal Saline. • Assess the wound for odour and offensive exudate, if present apply Aquacel Ag (apply dry to

wound). Ensure an overlap onto ‘good’ skin of at least 3 cms. • Apply a secondary retentive dressing. Leave intact for 4 to 6 days. • If the wound is clean and bleeding has been controlled. Re-dress with Calcium Alginate and

retentive secondary dressing (such as Mesorb and Hypafix) . Reassess 8th hourly and leave the dressing intact for 7 days.

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Donor Site Management Dressing removal

Aim: • Observe donor site wound progress • Provide appropriate management for level of healing Taking donor down at day 8 to 10 post harvesting. • Donor sites dressed with either calcium alginate or

silicone dressings should be fully taken down and assessed within this time frame unless otherwise advised by the Burns/Plastics Team, Surgical team or Burns/Plastics CNC.

• Donor sites dressed with Omiderm should be taken down to the primary layer. If the Omiderm remains adhered leave intact, trim lifting edges, and cover with protective layer such as an adhesive tape dressing (e.g. Hypafix)

Donor healed (Re-epithelialised) • Apply moisturiser – water based. Leave exposed. • Educate patient on donor site care including the

need to continue moisturising, and ensure shear and friction is prevented.

• Discuss sun care options with the patient.

Donor not healed • Assess pain and provide analgesia as necessary. Reassess periodically during procedure • Assess and document appearance of the unhealed donor. • If donor is raw but there is no sign of wound infection – apply appropriate dressing such as

calcium alginate, silicone or film dressing and leave intact for a further 3 to 4 days. • Take a wound swab, if the wound has obvious signs of infection and healing has not

progressed over the last 10 days. Discuss the best dressing options with appropriate staff such as Burns/Plastics CNC.

• Document course of action in the integrated notes and inform the Burns/Plastics Registrar. • Continue to reassess the dressings and leave the dressing intact for prescribed period of time. • The surgeon, and/or the Burns/Plastics CNC must be notified if the donor site remains

unhealed after a further 7 days. They will direct an appropriate course of action.

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The Multidisciplinary team Burn care is conducted by members of a multidisciplinary burn team which include medical, surgical, intensive care, nursing, physiotherapy, occupational therapy, dietetics, social work, psychiatry, psychology, speech therapy, pharmacy and technicians. A multidisciplinary approach to burn management is essential for optimal functional and cosmetic outcome. Serious long term physical and psychosocial morbidity may be associated with a burn injury. All members of the burn management team interact throughout the patient’s management, from admission to discharge and beyond to support the patient and family in reintegration. All team members contribute to patient care throughout the early management, ongoing clinical intervention periods during all phases of care, and continuous educative support to the patient, family and staff. For further information regarding multidisciplinary care please refer to the following documents:

• Burn Survivor Rehabilitation: Principles and Guidelines for the Allied Health

Professional (ANZBA) http://www.health.nsw.gov.au/gmct/burninjury/docs/anzba_ahp_guidelines_october_2007.pdf

• Nutrition & Dietetics: Principles and Guidelines for Adult & Paediatric Burns Patient Management http://www.health.nsw.gov.au/gmct/burninjury/docs/nutrition_burns_cpgs.pdf

• NSW Severe Burn Injury Service Clinical Practice Guidelines Speech Pathology for Burn Patient Management http://www.health.nsw.gov.au/gmct/burninjury/docs/speech_pathology_adults.pdf

• NSW Severe Burn Injury Service Clinical Practice Guidelines Play Therapy for Burn

Injured Paediatric Patients http://www.health.nsw.gov.au/gmct/burninjury/docs/play_therapy_cpg_children.pdf

All of these documents are available via the NSW Severe Burn Injury Service Website:

• http://www.health.nsw.gov.au/gmct/burninjury Also available on this website are:

• NSW Severe Burn Injury Service Burn Transfer Guidelines http://www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_012.pdf

• NSW Severe Burn Injury Service Model of Care http://www.health.nsw.gov.au/gmct/burninjury/docs/burninjury_moc.pdf

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http://www.health.nsw.gov.au/gmct/burninjury/docs/anzba_ahp_guidelines_october_2007.pdf

http://www.health.nsw.gov.au/gmct/burninjury/docs/speech_pathology_adults.pdf

http://www.health.nsw.gov.au/gmct/burninjury/docs/play_therapy_cpg_children.pdf

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


http://www.health.nsw.gov.au/gmct/burninjury/docs/burninjury_moc.pdf

References 1. Australian & New Zealand Burn Association. 2006, Emergency Management of Severe

Burns (EMSB), Course Manual (11th Ed.). 2. Abdi, S. & Zhou, Y. 2002, ‘Management of pain after burn injury’, Current Opinion

Anaesthesiology, vol.15, pp.563-567. 3. Carrougher J. G 1998, Burn Care and Therapy. Mosby Inc. Missouri 4. Chi, K. and Garner, W. 2002, ‘Acute burns’. Plastic and Reconstructive Surgery, vol.105,

no.7, pp.2482-2493. 5. Demling R.H & DeSanti L. 2001, ‘The rate of epithelialization across meshed skin grafts

increases with exposure to silver’. Burns, vol. 28, pp.264-266. 6. Herndon, D, N. (ed.) 2007, Total Burn Care (3rd Ed.). Saunders. London. 7. Faucher, L.D. 2003, ‘Modern pain management in burn care’, Problems in General Surgery,

vol. 20, no.1, pp.80-87. 8. Kagan, R.J. & Smith, S.C. 2000, ‘Evaluation and treatment of thermal injuries’, Dermatology

Nursing, vol.12, no.5, pp.334-350. 9. Jackson, D. 1953, ‘The diagnosis of the depth of burning’, British Journal of Plastic Surgery,

vol.40, pp.588 -96. 10. Merz, J., Schrand, C., Mertens, D., Foote, C., Porter, K. & Regnold, L. 2003, ‘Wound care of

the pediatric burn patient’, AACN Clinical Issues, vol.14, no.4, pp.429-441. 11. Northern Sydney Central Coast Area Health Service 2006, Wound Donor Site Management

Guideline, Accessed via http://www.nsccahs.health.nsw.gov.au/services/wound.care/2008draftdonorsiteguidelineswithsummarypage.pdf

12. NSW Severe Burn Injury Service: Burn Transfer Guidelines, 2008. NSW Health (available

via SBIS website: http://www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_012.pdf ). 13. Principles of Best Practise: A World Union of Wound Healing Societies’ Initiative 2007

“Wound exudate and the role of dressings: A consensus document”. Accessed from http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

14. Reed, J.L. & Pomerantz, W.J. 2005, ‘Emergency management of pediatric burns’, Pediatric

Emergency Care, vol. 21, no.2, pp.118-129. 15. Royal Children’s Hospital Melbourne ‘Burns Unit: Clinical Information’ accessed 12/06/07

from http://www.rch.org.au/burns/clinical/index.cfm?doc_id=2012 16. Sandip K. P, Cortiella J & Herndon D., 1997, “The Relationships between Burn Pain,

Anxiety and Depression”, Burns, vol.23, pp404-417.

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http://www.nsccahs.health.nsw.gov.au/services/wound.care/2008draftdonorsiteguidelineswithsummarypage.pdf

http://www.nsccahs.health.nsw.gov.au/services/wound.care/2008draftdonorsiteguidelineswithsummarypage.pdf



http://www.rch.org.au/burns/clinical/index.cfm?doc_id=2012

http://hrcak.srce.hr/file/6947

http://hrcak.srce.hr/file/6947

17. Sargent, R.L. 2006, ‘Management of blisters in the partial-thickness burn: an integrative research review’, Journal of Burn Care & Rehabilitation, vol.1, pp.66-81.

18. Taylor, K. 2001, ‘The management of minor burns and scalds in children’, Nursing Standard,

vol.16, no.11, pp.45-52, 54. 19. The Children’s Hospital at Westmead. Handbook 1999. Section 29. 20. Tredget E.E, Shankowsky H.A, Groeneveld A & Burrell R.E 1998, ‘A matched- pair,

randomized study evaluating the efficacy and safety of Acticoat silver-coated dressing for the treatment of burn wounds’. Journal of Burn Care and Rehabilitation, vol.19, no.6, pp.531-537.

21. Wright J.B, Lam K & 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.

22. Yin H.Q, Langford K & Burrell R.E 1999, ‘Comparative evaluation of the antimicrobial

activity of Acticoat antimicrobial barrier dressing’. Journal of Burn Care & Rehabilitation vol.20, no.3, pp.195-199.

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Websites • NSW Severe Burn Injury Service

http://www.health.nsw.gov.au/gmct/burninjury • 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 a. http://www.skinhealing.com/3_1_burntreatments.shtml b. http://www.essentialdayspa.com/Skin_Anathomy_and_Physiology.htm c. http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/skinlsn/skini.htm d. http://www.nurse-prescriber.co.uk/education/anatomy/anatomy2.htm e. http://reference.allrefer.com/encyclopedia/S/skin.html f. http://www.swiss-creations.com/sc-14story.htm#The%20Human%20Skin

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

http://www.worldburn.org/

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

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

burn wound management

Documents