Management of Burns and Scalds in Primary Care

Home , Electrical burn

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Composite Kua tawhiti ke to haerenga mai, kia kore haere tonu He tino nui rawa ou mahi Kia kore e mahi nui tonu

sir james henare of ngati hine iwi from te tai tokerau

We have come too far not to go further We have done too much not to do more

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 2 55/17/07/17/07 12:11:0312:11:03 PMPM Endorsements

This guideline has been endorsed by the Australian and New Zealand Burn Association (until 2009), the Burn Support Group Charitable Trust, the Counties Manukau District Health Board (until 2009), the Royal New Zealand College of General Practitioners and St John.

The Royal New Zealand College of General Practitioners

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4 55/17/07/17/07 12:11:0512:11:05 PMPM Contents

Endorsements ...... 3 Purpose ...... 9 About the guideline ...... 11 Summary ...... 17 Chapters 1. Burn injuries and burns prevention in New Zealand ...... 27 2. First aid ...... 31 3. Burn assessment ...... 35 4. Referral...... 45 5. Management of epidermal burns or scalds...... 47 6. Management of superﬁ cial and mid dermal burns or scalds ...... 49 7. Management of chemical injury ...... 59 8. Management of electrical injury ...... 63 9. Pain management...... 67 10. Psychological consequences of burn injury ...... 71 11. Burn injuries in Ma¯ori ...... 77 12. Burn injuries in Paciﬁ c peoples ...... 79 13. Complementary and alternative medicines ...... 81 14. Implementation and evaluation ...... 83

Appendices A. Evidence and recommendation grading system ...... 89 B. Wound care options ...... 91 C. DSM-IV criteria for post-traumatic stress disorder ...... 95 D. Useful resources ...... 97

Abbreviations and acronyms ...... 99 Glossary ...... 101 References ...... 103

Recommendations and good practice points

Chapters 1. Burn injuries and burns prevention in New Zealand ...... 27 Opportunities for prevention ...... 28 2. First aid ...... 31 Stopping the burning process and cooling ...... 31 Gel pads ...... 32 Initial coverings: polyvinyl chloride ﬁ lm (cling ﬁ lm) ...... 33

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5 55/17/07/17/07 12:11:0512:11:05 PMPM 3. Burn assessment ...... 35 Emergency management ...... 35 Burn size: assessment and recording of total body surface area burn ...... 38 Burn depth ...... 41 Non-accidental injury ...... 42 Classifi cation of burns ...... 43 4. Referral ...... 45 Emergency referral ...... 45 Referral between services ...... 46 5. Management of epidermal burns or scalds ...... 47 Dressings and creams (good practice points only)...... 47 6. Management of superfi cial and mid dermal burns or scalds ...... 49 Preventing infection (good practice points only) ...... 49 Wound healing ...... 52 When to review (good practice point only) ...... 54 Management of blisters (good practice points only) ...... 54 Scarring ...... 55 7. Management of chemical injury ...... 59 First aid ...... 59 Eye injury ...... 60 Specifi c substances: hydrofl uoric acid (good practice point only) ...... 60 Specifi c substances: phosphorus (good practice point only) ...... 62 8. Management of electrical injury ...... 63 Management of electrical injury ...... 63 ECG monitoring ...... 64 9. Pain management ...... 67 Burn pain management ...... 67 10. Psychological consequences of burn injury ...... 71 Adverse psychological responses to trauma ...... 71 11. Burn injuries in Ma¯ori ...... 77 Good practice points ...... 77 12. Burn injuries in Pacifi c peoples ...... 79 Good practice points ...... 79

Algorithms (see Summary, pages 17–25)

1. Initial assessment and management of burns and scalds ...... 18 2. Ongoing assessment and management of burns and scalds in primary care ...... 24

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3.1 Assessment of burn size: Rule of Nines ...... 39 3.2 Assessment of burn size: Lund and Browder chart* ...... 40 * See also Notes to algorithm 1: note 2: burn assessment: assessment of burn size ...... 22

List of tables

1.1 Burns from fi re or fl ames: age specifi c rates for 2000–2004 ...... 27 1.2 Burns due to hot substances and objects, caustic or corrosive material or steam:28 age-specifi c rates for 2000–2004 ...... 28 3.1 Airway maintenance ...... 36 3.2 Key points of a burn history ...... 37 3.3 Classifi cation of burns based on depth* ...... 44 10.1 Diagnosis according to duration of stress symptoms ...... 72 * See also Notes to algorithm 1: note 2: burn assessment: depth assessment ...... 20

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8 55/17/07/17/07 12:11:0612:11:06 PMPM Purpose

The purpose of this guideline is to provide a summary of current New Zealand and overseas evidence informing the assessment and management of burn injuries in the primary care setting in New Zealand. The guideline has been developed for health care practitioners who care for adults or children with burn injuries, and health service provider organisations and funders. It provides a ﬁ rst step in gathering the evidence base and ensuring the coordination of burns care nationally across the health sector in New Zealand.

The focus of the guideline is the appropriate assessment and management of burns in the primary care setting speciﬁ cally, and appropriate referral practice from primary care to secondary care and regional burns unit services. The guideline speciﬁ cally excludes consideration of large, full thickness burns that are more likely to be managed in secondary care. Similarly, scar management and associated specialist services provided in secondary care, such as physiotherapy, occupational therapy and speech language therapy, are not a focus of this guideline.

The guideline identiﬁ es evidence-based practice for most people, in most circumstances. It thus forms the basis for decision-making by the health care practitioner in discussion with an individual with a burn injury in developing an individualised care plan.

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1010 55/17/07/17/07 12:11:0612:11:06 PMPM About the guideline

Foreword The New Zealand Guidelines Group Incorporated (NZGG) is a not-for-proﬁ t organisation established to promote effective health and disability services. Guidelines make a contribution to this aim by sharing the latest international studies and interpreting these in a practical way for dissemination and implementation in the New Zealand setting. Guidelines consider both the evidence and the current availability of resources in the publicly funded health system to ensure that the recommendations are realistic, promote best practice, and inform policy and planning.

This guideline was developed by NZGG in partnership with the Counties Manukau District Health Board (CMDHB), with Stephen Mills as Chair of the Guideline Development Team, and was funded by the Accident Compensation Corporation (ACC).

Gaps between current practice and evidence This guideline for the management of burns and scalds in primary care has been developed to address perceived gaps between current evidence and practice in New Zealand. Although the size of these gaps has not been thoroughly documented, there appear to be uncertainties in treatment, variation in management practices and an under-utilisation of cold water therapy for burns.

Although there are other international guidelines that have been published on the management of burns and scalds, they were not considered to be suitable for use in New Zealand.

First aid management of burns The New Zealand public appears to have a lack of understanding regarding the benefi ts of cold water therapy. A prospective observational study of people with burns presenting to Middlemore Hospital in 2002 found that 59.5% of a total 121 people did not receive adequate burns fi rst aid treatment (defi ned as cold water therapy in either stationary or running water for 10 minutes or more).1 Further analysis by age and ethnicity suggested that Ma¯ori and Pacifi c peoples, and children were less likely to receive adequate fi rst aid treatment.

The study found that adequate ﬁ rst aid treatment resulted in fewer people with burns requiring split-skin graft procedures. There was also an association with fewer surgical debridement procedures. Scald injuries in particular required fewer procedures following adequate burns ﬁ rst aid treatment. The potential savings estimated in 2002 from scald injury care alone amounted to $75,000–100,000 per annum.1

Burn size estimation Estimations of burn size are necessary in the pre-hospital situation in order to assess initial fl uid requirements and determine referral criteria. A number of tools can be used to assist health practitioners in estimating the total body surface area (TBSA) (see Chapter 3, Burn size). Three observational studies were found assessing the variability of burn size estimation in the pre-hospital environment.2-4 Results of these studies suggest that burn size is often overestimated. As a consequence of this, people with burns may receive inappropriate volumes of fl uid and could be transferred to a burns unit unnecessarily. The TBSA estimated in pre-hospital situations is often overestimated where the burnt area is small and underestimated where the burnt area is large.3 Unfortunately the participants of these studies often had burns that would be more severe than those found in primary care, therefore the fi ndings may not be directly applicable.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1111 55/17/07/17/07 12:11:0712:11:07 PMPM Use of dressing products in primary care International evidence is lacking around the use of dressing products in primary care. Silver sulphadiazine is understood to be widely used at present on burns in primary care. This practice is supported by the expert opinion of the Guideline Development Team for its properties as an anti-infective agent. However, extended use of silver sulphadiazine on non-infected wounds has been shown to have adverse effects on the time to healing in burn wounds. There are a number of randomised controlled trials (RCTs) comparing silver sulphadiazine cream with other dressings and topical treatments. All of these studies found that silver sulphadiazine increased time to healing. However, in these studies silver sulphadiazine cream was applied to the burn wound until complete healing/re-epithelialisation. No studies were found comparing shorter-term use of silver sulphadiazine cream with other dressings or topical treatments.

Expert opinion strongly favours the use of moist wound-healing products for superfi cial and mid dermal burns, although the evidence is scanty and inconsistent. There is no convincing evidence from primary RCTs that any other dressing product heals wounds signifi cantly faster than paraffi n gauze (which is considered a non-moist dressing).

Evidence and recommendation grading system All studies relating to the beneﬁ ts or harms of interventions are graded for quality. Each study has been assigned an overall level of evidence: good (+), fair (~) or poor (x). Study details and levels of evidence are summarised in evidence tables, which are used to formulate recommendations. The evidence tables are available at http://www.nzgg.org.nz. Studies with an ‘x’ level of evidence had questionable validity and were not considered relevant to the formulation of recommendations. Descriptive research, included for information, was not graded for quality.

For further details about the evidence and recommendation grading system see Appendix A.

Guideline development process In 2005, ACC commissioned NZGG to develop an adapted guideline based on reliable and valid evidence-based sources of summarised evidence available internationally. The Guideline Development Team agreed to use two other relevant guidelines5-7 as a template to further deﬁ ne the scope of the project. This approach has allowed the Guideline Development Team to conduct its own systematic reviews of key question areas and to consider the syntheses and synopses of the evidence performed and published by others. This process of adaptation was thought appropriate in a topic area where there are few large, well conducted randomised studies.

The Guideline Development Team was convened by NZGG and CMDHB. This involved formally approaching representative professional colleges and stakeholder organisations to invite them to nominate people to be members of the Team.

Two face-to-face meetings were held in Auckland during August 2005. The goals of the ﬁ rst meeting were to train members of the team in the processes of guideline development, to identify relevant clinical questions and to make decisions about the scope of the guideline.

Individual sub-committee members then searched for new studies in narrowly-focused topic areas and reviewed the evidence. In order to avoid the substantial costs and delays associated with translating foreign language publications, only English language articles were used. Only the most rigorous studies for each question were retrieved for the assessment and extraction of data. Details of the clinical questions, comprehensive search strategy and evidence tables are available on the NZGG (http://www.nzgg.org.nz) website.

The evidence on which the recommendations are based was graded using the grading system developed by NZGG. See Appendix A for more information on the grading system. 12

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1212 55/17/07/17/07 12:11:0712:11:07 PMPM The second meeting of the Guideline Development Team was held in November 2005. At this meeting the evidence in each area was presented in evidence tables to the Guideline Development Team and a Considered Judgement process8 was used to agree levels of evidence and draft recommendations. The Guideline Development Team also drafted an algorithm at this stage.

The statement and recommendations were drafted, reviewed and revised by sub-groups then reviewed by the whole Team. Resources and appendices were drafted in the same way. This process continued until the draft document was at a stage for peer review and consultation. Opinions were sought at this stage about the feasibility of implementing the recommendations in the guideline.

Copies of the draft were sent to key individuals and sector groups for comment and peer review. Ma¯ori and Pacifi c perspectives on burn injuries and their management were incorporated. These comments were approved by the Team and incorporated into the fi nal document. The draft guideline was sent to sector groups for peer review in February 2006 and the fi nal guideline was re-circulated in July 2006.

Guideline Development Team This guideline was developed by a multidisciplinary team of practitioners, selected to represent professional, cultural and consumer perspectives. The Team members were:

Stephen Mills (Chair) Plastic and Reconstructive Surgeon, Middlemore Hospital Chris Goudie Adult Burns Clinical Nurse Specialist, Middlemore Hospital Debbie Murray Paediatric Clinical Nurse Specialist, Middlemore Hospital Linda Jackson Clinical Nurse Educator, Middlemore Hospital Andrew Jull Research Fellow, Clinical Trials Research Unit, University of Auckland Anna Munnoch Emergency Care, Clinical Nurse Educator, Middlemore Hospital Vera Steenson Auckland Burn Support Group, consumer perspective Frances James Clinical Psychologist, Middlemore Hospital Kate Middlemiss National Burns Centre Establishment Manager, Middlemore Hospital Carolyn Braddock Regional Burns Centre Manager, Hutt Valley District Health Board Maureen Allan Te Tai Tokerau Primary Health Organisation, Ma¯ori perspective Carol Ford Primary Care and Rural Nursing, Ngati Porou Hauora Heidi Muller General Practitioner, Health Pacifi ca, Ta Pasefi ka, Pacifi c perspective Rob Kofoed Convenor, New Zealand Accident and Medical Practitioners’ Association Larry Skiba General Practitioner, Royal New Zealand College of General Practitioners

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1313 55/17/07/17/07 12:11:0712:11:07 PMPM NZGG team Rob Cook Project Manager and GP Catherine Coop Researcher/Project Manager from February 2006 Mark Ayson Researcher Anne Buckley Medical Editor/Writer Mai Dwairy Researcher until March 2006 Anne Lethaby Senior Researcher Jane Marjoribanks Researcher

For ﬁ rst meeting training/presentations: Cindy Farquhar NZGG Board Anne Lethaby NZGG Project Manager and Effective Practice, Informatics and Quality Improvement (EPIQ) Researcher Sue Wells Senior Lecturer Clinical Epidemiology, University of Auckland

ACC observers: James Chal Manager Research and Information Services Zhi-ling ‘Jim’ Zhang Evidence Based Healthcare Researcher, Research Services Chrissie Cope Manager Primary Care Services, Healthwise Sonya Murray Evidence Based Healthcare Researcher, Research Services

Declarations of competing interests There have been no competing interests declared for this guideline.

Consultation At the start of the guideline development process, a number of organisations with a speciﬁ c interest in the management of burns and scalds nominated team members to be part of the Guideline Development Team. Feedback was sought from these organisations after they had reviewed a draft of the guideline. During this period of consultation the draft was also distributed widely to other interested individuals and they were invited to comment on the draft.

Comments were received from the following organisations or individuals: • Anna Knuckey, Product Manager, Jackson Allison Medical and Surgical Limited, Auckland • Antonia Rippey, Occupational Therapist, CMDHB, Auckland • Bice Awan, Chief Executive, Skylight, Wellington • Bernard Hoste, Export and Business Development, Scarban, Tricolast NV, Belgium • Caitlin Harvey, Occupational Therapist, Waikato District Health Board, Hamilton 14

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1414 55/17/07/17/07 12:11:0812:11:08 PMPM • Chris Adams, Consultant Plastic Surgeon, Wellington Regional Plastic Surgery and Burns Unit, Hutt Hospital, Wellington • Connie Mahu, Wha¯nau Support Worker for Ma¯ori Health, Middlemore Hospital • Glen Charlett, Director, Access Health Care Limited • Heather Cleland, Director, Victoria Adult Burns Service, Alfred Hospital, Melbourne • Janet Copeland, Research Liaison Ofﬁ cer, New Zealand Society of Physiotherapists Inc, Wellington • Jason Wasiak, Research Ofﬁ cer, Victoria Adult Burns Service, Alfred Hospital, Melbourne • Kirsten Taylor, Senior Physiotherapist, Middlemore Hospital, Auckland • Marilyn Rosewarne, Member New Zealand College of Practice Nurses, Tauranga • Rhys Jones, Senior Lecturer in Ma¯ori Health, The University of Auckland, Auckland • Siobhan Molloy, Executive Director, New Zealand Association of Occupational Therapists, Wellington • Stewart Sinclair, Clinical Director, Plastic Surgery Department, Christchurch Hospital, Christchurch • Tony Smith, Medical Advisor, St John Northern Region, Auckland • William Levack, Lecturer in Rehabilitation, Department of Medicine, Wellington School of Medicine and Health Science, University of Otago, Wellington

Acknowledgements We would like to thank Maureen Allen, Connie Mahu and Rhys Jones for their contribution towards Chapter 10, Burn injuries in Ma¯ori and Kelly Waddell and Francois Stapelberg for their contributions towards the pain management section in Chapter 6. Thanks also to Debbie Murray and Linda Jackson from Middlemore Hospital for their support and contributions.

Funding This guideline was commissioned and funded by ACC and development and production were independently managed by NZGG. ACC staff members were co-opted onto the Guideline Development Team to provide advice about ACC internal processes. All evidence appraisals, reporting and formulation of recommendations are independent of ACC, and NZGG retains editorial independence.

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1616 55/17/07/17/07 12:11:0812:11:08 PMPM Summary

Key messages • Children under the age of fi ve are most at risk of burns and scalds. • All burns and scalds should be cooled immediately in running tap water (8–15°C) for at least 20 minutes. – Avoid hypothermia: keep the person with the burn as warm as possible; consider turning the temperature of the water up to 15°C (tepid). • Gel pads or other fl uids can be used as an alternative to running tap water where water is unavailable or not practical. • If there has been a delay in starting cooling, this should still be started up to three hours after injury. • Initial management should include an antimicrobial dressing or cream and, following this, dressings should encourage re-epithelialisation by moist wound healing. • Burn injuries constitute signifi cant trauma and can cause or exacerbate psychological distress.

Referral to a specialist burns unit • The referral criteria endorsed by the Australian and New Zealand Burn Association (ANZBA) should be considered by primary health care practitioners when assessing whether burns require treatment in a specialist burns unit (see Algorithm 1, Note 4). • Other reasons for referral to a hospital may include: an ongoing requirement for narcotic analgesia, intravenous (IV) ﬂ uids, elevation or frequent or complex dressings; signiﬁ cant comorbidities, social/ psychosocial indicators or suspected non-accidental injuries; or a need for other specialist services, eg, physiotherapy. • The depth of a burn injury should be reassessed, preferably by the same clinician, two to three days after the initial assessment. • Any burns that are unlikely to heal within 21 days without grafting (deep dermal and/or full thickness burns) should be referred to a burns unit for scar management by day 10–14.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1717 55/17/07/17/07 12:11:0812:11:08 PMPM Algorithm 1: Initial assessment and management of burns and scalds

Child or adult with a new burn injury

First aid, emergency examination and treatment (Note 1)

Assess and record cause, non- accidental injury, clinical features, burn size, location and depth (Note 2)

Decide the level of care needed

Continue managing in primary care. Refer to Algorithm 2: Ongoing Is hospital care indicated? No (Note 3) assessment and management of burns and scalds in primary care

Yes

Is specialist burns unit No Immediate referral to nearest hospital care indicated? (Note 4)

Yes

Suitable for transfer to a No regional burns unit?

Yes

Immediate referral to nearest regional burns unit 18

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1818 55/17/07/17/07 12:11:0912:11:09 PMPM Notes to Algorithm 1

Note 1: First aid, emergency examination and treatment First aid • Ensure your own safety. • Stop the burning. • In electrical injuries, disconnect the person from the source of electricity. • Cool the burn: – cool with running tap water (8–15°C) for at least 20 minutes (no ice). Irrigation of chemical burns should continue for one hour. – avoid hypothermia: keep the person with the burn as warm as possible; consider turning the temperature of the water up to 15°C (tepid). • Remove clothing and jewellery. • Cover the burn: – cover with cling ﬁ lm or a clean, dry cloth. – avoid topical treatments until the depth of the burn has been assessed. • Administer analgesia.

Emergency examination and treatment

Primary survey* Airway maintenance with cervical spine control Breathing Circulation with haemorrhage control Disability – neurological status Exposure + environmental control Fluid resuscitation proportional to burn size

Fluid resuscitation • Burns of >10% body surface area in children and >15% in adults warrant fl uid resuscitation. • Give fl uids: – 24-hour requirement: 3–4ml crystalloid solution per kg per % burn. – plus maintenance fl uids for children. – give half of the fl uids over the fi rst eight hours, the remainder over the next 16 hours.

Prevention of tetanus There is a risk of tetanus following a burn injury. Refer to the guidelines on the prevention of tetanus following injury, which are available from the Ministry of Health’s Immunisation Handbook 2006.9 Continued …

* Reproduced from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns. 19 8th Edition;2004.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 1919 55/17/07/17/07 12:11:0912:11:09 PMPM Note 2: Burn assessment Depth assessment The following table provides guidance in assessing the depth of burn injury. table: classification of burns based on depth anzba 2004 classification Epidermal former classification Superﬁ cial epidermal example UV light, very short ﬂ ash appearance Dry and red, blanches with pressure, no blisters sensation May be painful healing time Within seven days scarring No scarring

anzba 2004 classification Superfi cial dermal former classification Superfi cial partial thickness example Scald (spill or splash), short fl ash appearance Pale pink with fi ne blistering, blanches with pressure sensation Usually extremely painful healing time Within 14 days scarring Can have colour match defect Low risk of hypertrophic scarring

anzba 2004 classification Mid dermal former classification Partial thickness example Scald (spill), ﬂ ame, oil or grease appearance Dark pink with large blisters Capillary reﬁ ll sluggish sensation May be painful healing time 14–21 days scarring Moderate risk of hypertrophic scarring

anzba 2004 classification Deep dermal former classification Deep partial thickness example Scald (spill), ﬂ ame, oil or grease appearance Blotchy red, may blister, no capillary reﬁ ll In child, may be dark lobster red with mottling sensation No sensation healing time Over 21 days: grafting probably needed scarring High risk of hypertrophic scarring

anzba 2004 classification Full thickness former classification Full thickness example Scald (immersion), ﬂ ame, steam, oil, grease, chemical, high-volt electricity appearance White, waxy or charred, no blisters, no capillary reﬁ ll May be dark lobster red with mottling in child sensation No sensation healing time Does not heal spontaneously, grafting needed if >1cm 20 scarring Will scar

Adapted from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns. 8th Edition; 2004.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 2020 55/17/07/17/07 12:11:0912:11:09 PMPM Chemical and electrical injuries6 Chemical burns: Copious irrigation should continue for one hour

Do not attempt to neutralise chemical burns in primary care

All chemical burns should be referred to a burns unit

Chemical eye injuries: Treat all chemical burns to the eye with copious irrigation of water

Ensure contact lenses have been removed

All signiﬁ cant chemical injuries to the eye should be referred acutely to ophthalmology services

Electrical injuries: Small entry and exit wounds may be associated with severe deep tissue damage

An electrocardiogram (ECG) should be carried out to detect arrhythmias

All electrical injuries should be referred to a burns unit

Non-accidental injuries Indicators of possible non-accidental burns or scalds include the following: • delay in seeking help • historical accounts of injury differ over time • history inconsistent with the injury presented or with the developmental capacity of a child • past abuse or family violence • inappropriate behaviour/interaction of child or caregivers • glove and sock pattern scalds • scalds with clear-cut immersion lines • symmetrical burns of uniform depth • restraint injuries on upper limbs • other signs of physical abuse or neglect.

Refer to a regional burns unit if non-accidental injury is suspected. Continued …

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 2121 55/17/07/17/07 12:11:1112:11:11 PMPM Assessment of burn size: Lund and Browder chart % Total Body Surface Area Burn Be clear and accurate, and do not include erythema

A % A

1 1

13 13 22 22

region partial loss thickness full loss thickness

1B/c 1B/c Head 1B/c 1B/c

Neck 1 2B/c 2B/c 1B/c 1B/c Ant. trunk 1B/c 1B/c

BB Post. trunk BB

Right arm

Left arm

Buttocks CC CC Genitalia

Right leg

Left leg 1D/e 1D/e 1D/e 1D/e total burn

area age 0 1 5 10 15 adult

A = B/c of head 9 B/c 8 B/c 6 B/c 5 B/c 4 B/c 3 B/c

B = B/c of one thigh 2 D/e 3 B/e 44 B/c 4 B/c 4 D/e

C = B/c of one lower leg 2 B/c 2 B/c 2 D/e 33 B/e 3 B/c

22 Reproduced with permission from: Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment and resuscitation. BMJ 2004;329;101–3.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 2222 55/17/07/17/07 12:11:1112:11:11 PMPM Note 3: Considerations for referral for hospital care Burns of lesser severity than those meeting the criteria for regional burns unit care but with one or more of the following risk factors: • ongoing requirement for narcotic analgesia or failure to manage dressing-change pain • IV ﬂ uids required • where oedema may be a problem • social and/or psychosocial indicators • suspected non-accidental injury • frequent or complex dressing issues • signiﬁ cant comorbidities • request for other specialist services, eg, physiotherapy.

Note 4: Referral criteria for regional burns unit care The following criteria are endorsed by the ANZBA in assessing whether burns require treatment in a specialised burns unit:33 • burns greater than 10% of total body surface area (TBSA) • burns of special areas – face, hands, feet, genitalia, perineum and major joints • full thickness burns greater than 5% of TBSA • electrical burns • chemical burns • burns with an associated inhalational injury • circumferential burns of the limbs or chest • burns in the very young or very old • burns in people with pre-existing medical or psychological disorders that could complicate management, prolong recovery or increase mortality • burns with associated trauma.

NOTE: Referral to the National Burn Centre is made through a regional burns unit. There are regional burns units at Christchurch (03 364 0640), Hutt Valley (04 566 6999), Waikato (07 839 8899) and Middlemore (09 276 0000) Hospitals.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 2323 55/17/07/17/07 12:11:1212:11:12 PMPM Algorithm 2: Ongoing assessment and management of burns and scalds in primary care

Child or adult with a burn injury that can be managed in primary care

Day 1: Assessment of depth (Note 2)

Epidermal Superﬁ cial/Mid dermal Deep dermal/full thickness

Antimicrobial dressing Blister and oedema Is the burn area Moisturising cream management (Note 5) Review after 48 hours >1cm wide? Pain relief (Note 6) Yes Daily review

Refer acutely Day 3: Reassessment Day 3: Reassessment No as appropriate (Notes 3 and 4)

Intact skin? Reassess Antimicrobial dressing (eg, burn depth (Note 2). Is it silver sulphadiazine cream) signiﬁ cantly worse (likely to Pain relief (Note 6) be full thickness)? Yes No No Yes Daily review

Change to moist wound- healing product or Healed, alternatively double- Days 5–7: continue layer parafﬁ n gauze Change to moist wound- moisturiser Review within 72 hours healing product and sunblock Monitor for signs of infection No

Days 10–14 Is healing progressing? No Is healing likely within seven days?

Yes

Yes Continue with dressings as above Monitor for signs of infection (Note 7)

Healed. Consider rehabilitation needs (Note 8) Continue with dressings

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 2424 55/17/07/17/07 12:11:1212:11:12 PMPM Notes to Algorithm 2

Note 5: Management of blisters and oedema Management of blisters • Preferably leave small blisters intact unless likely to burst or interfere with joint movement • If necessary, drain ﬂ uid by snipping a hole in the blister.

Management of oedema • Where possible, elevate affected area • Remove jewellery or constricting clothing.

Note 6: Pain management for adults and children Immediately after the injury • Cool and cover the burn (with cling ﬁ lm or a clean, dry cloth).

Background pain • Paracetamol and non-steroidal anti-inﬂ ammatory drugs (NSAIDs), alone or in combination with opioids • Aspirin products should be avoided.

Intermittent or procedural pain • Consider administering short-acting opioids • Supplementary anxiolytics if indicated • Supplement pharmacological therapy with non-pharmacological approaches • Refer to secondary care if failing to manage dressing-change pain.

Note 7: Signs of infection Signs of infection • Surrounding redness, increasing pain, increased exudate/pus, swelling, fever or local wound temperature increase, lymphangitis or increased irritability in a child.

Suggested management • Swab the wound • Consider re-starting topical silver sulphadiazine • Consider starting oral antibiotics • For more serious infection, refer acutely to secondary care.

Note 8: Psychological consequences of burn injury • Monitor for stress disorders and depression • Be aware of the risk of sleep disorders • Consider services that may be able to support families affected by the psychological impact of burn injuries.

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Chapter 1 Burn injuries and burns prevention in New Zealand

Evidence statements • Most burns occur at home. • Children under ﬁ ve are at the highest risk, with hot liquids being the leading cause of injury in this age group. • Ma¯ori are at increased risk, particularly in the under-ﬁ ve age group. • Males are at increased risk at all ages.

Evidence Burns and scalds are a leading cause of injury to children in New Zealand, with children aged fi ve years and under being most at risk, especially toddlers as they become more mobile with little awareness of danger. Every year, about seven or eight New Zealand children aged 15 years and under die as a result of burns or scalds. In most cases, fatalities are the result of house or car fi res. Over two-thirds of those who die are aged fi ve years and under10 and over a third are Ma¯ori.11

On average about 475 children under 15 years are admitted to hospital every year as a result of burns or scalds, of whom 80% are aged fi ve years and under.10 In 2002–3, 436 children under fi ve years were admitted to public hospitals with burns and scalds. Most of these injuries involved hot liquids: about 34% were caused by hot drinks, food, fat or cooking oils, 20% by hot tap water, 25% by other hot fl uids and 8% by exposure to fi re or fl ames. Over 35% of children aged fi ve years and under admitted to hospital were Ma¯ori, and over 60% were boys.12

During 2002 and 2003 the total number of adults and children admitted to public hospital with burn injuries was 1311. Thirty-three per cent of these burns were fi re, fl ame or smoke related and 77% were due to scalds and contact with hot objects. Ma¯ori comprised 26% of total admissions and Pacifi c peoples comprised 10.5%. Overall 66% of admissions were male, with higher rates of injury in all age groups.12 Most burn injuries occur at home (this applies to about 63% of fi re or fl ame burns and 70% of scalds).13

Further data from the Injury Prevention Research Unit on age-speciﬁ c rates of burn injury over the period 2000–2004 is provided in Tables 1.1 and 1.2. This data includes ﬁ rst admissions only (excluding day patients) with a primary diagnosis of injury. table 1.1: burns from fire or flames: age-specific rates (per 100,000 population) for 2000–2004

age (years) rate

<15 4.9

15–24 11.1

25–44 7.1

45–64 4.1

65+ 2.9 27 Reproduced from: Dow NA, Stephenson SCR, Allnatt DM. Trends In Thermal Injury. Fact Sheet No. 21. Dunedin: Injury Prevention Research Unit, University of Otago; 2001.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 2727 55/17/07/17/07 12:11:1312:11:13 PMPM table 1.2: burns due to hot substances and objects, caustic or corrosive material or steam: age- specific rates (per 100,000 population) for 2000–2004

age (years) rate

0–4 79.8

5–14 8.5

15–24 6.5

25–44 7.4

45–64 5.7

65+ 7.8

Reproduced from: Dow NA, Stephenson SCR, Allnatt DM. Trends In Thermal Injury. Fact Sheet No. 21. Dunedin: Injury Prevention Research Unit, University of Otago; 2001.

ACC data on burn injuries, which is based on claim numbers for burn injuries covering a three-ﬁ nancial-year period (1 July 2001 to 30 June 2004), shows that there were 65,089 new claimants of burn injury in all age groups, in the three-year period.14 This number is much higher than other data (locally and internationally), and is probably because ACC covers general practitioner treatments and visits for very minor burn injuries for compensation. For burn injuries, the ratio of males to females is 1.12 to 1.00, and there were 20 fatalities in that period. Children aged under 15 years constituted 33% of burn-related claims.

As in New Zealand, overseas literature reports that children under ﬁ ve years have the highest risk of both burn-related death15 and burn-related hospitalisations.16,17 Epidemiological studies conducted in a number of countries show that children in this age group have the highest burn-incidence rate.18-23 In this age group, scalds typically account for 50% of thermal injuries logged in emergency departments, and scalds are also more likely to lead to hospitalisation than any other burn injuries.17,24,25 Up to 80% of all childhood burn injuries in developed countries occur at home,23 and over 90% occur at home in developing countries.18,21

Opportunities for prevention recommendations grade

Primary care providers should provide advice on smoke alarms. A

Primary care providers should support local initiatives in primary prevention, where possible. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice points

Primary care providers should provide advice on the regulation of hot water temperature and ✓ appropriate ﬁ rst aid management.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

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Evidence statements • The hot water temperature in the home should be regulated to reach the taps at no more than 50°C. • There is evidence from the United States (US) that smoke detector legislation can reduce the number of ﬁ re- related deaths compared with communities without smoke detector legislation. • There is evidence that the community-based provision of free smoke alarms (with or without installation) reduces ﬁ re-related injuries. • Simple educational initiatives improve safety in the home.

Evidence Common preventable causes of serious thermal injury include scalding water and lack of smoke detectors. A 1947 study found that full thickness burns occurred in adult skin in two seconds at 66°C whereas at 54°C this took 30 seconds.26 In a large US case-control study the absence of a smoke detector increased the risk of death in a residential ﬁ re by over 60%.27

The primary care setting offers numerous opportunities for promoting safety measures to prevent burns and scalds since young children are the population most at risk and they are usually seen routinely. There is good evidence that advice in this setting promotes good practices with regard to ﬁ re safety, although evidence is lacking of a direct impact on injuries.28

Similarly, while an educational strategy may improve safety consciousness,29 there is little evidence about community-based interventions that impact on the rate of injuries.30 However, individual regulatory measures, such as the installation of temperature controls on hot water cylinders, appear to have had some impact.

A systematic review of individual-level injury prevention strategies delivered in primary and acute care settings showed that such strategies increased smoke alarm ownership and the maintenance of a safe hot water temperature.28 The most effective interventions used a combination of methods, such as counselling, demonstrations, the provision of free or subsidised safety devices, and reinforcement. None of the relevant trials reported outcomes on ﬁ re-related injuries speciﬁ cally.

A small New Zealand study29 showed an improvement in the ability of children to recognise ﬁ re safety hazards around the home and in families’ self-reported safety practices, such as keeping pot handles turned in. The most problematic recommendation was to reduce the hot water temperature.

A systematic review found very limited research on the effectiveness of community-based injury-prevention programmes to prevent burns and scalds in children. Only one of the three eligible studies reported a reduction in burn injuries and there were weaknesses in the methodology of this study.30

Regulation of hot water temperature to reduce the risk of scalds • The safest long-term option is to install a tempering valve in the hot water cylinder. This is done by a plumber. It ensures that hot water reaches the taps at the appropriate temperature. Since 1993 the New Zealand Building Code has required that tempering valves be installed in new homes. • Another option is to turn down the thermostat on the hot water cylinder. If a consumer-adjustable thermostat is not ﬁ tted, an electrician can install one. However, the tempering valve option is safer and is also more energy efﬁ cient in the long term. • An adult should be able to hold their wrist under the running water. • If in doubt, check the hot water temperature with a thermometer.

For more information, see the New Zealand Fire Service website Fire Safety Tips (http://www.ﬁ re.org.nz/home_kids/tips/hotwater.htm).

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3030 55/17/07/17/07 12:11:1412:11:14 PMPM 2 Chapter 2 First aid

Stopping the burning process and cooling recommendations grade

Ensure your own safety. C

If on ﬁ re, ‘stop, drop and roll’, smother with blanket or douse with water. C

For electrical burns, disconnect the person from the source of electricity. C

Remove clothing and jewellery. C

Cool burns or scalds by immediate immersion in running tap water (8–15°C) for at least 20 C minutes. Irrigation of chemical burns should continue for one hour.

Do not use ice for cooling. C

Avoid hypothermia: keep the person with the burn as warm as possible, consider turning the C temperature of the water up to 15°C (tepid).

If there has been a delay in starting cooling, this should still be started up to three hours after C injury.

Do not attempt to remove tar. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

Evidence statements • Clothing can retain heat, even in a scald injury. • Cooling burns reduces the severity of tissue damage. • Running tap water at 15°C (tepid) is as effective as other forms of cooling. • Alternative liquids, such as milk or soft drinks, may be used when running tap water is unavailable. • Be aware of the risk of hypothermia, especially in children and older people. • Application of ice may deepen the wound and increase the risk of hypothermia.

Evidence The evidence for stopping the burning process derives largely from expert opinion.31,32 Flames should be doused with water or smothered with a blanket or by rolling the person on the ground. Clothing can retain heat and should be removed as soon as possible unless adherent. Jewellery should also be removed and if oedema is present elevate the affected area. Tar burns should be cooled with water, but the tar itself should not be removed. In the case of electrical burns, ensure the power source is turned off and the scene is safe before cooling with water. Expert opinion suggests that if running tap water is unavailable to cool the burn wound, alternative liquids may be used, such as milk or soft drinks. 31

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3131 55/17/07/17/07 12:11:1412:11:14 PMPM There is good evidence that immediate cooling of burns reduces the severity of tissue damage. However, the optimum duration and temperature of cooling is largely a matter of expert opinion. The Guideline Development Team extrapolated the low-level evidence from a variety of sources to reach a weakly graded conclusion. Irrigation of chemical burns should continue for one hour. See Chapter 7, Management of chemical injury for the evidence supporting this statement and further information on the management of chemical burns.

Cooling large areas of skin may result in hypothermia, especially in children.31 Therefore, while it is recommended that the burn wound is cooled by irrigating or immersing in running water, the person with the burn needs to be kept as warm as possible. Ideally the water should be tepid (15°C). Ice or iced water should not be used as intense vasoconstriction can cause burn progression31 and also increases the risk of hypothermia.33 In an animal study, the application of ice for 10 minutes resulted in a deeper wound compared with no treatment at all.34

A case series study of 695 children with burns in Vietnam found that immediate cooling with cold water signiﬁ cantly reduced the risk of sustaining a deep burn, with an estimated 32% reduction in the need for skin grafting.35 Similarly, a study of 121 people with burns presenting to Middlemore Hospital found that adequate burns ﬁ rst aid treatment (cooling) was associated with a reduced number of skin-grafting procedures.1

Another large case series showed a signiﬁ cantly decreased length of hospital stay in people with less than 30% TBSA burns who received ﬁ rst aid by water cooling.36

In a randomised single-blinded study37 of 24 volunteers, no prolonged anti-inﬂ ammatory or anti-hyperanalgesic effects were observed after 30 minutes’ cooling to 8°C, initiated within 15 minutes after an epidermal burn injury (although the data did not contradict the clinical observation that cooling following a more severe burn or scalding has a pain-relieving effect). An earlier experimental study supported these ﬁ ndings.38

Other evidence on cooling derives from animal studies. The methods, duration and temperature of cooling used in these studies varied widely.

One experimental study39 found faster healing at 21 days in deep partial thickness scalds cooled with either tap water (at 15°C, applied on gauze every three minutes) or hydrogel, than in uncooled scalds. Similarly, another experimental study40 found that scalds treated by ice-water immersion at 10 minutes post-burn for 30 minutes sustained less damage to the epidermis, basement membrane and dermal microvasculature and had less oedema than those untreated. A transient reduction in oedema volume in scalds was also found in another study,41 which lasted longer with decreasing temperature and increased cooling time. The most pronounced effect was obtained after cooling at 0°C for 120 minutes.

One study investigated the optimum period of cooling.42 This involved cooling burns at 8°C for time periods from 15 to 120 minutes. The results suggested that 30 minutes was the optimal duration of cooling.

Another study investigated when the cooling strategy should be started.43 This study began cooling wounds from 10 minutes to 60 minutes post-burn and found markedly better healing when cooling (ice water 0–3°C bath for 30 minutes) was commenced within 30 minutes of burning, compared with 60 minutes after burning.

Gel pads recommendation grade

Gel pads can be used as an alternative to running tap water where water is unavailable or not C practical.

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3232 55/17/07/17/07 12:11:1512:11:15 PMPM 2 Evidence statements • There is insufﬁ cient evidence about the effectiveness of burn gels in comparison with running water.

Evidence There was insufﬁ cient evidence to assess adequately whether hydrogel dressings are more effective at cooling or reducing pain than water. Three published studies (two case series in people with burns or wounds and one comparative study in volunteers with non-burned skin) and four studies downloaded from the internet (one in pigs, one with volunteers with non-burned skin and two with people with burns) were identiﬁ ed. One of these studies directly compared the cooling properties of hydrogel dressings with cold water (in people without burns). One comparative study compared hydrogels with other types of dressing for other outcomes, such as healing time and hospital stay. Pain relief was assessed by only one case series.

Findings An experimental animal study of fair quality44 found that cooling with a gel dressing at different time periods was more rapid and effective than air cooling and the immediate application of gauze in burned pigs. A poor-quality case series of 131 adults with scalds and burns45 recorded body temperature rectally and at the skin surface for cold water cooling compared with gel cooling in healthy volunteers without burns. Cold water therapy for 20 to 30 minutes, but not gel cooling, induced hypothermia in participants. The case series also reported that 73% of participants using a gel dressing had a reduction of pain (described as ‘appropriate’, ‘permanent’ or ‘total’) and 36% used no analgesics. The dressing was described as ‘easy’ to administer in 98% of cases.

A controlled trial of fair quality46 reported that hydrogel dressing with air movement was more effective than hydrogel dressing alone, with a thick bandage or with a bandage plus air movement, in reducing skin temperature in healthy volunteers without burns. Due to the paucity of good-quality randomised evidence, we have been unable to directly compare the effectiveness of burn gels with cold water for cooling and reducing pain. The identiﬁ ed studies did not report any adverse events when burn gels were used.

Initial coverings Polyvinyl chloride ﬁ lm (cling ﬁ lm) recommendations grade

Following cooling, polyvinyl chloride (PVC) ﬁ lm may be used as a temporary cover prior to C hospital assessment. It should be applied by persons knowledgeable in its use.

PVC ﬁ lm should be layered onto the wound and not applied circumferentially around a limb. C

Topical creams should not be applied as they may interfere with subsequent assessment. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice point

PVC ﬁ lm should not be used as a substitute for a dressing product. ✓

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3333 55/17/07/17/07 12:11:1512:11:15 PMPM Evidence statements • The application of PVC fi lm can relieve pain. It is transparent for inspection. It is clean and easy to remove. • A clean, dry cloth may be used to cover the wound if PVC fi lm is not available. • The use of PVC fi lm as an alternative to silver sulphadiazine cream makes the subsequent assessment of wound depth easier in people who are transferred within four hours to secondary care. • There is a risk of constriction if PVC fi lm is wound around a limb that subsequently swells.

Evidence Insuffi cient evidence was identifi ed to determine the benefi t of PVC fi lm. A non-systematic review, a microbiological study and a case series were identifi ed which assessed water-impermeable PVC fi lm as a dressing for burns.47-49

Findings Cling fi lm plastic wrap is sold throughout New Zealand, mainly to cover food. It is composed of plasticised PVC fi lm. Based on experience in an English burns unit, Wilson47 concluded in his review that plasticised PVC fi lm was easy to use, safe and cheap and caused no pain. It was found to be particularly useful before surgery and before transfer to the burns unit in the hospital. In a microbiological study of 24 people with partial or full thickness burns who used PVC fi lm as a temporary dressing,48 bacteria were cultured from the initial exudate in only 3 out of 37 burns and subsequent bacterial cultures showed no differences from what was usually found in burn wounds. Laboratory investigations indicated that the wrap had no antibacterial effect on the burn wounds. The other case series49 reported that PVC fi lm as a wound covering enhanced the ability of thermography to assess the damage to the skin blood vessels prior to early surgery. The PVC fi lm did not interfere with the measurement of surface temperature and avoided the cooling effect of evaporation at the site of the wound.

PVC ﬁ lm is often used as a temporary covering of a burn wound. It is pliable, non-adherent and impermeable, acts as a barrier and is transparent for inspection. After the ﬁ rst few centimetres it is essentially sterile. It should be applied in layers and not circumferentially like a bandage, to prevent any tourniquet effect if tissue oedema develops.6

The Guideline Development Team suggests that if cling fi lm is unavailable, a clean, dry cotton sheet (preferably sterile) may be used as a fi rst aid measure at home. In the primary care setting a double-layer paraffi n gauze dressing may be used. Hand burns can be covered with a clear plastic bag. Topical creams should not be applied at this stage as they may interfere with the subsequent assessment of the burn.31

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Emergency management recommendations grade

For major burns perform an ABCDEF primary survey and X-rays, as indicated. C

Address analgesic requirements. C

Establish and record the cause of the burn, the exact mechanism and timing of injury, other C risk factors and what ﬁ rst aid has been given.

Assess burn size and depth. C

Give tetanus prophylaxis if required. C

Be alert to the possibility of non-accidental injury. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

Evidence Measures recommended for the assessment and initial management of burns derive largely from international expert opinion.50,51 The chance of survival following burn injury has increased steadily over the past 60 years, in tandem with the introduction of such measures.52,53

Several large case series studying factors predictive of death following burn injury reported a strong correlation between prognosis and two factors: burn area (particularly deep burn area) and age.54-57 In addition, studies have found inhalational injuries to be a strong predictor of mortality.52,58-60 There is also evidence that other factors, such as alcohol, contribute signiﬁ cantly to outcome.61

ABCDEF primary survey Airway maintenance with cervical spine control • Ensure airway is clear and open, keep movement of cervical spine to a minimum. • Inhalation of hot gases can cause a burn above the vocal cords that may become oedematous over the following hours; a seemingly well person, especially a child, may deteriorate later. See Table 3.1 for signs of inhalational injury. • If the patency of the airway is at risk, intubate.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3535 55/17/07/17/07 12:11:1612:11:16 PMPM table 3.1 airway maintenance

signs of inhalational injury indications for intubation

History of ﬂ ame burns or burns in an enclosed space Erythema or swelling of the oropharynx on direct visualisation Full thickness or deep dermal burns to face, neck or upper torso Change in voice, with hoarseness or harsh cough

Singed nasal hair Stridor, tachypnoea or dyspnoea

Carbonaceous sputum or carbon particles in oropharynx

Adapted from: Hettiaratchy S, Papini R. Initial management of a major burn: 1– overview. BMJ 2004;328: 155–7.

Breathing • Expose chest and ensure adequate and equal expansion. • Provide supplemental oxygen. • Damage below the vocal cords can be caused by severe chest burns, blast injury or inhalation of smoke or carbon monoxide. The products of combustion can directly irritate the lungs and cause bronchospasm or pulmonary oedema. People with asthma are particularly at risk.

Circulation with haemorrhage control • Check for bleeding due to other injuries. • Stop bleeding with direct pressure. • Check pulse and peripheral circulation. • Hypotension is not the normal initial response to a burn: check for other causes. • Normal return from capillary blanch test is two seconds. A deep circumferential extremity burn can act as a tourniquet, causing vascular insufﬁ ciency and distal ischaemia which may become apparent some hours after the burn.

Disability: Neurological status • Establish level of consciousness. • Poisoning from inhalation of noxious gases can cause confusion, dizziness, headaches and seizures. • Hypovolaemia and shock can also cause confusion.

Exposure with environmental control • Remove clothing and jewellery and examine the whole person, including the back, for burn area and co- injuries. • Keep the person warm: hypothermia develops easily, especially in children.

Fluid resuscitation • Establish intravenous access with two large peripheral intravenous lines. • Take blood for full blood count, urea and electrolytes, coagulation screen, amylase and carboxyhaemoglobin. • The main aim is to maintain tissue perfusion to the wound and prevent the burn deepening and to avoid hypoperfusion or oedema. • Burns of >10% body surface area in children and >15% in adults warrant resuscitation. • Give fl uids: – 24-hour requirement: 3–4ml crystalloid solution per kg per % burn – plus maintenance fl uids for children – give half over the fi rst eight hours, the remainder over the next 16 hours. • If haemorrhage occurs from other injuries, replace with blood. 36

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3636 55/17/07/17/07 12:11:1612:11:16 PMPM • Monitor with urinary catheter, ECG, pulse, blood pressure, respiratory rate, pulse oximetry or blood gases as appropriate. • Insert nasogastric tube for larger burns or associated injuries. 3 X-rays • In traumatic injury, order X-rays as indicated.

Pain relief • Give intravenous morphine. • Use small incremental doses of intravenous morphine until pain is controlled and reassess regularly.

For further information on pain management see Chapter 9, Pain management.

Burn history • Knowledge of the cause of the burn, the exact mechanism and timing of injury and what prior treatment has been given helps to indicate the likely severity of the burn, the likelihood of inhalational or other co-injuries, the presence of contributing underlying causes (eg, faintness, seizure, alcohol) and the possibility of non- accidental injury. See also Table 3.2 for key points of a burn history. table 3.2: key points of a burn history

exact mechanism

Type of burn agent (scald, fl ame, electrical, chemical) Is there a risk of concomitant injuries (such as fall from height, road traffi c crash, explosion)? How did it come into contact with the patient? Is there a risk of inhalational injuries (did the burn What fi rst aid was performed? occur in an enclosed space?) What treatment has been started?

exact timings

When did the injury occur? How long was cooling applied?

How long was the patient exposed to the energy When was ﬂ uid resuscitation started? source?

exact injury

Scalds Electrocution injuries • What was the liquid? Was it boiling or recently • What was the voltage (domestic or industrial)? boiled? • Was there a ﬂ ash or arcing? • If tea or coffee, was milk in it? • Contact time? • Was a solute in the liquid? (Raises boiling Chemical temperature and causes worse injury, such as • What was the chemical? boiling rice) • Is there any suspicion of non-accidental injury?

Adapted from: Hettiaratchy S, Papini R. Initial management of a major burn: 1– overview. BMJ 2004;328: 155–7.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3737 55/17/07/17/07 12:11:1612:11:16 PMPM Factors inﬂ uencing management and prognosis • The size and depth of burns indicate their likely severity, the need for ﬂ uid resuscitation, the potential risk of complications, the rate of healing, the amount of scarring that can be expected, and the need for specialist care. However, a burn is rarely uniform: a mixed pattern of burn is usually found. • The prognosis for people with major burns is well correlated to the area of the burn (TBSA), the presence of inhalational injury, and age.

Burn size Assessment and recording of total body surface area burn recommendation grade

Where time allows, use the Lund and Browder chart as the standard assessment tool for B estimating the TBSA of the burn.

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

Evidence statements • Lund and Browder charts are more accurate than either the Rule of Nines or palm size in identifying TBSA. • Lund and Browder charts become less accurate at the extremes of age and body mass index (BMI). • The Rule of Nines can be faster and more convenient to perform in emergency situations but is not accurate for children and should not be used in those clinical settings. • A person’s hand size (palm including ﬁ ngers) approximates to 0.8–1.0% of TBSA. The 1% rule can be cautiously used to estimate the size of small burns (<10%) in primary care. • Computer assessments of burn size are not sufﬁ ciently developed for routine use in primary care.

The measurement of burn surface area is important during the initial management of people with burns for estimating ﬂ uid requirements and determining referral criteria. It is essential that all of the burn is exposed and assessed. During assessment the environment should be kept warm, and small areas of skin exposed sequentially to reduce heat loss. Erythema should not be included.51

Evidence The practice of using a person’s hand size to approximate 1% body area is commonly taught on emergency medicine courses but has not been well validated.62-67 This practice should be used with caution, particularly in children or for people who are obese (BMI >30) as it does not allow for variations in individual body weight or age. For small areas, up to about 5%, the whole hand (palm plus digits) should be taken to approximate 0.8–1.0% of TBSA.

Five observational studies were found comparing the Rule of Nines burn area chart (see Figure 3.1) with other methods of estimating burn surface area. The Rule of Nines has been found to provide reasonable estimates for burned body surface area for most children and adults.68 For people who are obese or weighing more than 80kg (BMI >30), a Rule of Fives is proposed by one author:69 5% body surface area for each arm, 5x4 or 20% for each leg, 10x5 or 50% for the trunk, and 2% for the head. For infants weighing less than 10kg (BMI <18) a Rule of Eights is proposed: 8% for each arm, 8x2 or 16% for each leg, 8x4 or 32% for the trunk, and 20% for the head.

Computer methods of size estimation have been described for use in various skin disorders. Three studies were reviewed which were considered applicable to burn size assessment. Two observational studies70,71 found a close correlation between the computer methods of size estimation and objective measurement. The participants of one study found a computer program was easy to use and potentially useful in the person’s care.72 No direct quantitative comparisons with manual methods, in people with burns, were found. 38

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3838 55/17/07/17/07 12:11:1712:11:17 PMPM Six different types of burn area charts were compared in one observational study.73 Four of the six were either Lund and Browder (see Figure 3.2) or a modiﬁ ed version of Lund and Browder, and there were two versions of the Rule of Nines represented. Utilising 10 drawings of burns on the six different charts, this study found that the Rule of Nines often overestimated the burn size and was more variable, but could be performed somewhat 3 faster than the Lund and Browder method. The Rule of Nines’ estimates were 3% larger than the Lund and Browder estimates for the same burn representation.

A modiﬁ cation to the Lund and Browder chart has been proposed that adjusts for breast burns in larger- breasted women,74 as breast burns in these women can be underestimated by as much as 5%.

In the primary care setting it is anticipated by the Guideline Development Team that the use of speciﬁ c adjustments in estimates of burn area to take account of obesity and large breast size would be precluded by other clinical priorities. figure 3.1: assessment of burn size: rule of nines

Front 18% Back 18% 18%

9% 9% Front 18% Back 18% 1% 9% 9%

18% 18%

14% 14%

Adapted from: Australian and New Zealand Burn Association Limited, Emergency Management of Severe Burns (EMSB): Course Manual 2004. 39

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 3939 55/17/07/17/07 12:11:1712:11:17 PMPM figure 3.2: assessment of burn size: lund and browder chart % Total Body Surface Area Burn Be clear and accurate, and do not include erythema

A % A

1 1

13 13 22 22

region partial loss thickness full loss thickness

1B/c 1B/c Head 1B/c 1B/c

Neck 1 2B/c 2B/c 1B/c 1B/c Ant. trunk 1B/c 1B/c

BB Post. trunk BB

Right arm

Left arm

Buttocks CC CC Genitalia

Right leg

Left leg 1D/e 1D/e 1D/e 1D/e total burn

area age 0 1 5 10 15 adult

A = B/c of head 9 B/c 8 B/c 6 B/c 5 B/c 4 B/c 3 B/c

B = B/c of one thigh 2 D/e 3 B/e 44 B/c 4 B/c 4 D/e

C = B/c of one lower leg 2 B/c 2 B/c 2 D/e 33 B/e 3 B/c

40 Reproduced with permission from: Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment and resuscitation. BMJ 2004;329;101–3.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4040 55/17/07/17/07 12:11:1712:11:17 PMPM Burn depth recommendations grade 3 The depth of a burn injury should be reassessed two to three days after the initial C assessment, preferably by the same clinician.

Testing for pinprick sensation by using a needle should be avoided. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice point

The extent and speed of capillary reﬁ ll can be used as a clinical method of assessing burn ✓ depth.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • Burns can be diffi cult to assess accurately in the fi rst few days following injury, particularly in areas of poor circulation or infection. • Burn depth is easier to assess after the initial oedema and infl ammatory reaction have settled. • The extent and speed of capillary refi ll is the most useful clinical method to assess burn depth. • There is insuffi cient evidence that the newer technologies (laser doppler, thermography, radioisotopes) are practical or useful in assessing burns in the primary care setting. • Testing for pinprick sensation is painful and can be frightening for children and is not a sensitive test for assessing burn depth. • An estimate of burn depth is important in planning treatment, but is not required for calculating fl uid requirements for acute resuscitation.

Evidence There is little reliable evidence on the assessment of burn depth and the above recommendations derive largely from expert opinion.

Although it is relatively uncomplicated to diagnose very superfi cial burns and very deep burns, those of intermediate thickness are more problematic as their surface appearance alone is deceptive. The extent and speed of capillary refi ll is considered the most useful clinical method to assess burn depth.51 However, the presence of a dermal circulation, as measured by capillary refi ll at 24 hours post-injury, does not necessarily mean that the burn will remain superfi cial. Burns can increase in severity and depth over the fi rst few days, particularly in areas of poor circulation or infection. Burn depth is easier to assess after the initial oedema and infl ammatory reaction have settled.

Testing for burn depth by using pinprick sensation requires a high degree of compliance and is not appropriate for young children, or for people who are confused or shocked. Moreover, the accuracy of the test is limited.75 Biopsy and histology are generally considered to be the gold standards for assessment of burn depth, but are impractical for routine clinical use.

Most studies76-78 assess burns after 48 hours or so and therefore there is little evidence assessing the diagnostic accuracy of tools used to assess depth in the acute setting. Laser Doppler, transcutaneous microscopy, reﬂ ectance ﬂ uoroscopy, radioisotope studies, ultrasound and thermography have all been tried, but are still seen as research tools. The depth of a burn on any individual subject will vary from one location to another, 41

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4141 55/17/07/17/07 12:11:1812:11:18 PMPM so all controlled trials of these tools suffer from a difﬁ culty in matching the areas sampled. Despite this, some studies of newer techniques have shown promise in a research setting. The practical problems for the application of these techniques to clinical use include: • direct contact with the skin surface is sometimes needed • some tests are invasive • burns in some body areas cannot be tested • a lack of agreed standardisation of the thresholds • investigator bias is introduced by the need to choose a sample area.

A small blinded prospective study (of 23 people with 41 wounds) compared clinician assessment with laser doppler imaging to gauge burn depth in adults with acute burns of indeterminate depth.79 Burns were assessed daily; in most cases the fi rst scan was done one day post-burn (maximum two days). Clinician assessment correctly predicted which of the 41 wounds required excision and grafting (sensitivity 100%), while the laser doppler technique erroneously predicted healing in 8 out of 21 cases when biopsy results confi rmed deep partial thickness (mid to deep dermal) or full thickness burns (sensitivity 62%). Conversely, surgeons frequently overestimated burn depth, resulting in unnecessary excision and grafting for seven people (specifi city 61.5%), whereas the laser doppler was 100% specifi c.

Other studies of newer technologies assessed wounds in a non-acute setting, so were not relevant to primary care.

Non-accidental injury recommendations grade

If non-accidental injury is suspected, refer to a regional burns unit. C

If non-accidental injury is suspected, examine for other signs of abuse and photograph C injuries.

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

Evidence The high incidence of non-accidental burns and scalds necessitates that primary care staff be alert to this possibility. It is estimated that around 6–8% of paediatric burns are non-accidental, with children aged under three years being at highest risk.80-82 A high rate of repetitive injury has been reported among abused children.83,84 Older and disabled adults are also at increased risk.85

• Indicators of possible non-accidental burns or scalds include the following:6,86 – delay in seeking help – historical accounts of injury differ over time – history inconsistent with the injury presented or with the developmental capacity of a child – past abuse or family violence – glove and sock pattern scalds – scalds with clear-cut immersion lines – symmetrical burns of uniform depth – other signs of physical abuse or neglect. • Other possible indicators of non-accidental injury may include: – inappropriate behaviour/interaction of child or caregivers – restraint injuries on upper limbs.

42 Refer to a regional burns unit if non-accidental injury is suspected.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4242 55/17/07/17/07 12:11:1812:11:18 PMPM Tetanus There is a risk of tetanus following a burn injury. For guidelines on the prevention of tetanus following injury, refer to the Ministry of Health Immunisation Handbook 2006.9 3

Classiﬁ cation of burns recommendations grade

Avoid use of the terms ﬁ rst-degree/primary, second-degree/secondary and third-degree C burns.

Distinguish between burns that will probably heal without skin grafting and those that will C probably require grafting (deep dermal burns and full thickness burns).

Burns that are unlikely to heal within 21 days without grafting should be referred early to C secondary care, ideally by day 10–14.

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice point

Use the ANZBA system of burn classiﬁ cation. ✓

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • A burn wound that has not healed within three weeks has an increased risk of signiﬁ cant scarring, infection and functional limitation. • Early excision and grafting reduces mortality and shortens hospital stay. • Extensive burns that are expected to heal spontaneously may still need to be managed in a hospital setting.

Evidence Burns are generally classiﬁ ed by depth, as the ability of a burn to regenerate epithelium depends on the number of viable keratinocytes in the wound bed (as well as the wound environment).

International expert opinion notes that superﬁ cial dermal wounds should heal within two weeks, but deeper wounds are difﬁ cult to assess and may well require grafting, especially if the injuries are extensive or in cosmetically or functionally sensitive areas. The incidence of scarring rises if epithelialisation is delayed beyond three weeks; all wounds that show minimal signs of healing by 10 days should be referred for assessment. Full thickness wounds will most likely require grafting.87

A meta-analysis of six randomised controlled trials (RCTs) of the early excision of burns showed that, in people without inhalational injury, early excision reduced mortality and length of hospital stay. However, there was a greater volume of blood loss in people undergoing surgery.88

The ANZBA33 uses a fi ve-point table. This is recommended for use in preference to the older systems, particularly the fi rst- to third-degree classifi cation, which does not differentiate between burns that are likely to heal spontaneously (superfi cial dermal) and those that are likely to require grafting (mid dermal and deeper).

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4343 55/17/07/17/07 12:11:1912:11:19 PMPM table 3.3: classification of burns based on depth anzba 2004 classification Epidermal former classification Superﬁ cial epidermal example UV light, very short ﬂ ash appearance Dry and red, blanches with pressure, no blisters sensation May be painful healing time Within seven days scarring No scarring

Adapted from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns. 8th Edition. 2004.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4444 55/17/07/17/07 12:11:1912:11:19 PMPM Chapter 4 Referral

4 Emergency referral recommendations grade

Health care practitioners should follow the ANZBA referral guidance when deciding the level of C care that is appropriate for people with a new burn injury.

When seen in primary care, smaller burns that look like they will fail to heal by 14 days should C be discussed with a secondary care service for consideration of an acute referral.

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

Evidence statements • ANZBA guidance on referral is universally accepted throughout New Zealand. • International systems of referral are all consistent with ANZBA guidance.

Evidence In 2001 the American Burn Association proposed a list of conditions that generally require a referral to a burns unit.89 In New Zealand there are burns units in Christchurch, Hutt Valley, Waikato and Middlemore Hospitals. The following criteria are endorsed by ANZBA in assessing whether burns require treatment in a specialised burns unit:33 • burns greater than 10% of TBSA • burns of special areas – face, hands, feet, genitalia, perineum and major joints • full thickness burns greater than 5% of TBSA • electrical burns • chemical burns • burns with an associated inhalation injury • circumferential burns of the limbs or chest • burns in the very young or very old • burns in people with pre-existing medical and/or psychological disorders that could complicate management, prolong recovery or increase mortality • burns with associated trauma.

Levels of care Evidence statement • Evidence from the US experience with trauma systems indicates that a regional approach to providing specialist burn management expertise and a central approach to treating the very severely injured on a national basis can both improve a person’s outcome and be cost-effective.

Evidence There are four levels of care for burns injuries in New Zealand: • primary care including accident and medical centre care 45

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4545 55/17/07/17/07 12:11:2012:11:20 PMPM • secondary care in a hospital • regional burns unit care (Christchurch, Hutt Valley, Waikato and Middlemore) • National Burn Centre level care (Middlemore).

In 2002, the Ministry of Health supported the development of a National Burn Centre based at Middlemore Hospital in Auckland. This Centre will be part of an organised system of care with a network of regional burns units in Christchurch, Hutt Valley and Waikato. Middlemore will continue to act as a regional unit for the northern part of the North Island. People referred to Middlemore from regional units will return for ongoing care and rehabilitation when possible. Adults and children will be treated in the facility.

A review of trauma services and organisation completed by the American Burn Association looked at the evidence for improved personal outcomes from the centralisation of trauma services that occurred in the US through the 1980s and 1990s. It reported improvements in survival, length of stay and costs in centres with higher programme numbers (higher numbers of people treated) and higher surgeon case volumes (higher numbers of people treated by each surgeon) and where people were transferred directly to a trauma centre from the scene of injury.89 Although we found few high-quality studies of similar system change in burn care, it seems reasonable to expect a similar beneﬁ t will extend to all trauma cases.

Australia and the United Kingdom (UK) have reviewed the provision of national burns services and the evaluation and outcomes, when reported, may help inform any restructuring in New Zealand. In the interim the Guideline Development Team found no ﬁ rm evidence that could support or refute the beneﬁ ts of the New Zealand model of care.

Referral between services recommendations grade

Transfer between services is facilitated by prompt assessment, recognised communication C channels and locally developed protocols agreed between centres on whom to transfer and when to transfer.

Referrals to National Burn Centre level care should be via the regional burns units. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice point

Primary care and accident services will generally develop their own systems for referral ✓ depending on the distances involved in travel to secondary services or regional burns units. In general, those people who have less severe injuries than in the ANZBA criteria, but who still require inpatient care, should be referred to local secondary services.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements A lack of data internationally on the relative merits of different service conﬁ gurations, and the lack of applicability to New Zealand’s unique circumstances and demographics suggest that evaluation of outcomes and referral volumes between services will be needed.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4646 55/17/07/17/07 12:11:2012:11:20 PMPM Chapter 5 Management of epidermal burns or scalds

Dressings and creams good practice points 5 A protective dressing or cream product can be used for comfort in epidermal burns and scalds. ✓

Review epidermal burns or scalds after 48 hours. If the skin is broken, change to a moist ✓ wound-healing product (or alternatively double-layer parafﬁ n gauze).

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • There is no compelling evidence to demonstrate an advantage for one wound-care product over another in the management of epidermal burns and scalds.

Evidence There is very little reliable evidence on the management of epidermal burns and scalds. Three small RCTs were found on the management of epidermal burns and scalds, all of fair quality. One very small split-sample RCT90 (n=12) compared topical steroid cream (clobetasol) and placebo for treating pain and infl ammation in volunteers with superfi cial (epidermal) thermal burns. Another very small split-sample RCT (n=6)91 assessed erythemal reactions in volunteers with ultra violet (UV) induced skin damage, comparing melatonin, antioxidant creams and Aloe vera in various combinations with no treatment. A larger RCT92 (n=50) compared healing time and bacterial colonisation rates between hydrocolloid and medicated paraffi n gauze with or without silver sulphadiazine.

Findings None of these trials found any statistically signiﬁ cant difference between any of the treatments for any of the outcomes measured, except that povidone-iodine-impregnated gauze was twice as expensive as standard parafﬁ n gauze.

Guidance on dressings and creams from Guideline Development Team opinion includes the use of a protective dressing or cream product for comfort in epidermal burns and scalds, with review after 48 hours. If the skin is broken, the protective dressing or cream product should be changed to a moist wound-healing product or alternatively to double-layer parafﬁ n gauze.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4747 55/17/07/17/07 12:11:2112:11:21 PMPM 48

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4848 55/17/07/17/07 12:11:2112:11:21 PMPM Chapter 6 Management of superﬁ cial and mid dermal burns or scalds

Dressings and topical therapy Dressing products which are unlikely to be found in primary care for use with burns were speciﬁ cally excluded. The outcomes ‘time to healing’ and ‘infection’ were key questions posed to the literature by the Guideline Development Team. Wasiak and Cleland93 provided a discussion of other outcomes, such as pain and number of dressing changes. A table describing various wound products and their uses has been compiled using 6 information from manufacturers and Guideline Development Team experience in burn care (see Appendix B).

Preventing infection good practice points

Products with antimicrobial action (such as silver sulphadiazine cream) should be used on all ✓ burns for the ﬁ rst 72 hours (three days) after burn injury.

Burn wounds with signs of mild cellulitis can be treated with topical silver sulphadiazine ✓ and/or oral antibiotics.

Acute referral to secondary care is required for people with burns with signs of serious or ✓ systemic infection.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • Although there is little evidence supporting the use of silver sulphadiazine for non-infected burns, clinical experience in New Zealand populations supports the routine use of silver sulphadiazine or other antimicrobial creams for the ﬁ rst three days to prevent infection. • If infection is suspected, longer-term use of silver sulphadiazine may be indicated. • There is no evidence comparing short-term (three day) use of silver sulphadiazine cream with other wound- dressing practices.

Most burn wounds are initially sterile. Careful aseptic wound-care procedures along with the use of antimicrobial cream for the ﬁ rst three days are generally sufﬁ cient to prevent infection. The wound should be regularly monitored, as infection can delay healing, increase scarring and potentially cause systemic infection.

The signs and symptoms of infection include the following: • warmth and/or redness around the wound • increasing pain • increasing exudate, odour or pus from the wound site • increasing swelling or tenderness • fever or local wound temperature increase • lymphangitis 49 • increased irritability in a child.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 4949 55/17/07/17/07 12:11:2112:11:21 PMPM The use of silver sulphadiazine is recommended for the ﬁ rst three days following burn injury due to the high incidence of community-acquired Staphylococcus aureus sepsis (SAS) in the New Zealand population.94

If infection is suspected, expert consensus favours swabbing the wound and considering the use (or re-use) of topical silver sulphadiazine and/or oral antibiotics. It is considered appropriate to extend the use of silver sulphadiazine beyond three days if infection is suspected or present. Acute referral to secondary care is required for people with burns with signs of serious or systemic infection.

If after three days there is no infection, consider changing to a product that encourages moist wound healing.

Evidence The evidence from published literature on the prevention of burn infection is inconsistent and of limited quality. There were nine fair-quality RCTs comparing silver sulphadiazine with other dressings and topical treatments (n=18 to 104).92,95-102

Two RCTs compared silver sulphadiazine with a silicon mesh dressing,98,102 and another RCT compared silver sulphadiazine with a synthetic barrier dressing (n=18).101

One fair-quality RCT (n=50) compared three types of dressings: a medicated (chlorhexidine) parafﬁ n gauze dressing, a hydrocolloid dressing, and a hydrocolloid dressing with silver sulphadiazine cream.92 Another fair-quality RCT99 (n=30) compared a silver-coated high-density polyethylene mesh dressing with a solution containing 0.5% silver nitrate. A fair-quality RCT100 (n=121) compared 1% silver sulphadiazine with a combination of 1% silver sulphadiazine and 0.2% chlorhexidine digluconate.

Five fair-quality RCTs all conducted by the same group95-97,103,104 compared bacterial colonisation rates in partial thickness (dermal) burns treated with honey, with silver sulphadiazine-impregnated gauze (three studies), polyurethane ﬁ lm, soframycin, parafﬁ n gauze, dry gauze and exposure. These studies were unblinded and of variable size (n=50, 92, 100, 104 and 900). Bacterial colonisation rates were lower with honey in four of the studies. In one study comparing silver sulphadiazine with honey, infection rates were similar for both groups.

No controlled evidence was found on the treatment of infected burns in primary care.

Findings Although silver sulphadiazine cream is widely used for the prevention of infection of superﬁ cial and mid dermal burns,105,106 there is currently little evidence supporting its use. The evidence is inconsistent and of limited quality.

One unblinded RCT found that there was a wider variety of bacterial fl ora and a larger amount of bacterial growth with the use of a silicone mesh dressing compared with silver sulphadiazine.102 However, this study found no differences in the signs of infection or the amount of wound drainage in both groups. Another study comparing the same products also found no signifi cant difference in the number of infections.98 No signifi cant differences in infection rates were found when comparing silver sulphadiazine cream with a synthetic barrier dressing.101 One of the studies conducted by Subrahmanyam96 also found similar rates of infection between silver sulphadiazine and honey.

Six studies found a difference in rates of infection/bacterial colonisation.

One study found less wound colonisation and infection using a combination of 1% silver sulphadiazine and 0.2% chlorhexidine digluconate versus 1% silver sulphadiazine alone.100 The overall incidence of wound bacterial colonisation was signifi cantly less using a combination of 1% silver sulphadiazine and 0.2% chlorhexidine digluconate (65% vs 88%). There was also signifi cantly less wound colonisation by Staphylococcus aureus (41% vs 64%). Clinical wound infection with Staphylococcus aureus developed in one person treated with the combined cream as opposed to fi ve people treated with 1% silver sulphadiazine alone. 50

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5050 55/17/07/17/07 12:11:2112:11:21 PMPM However, this result did not reach statistical signiﬁ cance (p=0.16). Another study found that a silver-coated dressing had lower rates of burn wound sepsis (>105/g) (n=5 vs n=16) and bacteraemia (n=1 vs n=5) in the silver-coated dressing group. However, the results did not reach statistical signiﬁ cance at the 0.05 level.99

Two RCTs carried out by the same group95,97 found that bacterial colonisation rates were signifi cantly lower with the use of honey as a dressing. One study found that medicated (chlorhexidine) paraffi n gauze had the least increase in bacteria92 when compared with a hydrocolloid dressing, with or without silver sulphadiazine (p<0.01). However, this study also found that there was no signifi cant difference in the increased incidence of pathogens during treatment in all three groups.

Toxic shock syndrome Evidence statements • Deaths from toxic shock syndrome are very rare in New Zealand, but are potentially preventable. • In rare cases the rapid onset of symptoms of systemic infection with burns may be due to toxic shock 6 syndrome.

Evidence Toxic shock syndrome is a rare complication of SAS infection. Most of the evidence of toxic shock in people with burns applies to children, but the syndrome has also been reported in adults.107 Reports of toxic shock syndrome in New Zealand are very rare, though anecdotally deaths have been reported in children.

There is no deﬁ nite diagnostic test for toxic shock syndrome and its symptoms are similar to those of other infections, namely fever, rash, diarrhoea, vomiting and hypotension. The diagnosis is generally made using the US Centers for Disease Control and Prevention criteria listed below.108 Diarrhoea, vomiting and oliguria are early signs, which may occur prior to the development of shock and help establish a timely diagnosis. If people with burns undergo a sudden change, especially the rapid onset of fever and gastrointestinal upset, the possibility of toxic shock syndrome should be considered.107

Although early intervention and the administration of effective antimicrobials are essential in the management of toxic shock syndrome, probably the single most important therapeutic measure is the administration of antibodies as human immunoglobulin, fresh frozen plasma or fresh blood, producing a state of passive immunity in the recipient.109

The Centers for Disease Control have identifi ed the following fi ve clinical criteria for toxic shock syndrome:108 1. Temperature =/>38.9°C. 2. Low blood pressure (including fainting or dizziness on standing). 3. Widespread red fl at rash. 4. Shedding of skin, especially on palms and soles, one to two weeks after onset of illness. 5. Abnormalities in three or more of the following organ systems: – gastrointestinal: vomiting or diarrhoea – muscular: severe muscle pain – hepatic: decreased liver function – renal: raised urea or creatinine levels – haematologic: bruising due to low blood platelet count – central nervous system: disorientation or confusion. 6. Mucous membranes: red eyes, mouth and vagina due to increased blood fl ow to these areas.

A survey of children in burns units in the UK found no association between the management of the burn wound and the subsequent development of toxic shock syndrome.109

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5151 55/17/07/17/07 12:11:2212:11:22 PMPM Wound healing recommendations grade

Use dressings that encourage re-epithelialisation by moist wound healing. C

The prolonged use of silver sulphadiazine cream (more than seven days) should be avoided in B non-infected burns.

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice points

Following initial silver sulphadiazine cream or antimicrobial dressing, a technique that ✓ promotes moist wound healing (such as a hydrocolloid dressing) is recommended.

The convenience of a reduced number of dressing changes with hydrocolloid products should ✓ be considered where this is important to the person.

Double-layer parafﬁ n gauze can be used where hydrocolloids are unavailable. ✓

Moisturisers and non-drying, non-perfumed soap should be used to protect the skin after ✓ burn injury and may also be helpful for pruritis.

Burn wounds require extra care when exposed to sun. ✓

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • Convenience of use, reduced pain or number of dressing changes makes moist wound-healing products preferable. • There is insuffi cient evidence to recommend one moist wound-healing product over another. • Prolonged use of silver sulphadiazine cream (more than seven days) may delay healing. • There is a lack of evidence that any dressing product is superior to paraffi n gauze in reducing the overall time to healing. • Hydrocolloid products can be changed every three to fi ve days in wounds that are non-infected or have heavy exudates.

Evidence

Moist wound-healing versus non-moist healing products Expert opinion strongly favours the use of moist wound-healing products for superﬁ cial and mid dermal burns, although the evidence from RCTs is scanty and inconsistent.

Seven small fair-quality RCTs (n=50 to 98) compared moist with non-moist healing products for partial thickness (dermal) burns.92,104,110-114 None was blinded. The moist healing products included polyurethane ﬁ lm/foam and hydrocolloids and the non-moist products included parafﬁ n gauze and honey. Two of these studies compared hydrocolloids with a non-moist dressing plus silver sulphadiazine.110,114

As described below, only three of the six RCTs showed a difference in time to healing between moist and non- moist healing products.104,111,114

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5252 55/17/07/17/07 12:11:2212:11:22 PMPM One study found hydrocolloids healed wounds signiﬁ cantly faster than gauze and silver sulphadiazine.114 Three other studies reported a similar healing time for hydrocolloids and parafﬁ n gauze/tulle gras.92,110,113

Comparisons between polyurethane fi lm/foam and paraffi n gauze for burns were also inconsistent. One study reported that burns healed signifi cantly faster with polyurethane fi lm111 and one study reported no difference between these products in healing rates.112 One study found that honey healed signifi cantly faster than polyurethane fi lm.104

There is no convincing evidence from primary RCTs that any other dressing product heals wounds signifi cantly faster than paraffi n gauze (which is considered a non-moist dressing). Since paraffi n gauze tends to dry out (expert opinion), occlusive moist wound-healing products may be considered for wounds as the volume of wound exudate diminishes.

There is good evidence from a systematic review that moist dressings are superior to non-moist dressings for healing time, comfort and infection rates for burn donor sites.115 However, it is uncertain whether this evidence is applicable to the care of superﬁ cial and/or mid dermal burns in primary care. 6 Dressing changes One RCT reported that hydrocolloid required fewer dressing changes than parafﬁ n gauze,92 but another reported no difference between them.116

Silver sulphadiazine cream compared with other dressings and topical treatments Twelve RCTs were found comparing silver sulphadiazine cream with other dressings and topical treatments. These studies were rated either fair (10) or good quality (2). The largest study had 111 participants and six of the studies had more than 50 participants. Ten of the 12 studies found that silver sulphadiazine signiﬁ cantly increased time to healing. However, in all of these studies, silver sulphadiazine was applied until complete healing (re-epithelialisation). No studies were found comparing shorter-term use of silver sulphadiazine cream with other dressings or topical treatments.

Four of the 14 studies were fair-quality RCTs comparing silver sulphadiazine with other dressings. Two RCTs comparing hydrocolloid dressings versus silver sulphadiazine found that silver sulphadiazine signiﬁ cantly increased time to healing.92,114 One RCT found that silver sulphadiazine increased time to healing when compared with a silicone-coated nylon dressing.98 One RCT found no signiﬁ cant difference in time to wound healing comparing a combination of chlorhexidine-impregnated gauze dressing plus silver sulphadiazine cream with hydrocolloid dressing.110

A further seven RCTs were found comparing silver sulphadiazine with various topical treatments. Two of these studies compared silver sulphadiazine cream with a combination of hyaluronic acid and silver sulphadiazine cream.117,118 These good-quality studies both reported that time to healing was signiﬁ cantly reduced using the combined hyaluronic acid and silver sulphadiazine cream. One fair-quality RCT compared silver sulphadiazine with a combination of cerium nitrate and silver sulphadiazine.119 This study found that the time to healing was reduced by almost eight days when using a combination of cerium nitrate and silver sulphadiazine when compared with silver sulphadiazine alone. However, the results just failed to reach statistical signiﬁ cance at the 0.05 level. Another RCT (n=15) compared silver sulphadiazine cream with collagenase ointment and an antibiotic spray.120 This study also found that silver sulphadiazine increased time to healing.

Silver sulphadiazine compared with alternative therapies for time to healing Three fair-quality RCTs95,96,97 compared time to healing in partial thickness (dermal) burns treated with honey (non-manuka) versus silver sulphadiazine. In all of these studies, superﬁ cial and partial thickness (epidermal and dermal) burns treated with honey healed faster than those dressed with silver sulphadiazine. These studies were fairly small, none was blinded and all the honey studies were conducted by the same researchers.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5353 55/17/07/17/07 12:11:2212:11:22 PMPM A large unblinded RCT121 compared moist exposed burn ointment with silver sulphadiazine and found no difference in time to healing.

Healing wounds and donor sites are vulnerable to dry skin and sunburn Expert opinion favours the use of moisturisers and non-drying, non-perfumed soap to prevent the skin drying out, as this could lead to skin breakdown and secondary infection. Education on sun protection is also important. Extra care needs to be taken at times of sun exposure. Sunscreen and/or protective clothing should be worn if working or playing outside.122

Pruritis can also be a problem following burn injury. Persistent pruritis occurs after about 15% of burn injuries, with a further 44% of people reporting occasional pruritis. A systematic review of relevant studies found that a variety of interventions were reported to be beneﬁ cial, including medications, massage and transcutaneous electrical nerve stimulation, but none of the studies provided high-quality evidence on which treatment recommendations could be based.123 The clinical experience of the Guideline Development Team suggests that moisturisers are beneﬁ cial.

When to review good practice point

Superﬁ cial and mid dermal burns should be reviewed daily for the ﬁ rst three days, then ✓ subsequently every three days.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

In the absence of randomised data to answer the question ‘how often should a burn be reviewed?’, the Guideline Development Team discussed three aspects it considered relevant: • the expected speed of healing for burns of differing depths • the safety/risk of continued primary care management • the expected time-lag between the identiﬁ cation of a problem, referral and a deﬁ nitive specialist opinion.

A good practice point based on the experience of the Guideline Development Team was considered appropriate.

Management of blisters good practice points

Preferably leave small blisters intact unless likely to burst or interfere with joint movement. ✓

If necessary, drain ﬂ uid by snipping a hole in the blister. ✓

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • There is little evidence to guide the management of blisters. • The bed of a deroofed blister can be more painful than an intact blister.

Burn blisters occur primarily in superﬁ cial dermal and mid dermal burns, but also may overlay deep dermal burns. They are a result of inﬂ ammatory changes that occur early in burn injury, whereby increased capillary permeability allows oedema formation between the epidermis and dermis.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5454 55/17/07/17/07 12:11:2312:11:23 PMPM Evidence One controlled trial of 202 people with partial thickness (dermal) burns124 was identiﬁ ed of relevance. In this study, randomisation was unclear. There were two treatment groups: aspirated and deroofed blisters. The intact blister group was left for 10 days before burn blister ﬂ uid was aspirated for analysis. The study assessed infection rates and pain scores.

An RCT of second-degree (dermal) burns in pigs125 was also found. In this study, 42 burns in two pigs (randomised to debridement or no debridement) were assessed for infection and re-epithelialisation rates.

Findings In the Swain study,124 the incidence of infection (bacterial colonisation) in the intact blister group was 14% compared with 76% in the deroofed blister group (p<0.05). Aspiration of fl uid (in the intact blister group at 10 days) reduced pain in 34% of participants compared with 0% in the deroofed group. Deroofi ng worsened pain in 43% compared with 19% in the aspiration group. In the Singer trial, infection rates were higher in deroofed burns (p<0.001).125 6 There is a paucity of evidence to answer the question of whether deroofi ng is associated with less pain or faster healing compared with leaving blisters intact. A recently published review126 concluded that it may be worthwhile to consider healing rates associated with different dressing applications because they are an indirect measure of healing in intentionally deroofed versus intact blister management in a partial thickness (dermal) burn. On balance, until there is more evidence, small blisters should be left intact to reduce the risk of infection, but if anatomical position necessitates intervention for functional purposes, aspiration appears to result in less pain than deroofi ng.

Scarring recommendation grade

Any burns that are unlikely to heal within 21 days without grafting should be referred to a C burns unit for scar management by day 10–14.

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice point

A person presenting with scarring some months after a burn should still be referred for ✓ specialist opinion.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • Silicone sheeting may be of benefi t in reducing scarring, although the evidence is of poor quality. • Pressure garments may also be of benefi t, but the evidence is inconclusive. • Burns that do not heal within 21 days are likely to cause scarring, which can result in signifi cant morbidity for the person.

Healing process Scarring can result in long-term functional disability and changes in appearance, both of which are an indication for specialised care.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5555 55/17/07/17/07 12:11:2312:11:23 PMPM The normal process of wound healing by secondary intention involves the processes of epithelialisation and wound contraction. Epithelial cells require a matrix to migrate across. In a superﬁ cial wound the dermis is well intact, there are numerous epithelial cells and melanocytes within the dermis, epithelialisation is rapid and wound contraction is not a feature. Hence, there is minimal scarring or alteration in appearance.

In a deeper burn there is less dermis and epithelialisation is prolonged, allowing the formation of granulation tissue. This granulation tissue contains large numbers of ﬁ broblasts and myoﬁ broblasts127 that are believed to produce wound contraction and scarring. Also, the melanocytes which are deep in the dermis may have been injured and/or destroyed, leading to altered pigmentation. Early debridement and skin grafting interrupt this process of granulation formation and so reduce the risk of contraction, which can still occur with grafting, but usually to a lesser extent.

In a healed wound the processes of collagen deposition and angiogenesis have led to the laying down of collagen fi bres in a haphazard arrangement with a large infl ux of blood vessels. Over subsequent months the wound goes through maturation where the metalloproteinases remodel the wound so that it softens and becomes less red. However, if there are continuing adverse factors such as infl ammation, infection or tension, the process of scar maturation is hindered or prevented.

When the process of scar maturation is hindered, there is an increased risk of hypertrophic scarring. Hypertrophic scars are thick, raised areas, usually darker than the surrounding skin, which remain within the conﬁ nes of the original wound and tend to regress over time.128

Another form of scarring that occurs less frequently is keloid scarring, in which the scar grows beyond the borders of the original wound and does not regress spontaneously. Keloid scarring tends to occur in genetically predisposed individuals and is more common in people of Asian descent and people with darker skin.129

Predictors of scarring Risk factors for scarring identiﬁ ed in the literature include burn severity and non-white skin. It is unclear whether the risk is higher in children.123 Burn wounds that fail to heal within two to three weeks are at high risk of scarring.130

Evidence on interventions for scarring One RCT was identifi ed comparing massage together with pressure treatment with pressure treatment alone as treatments for hypertrophic scars in children.131 One Cochrane systematic review132 and one evidence- based report133 were identifi ed on silicone gel sheeting for both the prevention and treatment of hypertrophic and keloid scars. One Cochrane protocol,134 three non-systematic reviews130,135,136 and three RCTs137-139 were identifi ed. One of these RCTs compared pressure garments with no treatment, one RCT compared different types of pressure garments and the other compared different levels of compression on scar erythema and thickness.139

No controlled trial evidence was found on other interventions such as intralesional steroid injections or laser treatment.

Findings on interventions for scarring There was little evidence on interventions for scarring on which to base recommendations.

Massage No evidence was found that massage is helpful in either the prevention or treatment of scars.

Silicon gel sheeting The Cochrane review (including 13 RCTs) evaluating the effects of silicon gel sheeting for the prevention or treatment of scars reported that silicon gel sheeting signiﬁ cantly reduced the incidence of hypertrophic scarring 56

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5656 55/17/07/17/07 12:11:2412:11:24 PMPM in people prone to scarring (RR 0.46, 95% CI 0.21 to 0.98). A signifi cant improvement in scar elasticity (RR 8.6, 95% CI 2.55 to 29.02) was also reported. However, as the studies were highly susceptible to bias, the authors concluded the evidence of benefi t was weak. Similarly, the ACC evidence report concluded that the effectiveness of silicone gel sheeting in scar management could not be confi rmed.

Pressure garments The evidence for pressure garments was also inconclusive. Pressure garments have been commonly used for more than three decades, but the optimal pressure and duration has not been confi rmed by controlled trials. Pressure garments are usually used in a hospital setting or outpatient clinics.135 They are also associated with signifi cant adverse events, such as overheating, pruritis, wound breakdown and abnormal bone growth.136,140 However, the comparative trial comparing two different levels of pressure (initial pressure of 20mm Hg vs 12mm Hg) reported that there was a signifi cant difference in the thickness of the scar at one month with the higher pressure than with the lower pressure. No differences were found for erythema. A clear association was shown between the persistence of erythema and hypertrophic scar formation. A multicentre comparative trial is currently underway to clarify the role of pressure garments on scar management.139 6

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5858 55/17/07/17/07 12:11:2412:11:24 PMPM Chapter 7 Management of chemical injury

General treatment advice First aid recommendations grade

Irrigation of chemical burns should continue for one hour. C

All chemical burns should be referred to a burns unit. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice point 7

Acid burns should not be neutralised with an alkali in primary care. ✓

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • There is an increased risk of systemic complications following chemical burns.

Evidence Four retrospective observational studies were considered relevant.141-144 No controlled studies or systematic reviews were found. Six non-systematic reviews were also included to ascertain the consensus of expert opinion.145-150 Three other retrospective observational studies were selected for their review of the relevant literature.151-153

An 11-year retrospective case series (n=51) compared those people who had immediate irrigation (group A) with those who had delayed irrigation (group B). The size of burn was similar in the two groups (19.7% TBSA in group A vs 17.2% TBSA in group B). In group A, 19% required skin grafting compared with 36% in group B. Mortality was 9.5% (group A) compared with 21% (group B). Length of stay in hospital was 7.2 days (group A) compared with 16.2 days (group B).142

In a four-year retrospective case series (n=35), people who received immediate irrigation to their chemical burn had signiﬁ cantly less incidence of full thickness injury and spent half as long in hospital.143

An eight-year retrospective case series (n=24) found that all people with delayed presentation (n=5) had deep burns that required excision and grafting. All burns in this series were irrigated for 45 minutes to an hour at the burns unit.144

However, a fourth retrospective case series (n=173) found no signiﬁ cant statistical difference in the number of deep burns between those who had immediate irrigation of their wounds and those without immediate irrigation (37.5 vs 46% respectively). Mean hospital stay was 5.8 and 4.8 days respectively (not statistically signiﬁ cant).141

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 5959 55/17/07/17/07 12:11:2412:11:24 PMPM Several non-systematic reviews were considered, all with consistent opinions regarding chemical burns to the skin. They made the following recommendations: 1. Immediate removal of clothing and copious irrigation with water for a period of at least one hour.33,141,142,144-152 2. No attempt should be made to neutralise an acid burn with an alkali as this may delay irrigation and cause more injury due to heat produced by an exothermic reaction.144,147-149,152 3. There is a risk of systemic complications following chemical burns with hydroﬂ uoric acid, formic acid, phenol, white phosphorus, nitrites and hydrocarbons.33,142,144-148,150-152 4. Chemical burns meet the criteria for referral to a specialised burns unit.33,151

Eye injury recommendations grade

All signiﬁ cant chemical injuries to the eye should be referred acutely to ophthalmology C services.

Treat all chemical burns to the eye with copious irrigation of water. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

Chemical burns to the eyes are associated with residual visual impairment. Physical signs include blepharospasm, tearing, conjunctivitis and uncontrolled forceful rubbing of the eye. Rapid swelling of the corneal epithelium occurs and clouding of the anterior layers of stroma. Cells may be seen ﬂ oating within the anterior chamber.

Specialist assessment is required for early signs of corneal ulceration or perforation, and the possible late complications of cataract, secondary glaucoma, iridocyclitis and symblepharon.33

Speciﬁ c substances Hydroﬂ uoric acid good practice point

Anyone exposed to hydrofl uoric acid should be promptly referred to a burns unit for defi nitive ✓ treatment after appropriate fi rst aid.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • Hydrofl uoric acid exposure of <2% TBSA can be fatal.33 • Calcium gluconate gel, infi ltration or intra-arterial and/or intravenous therapy corrects the hypocalcaemia of hydrofl uoric acid burns and reduces pain.

Hydroﬂ uoric acid is a very strong acid. It is used widely, mainly in industrial settings, but it is also found domestically in rust removers and aluminium cleaners.154-161

Features of hydrofl uoric acid exposure include severe cutaneous burns, as well as possible systemic and lethal toxicity. Hydrofl uoric acid penetrates the skin easily and enters the deeper tissues where it releases the fl uoride ion. This ion readily binds with calcium and magnesium and it is this property that makes hydrofl uoric acid especially dangerous.157,160 Even minor exposure to dilute solutions can cause problems in the deeper tissues, and symptoms and injury may be delayed.154,156,157

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 6060 55/17/07/17/07 12:11:2512:11:25 PMPM The systemic effects of hydrofl uoric acid exposure are due to the fl uoride ion binding with serum calcium causing hypocalcaemia which can result in cardiac arrhythmias.154-157,160 Exposure to even small amounts of hydrofl uoric acid can result in death, usually due to ventricular arrhythmias.154,156,157,160,162-164

Evidence Eleven observational studies or case reports154-156,159,161-163,165-168 and four non-systematic reviews157,158,160,164 were reviewed for the guideline. No controlled human studies were located.

A prospective study of 10 people with hydroﬂ uoric acid dermal burns of digits found rapid pain relief with intra-arterial administration of 10% calcium gluconate. All had full functional recovery of their digits with good cosmetic appearance.159

In a 10-year case series of treatments for hydroﬂ uoric acid burns at one facility, 28 of 85 people were treated with local inﬁ ltration of 10% calcium gluconate. Only one person (4%) had progression of their injury compared with 14–70% in the other treatment groups. All people treated with calcium gluconate experienced pain relief following the injections.161

Another retrospective case series of the authors’ institutional experience found 42 people with hydrofl uoric acid burns for the period 1977–1999. There were 11 recorded cases of hypocalcaemia, which were treated successfully with oral and intravenous calcium supplementation. There were no deaths.165 7 In a report of seven cases with hydrofl uoric acid burns to their hands and/or fi ngers, the authors reported good pain relief after treatment with calcium gluconate. Calcium gluconate jelly (4%) was applied in fi ve cases and four had subcutaneous injections with 8.5% calcium gluconate.166

A case report of one person described the use of calcium gluconate gel topically, cutaneous and subcutaneous injections of 10% calcium gluconate, magnesium chloride and 2% xilocain, and the intravenous use of calcium gluconate which successfully corrects the hypocalcaemia.155

Another case report of one person exposed to a household rust remover described treatment with calcium gluconate gel and intra-arterial calcium gluconate infusion with good outcome.167

In another report, two cases of skin injury and inhalational exposure to hydroﬂ uoric acid were described which were successfully treated with application of 2.5% calcium gluconate jelly and 5% calcium gluconate nebulised solution.168

In a report of three cases of hydroﬂ uoric acid skin injuries (TBSA 5–25%), two people died as a result of cardiac arrest.163 Another reported a case of 15.5% TBSA hydroﬂ uoric acid burn where the person died.154

The last case report was of a man with 44% TBSA burn from hydrofl uoric acid who developed recurrent ventricular tachyarrhythmias and subsequently recovered. The authors cite several fatal cases of ventricular fi brillation reported in other studies following 2.5–22% full thickness TBSA burns due to exposure to more than 50% hydrofl uoric acid.156

The four non-systematic reviews all have consistent fi ndings. In a comprehensive literature review of hydrofl uoric acid burns,157 the authors described several reported cases of death from skin exposure of 2.5–10% TBSA. This is supported by the other reviews.158,160,164 • They all emphasise the importance of immediate, copious and prolonged lavage of the affected area with water.154,157-160,163 • For dermal exposure to hydrofl uoric acid, the liberal and frequent application of 2.5% calcium gluconate gel is recommended by all authors. • If pain relief is incomplete or symptoms recur, subcutaneous injections of calcium gluconate are indicated. Both these treatments have been shown to relieve pain.154,157,160,161,163 • Good results have been demonstrated with intra-arterial administration of calcium gluconate. • Calcium gluconate is also administered intravenously to correct the hypocalcaemia due to hydrofl uoric acid 61 exposure.154,157,160,161,163

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 6161 55/17/07/17/07 12:11:2512:11:25 PMPM Phosphorus good practice point

Anyone exposed to phosphorus should be promptly referred to a burns unit for deﬁ nitive ✓ treatment after appropriate ﬁ rst aid.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

White phosphorus is commonly used as an incendiary in the manufacture of ammunition and is also used for the manufacture of certain fertilizers, ﬁ reworks and distress ﬂ ares. It readily ignites in the presence of air.

Evidence statements • The person should be transported with the affected area either submerged in water or saline or covered with water- or saline-soaked dressings.

Evidence Four retrospective observational studies,142,151,152,169 two single case reports170,171 and three non-systematic reviews146,147,172 were reviewed. All selected articles had a consensus of opinion: 1. The initial treatment consists of prompt removal of clothing and immediate copious irrigation with water. 2. The person should be transported with the affected area either submerged in water or saline or covered with water- or saline-soaked dressings to prevent the re-ignition of the retained particles of phosphorus.

Absorption of phosphorus can cause systemic complications including hypocalcaemia, hyperphosphataemia, cardiac arrhythmias, renal and hepatic toxicity, and sudden death.146,151,152,169

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 6262 55/17/07/17/07 12:11:2512:11:25 PMPM Chapter 8 Management of electrical injury

recommendation grade

All electrical injuries should be referred to a burns unit. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

Evidence statements • High-voltage electrical current damages deep tissues (muscle and nerves). This damage is sometimes not apparent at the initial inspection. • Cardiac abnormalities can occur following electrical injury. These are frequently transient.

Electrical injuries can be divided into three groups: low-voltage (<1000V), high-voltage (>1000V) and lightning strike.

Low-voltage electrical injuries can cause signifi cant local contact burns and may cause arrhythmias or cardiac arrest. They can cause tetany or muscle spasm that will prevent the person releasing the source of current and may cause fractures.173-175 8 High-voltage electrical injuries result in severe skin burns and may cause respiratory and cardiac arrest.175 High- voltage electrical current can lead to necrosis of muscle, bone and nervous tissue because of the development of intense heat in bone, which is a poor conductor.176,177 Sometimes there are only localised skin injuries at the entrance and exit sites, and a small skin burn or normal-looking skin can hide deep, massive tissue damage to bone, muscles and nerves. There can be extensive arcing, fl ash and fl ame burns as well.178 People who suffer a high-voltage injury are at increased risk of complications including compartment syndrome, cardiac damage and neurological and ophthalmologic problems. Amputation rates above 50% have been reported.145

In lightning strike, a direct strike is usually lethal. In many cases, the majority of the current can pass over the surface of the body (called ‘ﬂ ashover’). Respiratory and cardiac arrest are common.179 Up to 74% of survivors have signiﬁ cant permanent sequelae.173,180-184

Cardiac abnormalities Evidence Ten observational studies178,185-193 were found to be relevant. No controlled human studies were located.

In a prospective case series of admissions with high-voltage injury (n=15) to a burns unit over a year, 27% had an abnormal ECG on admission, of which all reverted to normal over time. No arrhythmias developed during their hospital stay. None had any clinical evidence of cardiac dysfunction.187

A four-year retrospective case series reported ﬁ ve people with high-voltage electrical injury.191 Two people had ECG abnormalities acutely (one atrial ﬁ brillation and one second-degree atrioventricular heart block). These resolved by the third day post-injury. At both follow-up periods (two and six months), all ECGs were normal and no clinical signs of cardiac damage were found. However, on thallium scintigraphy, there was evidence of myocardial hypoperfusion in all cases.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 6363 55/17/07/17/07 12:11:2612:11:26 PMPM Another case series study found that 9 out of 10 consecutive people with high-voltage electrical injury had one or more signiﬁ cant cardiac rhythm and/or functional abnormalities during their stay in hospital. At follow-up (4–48 months after discharge) ﬁ ve people showed signs or symptoms of cardiac dysfunction.185

In a retrospective case series of 48 consecutive people with high-voltage injury, eight (16%) had some cardiac event, four (8.3%) had a cardiac arrest at the place of injury, two (4.2%) had a myocardial infarction and two (4.2%) had a cardiac arrhythmia.190

Another observational study found that 13 out of 24 (54%) people being treated for a high-voltage injury had evidence of myocardial injury.189

A 10-year retrospective case series reported cardiac complications (either arrhythmias or ischaemia or myocardial infarction) in 10–46% of those with a high-voltage injury (n=36).188

Another retrospective case series of children (n=185) admitted to a burns unit over a 10-year period found 33% of high-voltage burns (n=58) required amputation and 29% had deep muscle involvement, and 7% had a cardiac arrest.178

One retrospective case series of all admissions (n=179) to a burns unit over ﬁ ve years found a high incidence of compartment syndrome (54%) and amputation (42%) in those with a high-voltage injury (n=55).186

Another observational case series study of all admissions with electrical burns (n=173) found a signiﬁ cant difference between the incidence of amputations between high- and low-voltage injuries (36.6% and 17.9% respectively; p<0.01). ECG changes were seen in 7% of the low-voltage group (n=132) and 12% of the high- voltage group (n=41).192

This is supported by a retrospective case series (n=195) of high-voltage electrical injury admissions over a 19- year period. The authors found 56 (29%) people underwent fasciotomy within 24 hours of injury and 80 (41%) people underwent amputation.193

ECG monitoring recommendations grade

Following electrical injuries people should receive a resting 12-lead ECG. C

If this initial ECG is normal in people with low-voltage injuries, there is no need for a repeat B ECG or for continuous monitoring.

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

Evidence statements • Electrical injury can trigger cardiac arrhythmias. • The incidence of ECG abnormality or arrhythmia developing after a normal initial 12-lead ECG in people with low-voltage electrical injuries is very low.

Evidence Ten observational studies were identiﬁ ed as relevant, all with consistent results.194-203 Five studies were of children with mainly low-voltage electrical injuries194,195,200-202 and one was of children with mixed voltage electrical injuries.197 Two studies were of all admissions (adults and children) with low-voltage injuries196,199 and the other two were of all admissions with mixed-voltage injuries.198,203

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 6464 55/17/07/17/07 12:11:2612:11:26 PMPM A three-year prospective observational study (n=212) found that asymptomatic people with a normal ECG on presentation after low-voltage injury do not need ECG monitoring.196 In 196 presentations there were eight episodes with ECG abnormalities that required cardiac monitoring. There were no re-presentations with cardiac arrhythmias after discharge in a four-year follow-up period.

A 10-year retrospective case series (n=38) of all admissions of children with mixed high- and low-voltage injuries found that none of the children had or developed cardiac abnormalities.197 ECGs were recorded on admission in all cases and all children were monitored for 24 hours or more. The only abnormalities were non- speciﬁ c temporary ST segment changes in the ECGs of three children.

Six other retrospective case series reviews of electrical injuries were found, four of children and two of adults. One of children (n=44) found no arrhythmias developed over a 5- to 24-hour hour period if the person was asymptomatic and had a normal ECG at presentation.201 Of the 40 low-voltage injuries, only one had an abnormal ECG, which eventually resolved.

Another (n=151) found no adverse outcomes in those children with normal ECGs. Only one had an abnormal ECG at presentation. One hundred and thirteen people (80%) had cardiac monitoring with no arrhythmias noted. No late arrhythmias developed in the 112 children who were seen for follow-up.195

One other study in children (n=35) found an abnormal ECG in one of the 17 children in the low-voltage group in which an ECG was obtained. The abnormality resolved within 24 hours. No serious arrhythmias were detected in any child with a normal ECG on admission.202

Another study of 70 children with low-voltage electrical injuries found 2 out of 53 ECGs performed showed what were considered benign arrhythmias. The authors concluded that cardiac monitoring is not required in people 8 who remain asymptomatic for four hours.200

Another study (n=20) of children and adults found no need to monitor if the initial ECG was normal and the person was asymptomatic on presentation. One person had an arrhythmia that resolved after treatment and did not recur during the next 24 hours.199

In the other study of children and adults (n=70), 11 developed an arrhythmia at the time of injury. Six died in the emergency department and the rest were discharged without cardiac complications. One person had a persistent right bundle branch block on discharge.198

One retrospective study (n=224) evaluated practice guidelines for the cardiac monitoring of children who sustain an electrical injury. A total of 164 ECGs were done and 15 were abnormal. Eight of these were determined not to be caused by the electrical injury. Twenty-nine people had cardiac monitoring, of which all were normal except one with benign extrasystoles. One hundred and seventy-two people were seen for follow- up and none had any untoward events. According to coroners’ records, none of the 224 people in this study died due to this complication post-discharge from hospital.194

In another retrospective case series (n=145) four people had cardiac abnormalities (three had occasional ectopic beats and the other developed atrial ﬁ brillation after a high-voltage injury). All had these abnormalities at the time of admission.203

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 6666 55/17/07/17/07 12:11:2712:11:27 PMPM Chapter 9 Pain management

Burn pain management recommendations grade

Immediately after the injury, cooling and covering the burn may provide analgesia. C

Paracetamol and NSAIDs can be used to manage background pain. C

Consider administering opioids for intermittent and procedural pain. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice points

Refer to secondary care if failing to manage dressing-change pain. ✓

Consider the use of non-pharmacological approaches as a supplement to pharmacological ✓ management of pain. This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available. 9 Evidence statements • Burn pain can be more complex than typical post-operative pain as it includes background, intermittent and procedural pain (due to dressing changes and other interventions). • It is important to conduct a thorough pain assessment to determine whether background, intermittent or procedural pain is the greatest problem for the individual. • The pain experienced following burns varies greatly from one individual to another. • The worst pain score should be less than 5 on a scale of 0–10. Scores of 5 or higher interfere with sleep, activity and mood.

Burn injuries can cause intense and prolonged pain, made worse by the need to change dressings frequently to prevent infection and aid healing. Pain associated with burn injury and treatment is often managed poorly; reasons for this include failure to use and document pain scores from pain-measurement tools, unfamiliarity with suitable analgesic regimes, and concerns about opioid side effects.204,205

Immediately after the burn injury, simple measures such as cooling and covering the burn can reduce pain.206 The treatment of severe pain beyond simple measures should include titration in intravenous opioids.

Burn pain is often more complex than typical post-operative pain.204 It can be divided into: • background pain (associated with the injury) • intermittent or breakthrough pain (intense pain episodes not relieved by routinely administered analgesics) • procedural pain (pain related to dressing changes and other interventions).

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 6767 55/17/07/17/07 12:11:2712:11:27 PMPM The aim of zero background pain in burn injuries is achievable and realistic. However, procedural burn pain as a result of dressing changes is difﬁ cult to assess and manage and there is little consensus on how best to determine or control this pain.

Evidence Two guidelines were identifi ed that dealt with pain management, but not specifi cally burns.207,208 A number of RCTs were identifi ed.37,205,209-225 Most were very small and many were conducted among volunteers using experimentally induced burns.209,215,218-220,222,225 Overall their fi ndings were of limited applicability to primary care. Two studies assessed the effect on pain response of different types of burn ointment compared with placebo205,221 and one evaluated local cooling.37 Three studies addressed the role of opioids in children,210,223,225 fi ve assessed distraction techniques such as massage,213,214 music therapy211,212 and sensory focusing217 and two compared ibuprofen with placebo.209,224 A further six assessed the role of other medications such as remifentanil and gabapentin,215 riluzole,216 lidocaine,218 dextromethorphan219 and ketamine.220,222

Findings There was no consistent ﬁ nding from the identiﬁ ed RCTs, which were performed in varying settings, with varying severity of burns and in varying groups of people. Most of the recommendations for management of pain are based on best practice in burns units.

Pain management should be integrated into the person’s overall care plan. This plan should provide both pharmacological and non-pharmacological approaches. It has been suggested that background pain and pain resulting from procedures, such as dressing changes and physiotherapy, need to be evaluated and treated separately.226 It is important to conduct a thorough pain assessment to determine which type of pain is the greatest problem. The pain experienced by people with burns varies greatly from person to person.227 For this reason, treatment protocols stipulate low starting doses of analgesia and allow for adjustments to be made based on individual pain assessment. Pain measurement scales should be used to assess the degree of pain. A person’s worst pain score should be less than 5 (on a visual analogue scale of 0–10). Scores of 5 or higher interfere with sleep, activity and mood.228 Therefore, the goal at minimum should be to reduce pain to lower than this level.

Analgesics should be given regularly to control background pain. Paracetamol and NSAIDS (eg, ibuprofen), alone or in combination with opioids, are often appropriate for use in people with small burn wounds.204 Aspirin products should be avoided because of platelet inhibition and the risk of bleeding.7

People with burns may require treatment of procedural pain before dressing changes and during increased physical activity to facilitate cooperation during dressing change and physiotherapy, as well as minimise the risk of developing chronic pain.

Use of opioids Opioid medications are used in children as well as adults for moderate to severe burn pain. Opioids are useful because they are available in a variety of dose forms that can support a person’s individualised needs. Long- acting opioids can be used for background pain and short-acting opioids can be used for painful procedures such as changing dressings. Opioids may be supplemented with anxiolytics to reduce anxiety, if necessary. There is little evidence to guide the choice of opioid medication. Morphine sulphate is the opioid analgesic standard. The pharmacokinetic properties are largely unchanged in burn-injured patients. Pethidine should be avoided because of side effects associated with the metabolite norpethidine, including dysphoria, agitation and seizures.204 During dressing changes, conscious sedation with an immediate-acting opioid such as fentanyl may minimise the risk of over-sedation. Other techniques for managing pain and anxiety in children during procedures include using inhaled nitrous oxide, ketamine either enterally or parenterally, or anxiolysis with a

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 6868 55/17/07/17/07 12:11:2712:11:27 PMPM benzodiazepine such as midazolam.229 Deep-sedation techniques as provided by an anaesthetist may include dexmedetomidine or propofol infusion up to general anaesthesia.

Non-pharmacological interventions Non-pharmacological interventions are recommended to supplement, not replace, pharmacological management of pain. These interventions include cognitive behavioural therapy (CBT) (eg, relaxation, imagery), hypnosis and physical therapies such as massage. They can provide people with a sense of control during rehabilitation from their injuries.

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7070 55/17/07/17/07 12:11:2812:11:28 PMPM Chapter 10 Psychological consequences of burn injury

Adverse psychological responses to trauma recommendations grade

Monitor people with burn injuries for signs of stress disorders or depression. C

Recognise and treat pre-existing disorders and comorbidities (including alcohol and drug B dependence) associated with post-traumatic stress disorder (PTSD).

Refer people with acute or chronic PTSD for specialist mental health management. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice points

Be aware of services that may be able to support families affected by the psychological ✓ impacts of burn injuries.

Be aware of the increased risk of sleep disorders after burn injuries. ✓

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Burn injuries constitute signiﬁ cant trauma and can cause or exacerbate psychological problems such as acute or persistent stress disorders and depression. Psychological trauma may be compounded by injury-related 10 phenomena such as pain, physical disability and disﬁ gurement. The psychological consequences of burns to a child are likely to involve other family members as well.

Psychological reactions to trauma are categorised by the timeframe since the event (see Table 10.1).

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7171 55/17/07/17/07 12:11:2812:11:28 PMPM table 10.1: diagnosis according to duration of stress symptoms

duration of symptoms diagnosis comments

Less than one month Acute stress disorder These are symptoms that occur in the immediate (not PTSD) aftermath of the stressor and may be transient and self-limited. Although not yet diagnosable as PTSD, the presence of severe symptoms during this period is a risk factor for developing PTSD.

One to three months Acute PTSD Active treatment during this acute phase of PTSD may help to reduce the otherwise high risk of developing chronic PTSD.

Three months or longer Chronic PTSD Long-term symptoms may need longer and more aggressive treatment and are likely to be associated with a higher incidence of comorbid disorders.

Reproduced from: Foa EB, Davidson JRT, Frances A. The expert consensus guideline series: Treatment of posttraumatic stress disorder. J Clin Psychiatry 1999;60 (Suppl 16).

Acute stress disorder Evidence statements • The onset of acute stress disorder in the ﬁ rst month after a burn injury increases the risk of subsequent PTSD.

A diagnosis of acute stress disorder can be made as early as three days following trauma. American Psychiatric Association diagnostic criteria230 require the presence of at least three of the following dissociative symptoms: • depersonalisation • derealisation • time distortion and/or daze • numbing and amnesia.

In addition one or more symptoms must be present from each of the three PTSD clusters, namely re-experience of the traumatic event, avoidance and hyperarousal (see Appendix C).

The prevalence of acute stress disorder after burns is unclear, partly due to variability in the assessment tools and diagnostic criteria used. A systematic review of relevant studies reported a range of 11–32% in adults.123 All the studies were small with a high potential for bias. Another small study, involving 63 children aged one to four years hospitalised with burn injuries, and their parents, reported symptoms of acute stress in nearly 30% (15/52) of the children analysed.231 The authors identiﬁ ed a pathway whereby pain in the child was strongly associated with acute parental stress, and parental stress led to acute stress in the child.

Predictors of acute stress disorder found in the literature included burn size, poor pre-burn mental health and attribution of blame for the injury to a third party.123

People with acute stress disorder are at high risk of subsequent PTSD. In one study of 83 adults hospitalised with burns,232 19% (16/83) were diagnosed with acute stress disorder and all but one subsequently developed PTSD.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7272 55/17/07/17/07 12:11:2812:11:28 PMPM POST-TRAUMATIC STRESS DISORDER Evidence statements • There is evidence of an increased risk of PTSD after burns. • There is some evidence that the incidence of PTSD is related to the size and location of the burn. • CBT and selective serotonin reuptake inhibitors (SSRIs) have been shown to relieve the symptoms of PTSD resulting from non-burn events.

A diagnosis of PTSD is made when a person: has experienced a traumatic event with actual or perceived threat of serious injury or death to self or others; has reacted with intense fear, helplessness or horror; and meets symptom criteria in three primary clusters (re-experience of traumatic event, avoidance or numbing, hyperarousal) over a period of more than one month.

The DSM-IV. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)230 criteria (see Appendix C) for PTSD are used to diagnose PTSD. The diagnosis requires a combination of symptoms including at least one re-experiencing symptom, three symptoms of avoidance and emotional numbing, and two hyperarousal symptoms.

Evidence on the prevalence of PTSD is inconsistent. Some studies include only inpatients while others include outpatients. Most have relatively small sample sizes and some exclude personal psychiatric history. Moreover, a variety of assessment methods have been used.

Three studies which used validated assessment methods found prevalence rates of 20–45% at a follow- up period of 6–12 months in adults admitted to hospital after burns. These studies were small with a high likelihood of bias.123

Evidence Evidence on predictors for PTSD is also inconsistent. The only study in the systematic review123 without a high likelihood of bias233 found a signifi cant association between chronic PTSD and a history of PTSD symptoms, female sex, size and location of burn. This study did not assess pre-burn mental health or pre-burn history of substance abuse, both of which were identifi ed in other studies as signifi cant predictors of PTSD. 10 There is very little research relating to the treatment of PTSD in people with burn injuries. One RCT234 allocated participants to an individual and/or couple psychological debriefi ng intervention group or a control group that received no intervention. Of the 110 participants who were assessed, 26% in the intervention group had PTSD at 13 months follow-up compared with only 9% in the control group. These fi ndings are consistent with other studies showing that single-session debriefi ng may be actively harmful.123

Esselman et al123 found no convincing evidence of interventions to reduce the risk of developing PTSD in people with burns. However, there has been very little research in this area and effective pharmaceutical and psychological treatments have been reported in the general trauma literature. CBT has been shown to be beneﬁ cial,235 in particular, exposure therapy236 and stress inoculation training.237 SSRIs are also effective and are recommended as ﬁ rst-line agents in the pharmacotherapy of PTSD.238 Treatment techniques need to be researched and validated with people with burns.

Depression Evidence statement • There is some evidence of an increased risk of depression after burns.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7373 55/17/07/17/07 12:11:2912:11:29 PMPM Evidence People with burns are also at risk of depression. The relevant evidence is scanty, consisting of six small studies with a very high likelihood of bias.123

Estimates of the prevalence of depression in people with burns vary greatly, reﬂ ecting disparity in the assessment tools and diagnostic criteria used, the timing of assessment and the populations sampled. Rates of 16–53% are reported at various follow-up points from 3 days to 32 years, with no consistent trend over time.123

Predictors of post-burn depression in the literature include pre-burn mood disorders, burn severity and location and style of problem-solving.123

No therapeutic studies for depression in burn survivors were found. However, the general literature supports the use of SSRIs for depression.239

Sleep disorders Evidence statement • There is a high risk of sleep disorders after burn injury, which is compounded by pain and by stress disorders.

Evidence The Esselman et al systematic review123 reviewed 16 studies of secondary sleep disorders, including 11 studies of sleep disorders secondary to burn injuries. All these studies had a relatively high risk of bias. Secondary sleep disorders include insomnia, hypersomnia, nightmares, night terrors and sleepwalking.230

Difede et al232 reported that in their study of 83 adults hospitalised with burns, the most common symptom of stress, reported by 76% of participants with or without acute stress disorder (ASD), was difﬁ culty falling asleep and staying asleep. A small paediatric inpatient study (n = 25) also found a high prevalence of sleep disorders, such as nightmares (88% of participants), problems with sleep onset (68%) and problems with sleep maintenance (88%).240 Similarly, such symptoms were reported in 73% of 74 participants a week after discharge from hospital.241

During the ﬁ rst six months after burns or other trauma, the incidence of insomnia reported in the literature ranged from 37% to 51% and at one year was 22–37%. Although insomnia thus tended to improve over the ﬁ rst year, nightmares were reported in up 30% of participants at both six months and one year post-burn.123

Esselmann et al123 reported that both early and late post-burn studies indicated the intertwining of sleep disorders and symptoms of ASD, PTSD and depression. Pain is another factor that may compound sleep disorders.241,242

There is no reliable evidence on pharmacological or behavioural treatments for sleep disorders after burns. CBT has been found effective for treating sleep disorders in medical patients.123

Post-traumatic stress disorder and parents of children with burns Evidence statements • There is evidence of an increased risk of acute stress or PTSD for the parents of children with burns, especially large or painful burns. • How well a child copes with a burn injury will depend on how well the family is coping with the trauma. • Resources are available for people who have experienced burn trauma and for their families (see Appendix D).

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7474 55/17/07/17/07 12:11:2912:11:29 PMPM Evidence There is some evidence that the parents of children with burns are at increased risk of PTSD, although the relevant studies are all very small with cross-sectional design and a high likelihood of bias.

A study (n=25) of children and adolescents with burns reported that 52% of mothers had past or present PTSD,243 the most signiﬁ cant predictive factor for maternal PTSD in the mother being the size of the burn. Another study reported a correlation between maternal and child stress syndromes in the families of paediatric burn survivors.244 Similarly, a recent study (n=52 analysed) in younger children (aged one to four years) reported a vicious cycle whereby pain in the child caused acute stress disorder in the parents, which then increased the likelihood of acute stress in the child.231

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7676 55/17/07/17/07 12:11:3012:11:30 PMPM Chapter 11 Burn injuries in Ma¯ori

good practice points

Be aware that Ma¯ori tamariki (children) are at increased risk of burn-related injuries and ✓ deaths.

Consider ways to deliver care that will overcome access barriers, if necessary, such as nurse ✓ home visiting for dressing changes.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • Tamariki are at increased risk of burn-related injuries and deaths. • Tamariki have a relatively high level of involvement in home activities that carry a burn or scald risk.

Background Every year, about seven or eight New Zealand children aged 15 years and under die as a result of burns or scalds. In most cases fatalities are the result of house or car ﬁ res. Over two-thirds of those who die are under the age of ﬁ ve years10 and over one-third are Ma¯ori.11

Analysis of New Zealand Health Information Service hospitalisation data for injury between 1985 and 1994 indicates that Ma¯ori children are at high risk of burn-related injuries.245 Injuries from ﬁ re and burns account for 20% of all injuries that require hospital care for children under one year, making this the second most common cause of hospitalisation due to injury in this age group. A further 18% of injuries are caused by contact with hot water or hot substances. During the same period, 5% of injury hospitalisations for kauma¯tua (elder) aged 65 years or older were for burns or injury as a result of ﬁ re. 11 Prevention Tamariki form the largest group of the Ma¯ori population. If they continue to be over-represented in burns statistics this will impact on the hauora (health and wellbeing) of the individual, the wha¯nau, the hapu¯ and iwi now and in the future. The following studies provide some guidance in the future planning of prevention strategies. There are also further suggestions in Chapter 14, Implementation and evaluation.

Tamariki (aged 7–13 years) have been found to have a higher level of involvement in home activities that carry a burn or scald risk, such as running a bath or using matches.29 These ﬁ ndings suggest a difference in children’s involvement in household tasks in Ma¯ori homes. This may be due to a variety of cultural, social and economic factors. Prevention strategies need to systematically identify and remove barriers to developing safe environments.

Tamariki were found to have a generally good understanding of safety knowledge in this survey,29 recognising the correct safety action to take in the event of a ﬁ re or when they received a burn. In contrast, an Auckland study in 2002 suggested that Ma¯ori may be less likely to use cold water therapy on burns compared with people of European descent.1 77

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7777 55/17/07/17/07 12:11:3012:11:30 PMPM Primary care practitioners can contribute to the prevention of burn injuries by providing information on the prevention of burn injuries and appropriate ﬁ rst aid management and supporting local initiatives in primary prevention.

Delivery of care There are a variety of factors that may inﬂ uence access to and utilisation of primary care services. Financial, geographical or cultural barriers may be an issue for some Ma¯ori. Aside from the cost of services, some Ma¯ori may have different attitudes and beliefs concerning illness and doctors, and different cultural patterns of help- seeking. Ma¯ori are more likely to forgo general practitioner visits and prescription items (11.4% vs 5.8% for the total population) or prescription items alone (13.0% vs 4.6% for the total population) because of cost.246 Issues such as lack of transport or access to a telephone will also make access to primary health care more difﬁ cult. As a result, some Ma¯ori individuals with minor burns may postpone visiting a general practitioner or be reluctant to continue with frequent visits for dressing changes. These are things that may apply to some Ma¯ori, but other Ma¯ori will have very different social circumstances, values, beliefs and health care practices. Primary care practitioners can assist in removing the barriers to care by considering alternative ways to deliver care, such as nurse home visiting for dressing changes.

There are reports of a number of traditional herbal remedies playing a part in the treatment of burns and scalds among Ma¯ori. For further information see Chapter 13, Complementary and alternative medicines.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7878 55/17/07/17/07 12:11:3012:11:30 PMPM Chapter 12 Burn injuries in Paciﬁ c peoples

good practice points

Be aware that Paciﬁ c children may be at increased risk from hot water scalds. ✓

Consider ways to deliver care that will overcome access barriers, if necessary (such as nurse ✓ home visiting for dressing changes).

Be aware that language can be a barrier. Encourage a bilingual family member or practice ✓ nurse to assist with communication. Ideally, Pacifi c Island population-specifi c translators should be made available to services that provide for Pacifi c peoples.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

Evidence statements • Paciﬁ c children aged 0 to 4 years appear to be at increased risk from hot water scalds. • Paciﬁ c children have a higher level of involvement in home activities that carry a burn or scald risk.

Paciﬁ c children aged 0 to 4 years appear to be at increased risk from hot water scalds.247 SafeKids New Zealand has reported data gathered by the New Zealand Health Information Service showing that hot water scalds are the second most common cause of hospitalisations for unintentional injury among Paciﬁ c children.247

Prevention A study in Waitakere City showed that Paciﬁ c children (aged 7–13) had a higher level of involvement in home activities that carry a burn or scald risk, such as running a bath or using matches.29 These levels of involvement in activities with higher burn and scald risk for the child may be due to a variety of cultural, social and economic factors. Prevention strategies need to systematically identify and remove barriers to developing safe environments in order to be effective with Paciﬁ c children and their families.

Pacifi c concepts of health and illness Pacifi c peoples in New Zealand are a diverse population, coming from 22 different island nations, each with 12 a distinct language and culture. Many Pacifi c peoples view health in a holistic way, as the total wellbeing of the individual within the context of the family and the community. In addition to physical, mental and social wellbeing (the aspects of health defi ned by the World Health Organization), many Pacifi c peoples regard spiritual wellbeing as equally essential to health.248

Health care practitioners are regarded as authority fi gures by many Pacifi c peoples. As a result, out of respect, individuals may often be hesitant to say what they really think to the doctor or nurse. For example, they may say that they understand an explanation given regarding treatment even when they do not. As it is respectful to respond politely with affi rmation to a person of higher status, the individual may agree to follow-up even when they know they may not be able to afford the fee for the follow-up consultation. In addition, the individual may not attend the follow-up appointment if they have not complied with the recommended treatment, conscious that the doctor may be disappointed. 79

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 7979 55/17/07/17/07 12:11:3112:11:31 PMPM There are reports of a number of traditional herbal remedies playing a part in the treatment of burns and scalds among Paciﬁ c peoples. For further information see Chapter 13, Complementary and alternative medicines.

Delivery of care There are a variety of factors that may infl uence access to and utilisation of primary care services by Pacifi c peoples. Financial, geographical or cultural barriers may be an issue for some Pacifi c peoples. Pacifi c peoples are over-represented in the lower end of the socioeconomic spectrum compared with other New Zealanders. As a result, some Pacifi c peoples may experience fi nancial barriers to care. Pacifi c peoples are more likely to forgo general practitioner visits and prescription items (8.0% vs 5.8% for the total population) or prescription items alone (8.4% vs 4.6% for the total population) because of cost.246 Aside from the cost of services, some Pacifi c peoples may have different attitudes or beliefs concerning illness or doctors. Issues such as lack of transport or access to a telephone will also make access to primary health care more diffi cult. As a result, some Pacifi c individuals with minor burns may postpone visiting a general practitioner or be reluctant to continue with frequent visits for dressing changes.

Language is a major barrier to health care for some Pacifi c peoples. Good primary care practice would include encouraging a bilingual family member or practice nurse to assist with translation. Ideally, Pacifi c Island population-specifi c translators should be made available to services that provide for Pacifi c peoples.

These are things that may apply to some Paciﬁ c peoples, but other Paciﬁ c peoples will have very different social circumstances, values, beliefs and health care practices.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8080 55/17/07/17/07 12:11:3112:11:31 PMPM Chapter 13 Complementary and alternative medicines

Evidence statements • Systematic reviews of hyperbaric oxygen therapy have found that there is insuffi cient evidence to support the routine use of hyperbaric oxygen therapy in the treatment of thermal burns. • There is some evidence that honey helps superfi cial and partial thickness burns to heal faster compared with conventional dressings, but more research is needed. • There are no studies on the use of manuka honey as a topical agent in the treatment of burns. • There is no convincing evidence of any benefi t in using Aloe vera for thermal burns. • There is no convincing evidence to support the use of moist exposed burn ointment for burns in preference to conventional dressings.

Evidence There is very little reliable evidence on the use of complementary and alternative medicines for burns.

Two systematic reviews of the use of hyperbaric oxygen therapy for the treatment of burns reported that there was insufﬁ cient evidence to support its routine use.133,249

A good-quality systematic review of Aloe vera for wound healing250 found no RCTs involving accidental burns. In a small (n=27) non-randomised split-sample study of partial (dermal) and full thickness burns, the distal part of each burn was treated with Aloe vera and the proximal with parafﬁ n gauze.251 Time to healing was signiﬁ cantly faster with Aloe vera, with only minor adverse effects (such as transient discomfort and pain) in both groups.

There were several studies on moist exposed burn ointment but only four were RCTs and none was blinded. One of these studies, reported in three publications,205,252,253 compared time to healing, pain and cost-effectiveness in moist exposed burn ointment and conventional dressings such as parafﬁ n gauze and silver sulphadiazine. Outcomes were similar in both groups.

One large unblinded RCT121 compared moist exposed burn ointment with silver sulphadiazine for time to healing, pain and rate of infection in 508 people of varying age hospitalised with differing types of burn. In the moist exposed burn ointment group, partial thickness (dermal) burns healed signiﬁ cantly faster with less pain (p<0.01) and a signiﬁ cantly lower incidence of infection (p<0.01). However, the quality of this study is uncertain, and as noted elsewhere in this guideline prolonged use of silver sulphadiazine cream is not recommended as it may delay healing. Two other small unblinded RCTs of moist exposed burn ointment,254,255 both by the same author, reported that moist exposed burn ointment may be more cost effective for second-degree (dermal) burns than a range of standard therapies. However, ‘standard therapies’ in these studies included a wide variety of dissimilar comparators.

There were six fair-quality RCTs of honey (non-manuka honey) for partial (dermal) and full thickness burns, all conducted without blinding by the same research group in India.95-97,103,104,256 Five95-97,104,256 included 50–100 participants and one103 included 900 participants. In four95-97,104 of these studies, superﬁ cial and partial thickness (epidermal and dermal) burns dressed with honey healed signiﬁ cantly faster than those dressed with conventional dressings, with lower bacterial colonisation rates. The majority of these studies compared honey with the prolonged use of silver sulphadiazine cream. The sixth study256 compared honey with tangential excision and grafting for ‘moderate’ burns and reported that outcomes were better with grafting. Other RCTs of

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8181 55/17/07/17/07 12:11:3112:11:31 PMPM honey conducted by the same group were not considered because they used comparators unlikely to be used in New Zealand, such as amniotic membrane and potato peel.

Small RCTs found no evidence of healing effect for antioxidant ointments91 or for calendula or bovine ﬁ brinolysin ointment for burns,257 nor for homoeopathic cantharis for burn pain.258

There are reports that harakeke,259 also known as New Zealand ﬂ ax, has played a part in the treatment and healing of burns and scalds among Ma¯ori. Another Ma¯ori remedy in the treatment of burns and scalds is kawakawa leaves and bark.260 As no RCTs were found to support the use of these remedies, the Guideline Development Team does not recommend their use as a primary or sole method of care.

Some Pacifi c peoples may use traditional medicine as a fi rst-line treatment for burns/illnesses, or if they feel that Western medicine has not worked. There are reports of numerous medicinal plants being used for burns in the South Pacifi c region. A few examples include the scraped bark of ‘ifi ’ in Tonga (Inocarpus fagifer, also known as Tahitian chestnut), the grated seed of ‘utu’ (Barringtonia asiatica) and the starch from the root ‘pia’ (Tacca leontapetaloides) in the Cook islands.261,262 As no RCTs were found to suppport the use of these herbal remedies, the Guideline Development Team does not recommend their use as a primary or sole method of care.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8282 55/17/07/17/07 12:11:3112:11:31 PMPM Chapter 14 Implementation and evaluation

Overview The aim of this guideline is to ensure that for individuals with burn injuries there: • is appropriate initial assessment and care in the primary care setting • are more appropriate referrals to secondary care and regional burns units • is more information sharing between providers (common language and tools) • is more uniformity in burn assessments and outcome measurements • is improved targeting and use of effective interventions.

Distribution strategies Publication of the full guideline The full guideline is available free for download from the ACC website (http://www.acc.co.nz) and the NZGG website (http://www.nzgg.org.nz). The NZGG website also provides supporting documents, including the search strategy and evidence tables for the guideline. Print copies are also available.

It is recommended that efforts are made to create weblinks to the full guideline and summary from medical colleges, professional bodies and other interest groups.

Quick reference clinical format A summary booklet is being produced with the key messages and algorithms to guide the management of people with burns and scalds in primary care. The availability of a quick reference summary will make the use of the guideline recommendations easier for clinicians.

Dissemination The full guideline/summary should be distributed to the following groups: • general practitioners • primary health care nurses • iwi/Ma¯ori health providers • Paciﬁ c health providers • ANZBA • burn support groups • safety and prevention groups • armed services, ﬁ re services, and ambulance services • district health boards • primary health organisations • independent practitioner associations • academic lecturers/curriculum planners involved in medical training 14 • medical colleges/professional bodies • pharmacists.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8383 55/17/07/17/07 12:11:3212:11:32 PMPM Promotion Guideline launch The Guideline Development Team suggests that the guideline be launched at an appropriate event or conference to signal the start of the implementation phase. Such an event might be a conference held by the Royal New Zealand College of General Practitioners or other primary health care organisation, or a conference focusing on wound care. Further opportunities for presentations at other relevant local meetings and conferences will be pursued to help primary care practitioners become familiar with the guideline.

Media The guideline needs to be promoted in the media, including the local medical press. Publicity needs to encompass journals and health professional publications such as: New Zealand Medical Journal, New Zealand Nursing Journal and NZ Doctor. Mainstream media can also be targeted through the use of media releases to newspapers and television programmes. This could include Ma¯ori and Paciﬁ c magazines, radio and television.

Promoting safety messages It is recommended that the development of consumer information be funded to inform people about safety measures to prevent burns and scalds.

Additional strategies should be considered to promote burns safety measures through primary care, as young children, the population most at risk, are usually seen routinely.

Consumer information should be offered in Ma¯ori and Paciﬁ c languages in written and oral forms, eg, CDs and DVDs.

Education Professional education Professional education activities could include: • Organising information and education seminars/workshops (based on the guideline) for practitioners, primary health organisations, independent practitioner associations and district health boards. • Speciﬁ c educational initiatives and ongoing updates for particular groups (eg, general practitioners, practice nurses). • Local continuing medical education activities that include this guideline as part of their programme. • Developing local strategies to reduce barriers to follow-up care for people with burns, particularly Ma¯ori and Paciﬁ c peoples.

Community education Community education activities could include: • School-based education to teach safe practices to children, which is tailored to meet the needs of children from different communities. • Education to teach safe practices to children under ﬁ ve years old. • Encouraging existing home-visit providers to families with young children (particularly with infants 12–18 months of age) to remind them about burn risk and burns ﬁ rst aid. • Offering training to providers of home-visit services (eg, Plunket, Tamariki Ora), pre-school units and health clinics where pre-schoolers are seen. • Designing a consumer resource for Ma¯ori in consultation with iwi providers. • Monitoring the educational information that is given out.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8484 55/17/07/17/07 12:11:3212:11:32 PMPM Research and evaluation Research There is a lack of RCTs relating to burn assessment and treatment. The Guideline Development Team suggests that a Delphi process be used to formally rank the research interest areas in burns. The Delphi process is a structured process that uses a series (or rounds) of questionnaires to gather information and rounds are continued until ‘group’ consensus is reached. This process is popular in health research because it allows the inclusion of a large number of individuals across diverse locations and areas of expertise and avoids the situation where a speciﬁ c expert might be anticipated to dominate the consensus process.263

The following areas for further research were identifi ed: • cost-benefi t analyses of using dressings. What is cost-effective wound care for burn injuries in primary care? • a targeted prevention campaign for Ma¯ori and Pacifi c children aged fi ve years and under (visiting mothers who have children 12–18 months to remind them about burn risk and fi rst aid for burns) and a follow-up on its effectiveness • a study to investigate the effectiveness of traditional remedies (such as kawakawa) on superfi cial and mid dermal burns • a study to investigate the effectiveness of various interventions for scarring following burn injuries • a study to identify the resources and support services needed for people with burn injuries in New Zealand.

Evaluation An appropriate response to this guideline will be a decrease in the number of late referrals to burn services. Successful implementation of the guideline may result in an increase in overall referrals to secondary care. Another outcome of interest would be the incidence of skin grafting and scarring following burn injuries. Currently, there is no benchmark for this information to measure any change in these areas.

The actual impact of this guideline in practice can be evaluated by the collection of the following information: • the effect on referrals for hospital-level care or regional burns unit care. Making a comparison of baseline referral information before the distribution of the guideline, and referral numbers and patterns after guideline implementation • referral indications for hospital-level care or regional burns unit care. Making a comparison before and after referral indications.

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8686 55/17/07/17/07 12:11:3312:11:33 PMPM Appendices

A. Evidence and recommendation grading system

B. Wound care options

C. DSM-IV criteria for post-traumatic stress disorder

D. Useful resources

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AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8888 55/17/07/17/07 12:11:3312:11:33 PMPM Appendix A: Evidence and recommendation grading system

Studies were graded using a two-tier system that is detailed in the Handbook for the Preparation of Explicit Evidence-Based Clinical Practice Guidelines, published in November 2001 by NZGG. This system has been adapted from other grading systems currently in use, in particular the Scottish Intercollegiate Guideline Network system.

The literature searches for this guideline concentrated on ﬁ nding high-grade evidence to answer the identiﬁ ed clinical questions, such as systematic reviews, RCTs and, where these were not available, observational studies such as well designed cohort and case control studies. Only these types of study design were graded. Where these types of study were not available, less rigorous study designs such as cross-sectional studies and case studies were considered but were not formally graded.

The two-tier system follows this process: 1. Critical appraisal of individual relevant studies (identifi ed from the searching) and assigning of a level of evidence for the fi rst section of the GATEFRAME checklist that is incorporated into the evidence tables. A random sample of appraisals in the guideline was performed independently by two assessors and the results compared. 2. Joint consensus by the Guideline Development Team on the issues of volume, consistency, clinical relevance and applicability of the body of evidence in the evidence table (fi lling out the NZGG Considered Judgement form for each clinical question) and the development of graded recommendations that attempt to answer the clinical questions posed.

Developing recommendations Recommendations were formulated by joint meetings of the multidisciplinary Guideline Development Team. The Team considered the entire body of evidence (summarised in the evidence tables) and ﬁ lled out Considered Judgement forms for each clinical question that was identiﬁ ed as being relevant to the guideline (see http:// www.nzgg.org.nz). The following aspects were discussed: volume of evidence, applicability to the New Zealand setting, consistency and clinical impact, with the aim of achieving consensus. Consensus was sought and achieved over the wording of the recommendation and grading. In this guideline, where a recommendation is based on the clinical experience of members of the Guideline Development Team, this is referred to as a good practice point.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 8989 55/17/07/17/07 12:11:3312:11:33 PMPM Grading of recommendations The NZGG grades of recommendation are as follows:

recommendations grade

The recommendation is supported by good evidence (where there are a number of studies A that are valid, consistent, applicable and clinically relevant).

The recommendation is supported by fair evidence (based on studies that are valid, but B there are some concerns about the volume, consistency, applicability and clinical relevance of the evidence that may cause some uncertainty but are not likely to be overturned by other evidence).

The recommendation is supported by international expert opinion. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations.

good practice point

Where no evidence is available, best practice recommendations are made based on the ✓ experience of the Guideline Development Team, or feedback from consultation within New Zealand.

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9090 55/17/07/17/07 12:11:3412:11:34 PMPM Appendix B: Wound care options

This table describes various wound products and their uses. It has been compiled using information from manufacturers and Guideline Development Team experience in burn care.

wear name indications advantages disadvantages time

Parafﬁ n or Burns with Covers and protects Limited moisture 24–48 silicone- minimal exudate retention hours Non-sensitising impregnated Grafts when May cause trauma on ﬁ bres Non-irritant healing well removal

Requires a secondary dressing to keep it in place and maintain moisture balance

Hydrocolloids For burns with Maintains moisture balance Not recommended Three to light to moderate for heavily exudating seven days Can help with autolytic exudate burns, sinuses or debridement tracts Sloughy and Self-adhesive and moulds necrotic burns May tear fragile well surrounding skin on Impermeable to bacteria and removal contaminants Dressing odour can be No secondary dressing offensive required Gel can be mistaken for pus

Transparent Superfi cial burns Impermeable to bacteria and Not recommended for One to fi lms contaminants exudating burns or three days Burns with little new burns or no exudate Supports autolytic debridement Requires dry border to As protection adhere for fragile Allows visualisation of the compromised wound Can be diffi cult to areas of handle No secondary dressing unbroken skin required May not stay in place in areas of moisture

Continued …

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9191 55/17/07/17/07 12:11:3412:11:34 PMPM wear name indications advantages disadvantages time

Hydrogels For necrotic and Rehydrates the wound bed Not recommended for One to two sloughy burns moderate or heavily days Aids autolytic debridement exudating burns Deep-cavity burns Fills dead space in cavity with necrosis and Requires secondary burns slough and light dressing exudate Small amount of absorptive Can macerate wound action edges if not carefully Can be soothing and reduce applied pain Can soak into some secondary dressings

Alginates For partial and Absorbs 20 times its own Not recommended One to four full thickness weight for lightly exudating days burns with wounds or wounds Forms a gel over wound moderate to with eschar (a dry scab heavy exudate Supports debridement or slough)

Wounds with Fills dead space (comes in If dries out can be undermining or wicks as well as sheets) difﬁ cult to remove sinus tracts Easy to remove if gelled Requires a secondary Wounds with Easy to use and cut to ﬁ t dressing necrotic tissue with exudate

Infected wounds

Hydroﬁ bres Partial thickness Absorbs 25 times its own Not recommended for 1–14 days burns weight dry burns – will adhere to a dry wound Moderate to Vertically wicks ﬂ uid heavily exudating therefore controls lateral Not recommended for burns spread of exudate burns with eschar

Can ﬁ ll dead space (comes in Requires a secondary wicks as well as sheets) dressing to secure it

Tensile strength comparable to gauze

Forms a gel over wound

Reduces maceration of surrounding skin

Easy to use and cut to ﬁ t

Easy to remove if gelled

Continued … 92

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9292 55/17/07/17/07 12:11:3412:11:34 PMPM wear name indications advantages disadvantages time

Foams Partial and full Non-adherent Not recommended for One to ﬁ ve thickness burns burns with little or no days Does not cause trauma on with minimal exudate removal to moderate May macerate exudate Easy to use and apply surrounding skin if it is Secondary May be used under not protected dressing compression Needs to be taped if to provide it is in non-adhesive additional form absorption

Silver Partial and full Generally absorbs exudate Not recommended for 1–14 days dressings thickness burns dry burns or burns with depending Delivers antibacterial/ eschar upon Different Burns that appear antimicrobial component product products act to be infected to wound bed – effective Manufacturers’ chosen differently at against gram-positive and instructions need the wound bed gram-negative bacteria, careful consideration as per dressing fungal infections prior to application type, eg, depending on product hydroﬁ bre or chosen wound contact Requires secondary dressing dressing to secure

Silver creams Partial and full Maintains moisture balance Non-absorptive Daily thickness burns dressing Antibacterial/Antimicrobial Can cause its own required Dry eschars to multiple organisms pseudo eschar which can be difﬁ cult to Infected burns Antibacterial effect remove penetrates eschar Prolonged use is Aids in autolytic debridement detrimental to wound Comfortable for person cells and can delay Easy to apply healing Requires a secondary dressing

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9393 55/17/07/17/07 12:11:3512:11:35 PMPM 94

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9494 55/17/07/17/07 12:11:3512:11:35 PMPM Appendix C: DSM-IV criteria for post-traumatic stress disorder

The following table has been reproduced from the DSM-IV criteria.230

The diagnosis of PTSD requires a combination of symptoms including at least one re-experiencing symptom, three symptoms of avoidance and emotional numbing, and two hyperarousal symptoms.

The person has been exposed to a traumatic event in which both of the following have been present: A. 1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganised or agitated behaviour.

The traumatic event is persistently re-experienced in one (or more) of the following ways: • recurrent and intrusive distressing recollections of the event, including images, B. thoughts or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed • recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognisable content • acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative ﬂ ashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-speciﬁ c re-enactment may occur • intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event • physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the C. following: • efforts to avoid thoughts, feelings or conversations associated with the trauma • efforts to avoid activities, places or people that arouse recollections of the trauma • inability to recall an important aspect of the trauma • markedly diminished interest or participation in signiﬁ cant activities • feeling of detachment or estrangement from others • restricted range of affect (eg, unable to have loving feelings) • sense of a foreshortened future (eg, does not expect to have a career, marriage, children or a normal life span).

Continued … 95

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9595 55/17/07/17/07 12:11:3512:11:35 PMPM Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: D. • difﬁ culty falling or staying asleep • irritability or outbursts of anger • difﬁ culty concentrating • hypervigilance • exaggerated startle response. E. Duration of the disturbance (symptoms in Criteria B, C and D) is more than one month.

The disturbance causes clinically signiﬁ cant distress or impairment in social, occupational F. or other important areas of functioning. Specify if: Acute – if duration of symptoms is less than three months Chronic – if duration of symptoms is three months or more.

Specify if: Delayed onset – if onset of symptoms is at least six months after the stressor.

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9696 55/17/07/17/07 12:11:3512:11:35 PMPM Appendix D: Useful resources

Burn associations • Australian and New Zealand Burn Association – htpp://www.anzba.org.au • American Burn Association – http://www.ameriburn.org • International Society for Burn Injury – http://www.worldburn.org

Support Groups Burn Support – Waikato Burn support organisation in Waikato.

http://www.burnsupport.org.nz

Burn Support Foundation Inc A non-proﬁ t, self-help organisation helping burn survivors and their families return to productive lifestyles following injury. This organisation provides a free newsletter and organises two weekend camps per year.

PO Box 476, Paddington, 2021

New South Wales, Australia

Burn Support Group Charitable Trust Inc Produces a regular newsletter, runs workshops, education evenings and an annual camp for children. It also provides education/prevention work and visits inpatients.

http://www.burns.org.nz

Burn Support Groups Database A register of burn support groups world-wide. Non-burn support groups also are invited to register.

http://www.burnsupportgroupsdatabase.com

Burn Survivors On Line Provides information and support for burn survivors and their families throughout the world.

http://www.burnsurvivorsonline.com/

Changing Faces Provides free and conﬁ dential help, support and information for children (and their parents) and adults who have facial disﬁ gurements.

http://www.changingfaces.co.uk

Phoenix Society for Burn Survivors International, non-proﬁ t, self-help organisation helping burn survivors and their families return to happy and productive lives following injury.

http://www.phoenix-society.org

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9797 55/17/07/17/07 12:11:3612:11:36 PMPM Skylight Skylight provides a national support service for New Zealand children and young people who are experiencing change, loss and grief – whatever its cause.

http://www.skylight.org.nz

Survivors of Burn Injury Burn resource centre for survivors of burn injury.

http://www.burnsurvivor.com

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9898 55/17/07/17/07 12:11:3612:11:36 PMPM Abbreviations and acronyms

ACC Accident Compensation Corporation

ANZBA Australian and New Zealand Burn Association

BMI Body mass index

CBT Cognitive behavioural therapy

CMDHB Counties Manukau District Health Board

ECG Electrocardiogram

NZGG New Zealand Guidelines Group

PTSD Post-traumatic stress disorder

PVC Polyvinyl chloride

RCT Randomised controlled trial

RR Relative risk

SAS Staphylococcus aureus sepsis

SSRIS Selective serotonin reuptake inhibitors

TBSA Total body surface area

UK United Kingdom

US United States of America

UV Ultraviolet

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 9999 55/17/07/17/07 12:11:3612:11:36 PMPM 100

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 100100 55/17/07/17/07 12:11:3712:11:37 PMPM Glossary

Angiogenesis The formation of new blood vessels.

Arrhythmia Any deviation from the normal rhythm, eg, of the heart.

Atrial ﬁ brillation Very rapid, uncoordinated contractions of the atria of the heart.

Blepharospasm A spasm of the eyelid.

Body mass index (BMI) An indicator of body fatness. Calculated from the formula weight/height squared, where weight is in kilograms and height is in metres.

Case control studies Sometimes described as retrospective, these studies look back in time at a group of individuals with a particular disease or outcome and compare it with a suitable control group of individuals without the disease or outcome.

Compartment syndrome A potentially limb- and life-threatening complication pressure leads to vascular occlusion, which in turn causes hypoxia, necrosis and a further increase in pressure.

Debridement Thorough cleansing of a wound, with removal of all foreign matter and injured or infected tissue.

Depersonalisation A subjective feeling of having lost one’s personality.

Dysphoria A state of feeling unwell or unhappy.

Dyspnoea Difﬁ cult or laboured breathing.

Ectopy Pertaining to a beat or rhythm occurring outside its normal location or at the wrong time.

Erythema Reddening of the skin.

Exudate The material composed of serum, fi brin and white blood cells that escapes from blood vessels into a superfi cial lesion or area of infl ammation.

Fasciotomy Incision of a fascia, a connective tissue sheath which unites the skin to the underlying tissues and also surrounds many muscles.

Hapu¯ Groups of wha¯nau with common ancestral links; sub-tribe.

Hydrocolloid Any of several substances that yield gels with water.

Hyperalgesia Increased sensitivity to pain or enhanced intensity of the pain experience.

Hyperphosphataemia Excessive phosphates in the blood.

Hypertrophic scarring Thick raised areas, usually darker than the surrounding skin, which remain within the conﬁ nes of the original wound and tend to reduce over time.

Hypocalcaemia A deﬁ ciency of calcium in the blood.

101

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 101101 55/17/07/17/07 12:11:3712:11:37 PMPM Hypoperfusion Decreased blood ﬂ ow through an organ.

Hypothermia Below normal body temperature.

Hypovolaemia An abnormally low volume of blood circulating through the body.

Insomnia Sleeplessness.

Iridocyclitis Inﬂ ammation of the iris and ciliary body of the eye.

Ischaemia Deﬁ cient blood supply.

Iwi A social and political unit made up of several hapu¯ sharing common descent; Ma¯ori tribe or nation.

Kauma¯tua Wise and experienced older members of a wha¯nau, usually aged over 55 years.

Keloid scarring A scar that grows beyond the borders of the original wound and does not reduce spontaneously.

Lavage Irrigation of or washing out of a body cavity.

Lymphangitis Inﬂ ammation of a lymph vessel.

Metalloproteinases Enzymes that are involved in the degradation of the extracellular matrix.

Myocardial infarction Damage to heart muscle that results typically from the partial or complete blocking of a coronary artery.

Necrosis Localised death of tissue.

Occlusive dressing A dressing that prevents air reaching a wound and that retains moisture, heat, body ﬂ uids and medication.

Oedema Swelling.

Oliguria Reduced urine output.

Pruritis Itching.

Randomised controlled trials (RCTs) Trials in which individuals in a population are randomly allocated into two groups. The two groups are usually called the study or experimental group, and the control group, which does not receive the intervention. The results are compared by comparing rates of one or more outcomes (endpoints) between the two groups. Randomised controlled trials are generally regarded as the most scientiﬁ cally rigorous method of assessing the effectiveness of treatments and other interventions (eg, screening procedures).

Secondary care Public hospitals, hospital-based services and specialist services.

Symblepharon Adhesion between an eyelid and the eyeball.

Tamariki Children.

Tetany A condition of muscular hyperexcitability leading to cramps and spasms.

Wha¯nau The extended family. Relationships that have blood links to a common ancestor; extended family. 102

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 102102 55/17/07/17/07 12:11:3712:11:37 PMPM References

1. Skinner A, Peat B. Burns treatment for children and adults: A study of initial burns fi rst aid and hospital care. N Z Med J 2002;115(1163):U199. 2. Berkebile BL, Goldfarb IW, Slater H. Comparison of burn size estimates between prehospital reports and burn center evaluations. J Burn Care Rehabil 1986;7(5):411-2. 3. Collis N, Smith G, Fenton OM. Accuracy of burn size estimation and subsequent fl uid resuscitation prior to arrival at the Yorkshire Regional Burns Unit. A three year retrospective study. Burns 1999;25(4):345-51. 4. Hammond JS, Ward CG. Transfers from emergency room to burn center: Errors in burn size estimate. J Trauma 1987;27(10):1161-5. 5. Public Health Division. Management guidelines for people with burn injury. NSW Health Department; 1996. 6. PRODIGY Knowledge. Burns and scalds. Revised November 2004. Sowerby Centre for Health Informatics at Newcastle Limited. (SCHIN); 1998. http://www.prodigy.nhs.uk/burns_and_scalds [accessed August 2005]. 7. Morgan ED, Bledsoe SC, Barker J. Ambulatory management of burns. Am Fam Physician 2000;62(9):2015- 26. 8. New Zealand Guidelines Group. NZGG Training Handbook. Wellington: New Zealand Guidelines Group; 2003 http://www.nzgg.org.nz/download/fi les/nzgg_guideline_handbook.pdf. 9. Ministry of Health. Immunisation Handbook 2006. Wellington: Ministry of Health; 2006 http://www.moh. govt.nz/moh.nsf/pagesmh/4617/$File/2006-immunisation-handbook-all.pdf. 10. Injury Prevention Research Unit, University of Otago. Injury to children in NZ resulting in death or hospitalisation. Fact Sheet No. 22. Dunedin: Injury Prevention Research Unit, University of Otago; 2001. 11. SafeKids New Zealand. Factsheet: Childhood Burn Injury; n.d. http://www.safekids.org.nz/factsheets/ Factsheet%20-%20Childhood%20Burn%20Injury%20.pdf [accessed July 2006]. 12. New Zealand Health Information Service. Selected Morbidity Data for Publicly Funded Hospitals 1 July 2002 to 30 June 2003. Wellington: Ministry of Health; 2006. 13. Injury Prevention Research Unit, University of Otago. Trends in Thermal Injury. Fact Sheet No. 21. Dunedin: Injury Prevention Research Unit; 2001. 14. Zhang Z-lJ. General patterns of burn injury in ACC claim data. Presentation. Auckland: ACC; August, 2005. 15. Morrow SE, Smith DL, Cairns BA, et al. Etiology and outcome of pediatric burns. J Pediatr Surg 1996;31(3):329-33. 16. Chien WC, Pai L, Lin CC, et al. Epidemiology of hospitalized burns patients in Taiwan. Burns 2003;29(6):582-8. 17. Laloe V. Epidemiology and mortality of burns in a general hospital of eastern Sri Lanka. Burns 2002;28(8):778-81. 18. Lari AR, Panjeshahin MR, Talei AR, et al. Epidemiology of childhood burn injuries in Fars Province, Iran. J Burn Care Rehabil 2002;23(1):39-45. 19. Wilkinson E. The epidemiology of burns in secondary care, in a population of 2.6 million people. Burns 1998;24(2):139-43. 20. Mahaluxmivala S, Borkar A, Mathur A, et al. A retrospective study of etiopathological and preventive factors in a burns unit in Saudi Arabia. Burns 1997;23(4):333-7. 103

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 103103 55/17/07/17/07 12:11:3712:11:37 PMPM 21. Bang RL, Ebrahim MK, Sharma PN. Scalds among children in Kuwait. Eur J Epidemiol 1997;13(1):33-9. 22. Fukunishi K, Takahashi H, Kitagishi H, et al. Epidemiology of childhood burns in the Critical Care Medical Center of Kinki University Hospital in Osaka, Japan. Burns 2000;26(5):465-9. 23. Zeitlin R, Somppi E, Jarnberg J. Paediatric burns in central Finland between the 1960s and the 1980s. Burns 1993;19(5):418-22. 24. Hockey R. Safe hot tap water and the risk of scalds and Legionella infection. Injury Prevention 2002;8(2):170. 25. Ray JG. Burns in young children: A study of the mechanism of burns in children aged 5 years and under in the Hamilton, Ontario burn unit. Burns 1995;21(6):463-6. 26. Moritz AR, Henriques FC. Studies of thermal injury: The relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol 1947;23:695. 27. Runyan CW, Bangdiwala SI, Linzer MA, et al. Risk factors for fatal residential ﬁ res. N Engl J Med 1992;327(12):859-63. 28. DiGuiseppi C, Higgins JP. Systematic review of controlled trials of interventions to promote smoke alarms. Arch Dis Child 2000;82(5):341-8. 29. Harre N, Coveney A. School-based scalds prevention: Reaching children and their families. Health Educ Res 2000;15(2):191-202. 30. Turner C, Spinks A, McClure R, et al. Community-based interventions for the prevention of burns and scalds in children. Cochrane Database Syst Rev 2004(3):CD004335. 31. Hudspith J, Rayatt S. First aid and treatment of minor burns. BMJ 2004;328(7454):1487-9. 32. British Burn Association. Pre-hospital approach to burns patient management. Manchester: British Burn Association; 2002 http://www.britishburnassociation.org/Downloads/pre-hosp.pdf [accessed August 2006]. 33. Australian and New Zealand Burn Association. Emergency management of severe burns: Course manual. 8th ed: Australian and New Zealand Burn Association Limited; 2004. 34. Sawada Y, Urushidate S, Yotsuyanagi T, et al. Is prolonged and excessive cooling of a scalded wound effective? Burns 1997;23(1):55-8. 35. Nguyen NL, Gun RT, Sparnon AL, et al. The importance of initial management: A case series of childhood burns in Vietnam. Burns 2002;28(2):167-72. 36. Tung K, Chen M, Wang H, et al. A seven-year epidemiology study of 12,381 admitted burn patients in Taiwan – using the internet system of the childhood burn foundation. Burns 2005;31S:S12-7. 37. Werner MU, Lassen B, Pedersen JL, et al. Local cooling does not prevent hyperalgesia following burn injury in humans. Pain 2002;98(3):297-303. 38. Raghupati N. First-aid treatment of burns: Efﬁ cacy of water cooling. Br J Plast Surg 1968;21(1):68-72. 39. Jandera V, Hudson DA, de Wet PM, et al. Cooling the burn wound: Evaluation of different modalites. Burns 2000;26(3):265-70. 40. de Camara DL, Raine T, Robson MC. Ultrastructural aspects of cooled thermal injury. J Trauma 1981;21(11):911-9. 41. Jakobsson OP, Arturson G. The effect of prompt local cooling on oedema formation in scalded rat paws. Burns 1985;12(1):8-15. 42. Blomgren I, Eriksson E, Bagge U. Effect of cold water immersion on oedema formation in the scalded mouse ear. Burns 1982;9(1):17-20.

104

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 104104 55/17/07/17/07 12:11:3812:11:38 PMPM 43. Raine TJ, Heggers JP, Robson MC, et al. Cooling the burn wound to maintain microcirculation. J Trauma 1981;21(5):394-7. 44. Mertz PM, Davis SC, Cazzaniga AL, et al. To assess second-degree burn wound treatment with water-jel. Carlstadt NJ: Trilling Medical Technologies Inc; 1990. 45. Castner T, Harz C, Schlor J. Cooling out of the bag. Water-jel burn dressings. Markdorf, Germany: Institute for Emergency Medicine; 2000. 46. Coats TJ, Edwards C, Newton R, et al. The effect of gel burns dressings on skin temperature. Emerg Med J 2002;19(3):224-5. 47. Wilson GR, French G. Plasticized polyvinylchloride as a temporary dressing for burns. BMJ 1987;294(6571):556-7. 48. Milner RH, Hudson SJ, Reid CA. Plasticized polyvinyl chloride fi lm as a primary burns dressing: A microbiological study. Burns Incl Therm Inj 1988;14(1):62-5. 49. Cole M, Shakespeare PG, Chissell HG, et al. Thermographaphic assessment of burns using a nonpermeable membrane as a wound covering. Burns 1991;17(2):117-22. 50. Hettiaratchy S, Papini R. Initial management of a major burn: I – overview. BMJ 2004;328(7455):1555-7. 51. Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment and resuscitation. BMJ 2004;329(7457):101-3. 52. Brusselaers N, Hoste EA, Monstrey S, et al. Outcome and changes over time in survival following severe burns from 1985 to 2004. Intensive Care Med 2005;31(12):1648-53. 53. Saffl e JR, Zeluff GR, Warden GD. Intramuscular pressure in the burned arm: Measurement and response to escharotomy. Am J Surg 1980;140(6):825-31. 54. Smith DL, Cairns BA, Ramadan F, et al. Effect of inhalation injury, burn size, and age on mortality: A study of 1447 consecutive burn patients. J Trauma 1994;37(4):655-9. 55. Germann G, Barthold U, Lefering R, et al. The impact of risk factors and pre-existing conditions on the mortality of burn patients and the precision of predictive admission-scoring systems. Burns 1997;23(3):195-203. 56. Griffe O, Gartner R, Captier G, et al. Evaluation of prognostic factors in the burned patient. Ann Chir Plast Esthet 2001;46(3):167-72. 57. Smith DJ, Jr., Thomson PD, Garner WL, et al. Burn wounds: infection and healing. Am J Surg 1994;167(1A):46S-8S. 58. O’Keefe GE, Hunt JL, Purdue GF. An evaluation of risk factors for mortality after burn trauma and the identifi cation of gender-dependent differences in outcomes. J Am Coll Surg 2001;192(2):153-60. 59. Ryan CM, Schoenfeld DA, Thorpe WP, et al. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998;338(6):362-6. 60. Wolf SE, Rose JK, Desai MH, et al. Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or = 70% full-thickness). Ann Surg 1997;225(5):554-65. 61. Raff T, Germann G, Barthold U. Factors infl uencing the early prediction of outcome from burns. Acta Chir Plast 1996;38(4):122-7. 62. Amirsheybani HR, Crecelius GM, Timothy NH, et al. The natural history of the growth of the hand: I. Hand area as a percentage of body surface area. Plast Reconstr Surg 2001;107(3):726-33. 63. Berry MG, Evison D, Roberts AH. The infl uence of body mass index on burn surface area estimated from the area of the hand. Burns 2001;27(6):591-4.

105

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 105105 55/17/07/17/07 12:11:3812:11:38 PMPM 64. Nagel TR, Schunk JE. Using the hand to estimate the surface area of a burn in children. Pediatr Emerg Care 1997;13(4):254-5. 65. Perry RJ, Moore CA, Morgan BD, et al. Determining the approximate area of a burn: An inconsistency investigated and re-evaluated. BMJ 1996;312(7042):1338. 66. Rossiter ND, Chapman P, Haywood IA. How big is a hand? Burns 1996;22(3):230-1. 67. Sheridan RL, Petras L, Basha G, et al. Planimetry study of the percent of body surface represented by the hand and palm: Sizing irregular burns is more accurately done with the palm. J Burn Care Rehabil 1995;16(6):605-6. 68. Kanthraj GR, Srinivas CR, Shenoi SD, et al. Comparison of computer-aided design and rule of nines methods in the evaluation of the extent of body involvement in cutaneous lesions. Arch Dermatol 1997;133(7):922-3. 69. Livingston EH, Lee S. Percentage of burned body surface area determination in obese and nonobese patients. J Surg Res 2000;91(2):106-10. 70. Tripodi S, Panetta V, Pelosi S, et al. Measurement of body surface area in atopic dermatitis using specifi c pc software (scoradcard). Pediatr Allergy Immunol 2004;15(1):89-92. 71. Scott-Conner CE, Clarke KM, Conner HF. Burn area measurement by computerized planimetry. J Trauma 1988;28(5):638-41. 72. Neuwalder JM, Sampson C, Breuing KH, et al. A review of computer-aided body surface area determination: Sage ii and epri’s 3d burn vision. J Burn Care Rehabil 2002;23(1):55-9; discussion 4. 73. Wachtel TL, Berry CC, Wachtel EE, et al. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns 2000;26(2):156-70. 74. Hidvegi N, Nduka C, Myers S, et al. Estimation of breast burn size. Plast Reconstr Surg 2004;113(6):1591- 7. 75. Bennett JE, Dingman RO. Evaluation of burn depth by the use of radioactive isotopes – an experimental study. Plast Reconstr Surg 1975;20(4):261-72. 76. Hemington-Gorse SJ. A comparison of laser doppler imaging with other measurement techniques to assess burn depth. J Wound Care 2005;14(4):151-3. 77. Renkielska A, Nowakowski A, Kaczmark M, et al. Static thermography revisited – an adjunct method for determining the depth of burn injury. Burns 2005;31(6):768-75. 78. Chatterjee JS. A critical evaluation of the clinimetrics of laser doppler as a method of burn assessment in clinical practice. J Burn Care Res 2006;27(2):123-30. 79. Jeng JC, Bridgeman A, Shivnan L, et al. Laser doppler imaging determines need for excision and grafting in advance of clinical judgment: A prospective blinded trial. Burns 2003;29(7):665-70. 80. Andronicus M, Oates RK, Peat J, et al. Non-accidental burns in children. Burns 1998;24(6):552-8. 81. Herndon DN, Rutan RL, Rutan TC. Management of the pediatric patient with burns. J Burn Care Rehabil 1993;14(1):3-8. 82. Hight DW, Bakalar HR, Lloyd JR. Infl icted burns in children. Recognition and treatment. JAMA 1979;242(6):517-20. 83. Ebbin AJ, Gollub MH, Stein AM, et al. Battered child syndrome at the Los Angeles county general hospital. Am J Dis Child 118(4):660-7 1969;118(4):660-7. 84. Friedman SB, Morse CW. Child abuse: A fi ve-year follow-up of early case fi nding in the emergency department. Pediatrics 1974;54(4):404-10.

106

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 106106 55/17/07/17/07 12:11:3812:11:38 PMPM 85. Bowden ML, Grant ST, Vogel B, et al. The elderly, disabled and handicapped adult burned through abuse and neglect. Burns Incl Therm Inj 1988;14(6):447-50. 86. Ministry of Health. Suspected child abuse and neglect: Recommended referral process for general practitioners. Wellington: Ministry of Health; 2000. 87. Papini R. Management of burn injuries of various depths. BMJ 2004;329(7458):158-60. 88. Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns 2006;32(2):145-50. 89. Organization and delivery of burn care. J Burn Care Rehabil 2001;1S-4S. 90. Pedersen JL, Moiniche S, Kehlet H. Topical glucocorticoid has no antinociceptive or anti-infl ammatory effect in thermal injury. Br J Anaesth 1994;72(4):379-82. 91. Dreher F, Denig N, Gabard B, et al. Effect of topical antioxidants on UV-induced erythema formation when administered after exposure. Dermatology 1999;198(1):52-5. 92. Thomas SS, Lawrence JC, Thomas A. Evaluation of hydrocolloids and topical medication in minor burns. J Wound Care 1995;4(5):218-20. 93. Wasiak J, Cleland H. Burns (minor thermal). Clin Evid 2005;Dec(14):2388-96. 94. Miles F, Voss L, Segedin E, et al. Review of staphylococcus aureus infections requiring admission to a paediatric intensive care unit. Arch Dis Child 2005;90(12):1274-8. 95. Subrahmanyam M. Effect of topical application of honey on burn wound healing. Annals of Burns and Fire Disaster 2001;XIV:143-5. 96. Subrahmanyam M. A prospective randomised clinical and histological study of superfi cial burn wound healing with honey and silver sulfadiazine. Burns 1998;24(2):157-61. 97. Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg 1991;78(4):497-8. 98. Bugmann P, Taylor S, Gyger D, et al. A silicone-coated nylon dressing reduces healing time in burned paediatric patients in comparison with standard sulfadiazine treatment: A prospective randomized trial. Burns 1998;24(7):609-12. 99. Tredget EE, Shankowsky HA, Groeneveld A, et al. A matched-pair, randomized study evaluating the effi cacy and safety of acticoat silver-coated dressing for the treatment of burn wounds. J Burn Care Rehabil 1998;19(6):531-7. 100. Inman RJ, Snelling CF, Roberts FJ, et al. Prospective comparison of silver sulfadiazine 1 per cent plus chlorhexidine digluconate 0.2 per cent (silvazine) and silver sulfadiazine 1 per cent (fl amazine) as prophylaxis against burn wound infection. Burns Incl Therm Inj 1984;11(1):35-40. 101. Curreri PW, Desai MH, Bartlett RH, et al. Safety and effi cacy of a new synthetic burn dressing: A multicenter study. Arch Surg 1980;115(8):925-7. 102. Gotschall CS, Morrison MI, Eichelberger MR. Prospective, randomized study of the effi cacy of mepitel on children with partial-thickness scalds. J Burn Care Rehabil 1998;19(4):279-83. 103. Subrahmanyam M. Honey dressing versus boiled potato peel in the treatment of burns: A prospective randomized study. Burns 1996;22(6):491-3. 104. Subrahmanyam M. Honey impregnated gauze versus polyurethane fi lm (opsite) in the treatment of burns – a prospective randomised study. Br J Plast Surg 1993;46(4):322-3. 105. Edwards-Jones V, Greenwood JE. What’s new in burn microbiology?: James Laing memorial prize essay 2000. Burns 2003;29(1):15-24. 106. Hermans MH. Results of a survey on the use of different treatment options for partial and full thickness burns. Burns 1998;24(6):539-51.

107

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 107107 55/17/07/17/07 12:11:3912:11:39 PMPM 107. Masaki F, Gozo N, Yuichi H, et al. Fatal possible toxic shock syndrome in an adult following 15% scald burn. Burns 2004;30(2):181-4. 108. Wharton M, Chorba TL, Vogt RL, et al. Case defi nitions for public health surveillance. MMWR 1990;39(45):822-4. 109. Edwards-Jones V, Dawson MM, Childs C. A survey into toxic shock syndrome (TSS) in UK burns units. Burns 2000;26(4):323-33. 110. Afi lalo M, Dankoff J, Guttman A, et al. Duoderm hydroactive dressing versus silver sulphadiazine/bactigras in the emergency treatment of partial skin thickness burns. Burns 1992;18(4):313-6. 111. Neal DE, Whalley PC, Flowers MW, et al. The effects of an adherent polyurethane fi lm and conventional absorbent dressing in patients with small partial thickness burns. Br J Clin Pract 1981;35(7-8):254-7. 112. Poulsen TD, Freund KG, Arendrup K, et al. Polyurethane fi lm (opsite) vs. Impregnated gauze (jelonet) in the treatment of outpatient burns: A prospective, randomized study. Burns 1991;17(1):59-61. 113. Wright A, MacKechnie DW, Paskins JR. Management of partial thickness burns with granufl ex ‘e’ dressings. Burns 1993;19(2):128-30. 114. Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. J Trauma 1990;30(7):857-65. 115. Wiechula R. The use of moist wound-healing dressings in the management of split-thickness skin graft donor sites: A systematic review. Int J Nurs Pract 2003;9(2):S9-17. 116. Wright A, MacKechnie DWM, Paskins JR. Management of partial thickness burns with granufl ex ‘e’ dressings. Burns 1993;19(2):128-30. 117. Costagliola M, Agrosi M. Second-degree burns: A comparative, multicenter, randomized trial of hyaluronic acid plus silver sulfadiazine vs. silver sulfadiazine alone. Curr Med Res Opin 2005;21(8):1235. 118. Koller J. Topical treatment of partial thickness burns by silver sulfadiazine plus hyaluronic acid compared to silver sulfadiazine alone: A double-blind, clinical study. Drugs Exp Clin Res 2004;30(5-6):183-90. 119. de Gracia CG. An open study comparing topical silver sulfadiazine and topical silver sulfadiazine-cerium nitrate in the treatment of moderate and severe burns. Burns 2001;27(1):67-74. 120. Soroff HS, Sasvary DH. Collagenase ointment and polymyxin b sulfate/bacitracin spray versus silver sulfadiazine cream in partial-thickness burns: A pilot study. J Burn Care Rehabil 1994;15(1):13-7. 121. Zhang X. Report of moist exposed burn ointment: Phase iii clinical trials multicentre study. Chinese Journal of Burns, Wounds and Surface Ulcers 2000;12(2):11-5. 122. Edgar D, Brereton M. Rehabilitation after burn injury. BMJ 2004;329(7461):343-5. 123. Esselman P, Thombs B, Magyar-Russell G, et al. Burn rehabilitation: State of the science. Am J Phys Med Rehabil 2006;85:388-413. 124. Swain AH, Azadian BS, Wakeley CJ, et al. Management of blisters in minor burns. BMJ 1987;295(6591): 81. 125. Singer AJ, Thode HC, Jr., McClain SA. The effects of epidermal debridement of partial-thickness burns on infection and reepithelialisation in swine. Acad Emerg Med 2000;7(2):114-9. 126. Sargent R. Management of blisters in the partial-thickness burn: An integrative research review. J Burn Care Res 2006;27(1):66-81. 127. Desmouliere A. Tissue remodeling during healing, role of apoptosis. Paper presented at Euroconference on tissue repair and ulcer/wound healing: molecular mechanisms, therapeutic targets and future directions: Paris, 17-18 March; 2005. 128. Linares M. From wound to scar. Burns 1996;22(5):339-52.

108

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 108108 55/17/07/17/07 12:11:3912:11:39 PMPM 129. Mutalik S. Treatment of keloids and hypertrophic scars. Indian J Dermatol Venereol Leprol 2005;71:3-8. 130. Carr-Collins JA. Pressure techniques for the prevention of hypertrophic scar. Clin Plast Surg 1992;19(3):733-43. 131. Patino O, Novick C, Merlo A, et al. Massage in hypertrophic scars. J Burn Care Rehabil 1999;20(3):268-71; Discussion 7. 132. O’Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev 2006(1):CD003826. 133. Zhang ZL, Bennett S, Bowens A. Evidence based review: Hyperbaric oxygen therapy – evidence of effectiveness: Accident Compensation Corporation (ACC); 2004. 134. Anzarut A, Singh P, Tredget E, et al. Pressure garment therapy after burn injury (protocol). Cochrane Database Syst Rev 2004(2):Art. No.: CD004984. DOI: 10.1002/14651858.CD004984. 135. Ward RS. Pressure therapy for the control of hypertrophic scar formation after burn injury. A history and review. J Burn Care Rehabil 1991;12(3):257-62. 136. Macintyre L, Baird M. Pressure garments for use in the treatment of hypertrophic scars –a review of the problems associated with their use. Burns 2006;32(1):10-5. 137. Kealey GP, Jensen KL, Laubenthal KN, et al. Prospective randomized comparison of two types of pressure therapy garments. J Burn Care Rehabil 1990;11(4):334-6. 138. Chang P, Laubenthal KN, Lewis RW, 2nd, et al. Prospective, randomized study of the efﬁ cacy of pressure garment therapy in patients with burns. J Burn Care Rehabil 1995;16(5):473-5. 139. Van den Kerckhove E, Stappaerts K, Fieuws S, et al. The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring. Burns 2005;31(6):696-702. 140. Johnson J, Greenspan B, Gorga D, et al. Compliance with pressure garment use in burn rehabilitation. J Burn Care Rehabil 1994;15(2):180-8. 141. Singer A, Sagi A, Ben Meir P, et al. Chemical burns: Our 10-year experience. Burns 1992;18(3):250-2. 142. Sykes RA, Mani MM, Hiebert JM. Chemical burns: Retrospective review. J Burn Care Rehabil 1986;7(4):343- 7. 143. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: Effect of prompt ﬁ rst aid. Journal of Trauma Injury Infection & Critical Care 1982;22(5):420-3. 144. Cartotto RC, Peters WJ, Neligan PC, et al. Chemical burns. Can J Surg 1996;39(3):205-11. 145. Smith ML. Pediatric burns: Management of thermal, electrical, and chemical burns and burn-like dermatologic conditions. Pediatric Annals 2000;29(6):367-78. 146. Edlich RF, Farinholt HM, Winters KL, et al. Modern concepts of treatment and prevention of chemical injuries. J Long Term Eff Med Implants 2005;15(3):303-18. 147. Rodeheaver GT, Hiebert JM, Edlich RF. Initial treatment of chemical skin and eye burns. Compr Ther 1982;8(5):37-43. 148. Stewart CE. Chemical skin burns. Am Fam Physician 1985;31(6):149-57. 149. Winfree J, Barillo DJ. Burn management. Nonthermal injuries. Nurs Clin North Am 1997;32(2):275-96. 150. Orcutt TJ, Pruitt BA. Chemical injuries of the upper extremity. Major Probl Clin Surg 1976;19:84-95. 151. Barillo DJ, Cancio LC, Goodwin CW. Treatment of white phosphorus and other chemical burn injuries at one burn center over a 51-year period. Burns 2004;30(5):448-52. 152. Mozingo DW, Smith AA, McManus WF, et al. Chemical burns. J Trauma 1988;28(5):642-7.

109

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 109109 55/17/07/17/07 12:11:3912:11:39 PMPM 153. Xie Y, Tan Y, Tang S. Epidemiology of 377 patients with chemical burns in Guangdong province. Burns 2004;30(6):569-72. 154. Wedler V, Guggenheim M, Moron M, et al. Extensive hydrofl uoric acid injuries: A serious problem. J Trauma 2005;58(4):852-7. 155. Gallerani M, Bettoli V, Peron L, et al. Systemic and topical effects of intradermal hydrofl uoric acid. Am J Emerg Med 1998;16(5):521-2. 156. Yamaura K, Kao B, Iimori E, et al. Recurrent ventricular tachyarrhythmias associated with QT prolongation following hydrofl uoric acid burns. J Toxicol Clin Toxicol 1997;35(3):311-3. 157. Kirkpatrick JJ, Enion DS, Burd DA. Hydrofl uoric acid burns: A review. Burns 1995;21(7):483-93. 158. Matsuno K. The treatment of hydrofl uoric acid burns. Occup Med (Lond) 1996;46(4):313-7. 159. Lin TM, Tsai CC, Lin SD, et al. Continuous intra-arterial infusion therapy in hydrofl uoric acid burns. J Occup Environ Med 2000;42(9):892-7. 160. Caravati EM. Acute hydrofl uoric acid exposure. Am J Emerg Med 1988;6(2):143-50. 161. Iverson RE, Laub DR, Madison MS. Hydrofl uoric acid burns. Plast Reconstr Surg 1971;48(2):107-12. 162. Muriale L, Lee E, Genovese J, et al. Fatality due to acute fl uoride poisoning following dermal contact with hydrofl uoric acid in a palynology laboratory. Ann Occup Hyg 1996;40(6):705-10. 163. Sheridan RL, Ryan CM, Quinby WC, Jr, et al. Emergency management of major hydrofl uoric acid exposures. Burns 1995;21(1):62-4. 164. Bertolini JC. Hydrofl uoric acid: A review of toxicity. J Emerg Med 1992;10(2):163-8. 165. Hatzifotis M, Williams A, Muller M, et al. Hydrofl uoric acid burns. Burns 2004;30(2):156-9. 166. Ohata U, Hara H, Suzuki H. 7 cases of hydrofl uoric acid burn in which calcium gluconate was effective for relief of severe pain. Contact Dermatitis 2005;52(3):133-7. 167. Mangion SM, Beulke SH, Braitberg G. Hydrofl uoric acid burn from a household rust remover. Med J Aust 2001;175(5):270-1. 168. Kono K, Watanabe T, Dote T, et al. Successful treatments of lung injury and skin burn due to hydrofl uoric acid exposure. Int Arch Occup Environ Health 2000;73 Suppl:S93-7. 169. Chou TD, Lee TW, Chen SL, et al. The management of white phosphorus burns. Burns 2001;27(5):492-7. 170. Konjoyan TR. White phosphorus burns: Case report and literature review. Mil Med 1983;148(11):881-4. 171. Davis KG. Acute management of white phosphorus burn. Mil Med 2002;167(1):83-4. 172. Kaufman T, Ullmann Y, Har-Shai Y. Phosphorus burns: A practical approach to local treatment. J Burn Care Rehabil 1988;9(5):474-5. 173. Fontanarosa PB. Electrical shock and lightning strike. Ann Emerg Med 1993;22(2 Pt 2):378-87. 174. Orme S, Channer KS. Tachycardia following low-tension electrocution. Postgrad Med J 1999;75(885):439- 40. 175. Bingham H. Electrical burns. Clin Plast Surg 1986;13(1):75-85. 176. Edlich RF, Farinholt HM, Winters KL, et al. Modern concepts of treatment and prevention of electrical burns. J Long Term Eff Med Implants 2005;15(5):511-32. 177. Koumbourlis AC. Electrical injuries. Crit Care Med 2002;30(11 Suppl). 178. Rai J, Jeschke MG, Barrow RE, et al. Electrical injuries: A 30-year review. J Trauma 1999;46(5):933-6. 179. Edlich RF, Farinholt HM, Winters KL, et al. Modern concepts of treatment and prevention of lightning injuries. J Long Term Eff Med Implants 2005;15(2):185-96.

110

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 110110 55/17/07/17/07 12:11:4012:11:40 PMPM 180. Fish RM. Electric injury, part iii: Cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med 2000;18(2):181-7. 181. Muehlberger T, Vogt PM, Munster AM. The long-term consequences of lightning injuries. Burns 2001;27(8):829-33. 182. Grube BJ, Heimbach DM, Engrav LH, et al. Neurologic consequences of electrical burns. J Trauma 1990;30(3):254-8. 183. Norman ME, Albertson D, Younge BR. Ophthalmic manifestations of lightning strike. Surv Ophthalmol 2001;46(1):19-24. 184. Ratnayake B, Emmanuel ER, Walker CC. Neurological sequelae following a high voltage electrical burn. Burns 1996;22(7):574-7. 185. Guinard JP, Chiolero R, Buchser E, et al. Myocardial injury after electrical burns: Short and long term study. Scand J Plast Reconstr Surg Hand Surg 1987;21(3):301-2. 186. Garcia-Sanchez V, Gomez Morell P. Electric burns: High- and low-tension injuries. Burns 1999;25(4):357- 60. 187. Housinger TA, Green L, Shahangian S, et al. A prospective study of myocardial damage in electrical injuries.[erratum appears in J Trauma 1986 Jul;26(7):659]. J Trauma 1985;25(2):122-4. 188. Hammond J, Ward CG. Myocardial damage and electrical injuries: Signiﬁ cance of early elevation of CPK-MB isoenzymes. South Med J 1986;79(4):414-6. 189. Chandra NC, Siu CO, Munster AM. Clinical predictors of myocardial damage after high voltage electrical injury. Crit Care Med 1990;18(3):293-7. 190. Purdue GF, Hunt JL. Electrocardiographic monitoring after electrical injury: Necessity or luxury. J Trauma 1986;26(2):166-7. 191. Matsumura H, Kobayashi Y, Mann R, et al. Residual myocardial damage following electrical injuries. J Burn Care Rehabil 1997;18(4):299-305. 192. Xiao J, Cai BR. A clinical study of electrical injuries. Burns 1994;20(4):340-6. 193. Cancio LC, Jimenez-Reyna JF, Barillo DJ, et al. One hundred ninety-ﬁ ve cases of high-voltage electric injury. J Burn Care Rehabil 2005;26(4):331-40. 194. Bailey B, Gaudreault P, Thivierge RL. Experience with guidelines for cardiac monitoring after electrical injury in children. Am J Emerg Med 2000;18(6):671-5. 195. Bailey B, Gaudreault P, Thivierge RL, et al. Cardiac monitoring of children with household electrical injuries. Ann Emerg Med 1995;25(5):612-7. 196. Blackwell N, Hayllar J. A three year prospective audit of 212 presentations to the emergency department after electrical injury with a management protocol. Postgrad Med J 2002;78(919):283-5. 197. Celik A, Ergun O, Ozok G. Pediatric electrical injuries: A review of 38 consecutive patients. J Pediatr Surg 2004;39(8):1233-7. 198. Cunningham PA. The need for cardiac monitoring after electrical injury. Med J Aust 1991;154(11):765-6. 199. Fatovich DM, Lee KY. Household electric shocks: Who should be monitored? Med J Aust 1991;155(5):301- 3. 200. Garcia CT, Smith GA, Cohen DM, et al. Electrical injuries in a pediatric emergency department. Ann Emerg Med 1995;26(5):604-8. 201. Wilson CM, Fatovich DM. Do children need to be monitored after electric shocks? J Paediatr Child Health 1998;34(5):474-6.

111

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 111111 55/17/07/17/07 12:11:4012:11:40 PMPM 202. Wallace BH, Cone JB, Vanderpool RD, et al. Retrospective evaluation of admission criteria for paediatric electrical injuries. Burns 1995;21(8):590-3. 203. Arrowsmith J, Usgaocar RP, Dickson WA. Electrical injury and the frequency of cardiac complications. Burns 1997;23(7-8):576-8. 204. Ulmer JF. Burn pain management: A guideline-based approach. J Burn Care Rehabil 1998;19(2):151-9. 205. Ang E, Lee ST, Gan CSG, et al. Pain control in a randomized, controlled, clinical trial comparing moist exposed burn ointment and conventional methods in patients with partial-thickness burns. J Burn Care Rehabil 2003;24(5):289-96. 206. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Acute pain management: Scientifi c evidence. 2nd ed: Australian and New Zealand College of Anaesthetists; 2005. 207. Carr E. Pain-free states. Nurs Times 1992;88(48):44-6. 208. Jacox A, Carr DB, Payne R. New clinical-practice guidelines for the management of pain in patients with cancer. N Engl J Med 1994;330(9):651-5. 209. Bickel A, Dorfs S, Schmelz M, et al. Effects of antihyperalgesic drugs on experimentally induced hyperalgesia in man. Pain 1998;76:317-25. 210. Borland ML, Bergesio R, Pascoe EM, et al. Intranasal fentanyl is an equivalent analgesic to oral morphine in paediatric burns patients for dressing changes: A randomised double blind crossover study. Burns 2005;31(7):831-7. 211. Ferguson SL, Voll KV. Burn pain and anxiety: The use of music relaxation during rehabilitation. J Burn Care Rehabil 2004;25(1):8-14. 212. Fratianne RB, Prensner JD, Huston MJ, et al. The effect of music-based imagery and musical alternate engagement on the burn debridement process. J Burn Care Rehabil 2001;22(1):47-53. 213. Field T, Peck M, Krugman S, et al. Burn injuries benefi t from massage therapy. J Burn Care Rehabil 1998;19(3):241-4. 214. Field T, Peck M, Hernandez-Reif M, et al. Postburn itching, pain, and psychological symptoms are reduced with massage therapy. J Burn Care Rehabil 2000;21(3):189-93. 215. Gustorff B, Hoechtl K, Sycha T, et al. The effects of remifentanil and gabapentin on hyperalgesia in a new extended infl ammatory skin pain model in healthy volunteers. Anesth Analg 2004;98(2):401-7. 216. Hammer NA, Lilleso J, Pedersen JL, et al. Effect of riluzole on acute pain and hyperalgesia in humans. Br J Anaesth 1999;82(5):718-22. 217. Haythornthwaite JA, Lawrence JW, Fauerbach JA. Brief cognitive interventions for burn pain. Ann Behav Med 2001;23(1):42-9. 218. Holthusen H, Irsfeld S, Lipfert P. Effect of pre- or post-traumatically applied I.V. Lidocaine on primary and secondary hyperalgesia after experimental heat trauma in humans. Pain 2000;88(3):295-302. 219. Ilkjaer S, Dirks J, Brennum J, et al. Effect of systemic n-methyl-d-aspartate receptor antagonist (dextromethorphan) on primary and secondary hyperalgesia in humans. Br J Anaesth 1997;79(5):600-5. 220. Ilkjaer S, Petersen KL, Brennum J, et al. Effect of systemic n-methyl-d-aspartate receptor antagonist (ketamine) on primary and secondary hyperalgesia in humans. Br J Anaesth 1996;76(6):829-34. 221. Long TD, Cathers TA, Twillman R, et al. Morphine-infused silver sulfadiazine (miss) cream for burn analgesia: A pilot study. J Burn Care Rehabil 2001;22(2):118-23. 222. Mikkelsen S, Jorgensen H, Larsen PS, et al. Effect of oral ketamine on secondary hyperalgesia, thermal and mechanical pain thresholds, and sedation in humans. Reg Anesth Pain Med 2000;25(5):452-8.

112

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 112112 55/17/07/17/07 12:11:4012:11:40 PMPM 223. Patterson DR, Ptacek JT, Carrougher G, et al. The 2002 Lindberg award. PRN vs regularly scheduled opioid analgesics in pediatric burn patients. J Burn Care Rehabil 2002;23(6):424-30. 224. Petersen KL, Brennum J, Dahl JB. Experimental evaluation of the analgesic effect of ibuprofen on primary and secondary hyperalgesia. Pain 1997;70(2-3):167-74. 225. Sharar SR, Carrougher GJ, Selzer K, et al. A comparison of oral transmucosal fentanyl citrate and oral oxycodone for pediatric outpatient wound care. J Burn Care Rehabil 2002;23(1):27-31. 226. Latarjet J. [The pain from burns] French. Pathol Biol (Paris) 2002;50(2):127-33. 227. Choiniere M, Melzack R, Rondeau J, et al. The pain of burns: Characteristics and correlates. J Trauma 1989;29(11):1531-9. 228. Cleeland CS, Ryan KM. Pain assessment: Global use of the brief pain inventory. Ann Acad Med Singapore 1994;23(2):129-38. 229. Paediatrics and Child Health Division, The Royal Australasian College of Physicians. Guideline statement: Management of procedure-related pain in children and adolescents. Sydney: Royal Australasian College of Physicians; 2005. 230. American Psychiatric Association. DSM-IV. Diagnostic and statistical manual of mental disorders. Washington (DC): American Psychiatric Association; 1994. 231. Stoddard FJ, Saxe G, Ronfeldt H, et al. Acute stress symptoms in young children with burns. J Am Acad Child Adolesc Psychiatry 2006;45(1):87-93. 232. Difede J, Ptacek JT, Roberts J, et al. Acute stress disorder after burn injury: A predictor of posttraumatic stress disorder? Psychosom Med 2002;64(5):826-34. 233. Van Loey NEE, Maas CJM, Faber AW, et al. Predictors of chronic posttraumatic stress symptoms following burn injury: Results of a longitudinal study. J Trauma Stress 2003;16(4):361-9. 234. Bisson JI, Jenkins PL, Alexander J, et al. Randomised controlled trial of psychological debrieﬁ ng for victims of acute burn trauma. Br J Psychiatry 1997;171:78-81. 235. Ehlers A, Clark D, Hackmann A, et al. A randomized controlled trial of cognitive therapy, a self-help booklet and repeated assessments as early interventions for post-traumatic stress disorder. Arch Gen Psychiatry 2003;60:1024-32. 236. Foa EB. Psychosocial treatment of posttraumatic stress disorder. J Clin Psychiatry 2000;61 Suppl 5:43-8; discussion 9-51. 237. Brunello N, Davidson JR, Deahl M, et al. Posttraumatic stress disorder: Diagnosis and epidemiology, comorbidity and social consequences, biology and treatment. Neuropsychobiology 2001;43(3):150-62. 238. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2006(1):Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub2. 239. Kennedy SH, Lam RW, Cohen NL, et al. Clinical guidelines for the treatment of depressive disorders iv. Medications and other biological treatments. Can J Psychiatry 2001;46(Suppl 1):38S-58S. 240. Robert R, Meyer WJ, 3rd, Villarreal C, et al. An approach to the timely treatment of acute stress disorder. J Burn Care Rehabil 1999;20(3):250-8. 241. Boeve S, Aaron L, Martin-Herz S, et al. Sleep disturbance after burn injury. J Burn Care Rehabil 2002;23:32-8. 242. Raymond I, Ancoli-Israel S, Choiniere M. Sleep disturbances, pain and analgesia in adults hospitalized for burn injuries. Sleep Med 2004;5(6):551-9. 243. Rizzone LP, Stoddard FJ, Murphy JM, et al. Posttraumatic stress disorder in mothers of children and adolescents with burns. J Burn Care Rehabil 1994;15(2):158-63.

113

AACC15029-2CC15029-2 Pr#6.inddPr#6.indd 113113 55/17/07/17/07 12:11:4112:11:41 PMPM 244. Meyer WJ, Blakeney P, Moore P, et al. Parental well-being and behavioral adjustment of pediatric survivors of burns. J Burn Care Rehabil 1994;15(1):62-8. 245. Broughton J. Injury to Maori: Does it really have to be like this? Dunedin: The Ngai Tahu Maori Health Research Unit and the Injury Prevention Research Unit, Department of Preventative and Social Medicine, University of Otago; 1999. 246. Ministry of Health. General practitioners fees information: A summary of key fi ndings from fi ve reports. Wellington: Ministry of Health; 2004. 247. SafeKids New Zealand. Factsheet: Pacifi c islands child injury: SafeKids New Zealand; n.d. http://www. safekids.org.nz/index.php/pi_pageid/42 [accessed June 2006]. 248. Ministry of Health. Making a Pacifi c difference: Strategic initiatives for the health of Pacifi c peoples. Wellington: Ministry of Health; 1997. 249. Villanueva E, Bennett MH, Wasiak J, et al. Hyperbaric oxygen therapy for thermal burns. Cochrane Database Syst Rev 2004(2):Art. No.: CD004727. DOI: 10.1002/14651858.CD004727.pub2. 250. Vogler BK. Aloe vera: A systematic review of its clinical effectiveness. Br J Gen Pract 1999;49:823-8. 251. Visuthikosol V, Chowchuen B, Sukwanarat Y, et al. Effect of aloe vera gel to healing of burn wound: a clinical and histologic study. J Med Assoc Thai 1995;78(8):403-9. 252. Ang ES, Lee ST, Gan CS, et al. Evaluating the role of alternative therapy in burn wound management: Randomized trial comparing moist exposed burn ointment with conventional methods in the management of patients with second-degree burns. Medscape General Medicine 2001;3(2):3. 253. Ang ES, Lee ST, Gan CS, et al. The role of alternative therapy in the management of partial thickness burns of the face – experience with the use of moist exposed burn ointment (MEBO) compared with silver sulphadiazine. Ann Acad Med Singapore 2000;29(1):7-10. 254. Atiyeh BS, Dham R, Kadry M, et al. Benefi t-cost analysis of moist exposed burn ointment. Burns 2002;28(7):659-63. 255. Atiyeh BS, Dham R, Dib ME. Cost-effectiveness of moist exposed burn therapy. Journal of Burns and Surgical Wound Care 2004;3(1). 256. Subrahmanyam M. Early tangential excision and skin grafting of moderate burns is superior to honey dressing: A prospective randomised trial. Burns 1999;25(8):729-31. 257. Lievre M, Marichy J, Baux S, et al. Controlled study of three ointments for the local management of 2nd and 3rd degree burns. Clinical Trials Meta-Analysis 1992;28(1):9-12. 258. Leaman AM, Gorman D. Cantharis in the early treatment of minor burns. Arch Emerg Med 1989;6(4):259- 61. 259. School of Pharmacy, University of Otago. Te rongoa Maori herbal medicine: Harakeke; n.d. http:// pharmacy.otago.ac.nz/rongoa/pages/harakeke.html [accessed June 2006]. 260. Matauranga Kura Taiao Project. Maori medicine – kawakawa: Aotea Harbour; n.d. http://www. aoteamoana.co.nz/tradition/kawakawa.htm [accessed August 2006]. 261. Whistler WA. Tongan herbal medicine. Honolulu, Hawaii: University of Hawaii Press; 1992. 262. World Health Organization, Regional Offi ce for the Western Pacifi c. Medicinal plants in the South Pacifi c: Information on 102 commonly used medicinal plants in the South Pacifi c. Manila: WHO Regional Offi ce for the Western Pacifi c; 1998. 263. Jairath N, Weinstein J. The Delphi methodology (part one): A useful administrative approach. Can J Nurs Adm 1994;7(3):29-42.

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