Effective Skin and Wound Management in Non-Complex Burns

Home , Burn, Chemical burn, Electrical burn, Lund and Browder chart, Wallace rule of nines, Wound

I NTERNATIONAL BEST PRACTICE BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS

3 BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS FOREWORD

Supported by an educational This document is a practical guide to the management of burn injuries for grant from B Braun healthcare professionals everywhere who are non-burns specialists.

With an emphasis on presenting hands-on and relevant clinical information, it focuses on the evaluation and management of non-complex burn injuries

The views presented in this that are appropriate for treatment outside of specialist burns units. However, document are the work of the it also guides readers through the immediate emergency management of all authors and do not necessarily burns and highlights the importance of correctly and expediently identifying reﬂect the opinions of B Braun. For further information about B Braun complex wounds that must be transferred rapidly for specialist care. Finally, it wound care products, please go to: looks at the ongoing management of newly healed burn wounds and post- http://www.woundcare-bbraun.com discharge rehabilitation.

© Wounds International 2014 The document acknowledges the importance of continuous and integrated Published by input from all members of the multidisciplinary team, where such a team Wounds International exists, while recognising the role and resources of singlehanded and outreach A division of Schofield Healthcare Media Limited generalists providing a complete care service. Enterprise House 1–2 Hatfields Although strategies vary within and between regions, this document seeks to London SE1 9PG, UK www.woundsinternational.com present the essential key best practice principles that can be applied univer- sally and adapted according to local knowledge and resources.

EXPERT WORKING GROUP Bishara Atiyeh, Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, To cite this document. American University of Beirut Medical Centre, Department of Surgery, Lebanon International Best Practice Juan P Barret, Head, Department of Plastic Surgery and Burns & Director, Burn Center/Face and Guidelines: Effective skin and Hand Transplantation Program & Professor of Surgery, Department of Surgery, University wound management of non- Hospital Vall d’Hebron, Barcelona, Spain complex burns. Wounds Interna- Professor Hu Dahai, Professor of Surgery, Department of Burns and Cutaneous Surgery, Xijing tional, 2014. Hospital, The Fourth Military Medical University, Xi'an, PR China Free download available from: Professor Franck Duteille, Head of Plastic, Reconstructive and Aesthetic Surgery Unit and Burns www.woundsinternational.com Centre, CHU, Nantes, France Ann Fowler, Burns Outreach Senior Nurse Practitioner, Stoke Mandeville Hospital, UK Dr Stuart Enoch, Director of Education and Research, Doctors Academy Group, Cardiff, UK, Visiting Professor, Department of Biomedical Technology, Noorull Islam University, India Elizabeth Greenfield, Administrative Director, International Society for Burn Injury, Texas, USA André Magnette, Head Nurse, Burns Unit, Centre Hospitalier Universitaire de Liège, Belgium Heinz Rode, Emeritus Professor of Paediatric Surgery, Red Cross Children's Hospital, University of Cape Town, South Africa Professor Xia Zhao-fan, Professor and Chairman, Department of Burn Surgery, Changhai Hospital, Second Military Medical University, Shanghai, PR China

3C BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS INTRODUCTION

Introduction

Burn injuries present many challenges to the In developing low- and middle-income BOX 2: REGIONAL DIFFER- diverse range of healthcare professionals who countries (LMICs), burn injuries are an in- ENCES IN BURN RATES5 encounter them worldwide. The European domitable problem, and much more common Q Infants in the WHO Burns Association describes a burn injury as a than in the USA and Europe or other high- African Region have three 3 complex trauma needing multidisciplinary and income developed countries . However, the times the incidence of 1 continuous therapy . exact number of burns in LMICs is difficult burn deaths of infants to determine. A conservative estimate puts worldwide Most non-complex burn injuries (see Box 1 the number of people admitted to hospital Q Boys under 5 years living for definitions) will heal spontaneously with with burns in India (population over 1 billion) in LMICs of the WHO conservative treatment. However, the quality at some 700,000 to 800,000 each year4. Eastern Mediterranean of initial care will affect the pain and distress a WHO reports that the majority of burn- Region are almost twice patient may experience, and will greatly influ- related deaths occur in LMICs, in particular as likely to die from burns ence the aesthetic and functional outcome. South-east Asia (Figure 1) (Box 25). as boys living in LMICs of the WHO European Studies show that burn injuries that take more Region than 2–3 weeks to heal are much more likely Q The incidence of burn 2 to result in hypertrophic scarring . FIGURE 1: Regional distribution of injuries requiring medical fire-related mortality6 care is nearly 20 times Complex burns must be promptly and appro- higher in the WHO West- priately identified and referred. Practitioners ern Pacific Region than in called on scene must also be well versed in 4% the WHO Region of the emergency management, including optimal 9% Americas fluid resuscitation and wound care, prior to transfer. 9%

BOX 1: DEFINITIONS 53% 10% This document uses the following definitions

Non-complex burn: (previously described as 15% minor burns) any partial thickness thermal burn covering )15% total body surface area (TBSA) in adults or )10% in children ()5% in children younger than 1 year) that does not affect a critical area*. Includes deep dermal South-east Asia Western Pacific burns covering )1% of the body. Africa Europe

Complex burn: (previously described as ma- Eastern Mediterranean USA jor burns) any thermal burn injury affecting a critical area* or covering >15% TBSA in adults or >10% in children (>5% in children younger than 1 year). All chemical and electrical burns Illiteracy, poverty and urban overcrowding, are considered complex. along with social, infrastructural, economic and cultural issues complicate further the *Burns to hands, feet, face, perineum or geni- universal challenges of prevention and man- talia, burns crossing joints and circumferential agement3,4. A discussion of the strategies burns needed to address these issues is beyond the scope of this document, but the main points for consideration are listed in Box 3 (see p2). SIZE OF THE PROBLEM Worldwide, an estimated 6 million people Survival outcomes in developed coun- seek medical treatment for burns annually, but tries have improved dramatically over most are treated in outpatient clinics (World the decades, so the emphasis today is on Burn Foundation www.burnfoundation.com). restoring post-burn function, appearance However, the lack of national and international and confidence by taking a considered registration of burns injuries makes it difficult multidisciplinary approach at all stages of to estimate the true cost of burns. management9,10.

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 1 INTRODUCTION

must be made clear to first-aid physicians BOX 3: STRATEGIES FOR BURN MANAGEMENT IN LMICs. ADAPTED who work at the scene of burn accidents FROM4,6,7,8 and to those involved in after-treatment in hospitals how extremely important it is to QInclude burns as part of the national health possess adequate basic knowledge15. agenda QDrive effective prevention programmes, Inappropriate or poor treatment may result including burn educational campaigns in schools in complications, such as infection and scar- QCreate a central registry of burns to docu- ring, unnecessary pain and anxiety for the ment extent of burns patient and family and increased societal Q Improve pre-hospital care with promotion costs (e.g. temporary loss of school or work of better referral systems based on triage activities). QDevelop regional centres of excellence with basic burn care undertaken at district TRAINING AND EXPERIENCE and base hospitals Most burn injuries (around 90% in the UK QDefine health needs based on priorities de- and the USA) are non-complex wounds fined locally with optimisation of existing that can be safely and effectively managed facilities to achieve minimally acceptable outside of specialist burns units10,12,13,16. standards of care Non-complex burns are commonly assessed QImplement cost-effective treatment ap- by a range of healthcare professionals, and proaches (re-use/recycle/adapt available there is a need to have agreement about resources) what types of injury need referral to a spe- Q Develop a national body of burn pro- cialist burn facility. However, distinguishing fessionals to educate healthcare staff between complex and non-complex burns is involved in burn care not straightforward, and many non-specialist doctors and nurses lack experience or formal training in burn management.

Using the UK (population about 60 million) In a survey carried out in the minor burn fa- to illustrate the size of the problem in devel- cility of the Royal Perth Hospital in Australia, oped countries, each year around10,11: only 39% of patients had received appropri- Q 250,000 people receive burn injuries ate first aid from their primary healthcare Q 175,000 of people with burns attend provider17. In a review of minor burns care in emergency departments hospital emergency departments in Ontario, Q 16,000 of these are admitted to hospital Canada, 70% of clinicians surveyed said for specialist care they would not measure burn area when Q 1,000 people have burns severe enough assessing a patient and 45% did not discuss for formal fluid resuscitation analgesic requirements18. Both are key Q 300 people die as a result of their burn components of burn care. These are serious injury. issues as poor initial management can cause a superficial burn wound to progress to a In the USA (population about 314 million), deeper, more complex wound19. each year around12,13: Q 1.25 million people receive burn injuries In some parts of the world, uncertainty and Q 450,000 of these receive medical misconceptions about management are treatment complicated by limited resources and lack of Q 40,000 people require in-hospital care, support personnel. including 30,000 at hospital burn centres Q 5,500 people die as a result of their burn injury.

A European-wide systematic review found that, across Europe, mortality rates vary from 1.4% to 18%14. There was a clear cor- relation between prognosis and the extent and depth of the burn injury. Therefore, it

32 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS CAUSES OF BURNS Causes of burns

Burns are caused by exposure to thermal (heat), electrical, chemical or radiation sources. Children under 5 years and the elderly are at increased risk of burn injury

CAUSES OF BURN BY AGE FIGURE 2: Causes of burns by incidence in the Children account for almost half of the popula- UK . Adapted from23 tion with severe burn injury and children below five years of age account for 50–80% of all 5% childhood burns20. Burns are the eleventh most common cause of death in children aged 1–9 years and the fifth most common cause of non-fatal childhood injuries. Globally, the

majority of children with burns are boys with a 40% ratio of 2:1 to girls, and there is a higher mortal- 55% ity rate from burns among boys20.

Most childhood burns occur in the home; scalds are the most common burn type (accounting for 60–70% of all hospitalised burn patients), followed by flame and contact 21,22 burns (Box 4). Chemical Flame Scalds and electrical The vast majority of adult burns occur in the home, outdoors or in the workplace. These result from thermal (scalds, flame, contact), decreased after legislation restricting the electrical or chemical sources. Other important design and material of night clothing. In causes include radiation and extreme cold developing countries, flame injuries are the (frostbite). most common form of burn, occurring mainly in women aged 16–35 years21,22. This group Who is at increased risk? spends long periods cooking at floor level in Those most vulnerable to burn injury include: loose-fitting clothing, using equipment that Q Children may be unsafe4,6 (Figure 3). Figure 3: Flame burn wound. Q Elderly people Photo courtesyProfessor Franck Q Those with reduced mental capacity, e.g. BOX 4: CAUSES OF BURNS BY AGE IN THE Duteille those with dementia or learning difficulties UK. ADAPTED FROM23 and those who may not recognise or react to a dangerous situation Young children (1–4 years) Q 20% of all patients with burns Q Those with reduced mobility and anyone with sensory impairment, which may pre- Q 70% due to scalds vent a quick response to injury. Q Boys more likely to be burnt than girls (due to behavioural differences)

MECHANISM OF INJURY Older children and adolescents (5–14 years) It is important to consider the mechanism by Q 10% of all patients with burns which a burn was caused, as this influences Figure 4: Scald burn wound. Q Teenagers often injured from illicit Photo courtesy Professor Franck the pathophysiology of the injury and, there- activities involving accelerants or Duteille fore, how it should be managed. electrocution

THERMAL BURNS Working age (15–64 years) Q 60% of all patients with burns Most burns are thermal injuries and these pre- Q Predominantly flame burns dominantly comprise scalds and flame injuries Q Around 33% work-related incidents (Figure 2)23. Elderly people (>65 years) Flame injuries Q 10% of all patients with burns In developed countries, flame injuries are most Q At higher risk of scalds, contact burns and commonly seen in men and women of working Figure 5: Scald burn wound showing flame burns (due to effects of aging, such typical map of Africa topography. age (15–64 years). The incidence in children as immobility and slowed reactions) Photo courtesy André Magnette

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 3 CAUSES OF BURNS

Flame injuries tend to be of any depth Flash burns (high voltage) occur when a (partial or full thickness — see Definitions person is exposed to an arc of high-voltage of burn depths, p10) and often a mixture of current, but the current does not actually depths. enter the body. The associated heat energy causes superficial burns to exposed body Scalds parts (such as face, neck, hands and upper Scalds are frequently due to spilling of hot limbs). Ignited clothing may cause deeper drinks and liquids, and immersion in a hot burns. Figure 6: Contact burn wound. Photo courtesy Professor Franck bath or shower (Figure 4, p3). They account Duteille for around 70% of burns in children, although Electrical burns may interfere with the they are also common in elderly people. cardiac cycle and cause arrhythmias. Cardiac monitoring should be considered Scalds tend to cause superficial or superfi- on admission. cial dermal burns, and may involve a large area of skin. In children who have pulled a CHEMICAL BURNS hot liquid onto themselves from a height, a Burn injuries from corrosive agents occur typical ‘map of Africa’ distribution may be mainly in industrial accidents, but they seen with a large area of burn at the top and can also result from products found in the Figure 7: Deep dermal contact a smaller area underneath (Figure 5, p3). home. burn wound. Photo courtesy André Magnette Contact burns Chemical burns are caused by: Contact burns occur either when the skin Q Acids (e.g. sulphuric, nitric, hydrofluoric, touches an extremely hot object (often hydrochloric and phosphoric) seen in industrial accidents) or when it Q Alkalis/bases (e.g. sodium or potassium touches a less hot object for a very long hydroxide, sodium or calcium hypochlo- time. The latter may be seen in people who rite, ammonia or phosphates, and have lost consciousness, such as those chemicals in household cleaning agents, with epilepsy or who misuse alcohol or bleaches and cement). These tend to Figure 8: Electrical burn. Photo drugs, or in elderly people after a fall or cause deeper burns than acids courtesy Professor Franck blackout. Q Organic products (e.g. bitumen). Duteille Common sources of contact burns include Chemical burns tend to cause deep dermal irons, oven doors, vitro-ceramic cooking or full thickness burns because the tissues stations, radiators and the glass fronts of continue to be damaged until the chemi- gas fires (Figure 6). cal is completely removed (e.g. by copious irrigation) (Figures 10–12, p5). Contact burns tend to cause deep dermal or full thickness burns (Figure 7). Be aware of the serious effects of absorption of chemical products from the skin. ELECTRICAL BURNS For example mercury can cause renal Electrical burns occur when electricity flows failure even from a small area of local skin through the body from an entry point to an damage. exit point. The burn is caused by the heat energy of the electric current damaging tissue PATHOPHYSIOLOGY Figure 9: Electrical burn. Photo along its path of flow (Figures 8 and 9). The pathophysiology of burn wounds is courtesy Professor Franck a slowly evolving process, unlike many Duteille The extent of tissue damage is determined other forms of trauma24. Whatever the by the voltage of the current: mechanism, burn injuries cause a local Q Low-voltage (domestic current) burns response and, in complex burns, a systemic — Small, deep contact burns are seen at response. the entry and exit points Q High-voltage burns Local response — Currents of more than 1,000 volts The local response to a burn injury consists cause extensive deep tissue damage of inflammation, regeneration and repair. and even limb loss. Currents of more A burn may be divided into three zones than 70,000 volts are usually fatal. (Figure 13, p5):

34 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS CAUSES OF BURNS

Q Zone of coagulation/necrosis Systemic response — At the centre of the wound In complex burns of more than 20–30% — No tissue perfusion TBSA, there is also a systemic response due — Irreversible tissue damage due to to the extensive release of inflammatory coagulation of proteins mediators at the injury site. The effects are far reaching and include systemic hypoten- Q Zone of stasis sion, bronchoconstriction, a threefold increase — Surrounds the central zone of coagu- in basal metabolic rate and a reduced immune lation response25. — Decreased tissue perfusion — Some chance of tissue recovery with Figure 10: Dry necrotic eschar optimal management covered chemical burn. Photo courtesy Professor Franck Duteille Q Zone of hyperaemia — At the periphery of the wound — Good tissue perfusion — Tissue recovery likely.

These zones are dynamic environments. In the superficial areas and around the edges, the usual process of repair occurs (ingrowth of capillaries and fibroblasts followed by formation of granulation tissue and scar). After 3–4 days, loss of tissue viability in the zone of stasis (for example, due to delayed or suboptimal management) will cause the burn wound to become deeper and wider. Figure 11: Chemical burn with acid. Such wounds tend to be superficial and self-limiting. Photo courtesy Professor Franck Duteille

FIGURE 13: Zones of a burn injury (photo courtesy Professor Heinz Rode)

Zone of hyperaemia Viable tissue

Figure 12: Chemical burn due to sodium hydroxide (caustic soda) a strong alkali. Photo courtesy André Magnette

Zone of stasis Decreased tissue perfusion Obliteration of microcirculation, release

of mediators — TXA, anti-O2 ischaemic reperfusion injury, increase in local vascular permeability

Central zone of necrosis Coagulative necrosis

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 5 EMERGENCY MANAGEMENT Emergency management of non-complex burns

Clinicians working in the emergency department or community must be confident in assessing and managing burn injury to ensure optimal outcomes

GENERAL FIRST AID In some situations an antidote can combat the First aid and initial management of the burn effects of the chemical irritant (e.g. calcium site can limit tissue damage and subsequent gluconate gel will inactivate hydrofluoric acid). mortality26. Emergency management contin- Some regions therefore recommend seeking ad- ues to be effective for up to 3 hours after the vice from a regional or national toxicology unit. initial burn injury. Irrigation of electrical burns is not appropriate If you are the first on scene responder, the because the heat damage occurs deep under priorities are to: the surface of the skin. Water irrigation defi- Q Check that it is safe to approach the pa- nitely must not be performed before turning tient, call for help and, if appropriate, wear off the electric power source. appropriate personal protective equipment Q Stop the burning process (extinguish any Remember: cool the burn, not the patient. flames using ‘drop and roll’ or turn off the Cooling large areas can cause hypothermia, electricity supply, as appropriate) and especially in children29. For this reason, do remove the patient to a safe place with not apply wet soaks or ice packs, or use fresh air. Remove non-adherent clothing these during transit. Patients should be and any potentially restricting jewellery covered with coats, sheets or blankets to Q Apply general first aid to cool the burn keep them warm. wound. Cover the burn Cool the burn wound In most instances, burns should be covered Cooling thermal burns with tepid, running immediately after cooling. Covering the water (12–18˚C) removes heat and prevents burn helps to: progression of a thermal burn injury and Q Prevent bacterial colonisation29,35 limits tissue damage27. It can also reduce Q Prevent dessication36 pain, cleanse the wound and minimise swell- Q Relieve pain from exposed nerve ing. This is effective if performed within 20 endings37. minutes of the injury occurring16 and should be continued for up to 30 minutes28,29,30. Layers of polyvinylchloride (PVC) film (i.e. cling film, Glad wrap, Saran wrap) forms If water is not available then wet towels/ an excellent emergency dressing for an compresses or hydrogels (in adults only) acute burn injury (Figure 14). The layers of Figure 14: Cling film for dressing are a second-line alternative31,32, although film must be laid over the burn rather than burn wounds. Lay on wound to prevent external contamination. they may be prohibitively expensive in some wrapped circumferentially, to avoid the Allows inspection of wound, is regions. possibility of constriction. If PVC film or a non-adherent, conformable and cost-effective alternative is not available, essentially sterile. Photo cour- Ice or very cold water should be avoided then a clean, cotton sheet or similar is tesy Professor Heinz Rode because it causes vasoconstriction and may, appropriate. paradoxically, deepen the wound27. Cellophane transparent film (made from Chemical burns require longer periods of regenerated cellulose) can worsen chemical copious irrigation — until the injury no longer burns so dressings soaked with water/saline causes pain or the pH has been normalised or hydrogels should be used instead, taking (e.g. by testing with urine pH sticks). Corro- care to avoid hypothermia10. sive agents continue to cause tissue damage until they are completely removed. Eye inju- In hot, humid, subtropical climates, burn ries should be irrigated copiously with sterile dressings become rapidly saturated and saline. Diphoterine® solution, if available, is infected. Burn wounds should therefore be a very effective washing agent for chemical left exposed, or loosely covered with a clean burns33,34. towel or moisture-retentive ointment.

36 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS EMERGENCY MANAGEMENT

Do NOT apply topical antimicrobial creams at In patients who are clearly well other than BOX 5: PRIMARY SURVEY this stage, as they will hinder later assessment an obviously non-complex burn injury, FOR PATIENTS WITH BURN of the wound. it is acceptable to move straight to the INJURIES secondary survey. A Airway maintenance with RELIEVE PAIN cervical spine control Pain management in patients with burn inju- Fluid resuscitation B Breathing and ries is often inadequate. While cooling and Effective fluid resuscitation is the corner- ventilation covering the burn gives some relief, opioids stone of management in major burns. If C Circulation with may be needed initially for pain control. the burn area is over 15% in adults or 10% haemorrhage control D Disability — neurological in children, intravenous fluids should be assessment Superficial epidermal burns can be ex- started as soon as possible on scene (e.g. E Exposure — preventing tremely painful (more so than deep wounds) using the rule of 10, see Box 6), although hypothermia because the nerve endings remain intact but transfer should not be delayed by more F Fluid resuscitation exposed. Medicate with a combination of than two cannulation attempts16,29,37,40. paracetamol with a low to moderate potency For physiological reasons the threshold is opioid at the correct dose. Subsequently, closer to 10% in the elderly (>60 years)11. BOX 7: SUGGESTED a non-steroidal anti-inflammatory drug is REGIMEN FOR FLUID sufficient. BOX 6: THE RULE OF 10 RESUSCITATION. ADAPTED FROM31 1. Estimate burn size to the nearest 10 Patients with partial thickness dermal burns Adults should be given intravenous opioids at a 2. %TBSA x 10 = Initial fluid rate in ml/h (for adults weighing 40-80kg) Resuscitation fluid alone (first dose appropriate to body weight10,16,38 or 24 hours) 3. For every 10kg above 80kg, increase the intranasal diamorphine10. Q Give 3–4ml (3ml in super- rate by 100ml/h ficial and partial thickness Cooling gels (e.g. Burnshield) may be used burns/4ml in full thickness to cool the burn and relieve pain in the initial Various resuscitation fluids are available burns or those with as- 16 sociated inhalation injury) stages . A full discussion of pain relief as and there is no ideal regimen to follow. Hartmann's solution/kg part of ongoing management is given in Healthcare professionals should refer to body weight/%TBSA. Half Management of non-complex burn wounds local protocols. However, a commonly of this calculated volume is (p17). used regimen using crystalloid Hartmann's given in the first 8 hours af- solution and the Parkland formula to calcu- ter injury and the remaining The tetanus status of the patient should late the volume required is given in Box 7. half in the second 16-hour period be determined and immunisation given if indicated39. BURN-SPECIFIC EVALUATION — Children SECONDARY SURVEY Resuscitation fluid as above ASSESSMENT — PRIMARY SURVEY A patient history and physical examination plus maintenance (0.45% All burn victims should be evaluated first as (sometimes known as the secondary sur- saline with 5% dextrose, the volume should be titrated trauma patients, using advanced trauma life- vey) should identify issues that impact on against nasogastric feeds or 1,29,39 support guidelines . This is often known the immediate management of the patient oral intake): as the primary survey, and it aims to identify and/or have implications for transfer deci- Q Give 100ml/kg for the and stabilise any life-threatening injuries. sions. The evaluation should determine13: first 10kg body weight plus The mnemonic ABCDEF indicates the order Q Approximate wound size (see Evalu- 50ml/kg for the next 10kg of priority for addressing problems (Box 5). ating burn injury: assessing area and body weight plus 20ml/kg depth, p9) for each extra kg For burn victims, there should be a particu- Q Approximate wound depth (see Evalu- lar emphasis on the airway and breathing. ating burn injury: assessing area and These may be compromised by38: depth, p9) Q Mechanical restriction of breathing (e.g. Q Location of burn injury (including any due to a circumferential deep dermal burn involvement of the face, eyes, ears, limiting chest expansion or a burn to the hands, genitals or feet) lower part of the face) Q Presence of an inhalation injury Q Blast injury (e.g. causing penetration of Q Presence of a circumferential deep the lung) dermal burn injury Q Smoke inhalation (e.g. combustion prod- Q The cause of the burn injury (thermal, ucts causing lung irritation and the effects electrical or chemical) of carboxyhaemoglobin). Q Suspicion of abusive injury.

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 7 EMERGENCY MANAGEMENT

BOX 8: WHERE THERE IS A In addition, the following situations may based purely on the size and depth of the DELAY IN TRANSFER TO A warrant special consideration or referral burn, and careful assessment of the patient 41 BURNS SERVICE even if the burn is non-complex: is required . If there is uncertainty whether Q Any co-existing medical conditions (e.g. referral is appropriate, seek specialist advice If the time from burn to ar- rival at a burns service is <6 cardiac disease, diabetes, pregnancy or (Figure 15). hours and the burn is clean: immune-compromised state) Q Wash burn wound, cover Q Any predisposing factors that may When transfer is delayed, ensure the burn with plastic cling wrap for require further investigation or treatment is suitably dressed (Box 8) to avoid con- transfer (do not wrap (e.g. a burn resulting from a fit or faint) tamination. circumferentially), allowing Q The possibility of non-accidental injury for easy assessment at Q The person’s social circumstances (e.g. Telemedicine and transmission of photo- the burns service without an older person living alone). graphs to the burn unit may help make a undue discomfort from more accurate estimate of the burn extent. removal of dressings Therefore admissions criteria to specialist care (burns unit or plastic surgery) are not If transfer is likely to be >6 hours or the burn is dirty: Q Dirty or charred burns should be washed with sterile water/tap water (de- FIGURE 15: Emergency management pathway for burns pending on local protocol) and dressed with a silver product (impregnated silver Stop burning process dressing or topically applied Remove jewellery or hot clothing FIRST AID silver sulfadiazine cream) Q Clean burns should be dressed with a low-adher- Cool the burn ent silicone dressing Place under running cool tap water for 20 minutes or apply hydrogel

Provide analgesia according to pain protocol — superficial and partial thickness dermal burns INITIAL are very painful

Check for trauma and any life-threatening injuries

Check tetanus status and provide immunisation if PRIMARY SURVEY indicated according to local protocols

Assess burn size SECONDARY SURVEY

Assess burn depth

Does patient require admission to burns unit? Ensure burn is covered and prepare YES patient for transfer

UNSURE Contact burns unit for advice. Use telemedicine if appropriate

NO Debride blisters and remove all loose burned tissue Follow protocols for local wound management, with review at 10–14 days (p15) If poor progress, refer to burns unit for specialist advice

38 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS ASSESSING AREA Evaluating a burn injury: AND DEPTH Assessing area and depth The total area of the burn is significant as the skin acts as a barrier to the environment

The cause of injury, depth and extent of a non- Three methods are commonly used: complex burn should be assessed in the Q Lund and Browder chart same way as for more complex burns. Q Wallace’s ‘rule of nines’ Q Palmar surface. Timely and accurate estimation of the surface area and depth of a burn injury Lund and Browder chart is essential for determining appropriate The Lund and Browder chart is one of the management, ensuring rapid healing and most commonly used methods for assess- preventing complications. ing burn area42. It takes into account the variation of body surface area with growth It is important to expose and assess all of and can be used for both adults and chil- the burn. With large burns, parts of the dren (Figure 16). body can be uncovered in turn to help keep the patient warm. Wallace’s rule of nines This is a useful tool for estimating burn ASSESSING BURN AREA area in adults43. The body is divided into Total burn area is expressed as the percent- regions divisible by 9 and the total burn age of the TBSA. It is vital for establishing area can be calculated by estimation from fluid resuscitation needs and for monitoring a standard diagram (Figure 17). healing progress.

FIGURE 16: Lund and Browder chart FIGURE 17: Rule of nines (adults)

% Total body surface area burn

A % A 41/2% 1 1 Region PTL FTL 9% 49%1/2% 13 Head 13 2 2 2 2 4 4 Neck 1/2% 1/2% 1/2% 1/2%

4 9% 4 9% 11/2 11/2 1/2 1/2 Ant. trunk 1 1 1 21/2 21/2 1% Post. trunk 11/2 B B 11/2 Right arm 11/2 B B 11/2 Left arm C C Buttocks 9% 9% 9% 9% C C Genitalia 13/4 13/4 Right leg 13/4 13/4 Left leg Total burn Paediatric assessment ruler 1 yr 2 yr 3 yr 4 yr 5 yr 6 yr 7 yr 8 yr 9 yr 10 yr–adult 9 Area Age 0 1 5 10 15 Adult 14 13 12 11 10 18 17 16 15 A= 1/2 of head 9 1/2 8 1/2 6 1/2 5 1/2 4 1/2 3 1/2 18 18 18 18 18 18 18 18 B= 1/2 of one 23/4 3 1/4 4 4 1/2 4 1/2 43/4 9 18 9 9 18 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 1 9 thigh 14.5 14.5 15.5 15.5 17.5 17.5 16.5 16.5 14 14 18 18 16 16 15 15 17 17 18 18 C= 1/2 of one 21/2 21/2 23/4 3 3 1/4 3 1/2 lower leg Body surface area percentiles for each age group. Select patient's age to determine body surface area ratio for each body area to calculate burn size. Adapted from Victoria Burns Service www.vicburns.org.au

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 9 ASSESSING AREA AND DEPTH

Palmar surface Definitions of burn depth FIGURE 18: Palmar surface A simple method to estimate burn area is Burn injuries are classified into two groups ac- to consider the palm of the patient’s hand cording to the amount of tissue damage. with closed fingers as representing ap- proximately 1% of the body surface area. It 1. Superficial partial thickness burns (also is effective for estimating the area of small known as first and second degree) burns (<15%) or large burns (>85%). In Most burns are partial thickness burns or have large burns, the burnt area can be quickly an element of this depth47. These injuries do not calculated by estimating the area of un- extend through all the layers of skin. They may injured skin and subtracting it from 100 be further classified into: (Figure 18). Q Superficial/epidermal (also known as superficial first degree) When estimating TBSA, do not include — Only the epidermis is damaged (Figure 19, simple erythema (reddening of the sur- p11) rounding skin) in your calculation41. — Typified by sunburn — No blistering The hand area (palm In practice, burn size is estimated correctly Q Superficial dermal (also known as superficial and digits) approxi- only one third of the time. A single-centre partial thickness) mates to 1% of the study comparing the initial assessment of — Burn extends into the upper layers of the total body surface TBSA in the emergency room with the final dermis 44 area evaluation made in the burn centre showed — Painful (due to exposed superficial that the TBSA was overestimated by over nerves) 100% in 24 out of 134 patients45. Nichter — Blistering present (Figure 20, p11) et al described an error rate of 29% using Q Deep dermal (also known as deep partial thick- the rule of nines and Lund and Browder ness) charts46. — Burn extends into the deeper layers of the dermis, but not into the underlying A summary of the advantages and disad- subcutaneous tissues (Figure 21, p11) vantages of the three main assessment — Seen with burns from hot fat or oil tools is given in Table 1. — Healing associated with some contraction and scarring. ASSESSING BURN DEPTH The depth of a burn is determined by the 2. Full thickness burns (also known as third amount of energy delivered to the skin and degree) the thickness of the skin. It is a key meas- Q Burn extends through all layers of the skin ure of long-term prognosis, and the assess- and into the subcutaneous tissues ment will directly inform the management Q Underlying tissue may appear pale or black- plan. ened Q Remaining skin may be dry and white, brown Burn depth may increase with time, so re- or black with no blisters (Figure 22, p11) assessment after 24–72 hours is essential. Q Healing associated with considerable contraction and scarring. Before looking at techniques for estimating burn depth, it is important to understand Severe full thickness burns (fourth degree) the terminology used. extend into muscle and bone.

TABLE 1: Burn area assessment tools: pros and cons

Method Pros Cons Palmar Quick and easy for small Not accurate for medium burns surface or large burns Rule of nines Quick and easy in adults Tends to overestimate area; not accurate for children Lund and Most accurate method; Takes time to record and calculate values Browder suitable for adults and children

310 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS ASSESSING AREA AND DEPTH

TABLE 2: Characteristics of burn types according to depth

Burn type Appearance Blisters Capillary Sensa- Treatment refill/ tion blanching on pressure Superficial epider- Red and Not Brisk Painful Usually heals within 7 mal (superficial/first glistening present days with conservative degree) (moist) treatment No scarring Figure 19: Superficial epidermal Superficial dermal Red/pale pink Large Brisk, but Painful Usually heals within 14 burn. Photo courtesy André (superficial partial blisters with slower days with conservative Magnette thickness) return treatment No scarring Deep dermal (deep Dry, blotchy/ May be Absent Variable Although can heal with partial thickness) mottled and present conservative treat- cherry red/ ment, complex burns stained may require surgical appearance intervention Possible scarring Figure 20: Superficial dermal Full thickness (third Dry, leathery, Not Absent Absent Complex full thickness burn. Photo courtesy Professor degree) white or black present wounds seldom heal Franck Duteille (charred). with conservative treat- Eschar may ment. Usually requires be present surgical intervention

Assessment of burn depth Burn depth is determined by making a sub- jective assessment of the characteristics of the injury (Table 2). This is not easy; in one comparison of assessments by experienced sur- 48 geons, there was only a 60–80% concurrence . Figure 21: Deep dermal burn. Other objective methods are available (e.g. Photo courtesy Professor Franck biopsy and histology, thermography and laser Duteille doppler), but these are expensive tools requiring expert operators and are not practical outside of specialist burn units49.

Burn depth may be heterogeneous, ranging from superficial in some parts to deep dermal or full thickness in other areas. Figure 22: Full thickness burn. It may be necessary to deroof any blisters and/ Photo courtesy Professor Franck or debride dead skin to be able to visualise the Duteille wound bed (see Management of non-complex burn wounds p15).

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 11 TAKING A FULL HISTORY Evaluating a burn injury: Taking a full history

A detailed history informs the decision to refer the patient and guides subsequent management26

BOX 9: NUTRITIONAL A detailed history should include49: Q Was there a flash or arcing? ASSESSMENT Q Exactly how the injury was sustained A patient's nutritional Q Medical and social history Chemical burn injuries status can affect how well Q Nutritional status (Box 9) Q What was the chemical? the burn wound heals. A Q Details of any emergency management/first Q What was the strength/concentration? full nutritional assessment aid performed Q Does the patient have any information with should be taken to identify any nutritional deficiencies Q Family contact details. them about the agent involved? that might affect wound healing or shed light on the MECHANISM OF INJURY MEDICAL HISTORY underlying cause of the Detailed information should be sought about A full medical history may reveal factors that can burn (e.g. history of falls). the cause (thermal, chemical, electrical) of the affect the depth of the wound, for example, pa- One such assessment tool is the Malnutrition Uni- burn injury. tients with diabetes can be prone to micro-and versal Screening (MUST) macrovascular complications51. Comorbidities Tool50 The size and depth of tissue damage is deter- may also be relevant to potential interventions mined by the temperature or strength of the (e.g. chronic obstructive pulmonary disease injuring agent and the amount of time it was and ischaemic heart disease). The history may in contact with the skin. You should therefore determine why the patient suffered the burn. ask29,49: Many patients receive burn injuries because Q What was the exact cause of the injury? they are vulnerable; for example, they may have Q When did the injury occur? had an epileptic seizure or a stroke or have Q How did the injuring agent (e.g. flame, been intoxicated. Elderly patients may have lost chemical, electrical current) come into con- consciousness or have fallen, and there may be tact with the patient? an underlying cause for this24. You should ask Q For how long was the patient exposed to the about: injuring agent? Q Previous and current medical problems Q Medicines they are taking/vaccinations Specific questions for different causes are as Q Allergies follows. Q Smoking habits (may affect blood gas Scald injuries analysis) Q What was the liquid? Q Possible pregnancy (the unborn child needs Q Was it boiling or recently boiled? special consideration)52. Q For hot drinks, was milk added (this will lower the temperature)? EMERGENCY MANAGEMENT Q Was a solute, such as food to be cooked, UNDERTAKEN added to the boiling water (this will raise the The extent and quality of any first aid undertak- boiling temperature)? en will give clues to the expected burn depth. You should ask: Contact burn injuries Q What first aid was performed? Q What setting was the heat source on? Q How long was cooling applied? Q Was fluid resuscitation started and when? Flame burn injuries Q What treatment has been started? Q Was the patient exposed to a flash or did they have direct contact with the flame? NON-ACCIDENTAL INJURY Q Did it occur in an open/closed space? It is important to be vigilant for signs and Q What was the source of the fire (i.e. what symptoms of non-accidental injury when materials were ignited? Were flammable evaluating a burn, particularly in a vulnerable liquids involved, which may intoxicate by patient. Some 3–10% of burns in children are absorption)? due to non-accidental injury25. Any suspicion should prompt an immediate hospital admis- Electrical burn injuries sion (regardless of the complexity of the burn) Q What was the voltage (domestic/industrial)? and notification of social services.

312 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS WHEN TO REFER Evaluating a burn injury: When to refer

BOX 11: TOXIC SHOCK Keep in mind the expected evolution of the burn injury; if healing does not progress SYNDROME as predicted, then the patient should be referred to a burn unit Q Usually occurs in small burns (>10% TBSA) Once the burn injury has been evaluated the worldwide, and many burns can be man- Q May present with: team must decide whether the patient should aged effectively in general hospitals. Only the — Fever — Rash of any type be transferred to a specialist burns unit or most complex cases should be referred to a — Diarrhoea/vomiting is suitable for outpatient management. In specialist burn facility. Non-complex burns — Irritability general, all complex burn injuries should be heal spontaneously, and only those requiring — Drowsiness hospitalised (Box 10)1,11,29,39,53. surgical consultation will require referral. — Poor feeding — Capillary refill >3 seconds The decision should be based on: Be aware of toxic shock syndrome — a rare — Tachycardia Q Size of the burn injury (TBSA) but fatal complication of small burns in chil- — Tachypnoea Q Depth of the burn injury dren (Box 11). — Mucosal hyperaemia Q Mechanism of the burn Q Usually manifests 2–4 Q Site of the burn wound In developing countries, referral is complicated days post injury Q Pain not adequately controlled with oral by the fact that specialist burn units tend to be Q Burn wound often ap- analgesia located in large cities, which are often difficult pears 'clean' Q Patient often deterio- Q Other (e.g. living alone, inadequate support to reach. Many units have limited resources, rates rapidly at home or inability to cope with dressing lack operating time and may not be able to Q Children <2 years are care, or problems in attending appoint- cope with the high volume of referrals. They particularly susceptible ments due to transport difficulties). may be staffed by general surgeons without Q Once shock develops, formal training in burn injuries and so complex mortality may be as If there is any doubt about whether to refer a surgical interventions are not available to the high as 50% patient, discuss the injury with a consultant in vast majority of patients who need them3,4. Adapted from Guidelines for your local specialist burns unit. Telemedicine can be an invaluable tool here, the Management of Paediatric especially if access to a burns specialist is Burns. Available from www. There is a shortage of specialist burns beds remote. wch.sa.gov.au

BOX 10: CRITERIA FOR REFERRING BURN INJURIES TO A SPECIALISED BURN UNIT A complex burn injury comprises and is likely to be associated with: Q Large size: — >10% TBSA in children (>5% in children younger than 1 year) — >15% TBSA in adults Q All full thickness burns in any age group and any extent Q Deep dermal burns >5% TBSA in adults and all deep dermal burns in children Q Mechanism of injury: — All chemical and electrical burns — Exposure to ionising radiation — High-pressure steam injury — Suspected non-accidental injury Q Age (<10 or >49 years) Q Site of injury (there are no absolute criteria, but the following should be considered): — Face, hands, genitals or perineum — Any flexural surface such as neck, axilla, front of elbows OR back of the knee Q Circumferential deep burns in any age group Q Burns with a suspicion of inhalation injury Q Co-existing conditions that could complicate burn management, prolong recovery or affect mortality Q Associated injuries (fractures, head injury or crush injuries) Q Septic burn wounds Q Burn patients who require special social, emotional or long-term rehabilitation support

Late referrals (e.g. wounds not healed with conservative treatment within 10 days) are discussed in Management of non-complex burn wounds (p14)

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 13 MANAGEMENT OF NON-COMPLEX BURN WOUNDS Management of non-complex burn wounds

Patients with non-complex burns can be managed as outpatients in emergency departments, minor injuries clinics, walk-in centres and GP surgeries rather than specialist centres

The care of patients with non-complex burn and control of bacteria through moist wound injuries is usually nurse-led, and services healing (Figure 23). Superficial and superficial should be aimed at: dermal burns generally heal rapidly (within Q Preventing or reducing the risk of wound one week) with the support of simple meas- infection ures (e.g. soothing gels, such as aloe vera), Q Applying moist wound care while dermal burns will require a secondary Q Optimising pain relief dressing and may take up to 2 weeks to heal. Q Providing patient education. Factors that delay healing or lead to wound progression include wound infection, presence Local burn wound management is one of the of hypergranulation tissue, wound dessica- most important aspects of burn therapy after tion and systemic issues such as hypotension. the emergency treatment phase and can have Deep dermal wounds are more difficult to considerable influence on time to healing54. treat, but some will heal without surgical inter- The goals of local wound management are vention if a moist wound environment that is the prevention of dessication of viable tissue free from infection is encouraged.

FIGURE 23: Local burn wound treatment

Superficial/epidermal burn Superficial dermal burn Deep dermal burn Full thickness burn

Wash with soap and water Cleanse/debride Cleanse/debride Initial Apply soothing gels (e.g. aloe Manage exudate if present Ensure moist wound treatment vera)/moisturising creams (usually first 72 hours) healing Manage blisters Provide analgesia Provide analgesia

Select appropriate dressing(s) based on exudate level, infection risk and risk of adherence to wound Review after 48 hours, then every 3–5 days

Refer to burns unit 7 days Healing satisfactorily Local infection (e.g. exudate, Progression to full redness, friable tissue) thickness burn

If appropriate, continue Treat with topical with wound dressing/skin antimicrobial to care regimen manage infection and hypergranulation and review 2–3 days

Fully healed Healing satisfactorily Healing not progressing Refer to burns unit 14 days Advise on skin care/scar for advice/surgical management consultation

If appropriate, continue with simple wound dressing and review at dressing change

Fully healed Advise on skin care/scar management

314 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS MANAGEMENT OF NON-COMPLEX BURN WOUNDS

CLEANSING AND DEBRIDEMENT Taking photos of the wound will help moni- A new burn is essentially sterile and it tor healing progress and may be useful if is important to keep it clean and moist specialist advice about assessment and to promote the development of healthy treatment needs to be sought. granulation tissue. To minimise the risk of microbial contamination, all wounds should BURN WOUND DRESSINGS undergo some form of cleansing to remove Selecting a dressing foreign bodies, soluble debris, necrotic A wide variety of dressings is available for tissue or slough, all of which can become the treatment of partial thickness burn Figure 24: Blisters are common a focus for infection1,39,53. Irrigation is the wounds, but none has strong evidence to features of superficial dermal 60 burns. The skin covering the preferred method for cleansing wounds, support their use . Understanding the key blister is dead and is separated and various solutions can be used, including principles of dressing selection will help to from the base by inflammatory normal saline or warm tap water. Mild soap simplify the process. oedema fluid (blister fluid). may also be used. Topical wound irrigation Photo courtesy Professor Heinz solutions containing topical antiseptics (e.g. Traditional dressings include a combina- Rode polyhexamethylene biguanide [PHMB]) can tion of paraffin-impregnated gauze and an be considered to maintain a low bacterial absorbent cotton wool layer61. However, load, reducing the risk of infection55, 56 and these simple dressings tend to adhere to the improving time to healing55. wound surface53.

Wound cleansing is an integral part of burn Advances in dressing technology has lead management. To optimise burn wound to a wider range of dressing options, some healing, further evidence-based studies to of which may offer advantages over tradi- confirm the positive effects of topical antimi- tional products in terms of time to healing, Figure 25: When the blister crobial agents are needed to form a unified pain experienced and frequency of dressing ruptures (or is deroofed), the 57 60 underlying dermis is exposed. approach . changes . The characteristics of a good Dessication of the exposed burn wound dressing have been described dermis may affect the depth Debridement of the wound and wound edges as53: of tissue loss. Photo courtesy to remove necrotic tissue can reduce the risk Q Maintains a moist wound environment Professor Heinz Rode of infection and encourage epithelialisation30. Q Contours easily This may be a one-off debridement or ongo- Q Non-adherent to protect delicate skin ing for maintenance. It is important to use a Q Retains close contact with the wound bed debridement method that is appropriate to Q Easy to apply and remove the location of the wound, amount of tissue Q Painless on application and removal to be removed and the needs of the patient Q Protects against infection as well as the skill of the healthcare profes- Q Cost-effective. sional58. Appropriate analgesia should be given before dressing change — it should not A simple non-adhesive wound contact layer be painful for the patient. If surgical debri- with a secondary absorbent layer is effective dement is indicated, the patient should be for most non-complex superficial dermal sedated and given a general anaesthetic. burns (Table 3). Pain is also an important consideration and, where possible, non- Managing blisters adherent products (e.g. incorporating soft The general consensus is that blisters greater silicone) should be considered. These can than 1cm2 should be deroofed, while smaller remain in place for a few days, allowing blisters should be left intact16. Blisters on the the wound bed remain undisturbed. The palm of the hand should be left intact (as secondary absorbent layer can be changed deroofing is painful here) unless they restrict more often to manage exudate62. movement25 (Figures 24 and 25). After deroofing, any remaining dead skin should be Where a burn injury is a mixture of depths, removed with sterile scissors. your choice of dressing should be based on the predominant depth26. At this point, you should also take swabs for microbiology if infection is suspected, In some LMICs the use of expensive com- although giving routine prophylactic antibiot- mercially produced dressing products may ics is not recommended1,13,53,59. not be viable. The development of cheaper,

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 15 MANAGEMENT OF NON-COMPLEX BURN WOUNDS

FIGURE 26: Dressing selection based on extent of burn injury

Superficial/ Superficial dermal burn Small area epidermal burn Deep dermal burn

Gels to soothe Absorbent dressings (eg foams, alginates +/- CMC, Hydrogels/honey dressings (sloughy Initial (e.g. aloe vera) hydrocolloids) for moderate to high exuding wounds wounds) primary or moisturising Low-adherent (e.g. silicone wound contact layer) Foams (moderate to high exudate) dressing cream Film dressings for low exuding wounds Hydrocolloids (difficult-to-dress areas) Antimicrobials (e.g. silver-impregnated dressings, Antimicrobials (e.g. silver impregnated paste or SSD) if contaminated dressings, paste or SSD) if contaminated

Superficial burns produce significant amounts of exudate in the first 72 hours Initial Absorbent dressings should be considered to manage excess exudate. When exudate reduces, change to secondary retention dressing, which can be changed every 3 days dressing Consider the use of an adhesive remover if the dressing has adhered to the wound to avoid traumatic removal

TABLE 3: Common dressing types for non-complex burns

Type Description Actions Indications/use Precautions/contra-indications Alginate/ Alginates are a natural wound dressing Absorbs fluid Moderate to high Do not use on dry wounds carboxy- derived from algae and seaweed Promotes autolytic exudate Use with caution on friable methyl These may be combined with CMC debridement tissue (may cause bleeding) cellulose gelling fibres Moisture control (CMC) Dressings made from CMC alone are Conforms to wound bed know as Hydrofiber Foam Generally made from a hydrophilic Absorbs fluid Moderate to high Do not use on burn wounds polyurethane foam Moisture control exudate with minimal exudate Conforms to wound bed May be left in place for 2–3 days Honey Wound dressing incorporating medical- Antimicrobial Sloughy, low to May cause 'drawing' pain grade honey moderate exudate (osmotic effect) wounds and/or Known sensitivity evidence of local infection Hydrocolloid Opaque dressing made of gel-forming Absorbs fluid ‘Difficult-to-dress Do not use on highly exuding components. Dressings are biodegrad- Promotes autolytic areas’, such as burns able, non-breathable (occlusive) and debridement digits, heel, elbow, May cause maceration adhere to the skin sacrum May cause hypergranulation Hydrogels Hydrophillic polymer dressing Moisture control Sloughy wounds Do not use on highly exuding Promotes autolytic wounds or where anaerobic debridement infection is suspected Cooling May cause maceration Low-adherent Wound contact layer or dressing with Protects new tissue Low or minimal Known sensitivity to silicone silicone or lipo-colloid matrix growth exudate Atraumatic to periwound skin Conformable to body contours Polyhexanide Antiseptic impregnated dressing Antimicrobial Low to high Known sensitivity to PHMB (PHMB) exuding wounds Clinical signs of local infection Polyurethane Semi-permeable dressing Moisture control Low exudate Should not be used in infected film Breathable bacterial May be left in place or heavily exuding burns barrier for 2–3 days Transparent (allows visualisation of wound) Silver Topical preparations including SSD Antimicrobial Clinical signs of Some may cause discolouration cream, impregnated dressings and paste local infection Known sensitivity Combined presentation with foam and Low to high Discontinue after 2 weeks if no alginates/CMC for increased absorbency exudate improvement and re-evaluate

316 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS MANAGEMENT OF NON-COMPLEX BURN WOUNDS

alternative dressings using locally sourced to have the dressing changed if it is wet or materials, including banana leaf dressings, dirty, loose or smelling offensive69. honey, papaya, and boiled potato peel bandages have been shown to be effective in the Dressing changes management of burn injuries30. The first dressing change should be 48 hours after injury and then every 3–5 days Role of antimicrobials in preventing and thereafter, depending on how healing is treating infection progressing. Wound infections are one of the most serious problems that occur in the acute phase Where possible, dressings that have a after a burn injury63. Topical antimicrobi- tendency to adhere to the skin — such als can be used for prevention of infection as alginate and paraffin gauze (Jelonet®) in extended burns and are indicated in the dressings — should be avoided and mod- presence of signs and symptoms of local ern alternatives such as a soft silicone infection (e.g. slough, hypergranulation tis- wound contact layer and foam dressing sue, dark/friable granulation tissue). Topical should be used to ensure atraumatic and antimicrobials should be efficacious without pain-free removal. increasing the risk of resistance or allergic reactions64. They should also allow visual Dressings should be changed immediately inspection, and balance dehydration with if they become painful, foul smelling or risk of maceration64. saturated (strikethrough). It is important to remind patients to look out for these The most commonly used topical antimi- signs and to monitor for signs of infection. crobial in burn wounds is silver sulfadiazine (SSD) cream (Flamazine‰). This is a broad- Any non-complex burn wound that has not spectrum agent, which is effective against healed within 2 weeks should be referred Gram-negative bacteria (e.g. Pseudomonas). to a burn surgeon for possible excision and It can be applied as a 1cm thick layer and grafting11,53. needs to be washed off and redressed daily. However, SSD cream may itself delay heal- Where the patient refuses referral or hospi- ing due to a toxic effect60. Impregnated tal or surgical intervention, a conservative dressings or pastes, using other forms of approach may be adopted using Flamma- silver, most notably elemental silver or in the cerium‰ (cerium nitrate-silver sulfadi- ionic state (Ag+), have been demonstrated azine)70. This may also be used in patients to have a broad antimicrobial effect65–67 and not suitable for surgery because of comor- may have some benefit over SSD dressings bidity, general age or frailty. The product is in terms of time to healing60. thought reduce the inflammatory response to burn injury, decrease bacterial colonisa- Prophylactic use of systemic antibiotics tion and provide a firm eschar for improved is not recommended. However, systemic wound management70. antibiotics may be given in patients with suspected toxic epidermal necrolysis or beta PAIN MANAGEMENT haemolytic streptococcus infection. Pain management in patients with burn injuries is often inadequate; pain is com- Applying a dressing monly underestimated and under-treated, When applying dressings it is important to even in specialist burn units71. use an aseptic or non-touch technique68 to reduce the risk of cross-infection. Ideally, all patients should have a pain management plan based on individualised Ensure dressings do not impede patient mo- pain scores1. A structured approach to pain bility and are secured to prevent slippage16. management should be used, for exam- To avoid damaging fragile or newly healed ple based on the WHO analgesic ladder skin, adhesive tape should not be applied (Figure 27)1,72. and non-adhesive dressings or retention bandages selected. Patients should be ad- Superficial burn injuries can be extremely vised to keep the dressing clean and dry and painful. The pain can be exacerbated by

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 17 MANAGEMENT OF NON-COMPLEX BURN WOUNDS

Patients often describe pain when they are 72 FIGURE 27: WHO analgesia ladder Step 3 actually experiencing itching. It is important to help the patient distinguish between Strong opioid Step 2 these sensations to avoid unnecessary use for moderate to of opioids. The benefits of pain relief should Weak opioid severe pain be clearly explained (especially in rela- Step 1 for mild to (e.g. morphine) tion to night pain, which can cause sleep Non-opioid moderate pain disturbance) to improve concordance with +/– non-opioid treatment and reduce risk of anxiety and (e.g. asprin, (e.g. codeine) +/– adjuvant depression. paracetamol +/– non-opioid or NSAID) +/– adjuvant Pain persisting Pain that becomes more frequent or +/– adjuvant or increasing intense should trigger a review of the pain Pain persisting management plan, and it may be necessary or increasing to change the patient’s regular analgesia74. Pain controlled PATIENT EDUCATION Patients may forget instructions when they procedures such as cleansing and debride- are in pain or upset by their burn injury41. ment, dressing changes, application of gels Written information should be provided or creams and physiotherapy. If not already at the key stages of management to help given, analgesia should be provided well patients and their families or carers make before of any interventions are performed. If informed decisions about their care. It necessary, procedures should be delayed to should be clear, understandable, evidence allow pain relief to reach its full effect73. based and culturally sensitive75.

It is important to ask about pain at dress- The UK National Burn Care Network rec- ing changes. Pain ratings can be recorded ommends that all patients should be given throughout the day using a simple 4- or information on75: 10-point pain scale to inform the dosing regi- Q Pain and itch management men for managing background pain. Inad- Q Resuming activities of daily living equate control of pain (score of 4 or greater Q Preventing burns in the future on a scale of 0–10) can increase patients’ Q Recognition of complications associated anxiety, which may lead to negative associa- with a burn injury tions with wound care interventions73,74. Q Aftercare of the burn wound (scar management and protection) Non-pharmacological measures (e.g. Q Psychosocial care, information and hypnosis, cognitive behavioural therapy and support available relaxation techniques) can also be consid- Q Key contact details (including 24-hour ered if they are available locally1. The value access to the clinical team) of friendly conversation and distraction Q Patient support groups techniques should not be underestimated, Q Follow-up appointment details and and children can be encouraged to take part location. in dressing changes to put them at ease74.

318 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS CONTINUING CARE OF PATIENTS WITH Continuing care of patients with a A BURN INJURY burn injury

BOX 12: RISK FACTORS FOR Follow-up care after burn injury with support from the multidisciplinary team is HYPERTROPHIC SCARRING necessary to ensure all aspects of care are coordinated and patient needs are met Q Inadequate first aid and fluid resuscitation Q Suboptimal wound and The effects of burn injuries — both physical (30–50) for 12–24 months to prevent dressing management and psychological — are long lasting. Pro- further thermal damage and pigmentation Q Burn wound infection viding continuous, holistic and, preferably, changes. This is important even in temper- Q Position in hospital multidisciplinary care with long-term follow- ate European countries from March/April. Q Concomitant medical up will help to prevent the acute wound In all regions, when the sun is strong pa- conditions becoming a chronic disability. tients should also wear a hat, long-sleeved Q Deeper burn depth tops and trousers if going outside and GENERAL HEALTH should avoid sun exposure between noon To improve burn wound healing and general and 4pm. If the new skin is allowed to tan, health, encourage patients to: it may appear permanently blotchy69. Q Eat a high-calorie/high-protein diet with fresh fruit and vegetables and avoid BURN ITCH refined foods and commercially-baked Burn wound itching usually begins at the products time of wound closure and peaks at 2–6 Q Maintain hydration — drink 6–8 glasses of months after injury76. It can be worsened water a day and avoid caffeine and alcohol by heat, stress and physical activity16. Q Take a multivitamin or daily nutritional There are no preventative measures, with supplement (especially in those who are the exception of skin moisturisers, to Figure 28: Hypertrophic scar- immunocompromised) maintain moisture and hydration. These ring. Photo courtesy Professor Q Stop smoking may be combined with a suitable aromath- Franck Duteille Q Attend to basic principles of cleanliness erapy product (consult local aromatherapy and good personal hygiene. specialist) or topical antihistamine to ease itching76. SKIN CARE Healed burns can be sensitive, develop dry, Oral medication, including antihistamines scaly skin and have irregular pigmentation. (such as chlorphenamine) and analgesics The skin is delicate and vulnerable to injury. may also help16. Custom-made pressure Figure 29: Scar with retrac- The area should be moisturised daily with a garments can also be considered to reduce tion. Photo courtesy Professor non-perfumed emollient (e.g. mineral oil/baby itching. Keeping the area cool (e.g. by using Franck Duteille oil, petroleum jelly or almond or coconut oil) a fan, keeping towels or moisturiser in the and massaged using a downwards, circular fridge and wearing loose clothing made of motion to reduce dryness and to keep the natural materials) and relaxation, distrac- healed area supple. This should be continued tion and desensitisation techniques can until the burn area is no longer dry or itchy provide relief77. (usually around 3–6 months, but emollients may need to be applied for up to 12 months). Patients should be encouraged to keep fingernails short and to 'pat not scratch'. The skin should be cleaned every day due For those affected by night-time itching, to build up of moisturiser, which can cause patients should take an antihistamine be- irritation. Once dressings are no longer fore bedtime to reduce the risk of scratch- required, patients may take a bath or shower. ing at night. Using non-perfumed products will help to prevent skin reactions69. HYPERTROPHIC SCARRING The overlying skin on a healed burn injury Newly healed skin may be sensitive to tem- should be soft, flat, pale in colour and barely perature and can be numb in places. Patients visible77. In deep burns and where heal- should test the temperature of bath/shower ing has been delayed, however, abnormal water before immersion69. hypertrophic scarring may occur 4–6 weeks following injury to the deep dermis (Figure Patients should be advised to use a sun 28). Factors that increase the risk of hyper- cream with a high sun protection factor trophic scarring are given in Box 12.

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 19 CONTINUING CARE OF PATIENTS WITH A BURN INJURY

In a retrospective follow-up study of children months as the size and shape of the scar with burn injuries, hypertrophic scarring had changes77,80. occurred in less than 20% of superficial scalds that healed within 21 days, but it oc- Contact media curred in up to 90% of injuries that took 30 Silicone gel sheets and elastomer moulds days or more to heal2. can be used to soften and flatten the scar, reduce redness and increase pliability78,79. Hypertrophic scarring results from the Silicone sheets are worn for up to 23 hours a build-up of a dense, thick, non-uniform layer day, but should be removed once or twice a of collagen fibres during wound healing77. day to clean the scar and avoid maceration of The classic signs of a hypertrophic scar are the skin. Elastomer moulds are useful for ar- described in terms of the 3Rs — raised, rigid eas where it is difficult to mould the silicone, and red78. Other features include78: such as toes and the web spaces between Q Altered pigmentation them65,77,79. Q Contractures (shortening of the scar and underlying tissues after the wound has Physiotherapy closed) (Figure 29, p19) Patients with hypertrophic scars should be Q Altered sensation referred to a physiotherapist for support Q Pain with maintaining movement and function. Q Itch. If contractures develop, the physiotherapist can fit an individually tailored thermoplastic The scar becomes smaller and less vis- splint, which will apply a stretch to the scar ible with time, although it can take up to 2 tissue78. Usually patients are advised to wear years for the scarring to fully settle69. Lack the splint overnight and then exercise the of elastin means the scar is less pliable area, or use the area as normally as possible, than normal skin and, when combined with during the day. contractures, this may limit mobility (for example, reduced ability to straighten the leg Camouflage when scarring occurs behind the knee)78. Camouflaging cosmetics are a useful adjunct and can increase confidence and Managing hypertrophic scarring self-esteem. Patients should be referred to Massage and moisturising specialist scar services, where available, Some scars may respond to simple meas- where a consultant will help select the most ures, such as massage and moisturising. A appropriate shade and advise on application. non-perfumed emollient should be mas- Products may also be available in high-street saged into the skin two to three times a day, make-up counters and via some charities. using a circular motion that is firm enough Not all scars will benefit from camouflag- to cause the skin to blanche. This action ing cosmetics (e.g. some scars with varying helps to realign the collagen fibres into a texture or contours) and it is important to more normal, uniform pattern78. manage patients’ expectations78.

Pressure garments MULTIDISCIPLINARY SUPPORT Pressure is thought to encourage reorienta- Once the burn wound itself has healed, tion of the collagen fibres and quicken the patients must come to terms with the emo- maturation of the scar77,79. Wearing a pres- tional and physical after-effects of the injury. sure garment appears to reduce redness and Multidisciplinary support from the commu- soften and flatten the scar78. Classic pres- nity team is vital at this time of transition. sure garments may also be combined with a silicone silastic sheet, gelsheet or pad79. Psychosocial support Burn injuries — even minor ones — can have Pressure garments must be worn for up to a devastating impact on the psychological 23 hours a day for one to two years, de- health of a patient. For example, coping with pending on the extent of scarring. Patients flashbacks, changes in body image, and the need to be referred to a specialist burns stress of returning to work can continue for service to be individually measured and months or years after the initial event, with they may need to be remeasured every 3 a subsequent deterioration in quality of life.

320 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS CONTINUING CARE OF PATIENTS WITH A BURN INJURY

All patients — even those who appear on the Children and their families BOX 13: USEFUL LINKS surface to be coping — should receive planned Families of children who have been burnt follow-up appointments and be screened for may suffer profound psychological, emo- Q American Burn symptoms of distress. Psychotherapy must be tional, social and financial consequences1,84. Association www.ameriburn.org offered if needed. The European Burns Association states that 1 Q Australian New Zealand healthcare professionals should : Burn Association Depression has a significant prevalence in Q Offer continuous psychosocial support at www.anzba.org.au burns patients as a consequence of their injury all stages of a child’s recovery Q British Burn Association and the impacts on their lives1. Q Promote cohesion, reduce conflict and www.britishburnassocia- increase the stability of families tion.org/ It is important to identify signs and symptoms Q Adapt to individual needs and pay special Q European Burns Associa- of anxiety and depression and provide special- attention to cultural aspects. tion euroburn.org ist management to maximise quality of life and Q Euro-Mediterranean Council for Burns prevent future problems. Guidelines (many Involving the family in the general care of www.medbc.com produced by associations/societies) and local the child’s wound can help promote positive Q International Society for protocols should be followed1,81,82 (Box 13). feelings1. Burn Injuries www.worldburn.org Support groups, peer counselling and burn Preparation for returning to school should camps can be important. Major burn centres begin early and should take into considera- Journals: should have a network of burns survivors who tion the developmental level of the child, Q Annals of Burns and Fire 83 Disasters are willing to talk to patients (Box 13). the style and needs of the child and of their www.medbc.com/annals/ 1 family, and support for teachers . Q Burns Physiotherapy/occupational therapy www.sciencedirect. All healed scars should be reviewed at two BURN PREVENTION com/science/jour- months to identify patients with physical limi- Greater application of educational pro- nal/03054179 tations. Where necessary, patients should be grammes in schools and public health cam- Q Burn & Trauma referred for physiotherapy and/or occupational paigns can help to lower the burden of burn www.burnstrauma.com therapy for help with exercise, general day-to- injury globally. These have been successful, Q Journal of Burn Care & 85 Research day activities and scar management. especially in LMICs . This is especially www.burncareresearch. important due to lack of resources and spe- com 21,86 Continuous and consistent support and advice cialist burn facilities in these regions . Q International Journal of is essential to help motivate patients. Patients Burns and Trauma should be encouraged to take responsibility for Simple safety measures can reduce the risk www.ijbt.org their treatment77. of burn injury: Patient support: Q Install smoke alarms in strategic loca- Q Changing Faces Returning to work tions www.changingfaces. Most patients will want to return to their previ- Q Make a fire-escape plan org.uk ous quality/standard of life as quickly as pos- Q Set water temperature at 50˚C and Q Katie Piper Foundation sible and this should be encouraged. However, install thermostatic mixer taps www.katiepiper some patients will need to take long periods off Q Put cold water in the bath first and test foundation.org.uk work and may be under pressure by insurance water Q WAFS Burn camp wafs.org/ companies to return to work quickly. Also, on Q Follow safety measures in the kitchen, summer_camp.asp returning they may need to negotiate changes bathroom and outside area to their hours, days or job status. Ideally, all Q Store cleaning solutions and paints in working-age patients should be offered an containers in well-ventilated areas and individualised vocational rehabilitation plan and keep out of reach of children a professional counsellor who can guide them Q Store matches safely through the return-to-work process1. However, Q Take care with any flammable substances this is not likely to be a realistic goal in develop- used to start fires, such as lighter fluid ing countries where, for example, a 90% drop- Q Check electrical appliances regularly. out from rehabilitation occurs after 1 year.

Healthcare professionals should acknowledge patients’ return to work as an important factor in wellbeing, self-perceived health and quality of life1.

BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 21 REFERENCES

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BEST PRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS 23 NOTES

324 BEST PRACTICEPRACTICE GUIDELINES: EFFECTIVE SKIN AND WOUND MANAGEMENT OF NON-COMPLEX BURNS A Wounds International publication www.woundsinternational.com