The Management of Burn and Teens

A Guide for Parents and Families Every year, the Montreal About the Montreal Children’s Hospital Children’s Hospital Emergency Trauma Centre Department treats more than •• A provincially designated Pediatric and Adolescent 17,000 children and teens for Trauma Centre and Neurotrauma Centre of Expertise trauma-related . Our •• Rapid access to expert medical, surgical, nursing, patients come from all regions rehabilitation and psychosocial trauma specialists of Québec. •• Cutting-edge programs designed to meet the complex Over 400 of these children and multifaceted needs of all types and severity of and teens sustain injuries that trauma require hospitalization and the •• Specialized programs include: Trauma, Neurotrauma, involvement of many specialists. Burn Trauma, Prevention, Trauma Research, Every year, the Trauma Centre Mild Program and Concussion receives more than 150 patient Clinic transfers in need of tertiary •• Interprofessional patient and family centered approach trauma expertise from regional to all types of trauma care, from urgent and critical care centres. As well as thousands throughout the stages of recovery, early rehabilitation, of outpatients referred by discharge home and school reintegration community physicians and •• State-of-the-art equipment regional centres for consultation •• Affiliated with Health Canada for CHIRPP - Canadian and specialized trauma care. Hospitals Injury Reporting and Prevention Program The Management of Burn Trauma A Guide for Parents and Families in Children and Teens

Having a child in the hospital with a burn injury can be a traumatic experience. This booklet has been designed to provide you with information on what to expect throughout the different phases of your child’s hospitalization, treatment and recovery. We hope it answers many of your questions.

The Burn : A Family Centered Approach “Family-centered care is based on the belief that the family is a child’s primary source of strength and support. Healthcare professionals are the experts on health and . Parents are the experts on their child and they can offer essential information to enhance their child’s . A successful partnership between healthcare providers and families is based on mutual trust, respect and responsibility.” —The Montreal Children’s Hospital Patient and Family Centered Care Policy

1 We never expect that our life will change in an instant. We are in a state of panic, we are unsure of how to react and we do not know what to expect. When I was burned, I was immediately sent to the Montreal Children’s Hospital Trauma Centre. Upon my arrival, there were many staff members waiting and ready to take care of me. Initially, I was afraid because I didn’t know what was going to happen, however the care I received during my hospital stay was exceptional.

Without the support of the team of nurses, doctors, surgeons and my family, I would have never overcome this event. Thanks to them, I had a reason to smile everyday despite all the I was enduring.

Today, I am in a body that has undergone many plastic surgeries. The exceptional work of the entire team was so wonderful for which I have so many memories. The entire team made my hospital stay positive, moving and unforgettable. Thank you to the Montreal Children’s! – Véronique “There is a story behind every .”

2 Written by Edited by Content Other Review Contributors

Mirko S. Gilardino Angeliki Souranis M.D, MSc, FRCSC, Social Worker FACS Anne-Marie Hurteau Board-Certified Audiologist Plastic Surgeon Caroline Richer recognized by both Speech and Language the Canadian Society Pathologist of Plastic Surgeons and the American Doreen Shalla Diane Richard Debbie Friedman Amanda Fitzgerald Board of Plastic Spiritual Care BSc. RN BSc. pht. M. Mgmt. Professional Trauma Coordinator Trauma Director Administrative Montreal Children’s Helen Magdalinos Burn Trauma Program Director Canadian Procedures Specialist Hospital, MUHC Child Life Specialist Montreal Children’s Hospitals Injury Montreal Children’s Jessica Nolet Hospital, MUHC Reporting and Hospital, MUHC Physiotherapist Prevention Program Justine Noiseux Montreal Children’s Social Worker Hospital, MUHC Katrine Doucet Assistant Professor, Speech and Language Department of Pathologist Pediatrics, Faculty Line Parent of , McGill Occupational University Therapist Lise Gagnon Child Life Specialist Rachel Boisjoli Psychologist 3 Special A note acknowledgements to the reader

We wish to thank the Quebec The information you are about to read is intended for the family of a child or Firefighters Foundation for Major adolescent who has sustained a burn trauma. It is our objective to enhance your Burn Victims for their financial understanding of pediatric and adolescent burn care management. Information support of this publication. regarding the spectrum of burn trauma care and the role of the different specialists will be discussed. Our extreme gratitude is also extended to the families who so Issues related to burn classification, recovery stages, rehabilitation, returning graciously allowed us to use their home, school re-integration and outcome are covered in the booklet you are photographs in this publication: about to read. Émile, Cathy and Patrice Couillard, Ivy and Isabelle Maheu and We hope that as burn trauma victims and families living through the experience Véronique Potvin. you will find that the information will respond to your questions and assist you through the stages of recovery and facilitate your return home. Families play a key role in assisting the patient to achieve their maximum potential. The content of this booklet is reflective of the experience and expertise of the Burn Trauma Program of the Montreal Children’s Hospital Trauma Centre of the McGill University Health Centre.

4 The Management of Burn Trauma A Guide for Parents and Families in Children and Teens

Contents Healing ...... 21 and Open Areas ...... 34 ...... 21 Discoloration ...... 34 Positioning and Splinting ...... 23 Sun Sensitivity ...... 35 The Montreal Children’s ...... 24 Swimming ...... 35 Hospital Burn Trauma Program .6 Nutrition ...... 25 Diet ...... 35 The MCH Trauma Burn Team ...... 6 Psychological and Social Impact . . . 25 ...... 35 Discharge Planning ...... 26 Returning to School ...... 36. Understanding the Burn Injury The Rehabilitation Phase . . . . 28 How to change a . . . 38 Minimizing Scars after a Burn . . . .28 Equipment ...... 38 The ...... 12 . Preventing Instructions for Changing a Dressing . 38 Following a Burn ...... 30 Individualized Instructions . . . . . 39 Determining the severity of a burn ...... 12 Caring for Your Burn Your Splint: Wear and Care . . . 40 Burn Location ...... 14 Splint Care ...... 40 Burn Size ...... 14 at Home Precautions ...... 40 Burn Depth ...... 14 Important recommendations . . 32 When to Wear your Splint . . . . 40. Dressing Change and/or Irrigation . . 32 Individualized Instructions . . . . . 41 During Your Hospital Compressive Garments and Splints . . 33 How to use a Silicone Stay Exercises ...... 33 Gel Sheet ...... 42 Skin Care ...... 33 Recommendations ...... 42 The emergent phase ...... 16 Scar ...... 33 References ...... 44 The acute phase ...... 17 Precautions ...... 34 Wound Care ...... 19 Itching ...... 34 Useful links ...... 44

5 The MCH Trauma Burn team The Montreal Children’s Hospital Burn Trauma Acute Pain Service A team of anesthetists and nurses who specialize in pain management Program are consulted to work collaboratively with the Burn Trauma Team in order to effectively The Montreal Children’s Hospital Burn Trauma manage pain following a burn trauma. Program specializes in emergency care, critical care, early rehabilitation, and ambulatory Audiologist An Audiologist is consulted if the management for all types and severities of burn patient’s burn has affected the , hearing trauma. Caring for a burn patient and supporting or the ability to communicate. Audiologists the family requires a team approach. Burn Trauma evaluate hearing and provide treatment as Specialists provide the patient with medical, needed at the bedside or in the Audiology surgical, nursing, rehabilitation and psychosocial Department. care. The patient- and family-centered team approach Burn Trauma Coordinator A member of the and involvement of Trauma Specialists begins interprofessional team who coordinates in the Emergency Department and continues the care of the patient which includes through the critical care phases to early ensuring communication and collaboration rehabilitation, recovery phases and through within the interprofessional team. The Burn transfer to a rehabilitation centre, community Trauma Coordinator also helps to ensure a resource or discharge home. smooth transition from hospitalization to a rehabilitation centre or discharge home.

6 The Burn Trauma Coordinator ensures that The Child Life Specialist provides distraction family needs are met and will follow them and relaxation techniques during wound care regularly throughout the different stages and other medical procedures. Teaching dolls, of recovery. medical play and expressive therapy all help make procedures less traumatic. Child Life Specialist A specialist who provides The Child Life Specialist offers support support to children, teens and their through the stages of recovery, the return families during hospitalization. Through home and during school reintegration as developmentally appropriate activities, needed. Sibling support is also offered the Child Life Specialist helps patients adjust as appropriate. to the hospital setting, reduce stress and promote positive coping mechanisms. Clinical Nutritionist A specialist who assesses Children are frequently overwhelmed during and makes recommendations regarding an unplanned hospitalization. Following the nutritional requirements needed to a burn trauma, children have particular promote optimal . The Clinical emotional and psychological needs that Nutritionist works collaboratively with differ from those of other patients. The the patient and family in order to promote goal of the Child Life Specialist is to help healthy eating habits during hospitalization the patient regain a sense of control by that can be continued at home upon expressing feelings, exploring body image discharge post burn injury. and understanding treatments. Through play, the Child Life Specialist helps to restore functional skills.

7 Critical Care Physician A physician who and others to prevent contractures. Some specializes in caring for critically ill patients interventions include: splinting, positioning, in the Pediatric Intensive Care Unit. passive and active range of motion exercises.

Emergentologist A specialist who treats Physiotherapist Evaluates the patient’s ability patients with acute illnesses or injuries to move his/her body and to perform daily requiring immediate medical attention in activities. The Physiotherapist’s goal is to the Emergency Department. prevent scar , restore normal range of motion (ROM) of the involved joints General Surgeon A physician who specializes in and to assist the patient in achieving their the treatment of patients with acute injuries highest level of function. The Physiotherapist such as a burn trauma. concentrates on gross motor function which includes: gait training, stairs, balance, Nurse A member of the interprofessional coordination, strengthening and improving team who assesses, plans, implements and cardiovascular endurance. Recommendations evaluates the care of the patient. for equipment are made as needed.

Occupational Therapist A therapist who Plastic Surgeon A surgical specialist whose facilitates the patient in maintaining expertise encompasses all areas of burn independence when performing daily trauma care. activities. Interventions may include therapeutic activities to improve mobility

8 Resident A physician who is facilitate communication between the being trained in plastic surgery following patient/family and the treating team. The completion of medical school. Social Worker will also provide travel and ­accommodation needs assessment as well as Psychologist The Psychologist supports the facilitate arrangements for parents requiring patient by helping them regain an optimal time off work. They will continuously monitor level of functioning. Victims of burn trauma the individual psychosocial needs of the patient occasionally experience psychological and family throughout the hospital stay. symptoms that can impair social functioning in school or at home. Some may experience Speech and Language Pathologist A Speech nightmares, flashbacks or avoidance, all of and Language Pathologist is involved with which may be difficult to manage. Treatment patients who have sustained inhalation is recommended when symptoms affect the burn injuries. These patients often have functioning of the child or influence behavior. difficulty communicating due to injury to Furthermore, emotional issues such as low the vocal tract and/or vocal folds. The Speech self-esteem may require a more targeted and Language Pathologist may be involved treatment plan. when a patient is intubated and alert. The Speech and Language Pathologist helps the Social Worker The Social Worker provides patient establish a personalized method of emotional and practical support to the ­patient non‑verbal communication, for example, and family throughout hospitalization and through the use of a communication book. following discharge by offering a variety of coping methods. The Social Worker will

9 Once the patient is extubated, the Speech Spiritual Care Professional A professional who and Language Pathologist assesses speech has received specialized training. They offer and voice to avoid risk of further damage to support and coping strategies to the patient the vocal folds. Healthy vocal hygiene habits and their family during a period of illness are explained and reinforced. or hospitalization. Spiritual Care Services is Over time, the Speech and Language available 24 hours a day, 7 days a week. Pathologist’s recommendations will evolve and may include: Other specialists may be consulted as indicated. •• Avoid whispering •• Avoid forcing the voice •• Discourage staff and family members from asking the child to raise his/her voice •• Promote the use of alternative communication methods •• Encourage voice use only when vocal quality is deemed adequate •• Drink more water (if medically possible)

10 Understanding the Burn Injury

• The skin

• Determining the severity of a burn

11 The skin Determining the severity of a burn Normal skin consists of two main layers: the and the . The epidermis is the The overall severity of a burn is determined by outer layer of the skin and acts as the first line of a variety of factors. Depth, size and location are defence to the environment. The dermis contains all considered when evaluating the severity of a glands, hair follicle roots and . burn. Knowing the severity will help determine The skin serves as a physical barrier against the and predict the healing process as well as the environment. Specific functions include: likehood of complications. •• Protective agent against Hospitalization following a burn trauma is based on:

Understanding the Burn Injury •• Protects against body fluid loss preventing dehydration •• Burn location •• Controls body temperature •• Burn size •• Excretes some waste products •• Burn depth •• Receives sensory stimuli •• Produces vitamin D These essential functions are reduced with a partial thickness burn, and eliminated with a full thickness burn.

12 Burn depth explanation depth Burn • • • • burn second-degree S • • F • • • • • • irst-degree burn irst-degree uperficial uperficial healed within 2weeks within healed if scar usually not does and Heals independently painful very Usually blisters and red Moist, dermis the of part and epidermis Damage to the skin of (epidermis) layer outer to the Limited () painful and red Dry, • • • • • • • • T • D • • • • • • • • • hird-degree burn hird-degree eep second-degree burn second-degree eep Requires surgery and grafting and surgery Requires painful not Usually brown) or red black, (white, incolor varies Dry, fat) (into destroyed skin of thickness Entire Full thickness grafting and surgery May require painful very to white, red moist, Less and epidermis Damage to the thickness partial Deep the deeper dermis the deeper 13 Understanding the Burn Injury 14 Understanding the Burn Injury second or third or degree. second depthBurn is classified as either first, de Burn bythe burn. total area affected body sizeBurn as apercentage is expressed of the size Burn attention. special require joint areas, limbs and/or torso, as well as burns over andgenitals, those that feet, encircle the hands, the face, eyes, Burns affecting B urn lo p ca th tion Burn size percentage size Burn diagram B =½of thigh C =½of leg A =½of head Surface 14 15 2 16 C B 13 1 1 A 16 C B 2 ¾ 2 ½ 9 ½ 0 2 15 14 2 ½ 8 ½ 3 ¼ 1 14 15 Years 2 2 ¾ 6 ½ 4 5 16 25 C B 13 A 1 25 5 ½ 16 4 ¼ 10 C B 3 2 15 14 4 ½ 4 ½ 3 ¼ 15 During Your Hospital Stay

• The emergent phase

• The acute phase

• The Rehabilitation Phase

15 There are different phases involved in Stabilization occurs during the emergent period and includes the following: burn care. Burn severity will determine •• Airway/Breathing Smoke inhalation can the length of each recovery stage. cause swelling of the airway. The patient may need a tube inserted to help with breathing Trauma care is unique to each patient’s and to give the lungs an opportunity to heal. The tube is connected to a ventilator specific condition and individualized that pushes air in and out of the lungs. The patient is given medication to keep them

During Your HospitalDuring Your Stay needs. sedated and more comfortable. •• Hydration Burns cause body fluid loss. The emergent phase Intravenous lines are inserted to ensure that the patient remains hydrated. A Foley The emergent phase refers to the first few days catheter is inserted into the bladder to post-burn. The severity of the injury sustained is monitor fluid levels (output) and is also used determined. Urgent care is provided; intravenous to keep peri-anal burns clean. therapy and wound care are started. During this phase, vital signs are monitored and all fluids taken in and eliminated are recorded. Observation is ongoing for signs of potential complications. ■■ Infusion of specialized fluids and medication directly into a vein. ■■ Foley catheter Flexible tube inserted into the bladder used to drain urine.

16 •• Feeding tube (NG or NJ) A small tube The acute phase inserted through the nose or mouth that extends into the stomach. A feeding tube The acute phase begins and remains until all is inserted when the patient is intubated or full‑thickness are covered by skin grafts. has insufficient caloric intake. Burn patients The objectives during this period include: require additional calories and protein in •• Removal of dead tissue () and covering order to heal. the wounds with skin grafts (if required) •• Initial and dressing Once •• Providing adequate nutrition stabilized, wounds are cleaned and a burn •• Preventing complications

dressing is applied. The patient is then HospitalDuring Your Stay •• Preventing contractures either transferred to the Pediatric Intensive Care Unit (PICU) or to the Surgical/Trauma •• Meeting the individualized and evolving Unit. The location is based on specific care emotional needs of the patient and family requirements. For a burn wound to heal, the wound(s) need to be cleaned regularly, which may involve daily, bi‑weekly or weekly cleansing. Wound care can Many other tubes, lines and equipment be done in the Operating Room, Treatment Room may be used throughout your child’s or at the bedside depending on specific needs. treatment, each of which has an The size of the burn, the treatment required and important function in the care process. the patient’s condition will determine where the Do not hesitate to ask questions about equipment and its purpose. ■■ Contractures Tightening of the skin following a second or third degree burn.

17 dressing change will be done. When medically Otherwise, this aspect of care can be permitted, some patients choose to remain in performed by a Nurse, Physiotherapist or their hospital room for treatment while others Occupational Therapist on the unit during a prefer to have their treatments done in the unit’s dressing change. Treatment Room. Having treatments done in •• Escharotomies The dead skin and tissue on the Treatment Room may help preserve the safe a burn is called eschar. A burn that surrounds feeling of the hospital room. a body part may cause the area to swell and tighten, subsequently impairing blood Wound care flow to the area. When this occurs, Plastic

During Your HospitalDuring Your Stay Wound care may include wound cleaning, Surgeons make an incision in the burned area debridement, grafting, escharotomies and in order to relieve the pressure. dressing changes: •• Grafting Deeper burns rarely heal on their •• Wound cleaning The first step involved own therefore requiring a skin . A skin in wound care is to clean the burned skin. graft is a very thin piece of skin that is taken Warm water and gauze is used to remove from an area of the body unaffected by the dead tissue. This step is essential to wound burn and then used to cover the burn. The healing and for preventing infection. site from which the graft is removed will heal on its own in approximately 10-14 days •• Debridement Occasionally surgical and can be used again for future grafting. equipment is needed to remove dead skin. If The most common areas used as a donor wounds are deep, debridement is performed site include the legs, back and buttocks; by a Plastic Surgeon in the operating room. less frequently used are the chest and arms.

18 • • anxiety. A medication to help control pain and diminish willa nurse or the give doctor patient cause pain. to Prior the dressing change, D sheet of skin grafts: types are two Plastic Surgeons in the Operating Room. There the are of dressing used to coverA variety types r essing changes essing donor sitedonor

variety of variety . is performed by by is. Skin performed grafting

Trauma Specialists will T his procedure may procedure his and mesh and . ■ ■ ■ ■ ■ ■ a cover and to stretch it graft skin sh permitting equipment medical M aburn. to cover entirety graft skin eet S burn. the by affected areas to cover used and nor site D procedure. the throughout and coping techniques distraction provide will to wear items. these Child The Specialist Life the risk You of infection. too may required be masks and to gloves as diminish necessary periods of time. team The will wear gowns, that wounds for extended are not exposed Trauma Burn The Teamso efficiently works Attendant. Child Specialist Life and aPatient Care Therapist, Occupational Physiotherapist, Trauma Coordinator, Nurses, Resident, Plasticinclude: Surgery Plastic Surgeon, presentbe during the procedure and may

h o large area affected by the burn. the by affected area large e

A rea of the body from which skin is taken is taken skin which from body the of rea

T T hin layer of skin modified by modified skin of hin layer hin layer of skin used in its inits used skin of hin layer 19 During Your Hospital Stay 20 During Your Hospital Stay healing burn. healing the of evolution the to see opportunity have the also will you time, this At child. your comfort and reassure will Your presence procedures. during child their to accompany encouraged therefore are and team the of part integral an are Parents The bandages/dressings are removed and all All grafts are immobilized to prevent wounds are cleaned to remove dead tissue movement and promote healing. and exudates. The wounds are then assessed The first dressing change is done at approxi- by the Plastic Surgeon who will determine mately five days post surgery. Dressings are when the next dressing change will take place worn until all wounds have healed. or if surgery is required. The Physiotherapist and Occupational Wound healing Therapist will assess range of motion and Varies depending on the size and depth of the function, perform exercises and determine burn, individual healing ability, nutrition and

if splints are required. The wounds are then HospitalDuring Your Stay infection. This stage can often be a challenging covered with a dressing or ointment time for the patient and family. An update of depending on the size and area of the body the treatment plan will be discussed regularly affected by the burn. The frequency of with you. dressing changes varies and can range from daily to weekly. Scars Depth of the wound, healing time, complications and treatment will affect scarring. Some patients ■■ Exudates Refers to the fluid that leaks from an open wound. scar more profoundly than others therefore ■■ Range of motion Full movement of a joint, making it more difficult to predict how much range of flexion and extension. scarring a patient will have. Once the wound ■■ Splint A rigid material made of either heals, the scar will typically be red in appearance plaster or plastic used to support and/or immobilize and is referred to as an “immature” scar. a limb.

21 From about three months to two years post burn Scars may feel sensitive or hurt when touched; the scar will likely become paler, flatter and softer regular massage can help control this and and is referred to as a “mature scar.” eventually the area will become less sensitive. It is recommended to use an unscented Deep second-degree and third-degree burns can moisturizing cream during scar massage. Once continue to produce scar tissue up to two years the burn wounds are healed the Occupational following the injury. At this point in time, some Therapist will teach you the proper techniques scars will gradually improve while others may used in scar massage. become permanent. The Plastic Surgeon will provide you with information concerning scarring. During Your HospitalDuring Your Stay Surgical procedures that can be done at a later time to improve the appearance of permanent scars may also be discussed. Scar massage Scar tissue may stick to the underlying muscles, , blood vessels, nerves and . Massage can prevent this from occurring and helps to maintain the flexibility of the scar tissue. Scar massage involves rubbing and moving the skin and underlying tissue in a firm manner.

Mature scar

22 Positioning and splinting It is essential for the rehabilitation process to begin immediately following hospitalization and continue through discharge. Both the Physiotherapist and Occupational Therapist closely monitor and oversee this aspect of burn care. They will assess the patient’s need for splinting and positioning. An individualized program will be developed which will include range of motion exercises and stretching to HospitalDuring Your Stay ensure all joints are loose and functional. Proper positioning is essential for optimal healing and to prevent contractures. If the joints are not stretched regularly and positioned properly they eventually become tight and difficult to straighten. This will have a direct impact on function, rehabilitation potential and the patient’s ability to perform daily activities.

Positioning and splinting is essential to the rehabilitation process.

23 Pain management Trauma Specialists will ask your child (age permitting) to rate their pain using a pain scale. Children with burn injuries experience pain. The This tool helps the nurses determine when intensity will vary according to the degree of burn and how much pain medication to give your child and individual tolerance levels. Pain medication in order to ensure comfort. is given orally or through an IV before procedures and therapy sessions as well as on a regular The Child Life Specialist will also help your child basis. The objective is to maintain optimal levels control pain using various coping techniques. of comfort. Education and preparation helps manage anxiety surrounding procedures and treatments.

During Your HospitalDuring Your Stay Some parents express concern regarding the The Child Life Specialist will teach your child regular use of pain medication and addiction. to identify comforting ways to reduce anxiety. It is rare for children to develop an addiction to If you have questions about pain medication, pain medication because they are given small you are encouraged to speak with your child’s quantities for only a short period of time. Trauma Coordinator, Nurse, Doctor or the Pain Management Team. a pain scale

24 Nutrition Burn injury patients often lack an appetite. Family members and nursing staff should be patient, The nutritional needs of burn injury patients supportive and encourage the patient to eat. differ from those of healthy individuals. The Nourishing snacks or supplements are often body requires a lot of energy to heal therefore provided between regular meals. it needs more calories, protein and vitamins. The nutritional support required will depend on: Vitamin supplements can also be given as •• The patient’s pre-burn nutritional status needed. The Clinical Nutritionist will develop an optimal diet based on your child’s individual •• The total body surface area (TBSA) affected needs.

by the burn and the degree of burn HospitalDuring Your Stay •• The patient’s nutritional intake during Psychological and social impact hospitalization We are committed to meeting the individual The well-nourished patient with a minor burn psychological needs of the patient and family injury will not require additional nutritional throughout burn treatment and recovery. support beyond that of a regular diet. This of To facilitate this process we encourage parents course relies on the patient maintaining their and caregivers to collaborate with the team usual nutritional intake. Given the amount of when developing individualized care plans. energy required throughout the healing process, These plans are designed to meet the child’s a moderate burn injury patient with good medical, rehabilitation and psychological needs pre‑burn nutrition, as well as a major burn will as well as the family’s needs throughout the require a high caloric and protein diet. different phases of recovery.

25 Children will often experience a variety of hospital stay. This is a difficult time for your child; emotions following a burn trauma as well as during love, support and providing clear expectations an unplanned hospital stay. Children with burn are beneficial. injuries may also experience changes in behavior and emotion. It is common for children to feel pain, Discharge planning stress, anxiety, anger, guilt, isolation, and to report Upon admission to the hospital, the Burn Trauma low self-esteem and loneliness. Common reactions Coordinator and other team members will begin to these emotions are aggression, nightmares and discussing and planning your child’s discharge even developmental regression in younger children with you. Some burn patients will be discharged

During Your HospitalDuring Your Stay (i.e. bed wetting or thumb sucking). home, while others may require a stay in a Your child’s sense of body image may also be rehabilitation centre before returning home. affected depending on their age. The way in The team will also determine when your child is which a child perceives themselves following a ready to be discharged from the hospital from a burn injury is an important concern. The MCH medical, nursing and rehabilitation perspective. Psychosocial Team, consisting of a Social Worker, The severity of the burn injury and rehabilitation Child Life Specialist, Psychologist and Spiritual needs will be the determining factors as to Care, will address these and other concerns that whether or not your child will be transferred to you may have about your child. Professional a rehabilitation centre for a period of in-patient counseling is available if there are other aspects or out-patient care. Alternatively, your child may of your child’s behavior which concern you. go home with out-patient follow-up care at It is important to maintain a structured and the Montreal Children’s Hospital Trauma Centre. consistent approach similar to the one at home Services may also be organized through your regarding your child’s discipline during the community CLSC.

26 phases of burn treatment and recovery. and treatment burn of phases different the throughout family and patient the of needs psychological individual the to meeting committed We are 27 During Your Hospital Stay The Rehabilitation Minimizing scars after a burn Phase Compressive garments are used to reduce scarring. Children with deep burns are required to The rehabilitation phase involves resuming daily wear compressive garments. For optimal results, activities and helping your child to reach their the garments must be worn 23 hours per day functional potential. Patients and families often for up to two years following the burn injury and report that the period following discharge is can only be removed while bathing. You will need challenging. In fact, many patients and families to have at least two sets of compressive garments have expressed that the first 18 months following so that one can be worn at all times even during

During Your HospitalDuring Your Stay discharge from hospital are often more difficult laundering. for the patient than the hospital stay itself. Hypertrophic scars Hypertrophic scars are a The rehabilitation goals at this time include: challenging of burn injuries. Tissue maintaining and increasing range of motion formation is often excessive and can result in of joints, muscle strengthening, increasing thick and swollen scars. Typically, hypertrophic ­functional activities, scar management, scars develop once deep burns have healed. It is reconstructive surgery (if needed) and emotional important to note that the burn healing process and psychological support. continues within the deeper layers of the skin even though the surface has healed.

■■ Compressive garment Form-fitting clothes worn over burned areas to help minimize scarring.

28 There are different methods used to help prevent and reduce hypertrophic scarring which include: •• Compressive garments •• Gel sheet •• Scar massage •• Injections •• Surgical incision The Plastic Surgeon, Occupational Therapist and Trauma Coordinator will discuss available options. HospitalDuring Your Stay

■■ Gel sheet Specialized sheet made of silicone used under the compressive garments to help reduce scarring.

Compressive garments PREVENTING CONTRACTURES • Wear a splint • Perform range of motion exercises • Promote independence in function

29 Preventing contractures following a burn A contracture is a serious complication of a burn injury. Contractures develop when a burn scar matures, thickens and tightens preventing or limiting movement. If your child develops a contracture, they will not be able to mobilize the scarred area normally.

During Your HospitalDuring Your Stay Have your child perform normal daily activities as much as possible. Movement that occurs during these daily activities such as eating, brushing teeth and hair as well as getting dressed will help keep the scar area stretched. It is important to encourage your child to continue doing these activities despite the fact that they may find them challenging.

Rehabilitation following a burn trauma

30 Caring for Your Burn at Home

• Important recommendations to follow

31 Once your child is ready to return home, you Important will receive instructions that will help you care recommendations for them. An individualized plan will be discussed and written instructions will be provided. Dressing change and/or irrigation Your individualized discharge plan will include Your child may have healing burned areas still medication requirements, dietary needs, requiring dressing changes and/or irrigation after suggested daily activities, return to school discharge. The dressing change will either be done integration plan, home care supplies and at the hospital, local CLSC or at home. You will equipment, wound care instructions as well be given specific instructions on how to change as information on potential complications. and/or irrigate the dressing if needed following Home at Burn Your for Caring Follow-up appointments will be arranged and discharge. Refer to the guidelines at the end of given to you at the time of discharge. the booklet for additional details. The frequency Returning home after a burn injury involves an of dressing changes may vary and you will adjustment period for both the child and family. therefore be provided with a schedule. It is best You will likely experience a variety of feelings and to give your child the prescribed pain medication emotions which are normal and to be expected 30 minutes before the dressing change begins. following a burn injury. You may feel afraid, anxious, or uneasy about leaving the hospital and about your child’s appearance and how others will react. The Trauma Specialists who were involved in your child’s care will remain available as a resource upon discharge home.

32 Compressive garments and splints Skin care Your child may be required to wear compressive Healed wounds, skin grafts, donor sites and garments and splints in order to: scars all need regular moisturizing to prevent •• Manage scars dryness, cracking and discomfort. Newly healed skin is unable to lubricate itself in the same way •• Prevent contractures undamaged skin can. •• Decrease itchiness •• Unscented lotions/creams should be applied Compressive garments should be hand washed gently to the area then gradually progress to using a mild soap, rinsed well, patted gently on a massage a towel, and finally hung out to dry. Do not use •• Moisturizing should be done two to three bleach products or put the compressive garment times per day or more if the skin is very dry Home at Burn Your for Caring in the dryer as this will damage the garment. •• It is extremely important that the skin is ­Garments should be changed approximately every cleaned each day as the build-up of cream three months. Make sure to contact the Occupa- can cause skin irritation tional Therapist if the garment becomes too loose or if other changes to the garment concern you. Scar massage Exercises Once the wound is fully healed begin scar massage. It is essential to ensure that your child performs the daily recommended exercises provided by the •• Massage the scar two to three times a day Burn Team. The Physiotherapist and Occupational for five to 10 minutes at a time Therapist will provide you with a written sheet of exercises prior to your discharge home.

33 •• Continue scar massage until the scar has •• If itching is intolerable and prevents your matured. A mature scar appears pale, flat child from sleeping, contact the Plastic and/or soft Surgeon who may then prescribe medication •• Moisturize the mature scar regularly to reduce itching

Precautions Blisters and open areas •• Do not massage open wounds May develop in newly healed skin and may form •• If the scar becomes sore, blisters, reopens or after minor hits, scrapes or scratches. Can also a rash develops, stop massaging and contact be caused by friction from tight clothing, as well the Occupational Therapist or the Trauma as from not wearing compressive garments or not wearing them properly. With time, the skin Home at Burn Your for Caring Coordinator toughens and blistering is less frequent. It may Itching be necessary to apply a small dressing until the wound heals. Burn injured areas and donor sites may be very itchy for a prolonged period of time. This Discoloration can be very uncomfortable especially at night. The following are some tips that may help ease Once burn healing has begun you may notice that the discomfort: your child’s skin is a different color in comparison to the skin on the rest of their body. This is •• Dress your child in loose, light-weight clothing expected and is part of the normal healing process. •• Compressive garments should be worn all day It may appear light, deep pink or brownish in •• Use an unscented body lotion or cream to color. The extent of discoloration varies with each moisturize healed wounds individual depending on their natural skin tone.

34 In superficial and/or some second-degree burns, Swimming the skin’s natural color may return within several If burn injury wounds are fully closed and healed months. Other areas may take much longer and your child is permitted to swim in a pool, lake some discoloration can be permanent in burns of or ocean. However, it is important to note that greater depth. chlorine tends to dry out burn scars. Make sure Sun sensitivity to rinse the body well after swimming and remember to apply extra moisturizing cream on Newly healed skin and donor sites are extremely the scar. sensitive to sun exposure. The area tends to sunburn quickly especially within the first year Diet

following a burn injury. Home at Burn Your for Caring It is important that your child maintain a •• Limit sun exposure as much as possible well-balanced and nutritious diet at home as •• Protect the skin by wearing light clothing to the healing process continues. The Clinical cover the areas affected by the burn Nutritionist will provide you with information •• Wear a large hat if the face and neck were regarding your child’s caloric needs at home and burned make suggestions on how you can fulfill them. •• Apply a high factor sun screen with both UVA Medication and UVB protection Your child may be discharged home with several It is important to remember that pressure different . A nurse will review how garments do not protect the skin from sunburn. and when to take these medications, what they are used for and discuss any possible side effects.

35 Returning to school Returning to school can be a challenging time for children and teens who have sustained a burn injury. Nonetheless, it is beneficial for them to return to their academic and social activities as soon as they can. To help with this transition, a member of the Psychosocial Team can go to your child’s school ahead of time to help prepare classmates and teachers for your child’s return. This often helps students understand burn Home at Burn Your for Caring trauma and to recognize what their classmate has experienced. It also provides an excellent opportunity to discuss burn trauma prevention. If you feel that any of the above would facilitate your child’s school reintegration, contact the Burn Trauma Coordinator.

36 514 8 Friday to Monday B 514 8 Friday to Monday Alterna TraumaThe Specialists remain available to you and your child upon discharge. • • • Contact the M Contact THE TR urn T urn - - Wound odor Increase in wound pain Fever 412 412 r - - tive C tive a 4400 4400 um A UM a , extension 23310 extension , , extension 23535 extension , C Pro a H B re M re a.m. to 4 a.m. to 6 A P urn T urn g r odule nurse a m RO rauma Program if your child experiences any the following: of your if rauma child Program experiences p.m. p.m. p.m. G R

A M IS HERE FOR YOU 514 Monday to Friday 8 Friday to Monday S Pl 514 Av • • ur a at times ailable all - - sti g part of the of body part Increased swelling to the burn injured changes dressing Bleeding the wound from between 412 412 i ca c S - - l/ 4400 4400 ur T r g a ery Clini , extension 23206 extension , , extension 22433 extension , um a.m. to 4 a U nit 7 nit c p.m. C 1

37 Caring for Your Burn at Home 38 Caring for Your Burn at Home I • • • • • Equip Ensure that you have all the supplies up neatly you and set need that the area is clean. H 4 3 2 1 dressin a nstru • • • • • . . . . ow to cha ow to Cream, ointment or prescribed dressingCream, ointment orprescribed Tape Kerlix) (e.g. bandage Gauze gauze Sterile Sterile water Wash your hands again Remove the old dressingRemove old the (s) and Wash your hands water warm with plastic Discard the old dressing (s) in asmall ment soap c tions for c for tions bag g ng e a e ha ng g dressin ing

0 1 9 5 11 8 7 6 ...... Tape the in wrap place Clean equipmentClean the leg is the ankle from burned, wrap up to ifthe example, For away the heart. from wrappingBegin at the point furthest Wrap the dressing the with gauze bandage. to the wound Apply the cream, ointment or dressing agauzeGently with pat the area dry dressinga new cream/ointment applying residue before Gently clean the wound. remove Always Wash your hands Wash your knee Individu a c instru lized tions 39 Caring for Your Burn at Home 40 Caring for Your Burn at Home Sp Y • • • • • • • • • • • • our Sp lint ca clean skin clean on the insidedry and reapply itto dry, swimming,After ensure the splint is the skin or damage the splint the splint. It might change theaffect fit, or repair to modify not Do try Department. altered, the Occupational contact Therapy If your splint shape or its breaks is shape (heater, oven, window) as itcan alter the notDo leave your splint near aheat source cleaning after carefully yourThoroughly skin dry and splint A brush may used to be clean your splint it may alter the shape of the splint mild soap. not Do use hot water because Clean the splint using lukewarm water and re lint: W e r and C ar are W splint the wearing and stop Department Occupational Therapy If either of the above develops the contact • • Pre

• • hen to we hen

ca numbness to the affected limb affected the to numbness Note any signs of discomfort and/or material to the developed skin damage or an allergic rash may have blisters. Apressure point may causing be for signs ofObserve redness, rash or Splint can removed be for skin care Splint can removed be for exercises Remove splint every Remove splint every At night and during periods rest day the During utions a r your s p lint hours Individu 514-412-4407 O and/or the please contact schedule, application fit, or concerns its regarding I treatment. of part and isan important designed custom was T he splint prescribed by your doctor by your doctor he splint prescribed ccupational T a c instru lized . herapy D herapy f you have questions epartment at at epartment tions 41 Caring for Your Burn at Home 42 Caring for Your Burn at Home • • • • • R H • • • • • e ow to use aS c ommend Increase wearing time hours aday to 24 - - of: maximum siliconeThe should sheet usedfor a be hours) day per 24 a minimum of 12 period hours (preferably siliconeThe should sheet applied be for assheet itmay adhere to the surface notDo use paper towels the silicone to dry frequently more itshouldor physical cleaned be activity skin. If there is asubstantial heat exposure non Wash daily the twice sheet mild, with Apply the adhesive side skin to clean, dry - - 8 hours the following day application first the for hours 4 ‑ oily soap and reapply to clean, dry a tions ili c one S Gel heet silicone sheet T develops,or rash call the O I • f skin irritation, softening, skin breakdown breakdown skin softening, irritation, skin f • herapy D herapy typically last threetypically 3-4 weeks deteriorate, itshould changed. be Sheets Once the silicone begins sheet to epartment and stop wearing and stop the epartment ccupational You will meet with the MCH Trauma Burn Program members on a regular basis. Your questions and concerns are important to us. We encourage you to write down questions, concerns and/or suggestions that you wish to discuss with the team at a later time. Home at Burn Your for Caring

43 References Useful links

The American Burn Association About face Burnsurgery.org aboutface.ca The Montreal Children’s Hospital Association des grands brûlés F.L.A.M. Burn Trauma Protocol www.assdesgrandsbrulesflam.ca Canadian Burn Survivors Community www.canadianburnsurvivors.ca Entraide grands brûlés www.entraidegb.org/home_en.htm Fondation des pompiers du Québec pour les grands brûlés fondationdespompiers.ca The Montreal Children’s Hospital Trauma Centre thechildren.com/trauma/en/ Phoenix Society for Burn Survivors www.phoenix-society.org

44