Download INJURY – BURNS Royal Perth Hospital Nurse Practitioner – Emergency Services

Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Nurse Practitioner
•
Medical Practitioner +/Nurse Practitioner
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Primary survey
assessment
History
Chemical burns
Circumferential burns
Major burns requiring resuscitative
interventions
• Burns complicated by inhalation injury
• Burns complicated by electrical injury
Initial Assessment and Interventions
• Airway
• Breathing
• Circulation
• Nature of burn i.e. thermal, chemical,
electrical
• MIST Mechanism, injuries sustained, signsvitals, treatment given pre hospital
management
• Ability to function/perform
ADL’s/occupation/social assessment
• Past medical history-medications
• Allergies-immunisations especially tetanus
• Last food and fluids
• Compensable statusMVIT/WC/DVA/Private insurance
Focused clinical
assessment
•
Pain assessment
•
Analgesia /
First Aid [2, 3]
Imaging
Scope
Minor burn injuries
Outcomes
Identify patients suitable for
ED NP CPG
Identify patients not suitable
for ED NP guideline and
redirect ED NP Mx to usual
ED care with ED NP part of
the ED team.
Outcomes
Abnormal primary survey
identified → exit CPG
Patient identified as not
suitable for ED NP CPG →
exit CPG
Assess the size, location and depth using
Wallace’s ‘rule of nines’ [1, 2]
-colour
-blistering
-sensation
-capillary return
-exudates
Wound assessment either
epidermal or superficial
dermal burn
Abnormal findings identified
for ED NP CPG → exit CPG
Pain scale numeric, depending on nature
and depth of burn, pain can be mild to
severe
• Administration of analgesia
• First Aid
• Rest
• Immobilisation
• Elevation
• Irrigation with room temperature water for
up to 20 minutes
• Remove jewellery and clothing gently
• Clean with sterile sodium chloride
Working diagnosis and Investigations
• No imaging required if
- no concurrent injuries
Determine need for and type
of analgesia
Reduction/relief of pain
Minimise/prevent possible
complications
Outcomes
Identify specific cause and
determine patient
management
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
1
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Pathology
•
Not applicable
Interpretation of results (diagnostic features) and management decisions
Goals of Treatment
• Protect the wound during the healing
process
• Prevent infection
• Provide pain relief
Provisional
Diagnosis
Epidermal Burn [1]
• ED NP review with view for discharge
i.e. Sunburn or minor
• Dressing required as per amount of
flash injuries, minimal
exudates, pain, contamination and location
exposure time.
• Expected to heal spontaneously within 7-14
Epidermal in depth, red,
days with minimal scarring
PS minimal, heals within
• No dressing unless protection required [3, 4]
7-14 days, no cosmetic
• Patient education/health promotion +/defects
• Follow up appointment with LMO if required.
Superficial Dermal
Burn [1]
i.e. Epidermal and
papillary dermis
involvement, blisters
present, extremely
painful with exposed
nerve endings, heals in
about 14 days,
•
•
Mid Dermal Burn
i.e. Larger zone of
necrosis, Large zone of
stasis,
Can be painful,
Delayed capillary return,
Blisters,
Dark pink
•
Deep Dermal Burn [1]
Some blistering,
Blotchy red base,
Does not blanch,
Reduced sensation to
pinprick,
Surgical correction
•
Full thickness [1]
Both layers of skin
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•
•
•
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•
•
•
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•
•
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•
•
Outcomes
Patient identified as suitable
for ED NP
CPG and discharged safely
ED NP review with view for discharge
Dressing required as per amount of
exudates, pain, contamination and location
Expected to have more exudates and more
absorbent dressing more appropriate.
Dressing selection as per ‘Suggested
Dressings’ see Appendices
Patient education/health promotion
Follow up appointment with LMO or follow
up with Burns Registrar or Burns Nurse
Clinic
ED NP review in consultation with Burns
Staff with view for admission
Review and maintain adequate analgesia
Maintain hydration
Document fluid balance
Patient education and health promotion
Medication as per formulary
Dressing selection as per ‘Suggested
Dressings’ see Appendices
Patient identified as suitable
for ED NP CPG and
discharged safely
ED NP review in consultation with Burns
staff with view for admission
Review and maintain adequate analgesia
Maintain hydration
Document fluid balance
Patient education and health promotion
Medication as per formulary
Dressings as advised
Assessment by Burns Staff
with view for +/- admission
ED NP review in consultation with Burns
Unit with view for admission
Assessment by Burns Unit
and admission/transfer
Patient referred to specialty
units for intervention prior to
discharge home safely.
Call Burns Unit CNS, Burns
Reg or Burns Fellow.
Assessment by Burns Unit
and admission/transfer
arranged.
Call Burns Unit CNS, Burns
Reg or Burns Fellow.
Call Burns Unit CNS, Burns
Reg or Burns Fellow.
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
2
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
destroyed, May affect
deeper structures,
Dense, white, waxy or
charred appearance,
No sensation to pinprick,
Leathery appearance
Acute
Referral
When to return
•
•
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Review and maintain adequate analgesia
Maintain hydration
Document fluid balance
Patient education and health promotion
Medication as per formulary
Dressings as advised
arranged.
Call Burns Reg or Burns
Fellow.
Criteria for specialised burns treatment [2, 3]
• Burns greater than 10% of TBSA
• Special areas – face, hands, feet, genitalia,
perineum and major joints
• Full thickness burns greater than 5 % of
TBSA
• Electrical or chemical burns
• Burns with inhalation injury
• Circumferential burns of limbs or chest
• Those with pre-existing medical disorders
that could complicate management, prolong
recovery or increase mortality
• Burns with associated trauma
Patient Discharge Education
• Verbal instructions from ED NP
• ED written patient information
Outcomes
Ensure patient understands
problem, treatment, follow up
and is safe for discharge
home
Follow up
appointments
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•
•
Verbal instructions from ED NP
Written instructions for LMO
OPD appointment book (if applicable)
Ensure patient understands
problem, treatment, follow up
and is safe for discharge
home
Safety
•
•
Appropriate dressing fitted to burn
Correct fitting of aids ie. broad arm sling,
crutches with instructions from ED NP
Patients greater than 60 yrs of age
-referral to physiotherapy
-referral to care coordinator
Ensure patient understands
problem, treatment, follow up
and is safe for discharge
home
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Specific care
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Other
Referrals
•
Verbal instructions from ED NP
Written information regarding dressing
changes and burn care
Referrals may be made for specific patient
problems or as required to;
- care coordination
- social work
- physiotherapy
- drug and alcohol counselor
- Aboriginal liaison officer
Ensure patient understands
problem, treatment, follow up
and is safe for discharge
home
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
3
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Certificates
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Letters
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Absence from work certificates
WC certificate
Certificate of attendance
Local medical officer letter
Appropriate documentation
completed
Ensures continuity of care
and referral to health care
team
Medications
Analgesia
See separate Analgesia Clinical Protocol for analgesia in ED
which includes IV narcotics.
Standard analgesia for patients admitted to Burns Unit are:
1. Paracetamol 1G QID regularly,
2. Tramadol IR 50 – 100 mg prn 1 hourly, maximum
1000mg/24 hours
3. Oxycodone 10 – 20mg prn 1 hourly (must be prescribed by
Medical Officer)
Other
(See attached Management of Burns pain by Prof. Schug, Head
of Pain Medicine)
Tetanus Immunoglobulin intramuscular Injection
Outcomes
Patients given
analgesia appropriate
to allergies, current
medications and past
medical history
Analgesia requirements
determined by ongoing
assessment of pain and
adequate analgesia
provided
Patients with excessive
pain or pain unrelieved
by analgesia need
review by EP
Adsorbed diphtheria and tetanus toxoids (ADT) 0.5mL
intramuscular Injection
Refer to Australian Immunisation Handbook 8th Edition - section
on Immunisation for tetanus prone wounds - for dosage regimen
(dependent upon previous immunisation status and type of
exposure) online @ http://www1.health.gov.au/immhandbook/
Topical agents
Superficial Burns: Algasite and fixamol. Review within 3 days
in Burns Clinic
Partial / full thickness burns: Acticoat® & cover with
Duoderm®. Review within 3 days by Burns Clinic.
Intravenous
fluids
Unexpected
representation
Missed problem
0.9% Sodium Chloride Intravenous fluid: 5-10ml flush of
Intravenous cannulae 6/24 or Infusion 500ml to 1000ml at 1 12hrly titrated to patients requirements
Clinical audit evaluation strategies
Emergency Department attendance register and ED NP clinical
log
Emergency Department x-ray review
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
4
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
1.
2.
3.
4.
5.
References
Hettiaratchy, S. and R. Papini, Initial management of a major burn: II - Assessment and resuscitation.
British Medical Journal, 2004. 329(7457): p. 101.
Multidisciplinary Burn Management Programme. Burns Unit. Royal Perth Hospital 1995 Revised: Jan
2006
Royal Children's Hospital Melbourne Clinical Practice Guidelines: Burns
Hudspith, J. and S. Rayatt, First aid and treatment of minor burns. British medical journal, 2004.
328(7454): p. 1487 -1489.
eMIMS. [eMIMS on Clinical Information Access Online website] 2006 [cited 2006 Mar 16]; Available
from: http://www.use.hcn.com.au/html/wah/godirect.html.or Hospital Intranet
Authorship and endorsement
(This Guideline has been developed in collaboration with the WADH Review Committee)
This CPG was written by:
This CPG has been reviewed and is endorsed by
Bronwyn Nicholson
Emergency Nurse Practitioner
Joondalup Health Campus
Terry Jongen
Nurse Practitioner
Emergency Services
Royal Perth Hospital
Dr Steve Dunjey
Emergency Medicine Specialist
Emergency Services
Royal Perth Hospital
Dr Jim Cooper
Head of Department
Emergency Department
Royal Perth Hospital
Dr Harry Patterson
Emergency Medicine Specialist
Emergency Department
Royal Perth Hospital
Reviewed by
Dr Fiona Wood
Head of Burns Unit
Joy Fong
Clinical Nurse Consultant
Burn Unit
Dr Swithin Song
Senior Radiologist
Division of Imaging Services
Dr Peter Goldswain
Chair, Drug Therapeutics Committee
Royal Perth Hospital
Key to terms
ED NP- Emergency Department Nurse Practitioner
EP- Emergency Physician
PS- Pain Score
S1-S4- Schedule of the drug administration act
LMO- Local Medical Officer
OP- Outpatients
Appendices
Pain scale
Suggested Dressings for Management of the Minor
Burn Wound
Rule of ‘9’s
Guidelines for Management of Minor Burn Injury
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
5
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
CPG- Clinical Practice Guideline
WC- Work cover
MVIT – Motor Vehicle Insurance Trust
DVA- Department of Veteran Affairs
Written: March 2006
Reviewed: July 2010
Alan Noonan Locum Nurse Practitioner
Michelle Carberry Emergency Nurse Practitioner
using Retention Dressings
Care of the Minor Facial Burn
Review date: July 2013
Appendices
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•
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Guidelines for the management of Minor Burns using retention dressings.
Care of minor facial burns.
Management of minor burns.
Management of burn pain.
Burn information.
page
6
7
10
12
14
GUIDELINES FOR THE MANAGEMENT OF MINOR BURN INJURY
USING RETENTION DRESSINGS
(Such as ‘Fixomull Stretch’ or ‘Hypafix’)
Consider referral to a specialised Burns Centre if the burn falls into one of the
following categories:
hands
face
feet
perineum
chemical burns
major joint involvement
circumferential burns
full thickness burns
electrical burns
any infected burns
Body Surface Area
> 10% adult patient
> 5% child less than
18 months of age
APPLICATION OF DRESSING:
1. Analgesic requirements:
a. consider requirements for initial treatment (may require intravenous / intramuscular
narcotic).
b. once dressing is intact oral analgesia should be adequate, if not reassess.
2. Wash the burn wound under running water.
3. Debride blisters, except palm and sole, which need to be slit (create an ellipse) to
allow for adequate decompression and to prevent the blister re-occurring.
4. Ensure the surrounding skin is dry - the dressing will not adhere to moist skin.
5. Apply the retention dressing to the surface of the wound - no interface gauze/cream
is required. Allow an overlap of two centimetres of retention dressing on to intact
skin.
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
6
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
6. If covering a joint surface, apply with the line of the stretch of the non-woven
fabric following the line of flexion of the joint.
DO NOT STRETCH WITH APPLICATION.
7. When joining two pieces of retention dressing over the wound surface allow no
more than 2 centimetres overlap of the dressing. Overlap can reduce the
effectiveness of the dressing by preventing moisture vapour permeability.
8. Discharge patient with information sheet on care of and removal of the dressing.
9. Review in 2 - 5 days.
10. If ‘blisters’ form beneath the retention dressing they can be treated without
removing all of the dressing. Simply cut away the retention dressing covering the
blistered area. The blistered skin will come away with the dressing releasing the
exudate. The raw area remaining is then treated as the burn area was initially, i.e. clean, dry and
apply a patch of retention dressing with an overlap of no greater than 2cm..
CARE OF THE MINOR FACIAL BURN
1. Wash your face carefully twice each day with a simple non-perfumed soap and water, when showering
or bathing.
2. Men should shave each day to reduce the risk of infection.
3. Remove any loose tissue and crusting while showering.
4. Gently pat with a clean towel. Apply a thin smear of emollient-based ointment to all burn areas except
for the eyelids.
5. Take special care of the eyes, applying eye ointment, as directed by your doctor, to the eye lids.
6. After eating or drinking, apply an oily cream such as ‘lanoline’ to the lips to prevent them from
becoming dry and cracked. This helps to reduce infection.
7. It is necessary to take special care of burns to the ears, by gently cleaning the ears while showering
and applying a thin smear of an emollient based ointment to prevent drying. Pressure on the ears while
they are healing may reduce the blood supply causing further damage to the skin and increasing the
risk of infection.
8. The burn may cause the face to swell. Sitting up on two or more pillows at night will help to reduce
facial swelling.
9. If your wound increases in pain or you are concerned about the swelling, contact the clinic for review
by the nurse.
Retention dressings such as ‘Fixomull Stretch’ and ‘Hypafix’ are not recommended for
use on facial burns.
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
7
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
8
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
9
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Royal Perth Hospital
Surgical Division
MANAGEMENT of MINOR BURN INJURIES
Minor burn injuries are burns to less than 10% TBSA.
1. Superficial burns:
Skin loss to epithelial layer.
Should heal in 7 - 10 days with no scars.
Pink, red, painful, erythema, sometimes with
blistering.
First Aid
Cooling for at least 20-3Omins with water immediately.
Dressings
May be nursed with no dressing if only erytheniatous. Use emollient cream
If blisters appear, debride blisters if red wound bed, apply either Alginate and Fixomul and
re-dress in 2-3 days.
OR
Apply Duoderm (hydrocolloid) and re-dress in 2-3 days.
If after blisters were debrided wound bed is pink (and the injury is not a scald) apply
retention dressing and wash daily. Check in 2-3 days.
2. Partial Burns:
Skin loss to epithelium and part of dermis will heal if superficial partial. But if deep, partial
skin loss will need surgery and grafting.
Mottled pink, painful and blistering, intact hairs.
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
10
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
First aid:
As for superficial burns.
Dressings
Wash with chlorhexidine soap and water. Debride any blisters. Apply Alginate and
Fixomul Check in 2-3 days
OR
Apply Duoderm. Check in 2-3 days. (Apply Alginate if wound exudative, Duoderm if
wound bed is sloughy and dry.)
ANTIMICROBIALS
If antimicrobial is required:
a)
use silvazine cream (for dry, sloughy eschar or infection). Apply thickly, cover with
gauze and secure dressing. This dressing should be done BD
but if outpatient status, daily dressings.
b)
use Acquacel AG - hydrofibre with silver (for exudative burns). Change daily or
second daily.
c)
use Acticoat if required, may be placed under a
hydrocolloid dressing
3. Full Thickness Burns:
Skin loss to all of skin layers may be down to fascia or muscle or bone.
Will need surgery for debridemenlt and skin grafting.
White appearance or may present as black and leathery eschars, no pain, no intact hairs.
First aid:
As for superficial burns
Dressings:
Wash with chlorhexadine soap and water. Debride any dead or loose skin.
Apply Silvazine cream or Acticoat (silver impregnated dressings.)
Refer to Burns Unit, Royal Perth Hospital.
Compiled by:
Date:
Reviewed by:
Date:
Joy Fong, CNC Burns Unit, Royal Perth Hospital
Feb2005.
Joy Fong, CNC, Burns Unit, RPH
Feb 2009
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
11
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
ROYAL PERTH HOSPITAL
Management of Burns Pain
Background Non-Opioid Analgesia
All patients with pain due to burns injury should have regular non-opioid
analgesia prescribed:
• Paracetamol I q QID
o Can be prescribed for all patients, but reduce dose to 500 mg QID
in patients with body weight below 45 kg or with significant liver
impairment or alcoholism
o Preferred route of administration is oral; if patients are NBM, switch
to IV administration.
• COX-2 Inhibitors
o Should be used with care in patients at risk of renal failure (past
history of renal impairment, hypovolaemia, hypotension, other
medications with renal toxicity (ACE inhibitors, aminoglycoside
antibiotics
o Celebrex 100-200mg BD if oral intake possible
o Parecoxib 40 mq BD if parenteral administration required
Break-Through Opioid Analgesia
For initial titration of analgesic requirements, opioids should be used.
• In severe pain or in patients kept NBM, this should ideally been done by
using IV PCA fentanyl or, if patient is unable to use PCA, fentanyl by IV
infusions.
o PCA or IV infusions should be initiated by calling the Pain Medicine
Service.
o There might be the additional need for a ketamine infusion to
improve opioid efficacy, again initiated by Pain Medicine Service.
• In less severe pain and patient tolerating oral intake, the following should
be prescribed:
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
12
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
o Tramadol IR 50-1 00 mci PRN lhrly (max 1000 mg/24 hrs)
• Tramadol is preferable in patients with previous problems
with opioids (respiratory depression, sedation, constipation,
abuse).
o. Oxycodone 10-20 mq PRN Ihrly
• Oxycodone might be needed in more severe pain, but one
has to be careful to avoid constipation.
Background Opioid Analgesia
If patients are requiring breakthrough analgesia regularly or have continuous
pain, then background analgesia by slow-release opioids should be provided.
It is useful initially, to replace 50% of the daily breakthrough requirements by a
slow-release version of the opioid used for breakthrough pain:
• Tramadol SR BD, or
• Oxycontin SR BD
Dose adjustments should be made in a way that immediate release opioids are
only required a few times a day or only for dressing changes/mobilization.
If no immediate release opioids are requested by the patient for a few days, it is
likely, that the dose of background opioids is too high and this should lead to a
dose reduction!
Analgesia for Dressing Changes
Pain caused by dressing changes is often severe and requires aggressive
management using opioids, Entonox and/or ketamine.
• For severe pain from more complex dressing changes, parenteral opioids
via PCA or ketamine/midazolam via PCA should be used. These
modalities as well as the use of Entonox should be initiated by the Pain
Medicine Service.
• For minor dressing changes or in later stages, often appropriately high
oral doses of immediate release opioids are sufficient, if given at least 3040 minutes prior to the procedure.
Compiled by: Professor Stephan Schug
Head of Pain Medicine
RPH
Date: 2008
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
13
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Royal Perth Hospital
SURGICAL DIVISION
BURN INFORMATION
A burn injury refers to the damage caused to the skin and sometimes to the deeper structures
by:
1)
2)
3)
4)
Thermal - flame, scalds.
Electricity
Chemical agents
Radiation.
Burns are further classified by:
1). Depth -
Superficial - pink, red, painful.
Partial thickness - mottled pink, painful, blisters, intact hairs.
Full thickness - white, black, leathery, no pain, no intact hairs, thrombosed
blood vessels
2). Area Wallaces' Rule of Nines is used at Royal Perth Hospital to determine the
percentage of the body that has been burnt.
Rule of Nines
Head- 9%
Each arm - 9%
Trunk front - 18%
Trunk back - 18%
Each leg 18%
Perineum - 1%
Palm - 1%
10% and less - minor burns
10-30% - moderate burns
30% and above - major burns
60% and above - severe burns
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
14
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
3). Cause - Agent causing burns, eg
• electrical - may cause deep bums
• hydrofluoric acid (50% concentration or more) - fatal if concentrated to more than
5%TBA
General First Aid
Burn first aid must be given to improve the final outcome of the burn.
I. Give first aid and burn first aid, stop burning process and cool burns with cool running water
for at least 20 minutes.
2. Resuscitate the victim as required:
•
Clear the airway
•
Restore the breathing
•
Restore circulation
•
Administer oxygen if available (preferably, warm humidified oxygen if inhalational injury
suspected.)
•
Check for spinal cord injury.
3. Keep the patient warm at all times.
4. Remove non adherent clothing - rings, any article which may affect circulation. (Keep
jewellery with patient - document.)
5. Get the patient to medical aid as soon as possible.
6. Minor burn - cool water treatment for 20 minutes, then wash the wounds and dress with
appropriate dressing. Give oral fluids and oral analgesia.
7. Major burn - cool water treatment for 10 minutes, then wrap the victim in clean linen or
wrung out towels or sheets (soaked with water). Keep warm with outer blanket and
transport to medical aid as soon as possible.
Specific First Aid
Scalds
Douse the burnt part in cool water for at least 20 minutes. (NEVER use ice as ice causes
vasoconstriction of blood vessels).
Remove all wet clothing. The burn will be deepest where the clothing is thickest - at hem lines or
where the liquid is held in the folds of the skin or the natural crease where dispersion of heat is
delayed.
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
15
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Hot fat burns may be a combination of flame and scald burn. Hot fat burns are
usually deep partial thickness burns.
Scald burn may take a few days to define itself.
Flame burns
Remove the victim from the flame source and put out the fire. DO NOT allow the victim to
run.
Allay panic.
Immediately douse with cold water OR force the victim to the ground and
smother the flames.
IF clothing is smouldering, remove them. Cut loose clothing off, leave
adhered clothing.
Electrical burns
Disconnect the source or move from contact. Care must be taken with high voltage lines
unless specially trained.
There is usually a point of entry and exit - deeper tissues are always
involved. These burns are usually much more serious than they appear.
The victim may have a cardiac or respiratory arrest which may require resuscitation.
Electrical burns may need cardiac monitoring if there are ECG changes post injury.
Chemical burns
Usually an acid or an alkali.
Brush off any solid particles.
Wash with copious amounts of running water for at LEAST 20 minutes. Ensure that the water is
drained away safely. It is important to remove any clothing which may have chemical spill on it
as this may wash onto the skin and increase burn area.
It is important to wash chemical bums with running cool water. Do not use neutralising
agents except for hydrofluoric acid burns.
Hydrofluoric acid burn is neutralised topically with calcium gluconate gel. This acid will
continue to spread until it is neutralised, therefore may require injection of calcium giuconate
10% solution around the periphery of the burn by the medical staff. Pain will dictate the presence
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
16
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
of hydrofluoric acid left in the burn. Hydrofluoric acid bums (depending on the concentration) can
be fatal even in as small a burn as a 5% BSA.
Phosphorous burns MUST be kept wet at all times using a copper sulphate solution. Copper
sulphate 2% will stain the phosphorous and facilitate its removal manually.
Bitumen/tar burns may be removed by oil compresses after initial cooling process. Analgesia is
required here.
Lime/cement burns - dust off excess chemical and wash with copious amounts of running
water.
In industry, an agent called Diphoterine which is an amphoteric agent which will neutralise both
acid and base (alkali) burns. If the burn is immediately sprayed with Diphoterine the chemical is
neutralised.
Eye injuries
Hold the eyelids open and wash under gentle, cool, running water for at LEAST 15 minutes.
Solid particles trapped under the lid must be removed, eg by running a glass rod under the lid.
The eyes may be stained with Fluorescein sodium minims to ascertain corneal burns.
Other details which are of vital importance on admission are:
1). Age, religion and personal data, including phone number of relatives in either country or city
areas, or a way they can be contacted. If relatives are accompanying the victim or if they are en
route.
2). Exact details of the circumstances of the accident, any other associated injuries or any
possibility of smoke inhalation injury. Whether it was an explosion injury.
3). Exact time of injury.
4). Fluid intake and output since the injury.
5). Record of all drugs given prior to admission, especially analgesia, antiemetics and tetanus
toxoid.
6). Record if oxygen has been administered and time initiated.
7). Whether the victim is known to be a heavy drinker or if the victim was drinking heavily at the
time of the injury (resuscitation may be more difficult and initial output can be misleading).
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
17
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
8). Possibility of drug dependence
9). All past medical history and allergies.
10). Record of any tests of x-rays carried out at the regional hospital.
Treatment of burns
Silver sulphadiazine cream (SSD cream) is used for partial thickness burns. It is
spread thickly over the area and covered with a light gauze or chux dressing and held in place
with Fastanet.
Exudate from the burn mixed with some cream will develop over the partial thickness
burn - appears as a slimy white later. This may lift or be debrided off.
If using SSD on faces please apply SSD onto gauze strips and apply to face, cover with dry
gauze and secure. Avoid eyes, mouth and nostrils.
As the area heals and becomes pink and healthy dressings may be adjusted.
Emollient cream is used for lubricating healed areas.
Other dressings such as hydrocolloids or retention dressings may be used on smaller or
superficial bums.
Acticoat - silver impregnated dressing
If using Acticoat it is only necessary to dress the burns daily to 3rd daily. (Follow product
instructions)
Facial burns
A shower is very beneficial as the running water cleans the face well, hair washing at each
shower is essential.
Clean off all debris with saline three times a day and carefully apply a thin smear of emollient or
Vaseline. If the face becomes very dry or crusty, 4 hourly normal saline compresses are of
benefit.
Eye care should be attended strictly 4 hourly and chloromycetin eye drops applied.
Chloromycetin eye ointment is applied to the eyelids and to the eyes at night.
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
18
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Special attention MUST be paid to the pinna of the ear if burnt. If it becomes infected, the
cartilage may have to be removed and drainage established (antibiotics are of little value as the
pinna has very minimal blood supply). Betadine and jelonet or a smear of SSD cream on the
gauze and regular cleansing with soap and water is essential.
Apply Lanolin to the lips frequently when lips are dry and after food and as soon as the face is
healed, cease the greasy cream and allow the patient to use water based moisturiser, eg vitamin
E cream, Nivea, etc.
DO NOT apply retention dressings on a person's face. For superficial burns apply emollient
cream. If the burn is partial thickness or full thickness, SSD may be applied. SSD is spread on
gauze and applied over the face.
Care of minor burn as out-patient
1). Ensure adequate oral analgesia.
2). Elevation of the burn area is essential. If burnt on the legs or feet, the patient must be
able to get adequate rest with the legs elevated.
3). Clean with soap and water. If it becomes obvious that the blister needs deroofing then
cut away any loose dead skin.
Apply appropriate dressing such as jelonet, melolin, duoderm, alginate or hydrogelor fixomull
based on your wound assessment. Apply tubigrip to legs to reduce oedema and aid venous
return.
4). When healed, keep the skin supple with water based moisturiser. Be sure the patient
understands the importance of thoroughly washing the burnt area and removing the cream
before applying more.
General
Psychosocial support for the patient and relatives is vital.
The pain and loss of body image can be just as devastating to a relatively minor burn as it is to a
major burn.
Pressure garments are used to prevent hypertrophic scarring, but must be worn 23 hours per
day. The need to use these for scar management will be assessed the consulting surgeon.
Garments should be warn as soon as the grafts are stable.
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
19
Royal Perth Hospital
Nurse Practitioner – Emergency Services
CLINICAL PRACTICE PROTOCOL
INJURY – BURNS
Always ensure that the relatives see the burn early in the treatment and are aware of the gradual
improvement - it is very traumatic to see the area without dressing when healed for the first time.
Antibiotics are not used normally but only when there are clinical signs of infection.
Compiled by:
Joy Fong
CNC Plastic and Burns Units
Royal Perth Hospital
Phone (08) 92243578 Page: 2908
Date:
January 2004
Review:
April 2008
Revised by:
Joy Fong CNC Burns Service, Burns Ambulatory Service, Royal Perth Hospital.
Phone
(08) 92243578 Page: 2908
Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the
creation of the Clinical Practice Guidelines
20