Burns
This section on Burns is based on a summary from the New Zealand Guidelines group for
ACC (2007). Evidence Based Best Practice Guideline: Management of Burns and Scalds in
Primary Care. Wellington, New Zealand. Please refer to copy of guidelines for more in-depth
information.
An electronic copy can be downloaded from: www.acc.co.nz or to get a printed copy phone
ACC Stationary Orderline 0800 222 070.
If information is from a different source it will be referenced separately.
Definition
A burn is tissue injury caused by heat, friction, extreme cold, electricity, radiation or chemicals.
Burns usually break the skin and thus can cause infection, fluid loss and loss of temperature
control. Deep burns can damage underlying tissues. Burns may also damage the respiratory
system and the eyes.
Burns are classified by the source, such as thermal, electrical or radiation burns. The depth
also classifies them. The deeper the burn, the more severe it is.
Initial assessment and management of Burns and scalds
First Aid (Care that should commence in the community)
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Ensure your own safety
Stop the burning
In electrical injuries, disconnect the person from the source of electricity
Cool the burn, with running tap water (8-15 degrees Celsius) for at least 20 minutes (no
ice). Irrigation of chemical burns should occur for one hour
-Avoid hypothermia: keep the person as warm as possible, consider turning the
temperature up to 15 degrees celsius (tepid)
-can be started up to three hours after injury
Remove clothing and jewellery
Cover the burn with cling film (layered not applied circumferentally) or a clean dry cloth
(avoid topical treatments until the burn depth has been assessed).
Administer analgesia
Seek medical advice
Emergency management
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For major burns perform an ABCDEF primary survey and x-rays as indicated.
Assess analgesic requirements
Establish and record the cause of the burn, the exact mechanism and timing of the
injury, other risk factors and what first aid has been given.
Assess Burn size and depth (page )
Give tetanus prophylactic if required.
Be alert to the possibility of non accidental injury (Page )
Decide on the level of care needed, is a specialist burns unit indicated (see referral
criteria)?
A= Airway maintenance with cervical spine control
B= Breathing
C=Circulation with hemorrhage control
D=Disability =neurological status
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E= Exposure + environmental control (remove jewelry and clothing examine the whole
person. Keep the person warm hypothermia develops quickly especially in children
F=Fluid resuscitation proportional to burn size. Consult pediatrician for children.
Signs of inhalation injury:
History of flame burns or burns in an enclosed space
Full thickness or deep dermal burns to face, neck or upper torso
Singed nasal hair
Carbonaceous sputum or carbon particles in oropharynx
Indications for intubation:
Erythma or swelling of the oropharynx on direct visualization
Change in voice with hoarseness or harsh cough
Stidor, tachypnoea or dyspnoea
Fluid Resuscitation
 Establish intravenous access with two large peripheral intravenous lines.
 Take full blood count, urea electrolytes, coagulation screen, amylase and
carboxyhaemoglobin
 The main aim is to maintain tissue perfusion to the wound and prevent the burn
deepening and to avoid hypoperfusion or oedema.
 Burns of >10% body surface area in children and >15% in adults warrant fluid
resuscitation
 Give fluids:
 24hour requirement:3-4ml crystalloid solution per kg per % burn
 Plus maintenance fluids for children
 Give half of the fluids over the first eight hours, the remainder over the next 16
hours.
Pain management
Paracetamol and NSAIDs can be useful to manage background pain.
Consider administering opioids for intermittent or procedural pain.
Metabolic and electrolyte disturbances
 In initial stages, avoid over-cooling of burn (see first aid above). This could lead to
hypothermia.
 Monitor fluid balance and blood results.
 Patients tolerating oral fluids and nutrition require increased calorie and protein intake. Dietician referral required.
Electrical Burns:
Small entry and exit wounds maybe associated with severe deep tissue damage.
An electrocardiogram (ECG) should be carried out to detect arrythmias
All electrical burns should be referred to a burns unit
Circumferential Burns.
Burns of the circumference of a limb i.e. arm, leg, or the torso. These burns can affect
circulation
 Monitor burns to ensure blood supply to skin. Eschar may occur 6 – 12 hours after
burn.
 Monitor the colour, warmth, sensation, and movement (CWSM) regularly.
 Toes and fingers of the burnt limb must remain visible.
 Ensure dressings are not tight.
 If necessary, an escharotomy is performed. This is a surgical incision to enable blood
flow distal to the eschar.
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Burn Depth
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The depth of a burn should be reassessed two to three days after the initial
assessment, preferably by the same clinician (burn depth is easier to assess after the
initial oedema and inflammatory reaction has settled).
Testing for pinprick sensation should be avoided.
The extend and speed of capillary refill can be used as a clinical method of assessing
burn depth
Classification of Burns based on Depth ANZBA Classification (2004):
Epidermal Burns
e.g UV light, very short flash
Appearance: dry and red, painful, blanches with pressure and there are no blisters
Sensation: maybe painful
Healing time: seven days
Scarring: no scarring.
Superficial Dermal
e.g scald (spill or splash) short flash
Appearance: pale pink with fine blistering blanches with pressure.
Sensation: usually extremely painful
Healing Time: within 14 days
Scarring: cab have colour match defect. Low risk of hypertropic scarring
Mid Dermal
e.g scald (spill), flame oil or grease
Appearance: Dark pink with large blisters, capillary refill sluggish.
Sensation: Maybe painful
Healing time: 14 -21 days
Scarring: moderate risk of hypertropic scarring.
Deep Dermal
e.g Scald(spill), flame oil or grease
Appearance:Blotchy red may blister, no capillary refill. In child maybe dark lobster red with
mottling.
Sensation: no sensation
Healing time: over 21 days, grafting probably needed
Scarring: High risk of scarring
Full Thickness
e.g.Scald (immersion), flame, steam oil, or grease chemical high volt electricity
Appearance: white waxy or charred,no blisters, no capillary refill. Maybe dark lobster red with
mottling in child.
Sensation: No sensation
Healing time: Does not heal spontaneously, grafting needed if greater than 1cm
Scarring; will scar.
Distinguish between burns that will probably heal without skin grafting and those that will
probably require grafting (deep dermal burns and full thickness).
****Burn Depth Assessment tables x2
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Non Accidental burns
 Indicators of possible non accidental burns or scalds include the following:
 Delay in seeking help
 Historical accounts of injury differ over time
 History inconsistent with the injury presented or with the developmental capacity of the
child
 Past abuse or family violence
 Glove and sock pattern scalds
 Scalds with clear cut immersion lines
 Symmetrical burns with uniform depth
 Other signs of physical abuse or neglect
Other possible indicators of non accidental injury may include:
 Inappropriate behaviour/interaction of child or caregivers
 Restraint injuries on upper limbs
If suspected refer to Social Worker.
Burns Transfer Criteria
Criteria for referral1
 Burns greater than 10% Total Body Surface Area (TBSA). (See page for Lund and
Browder chart for estimating TBSA).
 Burns of special area – face, hands, feet, genitalia, perineum and major joints.
 Full thickness burns greater than 5% TBSA.
 Electrical burns.
 Chemical burns.
 Burns with associated inhalation injury.
 Circumferential burns of the limbs or chest.
 Burns at the extremes of age – children and the elderly.
 Burn injury in those with pre-existing medical or physiological disorders, which could
complicate management, prolong recovery or increase mortality.
 Any burn patient with associated trauma.
Severely burned patients are usually transferred to Waikato Hospital Burn’s Unit. Referral by
telephone requires Consultant to on call registrar of burns unit.
Transfer between services is facilitated by prompt assessment, medical photographs.
Jane Widdowson CNE Burns, Plastics and Maxillofacial Surgery, Health Waikato
Preparation of the patient for transfer
 Endotracheal intubation should be considered/ performed prior to transfer.
 Administer 100% humidified oxygen.
 IV access is established and fluid commenced.
 If transfer is within 6 hours of burn, apply glad wrap or other instructions given by
accepting registrar or consultant. Do not apply SSD cream
 Avoid hypothermia. Keep pt warm. Do not leave patient lying in wet sheets.
 Administer analgesic IV only.
 Fax completed burns assessment form with patient details to burns unit (Form available
from ED and digital photos).
 Use aseptic technique to clean the burn with saline
1
EMSB Course Manual 1996
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 Remove loose skin with sterile scissors
Jane Widdowson CNE Burns, Plastics and Maxillofacial Surgery, Health Waikato
If the patient is to be treated at Tairawhiti District Health Board, the principles of managing
burns relate to assessment for and treatment of:
Management of Epidermal Burns or Scalds
These patients are no normally admitted consider referral to District Nurse or Paeditric
Outreach Nurses.
A protective dressing or moisturising cream can be used for comfort in epidermal burns and
scalds.
Review epidermal burns or scalds after 48hours. If the skin is broken change to a moist wound
healing product.
Management of superficial and mid and deep dermal burns or scalds
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Not usually admitted consider referral to District Nurses or Pediatric Outreach Nurses
Use aseptic technique to clean the burn with saline
Remove loose skin with sterile scissors
Products with an antimicrobial action should be used on all burns for the first 72hours
(three days) after burn injury to prevent infection.
Acticoat is the preferred product or can use silver sulphadiazine cream (SSD cream).
Refer to page … for application of acticoat and SSD cream.
After 3 days if there is no infection consider changing to a product that provides re
epithelialisation by moist wound healing e.g film, foam, hydrocolloids.
Nanocrystalline silver (Acticoat) is the preferred dressing for initial management of burns
due to the fact it reduces the time it takes for the burn to epithelise, reduced dressing changes
and trauma of dressing changes associated with the application and removal of SSD cream. It
reduced the requirement for grafting and long term scar management and length of time in
hospital thus making it a cost effective dressing with better client outcomes (Cuttle et al 2007). In
addition to the latter it has also be shown to reduce the incidence of infection (Fong & Fowler,
2005). It has also been recommended for use because the slow release of silver is less likely
to produce a toxic effect that has been associated with the use of SSD cream. (Atiyeh et al ,
2007).
References:
Fong, J., and Fowler, B. (2005). A silver coated dressing reduces the early burn wound cellulitis and associated
costs of inpatient treatment: Comparative patient care audits. Burns 31 562-567
Cuttle, L., Naidu S., Mill, J., Hoskins, W., Das, K., & Kimble, M. (2007). A retrospective cohort study of Acticaot
versus Silvavine in a paediatric population. Burns 33 701-70.
Atiyeh, B., Costagliola, M., Hayek,S., & Dibo, S. (2007). Effect of silver on burn wound infection control and
healing: Review of literature Burns 33 139-148
Management of Blisters:
Preferably leave small blisters intact unless likely to burst or interfere with joint movement.
If necessary drain fluid by snipping a hole in the blister.
Note: a deroofed blister can be more painful than an intact blister.
Review of superficial and mid dermal burns:
Daily for the first three days by lifting the edge of the acticoat dressing then subsequently
every three days.
Consider referral to District Nurses, Paediatric Outreach Nurses.
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Infection
Regular monitoring is important as infection can delay healing, increase scarring and
potentially cause systemic infection.
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Swab the wound
Use nanocrystylline silver (acticoat)
Antibiotic cover.
Ensure tetanus toxoid has been given.
Daily reassessment of healing must be carried out.
Healing wounds :
Education re protection from sun, sunscreen or protective clothing should be worn.
Daily moisturisers and non drying non perfumed soap should be used to protect the skin after
burn injury and may also be helpful for pruritis.
Prevention of Contractures
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Involve scar management service and physiotherapy re positioning of burnt limb and
range of movement and exercises to maintain normal function.
 Physiotherapist should assess movement with the burns dressing removed.
Scarring
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Often scarring is inevitable following burns that involve the deep dermal layers even
with grafting.
Children and those with dark skin pigmentation are often at higher risk for developing
scarring. Since scarring can take an average of 18 months to mature and often gets
worse before it improves it is crucial that patient and family are educated and involved
early to achieve the best possible outcome.
Scarring can result in long term functional disability and changes in appearance both of
which are an indication for specialist care.
Any burns that are unlikely to heal within 21days without grafting should be referred to a
burns service for scar management by day 10-14. Contact Burns and Scar
Management Service Ext 8096
At three weeks the healed area may appear flat and supple however scarring may still
eventuate. A referral to scar management is advised to monitor progress.
A person presenting with scarring some months after a burn should still be referred for
specialist opinion.
Scar Management may also involve the use of pressure garments, silicone, contact
media and moisturizers to flatten and soften scars as well as splinting to prevent or
correct contractures (Rob Heath, Smith and Nephew Scar Management 2009).
Psychological consequences of a burns injury
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Monitor people for signs of stress or depression.
Recognize and treat pre existing disorders and co morbidities (including alcohol and
drug dependence) associated with post traumatic stress disorder (PTSD).
Refer people with acute or chronic PTSD for specialist mental health management.
Be aware of increases risk of sleep disorders after burn injuries.
Support groups: www.burnsupport.org.nz
www.burns.org.nz
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References:
New Zealand Guidelines group for ACC. (2007). Evidence Based Best Practice Guideline:
Management of Burns and Scalds in Primary Care. Wellington, New Zealand.
An electronic copy can be downloaded from: www.acc.co.nz or to get a printed copy phone
ACC Stationary Orderline 0800 222 070.
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Dressing Application
To ensure appropriate and effective use of Nanocrystalline Silver Acticoat in the
management of burn wounds.
1.
Definitions
Nanocrystalline Silver Acticoat ™ - antimicrobial barrier dressing that contains nanocrystalline
silver. Consists of layers of rayon which are sandwiched between layers of silver-coated, low
adherent, polyethylene net. Indicated for use as an anti-microbial barrier over partial and full
thickness wounds (burns) as prophylactic or when infection is present. (Silver ion activity lasts
for up to 3 days, Acticoat ™ 7 also available – silver activity lasts up to 7 days dependent on
exudate levels.)
2. Competency required
Decision to use Acticoat should be by medical staff or delegated to an appropriately skilled
senior nurse. Product application and ongoing care is by nursing staff who have received
education and training in its use.
3.
Contraindication/precautions
Patients allergic to silver, patients undergoing MRI scans, do not use with oil based products,
avoid contact with electrodes.
4.
Equipment
Dressing pack, Dressing saline, Debriding set, gloves
Acticoat™ dressings
Sterile Water for irrigation
+/- hyperfix
Secondary dressings – gauze roll, crepe, surginet etc
Method – Initial outer dressing change and ongoing management
Process
Explain procedure to patient
Assess need for analgesia and
administer as prescribed
Cleanse wound and surrounding skin
using saline + soap and water.
Assess burn wound depth pg…
Debride loose skin and blisters pg…
Cut the Acticoat to the shape/size of
the wound.
Moisten the Acticoat with sterile water
either by pouring onto the dressing or
by submerging into gallipot .(DO NOT
USE SALINE)
Wring out excess water
Apply Acticoat to wound – it does not
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Rationale
Gain informed consent
Burns debridement is painful, some
patients may also experience stinging
on application of Acticoat
Decontaminate, reduce risk of
infection
Depth diagnosis important to direct
ongoing management
This skin is non-viable
Prevent maceration of surrounding
skin
Activates the release of the silver ions
Saline will formulate silver chloride
which will affect the availability of
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matter which way up
silver to the wound.
Key point – secondary dressings:
Acticoat must be kept moist to
continue to release silver ions onto
wound bed.
Choices of secondary dressings
include:
Hyperfix keep moist by showering
and or use of saline given to you by
nurse. Pat dry with clean towel or
sterile gauze. Application four times a
day or when necessary to keep moist
to touch.
Final dressing layer options:
Gamgee/gauze roll. Change
secondary dressing when there is
strike though.
Crepe bandage, surginet etc to
secure
Document wound assessment and
ongoing dressing management in
clinical notes.
A portion of the primary Acticoat
dressing should be inspected to
determine whether further moistening
is required.
Waikato DHB predominantly uses
Acticoat – 3 day version therefore full
dressing change and wound review is
required at this time.
To keep Acticoat moist
For padding and or to absorb
exudate.
Antimicrobial activity ceases if
Acticoat is dry
When Acticoat is removed, staining
or the periwound skin and/or the
wound bed may be seen. This is
transient.
5.
References
Application Guidelines Acticoat and Acticoat 7. Smith & Nephew product brochure.
Ovington, L., G. (2004) The truth about silver. Ostomy Wound Management. 50 (9a).
Jane Widdowson CNL Burns, Plastics and Maxillofacial Surgery, Health Waikato
Application of SSD Cream
 Apply SSD cream 3-5mm thick for 3-4 days.
 Cover SSD cream with Paranet gauze, combine and fix with loose bandage.
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 Daily shower or bath using copious amounts of water to remove dead tissue and SSD
cream. Requires adequate pain relief especially with children
 Wounds must be reassessed daily for first three days.
 If healing well, treat as a superficial burn.
Note: SDD cream needs to be cleaned off daily as it builds up an eschar and on non infected
wounds shouldn’t be applied longer than 7 days as it may delay healing.
Facial burns:
 Do not apply SSD cream to facial areas as it causes tattooing or staining of the skin.
 Clip of trim singed hair
 Debride blisters and loose skin (Pg…)
 Apply olive or paraffin oil 1-2 hourly. There is no need to cover burns with a dressing.
 If the burn is severe enough to warrant admission, do not use pillow on bed, elevate the
head of the bed 30 ° instead. Use of the pillow can cause contractures.
 Daily showering with use of Dermaveen bath oil to remove crusts.
Ears: deep burns to the external ear predispose the auricular cartilage to chondritis and
necrosis resulting in late ear deformities and tissue loss.
 Avoid pressure on the auricle no pillows
 Cleanse as above and apply topical application usually SSD due to conformability
 Remove excess exudate from ear canal as required. Placing a jelonet plug in the ear
canal may help prevent accumulation.
 Consult surgeon before debriding blisters.
Lips:
Keep lubricated with white soft paraffin/Vaseline
Avoid prematurely removing crusts as lips tear and bleed easily
Eyes: (including eyelids or singed lashes)
Manage as per ophthalmologist Rx if corneal damage is present.
Regular eye toilets using saline and gauze
Apply artificial tears or prescribed ointment as directed (reduces corneal drying and infection)
Beards: Usually it is difficult to shave a beard on a conscious patient. The aim is to minimize
the build up of exudate/crust and thus avoid infection.
Shave if possible (preferably while under general anesthetic)
Wash and remove crustings /exudate regularly
Jane Widdowson (2009) CNE Burns, Plastics and Maxillofacial Surgery, Health Waikato
Hands
 Avoid restricting the movement of fingers as this may decrease function.
 Apply acticoat and hyperfix (length wise on fingers to avoid constriction)
 Cover foot in SSD cream. Place inside sterile plastic bag and elevate.
Feet
 Apply acticoat and hyperfix (length wise on fingers to avoid constriction)
 Place Paranet gauze between the toes to prevent them adhering (and healing) to each
other.
 Cover foot in SSD cream. Place inside sterile plastic bag and elevate.
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CHART FOR ESTIMATING SEVERITY OF BURN WOUNDS
Name: ______________________________ Ward ______________
NHI No: _____________________________ Date: ______________
SUPERFICIAL
DEEP
%
Region
Head
A
Neck
Ant. Trunk
Post. Trunk
Rt Arm
Lft Arm
Buttocks
B
B
B
B
Genitalia
Rt Leg
C
C
C
C
Total Burn
RELATIVE PERCENTAGE OF BODY SURFACE AREA
AFFECTED BY GROWTH
AREA
A = ½ of Head
B = ½ of one
thigh
C = ½ of one leg
AGE 0
9½
1yrs
8½
5yrs
6½
10yrs
5½
15yrs
4½
ADULT
3½
2¾
3¼
4
4½
4½
4¾
2½
2½
2¾
3
3¼
3½
LUND & BOWDER CHARTS
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Patient Guidelines
Caring For Burns Using Acticoat
What is acticoat?
Acticoat is a special silver dressing that when moistened will form a protective barrier helping
to prevent bacteria from entering your wound.
While Healing:
1. If you have acticoat silver on your wound this dressing can stay on for three days.The
wound will be reviewed daily by gently lifting an edge of the dressing up.
2. To activate the silver in the dressing it must be keep moist (not wet) by using water not
saline.
3. You will be given a supply of water or alternatively if you are on town supply you may
shower. Pat dry with gauze or a clean towel. This will need to be done every four hours
or when necessary.
4. If soaked in water for over five minutes, the dressing will become soggy and
increase the risk of infection.
5. Avoid activities that may cause injury to the wound, or lead to bleeding or infection.
For example: digging in the sand, swimming, gardening, mechanical repairs.
6. If the wound becomes red and hot with an increase in pain fluid or swelling
beneath the dressing or blisters form, contact your nurse or see your GP.
7. The nurse will remove the dressing after 3 days and review the wound and reapply an
appropriate dressing.
8. Acticoat may cause a silver glitter effect on your wound or some mild staining on the
surrounding skin.This is nothing to worry about it is just the silver released from the
dressing (and only lasts a short time) Once your wound has healed the slight grey
silvery appearance may remain for a short period of time.
References:
Smith and Nephew (2005). A Patients Guide to Acticoat.
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