4.

On Presentation of Burn Patient to ED – Flowchart

Perform Primary & Secondary

Surveys

Obtain Clear History of Burn Injury

• Mechanism of Injury, How and When burnt
• Any First Aid (what, how long?). Continue
cooling if within 3 hours of burn
• Were clothes removed?

Give Appropriate Pain

Relief

Assess % TBSA (total body surface

area) using Rule of Nines

Does it meet referral criteria?

• Partial/full thickness burns in adults >10% TBSA.

• Partial/full thickness burns in children >5% TBSA.
• Any priority areas are involved, i.e. face/neck, hands, feet,
perineum, genitalia and major joints.
• Caused by chemical or electricity, including lightning.
• Any circumferential burn.
• Burns with concomitant trauma or pre-existing medical condition.
• Burns with associated inhalation injury.
• Suspected non-accidental injury.
• Pregnancy with cutaneous burns.

YES NO

Refer to appropriate Burn Unit (contact Minor Burn:

burn registrar/fellow/ or plastic surgical Can be managed in outlying
registrar): hospitals and clinics, (see Minor Burn
• Royal North Shore Hospital Management booklet)
Ph: (02) 9926 8940 (Burn Unit) • Assess burn wound
Ph: (02) 9926 7988 (Ambulatory Care) • Apply appropriate dressing
• Concord Repatriation General Hospital • Arrange follow-up dressing and
Ph: (02) 9767 7776 (Burn Unit) review
Ph: (02) 9767 7775 (Ambulatory Care) • Prescribe pain relief as
• The Children’s Hospital at Westmead required
(all paediatrics <16yrs) • Contact Burn Unit for any
Ph: (02) 9845 1114 (Burn Unit) questions, co-management or
Ph: (02) 9845 1850 (Ambulatory Care) review

Page 15
5.3 SBIS Transfer Criteria
Can be classified into 3 sections (see criteria below)

For further information see NSW Statewide Burn Injury Service Transfer Guidelines
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns_Transfer_Guidelines
_2013-14_-_web.pdf#zoom=100.

Outcome: Severe and minor burns are defined and transfer criteria is outlined

Page 17
6.2 Burn Patient Dressing Decision-Making Tree

5.
Patient with
Burns

Adequate First
Aid

Yes No

Mechanism – Mechanism –
flame, electrical, flame, electrical,
hot oil. hot oil
Or extended Or extended
exposure to exposure to
heat source? heat source?

No Yes No Yes

Capillary refill
<2 secs?
Probable Probable
superficial burn. deeper burn.
Dress with film, Dress with
silicone or silver or
Yes No
hydrocolloid antimicrobial
dressing and dressing and
review in 7-10 review in 3
days days

Page 19
3.2 Surface Area Assessment

3.2.1 Rule of Nines

Adult Child
For every year of life after
12 months take 1%
from the head and add
½% to each leg,
until the age of 10 years
when adult proportions

3.2.2 Palmar Method

• Palm and fingers of the patient = 1% TBSA

• Useful for small and scattered burns
• Can be used for subtraction e.g. full arm burnt except for
hand-sized area = 8% TBSA

Page 9
 3.4.3 Burn Wound Depth Assessment Table
Depth Colour Blisters Capillary Refill Healing Scarring

Epidermal Red No Brisk Within 7 days None

1-2 sec
Superficial Red / Pale Pink Small Brisk Within 14 days None
Dermal 1-2 sec Slight colour
(Superficial mismatch
Partial)
Mid-Dermal Dark Pink Present Sluggish 2-3 weeks Yes
(Partial) >2 sec Grafting may be (if healing
required >3wks)
Deep Dermal Blotchy Red / +/- Sluggish Grafting required Yes
(Deep Partial) White >2 sec /
Absent
Full Thickness White / Brown / No Absent Grafting required Yes
Black (charred) /
Deep Red
Sources: Modified from EMSB Course Manual, p461; Partial Thickness Burns – Current Concepts as to Pathogenesis and Treatment, p21. (Jan
Darke CNC RNSH)

3.4.4 Capillary Refill

Pictures by Rae Johnson CNC CRGH

If there is a blister lift small area of skin. Apply pressure to wound bed and observe for capillary
refill, replace skin as biological dressing if acceptable refill time.

Page 12
3.5 Recognising Burn Depths
Aim:
• Define burn wound depths

Epidermal Burn Superficial Dermal Burn Mid Dermal Burn

• Blisters present or • Heterogeneous, variable

• Skin intact, red, brisk
capillary refill denuded depths
• Pink, brisk capillary refill • Dark pink, sluggish
• Erythema not included
• Should heal within 7-14 capillary refill
in % TBSA assessment
• Heal spontaneously days with minimal • Should heal within 14 -
within 3-7 days with dressing requirements 21 days
moisturiser or • Deeper areas or over a
protective dressing joint may need surgical
intervention and referral

Deep Dermal Burn Full Thickness Burn

• Heterogeneous, • Outer skin, and some underlying tissue dead

variable depths • White, brown, red, black
• Blotchy red/white • No capillary refill
Sluggish to absent • Surgical intervention and long-term scar management
capillary refill required
• Surgical intervention • Refer to specialist unit
• Refer to specialist unit

Page 13
3.5.1 Wound Appearance
The wound appearance can change over a period of time, especially during the first 7
days following injury.

This patient suffered a scald burn. Notice the changing appearance of the wound over
just a few days.

Day1 Day 2 Day 5

Outcome: wound depths are defined

Page 14
 6.5 Selecting an Appropriate Dressing – Quick Reference Guide
What Dressing Dressing Options Dressing Product Dressing Application
• Silicone/foam Silicone Eg • Apply to clean wound bed
• Film • Mepilex ® • Cover with fixation/retention
• Vaseline • Mepilex Lite® dressing
• Allevyn®
Gauze • Change 3-7 days depending on
• Silver level of exudate
• Hydrocolloid Also available with
silver
• MepilexAg
• Hydrocolloid Hydrocolloid Eg • Apply to clean wound bed
• Film • Comfeel® • Change 3-4 days depending on
• Silicone • Duoderm® level of exudate
• Vaseline
Gauze
• Silver

• Vaseline Vaseline Gauze Eg • Apply directly to wound

Gauze • Bactigras® • 2 layers for acute wounds, 1 layer
• Film • Jelonet® for almost healed wounds
• Silicone • Curity® • Cover with appropriate secondary
• Silver • Adaptic®
dressing
• Hydrocolloid • Change every 1-3 days

• Silver Silver Eg • Apply to moist wound bed

• Silicone • AquacelAg® • Allow 2-5 cm overlap
• Vaseline • Cover with secondary dressing
Gauze • Review in 7-10 days, remove
• Hydrocolloid secondary dressing
• Leave intact until healed, trimming
edges as required. Do not use if
frequent dressing change required
• Silver Silver Eg • Wet Acticoat with H 2 0; drain and
• Vaseline • Acticoat® apply blue side down
Gauze • Insert irrigation system for Acticoat7
• Hydrocolloid • Moistened secondary dressing to
optimise desired moisture level
• Replace 3-4 days (Acticoat) or 7
days (Acticoat 7)
• Silver Silver Eg • Apply generous amount to sterile
• Vaseline • Flammazine® handtowel to ease application
Gauze • Cover with secondary dressing
• Hydrocolloid • Not recommended for most
burns due to changes to wound
appearance and frequency of
required dressing changes –
daily

Page 23
6.7 Specific Dressing Application

6.7.1 Mepilex Application

Clean wound Apply directly

bed to wound

6.7.2 Mepilex Ag Application

Clean wound Apply directly Apply stabilisation

bed to wound dressing if required

6.7.3 Acticoat Application

Clean wound Moisten Apply to Apply moistened

bed Acticoat with wound, either secondary dressing
water NOT side down and stabilise as
saline above

Page 26
6.7.4 AquacelAg Application

Clean wound Apply to Leave intact

bed wound

6.7.5 Bactigras Application

Clean wound Apply Bactigras. Appropriate external

bed 2 layers for moist dressings
wounds

6.7.6 Problem dressings

Issue
Primary dressing slipped off wound. Secondary dressing stuck causing
trauma

Solution
Use appropriate fixation dressing over primary and secondary dressings

Page 27
6.8 Dressing Fixation Application

6.8.1 Self Adherent Tape Application

Start at base Then work from Anchor to Place pieces

of hand tips of fingers in coban on through web
working with a spiral hand spaces of each
a slight covering half of finger to
stretch the previous separate
coban

6.8.2 Adhesive Tape Application

Can be used on many areas of the body to fix dressing in place

7
NB This is not a primary dressing and must not be used on areas of skin

6.8.3 Tubular Bandage Application

Cut to length, Put onto Apply to area Remove

then cut slit for applicator wrinkles
thumb

Page 28
6.8.4 Problem Fixation Dressings

Issue
8 Swelling, pressure areas and reduced blood flow in peripheries

9 Solution
Remove wrinkles in Tubigrip and incorporate feet and hands even if not burnt to
prevent pressure areas and swelling

Issue Issue Issue

Patient unable Dressing falls off Tape applied over pressure
to move hand quickly dressing can lead to
adequately Solution pressure areas
Solution Use appropriate Solution
Wrap fingers fixation dressing Use appropriate fixation
individually dressing

Page 29
 9.1 Burn Wound Management: Wound Care Product Selection

Aim: To choose the most suitable wound care product to reduce infection, promote wound healing, and minimize scarring.

9.1.2 SILVER
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Acticoat/Acticoat 7 • Broad spectrum • Partial to full • Moisten Acticoat with H 2 0; • Initial stinging on
• 2 layered/3 layered antimicrobial thickness remove excess and apply application – provide
nanocrystalline Ag protection • Grafts & donor sites blue side down prophylactic pain relief
coated mesh with inner • Decreases • Infected wounds • Moistened secondary • Temporary skin staining
rayon layer. exudate formation • Over Biobrane & dressing to optimise desired • Maintain normothermia –
• Silver ions released • Decreases eschar Integra moisture level use warm blankets.
with greater surface autolysis • TENS & SJS • Replace 3-4 days (Acticoat)
area + increased or 7 days (Acticoat 7)
solubility
Mepilex Ag • Absorb exudate • Superficial to mid- • Apply to clean wound bed
• Hydrophilic from wound bed dermal burns. • Cover with fixation/retention
polyurethane foam with • Low to moderately dressing
soft silicone layer and exuding wound
waterproof outer layer
Aquacel Ag • Broad spectrum • Partial to deep partial • Apply to clean wound bed • Exudate level indicates
• Sodium antimicrobial thickness burn • Cover with fixation/retention frequency of dressing
carboxymethycellulose
protection • Moderately exuding dressing change
(CMC) & 1.2% ionic Ag
in fibrous material • Facilitates wound
• Silver ions released debridement • Moderate bacterial
with greater surface • Decreases load
area + increased exudate formation
solubility • Absorbs exudate

Page 32
Flamazine • Reduces infection • Partial to full • Apply generous amount to • Change daily, remove old
• Silver Sulphadiazine • Enhances healing thickness sterile handtowel to ease cream
1% • Infected wounds application • Contraindicated during
• Apply to wound first trimester of pregnancy
• Cover with secondary • Not recommended for most
dressing burns due to changes to
wound appearance and
frequency of required
dressing changes
AtraumanAg • Broad spectrum • Partial to full • Apply directly to wound • Do not use with paraffin
Coarsely woven water- antimicrobial thickness • Cover with appropriate dressing
repellent polyamide protection • Grafts & donor sites secondary dressing •
33xudate coated with
• Low cytotoxicity • Moderately infected • Leave intact up to 7 days,
metallic silver
wounds dependent on the wound
• TENS & SJS
Contreet H • Broad spectrum • Low to moderate • No secondary dressing • Not evaluated for
• Sodium antimicrobial exudating wounds • Change if leaking or when pregnancy or on children.
carboxymethycellulose protection • Partial thickness exudate is at edge of Consult with RMO prior to
(CMC) & 1.2% ionic • Facilitates burns dressing. application.
silver wafer debridement • Donor sites • Can remain intact up to 7 • To be removed if radiation,
• Silver ions released • Decreases • Infected wounds. days. ultrasonic, diathermy or
with greater surface exudate formation • Overlap dressing 1.5 cm from microwaves treatment
area + increased wound perimeter. applied.
solubility
Contreet • Broad spectrum • Partial thickness • Overlap dressing so that that • Has not been evaluated
• Polyurethane Foam antimicrobial burns it is 2cm from edge of wound during pregnancy or on
wound dressing with protection • Donor sites • Change if leaking or when children. Consult with
1.2% ionic silver. • Absorbs exudate • Highly exudating exudate is at edge of RMO prior to application.
• Silver ions released • Decreases wounds dressing. • To be removed if radiation,
with greater surface exudate formation • Can remain intact 7 days ultrasonic, diathermy or
area + increased • Retention dressing microwaves treatment
solubility applied.
Page 33
 Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Flamacerium • Creates dry • Burns Specialist to • Apply to body pad or
inactive wound decide application. combine dressing then onto
NB Only to be used by • Decreases • Early application wound
burn units under order by a bacterial load • Consult with RMO for
treating burn specialist repeat application at
48 hrs

8.1.2 GAUZE (moist)

Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Bactigras • Non adherent • Partial thickness • Apply directly to wound
• Chlorhexidine antiseptic dressing wounds • 2 layers for acute wounds, 1
impregnated vas
layer for almost healed
gauze
wounds
• Cover with appropriate
secondary dressing
• Change every 1-3 days
Jelonet, Adaptic, Curity • Non adherent • Clean Partial • As above
• Petrolatum/Vaseline conservative thickness wounds.
impregnated gauze dressing
Xeroform • Non adherent • Partial thickness • Secondary dressing to
• Mesh gauze wounds optimise desired moisture
impregnated with 3%
• Light exudating level
Xeroform (Bismuth
Tribomophophenate) wounds

Page 34
 8.1.3 FILM & HYDOCOLLOID
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Tegaderm, Opsite, • Barrier to • Small isolated • Apply directly to wound • Only use when
IV3000 contaminants wounds • No secondary dressing surrounding tissue not
• Adhesive, conformable • Some blisters required compromised
film dressing
Comfeel • CMC combines • Devitalised tissue, • Allow 2cm margin around
• Hydrocolloids contain with exudate to aid sloughy wounds wound.
carboxymethylcellulose autolysis of • Low to moderately • Can remain intact 2-3 days
(CMC). devitalised tissue. exudating wounds • Wafers up to 5 days if no
• Hydrocolloid wafer • Provides moist signs infection.
• Hydrocolloid paste wound
environment
• Absorbs exudate.
Duoderm • Provides moist • Exudating wounds • Apply directly to area • Only use when
• Hydrocolloid wafer wound • Scars • No secondary dressing surrounding tissue not
environment required compromised
• Absorbs exudate.
• Assists scar
management in
healed wounds

Page 35
 8.1.4 FOAM
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Lyofoam • Absorb exudate • Pads areas such as • Apply shiny side down, over • N/A
• Two layer from wound bed behind ears to primary dressing
polyurethane foam protect delicate
tissues.
• Secondary dressing
Mepilex Transfer • Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
• Hydrophilic from wound bed dermal burns. • Cover with absorbent wounds
polyurethane foam with and transfers to secondary dressing
soft silicone layer outer dressing
Mepilex Lite • Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
• Hydrophilic from wound bed dermal burns. • Cover with fixation/retention wounds
polyurethane foam with dressing
soft silicone layer and
waterproof outer layer
Mepilex Border • Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
• Hydrophilic from wound bed dermal burns. • No need for secondary wounds
polyurethane foam with dressing
soft silicone layer,
adhesive external layer
Biatain • Highly absorbent • Highly exudating • Retention dressing to secure • Remove if radiation,
• Foam dressing foam that absorbs wounds • Change when exudate ultrasonic, diathermy or
exudate approaches 2 cm from the microwaves treatment.
edge of the dressing
Allevyn • Absorb exudate • Exudating wounds • Use as primary or secondary • Avoid use with oxidising
• Non-adherent from wound bed • Granulation dressing, white side down agents
hydrocellular foam • Retention dressing to secure
• Change when exudate
approaches 2 cm from edge

Page 36
 9.1.5 ABSORBENT
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Exudry • Absorbs high exudate • Over primary • Apply appropriate primary
• Non-adherent, highly • Protects against dressing dressing
absorbent, shearing • Then apply outer absorbent
permeable dressing. dressing
Mesorb • Absorbs exudate • As above • As above
• Sterile absorbent
pad
Webril • Protective • As above • As above • May adhere if inappropriate
• Cotton wool primary dressing
bandage
Telfa, Melolite • Non-adherent • As above • As above
• Non-adherent,
absorbent wound
dressing pad
Combine • Absorbs exudate • As above • As above • May adhere if inappropriate
• Absorbent pad primary dressing

Kaltostat, Algisite, • Absorbent dressing • Donor sites • Apply directly to wound • Replace when 37xudates no
Algoderm • Moist wound • Granulating wounds longer absorbed or infection
• Calcium sodium environment • Excessively bleeding
evident.
alginate wound • Donor site leave intact at
• Haemostatic wounds least 10 days
dressing

Page 37
9.1.6 SKIN / DERMAL SUBSTITUTES
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Cultured Epithelial • Assists with skin • Burns Medical • Used in conjunction with • Only used in
Autograft (CEA) / closure Specialist will indicate autograft specialist Burn Unit
Keratinocyte Spray
• Reduces need for application
Only used in specialist extensive donor • Excised full thickness
Burn Unit skin harvesting and deep partial
thickness burns.
Biobrane • Temporary skin • If limited donor skin • Appropriate secondary • Granulation may
• Biosynthetic cover available or loss dressing incorporate Biobrane
dressing made up of
• Decreases risk of • Applied over debrided into regenerating skin
collagen coated
nylon bonded to infection wound bed layer
silicone. • Reduces • Generally in theatres
evaporative water
loss.
Integra • Dermal • Surgical indication and • Burn debrided, Integra • No paraffin,
• Bovine tendon replacement. The application by Burns applied, 3 weeks silastic moisturisers, Silvazine
collagen and
matrix layer allows Medical Specialist layer peeled off and SSG dressings or water as
glycosaminoglycan
cross linked fibres the infiltration of • Full thickness burns applied. this will lift Integra.
with a silastic top fibroblasts, over a flexor joints • Acticoat applied over Integra • Not to be applied to
layer. macrophages, • • Area immobilised and splint people with known
lymphocytes and applied. sensitivities to
capillaries to • If Integra lifting consult with collagen, silastic.
generate the new RMO, remove affected
dermis. Integra, cleans gently
(saline) and apply Acticoat.

Page 38
9.1.7 SILICONE (use in consultation by specialist therapists)
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Mepitel • Non stick • Painful open • Can be left intact 2 – 3 days • Do not apply if
• Transparent, open dressing granulating wounds if exudates minimal sensitive to silicone.
• Exudate moves • Partial thickness burns • Secondary dressing to
mesh, polyamide net,
vertically • Skin tears optimise desired moisture
coated with soft level
silicone layer
Cica Care • Scar softening • Reduces effects of scar • Apply to affected area as • Strict initial usage
• Silicone sheet instructed by therapist regime to assess
sensitivity
• Avoid if allergic to
silicone
Mepiform • Scar softening • Reduces effects of scar • Apply to affected area as • Avoid if allergic to
• Silicone sheet instructed by therapist silicone
• Can be used up to 23
hours/day

Page 39
9.1.8 OTHER
Wound Care Function Indications Application Note / Precautions
Product Why? When? How?
What?
Surfasoft • Reduces friction rub • Applied in the OT • Surfasoft applied wet (sterile • Apply olive oil prior to day
• Woven over graft over meshed grafts. normal saline) of removal (day 4 usually).
polyamide • Exudate able to pass • • Leave intact 5 days unless • Peel off gently. If adhered
transparent
through dressing infection evident. reapply oil.
dressing.
• Easy to view graft.
Solosite, Intrasite, • Re-hydrate wounds • Dry, necrotic • Apply directly onto wound,
Purilon and absorbs some • Low exudating cover with Tegaderm
• Hydrogels exudate into the gel. • Cavity wounds. • Apply onto Lyofoam
Bactigras, Kerlix or Exudry
Saline Dressings • Draws exudate away • Granulating wounds • Bactigras, saline soaked • Do not allow dressing to
from wound • Sloughy wounds Kerlix, Webril or body pad dry out or it will adhere to
• TDS or re-irrigating TDS. wound
Iodine • Anti microbial agent • Wounds infected with • Dab onto wound • Avoid use if sensitive to
Betadine gram +ve & -ve iodine, or thyroid
bacteria, spores, condition.
fungi, viruses proteus. • Iodine toxicity may occur,
Hydrocortisone • Reduces blood flow to • Hypergranulating • Apply direct to wound or to • Change daily
Cream hypergranulated wounds dressing • Short term usage only
eg Betnovate, wound
Diprosone
Silver Nitrate • Cauterises • Hypergranulating • Apply direct to affected area • Single application, can be
Cauterizing agent hypergranulated wounds repeated if necessary
wound
Bepanthen • Antiseptic with • Superficial burns • Apply thin film to wound • Do not apply too thick
Antiseptic cream moisturising • Newly healed partial • For hand burns cover with • Do not use longer than 7
capabilities thickness burns cotton glove days

Page 40
9.1.9 MOISTURISER
Wound Care Function Indications Application Note / Precautions
Product Why? When? How?
What?
Dermaveen Bath • Helps to remove and • Epithelialised, dry • Massage onto wounds and • Do not apply if known
and Shower oil clean devitalised skin healed areas. sensitivities to oatmeal.
• Oatmeal based oil tissue and exudate • Folliculitis • Wash with warm water and
when massaged onto pat dry.
wounds.
• Can relieve pruritus
Paraffin • Prevents wound from • Face / lips • Apply layer to affected area,
drying out • Superficial and Partial do not rub in
thickness burns
Lacrilube • Prevents wound from • Burns around the eye • As Above
drying out
Lanolin • Moisturiser • Burnt Lips • As Above
• dry, healing wounds
Sorbolene • Can be used as a • Dry, healing • Massage small amount into
• Sorbolene + 10% moisturiser or ‘soap’ exudating and required areas of healing
Glycerin devitalised tissue wound.
Dermaveen • Rehydrates new • Epithelialised wounds • Massage onto healing • Do not apply if known
• Oatmeal based epithelium, may • Grafts and donor wound sensitivities to oatmeal.
moisturiser relieve pruritus sites

Page 41
9.1.10 RETENTION / FIXATION
Wound Care Function Indications Application Note / Precautions
Product Why? When? How?
What?
Hypafix, Fixamul, • Stabilises primary and • Superficial partial • Remove 7 – 10 days when • DO NOT use on open
Mefix secondary dressings thickness (skin intact) epithelialised. areas as primary dressing
• Adhesive non • Protects epidermis • Stabilising external • Removed easily with De- • Do not apply to people
woven fabric whilst healing and dressing layer Solve-It (immediate) or olive who may have delayed
initially after oil (takes 30-60mins). healing or fragile skin (eg
epithelialisation the elderly).
Tubigrip • Tissue support • Healing or • Measuring tapes to be used • Avoid application to upper
• Tubular pressure • Pressure to healing epithelialised wounds to decide appropriate size arms and upper thighs, as
bandage and epithelialised and pressure. soft tissue damage may
67%cotton and wounds. • Utilise rings for application. occur.
30% rayon. • Remove if painful/tingling
Coban • Stabilises primary and • Healing or • Adheres to itself but not the • Do not apply with full
• Self adherent secondary dressings epithelialised wounds skin stretch as this may impair
wrap bandage • Pressure to wounds. • Apply with gentle stretch blood flow to peripheries
only

9.1.11 SUPPLIERS
Company Products Website
Smith & Nephew Acticoat, Silvazine, Bactigras, Jelonet, Allevyn, Exudry, http://wound.smith-nephew.com/au/node.asp?NodeId=3820
Melolite, Algisite, Cica Care, Solosite, Intrasite, Hypafix
Molnlycke MepilexAg, Mepilex Transfer, Mepilex Lite, Mepitel, http://www.molnlycke.com/item.asp?id=39328&lang=2&si=336
Mepiform, Mefix, Lyofoam, Tubigrip, Lyofoam
Convatec Aquacel Ag, Duoderm, Kaltostat http://www.convatec.com
Tyco Curity, Mesorb, Webril, Telfa, Surfasoft www.tycohealthcare.com.au
3M Tegaderm, Coban www.3m.com/intl/au
Coloplast Comfeel Wafer, Comfeel Paste, Biatain www.coloplast.com.au
Hartman AtraumanAg www.hartmann-online.com.au
Mylan Laboratories Biobrane www.mylan.com
SSL Tubigrip www.sslaustralia.com.au

Page 42
 Clinical Practice Guidelines:
Burn Patient Management

ACI Statewide Burn Injury Service

Date: May 2014

Version: 2.0
Release Status: Final
Release Date: May 2014
Author: Siobhan Connolly
Owner: Agency for Clinical Innovation
Acknowledgements
These guidelines were developed with the collaboration of the members of the
Multidisciplinary Team of the ACI Statewide Burn Injury Service (from Royal North
Shore Hospital, Concord Repatriation General Hospital and The Children’s Hospital
at Westmead).

AGENCY FOR CLINICAL INNOVATION

Tower A, Level 15, Zenith Centre
821-843 Pacific Highway
Chatswood NSW 2067

Agency for Clinical Innovation

PO Box 699 Chatswood NSW 2057
T +61 2 8644 2200 | F +61 2 8644 2151
E info@aci.nsw.gov.au | http://www.aci.health.nsw.gov.au/networks/burn-injury

Produced by:

Siobhan Connolly
ACI Statewide Burn Injury Service
Ph. 02 9926 5621
Email. siobhan.connolly@aci.health.nsw.gov.au

Further copies of this publication can be obtained from:

ACI Statewide Burn Injury Service
website at: http://www.aci.health.nsw.gov.au/networks/burn-injury

Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced
in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source.

It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires
written permission from the Agency for Clinical Innovation.

© Agency for Clinical Innovation 2011

Contributors
Siobhan Connolly Burn Prevention/Education Officer
ACI Statewide Burn Injury Service

Megan Brady Clinical Nurse Specialist (CNS) – Burns

Concord Repatriation General Hospital

Peter Campbell Clinical Nurse Consultant (CNC) – Burns/Plastics

Royal North Shore Hospital

Bernard Clarke Registered Nurse - ICU

Royal North Shore Hospital

Jan Darke Clinical Nurse Consultant (CNC) – Burns/Plastics

Royal North Shore Hospital

Diane Elfleet Nurse Unit Manager (NUM) – Burns/Plastics

Royal North Shore Hospital

Madeleine Jacques Registered Nurse – Burns

The Children’s Hospital at Westmead

Rae Johnson Clinical Nurse Consultant (CNC) – Burns

Concord Repatriation General Hospital

Nicole Klingstrom Clinical Nurse Educator – Burns

The Children’s Hospital at Westmead

Deborah Maze Nursing Clinical Coordinator – Burns

The Children’s Hospital at Westmead

Chris Parker Nurse Unit Manager (NUM) – Burns/Plastics

Concord Repatriation General Hospital

Sarah Roberts Clinical Nurse Specialist (CNS) – Burns

Concord Repatriation General Hospital

Sue Taggart Clinical Nurse Consultant (CNC) - Burns Support / ICU

Concord Repatriation General Hospital

Kelly Waddell Nurse Practitioner - Burns

The Children’s Hospital at Westmead

Anne Darton Network Manager

ACI Statewide Burn Injury Service

Prof Peter Maitz Burn and Reconstructive Surgeon

Concord Repatriation General Hospital

Dr John Harvey Paediatric and Burn Surgeon

The Children’s Hospital at Westmead

A/Prof David Milliss ICU Consultant

Concord Repatriation General Hospital

Page i
Agency for Clinical Innovation

NSW Health describes the Agency for Clinical Innovation (ACI) in the following way:
“ACI is a board-governed statutory health corporation that reports to the NSW
Minister for Health and the Director-General of NSW Health. Established by the NSW
Government in direct response to the Garling Inquiry into Acute Care Services in
NSW Public Hospitals, the ACI is building on the work of the Greater Metropolitan
Clinical Taskforce (GMCT), and engaging doctors, nurses, allied health
professionals, managers and the wider community in the process of researching,
designing and delivering evidence-based improvements to the way specific
treatments and services are provided within the NSW public health system. As one of
the "pillars of reform" identified by the former Commissioner Peter Garling SC, the
ACI works closely with the Bureau for Health Information, Clinical Excellence
Commission, the Clinical Education and Training Institute and the Cancer Institute
NSW (NSW Health, 2011).

Abbreviations

ACI Agency for Clinical Innovation

SBIS ACI Statewide Burn Injury Service
ANZBA Australian and New Zealand Burn Association
EMSB Emergency Management of Severe Burns course
ED Emergency Department
TBSA Total Body Surface Area
IV Intravenous
IM Intramuscular
IDC In-Dwelling Catheter
C spine Cervical spine
MBA Motorbike Accident
IPL Intense Pulse Light
LPG Liquid Petroleum Gas
LDI Laser Doppler Imaging

Page ii
TABLE OF CONTENTS
ACKNOWLEDGMENTS

CONTRIBUTORS

AGENCY FOR CLINICAL INNOVATION

ABRIEVIATIONS

1. INTRODUCTION 2
1.1 Purpose 2

2. MANAGEMENT OF THE BURN WOUND: FIRST AID 3

3. EMERGENCY ASSESSMENT AND MANAGEMENT OF SEVERE BURNS 5

3.1 Acute Management 5
3.2 Surface Area Assessment 9
3.3 Pain Management 10
3.4 Initial Assesssment of the Burn Wound Depth 11
3.5 Recognising Burn Depths 13

4. ON PRESENTATION OF BURN PATIENT TO THE ED - FLOWCHART 15

5. BURN UNIT ADMISSION CRITERIA 16

6. BURN WOUND MANAGEMENT 18

6.1 Burn Wound Healing Principles and Concepts 18
6.2 Burn Patient Dressing Decision-Making Tree 19
6.3 Cleansing and Debriding the Burn Wound 20
6.4 Digital Photograph of the Burn Wound 22
6.5 Selecting an Appropriate Dressing: Quick Reference Guide 24
6.6 Dressing Procedure 25
6.7 Specific Dressing Application 27
6.8 Dressing Fixation Application 29

7. THE MULTIDISCIPLINARY TEAM 31

8. WEBSITES 32

9. APPENDICES 32
9.1 Burn Wound Managament: Wound Care Product Selection 33
1. Introduction
1.1 Purpose
The following guidelines were developed by specialist staff working within the ACI
Statewide Burn Injury Service (SBIS) from the tertiary Burns Units at The Children’s
Hospital at Westmead, Royal North Shore Hospital and Concord Repatriation General
Hospital. They were designed for use by staff working in these Burn Units to guide
practice, not to replace clinical judgement.

Burn Units provide specialist, multidisciplinary care in the management of burn injuries
due to the continued reinforcement of treatment modalities, which is not readily available
in outlying areas. Burn care involves high expense for wound management materials,
staffing, equipment and long term scar management products. There are also commonly
long term issues arising from the initial trauma, resultant scars and the ongoing effects
these have on the patient and their family.

It is acknowledged that primary care or follow up management of burn injuries may occur
outside of specialist units, particularly for patients with a minor burn. These guidelines are
designed as a practical guide to complement relevant clinical knowledge and the care and
management techniques required for effective patient management. Clinicians working
outside a specialist burn unit are encouraged to liaise closely with their colleagues within
the specialist units for advice and support in burn patient management.

Due to the dynamic nature of burn wounds and the large and changing number of
available wound management products, it is not possible to state emphatically which
product is superior for each wound, however suggestions of possible dressings for
different wound types are included in this document, along with application advice.

1.2 References
Please refer to Clinical Practice Guidelines: Summary of Evidence, available via the SBIS
website for supporting material for this document.
http://www.aci.health.nsw.gov.au/networks/burninjury.

Page 2
2. Management of the Burn Wound – First Aid

Aim:
• Stop the Burning Process
• Cool the Burn Wound

2.1 Stop the Burning Process

• Remove patient from the source of injury.
• If on fire STOP, DROP, COVER face & ROLL
• Remove hot, scalding or charred clothing.
• Avoid self-harm during above steps.

2.2 Cool the Burn Wound

• Cool burn with cold running tap water for at least 20 minutes
• Ideal water temperature for cooling is 15°C, range 8°C to 25°C
• Cooling is effective up to 3 hours after injury
• Keep the remaining areas dry and warm to avoid hypothermia. If patient’s body
temperature falls below 35°C - stop cooling.
NB
• Ice should not be used as it causes vasoconstriction and hypothermia. Ice can also
cause burning when placed directly against the skin.
• Duration of running water should be at least 20 minutes unless other factors prevent
this (eg. large burn causing rapid heat loss, hypothermia, and multiple traumas).
• Wet towels / pads are not efficient at cooling the burn as they do not cool the wound
adequately. They should not be used unless there is no water readily available ie in
transit to medical care. If required use 2 moistened towels / pads and alternate at 30
second intervals.
• Remove any jewellery or constrictive clothing as soon as possible.

2.3 Seek medical advice

• Dial “000” (Triple Zero) for any burn over 10% of the body for adults, 5% of the body
for children, or when there are associated trauma or concerns.
• Visit a local doctor if the burn is larger than the size of a 20c piece with blisters, or if
there are any concerns about the burn.

Plastic cling wrap is an appropriate simple dressing for transferring patients with
burn injuries to a specialist burns unit. It protects against bacterial colonisation
and excess fluid and heat loss.

2.4 On arrival at Hospital

• Place the person on a clean dry sheet and keep them warm.
• Keep the burn covered with plastic cling wrap and a clean sheet when not being
assessed.
• Elevate burnt limbs.
• Small burns may require continuous application of water to reduce pain.
• Chemical burns require copious amounts of water for prolonged periods. A shower is
preferable. Identify the chemical involved. If the chemical is a powder first brush off
excess, then irrigate.

Page 3
• Eye burns require an eye stream (saline) or an IV bag of saline attached to a giving
set and placed over the open eye to flush it adequately until ph is neutral

Outcome: The burning process is stopped and the burn wound is cooled.

For further information see ACI Statewide Burn Injury Service Transfer Guidelines
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns_Transfer_Guidelines
_2013-14_-_web.pdf#zoom=100.

Page 4
3.
Emergency Assessment and Management of Severe Burns

Aim:
Immediate life threatening conditions are identified and emergency management
commenced.

3.1 Acute Management

3.1.1 Primary Survey

A. Airway maintenance with cervical spine control
• Stabilise the neck for suspected cervical spine injury.
• It is important to maintain a patent airway. Inspect the airway for foreign
material/oedema. If the patient is unable to respond to verbal commands open the
airway with a chin lift and jaw thrust.
• Keep movement of the cervical spine to a minimum and never hyperflex or
hyperextend the head or neck.
• Insert a Guedel Airway if airway patency is compromised. Think about early
intubation.

B. Breathing and Ventilation

• Administer 100% oxygen
• Expose the chest and ensure that chest expansion is adequate and bilaterally equal
– beware circumferential deep dermal or full thickness chest burns – is escharotomy
required?
• Palpate for crepitus and for rib fractures
• Auscultate for breath sound bilaterally
• Ventilate via a bag and mask or intubate the patient if necessary.
• Monitor respiratory rate – beware if rate <10 or > 20 per minute.
• Apply pulse oximeter monitor
• Consider carbon monoxide poisoning – non burnt skin may by cherry pink in colour
in a non-breathing patient (send blood for carboxyhaemaglobin)

C. Circulation with Haemorrhage Control

• Inspect for any obvious bleeding – stop with direct pressure.
• Monitor and record the peripheral pulse for rate, strength (strong, weak) and rhythm,
• Apply capillary blanching test (centrally and peripherally to burnt and non-burnt
areas) – normal return is two seconds. Longer indicates poor perfusion due to
hypotension, hypovolaemia or need for escharotomy on that limb; check another
limb.
• Monitor circulation of peripheries if there is a circumferential burn present. Firstly
elevate the limb to reduce oedema and aid blood flow (Kagan & Smith 2000). If this
does not prove effective then it may be necessary to perform an escharotomy.

D. Disability: Neurological Status

• Establish level of consciousness:
A - Alert
V - Response to Vocal stimuli
P - Responds to Painful stimuli
U - Unresponsive
Page 5
• Examine pupils response to light for reaction and size.
• Be alert for restlessness and decreased levels of consciousness – hypoxaemia, CO
intoxication, shock, alcohol, drugs and analgesia influence levels of consciousness.

E. Exposure with Environmental Control

• Remove all clothing and jewellery.
• Keep patient warm
• Hypothermia can have detrimental effects on the patient. It is important to ensure
that the patient is kept warm, especially during first aid cooling periods.
• Log roll patient, remove wet sheets and examine posterior surfaces for burns and
other injuries.

F. Fluids Resuscitation
• Fluid Resuscitation will be required for a patient who has sustained a burn >10% for
children, >15% for adults.
• Estimate burn area using Rule of Nines. For smaller burns the palmar surface
(including fingers) of the patient’s hand (represents 1% TBSA) can be used to
calculate the %TBSA burnt.
• Insert 2 large bore, peripheral IV lines preferably through unburned tissue.
• Collect bloods simultaneously for essential base line bloods - FBC/EUC/ LFT.
/Group & hold/Coags. Others to consider – Drug/alcohol
screen/Amylase/Carboxyhaemoglobin
• Obtain patients body weight in kgs.
• Commence resuscitation fluids, IV Hartmann’s solution at an initial rate of the
Modified Parkland Formula and adjust according to urine output:

3-4 mls x kgs x % TBSA burnt = IV fluid mls to be given in 24hrs following the injury
Give ½ of this fluid in the first 8hrs from the time of injury
Give a ½ of this fluid in the following 16hrs

• Children less than 30kg require 5% dextrose /N/2 saline for maintenance fluids in
addition to resuscitation fluids.
• Insert an IDC for all burns >10% for children, >15% for adults and attach hourly
urine bag. IV fluids are adjusted each hour according to the previous hour’s urine
output.
REMEMBER: The infusion rate is guided by the urine output, not by formula.
The urine output should be maintained at a rate
Adult 0.5 / kg / hr
Children 1 ml / kg / hr

• If urine output <0.5mls/kg/hr increase IV fluids by 1/3 of current IV fluid amount. If

urine output >1ml/hr for adults or >2ml/kg/hr for children decrease IV fluids by 1/3 of
current IV fluid amount (see fluid balance chart on following page).

Eg: Last hrs urine = 20mls, received 1200mls/hr, increase IV to 1600mls/hr

Last hrs urine = 100mls, received 1600mls/hr, decrease IV to 1065mls.
• More IV fluids are required:
1. When haemochromogenuria (dark red, black urine) is evident.
Haemochromogenuria occurs when the person has endured thermal damage to
muscle eg electrical injury. Mannitol may be ordered if haemochromogenuria
evident.
2. Inhalation Injury.

Page 6
 3. Electrical injury
4. Delayed resuscitation
5. Fluid loss prior to burn eg fire fighter, diuretics, alcohol etc.
• ECG, pulse, blood pressure, respiratory rate, pulse oximetry or arterial blood gas
analysis as appropriate.

3.1.2 Nutrition
• Insert nasogastric/ nasojejunal tube for larger burns (>20% TBSA in adults; >15%
TBSA in children) or if associated injuries. See SBIS Nutrition & Dietetics
Guidelines.

3.1.3 Pain Relief

• Give morphine (or other appropriate analgesia) slowly, intravenously and in small
increments according to pain score and sedation scale (see Page 18).

3.1.4 Secondary Survey

Perform a comprehensive secondary survey.

3.1.4.1 History
A - Allergies
M - Medications
P - Past Illnesses
L - Last Meal
E - Events/Environment related to injury
3.1.4.2 Mechanism of Injury
• Gather information from the patient or others the following:
o Date and time of burn injury, date and time of first presentation.
o Source of injury and length of contact time.
o Clothing worn.
o Activities at time of burn injury.
o Adequacy of first aid.
3.1.4.3 Head to Toe Assessment
• Reassess A, B, C, D, E, and F
3.1.4.4 Other actions
• Record and document
• Swab all burn wounds and send to microbiology.

3.1.5 Circulation:
If the patient has a circumferential full thickness burn it may impede circulation and or
ventilation (if burn around chest).
• Contact the Burns Registrar at a specialist burns unit.
• Elevate the effected limb above the heart line.
• Commence a circulation chart.
• Escharotomy may be necessary to relieve pressure if circulation is compromised.

3.1.6 Psychosocial Care

• Document next of kin and telephone number.
• Inform and provide support to family.
• Obtain relevant psychosocial information during assessment and document.
• Contact relevant Social Worker, Psychologist or Psychiatrist

Page 7
3.1.7 Re-evaluate
• Give tetanus prophylaxis if required
• Note urine colour for haemochromogenuria
• Laboratory investigations:
o Haemoglobin/ haematocrit
o Urea/creatinine
o Electrolytes
o Urine microscopy
o Arterial blood gases, carboxyhaemoglobin/
o Electrocardiogram

Outcome: Life threatening injuries are identified and patient receives

emergency management

Page 8
3.2 Surface Area Assessment

3.2.1 Rule of Nines

Adult Child
For every year of life after
12 months take 1%
from the head and add
½% to each leg,
until the age of 10 years
when adult proportions

3.2.2 Palmar Method

• Palm and fingers of the patient = 1% TBSA

• Useful for small and scattered burns
• Can be used for subtraction e.g. full arm burnt except for
hand-sized area = 8% TBSA

Page 9
3.3 Pain Management

Aim:
• To reduce pain levels that are unacceptable to the patient
• To minimise the risk of excessive or inadequate analgesia

3.3.1 Assessment
• How much pain does the patient have? Utilise a scale such as the Visual Analogue
Scale (VAS) at regular intervals every 3-5 minutes, document.
• How much analgesia has the patient been given prior to arrival?
• Ask the patient if they use illicit drugs and alcohol.
• Weigh patient so that analgesic amounts are adequate.

3.3.2 Acute Management

• Give small increments of IV narcotic. A standard stat dose of IV morphine is 2.5 - 10
mg for adults and 0.1 - 0.2 mg/kg of body weight for children.
• The dose should be titrated against the patient’s response, including the respiratory
rate.
• A narcotic infusion can be commenced once the initial treatments have stabilised
the patient.
• Burn procedures may require analgesia beforehand allowing time for it to take
effect. The drug of choice is determined on an individual basis and may include an
opiate such as morphine, with paracetamol. Oral midazolam may also be used for
its dissociative, anxiolytic and sedative qualities. Antihistamines can be useful in
patients where there is excessive itch, but should not be used in conjunction with
midazolam. Inhaled nitrous oxide mixture is often used during dressing removal and
reapplication in some cases.
• Tapes, music and overhead pictures are useful diversion/distraction techniques. For
children a play therapist can also assist with procedures. Provision of diversion/
distraction therapy can help decrease pain and anxiety for both adults and children.
• Anti-emetics may be necessary when narcotics are given.
• Aperients to be administered when narcotics given to avoid constipation.
• Oral analgesia may be administered to patients with minor burns.
• Follow local hospital/institutional Pain Management Guidelines.

3.3.3 Special Considerations:

Narcotic IM injections should not be administered for major burns as peripheral shut down
occurs in burns > 10% TBSA. Absorption of the drug will not take place so pain relief will
not be achieved. As circulation improves an overdose of the opiate may occur.

Outcome: Pain is kept at an acceptable level

Page 10
3.4 Initial Assessment of the Burn Wound Depth
Aim:
• To determine the depth of the burn wound.
• Epidermal, superficial dermal (superficial partial), mid-dermal (partial), deep dermal
(deep partial), and full thickness are terms to describe the depth of burn injury.

3.4.1 To determine the depth of the injury several aspects should be investigated
• Clinical examination of the burn, including capillary refill
• Source and mechanism of the injury, including heat level, chemical concentration,
and contact time with source.
• First aid. Prompt first aid will reduce further destruction of the zone of stasis.
• Age of the patient
• Pre existing disease or medical condition

3.4.2 Burn Skin Depth

Epidermal

Superficial Dermal

Mid Dermal

Deep Dermal

Full Thickness

http://www.skinhealing.com/2_2_skinburnsscars.shtml

Page 11
 3.4.3 Burn Wound Depth Assessment Table
Depth Colour Blisters Capillary Refill Healing Scarring

Epidermal Red No Brisk Within 7 days None

1-2 sec
Superficial Red / Pale Pink Small Brisk Within 14 days None
Dermal 1-2 sec Slight colour
(Superficial mismatch
Partial)
Mid-Dermal Dark Pink Present Sluggish 2-3 weeks Yes
(Partial) >2 sec Grafting may be (if healing
required >3wks)
Deep Dermal Blotchy Red / +/- Sluggish Grafting required Yes
(Deep Partial) White >2 sec /
Absent
Full Thickness White / Brown / No Absent Grafting required Yes
Black (charred) /
Deep Red
Sources: Modified from EMSB Course Manual, p461; Partial Thickness Burns – Current Concepts as to Pathogenesis and Treatment, p21. (Jan
Darke CNC RNSH)

3.4.4 Capillary Refill

Pictures by Rae Johnson CNC CRGH

If there is a blister lift small area of skin. Apply pressure to wound bed and observe for capillary
refill, replace skin as biological dressing if acceptable refill time.

Page 12
3.5 Recognising Burn Depths
Aim:
• Define burn wound depths

Epidermal Burn Superficial Dermal Burn Mid Dermal Burn

• Blisters present or • Heterogeneous, variable

• Skin intact, red, brisk
capillary refill denuded depths
• Pink, brisk capillary refill • Dark pink, sluggish
• Erythema not included
• Should heal within 7-14 capillary refill
in % TBSA assessment
• Heal spontaneously days with minimal • Should heal within 14 -
within 3-7 days with dressing requirements 21 days
moisturiser or • Deeper areas or over a
protective dressing joint may need surgical
intervention and referral

Deep Dermal Burn Full Thickness Burn

• Heterogeneous, • Outer skin, and some underlying tissue dead

variable depths • White, brown, red, black
• Blotchy red/white • No capillary refill
Sluggish to absent • Surgical intervention and long-term scar management
capillary refill required
• Surgical intervention • Refer to specialist unit
• Refer to specialist unit

Page 13
3.5.1 Wound Appearance
The wound appearance can change over a period of time, especially during the first 7
days following injury.

This patient suffered a scald burn. Notice the changing appearance of the wound over
just a few days.

Day1 Day 2 Day 5

Outcome: wound depths are defined

Page 14
4. On Presentation of Burn Patient to ED – Flowchart

Perform Primary & Secondary

Surveys

Obtain Clear History of Burn Injury

• Mechanism of Injury, How and When burnt
• Any First Aid (what, how long?). Continue
cooling if within 3 hours of burn
• Were clothes removed?

Give Appropriate Pain

Relief

Assess % TBSA (total body surface

area) using Rule of Nines

Does it meet referral criteria?

• Partial/full thickness burns in adults >10% TBSA.

• Partial/full thickness burns in children >5% TBSA.
• Any priority areas are involved, i.e. face/neck, hands, feet,
perineum, genitalia and major joints.
• Caused by chemical or electricity, including lightning.
• Any circumferential burn.
• Burns with concomitant trauma or pre-existing medical condition.
• Burns with associated inhalation injury.
• Suspected non-accidental injury.
• Pregnancy with cutaneous burns.

YES NO

Refer to appropriate Burn Unit (contact Minor Burn:

burn registrar/fellow/ or plastic surgical Can be managed in outlying
registrar): hospitals and clinics, (see Minor Burn
• Royal North Shore Hospital Management booklet)
Ph: (02) 9926 8940 (Burn Unit) • Assess burn wound
Ph: (02) 9926 7988 (Ambulatory Care) • Apply appropriate dressing
• Concord Repatriation General Hospital • Arrange follow-up dressing and
Ph: (02) 9767 7776 (Burn Unit) review
Ph: (02) 9767 7775 (Ambulatory Care) • Prescribe pain relief as
• The Children’s Hospital at Westmead required
(all paediatrics <16yrs) • Contact Burn Unit for any
Ph: (02) 9845 1114 (Burn Unit) questions, co-management or
Ph: (02) 9845 1850 (Ambulatory Care) review

Page 15
5. Burns Unit Admission Criteria

Aim:
• Define the difference between severe and minor burns
• Define SBIS burn transfer criteria

5.1 Severe burns

These are burns which require referral to a specialised tertiary burns unit. These units
include adult units at Royal North Shore Hospital and Concord Repatriation General
Hospital, and the paediatric unit at The Children’s Hospital at Westmead.

5.1.2 Acute period - first 24-48 hours - may be longer in severe burns.

NSW Burn Units will admit patients who meet the criteria for a severe burn (see table
5.3.1). They will also admit patients who have major skin loss due to trauma or disease,
or require post burn reconstructive surgery. Additionally Burns Units will admit patients
requiring pain management, physical or psychosocial support.

5.1.3 Special Considerations:

• Burn Unit staff are available for consultation on any burn patient as required. See
Page 24 for digital photograph information
• If the patient requires admission, referring staff must liaise with Burns Unit staff prior
to sending the patient to the unit.
• Patients with respiratory involvement and/or large %TBSA are generally managed in
the Intensive Care until they can be cared for in the ward setting.
• Child Protection Unit (CPU) involvement required for all suspected non-accidental
injuries in children. Psychiatry involvement required for adult suspected non-
accidental injuries.

5.2 Minor Burns

A minor burn is defined as a burn which does not meet any of the above criteria for
referral to specialist burn unit and there are no adverse physical or social circumstances
to outpatient management.

These are burns which can be managed in outlying hospitals/medical centres, or via the
ambulatory care units within the referral hospitals named above or co managed with the
burns units. It is recommended that there is at least some discussion with burn unit to aid
planning for appropriate management.

Page 16
5.3 SBIS Transfer Criteria
Can be classified into 3 sections (see criteria below)

For further information see NSW Statewide Burn Injury Service Transfer Guidelines
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns_Transfer_Guidelines
_2013-14_-_web.pdf#zoom=100.

Outcome: Severe and minor burns are defined and transfer criteria is outlined

Page 17
6. Burn Wound Management

6.1 Burn Wound Healing Principles and Concepts

6.1.1 Principles
To promote wound healing and ease patient discomfort observe the following
principles:
• Ensure adequate perfusion
• Minimise bacterial contamination
• Minimize negative effects of inflammation
• Provide optimal wound environment
• Promote adequate nutrition and fluid management
• Provide adequate pain management
• Promoting re-epithelialisation
• Provide pressure management

6.1.2 Concepts
To ensure the above principles are observed utilise the following concepts for burn
wound management:
• Cleansing – wound surface should be free of slough, exudate, haematoma and
creams
• Debridement – removal of loose, devitalised tissue and non-surgical removal of
eschar
• Dressing
o choose appropriate primary dressing to maintain optimal moisture level and
promote wound healing
o Exudate management - appropriate absorbency level of dressing must be
considered on application
o consider pain and trauma on dressing removal, consider long-term dressing
wherever possible, aim for prevention of trauma on dressing removal
o application - protect against alteration to distal perfusion due to constrictive
dressings, protect against wound bed colonisation
• Pressure – to manage oedema and minimise the effects of scarring

Page 18
6.2 Burn Patient Dressing Decision-Making Tree

5.
Patient with
Burns

Adequate First
Aid

Yes No

Mechanism – Mechanism –
flame, electrical, flame, electrical,
hot oil. hot oil
Or extended Or extended
exposure to exposure to
heat source? heat source?

No Yes No Yes

Capillary refill
<2 secs?
Probable Probable
superficial burn. deeper burn.
Dress with film, Dress with
silicone or silver or
Yes No
hydrocolloid antimicrobial
dressing and dressing and
review in 7-10 review in 3
days days

Page 19
6.3 Cleansing and Debriding the Burn Wound

6.3.1 Aim:
• Remove exudate and creams
• Debride devitalised and loose tissue
• Prevent damaging the healing burn wound.
• Minimise bacterial contamination
• Minimise psychological trauma to patient, carers and staff.
• Reassess the wound

6.3.2 Pain Management

• Adequate analgesia (refer to pain management guidelines 3.3)
• For specific pharmacological and non pharmacological pain management strategies
see Clinical Practice Guidelines: Summary of Evidence. Older children and adult
patients are involved, wherever possible, in the procedure as this gives them a
sense of control.

6.3.3 Preparation
• The patient should be given adequate explanation of the procedure.
• Prepare environment and equipment eg warm environment. The patient with an
acute burn wound should be washed and dried within 30 minutes or less, if possible.
Longer sessions may cause heat loss, pain, stress and sodium loss (water is
hypotonic). Keep the bathroom well heated.

6.3.4 Cleansing
• The wound is cleansed gently to remove loose devitalised tissue, exudate and old
dressings or creams.
• Wash with soft combines or sterile handtowels (ie Chux or Daylees) in diluted
approved solution such as chlorhexidine gluconate (diluted in water 1:2000), dilute
betadine, pre-impregnated chlorhexidine sponges or saline. Use cloth for unburnt
parts of the body to maintain hygiene.
• Dry the patient well, as moisture left behind may macerate the burn and provide an
ideal environment for bacterial contamination.

6.3.5 Debridement
• Complete a holistic patient and wound assessment – not all wounds require
debridement. Clinically examine the patient, does the wound require debridement,
can the patient tolerate debridement, what is the patients clinical pathway (eg
surgical, non surgical, conservative treatment, comfort care?)
• Select the most appropriate method of debridement (see Summary of Evidence for
different methods)

6.3.6 Exudate Management

• There will be high exudate from the wound in the first 72hrs post injury
• Appropriate dressing will be required to manage exudate level
• Maintain optimal moisture balance

Page 20
6.3.7 Special Considerations
• Assess and monitor for possible hypersensitivity or allergic responses to products
• Burns to scalp and excessively hairy areas should be shaved to allow initial
assessment and ongoing wound management, thus preventing folliculitis. Ideally
this should extend 2-5cm past the boundary of the burn to ensure full visualisation
and prevent hair impeding skin regeneration. The necessity for this procedure
should be discussed with the patients as sometimes religious beliefs preclude
cutting of the hair under normal circumstances, and may cause great distress if they
do not understand the rationale.
• Prophylactic antibiotics are not routinely given to burn patients as they do not reduce
the risk of infection. Antibiotics are only given to patients with known infections
and are prescribed to sensitivities, consultation with Infectious Diseases is
strongly recommended.

Outcome: The burn wound is visibly clean.

Page 21
6.4 Digital Photograph of the Burn Wound

6.4.1 Aim:
• Allow ease of communication between Burn Units and external hospitals or health
care facilities
• Assist with monitoring of wounds progress
• Minimises prolonged or multiple exposure of patients
• Reduces issue of infection control by reducing attending staff numbers

6.4.2 Preparation
• The patient should be given adequate explanation of the procedure and sign a
consent prior to any photographs being taken.
• Taking of photos should not delay the dressing procedure for extended periods due
to the risk of hypothermia and distress to the patient.
• Turn off overhead heat light whilst taking photographs as they can lead to
discolouration.
• Consider colouring. Dark skin on stark white background can give illusion of greater
severity of burn. Very pale skin on white background will not give enough contrast.
• Aim for neutral colour background such as green sterile sheet.

6.4.3 Procedure
• Patient should be made comfortable on clean dry sheet.
• Take a photo of the patient’s hospital sticker for identification.
• If patient has extensive burns take global photograph to show where burn occurs on
body.
• For small burns lay a measure rule next to the wound to display wound size.
• Consider patient’s dignity especially if burns around perineum or genitalia. Use small
cloth to cover non-involved areas.
6.4.3.1 Tips:
° Take numerous pictures, with and without flash if necessary, extras can be
deleted when downloading.
° Label photos stating date photo taken, days post burn injury, patient
identification, anatomical position and orientation

6.4.4 Storage
• To preserve confidentiality all images must be stored in a limited access area, such
as password protected.
• For ease of access to appropriate images each should be stored in an easily
recognisable pattern such as under medical record number and date taken.

6.4.5 Emailing pictures

It is possible to email digital photographs of burn wound to burn units. Contact must be
made between referring and accepting medical/nursing staff. Photographs must be taken
in accordance with above guidelines and must be accompanied by injury history and
consent.
6.4.5.1 Email Consultation Addresses
• CHW: kidsburns@chw.edu.au
• RNSH: burnsconsult@nsccahs.health.nsw.gov.au
• CRGH: crghburns@email.cs.nsw.gov.au

Outcome: The burn wound is photographed.

Page 22
 6.5 Selecting an Appropriate Dressing – Quick Reference Guide
What Dressing Dressing Options Dressing Product Dressing Application
• Silicone/foam Silicone Eg • Apply to clean wound bed
• Film • Mepilex ® • Cover with fixation/retention
• Vaseline • Mepilex Lite® dressing
• Allevyn®
Gauze • Change 3-7 days depending on
• Silver level of exudate
• Hydrocolloid Also available with
silver
• MepilexAg
• Hydrocolloid Hydrocolloid Eg • Apply to clean wound bed
• Film • Comfeel® • Change 3-4 days depending on
• Silicone • Duoderm® level of exudate
• Vaseline
Gauze
• Silver

• Vaseline Vaseline Gauze Eg • Apply directly to wound

Gauze • Bactigras® • 2 layers for acute wounds, 1 layer
• Film • Jelonet® for almost healed wounds
• Silicone • Curity® • Cover with appropriate secondary
• Silver • Adaptic®
dressing
• Hydrocolloid • Change every 1-3 days

• Silver Silver Eg • Apply to moist wound bed

• Silicone • AquacelAg® • Allow 2-5 cm overlap
• Vaseline • Cover with secondary dressing
Gauze • Review in 7-10 days, remove
• Hydrocolloid secondary dressing
• Leave intact until healed, trimming
edges as required. Do not use if
frequent dressing change required
• Silver Silver Eg • Wet Acticoat with H 2 0; drain and
• Vaseline • Acticoat® apply blue side down
Gauze • Insert irrigation system for Acticoat7
• Hydrocolloid • Moistened secondary dressing to
optimise desired moisture level
• Replace 3-4 days (Acticoat) or 7
days (Acticoat 7)
• Silver Silver Eg • Apply generous amount to sterile
• Vaseline • Flammazine® handtowel to ease application
Gauze • Cover with secondary dressing
• Hydrocolloid • Not recommended for most
burns due to changes to wound
appearance and frequency of
required dressing changes –
daily

Page 23
6.6 Dressing Procedure

6.6.1 Aim:
• To apply most appropriate dressing using correct technique
• To apply dressing in timely manner to avoid hypothermia, excess pain or trauma
• To maintain an aseptic technique at all times

6.6.2 Dressing notes

• Healed areas of skin need moisturising with appropriate moisturiser; a small amount
is rubbed in until absorbed.
• Secondary dressings must not come in contact with the wound as they may adhere
and cause trauma on removal.
• Care must be taken not to tightly wrap primary dressings circumferentially around
the burns.
• Post procedure pain relief may be required for some patients.
• Occlusive dressings should not be applied to infected wounds

6.6.3 Dressing Specialised Areas

Specialised areas include face, head, neck, ears, hands, perineum and genitals. These
areas require the application of complex dressings which should only be carried out by
experienced clinicians. If attending these types of dressings in areas other than a burn
unit please seek advice from Burns Unit staff and access resources available on the SBIS
website.

6.6.3.1 Face, Head, Neck

• Tracheostomy tape may be used to secure a naso-gastric tube when adhesive tape
is unsuitable due to burns around the nose.

6.6.3.2 Ears
• The area behind the ear should be padded to avoid burnt surfaces coming into
contact with each other and the area incorporated into the head dressing if
appropriate.
• Bactigras or Jelonet are often the dressings of choice on ears.
• Doughnuts made of a soft foam such as Lyofoam can be made to fit around the ear
to help prevent pressure on the ear.
• To protect the helix (cartilage) of the ear, the ear must lie in a natural position and
the padding must be high enough so that any pressure from the bandaging is borne
by the padding.

6.6.3.3 Hands & Fingers

• In the first 24-48 hours if the fingers are swollen, it is sometimes recommended to
dress each finger separately by applying an appropriate primary dressing. The
whole hand is then bandaged as shown in FIG.1. This method inhibits normal
functioning and mobility and should only be used when necessitated.

connolly Page 24
• At all other times, and once oedema has subsided, the fingers should be individually
bandaged as shown in Fig.2. These bandages allow better mobility and enhance
functional ability.

FIG.1. FIG.2.

6.6.3.4 Feet
• The web spaces between the toes should be separated but it is often difficult to
bandage toes separately due to their size.
• A large supportive dressing allows for mobilisation and helps keep the toes in a
normal position. Foam padding (i.e. Lyofoam, Allevyn) can be used to protect burnt
soles.

6.6.3.5 Perineum
• Males: If the penis and/or scrotum are burnt, apply appropriate primary dressing
with outer supportive dressings. A scrotal support may be necessary.
• Females: Dressing the female perineum is more difficult but the type of dressing is
the same as for males.
• Children: When still in nappies, dressings such as Bactigras can be cut to size and
placed in the nappy.
• Patients with perineal burns are generally catheterised to decrease pain and allow
for the area to be kept as clean as possible.

6.6.3.6 Tips:

• It is important to separate burnt surfaces

• Occlusive dressings should not be applied to infected wounds
• Care must be taken not to tightly wrap primary dressings circumferentially around
the burns.
• Secondary dressings must not come in contact with the wound as they may adhere
and cause trauma on removal.
• When bandaging start distally and work proximally, from feet or hands. It may be
necessary to incorporate feet or hands, even if they are not burnt to avoid oedema
formation.
• Elevate the arms and legs, especially in the acute period to reduce oedema.
• Legs should be bandaged straight and splints may be necessary.
• Healed areas of skin need moisturising with appropriate moisturiser; a small amount
is rubbed in until absorbed.
• Post procedure pain relief may be required for some patients.

Outcome: A correct timely dressing is applied aseptically

Page 25
6.7 Specific Dressing Application

6.7.1 Mepilex Application

Clean wound Apply directly

bed to wound

6.7.2 Mepilex Ag Application

Clean wound Apply directly Apply stabilisation

bed to wound dressing if required

6.7.3 Acticoat Application

Clean wound Moisten Apply to Apply moistened

bed Acticoat with wound, either secondary dressing
water NOT side down and stabilise as
saline above

Page 26
6.7.4 AquacelAg Application

Clean wound Apply to Leave intact

bed wound

6.7.5 Bactigras Application

Clean wound Apply Bactigras. Appropriate external

bed 2 layers for moist dressings
wounds

6.7.6 Problem dressings

Issue
Primary dressing slipped off wound. Secondary dressing stuck causing
trauma

Solution
Use appropriate fixation dressing over primary and secondary dressings

Page 27
6.8 Dressing Fixation Application

6.8.1 Self Adherent Tape Application

Start at base Then work from Anchor to Place pieces

of hand tips of fingers in coban on through web
working with a spiral hand spaces of each
a slight covering half of finger to
stretch the previous separate
coban

6.8.2 Adhesive Tape Application

Can be used on many areas of the body to fix dressing in place

7
NB This is not a primary dressing and must not be used on areas of skin

6.8.3 Tubular Bandage Application

Cut to length, Put onto Apply to area Remove

then cut slit for applicator wrinkles
thumb

Page 28
6.8.4 Problem Fixation Dressings

Issue
8 Swelling, pressure areas and reduced blood flow in peripheries

9 Solution
Remove wrinkles in Tubigrip and incorporate feet and hands even if not burnt to
prevent pressure areas and swelling

Issue Issue Issue

Patient unable Dressing falls off Tape applied over pressure
to move hand quickly dressing can lead to
adequately Solution pressure areas
Solution Use appropriate Solution
Wrap fingers fixation dressing Use appropriate fixation
individually dressing

Page 29
7 The Multidisciplinary team

Burn care is conducted by members of a multidisciplinary burn team which include

medical, surgical, intensive care, nursing, physiotherapy, occupational therapy, dietetics,
social work, psychiatry, psychology, speech therapy, pharmacy and technicians. A
multidisciplinary approach to burn management is essential for optimal functional and
cosmetic outcome. Serious long term physical and psychosocial morbidity may be
associated with a burn injury. All members of the burn management team interact
throughout the patient’s management, from admission to discharge and beyond to
support the patient and family in reintegration. All team members contribute to patient
care throughout the early management, ongoing clinical intervention periods during all
phases of care, and continuous educative support to the patient, family and staff.

For further information regarding multidisciplinary care please refer to the following
documents:

• Burn Survivor Rehabilitation: Principles and Guidelines for the Allied Health
Professional (ANZBA)
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/162629/anzba_ahp_guidelines_october_2007.pdf

• Clinical Practice Guidelines: Nutrition Burn Patient Management

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf

• Clinical Practice Guidelines Speech Pathology Burn Patient Management

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0020/162641/SBIS_Speech_Path_CPG_2011.pdf

• Practice Guidelines: Child Life Therapy Burn Patient Management

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/162638/SBIS_Child_life_therapy_CPG_2011.pdf

• Clinical Practice Guidelines: Social Work (adults) Burn Patient Management

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/162637/SBIS_Adult_Social_Work_CPG_new_format.pdf

• Clinical Practice Guidelines: Social Work; Paediatric Burn Patient Management

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/162640/SBIS_Paed_Social_Work_CPG_new_format.pdf

All of these documents are available via the ACI Statewide Burn Injury Service Website:
• http://www.aci.health.nsw.gov.au/networks/burn-injury

Also available on this website are:

• Clinical Practice Guidelines: Burn Patient Management, Summary of Evidence

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0020/162632/CPG_Evidence_2011.pdf

• Minor Burn Management

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/162635/Minor_Burn_Management_2012.pdf

• Clinical Practice Guidelines: Escharotomy for Burn Patients

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/162633/Escharotomy_CPG_new_format.pdf

• NSW Statewide Burn Injury Service Burn Transfer Guidelines

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/GL2008_012.pdf

• NSW Statewide Burn Injury Service Model of Care

http://www.health.nsw.gov.au/gmct/burninjury/docs/burninjury_moc.pdf

Page 30
8 Websites

There are many useful websites. For a few examples please see the list below.

• ACI Statewide Burn Injury Service

http://www.health.nsw.gov.au/gmct/burninjury
• Australian New Zealand Burn Association
http://www.anzba.org.au
• Journal of Burn Care & Research
www.burncareresearch.com
• International Society for Burn Injuries
http://www.worldburn.org
• Burnsurgery.org
http://www.burnsurgery.com/
• Annals of Burns and Fire Disasters
http://www.medbc.com/annals/
• Management Guidelines for People with Burn Injury
www.health.nsw.gov.au/public-health/burns/burnsmgt.pdf
• Resident Orientation Manual – Acute Burn Management
www.totalburncare.com/orientation_acute_burn_mgmt.htm
• Skin Healing
http://www.skinhealing.com

9 Appendices

9.1 Burn Wound Management: Wound Care Product Selection

Page 31
 9.1 Burn Wound Management: Wound Care Product Selection

Aim: To choose the most suitable wound care product to reduce infection, promote wound healing, and minimize scarring.

9.1.2 SILVER
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Acticoat/Acticoat 7 • Broad spectrum • Partial to full • Moisten Acticoat with H 2 0; • Initial stinging on
• 2 layered/3 layered antimicrobial thickness remove excess and apply application – provide
nanocrystalline Ag protection • Grafts & donor sites blue side down prophylactic pain relief
coated mesh with inner • Decreases • Infected wounds • Moistened secondary • Temporary skin staining
rayon layer. exudate formation • Over Biobrane & dressing to optimise desired • Maintain normothermia –
• Silver ions released • Decreases eschar Integra moisture level use warm blankets.
with greater surface autolysis • TENS & SJS • Replace 3-4 days (Acticoat)
area + increased or 7 days (Acticoat 7)
solubility
Mepilex Ag • Absorb exudate • Superficial to mid- • Apply to clean wound bed
• Hydrophilic from wound bed dermal burns. • Cover with fixation/retention
polyurethane foam with • Low to moderately dressing
soft silicone layer and exuding wound
waterproof outer layer
Aquacel Ag • Broad spectrum • Partial to deep partial • Apply to clean wound bed • Exudate level indicates
• Sodium antimicrobial thickness burn • Cover with fixation/retention frequency of dressing
carboxymethycellulose
protection • Moderately exuding dressing change
(CMC) & 1.2% ionic Ag
in fibrous material • Facilitates wound
• Silver ions released debridement • Moderate bacterial
with greater surface • Decreases load
area + increased exudate formation
solubility • Absorbs exudate

Page 32
Flamazine • Reduces infection • Partial to full • Apply generous amount to • Change daily, remove old
• Silver Sulphadiazine • Enhances healing thickness sterile handtowel to ease cream
1% • Infected wounds application • Contraindicated during
• Apply to wound first trimester of pregnancy
• Cover with secondary • Not recommended for most
dressing burns due to changes to
wound appearance and
frequency of required
dressing changes
AtraumanAg • Broad spectrum • Partial to full • Apply directly to wound • Do not use with paraffin
Coarsely woven water- antimicrobial thickness • Cover with appropriate dressing
repellent polyamide protection • Grafts & donor sites secondary dressing •
33xudate coated with
• Low cytotoxicity • Moderately infected • Leave intact up to 7 days,
metallic silver
wounds dependent on the wound
• TENS & SJS
Contreet H • Broad spectrum • Low to moderate • No secondary dressing • Not evaluated for
• Sodium antimicrobial exudating wounds • Change if leaking or when pregnancy or on children.
carboxymethycellulose protection • Partial thickness exudate is at edge of Consult with RMO prior to
(CMC) & 1.2% ionic • Facilitates burns dressing. application.
silver wafer debridement • Donor sites • Can remain intact up to 7 • To be removed if radiation,
• Silver ions released • Decreases • Infected wounds. days. ultrasonic, diathermy or
with greater surface exudate formation • Overlap dressing 1.5 cm from microwaves treatment
area + increased wound perimeter. applied.
solubility
Contreet • Broad spectrum • Partial thickness • Overlap dressing so that that • Has not been evaluated
• Polyurethane Foam antimicrobial burns it is 2cm from edge of wound during pregnancy or on
wound dressing with protection • Donor sites • Change if leaking or when children. Consult with
1.2% ionic silver. • Absorbs exudate • Highly exudating exudate is at edge of RMO prior to application.
• Silver ions released • Decreases wounds dressing. • To be removed if radiation,
with greater surface exudate formation • Can remain intact 7 days ultrasonic, diathermy or
area + increased • Retention dressing microwaves treatment
solubility applied.
Page 33
 Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Flamacerium • Creates dry • Burns Specialist to • Apply to body pad or
inactive wound decide application. combine dressing then onto
NB Only to be used by • Decreases • Early application wound
burn units under order by a bacterial load • Consult with RMO for
treating burn specialist repeat application at
48 hrs

8.1.2 GAUZE (moist)

Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Bactigras • Non adherent • Partial thickness • Apply directly to wound
• Chlorhexidine antiseptic dressing wounds • 2 layers for acute wounds, 1
impregnated vas
layer for almost healed
gauze
wounds
• Cover with appropriate
secondary dressing
• Change every 1-3 days
Jelonet, Adaptic, Curity • Non adherent • Clean Partial • As above
• Petrolatum/Vaseline conservative thickness wounds.
impregnated gauze dressing
Xeroform • Non adherent • Partial thickness • Secondary dressing to
• Mesh gauze wounds optimise desired moisture
impregnated with 3%
• Light exudating level
Xeroform (Bismuth
Tribomophophenate) wounds

Page 34
 8.1.3 FILM & HYDOCOLLOID
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Tegaderm, Opsite, • Barrier to • Small isolated • Apply directly to wound • Only use when
IV3000 contaminants wounds • No secondary dressing surrounding tissue not
• Adhesive, conformable • Some blisters required compromised
film dressing
Comfeel • CMC combines • Devitalised tissue, • Allow 2cm margin around
• Hydrocolloids contain with exudate to aid sloughy wounds wound.
carboxymethylcellulose autolysis of • Low to moderately • Can remain intact 2-3 days
(CMC). devitalised tissue. exudating wounds • Wafers up to 5 days if no
• Hydrocolloid wafer • Provides moist signs infection.
• Hydrocolloid paste wound
environment
• Absorbs exudate.
Duoderm • Provides moist • Exudating wounds • Apply directly to area • Only use when
• Hydrocolloid wafer wound • Scars • No secondary dressing surrounding tissue not
environment required compromised
• Absorbs exudate.
• Assists scar
management in
healed wounds

Page 35
 8.1.4 FOAM
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Lyofoam • Absorb exudate • Pads areas such as • Apply shiny side down, over • N/A
• Two layer from wound bed behind ears to primary dressing
polyurethane foam protect delicate
tissues.
• Secondary dressing
Mepilex Transfer • Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
• Hydrophilic from wound bed dermal burns. • Cover with absorbent wounds
polyurethane foam with and transfers to secondary dressing
soft silicone layer outer dressing
Mepilex Lite • Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
• Hydrophilic from wound bed dermal burns. • Cover with fixation/retention wounds
polyurethane foam with dressing
soft silicone layer and
waterproof outer layer
Mepilex Border • Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
• Hydrophilic from wound bed dermal burns. • No need for secondary wounds
polyurethane foam with dressing
soft silicone layer,
adhesive external layer
Biatain • Highly absorbent • Highly exudating • Retention dressing to secure • Remove if radiation,
• Foam dressing foam that absorbs wounds • Change when exudate ultrasonic, diathermy or
exudate approaches 2 cm from the microwaves treatment.
edge of the dressing
Allevyn • Absorb exudate • Exudating wounds • Use as primary or secondary • Avoid use with oxidising
• Non-adherent from wound bed • Granulation dressing, white side down agents
hydrocellular foam • Retention dressing to secure
• Change when exudate
approaches 2 cm from edge

Page 36
 9.1.5 ABSORBENT
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Exudry • Absorbs high exudate • Over primary • Apply appropriate primary
• Non-adherent, highly • Protects against dressing dressing
absorbent, shearing • Then apply outer absorbent
permeable dressing. dressing
Mesorb • Absorbs exudate • As above • As above
• Sterile absorbent
pad
Webril • Protective • As above • As above • May adhere if inappropriate
• Cotton wool primary dressing
bandage
Telfa, Melolite • Non-adherent • As above • As above
• Non-adherent,
absorbent wound
dressing pad
Combine • Absorbs exudate • As above • As above • May adhere if inappropriate
• Absorbent pad primary dressing

Kaltostat, Algisite, • Absorbent dressing • Donor sites • Apply directly to wound • Replace when 37xudates no
Algoderm • Moist wound • Granulating wounds longer absorbed or infection
• Calcium sodium environment • Excessively bleeding
evident.
alginate wound • Donor site leave intact at
• Haemostatic wounds least 10 days
dressing

Page 37
9.1.6 SKIN / DERMAL SUBSTITUTES
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Cultured Epithelial • Assists with skin • Burns Medical • Used in conjunction with • Only used in
Autograft (CEA) / closure Specialist will indicate autograft specialist Burn Unit
Keratinocyte Spray
• Reduces need for application
Only used in specialist extensive donor • Excised full thickness
Burn Unit skin harvesting and deep partial
thickness burns.
Biobrane • Temporary skin • If limited donor skin • Appropriate secondary • Granulation may
• Biosynthetic cover available or loss dressing incorporate Biobrane
dressing made up of
• Decreases risk of • Applied over debrided into regenerating skin
collagen coated
nylon bonded to infection wound bed layer
silicone. • Reduces • Generally in theatres
evaporative water
loss.
Integra • Dermal • Surgical indication and • Burn debrided, Integra • No paraffin,
• Bovine tendon replacement. The application by Burns applied, 3 weeks silastic moisturisers, Silvazine
collagen and
matrix layer allows Medical Specialist layer peeled off and SSG dressings or water as
glycosaminoglycan
cross linked fibres the infiltration of • Full thickness burns applied. this will lift Integra.
with a silastic top fibroblasts, over a flexor joints • Acticoat applied over Integra • Not to be applied to
layer. macrophages, • • Area immobilised and splint people with known
lymphocytes and applied. sensitivities to
capillaries to • If Integra lifting consult with collagen, silastic.
generate the new RMO, remove affected
dermis. Integra, cleans gently
(saline) and apply Acticoat.

Page 38
9.1.7 SILICONE (use in consultation by specialist therapists)
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Mepitel • Non stick • Painful open • Can be left intact 2 – 3 days • Do not apply if
• Transparent, open dressing granulating wounds if exudates minimal sensitive to silicone.
• Exudate moves • Partial thickness burns • Secondary dressing to
mesh, polyamide net,
vertically • Skin tears optimise desired moisture
coated with soft level
silicone layer
Cica Care • Scar softening • Reduces effects of scar • Apply to affected area as • Strict initial usage
• Silicone sheet instructed by therapist regime to assess
sensitivity
• Avoid if allergic to
silicone
Mepiform • Scar softening • Reduces effects of scar • Apply to affected area as • Avoid if allergic to
• Silicone sheet instructed by therapist silicone
• Can be used up to 23
hours/day

Page 39
9.1.8 OTHER
Wound Care Function Indications Application Note / Precautions
Product Why? When? How?
What?
Surfasoft • Reduces friction rub • Applied in the OT • Surfasoft applied wet (sterile • Apply olive oil prior to day
• Woven over graft over meshed grafts. normal saline) of removal (day 4 usually).
polyamide • Exudate able to pass • • Leave intact 5 days unless • Peel off gently. If adhered
transparent
through dressing infection evident. reapply oil.
dressing.
• Easy to view graft.
Solosite, Intrasite, • Re-hydrate wounds • Dry, necrotic • Apply directly onto wound,
Purilon and absorbs some • Low exudating cover with Tegaderm
• Hydrogels exudate into the gel. • Cavity wounds. • Apply onto Lyofoam
Bactigras, Kerlix or Exudry
Saline Dressings • Draws exudate away • Granulating wounds • Bactigras, saline soaked • Do not allow dressing to
from wound • Sloughy wounds Kerlix, Webril or body pad dry out or it will adhere to
• TDS or re-irrigating TDS. wound
Iodine • Anti microbial agent • Wounds infected with • Dab onto wound • Avoid use if sensitive to
Betadine gram +ve & -ve iodine, or thyroid
bacteria, spores, condition.
fungi, viruses proteus. • Iodine toxicity may occur,
Hydrocortisone • Reduces blood flow to • Hypergranulating • Apply direct to wound or to • Change daily
Cream hypergranulated wounds dressing • Short term usage only
eg Betnovate, wound
Diprosone
Silver Nitrate • Cauterises • Hypergranulating • Apply direct to affected area • Single application, can be
Cauterizing agent hypergranulated wounds repeated if necessary
wound
Bepanthen • Antiseptic with • Superficial burns • Apply thin film to wound • Do not apply too thick
Antiseptic cream moisturising • Newly healed partial • For hand burns cover with • Do not use longer than 7
capabilities thickness burns cotton glove days

Page 40
9.1.9 MOISTURISER
Wound Care Function Indications Application Note / Precautions
Product Why? When? How?
What?
Dermaveen Bath • Helps to remove and • Epithelialised, dry • Massage onto wounds and • Do not apply if known
and Shower oil clean devitalised skin healed areas. sensitivities to oatmeal.
• Oatmeal based oil tissue and exudate • Folliculitis • Wash with warm water and
when massaged onto pat dry.
wounds.
• Can relieve pruritus
Paraffin • Prevents wound from • Face / lips • Apply layer to affected area,
drying out • Superficial and Partial do not rub in
thickness burns
Lacrilube • Prevents wound from • Burns around the eye • As Above
drying out
Lanolin • Moisturiser • Burnt Lips • As Above
• dry, healing wounds
Sorbolene • Can be used as a • Dry, healing • Massage small amount into
• Sorbolene + 10% moisturiser or ‘soap’ exudating and required areas of healing
Glycerin devitalised tissue wound.
Dermaveen • Rehydrates new • Epithelialised wounds • Massage onto healing • Do not apply if known
• Oatmeal based epithelium, may • Grafts and donor wound sensitivities to oatmeal.
moisturiser relieve pruritus sites

Page 41
9.1.10 RETENTION / FIXATION
Wound Care Function Indications Application Note / Precautions
Product Why? When? How?
What?
Hypafix, Fixamul, • Stabilises primary and • Superficial partial • Remove 7 – 10 days when • DO NOT use on open
Mefix secondary dressings thickness (skin intact) epithelialised. areas as primary dressing
• Adhesive non • Protects epidermis • Stabilising external • Removed easily with De- • Do not apply to people
woven fabric whilst healing and dressing layer Solve-It (immediate) or olive who may have delayed
initially after oil (takes 30-60mins). healing or fragile skin (eg
epithelialisation the elderly).
Tubigrip • Tissue support • Healing or • Measuring tapes to be used • Avoid application to upper
• Tubular pressure • Pressure to healing epithelialised wounds to decide appropriate size arms and upper thighs, as
bandage and epithelialised and pressure. soft tissue damage may
67%cotton and wounds. • Utilise rings for application. occur.
30% rayon. • Remove if painful/tingling
Coban • Stabilises primary and • Healing or • Adheres to itself but not the • Do not apply with full
• Self adherent secondary dressings epithelialised wounds skin stretch as this may impair
wrap bandage • Pressure to wounds. • Apply with gentle stretch blood flow to peripheries
only

9.1.11 SUPPLIERS
Company Products Website
Smith & Nephew Acticoat, Silvazine, Bactigras, Jelonet, Allevyn, Exudry, http://wound.smith-nephew.com/au/node.asp?NodeId=3820
Melolite, Algisite, Cica Care, Solosite, Intrasite, Hypafix
Molnlycke MepilexAg, Mepilex Transfer, Mepilex Lite, Mepitel, http://www.molnlycke.com/item.asp?id=39328&lang=2&si=336
Mepiform, Mefix, Lyofoam, Tubigrip, Lyofoam
Convatec Aquacel Ag, Duoderm, Kaltostat http://www.convatec.com
Tyco Curity, Mesorb, Webril, Telfa, Surfasoft www.tycohealthcare.com.au
3M Tegaderm, Coban www.3m.com/intl/au
Coloplast Comfeel Wafer, Comfeel Paste, Biatain www.coloplast.com.au
Hartman AtraumanAg www.hartmann-online.com.au
Mylan Laboratories Biobrane www.mylan.com
SSL Tubigrip www.sslaustralia.com.au

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