Assessment and Management of Burns Procedure 1.0 • •
2.0
Purpose This document provides a guideline for the initial assessment and management of patients with burns and scalds outside of a Regional Burns Unit. This is not intended as a full therapeutic manual for burns treatment. Application
This procedure applies to teams of West Coast DHB health professionals caring for patients with burns and scalds outside a Regional Burns Unit. 3.0
Definitions
For the purposes of this procedure the following definitions apply: CCU Critical Care Unit U&E Urea and Electrolytes DN District Nursing TBSA Total Burn Surface Area ICU Intensive Care Unit IV Intravascular IM Intramuscular FBC Full Blood Count CoHb Carboxyhaemoglobin NAI Non Accidental Injury NBC National Burns Centre RBC Regional Burns Centre 4.0
Responsibilities
For the purposes of this procedure Medical staff are to follow this procedure for the treatment of all patients with Burns and Scalds. 5.0
Related Documents
The following documents / resources are available: • Management of Burns and Scalds in Primary Care – ACC 2007 • National Burn Service Referral Form • Referral Pathway to Regional Burn Units • National Burn Service Initial Assessment – Guideline • WCDHB Child Protection procedure WCDHB-FVP001 Version 7 Discharge Information for Patients with Burns • Understanding your Burn * • Discharge Information Following a Burn Injury * * Information kindly provided by Canterbury DHB Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
Page 1
6.0
Process
This guideline includes the following: 1. 2. 3. 4. 5. 6. 7. 8.
Emergency Assessment of Burn Injuries First Aid Management of Burn Injuries Referral Guidelines Wound assessment Fluid Resuscitation Wound Management General Considerations Discharge Guidelines
1.
IMPORTANT:
Contact Christchurch Regional Burn Unit with any concerns or questions about any burn injuries or treatment.
IMPORTANT:
All burn injuries in paediatric patients (5% TBSA in a child 2. Full thickness burn >5% TBSA in either adult or child 3. Burns of special areas: face, hands, feet, perineum 4. Electrical Burn 5. Chemical Burn 6. Burn associated with an inhalation injury 7. Circumferential burns of limbs / chest 8. Burn at the extremes of age (e.g. 70 yrs) 9. Associated trauma 10. Non-accidental injury 11. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or increase mortality 12. Any burn which has failed to heal with conservative management after 2 weeks IMPORTANT:
Referrals to the National Burn Centre must always be made through the local Regional Burn Unit.
Download referral form (www.nationalburnservice.co.nz) or from link below NBS referralform.pdf
and fax to Christchurch Regional Burn Unit: •
Canterbury Regional Burn Unit, Christchurch Hospital Phone: (03) 364 0640 (ask for on Call Plastic Surgery Registrar) Fax: (03) 364 0456 (Dept. Plastic Surgery)
Admission into any hospital is typically based around one of the following: 1.
The need for wound care which cannot be delivered as an outpatient e.g. frequent or complex dressing issues)
2.
Analgesic requirements too great to be managed as an outpatient (e.g. ongoing narcotic analgesia requirement or failure to manage dressing change pain)
3.
Functional, social and / or psychosocial indicators requiring rehabilitation or specialist services (e.g. physiotherapy, occupational therapy)
4.
Concerns over progression of the burn injury and or its sequelae (e.g. oedema compromising circulation or airway)
Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
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4.
Wound Assessment 1. 2. 3. 4.
1.
History Burn Depth Body Surface Area Estimation Non-accidental Injury
History / Documentation • • • • • • • • •
Cause of burn injury: Flame, electricity, chemical Time of injury First Aid Measures Other trauma Past Medical History Medications / allergies / vaccination history Initial management Communication / advice from NBC / RBUs
2.
Burn Depth ANZBA Classification
i.
Epidermal Example: Appearance: Sensation: Healing time: Scarring:
UV light, very short flash Dry and red, blanches with pressure, no blisters May be painful Within 7 days No scarring
ii
Superficial dermal Example: 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: Can have colour match defect. Low risk of hypertrophic scarring
iii
Mid dermal Example: Appearance: Sensation: Healing time: Scarring:
iv
Deep dermal Example: Appearance: Sensation: Healing time: Scarring:
Scald (spill) flame, oil or grease Dark pink with large blisters. Capillary refill sluggish. In child may be dark lobster red with blotching. May be painful 14 – 21 days Moderate risk of hypertrophic scarring Scald (spill) flame, oil or grease Blotchy red, may blister, no capillary refill. In child may be dark lobster red with mottling. No sensation Over 21 days; grafting probably needed High risk of hypertrophic scarring
Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
Page 5
v
Full Thickness Example: Appearance: Sensation: Healing time: Scarring:
Scald (immersion) flame, steam, oil , grease, chemical, high volt electricity White, waxy or charred, no blisters, no capillary refill. In child may be dark lobster red with mottling. No sensation Does not heal spontaneously, grafting needed if >1 cm Will scar
3.
Body Surface Estimation
i.
Rule of Nines: Adults • Head 9% • Anterior chest 9%, • Abdomen 9% • Upper / mid / low back 18% • Each lower limb 18%, Each upper limb 9% • Perineum 1%
Children Important: in a child up to 1 yr or age: • Head and neck 18% • Front of torso 18% • Back of torso 18% • Each upper limb 9% • Each lower limb 14%
For every year of life above 1 yr:
The head decreases by approximately 1% and each leg gains 0.5% e.g. if a child is 3 yrs then head and neck approximately 16% and legs 15% each
Ii
Note: The rule of nine’s is different in children
iii
Area of patient’s palm with fingers extended: 1% approximates to 1% surface area – useful for estimating small burns
Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
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IMPORTANT:
Non-accidental injuries should be considered for all at risk populations, both paediatric and geriatric and local protocols followed
Non-Accidental Injury (NAI)
4.
Indicators of potential NAI or scalds include:
1.
Delay in seeking help
2.
Historical accounts that differ over time
3.
History inconsistent with wound appearance or development of child
4.
Past history of NAI
5.
Inappropriate behaviour by patient/caregivers
6.
Scalds with defined immersion lines: glove and stocking pattern
7.
Symmetrical pattern Note: Where there is concern about inflicted injury the on call paediatrician in Christchurch and the West Coast District Health Board Child Protection Co-ordinator must be contacted. Child Protection Coordinator contact details are as follows: •
[email protected] • Direct Dial Number (external): 03 769 7400 • Internal Extension Number: 2652 • Mobile Number: 027 512 6167 The investigation of non-accidental injury should not be performed by the patient’s primary surgical/nursing team, but by a dedicated team skilled in child protection. •
Please refer to the WCDHB Child Protection procedure WCDHB-FVP001 Version 7
Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
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5.
Fluid Resuscitation
Intravenous resuscitation required for: • All adult patients with >15% TBSA injury • All paediatric patients with >10% TBSA injury
IMPORTANT:
1.
Any patient with a burn size requiring fluid resuscitation must be discussed with Christchurch Regional Burn Unit and have hourly urine outputs measured.
Estimation of Fluid Needs for the first 24 hours The extent of the burn is calculated using the “rule of nines” or a burn body chart (available on the National Burn Service Referral Form). If possible obtain the weight of the patient. This data is then used in a fluid resuscitation formula. NOTE: The calculation of fluid requirements commences at the time of burn not from the time of presentation
2.
Adults > 15% TBSA Resuscitation Volume: 3 – 4ml crystalloids (Hartmann’s solution) x kg body weight x percent burn
Children > 10% TBSA Resuscitation Volume: 3 – 4 ml crystalloiods (Hartmann’s solution) x kg body weight x percent burn PLUS maintenance with 5% Glucose +/- 20 MMol Potassium Chloride in 0.45% (½ normal) saline 1 • • •
100ml / kg up to 10 kg plus 50ml / kg from 10 – 20 kg plus 20ml / kg from 20 – 30 kg
For children 15% burns). Note: the presence of haemochromagens in the urine (dark discolouration) indicates the presence of muscle and blood breakdown products and requires increasing goal urine output to 1-2 ml x kg x hr
Adults:
Children:
0.5 ml / kg / hr
1 ml / kg / hr
Monitor bloods At least once during each resuscitation period. FBC, Haematocrit, U&E, CoHb 2 x IV cannula if child has 10% > TBSA burn Colloid 0.3 – 0.5% / kg / TBSA can be considered After the first 18-24 hrs, for very large burns, inhalation injury, large paediatric burns
1
West Coast DHB stock 500 ml bags of 0.45% Sodium Chloride and 2.5% Glucose in Parfitt Ward. Add a further 25 mls of 50% glucose to each bag to make up 5% solution above. If the only solution available is half normal (0.45%) Sodium Chloride without any glucose, add 50 ml of 50% glucose to each 500 ml; bag to make up 5% glucose solution
Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
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6.
Wound Management
Definitive management of burn wounds should be performed in facility where final treatment will take place. IMPORTANT:
Burn wounds are initially sterile and routine use of systemic antibiotics is not advised
1.
Take wound swab prior to cleaning and applying dressing
2.
Debride all loose skin, clean wounds with chlorhexidine irrigation 1% solution
3.
Blisters
4.
If patient due for transfer and will reach Christchurch Regional Burn Unit within 8 hours, cling film is an acceptable dressing.
5.
If patient due for transfer within 24 hours dress wounds with simple dressing: non-adherent layer and secondary pad (not Jelonet as this will dry out with heat of the burn).
6.
If transfer is to be delayed more than 24 hours commence dressing with silver product such as Acticoat after consultation with Christchurch Regional Burn Unit.
7.
Daily review of wound / dressing initially appropriate
8.
For mixed depth burns consider use of Silver dressing such as Acticoat or equivalent.
9.
Acticoat needs to be changed every 3 or 7 days depending on the acticoat product used. Moisten with water not saline (as this will inactivate the silver).
10.
Eyes Irrigate gently with saline • Fluorescein to identify corneal injury • Copious irrigation for chemical injury • Chloramphenicol 1% ointment • All ocular injuries should have an ophthalmological review IMPORTANT: Toxic Shock Syndrome can develop rapidly even in very small burns. 2 Maintain a high level of suspicion. If in doubt remove all dressings and commence appropriate treatment early!
i. leave small blisters intact: ii. debride blisters over joints or if restricting movement iii. snip large, tense blisters
•
NB: For West Coast –
If Patient is admitted locally: Follow steps 7 – 9 above. If Patient is not admitted: Follow steps 7 – 9 above and ensure outpatient follow up with medical review within 72 hours post discharge
2
See page 11 of this document
Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
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7.
General Consideration • • • •
Patients with burns are best managed by a multi-disciplinary team Early involvement of all team members improves patient outcomes Consider the use of Telemedicine to enable review of the Burns by the Christchurch Team Cultural needs of the patient / whanau must be considered e.g. treating and dressing head burns for Maori.
The most effective analgesia for a burn in the first instance is to occlude the wound. 1.
Analgesia: Opiates: IV/oral (not IM) morphine Entonox: for procedural pain Supervised sedation Analgesia: The patient who has openly disclosed drug dependency requires higher than average analgesia dosages. Review by an Anaesthetist may be appropriate.
2.
Consider either splintage or active mobilisation of all joints / hands / ankles
3.
Any concern regarding airway injury must have CCU / Anaesthetic review
4.
>65 years: consider Geriatric / Rehab review
5.
Paediatric review as needed
6. 7.
Psychological / Psychiatric review as necessary Burn patients have high rates of premorbid psychiatric conditions than the normal population Kaiawhina to be contacted if required by the patient / and / or whanau.
8.
Early nutritional review / Vitamin implementation
9.
Ophthalmology review for all ocular injuries
10.
Nasogastric tube – for medication / nutrition / gastric decompression
8.
Discharge Guidelines 1.
2. 3.
4.
5.
Follow up All patients must be given the date and time for a follow up appointment with an RMO / GP / Consultant prior to discharge. Follow up appointment must occur 72 hours from the initial burn time. A referral to physiotherapy must take place prior to discharge. Prescription Appropriate analgesia to be provided to patients Referral to District Nursing to include the following: • Details of the prescription for analgesia • Information on the percentage and depth of burn to be provided to DN team • Current silver dressing regime • Consultant, date and time of follow up District Nursing Team to review: • Maintain silver dressing regime • Assess risk of infections daily with early referral back to the team; Emergency Department or General Practitioner when / if infection is suspected • Liaise with physiotherapy as appropriate Information to be provided to patients with burns: • Discharge Information Following a Burn Injury • S&S of infection • Understanding your Burn Injury • Recovering from a Burn Injury (This information should be given the day burn injury (on admission or discharge).
Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
Page 10
7.0
Precautions & Considerations
Signs and Symptoms of Burn Injury Infection •
Signs and Symptoms of infection following burn injury include:
•
Swelling, pain, ooze at burn site
•
Redness or flushed appearance
•
Loss of function
The following symptoms may indicate Toxic Shock Syndrome: • High Fever (greater than 38.8°C) • Sunburn-like rash that can be anywhere on the body, including the palms of the hands and soles of the feet • Vomiting or diarrhoea • Severe muscle aches or weakness • Bright red colouring of the eyes, mouth or throat • Headache, confusion, disorientation or seizures
8.0 • • • • •
References New Zealand National Burns Centre Christchurch Regional Burns Centre Emergency Management of Severe Burns Course Manual 2004 New Zealand National Burns Group – Counties Manakau DHB 2011 WCDHB Child Protection procedure WCDHB-FVP001 Version 7
9.0
Key Words • • • • • •
Burns Severe National Assessment Treatment Wounds
• • • • • •
Guideline Internal Burns Burn Depth Dermal Resuscitation Christchurch
Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
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Assessment and Management of Burns Procedure Document Owner: Clinical Nurse Educator Surgical Services and A & E Nurse Manager WCDHB – PNn0130 Version 2 issued Dec 2012 updated August 2015
Page 12
WOUND MANAGEMENT – FLOW CHART •
Primary and Secondary Survey treat life-threatening injuries
• • • • • • • • • •
• •
Complete First Aid 20 minutes, tepid running water up to 3 hours post-burn
• •
Assessment Burn size (see Lund & Bowder Chart) Burn depth
• •
Referral Criteria to a Regional Burn Unit Burn >10% TBSA adult >5% TBSA child Full thickness >5% TBSA Special area (face, hands, feet, perineum or major joints) Electrical burns Chemical burns Associated inhalation injury Circumferential burns of the limbs or chest Burns at the extreme of age (children or elderly) Pre-existing medical disorders which could complicate management, prolong recovery or affect mortality Associated trauma Suspected non-accidently injury
Regional Burns Unit Canterbury District Health Board Phone 03 364 0640 (as for Plastics Registrar on call) Fax 03 364 0456
EPIDERMAL
SUPERFICIAL / MID DERMAL
DEEP DERMAL / FULL THICKNESS
Should heal
Should heal within 14 days
Will probably require surgery
Moisturising cream
Antimicrobial dressing / Specialist dressing Blister & Oedema management Pain relief Consider Surgery
No
Yes
Day 3 – Re Assessment
Intact Skin
No
Burn depth progression
Consider Surgery
Yes
Yes SURGERY
Yes
Change to moist wound healing product if possible on • day 3 (epidermal to superficial dermal) or • day 5 (mid to deep dermal)
No
Healed Continue moisturiser & sunblock Change to moist wound healing product if possible otherwise continue with antimicrobial dressing
Reassess every 3 to 5 days Monitor for signs of wound infection or sepsis Healed Continue moisturiser & sun block Consider scar & rehabilitation needs
No
HEALED
Likely treated
