Management of Burns and Scalds in Primary Care - ACC Homepage

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					        Kua tawhiti ke to haerenga mai,
               kia kore haere tonu
            He tino nui rawa ou mahi
            Kia kore e mahi nui tonu

sir james henare of ngati hine iwi from te tai tokerau


        We have come too far not to go further
        We have done too much not to do more




                                                         1
2
Endorsements
This guideline has been endorsed by the Australian and New Zealand Burn Association (until 2009), the Burn
Support Group Charitable Trust, the Counties Manukau District Health Board (until 2009), the Royal New
Zealand College of General Practitioners and St John.




                                         The Royal New Zealand
                                         College of General Practitioners




                                                                                                             3
4
Contents
Endorsements ..................................................................................................................................................3
Purpose ............................................................................................................................................................9
About the guideline ........................................................................................................................................11
Summary ........................................................................................................................................................17
Chapters
    1.      Burn injuries and burns prevention in New Zealand ........................................................................27
    2.      First aid ..........................................................................................................................................31
    3.      Burn assessment ............................................................................................................................35
    4.      Referral...........................................................................................................................................45
    5.      Management of epidermal burns or scalds......................................................................................47
    6.      Management of superficial and mid dermal burns or scalds ........................................................... 49
    7.      Management of chemical injury ......................................................................................................59
    8.      Management of electrical injury ......................................................................................................63
    9.      Pain management...........................................................................................................................67
    10. Psychological consequences of burn injury .....................................................................................71
                                        ¯ori
    11. Burn injuries in Ma .....................................................................................................................77
    12. Burn injuries in Pacific peoples .......................................................................................................79
    13. Complementary and alternative medicines .....................................................................................81
    14. Implementation and evaluation ......................................................................................................83

Appendices
   A.    Evidence and recommendation grading system ..............................................................................89
   B.    Wound care options........................................................................................................................91
   C.    DSM-IV criteria for post-traumatic stress disorder............................................................................95
   D.    Useful resources .............................................................................................................................97

Abbreviations and acronyms ...........................................................................................................................99
Glossary .......................................................................................................................................................101
References....................................................................................................................................................103




Recommendations and good practice points
Chapters
   1.    Burn injuries and burns prevention in New Zealand ........................................................................27
         Opportunities for prevention...........................................................................................................28
   2.    First aid .........................................................................................................................................31
         Stopping the burning process and cooling ......................................................................................31
         Gel pads .........................................................................................................................................32
         Initial coverings: polyvinyl chloride film (cling film) .........................................................................33


                                                                                                                                                                        5
     3.    Burn assessment ...........................................................................................................................35
           Emergency management.................................................................................................................35
           Burn size: assessment and recording of total body surface area burn ..............................................38
           Burn depth .....................................................................................................................................41
           Non-accidental injury......................................................................................................................42
           Classification of burns ....................................................................................................................43
     4.    Referral .........................................................................................................................................45
           Emergency referral ..........................................................................................................................45
           Referral between services ...............................................................................................................46
     5.    Management of epidermal burns or scalds .....................................................................................47
           Dressings and creams (good practice points only)...........................................................................47
     6.    Management of superficial and mid dermal burns or scalds ...........................................................49
           Preventing infection (good practice points only) .............................................................................49
           Wound healing ...............................................................................................................................52
           When to review (good practice point only) ......................................................................................54
           Management of blisters (good practice points only) ........................................................................54
           Scarring..........................................................................................................................................55
     7.    Management of chemical injury .....................................................................................................59
           First aid ..........................................................................................................................................59
           Eye injury .......................................................................................................................................60
           Specific substances: hydrofluoric acid (good practice point only)....................................................60
           Specific substances: phosphorus (good practice point only) ...........................................................62
     8.    Management of electrical injury.....................................................................................................63
           Management of electrical injury ......................................................................................................63
           ECG monitoring...............................................................................................................................64
     9.    Pain management..........................................................................................................................67
           Burn pain management ..................................................................................................................67
     10.   Psychological consequences of burn injury ....................................................................................71
           Adverse psychological responses to trauma....................................................................................71
     11.                            ¯ori
           Burn injuries in Ma ....................................................................................................................77
           Good practice points ......................................................................................................................77
     12.   Burn injuries in Pacific peoples ......................................................................................................79
           Good practice points ......................................................................................................................79




    Algorithms (see Summary, pages 17–25)
     1.    Initial assessment and management of burns and scalds................................................................18
     2.    Ongoing assessment and management of burns and scalds in primary care ....................................24




6
List of figures
 3.1 Assessment of burn size: Rule of Nines ...........................................................................................39
 3.2 Assessment of burn size: Lund and Browder chart*.........................................................................40
 * See also Notes to algorithm 1: note 2: burn assessment: assessment of burn size ...................................22




List of tables
 1.1    Burns from fire or flames: age specific rates for 2000–2004 ...........................................................27
 1.2    Burns due to hot substances and objects, caustic or corrosive material or steam:28 age-specific rates
        for 2000–2004 ...............................................................................................................................28
 3.1 Airway maintenance .......................................................................................................................36
 3.2 Key points of a burn history ............................................................................................................37
 3.3 Classification of burns based on depth* .........................................................................................44
 10.1 Diagnosis according to duration of stress symptoms .......................................................................72
 * See also Notes to algorithm 1: note 2: burn assessment: depth assessment ...........................................20




                                                                                                                                                          7
8
Purpose
The purpose of this guideline is to provide a summary of current New Zealand and overseas evidence informing
the assessment and management of burn injuries in the primary care setting in New Zealand. The guideline
has been developed for health care practitioners who care for adults or children with burn injuries, and health
service provider organisations and funders. It provides a first step in gathering the evidence base and ensuring
the coordination of burns care nationally across the health sector in New Zealand.

The focus of the guideline is the appropriate assessment and management of burns in the primary care setting
specifically, and appropriate referral practice from primary care to secondary care and regional burns unit
services. The guideline specifically excludes consideration of large, full thickness burns that are more likely
to be managed in secondary care. Similarly, scar management and associated specialist services provided in
secondary care, such as physiotherapy, occupational therapy and speech language therapy, are not a focus of
this guideline.

The guideline identifies evidence-based practice for most people, in most circumstances. It thus forms the
basis for decision-making by the health care practitioner in discussion with an individual with a burn injury in
developing an individualised care plan.




                                                                                                                   9
10
About the guideline

Foreword
The New Zealand Guidelines Group Incorporated (NZGG) is a not-for-profit organisation established to promote
effective health and disability services. Guidelines make a contribution to this aim by sharing the latest
international studies and interpreting these in a practical way for dissemination and implementation in the New
Zealand setting. Guidelines consider both the evidence and the current availability of resources in the publicly
funded health system to ensure that the recommendations are realistic, promote best practice, and inform
policy and planning.

This guideline was developed by NZGG in partnership with the Counties Manukau District Health Board
(CMDHB), with Stephen Mills as Chair of the Guideline Development Team, and was funded by the Accident
Compensation Corporation (ACC).


Gaps between current practice and evidence
This guideline for the management of burns and scalds in primary care has been developed to address
perceived gaps between current evidence and practice in New Zealand. Although the size of these gaps has not
been thoroughly documented, there appear to be uncertainties in treatment, variation in management practices
and an under-utilisation of cold water therapy for burns.

Although there are other international guidelines that have been published on the management of burns and
scalds, they were not considered to be suitable for use in New Zealand.

First aid management of burns
The New Zealand public appears to have a lack of understanding regarding the benefits of cold water therapy.
A prospective observational study of people with burns presenting to Middlemore Hospital in 2002 found that
59.5% of a total 121 people did not receive adequate burns first aid treatment (defined as cold water therapy in
either stationary or running water for 10 minutes or more).1 Further analysis by age and ethnicity suggested that
  ¯ori
Ma and Pacific peoples, and children were less likely to receive adequate first aid treatment.

The study found that adequate first aid treatment resulted in fewer people with burns requiring split-skin
graft procedures. There was also an association with fewer surgical debridement procedures. Scald injuries
in particular required fewer procedures following adequate burns first aid treatment. The potential savings
estimated in 2002 from scald injury care alone amounted to $75,000–100,000 per annum.1

Burn size estimation
Estimations of burn size are necessary in the pre-hospital situation in order to assess initial fluid requirements
and determine referral criteria. A number of tools can be used to assist health practitioners in estimating the
total body surface area (TBSA) (see Chapter 3, Burn size). Three observational studies were found assessing the
variability of burn size estimation in the pre-hospital environment.2-4 Results of these studies suggest that burn
size is often overestimated. As a consequence of this, people with burns may receive inappropriate volumes
of fluid and could be transferred to a burns unit unnecessarily. The TBSA estimated in pre-hospital situations
is often overestimated where the burnt area is small and underestimated where the burnt area is large.3
Unfortunately the participants of these studies often had burns that would be more severe than those found in
primary care, therefore the findings may not be directly applicable.

                                                                                                                     11
     Use of dressing products in primary care
     International evidence is lacking around the use of dressing products in primary care. Silver sulphadiazine
     is understood to be widely used at present on burns in primary care. This practice is supported by the expert
     opinion of the Guideline Development Team for its properties as an anti-infective agent. However, extended use
     of silver sulphadiazine on non-infected wounds has been shown to have adverse effects on the time to healing
     in burn wounds. There are a number of randomised controlled trials (RCTs) comparing silver sulphadiazine
     cream with other dressings and topical treatments. All of these studies found that silver sulphadiazine
     increased time to healing. However, in these studies silver sulphadiazine cream was applied to the burn
     wound until complete healing/re-epithelialisation. No studies were found comparing shorter-term use of silver
     sulphadiazine cream with other dressings or topical treatments.

     Expert opinion strongly favours the use of moist wound-healing products for superficial and mid dermal burns,
     although the evidence is scanty and inconsistent. There is no convincing evidence from primary RCTs that any
     other dressing product heals wounds significantly faster than paraffin gauze (which is considered a non-moist
     dressing).


     Evidence and recommendation grading system
     All studies relating to the benefits or harms of interventions are graded for quality. Each study has been
     assigned an overall level of evidence: good (+), fair (~) or poor (x). Study details and levels of evidence are
     summarised in evidence tables, which are used to formulate recommendations. The evidence tables are
     available at http://www.nzgg.org.nz. Studies with an ‘x’ level of evidence had questionable validity and were
     not considered relevant to the formulation of recommendations. Descriptive research, included for information,
     was not graded for quality.

     For further details about the evidence and recommendation grading system see Appendix A.


     Guideline development process
     In 2005, ACC commissioned NZGG to develop an adapted guideline based on reliable and valid evidence-based
     sources of summarised evidence available internationally. The Guideline Development Team agreed to use two
     other relevant guidelines5-7 as a template to further define the scope of the project. This approach has allowed
     the Guideline Development Team to conduct its own systematic reviews of key question areas and to consider
     the syntheses and synopses of the evidence performed and published by others. This process of adaptation was
     thought appropriate in a topic area where there are few large, well conducted randomised studies.

     The Guideline Development Team was convened by NZGG and CMDHB. This involved formally approaching
     representative professional colleges and stakeholder organisations to invite them to nominate people to be
     members of the Team.

     Two face-to-face meetings were held in Auckland during August 2005. The goals of the first meeting were to train
     members of the team in the processes of guideline development, to identify relevant clinical questions and to
     make decisions about the scope of the guideline.

     Individual sub-committee members then searched for new studies in narrowly-focused topic areas and reviewed
     the evidence. In order to avoid the substantial costs and delays associated with translating foreign language
     publications, only English language articles were used. Only the most rigorous studies for each question were
     retrieved for the assessment and extraction of data. Details of the clinical questions, comprehensive search
     strategy and evidence tables are available on the NZGG (http://www.nzgg.org.nz) website.

     The evidence on which the recommendations are based was graded using the grading system developed by
     NZGG. See Appendix A for more information on the grading system.
12
The second meeting of the Guideline Development Team was held in November 2005. At this meeting the
evidence in each area was presented in evidence tables to the Guideline Development Team and a Considered
Judgement process8 was used to agree levels of evidence and draft recommendations. The Guideline
Development Team also drafted an algorithm at this stage.

The statement and recommendations were drafted, reviewed and revised by sub-groups then reviewed by
the whole Team. Resources and appendices were drafted in the same way. This process continued until the
draft document was at a stage for peer review and consultation. Opinions were sought at this stage about the
feasibility of implementing the recommendations in the guideline.

                                                                                                 ¯ori
Copies of the draft were sent to key individuals and sector groups for comment and peer review. Ma and
Pacific perspectives on burn injuries and their management were incorporated. These comments were approved
by the Team and incorporated into the final document. The draft guideline was sent to sector groups for peer
review in February 2006 and the final guideline was re-circulated in July 2006.

Guideline Development Team
This guideline was developed by a multidisciplinary team of practitioners, selected to represent professional,
cultural and consumer perspectives. The Team members were:

Stephen Mills (Chair)
   Plastic and Reconstructive Surgeon, Middlemore Hospital
Chris Goudie
   Adult Burns Clinical Nurse Specialist, Middlemore Hospital
Debbie Murray
   Paediatric Clinical Nurse Specialist, Middlemore Hospital
Linda Jackson
   Clinical Nurse Educator, Middlemore Hospital
Andrew Jull
   Research Fellow, Clinical Trials Research Unit, University of Auckland
Anna Munnoch
   Emergency Care, Clinical Nurse Educator, Middlemore Hospital
Vera Steenson
   Auckland Burn Support Group, consumer perspective
Frances James
   Clinical Psychologist, Middlemore Hospital
Kate Middlemiss
   National Burns Centre Establishment Manager, Middlemore Hospital
Carolyn Braddock
   Regional Burns Centre Manager, Hutt Valley District Health Board
Maureen Allan
                                                   ¯ori
   Te Tai Tokerau Primary Health Organisation, Ma perspective
Carol Ford
   Primary Care and Rural Nursing, Ngati Porou Hauora
Heidi Muller
   General Practitioner, Health Pacifica, Ta Pasefika, Pacific perspective
Rob Kofoed
   Convenor, New Zealand Accident and Medical Practitioners’ Association
Larry Skiba
   General Practitioner, Royal New Zealand College of General Practitioners

                                                                                                                 13
     NZGG team
     Rob Cook
        Project Manager and GP
     Catherine Coop
        Researcher/Project Manager from February 2006
     Mark Ayson
        Researcher
     Anne Buckley
        Medical Editor/Writer
     Mai Dwairy
        Researcher until March 2006
     Anne Lethaby
        Senior Researcher
     Jane Marjoribanks
        Researcher

     For first meeting training/presentations:
     Cindy Farquhar
        NZGG Board
     Anne Lethaby
        NZGG Project Manager and Effective Practice, Informatics and Quality Improvement (EPIQ) Researcher
     Sue Wells
        Senior Lecturer Clinical Epidemiology, University of Auckland

     ACC observers:
     James Chal
        Manager Research and Information Services
     Zhi-ling ‘Jim’ Zhang
        Evidence Based Healthcare Researcher, Research Services
     Chrissie Cope
        Manager Primary Care Services, Healthwise
     Sonya Murray
        Evidence Based Healthcare Researcher, Research Services

     Declarations of competing interests
     There have been no competing interests declared for this guideline.

     Consultation
     At the start of the guideline development process, a number of organisations with a specific interest in the
     management of burns and scalds nominated team members to be part of the Guideline Development Team.
     Feedback was sought from these organisations after they had reviewed a draft of the guideline. During this
     period of consultation the draft was also distributed widely to other interested individuals and they were invited
     to comment on the draft.

     Comments were received from the following organisations or individuals:
     • Anna Knuckey, Product Manager, Jackson Allison Medical and Surgical Limited, Auckland
     • Antonia Rippey, Occupational Therapist, CMDHB, Auckland
     • Bice Awan, Chief Executive, Skylight, Wellington
     • Bernard Hoste, Export and Business Development, Scarban, Tricolast NV, Belgium
     • Caitlin Harvey, Occupational Therapist, Waikato District Health Board, Hamilton
14
• Chris Adams, Consultant Plastic Surgeon, Wellington Regional Plastic Surgery and Burns Unit, Hutt Hospital,
  Wellington
• Connie Mahu, Wha                                ¯ori
                     ¯nau Support Worker for Ma Health, Middlemore Hospital
• Glen Charlett, Director, Access Health Care Limited
• Heather Cleland, Director, Victoria Adult Burns Service, Alfred Hospital, Melbourne
• Janet Copeland, Research Liaison Officer, New Zealand Society of Physiotherapists Inc, Wellington
• Jason Wasiak, Research Officer, Victoria Adult Burns Service, Alfred Hospital, Melbourne
• Kirsten Taylor, Senior Physiotherapist, Middlemore Hospital, Auckland
• Marilyn Rosewarne, Member New Zealand College of Practice Nurses, Tauranga
                                     ¯ori
• Rhys Jones, Senior Lecturer in Ma Health, The University of Auckland, Auckland
• Siobhan Molloy, Executive Director, New Zealand Association of Occupational Therapists, Wellington
• Stewart Sinclair, Clinical Director, Plastic Surgery Department, Christchurch Hospital, Christchurch
• Tony Smith, Medical Advisor, St John Northern Region, Auckland
• William Levack, Lecturer in Rehabilitation, Department of Medicine, Wellington School of Medicine and
  Health Science, University of Otago, Wellington

Acknowledgements
We would like to thank Maureen Allen, Connie Mahu and Rhys Jones for their contribution towards Chapter
10, Burn injuries in Ma and Kelly Waddell and Francois Stapelberg for their contributions towards the pain
                       ¯ori
management section in Chapter 6. Thanks also to Debbie Murray and Linda Jackson from Middlemore Hospital
for their support and contributions.

Funding
This guideline was commissioned and funded by ACC and development and production were independently
managed by NZGG. ACC staff members were co-opted onto the Guideline Development Team to provide advice
about ACC internal processes. All evidence appraisals, reporting and formulation of recommendations are
independent of ACC, and NZGG retains editorial independence.




                                                                                                                15
16
Summary

Key messages
• Children under the age of five are most at risk of burns and scalds.
• All burns and scalds should be cooled immediately in running tap water (8–15°C) for at least 20 minutes.
  – Avoid hypothermia: keep the person with the burn as warm as possible; consider turning the temperature
      of the water up to 15°C (tepid).
• Gel pads or other fluids can be used as an alternative to running tap water where water is unavailable or not
  practical.
• If there has been a delay in starting cooling, this should still be started up to three hours after injury.
• Initial management should include an antimicrobial dressing or cream and, following this, dressings should
  encourage re-epithelialisation by moist wound healing.
• Burn injuries constitute significant trauma and can cause or exacerbate psychological distress.


Referral to a specialist burns unit
• The referral criteria endorsed by the Australian and New Zealand Burn Association (ANZBA) should be
  considered by primary health care practitioners when assessing whether burns require treatment in a
  specialist burns unit (see Algorithm 1, Note 4).
• Other reasons for referral to a hospital may include: an ongoing requirement for narcotic analgesia,
  intravenous (IV) fluids, elevation or frequent or complex dressings; significant comorbidities, social/
  psychosocial indicators or suspected non-accidental injuries; or a need for other specialist services, eg,
  physiotherapy.
• The depth of a burn injury should be reassessed, preferably by the same clinician, two to three days after the
  initial assessment.
• Any burns that are unlikely to heal within 21 days without grafting (deep dermal and/or full thickness burns)
  should be referred to a burns unit for scar management by day 10–14.




                                                                                                                   17
     Algorithm 1:
     Initial assessment and management of burns and scalds

       Child or adult with a new burn injury



              First aid, emergency examination
                    and treatment (Note 1)




               Assess and record cause, non-
           accidental injury, clinical features, burn
              size, location and depth (Note 2)




               Decide the level of care needed




                                                              Continue managing in primary care.
                  Is hospital care indicated?                   Refer to Algorithm 2: Ongoing
                                                        No
                           (Note 3)                            assessment and management of
                                                               burns and scalds in primary care


                              Yes




                    Is specialist burns unit
                                                        No   Immediate referral to nearest hospital
                   care indicated? (Note 4)



                              Yes



                  Suitable for transfer to a
                                                        No
                    regional burns unit?



                              Yes


                Immediate referral to nearest
                    regional burns unit
18
Notes to Algorithm 1

Note 1: First aid, emergency examination and treatment
First aid
• Ensure your own safety.
• Stop the burning.
• In electrical injuries, disconnect the person from the source of electricity.
• Cool the burn:
  – cool with running tap water (8–15°C) for at least 20 minutes (no ice). Irrigation of chemical burns should
     continue for one hour.
  – avoid hypothermia: keep the person with the burn as warm as possible; consider turning the temperature
     of the water up to 15°C (tepid).
• Remove clothing and jewellery.
• Cover the burn:
  – cover with cling film or a clean, dry cloth.
  – avoid topical treatments until the depth of the burn has been assessed.
• Administer analgesia.

Emergency examination and treatment
Primary survey*
Airway maintenance with cervical spine control
Breathing
Circulation with haemorrhage control
Disability – neurological status
Exposure + environmental control
Fluid resuscitation proportional to burn size

Fluid resuscitation
• Burns of >10% body surface area in children and >15% in adults warrant fluid resuscitation.
• Give fluids:
   – 24-hour requirement: 3–4ml crystalloid solution per kg per % burn.
   – plus maintenance fluids for children.
   – give half of the fluids over the first eight hours, the remainder over the next 16 hours.

Prevention of tetanus
There is a risk of tetanus following a burn injury. Refer to the guidelines on the prevention of tetanus following
injury, which are available from the Ministry of Health’s Immunisation Handbook 2006.9
                                                                                                              Continued …




*   Reproduced from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.             19
    8th Edition;2004.
     Note 2: Burn assessment
     Depth assessment
     The following table provides guidance in assessing the depth of burn injury.
     table: classification of burns based on depth
     anzba 2004 classification Epidermal
     former classification     Superficial epidermal
     example                       UV light, very short flash
     appearance                    Dry and red, blanches with pressure,
                                   no blisters
     sensation                     May be painful
     healing time                  Within seven days
     scarring                      No scarring

     anzba 2004 classification Superficial dermal
     former classification     Superficial partial thickness
     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

     anzba 2004 classification Mid dermal
     former classification     Partial thickness
     example                       Scald (spill), flame, oil or grease
     appearance                    Dark pink with large blisters
                                   Capillary refill sluggish
     sensation                     May be painful
     healing time                  14–21 days
     scarring                      Moderate risk of hypertrophic scarring

     anzba 2004 classification Deep dermal
     former classification     Deep partial thickness
     example                       Scald (spill), flame, oil or grease
     appearance                    Blotchy red, may blister, no capillary
                                   refill
                                   In child, may be dark lobster red with
                                   mottling
     sensation                     No sensation
     healing time                  Over 21 days: grafting probably needed
     scarring                      High risk of hypertrophic scarring

     anzba 2004 classification Full thickness
     former classification     Full thickness
     example                       Scald (immersion), flame, steam, oil,
                                   grease, chemical, high-volt electricity
     appearance                    White, waxy or charred, no blisters, no
                                   capillary refill
                                   May be dark lobster red with mottling
                                   in child
     sensation                     No sensation
     healing time                  Does not heal spontaneously, grafting
                                   needed if >1cm
20   scarring                      Will scar

     Adapted from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.
     8th Edition; 2004.
Chemical and electrical injuries6
Chemical burns:           Copious irrigation should continue for one hour

                          Do not attempt to neutralise chemical burns in primary care

                          All chemical burns should be referred to a burns unit

Chemical eye injuries:    Treat all chemical burns to the eye with copious irrigation of water

                          Ensure contact lenses have been removed

                          All significant chemical injuries to the eye should be referred acutely to
                          ophthalmology services

Electrical injuries:      Small entry and exit wounds may be associated with severe deep tissue damage

                          An electrocardiogram (ECG) should be carried out to detect arrhythmias

                          All electrical injuries should be referred to a burns unit

Non-accidental injuries
Indicators of possible non-accidental burns or scalds include the following:
• delay in seeking help
• historical accounts of injury differ over time
• history inconsistent with the injury presented or with the developmental capacity of a child
• past abuse or family violence
• inappropriate behaviour/interaction of child or caregivers
• glove and sock pattern scalds
• scalds with clear-cut immersion lines
• symmetrical burns of uniform depth
• restraint injuries on upper limbs
• other signs of physical abuse or neglect.

Refer to a regional burns unit if non-accidental injury is suspected.
                                                                                                      Continued …




                                                                                                                    21
     Assessment of burn size: Lund and Browder chart
                                  % Total Body Surface Area Burn
                                        Be clear and accurate, and do not include erythema




                             A                                          %                                    A


                             1                                                                               1



                                                                   thickness loss

                                                                   thickness loss
                         13                                        partial                                   13
             2                           2                                                     2                          2
                                                                   full
                                                    region

         1B/c                            1B/c       Head                                    1B/c                          1B/c

                                                    Neck
                             1                                                                        2B/c        2B/c
      1B/c                                   1B/c   Ant. trunk                       1B/c                                       1B/c

                    B             B                 Post. trunk                                         B            B

                                                    Right arm

                                                    Left arm

                                                    Buttocks

                    C             C                                                                     C           C
                                                    Genitalia

                                                    Right leg

                                                    Left leg
                  1D/e           1D/e                                                                 1D/e        1D/e
                                                    total burn


      area                                             age 0          1              5             10             15      adult

      A = B/c of head                                      9 B/c     8 B/c          6 B/c          5 B/c          4 B/c       3 B/c

      B = B/c of one thigh                                 2 D/e     3 B/e           4             4 B/c          4 B/c       4 D/e

      C = B/c of one lower leg                             2 B/c     2 B/c          2 D/e           3             3 B/e       3 B/c


22   Reproduced with permission from: Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment
     and resuscitation. BMJ 2004;329;101–3.
Note 3: Considerations for referral for hospital care
Burns of lesser severity than those meeting the criteria for regional burns unit care but with one or more of the
following risk factors:
• ongoing requirement for narcotic analgesia or failure to manage dressing-change pain
• IV fluids required
• where oedema may be a problem
• social and/or psychosocial indicators
• suspected non-accidental injury
• frequent or complex dressing issues
• significant comorbidities
• request for other specialist services, eg, physiotherapy.


Note 4: Referral criteria for regional burns unit care
The following criteria are endorsed by the ANZBA in assessing whether burns require treatment in a specialised
burns unit:33
• burns greater than 10% of total body surface area (TBSA)
• burns of special areas – face, hands, feet, genitalia, perineum and major joints
• full thickness burns greater than 5% of TBSA
• electrical burns
• chemical burns
• burns with an associated inhalational injury
• circumferential burns of the limbs or chest
• burns in the very young or very old
• burns in people with pre-existing medical or psychological disorders that could complicate management,
  prolong recovery or increase mortality
• burns with associated trauma.

NOTE: Referral to the National Burn Centre is made through a regional burns unit. There are regional burns units
at Christchurch (03 364 0640), Hutt Valley (04 566 6999), Waikato (07 839 8899) and Middlemore
(09 276 0000) Hospitals.




                                                                                                                    23
     Algorithm 2:
     Ongoing assessment and management of burns and scalds in primary care

                   Child or adult with a burn injury that can be managed in primary care


                                                    Day 1: Assessment of depth (Note 2)




                 Epidermal                                Superficial/Mid dermal               Deep dermal/full thickness



                                                          Antimicrobial dressing
                                                           Blister and oedema
             Moisturising cream                                                                    Is the burn area
                                                          management (Note 5)
            Review after 48 hours                                                                     >1cm wide?
                                                           Pain relief (Note 6)
                                                                                                                               Yes
                                                               Daily review


                                                                                                                       Refer acutely
            Day 3: Reassessment                            Day 3: Reassessment                            No          as appropriate
                                                                                                                      (Notes 3 and 4)




                Intact skin?                                      Reassess                    Antimicrobial dressing (eg,
                                                          burn depth (Note 2). Is it          silver sulphadiazine cream)
                                                        significantly worse (likely to              Pain relief (Note 6)
                                                             be full thickness)?
                                                                                                       Daily review
          Yes                   No             No                                       Yes


                                 Change to moist wound-
                                    healing product or
           Healed,                alternatively double-                                              Days 5–7:
          continue                 layer paraffin gauze                                         Change to moist wound-
         moisturiser
                                 Review within 72 hours                                           healing product
        and sunblock
                                   Monitor for signs of
                                         infection
                                                                                                                                No


                                                                                                     Days 10–14
                                        Is healing
                                       progressing?                            No               Is healing likely within
                                                                                                     seven days?


                                            Yes

                                                                                                         Yes
                             Continue with dressings as above
                            Monitor for signs of infection (Note 7)



                       Healed. Consider rehabilitation needs (Note 8)                          Continue with dressings


24
Notes to Algorithm 2

Note 5: Management of blisters and oedema
Management of blisters
• Preferably leave small blisters intact unless likely to burst or interfere with joint movement
• If necessary, drain fluid by snipping a hole in the blister.

Management of oedema
• Where possible, elevate affected area
• Remove jewellery or constricting clothing.


Note 6: Pain management for adults and children
Immediately after the injury
• Cool and cover the burn (with cling film or a clean, dry cloth).

Background pain
• Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), alone or in combination with opioids
• Aspirin products should be avoided.

Intermittent or procedural pain
• Consider administering short-acting opioids
• Supplementary anxiolytics if indicated
• Supplement pharmacological therapy with non-pharmacological approaches
• Refer to secondary care if failing to manage dressing-change pain.


Note 7: Signs of infection
Signs of infection
• Surrounding redness, increasing pain, increased exudate/pus, swelling, fever or local wound temperature
   increase, lymphangitis or increased irritability in a child.

Suggested management
• Swab the wound
• Consider re-starting topical silver sulphadiazine
• Consider starting oral antibiotics
• For more serious infection, refer acutely to secondary care.


Note 8: Psychological consequences of burn injury
• Monitor for stress disorders and depression
• Be aware of the risk of sleep disorders
• Consider services that may be able to support families affected by the psychological impact of burn injuries.




                                                                                                                  25
26
                                                                                                                             1




Chapter 1
Burn injuries and burns prevention in
New Zealand
Evidence statements
•   Most burns occur at home.
•   Children under five are at the highest risk, with hot liquids being the leading cause of injury in this age group.
•     ¯ori
    Ma are at increased risk, particularly in the under-five age group.
•   Males are at increased risk at all ages.

Evidence
Burns and scalds are a leading cause of injury to children in New Zealand, with children aged five years and
under being most at risk, especially toddlers as they become more mobile with little awareness of danger. Every
year, about seven or eight New Zealand children aged 15 years and under die as a result of burns or scalds. In
most cases, fatalities are the result of house or car fires. Over two-thirds of those who die are aged five years
and under10 and over a third are Ma 11
                                    ¯ori.

On average about 475 children under 15 years are admitted to hospital every year as a result of burns or scalds,
of whom 80% are aged five years and under.10 In 2002–3, 436 children under five years were admitted to public
hospitals with burns and scalds. Most of these injuries involved hot liquids: about 34% were caused by hot
drinks, food, fat or cooking oils, 20% by hot tap water, 25% by other hot fluids and 8% by exposure to fire or
flames. Over 35% of children aged five years and under admitted to hospital were Ma    ¯ori, and over 60% were
boys.12

During 2002 and 2003 the total number of adults and children admitted to public hospital with burn injuries
was 1311. Thirty-three per cent of these burns were fire, flame or smoke related and 77% were due to scalds
                                ¯ori
and contact with hot objects. Ma comprised 26% of total admissions and Pacific peoples comprised 10.5%.
Overall 66% of admissions were male, with higher rates of injury in all age groups.12 Most burn injuries occur at
home (this applies to about 63% of fire or flame burns and 70% of scalds).13

Further data from the Injury Prevention Research Unit on age-specific rates of burn injury over the period
2000–2004 is provided in Tables 1.1 and 1.2. This data includes first admissions only (excluding day patients)
with a primary diagnosis of injury.
table 1.1: burns from fire or flames: age-specific rates (per 100,000 population) for 2000–2004

                               age (years)                                 rate

                                     <15                                    4.9

                                    15–24                                  11.1

                                    25–44                                   7.1

                                    45–64                                   4.1

                                     65+                                    2.9
                                                                                                                        27
Reproduced from: Dow NA, Stephenson SCR, Allnatt DM. Trends In Thermal Injury. Fact Sheet No. 21. Dunedin:
Injury Prevention Research Unit, University of Otago; 2001.
     table 1.2: burns due to hot substances and objects, caustic or corrosive material or steam: age-
     specific rates (per 100,000 population) for 2000–2004

                                               age (years)                                                    rate

                                                        0–4                                                    79.8

                                                       5–14                                                     8.5

                                                      15–24                                                     6.5

                                                      25–44                                                     7.4

                                                      45–64                                                     5.7

                                                        65+                                                     7.8

     Reproduced from: Dow NA, Stephenson SCR, Allnatt DM. Trends In Thermal Injury. Fact Sheet No. 21. Dunedin:
     Injury Prevention Research Unit, University of Otago; 2001.

     ACC data on burn injuries, which is based on claim numbers for burn injuries covering a three-financial-year
     period (1 July 2001 to 30 June 2004), shows that there were 65,089 new claimants of burn injury in all age
     groups, in the three-year period.14 This number is much higher than other data (locally and internationally),
     and is probably because ACC covers general practitioner treatments and visits for very minor burn injuries for
     compensation. For burn injuries, the ratio of males to females is 1.12 to 1.00, and there were 20 fatalities in
     that period. Children aged under 15 years constituted 33% of burn-related claims.

     As in New Zealand, overseas literature reports that children under five years have the highest risk of both
     burn-related death15 and burn-related hospitalisations.16,17 Epidemiological studies conducted in a number
     of countries show that children in this age group have the highest burn-incidence rate.18-23 In this age group,
     scalds typically account for 50% of thermal injuries logged in emergency departments, and scalds are also more
     likely to lead to hospitalisation than any other burn injuries.17,24,25 Up to 80% of all childhood burn injuries in
     developed countries occur at home,23 and over 90% occur at home in developing countries.18,21


     Opportunities for prevention
      recommendations                                                                                                                                    grade

      Primary care providers should provide advice on smoke alarms.                                                                                           A

      Primary care providers should support local initiatives in primary prevention, where possible.                                                          C
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



      good practice points

      Primary care providers should provide advice on the regulation of hot water temperature and                                                             ✓
      appropriate first aid management.
      This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.




28
                                                                                                                       1



Evidence statements
• The hot water temperature in the home should be regulated to reach the taps at no more than 50°C.
• There is evidence from the United States (US) that smoke detector legislation can reduce the number of fire-
  related deaths compared with communities without smoke detector legislation.
• There is evidence that the community-based provision of free smoke alarms (with or without installation)
  reduces fire-related injuries.
• Simple educational initiatives improve safety in the home.

Evidence
Common preventable causes of serious thermal injury include scalding water and lack of smoke detectors. A
1947 study found that full thickness burns occurred in adult skin in two seconds at 66°C whereas at 54°C this
took 30 seconds.26 In a large US case-control study the absence of a smoke detector increased the risk of death
in a residential fire by over 60%.27

The primary care setting offers numerous opportunities for promoting safety measures to prevent burns and
scalds since young children are the population most at risk and they are usually seen routinely. There is good
evidence that advice in this setting promotes good practices with regard to fire safety, although evidence is
lacking of a direct impact on injuries.28

Similarly, while an educational strategy may improve safety consciousness,29 there is little evidence about
community-based interventions that impact on the rate of injuries.30 However, individual regulatory measures,
such as the installation of temperature controls on hot water cylinders, appear to have had some impact.

A systematic review of individual-level injury prevention strategies delivered in primary and acute care
settings showed that such strategies increased smoke alarm ownership and the maintenance of a safe hot
water temperature.28 The most effective interventions used a combination of methods, such as counselling,
demonstrations, the provision of free or subsidised safety devices, and reinforcement. None of the relevant
trials reported outcomes on fire-related injuries specifically.

A small New Zealand study29 showed an improvement in the ability of children to recognise fire safety hazards
around the home and in families’ self-reported safety practices, such as keeping pot handles turned in. The
most problematic recommendation was to reduce the hot water temperature.

A systematic review found very limited research on the effectiveness of community-based injury-prevention
programmes to prevent burns and scalds in children. Only one of the three eligible studies reported a reduction
in burn injuries and there were weaknesses in the methodology of this study.30

Regulation of hot water temperature to reduce the risk of scalds
• The safest long-term option is to install a tempering valve in the hot water cylinder. This is done by a
  plumber. It ensures that hot water reaches the taps at the appropriate temperature. Since 1993 the
  New Zealand Building Code has required that tempering valves be installed in new homes.
• Another option is to turn down the thermostat on the hot water cylinder. If a consumer-adjustable thermostat
  is not fitted, an electrician can install one. However, the tempering valve option is safer and is also more
  energy efficient in the long term.
• An adult should be able to hold their wrist under the running water.
• If in doubt, check the hot water temperature with a thermometer.

For more information, see the New Zealand Fire Service website Fire Safety Tips
(http://www.fire.org.nz/home_kids/tips/hotwater.htm).




                                                                                                                  29
30
                                                                                                                                                                     2
Chapter 2
First aid

Stopping the burning process and cooling
    recommendations                                                                                                                                    grade

    Ensure your own safety.                                                                                                                                 C

    If on fire, ‘stop, drop and roll’, smother with blanket or douse with water.                                                                             C

    For electrical burns, disconnect the person from the source of electricity.                                                                             C

    Remove clothing and jewellery.                                                                                                                          C

    Cool burns or scalds by immediate immersion in running tap water (8–15°C) for at least 20                                                               C
    minutes. Irrigation of chemical burns should continue for one hour.

    Do not use ice for cooling.                                                                                                                             C

    Avoid hypothermia: keep the person with the burn as warm as possible, consider turning the                                                              C
    temperature of the water up to 15°C (tepid).

    If there has been a delay in starting cooling, this should still be started up to three hours after                                                     C
    injury.

    Do not attempt to remove tar.                                                                                                                           C
    Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



Evidence statements
•     Clothing can retain heat, even in a scald injury.
•     Cooling burns reduces the severity of tissue damage.
•     Running tap water at 15°C (tepid) is as effective as other forms of cooling.
•     Alternative liquids, such as milk or soft drinks, may be used when running tap water is unavailable.
•     Be aware of the risk of hypothermia, especially in children and older people.
•     Application of ice may deepen the wound and increase the risk of hypothermia.

Evidence
The evidence for stopping the burning process derives largely from expert opinion.31,32 Flames should be doused
with water or smothered with a blanket or by rolling the person on the ground. Clothing can retain heat and
should be removed as soon as possible unless adherent. Jewellery should also be removed and if oedema
is present elevate the affected area. Tar burns should be cooled with water, but the tar itself should not be
removed. In the case of electrical burns, ensure the power source is turned off and the scene is safe before
cooling with water. Expert opinion suggests that if running tap water is unavailable to cool the burn wound,
alternative liquids may be used, such as milk or soft drinks.
                                                                                                                                                                31
     There is good evidence that immediate cooling of burns reduces the severity of tissue damage. However, the
     optimum duration and temperature of cooling is largely a matter of expert opinion. The Guideline Development
     Team extrapolated the low-level evidence from a variety of sources to reach a weakly graded conclusion.
     Irrigation of chemical burns should continue for one hour. See Chapter 7, Management of chemical injury for the
     evidence supporting this statement and further information on the management of chemical burns.

     Cooling large areas of skin may result in hypothermia, especially in children.31 Therefore, while it is
     recommended that the burn wound is cooled by irrigating or immersing in running water, the person with
     the burn needs to be kept as warm as possible. Ideally the water should be tepid (15°C). Ice or iced water
     should not be used as intense vasoconstriction can cause burn progression31 and also increases the risk of
     hypothermia.33 In an animal study, the application of ice for 10 minutes resulted in a deeper wound compared
     with no treatment at all.34

     A case series study of 695 children with burns in Vietnam found that immediate cooling with cold water
     significantly reduced the risk of sustaining a deep burn, with an estimated 32% reduction in the need for skin
     grafting.35 Similarly, a study of 121 people with burns presenting to Middlemore Hospital found that adequate
     burns first aid treatment (cooling) was associated with a reduced number of skin-grafting procedures.1

     Another large case series showed a significantly decreased length of hospital stay in people with less than 30%
     TBSA burns who received first aid by water cooling.36

     In a randomised single-blinded study37 of 24 volunteers, no prolonged anti-inflammatory or anti-hyperanalgesic
     effects were observed after 30 minutes’ cooling to 8°C, initiated within 15 minutes after an epidermal burn
     injury (although the data did not contradict the clinical observation that cooling following a more severe burn or
     scalding has a pain-relieving effect). An earlier experimental study supported these findings.38

     Other evidence on cooling derives from animal studies. The methods, duration and temperature of cooling used
     in these studies varied widely.

     One experimental study39 found faster healing at 21 days in deep partial thickness scalds cooled with either
     tap water (at 15°C, applied on gauze every three minutes) or hydrogel, than in uncooled scalds. Similarly,
     another experimental study40 found that scalds treated by ice-water immersion at 10 minutes post-burn for 30
     minutes sustained less damage to the epidermis, basement membrane and dermal microvasculature and had
     less oedema than those untreated. A transient reduction in oedema volume in scalds was also found in another
     study,41 which lasted longer with decreasing temperature and increased cooling time. The most pronounced
     effect was obtained after cooling at 0°C for 120 minutes.

     One study investigated the optimum period of cooling.42 This involved cooling burns at 8°C for time periods from
     15 to 120 minutes. The results suggested that 30 minutes was the optimal duration of cooling.

     Another study investigated when the cooling strategy should be started.43 This study began cooling wounds
     from 10 minutes to 60 minutes post-burn and found markedly better healing when cooling (ice water 0–3°C
     bath for 30 minutes) was commenced within 30 minutes of burning, compared with 60 minutes after burning.


     Gel pads
      recommendation                                                                                                                                     grade

      Gel pads can be used as an alternative to running tap water where water is unavailable or not                                                           C
      practical.
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



32
                                                                                                                                                                  2
Evidence statements
• There is insufficient evidence about the effectiveness of burn gels in comparison with running water.

Evidence
There was insufficient evidence to assess adequately whether hydrogel dressings are more effective at cooling
or reducing pain than water. Three published studies (two case series in people with burns or wounds and one
comparative study in volunteers with non-burned skin) and four studies downloaded from the internet (one in
pigs, one with volunteers with non-burned skin and two with people with burns) were identified. One of these
studies directly compared the cooling properties of hydrogel dressings with cold water (in people without
burns). One comparative study compared hydrogels with other types of dressing for other outcomes, such as
healing time and hospital stay. Pain relief was assessed by only one case series.

Findings
An experimental animal study of fair quality44 found that cooling with a gel dressing at different time periods was
more rapid and effective than air cooling and the immediate application of gauze in burned pigs. A poor-quality
case series of 131 adults with scalds and burns45 recorded body temperature rectally and at the skin surface for
cold water cooling compared with gel cooling in healthy volunteers without burns. Cold water therapy for 20 to
30 minutes, but not gel cooling, induced hypothermia in participants. The case series also reported that 73% of
participants using a gel dressing had a reduction of pain (described as ‘appropriate’, ‘permanent’ or ‘total’) and
36% used no analgesics. The dressing was described as ‘easy’ to administer in 98% of cases.

A controlled trial of fair quality46 reported that hydrogel dressing with air movement was more effective
than hydrogel dressing alone, with a thick bandage or with a bandage plus air movement, in reducing skin
temperature in healthy volunteers without burns. Due to the paucity of good-quality randomised evidence, we
have been unable to directly compare the effectiveness of burn gels with cold water for cooling and reducing
pain. The identified studies did not report any adverse events when burn gels were used.


Initial coverings
Polyvinyl chloride film (cling film)

 recommendations                                                                                                                                    grade

 Following cooling, polyvinyl chloride (PVC) film may be used as a temporary cover prior to                                                               C
 hospital assessment. It should be applied by persons knowledgeable in its use.

 PVC film should be layered onto the wound and not applied circumferentially around a limb.                                                               C

 Topical creams should not be applied as they may interfere with subsequent assessment.                                                                  C
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




 good practice point

 PVC film should not be used as a substitute for a dressing product.                                                                                      ✓
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.




                                                                                                                                                             33
     Evidence statements
     • The application of PVC film can relieve pain. It is transparent for inspection. It is clean and easy to remove.
     • A clean, dry cloth may be used to cover the wound if PVC film is not available.
     • The use of PVC film as an alternative to silver sulphadiazine cream makes the subsequent assessment of
       wound depth easier in people who are transferred within four hours to secondary care.
     • There is a risk of constriction if PVC film is wound around a limb that subsequently swells.

     Evidence
     Insufficient evidence was identified to determine the benefit of PVC film. A non-systematic review, a
     microbiological study and a case series were identified which assessed water-impermeable PVC film as a
     dressing for burns.47-49

     Findings
     Cling film plastic wrap is sold throughout New Zealand, mainly to cover food. It is composed of plasticised
     PVC film. Based on experience in an English burns unit, Wilson47 concluded in his review that plasticised PVC
     film was easy to use, safe and cheap and caused no pain. It was found to be particularly useful before surgery
     and before transfer to the burns unit in the hospital. In a microbiological study of 24 people with partial or full
     thickness burns who used PVC film as a temporary dressing,48 bacteria were cultured from the initial exudate in
     only 3 out of 37 burns and subsequent bacterial cultures showed no differences from what was usually found in
     burn wounds. Laboratory investigations indicated that the wrap had no antibacterial effect on the burn wounds.
     The other case series49 reported that PVC film as a wound covering enhanced the ability of thermography to
     assess the damage to the skin blood vessels prior to early surgery. The PVC film did not interfere with the
     measurement of surface temperature and avoided the cooling effect of evaporation at the site of the wound.

     PVC film is often used as a temporary covering of a burn wound. It is pliable, non-adherent and impermeable,
     acts as a barrier and is transparent for inspection. After the first few centimetres it is essentially sterile. It should
     be applied in layers and not circumferentially like a bandage, to prevent any tourniquet effect if tissue oedema
     develops.6

     The Guideline Development Team suggests that if cling film is unavailable, a clean, dry cotton sheet (preferably
     sterile) may be used as a first aid measure at home. In the primary care setting a double-layer paraffin gauze
     dressing may be used. Hand burns can be covered with a clear plastic bag. Topical creams should not be
     applied at this stage as they may interfere with the subsequent assessment of the burn.31




34
Chapter 3
Burn assessment                                                                                                                                                   3



Emergency management
 recommendations                                                                                                                                    grade

 For major burns perform an ABCDEF primary survey and X-rays, as indicated.                                                                              C

 Address analgesic requirements.                                                                                                                         C

 Establish and record the cause of the burn, the exact mechanism and timing of injury, other                                                             C
 risk factors and what first aid has been given.

 Assess burn size and depth.                                                                                                                             C

 Give tetanus prophylaxis if required.                                                                                                                   C

 Be alert to the possibility of non-accidental injury.                                                                                                   C
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



Evidence
Measures recommended for the assessment and initial management of burns derive largely from international
expert opinion.50,51 The chance of survival following burn injury has increased steadily over the past 60 years, in
tandem with the introduction of such measures.52,53

Several large case series studying factors predictive of death following burn injury reported a strong correlation
between prognosis and two factors: burn area (particularly deep burn area) and age.54-57 In addition, studies
have found inhalational injuries to be a strong predictor of mortality.52,58-60 There is also evidence that other
factors, such as alcohol, contribute significantly to outcome.61

ABCDEF primary survey
Airway maintenance with cervical spine control
• Ensure airway is clear and open, keep movement of cervical spine to a minimum.
• Inhalation of hot gases can cause a burn above the vocal cords that may become oedematous over the
   following hours; a seemingly well person, especially a child, may deteriorate later. See Table 3.1 for signs of
   inhalational injury.
• If the patency of the airway is at risk, intubate.




                                                                                                                                                             35
     table 3.1 airway maintenance

      signs of inhalational injury                            indications for intubation

      History of flame burns or burns in an enclosed space     Erythema or swelling of the oropharynx on direct
                                                              visualisation
      Full thickness or deep dermal burns to face, neck or
      upper torso                                             Change in voice, with hoarseness or harsh cough

      Singed nasal hair                                       Stridor, tachypnoea or dyspnoea

      Carbonaceous sputum or carbon particles in
      oropharynx

     Adapted from: Hettiaratchy S, Papini R. Initial management of a major burn: 1– overview. BMJ 2004;328: 155–7.

     Breathing
     • Expose chest and ensure adequate and equal expansion.
     • Provide supplemental oxygen.
     • Damage below the vocal cords can be caused by severe chest burns, blast injury or inhalation of smoke or
        carbon monoxide. The products of combustion can directly irritate the lungs and cause bronchospasm or
        pulmonary oedema. People with asthma are particularly at risk.

     Circulation with haemorrhage control
     • Check for bleeding due to other injuries.
     • Stop bleeding with direct pressure.
     • Check pulse and peripheral circulation.
     • Hypotension is not the normal initial response to a burn: check for other causes.
     • Normal return from capillary blanch test is two seconds. A deep circumferential extremity burn can act as a
        tourniquet, causing vascular insufficiency and distal ischaemia which may become apparent some hours
        after the burn.

     Disability: Neurological status
     • Establish level of consciousness.
     • Poisoning from inhalation of noxious gases can cause confusion, dizziness, headaches and seizures.
     • Hypovolaemia and shock can also cause confusion.

     Exposure with environmental control
     • Remove clothing and jewellery and examine the whole person, including the back, for burn area and co-
        injuries.
     • Keep the person warm: hypothermia develops easily, especially in children.

     Fluid resuscitation
     • Establish intravenous access with two large peripheral intravenous lines.
     • Take blood for full blood count, urea and electrolytes, coagulation screen, amylase and carboxyhaemoglobin.
     • The main aim is to maintain tissue perfusion to the wound and prevent the burn deepening and to avoid
        hypoperfusion or oedema.
     • Burns of >10% body surface area in children and >15% in adults warrant resuscitation.
     • Give fluids:
        – 24-hour requirement: 3–4ml crystalloid solution per kg per % burn
        – plus maintenance fluids for children
        – give half over the first eight hours, the remainder over the next 16 hours.
     • If haemorrhage occurs from other injuries, replace with blood.
36
• Monitor with urinary catheter, ECG, pulse, blood pressure, respiratory rate, pulse oximetry or blood gases as
  appropriate.
• Insert nasogastric tube for larger burns or associated injuries.
                                                                                                                            3
X-rays
• In traumatic injury, order X-rays as indicated.

Pain relief
• Give intravenous morphine.
• Use small incremental doses of intravenous morphine until pain is controlled and reassess regularly.

For further information on pain management see Chapter 9, Pain management.

Burn history
• Knowledge of the cause of the burn, the exact mechanism and timing of injury and what prior treatment has
  been given helps to indicate the likely severity of the burn, the likelihood of inhalational or other co-injuries,
  the presence of contributing underlying causes (eg, faintness, seizure, alcohol) and the possibility of non-
  accidental injury. See also Table 3.2 for key points of a burn history.
table 3.2: key points of a burn history

 exact mechanism

 Type of burn agent (scald, flame, electrical, chemical)     Is there a risk of concomitant injuries (such as fall
                                                            from height, road traffic crash, explosion)?
 How did it come into contact with the patient?
                                                            Is there a risk of inhalational injuries (did the burn
 What first aid was performed?
                                                            occur in an enclosed space?)
 What treatment has been started?

 exact timings

 When did the injury occur?                                 How long was cooling applied?

 How long was the patient exposed to the energy             When was fluid resuscitation started?
 source?

 exact injury

 Scalds                                                     Electrocution injuries
 • What was the liquid? Was it boiling or recently          • What was the voltage (domestic or industrial)?
   boiled?                                                  • Was there a flash or arcing?
 • If tea or coffee, was milk in it?                        • Contact time?
 • Was a solute in the liquid? (Raises boiling
                                                            Chemical
   temperature and causes worse injury, such as
                                                            • What was the chemical?
   boiling rice)
 • Is there any suspicion of non-accidental injury?


Adapted from: Hettiaratchy S, Papini R. Initial management of a major burn: 1– overview. BMJ 2004;328: 155–7.




                                                                                                                       37
     Factors influencing management and prognosis
     • The size and depth of burns indicate their likely severity, the need for fluid resuscitation, the potential risk of
        complications, the rate of healing, the amount of scarring that can be expected, and the need for specialist
        care. However, a burn is rarely uniform: a mixed pattern of burn is usually found.
     • The prognosis for people with major burns is well correlated to the area of the burn (TBSA), the presence of
        inhalational injury, and age.


     Burn size
     Assessment and recording of total body surface area burn

      recommendation                                                                                                                                     grade

      Where time allows, use the Lund and Browder chart as the standard assessment tool for                                                                   B
      estimating the TBSA of the burn.
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



     Evidence statements
     • Lund and Browder charts are more accurate than either the Rule of Nines or palm size in identifying TBSA.
     • Lund and Browder charts become less accurate at the extremes of age and body mass index (BMI).
     • The Rule of Nines can be faster and more convenient to perform in emergency situations but is not accurate
       for children and should not be used in those clinical settings.
     • A person’s hand size (palm including fingers) approximates to 0.8–1.0% of TBSA. The 1% rule can be
       cautiously used to estimate the size of small burns (<10%) in primary care.
     • Computer assessments of burn size are not sufficiently developed for routine use in primary care.

     The measurement of burn surface area is important during the initial management of people with burns for
     estimating fluid requirements and determining referral criteria. It is essential that all of the burn is exposed
     and assessed. During assessment the environment should be kept warm, and small areas of skin exposed
     sequentially to reduce heat loss. Erythema should not be included.51

     Evidence
     The practice of using a person’s hand size to approximate 1% body area is commonly taught on emergency
     medicine courses but has not been well validated.62-67 This practice should be used with caution, particularly
     in children or for people who are obese (BMI >30) as it does not allow for variations in individual body weight
     or age. For small areas, up to about 5%, the whole hand (palm plus digits) should be taken to approximate
     0.8–1.0% of TBSA.

     Five observational studies were found comparing the Rule of Nines burn area chart (see Figure 3.1) with other
     methods of estimating burn surface area. The Rule of Nines has been found to provide reasonable estimates for
     burned body surface area for most children and adults.68 For people who are obese or weighing more than 80kg
     (BMI >30), a Rule of Fives is proposed by one author:69 5% body surface area for each arm, 5x4 or 20% for each
     leg, 10x5 or 50% for the trunk, and 2% for the head. For infants weighing less than 10kg (BMI <18) a Rule of
     Eights is proposed: 8% for each arm, 8x2 or 16% for each leg, 8x4 or 32% for the trunk, and 20% for the head.

     Computer methods of size estimation have been described for use in various skin disorders. Three studies
     were reviewed which were considered applicable to burn size assessment. Two observational studies70,71
     found a close correlation between the computer methods of size estimation and objective measurement. The
     participants of one study found a computer program was easy to use and potentially useful in the person’s
     care.72 No direct quantitative comparisons with manual methods, in people with burns, were found.
38
Six different types of burn area charts were compared in one observational study.73 Four of the six were either
Lund and Browder (see Figure 3.2) or a modified version of Lund and Browder, and there were two versions of
the Rule of Nines represented. Utilising 10 drawings of burns on the six different charts, this study found that
the Rule of Nines often overestimated the burn size and was more variable, but could be performed somewhat              3
faster than the Lund and Browder method. The Rule of Nines’ estimates were 3% larger than the Lund and
Browder estimates for the same burn representation.

A modification to the Lund and Browder chart has been proposed that adjusts for breast burns in larger-
breasted women,74 as breast burns in these women can be underestimated by as much as 5%.

In the primary care setting it is anticipated by the Guideline Development Team that the use of specific
adjustments in estimates of burn area to take account of obesity and large breast size would be precluded by
other clinical priorities.
figure 3.1: assessment of burn size: rule of nines



                          9%




                      Front 18%
                      Back 18%
                                                                                   18%



            9%                          9%
                                                                               Front 18%
                                                                               Back 18%
                          1%                                        9%                           9%

                    18%        18%




                                                                          14%             14%




Adapted from: Australian and New Zealand Burn Association Limited, Emergency Management of Severe Burns
(EMSB): Course Manual 2004.

                                                                                                                   39
     figure 3.2: assessment of burn size: lund and browder chart
                                                % Total Body Surface Area Burn
                                        Be clear and accurate, and do not include erythema




                             A                                           %                                    A


                             1                                                                                1



                                                                    thickness loss

                                                                    thickness loss
                         13                                         partial                                   13
             2                           2                                                      2                          2
                                                                    full
                                                     region

         1B/c                            1B/c        Head                                    1B/c                          1B/c

                                                     Neck
                             1                                                                         2B/c        2B/c
      1B/c                                   1B/c    Ant. trunk                       1B/c                                       1B/c

                    B             B                  Post. trunk                                         B            B

                                                     Right arm

                                                     Left arm

                                                     Buttocks

                    C             C                                                                      C           C
                                                     Genitalia

                                                     Right leg

                                                     Left leg
                  1D/e           1D/e                                                                  1D/e        1D/e
                                                     total burn


      area                                              age 0          1              5             10             15      adult

      A = B/c of head                                       9 B/c     8 B/c          6 B/c          5 B/c          4 B/c       3 B/c

      B = B/c of one thigh                                  2 D/e     3 B/e           4             4 B/c          4 B/c       4 D/e

      C = B/c of one lower leg                              2 B/c     2 B/c          2 D/e           3             3 B/e       3 B/c


     Reproduced with permission from: Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment
40
     and resuscitation. BMJ 2004;329;101–3.
Burn depth
 recommendations                                                                                                                                    grade
                                                                                                                                                                  3
 The depth of a burn injury should be reassessed two to three days after the initial                                                                     C
 assessment, preferably by the same clinician.

 Testing for pinprick sensation by using a needle should be avoided.                                                                                     C
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




 good practice point

 The extent and speed of capillary refill can be used as a clinical method of assessing burn                                                              ✓
 depth.
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



Evidence statements
• Burns can be difficult to assess accurately in the first few days following injury, particularly in areas of poor
  circulation or infection.
• Burn depth is easier to assess after the initial oedema and inflammatory reaction have settled.
• The extent and speed of capillary refill is the most useful clinical method to assess burn depth.
• There is insufficient evidence that the newer technologies (laser doppler, thermography, radioisotopes) are
  practical or useful in assessing burns in the primary care setting.
• Testing for pinprick sensation is painful and can be frightening for children and is not a sensitive test for
  assessing burn depth.
• An estimate of burn depth is important in planning treatment, but is not required for calculating fluid
  requirements for acute resuscitation.

Evidence
There is little reliable evidence on the assessment of burn depth and the above recommendations derive largely
from expert opinion.

Although it is relatively uncomplicated to diagnose very superficial burns and very deep burns, those of
intermediate thickness are more problematic as their surface appearance alone is deceptive. The extent and
speed of capillary refill is considered the most useful clinical method to assess burn depth.51 However, the
presence of a dermal circulation, as measured by capillary refill at 24 hours post-injury, does not necessarily
mean that the burn will remain superficial. Burns can increase in severity and depth over the first few days,
particularly in areas of poor circulation or infection. Burn depth is easier to assess after the initial oedema and
inflammatory reaction have settled.

Testing for burn depth by using pinprick sensation requires a high degree of compliance and is not appropriate
for young children, or for people who are confused or shocked. Moreover, the accuracy of the test is limited.75
Biopsy and histology are generally considered to be the gold standards for assessment of burn depth, but are
impractical for routine clinical use.

Most studies76-78 assess burns after 48 hours or so and therefore there is little evidence assessing the diagnostic
accuracy of tools used to assess depth in the acute setting. Laser Doppler, transcutaneous microscopy,
reflectance fluoroscopy, radioisotope studies, ultrasound and thermography have all been tried, but are still
seen as research tools. The depth of a burn on any individual subject will vary from one location to another,

                                                                                                                                                             41
     so all controlled trials of these tools suffer from a difficulty in matching the areas sampled. Despite this,
     some studies of newer techniques have shown promise in a research setting. The practical problems for the
     application of these techniques to clinical use include:
     • direct contact with the skin surface is sometimes needed
     • some tests are invasive
     • burns in some body areas cannot be tested
     • a lack of agreed standardisation of the thresholds
     • investigator bias is introduced by the need to choose a sample area.

     A small blinded prospective study (of 23 people with 41 wounds) compared clinician assessment with laser
     doppler imaging to gauge burn depth in adults with acute burns of indeterminate depth.79 Burns were assessed
     daily; in most cases the first scan was done one day post-burn (maximum two days). Clinician assessment
     correctly predicted which of the 41 wounds required excision and grafting (sensitivity 100%), while the laser
     doppler technique erroneously predicted healing in 8 out of 21 cases when biopsy results confirmed deep
     partial thickness (mid to deep dermal) or full thickness burns (sensitivity 62%). Conversely, surgeons frequently
     overestimated burn depth, resulting in unnecessary excision and grafting for seven people (specificity 61.5%),
     whereas the laser doppler was 100% specific.

     Other studies of newer technologies assessed wounds in a non-acute setting, so were not relevant to primary
     care.


     Non-accidental injury
      recommendations                                                                                                                                    grade

      If non-accidental injury is suspected, refer to a regional burns unit.                                                                                  C

      If non-accidental injury is suspected, examine for other signs of abuse and photograph                                                                  C
      injuries.
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



     Evidence
     The high incidence of non-accidental burns and scalds necessitates that primary care staff be alert to this
     possibility. It is estimated that around 6–8% of paediatric burns are non-accidental, with children aged
     under three years being at highest risk.80-82 A high rate of repetitive injury has been reported among abused
     children.83,84 Older and disabled adults are also at increased risk.85

     • Indicators of possible non-accidental burns or scalds include the following:6,86
       – delay in seeking help
       – historical accounts of injury differ over time
       – history inconsistent with the injury presented or with the developmental capacity of a child
       – past abuse or family violence
       – glove and sock pattern scalds
       – scalds with clear-cut immersion lines
       – symmetrical burns of uniform depth
       – other signs of physical abuse or neglect.
     • Other possible indicators of non-accidental injury may include:
       – inappropriate behaviour/interaction of child or caregivers
       – restraint injuries on upper limbs.
42   Refer to a regional burns unit if non-accidental injury is suspected.
Tetanus
There is a risk of tetanus following a burn injury. For guidelines on the prevention of tetanus following injury,
refer to the Ministry of Health Immunisation Handbook 2006.9
                                                                                                                                                                  3

Classification of burns
 recommendations                                                                                                                                    grade

 Avoid use of the terms first-degree/primary, second-degree/secondary and third-degree                                                                    C
 burns.

 Distinguish between burns that will probably heal without skin grafting and those that will                                                             C
 probably require grafting (deep dermal burns and full thickness burns).

 Burns that are unlikely to heal within 21 days without grafting should be referred early to                                                             C
 secondary care, ideally by day 10–14.
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




 good practice point

 Use the ANZBA system of burn classification.                                                                                                             ✓
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



Evidence statements
• A burn wound that has not healed within three weeks has an increased risk of significant scarring, infection
  and functional limitation.
• Early excision and grafting reduces mortality and shortens hospital stay.
• Extensive burns that are expected to heal spontaneously may still need to be managed in a hospital setting.

Evidence
Burns are generally classified by depth, as the ability of a burn to regenerate epithelium depends on the number
of viable keratinocytes in the wound bed (as well as the wound environment).

International expert opinion notes that superficial dermal wounds should heal within two weeks, but deeper
wounds are difficult to assess and may well require grafting, especially if the injuries are extensive or in
cosmetically or functionally sensitive areas. The incidence of scarring rises if epithelialisation is delayed beyond
three weeks; all wounds that show minimal signs of healing by 10 days should be referred for assessment. Full
thickness wounds will most likely require grafting.87

A meta-analysis of six randomised controlled trials (RCTs) of the early excision of burns showed that, in people
without inhalational injury, early excision reduced mortality and length of hospital stay. However, there was a
greater volume of blood loss in people undergoing surgery.88

The ANZBA33 uses a five-point table. This is recommended for use in preference to the older systems, particularly
the first- to third-degree classification, which does not differentiate between burns that are likely to heal
spontaneously (superficial dermal) and those that are likely to require grafting (mid dermal and deeper).




                                                                                                                                                             43
     table 3.3: classification of burns based on depth
     anzba 2004 classification Epidermal
     former classification     Superficial epidermal
     example                    UV light, very short flash
     appearance                 Dry and red, blanches with pressure,
                                no blisters
     sensation                  May be painful
     healing time               Within seven days
     scarring                   No scarring

     anzba 2004 classification Superficial dermal
     former classification     Superficial partial thickness
     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

     anzba 2004 classification Mid dermal
     former classification     Partial thickness
     example                    Scald (spill), flame, oil or grease
     appearance                 Dark pink with large blisters
                                Capillary refill sluggish
     sensation                  May be painful
     healing time               14–21 days
     scarring                   Moderate risk of hypertrophic scarring

     anzba 2004 classification Deep dermal
     former classification     Deep partial thickness
     example                    Scald (spill), flame, oil or grease
     appearance                 Blotchy red, may blister, no capillary
                                refill
                                In child, may be dark lobster red with
                                mottling
     sensation                  No sensation
     healing time               Over 21 days: grafting probably needed
     scarring                   High risk of hypertrophic scarring

     anzba 2004 classification Full thickness
     former classification     Full thickness
     example                    Scald (immersion), flame, steam, oil,
                                grease, chemical, high-volt electricity
     appearance                 White, waxy or charred, no blisters, no
                                capillary refill
                                May be dark lobster red with mottling
                                in child
     sensation                  No sensation
     healing time               Does not heal spontaneously, grafting
                                needed if >1cm
44   scarring                   Will scar

     Adapted from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.
     8th Edition. 2004.
Chapter 4
Referral

                                                                                                                                                                  4
Emergency referral
 recommendations                                                                                                                                    grade

 Health care practitioners should follow the ANZBA referral guidance when deciding the level of                                                          C
 care that is appropriate for people with a new burn injury.

 When seen in primary care, smaller burns that look like they will fail to heal by 14 days should                                                        C
 be discussed with a secondary care service for consideration of an acute referral.
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



Evidence statements
• ANZBA guidance on referral is universally accepted throughout New Zealand.
• International systems of referral are all consistent with ANZBA guidance.

Evidence
In 2001 the American Burn Association proposed a list of conditions that generally require a referral to a burns
unit.89 In New Zealand there are burns units in Christchurch, Hutt Valley, Waikato and Middlemore Hospitals. The
following criteria are endorsed by ANZBA in assessing whether burns require treatment in a specialised burns
unit:33
• burns greater than 10% of TBSA
• burns of special areas – face, hands, feet, genitalia, perineum and major joints
• full thickness burns greater than 5% of TBSA
• electrical burns
• chemical burns
• burns with an associated inhalation injury
• circumferential burns of the limbs or chest
• burns in the very young or very old
• burns in people with pre-existing medical and/or psychological disorders that could complicate
    management, prolong recovery or increase mortality
• burns with associated trauma.


Levels of care
Evidence statement
• Evidence from the US experience with trauma systems indicates that a regional approach to providing
  specialist burn management expertise and a central approach to treating the very severely injured on a
  national basis can both improve a person’s outcome and be cost-effective.

Evidence
There are four levels of care for burns injuries in New Zealand:
• primary care including accident and medical centre care                                                                                                    45
     • secondary care in a hospital
     • regional burns unit care (Christchurch, Hutt Valley, Waikato and Middlemore)
     • National Burn Centre level care (Middlemore).

     In 2002, the Ministry of Health supported the development of a National Burn Centre based at Middlemore
     Hospital in Auckland. This Centre will be part of an organised system of care with a network of regional burns
     units in Christchurch, Hutt Valley and Waikato. Middlemore will continue to act as a regional unit for the northern
     part of the North Island. People referred to Middlemore from regional units will return for ongoing care and
     rehabilitation when possible. Adults and children will be treated in the facility.

     A review of trauma services and organisation completed by the American Burn Association looked at the
     evidence for improved personal outcomes from the centralisation of trauma services that occurred in the US
     through the 1980s and 1990s. It reported improvements in survival, length of stay and costs in centres with
     higher programme numbers (higher numbers of people treated) and higher surgeon case volumes (higher
     numbers of people treated by each surgeon) and where people were transferred directly to a trauma centre from
     the scene of injury.89 Although we found few high-quality studies of similar system change in burn care, it seems
     reasonable to expect a similar benefit will extend to all trauma cases.

     Australia and the United Kingdom (UK) have reviewed the provision of national burns services and the
     evaluation and outcomes, when reported, may help inform any restructuring in New Zealand. In the interim
     the Guideline Development Team found no firm evidence that could support or refute the benefits of the New
     Zealand model of care.


     Referral between services
      recommendations                                                                                                                                    grade

      Transfer between services is facilitated by prompt assessment, recognised communication                                                                 C
      channels and locally developed protocols agreed between centres on whom to transfer and
      when to transfer.

      Referrals to National Burn Centre level care should be via the regional burns units.                                                                    C
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




      good practice point

      Primary care and accident services will generally develop their own systems for referral                                                                ✓
      depending on the distances involved in travel to secondary services or regional burns units. In
      general, those people who have less severe injuries than in the ANZBA criteria, but who still
      require inpatient care, should be referred to local secondary services.
      This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



     Evidence statements
     A lack of data internationally on the relative merits of different service configurations, and the lack of
     applicability to New Zealand’s unique circumstances and demographics suggest that evaluation of outcomes
     and referral volumes between services will be needed.




46
Chapter 5
Management of epidermal burns or scalds

Dressings and creams
 good practice points
                                                                                                                                                    5
 A protective dressing or cream product can be used for comfort in epidermal burns and scalds.                                             ✓

 Review epidermal burns or scalds after 48 hours. If the skin is broken, change to a moist                                                 ✓
 wound-healing product (or alternatively double-layer paraffin gauze).
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



Evidence statements
• There is no compelling evidence to demonstrate an advantage for one wound-care product over another in
  the management of epidermal burns and scalds.

Evidence
There is very little reliable evidence on the management of epidermal burns and scalds. Three small RCTs
were found on the management of epidermal burns and scalds, all of fair quality. One very small split-sample
RCT90 (n=12) compared topical steroid cream (clobetasol) and placebo for treating pain and inflammation in
volunteers with superficial (epidermal) thermal burns. Another very small split-sample RCT (n=6)91 assessed
erythemal reactions in volunteers with ultra violet (UV) induced skin damage, comparing melatonin, antioxidant
creams and Aloe vera in various combinations with no treatment. A larger RCT92 (n=50) compared healing time
and bacterial colonisation rates between hydrocolloid and medicated paraffin gauze with or without silver
sulphadiazine.

Findings
None of these trials found any statistically significant difference between any of the treatments for any of the
outcomes measured, except that povidone-iodine-impregnated gauze was twice as expensive as standard
paraffin gauze.

Guidance on dressings and creams from Guideline Development Team opinion includes the use of a protective
dressing or cream product for comfort in epidermal burns and scalds, with review after 48 hours. If the skin
is broken, the protective dressing or cream product should be changed to a moist wound-healing product or
alternatively to double-layer paraffin gauze.




                                                                                                                                               47
48
Chapter 6
Management of superficial and mid dermal
burns or scalds

Dressings and topical therapy
Dressing products which are unlikely to be found in primary care for use with burns were specifically excluded.
The outcomes ‘time to healing’ and ‘infection’ were key questions posed to the literature by the Guideline
Development Team. Wasiak and Cleland93 provided a discussion of other outcomes, such as pain and number
of dressing changes. A table describing various wound products and their uses has been compiled using                                               6
information from manufacturers and Guideline Development Team experience in burn care (see Appendix B).


Preventing infection
 good practice points

 Products with antimicrobial action (such as silver sulphadiazine cream) should be used on all                                             ✓
 burns for the first 72 hours (three days) after burn injury.

 Burn wounds with signs of mild cellulitis can be treated with topical silver sulphadiazine                                                ✓
 and/or oral antibiotics.

 Acute referral to secondary care is required for people with burns with signs of serious or                                               ✓
 systemic infection.
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



Evidence statements
• Although there is little evidence supporting the use of silver sulphadiazine for non-infected burns,
  clinical experience in New Zealand populations supports the routine use of silver sulphadiazine or other
  antimicrobial creams for the first three days to prevent infection.
• If infection is suspected, longer-term use of silver sulphadiazine may be indicated.
• There is no evidence comparing short-term (three day) use of silver sulphadiazine cream with other wound-
  dressing practices.

Most burn wounds are initially sterile. Careful aseptic wound-care procedures along with the use of
antimicrobial cream for the first three days are generally sufficient to prevent infection. The wound should be
regularly monitored, as infection can delay healing, increase scarring and potentially cause systemic infection.

The signs and symptoms of infection include the following:
• warmth and/or redness around the wound
• increasing pain
• increasing exudate, odour or pus from the wound site
• increasing swelling or tenderness
• fever or local wound temperature increase
• lymphangitis
                                                                                                                                               49
• increased irritability in a child.
     The use of silver sulphadiazine is recommended for the first three days following burn injury due to the high
     incidence of community-acquired Staphylococcus aureus sepsis (SAS) in the New Zealand population.94

     If infection is suspected, expert consensus favours swabbing the wound and considering the use (or re-use)
     of topical silver sulphadiazine and/or oral antibiotics. It is considered appropriate to extend the use of silver
     sulphadiazine beyond three days if infection is suspected or present. Acute referral to secondary care is
     required for people with burns with signs of serious or systemic infection.

     If after three days there is no infection, consider changing to a product that encourages moist wound healing.

     Evidence
     The evidence from published literature on the prevention of burn infection is inconsistent and of limited quality.
     There were nine fair-quality RCTs comparing silver sulphadiazine with other dressings and topical treatments
     (n=18 to 104).92,95-102

     Two RCTs compared silver sulphadiazine with a silicon mesh dressing,98,102 and another RCT compared silver
     sulphadiazine with a synthetic barrier dressing (n=18).101

     One fair-quality RCT (n=50) compared three types of dressings: a medicated (chlorhexidine) paraffin gauze
     dressing, a hydrocolloid dressing, and a hydrocolloid dressing with silver sulphadiazine cream.92 Another
     fair-quality RCT99 (n=30) compared a silver-coated high-density polyethylene mesh dressing with a solution
     containing 0.5% silver nitrate. A fair-quality RCT100 (n=121) compared 1% silver sulphadiazine with a
     combination of 1% silver sulphadiazine and 0.2% chlorhexidine digluconate.

     Five fair-quality RCTs all conducted by the same group95-97,103,104 compared bacterial colonisation rates in partial
     thickness (dermal) burns treated with honey, with silver sulphadiazine-impregnated gauze (three studies),
     polyurethane film, soframycin, paraffin gauze, dry gauze and exposure. These studies were unblinded and of
     variable size (n=50, 92, 100, 104 and 900). Bacterial colonisation rates were lower with honey in four of the
     studies. In one study comparing silver sulphadiazine with honey, infection rates were similar for both groups.

     No controlled evidence was found on the treatment of infected burns in primary care.

     Findings
     Although silver sulphadiazine cream is widely used for the prevention of infection of superficial and mid dermal
     burns,105,106 there is currently little evidence supporting its use. The evidence is inconsistent and of limited
     quality.

     One unblinded RCT found that there was a wider variety of bacterial flora and a larger amount of bacterial
     growth with the use of a silicone mesh dressing compared with silver sulphadiazine.102 However, this study
     found no differences in the signs of infection or the amount of wound drainage in both groups. Another study
     comparing the same products also found no significant difference in the number of infections.98 No significant
     differences in infection rates were found when comparing silver sulphadiazine cream with a synthetic barrier
     dressing.101 One of the studies conducted by Subrahmanyam96 also found similar rates of infection between
     silver sulphadiazine and honey.

     Six studies found a difference in rates of infection/bacterial colonisation.

     One study found less wound colonisation and infection using a combination of 1% silver sulphadiazine
     and 0.2% chlorhexidine digluconate versus 1% silver sulphadiazine alone.100 The overall incidence of
     wound bacterial colonisation was significantly less using a combination of 1% silver sulphadiazine and
     0.2% chlorhexidine digluconate (65% vs 88%). There was also significantly less wound colonisation by
     Staphylococcus aureus (41% vs 64%). Clinical wound infection with Staphylococcus aureus developed in one
     person treated with the combined cream as opposed to five people treated with 1% silver sulphadiazine alone.

50
However, this result did not reach statistical significance (p=0.16). Another study found that a silver-coated
dressing had lower rates of burn wound sepsis (>105/g) (n=5 vs n=16) and bacteraemia (n=1 vs n=5) in the
silver-coated dressing group. However, the results did not reach statistical significance at the 0.05 level.99

Two RCTs carried out by the same group95,97 found that bacterial colonisation rates were significantly lower
with the use of honey as a dressing. One study found that medicated (chlorhexidine) paraffin gauze had the
least increase in bacteria92 when compared with a hydrocolloid dressing, with or without silver sulphadiazine
(p<0.01). However, this study also found that there was no significant difference in the increased incidence of
pathogens during treatment in all three groups.


Toxic shock syndrome
Evidence statements
• Deaths from toxic shock syndrome are very rare in New Zealand, but are potentially preventable.
• In rare cases the rapid onset of symptoms of systemic infection with burns may be due to toxic shock                    6
  syndrome.

Evidence
Toxic shock syndrome is a rare complication of SAS infection. Most of the evidence of toxic shock in people
with burns applies to children, but the syndrome has also been reported in adults.107 Reports of toxic shock
syndrome in New Zealand are very rare, though anecdotally deaths have been reported in children.

There is no definite diagnostic test for toxic shock syndrome and its symptoms are similar to those of other
infections, namely fever, rash, diarrhoea, vomiting and hypotension. The diagnosis is generally made using the
US Centers for Disease Control and Prevention criteria listed below.108 Diarrhoea, vomiting and oliguria are early
signs, which may occur prior to the development of shock and help establish a timely diagnosis. If people with
burns undergo a sudden change, especially the rapid onset of fever and gastrointestinal upset, the possibility of
toxic shock syndrome should be considered.107

Although early intervention and the administration of effective antimicrobials are essential in the management
of toxic shock syndrome, probably the single most important therapeutic measure is the administration of
antibodies as human immunoglobulin, fresh frozen plasma or fresh blood, producing a state of passive
immunity in the recipient.109

The Centers for Disease Control have identified the following five clinical criteria for toxic shock syndrome:108
1. Temperature =/>38.9°C.
2. Low blood pressure (including fainting or dizziness on standing).
3. Widespread red flat rash.
4. Shedding of skin, especially on palms and soles, one to two weeks after onset of illness.
5. Abnormalities in three or more of the following organ systems:
   – gastrointestinal: vomiting or diarrhoea
   – muscular: severe muscle pain
   – hepatic: decreased liver function
   – renal: raised urea or creatinine levels
   – haematologic: bruising due to low blood platelet count
   – central nervous system: disorientation or confusion.
6. Mucous membranes: red eyes, mouth and vagina due to increased blood flow to these areas.

A survey of children in burns units in the UK found no association between the management of the burn wound
and the subsequent development of toxic shock syndrome.109

                                                                                                                     51
     Wound healing
      recommendations                                                                                                                                    grade

      Use dressings that encourage re-epithelialisation by moist wound healing.                                                                               C

      The prolonged use of silver sulphadiazine cream (more than seven days) should be avoided in                                                             B
      non-infected burns.
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




      good practice points

      Following initial silver sulphadiazine cream or antimicrobial dressing, a technique that                                                                ✓
      promotes moist wound healing (such as a hydrocolloid dressing) is recommended.

      The convenience of a reduced number of dressing changes with hydrocolloid products should                                                               ✓
      be considered where this is important to the person.

      Double-layer paraffin gauze can be used where hydrocolloids are unavailable.                                                                             ✓

      Moisturisers and non-drying, non-perfumed soap should be used to protect the skin after                                                                 ✓
      burn injury and may also be helpful for pruritis.

      Burn wounds require extra care when exposed to sun.                                                                                                     ✓
      This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



     Evidence statements
     • Convenience of use, reduced pain or number of dressing changes makes moist wound-healing products
       preferable.
     • There is insufficient evidence to recommend one moist wound-healing product over another.
     • Prolonged use of silver sulphadiazine cream (more than seven days) may delay healing.
     • There is a lack of evidence that any dressing product is superior to paraffin gauze in reducing the overall time
       to healing.
     • Hydrocolloid products can be changed every three to five days in wounds that are non-infected or have heavy
       exudates.

     Evidence
     Moist wound-healing versus non-moist healing products
     Expert opinion strongly favours the use of moist wound-healing products for superficial and mid dermal burns,
     although the evidence from RCTs is scanty and inconsistent.

     Seven small fair-quality RCTs (n=50 to 98) compared moist with non-moist healing products for partial thickness
     (dermal) burns.92,104,110-114 None was blinded. The moist healing products included polyurethane film/foam and
     hydrocolloids and the non-moist products included paraffin gauze and honey. Two of these studies compared
     hydrocolloids with a non-moist dressing plus silver sulphadiazine.110,114

     As described below, only three of the six RCTs showed a difference in time to healing between moist and non-
     moist healing products.104,111,114


52
One study found hydrocolloids healed wounds significantly faster than gauze and silver sulphadiazine.114 Three
other studies reported a similar healing time for hydrocolloids and paraffin gauze/tulle gras.92,110,113

Comparisons between polyurethane film/foam and paraffin gauze for burns were also inconsistent. One study
reported that burns healed significantly faster with polyurethane film111 and one study reported no difference
between these products in healing rates.112 One study found that honey healed significantly faster than
polyurethane film.104

There is no convincing evidence from primary RCTs that any other dressing product heals wounds significantly
faster than paraffin gauze (which is considered a non-moist dressing). Since paraffin gauze tends to dry out
(expert opinion), occlusive moist wound-healing products may be considered for wounds as the volume of
wound exudate diminishes.

There is good evidence from a systematic review that moist dressings are superior to non-moist dressings for
healing time, comfort and infection rates for burn donor sites.115 However, it is uncertain whether this evidence
is applicable to the care of superficial and/or mid dermal burns in primary care.
                                                                                                                         6
Dressing changes
One RCT reported that hydrocolloid required fewer dressing changes than paraffin gauze,92 but another reported
no difference between them.116

Silver sulphadiazine cream compared with other dressings and topical treatments
Twelve RCTs were found comparing silver sulphadiazine cream with other dressings and topical treatments.
These studies were rated either fair (10) or good quality (2). The largest study had 111 participants and six of
the studies had more than 50 participants. Ten of the 12 studies found that silver sulphadiazine significantly
increased time to healing. However, in all of these studies, silver sulphadiazine was applied until complete
healing (re-epithelialisation). No studies were found comparing shorter-term use of silver sulphadiazine cream
with other dressings or topical treatments.

Four of the 14 studies were fair-quality RCTs comparing silver sulphadiazine with other dressings. Two RCTs
comparing hydrocolloid dressings versus silver sulphadiazine found that silver sulphadiazine significantly
increased time to healing.92,114 One RCT found that silver sulphadiazine increased time to healing when
compared with a silicone-coated nylon dressing.98 One RCT found no significant difference in time to wound
healing comparing a combination of chlorhexidine-impregnated gauze dressing plus silver sulphadiazine cream
with hydrocolloid dressing.110

A further seven RCTs were found comparing silver sulphadiazine with various topical treatments. Two of these
studies compared silver sulphadiazine cream with a combination of hyaluronic acid and silver sulphadiazine
cream.117,118 These good-quality studies both reported that time to healing was significantly reduced using the
combined hyaluronic acid and silver sulphadiazine cream. One fair-quality RCT compared silver sulphadiazine
with a combination of cerium nitrate and silver sulphadiazine.119 This study found that the time to healing
was reduced by almost eight days when using a combination of cerium nitrate and silver sulphadiazine when
compared with silver sulphadiazine alone. However, the results just failed to reach statistical significance at
the 0.05 level. Another RCT (n=15) compared silver sulphadiazine cream with collagenase ointment and an
antibiotic spray.120 This study also found that silver sulphadiazine increased time to healing.

Silver sulphadiazine compared with alternative therapies for time to healing
Three fair-quality RCTs95,96,97 compared time to healing in partial thickness (dermal) burns treated with honey
(non-manuka) versus silver sulphadiazine. In all of these studies, superficial and partial thickness (epidermal
and dermal) burns treated with honey healed faster than those dressed with silver sulphadiazine. These studies
were fairly small, none was blinded and all the honey studies were conducted by the same researchers.

                                                                                                                    53
     A large unblinded RCT121 compared moist exposed burn ointment with silver sulphadiazine and found no
     difference in time to healing.

     Healing wounds and donor sites are vulnerable to dry skin and sunburn
     Expert opinion favours the use of moisturisers and non-drying, non-perfumed soap to prevent the skin drying
     out, as this could lead to skin breakdown and secondary infection. Education on sun protection is also
     important. Extra care needs to be taken at times of sun exposure. Sunscreen and/or protective clothing should
     be worn if working or playing outside.122

     Pruritis can also be a problem following burn injury. Persistent pruritis occurs after about 15% of burn injuries,
     with a further 44% of people reporting occasional pruritis. A systematic review of relevant studies found that
     a variety of interventions were reported to be beneficial, including medications, massage and transcutaneous
     electrical nerve stimulation, but none of the studies provided high-quality evidence on which treatment
     recommendations could be based.123 The clinical experience of the Guideline Development Team suggests that
     moisturisers are beneficial.


     When to review
      good practice point

      Superficial and mid dermal burns should be reviewed daily for the first three days, then                                                    ✓
      subsequently every three days.
      This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.


     In the absence of randomised data to answer the question ‘how often should a burn be reviewed?’, the
     Guideline Development Team discussed three aspects it considered relevant:
     • the expected speed of healing for burns of differing depths
     • the safety/risk of continued primary care management
     • the expected time-lag between the identification of a problem, referral and a definitive specialist opinion.

     A good practice point based on the experience of the Guideline Development Team was considered appropriate.


     Management of blisters
      good practice points

      Preferably leave small blisters intact unless likely to burst or interfere with joint movement.                                           ✓

      If necessary, drain fluid by snipping a hole in the blister.                                                                               ✓
      This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



     Evidence statements
     • There is little evidence to guide the management of blisters.
     • The bed of a deroofed blister can be more painful than an intact blister.

     Burn blisters occur primarily in superficial dermal and mid dermal burns, but also may overlay deep dermal
     burns. They are a result of inflammatory changes that occur early in burn injury, whereby increased capillary
     permeability allows oedema formation between the epidermis and dermis.


54
Evidence
One controlled trial of 202 people with partial thickness (dermal) burns124 was identified of relevance. In this
study, randomisation was unclear. There were two treatment groups: aspirated and deroofed blisters. The
intact blister group was left for 10 days before burn blister fluid was aspirated for analysis. The study assessed
infection rates and pain scores.

An RCT of second-degree (dermal) burns in pigs125 was also found. In this study, 42 burns in two pigs
(randomised to debridement or no debridement) were assessed for infection and re-epithelialisation rates.

Findings
In the Swain study,124 the incidence of infection (bacterial colonisation) in the intact blister group was 14%
compared with 76% in the deroofed blister group (p<0.05). Aspiration of fluid (in the intact blister group at 10
days) reduced pain in 34% of participants compared with 0% in the deroofed group. Deroofing worsened pain
in 43% compared with 19% in the aspiration group. In the Singer trial, infection rates were higher in deroofed
burns (p<0.001).125                                                                                                                                               6
There is a paucity of evidence to answer the question of whether deroofing is associated with less pain or
faster healing compared with leaving blisters intact. A recently published review126 concluded that it may be
worthwhile to consider healing rates associated with different dressing applications because they are an
indirect measure of healing in intentionally deroofed versus intact blister management in a partial thickness
(dermal) burn. On balance, until there is more evidence, small blisters should be left intact to reduce the risk
of infection, but if anatomical position necessitates intervention for functional purposes, aspiration appears to
result in less pain than deroofing.


Scarring
 recommendation                                                                                                                                     grade

 Any burns that are unlikely to heal within 21 days without grafting should be referred to a                                                             C
 burns unit for scar management by day 10–14.
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




 good practice point

 A person presenting with scarring some months after a burn should still be referred for                                                                 ✓
 specialist opinion.
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



Evidence statements
• Silicone sheeting may be of benefit in reducing scarring, although the evidence is of poor quality.
• Pressure garments may also be of benefit, but the evidence is inconclusive.
• Burns that do not heal within 21 days are likely to cause scarring, which can result in significant morbidity for
  the person.

Healing process
Scarring can result in long-term functional disability and changes in appearance, both of which are an indication
for specialised care.


                                                                                                                                                             55
     The normal process of wound healing by secondary intention involves the processes of epithelialisation and
     wound contraction. Epithelial cells require a matrix to migrate across. In a superficial wound the dermis is well
     intact, there are numerous epithelial cells and melanocytes within the dermis, epithelialisation is rapid and
     wound contraction is not a feature. Hence, there is minimal scarring or alteration in appearance.

     In a deeper burn there is less dermis and epithelialisation is prolonged, allowing the formation of granulation
     tissue. This granulation tissue contains large numbers of fibroblasts and myofibroblasts127 that are believed to
     produce wound contraction and scarring. Also, the melanocytes which are deep in the dermis may have been
     injured and/or destroyed, leading to altered pigmentation. Early debridement and skin grafting interrupt this
     process of granulation formation and so reduce the risk of contraction, which can still occur with grafting, but
     usually to a lesser extent.

     In a healed wound the processes of collagen deposition and angiogenesis have led to the laying down of
     collagen fibres in a haphazard arrangement with a large influx of blood vessels. Over subsequent months
     the wound goes through maturation where the metalloproteinases remodel the wound so that it softens and
     becomes less red. However, if there are continuing adverse factors such as inflammation, infection or tension,
     the process of scar maturation is hindered or prevented.

     When the process of scar maturation is hindered, there is an increased risk of hypertrophic scarring.
     Hypertrophic scars are thick, raised areas, usually darker than the surrounding skin, which remain within the
     confines of the original wound and tend to regress over time.128

     Another form of scarring that occurs less frequently is keloid scarring, in which the scar grows beyond the
     borders of the original wound and does not regress spontaneously. Keloid scarring tends to occur in genetically
     predisposed individuals and is more common in people of Asian descent and people with darker skin.129

     Predictors of scarring
     Risk factors for scarring identified in the literature include burn severity and non-white skin. It is unclear whether
     the risk is higher in children.123 Burn wounds that fail to heal within two to three weeks are at high risk of
     scarring.130

     Evidence on interventions for scarring
     One RCT was identified comparing massage together with pressure treatment with pressure treatment alone
     as treatments for hypertrophic scars in children.131 One Cochrane systematic review132 and one evidence-
     based report133 were identified on silicone gel sheeting for both the prevention and treatment of hypertrophic
     and keloid scars. One Cochrane protocol,134 three non-systematic reviews130,135,136 and three RCTs137-139 were
     identified. One of these RCTs compared pressure garments with no treatment, one RCT compared different
     types of pressure garments and the other compared different levels of compression on scar erythema and
     thickness.139

     No controlled trial evidence was found on other interventions such as intralesional steroid injections or laser
     treatment.

     Findings on interventions for scarring
     There was little evidence on interventions for scarring on which to base recommendations.

     Massage
     No evidence was found that massage is helpful in either the prevention or treatment of scars.

     Silicon gel sheeting
     The Cochrane review (including 13 RCTs) evaluating the effects of silicon gel sheeting for the prevention or
     treatment of scars reported that silicon gel sheeting significantly reduced the incidence of hypertrophic scarring
56
in people prone to scarring (RR 0.46, 95% CI 0.21 to 0.98). A significant improvement in scar elasticity (RR
8.6, 95% CI 2.55 to 29.02) was also reported. However, as the studies were highly susceptible to bias, the
authors concluded the evidence of benefit was weak. Similarly, the ACC evidence report concluded that the
effectiveness of silicone gel sheeting in scar management could not be confirmed.

Pressure garments
The evidence for pressure garments was also inconclusive. Pressure garments have been commonly used for
more than three decades, but the optimal pressure and duration has not been confirmed by controlled trials.
Pressure garments are usually used in a hospital setting or outpatient clinics.135 They are also associated with
significant adverse events, such as overheating, pruritis, wound breakdown and abnormal bone growth.136,140
However, the comparative trial comparing two different levels of pressure (initial pressure of 20mm Hg vs
12mm Hg) reported that there was a significant difference in the thickness of the scar at one month with the
higher pressure than with the lower pressure. No differences were found for erythema. A clear association was
shown between the persistence of erythema and hypertrophic scar formation. A multicentre comparative trial is
currently underway to clarify the role of pressure garments on scar management.139                                      6




                                                                                                                   57
58
Chapter 7
Management of chemical injury

General treatment advice
First aid

 recommendations                                                                                                                                    grade

 Irrigation of chemical burns should continue for one hour.                                                                                              C

 All chemical burns should be referred to a burns unit.                                                                                                  C
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




 good practice point                                                                                                                                              7

 Acid burns should not be neutralised with an alkali in primary care.                                                                                    ✓
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



Evidence statements
• There is an increased risk of systemic complications following chemical burns.

Evidence
Four retrospective observational studies were considered relevant.141-144 No controlled studies or systematic
reviews were found. Six non-systematic reviews were also included to ascertain the consensus of expert
opinion.145-150 Three other retrospective observational studies were selected for their review of the relevant
literature.151-153

An 11-year retrospective case series (n=51) compared those people who had immediate irrigation (group A)
with those who had delayed irrigation (group B). The size of burn was similar in the two groups (19.7% TBSA
in group A vs 17.2% TBSA in group B). In group A, 19% required skin grafting compared with 36% in group B.
Mortality was 9.5% (group A) compared with 21% (group B). Length of stay in hospital was 7.2 days (group A)
compared with 16.2 days (group B).142

In a four-year retrospective case series (n=35), people who received immediate irrigation to their chemical burn
had significantly less incidence of full thickness injury and spent half as long in hospital.143

An eight-year retrospective case series (n=24) found that all people with delayed presentation (n=5) had deep
burns that required excision and grafting. All burns in this series were irrigated for 45 minutes to an hour at the
burns unit.144

However, a fourth retrospective case series (n=173) found no significant statistical difference in the number
of deep burns between those who had immediate irrigation of their wounds and those without immediate
irrigation (37.5 vs 46% respectively). Mean hospital stay was 5.8 and 4.8 days respectively (not statistically
significant).141


                                                                                                                                                             59
     Several non-systematic reviews were considered, all with consistent opinions regarding chemical burns to the
     skin. They made the following recommendations:
     1. Immediate removal of clothing and copious irrigation with water for a period of at least one hour.33,141,142,144-152
     2. No attempt should be made to neutralise an acid burn with an alkali as this may delay irrigation and cause
        more injury due to heat produced by an exothermic reaction.144,147-149,152
     3. There is a risk of systemic complications following chemical burns with hydrofluoric acid, formic acid, phenol,
        white phosphorus, nitrites and hydrocarbons.33,142,144-148,150-152
     4. Chemical burns meet the criteria for referral to a specialised burns unit.33,151

     Eye injury

      recommendations                                                                                                                                    grade

      All significant chemical injuries to the eye should be referred acutely to ophthalmology                                                                 C
      services.

      Treat all chemical burns to the eye with copious irrigation of water.                                                                                   C
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



     Chemical burns to the eyes are associated with residual visual impairment. Physical signs include
     blepharospasm, tearing, conjunctivitis and uncontrolled forceful rubbing of the eye. Rapid swelling of the
     corneal epithelium occurs and clouding of the anterior layers of stroma. Cells may be seen floating within the
     anterior chamber.

     Specialist assessment is required for early signs of corneal ulceration or perforation, and the possible late
     complications of cataract, secondary glaucoma, iridocyclitis and symblepharon.33


     Specific substances
     Hydrofluoric acid

      good practice point

      Anyone exposed to hydrofluoric acid should be promptly referred to a burns unit for definitive                                                            ✓
      treatment after appropriate first aid.
      This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



     Evidence statements
     • Hydrofluoric acid exposure of <2% TBSA can be fatal.33
     • Calcium gluconate gel, infiltration or intra-arterial and/or intravenous therapy corrects the hypocalcaemia of
       hydrofluoric acid burns and reduces pain.

     Hydrofluoric acid is a very strong acid. It is used widely, mainly in industrial settings, but it is also found
     domestically in rust removers and aluminium cleaners.154-161

     Features of hydrofluoric acid exposure include severe cutaneous burns, as well as possible systemic and lethal
     toxicity. Hydrofluoric acid penetrates the skin easily and enters the deeper tissues where it releases the fluoride
     ion. This ion readily binds with calcium and magnesium and it is this property that makes hydrofluoric acid
     especially dangerous.157,160 Even minor exposure to dilute solutions can cause problems in the deeper tissues,
     and symptoms and injury may be delayed.154,156,157

60
The systemic effects of hydrofluoric acid exposure are due to the fluoride ion binding with serum calcium
causing hypocalcaemia which can result in cardiac arrhythmias.154-157,160 Exposure to even small amounts of
hydrofluoric acid can result in death, usually due to ventricular arrhythmias.154,156,157,160,162-164

Evidence
Eleven observational studies or case reports154-156,159,161-163,165-168 and four non-systematic reviews157,158,160,164 were
reviewed for the guideline. No controlled human studies were located.

A prospective study of 10 people with hydrofluoric acid dermal burns of digits found rapid pain relief with
intra-arterial administration of 10% calcium gluconate. All had full functional recovery of their digits with good
cosmetic appearance.159

In a 10-year case series of treatments for hydrofluoric acid burns at one facility, 28 of 85 people were treated
with local infiltration of 10% calcium gluconate. Only one person (4%) had progression of their injury compared
with 14–70% in the other treatment groups. All people treated with calcium gluconate experienced pain relief
following the injections.161

Another retrospective case series of the authors’ institutional experience found 42 people with hydrofluoric
acid burns for the period 1977–1999. There were 11 recorded cases of hypocalcaemia, which were treated
successfully with oral and intravenous calcium supplementation. There were no deaths.165                                           7
In a report of seven cases with hydrofluoric acid burns to their hands and/or fingers, the authors reported good
pain relief after treatment with calcium gluconate. Calcium gluconate jelly (4%) was applied in five cases and
four had subcutaneous injections with 8.5% calcium gluconate.166

A case report of one person described the use of calcium gluconate gel topically, cutaneous and subcutaneous
injections of 10% calcium gluconate, magnesium chloride and 2% xilocain, and the intravenous use of calcium
gluconate which successfully corrects the hypocalcaemia.155

Another case report of one person exposed to a household rust remover described treatment with calcium
gluconate gel and intra-arterial calcium gluconate infusion with good outcome.167

In another report, two cases of skin injury and inhalational exposure to hydrofluoric acid were described which
were successfully treated with application of 2.5% calcium gluconate jelly and 5% calcium gluconate nebulised
solution.168

In a report of three cases of hydrofluoric acid skin injuries (TBSA 5–25%), two people died as a result of cardiac
arrest.163 Another reported a case of 15.5% TBSA hydrofluoric acid burn where the person died.154

The last case report was of a man with 44% TBSA burn from hydrofluoric acid who developed recurrent
ventricular tachyarrhythmias and subsequently recovered. The authors cite several fatal cases of ventricular
fibrillation reported in other studies following 2.5–22% full thickness TBSA burns due to exposure to more than
50% hydrofluoric acid.156

The four non-systematic reviews all have consistent findings. In a comprehensive literature review of
hydrofluoric acid burns,157 the authors described several reported cases of death from skin exposure of
2.5–10% TBSA. This is supported by the other reviews.158,160,164
• They all emphasise the importance of immediate, copious and prolonged lavage of the affected area with
   water.154,157-160,163
• For dermal exposure to hydrofluoric acid, the liberal and frequent application of 2.5% calcium gluconate gel
   is recommended by all authors.
• If pain relief is incomplete or symptoms recur, subcutaneous injections of calcium gluconate are indicated.
   Both these treatments have been shown to relieve pain.154,157,160,161,163
• Good results have been demonstrated with intra-arterial administration of calcium gluconate.
• Calcium gluconate is also administered intravenously to correct the hypocalcaemia due to hydrofluoric acid                   61
   exposure.154,157,160,161,163
     Phosphorus

      good practice point

      Anyone exposed to phosphorus should be promptly referred to a burns unit for definitive                                                    ✓
      treatment after appropriate first aid.
      This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.


     White phosphorus is commonly used as an incendiary in the manufacture of ammunition and is also used for
     the manufacture of certain fertilizers, fireworks and distress flares. It readily ignites in the presence of air.

     Evidence statements
     • The person should be transported with the affected area either submerged in water or saline or covered with
       water- or saline-soaked dressings.

     Evidence
     Four retrospective observational studies,142,151,152,169 two single case reports170,171 and three non-systematic
     reviews146,147,172 were reviewed. All selected articles had a consensus of opinion:
     1. The initial treatment consists of prompt removal of clothing and immediate copious irrigation with water.
     2. The person should be transported with the affected area either submerged in water or saline or covered with
        water- or saline-soaked dressings to prevent the re-ignition of the retained particles of phosphorus.

     Absorption of phosphorus can cause systemic complications including hypocalcaemia, hyperphosphataemia,
     cardiac arrhythmias, renal and hepatic toxicity, and sudden death.146,151,152,169




62
Chapter 8
Management of electrical injury

 recommendation                                                                                                                                     grade

 All electrical injuries should be referred to a burns unit.                                                                                              C
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



Evidence statements
• High-voltage electrical current damages deep tissues (muscle and nerves). This damage is sometimes not
  apparent at the initial inspection.
• Cardiac abnormalities can occur following electrical injury. These are frequently transient.

Electrical injuries can be divided into three groups: low-voltage (<1000V), high-voltage (>1000V) and lightning
strike.

Low-voltage electrical injuries can cause significant local contact burns and may cause arrhythmias or cardiac
arrest. They can cause tetany or muscle spasm that will prevent the person releasing the source of current and
may cause fractures.173-175                                                                                                                                         8
                                                                                                                                                         175
High-voltage electrical injuries result in severe skin burns and may cause respiratory and cardiac arrest. High-
voltage electrical current can lead to necrosis of muscle, bone and nervous tissue because of the development
of intense heat in bone, which is a poor conductor.176,177 Sometimes there are only localised skin injuries at the
entrance and exit sites, and a small skin burn or normal-looking skin can hide deep, massive tissue damage to
bone, muscles and nerves. There can be extensive arcing, flash and flame burns as well.178 People who suffer
a high-voltage injury are at increased risk of complications including compartment syndrome, cardiac damage
and neurological and ophthalmologic problems. Amputation rates above 50% have been reported.145

In lightning strike, a direct strike is usually lethal. In many cases, the majority of the current can pass over the
surface of the body (called ‘flashover’). Respiratory and cardiac arrest are common.179 Up to 74% of survivors
have significant permanent sequelae.173,180-184


Cardiac abnormalities
Evidence
Ten observational studies178,185-193 were found to be relevant. No controlled human studies were located.

In a prospective case series of admissions with high-voltage injury (n=15) to a burns unit over a year, 27% had
an abnormal ECG on admission, of which all reverted to normal over time. No arrhythmias developed during
their hospital stay. None had any clinical evidence of cardiac dysfunction.187

A four-year retrospective case series reported five people with high-voltage electrical injury.191 Two people had
ECG abnormalities acutely (one atrial fibrillation and one second-degree atrioventricular heart block). These
resolved by the third day post-injury. At both follow-up periods (two and six months), all ECGs were normal
and no clinical signs of cardiac damage were found. However, on thallium scintigraphy, there was evidence of
myocardial hypoperfusion in all cases.


                                                                                                                                                               63
     Another case series study found that 9 out of 10 consecutive people with high-voltage electrical injury had one
     or more significant cardiac rhythm and/or functional abnormalities during their stay in hospital. At follow-up
     (4–48 months after discharge) five people showed signs or symptoms of cardiac dysfunction.185

     In a retrospective case series of 48 consecutive people with high-voltage injury, eight (16%) had some cardiac
     event, four (8.3%) had a cardiac arrest at the place of injury, two (4.2%) had a myocardial infarction and two
     (4.2%) had a cardiac arrhythmia.190

     Another observational study found that 13 out of 24 (54%) people being treated for a high-voltage injury had
     evidence of myocardial injury.189

     A 10-year retrospective case series reported cardiac complications (either arrhythmias or ischaemia or
     myocardial infarction) in 10–46% of those with a high-voltage injury (n=36).188

     Another retrospective case series of children (n=185) admitted to a burns unit over a 10-year period found
     33% of high-voltage burns (n=58) required amputation and 29% had deep muscle involvement, and 7% had a
     cardiac arrest.178

     One retrospective case series of all admissions (n=179) to a burns unit over five years found a high incidence of
     compartment syndrome (54%) and amputation (42%) in those with a high-voltage injury (n=55).186

     Another observational case series study of all admissions with electrical burns (n=173) found a significant
     difference between the incidence of amputations between high- and low-voltage injuries (36.6% and 17.9%
     respectively; p<0.01). ECG changes were seen in 7% of the low-voltage group (n=132) and 12% of the high-
     voltage group (n=41).192

     This is supported by a retrospective case series (n=195) of high-voltage electrical injury admissions over a 19-
     year period. The authors found 56 (29%) people underwent fasciotomy within 24 hours of injury and 80 (41%)
     people underwent amputation.193


     ECG monitoring
      recommendations                                                                                                                                    grade

      Following electrical injuries people should receive a resting 12-lead ECG.                                                                              C

      If this initial ECG is normal in people with low-voltage injuries, there is no need for a repeat                                                        B
      ECG or for continuous monitoring.
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.



     Evidence statements
     • Electrical injury can trigger cardiac arrhythmias.
     • The incidence of ECG abnormality or arrhythmia developing after a normal initial 12-lead ECG in people with
       low-voltage electrical injuries is very low.

     Evidence
     Ten observational studies were identified as relevant, all with consistent results.194-203 Five studies were of
     children with mainly low-voltage electrical injuries194,195,200-202 and one was of children with mixed voltage
     electrical injuries.197 Two studies were of all admissions (adults and children) with low-voltage injuries196,199 and
     the other two were of all admissions with mixed-voltage injuries.198,203


64
A three-year prospective observational study (n=212) found that asymptomatic people with a normal ECG on
presentation after low-voltage injury do not need ECG monitoring.196 In 196 presentations there were eight
episodes with ECG abnormalities that required cardiac monitoring. There were no re-presentations with cardiac
arrhythmias after discharge in a four-year follow-up period.

A 10-year retrospective case series (n=38) of all admissions of children with mixed high- and low-voltage
injuries found that none of the children had or developed cardiac abnormalities.197 ECGs were recorded on
admission in all cases and all children were monitored for 24 hours or more. The only abnormalities were non-
specific temporary ST segment changes in the ECGs of three children.

Six other retrospective case series reviews of electrical injuries were found, four of children and two of adults.
One of children (n=44) found no arrhythmias developed over a 5- to 24-hour hour period if the person was
asymptomatic and had a normal ECG at presentation.201 Of the 40 low-voltage injuries, only one had an
abnormal ECG, which eventually resolved.

Another (n=151) found no adverse outcomes in those children with normal ECGs. Only one had an abnormal
ECG at presentation. One hundred and thirteen people (80%) had cardiac monitoring with no arrhythmias
noted. No late arrhythmias developed in the 112 children who were seen for follow-up.195

One other study in children (n=35) found an abnormal ECG in one of the 17 children in the low-voltage group in
which an ECG was obtained. The abnormality resolved within 24 hours. No serious arrhythmias were detected in
any child with a normal ECG on admission.202

Another study of 70 children with low-voltage electrical injuries found 2 out of 53 ECGs performed showed what
were considered benign arrhythmias. The authors concluded that cardiac monitoring is not required in people               8
who remain asymptomatic for four hours.200

Another study (n=20) of children and adults found no need to monitor if the initial ECG was normal and the
person was asymptomatic on presentation. One person had an arrhythmia that resolved after treatment and did
not recur during the next 24 hours.199

In the other study of children and adults (n=70), 11 developed an arrhythmia at the time of injury. Six died
in the emergency department and the rest were discharged without cardiac complications. One person had a
persistent right bundle branch block on discharge.198

One retrospective study (n=224) evaluated practice guidelines for the cardiac monitoring of children who
sustain an electrical injury. A total of 164 ECGs were done and 15 were abnormal. Eight of these were
determined not to be caused by the electrical injury. Twenty-nine people had cardiac monitoring, of which all
were normal except one with benign extrasystoles. One hundred and seventy-two people were seen for follow-
up and none had any untoward events. According to coroners’ records, none of the 224 people in this study
died due to this complication post-discharge from hospital.194

In another retrospective case series (n=145) four people had cardiac abnormalities (three had occasional
ectopic beats and the other developed atrial fibrillation after a high-voltage injury). All had these abnormalities
at the time of admission.203




                                                                                                                     65
66
Chapter 9
Pain management

Burn pain management
 recommendations                                                                                                                                    grade

 Immediately after the injury, cooling and covering the burn may provide analgesia.                                                                      C

 Paracetamol and NSAIDs can be used to manage background pain.                                                                                           C

 Consider administering opioids for intermittent and procedural pain.                                                                                    C
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




 good practice points

 Refer to secondary care if failing to manage dressing-change pain.                                                                                      ✓

 Consider the use of non-pharmacological approaches as a supplement to pharmacological                                                                   ✓
 management of pain.
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.
                                                                                                                                                                  9
Evidence statements
• Burn pain can be more complex than typical post-operative pain as it includes background, intermittent and
  procedural pain (due to dressing changes and other interventions).
• It is important to conduct a thorough pain assessment to determine whether background, intermittent or
  procedural pain is the greatest problem for the individual.
• The pain experienced following burns varies greatly from one individual to another.
• The worst pain score should be less than 5 on a scale of 0–10. Scores of 5 or higher interfere with sleep,
  activity and mood.

Burn injuries can cause intense and prolonged pain, made worse by the need to change dressings frequently
to prevent infection and aid healing. Pain associated with burn injury and treatment is often managed poorly;
reasons for this include failure to use and document pain scores from pain-measurement tools, unfamiliarity
with suitable analgesic regimes, and concerns about opioid side effects.204,205

Immediately after the burn injury, simple measures such as cooling and covering the burn can reduce pain.206
The treatment of severe pain beyond simple measures should include titration in intravenous opioids.

Burn pain is often more complex than typical post-operative pain.204 It can be divided into:
• background pain (associated with the injury)
• intermittent or breakthrough pain (intense pain episodes not relieved by routinely administered analgesics)
• procedural pain (pain related to dressing changes and other interventions).




                                                                                                                                                             67
     The aim of zero background pain in burn injuries is achievable and realistic. However, procedural burn pain
     as a result of dressing changes is difficult to assess and manage and there is little consensus on how best to
     determine or control this pain.

     Evidence
     Two guidelines were identified that dealt with pain management, but not specifically burns.207,208 A number
     of RCTs were identified.37,205,209-225 Most were very small and many were conducted among volunteers using
     experimentally induced burns.209,215,218-220,222,225 Overall their findings were of limited applicability to primary
     care. Two studies assessed the effect on pain response of different types of burn ointment compared with
     placebo205,221 and one evaluated local cooling.37 Three studies addressed the role of opioids in children,210,223,225
     five assessed distraction techniques such as massage,213,214 music therapy211,212 and sensory focusing217 and two
     compared ibuprofen with placebo.209,224 A further six assessed the role of other medications such as remifentanil
     and gabapentin,215 riluzole,216 lidocaine,218 dextromethorphan219 and ketamine.220,222

     Findings
     There was no consistent finding from the identified RCTs, which were performed in varying settings, with varying
     severity of burns and in varying groups of people. Most of the recommendations for management of pain are
     based on best practice in burns units.

     Pain management should be integrated into the person’s overall care plan. This plan should provide both
     pharmacological and non-pharmacological approaches. It has been suggested that background pain and pain
     resulting from procedures, such as dressing changes and physiotherapy, need to be evaluated and treated
     separately.226 It is important to conduct a thorough pain assessment to determine which type of pain is the
     greatest problem. The pain experienced by people with burns varies greatly from person to person.227 For this
     reason, treatment protocols stipulate low starting doses of analgesia and allow for adjustments to be made
     based on individual pain assessment. Pain measurement scales should be used to assess the degree of pain.
     A person’s worst pain score should be less than 5 (on a visual analogue scale of 0–10). Scores of 5 or higher
     interfere with sleep, activity and mood.228 Therefore, the goal at minimum should be to reduce pain to lower
     than this level.

     Analgesics should be given regularly to control background pain. Paracetamol and NSAIDS (eg, ibuprofen),
     alone or in combination with opioids, are often appropriate for use in people with small burn wounds.204 Aspirin
     products should be avoided because of platelet inhibition and the risk of bleeding.7

     People with burns may require treatment of procedural pain before dressing changes and during increased
     physical activity to facilitate cooperation during dressing change and physiotherapy, as well as minimise the risk
     of developing chronic pain.

     Use of opioids
     Opioid medications are used in children as well as adults for moderate to severe burn pain. Opioids are useful
     because they are available in a variety of dose forms that can support a person’s individualised needs. Long-
     acting opioids can be used for background pain and short-acting opioids can be used for painful procedures
     such as changing dressings. Opioids may be supplemented with anxiolytics to reduce anxiety, if necessary.
     There is little evidence to guide the choice of opioid medication. Morphine sulphate is the opioid analgesic
     standard. The pharmacokinetic properties are largely unchanged in burn-injured patients. Pethidine should be
     avoided because of side effects associated with the metabolite norpethidine, including dysphoria, agitation
     and seizures.204 During dressing changes, conscious sedation with an immediate-acting opioid such as fentanyl
     may minimise the risk of over-sedation. Other techniques for managing pain and anxiety in children during
     procedures include using inhaled nitrous oxide, ketamine either enterally or parenterally, or anxiolysis with a


68
benzodiazepine such as midazolam.229 Deep-sedation techniques as provided by an anaesthetist may include
dexmedetomidine or propofol infusion up to general anaesthesia.

Non-pharmacological interventions
Non-pharmacological interventions are recommended to supplement, not replace, pharmacological
management of pain. These interventions include cognitive behavioural therapy (CBT) (eg, relaxation, imagery),
hypnosis and physical therapies such as massage. They can provide people with a sense of control during
rehabilitation from their injuries.




                                                                                                                      10




                                                                                                                 69
70
Chapter 10
Psychological consequences of burn injury

Adverse psychological responses to trauma
 recommendations                                                                                                                                    grade

 Monitor people with burn injuries for signs of stress disorders or depression.                                                                          C

 Recognise and treat pre-existing disorders and comorbidities (including alcohol and drug                                                                B
 dependence) associated with post-traumatic stress disorder (PTSD).

 Refer people with acute or chronic PTSD for specialist mental health management.                                                                        C
 Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.




 good practice points

 Be aware of services that may be able to support families affected by the psychological                                                                 ✓
 impacts of burn injuries.

 Be aware of the increased risk of sleep disorders after burn injuries.                                                                                  ✓
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.


Burn injuries constitute significant trauma and can cause or exacerbate psychological problems such as acute
or persistent stress disorders and depression. Psychological trauma may be compounded by injury-related
phenomena such as pain, physical disability and disfigurement. The psychological consequences of burns to a
                                                                                                                                                                  10
child are likely to involve other family members as well.

Psychological reactions to trauma are categorised by the timeframe since the event (see Table 10.1).




                                                                                                                                                             71
     table 10.1: diagnosis according to duration of stress symptoms

      duration of
      symptoms                   diagnosis                  comments

      Less than one month        Acute stress disorder      These are symptoms that occur in the immediate
                                 (not PTSD)                 aftermath of the stressor and may be transient and
                                                            self-limited. Although not yet diagnosable as PTSD, the
                                                            presence of severe symptoms during this period is a risk
                                                            factor for developing PTSD.

      One to three months        Acute PTSD                 Active treatment during this acute phase of PTSD may
                                                            help to reduce the otherwise high risk of developing
                                                            chronic PTSD.

      Three months or longer     Chronic PTSD               Long-term symptoms may need longer and more
                                                            aggressive treatment and are likely to be associated with
                                                            a higher incidence of comorbid disorders.

     Reproduced from: Foa EB, Davidson JRT, Frances A. The expert consensus guideline series: Treatment of
     posttraumatic stress disorder. J Clin Psychiatry 1999;60 (Suppl 16).


     Acute stress disorder
     Evidence statements
     • The onset of acute stress disorder in the first month after a burn injury increases the risk of subsequent PTSD.

     A diagnosis of acute stress disorder can be made as early as three days following trauma. American Psychiatric
     Association diagnostic criteria230 require the presence of at least three of the following dissociative symptoms:
     • depersonalisation
     • derealisation
     • time distortion and/or daze
     • numbing and amnesia.

     In addition one or more symptoms must be present from each of the three PTSD clusters, namely re-experience
     of the traumatic event, avoidance and hyperarousal (see Appendix C).

     The prevalence of acute stress disorder after burns is unclear, partly due to variability in the assessment tools
     and diagnostic criteria used. A systematic review of relevant studies reported a range of 11–32% in adults.123
     All the studies were small with a high potential for bias. Another small study, involving 63 children aged one to
     four years hospitalised with burn injuries, and their parents, reported symptoms of acute stress in nearly 30%
     (15/52) of the children analysed.231 The authors identified a pathway whereby pain in the child was strongly
     associated with acute parental stress, and parental stress led to acute stress in the child.

     Predictors of acute stress disorder found in the literature included burn size, poor pre-burn mental health and
     attribution of blame for the injury to a third party.123

     People with acute stress disorder are at high risk of subsequent PTSD. In one study of 83 adults hospitalised
     with burns,232 19% (16/83) were diagnosed with acute stress disorder and all but one subsequently developed
     PTSD.


72
POST-TRAUMATIC STRESS DISORDER
Evidence statements
• There is evidence of an increased risk of PTSD after burns.
• There is some evidence that the incidence of PTSD is related to the size and location of the burn.
• CBT and selective serotonin reuptake inhibitors (SSRIs) have been shown to relieve the symptoms of PTSD
  resulting from non-burn events.

A diagnosis of PTSD is made when a person: has experienced a traumatic event with actual or perceived
threat of serious injury or death to self or others; has reacted with intense fear, helplessness or horror; and
meets symptom criteria in three primary clusters (re-experience of traumatic event, avoidance or numbing,
hyperarousal) over a period of more than one month.

The DSM-IV. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)230 criteria (see Appendix C) for
PTSD are used to diagnose PTSD. The diagnosis requires a combination of symptoms including at least one
re-experiencing symptom, three symptoms of avoidance and emotional numbing, and two hyperarousal
symptoms.

Evidence on the prevalence of PTSD is inconsistent. Some studies include only inpatients while others include
outpatients. Most have relatively small sample sizes and some exclude personal psychiatric history. Moreover, a
variety of assessment methods have been used.

Three studies which used validated assessment methods found prevalence rates of 20–45% at a follow-
up period of 6–12 months in adults admitted to hospital after burns. These studies were small with a high
likelihood of bias.123

Evidence
Evidence on predictors for PTSD is also inconsistent. The only study in the systematic review123 without a high
likelihood of bias233 found a significant association between chronic PTSD and a history of PTSD symptoms,
female sex, size and location of burn. This study did not assess pre-burn mental health or pre-burn history of
substance abuse, both of which were identified in other studies as significant predictors of PTSD.
                                                                                                                          10
There is very little research relating to the treatment of PTSD in people with burn injuries. One RCT234 allocated
participants to an individual and/or couple psychological debriefing intervention group or a control group that
received no intervention. Of the 110 participants who were assessed, 26% in the intervention group had PTSD
at 13 months follow-up compared with only 9% in the control group. These findings are consistent with other
studies showing that single-session debriefing may be actively harmful.123

Esselman et al123 found no convincing evidence of interventions to reduce the risk of developing PTSD in
people with burns. However, there has been very little research in this area and effective pharmaceutical and
psychological treatments have been reported in the general trauma literature. CBT has been shown to be
beneficial,235 in particular, exposure therapy236 and stress inoculation training.237 SSRIs are also effective and
are recommended as first-line agents in the pharmacotherapy of PTSD.238 Treatment techniques need to be
researched and validated with people with burns.


Depression
Evidence statement
• There is some evidence of an increased risk of depression after burns.




                                                                                                                     73
     Evidence
     People with burns are also at risk of depression. The relevant evidence is scanty, consisting of six small studies
     with a very high likelihood of bias.123

     Estimates of the prevalence of depression in people with burns vary greatly, reflecting disparity in the
     assessment tools and diagnostic criteria used, the timing of assessment and the populations sampled. Rates of
     16–53% are reported at various follow-up points from 3 days to 32 years, with no consistent trend over time.123

     Predictors of post-burn depression in the literature include pre-burn mood disorders, burn severity and location
     and style of problem-solving.123

     No therapeutic studies for depression in burn survivors were found. However, the general literature supports the
     use of SSRIs for depression.239


     Sleep disorders
     Evidence statement
     • There is a high risk of sleep disorders after burn injury, which is compounded by pain and by stress
       disorders.

     Evidence
     The Esselman et al systematic review123 reviewed 16 studies of secondary sleep disorders, including 11 studies
     of sleep disorders secondary to burn injuries. All these studies had a relatively high risk of bias. Secondary
     sleep disorders include insomnia, hypersomnia, nightmares, night terrors and sleepwalking.230

     Difede et al232 reported that in their study of 83 adults hospitalised with burns, the most common symptom
     of stress, reported by 76% of participants with or without acute stress disorder (ASD), was difficulty falling
     asleep and staying asleep. A small paediatric inpatient study (n = 25) also found a high prevalence of sleep
     disorders, such as nightmares (88% of participants), problems with sleep onset (68%) and problems with sleep
     maintenance (88%).240 Similarly, such symptoms were reported in 73% of 74 participants a week after discharge
     from hospital.241

     During the first six months after burns or other trauma, the incidence of insomnia reported in the literature
     ranged from 37% to 51% and at one year was 22–37%. Although insomnia thus tended to improve over the first
     year, nightmares were reported in up 30% of participants at both six months and one year post-burn.123

     Esselmann et al123 reported that both early and late post-burn studies indicated the intertwining of sleep
     disorders and symptoms of ASD, PTSD and depression. Pain is another factor that may compound sleep
     disorders.241,242

     There is no reliable evidence on pharmacological or behavioural treatments for sleep disorders after burns. CBT
     has been found effective for treating sleep disorders in medical patients.123


     Post-traumatic stress disorder and parents of children with burns
     Evidence statements
     • There is evidence of an increased risk of acute stress or PTSD for the parents of children with burns,
       especially large or painful burns.
     • How well a child copes with a burn injury will depend on how well the family is coping with the trauma.
     • Resources are available for people who have experienced burn trauma and for their families (see Appendix
       D).

74
Evidence
There is some evidence that the parents of children with burns are at increased risk of PTSD, although the
relevant studies are all very small with cross-sectional design and a high likelihood of bias.

A study (n=25) of children and adolescents with burns reported that 52% of mothers had past or present
PTSD,243 the most significant predictive factor for maternal PTSD in the mother being the size of the burn.
Another study reported a correlation between maternal and child stress syndromes in the families of paediatric
burn survivors.244 Similarly, a recent study (n=52 analysed) in younger children (aged one to four years) reported
a vicious cycle whereby pain in the child caused acute stress disorder in the parents, which then increased the
likelihood of acute stress in the child.231




                                                                                                                          10




                                                                                                                     75
76
Chapter 11
                  ¯
Burn injuries in Maori

 good practice points

 Be aware that Ma tamariki (children) are at increased risk of burn-related injuries and
                ¯ori                                                                                                                       ✓
 deaths.

 Consider ways to deliver care that will overcome access barriers, if necessary, such as nurse                                             ✓
 home visiting for dressing changes.
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.




Evidence statements
• Tamariki are at increased risk of burn-related injuries and deaths.
• Tamariki have a relatively high level of involvement in home activities that carry a burn or scald risk.


Background
Every year, about seven or eight New Zealand children aged 15 years and under die as a result of burns or
scalds. In most cases fatalities are the result of house or car fires. Over two-thirds of those who die are under
the age of five years10 and over one-third are Ma 11
                                                  ¯ori.

Analysis of New Zealand Health Information Service hospitalisation data for injury between 1985 and 1994
indicates that Ma children are at high risk of burn-related injuries.245 Injuries from fire and burns account for
                 ¯ori
20% of all injuries that require hospital care for children under one year, making this the second most common
cause of hospitalisation due to injury in this age group. A further 18% of injuries are caused by contact with hot
water or hot substances. During the same period, 5% of injury hospitalisations for kauma   ¯tua (elder) aged 65
years or older were for burns or injury as a result of fire.
                                                                                                                                                    11
Prevention
                                          ¯ori
Tamariki form the largest group of the Ma population. If they continue to be over-represented in burns
                                                                                          ¯nau, the hapu and
statistics this will impact on the hauora (health and wellbeing) of the individual, the wha            ¯
iwi now and in the future. The following studies provide some guidance in the future planning of prevention
strategies. There are also further suggestions in Chapter 14, Implementation and evaluation.

Tamariki (aged 7–13 years) have been found to have a higher level of involvement in home activities that
carry a burn or scald risk, such as running a bath or using matches.29 These findings suggest a difference in
                                                 ¯ori
children’s involvement in household tasks in Ma homes. This may be due to a variety of cultural, social and
economic factors. Prevention strategies need to systematically identify and remove barriers to developing safe
environments.

Tamariki were found to have a generally good understanding of safety knowledge in this survey,29 recognising
the correct safety action to take in the event of a fire or when they received a burn. In contrast, an Auckland
                                  ¯ori
study in 2002 suggested that Ma may be less likely to use cold water therapy on burns compared with people
of European descent.1
                                                                                                                                               77
     Primary care practitioners can contribute to the prevention of burn injuries by providing information on the
     prevention of burn injuries and appropriate first aid management and supporting local initiatives in primary
     prevention.


     Delivery of care
     There are a variety of factors that may influence access to and utilisation of primary care services. Financial,
     geographical or cultural barriers may be an issue for some Ma  ¯ori. Aside from the cost of services, some Ma  ¯ori
     may have different attitudes and beliefs concerning illness and doctors, and different cultural patterns of help-
                 ¯ori
     seeking. Ma are more likely to forgo general practitioner visits and prescription items (11.4% vs 5.8% for the
     total population) or prescription items alone (13.0% vs 4.6% for the total population) because of cost.246 Issues
     such as lack of transport or access to a telephone will also make access to primary health care more difficult. As
                       ¯ori
     a result, some Ma individuals with minor burns may postpone visiting a general practitioner or be reluctant
     to continue with frequent visits for dressing changes. These are things that may apply to some Ma    ¯ori, but other
        ¯ori
     Ma will have very different social circumstances, values, beliefs and health care practices. Primary care
     practitioners can assist in removing the barriers to care by considering alternative ways to deliver care, such as
     nurse home visiting for dressing changes.

     There are reports of a number of traditional herbal remedies playing a part in the treatment of burns and scalds
     among Ma  ¯ori. For further information see Chapter 13, Complementary and alternative medicines.




78
Chapter 12
Burn injuries in Pacific peoples

 good practice points

 Be aware that Pacific children may be at increased risk from hot water scalds.                                                             ✓

 Consider ways to deliver care that will overcome access barriers, if necessary (such as nurse                                             ✓
 home visiting for dressing changes).

 Be aware that language can be a barrier. Encourage a bilingual family member or practice                                                  ✓
 nurse to assist with communication. Ideally, Pacific Island population-specific translators
 should be made available to services that provide for Pacific peoples.
 This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.



Evidence statements
• Pacific children aged 0 to 4 years appear to be at increased risk from hot water scalds.
• Pacific children have a higher level of involvement in home activities that carry a burn or scald risk.

Pacific children aged 0 to 4 years appear to be at increased risk from hot water scalds.247 SafeKids New Zealand
has reported data gathered by the New Zealand Health Information Service showing that hot water scalds are
the second most common cause of hospitalisations for unintentional injury among Pacific children.247


Prevention
A study in Waitakere City showed that Pacific children (aged 7–13) had a higher level of involvement in home
activities that carry a burn or scald risk, such as running a bath or using matches.29 These levels of involvement
in activities with higher burn and scald risk for the child may be due to a variety of cultural, social and
economic factors. Prevention strategies need to systematically identify and remove barriers to developing safe
environments in order to be effective with Pacific children and their families.


Pacific concepts of health and illness
Pacific peoples in New Zealand are a diverse population, coming from 22 different island nations, each with                                          12
a distinct language and culture. Many Pacific peoples view health in a holistic way, as the total wellbeing of
the individual within the context of the family and the community. In addition to physical, mental and social
wellbeing (the aspects of health defined by the World Health Organization), many Pacific peoples regard
spiritual wellbeing as equally essential to health.248

Health care practitioners are regarded as authority figures by many Pacific peoples. As a result, out of respect,
individuals may often be hesitant to say what they really think to the doctor or nurse. For example, they may
say that they understand an explanation given regarding treatment even when they do not. As it is respectful to
respond politely with affirmation to a person of higher status, the individual may agree to follow-up even when
they know they may not be able to afford the fee for the follow-up consultation. In addition, the individual may
not attend the follow-up appointment if they have not complied with the recommended treatment, conscious
that the doctor may be disappointed.
                                                                                                                                               79
     There are reports of a number of traditional herbal remedies playing a part in the treatment of burns and scalds
     among Pacific peoples. For further information see Chapter 13, Complementary and alternative medicines.


     Delivery of care
     There are a variety of factors that may influence access to and utilisation of primary care services by Pacific
     peoples. Financial, geographical or cultural barriers may be an issue for some Pacific peoples. Pacific peoples
     are over-represented in the lower end of the socioeconomic spectrum compared with other New Zealanders. As
     a result, some Pacific peoples may experience financial barriers to care. Pacific peoples are more likely to forgo
     general practitioner visits and prescription items (8.0% vs 5.8% for the total population) or prescription items
     alone (8.4% vs 4.6% for the total population) because of cost.246 Aside from the cost of services, some Pacific
     peoples may have different attitudes or beliefs concerning illness or doctors. Issues such as lack of transport
     or access to a telephone will also make access to primary health care more difficult. As a result, some Pacific
     individuals with minor burns may postpone visiting a general practitioner or be reluctant to continue with
     frequent visits for dressing changes.

     Language is a major barrier to health care for some Pacific peoples. Good primary care practice would include
     encouraging a bilingual family member or practice nurse to assist with translation. Ideally, Pacific Island
     population-specific translators should be made available to services that provide for Pacific peoples.

     These are things that may apply to some Pacific peoples, but other Pacific peoples will have very different social
     circumstances, values, beliefs and health care practices.




80
Chapter 13
Complementary and alternative medicines
Evidence statements
• Systematic reviews of hyperbaric oxygen therapy have found that there is insufficient evidence to support the
  routine use of hyperbaric oxygen therapy in the treatment of thermal burns.
• There is some evidence that honey helps superficial and partial thickness burns to heal faster compared with
  conventional dressings, but more research is needed.
• There are no studies on the use of manuka honey as a topical agent in the treatment of burns.
• There is no convincing evidence of any benefit in using Aloe vera for thermal burns.
• There is no convincing evidence to support the use of moist exposed burn ointment for burns in preference to
  conventional dressings.

Evidence
There is very little reliable evidence on the use of complementary and alternative medicines for burns.

Two systematic reviews of the use of hyperbaric oxygen therapy for the treatment of burns reported that there
was insufficient evidence to support its routine use.133,249

A good-quality systematic review of Aloe vera for wound healing250 found no RCTs involving accidental burns. In
a small (n=27) non-randomised split-sample study of partial (dermal) and full thickness burns, the distal part of
each burn was treated with Aloe vera and the proximal with paraffin gauze.251 Time to healing was significantly
faster with Aloe vera, with only minor adverse effects (such as transient discomfort and pain) in both groups.

There were several studies on moist exposed burn ointment but only four were RCTs and none was blinded. One
of these studies, reported in three publications,205,252,253 compared time to healing, pain and cost-effectiveness
in moist exposed burn ointment and conventional dressings such as paraffin gauze and silver sulphadiazine.
Outcomes were similar in both groups.

One large unblinded RCT121 compared moist exposed burn ointment with silver sulphadiazine for time to
healing, pain and rate of infection in 508 people of varying age hospitalised with differing types of burn. In the
moist exposed burn ointment group, partial thickness (dermal) burns healed significantly faster with less pain
(p<0.01) and a significantly lower incidence of infection (p<0.01). However, the quality of this study is uncertain,
and as noted elsewhere in this guideline prolonged use of silver sulphadiazine cream is not recommended as
it may delay healing. Two other small unblinded RCTs of moist exposed burn ointment,254,255 both by the same
author, reported that moist exposed burn ointment may be more cost effective for second-degree (dermal) burns
than a range of standard therapies. However, ‘standard therapies’ in these studies included a wide variety of
dissimilar comparators.

There were six fair-quality RCTs of honey (non-manuka honey) for partial (dermal) and full thickness burns, all
conducted without blinding by the same research group in India.95-97,103,104,256 Five95-97,104,256 included 50–100
participants and one103 included 900 participants. In four95-97,104 of these studies, superficial and partial
thickness (epidermal and dermal) burns dressed with honey healed significantly faster than those dressed
with conventional dressings, with lower bacterial colonisation rates. The majority of these studies compared
honey with the prolonged use of silver sulphadiazine cream. The sixth study256 compared honey with tangential
excision and grafting for ‘moderate’ burns and reported that outcomes were better with grafting. Other RCTs of


                                                                                                                      81
     honey conducted by the same group were not considered because they used comparators unlikely to be used in
     New Zealand, such as amniotic membrane and potato peel.

     Small RCTs found no evidence of healing effect for antioxidant ointments91 or for calendula or bovine fibrinolysin
     ointment for burns,257 nor for homoeopathic cantharis for burn pain.258

     There are reports that harakeke,259 also known as New Zealand flax, has played a part in the treatment and
     healing of burns and scalds among Ma                  ¯ori
                                            ¯ori. Another Ma remedy in the treatment of burns and scalds is
     kawakawa leaves and bark.260 As no RCTs were found to support the use of these remedies, the Guideline
     Development Team does not recommend their use as a primary or sole method of care.

     Some Pacific peoples may use traditional medicine as a first-line treatment for burns/illnesses, or if they feel
     that Western medicine has not worked. There are reports of numerous medicinal plants being used for burns in
     the South Pacific region. A few examples include the scraped bark of ‘ifi’ in Tonga (Inocarpus fagifer, also known
     as Tahitian chestnut), the grated seed of ‘utu’ (Barringtonia asiatica) and the starch from the root ‘pia’ (Tacca
     leontapetaloides) in the Cook islands.261,262 As no RCTs were found to suppport the use of these herbal remedies,
     the Guideline Development Team does not recommend their use as a primary or sole method of care.




82
Chapter 14
Implementation and evaluation

Overview
The aim of this guideline is to ensure that for individuals with burn injuries there:
• is appropriate initial assessment and care in the primary care setting
• are more appropriate referrals to secondary care and regional burns units
• is more information sharing between providers (common language and tools)
• is more uniformity in burn assessments and outcome measurements
• is improved targeting and use of effective interventions.


Distribution strategies
Publication of the full guideline
The full guideline is available free for download from the ACC website (http://www.acc.co.nz) and the NZGG
website (http://www.nzgg.org.nz). The NZGG website also provides supporting documents, including the search
strategy and evidence tables for the guideline. Print copies are also available.

It is recommended that efforts are made to create weblinks to the full guideline and summary from medical
colleges, professional bodies and other interest groups.

Quick reference clinical format
A summary booklet is being produced with the key messages and algorithms to guide the management of
people with burns and scalds in primary care. The availability of a quick reference summary will make the use of
the guideline recommendations easier for clinicians.

Dissemination
The full guideline/summary should be distributed to the following groups:
• general practitioners
• primary health care nurses
          ¯ori
• iwi/Ma health providers
• Pacific health providers
• ANZBA
• burn support groups
• safety and prevention groups
• armed services, fire services, and ambulance services
• district health boards
• primary health organisations
• independent practitioner associations
• academic lecturers/curriculum planners involved in medical training                                                   14
• medical colleges/professional bodies
• pharmacists.



                                                                                                                   83
     Promotion
     Guideline launch
     The Guideline Development Team suggests that the guideline be launched at an appropriate event or conference
     to signal the start of the implementation phase. Such an event might be a conference held by the Royal New
     Zealand College of General Practitioners or other primary health care organisation, or a conference focusing on
     wound care. Further opportunities for presentations at other relevant local meetings and conferences will be
     pursued to help primary care practitioners become familiar with the guideline.

     Media
     The guideline needs to be promoted in the media, including the local medical press. Publicity needs to
     encompass journals and health professional publications such as: New Zealand Medical Journal, New Zealand
     Nursing Journal and NZ Doctor. Mainstream media can also be targeted through the use of media releases to
                                                                  ¯ori
     newspapers and television programmes. This could include Ma and Pacific magazines, radio and television.

     Promoting safety messages
     It is recommended that the development of consumer information be funded to inform people about safety
     measures to prevent burns and scalds.

     Additional strategies should be considered to promote burns safety measures through primary care, as young
     children, the population most at risk, are usually seen routinely.

                                                ¯ori
     Consumer information should be offered in Ma and Pacific languages in written and oral forms, eg, CDs and
     DVDs.


     Education
     Professional education
     Professional education activities could include:
     • Organising information and education seminars/workshops (based on the guideline) for practitioners,
        primary health organisations, independent practitioner associations and district health boards.
     • Specific educational initiatives and ongoing updates for particular groups (eg, general practitioners, practice
        nurses).
     • Local continuing medical education activities that include this guideline as part of their programme.
                                                                                                             ¯ori
     • Developing local strategies to reduce barriers to follow-up care for people with burns, particularly Ma and
        Pacific peoples.

     Community education
     Community education activities could include:
     • School-based education to teach safe practices to children, which is tailored to meet the needs of children
       from different communities.
     • Education to teach safe practices to children under five years old.
     • Encouraging existing home-visit providers to families with young children (particularly with infants 12–18
       months of age) to remind them about burn risk and burns first aid.
     • Offering training to providers of home-visit services (eg, Plunket, Tamariki Ora), pre-school units and health
       clinics where pre-schoolers are seen.
                                             ¯ori
     • Designing a consumer resource for Ma in consultation with iwi providers.
     • Monitoring the educational information that is given out.


84
Research and evaluation
Research
There is a lack of RCTs relating to burn assessment and treatment. The Guideline Development Team suggests
that a Delphi process be used to formally rank the research interest areas in burns. The Delphi process is
a structured process that uses a series (or rounds) of questionnaires to gather information and rounds are
continued until ‘group’ consensus is reached. This process is popular in health research because it allows
the inclusion of a large number of individuals across diverse locations and areas of expertise and avoids the
situation where a specific expert might be anticipated to dominate the consensus process.263

The following areas for further research were identified:
• cost-benefit analyses of using dressings. What is cost-effective wound care for burn injuries in primary care?
                                         ¯ori
• a targeted prevention campaign for Ma and Pacific children aged five years and under (visiting mothers
  who have children 12–18 months to remind them about burn risk and first aid for burns) and a follow-up on
  its effectiveness
• a study to investigate the effectiveness of traditional remedies (such as kawakawa) on superficial and mid
  dermal burns
• a study to investigate the effectiveness of various interventions for scarring following burn injuries
• a study to identify the resources and support services needed for people with burn injuries in New Zealand.

Evaluation
An appropriate response to this guideline will be a decrease in the number of late referrals to burn services.
Successful implementation of the guideline may result in an increase in overall referrals to secondary care.
Another outcome of interest would be the incidence of skin grafting and scarring following burn injuries.
Currently, there is no benchmark for this information to measure any change in these areas.

The actual impact of this guideline in practice can be evaluated by the collection of the following information:
• the effect on referrals for hospital-level care or regional burns unit care.
  Making a comparison of baseline referral information before the distribution of the guideline, and referral
  numbers and patterns after guideline implementation
• referral indications for hospital-level care or regional burns unit care.
  Making a comparison before and after referral indications.




                                                                                                                        14




                                                                                                                   85
86
Appendices

A.   Evidence and recommendation grading system

B.   Wound care options

C.   DSM-IV criteria for post-traumatic stress disorder

D.   Useful resources




                                                          87
88
Appendix A:
Evidence and recommendation grading
system
Studies were graded using a two-tier system that is detailed in the Handbook for the Preparation of Explicit
Evidence-Based Clinical Practice Guidelines, published in November 2001 by NZGG. This system has been
adapted from other grading systems currently in use, in particular the Scottish Intercollegiate Guideline Network
system.

The literature searches for this guideline concentrated on finding high-grade evidence to answer the identified
clinical questions, such as systematic reviews, RCTs and, where these were not available, observational studies
such as well designed cohort and case control studies. Only these types of study design were graded. Where
these types of study were not available, less rigorous study designs such as cross-sectional studies and case
studies were considered but were not formally graded.

The two-tier system follows this process:
1. Critical appraisal of individual relevant studies (identified from the searching) and assigning of a level of
   evidence for the first section of the GATEFRAME checklist that is incorporated into the evidence tables. A
   random sample of appraisals in the guideline was performed independently by two assessors and the results
   compared.
2. Joint consensus by the Guideline Development Team on the issues of volume, consistency, clinical relevance
   and applicability of the body of evidence in the evidence table (filling out the NZGG Considered Judgement
   form for each clinical question) and the development of graded recommendations that attempt to answer the
   clinical questions posed.


Developing recommendations
Recommendations were formulated by joint meetings of the multidisciplinary Guideline Development Team. The
Team considered the entire body of evidence (summarised in the evidence tables) and filled out Considered
Judgement forms for each clinical question that was identified as being relevant to the guideline (see http://
www.nzgg.org.nz). The following aspects were discussed: volume of evidence, applicability to the New Zealand
setting, consistency and clinical impact, with the aim of achieving consensus. Consensus was sought and
achieved over the wording of the recommendation and grading. In this guideline, where a recommendation is
based on the clinical experience of members of the Guideline Development Team, this is referred to as a good
practice point.




                                                                                                                    89


                                                                                                                         A
     Grading of recommendations
     The NZGG grades of recommendation are as follows:

      recommendations                                                                                                                           grade

      The recommendation is supported by good evidence (where there are a number of studies                                                       A
      that are valid, consistent, applicable and clinically relevant).

      The recommendation is supported by fair evidence (based on studies that are valid, but                                                      B
      there are some concerns about the volume, consistency, applicability and clinical relevance
      of the evidence that may cause some uncertainty but are not likely to be overturned by other
      evidence).

      The recommendation is supported by international expert opinion.                                                                            C
      Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations.



      good practice point

      Where no evidence is available, best practice recommendations are made based on the                                                        ✓
      experience of the Guideline Development Team, or feedback from consultation within
      New Zealand.
      This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.




90
Appendix B: Wound care options
This table describes various wound products and their uses. It has been compiled using information from
manufacturers and Guideline Development Team experience in burn care.

                                                                                                 wear
 name              indications          advantages                      disadvantages            time

 Paraffin or        Burns with           Covers and protects             Limited moisture         24–48
 silicone-         minimal exudate                                      retention                hours
                                        Non-sensitising
 impregnated
                   Grafts when                                          May cause trauma on
 fibres                                  Non-irritant
                   healing well                                         removal

                                                                        Requires a secondary
                                                                        dressing to keep it in
                                                                        place and maintain
                                                                        moisture balance

 Hydrocolloids     For burns with       Maintains moisture balance      Not recommended          Three to
                   light to moderate                                    for heavily exudating    seven days
                                        Can help with autolytic
                   exudate                                              burns, sinuses or
                                        debridement
                                                                        tracts
                   Sloughy and
                                        Self-adhesive and moulds
                   necrotic burns                                       May tear fragile
                                        well
                                                                        surrounding skin on
                                        Impermeable to bacteria and     removal
                                        contaminants
                                                                        Dressing odour can be
                                        No secondary dressing           offensive
                                        required
                                                                        Gel can be mistaken
                                                                        for pus

 Transparent       Superficial burns     Impermeable to bacteria and     Not recommended for      One to
 films                                   contaminants                    exudating burns or       three days
                   Burns with little
                                                                        new burns
                   or no exudate        Supports autolytic
                                        debridement                     Requires dry border to
                   As protection
                                                                        adhere
                   for fragile          Allows visualisation of the
                   compromised          wound                           Can be difficult to
                   areas of                                             handle
                                        No secondary dressing
                   unbroken skin
                                        required                        May not stay in place
                                                                        in areas of moisture

                                                                                                 Continued …




                                                                                                               91


                                                                                                                    A
                                                                                               wear
     name         indications         advantages                     disadvantages             time

     Hydrogels    For necrotic and    Rehydrates the wound bed       Not recommended for       One to two
                  sloughy burns                                      moderate or heavily       days
                                      Aids autolytic debridement
                                                                     exudating burns
                  Deep-cavity burns
                                      Fills dead space in cavity
                  with necrosis and                                  Requires secondary
                                      burns
                  slough and light                                   dressing
                  exudate             Small amount of absorptive
                                                                     Can macerate wound
                                      action
                                                                     edges if not carefully
                                      Can be soothing and reduce     applied
                                      pain
                                                                     Can soak into some
                                                                     secondary dressings

     Alginates    For partial and     Absorbs 20 times its own       Not recommended           One to four
                  full thickness      weight                         for lightly exudating     days
                  burns with                                         wounds or wounds
                                      Forms a gel over wound
                  moderate to                                        with eschar (a dry scab
                  heavy exudate       Supports debridement           or slough)

                  Wounds with         Fills dead space (comes in     If dries out can be
                  undermining or      wicks as well as sheets)       difficult to remove
                  sinus tracts        Easy to remove if gelled       Requires a secondary
                  Wounds with         Easy to use and cut to fit      dressing
                  necrotic tissue
                  with exudate

                  Infected wounds

     Hydrofibres   Partial thickness   Absorbs 25 times its own       Not recommended for       1–14 days
                  burns               weight                         dry burns – will adhere
                                                                     to a dry wound
                  Moderate to         Vertically wicks fluid
                  heavily exudating   therefore controls lateral     Not recommended for
                  burns               spread of exudate              burns with eschar

                                      Can fill dead space (comes in   Requires a secondary
                                      wicks as well as sheets)       dressing to secure it

                                      Tensile strength comparable
                                      to gauze

                                      Forms a gel over wound

                                      Reduces maceration of
                                      surrounding skin

                                      Easy to use and cut to fit

                                      Easy to remove if gelled

                                                                                               Continued …
92
                                                                                                  wear
name              indications         advantages                      disadvantages               time

Foams             Partial and full    Non-adherent                    Not recommended for         One to five
                  thickness burns                                     burns with little or no     days
                                      Does not cause trauma on
                  with minimal                                        exudate
                                      removal
                  to moderate
                                                                      May macerate
                  exudate             Easy to use and apply
                                                                      surrounding skin if it is
                  Secondary           May be used under               not protected
                  dressing            compression
                                                                      Needs to be taped if
                  to provide
                                                                      it is in non-adhesive
                  additional
                                                                      form
                  absorption




Silver            Partial and full    Generally absorbs exudate       Not recommended for         1–14 days
dressings         thickness burns                                     dry burns or burns with     depending
                                      Delivers antibacterial/
                                                                      eschar                      upon
Different         Burns that appear   antimicrobial component
                                                                                                  product
products act      to be infected      to wound bed – effective        Manufacturers’
                                                                                                  chosen
differently at                        against gram-positive and       instructions need
the wound bed                         gram-negative bacteria,         careful consideration
as per dressing                       fungal infections               prior to application
type, eg,                                                             depending on product
hydrofibre or                                                          chosen
wound contact
                                                                      Requires secondary
dressing
                                                                      dressing to secure

Silver creams     Partial and full    Maintains moisture balance      Non-absorptive              Daily
                  thickness burns                                                                 dressing
                                      Antibacterial/Antimicrobial     Can cause its own
                                                                                                  required
                  Dry eschars         to multiple organisms           pseudo eschar which
                                                                      can be difficult to
                  Infected burns      Antibacterial effect
                                                                      remove
                                      penetrates eschar
                                                                      Prolonged use is
                                      Aids in autolytic debridement
                                                                      detrimental to wound
                                      Comfortable for person          cells and can delay
                                      Easy to apply                   healing

                                                                      Requires a secondary
                                                                      dressing




                                                                                                               93


                                                                                                                    A
94
Appendix C:
DSM-IV criteria for post-traumatic stress
disorder
The following table has been reproduced from the DSM-IV criteria.230

The diagnosis of PTSD requires a combination of symptoms including at least one re-experiencing symptom,
three symptoms of avoidance and emotional numbing, and two hyperarousal symptoms.

                    The person has been exposed to a traumatic event in which both of the following have

     A.             been present:
                    1. The person experienced, witnessed or was confronted with an event or events that
                       involved actual or threatened death or serious injury, or a threat to the physical
                       integrity of self or others.
                    2. The person’s response involved intense fear, helplessness, or horror. Note: In children,
                       this may be expressed instead by disorganised or agitated behaviour.

                    The traumatic event is persistently re-experienced in one (or more) of the following ways:

     B.             • recurrent and intrusive distressing recollections of the event, including images,
                      thoughts or perceptions. Note: In young children, repetitive play may occur in which
                      themes or aspects of the trauma are expressed
                    • recurrent distressing dreams of the event. Note: In children, there may be frightening
                      dreams without recognisable content
                    • acting or feeling as if the traumatic event were recurring (includes a sense of reliving
                      the experience, illusions, hallucinations and dissociative flashback episodes, including
                      those that occur upon awakening or when intoxicated). Note: In young children,
                      trauma-specific re-enactment may occur
                    • intense psychological distress at exposure to internal or external cues that symbolise or
                      resemble an aspect of the traumatic event
                    • physiological reactivity on exposure to internal or external cues that symbolise or
                      resemble an aspect of the traumatic event.

                    Persistent avoidance of stimuli associated with the trauma and numbing of general

     C.             responsiveness (not present before the trauma), as indicated by three (or more) of the
                    following:
                    • efforts to avoid thoughts, feelings or conversations associated with the trauma
                    • efforts to avoid activities, places or people that arouse recollections of the trauma
                    • inability to recall an important aspect of the trauma
                    • markedly diminished interest or participation in significant activities
                    • feeling of detachment or estrangement from others
                    • restricted range of affect (eg, unable to have loving feelings)
                    • sense of a foreshortened future (eg, does not expect to have a career, marriage,
                        children or a normal life span).

                                                                                                    Continued …
                                                                                                                  95


                                                                                                                       A
                   Persistent symptoms of increased arousal (not present before the trauma), as indicated by

       D.          two (or more) of the following:
                   • difficulty falling or staying asleep
                   • irritability or outbursts of anger
                   • difficulty concentrating
                   • hypervigilance
                   • exaggerated startle response.

                   Duration of the disturbance (symptoms in Criteria B, C and D) is more than one month.

       E.
                   The disturbance causes clinically significant distress or impairment in social, occupational

       F.          or other important areas of functioning.


     Specify if:   Acute – if duration of symptoms is less than three months
                   Chronic – if duration of symptoms is three months or more.


     Specify if:   Delayed onset – if onset of symptoms is at least six months after the stressor.




96
Appendix D: Useful resources

Burn associations
• Australian and New Zealand Burn Association – htpp://www.anzba.org.au
• American Burn Association – http://www.ameriburn.org
• International Society for Burn Injury – http://www.worldburn.org


Support Groups
Burn Support – Waikato
Burn support organisation in Waikato.

http://www.burnsupport.org.nz

Burn Support Foundation Inc
A non-profit, self-help organisation helping burn survivors and their families return to productive lifestyles
following injury. This organisation provides a free newsletter and organises two weekend camps per year.

PO Box 476, Paddington, 2021

New South Wales, Australia

Burn Support Group Charitable Trust Inc
Produces a regular newsletter, runs workshops, education evenings and an annual camp for children. It also
provides education/prevention work and visits inpatients.

http://www.burns.org.nz

Burn Support Groups Database
A register of burn support groups world-wide. Non-burn support groups also are invited to register.

http://www.burnsupportgroupsdatabase.com

Burn Survivors On Line
Provides information and support for burn survivors and their families throughout the world.

http://www.burnsurvivorsonline.com/

Changing Faces
Provides free and confidential help, support and information for children (and their parents) and adults who
have facial disfigurements.

http://www.changingfaces.co.uk

Phoenix Society for Burn Survivors
International, non-profit, self-help organisation helping burn survivors and their families return to happy and
productive lives following injury.

http://www.phoenix-society.org

                                                                                                                 97


                                                                                                                      A
     Skylight
     Skylight provides a national support service for New Zealand children and young people who are experiencing
     change, loss and grief – whatever its cause.

     http://www.skylight.org.nz

     Survivors of Burn Injury
     Burn resource centre for survivors of burn injury.

     http://www.burnsurvivor.com




98
Abbreviations and acronyms

ACC     Accident Compensation Corporation

ANZBA   Australian and New Zealand Burn Association

BMI     Body mass index

CBT     Cognitive behavioural therapy

CMDHB   Counties Manukau District Health Board

ECG     Electrocardiogram

NZGG    New Zealand Guidelines Group

PTSD    Post-traumatic stress disorder

PVC     Polyvinyl chloride

RCT     Randomised controlled trial

RR      Relative risk

SAS     Staphylococcus aureus sepsis

SSRIS   Selective serotonin reuptake inhibitors

TBSA    Total body surface area

UK      United Kingdom

US      United States of America

UV      Ultraviolet




                                                      99
100
Glossary

Angiogenesis       The formation of new blood vessels.

Arrhythmia         Any deviation from the normal rhythm, eg, of the heart.

Atrial fibrillation Very rapid, uncoordinated contractions of the atria of the heart.

Blepharospasm      A spasm of the eyelid.

Body mass index (BMI)
                 An indicator of body fatness. Calculated from the formula weight/height squared, where
                 weight is in kilograms and height is in metres.

Case control studies
                  Sometimes described as retrospective, these studies look back in time at a group of
                  individuals with a particular disease or outcome and compare it with a suitable control group
                  of individuals without the disease or outcome.

Compartment syndrome
                A potentially limb- and life-threatening complication pressure leads to vascular occlusion,
                which in turn causes hypoxia, necrosis and a further increase in pressure.

Debridement        Thorough cleansing of a wound, with removal of all foreign matter and injured or infected
                   tissue.

Depersonalisation A subjective feeling of having lost one’s personality.

Dysphoria          A state of feeling unwell or unhappy.

Dyspnoea           Difficult or laboured breathing.

Ectopy             Pertaining to a beat or rhythm occurring outside its normal location or at the wrong time.

Erythema           Reddening of the skin.

Exudate            The material composed of serum, fibrin and white blood cells that escapes from blood
                   vessels into a superficial lesion or area of inflammation.

Fasciotomy         Incision of a fascia, a connective tissue sheath which unites the skin to the underlying tissues
                   and also surrounds many muscles.

   ¯
Hapu                           ¯nau with common ancestral links; sub-tribe.
                   Groups of wha

Hydrocolloid       Any of several substances that yield gels with water.

Hyperalgesia       Increased sensitivity to pain or enhanced intensity of the pain experience.

Hyperphosphataemia
               Excessive phosphates in the blood.

Hypertrophic scarring
                  Thick raised areas, usually darker than the surrounding skin, which remain within the
                  confines of the original wound and tend to reduce over time.

Hypocalcaemia      A deficiency of calcium in the blood.

                                                                                                                      101
      Hypoperfusion     Decreased blood flow through an organ.

      Hypothermia       Below normal body temperature.

      Hypovolaemia      An abnormally low volume of blood circulating through the body.

      Insomnia          Sleeplessness.

      Iridocyclitis     Inflammation of the iris and ciliary body of the eye.

      Ischaemia         Deficient blood supply.

      Iwi                                                                 ¯                          ¯ori
                        A social and political unit made up of several hapu sharing common descent; Ma tribe or
                        nation.

          ¯
      Kauma tua                                                   ¯nau, usually aged over 55 years.
                        Wise and experienced older members of a wha

      Keloid scarring   A scar that grows beyond the borders of the original wound and does not reduce
                        spontaneously.

      Lavage            Irrigation of or washing out of a body cavity.

      Lymphangitis      Inflammation of a lymph vessel.

      Metalloproteinases
                       Enzymes that are involved in the degradation of the extracellular matrix.

      Myocardial infarction
                         Damage to heart muscle that results typically from the partial or complete blocking of a
                         coronary artery.

      Necrosis          Localised death of tissue.

      Occlusive dressing
                        A dressing that prevents air reaching a wound and that retains moisture, heat, body fluids
                        and medication.

      Oedema            Swelling.

      Oliguria          Reduced urine output.

      Pruritis          Itching.

      Randomised controlled trials (RCTs)
                      Trials in which individuals in a population are randomly allocated into two groups. The two
                      groups are usually called the study or experimental group, and the control group, which does
                      not receive the intervention. The results are compared by comparing rates of one or more
                      outcomes (endpoints) between the two groups. Randomised controlled trials are generally
                      regarded as the most scientifically rigorous method of assessing the effectiveness of
                      treatments and other interventions (eg, screening procedures).

      Secondary care    Public hospitals, hospital-based services and specialist services.

      Symblepharon      Adhesion between an eyelid and the eyeball.

      Tamariki          Children.

      Tetany            A condition of muscular hyperexcitability leading to cramps and spasms.

        ¯
      Wha nau           The extended family. Relationships that have blood links to a common ancestor; extended
                        family.
102
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