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Royal Adelaide Hospital – Burns Unit
First aid and
emergency
management
of adult burns
2011 Practice guidelines
Burns Unit Direct Line
> Tel: 8222 4462
or 8222 5512
> Fax: 8222 5676
Medical Director John Greenwood A.M.
Clinical Service Co-Ordinator Sheila Kavanagh O.A.M.
Contents
Resources available through RAH Burns Service
3
>>burns assessment team
3
>>education
3
>>clinical guidelines
3
>>clinical services
3
RAH criteria for Burn Unit referral
4
First aid: General
5
First aid:
6
>>scalds
6
>>electrical injury
6
>>chemical injury
6
>>bitumen burns
6
Emergency management
Appendix A – Community first aid protocol for thermal injury
7-8
9
Appendix B – Protocol for the management of chemical skin injuries
10
Appendix C – Electrical burn injury
11
Appendix D – Escharotomy
12
Appendix E – Management of small thermal burns < 15%
13
Appendix F – Dressing guidelines for minor burn injuries in adults
14-15
Appendix G – Modified Lund and Browder chart (Adult)
17
Appendix H – Blank body chart
18
Appendix I – Modified Parkland fluid resuscitation formula 19
Appendix J – Protocol for burn depth assessment
20
Appendix K – Protocol for Hydrogel cooling products use
21
Appendix L – Primary burn wound care guidelines
22
Appendix M – Lower airway injury
23
Appendix N – Upper airway injury
24
Appendix O – Facial burn
25
Appendix P – Management of foot burns
26
Appendix Q – Management of hydrofluoric acid burns <2%
27
Appendix R – Management of hydrofluoric acid burns >2% 28
First aid and emergency management of adult burns, June 2011
page 2
Resources available through RAH Burns service
Burns assessment team
>>A full medical/nursing team is available as an adjunct to MedSTAR in multiple burn
casualty situations
>>A nurse specialist is available for situations where immediate up-skilling of staff in burn
dressing management is required
Staff education
The Burns Team can provide education sessions tailored to your needs. Current options
include:
>>all-day education session aimed primarily at nursing and emergency services, with
breakout sessions for therapy groups, operating room staff etc
>>evening sessions for GPs – normally run in conjunction with the all day session
>>evening session of one to four hours duration
Clinical guidelines
>>Laminated A3 copies of any flow chart contained with this document are available.
>>Laminated A3 posters of the Guidelines for minor burn management are available
>>the Guidelines for minor burn management document can be downloaded from the
RAH Burns Unit website at www.rah.sa.gov.au/burns
Clinical services
>>Advice for acute burn management
>>Review of scarring/contractures
>>Scar management advice
>>Wound management advice
>>Psychosocial advice
>>Occupational therapy advice
page 3
First aid and emergency management of adult burns, June 2011
RAH criteria for Burn Unit referral
(Including telephone consultations and patient transfers for persons aged 16 years and over)
1. Burns greater than 10% of total body surface area (TBSA)
2. Burns of special areas – face, hands, major joints, feet and genitalia
3. Full thickness burns
4. Electrical burns – to allow for full assessment
5. Chemical burns – to allow for full assessment
6. Circumferential burns of limbs or chest
7. Burns at the extremes of age (children and elderly)
8.Burn injury in patients with a pre-existing medical disorder (or other disability)
which could complicate management, prolong recovery or increase risk of mortality
9. Burns with associated inhalation injury
10. Any burn patient with concomitant trauma
11.Any patient with pre-existing psychiatric disorder that may compromise
management
12.Any other burn that the referring department is not happy about or
confident to send home!
These criteria are based on the Australian and New Zealand Burn
Association guidelines for Burn Unit referral.
First aid and emergency management of adult burns, June 2011
page 4
General first aid
(See appendix A)
Danger – ensure your own safety and wear appropriate personal
protective equipment
Stop the burning process
Cool the burn wound
A – Airway (protecting cervical spine)
B – Breathing (add oxygen)
C – Circulation (add haemorrhage control)
Minor Burn
>>Continue cold water irrigation for 20 minutes
>>Keep non-burn area warm
>>Cover with non-adherent dressing
>>Seek medical advice
Major Burn
>>Cold water treatment to burn for up to 20 minutes
>>Wrap loosley in clean linen or cling wrap (do not cling wrap the face or chemical burns)
>>Keep warm with outer blanket
>>Commence intravenous fluids and transport to hospital
>>If transfer is going to be delayed, refer to ‘Primary burn wound care guidelines –
Adults’ (Appendix L)
>>Do not hesitate to contact Burns Unit for clarification if required
Ice should never be used – it causes vasoconstriction leading to further tissue damage
and hypothermia.
Flame burns (see Appendix A)
>>For flame burns instruct the person to ‘stop, cover, drop and roll’ – extinguish flames
with a blanket
>>Remove the heat source
>>Apply cool running water to the burn for 10-20 minutes
>>Resuscitate if necessary.
>>Remove non-adherent clothing and potentially constricting jewellery.
Special cautions exist with the use of hydrogels – see Appendix K
page 5
First aid and emergency management of adult burns, June 2011
First aid – burn type specific
Scalds (see Appendix A)
>>Remove all soaked clothing instantly – every second counts as clothing soaked in hot water retains heat.
>>A scald is deepest:
>> where the clothing is thicker
>> where the liquid is held in a natural fold of the skin or
>> where the clothing is compressed in the natural creases of the body.
>>Immediately cool the burn with running cold water for 20 minutes.
Chemical (see Appendix B):
>>Protective clothing for first aid givers
>>Remove all contaminated clothing
>>Powdered agents should be brushed from the skin
>>Areas of contact should be irrigated with copious amounts of cool running water.
Avoid washing chemical over unaffected skin. Take care that footwear is removed
to avoid pooling of the chemical in the shoes
>>Chemical eye injuries require continuous irrigation until ophthalmological review is available – always ensure that the unaffected eye is uppermost when irrigating
to avoid contamination.
Bitumen (see Appendix B)
>>Immediately drench with cold water until the bitumen has lost all of its heat
>>Leave bitumen intact unless it is compromising the airway or circulation.
Electrical (see Appendix C)
>>Turn off mains / switch off at source (power point)
>>Remove patient from electricity source, remembering your own safety
>>Spine protection – this is of particular importance as fractures of the spine may occur following the violent muscular jactitations that occur during the conduction of
electrical current through the body
>>Cervical spine protection is mandatory
>>ECG
First aid and emergency management of adult burns, June 2011
page 6
Emergency management
1. First aid (see Appendix A)
2. Airway management (see Appendix M and N)
>>Administer oxygen to all patients with a major burn
>>Cervical spine protection
>>Assess for signs of inhalation injury. Endotracheal intubation is advisable early if signs
of inhalation injury are present
3. Circulatory management
>>Burns >15% should be given formal intravenous fluid resuscitation as per the
Modified Parkland Formula (see Appendix I)
>>Insert two large bore (16G) peripheral cannula (through damaged tissue if necessary)
4. Insert naso-enteric tube
>>Burns >20 %
5. Pain relief
>>Small doses of IV morphine titrated to pain and sedation scores
>>Intramuscular, subcutaneous and oral analgesics are absorbed unreliably in burn injury due to fluid shifts and GI stasis
6. Urinary catheter
>>All patients receiving intravenous fluid resuscitation should have a urinary catheter
inserted
7. Assess capillary return and neurovascular perfusion regularly
>>Circumferential extremity burns may obstruct venous return and capillary flow to a
level resulting in muscle ischaemia and necrosis
>>Elevate limbs
>>Contact Burns Unit urgently for advice re management
>>Escharotomy may be necessary (see Appendix D)
page 7
First aid and emergency management of adult burns, June 2011
8. Assess effectiveness of ventilation
>>Circumferential chest burns may restrict ventilatory excursion and a chest escharotomy may be necessary. Contact the Director of the Burns Unit through RAH switchboard
for advice.
9. Emotional support
>>Severe burns often occur under stressful circumstances and cause distress to patients, friends and relatives. Reassurance and good communication are the most important
tools at this time. Local support services should be accessed for ongoing support. The
Burns Unit social worker or clinical psychologist may be contacted through the Burns
Unit for advice and assistance.
>>Emergency service personnel and hospital staff may also require support and local
critical incident response protocols should be initiated if appropriate. The Burns Unit
social worker or clinical psychologist may be contacted through the Burns Unit for
advice and assistance.
10. Initial laboratory investigations
>>Baseline Hb
>>Haematocrit
>>Electrolytes including blood glucose
>>Urinalysis
>>Trauma series x-rays
11. Tetanus immunisation
>>Follow the NHMRC guidelines
>>Australian Immunisation Handbook 8th Edition for tetanus prophylaxis
>>Burns are deemed to be a tetanus prone wound
First aid and emergency management of adult burns, June 2011
page 8
Appendix A
Community first aid protocol for thermal Injury
Thermal burn
Scald
Take care!
Remove scalding agent
(water, hot fat etc)
Remove hot or soaked
clothing
Radiant heat/contact
Flame
Clothing on fire
Flash burn to
skin only
Take care!
Extinguish flames
(stop, cover, drop and roll)
Cool the burn wound –
do not use ice, ice-water or icepacks!!!
Running cold water available
Still cold water available
No water available
20 minutes under cold
running tap water (~15oC).
Remove jewellery once
cooling commenced.
Submerge burned area in
water or use towels/cloths
soaked in water and
applied to burns. Refresh
the water in the towels
every two to three minutes
for total of 20 minutes.
Remove jewellery once
cooling commenced.
Smear hydrogel* eg
BurnAid or hydrogel
impregnated towels
over the surface of the
burn. Remove
jewellery once cooling
commenced.
*Consult hydrogel protocol prior
to use
Gently pat dry with clean
towel
Cover with cling film
(not face) or non adherent
dressing
Wrap clean towel
around hydrogel
Seek medical attention/advice. Advice can be obtained on a
24 hour basis by phoning the Burns Unit at the Royal
Adelaide Hospital on 8222 5512 or 8222 4462
page 9
First aid and emergency management of adult burns, June 2011
Appendix B
Emergency Department protocol for the
management of chemical skin injuries
Chemical Injury
Personal protective equipment
Bitumen
Liquid
Alkali
Acid
Irrigate to the
floor* for up
to two hours.
Use the
patient’s
subjective
cessation of
burning
sensation as
end-point
Personal protective equipment
Irrigate to the
floor* for up
to one hour.
Use the
patient’s
subjective
cessation of
burning
sensation as
end-point
Ophthalmic opinion
immediately if face involved
Cool with
running water or
water soaks
Soften and dress
with yellow soft
paraffin only
Do not
attempt to
remove
but allow to
detach
spontaneously
over time
Solid
Powder
Alkali metal
Do not apply water!
Brush off
powder.
Remove
adherent large
particles with
forceps
Pick metal
particles off
skin with
forceps
Irrigate with
water using
patient’s
subjective
cessation of
burning
sensation as
end-point
Irrigate for up
to two hours.
Use the
patient’s
subjective
cessation of
burning
sensation as
end-point
Liaise with Burns Unit for advice regarding
appropriate dressings
Admit to Burns Unit/ICU as appropriate
*From contaminated area to floor directly to avoid run-off injury to other areas if possible
First aid and emergency management of adult burns, June 2011
page 10
Appendix C
Emergency Department Protocol for Electrical Burns
(low voltage = A/C<1000V)
>> Remove hot clothing and
jewellery
>> Standard primary survey full
trauma clearance
Examine for contact wounds
(especially. scalp, hands, feet)
Exclude concomitant bone fracture/
joint dislocation, particularly shoulder
dislocation and thoracolumbar bony injury
(even in presence of longstanding history
of joint pain)
>> Monitor limbs hourly - assess capillary
refill, skin colour and sensation
>> Compartment syndrome suspected?
(increased tension in compartment,
pain on passive stretching, decreased
peripheral sensation, prolonged
capillary refill)
Immediate contact Burns Fellow/
Director for fasciotomy and admission
>> Catheterise - if haemochromogenuria/
pigment in urine then increase fluids
to give urine output >2ml/kg/hr
>> Consider mannitol 12g/l administered
fluid and urine alkalinisation
12 lead ECG
>> If abnormalities or history of
unconsciousness, admit and cardiac
monitor for 24 hours in monitored bed
>> Repeat cardiac enzymes 6 hourly
Full (documented) neurological exam
- peripheral and spinal nerves
>> Estimate burn depth and area
>> Record on Lund and Browder
chart
Contact Burns Unit and plastics
registrar re admission
Wrap loosely in cling film (not facial burns)
>> Resuscitate if >15% TBSA
John Greenwood and Sheila Kavanagh, June 2011.
page 11
First aid and emergency management of adult burns, June 2011
Appendix D
Escharotomy
In the presence of any circumferential burn, advice should be sought from
the Burns Unit consultant (contact through RAH switchboard 8222 4000).
An escharotomy should be considered when there is
a circumferential deep dermal or full thickness burn
injury (dry wound) and where:
>>a delay in transfer to the tertiary Burns Unit is expected
or
>>there is evidence of circulatory compromise indicated by an extended capillary refill time compared to unburned or non circumferential burned limb.
Escharotomy is designed to divide inelastic burned skin
and the incision does not usually need to be extended
far into the underlying fat.
This procedure is not to be undertaken lightly, as it has
the potential for considerable damage to underlying
structures. These include:
>>common peroneal nerve at the outside of the knee
(over neck of Fibula)
>>radial nerve at the wrist (superficial branch)
>>ulnar nerve at the elbow
>>cephalic vein at the wrist
>>great saphenous vein and nerve at ankle.
Equipment
>>Local anaesthetic infiltration with Adrenaline (if patient awake)
>>Povidone lodine
>>Cutting monopolar diathermy with either needle or blads (set to equal cutting/
coagulation). A normal scalpel may be used in the absence of this but more bleeding
should be expected
>>Bipolar diathermy for haemostasis
>>KaltostatTM for dressing escharotomy wound. Cover with antibacterial dressing and
bandage then elevate limb.
First aid and emergency management of adult burns, June 2011
page 12
Appendix E
Management of small thermal burns (<15% TBSA)
Remove jewellery/hot clothing
Yes
Is it within one hour?
Cooled?
Yes
No
Analgesia according
to pain protocol,
tetanus prophylaxis
according to protocol
No
Place under
running cool tap
water (at 15oC)
for 20 minutes
or
Apply hydrogel
(refer protocol)
Assess burn size using
Lund and Browder
chart
Assess burn depth
Do not use
ice or ice
water
Does injury fit criteria for
admission?
Yes
Equivocal
No
Contact Burns Unit and
plastics registrar. Leave
hydrogel if applied or wrap
in cling film (not facial or
chemical burns) and send to
Burns Unit.
Fast patient until reviewed
Contact plastics
registrar.
Fast patient until
reviewed.
Clean wound and debride
blisters. Follow RAH dressing
guidelines for minor burn
injuries in adults
page 13
First aid and emergency management of adult burns, June 2011
Appendix F Dressing guidelines for minor burn injuries in adults
Please refer to RAH Criteria for Burn Unit referral (Including telephone consultations and patient transfers)
Aims of burn wound dressings
>>Promote healing
>>Prevent desiccation of the wound
>>Prevent or treat infection
>>Patient comfort – pain, exudate, odour management
>>Ease of management for patient and staff
>>Allow normal movement
Initial burn wound care
>>Remove restrictive jewellery (ie rings) as soon as possible
>>Pain relief – superficial and partial thickness burns are very painful
>>Wash area with antiseptic sponge eg Medisponge
>>Shave any body hair from burn wound and at least 2.5cm margin surrounding burn
site (do not shave eyebrows)
>>Debride blisters and remove all loose burned tissue
>>Assess wound depth by pressing on wound bed and looking for presence of capillary
refill according to the burn wound assessment chart (Appendix J)
>>Use the appropriate dressing based on the wound depth, site and likelihood of
infection
>>Elevation of limbs to reduce oedema formation
Superficial burns – unblistered (erythema, sunburn or healed burns)
>>Wash with non-perfumed soap and dry well
>>Apply moisturising cream. May need to do this several times a day
>>Advise patient regarding the use of sun-block agents
physical – hats and long sleeved shirts
chemical – SPF factor 30+
Important note
Partial thickness burns due to petrol, friction, flames, chemicals ‘cooking’ water, hot oil
or other contaminated/car radiator water dirty materials often become infected resulting
in burn wound progression ie tissue death requiring surgical intervention. It is prudent to
treat these with a topical anti-bacterial (silver containing) dressing. Systemic antibiotics
are usually only used when there has been organisms identified in conjunction with a
clinical picture of a wound infection.
First aid and emergency management of adult burns, June 2011
page 14
Superficial burns/clean partial thickness burns
>>If exudate present (usually first 72 hours) – Hydrocolloid dressing eg DuodermTM
>>Will need changing within 48 hours otherwise it will leak and become malodorous
>>When exudate ceases, dressing can change to a retention dressing such as Hypafix TM
which can be changed every three days
>>Patient can then wash over the HypafixTM twice a day with gentle soap and water and
pat dry with a clean towel
>>Use an adhesive remover such as ZoffTM to remove HypafixTM. In the absence of a
commercial adhesive remover, liquid paraffin or vegetable oil can be used. This should
be applied to the Hypafix 60 minutes before attempting to remove it. This will avoid
traumatic removal of new epithelium
Contaminated/infected partial thickness burns
Small full thickness burns (eg under size of a 20 cent piece)
Three day ActicoatTM
>>Apply ActicoatTM directly to wound, secure with HypafixTM
>>Patient instructed to keep dressing activated by dampening under tap at home once a
day or when dressing starts to feel too dry
>>For some patients, it can cause a stinging or burning sensation on application. This
can be minimised by resting the product after activation with water for a couple of
minutes before application.
Silver Sulphadiazine CreamTM (SSD)
>>Apply a one centimetre thick layer of SSD cream to the wound with secondary
dressing otherwise drying out will occur making dressing removal difficult and/or
painful
>>SSD needs to be washed off the wound (Medisponge) and redressed daily
>>SSD can change partial thickness wound appearance, making it look as though the
wound has become deeper
>>Not recommended for anyone with a sulphur allergy
>>Do not use on the face – can cause corneal ulceration
>>For some patients it can cause a stinging or burning sensation on application, if this
does not settle within 30 minutes remove SSD and choose alternative dressing
page 15
First aid and emergency management of adult burns, June 2011
Facial Burns (Appendix O)
>>Ophthalmic review (within 12 hours)
>>Male patients shave one or twice daily depending on rate of beard growth
>>Daily hair wash
>>Four hourly cleaning of facial burns with normal saline using aseptic technique.
Debride the blisters and remove crusts. Pay particular attention to eye and ear care
>>Apply sterile soft paraffin to raw areas.
>>Apply moisturising cream to healed areas
>>Advise patient to stay out of sun and dusty conditions
Oedema
>>Swelling to the burned area can be reduced by elevation
>>Patients with burns to the face and neck are best nursed sitting up (~450 at the hip)
Considerations for hospital admission
>>Pain not adequately controlled with oral analgesia
>>Infection – cellulitis of burn wound requiring intravenous antibiotics
>>Need for bed rest with lower limb(s) elevated
>>Living alone and inadequate support at home
>>Inability to cope with own dressing care
>>Transport difficulties – eg getting to appointments for dressing changes
First aid and emergency management of adult burns, June 2011
page 16
Appendix G Modified Lund and Browder chart (adult)
3
4
1
1
13
2
1 1/ 2
2
1 1/ 2
1 1/ 2
1
1 1/ 4
61 / 2
6 1/ 2
1 1/ 4
1 1/ 4
3 1/ 2 3 1/ 2
1 3/ 4
page 17
2
1 1/ 2
2 1/ 2
2 1/ 2
4
4
1 1/ 4
2 1/ 2 2 1/ 2
13/ 4
Anterior
52
13
2
1 3/ 4
1 3/ 4
Posterior
48
First aid and emergency management of adult burns, June 2011
Appendix H
Anterior
First aid and emergency management of adult burns, June 2011
Posterior
page 18
Appendix I
Royal Adelaide Hospital modified Parkland resuscitation protocol for adults
with >15% total burn surface area
>>Assess total burns surface area (TBSA) using the Lund and Browder chart.
>>Assess patient body weight as accurately as possible (in kilogrammes).
>>First 24 hours Total Fluid requirement derived via formula:
Total (mls) = 4ml x weight kg x % TBSA
>>In the first period of eight hours from the time of the burn, give one half of the
total calculated fluid required as Hartmann’s solution. Normal saline may be used if Hartmann’s solution is not available. Timing begins at the time of the burn, not at the
time of arrival at hospital
Maintenance fluid is not required in adults
>>During the second period of 16 hours, give the remaining half of the calculated
total fluid requirement as Hartmans solution. Normal saline may be used if
Hartmann’s solution is not available.
>>Second 24 hours fluid requirement is Albumex 4 via the formula:
Total (mls) = 0.5ml x weight kg x % TBSA
>>The patient may need no further intravenous fluid
>>The urine output should be measured each hour and the Medical Officer notified every
two-hour period
>> The urine output is to be maintained between 0.5ml and 1ml per kilogram body
weight per hour
>>Venous blood should be sent for Hb, PCV and Serum Electrolytes on admission and
6-hourly until transfer
>>Monitoring
>> Indwelling catheter – mandatory
>> Nasogastric tube – if indicated
page 19
First aid and emergency management of adult burns, June 2011
Appendix J
Burn wound assessment chart
Protocol for burn depth assessment
Look at the burn
Epidermal
Yes
Is there epidermal
integrity? (Nikolsky
Sign* see below)
No
Run a gloved finger over the burn
Thin walled
or popped
Superficial
dermal
Other signs:
blanches with
pressure, very
painful, very oozy
Type of blister
Is it
slippery?
Yes
No
Thick walled
Red
White
Mid dermal
Other signs: some
mottling, blanching
sluggish, darker/
red base, some
anaesthesia, less
oozy
*A positive Nikolsky sign
occurs when the epidermis of
skin detaches from the dermis/
burn bed with slight friction.
First aid and emergency management of adult burns, June 2011
Burn Colour
Deep dermal
Other signs:
decreased
sensation, absent
or reduced
refilling after
blanching, fixed
mottling, little or
no ooze
Full thickness
Other signs:
anaesthesia, no
refilling after
blanching, may
be amber and
translucent with
visible black vessels,
may be waxy, hairs
fall out easily, dry
page 20
Appendix K
Use of hydrogel cooling products for burn Injury first aid and primary
wound dressing care
Burn assessment
(see A)
Chemical and
cold injury
burns
Do not use
Please contact
RAH Burns
registrar
through RAH
switchboard
(8222 4000) for
advice
Thermal,
electrical
and
ionising
radiation
burns
Assess patient
risk (see B)
A. Burn assessment > Cause of burn
> First aid (type and length)
> Depth
> % total burn surface area (TBSA)
> Site of burn
> Immediate risk to circulation/ ventilation
>Need for transfer to RAH Burns
Unit
B. Patient risk
Extreme
> Neonates
High
> The very young
> The elderly
> Burn surface area > 15%
Low
> Burns <15%
> Fit healthy persons 10 – 60 yo
Low risk
High risk
Extreme
>
Hydrogel products
should only be
used for initial
cooling (a period
of no more than
20 minutes).
After that time
they should be
removed
Hydrogel products
should only be
used for NO more
than 10 minutes,
then removed
>
>
Use as per
manufacturers
guidelines.
Monitor patients
temperature
regularly
Warm non burned areas
page 21
First aid and emergency management of adult burns, June 2011
Appendix L
Primary burn wound care guidelines – adults
A.
Emergency management
Refer RAH first aid and emergency management guidelines
B. Burn assessment
Emergency burn
management
(see A)
>
Cause of burn
First aid (type and length)
> Depth
> % total body surface area (TBSA)
> Site of burn
> Immediate risk to circulation/ventilation
>Need for transfer/consultation* to RAH
Burns Unit
>
C. Transfer to RAH burns unit
Burn assessment
(see B)
Transfer to RAH
Burns Unit
(see C)
Minor Burn
suitable for local
management
(see D)
Note: hydrogel products such as Burn AidTM
specifically designed for burn first aid use
are those referred to below.
Anticipated time to arrival at RAH.
<1 hour
>Face - wet soaks or hydrogel
(see hydrogel protocol.
>Other burn areas - cling film or hydrogel
(see hydrogel protocol).
1 - 4 hours
>Face – wet soaks, soft paraffin or
hydrogel (see hydrogel protocol).
> Other burn areas – cling film or hydrogel (see hydrogel protocol).
4 - 24hours
> Face – soft paraffin.
>Other burn areas – Atrauman AgTM/
InadineTM
>24 Hours
For any chemical injury please
contact RAH Burns registrar
through RAH switchboard
(8222 4000) for advice.
>
Face – soft paraffin.
> Other burn areas – ActicoatTM
D. Minor burn for local
management
>Follow
RAH dressing guidelines for
minor burn management
*Consultation may consist of discussion, or the tranfer of photographic images of burn injury for appropriate advice
First aid and emergency management of adult burns, June 2011
page 22
Appendix M
Lower airway injury
0 hours
Time of injury
Lower airway injury
– low risk
Lower airway injury – high risk
>History of prolonged confinement in smoke filled
environment ie house or car fire, including under car hood
> ‘Flash’ or short contact with
thermal agent
>No confinement in smoke
filled environment
> Scald injury
> Significant facial burns
> History of unconsciousness or obtundation
> Raised carboxyhaemoglobin
> Hypoxia
> Contact burn injury
> Respiratory difficulty (dyspnoea, tachypnoea, increased
>Normal mentation/speech
>Normal appearance on bronchoscopy below
the cords
>
>
>
>
use of accessory muscles and increased work of breathing)
Sooty or productive sputum
Confusion, obtundation, unconsciousness
Wheezing or added sounds on auscultation
Abnormal finding below the cords on bronchoscopy
If lower airway risk – low
If lower airway risk – high
Rx
Rx
> O2
> O2
> Trauma Clearance ASAP
> Elevate 45° at hips when C-spine clear
> Chest X-ray
>Intubation – long term (if required)
> ABGs
> ? nebulised Adrenaline/Heliox > Bronchoscopy/review survival status
> Trauma Clearance ASAP
> Elevate 45° at hips when C-spine clear
> Chest X-ray
> Notify duty ICU Dr
> Notify burns registrar
Obs
Obs
> Continuous SaO2
> Continuous visual observation
> Continuous SaO2
> Continuous visual observation
> 15 minute airway observations
> 15 minute airway observations
Placement: Burns Unit
4 hours post injury
90% oedema
present
Placement: HDU/ICU
> O2
Deterioration in condition
– code blue
> Continuous SaO2
> Contact duty anaesthetist
> 1/24 observations
> Intubate
> Elevate 45° at hips when C-spine clear
> ICU
No deterioration in condition
Placement: Burns Unit
12 hours post injury
maximal oedema
(superficial burn)
18 hours post injury
maximal oedema
(deep burn)
page 23
No deterioration in condition
> Continuous SaO2
> 4/24 observations
> Elevate 45° at hips when C-spine clear
Placement: Burns Unit
First aid and emergency management of adult burns, June 2011
Appendix N
Upper Airway Injury
0 hours
Time of injury
Upper airway injury
– low risk
Upper airway injury
– high risk
>History of ‘flash’ or short contact with thermal
>Burns to mouth, nose and
pharynx
agent such gas/petrol explosion characterized by
superficial facial burn or erythema, with some
singing of facial hair/nostril hair.
> Steam inhalation
> Intra oral burns or blisters
> Normal voice at initial examination
> Hoarse voice
> Inspiratory stridor
If upper airway risk – low
If upper airway risk – high
Rx
Rx
> O2
> Trauma Clearance ASAP
> O2
> Trauma Clearance ASAP
> Elevate 45° at hips when C-spine clear
>Elevate 45° at hips when C-spine
> Chest X-ray
> Notify duty ICU Dr
> Notify burns registrar
Obs
> Continuous SaO2
> Continuous visual observation
> 15 minute airway observations
Placement: Burns Unit
4 hours post injury
90% oedema
present
clear
> Chest x-ray
> Intubation – short term (if required)
> ABGs
> ? nebulised Adrenaline/Heliox Obs
> Continuous SaO2
> Continuous visual observation
> 15 minute airway observations
Placement: HDU/ICU
> O2
Deterioration in condition
– code blue
> Continuous SaO2
> Contact duty anaesthetist
> 1/24 observations
> Intubate
> Elevate 45° at hips when C-spine clear
> ICU
No deterioration in condition
Placement: Burns Unit
12 hours post injury
maximal oedema
(superficial burn)
18 hours post injury
maximal oedema
(deep burn)
No deterioration in condition
> Continuous SaO2
> 4/24 observations
> Elevate 45° at hips when C-spine clear
Placement: Burns Unit
First aid and emergency management of adult burns, June 2011
page 24
Appendix O
Management of facial burns
Facial burns mandatory
eye stanining
Superficial
Mid dermal
Deep dermal
Full Thickness
Four hourly soft
paraffin
Theatre for debridement
No
Intubated?
Four hourly soft paraffin
Yes
Aquacel Ag™
Signs of Infection
>> Pain
>> Vascularity
>>Wound
deterioration
>>Abnormal ooze
Swab wound
Bacteriology
Discuss with burns
consultant re order
for Chloramphenicol
ointment
Virology
Possibility of Herpes
simplex burn
infection (especially
‘coldsore’ sufferers)
>>Odour
>>Overgranulation
Start Acyclovir
page 25
First aid and emergency management of adult burns, June 2011
Appendix P
Management of burns to the foot
Each foot is colonised by 1,000,000,000,000 bacteria. Inadequate management of
foot burns frequently results in serious infection. This can then lead to a need for skin
grafting (where spontaneous healing was expected) and even digital/other amputation.
Avoid any constrictive/abrasive footwear. Loose footwear should be worn ie thongs or
slippers. Initial elevation for at least 24 hours is of utmost importance in preventing burn
depth progression. Time off work should be considered especially for those whose jobs
entail standing or a hot dusty dirty environment.
Does the patient have diabetes mellitus/paraplegia or other
peripheral vascular disease?
Yes
No
Discuss with
burn consultant
Epidermal (sunburn/
no blistering
>>Clean skin
>>Moisturising cream
>>Massage
>>Analgesia
Full thickness/
Deep dermal
Assess burn
depth
Superficial dermal
Mid dermal
>>Elevation (toilet privileges
>>Elevation (toilet privileges
>>Analgesia
>>Analgesia
>>Meticulous wound cleaning
>>Meticulous wound cleaning
>>De-roof blisters
>>De-roof blisters
>>Silver dressing
>>Silver dressing
>>Consider antibiotics
>>Routine antibiotics
only)
(depends on aetiology and
likely patient compliance
with treatment)
>>Consider hospital admission
if patient unlikely to
elevate foot for 24 hours
(ie mothers with young
children)
only)
>>Consider hospital admission
if patient unlikely to elevate
foot for 24 hours
>>Assess wound every
two days
>>Assess wound every
three days
First aid and emergency management of adult burns, June 2011
page 26
Appendix Q
Hydrofluoric Acid Treatment Protocol (Burns <2% TBSA and HF
concentration <10%)
Irrigation for 30 minutes to one hour to
remove H+ ion effect (burn); ends with patient’s
subjective cessation of ‘burning’ sensation
Apply calcium gluconate 10% gel to skin of
entire burn area. Wash and reapply gel every
15 minutes
If primary survey passed transport to RAH, if
not, consult at nearest Trauma Centre
No deep tissue
discomfort
Burns Unit
consultant and
toxicology consults
Wash and reapply gel every
15 minutes for one hour or
cessation of pain, consider
removal of nails and application
of gel to bed if affected
No Deep tissue discomfort
develops
Burn Unit admission overnight
then D/C and standard FU
Deep tissue discomfort
(aching/pain
subcutaneously)
Single digit: sites of aching/
deep pain injected with
10% calcium gluconate
solution 0.5cm2 into affected
subcutaneous tissue, pulp
spaces and compartments of
digit. If nail bed affected, nail
removal mandatory followed
by injection into nail bed
Spreading/continuing ache
Intra-arterial (via radial artery) injection of 10% calcium
gluconate (after Allen’s test shows patient ulnar artery)
Spreading/continuing ache
Intravenous injective of calcium gluconate using modified
Bier’s Block technique
Spreading/continuing ache
Consider isolated limb perfusion
page 27
>1 digit affected
1g of Calcium
Gluconate in 40mls of
normal saline over four
hours
Place IV proximal
to burn. Inflate cuff
above arterial pressure.
Instil 1g of Calcium
Gluconate diluted in
Normal Saline 40mls.
Deflate cuff in 20
minutes
First aid and emergency management of adult burns, June 2011
Appendix R
Hydrofluoric Acid Treatment Protocol (Burns >2% TBSA or
HF concentration >10%)
Patient is at risk of systemic fluoride poisoning
Immediate Burn Unit and toxicology consultation
Local burn management as per protocol for <2% TBSA flow chart
VBG or ABG (check Ca2+/K+) MBA20 and Mg2+ ECG
Patient stable and investigations
normal
Patient unstable or investigations
abnormal
HDU/ICU
six hourly ECG and venous gas
Twice daily MBA20
Aggressive replacement of Ca2+
and Mg2+
Hourly VBG/ABG
six hourly ECG, MBA20, Mg2+
First aid and emergency management of adult burns, June 2011
page 28