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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
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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
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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
11. Burn injuries in Ma¯ori .....................................................................................................................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
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3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
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
Referral .........................................................................................................................................45
Emergency referral ..........................................................................................................................45
Referral between services ...............................................................................................................46
Management of epidermal burns or scalds .....................................................................................47
Dressings and creams (good practice points only)...........................................................................47
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
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
Management of electrical injury.....................................................................................................63
Management of electrical injury ......................................................................................................63
ECG monitoring...............................................................................................................................64
Pain management..........................................................................................................................67
Burn pain management ..................................................................................................................67
Psychological consequences of burn injury ....................................................................................71
Adverse psychological responses to trauma....................................................................................71
Burn injuries in Ma¯ori ....................................................................................................................77
Good practice points ......................................................................................................................77
Burn injuries in Paciﬁc peoples ......................................................................................................79
Good practice points ......................................................................................................................79
Algorithms (see Summary, pages 17–25)
1.
2.
Initial assessment and management of burns and scalds................................................................18
Ongoing assessment and management of burns and scalds in primary care ....................................24
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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
1.2
Burns from ﬁre or ﬂames: age speciﬁc rates for 2000–2004 ...........................................................27
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
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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.
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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
Ma¯ori 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.
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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.
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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.
Copies of the draft were sent to key individuals and sector groups for comment and peer review. Ma¯ori 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
Te Tai Tokerau Primary Health Organisation, Ma¯ori 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
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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
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• Chris Adams, Consultant Plastic Surgeon, Wellington Regional Plastic Surgery and Burns Unit, Hutt Hospital,
Wellington
• Connie Mahu, Wha¯nau Support Worker for Ma¯ori 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
• Rhys Jones, Senior Lecturer in Ma¯ori 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¯ori and Kelly Waddell and Francois Stapelberg for their contributions towards the pain
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.
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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.
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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, nonaccidental injury, clinical features, burn
size, location and depth (Note 2)
Decide the level of care needed
Is hospital care indicated?
(Note 3)
No
Continue managing in primary care.
Refer to Algorithm 2: Ongoing
assessment and management of
burns and scalds in primary care
No
Immediate referral to nearest hospital
Yes
Is specialist burns unit
care indicated? (Note 4)
Yes
Suitable for transfer to a
regional burns unit?
No
Yes
Immediate referral to nearest
regional burns unit
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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 …
*
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Reproduced from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.
8th Edition;2004.
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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
appearance
sensation
healing time
scarring
UV light, very short ﬂash
Dry and red, blanches with pressure,
no blisters
May be painful
Within seven days
No scarring
anzba 2004 classification Superﬁcial dermal
former classification
Superﬁcial partial thickness
example
appearance
sensation
healing time
scarring
Scald (spill or splash), short ﬂash
Pale pink with ﬁne blistering, blanches
with pressure
Usually extremely painful
Within 14 days
Can have colour match defect
Low risk of hypertrophic scarring
anzba 2004 classification Mid dermal
former classification
Partial thickness
example
appearance
sensation
healing time
scarring
Scald (spill), ﬂame, oil or grease
Dark pink with large blisters
Capillary reﬁll sluggish
May be painful
14–21 days
Moderate risk of hypertrophic scarring
anzba 2004 classification Deep dermal
former classification
Deep partial thickness
appearance
Scald (spill), ﬂame, oil or grease
Blotchy red, may blister, no capillary
reﬁll
sensation
In child, may be dark lobster red with
mottling
No sensation
Over 21 days: grafting probably needed
High risk of hypertrophic scarring
example
healing time
scarring
anzba 2004 classification Full thickness
former classification
Full thickness
example
appearance
sensation
healing time
20
scarring
Scald (immersion), ﬂame, steam, oil,
grease, chemical, high-volt electricity
White, waxy or charred, no blisters, no
capillary reﬁll
May be dark lobster red with mottling
in child
No sensation
Does not heal spontaneously, grafting
needed if >1cm
Will scar
Adapted from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.
8th Edition; 2004.
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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 …
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Assessment of burn size: Lund and Browder chart
% Total Body Surface Area Burn
A
1
13
2
2
region
1B/c
1B/c
%
A
partial
thickness loss
full
thickness loss
Be clear and accurate, and do not include erythema
1
13
2
2
1B/c
Head
1B/c
Neck
1
1B/c
1B/c
B
B
1B/c
Ant. trunk
2B/c
2B/c
B
B
C
C
1D/e
1D/e
Post. trunk
1B/c
Right arm
Left arm
Buttocks
C
C
Genitalia
Right leg
Left leg
1D/e
1D/e
total burn
area
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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
and resuscitation. BMJ 2004;329;101–3.
5/17/07 12:11:11 PM
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
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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
Moisturising cream
Review after 48 hours
Antimicrobial dressing
Blister and oedema
management (Note 5)
Pain relief (Note 6)
Daily review
Is the burn area
>1cm wide?
Day 3: Reassessment
Day 3: Reassessment
Intact skin?
Reassess
burn depth (Note 2). Is it
signiﬁcantly worse (likely to
be full thickness)?
Yes
Healed,
continue
moisturiser
and sunblock
No
No
Yes
No
Yes
Change to moist woundhealing product or
alternatively doublelayer parafﬁn gauze
Review within 72 hours
Monitor for signs of
infection
Refer acutely
as appropriate
(Notes 3 and 4)
Antimicrobial dressing (eg,
silver sulphadiazine cream)
Pain relief (Note 6)
Daily review
Days 5–7:
Change to moist woundhealing product
No
Is healing
progressing?
No
Days 10–14
Is healing likely within
seven days?
Yes
Continue with dressings as above
Monitor for signs of infection (Note 7)
Healed. Consider rehabilitation needs (Note 8)
Yes
Continue with dressings
24
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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
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26
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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.
Ma¯ori 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¯ori.11
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
and contact with hot objects. Ma¯ori 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.
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table 1.2: burns due to hot substances and objects, caustic or corrosive material or steam: agespecific 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
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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 ﬁrerelated 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
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30
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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
minutes. Irrigation of chemical burns should continue for one hour.
C
Do not use ice for cooling.
C
Avoid hypothermia: keep the person with the burn as warm as possible, consider turning the
temperature of the water up to 15°C (tepid).
C
If there has been a delay in starting cooling, this should still be started up to three hours after
injury.
C
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
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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
practical.
C
Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.
32
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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
hospital assessment. It should be applied by persons knowledgeable in its use.
C
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
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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
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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
risk factors and what ﬁrst aid has been given.
C
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
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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
Singed nasal hair
Change in voice, with hoarseness or harsh cough
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 coinjuries.
• 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
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• 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 nonaccidental 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)
How did it come into contact with the patient?
What ﬁrst aid was performed?
Is there a risk of concomitant injuries (such as fall
from height, road trafﬁc crash, explosion)?
Is there a risk of inhalational injuries (did the burn
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
source?
When was ﬂuid resuscitation started?
exact injury
Scalds
• What was the liquid? Was it boiling or recently
boiled?
• If tea or coffee, was milk in it?
• Was a solute in the liquid? (Raises boiling
temperature and causes worse injury, such as
boiling rice)
• Is there any suspicion of non-accidental injury?
Electrocution injuries
• What was the voltage (domestic or industrial)?
• Was there a ﬂash or arcing?
• Contact time?
Chemical
• What was the chemical?
Adapted from: Hettiaratchy S, Papini R. Initial management of a major burn: 1– overview. BMJ 2004;328: 155–7.
37
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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
estimating the TBSA of the burn.
B
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
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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
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.
3
A modiﬁcation to the Lund and Browder chart has been proposed that adjusts for breast burns in largerbreasted 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%
9%
18%
9%
Front 18%
Back 18%
1%
18%
9%
9%
18%
14%
14%
Adapted from: Australian and New Zealand Burn Association Limited, Emergency Management of Severe Burns
(EMSB): Course Manual 2004.
39
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figure 3.2: assessment of burn size: lund and browder chart
% Total Body Surface Area Burn
A
1
13
2
2
region
1B/c
1B/c
%
A
partial
thickness loss
full
thickness loss
Be clear and accurate, and do not include erythema
1
13
2
2
1B/c
Head
1B/c
Neck
1
1B/c
1B/c
B
B
1B/c
Ant. trunk
2B/c
2B/c
B
B
C
C
1D/e
1D/e
Post. trunk
1B/c
Right arm
Left arm
Buttocks
C
C
Genitalia
Right leg
Left leg
1D/e
1D/e
total burn
area
40
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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
and resuscitation. BMJ 2004;329;101–3.
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Burn depth
recommendations
grade
3
The depth of a burn injury should be reassessed two to three days after the initial
assessment, preferably by the same clinician.
C
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
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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
injuries.
C
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
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Refer to a regional burns unit if non-accidental injury is suspected.
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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
burns.
C
Distinguish between burns that will probably heal without skin grafting and those that will
probably require grafting (deep dermal burns and full thickness burns).
C
Burns that are unlikely to heal within 21 days without grafting should be referred early to
secondary care, ideally by day 10–14.
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
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
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table 3.3: classification of burns based on depth
anzba 2004 classification Epidermal
former classification
Superﬁcial epidermal
example
appearance
sensation
healing time
scarring
UV light, very short ﬂash
Dry and red, blanches with pressure,
no blisters
May be painful
Within seven days
No scarring
anzba 2004 classification Superﬁcial dermal
former classification
Superﬁcial partial thickness
example
appearance
sensation
healing time
scarring
Scald (spill or splash), short ﬂash
Pale pink with ﬁne blistering, blanches
with pressure
Usually extremely painful
Within 14 days
Can have colour match defect
Low risk of hypertrophic scarring
anzba 2004 classification Mid dermal
former classification
Partial thickness
example
appearance
sensation
healing time
scarring
Scald (spill), ﬂame, oil or grease
Dark pink with large blisters
Capillary reﬁll sluggish
May be painful
14–21 days
Moderate risk of hypertrophic scarring
anzba 2004 classification Deep dermal
former classification
Deep partial thickness
appearance
Scald (spill), ﬂame, oil or grease
Blotchy red, may blister, no capillary
reﬁll
sensation
In child, may be dark lobster red with
mottling
No sensation
Over 21 days: grafting probably needed
High risk of hypertrophic scarring
example
healing time
scarring
anzba 2004 classification Full thickness
former classification
Full thickness
example
appearance
sensation
healing time
44
scarring
Scald (immersion), ﬂame, steam, oil,
grease, chemical, high-volt electricity
White, waxy or charred, no blisters, no
capillary reﬁll
May be dark lobster red with mottling
in child
No sensation
Does not heal spontaneously, grafting
needed if >1cm
Will scar
Adapted from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.
8th Edition. 2004.
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Chapter 4
Referral
4
Emergency referral
recommendations
grade
Health care practitioners should follow the ANZBA referral guidance when deciding the level of
care that is appropriate for people with a new burn injury.
C
When seen in primary care, smaller burns that look like they will fail to heal by 14 days should
be discussed with a secondary care service for consideration of an acute referral.
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
• 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
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• 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
channels and locally developed protocols agreed between centres on whom to transfer and
when to transfer.
C
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
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Chapter 5
Management of epidermal burns or scalds
Dressings and creams
good practice points
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).
✓
5
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
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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
information from manufacturers and Guideline Development Team experience in burn care (see Appendix B).
6
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 wounddressing 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
• increased irritability in a child.
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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
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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
syndrome.
6
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
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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
non-infected burns.
B
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 nonmoist healing products.104,111,114
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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.
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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.
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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
burns unit for scar management by day 10–14.
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
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.
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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 evidencebased 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
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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
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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.
7
good practice point
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
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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
services.
C
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
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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
exposure.154,157,160,161,163
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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
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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
High-voltage electrical injuries result in severe skin burns and may cause respiratory and cardiac arrest.175 Highvoltage 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.
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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 highvoltage group (n=41).192
This is supported by a retrospective case series (n=195) of high-voltage electrical injury admissions over a 19year 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
ECG or for continuous monitoring.
B
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
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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 nonspeciﬁc 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
who remain asymptomatic for four hours.200
8
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 followup 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
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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).
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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. Longacting 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
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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
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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
dependence) associated with post-traumatic stress disorder (PTSD).
B
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
child are likely to involve other family members as well.
10
Psychological reactions to trauma are categorised by the timeframe since the event (see Table 10.1).
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table 10.1: diagnosis according to duration of stress symptoms
duration of
symptoms
diagnosis
comments
Less than one month
Acute stress disorder
(not PTSD)
These are symptoms that occur in the immediate
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.
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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 followup 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.
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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).
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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
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Chapter 11
Burn injuries in Ma¯ori
good practice points
Be aware that Ma¯ori tamariki (children) are at increased risk of burn-related injuries and
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¯ori.11
Analysis of New Zealand Health Information Service hospitalisation data for injury between 1985 and 1994
indicates that Ma¯ori children are at high risk of burn-related injuries.245 Injuries from ﬁre and burns account for
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
Tamariki form the largest group of the Ma¯ori population. If they continue to be over-represented in burns
statistics this will impact on the hauora (health and wellbeing) of the individual, the wha¯nau, the hapu¯ and
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
children’s involvement in household tasks in Ma¯ori 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
study in 2002 suggested that Ma¯ori may be less likely to use cold water therapy on burns compared with people
of European descent.1
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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 helpseeking. Ma¯ori 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
a result, some Ma¯ori 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
Ma¯ori 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.
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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
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
12
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.
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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.
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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
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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. Another Ma¯ori 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.
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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
• iwi/Ma¯ori 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
• medical colleges/professional bodies
• pharmacists.
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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
newspapers and television programmes. This could include Ma¯ori 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.
Consumer information should be offered in Ma¯ori 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.
• Developing local strategies to reduce barriers to follow-up care for people with burns, particularly Ma¯ori 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.
• Designing a consumer resource for Ma¯ori in consultation with iwi providers.
• Monitoring the educational information that is given out.
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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?
• a targeted prevention campaign for Ma¯ori 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.
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Appendices
A.
Evidence and recommendation grading system
B.
Wound care options
C.
DSM-IV criteria for post-traumatic stress disorder
D.
Useful resources
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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.
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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
that are valid, consistent, applicable and clinically relevant).
A
The recommendation is supported by fair evidence (based on studies that are valid, but
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).
B
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.
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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.
name
indications
advantages
disadvantages
wear
time
Parafﬁn or
siliconeimpregnated
ﬁbres
Burns with
minimal exudate
Covers and protects
Limited moisture
retention
24–48
hours
Grafts when
healing well
Non-sensitising
Non-irritant
May cause trauma on
removal
Requires a secondary
dressing to keep it in
place and maintain
moisture balance
Hydrocolloids
For burns with
light to moderate
exudate
Sloughy and
necrotic burns
Maintains moisture balance
Can help with autolytic
debridement
Self-adhesive and moulds
well
Impermeable to bacteria and
contaminants
No secondary dressing
required
Transparent
ﬁlms
Superﬁcial burns
Burns with little
or no exudate
As protection
for fragile
compromised
areas of
unbroken skin
Impermeable to bacteria and
contaminants
Supports autolytic
debridement
Allows visualisation of the
wound
No secondary dressing
required
Not recommended
for heavily exudating
burns, sinuses or
tracts
Three to
seven days
May tear fragile
surrounding skin on
removal
Dressing odour can be
offensive
Gel can be mistaken
for pus
Not recommended for
exudating burns or
new burns
One to
three days
Requires dry border to
adhere
Can be difﬁcult to
handle
May not stay in place
in areas of moisture
Continued …
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name
indications
advantages
disadvantages
Hydrogels
For necrotic and
sloughy burns
Rehydrates the wound bed
Not recommended for
moderate or heavily
exudating burns
Deep-cavity burns
with necrosis and
slough and light
exudate
Aids autolytic debridement
Fills dead space in cavity
burns
Small amount of absorptive
action
Can be soothing and reduce
pain
Alginates
One to two
days
Requires secondary
dressing
Can macerate wound
edges if not carefully
applied
Can soak into some
secondary dressings
For partial and
full thickness
burns with
moderate to
heavy exudate
Absorbs 20 times its own
weight
Supports debridement
Not recommended
for lightly exudating
wounds or wounds
with eschar (a dry scab
or slough)
Wounds with
undermining or
sinus tracts
Fills dead space (comes in
wicks as well as sheets)
If dries out can be
difﬁcult to remove
Easy to remove if gelled
Wounds with
necrotic tissue
with exudate
Easy to use and cut to ﬁt
Requires a secondary
dressing
Forms a gel over wound
wear
time
One to four
days
Infected wounds
Hydroﬁbres
Partial thickness
burns
Absorbs 25 times its own
weight
Moderate to
heavily exudating
burns
Vertically wicks ﬂuid
therefore controls lateral
spread of exudate
Can ﬁll dead space (comes in
wicks as well as sheets)
Not recommended for
dry burns – will adhere
to a dry wound
1–14 days
Not recommended for
burns with eschar
Requires a secondary
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 …
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name
indications
advantages
disadvantages
Foams
Partial and full
thickness burns
with minimal
to moderate
exudate
Non-adherent
Not recommended for
burns with little or no
exudate
Secondary
dressing
to provide
additional
absorption
May be used under
compression
Silver
dressings
Partial and full
thickness burns
Generally absorbs exudate
Different
products act
differently at
the wound bed
as per dressing
type, eg,
hydroﬁbre or
wound contact
dressing
Burns that appear
to be infected
Silver creams
Partial and full
thickness burns
Does not cause trauma on
removal
Easy to use and apply
Delivers antibacterial/
antimicrobial component
to wound bed – effective
against gram-positive and
gram-negative bacteria,
fungal infections
wear
time
One to ﬁve
days
May macerate
surrounding skin if it is
not protected
Needs to be taped if
it is in non-adhesive
form
Not recommended for
dry burns or burns with
eschar
Manufacturers’
instructions need
careful consideration
prior to application
depending on product
chosen
1–14 days
depending
upon
product
chosen
Requires secondary
dressing to secure
Dry eschars
Infected burns
Maintains moisture balance
Non-absorptive
Antibacterial/Antimicrobial
to multiple organisms
Can cause its own
pseudo eschar which
can be difﬁcult to
remove
Antibacterial effect
penetrates eschar
Aids in autolytic debridement
Comfortable for person
Easy to apply
Daily
dressing
required
Prolonged use is
detrimental to wound
cells and can delay
healing
Requires a secondary
dressing
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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.
A.
The person has been exposed to a traumatic event in which both of the following have
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.
B.
The traumatic event is persistently re-experienced in one (or more) of the following ways:
• 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.
C.
Persistent avoidance of stimuli associated with the trauma and numbing of general
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 …
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D.
Persistent symptoms of increased arousal (not present before the trauma), as indicated by
two (or more) of the following:
• difﬁculty falling or staying asleep
• irritability or outbursts of anger
• difﬁculty concentrating
• hypervigilance
• exaggerated startle response.
E.
F.
Duration of the disturbance (symptoms in Criteria B, C and D) is more than one month.
The disturbance causes clinically signiﬁcant distress or impairment in social, occupational
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.
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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
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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
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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
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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¯
Groups of wha¯nau with common ancestral links; sub-tribe.
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.
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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
A social and political unit made up of several hapu¯ sharing common descent; Ma¯ori tribe or
nation.
Kauma¯ tua
Wise and experienced older members of a wha¯nau, usually aged over 55 years.
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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References
1.
Skinner A, Peat B. Burns treatment for children and adults: A study of initial burns ﬁrst aid and hospital
care. N Z Med J 2002;115(1163):U199.
2.
Berkebile BL, Goldfarb IW, Slater H. Comparison of burn size estimates between prehospital reports and
burn center evaluations. J Burn Care Rehabil 1986;7(5):411-2.
3.
Collis N, Smith G, Fenton OM. Accuracy of burn size estimation and subsequent ﬂuid resuscitation prior to
arrival at the Yorkshire Regional Burns Unit. A three year retrospective study. Burns 1999;25(4):345-51.
4.
Hammond JS, Ward CG. Transfers from emergency room to burn center: Errors in burn size estimate. J
Trauma 1987;27(10):1161-5.
5.
Public Health Division. Management guidelines for people with burn injury. NSW Health Department;
1996.
6.
PRODIGY Knowledge. Burns and scalds. Revised November 2004. Sowerby Centre for Health Informatics
at Newcastle Limited. (SCHIN); 1998. http://www.prodigy.nhs.uk/burns_and_scalds [accessed August
2005].
7.
Morgan ED, Bledsoe SC, Barker J. Ambulatory management of burns. Am Fam Physician 2000;62(9):201526.
8.
New Zealand Guidelines Group. NZGG Training Handbook. Wellington: New Zealand Guidelines Group;
2003 http://www.nzgg.org.nz/download/ﬁles/nzgg_guideline_handbook.pdf.
9.
Ministry of Health. Immunisation Handbook 2006. Wellington: Ministry of Health; 2006 http://www.moh.
govt.nz/moh.nsf/pagesmh/4617/$File/2006-immunisation-handbook-all.pdf.
10.
Injury Prevention Research Unit, University of Otago. Injury to children in NZ resulting in death or
hospitalisation. Fact Sheet No. 22. Dunedin: Injury Prevention Research Unit, University of Otago; 2001.
11.
SafeKids New Zealand. Factsheet: Childhood Burn Injury; n.d. http://www.safekids.org.nz/factsheets/
Factsheet%20-%20Childhood%20Burn%20Injury%20.pdf [accessed July 2006].
12.
New Zealand Health Information Service. Selected Morbidity Data for Publicly Funded Hospitals 1 July
2002 to 30 June 2003. Wellington: Ministry of Health; 2006.
13.
Injury Prevention Research Unit, University of Otago. Trends in Thermal Injury. Fact Sheet No. 21. Dunedin:
Injury Prevention Research Unit; 2001.
14.
Zhang Z-lJ. General patterns of burn injury in ACC claim data. Presentation. Auckland: ACC; August, 2005.
15.
Morrow SE, Smith DL, Cairns BA, et al. Etiology and outcome of pediatric burns. J Pediatr Surg
1996;31(3):329-33.
16.
Chien WC, Pai L, Lin CC, et al. Epidemiology of hospitalized burns patients in Taiwan. Burns
2003;29(6):582-8.
17.
Laloe V. Epidemiology and mortality of burns in a general hospital of eastern Sri Lanka. Burns
2002;28(8):778-81.
18.
Lari AR, Panjeshahin MR, Talei AR, et al. Epidemiology of childhood burn injuries in Fars Province, Iran. J
Burn Care Rehabil 2002;23(1):39-45.
19.
Wilkinson E. The epidemiology of burns in secondary care, in a population of 2.6 million people. Burns
1998;24(2):139-43.
20.
Mahaluxmivala S, Borkar A, Mathur A, et al. A retrospective study of etiopathological and preventive
factors in a burns unit in Saudi Arabia. Burns 1997;23(4):333-7.
103
ACC15029-2 Pr#6.indd 103
5/17/07 12:11:37 PM
21.
Bang RL, Ebrahim MK, Sharma PN. Scalds among children in Kuwait. Eur J Epidemiol 1997;13(1):33-9.
22.
Fukunishi K, Takahashi H, Kitagishi H, et al. Epidemiology of childhood burns in the Critical Care Medical
Center of Kinki University Hospital in Osaka, Japan. Burns 2000;26(5):465-9.
23.
Zeitlin R, Somppi E, Jarnberg J. Paediatric burns in central Finland between the 1960s and the 1980s.
Burns 1993;19(5):418-22.
24.
Hockey R. Safe hot tap water and the risk of scalds and Legionella infection. Injury Prevention
2002;8(2):170.
25.
Ray JG. Burns in young children: A study of the mechanism of burns in children aged 5 years and under in
the Hamilton, Ontario burn unit. Burns 1995;21(6):463-6.
26.
Moritz AR, Henriques FC. Studies of thermal injury: The relative importance of time and surface
temperature in the causation of cutaneous burns. Am J Pathol 1947;23:695.
27.
Runyan CW, Bangdiwala SI, Linzer MA, et al. Risk factors for fatal residential ﬁres. N Engl J Med
1992;327(12):859-63.
28.
DiGuiseppi C, Higgins JP. Systematic review of controlled trials of interventions to promote smoke alarms.
Arch Dis Child 2000;82(5):341-8.
29.
Harre N, Coveney A. School-based scalds prevention: Reaching children and their families. Health Educ
Res 2000;15(2):191-202.
30.
Turner C, Spinks A, McClure R, et al. Community-based interventions for the prevention of burns and
scalds in children. Cochrane Database Syst Rev 2004(3):CD004335.
31.
Hudspith J, Rayatt S. First aid and treatment of minor burns. BMJ 2004;328(7454):1487-9.
32.
British Burn Association. Pre-hospital approach to burns patient management. Manchester: British Burn
Association; 2002 http://www.britishburnassociation.org/Downloads/pre-hosp.pdf [accessed August
2006].
33.
Australian and New Zealand Burn Association. Emergency management of severe burns: Course manual.
8th ed: Australian and New Zealand Burn Association Limited; 2004.
34.
Sawada Y, Urushidate S, Yotsuyanagi T, et al. Is prolonged and excessive cooling of a scalded wound
effective? Burns 1997;23(1):55-8.
35.
Nguyen NL, Gun RT, Sparnon AL, et al. The importance of initial management: A case series of childhood
burns in Vietnam. Burns 2002;28(2):167-72.
36.
Tung K, Chen M, Wang H, et al. A seven-year epidemiology study of 12,381 admitted burn patients in
Taiwan – using the internet system of the childhood burn foundation. Burns 2005;31S:S12-7.
37.
Werner MU, Lassen B, Pedersen JL, et al. Local cooling does not prevent hyperalgesia following burn injury
in humans. Pain 2002;98(3):297-303.
38.
Raghupati N. First-aid treatment of burns: Efﬁcacy of water cooling. Br J Plast Surg 1968;21(1):68-72.
39.
Jandera V, Hudson DA, de Wet PM, et al. Cooling the burn wound: Evaluation of different modalites. Burns
2000;26(3):265-70.
40.
de Camara DL, Raine T, Robson MC. Ultrastructural aspects of cooled thermal injury. J Trauma
1981;21(11):911-9.
41.
Jakobsson OP, Arturson G. The effect of prompt local cooling on oedema formation in scalded rat paws.
Burns 1985;12(1):8-15.
42.
Blomgren I, Eriksson E, Bagge U. Effect of cold water immersion on oedema formation in the scalded
mouse ear. Burns 1982;9(1):17-20.
104
ACC15029-2 Pr#6.indd 104
5/17/07 12:11:38 PM
43.
Raine TJ, Heggers JP, Robson MC, et al. Cooling the burn wound to maintain microcirculation. J Trauma
1981;21(5):394-7.
44.
Mertz PM, Davis SC, Cazzaniga AL, et al. To assess second-degree burn wound treatment with water-jel.
Carlstadt NJ: Trilling Medical Technologies Inc; 1990.
45.
Castner T, Harz C, Schlor J. Cooling out of the bag. Water-jel burn dressings. Markdorf, Germany: Institute
for Emergency Medicine; 2000.
46.
Coats TJ, Edwards C, Newton R, et al. The effect of gel burns dressings on skin temperature. Emerg Med J
2002;19(3):224-5.
47.
Wilson GR, French G. Plasticized polyvinylchloride as a temporary dressing for burns. BMJ
1987;294(6571):556-7.
48.
Milner RH, Hudson SJ, Reid CA. Plasticized polyvinyl chloride ﬁlm as a primary burns dressing: A
microbiological study. Burns Incl Therm Inj 1988;14(1):62-5.
49.
Cole M, Shakespeare PG, Chissell HG, et al. Thermographaphic assessment of burns using a
nonpermeable membrane as a wound covering. Burns 1991;17(2):117-22.
50.
Hettiaratchy S, Papini R. Initial management of a major burn: I – overview. BMJ 2004;328(7455):1555-7.
51.
Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment and resuscitation. BMJ
2004;329(7457):101-3.
52.
Brusselaers N, Hoste EA, Monstrey S, et al. Outcome and changes over time in survival following severe
burns from 1985 to 2004. Intensive Care Med 2005;31(12):1648-53.
53.
Safﬂe JR, Zeluff GR, Warden GD. Intramuscular pressure in the burned arm: Measurement and response to
escharotomy. Am J Surg 1980;140(6):825-31.
54.
Smith DL, Cairns BA, Ramadan F, et al. Effect of inhalation injury, burn size, and age on mortality: A study
of 1447 consecutive burn patients. J Trauma 1994;37(4):655-9.
55.
Germann G, Barthold U, Lefering R, et al. The impact of risk factors and pre-existing conditions on
the mortality of burn patients and the precision of predictive admission-scoring systems. Burns
1997;23(3):195-203.
56.
Griffe O, Gartner R, Captier G, et al. Evaluation of prognostic factors in the burned patient. Ann Chir Plast
Esthet 2001;46(3):167-72.
57.
Smith DJ, Jr., Thomson PD, Garner WL, et al. Burn wounds: infection and healing. Am J Surg
1994;167(1A):46S-8S.
58.
O’Keefe GE, Hunt JL, Purdue GF. An evaluation of risk factors for mortality after burn trauma and the
identiﬁcation of gender-dependent differences in outcomes. J Am Coll Surg 2001;192(2):153-60.
59.
Ryan CM, Schoenfeld DA, Thorpe WP, et al. Objective estimates of the probability of death from burn
injuries. N Engl J Med 1998;338(6):362-6.
60.
Wolf SE, Rose JK, Desai MH, et al. Mortality determinants in massive pediatric burns. An analysis of 103
children with > or = 80% TBSA burns (> or = 70% full-thickness). Ann Surg 1997;225(5):554-65.
61.
Raff T, Germann G, Barthold U. Factors inﬂuencing the early prediction of outcome from burns. Acta Chir
Plast 1996;38(4):122-7.
62.
Amirsheybani HR, Crecelius GM, Timothy NH, et al. The natural history of the growth of the hand: I. Hand
area as a percentage of body surface area. Plast Reconstr Surg 2001;107(3):726-33.
63.
Berry MG, Evison D, Roberts AH. The inﬂuence of body mass index on burn surface area estimated from
the area of the hand. Burns 2001;27(6):591-4.
105
ACC15029-2 Pr#6.indd 105
5/17/07 12:11:38 PM
64.
Nagel TR, Schunk JE. Using the hand to estimate the surface area of a burn in children. Pediatr Emerg Care
1997;13(4):254-5.
65.
Perry RJ, Moore CA, Morgan BD, et al. Determining the approximate area of a burn: An inconsistency
investigated and re-evaluated. BMJ 1996;312(7042):1338.
66.
Rossiter ND, Chapman P, Haywood IA. How big is a hand? Burns 1996;22(3):230-1.
67.
Sheridan RL, Petras L, Basha G, et al. Planimetry study of the percent of body surface represented by
the hand and palm: Sizing irregular burns is more accurately done with the palm. J Burn Care Rehabil
1995;16(6):605-6.
68.
Kanthraj GR, Srinivas CR, Shenoi SD, et al. Comparison of computer-aided design and rule of nines
methods in the evaluation of the extent of body involvement in cutaneous lesions. Arch Dermatol
1997;133(7):922-3.
69.
Livingston EH, Lee S. Percentage of burned body surface area determination in obese and nonobese
patients. J Surg Res 2000;91(2):106-10.
70.
Tripodi S, Panetta V, Pelosi S, et al. Measurement of body surface area in atopic dermatitis using speciﬁc
pc software (scoradcard). Pediatr Allergy Immunol 2004;15(1):89-92.
71.
Scott-Conner CE, Clarke KM, Conner HF. Burn area measurement by computerized planimetry. J Trauma
1988;28(5):638-41.
72.
Neuwalder JM, Sampson C, Breuing KH, et al. A review of computer-aided body surface area
determination: Sage ii and epri’s 3d burn vision. J Burn Care Rehabil 2002;23(1):55-9; discussion 4.
73.
Wachtel TL, Berry CC, Wachtel EE, et al. The inter-rater reliability of estimating the size of burns from
various burn area chart drawings. Burns 2000;26(2):156-70.
74.
Hidvegi N, Nduka C, Myers S, et al. Estimation of breast burn size. Plast Reconstr Surg 2004;113(6):15917.
75.
Bennett JE, Dingman RO. Evaluation of burn depth by the use of radioactive isotopes – an experimental
study. Plast Reconstr Surg 1975;20(4):261-72.
76.
Hemington-Gorse SJ. A comparison of laser doppler imaging with other measurement techniques to
assess burn depth. J Wound Care 2005;14(4):151-3.
77.
Renkielska A, Nowakowski A, Kaczmark M, et al. Static thermography revisited – an adjunct method for
determining the depth of burn injury. Burns 2005;31(6):768-75.
78.
Chatterjee JS. A critical evaluation of the clinimetrics of laser doppler as a method of burn assessment in
clinical practice. J Burn Care Res 2006;27(2):123-30.
79.
Jeng JC, Bridgeman A, Shivnan L, et al. Laser doppler imaging determines need for excision and grafting in
advance of clinical judgment: A prospective blinded trial. Burns 2003;29(7):665-70.
80.
Andronicus M, Oates RK, Peat J, et al. Non-accidental burns in children. Burns 1998;24(6):552-8.
81.
Herndon DN, Rutan RL, Rutan TC. Management of the pediatric patient with burns. J Burn Care Rehabil
1993;14(1):3-8.
82.
Hight DW, Bakalar HR, Lloyd JR. Inﬂicted burns in children. Recognition and treatment. JAMA
1979;242(6):517-20.
83.
Ebbin AJ, Gollub MH, Stein AM, et al. Battered child syndrome at the Los Angeles county general hospital.
Am J Dis Child 118(4):660-7 1969;118(4):660-7.
84.
Friedman SB, Morse CW. Child abuse: A ﬁve-year follow-up of early case ﬁnding in the emergency
department. Pediatrics 1974;54(4):404-10.
106
ACC15029-2 Pr#6.indd 106
5/17/07 12:11:38 PM
85.
Bowden ML, Grant ST, Vogel B, et al. The elderly, disabled and handicapped adult burned through abuse
and neglect. Burns Incl Therm Inj 1988;14(6):447-50.
86.
Ministry of Health. Suspected child abuse and neglect: Recommended referral process for general
practitioners. Wellington: Ministry of Health; 2000.
87.
Papini R. Management of burn injuries of various depths. BMJ 2004;329(7458):158-60.
88.
Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns 2006;32(2):145-50.
89.
Organization and delivery of burn care. J Burn Care Rehabil 2001;1S-4S.
90.
Pedersen JL, Moiniche S, Kehlet H. Topical glucocorticoid has no antinociceptive or anti-inﬂammatory
effect in thermal injury. Br J Anaesth 1994;72(4):379-82.
91.
Dreher F, Denig N, Gabard B, et al. Effect of topical antioxidants on UV-induced erythema formation when
administered after exposure. Dermatology 1999;198(1):52-5.
92.
Thomas SS, Lawrence JC, Thomas A. Evaluation of hydrocolloids and topical medication in minor burns. J
Wound Care 1995;4(5):218-20.
93.
Wasiak J, Cleland H. Burns (minor thermal). Clin Evid 2005;Dec(14):2388-96.
94.
Miles F, Voss L, Segedin E, et al. Review of staphylococcus aureus infections requiring admission to a
paediatric intensive care unit. Arch Dis Child 2005;90(12):1274-8.
95.
Subrahmanyam M. Effect of topical application of honey on burn wound healing. Annals of Burns and Fire
Disaster 2001;XIV:143-5.
96.
Subrahmanyam M. A prospective randomised clinical and histological study of superﬁcial burn wound
healing with honey and silver sulfadiazine. Burns 1998;24(2):157-61.
97.
Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg 1991;78(4):497-8.
98.
Bugmann P, Taylor S, Gyger D, et al. A silicone-coated nylon dressing reduces healing time in burned
paediatric patients in comparison with standard sulfadiazine treatment: A prospective randomized trial.
Burns 1998;24(7):609-12.
99.
Tredget EE, Shankowsky HA, Groeneveld A, et al. A matched-pair, randomized study evaluating the
efﬁcacy and safety of acticoat silver-coated dressing for the treatment of burn wounds. J Burn Care Rehabil
1998;19(6):531-7.
100. Inman RJ, Snelling CF, Roberts FJ, et al. Prospective comparison of silver sulfadiazine 1 per cent plus
chlorhexidine digluconate 0.2 per cent (silvazine) and silver sulfadiazine 1 per cent (ﬂamazine) as
prophylaxis against burn wound infection. Burns Incl Therm Inj 1984;11(1):35-40.
101. Curreri PW, Desai MH, Bartlett RH, et al. Safety and efﬁcacy of a new synthetic burn dressing: A multicenter
study. Arch Surg 1980;115(8):925-7.
102. Gotschall CS, Morrison MI, Eichelberger MR. Prospective, randomized study of the efﬁcacy of mepitel on
children with partial-thickness scalds. J Burn Care Rehabil 1998;19(4):279-83.
103. Subrahmanyam M. Honey dressing versus boiled potato peel in the treatment of burns: A prospective
randomized study. Burns 1996;22(6):491-3.
104. Subrahmanyam M. Honey impregnated gauze versus polyurethane ﬁlm (opsite) in the treatment of burns
– a prospective randomised study. Br J Plast Surg 1993;46(4):322-3.
105. Edwards-Jones V, Greenwood JE. What’s new in burn microbiology?: James Laing memorial prize essay
2000. Burns 2003;29(1):15-24.
106. Hermans MH. Results of a survey on the use of different treatment options for partial and full thickness
burns. Burns 1998;24(6):539-51.
107
ACC15029-2 Pr#6.indd 107
5/17/07 12:11:39 PM
107. Masaki F, Gozo N, Yuichi H, et al. Fatal possible toxic shock syndrome in an adult following 15% scald
burn. Burns 2004;30(2):181-4.
108. Wharton M, Chorba TL, Vogt RL, et al. Case deﬁnitions for public health surveillance. MMWR
1990;39(45):822-4.
109. Edwards-Jones V, Dawson MM, Childs C. A survey into toxic shock syndrome (TSS) in UK burns units. Burns
2000;26(4):323-33.
110. Aﬁlalo M, Dankoff J, Guttman A, et al. Duoderm hydroactive dressing versus silver sulphadiazine/bactigras
in the emergency treatment of partial skin thickness burns. Burns 1992;18(4):313-6.
111. Neal DE, Whalley PC, Flowers MW, et al. The effects of an adherent polyurethane ﬁlm and conventional
absorbent dressing in patients with small partial thickness burns. Br J Clin Pract 1981;35(7-8):254-7.
112. Poulsen TD, Freund KG, Arendrup K, et al. Polyurethane ﬁlm (opsite) vs. Impregnated gauze (jelonet) in the
treatment of outpatient burns: A prospective, randomized study. Burns 1991;17(1):59-61.
113. Wright A, MacKechnie DW, Paskins JR. Management of partial thickness burns with granuﬂex ‘e’ dressings.
Burns 1993;19(2):128-30.
114. Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid dressing and silver sulfadiazine cream
in the outpatient management of second-degree burns. J Trauma 1990;30(7):857-65.
115. Wiechula R. The use of moist wound-healing dressings in the management of split-thickness skin graft
donor sites: A systematic review. Int J Nurs Pract 2003;9(2):S9-17.
116. Wright A, MacKechnie DWM, Paskins JR. Management of partial thickness burns with granuﬂex ‘e’
dressings. Burns 1993;19(2):128-30.
117. Costagliola M, Agrosi M. Second-degree burns: A comparative, multicenter, randomized trial of hyaluronic
acid plus silver sulfadiazine vs. silver sulfadiazine alone. Curr Med Res Opin 2005;21(8):1235.
118. Koller J. Topical treatment of partial thickness burns by silver sulfadiazine plus hyaluronic acid compared
to silver sulfadiazine alone: A double-blind, clinical study. Drugs Exp Clin Res 2004;30(5-6):183-90.
119. de Gracia CG. An open study comparing topical silver sulfadiazine and topical silver sulfadiazine-cerium
nitrate in the treatment of moderate and severe burns. Burns 2001;27(1):67-74.
120. Soroff HS, Sasvary DH. Collagenase ointment and polymyxin b sulfate/bacitracin spray versus silver
sulfadiazine cream in partial-thickness burns: A pilot study. J Burn Care Rehabil 1994;15(1):13-7.
121. Zhang X. Report of moist exposed burn ointment: Phase iii clinical trials multicentre study. Chinese Journal
of Burns, Wounds and Surface Ulcers 2000;12(2):11-5.
122. Edgar D, Brereton M. Rehabilitation after burn injury. BMJ 2004;329(7461):343-5.
123. Esselman P, Thombs B, Magyar-Russell G, et al. Burn rehabilitation: State of the science. Am J Phys Med
Rehabil 2006;85:388-413.
124. Swain AH, Azadian BS, Wakeley CJ, et al. Management of blisters in minor burns. BMJ 1987;295(6591):
81.
125. Singer AJ, Thode HC, Jr., McClain SA. The effects of epidermal debridement of partial-thickness burns on
infection and reepithelialisation in swine. Acad Emerg Med 2000;7(2):114-9.
126. Sargent R. Management of blisters in the partial-thickness burn: An integrative research review. J Burn
Care Res 2006;27(1):66-81.
127. Desmouliere A. Tissue remodeling during healing, role of apoptosis. Paper presented at Euroconference
on tissue repair and ulcer/wound healing: molecular mechanisms, therapeutic targets and future
directions: Paris, 17-18 March; 2005.
128. Linares M. From wound to scar. Burns 1996;22(5):339-52.
108
ACC15029-2 Pr#6.indd 108
5/17/07 12:11:39 PM
129. Mutalik S. Treatment of keloids and hypertrophic scars. Indian J Dermatol Venereol Leprol 2005;71:3-8.
130. Carr-Collins JA. Pressure techniques for the prevention of hypertrophic scar. Clin Plast Surg
1992;19(3):733-43.
131. Patino O, Novick C, Merlo A, et al. Massage in hypertrophic scars. J Burn Care Rehabil 1999;20(3):268-71;
Discussion 7.
132. O’Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars.
Cochrane Database Syst Rev 2006(1):CD003826.
133. Zhang ZL, Bennett S, Bowens A. Evidence based review: Hyperbaric oxygen therapy – evidence of
effectiveness: Accident Compensation Corporation (ACC); 2004.
134. Anzarut A, Singh P, Tredget E, et al. Pressure garment therapy after burn injury (protocol). Cochrane
Database Syst Rev 2004(2):Art. No.: CD004984. DOI: 10.1002/14651858.CD004984.
135. Ward RS. Pressure therapy for the control of hypertrophic scar formation after burn injury. A history and
review. J Burn Care Rehabil 1991;12(3):257-62.
136. Macintyre L, Baird M. Pressure garments for use in the treatment of hypertrophic scars –a review of the
problems associated with their use. Burns 2006;32(1):10-5.
137. Kealey GP, Jensen KL, Laubenthal KN, et al. Prospective randomized comparison of two types of pressure
therapy garments. J Burn Care Rehabil 1990;11(4):334-6.
138. Chang P, Laubenthal KN, Lewis RW, 2nd, et al. Prospective, randomized study of the efﬁcacy of pressure
garment therapy in patients with burns. J Burn Care Rehabil 1995;16(5):473-5.
139. Van den Kerckhove E, Stappaerts K, Fieuws S, et al. The assessment of erythema and thickness on burn
related scars during pressure garment therapy as a preventive measure for hypertrophic scarring. Burns
2005;31(6):696-702.
140. Johnson J, Greenspan B, Gorga D, et al. Compliance with pressure garment use in burn rehabilitation. J
Burn Care Rehabil 1994;15(2):180-8.
141. Singer A, Sagi A, Ben Meir P, et al. Chemical burns: Our 10-year experience. Burns 1992;18(3):250-2.
142. Sykes RA, Mani MM, Hiebert JM. Chemical burns: Retrospective review. J Burn Care Rehabil 1986;7(4):3437.
143. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: Effect of prompt ﬁrst aid. Journal of Trauma Injury
Infection & Critical Care 1982;22(5):420-3.
144. Cartotto RC, Peters WJ, Neligan PC, et al. Chemical burns. Can J Surg 1996;39(3):205-11.
145. Smith ML. Pediatric burns: Management of thermal, electrical, and chemical burns and burn-like
dermatologic conditions. Pediatric Annals 2000;29(6):367-78.
146. Edlich RF, Farinholt HM, Winters KL, et al. Modern concepts of treatment and prevention of chemical
injuries. J Long Term Eff Med Implants 2005;15(3):303-18.
147. Rodeheaver GT, Hiebert JM, Edlich RF. Initial treatment of chemical skin and eye burns. Compr Ther
1982;8(5):37-43.
148. Stewart CE. Chemical skin burns. Am Fam Physician 1985;31(6):149-57.
149. Winfree J, Barillo DJ. Burn management. Nonthermal injuries. Nurs Clin North Am 1997;32(2):275-96.
150. Orcutt TJ, Pruitt BA. Chemical injuries of the upper extremity. Major Probl Clin Surg 1976;19:84-95.
151. Barillo DJ, Cancio LC, Goodwin CW. Treatment of white phosphorus and other chemical burn injuries at one
burn center over a 51-year period. Burns 2004;30(5):448-52.
152. Mozingo DW, Smith AA, McManus WF, et al. Chemical burns. J Trauma 1988;28(5):642-7.
109
ACC15029-2 Pr#6.indd 109
5/17/07 12:11:39 PM
153. Xie Y, Tan Y, Tang S. Epidemiology of 377 patients with chemical burns in Guangdong province. Burns
2004;30(6):569-72.
154. Wedler V, Guggenheim M, Moron M, et al. Extensive hydroﬂuoric acid injuries: A serious problem. J Trauma
2005;58(4):852-7.
155. Gallerani M, Bettoli V, Peron L, et al. Systemic and topical effects of intradermal hydroﬂuoric acid. Am J
Emerg Med 1998;16(5):521-2.
156. Yamaura K, Kao B, Iimori E, et al. Recurrent ventricular tachyarrhythmias associated with QT prolongation
following hydroﬂuoric acid burns. J Toxicol Clin Toxicol 1997;35(3):311-3.
157. Kirkpatrick JJ, Enion DS, Burd DA. Hydroﬂuoric acid burns: A review. Burns 1995;21(7):483-93.
158. Matsuno K. The treatment of hydroﬂuoric acid burns. Occup Med (Lond) 1996;46(4):313-7.
159. Lin TM, Tsai CC, Lin SD, et al. Continuous intra-arterial infusion therapy in hydroﬂuoric acid burns. J Occup
Environ Med 2000;42(9):892-7.
160. Caravati EM. Acute hydroﬂuoric acid exposure. Am J Emerg Med 1988;6(2):143-50.
161. Iverson RE, Laub DR, Madison MS. Hydroﬂuoric acid burns. Plast Reconstr Surg 1971;48(2):107-12.
162. Muriale L, Lee E, Genovese J, et al. Fatality due to acute ﬂuoride poisoning following dermal contact with
hydroﬂuoric acid in a palynology laboratory. Ann Occup Hyg 1996;40(6):705-10.
163. Sheridan RL, Ryan CM, Quinby WC, Jr, et al. Emergency management of major hydroﬂuoric acid exposures.
Burns 1995;21(1):62-4.
164. Bertolini JC. Hydroﬂuoric acid: A review of toxicity. J Emerg Med 1992;10(2):163-8.
165. Hatzifotis M, Williams A, Muller M, et al. Hydroﬂuoric acid burns. Burns 2004;30(2):156-9.
166. Ohata U, Hara H, Suzuki H. 7 cases of hydroﬂuoric acid burn in which calcium gluconate was effective for
relief of severe pain. Contact Dermatitis 2005;52(3):133-7.
167. Mangion SM, Beulke SH, Braitberg G. Hydroﬂuoric acid burn from a household rust remover. Med J Aust
2001;175(5):270-1.
168. Kono K, Watanabe T, Dote T, et al. Successful treatments of lung injury and skin burn due to hydroﬂuoric
acid exposure. Int Arch Occup Environ Health 2000;73 Suppl:S93-7.
169. Chou TD, Lee TW, Chen SL, et al. The management of white phosphorus burns. Burns 2001;27(5):492-7.
170. Konjoyan TR. White phosphorus burns: Case report and literature review. Mil Med 1983;148(11):881-4.
171. Davis KG. Acute management of white phosphorus burn. Mil Med 2002;167(1):83-4.
172. Kaufman T, Ullmann Y, Har-Shai Y. Phosphorus burns: A practical approach to local treatment. J Burn Care
Rehabil 1988;9(5):474-5.
173. Fontanarosa PB. Electrical shock and lightning strike. Ann Emerg Med 1993;22(2 Pt 2):378-87.
174. Orme S, Channer KS. Tachycardia following low-tension electrocution. Postgrad Med J 1999;75(885):43940.
175. Bingham H. Electrical burns. Clin Plast Surg 1986;13(1):75-85.
176. Edlich RF, Farinholt HM, Winters KL, et al. Modern concepts of treatment and prevention of electrical burns.
J Long Term Eff Med Implants 2005;15(5):511-32.
177. Koumbourlis AC. Electrical injuries. Crit Care Med 2002;30(11 Suppl).
178. Rai J, Jeschke MG, Barrow RE, et al. Electrical injuries: A 30-year review. J Trauma 1999;46(5):933-6.
179. Edlich RF, Farinholt HM, Winters KL, et al. Modern concepts of treatment and prevention of lightning
injuries. J Long Term Eff Med Implants 2005;15(2):185-96.
110
ACC15029-2 Pr#6.indd 110
5/17/07 12:11:40 PM
180. Fish RM. Electric injury, part iii: Cardiac monitoring indications, the pregnant patient, and lightning. J
Emerg Med 2000;18(2):181-7.
181. Muehlberger T, Vogt PM, Munster AM. The long-term consequences of lightning injuries. Burns
2001;27(8):829-33.
182. Grube BJ, Heimbach DM, Engrav LH, et al. Neurologic consequences of electrical burns. J Trauma
1990;30(3):254-8.
183. Norman ME, Albertson D, Younge BR. Ophthalmic manifestations of lightning strike. Surv Ophthalmol
2001;46(1):19-24.
184. Ratnayake B, Emmanuel ER, Walker CC. Neurological sequelae following a high voltage electrical burn.
Burns 1996;22(7):574-7.
185. Guinard JP, Chiolero R, Buchser E, et al. Myocardial injury after electrical burns: Short and long term study.
Scand J Plast Reconstr Surg Hand Surg 1987;21(3):301-2.
186. Garcia-Sanchez V, Gomez Morell P. Electric burns: High- and low-tension injuries. Burns 1999;25(4):35760.
187. Housinger TA, Green L, Shahangian S, et al. A prospective study of myocardial damage in electrical
injuries.[erratum appears in J Trauma 1986 Jul;26(7):659]. J Trauma 1985;25(2):122-4.
188. Hammond J, Ward CG. Myocardial damage and electrical injuries: Signiﬁcance of early elevation of CPK-MB
isoenzymes. South Med J 1986;79(4):414-6.
189. Chandra NC, Siu CO, Munster AM. Clinical predictors of myocardial damage after high voltage electrical
injury. Crit Care Med 1990;18(3):293-7.
190. Purdue GF, Hunt JL. Electrocardiographic monitoring after electrical injury: Necessity or luxury. J Trauma
1986;26(2):166-7.
191. Matsumura H, Kobayashi Y, Mann R, et al. Residual myocardial damage following electrical injuries. J Burn
Care Rehabil 1997;18(4):299-305.
192. Xiao J, Cai BR. A clinical study of electrical injuries. Burns 1994;20(4):340-6.
193. Cancio LC, Jimenez-Reyna JF, Barillo DJ, et al. One hundred ninety-ﬁve cases of high-voltage electric injury.
J Burn Care Rehabil 2005;26(4):331-40.
194. Bailey B, Gaudreault P, Thivierge RL. Experience with guidelines for cardiac monitoring after electrical
injury in children. Am J Emerg Med 2000;18(6):671-5.
195. Bailey B, Gaudreault P, Thivierge RL, et al. Cardiac monitoring of children with household electrical
injuries. Ann Emerg Med 1995;25(5):612-7.
196. Blackwell N, Hayllar J. A three year prospective audit of 212 presentations to the emergency department
after electrical injury with a management protocol. Postgrad Med J 2002;78(919):283-5.
197. Celik A, Ergun O, Ozok G. Pediatric electrical injuries: A review of 38 consecutive patients. J Pediatr Surg
2004;39(8):1233-7.
198. Cunningham PA. The need for cardiac monitoring after electrical injury. Med J Aust 1991;154(11):765-6.
199. Fatovich DM, Lee KY. Household electric shocks: Who should be monitored? Med J Aust 1991;155(5):3013.
200. Garcia CT, Smith GA, Cohen DM, et al. Electrical injuries in a pediatric emergency department. Ann Emerg
Med 1995;26(5):604-8.
201. Wilson CM, Fatovich DM. Do children need to be monitored after electric shocks? J Paediatr Child Health
1998;34(5):474-6.
111
ACC15029-2 Pr#6.indd 111
5/17/07 12:11:40 PM
202. Wallace BH, Cone JB, Vanderpool RD, et al. Retrospective evaluation of admission criteria for paediatric
electrical injuries. Burns 1995;21(8):590-3.
203. Arrowsmith J, Usgaocar RP, Dickson WA. Electrical injury and the frequency of cardiac complications. Burns
1997;23(7-8):576-8.
204. Ulmer JF. Burn pain management: A guideline-based approach. J Burn Care Rehabil 1998;19(2):151-9.
205. Ang E, Lee ST, Gan CSG, et al. Pain control in a randomized, controlled, clinical trial comparing moist
exposed burn ointment and conventional methods in patients with partial-thickness burns. J Burn Care
Rehabil 2003;24(5):289-96.
206. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Acute pain management:
Scientiﬁc evidence. 2nd ed: Australian and New Zealand College of Anaesthetists; 2005.
207. Carr E. Pain-free states. Nurs Times 1992;88(48):44-6.
208. Jacox A, Carr DB, Payne R. New clinical-practice guidelines for the management of pain in patients with
cancer. N Engl J Med 1994;330(9):651-5.
209. Bickel A, Dorfs S, Schmelz M, et al. Effects of antihyperalgesic drugs on experimentally induced
hyperalgesia in man. Pain 1998;76:317-25.
210. Borland ML, Bergesio R, Pascoe EM, et al. Intranasal fentanyl is an equivalent analgesic to oral morphine
in paediatric burns patients for dressing changes: A randomised double blind crossover study. Burns
2005;31(7):831-7.
211. Ferguson SL, Voll KV. Burn pain and anxiety: The use of music relaxation during rehabilitation. J Burn Care
Rehabil 2004;25(1):8-14.
212. Fratianne RB, Prensner JD, Huston MJ, et al. The effect of music-based imagery and musical alternate
engagement on the burn debridement process. J Burn Care Rehabil 2001;22(1):47-53.
213. Field T, Peck M, Krugman S, et al. Burn injuries beneﬁt from massage therapy. J Burn Care Rehabil
1998;19(3):241-4.
214. Field T, Peck M, Hernandez-Reif M, et al. Postburn itching, pain, and psychological symptoms are reduced
with massage therapy. J Burn Care Rehabil 2000;21(3):189-93.
215. Gustorff B, Hoechtl K, Sycha T, et al. The effects of remifentanil and gabapentin on hyperalgesia in a new
extended inﬂammatory skin pain model in healthy volunteers. Anesth Analg 2004;98(2):401-7.
216. Hammer NA, Lilleso J, Pedersen JL, et al. Effect of riluzole on acute pain and hyperalgesia in humans. Br J
Anaesth 1999;82(5):718-22.
217. Haythornthwaite JA, Lawrence JW, Fauerbach JA. Brief cognitive interventions for burn pain. Ann Behav
Med 2001;23(1):42-9.
218. Holthusen H, Irsfeld S, Lipfert P. Effect of pre- or post-traumatically applied I.V. Lidocaine on primary and
secondary hyperalgesia after experimental heat trauma in humans. Pain 2000;88(3):295-302.
219. Ilkjaer S, Dirks J, Brennum J, et al. Effect of systemic n-methyl-d-aspartate receptor antagonist
(dextromethorphan) on primary and secondary hyperalgesia in humans. Br J Anaesth 1997;79(5):600-5.
220. Ilkjaer S, Petersen KL, Brennum J, et al. Effect of systemic n-methyl-d-aspartate receptor antagonist
(ketamine) on primary and secondary hyperalgesia in humans. Br J Anaesth 1996;76(6):829-34.
221. Long TD, Cathers TA, Twillman R, et al. Morphine-infused silver sulfadiazine (miss) cream for burn
analgesia: A pilot study. J Burn Care Rehabil 2001;22(2):118-23.
222. Mikkelsen S, Jorgensen H, Larsen PS, et al. Effect of oral ketamine on secondary hyperalgesia, thermal and
mechanical pain thresholds, and sedation in humans. Reg Anesth Pain Med 2000;25(5):452-8.
112
ACC15029-2 Pr#6.indd 112
5/17/07 12:11:40 PM
223. Patterson DR, Ptacek JT, Carrougher G, et al. The 2002 Lindberg award. PRN vs regularly scheduled opioid
analgesics in pediatric burn patients. J Burn Care Rehabil 2002;23(6):424-30.
224. Petersen KL, Brennum J, Dahl JB. Experimental evaluation of the analgesic effect of ibuprofen on primary
and secondary hyperalgesia. Pain 1997;70(2-3):167-74.
225. Sharar SR, Carrougher GJ, Selzer K, et al. A comparison of oral transmucosal fentanyl citrate and oral
oxycodone for pediatric outpatient wound care. J Burn Care Rehabil 2002;23(1):27-31.
226. Latarjet J. [The pain from burns] French. Pathol Biol (Paris) 2002;50(2):127-33.
227. Choiniere M, Melzack R, Rondeau J, et al. The pain of burns: Characteristics and correlates. J Trauma
1989;29(11):1531-9.
228. Cleeland CS, Ryan KM. Pain assessment: Global use of the brief pain inventory. Ann Acad Med Singapore
1994;23(2):129-38.
229. Paediatrics and Child Health Division, The Royal Australasian College of Physicians. Guideline statement:
Management of procedure-related pain in children and adolescents. Sydney: Royal Australasian College of
Physicians; 2005.
230. American Psychiatric Association. DSM-IV. Diagnostic and statistical manual of mental disorders.
Washington (DC): American Psychiatric Association; 1994.
231. Stoddard FJ, Saxe G, Ronfeldt H, et al. Acute stress symptoms in young children with burns. J Am Acad
Child Adolesc Psychiatry 2006;45(1):87-93.
232. Difede J, Ptacek JT, Roberts J, et al. Acute stress disorder after burn injury: A predictor of posttraumatic
stress disorder? Psychosom Med 2002;64(5):826-34.
233. Van Loey NEE, Maas CJM, Faber AW, et al. Predictors of chronic posttraumatic stress symptoms following
burn injury: Results of a longitudinal study. J Trauma Stress 2003;16(4):361-9.
234. Bisson JI, Jenkins PL, Alexander J, et al. Randomised controlled trial of psychological debrieﬁng for victims
of acute burn trauma. Br J Psychiatry 1997;171:78-81.
235. Ehlers A, Clark D, Hackmann A, et al. A randomized controlled trial of cognitive therapy, a self-help booklet
and repeated assessments as early interventions for post-traumatic stress disorder. Arch Gen Psychiatry
2003;60:1024-32.
236. Foa EB. Psychosocial treatment of posttraumatic stress disorder. J Clin Psychiatry 2000;61 Suppl 5:43-8;
discussion 9-51.
237. Brunello N, Davidson JR, Deahl M, et al. Posttraumatic stress disorder: Diagnosis and epidemiology,
comorbidity and social consequences, biology and treatment. Neuropsychobiology 2001;43(3):150-62.
238. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane
Database Syst Rev 2006(1):Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub2.
239. Kennedy SH, Lam RW, Cohen NL, et al. Clinical guidelines for the treatment of depressive disorders iv.
Medications and other biological treatments. Can J Psychiatry 2001;46(Suppl 1):38S-58S.
240. Robert R, Meyer WJ, 3rd, Villarreal C, et al. An approach to the timely treatment of acute stress disorder. J
Burn Care Rehabil 1999;20(3):250-8.
241. Boeve S, Aaron L, Martin-Herz S, et al. Sleep disturbance after burn injury. J Burn Care Rehabil
2002;23:32-8.
242. Raymond I, Ancoli-Israel S, Choiniere M. Sleep disturbances, pain and analgesia in adults hospitalized for
burn injuries. Sleep Med 2004;5(6):551-9.
243. Rizzone LP, Stoddard FJ, Murphy JM, et al. Posttraumatic stress disorder in mothers of children and
adolescents with burns. J Burn Care Rehabil 1994;15(2):158-63.
113
ACC15029-2 Pr#6.indd 113
5/17/07 12:11:41 PM
244. Meyer WJ, Blakeney P, Moore P, et al. Parental well-being and behavioral adjustment of pediatric survivors
of burns. J Burn Care Rehabil 1994;15(1):62-8.
245. Broughton J. Injury to Maori: Does it really have to be like this? Dunedin: The Ngai Tahu Maori Health
Research Unit and the Injury Prevention Research Unit, Department of Preventative and Social Medicine,
University of Otago; 1999.
246. Ministry of Health. General practitioners fees information: A summary of key ﬁndings from ﬁve reports.
Wellington: Ministry of Health; 2004.
247. SafeKids New Zealand. Factsheet: Paciﬁc islands child injury: SafeKids New Zealand; n.d. http://www.
safekids.org.nz/index.php/pi_pageid/42 [accessed June 2006].
248. Ministry of Health. Making a Paciﬁc difference: Strategic initiatives for the health of Paciﬁc peoples.
Wellington: Ministry of Health; 1997.
249. Villanueva E, Bennett MH, Wasiak J, et al. Hyperbaric oxygen therapy for thermal burns. Cochrane
Database Syst Rev 2004(2):Art. No.: CD004727. DOI: 10.1002/14651858.CD004727.pub2.
250. Vogler BK. Aloe vera: A systematic review of its clinical effectiveness. Br J Gen Pract 1999;49:823-8.
251. Visuthikosol V, Chowchuen B, Sukwanarat Y, et al. Effect of aloe vera gel to healing of burn wound: a
clinical and histologic study. J Med Assoc Thai 1995;78(8):403-9.
252. Ang ES, Lee ST, Gan CS, et al. Evaluating the role of alternative therapy in burn wound management:
Randomized trial comparing moist exposed burn ointment with conventional methods in the management
of patients with second-degree burns. Medscape General Medicine 2001;3(2):3.
253. Ang ES, Lee ST, Gan CS, et al. The role of alternative therapy in the management of partial thickness
burns of the face – experience with the use of moist exposed burn ointment (MEBO) compared with silver
sulphadiazine. Ann Acad Med Singapore 2000;29(1):7-10.
254. Atiyeh BS, Dham R, Kadry M, et al. Beneﬁt-cost analysis of moist exposed burn ointment. Burns
2002;28(7):659-63.
255. Atiyeh BS, Dham R, Dib ME. Cost-effectiveness of moist exposed burn therapy. Journal of Burns and
Surgical Wound Care 2004;3(1).
256. Subrahmanyam M. Early tangential excision and skin grafting of moderate burns is superior to honey
dressing: A prospective randomised trial. Burns 1999;25(8):729-31.
257. Lievre M, Marichy J, Baux S, et al. Controlled study of three ointments for the local management of 2nd and
3rd degree burns. Clinical Trials Meta-Analysis 1992;28(1):9-12.
258. Leaman AM, Gorman D. Cantharis in the early treatment of minor burns. Arch Emerg Med 1989;6(4):25961.
259. School of Pharmacy, University of Otago. Te rongoa Maori herbal medicine: Harakeke; n.d. http://
pharmacy.otago.ac.nz/rongoa/pages/harakeke.html [accessed June 2006].
260. Matauranga Kura Taiao Project. Maori medicine – kawakawa: Aotea Harbour; n.d. http://www.
aoteamoana.co.nz/tradition/kawakawa.htm [accessed August 2006].
261. Whistler WA. Tongan herbal medicine. Honolulu, Hawaii: University of Hawaii Press; 1992.
262. World Health Organization, Regional Ofﬁce for the Western Paciﬁc. Medicinal plants in the South Paciﬁc:
Information on 102 commonly used medicinal plants in the South Paciﬁc. Manila: WHO Regional Ofﬁce for
the Western Paciﬁc; 1998.
263. Jairath N, Weinstein J. The Delphi methodology (part one): A useful administrative approach. Can J Nurs
Adm 1994;7(3):29-42.
114
ACC15029-2 Pr#6.indd 114
5/17/07 12:11:41 PM
115
ACC15029-2 Pr#6.indd 115
5/17/07 12:11:42 PM
116
ACC15029-2 Pr#6.indd 116
5/17/07 12:11:42 PM
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