INJURY – BURNS Royal Perth Hospital Nurse Practitioner – Emergency Services
Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Nurse Practitioner • Medical Practitioner +/Nurse Practitioner • • • Primary survey assessment History Chemical burns Circumferential burns Major burns requiring resuscitative interventions • Burns complicated by inhalation injury • Burns complicated by electrical injury Initial Assessment and Interventions • Airway • Breathing • Circulation • Nature of burn i.e. thermal, chemical, electrical • MIST Mechanism, injuries sustained, signsvitals, treatment given pre hospital management • Ability to function/perform ADL’s/occupation/social assessment • Past medical history-medications • Allergies-immunisations especially tetanus • Last food and fluids • Compensable statusMVIT/WC/DVA/Private insurance Focused clinical assessment • Pain assessment • Analgesia / First Aid [2, 3] Imaging Scope Minor burn injuries Outcomes Identify patients suitable for ED NP CPG Identify patients not suitable for ED NP guideline and redirect ED NP Mx to usual ED care with ED NP part of the ED team. Outcomes Abnormal primary survey identified → exit CPG Patient identified as not suitable for ED NP CPG → exit CPG Assess the size, location and depth using Wallace’s ‘rule of nines’ [1, 2] -colour -blistering -sensation -capillary return -exudates Wound assessment either epidermal or superficial dermal burn Abnormal findings identified for ED NP CPG → exit CPG Pain scale numeric, depending on nature and depth of burn, pain can be mild to severe • Administration of analgesia • First Aid • Rest • Immobilisation • Elevation • Irrigation with room temperature water for up to 20 minutes • Remove jewellery and clothing gently • Clean with sterile sodium chloride Working diagnosis and Investigations • No imaging required if - no concurrent injuries Determine need for and type of analgesia Reduction/relief of pain Minimise/prevent possible complications Outcomes Identify specific cause and determine patient management Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 1 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Pathology • Not applicable Interpretation of results (diagnostic features) and management decisions Goals of Treatment • Protect the wound during the healing process • Prevent infection • Provide pain relief Provisional Diagnosis Epidermal Burn [1] • ED NP review with view for discharge i.e. Sunburn or minor • Dressing required as per amount of flash injuries, minimal exudates, pain, contamination and location exposure time. • Expected to heal spontaneously within 7-14 Epidermal in depth, red, days with minimal scarring PS minimal, heals within • No dressing unless protection required [3, 4] 7-14 days, no cosmetic • Patient education/health promotion +/defects • Follow up appointment with LMO if required. Superficial Dermal Burn [1] i.e. Epidermal and papillary dermis involvement, blisters present, extremely painful with exposed nerve endings, heals in about 14 days, • • Mid Dermal Burn i.e. Larger zone of necrosis, Large zone of stasis, Can be painful, Delayed capillary return, Blisters, Dark pink • Deep Dermal Burn [1] Some blistering, Blotchy red base, Does not blanch, Reduced sensation to pinprick, Surgical correction • Full thickness [1] Both layers of skin • • • • • • • • • • • • • • • • • Outcomes Patient identified as suitable for ED NP CPG and discharged safely ED NP review with view for discharge Dressing required as per amount of exudates, pain, contamination and location Expected to have more exudates and more absorbent dressing more appropriate. Dressing selection as per ‘Suggested Dressings’ see Appendices Patient education/health promotion Follow up appointment with LMO or follow up with Burns Registrar or Burns Nurse Clinic ED NP review in consultation with Burns Staff with view for admission Review and maintain adequate analgesia Maintain hydration Document fluid balance Patient education and health promotion Medication as per formulary Dressing selection as per ‘Suggested Dressings’ see Appendices Patient identified as suitable for ED NP CPG and discharged safely ED NP review in consultation with Burns staff with view for admission Review and maintain adequate analgesia Maintain hydration Document fluid balance Patient education and health promotion Medication as per formulary Dressings as advised Assessment by Burns Staff with view for +/- admission ED NP review in consultation with Burns Unit with view for admission Assessment by Burns Unit and admission/transfer Patient referred to specialty units for intervention prior to discharge home safely. Call Burns Unit CNS, Burns Reg or Burns Fellow. Assessment by Burns Unit and admission/transfer arranged. Call Burns Unit CNS, Burns Reg or Burns Fellow. Call Burns Unit CNS, Burns Reg or Burns Fellow. Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 2 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS destroyed, May affect deeper structures, Dense, white, waxy or charred appearance, No sensation to pinprick, Leathery appearance Acute Referral When to return • • • • • • Review and maintain adequate analgesia Maintain hydration Document fluid balance Patient education and health promotion Medication as per formulary Dressings as advised arranged. Call Burns Reg or Burns Fellow. Criteria for specialised burns treatment [2, 3] • Burns greater than 10% of TBSA • Special areas – face, hands, feet, genitalia, perineum and major joints • Full thickness burns greater than 5 % of TBSA • Electrical or chemical burns • Burns with inhalation injury • Circumferential burns of limbs or chest • Those with pre-existing medical disorders that could complicate management, prolong recovery or increase mortality • Burns with associated trauma Patient Discharge Education • Verbal instructions from ED NP • ED written patient information Outcomes Ensure patient understands problem, treatment, follow up and is safe for discharge home Follow up appointments • • • Verbal instructions from ED NP Written instructions for LMO OPD appointment book (if applicable) Ensure patient understands problem, treatment, follow up and is safe for discharge home Safety • • Appropriate dressing fitted to burn Correct fitting of aids ie. broad arm sling, crutches with instructions from ED NP Patients greater than 60 yrs of age -referral to physiotherapy -referral to care coordinator Ensure patient understands problem, treatment, follow up and is safe for discharge home • Specific care • • Other Referrals • Verbal instructions from ED NP Written information regarding dressing changes and burn care Referrals may be made for specific patient problems or as required to; - care coordination - social work - physiotherapy - drug and alcohol counselor - Aboriginal liaison officer Ensure patient understands problem, treatment, follow up and is safe for discharge home Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 3 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Certificates • • • Letters • Absence from work certificates WC certificate Certificate of attendance Local medical officer letter Appropriate documentation completed Ensures continuity of care and referral to health care team Medications Analgesia See separate Analgesia Clinical Protocol for analgesia in ED which includes IV narcotics. Standard analgesia for patients admitted to Burns Unit are: 1. Paracetamol 1G QID regularly, 2. Tramadol IR 50 – 100 mg prn 1 hourly, maximum 1000mg/24 hours 3. Oxycodone 10 – 20mg prn 1 hourly (must be prescribed by Medical Officer) Other (See attached Management of Burns pain by Prof. Schug, Head of Pain Medicine) Tetanus Immunoglobulin intramuscular Injection Outcomes Patients given analgesia appropriate to allergies, current medications and past medical history Analgesia requirements determined by ongoing assessment of pain and adequate analgesia provided Patients with excessive pain or pain unrelieved by analgesia need review by EP Adsorbed diphtheria and tetanus toxoids (ADT) 0.5mL intramuscular Injection Refer to Australian Immunisation Handbook 8th Edition - section on Immunisation for tetanus prone wounds - for dosage regimen (dependent upon previous immunisation status and type of exposure) online @ http://www1.health.gov.au/immhandbook/ Topical agents Superficial Burns: Algasite and fixamol. Review within 3 days in Burns Clinic Partial / full thickness burns: Acticoat® & cover with Duoderm®. Review within 3 days by Burns Clinic. Intravenous fluids Unexpected representation Missed problem 0.9% Sodium Chloride Intravenous fluid: 5-10ml flush of Intravenous cannulae 6/24 or Infusion 500ml to 1000ml at 1 12hrly titrated to patients requirements Clinical audit evaluation strategies Emergency Department attendance register and ED NP clinical log Emergency Department x-ray review Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 4 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS 1. 2. 3. 4. 5. References Hettiaratchy, S. and R. Papini, Initial management of a major burn: II - Assessment and resuscitation. British Medical Journal, 2004. 329(7457): p. 101. Multidisciplinary Burn Management Programme. Burns Unit. Royal Perth Hospital 1995 Revised: Jan 2006 Royal Children's Hospital Melbourne Clinical Practice Guidelines: Burns Hudspith, J. and S. Rayatt, First aid and treatment of minor burns. British medical journal, 2004. 328(7454): p. 1487 -1489. eMIMS. [eMIMS on Clinical Information Access Online website] 2006 [cited 2006 Mar 16]; Available from: http://www.use.hcn.com.au/html/wah/godirect.html.or Hospital Intranet Authorship and endorsement (This Guideline has been developed in collaboration with the WADH Review Committee) This CPG was written by: This CPG has been reviewed and is endorsed by Bronwyn Nicholson Emergency Nurse Practitioner Joondalup Health Campus Terry Jongen Nurse Practitioner Emergency Services Royal Perth Hospital Dr Steve Dunjey Emergency Medicine Specialist Emergency Services Royal Perth Hospital Dr Jim Cooper Head of Department Emergency Department Royal Perth Hospital Dr Harry Patterson Emergency Medicine Specialist Emergency Department Royal Perth Hospital Reviewed by Dr Fiona Wood Head of Burns Unit Joy Fong Clinical Nurse Consultant Burn Unit Dr Swithin Song Senior Radiologist Division of Imaging Services Dr Peter Goldswain Chair, Drug Therapeutics Committee Royal Perth Hospital Key to terms ED NP- Emergency Department Nurse Practitioner EP- Emergency Physician PS- Pain Score S1-S4- Schedule of the drug administration act LMO- Local Medical Officer OP- Outpatients Appendices Pain scale Suggested Dressings for Management of the Minor Burn Wound Rule of ‘9’s Guidelines for Management of Minor Burn Injury Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 5 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS CPG- Clinical Practice Guideline WC- Work cover MVIT – Motor Vehicle Insurance Trust DVA- Department of Veteran Affairs Written: March 2006 Reviewed: July 2010 Alan Noonan Locum Nurse Practitioner Michelle Carberry Emergency Nurse Practitioner using Retention Dressings Care of the Minor Facial Burn Review date: July 2013 Appendices • • • • • Guidelines for the management of Minor Burns using retention dressings. Care of minor facial burns. Management of minor burns. Management of burn pain. Burn information. page 6 7 10 12 14 GUIDELINES FOR THE MANAGEMENT OF MINOR BURN INJURY USING RETENTION DRESSINGS (Such as ‘Fixomull Stretch’ or ‘Hypafix’) Consider referral to a specialised Burns Centre if the burn falls into one of the following categories: hands face feet perineum chemical burns major joint involvement circumferential burns full thickness burns electrical burns any infected burns Body Surface Area > 10% adult patient > 5% child less than 18 months of age APPLICATION OF DRESSING: 1. Analgesic requirements: a. consider requirements for initial treatment (may require intravenous / intramuscular narcotic). b. once dressing is intact oral analgesia should be adequate, if not reassess. 2. Wash the burn wound under running water. 3. Debride blisters, except palm and sole, which need to be slit (create an ellipse) to allow for adequate decompression and to prevent the blister re-occurring. 4. Ensure the surrounding skin is dry - the dressing will not adhere to moist skin. 5. Apply the retention dressing to the surface of the wound - no interface gauze/cream is required. Allow an overlap of two centimetres of retention dressing on to intact skin. Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 6 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS 6. If covering a joint surface, apply with the line of the stretch of the non-woven fabric following the line of flexion of the joint. DO NOT STRETCH WITH APPLICATION. 7. When joining two pieces of retention dressing over the wound surface allow no more than 2 centimetres overlap of the dressing. Overlap can reduce the effectiveness of the dressing by preventing moisture vapour permeability. 8. Discharge patient with information sheet on care of and removal of the dressing. 9. Review in 2 - 5 days. 10. If ‘blisters’ form beneath the retention dressing they can be treated without removing all of the dressing. Simply cut away the retention dressing covering the blistered area. The blistered skin will come away with the dressing releasing the exudate. The raw area remaining is then treated as the burn area was initially, i.e. clean, dry and apply a patch of retention dressing with an overlap of no greater than 2cm.. CARE OF THE MINOR FACIAL BURN 1. Wash your face carefully twice each day with a simple non-perfumed soap and water, when showering or bathing. 2. Men should shave each day to reduce the risk of infection. 3. Remove any loose tissue and crusting while showering. 4. Gently pat with a clean towel. Apply a thin smear of emollient-based ointment to all burn areas except for the eyelids. 5. Take special care of the eyes, applying eye ointment, as directed by your doctor, to the eye lids. 6. After eating or drinking, apply an oily cream such as ‘lanoline’ to the lips to prevent them from becoming dry and cracked. This helps to reduce infection. 7. It is necessary to take special care of burns to the ears, by gently cleaning the ears while showering and applying a thin smear of an emollient based ointment to prevent drying. Pressure on the ears while they are healing may reduce the blood supply causing further damage to the skin and increasing the risk of infection. 8. The burn may cause the face to swell. Sitting up on two or more pillows at night will help to reduce facial swelling. 9. If your wound increases in pain or you are concerned about the swelling, contact the clinic for review by the nurse. Retention dressings such as ‘Fixomull Stretch’ and ‘Hypafix’ are not recommended for use on facial burns. Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 7 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 8 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 9 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Royal Perth Hospital Surgical Division MANAGEMENT of MINOR BURN INJURIES Minor burn injuries are burns to less than 10% TBSA. 1. Superficial burns: Skin loss to epithelial layer. Should heal in 7 - 10 days with no scars. Pink, red, painful, erythema, sometimes with blistering. First Aid Cooling for at least 20-3Omins with water immediately. Dressings May be nursed with no dressing if only erytheniatous. Use emollient cream If blisters appear, debride blisters if red wound bed, apply either Alginate and Fixomul and re-dress in 2-3 days. OR Apply Duoderm (hydrocolloid) and re-dress in 2-3 days. If after blisters were debrided wound bed is pink (and the injury is not a scald) apply retention dressing and wash daily. Check in 2-3 days. 2. Partial Burns: Skin loss to epithelium and part of dermis will heal if superficial partial. But if deep, partial skin loss will need surgery and grafting. Mottled pink, painful and blistering, intact hairs. Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 10 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS First aid: As for superficial burns. Dressings Wash with chlorhexidine soap and water. Debride any blisters. Apply Alginate and Fixomul Check in 2-3 days OR Apply Duoderm. Check in 2-3 days. (Apply Alginate if wound exudative, Duoderm if wound bed is sloughy and dry.) ANTIMICROBIALS If antimicrobial is required: a) use silvazine cream (for dry, sloughy eschar or infection). Apply thickly, cover with gauze and secure dressing. This dressing should be done BD but if outpatient status, daily dressings. b) use Acquacel AG - hydrofibre with silver (for exudative burns). Change daily or second daily. c) use Acticoat if required, may be placed under a hydrocolloid dressing 3. Full Thickness Burns: Skin loss to all of skin layers may be down to fascia or muscle or bone. Will need surgery for debridemenlt and skin grafting. White appearance or may present as black and leathery eschars, no pain, no intact hairs. First aid: As for superficial burns Dressings: Wash with chlorhexadine soap and water. Debride any dead or loose skin. Apply Silvazine cream or Acticoat (silver impregnated dressings.) Refer to Burns Unit, Royal Perth Hospital. Compiled by: Date: Reviewed by: Date: Joy Fong, CNC Burns Unit, Royal Perth Hospital Feb2005. Joy Fong, CNC, Burns Unit, RPH Feb 2009 Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 11 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS ROYAL PERTH HOSPITAL Management of Burns Pain Background Non-Opioid Analgesia All patients with pain due to burns injury should have regular non-opioid analgesia prescribed: • Paracetamol I q QID o Can be prescribed for all patients, but reduce dose to 500 mg QID in patients with body weight below 45 kg or with significant liver impairment or alcoholism o Preferred route of administration is oral; if patients are NBM, switch to IV administration. • COX-2 Inhibitors o Should be used with care in patients at risk of renal failure (past history of renal impairment, hypovolaemia, hypotension, other medications with renal toxicity (ACE inhibitors, aminoglycoside antibiotics o Celebrex 100-200mg BD if oral intake possible o Parecoxib 40 mq BD if parenteral administration required Break-Through Opioid Analgesia For initial titration of analgesic requirements, opioids should be used. • In severe pain or in patients kept NBM, this should ideally been done by using IV PCA fentanyl or, if patient is unable to use PCA, fentanyl by IV infusions. o PCA or IV infusions should be initiated by calling the Pain Medicine Service. o There might be the additional need for a ketamine infusion to improve opioid efficacy, again initiated by Pain Medicine Service. • In less severe pain and patient tolerating oral intake, the following should be prescribed: Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 12 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS o Tramadol IR 50-1 00 mci PRN lhrly (max 1000 mg/24 hrs) • Tramadol is preferable in patients with previous problems with opioids (respiratory depression, sedation, constipation, abuse). o. Oxycodone 10-20 mq PRN Ihrly • Oxycodone might be needed in more severe pain, but one has to be careful to avoid constipation. Background Opioid Analgesia If patients are requiring breakthrough analgesia regularly or have continuous pain, then background analgesia by slow-release opioids should be provided. It is useful initially, to replace 50% of the daily breakthrough requirements by a slow-release version of the opioid used for breakthrough pain: • Tramadol SR BD, or • Oxycontin SR BD Dose adjustments should be made in a way that immediate release opioids are only required a few times a day or only for dressing changes/mobilization. If no immediate release opioids are requested by the patient for a few days, it is likely, that the dose of background opioids is too high and this should lead to a dose reduction! Analgesia for Dressing Changes Pain caused by dressing changes is often severe and requires aggressive management using opioids, Entonox and/or ketamine. • For severe pain from more complex dressing changes, parenteral opioids via PCA or ketamine/midazolam via PCA should be used. These modalities as well as the use of Entonox should be initiated by the Pain Medicine Service. • For minor dressing changes or in later stages, often appropriately high oral doses of immediate release opioids are sufficient, if given at least 3040 minutes prior to the procedure. Compiled by: Professor Stephan Schug Head of Pain Medicine RPH Date: 2008 Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 13 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Royal Perth Hospital SURGICAL DIVISION BURN INFORMATION A burn injury refers to the damage caused to the skin and sometimes to the deeper structures by: 1) 2) 3) 4) Thermal - flame, scalds. Electricity Chemical agents Radiation. Burns are further classified by: 1). Depth - Superficial - pink, red, painful. Partial thickness - mottled pink, painful, blisters, intact hairs. Full thickness - white, black, leathery, no pain, no intact hairs, thrombosed blood vessels 2). Area Wallaces' Rule of Nines is used at Royal Perth Hospital to determine the percentage of the body that has been burnt. Rule of Nines Head- 9% Each arm - 9% Trunk front - 18% Trunk back - 18% Each leg 18% Perineum - 1% Palm - 1% 10% and less - minor burns 10-30% - moderate burns 30% and above - major burns 60% and above - severe burns Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 14 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS 3). Cause - Agent causing burns, eg • electrical - may cause deep bums • hydrofluoric acid (50% concentration or more) - fatal if concentrated to more than 5%TBA General First Aid Burn first aid must be given to improve the final outcome of the burn. I. Give first aid and burn first aid, stop burning process and cool burns with cool running water for at least 20 minutes. 2. Resuscitate the victim as required: • Clear the airway • Restore the breathing • Restore circulation • Administer oxygen if available (preferably, warm humidified oxygen if inhalational injury suspected.) • Check for spinal cord injury. 3. Keep the patient warm at all times. 4. Remove non adherent clothing - rings, any article which may affect circulation. (Keep jewellery with patient - document.) 5. Get the patient to medical aid as soon as possible. 6. Minor burn - cool water treatment for 20 minutes, then wash the wounds and dress with appropriate dressing. Give oral fluids and oral analgesia. 7. Major burn - cool water treatment for 10 minutes, then wrap the victim in clean linen or wrung out towels or sheets (soaked with water). Keep warm with outer blanket and transport to medical aid as soon as possible. Specific First Aid Scalds Douse the burnt part in cool water for at least 20 minutes. (NEVER use ice as ice causes vasoconstriction of blood vessels). Remove all wet clothing. The burn will be deepest where the clothing is thickest - at hem lines or where the liquid is held in the folds of the skin or the natural crease where dispersion of heat is delayed. Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 15 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Hot fat burns may be a combination of flame and scald burn. Hot fat burns are usually deep partial thickness burns. Scald burn may take a few days to define itself. Flame burns Remove the victim from the flame source and put out the fire. DO NOT allow the victim to run. Allay panic. Immediately douse with cold water OR force the victim to the ground and smother the flames. IF clothing is smouldering, remove them. Cut loose clothing off, leave adhered clothing. Electrical burns Disconnect the source or move from contact. Care must be taken with high voltage lines unless specially trained. There is usually a point of entry and exit - deeper tissues are always involved. These burns are usually much more serious than they appear. The victim may have a cardiac or respiratory arrest which may require resuscitation. Electrical burns may need cardiac monitoring if there are ECG changes post injury. Chemical burns Usually an acid or an alkali. Brush off any solid particles. Wash with copious amounts of running water for at LEAST 20 minutes. Ensure that the water is drained away safely. It is important to remove any clothing which may have chemical spill on it as this may wash onto the skin and increase burn area. It is important to wash chemical bums with running cool water. Do not use neutralising agents except for hydrofluoric acid burns. Hydrofluoric acid burn is neutralised topically with calcium gluconate gel. This acid will continue to spread until it is neutralised, therefore may require injection of calcium giuconate 10% solution around the periphery of the burn by the medical staff. Pain will dictate the presence Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 16 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS of hydrofluoric acid left in the burn. Hydrofluoric acid bums (depending on the concentration) can be fatal even in as small a burn as a 5% BSA. Phosphorous burns MUST be kept wet at all times using a copper sulphate solution. Copper sulphate 2% will stain the phosphorous and facilitate its removal manually. Bitumen/tar burns may be removed by oil compresses after initial cooling process. Analgesia is required here. Lime/cement burns - dust off excess chemical and wash with copious amounts of running water. In industry, an agent called Diphoterine which is an amphoteric agent which will neutralise both acid and base (alkali) burns. If the burn is immediately sprayed with Diphoterine the chemical is neutralised. Eye injuries Hold the eyelids open and wash under gentle, cool, running water for at LEAST 15 minutes. Solid particles trapped under the lid must be removed, eg by running a glass rod under the lid. The eyes may be stained with Fluorescein sodium minims to ascertain corneal burns. Other details which are of vital importance on admission are: 1). Age, religion and personal data, including phone number of relatives in either country or city areas, or a way they can be contacted. If relatives are accompanying the victim or if they are en route. 2). Exact details of the circumstances of the accident, any other associated injuries or any possibility of smoke inhalation injury. Whether it was an explosion injury. 3). Exact time of injury. 4). Fluid intake and output since the injury. 5). Record of all drugs given prior to admission, especially analgesia, antiemetics and tetanus toxoid. 6). Record if oxygen has been administered and time initiated. 7). Whether the victim is known to be a heavy drinker or if the victim was drinking heavily at the time of the injury (resuscitation may be more difficult and initial output can be misleading). Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 17 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS 8). Possibility of drug dependence 9). All past medical history and allergies. 10). Record of any tests of x-rays carried out at the regional hospital. Treatment of burns Silver sulphadiazine cream (SSD cream) is used for partial thickness burns. It is spread thickly over the area and covered with a light gauze or chux dressing and held in place with Fastanet. Exudate from the burn mixed with some cream will develop over the partial thickness burn - appears as a slimy white later. This may lift or be debrided off. If using SSD on faces please apply SSD onto gauze strips and apply to face, cover with dry gauze and secure. Avoid eyes, mouth and nostrils. As the area heals and becomes pink and healthy dressings may be adjusted. Emollient cream is used for lubricating healed areas. Other dressings such as hydrocolloids or retention dressings may be used on smaller or superficial bums. Acticoat - silver impregnated dressing If using Acticoat it is only necessary to dress the burns daily to 3rd daily. (Follow product instructions) Facial burns A shower is very beneficial as the running water cleans the face well, hair washing at each shower is essential. Clean off all debris with saline three times a day and carefully apply a thin smear of emollient or Vaseline. If the face becomes very dry or crusty, 4 hourly normal saline compresses are of benefit. Eye care should be attended strictly 4 hourly and chloromycetin eye drops applied. Chloromycetin eye ointment is applied to the eyelids and to the eyes at night. Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 18 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Special attention MUST be paid to the pinna of the ear if burnt. If it becomes infected, the cartilage may have to be removed and drainage established (antibiotics are of little value as the pinna has very minimal blood supply). Betadine and jelonet or a smear of SSD cream on the gauze and regular cleansing with soap and water is essential. Apply Lanolin to the lips frequently when lips are dry and after food and as soon as the face is healed, cease the greasy cream and allow the patient to use water based moisturiser, eg vitamin E cream, Nivea, etc. DO NOT apply retention dressings on a person's face. For superficial burns apply emollient cream. If the burn is partial thickness or full thickness, SSD may be applied. SSD is spread on gauze and applied over the face. Care of minor burn as out-patient 1). Ensure adequate oral analgesia. 2). Elevation of the burn area is essential. If burnt on the legs or feet, the patient must be able to get adequate rest with the legs elevated. 3). Clean with soap and water. If it becomes obvious that the blister needs deroofing then cut away any loose dead skin. Apply appropriate dressing such as jelonet, melolin, duoderm, alginate or hydrogelor fixomull based on your wound assessment. Apply tubigrip to legs to reduce oedema and aid venous return. 4). When healed, keep the skin supple with water based moisturiser. Be sure the patient understands the importance of thoroughly washing the burnt area and removing the cream before applying more. General Psychosocial support for the patient and relatives is vital. The pain and loss of body image can be just as devastating to a relatively minor burn as it is to a major burn. Pressure garments are used to prevent hypertrophic scarring, but must be worn 23 hours per day. The need to use these for scar management will be assessed the consulting surgeon. Garments should be warn as soon as the grafts are stable. Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 19 Royal Perth Hospital Nurse Practitioner – Emergency Services CLINICAL PRACTICE PROTOCOL INJURY – BURNS Always ensure that the relatives see the burn early in the treatment and are aware of the gradual improvement - it is very traumatic to see the area without dressing when healed for the first time. Antibiotics are not used normally but only when there are clinical signs of infection. Compiled by: Joy Fong CNC Plastic and Burns Units Royal Perth Hospital Phone (08) 92243578 Page: 2908 Date: January 2004 Review: April 2008 Revised by: Joy Fong CNC Burns Service, Burns Ambulatory Service, Royal Perth Hospital. Phone (08) 92243578 Page: 2908 Health Department of Western Australia wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of the Clinical Practice Guidelines 20
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