Ten Top Tips
Clinical Update TEN TOP TIPS Management of burn wounds
“ Clinicians should become familiar with their local policies and
procedures on
referral to their regional burns service.”
any surgical intervention can be planned promptly. Early skin grafting has been shown to result in faster wound healing and a reduction in wound infection.[22]
5
DRESSING SELECTION FOR BURN WOUNDS
The following dressings should be considered when managing burns: • Use cling film if transferring to a burns unit as a temporary dressing. This or any other dressing should not be applied onto a chemical injury until the chemical component has been sufficiently irrigated as guided by wound pH. It should be remembered that cling film should be only one layer thick and never used on face burns (also see Top Tip #10).
• For facial burns use liquid / soft paraffin or saline soaked gauze. All facial burns must be seen by a burns unit.[23]
REFERENCES cont.
10. London and South East Burn Network (2011) Consensus on burn blister management. LSEBN, London
11. Enoch S et al (2009) Emergency and early management of burns and scalds. BMJ 338: b1037
12. Hayek S et al (2010) Burn wound cleansing - a myth or a scientific practice. Ann Burns Fire Disasters 23(1): 19–24
13. NICE (2008) Surgical site infection: prevention and treatment of surgical site infection. NICE, London
14. Lund CC, Browder NC (1944) The estimation of areas of burns. Surgery, Gynaecology, Obstetrics 79: 352–8
15. Durrant CAT et al (2008) Thermal injury: the first 24 hours. Current Anaesthesia & Critical Care 19(5–6): 256–63
16. Hettiaratchy S, Papini R (2004) Initial management of a major burn: II -- assessment and resuscitation. BMJ 329(7457): 101–3
17. Rawlins JM (2011) Management of burns. Surgery 29(10): 523–8
18. Johnson RM, Richard R (2003) Partial- thickness burns: identification and management. Adv Skin Wound Care 16(4): 178–87
19. Pape SA et al (2001) Burns: The First Five Days. Smith & Nephew, Hull
20. Cubison T et al (2006) Evidence for the link between healing time and the development of hypertrophic scars in paediatric burns. Burns 32(8): 992–9
•
• Atraumatic, low-tack dressings may be used. Non-stick silicone / lipo-colloid mesh dressings can be used as a primary layer, with secondary padding and joint to joint bandaging. Distal to proximal figure- of-eight bandaging will aid circulation and reduce oedema.[24]
Tight bandaging
should be avoided on limb burns, in case of oedema and swelling.
• For smaller burns non-stick foams are ideal dressings as they are easy to apply, easy to remove, maintain a moist wound healing environment and are available in a range of shapes and sizes.
• Topical creams, such as silver sulfadiazine, should be avoided.[25]
Silver sulfadiazine
should only be used if the wound has been assessed by a burns service as the creams can change the colour of wound tissue, making subjective depth assessment difficult.[26]
Increased capillary permeability in the first 48–72 hours following a burn injury means increased exudate,[27]
so these
wounds should initially be dressed with a highly-absorbent dressing. Using the appropriate primary dressing as mentioned above will prevent dressing adhering to the wound. Dressings should be changed after 48 hours as strikethrough is likely.[28]
• Prolonged use of hydrogel dressings, especially in children and older people with larger burn areas, can cause hypothermia and should be avoided.[6]
12
first 48 hours following burn injury. Oedema interferes with tissue perfusion and wound healing by increasing the diffusion distance between capillaries and cells.[29]
6 Thus, where
possible, the wounded area should be elevated to reduce swelling. Slings should be avoided as these may restrict
patient movement, pillows can be used when sitting or laying down. Principles of reduction should be adhered to including movement, compression, elevation or positioning of limbs for gravity assisted flow of oedema from limbs. The potential splining effect of slings will not control oedema, it will only channel fluid to an immobile area.[30]
7
KNOW WHEN AND WHERE TO REFER
The London and South East of England Burn Network (LSEBN) have developed the below referral criteria.[25]
The LSEBN criteria are based
on international evidence and expert opinion, but clinicians should become familiar with their local policies and procedures on referral to their regional burns service. Consider telemedicine if available, which allows pictures to be sent securely for expert review and treatment advice.[31]
Referral
should be sought in the following cases: Adults: • >3% TBSA partial thickness burn • All deep dermal and full thickness burns • All burns associated with electrical shock • All burns associated with chemical burn • All burns associated with non-accidental injury (see Top Tip #9)
• All burns to face, hands, perineum, feet • All burns circumferential to limbs or trunk or neck
• All burns with inhalation injury • All burns not healed within two weeks Children: • >1% TBSA partial thickness burn • All deep dermal and full thickness, circumferential burns and burns involving the face, hands, soles of feet, perineum
• All burns associated with smoke inhalation, electrical shock or trauma
• Severe metabolic disturbance • Burn wound infection • All children “unwell with a burn" • Unhealed burns after 2 weeks • Neonatal burns of any size • All children with burns and child protection concerns (see Top Tip #9)
Wounds International Vol 5 | Issue 1 | ©Wounds International 2014 |
www.woundsinternational.com
ELEVATE TO REDUCE OEDEMA Oedema occurs most commonly in the
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