Professional Documents
Culture Documents
Contents
Resources available through RAH Burns Service
>>education
>>clinical guidelines
>>clinical services
First aid:
>>scalds
>>electrical injury
>>chemical injury
>>bitumen burns
Emergency management
Appendix A Community first aid protocol for thermal injury
7-8
9
10
11
Appendix D Escharotomy
12
13
14-15
17
18
19
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Staff education
The Burns Team can provide education sessions tailored to your needs. Current options
include:
>>all-day education session aimed primarily at nursing and emergency services, with
breakout sessions for therapy groups, operating room staff etc
>>evening sessions for GPs normally run in conjunction with the all day session
>>evening session of one to four hours duration
Clinical guidelines
>>Laminated A3 copies of any flow chart contained with this document are available.
>>Laminated A3 posters of the Guidelines for minor burn management are available
>>the Guidelines for minor burn management document can be downloaded from the
RAH Burns Unit website at www.rah.sa.gov.au/burns
Clinical services
>>Advice for acute burn management
>>Review of scarring/contractures
>>Scar management advice
>>Wound management advice
>>Psychosocial advice
>>Occupational therapy advice
page 3
These criteria are based on the Australian and New Zealand Burn
Association guidelines for Burn Unit referral.
page 4
Major Burn
>>Cold water treatment to burn for up to 20 minutes
>>Wrap loosley in clean linen or cling wrap (do not cling wrap the face or chemical burns)
>>Keep warm with outer blanket
>>Commence intravenous fluids and transport to hospital
>>If transfer is going to be delayed, refer to Primary burn wound care guidelines
Adults (Appendix L)
>>Do not hesitate to contact Burns Unit for clarification if required
Ice should never be used it causes vasoconstriction leading to further tissue damage
and hypothermia.
page 5
page 6
Emergency management
3. Circulatory management
>>Burns >15% should be given formal intravenous fluid resuscitation as per the
Modified Parkland Formula (see Appendix I)
>>Insert two large bore (16G) peripheral cannula (through damaged tissue if necessary)
5. Pain relief
>>Small doses of IV morphine titrated to pain and sedation scores
>>Intramuscular, subcutaneous and oral analgesics are absorbed unreliably in burn injury
due to fluid shifts and GI stasis
6. Urinary catheter
>>All patients receiving intravenous fluid resuscitation should have a urinary catheter
inserted
page 7
9. Emotional support
>>Severe burns often occur under stressful circumstances and cause distress to patients,
friends and relatives. Reassurance and good communication are the most important
tools at this time. Local support services should be accessed for ongoing support. The
Burns Unit social worker or clinical psychologist may be contacted through the Burns
Unit for advice and assistance.
>>Emergency service personnel and hospital staff may also require support and local
critical incident response protocols should be initiated if appropriate. The Burns Unit
social worker or clinical psychologist may be contacted through the Burns Unit for
advice and assistance.
page 8
Appendix A
Community first aid protocol for thermal Injury
Thermal burn
Scald
Take care!
Remove scalding agent
(water, hot fat etc)
Radiant heat/contact
Flame
Clothing on fire
Flash burn to
skin only
Take care!
Extinguish flames
(stop, cover, drop and roll)
No water available
Smear hydrogel* eg
BurnAid or hydrogel
impregnated towels
over the surface of the
burn. Remove
jewellery once cooling
commenced.
*Consult hydrogel protocol prior
to use
page 9
Appendix B
Emergency Department protocol for the
management of chemical skin injuries
Chemical Injury
Personal protective equipment
Bitumen
Liquid
Alkali
Acid
Irrigate to the
floor* for up
to two hours.
Use the
patients
subjective
cessation of
burning
sensation as
end-point
Irrigate to the
floor* for up
to one hour.
Use the
patients
subjective
cessation of
burning
sensation as
end-point
Ophthalmic opinion
immediately if face involved
Cool with
running water or
water soaks
Do not
attempt to
remove
but allow to
detach
spontaneously
over time
Solid
Powder
Alkali metal
Brush off
powder.
Remove
adherent large
particles with
forceps
Pick metal
particles off
skin with
forceps
Irrigate with
water using
patients
subjective
cessation of
burning
sensation as
end-point
Irrigate for up
to two hours.
Use the
patients
subjective
cessation of
burning
sensation as
end-point
page 10
Appendix C
Emergency Department Protocol for Electrical Burns
(low voltage = A/C<1000V)
12 lead ECG
page 11
Appendix D
Escharotomy
In the presence of any circumferential burn, advice should be sought from
the Burns Unit consultant (contact through RAH switchboard 8222 4000).
An escharotomy should be considered when there is
a circumferential deep dermal or full thickness burn
injury (dry wound) and where:
>>a delay in transfer to the tertiary Burns Unit is
expected
or
>>there is evidence of circulatory compromise indicated
by an extended capillary refill time compared to
unburned or non circumferential burned limb.
Escharotomy is designed to divide inelastic burned skin
and the incision does not usually need to be extended
far into the underlying fat.
This procedure is not to be undertaken lightly, as it has
the potential for considerable damage to underlying
structures. These include:
>>common peroneal nerve at the outside of the knee
(over neck of Fibula)
>>radial nerve at the wrist (superficial branch)
>>ulnar nerve at the elbow
>>cephalic vein at the wrist
>>great saphenous vein and nerve at ankle.
Equipment
>>Local anaesthetic infiltration with Adrenaline (if patient awake)
>>Povidone lodine
>>Cutting monopolar diathermy with either needle or blads (set to equal cutting/
coagulation). A normal scalpel may be used in the absence of this but more bleeding
should be expected
>>Bipolar diathermy for haemostasis
>>KaltostatTM for dressing escharotomy wound. Cover with antibacterial dressing and
bandage then elevate limb.
page 12
Appendix E
Management of small thermal burns (<15% TBSA)
Remove jewellery/hot clothing
Yes
Cooled?
Yes
No
Analgesia according
to pain protocol,
tetanus prophylaxis
according to protocol
No
Place under
running cool tap
water (at 15oC)
for 20 minutes
or
Apply hydrogel
(refer protocol)
Do not use
ice or ice
water
Yes
Equivocal
No
Contact plastics
registrar.
Fast patient until
reviewed.
page 13
Important note
Partial thickness burns due to petrol, friction, flames, chemicals cooking water, hot oil
or other contaminated/car radiator water dirty materials often become infected resulting
in burn wound progression ie tissue death requiring surgical intervention. It is prudent to
treat these with a topical anti-bacterial (silver containing) dressing. Systemic antibiotics
are usually only used when there has been organisms identified in conjunction with a
clinical picture of a wound infection.
page 14
page 15
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1
1
13
1 1/ 2
1 1/ 2
1 1/ 2
1
1 1/ 4
61 / 2
6 1/ 2
1 1/ 4
1 1/ 4
3 1/ 2 3 1/ 2
1 3/ 4
page 17
1 1/ 2
2 1/ 2
2 1/ 2
1 1/ 4
2 1/ 2 2 1/ 2
13/ 4
Anterior
52
13
1 3/ 4
1 3/ 4
Posterior
48
Appendix H
Anterior
Posterior
page 18
Appendix I
>>Assess total burns surface area (TBSA) using the Lund and Browder chart.
>>Assess patient body weight as accurately as possible (in kilogrammes).
>>First 24 hours Total Fluid requirement derived via formula:
Total (mls) = 4ml x weight kg x % TBSA
>>In the first period of eight hours from the time of the burn, give one half of the
total calculated fluid required as Hartmanns solution. Normal saline may be used if
Hartmanns solution is not available. Timing begins at the time of the burn, not at the
time of arrival at hospital
page 19
Appendix J
Yes
Is there epidermal
integrity? (Nikolsky
Sign* see below)
No
Thin walled
or popped
Superficial
dermal
Other signs:
blanches with
pressure, very
painful, very oozy
Type of blister
Is it
slippery?
Yes
No
Thick walled
Red
White
Mid dermal
Other signs: some
mottling, blanching
sluggish, darker/
red base, some
anaesthesia, less
oozy
Burn Colour
Deep dermal
Other signs:
decreased
sensation, absent
or reduced
refilling after
blanching, fixed
mottling, little or
no ooze
Full thickness
Other signs:
anaesthesia, no
refilling after
blanching, may
be amber and
translucent with
visible black vessels,
may be waxy, hairs
fall out easily, dry
page 20
Appendix K
Use of hydrogel cooling products for burn Injury first aid and primary
wound dressing care
Burn assessment
(see A)
Chemical and
cold injury
burns
Do not use
Please contact
RAH Burns
registrar
through RAH
switchboard
(8222 4000) for
advice
Thermal,
electrical
and
ionising
radiation
burns
Assess patient
risk (see B)
A. Burn assessment
> Cause of burn
> First aid (type and length)
> Depth
> % total burn surface area (TBSA)
> Site of burn
> Immediate risk to circulation/
ventilation
> Need for transfer to RAH Burns
Unit
B. Patient risk
Extreme
> Neonates
High
> The very young
> The elderly
> Burn surface area > 15%
Low
> Burns <15%
> Fit healthy persons 10 60 yo
Low risk
High risk
Extreme
>
Hydrogel products
should only be
used for initial
cooling (a period
of no more than
20 minutes).
After that time
they should be
removed
Hydrogel products
should only be
used for NO more
than 10 minutes,
then removed
>
>
Use as per
manufacturers
guidelines.
Monitor
patients
temperature
regularly
Warm non
burned areas
page 21
Appendix L
A.
Emergency management
B. Burn assessment
Emergency burn
management
(see A)
>
Cause of burn
First aid (type and length)
> Depth
> % total body surface area (TBSA)
> Site of burn
> Immediate risk to circulation/ventilation
> Need for transfer/consultation* to RAH
Burns Unit
>
Transfer to RAH
Burns Unit
(see C)
Minor Burn
suitable for local
management
(see D)
>
> Follow
*Consultation may consist of discussion, or the tranfer of photographic images of burn injury for appropriate advice
page 22
Appendix M
Lower airway injury
0 hours
Time of injury
thermal agent
> No confinement in smoke
filled environment
> Scald injury
bronchoscopy below
the cords
>
>
>
>
Rx
Rx
> O2
> O2
> Trauma Clearance ASAP
> Elevate 45 at hips when C-spine clear
> Chest X-ray
> Intubation long term (if required)
> ABGs
> ? nebulised Adrenaline/Heliox
> Bronchoscopy/review survival status
Obs
Obs
Placement: HDU/ICU
> O2
Deterioration in condition
code blue
> Intubate
> ICU
No deterioration in condition
page 23
No deterioration in condition
> Continuous SaO2
> 4/24 observations
> Elevate 45 at hips when C-spine clear
Appendix N
Upper Airway Injury
0 hours
Time of injury
pharynx
Rx
Rx
> O2
> Trauma Clearance ASAP
> O2
> Trauma Clearance ASAP
Obs
> Continuous SaO2
> Continuous visual observation
> 15 minute airway observations
clear
Obs
> Continuous SaO2
> Continuous visual observation
> 15 minute airway observations
Placement: HDU/ICU
> O2
Deterioration in condition
code blue
> Intubate
> ICU
No deterioration in condition
No deterioration in condition
> Continuous SaO2
> 4/24 observations
> Elevate 45 at hips when C-spine clear
page 24
Appendix O
Management of facial burns
Deep dermal
Full Thickness
No
Intubated?
Yes
Aquacel Ag
Signs of Infection
>> Pain
>> Vascularity
>>Wound
deterioration
>>Abnormal ooze
Swab wound
Bacteriology
Virology
Possibility of Herpes
simplex burn
infection (especially
coldsore sufferers)
>>Odour
>>Overgranulation
Start Acyclovir
page 25
Appendix P
Yes
No
Discuss with
burn consultant
Epidermal (sunburn/
no blistering
>>Clean skin
>>Moisturising cream
>>Massage
>>Analgesia
Full thickness/
Deep dermal
Assess burn
depth
Superficial dermal
Mid dermal
>>Analgesia
>>Analgesia
>>De-roof blisters
>>De-roof blisters
>>Silver dressing
>>Silver dressing
>>Consider antibiotics
>>Routine antibiotics
only)
only)
page 26
Appendix Q
Hydrofluoric Acid Treatment Protocol (Burns <2% TBSA and HF
concentration <10%)
No deep tissue
discomfort
Burns Unit
consultant and
toxicology consults
Spreading/continuing ache
1g of Calcium
Gluconate in 40mls of
normal saline over four
hours
Place IV proximal
to burn. Inflate cuff
above arterial pressure.
Instil 1g of Calcium
Gluconate diluted in
Normal Saline 40mls.
Deflate cuff in 20
minutes
Appendix R
Hydrofluoric Acid Treatment Protocol (Burns >2% TBSA or
HF concentration >10%)
Local burn management as per protocol for <2% TBSA flow chart
HDU/ICU
six hourly ECG and venous gas
Twice daily MBA20
Hourly VBG/ABG
six hourly ECG, MBA20, Mg2+
page 28