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Burn Patient Management Guidelines
Burn Patient Management Guidelines
4th Edition
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ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management
Acknowledgements
These guidelines were developed with the collaboration of the members of the Multidisciplinary Team of the ACI Statewide
Burn Injury Service (from Royal North Shore Hospital [RNSH], Concord Repatriation General Hospital [CRGH] and The
Children’s Hospital at Westmead [CHW]).
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page i
Abbreviations
Ag Silver
C Centigrade
ECG Electrocardiogram
ED Emergency Department
hr(s) Hour(s)
IV Intravenous
IM Intramuscular
kg Kilograms
Max Maximum
Mg Milligrams
mL Millilitres
mm Millimetres
yrs years
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page ii
Contents
Acknowledgements i
Abbreviations ii
Introduction 1
Management of the burn wound – first aid 2
Emergency assessment and management of severe burns 3
Assessment of burn injury: Total Body Surface Area 6
Pain 7
Initial assessment of the burn wound depth 8
Burn unit admission criteria 11
Burn wound management 12
Selecting an appropriate dressing – quick reference guide 16
The multidisciplinary team 24
Websites 25
Appendices 26
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page iii
Introduction
The following guidelines were developed by specialist staff It is acknowledged that primary care or follow up
working within the ACI Statewide Burn Injury Service (SBIS) management of burn injuries may occur outside of specialist
from the tertiary burn units at The Children’s Hospital at units, particularly for patients with a minor burn. These
Westmead (CHW), Royal North Shore Hospital (RNSH) guidelines are designed as a practical guide to complement
and Concord Repatriation General Hospital (CRGH). The relevant clinical knowledge and the care and management
guidelines are designed for use by staff working in these burn techniques required for effective patient management.
units, and clinicians working in other areas and facilities, to Clinicians working outside a specialist burn unit are
guide practice, not to replace clinical judgement. encouraged to liaise closely with their colleagues within
the specialist units for advice and support in burn patient
Burn units provide specialist, multidisciplinary care in the
management.
management of burn injuries, which is not readily available
in outlying areas. They re‑evaluate and adjust treatments Due to the dynamic nature of burn wounds and the large and
according to current research and recommendations. Burn changing number of available wound management products,
care involves high expense for wound management materials, it is not possible to state emphatically which product is
staffing, equipment and long term scar management superior for each wound, however suggestions of possible
products. There are also commonly long‑term issues arising dressings for different wound types are included in this
from the initial trauma, resultant scars and the ongoing document, along with application advice.
effects these have on the patient and their family.
NB For the purpose of this guideline a child is defined as less
than 16 years of age.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 1
Management of the burn wound – first aid
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 2
Emergency assessment and management of severe burns
• Expose the chest and ensure that chest expansion is • Examine pupil response to light for reaction and size.
adequate and bilaterally equal. • Be alert for restlessness and decreased levels of
• Palpate for crepitus and abnormalities such as rib fractures. consciousness – hypoxaemia, carbon monoxide
• Auscultate for breath sounds bilaterally. intoxication, shock, alcohol, drugs and analgesia influence
levels of consciousness.
• Ventilate via a bag and mask or intubate the patient
if necessary. E. Exposure, environmental control and estimate
• Monitor respiratory rate burn size
– beware if rate is <10 or >20 per minute.
• Remove all clothing and jewellery.
• Apply pulse oximeter monitor.
• Keep patient warm.
• Beware circumferential deep dermal or full thickness chest
• Hypothermia can have detrimental effects on the patient.
burns – is escharotomy required?
It is important to ensure that the patient is kept warm,
• Consider carbon monoxide poisoning, non‑burnt skin may especially during first aid cooling periods.
be cherry pink in colour in a non‑breathing patient (send
• Log roll patient, remove wet sheets and examine posterior
blood for carboxyhaemaglobin).
surfaces for burns and other injuries.
• Estimate total body surface area (TBSA) burn size using
Rule of Nines or Paediatric Rule of Nines (see Chapter 4).
For smaller burns the palmar surface of the patient’s hand
(including fingers) represents 1% TBSA and can be used to
calculate the %TBSA burnt.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 3
F. Fluid resuscitation • If urine output <0.5ml/kg/hr increase IV fluids by 1/3
• Fluid resuscitation will be required for a patient who has of current IV fluid amount. E.g. Last hrs urine = 20ml,
sustained a burn >10% for children, >20% for adults. received 1200ml/hr, increase IV to 1600ml/hr.
• Insert two large bore peripheral IV lines preferably through • If urine output >1ml/hr for adults or >2ml/kg/hr for
unburnt tissue. children decrease IV fluids by 1/3 of current IV fluid
amount. E.g. Last hrs urine = 100ml, received 1600ml/hr,
• Collect bloods simultaneously for essential base
decrease IV to 1065ml.
line bloods: FBC/EUC/ LFT/Group and hold/Coags.
Others to consider: Drug/alcohol screen, amylase, • More IV fluids are required:
carboxyhaemoglobin. −− when haemochromogenuria (dark red/black urine)
• Obtain patients body weight in kg. is evident. Haemochromogenuria occurs when the
person has endured thermal damage to muscle e.g.
• Commence resuscitation fluids, IV Hartmann’s solution at
electrical injury. For haemochromogenuria aim for a
an initial rate of the Modified Parkland Formula and adjust
urine output of 2ml/kg/hr
according to urine output.
−− for an inhalation injury
−− The Modified Parkland Formula is used to calculate
the fluid volumes needed for resuscitation and to −− for an electrical injury
generate the desired urine output. −− after delayed resuscitation
−− if there is fluid loss prior to burn e.g. fire fighter,
Modified Parkland Formula diuretics, alcohol etc.
• Document ECG, pulse, blood pressure, respiratory rate,
[Calculated from the time of injury]
pulse oximetry or arterial blood gas analysis as appropriate.
3ml Hartmann solution x kg body weight x % TBSA
½ given in the first 8 hrs
Nutrition
½ given in the following 16 hrs
• Insert nasogastric or nasojejunal tube for larger burns
(>20% TBSA in adults; >10% TBSA in children) or if
associated injuries. See SBIS Nutrition Burn Patient
• Children less than 16 yrs old require maintenance fluids Management Guideline.
e.g. 5% dextrose in 0.9% sodium chloride (or appropriate
fluid), in addition to resuscitation fluids. Pain relief
• Insert an IDC for all burns >10% for children, >20% for • Give morphine (or other appropriate analgesia) slowly,
adults and attach hourly urine bag. IV fluids are adjusted intravenously and in small increments according to pain
each hour according to the previous hour’s urine output. score and sedation scale (see Pain chapter).
Remember
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 4
Secondary survey Other actions
Perform a comprehensive secondary survey. Record and document
History Circumferential burns
A – Allergies If the patient has a circumferential deep dermal to full
M – Medications thickness burn it may impede circulation and/or ventilation
P – Past illnesses (if burn around chest).
L – Last meal
E – Events or Environment related to injury • Contact the burn registrar at a specialist burn unit.
• Elevate the affected limb above the heart line.
Mechanism of injury
• Start a circulation chart and monitor capillary refill in
Gather information from the patient or others about affected limb hourly.
the following.
• Escharotomy may be necessary to relieve pressure if
• Date and time of burn injury, date and time of circulation is compromised.
first presentation
• Source of injury and length of contact time
Psychosocial care
• Document next of kin and telephone number.
• Clothing worn
• Inform and provide support to family.
• Activities at time of burn injury
• Obtain relevant psychosocial information during
• Adequacy of first aid.
assessment and document.
Head to toe assessment • Contact relevant social worker, psychologist or psychiatrist.
Reassess A, B, C, D, E, and F.
Re‑evaluate
• Give tetanus prophylaxis if required.
• Note urine colour for haemochromogenuria.
• Laboratory investigations:
−− Haemoglobin/haematocrit
−− Urea/creatinine
−− Electrolytes
−− Urine microscopy
−− Arterial blood gases, carboxyhaemoglobin
−− Electrocardiogram.
Outcome
Life threatening injuries are identified and patient receives
emergency management.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 5
Assessment of burn injury: Total Body Surface Area
Rule of Nines
The ‘Rule of Nines’ divides the body surface into areas of 9% or multiples of 9%, with the exception of the perineum which is
estimated at 1%. This allows the extent of the burn to be estimated with reproducible accuracy.
Additionally small burns may be estimated by using the palmar surface (fingers and palm) of the patient’s hand, which
approximates to 1% body surface area.
9%
Front 18%
Back 18%
18%
9% 9%
Front 18%
1% Back 18%
9% 9%
18% 18%
14% 14%
1%
Children have different body surface area proportions: Use the Paediatric Rule of Nines and adjust for age by taking 1%
TBSA from the head and adding ½% TBSA to each leg for each year of life until ≥8 years. At 9 years 1% is added to perineum.
Proportions are then the same as an adult.
Images reproduced with permission from: Australian & New Zealand Burn Association, Emergency Management of Severe Burns Course Manual 18th Ed. 2016.
The NSW ITIM Trauma App has burn calculators to assist with the assessment and calculations.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 6
Pain
Acute management
• Give small increments of IV opioid. A standard stat dose of
IV morphine is 2.5–10mg for adults and 0.1–0.2mg/kg of
body weight for children.
• The dose should be titrated against the patient’s response,
including the respiratory rate.
• A opioid infusion can be commenced once the initial
treatments have stabilised the patient.
• Burn procedures may require analgesia beforehand
allowing time for it to take effect. The drug of choice
is determined on an individual basis and may include
an opiate, such as morphine, with paracetamol. Oral
midazolam may also be used for its dissociative, anxiolytic
and sedative qualities. Antihistamines can be useful in
patients where there is excessive itch, but should not
be used in conjunction with midazolam. Inhaled nitrous
oxide mixture is often used during dressing removal and
reapplication in some cases.
• Provision of diversion therapy can help decrease pain and
anxiety for both adults and children. Games, movies and
music are useful diversion techniques. For children a child
life therapist can also assist with procedures.
• Anti‑emetics may be necessary when opioids are given.
• When opioids are given aperients should be administered
to avoid constipation.
• Oral analgesia may be administered to patients with
minor burns.
• Follow local hospital or institutional pain
management guidelines.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 7
Initial assessment of the burn wound depth
Aim
To determine the depth of the burn wound.
Burn depth
Skin layer
Epidermal
Epidermis
Superficial Dermal
Mid Dermal
Dermis
Deep Dermal
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 8
Burn wound depth assessment table
Depth Colour Blisters Capillary refill Healing Scarring
Epidermal Red No Brisk Within 7 days None
1–2 sec
Superficial dermal Red / Pale pink Small Brisk Within 14 days None
1–2 sec Slight colour mismatch
Mid‑dermal Dark pink Present Sluggish 2–3 weeks Yes
>2 sec Grafting may be (if healing >3wks)
required
Deep dermal Blotchy red / white +/– Sluggish Grafting required Yes
>2 sec / absent
Full thickness White / brown / black No Absent Grafting required Yes
(charred) / deep red
Sources: M
odified from Emergency Management of Severe Burns Course Manual, p461; Partial Thickness Burns – Current Concepts as to Pathogenesis and Treatment, p21. (Jan Darke CNC RNSH)
Wound appearance
The wound appearance can change over a period of time, especially during the first seven days following injury.
This patient suffered a scald burn. Notice changing appearance of the wound over just a few days.
Outcome
Wound depths are defined.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 9
On presentation of burn patient to emergency department flowchart
Yes No
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 10
Burn unit admission criteria
Outcome
Severe and minor burns are defined and transfer criteria is outlined.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 11
Burn wound management
Aim Concepts
Define the principles and concepts of burn wound healing. To ensure the above principles are observed, use the following
concepts for burn wound management.
Principles • Cleansing – wound surface should be free of slough,
To promote wound healing and ease patient discomfort, exudate, haematoma and creams.
observe the following principles. • Debridement – removal of loose, devitalised tissue (i.e.
• Ensure adequate perfusion. blister skin) and non‑surgical removal of eschar.
Outcome
Burn wound healing principles and concepts are defined.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 12
Burn patient dressing decision‑making tree
Mechanism Mechanism
scald, flash flame, etc. or short flame, electrical, hot oil, etc. or
exposure to heat source? extended exposure to heat source?
No Yes Yes
Yes No
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 13
Cleansing and debriding the burn wound
Aims Debridement
• Remove exudate and creams. • Complete a holistic patient and wound assessment, not
• Debride devitalised and loose tissue. all wounds require debridement. Clinically examine the
patient.
• Prevent damaging the healing burn wound.
−− Does the wound require debridement?
• Minimise bacterial contamination.
−− Can the patient tolerate debridement?
• Minimise psychological trauma to patient,
carers and staff. −− What is the patient’s clinical pathway (e.g. surgical,
non‑surgical, conservative treatment, comfort care)?
• Reassess the wound.
• Select the most appropriate method of debridement (see
Pain management Summary of Evidence for different methods)
• Adequate analgesia (refer to pain management section 5)
Exudate management
• For specific pharmacological and non‑pharmacological
• There will be high exudate from the wound in the first
pain management strategies see Clinical Practice
72hrs post injury.
Guidelines: Summary of Evidence.
• Appropriate dressing will be required to manage
Preparation exudate level.
• The patient should be given adequate explanation of the • Maintain optimal moisture balance.
procedure. Older children and adult patients are involved,
wherever possible, in the procedure as this gives them a Special considerations
sense of control. • Assess and monitor for possible hypersensitivity or allergic
• Prepare environment and equipment e.g. warm responses to products.
environment. The patient with an acute burn wound • Burns to scalp and excessively hairy areas should be
should be washed and dried within 30 minutes or less, if shaved to allow initial assessment and ongoing wound
possible. Longer sessions may cause heat loss, pain, stress management, thus to prevent folliculitis. Ideally this should
and sodium loss (water is hypotonic). Keep the bathroom extend 2–5cm past the boundary of the burn to ensure full
well heated. visualisation and prevent hair impeding skin regeneration.
The necessity for this procedure should be discussed with
Cleansing the patient, as sometimes religious beliefs preclude cutting
• The wound is cleansed gently to remove loose devitalised of the hair under normal circumstances, and may cause
tissue, exudate and old dressings or creams. great distress if they do not understand the rationale.
• Wash with soft cloth such as sterile handtowels (i.e. • Prophylactic antibiotics are not routinely given to burn
Chux® or Daylees®) in diluted approved solution (ie saline, patients as they do not reduce the risk of infection.
Prontosan®, Microdacyn®, chlorhexidine gluconate [diluted Antibiotics are only given to patients with known
in water 1:2000], dilute betadine). Use cloth for unburnt infections and are prescribed to sensitivities, consultation
parts of the body to maintain hygiene. with infectious disease staff is strongly recommended.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 14
Digital photography of the burn wound
Aims Storage
• Allow ease of communication between burn units • To preserve confidentiality all images must be stored in a
and external hospitals or healthcare facilities. limited access area, such as with password protection.
• Assist with monitoring of wound progress. • For ease of access to appropriate images, each should be
• Minimise prolonged or multiple exposure of patients. stored in an easily recognisable pattern, such as under
medical record number and date taken.
• Reduce issue of infection control by reducing
attending staff numbers.
Emailing pictures
Preparation It is possible to email digital photographs of burn wound
to burn units. Contact must be made between referring
• The patient should be given adequate explanation of
and accepting medical or nursing staff. Photographs must
the procedure and sign a consent form prior to any
be taken in accordance with above guidelines and must be
photographs being taken.
accompanied by injury history and consent.
• Taking of photos should not delay the dressing procedure
for extended periods due to the risk of hypothermia and Email consultation addresses
distress to the patient. CHW: kidsburns@chw.edu.au
• Turn off overhead heat light whilst taking photographs as RNSH: NSLHD‑BurnsConsult@health.nsw.gov.au
they can lead to discolouration. CRGH: Slhd‑concordburnsunit@health.nsw.gov.au
• Consider colouring. Dark skin on stark white background
can give illusion of greater severity of burn. Very pale skin
Outcome
on white background will not give enough contrast. The burn wound is photographed.
Procedure
• Patient should be made comfortable on clean dry sheet.
• Take a photo of the patient’s hospital sticker for identification.
• If patient has extensive burns take global photograph to
show where burn occurs on body.
• For small burns lay a measure rule next to the wound to
display wound size.
• Consider patient’s dignity especially if burns around
perineum or genitalia. Use small cloth to cover
non‑involved areas.
Tips
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 15
Selecting an appropriate dressing – quick reference guide
• Silver Silver e.g. • Wet Acticoat with H20; drain and apply blue side down
• Impregnated gauze • Acticoat® • Insert irrigation system for Acticoat 7
• Hydrocolloid • Moistened secondary dressing to optimise desired
moisture level
• Replace 3–4 days (Acticoat) or 7 days (Acticoat 7)
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 16
Dressing procedure
Figure 1 Figure 2
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 17
Feet
Tips
• The web spaces between the toes should be separated
but it is often difficult to bandage toes separately due to • It is important to separate burnt surfaces.
their size.
• Occlusive dressings should not be applied to
• A large supportive dressing allows for mobilisation and infected wounds.
helps keep the toes in a natural position. Foam padding can
• Care must be taken not to tightly wrap primary
be used to protect burnt soles.
dressings circumferentially around the burns.
Perineum • Secondary dressings must not come in contact with
• Patients with perineal burns are generally catheterised to the wound as they may adhere and cause trauma
decrease pain and allow for the area to be kept as clean on removal.
as possible. Bowel management systems may also be • When bandaging start distally and work proximally,
required to prevent soiling of dressings. from feet or hands. It may be necessary to
• Impregnated gauze, 2–3 layers, can be cut to size incorporate feet or hands, even if they are not
and placed in nappy for young children or on a pad in burnt to avoid oedema formation.
underwear for older children and adults. • Elevate the arms and legs, especially in the acute
Change as required. period to reduce oedema.
• Males • Legs should be bandaged straight and splints may
If the penis and/or scrotum are burnt, apply appropriate be necessary.
primary dressing with outer supportive dressings. A scrotal • Healed areas of skin need moisturising with
support may be necessary. appropriate moisturiser. A small amount is rubbed
in until absorbed.
Outcome • Even if analgesia has been administered before or
The most appropriate cleansing and dressing is applied using during procedure, post‑procedure pain relief may
aseptic technique. be required for some patients.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 18
Specific dressing application
Acticoat® application
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 19
AquacelAg® application
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 20
Problem dressings
Issue Issue
Primary dressing slipped off wound. Secondary dressing stuck causing trauma.
Solution Solution
Use appropriate fixation dressing over Use appropriate fixation dressing over
primary and secondary dressings. primary and secondary dressings.
Issue
Maceration of surrounding
unburnt skin.
Solution
Use appropriate dressing on
burn wound only.
Do not leave wet or moist
dressing on large areas of
unburnt skin.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 21
Dressing fixation application
Start at base of hand Then work from tips of Place pieces through web
working with fingers in a spiral covering Anchor to tape on hand spaces of each finger
a slight stretch half of the previous tape to separate
NB: Care must be taken not to wrap tightly. Check distal vascularity post application.
NB: This is not suitable as a primary dressing and must not be used on areas of skin loss.
* Alternative to applicator can be large tin with both ends removed, cleaned and
ends sealed with tape or similar
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 22
Problem fixation dressings
Issue
Swelling, pressure injuries and reduced blood flow in peripheries.
Solution
Remove wrinkles in tubular bandage and incorporate feet and hands even if not burnt to prevent pressure injuries and swelling.
Issue Issue
Issue
Patient unable to move Tape applied over pressure dressing
Dressing falls off quickly.
hand adequately. can lead to pressure injuries.
Solution
Solution Solution
Use appropriate
Wrap fingers individually. Use appropriate fixation dressing.
fixation dressing.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 23
The multidisciplinary team
Burn management is conducted by members of a multidisciplinary burn team which include medical, surgical, intensive care,
nursing, physiotherapy, occupational therapy, dietetics, social work, psychiatry, psychology, speech therapy, pharmacy and
technicians. A multidisciplinary approach to burn management is essential for optimal functional and cosmetic outcome. Serious
long term physical and psychosocial morbidity may be associated with a burn injury. All members of the burn team interact
throughout the patient’s management, from admission to discharge and beyond to support the patient and family in reintegration.
All team members contribute to patient care throughout the early management, ongoing clinical intervention periods during all
phases of care, and continuous education and support to the patient, family and staff.
For further information regarding multidisciplinary care please refer to the following documents:
• Clinical Guideline: Burn Physiotherapy and Occupational Therapy Guidelines
www.aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/Burns‑PT‑OT‑Guidelines.pdf
• Clinical Practice Guidelines: Nutrition Burn Patient Management
www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf
• Clinical Practice Guidelines Speech Pathology Burn Patient Management
www.aci.health.nsw.gov.au/__data/assets/pdf_file/0020/162641/SBIS_Speech_Path_CPG_2011.pdf
• Practice Guidelines: Child Life Therapy Burn Patient Management
www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/162638/SBIS_Child_life_therapy_CPG_2011.pdf
• Clinical Practice Guidelines: Social Work (adults) Burn Patient Management
www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/162637/SBIS_Adult_Social_Work_CPG_new_format.pdf
• Clinical Practice Guidelines: Social Work; Paediatric Burn Patient Management
www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/162640/SBIS_Paed_Social_Work_CPG_new_format.pdf
All of these documents are available via the ACI Statewide Burn Injury Service Website:
www.aci.health.nsw.gov.au/resources/burn‑injury
Also available on this website are:
• Clinical Practice Guidelines: Burn Patient Management, Summary of Evidence
• Minor Burn Management
• Clinical Practice Guidelines: Escharotomy for Burn Patients
• NSW Statewide Burn Injury Service Burn Transfer Guidelines
• NSW Statewide Burn Injury Service Model of Care
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 24
Websites
There are many useful websites. For a few examples please see the list below.
• ACI Statewide Burn Injury Service www.aci.health.nsw.gov.au/resources/burn‑injury
• Australian New Zealand Burn Association www.anzba.org.au
• Journal of Burn Care & Research www.burncareresearch.com
• International Society for Burn Injuries www.worldburn.org
• Annals of Burns and Fire Disasters www.medbc.com/annals/
• Total Burn Care: Resident Orientation Manual – Acute Burn Management (Galveston Shriners Burn Hospital and The University
of Texas Medical Branch Blocker Burn Unit) www.totalburncare.com/orientation_acute_burn_mgmt.htm
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 25
Appendices
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 26
Appendix 1: Burn wound management: wound care product selection
Silver
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Acticoat®, Acticoat7® • Broad spectrum • Dermal to full • Moisten Acticoat® • Initial stinging on application
2 layered/3 layered antimicrobial protection thickness with H20; remove −− provide prophylactic
nanocrystalline Ag • Decreases exudate • Grafts and excess water, apply pain relief
coated mesh with inner formation donor sites either side down
• Temporary skin staining
rayon layer. • Decreases eschar • Infected wounds • Moistened secondary
dressing to optimise • Maintain normothermia
autolysis • Over Biobrane desired moisture level −− use warm blankets
Acticoat®Flex and Integra
• Replace 3–4 days
Nanocrystalline Ag (Acticoat®Acticoat® Flex)
coated mesh or 7 days (Acticoat7®)
MepilexAg®, • Absorb exudate from • Superficial to mid • Apply to clean
MepilexAg® Transfer wound bed dermal burns. wound bed
Hydrophilic polyurethane • Low to moderately • Cover with fixation or
foam with soft silicone layer exuding wound retention dressing
and waterproof outer layer
AquacelAg® • Broad spectrum • Dermal • Apply to clean • Exudate level indicates
Sodium antimicrobial protection thickness burn wound bed frequency of dressing change
carboxymethycellulose and • Facilitates debridement • Moderately • Cover with fixation or
1.2% ionic Ag in fibrous • Decreases exudate exuding wound retention dressing
material formation • Moderate
• Absorbs exudate bacterial load
Allevyn®Ag, Allevyn®Ag • Absorb exudate from • Exudating wounds • Use as primary or • Avoid use with
Gentle wound bed • Granulation secondary dressing, oxidising agents
Non‑adherent hydrocellular white side down
foam with silver • Retention dressing to
secure
• Change when exudate
approaches 2cm from
edge
Biatain®Ag • Highly absorbent foam • Highly exudating • Retention dressing • Remove if radiation,
Foam dressing with silver that absorbs exudate wounds to secure ultrasonic, diathermy or
• Change when exudate microwaves treatment
approaches 2cm from
the edge of the dressing
Durafiber®AG • Broad spectrum • Dermal • Apply to clean • Exudate level indicates
Cellulose ethyl sulphonate antimicrobial protection thickness burn wound bed frequency of dressing change
fibre dressing with ionic • Facilitates debridement • Moderately • Cover with fixation or
silver • Decreases exudate exuding wound retention dressing
formation • Moderate
• Absorbs exudate bacterial load
Flamazine® • Reduces infection • Dermal to • Apply generous amount • Change daily, remove
Silver sulphadiazine 1% full thickness to sterile handtowel to old cream
• Infected wounds ease application • Contraindicated during first
• Apply to wound trimester of pregnancy
• Cover with • Not recommended for
secondary dressing most burns due to changes
to wound appearance
and frequency of required
dressing changes
Flammacerium® • Creates dry inactive • Burn specialist to • Apply to body pad or • Only to be used by burn units
Silver sulfadiazine 1% wound decide application. combine dressing then under order by a treating burn
• Decreases bacterial load • Consult with onto wound specialist
+ cerium nitrate 2.2%
specialist for
repeat application
at 48 hrs
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 27
Impregnated gauze
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Bactigras® • Non adherent • Dermal thickness • Apply directly to wound
Chlorhexidine impregnated antiseptic dressing wounds • 2 layers for acute
paraffin gauze wounds, 1 layer for
almost healed wounds
• Cover with appropriate
secondary dressing
• Change every 1–3 days
Jelonet®, Adaptic®, • Non adherent • Clean dermal • As above
Curity® conservative dressing thickness wounds.
Paraffin impregnated gauze
Xeroform® • Non adherent • Dermal • Secondary dressing
Mesh gauze thickness wounds to optimise desired
impregnated with 3% • Light exudating moisture level
Xeroform® (Bismuth wounds
tribomophophenate)
Film
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Tegaderm®, Opsite®, • Barrier to contaminants • Small isolated • Apply directly to wound • Only use when
AsGuard®, Curapor®, wounds • No secondary surrounding tissue
Hydrofilm®, Mepitel • Some blisters dressing required not compromised
Film®, Curimed®,
Medstock®
Adhesive, conformable
film dressing
Hydrocolloid
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Comfeel® • CMC combines with • Devitalised tissue, • Allow 2cm margin around
Hydrocolloid containing exudate to aid autolysis sloughy wounds wound
carboxymethylcellulose of devitalised tissue • Low to moderately • Can remain intact 2–3 days
(CMC) • Provides moist wound exudating wounds • Wafers up to 5 days if no
Hydrocolloid wafer environment signs infection
Hydrocolloid paste • Absorbs exudate
Duoderm®, • Provides moist wound • Exudating wounds • Apply directly to area • Only use when
Suprasorb® H, environment • Scars • No secondary surrounding tissue
Hydrocoll®, Osmocol® • Absorbs exudate dressing required not compromised
Hydrocolloid wafer • Assists scar
management in
healed wounds
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 28
Foam
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Mepilex® Transfer • Absorb exudate from • Superficial to mid • Apply to clean wound bed • Avoid use on
Hydrophilic polyurethane wound bed and dermal burns • Cover with absorbent infected wounds
foam with soft silicone layer transfers to outer secondary dressing
dressing
Mepilex® Lite, • Absorb exudate from • Superficial to mid • Apply to clean wound bed • Avoid use on
Askina® Foam wound bed dermal burns • Cover with fixation or infected wounds
Hydrophilic polyurethane retention dressing
foam with soft silicone layer
and waterproof outer layer
Mepilex® Border, • Absorb exudate from • Superficial to mid • Apply to clean wound bed • Avoid use on
Askina® DresSil wound bed dermal burns • No need for infected wounds
Hydrophilic polyurethane secondary dressing
foam with soft silicone
layer, adhesive external
layer
Biatain®, • Highly absorbent foam • Highly • Retention dressing to secure • Remove if radiation,
Biatain®Silicone, that absorbs exudate exudating wounds • Change when exudate ultrasonic, diathermy or
Suprasorb®, approaches 2cm from the microwaves treatment
Aquacel® Foam edge of the dressing
Foam dressing
Allevyn®, Allevyn® • Absorb exudate from • Exudating wounds • Use as primary or secondary • Avoid use with
Gentle wound bed • Granulation dressing, white side down oxidising agents
Non‑adherent hydrocellular • Retention dressing to secure
foam • Change when exudate
approaches 2cm from edge
Absorbent
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Exudry® • Absorbs high exudate • Over primary • Apply appropriate
Non‑adherent, • Protects against shearing dressing primary dressing
highly absorbent, • Then apply outer
permeable dressing absorbent dressing
Mesorb®, Zetuvit® • Absorbs exudate • As above • As above
Sterile absorbent pad
Webril® • Protective • As above • As above • May adhere if
Cotton bandage inappropriate
primary dressing
Telfa®, Melolite® • Non‑adherent • As above • As above
Non‑adherent, absorbent
wound dressing pad
Combine® • Absorbs exudate • As above • As above • May adhere if
Absorbent pad inappropriate
primary dressing
Kaltostat®, Algisite®, • Absorbent dressing • Donor sites • Apply directly to wound • Replace when exudate
Algoderm® • Moist wound • Granulating no longer absorbed or
Calcium sodium alginate environment wounds infection evident
wound dressing • Haemostatic • Excessively • Donor site leave intact at
bleeding wounds least 10 days
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 29
Skin or dermal substitutes
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Cultured epithelial • Assists with skin closure • Burns medical • Used in conjunction • Only used in specialist
autograft (CEA) / • Reduces need for specialist with autograft burn unit
keratinocyte spray extensive donor will indicate
Only used in specialist skin harvesting application
burn unit • Excised full
thickness and
deep dermal
thickness burns
Biobrane® • Temporary skin cover • If limited donor • Appropriate secondary • Granulation may
Biosynthetic dressing made • Decreases risk skin available dressing incorporate Biobrane into
up of collagen coated nylon of infection or loss regenerating skin layer
bonded to silicone • Reduces evaporative • Applied over
water loss debrided
wound bed
Integra® • Dermal replacement. • Surgical indication • Burn debrided, Integra • No paraffin, moisturisers,
Bovine tendon collagen and The matrix layer and application applied, 3 weeks silastic Silvazine dressings or
glycosaminoglycan cross allows the infiltration by burns medical layer peeled off and skin water as this will lift
linked fibres with a silastic of fibroblasts, specialist graft applied Integra
top layer macrophages, • Full thickness burns • Area immobilised and • Not to be applied to
lymphocytes and over a flexor joints splint applied people with known
capillaries to generate sensitivities to collagen
the new dermis • If Integra lifting consult with
medical officer, remove or silastic
affected Integra,
clean gently (saline)
and apply Acticoat
Silicone
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Mepitel® • Non‑stick dressing • Painful open • Can be left intact 2–3 days if • Do not apply if sensitive
Transparent, open mesh, granulating exudates minimal to silicone
polyamide net, coated with wounds • Secondary dressing
soft silicone layer • Dermal thickness to optimise desired
burns moisture level
• Skin tears
Askina® Skilnet • Non‑stick dressing • Painful open • Can be left intact 2–3 days if • Do not apply if sensitive
Conformable non‑woven granulating exudates minimal to silicone
material, coated on both wounds • Secondary dressing
sides with soft silicone • Dermal thickness to optimise desired
burns moisture level
• Skin tears
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 30
Other
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Solosite®, Intrasite®, • Re‑hydrate wounds and • Dry, necrotic • Apply directly onto wound,
Purilon®, Microdacyn® absorbs some exudate • Low exudating cover with film
gel, Askina®, Hydrosorb® into the gel OR
gel, Prontosan® • Cavity wounds
• Apply to secondary dressing
Hydrogels and apply onto wound
Bepanthen® • Antiseptic with • Superficial burns • Apply thin film to wound • Do not apply too thick
Antiseptic cream moisturising capabilities • Newly healed • For hand burns cover with • Do not use longer than
dermal thickness cotton glove 7 days
burns
Hydrocortisone cream • Reduces blood flow to • Hypergranulating • Apply direct to wound • Change daily
e.g. Betnovate®, hypergranulated wound wounds or to dressing • Short term usage only
Diprosone®
Silver nitrate cauterizing • Cauterises • Hypergranulating • Apply direct to affected area • Single application, can be
agent hypergranulated wound wounds repeated if necessary
Inadine®PVP‑I NA • Manages bacterial • Wound infected • Apply as primary dressing or
Low adherent knitted contamination and with bacteria, in combination with other
viscose fabric impregnated prevents infection. microbacteria, dressings. Change dressing
with polyethylene glycol fungi, protozoa & when colour goes from
containing 10% Povidone viruses. orange to white.
Iodine.
Iodosorb® • Assists healing • Chronic and • Cut to size and apply • Avoid use if sensitive
Cadexomer Iodine • Reduces bacteria infected wounds to wound to iodine, or thyroid
condition
• Facilitates de‑sloughing
• Iodine toxicity may occur
• Absorbs exudate
Iodine® Betadine® • Anti‑microbial agent • Wounds infected • Dab onto wound • Avoid use if sensitive
with gram +ve to iodine,
and –ve bacteria, or thyroid condition
spores, fungi, • Iodine toxicity may occur
viruses proteus.
Prontosan® • Removes debris, slough, • Colonised wounds • Use solution to
Wound irrigation solution bioburden and biofilm cleanse wound
containing polihexanide
and betaine
Microdacyn® • Removes debris, slough, • Colonised wounds • Use solution to
Hypochlorous acid and bioburden and biofilm cleanse wound
sodium hypochlorite pH
neutral super oxidized
solution
Mesalt® • Stimulates the cleansing • Medium to high • Apply to wound. Change
Absorbent non‑woven of heavily discharging levels of exudate daily as indicated
dressing impregnated with and discharging infected
sodium chloride wounds
Surfasoft® • Reduces friction rub • Applied in the • Surfasoft applied wet (sterile • Apply olive oil prior to day
Woven polyamide over graft operating theatre normal saline) of removal (day 4 usually)
transparent dressing. • Exudate able to pass over meshed • Leave intact 5 days unless • Peel off gently. If adhered
through dressing grafts infection evident reapply oil
• Easy to view
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 31
Moisturising products
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Dermaveen® bath and • Helps remove and • Epithelialised, • Massage onto wounds and • Do not apply if known
shower oil clean devitalised tissue dry skin healed areas sensitivities to oatmeal
Oatmeal based oil and exudate when • Folliculitis • Wash with warm water and
massaged onto wound pat dry
• Can relieve pruritus
Paraffin • Prevents wound from • Face / lips • Apply layer to affected area,
drying out • Superficial and do not rub in
dermal thickness
burns
Lacrilube® • Prevents wound from • Burns around • As above
drying out the eye
Lanolin • Moisturiser • Burnt lips • As above
• Dry, healing
wounds
Sorbolene • Can be used as a • Dry, healing • Massage small amount into
Sorbolene + 10% Glycerin moisturiser or ‘soap’ exudating and required areas of healing
devitalised tissue wound
Dermaveen® • Rehydrates new • Epithelialised • Massage onto • Do not apply if known
Oatmeal based moisturiser epithelium, may relieve wounds healing wound sensitivities to oatmeal
pruritus • Grafts and
donor sites
Retention / fixation
Wound care product Function Indications Application Notes and precautions
What? Why? When? How?
Hypafix®, Fixamul®, • Stabilises primary and • Superficial • Remove 7–10 days when • DO NOT use on open
Mefix®, Primafix® secondary dressings dermal thickness epithelialised areas as primary dressing
Adhesive non‑woven fabric • Protects epidermis while (skin intact) • Removed easily with De‑ • Do not apply to people
healing and initially after • Stabilising external Solve‑It (immediate) or olive who may have delayed
epithelialisation dressing layer oil (takes 30–60mins) healing or fragile skin
(e.g. the elderly)
Tubigrip®, Tubular Form® • Tissue support • Healing or • Measuring tapes to be used • Closely monitor use on
Tubular pressure bandage • Pressure to healing and epithelialised to decide appropriate size upper arms and upper
67% cotton and 30% rayon epithelialised wounds wounds and pressure thighs, as soft tissue
• Use rings for application damage may occur.
• Remove if painful
/tingling
Tubifast® • Tissue support • Healing or • Use appropriate size • Remove if painful
Tubular pressure bandage • Assist keeping dressing epithelialised • Use rings for application /tingling
in place wounds
Coban® • Stabilises primary and • Healing or • Adheres to itself but not • Do not apply with full
Self‑adherent wrap secondary dressings epithelialised the skin stretch as this may impair
bandage • Pressure to wounds wounds • Apply with gentle blood flow to peripheries
stretch only
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 32
Suppliers
Company Products Website
3M Tegaderm®, Coban®, Cavilon® www.3m.com/intl/au
B.Braun Askina® Foam, Askina® DresSil, Prontosan®, Carbosorb® www.bbraun.com.au/
BSN Medical Fixomull , Hypafix
® ®
www.bsnmedical.com/products/
Coloplast Comfeel Wafer, Comfeel Paste, Biatain , Biatain Ag
® ® ® ®
www.coloplast.com.au
Convatec AquacelAg®, Duoderm®, Kaltostat® www.convatec.com
Hartmann Zetuvit® https://hartmann.info/en‑au
KCI Medical Inadine , Adaptic ,
® ®
https://www.bbraun.com.au/en.html
Lohmann & Rauscher
Suprasorb H https://www.lohmann‑rauscher.com/au‑en/
Pty Ltd
Medtronic Australia /
Curity®, Telfa®, AMD®, Webril®, Vaseline®, Kerlix® www.medtronic.com/au‑en/index.html
Covidien
MepilexAg®, Mepilex® Transfer, Mepilex® Lite, Mepitel®,
Molnlycke www.molnlycke.com/item.
Mepiform®, Mefix®, Mepore®, Tubigrip®, Tubifast®
Acticoat®, Silvazine®, Bactigras®, Jelonet®, Allevyn®, Exudry®,
Smith & Nephew Melolite®, Algisite®, CicaCare®, Solosite®, Intrasite®, Primafix®, http://wound.smith‑nephew.com/australia/
Iodosorb®, Biobrane®
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 33
Appendix 2: recognising burn depths chart
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 34
Appendix 3: Minor burn blister management
Prior to de-roofing
• Assess blister size. Burn blisters ≤5mm can be left intact. Blister in situ
• If patient is being transferred to a burn unit contact the receiving unit
before de-roofing.
• Obtain consent from the patient or family.
• Administer appropriate analgesia and allow time to take effect prior to
procedure.
• Take digital image before and after de-roofing procedure if possible.
Contacts
Royal North Shore Hospital – NSLHD-BurnsConsult@health.nsw.gov.au The Children’s Hospital at Westmead (all paediatrics <16yrs) – kidsburns@chw.edu.au
Burn Unit (02) 9463 2111 Ambulatory Care (02) 9463 2110 Burn Unit (02) 9845 1114 Ambulatory Care (02) 9845 1850
Concord Repatriation Hospital - slhd-concordburnsunit@health.nsw.gov.au ACI Statewide Burn Injury Service resources
Burn Unit (02) 9767 7776 Ambulatory Care (02) 9767 7775 aci.health.nsw.gov.au/resources/burn-injury
Reference
1_ Burns Patient Management: Summary of Evidence, for supporting material for this document.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 35
Appendix 4: NSW Trauma App
The NSW Trauma App was created by the Institute of Trauma and Injury Management (ITIM). It includes information on traumatic
injured patients, including a section on burn management. The app can be downloaded from iTunes and Google Play.
Useful tools included in the Burn section include algorithms on recognition and management of specific issues such as
circumferential burns. Also included are the calculators which are useful for calculating burn size and fluid requirements. Below are
examples of views of the calculators.
ACI Statewide Burn Injury Service – Clinical Guidelines: Burn Patient Management Page 36