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Burns - Debridement of blisters

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Indications

Blisters >6mm diameter

Blisters over joints or high mobility areas

Burns involving hot oil (high risk of deep underlying burns)

Ruptured blisters

Contraindications (absolute in bold)

Uncontrolled pain

Burns unit transfers

Remote area where appropriate dressing not available or high infection risk

Non-compliant patients (dementia, learning difficulties)

Alternatives

Leave intact

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Pain

Infection

Procedural hygiene

Standard precautions

Standard aseptic non-touch technique

PPE: sterile gloves, surgical mask

Area

Any bed space

Staff

Procedural clinician

Equipment

Dressing pack

Scissors and forceps

0.9% saline

Positioning

Position of patient comfort

Medication

Premedication 30-60 minutes prior to procedure (paracetamol, ibuprofen, codeine, oxycodone)

Consider intranasal fentanyl 1.5mcg/kg

Consider morphine IV 5-10mg (adjusted to co-morbid status)

Consider inhaled nitrous oxide or methoxyflurane

Sequence

Take digital image before and after procedure

Cleanse area with normal saline

De-roof thin walled blisters with moist gauze and gentle pressure

De-roof thick walled blisters with forceps and scissors

Dress with moist low or non-adherent dressing (see first aid and primary burn dressing guide)

Post-procedure care

Leave dressing intact, clean and dry until review by GP or burn clinic in 2-3 days

Pain relief prescription and advice

Avoid smoking due to adverse effects on wound healing

Document completion of procedure

Tips

Removal of blisters and cleansing burns is painful and requires pain relief

Burns nerve endings cause elevated pain even after debridement, assessment and dressing

Debridement is not a treatment priority for people with severe burns being transferred to a burns unit

Discussion

Burn blisters occur primarily in superficial dermal burns but also may overlay deeper burns. They result from inflammation causing increased capillary permeability with oedema separating the epidermis from the underlying dermis.

There is debate about the most appropriate management of blisters in burn wounds. Small blisters help control pain and provide a sterile environment for healing. These are generally left intact. Larger blisters will usually rupture spontaneously with loss of these benefits and are generally debrided allowing assessment of the wound bed, application of antimicrobial dressings and increased joint mobility.

First aid and primary dressings are discussed separately. Suitable dressings include:

Foam (Allevyn, Wound Aid Foam, Mepilex, Biatain, Silicone, Biotin)

Alginates (Algisite M, Kaltostat, Melgisorb)

Silicon plus absorbable secondary dressing (Mepitel)

Paraffin gauze plus absorbable secondary dressing (Jelonet)

Silicone dressings (Mepilex)

Silver products (Acticoat, Mepilex Ag, Aquacel Ag, Flamazine, Biatain Ag, Allevyn Ag)

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

ACI State-wide Burn Injury Service

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australia and New Zealand Burns Association. Resources. n.d. Available from https://anzba.org.au/resources/

Victorian Adult Burns Service at the Alfred. Burns management guidelines. Melbourne: Victorian Adult Burns Service; various dates. Available from: https://www.vicburns.org.au/burn-assessment-overview/burn-pathophysiology/

European Burns Association. European practice guidelines for burns care. Barcelona: European Burns Association; 2017. 147 pp. EBA – Guidelines – Version 4 2017. Available from: https://www.euroburn.org/wp-content/uploads/EBA-Guidelines-Version-4-2017.pdf

NSW Agency for Clinical Innovation. Minor burn blister management. Sydney: ACI; 2019. 1pp. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/324472/Minor-burn-blister-management.pdf

NSW Agency for Clinical Innovation. Burn patient management. 4th ed. Sydney: ACI; 2019. 36pp. Available from: https://www.aci.health.nsw.gov.au/networks/burn-injury/resources

NSW Agency for Clinical Innovation. Burn patient management: summary of evidence. 4th ed. Sydney: ACI; 2018. 19pp. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0016/250009/Burns-summary-of-evidence.pdf

NSW Agency for Clinical Innovation. Minor burn management. 4th ed. Sydney: ACI; 2017 [updated 2019]. 10pp. Available from: https://www.aci.health.nsw.gov.au/networks/burn-injury/resources

Sydney Children’s Hospital Network. Burns management practice guideline. Sydney: SCHN; 2019. 58pp. Guideline 2006-8142 v6. Available from: https://www.schn.health.nsw.gov.au/_policies/pdf/2006-8142.pdf

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Harshman J, Roy M, Cartotto R. Emergency care of the burn patient before the burn center: a systematic review and meta-analysis. J Burn Care Res. 2019;40(2):166-188. doi:10.1093/jbcr/iry060

Sargent RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res. 2006;27(1):66-81. doi:10.1097/01.bcr.0000191961.95907.b1

Murphy F, Amblum J. Treatment for burn blisters: debride or leave intact?. Emerg Nurse. 2014;22(2):24-27. doi:10.7748/en2014.04.22.2.24.e1300

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