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Burns - First aid and dressing

Indications

All burns

Contraindications (absolute in bold)

Associated severe injuries which prevent immediate burn treatment, including:

Airway compromise requiring intubation

Breathing or circulatory compromise

Limb-threatening injuries

Hypothermia

Alternatives

Delayed first aid and dressings

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

Procedural hygiene

Standard precautions

Standard aseptic non-touch technique

PPE: sterile gloves (adding apron, surgical mask, protective eyewear if chemical burns)

Area

Any treatment space appropriate to injury severity

Staff

Procedural clinician and assistant

Equipment

Running water

Wet combines or towels (preferably sterile)

Gauze squares

Saline or aqueous chlorhexidine 0.2%

Scissors and forceps

Burns dressing (see discussion below)

Positioning

Position of patient comfort

Medication

Consider oral medication 30-60 minutes prior to procedure (1g paracetamol, 400mg ibuprofen, 5mg oxycodone)

Consider intranasal fentanyl 1.5mcg/kg

Consider morphine IV 5-10mg or 0.1mg/kg repeated as required

Consider inhaled nitrous oxide or methoxyflurane

Cleansing and dressing burns is painful and requires pain relief

Sequence (first aid)

Cool burn with cool (15 degrees) running tap water unless body temperature falls below 35 degrees

Wet towels and pads may be used if running water is not available or practical (replace every 20 seconds)

Keep the remaining areas dry and warm (avoid hypothermia)

Remove jewellery and constrictive clothing

Chemical burns: remove agent and contaminated clothing, prolonged irrigation (1-2 hrs) away from unaffected areas

Eye burns: saline irrigation (Morgan lens or IV bag and giving set) for >15 minutes until pH neutral

Sequence (wound bed preparation)

Clean gently with gauze or sterile handtowel and saline or aqueous chlorhexidine 0.2%

Gently remove loose skin and any residual non-viable epidermis or debris (use scissors and forceps if required)

Clean until free of slough, exudate, haematoma and previous dressing or cream

Dry the area well (moisture may macerate the burn and encourage bacterial growth)

Shave the burn area and a 2cm margin (hair follicles harbour bacteria increasing infection risk)

Sequence (dressing)

Refer to discussion for information on choice of dressing

Special areas require burns referral centre discussion prior to dressing (hands, face, head, genitals)

Placing primary dressing non-circumferentially (in case of swelling)

Completely cover burn (forming a barrier for infection)

Consider placing and securing extra gauze over permeable dressings (if exudate expected)

Post-procedure care

Consider burn unit referral

Burns greater than 10% total body surface area (5% in children)

Full-thickness burns

Burns of special areas (face, hands, feet, genitalia, perineum)

Circumferential limb or chest burn

Burns with inhalation injury

Electrical burns

Chemical burns

Burns with pre-existing illness

Burns associated with major trauma

Burns in young children and the elderly

Burn injury in pregnant women

Non-accidental burns

Provide tetanus toxoid and ongoing pain relief

Tetanus toxoid if last booster immunisation given greater than 5 years ago

Paracetamol 1g orally four times a day

Ibuprofen 400mg orally three times a day

Endone 5mg orally up to four times a day (for severe pain)

Consider admission if pain not well controlled in the emergency department with these medications

Provide general burns advice

Leave dressing intact and keep clean and dry until review

Elevate the affected part of the body in the days following injury (minimises swelling)

Avoid swimming and dirty environments until wounds completely healed (minimise infection)

Advise itch may be a problem while healing (suggest moisturiser and antihistamines)

Advise smoking cessation to aid in wound healing

Once healed, avoid strong soap, moisturise twice daily and avoid sun exposure (reduces scarring)

Scarring is difficult to predict but most wounds healing in less than 14 days will not scar

Arrange ongoing care

Arrange GP or burns unit review in 48-72 hours to reassess depth and monitor healing

Advise patient to take analgesia 30-60 minutes prior to dressing change

Advise to return to the emergency department if they have increased pain, redness, swelling, fever, chills or rash

Tips

Cooling with running water is effective up to three hours after injury

Hydrogel dressings can be used for first aid in situations where there is no access to water (water preferred)

Never use ice or iced water on burns (vasoconstriction can worsen injury)

Plastic cling wrap is an appropriate initial dressing for severe burns (apply while treating other injuries)

Prophylactic systemic antibiotics do not reduce the risk of infection and are generally not recommended

Discussion

Dressing choice is flexible, and you should make the best choice from your available options, discussing with a burns unit if required. Dressings provide a barrier to infection and should be non-adherent to the wound.

Dressings also maintain a moisture level which promotes healing. Generally, superficial (epidermal) burns become dry and benefit from dressings providing additional moisture. Deeper (dermal) burns become exudative and will benefit from a dressing which draws moisture away from the burn. Antimicrobial dressings are generally not required (expensive and may impair wound healing). They are only used for wounds with increased risk of infection (large, deep or contaminated wounds).

Suggested minor burns dressings (ANZBA)

Epidermal (hydrating dressings)

Hydrogels (Solosite, Intrasite, Solugel, Normlgel, Purilon Gel)

Moisturisers

Vaseline

Superficial dermal (absorbent dressings)

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)

Mid-dermal to full-thickness (antimicrobial) dressings

Silver dressings (Acticoat, Mepilex Ag, Aquacel Ag, Flamazin)

The Victorian Adult Burns Service at the Alfred has a useful algorithm you can also follow to guide dressing choice: www.vicburns.org.au/post-burn-management/guidelines/dressing-decision-tree/

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 at the Alfred; 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. 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

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

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.

© Agency for Clinical Innovation 2021