acc15029-1-pr#6 5/17/07 12:15 pm page 1file/burns_full.pdf · the assessment and management of burn...

ACC15029-1-Pr#6 5/17/07 12:15 PM

Composite

C M Y CM MY CY CMY K

Kua tawhiti ke to haerenga mai,

kia kore haere tonu

He tino nui rawa ou mahi

Kia kore e mahi nui tonu

sir james henare of ngati hine iwi from te tai tokerau

We have come too far not to go further

We have done too much not to do more

1

ACC15029-2 Pr#6.indd 1ACC15029-2 Pr#6.indd 1 5/17/07 12:11:01 PM5/17/07 12:11:01 PM

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Endorsements

This guideline has been endorsed by the Australian and New Zealand Burn Association (until 2009), the Burn

Support Group Charitable Trust, the Counties Manukau District Health Board (until 2009), the Royal New

Zealand College of General Practitioners and St John.

��

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Contents

Endorsements ..................................................................................................................................................3Purpose ............................................................................................................................................................9About the guideline ........................................................................................................................................11Summary ........................................................................................................................................................17Chapters

1. Burn injuries and burns prevention in New Zealand ........................................................................27

2. First aid ..........................................................................................................................................31

3. Burn assessment ............................................................................................................................35

4. Referral...........................................................................................................................................45

5. Management of epidermal burns or scalds......................................................................................47

6. Management of superfi cial and mid dermal burns or scalds ........................................................... 49

7. Management of chemical injury ......................................................................................................59

8. Management of electrical injury ......................................................................................................63

9. Pain management...........................................................................................................................67

10. Psychological consequences of burn injury .....................................................................................71

11. Burn injuries in Maori .....................................................................................................................77

12. Burn injuries in Pacifi c peoples .......................................................................................................79

13. Complementary and alternative medicines .....................................................................................81

14. Implementation and evaluation ......................................................................................................83

AppendicesA. Evidence and recommendation grading system ..............................................................................89

B. Wound care options ........................................................................................................................91

C. DSM-IV criteria for post-traumatic stress disorder ............................................................................95

D. Useful resources .............................................................................................................................97

Abbreviations and acronyms ...........................................................................................................................99Glossary .......................................................................................................................................................101References ....................................................................................................................................................103

Recommendations and good practice points

Chapters1. Burn injuries and burns prevention in New Zealand ........................................................................27 Opportunities for prevention ...........................................................................................................28

2. First aid .........................................................................................................................................31 Stopping the burning process and cooling ......................................................................................31

Gel pads .........................................................................................................................................32

Initial coverings: polyvinyl chloride fi lm (cling fi lm) .........................................................................33

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3. Burn assessment ...........................................................................................................................35 Emergency management .................................................................................................................35

Burn size: assessment and recording of total body surface area burn ..............................................38

Burn depth .....................................................................................................................................41

Non-accidental injury ......................................................................................................................42

Classifi cation of burns ....................................................................................................................43

4. Referral .........................................................................................................................................45 Emergency referral ..........................................................................................................................45

Referral between services ...............................................................................................................46

5. Management of epidermal burns or scalds .....................................................................................47 Dressings and creams (good practice points only)...........................................................................47

6. Management of superfi cial and mid dermal burns or scalds ...........................................................49 Preventing infection (good practice points only) .............................................................................49

Wound healing ...............................................................................................................................52

When to review (good practice point only) ......................................................................................54

Management of blisters (good practice points only) ........................................................................54

Scarring ..........................................................................................................................................55

7. Management of chemical injury .....................................................................................................59 First aid ..........................................................................................................................................59

Eye injury .......................................................................................................................................60

Specifi c substances: hydrofl uoric acid (good practice point only) ....................................................60

Specifi c substances: phosphorus (good practice point only) ...........................................................62

8. Management of electrical injury .....................................................................................................63 Management of electrical injury ......................................................................................................63

ECG monitoring ...............................................................................................................................64

9. Pain management ..........................................................................................................................67 Burn pain management ..................................................................................................................67

10. Psychological consequences of burn injury ....................................................................................71 Adverse psychological responses to trauma ....................................................................................71

11. Burn injuries in Maori ....................................................................................................................77 Good practice points ......................................................................................................................77

12. Burn injuries in Pacifi c peoples ......................................................................................................79 Good practice points ......................................................................................................................79

Algorithms (see Summary, pages 17–25)

1. Initial assessment and management of burns and scalds ................................................................18

2. Ongoing assessment and management of burns and scalds in primary care ....................................24

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List of fi gures

3.1 Assessment of burn size: Rule of Nines ...........................................................................................39

3.2 Assessment of burn size: Lund and Browder chart* .........................................................................40

* See also Notes to algorithm 1: note 2: burn assessment: assessment of burn size ...................................22

List of tables

1.1 Burns from fi re or fl ames: age specifi c rates for 2000–2004 ...........................................................27

1.2 Burns due to hot substances and objects, caustic or corrosive material or steam:28 age-specifi c rates

for 2000–2004 ...............................................................................................................................28

3.1 Airway maintenance .......................................................................................................................36

3.2 Key points of a burn history ............................................................................................................37

3.3 Classifi cation of burns based on depth* .........................................................................................44

10.1 Diagnosis according to duration of stress symptoms .......................................................................72

* See also Notes to algorithm 1: note 2: burn assessment: depth assessment ...........................................20

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Purpose

The purpose of this guideline is to provide a summary of current New Zealand and overseas evidence informing

the assessment and management of burn injuries in the primary care setting in New Zealand. The guideline

has been developed for health care practitioners who care for adults or children with burn injuries, and health

service provider organisations and funders. It provides a fi rst step in gathering the evidence base and ensuring

the coordination of burns care nationally across the health sector in New Zealand.

The focus of the guideline is the appropriate assessment and management of burns in the primary care setting

specifi cally, and appropriate referral practice from primary care to secondary care and regional burns unit

services. The guideline specifi cally excludes consideration of large, full thickness burns that are more likely

to be managed in secondary care. Similarly, scar management and associated specialist services provided in

secondary care, such as physiotherapy, occupational therapy and speech language therapy, are not a focus of

this guideline.

The guideline identifi es evidence-based practice for most people, in most circumstances. It thus forms the

basis for decision-making by the health care practitioner in discussion with an individual with a burn injury in

developing an individualised care plan.

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About the guideline

ForewordThe New Zealand Guidelines Group Incorporated (NZGG) is a not-for-profi t organisation established to promote

effective health and disability services. Guidelines make a contribution to this aim by sharing the latest

international studies and interpreting these in a practical way for dissemination and implementation in the New

Zealand setting. Guidelines consider both the evidence and the current availability of resources in the publicly

funded health system to ensure that the recommendations are realistic, promote best practice, and inform

policy and planning.

This guideline was developed by NZGG in partnership with the Counties Manukau District Health Board

(CMDHB), with Stephen Mills as Chair of the Guideline Development Team, and was funded by the Accident

Compensation Corporation (ACC).

Gaps between current practice and evidence This guideline for the management of burns and scalds in primary care has been developed to address

perceived gaps between current evidence and practice in New Zealand. Although the size of these gaps has not

been thoroughly documented, there appear to be uncertainties in treatment, variation in management practices

and an under-utilisation of cold water therapy for burns.

Although there are other international guidelines that have been published on the management of burns and

scalds, they were not considered to be suitable for use in New Zealand.

First aid management of burns

The New Zealand public appears to have a lack of understanding regarding the benefi ts of cold water therapy.

A prospective observational study of people with burns presenting to Middlemore Hospital in 2002 found that

59.5% of a total 121 people did not receive adequate burns fi rst aid treatment (defi ned as cold water therapy in

either stationary or running water for 10 minutes or more).1 Further analysis by age and ethnicity suggested that

Maori and Pacifi c peoples, and children were less likely to receive adequate fi rst aid treatment.

The study found that adequate fi rst aid treatment resulted in fewer people with burns requiring split-skin

graft procedures. There was also an association with fewer surgical debridement procedures. Scald injuries

in particular required fewer procedures following adequate burns fi rst aid treatment. The potential savings

estimated in 2002 from scald injury care alone amounted to $75,000–100,000 per annum.1

Burn size estimation

Estimations of burn size are necessary in the pre-hospital situation in order to assess initial fl uid requirements

and determine referral criteria. A number of tools can be used to assist health practitioners in estimating the

total body surface area (TBSA) (see Chapter 3, Burn size). Three observational studies were found assessing the

variability of burn size estimation in the pre-hospital environment.2-4 Results of these studies suggest that burn

size is often overestimated. As a consequence of this, people with burns may receive inappropriate volumes

of fl uid and could be transferred to a burns unit unnecessarily. The TBSA estimated in pre-hospital situations

is often overestimated where the burnt area is small and underestimated where the burnt area is large.3

Unfortunately the participants of these studies often had burns that would be more severe than those found in

primary care, therefore the fi ndings may not be directly applicable.

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Use of dressing products in primary care

International evidence is lacking around the use of dressing products in primary care. Silver sulphadiazine

is understood to be widely used at present on burns in primary care. This practice is supported by the expert

opinion of the Guideline Development Team for its properties as an anti-infective agent. However, extended use

of silver sulphadiazine on non-infected wounds has been shown to have adverse effects on the time to healing

in burn wounds. There are a number of randomised controlled trials (RCTs) comparing silver sulphadiazine

cream with other dressings and topical treatments. All of these studies found that silver sulphadiazine

increased time to healing. However, in these studies silver sulphadiazine cream was applied to the burn

wound until complete healing/re-epithelialisation. No studies were found comparing shorter-term use of silver

sulphadiazine cream with other dressings or topical treatments.

Expert opinion strongly favours the use of moist wound-healing products for superfi cial and mid dermal burns,

although the evidence is scanty and inconsistent. There is no convincing evidence from primary RCTs that any

other dressing product heals wounds signifi cantly faster than paraffi n gauze (which is considered a non-moist

dressing).

Evidence and recommendation grading systemAll studies relating to the benefi ts or harms of interventions are graded for quality. Each study has been

assigned an overall level of evidence: good (+), fair (~) or poor (x). Study details and levels of evidence are

summarised in evidence tables, which are used to formulate recommendations. The evidence tables are

available at http://www.nzgg.org.nz. Studies with an ‘x’ level of evidence had questionable validity and were

not considered relevant to the formulation of recommendations. Descriptive research, included for information,

was not graded for quality.

For further details about the evidence and recommendation grading system see Appendix A.

Guideline development processIn 2005, ACC commissioned NZGG to develop an adapted guideline based on reliable and valid evidence-based

sources of summarised evidence available internationally. The Guideline Development Team agreed to use two

other relevant guidelines5-7 as a template to further defi ne the scope of the project. This approach has allowed

the Guideline Development Team to conduct its own systematic reviews of key question areas and to consider

the syntheses and synopses of the evidence performed and published by others. This process of adaptation was

thought appropriate in a topic area where there are few large, well conducted randomised studies.

The Guideline Development Team was convened by NZGG and CMDHB. This involved formally approaching

representative professional colleges and stakeholder organisations to invite them to nominate people to be

members of the Team.

Two face-to-face meetings were held in Auckland during August 2005. The goals of the fi rst meeting were to train

members of the team in the processes of guideline development, to identify relevant clinical questions and to

make decisions about the scope of the guideline.

Individual sub-committee members then searched for new studies in narrowly-focused topic areas and reviewed

the evidence. In order to avoid the substantial costs and delays associated with translating foreign language

publications, only English language articles were used. Only the most rigorous studies for each question were

retrieved for the assessment and extraction of data. Details of the clinical questions, comprehensive search

strategy and evidence tables are available on the NZGG (http://www.nzgg.org.nz) website.

The evidence on which the recommendations are based was graded using the grading system developed by

NZGG. See Appendix A for more information on the grading system. 12


The second meeting of the Guideline Development Team was held in November 2005. At this meeting the

evidence in each area was presented in evidence tables to the Guideline Development Team and a Considered

Judgement process8 was used to agree levels of evidence and draft recommendations. The Guideline

Development Team also drafted an algorithm at this stage.

The statement and recommendations were drafted, reviewed and revised by sub-groups then reviewed by

the whole Team. Resources and appendices were drafted in the same way. This process continued until the

draft document was at a stage for peer review and consultation. Opinions were sought at this stage about the

feasibility of implementing the recommendations in the guideline.

Copies of the draft were sent to key individuals and sector groups for comment and peer review. Maori and

Pacifi c perspectives on burn injuries and their management were incorporated. These comments were approved

by the Team and incorporated into the fi nal document. The draft guideline was sent to sector groups for peer

review in February 2006 and the fi nal guideline was re-circulated in July 2006.

Guideline Development Team

This guideline was developed by a multidisciplinary team of practitioners, selected to represent professional,

cultural and consumer perspectives. The Team members were:

Stephen Mills (Chair) Plastic and Reconstructive Surgeon, Middlemore Hospital

Chris Goudie Adult Burns Clinical Nurse Specialist, Middlemore Hospital

Debbie Murray Paediatric Clinical Nurse Specialist, Middlemore Hospital

Linda Jackson Clinical Nurse Educator, Middlemore Hospital

Andrew Jull Research Fellow, Clinical Trials Research Unit, University of Auckland

Anna Munnoch Emergency Care, Clinical Nurse Educator, Middlemore Hospital

Vera Steenson Auckland Burn Support Group, consumer perspective

Frances James Clinical Psychologist, Middlemore Hospital

Kate Middlemiss National Burns Centre Establishment Manager, Middlemore Hospital

Carolyn Braddock Regional Burns Centre Manager, Hutt Valley District Health Board

Maureen Allan Te Tai Tokerau Primary Health Organisation, Maori perspective

Carol Ford Primary Care and Rural Nursing, Ngati Porou Hauora

Heidi Muller General Practitioner, Health Pacifi ca, Ta Pasefi ka, Pacifi c perspective

Rob Kofoed Convenor, New Zealand Accident and Medical Practitioners’ Association

Larry Skiba General Practitioner, Royal New Zealand College of General Practitioners

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NZGG team

Rob Cook Project Manager and GP

Catherine Coop Researcher/Project Manager from February 2006

Mark Ayson Researcher

Anne Buckley Medical Editor/Writer

Mai Dwairy Researcher until March 2006

Anne Lethaby Senior Researcher

Jane Marjoribanks Researcher

For fi rst meeting training/presentations:

Cindy Farquhar NZGG Board

Anne Lethaby NZGG Project Manager and Effective Practice, Informatics and Quality Improvement (EPIQ) Researcher

Sue Wells Senior Lecturer Clinical Epidemiology, University of Auckland

ACC observers:

James Chal Manager Research and Information Services

Zhi-ling ‘Jim’ Zhang Evidence Based Healthcare Researcher, Research Services

Chrissie Cope Manager Primary Care Services, Healthwise

Sonya Murray Evidence Based Healthcare Researcher, Research Services

Declarations of competing interests

There have been no competing interests declared for this guideline.

Consultation

At the start of the guideline development process, a number of organisations with a specifi c interest in the

management of burns and scalds nominated team members to be part of the Guideline Development Team.

Feedback was sought from these organisations after they had reviewed a draft of the guideline. During this

period of consultation the draft was also distributed widely to other interested individuals and they were invited

to comment on the draft.

Comments were received from the following organisations or individuals:

• Anna Knuckey, Product Manager, Jackson Allison Medical and Surgical Limited, Auckland

• Antonia Rippey, Occupational Therapist, CMDHB, Auckland

• Bice Awan, Chief Executive, Skylight, Wellington

• Bernard Hoste, Export and Business Development, Scarban, Tricolast NV, Belgium

• Caitlin Harvey, Occupational Therapist, Waikato District Health Board, Hamilton

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• Chris Adams, Consultant Plastic Surgeon, Wellington Regional Plastic Surgery and Burns Unit, Hutt Hospital,

Wellington

• Connie Mahu, Whanau Support Worker for Maori Health, Middlemore Hospital

• Glen Charlett, Director, Access Health Care Limited

• Heather Cleland, Director, Victoria Adult Burns Service, Alfred Hospital, Melbourne

• Janet Copeland, Research Liaison Offi cer, New Zealand Society of Physiotherapists Inc, Wellington

• Jason Wasiak, Research Offi cer, Victoria Adult Burns Service, Alfred Hospital, Melbourne

• Kirsten Taylor, Senior Physiotherapist, Middlemore Hospital, Auckland

• Marilyn Rosewarne, Member New Zealand College of Practice Nurses, Tauranga

• Rhys Jones, Senior Lecturer in Maori Health, The University of Auckland, Auckland

• Siobhan Molloy, Executive Director, New Zealand Association of Occupational Therapists, Wellington

• Stewart Sinclair, Clinical Director, Plastic Surgery Department, Christchurch Hospital, Christchurch

• Tony Smith, Medical Advisor, St John Northern Region, Auckland

• William Levack, Lecturer in Rehabilitation, Department of Medicine, Wellington School of Medicine and

Health Science, University of Otago, Wellington

Acknowledgements

We would like to thank Maureen Allen, Connie Mahu and Rhys Jones for their contribution towards Chapter

10, Burn injuries in Maori and Kelly Waddell and Francois Stapelberg for their contributions towards the pain

management section in Chapter 6. Thanks also to Debbie Murray and Linda Jackson from Middlemore Hospital

for their support and contributions.

Funding

This guideline was commissioned and funded by ACC and development and production were independently

managed by NZGG. ACC staff members were co-opted onto the Guideline Development Team to provide advice

about ACC internal processes. All evidence appraisals, reporting and formulation of recommendations are

independent of ACC, and NZGG retains editorial independence.

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Summary

Key messages• Children under the age of fi ve are most at risk of burns and scalds.

• All burns and scalds should be cooled immediately in running tap water (8–15°C) for at least 20 minutes.

– Avoid hypothermia: keep the person with the burn as warm as possible; consider turning the temperature

of the water up to 15°C (tepid).

• Gel pads or other fl uids can be used as an alternative to running tap water where water is unavailable or not

practical.

• If there has been a delay in starting cooling, this should still be started up to three hours after injury.

• Initial management should include an antimicrobial dressing or cream and, following this, dressings should

encourage re-epithelialisation by moist wound healing.

• Burn injuries constitute signifi cant trauma and can cause or exacerbate psychological distress.

Referral to a specialist burns unit• The referral criteria endorsed by the Australian and New Zealand Burn Association (ANZBA) should be

considered by primary health care practitioners when assessing whether burns require treatment in a

specialist burns unit (see Algorithm 1, Note 4).

• Other reasons for referral to a hospital may include: an ongoing requirement for narcotic analgesia,

intravenous (IV) fl uids, elevation or frequent or complex dressings; signifi cant comorbidities, social/

psychosocial indicators or suspected non-accidental injuries; or a need for other specialist services, eg,

physiotherapy.

• The depth of a burn injury should be reassessed, preferably by the same clinician, two to three days after the

initial assessment.

• Any burns that are unlikely to heal within 21 days without grafting (deep dermal and/or full thickness burns)

should be referred to a burns unit for scar management by day 10–14.

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Algorithm 1:Initial assessment and management of burns and scalds

Child or adult with a new burn injury

Immediate referral to nearest

regional burns unit

First aid, emergency examination

and treatment (Note 1)

No

Yes

Assess and record cause, non-

accidental injury, clinical features, burn

size, location and depth (Note 2)

Decide the level of care needed

Is specialist burns unit

care indicated? (Note 4)

Suitable for transfer to a

regional burns unit?

Continue managing in primary care.

Refer to Algorithm 2: Ongoing

assessment and management of

burns and scalds in primary care

Immediate referral to nearest hospital

Is hospital care indicated?

(Note 3)

No

No

Yes

Yes

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Notes to Algorithm 1

Note 1: First aid, emergency examination and treatment

First aid

• Ensure your own safety.

• Stop the burning.

• In electrical injuries, disconnect the person from the source of electricity.

• Cool the burn:

– cool with running tap water (8–15°C) for at least 20 minutes (no ice). Irrigation of chemical burns should

continue for one hour.

– avoid hypothermia: keep the person with the burn as warm as possible; consider turning the temperature

of the water up to 15°C (tepid).

• Remove clothing and jewellery.

• Cover the burn:

– cover with cling fi lm or a clean, dry cloth.

– avoid topical treatments until the depth of the burn has been assessed.

• Administer analgesia.

Emergency examination and treatment

Primary survey*

Airway maintenance with cervical spine control

Breathing

Circulation with haemorrhage control

Disability – neurological status

Exposure + environmental control

Fluid resuscitation proportional to burn size

Fluid resuscitation• Burns of >10% body surface area in children and >15% in adults warrant fl uid resuscitation.

• Give fl uids:

– 24-hour requirement: 3–4ml crystalloid solution per kg per % burn.

– plus maintenance fl uids for children.

– give half of the fl uids over the fi rst eight hours, the remainder over the next 16 hours.

Prevention of tetanusThere is a risk of tetanus following a burn injury. Refer to the guidelines on the prevention of tetanus following

injury, which are available from the Ministry of Health’s Immunisation Handbook 2006.9

Continued …

* Reproduced from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.8th Edition;2004.

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Note 2: Burn assessment

Depth assessment

The following table provides guidance in assessing the depth of burn injury.

table: classification of burns based on depth

anzba 2004 classification Full thicknessformer classification Full thicknessexample Scald (immersion), fl ame, steam, oil,

grease, chemical, high-volt electricityappearance White, waxy or charred, no blisters, no

capillary refi ll

May be dark lobster red with mottling in child

sensation No sensationhealing time Does not heal spontaneously, grafting

needed if >1cmscarring Will scar

anzba 2004 classification Deep dermalformer classification Deep partial thicknessexample Scald (spill), fl ame, oil or greaseappearance Blotchy red, may blister, no capillary

refi ll

In child, may be dark lobster red with mottling

sensation No sensationhealing time Over 21 days: grafting probably neededscarring High risk of hypertrophic scarring

anzba 2004 classification Mid dermalformer classification Partial thicknessexample Scald (spill), fl ame, oil or greaseappearance Dark pink with large blisters

Capillary refi ll sluggishsensation May be painfulhealing time 14–21 daysscarring Moderate risk of hypertrophic scarring

anzba 2004 classification Superfi cial dermalformer classification Superfi cial partial thicknessexample Scald (spill or splash), short fl ashappearance Pale pink with fi ne blistering, blanches

with pressuresensation Usually extremely painfulhealing time Within 14 daysscarring Can have colour match defect

Low risk of hypertrophic scarring

anzba 2004 classification Epidermalformer classification Superfi cial epidermalexample UV light, very short fl ashappearance Dry and red, blanches with pressure,

no blisterssensation May be painfulhealing time Within seven daysscarring No scarring

Adapted from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.

8th Edition; 2004.

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Chemical and electrical injuries6

Chemical burns: Copious irrigation should continue for one hour

Do not attempt to neutralise chemical burns in primary care

All chemical burns should be referred to a burns unit

Chemical eye injuries: Treat all chemical burns to the eye with copious irrigation of water

Ensure contact lenses have been removed

All signifi cant chemical injuries to the eye should be referred acutely to

ophthalmology services

Electrical injuries: Small entry and exit wounds may be associated with severe deep tissue damage

An electrocardiogram (ECG) should be carried out to detect arrhythmias

All electrical injuries should be referred to a burns unit

Non-accidental injuries

Indicators of possible non-accidental burns or scalds include the following:

• delay in seeking help

• historical accounts of injury differ over time

• history inconsistent with the injury presented or with the developmental capacity of a child

• past abuse or family violence

• inappropriate behaviour/interaction of child or caregivers

• glove and sock pattern scalds

• scalds with clear-cut immersion lines

• symmetrical burns of uniform depth

• restraint injuries on upper limbs

• other signs of physical abuse or neglect.

Refer to a regional burns unit if non-accidental injury is suspected.

Continued …

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Assessment of burn size: Lund and Browder chart% Total Body Surface Area Burn

Be clear and accurate, and do not include erythema

%

region part

ial

thic

kn

ess

lo

ss

full

thic

kn

ess

lo

ss

Head

Neck

Ant. trunk

Post. trunk

Right arm

Left arm

Buttocks

Genitalia

Right leg

Left leg

total burn

area age 0 1 5 10 15 adult

A = B/c of head 9 B/c 8 B/c 6 B/c 5 B/c 4 B/c 3 B/c

B = B/c of one thigh 2 D/e 3 B/e 4 4 B/c 4 B/c 4 D/e

C = B/c of one lower leg 2 B/c 2 B/c 2 D/e 3 3 B/e 3 B/c

A

B B

C C C C

B B

A

1B/c

1B/c

1B/c

1B/c

1D/e 1D/e

1

2 213

1

2 2

1B/c 1B/c

1B/c 1B/c

1D/e 1D/e

1

13

2B/c 2B/c

Reproduced with permission from: Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment

and resuscitation. BMJ 2004;329;101–3.22


Note 3: Considerations for referral for hospital careBurns of lesser severity than those meeting the criteria for regional burns unit care but with one or more of the

following risk factors:

• ongoing requirement for narcotic analgesia or failure to manage dressing-change pain

• IV fl uids required

• where oedema may be a problem

• social and/or psychosocial indicators

• suspected non-accidental injury

• frequent or complex dressing issues

• signifi cant comorbidities

• request for other specialist services, eg, physiotherapy.

Note 4: Referral criteria for regional burns unit careThe following criteria are endorsed by the ANZBA in assessing whether burns require treatment in a specialised

burns unit:33

• burns greater than 10% of total body surface area (TBSA)

• burns of special areas – face, hands, feet, genitalia, perineum and major joints

• full thickness burns greater than 5% of TBSA

• electrical burns

• chemical burns

• burns with an associated inhalational injury

• circumferential burns of the limbs or chest

• burns in the very young or very old

• burns in people with pre-existing medical or psychological disorders that could complicate management,

prolong recovery or increase mortality

• burns with associated trauma.

NOTE: Referral to the National Burn Centre is made through a regional burns unit. There are regional burns units

at Christchurch (03 364 0640), Hutt Valley (04 566 6999), Waikato (07 839 8899) and Middlemore

(09 276 0000) Hospitals.

23


Algorithm 2:Ongoing assessment and management of burns and scalds in primary care

Child or adult with a burn injury that can be managed in primary care

Day 1: Assessment of depth (Note 2)

Epidermal

Reassessburn depth (Note 2). Is it

signifi cantly worse (likely to be full thickness)?

Intact skin?

Is the burn area>1cm wide?

Superfi cial/Mid dermal Deep dermal/full thickness

Moisturising creamReview after 48 hours

Day 3: Reassessment

Antimicrobial dressing

Blister and oedema management (Note 5)

Pain relief (Note 6)

Daily review

Day 3: Reassessment

Change to moist wound-healing product or

alternatively double-layer paraffi n gauze

Review within 72 hours

Monitor for signs of infection

Healed, continue

moisturiser and sunblock

Continue with dressings as above

Monitor for signs of infection (Note 7)

Days 10–14

Is healing likely withinseven days?

Continue with dressingsHealed. Consider rehabilitation needs (Note 8)

Antimicrobial dressing (eg, silver sulphadiazine cream)

Pain relief (Note 6)

Daily review

Days 5–7:

Change to moist wound-healing product

Refer acutely as appropriate (Notes 3 and 4)

Is healingprogressing?

Yes

Yes

No No

No

No

No

Yes

Yes

Yes

24


Notes to Algorithm 2

Note 5: Management of blisters and oedemaManagement of blisters

• Preferably leave small blisters intact unless likely to burst or interfere with joint movement

• If necessary, drain fl uid by snipping a hole in the blister.

Management of oedema

• Where possible, elevate affected area

• Remove jewellery or constricting clothing.

Note 6: Pain management for adults and childrenImmediately after the injury

• Cool and cover the burn (with cling fi lm or a clean, dry cloth).

Background pain

• Paracetamol and non-steroidal anti-infl ammatory drugs (NSAIDs), alone or in combination with opioids

• Aspirin products should be avoided.

Intermittent or procedural pain

• Consider administering short-acting opioids

• Supplementary anxiolytics if indicated

• Supplement pharmacological therapy with non-pharmacological approaches

• Refer to secondary care if failing to manage dressing-change pain.

Note 7: Signs of infectionSigns of infection

• Surrounding redness, increasing pain, increased exudate/pus, swelling, fever or local wound temperature

increase, lymphangitis or increased irritability in a child.

Suggested management

• Swab the wound

• Consider re-starting topical silver sulphadiazine

• Consider starting oral antibiotics

• For more serious infection, refer acutely to secondary care.

Note 8: Psychological consequences of burn injury• Monitor for stress disorders and depression

• Be aware of the risk of sleep disorders

• Consider services that may be able to support families affected by the psychological impact of burn injuries.

25


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1

Chapter 1Burn injuries and burns prevention inNew Zealand

Evidence statements

• Most burns occur at home.

• Children under fi ve are at the highest risk, with hot liquids being the leading cause of injury in this age group.

• Maori are at increased risk, particularly in the under-fi ve age group.

• Males are at increased risk at all ages.

Evidence

Burns and scalds are a leading cause of injury to children in New Zealand, with children aged fi ve years and

under being most at risk, especially toddlers as they become more mobile with little awareness of danger. Every

year, about seven or eight New Zealand children aged 15 years and under die as a result of burns or scalds. In

most cases, fatalities are the result of house or car fi res. Over two-thirds of those who die are aged fi ve years

and under10 and over a third are Maori.11

On average about 475 children under 15 years are admitted to hospital every year as a result of burns or scalds,

of whom 80% are aged fi ve years and under.10 In 2002–3, 436 children under fi ve years were admitted to public

hospitals with burns and scalds. Most of these injuries involved hot liquids: about 34% were caused by hot

drinks, food, fat or cooking oils, 20% by hot tap water, 25% by other hot fl uids and 8% by exposure to fi re or

fl ames. Over 35% of children aged fi ve years and under admitted to hospital were Maori, and over 60% were

boys.12

During 2002 and 2003 the total number of adults and children admitted to public hospital with burn injuries

was 1311. Thirty-three per cent of these burns were fi re, fl ame or smoke related and 77% were due to scalds

and contact with hot objects. Maori comprised 26% of total admissions and Pacifi c peoples comprised 10.5%.

Overall 66% of admissions were male, with higher rates of injury in all age groups.12 Most burn injuries occur at

home (this applies to about 63% of fi re or fl ame burns and 70% of scalds).13

Further data from the Injury Prevention Research Unit on age-specifi c rates of burn injury over the period

2000–2004 is provided in Tables 1.1 and 1.2. This data includes fi rst admissions only (excluding day patients)

with a primary diagnosis of injury.

table 1.1: burns from fire or flames: age-specific rates (per 100,000 population) for 2000–2004

age (years) rate

<15 4.9

15–24 11.1

25–44 7.1

45–64 4.1

65+ 2.9

Reproduced from: Dow NA, Stephenson SCR, Allnatt DM. Trends In Thermal Injury. Fact Sheet No. 21. Dunedin:

Injury Prevention Research Unit, University of Otago; 2001.

27


table 1.2: burns due to hot substances and objects, caustic or corrosive material or steam: age-specific rates (per 100,000 population) for 2000–2004

age (years) rate

0–4 79.8

5–14 8.5

15–24 6.5

25–44 7.4

45–64 5.7

65+ 7.8

Reproduced from: Dow NA, Stephenson SCR, Allnatt DM. Trends In Thermal Injury. Fact Sheet No. 21. Dunedin:

Injury Prevention Research Unit, University of Otago; 2001.

ACC data on burn injuries, which is based on claim numbers for burn injuries covering a three-fi nancial-year

period (1 July 2001 to 30 June 2004), shows that there were 65,089 new claimants of burn injury in all age

groups, in the three-year period.14 This number is much higher than other data (locally and internationally),

and is probably because ACC covers general practitioner treatments and visits for very minor burn injuries for

compensation. For burn injuries, the ratio of males to females is 1.12 to 1.00, and there were 20 fatalities in

that period. Children aged under 15 years constituted 33% of burn-related claims.

As in New Zealand, overseas literature reports that children under fi ve years have the highest risk of both

burn-related death15 and burn-related hospitalisations.16,17 Epidemiological studies conducted in a number

of countries show that children in this age group have the highest burn-incidence rate.18-23 In this age group,

scalds typically account for 50% of thermal injuries logged in emergency departments, and scalds are also more

likely to lead to hospitalisation than any other burn injuries.17,24,25 Up to 80% of all childhood burn injuries in

developed countries occur at home,23 and over 90% occur at home in developing countries.18,21

Opportunities for prevention

recommendations grade

Primary care providers should provide advice on smoke alarms. A

Primary care providers should support local initiatives in primary prevention, where possible. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations – refer to Appendix A for grading details.

good practice points

Primary care providers should provide advice on the regulation of hot water temperature and

appropriate fi rst aid management.

✓

This is the opinion of the Guideline Development Team, or feedback from consultation within New Zealand where no evidence is available.

28


1

Evidence statements

• The hot water temperature in the home should be regulated to reach the taps at no more than 50°C.

• There is evidence from the United States (US) that smoke detector legislation can reduce the number of fi re-

related deaths compared with communities without smoke detector legislation.

• There is evidence that the community-based provision of free smoke alarms (with or without installation)

reduces fi re-related injuries.

• Simple educational initiatives improve safety in the home.

Evidence

Common preventable causes of serious thermal injury include scalding water and lack of smoke detectors. A

1947 study found that full thickness burns occurred in adult skin in two seconds at 66°C whereas at 54°C this

took 30 seconds.26 In a large US case-control study the absence of a smoke detector increased the risk of death

in a residential fi re by over 60%.27

The primary care setting offers numerous opportunities for promoting safety measures to prevent burns and

scalds since young children are the population most at risk and they are usually seen routinely. There is good

evidence that advice in this setting promotes good practices with regard to fi re safety, although evidence is

lacking of a direct impact on injuries.28

Similarly, while an educational strategy may improve safety consciousness,29 there is little evidence about

community-based interventions that impact on the rate of injuries.30 However, individual regulatory measures,

such as the installation of temperature controls on hot water cylinders, appear to have had some impact.

A systematic review of individual-level injury prevention strategies delivered in primary and acute care

settings showed that such strategies increased smoke alarm ownership and the maintenance of a safe hot

water temperature.28 The most effective interventions used a combination of methods, such as counselling,

demonstrations, the provision of free or subsidised safety devices, and reinforcement. None of the relevant

trials reported outcomes on fi re-related injuries specifi cally.

A small New Zealand study29 showed an improvement in the ability of children to recognise fi re safety hazards

around the home and in families’ self-reported safety practices, such as keeping pot handles turned in. The

most problematic recommendation was to reduce the hot water temperature.

A systematic review found very limited research on the effectiveness of community-based injury-prevention

programmes to prevent burns and scalds in children. Only one of the three eligible studies reported a reduction

in burn injuries and there were weaknesses in the methodology of this study.30

Regulation of hot water temperature to reduce the risk of scalds

• The safest long-term option is to install a tempering valve in the hot water cylinder. This is done by a

plumber. It ensures that hot water reaches the taps at the appropriate temperature. Since 1993 the

New Zealand Building Code has required that tempering valves be installed in new homes.

• Another option is to turn down the thermostat on the hot water cylinder. If a consumer-adjustable thermostat

is not fi tted, an electrician can install one. However, the tempering valve option is safer and is also more

energy effi cient in the long term.

• An adult should be able to hold their wrist under the running water.

• If in doubt, check the hot water temperature with a thermometer.

For more information, see the New Zealand Fire Service website Fire Safety Tips

(http://www.fi re.org.nz/home_kids/tips/hotwater.htm).

29


30


2

Chapter 2First aid

Stopping the burning process and cooling


Ensure your own safety. C

If on fi re, ‘stop, drop and roll’, smother with blanket or douse with water. C

For electrical burns, disconnect the person from the source of electricity. C

Remove clothing and jewellery. C

Cool burns or scalds by immediate immersion in running tap water (8–15°C) for at least 20

minutes. Irrigation of chemical burns should continue for one hour.

C

Do not use ice for cooling. C

Avoid hypothermia: keep the person with the burn as warm as possible, consider turning the

temperature of the water up to 15°C (tepid).

C

If there has been a delay in starting cooling, this should still be started up to three hours after

injury.

C

Do not attempt to remove tar. C


Evidence statements

• Clothing can retain heat, even in a scald injury.

• Cooling burns reduces the severity of tissue damage.

• Running tap water at 15°C (tepid) is as effective as other forms of cooling.

• Alternative liquids, such as milk or soft drinks, may be used when running tap water is unavailable.

• Be aware of the risk of hypothermia, especially in children and older people.

• Application of ice may deepen the wound and increase the risk of hypothermia.

Evidence

The evidence for stopping the burning process derives largely from expert opinion.31,32 Flames should be doused

with water or smothered with a blanket or by rolling the person on the ground. Clothing can retain heat and

should be removed as soon as possible unless adherent. Jewellery should also be removed and if oedema

is present elevate the affected area. Tar burns should be cooled with water, but the tar itself should not be

removed. In the case of electrical burns, ensure the power source is turned off and the scene is safe before

cooling with water. Expert opinion suggests that if running tap water is unavailable to cool the burn wound,

alternative liquids may be used, such as milk or soft drinks.

31


There is good evidence that immediate cooling of burns reduces the severity of tissue damage. However, the

optimum duration and temperature of cooling is largely a matter of expert opinion. The Guideline Development

Team extrapolated the low-level evidence from a variety of sources to reach a weakly graded conclusion.

Irrigation of chemical burns should continue for one hour. See Chapter 7, Management of chemical injury for the

evidence supporting this statement and further information on the management of chemical burns.

Cooling large areas of skin may result in hypothermia, especially in children.31 Therefore, while it is

recommended that the burn wound is cooled by irrigating or immersing in running water, the person with

the burn needs to be kept as warm as possible. Ideally the water should be tepid (15°C). Ice or iced water

should not be used as intense vasoconstriction can cause burn progression31 and also increases the risk of

hypothermia.33 In an animal study, the application of ice for 10 minutes resulted in a deeper wound compared

with no treatment at all.34

A case series study of 695 children with burns in Vietnam found that immediate cooling with cold water

signifi cantly reduced the risk of sustaining a deep burn, with an estimated 32% reduction in the need for skin

grafting.35 Similarly, a study of 121 people with burns presenting to Middlemore Hospital found that adequate

burns fi rst aid treatment (cooling) was associated with a reduced number of skin-grafting procedures.1

Another large case series showed a signifi cantly decreased length of hospital stay in people with less than 30%

TBSA burns who received fi rst aid by water cooling.36

In a randomised single-blinded study37 of 24 volunteers, no prolonged anti-infl ammatory or anti-hyperanalgesic

effects were observed after 30 minutes’ cooling to 8°C, initiated within 15 minutes after an epidermal burn

injury (although the data did not contradict the clinical observation that cooling following a more severe burn or

scalding has a pain-relieving effect). An earlier experimental study supported these fi ndings.38

Other evidence on cooling derives from animal studies. The methods, duration and temperature of cooling used

in these studies varied widely.

One experimental study39 found faster healing at 21 days in deep partial thickness scalds cooled with either

tap water (at 15°C, applied on gauze every three minutes) or hydrogel, than in uncooled scalds. Similarly,

another experimental study40 found that scalds treated by ice-water immersion at 10 minutes post-burn for 30

minutes sustained less damage to the epidermis, basement membrane and dermal microvasculature and had

less oedema than those untreated. A transient reduction in oedema volume in scalds was also found in another

study,41 which lasted longer with decreasing temperature and increased cooling time. The most pronounced

effect was obtained after cooling at 0°C for 120 minutes.

One study investigated the optimum period of cooling.42 This involved cooling burns at 8°C for time periods from

15 to 120 minutes. The results suggested that 30 minutes was the optimal duration of cooling.

Another study investigated when the cooling strategy should be started.43 This study began cooling wounds

from 10 minutes to 60 minutes post-burn and found markedly better healing when cooling (ice water 0–3°C

bath for 30 minutes) was commenced within 30 minutes of burning, compared with 60 minutes after burning.

Gel pads

recommendation grade

Gel pads can be used as an alternative to running tap water where water is unavailable or not

practical.

C


32


2Evidence statements

• There is insuffi cient evidence about the effectiveness of burn gels in comparison with running water.

Evidence

There was insuffi cient evidence to assess adequately whether hydrogel dressings are more effective at cooling

or reducing pain than water. Three published studies (two case series in people with burns or wounds and one

comparative study in volunteers with non-burned skin) and four studies downloaded from the internet (one in

pigs, one with volunteers with non-burned skin and two with people with burns) were identifi ed. One of these

studies directly compared the cooling properties of hydrogel dressings with cold water (in people without

burns). One comparative study compared hydrogels with other types of dressing for other outcomes, such as

healing time and hospital stay. Pain relief was assessed by only one case series.

Findings

An experimental animal study of fair quality44 found that cooling with a gel dressing at different time periods was

more rapid and effective than air cooling and the immediate application of gauze in burned pigs. A poor-quality

case series of 131 adults with scalds and burns45 recorded body temperature rectally and at the skin surface for

cold water cooling compared with gel cooling in healthy volunteers without burns. Cold water therapy for 20 to

30 minutes, but not gel cooling, induced hypothermia in participants. The case series also reported that 73% of

participants using a gel dressing had a reduction of pain (described as ‘appropriate’, ‘permanent’ or ‘total’) and

36% used no analgesics. The dressing was described as ‘easy’ to administer in 98% of cases.

A controlled trial of fair quality46 reported that hydrogel dressing with air movement was more effective

than hydrogel dressing alone, with a thick bandage or with a bandage plus air movement, in reducing skin

temperature in healthy volunteers without burns. Due to the paucity of good-quality randomised evidence, we

have been unable to directly compare the effectiveness of burn gels with cold water for cooling and reducing

pain. The identifi ed studies did not report any adverse events when burn gels were used.

Initial coverings

Polyvinyl chloride fi lm (cling fi lm)


Following cooling, polyvinyl chloride (PVC) fi lm may be used as a temporary cover prior to

hospital assessment. It should be applied by persons knowledgeable in its use.

C

PVC fi lm should be layered onto the wound and not applied circumferentially around a limb. C

Topical creams should not be applied as they may interfere with subsequent assessment. C


good practice point

PVC fi lm should not be used as a substitute for a dressing product. ✓


33


Evidence statements

• The application of PVC fi lm can relieve pain. It is transparent for inspection. It is clean and easy to remove.

• A clean, dry cloth may be used to cover the wound if PVC fi lm is not available.

• The use of PVC fi lm as an alternative to silver sulphadiazine cream makes the subsequent assessment of

wound depth easier in people who are transferred within four hours to secondary care.

• There is a risk of constriction if PVC fi lm is wound around a limb that subsequently swells.

Evidence

Insuffi cient evidence was identifi ed to determine the benefi t of PVC fi lm. A non-systematic review, a

microbiological study and a case series were identifi ed which assessed water-impermeable PVC fi lm as a

dressing for burns.47-49

Findings

Cling fi lm plastic wrap is sold throughout New Zealand, mainly to cover food. It is composed of plasticised

PVC fi lm. Based on experience in an English burns unit, Wilson47 concluded in his review that plasticised PVC

fi lm was easy to use, safe and cheap and caused no pain. It was found to be particularly useful before surgery

and before transfer to the burns unit in the hospital. In a microbiological study of 24 people with partial or full

thickness burns who used PVC fi lm as a temporary dressing,48 bacteria were cultured from the initial exudate in

only 3 out of 37 burns and subsequent bacterial cultures showed no differences from what was usually found in

burn wounds. Laboratory investigations indicated that the wrap had no antibacterial effect on the burn wounds.

The other case series49 reported that PVC fi lm as a wound covering enhanced the ability of thermography to

assess the damage to the skin blood vessels prior to early surgery. The PVC fi lm did not interfere with the

measurement of surface temperature and avoided the cooling effect of evaporation at the site of the wound.

PVC fi lm is often used as a temporary covering of a burn wound. It is pliable, non-adherent and impermeable,

acts as a barrier and is transparent for inspection. After the fi rst few centimetres it is essentially sterile. It should

be applied in layers and not circumferentially like a bandage, to prevent any tourniquet effect if tissue oedema

develops.6

The Guideline Development Team suggests that if cling fi lm is unavailable, a clean, dry cotton sheet (preferably

sterile) may be used as a fi rst aid measure at home. In the primary care setting a double-layer paraffi n gauze

dressing may be used. Hand burns can be covered with a clear plastic bag. Topical creams should not be

applied at this stage as they may interfere with the subsequent assessment of the burn.31

34


3

Chapter 3Burn assessment

Emergency management


For major burns perform an ABCDEF primary survey and X-rays, as indicated. C

Address analgesic requirements. C

Establish and record the cause of the burn, the exact mechanism and timing of injury, other

risk factors and what fi rst aid has been given.

C

Assess burn size and depth. C

Give tetanus prophylaxis if required. C

Be alert to the possibility of non-accidental injury. C


Evidence

Measures recommended for the assessment and initial management of burns derive largely from international

expert opinion.50,51 The chance of survival following burn injury has increased steadily over the past 60 years, in

tandem with the introduction of such measures.52,53

Several large case series studying factors predictive of death following burn injury reported a strong correlation

between prognosis and two factors: burn area (particularly deep burn area) and age.54-57 In addition, studies

have found inhalational injuries to be a strong predictor of mortality.52,58-60 There is also evidence that other

factors, such as alcohol, contribute signifi cantly to outcome.61

ABCDEF primary surveyAirway maintenance with cervical spine control

• Ensure airway is clear and open, keep movement of cervical spine to a minimum.

• Inhalation of hot gases can cause a burn above the vocal cords that may become oedematous over the

following hours; a seemingly well person, especially a child, may deteriorate later. See Table 3.1 for signs of

inhalational injury.

• If the patency of the airway is at risk, intubate.

35


table 3.1 airway maintenance

signs of inhalational injury indications for intubation

History of fl ame burns or burns in an enclosed space

Full thickness or deep dermal burns to face, neck or

upper torso

Singed nasal hair

Carbonaceous sputum or carbon particles in

oropharynx

Erythema or swelling of the oropharynx on direct

visualisation

Change in voice, with hoarseness or harsh cough

Stridor, tachypnoea or dyspnoea

Adapted from: Hettiaratchy S, Papini R. Initial management of a major burn: 1– overview. BMJ 2004;328: 155–7.

Breathing

• Expose chest and ensure adequate and equal expansion.

• Provide supplemental oxygen.

• Damage below the vocal cords can be caused by severe chest burns, blast injury or inhalation of smoke or

carbon monoxide. The products of combustion can directly irritate the lungs and cause bronchospasm or

pulmonary oedema. People with asthma are particularly at risk.

Circulation with haemorrhage control

• Check for bleeding due to other injuries.

• Stop bleeding with direct pressure.

• Check pulse and peripheral circulation.

• Hypotension is not the normal initial response to a burn: check for other causes.

• Normal return from capillary blanch test is two seconds. A deep circumferential extremity burn can act as a

tourniquet, causing vascular insuffi ciency and distal ischaemia which may become apparent some hours

after the burn.

Disability: Neurological status

• Establish level of consciousness.

• Poisoning from inhalation of noxious gases can cause confusion, dizziness, headaches and seizures.

• Hypovolaemia and shock can also cause confusion.

Exposure with environmental control

• Remove clothing and jewellery and examine the whole person, including the back, for burn area and co-

injuries.

• Keep the person warm: hypothermia develops easily, especially in children.

Fluid resuscitation

• Establish intravenous access with two large peripheral intravenous lines.

• Take blood for full blood count, urea and electrolytes, coagulation screen, amylase and carboxyhaemoglobin.

• The main aim is to maintain tissue perfusion to the wound and prevent the burn deepening and to avoid

hypoperfusion or oedema.

• Burns of >10% body surface area in children and >15% in adults warrant resuscitation.

• Give fl uids:

– 24-hour requirement: 3–4ml crystalloid solution per kg per % burn

– plus maintenance fl uids for children

– give half over the fi rst eight hours, the remainder over the next 16 hours.

• If haemorrhage occurs from other injuries, replace with blood.

36


3

• Monitor with urinary catheter, ECG, pulse, blood pressure, respiratory rate, pulse oximetry or blood gases as

appropriate.

• Insert nasogastric tube for larger burns or associated injuries.

X-rays• In traumatic injury, order X-rays as indicated.

Pain relief• Give intravenous morphine.

• Use small incremental doses of intravenous morphine until pain is controlled and reassess regularly.

For further information on pain management see Chapter 9, Pain management.

Burn history• Knowledge of the cause of the burn, the exact mechanism and timing of injury and what prior treatment has

been given helps to indicate the likely severity of the burn, the likelihood of inhalational or other co-injuries,

the presence of contributing underlying causes (eg, faintness, seizure, alcohol) and the possibility of non-

accidental injury. See also Table 3.2 for key points of a burn history.

table 3.2: key points of a burn history

exact mechanism

Type of burn agent (scald, fl ame, electrical, chemical)

How did it come into contact with the patient?

What fi rst aid was performed?

What treatment has been started?

Is there a risk of concomitant injuries (such as fall

from height, road traffi c crash, explosion)?

Is there a risk of inhalational injuries (did the burn

occur in an enclosed space?)

exact timings

When did the injury occur?

How long was the patient exposed to the energy

source?

How long was cooling applied?

When was fl uid resuscitation started?

exact injury

Scalds

• What was the liquid? Was it boiling or recently

boiled?

• If tea or coffee, was milk in it?

• Was a solute in the liquid? (Raises boiling

temperature and causes worse injury, such as

boiling rice)

• Is there any suspicion of non-accidental injury?

Electrocution injuries

• What was the voltage (domestic or industrial)?

• Was there a fl ash or arcing?

• Contact time?

Chemical

• What was the chemical?

Adapted from: Hettiaratchy S, Papini R. Initial management of a major burn: 1– overview. BMJ 2004;328: 155–7.

37


Factors infl uencing management and prognosis• The size and depth of burns indicate their likely severity, the need for fl uid resuscitation, the potential risk of

complications, the rate of healing, the amount of scarring that can be expected, and the need for specialist

care. However, a burn is rarely uniform: a mixed pattern of burn is usually found.

• The prognosis for people with major burns is well correlated to the area of the burn (TBSA), the presence of

inhalational injury, and age.

Burn size

Assessment and recording of total body surface area burn


Where time allows, use the Lund and Browder chart as the standard assessment tool for

estimating the TBSA of the burn.

B


Evidence statements

• Lund and Browder charts are more accurate than either the Rule of Nines or palm size in identifying TBSA.

• Lund and Browder charts become less accurate at the extremes of age and body mass index (BMI).

• The Rule of Nines can be faster and more convenient to perform in emergency situations but is not accurate

for children and should not be used in those clinical settings.

• A person’s hand size (palm including fi ngers) approximates to 0.8–1.0% of TBSA. The 1% rule can be

cautiously used to estimate the size of small burns (<10%) in primary care.

• Computer assessments of burn size are not suffi ciently developed for routine use in primary care.

The measurement of burn surface area is important during the initial management of people with burns for

estimating fl uid requirements and determining referral criteria. It is essential that all of the burn is exposed

and assessed. During assessment the environment should be kept warm, and small areas of skin exposed

sequentially to reduce heat loss. Erythema should not be included.51

Evidence

The practice of using a person’s hand size to approximate 1% body area is commonly taught on emergency

medicine courses but has not been well validated.62-67 This practice should be used with caution, particularly

in children or for people who are obese (BMI >30) as it does not allow for variations in individual body weight

or age. For small areas, up to about 5%, the whole hand (palm plus digits) should be taken to approximate

0.8–1.0% of TBSA.

Five observational studies were found comparing the Rule of Nines burn area chart (see Figure 3.1) with other

methods of estimating burn surface area. The Rule of Nines has been found to provide reasonable estimates for

burned body surface area for most children and adults.68 For people who are obese or weighing more than 80kg

(BMI >30), a Rule of Fives is proposed by one author:69 5% body surface area for each arm, 5x4 or 20% for each

leg, 10x5 or 50% for the trunk, and 2% for the head. For infants weighing less than 10kg (BMI <18) a Rule of

Eights is proposed: 8% for each arm, 8x2 or 16% for each leg, 8x4 or 32% for the trunk, and 20% for the head.

Computer methods of size estimation have been described for use in various skin disorders. Three studies

were reviewed which were considered applicable to burn size assessment. Two observational studies70,71

found a close correlation between the computer methods of size estimation and objective measurement. The

participants of one study found a computer program was easy to use and potentially useful in the person’s

care.72 No direct quantitative comparisons with manual methods, in people with burns, were found. 38


3

Six different types of burn area charts were compared in one observational study.73 Four of the six were either

Lund and Browder (see Figure 3.2) or a modifi ed version of Lund and Browder, and there were two versions of

the Rule of Nines represented. Utilising 10 drawings of burns on the six different charts, this study found that

the Rule of Nines often overestimated the burn size and was more variable, but could be performed somewhat

faster than the Lund and Browder method. The Rule of Nines’ estimates were 3% larger than the Lund and

Browder estimates for the same burn representation.

A modifi cation to the Lund and Browder chart has been proposed that adjusts for breast burns in larger-

breasted women,74 as breast burns in these women can be underestimated by as much as 5%.

In the primary care setting it is anticipated by the Guideline Development Team that the use of specifi c

adjustments in estimates of burn area to take account of obesity and large breast size would be precluded by

other clinical priorities.

figure 3.1: assessment of burn size: rule of nines

9%

9% 9%

1%

18% 18%

Front 18%Back 18%

18%

14% 14%

9% 9%

Front 18%Back 18%

Adapted from: Australian and New Zealand Burn Association Limited, Emergency Management of Severe Burns

(EMSB): Course Manual 2004.

39


figure 3.2: assessment of burn size: lund and browder chart

% Total Body Surface Area Burn

Be clear and accurate, and do not include erythema

%

region part

ial

thic

kn

ess

lo

ss

full

thic

kn

ess

lo

ss

Head

Neck

Ant. trunk

Post. trunk

Right arm

Left arm

Buttocks

Genitalia

Right leg

Left leg

total burn

area age 0 1 5 10 15 adult

A = B/c of head 9 B/c 8 B/c 6 B/c 5 B/c 4 B/c 3 B/c

B = B/c of one thigh 2 D/e 3 B/e 4 4 B/c 4 B/c 4 D/e

C = B/c of one lower leg 2 B/c 2 B/c 2 D/e 3 3 B/e 3 B/c

A

B B

C C C C

B B

A

1B/c

1B/c

1B/c

1B/c

1D/e 1D/e

1

2 213

1

2 2

1B/c 1B/c

1B/c 1B/c

1D/e 1D/e

1

13

2B/c 2B/c

Reproduced with permission from: Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment

and resuscitation. BMJ 2004;329;101–3.40


3

Burn depth


The depth of a burn injury should be reassessed two to three days after the initial

assessment, preferably by the same clinician.

C

Testing for pinprick sensation by using a needle should be avoided. C


good practice point

The extent and speed of capillary refi ll can be used as a clinical method of assessing burn

depth.

✓


Evidence statements

• Burns can be diffi cult to assess accurately in the fi rst few days following injury, particularly in areas of poor

circulation or infection.

• Burn depth is easier to assess after the initial oedema and infl ammatory reaction have settled.

• The extent and speed of capillary refi ll is the most useful clinical method to assess burn depth.

• There is insuffi cient evidence that the newer technologies (laser doppler, thermography, radioisotopes) are

practical or useful in assessing burns in the primary care setting.

• Testing for pinprick sensation is painful and can be frightening for children and is not a sensitive test for

assessing burn depth.

• An estimate of burn depth is important in planning treatment, but is not required for calculating fl uid

requirements for acute resuscitation.

Evidence

There is little reliable evidence on the assessment of burn depth and the above recommendations derive largely

from expert opinion.

Although it is relatively uncomplicated to diagnose very superfi cial burns and very deep burns, those of

intermediate thickness are more problematic as their surface appearance alone is deceptive. The extent and

speed of capillary refi ll is considered the most useful clinical method to assess burn depth.51 However, the

presence of a dermal circulation, as measured by capillary refi ll at 24 hours post-injury, does not necessarily

mean that the burn will remain superfi cial. Burns can increase in severity and depth over the fi rst few days,

particularly in areas of poor circulation or infection. Burn depth is easier to assess after the initial oedema and

infl ammatory reaction have settled.

Testing for burn depth by using pinprick sensation requires a high degree of compliance and is not appropriate

for young children, or for people who are confused or shocked. Moreover, the accuracy of the test is limited.75

Biopsy and histology are generally considered to be the gold standards for assessment of burn depth, but are

impractical for routine clinical use.

Most studies76-78 assess burns after 48 hours or so and therefore there is little evidence assessing the diagnostic

accuracy of tools used to assess depth in the acute setting. Laser Doppler, transcutaneous microscopy,

refl ectance fl uoroscopy, radioisotope studies, ultrasound and thermography have all been tried, but are still

seen as research tools. The depth of a burn on any individual subject will vary from one location to another,

41


so all controlled trials of these tools suffer from a diffi culty in matching the areas sampled. Despite this,

some studies of newer techniques have shown promise in a research setting. The practical problems for the

application of these techniques to clinical use include:

• direct contact with the skin surface is sometimes needed

• some tests are invasive

• burns in some body areas cannot be tested

• a lack of agreed standardisation of the thresholds

• investigator bias is introduced by the need to choose a sample area.

A small blinded prospective study (of 23 people with 41 wounds) compared clinician assessment with laser

doppler imaging to gauge burn depth in adults with acute burns of indeterminate depth.79 Burns were assessed

daily; in most cases the fi rst scan was done one day post-burn (maximum two days). Clinician assessment

correctly predicted which of the 41 wounds required excision and grafting (sensitivity 100%), while the laser

doppler technique erroneously predicted healing in 8 out of 21 cases when biopsy results confi rmed deep

partial thickness (mid to deep dermal) or full thickness burns (sensitivity 62%). Conversely, surgeons frequently

overestimated burn depth, resulting in unnecessary excision and grafting for seven people (specifi city 61.5%),

whereas the laser doppler was 100% specifi c.

Other studies of newer technologies assessed wounds in a non-acute setting, so were not relevant to primary

care.

Non-accidental injury


If non-accidental injury is suspected, refer to a regional burns unit. C

If non-accidental injury is suspected, examine for other signs of abuse and photograph

injuries.

C


Evidence

The high incidence of non-accidental burns and scalds necessitates that primary care staff be alert to this

possibility. It is estimated that around 6–8% of paediatric burns are non-accidental, with children aged

under three years being at highest risk.80-82 A high rate of repetitive injury has been reported among abused

children.83,84 Older and disabled adults are also at increased risk.85

• Indicators of possible non-accidental burns or scalds include the following:6,86

– delay in seeking help

– historical accounts of injury differ over time

– history inconsistent with the injury presented or with the developmental capacity of a child

– past abuse or family violence

– glove and sock pattern scalds

– scalds with clear-cut immersion lines

– symmetrical burns of uniform depth

– other signs of physical abuse or neglect.

• Other possible indicators of non-accidental injury may include:

– inappropriate behaviour/interaction of child or caregivers

– restraint injuries on upper limbs.

Refer to a regional burns unit if non-accidental injury is suspected. 42


3

TetanusThere is a risk of tetanus following a burn injury. For guidelines on the prevention of tetanus following injury,

refer to the Ministry of Health Immunisation Handbook 2006.9

Classifi cation of burns


Avoid use of the terms fi rst-degree/primary, second-degree/secondary and third-degree

burns.

C

Distinguish between burns that will probably heal without skin grafting and those that will

probably require grafting (deep dermal burns and full thickness burns).

C

Burns that are unlikely to heal within 21 days without grafting should be referred early to

secondary care, ideally by day 10–14.

C


good practice point

Use the ANZBA system of burn classifi cation. ✓


Evidence statements

• A burn wound that has not healed within three weeks has an increased risk of signifi cant scarring, infection

and functional limitation.

• Early excision and grafting reduces mortality and shortens hospital stay.

• Extensive burns that are expected to heal spontaneously may still need to be managed in a hospital setting.

Evidence

Burns are generally classifi ed by depth, as the ability of a burn to regenerate epithelium depends on the number

of viable keratinocytes in the wound bed (as well as the wound environment).

International expert opinion notes that superfi cial dermal wounds should heal within two weeks, but deeper

wounds are diffi cult to assess and may well require grafting, especially if the injuries are extensive or in

cosmetically or functionally sensitive areas. The incidence of scarring rises if epithelialisation is delayed beyond

three weeks; all wounds that show minimal signs of healing by 10 days should be referred for assessment. Full

thickness wounds will most likely require grafting.87

A meta-analysis of six randomised controlled trials (RCTs) of the early excision of burns showed that, in people

without inhalational injury, early excision reduced mortality and length of hospital stay. However, there was a

greater volume of blood loss in people undergoing surgery.88

The ANZBA33 uses a fi ve-point table. This is recommended for use in preference to the older systems, particularly

the fi rst- to third-degree classifi cation, which does not differentiate between burns that are likely to heal

spontaneously (superfi cial dermal) and those that are likely to require grafting (mid dermal and deeper).

43


table 3.3: classification of burns based on depth

anzba 2004 classification Full thicknessformer classification Full thicknessexample Scald (immersion), fl ame, steam, oil,

grease, chemical, high-volt electricityappearance White, waxy or charred, no blisters, no

capillary refi ll

May be dark lobster red with mottling in child

sensation No sensationhealing time Does not heal spontaneously, grafting

needed if >1cmscarring Will scar

anzba 2004 classification Deep dermalformer classification Deep partial thicknessexample Scald (spill), fl ame, oil or greaseappearance Blotchy red, may blister, no capillary

refi ll

In child, may be dark lobster red with mottling

sensation No sensationhealing time Over 21 days: grafting probably neededscarring High risk of hypertrophic scarring

anzba 2004 classification Mid dermalformer classification Partial thicknessexample Scald (spill), fl ame, oil or greaseappearance Dark pink with large blisters

Capillary refi ll sluggishsensation May be painfulhealing time 14–21 daysscarring Moderate risk of hypertrophic scarring

anzba 2004 classification Superfi cial dermalformer classification Superfi cial partial thicknessexample Scald (spill or splash), short fl ashappearance Pale pink with fi ne blistering, blanches

with pressuresensation Usually extremely painfulhealing time Within 14 daysscarring Can have colour match defect

Low risk of hypertrophic scarring

anzba 2004 classification Epidermalformer classification Superfi cial epidermalexample UV light, very short fl ashappearance Dry and red, blanches with pressure,

no blisterssensation May be painfulhealing time Within seven daysscarring No scarring

Adapted from: Australian and New Zealand Burn Association Limited. Emergency Management of Severe Burns.

8th Edition. 2004.

44


4

Chapter 4Referral

Emergency referral


Health care practitioners should follow the ANZBA referral guidance when deciding the level of

care that is appropriate for people with a new burn injury.

C

When seen in primary care, smaller burns that look like they will fail to heal by 14 days should

be discussed with a secondary care service for consideration of an acute referral.

C


Evidence statements

• ANZBA guidance on referral is universally accepted throughout New Zealand.

• International systems of referral are all consistent with ANZBA guidance.

Evidence

In 2001 the American Burn Association proposed a list of conditions that generally require a referral to a burns

unit.89 In New Zealand there are burns units in Christchurch, Hutt Valley, Waikato and Middlemore Hospitals. The

following criteria are endorsed by ANZBA in assessing whether burns require treatment in a specialised burns

unit:33

• burns greater than 10% of TBSA

• burns of special areas – face, hands, feet, genitalia, perineum and major joints

• full thickness burns greater than 5% of TBSA

• electrical burns

• chemical burns

• burns with an associated inhalation injury

• circumferential burns of the limbs or chest

• burns in the very young or very old

• burns in people with pre-existing medical and/or psychological disorders that could complicate

management, prolong recovery or increase mortality

• burns with associated trauma.

Levels of care

Evidence statement

• Evidence from the US experience with trauma systems indicates that a regional approach to providing

specialist burn management expertise and a central approach to treating the very severely injured on a

national basis can both improve a person’s outcome and be cost-effective.

Evidence

There are four levels of care for burns injuries in New Zealand:

• primary care including accident and medical centre care 45


• secondary care in a hospital

• regional burns unit care (Christchurch, Hutt Valley, Waikato and Middlemore)

• National Burn Centre level care (Middlemore).

In 2002, the Ministry of Health supported the development of a National Burn Centre based at Middlemore

Hospital in Auckland. This Centre will be part of an organised system of care with a network of regional burns

units in Christchurch, Hutt Valley and Waikato. Middlemore will continue to act as a regional unit for the northern

part of the North Island. People referred to Middlemore from regional units will return for ongoing care and

rehabilitation when possible. Adults and children will be treated in the facility.

A review of trauma services and organisation completed by the American Burn Association looked at the

evidence for improved personal outcomes from the centralisation of trauma services that occurred in the US

through the 1980s and 1990s. It reported improvements in survival, length of stay and costs in centres with

higher programme numbers (higher numbers of people treated) and higher surgeon case volumes (higher

numbers of people treated by each surgeon) and where people were transferred directly to a trauma centre from

the scene of injury.89 Although we found few high-quality studies of similar system change in burn care, it seems

reasonable to expect a similar benefi t will extend to all trauma cases.

Australia and the United Kingdom (UK) have reviewed the provision of national burns services and the

evaluation and outcomes, when reported, may help inform any restructuring in New Zealand. In the interim

the Guideline Development Team found no fi rm evidence that could support or refute the benefi ts of the New

Zealand model of care.

Referral between services


Transfer between services is facilitated by prompt assessment, recognised communication

channels and locally developed protocols agreed between centres on whom to transfer and

when to transfer.

C

Referrals to National Burn Centre level care should be via the regional burns units. C


good practice point

Primary care and accident services will generally develop their own systems for referral

depending on the distances involved in travel to secondary services or regional burns units. In

general, those people who have less severe injuries than in the ANZBA criteria, but who still

require inpatient care, should be referred to local secondary services.

✓


Evidence statements

A lack of data internationally on the relative merits of different service confi gurations, and the lack of

applicability to New Zealand’s unique circumstances and demographics suggest that evaluation of outcomes

and referral volumes between services will be needed.

46


5

Chapter 5Management of epidermal burns or scalds

Dressings and creams


A protective dressing or cream product can be used for comfort in epidermal burns and scalds. ✓

Review epidermal burns or scalds after 48 hours. If the skin is broken, change to a moist

wound-healing product (or alternatively double-layer paraffi n gauze).

✓


Evidence statements

• There is no compelling evidence to demonstrate an advantage for one wound-care product over another in

the management of epidermal burns and scalds.

Evidence

There is very little reliable evidence on the management of epidermal burns and scalds. Three small RCTs

were found on the management of epidermal burns and scalds, all of fair quality. One very small split-sample

RCT90 (n=12) compared topical steroid cream (clobetasol) and placebo for treating pain and infl ammation in

volunteers with superfi cial (epidermal) thermal burns. Another very small split-sample RCT (n=6)91 assessed

erythemal reactions in volunteers with ultra violet (UV) induced skin damage, comparing melatonin, antioxidant

creams and Aloe vera in various combinations with no treatment. A larger RCT92 (n=50) compared healing time

and bacterial colonisation rates between hydrocolloid and medicated paraffi n gauze with or without silver

sulphadiazine.

Findings

None of these trials found any statistically signifi cant difference between any of the treatments for any of the

outcomes measured, except that povidone-iodine-impregnated gauze was twice as expensive as standard

paraffi n gauze.

Guidance on dressings and creams from Guideline Development Team opinion includes the use of a protective

dressing or cream product for comfort in epidermal burns and scalds, with review after 48 hours. If the skin

is broken, the protective dressing or cream product should be changed to a moist wound-healing product or

alternatively to double-layer paraffi n gauze.

47


48


6

Chapter 6Management of superfi cial and mid dermal burns or scalds

Dressings and topical therapyDressing products which are unlikely to be found in primary care for use with burns were specifi cally excluded.

The outcomes ‘time to healing’ and ‘infection’ were key questions posed to the literature by the Guideline

Development Team. Wasiak and Cleland93 provided a discussion of other outcomes, such as pain and number

of dressing changes. A table describing various wound products and their uses has been compiled using

information from manufacturers and Guideline Development Team experience in burn care (see Appendix B).

Preventing infection


Products with antimicrobial action (such as silver sulphadiazine cream) should be used on all

burns for the fi rst 72 hours (three days) after burn injury.

✓

Burn wounds with signs of mild cellulitis can be treated with topical silver sulphadiazine

and/or oral antibiotics.

✓

Acute referral to secondary care is required for people with burns with signs of serious or

systemic infection.

✓


Evidence statements

• Although there is little evidence supporting the use of silver sulphadiazine for non-infected burns,

clinical experience in New Zealand populations supports the routine use of silver sulphadiazine or other

antimicrobial creams for the fi rst three days to prevent infection.

• If infection is suspected, longer-term use of silver sulphadiazine may be indicated.

• There is no evidence comparing short-term (three day) use of silver sulphadiazine cream with other wound-

dressing practices.

Most burn wounds are initially sterile. Careful aseptic wound-care procedures along with the use of

antimicrobial cream for the fi rst three days are generally suffi cient to prevent infection. The wound should be

regularly monitored, as infection can delay healing, increase scarring and potentially cause systemic infection.

The signs and symptoms of infection include the following:

• warmth and/or redness around the wound

• increasing pain

• increasing exudate, odour or pus from the wound site

• increasing swelling or tenderness

• fever or local wound temperature increase

• lymphangitis

• increased irritability in a child.49


The use of silver sulphadiazine is recommended for the fi rst three days following burn injury due to the high

incidence of community-acquired Staphylococcus aureus sepsis (SAS) in the New Zealand population.94

If infection is suspected, expert consensus favours swabbing the wound and considering the use (or re-use)

of topical silver sulphadiazine and/or oral antibiotics. It is considered appropriate to extend the use of silver

sulphadiazine beyond three days if infection is suspected or present. Acute referral to secondary care is

required for people with burns with signs of serious or systemic infection.

If after three days there is no infection, consider changing to a product that encourages moist wound healing.

Evidence

The evidence from published literature on the prevention of burn infection is inconsistent and of limited quality.

There were nine fair-quality RCTs comparing silver sulphadiazine with other dressings and topical treatments

(n=18 to 104).92,95-102

Two RCTs compared silver sulphadiazine with a silicon mesh dressing,98,102 and another RCT compared silver

sulphadiazine with a synthetic barrier dressing (n=18).101

One fair-quality RCT (n=50) compared three types of dressings: a medicated (chlorhexidine) paraffi n gauze

dressing, a hydrocolloid dressing, and a hydrocolloid dressing with silver sulphadiazine cream.92 Another

fair-quality RCT99 (n=30) compared a silver-coated high-density polyethylene mesh dressing with a solution

containing 0.5% silver nitrate. A fair-quality RCT100 (n=121) compared 1% silver sulphadiazine with a

combination of 1% silver sulphadiazine and 0.2% chlorhexidine digluconate.

Five fair-quality RCTs all conducted by the same group95-97,103,104 compared bacterial colonisation rates in partial

thickness (dermal) burns treated with honey, with silver sulphadiazine-impregnated gauze (three studies),

polyurethane fi lm, soframycin, paraffi n gauze, dry gauze and exposure. These studies were unblinded and of

variable size (n=50, 92, 100, 104 and 900). Bacterial colonisation rates were lower with honey in four of the

studies. In one study comparing silver sulphadiazine with honey, infection rates were similar for both groups.

No controlled evidence was found on the treatment of infected burns in primary care.

Findings

Although silver sulphadiazine cream is widely used for the prevention of infection of superfi cial and mid dermal

burns,105,106 there is currently little evidence supporting its use. The evidence is inconsistent and of limited

quality.

One unblinded RCT found that there was a wider variety of bacterial fl ora and a larger amount of bacterial

growth with the use of a silicone mesh dressing compared with silver sulphadiazine.102 However, this study

found no differences in the signs of infection or the amount of wound drainage in both groups. Another study

comparing the same products also found no signifi cant difference in the number of infections.98 No signifi cant

differences in infection rates were found when comparing silver sulphadiazine cream with a synthetic barrier

dressing.101 One of the studies conducted by Subrahmanyam96 also found similar rates of infection between

silver sulphadiazine and honey.

Six studies found a difference in rates of infection/bacterial colonisation.

One study found less wound colonisation and infection using a combination of 1% silver sulphadiazine

and 0.2% chlorhexidine digluconate versus 1% silver sulphadiazine alone.100 The overall incidence of

wound bacterial colonisation was signifi cantly less using a combination of 1% silver sulphadiazine and

0.2% chlorhexidine digluconate (65% vs 88%). There was also signifi cantly less wound colonisation by

Staphylococcus aureus (41% vs 64%). Clinical wound infection with Staphylococcus aureus developed in one

person treated with the combined cream as opposed to fi ve people treated with 1% silver sulphadiazine alone.

50


6

However, this result did not reach statistical signifi cance (p=0.16). Another study found that a silver-coated

dressing had lower rates of burn wound sepsis (>105/g) (n=5 vs n=16) and bacteraemia (n=1 vs n=5) in the

silver-coated dressing group. However, the results did not reach statistical signifi cance at the 0.05 level.99

Two RCTs carried out by the same group95,97 found that bacterial colonisation rates were signifi cantly lower

with the use of honey as a dressing. One study found that medicated (chlorhexidine) paraffi n gauze had the

least increase in bacteria92 when compared with a hydrocolloid dressing, with or without silver sulphadiazine

(p<0.01). However, this study also found that there was no signifi cant difference in the increased incidence of

pathogens during treatment in all three groups.

Toxic shock syndrome

Evidence statements

• Deaths from toxic shock syndrome are very rare in New Zealand, but are potentially preventable.

• In rare cases the rapid onset of symptoms of systemic infection with burns may be due to toxic shock

syndrome.

Evidence

Toxic shock syndrome is a rare complication of SAS infection. Most of the evidence of toxic shock in people

with burns applies to children, but the syndrome has also been reported in adults.107 Reports of toxic shock

syndrome in New Zealand are very rare, though anecdotally deaths have been reported in children.

There is no defi nite diagnostic test for toxic shock syndrome and its symptoms are similar to those of other

infections, namely fever, rash, diarrhoea, vomiting and hypotension. The diagnosis is generally made using the

US Centers for Disease Control and Prevention criteria listed below.108 Diarrhoea, vomiting and oliguria are early

signs, which may occur prior to the development of shock and help establish a timely diagnosis. If people with

burns undergo a sudden change, especially the rapid onset of fever and gastrointestinal upset, the possibility of

toxic shock syndrome should be considered.107

Although early intervention and the administration of effective antimicrobials are essential in the management

of toxic shock syndrome, probably the single most important therapeutic measure is the administration of

antibodies as human immunoglobulin, fresh frozen plasma or fresh blood, producing a state of passive

immunity in the recipient.109

The Centers for Disease Control have identifi ed the following fi ve clinical criteria for toxic shock syndrome:108

1. Temperature =/>38.9°C.

2. Low blood pressure (including fainting or dizziness on standing).

3. Widespread red fl at rash.

4. Shedding of skin, especially on palms and soles, one to two weeks after onset of illness.

5. Abnormalities in three or more of the following organ systems:

– gastrointestinal: vomiting or diarrhoea

– muscular: severe muscle pain

– hepatic: decreased liver function

– renal: raised urea or creatinine levels

– haematologic: bruising due to low blood platelet count

– central nervous system: disorientation or confusion.

6. Mucous membranes: red eyes, mouth and vagina due to increased blood fl ow to these areas.

A survey of children in burns units in the UK found no association between the management of the burn wound

and the subsequent development of toxic shock syndrome.109

51


Wound healing


Use dressings that encourage re-epithelialisation by moist wound healing. C

The prolonged use of silver sulphadiazine cream (more than seven days) should be avoided in

non-infected burns.

B



Following initial silver sulphadiazine cream or antimicrobial dressing, a technique that

promotes moist wound healing (such as a hydrocolloid dressing) is recommended.

✓

The convenience of a reduced number of dressing changes with hydrocolloid products should

be considered where this is important to the person.

✓

Double-layer paraffi n gauze can be used where hydrocolloids are unavailable. ✓

Moisturisers and non-drying, non-perfumed soap should be used to protect the skin after

burn injury and may also be helpful for pruritis.

✓

Burn wounds require extra care when exposed to sun. ✓


Evidence statements

• Convenience of use, reduced pain or number of dressing changes makes moist wound-healing products

preferable.

• There is insuffi cient evidence to recommend one moist wound-healing product over another.

• Prolonged use of silver sulphadiazine cream (more than seven days) may delay healing.

• There is a lack of evidence that any dressing product is superior to paraffi n gauze in reducing the overall time

to healing.

• Hydrocolloid products can be changed every three to fi ve days in wounds that are non-infected or have heavy

exudates.

Evidence

Moist wound-healing versus non-moist healing productsExpert opinion strongly favours the use of moist wound-healing products for superfi cial and mid dermal burns,

although the evidence from RCTs is scanty and inconsistent.

Seven small fair-quality RCTs (n=50 to 98) compared moist with non-moist healing products for partial thickness

(dermal) burns.92,104,110-114 None was blinded. The moist healing products included polyurethane fi lm/foam and

hydrocolloids and the non-moist products included paraffi n gauze and honey. Two of these studies compared

hydrocolloids with a non-moist dressing plus silver sulphadiazine.110,114

As described below, only three of the six RCTs showed a difference in time to healing between moist and non-

moist healing products.104,111,114

52


6

One study found hydrocolloids healed wounds signifi cantly faster than gauze and silver sulphadiazine.114 Three

other studies reported a similar healing time for hydrocolloids and paraffi n gauze/tulle gras.92,110,113

Comparisons between polyurethane fi lm/foam and paraffi n gauze for burns were also inconsistent. One study

reported that burns healed signifi cantly faster with polyurethane fi lm111 and one study reported no difference

between these products in healing rates.112 One study found that honey healed signifi cantly faster than

polyurethane fi lm.104

There is no convincing evidence from primary RCTs that any other dressing product heals wounds signifi cantly

faster than paraffi n gauze (which is considered a non-moist dressing). Since paraffi n gauze tends to dry out

(expert opinion), occlusive moist wound-healing products may be considered for wounds as the volume of

wound exudate diminishes.

There is good evidence from a systematic review that moist dressings are superior to non-moist dressings for

healing time, comfort and infection rates for burn donor sites.115 However, it is uncertain whether this evidence

is applicable to the care of superfi cial and/or mid dermal burns in primary care.

Dressing changesOne RCT reported that hydrocolloid required fewer dressing changes than paraffi n gauze,92 but another reported

no difference between them.116

Silver sulphadiazine cream compared with other dressings and topical treatmentsTwelve RCTs were found comparing silver sulphadiazine cream with other dressings and topical treatments.

These studies were rated either fair (10) or good quality (2). The largest study had 111 participants and six of

the studies had more than 50 participants. Ten of the 12 studies found that silver sulphadiazine signifi cantly

increased time to healing. However, in all of these studies, silver sulphadiazine was applied until complete

healing (re-epithelialisation). No studies were found comparing shorter-term use of silver sulphadiazine cream

with other dressings or topical treatments.

Four of the 14 studies were fair-quality RCTs comparing silver sulphadiazine with other dressings. Two RCTs

comparing hydrocolloid dressings versus silver sulphadiazine found that silver sulphadiazine signifi cantly

increased time to healing.92,114 One RCT found that silver sulphadiazine increased time to healing when

compared with a silicone-coated nylon dressing.98 One RCT found no signifi cant difference in time to wound

healing comparing a combination of chlorhexidine-impregnated gauze dressing plus silver sulphadiazine cream

with hydrocolloid dressing.110

A further seven RCTs were found comparing silver sulphadiazine with various topical treatments. Two of these

studies compared silver sulphadiazine cream with a combination of hyaluronic acid and silver sulphadiazine

cream.117,118 These good-quality studies both reported that time to healing was signifi cantly reduced using the

combined hyaluronic acid and silver sulphadiazine cream. One fair-quality RCT compared silver sulphadiazine

with a combination of cerium nitrate and silver sulphadiazine.119 This study found that the time to healing

was reduced by almost eight days when using a combination of cerium nitrate and silver sulphadiazine when

compared with silver sulphadiazine alone. However, the results just failed to reach statistical signifi cance at

the 0.05 level. Another RCT (n=15) compared silver sulphadiazine cream with collagenase ointment and an

antibiotic spray.120 This study also found that silver sulphadiazine increased time to healing.

Silver sulphadiazine compared with alternative therapies for time to healingThree fair-quality RCTs95,96,97 compared time to healing in partial thickness (dermal) burns treated with honey

(non-manuka) versus silver sulphadiazine. In all of these studies, superfi cial and partial thickness (epidermal

and dermal) burns treated with honey healed faster than those dressed with silver sulphadiazine. These studies

were fairly small, none was blinded and all the honey studies were conducted by the same researchers.

53


A large unblinded RCT121 compared moist exposed burn ointment with silver sulphadiazine and found no

difference in time to healing.

Healing wounds and donor sites are vulnerable to dry skin and sunburnExpert opinion favours the use of moisturisers and non-drying, non-perfumed soap to prevent the skin drying

out, as this could lead to skin breakdown and secondary infection. Education on sun protection is also

important. Extra care needs to be taken at times of sun exposure. Sunscreen and/or protective clothing should

be worn if working or playing outside.122

Pruritis can also be a problem following burn injury. Persistent pruritis occurs after about 15% of burn injuries,

with a further 44% of people reporting occasional pruritis. A systematic review of relevant studies found that

a variety of interventions were reported to be benefi cial, including medications, massage and transcutaneous

electrical nerve stimulation, but none of the studies provided high-quality evidence on which treatment

recommendations could be based.123 The clinical experience of the Guideline Development Team suggests that

moisturisers are benefi cial.

When to review

good practice point

Superfi cial and mid dermal burns should be reviewed daily for the fi rst three days, then

subsequently every three days.

✓


In the absence of randomised data to answer the question ‘how often should a burn be reviewed?’, the

Guideline Development Team discussed three aspects it considered relevant:

• the expected speed of healing for burns of differing depths

• the safety/risk of continued primary care management

• the expected time-lag between the identifi cation of a problem, referral and a defi nitive specialist opinion.

A good practice point based on the experience of the Guideline Development Team was considered appropriate.

Management of blisters


Preferably leave small blisters intact unless likely to burst or interfere with joint movement. ✓

If necessary, drain fl uid by snipping a hole in the blister. ✓


Evidence statements

• There is little evidence to guide the management of blisters.

• The bed of a deroofed blister can be more painful than an intact blister.

Burn blisters occur primarily in superfi cial dermal and mid dermal burns, but also may overlay deep dermal

burns. They are a result of infl ammatory changes that occur early in burn injury, whereby increased capillary

permeability allows oedema formation between the epidermis and dermis.

54


6

Evidence

One controlled trial of 202 people with partial thickness (dermal) burns124 was identifi ed of relevance. In this

study, randomisation was unclear. There were two treatment groups: aspirated and deroofed blisters. The

intact blister group was left for 10 days before burn blister fl uid was aspirated for analysis. The study assessed

infection rates and pain scores.

An RCT of second-degree (dermal) burns in pigs125 was also found. In this study, 42 burns in two pigs

(randomised to debridement or no debridement) were assessed for infection and re-epithelialisation rates.

Findings

In the Swain study,124 the incidence of infection (bacterial colonisation) in the intact blister group was 14%

compared with 76% in the deroofed blister group (p<0.05). Aspiration of fl uid (in the intact blister group at 10

days) reduced pain in 34% of participants compared with 0% in the deroofed group. Deroofi ng worsened pain

in 43% compared with 19% in the aspiration group. In the Singer trial, infection rates were higher in deroofed

burns (p<0.001).125

There is a paucity of evidence to answer the question of whether deroofi ng is associated with less pain or

faster healing compared with leaving blisters intact. A recently published review126 concluded that it may be

worthwhile to consider healing rates associated with different dressing applications because they are an

indirect measure of healing in intentionally deroofed versus intact blister management in a partial thickness

(dermal) burn. On balance, until there is more evidence, small blisters should be left intact to reduce the risk

of infection, but if anatomical position necessitates intervention for functional purposes, aspiration appears to

result in less pain than deroofi ng.

Scarring


Any burns that are unlikely to heal within 21 days without grafting should be referred to a

burns unit for scar management by day 10–14.

C


good practice point

A person presenting with scarring some months after a burn should still be referred for

specialist opinion.

✓


Evidence statements

• Silicone sheeting may be of benefi t in reducing scarring, although the evidence is of poor quality.

• Pressure garments may also be of benefi t, but the evidence is inconclusive.

• Burns that do not heal within 21 days are likely to cause scarring, which can result in signifi cant morbidity for

the person.

Healing process

Scarring can result in long-term functional disability and changes in appearance, both of which are an indication

for specialised care.

55


The normal process of wound healing by secondary intention involves the processes of epithelialisation and

wound contraction. Epithelial cells require a matrix to migrate across. In a superfi cial wound the dermis is well

intact, there are numerous epithelial cells and melanocytes within the dermis, epithelialisation is rapid and

wound contraction is not a feature. Hence, there is minimal scarring or alteration in appearance.

In a deeper burn there is less dermis and epithelialisation is prolonged, allowing the formation of granulation

tissue. This granulation tissue contains large numbers of fi broblasts and myofi broblasts127 that are believed to

produce wound contraction and scarring. Also, the melanocytes which are deep in the dermis may have been

injured and/or destroyed, leading to altered pigmentation. Early debridement and skin grafting interrupt this

process of granulation formation and so reduce the risk of contraction, which can still occur with grafting, but

usually to a lesser extent.

In a healed wound the processes of collagen deposition and angiogenesis have led to the laying down of

collagen fi bres in a haphazard arrangement with a large infl ux of blood vessels. Over subsequent months

the wound goes through maturation where the metalloproteinases remodel the wound so that it softens and

becomes less red. However, if there are continuing adverse factors such as infl ammation, infection or tension,

the process of scar maturation is hindered or prevented.

When the process of scar maturation is hindered, there is an increased risk of hypertrophic scarring.

Hypertrophic scars are thick, raised areas, usually darker than the surrounding skin, which remain within the

confi nes of the original wound and tend to regress over time.128

Another form of scarring that occurs less frequently is keloid scarring, in which the scar grows beyond the

borders of the original wound and does not regress spontaneously. Keloid scarring tends to occur in genetically

predisposed individuals and is more common in people of Asian descent and people with darker skin.129

Predictors of scarringRisk factors for scarring identifi ed in the literature include burn severity and non-white skin. It is unclear whether

the risk is higher in children.123 Burn wounds that fail to heal within two to three weeks are at high risk of

scarring.130

Evidence on interventions for scarring

One RCT was identifi ed comparing massage together with pressure treatment with pressure treatment alone

as treatments for hypertrophic scars in children.131 One Cochrane systematic review132 and one evidence-

based report133 were identifi ed on silicone gel sheeting for both the prevention and treatment of hypertrophic

and keloid scars. One Cochrane protocol,134 three non-systematic reviews130,135,136 and three RCTs137-139 were

identifi ed. One of these RCTs compared pressure garments with no treatment, one RCT compared different

types of pressure garments and the other compared different levels of compression on scar erythema and

thickness.139

No controlled trial evidence was found on other interventions such as intralesional steroid injections or laser

treatment.

Findings on interventions for scarring

There was little evidence on interventions for scarring on which to base recommendations.

MassageNo evidence was found that massage is helpful in either the prevention or treatment of scars.

Silicon gel sheetingThe Cochrane review (including 13 RCTs) evaluating the effects of silicon gel sheeting for the prevention or

treatment of scars reported that silicon gel sheeting signifi cantly reduced the incidence of hypertrophic scarring

56


6

in people prone to scarring (RR 0.46, 95% CI 0.21 to 0.98). A signifi cant improvement in scar elasticity (RR

8.6, 95% CI 2.55 to 29.02) was also reported. However, as the studies were highly susceptible to bias, the

authors concluded the evidence of benefi t was weak. Similarly, the ACC evidence report concluded that the

effectiveness of silicone gel sheeting in scar management could not be confi rmed.

Pressure garmentsThe evidence for pressure garments was also inconclusive. Pressure garments have been commonly used for

more than three decades, but the optimal pressure and duration has not been confi rmed by controlled trials.

Pressure garments are usually used in a hospital setting or outpatient clinics.135 They are also associated with

signifi cant adverse events, such as overheating, pruritis, wound breakdown and abnormal bone growth.136,140

However, the comparative trial comparing two different levels of pressure (initial pressure of 20mm Hg vs

12mm Hg) reported that there was a signifi cant difference in the thickness of the scar at one month with the

higher pressure than with the lower pressure. No differences were found for erythema. A clear association was

shown between the persistence of erythema and hypertrophic scar formation. A multicentre comparative trial is

currently underway to clarify the role of pressure garments on scar management.139

57


58


7

Chapter 7Management of chemical injury

General treatment advice

First aid


Irrigation of chemical burns should continue for one hour. C

All chemical burns should be referred to a burns unit. C


good practice point

Acid burns should not be neutralised with an alkali in primary care. ✓


Evidence statements

• There is an increased risk of systemic complications following chemical burns.

Evidence

Four retrospective observational studies were considered relevant.141-144 No controlled studies or systematic

reviews were found. Six non-systematic reviews were also included to ascertain the consensus of expert

opinion.145-150 Three other retrospective observational studies were selected for their review of the relevant

literature.151-153

An 11-year retrospective case series (n=51) compared those people who had immediate irrigation (group A)

with those who had delayed irrigation (group B). The size of burn was similar in the two groups (19.7% TBSA

in group A vs 17.2% TBSA in group B). In group A, 19% required skin grafting compared with 36% in group B.

Mortality was 9.5% (group A) compared with 21% (group B). Length of stay in hospital was 7.2 days (group A)

compared with 16.2 days (group B).142

In a four-year retrospective case series (n=35), people who received immediate irrigation to their chemical burn

had signifi cantly less incidence of full thickness injury and spent half as long in hospital.143

An eight-year retrospective case series (n=24) found that all people with delayed presentation (n=5) had deep

burns that required excision and grafting. All burns in this series were irrigated for 45 minutes to an hour at the

burns unit.144

However, a fourth retrospective case series (n=173) found no signifi cant statistical difference in the number

of deep burns between those who had immediate irrigation of their wounds and those without immediate

irrigation (37.5 vs 46% respectively). Mean hospital stay was 5.8 and 4.8 days respectively (not statistically

signifi cant).141

59


Several non-systematic reviews were considered, all with consistent opinions regarding chemical burns to the

skin. They made the following recommendations:

1. Immediate removal of clothing and copious irrigation with water for a period of at least one hour.33,141,142,144-152

2. No attempt should be made to neutralise an acid burn with an alkali as this may delay irrigation and cause

more injury due to heat produced by an exothermic reaction.144,147-149,152

3. There is a risk of systemic complications following chemical burns with hydrofl uoric acid, formic acid, phenol,

white phosphorus, nitrites and hydrocarbons.33,142,144-148,150-152

4. Chemical burns meet the criteria for referral to a specialised burns unit.33,151

Eye injury


All signifi cant chemical injuries to the eye should be referred acutely to ophthalmology

services.

C

Treat all chemical burns to the eye with copious irrigation of water. C


Chemical burns to the eyes are associated with residual visual impairment. Physical signs include

blepharospasm, tearing, conjunctivitis and uncontrolled forceful rubbing of the eye. Rapid swelling of the

corneal epithelium occurs and clouding of the anterior layers of stroma. Cells may be seen fl oating within the

anterior chamber.

Specialist assessment is required for early signs of corneal ulceration or perforation, and the possible late

complications of cataract, secondary glaucoma, iridocyclitis and symblepharon.33

Specifi c substances

Hydrofl uoric acid

good practice point

Anyone exposed to hydrofl uoric acid should be promptly referred to a burns unit for defi nitive

treatment after appropriate fi rst aid.

✓


Evidence statements

• Hydrofl uoric acid exposure of <2% TBSA can be fatal.33

• Calcium gluconate gel, infi ltration or intra-arterial and/or intravenous therapy corrects the hypocalcaemia of

hydrofl uoric acid burns and reduces pain.

Hydrofl uoric acid is a very strong acid. It is used widely, mainly in industrial settings, but it is also found

domestically in rust removers and aluminium cleaners.154-161

Features of hydrofl uoric acid exposure include severe cutaneous burns, as well as possible systemic and lethal

toxicity. Hydrofl uoric acid penetrates the skin easily and enters the deeper tissues where it releases the fl uoride

ion. This ion readily binds with calcium and magnesium and it is this property that makes hydrofl uoric acid

especially dangerous.157,160 Even minor exposure to dilute solutions can cause problems in the deeper tissues,

and symptoms and injury may be delayed.154,156,157

60


7

The systemic effects of hydrofl uoric acid exposure are due to the fl uoride ion binding with serum calcium

causing hypocalcaemia which can result in cardiac arrhythmias.154-157,160 Exposure to even small amounts of

hydrofl uoric acid can result in death, usually due to ventricular arrhythmias.154,156,157,160,162-164

Evidence

Eleven observational studies or case reports154-156,159,161-163,165-168 and four non-systematic reviews157,158,160,164 were

reviewed for the guideline. No controlled human studies were located.

A prospective study of 10 people with hydrofl uoric acid dermal burns of digits found rapid pain relief with

intra-arterial administration of 10% calcium gluconate. All had full functional recovery of their digits with good

cosmetic appearance.159

In a 10-year case series of treatments for hydrofl uoric acid burns at one facility, 28 of 85 people were treated

with local infi ltration of 10% calcium gluconate. Only one person (4%) had progression of their injury compared

with 14–70% in the other treatment groups. All people treated with calcium gluconate experienced pain relief

following the injections.161

Another retrospective case series of the authors’ institutional experience found 42 people with hydrofl uoric

acid burns for the period 1977–1999. There were 11 recorded cases of hypocalcaemia, which were treated

successfully with oral and intravenous calcium supplementation. There were no deaths.165

In a report of seven cases with hydrofl uoric acid burns to their hands and/or fi ngers, the authors reported good

pain relief after treatment with calcium gluconate. Calcium gluconate jelly (4%) was applied in fi ve cases and

four had subcutaneous injections with 8.5% calcium gluconate.166

A case report of one person described the use of calcium gluconate gel topically, cutaneous and subcutaneous

injections of 10% calcium gluconate, magnesium chloride and 2% xilocain, and the intravenous use of calcium

gluconate which successfully corrects the hypocalcaemia.155

Another case report of one person exposed to a household rust remover described treatment with calcium

gluconate gel and intra-arterial calcium gluconate infusion with good outcome.167

In another report, two cases of skin injury and inhalational exposure to hydrofl uoric acid were described which

were successfully treated with application of 2.5% calcium gluconate jelly and 5% calcium gluconate nebulised

solution.168

In a report of three cases of hydrofl uoric acid skin injuries (TBSA 5–25%), two people died as a result of cardiac

arrest.163 Another reported a case of 15.5% TBSA hydrofl uoric acid burn where the person died.154

The last case report was of a man with 44% TBSA burn from hydrofl uoric acid who developed recurrent

ventricular tachyarrhythmias and subsequently recovered. The authors cite several fatal cases of ventricular

fi brillation reported in other studies following 2.5–22% full thickness TBSA burns due to exposure to more than

50% hydrofl uoric acid.156

The four non-systematic reviews all have consistent fi ndings. In a comprehensive literature review of

hydrofl uoric acid burns,157 the authors described several reported cases of death from skin exposure of

2.5–10% TBSA. This is supported by the other reviews.158,160,164

• They all emphasise the importance of immediate, copious and prolonged lavage of the affected area with

water.154,157-160,163

• For dermal exposure to hydrofl uoric acid, the liberal and frequent application of 2.5% calcium gluconate gel

is recommended by all authors.

• If pain relief is incomplete or symptoms recur, subcutaneous injections of calcium gluconate are indicated.

Both these treatments have been shown to relieve pain.154,157,160,161,163

• Good results have been demonstrated with intra-arterial administration of calcium gluconate.

• Calcium gluconate is also administered intravenously to correct the hypocalcaemia due to hydrofl uoric acid

exposure.154,157,160,161,163

61


Phosphorus

good practice point

Anyone exposed to phosphorus should be promptly referred to a burns unit for defi nitive

treatment after appropriate fi rst aid.

✓


White phosphorus is commonly used as an incendiary in the manufacture of ammunition and is also used for

the manufacture of certain fertilizers, fi reworks and distress fl ares. It readily ignites in the presence of air.

Evidence statements

• The person should be transported with the affected area either submerged in water or saline or covered with

water- or saline-soaked dressings.

Evidence

Four retrospective observational studies,142,151,152,169 two single case reports170,171 and three non-systematic

reviews146,147,172 were reviewed. All selected articles had a consensus of opinion:

1. The initial treatment consists of prompt removal of clothing and immediate copious irrigation with water.

2. The person should be transported with the affected area either submerged in water or saline or covered with

water- or saline-soaked dressings to prevent the re-ignition of the retained particles of phosphorus.

Absorption of phosphorus can cause systemic complications including hypocalcaemia, hyperphosphataemia,

cardiac arrhythmias, renal and hepatic toxicity, and sudden death.146,151,152,169

62


8

Chapter 8Management of electrical injury


All electrical injuries should be referred to a burns unit. C


Evidence statements

• High-voltage electrical current damages deep tissues (muscle and nerves). This damage is sometimes not

apparent at the initial inspection.

• Cardiac abnormalities can occur following electrical injury. These are frequently transient.

Electrical injuries can be divided into three groups: low-voltage (<1000V), high-voltage (>1000V) and lightning

strike.

Low-voltage electrical injuries can cause signifi cant local contact burns and may cause arrhythmias or cardiac

arrest. They can cause tetany or muscle spasm that will prevent the person releasing the source of current and

may cause fractures.173-175

High-voltage electrical injuries result in severe skin burns and may cause respiratory and cardiac arrest.175 High-

voltage electrical current can lead to necrosis of muscle, bone and nervous tissue because of the development

of intense heat in bone, which is a poor conductor.176,177 Sometimes there are only localised skin injuries at the

entrance and exit sites, and a small skin burn or normal-looking skin can hide deep, massive tissue damage to

bone, muscles and nerves. There can be extensive arcing, fl ash and fl ame burns as well.178 People who suffer

a high-voltage injury are at increased risk of complications including compartment syndrome, cardiac damage

and neurological and ophthalmologic problems. Amputation rates above 50% have been reported.145

In lightning strike, a direct strike is usually lethal. In many cases, the majority of the current can pass over the

surface of the body (called ‘fl ashover’). Respiratory and cardiac arrest are common.179 Up to 74% of survivors

have signifi cant permanent sequelae.173,180-184

Cardiac abnormalities

Evidence

Ten observational studies178,185-193 were found to be relevant. No controlled human studies were located.

In a prospective case series of admissions with high-voltage injury (n=15) to a burns unit over a year, 27% had

an abnormal ECG on admission, of which all reverted to normal over time. No arrhythmias developed during

their hospital stay. None had any clinical evidence of cardiac dysfunction.187

A four-year retrospective case series reported fi ve people with high-voltage electrical injury.191 Two people had

ECG abnormalities acutely (one atrial fi brillation and one second-degree atrioventricular heart block). These

resolved by the third day post-injury. At both follow-up periods (two and six months), all ECGs were normal

and no clinical signs of cardiac damage were found. However, on thallium scintigraphy, there was evidence of

myocardial hypoperfusion in all cases.

63


Another case series study found that 9 out of 10 consecutive people with high-voltage electrical injury had one

or more signifi cant cardiac rhythm and/or functional abnormalities during their stay in hospital. At follow-up

(4–48 months after discharge) fi ve people showed signs or symptoms of cardiac dysfunction.185

In a retrospective case series of 48 consecutive people with high-voltage injury, eight (16%) had some cardiac

event, four (8.3%) had a cardiac arrest at the place of injury, two (4.2%) had a myocardial infarction and two

(4.2%) had a cardiac arrhythmia.190

Another observational study found that 13 out of 24 (54%) people being treated for a high-voltage injury had

evidence of myocardial injury.189

A 10-year retrospective case series reported cardiac complications (either arrhythmias or ischaemia or

myocardial infarction) in 10–46% of those with a high-voltage injury (n=36).188

Another retrospective case series of children (n=185) admitted to a burns unit over a 10-year period found

33% of high-voltage burns (n=58) required amputation and 29% had deep muscle involvement, and 7% had a

cardiac arrest.178

One retrospective case series of all admissions (n=179) to a burns unit over fi ve years found a high incidence of

compartment syndrome (54%) and amputation (42%) in those with a high-voltage injury (n=55).186

Another observational case series study of all admissions with electrical burns (n=173) found a signifi cant

difference between the incidence of amputations between high- and low-voltage injuries (36.6% and 17.9%

respectively; p<0.01). ECG changes were seen in 7% of the low-voltage group (n=132) and 12% of the high-

voltage group (n=41).192

This is supported by a retrospective case series (n=195) of high-voltage electrical injury admissions over a 19-

year period. The authors found 56 (29%) people underwent fasciotomy within 24 hours of injury and 80 (41%)

people underwent amputation.193

ECG monitoring


Following electrical injuries people should receive a resting 12-lead ECG. C

If this initial ECG is normal in people with low-voltage injuries, there is no need for a repeat

ECG or for continuous monitoring.

B


Evidence statements

• Electrical injury can trigger cardiac arrhythmias.

• The incidence of ECG abnormality or arrhythmia developing after a normal initial 12-lead ECG in people with

low-voltage electrical injuries is very low.

Evidence

Ten observational studies were identifi ed as relevant, all with consistent results.194-203 Five studies were of

children with mainly low-voltage electrical injuries194,195,200-202 and one was of children with mixed voltage

electrical injuries.197 Two studies were of all admissions (adults and children) with low-voltage injuries196,199 and

the other two were of all admissions with mixed-voltage injuries.198,203

64


8

A three-year prospective observational study (n=212) found that asymptomatic people with a normal ECG on

presentation after low-voltage injury do not need ECG monitoring.196 In 196 presentations there were eight

episodes with ECG abnormalities that required cardiac monitoring. There were no re-presentations with cardiac

arrhythmias after discharge in a four-year follow-up period.

A 10-year retrospective case series (n=38) of all admissions of children with mixed high- and low-voltage

injuries found that none of the children had or developed cardiac abnormalities.197 ECGs were recorded on

admission in all cases and all children were monitored for 24 hours or more. The only abnormalities were non-

specifi c temporary ST segment changes in the ECGs of three children.

Six other retrospective case series reviews of electrical injuries were found, four of children and two of adults.

One of children (n=44) found no arrhythmias developed over a 5- to 24-hour hour period if the person was

asymptomatic and had a normal ECG at presentation.201 Of the 40 low-voltage injuries, only one had an

abnormal ECG, which eventually resolved.

Another (n=151) found no adverse outcomes in those children with normal ECGs. Only one had an abnormal

ECG at presentation. One hundred and thirteen people (80%) had cardiac monitoring with no arrhythmias

noted. No late arrhythmias developed in the 112 children who were seen for follow-up.195

One other study in children (n=35) found an abnormal ECG in one of the 17 children in the low-voltage group in

which an ECG was obtained. The abnormality resolved within 24 hours. No serious arrhythmias were detected in

any child with a normal ECG on admission.202

Another study of 70 children with low-voltage electrical injuries found 2 out of 53 ECGs performed showed what

were considered benign arrhythmias. The authors concluded that cardiac monitoring is not required in people

who remain asymptomatic for four hours.200

Another study (n=20) of children and adults found no need to monitor if the initial ECG was normal and the

person was asymptomatic on presentation. One person had an arrhythmia that resolved after treatment and did

not recur during the next 24 hours.199

In the other study of children and adults (n=70), 11 developed an arrhythmia at the time of injury. Six died

in the emergency department and the rest were discharged without cardiac complications. One person had a

persistent right bundle branch block on discharge.198

One retrospective study (n=224) evaluated practice guidelines for the cardiac monitoring of children who

sustain an electrical injury. A total of 164 ECGs were done and 15 were abnormal. Eight of these were

determined not to be caused by the electrical injury. Twenty-nine people had cardiac monitoring, of which all

were normal except one with benign extrasystoles. One hundred and seventy-two people were seen for follow-

up and none had any untoward events. According to coroners’ records, none of the 224 people in this study

died due to this complication post-discharge from hospital.194

In another retrospective case series (n=145) four people had cardiac abnormalities (three had occasional

ectopic beats and the other developed atrial fi brillation after a high-voltage injury). All had these abnormalities

at the time of admission.203

65


66


9

Chapter 9Pain management

Burn pain management


Immediately after the injury, cooling and covering the burn may provide analgesia. C

Paracetamol and NSAIDs can be used to manage background pain. C

Consider administering opioids for intermittent and procedural pain. C



Refer to secondary care if failing to manage dressing-change pain. ✓

Consider the use of non-pharmacological approaches as a supplement to pharmacological

management of pain.

✓


Evidence statements

• Burn pain can be more complex than typical post-operative pain as it includes background, intermittent and

procedural pain (due to dressing changes and other interventions).

• It is important to conduct a thorough pain assessment to determine whether background, intermittent or

procedural pain is the greatest problem for the individual.

• The pain experienced following burns varies greatly from one individual to another.

• The worst pain score should be less than 5 on a scale of 0–10. Scores of 5 or higher interfere with sleep,

activity and mood.

Burn injuries can cause intense and prolonged pain, made worse by the need to change dressings frequently

to prevent infection and aid healing. Pain associated with burn injury and treatment is often managed poorly;

reasons for this include failure to use and document pain scores from pain-measurement tools, unfamiliarity

with suitable analgesic regimes, and concerns about opioid side effects.204,205

Immediately after the burn injury, simple measures such as cooling and covering the burn can reduce pain.206

The treatment of severe pain beyond simple measures should include titration in intravenous opioids.

Burn pain is often more complex than typical post-operative pain.204 It can be divided into:

• background pain (associated with the injury)

• intermittent or breakthrough pain (intense pain episodes not relieved by routinely administered analgesics)

• procedural pain (pain related to dressing changes and other interventions).

67


The aim of zero background pain in burn injuries is achievable and realistic. However, procedural burn pain

as a result of dressing changes is diffi cult to assess and manage and there is little consensus on how best to

determine or control this pain.

Evidence

Two guidelines were identifi ed that dealt with pain management, but not specifi cally burns.207,208 A number

of RCTs were identifi ed.37,205,209-225 Most were very small and many were conducted among volunteers using

experimentally induced burns.209,215,218-220,222,225 Overall their fi ndings were of limited applicability to primary

care. Two studies assessed the effect on pain response of different types of burn ointment compared with

placebo205,221 and one evaluated local cooling.37 Three studies addressed the role of opioids in children,210,223,225

fi ve assessed distraction techniques such as massage,213,214 music therapy211,212 and sensory focusing217 and two

compared ibuprofen with placebo.209,224 A further six assessed the role of other medications such as remifentanil

and gabapentin,215 riluzole,216 lidocaine,218 dextromethorphan219 and ketamine.220,222

Findings

There was no consistent fi nding from the identifi ed RCTs, which were performed in varying settings, with varying

severity of burns and in varying groups of people. Most of the recommendations for management of pain are

based on best practice in burns units.

Pain management should be integrated into the person’s overall care plan. This plan should provide both

pharmacological and non-pharmacological approaches. It has been suggested that background pain and pain

resulting from procedures, such as dressing changes and physiotherapy, need to be evaluated and treated

separately.226 It is important to conduct a thorough pain assessment to determine which type of pain is the

greatest problem. The pain experienced by people with burns varies greatly from person to person.227 For this

reason, treatment protocols stipulate low starting doses of analgesia and allow for adjustments to be made

based on individual pain assessment. Pain measurement scales should be used to assess the degree of pain.

A person’s worst pain score should be less than 5 (on a visual analogue scale of 0–10). Scores of 5 or higher

interfere with sleep, activity and mood.228 Therefore, the goal at minimum should be to reduce pain to lower

than this level.

Analgesics should be given regularly to control background pain. Paracetamol and NSAIDS (eg, ibuprofen),

alone or in combination with opioids, are often appropriate for use in people with small burn wounds.204 Aspirin

products should be avoided because of platelet inhibition and the risk of bleeding.7

People with burns may require treatment of procedural pain before dressing changes and during increased

physical activity to facilitate cooperation during dressing change and physiotherapy, as well as minimise the risk

of developing chronic pain.

Use of opioidsOpioid medications are used in children as well as adults for moderate to severe burn pain. Opioids are useful

because they are available in a variety of dose forms that can support a person’s individualised needs. Long-

acting opioids can be used for background pain and short-acting opioids can be used for painful procedures

such as changing dressings. Opioids may be supplemented with anxiolytics to reduce anxiety, if necessary.

There is little evidence to guide the choice of opioid medication. Morphine sulphate is the opioid analgesic

standard. The pharmacokinetic properties are largely unchanged in burn-injured patients. Pethidine should be

avoided because of side effects associated with the metabolite norpethidine, including dysphoria, agitation

and seizures.204 During dressing changes, conscious sedation with an immediate-acting opioid such as fentanyl

may minimise the risk of over-sedation. Other techniques for managing pain and anxiety in children during

procedures include using inhaled nitrous oxide, ketamine either enterally or parenterally, or anxiolysis with a

68


10

benzodiazepine such as midazolam.229 Deep-sedation techniques as provided by an anaesthetist may include

dexmedetomidine or propofol infusion up to general anaesthesia.

Non-pharmacological interventionsNon-pharmacological interventions are recommended to supplement, not replace, pharmacological

management of pain. These interventions include cognitive behavioural therapy (CBT) (eg, relaxation, imagery),

hypnosis and physical therapies such as massage. They can provide people with a sense of control during

rehabilitation from their injuries.

69


70


10

Chapter 10Psychological consequences of burn injury

Adverse psychological responses to trauma


Monitor people with burn injuries for signs of stress disorders or depression. C

Recognise and treat pre-existing disorders and comorbidities (including alcohol and drug

dependence) associated with post-traumatic stress disorder (PTSD).

B

Refer people with acute or chronic PTSD for specialist mental health management. C



Be aware of services that may be able to support families affected by the psychological

impacts of burn injuries.

✓

Be aware of the increased risk of sleep disorders after burn injuries. ✓


Burn injuries constitute signifi cant trauma and can cause or exacerbate psychological problems such as acute

or persistent stress disorders and depression. Psychological trauma may be compounded by injury-related

phenomena such as pain, physical disability and disfi gurement. The psychological consequences of burns to a

child are likely to involve other family members as well.

Psychological reactions to trauma are categorised by the timeframe since the event (see Table 10.1).

71


table 10.1: diagnosis according to duration of stress symptoms

duration of symptoms diagnosis comments

Less than one month Acute stress disorder

(not PTSD)

These are symptoms that occur in the immediate

aftermath of the stressor and may be transient and

self-limited. Although not yet diagnosable as PTSD, the

presence of severe symptoms during this period is a risk

factor for developing PTSD.

One to three months Acute PTSD Active treatment during this acute phase of PTSD may

help to reduce the otherwise high risk of developing

chronic PTSD.

Three months or longer Chronic PTSD Long-term symptoms may need longer and more

aggressive treatment and are likely to be associated with

a higher incidence of comorbid disorders.

Reproduced from: Foa EB, Davidson JRT, Frances A. The expert consensus guideline series: Treatment of

posttraumatic stress disorder. J Clin Psychiatry 1999;60 (Suppl 16).

Acute stress disorder

Evidence statements

• The onset of acute stress disorder in the fi rst month after a burn injury increases the risk of subsequent PTSD.

A diagnosis of acute stress disorder can be made as early as three days following trauma. American Psychiatric

Association diagnostic criteria230 require the presence of at least three of the following dissociative symptoms:

• depersonalisation

• derealisation

• time distortion and/or daze

• numbing and amnesia.

In addition one or more symptoms must be present from each of the three PTSD clusters, namely re-experience

of the traumatic event, avoidance and hyperarousal (see Appendix C).

The prevalence of acute stress disorder after burns is unclear, partly due to variability in the assessment tools

and diagnostic criteria used. A systematic review of relevant studies reported a range of 11–32% in adults.123

All the studies were small with a high potential for bias. Another small study, involving 63 children aged one to

four years hospitalised with burn injuries, and their parents, reported symptoms of acute stress in nearly 30%

(15/52) of the children analysed.231 The authors identifi ed a pathway whereby pain in the child was strongly

associated with acute parental stress, and parental stress led to acute stress in the child.

Predictors of acute stress disorder found in the literature included burn size, poor pre-burn mental health and

attribution of blame for the injury to a third party.123

People with acute stress disorder are at high risk of subsequent PTSD. In one study of 83 adults hospitalised

with burns,232 19% (16/83) were diagnosed with acute stress disorder and all but one subsequently developed

PTSD.

72


10

POST-TRAUMATIC STRESS DISORDER

Evidence statements

• There is evidence of an increased risk of PTSD after burns.

• There is some evidence that the incidence of PTSD is related to the size and location of the burn.

• CBT and selective serotonin reuptake inhibitors (SSRIs) have been shown to relieve the symptoms of PTSD

resulting from non-burn events.

A diagnosis of PTSD is made when a person: has experienced a traumatic event with actual or perceived

threat of serious injury or death to self or others; has reacted with intense fear, helplessness or horror; and

meets symptom criteria in three primary clusters (re-experience of traumatic event, avoidance or numbing,

hyperarousal) over a period of more than one month.

The DSM-IV. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)230 criteria (see Appendix C) for

PTSD are used to diagnose PTSD. The diagnosis requires a combination of symptoms including at least one

re-experiencing symptom, three symptoms of avoidance and emotional numbing, and two hyperarousal

symptoms.

Evidence on the prevalence of PTSD is inconsistent. Some studies include only inpatients while others include

outpatients. Most have relatively small sample sizes and some exclude personal psychiatric history. Moreover, a

variety of assessment methods have been used.

Three studies which used validated assessment methods found prevalence rates of 20–45% at a follow-

up period of 6–12 months in adults admitted to hospital after burns. These studies were small with a high

likelihood of bias.123

Evidence

Evidence on predictors for PTSD is also inconsistent. The only study in the systematic review123 without a high

likelihood of bias233 found a signifi cant association between chronic PTSD and a history of PTSD symptoms,

female sex, size and location of burn. This study did not assess pre-burn mental health or pre-burn history of

substance abuse, both of which were identifi ed in other studies as signifi cant predictors of PTSD.

There is very little research relating to the treatment of PTSD in people with burn injuries. One RCT234 allocated

participants to an individual and/or couple psychological debriefi ng intervention group or a control group that

received no intervention. Of the 110 participants who were assessed, 26% in the intervention group had PTSD

at 13 months follow-up compared with only 9% in the control group. These fi ndings are consistent with other

studies showing that single-session debriefi ng may be actively harmful.123

Esselman et al123 found no convincing evidence of interventions to reduce the risk of developing PTSD in

people with burns. However, there has been very little research in this area and effective pharmaceutical and

psychological treatments have been reported in the general trauma literature. CBT has been shown to be

benefi cial,235 in particular, exposure therapy236 and stress inoculation training.237 SSRIs are also effective and

are recommended as fi rst-line agents in the pharmacotherapy of PTSD.238 Treatment techniques need to be

researched and validated with people with burns.

Depression

Evidence statement

• There is some evidence of an increased risk of depression after burns.

73


Evidence

People with burns are also at risk of depression. The relevant evidence is scanty, consisting of six small studies

with a very high likelihood of bias.123

Estimates of the prevalence of depression in people with burns vary greatly, refl ecting disparity in the

assessment tools and diagnostic criteria used, the timing of assessment and the populations sampled. Rates of

16–53% are reported at various follow-up points from 3 days to 32 years, with no consistent trend over time.123

Predictors of post-burn depression in the literature include pre-burn mood disorders, burn severity and location

and style of problem-solving.123

No therapeutic studies for depression in burn survivors were found. However, the general literature supports the

use of SSRIs for depression.239

Sleep disorders

Evidence statement

• There is a high risk of sleep disorders after burn injury, which is compounded by pain and by stress

disorders.

Evidence

The Esselman et al systematic review123 reviewed 16 studies of secondary sleep disorders, including 11 studies

of sleep disorders secondary to burn injuries. All these studies had a relatively high risk of bias. Secondary

sleep disorders include insomnia, hypersomnia, nightmares, night terrors and sleepwalking.230

Difede et al232 reported that in their study of 83 adults hospitalised with burns, the most common symptom

of stress, reported by 76% of participants with or without acute stress disorder (ASD), was diffi culty falling

asleep and staying asleep. A small paediatric inpatient study (n = 25) also found a high prevalence of sleep

disorders, such as nightmares (88% of participants), problems with sleep onset (68%) and problems with sleep

maintenance (88%).240 Similarly, such symptoms were reported in 73% of 74 participants a week after discharge

from hospital.241

During the fi rst six months after burns or other trauma, the incidence of insomnia reported in the literature

ranged from 37% to 51% and at one year was 22–37%. Although insomnia thus tended to improve over the fi rst

year, nightmares were reported in up 30% of participants at both six months and one year post-burn.123

Esselmann et al123 reported that both early and late post-burn studies indicated the intertwining of sleep

disorders and symptoms of ASD, PTSD and depression. Pain is another factor that may compound sleep

disorders.241,242

There is no reliable evidence on pharmacological or behavioural treatments for sleep disorders after burns. CBT

has been found effective for treating sleep disorders in medical patients.123

Post-traumatic stress disorder and parents of children with burns

Evidence statements

• There is evidence of an increased risk of acute stress or PTSD for the parents of children with burns,

especially large or painful burns.

• How well a child copes with a burn injury will depend on how well the family is coping with the trauma.

• Resources are available for people who have experienced burn trauma and for their families (see Appendix

D).

74


10

Evidence

There is some evidence that the parents of children with burns are at increased risk of PTSD, although the

relevant studies are all very small with cross-sectional design and a high likelihood of bias.

A study (n=25) of children and adolescents with burns reported that 52% of mothers had past or present

PTSD,243 the most signifi cant predictive factor for maternal PTSD in the mother being the size of the burn.

Another study reported a correlation between maternal and child stress syndromes in the families of paediatric

burn survivors.244 Similarly, a recent study (n=52 analysed) in younger children (aged one to four years) reported

a vicious cycle whereby pain in the child caused acute stress disorder in the parents, which then increased the

likelihood of acute stress in the child.231

75


76


11

Chapter 11Burn injuries in Maori


Be aware that Maori tamariki (children) are at increased risk of burn-related injuries and

deaths.

✓

Consider ways to deliver care that will overcome access barriers, if necessary, such as nurse

home visiting for dressing changes.

✓


Evidence statements• Tamariki are at increased risk of burn-related injuries and deaths.

• Tamariki have a relatively high level of involvement in home activities that carry a burn or scald risk.

BackgroundEvery year, about seven or eight New Zealand children aged 15 years and under die as a result of burns or

scalds. In most cases fatalities are the result of house or car fi res. Over two-thirds of those who die are under

the age of fi ve years10 and over one-third are Maori.11

Analysis of New Zealand Health Information Service hospitalisation data for injury between 1985 and 1994

indicates that Maori children are at high risk of burn-related injuries.245 Injuries from fi re and burns account for

20% of all injuries that require hospital care for children under one year, making this the second most common

cause of hospitalisation due to injury in this age group. A further 18% of injuries are caused by contact with hot

water or hot substances. During the same period, 5% of injury hospitalisations for kaumatua (elder) aged 65

years or older were for burns or injury as a result of fi re.

Prevention Tamariki form the largest group of the Maori population. If they continue to be over-represented in burns

statistics this will impact on the hauora (health and wellbeing) of the individual, the whanau, the hapu and

iwi now and in the future. The following studies provide some guidance in the future planning of prevention

strategies. There are also further suggestions in Chapter 14, Implementation and evaluation.

Tamariki (aged 7–13 years) have been found to have a higher level of involvement in home activities that

carry a burn or scald risk, such as running a bath or using matches.29 These fi ndings suggest a difference in

children’s involvement in household tasks in Maori homes. This may be due to a variety of cultural, social and

economic factors. Prevention strategies need to systematically identify and remove barriers to developing safe

environments.

Tamariki were found to have a generally good understanding of safety knowledge in this survey,29 recognising

the correct safety action to take in the event of a fi re or when they received a burn. In contrast, an Auckland

study in 2002 suggested that Maori may be less likely to use cold water therapy on burns compared with people

of European descent.1

77


Primary care practitioners can contribute to the prevention of burn injuries by providing information on the

prevention of burn injuries and appropriate fi rst aid management and supporting local initiatives in primary

prevention.

Delivery of careThere are a variety of factors that may infl uence access to and utilisation of primary care services. Financial,

geographical or cultural barriers may be an issue for some Maori. Aside from the cost of services, some Maori

may have different attitudes and beliefs concerning illness and doctors, and different cultural patterns of help-

seeking. Maori are more likely to forgo general practitioner visits and prescription items (11.4% vs 5.8% for the

total population) or prescription items alone (13.0% vs 4.6% for the total population) because of cost.246 Issues

such as lack of transport or access to a telephone will also make access to primary health care more diffi cult. As

a result, some Maori individuals with minor burns may postpone visiting a general practitioner or be reluctant

to continue with frequent visits for dressing changes. These are things that may apply to some Maori, but other

Maori will have very different social circumstances, values, beliefs and health care practices. Primary care

practitioners can assist in removing the barriers to care by considering alternative ways to deliver care, such as

nurse home visiting for dressing changes.

There are reports of a number of traditional herbal remedies playing a part in the treatment of burns and scalds

among Maori. For further information see Chapter 13, Complementary and alternative medicines.

78


12

Chapter 12Burn injuries in Pacifi c peoples


Be aware that Pacifi c children may be at increased risk from hot water scalds. ✓

Consider ways to deliver care that will overcome access barriers, if necessary (such as nurse

home visiting for dressing changes).

✓

Be aware that language can be a barrier. Encourage a bilingual family member or practice

nurse to assist with communication. Ideally, Pacifi c Island population-specifi c translators

should be made available to services that provide for Pacifi c peoples.

✓


Evidence statements

• Pacifi c children aged 0 to 4 years appear to be at increased risk from hot water scalds.

• Pacifi c children have a higher level of involvement in home activities that carry a burn or scald risk.

Pacifi c children aged 0 to 4 years appear to be at increased risk from hot water scalds.247 SafeKids New Zealand

has reported data gathered by the New Zealand Health Information Service showing that hot water scalds are

the second most common cause of hospitalisations for unintentional injury among Pacifi c children.247

PreventionA study in Waitakere City showed that Pacifi c children (aged 7–13) had a higher level of involvement in home

activities that carry a burn or scald risk, such as running a bath or using matches.29 These levels of involvement

in activities with higher burn and scald risk for the child may be due to a variety of cultural, social and

economic factors. Prevention strategies need to systematically identify and remove barriers to developing safe

environments in order to be effective with Pacifi c children and their families.

Pacifi c concepts of health and illnessPacifi c peoples in New Zealand are a diverse population, coming from 22 different island nations, each with

a distinct language and culture. Many Pacifi c peoples view health in a holistic way, as the total wellbeing of

the individual within the context of the family and the community. In addition to physical, mental and social

wellbeing (the aspects of health defi ned by the World Health Organization), many Pacifi c peoples regard

spiritual wellbeing as equally essential to health.248

Health care practitioners are regarded as authority fi gures by many Pacifi c peoples. As a result, out of respect,

individuals may often be hesitant to say what they really think to the doctor or nurse. For example, they may

say that they understand an explanation given regarding treatment even when they do not. As it is respectful to

respond politely with affi rmation to a person of higher status, the individual may agree to follow-up even when

they know they may not be able to afford the fee for the follow-up consultation. In addition, the individual may

not attend the follow-up appointment if they have not complied with the recommended treatment, conscious

that the doctor may be disappointed.

79


There are reports of a number of traditional herbal remedies playing a part in the treatment of burns and scalds

among Pacifi c peoples. For further information see Chapter 13, Complementary and alternative medicines.

Delivery of careThere are a variety of factors that may infl uence access to and utilisation of primary care services by Pacifi c

peoples. Financial, geographical or cultural barriers may be an issue for some Pacifi c peoples. Pacifi c peoples

are over-represented in the lower end of the socioeconomic spectrum compared with other New Zealanders. As

a result, some Pacifi c peoples may experience fi nancial barriers to care. Pacifi c peoples are more likely to forgo

general practitioner visits and prescription items (8.0% vs 5.8% for the total population) or prescription items

alone (8.4% vs 4.6% for the total population) because of cost.246 Aside from the cost of services, some Pacifi c

peoples may have different attitudes or beliefs concerning illness or doctors. Issues such as lack of transport

or access to a telephone will also make access to primary health care more diffi cult. As a result, some Pacifi c

individuals with minor burns may postpone visiting a general practitioner or be reluctant to continue with

frequent visits for dressing changes.

Language is a major barrier to health care for some Pacifi c peoples. Good primary care practice would include

encouraging a bilingual family member or practice nurse to assist with translation. Ideally, Pacifi c Island

population-specifi c translators should be made available to services that provide for Pacifi c peoples.

These are things that may apply to some Pacifi c peoples, but other Pacifi c peoples will have very different social

circumstances, values, beliefs and health care practices.

80


Chapter 13Complementary and alternative medicines

Evidence statements

• Systematic reviews of hyperbaric oxygen therapy have found that there is insuffi cient evidence to support the

routine use of hyperbaric oxygen therapy in the treatment of thermal burns.

• There is some evidence that honey helps superfi cial and partial thickness burns to heal faster compared with

conventional dressings, but more research is needed.

• There are no studies on the use of manuka honey as a topical agent in the treatment of burns.

• There is no convincing evidence of any benefi t in using Aloe vera for thermal burns.

• There is no convincing evidence to support the use of moist exposed burn ointment for burns in preference to

conventional dressings.

Evidence

There is very little reliable evidence on the use of complementary and alternative medicines for burns.

Two systematic reviews of the use of hyperbaric oxygen therapy for the treatment of burns reported that there

was insuffi cient evidence to support its routine use.133,249

A good-quality systematic review of Aloe vera for wound healing250 found no RCTs involving accidental burns. In

a small (n=27) non-randomised split-sample study of partial (dermal) and full thickness burns, the distal part of

each burn was treated with Aloe vera and the proximal with paraffi n gauze.251 Time to healing was signifi cantly

faster with Aloe vera, with only minor adverse effects (such as transient discomfort and pain) in both groups.

There were several studies on moist exposed burn ointment but only four were RCTs and none was blinded. One

of these studies, reported in three publications,205,252,253 compared time to healing, pain and cost-effectiveness

in moist exposed burn ointment and conventional dressings such as paraffi n gauze and silver sulphadiazine.

Outcomes were similar in both groups.

One large unblinded RCT121 compared moist exposed burn ointment with silver sulphadiazine for time to

healing, pain and rate of infection in 508 people of varying age hospitalised with differing types of burn. In the

moist exposed burn ointment group, partial thickness (dermal) burns healed signifi cantly faster with less pain

(p<0.01) and a signifi cantly lower incidence of infection (p<0.01). However, the quality of this study is uncertain,

and as noted elsewhere in this guideline prolonged use of silver sulphadiazine cream is not recommended as

it may delay healing. Two other small unblinded RCTs of moist exposed burn ointment,254,255 both by the same

author, reported that moist exposed burn ointment may be more cost effective for second-degree (dermal) burns

than a range of standard therapies. However, ‘standard therapies’ in these studies included a wide variety of

dissimilar comparators.

There were six fair-quality RCTs of honey (non-manuka honey) for partial (dermal) and full thickness burns, all

conducted without blinding by the same research group in India.95-97,103,104,256 Five95-97,104,256 included 50–100

participants and one103 included 900 participants. In four95-97,104 of these studies, superfi cial and partial

thickness (epidermal and dermal) burns dressed with honey healed signifi cantly faster than those dressed

with conventional dressings, with lower bacterial colonisation rates. The majority of these studies compared

honey with the prolonged use of silver sulphadiazine cream. The sixth study256 compared honey with tangential

excision and grafting for ‘moderate’ burns and reported that outcomes were better with grafting. Other RCTs of

81


honey conducted by the same group were not considered because they used comparators unlikely to be used in

New Zealand, such as amniotic membrane and potato peel.

Small RCTs found no evidence of healing effect for antioxidant ointments91 or for calendula or bovine fi brinolysin

ointment for burns,257 nor for homoeopathic cantharis for burn pain.258

There are reports that harakeke,259 also known as New Zealand fl ax, has played a part in the treatment and

healing of burns and scalds among Maori. Another Maori remedy in the treatment of burns and scalds is

kawakawa leaves and bark.260 As no RCTs were found to support the use of these remedies, the Guideline

Development Team does not recommend their use as a primary or sole method of care.

Some Pacifi c peoples may use traditional medicine as a fi rst-line treatment for burns/illnesses, or if they feel

that Western medicine has not worked. There are reports of numerous medicinal plants being used for burns in

the South Pacifi c region. A few examples include the scraped bark of ‘ifi ’ in Tonga (Inocarpus fagifer, also known

as Tahitian chestnut), the grated seed of ‘utu’ (Barringtonia asiatica) and the starch from the root ‘pia’ (Tacca

leontapetaloides) in the Cook islands.261,262 As no RCTs were found to suppport the use of these herbal remedies,

the Guideline Development Team does not recommend their use as a primary or sole method of care.

82


14

Chapter 14Implementation and evaluation

OverviewThe aim of this guideline is to ensure that for individuals with burn injuries there:

• is appropriate initial assessment and care in the primary care setting

• are more appropriate referrals to secondary care and regional burns units

• is more information sharing between providers (common language and tools)

• is more uniformity in burn assessments and outcome measurements

• is improved targeting and use of effective interventions.

Distribution strategies

Publication of the full guideline

The full guideline is available free for download from the ACC website (http://www.acc.co.nz) and the NZGG

website (http://www.nzgg.org.nz). The NZGG website also provides supporting documents, including the search

strategy and evidence tables for the guideline. Print copies are also available.

It is recommended that efforts are made to create weblinks to the full guideline and summary from medical

colleges, professional bodies and other interest groups.

Quick reference clinical format

A summary booklet is being produced with the key messages and algorithms to guide the management of

people with burns and scalds in primary care. The availability of a quick reference summary will make the use of

the guideline recommendations easier for clinicians.

Dissemination

The full guideline/summary should be distributed to the following groups:

• general practitioners

• primary health care nurses

• iwi/Maori health providers

• Pacifi c health providers

• ANZBA

• burn support groups

• safety and prevention groups

• armed services, fi re services, and ambulance services

• district health boards

• primary health organisations

• independent practitioner associations

• academic lecturers/curriculum planners involved in medical training

• medical colleges/professional bodies

• pharmacists.

83


Promotion

Guideline launch

The Guideline Development Team suggests that the guideline be launched at an appropriate event or conference

to signal the start of the implementation phase. Such an event might be a conference held by the Royal New

Zealand College of General Practitioners or other primary health care organisation, or a conference focusing on

wound care. Further opportunities for presentations at other relevant local meetings and conferences will be

pursued to help primary care practitioners become familiar with the guideline.

Media

The guideline needs to be promoted in the media, including the local medical press. Publicity needs to

encompass journals and health professional publications such as: New Zealand Medical Journal, New Zealand

Nursing Journal and NZ Doctor. Mainstream media can also be targeted through the use of media releases to

newspapers and television programmes. This could include Maori and Pacifi c magazines, radio and television.

Promoting safety messages

It is recommended that the development of consumer information be funded to inform people about safety

measures to prevent burns and scalds.

Additional strategies should be considered to promote burns safety measures through primary care, as young

children, the population most at risk, are usually seen routinely.

Consumer information should be offered in Maori and Pacifi c languages in written and oral forms, eg, CDs and

DVDs.

Education

Professional education

Professional education activities could include:

• Organising information and education seminars/workshops (based on the guideline) for practitioners,

primary health organisations, independent practitioner associations and district health boards.

• Specifi c educational initiatives and ongoing updates for particular groups (eg, general practitioners, practice

nurses).

• Local continuing medical education activities that include this guideline as part of their programme.

• Developing local strategies to reduce barriers to follow-up care for people with burns, particularly Maori and

Pacifi c peoples.

Community education

Community education activities could include:

• School-based education to teach safe practices to children, which is tailored to meet the needs of children

from different communities.

• Education to teach safe practices to children under fi ve years old.

• Encouraging existing home-visit providers to families with young children (particularly with infants 12–18

months of age) to remind them about burn risk and burns fi rst aid.

• Offering training to providers of home-visit services (eg, Plunket, Tamariki Ora), pre-school units and health

clinics where pre-schoolers are seen.

• Designing a consumer resource for Maori in consultation with iwi providers.

• Monitoring the educational information that is given out.

84


14

Research and evaluation

Research

There is a lack of RCTs relating to burn assessment and treatment. The Guideline Development Team suggests

that a Delphi process be used to formally rank the research interest areas in burns. The Delphi process is

a structured process that uses a series (or rounds) of questionnaires to gather information and rounds are

continued until ‘group’ consensus is reached. This process is popular in health research because it allows

the inclusion of a large number of individuals across diverse locations and areas of expertise and avoids the

situation where a specifi c expert might be anticipated to dominate the consensus process.263

The following areas for further research were identifi ed:

• cost-benefi t analyses of using dressings. What is cost-effective wound care for burn injuries in primary care?

• a targeted prevention campaign for Maori and Pacifi c children aged fi ve years and under (visiting mothers

who have children 12–18 months to remind them about burn risk and fi rst aid for burns) and a follow-up on

its effectiveness

• a study to investigate the effectiveness of traditional remedies (such as kawakawa) on superfi cial and mid

dermal burns

• a study to investigate the effectiveness of various interventions for scarring following burn injuries

• a study to identify the resources and support services needed for people with burn injuries in New Zealand.

Evaluation

An appropriate response to this guideline will be a decrease in the number of late referrals to burn services.

Successful implementation of the guideline may result in an increase in overall referrals to secondary care.

Another outcome of interest would be the incidence of skin grafting and scarring following burn injuries.

Currently, there is no benchmark for this information to measure any change in these areas.

The actual impact of this guideline in practice can be evaluated by the collection of the following information:

• the effect on referrals for hospital-level care or regional burns unit care.

Making a comparison of baseline referral information before the distribution of the guideline, and referral

numbers and patterns after guideline implementation

• referral indications for hospital-level care or regional burns unit care.

Making a comparison before and after referral indications.

85


86


Appendices

A. Evidence and recommendation grading system

B. Wound care options

C. DSM-IV criteria for post-traumatic stress disorder

D. Useful resources

87


88


A

Appendix A:Evidence and recommendation grading system

Studies were graded using a two-tier system that is detailed in the Handbook for the Preparation of Explicit

Evidence-Based Clinical Practice Guidelines, published in November 2001 by NZGG. This system has been

adapted from other grading systems currently in use, in particular the Scottish Intercollegiate Guideline Network

system.

The literature searches for this guideline concentrated on fi nding high-grade evidence to answer the identifi ed

clinical questions, such as systematic reviews, RCTs and, where these were not available, observational studies

such as well designed cohort and case control studies. Only these types of study design were graded. Where

these types of study were not available, less rigorous study designs such as cross-sectional studies and case

studies were considered but were not formally graded.

The two-tier system follows this process:

1. Critical appraisal of individual relevant studies (identifi ed from the searching) and assigning of a level of evidence for the fi rst section of the GATEFRAME checklist that is incorporated into the evidence tables. A

random sample of appraisals in the guideline was performed independently by two assessors and the results

compared.

2. Joint consensus by the Guideline Development Team on the issues of volume, consistency, clinical relevance

and applicability of the body of evidence in the evidence table (fi lling out the NZGG Considered Judgement

form for each clinical question) and the development of graded recommendations that attempt to answer the

clinical questions posed.

Developing recommendationsRecommendations were formulated by joint meetings of the multidisciplinary Guideline Development Team. The

Team considered the entire body of evidence (summarised in the evidence tables) and fi lled out Considered

Judgement forms for each clinical question that was identifi ed as being relevant to the guideline (see http://

www.nzgg.org.nz). The following aspects were discussed: volume of evidence, applicability to the New Zealand

setting, consistency and clinical impact, with the aim of achieving consensus. Consensus was sought and

achieved over the wording of the recommendation and grading. In this guideline, where a recommendation is

based on the clinical experience of members of the Guideline Development Team, this is referred to as a good

practice point.

89


Grading of recommendationsThe NZGG grades of recommendation are as follows:


The recommendation is supported by good evidence (where there are a number of studies

that are valid, consistent, applicable and clinically relevant).

A

The recommendation is supported by fair evidence (based on studies that are valid, but

there are some concerns about the volume, consistency, applicability and clinical relevance

of the evidence that may cause some uncertainty but are not likely to be overturned by other

evidence).

B

The recommendation is supported by international expert opinion. C

Grades indicate the strength of the supporting evidence, rather than the importance of the recommendations.

good practice point

Where no evidence is available, best practice recommendations are made based on the

experience of the Guideline Development Team, or feedback from consultation within

New Zealand.

✓


90


A

Appendix B: Wound care options

This table describes various wound products and their uses. It has been compiled using information from

manufacturers and Guideline Development Team experience in burn care.

name indications advantages disadvantageswear time

Paraffi n or

silicone-

impregnated

fi bres

Burns with

minimal exudate

Grafts when

healing well

Covers and protects

Non-sensitising

Non-irritant

Limited moisture

retention

May cause trauma on

removal

Requires a secondary

dressing to keep it in

place and maintain

moisture balance

24–48

hours

Hydrocolloids For burns with

light to moderate

exudate

Sloughy and

necrotic burns

Maintains moisture balance

Can help with autolytic

debridement

Self-adhesive and moulds

well

Impermeable to bacteria and

contaminants

No secondary dressing

required

Not recommended

for heavily exudating

burns, sinuses or

tracts

May tear fragile

surrounding skin on

removal

Dressing odour can be

offensive

Gel can be mistaken

for pus

Three to

seven days

Transparent

fi lms

Superfi cial burns

Burns with little

or no exudate

As protection

for fragile

compromised

areas of

unbroken skin

Impermeable to bacteria and

contaminants

Supports autolytic

debridement

Allows visualisation of the

wound

No secondary dressing

required

Not recommended for

exudating burns or

new burns

Requires dry border to

adhere

Can be diffi cult to

handle

May not stay in place

in areas of moisture

One to

three days

Continued …

91



Hydrogels For necrotic and

sloughy burns

Deep-cavity burns

with necrosis and

slough and light

exudate

Rehydrates the wound bed

Aids autolytic debridement

Fills dead space in cavity

burns

Small amount of absorptive

action

Can be soothing and reduce

pain

Not recommended for

moderate or heavily

exudating burns

Requires secondary

dressing

Can macerate wound

edges if not carefully

applied

Can soak into some

secondary dressings

One to two

days

Alginates For partial and

full thickness

burns with

moderate to

heavy exudate

Wounds with

undermining or

sinus tracts

Wounds with

necrotic tissue

with exudate

Infected wounds

Absorbs 20 times its own

weight

Forms a gel over wound

Supports debridement

Fills dead space (comes in

wicks as well as sheets)

Easy to remove if gelled

Easy to use and cut to fi t

Not recommended

for lightly exudating

wounds or wounds

with eschar (a dry scab

or slough)

If dries out can be

diffi cult to remove


dressing

One to four

days

Hydrofi bres Partial thickness

burns

Moderate to

heavily exudating

burns

Absorbs 25 times its own

weight

Vertically wicks fl uid

therefore controls lateral

spread of exudate

Can fi ll dead space (comes in

wicks as well as sheets)

Tensile strength comparable

to gauze

Forms a gel over wound

Reduces maceration of

surrounding skin

Easy to use and cut to fi t

Easy to remove if gelled

Not recommended for

dry burns – will adhere

to a dry wound

Not recommended for

burns with eschar


dressing to secure it

1–14 days

Continued …92


A


Foams Partial and full

thickness burns

with minimal

to moderate

exudate

Secondary

dressing

to provide

additional

absorption

Non-adherent

Does not cause trauma on

removal

Easy to use and apply

May be used under

compression

Not recommended for

burns with little or no

exudate

May macerate

surrounding skin if it is

not protected

Needs to be taped if

it is in non-adhesive

form

One to fi ve

days

Silver

dressings

Different

products act

differently at

the wound bed

as per dressing

type, eg,

hydrofi bre or

wound contact

dressing

Partial and full

thickness burns

Burns that appear

to be infected

Generally absorbs exudate

Delivers antibacterial/

antimicrobial component

to wound bed – effective

against gram-positive and

gram-negative bacteria,

fungal infections

Not recommended for

dry burns or burns with

eschar

Manufacturers’

instructions need

careful consideration

prior to application

depending on product

chosen

Requires secondary

dressing to secure

1–14 days

depending

upon

product

chosen

Silver creams Partial and full

thickness burns

Dry eschars

Infected burns

Maintains moisture balance

Antibacterial/Antimicrobial

to multiple organisms

Antibacterial effect

penetrates eschar

Aids in autolytic debridement

Comfortable for person

Easy to apply

Non-absorptive

Can cause its own

pseudo eschar which

can be diffi cult to

remove

Prolonged use is

detrimental to wound

cells and can delay

healing


dressing

Daily

dressing

required

93


94


A

Appendix C:DSM-IV criteria for post-traumatic stress disorder

The following table has been reproduced from the DSM-IV criteria.230

The diagnosis of PTSD requires a combination of symptoms including at least one re-experiencing symptom,

three symptoms of avoidance and emotional numbing, and two hyperarousal symptoms.

A.The person has been exposed to a traumatic event in which both of the following have

been present:

1. The person experienced, witnessed or was confronted with an event or events that

involved actual or threatened death or serious injury, or a threat to the physical

integrity of self or others.

2. The person’s response involved intense fear, helplessness, or horror. Note: In children,

this may be expressed instead by disorganised or agitated behaviour.

B.The traumatic event is persistently re-experienced in one (or more) of the following ways:

• recurrent and intrusive distressing recollections of the event, including images,

thoughts or perceptions. Note: In young children, repetitive play may occur in which

themes or aspects of the trauma are expressed

• recurrent distressing dreams of the event. Note: In children, there may be frightening

dreams without recognisable content

• acting or feeling as if the traumatic event were recurring (includes a sense of reliving

the experience, illusions, hallucinations and dissociative fl ashback episodes, including

those that occur upon awakening or when intoxicated). Note: In young children,

trauma-specifi c re-enactment may occur

• intense psychological distress at exposure to internal or external cues that symbolise or

resemble an aspect of the traumatic event

• physiological reactivity on exposure to internal or external cues that symbolise or

resemble an aspect of the traumatic event.

C.Persistent avoidance of stimuli associated with the trauma and numbing of general

responsiveness (not present before the trauma), as indicated by three (or more) of the

following:

• efforts to avoid thoughts, feelings or conversations associated with the trauma

• efforts to avoid activities, places or people that arouse recollections of the trauma

• inability to recall an important aspect of the trauma

• markedly diminished interest or participation in signifi cant activities

• feeling of detachment or estrangement from others

• restricted range of affect (eg, unable to have loving feelings)

• sense of a foreshortened future (eg, does not expect to have a career, marriage,

children or a normal life span).

Continued …

95


D.Persistent symptoms of increased arousal (not present before the trauma), as indicated by

two (or more) of the following:

• diffi culty falling or staying asleep

• irritability or outbursts of anger

• diffi culty concentrating

• hypervigilance

• exaggerated startle response.

E.Duration of the disturbance (symptoms in Criteria B, C and D) is more than one month.

F.The disturbance causes clinically signifi cant distress or impairment in social, occupational

or other important areas of functioning.

Specify if: Acute – if duration of symptoms is less than three months

Chronic – if duration of symptoms is three months or more.

Specify if: Delayed onset – if onset of symptoms is at least six months after the stressor.

96


A

Appendix D: Useful resources

Burn associations• Australian and New Zealand Burn Association – htpp://www.anzba.org.au

• American Burn Association – http://www.ameriburn.org

• International Society for Burn Injury – http://www.worldburn.org

Support Groups

Burn Support – Waikato

Burn support organisation in Waikato.

http://www.burnsupport.org.nz

Burn Support Foundation Inc

A non-profi t, self-help organisation helping burn survivors and their families return to productive lifestyles

following injury. This organisation provides a free newsletter and organises two weekend camps per year.

PO Box 476, Paddington, 2021

New South Wales, Australia

Burn Support Group Charitable Trust Inc

Produces a regular newsletter, runs workshops, education evenings and an annual camp for children. It also

provides education/prevention work and visits inpatients.

http://www.burns.org.nz

Burn Support Groups Database

A register of burn support groups world-wide. Non-burn support groups also are invited to register.

http://www.burnsupportgroupsdatabase.com

Burn Survivors On Line

Provides information and support for burn survivors and their families throughout the world.

http://www.burnsurvivorsonline.com/

Changing Faces

Provides free and confi dential help, support and information for children (and their parents) and adults who

have facial disfi gurements.

http://www.changingfaces.co.uk

Phoenix Society for Burn Survivors

International, non-profi t, self-help organisation helping burn survivors and their families return to happy and

productive lives following injury.

http://www.phoenix-society.org

97


Skylight

Skylight provides a national support service for New Zealand children and young people who are experiencing

change, loss and grief – whatever its cause.

http://www.skylight.org.nz

Survivors of Burn Injury

Burn resource centre for survivors of burn injury.

http://www.burnsurvivor.com

98


Abbreviations and acronyms

ACC Accident Compensation Corporation

ANZBA Australian and New Zealand Burn Association

BMI Body mass index

CBT Cognitive behavioural therapy

CMDHB Counties Manukau District Health Board

ECG Electrocardiogram

NZGG New Zealand Guidelines Group

PTSD Post-traumatic stress disorder

PVC Polyvinyl chloride

RCT Randomised controlled trial

RR Relative risk

SAS Staphylococcus aureus sepsis

SSRIS Selective serotonin reuptake inhibitors

TBSA Total body surface area

UK United Kingdom

US United States of America

UV Ultraviolet

99


100


Glossary

Angiogenesis The formation of new blood vessels.

Arrhythmia Any deviation from the normal rhythm, eg, of the heart.

Atrial fi brillation Very rapid, uncoordinated contractions of the atria of the heart.

Blepharospasm A spasm of the eyelid.

Body mass index (BMI)An indicator of body fatness. Calculated from the formula weight/height squared, where

weight is in kilograms and height is in metres.

Case control studiesSometimes described as retrospective, these studies look back in time at a group of

individuals with a particular disease or outcome and compare it with a suitable control group

of individuals without the disease or outcome.

Compartment syndromeA potentially limb- and life-threatening complication pressure leads to vascular occlusion,

which in turn causes hypoxia, necrosis and a further increase in pressure.

Debridement Thorough cleansing of a wound, with removal of all foreign matter and injured or infected

tissue.

Depersonalisation A subjective feeling of having lost one’s personality.

Dysphoria A state of feeling unwell or unhappy.

Dyspnoea Diffi cult or laboured breathing.

Ectopy Pertaining to a beat or rhythm occurring outside its normal location or at the wrong time.

Erythema Reddening of the skin.

Exudate The material composed of serum, fi brin and white blood cells that escapes from blood

vessels into a superfi cial lesion or area of infl ammation.

Fasciotomy Incision of a fascia, a connective tissue sheath which unites the skin to the underlying tissues

and also surrounds many muscles.

Hapu Groups of whanau with common ancestral links; sub-tribe.

Hydrocolloid Any of several substances that yield gels with water.

Hyperalgesia Increased sensitivity to pain or enhanced intensity of the pain experience.

HyperphosphataemiaExcessive phosphates in the blood.

Hypertrophic scarringThick raised areas, usually darker than the surrounding skin, which remain within the

confi nes of the original wound and tend to reduce over time.

Hypocalcaemia A defi ciency of calcium in the blood.

101


Hypoperfusion Decreased blood fl ow through an organ.

Hypothermia Below normal body temperature.

Hypovolaemia An abnormally low volume of blood circulating through the body.

Insomnia Sleeplessness.

Iridocyclitis Infl ammation of the iris and ciliary body of the eye.

Ischaemia Defi cient blood supply.

Iwi A social and political unit made up of several hapu sharing common descent; Maori tribe or

nation.

Kaumatua Wise and experienced older members of a whanau, usually aged over 55 years.

Keloid scarring A scar that grows beyond the borders of the original wound and does not reduce

spontaneously.

Lavage Irrigation of or washing out of a body cavity.

Lymphangitis Infl ammation of a lymph vessel.

MetalloproteinasesEnzymes that are involved in the degradation of the extracellular matrix.

Myocardial infarctionDamage to heart muscle that results typically from the partial or complete blocking of a

coronary artery.

Necrosis Localised death of tissue.

Occlusive dressingA dressing that prevents air reaching a wound and that retains moisture, heat, body fl uids

and medication.

Oedema Swelling.

Oliguria Reduced urine output.

Pruritis Itching.

Randomised controlled trials (RCTs)Trials in which individuals in a population are randomly allocated into two groups. The two

groups are usually called the study or experimental group, and the control group, which does

not receive the intervention. The results are compared by comparing rates of one or more

outcomes (endpoints) between the two groups. Randomised controlled trials are generally

regarded as the most scientifi cally rigorous method of assessing the effectiveness of

treatments and other interventions (eg, screening procedures).

Secondary care Public hospitals, hospital-based services and specialist services.

Symblepharon Adhesion between an eyelid and the eyeball.

Tamariki Children.

Tetany A condition of muscular hyperexcitability leading to cramps and spasms.

Whanau The extended family. Relationships that have blood links to a common ancestor; extended

family.

102


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