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CARE OF BURN PATIENTS IN THE HOSPITAL

Sheila Kavanagh OAM, RN, RM, Bnurs, Royal Adelaide Hospital, Adelaide, Australia; Alette
de Jong RN, MSc, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands; Nursing Committee
of the International Society for Burn Injuries
Introduction
In caring for the patient with a burn injury it is important to remember that many factors
impact on the care that we are able to deliver. This is of particular relevance in the area of
wound care. Access to costly wound products is not an option in many settings. In these
situations, creativity and innovation have led to many excellent alternatives being developed.
In some instances sophisticated products are available but lack of clinical experience makes
them difficult to use. Wound care needs to be undertaken in the context of the local
environment.
THE BURN WOUND
It is appropriate to highlight the functions of the skin as they underpin the management of
the burn wound:
Protection
Immunological
Fluid, protein and electrolyte homeostasis
Thermoregulation
Neurosensory
Social interactive
Metabolism
A burn injury results in either the loss or disruption of some or all of these functions. The
burns nurse must assess all of these factors when deciding on an appropriate nursing
management plan.
Thermal energy effects
The three mechanisms that energy transfers by, are conduction, convection and radiation.
All of these mechanisms affecting heat transfer may deliver heat to, or away from, living
tissues.
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Sustained temperatures result in cellular dysfunction and early denaturation of protein.
1
As
the temperature or the time of exposure increases, then cell damage increases.
Nguyen, Gun, Sparnon and Ryan
2
concur with other studies in demonstrating the beneficial
effects of cooling on reducing tissue damage and wound healing time.
The question often asked, is how long after the burn injury, is it still worthwhile to commence
cooling. Nguyen et al
2
conclude from various authors that although immediate cooling is
preferable, even a 30 minute delay in application of cooling is still beneficial to the burn
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wound. The same authors do point out that the application of cooling 60 minutes after injury,
does not demonstrate any benefit.
Impairment of blood flow in the zone of stasis can occur from shortly after the burn injury up
to 48 hours post-burn
1
. If blood flow is compromised, this may lead to the eventual necrosis
of cells in this zone.
Clinical management that will promote the recovery of this zone includes:
Wound dressing chosen to aid moist wound healing
The use of topical antimicrobial agents
Adequate fluid resuscitation / hydration
Elevation of burnt area to minimise oedema
Advising patient to avoid / minimise smoking
Management of systemic diseases such as diabetes monitor & stabilise blood
sugar levels.
Burn wound oedema
It is important to have an understanding of the timeframe of oedema development and
resolution. The ability of the tissues to receive oxygen and nutrients is reduced during this
time, while susceptibility to infection is increased.
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The impact of this on clinical management is that strategies to aid recovery of the zone of
stasis must extend until oedema resolution has occurred.
Burn inflammation
Inflammation becomes prominent at 7-10 days post injury. It is at this time that blood flow in
the burn wound is at its maximal level. Surgery therefore, may be hazardous due to an
increased risk of blood loss. This is one of the reasons that early burn wound excision, is
favoured by many burn surgeons.
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Burn wound depth
Burn depth in Australia is most frequently described using the following classification
system:
Epidermal
Superficial Dermal
Mid-Dermal
Deep Dermal
Full thickness
Other classification systems refer to 1
st
, 2
nd
and 3
rd
degree injury. This system however is
subjected to personal interpretation of the classification. The advantage of the descriptive
system is that it removes any ambiguity. This is especially useful when discussing burn
wound management over the phone.
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The burn blister
This is a subject still debated at length by various practitioners. A review of the literature by
Flanangan & Graham
3
led them to conclude thatempirical evidence over the last 50 years
both supports and refutes the routine debridement of blisters. Authors such as Williams
1
,
Pankhurst and Pochkhanawala
4
and Carrougher
5
conclude that small blisters can be let
intact, but as a general rule, blisters should be debrided and the wound dressed.
How this translates into clinical practice is based on treating every patient individually. A
variety of factors should be taken into consideration when deciding wether to de-roof blisters
or leave them intact.
In the paediatric setting, blisters on the palm of the hand and sole of the foot are often left
intact for a period of 48hours.
In the adult, large blisters on the palm of the hand may impede function to a level that is
unacceptable.
It has already been mentioned that the size of the blister should be taken into consideration.
Factors affecting wound healing
Both the very young and the elderly have very thin skin that makes them more susceptible to
significant burn injury
Other factors that affect wound healing include:
Nutrition
Infection
Associated illnesses such as diabetes mellitus, malignancy and vascular
insufficiency
Cytotoxic treatments
Burn wound healing
Factors that will enable healing to occur include wound care, good nutrition, maintenance of
function, positive attitude and co-operation from the patient. Oedema reduction, prevention
of burn wound infection and adequate analgesia will also contribute to optimal patient
outcome.
The achievement of these goals involves the whole burn team, Every team member has a
responsibility to maintain a high standard in relation to infection control strategies.
Care of the wound itself should be designed to:
Promote spontaneous healing
Prevent further tissue loss
Prevent infection
Provide optimal conditions for surgery if required
Be as painless as possible
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Be acceptable to the patients needs
Wound cleansing
It is interesting to note that in the general wound care arena, there has been much
discussion on the choice of wound cleansing solutions. Most studies have not looked at burn
wounds. The Joanna Briggs Institute Best Practice information sheet Solutions, techniques
and pressure for wound cleansing
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excluded studies that compared solutions for patients
with burns.
Many authors including Carrougher
5
, and Pankhurst & Pochkhanawala
4
, report that in
practice most burns units bath or shower their patients with tap water. Some centres use
mild antiseptic impregnated sponges. Extreme caution should be exercised when using
solutions that have been shown to be toxic to cells.
The maintenance of the temperature of the burn wound has been identified as beneficial by
numerous authors. Methods of achieving this include:
Warming cleansing solutions
Warm ambient temperature
Avoid lengthy dressing changes
Avoid exposure of wet wound surfaces
Ambulant patients, with minimal wound care needs, use independent showering. Burns
units may use burn baths, portable shower trolleys, or a combination of both in their
management of patients. The burns nurse will need to decide which is the most appropriate
choice. Factors that need to be taken into consideration include:
Age of patient
Patient ability to lie still
Extent of open burn wound
Presence of wound infection
Available equipment
Available space
Patients need for physical therapy
Wounds or dressings that may benefit from soaking
Konop
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states that the disadvantages of hydrotherapy include the risks of auto-
contamination and electrolyte imbalance. Carrougher
5
warns against excessive immersion
times over 30 minutes that may cause sodium and heat loss, in addition to pain and anxiety
associated with prolonged exposure.
Cleansing and debridement should be careful, gentle and minimal. Body hair within the burn
and to within 2.5cm of the wound periphery should be shaved, with the exception of the
eyebrows.
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This will:
Contribute to a decrease in the bacterial load on the wound surface
Make the application and integrity of occlusive dressings easier
Make the removal of occlusive dressings easier and less painful.
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Mechanisms of wound debridement
There are five methods of wound debridement that may be utilised in wound management.
1. autolytic - the use of moist dressing such as hydrogels or hydrocolloids may
facilitate this.
2. surgical fascial, tangential or sharp debridement with scissors or scalpel
3. enzymatic e.g. fibrinolysins, (mashed papaya is used in Africa)
4. mechanical wet to dry dressings (danger of damage to new epithelium),
pulse lavage, gentle washing.
5. biological larvae of Lucilia sericata
Burn wound dressings
Various biologic, biosynthetic and synthetic wound dressings are used in burn care.
Selection and use of these products depends on the condition of the wound bed, the
inherent properties of the dressing and the goals of therapy.
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In practice, different products
seem to work for some centres and not for others. Patient population demographics and the
local environment may all impact on the success or failure of certain dressing products.
Pankhurst and Pochkhanawala
4
summarise the ideal burn dressing as one that must:
Protect the wound from physical damage and micro-organisms
Be comfortable, compliant and durable
Be non-toxic, non-adherent, and non-irritant
Allow gaseous exchange
Allow high humidity at the wound
Be compatible with topical therapeutic agents
Be able to allow maximum activity for the wound to heal without retarding or
inhibiting any stage of the process
When selecting a suitable dressing, numerous factors need to be taken into consideration:
Depth of the burn (This determines the amount of exudate)
Site of the burn
Extent of the burn
Type of first aid (cooling with dirty river water may increase the risk of infection)
Cause of the burn (burns caused by flammable liquids or hot oil have a high
potential for infection)
Patients ability to manage dressing
Health professionals ability to manage dressing
Functional impact of dressing on patients lifestyle
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Associated pain
Urgency of time to healing
Cost
Management of the circumferential burn
In any circumferential burn, there is a risk of circulatory or respiratory compromise,
depending on the site of the burn. Restriction normally occurs in full thickness burns, but
may occur in deep dermal injury. If this compromise occurs, then an escharotomy must be
performed. This is a longitudinal incision that runs the length of the burn. The incision should
start in unburned skin and continue over into unburned skin at the distal end of the incision if
possible. There will be some bleeding from the incision and a haemostatic alginate should
be used on the escharotomy incision if full excision of the eschar is to occur at another time.
In any circumferential burn, care must be taken when applying dressings to ensure that:
They are not constrictive in any way
They allow for full assessment of neurovascular or respiratory status
The limb is elevated
Management of the superficial burn
In the very superficial burn with no epidermal loss, no dressing will be required. These burns
are very painful and a topical analgesic cream may be useful. This can be followed by the
use of a moisturising cream when the pain has eased.
The superficial burn can be treated by a variety of wound products. These should be chosen
to protect the wound and encourage re-epithelialization. Product groups that are commonly
used include Polyurethane semipermeable films, Hydrocolloids and retention dressings. If
infection is present or a there is a high risk of potential for infection to occur, an antibacterial
dressing should be chosen.
Management of the partial thickness burn
The management of the partial thickness burn injury and the split thickness skin graft donor
site is very similar. The donor site should have a low risk of infection and anti bacterial
dressings are not normally required. Product groups that may be considered for this depth of
burn, include:
Hydrocolloids
Polyurethane films
Biologic dressings
Biosynthetic dressings
Alginates
Polyurethane membrane supported gel
Foams
Antimicrobial products such as products containing silver.
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Vaseline gauze (in Africa this is a dressing that nurses make themselves when
dressings such as those listed above are not available. They have found this a
great improvement on using plain dry gauze)
The use of temporary skin substitutes such as Biobrane! and Transcyte! have become
more widely used in the treatment of mid to deep dermal burn injury. As these products do
not have any anti-bacterial properties, meticulous wound cleaning must occur prior to
application. Many centres give patients a general anaesthetic to allow for a thorough
cleansing without causing undue distress to the patient. The use of retentive tape to fix
these substitutes instead of using staples minimises further painful episodes that are
associated with staple removal.
As with the superficial burns, the presence or suspicion of infection will make the use of an
antibacterial dressing obligatory.
Management of the full thickness burn
Full thickness burn injuries are treated with antimicrobial dressings. The most common
dressing used in Australia & New Zealand have, until recently, been Silver Sulphadiazine
cream and Silver Nitrate Solution. There are now a wide variety of products containing silver
available.
The choice of product can be guided by the same principles of choice for any dressing.
There are advantages and disadvantages to all of the Silver products. Factors to be
considered in addition to those listed above, include:
Likely time to surgery (pointless to use most expensive product if it is going to be
removed in a very short period of time)
Proximity of skin grafts or skin substitutes (creams may cause separation of
substitutes or grafts)
Presence of escharotomy site
Access required
Temperature of patient
Availability
Alternative dressings
In some countries the use of expensive commercially produced dressing products is not
viable. Economic reality is a fact of life. Many centres have been very creative in the
development of alternative dressings. The use of amniotic membrane, banana leaf dressing,
honey, papaya and Boiled Potato Peel Bandage, have all been reported in the literature.
What these reports have shown is that there are alternatives that may be very effective in
the management of burn injuries.
Suggested reading:
Gore, M. & Akolekar, D. 2003, Evaluation of banana leaf dressing for partial
thickness burn wounds, in Burns, Vol 29, pp487-492.
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Burn Itch
Burn itch is still very common in many patients who have suffered a burn injury. There are
many strategies used to minimise this. The following summary is provided by Demling &
DeSanti
Demling, R & De Santi, L. 2002, The itching Burn Wound, [Online], viewed 7 July 2004,
http://www.burnsurgery.org/Modules/itch/p1/p1toc.htm
Non-pharmacological Pharmacological
Moisturising cream Oral antihistamines
Massage Oral analgesics
Colloidal oatmeal products Topical analgesic
Cool bath / shower Topical antihistamine
Compression garments Doxepin cream 5%
References
1. Williams, W. 2002, Pathophysiology of the burn wound, in Herndon, D.(ed) Total
Burn Care, 2
nd
edition, Saunders, London, pp 514-521.
2. Nguyen, N., Gun, R., Sparnon, A. & Ryan, P. 2002, The importance of immediate
cooling a case series of childhood burns in Vietnam, Burns, Vol28, No 2, pp 173-176.
3. Flannagan, M. & Graham, J. 2001, Should burn blisters be left intact or debrided?,
Journal Of wound Care, February, Vol 10, No 2, pp 41 45.
4. Pankhurst, S. and Pochkhanawala, T. 2002, Wound Care, in Bosworth Bousfield,
C. (ed) Burn Trauma Management & Nursing Care, 2
nd
edition, Whurr Publishers,
London, pp 81-108.
5. Carrougher, G. 1998, Burn Wound Assessment and Topical Treatment, in
Carrougher, G. (ed) Burn Care and Therapy, Mosby, Missouri, pp 133-165.
6. JBI, 2003 Solutions, techniques and pressure for wound cleansing, Best practice,
Vol 7, Iss 1, Blackwell Publishing Asia, Australia
7. Konop, D. 1991, General local treatment, in Trofino, R.(ed)Nursing Care of the
Burn Injured Patient, FA Davis, Philadelphia, pp 42-67.
Suggested readings /sources
Bosworth Bousfield, C. (ed) Burn Trauma Management & Nursing Care, 2
nd
edition,
Whurr Publishers, London
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Carrougher, G. (ed) Burn Care and Therapy, Mosby, Missouri
Herndon, D.(ed) Total Burn Care, 2
nd
edition, Saunders, London,
http://www.burnsurgery.com
http://www.worldwidewounds.com