Table 1

Initial assessment of a major burn

• Perform an ABCDEF primary survey

A—Airway with cervical spine control, B—Breathing, C—Circulation, D—Neurological disability, E—Exposure
with environmental control, F—Fluid resuscitation

• Assess burn size and depth (see later article for detail)

• Establish good intravenous access and give fluids

• Give analgesia

• Catheterise patient or establish fluid balance monitoring

• Take baseline blood samples for investigation

• Dress wound

• Perform secondary survey, reassess, and exclude or treat associated injuries

• Arrange safe transfer to specialist burns facility

This article outlines the structure of the initial assessment. The next article will cover the detailed
assessment of burn surface area and depth and how to calculate the fluid resuscitation formula.
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History taking
The history of a burn injury can give valuable information about the nature and extent of the
burn, the likelihood of inhalational injury, the depth of burn, and probability of other injuries.
The exact mechanism of injury and any prehospital treatment must be established.established.
Table 2
Key points of a burn history

Exact mechanism

• Is there risk of concomitant injuries (such as fall

• Type of burn agent (scald, flame, electrical, chemical)
from height, road traffic crash, explosion)?

• Is there risk of inhalational injuries (did burn occur

• How did it come into contact with patient?
in an enclosed space)?

• What first aid was performed?

• What treatment has been started?

Exact timings

• When did the injury occur? • How long was cooling applied?
 • How long was patient exposed to energy source? • When was fluid resuscitation started?

Exact injury

Scalds Electrocution injuries

• What was the liquid? Was it boiling or recently boiled? • What was the voltage (domestic or industrial)?

• If tea or coffee, was milk in it? • Was there a flash or arcing?

• Was a solute in the liquid? (Raises boiling temperature

• Contact time
and causes worse injury, such as boiling rice)

Chemical injuries

• What was the chemical?

Is there any suspicion of non-accidental injury?

• See previous article

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A patient's history must be obtained on admission, as this may be the only time that a first hand
history is obtainable. Swelling may develop around the airway in the hours after injury and
require intubation, making it impossible for the patient to give a verbal history. A brief medical
history should be taken, outlining previous medical problems, medications, allergies, and
vaccinations. Patients' smoking habits should be determined as these may affect blood gas
analyses.
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Primary survey
The initial management of a severely burnt patient is similar to that of any trauma patient. A
modified “advanced trauma life support” primary survey is performed, with particular emphasis
on assessment of the airway and breathing. The burn injury must not distract from this sequential
assessment, otherwise serious associated injuries may be missed.

A—Airway with cervical spine control

An assessment must be made as to whether the airway is compromised or is at risk of
compromise. The cervical spine should be protected unless it is definitely not injured. Inhalation
of hot gases will result in a burn above the vocal cords. This burn will become oedematous over
the following hours, especially after fluid resuscitation has begun. This means that an airway that
is patent on arrival at hospital may occlude after admission. This can be a particular problem in
small children.children.
Table 3
Airway management

Signs of inhalational injury Indications for intubation

• Erythema or swelling of oropharynx on direct

• History of flame burns or burns in an enclosed space
visualisation

• Full thickness or deep dermal burns to face, neck, or

• Change in voice, with hoarseness or harsh cough
upper torso

• Singed nasal hair

 • Carbonaceous sputum or carbon particles in oropharynx • Stridor, tachypnoea, or dyspnoea

Direct inspection of the oropharynx should be done by a senior anaesthetist. If there is any
concern about the patency of the airway then intubation is the safest policy. However, an
unnecessary intubation and sedation could worsen a patient's condition, so the decision to
intubate should be made carefully.carefully.
Figure 1

Carbonaceous particles staining a patient's face after a burn in an enclosed space. This suggests there is
inhalational injury

B—Breathing
All burn patients should receive 100% oxygen through a humidified non-rebreathing mask on
presentation. Breathing problems are considered to be those that affect the respiratory system
below the vocal cords. There are several ways that a burn injury can compromise respiration.
Mechanical restriction of breathing—Deep dermal or full thickness circumferential burns of the
chest can limit chest excursion and prevent adequate ventilation. This may require escharotomies
(see next article).
Blast injury—If there has been an explosion, blast lung can complicate ventilation. Penetrating
injuries can cause tension pneumothoraces, and the blast itself can cause lung contusions and
alveolar trauma and lead to adult respiratory distress syndrome.syndrome.

Figure 2
Acute bronchoscopy being performed to assess amount of damage to the bronchial tree. Patient has been
covered in a blanket and a heat lamp placed overhead to prevent excessive cooling
Smoke inhalation—The products of combustion, though cooled by the time they reach the lungs,
act as direct irritants to the lungs, leading to bronchospasm, inflammation, and bronchorrhoea.
The ciliary action of pneumocytes is impaired, exacerbating the situation. The inflammatory
exudate created is not cleared, and atelectasis or pneumonia follows. The situation can be
particularly severe in asthmatic patients. Non-invasive management can be attempted, with
nebulisers and positive pressure ventilation with some positive end-expiratory pressure.
However, patients may need a period of ventilation, as this allows adequate oxygenation and
permits regular lung toileting.
Carboxyhaemoglobin—Carbon monoxide binds to deoxyhaemoglobin with 40 times the affinity
of oxygen. It also binds to intracellular proteins, particularly the cytochrome oxidase pathway.
These two effects lead to intracellular and extracellular hypoxia. Pulse oximetry cannot
differentiate between oxyhaemoglobin and carboxyhaemoglobin, and may therefore give normal
results. However, blood gas analysis will reveal metabolic acidosis and raised
carboxyhaemoglobin levels but may not show hypoxia. Treatment is with 100% oxygen, which
displaces carbon monoxide from bound proteins six times faster than does atmospheric oxygen.
Patients with carboxyhaemoglobin levels greater than 25-30% should be ventilated. Hyperbaric
therapy is rarely practical and has not been proved to be advantageous. It takes longer to shift the
carbon monoxide from the cytochrome oxidase pathway than from haemoglobin, so oxygen
therapy should be continued until the metabolic acidosis has cleared.cleared.
Table 4
Signs of carboxyhaemoglobinaemia

COHb levels Symptoms

0-10% Minimal (normal level in heavy smokers)

10-20% Nausea, headache

20-30% Drowsiness, lethargy

30-40% Confusion, agitation

40-50% Coma, respiratory depression

>50% Death

COHb = Carboxyhaemoglobin

C—Circulation
Intravenous access should be established with two large bore cannulas preferably placed through
unburnt tissue. This is an opportunity to take blood for checking full blood count, urea and
electrolytes, blood group, and clotting screen. Peripheral circulation must be checked. Any deep
or full thickness circumferential extremity burn can act as a tourniquet, especially once oedema
develops after fluid resuscitation. This may not occur until some hours after the burn. If there is
any suspicion of decreased perfusion due to circumferential burn, the tissue must be released
with escharotomies (see next article).article).
 Open in a separate window
Figure 3
Algorithm for primary survey of a major burn injury
Profound hypovolaemia is not the normal initial response to a burn. If a patient is hypotensive
then it is may be due to delayed presentation, cardiogenic dysfunction, or an occult source of
blood loss (chest, abdomen, or pelvis).

D—Neurological disability
All patients should be assessed for responsiveness with the Glasgow coma scale; they may be
confused because of hypoxia or hypovolaemia.
E—Exposure with environment control
The whole of a patient should be examined (including the back) to get an accurate estimate of the
burn area (see later) and to check for any concomitant injuries. Burn patients, especially children,
easily become hypothermic. This will lead to hypoperfusion and deepening of burn wounds.
Patients should be covered and warmed as soon as possible.

F—Fluid resuscitation
The resuscitation regimen should be determined and begun. This is based on the estimation of
the burn area, and the detailed calculation is covered in the next article. A urinary catheter is
mandatory in all adults with injuries covering > 20% of total body surface area to monitor urine
output. Children's urine output can be monitored with external catchment devices or by weighing
nappies provided the injury is < 20% of total body area. In children the interosseous route can be
used for fluid administration if intravenous access cannot be obtained, but should be replaced by
intravenous lines as soon as possible.possible.
Table 5
Investigations for major burns*

General

• Full blood count, packed cell volume, urea and electrolyte concentration, clotting screen

• Blood group, and save or crossmatch serum

Electrical injuries

• 12 lead electrocardiography

• Cardiac enzymes (for high tension injuries)

 Inhalational injuries

• Chest x ray

• Arterial blood gas analysis

Can be useful in any burn, as the base excess is predictive of the amount of fluid resuscitation required

Helpful for determining success of fluid resuscitation and essential with inhalational injuries or exposure to
carbon monoxide

Any concomitant trauma will have its own investigations

*

Analgesia
Superficial burns can be extremely painful. All patients with large burns should receive
intravenous morphine at a dose appropriate to body weight. This can be easily titrated against
pain and respiratory depression. The need for further doses should be assessed within 30
minutes.

Investigations
The amount of investigations will vary with the type of burn.burn.
Table 6
Indications for referral to a burns unit

All complex injuries should be referred

A burn injury is more likely to be complex if associated with:

• Extremes of age—under 5 or over 60 years

• Site of injury

Face, hands, or perineum

Feet (dermal or full thickness loss)

Any flexure, particularly the neck or axilla

Circumferential dermal or full thickness burn of limb, torso, or neck

• Inhalational injury

Any substantial injury, excluding pure carbon monoxide poisoning

• Mechanism of injury

Chemical injury >5% of total body surface area

Exposure to ionising radiation

High pressure steam injury

High tension electrical injury

Hydrofluoric acid burn >1% of total body surface area

Suspicion of non-accidental injury

• Large size (dermal or full thickness loss)

Paediatric (< 16 years old) >5% of total body surface area

Adult (≥ 16 years) > 10% of total body surface area

• Coexisting conditions

Any serious medical conditions (cardiac dysfunction, immunosuppression, pregnancy)

Any associated injuries (fractures, head injuries, crush injuries)

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Secondary survey
At the end of the primary survey and the start of emergency management, a secondary survey
should be performed. This is a head to toe examination to look for any concomitant injuries.
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Dressing the wound

Once the surface area and depth of a burn have been estimated, the burn wound should be
washed and any loose skin removed. Blisters should be deroofed for ease of dressing, except for
palmar blisters (painful), unless these are large enough to restrict movement. The burn should
then be dressed.
For an acute burn which will be referred to a burn centre, cling film is an ideal dressing as it
protects the wound, reduces heat and evaporative losses, and does not alter the wound
appearance. This will permit accurate evaluation by the burn team later. Flamazine should not be
used on a burn that is to be referred immediately, since it makes assessment of depth more
difficult.
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Referral to a burns unit

The National Burn Care Review has established referral guidelines to specialist units. Burns are
divided into complex burns (those that require specialist intervention) and non-complex burns
(those that do not require immediate admission to a specialist unit). Complex burns should be
referred automatically. If you are not sure whether a burn should be referred, discuss the case
with your local burns unit. It is also important to discuss all burns that are not healed within two
weeks.weeks.
Table 7
Key points

• Perform a systematic assessment as with any trauma patient (don't get distracted by the burn)

• Beware of airway compromise

• Provide adequate analgesia

• Exclude any concomitant injuries

 • Discuss with a burns unit early

• If in doubt, reassess

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Notes
This is the fourth in a series of 12 articles
The ABC of burns is edited by Shehan Hettiaratchy; Remo Papini; and Peter Dziewulski,
consultant burns and plastic surgeon, St Andrews Centre for Plastic Surgery and Burns,
Broomfield Hospital, Chelmsford. The series will be published as a book in the autumn.
Competing interests: RP has been reimbursed by Johnson & Johnson, manufacturer of Integra,
and Smith & Nephew, manufacturer of Acticoat and TransCyte, for attending symposia on burn
care.
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Further reading and resources

 • Sheridan R. Burns. Crit Care Med 2002;30: S500-14 [PubMed] [Google Scholar]
 • British Burn Association. E
he Lund and Browder chart is a tool useful in the management of burns for estimating the total
body surface area affected. It was created by Dr. Charles Lund, Senior Surgeon at Boston City
Hospital, and Dr. Newton Browder, based on their experiences in treating over 300 burn victims
injured at the Cocoanut Grove fire in Boston in 1942.[1]
Unlike the Wallace rule of nines, the Lund and Browder chart takes into consideration of age of the
person,[2] with decreasing percentage BSA for the head and increasing percentage BSA for the legs
as the child ages, making it more useful in pediatric burns.

Nursing management of burn injuries



 Introduction
 Aim
 Definition of Terms
 Assessment
 Management
 Companion Documents
 Links
 Evidence Table
 References

Introduction
Children have a high risk of sustaining a burn injury due to their physiological, psychological, and
developmental differences.

Burn injuries have a significant impact on paediatric patients and may affect a range of body systems.
The impact of these injuries on children and families is often long lasting. As the injury itself and required
treatment often causes distress, pain and anxiety, appropriate management by nurses is essential in
providing family centered care.

Ongoing care requirements are based on the size, depth, anatomical site and mechanism of injury.

Aim
The aim of this clinical guideline is to assist and support nursing staff at The Royal Children’s Hospital to
plan and deliver care to children with burn injuries, across all departments including: Emergency,
Paediatric Intensive Care Unit, Inpatient Units, Theatres and Outpatients.

Definition of terms
 Burns Multidisciplinary Team – consist of Burns Consultant/Fellow, Burns Clinical Nurse
Consultant, Burns register/resident, Nurse Coordinator, Occupational Therapist, Physiotherapist,
Dietitian, Social Work, Play therapy, Specialist Clinics Team.
 % TBSA – percentage of total body surface area burnt (not including erythema or superficial
burns) calculated using the Lund Browder chart.
 Minor Burn – In paediatric burns a minor burn is considered to be less than 10% TBSA
 Major Burn – In paediatric burns a major burn is considered to be more than 10% TBSA

Assessment
Burn injuries cause a significant insult on the body and a thorough ABCD assessment, followed by a full
head to toe and focused assessment are vital to ensure clinical issues/deterioration are identified early
and appropriate management initiated.

Assessment of the pediatric patient with a burn injury should occur on admission, when the patient’s
condition changes and regularly throughout care.

Detailed information regarding completion and documentation of ABCD, head to toe and focused
assessments can be located on the Nursing Assessment Clinical Guideline.

Burns specific information is outlined below.

Airway and Breathing

Assessment and monitoring of airway patency and breathing should be carefully observed as patients at
risk of inhalation burns can deteriorate up to 72 hours post burn injury, particularly if they have:

 Sustained burns in an enclosed space (at risk due to smoke inhalation)

 Have facial burns
 Singed nasal hairs
 Facial swelling
 Blackened sputum
 Stridor or hoarseness of voice
 Respiratory distress/increased work of breathing

If inhalation burns are suspected high flow oxygen therapy via a Hudson mask should be administered to
the patient and changes/abnormal findings reported to the treating team immediately for further
assessment and management.

Circulation
Children who sustain burns injuries are at increased risk of circulatory compromise due to significant fluid
loss and fluid shifts, these patients must be closely monitored for:

 Signs and symptoms of hypovolemia.

 Signs and symptoms of hypothermia.

Other circulatory concerns include:

 Circumferential burns should be identified, monitored for circulatory compromise ( neurovascular

observations nursing guideline) and the affected area elevated where ever possible.
 Consider the need for an ECG and continuous cardiac monitoring if the burn is of electrical origin.

Pain assessment
Burn injuries are often associated with extreme amounts of pain and discomfort due to damaged/loss of
skin coupled with widespread oedema.

A detailed pain assessment must be completed upon arrival to hospital and then continued at regular
intervals (1-4 hourly minimum) throughout the patient’s admission, prior to/during procedures as well as
during outpatient visits. Re-evaluation of pain, post pain management is vital to ensure analgesia is
adequate.

Detailed information regarding paediatric pain assessment can be located on the Pain Assessment
Nursing Clinical Guideline. Information regarding procedural pain management can be located on
the Procedural Pain Management Clinical Guideline.

Wound assessment
Assessment of the burn injury should occur on the initial presentation to the Royal Children’s Hospital as
well as prior to completing wound care throughout the inpatient stay and outpatient visits. Burn injuries
can take up to 10 days to truly present the depth and extent of injury so reassessment is vital. As burn
injuries heal accurate wound assessment will ensure wound management is altered as needed to ensure
appropriate wound care continues to be delivered to the patient.

Wound assessment of a burn injury includes (available on Electronic medical Records):

 Assessment of Total Body Surface Area (TBSA) burnt, utilising the Lund Browder chart. Areas of
erythema and superficial burns are not included in calculations of TBSA.
 Assessment of depth of burn injury
 Assessment of wound healing

Accurate documentation of wound assessment should be recorded.

Further information regarding wound assessment in a burn injury can be located on the Burns Clinical
Practice Guideline as well as the Burns Unit: Clinical Information.

Further information regarding wound assessment and healing can be located on the Wound Care Clinical
nursing guideline.

History
A thorough patient history should be collected on admission to hospital.
Specific information regarding the burn injury must be obtained from the patient, family and first
responders as this will inform ongoing treatment. History taking should include:

 Time of injury
 Mechanism of injury: How the burn occurred/type of burn, including length of exposure and
estimated temperatures of heat source.
 Was first aid completed? If so, what type and for how long?
 Tetanus status of the patient (if not up to date consider immunisation, see Immunisation of
inpatients Clinical Guideline.

In addition to this information a detailed patient and family history should also be obtained. Further
information regarding this can be located on the Nursing Assessment Nursing Clinical Guideline.

Non accidental injuries must be considered when the history does not match with the injury or
inconsistencies with the history/story occur. Refer to medical staff & social work. Victorian Forensic
Paediatric Medical Service (VPFMS) can also be notified.
For further information regarding non accidental injuries refer to the Child Abuse Clinical Guideline.

Social history
Burn injuries are traumatic and life altering events which can significantly impact the patient and their
family. Early support from social work, contact with play therapists and chaplains should be offered to the
child, siblings and family. It may also be appropriate to consider referrals to mental health/psychology.

For families from non-English speaking backgrounds interpreters must be utilised throughout the
admission and follow up.

Families who have traveled over 100km to reach the hospital should be given Victorian Patient Transport
Assistance Scheme (VPTAS) forms.

Management
First Aid
Completion of first aid for a child who has sustained a burn injury is an important initial aspect of care as it
assists with pain relief as well as minimising the progression of tissue damage. First aid is effective for up
to three hours post time of injury. If appropriate first aid was not initiated and it is still within the 3 hour
time frame post burn injury, first aid should be completed as outlined below, prior to any wound care:

 The area of tissue damage should be cooled with cool running water for 20 minutes.
 Cooling for longer than 20minutes is not beneficial.
 Ensure the unburnt areas of the patient are covered and warm to prevent hypothermia.

Further information regarding burn injury first aid including burns to the eye area and chemical burns can
be found on the Burns Clinical Practice Guideline.

Fluids
Burn injuries greater than 10% TBSA and including the dermis result in circulatory compromise secondary
to fluid loss via damaged tissue, widespread vasodilation as well as increase capillary permeability and
fluid shifts (third spacing). This can result in hypovolemia leading to burns shock. Therefore it is vital that
adequate fluid is administered to the patient in combination with ongoing circulatory and fluid balance
assessment.

 A Strict Fluid Balance must be maintained at all times, including all intake (both intravenous and
oral) and strict measurement of all output (weigh nappies, weigh pans/bottle, measure IDC)
 Fluid resuscitation is required in patients who have >10-15% TBSA.
 Patients receiving fluid resuscitation should have two large bore Intravenous cannulas inserted
 Fluid resuscitation is calculated utilising the modified parkland formula. For further information
regarding this please see the Burns Clinical Guideline.
 Intravenous maintenance fluid should be administered in conjunction with fluid resuscitation, if
child is unable to tolerate oral fluids. Intravenous fluids should be titrated with oral fluids.
 An IDC is essential for patients receiving fluid resuscitation to allow close monitoring of fluid
status and adjustment of IVT as necessary.
 Expected urine output is 1ml/kg/hr unless otherwise stated by the medical team.
 U&E’s should be monitored 8 hourly while patient is receiving fluid resuscitation.
 Fluid resuscitation rates may need to be adjusted to accommodate the patients fluctuating fluid
status.
 Patients should be weighed once a week whilst admitted.

Analgesia
Burn pain can be extremely intense and distressing for paediatric patients and can also be challenging to
manage due to the individual experience and its unique characteristics.

 Initial and ongoing pain management is vital to ensure patient comfort, maximise healing and
minimise risk of mental trauma/post-traumatic stress.
  Initial pain relief should be administered immediately following an accurate pain assessment,
further information regarding initial pain management can be located on the Burns Clinical
Practice Guideline.
 Regular pain relief should be charted and administered, consider a combination of Paracetamol
and Opioids initially.
 Recommended routes of administration of analgesia include: oral, intravenous or intranasal.
Intramuscular is not recommended in patients with burn injuries.
 Pre-emptive analgesia may be necessary prior to re-positioning, physiotherapy and follow up
outpatient appointments.
 Reassessment and evaluation of pain management is vital, referral to Children’s Pain
Management Service may be necessary.

Burn pain experienced by patients is likely to increase during procedures such as dressing changes.
Management of pain during burn dressing changes is discussed in detail below ( preparing for a dressing
change).
Once dressings have been applied and wound healing is progressing, patients are more comfortable and
may require less analgesia.

Preparation for Burns Dressing

Preparation of patient and family
Burn dressing changes can produce feelings of anxiety and distress in both patients and their families. It
is very important that both patients and families are physically and emotionally prepared and well
informed regarding the procedure and the pain management options.

 Families/primary care givers should be given a thorough explanation of the procedure, where
appropriate pictures could be used to visualise the procedure along with orientation to the
treatment room/bathroom to be used.
 Involve the parents where possible when providing an age appropriate explanation of the
procedure to the patient.
 Optimising the parent’s role may assist in reducing both the child’s and parents anxiety during the
procedure. Involving them in distraction and support of the child may be useful. However not all
families will want to be involved and staff should be sensitive to parents who choose not to be
present.
 Referral to play therapy prior to the procedure may assist in explaining and preparing the patient
for the dressing change.
Play therapy are also able to empower the child to identify distraction techniques, as well as
provide support and distraction throughout the procedure. For older children distraction
techniques should be discussed with the child. Distraction should be utilised by
 staff and/or parents.
 Where possible and appropriate children should be given the opportunity to choose whether they
want to participate in wound care for example assisting to remove dressings.
 Consider the benefit of social work support for patients and parents who may require additional
support before or after a dressing change.
 It may be hard to distinguish between a patient’s pain and anxiety associated with burns
dressings, good communication with family prior to and during the procedure will assist in this.

For further information, staff and families can access reducing children’s discomfort during tests and
procedures kids health info factsheet.

Assessment
Children who are planned to undergo a burns dressing change should have an ABCD assessment
completed along with pain assessment prior to the dressing change commencing. This will assist the
nurse in ensuring appropriate pre-emptive analgesia is selected for the patient ( ABCD / Pain assessment
above).

The child will require continuous ABCD monitoring and pain assessment throughout the procedure to
ensure that analgesics provide are adequate and effective.

The child’s personal hygiene requirements should also be assessed at this time as this will assist the
nurse in identifying children who should be bathed (bath/shower) prior to having a new dressing applied.
Children who may require bathing (bath/shower) include those with large % TBSA burns, those whose
dressing prevent them from bathing/showering on a daily basis and may be age dependent.

Pre Medication/ Pain Relief

Burns dressing changes can be painful and distressing for children, it is an individual experience,
however burns with larger % TBSA, those that contain partial thickness burns and any that require
extensive debridement are likely to be more painful.
Nursing staff should assess the child’s pain prior to the procedure commencing and pre-emptive
analgesia should be administered. Staff should re-evaluate the effectiveness prior to the procedure
commencing and throughout the procedure.
Choice of analgesia is an individual process and staff should take into account the % TBSA, depth,
amount of debridement required as well as the pain tolerance, distress and past experience of the child.
Review of analgesia/sedation requirements for previous dressing changes is essential.
The Children’s Pain Management Service (CPMS) may also be utilised to assist in planning procedural
pain relief for burns dressing changes.
Options may include:

 Simple analgesia such as Paracetamol and NSAIDs

 Oral Analgesia such as Opioids (Oxycodone), Tramadol, Ketamine and Oral Sedatives such as
Benzodiazepines e.g. Diazepam, Midazolam
 Intravenous Sedation/Analgesics including infusions, PCA or intermittent bolus
(Morphine/Fentanyl/Ketamine)
 Nitrous Oxide (refer to the procedural sedation ward and ambulatory care procedure)
 Intranasal medications such as Intranasal Fentanyl
 Anaesthetics may be involved to provide sedation (Ketamine/Propofol) and continuous monitoring
of the patient.

A combination of the above options may be ordered and utilised to provide pain relief. Note for patients
receiving an anaesthetic or Nitrous Oxide the need for administration of medications with analgesic
effects should be considered to assist in pain management post burn dressing change. Further
information regarding this can be located on the Procedural Sedation – ward and ambulatory care
procedure or through consultation with CPMS or comfort kids.
Pain Assessment should occur continuously throughout the procedure by observing the behaviour and
comfort level of the child as well as using an appropriate pain assessment scale.
If analgesia and sedative agents prescribed are not providing effective pain management/sedation then
the procedure should be paused until appropriate analgesia/sedation is available and pain is
manageable. Escalation to the children’s pain management service on pager 5773 or Burns resident on
pager 4021 can occur at any stage throughout the procedure.
As the patient’s burn injury heals, analgesia and sedative agents utilised throughout the procedure should
start to be slowly weaned with the support of CPMS, medical teams and senior nursing staff.
All sedative agents should be administered in line with the Sedation and Procedural Sedation Ward and
Ambulatory Areas procedure.
Staffing Requirements
To complete a burns dressing change in a safe and time efficient manner which minimises patient and
family distress, staffing requirements must be considered.

 Simple analgesia: 1-2 nursing staff of which 1 is experienced in burns dressing changes.
 Oral sedation agents: 2-3 nursing staff of which 1 monitors the patient, 1 is experienced in burns
dressing and 1 staff member assists.
 Nitrous Oxide: 2-4 nursing staff of which 1 is accredited in nitrous oxide administration, 1 is
experienced in burns dressing and 1-2 staff members assists
 IV agents: An Anaesthetist and Anaesthetic technician are required; 2-3 nursing staff of which 1 is
experienced in burns dressing and 1-2 nursing staff members to assist

Additionally allocating the role of distraction and non-pharmacological pain management techniques
should be considered and assigned to either a parent, play therapist or additional staff member as
appropriate.
All roles must be designated prior to commencement of dressing change and the patient should remain in
line of sight to staff at all times. For further information refer to the Sedation and Procedural Sedation
Guideline Ward and Ambulatory Care Areas procedure.
Burn injuries which have a large TBSA percentage and patients with reduced mobility may require
increased staff numbers to assist in dressing changes. For further information refer to the High
Dependency and Special Nursing Care nursing guideline.

Preparation of environment and equipment

 Location of burns dressing change is dependent on the following: age of child, % TBSA burnt,
sedative agent require and length of procedure to ensure patient safety and OH&S considerations
for staff.
 For children who have larger %TBSA burn injuries (>10%) consider using a treatment area where
heaters can be utilised to minimise the risk of hypothermia. These heaters should be turned on
prior to the dressing change commencing. (i.e. Platypus Burns
 Bathroom, Theatre, ED Resus)
 Adequate preparation of the environment should be completed prior to the child being taken into
the treatment room/bathroom.
 Utilise the dressing trolley to prepare the products required, and consider the need for wound
swabs.
 Consider the need to organise:

 Physiotherapy/Occupational therapy – to review patient mobility and splinting

requirements.
 Medical team – to review burn injury and wound healing.
 Clinical photography

Staff Roles
Prior to the procedure a team leader should be allocated. Other team member’s roles/responsibilities ie.
Dressings nurse, sedationist, observations nurse, hygiene nurses should also be communicated.
An ISBAR handover should also occur; identifying patient name, age, weight, allergies, procedure, any
pre procedure medication and staff roles.

Burns dressing
Staff should adhere to the aseptic technique procedure for all aspects of wound care outlined below.

Removal of previous dressing

Removal of the previous dressing should not damage the healing burn wound and should be as
atraumatic as possible. The use of an adhesive remover, normal saline or water will assist with gentle
removal of previous dressings.

Wound Management
Clean the wound using a soft wipe with water, normal saline, pH neutral soap or cetrimide (please note
cetrimide is not to be used on face or scalp). Enough pressure should be applied to debride the damaged
skin and remove exudate, loose skin and slough.
Consider the need for a wound swab and complete if necessary.
Debridement of any blisters present allows for wound bed assessment and appropriate dressing
application.
The wound and surrounding skin should be dry before application of the dressing. If the patient has had a
bath, pat dry the surrounding skin with clean towels or gauze. Cling wrap could also be utilised to protect
the burn if there is an anticipated delay in application of new dressing.

Personal Hygiene
Ensure the patient’s personal hygiene is thoroughly attended to if the burns dressing change is occurring
in the bath or shower. If the patient is not having a bath use a sponge to clean non dressed areas.

Application of Burns Dressing

 A thorough wound assessment should occur with every dressing change and will determine the
appropriate dressing required (see wound assessment above).
 Dressings should cover all area where tissue damage has occurred but avoid unburnt skin as
maceration may occur.
 When taping a dressing consider the sensitivity of skin and the age of the child. The dressing
should be secured but taping not excessive.
 A crepe bandage/tubifast/tubigrip assists with securing dressings as well as absorbing some
excess fluid. They also add pressure to support with scar management.
 Oedema is common in the initial days post burn, therefore tight circumferential bandages should
not be applied. Elevation of the limb in the immediate days post injury will limit swelling.
 Dermal burns produce a large amount of exudate in the initial few days and changing of the outer
bandage or tubifast may need to occur. Where possible retaping/securement of the dressing
should occur unless a dressing change is scheduled.

Common burn dressing product

Acticoat™ – - Moisten Acticoat ™ with sterile w

Note – Acticoat™ is a 3 day application activate
Acticoat 7™ is a 7 day application
- Wring out excess water from Actic
Acticoat Flex is a 3 or 7 day application
forceps. Silver or blue side to wound.
Commonly used on partial to full thickness burns as well as burns of - Cover Acticoat ™ with Intrasite Co
indeterminable depth in initial stages of injury.
- Cover the 2 layers with cling wrap
appropriate size, ensuring no overlap of
healthy skin.
- Apply dressing to wound
 - Secure with tape e.g. Hypafix ™ o
- Reinforce dressing with crepe and
- Please review the Burns Unit: Clin
pictures of an Acticoat™ dressing (hype

Mepilex Ag™ - Self-adhesive

Commonly used on superficial, mid dermal or deep dermal to full Secure with tape e.g. Hypafix ™ or Mef
thickness facial burns or on areas where it is difficult to
secure acticoat.

Bactigras™ - Use in conjunction with gauze.

Commonly used on superficial dermal wounds and skin grafts. - Secure with tape e.g. Hypafix ™ o
tubifast.

Xeroform™ - Kenacomb™ ointment may be app

xeroform™ to areas of hyper granulatio
Commonly used on small areas of unhealed burn when Silver
products are no longer required. Also used on areas of - Use in conjunction with Melolin™
hypergranulation.
- Secure with tape e.g. Hypafix ™ o
tubifast.

Additional products may be utilised on burns wounds at the discretion of medical and nursing staff.
For further information regarding the above and additional products please refer to the wound care
guideline.

Specific body areas

Facial Burn’s Care
Facial burns may require regular wound care including cleansing followed by application of paraffin
cream. Parents should be encouraged to be involved in providing this care.
If dressings are utilised on the face balaclavas can be made from tubifast and used to secure dressing
products.
Additional information can be located on the Burns Medical Treatment.

Hand Burn’s Care

Any dressing applied to fingers, should ensure fingers are taped individually. Initially fingers which have
circumferential burns should be dressed with the finger tips exposed to monitor neurovascular status.
Once oedema has decreased the finger tips can be enclosed in the dressing.
Referral to hand therapy is vital.

Documentation
A summary post dressing change should be documented including: pain relief/ sedation and effect, non-
pharmacological techniques and effect, parental involvement, wound assessment, dressing product
utilised, staff present (including allied health, interpreter etc.) and plan of ongoing care. See Nursing
Documentation Clinical Guideline for further information.

Nutrition
Nutrition plays a vital role in burn healing, minimising complications of care and meeting the increased
metabolic demands associated with paediatric patients with burns. A diet high in protein, calcium, energy
and micronutrients (in particular Zinc and Vitamin C) has been shown to be most beneficial for wound
healing. Children should be encouraged to eat and drink foods high in these nutrients and nutritional
supplements such as Sustagen™ may also be required.
Insertion of a nasogastric tube and commencement of enteral feeds should be considered for children
who sustain significant burn injuries and/or facial burns and are unable to tolerate adequate oral intake.
Where possible feeds should commence within 6 - 8 hours of the burn injury.
Referral to the Burns Team Dietician is recommended for all patients with significant burn injuries, facial
burns, infants as well as patients who are not tolerating adequate oral intake.
Children with significant burn injuries are at risk of acute gastric ulceration and a H2 antagonist should be
considered for these patients.

Management of Itch
Itching is a common and debilitating issue in the healing phase of a burn injury.
The following may assist in reducing itch:
- Advise child and parent to avoid scratching - short finger nails will assist in this.
- Consider use of antihistamines i.e. Periactin or Certizdine
- Avoid overheating the child
- Fragrance free moisturiser (Sorbolene™) may assist.
- Distraction will play a big role in patient comfort
- Massage with the use of oatmeal containing product

Scar management:
Strategies to reduce scar development post burn injury include:

 Regular bathing and showering

 Massage with fragrance free moisturiser (Sorbolene™) should be massaged into the healed skin
at least twice daily to daily.
 Pressure therapy in the form of tubifast, tapes, pressure garments and silicone may be prescribed
by Physiotherapy (PT) or Occupational therapy (OT). It is often recommended that garments are
worn continuously except during personal hygiene. Nursing staff should monitor for pressure
areas when such garments are in use and report concerns back to PT/OT.

Physiotherapy / occupational therapy – splinting & positioning:

Physiotherapy (PT) and Occupational therapy (OT) may be necessary throughout both inpatient stay and
outpatient management for patients who have sustained a burn injury.
Significant burn wounds and those over joints are at high risk of contracture development. This can have
an impact on both growth and mobility. Prevention of contractures needs to occur early and to assist in
this PT and OT will prescribe patients with a splinting and positioning regime. To aid PT/OT in assessing
the patient’s burn injury and range of movement it is often beneficial for them to attend changes of
dressings.
It is vital that these regimes are adhered to by nursing staff. Paediatric patients may find the splints and
positioning regimes uncomfortable and distressing. It is important to educate both patient and family that
the position of comfort is likely to result in contractures. Strategies to support splinting and positioning
regimes include:

 Regular and pre-emptive analgesia

 Play therapy, distraction and rewards (i.e. sticker charts)
 Ongoing education and positive reinforcement
 Consistency in care

Concerns regarding splinting and positioning regimes should be documented and reported back to PT/OT
so as appropriate alterations to regimes can be initiated.

Discharge planning
The decision for a patient to be discharged should have involvement from the burns multidisciplinary team
and family meetings may be beneficial for planning purposes. Early discussion regarding discharge may
facilitate a smoother transition home for the family.
Children may be ready for discharge when:

 Pain is able to be appropriately managed at home

 An appropriate plan for wound care and follow up has been made
 Nutritional requirements are being met
 Mobility, positioning and splinting are able to be managed at home
 If needed pressure garments are tolerated

The following should be discussed with the family and child prior to discharge

 Pain management and itch plan, including plan for procedures (outpatients dressing changes)
 Home care of burn wound
 Nutritional requirements
 PT/OT recommendations
 Medical review
 When to return to hospital – ED/Specialist Clinics

Companion documents
 Nursing competency workbook – burns dressing, assessment, and fluid management of burns.

Links
 Lund Browder chart
 RCH Nursing Guidelines
 Nursing Assessment
 Neurovascular Observations
 Extravasation guideline
 Pain Assessment and Measurement
 Nursing Documentation
 High Dependency and Special Nursing Care
 Immunisation of inpatients
 Wound Care
 RCH Clinical Guidelines
 Burns
  Child Abuse
 RCH Policy and Procedures (RCH access only)
 Aseptic technique
 Procedural sedation - ward and ambulatory areas
 RCH Burns Department (limited access)
 Clinical Information
 Kids health info factsheets
 Burns on the face
 Burns clinic at RCH
Wallace rule of nines
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The Wallace rule of nines is a tool used in pre-hospital and emergency medicine to estimate
the total body surface area (BSA) affected by a burn. In addition to determining burn severity, the
measurement of burn surface area is important for estimating patients' fluid requirements and
determining hospital admission criteria.[1]
The rule of nines was devised by Pulaski and Tennison in 1947, and published by Alexander Burns
Wallace in 1951.
To estimate the body surface area of a burn, the rule of nines assigns BSA values to each major
body part:[2]

Estimated BSA

Body Part

Adults Children

Entire left arm 9% 9%

Entire right arm 9% 9%

Entire head 9% 18%

Entire chest 9% 9%

Entire abdomen 9% 9%

Entire back 18% 18%

 Entire left leg 18% 13.5%

Entire right leg 18% 13.5%

Groin 1% 1%

Burn severity is determined through, among other things, the size of the skin affected. The image shows the
makeup of different body parts, to help assess burn size.

This allows the emergency medical provider to obtain a quick estimate of how much body surface
area is burned. For example, if a patient's entire back (18%) and entire left leg (18%) are burned,
about 36% of the patient's BSA is affected. The BSAs assigned to each body part refer to the entire
body part.[3] So, for example, if half of a patient's left leg were burned, it would be assigned a BSA
value of 9% (half the total surface area of the leg). Thus, if a patient's entire back (18%), but only half
of their left leg (9%) was burned, the amount of BSA affected would be 27%.

Accuracy[edit]
Some studies have raised concerns about the rule of nines' accuracy with obese patients, noting that
"the proportional contribution of various major body segments to the total body surface area changes
with obesity."[1] One study found the rule's accuracy to be "reasonable" for patients weighing up to
80 kg, but proposed a new "rule of fives" for patients over that weight:[1]

 5% body surface area for each arm

 20% BSA for each leg
 50% for the trunk, and
 2% for the head.
Other studies have found that the rule of nines tends to over-estimate total burn area,[4] and that
ratings can be subjective,[5] but that it can be performed quickly and easily, and provide reasonable
estimates for initial management of burn patients.[4]
The rule of nines was designed for adult patients. It is less accurate in young children due to their
proportionally bigger heads and smaller mass in the legs and thighs, although one study did find it
was accurate for patients as small as 10 kg.[1] To account for children's proportional differences, a
"rule of nines for children" was proposed.[6] The head is assigned 18% BSA while each leg is 13.5%.
The remainder of the body parts retain the same BSA percentages used in the adult rule of nines.[7]

See also