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Burns - Post Acute Care and Dressings

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  • See also

    Burns - Acute Management
    Acute Pain Management
    Wound assessment and management

    Key Points

    1. Optimal pain relief, wound healing and the prevention of complications are key in burn care
    2. Burn management requires a multidisciplinary approach

    Background

    The extent and type of burn dictates the level of care required. See Burns - Acute Management

    Assessment

    As per Burns - Acute Management

    Management

    The principles of burn wound management are

    1. Relieve pain & distress
    2. Apply and maintain an appropriate dressing
      1. Limit fluid loss
      2. Prevent infection
      3. Promote healing
    3. Optimise nutrition
    4. Prevent complications

    Analgesia

    • Manage pain using multimodal analgesia
    • Control itch with non-sedating antihistamines
    • Mitigate stress and anxiety with techniques such as distraction and therapeutic play
    • Additional analgesia and sedation should be used prior to dressing cares. Anxiety and distress increases a child’s analgesia requirements and reduce compliance with cares

    Burns Dressings

    • The size, depth, area of the burn and amount of moisture required for optimal healing, are considered when selecting a dressing type
    • Acute burns are initially covered with both a:
      • Primary dressing on the wound. Examples include silver impregnated (ActicoatTM, Mepliex ® Ag) or medicated paraffin (BactigrasTM) dressings
      • Secondary dressing over the primary dressing to absorb exudate and secure the primary dressing in place. Examples include low-adherent (e.g. Mepitel™, MelolinTM with HyperfixTM) or crepe dressings
    • Dressing advice can be obtained from a local paediatric burns unit

    Dressing changes

    • Daily dressing changes are not advised
    • Timing of dressing change relates to the product applied (e.g. Acticoat 3TMneeds to be changed in 3 days; Acticoat 7TM in 7 days)
    • If there are concerns of poor wound healing, particularly if there are no signs of healing within 10 days, refer to paediatric burn service for assessment
    • Supplementary and adjunct procedural analgesia may be indicated. Consider nitrous oxide or intranasal fentanyl

    Nutrition

    • Children with burns have increased metabolic and nutritional requirements
    • Early nasogastric feeding should be started in children with facial burns, injuries or comorbidities that prevent adequate oral intake
    • Regular weight measurements aid assessment of adequate nutrition
    • A dietitian should be consulted to ensure nutritional needs are met. Consider assessing and supplementing vitamin A, vitamin C and zinc levels to promote wound healing

    Preventing Burn Complications

    • Positioning
      • Burn areas should be elevated to limit oedema and monitored for compromise of peripheral circulation. Splinting may also be needed to prevent contractures and maintain range of movement
      • Consult an occupational therapist and/or physiotherapist for:
        • Deep dermal or full thickness burns crossing flexor surfaces of a joint
        • Circumferential burns
        • Significant oedema limiting limb function or vascular integrity (poor capillary return, cool to touch distal to burn)

    Preventing Infection

    • Gloves must be worn for dressing changes
    • Burns TBSA >10% may require additional infection control measures including isolation – follow local Burns Unit infection precautions
    • Fever is a common reaction to the hypermetabolic state and immune response following a burn. Child must be assessed for other causes
    • Prophylactic antibiotics are not recommended in burns
    • If there is concern the burn wound is infected, send a swab for MCS and treat with empiric antibiotics as per local guidelines
    • Toxic shock syndrome (TSS) is a rare complication of an infected burn and can be life threatening. See Sepsis - assessment and management

    Psychosocial care
    The consequences of a child sustaining a burn can be profound on the child and family. Caring for the child includes support for family members, which may include multidisciplinary team approach to support rehabilitation and transition back to community and school

    Consider consultation with local paediatric team when

    • Concern regarding ability to care for burns at home
    • Suspected non accidental injury, self-inflicted burns or assault

    Consider transfer when

    • Child requiring care beyond the comfort level of the hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when

    • Carer able to provide adequate care for child’s burn and follow-up assured
    • Minor burns may be referred to an outpatient burn service for follow-up within 1 week

    Parent information

    Burns - rehabilitation

    Last updated May 2020

  • Reference List

    1. Australian and New Zealand Burn Association Ltd (ANZBA) (2019).   Emergency Management of Severe Burns course manual (version 18).  (c) Copyright, Australian and New Zealand Burn Association.  Produced with permission.
    2. NSW Burns Transfer guidelines: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns-Transfer-Guidelines.pdf
    3. Queensland Paediatric burns Guideline https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/guidelines/gdl-paediatric-burns.pdf
    4. South Australia Women’s and Children’s hospital Paediatric Burns Service guidelines: http://www.wch.sa.gov.au/services/az/divisions/psurg/burns/documents/WCHN_paediatric_burns_service_guidelines_july-2018.pdf
    5. Trauma Victoria Paediatric Burns guideline: file:///C:/Users/caseyv/Downloads/Burns%20guideline_V2%2016102017%20update%20poster%20201118.pdf