Burn Wound Assessment and Infections

Transcription

1 Burn Wound Assessment and Infections Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality Family Health: Burns Date of submission August 2016 Date on which guideline must be August 2019 reviewed (one to five years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Guideline for Wound Assessment and Management of Burn Wound Infections in the Paediatric Patient Andrea Cronshaw Clinical Nurse Specialist Indicated for patients who have sustained a burn injury who require the depth of burn and total body surface area to be assessed. Burns can be caused by thermal, chemical or electrical mechanisms. The amount of tissue damage and the depth of burn is related to the depth of the temperature or strength of the injuring agent and how long of time that the agent has been in contact with the skin. Key Words Child. Children; Paediatrics; Wound assessment, wound infection Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? 1a meta analysis of randomised controlled trials 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasi-experimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer Consultation Process X X Burns Multi-Disciplinary Team to include: Mr Clarkson, Mr Mandal, Mr O Boyle, Dr Sussens and Mary Kennedy. Staff within Nottingham Children s Hospital Target audience This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. 1

2 Document Control Document Amendment Record Version Issue Date Author V1 V2 Aug 2016 Andrea Cronshaw General Notes: Summary of changes for new version: Updated minor injuries flow chart in line with the guidance updated by the Midlands Burns Operational Delivery Statement of Compliance with Child Health Guidelines SOP This guideline has had only minor changes made and therefore this version has not been circulated to all for review. A previous version had been approved by circulation to senior team members. Martin Hewitt Clinical Guideline Lead 15 August

3 Burn Wound Assessment Introduction Burns can be caused by thermal, chemical or electrical mechanisms. The amount of tissue damage and the depth of burn is related to the depth of the temperature or strength of the injuring agent and how long of time that the agent has been in contact with the skin. Estimation of the Area of Burn The two important determinants of the seriousness of the burn injury are the area and depth of the burn. The greater the surface area of the body injured, the greater the mortality rate. Accurate assessment of the area of the burn is a necessity and Lund and Browder Charts are used to assess the total body surface area burnt. The charts come in a variety of sizes: baby, 2 year old, 5 year old, 10 year old, 15 year old and heavy adult. An adjunct to working out total body surface area is to use the area of the palmer surface of the patient s hand, which is approximately 1% body surface area. 1% Estimation of the Depth of the Burn Depending upon the depth of tissue damage, burns may be classified as: Erythema (Superficial) Superficial Partial Thickness Deep Partial Thickness (Deep Dermal) Full Thickness 3

4 Superficial Burns (Erythema) Erythema is redness of the skin and disappears when you press it. Erythema is not counted when estimating total body surface area of a burn injury. These burns affect only the epidermis. Common causes of these burns are sunburns and minor flash injuries. Superficial burns are painful and heal quickly, usually within one week. Superficial Partial Thickness Burns Superficial Partial Thickness burns include the epidermis and the superficial part of the dermis. Blisters and the skin covering the blister are dead and are separated from the living base by the inflammatory oedema fluid. Superficial partial thickness burns are very painful and usually heal within 14 days, without scarring, but may leave residual changes in skin colour. Deep Partial Thickness (Deep Dermal) Burns Deep dermal burns may have some blistering, but the base of the blister demonstrates a blotchy red colour. Capillary refill may be sluggish and tissue and oedema and blistering will be present. Dermal nerve endings are situated at the deep dermal level and sensation to pinprick and light touch may be lost, but the burn will be painful and analgesia is necessary. Full Thickness Burns Full thickness burns destroy both layers of skin and may penetrate more deeply into underlying structures. These burns have a dense white, and in some case a charred appearance. The sensory nerves in the dermis are destroyed and there is no sensation. Despite this full thickness burns are very painful and analgesia is required. 4

5 Diagnosis of Burn Depth Depth Colour Blisters Capillary Refill Sensation Healing Epidermal Red No Present Painful Yes Superficial Dermal Pale pink Small Present Painful Yes Mid- Dermal Dark pink Present Sluggish +/- Usual Deep Dermal Blotchy red +/- Absent Absent No Full Thickness White No Absent Absent NO 5

6 Management of Minor Burn Injuries Dressing Flowchart Cool burn wound if appropriate first aid not given, and it is <3 hours Burn assessed by ED Clinician, decision made that referral to Burns Service is not required and considered suitable for clinic. Give adequate analgesia prior to cleaning and dressing change. Swab the wound and then thoroughly clean wound, remove all loose / dead skin and de roof large blisters, a diluted antiseptic solution may be used. Epidermal Burn Superficial dermal burn Deep dermal burn Small full thickness burn Contact local burn service for advice A non-adherent dressing with or without antimicrobial properties, depending on local protocol or clinical guideline A non-adherent antimicrobial dressing A non-adherent antimicrobial dressing If wound clean and microbiology swabs = no growth, consider a non-adherent dressing without antimicrobial properties unless otherwise clinically indicate If wound reepithelialised but fragile continue longer with a protective dressing Wound Healed Massage with a nonscented moisturiser As appropriate refer to physio/ot/dietician/psychologist Give advice about sun protection and about returning to normal activities, e.g. swimming and PE If the wound is not healed after 2 weeks contact your local burns service 6

7 Management of Major Burn Injuries Dressing Flowchart Burn assessed by Clinician. Thoroughly clean wound and remove all loose / dead skin, a diluted antiseptic solution may be used. Deep Partial Thickness Burn Small Full Thickness Burn Large Full Thickness Burn A non-adherent antimicrobial dressing and review regularly for dressing changes. A non-adherent antimicrobial dressing and surgical review by the burns and plastics team. A non-adherent antimicrobial dressing and surgical review by the burns and plastics team and consider surgery. If wound clean and microbiology swabs = no growth, consider a non-adherent dressing without antimicrobial properties unless otherwise clinically indicated If wound reepithelialised but fragile continue longer with a protective dressing Wound Healed Massage with a nonscented moisturiser As appropriate refer to physio/ot/dietician/ psychologist If the wound is not healed after 10 days, review wound for further treatment. 7

8 Management of Wound Infections Bacterial infection frequently complicates wound healing and this risk increased in patients who have burn wounds, due to large amounts of necrotic tissue and cell debris are present in the wound providing a good culture medium for bacteria. All wounds should be swabbed: On first presentation to hospital. If the wound is smelly If the wound is oozing pus Patient is unwell Paediatric patients do not routinely receive prophylaxis antibiotics unless they are unwell and symptomatic. If a patient requires antibiotics, the Trust s Guidelines on the use of antibiotics must be followed. Documentation of Wounds All wounds should be documented on the Trusts Wound Care Documentation. All wounds should be clearly described with what they have been cleaned with, dressed with and when the next review is. 8

9 References 1. Midlands Burns Operational Delivery Network (2016) Midland Burn ODN Guidelines for Minor Burn Injuries Dressings National Network for Burn Care (NNBC) (2013) National Burn Care Standards. ndards_2013.pdf Guidhttp:// spxelines Guidelinefor the Admission and Trans Document Control Document Amendment Record Version Issue Date Author Description General Notes: Summary of changes for new version: 9

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