Definitions for grades of recommendation (A-C and good practice points [GPP]) are provided at the end of the "Major Recommendations" field.
Prevention
Opportunities for Prevention
A - Primary care providers should provide advice on smoke alarms.
C - Primary care providers should support local initiatives in primary prevention, where possible.
GPP - Primary care providers should provide advice on the regulation of hot water temperature and appropriate first aid management.
First Aid
Stopping the Burning Process and Cooling
C - Ensure your own safety.
C - If on fire, '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 to 15 degrees 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 degrees 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.
Gel Pads
C - Gel pads can be used as an alternative to running tap water where water is unavailable or not practical.
Initial Coverings
Polyvinyl Chloride Film (Cling Film)
C - Following cooling, polyvinyl chloride (PVC) film may be used as a temporary cover prior to hospital assessment. It should be applied by persons knowledgeable in its use.
C - PVC film 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.
GPP - PVC film should not be used as a substitute for a dressing product.
Burn Assessment
Emergency Management
C - 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 first 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.
*ABCDEF primary survey:
Airway maintenance with cervical spine control
Breathing
Circulation with haemorrhage control
Disability: Neurological status
Exposure with environmental control
Fluid resuscitation
Burn Size
Assessment and Recording of Total Body Surface Area Burn (TBSA)
B - Where time allows, use the Lund and Browder chart as the standard assessment tool for estimating the TBSA of the burn.
Burn Depth
C - 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.
GPP - The extent and speed of capillary refill can be used as a clinical method of assessing burn depth.
Non-Accidental Injury
C - 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.
Classification of Burns
C - Avoid use of the terms first-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 to 14.
GPP - Use the Australian and New Zealand Burn Association (ANZBA) system of burn classification (see Table 3.3 of the original guideline document for the ANZBA classification of burns based on depth with photographs).
Referral
Emergency Referral
C - 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.
Referral Between Services
C - 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.
GPP - 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.
Management of Epidermal Burns or Scalds
Dressings and Creams
GPP - A protective dressing or cream product can be used for comfort in epidermal burns and scalds.
GPP - Review epidermal burns or scalds after 48 hours. If the skin is broken, change to a moist wound-healing product (or alternatively double-layer paraffin gauze).
Management of Superficial and Mid Dermal Burns or Scalds
Preventing Infection
GPP - Products with antimicrobial action (such as silver sulphadiazine cream) should be used on all burns for the first 72 hours (three days) after burn injury.
GPP - Burn wounds with signs of mild cellulitis can be treated with topical silver sulphadiazine and/or oral antibiotics.
GPP - Acute referral to secondary care is required for people with burns with signs of serious or systemic infection.
Wound Healing
C - Use dressings that encourage re-epithelialisation by moist wound healing.
B - The prolonged use of silver sulphadiazine cream (more than seven days) should be avoided in non-infected burns.
GPP - Following initial silver sulphadiazine cream or antimicrobial dressing, a technique that promotes moist wound healing (such as a hydrocolloid dressing) is recommended.
GPP - The convenience of a reduced number of dressing changes with hydrocolloid products should be considered where this is important to the person.
GPP - Double-layer paraffin gauze can be used where hydrocolloids are unavailable.
GPP - Moisturisers and non-drying, non-perfumed soap should be used to protect the skin after burn injury and may also be helpful for pruritus.
GPP - Burn wounds require extra care when exposed to sun.
When to Review
GPP - Superficial and mid dermal burns should be reviewed daily for the first three days, then subsequently every three days.
Management of Blisters
GPP - Preferably leave small blisters intact unless likely to burst or interfere with joint movement.
GPP - If necessary, drain fluid by snipping a hole in the blister.
Scarring
C - 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 to 14.
GPP - A person presenting with scarring some months after a burn should still be referred for specialist opinion.
Management of Chemical Injury
General Treatment Advice
First Aid
C - Irrigation of chemical burns should continue for one hour.
C - All chemical burns should be referred to a burns unit.
GPP - Acid burns should not be neutralised with an alkali in primary care.
Eye Injury
C - All significant 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.
Specific Substances
Hydrofluoric Acid
GPP - Anyone exposed to hydrofluoric acid should be promptly referred to a burns unit for definitive treatment after appropriate first aid.
Phosphorus
GPP - Anyone exposed to phosphorus should be promptly referred to a burns unit for definitive treatment after appropriate first aid.
Management of Electrical Injury
C - All electrical injuries should be referred to a burns unit.
Electrocardiogram (ECG) Monitoring
C - Following electrical injuries people should receive a resting 12-lead ECG.
B - If this initial ECG is normal in people with low-voltage injuries, there is no need for a repeat ECG or for continuous monitoring.
Pain Management
Burn Pain Management
C - Immediately after the injury, cooling and covering the burn may provide analgesia.
C - Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage background pain.
C - Consider administering opioids for intermittent and procedural pain.
GPP - Refer to secondary care if failing to manage dressing-change pain.
GPP - Consider the use of non-pharmacological approaches as a supplement to pharmacological management of pain.
Psychological Consequences of Burn Injury
Adverse Psychological Responses to Trauma
C - Monitor people with burn injuries for signs of stress disorders or depression.
B - Recognise and treat pre-existing disorders and comorbidities (including alcohol and drug dependence) associated with post-traumatic stress disorder (PTSD).
C - Refer people with acute or chronic PTSD for specialist mental health management.
GPP - Be aware of services that may be able to support families affected by the psychological impacts of burn injuries.
GPP - Be aware of the increased risk of sleep disorders after burn injuries.
Burn Injuries in Maori
GPP - Be aware that Māori tamariki (children) are at increased risk of burn-related injuries and deaths.
GPP - Consider ways to deliver care that will overcome access barriers, if necessary, such as nurse home visiting for dressing changes.
Burn Injuries in Pacific Peoples
GPP - Be aware that Pacific children may be at increased risk from hot water scalds.
GPP - Consider ways to deliver care that will overcome access barriers, if necessary (such as nurse home visiting for dressing changes).
GPP - Be aware that language can be a barrier. Encourage a bilingual family member or practice nurse to assist with communication. Ideally, Pacific Island population-specific translators should be made available to services that provide for Pacific peoples.
Definitions:
Grades of Recommendation
- A - The recommendation is supported by good evidence (where there are a number of studies that are valid, consistent, applicable and clinically relevant).
- B - 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).
- C - The recommendation is supported by international expert opinion.
- GPP - Where no evidence was available, best practice recommendations were made based on the experience of the Guideline Development Team, or feedback from consultation within New Zealand.
