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1. Key messages ..................................................................................................................... 1

2. Rapid Reference Guideline ................................................................................................ 3

3. Introduction ....................................................................................................................... 4

4. Early activation .................................................................................................................. 5

5. Primary survey ................................................................................................................... 6

6. Secondary survey ............................................................................................................... 8

7. Planning and communication .......................................................................................... 11

8. Early management ........................................................................................................... 13

9. Retrieval and transfer ...................................................................................................... 17

10. Guideline implementation ............................................................................................... 18

1. Key messages

The Victorian State Trauma System provides support and retrieval services for critically injured patients requiring definitive care, transfer and management. This guideline provides evidence-based advice on the initial management and transfer of major trauma patients who present to Victorian health services with severe burn injuries.

This guideline is intended for use by frontline clinical staff that provide early care for major trauma patients outside of a major trauma service (MTS); however, access to this resource is not restricted to any one group. These severe burn management guidelines provide up-to-date information for frontline healthcare clinicians.

These guidelines align with the Victorian state burns clinical practice guidelines developed by Victoria’s two burn services. They provide the user with accessible resources to effectively and confidently provide early care for critically injured burns patients. The guideline has been assessed using the AGREE methodology for guideline development and is auspiced by the Victorian State Trauma Committee.

Clinical emphasis points

A burn is a complex trauma that requires multidisciplinary care and ongoing therapy.

Patients with facial, neck and inhalation burns can have difficulty maintaining their airway and deteriorate rapidly; any signs of oedema should prompt early intubation.

Early management of burns patients aims to restore fluid loss, maintain adequate oxygenation, prevent hypothermia and address pain management.

Supplemental warmed and humidified oxygen should be provided to all burns patients in the initial management.

Accurate early identification of the burn depth and percentage of total body surface area (TBSA) will guide treatment.

Burns that are extensive or complicated should be managed in a specialised unit.

Once identified that the patient is suffering from a major burns trauma, early activation of the retrieval process is crucial.

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All inter-hospital transfer of adult major trauma patients should be referred via ARV (1300 368661).

All inter-hospital transfer of paediatric major trauma patients should be referred via PIPER (1300 137650).

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2. Overview

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3. Introduction

Every year in Victoria, around 5,000 presentations to emergency departments are related to burns.i Emergency department presentations, hospital admissions and deaths have remained stable, though rates of burns remain high in males, children and older people.

A burn is a complex trauma that requires multidisciplinary care and ongoing therapy. Burns can range from minor to severe and may be thermal, electrical or chemical. Burn injuries can have a devastating impact on both the patient and family, resulting in both physical and psychological scarring.

Full personal protective equipment (PPE) for health professionals must be worn throughout treatment to ensure the safety of care providers.

Thermal burns

A heat induced, or thermal, burn occurs when the skin comes into contact with a source of heat such as a fire, a hot surface, scalding liquid or heated objects. Thermal burns are the most common type of burn and affect roughly 1% of the population per year.ii

Electrical burns

Electrical injuries are classified as low (< 1,000 volts) or high (> 1,000 volts)iii however arc flash or arc explosion should also be treated as a high voltage injury presentation. A thorough history of the incident is crucial to understanding the degree of injury. The size of the entry or exit wound does not necessarily correlate with the amount of deep-tissue damage that may have occurred. The route through which the current has flowed is most important. Conduction of electrical current through the mediastinum may cause myocardial damage and associated local tissue destruction. Arrhythmias may occur immediately and up to 24 hours post injury,ii therefore continuous electrocardiogram (ECG) monitoring is required in all electrical burns patients who have an ECG abnormality. For these injuries, initial management is the same as for thermal burns. Adequate fluid resuscitation is important, as in all severe burns. This is especially important in electrical burns due to the destruction of deep-tissue regions and the possibility of developing rhabdomyolysis.

Chemical burns

Chemicals will continue to cause damage while on the skin. Dry chemicals should be brushed off. The main goal in initial treatment is decontamination; remove all contact of the chemical from clothing and thoroughly irrigate the burns. Damage to tissue will continue to occur until the agent is weakened by dilution or inactivated with a specific neutralising agent. The amount of damage to tissue is directly related to the strength and volume of the agent, as well as the manner and duration of contact with the skin, the extent of penetration and the mechanism of action. Similarly, a thorough history of the exposure must be established to ascertain possible damage.iv

Severe burns

A severe burn injury requiring immediate transfer to a MTS includes any burn greater than 20% TBSA, high-voltage electrical injury burns and any inhalation burns. A patient who has suffered a severe burn injury should be assessed and managed as a major trauma patient. Polytrauma may also co-exist, especially when there is a significant mechanism of injury. All patients with severe burns must receive a rapid and systematic primary and secondary

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survey. The main goal is to ensure optimum resuscitation in the emergency setting as well as activation of the retrieval network, with timely transfer to an appropriate burns facility. For non-severe burns injuries, refer to the Victorian state burns clinical practice guidelines for management and to ascertain whether a non-immediate transfer to a specialist facility is required.

4. Early activation

Emergency medical services responding to the scene will notify ARV and the receiving hospital that a trauma patient is on their way. This may be a major, metropolitan or regional trauma service or an urgent care centre, depending on distance, facilities available and the patient’s condition. Notification information may be crucial to managing the severely injured patient and can allow for communication to vital members of the response team as well as time to prepare the department for the patient’s arrival.

The following sequence of actions should take place upon initial notification:

1. Gather vital information from the notifier using the MIST mnemonicv:

M Mechanism of injury

I Injuries found or suspected

S Signs: respiratory rate, pulse, blood pressure, SpO2, GCS or AVPU

T Treatment given

2. PPE is vital in the care of trauma patients. Ensure all staff involved in patient care are wearing gloves, aprons and eye protection.

3. Activate the trauma team and available support departments (medical imaging, pathology). In small health service settings this may only consist of a clinician and a nurse. Additional staff may be gathered from wards or on call. It may be necessary to utilise the skills of all available resources including emergency response personnel in the initial trauma management.

4. Set up the trauma bay to receive the patient, including equipment checks, documentation, medications and resuscitation equipment.

5. Designate roles and specific tasks to staff and maintain an approach based on teamwork. Ensure good communication between all parties involved in managing the trauma. Use closed-loop communication, which ensures accuracy in information shared between response staff. Repeat instructions, make eye contact and provide feedback. Misinterpreted information may lead to adverse events.

If there is no prior notification of the patient, then rapid activation of the trauma team request must take place and any additional resources notified. If it is anticipated that transfer to a MTS will be required, early retrieval activation is essential (phone ARV on 1300 368 661).

Early retrieval activation ensures access to critical care advice and a more effective retrieval response.

Early activation and timely critical care transfer improves clinical outcomes for the patient.

If you are undecided, call the ARV coordinator, who can provide expert guidance and advice over the phone or via tele/videoconference and link to a MTS as required.

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5. Primary survey

Use a systematic approach based on the ABCDEvi survey to assess and treat an acutely injured patient. The goal is to manage any life-threatening conditions and identify any emergent concerns, especially in a burns patient who may present with other underlying polytrauma complications.

Airway with cervical spine protection

The patient’s airway is at significant risk in severe burns injuries, especially where there is involvement of any facial or inhalation injuries. Airway stability must be assessed rapidly. Intubation becomes increasingly difficult as swelling develops in the first few hours following an injury, especially once fluid resuscitation has commenced. Early airway management is essential as signs of impending airway obstruction may not be immediately obvious. It is important to quickly identify those who may require intubation.

Assess for airway stability

Attempt to gather a response from the patient.

Look for signs of airway obstruction (use of accessory muscles, paradoxical chest movements and see-saw respirations).

Listen for any upper-airway noises and breath sounds. Are they absent, diminished or noisy?

Assess for inhalation injury

Suspect an inhalation injury if there has been any history of: exposure to fire and smoke in an enclosed setting; hoarseness or change in voice; harsh cough; stridor; burns to the face; head and neck swelling; singed nasal hair, eyebrows or eyelashes; or soot in the saliva, sputum, nose or mouth.

Assess for an inflamed oropharynx.

Early intubation is indicated with inhalation injuries.

Attempt simple airway manoeuvres if required

Open the airway using a chin lift and jaw thrust.

Suction the airway if excessive secretions are noted or if the patient is unable to clear their airway independently.

Insert an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA) if required.

If the airway is obstructed, simple airway opening manoeuvres should be performed, including suction, a jaw thrust or a chin lift. Care should be taken to not extend the cervical spine.

Caution: An NPA should not be inserted in patients with a head injury in whom a basal skull fracture has not been excluded.

Secure the airway if necessary (treat airway obstruction as a medical emergency)

Consider intubation early if there are any signs of:

decreased level of consciousness, unprotected airway, uncooperative/combative patient leading to distress and further risk of injury

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pending airway obstruction: stridor, hoarse voice, soot in the mouth or nose, blistering or burning around the mouth or nose

Maintain full spinal precautions if indicated

Suspect spinal injuries in all polytrauma patients. Ensure cervical collar, head blocks and in-line immobilisation is maintained throughout patient care.

Breathing and ventilation

Administer high flow 100% (15 L/min) of humidified oxygen

Assume carbon monoxide poisoning in patients who sustain burns in an enclosed area. Carbon monoxide preferentially binds to haemoglobin, leading to falsely reassuring oxygen saturation levels. Oxygen administration is pivotal, regardless of the oxygen saturation recording.

Assess the chest

Count the respiration rate – high rates are markers of a potential inhalation injury and a warning that the patient may deteriorate.

Note the depth, pattern and equal rise and fall. Remember that underlying chest injuries may also be present.

Listen to the chest and assess for any wheeze, stridor or decreased air entry.

Circumferential burns to the chest may inhibit chest wall expansion and make ventilation difficult; consider an escharotomy (see Early Management below).

Record the oxygen saturation (SpO2)

Note that SpO2 will not detect elevated carbon monoxide levels.

Circulation with haemorrhage control

Assess circulation and perfusion

Check the heart rate, blood pressure and neck veins.

Inspect for any signs of haemorrhage and apply direct pressure to any external wounds. Consider the potential for significant internal bleeding related to the mechanism of injury, which may lead to signs and symptoms of shock.

Insert two large-bore peripheral intravenous (IV) cannulas, preferably through non-burnt tissue. If access is difficult consider central or intraosseous insertion if the equipment/skills are available.

Commence fluid resuscitation as indicated for burns greater than 20% TBSA in adults.

Review the unburnt skin colour and check the temperature and capillary refill.

Monitor the circulation of the peripheries and trunk, especially distal to the burn wound if circumferential burns are present. Elevation of the affected limb will assist in managing swelling. Poor perfusion may indicate the need to perform an escharotomy.

If necessary, perform a FAST scan

If the patient is haemodynamically stable and there are no signs of significant internal bleeding then a FAST scan may be delayed until the secondary survey.

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Disability: neurological status

Assess level of consciousness

Inadequate oxygenation as well as inhalation of smoke and toxins may lead to a decreased level of consciousness.

Perform an initial AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive); check the pupillary response.

Test blood sugar levels

Ensure that any alterations in level of consciousness are not related to a metabolic cause.

Exposure/environmental control

Remove the patient’s clothing and any jewellery in order to prevent any further heat injury and to be able to fully assess all areas of the body.

In suspected chemical burns, clothing may remain contaminated. Inappropriate handling may expose the patient to further injury as well as the care provider. Wear appropriate PPE.

It is important to minimise heat loss for severe burns patients due to the risk of hypothermia secondary to the loss of skin integrity. It is important to monitor the patient’s temperature and keep them in a warm environment with warm IV fluids.

6. Secondary survey

The secondary survey is only to be commenced once the primary survey has been completed and any life-threatening injuries have been treated. If during the examination any deterioration is detected, go back and reassess the primary survey.

History

Taking an adequate history from the patient, bystanders or emergency personnel of the events surrounding the injury can assist with understanding the extent of the injury, the likelihood of inhalation burns and any possible other injuries.

Use the AMPLE acronymvii to assist with gathering pertinent information:

A Allergies

M Medication

P Past medical history (including tetanus status)

L Last meal

E Events leading to injury

Note what first aid has already been given to the patient.

Head-to-toe examination

During this examination, any injuries detected should be accurately documented and any required treatment should occur, such as covering wounds, managing non-life-threatening bleeding and splinting of fractures.

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Measuring burns

Assessing burn depth and calculating the percentage of the total body surface area burnt is important during the head-to-toe examination. This will allow fluid resuscitation requirements to be calculated and the severity of the injury to be determined to assess if transfer to a specialist facility is required.

Burns are classified according to the depth of injury. There are a number of burn classification tools that exist. They vary from categorising the degree of the burn, to descriptions of burn thickness.

Refer to Appendix 1: Burn depth characteristics.

The extent of the burn is measured as the percentage of TBSA. It is important to accurately document the location and area of the burn. The recommended tool for assisting in calculating this in adults is the Wallace rule of nines chart. While examining the patient it is helpful to have another staff member documenting the location and extent of the injuries as they are called out by the assessing clinician.

Refer to Appendix 2: Rule of nine (adult).

Head and face

Inspect the face and scalp. Look for any lacerations and bruising as well as mastoid or periorbital bruising, which is indicative of a base of skull fracture. Gently palpate for any depressions or irregularities in the skull. Check the eyelashes and eyebrows for singeing.

Look in the eyes for any burn injury, foreign body, subconjunctival haemorrhage, hyphaema, irregular iris, penetrating injury or contact lenses.

Assess the ears for any signs of cerebrospinal fluid leak, bleeding or blood behind the tympanic membrane.

Check the nose for any deformities, bleeding, nasal septal haematoma, cerebrospinal fluid leak or presence of any soot/ash as well as singeing of nasal hairs.

Look in the mouth for any lacerations to the gums, lips, tongue or palate. Note any swelling, which may indicate inhalation injury. Inspect the teeth, noting if any are loose, fractured or missing.

Test eye movements, pupillary reflexes, vision and hearing.

Palpate the bony margins of the orbit, maxilla, nose and jaw.

Inspect the jaw for any pain or trismus.

Neck

The cervical collar should be opened, the head supported with manual in-line stabilisation and the neck inspected.

Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness or deformity.

Check the soft tissues for bruising, pain and tenderness.

Complete the neck examination by observing the neck veins for distension and palpating the trachea and the carotid pulse. Note any tracheal deviation or crepitus.

The patient will need to be log rolled to complete the full examination. This can be combined with the back examination.

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Chest

The chest should be palpated for rib tenderness and subcutaneous emphysema. The entire thorax must be palpated including the supraclavicular fossae, right and left ribs and both axillae. A hand can be slid posteriorly along a supine patient to check for occult blood loss; however, a formal examination of the back of the chest occurs when the patient is log rolled.

Palpate for clavicle or rib tenderness.

Auscultate the lung fields; note any percussion, altered/reduced breath sounds, wheezing or crepitations.

Check the heart sounds: apex beat and presence and quality of heart sounds.

Abdomen

Inspect the abdomen. Palpate for areas of tenderness, especially over the liver, spleen, kidneys and bladder. Look for any bruising, lacerations or penetrating injuries.

Check the pelvis. Perform a pelvic x-ray if there is any suspicion of injury. Gently palpate for any tenderness. Do not spring the pelvis.viii Any additional manipulation may exacerbate haemorrhage. Apply a binder if a pelvic fracture is suspected.

Auscultate bowel sounds.

Inspect the perineum and external genitalia.

Limbs

Inspect all the limbs and joints, palpate for bony and soft-tissue tenderness and check joint movements, stability and muscular power. Note any bruising, lacerations or muscle, nerve or tendon damage. Look for any deformities, penetrating injuries or open fractures.

In electrical burns, look for any entry and exit wounds as well as signs indicating the development of compartment syndrome. These may be found centrally, not just on the limbs (check the head and chest).

Examine the sensory and motor function of any nerve roots or peripheral nerves that may have been injured.

Assess for circumferential burns that may constrict blood flow to all limbs and digits. Assess colour, warmth, movement, sensation and capillary refill distally.

Back

Log roll the patient. Maintain in-line stabilisation throughout. Inspect the entire length of the back and buttocks noting any bruising and lacerations.

Palpate the spine for any tenderness or steps between the vertebrae. Include a cervical examination at this stage.

Digital rectal examination should be performed in a trauma patient only if a spinal injury is suspected. Note any loss of tone or sensation.

Buttocks and perineum

Look for any soft-tissue injury such as bruising or lacerations.

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Genitalia

Inspect for soft-tissue injury such as bruising, lacerations or burns. Note any priapism that may indicate spinal injury.

The priorities for further investigation and treatment may now be considered and a plan for definitive care established.

7. Planning and communication

For a trauma team to run effectively there must be an identifiable leader who will direct the resuscitation, assess the priorities and make critical decisions. Good communication between the trauma team members is vital, as is ensuring that local senior staff are aware and can provide additional support if required.

Once the initial assessment and resuscitation is underway, is it important to plan the next steps in immediate management. Priorities for care must be based on sound clinical judgement, patient presentation and response to therapies. Awareness of limitations in resources as well as training in the emergency field is vital. If escalation of care to senior staff is warranted, then do so early in the patient care episode. Do not wait until the patient deteriorates to ask for assistance.

Frontline clinical staff should initiate contact with ARV early in the patient care pathway or, more importantly, as soon as it is identified that the patient meets the inter-hospital trauma transfer criteria or may have sustained injuries beyond the clinical skill set of the emergency department or urgent care centre. ARV can be contacted at any time throughout the patient care episode to offer or coordinate clinical advice and consultation.

ARV coordinators can facilitate a three-way conversation between the referral health service, specialist burn resources and the ARV consultant to discuss the best, timely management of the patient.

The decision of when to transfer an unstable patient should ideally be made by the transferring and receiving clinicians in collaboration with the retrieval service. Clear communication is crucial: the transmission of vital information allows receiving clinicians to mobilise needed resources while the inadvertent omission of such information can delay definitive care. Information should be conveyed in both verbal and written (via the patient record) form and should include the patient’s identifying information, relevant medical history, pre-hospital management and emergency department evaluation and treatment (including any procedures performed and imaging obtained).

ISBARix is an acronym for facilitating health professional communication ensuring clarity and completeness of information in verbal communication:

I Identify: Who are you and what is your role? Patient identifiers (at least three).

S Situation: What is going on with the patient?

B Background: What is the clinical background/context?

A Assessment: What do you think the problem is?

R Recommendation: What would you recommend? Identify risks - patient and occupational health and safety. Assign and accept responsibility/accountability.

It is important that additional communication with the ARV coordinator is initiated when there is:

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1. Significant deterioration in

conscious state

blood pressure

heart rate

respiratory status

oxygenation

2. Major clinical developments such as significantly abnormal diagnostic tests or new clinical signs.

3. The need for major interventions prior to the retrieval team arriving (for example, intubation or surgery). This will ensure the retrieval team is prepared, the patient receives the appropriate care en route and the patient is referred to the correct facility.

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8. Early management

Airway management

Fluid resuscitation

Escharotomy

Analgesia

Wound care

Prevent hypothermia

In-dwelling catheter

Monitoring

Glasgow Coma Scale

Pathology tests

X-ray/FAST scan

Naso/orogastric tube

Tetanus immunisation

Antibiotics

Reassess

Airway management

If there is potential that the patient’s airway may deteriorate due to inhalation injuries or oedema subsequent to fluid resuscitation, then intubation prior to retrieval should be discussed with the ARV consultants. Sit the patient up if possible to minimise airway oedema.

Bronchodilators such as salbutamol may be effective in the presence of bronchospasm.

Frequent reassessment of the patient must take place as resultant swelling may cause further airway compromise. In an intubated patient, end-tidal carbon dioxide (ETCO2) monitoring (if available) should be used to assess respiratory status and adequacy of ventilation.

Always have emergency airway equipment by the bedside.

Consider escharotomy of the chest wall if necessary (see Escharotomy section).

Fluid resuscitation

Effective fluid resuscitation is one of the cornerstones of modern burn care and possibly the advance that has most directly improved patient survival. Without a rapid and effective intervention, hypovolaemia/shock will develop in severe burns cases. Any delay in fluid administration complicates resuscitation and increases mortality.x

Begin fluid resuscitation with normal saline if the TBSA (for adults) is over 20%. Fluid requirements should be estimated using the Parkland formula and taken from the time of injury.

4 mL × TBSA% × kg = ____mL/24 hours

½ total in the first 8 hours post injury

½ total in the next 16 hours post injury

Take into account the amount of fluid given since treatment commenced. This formula should be used as a guide; titrate treatment to response and to the desired urine output of 0.5–1 mL/kg/hr.

It is important to maintain an accurate intake and output chart from the early stages of treatment in order to assess the effectiveness of fluid resuscitation. This will also assist retrieval staff with further management during transfer.

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Escharotomy

The requirement for an escharotomy and/or fasciotomy usually presents within the first few hours of injury. This procedure may be necessary to relieve pressure if circulation is compromised.

Indicators that a circumferential chest wound may require an escharotomy are where the chest wall movement is decreased or there are signs of any respiratory compromise.

Signs that circulation is compromised and a limb may require a fasciotomy are loss of circulation as evidenced by decreased capillary return, coolness, pallor, loss of palpable pulses and numbness. Early elevation may prevent the need to perform the procedure.

Prior to performing an escharotomy, discussion with ARV and Victorian Burns Service clinicians should always take place. ARV will facilitate a three-way conversation between all clinicians. If videoconferencing facilities are available at your facility then initiate.

For detailed instructions on how to perform the above, please refer to the escharotomy guide in the downloadable resources section via the Trauma Victoria website

Analgesia

Morphine is the preferred analgesic drug in the acute burns management phase.ii IV administration is the most effective route in burns due to its rapid absorption.

Administer as per local protocols and titrate to effect. Analgesia should be administered prior to wound care as treatment and dressing of burns can be particularly painful. Additional analgesic agents may need consideration in managing severe burn pain.

Consider prophylactic antiemetic administration, especially if retrieval and transfer is likely.

Wound care

1. First aid: Leave any clothing that is adhered to underlying skin. Immediately cooling burns with cool running tap water helps to reduce the severity of tissue damage and relieve pain. Cool wounds for up to 20 minutes (with running water if possible) in partial thickness and superficial burns, not in full thickness burns. Consider shorter times for patients with a large TBSA (> 10%) or for children or older people because hypothermia may be induced. Apply saline-soaked gauze to the affected areas, changing it regularly if free-flowing water is not accessible.

2. Dress: If the patient is being transferred to the burns unit within six hours, cover the wound with plastic cling film. It should be applied longitudinally (to allow for swelling) rather than circumferentially, which may have a tourniquet-like effect.

If none is available and/or the patient is unlikely to be transferred to the burns unit within six hours, cover with paraffin gauze / silver or non-adherent dressing. Once dressings are complete, elevate the affected limb if possible to assist in minimising burn wound oedema.xi Place the patient on a burn sheet to absorb any exudate and to allow for minimal adhesion.

It is important to document if the burns have been contaminated at time of injury or during care such as if the patient rolled in dirt at the time of injury or jumped into a dam to cool the burns.

For detailed dressing instructions, refer to the Victorian state burns clinical practice guidelines.

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Prevent hypothermia

It is important to maintain normothermia. Ensure the patient does not lose any excess heat due to the loss of skin and the metabolic effect of the burn. Make sure the wounds are covered and air is not able to circulate around them.

Use warmed IV fluids; cover the patient with extra warm blankets as well as keeping the room warm (a general guide is that if clinical staff are comfortable, it’s likely to be too cold for a burns victim).

If available, the use of a forced air-warming machine is encouraged. Ensure wound care is attended to prior to commencement. Avoid moist dressings when using a forced air-warming device due to evaporative cooling effects. Reassess the room temperature at regular intervals while awaiting the retrieval team.

In-dwelling catheter

A urinary catheter should be inserted and urine output measured hourly. The desired urine output for adults is 0.5–1.0 mL/kg/hr.xii

A urinalysis should also be performed to check for blood. Discoloured, brown urine may indicate myoglobinuria, a sign of rhabdomyolysis.

Monitoring

Monitoring of the heart rate, respiration rate, blood pressure and oxygen saturation should take place at 15/60 intervals or less if indicated. Monitor continuously via electronic monitoring if facilities are available. All monitoring should be maintained until the retrieval team arrives.

A baseline ECG should be taken prior to transfer if time permits and facilities exist.

Glasgow Coma Scale

A focused neurological assessment using the GCS should be performed (see table below). This should include a description of the patient’s level of consciousness as well as assessments of pupillary size and reactivity, gross motor function, and sensation. Document the findings and reassess at frequent intervals.

Best response

Eye opening Verbal response Motor response

1 Does not open eyes Makes no sounds Makes no movements

2 Opens eyes in response to painful stimuli

Incomprehensible sounds Extension to painful stimuli (decerebrate response)

3 Opens eyes in response to voice

Utters inappropriate words

Abnormal flexion to painful stimuli (decorticate response)

4 Opens eyes spontaneously Confused, disoriented Flexion or withdrawal to painful stimuli

5 N/A Oriented, converses normally

Localises painful stimuli

6 N/A N/A Obeys commands

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Pathology tests

Pathology tests should be taken for FBC (full blood count), UEC (urea, electrolytes and creatinine) and glucose as well as a blood gases if available. Consider taking a group and cross-match if the patient is involved in a trauma presentation with a high index of suspicion for further injuries.

X-ray/FAST scan

Consider further diagnostic imaging if available and indicated.

Consider the need for FAST (Focused Assessment with Sonography in Trauma) if available and staff are trained in its use. FAST is used primarily to detect pericardial and intraperitoneal blood and it is more accurate than any physical examination finding for detecting intra-abdominal injury.xiii

In haemodynamically stable patients, FAST can be delayed until the secondary survey and is ideally performed by a second operator while the remainder of the secondary survey is completed.

Naso/orogastric tube (N/OGT)

All patients should be kept nil orally in the initial post-resuscitation phase of injury. In severe burns, enteral feeding will begin upon transfer to the burns unit. Discuss the necessity of this with ARV and the burns unit in the early stages of management.

The potential for a base of skull fracture in polytrauma should be considered as a relative contraindication in the decision to insert an NGT. An OGT may be inserted following consultation and under direct visualisation.

Tetanus immunisation

Tetanus immunisation should be updated if necessary for any burns deeper than superficial-thickness. Tetanus immune globulin should be given to patients who have not received a complete primary immunisation.

Antibiotics

Routine IV antibiotic administration is not recommended in an initial, uncomplicated burn injury. It may facilitate the development of multi-resistant bacteria.xiv There may be some benefit if the wound has been contaminated or with pre-operative administration; discuss with ARV.

Reassess

The importance of frequent reassessment cannot be overemphasised. Patients should be re-evaluated at regular intervals as deterioration in a patient’s clinical condition can be swift. This will be evident in their vital signs and level of consciousness. If in doubt, repeat ABCDE.

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9. Retrieval and transfer

Urgent arrangements for transferring and retrieving severe burns injury patients should take place as soon as is possible. This includes:

all burn inhalation injuries

burns to greater than 20% TBSA

high-voltage electrical burns, including lightning injury.

Used with permission from www.vicburns.org.au

It is important to note that an exhaustive clinical workup and interventions is not always necessary or appropriate prior to transfer. Stabilisation and ensuring life-threatening problems are addressed, as well as taking measures to prevent deterioration en route, are essential aspects of early care. Delaying transfer to obtain laboratory results or imaging studies may simply delay access to definitive treatment. Often such studies must be repeated at the receiving facility.

Hospitals with specialist burns facilities should manage burns patients requiring critical care support. All health services are advised to avoid patient deterioration during inter-hospital transfer by the timely and proactive transfer of such patients to a MTS Currently in Victoria, burns specialist facilities are located at The Alfred and the Royal Children’s Hospital.

In liaison with ARV clinicians, interventions to stabilise patients prior to retrieval personnel arriving should be commenced. ARV will coordinate the retrieval and will evaluate the practicality and clinical needs involved in transferring the patient from the source hospital. Once retrieval staff arrive on scene, be prepared to give a thorough handover. Retrieval staff will assess the patient prior to transfer and may make changes to care in order to ensure the patient is safe during transfer.

The use of a transfer checklist can help to ensure that important information is not omitted and the patient is packaged accordingly.

Consultation about transferring non-urgent burns patients to a specialist facility should also take place where there are the following:

burns greater than 10% TBSA

burns to special areas and full-thickness burns involving the face, eyes, ears, hands, feet, major joints or genitalia

full-thickness burns greater than 5% TBSA

electrical burns

chemical burns

circumferential burns of the limbs or chest

burns with associated trauma

burns in the very young or older people

burn injury in patients with a pre-existing illness or disability that could adversely affect patient care and outcomes

suspected non-accidental injury in children

small area burns in patients with social problems, including children at risk

burns occurring in pregnant women

burn injuries that the referring unit is concerned about or are slow to heal.

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The transfer of these patients will be assessed on a case-by-case basis and an appropriate transfer timeline will be given according to need.

Refer to Appendix 3: Victorian state burns service transfer criteria.

10. Guideline implementation

These guidelines are designed to push for quality improvement using evidence-based practice across the entire care pathway. They aim to achieve consistent advancement in peoples’ health and lead to access of good-quality care.

Putting these guidelines into practice benefits everyone; this includes the staff directly involved in patient care, those involved in managing the health facility, local healthcare organisations and members of the public. It can help to monitor service improvements, demonstrate that high-quality care is being provided and also highlight areas for improvement.

One of the most difficult aspects of working with guidelines is how best to implement them into routine daily practice. Many of us provide patient care according to usual routines (‘how it’s always been done’) instead of looking at developments and change in practice to reflect the latest evidence-based research. Barriers to implementation can include organisational constraints, such as a lack of time, obstructive opinions of key people who may not agree with the evidence or do not want to change their practice, and lack of leadership to effect change. Additionally, there may be a perceived poor sense of competence by staff who question their skills.

In order for change to be effective there must be an identified need, a willingness to adapt and promote current practices, a driving force behind it and acceptance from all levels, be it individual, team or organisational. For these guidelines to be successfully implemented, the following is recommended.

High-level support and clear leadership

Successful implementation plans have a person on the board, such as a medical director, who drives the implementation agenda forward as well as a clear implementation policy approved at the highest level.

A nominated lead for the organisation

One person should be identified who is responsible for driving the education and development of these guidelines into practice. They should be involved in coordinating, disseminating and monitoring the implementation as well as for arranging educational events to promote the use of these guidelines in the workplace. The responsibility for this could be included into an existing role such as that of the clinical governance manager or anyone involved in quality assurance.

A multidisciplinary forum

The multidisciplinary forum should have decision-making powers and report to the chief executive or senior managers of the organisation. New guidelines should be reviewed after they are published and their relevance to the organisation assessed. A clinical lead for each guideline should be identified and steps taken to disseminate to the appropriate personnel. Implementation is most effective if a wide range of disciplines are involved in the forum.

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A local policy

Organisations should have a clear, structured policy in place for implementing new guidelines. This policy should be endorsed by the highest level of management and be available for all.

What can you do as an individual?

Become a project champion. One way to begin implementation in your workplace is to take the initiative and volunteer to represent your department. Review these guidelines and compare them with the current ones you have in place. Note any changes to practice that need to be addressed in order to standardise your organisation with current best practice.

In staff meetings, bring up the idea of implementation and seek feedback from other staff members on the best way to do this. Collaborate with colleagues across all boards and emphasise the importance of team communication and cohesion. Print handouts, send out links to workmates and arrange for flowchart posters to be placed in relevant areas.

If you have a clinical educator at your site, inform them of the current updates and discuss ways they can influence training and provide moulage-based simulation scenarios. Often training with the staff you work with on a regular basis can help to foster communication and a real sense of teamwork.

Speak with your organisation about placing access to the Victorian trauma guidelines on your intranet to allow easy access to the site.

Visit <www.trauma.reach.vic.gov.au>, which will be updated regularly and provide you with access to online learning modules and scheduled moderated remote tutorials.

As always, your feedback is encouraged. If you have any comments or suggestions, or would like to share how you have adopted these guidelines into your practice, we would appreciate your thoughts.

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Appendix 1: Burn depth characteristics

Used with permission from: http://www.vicburns.org.au/downloadable-posters.html

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Appendix 2: Rule of nine (adult)

Used with permission from: http://www.vicburns.org.au/downloadable-posters.html

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Appendix 3: Victorian state burns service transfer criteria

Used with permission from: http://www.vicburns.org.au/downloadable-posters.html

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Trauma Victoria

The Victorian State Trauma System (VSTS) facilitates the management and treatment of major trauma patients in Victoria. The VSTS aims to reduce preventable death and permanent disability and improve patient outcomes by matching the needs of injured patients to an appropriate level of treatment in a safe and timely manner.

The system works to have the right patient delivered to the right hospital in the shortest time.

One of the best ways to facilitate this is to provide an education resource to all clinicians.

Trauma Victoria is a statewide education initiative directed towards clinical staff (doctors, nurses, allied health, paramedics) who provide early patient care for major trauma outside of a MTS.

Guidelines are in place to support awareness of key aspects of the trauma system and early trauma care and include specialist trauma transfer guidelines.

A web-based learning management system provides modules to support each of the principle guideline areas. Skills tutorials on key trauma procedural interventions will also be accessible.

Moderated remote tutorials will be offered in the future. Clinicians will join a multisite, multiparty videoconferenced meeting room for tutorials and discussions on relevant trauma subjects. It will allow local practitioners to tap into specialised clinical knowledge and to develop their learning to the fullest extent.

Regional simulation and team training will also be supported via a remote expert facilitator and will involve regional and subregional simulation trainers. It will build capacity among simulation trainers to enhance local trauma team training programs.

Facilitated visits will also be arranged whereby medical, nursing and allied health staff may be placed for brief rotations with a MTS in order to increase their experience and familiarity in major trauma management. The aim is also to promote the development of clinical relationships between organisations.

Created by Adult Retrieval Victoria on behalf of the Victorian State Trauma System.

To receive this document in an accessible format phone Acute Programs on 9096 7741.

Authorised and published by the Victorian Government, 50 Lonsdale St, Melbourne.

© Department of Health, June 2014

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AGREE II score sheet – Burns guideline

Domain Item

AGREE II Rating

1: Strongly Disagree

7: Strongly

Agree

1 2 3 4 5 6 7

Scope and purpose

The overall objective(s) of the guideline is (are) specifically described.

X

The health question(s) covered by the guideline is (are) specifically described.

X

The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described.

X

Stakeholder involvement

The guideline development group includes individuals from all the relevant professional groups.

X

The views and preferences of the target population (patients, public, etc.) have been sought.

X

The target users of the guideline are clearly defined.

X

Rigor of development

Systematic methods were used to search for evidence.

X

The criteria for selecting the evidence are clearly described.

X

The strengths and limitations of the body of evidence are clearly described.

X

The methods for formulating the recommendations are clearly described.

X

The health benefits, side effects and risks have been considered in formulating the recommendations.

X

There is an explicit link between the recommendations and the supporting evidence.

X

The guideline has been externally reviewed by experts prior to its publication.

X

A procedure for updating the guideline is provided.

X

Clarity of presentation

The recommendations are specific and unambiguous.

X

The different options for management of the condition or health issue are clearly presented.

X

Key recommendations are easily identifiable.

X

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Domain Item

AGREE II Rating

1: Strongly Disagree

7: Strongly

Agree

1 2 3 4 5 6 7

Applicability The guideline describes facilitators and barriers to its application.

X

The guideline provides advice and/or tools on how the recommendations can be put into practice.

X

The potential resource implications of applying the recommendations have been considered.

X

The guideline presents monitoring and/or auditing criteria.

X

Editorial independence

The views of the funding body have not influenced the content of the guideline.

X

Competing interests of guideline development group members have been recorded and addressed.

X

Overall Guideline Assessment

Rate the overall quality of this guideline.

1- Lowest possible quality 7- Highest possible quality

X

Overall Guideline Assessment

I would recommend this guideline for use. Yes Yes, with modifications

No

X

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References

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th edition. Feb 2011.

Australian and New Zealand Burn Association. iii Australia. AS/NZS3000:2010 Australian/New Zealand Wiring Rules. Electricity Safety(Installations)

Regulations 2009. S.R. No. 164/2009. iv Rowley-Conwy G (2013) Management of major burns in the emergency department. Nursing

Standard. 27,33,62-68. v Ministry of Defence. Clinical guidelines for operation. Joint Services Publication 999. Change 3 - Sept

2012. p41. Available at: https://www.gov.uk/government/publications/jsp-999-clinical-guidelines-for-operations [Accessed April 4 2014]. vi American College of Surgeons. Advanced Trauma Life Support. 9

th Edition. American college of

Surgeons committee on Trauma. 2012, Chicago. vii

Gumm K. Major trauma initial assessment and management. In: Curtis K, Ramsden, C, Lord, B. Emergency and Trauma Care for nurses and paramedics. Sydney. Elsevier. 2011. p. 1160. viii

Lee C, Porter K. The pre hospital management of pelvic fractures. Emerg Med J. Feb 2007; 24(2): 130–133. ix Government of South Australia. SA Health. Available at: http://www.sahealth.sa.gov.au/ wps/

wcm/connect/public+content/sa+health+internet/clinical+resources/safety+and+quality/clinical+handover/isbar+-+identify+situation+background+assessment+and+recommendation. [Accessed April 2 2014]. x Latenser, B. Critical care of the burn patient: The first 48 hours. Crit Care Med. 2009; 37(10):2819-

2826. xi Ambulance Victoria 2013. Clinical Practice Guidelines for Ambulance and MICA Paramedics. 2014

Edition: Melbourne, Ambulance Victoria. xii

Pham T, Leopoldo C, Gibram N. American Burn Association Practice Guidelines Burn Shock Resuscitation. Journal of Burn Care and Research 2008 (29) p 257-266. xiii

Nishijima D, Simel D, Wisner D, Holmes J. Does this patient have a blunt intra -abdominal injury? JAMA, 2012 April 11, Vol. 307, No. 14 1517. xiv

Avni T, Levcovich A, Ad-El D, Leibovici L, Paul M. Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ. 2010.340:c241.doi:10.1136/bmj.c241.