Clinical Practice

Guidelines
BURN WOUND MANAGEMENT
FIRST WRITTEN 24/08/2006
REVISED 20/08/2008

NSW Severe Burn Injury Service Website: http://www.health.nsw.gov.au/gmct/burninjury

Concord Repatriation General Hospital Royal North Shore Hospital The Children’s Hospital at Westmead
Hospital Rd, Concord 9767 5000 Pacific Hwy, St Leonards 9926 7111 Hawkesbury Rd, Westmead 9845 000

Page 1 of 63
 Contents:
Page Number
1. Contributors 3
2. Introduction 4
3. Definitions of Burns 5
4. Anatomy and Physiology of the Skin 6
Structure of Skin 6
5. Pathophysiology of Burn Injuries: Local and systemic 8
Injury Zones of the Burn Wound 8
Management of the Burn Wound - First Aid 9
Emergency Assessment and Management of Severe Burns 11
Surface Area Assessment 14
Pain Management 15
Initial Assessment of the Burn Wound Depth 17
Burn Skin Depth 17
Assessment Of The Burn Wound 18
Capillary Refill 18
Recognising Burns 19
6. On Presentation of Burn Patient to ED - Flowchart 21
7. Burns Unit Admission Criteria 22
8. Burn Wound Management 23
Burn Wound Healing: Concepts & Principles 23
Cleansing and Debriding Burn Wound 24
Minor Burn Management (see link) 25
Digital Photograph of Burn Wound 26
Selecting an Appropriate Dressing 27
Wound Care Product Selection 28
- Silver 28
- Gauze (moist) 30
- Film & Hydrocolloid 31
- Foam 32
- Absorbent 33
- Skin Substitute 34
- Silicone 35
- Other Dressings 36
- Moisturiser 37
- Retention/Fixation 38
- Suppliers 38
Dressing Procedure 39
- Dressing Specialised Areas 39
Specific Dressing Application 41
- Omiderm 41
- Acticoat 41
- Mepilex 41
- Bactigras 42
- Aquacel Ag 42
8.9 Dressing Fixation Application 43
- Coban 43
- Hypafix/Mefix/Fixamul 43
9. Skin Grafting Management 44
Harvesting Donor Skin 45
Debriding Graft Site 46
Skin Graft Management in OT 48

Page 2 of 63
 10. Donor Site Management 50
Harvesting Donor Skin in OT 52
Donor Site Management in OT 54
Initial Inspection 55
Dressing Removal 56
11. The Multidisciplinary Team 57
12. References 58
13. Websites 59

Page 3 of 63
 Contributors:

Siobhan Connolly Burn Prevention/Education Officer

NSW Severe Burn Injury Service

Megan Brady Clinical Nurse Specialist (CNS) – Burns

Concord Repatriation General Hospital

Peter Campbell Clinical Nurse Consultant (CNC) – Burns/Plastics

Royal North Shore Hospital

Jan Darke Clinical Nurse Consultant (CNC) – Burns/Plastics

Royal North Shore Hospital

Diane Elfleet Nurse Unit Manager (NUM) – Burns/Plastics

Royal North Shore Hospital

Rae Johnson Clinical Nurse Consultant (CNC) – Burns

Concord Repatriation General Hospital

Nicole Klingstrom Clinical Nurse Educator – Burns

The Children’s Hospital at Westmead

Deborah Maze Nursing Clinical Coordinator – Burns

The Children’s Hospital at Westmead

Chris Parker Nurse Unit Manager (NUM) – Burns/Plastics

Concord Repatriation General Hospital

Dorothy Roberts Clinical Nurse Specialist (CNS) – Burns

Concord Repatriation General Hospital

Sue Taggart Clinical Nurse Consultant (CNC) - Burns Support / ICU

Concord Repatriation General Hospital

Kelly Waddell Transitional Nurse Practitioner - Burns

The Children’s Hospital at Westmead

Anne Darton Program Manager

NSW Severe Burn Injury Service

Prof Peter Maitz Burn and Reconstructive Surgeon

Concord Repatriation General Hospital

Members of the Multidisciplinary Team of the NSW Severe Burn Injury Service (from Royal
North Shore Hospital, Concord Repatriation General Hospital and The Children’s Hospital at
Westmead)

Page 4 of 63
 Introduction

The following guidelines were developed by specialist staff working within the NSW Severe Burn
Injury Service (SBIS) from the tertiary Burns Units at The Children’s Hospital at Westmead,
Royal North Shore Hospital and Concord Repatriation General Hospital. They were designed for
use by staff working in these Burn Units to guide practice, not to replace clinical judgement.

Burn Units provide specialist, multidisciplinary care in the management of burn injuries due to the
continued reinforcement of treatment modalities, which is not readily available in outlying areas.
Burn care involves high expense for wound management materials, staffing, equipment and long
term scar management products. There are generally also long term issues arising from the initial
trauma, resultant scars and the ongoing effects these have on the patient and their family.

It is acknowledged that primary care or follow up management of burn injuries may occur outside
of specialist units, particularly for patients with a minor burn. These guidelines are designed as a
practical guide to complement relevant clinical knowledge and the care and management
techniques required for effective patient management. Clinicians working outside a specialist burn
unit are encouraged to liaise closely with their colleagues within the specialist units for advice and
support in burn patient management.

Due to the dynamic nature of burn wounds and the large number of available wound management
products it is not possible to state emphatically which product is superior for each wound, however
suggestions of possible dressings for different wound types are included in this document, along
with application advice.

This document will be reviewed on a yearly basis at present, and updated as required with current
information at that time.

Page 5 of 63
Burn Injury Definitions
A burn injury is defined as damage to the skin caused by heat, radiation, friction or chemicals. The
injuries sustained are generally classified as:

• Chemical – direct contact with chemicals

• Contact – direct contact with hot objects
• Electrical – direct contact with an electrical current
• Flame – direct contact with open flame or fire
• Flash – exposure to the energy produced by explosive material
• Friction – rapid movement of a surface against the skin eg treadmill, MBA, etc
• Radiation – exposure to solar energy, radiotherapy, laser or IPL
• Radiant Heat – heat radiating from heaters, open fire places, etc
• Scald – hot liquids such as hot water and steam, hot fats, oils and foods

Page 6 of 63
 Anatomy and Physiology of the Skin
The skin, also referred to as the Integumentary System, is the largest organ of the body, with a
surface area of 1-2 metres. It is also the heaviest organ of the body; average adults have 4-7 kg of
skind.

The functions of the skin include:

o Temperature regulation
o Sensory interface
o Immune response
o Protection from bacterial invasion
o Control of fluid loss
o Metabolic function
o Psycho-social function

Structure of Skin

Skin structure consists of several layers, the uppermost being the epidermis and dermis, beneath
which are the subcutaneous fat, muscle and skeletal layers. The epidermis is the first barrier for
protection of foreign substance invasion. Keratinocytes are the principle cells of the epidermis,
gradually migrating to the surface and sloughed off in ‘desquamation’c. In the epidermis keratin is
flexible, but is thicker, stiffer and harder in the finger and toe nails. Hair is also made up of
keratind.

Page 7 of 63
The epidermis is comprised of five layersb,c
o stratum corneum
o stratum lucidium
o stratum granulosum
o stratum spinosum
o stratum germinativum

The dermis controls thermoregulation and supports the vascular network. Hair follicles, nerve
fibres, sweat glands and nails are located in the dermis layer and protrude through the epidermis 12.
The dermis contains mostly fibroblasts which secrete collagen and elastin. Immune cells defend
against foreign substances that have come through the epidermis.

The dermis consists of two layersc

o papillary dermis
o reticular layer

The subcutaneous fat cells insulate the body against the cold. When the body overheats the small
blood vessels carry warm blood near the surface for cooling.

Alterations to the skin affect the overall wellbeing of the individual.

Page 8 of 63
 Pathophysiology of Burn Injuries: Local and Systemic
Injury Zones of the Burn Wound9

Jackson Burn Wound Model

Epidermis
Zone of Coagulation
(Necrosis)
Dermis

Zone of Stasis
(Damage) Subcutaneous
Layer
Zone of Hyperaemia
(Survival)

• Burns consist of three zones of damage: the zone of coagulation, the zone of stasis and the
zone of hyperaemia.9
• The zone of coagulation, or necrosis, is the central area of a burn injury where there is the
greatest amount of damage. First aid measures do not alter the extent of injury in this area.
• The zone of stasis, also referred to as the zone of ischaemia or damage, lies outside the zone
of coagulation. Adequate first aid measures can have a beneficial affect on this zone.
• The outer layer is the zone of hyperaemia, or survival. In burns greater than 20% TBSA the
whole body becomes the zone of hyperaemia. This zone does not generally have any long
term effects, usually resolving after seven to ten days.8,10

Page 9 of 63
 Pathophysiology of Burn Injuries: Local and Systemic
Management of the Burn Wound - First Aid

Aim:
• Stop the Burning Process
• Cool the Burn Wound

1. Stop the Burning Process

• Remove patient from the source of injury.
• If on fire STOP, DROP, COVER face & ROLL
• Remove hot, scalding or charred clothing.
• Avoid self harm during above steps.

2. Cool the Burn Wound

• Cool burn with cold running tap water for at least 20 minutes
• Ideal water temperature for cooling is 15°C, range 8°C to 25°C
• Cooling effective up to 3 hrs after injury
• Keep the remaining areas dry and warm to avoid hypothermia. If patient’s body temperature
falls below 35°C - stop cooling.
NB
o Ice should not be used as it causes vasoconstriction and hypothermia. Ice can also
cause burning when placed directly against the skin.
o Duration of running water should be at least 20 minutes unless other factors prevent
this (eg. large burn causing rapid heat loss, hypothermia, and multiple traumas).
o Wet towels / pads are not efficient at cooling the burn as they heat up quickly. They
should not be used unless there is no water readily available ie in transit to medical
care. If required use 2 moistened towels / pads and alternate at 2 minute intervals.
o Remove any jewellery or constrictive clothing as soon as possible.

3. Seek medical advice

• Dial “000” (Triple Zero) for any burn over 10% of the body for adults, 5% of the body for
children, or when there are assosciated trauma or concerns.
• Visit local doctor if burn larger than 20c piece with blisters, or if any concerns about burns.

Plastic cling wrap is an appropriate simple dressing for transfering patients with burn
injuries to a specialist burns unit. It protects against colonisation and excess fluid and heat
loss.

4. On arrival at Hospital
• Place the person on a clean dry sheet and keep them warm.
• Keep the burn covered with plastic cling wrap or a clean sheet when not being assessed.
• Elevate burnt limbs.
• Small burns may require continuous application of water to reduce pain (eg spray pack).
• Chemical burns require copious amounts of water, and prolonged period of irrigation. A
shower is preferable. Identify the chemical involved. If the chemical is a powder first brush
off excess, then irrigate.
• Eye burns require an eye stream (saline) or an IV bag of saline attached to a giving set and
placed over the open eye to flush it adequately

NB The application of timely and effective first aid measures such as cold running water for 20
minutes given within the first three hours after injury can have a beneficial affect on the zone

Page 10 of 63
 of stasis by stopping the burning process and assisting in cell survival (see below).
Conversely the lack of effective first aid can lead to an increased chance of further tissue
necrosis as the zone of stasis can progress to coagulation.

Effectiveness of First Aid

With First Aid No First Aid

Outcomes: The burning process is stopped and the burn wound is cooled.

For further information see NSW Severe Burn Injury Service Transfer Guidelines12
http://www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_012.pdf

Page 11 of 63
 Pathophysiology of Burn Injuries: Local and Systemic
Emergency Assessment and Management of Severe Burns1

Aim:
Immediate life threatening conditions are identified and emergency management commenced.

Primary Survey
A. Airway maintenance with cervical spine control
• Inspect the airway for foreign material/oedema. If the patient is unable to respond to verbal
commands open the airway with a chin lift and jaw thrust; stabilize neck for suspected C
Spine injury.
• Keep movement of the cervical spine to a minimum and never hyperflex or hyperextend the
head or neck.
• Insert Guedells airway if airway patency is compromised. Think about early intubation.

B. Breathing and Ventilation

• Expose the chest and ensure that chest expansion is adequate and bilaterally equal – beware
circumferential deep dermal or full thickness chest burns – is escharotomy required?
• Administer 100% oxygen.
• Ventilate via a bag and mask or intubate the patient if necessary.
• Examine for carbon monoxide poisoning – non burnt skin may by cherry pink in colour in a
non-breathing patient
• Monitor respiratory rate – beware if rate <10 or > 20 per minute.

C. Circulation with Haemorrhage Control

• Monitor the peripheral pulse for rate, strength (strong, weak) and rhythm,
• Apply capillary blanching test (centrally and peripherally to burnt and non-burnt areas) –
normal return is two seconds. Longer indicates hypovolaemia or need for escharotomy on
that limb; check another limb.
• Inspect for any obvious bleeding – stop with direct pressure.

D. Disability: Neurological Status

• Establish level of consciousness:
A - Alert
V - Response to Vocal stimuli
P - Responds to Painful stimuli
U - Unresponsive
• Examine pupil response to light for briskness and equality.
• Be alert for restlessness and decreased levels of consciousness – hypoxaemia, shock, alcohol,
drugs and analgesia influence levels of consciousness.

E. Exposure with Environmental Control

• Remove all clothing and jewellery.
• Keep patient warm
• Roll and remove wet sheets and examine posterior surfaces for burns and other injuries.

Page 12 of 63
F. Fluids Resuscitation
• Fluid Resuscitation will be required for a patient that has sustained a burn >10% for children,
>15% for adults.
• Estimate burn area using Rule of Nines. For smaller burns the palmar surface (including
fingers) of the patient’s hand (represent 1% TBSA) can be used to calculate the %TBSA
burnt.
• Insert 2 large bore, peripheral IV lines preferably through unburned tissue.
• Collect bloods simultaneously for essential base line bloods - FBC/EUC/ LFT. /Group &
hold/Coags. Others to consider – Drug/alcohol screen/Amylase/Carboxyhaemoglobin
• Obtain patients body weight in kgs.
• Commence resuscitation fluids, IV Hartmann’s at an initial rate of the Parkland Formula but
adjust according to urine output:

4mls x kgs x % TBSA burnt = IV fluid mls to be given in 24hrs following the injury
Give ½ of this fluid in the first 8hrs from the time of injury
Give a ½ of this fluid in the following 16hrs

• Children less than 30kg require maintenance fluids in addition to resuscitation fluids.
• Insert an IDC for all burns >15% and attach hourly urine bag. IV Hartmann’s is adjusted
each hour according to the previous hour’s urine output.
REMEMBER: The infusion rate is guided by the urine output, not by formula.

The urine output should be maintained at a rate

Adult 0.5 – 1 ml / kg / hr
Children 0.5 – 2ml / kg / hr – * aim for 1 ml/kg/hr*

• If urine output <0.5mls/kg/hr increase IV fluids by 1/3 of current IV fluid amount. If urine
output >1ml/hr for adults or >2ml/kg/hr for children decrease IV fluids by 1/3 of current IV
fluid amount (see fluid balance chart on following page).

Eg: Last hrs urine = 20mls, received 1200mls/hr, increase IV to 1600mls/hr

Last hrs urine = 100mls, received 1600mls/hr, decrease IV to 1065mls.
• More IV fluids are required:
1. When pigmenturia (dark red, black urine) is evident. Pigmenturia occurs when the
person has endured thermal damage to muscle eg electrical injury. Mannitol may be
ordered if pigmenturia evident.
2. Inhalation Injury.
3. Delayed resuscitation.
• ECG, pulse, blood pressure, respiratory rate, pulse oximetry or arterial blood gas analysis as
appropriate.

Nutrition
• Insert nasogastric/ nasoduodenal tube for larger burns (>20% TBSA in adults; >15% TBSA
in children) or if associated injuries. See SBIS Nutrition & Dietetics Guidelines.

Pain Relief
• Give morphine (or other appropriate analgesia) slowly, intravenously and in small
increments according to pain score and sedation scale (see Page 18).

Page 13 of 63
Secondary Survey

History
A - Allergies
M - Medications
P - Past Illnesses
L - Last Meal
E - Events/Environment related to injury

Mechanism of Injury
Burn
• Gather information from the patient or others the following:
o Date and time of burn injury, date and time of first presentation.
o Source of injury and length of contact time.
o Clothing worn.
o Activities at time of burn injury.
o Adequacy of first aid.

Head to Toe Assessment

• Record and document
• Swab all burn wounds and send to microbiology.
• Reassess A, B, C, D, E, and F.

Circulation:
If the patient has a circumferential full thickness burn it will impede circulation and or ventilation
(if burn around chest).
• Contact the Burns Registrar at a specialist burns unit.
• Elevate the effected limb above the heart line.
• Commence a circulation chart.
• Escharotomy may be necessary to relieve pressure if circulation is compromised.

Psychosocial Care
• Document next of kin and telephone number.
• Inform and provide support to family.
• Obtain relevant psychosocial information during assessment and document.
• Contact relevant Social Worker, Psychologist or Psychiatrist

Re-evaluate
• Give tetanus prophylaxis if required
• Note urine colour for pigmenturia
• Laboratory investigations:
o Haemoglobin/haematocrit
o Urea/creatinine
o Electrolytes
o Urine microscopy
o Arterial blood gases
o Electrocardiogram

Page 14 of 63
 Pathophysiology of Burn Injuries: Local and Systemic
Surface Area Assessment

Rule of Nines a

Adult

Child

For every year of life after 12 months take

1% from the head and add ½% to each leg,
until the age of 10 years when adult proportions

Palmar Method

• Palm and fingers of the

patient = 1% TBSA
• Useful for small and
scattered burns
• Can be used for
subtraction e.g. full arm
burnt except for hand-
sized area = 8% TBSA

Page 15 of 63
 Pathophysiology of Burn Injuries: Local and Systemic

Pain Management

Aim:
• To reduce pain levels that are unacceptable to the patient
• To minimise the risk of excessive or inadequate analgesia

Assessment
• How much pain does the patient have? Utilise the Visual Analogue Scale (VAS) at regular
intervals every 3-5 minutes, document.
• How much analgesia has the patient been given prior to arrival?
• Ask the patient if they use illicit drugs and alcohol.
• Weigh patient so that analgesic amounts are adequate.

Acute Management
• Give small increments of IV narcotic. A standard stat dose of IV morphine is 2.5 - 10 mg for
adults and 0.1 - 0.2 mg/kg of body weight for children.
• The dose should be titrated against the patient’s response, including the respiratory rate.
• A narcotic infusion can be commenced once the initial treatments have stabilised the patient.
• Burn procedures may require analgesia beforehand allowing time for it to take effect. The
drug of choice is determined on an individual basis and may include an opiate such as
morphine, with paracetamol. Oral midazolam may also be used for its dissociative,
anxiolytic and sedative qualities. Antihistamines can be useful in patients where there is
excessive itch, but should not be used in conjunction with midazolam. Inhaled nitrous oxide
mixture is often used during dressing removal, and reapplication in some cases (see
protocol).
• Tapes, music and overhead pictures are useful diversional/distraction techniques. For
children a play therapist can also assist with procedures. Provision of diversion/distraction
therapy helps decrease pain and anxiety.
• Anti-emetics may be necessary when narcotics are given.
• Aperients to be administered when narcotics given to avoid constipation.
• Oral analgesia may be administered to patients with minor burns.
• Follow general hospital/institutional Pain Management Guidelines.

The 3 Stages of Pain Relief7,16

1. Background
a. Pain experienced, when at rest, in burned areas and treatment areas, e.g. donor site.
b. Constant and dull in nature.
c. Best treated with constant serum opioid levels, e.g. acute phase, continuous narcotic
infusion or slow released oral opioid as pain levels decrease.
2. Breakthrough
a. Rapid onset of pain and often short in duration.
b. Occurs whilst attending to simple activities such as walking or changing position in
bed.
c. Relieved by quick release oral opioids and for patients with IV access, PCA or
bolus doses.
3. Procedural Pain
a. High levels of intense pain for duration of procedure, e.g. wound dressing changes
and physiotherapy.
b. Requires higher more potent doses of opioid administration.

Page 16 of 63
 c. Can also utilise adjuncts such as diversion/distraction (see above)

Special Considerations:
Narcotic IMI’s should not be administered as peripheral shut down occurs in burns > 10%.
Absorption of the drug will not take place so pain relief will not be achieved. As circulation
improves an overdose of the opiate may occur.

Outcome: Pain is kept at an acceptable level

For further information see NSW Severe Burn Injury Service Transfer Guidelines12
http://www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_012.pdf

Page 17 of 63
 Pathophysiology of Burn Injuries: Local and Systemic
Initial Assessment of the Burn Wound Depth

Aim:
• To determine the depth of the burn wound.
• Epidermal, superficial dermal (superficial partial), mid-dermal (partial), deep dermal/(deep
partial), and full thickness are terms to describe the depth of burn injury.

To determine the depth of the injury several aspects should be investigated

• Clinical examination of the burn, including capillary refill
• Source and mechanism of the injury, including heat level, chemical concentration, and
contact time with source.
• First aid. Prompt first aid will reduce further destruction of the zone of stasis.
• Age of the patient
• Pre existing disease or medical condition

Burn Skin Depth

Epidermal
Superficial Dermal

Mid Dermal

Deep Dermal

Full Thickness

Assessment of The Burn Wound

http://www.skinhealing.com/2_2_skinburnsscars.shtml

Page 18 of 63
 Assessment of the Burn Wound

Depth Colour Blisters Capillary Refill Healing Scarring

Epidermal Red No Brisk Within 7 days None

1-2 sec
Superficial Dermal Red / Pale Pink Small Brisk Within 14 days None
(Superficial Partial) 1-2 sec Slight colour
mismatch
Mid-Dermal Dark Pink Present Sluggish 2-3 weeks Yes
(Partial) >2 sec Grafting may be (if healing >3wks)
required
Deep Dermal Blotchy Red / White +/- Sluggish Grafting required Yes
(Deep Partial) >2 sec /
Absent
Full Thickness White / Brown / Black No Absent Grafting required Yes
(charred) / Deep Red
Sources: Modified from EMSB Course Manual, p461; Partial Thickness Burns – Current Concepts as to Pathogenesis and Treatment, p21. (Jan Darke CNC RNSH)

Capillary Refill
Pictures by Rae Johnson CNC CRGH

If there is a blister lift small area of skin. Apply pressure to wound bed and observe for capillary refill, replace skin as
biological dressing if acceptable refill time.

Page 19 of 63
 Pathophysiology of Burn Injuries: Local and Systemic
Recognising Burn Depths

Epidermal Burn Superficial Dermal Burn Mid Dermal Burn

(Superficial Partial Thickness) (Mid Partial Thickness)

• Faint erythema not • Blanch to pressure • Heterogeneous, variable

included in % TBSA • Should heal within 7-10 depths
• Heal spontaneously days with minimal • Should heal within 14 days
within 3-7 days with dressing requirements • Deeper areas may need
protective dressing surgical intervention

Deep Dermal Burn Full Thickness Burn

(Deep Partial Thickness)

• Heterogeneous, • Outer skin, and some underlying tissue dead

variable depths • Present as white, brown, black
• Generally need • Surgical intervention and long-term scar management
surgical intervention required
• Refer to specialist unit • Refer to specialist unit

Page 20 of 63
• The wound appearance will change over a period of time, especially during the first 7 days
following injury.

This patient suffered a scald burn. Notice the changing appearance of the wound over just a few
days.

Day1 Day 2 Day 5

Page 21 of 63
 On Presentation of Burn Patient to ED

Perform Primary & Secondary

Surveys

Obtain Clear History of Burn Injury

• Mechanism of Injury, How and When burnt
• Any First Aid (what, how long?). Continue
cooling if within 3 hours of burn
• Were clothes removed?

Give Appropriate Pain Relief

Assess % TBSA (total body surface area)

using Rule of Nines

Does it meet referral criteria?

• Partial/full thickness burns in adults >10% TBSA.
• Partial/full thickness burns in children >5% TBSA.
• Any priority areas are involved, i.e. face/neck, hands, feet,
perineum, genitalia and major joints.
• Caused by chemical or electricity, including lightning.
• Any circumferential burn.
• Burns with concomitant trauma or pre-existing medical condition.
• Burns with associated inhalation injury.
• Suspected non-accidental injury.
• Pregnancy with cutaneous burns.

YES NO

Refer to appropriate Burn Unit: Minor Burn:

• Royal North Shore Hospital
Ph: (02) 9926 8940 (Burn Unit)
Ph: (02) 9926 7988 (Ambulatory Care)
• Concord Repatriation General Hospital
Ph: (02) 9767 7776 (Burn Unit)
Ph: (02) 9767 7775 (Ambulatory Care)
• The Children’s Hospital at Westmead
(all paediatrics <16yrs)
Ph: (02) 9845 1114 (Burn Unit)
Ph: (02) 9845 1850 (Ambulatory Care)
Can be managed in outlying hospitals
and clinics, (see Minor Burn
Management booklet)
• Assess burn wound
• Apply appropriate dressing
• Arrange follow-up dressing and
review
• Prescribe pain relief as required
• Contact Burn Unit for any
questions or for further review

Page 22 of 63
 Burns Unit Admission Criteria
DEFINITIONS

1. Severe burns

These are burns, which require referral to a specialised tertiary burns unit (see SBIS Transfer
Guidelines12). These units include adults units at Royal North Shore Hospital and Concord
Repatriation General Hospital, and the paediatric unit at The Children’s Hospital at Westmead.

A burn is classified as severe if:

a. it involves partial/full thickness burns in adults >10% TBSA (total body surface area).
b. it involves partial/full thickness burns in children >5% TBSA.
c. any priority areas are involved, i.e. face/neck, hands, feet, perineum, genitalia and major
joints.
d. it is caused by chemical or electricity, including lightning.
e. the burn is circumferential.
f. there are burns with concomitant trauma or pre-existing medical condition.
g. there are burns with associated inhalation injury.
h. the injury is suspected to be non-accidental.
i. there is pregnancy with cutaneous burns.

Acute period - first 24-48 hours - may be longer in severe burns.

NSW Burn Units will admit patients who address the criteria for a major burn. They will also
admit patients who have major skin loss due to trauma or disease, or require post burn
reconstructive surgery. Additionally Burns Units will admit patients requiring pain management,
physical or psychosocial support.

Special Considerations:

• Burn Unit staff are available for consultation on any burn patient as required. See Page 24
for digital photograph information
• If the patient requires admission, Emergency Department staff must liaise with Burns Unit
staff prior to sending the patient to the unit.
• Patients with respiratory involvement and/or large %TBSA are generally nursed in Intensive
Care until they can be cared for in the ward setting.
• Child Protection Unit (CPU) involvement required for all suspected non-accidental injuries
in children. Psychiatry involvement required for adult suspected non-accidental injuries.

2. Minor Burns

A minor burn does not meet any of the above criteria for referral to specialist burn unit and there
are no adverse physical or social circumstances to outpatient management.

These are burns which can be managed in outlying hospitals/medical centres, or via the ambulatory
care units within the referral hospitals named above. It is recommended that there is at least some
discussion with burn unit to aid planning for appropriate management

For further information see NSW Severe Burn Injury Service Transfer Guidelines12
http://www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_012.pdf

Page 23 of 63
 Burn Wound Management
Burn Wound Healing Principles and Concepts

Principles
To promote wound healing and ease patient discomfort observe the following principles:
• Ensure adequate perfusion
• Minimise bacterial contamination
• Minimize negative effects of inflammation
• Provide optimal wound environment
• Promote adequate nutrition and fluid management
• Provide adequate pain management
• Promoting re-epithelialisation
• Provide pressure management

Concepts
To ensure the above principles are observed utilise the following concepts for burn wound
management:
• Cleansing – wound surface should be free of slough, exudate, haematoma and creams
• Debridement – removal of loose, devitalised tissue and non-surgical removal of eschar
• Dressing
o choose appropriate primary dressing to maintain optimal moisture level and
promote wound healing
o Exudate management - appropriate absorbency level of dressing must be considered
on application
o consider pain and trauma on dressing removal, consider long-term dressing
wherever possible, aim for prevention of trauma on dressing removal
o application - protect against alteration to distal perfusion due to constrictive
dressings, protect against wound bed colonisation
• Pressure – to minimise the effects of scarring

Page 24 of 63
 Burn Patient Dressing Decision-Making Tree

Patient with Burns

Adequate First Aid

Yes No

Mechanism – Mechanism –
flame, electrical, flame, electrical,
hot oil. hot oil
Or extended Or extended
exposure to heat exposure to heat
source? source?

No Yes No Yes

Capillary refill
<2 secs?
Probable Probable
superficial burn. deeper burn.
Dress with film, Dress with
silicone or Yes No silver or
hydrocolloid antimicrobial
dressing and dressing and
review in 7-10 review in 3
days days

Page 25 of 63
 Burn Wound Management
Cleansing and Debriding the Burn Wound

Aim:
• Remove exudate and creams
• Debride devitalised and loose tissue
• Prevent damaging the healing burn wound.
• Minimise bacterial contamination
• Minimise psychological trauma to all concerned.
• Reassess the wound

1. Pain Management
• Adequate analgesia (refer to pain management guidelines)
• For specific pharmacological and non pharmacological pain management strateges see page
15. Older children and adult patients are involved, wherever possible, in the procedure as this
gives them a sense of control.

2. Preparation
• The patient should be given adequate explanation of the procedure.
• Prepare environment and equipment eg warm environment. The patient with an acute burn
wound should be washed and dried within 30 minutes or less, if possible. Longer sessions
may cause heat loss, pain, stress and sodium loss (water is hypotonic). Keep the bathroom
well heated.

3. Cleansing
• The wound is cleansed gently to remove loose devitalised tissue, exudate and old dressings
or creams.
• Wash with soft combines or sterile handtowels (Daylees) in diluted approved solution such
as Chlorhexidine Gluconate (diluted in water 1:2000), or pre-impregnated Chlorhexidine
sponges or saline. Use cloth for unburnt parts of the body to maintain hygiene.
• Dry the patient well, as moisture left behind may macerate the burn and provide an ideal
environment for bacterial contamination.

4. Exudate Management13
• There will be high exudate from the wound in the first 72hrs post injury
• Appropriate dressing will be required to manage exudate level
• Maintain optimal moisture balance
http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

Special Considerations
• Assess and monitor for possible hypersensitivity or allergic responses to products
• Burns to scalp and excessively hairy areas should be shaved to allow initial assessment and
ongoing wound management, thus preventing folliculitis. Ideally this should extend 2-5cm
past the boundary of the burn to ensure full visualisation and prevent hair impeding skin
regeneration.. The necessity for this procedure should be discussed with the patients as
sometimes religious beliefs preclude cutting of the hair under normal circumstances, and
may cause great distress if they do not understand the rationale.
• Burn wounds are an excellent medium for bacterial contamination, colonisation and localised
infection which may spread, resulting in systemic infection (reference – international wound
journal).

Page 26 of 63
• Prophylactic antibiotics are not routinely given to burn patients as they do not reduce the risk
of infection. Antibiotics are only given to patients with known infections and are
prescribed to sensitivities, consultation with Infectious Diseases is strongly
recommended.
• In the initial post-burn stage the patient may experience febrile periods. These do not
necessarily indicate infection, although they should be monitored. Febrile episodes are often
related to the release of large amounts of pyrogens resulting from the initial injury13

Flowchart displaying Exudate management sourced from

http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

Page 27 of 63
Flowchart displaying Exudate management sourced from
http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

Outcome: The burn wound is visibly clean.

Minor Burns
see Minor Burn Management document
http://www.health.nsw.gov.au/gmct/burninjury/docs/minor_burn_management.pdf

Page 28 of 63
 Burn Wound Management

Digital Photograph of the Burn Wound

Aim:
• Allow ease of communication between Burn Units and external hospitals or health care
facilities
• Assist with monitoring of wounds progress
• Minimises prolonged or multiple exposure of patients
• Reduces issue of infection control by reducing attending staff numbers

1. Preparation
• The patient should be given adequate explanation of the procedure and sign a consent prior
to any photographs being taken.
• Taking of photos should not delay the dressing procedure for extended periods due to the
risk of hypothermia and trauma to the patient.
• Turn off overhead heat light whilst taking photographs as they can lead to discolouration.
• Consider colouring. Dark skin on stark white background can give illusion of greater severity
of burn. Very pale skin on white background will not give enough contrast.
• Aim for neutral colour background such as green sterile sheet.

2. Procedure
• Patient should be made comfortable on clean dry sheet.
• Take a photo of the patient’s hospital sticker for identification.
• If patient has extensive burns take global photograph to show where burn occurs on body.
• For small burns lay a measure rule next to the wound to display wound size.
• Consider patient’s dignity especially if burns around perineum or genitalia. Use small cloth
to cover non-involved areas.

Tips:
° Take numerous pictures, with and without flash if necessary, extras can be deleted
when downloading.
° Label photos stating anatomical position and orientation

3. Storage
• To preserve confidentiality all images must be stored in a limited access area, such as
password protected.
• For ease of access to appropriate images each should be stored in an easily recognisable
pattern such as under medical record number and date taken.

4. Emailing pictures
It is possible to email digital photographs of burn wound to burn units. Contact must be made
between referring and accepting medical/nursing staff. Photographs must be taken in accordance
with above guidelines and must be accompanied by injury history and consent.

Outcome: The burn wound is photographed.

Page 29 of 63
 Burn Wound Management
Selecting an Appropriate Dressing
What Dressing Dressing Options Dressing Product Dressing Application
• Film (eg • Apply to moist wound bed
Omiderm) • Allow 2-5 cm overlap
• Silicone • Cover with absorbent secondary
• Vaseline dressing eg Lyofoam
Gauze • Review in 7-10 days, remove
• Silver secondary dressing
• Hydrocolloid • Leave intact until healed, trimming
edges as required
• Silicone (eg • Apply to clean wound bed
Mepilex Lite) • Cover with fixation/retention
• Film dressing
• Vaseline • Change 3-4 days depending on level
Gauze of exudate
• Silver
• Hydrocolloid

• Hydrocolloid • Apply to clean wound bed

(eg Comfeel) • Change 3-4 days depending on level
• Film of exudate
• Silicone
• Vaseline
Gauze
• Silver
• Vaseline • Apply directly to wound
Gauze (eg • 2 layers for acute wounds, 1 layer
Bactigras) for almost healed wounds
• Film • Cover with appropriate secondary
• Silicone dressing
• Silver • Change every 1-3 days
• Hydrocolloid

• Silver (eg • Wet Acticoat with H20; drain and

Acticoat) apply blue side down
• Vaseline • Insert irrigation system for Acticoat7
Gauze • Moistened secondary dressing to
• Hydrocolloid optimise desired moisture level
• Replace 3-4 days (Acticoat) or 7
days (Acticoat 7)
• Silver (eg • Apply generous amount to sterile
Silvazine) handtowel to ease application
• Vaseline • Cover with secondary dressing
Gauze • Not recommended for most burns
• Hydrocolloid due to changes to wound appearance
and frequency of required dressing
changes – daily

Page 30 of 63
 Burn Wound Management
Wound Care Product Selection

Aim: To choose the most suitable wound care product to reduce infection, promote wound healing, and minimize scarring.

SILVER
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Acticoat/Acticoat 7 • Broad spectrum • Partial to full thickness • Moisten Acticoat with H20; remove • Initial stinging on
• 2 layered/3 layered antimicrobial • Grafts & donor sites excess and apply blue side down application – provide
nanocrystalline Ag protection • Infected wounds • Moistened secondary dressing to prophylactic pain relief
coated mesh with inner • Decreases • Over Biobrane & optimise desired moisture level • Temporary skin staining
rayon layer. exudate Integra • Replace 3-4 days (Acticoat) or 7 • Maintain normothermia –
• Silver ions released with formation • TENS & SJS days (Acticoat 7) use warm blankets.
greater surface area + • Decreases eschar
increased solubility autolysis
AtraumanAg • Broad spectrum • Partial to full thickness • Apply directly to wound • Do not use with paraffin
• Coarsely woven water- antimicrobial • Grafts & donor sites • Cover with appropriate secondary dressing
repellent polyamide protection • Moderately infected dressing
textille coated with • Low cytotoxicity wounds • Leave intact up to 7 days,
metallic silver • TENS & SJS dependent on the wound
Aquacel Ag • Broad spectrum • Partial to deep partial • • Exudate level indicates
• Sodium antimicrobial thickness burn frequency of dressing
carboxymethycellulose
protection • Moderately exuding change
(CMC) & 1.2% ionic Ag
in fibrous material • Facilitates wound
• Silver ions released debridement • Moderate bacterial load
with greater surface • Decreases
area + increased exudate
solubility formation
• Absorbs exudate

Page 31 of 63
Silvazine (SSD) • Reduces infection • Partial to full thickness • Apply generous amount to sterile • Change daily, remove old
• Silver Sulphadiazine 1% • Enhances healing • Infected wounds handtowel to ease application cream
and Chlorhexidine • Apply to wound • Contraindicated during
Gluconate 0.2%. • Cover with secondary dressing first trimester of
pregnancy
Contreet H • Broad spectrum • Low to moderate • No secondary dressing • Not evaluated for
• Sodium antimicrobial exudating wounds • Change if leaking or when exudate pregnancy or on children.
carboxymethycellulose protection • Partial thickness burns is at edge of dressing. Consult with RMO prior
(CMC) & 1.2% ionic • Facillitates • Donor sites • Can remain intact up to 7 days. to application.
silver wafer debridement • Infected wounds. • Overlap dressing 1.5 cm from • To be removed if
• Silver ions released with • Decreases wound perimeter. radiation, ultrasonic,
greater surface area + exudate diathermy or microwaves
increased solubility formation treatment applied.
Contreet • Broad spectrum • Partial thickness burns • Overlap dressing so that that it is • Has not been evaluated
• Polyurethane Foam antimicrobial • Donor sites 2cm from edge of wound during pregnancy or on
wound dressing with protection • Highly exudating • Change if leaking or when exudate children. Consult with
silver. 1.2% ionic silver. • Absorbs exudate wounds is at edge of dressing. RMO prior to application.
• Silver ions released with • Decreases • Can remain intact 7 days • To be removed if
greater surface area + exudate • Retention dressing radiation, ultrasonic,
increased solubility formation diathermy or microwaves
treatment applied.

Wound Care Product Function Indications Application Note / Precautions

What? Why? When? How?
Flammcerium • Creates dry • Burns Specialist to • Apply to body pad or combine
inactive wound decide application. dressing then onto wound
• Decreases • Early application
NB Only to be used by burn
units under order by a bacterial load • Consult with RMO for
treating burn specialist repeat application at 48
hrs

Page 32 of 63
 GAUZE (moist)
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Bactigras • Non adherent antiseptic • Partial thickness • Apply directly to wound
• Chlorhexidine dressing wounds • 2 layers for acute wounds, 1
impregnated vas
layer for almost healed wounds
gauze
• Cover with appropriate
secondary dressing
• Change every 1-3 days
Jelonet, Adaptic, • Non adherent • Clean Partial thickness • As above
Curity conservative dressing wounds.
• Petrolatum/Vaseline
impregnated gauze
Xeroform • Non adherent • Partial thickness • Secondary dressing to optimise
• Mesh gauze wounds desired moisture level
impregnated with
• Light exudating wounds
3% Xeroform
(Bismuth
Tribomophophenate)

Page 33 of 63
FILM & HYDOCOLLOID
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Omiderm • Barrier to • Superficial to mid- • Apply to moist wound bed • Do not use if any
• Synthetic clear contaminants dermal burns. • Allow 2-5 cm overlap infection
hydrophilic • Allows moisture • SJS • Cover with absorbent secondary
non-adherent semi to be released • Donor sites dressing eg Lyofoam
permeable membrane. from the wound • Review after 7-10 days, remove
bed into an secondary dressing, trim from
absorbent outer healed areas.
dressing • Remains intact until healed
Tegaderm • Barrier to • Small isolated wounds • Apply directly to wound • Only use when
• Adhesive, conformable contaminants • Some blisters • No secondary dressing required surrounding tissue not
film dressing compromised
Comfeel • CMC combines • Devitalised tissue, • Allow 2cm margin around wound.
• Hydrocolloids contain with exudate to sloughy wounds • Can remain intact 2-3 days
carboxymethylcellulose aid autolysis of • Low to moderately • Wafers up to 5 days if no signs
(CMC). devitalised tissue. exudating wounds infection.
• Hydrocolloid wafer • Provides moist
• Hydrocolloid paste wound
environment
• Absorbs exudate.
Duoderm • Provides moist • Exudating wounds • Apply directly to area • Only use when
• Hydrocolloid wafer wound • Scars • No secondary dressing required surrounding tissue not
environment compromised
• Absorbs exudate.
• Assists scar
management in
healed wounds

Page 34 of 63
FOAM
Wound Care Product
What?
Lyofoam
• Two layer polyurethane
foam
Mepilex Transfer
• Hydrophilic polyurethane
foam with soft silicone
layer
Mepilex Lite
• Hydrophilic polyurethane
foam with soft silicone
layer and waterproof
outer layer
Mepilex Border
• Hydrophilic polyurethane
foam with soft silicone
layer and adhesive
external layer and border
Biatain
• Foam dressing
Allevyn
• Non-adherent
hydrocellular foam
Function Indications Application Note / Precautions
Why? When? How?
• Absorb exudate • Pads areas such as • Apply shiny side down, over • N/A
from wound bed behind ears to protect primary dressing
delicate tissues.
• Secondary dressing
over Omiderm
• Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
from wound bed dermal burns. • Cover with absorbent secondary wounds
and transfers to dressing
outer dressing
• Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
from wound bed dermal burns. • Cover with fixation/retention wounds
dressing
• Absorb exudate • Superficial to mid- • Apply to clean wound bed • Avoid use on infected
from wound bed dermal burns. • No need for secondary dressing wounds
• Highly absorbent • Highly exudating • Retention dressing to secure • Remove if radiation,
foam that absorbs wounds • Change when exudate approaches 2 ultrasonic, diathermy or
exudate cm from the edge of the dressing microwaves treatment.
• Absorb exudate • Exudating wounds • Use as primary or secondary • Avoid use with oxidising
from wound bed • Granulation dressing, white side down agents
• Retention dressing to secure
• Change when exudate approaches 2
cm from the edge of the dressing

Page 35 of 63
ABSORBENT
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Exudry • Absorbs high • Over primary dressing • Apply appropriate primary
• Non-adherent, highly exudate dressing
absorbent, permeable • Protects against • Then apply outer absorbent
dressing. shearing dressing
Mesorb • Absorbs exudate • As above • As above
• Sterile absorbent pad
Webril • Protective • As above • As above • May adhere if
• Cotton wool bandage inappropriate primary
dressing
Telfa, Melolite • Non-adherent • As above • As above
• Non-adherent,
absorbent wound
dressing pad
Combine • Absorbs exudate • As above • As above • May adhere if
• Absorbent pad inappropriate primary
dressing
Kaltostat, Algisite, • Absorbent dressing • Donor sites • Apply directly to wound • Replace when exudate no
Algoderm • Moist wound • Granulating wounds longer absorbed or
• Calcium sodium environment • Excessively bleeding
infection evident.
alginate wound • Donor site leave intact at
• Haemostatic wounds least 10 days
dressing

Page 36 of 63
SKIN / DERMAL SUBSTITUTES
Wound Care Product
What?
Cultured Epithelial
Autograft (CEA) /
Keratinocyte Spray
Only used in specialist
Burn Unit
Biobrane
• Biosynthetic dressing
made up of collagen
coated nylon bonded to
silicone.
Integra
• Bovine tendon
collagen and
glycosaminoglycan
cross linked fibres with
a silastic top layer.
Page 37 of 63
Function Indications Application Note / Precautions
Why? When? How?
• Assists with skin • Burns Medical Specialist • Used in conjunction with • Only used in specialist
closure will indicate application autograft Burn Unit
• Reduces need for • Excised full thickness
extensive donor and deep partial thickness
skin harvesting burns.
• Temporary skin • If limited donor skin • Appropriate secondary dressing • Granulation may
cover available or loss incorporate Biobrane into
• Decreases risk of • Applied over debrided regenerating skin layer
infection wound bed
• Reduces • Generally in theatres
evaporative water
loss.
• Dermal • Surgical indication and • Burn debrided, Integra applied, 3 • No paraffin, moisturisers,
replacement. The application by Burns weeks silastic layer peeled off and Silvazine dressings or
matrix layer allows Medical Specialist SSG applied. water as this will lift
the infiltration of • Full thickness burns over • Acticoat applied over Integra Integra.
fibroblasts, a flexor joints • Area immobilised and splint • Not to be applied to
macrophages, • applied. people with known
lymphocytes and • If Integra lifting consult with sensitivities to collagen,
capillaries to RMO, remove affected Integra, silastic.
generate the new cleans gently (saline) and apply
dermis. Acticoat.
SILICONE (use in consultation by specialist therapists)
Wound Care Product
What?
Mepitel
• Transparent, open mesh,
polyamide net, coated
with soft silicone layer
Cica Care
• Silicone sheet
Mepiform
• Silicone sheet
Page 38 of 63
Function Indications Application Note / Precautions
Why? When? How?
• Non stick • Painful open • Can be left intact 2 – 3 days if • Do not apply if sensitive
dressing granulating wounds exudate minimal to silicone.
• Exudate moves • Partial thickness burns • Secondary dressing to optimise
vertically • Skin tears desired moisture level
• Scar softening • Reduces effects of scar • Apply to affected area as instructed • Strict initial usage regime
by therapist to assess sensitivity
• Avoid if allergic to
silicone
• Scar softening • Reduces effects of scar • Apply to affected area as instructed • Avoid if allergic to
by therapist silicone
• Can be used up to 23 hours/day
OTHER
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Surfasoft • Reduces friction rub over • Applied in the OT over • Surfasoft applied wet (sterile • Apply olive oil prior to day
• Woven polyamide graft allowing it to meshed grafts. normal saline) of removal (day 4 usually).
transparent ‘take’. • • Leave intact 5 days unless • Peel off gently. If adhered
dressing.
• Exudate able to pass infection evident. reapply oil.
through dressing
• Easy to view graft.
Solosite, Intrasite, • Re-hydrate wounds and • Dry, necrotic • Apply directly onto wound,
Purilon absorbs some exudate • Low exudating cover with Tegaderm
• Hydrogels into the gel. • Cavity wounds. • Apply onto Lyofoam
Bactigras, Kerlix or Exudry
Saline Dressings • Draws exudate away • Granulating wounds • Bactigras, saline soaked • Do not allow dressing to dry
from wound • Sloughy wounds Kerlix, Webril or body pad out or it will adhere to wound
• TDS or re-irrigating TDS.
Iodine • Anti microbial agent • Wounds infected with • Dab onto wound • Avoid use if sensitive to
Betadine gram +ve & -ve iodine, or thyroid condition.
bacteria, spores, fungi, • Iodine toxicity may occur,
viruses and proteus. consult RMO prior to
application
Hydrocortisone • Reduces blood flow to • Hypergranulating • Apply direct to wound or to • Change daily
Cream hypergranulated wound wounds dressing • Short term usage only
eg Betnovate,
Diprosone
Silver Nitrate • Cauterises • Hypergranulating • Apply direct to affected area • Single application, can be
Cauterizing agent hypergranulated wound wounds repeated if necessary
Bepanthen • Antiseptic with • Superficial burns • Apply thin film to wound • Do not apply too thick layer
Antiseptic cream moisturising • Newly healed partial • For hand burns cover with • Do not use longer than 7
capabilities thickness burns cotton glove days

Page 39 of 63
MOISTURISER
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Dermaveen Bath • Helps to remove and • Epithelialised, dry skin • Massage onto wounds and • Do not apply if known
and Shower oil clean devitalised tissue • Folliculitis healed areas. sensitivities to oatmeal.
• Oatmeal based oil and exudate when • Wash with warm water and pat
massaged onto wounds. dry.
• Can relieve pruritus
Paraffin • Prevents wound from • Face / lips • Apply layer to affected area,
drying out • Superficial and Partial do not rub in
thickness burns
Lacrilube • Prevents wound from • Burns around the eye • As Above
drying out
Lanolin • Moisturiser • Burnt Lips • As Above
• dry, healing wounds
Sorbolene • Can be used as a • Dry, healing exudating • Massage small amount into
• Sorbolene + 10% moisturiser or ‘soap’ and devitalised tissue required areas of healing
Glycerin wound.
Dermaveen • Rehydrates new • Epithelialised wounds • Massage onto healing wound • Do not apply if known
• Oatmeal based epithelium, may relieve • Grafts and donor sites sensitivities to oatmeal.
moisturiser pruritus

Page 40 of 63
RETENTION / FIXATION
Wound Care Product Function Indications Application Note / Precautions
What? Why? When? How?
Hypafix, Fixamul, • Stabilises primary and • Superficial partial • Remove 7 – 10 days when • DO NOT use on open areas
Mefix secondary dressings thickness (skin intact) epithelialised. as primary dressing
• Adhesive non • Protects epidermis whilst • Stabilising external • Removed easily with De- • Do not apply to people who
woven fabric healing and initially after dressing layer Solve-It (immediate) or olive may have delayed healing or
epithelialisation oil (takes 30-60mins). fragile skin (eg the elderly).
Tubigrip • Tissue support • Healing or • Measuring tapes to be used to • Avoid application to upper
• Tubular pressure • Pressure to healing and epithelialised wounds decide appropriate size and arms and upper thighs, as
bandage 67%cotton epithelialised wounds. pressure. soft tissue damage may
and 30% rayon. • Utilise rings for application. occur.
• Remove if painful/tingling
Coban • Stabilises primary and • Healing or • Adheres to itself but not the • Do not apply with full
• Self adherent wrap secondary dressings epithelialised wounds skin stretch as this may impair
bandage • Pressure to wounds. • Apply with gentle stretch only blood flow to peripheries

SUPPLIERS
Company Products Website
Smith & Nephew Acticoat, Silvazine, Bactigras, Jelonet, Allevyn, Exudry, http://wound.smith-nephew.com/au/node.asp?NodeId=3820
Melolite, Algisite, Cica Care, Solosite, Intrasite, Hypafix
Molnlycke Mepilex Transfer, Mepilex Lite, Mepilex Border. Mepitel, http://www.molnlycke.com/item.asp?id=39328&lang=2&si=336
Mepiform, Mefix, Lyofoam, Tubigrip
Convatec Aquacel Ag, Duoderm, Kaltostat http://www.convatec.com
Tyco Curity, Mesorb, Webril, Telfa, Surfasoft www.tycohealthcare.com.au
Technology for Life Omiderm
3M Tegaderm, Coban www.3m.com/intl/au
Coloplast Comfeel Wafer, Comfeel Paste, Biatain www.coloplast.com.au
Aaxis Pacific Lyofoam www.aaxispacific.com.au
Hartman AtraumanAg www.hartmann-online.com.au
Mylan Laboratories Biobrane www.mylan.com
SSL Tubigrip www.sslaustralia.com.au

Page 41 of 63
 Burn Wound Management

Dressing Procedure

Aim:
• To apply most appropriate dressing using correct technique
• To apply dressing in timely manner to avoid hypothermia, excess pain or trauma
• To maintain an aseptic technique at all times

• Healed areas of skin need moisturising with appropriate moisturiser; a small amount is
rubbed in until absorbed.
• Secondary dressings must not come in contact with the wound as they may adhere and
cause trauma on removal.

NB
• Care must be taken not to tightly wrap primary dressings circumferentially around the
burns.
• Post procedure pain relief may be required for some patients.
• Occlusive dressings should not be applied to infected wounds

DRESSING SPECIALISED AREAS

Specialised areas include face, head, neck, ears, hands, perineum and genitals. These areas
require the application of complex dressings which should only be carried out by experienced
clinicians. If attending these types of dressings in areas other than a burn unit please seek advise
from Burns Unit staff and access resources available on SBIS website.

1. Face, Head, Neck

• Tracheostomy tape may be used to secure a naso-gastric tube when adhesive tape is
unsuitable due to burns around the nose.

2. Ears
• The area behind the ear should be padded to avoid burnt surfaces coming into contact with
each other and the area incorporated into the head dressing if appropriate.
• Bactigras or Jelonet are often the dressings of choice on ears.
• Doughnuts made of a soft foam such as Lyofoam can be made to fit around the ear to help
prevent pressure on the ear.
• To protect the helix (cartilage) of the ear, the ear must lie in a natural position and the
padding must be high enough so that any pressure from the bandaging is borne by the
padding.

3. Hands & Fingers

• In the first 24-48 hours if the fingers are swollen, it is sometimes recommended to dress
each finger separately by applying an appropriate primary dressing. The whole hand is
then bandaged as shown in FIG.1. This method inhibits normal functioning and mobility
and should only be used when necessitated.

Page 42 of 63
• At all other times, and once oedema has subsided, the fingers should be individually
bandaged as shown in Fig.2. These bandages allow better mobility and enhance functional
ability.

FIG.1. FIG.2.

4. Feet
• The web spaces between the toes should be separated but it is often difficult to bandage
toes separately due to their size.
• A large supportive dressing allows for mobilisation and helps keep the toes in a normal
position. Foam padding (i.e. Lyofoam, Allevyn) can be used to protect burnt soles.

5. Perineum
• Males: If the penis and/or scrotum are burnt, apply appropriate primary dressing with
outer supportive dressings. A scrotal support may be necessary.
• Females: Dressing the female perineum is more difficult but the type of dressing is the
same as for males.
• Children: When still in nappies, dressings such as Bactigras can be cut to size and placed in
the nappy.
• Patients with perineal burns are generally catheterised to decrease pain and allow for the
area to be kept as clean as possible.

Tips:

• It is important to separate burnt surfaces

• When bandaging start distally and work proximally, from feet or hands. It may be
necessary to incorporate feet or hands, even if they are not burnt to avoid oedema
formation.
• Elevate the arms and legs, especially in the acute period to reduce oedema.
• Legs should be bandaged straight and splints may be necessary.

Page 43 of 63
 Burn Wound Management

Specific Dressing Application

Omiderm application

Clean wound Apply Omiderm Cover with Fix with

bed, moisten if with 2-5 cm absorbent retention
required overlap secondary dressing dressing

Mepilex Application

Clean wound Apply directly to

bed wound surface

Acticoat Application

Clean wound Moisten Acticoat Apply to wound, Apply moistened

bed with water NOT either side down secondary dressing
saline and stabilise as above
Page 44 of 63
AquacelAG Application

Clean wound Apply to Leave intact

bed wound

Bactigras Application

Clean wound Apply Bactigras. 2 Appropriate external

bed layers for moist dressings
wounds

Problem dressings

Issue
Primary dressing slipped off wound. Secondary dressing stuck causing
trauma
Solution
Use appropriate fixation dressing over primary and secondary dressings

Page 45 of 63
Burn Wound Management

Dressing Fixation Application

Coban Application

Start at base of Then work Anchor to Place pieces

hand working from tips of coban on hand through
with a slight fingers in a webspaces of
stretch spiral covering each finger to
half of the separate
previous coban

Hypafix/Mefix/Fixamul Application

Can be used on many areas of the body to fix dressing in place

NB This is not a primary dressing and must not be used on areas of skin loss

Tubular Bandage Application

Cut to length, Put onto Apply to area Remove

then cut slit for aplicator wrinkles
thumb

Page 46 of 63
 Problem Fixation Dressings

Issue
Swelling, pressure areas and reduced blood flow in peripheries
Solution
Remove wrinkles in tubigrip and incorporate feet and hands even if not burnt to prevent
pressure areas and swelling

Issue Issue Issue

Patient unable Dressing falls off Tape applied over pressure
to move hand quickly dressing can lead to pressure
adequately Solution areas
Solution Use appropriate Solution
Wrap fingers fixation dressing Use appropriate fixation
individually dressing

Page 47 of 63
Skin Graft Management

Definition
A skin graft is a common surgical procedure in which the ‘graft’, a thin shaving of skin harvested
from the epidermal and papillary dermal tissue, is used to provide cover to replace a defect
elsewhere in the body. For coverage of areas where there is:
a. burn
b. lesion removed
c. skin tear with muscle defect
d. trauma etc

Wounds with skin loss affecting the deep dermal, subcutaneous and muscular tissue require a
skin graft to assist with healing. For example burn wounds considered deep partial to full
thickness (see Figure 1) would require a skin graft to facilitate healing.

Epidermal
Superficial Dermal

Mid Dermal

Deep Dermal

Full Thickness

Assessment of The Burn Wound

http://www.skinhealing.com/2_2_skinburnsscars.shtml

Figure 1. Burn skin depth diagram

Page 48 of 63
Skin Graft Management
Skin Grafting in OT

Harvesting donor skin

The required skin is removed (see page 50 for further information regarding donor sites)

Figure 2. Taking donor skin with dermatone.

Once the skin has been harvested it is laid flat with the moist side facing upwards ready for
application onto the graft site. If the area to cover is large the donor skin is meshed using a
meshing tool or blade. This involves tiny slits being made throughout the skin so that when
stretched the skin can cover a larger surface area.

Figure 3. Donor skin ready for application

Page 49 of 63
Debriding graft site
Prior to grafting the wound bed is cleaned and dead tissue or ‘eschar’ is removed. The area is
debrided to a bleeding wound bed to encourage optimum graft survival. Debridement may be
carried out in numerous ways including cutting away dead tissue using a surgical blade or a
waterjet tool such as the Versajet. The debridement method can be related to the available
equipment or the depth of the burn wound. A small or linear burn can be excised and primarily
closed

Excision and
primary closure

Debrided burn
wound bed

Figure 4. Debrided wound bed ready for graft application

Skin application
The donor skin is applied to the graft site, making sure that all areas are suitable covered.

Page 50 of 63
Figure 5. Applying donor skin
The graft skin is attached using staples, sutures, surgical glue or an adhesive dressing such as
Hypafix, depending on graft site requirements and the surgeon’s preference.

Figure 6. Graft insitu

Skin is generally applied in the operating theatre after the donor skin has been taken. However,
sometimes more skin is taken from the donor site than is applied during the operation. This skin
can be laid on the patient’s wounds in the ward area if the burn wound is not sufficiently covered
following surgery. When applying the skin the ‘shiny’ side should be placed face down onto the
wound surface using a sterile technique. Skin should be stabilised using an adhesive dressing
such as Hypafix or Steri strips. Care and management needs to be carried out as with any skin
graft following this procedure.

Page 51 of 63
 Skin Graft Management
Skin Graft Management in OT

Dressing Procedure

Aim:
• To allow the skin graft to heal through the bodies own process of re-epithelialisation
• To apply most appropriate dressing using correct technique
• To apply dressing in timely manner to avoid hypothermia, excess pain or trauma
• To maintain an aseptic technique at all times

Procedure:
• Once skin has been applied to graft site appropriate fixation is applied, eg staples, sutures,
adhesive dressing
• When the graft has been fixed in place the graft site is dressed with an appropriate dressing
such as a vaseline gauze or silicone dressing (see Selecting an Appropriate Dressing).
• Ensure area is cleaned using a sterile technique.
• Ensure any build up of blood/fluid under graft has been evacuated to reduce risk of graft
failure.
• Apply the primary dressing directly to the graft site. The primary dressing should have a 2-
5cm overlap and border. It is important to cover the whole area, on and slightly around the
wound site, to allow for movement.
• Apply a suitable dry absorbent secondary dressing such as a foam or pad dressing.
• Secondary dressings must not come in contact with the graft site as they may adhere and
cause trauma on removal.
• Use a fixation dressing such as an adhesive tape to secure the dressing.

NB
• Care must be taken not to tightly wrap primary dressings circumferentially around the
burns.

Page 52 of 63
 Skin Graft Management

Dressing removal

Aim:
• Observe skin graft progress
• Provide appropriate management for level of healing

Taking graft site down at day 3 to 7 post-op.

• Skin grafts should be fully taken down and assessed within this time frame unless otherwise
advised by the Plastics Team, Surgical team or CNC/NP Burns/Plastics.
• Remove dressing, taking care not to pull off graft in the process
• Graft is reviewed by appropriate clinical staff and wound management plan is formulated.

Dressing application:
• Graft site dressed utilizing principles discussed in burn wound management guideline.
• If graft is healed, discuss scar management with therapist and apply appropriate pressure
dressing or garment.
• If graft is unhealed but present dress with vaseline gauze or silicone dressing and appropriate
secondary dressing.
• If graft is lost assess for causative factors such as infection or friction and treat accordingly.
o For infection swab wound and send for culture. Clean wound bed thoroughly and
apply silver or other antimicrobial dressing and secondary dressing.
o For graft loss due to friction apply appropriate primary and secondary dressings
and ensure friction does not continue to occur. If friction is caused by patient
itching arrange for appropriate antihistamine. If friction is caused by proximity to
other body surface dress well with protective and padded dressing.

Page 53 of 63
 Donor Site Management11

Definition
A donor site is the area where epidermal and papillary dermal tissue is harvested to provide
cover to replace a defect elsewhere in the body. For coverage of areas where there is:
a. burn
b. lesion removed
c. skin tear with muscle defect
d. trauma etc

Tissue used for

donor site

Figure 1. Cross Section of Skin

Donor Sites
Common donor site areas include the thighs, buttocks and scalp as these areas are not readily
visible and can provide large strips of donor skin. However donor sites are often taken from an
area of the body closest in colour match for the graft site. If available skin is limited almost any
area on the body can be used.

Figure 1. Common Sites for Skin Harvesting

Page 54 of 63
 Donor Site Management

Harvesting the Donor Skin in OT

The required skin is removed with an electronic surgical cutting tool called a dermatone. The
dermatome has multiple depth settings and can take a very thin shaving of skin.

Figure 2. Dermatone

The selected area is prepared using Betadine and sterile drapes.

Figure 3. Area prepared for donor site

Page 55 of 63
The skin is stretched to allow even pressure on all areas of skin harvested, thus providing an even
piece of donor skin

Figure 4. Taking donor skin with dermatone.

Once the skin is harvested the donor site is left as a bleeding wound bed.

Figure 5. Fresh donor site

Page 56 of 63
 Donor Site Management

Donor Site Management in OT

Dressing Procedure
Aim:
• To allow the donor tissue to heal through the bodies own process of re-epithelialisation
• To apply most appropriate dressing using correct technique
• To apply dressing in timely manner to avoid hypothermia, excess pain or trauma
• To maintain an aseptic technique at all times

Figure 6. Dressing being applied to a donor site

1. Procedure:
• Once donor skin has been harvested, adrenaline soaks are placed on the bleeding wound to
assist with coagulation.
• When the bleeding has ceased the donor site is dressed with an appropriate dressing such
as a Calcium Alginate, Silicone dressing or Omiderm (see Selecting an Appropriate
Dressing).
• Apply the dressing directly to the donor site wound. The primary dressing should have a 2-
5cm overlap and border. It is important to cover the whole area, on and slightly around the
wound site, to allow for movement.
• A suitable dry absorbent secondary dressing such as Mesorb or Lyofoam will be applied
• Secondary dressings must not come in contact with the donor site as they may adhere and
cause trauma on removal.
• A fixation dressing such as an adhesive tape will be used to secure the dressing.

NB
• Care must be taken not to tightly wrap primary dressings circumferentially around the
burns.

Page 57 of 63
 Donor Site Management

Initial Inspection

Aim:
• Observe donor site wound progress at 24-48 hours
• Provide effective donor site management and problem solving

Procedure
• Assess pain and provide analgesia as necessary. Reassess periodically during procedure
• Observe for:
o Bleeding
o Offensive Smell
o Exudate Strike-through onto secondary dressing.
o Wet Primary dressing
o Increased pain
o Limb Swelling
• If the primary dressing is dry and clean – leave intact and provide a secondary retentive and
absorptive dressing.
• Ensure dressing is kept clean and dry (i.e. cover during showering with a plastic bag).

Figure 7. Exudating & bleeding donor site.

Managing complications
• If any of the previously mentioned signs or symptoms are noted, the area must be cleaned
thoroughly with Normal Saline.
• Assess the wound for odour and offensive exudate, if present apply Aquacel Ag (apply dry to
wound). Ensure an overlap onto ‘good’ skin of at least 3 cms.
• Apply a secondary retentive dressing. Leave intact for 4 to 6 days.
• If the wound is clean and bleeding has been controlled. Re-dress with Calcium Alginate and
retentive secondary dressing (such as Mesorb and Hypafix) . Reassess 8th hourly and leave
the dressing intact for 7 days.

Page 58 of 63
 Donor Site Management

Dressing removal

Aim:
• Observe donor site wound progress
• Provide appropriate management for level of healing

Taking donor down at day 8 to 10 post harvesting.

• Donor sites dressed with either calcium alginate or
silicone dressings should be fully taken down and
assessed within this time frame unless otherwise
advised by the Burns/Plastics Team, Surgical team or
Burns/Plastics CNC.
• Donor sites dressed with Omiderm should be taken
down to the primary layer. If the Omiderm remains
adhered leave intact, trim lifting edges, and cover
with protective layer such as an adhesive tape
dressing (e.g. Hypafix)

Donor healed (Re-epithelialised)

• Apply moisturiser – water based. Leave exposed.
• Educate patient on donor site care including the
need to continue moisturising, and ensure shear
and friction is prevented.
• Discuss sun care options with the patient.

Donor not healed

• Assess pain and provide analgesia as necessary. Reassess periodically during procedure
• Assess and document appearance of the unhealed donor.
• If donor is raw but there is no sign of wound infection – apply appropriate dressing such as
calcium alginate, silicone or film dressing and leave intact for a further 3 to 4 days.
• Take a wound swab, if the wound has obvious signs of infection and healing has not
progressed over the last 10 days. Discuss the best dressing options with appropriate staff such
as Burns/Plastics CNC.
• Document course of action in the integrated notes and inform the Burns/Plastics Registrar.
• Continue to reassess the dressings and leave the dressing intact for prescribed period of time.
• The surgeon, and/or the Burns/Plastics CNC must be notified if the donor site remains
unhealed after a further 7 days. They will direct an appropriate course of action.

Page 59 of 63
 The Multidisciplinary team
Burn care is conducted by members of a multidisciplinary burn team which include medical,
surgical, intensive care, nursing, physiotherapy, occupational therapy, dietetics, social work,
psychiatry, psychology, speech therapy, pharmacy and technicians. A multidisciplinary approach
to burn management is essential for optimal functional and cosmetic outcome. Serious long term
physical and psychosocial morbidity may be associated with a burn injury. All members of the
burn management team interact throughout the patient’s management, from admission to
discharge and beyond to support the patient and family in reintegration. All team members
contribute to patient care throughout the early management, ongoing clinical intervention periods
during all phases of care, and continuous educative support to the patient, family and staff.

For further information regarding multidisciplinary care please refer to the following documents:

• Burn Survivor Rehabilitation: Principles and Guidelines for the Allied Health
Professional (ANZBA)
http://www.health.nsw.gov.au/gmct/burninjury/docs/anzba_ahp_guidelines_october_2007.pdf

• Nutrition & Dietetics: Principles and Guidelines for Adult & Paediatric Burns Patient
Management
http://www.health.nsw.gov.au/gmct/burninjury/docs/nutrition_burns_cpgs.pdf

• NSW Severe Burn Injury Service Clinical Practice Guidelines Speech Pathology for
Burn Patient Management
http://www.health.nsw.gov.au/gmct/burninjury/docs/speech_pathology_adults.pdf

• NSW Severe Burn Injury Service Clinical Practice Guidelines Play Therapy for Burn
Injured Paediatric Patients
http://www.health.nsw.gov.au/gmct/burninjury/docs/play_therapy_cpg_children.pdf

All of these documents are available via the NSW Severe Burn Injury Service Website:

• http://www.health.nsw.gov.au/gmct/burninjury

Also available on this website are:

• NSW Severe Burn Injury Service Burn Transfer Guidelines

http://www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_012.pdf
• NSW Severe Burn Injury Service Model of Care
http://www.health.nsw.gov.au/gmct/burninjury/docs/burninjury_moc.pdf

Page 60 of 63
 References
1. Australian & New Zealand Burn Association. 2006, Emergency Management of Severe
Burns (EMSB), Course Manual (11th Ed.).

2. Abdi, S. & Zhou, Y. 2002, ‘Management of pain after burn injury’, Current Opinion
Anaesthesiology, vol.15, pp.563-567.

3. Carrougher J. G 1998, Burn Care and Therapy. Mosby Inc. Missouri

4. Chi, K. and Garner, W. 2002, ‘Acute burns’. Plastic and Reconstructive Surgery, vol.105,
no.7, pp.2482-2493.

5. Demling R.H & DeSanti L. 2001, ‘The rate of epithelialization across meshed skin grafts
increases with exposure to silver’. Burns, vol. 28, pp.264-266.

6. Herndon, D, N. (ed.) 2007, Total Burn Care (3rd Ed.). Saunders. London.

7. Faucher, L.D. 2003, ‘Modern pain management in burn care’, Problems in General Surgery,
vol. 20, no.1, pp.80-87.

8. Kagan, R.J. & Smith, S.C. 2000, ‘Evaluation and treatment of thermal injuries’, Dermatology
Nursing, vol.12, no.5, pp.334-350.

9. Jackson, D. 1953, ‘The diagnosis of the depth of burning’, British Journal of Plastic Surgery,
vol.40, pp.588 -96.

10. Merz, J., Schrand, C., Mertens, D., Foote, C., Porter, K. & Regnold, L. 2003, ‘Wound care of
the pediatric burn patient’, AACN Clinical Issues, vol.14, no.4, pp.429-441.

11. Northern Sydney Central Coast Area Health Service 2006, Wound Donor Site Management
Guideline, Accessed via
http://www.nsccahs.health.nsw.gov.au/services/wound.care/2008draftdonorsiteguidelineswit
hsummarypage.pdf

12. NSW Severe Burn Injury Service: Burn Transfer Guidelines, 2008. NSW Health (available
via SBIS website: http://www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_012.pdf ).

13. Principles of Best Practise: A World Union of Wound Healing Societies’ Initiative 2007
“Wound exudate and the role of dressings: A consensus document”. Accessed from
http://www.wuwhs.org/datas/2_1/4/consensus_exudate_ENG_FINAL.pdf

14. Reed, J.L. & Pomerantz, W.J. 2005, ‘Emergency management of pediatric burns’, Pediatric
Emergency Care, vol. 21, no.2, pp.118-129.

15. Royal Children’s Hospital Melbourne ‘Burns Unit: Clinical Information’ accessed 12/06/07
from http://www.rch.org.au/burns/clinical/index.cfm?doc_id=2012

16. Sandip K. P, Cortiella J & Herndon D., 1997, “The Relationships between Burn Pain,
Anxiety and Depression”, Burns, vol.23, pp404-417.

Page 61 of 63
17. Sargent, R.L. 2006, ‘Management of blisters in the partial-thickness burn: an integrative
research review’, Journal of Burn Care & Rehabilitation, vol.1, pp.66-81.

18. Taylor, K. 2001, ‘The management of minor burns and scalds in children’, Nursing Standard,
vol.16, no.11, pp.45-52, 54.

19. The Children’s Hospital at Westmead. Handbook 1999. Section 29.

20. Tredget E.E, Shankowsky H.A, Groeneveld A & Burrell R.E 1998, ‘A matched- pair,
randomized study evaluating the efficacy and safety of Acticoat silver-coated dressing for the
treatment of burn wounds’. Journal of Burn Care and Rehabilitation, vol.19, no.6, pp.531-
537.

21. Wright J.B, Lam K & Burrell R.E 1998, ‘Wound management in an era of increasing
bacterial antibiotic resistance: a role for topical silver treatment’. American Journal of
Infection Control, vol.26, pp. 572-577.

22. Yin H.Q, Langford K & Burrell R.E 1999, ‘Comparative evaluation of the antimicrobial
activity of Acticoat antimicrobial barrier dressing’. Journal of Burn Care & Rehabilitation
vol.20, no.3, pp.195-199.

Page 62 of 63
Websites

• NSW Severe Burn Injury Service

http://www.health.nsw.gov.au/gmct/burninjury
• Australian New Zealand Burn Association
http://www.anzba.org.au
• Journal of Burn Care & Research
www.burncareresearch.com
• International Society for Burn Injuries
http://www.worldburn.org
• Annals of Burns and Fire Disasters
http://www.medbc.com/annals/
• Management Guidelines for People with Burn Injury
www.health.nsw.gov.au/public-health/burns/burnsmgt.pdf
• Resident Orientation Manual - Acute Burn Management
www.totalburncare.com/orientation_acute_burn_mgmt.htm
• Skin Healing
http://www.skinhealing.com

Skin Information
a. http://www.skinhealing.com/3_1_burntreatments.shtml
b. http://www.essentialdayspa.com/Skin_Anathomy_and_Physiology.htm
c. http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/skinlsn/skini.htm
d. http://www.nurse-prescriber.co.uk/education/anatomy/anatomy2.htm
e. http://reference.allrefer.com/encyclopedia/S/skin.html
f. http://www.swiss-creations.com/sc-14story.htm#The%20Human%20Skin

Page 63 of 63