What is a donor site?

This is the wound site left behind when the skin graft has been taken to cover a burn wound. The skin can be taken from various sites around the body. The area to be used will be discussed with you/your child, before the surgery.

How long does it take to heal?

A donor site usually takes 10 to 14 days to heal however this is dependent on a number of factors such as, donor site size, patient comorbidities, patient age, current medications etc.  A dressing will be put on in theatre, and this should stay in place until healed. Sometimes the dressings need changing because they have slipped, leaked or become dirty.

Will the donor site be painful?

Donor sites can be painful and taking pain relief will help. Initially after theatre some strong pain relief like morphine may be needed, but usually simple painkillers like paracetamol and ibuprofen are sufficient. Your nurse will ensure that pain relief medicines are given as needed.

Who will remove the dressing?

It is possible that younger children and those with a larger area that has been grafted may require the first dressing change under strong analgesia or general anaesthetic. After this the dressings can usually be changed using pain relief either on the ward or in burns dressing out patients.

What will the wound look like?

The donor site looks like a big graze. It will look red when first healed but this will fade over the weeks and months, and should result in a pale and soft scar. Very occasionally it becomes raised and pink or darker than the surrounding skin, however even the more prominent donor scars improve with time.

How do I look after the healed donor site?

Once healed you will need to moisturise the donor area as well as the grafted burn site.

Sun Screen advice:

It is very important that both the graft and donor sites are protected from the sun as it is new thinner skin without the normal skin protection. It is very important that the affected areas are covered using high factor (>SPF30) sun protection cream (for both UVA and UVB) and protective clothing. As the new skin may burn very quickly and blister. If it becomes tanned this can be a permanent tan that can be blotchy and irregular. It is important to protect all newly healed areas from sun damage for at least 2 years.

Pain and itching:

You/your child may still require medicines after discharge from the hospital to help with pain and itching. Medication will be discussed with you and will be given to you to take home.

Itching can be a major problem for some patients. Regular creaming and massage helps. Wearing loose clothes made from natural materials can also help. If the itching does not settle and becomes an on-going problem please speak to the doctor or nurse at the hospital. There are medicines that can help.

Scar Management:

Following skin grafts there will a varying degree of scarring. Once the wounds have healed you/your child will be referred to the scar management team who will treat the scars to produce the best outcome.

Treatment of scarring includes creaming and massage, silicone creams and gels and pressure garments. These will be discussed with you/your child when the wounds are healed. If you/your child are worried about the scarring and you have not been seen by the scar management team, please contact the dressing clinic or outreach team.

Help from the Psychologist

If you/your child are finding it difficult to come to terms with the treatment plan or with the scars then help is available. Please speak to your nurse or surgeon at the hospital who may be able to help with this. It may be that you 

What is an escharotomy?

An escharotomy is a surgical procedure performed to allow greater circulation to that part of the body.

Why is it performed?

A severe injury, such as a very deep burn, can cause tissue to swell so much that blood no longer flows past the injury easily. The skin acts as a tight bandage, preventing the site of injury from expanding to accommodate the swelling, resulting in compression of the blood vessels, nerves, muscle and tissue below. This problem is often referred to as compartment syndrome.

When compartment syndrome develops it is a surgical emergency. The treatment is to cut into the skin and the tissues underneath to allow them to spread open, relieving the pressure building in the affected area.

Who performs the escharotomy?

The escharotomy will be performed by a senior member of the Burns Medical team.

Are the escharotomy lines closed afterwards?

Unlike a typical surgical incision, these incisions are not closed as the operated area requires continuous assessment and monitoring.

It is normal to be able to see the tissues and structures under the open incisions. Any open wound has a risk of infection so the area will be covered by sterile dressings and bandages.

As swelling reduces, the surgical incisions will begin to close and when the edges of the incision are close enough, the patient will return to theatre to have the wounds closed, or occasionally skin grafted.

Will there be a scar?

Escharotomies can result in abnormal scarring  that can present as thick, hypertrophic, retracting and painful scars. Scar therapists will be involved in managing the escharotomy scars from the day of the surgery to try and minimise these. 

This is a flexible waterproof dressing used to cover your burn/scald and reduce infection. When in contact with the wound, Duoderm forms a gel-like covering which can remain untouched for several days, but will need changing if leakage occurs.

How to change

1. Gently peel back Duoderm from the skin starting with a corner- it may be firmly stuck but is relatively painless to pull off.
2. Clean wound with water and remove ooze.
3. Remove the white paper backing from the fresh piece of Duoderm and apply smoothly over the wound. Do not stretch unnecessarily and ensure when cutting to size to leave a margin of 1 inch around wound.
4. Leave intact for up to 4 days unless leakage occurs.

About your Duoderm dressing smell

1. SMELL: You may notice an unpleasant smell from the dressing, which is not necessarily due to the wound. Duoderm itself does have an odour, so do not be concerned as it will disappear on cleansing.
2. LEAKAGE: This may occur around the edges of the dressing and has a yellow appearance – this is due to the Duoderm gel and is not pus.
3. WRINKLING: Duoderm will occasionally wrinkle up, and if this occurs apply a new dressing.
4. RASH: Occasionally a rash may occur around the edges of the Duoderm on very young children. If this happens –return to the Unit.

If you are unsure of anything, or have any questions or worries about this form of dressing, do not hesitate to telephone us on the Burns Unit.

Burns Unit: 020 3315 2500   Chelsea and Westminster Hospital (24hours)

Paediatric Burns Unit (Mars Ward) : 020 3315 3706 Chelsea and Westminster Hospital.

• Please clean the burnt areas of the face/ears/neck 3–4 times a day
• Use the Chlorhexidine (Hibiscrub) solution provided—a teaspoonful (5mls) in the foil bowl. Use warm water from the tap to dilute to a bowlful
• For burns around the eyes, wash with warm tap water only no Chlorhexidine (Hibiscrub)
• Using the gauze pieces, wet them in the solution, then wipe gently over the burn wound—do not ‘dab’, it needs to be wiped to clean it properly
• Use another piece of gauze to dry the wound
• Do not worry if any loose skin comes off
• The aim is to keep the wound clean—it will start to scab over in a few days.
• The face may swell in the first 24–48 hours—please try and sleep as upright as possible
• Apply thin layer of yellow paraffin provided after cleaning

Any queries, please call:

• Adult Burns Unit: 020 3315 2500
• Paediatric Burns Unit (Mars ward): 020 3315 3706

What is wound contraction and joint contracture?

As grafted or damaged skin heals, the edges of the wound contract to make the damaged area smaller (‘wound contraction’). Deeper wounds heal by forming scar tissue which shrinks and tightens as it forms.

When scar tissue forma over or near a joint, this “shrinking” (or contraction) pulls nearby tissues inwards. This tightening can cause movement at a joint to be limited. 

If nothing is done to stop the scar becoming tight over the joint, then muscles and other tissues may also get tight. This can lead to permanent restrictions in movement and is called a contracture.

How does scar tissue behave?

Scar tissue is a bit like cement. In the early stages it may be changed or moved, even though it has already started to “set”.  This is the most important time to start preventing contractures as they are more easily shaped, just like concrete.

Once set, it is extremely difficult to shape or move. Therefore, it is important to maintain movement and shape the scar tissue before it reaches this point.

Joint contracture can be prevented or minimised through a Therapy programme. Your Physiotherapist or Occupational Therapist will give you advice and instruct you about ways to minimise the formation of a contracture.

Ultimately, however, the hard work is up to you. Scar tissue tightens 24 hours a day so the more you can do to try stopping the tightening, the less chance you have of a contracture forming.  Though scar tissue may take up to 2 years to mature, prevention is much better than cure.  This can be very hard work over a long period of time, but may mean avoiding further surgery in the future.

Am I at risk of a contracture?

Factors which increase the risk of joint contracture include:

• Burns on or near joints, especially: fingers, hands, elbows, armpits, neck, hips, knees, ankles and toes.
• Grafted areas or deeper wounds which take longer than 3 weeks to heal. 
• Large burns
• Dark-skinned, Asian and red-haired individuals
• Any other current illness that means you find movement difficult

What can my therapist do to reduce contracture?

• Advice and education
• Positioning
• Exercises and stretches
• Splints
• Scar massage (once healed)

Your therapist will teach you exercises specific to your needs and advise you how to do these stretches yourself throughout the day. They may provide you with a combination of treatments to reduce contracture.

Holding the scar in a stretched position, through positioning, exercise or splinting, increases the length of the skin, scar and other soft tissues, such as muscle. Maintaining the length of these tissues helps prevent joint contracture.  Your stretches should be gently held for 2-5 minutes each and slowly increased as your scar relaxes.

Your therapist will teach you which stretches and exercises which are important for you. Remember that these may be different to other patients. 

What can I do to reduce contracture?

You have the biggest role to play in reducing the risk of contracture.

Your therapist cannot be with you every moment of the day and this is why it is important for you to understand contractures, learn how to do your stretches yourself and wear your splints correctly.  

It is not unusual to experience pain/discomfort following a burn injury.  This, however, should not prevent you from exercising.  Appropriate pain relief will make it easier for you to manage the exercises you are asked to do.  Pain when moving does not mean that you are causing damage - in factnotmoving as instructed may cause you more damage in the long run.

you have any questions relating to contractures, scar tissue or your Therapy programme, please ask you ward therapist or call the Burns Therapy Department to speak to a therapist.

Burns Therapy Department: 0208 746 5680.

Leaving hospital can be a busy time for you and there is often a lot to remember.  This information sheet should help remind you of the important things to do to continue preventing contracture.

Important information for you!

Just because you are leaving hospital, doesn’t mean that your scars will stop tightening. In fact, without your therapist, nurses and doctors around to remind you about your exercises, it is even more important that you understand what to do and when to do it.

What should I do when I leave hospital to prevent contractures?

Before you leave hospital, your therapist will come and see you to review your treatment and give you a home exercise programme.  It is very important that you continue to do the following when you leave hospital:

• Exercise
• Stretch
• Scar Massage
• Positioning
• Wear any splints your therapist has advised. 

It is very tempting to take a break from your Therapy programme when you first leave hospital; however, it is so important that you continue with your treatment. Remember, scar tissue can take 2 years to mature and what you do when you leave hospital continues to count.

Think about how you sit and where you rest your arms and legs.  Try to set up and continue an exercise routine at home.  Your therapist can give you some tips on how to fit all your exercises into your day.  An exercise diary may also help you to keep track of what to do and when.

Your therapist will organise an outpatient appointment for you to see a member of the Therapy team.  If you haven’t received an appointment before you leave hospital, please ask the ward staff.  If you have any questions once you are home please call the Burns Therapy Department.

Burns Therapy Department: 0208 746 5680

Introduction

If you have had a burn injury, your body’s response is to increase its metabolic rate to help the healing process (see glossary on page 1). Therefore your need for protein and calories may be slightly increased (see glossary on page 1).

During your hospital stay you may be seen by the dietitian who may recommend a high energy, high protein diet. This may incorporate nutritional supplement drinks (see page 4 for ‘nutritional supplements’). This may help to increase your overall energy and protein intake, as at the same time, it is common to feel like you have less of an appetite as normal. 

Poor Appetite

A poor appetite is very common following a burn injury. This can be for many reasons some of which include: being in hospital, worrying, restrictive dressings, pain, pain on dressing changes, constipation, dislike of hospital food, feeling sick, feeling weak and taste changes. However, at this time in hospital after your injury, your body’s nutritional needs tend to be much higher. Therefore it is important to view food as an essential part of the healing process and make as much effort with your eating and drinking as you can.

To help stimulate the appetite you can try:

• Eating more frequently; “little & often”, eg. 5-6 small meals or snacks, rather than 2-3 larger meals; try something every few hours. This is because not eating in itself can cause low appetite
• Eat what you want, whenever you want. Whilst in hospital, it can be useful to ask family and/or friends to bring in foods from outside the hospital
• If you’ve lost interest in food: Think of a food where the smell or sight of it usually makes you look forward to tasting it, then try a small portion 
• Make eating easy; choose simple meals & snacks, and when at home, ensure cupboards/fridge are well stocked; choose favourite foods
• Choose nutritious fluids: do not fill up on water, tea, coffee; remember that drinking before a meal can fill you up
• If taking supplement drinks, only have these after a meal, otherwise they may fill you up

Nutritional Supplements: prescribed by Dietitian

Sometimes high energy/high protein supplement drinks will be suggested by your dietitian.  These are easy ways to take in a concentrated amount of energy and are available on prescription.

• Only use supplements when your appetite / weight is low
• Use to ‘supplement the diet’, not as meal replacements
• Try to take after or between meals, not before or with meals
• Juice based drinks(eg Ensure plus juice) can be made into jellies or sorbets/slushes.  If too thick, they can be diluted with fizzy drinks - lemonade, ginger ale, Fanta, tango (try not to dilute with water alone).
• Milk based drinks (eg Ensure Plus, Fortisip Extra) can be frozen to make ice cream or heated, (remove from packet if heating in a microwave).  They can be added to custards or yoghurts.  If too thick, they can be diluted with milk.
• Food Fortifiers (eg, Protifar powder) can be added to foods and drinks to increase protein.
• Supplements can be mixed with alcohol after you have been discharged from hospital (if alcohol allowed  and does not interfere with medication).

Drinks

Liquids are important but can be filling. Try to ensure drinks provide calories by possibly substituting water/coffee/tea with some of the following:

• Cocoa, drinking chocolate, coffee (made with all milk, i.e. latté or cappuccino, cream, evaporated milk)
• Full fat milk (fortified) and milkshakes (fortified)
• Lucozade or energy drinks
•  Fruit juices and full sugar squashes eg. Ribena / Robinsons
•  Drinking yoghurt
•  Fizzy drinks, include ginger ale (NB. can cause bloating)
•  Fruit smoothies (bought or homemade with fortified milk) 

Food & Fluid Fortification

Choose high energy, high protein foods. Eating more of these will help you to gain/maintain weight. This means avoiding diet / slimline / low fat / no added sugar products.

Fats & oil have the highest amount of energy per gram compared with all other foods in our diet & are therefore invaluable in food fortification.  Fortify foods & fluids using the methods below whenever possible to add extra energy:

• Fortified milk - Add 3-4 tablespoons skimmed milk powder, (e.g. Marvel) to 1 pint full fat milk. Use this in soups, sauces,puddings, drinks, and on cereal
• Add butter or margarine spreads liberally on bread, toast, crackers, vegetables & potatoes
• Fry or add oil to dishes like rice & pasta
• Add yoghurt / fromage frais / cream cheese / creme fraiche / cream to stews, soups, drinks (use full fat products)
• Add grated cheese, cream / sour cream, fortified milk to soups & sauces. Have sauces on meats, potatoes and pasta
• Add evaporated milk to soup, sauces, milk & other puddings (eg jelly).

If you have been told by your Doctor / Dietitian that you have high cholesterol or heart problems, try using poly or mono-unsaturated oils/spreads whenever possible. This are better for heart health. High calorie foods good for heart health include:

Oils & Spreads: olive, vegetable (rapeseed), sunflower, safflower, soya, corn. Olive oil based spread

• Oily Fish: Mackerel, salmon, sardines, herring, trout, tuna
• Nuts: Walnuts, chestnuts, almonds, hazelnuts, peanuts, pistachio, pecans 
• Avocado: use in salads, sandwiches or as a snack 

Long Term Diet

Generally, you will need to eat a diet high in protein and energy up until your burn is fully healed or as advised by your dietitian. 

Once your burn is fully healed and your weight is stable, then you can switch to a healthier balanced diet that the general population are advised to follow. Please refer to pages 14 and 15 for guidance regarding this.

Vitamin and Mineral Supplementation

You may be prescribed vitamin and mineral supplements or a nutritional supplement whilst you are in hospital and after discharge from hospital.  Copper, selenium, zinc, vitamin C are regularly given to patients with a larger burn injury. This is because they help with wound healing. Please ask your Dietitian how long you need to take them after you are discharged from hospital.  Generally, supplements are no longer necessary when your burns have healed and you start to maintain your weight. 

Breakfast Ideas

• Cereals – Use fortified milk (see recipe). Porridge/Ready Brek, made with fortified milk, cream, evaporated milk, yoghurt. Try adding dried fruit, fresh fruit or nuts. Try adding honey, brown sugar, golden syrup or maple syrup to add taste to muesli or sugar coated cereals. Try cereal with fruit juice if milk is not tolerated. Remember cereals can be eaten any time of the day, hot or cold. NB: Scandishake, Build-up or Complan sachets & ‘Procal’  can be added to porridge.
• Eggs (poached, boiled, scrambled with salmon, omelette); try bread ‘fingers’ dipped into beaten egg & fried. Ensure eggs are well cooked.
• Cooked breakfasts (bacon, sausage, ham & baked beans).
• Bread/toasts (sweet or savoury toppings).
• Croissants, muffins, scones, pitta bread (sweet or savoury toppings).
• Waffles or crumpets (with maple syrup, honey, savoury spreads).
• Yoghurts, fromage frais (full fat), flavoured or plain (try adding dried / fresh fruit, nuts, honey, spices etc).
• If you find that eating in the morning makes you feel sick, try dry toast or crackers.

Easy Small Meal Ideas

Eating several small meals & snacks can be much easier than facing a large meal.

• Scrambled eggs, omelette, with added cheese, avocado, bacon, herbs etc
• Baked beans on toast (well buttered/spread), topped with melted cheese
• Cheese on toast (try spreading cream cheese & top with Cheddar/hard cheese)
• “Bacon buttie” – bacon with onions, mushrooms on bread or toast
• Mini pizzas: bought or homemade (can use bagel, muffin or crumpet as a base)
• Sausage rolls, pork pies, scotch eggs, Falafel
• Soups (canned/ packet,/homemade).  Add full fat milk, cream or cheese, croutons
• Flans, quiches, pies, pasties
• Sausages (or hotdogs), bacon, egg with baked beans
• Pancakes / kievs stuffed with vegetables/meats in cheese sauce
• Spaghetti, macaroni cheese (sold in small or large tins)
• Oily fish eg. Tinned mackerel, sardines or salmon on toast
• Takeaways: Burgers, fish & chips, Chinese, Indian, Kentucky Fried Chicken.
• Instant, frozen and microwave meals – can be very nutritious. 

High Energy Snack Ideas

• Cereals (see breakfast section) - can be eaten any time of the day
• Small sandwiches (see sandwich section) or toast with topping
• Muffins & scones (cheese or sweet), crumpets, croissants (filled), waffles, flapjacks
• Nuts (peanuts, pecan, cashew, pistachio,brazil, walnuts, almonds,), dried fruit, olives, Bombay Mix
• Avocado (with oil or seafood dressing)
• Milkshakes, ‘Fruit Smoothies’
• Tortilla crisps, breadsticks, pitta bread with dips  (Dips: taramasalata, houmous, cream cheese, satay / peanut, avocado / guacamole, sour cream)
•  Desserts (see next section) eg yoghurts, rice pudding, can be taken at any time.

If high cholesterol isn’t a problem for you, the following snacks may also be useful, as long as they are used as part of a balanced diet:

•  Doughnuts (large or mini), pastries; fruit strudels
•  Crisps
•  Mini pork pies, scotch eggs, sausage rolls, mini sausages
•  Cheese & biscuits (remember to also use butter or spread)
•  Samosas, bhajis

Puddings & Desserts

Fruit is an easy dessert, but quite low in energy, so try to combine it with other higher calorie ingredients.

Other dessert ideas can be used as snacks between meals.

• Fruit, served with full-fat yoghurt, cream, ice cream, custard, condensed/evaporated milk; tinned fruit in syrup; dried fruit & nuts (soaked in juices or alcohol, if allowed)
• Fruit yoghurts (full fat); Greek yoghurt & honey; fromage frais, crème fraiche (add extra dried / fresh fruit, nuts (flaked/chopped), honey, syrups, crunchy cereals, spices)
• Custards, mousse, fools, whips, crème caramel, blancmange
• Mini trifles, cheesecakes,banoffee pie
• Rice pudding, milk puddings (semolina, tapioca) – can add sugar, syrups, jam
• Ice-cream (including ready bought on stick)
• Jelly (make with evaporated milk or fruit-juice supplement drinks)
• Fruit crumbles, fruit pancakes or fritters, fruit pasties, pies.
• Flour based: Sticky toffee pudding, spotted dick, bread and butter pudding. Serve with cream, ice cream or custard
•  Cakes – chocolate, lemon drizzle, fruit sponge,Victoria sponge, carrot.

Sandwich Ideas

For variety & greater flavour, try using different breads (fresh, hot, toasted): rolls (eg with seeds), baps, French bread / bagettes, foccacia, naan, ciabatta, bagels, pitta bread, muffins, crumpets, scones, croissants. Always have at least two fillings eg. Ham and cheese.

Remember:

• White breads can be less filling/bulky than wholemeal types
• Try an ‘open sandwich’, ie only one slice of bread, with plenty of filling
• Ensure bread/roll is well spread with butter or margarine (not low fat varieties!)
• Use plenty of mayonnaise or salad cream (if enjoyed) - a dash of mustard or tomato puree adds flavour
• Try adding chopped herbs (fresh or dried) to add extra flavour.

Fillings:

• Fish: tuna, salmon, pilchards, sardines (tinned in oil), smoked/peppered mackerel
• Cheese, hard or soft, try different varieties; try a layer of cream cheese & topping with grated hard cheese
• Avocado &/or bacon
• Pastes eg olive, pesto, smoked mackerel, pate
• Meats: corned beef, cold meats, hams, chicken, spam
• Egg mayonnaise (ensure egg is well cooked)
• Peanut butter, tahini 
• Taramasalata, houmous, falafel 
• Sweet spreads: jam, marmalade, banana & honey, chocolate/nut spreads

Pastas & Rice

Pasta provides a good base to meals; try to use sauces that provide additional energy & protein:

• Try creamy sauces eg use cream, full fat milk, yoghurt / fromage frais
• Macaroni or cauliflower cheese; add croutons or cubes of ham / bacon / pancetta / salami / pepperoni
• Use grated cheese or sour cream to top tomato or vegetable based sauces
• Pesto or oil-based sauces
• Add avocado, nuts, bacon, olives, mackerel, hard boiled egg, prawns
•  If appetite is poor, use less pasta and more sauce.

Salads & Vegetables

Although full of vitamins & minerals, salads & vegetables can be filling, while providing little energy. The following ideas help increase calories.

• Serve with coleslaw, pasta, rice & potato salads
• Use mayonnaise & salad cream or oil-based dressings (not low-fat versions)
• Try adding chopped nuts, seeds, pinenuts, olives, dried fruit
• Add avocado, hard-boiled egg, bacon, ham, cubes of cheese
• Add pieces of sausage / hotdogs, chicken, fish (tinned or fresh)
• Try croutons (bought or homemade - cubes of bread fried in oil, herbs, garlic)
• Stirfrys: add nuts, tofu / quorn, chicken, fish; use oil in dressings  

Potatoes

Potatoes can provide easy & economical meals; try these:

• Filled jacket potatoes (see below) & potato skins (deep- fried)
• Chips, bought, oven cooked or deep-fried (can use unsaturated oils)
• Mashed potato (packet or homemade) - add butter / marg,  milk, cream or cheese
• Potato fritters - mash & fry with onion, cheese, bacon, ham etc.
• Potato layers - bake sliced potato with onion, cheese sauce, egg & milk
• Croquettes, bread crumbed potatoes, wedges, hash browns.
• Add potato to soups to thicken
• Use crisps (crushed) & grated cheese for toppings.

Jacket/Baked potatoes (See sandwich fillings for other ideas):    

• Tuna mayonnaise, sweetcorn and cheese
• Baked beans and cheese
• Bolognaise or chilli sauce, topped with grated cheese or sour cream
• Ratatouille, topped with grated cheese or sour cream
• Coleslaw
• Egg mayonnaise 
• Sausage and baked beans
• Pizza sauce and grated mozzarella
• Scrambled egg, tomato and green pepper
• Prawn mayonnaise / prawn cocktail
• Brie and cranberry sauce
•  Sauteed mushrooms, garlic and grated cheese

Glossary

Metabolic Rate – The amount of energy used by the body when at rest.

Calories – Unit of energy that comes from breaking down food from the digestive tract.

Protein – A type of essential nutrient that act as building block in the human body. Protein is an important source of fuel / energy for the body. Proteins are also involved in healing burn injuries.

Frequently asked questions

What is allograft?

Allograft skin is donated skin from deceased people

Why do I need allograft?

Allograft is commonly used in burn care to help your burns/wounds heal. It will provide a temporary cover to your burns, protecting your dermis and promoting healing.

It is used as a skin cover until auto grafting (own graft) is possible. It’s also sometimes used to protect auto grafts (sandwich technique)

Where does the skin come from?

Tissue is currently sourced from UK donors in compliance with rigorous ethical and clinical standards and supplied by NHS Blood and Transplant tissue services.

The consent process is approved by the Human Tissue Authority.

Are allografts safe?

Every tissue donor’s health and medical history is carefully checked to help rule out anyone who may pass on an infection.

Blood samples from tissue donors are tested for infection including Hepatitis B and C and HIV (virus that causes AIDS).

However, there’s always a small risk. Discuss this with your surgeon if you’re concerned.

How is the skin preserved?

Immediately following donation, it is decontaminated by antibiotic incubation, packaged and cryopreserved. It is then sterilised with gamma irradiation. The skin is donated in strips approximately 60mm wide and 0.3-0.5mm thick and packaged in individual packs containing approximately 120cm2-330cm2.

Once in hospital, it needs to be stored in a -80c freezer.

Who regulates the process?

The Human Tissue Authority. They inspect all hospitals with a licence to use allograft on a regular basis to ensure compliance with the process.

The Human Tissue Act is the law which governs consent for organ donation in England and Northern Ireland.

Will I reject the skin?

Skin does not behave in the same way than other organs. We do not expect donated skin to integrate with your own skin. However, there’s a small risk of this occurring. Discuss this with your surgeon if concerned.

Will the skin match my skin tone?

Allograft skin is usually under bandages so you will not be able to see it. However, sometimes it is left exposed on burns to the face.

A skin tone match cannot be offered or guaranteed as packets are not labelled with skin ethnic characteristics.

Can the donors be traced?

All donated skin is fully traceable. However, this information is not readily available. All donated skin packets have a unique barcode and donors can be traced in case of necessity.

Things to discuss with your doctor

Are alternative treatments available to me?

Some operations cannot be carried out without using a tissue transplant from another person, but it’s important to ask about alternative treatments.

Further reading

• NHS Tissue and eye services
• Human tissue authority
• Cell Tissue Bank. 2010 Feb. The use of human deceased donor skin allograft in burn care. Leon-Villapalos J1, Eldardiri M, Dziewulski P.

Next steps

Now your child has been discharged from the Burns Dressing Clinic it is important to understand a few points regarding your child’s healed skin

• The skin can fragile for the first month following healing
• The skin can remain red for up to 6 months following injury and can appear more red The skin may become more red when your child is distressed or when exercising (due to increased blood flow).
• Moisturising and massage is essential to hydrate your child’s skin (especially when dry). Please complete this 3-4 times daily
• Pigment can take longer to change therefore the skin may be lighter or darker in appearance and sun care protection is essential

Moisturising and massage

A plain, non-perfumed moisturising cream should be used. These can include: Aveeno, E45, Diprobase, Nivea, Cocoa Butter or Epiderm

Initially you should apply light pressure on the newly healed skin as it may be fragile however this should be increased so that when massaging you are applying enough pressure so that the tissues underneath becomes paler.

Please complete across the whole affected area in a circular motion for at least a few minutes depending on the size of your child’s newly healed skin.

To prevent a build-up of cream and blocked pores (which can occasionally cause spots) it is important to ensure all cream is absorbed into the skin; dab off any excess after massage.

Itch

Increased itching is common for your child’s newly healed skin. It is very important that you don’t scratch as this may cause the skin to break.  

To ease the itch it may be helpful to:

• Keep moisturising cream in the fridge
• Bathe in cool (not cold) water
• Wear cotton clothes and sleep under cotton bed sheets.

If these do not help, Children over the age of 1yrs can take over the counter chlorphenamine (Piriton©). Please follow instructions on packet and speak to Pharmacist about dosage.

Skin sensitivity

It is common for the affected area to be sensitive. To help with this you can:

• Perform regular massage
• Use different textures on the skin to get the new skin used to normal touch/textures (e.g. towels and cotton wool)
• Return to normal play and movement

Sun care

Your child’s newly healed skin doe s not have the same protection against the sun as it did previously and therefore is at very high risk of burning in the sun.

It is therefore important that appropriate sun care is carried out anytime your child is outside (e.g. factor 50 sun cream or covering the area).

Scarring

In the unlikely event of the area showing signs as listed below; please contact our Scar Therapy Department:

• Increase in height
• Increase in size
• Increase in firmness
• Increase in colour and itch
• Difficulty using the affected limb or generally struggling with normal play

Role of Scar Therapy

To help the scar flatten and stay mobile we are able to advise regarding the use of scar therapy techniques. These may include:

• Positioning/ Exercises and stretches
• Play
• Splints
• Scar massage
• Pressure garments (provided by therapies if required)
• Silicon

If you have questions about the information contained in this leaflet please don’t hesitate to contact our Burns Therapy Department either by telephone or email.

Please be aware that although you have been discharged from the Burns Dressing Clinic you can still contact Scar Therapy to discuss any concerns (within 1 year of your child’s burn injury).

Contact information

Burns and Plastics Therapy
Therapy Department
369 Fulham Road
London
SW10 9NH

T: 020 3315 5680

Or you can email burnstherapy.cw@nhs.net.

Please send the child’s name/ date of birth with updated photos and your question.

Paediatric Burns Psychology Service

If you are concerned about the psychological or behavioural impact of your child’s burn injury on them, on yourselves as parents, or on any member of your family, please contact our specialist burns psychology service.  

Our psychology team are able to offer support and advice on burn injury related concerns on:

Monday to Friday 9am–5pm

T: 020 3315 2504

Guidelines for patients with zinc tape dressings

This is a flexible tape dressing impregnated with zinc oxide. It is used to cover your burn and reduce infection. Zinc tape is antibacterial and promotes wound healing. It will need changing every day.

How to change

• Gently peel back the zinc tape from the skin starting with a corner- it may be firmly stuck but is relatively painless to pull off. It may help to soak the dressing first by having a bath or shower
• Clean wound with water and remove ooze
• Dry the wound
• Cut a new piece of zinc tape and apply over the wound
• Change the zinc tape daily

About your Zinc tape dressing

• SMELL: Zinc tape does not usually have an odour, if you have any concerns please call the burns unit.
• LEAKAGE: Zinc tape is intended for dry or slightly moist wounds. If the wound appears to be leaking, please call the burns unit to discuss a more suitable dressing.
• WRINKLING: Zinc tape will occasionally wrinkle up, and if this occurs apply a new dressing.
• RASH: Zinc tape does not usually cause a rash. If you are concerned about a rash please call the burns unit.

If you are unsure of anything, or have any questions or worries about this form of dressing, do not hesitate to telephone us on the Burns Unit 020 3315 3706.

Guidelines for patients with Duoderm dressings

This is a flexible waterproof dressing used to cover your burn/scald and reduce infection. When in contact with the wound, Duoderm forms a gel-like covering which can remain untouched for several days, but will need changing if leakage occurs.

How to change

• Gently peel back Duoderm from the skin starting with a corner- it may be firmly stuck but is relatively painless to pull off
• Clean wound with water and remove ooze
• Remove the white paper backing from the fresh piece of Duoderm and apply smoothly over the wound. Do not stretch unnecessarily and ensure when cutting to size to leave a margin of 1 inch around wound
• Leave intact for up to 4 days unless leakage occurs

About your Duoderm dressing

• SMELL: You may notice an unpleasant smell from the dressing, which is not necessarily due to the wound. Duoderm itself does have an odour, so do not be concerned as it will disappear on cleansing.
• LEAKAGE: This may occur around the edges of the dressing and has a yellow appearance – this is due to the Duoderm gel and is not pus.
• WRINKLING: Duoderm will occasionally wrinkle up, and if this occurs apply a new dressing.
• RASH: Occasionally a rash may occur around the edges of the Duoderm on very young children. If this happens –return to the Unit.

If you are unsure of anything, or have any questions or worries about this form of dressing, do not hesitate to telephone us on the Burns Unit 020 3315 3706.

How you might be affected

After any traumatic incident, it is normal to experience a number of stress reactions, which may continue for some weeks.

Traumatic events are shocking and emotionally overwhelming situations, and may arouse some powerful and upsetting feelings.

This leaflet is designed to give you some understanding of these common reactions and feelings, and to help you gain more control over them.

Overall people tend to be resilient and most people will recover without needing any professional help. However, this leaflet may be useful to you if you have recently experienced a traumatic event and are still trying to make sense of what has happened.

When traumatic events take place, our bodies react strongly. Because we are not calm or relaxed but feel under threat, our memory of events can be stored in
a different way, and in a different place to other day-to-day memories. This can lead to trauma memories being easily triggered, and sometimes recalled in a way which makes it feel like the event is happening all over again (re-experiencing).

Initial reactions

Reactions commonly experienced within the first few weeks of a traumatic incident include:

• Unpleasant thoughts or images about the event popping into your mind.
• Nightmares about the event.
• Not wanting to talk about what happened.
• Sleep difficulties and tiredness.
• Feeling helpless, angry or irritable.
• Wanting to avoid people, places or activities that remind you of the event.
• Feeling guilty or to blame for what happened.
• Concentration and memory problems.
• Headaches and bodily pain.
• Tearfulness and sadness.
• Fear and anxiety.
• Feeling numb or detached.

Re-experiencing

Re-experiencing (for example flashbacks, intrusive thoughts and nightmares) may:

• Be triggered by places, people, emotions, sounds, smells, tastes, physical sensations or images.
• Disturb daily living by happening when you are not expecting them and cannot control them.
• Make it feel like you are watching events as they happen to you.

These reactions are normal, understandable and usually reduce gradually over time.

What can I do that might be helpful?

• Reminding yourself that re-experiencing is normal following a traumatic event.
• Remember that the worst is over—the traumatic event happened in the past and is not happening to you now.
• Breathe deeply, slowly and calmly in through your nose and out through your mouth.
• Some people find it helpful to talk to those that they feel close to so that they can help when needed. They might be able to remind you of coping techniques, and that you are safe now.
• Remember: “My mind is doing its best to make sense of what happened.”
• Use grounding techniques (see below).

Coping skills

Grounding techniques

The main goal of grounding is to use your senses to focus your attention on your present surroundings. This gives you a safe way to feel greater control of what you are thinking and feeling, and allow you to find a balance of feeling emotions too much or too little.

Grounding techniques can be used during a flashback or after a nightmare to help bring you back to the ‘here and now’:

• Explore the space around you using all your senses. Describe objects, sounds, textures, colours, smells, shapes, numbers and temperature. For example, do not just notice “the chair is green", but look at it more closely. Is it textured? Is it fabric or plastic? What shade of green is it? How would you describe the shape?
• Switch on your body’s relaxation response by swallowing your saliva. You can do this by eating a mint, sweet, or by sipping some water. Try describing the flavours to yourself in detail.
• Notice the sensations in your body as you tense and relax different parts.
• Pick out things in the room that are the same colour, or things that are spelt with the same first letter.
• Use your own grounding object—a small, comforting, physical object which you can carry with you. You can focus on the detail of this object when you are re-experiencing.
• Use a grounding phrase (or song)—a few words which are positive and remind you that you are surviving in the present. For example, “I am safe” or “I’m ok”.

Looking after yourself

• Be patient with yourself—it may take time to process what has happened.
• Try to re-establish your usual routines.
• Spend time with people who make you feel safe and supported during this time.
• Take good care of yourself physically including exercising regularly, reducing alcohol/drug use and getting enough sleep. Drugs and alcohol may briefly numb your feelings or give immediate relief, but will also stop you from processing what has happened and soon create further physical and psychological problems for you to deal with.
• Talk to someone when you feel ready. This can help you piece together the event and understand things more clearly which may help in your recovery .
• Self-compassion—a helpful question might be: “what would you say to a friend who was in your situation?”

Toxic Shock Syndrome (TSS)

This leaflet aims to provide information for parents of children with an unhealed burn wound the signs and symptoms of TSS. The information in this leaflet will be discussed with you by one of the burns specialist nurses during your attendance at the burns unit.

What TSS?

TSS is a rare but life-threatening condition caused by bacteria getting into the body and releasing harmful toxins.

TSS gets worse very quickly and can be fatal if not treated promptly.

Causes

TSS is caused by either Staphylococcus or Streptococcus bacteria.

These bacteria normally live on the skin and in the nose or mouth without causing harm, but if they get deeper into the body they can release toxins that damage tissue and stop organs working.

Having an unhealed burn wound of any size increases your risk of getting TSS.

We strongly advise you keep a working thermometer to accurately record your child’s temperature.

Symptoms of TSS

The symptoms of TSS start suddenly and get worse quickly. They might include one or more of the following symptoms:

• A high temperature of 38°C and above
• Flu-like symptoms such as a headache, feeling cold, feeling tired, aching body, a sore throat and a cough
• Feeling and being sick
• Loose stools or Diarrhoea
• A widespread sunburn-like rash
• Lips, tongue and the whites of the eyes turning bright red
• Irritability
• Eating or drinking less than usual
• Decreased normal amount of wet nappies or not using the toilet as normal
• Dizziness or fainting
• Difficulty breathing
• Confusion
• Not well or “not themselves”

What to do if your child has symptoms of TSS?

TSS is a medical emergency and symptoms should not be ignored.

While these symptoms could be due to a different condition it is important to seek medical advice as soon as possible.

Parents must phone Mars ward as soon as possible if your child has any symptoms of TSS. The specialist burns nurse will then ask a series of questions to triage your child and provide clear advice on what next steps need to be taken.

If your child is difficult to rouse, has mottled appearance (blotchy purple markings on the body), has multiple symptoms or any signs of respiratory distress, then you must dial 999 immediately for review by the ambulance service.

Investigation and Treatment of TSS

If your child has TSS they will need to be admitted to hospital for investigations and supportive measures such as:

• Blood tests
• Wound swabs
• Intravenous antibiotics
• Intravenous fluids