Burn Care
Indications
● Minor burn wounds
Contraindications
Absolute contraindications
● None
Relative contraindications
● Wounds or other burn-related injuries that require transfer to a specialized burn
unit (see treatment of burns)
In these cases, decide together with the receiving burn center what burn care to provide before
transfer.
Complications
● Allergic reactions to topical antibiotics
Equipment
● Nonsterile gloves
● Cleansing solution, such as 2% chlorhexidine
● 25- and 21-gauge needles
● 10-mL syringe
● Local injectable anesthetic, such as 1% lidocaine
● Sterile scissors, forceps
● Nonadherent dressing
● Specialized burn wound dressings, if available and warranted (eg, petrolatum gauze
impregnated with 3% bismuth tribromophenate)
● Absorptive bulk dressing (such as 4 × 4 gauze dressings and tape, flexible rolled gauze
wrap for extremity burns)
Anatomy
● Burns involving the hands, feet, face, genitals, perineum, or major joints or burns
that are extensive often require transfer to a burn center.
Depth of skin injury:
● First-degree: Involving the epidermis only
● Second-degree (partial-thickness): Extending into the dermis
● Third-degree (full-thickness): Destroying the entire skin
Estimate the size of burn, expressed as percentage of total body surface area of partial-
thickness and full-thickness burns (see figure (A) Rule of nines (for adults) and (B) Lund-
Browder chart (for children)).
Procedure
Initial care of all burn wounds
● Stabilize patient as per trauma protocol.
● Irrigate chemical burns involving the skin or eyes with tap water, often for
prolonged periods.
● During the first 30 minutes after injury, use room temperature (20 to 25° C) or cold
tap-water irrigation, immersion, or compresses to limit the extent of the burn and
provide significant pain relief. Add ice chips to water or saline to lower the
temperature as needed. However, avoid immersing burned tissue in ice or ice
water because ice immersion increases pain and burn depth and increases the risk
of frostbite and, if the burn surface is large, systemic hypothermia.
● Treat pain before doing anything to the burn wound. For minor burns, nonsteroidal
anti-inflammatory drugs (NSAIDs) and acetaminophen also may be effective.
● Remove all clothing and gross debris from the burned area. Remove any jewelry
from the burn and distally, such as rings.
● Cover the burn with a moist, sterile dressing soaked in room temperature water or
saline. The dressing should be kept cool and moist to provide continued pain relief.
● Give tetanus toxoid-containing vaccine (eg, Td, Tdap) depending on patient's
vaccination history (see table Tetanus Prophylaxis in Routine Wound
Management). Incompletely immunized patients should also receive tetanus
immune globulin 250 units IM.
Transfer stable patients with major burns to a burn center. For other patients, complete burn
wound care.
Definitive burn wound care
● Clean the burned area gently with a clean cloth or gauze and soap and water or a
mild antibacterial wound cleanser such as chlorhexidine.
● Irrigate the wound with saline or water.
● Some physicians recommend leaving unruptured blisters intact, and others
recommend opening them with scissors and forceps. Regardless, loose skin and
broken blisters are devitalized tissue that should be debrided by peeling from the
wound and snipping with scissors close to the border with viable, attached
epidermis.
● Apply a sterile burn dressing, with or without a topical agent.
There are several options for burn dressings. Some are impregnated with antimicrobials (eg,
silver). Most are a form of gauze, but there are biosynthetic dressings with some of the
characteristics of skin that adhere to the wound and can be left in place for extended periods of
time. Some are typically used over a layer of antimicrobial cream or ointment, whereas those
containing an antimicrobial are not. In all cases, dressings should be sterile and have an
absorptive layer sufficient for the amount of exudate expected.
● Consider applying a layer of antibiotic cream or ointment such bacitracin or
mupirocin directly to all wounds except for 1st-degree or superficial burns.
Silver sulfadiazine, once a mainstay of topical burn treatment, is no longer
recommended because it is no better than other topical antibiotic
preparations and may impair wound healing (1). Silver sulfadiazine may be
used as a second line agent.
● Cover the wound surface. There are many commercial dressings available but a
fine-mesh gauze or commercial nonadherent gauze is appropriate.
● Cover and pad the wound with loose gauze fluffs. If fingers and toes are involved,
pad the web spaces and the digits individually and separate them with strips of
gauze. Wrap the entire dressing with an absorbent, slightly elastic material.
Aftercare
● Provide analgesics to take at home.
● Instruct the patient to elevate an affected limb to prevent swelling, which may
cause delayed healing or infection.
● Follow up in about 24 hours. At the first follow-up visit, remove the dressing and
reassess the burn for depth of injury and need for further debridement, then
redress.
The timing and location (eg, clinic, home) of subsequent dressing changes depend on
● The type of dressing used: Some dressings are intended to be left on for a period
of time and others are changed frequently.
● Patient and family capability: Large burns, areas requiring awkward or complicated
dressings, and patients with limited self-care skills, may need more frequent
professional care and/or less frequent changes.
● The amount of exudate produced by the wound: Drier burns need less frequent
dressing changes.
For self-care, patients should gently remove the old dressing, rinse the wound with lukewarm
tap water, and apply similar material as first used.
In any case, the wound should be examined 5 to 7 days after injury.
