Wound Care Basics: Assessing and Treating Burn Wounds

A burn is defined as damage to the skin and underlying tissues caused by heat, chemicals, or electricity. According to the American Burn Association, each year in the United States about 450,000 people receive medical attention for burn injuries, 4,000 people die due to fire and burns usually at the scene of the incident, and 45,000 people are hospitalized for burn injuries. The leading cause of fire death in the US is from fires due to smoking materials like cigarettes. Most burns occur in the home, involved less than 10% total body surface area (TBSA), and occur in men.¹

Burns are classified by assessing their depth. This can be assisted by the appearance of tissue and the amount of pain a patient is experiencing. First-degree or superficial burns typically present as blanchable erythema and can be painful. Second-degree burns can present as both superficial partial-thickness burns and deep partial-thickness burns. Second-degree superficial partial-thickness burns present as blisters or red, moist areas that are painful and can take 2-3 weeks to heal. Second-degree deep partial-thickness burns can appear wet or waxy and dry. They are typically painful to pressure only, require debridement, and take over three weeks to heal. Third-degree burns are waxy white, grey, or black and painless except to deep pressure as the nerves and vascular structures have been destroyed. They usually will not heal without debridement. Fourth-degree burns are wounds that involve muscle, fascia, organs, or bone and rarely heal without surgical intervention. The depth and degree of burns are critical prognostic indicators that also assist with disposition decisions and treatment. The depth or degree of a burn may not be immediately evident, and burns can appear deeper or more severe after a few days. The severity of burns is not only assigned by the TBSA affected and the depth or degree, but also the area of the body affected.^2,3

Treatment

Burn wound treatment aligns with generalized models of evidence-based wound care with a heavy emphasis on fluid resuscitation, early and serial excision/debridement of necrotic tissue, infection prevention, and pain control.

Antibiotics

Systematic reviews of burn patients have found no benefit in using systemic antibiotics to prevent burn wound infection and toxic shock syndrome.^4,5 Many clinicians think of silver sulfadiazine, also known as silvadene cream, when they think of burns. Silvadene is a topical cream that contains high levels of silver and a sulfa antibiotic. Despite its historic association as the most common burn treatment,⁶ some research has shown a significant increase in rates of burn wound infection and increased length of hospital stay with its use when compared to the use of dressings or skin substitutes.^5,7 The increased rates of burn wound infection with silver sulfadiazine use could be due to decreased oxidative burst and decreased viability of activated neutrophils that have been seen with silver in a porcine model.⁸ In addition, silver has been found to delay wound healing by contributing to DNA damage, promoting the expression of stress-related genes that induce oxidative stress.⁸

Dressings

Superficial, partial-thickness, and deep partial-thickness burns have been known to be extremely painful. Clinicians should choose dressings that maintain a moist healing environment. Some examples of dressing types associated with decreased pain include hydrogels and hydrogel sheets. A micellar surfactant gel (Plurogel; Medline, Chicago, IL) is available that can also help clear necrotic debris from the wound. Xenografts, allografts, and autografts are common in burn patients. Dehydrated fish xenografts are a newer product that shows promise in healing wounds.⁹ Veterinarians in California were noted to successfully apply fresh frozen tilapia skins to the paws of a bear with third-degree burns from a 2018 wildfire. Frozen tilapia skins were especially effective in that, um, patient population, as bears have been known to eat their wound dressings, contributing to intestinal blockages and other issues.¹⁰

Post Burn Treatment

Post-burn care incorporates the management of common symptoms, including swelling, pruritus, and scarring. Severe pruritus can occur in up to 87% of adult burns and 100% of pediatric burns.¹¹ It presents during wound healing but can persist well after epithelialization and scar maturation. First-line systemic treatment for post-burn pruritus are anti-histamines followed by other agents such as gabapentin and hydroxyzine. Topical treatments such as aloe vera, cocoa butter, colloidal oatmeal, silicone gel sheets, and topical glucocorticoids may also be effective.¹²

Conclusion

The American Burn Association recommends burns on the face, hands, major joints, and genitals or those involving more than 10% of the TBSA (and other criteria) warrant referral to a burn center after stabilizing the patient. Most minor burns can be treated in the home or wound center by adhering to evidence-based wound care recommendations.

References

1. Advanced Burn Life Support Course Provider Manual. 2018. American Burn Association. Accessed July 26,2021. http://ameriburn.org/wp-content/uploads/2019/08/2018-abls-providermanual.pdf
2. Wiktor A, Richards D. Treatment of minor thermal burns. UpToDate. Literature review current through Jun 2021. Last updated December 9, 2019
3. Centers for Disease Control and Prevention. Injury Prevention and Control: Data and Statistics (WISQARS). 2016. Accessed July 12, 2021. https://www.cdc.gov/injury/wisqars/fatal.html
4. Ramos G, Cornistein W, Cerino GT, Nacif G. Systemic antimicrobial prophylaxis in burn patients: systematic review. J Hosp Infect. 2017;97(2):105–114. doi:10.1016/j.jhin.2017.06.015
5. Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, Solà I, Bonfill Cosp X. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev. 2013;(6):CD008738. doi:10.1002/14651858.CD008738.pub2
6. Norman G, Christie J, Liu Z, et al. Antiseptics for burns. Cochrane Database Syst Rev. 2017;7(7):CD011821. doi:10.1002/14651858.CD011821.pub2
7. Nímia HH, Carvalho VF, Isaac C, Souza FÁ, Gemperli R, Paggiaro AO. Comparative study of Silver Sulfadiazine with other materials for healing and infection prevention in burns: a systematic review and meta-analysis. Burns. 2019;45(2):282–292. doi:10.1016/j.burns.2018.05.014
8. Nešporová K, Pavlík V, Šafránková B, et al. Effects of wound dressings containing silver on skin and immune cells [published correction appears in Sci Rep. 2021;11(1):4369]. Sci Rep. 2020;10(1):15216. doi:10.1038/s41598-020-72249-3
9. Kirsner RS, Margolis DJ, Baldursson BT, et al. Fish skin grafts compared to human amnion/chorion membrane allografts: a double-blind, prospective, randomized clinical trial of acute wound healing. Wound Repair Regen. 2020;28(1):75–80. doi:10.1111/wrr.12761
10. Quinton J. Healing burned animals with fish skins: innovative treatment could help solve global public health crisis. 2018. UC Davis Health News. Published September 17, 2020. Accessed July 26, 2021. https://www.ucdavis.edu/health/news/healing-animals-with-fish-skins
11. Goutos I, Dziewulski P, Richardson PM. Pruritus in burns: review article. J Burn Care Res. 2009;30(2):221–228. doi:10.1097/BCR.0b013e318198a2fa
12. Wiechman S, Sharar S. Management of burn wound pain and itching. UptoDate. Literature Review current through Jun 2021. Last updated February 24, 2020.