# Wound Management in Burns — ABA 2016

## Initial Wound Care

### Cooling

- Cool the burn wound with **tepid running tap water** (12-25 degrees C) for **20 minutes** as soon as possible after injury
- Cooling is most effective within the first **3 hours** post-burn
- **Do not** use ice or ice-cold water (risk of hypothermia and vasoconstriction worsening tissue injury)
- **Do not** apply butter, toothpaste, or other home remedies

### Cleaning

- Gently cleanse with **mild soap and water** or **dilute antiseptic solution** (e.g., chlorhexidine)
- Remove loose, non-viable tissue and debris
- **Large blisters** (> 2 cm or at risk of rupture): debride and remove blister roof
- **Small, intact blisters**: may be left intact if not on weight-bearing surfaces or over joints
- **Palmar and plantar blisters**: leave intact when possible to preserve barrier function

### Covering

Apply appropriate wound dressings based on burn depth:

| Burn Depth | Recommended Covering |
|---|---|
| **Superficial** | Moisturizer or aloe vera; no formal dressing required |
| **Superficial partial-thickness** | Non-adherent dressing + topical antimicrobial or silver-containing dressing |
| **Deep partial-thickness** | Topical antimicrobial agent (silver sulfadiazine or silver-containing dressing) |
| **Full-thickness** | Topical antimicrobial + plan for early surgical excision and grafting |

## Topical Antimicrobial Agents

Topical antimicrobials are the standard for **burn wound infection prophylaxis**. Systemic prophylactic antibiotics are **not recommended** as they do not prevent burn wound infection and promote antimicrobial resistance.

| Agent | Formulation | Spectrum | Key Properties | Limitations |
|---|---|---|---|---|
| **Silver sulfadiazine (SSD)** | 1% cream | Broad-spectrum (gram-positive, gram-negative, Candida) | Most widely used; painless application | May cause transient leukopenia; impedes re-epithelialization; sulfonamide allergy contraindication |
| **Mafenide acetate** | 11% cream or 5% solution | Broad-spectrum; penetrates eschar | Only agent that effectively penetrates thick eschar; useful for ear burns (chondritis prevention) | Painful on application; carbonic anhydrase inhibitor (metabolic acidosis risk) |
| **Silver-containing dressings** | Various (Acticoat, Mepilex Ag, Aquacel Ag) | Broad-spectrum | Less frequent dressing changes; less painful | Higher cost than SSD |
| **Bacitracin/polymyxin B** | Ointment | Gram-positive (bacitracin), gram-negative (polymyxin B) | Suitable for superficial burns, facial burns | Limited spectrum; not for deep burns |

### Topical Agent Selection Algorithm

```
Superficial partial-thickness burn
  -> Face? -> Bacitracin ointment (no SSD on face)
  -> Trunk/extremities? -> Silver sulfadiazine 1% cream or silver-containing dressing
  -> Ear cartilage involved? -> Mafenide acetate (prevents chondritis)

Deep partial-thickness or full-thickness burn
  -> Awaiting surgical excision? -> Silver sulfadiazine or mafenide acetate
  -> Thick eschar present? -> Mafenide acetate (penetrates eschar)
  -> Large TBSA, frequent dressing changes burdensome? -> Silver-containing dressing
```

## Escharotomy

### Indications

Escharotomy is an **emergency procedure** for circumferential or near-circumferential full-thickness burns that compromise distal circulation or respiratory function.

| Indication | Diagnostic Criteria |
|---|---|
| **Extremity vascular compromise** | Absent distal pulses on Doppler; SpO2 < 95% in distal extremity; compartment pressure > 30 mmHg |
| **Thoracic/abdominal respiratory compromise** | Increasing peak airway pressures; inadequate tidal volumes; clinical respiratory distress from chest wall constriction |
| **Abdominal compartment syndrome** | Bladder pressure > 20 mmHg with end-organ dysfunction |

### Timing

- Should be performed within **2-6 hours** after burn injury when clinical indications are present
- Delay increases risk of irreversible ischemic injury

### Technique

- Incisions are made through the **full thickness of the eschar** into subcutaneous fat
- Incisions **do not breach the deep fascial layer** (distinguishes escharotomy from fasciotomy)
- Standard incision lines:
  - **Extremities:** Medial and lateral mid-axial lines
  - **Chest:** Bilateral anterior axillary lines connected by a transverse subcostal incision
  - **Hands:** Dorsal longitudinal incisions between metacarpals
  - **Digits:** Mid-lateral incisions, avoid neurovascular bundles
- **No anesthesia required** for incisions through full-thickness burns (insensate tissue)

### Fasciotomy

Fasciotomy is indicated when:
- Clinical signs of compartment syndrome persist **after adequate escharotomy**
- **Electrical burns** with deep tissue injury (high suspicion for muscle compartment syndrome)
- Compartment pressure remains **> 30 mmHg** despite escharotomy

## Early Excision and Grafting

### Principles

Early surgical excision of nonviable burn tissue with immediate wound closure is the standard of care for deep partial-thickness and full-thickness burns that will not heal within 2-3 weeks.

### Timing

- **Early excision** (within the first **72 hours** post-injury) is associated with:
  - Decreased mortality
  - Reduced infection rates
  - Shorter hospital length of stay
  - Decreased blood loss compared to delayed excision
- For burns > 40% TBSA, **staged excision** may be necessary (limiting excision to 20% TBSA per operative session)

### Excision Techniques

| Technique | Description | Indication |
|---|---|---|
| **Tangential excision** | Sequential shaving of thin layers of burned tissue until viable, bleeding dermis is reached | Deep partial-thickness burns |
| **Fascial excision** | Excision of all tissue down to fascia | Very deep or extensively necrotic burns; massive TBSA burns |

### Wound Closure Options

| Option | Description | Indication |
|---|---|---|
| **Split-thickness skin graft (STSG)** | Gold standard; harvested from unburned donor sites | Primary closure for excised wounds |
| **Allograft (cadaveric skin)** | Temporary biologic coverage | Insufficient autograft available; staged procedures |
| **Xenograft (porcine skin)** | Temporary biologic dressing | Temporary coverage of superficial partial-thickness wounds |
| **Dermal substitutes** | Synthetic or biologic scaffolds (e.g., Integra) | Full-thickness burns where dermal template is needed |

## Infection Prevention and Management

### Prophylaxis

- **Systemic prophylactic antibiotics are NOT recommended** -- they do not prevent burn wound infection and promote antimicrobial resistance
- **Topical antimicrobials** are the standard prophylactic measure
- **Tetanus prophylaxis** is mandatory:
  - Immunization status must be assessed on admission
  - Administer **tetanus toxoid booster** if last dose > 5 years ago
  - Administer **tetanus immune globulin (TIG)** if vaccination history is unknown or incomplete (< 3 doses)

### Burn Wound Infection Diagnosis

Burn wound infection is diagnosed clinically and microbiologically:

| Feature | Finding |
|---|---|
| **Wound appearance changes** | Conversion of partial-thickness to full-thickness; dark brown/black discoloration; new eschar separation |
| **Systemic signs** | Fever, leukocytosis, hemodynamic instability |
| **Quantitative wound culture** | > 10^5 organisms per gram of tissue |
| **Wound biopsy** | Bacterial invasion into viable tissue (histological confirmation) |

### Treatment of Burn Wound Infection

```
Suspected burn wound infection
  -> Obtain wound cultures (surface swab AND tissue biopsy if possible)
  -> Start empiric systemic antibiotics covering gram-positive AND gram-negative organisms
      -> Typical empiric regimen: vancomycin + piperacillin-tazobactam or carbapenem
  -> Intensify topical antimicrobial therapy (consider mafenide acetate for eschar penetration)
  -> Surgical debridement of infected tissue
  -> Narrow antibiotics based on culture and sensitivity results
  -> Reassess wound daily for response to treatment
```

## Pain Management

Burns are among the most painful injuries. A **multimodal approach** is recommended.

### Multimodal Analgesia

| Component | Agents | Role |
|---|---|---|
| **Non-opioid analgesics** | Acetaminophen (1 g PO/IV q6h; max 4 g/day), NSAIDs (ibuprofen 400-600 mg PO q6h, ketorolac 15-30 mg IV q6h) | Baseline analgesia; opioid-sparing |
| **Opioid analgesics** | Morphine (0.1 mg/kg IV q2-4h PRN), hydromorphone (0.2-1 mg IV q2-4h PRN), fentanyl (25-100 mcg IV q1-2h PRN) | Moderate to severe pain; titrate to effect |
| **Neuropathic pain agents** | Gabapentin (300-600 mg PO TID), pregabalin (75-150 mg PO BID) | Neuropathic/dysesthetic pain; opioid-sparing |
| **Anxiolytics** | Lorazepam (0.5-2 mg IV/PO q4-6h PRN) | Procedural anxiety; adjunct to analgesia |
| **Procedural sedation** | Ketamine (0.5-1 mg/kg IV or 4-6 mg/kg PO), propofol, midazolam | Dressing changes, debridement |

### Pain Assessment

- Use validated pain scales consistently (Visual Analog Scale, Numeric Rating Scale)
- Assess and document pain at rest, with activity, and during procedures separately
- Anticipate and pre-treat pain before dressing changes and procedures

## Limitations

- Burn wound depth assessment may be inaccurate in the first 24-48 hours and may evolve over time; reassessment at 48-72 hours is recommended.
- Silver sulfadiazine, while widely used, has been associated with delayed wound healing in some studies; silver-containing dressings may be preferable for superficial partial-thickness burns.
- Optimal timing and extent of early excision in massive burns (> 50% TBSA) remain areas of clinical judgment; patient hemodynamic stability dictates operative feasibility.
- Pain management recommendations are based on expert consensus and extrapolation from general surgical pain literature, with limited burn-specific randomized controlled trial data.
