Debridement (removal of nonviable tissue) and wound dressings are used to decrease the risk of infection and decrease pain in superficial and partial thickness burns.
(See also Burns.)
Indications for Debriding and Dressing a Burn
Superficial and partial thickness burn wounds
Contraindications to Debriding and Dressing a Burn
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 patients, consult with the receiving burn center to decide whether to initiate certain aspects of burn care before transfer.
Complications of Debriding and Dressing a Burn
Allergic reactions to topical antibiotics
Equipment for Debriding and Dressing a Burn
Nonsterile gloves
Cleansing solution (eg, 2% chlorhexidine)Cleansing solution (eg, 2% chlorhexidine)
25- and 21-gauge needles
10-mL syringe
Local injectable anesthetic (eg, 1% lidocaine)Local injectable anesthetic (eg, 1% lidocaine)
Sterile scissors, forceps
Nonadherent dressing
Absorptive bulk dressing (such as 4 × 4 gauze dressings and tape, flexible rolled gauze wrap for extremity burns)
Relevant Anatomy for Debriding and Dressing a Burn
Burns involving the hands, feet, face, genitals, perineum, or involving major joints or burns that are circumferential or extensive often require transfer to a burn center.
Superficial (formerly called 1st-degree burns): Involving the epidermis only
Partial-thickness (formerly called 2nd-degree burns): Extending into the dermis
Full-thickness (formerly called 3rd-degree burns): Destroying the entire skin
For partial-thickness and full-thickness burns, estimate and document the size of burn, expressed as percentage of total body surface area (see figure [A] Rule of nines [for adults] and [B] Lund-Browder chart [for children]).
Positioning for Debriding and Dressing a Burn
Position to provide excellent exposure of burn wound
Step-by-Step Description of Debriding and Dressing a Burn
Initial care of all burn wounds
Diagnose and treat serious associated injuries. Any patient with other traumatic injuries should be fully evaluated to identify and treat life threatening injuries first.
Remove all clothing and gross debris from the burned area.
Remove all jewelry from the burn and also any that is distal to the burn to prevent entrapment from potential edema.
For chemical burns, irrigate with tap water for at least 20 minutes to remove any residual chemicals.
For thermal burns, irrigation will cool the injured area to prevent additional thermal damage, but optimal duration of irrigation has not been established (1).
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 (2). Do not immerse 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 as soon as possible. Analgesics can be given concurrently with initiation of irrigation. For severe pain, IV opioids (eg, fentanyl 1 mcg/kg, or morphine 0.1 mg/kg) can be administered and titrated as needed. For mild to moderate pain, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen may be sufficient (Treat pain as soon as possible. Analgesics can be given concurrently with initiation of irrigation. For severe pain, IV opioids (eg, fentanyl 1 mcg/kg, or morphine 0.1 mg/kg) can be administered and titrated as needed. For mild to moderate pain, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen may be sufficient (3).
Ensure that irrigation has removed all clothing and debris from the burned area.
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.). Incompletely immunized patients should also receive tetanus immune globulin 250 units IM.
Transfer stable patients with major burns (full-thickness burns > 1% TBSA, partial-thickness burns > 5% TBSA, burns of the hands, face, feet, or perineum (partial-thickness or deeper) to a burn center.
If patients do not require transfer to a burn center or other appropriate facility, definitive burn care may be provided.
Definitive burn wound care
Cleanse the burned area gently with a clean cloth or gauze and soap and water or a mild antibacterial wound cleanser such as chlorhexidine.Cleanse 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 clinicians recommend leaving unruptured blisters intact, and others recommend opening them with sterile scissors and forceps. Regardless, desquamated skin and broken blisters are devitalized tissue that should be debrided by peeling from the wound and excising with scissors close to the border with viable, attached epidermis (4).
Apply a sterile burn dressing, with or without a topical antimicrobial cream/ointment.
There are several options for burn dressings (5). Some are impregnated with antimicrobials (eg, silver). Most are a form of gauze, but there are biosynthetic dressings with some of the characteristics of skinX that adhere to the wound and can be left in place for extended periods of time (6). Some contain an antimicrobial, those that do not are typically applied over a layer of antimicrobial cream or ointment. 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 as bacitracin or mupirocin directly to all wounds except superficial burns. Silver sulfadiazine, once a mainstay of topical burn treatment, is Consider applying a layer of antibiotic cream or ointment such as bacitracin or mupirocin directly to all wounds except superficial burns. Silver sulfadiazine, once a mainstay of topical burn treatment, isno longer recommended because it is not more effective than other topical antibiotic preparations and may impair wound healing. However, it is sometimes still used for partial thickness burns (7).
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 additional layers of loose gauze fluffs which can absorb exudate from the burn wounds more effectively than gauze pads. 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 for Debriding and Dressing a Burn
Give instructions about taking analgesics at home, and provide or prescribe if appropriate.
Instruct the patient to elevate an affected limb to prevent swelling, which may cause delayed healing or infection.
Instruct the patient to return for follow-up visit about 24 hours after initial burn care. At this visit, remove the dressing and reassess the burn for depth of injury and need for further debridement, then redress. Frequency of additional visits depend on several factors, discussed below.
The timing and location (eg, clinic, home) of subsequent dressing changes depend on
The type of dressing used: The frequency of dressing changes vary, depending on the dressing material and the wound. Most should be changed daily.
Patient and family ability to perform wound care: Large burns, wound locations requiring awkward or complicated dressings, and/or patients who are not able to manage wound care (with or without help of others at home), may need more frequent professional care and/or less frequent dressing changes.
The amount of exudate produced by the wound: Drier burns need less frequent dressing changes.
For wound self-care, patients should wash hands with soap and water, gently remove the old dressing, rinse the wound with lukewarm tap water, and apply a similar dressing material as first used.
Warnings and Common Errors When Debriding and Dressing a Burn
Do not underestimate the need for procedural analgesia and sometimes sedation, particularly for complicated debridement or dressing changes. Inadequate analgesia deters thorough wound care.
Tips and Tricks for Debriding and Dressing a Burn
For burns on the face and neck: Cleanse the wound with chlorhexidine and debride blisters and any loose skin, then apply a topical antibiotic such as bacitracin but leave the wound uncovered. The wound can be washed 2 or 3 times per day, followed by reapplication of the topical agent. Encourage patients to sleep with their head elevated to help minimize or decrease swelling.For burns on the face and neck: Cleanse the wound with chlorhexidine and debride blisters and any loose skin, then apply a topical antibiotic such as bacitracin but leave the wound uncovered. The wound can be washed 2 or 3 times per day, followed by reapplication of the topical agent. Encourage patients to sleep with their head elevated to help minimize or decrease swelling.
Alternatives to IV opioids as analgesia for initial management include regional or nerve block anesthesia; inhaled nitrous oxide; or IV ketamine. Alternatives to IV opioids as analgesia for initial management include regional or nerve block anesthesia; inhaled nitrous oxide; or IV ketamine.
For debridement of small burns, local anesthetic injection may provide adequate analgesia.
Home burn care and dressing changes may be quite painful. For severe pain, an adequate supply of an oral opioid analgesic should be provided, and responsible analgesic use should be encouraged.
References
1. Djärv T, Douma M, Palmieri T, et al. Duration of cooling with water for thermal burns as a first aid intervention: A systematic review. Burns. 2022;48(2):251-262. doi:10.1016/j.burns.2021.10.007
2. International Society for Burn Injury (ISBI) Practice Guidelines Committee, Steering Committee, Advisory Committee. ISBI practice guidelines for burn care. Burns. 2016;42(5):953–1021. doi: 10.1016/j.burns.2016.05.013
3. Romanowski KS, Carson J, Pape K, et al. American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps. J Burn Care Res. 2020;41(6):1129-1151. doi:10.1093/jbcr/iraa119
4. Greenhalgh DG. Management of Burns. N Engl J Med. 2019;380(24):2349-2359. doi:10.1056/NEJMra1807442
5. Żwierełło W, Piorun K, Skórka-Majewicz M, et al. Burns: Classification, Pathophysiology, and Treatment: A Review. Int J Mol Sci. 2023;24(4):3749. Published 2023 Feb 13. doi:10.3390/ijms24043749
6. Aggarwala S, Harish V, Roberts S, et al. Treatment of Partial Thickness Burns: A Prospective, Randomized Controlled Trial Comparing Four Routinely Used Burns Dressings in an Ambulatory Care Setting. J Burn Care Res. 2021;42(5):934-943. doi:10.1093/jbcr/iraa158
7.Heyneman A, Hoeksema H, Vandekerckhove D, et al. The role of silver sulphadiazine in the conservative treatment of partial thickness burn wounds: A systematic review. Burns. 2016;42(7):1377–1386. doi:10.1016/j.burns.2016.03.029
