Burn wounds typically need debridement and/or dressing.
Debridement (removal of nonviable tissue) and wound dressings are used to decrease the risk of infection and provide comfort in minor burns.
(See also Burns.)
Indications for Debriding and Dressing a Burn
Minor 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 cases, decide together with the receiving burn center what burn care to provide 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, 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)
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.
Depth of skin injury:
Superficial (formerly 1st-degree burns): Involving the epidermis only
Partial-thickness (formerly 2nd-degree burns): Extending into the dermis
Full-thickness (formerly 3rd-degree burns): 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]).
Positioning for Debriding and Dressing a Burn
Patient comfort with excellent exposure of burned areas
Step-by-Step Description of Debriding and Dressing a Burn
Первинна обробка всіх опікових ран
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. The best analgesics for severe pain are usually IV opioids in titrated doses, such as fentanyl 1 mcg/kg, or morphine 0.1 mg/kg. 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 or piercings.
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.
Радикальна обробка опікової рани
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 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 as bacitracin or mupirocin directly to all wounds except 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. However, it is sometimes still used for partial thickness burns (1).
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 for Debriding and Dressing a Burn
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.
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 bland 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 include regional or nerve block anesthesia; inhaled nitrous oxide; or IV ketamine.
For debridement of small burns, local anesthetic injection may be adequate analgesia.
Home burn care and dressing changes may be quite painful. An adequate supply of an oral opioid analgesic should be provided, and responsible analgesic use should be encouraged.
Довідковий матеріал
1.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 42(7):1377–1386, 2016. doi:10.1016/j.burns.2016.03.029
Додаткова інформація
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Pham TN, Cancio CL, Gibran NS: American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res 29(1):257–266, 2008. doi: 10.1097/BCR.0b013e31815f3876
Kagan RJ, Peck MD, Ahrenholz DH, et al: Surgical management of the burn wound and use of skin substitutes: An expert panel white paper. J Burn Care Res 34(2):e60–e79, 2013. doi: 10.1097/BCR.0b013e31827039a6
International Society for Burn Injury (ISBI) Practice Guidelines Committee, Steering Committee, Advisory Committee: ISBI practice guidelines for burn care. Burns 42(5):953–1021, 2016. doi: 10.1016/j.burns.2016.05.013
