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Acute Burns - Treatment

Acute Burns - Treatment

Acute Burns - Treatment


This topic covers management of acute burns. For a review and framework for assessment of acute burns including first aid and initial care (primary assessment, assessment of inhalation injury, secondary assessment), classification of acute burn injuries, burn center referral criteria, documentation and ICD-10 coding, see topic "Acute Burns - Introduction and Assessment". For clinical guidelines and quality measures, see "Acute Burns - Overview". 

Treatment summary

Patients should be assessed, triaged and referred to a burn center as per criteria outlined in sections ‘Classification of Burn Injuries’ and ‘Burn center referral criteria’ in topic "Acute Burns - Introduction and Assessment". Management of minor, moderate and severe burn injuries require pain control, tetanus immunization and local wound care. Patients with moderate or severe burn injuries generally meet at least one burn center referral criterion. Nutrition should be optimized and antibiotics administered, if indicated. In addition, patients with severe burn injuries often require initial stabilization, coagulopathy management, thromboprophylaxis and surgical management. Table 1 provides details on management of burn injuries by severity. 

Hospital admission: Patients with inhalation injury, hemodynamic instability requiring monitoring, or any other risk factors that are potentially life threatening must be admitted to an intensive care unit. Other burn patients may be treated as outpatients or inpatients depending on specific conditions and criteria. See Burn center referral criteria’ in topic "Acute Burns - Introduction and Assessment", and 'Disposition' in Table 1 in this topic.

Whether the patient is treated in the outpatient or inpatient setting, an adequate treatment plan for acute burns should aim to:

Treat the cause/ provide systemic treatment. See details related to: 

  • Initial stabilization with fluid resuscitation, inhalation injury management 
  • Infection management 
  • Tetanus immunization
  • Nutritional optimization

Address patient's concerns

  • Pain control is critical to ensure comfort and help promote healing

Provide effective wound care

  • Local interventions: the primary goals of local wound management are the prevention of desiccation of viable tissue and the control of bacteria. Topical management will follow the same basic principles of wound management, including cleansing, debridement of nonviable tissue, infection control, and moisture management. See local wound care for superficial, superficial partial-thickness, deep partial-thickness and full-thickness burns in 'Local Interventions' in this topic. Table 2 shows local wound care interventions for burn injuries by burn depth, Table 3 shows dressings and topical products commonly utilized in burn injuries.
  • Surgical management: escharotomy is indicated for circumferential burns of the limbs and/or thorax that compromise blood circulation or oxygenation. Surgical excision of burns with or without definitive wound coverage with skin grafting is employed in the treatment of most full thickness burns, and often in patients with burn TBSA greater than 10%. See indications, techniques, and types of wound coverage.

Plan Reassessment: patient follow up intervals vary according to burn severity. 

Adjunctive Therapy: see details on biophysical interventions (e.g., negative pressure wound therapy, hyperbaric oxygen therapy), wound coverage with cellular and/or tissue products and biologics (e.g. mesenchymal stem cells)

ICD-10 coding: See section on 'Coding' in "Acute Burns - Introduction and Assessment"

Clinical guidelines and quality measures: See "Acute Burns - Overview".



This topic covers management of acute burns. For a review and framework for assessment of acute burns including first aid and initial care (primary assessment, assessment of inhalation injury, secondary assessment), classification of acute burn injuries, burn center referral criteria, documentation and ICD-10 coding, see topic "Acute Burns - Introduction and Assessment". For clinical guidelines and quality measures, see "Acute Burns - Overview". 


Patients should be assessed, triaged and referred to a burn center as per criteria outlined in sections ‘Classification of Burn Injuries’ and ‘Burn center referral criteria’ in topic "Acute Burns - Introduction and Assessment".

Treatment goals

 Treatment goals and plan are determined by the extent, depth of burns and overall patient status.

Management by Burns Severity

Table 1 below provides an overview on management of burn injuries by severity, based on clinical guidelines by the International Society for Burns Injuries (ISBI), American Burn Association (ABA), systematic reviews, and expert opinion.[1][2][3] 

Table 1. Overview on management of burn injuries by severity

Minor burnModerate burnMajor/severe burn
  • Partial-thickness burns <10% TBSA in patients 10 to 50 years old
  • Partial-thickness burns <5% TBSA in patients under 10 or over 50 years old
  • Full-thickness burns <2 % TBSA in any patient without other injury


  • Does not meet any of the burn center referral criteria as defined by the American Burn Association
  • Isolated injury
  • Does not affect feet, face, hands, perineum or major joints
  • Is not circumferential
  • Partial thickness burns 10-20% TBSA in adults
  • Partial thickness burns 5-10% TBSA in children or those over age 50
  • 2-5% full thickness burn
  • Low voltage burn, suspected inhalation injury, circumferential burn
  • Comorbid conditions predisposing to infection (e.g., diabetes mellitus, sickle cell anemia)
  • Partial thickness burns >20% TBSA in adults
  • Partial thickness burns >10% TBSA in children or those over age 50
  • >5% full thickness burn
  • High voltage burn
  • Chemical burn
  • Any clinically significant burn to the eyes, ears, genitalia, or major joints
  • Clinically significant concomitant (e.g., fracture, other major trauma)


  • Typically treated in the outpatient setting, provided none of the criteria for burn center referral is met. Intangible factors such as availability of resources, and patient’s self care ability should be taken into consideration during disposition planning
  • Most patients benefit from a consult/referral to a burn center to ensure proper management in the outpatient setting
  • Patients with full thickness burns should be evaluated by a burn center for the need for skin grafting
  • Generally meet one of the burn center referral criteria. After evaluation by burn center, patient may be treated as inpatient at a hospital with experience in burn management
  • Should be referred to or treated at a designated burn center
  • Patients with inhalation injury, hemodynamic instability requiring monitoring, or any other risk factors that are potentially life threatening must be admitted to an intensive care unit

Systemic treatment and patient's concerns

  • Pain control
  • Tetanus immunization
  • Pain control
  • Antibiotics if indicated
  • Tetanus immunization
  • Nutritional optimization

  • Initial stabilization 
  • Pain control
  • Coagulopathy management
  • Thromboprophylaxis
  • Antibiotics if indicated
  • Nutritional optimization

Local and/or surgical interventions

  • Local interventions (See Table 2)
  • Local interventions (See Table 2)

  • Local interventions, including potential escharotomy (See Table 2)
  • Surgical management (e.g. burn excision, autologous and other grafts, advanced wound management)

Treat the cause/ provide systemic treatment

Initial stabilization

Indicated for all major/severe burns and some moderate burns, before referral and after referral to a burn center.

Fluid resuscitation
  • Indications: fluid resuscitation is indicated for patients with more than 20% TBSA, older adults or children. Adequate hydration should be initiated as soon as the patient is assessed. Patients with less than 20% TBSA may achieve adequate hydration with oral fluids [4], which may be complemented with intravenous maintenance hydration. 
  • Formulas: various formulas are used to guide volume resuscitation, such as the Parkland or Modified Brooke Formula. Common to both formulas, the recommended fluid is Ringer’s lactate solution (RL), administered from 2 to 4 ml/kg/% of burns over a period of 24 hours.[1] As an example of typical regimen, in the first 24 hours patients receive 2ml/kg/% of RL plus maintenance fluid calculated at 50ml/kg body weight. In the next 48h fluid is given at the rate of 1ml/kg/% of RL plus maintenance fluid at 50ml/kg body weight. [5]
  • Assessment: resuscitation formulas only serve as a guideline; the patient's physiologic response must be the true marker for assessment of adequate volume replacement.. All the formulas guide resuscitation with the aim of achieving a diuresis between 0.3-0.5 ml/kg/h in adults and 1.0 ml/kg/h in children.[1]
    • In children, maintenance intravenous fluid administered after the first 24 hours must include glucose due to the risk of depleted hepatic glucose stores after 12 to 14 hours of fasting.[1] 
    • In adults, a recent randomized controlled trial with 200 patients concluded that dextrose normal saline (DNS) should be used as daily maintenance fluid with RL, as RL is low in sodium (130 mEq/L) as well in potassium (4mEq/L), and thus not sufficient to cover daily electrolyte requirements.[5]
    • Some patients (e.g. victims of electric burns or pulmonary/inhalation injury) may present with additional fluid requirements.[6]
Inhalation injury management
  • Inhalation injury is accompanied by plugs formed from dead epithelial cells, fibrin clots, and mucus, which potentiate the obstruction of the airways and result in inadequate ventilation. Diagnosis is confirmed by bronchoscopy. For details on assessment of inhalation injury, see 'Assessment of Inhalation Injury' in topic "Acute Burns - Introduction and Assessment".
  • Patients with inhalation injury require prompt management, including maintenance of airway patency and adequate ventilation to ensure optimal tissue oxygenation. Frequently, patients with severe inhalation injury require intubation. 
  • Respiratory physiotherapy combined with mucus-thinning/anti-inflammatory medications have been reported to improve outcomes. Despite the lack of globally-accepted standard for treatment, current data support use of bronchoscopy to remove plugs, nebulization with heparin, bronchodilators and N-acetylcysteine.[7]
  • Prophylactic antibiotics and corticosteroids are not indicated for treatment of inhalation injury.[2]

Infection management

  • For patients with partial or full-thickness burns with spreading or systemic clinical signs and/or symptoms of infection, hospital admission and treatment with systemic antibiotics are recommended.
  • 1CFor patients with acute burns of any extent or depth without symptoms or signs of infection, we recommend against use of systemic antibiotic prophylaxis to prevent infection (Grade 1C)
    • Rationale: a 2013 Cochrane systematic review did not find evidence that systemic antibiotic prophylaxis improves any of the primary outcome variables assessed (burn wound infection, sepsis, bacteraemia, urinary tract infection, or death associated with infection), when compared to placebo or to no active treatment.[8]

Tetanus immunization

  • For patients with burns deeper than superficial, the Centers for Disease Control (CDC) recommends that tetanus immunization be updated.[9][10] 
  • If the number of previous doses of tetanus toxoid is unknown or fewer than 3 doses, patients should receive tetanus immune globulin as well as tetanus vaccination. 



  • The metabolic response to burns is characterized by hypermetabolism, increased protein catabolism, and loss of lean body mass. The degree of hypermetabolism is approximately proportional to the extent of the burn; if TBSA exceeds 30%, significant changes in metabolism occur. This hypermetabolic state contributes directly to mortality.[11]
  • The presence of malnutrition also dampens the immune response, further compromising the capacity of the patient to prevent and/or recover from infections and other metabolic insults.[11] Scar formation in burns is also compromised by malnutrition, causing further delay in definitive healing.[11]
  • The increase in protein catabolism leads to loss of more than one kilogram of skeletal muscle per day, which may compromise movement of the diaphragm, potentially impairing respiratory function; it also contributes to the loss of strength and endurance, thereby prolonging the rehabilitation period. [11] Despite aggressive nutritional support, protein catabolism often exceeds anabolism, making weight loss after severe burn injuries a common occurrence.[2]

Nutrition goals

  •  The objective of nutrition in the context of a comprehensive plan of care is to minimize the amount of weight loss during recovery.

Nutritional assessment

To achieve the goal above, serial calculated assessments of nutritional status are necessary in order to appropriately estimate the daily caloric requirements.

  • The initial assessment must take into consideration pre-existing nutritional deficiencies such as marasmus or vitamin deficiency syndromes.[12]
  • Follow up assessments must include routine measurements (at least twice a week) of the patient’s weight.[8][12]
  • Various formulas for assessing nutritional status have been tested in adult and pediatric patients. The majority of these equations estimate the base caloric requirements per kilogram body weight or additional requirements above the calculated base quantity (based on the Harris-Benedict equation), adjusted by a factor due to stress from systemic trauma. Unfortunately, all these formulas suffer from some degree of imprecision, likely due to fluctuations in the metabolism of each patient that arise in association with inflammation, sepsis or surgical procedures. [13] However, use of these formulas is still considered best practice in burn centers all over the world.[2]

Nutrition plan

    A review [14] of the most recent international clinical guidelines on nutrition for patients with severe burns found that the European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines [15] provided the majority of information concerning nutrition support and medical nutrition therapy, compared to the other 7 appraised guidelines. A summary of the recommendations on nutrition for major burn injuries (i.e. > 20% TBSA, with or without inhalation injury) by the ESPEN guideline and others is provided below: 

    • Indication: Nutritional therapy should be initiated early, within 12 hours of injury.[15][16] 
      • Conventional oral diets or enteric feeds must be initiated as soon as possible (during the first 24 hours). The physiologic impetus for early nutrition in burn injury involves maintaining the thickness of the intestinal mucosa, controlling intestinal permeability, stimulating the gut-associated lymphoid tissue, supporting the processing of bacterial translocation.[2]
    • Route: Guidelines recommend favoring the enteral route in the majority of cases, as parenteral administration is rarely indicated and carries increased rate of complications.[15] 
      • The general expectation is that early enteral feeding will improve clinical outcomes, specifically by reducing post-burn hypermetabolism and improving the immune response, resulting in less weight loss and fewer infections.[17] The few exceptions where parenteral nutrition may be preferred is in the setting of short bowel syndrome, gastrointestinal fistulas, or bowel obstruction.[2] Post-pyloric feeding seems to be more efficient than gastric feeding in ensuring tolerance to enteral nutrition and energy supplementation. If intolerance to enteral nutrition develops, parenteral nutrition may be required.[18]
    • Energy requirements & predictive equations: ESPEN recommends considering indirect calorimetry as a gold standard to assess energy requirements. If not available or not suitable, the guideline recommends using the Toronto equation for adult burn patients. For children, we suggest use of Schoffield formula.[15] 
    • Proteins:
      • Protein requirements are higher than in other categories of patients, and should be set around 1.5-2.0 g/kg in adults and 3 g/kg/day in children.[2][15] 
      • ESPEN suggests glutamine supplementation (or ornithine alpha-ketoglutarate) but not arginine.[15] There is low certainty evidence that glutamine may reduce mortality among patients with severe burn injury.[19]
    • Glucose and glycemic control:
      • ESPEN suggests limiting carbohydrate delivery (prescribed for nutritional and drug dilution purpose to 60% of total energy intake, and not to exceed 5 mg/kg/min in both adults and children), and suggests keeping glucose levels under 8 mmol/l (145 mg/dl) and over 4.5 mmol/l (81 mg/dl), using continuous intravenous infusion of insulin.[15] 
    • Lipids: ESPEN suggests monitoring total fat delivery, and maintaining fat calories at < 35% of total energy intake.[15] 
    • Micronutrients: ESPEN suggests, in both adults and children, supplementation of zinc, copper and selenium, as well as of vitamin B1, C, D and E.[15] 
    • Metabolic modulation: ESPEN strongly recommends using non-nutritional strategies to attenuate hypermetabolism and hypercatabolism in both adults and children (e.g. warm ambient temperature, early surgical burn excision, non-selective beta-blockers, and oxandrolone).[15] The guideline recommends administering rhGH to children with burns with TBSA >60%, but not to adults.[15] 

    Address Patients' Concerns

    Pain control

    • Pain level will differ according to patients’ pain tolerance, as well as burn extent and severity. It is important to obtain pain control to promote comfort and optimize healing conditions. The WHO Analgesic Ladder provides guidance on appropriate pain management.[20]  
    • Novel analgesic medication regimens including agents such as ketamine are becoming increasingly prevalent in burn management, namely in severe burns where patients are intubated and require sedation.[21][22]

    Local Wound Care

    The primary goals of local wound management are the prevention of desiccation of viable tissue and the control of bacteria.[2] Topical management will follow the same basic principles of wound management, including cleansing, debridement of nonviable tissue, infection control, and moisture management.[2] See summary in Table 2 below.

    Table 2. Local wound care interventi ons for burn injuries [2] 

    InterventionSuperficial burn injurySuperficial partial thickness burn injury
    Deep partial thickness and full thickness burn injury
    • Gently cleanse by irrigation with neutral, non-irritating, non-toxic, non-antimicrobial cleansers such as tap water/ sterile saline
    • Gently cleanse by irrigation with neutral, non-irritating, non-toxic, non-antimicrobial cleansers such as tap water/ sterile saline
    • Cleanse with antimicrobials/antiseptics (e.g. chlorhexidine) after mechanical or surgical cleansing/debridement
    • Gently cleanse by irrigation with neutral, non-irritating, non-toxic, non-antimicrobial cleansers such as tap water/ sterile saline
    • Cleanse with antimicrobials/antiseptics (e.g. chlorhexidine) after mechanical or surgical cleansing/debridement 
    • No need for debridement
    • Effective debridement can be obtained with conservative sharp, mechanical and/or enzymatic debridement techniques
    • Bullae: when deciding whether unroof bullae or leave intact, factors such as potential for local infection, patient comfort, and ease of treatment must be considered
    • Non-viable tissue can be effectively removed via sharp debridement or surgical excision
    Infection and bioburden control
    • Usually not a concern, as involves only the epidermis 
    • If no signs of infection, consider limiting use of topical prophylactic antibiotics such as silver sulfadiazine (SSD) for prevention of infection or to promote wound healing
    • If signs of infection, collect wound culture, initiate topical antimicrobial dressings and empiric systemic antibiotic therapy
    • If no signs of infection, early tangential excision of necrotic tissue helps prevent infection 
    • If invasive infection, surgical excision and systemic antimicrobial therapy are recommended 
    Moisture management
    • Patient can self-apply moisturizers with essential fatty acids or vegetable oils to promote faster wound healing
    • Benefit from occlusion for long periods (at least one week) if injury is clean. If not clean, change every other day until signs of healing
    • Dressing choice depends on ulcer characteristics, clinical experience, patient preference, care setting and cost
    • May apply moisturizers with essential fatty acids or vegetable oil on the wound and periwound
    • Maintain wound moisture or provide moisture to dry wounds with:
      • Hydrogel, foam dressings, honey gel, contact layer
    • Manage exudate with:
      • Alginate, fiber gelling dressing (hydrofiber), foam dressings
    • See Wound Prep and Dress Tool, WoundReference's Dressing Feature Matrices 

  • Definitive wound coverage with autografts/ flaps is indicated
  • Wound bed preparation for definitive coverage can be accomplished by closed or open dressings.
  • For cases in which early tangential excision is planned, closed dressing technique is indicated. Topical antimicrobial is applied and covered with dressings to soften eschar.
  • For cases in which early excision is not feasible (e.g. palliation, lack of resources), or on face/ perineum, open technique is appropriate until eschar separation begins.
  • Open technique: apply vaseline-based gauze and/or topical antimicrobials on wounds. Once eschar separation begins, trim loose edges of eschar.
  • After eschar is removed by tangential excision or is naturally separated, remaining full-thickness defect (raw area) is managed as a chronic wound until definite wound closure, as follows:
  • For dry wounds, maintain wound moisture or provide moisture with: Hydrogelfoam dressings, honey gel, contact layer
  • For exudate management, consider using: Alginate, fiber gelling dressing (hydrofiber)foam dressings
  • See Wound Prep and Dress Tool, WoundReference's Dressing Feature Matrices 


    • For all acute burns regardless of size and depth: Keeping the wound bed clean helps prevent infections and is essential for expeditious healing.
      • Technique: cleansing with gentle washing is the most important component of burn wound cleansing. Cleansing by irrigation decreases bacterial count and helps promote healing. [2]
      • Cleanser: the beneficial effect of using antiseptics or antimicrobial agents for cleansing is unclear.[2] The ISBI Guidelines recommend [2]: 
        • For non-infected wounds: use tap water for cleansing non-infected wounds.
        • For heavily infected wounds with evident biofilm: use of antiseptics/antimicrobials as topical antimicrobials and not cleansing agents, after tap water/saline irrigation, to combat the exposed bacteria and organisms that became ‘‘accessible’’ after cleansing.
        • For burn injuries that need mechanical or surgical cleansing: cleansing with antimicrobials/antiseptics (e.g. chlorhexidine) is of great value after mechanical or surgical cleansing as this helps prevent the possible passage of the ‘‘denuded’’ bacteria to the newly opened spaces and/or bloodstream.


    • For all acute burns regardless of size and depth: Essential practices for local treatment include removal of contaminants, debris, foreign bodies, fibrinous exudates, and any nonviable tissue from the wound bed.
      • At each dressing change, remove previously used dressing materials, as well as exudates and crusts. Additionally, maintain the personal hygiene and comfort of the patient.[2]
    • For partial thickness burns (Figures 1 to 3): 
      • Effective debridement can be obtained with conservative sharp, mechanical and/or enzymatic debridement techniques.
        • Conservative sharp debridement may be performed with curettes, scissors, etc.
        • Mechanical debridement can be accomplished by brushing off non-viable tissue with sterile saline-moistened gauze or chlorhexidine surgical scrub brushes.
        • An enzymatic debrider (e.g. collagenase) may be applied over non-viable tissue after cleansing and before application of secondary dressings. Clinical studies support use of collagenase as a debriding agent for burns, however evidence is of high uncertainty due to high risk of bias of these studies.[23] Collagenase may also mitigate need for surgical excision by preventing burn conversion via down-regulation of the local inflammatory response.[24] Contraindications to collagenase include local infection, allergic reactions, and use in combination with certain dressings .
      • Bullae (or blisters) (Figure 3): Bullae are often present in acute partial thickness burn injuries. There is little consensus in literature as for whether or not they should be unroofed. Patients often present with blisters that have already been intentionally or inadvertently ruptured.[25] One advantage of unroofing bullae is the ability to visualize and appropriately assess the wound bed, as intact vesicles obscure the true depth. When deciding whether to unroof or leave bullae intact, factors such as potential for local infection, patient comfort, and ease of treatment must be considered.[26] There is some evidence supporting leaving bullae smaller than 6 mm intact.[26] 
    • For full-thickness burns: Non-viable tissue can be effectively removed with sharp debridement or surgical excision (see ‘Surgical management’)
    • For longstanding raw areas (i.e., full-thickness burns after eschar has been detached or surgically removed): like with other chronic wounds, biofilm is often present. Its removal is critical for healing, and this can be accomplished through mechanical debridement (fibrous pads, curettage) or sharp debridement.[2]

    Fig. 1. Right leg with partial thickness burn injury, covered with non-viable tissue. By Lebendiskaya N.

    Figure 2. The same patient in Figure 1, 1 week after conservative debridement (sharp and enzymatic), moisturizer, petroleum gauze and Unna's boot

                     Figure 3: Partial thickness burn injury with bullae

    Infection and Bioburden Control

    • Superficial burns or burns in the final phase or repair with no signs of infection do not benefit from topical antibiotics. Instead, an ointment (e.g, with essential fatty acids or vegetable oils) should be used to expedite wound healing. 
    • 2CFor partial thickness burn injuries with no signs of infection, we suggest clinicians consider limiting use of topical prophylactic antimicrobial agents such as silver sulfadiazine to prevent infection or promote wound healing (Grade 2C).
      • Rationale: Although commonly utilized on burn injuries, evidence gathered by 2 meta-analyses and 1 systematic review [8][27][28] shows that patients treated with prophylactic 1% silver sulfadiazine (SSD) have a higher risk of burn wound infection and longer length of hospital stay than those treated with dressings or skin substitutes (low certainty evidence, level C). As a result, use of SSD as a prophylactic topical antimicrobial agent is no longer routinely recommended. Despite its antimicrobial effect, there is no direct evidence that SSD prevents infection.[27] Furthermore, it is known to inhibit the growth of keratinocytes and fibroblasts, which may explain why partial thickness burns treated with SSD take longer to heal compared with silver dressings or dressings without silver.[27][28] 
      • Contraindications: If SSD is utilized on partial of full-thickness burns, it should be discontinued when epithelialization is complete. Also, eschars will not absorb topical antimicrobials and application of SSD will be ineffective until eschar is excised.[29] SSD should not be applied on patients with sulfa allergy and must be used with caution in pregnant/breastfeeding women, children younger than 2 years, individuals with G6pD deficiency, porphyria, hepatic, renal or hematological disease.[30]
      • Drug interactions: SSD should not be used with the enzymatic debriders collagenase or papain, as silver inactivates these enzymes. See topic "Products that inhibit collagenase enzymatic activity".
    • For partial-thickness burn injuries with clinical signs of infection, wound culture should be collected, then topical antimicrobial agents and empiric systemic antibiotics should be initiated. 
      • Topical antimicrobial agents include antimicrobial dressings (e.g. with silver, honey).
      • Empiric antimicrobial therapy should be effective against local strains of microbes and cover gram positive and gram negative organisms. Consult infectious disease professionals or hospital microbiology department to confirm that selected empiric antibiotics are appropriate. 
    • For full-thickness burn injuries, early tangential excision of the necrotic tissue has been shown to prevent wound infection.[31] For invasive infection, surgical excision of the infected wound and appropriate systemic antimicrobial therapy may be required.[32]
    • For patients being managed at healthcare facilities, if systemic signs of infection are present, investigation of potential sources of infection other than the burn wounds is also recommended (e.g., catheter-related infection, pneumonia, etc).[33]


    Specific dressing regimes for non-operative and post-operative management of burns will vary widely by geographic location; there is no current consensus or guideline that recommends specific types of dressing for the various types of burn injuries. Important factors to consider for dressing selection include clinical evidence, product availability, cost, facility resources, clinician familiarity and comfort with product application, patient status and condition (inpatient, bed-bound or ambulatory, or outpatient), exudate, burn depth and % TBSA, expected level of activity and mobility, any concomitant orthopedic injuries, and necessary invasive lines or devices. For specific information on dressings see Table 3 below, Wound Prep and Dress ToolWoundReference's Dressing Feature Matrices 

    • 2CFor partial thickness burn injuries with no signs of infection, we suggest use of dressings with or without silver to promote wound healing, instead of SSD (Grade 2C).[27][28] 
      • Rationale: A systematic review and meta-analysis evaluated healing rates and incidence of infection among burn patients treated with SSD, dressings with and without silver. Authors concluded that dressings with and without silver promote faster wound healing compared to SSD, and that burns treated with dressings without silver are less likely to become infected than burns with SSD. Authors found no differences between SSD and new silver materials in regards to infection rates.[27] 
      • Dressings that have shown increased effectiveness in healing partial thickness burn injuries include:
        • Honey-based dressings (compared to SSD or mafenide acetate, moderate certainty evidence level B) [34] 
        • Hydrogel (compared with usual care, low certainty evidence level C) [28]
        • Dressings with nanocrystalline silver or merbromin (compared to petroleum gauze or other non-antimicrobial treatments, moderate or low certainty evidence level B or C) [34]
      • When choosing dressings, humid and heat-preserving dressings are preferred.
        • Maintain wound moisture or provide moisture to dry wounds with:
          • Hydrogel, foam dressings, honey gel, contact layer
        • Manage exudate with:
            • Alginate, fiber gelling dressing (hydrofiber), foam dressings
      • Superficial partial thickness burns and donor sites of split-thickness skin grafts benefit from occlusion for long periods (at least one week) if the burn injury is clean. If the injury is dirty (e.g. covered with materials incorrectly used for first-aid such as coffee or sand), or if the patient presents more than 24 hours after the accident, it is advisable to change the dressing more frequently (e.g., every other day) until infection is ruled out and the wound has started to heal. 
    • For deep partial thickness or full-thickness burn injuries, definitive wound coverage with autografts/ flaps is indicated (see section 'Wound coverage with autologous skin grafting' below) Wound bed preparation for definitive coverage can be accomplished by closed or open dressings.[2]  
      • For cases in which early tangential excision is planned, closed dressing technique is indicated. Topical antimicrobial is applied on the wounds and covered with dressings to soften eschar. By the end of the first week after injury, virulent organisms begin active invasion of the unburned tissue. Closed technique allows eschar to remain soft to allow tangential excision. It also prolongs contact of the antimicrobial agent with the eschar, helping prevent infection and desiccation. 
      • For cases in which early excision is not feasible (e.g. palliation, lack of resources), or on face/ perineum, open technique is appropriate until eschar separation begins. In the open technique, vaseline-based gauze and/or topical antimicrobials are applied on wounds. Once eschar separation begins, trim loose edges of eschar. Risk of infection is higher and patient might experience pain during eschar removal. 
    • After eschar is removed by tangential excision or is naturally separated, remaining full-thickness defect (raw area) is managed as a chronic wound until definite wound closure is performed.

    As it relates to the application of dressings, a few practical points are listed below:

    • Bandages/wraps (e.g. elastic dressing retainers, elastic roll bandages, etc) may be required to retain primary dressings. In limbs with burns, the entire limb is typically wrapped distally to proximally to control edema. If possible, fingers should be spared from the dressing and the hand wrapped in a fashion that maximizes the patient's functional independence.
    • There are some specialty dressings manufactured specifically for burn injuries, including burn vests, arm, leg, and buttock pads; these can be somewhat bulky, and are ideally used for bedbound patients whose wounds require higher absorbency.
    • For bedbound burn patients, moisture management to prevent moisture-related pathogen proliferation (e.g. Pseudomonas infections) is an additional consideration. Sheets, and dressings with microclimate control may be used.
    • Prevention of hypothermia is crucial in burn patients, but prevention of hyperthermia and subsequent vasodilation and moisture loss is of equal importance. Specialty bed surfaces covers (e.g. KCI Skin IQ mattress cover) can draw away excess moisture from the skin/surface interface and assist with microclimate management. 

    The following Table 3 provides a brief overview of common dressing utilized in burns.

    Table 3. Dressings and topical products commonly utilized in burn injuries [35][28][36][37][38][39][40][41][42][43][44]

    Product CategoryProduct TypeAttributes

    Skin care

    Therapeutic Moisturizers

    • Oat Beta Glucan Ointment (e.g. Glucan Pro 3000). 
    • Aloe vera (e.g. Fruit of the Earth 100% Aloe Vera Gel, Trader Joe’s 99% Aloe Vera Gel)
    • Calendula (e.g. Califlora, Calendula ointment)
    • Water-based (e.g. Light: Aveno Daily, Moderate: Eucerin, Heavy: Aquaphor)
    • for periwound skin, superficial burns, and partial thickness burns

    Skin care

    Drying agents (e.g. Zeasorb powder)

    • for use under skin folds to prevent skin maceration


    Collagenase ointment (e.g. Santyl)

    • provides enzymatic debridement of adherent fibrinous exudates and nonviable tissue
    • anti-inflammatory action
    • used on partial thickness burns, sometimes used on deeper facial burns

    Topical antimicrobials

    Polysporin (powder or ointment)

    • overall gram+/- coverage
    • often mixed with collagenase to provide concurrent antimicrobial coverage with enzymatic debridement

    Topical antimicrobials

    1% silver sulfadiazine cream (Silvadene)

    • broad-spectrum antimicrobial coverage
    • twice daily dressing changes required
    • can delay healing, stain tissue, and create "pseudo-eschar"
    • relatively contraindicated in pregnant or nursing mothers, newborns, patients with sulfa allergy or glucose-6-phosphate dehydrogenase deficiency


    Silver Foam (Mepilex AG, Mepilex AG Transfer)

    • absorbent and non-adherent
    • silver impregnated
    • broad-spectrum antimicrobial coverage
    • decreased total cost compared with SSD 
    • good for skin graft donor sites and large surface areas


    Honey Dressings (Medihoney gel sheets, etc)

    • antiseptic
    • has been shown to promote faster healing compared to silver sulfadiazine


    Hydrogel sheets (e.g. Aqua clear and Nu-gel, Johnson & Johnson)

    • maintain wound moisture
    • fluid donating properties may also aid autolytic debridement
    • In its sheet form, gel is presented with a fixed three-dimensional macro structure


    Impregnated non-adherent gauze (Xeroform, Adaptic)

    • Xeroform contains bismuth which is bacteriostatic and supports epithelialization
    • Adaptic is not impregnated with active agents
    • impregnated gauzes can be used for superficial burns, or postoperatively over skin grafts until the areas are completely healed


    Silicone sheets (Mepitel, Mepitel AG, Adaptic Touch)

    • can be somewhat costly
    • can decrease pain and dressing change frequency
    • may remain intact while secondary absorptive dressings are changed


    Compression therapy (e.g, Unna's boot for legs, Viscopaste/ Kerlix wrap for arms)

    • help secure dressings, maintain moisture, and decrease edema

    Surgical Management


    • Escharotomy is indicated for full-thickness circumferential burns of the limbs with signs of reduced tissue perfusion (diminished or absent peripheral pulses) (Figure 4), and circumferential injuries of the thorax and chest that compromise ventilation and oxygenation (Figure 5).[2]
      • Although retrospective studies have been published, most studies do not describe in details when escharotomies should actually be performed.[45] Also, to date no randomized controlled study has explored the treatment of compartment syndromes in the thorax or extremities.[2]
    • When indicated, escharotomy is generally performed after the initiation of fluid resuscitation.[46] This procedure must be performed early in order to avoid complications from inadequate mechanical ventilation, such as atelectasis.

    Fig. 4. Full-thickness circumferential burn of right leg. Signs of reduced tissue perfusion may be present

    Fig. 5. Full-thickness circumferential burn injury of the thoracic and abdominal regions

    • Extremities: Incisions are made on the lateral and medial aspects along the longitudinal axis of the limbs, avoiding the path of the blood vessels (Figure 6); it is preferable to begin distally and proceed proximally, so that the incision can be discontinued when viable tissue is reached and bleeding is visualized.
      • In the event of electrical burns or circumferential burns in involving the hand, early decompression of the hand is indicated (Figure 7). In circumferential or electric burns of the upper extremity, it is often necessary to free the carpal tunnel and retinaculum of the forearm flexor muscles. Various structures are present in the reduced space of the wrist and decompression ensures effective return of perfusion to the distal aspect of the fingers.[1]

      Fig. 6. Escharotomy performed along the upper right extremity. 

      Fig. 7. Escharotomy of the hand

      • Circumferential burns of the thorax: For circumferential burns of the thorax, incisions over the anterior axillary lines and between the abdomen and thorax are indicated in order to facilitate chest excursion and subsequent lung expansion. Of note, an escharotomy in this area will not follow longitudinal lines (Figure 8).
      • Abdomen: Abdominal escharotomy must be performed whenever a circumferential or semi-circumferential burn is associated with evidence of abdominal compartment syndrome (ACS). ACS is a critical issue that may be associated with many forms of trauma (Figure 8). Burn injuries are a relatively uncommon cause of ACS, but burn patients may develop ACS even in the absence of severe abdominal wall burn injury. In these patients, ACS may result from massive blunt trauma, fluid overload with crystalloids, or septic shock. Therefore, the presence of full-thickness circumferential burns of the abdomen does not predicate ACS and inversely, the absence of abdominal burns does not exclude the presence of ACS. Furthermore, there is a notable  mortality rate among burn patients with ACS despite undergoing abdominal escharotomy, which raises questions about the efficacy of escharotomy in the treatment of ACS. ACS can be diagnosed by measuring the intravesical pressure (IVP) through a catheter inserted inside the urinary bladder. The normal IVP value is lower than 5 mmHg, but a value of up to 12 mmHg is accepted in trauma cases. Values higher than 25 mmHg indicate raised intra-abdominal pressure and require intervention, while values between 12 and 25 mmHg indicate the need for observation and serial assessments.[2]

      Fig. 8. Thoracic and abdominal escharotomy

      Surgical excision


      Surgical excision of burns with or without skin grafting is employed in the treatment of most full thickness burns, and often in patients with burn TBSA greater than 10%. Early excision (as early as 1 day post injury) and grafting reduces the length of hospital admission, improves long-term functional and cosmetic outcomes, and results in a better cost-benefit ratio.[47][48]

      Types of surgical excision:

      Surgical excision of burns may be described based on time (i.e. how long has elapsed since the burn injury) and based on depth of the excision.

      • By time elapsed since injury:
        • Early excision is the removal of necrotic tissue before invasive infection begins; however, the length of time is not universally defined and generally ranges from the first week to a maximum of 10 days after trauma; it is also dependent upon timing/onset of diuresis.
        • In late excision, a greater length of time is allowed to pass in order to allow for the observation of areas that are evolving, either toward repair or conversion to deeper injury. This period of time is also not defined, but generally ranges from 10 to 21 days. However, in the presence of infection, imminent surgical intervention is indicated.
      • By depth:
        • Tangential excision is a sequential strategy whereby pieces of necrotic tissue are gradually removed until viable tissue is exposed.
        • Total excision, also called fascial excision, is the removal of the burned tissue in addition to the subcutaneous tissue at a predetermined depth; it is normally performed to the level of the deep fascia for full-thickness burns.[2]
      • Dermal preservation during excision is crucial in order to obtain better healing and scar outcomes. Although standard of care remains early tangential excision through sharp excision with a knife or guarded straight blade, current evidence does not show superiority of one tool over another. As for methods, options besides sharp excision with knives/blades include enzymatic debridement (e.g. NexoBridTM, UK) or hydrosurgery (e.g. Versajet).[49]
      • Geographic location and size of burn unit, staff experience level, and provider board certification, can contribute to variations in practice. A survey by the American Burn Association showed that among respondents, 56% of surgeons will perform excision as early as post-burn day 1 and 73% will excise greater than 20% TBSA in one setting.[50]

      Strategies that may contribute to improved hemostasis include.[2]:

      • Infiltration of the subcutaneous tissue below the eschar of the burn and the donor site with a solution containing epinephrine, or the topical application of a solution containing epinephrine, or both;
      • Use of tourniquets when limb surgery is performed;
      • Prevention of hypothermia;
      • Use of compression dressings and limb elevation;
      • Total excision with electrocautery when indicated;
      • Limiting area of excisions and length of procedure.

      Wound coverage with autologous skin grafting

      • For full-thickness and deep partial thickness burn injuries: autologous skin grafting (Figures 9 to 18) has been shown to substantially improve outcomes compared to scar formation from healing by secondary intention. The accelerated healing of full-thickness burns afforded by skin grafting results in expedited patient recovery and reduces the incidence and severity of contractures. The benefits of skin grafting for full-thickness burns are so evident that there is a scarcity of controlled research to provide proof for these benefits.[51]
      Types of autologous skin grafts
      • Sheet: considered by many as the gold standard for coverage of burn wounds of up to 20% TBSA. Sheets are partial thickness skin grafts, harvested with pneumatic dermatomes (Figures 9 and 10) or special skin graft knives. Sheets offer superior cosmetic results compared to meshed grafts and are preferred for cosmetically sensitive areas such as face, neck and hands (Figures 11-16). Disadvantages of sheet skin grafts include the creation of a donor site scar (Figure 17) and the potential for collecting hematoma under the sheet, resulting in partial graft loss.[52]
      • Meshed: sheet skin grafts may be fenestrated with a mechanical meshing device and become “meshed” (Figure 18). Meshing allows for expansion of the graft and coverage of larger surfaces in the burn patient while using relatively smaller donor sites when compared with sheet grafting. Common mesh ratios include 2:1, 1.5:1, and less commonly 1:1, but expansions of up to 9 times are sometimes needed in patients with extensive burns and limited donor sites. Fenestrations in the graft allow exudates to drain, decreasing the risk of hematoma formation and graft loss. Disadvantages include worse scarring compared to sheet grafts (usually following a “meshed” pattern).[52]
               Fig. 9. Dermatome      
      Fig. 10. Dermatome. Harvest of a split-thickness skin graft
      Fig. 11. Full-thickness burn injury on right forearm and hand
      Fig. 12. Sheet split-thickness skin grafts on right hand

      Fig. 13. Same patient shown in Figure 11, 3 months after sheet split-thickness skin grafts

      Fig. 14. Range of motion preserved after sheet split thickness skin grafts

      Fig. 15. Deep partial thickness burn injury on face and neck 

      Fig. 16. Deep partial thickness burn injury on face and neck 2 months after sheet skin grafting 
      Fig. 17. Split-thickness skin graft donor area, right thigh
      Fig. 18. Appearance of a meshed skin graft

      Recently, devices have been approved by the FDA for preparation of autologous skin cell suspension at the point-of-care using a small sample of the patient's skin (e.g., Recell).

      • Indications: autologous skin cell suspension is indicated for direct application on acute partial-thickness burn wounds or application in combination with meshed autografts for acute full-thickness thermal burn wounds. Potential benefits include minimization of donor skin harvesting requirements and enhancement of re-epithelialization of widely meshed skin grafts.[53]® System combined with split-thickness meshed autografts for the reduction of donor skin to treat mixed-depth burn injuries. | Holmes JH 4th, Molnar JA, Shupp JW, Hickerson WL, King BT, Foster KN, Cairns BA, Carter JE et al. | 2019" target="_blank">[54] 
      • An industry-sponsored cost-effectiveness study concluded that use of autologous skin cell suspension compared to standard of care may reduce hospital costs and length of stay of severe burns in the U.S.[55]  


      In deeper burns (e.g. full thickness burns), especially in those caused by high-voltage electricity, early fasciotomy is indicated in the extremities to preserve perfusion and function (Figures 19 and 20). Necrotic tissue must be totally removed - particularly necrotic muscle which may cause potentially fatal cardiac, renal, and infectious complications, which could be prevented with aggressive burn excision. In some cases, amputation of a limb or a severely-compromised portion of it could be a life-saving measure.[2]

      Fig. 19. Full-thickness burn caused by high-voltage electricity on right hand

      Fig. 20. Same patient shown in Figure 16. Fasciotomy was required to treat acute carpal tunnel syndrome due to compartment syndrome

      Plan Reassessment

      Patient follow up intervals vary by case, but generally:

      • For superficial burns: treated as an outpatient with visits every 5 days
      • For superficial partial thickness burns: may be treated as outpatient or inpatient, depending on severity and location of the burn injury (see Table 1). If treated as an outpatient, follow up visits usually scheduled every 2-3 days
      • For deep partial thickness or full thickness burn injuries: patients are usually admitted to the hospital depending on severity and location of the burn injury (see Table 1), with daily or more frequent assessments. 

      Plan reassessment may happen at every visit or dressing change due to the dynamic nature of this acute condition, however use of adjunctive therapy may be indicated only when standard therapy fails to promote desired outcomes.  

      Adjunctive Therapy

      Biophysical interventions 

      Negative pressure wound therapy
      • For wounds that do not require grafting,  Negative Pressure Wound Therapy (NPWT) has been reported to facilitate epithelial closure. [56][57] NPWT has also been used to promote engraftment (AKA "graft take") of split-thickness skin grafts by bolstering, or enhancing immobilization of the grafts.[57][58] Nevertheless, evidence supporting use of NPWT to promote healing of burn wounds is of low certainty, derived primarily from case reports and retrospective studies. Randomized controlled clinical trials are needed to validate any putative benefits of NPWT in burns.[57]
      Hyperbaric oxygen therapy
      • For burn patients with carbon monoxide toxicity due to inhalation injury, Hyperbaric Oxygen Therapy (HBOT) is recommended as administration of supplemental oxygen has long been the cornerstone of therapy for patients suffering CO poisoning. See HBO topic "Acute Carbon Monoxide Poisoning"
      • For severe burn patients, adjunct HBOT 24-48 hours after injury has been studied for its potential to promote faster wound healing, decrease pain and prevent partial to full-thickness conversion.[59][60][61][62] However evidence to date is not sufficient to justify widespread routine use in clinical practice. Studies have been mostly carried out in animal models, and the few randomized controlled trials (RCTs) published so far have contradictory results.[61]  

      Wound Coverage

      Cellular and/or Tissue Products 

      Cellular and/or Tissue Products (CTP), also referred to as skin substitutes, have been long utilized in burns. CTPs were originally designed to replace autologous skin grafts in the treatment of burns and chronic wounds.[63] 

      For the management of partial thickness burns, evidence derived from RCTs suggests that:

      • Bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, and allogeneic cultured skin, are at least as efficacious as topical agents/wound dressings or allograft. [64]
      • Apligraf combined with autograft is at least as efficacious as autograft alone.[64]
      • Suprathel, a polylactide-based copolymer, was shown to result in satisfactory skin quality and scar formation outcomes for deep dermal burns as compared with autologous skin.[65] Another study compared Suprathel with Omiderm and concluded that although less cost-effective than Omiderm, Suprathel provided more patient comfort. [66]

      For the management of full thickness burns, evidence derived from RCTs suggests that:

      • In a 3-arm comparison among Integra(®), viscose cellulose sponge Cellonex™ or partial thickness skin autograft, all treatments after 12 months demonstrated equal clinical appearance, as well as histological and immunohistochemical findings.[67]
      • When compared with cadaveric skin allograft, Integra for treatment of full-thickness burns in pediatric patients was associated with statistically significant superior outcomes upon long term follow up (2 years). Outcomes included improved scarring in terms of height, thickness, vascularity, and pigmentation.[68]
      • For chronic burn wounds, amniotic membrane (fresh, lyophilized and/or irradiated) showed superiority in increasing the success rate of graft take in chronic burn wounds compared to conventional dressing.[69] 


      Cell-based therapy utilizing mesenchymal stem cells (MSCs), also known as mesenchymal stromal cells, is still considered experimental. Cell-based therapy with MSCs is currently being investigated as a therapeutic avenue for severe thermal burns, due to their ability to repair and replace cellular substrates, attenuate inflammation, increase angiogenesis and enhance migration of reparative cells. [70] Randomized clinical trials underway include studies evaluating use of MSCs to accelerate healing in patients with <20% TBSA partial thickness burns (NCT02104713) and in patients with partial or full thickness burns needing autologous skin grafts (NCT03113747).[71]


      A systematic review of foam dressings for partial thickness burns., 2019 Jun
      Journal: The American Journal of Emergency Medicine

      BACKGROUND: Partial thickness burns are the most common form of thermal burns. Traditionally, dressing for these burns is simple gauze with silver sulfadiazine (SSD) changed on a daily basis. Foam dressings have been proposed to offer the advantage of requiring less frequent dressing change and better absorption of exudates.

      OBJECTIVE: To compare the impact of silver-containing foam dressing to traditional SSD with gauze dressing on wound healing of partial thickness burns.

      METHODS: We performed a systematic literature search using PubMed, EMBASE, CINAHL, Web of Science, Cochrane Library database and Google Scholar for trials comparing traditional SSD dressings to that of silver-containing foam dressing on wound healing in partial thickness burns < 25% of the body surface area. We excluded studies that enrolled burns involving head, face, and genitals; burns older than or equal to 36 h, non-thermal burns, and immunocompromised patients. Quality of trials was assessed using the GRADE criteria. The main outcome, complete wound healing, is reported as percentages of wound with complete epithelialization after the follow up period. Relative risks of complete healing are also reported with respective 95% CI. Time to healing and pain score before, during, and after dressing change at each follow up visit are compared between the groups (means with standard deviation or medians with quartiles).

      RESULTS: We identified a total of 877 references, of which three randomized controlled trials (2 combined pediatric and adult trials and 1 adult trial) with a total of 346 patients met our inclusion criteria. All three trials compared silver-containing foam dressing to SSD and gauze on partial thickness burns. Moderate quality evidence indicated no significant difference in wound re-epithelialization between the groups across all three trials as confidence intervals for the relative risks all crossed 1. Although pain scores favored foam dressing at the first dressing change (7 days), there was no significant difference between the groups at the end of the treatment period at 28 days. Time to wound healing was also similar across the three trials with no statistical difference. Infection rates favored the foam-dressing group, but data were inconsistent.

      CONCLUSION: Moderate quality evidence indicates that there is no significant difference in wound healing between silver-containing foam dressing and SSD dressing. However, foam has the added benefit of reduced pain during the early treatment phase and potentially decreased infection rates.

      Copyright © 2019. Published by Elsevier Inc.

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      Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: European consensus guidelines update., 2020 Jun
      Journal: Burns

      INTRODUCTION: Bromelain-based Enzymatic Debridement has been introduced as an additional concept to the burn surgeon's armamentarium and is best indicated for mid-to deep dermal burns with mixed patterns. Increasing evidence has been published focusing on special regions and settings as well as on limitations of Enzymatic Debridement to improve patient care. To better guide Enzymatic Debridement in view of the increasing experience, there is a need to update the formerly published consensus guidelines with user-orientated recommendations, which were last produced in 2017.

      METHODS: A multi-professional expert panel of plastic surgeons and burn care specialists from twelve European centers was convened, to assist in developing current recommendations for best practices with use of Enzymatic Debridement. Consensus statements were based on peer-reviewed publications and clinical relevance, and topics for re-evaluation and refinement were derived from the formerly published European guidelines. For consensus agreement, the methodology employed was an agreement algorithm based on a modification of the Willy and Stellar method. For this study on Enzymatic Debridement, consensus was considered when there was at least 80 % agreement to each statement.

      RESULTS: The updated consensus guidelines from 2019 refer to the clinical experience and practice patterns of 1232 summarized patient cases treated by the panelists with ED in Europe (2017: 500 cases), reflecting the impact of the published recommendations. Forty-three statements were formulated, addressing the following topics: indications, pain management and anesthesia, large surface treatment, timing of application for various indications, preparation and application, post-interventional wound management, skin grafting, outcome, scar and revision management, cost-effectiveness, patient´s perspective, logistic aspects and training strategies. The degree of consensus was remarkably high, with consensus in 42 out of 43 statements (97.7%). A classification with regard to timing of application for Enzymatic Debridement was introduced, discriminating immediate/very early (≤12 h), early (12-72 h) or delayed (>72 h) treatment. All further recommendations are addressed in the publication.

      CONCLUSIONS: The updated guidelines in this publication represent further refinement of the recommended indication, application and post-interventional management for the use of ED. The published statements contain detailed, user-orientated recommendations aiming to align current and future users and prevent pitfalls, e.g. for the successful implementation of ED in further countries like the USA. The significance of this work is reflected by the magnitude of patient experience behind it, larger than the total number of patients treated in all published ED clinical trials.

      Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.

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      The use of hydrogen peroxide in the treatment of burn wound infection: a systematic review, and survey of current clinical practice in the United Kingdom., 2020 Apr 15
      Journal: International journal of burns and trauma

      BACKGROUND: Current treatment of burn wound infection (BWI) is with antibiotics and/or wound cleaning/superficial debridement. The overuse of antibiotics has contributed to antibiotic resistance. One possible solution is the use of hydrogen peroxide (H2O2). The aim of this study is to investigate the current use of H2O2 in the treatment of BWI through a comprehensive review of published evidence and a survey of current clinical practice.

      METHODS: A systematic review was performed on the clinical use of H2O2 in the treatment of BWI using four major search engines from inception to 1st July 2018. English-written full-text publications of any study design were included and data extraction was conducted in duplicate. An 11-question survey on the use of H2O2 in the treatment of BWI was sent to all burn services in the United Kingdom (UK).

      RESULTS: The systematic review generated 1,168 papers, with only one fulfilling inclusion criteria. This was a randomised control trial (RCT) which demonstrated that soaking grafts with 2% H2O2 prior to grafting improved graft take rate in infected burn wounds compared with grafts treated with saline prior to grafting, concluding that H2O2 can be recommended in the treatment of BWI intraoperatively. A 72.7% (16 burns services) response rate was achieved to the survey. Of these, 75% of burn services (n = 12) do not currently use H2O2 in clinical practice. Of the 25% (n = 4) which do use H2O2, no service had a protocol for its use. The most common reasons for not using H2O2 were a lack of published evidence and fear of side-effects.

      CONCLUSION: Only 1 paper suggests H2O2 to be effective in BWI treatment and there is no national consistency or protocol for the use of H2O2 in the treatment of BWI in the UK. More large-scale research is required to determine whether H2O2 may offer a solution to the need to use antibiotics to treat BWI.

      IJBT Copyright © 2020.

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      Local Treatment of Burns with Cell-Based Therapies Tested in Clinical Studies., 2021 Jan 21
      Journal: Journal of clinical medicine

      Effective wound management is an important determinant of the survival and prognosis of patients with severe burns. Thus, novel techniques for timely and full closure of full-thickness burn wounds are urgently needed. The purpose of this review is to present the current state of knowledge on the local treatment of burn wounds (distinguishing radiation injury from other types of burns) with the application of cellular therapies conducted in clinical studies. PubMed search engine and ClinicalTrials.gov were used to analyze the available data. The analysis covered 49 articles, assessing the use of keratinocytes (30), keratinocytes and fibroblasts (6), fibroblasts (2), bone marrow-derived cells (8), and adipose tissue cells (3). Studies on the cell-based products that are commercially available (Epicel®, Keraheal™, ReCell®, JACE, Biobrane®) were also included, with the majority of reports found on autologous and allogeneic keratinocytes. Promising data demonstrate the effectiveness of various cell-based therapies; however, there are still scientific and technical issues that need to be solved before cell therapies become standard of care. Further evidence is required to demonstrate the clinical efficacy and safety of cell-based therapies in burns. In particular, comparative studies with long-term follow-up are critical.

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      Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature., 2021 May 01
      Journal: Annals of Plastic Surgery

      INTRODUCTION: Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years.

      METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns.

      RESULTS: An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes.

      DISCUSSION: The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers.

      CONCLUSIONS: More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

      Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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      Use of infrared thermography for assessment of burn depth and healing potential: A systematic review., 2021 Jun 12
      Journal: Journal of Burn Care & Research

      INTRODUCTION: Burn wound depth assessments are an important component of determining patient prognosis and making appropriate management decisions. Clinical appraisal of the burn wound by an experienced burn surgeon is standard of care but has limitations. IR thermography is a technology in burn care that can provide a non-invasive, quantitative method of evaluating burn wound depth. IR thermography utilizes a specialized camera that can capture the infrared emissivity of the skin, and the resulting images can be analyzed to determine burn depth and healing potential of a burn wound. Though IR thermography has great potential for burn wound assessment, its use for this has not been well documented. Thus, we have conducted a systematic review of the current use of IR thermography to assess burn depth and healing potential.

      METHODS: A systematic review and meta-analysis of the literature was performed on PubMed and Google Scholar between June 2020-December 2020 using the following keywords: FLIR, FLIR ONE, thermography, forward looking infrared, thermal imaging + burn*, burn wound assessment, burn depth, burn wound depth, burn depth assessment, healing potential, burn healing potential. A meta-analysis was performed on the mean sensitivity and specificity of the ability of IR thermography for predicting healing potential. Inclusion criteria were articles investigating the use of IR thermography for burn wound assessments in adults and pediatric patients. Reviews and non-English articles were excluded.

      RESULTS: A total of 19 articles were included in the final review. Statistically significant correlations were found between IR thermography and laser doppler imaging (LDI) in 4/4 clinical studies. A case report of a single patient found that IR thermography was more accurate than LDI for assessing burn depth. Five articles investigated the ability of IR thermography to predict healing time, with four reporting statistically significant results. Temperature differences between burnt and unburnt skin were found in 2/2 articles. IR thermography was compared to clinical assessment in five articles, with varying results regarding accuracy of clinical assessment compared to thermography. Mean sensitivity and specificity of the ability of IR thermography to determine healing potential < 15 days was 44.5 and 98.8 respectively. Mean sensitivity and specificity of the ability of FLIR to determine healing potential < 21 days was 51.2 and 77.9 respectively.

      CONCLUSION: IR thermography is an accurate, simple, and cost-effective method of burn wound assessment. FLIR has been demonstrated to have significant correlations with other methods of assessing burns such as LDI and can be utilized to accurately assess burn depth and healing potential.

      © The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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      Effects and Safety of Different Silver Preparation in Burns Treatment: A Bayesian Network Meta-analysis., 2021 Apr 28
      Journal: The International Journal of Lower Extremity Wounds

      Silver formulation has been used for external use of burn wounds for several decades, mainly including silver sulfadiazine (SSD), nanosilver dressing (NSD), and silver ion dressing (SID). At present, there is no simultaneous comparison of the effects of silver formulation on burn wounds. The databases were retrieved in an orderly manner from the dates of their establishment to May 2020, including PubMed, the Cochrane Library, Web of Science, and Clinical Trials. Then a network meta-analysis was conducted using R and RevMan 5.1 software. A total of 13 randomized controlled trials (RCTs) involving 945 patients with burns were included. A pairwise meta-analysis of the results was presented: the wound healing time in the SID or NSD treatment group was less than that in the SSD group; and in relieving the pain there was a statistical difference between the SSD, SID, or NSD groups. Network meta-analysis of the results was presented: the wound healing time and relieving the pain in the SID or NSD treatment group were less than that in the SSD group, but there was no statistical difference between the SID and NSD groups. The possibility of NSD in the wound healing time being the best treatment was 75.2%, followed by SID (36.6%), and finally SSD (1.1%); and the possibility of NSD being the best relieving the pain was 83.5%; followed by SID (60.0%), and finally SSD (16.3%). According to the evidence, treatment for burns with NSD can improve the wound healing time and relieve the pain of wounds.

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      Fibroblast growth factor in the treatment of burns: A systematic review., 2021 Apr 14
      Journal: Burns

      INTRODUCTION: A burn is a trauma that breaks the skin barrier, causing local and systemic responses. Treatment is complex, multiprofessional and expensive. In addition to surgical treatment, topical dressings can be used to keep the wound moist, reduce the risk of infection and stimulate healing. Clinical studies show that topical use of fibroblast growth factors may accelerate healing. An assessment of the quality of the available evidence and its strength of recommendation is necessary.

      OBJECTIVE: This study aimed to evaluate the effectiveness and safety of topical use of fibroblast growth factor, compared to other topical treatments or placebo, in the healing of burns, to determine the strength of recommendation.

      METHOD: Based on a defined search strategy, randomized and quasi-randomized clinical trials, available in electronic databases, were gathered. These compare the topical use of FGF versus other topical or non-treatment. The primary outcome was healing and as adverse effects: pain, infection and mortality. The systematic review protocol was registered on the PROSPERO platform (CRD42018089556), developed in accordance with the "Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015" and within the "SWiM guideline 2019". GRADEpro was used for the critical analysis of the methodology of the studies.

      RESULTS: Four clinical trials were found, in which FGF reduced the healing time and improved the appearance of the scar. Two trials were determined to be of low strength, while two others have a moderate recommendation strength.

      CONCLUSION: This review gathered available evidence, between low and moderate recommendation strength for the use of FGF as a topical dressing. Further rigorous trials are needed to improve the strength of recommendation for topical use of FGF for burns.

      Copyright © 2021 Elsevier Ltd and ISBI. All rights reserved.

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      A systematic review and meta-analysis of randomized trials evaluating the efficacy of autologous skin cell suspensions for re-epithelialization of acute partial thickness burn injuries and split-thickness skin graft donor sites., 2021 Sep
      Journal: Burns

      BACKGROUND: This systematic review evaluated the efficacy of autologous skin cell suspensions (ASCS) on the re-epithelialization of partial thickness burn injuries and skin graft donor site wounds.

      METHODS: Four databases (EMBASE, Google Scholar, MEDLINE, Web of Science), grey literature and select journal hand-searching identified studies from 1975 - 2020. Randomized trials evaluating partial thickness burn management with non-cultured ASCS compared to any other intervention were included. Time to re-epithelialization (TTRE) was the primary outcome. Three independent researchers completed screening, data extraction and certainty of evidence assessment using Cochrane Risk of Bias Tool and Grading of Recommendations Assessment, Development and Evaluation.

      RESULTS: Five trials (n = 347) reported on adults (2 trials) and children (1 trial) with burn wounds, and adults with donor site wounds (2 trials). The effect of ASCS compared to control on TTRE in adult burn wounds was not estimable. TTRE was shorter in pediatric burn wounds (SMD -1.75 [95% CI: -3.45 to -0.05]) and adult donor site wounds (SMD-5.71 [95% CI: -10.61 to-0.81]) treated with ASCS. The certainty of evidence was very low.

      CONCLUSION: Compared to standard care, ACSC may reduce pediatric partial thickness burn wound and adult split-thickness skin graft donor site TTRE.


      Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.

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      Efficacy of stem cell therapy for burn wounds: a systematic review and meta-analysis of preclinical studies., 2020 Jul 29
      Journal: Stem Cell Research & Therapy

      BACKGROUND: Burns remain a serious public health problem with high morbidity and mortality rates worldwide. Although there are various treatment options available, there is no consensus on the best treatment for severe burns as of yet. Stem cell therapy has a bright prospect in many preclinical studies of burn wounds. The systematic review was performed for these preclinical studies to assess the efficacy and possible mechanisms of stem cells in treating burn wounds.

      METHODS: Twenty-two studies with 595 animals were identified by searching PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception to 13 May 2020. In addition, a manual search of references of studies was performed to obtain potential studies. No language or time restrictions were enforced. RevMan 5.3 was used for all data analysis.

      RESULTS: The overall meta-analysis showed that stem cell therapy significantly improved burn healing rate (SMD 3.06, 95% CI 1.98 to 4.14), irrespective of transplant type, burn area, and treatment method in the control group. Subgroup analyses indicated that hair follicle stem cells seemed to exert more beneficial effects on animals with burn wounds (SMD 7.53, 95% CI 3.11 to 11.95) compared with other stem cells. Furthermore, stem cell therapy seemed to exert more beneficial effects on burn wounds with second-degree (SMD 7.53, 95% CI 3.11 to 11.95) compared with third-degree (SMD 2.65, 95% CI 1.31 to 4.00).

      CONCLUSIONS: Meta-analysis showed that stem cell therapy exerts a healing function for burn wounds, mainly through angiogenesis and anti-inflammatory actions. These findings also demonstrate the need for considering variations in future clinical studies using stem cells to treat a burn wound in order to maximize the effectiveness. In general, stem cells can potentially become a novel therapy candidate for burn wounds.

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      Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States., 2019 May 07
      Journal: Advances in therapy

      INTRODUCTION: When introducing a new intervention into burn care, it is important to consider both clinical and economic impacts, as the financial burden of burns in the USA is significant. This study utilizes a health economic modeling approach to estimate cost-effectiveness and burn center budget-impact for the use of the RECELL® Autologous Cell Harvesting Device to prepare autologous skin cell suspension (ASCS) compared to standard of care (SOC) split-thickness skin graft (STSG) for the treatment of severe burn injuries requiring surgical intervention for definitive closure.

      METHODS: A hospital-perspective model using sequential decision trees depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, definitive closure) and predicts the relative differences between use of ASCS compared to SOC. Clinical inputs and ASCS impact on length of stay (LOS) were derived from clinical trials and real-world use data, American Burn Association National Burn Repository database analyses, and burn surgeon interviews. Hospital resource use and unit costs were derived from three US burn centers. A budget impact calculation leverages Monte Carlo simulation to estimate the overall impact to a burn center.

      RESULTS: ASCS treatment is cost-saving or cost-neutral (<  2% difference) and results in lower LOS compared to SOC across expected patient profiles and scenarios. In aggregate, ASCS treatment saves a burn center 14-17.3% annually. Results are sensitive to, but remain robust across, changing assumptions for relative impact of ASCS use on LOS, procedure time, and number of procedures.

      CONCLUSIONS: Use of ASCS compared to SOC reduces hospital costs and LOS of severe burns in the USA.

      FUNDING: AVITA Medical.

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      NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.


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      Topic 1172 Version 2.0


      This topic provides an evidence-based review and framework for assessment of acute burns, including epidemiology, risk factors, etiology, pathophysiology, first aid, primary and secondary assessment, transfer criteria, burns classification, documentation and ICD-10 coding

      Acute Burn Injury overview: evidence-based clinical guidelines, quality measures and resources