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How To Debride and Dress a Burn

By

Matthew J. Streitz

, MD, San Antonio Uniformed Services Health Education Consortium

Last full review/revision Sep 2020| Content last modified Sep 2020
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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

  • Minor burn wounds

Contraindications

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

  • Allergic reactions to topical antibiotics

Equipment

  • 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

  • Burns involving the hands, feet, face, genitals, perineum, or major joints or burns that are extensive often require transfer to a burn center.

Depth of skin injury:

  • First-degree: Involving the epidermis only

  • Second-degree (partial-thickness): Extending into the dermis

  • Third-degree (full-thickness): 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

  • Patient comfort with excellent exposure of burned areas

Step-by-Step Description of Procedure

Initial care of all burn wounds

  • 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.

  • 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.

Definitive burn wound care

  • Clean 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 bacitracin or mupirocin directly to all wounds except for 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 (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

  • 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

  • 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 burns on the face and neck: Clean 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.

  • 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.

Reference

More Information

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

Drugs Mentioned In This Article

Drug Name Select Trade
SILVADENE
Gammagard S/D
TYLENOL
BACIIM
XYLOCAINE
BACTROBAN
KETALAR
DURAMORPH PF, MS CONTIN
ACTIQ, DURAGESIC, SUBLIMAZE
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