Wound Management

Introduction to Wound Closure and Dressing

• The American Academy of Pediatrics recommends using skin adhesives for low-tension wounds, providing essentially painless closure, particularly for small, clean lacerations with well-approximated edges, and should be applied to dry, clean wound edges 1

Benefits and Applications of Skin Adhesives and Dressings

• Skin adhesives are best for small, clean lacerations with well-approximated edges, and should be applied to dry, clean wound edges, as recommended by the American Academy of Pediatrics 1
• Use non-adherent dressings for painful eroded areas (e.g., Mepitel or Atrauman) and denuded areas (e.g., Mepitel or Telfa) 2, 3
• Consider silver-containing products for sloughy areas only 3

Potential Complications of Dressing Application and Burn Care

• Using occlusive dressings inappropriately can lead to skin maceration, according to the Clinical Nutrition society 4
• Burn blisters should be left intact and loosely covered with a sterile dressing to improve healing and reduce pain, as recommended by the American Heart Association (Class IIa, LOE B) 5, 6, 7, 8
• For larger blisters, decompress by piercing with a sterile needle to release fluid and leave the blister roof intact as it serves as a biological dressing, as recommended by the British Association of Dermatologists 2, 9, 3
• Apply a thin layer (approximately 1/16 inch) of 1% silver sulfadiazine cream to second and third-degree burns, and reapply once to twice daily or whenever the cream has been removed by patient activity, as recommended by the Wound, Ostomy, and Continence Nurses Society 10
• Apply cold tap water (15°C to 25°C) as soon as possible after injury for up to 30 minutes, and continue until pain is relieved, without applying ice directly to the burn, as recommended by the American Heart Association 7, 8, 11
• Do not apply ice directly to burns as it can cause tissue ischemia (Class III, LOE B) 5, 6

Infection Prevention and Management

• For extensive areas of erosion, consider antiseptic-containing baths or soaks to prevent infection 2, 12
• Take swabs for bacterial and candidal culture from lesional skin on alternate days, and do not administer systemic antibiotics prophylactically 3, 13, 10
• Only use antibiotics when there are clinical signs of infection, and employ strict barrier nursing to reduce nosocomial infections 3
• Monitor for signs of infection, including increasing pain, redness, swelling, or discharge, and fever or systemic symptoms, to ensure prompt medical attention if necessary 14

Nutrition and Analgesia

• Provide continuous enteral nutrition throughout the acute phase, delivering 20-25 kcal/kg daily during the early catabolic phase, and increasing to 25-30 kcal/kg daily during the anabolic recovery phase, as recommended by the British Journal of Dermatology 3
• Start nutritional support within 12 hours after burn injury, preferring oral or enteral routes over parenteral nutrition, as recommended by the American Society for Parenteral and Enteral Nutrition 10
• Use multimodal analgesia, including titration of analgesic medications based on validated comfort and analgesia assessment scales, as recommended by the American Society of Anesthesiologists 10
• Consider ketamine as an adjunct for severe burn-induced pain, and employ non-pharmacological techniques (virtual reality, hypnosis) when appropriate for dressings in stable patients 10
• Use a patient-appropriate validated pain tool at least once daily, and offer analgesia prior to any blister procedure, as noted by the British Association of Dermatologists 3, 9

Burn Severity Assessment and Management

• The following table summarizes burn severity assessment criteria:

• Use the Lund-Browder chart (pediatric version) for accurate Total Body Surface Area (TBSA) measurement in children, and the palm method for quick estimation of TBSA in prehospital settings, as recommended by the American Society of Anesthesiologists 10
• Perform escharotomy if deep burns cause compartment syndrome affecting limbs, trunk, or compromise airways/circulation, as recommended by the Anaesthesia society 10
• Begin early range of motion exercises to prevent contractures, and consider massage therapy to soften scar tissue and improve circulation, as recommended by the American Occupational Therapy Association 10

Environmental Considerations and Wound Care

• Maintain ambient temperature between 25°C and 28°C, and use a pressure-relieving mattress 3
• Gently irrigate wounds with warmed sterile water, saline, or dilute chlorhexidine (1/5000), and apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the epidermis 3