Conservative treatment strategies
Burn wounds can be treated conservatively, either fully or temporarily while awaiting surgery. In cases where surgery is likely to be required, initial conservative treatment reduces the surface area requiring wound excision and grafting, resulting in a reduction in surgery time and limits blood loss.
Fully conservative treatment is suitable for the following types of burns:
- Epidermal burns
- Superficial partial thickness burns
- Deep dermal partial thickness burns
In these wounds, the burn depth may vary, from superficial partial thickness to full thickness. Start with conservative management, and once the partial thickness areas of the wounds have healed, the deeper, full thickness parts may require surgery. This approach promotes the take of the skin graft if surgery is required, as the inflammation reaction that occurs during the healing process improves the blood flow to the wound.
Temporarily conservative treatment is suitable for deeper burn wounds. This can be for a short period of time in an early excision and grafting strategy, or for a longer period, when delayed grafting is chosen due to limited resources or specific patient characteristics.
In general, there are three strategies for the conservative treatment of burn wounds:
- Closed wound method
- Semi-open wound method
- Exposure of the burn wound
Closed wound method
This is a closed dressing of any kind that isolates the wound from the environment, usually in combination with a topical agent (e.g. SSD).
In general, closed wound management is preferable to exposure of the burn wound. Perform proper cleaning and debridement, if required, before applying a dressing. This method is the best way to ensure prevention of infection and preparation of the eschar for early tangential excision. The number of dressing changes should be adjusted according to the needs of the individual patient.
The closed method of conservative treatment is recommended for most burns in burn protocols. It is used for fully conservative treatment of superficial partial thickness burns. It is also used for deeper defects, often as a temporarily conservative treatment while awaiting surgery. The closed method is the most frequently used method for post-surgical burn wound treatment.
The use of the closed method depends on the availability of the resources required. The patient and their burn wound must be properly prepared before a dressing can be applied.
No specific treatment is required for epidermal burns. Dressings are not required; use any topical agent available (e.g. body lotion, Vaseline) to reduce the pain.
Superficial partial thickness burns
These burns benefit from occlusion for long periods of time. Therefore, membranous dressings are frequently used to provide a moist wound healing environment and protect the wound from contamination. Choose the type and frequency of topical agent and dressing according to the wound condition, preference of the burn center and availability of the materials.
Deep dermal partial thickness burns
It is advisable to start with conservative treatment for these burns, because burn depth may be heterogeneous. Depth can range from superficial partial thickness in some areas to deep dermal partial thickness or even full thickness in other areas. Once the superficial areas of the wound have healed, the deeper parts will remain; these may require surgical treatment depending on the size of the wound. Choose the type and frequency of topical agent and dressing according to the wound condition, preference of the burn center and availability of the materials.
Full thickness burns
Full thickness burns require surgical treatment. A closed dressing is preferred until the day of surgery – SSD or a povidone-iodine soaked gauze are frequently used prior to surgery. Perform early excision when possible. If this is not feasible, for example in a resource-limited setting, dress full thickness burns using the open wound management technique (exposure of the burn wound), until eschar separation has begun.
Full thickness burns with exposed bone or tendon
In these burns, keep the wound bed with exposed bone or tendon moist using a closed wound method. Apply SSD, or NPT or Flamminal Hydro® if available, to allow granulation tissue to form. When bone or tendon is exposed, granulation tissue may help to achieve a graftable wound bed. Consider bone fenestration to promote the formation of granulation tissue from the bone marrow. A surgical approach using well vascularized flaps to cover essential non-graftable structures is recommended.
Semi-open wound method
A semi-open dressing usually consists of a thin protective gauze loosely covering the burn wound, fixed with a strapping or a loose bandage. It’s often used in combination with a topical agent (e.g. SSD).
This method is often used for facial burns, perineal burns, posterior burns and bedridden patients. It is also useful in situations where there are limited personnel, equipment or resources.
Exposure of the burn wound
The burn wound is left open to dry. You can use different topical agents, but be aware that ointments and creams stick to clothes and sheets, and they also attract dirt. In superficial dermal burns this is a painful method and is not recommended.
This method should be used for deep dermal partial thickness burns and full thickness burns. It can be used when early excision is not possible, to bridge the time before the eschar separates spontaneously. This method is in particularly useful for large surface burns in situations where there are limited personnel, equipment or resources. A study in Sierra Leone [TL11] showed that the open method had as good or better early outcomes than the closed method, at significantly lower costs.
Clean the burn wound daily by washing or showering and use a bed cradle to prevent sheets and blankets from touching the burn wound. From day one onwards, a dry and adherent crust develops. Leave this in place up to a maximum of four days, or until cracks appear in the crust. Cracks in the crust make the wound more prone to infection. If the crust is separating, perform debridement in small pieces.
Large surface burn
This is an example of ‘Exposure of the burn wound’. A bed cradle is used to prevent the sheets and blankets from touching the burn wound.
by cutting away the free crust and stop this blunt dissection when an area where the crust is still adherent is reached.