A burn patient may need complex, long-term treatment, so a treatment plan is essential. This requires decisions about where the patient should be treated, what treatment they need, and who should be involved.

Location of burn wound treatment

After stabilizing the burn patient, decide if the current facility is the best place for them to be treated. If the option is available, refer the patient to a well-equipped (burn) center. If you don’t do this immediately, you can always reconsider the option later.

Severe burns in neonates and pregnant women require individualized care, preferably by a specialized team. Always refer these patients to a burn center, if possible.

Goals of burn wound treatment

If the patient stays in the current facility, the next logical step is to make a treatment plan and to document this in the patient file. The treatment you choose will depend on the findings of the primary and secondary surveys.

The goal of burn wound treatment is to optimize the patient’s quality of life. The treatment should therefore aim to:

• optimize wound healing and thus wound closure
• provide adequate pain management
• prevent wound colonization and infection
• minimize scar formation

The initial treatment plan should be well designed, and you should evaluate the effects of the treatment methods continuously.

Smoking delays wound healing. If appropriate, advise the patient to stop smoking.

Factors determining the treatment plan

A number of factors affect the treatment plan you design, from the characteristics of the burn itself to the context of the treatment facility and the patient.

• Burn wound size, depth and location
• Age, general physical condition, comorbidities and medication
• Socioeconomic factors
• Limitations of clinic facilities and the medical team

Burn wound size, depth and location

These are the main factors determining the treatment plan. The diagnosis of burn depth is not always definitive; the burn may deepen during the first 24 to 48 hours post-injury. Although you can’t always prevent this, you can reduce the impact by optimizing wound conditions:

• Cool the burn properly with lukewarm running water for 10 minutes as soon as possible after the injury
• Administer proper fluid resuscitation
• Provide adequate burn wound treatment
• Elevate affected limbs to reduce edema
• Optimize the patient’s physical condition

Age, general physical condition and medication

The patient’s age affects their burn wound, and this may influence the timing of surgery. For example, wounds heal faster in children than in adults. Wounds in elderly patients take longer to heal because they have thin skin, so burns that appear superficial on initial examination may take weeks to heal or deepen to full thickness.

The patient’s body homeostasis and the pathophysiological response to burn injury may interfere with the timing of surgical treatment. Before surgical excision, ensure you correct dehydration and check that renal function is sufficient.

Extensive, deep burn injuries require early surgical excision, as they can have severe systemic effects.

You should also consider all comorbidities when designing the treatment plan. For example, in low and middle income countries, epilepsy is common in burn victims. Severe anemia is common in burn patients, especially children. Mental illnesses are common in burn victims in all settings.

Medication use can also affect the success of the treatment plan. For example, patients who have been taking corticosteroids for a long time may have very fragile, thin skin. This may hinder the harvesting of a split-thickness skin graft.

Socioeconomic factors

Socioeconomic factors may play a role, especially in resource-limited settings. A patient may refuse admission to the hospital due to a lack of funds. They may also refuse surgical treatment due to a lack of trust.

Limitations of clinic facilities and the medical team

Clinical and resource limitations may interfere with the treatment plan. For example, the medical team may not be appropriately trained to perform burn surgery. The burn team may not be well prepared or equipped due to a lack of materials. And the burn team may not have the skills and competencies to carry out specialized surgical techniques, such as (free) flap surgery.

Decision making for adequate burn wound treatment

You will need to make decisions about when and how to treat the burn patient. Always follow the general principles of burn wound treatment, keep in mind the factors influencing the choice of treatment, and consider the timing of surgery, if relevant.

Decide whether to use conservative treatment or surgical treatment. If the patient requires surgical treatment, you must choose between early excision and skin grafting or delayed excision and skin grafting.

If you choose early surgical treatment, cover the wound temporarily to prevent bacterial colonization and infection. In early and delayed surgery, you must apply a wound dressing that prevents wound colonization. A topical antiseptic such as SSD, Fucidin or honey is appropriate in most cases.

Patients with burn injuries may delay treatment and present with wounds that are already infected, particularly in low- and middle income countries. As a general rule, infection of a burn wound is not a contra-indication for skin grafting. If the physical condition of the patient allows, treat with radical debridement of the infected wound. However, in selected cases, especially with Pseudomonas infection, first treat with topical agents against Pseudomonas before planning skin grafting.

Conservative treatment

You might choose conservative treatment, either fully or as a temporary treatment awaiting surgery. In both cases, you will need to choose between three methods:

• Closed wound treatment method
• Semi-open method
• Exposure of the burn wound

Fully conservative treatment is advisable for:

• Epidermal burns
• Superficial partial thickness burns
• Deep dermal partial thickness burns

Fully conservative treatment is advisable for these wounds, at least initially. The burn depth may be heterogeneous, ranging from superficial partial thickness to full thickness. Once the partial thickness areas of the wound have healed, the deeper, full thickness parts will remain. These areas may require surgery, depending on their size and location.

If surgery is required, this approach promotes the take of the skin graft, as the inflammation reaction that occurs during the healing process improves the blood flow to the wound.

Initial conservative treatment also reduces the surface area that requires wound excision and grafting. This results in reduced surgery time and limits blood loss.

Surgical treatment

Surgery is advisable for deep dermal partial thickness burns and full thickness burns.

Deep dermal partial thickness burns

The burn depth of these wounds may be heterogeneous, ranging from superficial partial thickness to full thickness. It is advisable to start with conservative management. Once the partial thickness areas of these wounds have healed, the deeper, full thickness parts will remain. These may require surgery, depending on their size and location.

Full thickness burns

The timing of surgery for these burns depends on the burn wound size, depth and location. It also depends on the general condition of the patient and the resources available, such as the safety of anesthesia and facilities for blood transfusion.

Re-evaluate the treatment plan

You should re-evaluate the treatment plan regularly for multiple reasons, such as the wound deepening, complications, and delayed healing.

The diagnosis of burn depth is not always definitive, as the burn may deepen during the first 24-48 hours post-injury. When necessary, you should adjust the treatment plan based on a change in diagnosis of the burn.

Complications such as wound colonization and infection require you to re-evaluate the treatment plan. This is also necessary if the wound bed is not of sufficient quality for skin grafting.

Be prepared to switch from Plan A to Plan B. For example: