1. Significant resources are required for wound care of major burns. At the Role 1 or Role 2, consider rapidly transferring a patient to a higher echelon of care if possible, providing dry dressings and hypothermia protection enroute. Bear in mind that any dressings will likely be immediately removed upon arrival at the next echelon of care to facilitate patient evaluation.
2. Debride burns by removing sloughed skin, blisters, and debris, and apply an effective topical antimicrobial, within the first 24 hours postburn.
3. Whenever possible, do debridement in the OR, thereby providing a clean, warm environment to both examine the wounds and place sterile dressings. Use chlorhexidine gluconate or similar antiseptic cleanser. Debridement may be facilitated by scrub brushes and/or gauze sponges. Definitive removal of burn eschar (sharp/surgical excision) will be performed after stabilization and transport to the Burn Center.
4. Topical antimicrobials. One of the following regimens should be used for burn-wound care.
   - Alternating agents. After daily cleansing and debridement using CHG, apply a layer of mafenide acetate (Sulfamylon) cream in the morning, and silver sulfadiazine (Silvadene) cream 12 hours later. One 400-g container of burn cream covers about 20% TBSA. Although labor- and resource-intensive, this is the ideal regimen.
   - Silver-nylon dressings (e.g., Silverlon). This product is used in clean, fully debrided burns at low risk of infection. Apply to burns; cover with sterile gauze; moisten with clean or sterile water. Remoisten QID and as needed to keep dressings lightly moist. The dressing may be kept in place for 3-5 days if there is no evidence of infection. This is advantageous, for example, during long-distance evacuations.
   - Antimicrobial solutions. Apply gauze dressings, followed by diluted Dakin’s solution (e.g., quarter strength, 0.125%), 0.5% silver nitrate solution, or acetic acid. Reapply the same solution at least every 6 hours. Change dressings daily.
   - This topical agent has a limited spectrum of antimicrobial efficacy but is acceptable for small, clean, partial thickness burns treated on an outpatient basis. It may be covered by Xeroform gauze followed by a dry gauze dressing.
   - Medihoney or Manuka honey has been shown to be as effective as Silvadene for burn wounds. Honey can also promote healing in partial thickness burn wounds.26 Honey dressings should be applied twice a day and used with Adaptic or Xeroform gauze to keep the wound moist. Honey has strong antimicrobial properties but is not easy to keep in contact with the burn wounds because it melts. One technique is to layer the honey on the Adaptic or Xeroform gauze and then lay it over the burn wound followed by dry gauze. Honey can cause discomfort (burning/stinging) when applied, which subsides in 15-20 minutes. Honey should not be used on full thickness burns.
5. Face burns. Shave and debride the face, covering wounds with a topical antibiotic ointment QID such as bacitracin. Ear burns are prone to chondritis; apply Sulfamylon cream twice a day. (An alternative is Silvadene cream.) Avoid pressure from endotracheal tube ties or pillows.
6. Avoid over-wetting dressings to avoid maceration of tissues. Frequent assessment of the patient’s temperature is necessary to prevent hypothermia secondary to wet dressings, especially during air evacuation.