Significant personnel and supply resources are required for wound care of major burns. Consideration should be given to rapidly transferring a patient to a higher echelon of care utilizing dry dressings and hypothermia protection at the Role 1 or Role 2 levels. Bear in mind that any dressings will likely be immediately removed upon arrival at the next echelon of care to facilitate patient evaluation.
Whenever possible, debride (remove sloughed skin and blisters) burn wounds in the operating room (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 USAISR Burn Center.
1. Shave and debride the face, covering wounds with topical antibiotic ointment QID. Ear burns are prone to chondritis; apply mafenide acetate (Sulfamylon®) cream twice a day if available. Avoid pressure from endotracheal tube ties.
If mafenide acetate (Sulfamylon) is not available prior to or during transport, thoroughly clean twice a day and utilize silver sulfadiazine cream or any other topical antimicrobial ointment. Examine frequently for cellulitis advancing beyond the ear or for evidence of necrosis of the cartilage. This requires surgical debridement.
2. Wrap burns on the scalp, trunk, neck, and extremities in sterile gauze soaked with a 5% solution of Sulfamylon. Apply the solution QID and as needed to keep dressings lightly moist, but not so wet as to cause maceration.
3. Alternatively, burns may be dressed with silver-impregnated nylon, covered with sterile gauze and moistened with sterile water. One of the advantages of this type of burn dressing is the ability to leave the dressing in place for extended periods of time (up to 7 days) which is advantageous during delayed or long-distance evacuations.
4. 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.
5. In patients who cannot be safely evacuated for burn excision, consider using silver sulfadiazine cream alternated BID with mafenide acetate (Sulfamylon) cream to provide antimicrobial penetration of thick burn eschar as a bridge to surgical care.