BURNS

BURNS









Burns

Burns are often categorized as first-, second-, or third-degree burns. All burns should be quickly treated to reduce the temperature of the burned area and reduce damage to the skin and underlying tissue. Burns can cause potential fatal complications such as shock, infection, electrolyte imbalance and respiratory distress. Burns can also result in severe psychological and emotional distress due to scarring and deformity. When tissues are burned, fluid leaks into them from the blood vessels, causing swelling and pain. Older people and young children are particularly vulnerable to burns.

Updated 2008

Stream Overview

A systematic literature search for clinical practice guidelines on surgical wounds was completed using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in identifying the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

307 burns clinical practice guidelines were found in the English literature from 2002 until May 2007. Many of these published articles were excluded due to a variety of reasons. They were: not specifically addressing surgical wounds, articles, review papers, not CPGs, supplemental documents of a guideline and quick reference guides.

Of the identified papers, 8 guidelines were appraised by a minimum of three reviewers using the AGREE instrument. The AGREE instrument has six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead the guidelines that received the highest scores for most of the domains and particularly for rigour of development were ranked highest and their recommendations will be reported throughout this Acute Wounds – Burns stream.

The most highly ranked guidelines were Samson’s Wound-Healing Technologies: Low-Level Laser and Vacuum-Assisted Closure (2004); Jacob’s “Practice Management Guidelines for Nutritional Support of the Trauma Patient (2004); Simon’s “OT/PT Forum. Occupational Therapy and Physiotherapy for the Patient with Burns: Principles and Management Guidelines (2003); Alsbjorn’s Guidelines for the Management of Partial-thickness Burns in a General Hospital or Community Setting – Recommendations of a European Working Party (2006).

The following figure indicates the AGREE domain scores for these burns guidelines.

The following recommendations are intended to help busy clinicians provide excellent care. They are based on the high ranking guidelines that are referenced. Since each of the guidelines addresses a very specific topic, our recommendations are expressed in general terms to make them more useful to burn practitioners generally. Clinicians needing specifics are advised to review the appropriate guideline.

Identify and Treat the Cause Level of Evidence
1 Take a history and perform a physical examination of the burned skin. 5
Address patient-centered Concerns Level of Evidence
2 Provide ongoing support and education that is appropriate for the age, developmental, cognitive, and psychological status of the patient, family, and/or caregivers throughout all phases of recovery. 5
3 Enable the patient to identify the functional implications of his/her individual scar and contribute to planning future needs. 5
4 Ensure adequate pain management using a combination of medications and non-pharmacological techniques to allow for optimum function. 5
5 Discuss with the patient and encourage return to work as soon as possible. 5
Provide Local Wound Care Level of Evidence
6 Determine depth and extent of burn area or stage wound healing on an ongoing basis. 5
7 Prepare the wound using appropriate burn care principles, including minimizing edema, and cover the wound with an appropriate dressing. 5
8 Consult appropriate Professionals, including a Dietitian to ensure appropriate nutrition 3b
9 Implement scar management techniques. 5
10 Provide post burn wound care. 5
Provide Organizational Support Level of Evidence
11 Empower an interprofessional burn team ensuring involvement of appropriate professionals, e.g., Dietitian, OT, PT, and provide education and support. 5

High Ranking Guidelines
1 Quality Indicator: Type: CPG (Clinical Practice Guideline)
Samson DJ, Lefevre F, Aronson N. Wound-Healing Technologies: Low-Level Laser and Vacuum-Assisted Closure. Agency for Health Care Research and Quality. December 2004.
In this guideline the evidence on low-level laser therapy or vacuum-assisted closure (VAC) on wound-healing outcomes is systematically reviewed. These wound-healing technologies were assessed based on the incidence of complete wound closure, time to complete closure and adverse effects. Many factors influencing wound healing are indicated, such as poor nutrition, metabolic derangements, drugs, tissue hypoxia, infection and dry wound bed. VAC treatment was suggested to be used not for complete wound healing, but to advance the wound to a stage where wound healing is possible. These results and evidence comparing low-level laser therapy and VAC were limited due to poor trial quality. On going RCTs with greater sample sizes, group comparability and well defined primary outcomes may provide better evidence on outcomes of interest.
2 Quality Indicator: Type: CPG (Clinical Practice Guideline)
Jacobs DG, Jacobs DO, Kudsk KA, Moore FA, Oswanski MF, Poole GV, Sacks GS, ‘Tres‘ Scherer III LR, Sinclair KE. Practice Management Guidelines for Nutritional Support of the Trauma Patient. Journal of Trauma 57.3 (2004): 660-79.
This guideline provides principles of nutritional support such as route, timing, site of nutritional support, macronutrient formation, and monitoring and type of nutritional support for the treatment of trauma patients.
3 Quality Indicator: Type: CPG (Clinical Practice Guideline)
Simons M, King S, and Edgar D. Occupational Therapy and Physiotherapy for the Patient with Burns: Principles and Management Guidelines. Journal of Burn Care & Rehabilitation 24.5 (2003): 323-335.
This guideline provides key principles of respiratory management, edema management, splinting and positioning, physical function, scar management, and psychosocial and mutual elements such as work safety, education, pain management, and professional development in addressing patient needs as burns patients. Although it was developed for OT and PT practitioners, its usefulness is more universal. Levels of evidence were not reported.
4 Quality Indicator: Type: CPG (Clinical Practice Guideline)
Alsbjorn B, Gilbert P, Hartmann B, Kazmierski M, Monstrey S, Palao R, Roberto MA, Trier AV, Voinchet V. Guidelines for the Management of Partial-Thickness Burns in a General Hospital Or Community Setting-Recommendations of a European Working Party. Burns 33 (2007): 155-160.
This guideline provides key areas that need to be included in the treatment algorithm for burns, specifically the management of partial-thickness burns. They are: diagnosis and referral, wound preparation, wound covering and post-wound care, useful for all practitioners. The recommendations are based on consensus statements and expert opinion from burns specialists. The levels of evidence for the recommendations are not reported.

Bacterial Burden Control and Infection

Topical and prophylactic systemic antibiotics, advances in infection control in burn units, and early excision and grafting have all contributed to reducing infection-related morbidity and mortality among patients with serious burns. Serious burns destroy the skin barrier and depress the local and systemic immune response. The wound also provides a protein-rich avascular and necrotic environment favouring microbial colonization and proliferation and impairing migration of immune cells and delivery of systemic antibiotics. Burn wound infection delays epidermal maturation and increases scarring. Microbial invasion below the dermis may also cause bacteremia, sepsis, and multiple-organ dysfunction syndrome.

Within 48 hours of the injury, gram-positive organisms, such as staphylococci, heavily colonize the wound unless topical antimicrobials are used. After 5–7 days, other gram-positive organisms and gram-negative bacteria are also present. These organisms may be derived from the host’s gastrointestinal or upper respiratory flora or from the hospital environment. Yeasts and fungi may predominate later, due to use of broad-spectrum antibiotic therapy. Gram-negative organisms are now the most common bacteria implicated in invasive wound infections, due to their virulence and antimicrobial resistance. Organisms originating from the hospital environment tend to be more resistant than the patient’s normal flora. Emergence of bacterial resistance among a wide variety of pathogens limits treatment options for bacterial wound infections.

Wound colonization must be differentiated from infection. Colonization is present when bacteria can be cultured from the wound in the absence of clinical or microbiological signs of infection or histologic evidence of invasion into deeper tissues. Risk of invasive infection is influenced by the extent and depth of the burn, host factors and quantity and virulence of organisms colonizing the wound. Staphylococcus aureus is frequently responsible for early burn infections. In some centres, Pseudomonas aeruginosa is the most common cause of burn infections. Infection due to other bacteria, fungi and viruses has also increased. Anaerobic bacteria may occur with electrical burns or when open dressings rather than occlusive dressings are used. Burn infection has been categorized into several different types:

  • Burn wound impetigo: This type of infection may or may not be associated with systemic infection. Impetigo is associated with loss of epithelium from a previously epithelialized site, including grafts, partial-thickness burns healing by secondary intention, and donor sites. Impetigo is unrelated to hematoma formation, inadequate wound excision or mechanical graft disruption.
  • Burn-related surgical wound infection: Surgical infection includes unepithelialized excision and donor sites. Culture-positive purulent exudate, loss of wound covering, changes in wound appearance, and erythema in the normal skin around the wound characterize surgical infections.
  • Burn wound cellulitis: Cellulitis develops from extension of infection into healthy soft tissue around the wound or donor site. Burn wound cellulitis may be associated with localized pain, tenderness, swelling or heat; progression of erythema and swelling; and signs of lymphangitis and/or lymphadenitis extending from the affected area.
  • Invasive infection in unexcised burns: Unexcised deep burn wounds have an increased risk of invasive infection. Invasive infection may be associated with a rapid change in burn wound appearance or character, inflammation of surrounding normal tissue, histologic evidence of microbial invasion into tissue adjacent to the burn, positive blood cultures and systemic signs of sepsis.

Burn wound infection surveillance

The best approach to infection surveillance depends on the specific clinical situation. Samples should be collected every 24–48 hours during the first few days or weeks after injury. A single surface swab or biopsy sample does not adequately represent the microbial population of the wound. Multiple samples should be collected from various areas of the burn. After wound excision, sampling frequency can be decreased to weekly, as long as clinical signs of infection are not present.

  • Superficial swabs are the most convenient, least invasive approach for sampling excised burns. Swabs provide an adequate sampling of the flora on the wound surface and are also appropriate for areas where the skin is too thin for biopsy.
  • Quantitative culture and histologic analysis of wound tissue biopsies is the preferred technique for unexcised wounds and wounds in patients with sepsis. Quantitative bacteriology, however, is not predictive of sepsis or graft loss.
  • Simultaneous culture of tissue biopsies and blood and urine samples is the best approach to identify causative organisms in patients with sepsis and to diagnose uncommon types of infection. Positive blood cultures are a late sign of invasive infection.

Antibiotic selection and use

Topical antimicrobial agents are typically used twice daily until epithelialization is complete. Selection of a topical antimicrobial agent is based on the organisms cultured, the spectrum of the agent, results of nosocomial infection monitoring, and institutional resistance patterns. Commonly used agents include silver nitrate, silver sulfadiazine, mafenide acetate, nanocrystalline silver dressings, mupirocin and nystatin.

Prophylactic systemic antibiotic therapy has not been demonstrated to improve outcomes compared with topical therapy plus surgical excision. Furthermore, prophylactic antibiotics may be associated with an increased rate of wound infection; development of secondary infections, including antibiotic-associated diarrhea due to Clostridium difficile overgrowth; and increased resistance of endogenous and pathogenic bacteria.

Systemic antibiotic therapy should therefore be used selectively in burn patients and for a limited duration. Prophylactic antibiotics may be given to provide antibiotic coverage for burn excision, especially in patients with extensive injury. Individual culture and susceptibility data should be used to guide selection of effective antibiotic therapy for prophylaxis and for management of infection.

Identify and Treat the Cause Level of Evidence
1 Take a careful history Not Assessed
Address patient-centered Concerns Level of Evidence
2 Control pain and ensure comfort Not Assessed
Provide Local Wound Care Level of Evidence
3 Perform infection surveillance of burn wounds, every 24–48 hours during the first few days or weeks after injury, and less frequently after excision, if clinical signs of infection are not present. Not Assessed
4 Use superficial swabs for excised wounds and areas that are too thin to biopsy. Not Assessed
5 Perform quantitative culture and histologic analysis of wound tissue biopsies for unexcised wounds and wounds in patients with sepsis. Not Assessed
6 Perform simultaneous culture of tissue biopsies and blood and urine samples in patients with sepsis and to identify uncommon types of infection. Not Assessed
7 Use topical antimicrobial therapy twice daily on burns until epithelialization is complete. Not Assessed
8 Select a topical antimicrobial agent based on the organisms cultured, the spectrum of the agent, results of nosocomial infection monitoring, and institutional resistance patterns. Not Assessed
9 Use individual culture and susceptibility data to guide selection of effective antibiotic therapy for prophylaxis and for management of infection. Not Assessed
10 Use systemic antibiotic therapy selectively in burn patients and for a limited duration. Not Assessed
11 Give prophylactic antibiotics to provide antibiotic coverage for burn excision, especially in patients with extensive injury. Not Assessed
Provide Organizational Support Level of Evidence
12 Empower the burn team to provide excellent care and infection control. Not Assessed
Essential Publications
Essential Publications
1 Hyperbaric oxygen therapy Quality Indicator Type: Systematic review
Villanueva E, Bennett MH, Wasiak J, Lehm JP. Hyperbaric oxygen therapy for thermal burns. Cochrane Database of Systematic Reviews 2004, Issue 2.
This is a well-conducted systematic review that highlights the need for more evidence related to the topic of HBOT effectiveness, with important implications for both practice and research. In one RCT, the mean healing time was 19.7 days in those patients treated with HBOT versus the control group (mean: 43.8 days). Adverse events (pulmonary barotrauma, drug reactions, injury or death related to chamber fire) however were also reported from the treatment group.
2 Early enteral nutrition Quality Indicator Type: Systematic review
Marik PE, GP Zaloga. Early Enteral Nutrition in Acutely Ill Patients: A Systematic Review. Critical care medicine 2001: 29(12): 2264-70.
The results indicate that early feeding decreases infectious complications (p = 0.00006) and length of stay (p = 0.002). There results however should be interpreted with caution because of the significant heterogeneity between studies.
3 Early enteral nutrition Quality Indicator Type: Systematic review
Wasiak J, Cleland H, Jeffery R. Early Versus Late Enteral Nutritional Support in Adults with Burn Injury: A Systematic Review. Journal of Human Nutrition & Dietetics 2007; 20(2): 75-83.
In this systematic review of RCTs and CCTs, the quality of the individual studies was poor and the findings inconclusive. As a result, more well-designed studies are required to explore the benefits of early enternal nutritional support.
4 Immunonutrition Quality Indicator Type: Systematic review
Montejo JC, Zarazaga A, Lopez-Martinez J, Urrutia G, Roque M, Blesa AL, Celaya S, Conejero R, Galban C, Garcia de Lorenzo A, Grau T, Mesejo A, Ortiz-Leyba C, Planas M, Ordon~ez J Jimenez FJ. Immunonutrition in the Intensive Care Unit. A Systematic Review and Consensus Statement. Clinical Nutrition 2003; 22(3): 221This well-conducted systematic review contains important, detailed recommendations for future studies and systematic reviews illustrating the improvement in infection rate and length of hospital stay with pharmaconutrients. The use of diets enriched with pharmaconutrients could be recommended in ICU patients requiring enteral feeding. More investigation are however required in order to target the appropriate population of patients that can benefit from this nutritional therapy.
5 Honey Quality Indicator Type: Systematic review
Moore OA, Smith LA, Campbell F, Seers K, McQuay HJ, Moore RA. Systematic Review of the use of Honey as a Wound Dressing. BMC Complementary & Alternative Medicine 2001.
This review highlights the lack of high-quality studies. Nonetheless, the potential benefits of honey treatment for wound healing and infection rates have been elucidated, but these findings are inconclusive.
6 Honey Quality Indicator Type: RCT
Mashhood AA, Khan TA, Sami AN. Honey compared with 1% silver sulfadiazine cream in the treatment of superficial and partial thickness burns. Journal of Pakistan Association of Dermatologists 2007; 16(1): 14-19.
This is a RCT that explores the benefits in terms of healing rate, pain relief and bacterial clearance from honey treatment in comparison to 1% silver sulfadiazine. Patients treated with honey had their burns healed completely by 4 weeks versus 6 weeks in the 1% silver sulfadiazine group. As well, all patients in the treatment group were pain free by 3 weeks, while in the 1% silver sulfadiazine group this took 4 weeks. It took 3 weeks and 5 weeks for a positive swab culture from the wound to show no pathogens with honey and 1% silver sulfadiazine respectively
7 High-release nanocyrstalline dressing (Acticoat) Quality Indicator Type: RCT
Huang Y, Li X, Liao Z, Zhang G, Liu Q, Tang J, Pang Y, Liu X, Lou Q. A randomized comparative trial between Acticoat and SD-Ag in the treatment of residual burn wounds, including safety analysis. Burns 2007; 33(2):161-166.
In this well designed multi-centre RCT comparing high-release nanocyrstalline dressing (Acticoat) with SD-Ag, a non-significant trend toward Acticoat having shorter healing time was detected. As well, this study suggests significant evidence supporting the efficacy of Acticoat in bacterial clearance.

Management of Burn Scars

Hypertrophic scar formation is an important clinical problem in managing burn patients. Individuals vary considerably in their potential for scarring, but burn scars can produce permanent functional loss and disfigurement. Physical deformity due to scar contracture can be disabling. Factors that influence scar formation include body are of the injury, age of the individual and skin pigmentation. Hypertrophic scar formation is thought to be inevitable when epithelialization takes longer than 2 weeks in individuals with darkly pigmented skin and in children, or longer than 3 weeks in other patient types. A variety of scar problems can be seen:

  • Scar contracture: Scars crossing joints or skin creases at right angles may develop contractures when the scar is not fully mature. This type of scar is often hypertrophic and is typically disabling and dysfunctional.
  • Hypertrophic scar: This type of scar is often red, inflamed, itchy and painful, and it typically occurs on the trunk and extremities. Hypertrophic scars do not extend beyond the boundary of the initial injury.
  • Keloid scar: This type of scar extends past the boundary of the initial burn, and it is more common in people with darkly pigmented skin.

The main approach to limiting scarring after burns has been immediate skin replacement with split-thickness grafts or temporary skin replacements. Long-term improvement, however, has been modest. Massage, corticosteroid injection, pressure therapy, silicone dressings, splinting, and surgical scar revision have also been used to manage burn scars and limit hypertrophic scar formation. These approaches are largely empirical and have efficacy limitations.

  • Corticosteroid injection: High pressure is required to inject directly into a hypertrophic scar. As these injections are painful, general anaesthesia may be required, especially in children. Corticosteroid injection is usually limited to localized and symptomatic areas of early hypertrophic scars, particularly in areas where a cosmetic result is important.
  • Pressure: Use of pressure is recommended to prevent the development of hypertrophic scarring, but clinical trials have not determined the optimal pressure and duration of treatment. Pressure therapy can prevent scars but does little to remodel existing hypertrophic scars. A variety of techniques are available, but all are both complex and costly. Pressure garments must be tailored to individual patient needs and should be fitted as soon as possible after skin grafting. These garments have a lifespan of approximately 3 months. Acrylic face masks may be used for moderate-to-severe burns around the neck or face.
  • Silicone gel sheeting: Silicone sheeting can significantly reduce established scars, even many years after injury. A 2-month trial can identify responders. Contractures that are detected early in development can be treated with silicone inserts and pressure.
  • Splinting: Addition of a continuous-wear static splint to silicone inserts and pressure can maintain sustained stretch and improve outcomes in more developed contractures. Once full range of motion is achieved, splinting can be reduced to night-time wear until scar maturation is complete.
  • Surgical intervention: Surgery may be considered for scar contractures that do not fully respond to pressure, silicone sheeting and splinting. Useful surgical techniques for burn reconstruction, including management of contractures, consist of excisional release and grafting, incisional release and grafting, Z-plasty, tissue expansion and use of free flaps.

Extreme pruritus frequently occurs with healing burn wounds. In most patients, pruritus responds to massage, moisturizers, and oral antihistamines. Intense pruritus may require corticosteroid injection into the scar.

Identify and Treat the Cause Level of Evidence
1 Take a careful history asking about previous procedures or a family history of scarring. Not Assessed
Address patient-centered Concerns Level of Evidence
2 Document and treat pain, itch, and psychological sequellae. Not Assessed
Provide Local Wound Care Level of Evidence
3 Consider the early use of skin replacement to minimize hypertrophic scar formation in patients with burn wounds. Not Assessed
4 Consider the use of externally applied pressure therapy to prevent hypertrophic scar formation in patients with burns. Not Assessed
5 Consider use of silicone sheeting to manage established scars. Not Assessed
6 Consider static splinting to prevent scar contracture and loss of range of motion. Not Assessed
7 Use surgical interventions as necessary to manage hypertrophic scars and contractures. Not Assessed
Provide Organizational Support Level of Evidence
8 Empower the team to provide excellent scar management care. Not Assessed

Essential Publications

1 Photodamaged skin Quality Indicator Type: Systematic review
Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photodamaged skin. Cochrane Database of Systematic Reviews 2005, Issue 1.
In this systematic review of many single and double blind RCTs, there is a large scope of interventions pertaining to photodamaged skin. There is conclusive evidence that topical tretinoin improves the appearance of mild to moderate photodamage on the face and forearms, in the short term. However, erythema, scaling/dryness, burning/stinging and irritation may be experienced initially.
2 Silicone gel sheeting Quality Indicator Type: Systematic review
O’Brien L, Pandit A. Silicone gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database of Systematic Reviews 2006, Issue 1.
This is a good systematic review of RCTs and quasi RCTs, non-randomized trials. No differences were found between treatment with silicone gel sheeting versus control for improvement in scar colour, appearance, elasticity or relief of itching or pain in persons with keloid or hypertropic scars. Generally the reviewed studies were of poor quality indicating the need for further rigorous investigation of this topic.
3 Keloids and Hypertrophic Scars Quality Indicator Type: Systematic review
Leventhal, D, Furr M, Reiter D. Treatment of Keloids and Hypertrophic Scars. Arch Facial Plast Surg. 2006; 8:362-368
Review examined studies that measures success rate of various therapies and found a mean rate of 60% from all the studies. Additional research needs to be done to determine whether factors such as location, depth and duration of lesion, patient ethnicity, or prior response to therapy have any influence on treatment outcome.
4 Topical negative pressure Quality Indicator Type: Systematic review
Wasiak J, Cleland H. Topical negative pressure (TNP) for partial thickness burns. Cochrane Database of Systematic Reviews 2007, Issue 3.
Review examined studies measuring the rate of change in wound area and adverse treatment events No conclusive evidence was recovered. As a result, this study highlights the need for better quality RCTs on TNP as sample size was limited and the methodology to detect differences was inadequate.
5 Early excision of burns Quality Indicator Type: Systematic review
Ong YS, Samuel M, Song C. Meta-Analysis of Early Excision of Burns. Burns 2006; 32(2): 145-50.
This is a detailed systematic review with specific conclusions stating that patients receiving early excision treatment had significantly higher blood transfusion requirements (SMD 1.65 95% CI 0.51-2.80), but shorter hospital stays (WMD 8.89, CI 14.28-3.5). The need for better studies is however communicated as a number of out comes (wound healing time, duration of sepsis, operating room hours and long term morbidity) could not be pooled because of differences in outcome definition or the absence of relevant data.
6 Internet sites for burn scar management Quality Indicator Type: Systematic review
Bohacek L, Gomez M, Fish JS. An Evaluation of Internet Sites for Burn Scar Management. J Burn Care Rehab 2003; 24: 246–251.
This paper rated Internet sites for burn scar management. Highly ranking sites may be useful for health care professionals, administrators, patients and their families. Future work in this area is required because digital and computer technology appears infinite to the public, and healthcare professionals struggle to remain aware of the material that may influence their patient’s opinions and knowledge.
7 Silicone Quality Indicator Type: Systematic review
Fette A. Influence of Silicone on Abnormal Scarring. Plastic Surgical Nursing 2006; 26(2): 87-92.
This is a systematic review of prospective studies that received a low rating for quality, since the methodological rigour of individual studies was not considered. Despite this, occlusive silicone cream treatment versus petroleum jelly was successfully tested in split and full-thickness skin grafts, resulting in significantly less pigmentation and hardness (78%), less marginal scar hypertrophy (37%), redness (26%), and in an even narrower marginal scar (22%). Nonetheless, a reliable and validated animal model would be essential for further well-structured research.
8 Silicone gel sheeting Quality Indicator Type: RCT
Li-Tsang CW, Lau JC, Choi J, Chan CC, Jianan L. A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population. Burns 2006; 32(6): 678-683.
This study offers a comprehensive analysis into the addition of silicone gel sheeting (SGS) treatment to post-traumatic hypertrophic scar protocol among Chinese individuals as it was effective to reduce thickness, pain, itchiness and pliability of the scar. Scar thickness was significantly less in the SGS group than in the MT group at 2 months (p = 0.008) and 6 months (p < 0.001). There was no statistically significance between pain and itchiness between the two groups. The scars in the SGS group became softer, more pliable and the improvement between the two groups were significant in 2 months (p = 0.008), 4 months (p = 0.004) and 6 months (p < 0.001).
9 Negative pressure closure Quality Indicator Type: RCT
Llanos S, Danilla S, Barraza C, Armijo E, Pineros JL, Quintas M, Searle S, Calderon W. Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial. Ann.Surg. 2007; 244(5): 700-705.
This randomized, double-masked, controlled trial examines the benefits of negative pressure closure (NPC) for both healing, as it diminishes the loss of split thickness skin grafts (STSG) area, and decreased hospital stay. The medium loss of STSG in experimental NPC patients was 0.0 cm² versus 4.5 cm² in the control group (p = 0.001). The medium hospital stay was 13.7 days in the experimental NPC group versus 17 days in the control group (p < 0.001).
10 Skin substitutes Quality Indicator Type: RCT
Boyce ST, Kagan RJ, Greenhalgh DG, Warner P, Yakuboff KP, Palmieri T, Warden GD. Cultured skin substitutes reduce requirements for harvesting of skin autograft for closure of excised, full-thickness burns. Journal of Trauma-Injury Infection & Critical Care 2006; 60(4): 821-829.
The data obtained from this prospective study suggests that cultured skin substitutes (CSS) provide medical benefits and reduced complications for closure of burn wounds greater then 50% TBSA. The ratio of closed wound: donor skin areas for CSS at post-operative day 28 was significantly greater than for conventional 4:1 meshed autografts (p < 0.01). The percentage of total body surface area closed with CSS at post-operative day 28 was significantly less then AG (P < 0.05).
11 Topical morphine Quality Indicator Type: RCT
Welling A. A randomized controlled trial to test the analgesic efficacy of topical morphine on minor superficial and partial thickness burns in accident and emergency departments. Emergency Medicine Journal 2007; 24(6): 408-412.
This placebo-controlled RCT examined the potential benefits of topical morphine on superficial burns and chronic inflammatory wounds and found it to be ineffective. There were no significant differences between the pain scores found among the three treatments (p = 0.217), but the morphine group was administered the greatest amount of analgesia.

Prevention and Education

Many burns are superficial and do not involve a significant body surface are. These burns do not generally require hospitalization. More serious burns involve deeper tissues and a greater body surface area. Approximately 70,000 Americans suffer burns serious enough to require hospital or burn centre admission. Serious burns are associated with substantial morbidity, mortality and lifelong consequences. As a result, fire safety and burn prevention education is a critical issue for everyone. A commitment to supporting community burn prevention and education programs is a component of the team approach to patient care and hospital commitment to community health.

Education about burn prevention is critical for parents, children, medical and emergency professionals, and employees at workplaces where burn injuries are a risk. Educational programs and information are available from a variety of sources, including community and fire department programs; the Learn Not to Burn® (LNTB) Program, which is designed to teach children about burn prevention; school programs and workplace initiatives.

Burn prevention tips for the home include the following:

  • Install smoke detectors on every floor of the home and test them monthly.
  • Have an escape plan from each room of the house and ensure the entire family knows it.
  • Never leave a child unattended near an open flame or any other heat source.
  • Use flame-resistant sleepwear for infants and children.
  • Never leave a burning candle unattended, and keep candles away from clothes, hair and curtains.
  • Screen fireplaces with metal or glass. Use caution with wood stoves, fireplaces and portable heaters, as they can become very hot on the outside.
  • Ensure that your home has appropriate and working fire extinguishers in the kitchen and other areas where fires may start and learn how to use them.
  • Practice burn prevention in the kitchen:
  • Remain in the kitchen while cooking.
  • Place pots on back burners whenever possible and keep pot handles turned inward.
  • Remove hot foods from stove and oven carefully.
  • Avoid wearing loose clothing that can catch fire, and roll up long sleeves when cooking.
  • Keep flammable items, such as dishcloths and curtains, at least 3’ away from the stove top.
  • Do not reach over burners or other hot surfaces or over boiling pots or kettles. Invisible steam is hotter than visible steam (which has already cooled) and can cause serious burns.
  • Use extreme caution when deep frying foods or heating cooking oil, as hot oil can burst into flame. Water or other liquids dropped into hot oil are instantly converted to steam and can violently spray hot oil around.
  • Use caution with hot syrups as boiling sugar sticks to skin and can cause severe burns.
  • Careless smoking is the leading cause of fire-related deaths in homes. Dispose of cigarettes and matches carefully.
  • Protect children by keeping matches, lighters, chemicals and flammable liquids out of reach.
  • Ensure travel mugs have tight lids when drinking hot beverages around children.
  • Hot water can cause serious burns. Do not set hot water heaters higher than 120° F. Supervise children in the bathtub.
  • Do not overload electrical outlets. Ensure that electrical wires and cords have no damage. Use child-safety covers on wall outlets if young children are in the home.
  • Use and handle gasoline carefully and store it safely.
  • Do not use accelerants to start outdoor or indoor fires.

Know first aid for burns:

  • Eliminate the heat source and run cool water over burns to stop initial burning process. Do not use ice.
  • Stop, drop and roll to smother flames if clothes catch on fire.
  • Never use butter or salves on burns, as they can seal in heat.
Identify and Treat the Cause Level of Evidence
1 Know and practice fire safety and burn prevention. Not Assessed
Address patient-centered concerns Level of Evidence
2 Stress importance of preventative measures. Not Assessed
3 Consider psychosocial factors. Not Assessed
Provide Local Wound Care Level of Evidence
4 NA Not Assessed
Provide Organizational Support Level of Evidence
5 Support community burn prevention and education programs Not Assessed

Essential Publications

1 Community-based interventions Quality Indicator Type: Systematic review
Turner C, Spinks A,McClure R, Nixon J. Community-based interventions for the prevention of burns and scalds in children. Cochrane Database of Systematic Reviews 2004, Issue 2.
This well conducted systematic review involved two controlled trials in the community. When measuring injury rates, significant decreases in pediatric burn and scald injuries were found with intervention compared to the control group (1.26, 95% CI 0.84-1.90). Since only two studies met the inclusion criteria, the need for more quality studies with greater study time-frame and with adequately implemented counter-measures in the communities is required.
2 Burns- return to work Quality Indicator Type: Systematic review
Brych SB, Engrav LH, Rivara FP, Ptacek JT, Lezotte DC, Esselman PC, Kowalske KJ, Gibran NS. Time Off Work and Return to Work Rates After Burns: Systematic Review of the Literature and a Large Two-Center Series. Journal of Burn Care & Rehabilitation 2001; 22(6): 401-5.
The systematic review is based on RCT studies that found employment disruption after burn injury to be significant. 10 manuscripts with objective data showed a mean time off work of 17 weeks and found that the probability of returning to work was reduced by psychiatric history and extremity burns. Recommendations for future studies are made.
3 Burns-Psychological adjustment Quality Indicator Type: Systematic review
Noronha DO, Faust J. Identifying the Variables Impacting Post-Burn Psychological Adjustment: A Meta-Analysis. Journal of pediatric psychology 2007; 32(3): 380-91.
In this systematic review variables associated with risk for psychological adjustment were identified, including body location of burn, burn injury type, parental adjustment and child psychological function. More studies in this area are however required.
4 Burns-Psychological adjustment Quality Indicator Type: Systematic review
Thombs BD, Bresnick MG, Magyar-Russell G. Depression in Survivors of Burn Injury: A Systematic Review. General hospital psychiatry 2006; 28(6): 494-502. Study design: Systematic Review
This systematic review examined psychological adjustment in burn victims using depression questionnaires and two rating scales (Beck Depression Inventory (BDI) or the Hospital Anxiety and Depression Scale (HADS-D)). Major depression was identified in 10-40% of adults. The prevalence of significant depression systems in studies that used the HADS-D post discharge was 4-13% , whereas studies that used the BDI generally produced substantially higher rates between 13-26%. This study was of low quality study and requires a larger sample size in the future to better assess prevalence rates and risk factors.

Scar Classification Systems

Maturation of burn scars may take from 18 months to 2 years. Scar maturation is characterized by redness, pigmentation, pain, itching, hypertrophy, retraction and induration. Interventions during maturation can limit functional and cosmetic consequences of scarring. During this stage, assessment of inflammation and scar evolution is necessary to adapt treatments and evaluate treatment effects. Clinical assessment may use a variety of scar assessment scales, which may evaluate different scar characteristics. Scores become more reliable with rater experience and training. The major clinical assessment tools for burn scars are the following:

  • Vancouver Scar Scale (VSS): The VSS is also known as the Burn Scar Index. The VSS evaluates vascularity (redness), height (hypertrophy), pliability (contracture and elastic texture) and pigmentation. The VSS has been validated on defined scar areas of 4 cm2, but application of this subjective scale is difficult on large irregular areas where scarring is not homogeneous. Modifications proposed include separate assessments of colour, correlation between VSS and the patient’s subjective opinion and incorporation of a visual analogue scale.
  • Visual analogue scale (VAS): The VAS scale rates global aspects of the scar.
  • Modified VSS (MVSS): Modifications include use of two colour scales, for Caucasian and Aboriginal patients, to reduce subjectivity of the vascularity scale, and a Plexiglas tool to evaluate height and pigmentation scales. Inter-rater reliability testing found that only total scores should be used because individual subscale scores had inadequate reliability.
  • Patient and Observer Scar Assessment Scale (POSAS): POSAS includes the patient opinion; this scale was tested on linear scars. The observer scale includes vascularity, pigmentation, thickness, relief, pliability and surface area, whereas the patient scale assesses pain, itching, colour, stiffness, thickness and relief. Evaluation of this scale determined that the POSAS is a suitable, reliable, appropriate subjective and complete tool for evaluation of linear scars.
  • Manchester Scale: The Manchester Scale assesses colour compared with surrounding skin, matte or shiny appearance, contour (flush with surrounding skin to keloid), texture (normal to hard), margins (distinct or not), size and number (single or multiple). At each evaluation, these data are included with others in the Manchester scar proforma, along with a standardized colour photograph.

Despite subjectivity, clinical assessment scales are all useful in daily practice. The VSS may be more suitable for burn scars. Itching and pain are important to include in assessment of scar evolution.

Various technical tools can also be used to assess individual scar parameters more accurately than subjective assessment. Tristimulus colorimeter, durometer, cutometer and tonometer are reliable and easy-to-use tools to assess colour, height, induration, or pliability. In comparison, ultrasound scanners, laser Doppler and 3D analysis are more complicated, expensive and more used for research.

Identify and Treat the Cause Level of Evidence
1 NA Not Assessed
Address patient-centered Concerns Level of Evidence
2 NA Not Assessed
Provide Local Burn Care Level of Evidence
3 Select a clinical assessment system and use it consistently with burn patients. Not Assessed
Provide Organizational Support Level of Evidence
4 Educate all raters on the use of the selected system and review subjective interpretation periodically to maximize rater consistency. Not Assessed

Essential Publications

1 Description of Vancouver Scar Scale Quality Indicator Type: Scale Description
Baryza MJ, Baryza GA. The Vancouver Scar Scale: An Administrative Tool and Its Interrater Reliability. J Burn Care Rehabil 1995; 16:535-538.
In this article the Vancouver Scar Scale, its validation, and the use of a 3×5 inch plexiglass tool to aid assessment and documentation, are described. The VSS is used to rate burn scares evaluating such variables as vascularity, redness, height, hypertrophy, pliability, contracture and elastic scar texture and pigmentation.
2 Description of Visual Analogue Scale (VAS) Quality Indicator Type: Scale Description
Beausang E, Floyd H, Dunn KW, Orton CI, Ferguson MW. A new quantitative scale for clinical scar assessment. Plast Reconstr Surg, 1998; 102: 1954-61.
The VAS is a modified VSS scale that is used to rate global aspects of the scar. This scale requires 3 observes to be reliable. It is easy to use, does not rely on expensive equipment and is applicable to a wide range of scars from well healed surgical scars to problematic hypertorphic and keloid scars. It is thus a useful clinical tool in the evaluation of scar prevention or treatment regimens.
3 Description of Modified Vancuover Scar Scale (MVSS) Quality Indicator Type: Scale Description
Forbes- Duchart L, Marshall S, Strock A, Cooper JE. Determination of inter-rater reliability in pediatric burn scar assessment using a modified version of the Vancouver scar scale. J Burn Care Res, 2007; 28: 460-67
The VSS Plexiglas tool was modified using a pictorial color scale to aid with vascularity rating. This study analyzes the inter-rater reliability of the MVSS. Findings indicate that only total scores of the MVSS should be used when determining burn scar outcomes because individual subset scores have little reliability. Further modification of the MVSS and additional research with larger subject population is warranted to improve its clinical usefulness.
4 Description and Validation of Patient and Observer Scar Assessment Scale (POSAS) Quality Indicator Type: Validation study
Draaijers LJ, Tempelman FR, Botman YA, Tuinebreijer WE, Middelkoop E, Kreis RW, Van Zuijlen PP. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg, 2004; 113: 1960-5.
The POSAS consists of the observer scale which assesses vascularity, pigmentation, thickness, relief, pliability and surface area and the patient scale which assesses pain, itching, color, stiffness, thickness and relief. The POSAS is an appropriate objective tool for the evaluation of linear scars using patient opinion
5 Validation of Patient and Observer Scar Assessment Scale (POSAS) Quality Indicator Type: Validation study
Van der Kar AL, Corion U, Smeulders MJ, Draaijers LJ, Van der Horst CM, Van Zuijlen PP. Reliable and feasible evaluation of linear scars by patient and observe scar assessment scale. Plast Reconstr Surg, 2005; 116: 514-22.
This study assesses POSAS evaluation of 100 linear scars concerning vascularity, pigmentation, thickness, pliability and surface area as well as using a patient scale which examined pain, itchiness, color, stiffness, relief and thickness. The internal consistency of the observer and patient scales was good (=0.96 for observer and =0.94 for patient, p < 0.001). Good agreement was evident as the coefficient of variation of the total score was 10.4% for the observer scale and 15.8% for the patient scale. Based on internal consistency and agreement POSAS is a good objective tool for the evaluation of linear surgical scars.
6 Description of Manchester Scale Quality Indicator Type: Scale Description
Bayat A, McGrouther DA, Ferguson MWJ. Skin scarring. BMJ, 2003; 326:88- 92.
The Manchester Scale assesses 7 parameters associated with scars including scar color, skin appearance, contours from flush with surrounding skin to keloid, texture, margin distinction and size. This scale is a useful assessment for localised burns cars, especially for the development of hypertrophic or keloid scars, but does not include an analysis of vascularity.
7 Summary of VSS, VAS, POSAS and Manchester Scale Quality Indicator Type: Narrative Review
Roques C, Teot L. A critical analysis of measurements used to assess and manage scars. Lower Extremity Wounds, 2007; 6(4): 249-53.
This review clinical analyses four scar assessment tools, The Vancouver Scar Scale, Visual Analogue Scale, Patient and Observe Scar Assessment Scale and the Manchester Scale. Each scale is different and provides various methods of assessing different scar characteristics. Each scale is easy to use, but subject to errors. The VSS appears to be more suited to burn scars despite being subjective. Overall clinical assessment scales are subjective and each one rates different items useful for scar assessment, making each tool useful in daily practice.

Skin Grafts and Biologics

Excision and grafting

Early surgical excision and grafting are the treatment of choice for deep burns. For optimal function and cosmetic outcomes, critical areas should be grafted first. Layered or sequential excision is the method of choice in many centres. Approximately 200 mL blood loss is expected for each percent total body surface area (TBSA) excised and grafted. Use of tourniquets for extremity wounds, infiltration of a crystalloid with 2% epinephrine beneath the burn, electrocautery and epinephrine-soaked sponges may minimize blood loss.

Skin grafts and substitutes:

Depending on the clinical situation, a variety of skin grafting options are available. Negative pressure wound therapy may be used in conjunction with skin grafting to optimize outcomes in complex grafting problems, such as grafting on the hand and on bone.

  • Split-thickness skin grafts: These grafts are used for most burns. Sheet grafts are always used for the face and are ideal for burns covering
  • Full-thickness skin grafts with primary closure of donor site: This option should be used for small burns, as it produces excellent functional and cosmetic outcomes and minimal donor site morbidity.
  • Skin expansion: Expansion may be necessary for burns of more than 40% TBSA, using a meshing device. The least expanding mesh possible should be used for cosmetically and functionally important areas.
  • Cultured autologous epidermal sheets: These cultures need 2–3 weeks to grow; they are fragile and they are often associated with unstable epithelium and hypertrophic scarring. The use of cultured epidermal sheets is usually limited to patients with burns covering 85–90% TBSA.
  • Skin substitutes: The problem of wound contraction after skin grafting has led to the development of products with both an epidermal and a dermal component. Living skin equivalents, such as Apligraf; bilayer products, comprised of bovine collagen-based dermis and silastic epidermis; and bilayered sproduct of autologous fibroblasts in a collagen-glycosaminoglycan matrix with autologous keratinocytes all have application in preventing wound contraction after skin grafting.

Biologic dressings

Biologic dressings, or biosynthetic skin substitutes, act as temporary skin substitutes, which prevent wound contamination and reduce pain and fluid loss. They usually consist of a superficial epidermal analogue and a deeper dermal analogue. Biologic dressings may also deliver growth factors and matrix proteins to the wound, providing an optimal wound healing environment, speeding epithelialization and minimizing scarring. These dressings are associated with lower infection rates and faster healing rates than silver sulfadiazine.

Biologic dressings should be applied within the first 6 hours after the burn. The initial application may loosen, necessitating reapplication. Biologic dressings gradually peel off as skin epithelializes underneath them. Early separation of dressing from skin indicates an infection or a deeper wound requiring surgical treatment.

Identify and Treat the Cause Level of Evidence
1 NA Not Assessed
Address patient-centered Concerns Level of Evidence
2 NA Not Assessed
Provide Local Wound Care Level of Evidence
3 Use early excision and skin grafting to enhance healing of deep burn wounds. Not Assessed
4 Select the appropriate skin grafting technique for the clinical situation. Not Assessed
5 Use biologic dressings to provide an optimal wound healing environment and to minimize scarring. Not Assessed
Provide Organizational Support Level of Evidence
6 Provide infrastructure and training for optimnal graft procedures. Not Assessed

Essential Publications

1 Skin substitute (Suprathel) Quality Indicator Type: RCT
Schwarze H, Ku(Suntscher M, Uhlig C, Hellmann H, Prantl L, Noack N, Hartmann B. Suprathel, a new skin substitute, in the management of donor sites of split-thickness skin grafts: Results of a clinical study. Burns 2007; 33(7):850-854.
This two-centre RCT demonstrated the medical benefits of Suprathel (skin substitute) on wound healing, patient comfort and ease of care. Suprathel treated patients had a significantly lower pain score, and as compared to Jelonet had better plasticity and attachment to wound surfaces (p = 0.0002). There was no significant difference between Suprathel and Jelonet with regards to healing time and re-epithelization. The material effectiveness contributes to the reduction of overall treatment cost.
2 Skin substitute (cultured autologous keratinocytes) Quality Indicator Type: RCT
Magnusson M, Papini RP, Rea SM, Reed CC, Wood FM. Cultured autologous keratinocytes in suspension accelerate epithelial maturation in an in vivo wound model as measured by surface electrical capacitance. Plast.Reconstr.Surg. 2007; 19(2): 495-499.
This double-blinded, RCT analyzes the difference between cultured epithelial autografts and Dulbecco’s Modified Eagle’s Medium for the treatment of acute wounds. A statistically significant difference in surface electrical capacitance observed in the cultured epithelial autograft compared with the Dulbecco’s Modified Eagle’s Medium treated wounds at 5 days (p = 0.012) and 7 days (p = 0.036). It demonstrates that healing rate increased with the cultured epithelial autograft treatment.
3 Skin substitute Quality Indicator Type: RCT
Boyce ST, Kagan RJ, Greenhalgh DG, Warner P, Yakuboff KP, Palmieri T, Warden GD. Cultured skin substitutes reduce requirements for harvesting of skin autograft for closure of excised, full-thickness burns. Journal of Trauma-Injury Infection & Critical Care 2006; 60(4): 821-829.
The data obtained from this prospective RCT study suggests that cultured skin substitutes (CSS) provide medical benefits and reduced complications for closure of wounds greater then 50% TBSA.
4 Skin substitute (Suprathel) Quality Indicator Type: RCT
Uglig C, Rapp M, Hartmann R, Hierlemann H, Planck H, Dittell KOKI. Surprathel- An innovative, resorbable skin substitute for the treatment of burn victims. Burns 2007; 33(4): 221-229.
A good preliminary study examining the benefits of Surprathel in comparison to conventional paraffin gauze or Omiderm indicating that there was significantly less pain with Surprathel than with paraffin gauze or Omiderm.

Treatment

Initial assessment and management of the burn patient includes attention to the airway, breathing, circulation and thermoregulation. Initial assessment of burns includes depth, location, extent and etiology of the burn.

Initial management

  • Pain relief is the initial focus of burn management. Minor burns may be treated effectively with oral analgesics, whereas serious burns usually require intravenous analgesics. Analgesics should be administered before dressing procedures and as needed.
  • Debridement of loose necrotic tissue, gentle cleansing with a bland soap and application of dressings constitutes the traditional approach to burn management. The periphery of the wound should be shaved to remove hairs that can harbour bacteria. Blisters with a diameter greater than 1–2 cm should be debrided.
  • Initial topical antibiotic therapy should address gram-positive organisms, whereas after longer periods of time, gram-negative flora predominate. Milder antimicrobial agents, such as bacitracin, neosporin, polysporin and mupirocin, are used to treat small and superficial wounds. More potent agents, such as silver sulfadiazine, mafenide acetate and silver nitrate, may delay epithelialization. These agents are used to prevent bacterial invasion of extensive and deeper wounds. Topical antibiotic therapy is typically administered twice daily until complete epithelialization has occurred.

Clinical approaches

Approaches to clinical management differ, depending on burn wound depth:

  • Superficial and medium-depth partial thickness burn wounds: Management objectives are uncomplicated epithelialization, usually within 10–14 days, with preservation of viable dermal appendages and prevention of hypertrophic scarring.
  • Deeper partial-thickness wounds: These burns may require pressure garments to minimize hypertrophic scar formation. If healing has not occurred by 10–14 days, consideration should be given to skin grafting, which decreases scarring and speeds healing and recovery of function.
  • Full-thickness wounds: As all dermal appendages are destroyed, skin grafting is required to prevent contraction. Grafting can address functional and cosmetic issues in wounds covering

Surgical management

No prospective randomized trials have compared early excision with grafting after wound separation. However, the treatment of choice is now early excision and grafting. Selection of patients for surgical excision includes consideration of the following factors:

  • Patient age
  • Extent and location of the burn:
  • In the management of small burns, full-thickness grafts with primary closure of the donor site produce minimal morbidity and excellent functional and cosmetic results.
  • Sheet grafts are ideal for the face and burns covering40% TBSA may require skin expansion with a meshing device.
  • For burns >25% TBSA, excision is usually initiated 3–5 days after injury. Indeterminate-depth wounds may require 10–14 days to determine the need for grafting.
  • For massive burns (>40–50% TBSA) serial excision is performed every 2–3 days until the entire eschar has been removed, followed by skin grafting or use of biosynthetic dressings.
  • Optimal function and cosmetic results are achieved by grafting critical areas first.
  • Associated injuries and illnesses
  • Availability of autologous and allogeneic skin
  • Excisional timing, location and technique
  • Selection of graft donor sites.

Negative pressure wound therapy may assist in securing difficult skin grafts and optimize vascularization of matrix products.

Rehabilitation

Comprehensive rehabilitation begins as soon as possible after injury and usually involves a rehabilitation team. Successful functional and cosmetic outcomes may involve early range-of-motion exercises, appropriate positioning, pressure garments, splinting, and pressure facemasks. Pressure on healed wounds must be maintained 23 hours per day and used until scars have matured, approximately 12–18 months.

Follow-up care

Follow-up care of all partial- and full-thickness burns is critical. If wounds have epithelialized within 2–3 weeks of injury, patients should be followed for at least 2 months to monitor re-pigmentation and development of scar hypertrophy. Wounds healing in more than 3 weeks or requiring grafting may need pressure therapy.

Patient and family education is critical and should include instructions for wound care, appropriate nutrition to support wound healing and avoidance of ultraviolet light exposure for at least 1 year. Pruritus, which is common, should be managed to prevent scratching and damage to the healed skin

Identify and Treat the Cause Level of Evidence
1 Take a history and perform a physical examination of the burned skin. Not Assessed
Address patient-centered Concerns Level of Evidence
2 Provide ongoing support and education that is appropriate for the age, developmental, cognitive, and psychological status of the patient, family, and/or caregivers throughout all phases of recovery. Not Assessed
3 Enable the patient to identify the functional implications of his/her individual scar and contribute to planning future needs. Not Assessed
4 Ensure adequate pain management using a combination of medications and non-pharmacological techniques to allow for optimum function. Not Assessed
5 Discuss with the patient and encourage return to work as soon as possible. Not Assessed
Provide Local Wound Care Level of Evidence
6 Assess depth, location, extent and etiology of the burn to determine management approaches. Not Assessed
7 Provide adequate oral or intravenous pain management to burn patients. Not Assessed
8 Debride loose necrotic tissue, cleanse gently with a bland soap, apply appropriate topical antimicrobial agents twice daily, and use appropriate wound dressings. Not Assessed
9 Treat superficial and medium-depth partial thickness burns to achieve epithelialization, preserve viable dermal appendages and prevent hypertrophic scarring. Not Assessed
10 Use skin grafting and pressure garments as necessary for optimal functional and cosmetic outcomes in deeper partial-thickness wounds and in full-thickness wounds. Not Assessed
11 Use early excision and skin grafting whenever feasible. Not Assessed
12 Involve the rehabilitation team in patient care as soon as possible after the burn. Not Assessed
13 Institute follow-up care for all burn patients for at least 2 months. Not Assessed
14 Provide comprehensive patient and family education about wound care, nutrition, avoidance of ultraviolet light, and management of pruritus Not Assessed
Provide Organizational Support Level of Evidence
15 Empower an interprofessional burn team ensuring involvement of appropriate professionals, e.g., Dietitian, OT, PT, and provide education and support. Not Assessed

Essential Publications

1 Anticonvulsant drugs Quality Indicator Type: Systematic review
Wiffen P, Collins S, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database of Systematic Reviews 2005, Issue 3.
A well-organized, well-conducted systematic review with important implications for practice and research. There is however a lack of evidence showing that anticonvulsants have a beneficial effect on acute pain.
2 Hyperbaric oxygen therapy Quality Indicator Type: Systematic review
Villanueva E, Bennett MH, Wasiak J, Lehm JP. Hyperbaric oxygen therapy for thermal burns. Cochrane Database of Systematic Reviews 2004, Issue 2.
This is a well-conducted systematic review that highlights the need for more evidence related to the topic of HBOT effectiveness, with important implications for both practice and research. In one RCT, the mean healing time was 19.7 days in those patients treated with HBOT versus the control group(mean: 19.7 versus 43.8 days. Adverse events (pulmonary barotrauma, drug reactions, injury or death related to chamber fire) however were also reported from the treatment group.
3 Hyperbaric oxygen therapy Quality Indicator Type: Systematic review
Saunders PJ. Hyperbaric Oxygen Therapy in the Management of Carbon Monoxide Poisoning, Osteoradionecrosis, Burns, Skin Grafts, and Crush Injury. International Journal of Technology Assessment in Health Care 2003; 19(3): 521-5.
Review concludes that there is no convincing evidence that HBO2 is of benefit for the treatment of CO poisoning (severe or moderate), osteoradionecrosis, burns, skin grafts, or crush injury, and there is no case for a unit in the West Midlands region.
4 Lidocaine treatment Quality Indicator Type: Systematic review
Wasiak J, Cleland H. Lidocaine for pain relief in burn injured patients. Cochrane Database of Systematic Reviews 2007, Issue 3.
Study shows poor quality of RCTs and CCTs as there were no clinically relevant outcomes. Despite this, however, the review clearly states what it would have proceeded to do had better studies existed, and provides important implications for research.
5 Photodamaged skin Quality Indicator Type: Systematic review
Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photodamaged skin. Cochrane Database of Systematic Reviews 2005, Issue 1.
This study examines a large scope of interventions pertaining to photodamaged skin, and has included a large number of RCTs. There is conclusive evidence that topical tretinoin improves the appearance of mild to moderate photodamage on the face and forearms, in the short term. However, erythema, scaling/dryness, burning/stinging and irritation may be experienced initially.
6 Toxic epidermal necrolysis Quality Indicator Type: Systematic review
Majumdar S, Mockenhaupt M, Roujeau J-C,Townshend A. Interventions for toxic epidermal necrolysis. Cochrane Database of Systematic Reviews 2002, Issue 4.
No reliable evidence for the benefits of thalidomide treatment. Treatment with thalidomide was not shown to be effective and was associated with significantly higher mortality rates then placebo. The study was terminated as the mortality on the treatment arm was 83% compared to 30% on the control arm (relative risk 2.78, 95% CI 1.04-7.40).The study highlights contradictions in evidence and need for better RCTs.
7 Carbamazepine Quality Indicator Type: Systematic review
Wiffen PJ, McQuay HJ, Moore RA. Carbamazepine for acute and chronic pain. Cochrane Database of Systematic Reviews 2005, Issue 3.
Study highlights the need for better RCTs, and concludes that there is insufficient evidence to promote the use of carbamazepine for acute pain due to the small trial size. Two studies however did show NNT of effectiveness of 1.8 (95% Ci 1.4-2.8)
8 Early enteral nutrition Quality Indicator Type: Systematic review
Wasiak J, Cleland H, Jeffery R. Early versus delayed enteral nutrition support for burn injuries. Cochrane Database of Systematic Reviews 2006, Issue 3.
This review highlights the need for more evidence pertaining to this subject using larger sample size and more rigorous methodology. The evidence recovered from 3 studies concerning the benefit of early enternal nutrition support on standardized clinical outcomes including LOS and mortality were inconclusive
9 Early enteral nutrition Quality Indicator Type: Systematic review
Marik PE, GP Zaloga. Early Enteral Nutrition in Acutely Ill Patients: A Systematic Review. Critical care medicine 2001: 29(12): 2264-70.
The results indicate that early feeding decreases infectious complications (p = 0.00006) and length of stay (p = 0.002). There results however should be interpreted with caution because of the significant heterogeneity between studies.
10 Early enteral nutrition Quality Indicator Type: Systematic review
Wasiak J, Cleland H, Jeffery R. Early Versus Late Enteral Nutritional Support in Adults with Burn Injury: A Systematic Review. Journal of Human Nutrition & Dietetics 2007; 20(2): 75-83.
In this systematic review of RCTs and CCTs, the quality of the individual studies was poor and the findings inconclusive. As a result, more well-designed studies are required to explore the benefits of early enternal nutritional support.
11 Silicone gel sheeting Quality Indicator Type: Systematic review
O’Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database of Systematic Reviews 2006, Issue 1.
This is a good systematic review of RCTs and quasi RCTs, non-randomized trials. No differences were found between treatment with silicon gel sheeting versus control for improvement in scar colour, appearance, elasticity or relief of itching or pain in persons with keloid or hypertropic scars. Generally the reviewed studies were of poor quality indicating the need for further rigorous investigation of this topic.
12 Topical negative pressure Quality Indicator Type: Systematic review
Wasiak J, Cleland H. Topical negative pressure (TNP) for partial thickness burns. Cochrane Database of Systematic Reviews 2007, Issue 3.
Review examined studies measuring the rate of change in wound area and adverse treatment events. One study reported a significant difference in burn size at day 3 (p < 0.09) and day 5 (p < 0.04), but none by day 14. No conclusive evidence was recovered. As a result, this study highlights the need for better quality RCTs on TNP as sample size was limited and the methodology to detect differences was inadequate.
13 Tramadol Quality Indicator Type: Systematic review
Hollingshead J, Dühmke RM, Cornblath DR. Tramadol for neuropathic pain. Cochrane Database of Systematic Reviews 2006, Issue 3.
Data shows that tramadol is an effective treatment for neuropathic pain. Four trials showed that with tramadol treatment compared to placebo showed the NNT to reach at least 50% was 3.8 (95% CI 2.8-6.3).
14 Immunonutrition Quality Indicator Type: Systematic review
Montejo JC, Zarazaga A, Lopez-Martinez J, Urrutia G, Roque M, Blesa AL, Celaya S, Conejero R, Galban C, Garcia de Lorenzo A, Grau T, Mesejo A, Ortiz-Leyba C, Planas M, Ordon~ez J Jimenez FJ. Immunonutrition in the Intensive Care Unit. A Systematic Review and Consensus Statement. Clinical Nutrition 2003; 22(3): 221
This well-conducted systematic review contains important, detailed recommendations for future studies and systematic reviews illustrating the improvement in infection rate and length of hospital stay with pharmaconutrients. The use of diets enriched with pharmaconutrients could be recommended in ICU patients requiring enteral feeding. More investigation are however required in order to target the appropriate population of patients that can benefit from this nutritional therapy
15 Honey wound dressing Quality Indicator Type: Systematic review
Moore OA, Smith LA, Campbell F, Seers K, McQuay HJ, Moore RA. Systematic Review of the use of Honey as a Wound Dressing. BMC Complementary & Alternative Medicine 2001
This review highlights the lack of high-quality studies. Nonetheless, the potential benefits of honey treatment for wound healing and infection rates have been elucidated, but these findings are inconclusive.
16 Early excision of burns Quality Indicator Type: Systematic review
Ong YS, Samuel M, Song C. Meta-Analysis of Early Excision of Burns. Burns 2006; 32(2): 145-50.
Detailed systematic review with specific conclusions stating that patients receiving early excision treatment had significantly higher blood transfusion requirements (SMD 1.65 95% CI 0.51-2.80), but shorter hospital stays (WMD 8.89, CI 14.28-3.5). The need for better studies is however communicated as a number of out comes (wound healing time, duration of sepsis, operating room hours and long term morbidity) could not be pooled because of differences in outcome definition or the absence of relevant data.
17 Cerium Nitrate Treatment Quality Indicator Type: Systematic review
Garner JP, Heppell PSJ. Cerium Nitrate in the Management of Burns. Burns 2005; 31(5): 539-47.
This systematic review examined the benefit of cerium nitrate as a topical treatment for cutaneous burns. Data showed reduced mortality and morbidity by 50% in the treatment of severe burns. This benefit is derived from its ability to bind and denature the lipid protein complex liberated from burnt skin. The methodology of this study however, was poor and requires improvement.
18 Exogenous erythropoietin Quality Indicator Type: Systematic review
MacLaren R, Gasper J, Jung R, Vandivier RW. Use of exogenous erythropoietin in critically ill patients. Journal of Clinical Pharmacy and Therapeutics 2004; 29: 195–208.
rHuEPO reduces the need for transfusions. However, defining an optimal dosage regimen, identifying patients most likely to respond to rHuEPO, and determining risk factors for ICU associated anemia would provide information for appropriate rHu- EPO utilization.
19 Silicone Quality Indicator Type: Systematic review
Fette A. Influence of Silicone on Abnormal Scarring. Plastic Surgical Nursing 2006; 26(2): 87-92.
The study quality was not considered, although the methodology was poor and overall evidence low. Despite this occlusive silicone cream treatment versus petroleum jelly was successfully tested in split and full-thickness skin grafts, resulting in significantly less pigmentation and hardness (78%), less marginal scar hypertrophy (37%), redness (26%), and in an even narrower marginal scar (22%). Nonetheless, a reliable and validated animal model would be essential for further well-structured research.
20 Keloids and Hypertrophic Scars Quality Indicator Type: Systematic review
Leventhal, D, Furr M, Reiter D. Treatment of Keloids and Hypertrophic Scars. Arch Facial Plast Surg. 2006; 8:362-368.
Review examined studies that measures success rate of various therapies and found a mean rate of 60% from all the studies. Additional research needs to be done to determine whether factors such as location, depth and duration of lesion, patient ethnicity, or prior response to therapy have any influence on treatment outcome.
21 Prevention of Pressure Sores Quality Indicator Type: Systematic review
Gordon MD, Helich MM, Helvig EI, Marvin JA, Richard RL. Review of Evidence-Based Practice for the Prevention of Pressure Sores in Burn Patients. J Burn Care Rehabil 2004; 25: 38-410.
This systematic review examined the current evidence of practice in nursing, nutrition, and rehabilitation as it pertains to the prevention of pressure sores after burn injuries. They found insufficient data necessary for the characterization of nutrition assessment standards to prevent and treat pressure sores in burn patients It was however found that patient positioning is thought of as a physical approach to the prevention of burn scar contracture. Final research questions were generated towards the uultimate goal being the development of evidence-based practice guidelines.
22 High release nanocrystalline silver dressing Quality Indicator Type: RCT
Huang Y, Li X, Liao Z, Zhang G, Liu Q, Tang J, Pang Y, Liu X, Lou Q. A randomized comparative trial between Acticoat and SD-Ag in the treatment of residual burn wounds, including safety analysis. Burns 2007; 33(2):161-166.
In this well designed multi-centre RCT comparing Acticoat with SD-Ag, a non-significant trend toward Acticoat having shorter healing time was detected. As well, this study suggests significant evidence supporting the efficacy of Acticoat in bacterial clearance.
23 High release nanocrystalline silver dressing Quality Indicator Type: RCT
Muangman P, Chuntrasakul C, Silthram S, Suvanchote S, Benjathanung R, Kittidacha S, Rueksomtawin S. Comparison of efficacy of 1% silver sulfadiazine and Acticoat for treatment of partial-thickness burn wounds. Journal of the Medical Association of Thailand 2006; 89(7): 953-958.
Study confirms the advantages of Acticoat as a less painful alternative to wound care. Average pain scores in patients treated with Acticoat (4 ± 0.6) were significantly lower then those treated with 1% Ag-SD (5 ± 0.7). There were however no significant difference between wound and LOS between both groups (p > 0.05). The 1% AgSD treatment group received more split thickness skin grafts compared to patients treated with acticoat, but this was not significant (p = 0.32).
24 Silver Sulfadiazine Treatment Quality Indicator Type: RCT
Mashhood AA, Khan TA, Sami AN. Honey compared with 1% silver sulfadiazine cream in the treatment of superficial and partial thickness burns. Journal of Pakistan Association of Dermatologists 2007; 16(1): 14-19.
This is a RCT that explores the benefits in terms of healing rate, pain relief and bacterial clearance from honey treatment in comparison to 1% silver sulfadiazine. Patients treated with honey had their burns healed completely by 4 weeks versus 6 weeks in the 1% silver sulfadiazine group. As well, all patients in the treatment group were pain free by 3 weeks, while in the 1% silver sulfadiazine group this took 4 weeks. It took 3 weeks and 5 weeks for a positive swab culture from the wound to get sterile with honey and 1% silver sulfadiazine respectively.
25 Surprathel skin substitute Quality Indicator Type: RCT
Uhlig C, Rapp M, Hartmann R, Hierlemann H, Planck H, Dittell KOKI. Surprathel- An innovative, resorbable skin substitute for the treatment of burn victims. Burns 2007; 33(4): 221-229.
A good preliminary study examining the benefits of Surprathel in comparison to conventional paraffin gauze or Omiderm indicating that there was significantly less pain with Surprathel than with paraffin gauze or Omiderm. Surprathel is a porous membrane and its described production course guarantees a nearly symmetrical cross-section of the membrane with an interconnected structure of pores.
26 Suprathel skin substitute Quality Indicator Type: RCT
Schwarze H, Kuntscher M, Uhlig C, Hellmann H, Prantl L, Noack N, Hartmann B. Suprathel, a new skin substitute, in the management of donor sites of split-thickness skin grafts: Results of a clinical study. Burns 2007; 33(7):850-854.
This two-centre RCT demonstrated the medical benefits of Suprathel on wound healing, patient comfort and ease of care. Suprathel® represents an absorbable, synthetic wound dressing with properties of natural epithelium. Suprathel treated patients had a significantly lower pain score, and as compared to Jelonet had better plasticity and attachment to wound surfaces (p = 0.0002). There was no significant difference between Suprathel and Jelonet with regards to healing time and re-epithelization (p = 0.5). The material effectiveness contributes to the reduction of overall treatment cost.
27 Cultured skin substitutes Quality Indicator Type: RCT
Boyce ST, Kagan RJ, Greenhalgh DG, Warner P, Yakuboff KP, Palmieri T, Warden GD. Cultured skin substitutes reduce requirements for harvesting of skin autograft for closure of excised, full-thickness burns. Journal of Trauma-Injury Infection & Critical Care 2006; 60(4): 821-829.
The data obtained from this prospective study suggests that cultured skin substitutes (CSS) consisting of autologous cultured keratinocytes and fibroblasts that attaches to collagen-based sponges provides medical benefits and reduced complications for closure of burn wounds greater then 50% TBSA. The ratio of closed wound: donor skin areas for CSS at post-operative day 28 was significantly greater than for conventional 4:1 meshed autografts (p < 0.01). The percentage of total body surface area closed with CSS at post-operative day 28 was significantly less then AG (P < 0.05).
28 Cultured autologous keratinocytes skin substitute Quality Indicator Type: RCT
Magnusson M, Papini RP, Rea SM, Reed CC, Wood FM. Cultured autologous keratinocytes in suspension accelerate epithelial maturation in an in vivo wound model as measured by surface electrical capacitance. Plast. Reconstr. Surg. 2007; 19(2): 495-499.
This double-blinded, RCT analyzes the difference between cultured epithelial autografts and Dulbecco’s Modified Eagle’s Medium for the treatment of acute wounds. A statistically significant difference in surface electrical capacitance observed in the cultured epithelial autograft compared with the Dulbecco’s Modified Eagle’s Medium treated wounds at 5 days (p = 0.012) and 7 days (p = 0.036). It demonstrates that healing rate increased with the cultured epithelial autograft treatment.
29 Intensive rehabilitation therapy Quality Indicator Type: RCT
Okhovatia F and Zoubine N. A comparison between two burn rehabilitation protocols. Burns 2007; 33(4): 429-434.
This group match clinical trial examines the feasibility and efficacy of a more intensive burn rehabilitation therapy that proves more effective for preventing burn contractures then ordinary rehabilitation protocol and a trend toward shorter LOS. Due to the immobilization with ordinary rehabilitation protocol there was a 67% increase in burn scar contracture in group I (p < 0.01). here was no significance difference between groups (p > 0.05) for thrombosis and duration of stay in the hospital. Despite this insignificance, additional BRT releases patients 4 days earlier from the hospital, which helped reduce hospital costs.
30 Early enternal resuscitation and feeding Quality Indicator Type: RCT
Venter M, Rode H, Sive A, Visser M. Enternal resuscitation and early enternal feeding in children with major burns- Effect of McFarlane response to stress. Burns 2007; 33(4): 464-471.
This paper discusses the benefits of early resuscitation and enternal feeding in young infants and children for improved healing of major burns with reduced hormonal stress. The ER and EEF group showed an anabolic response with significantly higher insulin concentrations (p = 0.008) and insulin: glucose ratios (p = 0.043). Growth hormone concentration were significantly higher in the LEF group (p = 0.03).
31 Xenogenic acellular dermal matrix Quality Indicator Type: RCT
Fang X, Shen R, Tan J, Chen X, Pan Y, Ruan S, Zhang F, Lin Z, Zeng Y, Wang X, Lin Y, Wu Q. (2007). The study of inhibiting systematic inflammatory response syndrome by applying xenogenic (porcine) acellular dermal matrix on second-degree burns. Burns 2007; 33(4): 477-479.
This study indicates that use of xenogenic acellular dermal matrix versus bedtime ointment gauze in patients with second-degree burns results in lower CRP levels indicating less SIRS.
32 Trace element supplementation Quality Indicator Type: RCT
Berger MM, Baines M, Raffoul W, Benathan M, Chiolero RL, Reeves C, Revelly JP, Cayeux MC, Senechaud I, Shenkin A. Trace element supplementation after major burns modulates antioxidant status and clinical course by way of increased tissue trace element concentrations. Am.J.Clin.Nutr. 2007; 85(5): 1293-1300.
Randomized, placebo-controlled trial that examines the benefit of TE supplementation after major burns leading to reduced number of infectious complications and better wound healing. The number of infections was significantly lower in the TE group (p = 0.015) as a result of a reduction in pulmonary infection in the TE group (p = 0.03). Wound healing was improved in the TE group with lower requirements for re-grafting (p = 0.02).
33 Fenofibrate Quality Indicator Type: RCT
Cree MG, Zwetsloot JJ, Herndon DN, Qian T, Morio B, Fram R, Sanford AP, Aarsland A, Wolfe RR. Insulin sensitivity and mitochondrial function are improved in children with burn injury during a randomized controlled trial of fenofibrate. Ann. Surg. 2007; 245(2): 214-221.
This double-blind, placebo-controlled randomized trial examines the drop in glucose concentrations following fenofibrate treatment and suggests that it is effective as a new therapy for treating insulin resistance following severe burn injury. Average daily glucose concentration in the fenofibrate group was less then the control group (p = 0.003).
34 Silicone gel sheeting Quality Indicator Type: RCT
Li-Tsang CW, Lau JC, Choi J, Chan CC, Jianan L. A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population. Burns 2006; 32(6): 678-683.
This study offers a comprehensive analysis into the addition of silicone gel sheeting (SGS) treatment to post-traumatic hypertrophic scar protocol among Chinese individuals as it was effective to reduce thickness, pain, itchiness and pliability of the scar. Scar thickness was significantly less in the SGS group than in the MT group at 2 months (p = 0.008) and 6 months (p < 0.001). There was no statistically significance between pain and itchiness between the two groups. The scars in the SGS group became softer, more pliable and the improvement between the two groups were significant in 2 months (p = 0.008), 4 months (p = 0.004) and 6 months (p < 0.001).
35 Negative pressure closure Quality Indicator Type: RCT
Llanos S, Danilla S, Barraza C, Armijo E, Pineros JL, Quintas M, Searle S, Calderon W. Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial. Ann. Surg. 2007; 244(5): 700-705.
This randomized, double-masked, controlled trial examines the benefits of negative pressure closure (NPC) for both healing, as it diminishes the loss of split thickness skin grafts (STSG) area, and decreased hospital stay. The medium loss of STSG in experimental NPC patients was 0.0 cm² versus 4.5 cm² in the control group (p = 0.001). The medium hospital stay was 13.7 days in the experimental NPC group versus 17 days in the control group (p < 0.001).
36 Enteral arginine supplementation Quality Indicator Type: RCT
Marin VB, Rodriguez-Osiac L, Schlessinger L, Villegas J, Lopez M, Castillo-Duran C. Controlled study of enteral arginine supplementation in burned children: impact on immunologic and metabolic status. Nutrition 2006; 22(7-8): 705-712.
This double-blind, randomized, placebo-controlled trial investigates the potential benefits of using arginine-supplemented diets on burned children to improve mitogen-stimulated lymphoproliferation. Responses varied between the two groups on day 7 as the experimental group showed 144% increase in lymphoproliferation response (p < 0.05) while the control group only showed a 56% increase. Both groups however returned to normal baseline levels by day 14.
37 Glutamine granule-supplemented enteral nutrition Quality Indicator Type: RCT
Peng X, Yan H, You Z, Wang P, Wang S. Glutamine granule-supplemented enteral nutrition maintains immunological function in severely burned patients. Burns 2006; 32(5): 589-593.
This double-blind, RCT study examines the benefit of glutamine granule supplement to help heal and build immunological function in a severally burned patient. Wound healing was better and hospital stay days reduced in the glutamine group (46.59 ± 12.98 days versus 55.68 ± 17.36 p < 0.05). There was no significance difference between groups (p > 0.05) for thrombosis and duration of stay in the hospital.
38 Growth Hormone Quality Indicator Type: RCT
Przkora R, Herndon DN, Suman OE, Jeschke MG, Meyer WJ, Chinkes DL, Mlcak RP, Huang T, Barrow RE. Beneficial effects of extended growth hormone treatment after hospital discharge in pediatric burn patients. Ann. Surg. 2006; 243(6):796-801.
This double-blinded RCT conveys how rhGH treatment can markedly improve recovery, body composition, body function and hormone metabolism in severely burned children following hospital discharge and with fewer reconstructive procedures then with the placebo. rhGH treatment significantly improved height, weight, muscle strength, lean body mass, bone mineral content and cardiac function (p < 0.05) the number of operative reconstructive procedures was significantly lower in rhGH treatment group (p < 0.05).
39 Topical morphine Quality Indicator Type: RCT
Welling A. A randomized controlled trial to test the analgesic efficacy of topical morphine on minor superficial and partial thickness burns in accident and emergency departments. Emergency Medicine Journal 2007; 24(6): 408-412.
This placebo-controlled RCT examined the potential benefits of topical morphine on superficial burns and chronic inflammatory wounds and found it to be ineffective. There were no significant differences between the pain scores found among the three treatments (p = 0.217, but the morphine group was administered the greatest amount of analgesia.