IV. WOUND CARE
A. Pre-Hospital Wound Care: Cooling
Cooling of the burn using tap water is sensible as long as it does not delay in care and transfer to a hospital
facility. Cooling relieves pain and may reduce the depth of injury in evolving partial-thickness burns.
However, the exact method and length of cooling is still controversial. This course recommends that cooling
is appropriate by using tap water up to 30 minutes for burns %u2264 5% TBSA. In larger size injuries, the risk of
hypothermia and delay in care potentially outweighs the benefit of cooling.
B. Patients Who Meet Criteria for Referral to a Burn Center
Evaluation and treatment of life-threatening problems always takes precedence over the management of
the burn wound. The priorities for initial wound management differ from definitive wound management in
several ways. During initial stabilization, once the primary and secondary survey have been completed and
interventions planned, the provider should document the areas of second- and third-degree prior to transfer. To
avoid hypothermia, cover the patient with a dry clean dressing and keep the patient warm. There is no need to
cleanse extensive wounds in patients who are to undergo formal wound evaluation and cleansing once at the
burn center. The priority here is stabilization and rapid transfer. Elevate any extremity with a burn injury above
the level of the heart to minimize burn wound edema. Use pillows to ensure the extremity remains elevated
C. Patients Who Do Not Meet ABA Referral Criteria, or Patients With Anticipated Delay in Transfer to a Burn Center
If the patient%u2019s injuries do not meet criteria for referral, or if transfer to a burn center will exceed 24 hours
because of mass casualty or other logistical reasons, this course recommends the following 2 steps:
1. Cleansing the wound with a cleansing agent (i.e., soap or chlorhexidine) and removing dirt and debris from
the wound area, if present. Perform wound care one body section at a time to limit the exposed areas
to a minimum. Prepare warm water or warm saline ahead of time. Prepare all dressings ahead of time to
apply immediately upon completion of wound care for that specific area of the body. Warm water with
dilute chlorhexidine gluconate to cleanse the burn wounds is optimal due to broad-spectrum antimicrobial
coverage. Do not use chlorhexidine gluconate in close proximity to the eyes. It is acceptable to use
baby shampoo mixed with warm water to clean the head and neck area along with the rest of the body if
chlorhexidine gluconate is not available. Pre-medicate the patient for pain and anxiety control and maintain
a warm environment.
2. Gently debride blisters >2cm in size using sterile gauze or scissors; apply a topical antimicrobial
medication. Consult with the burn center for the preferred topical antimicrobial medication. Common
topical ointments are silver sulfadiazine for full-thickness burns and bacitracin for partial- thickness burns.
If topical antimicrobial dressings are to be applied, the primary and secondary dressings method should be
used. A primary dressing makes direct contact with the burn wound surface. For instance, 1% SSD (silver
sulfadiazine) is commonly used. This cream can be applied directly to the burn wound or impregnated into
gauze and then applied to the wound. Other topical ointments can be used, either alone or in combination,
depending on the depth of the wound. Examples are bacitracin, double- or triple-antibiotic ointment,
and petrolatum. A secondary dressing provides a layer to absorb drainage and will provide mechanical
protection. All secondary dressings are loosely secured with size appropriate rolled gauze or surgical
netting if available. Do not secure dressings in a constrictive manner that may interfere with perfusion.