Revised Guidelines for the Management of Burns

A panel of dermatology experts revised existing guidelines for the management of burns. The first iteration of these guidelines was published in 2016 and revised for 2020 by the Wound, Pressure Ulcer, and Burn Guidelines Drafting Committee of the Japanese Dermatological Association. Published in the Journal of Dermatology, the updated guidelines are intended to facilitate the diagnosis, treatment, and management of burn injury.

The expert panel conducted a review of the current literature using Medline, PubMed, Japana Centra Revuo Medicina Web, and the Cochrane Database of Systematic Reviews. Work published from 1980 to 2013 was reviewed in the first guideline set; more recent literature was included for the updated guidelines. Systemic reviews of randomized controlled trials (RCTs) and individual RCTs were prioritized in review, although cohort studies, case-control studies, and case series studies were also included. Recommendations were developed in response to specific “clinical questions” (CQs) of interest, including questions regarding burn severity evaluation, systemic management, infection prevention, and topical treatments. This edition comprised recommendations for a total of 27 clinical questions. Recommendations were presented based on the level of evidence, with the highest level of evidence provided by systematic reviews, meta-analyses, and RCTs.

The first set of CQs concerned the evaluation of burn severity. Experts recommended a classification based on clinical symptoms, per strong literature evidence. Weaker recommendations included the use of Doppler flowmetry or video microscopy. For estimating burn area, the rule of nines, the rule of fives, and the Lund and Browder Chart were strongly recommended. The Artz’s criteria were also endorsed as a tool for burn severity evaluation. Strong literature evidence identified total body surface area, presence of airway damage, area of third-degree burns, age, and burn index as useful prognostic indicators.

A series of recommendations were presented for the systematic management of burns. Fluid resuscitation was recommended for adults with 15% of the total body surface area affected. Isotonic electrolyte fluids were most strongly recommended for fluid resuscitation. Endotracheal intubation was strongly recommended in the case of airway burns, and steroid management was discouraged. Experts also added guidelines for electrical and chemical burns, for which inpatient care and lavage with water were recommended.

Regarding infection control, the guidelines suggested that preventive systemic antibiotics only be administered for immunocompromised patients, children, perioperative patients, and patients with known contaminated wounds. Anti-tetanus treatment and disinfection of burn sites was also suggested. Hydrotherapy was recommended for patients with minor burns not requiring hospitalization; for patients with more severe burns, hydrotherapy was only recommended if proper anti-infection measures were taken. A fecal management tube was suggested for perianal burns to prevent fecal contamination of the wound area.

The guidelines also addressed local treatment modalities, including escharotomy, silver sulfadiazine, and topical steroids. Escharotomy was recommended for reducing pressure. The most strongly endorsed dressing materials were silver-containing hydrofiber, silver alginate, and silver-containing polyurethane foam/soft silicone. Silver sulfadiazine was endorsed for the treatment of third-degree burns. Various topical agents and steroids were also recommended based on the level of burn severity. Bromelain was most strongly supported as a means of removing necrotic tissue from small third-degree burns.

These recommendations address the diagnosis, management, and treatment of first-to third-degree burns. Although the strength of evidence varied, experts emphasized recommendations with the most extensive literature support. Compared with the first iteration of recommendations, this latest edition added data from more recent studies and addressed chemical and electrical burns. “Our guidelines intend to facilitate the appropriate diagnosis and initial treatment of patients with minor to severe burns that are commonly encountered,” investigators wrote.

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Reference

Yoshino Y, Hashimoto A, Ikegami R, et al. Wound, pressure ulcer and burn guidelines – 6: Guidelines for the management of burns, second edition [published online April 28, 2020]. J Dermatol. doi: 10.1111/1346-8138.15335