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Treatment of burns

By Peter Millard | 04 Feb, 2013

SSD wounds and burns:

For me, one of the most fascinating uses of UpToDate is to compare it to evidence-based recommendations. In my circle of afficionados of evidence-based medicine, there is a tendency to believe that UpToDate’s recommendations are ‘evidence-based.’ If you read UpToDate regularly, you will find out that it is indeed somewhat better than conventional textbooks, but still has a long way to go before it could be remotely considered evidence-based.

For example, consider the chapter on treatment of burns (a topic very much on the mind of people who work in resource-limited settings). There is strong belief in Mozambique where I work that prophylactic antibiotics are effective in preventing infections. UpToDate clearly dispels that myth by saying: “There is no role for prophylactic IV antibiotics” in burn management.” (Section: “Emergency care of moderate and severe thermal burns in adults”)

However, in the sections on topical treatment of burns, UpToDate is at marked variance with the Cochrane review on the subject.

The Cochrane review (accessed 4 Feb, 2013) states that: “This review highlights the lack of conclusive evidence on the effects of silver-containing dressings or agents to prevent wound infection and to promote wound healing. In particular, there was no evidence to support the use of silver sulphadiazine (SSD) for prevention of wound infection in patients with partial-thickness burns. None of the trials indicated a beneficial effect for SSD for other outcomes when compared with other silver-containing or non-silver dressings. Furthermore, there was evidence that SSD may delay wound healing, may be more expensive, and may be more painful when applied to burns. The few trials on full-thickness burns and acute, chronic, or mixed wounds showed insufficient evidence for a beneficial effect of silver-containing dressings to decrease infection rates and to aid wound healing.”

Contrast the Cochrane review (our “Best Evidence”) to the UpToDate text on burn treatment. In the section on “Local treatment of burns: Topical antimicrobial agents and dressings” UpToDate states:
“ Local treatment of burns includes cleansing and debridement, topical antimicrobial agents, and dressings….. The use of topical antimicrobial agents and aggressive wound care has reduced the incidence of invasive wound infections for superficial partial-thickness burns devoid of epithelium, superficial full-thickness burns, and deeper burns.”
 and
“The selection and application of topical antimicrobials are to a great degree reflected in the art of the science.”
 and,
Summary: “We suggest using a topical antimicrobial agent or bismuth-impregnated petroleum based gauze (eg, Xeroform) as the initial burn wound coverage for superficial partial-thickness burns devoid of epithelium and deeper burns (Grade 2C). These agents provide a moist environment conducive to wound healing. Commonly used topical antimicrobial agents include silver sulfadiazine, combination antibiotics, and chlorhexidine.”
 and
“Silver sulfadiazine cream (SSD 1 percent) is the most commonly used burn wound dressing. This thick white cream is applied once or twice daily, and can be soothing.”

However, in the Section on “Treatment of minor thermal burns”, UpToDate states:
“Silver sulfadiazine (SSD) is commonly used for prophylaxis against infection but is generally not used for superficial burns. Treatment with SSD may slow wound healing and increases the frequency of dressing changes, resulting in increased pain.”

Thus, even within UpToDate, one section says that SSD is “soothing” and another says that it “increased pain.” The scientific evidence, as in Cochrane text above, shows that SSD increases pain.

What do other readers think about UpToDate’s evidence-base in your area of expertise?

Replies

 

Rob Sheridan Replied at 11:25 AM, 5 Feb 2013

Hi Peter,
I agree that "Up-To-Date" is not always consistent (nothing is I suppose!). I also agree with you that burn treatment in limited resource settings can be very challenging, treatment depending more on what's available than what's optimal. I'd love to discuss with you sometime.
Best Regards,
Rob Sheridan
Boston Shriners burn unit

Pierre Williot Replied at 1:05 PM, 10 Feb 2013

To All,
I am going on a surgical mission in a area with a high HIV-AIDS prevalence of 9%.

I would appreciate your input on the following questions:

1) Besides double golving technique and no finger handling of needle, any suggestions?
2) Is it ethical to request HIV-AIDS status of patients prior to surgical intervention? - What is the cost of these testings?
3) Should I bring retro-viral drugs?
4) Is it safe to bring a resident (junior - senior)?
4) Anything else that you could think of?

Sincerely,
Pierre Williot (Pediatric Urologist - Buffalo - New York)

Rebeca Plank Replied at 4:09 PM, 10 Feb 2013

I work in a travel clinic and we do offer a 28-day prescription for antiretrovirals in case of needle-stick for providers who are working in HIV-enedmic areas. You should be able to get a supply from your local Infectious Disease provider.

--------------------------------------------------------------------

Rebeca M Plank, MD

Associate Physician

Division of Infectious Diseases

Brigham and Women's Hospital

15 Francis Street, PBB-A-4

Boston, MA 02115

Phone: +1-617-525-9656

Fax: +1-617-732-6829





In Botswana mobile +267-7250-9391

Travis Tollefson Replied at 4:25 PM, 10 Feb 2013

Hi Pierre
You are asking some really important questions that may have some difference in opinion on the board, but. I have been working in Zimbabwe since 2006 and what has worked for us is to attempt to integrate within the current existing ministry of health protocols. The following are responses to your questions (my opinion only)
1. Consider every patient to be potentially positive and then surgical intervention is based on the individual health status and surgical candidacy regardless of their viral status. (e.g. standard workup with weight for age/height, general health, pulse Ox, Anesthesiology heart and lung exam, Hemaglobin, and additional cardio workup as indicated). If you are working within a system that would allow you to "triage" kids to start treatment, then another NGO or government program may be helpful with which to collaborate.
2. I feel strongly that your team should bring at least an emergency kit for at least two people to start immediate therapy in case of exposure. The speed at which the meds are started seem to represent the best therapy after a needle stick. Here is a reference: http://www.aafp.org/afp/2010/0715/p161.html
3. Surgery Residents both from the host country and the US have been an integral part of our team, but obviously you need to assess the context of the environment you are entering.
4) The answers to all of the above may be completely different depending on the hospital and health system you will be working within, but over-preparation is always better.
-Happy to talk if you'd like.
Travis

This Community is Archived.

This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.