Burns

Eleven Tests and Treatments to Question

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Burns Canada
Last updated: December 2020

Do not administer prophylactic antibiotics to patients presenting with acute burn injuries.
1

The available evidence does not support the routine use of early systemic antibiotic prophylaxis in the management of patients with acute burn injuries. In addition to exposing patients to side-effects, antibiotic use without indication encourages the development of resistance, thus reducing treatment options during the patient’s hospital course. Topical antimicrobial dressings are the standard of care for these patients.

Sources:

Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M. Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ. 2010;340:c241. Published 2010 Feb 15. PMID: 20156911.

Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, Solà I, Bonfill Cosp X. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev. 2013;(6):CD008738. Published 2013 Jun 6. PMID: 23740764.

Csenkey A, Jozsa G, Gede N, et al. Systemic antibiotic prophylaxis does not affect infectious complications in pediatric burn injury: A meta-analysis. PLoS One. 2019;14(9):e0223063. Published 2019 Sep 25. PMID: 31553768.

Ramos G, Cornistein W, Cerino GT, Nacif G. Systemic antimicrobial prophylaxis in burn patients: systematic review. J Hosp Infect. 2017;97(2):105-114. PMID: 28629932.

Tagami T, Matsui H, Fushimi K, Yasunaga H. Prophylactic Antibiotics May Improve Outcome in Patients With Severe Burns Requiring Mechanical Ventilation: Propensity Score Analysis of a Japanese Nationwide Database. Clin Infect Dis. 2016;62(1):60-66. PMID: 26405146.
Do not routinely swab open wounds and do not prescribe systemic antibiotics based on these results, without clinical features of local or systemic infection.
2

Most wound swabs in the context of a burn injury will yield bacterial growth. These organisms may be commensal organisms not responsible for wound infection or sepsis, and do not warrant therapy. The use of systemic agents predisposes to antimicrobial resistance, is expensive, and may also expose patients to unnecessary side-effects. Burn wound swabs should form part of standardized admission surveillance programs for resistant organisms such as MRSA.

Sources:

Copeland-Halperin LR, Kaminsky AJ, Bluefeld N, Miraliakbari R. Sample procurement for cultures of infected wounds: a systematic review. J Wound Care. 2016;25(4):S4-S10. PMID: 27068349.

Halstead FD, Lee KC, Kwei J, Dretzke J, Oppenheim BA, Moiemen NS. A systematic review of quantitative burn wound microbiology in the management of burns patients. Burns. 2018;44(1):39-56. PMID: 28784345.
Do not transfuse red blood cells to patients with burn injuries who have haemoglobin levels greater than 70 g/l, unless there is active haemorrhage or myocardial ischaemia.
3

Blood products are a limited resource. Blood transfusion is associated with adverse effects, including transfusion reactions, immunosuppression, lung injury, and circulatory overload. In the context of stable patients with burn injuries, who are not actively bleeding or with active myocardial ischaemia, the current evidence supports a restrictive transfusion trigger to maintain haemoglobin above 70g/l. Unnecessary transfusions can also be avoided by ordering and infusing one unit of red blood cells at a time (with interval blood tests to confirm indication for a further unit), rather than ordering two units immediately.

Sources:

Kwan P, Gomez M, Cartotto R. Safe and successful restriction of transfusion in burn patients. J Burn Care Res. 2006;27(6):826-834. PMID: 17091078.

Palmieri TL. Burn injury and blood transfusion. Curr Opin Anaesthesiol. 2019;32(2):247-251. PMID: 30817402.

Palmieri TL, Holmes JH 4th, Arnoldo B, et al. Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury. Ann Surg. 2017;266(4):595-602. PMID: 28697050.

Palmieri TL, Holmes JH, Arnoldo B, et al. Restrictive Transfusion Strategy Is More Effective in Massive Burns: Results of the TRIBE Multicenter Prospective Randomized Trial. Mil Med. 2019; 184(Suppl 1):11-15. PMID: 30371811.

Palmieri TL, Lee T, O’Mara MS, Greenhalgh DG. Effects of a restrictive blood transfusion policy on outcomes in children with burn injury. J Burn Care Res. 2007;28(1):65-70. PMID: 17211202.
Do not attempt to normalise albumin with albumin infusions following the acute phase of burn resuscitation.
4

Albumin infusions are part of the acute resuscitation strategy of many burn centres globally, and may be associated with the administration of smaller volumes of crystalloid. Patients with severe burn injuries frequently develop chronic hypoalbuminaemia following resuscitation, due to hypermetabolism, fluid and protein loss from wounds, and impaired albumin synthesis. Attempting to restore serum albumin levels with the continuous infusion of human albumin solutions does not appear to improve outcomes in burn patients, and is costly.

Sources:

Cartotto R, Callum J. A review of the use of human albumin in burn patients. J Burn Care Res. 2012;33(6):702-717. PMID: 23143614.

Cartotto R, Greenhalgh D. Colloids in Acute Burn Resuscitation. Crit Care Clin. 2016;32(4):507-523. PMID: 27600123.

Cartotto R, Greenhalgh DG, Cancio C. Burn State of the Science: Fluid Resuscitation [published correction appears in J Burn Care Res. 2017 Jul 1;38(4):269]. J Burn Care Res. 2017;38(3):e596-e604. PMID: 28328669.

Greenhalgh DG, Housinger TA, Kagan RJ, et al. Maintenance of serum albumin levels in pediatric burn patients: a prospective, randomized trial. J Trauma. 1995;39(1):67-74. PMID: 7636912.

Melinyshyn A, Callum J, Jeschke MC, Cartotto R. Albumin supplementation for hypoalbuminemia following burns: unnecessary and costly!. J Burn Care Res. 2013;34(1):8-17. PMID: 23128130.

Navickis RJ, Greenhalgh DG, Wilkes MM. Albumin in Burn Shock Resuscitation: A Meta-Analysis of Controlled Clinical Studies. J Burn Care Res. 2016;37(3):e268-e278. PMID: 25426807.
Do not administer opioid analgesics to patients with burn injuries without considering the co-administration of adjunctive agents, and psychological as well as physical strategies.
5

Reliance on opioids as the dominant or only analgesic is associated with harms including not only higher opioid requirements and significant side-effects e.g. nausea, constipation, drowsiness, but also dependence, diversion, and overdose. One should implement a multi-modal analgesic strategy including acetaminophen and NSAIDS if there are no contra-indications. One should also consider medications directed at neuropathic pain (e.g. gabapentin, pregabalin, duloxetine, amitriptyline), as well as physical (e.g. positioning) and psychological (e.g. distraction, relaxation, meditation) interventions to optimize mental health, reduce anxiety and promote effective sleep.

Sources:

James DL, Jowza M. Principles of Burn Pain Management. Clin Plast Surg. 2017; 44(4):737-747. PMID: 28888299.

Kim DE, Pruskowski KA, Ainsworth CR, Linsenbardt HR, Rizzo JA, Cancio LC. A Review of Adjunctive Therapies for Burn Injury Pain During the Opioid Crisis. J Burn Care Res. 2019; 40(6):983-995. PMID: 31259369.

Morgan M, Deuis JR, Frøsig-Jørgensen M, et al. Burn Pain: A Systematic and Critical Review of Epidemiology, Pathophysiology, and Treatment. Pain Med. 2018;19(4):708-734. PMID: 29036469.
Do not administer analgesia and sedation (e.g. opioids and benzodiazepines) without regular titration, interruption or dose reassessment of the administered agents.
6

It is important to regularly review the indication and dosage of analgesia and anxiolytics (including but not limited to opioids and benzodiazepines) in patients mechanically ventilated for their burn injuries. Higher doses of opioids and benzodiazepines are associated with delays in extubation, an increased risk of systemic infections (including ventilator associated pneumonia), deep vein thrombosis, delirium, and longer hospital stays, which in turn result in deconditioning, and long-term psychological effects.

Sources:

Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306. PMID: 23269131.

Fagin A, Palmieri T, Greenhalgh D, Sen S. A comparison of dexmedetomidine and midazolam for sedation in severe pediatric burn injury. J Burn Care Res. 2012;33(6):759-763. PMID: 23147214.

Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial [published correction appears in JAMA. 2013 Jan 16;309(3):237]. JAMA. 2012;308(19):1985-1992. PMID: 23180503.
Do not undertake medical or surgical procedures if these are inconsistent with the burn patient’s expressed goals of care.
7

All patients should have a goals of care discussion (between the health care team and the patient and/or substitute decision maker) during the first 48 hours of their hospital stay. This is especially relevant for patients with extensive burn injuries, the elderly, and those at high risk of death. Interventions should only be undertaken when they are in keeping with the patient’s previously expressed goals of care or best interests, as determined by the patient’s substitute decision-maker in conjunction with the clinical team.

Sources:

Bartley CN, Atwell K, Cairns B, Charles A. Predictors of withdrawal of life support after burn injury. Burns. 2019;45(2):322-327. PMID : 30442381.

Bayuo J, Bristowe K, Harding R, et al. The Role of Palliative Care in Burns: A Scoping Review. J Pain Symptom Manage. 2020;59(5):1089-1108. PMID: 31733355.

Mahar PD, Wasiak J, Cleland H, et al. Clinical differences between major burns patients deemed survivable and non-survivable on admission. Injury. 2015;46(5):870-873. PMID: 25707879.

Mularski RA, Puntillo K, Varkey B, et al. Pain management within the palliative and end-of-life care experience in the ICU [published correction appears in Chest. 2009 Aug;136(2):653]. Chest. 2009;135(5):1360-1369. PMID: 19420206.

Pham TN, Otto A, Young SR, et al. Early withdrawal of life support in severe burn injury. J Burn Care Res. 2012;33(1):130-135. PMID: 22240509.

Ray DE, Karlekar MB, Crouse DL, et al. Care of the Critically Ill Burn Patient. An Overview from the Perspective of Optimizing Palliative Care [published correction appears in Ann Am Thorac Soc. 2017 Dec;14(12):1866]. Ann Am Thorac Soc. 2017;14(7):1094-1102. PMID: 28590164.
Do not routinely initiate fluid resuscitation when the burn is less than 15% total body surface area (TBSA).
8

Partial and full thickness burns affecting less than 15% of the TBSA do not require specific directed fluid resuscitation. Patients with burn injuries under 15% can typically meet their requirements with maintenance intravenous fluid infusions or oral fluid intake alone. There may be other associated indications for fluid replacement, however, such as concomitant trauma, dehydration, alcohol intoxication, or other fluid losses.

Sources:

Cartotto R. Fluid resuscitation of the thermally injured patient. Clin Plast Surg. 2009;36(4):569-581. PMID: 19793552.

Gillenwater J, Garner W. Acute Fluid Management of Large Burns: Pathophysiology, Monitoring, and Resuscitation. Clin Plast Surg. 2017;44(3):495-503. PMID: 28576238.

Rae L, Fidler P, Gibran N. The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation. Crit Care Clin. 2016;32(4):491-505. PMID: 27600122.

Saffle JR. Fluid Creep and Over-resuscitation. Crit Care Clin. 2016;32(4):587-598. PMID: 27600130.

Saffle JI. The phenomenon of “fluid creep” in acute burn resuscitation. J Burn Care Res. 2007;28(3):382-395. PMID: 17438489.
Do not perform routine investigations such as daily blood tests or chest radiographs unless they will guide decision making with respect to management of the patient with burns.
9

The medical team should regularly reassess the indications for routine daily bloodwork and chest radiographs as the clinical course proceeds, especially when there has been no significant intervening condition change. Several studies have demonstrated the cost benefits of such a strategy, without compromising the delivery of optimal patient care.

Sources:

Ganapathy A, Adhikari NK, Spiegelman J, Scales DC. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. Crit Care. 2012;16(2):R68. Published 2012 Dec 12. PMID: 22541022.

Gershengorn HB, Wunsch H, Scales DC, Rubenfeld GD. Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation. JAMA Netw Open. 2018;1(4):e181119. Published 2018 Aug 3. PMID: 30646104.

Merkeley HL, Hemmett J, Cessford TA, et al. Multipronged strategy to reduce routine-priority blood testing in intensive care unit patients. J Crit Care. 2016;31(1):212-216. PMID: 26476580.

Rachakonda KS, Parr M, Aneman A, Bhonagiri S, Micallef S. Rational Clinical Pathology Assessment in the Intensive Care Unit. Anaesth Intensive Care. 2017;45(4):503-510. PMID: 28673222.

Sy E, Luong M, Quon M, et al. Implementation of a quality improvement initiative to reduce daily chest radiographs in the intensive care unit. BMJ Qual Saf. 2016;25(5):379-385. PMID: 26350068.
Do not excise and autograft partial thickness burns, including scald burns in children, without a period of wound care and observation, unless obvious deep partial thickness.
10

A significant proportion of partial thickness burn injuries will heal within two to three weeks without surgery. A period of observation of a week or more, especially in smaller burns, will allow the wound to manifest features of healing or the capacity to heal. This is especially true in the context of paediatric scald burns, the most common category of burn injuries globally. A conservative approach to the management of these wounds has the potential to reduce healthcare costs, the need for operative procedures, and the impact of donor site wound care and pain. There is also limited evidence to suggest that a wound that heals within three weeks is more likely to scar prominently when compared to a split thickness skin graft.

Sources:

de Graaf E, van Baar ME, Baartmans MGA, et al. Partial-thickness scalds in children: A comparison of different treatment strategies. Burns. 2017;43(4):733-740. PMID: 28040360.

Palmieri TL, Greenhalgh DG. Topical treatment of pediatric patients with burns: a practical guide. Am J Clin Dermatol. 2002;3(8):529-534. PMID: 12358554.

Vloemans AF, Hermans MH, van der Wal MB, Liebregts J, Middelkoop E. Optimal treatment of partial thickness burns in children: a systematic review. Burns. 2014;40(2):177-190. PMID: 24290852.
Do not recommend the administration of hydroxycobalamin (Vitamin B-12A or 'cyanokit') to patients prior to assessment in the burn centre, unless the history and investigations strongly support its use.
11

Evidence supporting the routine use of hydroxycobalamin is weak and may be associated with the development of renal impairment. Hydroxycobalamin may be administered in the burn centre in the setting of a severe inhalation injury and uncorrected worsening metabolic acidaemia. Patients with a strong clinical picture of severe inhalation injury who require prolonged transport to a burn centre may be the exception to this rule.

Sources:

Barillo DJ, Goode R, Esch V. Cyanide poisoning in victims of fire: analysis of 364 cases and review of the literature. J Burn Care Rehabil. 1994;15(1):46-57. PMID : 8150843.

Dépret F, Hoffmann C, Daoud L, et al. Association between hydroxocobalamin administration and acute kidney injury after smoke inhalation: a multicenter retrospective study. Crit Care. 2019;23(1):421. Published 2019 Dec 23. PMID: 31870461.

Dumestre D, Nickerson D. Use of cyanide antidotes in burn patients with suspected inhalation injuries in North America: a cross-sectional survey. J Burn Care Res. 2014;35(2):e112-e117. PMID: 23877146.

Legrand M, Michel T. Empiric use of hydroxocobalamin in patients with smoke inhlation injury: Not so fast!. Burns. 2017;43(4):886. PMID: 28057381.

MacLennan L, Moiemen N. Management of cyanide toxicity in patients with burns. Burns. 2015;41(1):18-24. PMID: 24994676.

Nguyen L, Afshari A, Kahn SA, McGrane S, Summitt B. Utility and outcomes of hydroxocobalamin use in smoke inhalation patients. Burns. 2017;43(1):107-113. PMID: 27554631.

Streitz MJ, Bebarta VS, Borys DJ, Morgan DL. Patterns of cyanide antidote use since regulatory approval of hydroxocobalamin in the United States. Am J Ther. 2014;21(4):244-249. PMID: 23689094.
How the list was created

This list was created by a working group of burn surgeons and intensivists from across Canada. The collaborators were: Rogers AD (FC Plast Surg, MSc, FACS), Amaral A (MD), Cartotto RC (MD, FRCSC), el Khatib A (MD), Fowler R (MDCM, MSc, FRCPC), Logsetty S (MD, FRCSC, FACS), Malik CC (MD, FRCS, FRCSC), Mason S (MD, PhD, FRCSC), Nickerson D (MD, FRCSC, FACS), Papp A (MD, PhD, FRCSC), Rasmussen J (MD, FRCSC), and Wallace D (MSc, MD).

A list of 35 themes were developed from initial discussions, and then a modified Delphi process using Survey Monkey enabled the collaborators to systematically stratify statements from 0-5 (strongly disagree, disagree, indifferent, agree and strongly agree). Consensus of expert opinion and evidence from the literature informed the final wording of the statements.

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