THE CLOSED (OCCLUSIVE) METHOD FOR BURNS

LOCAL ANTISEPTIC AGENTS are highly desirable for larger burns. Use: (1) Silver sulphadiazine cream. (2) 0.5% silver nitrate with 0.2% chlorhexidine changed every 4 days. (3) Povidone iodine. Or, less satisfactorily, use (4) cetrimide, or (5) chlorhexidine. In practice, you will probably have to use no antiseptic, or one of these last two.

APPLYING THE DRESSINGS FOR THE OCCLUSIVE METHOD

Use a ’no touch technique’. Use sterile forceps or sterile disposable gloves so that no human hand touches the burn or the dressings, and no sterile glove touches anything else in the room. If necessary, sedate the patient, or give him ketamine. Clean his burn and the skin around it with chlorhexidine solution. There is no need to puncture the blisters.

If a deep burn encircles a limb, you may need to do an escharotomy before applying a dressing.

Using a sterile spatula, spread one of the local antiseptic agents listed above on sterile gauze and apply this to the burn. Alternatively, and less satisfactorily, apply vaseline gauze.

Cover this with 2.5 cm of cotton wool and a crepe bandage. The dressing must extend 10 cm beyond the wound margins. If there is a wound over a flexure, apply the dressing with the joint in extension to prevent contractures (58.24). A thin plaster cast may prevent a child from removing his dressings.

CHANGING THE DRESSINGS WITH THE OCCLUSIVE METHOD

Partial thickness burns I f you are sure that a burn really is only partial thickness, you can leave the dressing on for 10 days, unless the indications given below require that you should remove it. When you remove the dressing the burn should be healed.

Full thickness burns The limit for leaving a dressing on is about 4 days which is about the limit of the effectiveness of the local antibacterial agent. This is the usual interval for changing the dressings of minor burns in outpatients. Remove the dressing earlier than this on the following indications:

(1) If the exudate soaks through the dressings. (2) Smell. (3) Swelling. (4) Pain. (5) Fever. (6) Regional lymphadenitis. (7) Restriction of the distal circulation. (8) Hyperpyrexia (this is only a danger in large burns). If changing the dressing is painful, give the patient ketamine ( A 8.1).

If you are using 0.5% silver nitrate, change the dressing daily.

If the inner layer of a dressing sticks to the wound and is not stinking, leave it, or it will tear off valuable epithelium as you try to remove it. Allow it to come off by itself later. If it stinks, soak it with saline and remove it. Dab the wound dry, don’t rub it.

Deep burns may shed their sloughs in the dressings. If sloughs have not separated in 2 weeks, remove them surgically under anaesthesia.

BACTERIOLOGY If possible, send a swab for culture each time you change a dressing.