Burns
In August 2010, Iain Chalmers contacted the Cochrane Editorial Unit to suggest a collection of Cochrane Reviews on the subject of burns and associated trauma. The idea originated from an evidence-based medicine initiative in the Gaza Strip, where the Burns Unit at the Shifa Hospital was an important focus of the discussions there. Loai Barqouni (a final-year medical student) and Nafiz Abu Shabaan (the Director of the Unit) are co-authors of a recently published case report on the management of white phosphorous burns.1 They and Khamis Elessi, who organised the evidence-based medicine initiative in Gaza, have also published a Cochrane Protocol on this topic with the Cochrane Wounds Group. For this Special Collection we are highlighting Cochrane Protocols in addition to completed Cochrane Reviews, to demonstrate the pipeline of planned Cochrane Reviews.
Also relevant to this collection on burns are the devastating bush fires in the state of Victoria, Australia, in February 2009. Scorching temperatures and high winds fanned a series of fast-moving fires that killed 173 people, destroyed 7500 homes, wiped out a million native animals and scorched more than 420,000 hectares of forest and land. In response, the Australasian Cochrane Centre and the Global Evidence Mapping Initiative partnered with the Alfred Hospital's Victorian Adult Burns Service to develop five rapid evidence summaries concerning the early management of burns in the emergency setting, which we have included below. This activity was supported by a Discretionary Fund award from The Cochrane Collaboration.
The Cochrane Reviews and Protocols in this collection have been prepared by the Cochrane Wounds Group and the Cochrane Injuries Group, and cover the following topics: topical and systemic treatments, nutrition, prevention, and treatments for scarring.
1. Al Barqouni LN, Skaik SI, Shaban NR, Barqouni N. White phosphorus burn. Lancet.2010;376(9734):68.
Rapid evidence summaries on the early management of burns in the emergency setting
Evidence Summary - Silver Based Products & Burns
Evidence Summary - Early Burn Pain Management
Evidence Summary - Early Cooling of Burns
Evidence Summary - Early Burns Dressings
Evidence Summary - Burns Blister Management
Topical treatments for burns
Dressings for superficial and partial thickness burns
An acute burn wound is a complex and evolving injury. Extensive burns produce, in addition to local tissue damage, systemic consequences. Treatment of partial thickness burn wounds is directed towards promoting healing, and a wide variety of dressings is currently available. Improvements in technology and advances in understanding of wound healing have driven the development of new dressings. Dressing selection should be based on effects of healing, but ease of application and removal, dressing change requirements, cost and patient comfort should also be considered. This review assesses the effects of burn wound dressings for superficial and partial thickness burns.
Topical negative pressure (TNP) for partial thickness burns
Treatments for burns include a variety of dressings, but newer strategies such as topical negative pressure therapy have been developed to try to promote the wound healing process and minimise burn wound progression. Topical negative pressure uses a suction force to drain excess fluids. This review assesses the effectiveness of topical negative pressure for those people with partial thickness burns.
Honey as a topical treatment for wounds
Honey is a viscous, supersaturated sugar solution derived from nectar gathered and modified by the honeybee, Apis mellifera. Honey has been used since ancient times as a remedy in wound care, and evidence from animal studies and some trials has suggested honey may accelerate wound healing. This review evaluates whether honey increases the rate of healing in acute wounds (burns, lacerations and other traumatic wounds) and chronic wounds (venous ulcers, arterial ulcers, diabetic ulcers, pressure ulcers, infected surgical wounds).
Topical silver for preventing wound infection
Silver-containing treatments are popular and used in wound treatments to combat a broad spectrum of pathogens, but evidence of their effectiveness in preventing wound infection or promoting healing has been lacking. This review evaluates the effects of silver-containing wound dressings and topical agents in preventing wound infection and healing of wounds.
PROTOCOL: Topical treatment for facial burns
The head and neck region is the most frequent site where a burn injury occurs. The face is highly vascularised and hosts vital areas that make the treatment of facial burns more complicated than treating burns on other parts of the body. Guidelines to support clinical decision-making in burn care are predominantly practice-based or are concerned with the general treatment of burns. This review will assess the effectiveness of topical interventions on wound healing in people with facial burns of all depths.
PROTOCOL: Aloe Vera for treating acute and chronic wounds
Aloe vera enjoys a great degree of popularity among the general population. It is used in a wide variety of products, including cosmetics, creams and toiletries. However, there are currently no up-to-date systematic reviews available on the effectiveness of this treatment for wound healing. This review will aim to determine the effects of aloe vera derived products (for example, dressings and topical gels) on the healing of acute (for example, lacerations, surgical and burns) and chronic wounds (for example, infected wounds, arterial and venous ulcers).
PROTOCOL: Cultured epithelial autograft in the treatment of acute burn wounds
Cultured epithelial autografting is a technique in which epidermal autologous cells are harvested and applied to a wound bed. Numerous case study reports and anecdotes are available of this technique, but there are no published systematic reviews or evidence-based guidelines to direct clinical decision-making in the use of cultured epithelial autograft in the treatment of acute burn wounds. This review will aim to determine the effects of cultured epithelial autografting on the healing of burn injuries compared with alternative methods of treatment or surgery.
Systemic treatment for people with burns
Colloids versus crystalloids for fluid resuscitation in critically ill patients
Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid, and debate is ongoing about the relative effectiveness of colloids compared with crystalloid fluids. This review evaluates the effects of colloids compared with crystalloids for fluid resuscitation in critically ill patients.
Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients
Hypertonic solutions are considered to have a greater ability to expand blood volume and thus elevate blood pressure, and can be administered as a small volume infusion over a short time period. On the other hand, the use of hypertonic solutions for volume replacement may also have important disadvantages. This review evaluates whether hypertonic crystalloid decreases mortality in patients with hypovolaemia.
Human albumin solution for resuscitation and volume expansion in critically ill patients
Human albumin solutions are used in a range of medical and surgical problems. Licensed indications are the emergency treatment of shock and other conditions where restoration of blood volume is urgent, burns, and hypoproteinaemia; however, human albumin solutions are more expensive than other colloids and crystalloids. This review evaluates the effect of human albumin and plasma protein fraction administration on the mortality of critically ill patients.
Pneumonia is an important cause of mortality in intensive care units. The incidence of pneumonia in intensive care unit (ICU) patients ranges between 7% and 40%, and the crude mortality from ventilator-associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in ICUs independently of other factors that are also strongly associated with such deaths. This review assesses the effects of prophylactic antibiotic regimens, such as selective decontamination of the digestive tract, for the prevention of respiratory tract infections and overall mortality in adults receiving intensive care.
PROTOCOL: Antibiotic prophylaxis for preventing burn wound infection
Prophylactic antibiotics have been considered useful to prevent and treat infections in people with burns, and in some centres patients with a positive microbiological culture from a burn site are given systemic antibiotic prophylaxis in an attempt to prevent wound infection and sepsis. However, this is now controversial as there is a paucity of high-quality research evidence to determine the effectiveness and cost-efficiency of antibiotic prophylaxis for preventing burn wound infection. This review will assess the effects of antibiotic prophylaxis for preventing burn wound infections.
Aerosolized prostacyclin for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)
Acute lung injury and acute respiratory distress syndrome are critical conditions that are associated with high mortality and morbidity. Aerosolised prostacyclin has been used to improve oxygenation despite the limited evidence available so far. This review assesses the benefits and harms of aerosolised prostacyclin in critically ill patients with acute lung injury and acute respiratory distress syndrome.
Hyperbaric oxygen therapy for thermal burns
Hyperbaric oxygen therapy consists of intermittently administering 100% oxygen at pressures greater than 1 atmosphere in a pressure vessel. This technology has been used to treat a variety of disease states and has been described as helping patients who have sustained burns. This review assesses the evidence for the benefit of hyperbaric oxygen therapy for the treatment of thermal burns.
Lidocaine for pain relief in burn injured patients
Pain is a major issue for patients suffering from many different types of wounds in particular those with burn injuries. Prompt, aggressive use of opioid analgesics such as morphine has been suggested as critical to avert the cycle of pain and anxiety, but side-effects are encountered. It is proposed that newer agents such as lidocaine could be effective in reducing pain and alleviating the escalating opioid dosage requirements in patients with burn injury. This review assesses the safety and effectiveness of intravenous lidocaine as a means of pain relief versus no therapy, placebo, other drugs or two or more of the above therapies in combination in patients exposed to burn injury.
Nutrition and supplementation for people with burns
Early versus delayed enteral nutrition support for burn injuries
A burn injury increases the body's metabolic demands, and therefore nutritional requirements. Provision of an adequate supply of nutrients is believed to lower the incidence of metabolic abnormalities, thus reducing septic morbidity, improving survival rates, and decreasing hospital length of stay. Enteral nutrition support is the best feeding method for patients who are unable to achieve an adequate oral intake to maintain gastrointestinal functioning; however, its timing (i.e. early versus late) needs to be established. This review assesses the effectiveness and safety of early versus late enteral nutrition support in adults with burn injury.
Nutritional support for critically ill children
Nutritional support in the critically ill child has not been well investigated and is a controversial topic within paediatric intensive care. There are no clear guidelines as to the best form or timing of nutrition in critically ill infants and children. This review evaluates the impact of enteral and total parenteral nutrition on clinically important outcomes for critically ill children.
Selenium supplementation for critically ill adults
Selenium is a trace mineral essential to health and has an important role in immunity, defence against tissue damage and thyroid function. Improving selenium status could help protect against overwhelming tissue damage and infection in critically ill adults. This review assesses the effects of selenium supplementation, including the selenium-containing compound ebselen, on adults recovering from critical illness.
In people with burn injuries energy and protein requirements increase to approximately double the requirements of a healthy person. The introduction of 'aggressive nutrition support' in burns patients in the early 1970s dramatically improved the rate of survival. However, inappropriate nutritional support could lead to adverse outcomes including a fatty liver, increased body fat mass and cardio-pulmonary complications. Confusion currently exists about the optimal feeding practices in people with burn injuries. This review will examine the evidence for the effectiveness of high-carbohydrate, high-protein, low-fat enteral feeds compared with low-carbohydrate, high-protein, high-fat enteral feeds, in people with burns.
PROTOCOL: Immunonutrition as an adjuvant therapy for burns
The idea of modulating immune system activity with specific nutrients is termed 'immunonutrition'. This intervention has been used for medicinal purposes since ancient times, having been applied in Ayurvedic medicine for over 3000 years; however, it is unclear whether immunonutrition should be routinely used in the management of burns patients. This review will assess the effects of the addition of immunonutrients (glutamine, arginine, BCAA, n-3 fatty acids or nucleotides), compared with an isonitrogenous diet, on clinical outcomes in burns patients.
Topical, systemic and nutritional treatment for people with phosphorous burns
PROTOCOL: Interventions for treating phosphorous burns
Phosphorus burns result from industrial and military injuries, and they are rarely encountered in usual clinical practice; however, these chemical burns can be fatal and are associated with significant morbidity and prolonged hospitalisation. A range of views exists regarding the optimal strategy for emergency management of a phosphorus burn. Current clinical practice is usually based on the experience of the practitioner rather than on any evidence base. This review will summarise the evidence for the effects (effectiveness and safety) of all interventions for treating people with phosphorus burns.
Prevention of burns
Community-based interventions for the prevention of burns and scalds in children
Burns and scalds are a significant cause of morbidity and mortality in children. Successful counter-measures to prevent burn- and scald-related injury have been identified. However, evidence indicating the successful roll-out of these counter-measures into the wider community is lacking. Community-based interventions in the form of multi-strategy, multi-focused programmes are hypothesised to result in a reduction in population-wide injury rates. This review assesses the effects of community-based interventions, defined as co-ordinated, multi-strategy initiatives, for reducing burns and scalds in children aged 14 years and under.
Interventions for promoting smoke alarm ownership and function
Globally, fire-related burns and smoke inhalation accounted for 238,000 deaths in 2000, a rate of 3.9 deaths/100,000, with children and people aged less than 44 years accounting for the highest proportion of deaths. Smoke alarm ownership has been associated with a reduced risk of residential fire death. This review evaluates interventions to promote residential smoke alarms, and assesses their effect on the prevalence of owned and working smoke alarms, and the incidence of fires and burns and other fire-related injuries.
Home safety education and provision of safety equipment for injury prevention
In industrialised countries injuries are the leading cause of childhood death, and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home, but there has been little meta-analytic evidence that child safety interventions for the home improve a range of safety practices or reduce injury rates. This review evaluates the effectiveness of home safety education, with or without the provision of low-cost, discounted or free equipment in increasing home safety practices or reducing child injury rates, and whether the effect varied by social group.
Interventions for preventing injuries in problem drinkers
Alcohol consumption has been linked with injuries through motor vehicle crashes, falls, drowning, fires and burns, and violence. In the USA, half of the estimated 100,000 deaths attributed to alcohol each year are due to intentional and unintentional injuries. The identification of effective interventions for the reduction of unintentional and intentional injuries due to problem drinking is, therefore, an important public health goal. This review assesses the effect of interventions for problem drinking on subsequent injury risk.
Educational interventions for the prevention of eye injuries
Ocular injury is a preventable cause of blindness, yet it remains a significant disabling health problem that affects all age groups. Injuries may occur in the home, in the workplace, during recreational activities or as a result of road crashes. Types of injuries vary from closed globe (contusion or lamellar laceration) to an open globe injury, which includes penetration and even perforation of the globe. To date, the main strategy to prevent these injuries has been to educate people to identify high-risk situations and to take correct action to avoid danger. This review assesses the evidence for the effectiveness of educational interventions for the prevention of eye injuries.
Treatment of scars
Silicon gel sheeting for preventing and treating hypertrophic and keloid scars
Keloid and hypertrophic scars are common and are caused by a proliferation of dermal tissue following skin injury. They cause functional and psychological problems for patients, and their management can be difficult. The use of silicon gel sheeting to prevent and treat hypertrophic scarring is still relatively new, and started in 1981 with treatment of burn scars. This review evaluates the effectiveness of silicon gel sheeting for preventing hypertrophic or keloid scarring in people with newly healed wounds, and for treating established scarring in people with existing keloid or hypertrophic scars.
Acknowledgements: Steve McDonald (Australasian Cochrane Centre) for drafting the introductory text, and Emma Sydenham (Cochrane Injuries Group), Sally Bell-Syer (Cochrane Wounds Group), and Iain Chalmers (James Lind Library) for comments, edits and article suggestions.
Image credit: Reprinted from The Lancet, Vol. 376, Loai Nabil Al Barqouni, Sobhi I Skaik, Nafiz R Abu Shaban, Nabil Barqouni, White phosphorus burn, Page 9734. Copyright (2010), with permission from Elsevier.
Date published: 8 December 2010
Contact: Cochrane Editorial Unit (editorial-unit@cochrane.org)
