Cochrane & Evidence Aid: resources for burns

thumbnail image: Burns

The Cochrane Reviews in this Evidence Aid Special Collection are free to access.

This collection brings together Cochrane Reviews on the topic of burns, and covers topical and systemic treatment, nutrition, prevention, and treatments for scarring. This collection, developed in collaboration with Evidence Aid (evidenceaid.org) was first published in December 2010, and last updated in July 2014 with new and updated Cochrane Reviews.

The collection was first published after Iain Chalmers suggested 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 (then a final-year medical student), Nafiz Abu Shabaan (the Director of the Unit) and Khamis Elessi (who organised the evidence-based medicine initiative in Gaza) wished to study the management of white phosphorous burns, and a full Cochrane Review has now been published. This collection, as well as being relevant to burns caused by human conflict, is also important for natural disasters such as wild fires.

The reviews in the collection have been prepared by the authors and editors from the Cochrane Anaesthesia Group, Cochrane Injuries Group and Cochrane Wounds Group.

Topical treatments for burns

Dressings for superficial and partial thickness burns

Despite some potentially positive findings, the evidence, which largely derives from trials with methodological shortcomings, is of limited usefulness in aiding clinicians in choosing suitable treatments.

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.

Negative pressure wound therapy for partial-thickness burns

There is not enough evidence regarding the use of negative pressure wound therapy (NPWT) for treating partial thickness burn wounds.

Treatments for burns include a variety of dressings, but newer strategies such as negative pressure wound therapy (NPWT) have been developed to try to promote the wound healing process and minimise burn wound progression. NPWT uses a suction force to drain excess fluids from the burn. This review assesses the effectiveness of NPWT for people with partial thickness burns.

Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention

There is no evidence for the effectiveness of negative pressure wound therapy (NPWT) on complete healing of wounds expected to heal by primary intention. There are clear cost benefits when non-commercial systems are used to create the negative pressure required for wound therapy, with no apparent reduction in clinical outcome. Pain levels are also rated lower when hospital systems are compared with their commercial counterparts. The high incidence of blisters occurring when NPWT is used following orthopaedic surgery suggests that the therapy should be limited until safety in this population is established.

Indications for the use of NPWT are broadening with a range of systems on the market, including those designed for use on clean, closed incisions and skin grafts. Earlier reviews concluded that the evidence for the effectiveness of NPWT was uncertain. This review assesses the effects of NPWT on surgical wounds (primary closure or skin grafting) that are expected to heal by primary intention.

Honey as a topical treatment for wounds

Honey dressings do not increase rates of healing significantly in venous leg ulcers when used as an adjuvant to compression. Honey may delay healing in partial- and full-thickness burns in comparison to early excision and grafting, and in cutaneous Leishmaniasis when used as an adjuvant with meglumine antimoniate. Honey might be superior to some conventional dressing materials, but there is considerable uncertainty about the replicability and applicability of this evidence.

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

There is insufficient evidence to establish whether silver-containing dressings or topical agents promote wound healing or prevent wound infection; some poor quality evidence for silver sulphadiazine suggests the opposite.

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.

Topical silver for treating infected wounds

There is insufficient evidence to recommend the use of silver-containing dressings or topical agents for treatment of infected or contaminated chronic wounds.

Topical silver treatments and silver dressings are increasingly used for the local treatment of contaminated or infected wounds; however, there is a lack of clarity regarding the evidence for their effectiveness. This review assesses the effects on wound healing of topical silver and silver dressings in the treatment of contaminated and infected acute or chronic wounds.

Aloe vera for treating acute and chronic wounds

There is currently an absence of high quality clinical trial evidence to support the use of Aloe vera topical agents or Aloe vera dressings as treatments for 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. Animal studies have suggested that Aloe vera may help accelerate the wound healing process. This review assesses the effects of Aloe vera-derived products (for example dressings and topical gels) on the healing of acute wounds (for example lacerations, surgical incisions and burns) and chronic wounds (for example infected wounds, arterial and venous ulcers).

Topical treatment for facial burns

There is insufficient high quality research and evidence to enable conclusions to be drawn about the effects of topical interventions on wound healing in people with facial burns.

Burn injuries are an important health problem, occurring frequently in the head and neck area. The head and neck area are central to a person’s identity and plays a vital role in communication - other basic abilities such as hearing, smelling, and breathing may also be affected as a direct result of a facial burn. Topical interventions are currently the basis of treatment of partial-thickness burns to the face. This review aims to assess the effects of topical interventions on wound healing in people with facial burns of any depth.

Antibiotic prophylaxis for preventing burn wound infection

There is some evidence from RCTs suggesting that the use of silver sulfadiazine when used directly on the burn is associated with significantly increased rates of infection and longer length of hospital stay compared with dressings or skin substitutes. However, studies were at unclear or high risk of bias. There is insufficient evidence overall to draw firm conclusions on the effectiveness of antibiotics on the rates of burn wound infection.

Burn wound infections delay the healing process, are associated with increased scarring and invasive infections and can also result in death. The aim of the systematic review was to assess the effectiveness of antibiotic prophylaxis on the rates of burn wound infections.

Systemic treatment for people with burns

Colloids versus crystalloids for fluid resuscitation in critically ill patients

There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. Furthermore, the use of hydroxyethyl starch might increase mortality. As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.

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 assesses the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.

Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients

This review does not give us enough data to be able to say whether hypertonic crystalloid is better than isotonic and near isotonic crystalloid for the resuscitation of patients with trauma or burns, or those undergoing surgery. However, the confidence intervals are wide and do not exclude clinically significant differences.

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

For patients with hypovolaemia, there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia. The possibility that there may be highly selected populations of critically ill patients in which albumin may be indicated remains open to question. However, in view of the absence of evidence of a mortality benefit from albumin and the increased cost of albumin compared to alternatives such as saline, it would seem reasonable that albumin should only be used within the context of well concealed and adequately powered randomised controlled trials.

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, such as in 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.

Antithrombin III for critically ill patients

Antithrombin III (AT III) cannot be recommended for critically ill patients based on the available evidence.

Critical illness is associated with uncontrolled inflammation and vascular damage which can result in multiple organ failure and death. AT III is an anticoagulant with anti-inflammatory properties but the efficacy and any harmful effects of AT III supplementation in critically ill patients are unknown. This review assesses the benefits and harms of AT III in critically ill patients.

Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care

A combination of topical and systemic prophylactic antibiotics reduces respiratory tract infections and overall mortality in adult patients receiving intensive care. Treatment based on the use of topical prophylaxis alone reduces respiratory infections but not mortality. The risk of resistance occurring as a negative consequence of antibiotic use was appropriately explored only in one trial, which did not show any such effect.

Pneumonia is an important cause of mortality in intensive care units (ICUs). The incidence of pneumonia in 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.

Aerosolized prostacyclin for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)

There is no current evidence to support or refute the routine use of aerosolized prostacyclin for patients with acute lung injury (ALI) and acute respiratory distress (ARDS).

ALI and ARDS 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

There is insufficient evidence to support or refute the effectiveness of hyperbaric oxygen therapy (HBOT) for the management of thermal burns.

HBOT 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 HBOT for the treatment of thermal burns.

Intravenous lidocaine for the treatment of background or procedural burn pain

As current clinical evidence is based on only one single randomised controlled trial as well as case series and reports, intravenous lidocaine must be considered a pharmacological agent under investigation in burns care, the effectiveness of which is yet to be determined with further well-designed and conducted clinical trials.

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

This systematic review has not found sufficient evidence to support or refute the effectiveness of early versus late enteral nutrition support in adults with burn injury. The trials showed some promising results that would suggest early enteral nutrition support may blunt the hypermetabolic response to thermal injury, but this is insufficient to provide clear guidelines for practice.

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

The one trial included in this review was of low methodological quality and found no statistically significant difference for mortality, sepsis, ventilator days, length of stay, unexpected adverse events, resting energy expenditure, nitrogen balance, or albumin levels.

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

There is limited evidence to recommend supplementation of critically ill patients with selenium or ebselen.

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.

High-carbohydrate, high-protein, low-fat versus low-carbohydrate, high-protein, high-fat enteral feeds for burns

The available evidence suggests that use of high-carbohydrate, high-protein, low-fat enteral feeds in patients with at least 10% total body surface area burns might reduce the incidence of pneumonia compared with use of a low-carbohydrate, high-protein, high-fat diet. The available evidence is inconclusive regarding the effect of either enteral feeding regimen on mortality. Note that the available evidence is limited to two small studies judged to be of moderate risk of bias.

In people with burn injuries energy and protein requirements increase to approximately double the requirements of a healthy person. Aggressive high-protein enteral feeding is used in the post-burn period to improve recovery and healing. However, inappropriate nutritional support could lead to adverse outcomes. This review examines the evidence for improved clinical outcomes in burn patients treated with high-carbohydrate, high-protein, low-fat enteral feeds (high-carbohydrate enteral feeds) compared with those treated with low-carbohydrate, high-protein, high-fat enteral enteral feeds (high-fat enteral feeds).

Topical, systemic and nutritional treatment for people with phosphorous burns

Interventions for treating phosphorus burns

First aid for phosphorus burns involves the common sense measures of acting promptly to remove the patient's clothes, irrigating the wound(s) with water or saline continuously, and removing phosphorus particles. There is no evidence that using copper sulphate to assist visualisation of phosphorus particles for removal is associated with better outcome, and some evidence that systemic absorption of copper sulphate may be harmful. We have so far been unable to identify any other comparisons relevant to informing other aspects of the care of patients with phosphorus 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. Removal of patients’ clothes, continuous irrigation of their wounds with cold solutions and removal of phosphorus particles are the most important elements of the management of phosphorus burns. This review summarises the evidence of effects (beneficial and harmful) of all interventions for treating people with phosphorus burns.

Prevention of burns

Community-based interventions for the prevention of burns and scalds in children

Only four studies were identified that met the inclusion criteria. Two found a reduction in rates of burns and scalding, and two found no effect following the intervention.

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

This review found that programmes to promote smoke alarms have at most modest beneficial effects on smoke alarm ownership and function, and no demonstrated beneficial effect on fires or fire-related injuries.

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

Home safety interventions provided most commonly as one-to-one, face-to-face education, in a clinical setting or at home, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. There was no consistent evidence that home safety education, with or without the provision of safety equipment was less effective in those at greater risk of injury.

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. 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.

Modification of the home environment for the reduction of injuries

There is insufficient evidence to determine whether interventions focused on modifying environmental home hazards reduce injuries.

Injury in the home is common, accounting for approximately a third of all injuries. The majority of injuries to children under five and people aged 75 and older occur at home. Multifactorial injury prevention interventions have been shown to reduce injuries in the home. However, few studies have focused specifically on the impact of physical adaptations to the home environment and the effectiveness of such interventions needs to be ascertained. This review assesses the effect of modifications to the home environment on the reduction of injuries due to environmental hazards.

Interventions for preventing injuries in problem drinkers

Interventions for problem drinking appear to reduce injuries and their antecedents (e.g. falls, motor vehicle crashes, suicide attempts). Because injuries account for much of the morbidity and mortality from problem drinking, larger studies are warranted to evaluate the effect of treating problem drinking on injuries.

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

The included studies do not provide reliable evidence that educational interventions are effective in preventing 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

There is weak evidence of a benefit of silicon gel sheeting as a prevention for abnormal scarring in high risk individuals, but the poor quality of research means a great deal of uncertainty prevails.

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), Emma Sydenham (Cochrane Injuries Group), Sally Bell-Syer (Cochrane Wounds Group), Iain Chalmers (James Lind Library), Claire Allen and Bonnix Kayabu (both Evidence Aid) 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: 08 December 2010; updated 07 August 2012, 28 November 2012, 21 May 2013, 08 August 2013 and 01 November 2013. Last updated 28 July 2014 with one updated Cochrane Review.

Contact: Cochrane Editorial Unit (editorial-unit@cochrane.org) for suggestions for additions or changes to this Special Collection or queries about the included Cochrane Reviews; and Evidence Aid (evidenceaid@cochrane.org) for information about this initiative.

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