What is the specific wound care for a patient with a burn injury to the hand?

Specific Wound Care for Burns

For burn wound care, immediately cool the burn with cold tap water (15-25°C) for 5-40 minutes, then clean the wound thoroughly, apply a moist dressing with petrolatum-based ointment or medical-grade honey (avoiding topical antibiotics unless infection is present), and cover with a clean nonadherent dressing. 1, 2

Initial Wound Cooling and Cleaning

• Cool burns with cold tap water (15-25°C) as soon as possible for 5-40 minutes to limit burn depth, reduce pain, and improve outcomes in adults with <20% TBSA and children with <10% TBSA 1

• Cooling is effective for up to three hours after injury and significantly reduces the need for skin grafting when performed for 20-40 minutes 1

• Avoid cooling large burns (>20% TBSA in adults, >10% in children) as this can cause hypothermia 1

• Never apply ice directly to burns as it causes tissue ischemia and damage 1

• Clean burn wounds thoroughly with tap water, isotonic saline, or antiseptic solution in a clean environment 1

• Thorough irrigation is essential for superficial wounds to remove all foreign matter 1

• Remove all jewelry near the burn site before swelling occurs to prevent vascular compromise 3

Pain Management During Wound Care

• Provide adequate pain control during wound care, which may require deep analgesia or general anesthesia for severe burns 1
• Use titrated intravenous opioids and ketamine for severe burn-induced pain 1
• Non-pharmacological treatments such as cooling and appropriate dressings improve pain control 1

Wound Dressing Selection and Application

For small partial-thickness burns managed outpatient:

• Apply petrolatum, petrolatum-based antibiotic ointment, medical-grade honey, or aloe vera to open burn wounds 1, 2
• Cover with a clean nonadherent dressing 1, 2
• Moist dressings significantly reduce complications including hypertrophic scarring compared to dry silver sulfadiazine dressings (RR 0.13; 95% CI 0.03-0.52) 1

For more extensive burns requiring silver sulfadiazine:

• Apply silver sulfadiazine to a thickness of approximately 1/16 inch once to twice daily 1, 4

• Avoid prolonged use on superficial burns as it may delay healing 1

• Evidence shows silver sulfadiazine was associated with increased burn wound infection (OR 1.87; 95% CI: 1.09-3.19) and longer hospital stays (mean difference 2.11 days) 2

• Continue treatment until satisfactory healing occurs or the burn site is ready for grafting 4

• Choose dressing type based on TBSA, local wound appearance, and patient's general condition 1

• Dressings should reduce pain, protect from external contamination, and limit heat loss 1

• When applying dressings on limbs, prevent bandages from creating a tourniquet effect and monitor distal perfusion 3

Infection Prevention and Management

Critical principle: Topical antibiotics should NOT be used as first-line treatment:

• Reserve topical antibiotics for infected wounds only 1, 2, 3

• Topical antibiotic prophylaxis has no beneficial effects on reducing infection or mortality in burn patients according to a comprehensive review of 36 RCTs (2117 participants) 2

• Do not use fusidic acid as it provides no benefit for burn wound prophylaxis and may contribute to antimicrobial resistance 2

• Do not administer systemic antibiotic prophylaxis routinely to burn patients 1, 3

• Monitor for signs of infection including increasing pain, redness, swelling, or purulent discharge 1, 3

• If infection develops, treat with appropriate antimicrobials targeting both gram-positive and gram-negative organisms as burn wound infections are typically polymicrobial 3

Special Considerations for Hand Burns

• Burns involving the hands require specialized burn center treatment 1, 3
• For circular burns on extremities, monitor closely for compartment syndrome 3
• Ensure proper wound care is performed only after adequate resuscitation in severe burns 1

Mandatory Referral Criteria to Burn Center

• Burns involving face, hands, feet, or genitals 1, 2, 3
• Burns covering >10% TBSA in adults or >5% in children 1, 2, 3
• All full-thickness burns 1
• Signs of inhalation injury 1, 2
• Signs of infection 1
• Circular burns causing compartment syndrome 1

Common Pitfalls to Avoid

• Do not use topical antibiotics routinely for uninfected wounds to prevent antimicrobial resistance 1, 2
• Do not use external cooling devices for prolonged periods due to hypothermia risk 1
• Do not apply ice directly to burns 1
• Avoid overestimating TBSA as this leads to fluid overresuscitation in 70-94% of cases 1