What is the primary wound covering method for a patient with full thickness burns?

Primary Wound Covering for Full-Thickness Burns

For full-thickness burns, apply a non-adherent dressing (such as Mepitel or Telfa) to the debrided wound bed with a secondary absorbent foam or burn dressing to collect exudate, avoiding prolonged use of silver sulfadiazine which delays healing and increases infection risk. 1, 2

Initial Wound Preparation

Before applying any dressing to full-thickness burns, the wound must be properly prepared:

• Clean the burn wound thoroughly with tap water, isotonic saline solution, or an antiseptic solution in a clean environment 1, 3
• Debride the wound under sterile conditions to remove devitalized tissue 4
• Provide adequate pain control during wound care using titrated intravenous opioids and ketamine for severe burns, as this may require deep analgesia or general anesthesia 1, 2

Primary Dressing Selection Algorithm

The choice of primary wound covering depends on the clinical context:

For Full-Thickness Burns Requiring Grafting (Most Common Scenario)

• Apply non-adherent dressings such as Mepitel (silicone-coated) or Telfa directly to the denuded dermis 3, 2
• Cover with secondary foam or burn dressing to absorb exudate 2
• Re-evaluate dressings daily to assess healing progress and detect early signs of infection 2

For Full-Thickness Burns with Skin Grafting

• Use mafenide acetate 5% solution-soaked dressings for newly grafted areas, keeping the gauze continuously wet by irrigating every 4 hours until graft vascularization occurs (typically 5 days) 5
• Apply one layer of fine mesh gauze directly to the grafted area, followed by eight-ply burn dressing wetted with the solution 5

Alternative Biologic Dressings (When Available)

• Fetal bovine collagen matrix (such as PriMatrix) can be applied to full-thickness burns and may allow spontaneous reepithelialization without subsequent skin grafting, demonstrating excellent long-term outcomes without hypertrophic scarring 6
• TransCyte (human fibroblast-cultured biologic covering) has shown faster healing times and reduced hypertrophic scarring compared to silver sulfadiazine, though this evidence is primarily for partial-thickness burns 7

What to Avoid in Full-Thickness Burns

Silver Sulfadiazine Should Be Avoided or Minimized

• Do not use silver sulfadiazine as first-line treatment for full-thickness burns, as it is associated with increased burn wound infection rates (OR = 1.87; 95% CI: 1.09 to 3.19) and longer hospital stays by an average of 2.11 days compared to alternative dressings 2
• If silver sulfadiazine is used, apply only to sloughy areas in severe burns, limit duration of use, and apply to a thickness of approximately 1/16 inch once to twice daily 1, 4
• Avoid prolonged use on any burn wounds as it delays healing 2

Other Critical Pitfalls

• Do not apply ice directly to burns as this causes tissue ischemia 1
• Avoid cooling large burns (>20% TBSA in adults, >10% in children) as this can cause hypothermia 1
• Do not use topical antibiotics as first-line treatment; reserve them for infected wounds only 1, 3
• Avoid systemic antibiotic prophylaxis routinely in burn patients 1, 3

When to Refer to Burn Center

Full-thickness burns require specialized management:

• All full-thickness burns should be referred to a burn center 1
• Mandatory referral criteria include burns involving face, hands, feet, perineum, or flexure lines; deep burns >5% TBSA; circular burns causing compartment syndrome; and infants <1 year of age 1
• Contact a burn specialist immediately to guide fluid resuscitation and determine transfer need, as specialist management is associated with better survival, reduced complications, and shorter hospital stays 1

Special Considerations for Full-Thickness Burns

• Escharotomy may be required if deep circumferential burns induce compartment syndrome that compromises airways, respiration, or circulation 1
• Continue treatment until satisfactory healing has occurred or until the burn site is ready for grafting 4
• Monitor for infection signs including increasing pain, redness, swelling, or purulent discharge 1, 3
• Initiate nutritional support within 12 hours after burn injury, preferably via oral or enteral routes 1