In a patient with bilateral lower‑limb flame burns and impaired renal function (serum creatinine 1.6 mg/dL), how should the wounds be dressed after fluid resuscitation and analgesia?

Dressing Bilateral Lower Limb Burns

After fluid resuscitation and analgesia, clean both lower limbs with tap water or isotonic saline, then apply a moist dressing (petrolatum-based ointment, medical-grade honey, or aloe vera) covered with a clean non-adherent secondary dressing, avoiding any circumferential wrapping that could create a tourniquet effect. 1

Pre-Dressing Wound Preparation

• Clean the burn wounds thoroughly using running tap water, isotonic saline solution, or an antiseptic solution in a clean environment before applying any dressing 1, 2
• Perform wound care only after adequate pain control is established, which may require deep analgesia or general anesthesia for extensive bilateral lower limb burns 1
• Thorough irrigation is essential to remove all foreign matter and debris from the wound surface 1

Dressing Selection and Application Technique

• Apply moist dressings such as petrolatum-based ointment, petrolatum-based antibiotic ointment, medical-grade honey, or aloe vera as the primary layer 1, 2
• Moist dressings significantly reduce complications including hypertrophic scarring compared to dry dressings (RR 0.13; 95% CI 0.03-0.52) 1
• Cover the moist layer with a clean non-adherent secondary dressing (such as Mepitel or Telfa) to maintain moisture, protect from contamination, and limit heat loss 1, 3
• When dressing limbs, prevent a tourniquet effect by avoiding circumferential wrapping that could compromise distal perfusion 1

Silver Sulfadiazine: Use With Caution

• If silver sulfadiazine is chosen, apply it to a thickness of approximately 1/16 inch once to twice daily 4
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 1
• Reapply immediately after hydrotherapy and to any areas from which it has been removed by patient activity 4

Infection Prevention Strategy

• Do not apply topical antibiotics prophylactically—reserve them only for wounds with confirmed infection to prevent antimicrobial resistance 1, 2
• Systemic antibiotic prophylaxis is not recommended routinely for burn patients 1, 2
• Monitor daily for signs of infection including increasing pain, redness, swelling, or purulent discharge 1, 2

Monitoring Distal Perfusion and Compartment Syndrome

• Continuously monitor distal perfusion after dressing application, checking for adequate capillary refill, pulses, and sensation 1
• Re-evaluate dressings daily to detect early complications such as compartment syndrome or infection 1
• Perform escharotomy within 48 hours if deep circumferential burns produce compartment syndrome that threatens limb perfusion 5, 1
• Escharotomies should ideally be performed at a burn center; if transfer is not feasible, obtain specialist advice before proceeding 5, 1

Special Considerations for Impaired Renal Function

• In patients with admission creatinine ≥1.21 mg/dL (as in this case with creatinine 1.6 mg/dL), anticipate markedly higher rates of sepsis, pneumonia, and mortality—therefore intensify renal monitoring 1
• Do not rely solely on serum creatinine to assess renal function in burn patients; obtain a 24-hour urine collection for accurate creatinine clearance, as serum creatinine-based equations are inadequate in burn patients 6
• The burn wound acts as an extrarenal site for creatinine loss, potentially falsely elevating calculated creatinine clearance while wounds remain open 7
• Monitor for burn-induced acute renal failure, which can occur early (due to hypovolaemia) or late (after one week, due to infection and endotoxaemia) 8

Burn Center Referral Criteria

• Bilateral lower limb burns representing >10% TBSA constitute an indication for immediate transfer to a specialized burn center 1, 2
• Direct admission to a burn center is associated with improved survival, fewer complications, shorter hospital stays, and lower costs compared to secondary transfer 1, 2

Critical Pitfalls to Avoid

• Do not use external cooling devices for prolonged periods on extensive bilateral lower limb burns, as they increase the risk of hypothermia 1, 2
• Do not over-resuscitate; monitor closely for fluid overload, especially in the setting of impaired renal function (creatinine 1.6 mg/dL) 1
• Do not delay burn center transfer; contact a burn specialist immediately to guide management 1
• Do not break blisters, as this increases infection risk 2