This month’s meeting of the Wilderness Medicine group discussed burn management in the wilderness and low resource settings. The article of interest, in a recent edition of Wilderness & Environmental Medicine, comes from two global health practitioners, one of whom is trained in Toxicology. They lend their take on a variety of low resource approaches to burn management.
Traditional burn management focuses on avoiding infection and keeping burns clean to heal naturally. Prior degrees of burn injuries have been replaced with superficial, partial, and full thickness designations. Classically, management includes cleaning the burn and applying a dressing often impregnated with Silver Sulfadiazine for burns of deep partial thickness and greater. These burns are often managed in burn centers equipped with antibiotics and plastic surgeons capable of applying grafts, a situation not often encountered in austere environments.
This month’s paper¹ discussed options in these low resource settings, where burn injury carries a higher morbidity and mortality. In the United States, 60-70% of total body surface area (TBSA) must be burned for patients to face a prognosis of 50% mortality, whereas in Nepal, patients with 20-30% TBSA burns face this same risk of death. In settings with less resources. How can we better care for these patients and mediate their risk of poor outcome or even death?
The authors noted the following conclusions. There is good evidence for using Oral Rehydration Solution (ORS) instead of IV therapy to rehydrate patients in accordance with the Parkland Formula. In addition, cold therapy (the use of cold water or cold compresses to control pain) is supported by moderate evidence, although using actual ice may worsen outcomes. Debridement of blisters is controversial. It is beneficial to remove inflammatory mediators contained in the blister fluid, but it may expose patients to infection. Lastly, they discussed mechanisms and evidence for a variety of alternative topical therapies and burn dressings, including honey, aloe vera, banana leaves, and potato peels.
Burns are initially sterile, but by day 5-7 are often colonized by Gram negative bacteria. Honey has been used to cover burns and is known to inhibit Pseudomonas growth due to its acidity and osmotic gradient. Aloe vera was studied in a 2007 meta-analysis² that concluded it was non-inferior to standard therapies, however the evidence for the study was rated as poor. Boiled banana leaves were deemed useful due to their non-adherent waxy coating. The authors noted it was important to boil them prior to use in order to remove bacteria that often resides on the leaves. Lastly, potato peels have been used (boil and peel a potato, placing the inside surface of the peel on the burn), though studies have been mixed, and solid evidence beyond case reports is lacking.
Often, patients with burns will want to remain in an austere environment and may not need to be evacuated (who wants to cut their trip short?). However, patients with burns over more than 20% TBSA , inhalation injuries, facial burns, circumferential burns, and those that are infected should be evacuated out of these environments when possible.
At the end of the discussion, we discussed our own burn stories, travels and experience treating these patients. After the discussion, agreed that we felt better equipped for our trips outside of the concrete jungle of Brooklyn, a key part of residency in New York City.
Original Paper for Further Review
Burns – Low Resource
1. Bitter, Cindy. Erickson, Timothy. Management of Burn Injuries in the Wilderness: Lessons from Low-Resource Settings. Wilderness & Environmental Medicine, 27, 519-525 (2016)
2. Maenthaisong, R. Chaiyakunapruk, N. Niruntraporn, S. Kongkaew, C. The efficacy of aloe vera used for burn wound healing: a systematic review. Burns. 33: 713-718 (2007)
BK in BK
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