More than 95% of burn-related deaths occur in low- and middle-income countries. Africa contributes to 15% of the global burn mortality. In South Africa, children <2-years of age and those from minority (migrant) groups face the highest risk of burn injuries in South Africa.1,2
A recent study by Banga et al, showed that about 50% of patients admitted to the Chris Hani-Baragwanath Hospital (Soweto, Johannesburg) were aged between 15- and 47-months, with a median age of 25-months.2
Of the participants, 58% were boys. Scalding (84%) was the most common injury, primarily occurring in the winter season (32%). The upper limb was the most common site of burn (75%). Severe burns were associated with thermal injury mechanisms, and multiple burn sites.2
A South African study of adult burn survivors showed that thermal burns were the most frequently reported type, accounting for 64.4% of cases, and the median total body surface area (TBSA) affected was 31% – predominantly the head (60.3%) and arms (71.2%).3
Burns affect various aspects of patient’s lives
The impact of burn injuries extends beyond physical health, affecting various aspects of a patients’ lives, including social, physiological and economic dimensions.1
Social and physiological dimensions
Children and young people who have suffered burn injuries are more susceptible to developing psychopathology compared to the general population, according to Woolard et al.4
Research shows an increased risk of post-traumatic stress disorder (nightmares and hypervigilance) within the first month after the burn injury, with long-term psychological issues such as anxiety, depression, sleep disturbances, social functioning, and diminished quality of life also being reported.4
The complexity of burn aftercare contributes to these challenges, involving invasive and painful treatments to improve function and reduce scarring. Frequent hospital visits serve as distressing reminders of the injury. 4
To design effective, trauma-informed, person-centred treatments for burn injuries, it is essential to understand the experience of the child or young person's perspective, stress Woolard et al.4
In their study, the team categorised the impact of burn injuries into burn-specific impacts (appearance concerns, family factors, and lifestyle factors), psychological impacts, and the recovery journey (coping strategies and support services).4
Participants reported appearance concerns due to scarring and the need for pressure garments, causing anxiety about how they would be perceived by others.4
Caregiver guilt was a consistent theme, with participants acknowledging their caregivers often blamed themselves, which stresses the need for caregiver support. Disruptions to schooling and lifestyle activities had a significant impact, causing anxiety and affecting social support.4
Participants also exhibited resilience, acknowledging negative emotions and adopting coping mechanisms like mindfulness and social support.
Participants advocated for mental health support to be a routine part of care for burn patients.4
Considering the impact on caregivers, a trauma-centred approach for the family unit, including resilience building and healthy coping mechanisms, recommended Woolard et al. Overall, understanding the experiences of burn patients is crucial for developing effective interventions and treatments, concluded the authors.4
Economic dimensions
According to the World Health Organization, the direct expenses associated with burn care vary considerably. A systematic review conducted in 2014 showed an average overall healthcare expenditure of ~R1.7m ($ 88 218) per burn patient, ranging from ~R14 000 ($704) to ~R14m ($ 717 306). In South Africa, ~R500m ($26m) is spend annually on the treatment of burns resulting from kerosene (paraffin) cookstove incidents.5
Beyond direct costs, indirect expenses such as foregone wages, extended care for deformities and emotional trauma, and the utilisation of family resources also contribute significantly to the socioeconomic impact of burn injuries.5
What does the optimal management of burn patients involve?
According to Allorto the optimal management of burn injuries relies on adherence to key principles. Each of these components significantly influences outcomes in burn care:6
- First aid measures
- Prompt washing of burn injuries
- Fluid resuscitation
- Early enteral feeding
- Appropriate dressing of burn injuries
- Effective analgesia.
In primary care, first aid for burns involves cooling the burn with cool running tap water, demonstrating a decrease in cellular damage and swelling. This approach enhances the inflammatory response, promotes healing, and reduces the need for skin grafting.
Ice application is discouraged due to its potential to cause prolonged vasoconstriction. Immediate removal of clothing and jewellery, along with the application of cling film or a clean non-adhesive dressing, is advised.6
In terms of blister management, Allorto highlighted a 2017 study indicating no significant difference in outcomes between deroofing or aspiration. Cleaning larger burns of all blisters and debris is recommended, although the choice of cleaning agent lacks clear evidence.6
Fluid resuscitation is crucial, considering the inflammatory response, vasodilation, and capillary leak associated with burn injuries. Use of Ringers lactate or equivalent fluid is preferred, and early enteral feeding is advocated for burns >15%-20% TBSA. Avoiding over-resuscitation, and fluid continuation post-24 hours should be based on clinical signs of dehydration.6
Dressing burn injuries involves avoiding prophylactic antibiotics, relying on good injury care, and using topical antimicrobial dressings judiciously (see below). Effective analgesia is crucial in burn care – especially considering the physiological and psychological impact of pain.6
Ketamine and methoxyflurane are recommended for procedural analgesia, and a dynamic approach to background analgesia, considering changing needs, is advocated. Addressing itching and psychological aspects, including anxiety and depression, is essential.6
Importance of selecting appropriate injury dressings
According to Allorto, appropriate burn injury dressing choices in primary management are extremely important. Injury dressing is crucial as it serves multiple functions. Firstly, it shields the injured epithelium, curbing microbial colonisation and maintaining skin position. Secondly, it should be occlusive to retain heat and moisture, enhancing healing conditions.6,7
Comfort provision to the sensitive injury is another essential aspect. Furthermore, an ideal dressing should possess various properties including moisture control, efficient exudate removal, gas exchange facilitation, low skin adhesion, mechanical stability, injury necrosis reduction, cost-effectiveness, non-toxicity, biocompatibility, and biodegradability.7
The choice of dressing depends on the burn injury characteristics. Superficial first-degree injuries with minimal barrier loss may not necessitate dressing, instead, topical balms, panthenol, and aloe vera gels suffice for pain relief and moisture maintenance.7
Conversely, second-degree superficial injuries may require daily dressing changes with topical antibiotics or temporary biological or synthetic dressings. Deeper burns often require excision and grafting, necessitating dressings focused on bacterial control and injury closure pre-surgery.7
Injury dressings come in various materials including natural polymers (chitosan, cellulose, collagen), synthetic polymers (polyvinylpyrrolidone, polyethylene oxide/polyethylene glycol, polylactic acid), and combinations thereof, available as hydrogels, films, foams, and more.7
Many dressings incorporate silver and other antimicrobial agents. The efficacy of these dressings varies. For partial-thickness superficial burns, biosynthetic epithelial substitutes like or advanced injury bioengineered alternative tissue-superficial can be used for post-injury cleaning. Despite their proven efficacy, availability remains an issue in South Africa.7
Hydrocolloid dressings are notable for their ability to absorb exudate and promote injury healing and is often preferred over paraffin-based gauze. Hydrogels offer flexibility and moisture retention, and often contain additional therapeutic agents for enhanced healing.7
Inorganic materials like silicate minerals and metal-containing materials possess haemostatic properties, while nanomaterials exhibit antibacterial activity and aid injury regeneration. Nanoparticles, both organic and inorganic, show promise in injury healing due to their unique properties and controlled release mechanisms.7
Overall, the choice of dressing significantly impacts burn injury healing, with a plethora of options available catering to diverse injury types and patient needs.7
The efficacy of antimicrobial dressings
Numerous studies have shown the critical association between a wound's microbial bioburden and its healing trajectory. Antimicrobial dressings offer promise in both healing and infection control.8
Wound bacteria are categorised as contamination, colonisation, or infection, each with distinct implications for healing. Symptoms of infected wounds include erythema, warmth, and increased drainage. Antimicrobial dressings are indicated for suspected colonisation or infection to impede bacterial growth and aid healing.8
Wound dressings play a dual role: Creating an ideal moisture environment for re-epithelialisation and acting as a barrier against microbial infiltration. Various dressing types such as hydrocolloid, hydrogel, foam, alginate, and antimicrobial variants, offer diverse clinical benefits. Antimicrobial dressings incorporate disinfectants, antiseptics, or antibiotics to diminish local wound bioburden, contributing to improved wound healing.8
The use of dressings that rely on a physical mode of action has proved extremely effective in managing bioburden. Dialkylcarbamoyl chloride (DACC™) a fatty acid derivative, utilises hydrophobic interaction, where hydrophobic particles aggregate in an aqueous environment.9
The dressings are coated with a fatty acid derivative, making them strongly hydrophobic. Since wound bacteria also have hydrophobic characteristics, they bind to the dressing fibres and are removed when the dressing is changed.9
In a multicentre investigation led by Kammerlander et al, examined a hydrophobic wound dressing in the management of patients with chronic wounds. The study assessed the dressing's efficacy in binding and removing bacteria from wounds without introducing chemically active agents. Evaluation criteria included its capacity to reduce inflammation, eradicate local infections, and enhance wound healing progression, alongside patient tolerance and clinician usability.9
Results showed that 81% of patients with infected wounds experienced effective treatment, with 21% of all wounds healing during the study period and 72% demonstrating improvements. Additionally, notable enhancements in pain symptoms were observed, and most patients expressed positivity towards the product. Clinicians also rated it highly, with 97% evaluating it as 'good' or 'very good'.9
Kleintjes et al used a wound dressing with hydrophobic interaction as a skin substitute based on previous observations suggesting successful healing of partial thickness burn wounds. The study included 27 patients with superficial and mid-partial thickness burns. Wound assessments were done twice weekly, evaluating factors such as wound appearance, slough, pus, biofilm, granulation, epithelium, smoothness, and colour.10
Results showed that most wounds appeared clean (59%), dry (51%), and pink (51%), with 27% appearing healed. Subjective pain related to the dressing was minimal. Minor complications, such as punctate bleeding points upon dressing removal, were noted in five patients (18.5%). The study concluded that the hydrophobic dressing serves as a cost-effective skin substitute with antibacterial and antiviral properties, making it a valuable addition to available skin substitutes.10
How long does it take for a burn injury to heal?
The healing process of burn injuries varies depending on their severity, ranging from superficial to complete injuries. Superficial burns typically affecting the epidermis heal within weeks without scarring, while deeper injuries necessitate longer healing times due to extensive tissue damage.7
Rapid injury cleansing, whether through surgical debridement or specialised dressings, plays a pivotal role. Autologous skin grafts remain the gold standard, although alternatives like artificial skin substitutes are actively explored for their potential to enhance closure, minimise scarring and streamline treatment processes.7
Conclusion
Effective treatment strategies for burn injuries require a multifaceted approach, considering both physical and psychological factors. With a disproportionate burden in low- and middle-income countries, particularly in Africa, understanding regional epidemiology and socioeconomic impacts is crucial.
Optimal management, as outlined by Allorto, emphasises adherence to key principles from initial first aid to injury dressing choices. By integrating evidence-based practices and prioritising patient-centred care, healthcare systems can mitigate the profound and far-reaching consequences of burn injuries on individuals and communities alike.
References
- Mathonsi KP, Arko-Cobbah E. Outcomes of burns patients in a developing country: A single centre’s experience. SAMJ, 2023.
- Banga AT, Westgarth-Taylor C, Grieve A. The epidemiology of paediatric burn injuries in Johannesburg, South Africa. J Pediatr Surg, 2023.
- Angelou IK, van Aswegen H, Wilson M, Grobler R. A profile of adult patients with major burns admitted to a Level 1 Trauma Centre and their functional outcomes at discharge: A retrospective review. S Afr J Physiother, 2022.
- Woolard A, Wickens N, McGivern L, et al. "I just get scared it's going to happen again": A qualitative study of the psychosocial impact of pediatric burns from the child's perspective. BMC Pediatr, 2023.
- World Health Organization. 2023. [Internet]. Accessed 5 March 2024. Available at: https://www.who.int/news-room/fact-sheets/detail/burns
- Allorto NL. Primary management of burn injuries: Balancing best practice with pragmatism. South African Family Practice, 2020.
- Radzikowska-Büchner E, Łopuszyńska I, Flieger W, et al. An Overview of Recent Developments in the Management of Burn Injuries. IntJ Mol Sci, 2023.
- Yousefian F, Hesari R, Jensen T, et al. Antimicrobial Wound Dressings: A Concise Review for Clinicians. Antibiotics (Basel), 2023.
- Kammerlander G, Locher E, Suess-Burghart A, et al. An investigation of Cutimed® Sorbact® as an antimicrobial alternative in wound management. Wounds UK, 2008.
- Kleintjes WG, Boggenpoel A, Diango K. A prospective descriptive study of Cutimed Sorbact® used as a skin substitute for the treatment of partial thickness burn wounds. Nursing Today, 2018.
