Emergency War Surgery NATO Handbook: Part I: Types of Wounds and Injuries: Chapter III: Burn Injury

Topical Chemotherapy

United States Department of Defense

If the burn patient can be moved to a definitive treatment installation within 48-72 hours, no specific topical antimicrobial therapy need be employed in the field. However, if either the tactical or logistical situation is such that treatment must be continued at a relatively forward area, topical chemotherapy should be begun once the patient has become hemodynamically stable. There are three topical antimicrobial agents which are commonly employed for burn wound care in civilian practice. Each agent has specific advantages and limitations with which the clinician must be familiar to provide optimum wound care. Both mafenide acetate and silver sulfadiazine are available in the form of topical creams which are commonly applied directly to the burn wound twice a day and do not require the twice or thrice daily application of occlusive dressings, as does the 0.5% silver nitrate soak treatment regimen.

Sulfamylon burn cream is an 11.1% suspension of mafenide acetate in a water dispersible base. The active ingredient, mafenide acetate, is water soluble and diffuses freely in the eschar to establish an effective antibacterial concentration throughout the eschar and at the viable/nonviable tissue interface where bacteria characteristically proliferate prior to invasion. Because of this characteristic, Sulfamylon is the best agent for use if the patient to be treated has heavily contaminated burn wounds or is received several days postburn and a dense bacterial population already exists on and within the eschar. The side effects of Sulfamylon burn cream are: (1) hypersensitivity reactions (usually responsive to antihistamines) in 7% of patients, (2) pain or discomfort of 20-30 minutes duration when applied to partial-thickness burns (seldom a cause for discontinuing Sulfamylon application), and (3) inhibition of carbonic anhydrase. The inhibition of carbonic anhydrase may produce both an early bicarbonate diuresis and an accentuation of postburn hyperventilation. The resulting reduction of serum bicarbonate levels renders such patients liable to a rapid shift from an alkalotic to an acidotic state, if pulmonary complications supervene, even with a measured pCO₂ at levels ordinarily considered to be normal. If acidosis should develop curing Sulfamylon therapy, the frequency of application of Sulfamylon burn cream should be reduced to once a day, or dosage omitted for a 24-48 hour period, with buffering employed as necessary and efforts made to improve pulmonary function.

Silver sulfadiazine burn cream is a 1% suspension of silver sulfadiazine in a water-miscible base. As a consequence of poor water solubility, the active agent shows only limited diffusion into the eschar. Silver sulfadiazine burn cream is most effective when applied to burn wounds immediately after thermal injury to prevent bacterial colonization of the burn wound surface as a prelude to intraeschar proliferation. This agent has the advantages of being painless when applied to the wound and being free from acid-base and electrolyte disturbances. The limitations of silver sulfadiazine burn cream include neutropenia, which usually relents when application is discontinued; hypersensitivity, which is rare; and ineffectiveness against certain strains of Pseudomonas organisms and virtually all strains of Enterobacter cloacae.

The characteristics of silver sulfadiazine burn cream recommend it for initial wound treatment at the first echelons of medical care, while the characteristics of Sulfamylon burn cream, especially its more efficient and broader spectrum of antimicrobial action, mandate that it be available for the care of patients with extensive burns at the definitive level of surgical care.

Either Sulfamylon R or silver sulfadiazine burn cream should be applied in a layer one-eighth inch thick to the entire burn wound with a sterile gloved hand immediately following initial debridement and wound care. Twelve hours later, to ensure con. sinuous topical chemotherapy, a one-eighth inch coat of cream should be reapplied to those areas of the burn wound from which it has been abraded by the bed clothes. The topical cream should be gently cleansed once each day from all of the burn wound and the wound inspected by the attending physician. Daily debridement should be carried out to a point of bleeding or pain without the use of general anesthesia. Following the debridement, the wound is again covered by the topical cream.

If topical antimicrobial creams are not available, multilayered occlusive gauze dressings, saturated with a 0.5% solution of silver nitrate, can be used. These soaks are changed two or three times each day and moistened every two hours to prevent evaporation from raising the silver nitrate concentration to cytotoxic levels within the soaks. Transeschar losses of sodium, potassium, chloride, and calcium should be anticipated and appropriately replaced. Silver nitrate soak therapy, as in the case of silver sulfadiazine burn cream therapy, is best used for bacterial control in burn patients who are received immediately after injury before significant microbial proliferation has occurred. Silver nitrate is immediately precipitated upon contact with proteinaceous material, does not penetrate the eschar, and consequently is ineffective in the treatment of established burn wound infection.

Approved for public release; Distribution is unlimited.

The listing of any non-Federal product in this CD is not an endorsement of the product itself, but simply an acknowledgement of the source. 

Operational Medicine 2001

Health Care in Military Settings

This web version is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

Contact Us  ·  ·  Other Brookside Products