Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of "Major Recommendations" field.
Practice Recommendations - Part A: Evaluation and Treatment
Recommendation 1
Methods to Reduce Inflammation
- Cooling, ice packs (Han, 2004)
- Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen (Morgan, 2000)
- Topical corticosteroids (Duteil et al., 2002; Han, 2004)
- Systemic corticosteroids (not recommended) (Han, 2004)
(Grade of recommendation = A; Quality of Evidence = Good)
Recommendation 2
Methods to Prevent Infection in Sunburn
- Diligent wound care with mild soap and water (Hudspith & Rayatt, 2004; Morgan, 2000)
- Application of non-adherent dressings if open areas present (Dowsett, 2002)
- Sterile saline soaks (Dowsett, 2002)
- Care of blisters, blebs (keep intact if possible and cover open wounds with sterile dressings) (Dowsett, 2002; Morgan 2000)
- Tetanus prophylaxis for burns deeper than superficial partial thickness (Kagan, 2002; Morgan, 2000)
- Topical antibiotics such as Bacitracin, or Silvadene (Kagan, 2002; Morgan, 2000)
- Simple dressings such as Telfa, Duoderm, Granuflex, Mepitel (Hudspith & Rayatt, 2004)
- Oral or injectable antibiotics (not recommended) (Dowsett, 2002)
- Chlorhexidine, povidone iodine (not recommended) (Morgan, 2000)
- Biologic dressings such as Burnsheild or Rescue Derm (Hudspith & Rayatt, 2004; Martineau & Dosch, 2006)
(Grade of Recommendation = B; Quality of Evidence= Good)
Recommendation 3
Comprehensive Pain Assessment
Methods to Evaluate Pain
- Location of pain
- Effect of pain on function and activities of daily living (i.e., work, interference with usual activities, etc.)
- Level of pain at rest and during activity
- Medication usage
- P - provoking or precipitating factors
- Q - quality of pain (what words does the person use to describe pain? - aching, throbbing)
- R - radiation of pain (does the pain extend from the site?)
- S - severity of pain (intensity, 0-10 scale)
- T - timing (occasional, intermittent, constant)
(Grade of Recommendation = C; Quality of Evidence= Good)
A standardized tool with established validity is used to assess the intensity of pain.
- Visual Analogue Scale (VAS)
- Numeric Rating Scale (NRS)
- Verbal Scale
- Faces Scale
- Behavioral Scale
(Grade of Recommendation = C; Quality of Evidence= Good)
Pharmacological Management of Pain: Selecting Appropriate Analgesics
Using the WHO (World Health Organization) Stepwise Approach to Pain
Ensure that the selection of analgesics is individualized to the person, taking into account:
- The type of pain (acute or chronic, nociceptive and/or neuropathic)
- Intensity of pain
- Potential for analgesic toxicity (age, renal impairment, peptic ulcer disease, thrombocytopenia)
- General condition of the person
- Concurrent medical conditions
- Response to prior or present medications
- Cost to the person and family
- The setting of care
(Grade of Recommendation = A; Quality of Evidence = Good)
Recognize that acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are used for the treatment of mild pain and for specific types of pain as adjuvant analgesics unless contraindicated.
(Grade of Recommendation = A; Quality of Evidence = Good)
Recognize that opioids are used for the treatment of moderate to severe pain, unless contraindicated, taking into consideration:
- Previous dose of analgesics
- Prior opioid history
- Frequency of administration
- Route of administration
- Incidence and severity of side effects
- Potential for age related adverse effects
- Renal function
(Grade of Recommendation = A; Quality of Evidence = Good)
Consider the following pharmacological principles in the use of opioids for the treatment of severe pain:
- Mixed agonist-antagonists (e.g., pentazocine) are not administered with opioids because the combination may precipitate a withdrawal syndrome and increase pain.
- The elderly generally receive greater peak and longer duration of action from analgesics than younger individuals, thus dosing should be initiated at lower doses and increased more slowly ("careful titration").
(Grade of Recommendation = B; Quality of Evidence = Good)
Recommendation 4
Methods to Treat Pain/Discomfort
- Non-steroidal anti-inflammatory drugs, acetaminophen (Morgan, 2000)
- Aspirin (Morgan, 2000)
- Topical anesthetics, analgesics such as Propolis, Solarcaine, or Witch Hazel (Ackerson, 2004; "Sunburn," 2006; Gregory et al., 2002)
- Short course of codeine or oxycodone (Hudspith & Rayatt, 2004; Oldfield & Perry, 2006; Brown, 2004)
- Anti-pruritics; Benadryl, Periactin, Atarax (Han, 2004)
- Bicarbonate of soda baths, Calamine lotion (Morgan, 2000)
- Green tea, cucumber, Echinaea, Mimosa tenuiflora (Duke, 2002; Schar & Altshul, 2003)
- General comfort measures; emollients, cool compresses, oatmeal soaks (Ackerson, 2004; "Sunburn," 2006; Perez, 2006)
- Relaxation and imagery (Kagen, 2002)
- Petroleum jelly, benzocaine, lidocaine, butter or greasy ointments (not recommended) (Perez, 2006)
(Grade of Recommendations = B; Quality of Evidence = Good)
Recommendation 5
Methods to Promote Healing
- Healthy diet with adequate protein (Johns Hopkins, 2006)
- Adequate hydration (Kagen, 2002)
- Rest (Johns Hopkins, 2006)
- Avoidance of alcohol (Johns Hopkins, 2006)
- Use of non-perfumed moisturizing lotions once epithelialization occurs to promote natural lubricating mechanisms (Perez, 2006)
- Avoidance of direct intense sun exposure (Perez, 2006)
- Loose comfortable clothing (Johns Hopkins, 2006)
(Grade of Recommendation = C; Quality of Evidence = Fair)
Recommendation 6
Alternative Therapies
- Vitamin C, E (Kagen, 2002)
- Aloe Vera (Ackerson, 2004)
- Oatmeal baths (Ackerson, 2004, Perez, 2006)
- Antioxidants (not recommended) (Han, 2004)
- Topical melatonin (not recommended) (Han, 2004)
- Milk ("Post-sunburn soothers," 2005)
(Grade of Recommendation = C; Quality of Evidence = Fair)
Practice Recommendations- Part B- Management
Follow-up
- Follow-up one day after initial visit
- Weekly until wound epithelialization begins
- Concurrent evaluation for infection/complications
Patient Teaching
- General care to promote healing and prevent infection
- Signs and symptoms of infection/complications
- Medication/wound care
- When to follow-up
- Sunburn protection
(Grade of Recommendation = C; Quality of Evidence = Good)
Definitions:
Quality of Evidence (Based on U.S. Preventative Services Task Force Ratings)
- Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
- Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
- Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
Strength of Recommendations (Based on the U.S. Preventive Services Task Force Ratings)
A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.
B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.
C. There is at least fair evidence that the recommendations can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.
D There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.
I. Evidence that the recommendation is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms can not be determined.
