Burn Wound Injury Dressing Selection

Original Editor - Stacy Schiurring based on the course by Diane Merwarth

Top Contributors - Stacy Schiurring and Jess Bell

Burn Wound Injury Standard of Care

Please see this document for a growing list of wound care terminology and definitions.

For a review of other steps in burn wound care, please see the following articles:

• Burn wound injury assessment
• Assessment of infection in burn wounds
• Burn wound injury cleansing techniques and solutions
• Non-surgical debridement of burn injuries

Current Standard of Care

The current standard of care for large and deep burn wounds is (1) early surgical excision and (2) wound closure. Wound closure can be achieved by skin grafting or temporary biological coverage for deep partial and full thickness burns.

Alternatives to Early Excision and Wound Closure

1. Surgical debridement followed by wound cleansing and regular dressing changes
   • preferred option for burns of indeterminate depth, where there are areas of deep partial thickness, full thickness or superficial burn injury
   • by performing ongoing wound care and allowing the more superficial areas to re-epithelialise, those areas that need debridement and skin grafting can be more easily defined
2. Local wound cleansing and dressing changes
   • indicated when surgery is not feasible or after debridement without grafting or temporary closure
   • common for smaller burn areas, including full thickness burns
   • standard for most superficial partial thickness burns

Exceptions to Standards of Care

1. Surgery is not feasible due to patient status, or resource availability
2. Grafting or skin substitutes are not appropriate due to (1) contaminated wounds, (2) native skin is too damaged or of too small an area to provide a skin graft, or (3) skin substitutes are not available

Burn wounds which (1) do not undergo surgical debridement, or that (2) underwent surgical debridement without application of a skin graft or temporary cover with a skin substitute will require ongoing dressing changes throughout the course of healing.

Role of Wound Dressings

In all cases where burn wounds are not grafted immediately, routine burn wound care and dressing changes are needed. The determination of dressings and frequency of interventions are based on a variety of factors that are described below.

Effective burn wound dressings:

• absorb and manage drainage
• minimise the risk of burn wound conversion
• maintain a moist wound environment
• minimise peri-wound maceration
• prevent excessive evaporation from the wound surface that can (1) cause the wound to become desiccated and (2) result in hypothermia
• provide topical antimicrobial protection
• minimise contamination from the external environment
• decrease oedema
• protect the wound
• be care provider friendly (ie. easy to apply and/or remove)
• reduce pain during (1) removal and application of the dressings and (2) during functional activities
• allow movement and function

Clinical Pearl: Benefits of Moist Wound Healing

Multiple studies have demonstrated that the application of moist wound dressings immediately after injury minimises the risk of burn wound conversion. The positive effects of a moist wound environment on wound healing include:

• increased keratin migration and re-epithelialisation
• increased collagen synthesis
• increased autolytic debridement
• decreased necrosis
• decreased pain
• decreased inflammation
• decreased scarring
• facilitation of cell-to-cell signaling
• providing a means of delivering topical treatment
• improved wound aesthetics after healing

Determining the Dressing Care Plan

Determining Dressing Change Frequency

Based on the burn wound or patient status, and on the type of dressing:

• status of the burn wound (or patient): dressing changes will be daily or more than planned in the following situations:
  • the dressing used is not antimicrobial, or the agent has short-acting antimicrobial properties
  • verified or suspected infection
  • significant areas of un-debrided eschar
  • drainage is not contained by the dressing
  • there are any other concerns
  • it is important to monitor for conversion

• need to balance concern for the wound and the desire to leave the wound undisturbed and not introduce risk for additional contamination
  • minimise risk of damage to healing tissue
• type of dressing or topical agent
  • ability of the dressing to maintain a moist environment

Determining Dressing and Topical Agent

Consider the following areas:

• depth and stage of healing of burn wound
• indications of infection
• amount of wound drainage
• clinical assessment of progress, or lack of progress, in wound healing
• ease of dressing application and removal
• availability of dressings and topical agents
• cost of topical agents and dressings

• dressings change as wound progresses (or doesn’t progress)

Burn Wound Dressing Options

This section includes a summary of gauze and gauze-like dressings and possible solutions, creams, and ointments that can be used in the treatment of burn wound injuries. Please see this article for more information on advanced dressings for burn care.

Table 1. Solutions used on dressings.

	Benefits	Risks
Saline	Non-antimicrobial Non-cytotoxic
Mafenide Acetate	Broad-spectrum Common for the treatment of pseudomonas	No antifungal coverage Monitor for metabolic acidosis
Sodium Hypochlorite	Broad spectrum	Cytotoxic at full (Dakin’s) and half-strength Mixed reports of cytotoxicity at 0.025% concentration
Hypochlorous acid	Broad-spectrum Non-cytotoxic
Povidone-Iodine	Broad-spectrum	Cytotoxic at full strength
Acetic acid (various reports of strengths, 0.25% up to 5%)	Broad-spectrum Used primarily for the treatment of pseudomonas

Table 2. Creams and ointments used on dressings

	Benefits	Risks	Burn-specific Considerations
Silver sulfadiazine	Effective against gram-positive (gram +) or gram-negative (gram –) bacteria, and some yeast	Transient leukocytopenia Avoid eyes and mucosal membranes Contraindications: Sulfa allergies, pregnant women, and infants <2 months of age Toxic to keratinocytes, delays re-epithelialisation	Full and deep-partial thickness burns: before debridement after debridement, if graft and/or temporary coverage is not performed
Mafenide acetate (sulfamyalon)	Effective against gram + and gram – bacteria NOT effective against fungal infections Most effective antimicrobial agent to penetrate eschar	Prolonged use, or use over large total body surface area (TBSA) may cause metabolic acidosis and respiratory complications Cytotoxic to fibroblasts and keratinocytes Delays re-epithelialisation	Use can be painful, especially on more superficial burns No longer the standard of care for use with burn wounds, except for: very short-term use very small burns deep partial or full thickness burns to the ears
Antibiotic ointments	Triple antibiotic (eg Neosporin): typically bacitracin, neomycin and polymyxin B: effective for gram + and gram – microbes Bacitracin: effective for gram + bacteria, but NOT gram – or yeast Mupirocin: effective against gram + microbes, including MRSA Gentamicin: broad-spectrum coverage; not commonly used for burn wounds	Change or discontinue the antibiotic used when: lack of effectiveness increased signs/symptoms of infection symptoms of antibiotic sensitivity or allergy	Recommended primarily for superficial partial thickness burn wounds
Medical grade honey	Broad-spectrum activity Maintains moist environment Less toxic and less costly than silver products Antimicrobial by acidity and osmotic gradient		Minimal evidence for its use with burn wounds, but research shows positive outcomes on superficial partial thickness burns
Cadexomer Iodine	Most effective against MSSA and MRSA

Table 3. Impregnated Antimicrobial Dressings

	Benefits	Risks	Burn-specific Considerations
Polyhexamethylene biguanide (PHMB)-impregnated dressing	Broad-spectrum antimicrobial agent used against gram + and gram – bacteria, yeast and fungi Less cytotoxic vs other antimicrobial agents		Recommended for superficial partial thickness burn wounds
Bismuth (eg. Xeroform gauze)	Effective against biofilm formation (inhibits polysaccharide capsule) Bacteriostatic against enteric microbes (C. diff, E. coli) Not cytotoxic	Contraindicated in patients with Bismuth allergy

Burn Wound Injury Areas of Special Concern

Guidelines for Blister Management

"In all of the literature that I've looked at over the past couple of decades, [blister management] hasn't changed. The approach to managing blisters is kind of a 50-50 split between that side of the issue that thinks that all blisters should be unroofed and debrided immediately and completely, and the side that thinks you should leave blisters alone and allow things to happen naturally." - Diane Merwarth, Physical Therapist, Wound Care Specialist

Blisters should be deroofed (unroofed) in the following situations:

1. During surgical cleansing and debridement
2. When the blister itself is disrupted
   • it has become a portal for entry of microbes
   • there is a risk of microbes trapped under loose skin
3. When appearance is questionable
   • thick, cloudy or opaque fluid
   • bloody or discoloured

Blisters should be left intact in the following situations:

1. If blisters are small and not disrupted
2. When they are not affecting function

Blisters should be drained but NOT deroofed in the following situations:

1. Large taut blisters with clear fluid
2. Blisters continuing to increase in size
3. Blisters are preventing function

Deroofing is the process whereby the 'roof' of the blister is removed under clean (aseptic) conditions to expose the viable tissue beneath.

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  Intact blisters

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  Left image: intact blister. Middle image: deroofed blister. Right image: re- epithelialization in wound bed.

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  Left image: blister intact. Right image: deroofed blister

All photos provided by and used with kind permission from Diane Merwarth, PT

Resources

Clinical Resources:

• Wound Antiseptics and European Guidelines for Antiseptic Application in Wound Treatment
• American Burn Association Guidelines for Burn Care Under Austere Conditions

Optional Additional Reading:

• Allorto NL. Primary management of burn injuries: Balancing best practice with pragmatism. South African Family Practice. 2020 Jan 1;62(1):1-4.