Burn Wound Treatment: Cleansing and Solutions

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

Top Contributors - Stacy Schiurring and Jess Bell

Introduction

Providing care to patients with burn wound injuries is a complex undertaking and requires collaborative management from an interdisciplinary team. The wound care professional providing care at the bedside must take the overall medical condition of the patient into consideration: (1) immunosuppression, (2) the extent of the burn wound, and (3) medical comorbidities,

Infection prevention, oedema management, and effective skilled wound care all contribute to proper healing of a burn wound injury. Wound cleansing is an important part of wound bed preparation. Unfortunately, there is not much evidence that supports a particular type of wound cleansing for burn wounds.

Burn Wound Cleansing

Wound cleansing is the removal of surface contaminants, loose debris, slough, softened necrosis, microbes and/or remnants of previous dressings from the wound surface and from the periwound skin.

First thing that's important to consider is that burn wounds are different than other types of wounds that you may encounter that need cleansing. In normal acute wounds or non-burn acute wounds and chronic wounds, those wounds can really withstand a fairly significant amount of mechanical force to clean the wound bed, remove all the debris, stimulate new granulation tissue, especially in those chronic wounds, to facilitate healing.

Burn wounds, on the other hand, are much more fragile. If you use too much mechanical force when cleaning a burn wound, you can destroy the newly formed epithelium and the new onset of growing epithelium from the wound margins and even within that burn wound. So they require a much more gentle touch. It's important to find that balance between effectively cleaning the surface of the burn wound and not being so strong that you're destroying that growing tissue.

There's one exception to that, and that, of course, is in the instance of a significant infection. If the burn wound is clinically visibly infected or you have laboratory findings that that burn wound is infected, then that infection can destroy the growing epithelium and granulation tissue and stop the healing progress at that point. So it's more important to get rid of the infection, even at the risk of damaging or destroying some of the newly healing tissue, because the infection's going to do that anyway. So eradicating that infection with a little bit more of an aggressive approach to wound cleansing and the topical agents that are used is beneficial in the short term. And then once that infection is under control, then obviously you would want to be more gentle and use less cytotoxic topical agents so that that burn wound can continue to progress and go on to healing.

Goals of Wound Cleansing

So we're talking about therapeutic wound cleansing, which is actively removing the contamination from the surface of the wound. And there are several goals that we want to accomplish by performing therapeutic wound cleansing. Number one, we want to minimise the risk of wound infection by removing all that contamination from the surface. Number two, we want to remove any residual topical agents, the drainage that has been collecting since the last dressing change. All of those things which can also create that environment for bacterial growth, or microbial growth, on the surface of the wound. We also want to remove any debris or loose, non-viable tissue from the surface of that wound because that can also put the patient at risk for infection, as well as slow down the healing process.

We also want to provide a clean environment if we're needing to collect a sample for laboratory study to decide if the wound is infected and what bacterial or microbial growth is causing that infection. So if you take a sample from a contaminated wound or one that hasn't been cleaned, you're going to get a lot of cross-contamination that may not have anything to do with what is actually causing the infection. So by cleaning that wound bed, you're collecting a more reliable sample, whether that be a biopsy or a swab culture for determination of what microbes are actually involved in that wound and the infection that might be going on. And finally, good wound cleansing can hydrate the surface of the wound and possibly hydrate any desiccated tissue that has started to form in that wound bed. By keeping the wound hydrated, you can preserve that viability, so that the wound can continue to heal.

Preparing for Wound Cleansing

The choice of using a sterile or a non-sterile solution to clean the wound is not clearly elucidated in the literature, and it's really based on wound assessment and the patient's status at the time that you're assessing that patient for that particular treatment. It's very important that pain is managed prior to starting the treatment because if a patient is in pain, they're not going to let you effectively clean the wound bed. It doesn't matter what topical agent or procedure you're doing, they will have a big part in saying, no, you can't do that. So pain management is extremely important in managing the care of a burn when we're cleaning it.

It's important that you use an adequate amount of solution when you're cleaning the burn wound. Now, there isn't really a defined volume for what is adequate. In non-burn-wound-type wounds, there is some evidence in the literature of how much solution you would use based on the size of the wound, but that does not transfer over to burn wound injuries. So it's just important that you use adequate solution and that you're thoroughly cleansing that wound with whatever solution you're using to clean that wound surface. And if you are irrigating with some device that applies any kind of mechanical force, you want to make sure that force is appropriate for that wound. And again, there really isn't a force that's defined for burn wounds.

You want to make sure the solution is at appropriate temperature. In most of the literature I found that they recommended room temperature or slightly warmer. I don't know if any of you have ever had a wound that's been treated by room temperature solution, but it feels like that solution was kept in the refrigerator. It feels very cold. So in my clinical practice, we typically warmed it to mid-90s in Fahrenheit, or even the low 100s in Fahrenheit. Typically for burn wounds, it was more like the mid-90s to low 90s, so that the burn wound wasn't shocked, the patient wasn't shocked by how cold that solution is. And also, cold solution actually slows down the healing process. So you want it to be somewhat close to body temperature or slightly cooler for the most effective application of a solution.

You want to make sure you use an aseptic technique. That doesn't always mean sterile technique, but definitely clean technique and appropriate PPE, (personal protective equipment) not only to protect that patient, but also to prevent cross-contamination when you go from one patient to another. And then you want to make sure that you're washing and cleaning the periwound skin as well. Any skin that was under the bandage that was just removed could potentially have the bacteria and the contamination from that burn wound that has soaked into the bandage and spread out and been in contact with the intact periwound skin as well. Plus that skin can become macerated or otherwise irritated by the bandage or the drainage. So really cleaning everything that was under the bandage, whether that's intact skin or burn wound, is important to keep the entire area clean as you're doing these cleaning procedures.

Wound Cleansing Strategies

So there's three basic types of wound cleansing strategies that I'm going to talk about. Immersion is the first one, basically putting a patient in a whirlpool tank or some other tank of water. The benefit of immersion is that it really effectively cleans the surface of the burn wound and everything that's in the water, and it thoroughly hydrates the burn wound. The process of putting somebody in a whirlpool tank not only saturates the wound by immersing it in that water, but if you turn on the whirlpool turbine, it agitates the water, and that provides the mechanical debridement to help cleanse the surface of the burn wound a little bit more effectively.

However, there are a lot of downsides or negative aspects to immersion for cleaning a burn wound. One is that it is very physiologically taxing on the patient. When you immerse the body in a warm tank of water, their heart rate goes up, their respirations go up, their blood pressure goes down, and that's all very taxing and fatiguing to that patient, and they have to recover from that after they've been immersed. Secondly, when they come out of the warm water that they were immersed in, they can develop hypothermia very quickly. So you want to make sure that the room is warm, if at all possible, and that as soon as they're out of the water, you dry them off and cover up whatever isn't open as far as a burn wound goes, so that they can start warming as quickly as possible. And you want to get the burn wound itself bandaged as quickly as possible to decrease that evaporative effect that causes some of that cooling and helps that patient warm up again.

There's also a significant risk of infection with immersion into a tank of some kind. There can be cross-contamination from the patient themselves, whether that be their skin flora, they might become incontinent in the tank, and that creates contamination risk. The normal flora and the perineum and from the mucus of the respiratory tract, that can also get into the water and contaminate that water, can put that patient at risk for an infection they may not already have. So that is one risk.

The second thing is that it's very difficult to clean the equipment. And even with really thorough and conscientious cleaning, there is often bacteria left behind, whether that be just planktonic bacteria or the biofilms that form in the pipes, in the faucets, in the drains, and on the surface of these metal, if they're metal, tanks that are used. And so they are often found residing in those pipes and on the surface, even after very rigorous cleansing. Then when you fill that water again, you're reintroducing that biofilm to the water and contaminating the patient once more.

The next method I want to talk to about cleaning a burn wound is showering or using running water. There is very little evidence that talks about using a shower in cleaning a burn wound other than anecdotal case reviews and case reports about the use of a shower, which seems to be very prevalent in the clinical setting. It is definitely less physiologically stressful to shower than it is to be immersed in a tank of warm water, which is one of the benefits. It also minimises the risk of the patient's cross-contamination because the running water, the patient isn't sitting in that contaminated water while they're getting cleansed, and the running water can just wash that all away. The water temperature really needs to be cooler than what you would take a normal shower at, because if the water's too warm, it will feel like it's burning again. So you want to make sure the patient can tolerate that temperature when they get in the shower.

Hypothermia is also a concern once the patient gets out of the shower. So if at all possible, the room that they're in and the room that they're going to for bandaging or whatever, should be warmer than normal. And you want to cover them as much as possible as quickly as possible, and get the burn wound bandaged as quickly as possible to alleviate that hypothermia.

The shower, the force of the shower against that burn wound can be overly aggressive. So very often, instead of the shower spray hitting the burn wound directly, we let it hit the intact skin and run over the surface of the wound to flush that wound of its contaminants that way. And it's also more tolerable pain-wise to do it that way. The other fact with showering is just like the tanks, biofilms can live in the shower head and the pipes leading to the shower head, so that risk of contamination, although not as great as it is with the immersion technique, is still present and potentially can cause harm to the patient. If you don't have a shower or it's not feasible for that patient at that time to go to where the shower is. You can also take a vessel, preferably a glass vessel or a metal vessel that can be disinfected very thoroughly, and fill it with whatever solution you're using to cleanse that burn wound and pour it over the burn wound in their bed or in a, you know, on a plastic shower bench or something so that you can clean the burn wound that way before you put bandaging on there.

And there's also reports in the literature about many caregivers doing the immersion technique first to thoroughly cleanse that burn wound. And follow it with a shower to wash all that contamination that happened while they were immersed from the surface of the burn wound. That takes quite a bit of time and I don't know that that's still commonly in practice, but it is potential, if, you know, immersing them is your best option for that particular patient, but you want to minimise some of the risks, you can follow it by washing them with running water to clean their burn wound.

The other technique that's also very common in clinical practice is soaking and then wiping. This soaking can be done by just saturating sterile gauze or bath towels or washcloths, and laying them over all of the surfaces of the burn wound, letting them soak for a certain period of time, which provides the hydration. And if there's an antimicrobial agent, provides that coverage as well. And then wiping the surface of the wound to remove the contamination, the slough, the debris with a mechanical force so that that burn wound can be cleaned that way. Unfortunately, there is no way to be consistent in how much pressure is applied when you're wiping the surface of that wound. Some people are very heavy-handed, some people are very light-handed, and you need to use adequate force to clean the surface, but not so strong that you're actually damaging that underlying wound bed. So it's a little bit difficult to monitor the strength of that pressure. According to the articles when they talked about non-burn wound irrigation, the mechanical force that was needed to be adequate for removing surface debris, but not too strong to destroy the tissue is between four and 15 pounds per square inch. There is no defined pressure for a burn injury or a way to really measure it, especially when you're doing the soak and wipe that is very common. This method of soaking and then wiping the burn wound is very effective for smaller burn wounds as well as for burn wounds that may be only superficial partial thickness and/or are healing well and you really want to be as light as possible to not destroy that new healing epithelium.

Wound Cleansing Solutions and Additives

So now I want to talk about the solutions or additives that we use to clean burn wounds. There are many that are non-antimicrobial, and these are specifically indicated for wounds that are not infected or showing signs of infection, and they're considered inert. That's sterile saline, sterile water, distilled water, potable water, even some of the wound cleansers that are available commercially. These are all considered to be non-cytotoxic. They do require some mechanical force to be effective in cleaning that wound bed. One of the things about potable water, if you're using tap water or well water, depending on where you are and what the source of that water is, it can be very contaminated. So you want to be careful when you're using potable water that you aren't using something that could have come from a contaminated source, or you would want to boil it first, and then let it cool before you used it on that patient.

Topical antiseptics or antimicrobial agents are used for their biocidal effect on bacteria, fungi, parasites, viruses, all of those contaminants that potentially can live in a burn wound, either in isolation as a single entity or polymicrobial, as most burn wounds are. The purpose of the topical antimicrobial agents is to decrease the bioburden on the surface of the burn wound. That can be particularly beneficial when the patient has vascular issues. A deep partial-thickness burn or a full-thickness burn has damaged or destroyed vasculature underlying that wound injury or a patient with a pre-existing vascular problem also has problems perfusing their whole body, but particularly the burn injury and therefore, systemic antibiotics aren't effective because they don't get to that burn wound necessarily. So the topical agents can really help control what's on the surface. And hopefully, if you've started that before the bacteria has penetrated that burn wound, then you can minimise the risk of them developing a serious infection.

So there are certain guidelines for when to use a topical antimicrobial or antiseptic agent, and those, again, are pretty consistent throughout the wound care field. Any patient with a high risk of infection, you would use a topical antimicrobial agent. If they're showing clinical signs of a local infection, then you want to initiate the use of a topical antimicrobial agent. Or you may use a topical agent in combination with a systemic antibiotic in the event they have a spreading or a systemic infection or when you're treating what you assume or know to be a biofilm where you do a surgical debridement and then you initiate both systemic and topical antimicrobial agents to try to really eliminate that biofilm and prevent it from reforming.

So when you're trying to decide which of the topical antimicrobial agents you want to use, there is a list of guidelines that you can follow to make your best decision on what's going to be best for that patient at any given time. Remembering that each time you do a dressing change, you're assessing that burn wound to see is it getting better, is it getting worse, is it not changing? And deciding whether you need to change the topical antimicrobial agent that you're using or to stop using them altogether in certain circumstances. So this list sort of just helps you get started on choosing the topical antimicrobial agent to start with. It should be broad spectrum. It should have a known efficacy for whatever microbes you know to be on that burn wound or suspect to be causing an infection at that particular time. Preferably, it should have no or low cytotoxicity to the healthy wound bed, or it should be not irritating the patient, and the patient shouldn't have an allergy to any of the components of it, obviously.

As far as the cytotoxicity goes, as I said before, if you're dealing with a significant infection, then it's more important to kill that bacteria first because if you don't, then that infection is going to destroy that wound healing and the healthy tissue and cause that wound to deteriorate. So it's again, finding that balance in what you're trying to achieve with whatever agent you choose to use. It should be fast acting and long lasting if at all possible. There should be no or low known bacterial resistance to the agent that you're using, and of course, it needs to be locally available and preferably something that has guidelines for how you would use it in the clinical practice before you choose the agent that you want to use.

So the agents that I'm going to talk about in this module is not comprehensive. These are the ones that are most common in the literature and most common in my clinical experience. But there are many of them out there. And so if you don't have access to the ones that I talk about and you have access to something else that's recommended for wound care, then obviously doing your own research and looking for the best evidence and the best use of that agent would be important. Many of these agents, if not all of the ones I'm going to talk about today, are also used to saturate the bandages that are applied to the burn wound to be left on until the next dressing change. But I will talk about those specifically for use on bandaging when we get to that module.

So the first one that I want to talk about is mafenide acetate known as Sulfamyalon, and it comes in a 5% solution. It is broad spectrum against gram-negative, particularly pseudomonas aeruginosa and anaerobic bacteria. But it is not effective at all against gram-positive bacteria, nor is it effective against fungus. So if you have a patient that you're using Sulfmyalon on, for instance, they have a significant pseudomonas infection, but you know they also have a fungal infection, or they're at high risk for developing one based on the criteria for that, then you would need to add an antifungal agent. And in most cases, they add nystatin powder to the Sulfamyalon solution to provide that antifungal coverage for that patient.

Use of Sulfamyalon also creates a risk for the patient developing metabolic acidosis, which is particularly a risk for patients who are in respiratory distress. So if the patient starts to develop those symptoms, then you need to discontinue the use of Sulfamyalon and use something else. It doesn't mean you can't go back to Sulfamyalon, it might be a situation where you will use it for a little while and then switch to something else if you're trying to treat a severe infection. But you have to discontinue use when they develop those signs of metabolic acidosis.

The next one I'm going to talk about is povidone iodine, known as Betadine. It comes in several different solution strengths, and it also has a scrub version to be used perioperatively or preoperatively to clean the skin, before surgery is performed. It is not recommended to use the scrub version of Betadine for burn wound cleaning because it has some additives in there that are cytotoxic and not good for burn tissue. Betadine is known to be broad spectrum. It's effective against bacteria, fungi, protozoa, and viruses. It's also known to penetrate biofilms, which is one of the few antimicrobial agents that can actually penetrate the biofilm. There is no known resistance against Betadine for microbes, but it is contraindicated to be used with patients with thyroid disease because of the iodine component, and depending on the strength of it, there is a dose-dependent cytotoxicity associated with Betadine.

When I first started practice, Betadine was used very commonly. It was the most common topical additive to whirlpools or to bandages, and it was found in the literature that at any strength that was antimicrobial, it was also cytotoxic. So we often diluted it, but again, there was really no control on how much you diluted it. They've changed some of the formulations, and they've also found that depending on the strength and the length of contact of the Betadine with the burn wound, it can effectively kill the microbes that you're trying to target without destroying the granulation tissue. So again, in use for cleansing when there's a short contact, it can be very effective in killing large types and groups of bacteria or microbes without destroying the wound bed. And again, if you have a severe infection, it's more important to get rid of those microbes.

Another one that's mentioned in the literature is polyhexamethylene biguinide, known as PHMB. But everything I found just talks about it being used as an additive to dressings, gauze dressings and foam dressings and not really as a cleansing agent. I mentioned it because they're potentially, they could come out with some kind of a solution that contains it because it is broad spectrum against Gram-negative and Gram-positive microbes as well as fungi, viruses, MRSA, (methicillin-resistant Staphylococcus aureus) and biofilms.

Another one that's very commonly used for burn care is acetic acid. In most of the documentation that I found, it investigated solutions anywhere from 0,5% to 5% acetic acid concentration. Commercially what I found and what I always used in my clinical practice was a 0,25% acetic acid, so it was not quite comparable to what I found in these studies that are more current. It is effective against planktonic bacteria. It's also known to help decrease biofilm colonisation. In a study that I found from 2014, it tested acetic acid along with several other antimicrobial agents, again, in the concentrations that I mentioned above, 0,5% to 5% against several multidrug-resistant strains of bacteria. And acetic acid was found to be effective against almost all of those multidrug-resistant bacteria. And then there are multiple studies showing that it's very effective against pseudomonas aeruginosa and is often used when you suspect pseudomonas as one of the first topical antimicrobial agents, specifically intended to target that pseudomonas infection.

Another type of topical agent are the superoxidised solutions, one of them being hypochlorous acid. Hypochlorous acid has a time-dependent response against pseudomonas as well as MRSA. There's no known toxicity with hypochlorous acid because it is basically a replication of the normal process of an oxidative reactive response that occurs naturally from the neutrophils when they are initially called to a wound to help fight infection. It's also found to help decrease an outbreak of MRSA in a burn unit. By using it to bathe the patient, you actually clean not only the burn wound, but their entire body. Just as you're bathing a patient with the hypochlorous acid solution, you can clean the burn wound and the skin and then bandage the burn wound as you intend to do so, and it has been found to decrease outbreaks of MRSA by using that particular solution.

The other form of a superoxidised solution is sodium hypochlorite, which I have the most experience with. The original form of sodium hypochlorite was known as Dakin's. It was created by a doctor named Carrel early in World War I, and then revised by Dr. Dakin, and hence it became known as Dakin's Solution. And back in World War I, it was very effective in minimising infections from those soldiers that laid in the field after injury until they could be taken to a medical unit for care. And it prevented a lot of amputations that had been occurring prior to the development of Dakin's. However, Dakin's was found to be, in its original formula, extremely cytotoxic, although it did also eradicate any microbial infection that was happening on the wound bed.

So it was redeveloped and has basically come back in new formulations and is again being used in clinical practice. But it has various dilutions from half-strength Dakin's to quarter-strength Dakin's, which is 0,125% sodium hypochlorite and a one-40th-strength Dakin's, which is 0,0125% sodium hypochlorite. What most of the research shows is that the full-strength Dakin's, the half-strength Dakin's, and the quarter-strength Dakin's are all cytotoxic to tissues, although they are extremely antimicrobial. And the one-40th-strength is not cytotoxic, but it's also not effective as an antimicrobial agent.

So in 1991, a researcher named Heggers investigated sodium hypochlorite at other concentrations, including the one that became our standard of care in my clinical practice, which is 0,025% sodium hypochlorite. So it's twice as strong as the one-40th strength, but less concentrated than the half-strength or the quarter-strength Dakin's. Heggers found that with contact up to 30 minutes in a, of course it was an in vitro study, the effectiveness of this concentration against bacteria was extremely successful through a broad range of bacteria, but it was not cytotoxic. They did find that the fibroblasts and the keratinocytes sloughed from the surface of the wound, but they remained viable in the solution that surrounded that wound. So they felt like even though they had slough from the surface, they were still active and effective in helping against the microbial growth and to help that wound heal. So 0,025% was our standard of care, not just with burn wounds, but with non-burn wounds as well in trying to maintain an appropriate and manageable level of bioburden on the surface of the wound.

Other solutions are also commercially available that are designed to help with burn wound cleansings. Many of them contain a surfactant. A surfactant has the additional benefit of separating the layer of non-viable tissue. Not necessarily eschar, but that pseudo-eschar and that slough and some of that coagulated debris that sits on the surface of the wound. It helps separate it from the underlying viable wound bed by breaking those bonds that are holding that material to the wound bed. And that not only helps with the mechanical debridement and cleaning of that burn, but it allows the antimicrobial agent to get to the surface of the burn wound and provide that antimicrobial coverage more effectively.

Chlorhexidine and soap are also mentioned and known to be used in clinical practice. One of their benefits is they have the surfactant, which allows for a good mechanical cleaning of the surface of the wound. However, there's no dosage control with either one of those. Chlorhexidine in its formulated strength is extremely cytotoxic and it needs to be diluted with water, but there's no formula for how much to dilute it, and it's very inconsistent in how that's done in clinical practice as well as soaps. So potentially it can remain cytotoxic. It's very important if you're using that to clean the burn wounds, particularly in the surgical setting, that you rinse it from the burn wound thoroughly so that there's no cytotoxic residual effect from those products.

And then there are commercial wound cleansers available. Most of them also have a surfactant added to them, and most of them are also antimicrobial. When they first came onto the market, they were very cytotoxic. Almost all of them were too cytotoxic for use, so they were all reformulated, and they now, to my knowledge, they're all less potent and therefore not cytotoxic to the wound bed and can be used very effectively, especially for smaller burn wounds or in the home setting.

Hydrogen peroxide is another agent that has long been used for cleaning wounds, not necessarily burn wounds, but wounds in general. But its standard concentration, which is 3%, is extremely cytotoxic to fibroblasts, keratinocytes, macrophages, and can stop wound healing or actually cause it to deteriorate if used for too long. When I first started doing wound care in the mid-80s, hydrogen peroxide was very normally given to a patient with instructions to use it every day until their wound healed and many wounds took a long time to heal because that hydrogen peroxide was so toxic. So it's not common to use it for burn wound injuries, but one of the benefits of hydrogen peroxide is the effervescing action that it has when it touches the wound bed and it becomes oxygenated and that effervescence can help loosen debris, dried blood, contaminants that are sort of adherent to that wound bed so that you can then mechanically wipe them away or debride them away. So it's effective if you use it for one or two treatments for a specific purpose in a defined area, but then you also want to make sure you rinse that product away before you bandage the burn wound so there's, again, not that lingering effect that can be cytotoxic to the tissue.

Once you have determined the type of wound cleansing intervention you're doing and the topical agent that you're using to take care of that burn wound, the next part of the plan is to decide how often that intervention needs to happen. So all of these topical agents that I talked about today are not sustained-released or time-released antimicrobial products. They have a very short-term effectiveness in being antimicrobial. So if you're just using them for cleansing and you're using a dressing that is antimicrobial with a time-dependent feature, you know, change it every three days or every five days, then the frequency of intervention is based on that particular dressing and the recommendations for the frequency of dressing changes. However, many of these solutions are also used to saturate the dressings that are applied. Just plain gauze that is not antimicrobial other than this topical agent that we're adding, or any other inert dressing that you're saturating with this particular topical agent. Those do not have that sustained release and need to be changed a minimum of once a day and that daily also pertains to wounds that have just a low amount of drainage, no real signs of infection, and they just need to be kept clean.

The dressing change needs to be done, at least BID (twice a day) with increasing drainage and increasing signs of infection, and potentially those patients that are at really high risk for developing an infection if care isn't done very strategically. They need to be changed even more often than BID when the signs of infection are severe, you have copious amounts of drainage, the wound is deteriorating, the patient has active signs of clinical infection. Then that care needs to be every eight hours, every six hours, even potentially every four hours to get that microbial bioburden off the surface of the wound. And you also want to use more vigorous techniques like I talked about earlier, to eradicate that bioburden from the surface of the wound. So you're putting at risk some of the healthy tissue to remove that infection that will destroy that healthy tissue if you don't get rid of it, as I said before.

And the frequency of dressing changes may vary in different parts of the body on the same patient. If they have an arm burn and a leg burn and a trunk burn, and they're all presenting at different levels of symptoms of infection or the progress toward healing, then the frequency of each of those areas may be different. You may be changing the arm burn every six hours and the leg burn every two or three days because you have an antimicrobial dressing on it. So really the assessment piece, as you're changing that dressing, will dictate how you're treating that burn, how often, what agents that you're using, and you may go back and forth from an antimicrobial agent to an inert agent as the picture of that burn wound changes with each dressing change.

So these pictures are designed just to kind of summarise what we've talked about with our topical agents today. If a patient presents with a very high risk of infection or a high risk of infection and they're having copious exudate, then you really need to be aggressive in how you're cleaning that burn wound and the topical antimicrobial agent that you're using. And it could be combined with surgical debridement as well, because once they're surgically debrided, you really need to clean that wound surface so any remaining bacteria can be eradicated as best as possible. So deep like full-thickness or deep partial-thickness burn wounds, large surface area burns, burns that have had eschar that hasn't been debrided and has been present for quite a while, burns that are already presenting with the look of infection. All of those really need aggressive frequent intervention to minimise that risk of infection and eradicate the microbial bioburden. When the burn is superficial partial-thickness, it's very small, it's showing signs of healing with epithelial budding throughout the burn wound, as well as new epithelial growth from the edges, then you want to be very gentle with that burn care, using inert products, not antimicrobial products, using very gentle care so that epithelial growth can continue and won't be destroyed by the interventions that we provide.

So in conclusion, when you're trying to decide what type of wound cleansing you're going to provide the burn patient and what topical agents you may use in cleaning the burn wounds, remember that unfortunately, there's not a lot of supportive evidence, but you do want to find evidence that will at least help you initiate that first intervention and the thought process behind it, and then you're assessing that burn wound each time you do the dressing change to make sure you're either getting the results that you want or if you're not, that you're revising your intervention to try to achieve those results.

There is quite a bit of expert agreement in using antimicrobial agents, especially when you're looking at the development of a local infection or even a more serious infection. And to be used in combination with systemic antibiotics for those more serious infections, as well as for management of biofilms and those patients that are at very high risk for developing an infection.

As I said, once the signs of infection have resolved, the wound shows really good healing, which means there isn't an infection or the wound wouldn't continue to heal, you may discontinue the use of antimicrobial agents and use the more inert agents. Again, remembering you may need to switch back and forth until that burn wound has effectively re-epithelialised.

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