Advanced Dressing Selection for Burn Wound Injuries

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

Top Contributors - Stacy Schiurring and Jess Bell

Characteristics and Guidelines of Antimicrobial Advanced Dressings

General characteristics include:

• broad spectrum against many microbes, including Methicillin-resistant Staphylococcus aureus (MRSA)
• manage light to moderate surface bioburden
• none are able to independently eradicate spreading or systemic infection, but can be an adjunct dressing when used in combination with systemic treatments
• lower occurrence of bacterial resistance

Antimicrobial advanced dressings are recommended:

• for patients at risk of developing a burn wound infection
• when there is evidence of increasing bioburden in the burn wound surface

When a patient has a confirmed or suspected infection, antimicrobial advanced dressings can be used, but must be used in combination with a systemic treatment (e.g. antibiotics).

When selecting an antimicrobial dressing for a burn wound, it is important to review the product information / inserts for recommendations on dressing change frequency, dressing application procedures, use of solutions (e.g., sterile water), and any potential contraindications. The wound care professional's clinical judgement, use of up-to-date evidence, and ongoing bedside assessment are also vital in creating and updating a wound care plan. Please review this article section on determining a dressing care plan as needed.

"... the different dressings perform differently on every patient and on different burn wounds. So again, it's the art of matching the dressing to the wound and then assessing it and trying to figure out the best combination and approach based on that particular patient and the response of their burn wound to each dressing. Even the same type of dressing produced by different manufacturers will respond differently to a given burn wound or a different patient." - Diane Merwarth, Physical Therapist, Wound Care Specialist

Antimicrobial Advanced Dressings for Burn Wound Care

Table 1. Antimicrobial advanced dressings (this is a limited list of available products on the market).

	Benefits	Risks	Burn-specific Considerations
Silver-Based	General silver-based dressings considerations: Multiple formulations and types of silver-based dressings are available Most silver-based dressings are effective for up to seven days	Cytotoxic to fibroblasts and keratinocytes, resulting in delayed re-epithelialisation	It is recommended that use is discontinued when signs / symptoms of infection are no longer present
	Nanocrystalline silver (Acticoat): broad spectrum for bacteria, yeast, and fungi	Can cause harmless and non-permanent skin staining (argyria) NOT compatible with MRI or radiation and must be removed prior to these procedures	Was developed specifically for the management of burn wounds
	Ionic silver: available in multiple forms of dressings (i.e. foams, hydrogels, hydrocolloids, etc.)		Each dressing type will perform differently on burn wounds
	Silver-based foam dressings: Non-adherent foams (Allevyn Gentle Ag, Mepilex Ag) Foam is pieced together and cut-to-fit to cover the burn wound surface	Slightly adherent to intact skin Tape use is not recommended due to poor adherence to foam and potential trauma to the periwound Mepilex Transfer Ag: minimal drainage will cause the dressing to adhere to the wound surface, causing potential damage to the wound bed	Bordered foam dressings (Allevyn Ag border, Mepilex Ag border) are NOT recommended for burn wounds
	Silver-based fabric-type dressings (TRITEC Silver, Assist Silver, Silverlon Wound & Burn Dressing) can be cut-to-fit to burn shape (except for Assist Silver) can be applied dry or moistened depending on the product used
	Collagen-ORC (oxidised regenerated cellulose) with silver: collagen facilitates granulation tissue formation indicated for acute AND chronic wounds
	Hydrofiber with silver HIGHLY absorbent		Has specific protocols for use
Gentian Violet/Methylene Blue Dressing	Less expensive than silver dressings		Limited evidence for use with burn wounds

Silver-based dressing protocols:

• most silver-based dressings are designed to manage moisture in the burn wound, but some require re-wetting (Acticoat, Silverlon), or can contribute to moisture in the burn wound (hydrogels)

Non-antimicrobial Advanced Dressings for Burn Wound Care

Non-antimicrobial advanced dressings are indicated for burns that are (1) nearing the end of their healing phase and / or (2) are superficial with a minimal infection risk. These dressings are designed to be left in place for several days to allow maximum opportunity for the patient's own body to heal in an uninterrupted, moist wound environment. Please see the resources section below for an optional additional video on non-antimicrobial dressing selection and types.

Non-antimicrobial advanced dressing options for burn wound care:

• alginates
• collagen-based products
• foams
• hydrocolloids
• hydrogels
• silicone sheets
• transparent films

Negative Pressure Wound Therapy for Burn Wounds

What is Negative Pressure Wound Therapy?

"Negative pressure wound therapy (NPWT) is a broad term used to describe a unique and versatile system that aids the optimization of wound healing through the application of sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue. It can be utilized to manage acute and chronic wounds, ranging from open fasciotomy wounds and diabetic foot ulcers to closed surgical incisions."

Application of NPWT is an advanced treatment method. Clinicians must have proper training and demonstrate competency prior to using NPWT as part of a wound therapy care plan. Please refer to local practice rights regarding the need for a medical doctor or advanced medical practitioner order for NPWT. As with all wound care treatment plans, NPWT requires thorough wound assessment prior to application and with each dressing change.

Indications for NPWT:

• complex wounds that are non-healing or at risk of non-healing
• acute wounds that cannot be closed by primary intention due to the risk of infection, active infection, skin tension, and / or oedma
• dehisced wounds
• to cultivate a healthy wound bed to improve the chance of a successful skin graft placement
• over surgically closed wounds via surgical procedure, skin flaps and/or grafts

Contraindications for NPWT:

• placement over exposed vasculature or organ surfaces
• placement over unexplored fistulae of unknown depth/route
• necrotic tissue or eschar present in the wound bed
• underlying malignancy
• active osteomyelitis should ideally be treated before initiating NPWT

NPWT is an emerging method of managing burn wounds and donor / recipient sites. However, it is used more extensively over new skin graft recipient sites than over the open burn wound injury itself. Recall that the standard of care in burn management is to close the burn wound via surgical procedure or / and skin graft placement.

Benefits of use of NPWT in burn wounds:

• facilitates a moist wound environment
• decreases tissue oedema
• increases blood flow to the wound
  • stimulates angiogenesis (the development of new blood vessels)
  • promotes granulation tissue formation

Due to the more aggressive nature of negative pressure therapy, specific treatment strategies are recommended for its use on burn wounds:

1. the use of a non-adherent layer between the wound surface and the NPWT foam to reduce tissue trauma and pain while the negative pressure is in place and during dressing changes
2. use of a lower pressure intensity than what is standard for non-burn-type wounds
3. use of anaesthesia or sedation during negative pressure dressing changes for adequate pain management

Clinical Pearl: Skin Grafts and Burn Wound Care

Skin grafting is a type of surgery which typically involves the surgical removal healthy skin from one part of the body that is then transplanted to another part of the body and used to close a clean open wound.

Two types of grafts are used to cover the wound bed:

1. Skin replacement is the application of healthy skin onto the wound bed and includes autograft (harvesting the patient's own healthy, intact skin) and allograft (skin graft donated from another person).
2. Skin substitute the application of biomaterial and engineered tissue graft

Skin grafts can be full-thickness skin grafts (FTSGs) or split-thickness skin grafts (STSGs).

• STSGs include the epidermis and upper layer of the dermis, and are the most commonly used for wound coverage

• FTSGs include the epidermis and dermis completely to the underlying fat layer.

Other important terms:

• Donor site: the surgical harvest location of healthy intact skin used to create a skin graft
• Graft site: the location of graft placement to close an open wound

Resources

Optional Additional Videos:

Please view this approximately 20-minute video (starting at 3:50) for a review of dressing selection and assessment and (starting at 9:55) non-antimicrobial dressing types. Please note that this video is not exclusive or specific to burn wound care.

Please view this 5-minute video for an overview of negative pressure wound therapy. This video also shows dressings used in negative pressure wound therapy.

Please view this 3-minute video to learn more about the physiological mechanisms of negative pressure wound therapy.