Burn Wound Injury Dressing Selection: Difference between revisions
No edit summary |
No edit summary |
||
Line 17: | Line 17: | ||
==== Current Standard of Care ==== | ==== Current Standard of Care ==== | ||
The current standard of care for large and deep burn wounds is (1) early surgical excision and (2) wound closure<ref>Merwarth, D. Management of Burn Wounds Programme. Introduction to Dressing Selection for Burn Wound Injuries. Physioplus. 2024.</ref> | The current standard of care for large and deep burn wounds is (1) early surgical excision and (2) wound closure<ref name=":1">Merwarth, D. Management of Burn Wounds Programme. Introduction to Dressing Selection for Burn Wound Injuries. Physioplus. 2024.</ref> | ||
* wound closure can be achieved by skin grafting or temporary biological coverage for deep partial and full thickness burns | * wound closure can be achieved by skin grafting or temporary biological coverage for deep partial and full thickness burns | ||
Line 32: | Line 32: | ||
# '''Grafting or skin substitutes 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. | # '''Grafting or skin substitutes 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 covered with a skin substitute will require ongoing dressing changes throughout the course of healing. | Burn wounds which (1) do not undergo surgical debridement, or that (2) underwent surgical debridement without application of a skin graft or temporary covered with a skin substitute will require ongoing dressing changes throughout the course of healing.<ref name=":1" /> | ||
== Role of Wound Dressings == | == Role of Wound Dressings == | ||
In all cases when burn wounds are not grafted immediately, routine burn wound care and dressing changes are needed. The determination of dressings and frequency of interventions is based on a variety of factors to be described below. | In all cases when burn wounds are not grafted immediately, routine burn wound care and dressing changes are needed. The determination of dressings and frequency of interventions is based on a variety of factors to be described below. <ref name=":1" /> | ||
'''Effective burn wound dressings provide the following''':<ref>Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T. [https://www.sciencedirect.com/science/article/pii/S2352556820300382#sec0210 Management of severe thermal burns in the acute phase in adults and children]. Anaesthesia Critical Care & Pain Medicine. 2020 Apr 1;39(2):253-67.</ref> | |||
'''Effective burn wound dressings provide the following''':<ref name=":1" /><ref>Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T. [https://www.sciencedirect.com/science/article/pii/S2352556820300382#sec0210 Management of severe thermal burns in the acute phase in adults and children]. Anaesthesia Critical Care & Pain Medicine. 2020 Apr 1;39(2):253-67.</ref> | |||
* Absorb and manage drainage | * Absorb and manage drainage | ||
* Minimise risk of [[Wound Care Terminology#B|burn wound conversion]] | * Minimise risk of [[Wound Care Terminology#B|burn wound conversion]] | ||
Line 51: | Line 52: | ||
<blockquote> | <blockquote> | ||
==== Clinical Pearl: Benefits of Moist Wound Healing ==== | ==== Clinical Pearl: Benefits of Moist Wound Healing ==== | ||
Multiple studies have demonstrated that 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: | Multiple studies have demonstrated that 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:<ref name=":1" /> | ||
* increases keratin migration and re-epithelialization | * increases keratin migration and re-epithelialization | ||
Line 68: | Line 69: | ||
==== Determining Dressing Change Frequency ==== | ==== Determining Dressing Change Frequency ==== | ||
Based on burn wound or patient status, and on type of dressing | Based on burn wound or patient status, and on type of dressing:<ref name=":1" /> | ||
* Status of burn wound (or patient) – daily or more than planned if: | * Status of burn wound (or patient) – daily or more than planned if: | ||
Line 146: | Line 147: | ||
!'''Burn-specific Considerations''' | !'''Burn-specific Considerations''' | ||
|- | |- | ||
|'''Silver sulfadiazine''' | |'''Silver sulfadiazine'''<ref>Oaks RJ, Cindass R. [https://www.ncbi.nlm.nih.gov/books/NBK556054/ Silver sulfadiazine]. StatPearls, 2022; NCBI Bookshelf (a service of the National Library of Medicine, NIH. © 2022, StatPearls LLC. Bookshelf ID: NBK556054PMID: 32310514</ref><ref name=":2">PATEL R, DESAI R, PATEL A, SHAH S, PRAJAPATI B, PATEL V, ALEXANDER A. [https://www.researchgate.net/profile/Bhupendra-Prajapati/publication/372422278_Burn_assessment_A_critical_review_on_care_advances_in_burn_healing_and_pre-clinical_animal_studies/links/64b90cc595bbbe0c6e4a4a9b/Burn-assessment-A-critical-review-on-care-advances-in-burn-healing-and-pre-clinical-animal-studies.pdf Burn assessment: A critical review on care, advances in burn healing and pre-clinical animal studies]. Journal of Research in Pharmacy. 2023 Jul 1;27(4).</ref> | ||
| | | | ||
* Effective against gram + or gram – bacteria, and some yeast | * Effective against gram + or gram – bacteria, and some yeast | ||
Line 163: | Line 164: | ||
* After debridement if graft and/or temporary coverage not performed | * After debridement if graft and/or temporary coverage not performed | ||
|- | |- | ||
|'''Mafenide acetate (sulfamyalon)''' | |'''Mafenide acetate''' <ref name=":2" />'''(sulfamyalon)''' | ||
| | | | ||
* Effective against gram + and gram – bacteria | * Effective against gram + and gram – bacteria | ||
Line 201: | Line 202: | ||
|Minimal evidence for use with burn wounds, however research shows positive outcomes on superficial partial thickness burns | |Minimal evidence for use with burn wounds, however research shows positive outcomes on superficial partial thickness burns | ||
|- | |- | ||
|'''Cadexomer Iodine''' | |'''Cadexomer Iodine'''<ref>Stuermer EK, Plattfaut I, Dietrich M, Brill F, Kampe A, Wiencke V, Ulatowski A, Geffken M, Rembe JD, Naumova EA, Debus SE. [https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2021.664030/full In vitro activity of antimicrobial wound dressings on P. aeruginosa wound biofilm]. Frontiers in Microbiology. 2021 May 14;12:664030.</ref> | ||
|Most effective against MSSA and MRSA | |Most effective against MSSA and MRSA | ||
| | | | ||
Line 235: | Line 236: | ||
<blockquote>"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</blockquote> | <blockquote>"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</blockquote> | ||
'''Blisters should be deroofed (unroofed) in the following situations''': | '''Blisters should be deroofed (unroofed) in the following situations''':<ref name=":1" /> | ||
# During surgical cleansing and debridement | # During surgical cleansing and debridement | ||
Line 244: | Line 245: | ||
#* Thick, cloudy or opaque fluid | #* Thick, cloudy or opaque fluid | ||
#* Bloody or discolored | #* Bloody or discolored | ||
'''Blisters should be left intact in the following situations''': | '''Blisters should be left intact in the following situations''':<ref name=":1" /> | ||
# If blisters are small and not disrupted | # If blisters are small and not disrupted | ||
# When not affecting function | # When not affecting function | ||
'''Blisters shoulder drained but NOT | '''Blisters shoulder drained but NOT deroofed in the following situations''':<ref name=":1" /> | ||
# Large taut blisters with clear fluid | # Large taut blisters with clear fluid |
Revision as of 03:52, 8 April 2024
Top Contributors - Stacy Schiurring and Jess Bell
This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (8/04/2024)
Burn Wound Injury Standard of Care[edit | edit source]
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
- Burn wound injury non-surgical debridement
Current Standard of Care[edit | edit source]
The current standard of care for large and deep burn wounds is (1) early surgical excision and (2) wound closure[1]
- wound closure can be achieved by skin grafting or temporary biological coverage for deep partial and full thickness burns
Alternatives to Early Excision/Grafting and Expections to Standard of Care[edit | edit source]
- Surgical debridement followed by wound cleansing and regular dressing changes
- preferred option for burns of indeterminate depth until burn depth determined
- can be the most appropriate option to allow healing of partial thickness burn size. This will allow for a smaller area of the burn wound will need a skin graft.
- 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
- Surgery not feasible due to patient status, or resource availability
- Grafting or skin substitutes 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 covered with a skin substitute will require ongoing dressing changes throughout the course of healing.[1]
Role of Wound Dressings[edit | edit source]
In all cases when burn wounds are not grafted immediately, routine burn wound care and dressing changes are needed. The determination of dressings and frequency of interventions is based on a variety of factors to be described below. [1]
Effective burn wound dressings provide the following:[1][2]
- Absorb and manage drainage
- Minimise risk of burn wound conversion
- Maintain a moist wound environment
- Minimise peri-wound maceration
- Prevent excessive evaporation from 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 edema
- Protect the wound
- Be careprovider 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[edit | edit source]
Multiple studies have demonstrated that 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:[1]
- increases keratin migration and re-epithelialization
- increases collagen synthesis
- increases autolytic debridement
- decreases necrosis
- decreases pain
- decreases inflammation
- decreases scarring
- facilitates cell-to-cell signaling
- provides means of delivering topical treatment
- improves wound aesthetics after healing
Determining Dressing Care Plan[edit | edit source]
Determining Dressing Change Frequency[edit | edit source]
Based on burn wound or patient status, and on type of dressing:[1]
- Status of burn wound (or patient) – daily or more than planned if:
- Dressing used is not antimicrobial, or agent has short-acting antimicrobial properties
- Verified or suspected infection
- Monitor for conversion
- Significant areas of undebrided eschar
- Drainage not contained by dressing
- Any other concerns
- Need to balance concern for wound and desire to leave wound undisturbed and not introduce risk for additional contamination
- Minimize risk of damage to healing tissue
- Type of dressing or topical agent
- Ability of dressing to maintain a moist environment
Determining Dressing and Topical Agent[edit | edit source]
- 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[edit | edit source]
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.
Benefits | Risks | |
---|---|---|
Saline |
|
|
Mafenide Acetate |
|
|
Sodium Hypochlorite[3] | broad spectrum |
|
Hypochlorous acid |
|
|
Povidone-Iodine[3] | broad-spectrum | cytotoxic at full strength |
Acetic acidvarious reports of strengths, 0.25% up to 5% |
|
Benefits | Risks | Burn-specific Considerations | |
---|---|---|---|
Silver sulfadiazine[4][5] |
|
Contra-indications:
|
Full and deep-partial thickness burns:
|
Mafenide acetate [5](sulfamyalon) |
|
|
|
Antibiotic ointments |
|
Change the antibiotic used or discontinue with clinical assessment which finds:
|
Recommended primarily for superficial partial thickness burn wounds |
Medical Grade honey |
|
Minimal evidence for use with burn wounds, however research shows positive outcomes on superficial partial thickness burns | |
Cadexomer Iodine[6] | Most effective against MSSA and MRSA |
Benefits | Risks | Burn-specific Considerations | |
---|---|---|---|
Polyhexamethylene biguanide[3] (PHMB)-impregnated dressing |
|
Recommended for superficial partial thickness burn wounds | |
Bismuth
(eg. Xeroform gauze) |
|
Contraindicated with allergy to Bismuth |
Burn Wound Injury Areas of Special Concern[edit | edit source]
Guidelines for Blister Management[edit | edit source]
"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
- When the blister itself is disrupted
- Now a portal for entry of microbes
- Risk of microbes trapped under loose skin
- When appearance is questionable
- Thick, cloudy or opaque fluid
- Bloody or discolored
Blisters should be left intact in the following situations:[1]
- If blisters are small and not disrupted
- When not affecting function
Blisters shoulder drained but NOT deroofed in the following situations:[1]
- Large taut blisters with clear fluid
- Blisters continuing to increase in size
- 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. [7]
Resources[edit | edit source]
- bulleted list
- x
or
- numbered list
- x
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Merwarth, D. Management of Burn Wounds Programme. Introduction to Dressing Selection for Burn Wound Injuries. Physioplus. 2024.
- ↑ Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T. Management of severe thermal burns in the acute phase in adults and children. Anaesthesia Critical Care & Pain Medicine. 2020 Apr 1;39(2):253-67.
- ↑ 3.0 3.1 3.2 Babalska ZŁ, Korbecka-Paczkowska M, Karpiński TM. Wound antiseptics and European guidelines for antiseptic application in wound treatment. Pharmaceuticals. 2021 Dec 2;14(12):1253.
- ↑ Oaks RJ, Cindass R. Silver sulfadiazine. StatPearls, 2022; NCBI Bookshelf (a service of the National Library of Medicine, NIH. © 2022, StatPearls LLC. Bookshelf ID: NBK556054PMID: 32310514
- ↑ 5.0 5.1 PATEL R, DESAI R, PATEL A, SHAH S, PRAJAPATI B, PATEL V, ALEXANDER A. Burn assessment: A critical review on care, advances in burn healing and pre-clinical animal studies. Journal of Research in Pharmacy. 2023 Jul 1;27(4).
- ↑ Stuermer EK, Plattfaut I, Dietrich M, Brill F, Kampe A, Wiencke V, Ulatowski A, Geffken M, Rembe JD, Naumova EA, Debus SE. In vitro activity of antimicrobial wound dressings on P. aeruginosa wound biofilm. Frontiers in Microbiology. 2021 May 14;12:664030.
- ↑ North Bristol NHS Trust. The de-roofing of burns blisters. Available from: https://www.mysurgerywebsite.co.uk/website/SWUK001/files/The%20De-roofing%20of%20Burns%20Blisters_NBT002996.pdf (accessed 2 April 2024).