Burn Wound Treatment: Cleansing and Solutions
Top Contributors - Stacy Schiurring and Jess Bell
Introduction[edit | edit source]
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, including: (1) immunosuppression, (2) the extent of the burn wound, and (3) medical comorbidities.
"Burn wound cleansing is an integral step in every wound management protocol. Yet a lot of this practice is based on myth rather than real scientific basis."
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. This article will explore the available literature and provide the best available evidence for burn wound management and cleansing recommendations.
Burn Wound Cleansing[edit | edit source]
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.
Burn wounds are much more fragile when compared to other wound types. Newly formed epithelium and the new onset of growing epithelium from the wound margins can easily be damaged. Therefore, a more gentle mechanical force is required when cleaning a burn wound.
Infection in a burn wound can also negatively affect the growing epithelium and granulation tissue and stop the healing progress. When a burn wound is visibly infected or infection is confirmed by laboratory findings, it is appropriate to use a slightly more aggressive approach to wound cleansing and topical agents. However, once the infection is under control, return to more gentle cleansing and less cytotoxic topical agents, which encourage the burn wound to progress to healing.
Client pain management is vital for effective and thorough wound cleansing. Fear of pain during wound care is often a top concern for clients.
Every client has the right to proper pain management, this can be remembered using the "six-Cs". Every client deserves:
- to be Checked for pain before, during and after the treatment
- to have the Cause of their pain determined
- to have the Consequences of treatment explained
- to have adequate pain Control
- to have the ability to Call time-outs during procedures
- to have Comfort
It is important to properly document pain management and pain ratings in the medical record. To learn more in-depth information about pain mechanisms, please read this article. To read more about general pain assessment techniques, please read this article.
Goals of Wound Cleansing[edit | edit source]
- To minimise the risk of wound infection by removing potential sources of contamination from the wound surface.
- To remove any residual topical agents and drainage that has been collecting on the wound surface since the last dressing change because they can create an environment for microbial growth.
- To remove any debris or loose, non-viable tissue from the surface of the wound to decrease infection risk. The presence of non-viable tissue can also slow down the healing process.
- To provide a clean environment for more reliable would culture sample or biopsy collection.
- To hydrate the surface of the wound, which can help preserve tissue viability and encourage further wound healing.
Wound Cleansing Considerations[edit | edit source]
- Sterile versus non-sterile solution. There is not strong literature support on the use of sterile versus non-sterile solutions to clean the wound. Rather, the decision should be based on the wound care professional's wound assessment and clinical judgement.
- Volume. An adequate amount of solution must be used to effectively clean a burn wound. However, there is not a defined volume identified in the literature. Enough solution should be used to thoroughly clean the wound surface.
- Force. When cleansing a burn wound with mechanical force, either manually or with a device, ensure that the force is appropriate for that wound using clinical judgement. The literature does not define the amount of force needed to properly clean a burn wound.
- Temperature. Solutions should be warmed to room temperature or slightly warmer. Typically, temperatures range from low to mid 90oF (32-35oC).
- Aseptic technique. Use aseptic (clean) technique with appropriate personal protective equipment (PPE).
- Periwound. It is important to properly cleanse the periwound area because any skin under the dressing has the potential to spread unwanted bacteria into the burn wound. Proper cleansing and moisture barrier protection will also prevent periwound maceration and irritation.
The following optional video provides a simple demonstration of bedside aseptic technique.
Wound Cleansing Strategies: Hydrotherapy[edit | edit source]
Water can be used in many different ways to treat medical conditions. According to the Centers for Disease Control and Prevention (CDC), "hydrotherapy involves the use of water for soothing pains and treating certain medical conditions" using equipment ranging in size from swimming pools to whirlpool tanks.
Hydrotherapy has a been a part of burn wound care since the 17th century. It can be performed by various methods, such as: immersion, shower, bedside irrigation or wiping. Despite its long history of use, there continues to be controversy around the most optimal method for cleansing burn wound injuries, and further research and clinical studies are needed. Due to the lack of evidence-based recommendations, most burn treatment centres are guided by a wound care professional's clinical experience. According to a study published in 2022, there are no current recommendations for the daily use of hydrotherapy for burn wound treatment. This study also points out that some research authors do not consider hydrotherapy as part of normal routine burn care mainly due to the risk of infection transmission when proper cleaning and preparation precautions are not observed.
Whirlpool Tank Immersion[edit | edit source]
Whirlpool therapy (WP therapy) can be used to treat burn wounds in need of extensive debridement. This cleansing strategy can utilise water jet agitation. The addition of antimicrobial agents further aide in cleansing and mechanical debridement. A full-body tank, such as a Hubbard tank, or a smaller extremity tank can be selected based on the location of the wound.
- effectively cleans the surface of the burn wound when using properly cleaned equipment; this process can be increased with use of the whirlpool turbine to agitate the water to provide mechanical debridement
- thoroughly hydrates the burn wound
- increases local circulation
- decreases wound pain
- decreases fever
- helps soak and gently remove dressings
- ultimately accelerates healing
- physiologically taxing on the patient
- patient can develop hypothermia very quickly after coming out of the warm water
- there is significant risk of infection, especially with full body immersion when using improperly cleaned equipment
- risk of infection from equipment - biofilms can form on whirlpool equipment or in water pipes and allow bacteria to evade antiseptics, antimicrobials, and even the most rigorous sterilisation procedures
The following optional video provides a brief overview on the formation and dispersion of biofilms.
Showering[edit | edit source]
This method involves exposing the burn wound to running water in a shower setup. A slightly cooler water temperature should be used during this method of burn wound cleansing. It is recommended that the room temperature be warm to protect the client from getting too cold due to the risk of hypothermia.
- less physiologically stressful than immersion method
- minimises the risk of cross-contamination
- hypothermia risk
- aggressive force of water hitting wound bed from shower head
- to modify the force, allow the water spray to hit the intact skin and run over the surface of the wound to flush that wound of contaminants
- risk of infection from equipment due to presence of biofilms, however the risk is less than the immersion method
Modifications and Considerations:
- in situations where there is limited or no access to a shower, the cleansing solution can be poured over the burn wound from a properly disinfected glass or metal vessel
- the immersion method can be followed up with a shower to remove any potential contaminates
- when selecting bathroom equipment, select simple equipment which is easy to disinfect - use single use disposable sheets and drapes
Soaking and Wiping[edit | edit source]
This technique is common in clinical practice. Soaking is performed by saturating sterile gauze or cloth with a cleansing solution, then covering the entire surface of the burn wound. There is not a determined amount of time for soaking, rather it is based on the wound care professional's wound assessment findings and clinical judgement. The wound surface is then wiped to perform mechanical debridement. Research has found that the mechanical force needed to remove surface debris from a non-burn wound without causing tissue damage ranges from 4 to 15 pounds per square inch (psi). There is no defined pressure for a burn injury.
This method is very effective for small burn wounds, superficial partial thickness burn wounds, or well healing burn wound injuries that require only light pressure for cleansing to protect new healing epithelium.
- soaking provides hydration to the wound
- use of antimicrobial agent decreases risk of cross-contamination
- mechanical debridement of wiping removes contamination, slough, and debris from the wound surface
- difficult to maintain consistent force when wiping the wound's surface
Wound Cleansing Solutions and Additives[edit | edit source]
Cleansing Solutions[edit | edit source]
Common cleansing solutions include:
- sterile saline
- sterile water
- distilled water
- potable water
- commercially available wound cleansers
These listed cleansers are considered to be non-antimicrobial, inert, and non-cytotoxic cleansing solutions. They all require some mechanical force to be effective in cleaning the burn wound surface.
What the research says: use of water in wound cleansing
A 2022 Cochrane Review attempted to assess the effects of water for wound cleansing. The review looked at studies which compared wound cleansing with tap water, cooled boiled water, distilled water, and normal saline.
- Cleansing with tap water may make little or no difference to wound healing compared with no cleansing; there is no data relating to the impact on wound infection.
- The effects of cleansing with tap water, cooled boiled water or distilled water compared with cleansing with saline are uncertain, as is the effect of distilled water compared with cooled boiled water.
- Data for other outcomes are limited across all the comparisons considered and are either uncertain or suggest that there may be little or no difference in the outcome.
While various cleansing solutions are available, normal saline is often preferred as it does not interfere with the normal healing process. However, tap water is commonly used in community settings and in low resource areas for cleansing wounds because it is "easily accessible, efficient and cost‐effective." Unfortunately there continues to be unresolved debate about its use and further research is indicated.
Clinical Applications: In places that rely on well water, or other water sources that may be contaminated, it is important to first boil the water and let it cool before using it to cleanse a wound. According to the World Health Organization, in 2020, 2 billion people without safely managed water services included:
- 1.2 billion people with basic services, meaning an improved water source located within a round trip of 30 minutes
- 282 million people with limited services, or an improved water source requiring more than 30 minutes to collect water
- 368 million people taking water from unprotected wells and springs
- 122 million people collecting untreated surface water from lakes, ponds, rivers and streams
Potable water sources in low- to middle-income countries (LMICs) may contain pathogenic bacterial flora, and the use of untreated tap water for wound cleansing may expose the wound to infection sources.
Topical antimicrobial agents[edit | edit source]
Antimicrobials are a group of agents and substances which reduce the possibility of infection and sepsis:
- Antibiotics are naturally derived from other microorganisms or synthetically created agents which are absorbed into the body for the purpose of killing or preventing bacterial multiplication. These substances can be given parenterally (intramuscularly, intravenously), orally, or applied topically to the skin.
- Antiseptics are chemical agents that slow or halt the growth of microorganisms on external body surfaces, including wounds, and aid in preventing infection. These substances are non-damaging to living tissue and skin. When applied to the skin, antiseptics are not absorbed in a significant quantity into the body.
- Disinfectants destroy microorganisms on non-living objects or surfaces.
- Antifungals agents slow or halt the growth of fungi, including yeasts. These substances can be given intravenously, orally or topically.
The purpose of topical antimicrobial agents is to decrease the bioburden on the surface of the burn wound. They are used for their biocidal effect on bacteria, fungi, parasites, and viruses.
Indications for use[edit | edit source]
Guidelines for when to use a topical antimicrobial or antiseptic agent:
- patients with a high risk of infection
- patients who are showing clinical signs of a local infection (this can be used in combination with a systemic antibiotic in the event of a spreading or systemic infection)
- wounds with an assumed or known biofilm formation (can also be used in combination with surgical debridement and systemic antibiotics)
Guidelines for selecting a topical antimicrobial agent:
- it should be broad spectrum
- it should have a known efficacy of treatment against suspected or known infection sources in the burn wound
- it should have no or low cytotoxicity to the healthy wound bed
- it should be not irritating the patient
- the patient should have no known allergy to any of the agent's components
- it should be fast acting and long lasting
- should have no or low known bacterial resistance to the agent
- it needs to be locally available
- has guidelines for use in clinical practice
The burn wound should be reassessed with each dressing removal and change, and the treatment plan of care adjusted as appropriate.
Special Topic: Cytotoxicity refers to the ability of a substance or process to damage cells and cause cell death, including the death of healthy cells and viable tissue in a wound bed.
When treating a significant infection, it can be more important to kill the invading bacteria at the risk of some healthy cell loss before the infection can become established. Infection in a wound bed will disrupt the expected wound healing process, destroy healthy viable tissue in the wound bed, and cause the wound to deteriorate. The wound care professional must be able to find a balance between initial viable tissue damage due to the cytotoxicity of the topical antimicrobial agent and allowing the infection to take hold, cause damage and delay wound healing and closure.
List of Topical Agents[edit | edit source]
Below is a non-exhaustive list of common of topical agents.
Burn Wound Cleansing Solutions:
|Mafenide acetate (Sulfamyalon)||5% solution||
||Its use is associated with a risk of developing metabolic acidosis, particularly in patients who are in respiratory distress|
|Povidone iodine (Betadine)||
|Hypochlorous acid||A super-oxidised solution (meaning it contains hypochlorous acid and sodium hypochlorite. These solutions are naturally acidic due to increased hydrogen ions)||
|Sodium hypochlorite (Dakin's Solution)||
||The original Dakin's formula is extremely cytotoxic|
Other cleansers and additives to consider:
|Polyhexamethylene biguinide (PHMB)||Used as an additive to dressings, gauze dressings and foam dressings rather than as a cleansing agent||
|Chlorhexidine||Contains surfactant||Allows for a good mechanical cleaning of the surface of the wound||
|Commercial wound cleansers||Most have an added surfactant||Most are antimicrobial||
Wound Cleansing Frequency[edit | edit source]
Considerations when determining wound cleansing frequency:
- Time-dependence. Do the topical agents contain sustained-released or time-released antimicrobial products? The product insert will provide more information.
- Drainage. The amount of drainage dictates the frequency of wound cleansing and required dressing changes, at least twice a day (BID) with increased drainage.
- Infection. Infected wounds require more frequent cleanings and dressing changes, at least twice a day with increasing signs of infection. Severe signs of infection require more frequent changes such as every 4-6 hours (q 4-6 hours).
- Location. The frequency of dressing changes may vary between different parts of the body, even on the same patient.
Reassessing the burn wound injury with each cleansing and dressing change will dictate the treatment interventions, cleansing frequency, and topical agents and dressing selection. This plan may be adjusted as the picture of the burn wound changes with each wound care treatment.
Resources[edit | edit source]
Optional Additional Recommended Reading:
- Fernandez R, Green HL, Griffiths R, Atkinson RA, Ellwood LJ. Water for wound cleansing. Cochrane database of systematic reviews. 2022(9).
- Tiglis M, Peride I, Neagu TP, Raducu L, Lascar I. Hydrotherapy in burn care: Pros, cons and suggestions. Romanian medical JouRnal. 2022 Jan 1;69(1):15.
- Vinaik R, Barayan D, Shahrokhi S, Jeschke MG. Management and prevention of drug resistant infections in burn patients. Expert review of anti-infective therapy. 2019 Aug 3;17(8):607-19.
References[edit | edit source]
- ↑ Markiewicz-Gospodarek A, Kozioł M, Tobiasz M, Baj J, Radzikowska-Büchner E, Przekora A. Burn wound healing: clinical complications, medical care, treatment, and dressing types: the current state of knowledge for clinical practice. International Journal of Environmental Research and Public Health. 2022 Jan 25;19(3):1338.
- ↑ Hayek S, El Khatib A, Atiyeh B. Burn wound cleansing-a myth or a scientific practice. Annals of burns and fire disasters. 2010 Mar 3;23(1):19.
- ↑ 3.0 3.1 Rodeheaver GT, Ratliff CR. Wound cleansing, wound irrigation, wound disinfection. InChronic wound care: A clinical source book for healthcare professionals 1997 (pp. 97-108). Health Management Publications, Wayne, Pa.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 4.32 Merwarth, D. Management of Burn Wounds Programme. Burn Wound Cleansing and Solutions. Physioplus. 2023.
- ↑ 5.0 5.1 5.2 Sibbald RG, Elliott JA, Persaud-Jaimangal R, Goodman L, Armstrong DG, Harley C, Coelho S, Xi N, Evans R, Mayer DO, Zhao X. Wound bed preparation. World Council of Enterostomal Therapists Journal. 2022 Mar 1;42(1):16-28.
- ↑ YouTube. Aseptic Technique | Grampians Health Ballarat. Available from: https://www.youtube.com/watch?v=VDngeM2NzPA&t=64s [last accessed 28/March/2023]
- ↑ Centers for Disease Control and Prevention. Water Use in Hydrotherapy Tanks. Available from: https://www.cdc.gov/healthywater/other/medical/hydrotherapy.html (accessed 21 March 2023).
- ↑ 8.0 8.1 Vinaik R, Barayan D, Shahrokhi S, Jeschke MG. Management and prevention of drug resistant infections in burn patients. Expert review of anti-infective therapy. 2019 Aug 3;17(8):607-19.
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Tiglis M, Peride I, Neagu TP, Raducu L, Lascar I. Hydrotherapy in burn care: Pros, cons and suggestions. Romanian medical JouRnal. 2022 Jan 1;69(1):15.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 Tao H, Butler JP, Luttrell T. The role of whirlpool in wound care. Journal of the American College of Clinical Wound Specialists. 2012 Mar 1;4(1):7-12.
- ↑ YouTube. Biofilm | The city of Microbes | Microbiology | Bacteriology | Cell Biology | Basic Science Series. Available from: https://www.youtube.com/watch?v=0Q4idjM4wfk [last accessed 28/March/2023]
- ↑ 12.0 12.1 12.2 Fernandez R, Green HL, Griffiths R, Atkinson RA, Ellwood LJ. Water for wound cleansing. Cochrane database of systematic reviews. 2022(9).
- ↑ The World Health Organization. Drinking-Water. Available from: https://www.who.int/news-room/fact-sheets/detail/drinking-water (accessed 29/March/2023).
- ↑ Nagoba BS, Suryawanshi NM, Selkar SP. Cleansing of wounds by tap water? Would it be safe to use in developing countries?. International Wound Journal. 2016 Oct;13(5):1071.
- ↑ 15.0 15.1 15.2 15.3 15.4 Nankervis H, Thomas KS, Delamere FM, Barbarot S, Rogers NK, Williams HC. Antimicrobials including antibiotics, antiseptics and antifungal agents. InScoping systematic review of treatments for eczema 2016 May. NIHR Journals Library.
- ↑ DermNet. Antiseptics. Available from: https://dermnetnz.org/topics/antiseptic (accessed 26 March 2023).
- ↑ Suzuki JB, Misch CE. Periodontal and maintenance complications. InMisch's Avoiding Complications in Oral Implantology 2018 Jan 1 (pp. 771-826). Mosby.
- ↑ 18.0 18.1 18.2 18.3 18.4 Sibbald RG, Elliott JA, Verma L, Brandon A, Persaud R, Ayello EA. Update: topical antimicrobial agents for chronic wounds. Advances in skin & wound care. 2017 Oct 1;30(10):438-50.
- ↑ Halstead FD, Rauf M, Moiemen NS, Bamford A, Wearn CM, Fraise AP, Lund PA, Oppenheim BA, Webber MA. The antibacterial activity of acetic acid against biofilm-producing pathogens of relevance to burns patients. PloS one. 2015 Sep 9;10(9):e0136190.
- ↑ 20.0 20.1 Gray D, Foster K, Cruz A, Kane G, Toomey M, Bay C, Kardos P, Ostovar GA. Universal decolonization with hypochlorous solution in a burn intensive care unit in a tertiary care community hospital. American Journal of Infection Control. 2016 Sep 1;44(9):1044-6.
- ↑ Haesler E. Evidence Summary: Super-oxidised solutions for chronic wounds. Wound Practice & Research: Journal of the Australian Wound Management Association. 2020 Sep 1;28(3):145-7.
- ↑ Levine JM. Dakin’s solution: past, present, and future. Advances in skin & wound care. 2013 Sep 1;26(9):410-4.
- ↑ Heggers JP, Sazy JA, Stenberg BD, Strock LL, McCauley RL, Herndon DN, Robson MC. Bactericidal and wound-healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award. The Journal of burn care & rehabilitation. 1991 Sep 1;12(5):420-4.