SECTION V: DAILY CARE OF THE BURN WOUND

The topics in this chapter include:

1. General principles of Wound Care

2. Superficial to mid-dermal burns

3. Deep burns

4. Wound conversion

A. General Principles of Wound Care

There are a number of general rules regarding burn care that must be followed: 

First, cardiopulmonary monitoring should continue during burn care. The addition of medications for wound care itself can only lead to a potential for further instability.

Second, invasive catheters, such as vascular and urethral, must not become wet at the skin site or be submerged in water.  These catheters are at high risk for being a source of systemic infection.

Third, the patient must not be allowed to have a significant heat loss.  Overhead heaters, warm water, and the sequential management of the wounds, rather than total patient exposure, are methods to avoid heat loss.

Fourth, the risks of bacterial cross-contamination must be controlled.  Risks related to transmission from personnel are minimized by the wearing of caps, mask, gloves, and a gown.  Transmission from a dirty wound to a clean wound can be minimized by exposing and cleaning these areas separately.  Preferably, the less infected areas should be done first and closed before approaching dirtier areas. 

The fifth principle is that adequate stress management, analgesia and sedation, should be initiated before initiation of burn care.  It is much easier to control pain and anxiety by pretreatment than it is to treat once it develops.  Antipyretics given before burn care attenuate the fever seen after wound manipulation.  Pretreatment of the dressing change with an antipyretic such as Ibuprofen, is indicated in patients who demonstrate a marked temperature spike, i.e.,  >103ºF after wound care. 

The sixth principle is that motion should not be impaired (exception: a new graft).  The patient needs to maintain joint motion and muscle activity to avoid stiffness and atrophy.

General Principles of Daily Care

If conversion is going to occur, it is typically several days (sometimes weeks) post-burn

Continue monitoring if indicated Avoid hypothermia

- warm room - warm water - do not expose entire body at once

Avoid Cross-Contamination

- Wear caps, masks, gown, gloves wash hands before and after - Expose, clean, and rewrap less infected areas first - Look for sources of bacteria in equipment used

Assure Adequate Control of Pain, Anxiety, Fever

- Pre-indication with narcotics and short-acting sedative - Use intravenous route - Consider antipyretic pre-treatment pre-burn care

Wound Dressing

- Use comfortable but no immobilizing dressing, as muscle activity is important! (exception: new grafts)

 B. Superficial to mid-dermal burns

Loose epidermis and remaining blisters are debrided from the wound surface.  Areas such as the face and ears are then treated open, usually with an ointment such as bacitracin to maintain wound moisture as well as control the predominantly gram-positive bacteria.  The open areas are usually gently washed daily with a dilute chlorhexidine solution to remove crust and surface exudates.  Areas such as the hands, upper and lower extremities, and trunk can be treated with a grease gauze impregnated with antibiotic ointment, usually Bacitracin.  The grease gauze is covered with several layers of dry absorbant gauze.  If the grease gauze appears well adhered to the superficial wound with no underlying exudates, the gauze does not need to be changed, as is the case with a donor site dressing.  If some exudates is present, the dressing should be removed, the wound gently washed with dilute soap and the dressing reapplied.  Exceptions would be the dirty wound that has not been totally cleaned of initial dirt and debris or the perineal or buttock wound where a silver based topical antibiotic is usually required.

Managing the Dressing
Inspect daily If gauze adherent and no exudates, simply change outer dry gauze Change dressing, wash surface and reapply if exudates present Use topical antibiotic if infection considered
Areas Treated Open with Bacitracin
Reapply ointment two to three times daily Gently wash off crusts, exudates, especially on face and neck
Areas Covered with Temporary Skin Substitutes
Change outer dry gauze daily to remove collected exudates Roll out small pockets of exudates from beneath substitute Can leave open without dressing once  drainage has ceased if substitute well adhered Remove skin substitute if exudate extensive or if nonadherent with topical agent and change to grease gauze method Remove once wound reepithelialized
The mid-dermal burn is at higher risk of infection or conversion compared to the more superficial burn.  Skin substitutes appear to provide better wound protection then grease gauze but they are also more expensive.

C. deEp burns

Initial non-surgical management is debridement of loose dead tissue and application of a silver based cream or dressing.  If using the cream silver sulfadiazine the wounds need to be gentle washed daily with removal of old cream and reapplication of new cream followed by a secondary dressing. 

If using a typical silver dressing, with a constant silver release for 3-7 days, an outer secondary dressing change is all that is required.  Some silver dressings require application of water to release more silver but the actual silver dressing can remain in place for 3-7 days.

Early surgical excision and skin closure is recommended.

Deep burn cleaned	Dressed with topical antibiotic followed by gauze to close The wound and maintain warmth

Viable tissue should not be left exposed unless it is to be occluded by a graft or a skin substitute because desiccation of the tissue with reformation of eschar is likely to occur.  This daily care procedure can be performed with home care (if minor) at the bedside or on a slant board in a hydrotherapy tank, avoiding total body immersion.  The bedside approach is particularly useful for the critically ill patient.

Silver is released from a silver sulfadiazine cream only for a matter of hours.  Therefore, the cream needs to be reapplied at least once a day.
Silver is released from a silver sulfadiazine cream only for a matter of hours.  Therefore, the cream needs to be reapplied at least once a day
Flexnet is helpful to hold dressings on, thereby avoiding circumferential wrapping	Silver sulfadiazine is removed and replaced twice a day

Pseudo eschar is an adherent surface layer of exudates which adheres to the wound typically in deeper burns with the use of topical antibiotic creams.  This film is hard to get off and also hard to distinguish from the process of wound conversion.Pseudo eschar present on wound surface

Silver release dressings have the advantage of a steady silver release for days so there are fewer dressing changes needed and a pseudoeschar typically doesn’t develop.
Although infection is not particularly common in the first several days post burn (unless the burn was heavily contaminated or inadequately cleaned), the wound bacterial flora should be monitored with surface cultures.  Positive cultures do not mean infection.  Infection is usually diagnosed by changes in the wound, systemic signs and biopsy.   The information on the organisms however will assist in the assessment of the adequacy of the topical agent being used as well as provide epidemiologic information, especially important in controlling resistant hospital-based organisms.
Why is Surgery Preferred for Deep Dermal Burns? Primary healing of a deep dermal burn often leads to hypertrophic scar or skin breakdown, especially if the burn takes over 6 weeks to heal.

D. Wound conversion

This term refers to the dynamic process whereby the Zone of Injury progresses to the Zone of Tissue Necrosis thereby deepening the wound.  Conversion is more likely with a mid to deep dermal injury because of less blood flow, longer time to healing and increased risk of excess inflammation and infection.  Also environmental hazards can readily lead to conversion of an open wound.  This process is in large part preventable with newer methods of early wound closure and better control of wound inflammation using slow release silver dressings or skin substitutes.

RISK FACTORS FOR WOUND CONVERSION
LOCAL	SYSTEMIC
Impaired Blood Flow	Septicemia
Increased inflammation (Infection, open wound, irritants)	Hypovolemia
Surface desiccation	Excess catabolism
Surface exudates buildup	Chronic illness
Mechanical trauma (dressing changes, shearing	Diabetes
Chemical trauma –topical agents	Steroid Use

 

If conversion is going to occur, it is typically several days (sometimes weeks) post-burn

Sect. IVSect. VI