WOUND CARE

WOUND CARE – First Aid, Initial Treatment, Daily Treatment, Healing Phase and Wound Care Methods

First Aid

If the patient arrives at the health facility without first aid having been given, drench the burn thoroughly with cool water to prevent further damage and remove all burned clothing.
If the burn area is limited, immerse the site in cold water for 30 minutes to reduce pain and edema and to minimize tissue damage
If the area of the burn is large, after it has been do used with cool water, apply clean wraps about the burned area (or the whole patient) to prevent systemic heat loss and hypothermia
Hypothermia is a particular risk
First 6 hours following injury are critical; transport the patient with severe burns to a hospital as soon as possible

Initial Treatment

Initially, burns are sterile. Focus the treatment on speedy healing and prevention of infection
In all cases, administer tetanus prophylaxis
Except in very small burns, debride all bullae. Excise adherent necrotic (dead) tissue initially and debride all necrotic tissue over the first several days
After debridgement, gently cleanse the burn with 0.25% (2.5 g/liter) chlorhexidine solution, 0.1% (1 g/liter) cetrimide solution, or another mild water-based antiseptic.
Do not use alcohol-based solutions
Gentle scrubbing with remove the loose necrotic tissue. Apply a thin layer of antibiotic cream (silver sulfadiazine)
Dress the burn with petroleum gauze and dry gauze thick enough to prevent seepage to the outer layers

Daily Treatment

Change the dressing daily (twice daily if possible) or as often as necessary to prevent seepage through the dressing. On each dressing change, remove any loose tissue.
Inspect the wounds for discoloration or hemorrhage, which indicate developing infection
Fever is not a useful sign as it may persist until the burn wound is closed
Cellulitis in the surrounding tissue is a better indicator of infection
Give systemic antibiotics in cases of hemolytic streptococcal wound infection or septicemia
Pseudomonas aeruginosa infection often results in septicemia and death. Treat with systemic aminoglycosides
Administer topical antibiotic chemotherapy daily. Silver nitrate (0.5% aqueous) is the cheapest, is applied with occlusive dressings but does not penetrate eschar. It depletes electrolytes and stains the local environment
Use silver sulfadiazine (1% miscible ointment) with a single layer dressing. It has limited eschar penetration and may cause neutropenia
Mafenide acetate (11% in a miscible ointment) is used without dressings. It penetrates eschar but causes acidosis. Alternating these agents is an appropriate strategy
Treat burned hands with special care to preserve function

Cover the hands with silver sulfadiazine and place them in loose polythene gloves or bags secured at the wrist with a crepe bandage;

Elevate the hands for the first 48 hours, and then start hand exercises;

At least once a day, remove the gloves, bathe the hands, inspect the burn and then reapply silver sulfadiazine and the gloves;

If skin grafting is necessary, consider treatment by a specialist after healthy granulation tissue appears

Healing Phase

The depth of the burn and the surface involved influence the duration of the healing phase. Without infection, superficial burns heal rapidly
Apply split thickness skin grafts to full-thickness burns after wound excision or the appearance of healthy granulation tissue
Plan to provide long-term care to the patient
Burns scars undergo maturation, at first being red, raised and uncomfortable. They frequently become hypertrophic and form keloids. They flatten, soften and fade with time, but the process is unpredictable and can take up to two years

In Children

The scars cannot expand to keep pace with the growth of the child and may lead to contractures
Arrange for early surgical release of contractures before they interfere with growth
Burn scars on the face lead to cosmetic deformity, ectropion and contractures about the lips. Ectropion can lead to exposure keratitis and blindness and lip deformity restricts eating and mouth care
Consider specialized care for these patients as skin grafting is often not sufficient to correct facial deformity

OTHER WOUND CARE METHODS

Exposure method: leaving a burn open is a poor option but where dressings are not possible it may be the only option. The patients is washed daily and kept of clean dry sheets with another sheet or mosquito net draped over a frame to reduce the pain from air currents and to reduce contamination from the environment. Ambient temperature control is important to maintain normothermia. Exposure is less painful for full-thickness burns than for partial thickness burns but has little else to recommend it

Tubbing: most modern burns units avoid the regular immersion of patients in water both because they practice early excision and grafting and because of the high-risks developing resistant strains of bacteria in the tub environment and of patient cross-infection. That said, tubbing can be helpful to clean the wounds and gently remove eschar as it separates. When early wound infections develop suspect the tub! Avoid the routine immersion of infected patients in filthy bathtubs of cold water on the basis of ignorance and tradition

Bland dressings: these provide a clean, moist wound healing environment, absorb antibiotic dressings. Where antibiotic dressings are scarce bland dressings are a very acceptable solution for burns. Expensive topical antibiotic dressings may be reserved for infected wounds. Paraffin gauze is widely available and can be manufactured locally. Honey and Ghee dressings were first advocated in Ayurvedic texts to thousand years ago and remain an excellent choice for bland burn dressings. Mix two parts honey with one part Ghee (clarified butter) and pour over a stack of gauze dressings in a tray. Cover and store. Vegetable oil or mineral oil may be substituted for Ghee. Gauze sheets can be applied directly to the wound in a single layer and covered with plain dry gauze to absorb exudates, then wrapped. Dressings should be changed at least every second day, or when soiled.

Antimicrobial dressing: there exist numerous topical antimicrobial agents that are effective in delaying the onset of invasive wound infections, but none prevent them entirely. This is why they must be used in conjunction with a goal of early surgical wound closure when possible. A brief review of the agents most likely to be available to low and middle income countries will follow. There are also alternative synthetic wound coverings and newer silver-ionized agents that can be used; however they are often very costly and inaccessible in low-income countries. A more detailed review, as well as instructions for preparations, can be found in these references

BURN WOUND DRESSINGS

Antimicrobial Salves

Silver sulfadiazine (flamazine, silvadene) – broad-spectrum antimicrobial, painless and easy to use, does not penetrate eschar, deeply may leave black tattoos from silver ion; mild inhibition of epithelialization

Mafenide acetate (sulfamylon) – broad-spectrum antimicrobial; penetrates eschar well; may cause pain in sensate skin; wide application causes metabolic acidosis, therefore only suitable for small areas; mild inhibition of epithelialization

Bacitracin – ease of application; painless; antimicrobial spectrum not as wide as above agents

Neomycin – ease of application; painless; antimicrobial spectrum not as wide

Polymycin B – ease of application; painless; antimicrobial spectrum not as wide

Nystatin (mycostatin) – effective in inhibiting most fungal growth; cannot be used in combination with mafenide acetate

Mupirocin (bactroban) – more effective staphylococcal coverage; does not inhibit epithelialization; expensive

Antimicrobial Soaks

0.5% silver nitrate – effective against all microorganisms; stains contacted areas; leaches sodium from wounds; may cause methemoglobinemia

5% mafenide acetate – wide antibacterial coverage; no fungal coverage; painful on application to sensate wound; wide application associated with metabolic acidosis, and therefore generally used for small high-risk areas such as cartilage coverage in nose and ears

0.025% sodium hypochlorite (Dakin solution) – effective against all microbes, particularly gram-positive organisms, mildly inhibits epithelialization

0.25% acetic acid – effective against most organisms, particularly gram-negative ones; mildly inhibits epithelialization

Synthetic Coverings

Opsite – provides a moisture barrier; inexpensive; decreased wound pain; use complicated by accumulation of transdate and exudates requiring removal; no antimicrobial properties

Biobrane – provides a wound barrier; associated with decreased pain; use complicated by accumulation of exudates risking invasive wound infection; no antimicrobial properties

Transcyte – provides a wound barrier; decreased pain; accelerated wound healing; use complicated by accumulation of exudates; no antimicrobial properties

Integra – provides complete wound closure and leaves a dermal equivalent; sporadic take rates; no antimicrobial properties. Allows for coverage with a very thin skin graft with no dermis; very expensive product

Biologic Coverings

Xenograft (pig skin) – completely closes the wound; provides some immunologic benefits; must be removed or allowed to slough

Allograft (homograft, cadaver skin) – provides all the normal functions of skin; can leave a dermal equivalent; epithelium must be removed or allowed to slough

SURGICAL TREATMENT OF BURNS/PLASTIC SURGERY FO BURNS OR WOUNDS

Urgent Procedures