Burn wound dressings

1. BURNS
DRESSINGS

2. Burns
Devastating incident with prolonged outcome with respect to
• Wound healing.
• Repeated infections.
• Prolonged hospitalization.
• Morbidity /mortality.
• Physical handicapped.
• Mental/psychological disturbances .
• Additional morbidity to patients (donor areas )
• Surgeon challenges with respect to closure of wounds /donor areas
• Once the initial resuscitation of burns patient done , focus shifts onto
wound management.

3. Classification of burn wounds

5. Local appearance of burn wounds
• Extensive burnt raw areas/blisters.
• Exudates containing serum/tissue fluids
• Dry Eschar wounds.(3rd degree burns)
• Pus /slough (infected wounds) .
• Surrounding skin erythema.
• Thrombosis of superficial veins.
• Singeing of hairs.
• Extremely Painful

6. Aim of burns dressings
• Proper covering of the burn wound.
• Prevent dryness of the wound by providing moisture
• Reduce the pain
• Reduce contamination of wound/bacterial invasion
• Reduce evaporative losses
• Joint should be immobilized to prevent contractures..

7. Principles of burns dressings
4 basic principles-
• Desiccated wound needs to be kept moist.
• Excess exudate need to be absorbed
• Slough/pus/necrotic tissue to be removed by
autolytic/chemical/surgical removal.
• Infected wound needs to be tackled- topical or
systemic antibiotics.

8. What makes the dressing material
IDEAL
• Provide moist environment.
• Effective barrier for microbes/foreign bodies.
• Prevent body tissue fluid loss
• Allows gaseous exchange
• Protect against shearing forces(adhesive)
• Non traumatic / non irritant
• Eliminate dead space.
• Helps in early epithelization.
• Easy for application
• Cost effective

9. Initial care of wound
• Immediate after burns wound is sterile.
• Hydrotherapy- wound washed with running water / normal
saline.
• Encircling objects/ornaments should be removed.
• Blisters- ruptured/deroofed/aspirated.
• managed later with either exposure mtd(open
technique)/closed mtd

10. Open method of dressings
• Introduced by Wallace 1948.
• Face/neck/perineum wounds treated by this
mtd.
• Used in >90% non salvageable pts .
• Wound left open->exudates dries up-> forms a
coating over wounds->prevents bacterial
colonization underneath
• Paraffin wax impregnated gauzes can be
placed on the wound

11. Advantages
• Less man power/less materials/easy wound
examination-re-assessment/early physiotherapy
Disadvantages
• Wound kept dry delayed epithelization.
• Over the joint repeated break in epithelium/scab
causes bleeding.
• Eschar takes long time to separate.
• Unsighty and uncomfortable for patient and
attenders.
• Evaporative loss increases->shock
• Hypothermia .

12. Bed side conventional dressings
• It can be dry or wet , used in full thickness wounds
• Should contain first layer of antimicrobials
• Second layer of mesh/non adherent gauze
• Third layer of absorbent ->gamzee/pads.
• In dry technique- Simple gauze can be used which is easily
available/inexpensive/highly absorbent.

13. Bed side conventional dressings
• In wet technique- saline with gauze or paraffin
wax/jellonet/tulli-grass/bacti-grass can be used
– Keeps the wound moist .
– Easy to remove doesn’t adhere to tissues.
– Does not damage underlying new epithelium
• Disadvantage
– porus/permiable to exogenous bacteria and high
infection rates
– Repeated changing in heavy exudative wounds

15. Topical antimicrobials used in burn
wounds .
• History- variety of local medications used in past.
 Tincture(600 B.C)
 vinegar soaked dressing (430 BC)
 greasy dressing(1596)
 tannic acid by Edward Davidson (1904)
 Gentian violet by Aldridge in 1933
 Petroleum gauze -Harvey Allen in 1942.
 Carbolic acid, mercurial compounds and aniline dyes
were used as inner layer of burn dressing( WW-2 )

16. Ideal topical antimicrobial agent
• Should have broad spectrum antimicrobial property
especially effective against
psuedomonas/staphaylococcus/klebshiella/enterococci.
• Penetrate eschar
• Less systemic absorption.
• Non allergic/irritant.
• Effective –minimal emergence of resistance.
• Cost effective.
• Minimal side effects.
• Easy application.

17. Silver sulphadiazene
• Synthesized by Fox-1968
• White crystalline, insoluble,water based 1% cream.
• Most commonly used topical agent.
• MOA-silver ion and sulfadiazene moeity released at
the wound site.silver ions destroy bacterial cell wall
,also damages DNA directly
• Sulfadiazene-PABA inhibitor,interupts bacterial
replication.
• Primary bacteriostatic,delayed colonization by 2
weeks
• Effective against Gm positive/negative/anerobes.

18. • Advantages
– Easy application
– Reduces pain, intermidiate eschar penetration
– Minimal systemic absorption
– Less incidence of resistance
• Disadvantages
– Transient leucopenia.
– Metheamoglobinemia(sulpha moiety)
– Neoepithelial damage
– Hypersensitivity reactions

19. Silver nitrate
• Used during WW-2 (10% solution)->toxicity.
• Recent years - 0.5% solution used
• MOA- similar to SSD, action is by Silver Ion.
• Bacteriostatic ,Effective against –Gm neg.
• 6-8 layer dressing done after wash and
Dressing to be soaked once in 2-3 hrs with
silver nitrate.

20. • Advantages
– Less evaporative loss/ wound kept moist.
– Early granulation because of early separation of
eschar/necrotic tissue.
– Painless
– Less resistance
• Disadvantages
– Inability to penetrate.
– Precipitation into silver chloride/sulpide ->staining
– Distilled water use as vehicle for application-
>dyselectrolytemia.
– Enterobacter species ->metabloise nitrate to nitrite and
cause metheamoglobinemia

22. Mefenide (11.1%)
• Methylated sulfonamide introduced in 1964
• Effective against psuedomonas,clostridium and
gm neg organisms and minimal antifungal
activity.
• Good penetration in eschars. Applied twice daily.
• Occlusive dressings not advised.
• Significant carbonic anhydrase inhibition property
• Banned in many countries due to its toxicity

23. • Advantage
– Effective in established wound infection
– Eschar penetration
• Disadvantage
– Significant pain.
– Metabolic acidosis and renal bicarbonate excretion
– Hyperventilation->resp distress
– Damage neo-epithelium
– Hypersensitivity raections
– Hemolytic anemia(rare)

24. Other local application agents
• Gentamycin-aminoglycoside(0.1%),effective against
pseudomonas /gm neg organisms./active eschar penetration.
S/E -Oto/nephrotoxicity.
• Bacitracin
• Chlorhexidine
• Povidone iodine-effective against staphylococcus,fungi.
• Polymixin-B
• Framycetin
• Soframycin
• Nanocrystalline silver based ointments

25. Temporary skin substitutes
• Biological
• synthetic

26. Permanent skin substitutes
• Epidermal
• Dermal
• composite

27. Biological dressings and skin
substitutes
• The ultimate aim in the treatment of burns is to achieve
wound closure.
• Wound closure in partial thickness burns occurs by
epithelialization.
• In extensive burns (30-40%) the wounds need to be covered
temporarily with some biological dressing material or skin
substitute till autografts are available.
• Once the epithelialization is complete, the biological
dressings and skin substitutes either come out of their own
or are peeled off

28. Temporary skin substitute
• Biological
– Amniotic membrane
– Collagen
– Allografts
– Xeno-grafts
• Synthetic
– Polyurethane Film
– Hydrogel
– Hydro fiber
– Hydrocolloid
– Alginates
– Foams(silver impregnated )

29. Amniotic membrane
• Placenta is procured from normal or cesarean section
deliveries.
• placental membrane dissected from the blood clots with a
sterile gauze swab.
• washed with normal saline /antibiotic sprays
and used to cover burn wounds..
• Both human and bovine amnion has been used
• Acts as excellent temporary cover for a few days
• Used in clean second degree burns or donor areas of
split skin grafts.
• Amnion can be stored for 2-3 days in sterile bottles
containing 0.25% sodium hypochlorite solution

30. • Treated with 0.25 percent sodium hypochlorite and 200,000 units of
penicillin, sterilized, dried and stored at room temperature up to nine
months
• Advantages
– It relieves pain
– Avoids discomfort during dressing change,
– reduces oozing
– protects underlying regenerating epithelium.
– No vascularization ->no rejection/reaction
• Disadvantages
– carries the risk of transmitting diseases like HIV/CMV

31. Amnion

32. Collagen
• Abundant protein/ 25-30% of body protein constitutes of
collagen .(mainly type -1)
• Fibrous protein of vertebrates and forms main constituent of
connective tissue.
• It can be isolated from tissues ,purified and preserved wet and
dried sheets , powdered form.
• Preservative used iso-prophyl alcohol.(wash with saline or
distilled water prior to use)
• It is hydrophilic and adheres firmly to raw wounds after getting
dried
• It has very low antigenicity.

33. • Sterilized by GAMMA radiation.
• Collagen powder and granules are available.
• Precaution to take while applying sheet
– To wash alcohol /rinse
– Contains porus sheet with thin nylon woven fibril.

34. • When healing is complete, the dried collagen automatically
falls off.
• provides good biological temporary cover in superficial and
deep partial thickness burns, SSG donor sites
• Reduces pain and evaporative losses
• Forms a barrier for microorganisms and thus reduces chances
of wound infection.
• No vascularization -> no rejection/reaction

35. Allograft/homograft
• In 1881 Girdner treated burns with skin harvested from
suicide victim.
• Availability of skin banks makes it possible to get the donor
preserved skin harvested from cadaver or live donors.
• Freeze dried and treated with glycerol and stored for several
years in acellular form
• Can be used as temporary cover in partial thickness burns
preventing evaporative loss of proteins and electrolytes
• Reduces pain

36. • HLA match being done in western countries
• Patient after allograft started on steroids and
immunosuppresents to avoid early rejection
• Rejection starts between 3-10 weeks by immune system .
• Allografts vascularise and thus immune/inflammatory repose
seen and bacterial load reduces.
• Mean time granulation tissue develops from beneath and wound
will be ready for auto-grafting.
• Disadvantage-
– immuno-supression can increase infection.
– Transmission of HIV/CMV/fungal infection
– Rejection (HLA II )

37. Indications-
• Extensive wound when local skin not available.
• Covering wide meshed autografts
• 2nd degree deep and 3rd degree burns
• Steven johnsons/TEN
• Waiting period for granulation to grow
• template for delayed application of keratinocytes

38. Xenografts
• Bromerg and song popularized porcine skin graft in 1965.
• Procured from pork/canine/bovine skin.
• Acts in similar manner to allografts.
• Does not get vascularized->no rejection.

39. Synthetic temporary skin substitutes
– Polyurethane Film
– Hydrogel
– Hydro fiber
– Hydrocolloid
– Alginates
– Foams(silver impregnated )

40. Polyurethane Film
• Semi permeable /transperent dressing materials.
• Made up of polyurethane/polyethelene
• Adhesive coating on one side
• Allows water vapour/gases,impermeable to water /bacteria
• Combined with antibiotic local applicants or gauze
• Applied to 2nd degree sup and deep burns/ssg donor areas

41. • Advantage
– Easy applicable
– Inspect wounds
– Maintain moist environment
– Reduces pain
– Adheres to surface ,elastic
• Disadvantage
– Non absorbant
– Cant use for infected wounds
– Strips off neo-epithelium

43. hydrogels
• Transparent polyethylene dressings
• Available as sheets and fillers /composition
90% water
• Non adhesive, needs covering over this layer
• Water released from gel helps in softening the
necrotic tissue and helps in auto debridement
and de-sloughing.
• Disadvantage- wound maceration

44. • Used in dry, necrotic, 3rd degree burns wounds
• Pressure sores
• Donor sites of ssg
• Radiation injuries

46. Hydro-colloid
• Contains adhesive, hydrophlic,gel forming
particles-gelatin covered with outer layer of
foam.
• Absorbant,impermeable to bacteria,water
proof,painless.
• Helps in autolytic debridement

47. • Encourages faster healing and re-epithelization
• Used in 2nd and 3rd degree burns wounds with
exudate and slough.
• Can be left in place for 5-7 days if minimal to
moderate soakage is present.

49. Alginates
• Derived from Calcium salts of alginates (sea
weeds)
• Sodium and calcium ions react with exudate
and form gel
• Provide moist environment available as
pastes,sheets ,powders
• Highly absorptive
• Used in moderate to high exudate
wounds/necrotic wounds with slough

50. Alginates

51. Hydrofibres
• Made up of sodium carboxy-methyl cellulose
with calcium ions
• Similar to alginates and similar properties.
• Excellent Ability to absorb the exudates.
• Can be left for 4-7 days
• Used in 2nd degree burns
• Ex-AQUACEL

53. Foams
• Made of polyurethene polymers
• Thick and thin /adhesive and non adhesive foams with
excellent absorptive capacity
• Helps in autolytic debridement
• Can be combined with antimicrobials/silver
impregnated.
• Used in moderate to high exudate wounds/necrotic
wounds with slough
• Ex- biotin AG/mepilex AG

54. Foams

55. Biobrane
• It is a two layered temporary, synthetic skin substitute.
• outer layer -ultrathin layer of silicon rubber(semi-permeable and
permits the exit of water vapors but prevents entry of bacteria
from the exterior).
• The inner layer -tightly woven nylon fabric.
• Inner layer has porcine collagen peptides covalently bonded.
• Silicone sheet is removed and later grafted.

56. Biobrane

57. • Opsite-made up of modified PVC
• Trancyte-bilayered
– dermal:collagen synthesised from human neonatal
fibroblast+ nylon mesh
– Epidermal:silicon sheet

58. Temporary skin substitute
• Biological
– Amniotic membrane
– Collagen
– Allografts
– Xeno-grafts
• Synthetic
– Polyurethane Film
– Hydrogel
– Hydro fiber
– Hydrocolloid
– Alginates
– Foams(silver impregnated )

59. Permanent skin substitute
• Dermal replacement
– Synthetic: integra / derma graft
– Biological: alloderm
• Epidermal replacement
– Cultured epidermal allograft(CEA)
– Cultured keratinocytes
• Composite replacement
• Dermal + epidermal cultured grafts.

60. Integra
• Synthetic bilayered dermal substitute.
• Outer- silicone layer
• Inner- bovine tendon collagen arranged in porous
matrix+cross linked shark cartilage gylcosaminoglycans
• Chondroitin maintains structural integrity and maintains
porus matrix for ingrowth of cellular structures
• Wound debridement done and integra applied.
• Dermal layer infiltrated with fibroblast and collagen
tissue + capillary invasion

61. • Silicone layer separates out in 2-4 weeks
• Outer layer grafted later.
• Less hypertrophic scarring /contractures
• Disadvantage – expensive/2 staged procedure.

62. Dermagraft
• Contains bio absorbable
polyglactin mesh with
allogenic neonatal
fibroblasts
• Applied after tangential
excision.
• More resistant to
contamination
• After 1 month mesh gets
absorbed and ssg can be
done on the dermal matrix

63. Alloderm
• Acellular dermal matrix
• Biological dermal substitute.
• Derived from cadaveric graft.
• Used in deep 2nd degree or 3rd degree wounds
• Harvested graft processed , de-epithelised , freeze
dried after screening for HIV/CMV/HBsAg.
• Applied on raw wound and grafted in single
sitting.

64. Cultured keratinocytes
• Cultured epidermal keratinocytes(CEA)
• Rheinwald and Green in 1975 -irradiated mice fibroblasts can
support the growth of human fibroblasts.
• technique -culture medium of fetal calf serum is used to grow
keratinocytes into sheets of epidermis from two to eight layers thick.
• sub-culturing, a three square centimeter sheet can be expanded five
thousand times to cover enough epithelium to cover the whole body
• Disadv-time consuming /high cost /sheering /lack of
adherence.(weak adhesive fibrils and enzymatic separation )

66. Composite graft
• Epidermal + dermal components (APLIGRAF)
• Apligraf-
– Dermal:neonatal fibroblast +bovine type 1collagen lattice
– Epidermal:human foreskin derived neonatal keratinocytes
(CEA)
• Used in 2nd degree deep/3rd degree burns
• In trials /not available for clinical use

69. • Applied after thorough debridement
• Used in bedsore/2nd and 3rd degree burns/chronic
wounds/electric burns/fasciotomy wounds
• Exposed vessels and vital structures to be avoided with VAC
application.

70. Recent advances
• Micro-grafting technique- grafts of size 0.8X 0.8 mm harvested
under LA,OPD basis .using xpansion micrografting tecnique
• Regenerative capacity of 1:100
• Technically demanding /expensive
• Fractional skin grafting- large no. of skin full thickness
microscopic skin harvested (700 mic) using hypodermic syringe
and under microscope/micro-sheets placed on raw areas randomly.
• no donor site morbidity/faster healing/technically demanding
• Autologous non cultured cell therapy (ReCell) – thin ssg
harvested /incubated , after mechanical agitation keratinocytes
separated ,suspended in lactate solution , treated with antibiotics
and sprayed over wound.
• Good expansion 1:80/expensive/mechanical damage to cells

71. Conclusion
• 1st degree-silver sulphadiazine/bacitracin/mupirocin LA
• 2nd degree superficial- paraffin gauze/silver
nitrate/Collagen/amnion/biofilms/hydro-
fibres/biobrane/trancyte/CEA
• 2nd degree deep
hydrocolloid/foam/alginates/autograft/xenograft/biobrane/integra
dermagraft.
• 3rd degree
mefenide/alginate/foams/alloderm/composite dermal+ epidermal
substitutes.

72. References
• Total burn care, David.Herdon ed.5
• Principles and practice of burns care –sujtha sarabai ed.1
• Grabb and Smith’s plastic surgery ed.8
• Handbook of burns,vol-2 P.kamolz,M.G.Jeschke ,ed.2

73. • Thank you…