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Aim of Burns Dressings and management of burns.pptx
- 3. AIM OF BURNS DRESSINGS - Proper covering of burn wound - Prevent dryness of wound by providing moisture - reduce the pain - Reduce the contamination of wound / bacterial invasion - Reduce evaporative loss - Joint to be mobilized to prevent contractures
- 4. PRINCIPLES OF BURNS DRESSINGS - Desiccated wounds need to be kept moist - Excess exudate needs 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
- 5. IDEAL DRESSING MATERIAL - Provide moist environment - Effective barrier for microbes / foreign bodies - Prevent body tissue fluid loss - Allow gaseous exchange - Protect against shearing forces - Non traumatic / non irritant
- 6. IDEAL DRESSING MATERIAL - Eliminate dead space - Helps in early epithelization - Easy application - Cost effective
- 7. INITIAL CARE OF WOUND - Immediate – sterile wound - Hydrotherapy – wound wash - Encircling objects to be removed
- 8. NATURAL POLYMERS IN BURN WOUND DRESSING
- 9. SYNTHETIC POLYMERS IN BURN WOUND DRESSING
- 10. TOPICAL ANTIMICROBIALS - Salves - Soaks - Silver impregnated
- 11. • Tincture • Vinegar soaked dressing • Greasy dressing • Tannic acid • Gentian violet • Petroleum gauze • Carbonic acid, mercurial compounds, Annaline dyes HISTORY
- 12. IDEAL ANTIMICROBIAL AGENT • Broad spectrum antimicrobial property ( Pseudomonas, Staphylococcus, Klebsiella, Enterococci) • Penetrate eschar • Less systematic absorption • Non allergic / irritant • Minimal resistance • Cost effective, easy application, less side effects
- 14. SILVER SULPHADIAZINE • Silvadene • White, crystalline, insoluble, water based 1% cream • Mechanism of action – Silver ions released at wound site destroys bacterial cell wall and damages DNA directly • Sulphadiazene – PABA inhibitor, interrupts bacterial replication • Primary bacteriostatic • Effective against gram positive, negative, and anaerobes
- 15. Advantages: • Easy application • Reduces pain • Less incidence of resistance Disadvantages: • Transient leucopenia • Does not penetrate eschar • Methemoglobinemia • Neoepithelial damage • Hypersensitivity reaction
- 16. MAFENIDE (5%) • Sulfamylon • Methylated sulphonamide • Against pseudomonas, clostridium and gram negative organisms • Minimal antifungal activity • Good penetration into eschars • Applied twice daily • Carbonic anhydrase inhibition activity – Metabolic acidosis
- 17. Advantages: • Effective in established wound infection • Eschar penetration Disadvantages: • Significant pain • Metabolic acidosis • Damages neoepithelium • Hypersensitivity reactions
- 19. SILVER NITRATE • Initially used during World War II @ 10% solution – toxicity • Now 0.6% solution used • Mechanism of action – similar to silvadene, action by silver ion • Bacteriostatic, broad spectrum, effective against Gram negative • 6-8 layer dressing done after wash & dressing to be soaked in 2- 3 hours with silver nitrate
- 20. Advantages: • Less evaporative loss, keeps wound moist • Early granulation due to early separation of eschar / necrotic tissue • Painless • Less resistance Disadvantages: • Does not penetrate eschar • Precipitates into silver chloride / sulphide – staining • Dyselectrolytemia • Methemoglobinemia
- 21. OTHER AGENTS
- 24. TEMPORARY SKIN SUBSTITUTES - Biological - Synthetic
- 25. BIOLOGICAL • Collagen • Allograft • Xeno-grafts • Amniotic membrane SYNTHETIC • Polyurethane film • Hydrogel • Hydrofiber • Hydrocolloid • Alginate • Foams (silver impregnated)
- 27. COLLAGEN
- 28. COLLAGEN • 25-30% of body proteins – collagen type I • Bovine collagen similar to human collagen • Usually bovine collagen used – has type I and type III collagens • Can be isolated from tissues, purified, preserved as wet and dried sheets, powdered forms • Preservative used – isopropyl alcohol • Wash with saline prior to use
- 29. • Hydrophilic – adheres firmly to raw wounds on drying • Very low antigenecity • Sterilized by GAMMA radiation • When healing is complete- falls off automatically • Good biological cover for superficial and deep partial thickness burns • Rdeuces pain and evaporative loss • Forms barrier for micro-organisms
- 33. AMNIOTIC MEMBRANE • Placenta procured placental membrane dissected from blood clots with sterile gauze swab washed with normal saline / antibiotic sprays • Human and bovine sources • Temporary cover for few days • Used in clean second degree burns or donor areas of SSG
- 34. • Amnion – stored for 2-3 days in sterile bottles with 0.25% sodium hypochlorite solution • Treated with 0.5% NaOCl and 2,00,000 units of penicillin sterilised, dried, stored upto 9 months at room temperature • Cryopresevation, lyophilization, glycerol preservation, gamma irradiation • Prevents evaporative loss • Reduces bacterial counts
- 35. • The main structure of the AM – multi-layered membrane • Epithelium - reservoir of biological active pluripotent stem cells • The basal membrane - extracellular-matrix proteins such as collagen and fibronectin • The stroma and the spongy layer - both contain various important regenerative factors and molecules • These components - induce cell growth, migration, and differentiation of epithelial cells, and to support preservation of the original epithelial phenotype
- 36. Advantages: • Relieves pain • Avoids discomfort during dressing change • Reduces oozing • Protects underlying regenerating epithelium Disadvantages: • Risk of transmitting CMV, HIV
- 38. ALLOGRAFT
- 39. ALLOGRAFT / HOMOGRAFT • 1881, Gardner treated burns – skin harvested from suicide victim • Skin banks – from cadaver or live donors • Freeze dried and treated with glycerol – stored for several weeks in acellular form • Temporary cover in partial thickness burns • Immunological and barrier function of normal skin • Prevents evaporative loss of proteins and electrolytes • Reduces pain
- 40. • HLA matching done • Post Allograft- started on steroids and immunosuppressive to avoid early rejection • Rejection by 3-10 weeks • Allograft vascularises and bacterial load reduces • Granulation tissue develops beneath Disavantage • Immunosuppression leading to infection • Transmission of HIV/CMV/fungal infection • Rejection
- 41. Indications: • Extensive wounds • Covering wide meshed autographs • 2nd degree and 3rd degree burns • Eventually due to Rejection, graft sloughs off underlying healthy recipient bed – autograft • Alloderm - dermal substitute procured from decellularized cadaveric dermis • Potential for minimizing scar contractures, particularly at joints, and improving cosmesis and functional outcomes
- 43. XENO-GRAFTS
- 44. XENOGRAFT • From porcine, canine, bovine skin • Acts similar to Allograft • Doesn’t get vascularised rejection rare
- 45. • 22-month-old girl with 6.5% TBSA superficial partial- thickness scald burns, primarily of the face: • post-burn day 3 before placement of PX (a) • postoperative day 1(b) • healing burns with partial xenograft separation on postoperative day 11 (c) • xenograft completely separated at 1 month post- burn (d) • the patient at 13 months post- burn (e)
- 48. • Semi permeable / transparent dressing • Polyurethane / polyethylene • Adhesive coating on one side • Allows water vapor/ gases • Impermeable to water / bacteria • Combined with antibiotic local applicants / gauze • For 2nd degree superficial and deep burns, SSG donor sites POLYURETHANE
- 49. Advantages: • Easily applicable • Can inspect wounds • Reduces pain • Maintains moist environment • Adheres to surface • Elastic Disadvantages: • Non absorbent • Not for infected wounds • Strips off neoepithelium
- 51. HYDROGEL
- 52. HYDROGEL • Hydrogels are three-dimensional network structures able to imbibe large amounts of water. • Hydrogels do not typically dissolve due to chemical or physical cross-links and/or chain entanglements. • They exist naturally in the form of polymer networks such as collagen or gelatin, or can be made synthetically.
- 53. • Transparent polyethylene dressings • Sheets and fillers, 90% water • non-adhesive, needs a covering • Water released from gel helps soften the necrotic tissue – auto debridement and sloughing Disadvantage – wound maceration Uses: • Dry, necrotic 3rd degree burns • Pressure sores • Radiation injuries
- 56. HYDROFIBER
- 57. HYDROFIBER • Sodium carboxy methyl cellulose with calcium ions • Forms a cohesive gel in contact with exudates • Similar to alginate • Excellent ability to absorb exudates • Antimicrobial action ( Dressings with silver ions) • Left in situ for 4-7 days • 2nd degree burns • Aquacel
- 59. ALGINATES
- 60. ALGINATES • Derived from calcium salts of alginates (brown sea weeds) • Sodium and calcium ions react with exudate and form gel • Moist environment as pastes, sheets, powders • Highly absorbent • Moderate to exudative wounds / necrotic wounds with slough
- 62. FOAMS
- 63. FOAMS • Made of Polyurethane polymers • Thick and thin / adhesive and non adhesive Foams • Excellent absorptive capacity • Autolytic debridement • Along with antimicrobial • Biatain AG (with silver)
- 65. BIOBRANE
- 66. BIOBRANE • Made of Polyurethane polymers • 2 layered temporary, synthetic skin substitute • Outer layer – silicone rubber (Semi permeable) • Inner layer – tightly woven nylon fabric • Coated with monomolecular layer of type I porcine collagen • Hydrophilic coating for fibrin ingrowth • Porosity – drains exudates, permeable to topical antibiotics • Barrier to bacteria and evaporation • Silicone layer is removed and later grafted
- 67. • Simple sheets or preshaped gloves • Placed onto clean fresh superficial second-degree burn wounds using steri-strips and bandages • Biobrane dressing dries up well adhered to burn wounds by 24 to 48 hours • The covered areas are kept open to air • Examined closely for the first few days • Epithelialization beneath the Biobrane sheet easily peeled off the wound • Serous fluid accumulates beneath the Biobrane sterile needle aspiration
- 68. • If foul-smelling exudate removed • Topical antimicrobial dressings applied • Reduce pain levels, fluid loss, healing time, instances of hypothermia, and hospital stay when compared with traditional dressings
- 70. TRANCYTE
- 71. TRANSCYTE • Bilayered • Human fibroblasts cultured on the nylon mesh of Biobrane
- 73. OPSITE
- 74. OPSITE • Semipermeable, semiocclusive polyurethane dressing (Tegaderm or Opsite) • Used also for central venous lines, artificial skin to prevent hypothermia in preterm babies • Insensible water loss reduced • Maintains water and electrolytes regulation
- 75. PERMANENT SKIN SUBSTITUTES - Epidermal - Dermal - Composite
- 76. DERMAL REPLACEMENT • Synthetic – Integra/ Derma graft • Biological – Alloderm EPIDERMAL REPLACEMENT • Cultured epidermal allograft (CEA) • Cultured keratinocytes COMPOSITE REPLACEMENT • Dermal + epidermal cultured grafts
- 77. INTEGRA
- 78. INTEGRA • Synthetic bilateral dermal substitute • Outer silicone layer • Inner bovine tendon collagen arranged in porous matrix + cross linked shark cartilage glycosamaniglycan • Chondroitin maintains structural integrity and maintains porous matrix for ingrowth of cellular structures • Dermal layer infiltrated with fibroblasts and collagen tissue + capillary invasion
- 79. • Silicone layer separates in 2-4 weeks • Outer layer grafted later • Less Hypertrophic scarring / contractures • Expensive / staged procedure
- 81. DERMAGRAFT
- 82. DERMAGRAFT • Bioabsorbable polyglactin mesh with allogenic neonatal fibroblasts • Applied after tangential excision after 3 days • Resistant to contamination • After 1 month, mesh gets absorbed and SSG can be done on dermal matrix
- 83. ALLODERM
- 84. ALLODERM • Acellular dermal matrix • Biological dermal substitute • From cadaveric graft • For deep 2nd or 3rd degree wounds • Harvested graft processed, de-epithelialised, freeze dried after screening for viruses • Single sitting applied on raw wound
- 86. CULTURED KERATINOCYTES • Cultured epithelial keratinocytes • Culture medium of fetal calf serum to grow keratinocytes into sheets of epidermis from 2-8 layers thick • Sub culturing – expanded 5000 times to cover the whole body • Time consuming / high cost
- 87. COMPOSITE GRAFT
- 88. COMPOSITE GRAFT • Epidermal + Dermal component • APLIGRAF • Dermal – neonatal fibroblasts + bovine type 1 collagen lattice • Epidermal – Human foreskin derived neonatal keratinocytes • For 2nd degree deep and 3rd degree burns • In trials
- 89. Conclusion • 1st degree – silver sulphadiazine / bacitracin/ mupirocin • 2nd degree – paraffin gauze / biofilms / hydrofibres / trancyte / CEA • 2nd degree deep – hydrochloride / foam / alginates / xenograft / biobrane / Integra / dermagraft • 3rd degree – alginates / foams / alloderm / composite dermal + epidermal substitutes