Dressing in Burn Wound,

1. Department of Plastic and Reconstructive Surgery
Hamdard Institute of Medical Sciences and Research
Dressings In Burn Patient
Dr Junaid Khurshid
Conflict of interest: None
Disclosures: None
Financial disclosure: none

2. SEVERITY OF BURN DEPENDS ON
1. BURN AREA
2. BURN DEPTH

3. BURN AREA
•Single most important factor that predicts:
•burn related mortality,
•need for specialized care,
•type and likelihood of complications.
•Burn size guides about initial resuscitation and subsequent
nutritional requirement.

4. Common guidelines used
•Rule of Nines(Wallace)
•Rule of Palm
•Lund-Browder Chart

5. Rule of Nines
•In the adult, most areas
of the body can be
divided roughly into
portions of 9%, or
multiples of 9.
•In small children,
relatively more area is
taken up by the head
and less by the lower
extremities.

6. Lund & Browder Chart
•The Lund & Browder chart is considered the most accurate
of all the methods as it assigns a specific number to each
body part.
•This method is most often used to measure burns in infants
and young children because it allows for developmental
changes in percentages of body surface area.

8. BURN DEPTH
•It is an important determinant of patient`s long term
appearance, functional outcome & mortality.
ASSESSMENT OF BURN DEPTH
•The standard technique is clinical observation
•Other techniques include
•methods to detect dead cells/ denatured collagen
•assessment of change in blood flow
•analysis of the color of the wound
•evaluation of physical changes like edema

10. GOALS
•Burn care requires multidisciplinary approach.
•The quality of burn care is no longer measured only by
survival, but also by long-term function and appearance.
•The surgeon`s goal for any burn is well-healed, durable
skin with normal function and near-normal appearance

11. FACTORS DETERMINING THE SEVERITY AND PROGNOSIS
•Size of burn.
•Depth of burn.
•Site of burn.
•Age of the patient.
•Associated co-morbidities.
•Associated trauma.
•Associated inhalation injury.

12. CARE AT SCENE / ON RECEPTION
•Remove from the source of injury
•Burning clothing is extinguished and removed
•100% oxygen given by venturi-mask
•All rings, watches, jewellery, and belts are removed
•Room-temperature water can be poured on the wound
within 15 minutes of injury to decrease the depth of the
wound.
•Iced water should never be used.

13. CARE IN EMERGENCY
Rule out life threatening injuries
•Manage the patient as per ATLS protocols
secure airway
adequate breathing
maintain circulation
•Tetanus prophylaxis
•Give analgesics by IV route
•Catheterise the patient

14. FLUID RESUSCITATION
•Primary goal of fluid resuscitation ----ensure end organ
perfusion.
•Replacement of volume by the least amount of fluid
necessary to maintain adequate organ perfusion.
•Increased times to initiating resuscitation of burned patients
result in poorer outcomes.
•Delay in resuscitation should be minimised.

15. •Venous access is best attained through short peripheral catheters in
unburned skin.
•Upper limb preferred over lower limb.
•Central line should be put in elderly patients with cardiopulmonary
disease.
•cephalic vein cut-down is useful in patients with difficult access .
•In children younger than 6 years, experienced practitioners can use
intra-medullary access in the proximal end of the tibia until IV access is
achieved.

16. Escharotomy
 Eschar = burned skin
 Escharotomy = cut burned skin to relieve underlying pressure
 The entire constricting eschar must be incised longitudinally to
completely relieve the impediment to blood flow
 Knife can be used, or cautery.
 Use local or no anesthesia.
Indications
•Tight unyielding eschar in circumferential burnt extremities.
•Respiratory embarrassment .
•Distal limb ischemia.

17. • Thoracic escharotomy is
performed bilaterally in the
anterior axillary lines.
• For escarotomy of extremity
the incision should be placed
along the mid-medial or mid-
lateral aspect of the
extremity, which avoid major
neurovascular and musculo-
tendinous structures,

18. Other considerations
Prevention of infection
Excision and early wound closure
Environmental support
Nutritional support

19. Ambient Temperature
 This loss of heat is offset by increased hypermetabolic
response by patient to generate heat.
 Heating the environment allows for the environmental
heat to provide energy for the water loss, thus reducing
the metabolic demand.
 This thermal equilibrium can be achieved by maintaining
the environment to 28 - 33°C.
 This can reduce the magnitude of hypermetabolic
response from 2 to 1.4times the resting energy
expenditure.

20. Burn Triangle
Burn Wound Sepsis Antibiotics
Nutrition
Supportive Care
Burn wound Dressing
Death
Healed Burn
Wound
BURN
OUTCOME

21. Burn Wound Care
 Once resuscitation fluids have started, adequate ventilation ensured
and other injuries ruled out, attention is diverted to the burn wound
 Admission photographs are taken
 Under adequate analgesia, loose skin tags/ blisters are debrided.
 Wound is washed with warm water and mild soap and dried with
clean cloth.
 Special beds such as citroen air suspension bed or Flexicare bed are
very helpful in treating burns of the back or other dependent areas.

22. WOUND CARE
First-degree burns
No dressing
Topical salves
Systemic nonsteroidal anti-inflammatory agents
Second-degree burns
Daily dressing changes and topical antibiotics
Temporary biologic or synthetic covering to close
the wound.
Deep second-degree and third-degree burn
Daily dressing changes and topical antibiotics
wound excision and grafting

23. ROLE OF DRESSING IN WOUND CARE
 To decrease bacterial count
 To decrease evaporative water and protein loss
 To diminish pain
 To prevent desiccation of vital structures
 To protect the wounds until skin grafting
 As a test to determine if wounds are ready to accept a skin graft

24. Dressing Room Setting
• Patients who undergo treatment at the burn center have to endure a daily
dressing change, a painful procedure that can last hours.
• The dressing is physically and mentally challenging.
• Ambient temperature should be 28-33 degree Celsius.

25. • Two aspects come together: the need for the very best medical care and the
desire to alleviate the patients suffering as much as possible.
• Creation of a non-frightening space with the look and feel of a pleasant bathing
area in a wellness center
• A space that reduces patient anxiety and stress and offers reassurance and
distraction.

26. Order of dressing in patients
• First graft dressing First
• Relatively Healthy wounds first
• Small wounds first
• Children first
• Extensive and relatively infected wounds to last
Analgesia
• NSAIDS
• Opoid analgesia
• Ketamine
• Sedation

27. Dressing frequency
•Dressing Material
•Depth of wounds
•Exudation
•Area of body
•Infection

28. Antimicrobial Salves Antimicrobial Soaks
Silver sulfadiazine 0.5% Silver nitrate
Mafenide acetate 5% Mafenide acetate
Bacitracin 0.025% Sodium hypochlorite (Dakin solution)
Neomycin 0.25% Acetic acid
Polymyxin B
Mupirocin
Nystatin
Topical antimicrobials

29. Silver sulfadiazine Mafenide Acetate Silver Nitrate
Advantage Painless Penetrates eschar No
hypersensitivity
Wound visible Wound visible Painless
Easy to use Easy to use No resistance
Eschar penetration
intermediate
No resistance
Disadvantage Neutropenia Pain Poor penetration
Carbonic anhydrase
inhibition
Hyponatremia
Respiratory alkolosis Discolor burn
wounds
TOPICAL CHEMOTHERAPEUTIC AGENTS

30. Silver Sulfadaiazine (SSD1%)
• Silver sulfadiazine is a medication used to prevent, manage, and treat
burn wound infections.
• It is a heavy metal topical agent with antibacterial properties.
• Known for its safety and tolerability.
• It is widely available and a drug with low cost , making it a common
choice to prevent infection in patients with burns.

31. Contd.
• Silver sulfadiazine is a broad-spectrum bactericidal antimicrobial
effective against gram-positive and gram-negative bacteria, as well as
some yeasts.
• It is active against Pseudomonas aeruginosa
• It is thick white cream, applied once or twice daily and is soothing.

32. Mechanism
• Silver sulfadiazine is a sulfonamide-containing antibacterial;
however, this does not inhibit folic acid synthesis, unlike other sulfa
drugs. Its ant-bactericidal effects are due to the silver ions
• As such, the silver ions only act superficially, and there is limited
eschar penetration.
• The drug produces its bactericidal effects by increasing cell wall
permeability through the impairment of DNA replication, the direct
modification of the lipid cell membrane, and/or the formation of
free radicals.

33. Adverse Effects
•It slows re-epithelization and should be stopped once there
is visible evidence of healing.
•With repeated use, a pseudoeschar will form over the
affected area preventing adequate assessment of the burn
wound.
•Most common side effects are hematological, including
agranulocytosis, aplastic anemia, hemolytic anemia, and
leukopenia.
•SSD is also oculotoxic and should not be used on the face.

34. Contraindications
•Persons with hypersensitivity.
•Pregnant women.
•Infants less than two months of age should refrain from
using silver sulfadiazine.
•SSD should not be used on the face.

35. Nanocrystalline silver
Nanocrystalline silver dressings are composed of a urethane
film embedded with elemental silver that provides sustained
release of silver into the wound

36. •Compared with older silver formulations, it has stronger
antimicrobial activity and longer-lasting properties that
reduce dressing change frequency to weekly, depending
upon the amount of exudate.
•Some nanocrystalline silver dressings (eg, Acticoat) require
frequent moistening with water to maintain activation

37. Mafenide acetate (Sulfamylon)
•8.5% water-soluble cream
•5% aqueous solution.

38. •It is effective against a broad range of
microorganisms, especially against all strains of P.
aeruginosa and Clostridium.
•After the wound has been cleansed of debris,
mafenide acetate 8.5% cream is applied to the
wound like butter (Lindberg's Butter).

39. Contd.
•The treated burn surface is left exposed for maximal
antimicrobial potency. The cream is applied a minimum of
twice daily.
•It has the ability to penetrate burn eschar and circumvent
the colonization of the burn.

40. Contd.
•The 5% solution is used to saturate an eight-ply gauze
dressing which is then applied to the burn wound.
•The dressing should be kept saturated with the mafenide
acetate 5% solution in order to achieve maximal
antimicrobial effects.
•The dressings may be changed every 8 hours. Mafenide
acetate 5% solution is proclaimed to have effective tissue-
penetrating ability and appears to be especially effective
after the dead tissue is removed from the granulating bed.

41. Disadvantages
•Protracted use, combined with its low environmental
pH, favors the growth of C. albicans.
•Carbonic anhydrase inhibition leads to metabolic
acidosis.
•If the patient with inhalation injury and respiratory
acidosis, the use of mafenide acetate over large
areas of the body may produce a metabolic acidosis,
which can be fatal.

42. Bacitracin
• Bacitracin is a cyclic polypeptide antibiotic
• Bacitracin is a topical antibiotic ointment widely used for superficial burns.
• Usually used in the exposed areas of body like hands and face.
• Many gram-positive bacteria, including Staphylococcus spp., Streptococcus
spp., Corynebacterium spp., Clostridium spp., and Actinomyces spp., are
susceptible to bacitracin.
• Some gram-negative organisms, such as Neisseria spp., also exhibit susceptibility;
however, most gram-negative organisms are resistant

43. Contd.
•Topical bacitracin use is recommended only for
minor skin injuries and should not be used over
larger areas of the body.
•All healthcare professionals should be aware of the
potential risks of an anaphylactoid reaction
secondary to bacitracin use and anyone with
confirmed contact dermatitis should avoid products
containing bacitracin.

44. Neomycin
•It is particularly effective against gram-negative
organisms.
•Neomycin belongs to aminoglycosides group of
antibiotics known works by inhibiting bacterial
protein synthesis leading to its bactericidal effect.

45. Polymyxins
•Polymyxins comprise a class of antibiotics targeting gram-
negative bacterial infections. Polymyxin B and Polymyxin E
(colistin) are the two drugs within this antibiotic class used
primarily in clinical practice.
•They are FDA approved for serious infections with multidrug-
resistant gram-negative bacteria, especially those caused by
Enterobacteriaceae, Pseudomonas
aeruginosa and Acinetobacter baumannii.

46. Polymyxins
• Polymyxins are often the only effective antibiotic agent against
multidrug-resistant organisms, particularly carbapenem-resistant
Enterobacteriaceae.
• They have become the last line of treatment for infections that are
resistant to other antibiotics

47. Chlorhexidine
• Chlorhexidine gluconate, a long-
lasting antimicrobial skin cleanser, is
often used with a gauze dressing for
burn wound coverage in superficial
partial-thickness burns.
•Chlorhexidine dressings do not
interfere with wound
reepithelialization, in contrast
to silver sulfadiazine.

48. Contraindications
•Deep burns
•Caution in neonates – rare association with
cutaneous burns

49. Honey
•Honey-derived wound care dressings heal
limited superficial partial-thickness
wounds.
•However, the safety, efficacy, and use
of honey-based dressings for the
treatment for more severe, extensive, or
complex thermal injury has not been
established.

50. Povidone-iodine
• Povidone-iodine ointment, including a liposomal preparation,
effectively combines antimicrobial therapy with a desired moist wound
environment.
• Despite a broad spectrum of antimicrobial activity, use of povidone-
iodine-containing products in burn care is controversial because of
cytotoxicity and delay in wound reepithelialization.

51. Contd.
•Another drawback to povidone-iodine
ointment compared with other topical agents
is that it must be applied four times a day for
maximal antimicrobial effect.

52. Contraindications
•Children under 2 years
•Pregnancy
•Breastfeeding
•Thyroid disorders
•Signs of re-epithelialization

53. Acetic Acid 1%
Acetic acid is a traditional antiseptic with an ancient
history claimed to go back more than 6,000 years.

54. • Since most pathogenic bacteria require a pH value higher than 6, their
growth is inhibited by application of acetic acid (Vienegar).
• It leads to reduction in bacterial protease activity.
• Low pH promotes wound healing and oxygen radical production for
killing of bacteria by improving cell oxygenation by Bohr effect
• Leads to increase in macrophage fibroblast activity and reduces toxicity
of bacterial end products
• All these actions collectively lead to rapid decontamination with
improved granulation

55. Contd.
• Interest in traditional antiseptics, including acetic acid, has been rekindled with
the rapidly increasing problem of antibiotic resistance.
• Acetic acid is readily available, inexpensive and does not have the systemic
adverse effects of some modern antiseptics.
Adverse Effects
• High concentrations inhibit epithelialization, inhibit PMNs and fibroblasts

56. Dakin's solution
•Dakin's solution (0.025% sodium
hypochlorite) is widely used in a
variety of difficult wound types and
burn wounds.
•It acts as a germicidal topical agent
that can dissolve necrotic tissue
debris.

57. Spectrum
•Effective agent against a broad spectrum of aerobic and
anaerobic bacteria as well as viruses, fungi, and spores.
•It has bactericidal activity against a variety of organisms,
including Enterococcus, Streptococcus mitis, Staphylococcus
aureus, Staphylococcus epidermidis, Escherichia
coli, Klebsiella pneumonia, Enterobacter cloacae, Serratia
marcescens, Proteus mirabilis, and Pseudomonas
aeruginosa. It even has been effective against organisms
highly resistant to antibiotics, such as methicillin-
resistant Staphylococcus aureus (MRSA) and vancomycin-
resistant Enterococcus (VRE)

58. DEBRIDING AGENTS
•Enzymatic debriding agents and proteolytics have been
successfully used for the early management of deeper and
indeterminate depth surgical burn wounds and eschar.
•The aim of using these agents is to expedite debridement
while affording a measure of specificity and dermal
preservation.
•These include collagenase derivatives, a variety of fruit
enzyme derivatives such as the papain/urea derivatives, as
well as bromelain derivatives.

60. •Bromelain derivative, anacaulase (NexoBrid), is used for the
treatment of small- to moderate-sized intermediate and
deep dermal thickness burn wounds.
•Cautions about bleeding risk, allergies, as well as adequate
analgesia needs to be considered

61. Collagen Dressings
• Usually derived from bovine or porcine collagen
• Come in a variety of preparations, including collagen particles, matrix
of either pure collagen, or collagen with other products, as
combination of collagen; oxidized, regenerated cellulose; and silver
• These dressings can be applied as powder or sheets to wounds.
• Collagen dressings are moderately expensive and may be promising
adjuvants to wound therapy, especially in peadriatic patients
• These dressings requiring lesser number of dressings and blood
transfusions, and shorter duration of hospital stay.

63. Negative Pressure Wound Therapy (NPVT)
•Can be used in partial thickness burn
•NPWT is used to help the drainage of excess fluid
and increase localized blood flow.
•Results in increased oxygen and nutrition to healing
wound which promotes healing

64. Skin Substitutes
These are heterogeneous group of biologic, synthetic, or biosynthetic
materials that can provide temporary or permanent coverage of open
skin wounds

65. Ideal Skin substitute
• Firm adherence to wound
• Barrier to water loss ,bacteria, heat loss
• Drapes well
• Readily available, cheap
• Grows with a child
• Can be applied in one operation
• Has a long shelf life
• Non-antigenic , Durable flexible, non-toxic
• Does not become hypertrophic

66. Advantages of Skin Substitutes
• Barrier to bacteria.
• Barrier to evaporative water
• Barrier to heat loss
• Decreases pain
• Avoids desiccation
• Reduces inflammation and thus scarring

68. BIOBRANE
•Acellular skin substitute
•Temporary ASD for donor site, partial thickness
wounds
•Can be stored at room temp for 3 years
• Special biobrane gloves for hand burns
• Healing time 7-14 days
• Adherence in 48-72 hrs

72. Integra
• It is a bi-layered skin substitute made of a silicone membrane as an epidermal
layer. It is impermeable to water and protects against infection.
• The dermal part is made of bovine collagen and shark chondroitin-6-sulphate
glycosaminoglycan.
• After coverage, the wound becomes revascularized within 2-3 weeks. At this
stage, the superficial silicone layer is removed and replaced by a very thin split
skin graft applied onto the neo-dermis bed.
• Advantages are immediate availability, allowing time for the neo-dermis
formation, and good aesthetic results.

73. Disadvantages
•It needs a two-step operation.
•Expensive
•Accumulation of exudate underneath it that may lead to
infection.
•Needs 3-4 weeks for culture.
•However Integra has been widely used in certain disaster
situations such as in the management of burn victims.

74. Alloderm
• Skin substitute formed from acellular matrix derived from a cadaveric dermis.
• Freeze-dried to render it immunologically inert.
• No epidermal layer.
• Acellular matrix provides a good natural medium for fibroblast and endothelial
cells to regenerate from the neodermis

75. TRANSCYTE
•Cellular allogenic skin substitutes
•Outer epidermal analog is a thin nonporous silicone film.
• The inner dermal analog - human neonatal foreskin
fibroblasts collagen type I, fibronectin and GAG

76. TRANSCYTE
•Temporary ASD,
•Applied in 24 hours of injury.
•Dermis layer down toward the patient.
•Dermabond-M skin glue to allow TransCyte to adhere
•Left in place until either spontaneous separation occurs
which indicates wound bed healing or the wound is dealt
with surgically
•Once cassette is open the dermis layer is facing up.
•Conformant 2 ASD

77. Transcyte:
Inner layer: Bioengineered human
dermal matrix.
Outer layer: Synthetic epidermal layer.

78. Apligraft
• Cellular allogenic skin substitutes
• Bilayer Prepared by mixing living fibroblasts from neonatal foreskin
with bovine collagen type I

79. Allograft Tissue
 Reported in the mid 19th century but popularised in 1950.
Cadaver Skin or living Donors.
Advantages
▪ Bilayer skin.
▪ Revascularize maintaining viability.
▪ Dermis incorporates.
Disadvantages
▪ Epidermis will reject.
▪ Difficult to obtain and store.
▪ Risk of disease transfer.

80. Why Allografts
•Xenografts are not commercially available in India.
•Biosynthetic skin substitutes are extremely expensive and
unaffordable for most of the burnt patients in our country.
The availability is also uncertain.
•Then the only alternative available is Skin Allografts obtained
from a human donor.

81. •The efficacy of skin allografts in the management of burn
wound was realized in 1881.
•These have also been shown to be the most effective of the
alternatives. In Western countries, besides better facilities
and resources, one of the main reasons for salvage of
patients with very large burn (e.g. 95% of TBSA) is availability
of skin Allografts.

82. Why Unique
•The skin allograft transplant differs from organ
transplantation as the skin grafts are used to provide
temporary long term protection and are not expected to
survive in the recipient permanently as transplanted organ.
•This means that neither ABO blood group nor HLA matching
is required for allograft skin transplantation.
•So, any human being can be a donor for anyone else.

83. Human Amnion
Human Amnion has fibronectin lattice as well as an epithelial cell layer
which can act as a barrier similar to epidermis.
Advantages
▪ Acts like biological barrier
▪ Easy to apply and remove
▪ Transparent
Disadvantages
▪ Difficult to obtain prepare and store
▪ Need to change every 2 days
▪ Disintegrate easily
▪ Risk of disease transfer

84. Allograft covering debrided burn

85. Xenografts
▪ Use of animal and reptile skin as a skin substitute dates back several
hundred years.
▪ Initial use on partial and full thickness burns.
▪ Current use only on partial thickness burns.
XENOGRAFTS: (PAST AND PRESENT)

86. Advantages
▪ Easy availability compared to Allografts
▪ Bioactive (collagen) inner surface
Disadvantages
▪ Cannot obtain blood supply from wound and will slough.
▪ Potential of disease transmission.
CURRENT USE OF PIG SKIN
Pig skin consists of a thin dermal layer (epidermis removed) which is stored
frozen to maintain adhesive properties.

87. Thank You