Burn Wound Management and Skin Substitutes
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This document discusses burn wound assessment, management, and dressings. It begins with assessing total body surface area burned, burn depth, and initial management. Importance is placed on burn wound closure and various acute burn wound products are described. Assessment of burn depth and wound progression over time is demonstrated through several case studies. A variety of temporary skin substitutes, dressings, and permanent skin grafts are presented.
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Burn Wound Management and Skin Substitutes
- 1. Sue Taggart CNC Burns Support CRGH BURNS UNCOVERED COVERED
- 2. Assessment of burns % Total Body Surface Area burnt Burn depth Initial management of the burn wound Importance of burn wound closure Describe acute burn wound products BURNS UNCOVERED - COVERED
- 3. TOTAL BODY SURFACE AREA (TBSA) RULE OF 9’S Palmar Method Palm & fingers of the patient = 1% TBSA
- 5. 5 Epidermis Dermis - capillaries - nerves Fat Epidermal Superficial Dermal Mid Dermal Deep Dermal Full Thickness Assessment of Burn Depth
- 6. ©EMSB Depth Colour Blisters Cap Refill Sensatio n Healing Epidermal Red No Present Present Yes Superficia l Dermal Pale Pink Small Present Pain + Yes 7-10d Mid- dermal Dark Pink Present Sluggish Pain + Usually 21d Deep Dermal Blotchy Red +/- Absent < Pain >3 wks Full thickness White No Absent <Pain No
- 7. Assess tissue perfusion - Blanching & capillary refill BURNS UNCOVERED - COVERED
- 8. BURNS UNCOVERED - COVERED Zone of injury – (stasis) Zone of stasis Jacksons Burn Model
- 9. BURNS UNCOVERED - COVERED Assess co morbidities
- 10. BURNS UNCOVERED - COVERED Day 5 Day 1 - 86yr F 18% bath scald Day 10
- 11. BURNS UNCOVERED - COVERED L O O K D O A I R W A Y B R E A T H I N G C I R C U L A T I O N D I S A B I L I T Y E X P O S U R E FLUIDS ANALGESIA TESTS TUBES Assess TBSA Rule of 9’s IV Fluids Parkland formula IDC/NG IV Opioids EUC/FBC/ABG/COA G Xrays A.M.P.L.E. History Head to Toe Examination Escaharotomy Tetanus Documentation and Transfer Support C spine O2 Haemorrhage control I.V. AVPU & Pupils Environmental Control Primary Survey First Aid Secondary Survey Emergency Management of Severe Burns (ANZBA 2014)
- 12. First Aid will provide pain relief as it decreases the inflammatory response, oedema, decreases cell damage ◦ Cold tap water 20 minutes, within 3hrs injury ◦ Aware of hypothermia (Cuttle and Kimble 2010) BURNS UNCOVERED - COVERED Cold tap water Burn Aid™
- 13. BURNS UNCOVERED - COVERED Escharotomy http://www.aci.health.nsw.gov.au/__data/assets/p df_file/0004/162634/Burns_Transfer_Guidelines_ 2013-14_-_web.pdf
- 14. Analgesia / sedation Betadine Incise medially /laterally avoiding nerves/veins Calcium alginate Antimicrobial dressing BURNS UNCOVERED - COVERED
- 15. BURNS UNCOVERED - COVERED Prontosan -.1 % Betaine (surfactant) and Polihexamethylene Biguanide PHMB (antimicrobial ) $12. 50 bottle Efective against Staphylococcus aureus, methicillin-resistant S. aureus, S. epidermidis, Pseudomonas aeruginosa, Escherichia Coli, and Klebsiella pneumonia, Anti fungal Cleansing
- 16. BURNS UNCOVERED - COVERED Epidermal burn/1°/Erythema Pain, red, intact, heal within <7 days Moisturise, protective dressing
- 17. BURNS UNCOVERED - COVERED Cleanse, silicone dressing eg Mepilex Lite™, retain with hypafix, elevate Superficial dermal/2°/Superficial Partial
- 18. BURNS UNCOVERED - COVERED Mid Dermal / 2 ° / Partial Thickness/ heals 7 - 10 days Incise blister, leave epidermis intact . 5% chlorhexidine with paraffin gauze Bactigras. - $12 roll
- 19. BURNS UNCOVERED - COVERED Deep Dermal burn /2°/Deep partial thickness burn Pink/white, pain , capillary refill >3 seconds. 2 - 3 weeks to heal, may require a graft Hydrocolloids dressings • gelatin, pectin, carboxymethylcellulose • Facilitates autolytic debridement Examples, Duoderm, comfeel wafer (10 x 10 cm2 $3.40 )
- 20. BURNS UNCOVERED - COVERED Full thickness burns / 3° white, leathery, charred, cherry red, no capillary refill, requires grafting
- 21. BURNS UNCOVERED - COVERED • Day 4 post flame burn • 93 yr old • 20% burn Full Thickness Burn / 3 ° Silver - Acticoat™
- 22. Nano crystaline silver Acticoat™ 40cm x 40cm $164 Reduces bacterial count by blocking the respiratory enzyme system and impairs DNA replication two layers of high-density polyethylene silver net with an inner layer of rayon Broad spectrum antimicrobial including gram pos/neg, MRSA, anti fungal slowly releases silver over 2 – 3 days if kept moist with water BURNS UNCOVERED - COVERED
- 23. BURNS UNCOVERED - COVERED Cling wrapMepilex Lite™ Solosite gel™ Hypafix™ border /sprayMoist kerlix™H2O
- 24. BURNS UNCOVERED - COVERED Biobrane Temporary skin substitute Day 1 – Contact burn 7% Dermal burn Ink cartridge exploded when thrown into fire Cost $41.17 per 100cm2 13cm x 38cm = $223 medium glove = $800
- 25. BURNS UNCOVERED - COVERED 10 days post burn Biobrane: The use of biosynthetic dressings is associated with a improved healing and a reduction in pain during burn dressings changes (Level I evidence Wasiak , 2009 Cochrane review)
- 26. BURNS UNCOVERED - COVERED Early Excision and Split Skin Grafting
- 27. BURNS UNCOVERED - COVERED SSG applied after debridement and surfasoft applied Surfasoft - polyamide transparent dressing $3.48 100cm2
- 28. BURNS UNCOVERED - COVERED 3 days post graft, surfasoft intact, reduces shearing allows exudate to move from wound to outer dressings
- 29. Burns uncovered - covered
- 30. BURNS UNCOVERED - COVERED Autologous SSG Allograft – donor screened Arrive frozen – 135c cryopreserved and streptomycin & penicillin. Thawed, rinsed, applied 40% TBSA $19,925
- 31. BURNS UNCOVERED - COVERED Kaltostat - $2.73 10 x 10 cm 2 Calcium/Sodium Alginate absorbent haemostatic fibre Aquacel Ag $20.07 10cm2 Broad spectrum CMC fibre Mepilex Transfer $ 7.42 10 x 10 cm Duoderm $2.34 10 x 10 cm Donor Sites
- 32. BURNS UNCOVERED - COVERED 93 yr female Day 10 post flame burn Day 1 post op, SSG, Biobrane Day 15 deceased Surgery – early excision ?
- 33. BURNS UNCOVERED - COVERED Day 5 post full thickness burn – delay in surgery Flammacerium applied. Flammazine provides Antimicrobial cover and the cerium nitrate hardens the eschar – reduces inflammatory Response Flammacerium Flammazine plus Cerium Nitrate $295 tub
- 34. Negative Wound Pressure Therapy VAC Foam $60, Cannister $65, Rent $65 day Burns uncovered - covered
- 35. BURNS UNCOVERED - COVERED Discharge7 days post surgery 10 days post surgery
- 36. BURNS UNCOVERED - COVERED Full thickness burn Neo Dermis applied - Pelnac™ 7 days post Pelnac 6 months post surgery 53 days post Pelnac 25 days post SSG
- 37. Conclusion Assess % Total Body Surface Area Rule of 9’s in the initial primary assessment Lund and Browder Chart Assess depth History Clinical examination - colour Capillary refill Burn wounds are dynamic Topical wound management can aid wound healing, control microbial activity, reduce pain Early excision of full thickness burn ideal BURNS UNCOVERED - COVERED
- 38. a nurse participant in Rudge’s (1998) study explained “...it’s such a horrific area to work in, visually... deal with the wound, wrap it up and they’re a person again” Mother of 21-year-old (32% flame burn) explained (Gullick et al 2014), “It took my breath away. It took everything I had not to cry... I had to think ‘This is your child, he’s no different’... A patient who had sustained a 36% flame burn (Skylas, Taggart, Gullick 2014) ‘Its hard and traumatic experience. I just wanted to get knocked out and just forget about it’. BURNS UNCOVERED - COVERED
- 39. 1. Herndon 2014 . Total Burn care Herndon, D. Total Burn Care, 2012. Forth Edition. Harcourt Ltd 2. Latenser B 2009. Critical Care of the burns patient: the first 48hrs: Critical Care Medicine Vol 37 no. 10 3. Cuttle L and Kimble R. (2010) First aid treatment of burn injuries. Wound Practice and Research, Vol. 18, No.1. 4. Orgill, D. P. and Piccolo N., Escharotomy and decompression therapies in burns. J Burn Care and Research, 2009. 30(5):p.759 -68 5. Wasiak J, Cleland H, Campbell F. (2009) Dressings for superficial and partial thickness burns (Review). The Cochrane Collaboration. Issue 1. 6. Macintrye PE, Scott DA, Schug SA, Visser EJ, Walker SM. (2010) Acute pain management: Scientific evidence. Australian and New Zealand College of Anaesthetists. 7. Greenwood JE, Clausen J, Kavanagh S. (2010) Experience with Biobrane; uses and caveats for success. Wound Practice and Research, Vol .18, No. 1, pp 50-56. 8. http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns_ Transfer_Guidelines_2013-14_-_web.pdf 9. Gullick J, Taggart S, Johnson R, Ko N 2014, The Trauma Bubble: Patient and family experience of serious burn injury, International Journal of Burn Care and Research. 10. Rudge T. Skin as cover: the discursive effects of 'covering' metaphors on wound care practices. Nurs Inq 1998;5:228-237. BURNS UNCOVERED - COVERED
- 41. Biobrane and Full thickness burns Burns uncovered - covered
- 42. BURNS UNCOVERED - COVERED Day 5 Day 1 - 86yr F 18% bath scald Day 10
- 43. DOMESTIC BATHROOM SCALDS IN THE ELDERLY • When elderly patients were ‘not fit for surgery’ the use of Versajet ™ successfully removed adherent burn tissue • Treatment continued with the application of hydrocolloids which supported autolytic debridement and epithelialisation Patient D 12 weeks post burn 4 weeks post Versajet ™
- 44. BURNS UNCOVERED - COVERED 7/9/12 Day 5 post burn day 2 post debridement Biobrane
- 45. BLISTER MANAGEMENT Option 2- Incise blister Day 1 Deep dermal burn - hot water scald
- 46. BLISTER MANAGEMENT Option 2 – Incise blister, Acticoat application
- 47. DEEP PARTIAL THICKNESS BURN Comfeel wafer™
- 48. Acticoat Metallic nano crystaline silver Broad spectrum antimicrobial including gram pos/neg, MRSA, Fungi minimizing the bacterial colonization of wounds 800 mcg/day Agryia Reacts much more slowly with chloride and thus is deactivated less rapidly in wounds – change every 2 -3 days Silvazine/Flammazine Ionic silver Active against Gram neg and positive bacteria minimizing the bacterial colonization of wounds Forms a pseudo-eschar over burn 3025 mcg/day rapidly deactivated by wound exudate (especially chloride ions), thus requiring daily application Contains sulphur - allergies Slows wound healing ( Wasiak 2009 The Cochrane Collaboration) BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
- 49. BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
- 50. Hypoperfusion: Full thickness burn - can not expand (protein denaturation and oedema). Perfusion is reduced therefore necessary to release burn surgically - escharotomy CASE STUDY: KUNUNURRA
- 51. BURNS UNCOVERED THEN COVERED Neuropathic Pain - Hyperalgesia, Allodynia ◦ Anti convulsants e.g. Gabopentin ◦ Anti depressants e.g. Amitriptaline ◦ Paracetamol ◦ Tramadol 8 days post contact burn 7 weeks post burn18 days post burn
- 52. Burn Wound dressings, Skin Substitutes and Bioengineered Skin Donor sites Duoderm $2.34 10cm2 Mepilex Transfer $7.42 10cm2
- 53. BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN Partial Thickness burns/Dermal Burns
- 54. BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN Cultured Epithelial Autografts - CEA
- 55. Skin biopsy for Cultured Epithelial Autografts CEA Burn Wound dressings, Skin Substitutes and Bioengineered Skin
- 56. Triad of critical care Hypothermia 33 ⁰c vasoconstriction/hypoperfusion Coagulopathy (ineffective platelet function) Myocardial performance Impairment of wound healing (Fredrikson 2011) BURNS UNCOVERED - COVERED
- 57. 57 WOUND PROGRESSION Day 1 post burn Day 3 Day 7 post burn, day 4 post Biobrane 74 yr old female, hot water scald
- 58. “My head looked like The Elephant Man... On the end of my shoulders was this thing like a Star Wars movie. It was disgusting… I was so embarrassed… my head blew up, so as the night went on I became uglier and uglier. It was like nothing I’d ever seen”
- 60. Wound healing trajectory BURNS UNCOVERED - COVERED