Wound Care

Dee Resha RN BSN LNC

Assisted by, edited with and otherwise harassed by: Don Hassencahl RN LMT
 Types of Burns
• Thermal
– Stop, drop, and roll
• Chemical
– Dilute chemicals
– Remove clothing
– Alkalis worse than acids
• Electrical
– Remove from source
 Skin Functions
• Maintains fluid and electrolyte balance
• Protects body from invasion
• Regulates body temperature
• Sensation
• Appearance
Depth of Burns
• Epidermis
• Dermis
• Subcutaneous tissue
and fat
• Muscle
Assessment of Depth of Burn
• FIRST DEGREE
• SUPERFICIAL
• Epidermal layer
• Pink, painful, and edematous
• Heals 3-5 days w/o scarring
• Causes:
– Flame
– Sun
– Flash from explosion
Assessment of Depth of Burn

• SUPERFICIAL
SECOND DEGREE
• Epidermis and papillary
region of dermis
• Blisters, bullae, serous fluid
• Cherry red moist appearing
• Painful, sensation intact
• Edematous
• Heals in 7-28 days with
minimal scarring
• Cause: flame, flash, scald,
contact
Assessment of Depth of Burn
• DEEP SECOND
DEGREE
• Epidermis and reticular region
of dermis
• Blisters, bullae, serous fluid
• Pale ivory moist appearing
• Painful, sensation intact
• Edematous
• Heals in 7-28 days with
variable scarring
• Cause: flame, flash, scald,
contact
Assessment of Depth of Burn
• THIRD DEGREE
• FULL THICKNESS
• Extends into subcutaneous tissue
• White, yellow, brown leathery
appearance
• Thrombosed vessels, loss of
elasticity, marked edema
• Possible escharotomy
• Painless to touch
• Requires grafting
• Causes: flame, electricity,
chemicals, prolonged exposure
• May take 2-3 days to fully present
true depth
Assessment of Depth of Burn
• FOURTH DEGREE
• Extends to muscle
• Loss of function
• Black, charred appearance
• May require amputation
• May require escharotomy and
fasciotomy
• Causes: very prolonged
exposure to flame, chemicals,
and high voltage
Escharotomy
• Full thickness,
circumferential burns
• Loss of circulation
• Loss of movement
• Performed medial
and lateral sides
• Relieves pressure
Zones of Injury
 Areas of Special Concern
• Face
• Ears
• Hands
• Feet
• Joints
• Perineum
 Special Types of Burn
• Tar and Wax
• Chemical Burns
– Material capable of causing necrosis
– Determine type of agent
• Strength
• Concentration
• Duration of contact
• Extent of penetration
• Mechanism of action
• MSDS sheets
– Alkaline materials worse than acid
• Acids cause coagulation necrosis
• Alkalis cause liquefaction necrosis allowing deeper penetration
– Estimation of size and extent difficult
 Special Types of Burn
• Smoke inhalation
– Carbon Monoxide Poisoning
• CO has stronger affinity for HGB than O2
• Signs of CO poisoning:
– Confusion, dizziness, HA, NV, flushed skin
• Treatment 100% FiO2
– Upper Airway Obstruction
• Common in head and neck burns and smoke inhalation
• Edema continues at least 24 hours
• Protect airway with intubation
• Edema usually decreases by post burn day 3
– Pulmonary Injury from Chemical Inhalation
• Develops ARDS within 24 hours post injury
• Pneumonia may occur as late as post burn day 10
 Special Types of Burn
• Electrical Burns – Renal
– Types: • Myoglobinuria leading to
• Contact points of entrance
and exit acute renal failure
• Arc wounds – Neurological
• Flame burns
• Loss of consciousness
– Cardiac
• Anoxia and arrhythmias
and/or anoxic injury
including V Fib • Neuropathy
– Pulmonary
• Muscular paralysis
– Musculoskeletal
• Spasms, tetany,
contractures,
compartment syndromes
– Gastrointestinal
• Ileus
 Special Types of Burn
• Electrical Burn Pathophysiology
– Electrical energy is converted to heat in direct
proportion to the resistance of the tissue
– Electricity takes the path of least resistance in
order of increasing magnitude:
• Nerve, blood vessels, muscle, skin, tendon, fat and
then bone
 Special Types of Burn
• Types of Electrical Current
– Direct current
• Lightning, car batteries, and defibrillators
– Alternating current
• Household appliances
• More dangerous than direct current at low voltage
• High voltage, high frequency AC is equally damaging as DC
• Currents >15mA result in tetany preventing voluntary release:
NO LET GO PHENOMENON
• 1000 volts is the minimum value for extensive tissue necrosis
and loss of limbs
 Special Types of Burn
• ARC BURNS
– External coursing of current along the surface
favoring the path of least resistance
– Can be drawn away by the person in contact for
distances up to 10 ft
• FLAME BURNS
– Results from ignition of clothing by electrical sparks
or arcing
• LIGHTNING
– Brief atmospheric discharge of electricity of enormous
energy
Special Types of Burn
• TENS OR STEVEN-
JOHNSON’S
SYNDROME
– Toxic epidermal necrolysis
mimics partial thickness
thermal injury
– Clinical symptoms are
fever, systemic toxicity and
cutaneous lesions
– Result of allergic reaction
to a drug
 Burns Associated with Child
Abuse
• History requiring closer evaluation
• Appearance of suspicious burns
• Documentation required
• Scalds with clear line of demarcation
typical of child abuse
• Other signs are wounds, fractures, bruises
and malnutrition
• Parent – child interactions
Rule of Nines
• Estimating size of burns –
total body surface area
[TBSA]
• Rule of palm
– Patient’s anterior hand
approximately 1% of body
surface area
• Note differences in
calculations for age
groups
 Wound Care
• Initial wound care
– Isolation or universal precautions
– Clean wounds – blisters debrided
– Shave hair for prevention of infection
• Daily wound care
– Pain med as needed
– Dressings soaked off
– Remove old topical and gently wash wounds. Debride loose tissue.
– Reapply topicals and dressings as ordered
• Debridement
– Remove dead tissue to get between dead and viable tissue
– Not so aggressive as to cause bleeding
– Some removed with coarse mesh gauze
– Debrided with sedation / analgesic / conscious sedation or general anesthesia
 Debridement
• Excision may involve
– Tangential excision – shaving layer by layer until a bleeding
[viable] bed is produced
– Primary or fascial excision – separate tissue at fascial layer to
minimize blood loss
– Fascia is the band or sheet of tissue investing or connecting
muscles
• Flaps & Amputation of non-viable limb are generally
referred to Plastic’s Service for further reconstruction
 Principles of Wound
Management
• Hemostasis and inflammation
– Platelets move to area
– Platelets release vasoactive substances leading to permeability
– Platelets release enzymes that attract leukocytes
– Platelets release growth factors which influence fibroblasts
– Wound characteitics: pink, warm, edematous, painful
• Wound 'clean up'
– Leukocytes [PMNs] begin ingesting bacteria and small debris
– Macrophages appear within 3-4 days and begin phagocytosis; release of
enzymes that trigger fibroblast response
– Lymphocytes release factors that activate granulocytes and fibroblasts
– Excessive or prolonged inflammation leads to greater macrophage response,
more fibroblast activity and greater scar formation
 Principles of Wound
Management
• Granulation tissue formation [begins 2-3 days]
– Macrophages stimulate endothelial cells from blood vessels begin
'budding' into wound, growing new capillaries
– Fibroblasts migrate to wound and begin laying down collagen [thin, rod-
like strands of protein]
– Some fibroblasts become myofibroblasts which have contractile
propertes…pulling wound margins toward middle
• Epithelialization
– Epidermal cells at margins of wound and surrounding epithelial
appendages begin multiplying and growing cells across wound surfaces
– Cell migration stops when epithelial cells meet
– If denuded area is too large for cells to migrate across, wound requires
grafting
 Infection
• Assess for infection [Sepsis]
– Disorientation, decreased UO, metabolic acidosis, tachypnea,
tachycardia, paralytic ileus, hyperglycemia, hyper[hypo]thermia
• Assessing bacterial loads
– Isolation
– Clinical signs
a. gram + colonization – sources, cellulitis, ‘melting graft’ syndrome
b. gram – colonization – sources, clinical signs, gram – shock
– Culture wounds by swab, punch biopsy, lab tests
 Non-surgical v. Surgical
Treatment of Burns
• TOPICAL AGENTS - most topicals are dressed with
coarse mesh gauze and dry [kerlex] wrap unless
specifically ordered to have moist dressings
• SSD [Silvadene - silver sulfadiazine cream]
– For unexcised burns and donor sites
– Water soluble & non-toxic, pain-free
– Bacterial spectrum against wide range of gram + / - organisms
and candida albicans
– Softens the eschar; may combine with exudate to form
gelatinous layer
– Applied 1 or 2 x/day with few side effects
 Non-surgical v. Surgical
Treatment of Burns
• Mafenide acetate cream - Sulfamylon
– Water soluble cream, actively diffusible into avascular tissue
[well-absorbed]
– Bacterial spectrum against gram + / - and some anaerobes,
painful on application
– Strong anhydrase inhibitor - can cause metabolic acidosis
– Can cause hypersensitivity reactions [rashes] so sulfa
– Cream or mixed in Sterile H2O as topical solution for specific
dressings
• Bacitracin or Petroleum ointments
– For shallow, partial thickness burns - to lips and face
– Against gram + organisms
– Sometimes used when MRSA discovered in wounds
 Non-surgical v. Surgical
Treatment of Burns
• Silver Nitrate [bulky wet dressings]
– Less frequently used secondary to staining and newer agents
• Dakin's Solution [0.025% sodium hypchlorite]
– Bactericidal without being tissue toxic
– Effective against Pseudomonas - not an antibiotic
• Bactroban [Mupericin] ointment
– For shallow, partial-thickness burns or donor sites
– Used for 'melting graft syndrome'
– Effective against gram +, used when MRSA cultured
 Non-surgical v. Surgical
Treatment of Burns
• Biobrane
– Biosynthetic dressing over donor sites or mesh autografts
– To be kept dry by positioning to achieve air flow [or air flow bed -
especially when used on posterior surfaces; sometimes dried
with heat lamp
– Left in place until wound heals beneath or urged off with SSD
application
• Xeroform
– Fine mesh gauze impregnated wit petrolatum and bismuth
– Primarily on donor sites
– Left exposed and encouraged to dry out
– In place until wound heals beneath
 Non-surgical v. Surgical
Treatment of Burns
• Aquaphor
– Lightly greased gauze that allows water / exudate
penetration
– For shallow wounds to prevent dressing adherence
and allow exudate to pass through

– Used less in some facilities secondary to belief

that Xeroform yields less occurrence of MRSA
than Aquaphor
 Non-surgical v. Surgical
Treatment of Burns
• Pigskin [Porcine Skin]
– Ideal material to cover large open wounds and control bacterial growth
– Prepare wounds for definitive closure
– Act as effective barrier to vapor and exudate
– *Ideal for treatment of TENS [Stevens Johnson Syndrome] as is Acticoat
• TransCyte
– For superficial and partial thickness burns
– Temporary skin substitute - not a wound dressing - applied once and stays on till
burn healed
– Also used on full thickness burns and left in place until autografting
– Changes from moist and clear in appearance to dry and crusty - may observe
yellow, green and brown discoloration
– Keep dry
– As healing occurs [wound epithelializes] the TransCyte will lift and the loose
edges should be trimmed
 Non-surgical v. Surgical
Treatment of Burns
• Silverlon Gloves & Wrap to BUE's [Barton
Gloves w/ SSD VUMC specific]
– Silver impregnated dressing for partial to full
thickness burns
– Moisten with Sterile Water every 4 hrs or prn to keep
moist
– Usually changed every 3 days
• BIP
– [Bismuth - iodophor - petrolatum] Ækeep exposed
tendons, ligaments, bones moist
Preservation of Tissue Bed Prior
to Grafting or Biological
Dressing
• Acticoat
– Silver activated b application of sterile water and
releases silver killing common bacteria as
Pseudomonas aerginosa, Pseudo stutzeri, and E-Coli
– Reduces potential of electrolyte imbalance
– Does not contain enzymes and will not debride wound
and eschar
– Effective barrier to bacterial penetration
– May be used over grafted partial thickness wounds
and INTEGRA
– Moisten every 6 hrs or prn to keep moist
 Preservation of Tissue Bed Prior
to Grafting or Biological
Dressing
• CEA [Epicel] - Cultured Epidermal Autografts [Cultured Skin]
– Wound bed needs to be meticulously prepared
– Early excision [within first 2 weeks of burn] with temporary covering of
homograft most suitable wound bed for grafting with CEA
– Coarse mesh gauze or bridal veil should be secured with staples to
protect CEA
– All devitalized tissue on and around area to be grafted with CEA should
be excised
– Recommend wound cultures 1 x/wk and 3 days pre-op to monitor
wound bed colonization
– Topical antibiotics to wound bed or dressing as with other biological
dressings if colonization a risk or simply cover with Xeroform or Adaptic
 Preservation of Tissue Bed Prior
to Grafting or Biological
• INTEGRA
Dressing
– Dermal regeneration template - a bi-layer skin replacement system
designed to provide immediate wound closure and permanent
regeneration of dermis
– a]bottom collagen / glycosaminoglcan [GAG] layer is a 3-dimensional
matrix of cross-linked collagen and GAG
– b]top silicone layer provides temporary epidermal coverage
– Bridal veil and stretch-net secured in place over INTEGRA with staples.
Application of Sulfamylon Solution or Acticoat Dressing are 2 agents
that are used to cover INTEGRA
• Daily observation done initially. Check facility for dressing
protocol.
• *Silastic Layer of INTEGRA is removed at approximately 3
weeks prior to autografting
Preservation of Tissue Bed Prior
to Grafting or Biological
Dressing
• INTEGRA [Cont]
• Monitor for:
– Good vascularization
– Neodermis formation [begins POD #1 but extends to POD #14-
28
• *Neodermis color will change thru progression from
red to pink to orange /peach to vanilla
– Neodermis blanches to touch and returns to orange /peachy
or vanilla color
– Granulation tissue is a deep red color and granular surface
bleeds easily - this forms at seam lines
Preservation of Tissue Bed Prior
to Grafting or Biological
Dressing
• Hematoma formation [usually form
within 24-48 hrs] treated by evacuation
• Treat with topical antimicrobials if
purulent or signs of infection - then
apply temporary covers [i.e. allograft]
until ready for autograft
Preservation of Tissue Bed Prior
to Grafting or Biological
Dressing
• Temporary Grafts
– Heterograft Æ non-human
– Homograft Æ human [i.e. cadaver or live donor]
– Allograft Æ non-human
– Autograft Æ human [sheet / mesh]; self
– INTEGRA Æ artificial skin
– Pedicle Flap [rotate and vascularize] / free flap -
capillaries by day 5 / attached by day 7
– Xenograft Æ non-human
Preservation of Tissue Bed Prior
to Grafting or Biological
Dressing
• Dressing takedown for any of the above should be
done daily or as ordered. May be necessary to do 2
x/day or as needed if risk or suspicion of infection /
colonization.
• More information on the types of potential bacteria /
organisms that may occur on excised wound bed
and /or grafts, and the topical agents used in treating
them are available on request or will be discussed
further during the Burn Core Workshop.
Preservation of Tissue Bed Prior
to Grafting or Biological
Dressing
• DONOR SITES - areas of harvested skin for
autografting
– Dressings used:
• Conformant
• Xeroform
• Beta Glucan
• Acticoat
• Silvadene
• Biobrane
• Sulfamylon Solution
Preservation of Tissue Bed Prior
to Grafting or Biological
Dressing
• Usually pressure dressing left intact for first
6-12 hrs to minimize bleeding then OTA
[open to air] to dry out and heal. As donor
site heals, dressing lifts and is trimmed off
accordingly.
• Donor sites usually are 2nd degree and heal
in 10-14 days; may be re-cropped once
healed
 Autograft Care
Types of autograft are 'sheet' or 'meshed'.
• Sheet Graft
– Whole graft laid intact on wound
– Used in cosmetic areas of body [face, neck, hands]
– Requires meticulous care to prevent accumulation of fluid beneath
which can impede vascularization
• Meshed Graft
– Skin passed thru machine which creates slits
– Can be expanded to cover larger wound
– Often wrapped and protected 3-5 days while becomes vascularized
• Alloderm [newer product]
– Radiation skin used in conjunction with autograft on areas where trying
to achieve greater flexibility … areas of release of contracture or
adhesions AND areas involving joints
 Autograft Care
• Care involves dressing plans,
deblebbing, use of splints /
compression, staple removal [5-10
days], specialty bed requirements and
mobility / immobility orders
• Grafts must be protected from
movement, pressure and shear.
 Post-surgical Healing Issues
• As the healing process evolves, burn wounds contract
destroying motion. Some common problems include:
– Shearing blisters
– Itching
– Contractures / Adhesions - secondary to the pliability and
mobility of tissues of joints
– Hypertrophic scarring - a raised, angry red mass which can
contract and distort surrounding skin*Not a KELOID which is a
scar that invades normal tissue
– Webbing - build up of scar tissue between digits if burn
dressings not applied appropriately to maintain spacing
– Chondritis - inflammatory process effecting the ears
 Post-surgical Healing Issues
• To minimize or prevent such problems it is an essential
to incorporate the Therapist's Role [OT / PT] in Burn
Care
– Splinting - when immobilization warranted after grafting; to
prevent deformity; for stretching soft tissue
– Pressure Garments - used to flatten hypertrophic areas and
provide vascular support to newly healed wounds, donor sites
and grafted areas
– Exercise Regimens
– Positioning - all involved extremities be elevated at all times.
When ambulating legs should be ace wrapped
 Post-surgical Healing Issues
• Typical problems & solutions
– Head / Scalp - occipital decubitus…frequent turning,
head positioner that distributes pressure
– Ears - chondritis - caused by pressure necrosis…no
pillow to keep ears free of pressure
– Neck - flexion deformity…no pillow
– Shoulders / Axilla - adduction contracture,
banding…position in 90 degrees of abduction / flexion
[arm trough, papoose, bedside tables
Post-surgical Healing Issues
– Elbows - elbow flexion contracture, loss of
supination, ulnar nerve compression and heterotopic
ossification…position in extension and supination
– Wrists - flexion contracture…support wrists in neutral
position with splints / pillows
– Hands - edema, claw hand deformity, decreased first
web space…elevation, resting hand splints, dynamic
flexion or extension splints, thumb splints
 Post-surgical Healing Issues
– Hips - flexion contracture…position flat, use
trochanter rolls at hips to prevent external rotation
– Knees - flexion contracture, peroneal nerve
palsy…elevate, avoid tight dressing, ace wraps for
vascular support for ambulation
– Ankles - plantar flexion contracture…foot splints
• OT / PT for Burn Patients, Nutritional Therapy
& Psychological Issues will be elaborated
upon further during another module of this
workshop.