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

– Types:• Contact points of entrance

and exit• Arc wounds• Flame burns

– Cardiac• Anoxia and arrhythmias

including V Fib– Pulmonary

• Muscular paralysis

– Renal• Myoglobinuria leading to

acute renal failure– Neurological

• Loss of consciousness and/or anoxic injury

• Neuropathy– 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’ syndromeb. 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] keep 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

Dressing• INTEGRA

– 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 non-human– Homograft human [i.e. cadaver or live donor]– Allograft non-human– Autograft human [sheet / mesh]; self– INTEGRA artificial skin– Pedicle Flap [rotate and vascularize] / free flap -

capillaries by day 5 / attached by day 7– Xenograft 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 CareTypes 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 heterotopicossification…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.