Course : B.

sc(Nursing)
Subject : Medical Surgical Nursing II
Unit number : IX-Burns
Topic : Burn Wound Management

Prepared by
Mrs.M.Kavitha
Asso.Prof.
 Objectives

At the end of the presentation the students will be able to

• define burn wound management
• enlist the goals of burn wound management
• discuss initial burn wound care management
• identify topical wound care management
• explain in detail about surgical wound care management
• outline patient education with burn wound
• state continuing care of patient with burn injury
 Introduction

• A basic understanding of 

burn wound treatment can reduce pain and facilitate healing of
all four types of burns
. Burns are specifically damage caused to one or multiple layers
of skin and flesh by external sources such as heat or chemicals,
and range in severity from minor to major. The level of severity
is denoted by the “degree,” with each degree noting a higher
level of damage starting at first degree and moving as far as the
fourth degree. Understanding and identifying burns properly will
increase your chances of successful treatment and effective
healing.
 Definition

Burn wounds Management includes

cleansing and debridement and routine burn
wound dressing changes, typically
incorporating topical antimicrobial agents to
prevent or control infection or to enhance
wound healing .
Burn Wound
Burn wound-Cont..

• First‐degree burn”: Epidermal burn that shows only reddening of

the injured area and cures without scars.

• “Second‐degree burn”: Usually classified into two types

according to the depth.
 Superficial dermal burn (SDB): A burn that forms a blister.
The dermis at the floor of the blister is red. Usually cures
after epithelialization in 1–2 weeks. Generally leaves no
hypertrophic scar.
Burn wound- Cont…

 Deep dermal burn (DDB): A burn that forms a blister. The

dermis at the floor of the blister is white and anemic. The
injury requires 3–4 weeks until cure by epithelialization but
is likely to leave hypertrophic scar or cicatricial keloid.
• “Third‐degree burn”: Deep burn causing necrosis of the full
thickness of the skin. It includes burns with a white or brown
leather‐like appearance and burns with completely charred skin.
Because epithelialization progresses only from the margins of the
injury, 1–3 months or longer is needed until cure, and
hypertrophic scar or cicatricial contracture occurs without skin
grafting.
 Selection of dressing

• The selection and application of burn

wound dressings and topical agents
depends
• The nature
• Extent of the burn wound,
• Nature of the Wound (eg, contamination,
infection)
• The patient's allergy history.
Burn wound management

1.Initial burn wound management

• Wound debridement

2.Topical burn wound management

• Wound dressing
• Topical antimicrobial for burn wound
• Anti microbial peptide
3.Surgical burn wound management
• Escharotomy
• Negative pressure wound therapy
• Stem cell therapy
Burn wound management-Cont…..

• Skin grafting with autograft

• Skin allograft and xenograft
• Uncultured skin autograft
• Cell suspensions
• Skin tissue engineering
• Hyperbaric oxygen therapy
• Growth factors and biological wound products
Goals

• Prevention of conversion owounds that dry out or develop an

infection can become deeper. A partial-thickness wound could
then convert to full-thickness and require skin grafting.
• Removal of devitalized tissue odebridement, either through
dressing changes or surgery, is necessary to clean the wounds
and prepare for spontaneous healing or grafting.
• Preparation of healthy granulation tissue ohealthy tissue, free of
eschar and nourished by a good blood supply, is essential for
new skin formation.
Goals-Cont…
• Minimization of systemic infection oeschar contains many
organisms. Removal is essential in order to decrease the
bacterial load and reduce the risk of burn wound infection.
• Completion of the autografting process ofull-thickness wounds
require the application of autologous skin grafts from available
donor sites.
• Limitation of scars and contractures owounds that heal well the
first time tend to have fewer scars and contractures. Some
degree of scar and contracture formation are, however, part of
the healing process and cannot be entirely prevented.
Initial burn wound management

• The basic steps of wound management are prevention of

further wound contamination, debridement of dead and
dying tissue, removal of debris and contaminants.
• provision of adequate wound drainage.
• promotion of a viable vascular bed and selection of an
appropriate method of closure
Initial burn wound management-cont..

Wound debridement
• Debridement is the removal of devitalised tissue from a wound
to encourage rapid onset of the proliferative phase of wound
healing.
1. Enzymatic
2. Mechanical or Hydrodynamic
3. Surgical
• Properly used enzymatic agents dissolve wound exudates,
coagulum and necrotic debris without directly harming living
tissue.
Initial burn wound management-cont..

Advantages
• to apply enzyme solutions
• without anaesthesia and to use them in areas with
• important structures such as nerves and tendons. Wet
• saline bandages over the wound will enhance the
• enzymatic action.
Initial burn wound management-cont..

Disadvantages
• expense,
• time required for adequate debridement
• frequency of dressing changes
Topical Burn Wound management…..
Wound dressing
A moist environment encourages angiogenesis
which is essential for the delivery of cellular
components for wound healing.
Purposes:
•to minimise haematoma and
•oedema formation, reduce dead space, protect
against
•additional contamination or trauma, absorb
drainage,
•establish adequate oxygen tension, maintain a
moist
•environment and minimise motion
Topical Burn Wound Management-Cont….

Characteristics-Burn wound dressing

•Ease of application
• Bioadhesiveness to the wound surface
• Sufficient water vapour permeability
• Easily sterilised
• Inhibition of bacterial invasion
• Good mechanical strength and elasticity
• Compatible with therapeutic agents
• Optimum oxygen permeability
• Biodegradability
• Non-toxic
 Topical Burn Wound Management-Cont…
Types of dressing used in burn
Topical Burn Wound Management-Cont…
Topical Burn Wound Management-Cont…
Topical Burn Wound Management-Cont….

• Dressing Changes
 First dressing change- 24-48hrs after injury
 Later Change – Once or twice per day
 During changes
• Soak the wound with normal saline
• Remove very slowly to avoid breakage of healed
skin
• Apply silver sulfadiazine or antibiotic ointment
 Non-Complex wound & no healing in 2 weeks Refer for
excision or grafting
Topical Burn Wound Management-Cont

Topical Antimicrobial for Burn Wound

• used prophylactically to prevent infection

• to kill the actually microbial cells that are proliferating
within the burn when an infection has developed
Topical Burn Wound Management-Cont….
Topical Antimicrobial for Burn Wound
Topical Burn Wound Management-Cont….

Antimicrobial peptide (AMP)

• AMPs are small (12–50 amino-acids), have a positive charge and an
amphipathic structure that enables them to interact with bacterial
membranes. AMPs have a higher affinity for microbial membranes
compared to the membranes of host cells and therefore preferentially lyse
the pathogenic, microorganisms
• to kill Gram-negative and Gram-positive bacteria
• (including strains that are resistant to conventional
• antibiotics), mycobacteria (including Mycobacterium
• tuberculosis), enveloped viruses, and fungi.
• AMPs also participate in multiple aspects of immunity
Surgical Management for Burn wound

• Escharatomy
Eschar- Full-thickness circumferential and near-
circumferential skin burns result in the formation of a tough,
inelastic mass of burnt tissue. The eschar, by virtue of this
inelasticity, results in the burn-induced compartment syndrome.
• Escharotomy is the surgical division of the nonviable eschar,
which allows the cutaneous envelope to become more
compliant. Hence, the underlying tissues have an increased
available volume to expand into, preventing further tissue injury
or functional compromise
Cont….

Negative pressure wound therapy

 The vacuum-assisted closure device used for stimulation
of mitogenesis and elaboration of growth factors, due to
imposed tissue strain, evacuation of excessive tissue fluid or
oedema, and reduction of bacterial colonization within the
wound.
 The NPWT has been used for a broad indication spectrum
ranging from eradication of infection and decrease of the
depth in cavity wounds to stimulation of granulation tissue in
areas with exposed tendon or bone.
Cont….
• Stem cell therapy
 To restore the damaged skin both structurally and
functionally to its original state by the great potential
of stem cells in improving the rate and quality of wound
healing and regenerating the skin and its appendages.
Mesenchymal stem cells appear to synthesize higher
amounts of collagen and several growth and angiogenic
factors
Cont….

• Skin Grafting with Autografts

 The patient donates its own tissue.
 remove a thin layer of skin from the donor site (most
 commonly a conspicuous area such as inner thighs and
buttocks) that includes the full epidermis and portion of
the dermis, or what is commonly known a split-thickness
graft.
 skin graft is then placed on the wound site, the graft is
meshed to enable stretching it over the larger area.
Cont….

• Skin Allografts and Xenografts

Allografts are harvested from consenting donors after death
and stored frozen in skin banks
• Xenografts made of pig skin have also been used for the
same purpose
Cont….

• Uncultured Skin graft

• Sheet graft(piece of donor skin that is used to patch a burned area is
about the same size as the burn size).
• Meshed skin graft(Meshing is a mean to enlarge donor skin. Meshing
involves running the donor skin through a machine that makes small
slits, which allows expansion similar to that in fish netting.
it allows blood and body fluids to drain from under the skin grafts,
preventing graft loss, and it allows the donor skin to cover a greater
burned area because it is expanded
Cont….

• Cultured skin graft(In massive burns, however, the available skin

donor sites for autografting may be very limited. This has fostered
the development of alternative methods such as autologous cultured
skin graft
• Cell cultured epithelial autograft
"gold standard" to resurface large wounds. So, cultured epidermal
sheet autografts became available to complement autologous split
thickness skin grafts in treating major burns or other large wounds.
Cont….

• Cell suspensions
technique of "epithelial cell seeding" to treat chronic wounds
and wound cavities. harvested epithelial cells or cell clusters by
scrap- ing off superficial epithelium from a patient´s forearm with
a surgical blade until fibrin was exudated from the wound. This
mixture was then applied to wounds.
used an aerosol device to spray epithelial cells on wounds
They noted that re-epithelialisation, re-growth of epithelial
tissue over a denuded surface, was quicker
Cont….

• Skin tissue engineering

The skin is indeed a complex structure incorporating a fusion of
several different cell types, integrated within a three dimensional
matrix containing both fibrillar and non-fibrillar elements.

• Essential characteristics are that it heals well and has the physical
properties of normal skin. To achieve effective healing, the tissue-
engineered products must attach well to the wound bed, be
supported by new vasculature, not be rejected by the immune
system and be capable of self repair throughout a patient’s life
Cont….

• Hyperbaric Oxygen Therapy

 use of 100% oxygen at pressures greater than
atmospheric pressure.
The increased atmospheric pressure increases arterial
oxygen pressure (PaO2), which in turn causes
vasoconstriction on the arterial end reduces capillary
pressure, which promotes fluid absorption into the venous
system thereby reducing oedema, as well as causing an
increase in hyper-oxygenated plasma to the tissues.
Cont….

Tissue repair processes such as collagen elongation and

deposition and bacterial killing by macrophages are dependent
upon oxygen, facilitate wound healing
• Growth Factors and Biologic Wound Products
 cellular mediators(eicosanoids, cytokines, nitric oxide, and
various growth factors)
Eicosanoids are arachadonic acid metabolites including
prostaglandins, prostacyclins, thromboxane, and leukotriene.
They primarily affect the early stages of wound healing including
initial vasoconstriction and later vasodilation, vascular
permeability, and inflammatory cell chemotaxis and adhesion.
Cont….

• Growth Factors and Biologic Wound Products

 cellular mediators(eicosanoids, cytokines, nitric oxide, and
various growth factors)
Eicosanoids are arachadonic acid metabolites including
prostaglandins, prostacyclins, thromboxane, and leukotriene.
They primarily affect the early stages of wound healing including
initial vasoconstriction and later vasodilation, vascular
permeability, and inflammatory cell chemotaxis and adhesion.
Patient Education

• Pain and itch management

• Resuming activities of daily living
• Preventing burns in the future
• Recognition of complications associated with a burn injury
• Aftercare of the burn wound (scar management and protection)
• Psychosocial care, information and support available
• Key contact details (including 24-hour access to the clinical
team)
• Patient support groups
• Follow-up appointment details and location.
Continuing care of patients with a burn injury

• Genaral health
• Skin care
• Burn itch
• Hypertrophic scarring
Continuing care of patients with a burn injury-Cont..

• General Health
Eat a high-calorie/high-protein diet with fresh fruit and
vegetables and avoid refined foods and commercially-baked
products
Maintain hydration — drink 6–8 glasses of water a day and
avoid caffeine and alcohol
Take a multivitamin or daily nutritional supplement (especially in
those who are immunocompromised)
Stop smoking QAttend to basic principles of cleanliness and
good personal hygiene.
Continuing care of patients with a burn injury-Cont..

• Skin care
 Healed burns-Sensitive/Dry scaly/Numb/Irregular
Pigmentation
 moisturised daily with a non-perfumed emollient (e.g.
mineral oil, petroleum jelly or almond or coconut oil)
 massaged using a downwards, circular motion to reduce
dryness and to keep the healed area supple
 use a sun cream with a high sun protection factor (30–50)
for 12–24 months to prevent further thermal damage and
pigmentation changes.
Continuing care of patients with a burn injury-Cont..

• Burn Itch
 usually begins at the time of wound closure and peaks at
2–6 months after injury
 Skin moisturizer
 Oral antihistamine
 Topical antihistamine
 Keep fingernails short-not to scratch
Continuing care of patients with a burn injury-Cont..

• Hypertrophic Scarring
 Dense, thick, non-uniform layer of collagen fibers
 3Rs — Raised, Rigid, Red
 Contractures & altered pigmentation
 Pain & Itch
 Massage and moisturize
 Pressure garments
 Physiotherapy
 Camouflage
Multidisciplinary support

• Psychosocial support
• Physiotherapy/Occupational therapy
• Returning to work
Summary

• Wounds are one of the most harmful and complex physical

injuries. They often happen unexpectedly and have the potential
to cause death, lifelong disfigurement and dysfunction. The
effective management of wounds will reduce the number of
complications and allow rapid return to normal function.
References

• http://www.uptodate.com
• http://www.rch.org.au/burns/clinical_information
• Westernhealth.net/uploads
• http://www.reserchgate.net
• http://online library.wiley.com
• http://www.woundsinternational.com