Burn Wound Care: Opened Method vs. Closed Method

Opened Wound Care

The antimicrobial cream is applied every 12 hours and wound is left open to the air without any dressing.

Advantages:
The wound can easily visualized, easier mobility and joint range of motion, and simplicity in wound care.

Disadvantages:
Increase chance of hypothermia from exposure.

Closed Wound Closure

Gauze dressings are wrapped carefully from the distal to the proximal are of the extremity to ensure circulation is not compromised. The dressings are changes every 8-12 hours.

Advantages:
Using this method will decreases evaporative fluid, decreases heat loss and aids in debridement.

Disadvantages:
The disadvantages of this method are mobility limitation, prevents effective range of motion exercises, and limited of wound assessment.

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Burn Wound Care: Wound Closure

Wound closure of burn area is performed on the fifth to twenty-first day. It is depend on the extent of the burn area. Wound closure can prevent infection and loss of fluid, promotes healing and prevents contractures.

There are two types of wound closure techniques: temporary wound covering and permanent wound covering (autografting).

Temporary Wound Covering

1. Biological

Amnion:
The amniotic membranes from human placenta are used, and dressing is changes every 48 hours with amnion.

Allograft Homograft:
The donated human cadaver skin is used. Extra monitor for wound, sign of infection and sign of rejection. The rejection can occur within 24 hours.


Xenograft Heterograft
Xenograft over granulation tissue is replaced every 2 to 5 days until the wound heals naturally or until closure with autograft is complete.

Biosynthetic and Synthetic
Visual infection of wound is possible because dressing are transparent or translucent. Wound exudates and signs of infection should be monitored.

2. Autografting
Autografting is surgical removal of a thin layer of the client’s unburn skins, which then is applied to the excised burn wound that provide permanent wound coverage. This procedure is performed in the operating room under anesthesia. Bleeding following the graft should be monitored because bleeding beneath an autograft can prevent adherent. Autograft areas are immobilized 3 to 7 days following surgery to allow time to adhere and attach to the wound bed.

There are four types of skin grafts:

• Split Thickness: Graft of half of the epidermis, applied in sheets or postage stamp-like pieces.
• Full Thickness: Graft consisting of epidermis and dermis are used for reconstructive surgery months or years after the initial surgery.
• Pedicle Flap: This is used for reconstructive surgery months or years after the initial inury.
• Cultured Epithelium: The client’s unburned skin is used. Isolation of keratinocytes and culturing of epithelial cells in a laboratory and then are attached to the burn wound.

CARE TO THE GRAFT SITE:

1. Immobilize and elevate graft site and keep from pressure.
2. Avoid weight bearing
3. Remove exudates (if any) using roll a cotton-tipped applicator over the graft to prevent infections.
4. Monitor for foul-smelling drainage, increased temperature, fluid accumulation, hematoma, and increased WBC.
5. Instruct the client to lubricate healing skin with cocoa butter as prescribed, avoid using fabric softeners and harsh detergents in the laundry, protect the affected area from sunlight, and use splints and support garment as prescribed.

CARE FOR THE DONOR SITE:

• The methods of care for the donor site may varies depending on physician’s preference.
• A moist gauze dressing is applied at the time of the surgery to maintain pressure and stop any oozing.
• Keep the donor site clean, dry, and free from pressure.
• Apply lubricating lotions to soften the area and reduce the itching.
• Prevent the client from scratching the donor site.

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Burn Wound Care: Hydrotherapy and Debridement

HYDROTHERAPY

Burn wound area are cleansed by immersion, showering or spraying and no more than 30 minutes to prevent increased sodium loss through the burn wound, heat loss, pain, and stress. Client should be premedicated before procedure. Bleeding should be minimize and maintain body temperature during procedure.

Hydrotherapy generally is not use for patients who are unstable or those with ne skin grafts. So if hydrotherapy is not use, burn wound areas are washed and rinsed in bed before the application of antimicrobial agents.

DEBRIDEMENT

Burn Debridement means the excision of devitalized tissue and foreign matter from burn wound area. It can prevent bacterial proliferation and promote wound healing. Debridement may be mechanical, enzymatic, or surgical.

Mechanical:
This mechanical technique uses scissor and forceps to lift and trim away loose eschar. It is a painful procedure and may be bleeding and requires a moist environment to be effective. Dressings are applied directly to the burn wound area: wet-to-dry or wet-to-wet dressing technique.

Enzymatic:
Enzymatic technique means using prepared proteolytic and fibrinolytic topical enzymes that digest necrotic tissue, which facilitates eschar removal.

Surgical:
The eschar area is excised and covered. It may be tangential (shaving of thin layers of eschar until viable tissue is reached) or fascial (used for deep burns and removal of burn tissue and underlying fat down to the fascia).

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Burn Injury Management - Phase

1. EMERGENT PHASE
The emergent phase begins at the time of injury and ends with the restoration of capillary permeability (fluid resuscitation): 48-72 hrs following the injury. Key point is to prevent hypovolemic shock and preserve vital organ functioning. It includes prehospital and emergency room care.

Pre-hospital Care

• Remove source of the burn
• Assess airway, breathing, and circulation,
• Conserve body heat
• Cover burns with sterile or clean cloths
• Remove jewelry and clothing
• Intravenous fluid (if needed)
• Quick transport

Emergency Room Care
It is a continuation of care administered at the scene and implemented as the hospital policy or standard procedures.


For Major burns:

• Assess the degree and extent of the burn area
• Ensure a patent airway and administer 100% oxygen, assess for respiratory distress, blisters and edema on oropharynx
• Check arterial gases and carboxyhemoglobin level
• Peripheral intravenous access
• Monitor vital sign closely
• Keep NPO
• Insert nasogastric tube as prescribed
• Tetanus Toxoid and Pain medication as prescribed
• Escharotomy or fasciotomy as prescribed

For Minor Burns:

• Pain medication (morphine sulfate or meperidine)
• Oral analgesic and Tetanus toxoid as prescribed
• Wound Care

2. RESUSCITATIVE PHASE

It begins with the initiation of fluids and ends when capillary integrity returns to near normal. Keys point is to prevent shock by maintaining adequate circulation blood volume and vital organ perfusion. And the successful fluid resuscitation is evaluated by stable vital signs, adequate urine output (30-50 mL/hr) palpable peripheral pulses, and a clear sensorium.

Fluid replacement is calculated from the time of injury not from the time of arrival at the hospital. The amount of fluid given is based on the body weight and extent of the injury.

Common Fluid Resuscitation Formulas (24 hours after burn injury)

Parkland (Baxter) Formula:

• 4 mL/kg per percent TBSA burned.
• Half is given in first 8 hours
• One-quarter each next 8 ours
• Solution: Lactated Ringer’s

Modified Brooke Formula:

• 2.0 mL/kg per percent TBSA burned
• Half is given in first 8 hours
• Half in next 16 hours
• Solution: Lactated Ringer’s

3. ACUTE PHASE

It begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun, usually 48-72 hours after the time of injury. Key point is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy.

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