Chapter 12: Wound Care

wound care:  ________tub daily

________ssd bid to___________________

________xeroform daily to______________

________bacitracin to_____________________

________sulfamyalon cream bid to____________

________other__________

I.    The management of burn wounds continues to rely largely on daily surveillance by routine clinical examination.  Care plans may vary depending on the appearance of the burn wound, skin graft, or donor site. 

II.  The burn dressing is central to burn wound care and serves three functions:

A.      protection of the thermally injured skin from bacterial colonization by wound isolation 

B.      minimizing metabolic disturbances by reducing evaporative heat loss and reducing shivering

C.      providing comfort by eliminating surface air currents from the wound and by absorbing wound secretions.          

III.     Tub daily

   Tubbing facilitates the removal of debris and exudate that accumulates between dressing changes. Patients receiving dressing changes should, if possible, be brought at least once daily to the burn tub to have wounds cleansed.  The frequency of tubbing can be increased if wounds have especially profuse drainage.

IV.             Topical Agents

A.    Systemic antibiotics are rarely able to reach areas of avascular eschar. Topically applied antimicrobials provide high concentrations of antibiotic on the wound surface, where microbial numbers are the highest.  Topical antimicrobial therapy delays and minimizes wound microbial colonization[i]  and the subsequent risk of invasive burn infection.  However, none of the topical antimicrobials will totally eliminate the colonization of major burns.  Only in conjunction with close clinical monitoring and debridements will topical antimicrobials provide the best defense against the septic burn wound.

B.    Initially there are few bacteria on the surface of the burn wound and usually consist of normal cutaneous flora such as Staphylococcus epidermidis, some diptheroids, and perhaps Staphylococcus aureus.  After several days, S. aureus numbers begin to increase and typically will predominate.  Gram-negative species can also appear, and usually are from the Pseudomonas, Proteus, Klebsiella, and coliform species.[ii]^,[iii],[iv]  Clostridium are seen in high-voltage electrical injuries.  

V.  ssd bid to___________________

C.     Silver sulfadiazine (a.k.a. Silvadeneâ, Thermazeneâ, and SSDâ) is the most commonly used prophylactic topical antimicrobial in burn patients.  SSD is an insoluble, white cream, available in a 1% concentration and is applied twice daily.  SSD has the advantages of being relatively painless to apply, and its activity against a wide variety of organisms, including S. aureus, E. coli, Klebsiella, Pseudomonas aeruginosa, Proteus, the Enterobacteriaceae, and Candida albicans.

D.      The disadvantages of SSD are its poor penetration of eschar, and a transient leukopenia which occurs 2 to 3 days after therapy is initiated.  This leukopenia occurs in between 5 and 15% of patients, resolves whether or not the agent is withdrawn, and is not associated with any infectious complications.  Often a yellow-gray film, termed  “pseudo-eschar,” may form as a result of interaction between SSD and the wound exudates that can mask true burn depth diagnosis.

IV.             sulfamyalon cream bid to____________

A.    Mafenide (a-amino-p-toluene sulfonamide monoacetate) or Sulfamylonâ, is a water-soluble cream.  It has excellent antibacterial activity against most gram-positive (including clostridia) and gram-negative species.  However, it has limited activity against some staphylococci, especially methicillin-resistant strains, and limited antifungal activity.¹  Sulfamylon has excellent eschar penetration.  It is applied twice daily.

B.    Sulfamylon is a potent carbonic anhydrase inhibitor, and hyperchloremic metabolic acidosis is frequent when it is used on large burns.[v]  Respiratory compensation for the acidosis is typical and is manifest by hyperventilation and low PaCO₂.  The risk of systemic toxicity increase as the area treated increases.   

IV.             bacitracin to_____________________

Bacitracin , Neosporin, and Polysporin are petroleum and mineral oil-based topical antimicrobial ointments.  They are bactericidal for a variety of gram-positive and gram-negative bacteria, but have limited ability to penetrate eschar.  These ointments are applied to partial-thickness burn wounds.

V.                xeroform daily to______________

Xeroform is a fine mesh gauze dressing containing bismuth, and is designed to be an inexpensive, nonadherent covering with some antimicrobial properties.  On partial-thickness wounds and skin grafts, xeroform is applied once daily and covered with gauze.  For skin graft donor sites it is applied once and left to air dry in place. 

VI.             other__________

A.    Acticoat is an antimicrobial silver-coated barrier wound dressing.  In a study comparing Acticoat to silver nitrate, silver sulfadiazine, and mafenide acetate, Acticoat had the lowest minimum inhibitory and bactericidal concentrations, and generated similar zones of inhibition to silver nitrate and silver sulfadiazine. Viable bacteria were undetectable 30 minutes after inoculation with the dressing, whereas it took 2 to 4 hours for silver nitrate and silver sulfadiazine to achieve the same result.[vi]

B.     The dressing is applied to a clean, partial-thickness burn and is covered with gauze.  The dressing is then moistened with sterile water once daily for three days, after which time the patient returns to have new Acticoat placed, which remains in place until the next follow-up appointment.