Indian Journal of Burns

GURU SPEAK
Year
: 2016  |  Volume : 24  |  Issue : 1  |  Page : 3--7

Care of the burn wound: As I do it


Arvind Madhusudan Vartak 
 Department of Plastic Surgery, Bai Jerbai Wadia Hospital for Children; Masina Hospital; S.L. Raheja Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Arvind Madhusudan Vartak
A 54, Indrayani, 24, J.K. Sawant Marg, Dadar (West), Mumbai - 400 028, Maharashtra
India

Abstract

Skin covers the entire body. It is the most important protective organ. Since the burn injury is most painful of all injuries, dressings play an important part of the management. Dressing of the burn wound is very essential to provide pain relief, to promote early healing, to prevent contractures, and to help early mobilization. Many workers from time immemorial have used different types of dressings so as to provide desired results. I use sterile polyethylene drape as a dressing material after covering it with the first layer of gauze soaked in silver sulfadiazine cream. The results are encouraging as there is near total absence of pain experienced by patients and removal is totally pain-free without any bleeding. There is no need for escharotomies, and there is early removal of the slough with no contracture. The polyethylene drapes are easily available in the market, easy to store, available sterile, and totally cost-effective. They help reduce the hospital stay of the patient. The need of anesthesia for surgeries such as escharotomies and debridement is significantly reduced.



How to cite this article:
Vartak AM. Care of the burn wound: As I do it.Indian J Burns 2016;24:3-7


How to cite this URL:
Vartak AM. Care of the burn wound: As I do it. Indian J Burns [serial online] 2016 [cited 2017 Nov 19 ];24:3-7
Available from: http://www.ijburns.com/text.asp?2016/24/1/3/195531


Full Text

 Introduction



Burn injury is most painful of all injuries. Dressing a burn wound can be a very unpleasant experience for the surgeon, nurses, and patients. Any dressing change which adheres to the burn wound leads to marked trauma to new epidermal tissue. This leads to delayed healing and a personal suffering of the injured patient. It also leads to psychological disturbance of the patients. Such dressing changes take long theater time and many times needs anesthesia which further increases time and complexity of the procedure.

I would like to draw the attention to the fact that healing of the burn wound is a natural process. It is incorrect to take any credit for it. Our job is restricted to create nearly physiological environment around the wound so that we prevent the forces which are most likely to retard wound healing. All efforts should be made to prevent a state of burn shock. If the condition of hypovolemic shock occurs, the prompt correction is mandatory so that tissue perfusion in the region of the wound is maintained. Remember living cell is always moist. Drying of the burn wound should be prevented.

Suitable moisture retaining closed dressing will maintain the moist environment and also prevent the contamination of the burn wound (which is in reality sterilized by heat). The dressing should increase the patient's comfort, reduce pain, control infection, and if possible eradicate infection.

Various methods of treatment of the burn wound have been tried. The exposure technique, as well as semi-closed dressing, is no more recommended as it leads to desiccation of the exposed tissues leading to necrosis of newly growing epidermis. Wound colonization and later invasive infection occur easily. When an eschar has formed, the infection bottles up underneath. In the presence of an invasive infection, superficial burn wounds can easily get converted into a deep wound.

Closed dressing is the only answer. However, the closed dressing requires manpower, preferably separate dressing theater, and may require facilities for general anesthesia. Many hospitals have space and financial constraints. This leads to a compromise. They prefer exposure technique. The antibacterial creams, ointment, and sometimes oils are applied and left open to dry. Right from the times of Ambroise Pare, many workers have developed a variety of dressing materials and techniques with their own advantages and disadvantages. In spite of all that the quest for the ideal dressing material still continues.

Ideal dressing should have following properties:[1],[2],[3],[4]

Should prevent drying of the burn wound and maintain moist environment Convert dry burn eschar to moist burn surface Superficial burns should heal rapidly In deep dermal burns, epithelial proliferation should take place without damage to the delicate, growing epidermal cells In infected burn wound, it should be possible to use antibacterial cream or ointment Should help to clean the burn wound In full thickness burns- should not cause damage to granulation tissue Should be easy to make and sterilize Should be easy to use Should be inexpensive Should relieve pain during resting periods Should be painless to apply Should absorb wound exudate Should be painless to remove Should not adhere to the burn wound so as to prevent damage during dressing change Should possess adequate elasticity to facilitate physiotherapy Should be biocompatible.

Living skin autographs are the best. Human skin allograft (homograft) is also used by many in extensive burns with limited availability of the donor area. Homograft can be used as a temporary cover in very extensive burns as biological cover after excision of necrotic tissue either primarily or delayed primary excision of the burn wound. Autograft and the homograft can be also be used in combination as alternate strips or as a sandwich graft. Newly developed synthetic skin substitutes [5] are temporary covers and economically beyond the reach of an average patient in India.

Various other dressing materials have been used by many in India and abroad. Boiled potato peal (BPP) bandages [6],[7] were developed by Dr. M.H. Keswani at Bai Jerbai Wadia Hospital for children following a chance remark by a visitor. When she saw a lyophilized (freeze dried) skin, she compared it with a potato peal. After extensive work, the potato peal bandages were born. They were extensively used for many years with good results.

Dr. Mathangi Ramakrishnan of Chennai successfully used amniotic membrane [Figure 1][8] as well as collagen sheets with good results. Dr. Madhuri Gore from Mumbai recommended banana leaf [Figure 2][9] for the burn wound. Dr. Ranjit Mirje of Kolhapur very well organized the use of fresh porcine skin grafts [Figure 3][10] and has been very much satisfied with results. We are now using a polyethylene film as an occlusive dressing material for all the patients.{Figure 1}{Figure 2}{Figure 3}

 Serendipity



We had been using BPP [6],[7] bandages for dressing of the burn wounds. On some occasions, BPP bandages were not available. Next day, patients complained of severe pain. It was noted that BPP bandages helped mainly by retention of moisture.

In January 1999, one day BPP [6] bandages were not available. Sterile polyethylene drapes were used instead of BPP on the burn wounds of a 16-year-old girl with 40% burn injury for a couple of days. Later, when BPP bandages were made available; it was planned to use it again. The girl refused to take it and insisted that she wants to continue the same green dressing as it had given her complete relief of pain throughout the day (polyethylene film which was then available was green colored) The same dressing was continued.

Since then, the polyethylene dressing was used on few other patients with similar results. We are now using polyethylene film as a regular dressing material ever since for all the patients, with no regrets.

 Material



Polyethylene film is freely available sterile in the market for use as surgical drapes. We have made use of this film for cover over the conventional dressing. More than 1000 patients have been treated by this technique for more than 15 years to our satisfaction.

 Method of Dressing



Initial dressing of surgeon's choice can be done. We prefer to use silver sulfadiazine cream or silver nitrate gel ointment depending on availability. After covering the wound with gauze soaked in the dressing material (povidone iodine ointment or solution can also be used), sterile polyethylene film is then applied [Figure 4] and [Figure 5]. This is followed by a layer of gauze and cotton bandages. Crape bandages are tied on the affected extremities if involved. Dressing is changed every day. Anesthesia or analgesia is not required during dressing procedure. Some patients may require oral or injectable analgesics immediately after the dressing due to burning pain associated with the use of antibacterial agent. This pain may last for about 20–45 min and then subsides spontaneously. The severity of pain depends on individual patient's tolerance.{Figure 4}{Figure 5}

 Discussion



In the search for a suitable synthetic burn wound dressing, various commercially available materials have been investigated.[11] Most of the products adhere to the wound by cementation of their porous surface into the coagulum of the wound.[12],[13] One of the main advantages of polyethylene film dressing is that it can be stored at room temperature with no harmful effects on its biological function. Furthermore, they are easily available, delivered ready for use, in sterile pack at a very low price.

Management of burn wound falls into three categories, i.e.,[14],[15]

Exposure Semi-closed dressing with antibacterial cream or ointment, a layer of cotton gauze, and bandages Cover with biological material or synthetic membrane.[6],[16],[17],[18],[19],[20]

I do not recommend exposure and semi-closed techniques.

The discharge or oozing from the burn wound is a normal physiological function. When wounds are kept open as employed in exposure technique; there is evaporation of water from wound discharge. This leads to thickening of secretion. There is false appearance of dryness of the wound, when occlusive dressing is applied in the form of biological or synthetic material, evaporation from the wound is prevented, and the secretion remains less viscous. In colloquial language, the dry wound is synonymous with healed wound in this part of the world. In reality, the amount of exudation from the wound is same. If the wound appears dry and the oozing is absent, it does not mean that the wound is healthy. In fact, when the wound appears too much dry in spite of closed dressing, it indicates that peripheral tissue perfusion is poor. This patient may be in a state of septic shock. Many times, the appearance of wound discharge is interpreted by most of us as increase of infection in the burn wound. It should be noted that the presence of a wound discharge is physiological function of the body and does not cause any damage to the tissues even when the wound appears soggy.

Polyethylene dressing prevents dehydration of tissues by retention of moisture and provides more physiological environment around the burn wound.

Golan et al.[16] reported complete relief of pain with omiderm. Sykes and Bailey [17] as well as Peter and Frandsen [18] treated hand burns with occlusive synthetics bags/gloves with good results.

Most of our patients are totally pain-free throughout the day. There may be initial burning pain due to whichever ointment is used. This pain is usually within the limits of patient's tolerance and lasts for 20–45 min.

It is our subjective observation that there is less fluid loss and reduced heat loss. However, this observation will require further studies to evaluate.

There is no formation of eschar. The dead slough remains moist and soft. In circumferential burns, the constrictive effects of eschar are absent. As a result of this, the escharotomies are rarely required. However, few cases of burns may require fasciotomies if the compartment syndrome is suspected (due to damage of muscles below the deep fascia, e.g., in electrical injury).

Burn eschar is devitalized skin cover for the burn wound. Eschar is good medium for growth of the microorganisms and does not provide protection from infection.[21]

The physiological environment created by this dressing would allow rapid epithelial regeneration to achieve faster healing. Moisture retention prevents the damage to the growing epidermis during dressing changes.[7],[22],[23]

This property of prevention of tissue dehydration and simple maintenance of wound hydration permits quicker wound healing as the rapid reversal of capillary flow in the “zone of stasis” prevents the necrosis of dermal elements (such as sweat glands and hair follicles).[24]

The patients who arrive late from other hospital, where exposure treatment is practiced, already have a dry Eschar on them. After application of polyethylene film, the Eschar becomes moist in 24–48 h and is converted to moist burn surface. The slough softens and separates faster, which comes out easily. This removal of slough is possible without anesthesia during dressing changes. The granulation tissue does not get damaged. Full thickness burn is ready for skin grafting much faster.

Polyethylene film is easily available in the market as sterile polyethylene drapes. It is inexpensive (cost of sterile polyethylene film required for whole body dressing at its maximum is INR 100/-).

Polyethylene film is extremely easy to use. It can be applied over any dressing of surgeon's choice and irrespective of the type of antibacterial cream or ointment used. It is soft and conforms well to body contours.

The application of dressing and removal of dressing is almost painless. We do not use anesthesia for change of dressing with this technique.

 To Summarize



Application and removal of dressing is totally painless The patient remains very comfortable between the dressings. Almost all the patients do not ask for any analgesic during the day or night. They sleep comfortably Movements of extremities are painless, and active mobilization is possible (I do not recommend passive mobility exercises) Environment around the wound remains adequately moist or at times it may be watery The polyethylene film is soft and contours well along the body curvatures With the use of crepe bandages, contractures are very well prevented Dry eschar gets moistened within 24 h Slough become softer and comes out spontaneously or can be removed easily Cleaning of the wound after removal of dressing is easier Removal of the dressing does not cause bleeding or pain Dressing is very economical and freely available in the market all over the country as sterile polyethylene drape Partial thickness burn heals rapidly In full thickness burn slough softens separates easily. Granulation tissue is ready for skin grafting much faster.

Further comparative studies are recommended to evaluate the observations mentioned above.

 Conclusion



Use of polyethylene film as an occlusive dressing for the burn wound has been found to be extremely useful. Relief of pain, patient comfort, easy mobilization, and undisturbed epithelial regeneration are the main advantages of this dressing. Author feels that further studies to evaluate this dressing technique will yield promising results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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