Several considerations come into play when determining the best wound care process and product for patients and families.
- Extent and depth of burn wound
- Time of presentation from burn injury
- Location of burn wound
- Patient/ Family resources to do dressing changes
Wound care does not have to be sterile…it just needs to be CLEAN.
- Hand hygiene!
- If you are in direct contact with the patient and their wounds, gown and gloves are required. Masks and hats are optional.
- We do expect routine gowning/ gloving in the room of any patients with >20% TBSA burn wound (not just during wound care).
- Prior to application or reapplication of any topical agent, the wounds should be thoroughly washed with warm water and mild soap and all devitalized tissue removed.
- All ointment-based dressing changes should be done once or twice a day. Durable silver dressings do not require changes more often than every 5-7 days but should be monitored for drainage or associated redness.
Topical Wound Agents 101
Bland Ointments– Aquaphor, Bacitracin/ Neosporin/ Polysporin
Bland ointments are a safe choice for a burn wound. Patients often insist upon some sort of topical agent and dressing and these are the “usual suspects” for initial treatment of outpatient burn wounds.
Aquaphor works as a barrier and a moisturizer; it’s effective for areas of superficial burn that don’t blister and peel, as well as for faces with superficial partial thickness burns or for very small superficial partial thickness burns on other body parts. It has no antimicrobial properties. It is a pain-free ointment.
Depending upon your facility, Bacitracin, Neosporin, or Polysporin ointment may be available for areas of superficial partial thickness burn. All three provide coverage of gram positive organisms (typical skin flora, but not MRSA!) and they are non-toxic to the cells in healing wounds. These agents are all used in conjunction with a non-stick gauze to wounds on the torso or extremities. Over time, patients may incur a rash from bacitracin if it is in prolonged contact with uninjured skin.
Silver Sulfadiazene (SSD/ Silvadene)
Silvadene does not typically cause pain when placed on wounds and is effective against gram negative and gram positive organisms. The “carrier” within the cream does help to emulsify pseudoeschar but it does not penetrate into eschar. SSD is toxic to fibroblasts, so we try to keep our usage of it short-term only with a specific goal for its use. Because of the broader spectrum coverage, it is a good option for deeper wounds or wounds that may be developing a burn wound cellulitis.
Mafenide Cream
Mafenide (Sulfamylon) cream penetrates eschar, making it good for use on areas with minimal soft tissue atop cartilage (nose, ears) or for small, very deep burns. It has gram positive and gram negative antimicrobial coverage. The biggest limitation in its use is that it can be extremely painful and therefore it isn’t tolerated by all patients.
Durable silver dressings (Mepilex Ag and others)
Durable silver dressings like Mepilex Ag provide good broad-spectrum coverage (silver is antimicrobial!), tend to be comfortable for patients, and only need to be removed for re-evaluation of the wound every 5-7 days. They cannot get wet, so if a patient is committed to showering completely on a daily basis, these are not a good option. Also, wounds can not be overly moist or Mepilex Ag will slide around and not stay in place, so it is sometimes not the best option immediately following initial wound debridement.
Other durable silver products include Restore and Acticoat. These are more often used as postoperative dressings or for complicated wounds. Note: None of these products requires any additional topical antimicrobial agent because they all have silver.
Topical Wound Agents 201
Mupirocin
Mupirocin (Bactroban) provides coverage for MRSA. It is not commonly used for initial wound care, but may be used if we suspect MRSA colonization of a wound or if someone has burn wound impetigo.
Irrigations/ Solutions (Dakins, Mafenide)
Aqueous solutions are typically reserved for grossly infected wounds or postoperative wounds. Dakin’s and Mafenide are the two that are most readily available and used.
Dakin’s solution was commonly used for burn care until mafenide and SSD became widely available. Sodium hypochlorite is bactericidal down to a concentration of 0.025% and does cover gram-negative organisms. It can be used as a lay-on soak that is changed every 8-12 hours, or it may be irrigated through red rubber catheters placed into the patient’s dressings.
2.5% Mafenide (Sulfamylon) soaks have particularly good efficacy against gram negative organisms. It does penetrate eschar and is bacteriostatic; however, it does not counteract yeast or fungus. If it is over extensive areas, it may be associated with a metabolic acidosis because it is a carbonic anhydrase inhibitor. It can also be painful and may not be tolerated.
Mafenide will rarely be used as a lay-on soak; more commonly it is instilled via red rubber catheters that are placed within the dressings.