Managing severe burn injuries: challenges and solutions in complex and chronic wound care

Figures & data

Table 1 Important growth factors and their principle responsibilities

Growth factor	Function
Platelet-derived growth factor	Chemotaxis, inducing cells to the wound bed
Transforming growth factor	Extracellular matrix synthesis, inhibition of cellular proliferation, neutrophil chemotaxis
Fibroblast growth factor	Endothelial cell, fibroblast, chondroblast, and osteoblast mitogenesis; angiogenesis
Epidermal growth factor	Fibroblast and keratinocyte proliferation
Vascular endothelial growth factor	Angiogenesis
Insulin-like growth factor	Granulation tissue formation and reepithelialization
Interleukins	Proinflammatory, immune cell growth/ differentiation

Figure 1 Dominant cellular components in the healing process.

Note: X-axis: time to 1 year; Y-axis: volume/quantity.

Figure 2 Summary of prominent wound-healing processes, clockwise after “trauma”.

Figure 3 Graft loss where regrafting was offered.

Figure 4 Graft loss on the back after major burn injury.

Note: Healing occurred subsequently using Prontosan gel and occasional silver nitrate applications to address overgranulation.

Figure 5 A traumatic degloving wound of the right thigh and buttock.

Notes: A cavity posterior-laterally was intentionally not autografted, and complete wound healing occurred with negative-pressure wound therapy and instillation.

Figure 6 The antioxidant proforma for patients with complex wounds and burns.

Figure 7 Outline of structured approach to wound assessment and management.

Table 2 Agents in common use at the RTBC

Agent	Percentage	Formulation	Biocompatibility^a	Chief indications at RTBC
Chlorhexidine digluconate	4%	Solution or soap	0.7	Surgical site preparation; broad spectrum
Sodium hypochlorite (Dakin’s 1:10)	0.05%	Solution	N/A	Topical antiseptic; broad spectrum, especially Gram-positive organisms
Povidone iodine (Betadine)	7.5% or 10%	Solution or soap	0.9	Surgical site preparation; broad spectrum
Acetic acid	0.5%	Solution	N/A	Topical antiseptic; Pseudomonas aeruginosa especially
Mafenide acetate (sulfamylon)	5%	Solution or powder	N/A	Ear burns; topical antiseptic
Polyhexamethylene biguanide (B. Braun, Melsungen, Germany)	0.1%	Gel or solution	>1	Topical antiseptic, wound irrigation, face care, biofilm
Silver nitrate	0.5%	Solution or sticks	<0.1	Suppress overgranulation
Silver sulfadiazine (Flamazine) (Smith and Nephew, Hull, UK)	1%	Cream	<0.1	Early burn wound antiseptic cream
Mupirocin (Bactroban) (GlaxoSmithKline, Brentford, UK)	^–	Ointment or cream	N/A	Restricted to MRSA infections and eradication
Bacitracin	–	Ointment or solution	N/A	Surgical irrigation
Polysporin (Polyderm) (B. Braun)	Polymyxin B sulfate/ bacitracin zinc	Ointment	N/A	Small unhealed areas, facial burn care

Notes:

a Biocompatibility index for selected antiseptic substances after 30-minute contact in minimal essential medium cell culture in the presence of 10% fetal bovine serum (L929 cells/Staphylococcus aureus).¹³ N/A indicates those not tested in referenced study. Data from Hirsch et al.¹⁵

Abbreviations: RTBC, Ross Tilley Burn Centre; MRSA, methicillin-resistant S. aureus; N/A, not available; -, not applicable.

Table 3 Summary of protocol for the use of antiseptic soaks for infected wounds at Ross Tilley Burn Centre

Tissue biopsy if possible to confirm infection, classification, agent, and resistance pattern Systemic antibiotics only if features of systemic infection, marked erythema, after definitive closure, if allograft is not available, in deep burns Early surgery for deep burns irrespective of infection; preferably, allograft coverage followed by autografting at a later stage when resolution of infection is noted If daily antiseptic soaks are deemed necessary (rather than the nanocrystalline silver Acticoat, for instance), acetic acid, Dakin’s 1:10, or sulfamylon soaks may be considered. Acetic acid has specific antimicrobial action against moist infected wounds suspected by its green exudate of harboring Pseudomonas. Dakin’s 1:10 or sulfamylon may be more appropriate for cellulitic burn wounds with or without exudate, although the latter may be restricted for cartilaginous areas. Silver nitrate may be reserved for resistance cases, on account of its unfavorable BI. Povidone iodine is reserved for operative preparation, and chlorhexidine digluconate for preoperative scrubs and mouthwashes Consider applying a negative-pressure dressing to facilitate antiseptic dressings via instillation rather than frequent dressing changes Appropriate systemic antibiotics should be administered at the time of induction of general anesthetic Strict limb elevation (if applicable), although physiotherapy should continue Protocol will differ depending on stage of care, pre- or postoperatively, autograft or allograft, deep or superficial burn Soaks should only be used for three consecutive days, after which the wound should be reassessed, and the need for ongoing antiseptic evaluated. Preferably, the wound should be reassessed on a daily basis Prontosan, either in gel or solution form, should be considered as a stand-alone agent, or as the agent to use after the 3 days of antiseptic soak therapy

Abbreviation: BI, biocompatibility index.

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