Burn Wound: An update focusing the
classification, Immune responses and management resources aid in healing
Shubhangi Dwivedi*, Prashant Tiwari
School of Pharmacy, Chouksey Engineering
College, Bilaspur, India-495004
*Corresponding Author E-mail: shubh12987@hmail.com
ABSTRACT:
Burns are one of the most familiar and distressing forms of trauma
which results from excess exposure to heat, caustic chemicals, solar,
lumpectomy/ mastectomy, or radiation. Burn wound development remains an amazing
challenge for burn diagnosis and therapy. Patients with serious thermal injury
require immediate specialized care in order to reduce morbidity and mortality.
Significant thermal injuries induce a state of immunosuppression that
predisposes burn patients to complications due to bacterial colonisation and
invasive bacterial infection. The review sheds spotlight on the current outline
of classifications of burn wound infections, immunological responses of burns,
treatment strategies. Early excision of the eschar has substantially decreased
the incidence of invasive burn wound infection and secondary sepsis, but most
deaths in severely burn-injured patients are still due to burn wound sepsis or
complications due to inhalation injury. Burn patients are also at risk for
developing sepsis secondary to pneumonia, catheter-related infections, and
suppurative thrombophlebitis. The introduction of silver-impregnated devices
(e.g., central lines and Foley urinary catheters) may reduce the incidence of
nosocomial infections due to prolonged placement of these devices. Moreover
bioresources from plant and animal has served as an existing therapy in healing
of wounds and in restoration of skin’s integrity. Improved outcomes for severely burned
patients have been accredited to medical advances in fluid resuscitation,
nutritional support, pulmonary and burn wound care, and infection control
parameters in the aid of such harrowing condition .
KEYWORDS: Burn Wound, Immunologic responses,
treatment, silver impregnated devices.
1. INTRODUCTION:
An intact
human skin surface is imperative to the preservation of body fluid homeostasis,
thermoregulation, and the host's shielding against infection. The skin also has
immunological, neurosensory, and metabolic functions such as vitamin D
metabolism but thermal injury results in infringement on the surface of the
skin. A basic knowledge of skin anatomy and physiology is required to
understand emergency burn assessment and approaches in burn care management(1-3).
Notable
thermal injuries induce a state of immunosuppression that predisposes burn
patients to infectious complications. Early annotations of the immunodeficiency
that follows thermal injury were linked to works on “burn toxins” (4-6).
Moreover these observations were supported by the findings of prolonged
allograft survival, anergy, and increased susceptibility to infection in burn
patients (7-12). Despite improvements in the preliminary care of burn patients,
systemic inflammatory response syndrome, severe sepsis, and multiple-organ
dysfunction syndrome still remain as major causes of morbidity and mortality
(13-15). As a consequence, of which further efforts in the development of
immune modulators shows signs for future imminent enduring research.
Host
defense against infection can be divided into innate and adaptive immune
responses. The innate immune response acts immediately after the integument
system is breached and relies on a phylogenetically ancient system for
microbial recognition in which germ line-encoded receptors (pattern recognition
receptors) recognize structural components of microorganisms and viruses
(pathogen-associated molecular patterns) (16). The adaptive immune response
often takes longer, especially if it involves exposure to new antigens.
However, the adaptive immune response is a more efficient system for dealing
with recurrent infections, relying on immune cell memory, antigen recognition,
and clonal proliferation. The immunosuppression associated with burn injuries
has effects on both of these systems. Many in vitro and in vivo studies have
been conducted to characterize the immune responses and the relationships
between various cell types and inflammatory mediators. (17-21) with the summation
of the fact that the post alterations occurs in immune response after injuries
caused by burns.
Burn wound
infections is a severe complications that occur in the acute period following
injury (22-27). The most important patient characteristics that influence
morbidity and mortality from burn wound infection and sepsis is outlined below.
In addition, the impact of early excision on reducing burn wound infections is
discussed. Other factors that have played a significant role in decreasing the
overall fatality rates from burn wound infection and sepsis include the use
of topical and prophylactic antibiotics and advances in infection control
measures in modern burn units.
Impetigo
involves the loss of epithelium from a previously reepithelialized surface,
such as grafted burns, partial-thickness burns allowed to close by secondary
intention, or healed donor sites. Burn wound impetigo is not related to
inadequate excision of the burn, mechanical disruption of the graft, or
hematoma formation.
Both
excised burn and donor sites that have not yet epithelialized are included in
Surgical wound infections in burn patients. The wound has purulent exudates
that is culture positive. Surgical wound infections in open areas of the burn
show loss of synthetic or biological covering of the wound, changes in wound
appearance (such as hyperemia), and erythema in the uninjured skin surrounding
the wound.
Burn wound
cellulitis results from an extension of infection into the healthy, uninjured
skin and soft tissues surrounding the burn wound or donor site. This condition
is recognized by extension of erythema in the uninjured skin surrounding the
burn beyond what is expected from the injury itself. Burn wound cellulitis is
not associated with other signs of wound infection, but at least one of the
following manifestations is present: localized pain or tenderness, swelling
or heat at the affected site, progression of erythema and swelling, and signs
of lymphangitis and/or lymphadenitis extending from the affected skin area
along routes of lymphatic drainage to the area.
Patients
with areas of unexcised deep partial-thickness or full-thickness burn wound
have an increased risk of developing an invasive infection (28-30). This
complication may be indicated by a speedy allied transformation in burn wound appearance or character such as
separation of the eschar or dark brown, black, or violaceous discoloration of
the eschar. Manifestations of invasive infection of unexcised burn wounds
include inflammation of the surrounding uninjured skin, such as edema,
erythema, warmth or tenderness, evidence of microbial invasion into adjacent
viable tissue on histological examination, and positive blood cultures with
isolation of a pathogen in the absence of another identifiable source of
infection and systemic signs of sepsis, i.e., tachypnea, hypotension, oliguria,
unexplained hyperglycemia (e.g., increased serum glucose level that develops at
a previously tolerated level of dietary carbohydrate), and/or mental confusion.
Effective treatment requires surgical excision of the burn in addition to the
medical measures outlined previously.
The best
approach for scheduled infection surveillance of burn wounds is to utilize the
most appropriate sampling technique for the type of burn wound area being
cultured, since no single method provides a clinically relevant and reliable
result for unexcised wounds (e.g., eschar) versus those that have been excised.
Superficial swabs provide an adequate sampling of the microbial flora present
on the wound surface and are the most apposite and least invasive methodology
currently available for sampling of excised burn areas. Surface swabs are also
the only type of sample that may be taken from areas where the skin is too thin
to do a biopsy, such as over the ears, eyes, and digits. However, quantitative
cultures of burn wound tissue biopsy samples along with concomitant
histological analysis are the preferred infection surveillance approach for
burn areas that have not been or cannot be excised. Tissue biopsy samples
should also be sent for quantitative culture from infected burn wound areas in
patients with sepsis.
Simultaneous
culture of quantitative tissue biopsy, blood, and urine samples provides the
best approach for recovery and identification of the causative organisms and
their antimicrobial susceptibilities in the septic burn patient. This method
also provides an accurate assessment of the depth and extent of burn infection
in areas of indeterminate injury. Tissue biopsy analyses are also necessary in
order to diagnose unusual types of burn wound infection due to fungi and
viruses.
The basic surgical trouble is to
achieve permanent replacement of skin in extensive full-thickness and deep
partial-thickness burn injuries along with chronic wounds.
In the present scenario, split-thickness skin grafts are considered as the best
material for surgical repair of an excised burn wound. But in case of
burns that affect greater than 50% of total body surface area,
split-thickness skin grafts cannot be harvested as the patient has insufficient
areas .
Non
surgical wounds include chronic ulcers (pressure or decubitus ulcers,
venous ulcers, diabetic ulcers, ischaemic ulcers), burns and
traumatic wounds. The prevalence of methicillin-resistant Staphylococcus
aureus (MRSA) colonisation (i.e. presence of MRSA in the absence of clinical
features of infection such as redness or pus discharge) or infection in chronic
ulcers varies between 7% and 30%. MRSA colonisation or infection of non
surgical wounds can result in MRSA bacteraemia (infection of the
blood) which is associated with a 30-day mortality of about 28% to 38% and a
one-year mortality of about 55%. People with non
surgical wounds colonised or infected with MRSA may be
reservoirs of MRSA, so it is important to treat them, however, we do not know
the optimal antibiotic regimen to use in these cases. Moreover, basic aim is to
compare the benefits (such as decreased mortality and improved quality of life)
and harms (such as adverse events related to antibiotic use) of all antibiotic
treatments in people with non surgical wounds with established
colonisation or infection caused by MRSA.
Collagen
based dressings which is extracted from bovine skin and Achilles tendons, are
reconstituted for acute burn wound management in coastal areas
like Chennai known for high humidity as
closed dressings becomes infected soon and treatment with topical
antimicrobials, like Silver Sulfadiazine cream, quickly gets desiccated.
Collagen membrane dressings, manufactured by the biomaterial laboratory of the
Central Leather Research Institute (CLRI), Government of India in Chennai, with
the procedural process is patented.
Moreover
existing burn management is no longer exclusively meant at patient continued
existence but also focuses on optimal functional and esthetic outcome. From a
practical point of view, in order to avert hypertrophic scarring and functional
impairment, burn care revolves around two major therapeutic options: one being
conservative therapy applying dressings for burns with the potential to heal
within 21 days, and the other being early excision and grafting, aiming to
obtain early wound closure for burns that otherwise would take longer than 3
weeks to heal. In recent years, several new silver impregnated dressings have
been developed and put on the market to overcome the shortcomings of 1% silver
sulfadiazine(SSD). Most of these dressings are (semi) occlusive, require less
dressing changes and demonstrate a prolonged antibacterial effect due to a
sustained release of silver ions . (31,32)
In view of
the lack of comparative studies on contemporary silver dressings in burn care,
the study by Verbelen. J et al ,analysed
on wound healing, bacteriology, economics, nurse and patient experience
and aimed to compare two frequently used silver dressings, the nanocrystalline
silver dressing Acticoat and the Hydrofiber silver dressing Aquacel Ag, in the
management of partial thickness burns with an objectively diagnosed healing
potential between 7 and 21 days with the conclusion that Aquacel Ag dressing
appreciably amplified ease for patients.
Appropriate wound dressing
selection is guided by an understanding of wound dressing properties
and an ability to match the level of drainage and depth of
a wound. Wounds should be assessed for necrosis and infection,
which need to be addressed prior to selecting an ideal dressing.
Moisture-retentive dressings including films, hydrogels, hydrocolloids, foams,
alginates, and hydrofibers are useful in a variety of clinical settings. Antimicrobial-impregnated
dressings can be useful in wounds that are
superficially infected and are at high risk for infection. For
refractory wounds that need more growth stimulation, tissue-engineered
dressings have become a viable option in the past few decades, especially those
that have been approved for burns, venous ulcers, and diabetic ulcers.
As wounds heal, the ideal dressing type may change, depending on the
amount of exudate and depth of the wound (33).
Delay
in wound healing, graft losses, and development of sepsis may be due
to Acinetobacter baumannii infections in burn patients. Determining
the risk factors for multidrug resistant A. baumannii (MDR-AB) infections is
essential for infection control which is assessed by evaluation of the risk factors
for wound infections caused by A. baumannii
in burn patients. Univariate analysis found that high acute
physiological and chronic health evaluation II score, first excision time
of wound, invasive device usage, admission day to hospital, and prior usage
of broad-spectrum antibiotics were risk factors for nosocomial infections with
the consequence that multiple factors contribute to multidrug resistance in A.
baumannii. A combination of an early diagnosis of wound infections,
appropriate antimicrobial treatments, surgical debridement, and
early wound closure may be effective in the management (34).
4.
Bioresources in the pharmacotherapy and healing of burns
For many
years poor and chronic non healing wounds have constituted a serious
problem to medicine. Moreover treating such wounds is an expensive
and a long-lasting process consequently in this regard Professor Scheller's
achievement is spotlighted in using ethanolic extract propolis(is a resinous
substance derived from bees’ wax extract). It is claimed to have antimicrobial
(antibiotic and antifungal), anti-inflammatory, or immunomodulating, emollient,
and cicatrisation-enhancing properties.(35,36) in the treatment of patients
suffering from burns, venous crural ulceration, local sacral bone pressure
ulcers, suppurative osteitis and arthritis, suppurative postoperative
local wound complications,
and infected traumatic wounds. Reports also suggest use of
Honey, a viscous, supersaturated sugar solution derived from nectar gathered
and modified by the honey bee Apis mellifera, with evidence of its capacity to
accelerate wound healing, particularly in acute wounds such as partial-
thickness burns . For many decades Calendula officinalis, Berberis , Hypercium
perforaturm and Aloe vera has shown
promising effect in ensuring reestablishment of the integrity of skin and
extracellular matrix.
Successful
reconstruction of extensive anterior chest wall defect following major
electrical burn represents a very challenging surgery. Herein it is
elaborated of using pedicled full-thickness abdominal flap combined with skin
grafting to treat this injury with severe infection and exposure of pericardium
and ribs in a Chinese patient. Following the performance of chest debridement
to remove necrotic and infected tissues and the injection of
broad-spectrum antibiotics to reduce infection, a pedicled full-thickness
abdominal flap was used to cover the exposed pericardium and ribs, and skin
grafting from the right leg of the patient was done to cover the exposed vital
tissues. The patient was followed up for a total of 3·5 years, and satisfactory
cosmetic and functional outcomes were obtained without complications. This
report provides an effective method for the surgeons who encounter similar
cases where reconstruction of extensive anterior chest wall is required.
Complications
of infection can increase burn-related morbidity and mortality. Early
detection of burn wound infection could lead to more precise and
effective treatment, reducing systemic complications and the need for
long-term, broad-spectrum intravenous antibiotics. Quantitative cultures from
biopsies are the accepted standard to determine infection. However, this
methodology can take days to yield results and is invasive (37).
Hyperbaric
oxygen therapy (HBOT) is the use of 100% oxygen at pressures greater than
atmospheric pressure. Today several approved applications and indications exist
for HBOT. HBOT has been successfully used as adjunctive therapy
for wound healing. Non-healing wounds such as diabetic and
vascular insufficiency ulcers have been one major area of study for hyperbaric
physicians where use of HBOT as an adjunct has been approved for use by way of
various studies and trials. HBOT is also indicated
for infected wounds like clostridial myonecrosis, necrotizing
soft tissue infections, Fournier's gangrene, as also for traumatic wounds,
crush injury, compartment syndrome, compromised skin grafts and flaps and
thermal burns (38).
CONCLUSION:
To deal
with traumatic situation of burns ,skeleton of burn wound is depicted which
includes classification, immune responses of burn wounds , pathophysiology,
epidemiology and some of the updated treatment tools via surgical or non
surgical techniques like incorporating silver im pregnated devives and healing via sources derived from plant
and animal origin mentioned in the article. So the current review focuses on
the updated knowledge about the healing agent and novel approaches so that in
forthcoming time it should be referred as a primary treatment plan and be
widely available at burn care units to achieve the utmost goal of patient
compliance.
ACKNOWLEDGEMENT:
The authors wish to thank the
department of School of Pharmacy, Chouksey Engineering College, Bilaspur, India
for providing all the facilities to make this work a success.
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Received on 18.04.2014 Modified
on 12.05.2014
Accepted on 08.06.2014 ©A&V Publications
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