Minor Burns and Wounds Student Version PDF

Minor Burns and Wounds Julie Wilkinson, PharmD, MS, BCPS Reading Assignment This presentation summarizes the textbook chapter: Stelter N, Minor burns, wounds, and sunburn. In: The Handbook of Nonprescription Drugs Learning Objectives Explain the layers of skin and different...

Minor Burns and Wounds Julie Wilkinson, PharmD, MS, BCPS Reading Assignment This presentation summarizes the textbook chapter: Stelter N, Minor burns, wounds, and sunburn. In: The Handbook of Nonprescription Drugs Learning Objectives Explain the layers of skin and differentiate injury based on the depth of skin involvement Recognize the identification of minor injuries and the steps for management Determine situations that need urgent medical attention Recommend self-care when appropriate Differentiate common dressings Identify pharmacologic products used as skin protectants Explain basics of management for more serious chronic wounds  Sunburn Overexposure to ultraviolet A (UVA) and B (UVB) from sun or tanning lights Thermal burn Skin contact with flames, scalding liquids, hot Burn objects Electrical burn Entry point and flow to exit point with heat Chemical burn Exposure to corrosive or reactive chemicals Wounds Abrasion Rubbing or friction to the epidermal layer Laceration Cut from a sharp-edged object Healing Process Inflammatory phase Hemostasis – thromboplastin is released from cells to initiate clot formation Collagen formation and one layer of epithelial cells Lasts 3-4 days Proliferative phase New connective tissue, epithelium, capillaries, and inflammatory cells Starting at 3 days and lasting approximately 3 weeks Maturation or remodeling phase Continual process of collagen synthesis and breakdown Peaks at 60 days Impaired Healing Process Local factors Systemic factors Inadequate tissue perfusion and Age over 60 years oxygenation Stress Inadequate moisture Poor nutrition Foreign material in the wound Diabetes Necrotic tissue Obesity Infection (most often Immune compromise from cancer, Staphylococcus and Streptococcus) alcoholism, smoking, medications Medications that interfere with clot formation, platelet function  Acute – generally healed within 1 month Wound Classification Chronic – greater than 1 month, requires referral Skin Layers Epidermis Protection, hydration, cell production, melanin Dermis Nerve endings, sweat glands, sebaceous glands, hair follicles, collagen, elastin Subcutaneous tissue Adipose tissue, temperature regulation, cushion, muscle connection, blood vessels Burn Presentation Superficial​ Painful area of erythema, involves only epidermis – no significant damage​ Superficial partial thickness​ Painful blistering, damage to epidermis​ Deep partial thickness​ Patchy white to red area with some blistering, intense pain​ Involves epidermis and part of dermis​ Full thickness​ Dry, leathery, painless area with no feeling​ Destruction of both dermis and epidermis – damaged skin will slough off Depth of Burns and Wounds A. Superficial partial- thickness B. Deep partial-thickness C. Full-thickness D.Subdermal Presentation Superficial Epidermis only Redness, nonblanching, unbroken, nonblistering Sunburn may have slight edema, redness begins 3-5 hours after exposure and peaks in 12-24 hours Heals without scarring in 3-7 days Superficial partial-thickness Broken skin which may drain fluid Pain, edema, erythema Blanching with pressure from capillary refill Sunburn includes blistering Healing with minimal scarring in 10-14 days Presentation based on depth Deep partial-thickness Edema, less blanching, minimal blistering Pain sensation may be altered Healing in 2-4 weeks with scarring Burns of this level need emergency department attention Full-thickness and Subdermal Hospital treatment % of BSA Rule of 9’s Estimation of the percentage of body surface area (BSA) affected Know the percentages on the image Alternate method The size of the patient’s hand including palm and fingers is approximately 1% Exclusions for Self-Treatment for Sunburn Large areas of blistering Signs of infection Fever over 103 F Areas of redness or red streaks spreading or moving away from Extreme pain open blisters Headache or confusion Open blisters draining pus Lightheadedness or vision changes Dehydration Severe swelling Sunburn Response Steps Analgesic (ibuprofen, acetaminophen) or topical gel analgesic Cool the skin for about 10 minutes several times each day Clean towel wet with cool tap water OR Cool bath with approximately 60 g baking soda Use a moisturizer, lotion, or gel Aloe vera or calamine lotion Hydrocortisone 1% three times per day for three days Avoid alcohol in the ingredients Drink additional water to prevent dehydration Avoid additional sun exposure For sunburned eyes, use cool wet towel, avoid contact lenses, avoid rubbing eyes https://www.mayoclinic.org/first-aid/first-aid-sunburn/basics/art-20056643 Burn Response Steps Identify cause, timing, depth, and size of injury Burns that occurred within 3 hours – irrigate with cool water for 20 minutes Remove rings or items constricting the area Apply skin protectant product and appropriate dressing Treat pain with NSAID or acetaminophen Assess need for tetanus immunization if skin is broken Tetanus booster every 10 years after series has been completed Repeat vaccine if a wound is dirty and it has been >5 years If burn worsens after 24-48 hours, refer to primary care provider Recommend scar prevention, sun protection, skin protectant Call 911 for Burns If… Depth involving all layers of the skin Skin appears dry and leathery Charred appearance with patches of white, brown or black Larger than 3 inches (about 8 centimeters) in diameter Covers the hands, feet, face, groin, buttocks or a major joint, or encircles an arm or leg Smoke inhalation occurred Rapid development of swelling https://www.mayoclinic.org/first-aid/first-aid-burns/basics/art-20056649 Wound Response Steps Identify cause, timing, depth, and size of injury Stop the bleeding Gentle pressure with a clean cloth Elevation Clean the injury by irrigation with tap water Soap only around the wound Use tweezers cleaned in alcohol to remove debris Apply skin protectant and appropriate dressing Change dressings daily Treat pain with NSAID or acetaminophen Wound Response Steps - Continued Assess need for tetanus immunization if skin is broken Tetanus booster every 10 years after series has been completed Repeat vaccine if a wound is dirty and it has been >5 years If injury does not heal within 7 days, refer to primary care provider Watch for signs of infection – redness, drainage, swelling, warmth, pain Darker skin infection streaks may appear puple-gray or darkening of skin Recommend scar prevention, sun protection, skin protectant Seek Prompt Medical Care if… Keeps bleeding after a few minutes of direct pressure Animal or human bite Determine rabies vaccination of pets Rabies consideration if a wild animal Deep and dirty Caused by a metal object Deep to the head, neck, scrotum, chest, or abdomen Potentially deep and over a joint https://www.mayoclinic.org/first-aid/first-aid-puncture-wounds/basics/art-20056665 Exclusions for Self-Treatment for Minor Burns and Wounds Chemical, electrical, or Preexisting medical disorders inhalation burn that may impair recovery Wound from animal or human Wound with foreign matter bite Chronic wound (>1 month) Deep partial thickness or deeper Location of face, hands, feet, Any injury that is suspected as major joints, genitals, perineum non-accidental Injury larger than 3 inches Signs of infection Worsening or not improving Circumferential burns after 7 days Treatment Goals Relieve symptoms Promote healing Minimize scarring Burn Cooling Continuous cooling of burns with running water for 20 minutes Slow burning, reduce pain, decrease inflammation As soon as possible with benefit up to 3 hours Avoid ice or ice-cold water Numbness, excessive vasoconstriction Wound Cleansing Gentle irrigation with tap water More aggressive cleaning if dirt or other contaminants Goals of preventing infection and promoting healing Avoid removing blisters or damaged skin to prevent harming healthy tissue Wound Dressing Avoid drying the wound which increases scab formation Newer dressings help create a moist environment Benefits Stimulate cell proliferation Encourage migration of epithelial cells for healing Provide a barrier to microbial contamination Absorb excess wound fluid Reduce the frequency of dressing changes If using a traditional dressing, combine with a skin protectant product Hydrocolloid Dressing Inner colloidal layer with gel-forming agents Outer water-impermeable layer Moist environment Partial-thickness wounds Minimal to moderate exudate Absorbs exudate from the wound Protection of intact skin with minor burns or blisters Transparent Adhesive Film Thin, elastic, waterproof polyurethane films Impermeable to bacteria Permeable to gas Not highly absorbent Only for superficial or superficial partial- thickness Benefit of flexibility and visibility Liquid Adhesive Bandage Also called tissue adhesives Spray or brush Clear polymer layer, flexible coating Slight burning with application Waterproof and may last 5-10 days Avoid over sutures, near eyes or mucous membranes May have antibacterial and antiseptic effect Cosmetic benefit and flexibility Some products include a topical analgesic Scar Prevention Avoid sun exposure Ultraviolet radiation increases pigmentation Use sunscreen Silicone therapy - preferred Occlusion and hydration of scar tissue Relief of itching and discomfort Use after wound healing Sheets – soft, semi-occlusive medical grade silicone with membrane backing Gel – apply a thin layer, dries and forms a transparent, gas permeable, water-impermeable coating Scar Prevention Mederma® Allantoin (skin protectant) and onion extract Not as effective as silicone Other products with limited evidence Mitomycin C Green tea Aloe vera Vitamin D or E Further options Laser Injections Systemic Analgesics Symptomatic relief No healing benefit NSAID Ibuprofen Naproxen Aspirin Acetaminophen Skin Protectant Protect from irritation Petrolatum Prevent drying of the stratum Aquaphor, CeraVe corneum White Petrolatum Promote moist healing Desitin, Vaseline Reduce pain Glycerin Neutrogena Norwegian Formula Scar prevention Hand Cream Emollients and moisturizers Cocoa butter Palmer’s Colloidal oatmeal Aveeno Antibiotic Ointment Prevention of infection – not treatment of active infection Variety of mechanisms against different bacteria Concern for antibiotic resistance Benefits are not clearly proven and may relate to the ointment base OTC Polymyxin/bacitracin/neomycin (Neosporin) Bacitracin and polymyxin (Polysporin) Rx Mupirocin (Bactroban) Bacitracin/neomycin/polymyxin B/hydrocortisone (Cortisporin) Topical Anesthetics Temporary pain relief Benzocaine, Lidocaine, Pramoxine Inactivate sodium channels in sensory neurons Interrupts transmission of electrical impulses in nerves Rapid onset and short duration of effect Gel, solution, spray, cream, ointment, patch Limited to topical use Systemic absorption of benzocaine can cause methemoglobinemia which leads to cyanosis, dyspnea, syncope, seizures, coma Antiseptic Destroy or inhibit microorganism growth May damage human cells promoting healing Chlorhexidine (Hibiclens) Hydrogen peroxide Povidone-iodine solution (Betadine) Lack evidence of benefit but include long history of use Strong evidence supports using clean tap water for wound irrigation for minor injuries Product Types Ointment – oleaginous Protective film Prevent water evaporation Recommended for minor burns and wounds when skin is intact With broken skin the ointment may hold too much moisture leading to maceration of skin and microbial growth Cream – water-based emulsion Allows some fluid to pass through Preferred if skin is broken Use a glove or gauze for application to avoid contaminating the product Product Types Lotion Spread easily Easier application to larger areas Spray Benefit of no touch application for less chance of contamination and less pain from application Hold the product 6 inches away and spray for 1-3 seconds Do not provide a protective layer Alcohol-based can irritate and dehydrate and are not preferred Special Consideration Age Decreased surface contact between dermis and epidermis can lead to separation of the dermal-epidermal junction Reduction in cutaneous blood flow Decrease in dermal lymphatic drainage decreases clearance of pathogens Diabetes Reduced wound healing Increased incidence of foot ulcers that are difficult to heal Hyperglycemia alters white blood cell function Obesity Impaired wound healing, increased risk of skin infection Pressure wounds or skin fold wounds need medical attention  Delay wound healing Direct skin damage Medication Anticoagulant Hypersensitivity interference Antimicrobial reaction Antineoplastic Anti-rheumatoid NSAIDs Colchicine Nicotine Steroids Vasoconstrictors Support for Nutrition Hydration wound and Smoking hinders wound healing Honey – moist environment, absorbs exudates, burn inhibits bacterial proliferation Aloe vera gel healing Calendula – anti-inflammatory and antibacterial Chronic and serious wounds Pressure sores are prevented with repositioning Relief of 5 minutes every 2 hours Seated patients repositioned every 15-60 minutes Arterial ulcers - secondary to peripheral vascular disease Very painful and usually located on lower extremities Venous ulcers result from dysfunction of venous valves Incompetent/damaged valves allow pooling of blood and high venous pressure in legs Abnormally high pressure causes damage to skin Treatment of chronic wounds Debridement – irrigation, hyperbaric oxygen, surgical, enzymatic, biologic (medical maggots) Cleaning with normal saline, sterile water Topical antibiotics Silver sulfadiazine – avoid in sulfa allergy and G6PD deficiency Triple antibiotic Enzymatic debridement - collagenase Collagenase (Santyl) Derived from fermentation of Clostridium histolyticum Proteolytic enzymes break down denatured collagen in necrotic tissue Does not interfere with healthy tissue or newly formed granulation tissue Removes detritus, promotes formation of granulation tissue, leads to epithelization of ulcers and burns Patient Burns may get worse over the first 24-48 hours, so follow-up in that timeframe is needed to Follow-up determine if a referral is needed Within 7 days minor injuries should show for Minor significant improvement with full healing in 14 days Injuries