What is the best course of treatment for an adult patient with an anterior abdominal wall burn wound who develops a bedsore (pressure ulcer) grade 2-3?

Management of Grade 2-3 Pressure Ulcers in Burn Patients

For an adult patient with an anterior abdominal wall burn who develops a grade 2-3 pressure ulcer, implement immediate pressure redistribution with advanced static mattresses, perform regular wound debridement, apply hydrocolloid dressings, and provide protein supplementation while maintaining meticulous burn wound care. 1, 2, 3

Immediate Pressure Redistribution

• Use advanced static mattresses or overlays as first-line pressure redistribution surfaces rather than alternating-air systems, as they provide adequate pressure relief at lower cost and allow repositioning intervals of up to 4 hours without increased ulcer incidence 1, 2
• Reposition the patient at least every 2 hours using a 30-degree tilt position rather than 90-degree lateral rotation to reduce pressure on bony prominences 1, 2
• Complete pressure offloading from the affected area is essential to prevent progression to higher stages 1, 3

Wound Care for the Pressure Ulcer

• Apply hydrocolloid dressings as primary treatment for grade 2 (blistered) pressure ulcers, as they are superior to gauze for reducing wound size and provide a moist healing environment 2, 3
• Clean the wound regularly with water or saline to remove debris, avoiding harsh antiseptics that damage healing tissue 2, 3
• Perform regular sharp debridement with a scalpel to remove necrotic tissue, which is necessary for proper wound healing, particularly if the ulcer progresses to grade 3 3
• Control exudate with appropriate dressings; hydrocolloid or foam dressings are equivalent for complete wound healing 2, 3

Common Pitfall

Do not use dressings with antimicrobial agents solely to accelerate healing, as evidence shows no clear benefit and may increase costs 2, 4. Reserve antimicrobial therapy for signs of infection.

Concurrent Burn Wound Management

• Continue burn wound care with appropriate dressings after initial resuscitation is complete 5
• Clean burn wounds with tap water, isotonic saline, or antiseptic solution before applying dressings 5
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may prolong healing 5
• Monitor for signs of burn wound infection, which typically involves polymicrobial organisms including Gram-positive and Gram-negative bacteria 5

Infection Management

• Reserve systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection (fever, hypotension, altered mental status), as pressure ulcer infections are typically polymicrobial requiring coverage of Gram-positive, Gram-negative, and anaerobic organisms 5, 2, 3
• Consider topical antimicrobial therapy only for superficial infection signs such as increased erythema, warmth, or purulent drainage 2
• Do not administer routine antibiotic prophylaxis for the burn wound unless specific indications exist 5

Evidence Nuance

While some older evidence suggested potential benefits of various antiseptics, a 2016 Cochrane review found no clear evidence that antimicrobial treatments improve pressure ulcer healing, and in some cases povidone iodine showed worse outcomes compared to non-antimicrobial alternatives 4. This supports the recommendation to avoid routine antimicrobial use.

Nutritional Support

• Assess nutritional status immediately, including body weight, body mass index, caloric counts, and serum protein levels 1
• Provide protein or amino acid supplementation if nutritional deficiencies are identified, as this can reduce wound size and risk of progression 1, 2, 3
• High protein oral nutritional supplements (30 energy percent) can reduce the risk of developing new pressure ulcers 1

Critical Consideration

Burn patients have exceptionally high micronutrient requirements that cannot be covered by standard nutrition alone, requiring supplementation with copper, zinc, selenium, and vitamins B, C, D, and E 5. This is particularly important when managing concurrent pressure ulcers.

Pain Management

• Administer analgesics 30-60 minutes before dressing changes or repositioning 2
• Consider topical lidocaine or morphine gel for wound-related pain during dressing changes 2
• For burn-related pain, short-acting opioids and ketamine are optimal choices; inhaled nitrous oxide can be useful when intravenous access is limited 5

Monitoring and Prevention of Progression

• Perform risk assessment using validated tools like the Braden Scale 1
• Assess the skin every shift and after each repositioning, being particularly attentive to both the burn and pressure ulcer areas 1
• If the pressure ulcer does not improve or progresses despite optimal management within 2 weeks, reassess all risk factors and interventions 1
• If no healing occurs within 6 weeks, evaluate for vascular compromise 3

Adjunctive Therapies

• Consider electrical stimulation as adjunctive therapy to accelerate wound healing for stage 2-4 ulcers 3
• Systemic hyperbaric oxygen therapy may increase healing incidence, though further studies are needed 3
• Evidence is insufficient for platelet-derived growth factor, bioengineered skin products, and other growth factors 3

Critical Pitfalls to Avoid

• Do not use alternating-air mattresses or low-air-loss beds without clear indication, as evidence does not show benefit over static surfaces and they add unnecessary cost 2, 3
• Avoid delaying nutritional assessment, as this increases risk of pressure ulcer progression 1
• Do not apply external cooling devices to burn wounds for prolonged periods during transport, as this risks hypothermia 5
• Ensure thromboprophylaxis is routinely prescribed for the burn patient 5