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Arms and legs
Can be decompressed with axially oriented medial and
lateral incisions.
Digital escharotomies are not typically needed.
Chest and upper abdomen
Can be decompressed with bilateral midaxillary
releases.
These can be connected with one or multiple horizontal
incision to form an “H.”
BURN WOUND CARE
All blisters and nonviable tissue should be débrided at the
bedside. Wounds should be dressed with a topical
antimicrobial agent.
Silvadene (1% silver sulfadiazine) has broad coverage for
gram-negative and positive bacteria.
Wound penetration is moderate.
Can damage the cornea so use near the eyes is
contraindicated.
*Can cause neutropenia so white blood cell count
should be followed.
Avoid in patients with sulfa allergy.
Sulfamylon (10% mafenide acetate) has broad coverage
for gram-positive bacteria and gram negative including
coverage of pseudomonas and is bacteriostatic.
Wound and eschar penetration is excellent.
Sulfamylon is the topic agent of choice for exposed
cartilage of the ear or nose.
*Sulfamylon is a carbonic anhydrase inhibitor and
can cause hyperchloremic acidosis, particularly
when used in large burns.
Avoid use in burns >20% TBSA.
Silver nitrate (0.5% solution) has broad-spectrum
coverage with coverage of Staphylococcus and
Pseudomonas.
Silver nitrate solution does not penetrate eschar well.
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Silver nitrate solution will discolor the adjacent skin and
surrounding dressings and bedding to a black color.
*Silver nitrate can cause hyponatremia. Sodium
level should be followed.
Cost effective.
Acticoat is a silver-impregnated dressing that is available
in sheets. Moisture activates the silver ions, which act as a
topical antimicrobial agent.
Sheets can be placed over clean burn wounds and
moistened with normal saline several times per day.
Dressings can be changed every 3-5 days.
Acticoat is available in glove form, which is ideal for
clean, partial-thickness burns of the hand.
Will also discolor the skin to a darker color from silver.
Bacitracin zinc ointment can provide coverage for grampositive organisms.
Bacitracin penetrates burn eschar.
Commonly used for facial burns.
Bacitracin is safe for use around the eye.
Xeroform is a sterile, fine mesh gauze impregnated with
3% Bismuth and petroleum.
Sheets are nonadherent to wound sites and helps
maintain a moist wound environment.
Used for superficial and partial thickness burns, as well
as fragile STSGs.
Provides little antimicrobial coverage. Frequently used
with bacitracin.
Preferred due to easy up-keep and flexible changing
schedule.
NUTRITIONAL SUPPLEMENTATION
A hypermetabolic response is common to all large burns
The metabolic rate is proportional to the size of the burn, up
to 60% TBSA, and remains constant thereafter.
This response begins soon after injury, reaching a plateau
by the end of the first week.
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Most burns >30% TBSA require intensive nutritional
support until wound healing is complete.
*Curreri formula for caloric requirements: 24 hour
caloric requirement = (25 kcal × kg body weight) + (40
kcal × %TBSA).
Protein requirements: 2.5-3 g/kg/d are recommended. In
children, requirements are 3-4 g/kg/d.
Intestinal feeding should be performed early
Initial feeds can be performed using a nasogastric tube.
If feeds are administered to the stomach, feeding should be
held 6 hours prior to the OR.
A postpyloric Dobhoff tube is appropriate for long-term
feeding. Postpyloric feeds can be continued in the
perioperative period.
Weekly nutrition labs, prealbumin levels are drawn to monitor
nutrition status.
Early involvement of a registered dietician is imperative.
SURGICAL MANAGEMENT OF BURN
WOUNDS
Initial débridement of blisters should be performed at the
bedside prior to initial wound dressing.
Formal débridement and grafting in the operating room is
performed after adequate resuscitation and when the patient is
hemodynamically stable
Early débridement can prevent burn wound infection; the
first débridement is often within 2-4 days of injury to allow
for tissue injury to declare itself.
For large burns, sequential débridement and grafting is
appropriate.
Ideally, all burn wounds would be grafted by 3 weeks to
prevent hypertrophic scar formation; however, in very large
burns, it is important to perform early escharotomies to
remove the large bioburden of dead tissue.
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Tangential excision allows sequential excision of thin layers of
nonviable tissue until bleeding, healthy tissue is reached.
At débridement, the most important distinction is between
superficial and deep partial-thickness burns.
*Superficial partial-thickness injuries will heal on
their own without grafting.
*Deep partial-thickness burns require skin grafting.
Delayed grafting can be performed if inadequate donor skin
is present. Cover wounds first with cadaveric allograft or a
nonbiologic dressing to protect against fluid losses and burn
wound infection (see below).
Grafting Techniques (See Chapter 2: Grafts)
Split-thickness grafts
Usually 12-14/1000th of an inch.
Thinner grafts preserve donor site for reharvesting and
have higher take rates but are more prone to
secondary contraction.
Meshing is typically performed at a 1:1.5 ratio to
increase surface area and for fluid to escape from beneath
the graft.
Higher mesh ratios (eg, 1:2, 1:3, or 1:4) can be used
but prolong healing.
Even if using a meshed graft, the less you need to
spread out the graft, the better the graft appearance
will be in the future and the less likely it will break
down.
Unmeshed sheet grafts are typically used on cosmetic
or functional areas, such as the face, breast, and hands.
Graft failure can occur for many reasons
Inadequate wound débridement prior to graft application is
the primary cause.
Infection: Quantitative cultures showing more than 105 cells
will result in graft loss.
Fluid collection beneath the graft, including hematoma
(most common) or seroma.
Shear force to graft from inadequate immobilization and
compression.
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Poor nutrition or overall physiologic status.
COVERAGE OPTIONS
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BURNS OF THE FACE, EYES, AND
EARS
The central face has deeper skin appendages and excellent
blood supply, resulting in a greater healing capacity.
Assessed Using the Subunit Principle: when >50% of a
subunit requires grafting, excision and grafting of the entire
subunit optimizes aesthetic outcome
Use unmeshed sheet grafts, applied by aesthetic units.
Thicker grafts (16-20/1000th of an inch) are preferable on
the face.
Facial grafting should be performed <2 weeks from the time
of injury to decrease scarring.
Eyes: lid edema usually protects the eyes in the early stages.
Patients are at risk of corneal exposure and corneal abrasion as
edema subsides.
Ophthalmology consult and fluorescent staining often
indicated to assess for corneal abrasions.
Eye lubrication and/or temporary tarsorrhaphy may be
required.
Definitive surgical correction to address anterior, middle,
and posterior lamella.
Goals
Restore the lid to the proper functional position.
Covering the inferior margin of the corneoscleral limbus
in neutral gaze.
Ears: ear skin is very thin and exposed cartilage is common.
*Twice-daily sulfamylon is the best wound dressing for
exposed cartilage.
Avoid any external pressure to the ear.
Suppurative chondritis requires urgent débridement.
If no cartilage exposure is present, split-thickness skin
grafting and a bolster are appropriate.
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Small amounts of exposed cartilage may be débrided to
allow primary wound closure.
Large amounts of exposed cartilage necessitate
vascularized coverage prior to grafting. An ipsilateral
temporal-parietal fascia flap is ideal.
BURNS OF THE HANDS AND FEET
Have a low threshold for early escharotomies of severely burned
extremities.
Superficial extremity burns are treated with elevation, topical
antimicrobials, and passive ROM for each joint BID.
*Burned hands should be splinted in the intrinsic plus
position with the thumb maximally abducted.
Important to get occupational therapy on board early to help with
splinting and ROM.
If prolonged hospitalization and severe burns with exposed
tendon, should consider K-wire hand in intrinsic plus.
Deep partial- and full-thickness burns
Early excision and sheet grafting are preferred, particularly
on the dorsum of the hand and fingers.
After 5 days of immobilization, ROM exercises should be
restarted.
Exposed tendon may require local tissue rearrangement vs flap
coverage vs integra placement.
Palmar skin is thick and only 20% of palmar burns ultimately
require resurfacing. A conservative approach is recommended
to preserve thick fascial attachments.
May need to perform z-plasties or local tissue rearrangements if
contractions develop (See Chapter 11: Burn Reconstruction).
Burns of the feet are managed similarly to hand burns.
GENITAL BURNS
Place burned foreskin into its normal position to prevent
paraphimosis.
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Topical antibiotic therapy may be instituted for several weeks as
needed. Any remaining open wounds should then be sheet
grafted.
Early consultation with an experienced urologist is
recommended. The Foley catheter may be removed at their
discretion.
OPHTHALMOLOGIC INJURY
Important to consult ophthalmology if concern for elevated
intraocular pressures
Important to keep eyes well lubricated and consider
tarsorrhaphy
ELECTRICAL INJURY
Electrical injuries represent <5% of burn injuries admitted to
major burn centers.
The typical patient is a young male; often work related.
Total body surface area (TBSA) is not necessarily associated
with prognosis and does not quantify damage to deep tissues.
MECHANISM OF INJURY
Pathophysiology of electrical burn is based on the following
Type of current: low frequency alternative current (AC)
results in muscle contraction where the person cannot let
go of the electrical source usually resulting in worse injury;
direct current (DC) usually causes a single shock.
Voltage: low voltage is <1000 V and high voltage is >1000
V.
*Resistance: tissue resistance in decreasing order =
bone, fat, tendon, skin, muscle, vessel, nerve. (Bone
heats to a high temperature and burns surrounding
structures.)
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Thermal: can generate temperatures over 100 degrees.
Electroporation: electrical force drives water into lipid membrane
and causes cell rupture.
Assessment of entry and exit wounds not always useful but
should be evaluated.
Difficult to determine type and severity of damage between
entrance and exit.
SYSTEMIC EFFECTS
All must be considered prior to determination of a management
plan.
Current flows through tissue can cause burns at entrance/exit
wounds and burns to deep tissue.
Current will preferentially travel along low-resistance
pathways.
Nerves and blood vessels have low resistance. Bone has
high resistance.
Current will pass through soft tissue, contact high-
resistance bone, and travel along bone until it exits to the
ground.
Vascular Injury to Nutrient Arteries
Damage to intima and media
Thrombosis
Cardiac Effects
Arrhythmia—EKG monitor for at least 24 hours
Coronary artery spasm
Myocardial injury and infarction
Gastrointestinal (GI) Effects
Injury to solid organs
Acute bowel perforation
Delayed bowel perforation
Gallstones after myoglobinuria
Genitourinary (GU) Effects
Rhabdomyolysis with elevated CK levels, hyperkalemia,
hyperphosphatemia, and myoglobinuria
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