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C. Gibson et al.
wound care and proper resuscitation. For those
patients who do require surgery, an essential
question is when to proceed with skin grafting.
Early (i.e., <7days) excision and grafting is the
general practice in HICs; however in LMICs surgery will often be delayed for weeks until any
partial thickness burns heal spontaneously and
the patient has developed a healthy bed of granulation tissue. A recent meta-analysis comparing
early vs. late excision and grafting failed to show
a mortality benet in either HICs or LMICs but
did show decreased sepsis and length of stay in
the early excision group [14]. These results
directly challenge the dogma that early excision
and grafting is the superior choice. The truth, as
always, is more nuanced and requires sharp clinical acumen to know when a patient is physiologically ready for surgery given the resources
available in a particular setting.
Type ofSurgery
Once it is determined that a patient requires surgery
for their burns, it is necessary to decide on the type
and extent of surgery, as well as the timing. The
mainstay treatment for an acute burn is split-thickness skin grafting. Many factors must be considered in preparation for surgery– such as availability
of blood, anesthesia, surgical equipment, personnel, etc.– that surgeons in HICs generally take for
granted. Practically speaking, without the availability of a blood bank or skin bank, it is not advised
to excise more than 10% TBSA in a single operation. If donor sites are scarce, then priority should
be given to grafting sensitive areas such as the face,
hands, genitalia, and joints. This will hopefully
lead to less hypertrophic scar and contracture in the
long run (see Chap. 32).
Availability of anesthesia will dictate how
extensive an operation can be. Most minor skin
grafting procedures can be performed under conscious sedation with just ketamine and will not
require a ventilator or an anesthesiologist. Lower
extremity burns can be grafted under spinal anesthesia which provides approximately 2–3hours
of paresthesia. Any skin grafting of signicant
size (>5% TBSA) will require general anesthesia
and knowledge of the options will help with safe
operative planning.
Acute burn surgery, i.e., burn wound excision
and split-thickness skin grafting, is inherently
bloody. All attempts should be made to limit
blood loss during surgery since blood replacement is difcult in most centers in LMICs. Some
techniques can be used routinely, such as injecting dilute epinephrine under burn wounds and
donor sites prior to excision or harvesting.
Tourniquets should be used liberally for extremity burns. Since a tourniquet machine is not
likely available in LMICs, one can fashion a
tourniquet from two Foley catheters placed proximally on the extremity. By taking a few extra
precautions, blood loss can be easily reduced by
a third or more.
Escharotomy andSloughectomy
Two surgical situations deserve special attention:
escharotomy and sloughectomy. When a patient
has a circumferential third degree burn on the
trunk, neck, or an extremity, they can quickly
develop compartment syndrome which can lead
to muscle necrosis, respiratory failure, and even
death. If a patient starts to exhibit the 5 P’s of
compartment syndrome (pain, pallor, paresthe-
sia, pulselessness, and paralysis), then one
should immediately perform an escharotomy of
the involved body part. The goal of an escharotomy is to release the eschar along the sides
thereby relieving the pressure and allowing the
underlying tissue to swell. Circumferential second degree burns generally do not cause compartment syndrome since part of the dermis is
intact and can stretch.
A sloughectomy is an operation that one will
only see practiced in LMICs [13]. Essentially, it
entails removing the slough– dead, moist tissue
overlying the burned area– by excisional debridement. A sloughectomy is required if there is concern for infection of the burn wound or if the
necrotic tissue is not spontaneously lifting after an
appropriate period of time. Sloughectomy can be
performed at the bedside. If extensive or if there is
concern for bleeding, then the sloughectomy
31 How toProvide Acute Burn Care inLow- andMiddle-Income Countries
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391
should be done in the operating theater. Once the
wound has been adequately debrided you can
either proceed with skin grafting if the wound bed
appears ready or continue with wound care until
healthy granulation tissue forms.
Postoperative Care
Postoperative care after burn surgery, whether
sloughectomy, skin grafting, or scar contracture
release, should follow the same principles
whether in HICs or in LMICs. This includes
appropriate wound care to protect both the surgical burn site and the donor site; appropriate
Fig. 31.5 Appropriate
splinting and positioning
after skin graft surgery.
(a) Shoulder positioning
at 90° of abduction, and
slight horizontal
adduction to prevent
brachial plexus stretch.
(b) Positioning of the
elbow in neutral. (c)
Positioning of the neck
in neutral or slight
cervical extension. (d)
Positioning of the knee
in neutral, positioning of
the ankle in neutral. (e)
Positioning of the wrist
in the intrinsic plus
position; 30°–40° of
wrist extension, 70°–90°
MCP exion, 0–20° of
IP exion. (f) 20° of hip
abduction, torso in
neutral, lower
extremities in neutral
avoiding external
rotation
ab
cd
ef
splinting, positioning, and immobilization of any
involved limbs; and daily evaluation for infection. Certain patients (i.e., children) may require
placement of a cast to ensure appropriate splinting is maintained throughout the early postoperative period. If there is a physiotherapist
available, their expertise should be enlisted to
help with postoperative splinting and position
monitoring. However, it would be useful for the
care giver to be familiar with some basic splinting positions in case a physiotherapist is not
available (Fig.31.5). Since family members are
often directly involved in a patient’s medical
treatment, they should also be educated on
splinting and encouraged to participate in the
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C. Gibson et al.
patient’s postoperative care. Until the local team
is comfortable with managing burn patients
postoperatively, we recommend visiting teams
remain at the healthcare facility during the
immediate postoperative period until it is clear
that the surgery was successful. In general, this
implies 5–7days after skin grafting and 3–5days
after simple scar contracture releases. Even if the
surgery was minor (e.g., <3% TBSA splitthickness skin graft or a simple z-plasty), it is
important to ensure a successful outcome, especially if burn surgery is a new treatment modality
in the region.
Postoperative care of the burn patient is unique
compared to many other surgical specialties. For
most, 4–6weeks of healing time, whether for surgical incisions, hernias, or broken bones, is sufcient to say that the patient has “fully recovered”
from surgery. For burn patients, however, remodeling of burn scar and skin graft sites is an ongoing process for at least a year. In order to
guarantee the best aesthetic and functional outcome, they will require ongoing physiotherapy to
prevent postoperative contractures, active scar
management (i.e., scar massage therapy, compression dressings, possible serial splinting,
physiotherapy exercises, etc.), and surveillance
for hypertrophic scar formation and scar contractures. While this is common practice for multidisciplinary burn teams in HICs, it is often an
overlooked but vital part of a patient’s care
towards full recovery from their burn injury. It is
not uncommon for a patient to recover from their
burn injuries while an inpatient, only to return
6months later with a severe scar contracture at
their prior burn site or even at an unburned site
(see Chap. 32)! Patients and their family should
be educated on appropriate postoperative physiotherapy exercises and encouraged to continue
splinting affected joints at night. Regularly
scheduled postoperative visits should be established for surveillance, either at the health center
or possibly through outreach programs if patients
cannot afford travel costs. As the patient gets farther out from their burn injury, visits can be
extended out to longer periods of time until the
patient develops a “mature” burn scar that is satisfactory to both patient and the practitioner
(approximately 1–1.5 years from burn injury).
By investing time and resources into helping
develop a local structured postoperative protocol,
one will achieve a higher degree of success and
meaningful recovery for the burn patients in the
region.
Role ofAntibiotics Postoperatively
In general, systemic antibiotics are not required
postoperatively unless the patient shows local or
systemic signs of infection preoperatively (e.g.,
erythema, purulent drainage, fever, leukocytosis). Surgical removal of the infected eschar followed by dressing the area with local
antimicrobials may be sufcient to control the
infection if it is limited only to the wound. We
recommend using systemic antibiotics sparingly
in order to avoid development of multi-drugresistant strains of bacteria. If available, culture
swabs of the wound are important to determine
the infectious pathogen. This will guide the antibiotic regimen. For Pseudomonas we recommend using acetic acid, sodium hypochlorite,
and/or gentamicin topically as this is readily
available in most LMICs. The use of antibiotics
for burn patients is a common practice among
local practitioners and may become a point of
conict between the visiting team and the local
providers; a healthy level of deference goes a
long way to building bridges.
Conclusion
Burn patients are arguably some of the most
complex patients in a healthcare system. Often,
when resources and personnel are not readily
available, their care will suffer and they can languish for weeks or months on the ward with
painful open wounds. The results of this neglect
are visible to the world as severe contractures
and hypertrophic scars (see Chap. 32). In HICs,
over a quarter of burn patients never return to
any form of employment [15] because of their
burn injuries. This number is likely even higher
in LMICs and represents a signicant social and
31 How toProvide Acute Burn Care inLow- andMiddle-Income Countries
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economic burden on families and communities.
However, with a dedicated team to provide
appropriate wound care, physiotherapy, and skin
grafting when necessary, many of the complications and disabilities associated with burns can
be avoided.
References
1. Peck MD. Epidemiology of burns throughout the
world. Part I: distribution and risk factors. Burns.
2011;37(7):1087–100. https://doi.org/10.1016/j.
burns.2011.06.005.
2. Burns. World Health Organization. https://www.who.
int/news- room/fact- sheets/detail/burns. Accessed 2
Apr 2022.
3. Gibson C, Bessey PQ, Gallagher JJ. The global
burn registry: a work in Progress. J Burn Care Res.
2020;41(5):929–34. https://doi.org/10.1093/jbcr/
iraa078.
4. Allorto NL, Clarke DL.Merits and challenges in the
development of a dedicated burn service at a regional
Hospital in South Africa. Burns. 2015;41(3):454–61.
https://doi.org/10.1016/j.burns.2014.07.021.
5. Borrelli MR. What is the role of plastic surgery
in global health? A review. World J Plast Surg.
2018;7(3):275–82. https://doi.org/10.29252/
wjps.7.3.275.
6. Harish V, Tiwari N, Fisher OM, Li Z, et al. First
aid improves clinical outcomes in burn injuries:
evidence from a cohort study of 4918 patients.
Burns. 2019;45(2):433–9. https://doi.org/10.1016/j.
burns.2018.09.024.
7. American Burn Association. Initial rst aid treatment
for minor burns. http://ameriburn.org/wp- content/
uploads/2017/05/burnrstaid.pdf. Accessed 2 Apr
2022.
8. Wallace HJ, O’Neill TB, Wood FM, Edgar DW, Rea
SM.Determinants of burn rst aid knowledge: crosssectional study. Burns. 2013;39(6):1162–9. https://
doi.org/10.1016/j.burns.2013.02.007.
9. Meara JG, Leather AJ, Hagander L, Alkire BC, etal.
Global surgery 2030: evidence and solutions for
achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. https://doi.
org/10.1016/s0140- 6736(15)60160- x.
10. Alvarado R, Chung KK, Cancio LC, Wolf SE. Burn
resuscitation. Burns. 2009;35(1):4–14. https://doi.
org/10.1016/j.burns.2008.03.008.
11. Eastridge B, Putz B, Ward A, editors. Burn Clinical
Practice Guideline. Austin, TX: Texas EMS Trauma
and Acute Care Foundation Trauma Division; 2016.
p.1–20.
12. Carson JS, Khosrozadeh H, Norbury WB, Herndon
DN. Nutritional needs and support for the burned
patient. In: Total burn care. 5th ed. Elsevier; 2018.
p.287–300.
13. King M, Bewes P.Burns. In: Primary surgery: trauma,
vol. 2. Oxford: Oxford University Press; 2013.
p.65–91.
14. Wong L, Rajandram R, Allorto N.Systematic review
of excision and grafting in burns: comparing outcomes
of early and late surgery in low and high-income
countries. Burns. 2021;47(8):1705–13. https://doi.
org/10.1016/j.burns.2021.07.001.
15. Mason ST, Esselman P, Fraser R, Schomer
K. Return to work after burn injury. J Burn Care
Res. 2012;33(1):101–9. https://doi.org/10.1097/
bcr.0b013e3182374439.
How toSurgically Reconstruct
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Acute andChronic Burn Wounds
inLow- andMiddle-Income
Countries
EinarEriksen
A great pleasure in life is doing what people say you cannot do.
– Walter Bagehot
Abbreviations
FTSG Full-thickness skin graft
LMICs Low- and middle-income countries
STSG Split-thickness skin graft
TBSA Total body surface area
Introduction
32
Burn survivors frequently develop various
degrees of handicaps and deformities which
impose a heavy burden on the families and the
society. The main reasons for the tragic post burn
outcome are lack of designated hospital facilities,
shortage of supplies and surgical equipment like
dermatomes (manual or electric), skin meshers,
skin staples as well as inadequate number of
trained and motivated staff.
Burn casualties seem to be one of the most common mechanisms of injury in the third world. The
majority of burns worldwide occur in low- and
middle-income countries (LMICs). Burn injuries
and poverty are quite often closely associated,
where children and females are the main victims.
These casualties seem to be linked to unprotected
replaces and ground level cooking.
E. Eriksen (*)
Children’s Burn & Wound Care Foundation,
Addis Ababa, Ethiopia
MCM Comprehensive Specialised Hospital,
Addis Ababa, Ethiopia
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_32
Aspects ofAcute Burn Treatment
Diagnosis ofAcute Burns
A basic knowledge of how to determine the
DEPTH and EXTENT (Total Body Surface
Area, TBSA) of thermal injuries will guide the
health professional in providing the best possible
treatment scheme for his patient.
The risk of future scarring and contracture development is closely associated with the depth as well
as the location of the wound. The deeper the wound
appears to be, the greater the risk of scar formation
and contracture development if wounds are left
without proper surgical care, like a skin graft.
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E. Eriksen
The depth of a burn injury is traditionally clas-
sied into three different levels:
First degree burn: When the supercial part of
the skin, the epidermis, has received too much
of sunshine, it reacts with mild erythema and
various degrees of pain.
Signs and symptoms: Mild erythema, pain,
and discomfort. No blister formation. Will
subside in a couple of days.
Second degree burn: Classied as supercial par-
tial thickness or deep partial thickness,
depending on how deep the injury penetrates
into the dermis of the skin.
Signs and symptoms: Blister formation, Pain,
Wet, Pink wound surface
Third degree burn: Both epidermis and dermis
are destroyed, often described as a fullthickness burn. In special areas where the
skin is normally thin, like the dorsum of the
hand and foot, structures like tendons, fascia, and even bony structures may be
exposed.
Sign and symptoms: Dry leather looking skin,
no pain on touching the affected area
Clinical importance:
First degree burn (sunburn) has little clinical
importance.
Second degree burn: Supercial wounds tend to
heal quicker and will seldom leave any signicant scar. The more supercial the wound is,
the more pain the patient will experience. It
heals usually within 2–3 weeks.
Third degree burn: If a wound has not healed
properly within 3 weeks, the wound is classied as a third degree or full-thickness burn
wound. This wound will eventually heal in
most instances with scar formation.
Reference is made to other textbooks for
more details about diagnosis of acute burns
with assessment of depth and extent of burn
wounds.
Principles forImproved Burn Care
A successful outcome for a burn victim starts
with showing interest, concern and motivation
about how best to provide care for the burn
patient. The sooner the burn victim gets in contact with experienced health professionals, the
better for the outcome. Even though a specialized
multidisciplinary burn center is the preferred
place for referral, such centers may not be easily
available in LMICs. Motivated trained health
professionals in any health facility can attend the
acute injured patient with required emergency
care, like IV uids, observation of vital signs,
measuring urinary output, assessment and dressing of the wounds until a planned referral has
been organized.
It may sometimes be difcult to decide the
depth of the wounds during the rst 24–48h. The
signs and symptoms of second and of third degree
burns should be applied when making a proper
assessment of the burn victim.
Keeping the wounds clean, removing and
peeling all loose blisters and changing the dressings on a daily/regular basis, is of paramount
importance in order to prevent a second degree
burn from getting infected and turning into a
deeper wound.
Topical antibiotics, like Flamazine (silver sulfadiazine cream), are very helpful in preventing
patients from ending up septic in deep burns.
Frequently, burns show up with a mixture of
second and third degree burn. It is advisable to
continue daily/regular dressing changes until all
the second degree wounds have healed
(2–3weeks), before planning skin grafts on the
remaining wounds.
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Surgical Intervention intheAcute
Stage
Surgical intervention is an emergency under the
following conditions:
Escharotomy Circumferential deep (third
degree) burns on the limbs, as well as the
trunk, are regarded an emergency situation.
The surgeon should without delay bring the
patient to the operating room to perform two
longitudinal escharotomy incisions of the limb
to prevent compromised circulation. Likewise,
two longitudinal and horizontal escharotomy
incisions on the trunk need to be performed to
make sure breathing is not compromised. In
both instances, longitudinal incisions should
run from just proximal to the circumferential
burn until just below the distal margin of the
burn.
Escahrectomy Surgical excision of dead tissue
(escharectomy) needs to be performed whenever
there is a clear demarcated deep infected third
degree burn in order to remove necrotic tissue
that otherwise may be a focus for septicemia.
Tourniquet should always be used when operating on limbs.
Skin Graft Procedures during
theEarly/Acute Stage
The only way to prevent burn victims from ending up with severe handicap, is to treat the wounds
as early as possible. Nothing will benet the
patient more than having the wounds covered
with skin graft within 3–4weeks post burn.
There are different approaches to deal with
acute burns. The choices should be made based
on the availability of experienced staff and how
the facilities are equipped.
Early skin graft procedures within the rst
2weeks are regarded state-of-the-art treatment in
standard burn centers. This requires optimal
facilities with regard to experienced staff, ICUs,
blood products, and laboratory support that often
may not be available in many LMICs.
In general, there are many advantages of
focusing on daily wound care until all second
degree wounds have healed and then address the
remaining deeper wounds that need skin grafts.
From our experience, wounds that have been
dressed by dedicated and trained staff on a daily
and regular basis for about 3–4 weeks appear
clean and ready for skin grafts.
When there is an isolated deep partial thickness or full thickness burn, an experienced burn
surgeon should consider early excision and grafting within the rst 2weeks. Early excisions signicantly reduce the risk of infection.
Excision of necrotic tissue on extremities
should be performed using tourniquet. This
reduces blood loss. Furthermore, the surgeon will
be able to determine the adequate depth of the
excision when tourniquet is applied. Most often,
early tangential excisions are followed by another
2–3days to make sure no necrosis is left behind
before applying skin grafts. Preventing graft loss
should be of greatest concern, and most of the
time it becomes a matter of whether or not the
wound is clean and ready to receive a skin graft.
Experienced burn surgeons will also excise
larger areas of third degree burns in the acute
stage in order to reduce the load of necrotic tissue.
From our experience, we usually cover the excised
wounds with topical antibiotics. We do repeated
surgical debridements, daily dressing changes and
wound inspections until we feel sure the wounds
appear free of necrotic tissue before applying the
skin grafts (Figs.32.1, 32.2, 32.3, and 32.4).
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Fig. 32.4 Fully grafted before 2 weeks of injury
Fig. 32.1 6 years old boy with ext. ame burn injury.
Admitted 5tf day post burn
Fig. 32.2 Tangential excision of necrotic tissue as soon
as patient is stabilized
Fig. 32.3 Repeated surgical debridements until all
necrosis are excised
Basic Surgical Equipment
Proper treatment of acute and chronic burns, burn
contractures require a standardized set of
equipment.
The following equipment is recommended:
Skin graft Meshers are mandatory, whatever
kind of surgical wounds are to be treated.
Graft take is enhanced markedly; larger areas
can be covered using a Mesher (Figs.32.5 and
32.6).
Although an electric dermatome is a great tool
when dealing with extensive burns, the authors
advise burn surgeons to get familiar of manual
dermatomes. There are several reasons why that
is important.
• Humby knives (Fig. 32.7) are inexpensive
and may last for years when taken great care
of.
• Blades are relatively inexpensive.
• Blades can be re-sterilized several times pro-
viding the edge is handled with utmost care.
• Humby knives can harvest wider grafts than
electric dermatomes – an important point
when dealing with reconstructive surgery.
• Electric dermatomes are expensive and dif-
cult to obtain and to maintain.
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Fig. 32.5 STSG Mesher
Fig. 32.6 STSG mesher withoutdermacarrier
Tourniquets (rubber bands) (Fig. 32.8)
are highly recommended whenever surgery
on the limbs is undertaken. Blood loss is significantly reduced. This helps the surgeon to
distinguish necrotic from healthy issue.
Surgery time is also shortened. There is lack
of blood supply in LMICs so transfusions are
limited.
Fig. 32.7 Humby Knife
Fig. 32.8 Rubber Band Turniquet
Skin staples (Fig. 32.9) make burn surgery
easier to perform. The equipment makes acute
burn surgery as well as post burn reconstructive
surgery far more efcient. Proper use of staples
shortens the theatre time considerably.
Diathermy machine/electrocautery
machine is needed to obtain meticulous hemo-
stasis before applying a skin graft to the recipient
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Fig. 32.9 Skin staple
wound area and this cannot be overemphasized.
This is of particular importance in dealing with
sheet grafts, FTSG and STSG. Adrenaline 1:1000
can be diluted and used topically to control bleeding. Usually 2 ml is added to 100–200 mL of
saline.
Surgical Technique inAcute
andChronic Burns
The surgeon will have different options at hand
for wound cover when planning closing an existing wound or releasing a contracture.
The Main Options Are
1. Z-plasty: The main indication is to correct
post burn linear scars crossing joint related
areas. Proper results depend on normal skin
tissue located adjacent to the linear scar
(seeFigs.32.75 and32.76).
2. Transposition ap: Ideal when joints, ten-
dons, and bony structures are exposed.
These aps are also very useful in post
burn joint reconstruction, often in combination with STSG or FTSG.
E. Eriksen
3. Distant ap: Useful aps in special challeng-
ing cases to be discussed under section “Post
Burn Contractures.”
4. Skin grafts: Skin grafts are differentiated in
Split Thickness Skin Grafts (STSGs) and Full
Thickness Skin Grafts (FTSG).
Skin grafts give good results and are easier
to deal with compared to aps, and should
always be considered when planning the closure
of a wound or reconstruction of a contracture.
In our experience, at least 80% of all burn
patients, acute as well as chronic, can be
treated very professionally using skin grafts
alone.
Split Thickness Skin Grafts (STSG)
• Common donor sites are the thighs, legs,
anks, and gluteal areas. Avoid harvesting
from forearms due topoor aesthetics.
• STSGs may vary in thickness, from supercial thin grafts to thicker grafts (~8 to
201000ths/inch).
• The degree of the dermal component of the
graft determines the result of the surgery. The
thicker the dermal component, the better
appearance and functional result.
• On the other hand, the thinner the dermal
component of the STSG, the sooner the donor
wound will heal, but the graft at the recipient
site may be subject for scarring(see Figs.32.10
and 32.11).
• The donor wound from a medium, “standard”
STSG will heal within 14days and typically
does not leave a noticeable scar.
• Thick STSG donor wound may take 3weeks
or more to heal.
• STSGs are frequently meshed in order to
cover larger areas (Fig.32.10).
• Sheet grafts are more functionally and cosmetically appealing compared to mesh
grafts(Fig. 32.12).
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