BURN WOUND MANAGEMENT

ByDr E Aravind

Under Guidance ofDr DSVL Narasimham MS

There is no greater trauma than a major burn injury

Mortality occurs immediately or after several weeks due to multi organ failure

Burns are seen mostly in extremes of ages either young or older people

Location plays a major role in treatment and outcome

DEPTH First degree—injury localized

to the epidermis Superficial second degree—

injury to the epidermis and superficial dermis

Deep second degree—injury through the epidermis and deep into the dermis

Third degree—full-thickness injury through the epidermis and dermis into the subcutaneous fat

Fourth degree—injury through the skin and subcutaneous fat into underlying muscle or bone

ESTIMATION OF BURN AREA BY RULE OF NINE

Adult Pt Pediatric Pt

PRE HOSPITAL CARE OF THE BURN WOUND It is basic and simple Only protection from the environment

with application of a clean dry dressing or sheet to cover the involved part.

By covering the wounds, contact to exposed nerve endings is prevented thus dimenishing the pain

Damp dressings should not be used Wrap in a blanket to minimize heat loss

ESCHAROTOMIES Done in deep second- and third-degree burn wounds

encompass the circumference of an extremity When peripheral circulation to the limb is

compromised Edema beneath a non yielding eschar impedes

venous outflow and eventually affects arterial inflow to the distal beds

This is recognized by numbness and tingling in the limb and increased pain in the digits

Tissue pressures greater than 40 mm Hg require escharotomy

Performed at the bedside by incising the lateral and medial aspects of the extremity with a scalpel or electrocautery unit

WOUND CARE Depends on the characteristics and size

of the wound Aim is rapid and painless healing Wound should be dressed with an

appropriate covering

It should protect the damaged epithelium, minimize bacterial and fungal colonization, and provide splinting action to maintain the desired position of function

It should be occlusive to reduce evaporative heat loss and minimize cold stress

It should provide comfort over the painful wound.

First-degree wounds Minor with minimal loss of barrier

function No dressing reqiured Treated with topical salves to decrease

pain and keep the skin moist Oral Nonsteroidal antiinflammatory

agents given to assist in pain control.

Second-degree wounds Require daily dressing changes with

topical antibiotics, cotton gauze, and elastic wraps

The wounds can be treated with a temporary biological or synthetic covering to close the wound

Deep second-degree and third-degree wounds

These wounds require excision and grafting for sizable burns

Choice of initial dressing should be aimed at holding bacterial proliferation in check and providing occlusion until the operation is performed

ANTIMICROBIALS These are divided into those given

topically and those given systemically Topical antibiotics can be divided into

two classes: salves and soaks

Slaves Salves are generally applied directly to

the wound with cotton dressings placed over them

Salves may be applied once or twice a day but may lose their effectiveness between dressing changes

Soaks Soaks are generally poured into cotton

dressings on the wound Remain effective because of antibiotic

solution

Synthetic and Biological Dressings Alternative to antimicrobial dressings They provide stable coverage without

painful dressing changes, provide a barrier to evaporative losses, and decrease pain in the wounds

These do not inhibit epithelialization Should be applied within 72 hours of the

injury, before high bacterial colonization of the wound occurs

Used to cover second-degree wounds while the underlying epithelium heals

To cover full-thickness wounds for which autograft is not yet available

Biological dressings include xenografts from swine and allografts from cadaver donors.

Applied to the wounds as of skin grafts perform the immunologic and barrier functions of

normal skin. Biological dressings are the optimal wound

coverage in the absence of normal skin. Latter biological dressings will be rejected by

usual immune mechanisms, causing the grafts to slough.

The open wound can be covered with autograft skin from the patient.

Severely burned patients are immunosuppressed, and biological dressings that have adhered will not reject for several weeks

Excision Done in deep second- and third-degree

burns They do not heal without autografting Early excision of the wound and

autografting has significantly reduced mortality

Done with hand skin graft knife, power dermatome

Sharp excision with knife or electro cautery is done in areas of cosmetic importance

Tangential Excision Repeated shaving of wound At depths of 0.005 to 0.01 inch till viable

dermal bed is reached Full thickness Excision Done with hand knife or dermatome at

thickness set at 0.015 to 0.03 inch till viable fat is reached

Fascial Excision Done in cases of involvement of deeper

tissues or infection Done with sharp No 11 blade It is mutilating and has permanent

disfuguration Bleeding will be more

Burn Wound Coverage Auto grafts are the main stay of

treatment If adequate auto graft is not available

cadaveric graft or xeno graft can be used temporarily

Cultured epithelial autografts are the present coverage of choice

Presently autograftwhen used along with allograft in mesed fashion gives good cosmetic results