Long term management and
complications of burns
• The Professor Stuart Pegg Adult Burns Unit is
a major referral centre for Queensland,
Northern New South Wales, Northern
Territory and the Pacific Islands.
• Multi-disciplinary team of health professionals
When to transfer:
• More than 10% of TBSA is burnt
• All full thickness burns (burns to face, ears, eyes,
hands, feet, genitalia, perineum or a major joint. Even
if less than 5%.)
• Electrical burns, chemical burns.
• Burns with an associated inhalation injury.
• Circumferential burns of the limbs or chest.
• Burns in the very young or very old.
• Burns in people with pre-existing medical disorders
that could complicate management, prolong recovery,
or increase mortality.
• Burns with associated trauma.
measure to reduce
Full thickness oedema and
the likelihood of
circumferential reduced circulatory
further damage to
burns can cause a blood volumes
the tissues that lie
tourniquet effect results in venous
distally to the
Tension within the Wound gapes open
tissues is relieved by exposing fatty tissue
cutting the skin with and some bleeding
conformable and a
a scalpel. will occur
• Acticoat Absorbent: absorbent antimicrobial
• IntraSite conformable : conformable hydrogel
dressing with IntraSite Gel and a non-woven
• Intrasite gel: amorphous hydrogel which
promotes rapid but gentle debridement of
necrotic tissue, whilst being able to loosen
and absorb slough and exudate
• Plastic wrap: prevents moisture loss
• Suspect smoke inhalation injury when nasal hairs are
singed, mechanism of burn involves closed spaces,
sputum is carbonaceous, or carboxyhemoglobin level >
5% in nonsmokers
• Electrical injury that causes burns may also produce
cardiac arrhythmias, which require immediate
• Pancreatitis occurs in severe burns
• Prior alcohol exposure may exacerbate the pulmonary
components of burn injury
• Nearly all burn patients have one or more septicemic
episodes during hospital course; gram-positive
infections initially, Pseudomonas infections later
Pathophysiology of infection in burn
Avascularity of the
Loss of the cutaneous
eschar + impairment of
barrier entry of the Wound is colonized
patient's own flora and with gram-positive
organisms from hospital bacteria
into the burn wound.
Day 7 wound
other microbes (G+,
G-, yeast from GIT
• As antibiotics more effective against
Pseudomonas have become available, fungi
(particularly Candida albicans, Aspergillus
spp., and the agents of mucormycosis) have
emerged as increasingly important pathogens
in burn-wound patients.
• The frequency of infection parallels the extent
and severity of the burn injury
thickness of dermis
• The thicker the dermal component = the more
the characteristics of normal skin are
maintained following grafting.
– Due to greater collagen content and the larger
number of dermal vascular plexuses and epithelial
– Thicker grafts require more favorable conditions
for survival because of the greater amount of
tissue requiring revascularization.
From: CURRENT Diagnosis & Treatment: Surgery, 13e > Chapter 41.
Plastic & Reconstructive Surgery > Grafts & Flaps > Types of Skin
Graft + -
Thin split-thickness Survive transplantation Fewest qualities of normal
most easily. Donor sites skin. Maximum
heal most rapidly. contraction. Least
resistance to trauma.
Thick spilt-thickness More qualities of normal Survive transplantation less
skin. Less contraction. well. Donor site heals
More resistant to trauma. slowly.
Sensation fair. Aesthetically
Full thickness Nearly all qualities of Survive transplantation
normal skin. Minimal least well. Donor site must
contraction. Very resistant be closed surgically. Donor
to trauma. Sensation good. sites are limited.
• To ensure survival of the graft, there must be
• (1) adequate vascularity of the recipient bed
• (2) complete contact between the graft and
• (3) adequate immobilization of the graft-bed
• (4) relatively few bacteria in the recipient
• Donor area: ideal donor site would provide a
graft identical to the skin surrounding the area
to be grafted.
• E.g. Colour and texture match in facial grafts
will be much better if the grafts are obtained
from above the region of the clavicles.
However, the amount of skin obtainable from
the supraclavicular areas is limited.
• Donor areas for
– very thin grafts will heal in 7–10 days, donor areas
– intermediate-thickness grafts may require 10–18
– thick grafts 18–21 days or longer.
• The donor site hypertrophic scar formation
or changes in skin pigmentation can occur
• The patient must take special care of the skin of the
• Prolonged exposure to sunlight should be avoided
• Hypertrophic scars and keloids can be diminished with
the use of pressure garments, which must be worn
until the scar matures—approx.12 months.
• Since the skin appendages are often destroyed by full-
thickness burns, creams and lotions are required to
prevent drying and cracking and to reduce itching