Long term management and complications of burns

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					Long term management and
  complications of burns
          Burns unit
          Skin grafts
                Burns units

• 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.
                                                     Escharotomy =
                              Increased blood
                            viscosity, localised
                                                   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
                                  stasis and

                                                      Dressed with
 Tension within the        Wound gapes open
                                                   Acticoat Absorbent,
tissues is relieved by     exposing fatty tissue
cutting the skin with       and some bleeding
                                                   conformable and a
      a scalpel.                will occur
                                                     loose bandage.
• 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
                                                     local immune
patient's own flora and   with gram-positive
                                                 responses  further
organisms from hospital        bacteria
                                                 bacterial colonization
 into the burn wound.
                                                   and proliferation

                            Day 7  wound
                            colonised with
                          other microbes (G+,
                           G-, yeast from GIT
                                and URT)
• 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
Skin grafts
              Split-thickness skin
              graft: variable
              thickness of dermis

               entire 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
                               Grafts >

Graft                   +                             -
Thin split-thickness    Survive transplantation       Fewest qualities of normal
                        most easily. Donor sites      skin. Maximum
                        heal most rapidly.            contraction. Least
                                                      resistance to trauma.
                                                      Sensation poor.
                                                      Aesthetically poor.
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
                        more acceptable.
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.
                        Aesthetically good.
• To ensure survival of the graft, there must be
• (1) adequate vascularity of the recipient bed
• (2) complete contact between the graft and
  the bed
• (3) adequate immobilization of the graft-bed
  unit, and
• (4) relatively few bacteria in the recipient
                Donor areas
• 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
  upon healing.
• The patient must take special care of the skin of the
  burn scar.
• 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

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