Long term management and complications of burns Burns unit Escharotomies Complications 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.

Escharotomies Full thickness circumferential burns can cause a tourniquet effect Increased blood viscosity, localised oedema and reduced circulatory blood volumes results in venous stasis and ischaemia. Escharotomy = prophylactic measure to reduce the likelihood of further damage to the tissues that lie distally to the circumferential eschar. Tension within the tissues is relieved by cutting the skin with a scalpel. Wound gapes open exposing fatty tissue and some bleeding will occur Dressed with Acticoat Absorbent, IntraSite conformable and a loose bandage.

Acticoat Absorbent: absorbent antimicrobial dressing IntraSite conformable : conformable hydrogel dressing with IntraSite Gel and a non-woven dressing

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

Complications 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 attention 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 wounds Loss of the cutaneous barrier  entry of the patient's own flora and organisms from hospital into the burn wound. Wound is colonized with gram-positive bacteria Avascularity of the eschar + impairment of local immune responses  further bacterial colonization 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 appendages – 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-thicknessSurvive transplantation most easily. Donor sites heal most rapidly. Fewest qualities of normal skin. Maximum contraction. Least resistance to trauma. Sensation poor. Aesthetically poor. Thick spilt-thicknessMore qualities of normal skin. Less contraction. More resistant to trauma. Sensation fair. Aesthetically more acceptable. Survive transplantation less well. Donor site heals slowly. Full thicknessNearly all qualities of normal skin. Minimal contraction. Very resistant to trauma. Sensation good. Aesthetically good. Survive transplantation least well. Donor site must be closed surgically. Donor 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 the bed (3) adequate immobilization of the graft-bed unit, and (4) relatively few bacteria in the recipient area.

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 days – 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