Burns and Burn Reconstruction


Chapter 22

Burns and Burn Reconstruction



Initial Evaluation



1. Burn severity or “degree”: Described based on depth of injury


• First degree (“superficial” partial thickness): Superficial, erythema, sometimes painful, epidermal integrity intact


• Second degree (“deep” partial thickness): Blisters, erythema, edema, very painful, epidermis violated, injury is into dermis


• Third degree (full thickness): Charred or translucent, “white” color, mild pain, pin prick absent


2. Burn volume: Described by total body surface area (TBSA) involved


• “Rule of nines” (see Figure 22.1)



• Lund and Browder method (see Figure 22.2)



3. Burn center referrals


• Outcomes of burns better at high-volume centers


• Criteria for referral to an accredited burn center (American Burn Association) (see Box 22.1)





Burn Management



1. Fluid resuscitation


• High-volume resuscitation is warranted in burns >20% TBSA


• Parkland formula


▪ (4 mL/kg) × (weight in kg) × (% TBSA) = total fluid to be infused over 24-hour period.


▪ Give half of this in the first 8 hours from the time that the burn injury occurred (not from time of presentation).


▪ Give remaining half during the next 16 hours.


• Titrate fluid resuscitation to urine output.


▪ Adults: image cc/kg/hr


▪ Pediatrics: 1 cc/kg/hr


▪ Urine output can be falsely elevated with elevated urine glucose (glycosuria), thereby overestimating a patient’s fluid status.


○ When following urine output in these patients, obtain a urinalysis to check for the presence of glucose.


2. Supportive care


• Systemic prophylactic antibiotics and steroids have not been shown to improve outcomes.


▪ Antibiotics are indicated in the presence of cellulitis, purulent drainage, and active infection.


○ Most common organisms are methicillin-resistant Staphylococcus aureus, Pseudomonas, and Klebsiella.


○ Initial coverage using broad-spectrum antibiotics (e.g., vancomycin and piperacillin-tazobactam) followed by culture-directed therapy


• Children are at high risk for hypoglycemia in the first 24 hours following a burn due to limited hepatic glycogen stores.


• Most common cause of death is bronchopneumonia.


3. Burn nutrition


• Large burns are associated with hypermetabolism.


• Elevated daily protein requirement for burn patients


▪ Adults: 1 to 2 g/kg/day


▪ Pediatrics: 2 to 3 g/kg/day


• Excessive carbohydrate/glucose administration can result in excessive water and carbon monoxide generation, leading to increasing edema and difficulty in weaning ventilator support.


• Enteral feeding is preferred to parenteral nutrition.


4. Topical antimicrobial agents


• Silver nitrate


▪ Advantages: Can provide antimicrobial coverage and some hemostasis


▪ Disadvantages: Must be frequently reapplied, stains tissue black, can cause electrolyte disturbances and methemoglobinemia


• Silver sulfadiazine (Silvadene)


▪ Advantages: Broad-spectrum antimicrobial coverage


▪ Disadvantages: Forms a yellowish-gray pseudoeschar that must be removed before reapplication, can cause leucopenia, cross-reactive with sulfa allergies, cannot penetrate eschar or cartilage


• Mafenide acetate (Sulfamylon)


▪ Advantages: Broad-spectrum antimicrobial coverage, penetrates eschar and cartilage, useful in setting of burn wound infection and suppurative chondritis


▪ Disadvantages: Painful when applied, can cause metabolic acidosis, secondary to inhibition of carbonic anhydrase


5. Surgical management/burn reconstruction


• Operative excision and grafting are recommended for burn wounds that are not likely to reepithelialize and heal within 3 weeks.


▪ The practice of early burn wound excision and grafting has reduced mortality from burn wound sepsis.


• Debride partial-thickness wounds with tangential excision until pinpoint bleeding is obtained, then perform skin graft.


• Skin substitutes may be used in patients who may not have enough donor site availability for burn wound coverage.


▪ Cultured epidermal autografts: Ex vivo expansion of donor keratinocytes


○ Advantages: Can obtain ~10,000-fold expansion; available in spray form


○ Disadvantages: Lack dermal component, rendering these grafts fragile and highly susceptible to sheer forces; grown with murine fibroblasts and fetal calf serum, which can contribute to rejection, infection


• Escharotomy


▪ Indications: Full-thickness circumferential skin burns that can cause ischemia to a distal extremity or part from development of compartment syndrome


▪ Symptoms


○ Dry, pale/whitish skin, nonblanching, insensate


○ “5 Ps”: pain, pallor, poikilothermia, paresthesia, pulselessness


▪ Perform at bedside as soon as the patient stabilized


▪ Make incisions in the following orientation and with a depth into the subcutaneous fat:


○ Arm/forearm: Longitudinal medial and lateral


○ Hand: Thenar/hypothenar, dorsal incisions 3× between metacarpals, digital midlateral lines


○ Chest wall: Midline, + /− transverse


○ Thigh/leg: Longitudinal medial and lateral


○ Foot: Dorsal, medial, lateral


• Reconstruction of burn wounds can be performed through skin grafts, pedicled flaps, and/or free flaps.


▪ Delay free flaps for at least 6 weeks after debridement in burn patients secondary to a hypercoagulable state; leads to an increased risk of microvascular thrombosis.

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Sep 2, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on Burns and Burn Reconstruction

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