Management of the burned
It is important to complete a detailed history of pre-existing problems and of the burn injury. A detailed physical examination and examination of the burned area is carried out. Adequate pain relief must be provided, usually by means of intravenous morphine. Good notes and a drawing of the burn area are needed. Smaller burns may be managed satisfactorily on an outpatient basis with arrangements for further dressing either at a hospital follow-up clinic or by the general practitioner. Patients with major burns should ideally be treated in a specialised burns unit. Indications for referral include:
• burns of special areas (face, hands, feet, perineum, genitalia);
• full-thickness burns >5 per cent body surface area;
• circumferential limb or chest burns;
• electrical burns;
• chemical burns;
• burns in children or the elderly;
• where nonaccidental injury is suspected in the case of a child;
• associated medical conditions or pregnancy;
• associated other trauma.
Adequate assessment, resuscitation and fluid administration should be secured before transfer of the patient. The trend towards early surgical excision and closure of the wound dictates that any patient with a wound which is unlikely to heal spontaneously should have the benefit of a plastic or burns surgical opinion at the earliest possible stage. A burns unit is often the most convenient place to undertake regular dressings. Dressing changes in an appropriate area are likely to minimise cross-infection, although formal isolation is rarely used unless a patient is shown to have an antibiotic-resistant organism, such as methicillin-resistant Staphylococcus aureus. The burns unit provides facilities for immediate physiotherapy and occupational therapy to minimise limb stiffness. Nutritional support is available. Early establishment of normal feeding appears to protect the small bowel mucosa and prevent translocation of Gram-negative bacteria. Inhalation injuries often require ventilation and monitoring by blood gases and bronchoscopy. These are best managed in a respiratory intensive care unit with appropriate surgical support for the management of the burn wound.
Epidermal burns with erythema and no blisters do not need dressings. Analgesia and moisturising cream are used. Burns the face are generally treated by exposure, largely because the difficulty of dressing . Where there is much crusting it may be necessary to apply an ointment such as petroleum jelly, particularly around the eyes, and frequent toilet of the eyes and orifices may be needed. Burns of the trunk and limbs are usually dressed. Where possible the burns should be inspected by an experienced doctor to check on the assessment of area and depth before the application of dressings, as appearances may subsequently be difficult to interpret. Superficial dermal burns with blistering are usually dressed to absorb exudate, prevent desiccation, provide pain relief, encourage epithelialisation and prevent infection. Appropriate dressings are plastic films, hydrocolloids, preserved cadaver or pig skin, alginates or paraffin gauze. A thick layer of gauze may then be placed on top to allow transudation of any fluid and layers of wool or padding are applied over this to act as a sump for exudate. Dressing changes are painful and should not be performed more than necessary. Partial-thickness skin injuries heal within 2—3 weeks. Any wound that remains unhealed or granulating at 3 weeks will not heal satisfactorily without surgical intervention. Plastic surgical advice should certainly be sought by 3 weeks or at an earlier stage if the wound is extensive or showing evidence of considerable slough formation. Enzyme preparations may be used to facilitate sloughing. Where deep burns are being managed with dressings a topical antimicrobial agent such as silver sulphadiazine cream is used.
There is controversy about the use of routine antibiotic administration. It is almost inevitable that a burned surface will become colonised by microorganisms. The administration of broad-spectrum antibiotics on a routine basis is likely to encourage the emergence of resistant organisms. Children suffering from burn wounds are often given routine antibiotics to limit the possibility of metastatic infection. Almost any organism may colonise a wound. Beta-haemolytic streptococci are likely to delay healing and should be treated. Staphylococcus aureus is a frequent pathogen and Pseudomonasparticularly grows on raw surfaces. These organisms may be best treated by local antiseptic preparations, although where there is any evidence of cellulitis, antibiotics should be administered. Frequent wound swabs should be cultured and where there is any rise in temperature, blood cultures should be taken.
Whether to administer an antibiotic before an organism is cultured from the blood is an individual clinical decision that depends on the severity of the patient’s condition.
Monitoring for the onset or progress of infection should consist of:
• routine temperature measurement;
• frequent wound swab cultures;
• wound inspection by an experienced doctor or nurse at the time of dressing change;
• blood cultures.
Toxic shock syndrome
Toxic shock syndrome (TSS) is a life-threatening, exotoxin-mediated disease caused by S. aureus. It can occur in children who often have small body surface area burns. It presents with fever, a rash, myalgia, diarrhoea and vomiting and can progress rapidly to hypotension and multiorgan failure. Treatment is by dressing change, fluid resuscitation, antibiotics and immunoglobulin. Mortality can be high, but prompt active intervention appears to be effective. It is important to have a high index of suspicion regarding this condition when treating burned children.
Partial-thickness burns should heal without surgical intervention, but full-thickness burns require surgical management. There are two alternative policies for deep burns. One can await spontaneous desloughing and apply split-skin grafts at 3 weeks. This policy has the advantage that early operation can be avoided, but has the disadvantage of slow healing and greater scarring that follows a granulating wound. Alternatively, early excision of the burn is carried out with the application of skin cover, usually a skin graft, but where indicated a flap. This has the advantage of obtaining rapid healing and early restoration of function, and minimises the risk of adverse scarring. Where facilities allow, a policy of early operation for deep burns is preferred. Early tangential excision of skin grafting is a technique used for deep dermal burns, usually performed within 48 hours. Successive layers of the burned tissue are shaved with a split-skin grafting knife until a healthy bleeding dermal bed is reached upon which the skin grafts are applied. The rationale of this treatment is that deep dermal burns will heal slowly with considerable scarring. The healing process can be expedited by this method. It is a technique that requires considerable experience in the interpretation of the wound bed. Any surgery of this type is associated with considerable blood loss and limbs should be operated on with the assistance of a tourniquet. On the trunk it may be necessary to use a dilute infusion of adrenaline subcutaneously. Following excision of burned tissue, skin cover is by split-skin autograft cover . This is harvested from a donor site on an unburned area of skin. Care should be taken in selecting the donor site to produce the least possible cosmetic deficit. All grafts in children should be harvested from the buttocks. With extensive burns, the thighs are the first choice and other sites on the limbs and trunks may be necessary in addition. The skin graft can be meshed to expand its area. This is a system by which the graft is expanded by passing it through a machine that places multiple cuts in the skin. The skin can then be stretched and the cuts open out into small, diamond-shaped wounds. In this way the skin can be expanded 1/2—3 times depending on the expansion of the diamonds. Meshed skin also has the advantage that it allows free drainage of fluid from beneath the graft area . Cadaveric allografts may be used for temporary cover. Cadaveric dermis has also been used as definitive cover with the addition of cultured autografts of keratinocytes. Keratinocyte grafting may have a larger role in establishing skin cover in the future. It is possible to grow large areas of keratinocyte autografts that facilitate healing, although the long-term future of the grafted skin cells remains uncertain. In deep burns, those with exposed structures (nerves, tendons, and vessels) or those overlying joints primary flap cover may be needed. Localised burns can usually be excised and closed in a single episode. Patients with extensive burn injuries may need repeated operations over many weeks to achieve healing. Once healed the process of rehabilitation can be more actively pursued.
Mobilisation and rehabilitation
The move towards earlier excision and skin cover and early mobilisation of the patient succeeds in reducing the incidence of complications such as infection and deep vein thrombosis. Most burns units have an intensive programme of physiotherapy and mobilisation without which limb oedema would progress to joint contractures.
Surgical reconstruction of the burn injury
The major complication of burn injury is scarring . Lumpy hypertrophic or keloid scars can be limited by the application of pressure, and patients are routinely fitted with Lycra pressure garments. Topical silicone sheeting may also be beneficial in limiting scar hypertrophy. Surgery is usually inappropriate for hypertrophic scars since they gradually improve with time. Where burn scars cross surfaces near-joint scar contractures may occur. Late surgical reconstruction may be needed to release these contractures . Broad contractures require releaser and insertion of skin grafts; such operations are particularly valuable inrestoring the range of motion of a joint, but often leave a less than pleasing aesthetic result. Where there is a localised linear contracture a better technique may be Y—V plasty . In some circumstances contractures can be released and burn scar area reduced by means of tissue expansion. This technique allows gradual stretching of marginal skin by implanting expander balloons under the adjacent normal skin. These are serially injected with saline through a port, thereby enlarging the expander andstretching the overlying skin. At a second operation the expander is removed and the excess skin stretched over the grafted area to aid reconstruction. Tissue expansion is particularly useful in reconstruction of burn alopoecia. Missing eyebrows can be reconstructed by hair-bearing grafts or flaps. Extensive procedures may be necessary to reconstruct facial features such as the eyelids, lips and nose. In the long term, areas healed by skin grafting may be unstable and chronic ulceration in a grafted area may rarely lead on to a squamous carcinoma.
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