Transcript Long term management and complications of burns

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
Day 7  wound
colonised with
other microbes (G+,
G-, yeast from GIT
and URT)
Avascularity of the
eschar + impairment of
local immune
responses  further
bacterial colonization
and proliferation
• 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-thickness
Survive 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-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
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 fullthickness burns, creams and lotions are required to
prevent drying and cracking and to reduce itching