A.
Excision and Grafting
The basic premise of excision and grafting is to remove full thickness and deep partial burns until clean viable bed is encountered and a skin graft is placed immediately to cover the wound
Early Excision
This is done within the 1 st 7 days post-burn, while the burn wound is not yet colonized by microorganism; thus reducing chances of infection and promoting good graft take
Preparation for OR- Prerequisites
1.
Stable vital signs
2.
Not in septic shock
3.
Afebrile
4.
Blood type and crossmatch for OR use. Estimated amount to replace losses during tangential excision at 200-400 ml/% BSA excised
5.
Albumin us normal (38-51g/L)
6.
No medical contraindications for surgery
Conduct for OR
1.
Make sure that the OR table is covered by sterile linen before the patient is transferred onto the table
2.
Keep the OR warm
3.
Prep the patient using betadine soap and betadine paint for the donor sit, betadine soap for the wound
4.
Prep the donor site
5.
Drape the donor site separate from the burn wound
Tangential Excision
1.
Harvest the split thickness graft (STSG), expounded in a later section
2.
Using a Humby knife or a mechanical dermatome. Make successive passes over the burn wound. The goal is to seek a layer of brisk punctuate bleeding. Whitish-gray areas do not bleed immediately after passage of the dermatome area are still not viable and still need to be excised
3.
Hemostatis is obtained by spraying the wound with a 1:100,000 epinephrine solution
(prepared by mixing 1 ampule of epinephrine containing 100 ml of 1:1000 epinephrine solution in 100 ml of sterile NSS). The wound is covered by a sterile sheet of rubber plastic
Op-site, Tegaderm or other similar dressing
4.
Apply pressure for 5-10 minutes. While waiting, one may work on other areas so as not to waste time
5.
Wash away the blood clots using NSS projected from a syringe. Points still bleeding can be controlled by cautery

6.
Apply STSG (expounded in later section)
7.
Limit OR time to at most 4 hours and work on at most 10% BSA per OR
Fascial Excision
Best used when excising large flat areas e.g. trunk where heavy bleeding might be encountered or when excision of the burn wounds has to be done with a minimum of blood loss. The operation is less bloody than tangential excision, but there is a cosmetic effect defect resulting from the procedure. It is of limited use in the extremities due to problems of edema in the area distal to the excision, the presence of avascular fascia in the joint areas (which could result in graft loss) and the presence of nerves in superficial locations which may be injured. It is also recommended in full thickness burns in the elderly since grafts on fat do nor survive.
1.
Harvest STSG
2.
Using electrocautery, excise full thickness of eschar including the subcutaneous fat until the fascia is encountered. Blood loss from this procedure is much less than tangential excision as bleeding comes from the perforators
3.
Apply the skin graft expounded in a later section
Harvesting the skin graft:
1.
Prep the door site with betadine soap and paint
2.
Harvest the STSG using a Humby knife or mechanical dermatome with thickness of 0.0010-
0.014 inch. A good skin graft contains the dermis as evidenced by whitened undersurface.
There should be dermis remaining in the donor site for epitheliazlization. If fatty tissues is noted where the graft is harvested, the graft is too thick.
3.
Hemostatis is secured using 1:100,00 epinephrine spray and plastic overly followed by pressure s described in hemostatis and tangential excision
4.
Cauterize any persistent bleeders
5.
Dress the donor site with hydrocolloid dress or by applying one layer of mesh gauze followed by layers of wet gauze. The wet gauze is removed after 8 hours and the donor site with a single layer of mesh is exposed for 30 minutes every hour for one day until scab will form which will later flake off as donor site heals
6.
Choice for donor sites: Thigh, leg
Back*
Scalp*
Anterior trunk
*will have to inject sterile NSS subcutaneously to elevate the skin and create a smooth flat surface to facilitate harvesting of skin graft
Applying the skin graft:

1.
In burns over joints and the face, do not mesh the skin. One may place widely spaced nicks using a blade (No.11) to prevent serum or blood from collecting under the graft. Otherwise skin grafts may be meshed to provide a greater area to be covered by the skin graft
2.
Make sure that the bed upon which the STSG would be applied has no active bleeding
3.
Secure the grafts to the bed. One may use a stainless steel stapler or one may suture the graft on to the bed. In the hands and the face , one must suture the graft using chromic 4.0
4.
Once graft is secure, apply a layer of non-adherent gauze (vaselinized or sofratulle)
5.
Place a layer of bulky wet dressing (cotton or gauze) to help the graft have firm contact with the bed
6.
Secure dressing using the over-bolus over flat areas or circumferential elastic bandages over flat extremities
7.
Apply splints to immobilize the joints with STSG
Care of the skin graft
1.
First graft opening could be as early as the 3 rd post-op day or as late as 5 th post-op day. Open early if the skin graft is suspected to be infected as when it has a foul-smelling odor
2.
Remove the bulky dressing slowly. Take care not to disturb the skin graft. Use copious amount of sterile water. Skin graft take is indicated by pinkish-color of graft and adherence to graft bed. Gently wash the area wit betadine soap and rinse with water. Dress the graft with bulky wet dressing,
3.
Staples can be removed at he 1 st dressing change
4.
Skin grafts can be dressed every day if not infected. If with good take, the skin graft can be left open on the 7 th post-op day. Small areas of graft loss (about thumb size) could be cleansed by mercurochrome
REVIEW QUESTIONS
B.
Name and differentiate 2 basic types of surgery used in the removal of burn tissue
Nutrition
Patients with moderate burn can be fed as early as 6-8 hours after the burn injury. Patients with larger burns can be fed 24 hours or as soon as ileus (which is a result of burn) resolves. Patient with burns have a hypermetabolic response and have metabolic nutritional requirements. This hypermetabolic state persists until burn wounds are covered. To ensure delivery of necessary calories in these patients, a nasogastric tube is inserted.
Calculations of patient’s nutritional requirements by using Curreri’s formula:

Adult: (25 x kg) / (40 x %BSA burn)

Children (60 x kg) / (35 x %BSA burn)

A rough guide is to use 2500 calories/day in an adult patient. Proteins are calculated at 2g/kgBW per day. Patients in the burn unit are asked to eat 6 eggs/day cooked in anyway they want. Give supplements of vitamin C and zinc.
REVIEW QUESTIONS
Give the formula in calculating a burn patient’s nutritional requirement
C.
Common Complications
1.
Sepsis

Most common cause of death in burns

Suspects sepsis if patient has fever, hypotension, conversion from partial to full thickness burns, presence of ecthyma gangranosum in the burn wound


Cultures if blood may be negative if there were antibiotics previously given
Start antibiotics
2.
ARDS

Occurs when in the setting of electrical or inhational/pulmonary injury

Presents as progressive hypoxemia unresponsive to increasing FiO2

X-rays may be normal in its early phase

Manage with intubation: 100 FiO2 and PEEP
3.
Contractures

Preventable by proper positioning and splinting

Coordinate with rehabilitation medicine resident regarding proper positioning
D.
Pain Control
May give Meperidine 50 mg IV Q6 or Nalbuphine Q4. Do not give narcotics IM since absorption is erratic
CRITERIA FOR DISCHARGE
1.
No existing complications of thermal injury such as inhalational injury
2.
Fluid resuscitation completed
3.
Adequate pain tolerance
4.
Adequate nutritional intake
5.
No anticipated septic complcations