Long-term management and complications (Jackie)




http://www.rch.org.au/burns/clinical/index.cfm?doc_id=2012
http://wound.smith-nephew.com/nz/Product.asp?NodeId=5558
Access medicine: quick answers, Harrison’s Online
http://www.alfred.org.au/Assets/Files/269_BurnsManagementResources.pdf (Burns
Management Resources)
Burns Unit

Multi-disciplinary team of health professionals:
o
o
o
o
o
o
o
o
o
o

Surgery
Nursing
Physiotherapy
Orthotics
Nutritional Services
Occupational Therapy
Education Department
Play Therapy
Social Work
Mental Health
When to transfer:
o
o
o
o
o
o
o
o
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 is performed by the consultant as a prophylactic measure to reduce the
likelihood of further damage to the tissues that lie distally to the circumferential eschar (n. A
dry scab or slough formed on the skin as a result of a burn).
Tension within the tissues is relieved by cutting the skin with a scalpel.
Wound gapes open exposing fatty tissue and some bleeding will occur.

The escharotomy is dressed with Acticoat Absorbent
( absorbent alginate dressing
provides antimicrobial protection and absorbency)
 Then put IntraSite conformable (conformable hydrogel dressing with IntraSite Gel and a nonwoven dressing), plastic wrap loosely (film inhibits evaporation of moisture) and a loose
bandage.
 Limb observations are necessary, as is elevation to monitor the effectiveness of the
escharotomy.
Burn dressings : http://www.rch.org.au/emplibrary/clinicalguide/dressings_table.pdf
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; grampositive infections initially, Pseudomonas infections later
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
 Autogenous graft or autograft: skin from same individual
 The thicker the dermal component =the more the characteristics of normal skin are
maintained following grafting.
o Due to greater collagen content and the larger number of dermal vascular plexuses
and epithelial appendages
o Thicker grafts require more favorable conditions for survival because of the greater
amount of tissue requiring revascularization.
 Split-thickness skin graft: variable thickness of dermis. Thin (0.005-0.012 in), intermediate
(0.012-0.018 in), or thick (0.018-0.030 in) based on the thickness of graft harvested.
o Can tolerate less ideal conditions for survival and have a much broader range of
application, e.g. resurface large wounds.
o





more fragile, especially when placed over areas with little underlying soft tissue bulk
for support
o contract more during healing, do not grow with the individual, and tend to be
smoother and shinier than normal skin
Full-thickness skin graft (FTSG) contains the entire dermis.
o Ideal for visible areas of the face that are inaccessible to local flaps or when local
flaps are not indicated.
o Retain more of the characteristics of normal skin
o Undergo less contraction while healing. Important on the face as well as on the
hands and over mobile joint surfaces.
A flap is a vascularized block of tissue that is mobilized from its donor site and transferred to
another location
o Graft brings no vascular pedicle and derives its blood flow from recipient site
revascularization, whereas a flap arrives with its blood supply intact.
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 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, whereas donor areas for
intermediate-thickness grafts may require 10–18 days and those for thick grafts 18–21 days
or longer. The donor site is not without impaired cosmesis, as 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 are particularly bothersome and
can be diminished with the use of pressure garments, which must be worn until the scar
matures—approximately 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.