i bc27f85be50b71b1 (140 page)

pressures. Tissue ischemia and loss of limb can ensue if these conditions are not treated with escharotomy or fasciotomy. Escharotomy is the surgical incision through eschar to decompress tissue below the

burn. Fasciotomy is the surgical incision thtOugh fascia to decompress

tissue within a fascial compartment. Both procedures are typically

performed at the bedside. Clinical indications for escharotOmy or fasciotOmy are decreased arterial blood flow, as determined by loss of Doppler flowmetry signal, or increased compartment pressure measurements (greater than or equal to 30 mm Hg) H

Burn Management in the Reparative Phase

Tissue healing at burn sites occurs over weeks to months according to

the depth of the burn and is described in Process of Wound Healing.

For a discussion of variables that can slow the process of burn healing, see FactOrs That Can Delay Wound Healing. After the healing process, a scar forms. A burn scar may be Ilormotrophic, with a normal appearance from the dermal collagen fibers that are arranged in an organized parallel formation, or hypertrophic, with an abnormal

appearance as a result of the disorganized formation of dermal collagen fibers.26

Burn management can be divided into twO major categories: the

surgical management of burns, and burn cleansing and debridement.

It is beyond the scope of this chapter to discuss in detail the indications, advantages, and disadvantages of specific surgical interventions

BURNS AND WOUNDS 455

that facilitate burn closure. Instead, surgical procedures related to

burn care are defined below.

Surgical Procedures

The cornetstone of present surgical burn management is early burn

excision and grafting. Excision is the surgical removal of eschar and

exposure of viable tissue to minimize infection and promote burn closure. Grafting is the implantation or transplantation of skin onto a prepared wound bedH Early burn closure minimizes infection, the

incidence of multisystem organ failure, and morbidity. Table 7-6

describes the different types of excision and grafting. Table 7-7

describes the different artificial and biological skin substitutes for use

when there is a lack of viable autograft sites.

Surgical excision and grafting are completed at any site if patient

survival will improve. If morbidity is greater than 50%, the priority is

for the excision and grafting of large flat areas to rapidly reduce the

burn wound area.25 Grafting is otherwise performed to maximize

functional outcome and cosmesis, with the hands, arms, face, feet,

and joint surfaces grafted before other areas of the body." Permanent

grafting is ideal; however, grafting may be temporary. Temporary

grafting is indica red for small wounds expected to heal secondarily

and for large wounds for which an autograft would not last or if permanent coverage is not available.29

Grafts, which typically adhere in 2-7 days, may not adhere or

"take" in the presence of any of the following27•28:

• An incomplete eschar excision

• Movement of the graft on the recipient site

• A septic recipient site

• A hematOma at the graft site

• A recipient site with poor blood supply

• Poor nutritional status

Clinical Tip

• To promote grafting Sllccess, restrictions on weight

bearing and movement of a specific joint or entire limb

456 ACUTE CARE HANDBOOK FOR PHYSICAl TI-IERAI'ISTS

Table 7-6. Types of Excision and Grafting

Procedure

Description

Tangential

Removal of eschar in successive layers down to the

excision

dermis

Full-thickness excision

Removal of eschar as a single layer down ro the

subcutaneous tissue

Autograft

Surgical harvescing of a patienr's own skin from

another part of the body (donor site) and placing

it permanently on the burn (recipient site)

Split-thickness skin

Autograft consisting of epidermis and a portion of

graft (STSG)

dermis

Full-thickness skin

Autograft consisting of epidermis and the entire

graft (FTSG)

dermis

Mesh graft

Autograft placed through a mesher (a machine that

expands the size of rhe graft usually 3-4 rimes)

before being placed on the recipienr site

Sheet graft

Autograft placed on the recipient site as a single

piece without meshing

Cultured epidermal

Autograft of unburned epidermal cells cultured in

autOgraft (CEA)

the laboratory

Composite skin graft

Autograft of unburned epidermal and dermal cells

cultured in the laboratory

Allogenic graft

Autograft of unburned epidermal cells and cadaver

skin cultured in the laboratory

Homograft

Temporary graft from cadaver skin

Heterograft

Temporary graft from another animal species,

(xcnogra ft)

typically of porcine skin

Amnion graft

Temporary graft from placenral membrane

Source: Data from SF Miller, MJ Staley, RL Richard. Surgical Management of [he Burn

Patient. In RL Richard, MJ Staley (cds), Burn Care and Rehabilitation: Principles and

Practice. Philadelphia: FA Davis, 1994.

Table 7-7. Temporary and Permanent Skin Substitutes for the Treatment of Burns

Product

Description

Use

Biobrane (Bertex Pharmaceu

Temporary graft option.

For small [Q medium superfiticals, Morgantown, WV)

Two-layered graft composed of nylon mesh impregnated

cial-thickness burns or parwith porcine collagen and silicone; the outer silicone

tial-thickness burns

layer is permeable ro gases but not to fluid or bacteria.

Has had limited success on

Applied wirhin 24 hours.

full-thickness burns because

Spontaneously separates from a healed wound in 10-]4

of infection

days.

May also be used to protect a

meshed autograft

Dermagrafr TC (Advanced

Temporary graft option.

For partial-thickness burns

Tissue Sciences, La Jolla.

Two-layered material composed of biological wound

CAl

healing factors (e.g., fibronectin, type 1 collagen,

tenascin) and growth factors (e.g., factor�) on an

external synthetic barrier.

TransCyte (Advanced Tissue

Temporary graft option.

Used for partial-thickness

Sciences, La Jolla, CAl

Composed of a polymer membrane and newborn human

burns that will require

�

c

fibroblast cells cultured on a porcine collagen-coatcd

dehridemenr and may heal

"

Z

nylon mesh. The fibroblasts secrete human dermal

without surgical inter

�

>

collagen, matrix proteins, and growth factors.

vention, or on excised deepz

o

partial or full-thickness

�

burns prior to autografting

c

�

...

'"

"