BURNS

1. BURNS
DR. S.M. BERA
MCS 2021 YEAR 1
MODERATOR: DR.ODUOR

2. BURNS TREATMERNT
• OBJECTIVES
• To describe prehospital management and the role of primary and
secondary survey
• Develop a method of fluid resuscitation that can be applied to patients
with moderate to severe burns utilizing the principles of fluid resuscitation
and the techniques of assessing fluid status
• Recognize the signs and symptoms of inhalational injuries and carbon
monoxide poisoning and know how to treat both.
• To describe etiology of fluid creep in burns management
• Explain why early excision and grafting has become the standard in the
treatment of burns and analyze the benefits and problems associated with
this treatment strategy in our context.

3. Pre-Hospital Treatment and First Aid
• On-site treatment and first aid
• Assessment as per ATLS
• Assume inhalational injury or carbon monoxide exposure and place
on 100% oxygen
• Wean off as possible to avoid oxygen toxicity.
• Assess need for intubation .
• Obtain large-bore IV access and give intravenous fluids .
• Assume all patients with burns are trauma patients .
• Consider other injuries

4. Flame Burns
• Remove victim from burning source and stop the burning process.
Synthetic fibers (nylon, polyester, rayon) burn rapidly and melt into the
person's skin.
clothing should be removed.
Involved skin should be washed with water
• Cover with clean dry towels in order to prevent hypothermia.
• Covering burns with plastic wrap or cling wrap can prevent moisture
loss and protect the tissue.

5. Electrical burns
• Always first survey the scene to ensure no further danger to the
rescuer.
• Don't become a victim yourself!
• Make sure the electrical source is switched off or that the victim has
been removed from source.
• Assess whether cardiopulmonary resuscitation is required.

6. Chemical burns
• If powder, dust off first.
• Then, run under water to wash off chemicals.
• Neutralizing agents are not recommended because the resulting
reactions can generate heat.

7. Primary and Secondary Surveys
• All patients with burns should be viewed as trauma patients primarily
because they can have other injuries in addition to their burns.
• Primary and secondary survey should be performed as with all
traumas with additional focus on burn-specific issues

8. A. Airway management
• Airway compromise can occur with direct upper airway heat injury
and smoke inhalation injury, both of which can cause tremendous
airway edema
• Anticipate the need for early intubation !
• The airway edema often worsens following fluid resuscitation making
elective intubation more difficult as time passes .
• The progression of edema can be extremely rapid and occur in just
minutes.
• Early intubation in high-risk patients can save lives!

9. • Signs such as peri-oral burns and singed nasal hairs do not necessarily
mean there has been upper airway injury but should prompt evaluation of
the oral and airway mucosa.
• Circumferential neck burns should prompt concern for airway loss.
• Hoarse voice, wheezing or stridor are much more concerning signs of
impending respiratory failure with subjective dyspnea being especially
ominous.
• These should prompt intubation!

10. • The 2016 International Society for Burn Injury clinical guidelines for
the care of the burn patient recommend intubation or tracheostomy,
only as an indication if the airway patency is jeopardized, whereas
observation and monitoring are the recommended treatment for
secondary upper airway burns due to inhalation.

15. B. Breathing
• Administer 100% humidified oxygen in any patient with inhalational
injury or any evidence of pulmonary dysfunction.
• Inhalation of certain chemical substances and toxins may cause
tracheobronchitis and chemical pneumonitis as well as edema of the
lower airways.
• This includes chemicals found in burning rubber, plastic, cotton,
wool, and glue.

16. Circumferential chest wall burns
• Certain full thickness chest wall burns, especially when circumferential, may
impair respiratory motion leading to respiratory insufficiency or failure.
• Escharotomy may be necessary in such situations and should be considered
early

18. Carbon monoxide poisoning.
• Always assume this possibility when burns occur in an enclosed or poorly
ventilated area.
• Administer 100% oxygen to treat CO poisoning.

19. Clinical Connection: Carbon monoxide poisoning
• Tasteless, odorless, non-irritating gas
• Major source of early mortality associated with burn injury.
• Greater affinity for hemoglobin than oxygen (200 times greater) .
• Competes with O2 to bind the hemoglobin.
• When CO binds to hemoglobin, the result is carboxyhemoglobin
(COHb).

20. • COHb molecules- decreased oxygen carrying capacity.
• Further, COHb molecules are less able to release their oxygen to the
tissues so that the oxygen bound to the COHb is less available to
tissues.
• Results in significant tissue oxygen impairment.
• Symptoms are based on carbon monoxide levels in blood
• Asymptomatic (at levels of 20%) to headache and nausea (20-30%) to
confusion (30-40%), coma (40-60%) and death (>60%).

21. Treatment
• Consists of high-flow 100% oxygen via a non-rebreather mask.
• Should be started in all patients with possible CO exposure.
• Carboxyhemoglobin has a cherry-red colour which is interpreted by a
pulse oximeter as being oxygenated hemoglobin, and so the oximetry
reading can be false elevated.

22. Circulation
• Any patient with >20% TBSA burns (> 10% in pediatric patients or the
elderly) requires immediate fluid resuscitation.
• Delays in resuscitation lead to poorer outcomes.
• Large-bore IV access should be obtained .
• The ideal is peripheral access through an unburned area of skin, however, if
this is not possible due to the extent of the burn, access in an area with
burned skin is preferable to no IV access.
• Upper extremity access is preferable to lower extremity access due to
increased risk of phlebitis in lower extremities.
• Fluid resuscitation with Ringer's lactate .

23. Disability and Evaluation of other injuries
• Burn patients could be victims of road traffic accidents, may have
fallen from a height, may have been involved in a blast injury or
explosion, or may have jumped from a burning building.
• Assume the possibility of spinal cord injury or head injury in such
patients.
• A burn patient could also have been the victim of another violent
crime .
• Burning a house can be used to cover other crimes and should be
examined for knife or bullet

24. Exposure and estimation of burn size and depth
• Remove all jewelry, rings, amulets, or necklaces as substantial edema
should be expected.
• Hypothermia is a significant concern in patients with large surface
area.
• Therefore, warmers and blankets should be used to prevent heat loss
and burns should be covered as soon as possible.
• All sources of cooling should be stopped.

25. Fluid Resuscitation
• The goals for fluid resuscitation should be to normalize
hemodynamics and tissue perfusion while minimizing the side effects
of the administration of fluid.
• Period of greatest capillary leak is in the first 12 hours post-burn
• Can last for 24-36 hours and cause significant side effects :
pulmonary edema and abdominal compartment syndrome.
• Despite these potential complications and side effects, it is vital for
survival that patients are quickly and adequately fluid resuscitated,
and any delay in resuscitation increases mortality for patients with
burns.

26. • The burn injury drives an inflammatory response that leads to
capillary leak
• As plasma leaks into the extravascular space, crystalloid
administration maintains the intravascular volume.
• Continuation of fluid volumes should depend on the time since injury,
urine output, and mean arterial pressure (MAP).
• As the capillary leak closes, the patient will require less volume to
maintain these two resuscitation endpoints.

27. • Children under 20 kg do not have sufficient glycogen stores to
maintain an adequate glucose level in response to the inflammatory
response.
• Specific pediatric formulas .
• The simplest approach is to deliver a weight-based maintenance IV
fluid with glucose supplementation in addition to the calculated
resuscitation with lactated Ringer’s.

29. • It is important to remember that any formula for burn resuscitation is
merely a guideline, and fluid must be titrated based on appropriate
response to therapy.
• Target MAP of 60 mmHg ensures optimal end-organ perfusion.
• Goals for urine output should be 0.5ML/kg/hr in adults and 1 to 1.5
mL/kg per h in pediatric patients.
• Some centers have found serum lactate to be a better predictor of
mortality in severe burns and others have found that base deficit
predicts eventual organ dysfunction and mortality.

30. • A classic study by Navar et al showed that burned patients with
inhalation injury required an average of 5.76 mL/kg per % burn, vs.
3.98 mL/kg per % burn for patients without inhalation injury.
• Prolonged mechanical ventilation may also play a role in increased
fluid.
• Those patients receiving higher fluid volumes were at increased risk
of complications and death.
• Common complications include abdominal compartment syndrome,
extremity compartment syndrome, intraocular compartment
syndrome, and pleural effusions.

31. Colloids in burn management
• The use of colloid as part of the burn resuscitation has generated
much interest over the years.
• In late resuscitation when the capillary leak has closed, colloid
administration may decrease overall fluid volumes and potentially
may decrease associated complications such as intra-abdominal
hypertension.

32. • A recent meta-analysis demonstrated a trend toward mortality
benefit for patients receiving albumin.
• However, albumin use has never been shown to definitively improve
mortality in burn patients and has controversial effects on mortality in
critically ill patients.
• Still, many burn centers use albumin as an adjunct during burn
resuscitation.

33. Hypertonic Saline
• Attempts to minimize fluid volumes in burn resuscitation have
included study of hypertonic solutions.
• A recent meta-analysis evaluating hyperosmotic vs. isoosmotic fluid
resuscitation demonstrates decreased total fluid load (vol/%TBSA per
weight) over the first 24 hours with use of hyperosmotic fluid with no
difference in total fluid, urine output, creatinine, or mortality.
• Downside of hypertonic fluid administration is hyperchloremic
acidosis.

34. Other adjuncts during initial burn
resuscitation
• High-dose ascorbic acid may decrease fluid volume requirements and
ameliorate respiratory embarrassment during resuscitation
• No mortality benefit has been noted thus far in two trials .
• Plasmapheresis has also been associated with decreased fluid
requirements and increased urine output in patients who require
higher resuscitative volumes than predicted to maintain adequate
urine output .
• It is postulated that plasmapheresis may filter out inflammatory
mediators, thus decreasing ongoing vasodilation and capillary.

35. BLOOD TRANSFUSION
• Immunomodulatory potentially immunosuppressive, which is one
explanation to the links between blood transfusions and increased
infection .
• A large multicenter study of blood transfusions in burn patients found
that increased numbers of transfusions were associated with
increased infections and higher mortality in burn patients, even when
correcting for burn severity.
• A follow-up study implementing a restrictive transfusion policy in
burned children showed that a hemoglobin threshold of 7 g/dL had
no more adverse outcomes vs. a traditional transfusion trigger of 10
g/dL.

36. • A recent randomized control trial in patients with >20% TBSA
compared outcomes of a restrictive to a liberal red blood cell
transfusion strategy (hemoglobin 7–8 vs. 10–11, respectively).
• There were no differences in blood stream infection, organ
dysfunction, ventilator days, time to wound healing, or 30-day
mortality between both groups.
• These data, in concert with other reported complications such as
transfusion-related lung injury,have led to recommendations that
blood transfusions be used only when there is an apparent
physiologic need.

37. Fluid creep
• Term coined by DR. Pruitt.
• Used to describe fluid resuscitation in excess of that predicted by the
Parkland formula and which is associated with abdominal compartment
syndrome (ACS)
• Fluid overload
• The consensus Parkland formula that has excluded colloid use, the impact
of goal-directed resuscitation, and the overzealous on the scene crystalloid
resuscitation combined with subsequent inefficient titration of fluid
administration and lack of timely reduction of infusion rates, have all
contributed to this phenomenon of fluid overloading.

38. • Patients often arrive at burn centers after receiving significantly large
amounts of crystalloid and much of their first 8-hour Parkland
requirements in just an hour or two because of inaccurate estimations of
burn size or overzealous and inattentive resuscitation
• Fluid creep may be considered an iatrogenic phenomenon resulting from
misuse of the originally described approaches to crystalloid resuscitation
by Baxter, who anticipated colloid infusion in the fourth 8-h period post-
burn.
• Departure from the original Baxter formula may help explain the
occurrence of fluid creep.

39. • With the onset of increased capillary permeability immediately
following burn injury, the initial leakage of proteins largely eliminates
the oncotic pressure gradient, favoring fluid flux from the
intravascular compartment.
• This is paralleled by a disruption of the “safety valve” against edema
formation of the densely configured collagen-hyaluronate interstitial
matrix, which increases interstitial compliance and generates
osmotically active fragments as well as negative “sucking” interstitial
pressure, facilitating rapid fluid sequestration.

40. • Despite the neutralization of the gradient within a few hours, as
interstitial gel is hydrated, compliance continues to increase, allowing
ongoing accumulation of fluid with little change in hydrostatic
pressure.
• Any excessive fluid given in the early post-burn period would thus
increase capillary hydrostatic pressure and further reduce oncotic
pressure, both contributing to a cycle of accelerated capillary leakage
requiring ever greater amounts of crystalloid infusion .
• This is probably why fluid requirements escalate to volumes far in
excess of Parkland calculations, seemingly without limit.

41. • With better pain management over the past decade, it appears that
opioid dosage correlates with fluid requirements and that fluid creep
is a consequence of the increasing use of narcotics during initial burn
care, a phenomenon referred to as “opioid creep”
• One theory is that increased opioid analgesic use results in peripheral
vasodilation and hypotension and the need for greater volumes of
bolused resuscitative fluids.

42. So, how do we decide how much fluid to give?
• Studies examining the pathophysiology of shock related to burns and
the type of fluid loss that occurs have led to the development of
several different guidelines for calculating and managing fluid
resuscitation.
• These guidelines all involve the administration of salt- and electrolyte-
containing (crystalloid) isotonic fluids (most commonly Ringer's
lactate).
• Though several such guidelines exist, the most common is the
Parkland Formula or Modified Parkland Formula.
• While this continues to be the most common, there are some
cautions with its use.

44. • Formulas guiding fluid resuscitation should only be used for TBSA burns >
20% in adults and 10% in children and the elderly.
• The trend is toward more restrictive fluid .
• The most recent ATLS guidelines suggest 2mL/kg/%TBSA for adults,
3mL/kg/%TBSA for children and 4mL/kg/%TBSA for those with electrical
burns.
• The first 8-hour and 24-hour periods are counted from the time of injury.
• All formulas should be calculated to give half of the volume in the first 8
hours following injury and the other half over the next 16 hours.

45. • Adequate fluid should ultimately be determined by urine output and
mean arterial pressure .
• An indwelling Foley catheter should be placed to monitor urinary
output.
• Fluid resuscitation rates should be adjusted and fluid boluses used as
needed.
• Given the high volume of resuscitation needed for most patients with
moderate to severe burns, issues can arise with normal saline .
• Therefore, continued resuscitation with Ringer's lactate is appropriate
even when an increased fluid rate or bolus is required.

46. QUESTION
• A 34-year old man is brought to casualty at your hospital at 6 pm with
40% total body surface area burns. He weighs 70 kg and the burns
reportedly occurred at 5 pm. He has already received 1L of fluid. Use
the Parkland Formula to calculate his fluid resuscitation rates.

47. • Total fluid requirement in the first 24 hours
• 4mL x 40% TBSA x 70 kg = 11,200mL
• The patient should receive 11,200mL in the first 24 hours following
the burn injury.
• Half should be given in the first 8 hours, the other half over the next
16 hours.
• 11,200mL ÷ 2 = 5,600mL
• 5,600mL should be given during hours 0-8 and 5,600mL should be
given during hours 8-24.

48. • Subtract any fluid received from what is to be given in the first 8 hours
• 5,600mL - 1,000mL = 4,600mL
• The patient needs to receive an additional 4,600mL over the first 8 hours
following injury in addition to the 1L he has been given.
• Calculate the hourly fluid rate for the first 8 hours.
• 4,600mL ÷ 7 hours = 657mL/hour
• The burn occurred one hour prior to the patient's admission to casualty.
Therefore in order to receive the remaining 4,600mL within the first 8
hours, it needs to be given in the next 7 hours (should be completed by
1am).

49. • Calculate the hourly fluid rate for the next 16 hours
• 5,600mL ÷ 16 = 350mL/hr
• Following the infusion over the first 8 hours, the patient should
receive 350mL/hr over the remaining 16 hours until 5pm tomorrow.

50. Other formulas

51. ther formulas

54. Escharotomies
• The skin involved in circumferential deep partial thickness or full thickness
burns is not able to stretch in the way that unburned skin can.
• As fluid resuscitation causes increased edema of the subcutaneous tissue,
there can be increased tissue pressure, which can impair vascular flow.
• If circulation is compromised as indicated by diminished pulses or
evidence of impaired perfusion, and fluid resuscitation is adequate, the
involved limb should undergo urgent escharotomy!
• Circumferential burns of the chest wall can impair breathing due to the
restriction of chest wall motion.
• In this situation, chest wall escharotomy is indicated.

55. • Escharotomies are generally performed at the bedside under IV
sedation or in the operating theatre using electro-cautery or a
surgical blade.
• In limbs, medial and/or lateral incisions are extended the full length
of the eschar to assure adequate release.
• May need to be extended above the joint above and the joint below.
• Pulses should be monitored for 48 hours.

56. • An escharotomy is not a fasciotomy, and only the burnt tissue should
be divided with preservation of the underlying fascia.
• However, escharotomy alone may fail to relieve intra-compartmental
pressures, and a formal fasciotomy under general anesthesia is
indicated.
• This may occur in high voltage electrical injuries.

57. Criteria for Admission of Burn Patients
• The decision to admit a patient with a burn injury is ultimately at the
discretion of the care provider, and many factors contribute to this
decision.
• Below are some guidelines for admission.
>10-15 percent TBSA burn if partial thickness, depending on depth (teens
and adults)
>5-10 percent TBSA burn if partial thickness, depending on depth (children
and older adults)
>2 percent TBSA burn if full thickness
Burns that involve the face, hands, perineum, or feet; cross a major joint;
or circumferential burn

58. Other criteria:
Patients with significant comorbidities
Psychiatric patients where wound care may be a challenge
Non-compliant patients
Patients with suspected or known history of drug abuse
Patients who may not be safe at home (situations of suspected abuse)

59. Treatment of Chemical Burns
• Chemical burns, while unusual, can be quite severe.
• They also require specialized treatment based on the chemical
present.
• All chemicals should be carefully removed from the patient's skin and
the area copiously irrigated with water for at least 30 minutes.

60. Powdered lye(alkali burns)
• Lye (sodium hydroxide) in its powdered form is highly corrosive and
can cause severe burns.
• Absorbs moisture from the air, and when in contact with water, it may
generate enough heat to ignite combustible materials.
• All lye should be brushed from the patient and contaminated clothing
removed and bagged.
• Providers should wear gloves to avoid contamination.
• Once powder has been removed, the area can be flushed with water
for 30 minutes.
• Remaining burns should then be appropriately managed.

61. Hydrofluoric acid burns
• Widely used in industrial work.
• In addition to the local burn wound that occurs, HFA is also known to cause
hypocalcemia through systemic absorption of fluoride ions, which bind calcium.
• Hypocalcaemia
• Calcium therapy .
• Topical, intravenous and intra-arterial administration of calcium gluconate.

62. Wound Care and Surgical Management of Burns

63. TOPICAL BURNS THERAPY
• Goals of topical burn care:
Protect the damaged skin.
This involves minimizing bacterial or fungal colonization and keeping the
wound appropriately moist so as not to worsen tissue loss or convert the
wound to a deeper burn.
Prevent heat loss.
Occlusive dressings help to minimize cold stress that occurs with large burn
wounds.
Provide comfort and reduce pain.

64. Local wound care and topical therapies
• The wounds may be washed thoroughly with soap and water
• Dilute antibacterial solution such as dilute chlorhexidine.
• Small blisters may be left intact
• Very large ones can be sterilely pierced to release fluid, however skin
can serve as a biological cover.

65. Common topical wound treatments:
• The ideal dressing or wound treatment for a burn :
Would allow for an appropriately moist environment.
 Prevent the loss of body heat,fluids and protein.
Allow for gas exchange.
Create a microbiologic barrier.
Be painless.
Prevent shear and trauma.
 Be easy to use.
Be cost-effective.
 Enhance physiologic closure.
• While the ideal dressing is skin, several dressings and coverage options are used, and
each accomplishes these goals to varying degrees.

66. Silver sulfadiazine:
Low- to moderate-cost
Little toxicity though has mild inhibition of epithelialization
Cannot penetrate an eschar
Contains both antifungal and antibiotic .
Has an analgesic effect
Can cause mild, harmless, and transient leukopenia

67. Sulfamylon (mafenide acetate)
Can penetrate an eschar.
May be painful to apply.
Of particular use with Pseudomonas and Enterococcus.
Application over large area of burn can cause metabolic acidosis.
Can be difficult to find and may not be available in some countries.

68. Silver nitrate (0.5%)
Broad spectrum antimicrobial activity
Also inexpensive
Staining of linens, towels, clothing, and other materials
Deficits of Na+, K+, Ca++, Cl- can occur
Does not penetrate an eschar
Can cause methemoglobnemia

69. Bacitracin, neomycin and polymyxin
B ointments
Can be used for smaller burns that are nearly healed, or superficial partial
thickness burns.
Do not have as wide of antimicrobial coverage.
Clear and painless and allow observation of the wound.
Commonly used on facial burns.
 Neomycin can cause an allergic reaction.

70. Dressing options:
• Silver impregnated dressings such as: Acticoat, Aquacel Ag, Mepilex
Ag (silicone-coated)
• Temporary biologic coverings such as: Amniotic membrane, potato
peel
• Temporary synthetic coverings such as: OpSite or Tegaderm

71. Treatment by Depth
• Superficial Burns
• Healing occurs rapidly with such burns and little is needed for
treatment beyond supportive measures such as pain control.

72. Superficial Partial Thickness Burns
• Healing is expected within 2 weeks.
• If healing has not occurred by 2 weeks, consider that the burn may have
been incorrectly assessed and is a deeper thickness.
• May progres to a deeper wound.
• When proper wound care is not achieved.
• Becomes dry or infected,
• Hypotensive
• Poor perfusion of the wound.
• For this reason, the ideal dressing involves the use of antimicrobial creams
or ointments with dressings that maintain a moist environment.

73. • Interestingly, a recent Cochrane review, while noting the lack of
enough data to drive decision making in wound care for superficial
partial thickness burns, did find evidence that burns treated with
biosynthetic coverings, silver dressings, silicone-coated silver
dressings (such as Mepilex-Ag), and hydrogels heal quicker than those
treated with silver sulfadiazine.

74. Deep Partial Thickness Burns
• Notoriously difficult to assess and treat.
• Healing slower and often associated with contractures.
• Better treated with excision to viable tissue and grafting.

75. Full Thickness Burns
• If left to heal on their own, they heal from the edges, resulting in
significant contraction of the wound area.
• For this reason, all such burns greater than about 1 cm in diameter
should be excised to viable tissue and grafted.
• For some, small full-thickness burns, excision with primary closure
may be a possibility instead of grafting.

76. Excision and Grafting
• Types of Excision
• Tangential
• Full Thickness Excision
• Fascial Excision

77. Tangential Excision
• Involves excising small slices of the burned tissue parallel to the skin
surface in a repeated way, to the point of punctate bleeding (a sign
of viable tissue).
• Allows identification of viable dermis that is able to support a graft
without sacrificing too much tissue.
• Ideal for partial thickness burns and allows immediate grafting of the
site.

80. Full Thickness Excision
• Excision of the full thickness of the skin.
• The wound bed, usually fat, should bleed if all non-viable tissue has
been removed.

81. Full thickness excision before and after

82. Fascial Excision
• Burns that involve muscle tissue or which have extensive, deep
infection .
• This degree of tissue excision results in considerable soft tissue defect
and should be done very sparingly

84. Clinical Connection: Hemostasis during burn
excision
• For all excisions, careful attention should be paid to blood loss,
• Can be extensive when excision is performed over a large area of the
body.
• Estimates are that as much as 3.5-5% of blood volume can be lost for
every 1% of body surface area that is excised.
• Blood for transfusion
• To minimize:
• Electrocautery
• Epinephrine-soaked sponges (with a solution strength of 1/40,000).

85. Wound Coverage
• Options for wound coverage are usually described by the source of
the tissue used.

86. Autograft
• Patient's own skin taken from a portion of unburned skin .
• Complete coverage with can be difficult with large burn wound
surface area (>40%).
• Donor sites most commonly the anterolateral thigh, back and
buttocks (especially in children).
• In large surface burn areas, it may become necessary to use less
common sites including the abdomen and arms.

87. Allograft (Homograft) – transplant between genetically disparate
individuals of the same species.
Xenograft (Heterograft) – graft transplanted between individuals of
different species.
Isograft (Syngeneic) – It is an allograft between highly inbred strains of
animals. Term employed in experimental transplantation.

88. Split-thickness
• A partial thickness of skin (epidermis and a superficial amount of dermis) is
transplanted to the burned surface.
• The donor site is now itself a partial thickness injury that will re-epithelialize
over time.
• Split thickness skin can be meshed to create a larger surface area of graft.
• Donor site skin can be re-harvested once epithelialization has occurred.

89. Full-thickness
• The full thickness of skin (epidermis and dermis) is transplanted to the burned
surface.
• Used for areas where excellent cosmetic (face) or functional (hands and
joints) results are necessary.
• However, usage is limited by available donor areas, which must be closed
primarily and may include behind the ear and the groin.

90. Acellular Dermal Matrix (ADM)
• Involve the use of cadaveric skin (alloderm, a form of allograft) or dermis taken
from animals such as pigs (xenoderm) in which all of the immune cells have been
removed leaving just the dermal matrix.
• Provides a scaffold, which over time, is replaced by the patient's own tissue.
• Can be used as a dermal substitute to replace grafting or in conjunction with skin
grafting.
• Considerations with the use of such graft materials include antigenic and
immunologic reactions
• Limited availability, and expense.

91. Engineered synthetic dermal substitutes
• Similar to ADM products but have some degree of synthetic
engineering in addtion to the biologic portion.
• The most common and well-known is Integra, which adds a layer of
silicone sheeting to the surface of the ADM to provide an epidermal-
like barrier for the wound.

92. Timing of Surgery:When should skin grafts be
performed?
• Ideally, all burns should be epithelialized by three weeks post-injury to
improve cosmetic and functional outcomes.
• Therefore, if a burn is not likely to heal within three weeks, then it should
be treated surgically with a skin graft.
• Early excision and grafting for the management of deep partial thickness
and full thickness burns should be accomplished within the first week
following the burn.
• This allows 2 weeks for healing, ensuring healing by the three-week point.
• This results in decreased burn wound infection and organ failure, better
graft take, decreased blood loss, decreased length of hospital stay,
decreased scarring and contracture, and decreased mortality, making it the
standard of care.

93. • Some problems faced in practicing early excision and grafting include:
Blood loss and need for blood products
Delayed presentation of patients with burns, and
Lack of donor skin sites and non-allograft options.
• However, a thoughtful and planned approach to this practice (use of
tourniquets when possible to reduce blood loss and prioritizing
deeper areas of burn when donor skin is sparse) can result in
successful burn management through early excision and grafting.

94. Reasons for graft failure
Haematoma – This is the most common cause of graft failure.
Infection - Skin grafts will generally grafts will not take if the bacterial count of the donor site exceeds
105/gm of tissue.
b Haemolytic streptococus is a contraindication to skin grafting..
Seroma – collection of fluid under the graft..
Shear i.e Lateral force placed on a graft.
Inappropriate bed – grafts will not survive on cartilage, tendon and endochondral bone denuded of
periosteum. Grafting previously irradiated tissue.
Technical errors e.g. placing graft upside down or allowing it to dry before application.

95. • END
• THANK YOU