In this presentation I would like to give you a concise overview on burn and cold injuries. Their principle of assesement and how they need to be adressed therapeutical wise.
Thermal accidents cause damage to the skin consigning unesthetical and functional limiting scars. If impairement of the skin is of small dimension then local and esthetic problems are in the foreground. If damage of the skin extents above ten percent then general problems like schock, dehydration or woundinfection with increased risk of sepsis, additional to the local problems, become more imminent.
Just to give you an idea about the incidence on burn victims let me emphasize a couple of numbers. In 1995 in Europe with a total of 512‘112 Million citizens 24‘986 burn victims were hospitalized which breaks it down to one heavily burned patient per 20‘000 persons. In the U.S. an estimated 1.4 Million combustion victims were in need of medical treatment. Based on a population of 286 Million citizens equals this to one heavily burned patient per 5000 persons.
The source of thermal injury varies according to geographical habits and social economic structures. Fire claims the majority accounting for about 50 % of burns, followed by scald and explosions. On the other hand chemical burns are very rare.
To evaluate the degree of a burned victim an accurate history is of great importance. Usually burn victims are awake and oriented despite the sometimes extensive burns. Only the ones suffering injuries from high voltage current or CO2 intoxicsation are deranged or comatose. The above mentioned Key questions need to be asked since they are helpful in anticipating certain complications.
To establish a therapy plan the burn injury needs to be assesed since this is very helpful whether a patient should receive surgical therapy. One has to be aware that burn injuries are a dynamic process and need to be reevaluated on a daily bases. A second degree burn which is initially evaluated as superficial partial thickness might turn out as a deep partial thickness burn thus requiring surgery.
This formula divides the body into parts considered to be 9% (arms, head) to 18% (legs, front, back) of total body skin surface in adults. The small child has a different surface area breakdown. The burn size (as % of total) can then be used in the resuscitation formula. Remember that a formula is only an estimate and adjustments need to be made based on patient’s status.
Let‘s take a look on those three general stages. First degree burns are characterized by erythema, pain and the abscence of blisters. First degrre burns are limited to the epidermis or upper layer of the skin. A typical example for a first degree burn is a sunburn. They are not life threatening and generally do not require intravenous fluid replacement. They usually take three to six days to heal without scaring.
Here you can see a typical clinical apperance of a sunburn. Beneath the peeled skin you can observe the new epidermis.
Superficial second degree burns are very painful, sensitive to temperature change and air exposure. Typically they blister and are moist, red, weeping burns which blanch with pressure. They heal in 7 to 21 days. Scarring is usually confined to changes in skin pigment.
Small second degree superficial burns can be covered, after excision of blisters, with a fat gauze and an occlusive dressing wchich should be left alone for ten days. Due to the occlusive dressing the burn injury is not exposed to air which reduces pain and
Blistering or easily unroofed burns which are wet or waxy dry, and are painful to pressure. Their color may range from patchy, cheesy white to red, and they do not blanch with pressure. They take over 21 days to heal and scarring may be severe. It is sometimes difficult to differentiate these burns from full-thickness burns.
A full thickness or third degree burn occurs with destruction of the entire epidermis and dermis, leaving no residual epidermal cells to repopulate. This wound will therefore not re-epithelialized and whatever area of the wound is not closed by wound contraction will require skin grafting.
Let me present the first clinical case. This is the hand of 42 year male which burned himself on a radiator after suffering from a stroke. The injury was assesed as a superficial partial thickness burn.
The blisters were removed surgically and the tissue was left to granulate.
The Thenar and Hypothenar region heals very well and usually doesn‘t require skin grafting.
The second case is a 12 year old boy who kept fireworks in his right pocket of his pants which eploded on him. Note the additional burn inyury on his left thigh as well.
Initially difficult to judge the injury, after wound excision, it showed areas of superficial partial thickness burn as well as deep partial thickness burn.
So called tangential excision was performed to get rid of the destroyed layers of skin.
This procedure can be performed also with a simple brush.
The goal of this procedure is to receive a wound surface on which skin grafting can be performed. Note the area of deep partial thickness burn with only punctual bleeding
In the next few slides I would like to give you a short overview on how skin grafting is performed in our institution. We use an airdriven Zimmer dermatome where a disposable blade can be attached and which tends to be less technique dependent. Next to it you can see different attachements which allow to choose different width of the graft. On the far right you can see the
In the next few slides I would like to give you a short overview on how skin grafting is performed in our institution. We use an airdriven dermatome where a blade can be attached
An appropriate donor site, typically the anterior, lateral, or medial part of the thigh; the buttock; or the medial aspect of the arm is selected. For larger defects, a large, flat donor surface is ideal for harvesting a skin graft. The selection of the donor site should account for the size of the graft to be harvested, ability to hide the donor site under clothing, and ease of access to the area for follow-up care
A surgical assistant draws a sterile piece of wood as a depressor across the donor site immediately in front of the dermatome cutting surface to provide a flat surface for the surgeon.
The surgeon applies the dermatome to the donor site with consistent light pressure, holding the device at a 30-45° angle to the skin surface. The movement of the dermatome in the surgeon's hand has been likened to a plane's landing and taking off. Another assistant carefully removes the harvested skin from the dermatome by using gentle traction.
The newly harvested skin is placed on a specific template, depending on the expansion ratio desired (1:1.5)
And the template and graft are pressed through the mesher by using a hand-crank mechanism; the process is analogous to the pressing of dough through a pasta machine. The use of skin meshed by using a machine often leads to a permanent diamond-plate appearance of the skin graft upon healing
After the graft is harvested, it is trimmed to fit the donor site. Some overlapping of the donor tissue with the recipient bed is acceptable; this overlap can be trimmed later upon suture or bolster removal.
The STSG is then secured in place by using either staples or interrupted 6-0 fast-absorbing gut sutures around the periphery. In our experience, a running suture around the periphery of the graft may inhibit revascularization and thus lead to poor graft survival. Next, a bolster may be applied to aid in graft apposition to the recipient bed, to decrease shearing forces, and to maintain a moist environment for the graft
On the next two slides you can see the result after skin grafting about three months after the intervention on this 12 year old patient. Note the cicatricial keloid in the area of the former deep partial thickness burn. Note the left thigh which was the donor site of the skin graft.
This slide shows an example of a full thickness or third degree burn.
A full thickness burn of the anterior and lateral chest wall can lead to severe restriction of chest wall motion, especially as edema develops beneath the non-viable tissue (eschar), even in the absence of a completely circumferential burn. Chest wall escharotomy may be required to relieve the restriction
The escharotomy incisions are placed along the anterior auxiliary lines with bilateral incisions connected by a subcostal incision. The incisions must extend completely through the eschar so that the subeschar space can expand and decrease tissue pressure. In a full thickness burn, nerve endings are destroyed along with the entire epidermis and dermis. Analgesics are usually not necessary for escharotomy.
