Burn surgery

Depend of the patient conditions in the burn, You may need one or more of the following procedures as ABC management: ^[1]

• Breathing assistance. If you’ve been burned on the face or neck, your throat may swell shut. If that appears likely, your doctor may insert a tube down your windpipe (trachea) to keep oxygen supplied to your lungs.
• Feeding tube. People with extensive burns or who are undernourished may need nutritional support. Your doctor may thread a feeding tube through your nose to your stomach.
• Easing blood flow around the wound. If a burn scab (eschar) goes completely around a limb, it can tighten and cut off the blood circulation. An eschar that goes completely around the chest can make it difficult to breathe. Your doctor may cut the eschar to relieve this pressure.
• Skin grafts. A skin graft is a surgical procedure in which sections of your own healthy skin are used to replace the scar tissue caused by deep burns. Donor skin from deceased donors or pigs can be used as a temporary solution.
• Plastic surgery. Plastic surgery (reconstruction) can improve the appearance of burn scars and increase the flexibility of joints affected by scarring.

Debridement:^[2] The term ”Debridement” is not only a surgical procedure. Debridement can be performed by surgical, chemical, mechanical, or autolytic procedures. Surgical modalities including early tangential excision (necrectomy) of the burned tissue and early wound closure primarily by skin grafts has led to significant improvement in mortality rates and substantially lower costs in these patients [25,26]. Furthermore, in some circumstances, escharotomy or even fasciotomy should be performed.

Indications of surgical debridement: Dermal substitutes or matrices can be used if a large burn area exists. Here are some examples: Note that in many occasions, an immediate coverage of wounds cannot be achieved. In this case, a temporary coverage is favoured. After stabilization of patient and wound bed, a planned reconstruction takes place to close wounds permanently. In this point, some methods can be performed including:

1. Deep second degree burns.

2. Burns of any type, that are heavily contaminated

3. Third degree circumferential burns with suspected compartment syndrome (think of: Escharotomy)

4. Circumferential burns around the wrist (think of: Carpal tunnel release).

Benefits of surgical debridement:

1. To reduce the amount of necrotic tissue (beneficial for prognosis)

2. To get a sample for diagnostic purposes (if needed).

Complications of debridement:

1. Pain.

2. Bleeding.

3. Infection.

4. Risk of removal of healthy tissue.

Contraindications:

1. Low body core temperature below 34°C.

2. Cardiovascular and respiratory system instability.

Any trainee should be aware of the following terms:

Tangential excision: Tangential excision of the superficial (burned) parts of the skin

Epifascial excision: This technique is reserved for burns extending at least to the subcuticular level.

Subfascial excision: indicated when burns extend very deep and reach the fascia and muscles. It is needed only in special cases.

Escharotomy: Indicated for third-degree and second degree deep dermal circumferential burns. This is used to prevent a soft tissue compartment syndrome, due to swelling after deep burn. An escharotomy is performed by making an incision through the eschar to expose the fatty tissue below.

Note that escharotomy lines on the thumb and little finger, as an international standard, should be always performed on the radial side and not on the ulnar side. Escharotomy incisions for the index finger, middle finger and ring finger are performed along the ulnar side.

• Fasciotomy: Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. An incision is made in the skin that extends into the fascia where it will relieve pressure. Note that Carpal Tunnel Syndrome (CTS) can result from the circumferential burns around the wrist by consecutive swelling. After any selected procedure from the above category, the resulted wound should be covered. Autografts, i.e. split thickness skin grafts (autologous skin transfer), remain the mainstay of treatment for many patients.

• Biobrane: Biosynthetic wound dressing constructed of a silicone film with a nylon fabric.
• Suprathel: Innovative skin substitute made of polylactide for the treatment of superficial dermal wounds especially the superficial second degree burns.
• Alloderm: Cultured and processed dermis used under skin graft to reproduce the layered structure of dermis and epidermis in a graft Integra: Bilayer wound matrix comprised of porous matrix of cross-linked bovine tendon collagen and glycosaminoglycan and a semi-permeable polysiloxane (silicone) layer. Must be used in a two-step-procedure ^[3].
• Matriderm: Three dimensional matrix consisting of collagen and elastin. Its use guides autologous cells for the construction of a “neo-dermis” ^[4][5]. Can be used in a single-step as well as in a two-step-procedure.
• Allografts: Cadaver Skin used for temporary cover.
• Xenografts: Graft taken from other species (bovine of swine) can be used as temporary cover.

Template:WikiDoc Sources