Second Phase of Acute Care of Burn Wound

Management:

• Initial copious irrigation with clean water, the burned area is treated immediately with copious 2.5% calcium gluconate gel.

• These wounds are generally extremely painful. Intradermal injection of 10 percent calcium gluconate / intra-arterial injection of calcium gluconate into the affected extremity or both may be required to alleviate symptoms.

• If after the airway is assessed and resuscitation is underway, then attention must be turned to the burn wound.

• Treatment depends on the characteristics and size of the wound.

• All treatments are aimed at rapid and painless healing Current therapy directed specifically toward burn wounds can be divided into three stages: Assessment, management, rehabilitation.

Each wound is dressed with an appropriate covering that serves several functions:

• It protects the damaged epithelium, minimizes bacterial and fungal colonization, and provides splinting action to maintain the desired position of function.

• The dressing is occlusive to reduce evaporative heat loss and minimize cold stress.

• The dressing needs to provide comfort over the painful wound.

Choice of Dressing:

• First-degree burns require no dressing and are treated with topical salves to decrease pain and keep the skin moist.

• Second-degree wounds can be treated with daily dressing changes and topical antibiotics, cotton gauze, and elastic wraps, Or the wounds can be treated with a temporary biologic or synthetic covering to close the wound. 

• Deep second degree and third-degree wounds require excision of dead tissue - eschar and skin grafting for sizable burns.

Antibiotic Creams or Gels:

Antibiotic agents with cream or gel base are used for burn dressing because these are water-soluble and easily absorbed by the wound surface. 

     Some antibiotic creams are:

• Silver sulfadiazine (Silverex) 

• Mafenide acetate (Sulfamylon) 

• Neomycin

• Nystatin (Mycostatin) 

• Mupirocin (Bactroban)

In noninfected raw wound with fresh granulation, sterile vaseline gauze impregnated with gentamycin is used as a primary cover. 

The oily layer prevents the dressing from sticking to the delicate granulation tissue. This minimizes bleeding and destruction of the granulation during dressing changes.

The combined gel of metrogyle (antibiotic) and sucral (granulation stimulator) may also be used for healing wounds to promote rapid granulation under antibiotic cover.

Biologic coverings:

Excision and grafting:

Early excision of eschar followed by grafting is currently done by most burn surgeons. 

1. Autograft:

An autograft (Fig. 1) uses skin and tissue harvested from the patients own body to cover open wounds or reconstruct the body surface such Grafts may consist of:

• Split skin grafts:

• Consisting of the upper layers of the epidermis, this graft is useful only as a temporary cover for the raw area following the second-degree burn. 
• It protects the delicate cells of the surviving stratum germinativum, which is expected to grow new skin. This graft needs no blood supply since it consists of only dead cells. 
• It is held in position with a pressure bandage and usually sloughs off after 3 weeks. 
• Routine mobilizing exercises and splinting can be done but no heat/ cold/ friction modality to be applied over the grafted area. 

Fig. 1: Autograft

• Partial-thickness grafts:

• Partial-thickness grafts Consisting of the whole of the epidermis and the upper layers of the dermis are harvested from the anterior abdominal wall or thigh, following deep second degree of the third burn. 
• Blood supply to the graft grows from the underlying subcutaneous layer.
• The graft is held in position with a pressure bandage. Routine mobilizing exercises and splinting can be done after 4 weeks but no heat/ cold/ friction modality to be applied over the grafted area.

• Full-thickness graft:

• Consisting of the whole of the epidermis, dermis, and part of the subcutaneous layer of collagen and fat including capillary network and nerve endings is harvested from anterior abdominal wall or thigh following deep second degree of the third burn. 
• This graft is used as a permanent cover after escharotomy. 
• Blood supply to the graft grows into the underlying subcutaneous layer. 
• The graft is held in position with sutures applied to the edges of the wound. Routine mobilizing exercises and splinting can be done after 6 weeks but no heat/ cold/ friction modality to be applied over the grafted area. 

• Pedicle grafts:

• Consisting of the whole of the epidermis, dermis, subcutaneous layer, and underlying soft tissue including a subcutaneous layer of collagen and fat including capillary network and nerve endings is harvested in the form of a tube from the anterior abdominal wall to reconstruct lost segment such as the nose, ear, hands, feet, etc. following the third or fourth-degree burn. 
• Blood supply to the graft grows into the underlying subcutaneous layer.
• Routine mobilizing exercises and splinting can be done after 6 weeks but no heat/cold/friction modality to be applied over the grafted area. 

2. Xenograft:

Xenografts (Fig. 2) consisting of the whole thickness of pig-skin, used to completely close the wound, provides some immunologic benefits that must be removed or allowed to slough.

Fig. 2: Steps in production of xenograft: (A) Healthy pigs, (B) isolated skin after the sacrifice of a healthy pig, (C) surface morphology of the skin graft harvested from the pig, (D) implanted pig xenograft in human leg burn wound

 

3. Allograft:

Allograft (Fig. 3) consisting of the whole thickness of living donor/ cadaver skin provides all the normal functions of the skin, can be used as a dermal equivalent over the short term to allow the wound to heal; epithelium must be removed or allowed to slough.

Fig. 3: Allograft skin and Autograft skin