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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
�
...
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