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TOTAL BURN CARE
2nd edition Reprinted with permission of Elsevier (excerpt from chapter 9, pages 101, 102, 106)
Evaluation of the burn wound management decisions Introduction In addition to the extent of burn and the age of the patient, the depth of burn is a primary determinant of mortality following thermal injury. Burn depth is also the primary determinant of the patient's long-term appearance and function. For many years burns were treated by daily washing, removal of loose dead tissue, and some sort of topical nostrum until they healed by themselves or, eventually, granulation tissue appeared in the base of the wound. Superficial dermal burns healed within 2 weeks and deep dermal burns healed over many weeks if infection was prevented. Full-thickness burns lost their eschar in 2-6 weeks by collagenase production from bacteria and mechanically by daily debridement. When the granulation bed became free of debris and relatively uninfected, split-thickness skin grafts were applied, usually some 3-8 weeks after injury, and a 50% graft take was considered to be acceptable. Repeated graftings eventually closed the wound. The prolonged and intense inflammatory response made hypertrophic scar and contractures part of normal burn treatment. Vigorous physical therapy, nutritional support, psychosocial support, and pain management were required on a daily basis for many weeks in order to yield a satisfactory result. Modern treatment involves early surgical removal of the burn. Rather than waiting for spontaneous separation, the eschar is now surgically removed early in the burn course and the wound closed with grafting techniques and acute flaps individualized to each patient. When non-operative treatment is the routine, the accurate assessment of burn depth is of little importance save for predicting mortality. On the other hand, with aggressive surgical treatment, an accurate estimation of burn depth becomes crucial. Burns which heal within 3 weeks generally do so without hypertrophic scarring of functional impairment, although long-term pigment changes are common. Burns which take longer than 3 weeks to heal often produce unsightly hypertrophic scars and frequently lead to functional impairment, as well as providing only a thin, fragile epithelial cover for many weeks or months. State of the art care now, at least in patients with small and moderate burns, involves early excision and grafting of all burns which will not heal within 3 weeks.1-5 The challenge is to determine which burns will heal within 3 weeks. An understanding of burn depth requires an understanding of skin thickness. The anatomy and pathophysiology of the skin is well covered in another chapter. The standard technique for determining burn depth has long been clinical observation of the wound. Unfortunately, the difference in burn depth between a burn which heals in 3 weeks and a deep dermal burn which will heal only after many weeks, or a full-thickness burn which will not heal at all, may be only a matter of only a few tenths of a millimeter. Further, a burn is a dynamic process for the first few days, and a burn which appears shallow on day 1 may appear deep by day 3. Finally, the kind of topical wound care used can dramatically change the appearance of the burn. Because of these limitations, and because of its increased importance in planning definitive burn wound care, interest has been stirred and technology has brought numerous devices and techniques to determine burn depth more precisely than clinical observation. Estimation of burn depth Clinical Observation Deep dermal burns extend into the reticular dermis and generally will take 3 or more weeks to heal. They also blister, but the wound surface is usually a mottled pink and white color immediately following the injury. The patient complains of discomfort rather than pain. When pressure is applied to the burn, capillaries refill slowly or not at all. The wound is often less sensitive to pinprick than the surrounding normal skin.6,7 By the second day the wound may be white and is usually fairly dry. Non-charred full-thickness burns can masquerade with many of the clinical findings of a deep dermal burn. Like deep dermal burns, they may be mottled in appearance. They rarely blanch on pressure, and may have a dry, white appearance. In some cases the burn may be translucent with clotted vessels visible in the depths. Some full-thickness burns, particularly immersion scalds, may have a red appearance, and can be confused by the uninitiated as a superficial dermal burn. They can be distinguished, however, because these red, full-thickness burns do not blanch with pressure. Evaluation by an inexperienced surgeon as to whether an apparent deep dermal burn will heal in 3 weeks is about 50% accurate8 - tossing a coin is about as useful a technique. In experienced hands, however, early excision and grafting provides better results than non-operative car for such 'indeterminate' burns.2 An intense search for a more precise diagnosis of burn depth has been mounted ever since it became important to determine whether the patient would benefit from early operation. A number of techniques have been used based on the physiology of the skin and alterations produced by burning. These techniques take advantage of:
Conclusion Although there are many different types of burn wounds, the extent of tissue destruction is always a function of the temperature of the heat source, the duration of contact and the thickness of the involved skin. Burns which are unlikely to heal in less than 3 weeks should be treated by early excision and grafting (within 7 days of injury). Benefits of this approach include reduction in length of hospital stay, earlier return to work or school, and optimal functional and cosmetic results. Research is ongoing to determine reliable methods of defining burn depth, so that those patients who need grafting may be treated expeditiously and so that the risks of operation can be avoided in those who do not. References 2. Engrav L, Heimbach D, Reus J, Harner T, Marcin JA. Early excision and grafting vs. nonoperative treatment of burns of indeterminant depth: a randomized prospective study. J Trauma 1983; 23: 1001 3. Frist W, Ackroyd F, Burke J, Bondoc C. Long-term functional results of selective treatment of hand burns. Am J Surg 1985; 149: 516-521 4. Gray D, Pine R, Harner T. Early excision versus conventional therapy in patients with 20% to 40% burns. Am J Surg 1982; 149: 76 5. Thompson P, Herndon DN, Abston S, Rutan T. Effect of early excision on patients with major thermal injury. J Trauma 1987; 27: 205-207 6. Jackson D. Second thoughts on the burn wound. J Trauma 1969; 9: 839 7. Bajaj SP, Nield DV, Rayment R, Khoo CT. A simple modification of the pinprick test for the assessment of burn depth in children. Burns Incl Thermal Inj 1988; 14: 468-472 8. Hlava P, Moserov AJ, Konigov AR. Validity of clinical assessment of the depth of a thermal injury. Acta Chir Plast 1983; 25: 202-208
This article was excerpted from the book
Total Burn Care, 2nd edition (2001), edited by David N. Herndon,
M.D. and is posted with permission from Elsevier.
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