Emergency Treatment of Severely Burned Pediatric Patients: Current Therapeutic Strategies

Gerd G. Gauglitz; David N. Herndon; Marc G. Jeschke

Disclosures

Pediatr Health. 2008;2(6):761-775. 

In This Article

Burn-wound Excision

Methods for handling burn wounds have changed in recent decades and are similar in adults and children. Increasingly aggressive early tangential excision of the burn tissue and early wound closure primarily by skin grafts has led to significant improvement in mortality rates and substantially lower costs in this particular patient population.[14,46,47,48,49] Furthermore, early wound closure has been found to be associated with a decreased severity of hypertrophic scarring, joint contractures and stiffness, and promotes quicker rehabilitation.[14,46] Techniques of burn-wound excision have envolved substantially over the past decade. In general, most areas are excised with a hand skin-graft knife or powered dermatome. Sharp excision with a knife or electrocautery is reserved for areas of functional cosmetic importance, such as the hand and face. In partial thickness wounds, an attempt is being made to preserve viable dermis, whereas in full thickness injury, all necrotic and infected tissue must be removed, thus leaving a viable wound bed of either fascia, fat or muscle.[50] The techniques that are mainly utilized are discussed below.

This technique was first described by Janzekovic in the 1970s and requires repeated shaving of deep dermal partial thickness burns using a Braithwaite, Watson, Goulian or dermatome set at a depth of 5-10/1000 inches until a viable dermal bed is reached, which is clinically achieved by punctuate bleeding from the dermal wound bed.[50]

A hand knife, such as the Watson or powered dermatome, is set at at 15-30/1000 inches and serial passes are made excising the full thickness wound. Excision is aided by traction on the excised eschar as it passes through the knife or dermatome. Adequate excision is signaled by a viable bleeding wound bed, which is usually fat.[50]

This technique is reserved for a burn extending down to through the fat into muscle, where the patient presents late with large infected wounds and inpatients with life-threatening invasive fungal infections. It involves surgical excision of the full thickness of the integument, including the subcutaneous fat down to the fascia using Goulian knives and number 11 blades. Unfortunately, fascial excision is mutilating and leaves a permanent contour defect, which is near impossible to reconstruct. Lymphatic channels are excised in this technique and peripheral lymphyedema may develop.[50]

Most patients can be managed with layered excisions that optimize later appearance and function. Published estimates of the amount of bleeding associated with these operations range within 3.5 to 5% of the blood volume for every 1% of the body surface excised.[51,52] The control of blood loss is one of the main determinants for outcome.[53] Therefore, several techniques should be applied to control blood loss. The local application of fibrin or thrombin spray, topical application of epinephrine 1:10000-10001:20000, epinephrine soaked laboratory pads (1:40000) and immediate electrocautery of the blood vessel can control blood loss.[54] The use of a sterilized tourniquet can also limit blood loss.[55] Lastly, pre-excisional tumescence with epinephrine saline can be used on the trunk, back and extremities, but not on the fingers.

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