MY STRATEGY FOR TREATING BURN INJURIES Warren Garner MD FACS Keck School of Medicine at USC Los Angeles, CA
ASSUMPTIONS: Burns which heal to normal have best outcome. Medical risk, functional recovery, appearance, pain, costs all matter Prioritization of these factors should result from discussion between Burn Team and Patients BEST outcome may have excessive costs
ASSUMPTIONS: Using resources to improve outcomes in children is always worthwhile Sicker and older patients, and patients with bigger injuries benefit from both removal of dead tissue and closure of wound Appearance matters. How much is patient centric Less functional and home is sometimes an excellent outcome.
Team Approach Burn Surgeons, Residents, Students Nurses Nutritionist, Pharmacist PT, OT Psychologist Social Worker Emergency Services (FD, Paramedics.)
Outcomes begin at time of injury Initial care defines how patient and their tissue tolerate and recover Maintain oxygenation and perfusion Begin support as patient stabilizes
Priority of Interventions When Treating a Serious Burn Save patient s life Close wounds Restore function Restore appearance But always remember the final goal: normal
Initial Assessment & Management Primary and secondary surveys TBSA estimation Define Burn depth Consider Fluid Resuscitation Referral Criteria
NEEDED TREATMENT AND BURN OUTCOME DEFINED BY: Burn Size (TBSA) Burn Depth Areas injured Associated injuries and illnesses
1st Degree Burns require LIMITED treatment Counseling Moisturizer Tetanus
nd 2 Degree Burn: Partial Thickness Superficial = pink, moist, edematous. Blisters Deep = paler, moist and edematous
nd 2 Degree Burn: Partial Thickness Large TBSA 2nd injuries can have intense physiologic response and develop MSF Must determine if endogenous wound healing will result in good outcome Sometimes surgery on injuries that MIGHT heal results in better outcome
3rd Degree Burn: Full Thickness Dry, leathery, generally insensate
rd 3 Degree Burn: Full Thickness Burn eschar, ungrafted wound, donor site are all wounds that impact physiology Can stage surgical treatment to limit impact, at cost of prolonging recovery Higher risk for all complications with greater TBSA
INITIAL WOUND MANAGEMENT Cover with clean, dry sheets Protect from heat loss Use thermal insulating blanket Do not use wet dressings or sheets Do not delay transfer for debridement or application of antimicrobial ointment No cold application
Healing the Cutaneous Injury Superficial injuries heal by epithelial migration if wound and patient are supported Occlusive dressing if wound (small burn, no eschar) and patient is healthy Antimicrobial dressing for all others
Antibacterial Dressing to Prevent Wound Infection Daily dressing if exudate, debris, biofilm Silver sulfadiazene 2% mupiricin Non-changing dressing if clean wound in healthy patient Ag dressings (Mepilex Ag, KeraContact Ag) Antimicrobial irrigants: Vashe wash, 5% sulfamylon Xeroform is NOT antibacterial
Ag Releasing Dressings More silver results in better antibacterial activity Protects against more than 150 pathogens, including antibioticresistant Pseudomonous, MRSA, VRE, Fungi, Candida Fabricated into sheets, foams, hydroabsorbent gels, compressive dressings
Healing the Cutaneous Injury Deeper injuries require surgery to restore barrier with epidermis STSG Sheet vs Meshed grafts Integra + thin STSG Flaps
Excision and Skin Grafting 1. When healing is not expected to progress without significant scar formation which limits function (2-3 weeks) 2. Decrease dead tissue load as soon as possible 3. Tangential excision 4. Pre-fascial excision
Early wound closure with an off-theshelf product solves many of the problems in the current treatment of difficult burns Closes wound earlier Better functional outcome At financial cost
My Viewpoint about Wound Closure Options with Significant TBSA Burn NOT Delayed excision Expanded meshed autograft Cadaver allograft/xenograft Synthetic epidermis Biobrane/Transcyte Integra/BTM
Delayed excision: Predictably results in wound infection and MSF Expanded meshed autograft: Poor appearance, more likely contractures and limited function Cadaver allograft: Effective temporary solution. Requires replacement after rejection. No long-term benefit. Acellular xenograft: Uncertain long-term risks. No long-term benefits Synthetic epidermis: Biobrane/Transcyte; infection risks. No long-term benefits
Split Thickness Skin Graft Epidermis and partial thickness of dermis Transplant to viable wound bed Meshed vs. Sheet Full thickness grafts are rarely used to treat acute burn injuries
Skin Substitutes SYNTHETIC EPIDERMIS; Transcyte Biologic wound healing accelerant Neonatal fibroblast SYNTHETIC DERMIS; Integra, BTM, Matriderm TEMPORARY SKIN; Allograft, zenograft Cultured epidermal autografts
Transcyte. 42% TBSA Burn POD 3
Integra Dermal Regeneration Template is a bilayer skin replacement system composed of a dermal regeneration layer and a temporary epidermal layer.
OTHER ISSUES IN BURN CARE
INTENTIONAL INJURIES
INDICATIONS OF INTENTIONAL BURN Linear burns No splash areas History does not make sense
NUTRITIONAL SUPPORT Effective wound healing needs adequate nutrition Enteral support always better eating > feedings > TPN >> starvation Gastric feedings with pro-kinetics Advanced feedings of uncertain benefit Glutamine yes Document efficacy with pre-albumin measurements
Management Principles: Pain Burns are painful injuries that require treatment Unpredictable absorption of PO or IM drugs Hemodynamically unstable patients Treat with small doses of IV narcotics At USC use morphine 1-2 mg q 2-5 min until pain is controlled
Management Principles: Psychosocial 40% of adult burn patients have a DSM diagnosis (including drug/etoh abuse) Abuse of children and elderly common Successful outcomes benefit from social support PTSD common
How to Manage an Outpatient Burn Evaluate burn Size, depth, location Define caregiver for follow-up and daily dressing Evaluate patient R/O abuse Continue treatment of concurrent medical problems DIABETES
How to Manage an Outpatient Burn: Daily Wound Care Debride all nonadherent, non-living tissue Drain and debride blisters Apply antimicrobial agent Silvadene Daily with gauze Bactroban Ag-dressing No daily dressing change
How to Manage an Outpatient Burn Follow-up in 2-3 days to confirm diagnosis and wound care Pain medicine Therapy/ROM Nutrition
Rehabilitation: Survival in NOT Enough Early Mobility (physical and occupational therapy) extremely important Social re-integration Return to Work Reconstruction to restore function and appearance
Priority of Interventions for a Plastic Surgeon NOT DEAD is not an acceptable level of outcome Minimize reconstruction with effective and aesthetic wound closure
Close Wounds Aesthetically Graft wounds that are not healing after 2 weeks Can allow small areas to heal with scar Sheet grafts >> meshed grafts > prolonged healing Regionalize donor sites Integra for closure of larger burns in children Integra for coverage of ungraftable wounds for contour benefits
Sometimes Surgery is the Best Answer Ungrafted FT Burn in Infant
HEAL Wounds Aesthetically Wound healing and remodeling continue for 2 years after injury Failure to continue treatment limits return to normal Moisturize healing grafts and wounds, including donor sites Limit hyperpigmentation with sunscreen Motion, stretching tissues, massage
QUALITY OF HEALING MATTERS TO THE PATIENT
Let Patient Chose Priority of Appearance in Reconstruction Always sheet graft children: they are worth the investment of time and resources Meshed grafts fully heal sooner: faster return to work Multiple reconstructions can result in loss of income and job loss
Meshed Grafts Always Look Bad
DONOR SITES Never normal Always look better than recipient site Hidden vs regionalized Easiest donor site for Surgeon is Malpractice
DONOR SITE 2 YEARS LATER
Technology for Better Outcome Use bioengineered matrix: Integra, BTM Heal donor sites faster with growth promoting dressings Prevent wound infections from delaying healing
Graft; with and without Integra
TWO CASES One simple One hard
39 year-old Male 4 wk s/p L hand FT burn from iron pan. Rxed Silvadene Burns allowed to demarcate; angiogenesis deeper tissues 55
Preoperative Volar L hand Dorsal L hand 56
Debrided wounds Volar L hand intraoperative s/p debridement, demonstrating exposed RF flexor tendon. 57
STSG harvest Lateral proximal L thigh STSG donor site. 58
STSG harvest Lateral proximal L thigh STSG donor site dressed with Mepilex AG. 59
STSG inset Volar L multi-digit wounds s/p STSG resurfacing. 60
POD #2 Volar L hand, POD #2 STSG 61
POD #7 Volar L hand, POD #7 STSG 62
POD #14 Volar L hand, POD #14 STSG 63
POD #28 Volar L hand, POD #28 STSG 64
POD #14 Medial Distal Proximal Lateral L thigh STSG donor site 65
13 yr old Male 42% TBSA burn with significant inhalation injury 5 siblings injured Day 1 Debrided back and grafted with Integra Day 5 STSG bilateral hands; Integra bilateral arms
Day of Injury; Chest and Back
Day of admission Right upper extremity burns
Day of admission Left upper extremity burns
Initial Course Day 1; back excised and grafted with Integra Day 2; operated on Sister Day 3 operated on other sister Day 4/5; worsening Inhalation Injury, hemodynamically unstable
Post burn day 6; OR, bilateral extremities
Post op Day 2
Post op Day 21
Day 24; Re-Grafting left hand and Over-grafting Integra bilateral arms
6 months post op
THANKS QUESTIONS????