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Developing countries have a major problem with burned patients. Most of the world's burn injuries, and 98% of the fire-related deaths, occur in developing countries. In part, this is due to exposure to open fires for cooking, heating, and other household tasks. Children in developing regions usually suffer burns from hot water and other liquids such as soup, from direct contact with flames, and from electrocution. Aside from the infections common after major burns, patients often suffer from anemia, malnutrition, persistent hypothermia, and tetanus.51
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Among the vital clinical issues in treating burns are: (a) the burns distract patients from sensing other injuries that may be more serious, (b) the burn injury may not be obvious (e.g., electrical and respiratory burns), and (c) the burns may indicate child or spousal abuse.
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WHO lists (Table 22-3) what it considers to be the essential resources for burn care worldwide, varying with four levels of hospital capabilities (described in Chapter 5, Basic Equipment).
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Burns involving <15% of body surface area (BSA) in adults and <10% BSA in children are considered "minor"; more extensive burns are "major." Major burns also include first-degree burns to the perineum and genitals, as well as inhalation burns. The BSA calculation normally considers only burns that are second-degree (partial thickness), third-degree (full thickness), and fourth-degree (full thickness plus underlying structures).
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A common method for (generally, over-) estimating the percentage of BSA burned is to use the area of the patient's palm as 1% BSA. However, the actual area of the palm alone is only 0.6% BSA in adult males and 0.56% BSA in females. The area of the palm plus the palmar surface of the fingers (not including the thumb) averages 1.2% of the individual's BSA in males and 1.15% BSA in females. For overweight individuals, the palm alone approximates 0.5% BSA and the palm plus fingers is 1% BSA.52 For most individuals, the calculation should be made using the area of 2 palms (without fingers) = 1% BSA.
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Commonly seen, tar burns pose a particular problem because they may continue to burn for some time. Tar is difficult to remove from the skin. There are two treatment options—use the one that requires the fewest resources. In all cases, cool the tar immediately to reduce continued burning. To do this, an extremity can be immersed in ice water for a short period. After that, there is a choice: to remove the tar or not.
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British burn surgeons report excellent results with leaving the tar in place if it is in a low-risk area of the body. The tar comes off as the skin desquamates. If located in a high-risk area, such as the eye, it can be removed with a nontoxic solvent, such as Neosporin. The British surgeons found that removing the tar did not change either the need for surgery or the time to heal.53
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If you must remove the tar, first cool it so that it hardens (but don't make the patient hypothermic). Then wipe it off using mineral or baby oil, alcohol, ether, acetone, kerosene, or gasoline. Many of these may cause further damage to the skin. Neosporin ointment or cream is an antibiotic dissolved in a petroleum base, so this will generally remove tar over a 12-hour period. Polysorbate (Tween 80) or De-Solv-It also are frequently available and work well without reported side effects.54 The question is, though, why bother?
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Non-opioid and mild opioid analgesics often are all that is necessary when treating burns. If a stronger analgesic is needed, especially for extensive dressing changes on partial-thickness burns, sedation is useful. Ketamine works well in these instances.
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Alternatives to pharmacologic analgesics are available. Clinicians and patients willing to try hypnosis (see Chapter 14, Anesthesia—Local and Regional) will find it useful. Another, easier method is to use music or videos as a distraction, especially during debridement. Equipment to do this is always available, since the most basic method is singing to or with the patient. Other modalities are to watch videos, listen to music, or play games based on either the video or music. These distractions lessen patients' anxiety and usually diminish the pain response.55,56
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Basic Monitoring and Treatment
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Evidence supports using hourly urine output to guide fluid therapy in burn resuscitation.57
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Hypothermia can be deadly in burn patients, especially if they were treated with saline wraps in a cool environment. Prevent thermal (cold) stress by keeping the environment as warm as possible, preferably from 80°F to 85°F (17°C to 29°C).58
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ECG leads can be placed using non-invasive methods, including with small hypodermic needles, as shown in Fig. 7-15.
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Decompressing the stomach early is vital in patients with major burns. The ileus they develop can lead to aspiration and respiratory distress, if not corrected.
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Nasogastric tubes can be secured in patients with facial burns by passing a large suture through the thin area between the anterior nasal septum and the skin (columella). When doing this, leave both suture ends long enough to make a knot below the nose and then wrap it around the NG tube and tie it. Leave some distance between where you tie a secure knot and the nose to prevent pressure necrosis on the columella. Use the remainder of the suture to tightly tie the NG tube.
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A less-invasive alternative is to use a 3-cm-long piece of rubber tubing with ≥1 cm internal diameter (ID). Cut an "X" through opposing sides of the tubing (Fig. 22-9) and a small hole at each end. Pass an NG tube through the "X." The friction should keep it in place; if not, use a suture to tie the NG tube to the small tubing. Fix the rubber tubing to the patient with a tie or thin tubing passed through the two holes at its ends. A second X-shaped hole can be made in the rubber tube to accommodate a second NG tube, an oxygen tube, or a nasal monitor (i.e., CO2).59
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"Experience in ‘need-based’ countries has shown that patients treated in a large, airy ward with good cross ventilation are less likely to get infected than those treated in a small air-conditioned room. However, fly-proofing the ward with nets on the doors and windows and ensuring that the distance between two beds is at least 5 feet are simple, but important, requisites which should not be ignored."60
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Burn patients often develop a rim of erythematous tissue at their wound margins. If it extends beyond this and the patient shows signs of infection, treat for beta-hemolytic streptococcal cellulitis.
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As soon as any ileus resolves, provide high-caloric nutrition orally or via an NG tube. See Chapter 33, Malnutrition, for feeding information.
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If the patient is conscious, even if nonverbal (e.g., a small child), their reaction to a pinprick can often differentiate between second-degree and third-degree burns. Using a sterile hypodermic needle, first touch a non-burned area. The adult patient should feel the touch as being sharp; a child should give an appropriate response for their age. A similar reaction results if the burn is second-degree (partial). In full-thickness (third-degree or fourth-degree) burns, the nerves are dead and there should be no reaction to the pinprick.
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All burns, or all parts of burns, are not always easy to categorize. A good rule is that any burn that remains unhealed after 3 weeks should be considered a full-thickness burn and should be treated by excision of the eschar (if still present) and skin grafting.60
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The American Burn Association's Practice Guidelines for Burn Resuscitation say that, based on the quality of available evidence,57
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- Adults and children with burns >20% BSA should undergo formal fluid resuscitation using estimates based on body size and surface area burned.
- Common formulas used to initiate resuscitation estimate a crystalloid need of 2 to 4 mL/kg body weight/%BSA during the first 24 hours.
- Fluid resuscitation, regardless of solution type or estimated need, should be titrated to maintain a urine output of approximately 0.5 to 1.0 mL/kg/hr in adults and 1.0 to 1.5 mL/kg/hr in children.
- Maintenance fluids should be administered to children in addition to their calculated fluid requirements caused by injury.
- Increased volume requirements can be anticipated in patients with full-thickness injuries, inhalation injuries, and delays in resuscitation.
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The addition of colloid-containing fluid following burn injury, especially after the first 12 to 24 hours postburn, may decrease overall fluid requirements.
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Consider oral resuscitation for awake, alert patients with moderately sized burns.
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Fluid loss and the calculations for fluid replacement begin at the time of burn, not when the patient arrives for medical care. In Zimbabwe, for example, the average delay in getting to medical treatment is 6 hours; in many regions or circumstances, it will be much longer. After 6 hours, for example, the fluid deficit is already about 6/8 × 2 mL/kg/%BSA burned. With that level of delay, one recommendation is to initially administer 2 mL/kg/hr Ringer's lactate until the fluid deficit is corrected.61
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The keys are (a) to administer the least amount of fluid necessary to maintain adequate organ perfusion and (b) to titrate the volume infused continually to avoid both under- and over-resuscitation.62
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Fluid Replacement Formulas
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All standard burn resuscitation formulas from burn centers in the United States use lactated Ringer's solution. Although lactated Ringer's is the most popular choice of crystalloid to use, there is no good evidence to support its use over normal (0.9%) saline (NS) or other similar isotonic crystalloid solutions.
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The formulas all give one-third the calculated amount of fluid over the first 8 hours post-burn; the balance is given over hours 9 to 24.
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Parkland (Baxter-Shires) Formula63
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- 4 mL × kg body weight × %BSA burned. Give ½ total calculated volume in the first 8 hours post-burn. Give the balance over hours 9 through 24.
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Modified Brooke Formula
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The Modified Brooke formula is "often quoted, [but] it is rarely correctly applied."61 Use this only for replacement fluids.
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- 2 mL × kg body weight × %BSA burned. Give half the total calculated volume in the first 8 hours post-burn. Give the balance over hours 9 through 24.
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Children require more fluids than do adults with similar-sized burns, in part due to their higher BSA-to-weight ratio. They need maintenance fluid in addition to the resuscitation fluid. An estimate is that children require 6 mL/kg/%BSA burned in the first 24 hours.64
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Shriners-Cincinnati (Older Children) Formula
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- 4 mL/kg/%BSA burned + 1500 mL/m2 BSA
- For younger children, they add 50 mEq NaHCO3 to the solution for the first 8 hours and change to 5% albumin in lactated Ringer's for the third 8-hour period.
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- 5 L/m2 %BSA burned + 2 L/m2 BSA
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Patients with deeper burns, a delay in resuscitation, or inhalation injuries may need more fluid than is specified in these formulas.
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In what has been termed "fluid creep," most seriously burned patients receive more rather than less fluid than is required, often more than 5 to 7 mL/kg/%BSA burned over the first 24 hours.65,66 This results in serious complications. Decrease fluid administration when urine output exceeds the target goal.
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Burn Patient Hydration—Oral
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In burned patients with no contraindications, such as an abdominal injury or intestinal obstruction, give oral salt and sodium bicarbonate solutions, such as Moyer's solution (3 g NaCl plus 1.5 g NaHCO3 in 1 L of water).67 Alternatively, use WHO's oral replacement therapy formula (20 g glucose, 3.5 g sodium chloride, 3 g sodium citrate, and 1.5 g potassium chloride in 1 L of clean water). The traditional mixture of one fistful of sugar, three pinches of common salt, and half a lemon in 1 L of clean water may also be used, especially during what may be a long transport to the nearest hospital.60 These solutions are adequate for adults with burns of up to 15% BSA and have been successfully used to treat burns of up to 30%.
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In resource-poor environments that lack both the materials and personnel to do intensive burn dressing changes, treating significant burns open ("exposure method") may be the best course; the saline method may be used on deep burns. Outpatient burns, especially those on the extremities, can be treated with occlusive dressings, while those on the hands and feet can be encased in plastic bags. Special dressings can be used when transferring patients to burn centers.
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Rapid Transfer Dressings68
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Standard plastic wrap (polyvinyl chloride) makes an excellent short-term burn dressing, especially for patients that must be transferred to burn centers. The benefits are that it is extremely inexpensive, is rapidly and easily applied and removed, does not adhere to the burns, does not cause hypothermia as saline dressings might, and allows clinicians at the burn center to more accurately estimate the size and depth of the burns, since there are no ointments or creams obscuring the burn wounds.
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To use plastic wrap in this fashion, use standard rolled sheets and, taking care to touch only the edges, lay it over the burned areas and adjacent areas to provide adequate margins. The plastic adheres to itself and decreases the patient's pain by barring air flow to first- and second-degree burns and other open wounds. Sheets, blankets, and clothing may be laid over wrapped areas without discomfort.
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On arrival, the plastic wrap is simply unwrapped or cut off. The wrap does not adhere to the burns, so the patient has no pain from this procedure. Because of concern about bacterial growth beneath the plastic, it has generally been used only for short-term dressings.
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Treating Burned Hands or Feet
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In resource-poor settings, treat significant burns of the hands or feet in a clear plastic bag. (Of course, it violates the rule to use plastic occlusive dressings only for short periods of time, but this has proven to be effective and safe.) The bag must be large enough for the patient to easily move his hand or foot; do not use a synthetic glove.
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Wrap gauze around his wrist or ankle and secure it with tape. Cover the hand or foot, or fill the bag with an antiseptic, such as silver sulfadiazine, if available. Place the hand or foot in the bag and use another bandage to secure the bag to the wrist or ankle over the initial gauze dressing. This forms a watertight "sweat band" to prevent the generally large amount of murky burn exudates from dripping down the forearm or leg.
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Encourage the patient to actively use his hand or foot immediately, but keep it elevated to reduce the inevitable swelling. Change the bag every 24 hours, washing the hand or foot thoroughly with soap and water, and replace the antiseptic, as necessary. Observe the vascular supply to the extremity to assess the need to do escharotomies, especially of the fingers or toes.58,69
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Usually done poorly due to inadequate materials, personnel, or understanding, this method should not be used for inpatient burn treatment in resource-poor environments. As Dr. King wrote, "Done badly, this method is a disaster, and too easily converts a partial thickness burn into a full thickness one."70 That is due to applying too little dressing over too small an area with infrequent dressing changes.
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If applying occlusive dressings on outpatients, the burned area needs to be covered in silver sulfadiazine or an alternative or with petroleum jelly gauze, followed by a thick (≥2.5-cm) dressing to occlude the wound and absorb exudate. The bandaging should extend 10 cm beyond the burned area. For partial-thickness burns, the dressings can remain in place for 10 days if there are no signs of infection (exudate seeping through bandages, swelling, increasing pain, fever, regional lymphadenitis, or decreased perfusion distal to the burn). Little children can have plaster splints applied to keep them from removing the dressing. In full-thickness burns, the dressing should be changed at least every 4 days or if any of the signs or symptoms noted above occurs. If using 0.5% silver nitrate, change the dressing daily.71
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Exposure (Open) Method
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Best used for partial-thickness burns, this method requires little nursing involvement. Clean the burned areas after providing adequate sedation and analgesia. Do not break intact blisters. Place the patient on sterile sheets in a warm (40°C[104°F]) room with ≥40% humidity. Make a cradle over him to keep a top sterile sheet off the burns (Fig. 22-10). (Other methods to improvise bed cradles to support top sheets are shown in Chapter 5, Basic Equipment, Figs. 5-4 and 5-5.) Use topical antibiotics, if available.72
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Saline Treatment Method
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The saline method of burn treatment keeps the burned area constantly wet with half-strength NS until it heals. Boiled sea water may also be used.73 This method is very useful for full-thickness burns.
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In this method, use a relatively thin layer of gauze and keep it constantly moist, not wet, by periodically dripping NS onto it from a container. The gauze only needs to be changed once a day; this is best done in a bath or under a shower. As the burns are mainly full thickness, dressing changes are not too painful, but give analgesics (generally paracetamol/acetaminophen) as necessary.
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Extremity wounds can also be treated this way, generally by dipping the extremity in the NS.
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Saline treatment is reported to be an excellent—and the least expensive—method of treating burns; however, it is time consuming. It is best done in a tiled burn-treatment room that also has a bath or shower. Family or friends can assist in this treatment.
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An obvious danger with this method, especially if treating a large surface area, is hypothermia. This occurs if the room is cool or if, even in a warm room, there is a draft. (Evaporation quickly cools the body.)
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Some clinicians use Eusol rather than NS if there is any sign of pseudomonas (the typical smell and green blue staining of dressings). In those cases, also use 0.5% silver nitrate (or silver sulfadiazine).74
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Using either the saline or exposure methods, debridement can be accomplished by "simple bathing or showering once or twice a day with ‘soap and water’ … [which] not only reduces pressure on the nurses but is more humane, less painful and far less costly. It also allows the active involvement of a relative or friend who can help with the bathing and feeding of the patient."60
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The two indications for an escharotomy are difficulty breathing and a pulseless extremity. Breathing problems stem from circumferential burns around the neck or chest. Pulseless extremities can be assessed by the lack of an audible pulse (use a Doppler, if available) or of a palpable pulse if that is all that is available. If using a Doppler, listen for pulses in the palm, not at the wrist. The decision to perform an escharotomy is clinical and, if the life or extremity is to be saved, the procedure must be done immediately. Note that progressive edema can develop rapidly, especially in the face of fluid over-hydration.
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The stiff eschar of a deep circumferential limb burn may cause a compartment syndrome when edema accumulates under it. Wide eschars on the chest, neck, and abdomen may restrict breathing. "Escharotomy may be done bed-side without anesthesia as the eschar itself is insensible. One or more longitudinal incisions are made through the eschar into bleeding subcutaneous tissue. The soft tissue pressure will widen the incisions and confirm that the escharotomy was necessary."75
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To perform an escharotomy, no anesthesia is necessary as incisions are made through dead, insensate tissues. Using a scalpel, incise the burned area into the underlying subcutaneous fat. When you have gone through the eschar (correctly), the tissue "pops" apart. For a thoracic escharotomy, begin the incision high in the midclavicular line (Fig. 22-11). Continue the incision along the anterior axillary lines down to the level of the costal margin. Extend the incision across the epigastrium as needed. For an extremity escharotomy, make the incision through the eschar along the mid-medial or mid-lateral joint line.76
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Many burns and escharotomy sites eventually require grafting. Small, full-thickness burns should be immediately excised and grafted.58 Thin partial-thickness skin grafts are the best dressing possible—they stimulate healing and help prevent wound infection. Improvise equipment to take partial thickness grafts when the normal equipment is not available.
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To take a graft, infuse the subcutaneous area (hypodermoclysis) with saline solution containing 1:1,000,000 dilution of epinephrine. This smoothes the site and reduces bleeding. This is essential when taking grafts from the scalp, and is helpful at other locations.
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While obtaining the graft, get hemostasis by applying warm gauze soaked in a 1:100,000 epinephrine solution. Once the graft is taken, dress the site with fine mesh petroleum jelly gauze. Apply a heat lamp until the gauze is dry, and leave the site open.
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Obtaining Partial-Thickness Grafts
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Free-hand split-thickness skin grafts can be taken with an ordinary scalpel. Even better is to use a razor blade with a needle holder handle or a barber's razor. These can take grafts of any thickness.42
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An easy way to perform this procedure is to first anesthetize the skin with a field block around the site. Hold uniform tension on the skin using two wooden blocks. Then make parallel incisions the length of the grafts and slightly wider apart than the scalpel blade's length. Initially, hold the blade at a 20-degree angle to the skin. After the first 0.5 cm of the graft is cut, hold the blade parallel to the skin and cut with a sawing motion.77 Hold the free edge of the graft with a skin hook (Fig. 22-12).
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Graft Preparation and Dressings
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When a skin mesher is not available for skin grafting, hand meshing can work as well. A #15 surgical blade can be used to make a 1:15 expansion graft; a #20 blade works well to make a 1:3 expansion graft.78
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Skin grafts and donor areas can be covered with a piece of sponge, which acts as an absorbent dressing. Put a layer of non-adherent petroleum jelly-impregnated gauze over the site and then suture the sponge onto the site using long sutures that cross over the sponge like it was a package (Fig. 22-13). The grafts themselves need not be sutured. Petroleum jelly dressings can be easily made; don't add antibiotic if they will be used on grafts.79
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Graft sites on extremities should be immobilized for 4 to 5 days and not inspected earlier unless there are indications of infection.
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Early physical therapy reduces the incidence of post-burn contractures and subsequent limited function.
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Various devices have been fabricated using inexpensive and readily available materials such as wood, cane, coat hanger wire, foam, rubber bands, clothes' pins, and plaster. The devices include hand (static and dynamic), elbow, knee, and mouth splints, as well as axillary pads. Underwear elastic, spandex material, and animal-leather sheets are used to fabricate inserts and pressure garments such as gloves, sleeves, and face masks. Airplane splints (for arms/shoulders) are fabricated with plaster and wood. Appropriate positioning of the burn patient in the emergent and acute phase of recovery can be achieved with homemade cane "IV" poles, pieces of wood, and foam.80
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When health care resources are scarce, a decision must be made about the treatment of extensive serious burns. With limited resources and experience, it may be rare to save the lives of patients with 50%, or even 30%, BSA deep burns, due to "pseudomonas infection, anemia, lack of extra nutrition and patient exhaustion."74 A physician group wrote: "Under these circumstances, it seems reasonable to utilize the limited resources of a ‘need based’ country like India to concentrate on saving the lives of those with burns of less than 50% of body surface area."60
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If a decision is made not to aggressively treat such patients, they still should receive the maximum comfort care possible.