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  1. Circumferential burns will require immediate surgery to improve circulation to distal extremities or to permit adequate breathing if the chest wall is burnt.
  2. Early excision and grafting is preferred as it minimises infection and hastens wound healing.
  3. The whole burn should be excised with in 48 hours.
  4. Regular dressing changes, further excision and grafting may be required.
  5. It should be remembered that blood loss may be excessive at these times. Blood loss can be reduced by using diathermy and/or applying gauze soaked in adrenaline (1: 200,000) during the burn excision.
  6. The problem with excision of a large burn is often the lack of donor skin to cover the excised burn.
  7. The patient's donor skin can be meshed, so as to increase the size.
  8. It can then be covered with cadaveric skin which acts as a biological dressing with growth stimulating properties.
  9. Artificial bovine skin (such as Integra®) may also be used but are expensive.
    1. Deep partial thickness Burns-
      Deep dermis is shaved off and SSG (THIERSCH GRAFTS) applied.
    2. Full thickness Burns-
      1. Dead part is removed and SSG applied in the position of maximal stretch.
      2. Sometimes may require full thickness grafts (WOLFE’s GRAFTS).


Partial thickness graft

Full Thickness Graft



Epidermis+ Dermis

Donor site require

No cover, as it regenerates spontaneously

Suturing, as it does not heal spontaneously

Most common donor site


Supraclavicular and Post auricular

Recipient uptake



Wound contraction/ Scar

More/ Poor cosmetically

Less/ Better cosmetically

  1. Physiotherapy begins after 5 days in case of skin grafting to allow the graft to settle down.
  2. Knife used for taking graft is called HUMBY’s Knife (DERMATOME for full thickness grafts) and blade used is called WOLFE’s blade.
  3. Escharotomy- Incising the whole length of limb in mid axial line. 
  1. Contraindications for Skin Grafting-
  2. Recipient area if Bare bone/ Cartilage and Tendon.
  3. Infection at the recipient site- Strepto Pneumoniae and Beta Hemolytic streptococcus.
    Previously irradiated recipient site.
  1. Types Of Graft-
    1. Autograft- Same patient
    2. Isograft- Identical twins
    3. Allograft- Same species
    4. Xenograft- Different species. 
  1. Pulmonary Smoke may damage the lungs in three ways:
    1. Intoxication /hypoxaemia
    2. Respiratory tract injury due to irritants
    3. Thermal damage
    4. Carbon monoxide has a higher affinity for haemoglobin than oxygen, and will lead to tissue anoxia.
    5. The severity of the poisoning depends on the proportion of Hb combined with carbon monoxide.
    6. Symptoms range from a throbbing headache with nausea and vomiting (<30%) to coma, convulsions and cardiac arrest (>60%).
    7. 100% oxygen is the initial treatment and may necessitate intubation and ventilation.
      1. The half-life of carboxyhaemoglobin (COHb) in air is 4 hours and in 100% oxygen, 80 minutes. Hyperbaric oxygen may be useful especially if there are significant neurological signs but may be difficult in a severely burnt patients.
    8. Pulse oximeters are inaccurate in the presence of carboxyhaemoglobin and cannot be relied upon.
    9. Other gases such as hydrogen sulphide, hydrogen cyanide and hydrogen chloride may be inhaled, particularly if paints or furniture have been involved in the fire.
    10. Cyanide poisoning is difficult to diagnose but a high index of suspicion should be had if the patient is apnoeic and has a metabolic acidosis indicating tissue hypoxia.
    11. Treatment is beyond the scope of this article but ventilation and antidotes (sodium thiosulphate) will be necessary.
    12. It is also important to consider the rescuers who may have been exposed to this gases.
    13. Soot is an irritant that will cause chemical injury if left in the airway.
    14. It can be treated with Bicarbonate (1.8%) nebulisers.
    15. Chemical toxins formed from combustion include chlorine, ammonia and phosgene.
    16. They have variable penetration into the respiratory tract but may cause serious airway injury.
      Thermal injury from flame or hot gases may also injure the upper respiratory tract although it is rarely severe as the upper airway will rapidly cool 'dry heat' and thereby minimise injury.
    17. Stream inhalational, however, can cause lower alveolar damage and carries a poor prognosis. Suspicion of a potential inhalational injury should be aroused if there is a history of a fire in an enclosed space, disturbed consciousness, facial burns, coughing, hoarse voice, airway soot and cyanosis.
    18. Specific investigations include COHb levels, arterial blood gases, and fibreoptic bronchoscopy.
    19. The management involves oxygen therapy and mechanical ventilation along with physiotherapy and tracheo- bronchial toileting.
      1. Increased fluid requirements will be necessary.
      2. If acute respiratory distress syndrome develops the patient will require specialist intensive care support.
    20. Renal failure may occur as a complication of renal hypoperfusion (inadequate resuscitation), septicaemia or haemoglobinuria/myoglobinuria.
      1. The latter may require alkalinisation of the urine in addition to maintaining an adequate perfusion pressure and the administration of mannitol (1g/Kg).
      2. Early renal dialysis may become necessary.
      3. Renal failure in association with burns has a high morbidity and mortality.
    21. Haematology Intravascular haemolysis along with wound losses will increase blood transfusion requirements.
      1. Haemoglobinuria may occur.
    22. Nutrition Patients are profoundly catabolic with a BMR peaking at 4 days.
      1. These patients require early and aggressive feeding preferably enterally to maintain intestinal mucosal integrity.
      2. Glutamine rich feeds may further reduce mucosal breakdown and also improve immune function.
    23. Curling's ulcers are associated with severe burns but can be prevented by early feeding and antacid prophylaxis.
    24. Cerebral Hyponatraemia complicating resuscitation may result in the burn encephalopathy syndrome. This is seen as cerebral irritability. 
  1. Sepsis
    1. Burn injury is associated with a generalised loss of immunocompetence, and sepsis remains a major cause of death in burns.
    2. Early sepsis (1-3 days post burn ) is usually streptococcal or staphylococcal.
    3. Late sepsis is usually due to Pseudomonas, acinetobacter and fungi.
    4. Prophylactic antibiotics should be avoided and instead regular cultures taken and appropriate therapy given when indicated. Some specialist burns centres recommend systemic decontamination of the digestive tract (SDD). Tetanus toxoid must be given. 
  2. Other problems
    1. Consider the possibility of underlying medical conditions that may have led to the burn injury for example epilepsy, a cerebrovascular event, hypoglycaemia, drug or alcohol overdose.
    2. Always attach an ECG if there is a history of heart disease or carbon monoxide inhalation.

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