General wound care

1. 5.Excision & grafting 3. Biological dressings 1.Cleaning & debridement General wound care 2.Antimicrobial Agents 4. Biosynthetic & Synthetic dressing

2. Excision and Grafting

3. Excision & Grafting the burn wound • Full thickness or extensive burn-spontaneous reepithelialization is not possible. • Skin transplant or a graft of the patient`s own skin (autograft) is required. • Main area for grafting-face for cosmetic and psychologic reasons, and joint, for movement • If the burn is extensive, chest and abdomen is grafted to reduce surface area.

4. Excision & Grafting the burn wound • During the procedure of excision and grafting, eschar is removed. • A graft is placed on clean, viable tissue. • With early excision, function is restore and scar tissue formation is minimized. • Extensive bleeding may be expected. • Burn wound can be cover by patient`s skin (autograft)

5. Cultured epithelial autografts • Pt with large body surface area burns, limited unburned skin available as a donor site for grafting. • Cultured epithelial autograft (CEA) is one method to obtain skin tissue from a person with limited available skin for harvesting. • CEA is grown for biopsies obtained from the patient`s own skin.

6. Cultured epithelial autografts • Taking one or two small (2 to 3 cm long by 1cm wide) biopsy specimens from unburned skin.( usually the groin or axilla) • Performed as soon as possible when the pt has been identified. • Specimen is sent to lab. • Skin specimen are cultivated in the culture medium that contain epidermal growth factor.

7. Cultured epithelial autografts • 18 – 25 days cultivated keratinocytes expand up to 10,000 and form a sheet that can be used as skin graft. • The cultured skin placed on the patient`s excised burn wounds. • CEA grafts are only epidermal cells, good care is required to prevent injury or infection.

8. Cultured epithelial autografts • CEA grafts generate permanent skin coverage because they generate from pt`s own cells. • This type of skin graft has played an important role in the survival of the pt with major burns with limited skin for donor harvesting. • Problems related to CEA include thin, friable skin (lack of dermal cells) and contracture development.

9. Wound closure • Skin grafting is usually required or preferred with full-thickness or deep partial thickness. • After eshar removed and development of a base of granulating tissue, graft`s of patient`s own skin (autograft) are applied. • Blood flow is established by 3rd or 4th , and by 7th and 10th day postgrafting, vascularity continuity and wound closure have been established.

10. TransCyte • The most recent temporary skin substitute. • This bioengineered substance is derived form human fibroblast cells grown within mesh. • This product is also a bilayer skin substitute • The outer epidermal analog is a thin nonporous silicone film with barrier functions comparable to skin. 

11. TransCyte • The inner dermal analog is layered with neonatal fibroblasts which produce products mainly collagen type I, fibronectin and glycosaminoglycans. •  Cryo-preservation destroys the fibroblasts but preserves the activity of fibroblast.- • These products do stimulate the wound healing process.  • A thin water layer is maintained at the wound surface for epidermal cell migration.

12. TransCyte • The nylon mesh provides flexibility and excellent adherence properties. • The product is peeled off after the wound has re-epithelialized. • TransCyte must be stored at –70 C° in order to preserve the bioactivity of the dermal matrix products. • TransCyte is also indicated for the temporary closure of the excised wound prior to grafting.  

13. TransCyte Advantages • Bilayer analog • Excellent adherence to a superficial to mid-dermal burn • Decreases pain • Provides bioactive dermal components • Maintains flexibility • Good outer barrier function

14. TransCyte Disadvantages • Need to store frozen till use • Relatively expensive

15. The two-layer structure, the inner layer being bioactive

16. Stored at -70°Centigrade

17. TransCyte for Partial Thickness Hand Burn Cutting the sheet to fit with a small overlap followed by initial immobilization until adherent

18. TransCyte on Foot Burn (3 days) Note flexibility of the dressing

19. TransCyte on Leg Burn (10 days) Opaque appearance indicating re-epithelialization beneath dressing for removal

20. TransCyte (Day 12) Skin substitute being removed

21. Escharotomy • Full thickness deep dermal burns which are nearly circumferential on the limbs, neck, thorax. • Act like tourniquets with the development of edema. • All extremity burns at risk should be monitored with at least hourly vascular checks of pulse or Doppler signal. • Escharotomies are longitudinal or crisscross incisions through such deep burns. • Done without analgesia and on the ward. • Does not bleed much.

22. Escharotomy

23. 5.Excision & grafting 3. Biological dressings 1.Cleaning & debridement General wound care 2.Antimicrobial Agents 4. Biosynthetic & Synthetic dressing

24. ACUTE PHASE Other medication Nutrition Wound Cleansing and debridement Relieving anxiety

25. Rehabilitation PHASE

26. Physical & Occupational therapy • Rigorous physical therapy with the physical therapist • To maintain optimal joint function. • A good time for exercise is during and after hydrotherapy • Skin is softer and bulky dressings are removed. • The patient with neck burns should sleep without pillows • Head hanging slightly over the top of the mattress to encourage hyperextension

27. Positioning • During this phase, patient must be maintained in positions that prevent contractures. • Contracture= abnormal flexion and fixition of a join cause by muscle atrophy and shortening • Minimizes formation of edema. • Prevents tissue destruction, and maintains soft tissues to facilitate recovery. • Patients should be positioned in a direction of comfort, especially around joints and flexor surfaces.

28. Positioning • Extremities should be elevated above the level of the heart using pillows, blankets, and towels. • Lower extremities should be elevated when the patient is sitting. • Patients who do not have endotracheal tubes or central lines may be placed prone to avoid pressure to posterior areas

29. Position and splinting • Turned from side to side to prevent the development of sacral pressure sores and to minimize discomfort from pressure on burns to these areas. • Burns to the upper extremities or hands should be evaluated by an occupational therapist. • Splints immobilize body parts and prevent contracture of the joint.

30. Exercises • Physical therapists work in conjunction with occupational therapists. • Assessment by the physical therapist to assist with ambulation, range of motion exercises necessary splints • Exercises are begun early, active and passive. • Range of motion (R0M), performed every 2 hours at bedside. • Early ambulation

33. Pressure garment. • Fitting of pressure garment, can prevent or reduce hyperthropic scarring. • Customade elastic pressure garments for 6 months and 1 year postgraft. • The psychologist plays an integral part in facilitating the psychological recovery of burn patients, and should be consulted for every patient admitted to the burn unit.

34. SPLINT