Surgical Treatment of Burns

Surgical Treatment of Burns

Author: Gail E Besner, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP more...

Updated: Apr 2, 2012

Background

Traumatic injuries cause more deaths in childhood than all other causes combined. Although motor vehicle injuries arethe foremost cause of death, each year approximately 440,000 children receive treatment for burns in the UnitedStates. More than 75,000 of these children require hospitalization, 10,000 experience severe permanent disability, and2,500 die from thermal injury. Burn injuries represent the third leading cause of mortality in patients younger than 5years. The overall morbidity from thermal injury has improved markedly over the years as a result of an aggressivemultidisciplinary approach to care for the pediatric patient with thermal injury.

Etiology

Approximately 90% of burns are caused by household accidents or child abuse. In children younger than 3 years,

scalds are responsible for most burns.[1] Scald burns may occur when a child pulls scalding liquid onto himself or mayresult from bathtub submersion injuries, which can often be quite severe. In older children, flame burns are morecommon. Space heaters, matches, and house fires are the most common etiologic factors for these burns, which areoften full thickness and constitute most fatal burns.

Pathophysiology

Appreciating the major differences between burn management in children and adults is important. Children have nearly3 times the body surface area (BSA)-to-body mass ratio of adults. Fluid losses are proportionately higher in childrenthan in adults. Consequently, children have relatively greater fluid resuscitation requirements and more evaporativewater loss than adults. The large BSA-to-body mass ratio of the child also predisposes the child to hypothermia, whichmust be aggressively avoided.

Children younger than 2 years have thinner layers of skin and insulating subcutaneous tissue than older children andadults. As a result, they lose more heat and water than adults do, and they lose these more rapidly than adults. In veryyoung children, temperature regulation is partially based on nonshivering thermogenesis, which further increasesmetabolic rate, oxygen consumption, and lactate production. In addition, because of disproportionately thin skin, a burnthat may initially appear to be partial thickness in a child may instead be full thickness in depth. Thus, the child's thinskin may make initial burn depth assessment difficult.

Presentation

The depth of burn is classified as follows (see the image below):

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Skin histology diagram.

Superficial partial thickness

These burns are superficial with injury to the epidermis and superficial dermis. These are second-degree burns andare characterized by ruptured weeping blisters. They are also erythematous and painful. Superficial partial-thicknessburns spontaneously heal within 1-3 weeks, usually without scarring (see the image below).

Superficial partial-thickness burn.

Deep partial thickness

These are deep burns with injury to the epidermis and deeper dermis, but some viable dermis remains. These arealso considered second-degree burns but are whiter and less erythematous as the depth into the dermis increases.Distinguishing between deep partial-thickness burns and full-thickness burns may initially be difficult. Deep partial-thickness burns heal spontaneously but often after 3-4 weeks. The degree of scarring is related to the length of timeneeded for reepithelialization. See the image below.

Deep partial-thickness burn.

Full thickness

Injury to the epidermis and entire dermis occurs. These are the third-degree burns that typically are white, brown, orblack. The eschar is leathery and insensate. These burns do not heal spontaneously (except for very small woundsthat heal by contraction). See the image below.

Full-thickness burn.

Electrical burns

Low-voltage injuries result from sources of less than 1000 volts and include oral injuries from biting electrical cords,outlet injuries from placing objects into wall sockets, and injuries from contacting live wires or indoor appliances.High-voltage injuries are caused by sources of more than 1000 volts and result from contact with a live wire outdoorsor from being struck by lightning.


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Children who have sustained high-voltage electrical injury require admission to the hospital with cardiac monitoring,serial electrocardiography, urinalysis, and determination of creatine kinase and urine myoglobin levels. Myoglobinuriaand hemoglobinuria should be aggressively treated with hydration, osmotic diuretics, and alkalinization of the urine toavoid renal failure. Extremities must be carefully monitored for the development of compartment syndrome,necessitating escharotomy or fasciotomy. Appropriate radiographic examinations should be performed to excludeconcomitant long bone injury.

Many children who have sustained low-voltage electrical injury can be treated as outpatients as long as (1) the patienthas no cardiac dysfunction, loss of consciousness, or history of tetany or wet skin during the accident; (2) the patientremains asymptomatic after 4 hours of observation in the emergency department; (3) the wounds are manageable inan outpatient setting; and (4) the patient can return for a wound check the following day. Parents of children with oralcommissure burns must be instructed in the application of pressure to the lip in the event that the burn erodes into thelabial artery, a complication that usually does not develop until several days after the injury.

Frostbite

Frostbite results from prolonged exposure to severe cold and usually affects the ears, nose, hands, and feet. Icecrystal formation in the tissues results in cellular dehydration, venous dilation and vasoconstriction causing peripheralblood pooling, and finally, tissue necrosis.

Signs and symptoms of frostbite include red, blue, or pale skin; a prickling sensation with superficial frostbite; painlessrigid skin with deep frostbite; and functional impairment.

Treatment involves placing the patient in a warm environment, removing clothing from the affected region, andrewarming the affected region by immersion in water at 100-105F for up to 30-45 minutes. Do not rewarm the frozenpart with massage or dry heat.

Chemical burns

Saturated clothing should be removed, powdered chemicals should be brushed off the skin, and the contaminatedarea irrigated with copious amounts of water for at least 20 minutes, and until the patient experiences a decrease in

pain in the wound.[2]

Chemical injuries to the eye are treated by forcing the eyelid open and flushing the eye with water or saline.

With gasoline injuries, the petroleum products may cause severe full-thickness cutaneous tissue damage, andabsorption of the hydrocarbon may cause pulmonary, hepatic, or renal failure.

Indications

Burn excision and grafting are recommended for all full-thickness burns and for deep partial-thickness burns that wouldappear to take more than 2-3 weeks to heal.

Relevant Anatomy

See Clinical for a discussion of relevant anatomy in patients with burn injuries.

Contraindications

Any condition that would ordinarily preclude the patient with burn injuries from having general anesthesia, otherwise nocontraindications to surgery are noted.

Contributor Information and DisclosuresAuthorGail E Besner, MD John E Fisher Endowed Chair in Neonatal Reseach, Director, Pediatric Surgical Research,Department of Surgery, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department ofSurgery, Ohio State University College of Medicine

Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy ofPediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association,American Medical Association, American Medical Women's Association, American Pediatric Surgical Association,Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of CriticalCare Medicine, Society of Surgical Oncology, and Society of University Surgeons

Disclosure: Nothing to disclose.


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Coauthor(s)Iyore Amy Otabor, MD Clinical Instructor House Staff, Department of General Surgery, The Ohio State UniversityCollege of Medicine

Iyore Amy Otabor, MD is a member of the following medical societies: American College of Surgeons, AmericanMedical Student Association/Foundation, and Student National Medical Association


Specialty Editor BoardDenis Bensard, MD Director of Pediatric Surgery and Trauma, Attending Adult and Pediatric Acute Care Surgery,Attending Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, Universityof Colorado School of Medicine

Denis Bensard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy ofPediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for AcademicSurgery, International Society for Minimally Invasive Cardiac Surgery, Society of American Gastrointestinal andEndoscopic Surgeons, Society of Laparoendoscopic Surgeons, Society of University Surgeons, and SouthwesternSurgical Congress


Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College ofPharmacy; Editor-in-Chief, Medscape Drug Reference


Michael G Caty, MD Professor of Surgery and Pediatrics, State University of New York at Buffalo; ConsultingStaff, Department of Pediatric Surgery, Children's Hospital of Buffalo

Michael G Caty, MD is a member of the following medical societies: American Academy of Pediatrics, AmericanCollege of Physician Executives, American College of Surgeons, American Medical Association, AmericanPediatric Surgical Association, Association for Academic Surgery, and Association for Surgical Education


H Biemann Othersen Jr, MD Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery,Medical University of South Carolina

H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, AmericanAcademy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, AmericanCancer Society, American College of Surgeons, American Medical Association, American Pediatric SurgicalAssociation, American Society for Parenteral and Enteral Nutrition, American Surgical Association, AmericanThoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society ofCritical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern MedicalAssociation, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association


Chief EditorHarsh Grewal, MD, FACS, FAAP Clinical Professor of Surgery, Temple University School of Medicine; Chief,Division of Pediatric Surgery, Cooper University Hospital

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics,American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education,Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric EndosurgeryGroup, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons,and Southwestern Surgical Congress


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O'Neill TB, Rawlins J, Rea S, Wood F. Complex chemical burns following a mass casualty chemical plant2.


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incident: How optimal planning and organisation can make a difference. Burns. Feb 20 2012;[Medline].

Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazenedressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. Sep

2011;4(3):183-7. [Medline]. [Full Text].

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Jeschke MG, Finnerty CC, Kulp GA, Przkora R, Micak RP, Herndon DN. Combination of recombinant humangrowth hormone and propanol decreases hypermetabolism and inflammation in severely burned children.Pediatr Crit Care Med. Mar 2008;9:209-216. [Medline].

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Coruh A, Yontar Y. Application of Split-Thickness Dermal Grafts in Deep Partial- and Full-Thickness Burns: ANew Source of Auto-Skin Grafting. J Burn Care Res. Nov 10 2011;[Medline].

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Chan MM, Chan GM. Nutritional therapy for burns in children and adults. Nutrition. Mar 2009;25(3):261-9.

[Medline].

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Besner GE. Burns. In: Glick PL, Pearl RH, Irish MS, et al, eds. Pediatric Surgery Secrets. ed. Philadelphia,

PA: Hanley & Belfus; 2000:246-52.

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Heimbach D. What's new in general surgery: burns and metabolism. J Am Coll Surg. Feb

2002;194(2):156-64. [Medline].

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Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J

Med. Oct 25 2001;345(17):1223-9. [Medline].

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Hildreth M, Gottschlich M. Nutritional support of the burned patient. In: Herndon D, ed. Total Burn Care.

Philadelphia, PA: WB Saunders Co; 1996:237-45.

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Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Besner G. A Silver Impregnated Antimicrobial DressingReduces Hospital Length of Stay for Pediatric Burn Patients. J Burn Care Research. May-Jun

2007;28:409-411. [Medline].

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Peters DA, Verchere C. Healing at Home: Comparing Cohorts of Children with Medium-Sized Burns Treatedas Outpatients With In-Hospital Applied Acticoat (TM) to those Children Treated as Inpatients with SilverSulfadiazine. J Burn Care Research. Mar-Apr 2006;27:198-201. [Medline].

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Sheridan RL, Weber JM, Schnitzer JJ, et al. Young age is not a predictor of mortality in burns. Pediatr Crit

Care Med. Jul 2001;2(3):223-224. [Medline].

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Kraft R, Herndon DN, Al-Mousawi AM, Williams FN, Finnerty CC, Jeschke MG. Burn size and survivalprobability in paediatric patients in modern burn care: a prospective observational cohort study. Lancet. Mar

17 2012;379(9820):1013-21. [Medline].

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Surgical Treatment of Burns Treatment & Management

Author: Gail E Besner, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP more...

Updated: Apr 2, 2012

Medical Therapy

Rapid assessment and treatment of immediate life-threatening conditions is mandatory in patients with burns.Endotracheal intubation is indicated in children with respiratory distress or airway compromise caused by airwayedema. Because of the small diameter of the pediatric airway, a low threshold for intubation should be maintained.Children with burns affecting more than 10% of the body surface area (BSA) should receive intravenous fluidresuscitation. Burn wounds should initially be covered with dry sterile sheets, and a thorough history and physicalexamination should be obtained. Wet sheets or cooling packs should not be used because this contributes tohypothermia. Patients should be kept warm by infusing warm intravenous fluids, elevating room temperatures, andminimizing patient exposure. Tetanus immunization should be administered as indicated.

Admission criteria

Hospital admission criteria for patients with thermal injury include the following:

Partial-thickness burns greater than 10% total BSA (TBSA)Full-thickness burns greater than 2% TBSABurns involving the face, hands, genitalia, perineum, or major jointsCircumferential extremity burnsAll high-voltage electrical burns, including lightning injuryAdmission of low-voltage electrical burns is selectiveChemical burnsInhalation injuryBurn injuries in patients with preexisting medical disorders that could complicate management, prolongrecovery, or affect mortality (eg, diabetes, immunosuppression)Suspected child abuseCases in which it is determined that it is in the best interest to admit the child (ie, parental inability to care for theburn)

Inhalation injury

Clues to inhalation injury include increased respiratory rate, hoarseness, being burned in an enclosed space, alteredmental status, head and neck burns, singed nasal hairs, inflamed oral mucosa, and carbonaceous sputum. Indicationsfor intubation include compromised upper airway patency, the need for ventilatory support as manifested by poor gasexchange or increased work of breathing, or compromised mental status. Correlation of the history and clinical findingscomprise the most practical approach to determining the need for intubation.

Important considerations regarding the pediatric airway include the fact that the larynx is more cephalad in children, thatchildren deteriorate faster than adults in terms of upper airway edema and alveolar-capillary block, and that repeatedintubation attempts may cause edema and obstruction. For these important reasons, experience in pediatric intubationis needed. Once an airway is established, securing the airway well is important, especially in patients with facial burns,to avoid accidental extubation (see the image below).


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Endotracheal tube immobilization in children. The figure demonstrates a method using umbilical tape to secure a pediatric endotrachealtube in patients with facial burns.

Carbon monoxide (CO) toxicity is the leading cause of death in patients with inhalation injury. CO is a byproduct ofcombustion that displaces O2 from the hemoglobin (Hgb) molecule. It has 250X the affinity of O2 for Hgb, therefore

shifting the Hgb-O2 disassociation curve to the left. This impairs O2 unloading at the tissue level and causes a switch to

anaerobic metabolism with severe metabolic acidosis. CO toxicity should be suspected with persistent metabolicacidosis despite adequate volume resuscitation. Remember that the PaO2 in an arterial blood gas will be normal since

the amount of O2 dissolved in arterial plasma is normal. In addition, the O2 sat (measured O2 saturation of Hgb) will be

normal on a standard pulse oximeter in the presence of CO toxicity since the oximeter cannot differentiate betweenHgb saturated with O2 and Hgb saturated with CO.

To treat CO toxicity, all patients with inhalation injury should be treated with 100% O2. This lowers the T of CO to

30-90 minutes whereas it would be 4-5 hours in room air. Therefore, all major burns should be treated with 100% O2until CO toxicity is ruled out or the CO level returns to normal. Hyperbaric oxygen (HBO) therapy (3 atm) leads to evenmore rapid displacement of CO within 20 minutes. Its use should be considered for CO greater than 50%, severeneurologic compromise, and nonresponsiveness to 100% O2.

Cyanide toxicity results from the burning of natural (wool, silk, cotton, paper) or synthetic (polyurethane, plastic, nylon,acrylic) products, which leads to the production of toxic hydrocyanide gas. Cyanide binds to the cytochrome oxidasesystem, inhibiting cellular metabolism and ATP production. It causes a shift to anaerobic metabolism with profoundmetabolic acidosis and obtundation. The treatment of cyanide toxicity involves administration of the cyanide antidotesodium thiosulfate (8 g intravenously if < 12 y; 12.5 g intravenously if 12 y). The antidote converts cyanide tonontoxic, excretable thiocyanate.

Smoke inhalation can also cause a chemically induced inflammatory reaction in the airways, leading to microbialcolonization and pneumonia. Affected patients may need ventilatory support. In severe cases, oscillating ventilatorsand extracorporeal membrane oxygenation (ECMO) have been successfully used in these patients.

Fluid resuscitation

Intravenous access may be obtained percutaneously or by cutdown, either peripherally or centrally. Peripheral accessin an unburned area is preferred. Intraosseous (IO) infusion may be lifesaving in the severely burned patient ifnecessary.

Several burn resuscitation formulas can be used in pediatric burn care; the modified Parkland formula is mostcommonly used. Ringer lactate solution is initially used in pediatric patients of all ages at 3-4 mL/kg for each percent ofBSA burned for the first 24 hours. One half of the calculated fluid needs are administered in the first 8 hours after theburn occurs, and the remaining half are administered over the following 16 hours. Maintenance fluids should beadministered concomitantly (this represents the modification to the Parkland formula for pediatric patients).

Representative fluid resuscitation guidelines for pediatric burn patients with burns more than 15% TBSA are asfollows:

Modified Parkland formula (Parkland formula plus maintenance fluids, used in patients who weigh less than 20kg)Resuscitation fluids - 3-4 mL Ringer lactate X weight (kg) X %TBSA burned (second-degree and third degree);half administered over the first 8 hours (from time of injury), remaining half administered over the next 16 hoursMaintenance fluids - Ringer lactate solution with 5% dextrose at 4 mL/kg/h for 0-10 kg, plus 2 mL/kg/h for 10-20kg, plus 1 mL/kg/h for each kg more than 20 kg

Prehospital fluids must also be considered. If prehospital fluid resuscitation is inadequate, the fluid deficit must beadded to the fluid rate calculated for the first 8 hours of resuscitation.

For patients with burns of 15% TBSA or less, the following are indicated:

Patients with burns 5-10% TBSA who are taking oral fluids well - Oral fluids onlyPatients with burns 5-10% TBSA who are not taking oral fluids well - Maintenance fluidsPatients with burns 10-15% TBSA - 150% maintenance fluids

The above recommendations are guidelines only. Patients with burns of more than 15% TBSA should have a urinary


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catheter placed. Desired urine output is 1 mL/kg/h for patients who weigh less than 30 kg and 30-50 mL/h for patientswho weigh more than 30 kg. For major burns, fluid resuscitation needs to be reassessed hourly based on the patient'surine output.

Rates of fluid administration should be altered based on the patient's response. If a patient presents after someperiod of delay and has not been resuscitated properly during that time, adjustments should be made in the calculatedfluid requirements to take these factors into account. Infants are at risk of developing hypoglycemia because of limitedglycogen stores; therefore, glucose levels should be monitored, and Ringer lactate solution with 5% dextrose shouldbe used for maintenance fluids. Assess response to fluid administration by measuring urine output via an indwellingurinary catheter. Monitoring sensorium, peripheral circulation, and blood pH is also helpful to assess the adequacy ofresuscitation.

Temperature regulation

As previously mentioned, children younger than 2 years lose heat and water more rapidly than older children and adultsbecause of their thinner layers of skin and insulating subcutaneous tissue; temperature regulation in these very youngchildren is partially based on nonshivering thermogenesis, which further increases metabolic rate, oxygenconsumption, and lactate production. Therefore, hypothermia in the pediatric burn patients should be avoided bypaying careful attention to increasing the room temperature, minimizing exposure time, and using radiant warmers, fluidwarmers, and other tools.

Systemic antibiotics

Prophylactic systemic antibiotics are not used in the treatment of burn patients because this increases the risk ofinfection with resistant organisms. Instead, the use of systemic antibiotics is reserved for the treatment of specificinfections, with antibiotics administered at the first sign of clinical infection. Antibiotic regimens are then modified asculture results and antimicrobial sensitivity results become available.

Burn wound cellulitis refers to infection spreading in dermal lymphatics in the nonburned skin surrounding a burn,usually occurring in the first few days after burn injury. Burn cellulitis is commonly caused by Streptococcus pyogenes.

Invasive burn wound sepsis leads to systemic toxicity with high fever, bacteremia, and a hyperdynamic circulatory statewith hypotension and cardiovascular collapse. Diagnosis can be made by either clinical examination, or by quantitativeburn wound cultures or burn wound histology.

Surgical Therapy

Devitalized skin and ruptured blisters should be debrided. Topical antibiotic therapy should be used to delay bacterialcolonization. Silver sulfadiazine cream (Silvadene) is a commonly used broad-spectrum topical antimicrobial cream. Itis applied as a thin layer with gauze dressings twice daily. It does cause transient neutropenia, which resolves even

with continued use of the agent.[3] Facial burns are usually treated with a combination antimicrobial product containingpolymyxin B, neomycin, and bacitracin (eg, Neosporin ointment) or an immunomodulating cream such as beta-Glucan(a cream that contains complex carbohydrate isolated from the cell wall of oats). The use of silver sulfadiazine creamis avoided on the central face because it may cause severe ocular irritation. Ear burns should be treated with mafenidecream (Sulfamylon) because the thin subcutaneous tissue in the ears predisposes to the development of chondritis.

Hydrotherapy provides wound and body cleansing with gentle removal of loose eschar and topical ointments. If used,hydrotherapy sessions are limited to 10-15 minutes once a day to decrease promotion of infection. Topical enzymepreparations such as Santyl (a collagenase-containing debriding ointment) can be applied to the burn surface tochemically debride devitalized tissue without injuring viable tissue. This allows earlier assessment of the wound bed,with fewer days to a clean wound bed and reepithelialization.

To avoid the need for painful dressing changes, artificial skin substitutes, such as Aquacel Ag and Acticoat, may beused for the treatment of partial-thickness burns. Aquacel Ag is a hydrofiber dressing in which antibacterial silver (Ag+)ions are incorporated into the dressing and released in a continuous sustained-release fashion for continuous topicalantimicrobial effects. The fibers in the dressing hydrate upon contact with the burn surface creating a viscous gel thatprevents fluid loss and traps bacteria. Once adherent to the burn surface, usually within 24-48 hours, the dressing canbe left in place for as long as 2 weeks, during which time reepithelialization is usually complete. If reepithelialization isnot complete by that time, the Aquacel Ag can be reapplied (see the image below).


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Aquacel Ag adherent to burn wounds.

Preoperative Details

Successful burn wound management in children demands conversion of open wounds to closed wounds as soon aspossible. The concept of early removal of burn eschar and immediate wound closure has gained widespreadacceptance. Evidence suggests that early eschar removal is effective in decreasing morbidity and improving themortality rate. Full-thickness burns (with the exception of very small injuries that are allowed to heal by contraction)should be grafted. The goal is to excise the wound within the first week of the injury. Additionally, deep partial-thicknessburns that take longer than 3 weeks to heal usually benefit from grafting, with less hypertrophic scarring and bettercosmetic results.

Intraoperative Details

Preoperatively, patients must be hemodynamically sound and have optimal acid-base, fluid, and electrolyte balance.Adequate blood must be available before considering excision and grafting. Preoperative antibiotics are not requiredunless patients have other compromising systemic diseases or invasive burn sepsis; however, a prophylactic dose ofa first-generation cephalosporin antibiotic may be used.

Attention to maintenance of body temperature at all times is extremely important. Burn excision involves tangentialremoval of thin slices of eschar until profuse pinpoint bleeding from a moist, viable, deep dermal surface orsubcutaneous fat is observed. Meticulous hemostasis is then obtained using epinephrine-soaked (1:100,000)sponges, topical spray thrombin, and electrocautery, followed by immediate grafting with thin sheets of autograft. Skingrafting involves harvesting partial-thickness pieces of skin from donor sites on unburned areas using a dermatome.The thickness of the harvested skin commonly is 8-12 thousandths of an inch, depending on the age and skinthickness of the patient. The grafts are then applied to the wound bed and secured.

Autograft skin is obviously preferred whenever possible. Unfortunately, patients with large burns may not have enoughautologous skin available for complete coverage. In such patients, burns can be excised and temporarily covered withnumerous biologic dressings (eg, cadaveric skin, pigskin) or skin substitutes. As more donor sites become available,the temporary wound covers are removed and the wounds are grafted. Studies have shown that growth hormone(0.15-0.2 mg/kg/d intramuscularly) can speed donor site healing, allowing more rapid reharvesting of healed donor

sites.[4, 5]

Meshed autografts are harvested from donor sites and passed through a meshing machine that cuts a series ofparallel offset slits in the grafts at various expansion ratios (eg, 1.5:1, 2:1). This technique allows expansion of the graftto cover a larger surface area. In addition, the interstices in the graft allow for drainage of fluids under the graft so thatthe grafts do not lift off their beds. Unfortunately, the meshed patterns of the grafts persist after healing and often leadto suboptimal cosmetic results.

Nonmeshed or sheet grafts are harvested the same way but are not passed through the meshing machine. The use ofsheet grafts leads to a better cosmetic result. Because the grafts do not expand, covering major areas with sheetgrafts alone is difficult. Nonetheless, sheet grafts should be used whenever possible, especially in highly visible andfunctional areas, such as the face, neck, hands, and joints. Sheet grafts should be inspected after approximately 48hours so that any underlying fluid can be aspirated to avoid loss of the graft. Dressings can be left in place for as longas 5 days if desired on meshed grafts, as long as no suspicion of infection is noted.

Follow-up

Avoidance of scarring and contracture is the best treatment.

Scar prevention

For burns that take longer than 3 weeks to heal, or for wounds that have been grafted, hypertrophic scarring can beminimized with the use of compression therapy with custom-made garments that apply 25-30 mm Hg pressure to allwounds. Gel pads can be added underneath or sewn into the garments to apply extra compression. Compressiontherapy is continued throughout the wound healing process (approximately 12-18 months). Lotion application withmassage therapy is used to keep the healed or grafted areas soft and supple.

Contracture prevention

Contractures refer to hypertrophic scar formation over joints that result in decreased range of motion. Aggressiveattention to occupational and physical therapy, with appropriate consultation, is necessary to ensure optimal results.


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Active and passive range of motion exercises are instituted and splints are worn at night and between exerciseperiods. Patients with burns are at risk for contractures are followed for years to monitor for the development of thesecomplications.

Psychological sequelae

Burn scarring can lead to significant psychological sequelae and the assistance of a trained psychologist orpsychiatrist can be an important addition to the overall care of these patients.

Patient education

For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient educationarticle Thermal (Heat or Fire) Burns.

Complications

Complications to surgery in patients with burns include bleeding, infection, or graft loss. If infection is suspected,dressings can be changed to include broad spectrum aqueous Sulfamylon solution.

Outcome and Prognosis

With the exception of infants, the prognosis for survival in children and adolescents is quite good. In the past decade,the size of a survivable injury has increased from 70% BSA burned to more than 95% BSA burned in children youngerthan 15 years.

A large, single-center study of pediatric burn patients analyzed the relationship between burn size and probability ofsurvival. A cohort of 952 severely burned patients of comparable age and sex distribution were studied. Resultssuggest that a burn size of roughly 60% BSA is a crucial threshold for postburn morbidity and mortality. Child burnvictims with greater than 60% BSA burns should be immediately transferred to a specialized burn center to combat the

increased risk of poor outcome associated with this burn size.[14]

Future and Controversies

Numerous areas in both the clinical and basic sciences are undergoing active research. One such area of interest isthe hypermetabolic response to severe burns and the association with increased energy expenditure and muscle-protein catabolism. Studies have investigated different mechanisms to attenuate the muscle-protein catabolism that

occurs frequently, despite appropriate nutritional support, in children with large burns.[6] These studies are promisingbecause attenuation of muscle-protein losses may improve strength and ability to recuperate.

A prospective randomized controlled trial of recombinant human growth hormone in combination with the beta-blockerpropanolol demonstrated attenuated hypermetabolism and inflammatory and acute phase responses after severe burn

injury.[4] Human growth hormone improves posttraumatic hypermetabolism, but its use alone is associated withhyperglycemia and increased free fatty acids and triglycerides. Concomitant administration of propanolol improved fatmetabolism and insulin sensitivity and avoided the adverse effects of recombinant growth hormone alone.

Another active area of research is in the development of cultured skin to treat very large burns. At present, culturedepidermal autografts (CEAs), which are grown from the patient's own uninjured epidermis, are commonly used.However, these grafts are very thin and fragile. In the future, cultured bilayered skin (epidermis and dermis) shouldlead to better functional and cosmetic results.

Contributor Information and DisclosuresAuthorGail E Besner, MD John E Fisher Endowed Chair in Neonatal Reseach, Director, Pediatric Surgical Research,Department of Surgery, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department ofSurgery, Ohio State University College of Medicine

Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy ofPediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association,American Medical Association, American Medical Women's Association, American Pediatric Surgical Association,Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of CriticalCare Medicine, Society of Surgical Oncology, and Society of University Surgeons



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Coauthor(s)Iyore Amy Otabor, MD Clinical Instructor House Staff, Department of General Surgery, The Ohio State UniversityCollege of Medicine

Iyore Amy Otabor, MD is a member of the following medical societies: American College of Surgeons, AmericanMedical Student Association/Foundation, and Student National Medical Association


Specialty Editor BoardDenis Bensard, MD Director of Pediatric Surgery and Trauma, Attending Adult and Pediatric Acute Care Surgery,Attending Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, Universityof Colorado School of Medicine

Denis Bensard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy ofPediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for AcademicSurgery, International Society for Minimally Invasive Cardiac Surgery, Society of American Gastrointestinal andEndoscopic Surgeons, Society of Laparoendoscopic Surgeons, Society of University Surgeons, and SouthwesternSurgical Congress


Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College ofPharmacy; Editor-in-Chief, Medscape Drug Reference


Michael G Caty, MD Professor of Surgery and Pediatrics, State University of New York at Buffalo; ConsultingStaff, Department of Pediatric Surgery, Children's Hospital of Buffalo

Michael G Caty, MD is a member of the following medical societies: American Academy of Pediatrics, AmericanCollege of Physician Executives, American College of Surgeons, American Medical Association, AmericanPediatric Surgical Association, Association for Academic Surgery, and Association for Surgical Education


H Biemann Othersen Jr, MD Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery,Medical University of South Carolina

H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, AmericanAcademy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, AmericanCancer Society, American College of Surgeons, American Medical Association, American Pediatric SurgicalAssociation, American Society for Parenteral and Enteral Nutrition, American Surgical Association, AmericanThoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society ofCritical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern MedicalAssociation, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association


Chief EditorHarsh Grewal, MD, FACS, FAAP Clinical Professor of Surgery, Temple University School of Medicine; Chief,Division of Pediatric Surgery, Cooper University Hospital

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics,American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education,Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric EndosurgeryGroup, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons,and Southwestern Surgical Congress


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Lowell G, Quinlan K, Gottlieb LJ. Preventing unintentional scald burns: moving beyond tap water. Pediatrics.

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O'Neill TB, Rawlins J, Rea S, Wood F. Complex chemical burns following a mass casualty chemical plant2.


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incident: How optimal planning and organisation can make a difference. Burns. Feb 20 2012;[Medline].

Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazenedressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. Sep

2011;4(3):183-7. [Medline]. [Full Text].

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Jeschke MG, Finnerty CC, Kulp GA, Przkora R, Micak RP, Herndon DN. Combination of recombinant humangrowth hormone and propanol decreases hypermetabolism and inflammation in severely burned children.Pediatr Crit Care Med. Mar 2008;9:209-216. [Medline].

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Coruh A, Yontar Y. Application of Split-Thickness Dermal Grafts in Deep Partial- and Full-Thickness Burns: ANew Source of Auto-Skin Grafting. J Burn Care Res. Nov 10 2011;[Medline].

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Chan MM, Chan GM. Nutritional therapy for burns in children and adults. Nutrition. Mar 2009;25(3):261-9.

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Besner GE. Burns. In: Glick PL, Pearl RH, Irish MS, et al, eds. Pediatric Surgery Secrets. ed. Philadelphia,

PA: Hanley & Belfus; 2000:246-52.

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Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J

Med. Oct 25 2001;345(17):1223-9. [Medline].

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Hildreth M, Gottschlich M. Nutritional support of the burned patient. In: Herndon D, ed. Total Burn Care.

Philadelphia, PA: WB Saunders Co; 1996:237-45.

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Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Besner G. A Silver Impregnated Antimicrobial DressingReduces Hospital Length of Stay for Pediatric Burn Patients. J Burn Care Research. May-Jun

2007;28:409-411. [Medline].

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Peters DA, Verchere C. Healing at Home: Comparing Cohorts of Children with Medium-Sized Burns Treatedas Outpatients With In-Hospital Applied Acticoat (TM) to those Children Treated as Inpatients with SilverSulfadiazine. J Burn Care Research. Mar-Apr 2006;27:198-201. [Medline].

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Sheridan RL, Weber JM, Schnitzer JJ, et al. Young age is not a predictor of mortality in burns. Pediatr Crit

Care Med. Jul 2001;2(3):223-224. [Medline].

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Kraft R, Herndon DN, Al-Mousawi AM, Williams FN, Finnerty CC, Jeschke MG. Burn size and survivalprobability in paediatric patients in modern burn care: a prospective observational cohort study. Lancet. Mar

17 2012;379(9820):1013-21. [Medline].

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Emergency Escharotomy

Author: Neelu Pal, MD; Chief Editor: Erik D Schraga, MD more...

Updated: Dec 13, 2011

Overview

Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass ofburnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. Thisis caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of theextremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse ofthe contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of30 mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to preventtissue death.

The circumferential eschar over the torso can lead to significant compromise of chest wall excursions and can hinderventilation. Abdominal compartment syndrome with visceral hypoperfusion is associated with severe burns of theabdomen and torso. Similarly, airway patency and venous return may be compromised by circumferential burnsinvolving the neck.

Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become morecompliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissueinjury or functional compromise (see image below). For more information on burn treatment, see eMedicine articleBurns, Rehabilitation and Reconstruction.

Escharotomy to release the chest wall and allow for ventilation of the patient.

Escharotomy is considered an emergent procedure in burn treatment protocols. However, it rarely needs to beperformed in the emergency department at the time of initial presentation of the severely burned patient. Advancedventilation methods allow the patient to be stabilized to allow for expeditious transfer to the intensive care unit or the

surgical suite, where the procedure can be performed under more controlled circumstances.[1, 2] For more information,see eMedicine article Burns, Resuscitation and Early Management.

Indications

Indications for emergency escharotomy are the presence of a circumferential eschar with one of the following:


News

Reference

Education

MEDLINE

Emergency Escharotomy http://emedicine.medscape.com/article/80583-overview

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Impending or established vascular compromise of the extremities or digits1.

Impending or established respiratory compromise due to circumferential torso burns[3]2.

Severely burned extremities should be elevated and range of motion exercises performed every 15-30 minutes astolerated by the patient. This can help to minimize tissue edema and elevated tissue pressures.

Neurovascular integrity should similarly be monitored frequently and in a scheduled manner. Capillary refilling time,

Doppler signals, pulse oximetry, and sensation distal to the burned area should be checked every hour.[4] Limb deepcompartment pressures should be checked initially to establish a baseline. Subsequently, any increase in capillary refilltime, decrease in Doppler signal, or change in sensation should lead to rechecking the compartment pressures.Compartment pressures greater than 30 mm Hg should be treated by immediate decompression via escharotomy and

fasciotomy, if needed.[5, 6] A decision-making algorithm is shown in the image below.

Decision-making algorithm for escharotomy in severely burned extremities.

Contraindications

Patients who have established irreversible gangrene of the extremity or digit in association with a circumferential ornear-circumferential eschar would not likely benefit from an escharotomy. This scenario is likely to be encountered inpatients who have been managed nonoperatively for a prolonged period of time, during which the neurovascular statusof the extremity involved was not monitored adequately. In this group of patients, the risks and potential complicationsof performing an escharotomy are to be weighed carefully against the benefits.

Anesthesia

In the severely burned patient who is obtunded and intubated, no anesthesia is required because the eschar is

nonviable tissue with complete destruction of nerve endings.[7]

Patients who are awake or conscious require sedation and, occasionally, general anesthesia, to allow theprocedure to be completed adequately. For more information, see Procedural Sedation.

Equipment

Sterile drapesPovidone-iodine solutionElectrocautery: Escharotomy can result in substantial blood loss; hence, it should be performed usingelectrocautery and in a controlled environment such as the operating room or the intensive care unit.Dressing materials

Positioning

Position the patient supine.Maintain the ability to move the patient into lateral positions to allow circumferential access to the extremity ortorso, as needed.

Technique

Clean the proposed surgical site with povidone-iodine solution and drape with sterile drapes.Use electrocautery to create incisions in the eschar up to the level of the subcutaneous fat.Severely burned limbs may require performance of fasciotomy concomitantly with the escharotomy.

This may be determined preoperatively by measurement of compartment pressures greater than 30


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mm Hg.Compartment pressures can be obtained intraoperatively after completion of the escharotomy. Ifelevation of pressure above 30 mm Hg is persistent, a fasciotomy should be performed.

Carry the incision of the eschar down through to the level of the subcutaneous fat. An immediate release intissue pressure is experienced as a discernible popping sensation.Carry the incisions approximately 1 cm proximal and distal to the extent of the burn.Areas overlying joints have densely adherent skin, and the incisions should extend across joints to allow fordecompression of neurovascular structures. Take care to avoid damage to the neurovascular bundles that run

superficially and near joints.[5]

Make escharotomy incisions for the chest, neck, and limbs as shown in the diagram below.

Diagrammatic representation of escharotomy incisions over the chest, neck, and limbs.

Make escharotomy incisions for the digits as shown in the diagram below.

Diagrammatic representation of escharotomy incisions over the digits.

Bleeding from escharotomy incisions should be controlled by use of the electrocautery.The resulting wounds are a potential source of infection and should be treated, as the burn wound, withapplication of topical antimicrobial and dressings.Adequacy of the escharotomy can be tested after completion by checking capillary filling pressures, using a

handheld Doppler, and by checking compartment pressures.[8]

Improvement in flow and decrease in compartment pressures indicate that the procedure is adequate.Persistent low Doppler signals or elevated compartment pressures indicate inadequate release oftissue pressure and a need for additional escharotomy incisions and, possibly, the addition offasciotomy.

Pearls

Escharotomy incisions for the limbs should be carried to the level of the thenar and hypothenar eminences forthe upper extremity and to the level of the great toe medially and the little toe laterally for the lower extremity.Limb escharotomy incisions run in close proximity to superficial veins, and these veins should be identified andpreserved, if possible. If the escharotomy incision transects these veins, adequate hemostasis should beensured using electrocautery or ligation.Digital escharotomy should be performed by a practitioner with experience in hand surgery for burns wheneverpossible. The locations of the incisions for decompression are near the digital neurovascular bundles, andinjury to these can lead to profound and permanent loss of function.

Complications

Complications of inadequate decompression[9] or of not performing an escharotomy when indicated are severe.[10]


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They include the following:

Muscle necrosisNerve injuryGangrene resulting in amputation of the limb or digitsRespiratory compromise due to inadequate ventilation as a result of compressive effect of chest and uppertorso burnsAbdominal compartment syndrome with visceral hypoperfusion as a result of abdominal wall and upper torso

burns[11]

Systemic complications of inadequate decompression including myoglobinuria, renal failure, hyperkalemia, andmetabolic acidosis

Complications of an escharotomy are as follows:

Excessive blood lossInadvertent fasciotomy: This results in exposure of the underlying viable tissue, which can become desiccated.Incision/injury to the underlying healthy tissue including neurovascular structures, especially in the extremitiesand digitsBacteremia: Underlying tissue may be infected, and the manipulation can result in bacteremia and septic shock.If underlying infection is suspected, the escharotomy should be performed under antibiotic coverage.Infection of the open escharotomy wounds: These wounds are treated with the same degree of care (withdressings and application of antimicrobial agents) as the burns wounds. These wounds also contribute to theongoing insensate fluid losses in a manner similar to the burns wounds.

Contributor Information and DisclosuresAuthorNeelu Pal, MD General Surgeon

Neelu Pal, MD is a member of the following medical societies: American College of Surgeons, American MedicalAssociation, and Society of American Gastrointestinal and Endoscopic Surgeons


Specialty Editor BoardMary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College ofPharmacy; Editor-in-Chief, Medscape Drug Reference


Chief EditorErik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency MedicalAssociates


Additional ContributorsThe authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature reviewand referencing for this article.

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Piccolo NS, Piccolo MS, Piccolo PD, Piccolo-Daher R, Piccolo ND, Piccolo MT. Escharotomies,fasciotomies and carpal tunnel release in burn patients--review of the literature and presentation of analgorithm for surgical decision making. Handchir Mikrochir Plast Chir. Jun 2007;39(3):161-7. [Medline].

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Roberts JR, Hedges JR, et al. Burn care procedures. In: Roberts JR, ed. Clinical Procedures in Emergency

Medicine. Vol 1. 4th ed. USA: Saunders; 2004:39.

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Burd A, Noronha FV, Ahmed K, Chan JY, Ayyappan T, Ying SY, et al. Decompression not escharotomy inacute burns. Burns. May 2006;32(3):284-92. [Medline].

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Feldmann ME, Evans J, O SJ. Early management of the burned pediatric hand. J Craniofac Surg. Jul

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Saffle JR, Zeluff GR, Warden GD. Intramuscular pressure in the burned arm: measurement and response toescharotomy. Am J Surg. Dec 1980;140(6):825-31. [Medline].

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Brown RL, Greenhalgh DG, Kagan RJ, Warden GD. The adequacy of limb escharotomies-fasciotomies afterreferral to a major burn center. J Trauma. Dec 1994;37(6):916-20. [Medline].

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Gravante G, Delogu D, Sconocchia G. "Systemic apoptotic response" after thermal burns. Apoptosis. Feb

2007;12(2):259-70. [Medline].

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Oda J, Ueyama M, Yamashita K, et al. Effects of escharotomy as abdominal decompression oncardiopulmonary function and visceral perfusion in abdominal compartment syndrome with burn patients. J

Trauma. Aug 2005;59(2):369-74. [Medline].

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Deitch EA. The management of burns. N Engl J Med. Nov 1 1990;323(18):1249-53. [Medline].12.


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Documents

Surgical Treatment of Burns