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Abstract Summary Burn-related injuries are a major global public health problem. The risk of burns is highest in low income and lower middle income countries. In high income countries, an increased risk of burns is found in minority populations, and in lower socioeconomic households. Flame/fire and scalds are the most common type of burn in adults and children. Children and elderly are at the highest risk of unintentional burns. While most burns are unintentional, child abuse, deliberate self-burning and personal violence are not uncommon. Approximately 90 percent of all burn-related deaths occur in lower middle income (LMC) or low income countries (LIC), while 3 percent occur in high income countries (HIC). For those who survive the burn injury, there is the added burden of a permanent disability and economic hardship for the victim and the family. The local and systemic inflammatory response to thermal injury is extremely complex, resulting in both local burn tissue damage and deleterious systemic effects on all other organ systems distant from the burn area itself. Although the inflammation is initiated almost immediately after the burn injury, the systemic response progresses with time, usually peaking 5 to 7 days after the burn injury. A burn is defined as a traumatic injury to the skin or other organic tissue primarily caused by thermal or other acute exposures. Cutaneous burns are classified according to the depth of tissue injury. A thorough estimation of burn size is essential to guide therapy. The extent of burns is expressed as the total percentage of body surface area (TBSA). The estimation of percent total body surface area includes partial-thickness, full-thickness, and fourth degree burns. Superficial burns are not included in the TBSA burn assessment. The most accurate method of assessment of TBSA burn in children and adults is the Lund-Browder chart. Multiple organ dysfunction syndrome (MODS) is a progressive disorder that commonly occurs in acutely ill patients and exists in a continuum with the systemic inflammatory response syndrome (SIRS) which affects most patients with a severe burn, with or without an infection. The risk of MODS increases with burn wounds >20 percent TBSA, increasing age, Summary 112 male gender, sepsis, hypoperfusion, and underresuscitation. Immediate fluid resuscitation upon admission to the emergency department is the fundamental approach to preventing acute kidney injury. Early renal failure can occur as a consequence of underperfusion and underresuscitation. A second period of risk occurs 2 to 14 days after the initial resuscitation, and is most likely related to sepsis. Gut mucosal atrophy occurs in the absence of intraluminal feeds and is another cause of gastrointestinal failure after severe burn injury. Early enteral nutrition, started 24 to 48 hours after burn injury, is one of the only therapies shown to decrease this complication. Depression and post-traumatic stress disorder (PTSD) are the most common psychologic problems, occurring in 13 to 23 percent and 13 to 45 percent of patients, respectively. Management of a patient with a severe burn injury is a long-term process that addresses the local burn wound care as well as the systemic, psychologic, and social consequences of the injury. The patients that should be transferred to a burn center as soon as stabilized include: Partial-thickness burns more than 10 percent of the total body surface area (TBSA) and burns involving the face, hands, feet, genitalia, perineum, and/or major joints. Concomitant burns and trauma (eg, fractures) in which the burn injury poses the greater immediate risk of morbidity and mortality. If the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment is necessary in these cases and should be in conjunction with the regional medical control plan. Acute management in the ICU includes continuation of respiratory support, fluid resuscitation, cardiovascular stabilization, pain control, and local management of burn wounds initiated in the emergency department. The goal of the ICU care is to maintain end-organ perfusion and prevent burn shock. Inpatient management focuses on wound healing, enteral nutrition, and rehabilitation. Long-term management includes management of longterm wound complications (eg, contractures), optimization of nutritional support, and psychosocial support to return to work and for re-immersion into society. Summary 113 The goal of reconstructive surgery for the burn patient is to restore function then cosmesis. There are special challenges for reconstruction of burns. A balance must be achieved between immobilization to allow for skin grafts or tissue flaps to heal and mobilization to restore function. Split thickness skin grafts (STSG) are more versatile than full thickness skin grafts (FTSG) and are used to reconstruct large burn wound areas and close donor flap sites. FTSG result in a more satisfactory esthetic appearance due to their pliability. The use of dermal regeneration templates (biosynthetic skin substitutes) has increased the number of reconstructive options for burn surgeons. The common purpose of these skin substitutes is to replicate the properties of normal skin by adding a dermal component to the reconstruction that is supplemented with a thin split skin autograft. Tissue expansion is a technique that expands an area of skin in preparation for its use as coverage of a burn defect or contracture. Tissue expansion occurs by prolonged, gradual stretching of skin by inserting prosthesis into an area of unburned skin immediately adjacent to the area to be covered. Flap reconstruction is the ideal option if tissues are available. Flaps for reconstruction can be classified according to circulation, composition, contiguity, and contour. STSG donor sites are managed intra-operatively by meticulous hemostasis and infiltration of a long lasting anesthetic to provide longterm postoperative pain relief. Covering the STSG donor site wounds (DSW) with a hydrocolloid dressing when such products are available because of the faster re-epithelialization. For clinical settings where hydrocolloid dressings are not available, alternative dressings include polyurethane film, alginate, or paraffin gauze. FTSG donor sites and flap defects are managed by meticulous hemostasis and primary wound closure, without tension. Facial transplantation procedure is a new and controversial reconstructive technique that offers hope to patients with severe facial burns, along with a lifetime requirement of immunosuppressive therapy. |