Atlas Lâm Sàng Về Quản Lý Và Điều Trị Bỏng (Clinical Atlas of Burn Management)

Clinical Atlas of Burn Management
44
Fig. 3.4: Another patient seen applying face cream to the
scald burn on forearm as it is soothing because of its water
content
Fig. 3.5: Toothpaste applied on silencer burn on leg
Fig. 3.6: Gentian violet applied on forearm of an infant
following scalds and it is causes epithelial staining. The stained
epithelium gets denuded once the blister gets ruptured
Fig. 3.7: Two weeks post-burn picture showing Gentian violet
painted over full thickness burns over the arm masking the
diagnosis in the initial phase. The separation of the gentian
violet stained eschar indicates the full thickness nature of
the injury

Initial Management of Burns
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Fig. 3.8: ‘Rattan jyot’ a favourite home remedy amongst the villagers is seen applied to burns in the belief that it would
allow scarless healing and patient reported 10 days post-burns. Though the area has not got infected and can be seen to be
healing, it has been reported to cause wound sepsis
BURN SURFACE AREA ASSESSMENT
Fig. 3.9: Wallace’s ‘Rule of 9’ divides body into anatomic regions that
represent 9 percent or multiples of 9 percent of the total body surface area
•
Head and neck, 9 percent
•
Front of trunk, 18 percent
•
Back of trunk, 18 percent
•
Upper limb each, 9 percent
•
Lower limb each, 18 percent
•
Perineum and external genitalia, 1 percent

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Lund and Browder’s Chart
Table 3.1: Lund and Browder’s chart showing changes in body surface area (%) with age
Infant
Age 1 yr
Age 5 yr
Age 10 yr
Age 15 yr
Adult
Head
19
17
13
11
9
7
Neck
2
2
2
2
2
2
Anterior trunk
13
13
13
13
13
13
Posterior trunk
13
13
13
13
13
13
Buttock
2.5
2.5
2.5
2.5
2.5
2.5
Perineum
1
1
1
1
1
1
Thigh
5.5
6.5
8
8.5
9
9.5
Leg
5
5
5.5
6
6.5
7
Foot
3.5
3.5
3.5
3.5
3.5
3.5
Upper arm
2.5
2.5
2.5
2.5
2.5
2.5
Lower arm
3
3
3
3
3
3
Hand
2.5
2.5
2.5
2.5
2.5
2.5
The most accurate method for burn surface area assessment is the age-specific Lund-Browder’s chart that
compensates for the changes in body proportions with growth. The burn area is drawn on a cartoon
figure, and an associated age-specific table is used to calculate the body surface area involved. This is especially
valuable for pediatric burns.
Rule of ‘Five’
Fig. 3.10: Lynch and Blocker developed a formula for estimating the extent of burns in children in multiples of ‘5’. It works
very well in infants where head and neck, anterior and posterior aspects of trunk are 20 percent each and each limb
constitutes 10 percent. For older children, this is slightly modified. The head, posterior trunk and lower limbs are 15 percent
each, anterior trunk is 20 percent and each upper limb is 10 percent

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Palmar Surface
The surface area of a patient’s palm (including fingers) is roughly 0.8 percent of total body surface area,
though it is taken as 1 percent for all practical purposes. Palmar surface area can be used to estimate
relatively small burns (<15% of total surface area) or very large burns (> 85%, when unburnt skin is
counted) or areas of irregular or nonconfluent burns.
Fig. 3.11: Palmar surface of patient's hand with fingers closed represents 1 percent of body surface area in both adults
and children and can be used to estimate relatively small burns or areas of nonconfluent burns
FORMULA FOR CORRECTION OF DIFFERENCES IN BODY SURFACE AREA IN CHILDREN
Percentage of area given for adult head and neck + (12 – Age in years) = Percentage of area
for head and neck in child
Percentage of area for both limb in adult – (12 – Age in years) = Percentage of area for Lower limb in child
For example, At 8 years the head and neck constitutes 9 + (12 – 8) = 13% of total body surface area. At 8 years
both lower limbs constitutes 36 – (12 – 8) = 32% of total body surface area, i.e. 16% for each lower limb.
BURN UNIT ADMISSION CRITERIA
•
Partial thickness burns greater than 15 percent total body surface area (TBSA) in adults and >10%
in children
•
Burns that involve the face, hands, feet, genitalia, perineum
•
Full thickness burns >1 percent in children and >3% in adults
•
Electrical burns, including lightning injury
•
Chemical burns
•
Inhalation injury
•
Burn injury in patients with pre-existing medical disorders that may complicate management,
prolong recovery or affect mortality
•
Any patients with burns and concomitant trauma (such as fractures) in which the burn injury
poses the greatest risk of morbidity or mortality.
•
Burned children if abuse is suspected.
All other patients can be treated on outpatient basis

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Fig. 3.12: Burn ICU at Safdarjung Hospital, New Delhi
(India) where all patients with moderate to severe burns need
to admitted for initial management. It should be well equipped
with multinodular monitors, ventilator, central oxygen supply
and suction facility, etc.
Fig. 3.13: All admitted patients should be catheterized and
central line to be inserted as first line of management. A
central line can be used not only for large fluid administration
but also for administering hyperosmotic fluids which can
otherwise cause thrombophlebitis in peripheral veins and can
also monitor the central venous pressure
Fig. 3.14: Femoral line may have to be put over a burned
area at times in case of extensive burns though it is not
advisable and should be avoided at all costs if possible or it
should be removed as soon as another line through normal
skin is secured
Fig. 3.15: Conventional venesection through long saphenous
vein above the medial malleolus used to be a favourite site
in the past but with the availability of central lines this should
be avoided as far as possible because it increases the risk of
thrombophlebitis and subsequent thromboembolism as it
delays the ambulation of the patient. This should be used
only in case of dire emergency when no other vein can be
cannulated and should be changed to a central line as soon
as shock is overcome

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49
Fig. 3.16: A multichannel femoral line is preferred as
multiple fluids can be given through single line and blood
sample for investigation can also be obtained from same
line thus avoiding repeated venous puncture for frequent
blood investigations. One of the channels can also be used
for invasive monitoring of cardiac output, blood pressure,
etc. In most of the severe burns superficial veins are usually
collapsed or not visible due to edema later and therefore
deeper veins have to be used for sampling. Multiple punctures
of deeper veins can therefore be avoided by using this
multichannel central catheter
Fig. 3.17: A subclavian line is also very useful for large
intravenous fluid administration
Fig. 3.18: An extensive burns patient in ICU is put on IV
fluids and catheterized for monitoring immediately, before
dressing the wounds
Fig. 3.19: Case of perineal burn due to contact with high
voltage wires with partial loss of penis. It is essential to
catheterize these patients to maintain whatever urethral
patency is present for reconstruction later and also for
monitoring the patient. In case catheterization is not possible,
a suprapubic cystostomy can be done followed by retrograde
catheterization

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Fig. 3.20: Another case of electric contact burn in penoscrotal
region with total loss of penis. Suprapubic cystostomy done
to divert urine
Fig. 3.22: High colored concentrated urine indicating
inadequate resuscitation
Fig. 3.21A: Chest trauma is very common in patients of
electric contact burn who are thrown at the distance due to
the electric shock, leading to fracture ribs and as seen in this
case it has manifested with pneumothorax for which a chest
tube has been inserted. Apart from the burn overall assessment
of the patient to rule out other injuries is of utmost
importance
Fig. 3.21B: Same patient with burn in forearm and hand
along with accompanying fracture of radius due to the fall,
which requires to be fixed externally with a fixator in order to
manage burns successfully

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Fig. 3.23: Small amount of dark brownish red urine in a
case of electric contact burn with gangrenous changes in
arm and hand, indicating myoglobinuria suggestive of renal
insult. The myoglobin pigments released from traumatized
muscles can cause blockage of the renal tubules eventually
leading to acute renal shutdown if not treated in time. Electric
burn patient requires higher amount of fluid for resuscitation
in order to get higher urine output to flush the kidneys
(approximately 4 ml/kg/hr) along with mannitol and
alkalinization of urine
Fig. 3.25: Multinodular vital signs monitor should be present
on every bed so as to display all the major parameters for
controlled monitoring and diagnosing any problem early
Fig. 3.24: Gradually improving color and amount of urine
(I to IV) with treatment given for myoglobinuria in the form
of rapid infusion of IV fluids, mannitol and sodium
bicarbonate. This prevents blockage of the renal tubules

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RESUSCITATION OF FLUID
Table 3.2: Resuscitation formulas (Adult) for first 24 hours
Name
Formula
Timing
Parkland Formula
4 ml/kg/%BSA RL
Half in first 8 hours, half in next 16 hours
Modified Brooke’s Formula 2ml/kg/% BSA of RL + 2500 ml 5%D Half in first 8 hours and half in next 16 hours
The calculated volume is then given at different rates; first 8 hours—half of total to be given, next 16
hours—half of total to be given. In next 24 hours—half of total fluid of first day to be given. Lactated
Ringer’s solution (RL) is the fluid of choice except in children under 2 years, who should receive 5 percent
dextrose with Ringer’s lactate. The goal is to maintain urine outputs in the range of 1.0 to 1.5 ml/kg/hr.
INHALATION INJURY
Suspicion Criteria
•
Individuals who sustained injury in a closed space
•
Patients with extensive burns or with burns of the face
•
Patients who were unconscious at the time of injury
•
Patients with singed nasal and facial hair, dyspnea, hoarseness or wheezing, tachypnea, cyanosis, stridor,
rhonchi or crackles
•
Patients who are coughing up carbonaceous sputum
•
Explosions with burns to head and torso
•
Carboxyhemoglobin level > 10 percent.
Fig. 3.27: Close up view of a patient who sustained burns
due to burning kerosene oil spilling on his face from the
nozzle of the stove leading to deep burns of nose with sign of
nostril mucosa and hairs and burns of lip and oral mucosa.
These are usually associated with inhalation injury
Fig. 3.26: Patient with deep burns of face and oral mucosa
showing edema of lips and oral mucosa, singening of nasal
mucosa and hair indicating inhalational injury

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PATHOPHYSIOLOGY OF INHALATION INJURY
Diagnostic Tests for Inhalation Injury
•
Measurement of asphyxiants in the blood (carboxyhemoglobin, cyanide)
•
Arterial blood gases
•
Chest roentgenogram
•
Endoscopic examination (laryngoscopy, nosophanygoscopy and bronchoscopy)
•
Radionuclide scanning
•
Pulmonary function tests (spirometry).
GRADING ON THE BASIS OF BRONCHOSCOPIC CRITERIA
Grade
Features
0
No signs or symptoms referable to the respiratory tract. Absence of carbonaceous deposits,
erythema, bronchorrhea or obstruction (No injury)
1
Signs and symptoms limited to the upper respiratory passages, including mild laryngitis.
Minor or patchy areas of erythema, carbonaceous deposits in peripheral or distal bronchi
(Mild injury)
2
Evidence of involvement of the trachea and bronchi or abnormal signs in the lungs other
than those of frank consolidation. Moderate degree of carbonaceous deposits, erythema,
bronchorrhea, with or without compromise of bronchi (Moderate injury)
3
Dyspnea, cyanosis, wheezing or transient stridor or frank signs of consolidation. Severe
inflammation with friability, copious carbonaceous deposits, bronchorrhea, bronchial
obstruction (Severe injury)
4
Evidence of extensive pulmonary involvement or of obstruction to the airways necessitating
tracheostomy or resulting in severe asphyxia. Evidence of mucosal sloughing, necrosis,
endoluminal obstruction (Massive injury)

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ALGORITHM FOR MANAGEMENT OF INHALATIONAL INJURY

Initial Management of Burns
55
Fig. 3.28: Facial burns with upper airway injury requires
100% oxygen inhalation by mask
Fig. 3.29: Sometimes nasal prongs are preferred for
oxygenation as patient with facial burns and severe edema
does not tolerate mask
Fig. 3.30: Case of inhalational injury was intubated because
patient could not maintain oxygen saturation on mask alone
and had abnormal blood gas values
Fig. 3.31: Inhalational injury patient even with minor to
moderate burns as in this case require admission to ICU and
immediate intubation and mechanical ventilation till
manifestations of inhalation injury are controlled

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Fig. 3.33: Patient with severe inhalational injury who came
after 24 hours. He could not be intubated because of severe
edema and tracheostomy had to be done for ventilation.
The patient improved after 5 days and was ready to be
weaned off from the tracheostomy
Fig. 3.34: Another patient with tracheostomy. Gross edema
of face, lips and oral mucosa with visible frothing from the
mouth indicates inhalational injury in which prophylactic
assisted ventilation can improve the condition of the patient
faster otherwise the chances of respiratory complications are
very high which can increase the mortality
Fig. 3.32: Adult patient with respiratory burns with severe
upper airway edema not allowing endotracheal intubation
and warranting a life saving tracheostomy

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Fig. 3.35A: Infant with 30 percent TBSA with facial burns in the
first 24 hours with increasing facial edema
Fig. 3.35B: Same patient had to be intubated and put on
a ventilator for respiratory distress within 48 hours

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ALGORITHM FOR MANAGEMENT OF COMPARTMENT SYNDROME IN EXTREMITIES

Initial Management of Burns
59
Fig. 3.37: Circumferential full thickness burns on chest
hindering the chest expansion. Escharotomy incisions given
longitudinally and transversely to improve the ventilation
Fig. 3.38A: Tight deep circumferential burns in forearm
compromising circulation to the limb and hand. Early
fasciotomy along the whole length of arm being given to
release the pressure on the underlying structures
Fig. 3.36A: Full thickness scalds in a 1-year-old baby
compromising the circulation to the hand with inadequate
escharotomy incisions
Fig. 3.36B: Escharotomy incisions being extended to
dorsum of hand extended all along the arm to improve the
circulation to the hand thus saving the limb

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Figs 3.38B and C: Fascia can be seen divided in the proximal muscular compartment of the forearm. In distal forearm
which contains only tendons and no muscle bellies a plain escharotomy incision at subcutaneous level usually suffices.
Release of the constricting effect improves the circulation which is shown by the appearance of the dilated veins
Fig. 3.39A: In electrical contact injury medial fasciotomy
incision has to be extended proximally in the non-burnt skin
also to relieve the compartment pressure since the passage
of electric current through the neurovascular bundles and
muscles causes inflammatory edema and compartment
syndrome. Full thickness skin burn is seen in the distal forearm
but there was gross edema in the proximal forearm
Fig. 3.39B: Similar incision on lateral side of forearm.
Timely incisions saved the hand of the patient
B
C

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Fig. 3.41A: Third degree circumferential flame burns to
upper arm of an infant because of inability of the infant to
protect himself. The hand is almost gangrenous and the
inelastic eschar in the arm can prevent the burnt skin from
expanding as edema develops which can compromise the
circulation to the entire limb leading to loss of entire arm
Fig. 3.41B: Escharotomies along entire length of arm are
mandatory in such circumferential burns to save as much of
the limb as possible
Fig. 3.40A: Electrical contact burn with entry point in palm
is seen with tightness around the wrist and clawing of fingers
because of edema. Damage in electrical injuries is usually
progressive for 2 to 3 days following burns. Marking done for
release of carpal tunnel and forearm
Fig. 3.40B: Same patient after incision given to release the
pressure. Grossly necrotic areas are not visible. Repeat
debridements may be required. Early vascularized cover is
essential in such cases to save the underlying neurovascular
structures and tendons which have got exposed

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Fig. 3.42A: Contact electrical burns with entry point in foot
causing compartment syndrome in leg requiring releasing
fasciotomy incisions to re-establish blood flow to the limb
Fig. 3.42B: Releasing incisions on other side of foot
Fig. 3.43: Case of high voltage electrical contact burn with
entry in hand and exit points in both feet developed gangrene
of both lower legs despite releasing fasciotomy incisions given
on both sides. A bilateral below knee amputation was
required
Fig. 3.44: Another patient of high voltage electrical burn
with fasciotomies done. Necrosis of muscles and underlying
other structures can be noticed. The hand could not be saved
in this case because of the severity of the injury. However
the fasciotomy helps in reducing the level of amputation

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Fig. 3.45C: Five days after a timely fasciotomy the hand
as well as the arm was saved from further damage
Fig. 3.45A: Entry point of high voltage current in hand
with deep burns in forearm required fasciotomy to relieve
the compartment pressure created by the muscle edema.
Incision seen on lateral side with sutures used to ligate
superficial veins
Fig. 3.45B: Medial incision in same arm

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Fig. 3.46A: An infant with full thickness circumferential
burns of both lower legs and charring of both feet due to
child lying unattended in a ‘jhuggi’ fire. Fasciotomy incisions
given to prevent secondary vascular damage and save as
much of limb as possible
Fig. 3.46B: Same patient after 2 weeks of conservative
dressings showing raw areas starting to granulate after the
separation of the full thickness eschar

Burn Wound Management 4

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66
Fig. 4.1A: Superficial dermal burns of forearm showing
blisters more than 5 cm size which require immediate attention
because the plasma exudates inside the blister form a thick
coagulum which is a good culture medium for micro-
organisms and is also difficult to evacuate later on
Fig. 4.1B: Blister being incised for draining fluid and
deroofing because blisters more than 5 cm are likely to get
ruptured during dressing and hence high chance of protein
rich fluid getting infected which can convert superficial
wounds to deeper wounds
Fig. 4.1C: Pink viable dermis visible after deroofing the
blister showing the thick coagulum which fills the blister.
This protein rich fluid is also believed to impair the local
immunity and retards fibrinolytic process thus delaying wound
healing
Figs 4.1D and E: Tenth day post-burn photograph of the
same forearm and hand which have healed well
D
E

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67
Fig. 4.2: Another patient with large blisters which are being
ruptured with a needle to drain the fluid and leaving the
epithelium of the blister to stay on the wound surface as a
biological dressing. This epithelium is dead therefore it cannot
act as a barrier for microorganism penetration. The main
advantage of this procedure is that the nerve endings on the
raw wound surface get a cover and the pain is much less
Fig. 4.3A: Eighty-five percent industrial burns following boiler
explosion in a factory. The usual picture is of mixed superficial
and deep burns
Fig. 4.3B: Debridement of all the loose dead skin before
dressing the part

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Fig. 4.4: Ruptured blister skin being removed and the
thick coagulum can be seen sticking to the bed
Fig. 4.5: In industrial accidents hand burns are usually very
deep as can be seen following the debridement of the loose
burnt skin
Fig. 4.6A: Closed dressing of extremities is preferred after
debridement and cleaning of loose skin and blisters. Upper
limb ready for dressing
Fig. 4.6B: After debridement a 1 cm thick layer of silver
sulphadiazine cream 1 percent is applied to the surface. 1
percent SSD is still the most preferred antimicrobial cream
for primary burn wound dressing. The silver ions released,
act on the bacterial cell wall and sulphadiazine moiety is a
competitive inhibitor of paraaminobenzoic acid (PABA) thus
inhibiting the metabolism in the microorganism

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69
Fig. 4.6C: Paraffin gauze applied over the cream as
nonadherent dressing for easy removal in subsequent dressing
Fig. 4.6D: Next, a layer of gauze is wrapped over the
paraffin and SSD
Fig. 4.6E: Gamgee pads form the subsequent layer for
absorption of the exudates from the wound surface
Fig. 4.6F: Firm compressive bandage tied over the Gamgee
along with a ball and bandage in the palm to maintain the
functional position of the hand

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Fig. 4.7A: Twenty-five percent scalds in a 5-year-old child
for which dry collagen dressing was used. Since the buttocks
and perineal area is involved the collagen dressing seals the
wound and prevents contamination of the wounds. This type
of dry dressing contains Type I collagen which is very similar
to the human collagen, hence is less immunogenic
Fig. 4.7B: As the wounds heal the outer nonabsorbable
layer of collagen sheet gradually gets peeled off from periphery
to center of the burn wound
Figs 4.7C and D: Completely healed wounds in the
same child after 2 weeks
Fig. 4.7D
Fig. 4.7C

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71
Fig. 4.8: Wet collagen dressing in 40 percent scalds in a
child. It contains Type III collagen which has been seen to
cause immune reaction in the form of unexplained fever. It
also requires pretreatment in the form of thorough washing
to remove the preservative. Therefore dry collagen is preferred
over wet collagen
Fig. 4.9A: Amniotic membrane dressing in burns is very
useful in developing countries as it is free of cost, easily
available in plenty and has all properties of a good biological
dressing. It is known to accelerate wound healing because of
its enzymatic properties. The only disadvantage is that prior
HBsAg, HIV and HCV testing has to be done to rule out
infections in the donor
Fig. 4.9B: Amnion being removed from
the placenta for use
Fig. 4.10A: Superficial and deep dermal burns of the back
was initially treated with 1 percent SSD cream but caused a
lot of soakage, which can act as a medium for transfer of
bacteria into the wound and dressing had to be changed
daily. It also causes a pseudoeschar formation over the wound
surface because of the cream base which is difficult and
painful to remove

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Fig. 4.10B: Nanocrystalline silver dressing (Acticoat)® being
applied to the wounds as it has definite advantages over the
1 percent SSD cream. It initially releases silver ions
immediately for rapid onset of its bactericidal action to
control infection and then a sustained release over 3 days.
As a result, the dressing changes are reduced to every 3 to 4
days. This reduces the chances of exposing the wounds to
contamination during frequent dressing changes
Fig. 4.10C: Wounds almost healed after 3 dressings with
nanocrystalline silver dressing. The gray staining is because
of the silver which eventually clears on its own once the
wound epithelializes
Fig. 4.10D: Same patient after 2 months with all areas
healed without much scarring
Fig. 4.11A: Another patient of 12 days old with 40 percent
infected burns with greenish staining of the deeper areas
indicating Pseudomonas invasion

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73
Fig. 4.11B: Systemic antibiotics were started and dressing
was changed over to nanocrystalline silver dressings
Fig. 4.11C: The wounds improved after two dressings and
some wounds in the periphery healed and deeper wounds
got prepared for grafting after 2 weeks
Figs 4.11D and E : Patient 2 months after grafting of
remaining wounds
Fig. 4.11D
Fig. 4.11E

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Fig. 4.12A: Another silver coated foam dressing (Calgigraf®)
containing calcium alginate also along with maltodextrin,
used for deep burns. The calcium alginate has a desloughing
action. The foam padding on one side absorbs the discharges
from the wounds, hence there is less soakage of the outer
dressing. Another advantage is that it is to be changed after
4 to 5 days only as the silver ions are released for longer time
Fig. 4.12B: Same patient’s wounds showing grayish blue
staining of the areas due to silver
Fig. 4.13: Dressing being done with epidermal growth factor
mixed with silver sulphadiazine (Epigrof®). Epidermal growth
factor (EGF) is one of the recombinant cytokine growth factors
which has been successfully used in treating burn wounds.
Their use has shown definite improvement in burn wound
healing in terms of rapid epithelialization, when compared
to silver sulphadiazine alone
Fig. 4.14A: Dressings done with nanocrystalline silver
impregnated dressing in burn wounds after they showed signs
of infection which increased depth of the wounds as seen on
left thigh

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75
Fig. 4.14B: Wounds showing improvement with the new
dressing, neoeschar got separated and granulation tissue
started appearing
Fig. 4.14C: One month after grafting of all raw areas
Fig. 4.15: Mafenide (Sulfamylon) is the most useful topical
antibacterial agent for established burn wound sepsis because
it has excellent eschar penetration

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Fig. 4.16A: Mixed superficial and deep dermal burns in
both hands and forearms of an industrial worker (flexor
aspect) (Courtesy: Dr N Jithendran, Global Hospital,
Hyderabad, Andhra Pradesh, India)
Fig. 4.16B: Extensor aspect of both arms of the same patient.
The deep dermal burns are mainly on dorsum of left hand
and forearm and rest are superficial dermal
Fig. 4.16C: Three weeks postoperative picture of the dorsal
aspect of the same patient following tangential excision of
the deep dermal wounds and conservative management of
the superficial burns
Fig. 4.16D: Flexor aspect of the arms of the same case

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Fig. 4.17A: Young boy with neglected deep burns in both
lower limbs presented with dirty pale raw areas in both legs
not fit for grafting. Patient required extensive preparation by
daily dressing initially with Eusol and later with povidone
iodine lotion to encourage granulation of the wounds
Fig. 4.17B: One month postoperative picture following
grafting of the areas after they improved by ‘conservative
measures’
Fig. 4.18A: Superficial scalds over both thighs and chest.
In pediatric patients even though clinically the wounds appear
to be superficial may actually be deep dermal
Fig. 4.18B: One week after conservative dressing with
1 percent SSD showing healed wounds in left thigh and leg,
but some areas in chest and right thigh are still raw seen as
white dermis indicating that these areas are deep dermal
even though in the first look they appeared to be superficial

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Fig. 4.19B: Same areas being tangentially excised with
Watson’s knife under tourniquet. The dead epidermis and
dermis is excised till healthy reticular dermis is reached. The
viable deep dermis is seen as shiny pinkish white reticulin
framework with punctate bleeding points of congested blood
under tourniquet
Fig. 4.19C: Same patient’s dorsum of hand being excised
tangentially
Fig. 4.19D: Skin graft applied immediately on the excised
areas after hemostasis is achieved
Fig. 4.19A: Deep dermal burns of forearm are ideal for
tangential excision and grafting

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Fig. 4.20A: Another patient with deep dermal burns of the
thigh with waxy white appearance. If managed by
conservative dressings it would heal in more than 3 weeks
and with hypertrophic scarring
Fig. 4.20B: Ideal treatment is primary tangential excision
of the dead tissue as shown with Watson’s knife
Fig. 4.20C: Since it is done without tourniquet, the
healthy bleeding dermis can be seen
Fig. 4.19E: Two month postoperative picture of
the same patient

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Fig. 4.21A: Acid burns of face and shoulder. It is difficult
to decide the depth in this case clinically as the burnt skin
has formed a thick eschar because of coagulation necrosis
Fig. 4.21B: Primary excision is done in a sequential manner
till a healthy viable bed is reached which varied from reticular
dermis to deeper tissues as shown in the picture
Fig. 4.21C: Skin grafting of same area following excision.
Ideally grafts applied to face should not be meshed for
aesthetic reasons but at times if hemostasis cannot be
achieved meshing helps in avoiding hematoma under graft
and improves graft take
Fig. 4.20D: Two weeks after primary skin grafting of
the same thigh

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Fig. 4.21E: Skin grafting of the same area
Fig. 4.22A: One-year-old neglected chronic post-burn raw
area with severely fibrosed bed. The area is therefore not
likely to accept graft
Fig. 4.22B: The unhealthy fibrous granulation tissue
has to be excised
Fig. 4.21D: Sequential excision over shoulder and upper
arm showing viable dermis as shiny white with multiple
bleeding points at places and deeper tissues at other places

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Fig. 4.22D: Thin skin graft applied to the excised bed
Fig. 4.22E: Two weeks postoperative picture showing good
graft take. Postoperative care in the form of gradual
mobilization with pressure garments and oil massage is
essential to keep the graft soft and supple, and prevent
breakdown of graft
Fig. 4.22C: Bleeding wound bed after removal of
fibrosed tissue

Burn Wound Management
83
Fig. 4.23A: Mixed superficial and deep dermal burns in
arm. (Courtesy: Dr N Jithendran, Global Hospital,
Hyderabad, Andhra Pradesh, India)
Figs 4.23B and C: (B) First debridement is done before
collagen sheet application. (C) Almost all burn areas heal
with collagen sheet, small residual raw areas are skin grafted.
Picture after skin grafting at first dressing
Fig. 4.24D: Picture after healing of wounds
Fig. 4.24A: Second degree deep burns over knee joint
(Courtesy: Dr N Jithendran, Global Hospital, Hyderabad,
Andhra Pradesh, India)
Figs 4.24B and C: Tangential excision of eschar followed
by skin grafting
B
C
B
C

Clinical Atlas of Burn Management
84
Fig. 4.25A: Two weeks old extensive burns being treated
conservatively as patient was not fit for primary excision. He
had deep wounds over upper arm and hand with white dead
dermis. In hands early coverage is a priority in order to avoid
wound contraction and subsequent deformities. Since these
wounds would not have healed spontaneously without
deformity, it was decided to excise all the remaining dead
tissue
Fig. 4.25B: Delayed excision of the dead tissue on
dorsum of hand till viable tissue was reached
Fig. 4.25C: Application of Integra®, a synthetic bi-laminate
product, on dorsum of hand. It has a deeper dermal analog
made of bovine collagen which gets integrated in the wound
bed providing the dermis which is absent in the wound and
an outer silicone layer. Ideally full thickness skin cover is
required for dorsum of hand in order to prevent secondary
contractures and full range of motion of all joints. But since
the take of a large full thickness graft is doubtful specially on
burn raw areas and also dearth of same in extensive burns,
therefore Integra is a good option for coverage of such wounds
Fig. 4.25D: Integra being applied to wound bed similarly
on upper arm after excision of dead tissue

Burn Wound Management
85
Figs 4.25G and H: Three months postoperative picture
of arm and hand with well settled grafts
Fig. 4.25I: Patient is able to form a fist easily because the
skin is soft and pliable unlike a normally grafted skin which
is stiff and nonresilient
Fig. 4.25E: In 3 weeks time once the dermal layer gets
vascularized, the outer silicone layer separates out, over which
skin graft can be applied
Fig. 4.25F: Very thin skin graft needs to be applied to this
neodermis which prevents a donor site deformity and second
crop of skin can be harvested from the same sites again if
required later
G
H

Clinical Atlas of Burn Management
86
Fig. 4.26C: Two months postoperative picture of the same
showing complete graft take
Fig. 4.26A: Six months old neglected full thickness burns
of leg showing a fibrosed raw area
Fig. 4.26B: Excision of the fibrosed bed under tourniquet.
Skin graft is applied only after achieving hemostasis

Burn Wound Management
87
Fig. 4.27A: Severely pale wound with scarce granulation
and profuse pus discharge indicating that it is unfit for grafting
Fig. 4.27B: Patient’s wounds improved with daily povidone
iodine and saline dressing and overall management of the
patient in the form of blood transfusion, correction of
hypoalbuminemia and high protein diet
Fig. 4.27C: Same wound grafted with full graft take

Clinical Atlas of Burn Management
88
Fig. 4.28A: If deep dermal burns of lower limb are put on
conservative management and happen to get infected, then
the deeper viable dermis also does not survive and the burn
wound presents like this after eschar separation. Dead dermis
is still present in between the granulation tissue and does not
come out easily and does not allow graft take also. It therefore,
requires further dressing with eusol which is a good
desloughing agent, followed by wet saline or povidone iodine
dressings which promote development of healthy granulation
tissue
Fig. 4.28B: Close-up view of same type of wound as shown
in Figure 4.28A showing dead reticular dermis interspersed
between granulation tissue. If graft is applied on this bed, it
will not take on the nonviable dermis. Therefore, either it
should be excised or dressed by desloughing agents till it
becomes healthy
Fig. 4.29: Angry red wound with fragile granulation tissue
bleeding profusely on touch indicating streptococcal infection
which is an absolute contraindication for grafting. Systemic
penicillin is still very effective for streptococcus and should
be started immediately
Fig. 4.30: A cachexic neglected 50 percent TBSA patient
with raw area chest showing slough, exposed ribs, pleura
and subcutaneous tissue. There is no granulation tissue at
all indicating severe anemia, hypoproteinemia. Chances of
survival of patients reaching this state are negligible

Burn Wound Management
89
Fig. 4.31A: Extensive raw area with healthy granulation
tissue following deep chemical burns destroying the ear and
eye completely
Fig. 4.31B: Healthy granulating wound on arm of same
patient ready for grafting
Fig. 4.31C: Seven days postgrafting of the same wounds
with good graft take
Fig. 4.31D: Three months postoperative picture of the
patient with well settled grafts. In chemical burns since the
depth of damage is more, the chances of secondary
contractures is also very high despite using splintage and
pressure garments

Clinical Atlas of Burn Management
90
Fig. 4.32A: Extensive raw areas in a 75 percent BSA burn
case in which stamp grafts have been used to cover the
area. The intervening areas between the stamps heal by
epithelialization from the margins of the graft, as a result
these areas tend to hypertrophy and give unsightly scars
Fig. 4.32B: Two months postoperative view of the same
patient with totally healed areas but with the formation of
perineal contractures which will require release
Fig. 4.33A: Five-year-old child who suffered from 40 percent
accidental scalds and was neglected for 6 months and
presented with severe contractures of both knees with
circumferential pale fibrosed raw areas in both lower legs
and posterior thighs. Patient was severely anemic and
hypoproteinemic at the time of admission
Fig. 4.31E: Lateral view of the same patient

Burn Wound Management
91
Fig. 4.33B: Homografts from mother applied to the raw
areas which gave time for correcting anemia and
hypoproteinemia and the wounds improved significantly.
Coverage of raw areas in such critically ill patients is a priority
over simultaneous release of such contractures in the first
stage as that would increase the raw areas and graft take in
the released areas will also be compromised because of
contamination from infected burn wound
Fig. 4.33C: Homografts were taken up well and once
patient’s general condition improved, the homografts were
removed as seen in this picture. Applying homograft is a
good way of ensuring the take of autograft in the second
stage over a surgically created sterile wound following
homograft removal
Fig. 4.33D: Healthy raw areas after removal of homografts
and autografts were then applied immediately in 2 stages
Fig. 4.33E: Three days after first stage of autografting

Clinical Atlas of Burn Management
92
Fig. 4.33F: One week after second stage of autografting.
The grafts were taken up well and patient’s general condition
improved dramatically. The contractures can be released after
3 months once the grafts mature
Fig. 4.34A: Deep burns in hand of an infant with gangrenous
changes in all finger tips. Even though the palmar skin is
thick if the contact period with the thermal agent is long as
in this case, the depth of damage is more. Hence, these
wounds do not epithelialized on their own. (Courtesy: Dr N
Jithendran, Global Hospital, Hyderabad, Andhra Pradesh,
India)
Fig. 4.34B: Dorsal aspect of same hand with gross
edema due to the injury
Fig. 4.34C: Two weeks of dressing of the hand allows
granulation tissue to appear and delineates the dead tips of
the fingers