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Third stage
Surgery
Lec-2
.د
سعدالله الزكو
1/1/2014
Skin graft
Definition: is a segment of epidermis and dermis that is removed from its blood supply at
donor site transferred into a recipient site.
Types:
1-Origin:
Autograft , allo-(homo)-, xeno(hetero).
2-Thickness:
Split (Thiersh ): thin ,intermediate, thick.
Full thickness (Wolfe).
Split skin graft (SSG)
Most useful and popular.
Contains epidermis and part of dermis.
Contract more postoperatively.
Survives more.
Full thickness graft:
Epidermis and entire dermis.
Normal color, texture, hair.
Not contract, less survive.
Donor site:
SSG :thigh buttock, abd. wall arm.
FSG: pre-, post-auricular, supraclav, upper eyelid.
Success of skin graft:
Vascular recipient bed.
Proper contact of graft with proper tension.
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No fluid beneath.
No movement.
Free from infection.
Immunological.
Indications of skin graft
Skin loss: post traumatic, post surgical, result of pathology (venous ulcer).
Mucosa loss: leukoplakia, reconstruction of vagina.
Contraindications:
Avascular recipient bed.
Infection.
Flaps
“ part of tissue which retains its vascular attachment to body, transplanted to reconstruct a
defect.”
The flap donor site closed by suture or SSG.
Classification
1. Content:
A. Skin.
B. Fascio-cutaneous.
C. Myo-cutaneous.
D. Muscle.
E. Osteo-myo-cutaneous.
2. Site:
A. Local : where donor area near recipient site.
Rotation.
Transposition.
Advancement.
B. Distant flap :where donor area at a distance from recipient site.
Transposition
Rotation
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C. Free flap: by using microsurgery.
3. Vascular pattern ( skin flaps):
A. Axial pattern: longer, easier ,safer.
B. Random pattern.
Indications of flaps
1. Cover recipient bed with poor vascular supply.
2. Reconstruction full thickness eyelids, lip, nose, cheeck .
3. Padding bony prominences.
4. When operation through the wound at later date.
5. Muscle flap provides a functional unit.
6. Provide sensation.
Burns
Coagulative necrosis of tissue due to heat.
Causes:
1. Flame 45%.
2. Hot liquid (scald)30%
3. Hot object.
4. Electric.
5. Chemical.
6. Others : semi liquid, steam, UVL,XR.
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Depth of burn: 4 degrees:
1. First : epidermis.
A. Erythema, edema, scaling.
B. Analgesic, oint.
2. Second:
A. Superficial 2
nd
.
Epidermis and superf. dermis .
Blisters painful to light touch red blanch positive.
Dressing – 1w.
A. Deep 2
nd
( deep dermal )
Epidermis and most dermis.
Painful to pinprik, milky white blanch –ve.
Early excision + grafting.
3. Third:
1. Epidermis and whole dermis.
2. White, brown or black.
3. Painless thrombosed V.S.
4. Early excision and grafting or dressing and late graft.
4. Fourth : muscle and bone.
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Extent :
1. Rule of nines.
2. Lund and Browder chart.
3. Palm method (1%).
Management of burns
1. ABC:
A. Airway clear.
B. Breathing humidified O2 , respirator.
C. Circulation cannula :
Blood sample (Hb., PCV, urea, electrolytes ).
Sedation.
IV Fluids.
2. Assessment :
A. History
B. Exam:
General
Local (depth, %).
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2. Sedation: (i.v)
Morphine , pethidine, + largactil.
4. Iv :
A. Given in :
10% + in children.
15% + in adults.
B. ½ amount in 8 h,1/4 in 8h, 1/4 in 8h.
5. Investigations: Hb, PCV, bl. urea, s.elect. , blood group.
6. Urine:
A. Foly’s catheter.
B. Hourly output (0.5-1 ml/kg/h)
7. Tetanus toxoid 0.5 ml
or 250 mg human immunoglobulin + toxoid.
8. Antibiotic : pencilline 5 days.
9. Nothing by mouth, N.G. tube
10. Wound care:
A. Clean, ointment (Flamazine).
B. Dressing ( open, closed)
C. Operation (SSG ,flaps)
Complications
1. Shock: neurogenic, hypovolemic, septic
2. Infection: wound, resp., urinary, septicemia.
3. Renal failure.
4. Curling ulcer.
5. Deformity, scars, keloid.
6. Metabolic.
7. Psychological.
8. Marjolin (sq. cell carcinoma).
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From other lecture
Severity of burn depend on:
1-Size.
2-Site.
3-Depth .
4-Age Increased mortality in less than two years of age because of
A-increase the surface area.
B-immature immune system.
C-immature kidneys.
Also increased mortality in patients over 50 years of age because of associated diseases.
5-Associated injury e.g. fractures, inhalation injury, head injury, internal bleeding
Indication for admission:
1-PTB > 15% in adult.
2-PTB > 10% in child.
3-FT B> 10% any age.
4-Burn in face , hand, foot , perineum ( except minor cases).
5-Inhalation injury.
6-Electrical burn.
7-Associated major medical illness e.g. DM.
8-Other considerations age, home situation and level of cooperation.
Burned skin after healing:
Hypo or hyper pigmentation.
Scar.
Susceptible for sun burn.
Dry.
Itching.
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Effects of burn injury (complications)
1-Local effects:
1- Tissue damage (leakage of serous fluid)
2- Inflammation (erythema)
3- Infection
2-Regional effects :( circulatory problems: limb circulation may be compromised).
3-Systemic effects :
1-fluid loss either external or internal.
2-multiple organ failure.
4-Systemic complications:
Curling ulcer( gastric or duodenal ) leading to acute hematamesis.
Immune suppression which increase the rate of septic complications.
Weight loss due to catabolism (response to trauma
5- nonspecific complications:
- UTI from catheterization .
-DVT and
- pulmonary embolism
Clinical Picture of Burn Injuries
1- Pain:
2- Acute Anxiety:
3- Fluid loss and dehydration:
4- Local tissue edema:
Superficial burn: blister
Deep burn: edema formation in the subcutaneous spaces then may be marked in head and
neck, with sever swelling which may obstruct the airway.
Limb edema may compromise the circulation.
5- Special sites:
Burn of the eyes are uncommon in house fires, the eyes may be involved in explosion
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injuries or chemical burns.
Burn in the nose, airway, mouth, and upper airway may occur in inhalation injuries.
6- Coma:
from carbon monoxide or cyanide poisoning.
Management of Burn
MINOR BURNS/OUT-PATIENT BURNS
Local burn wound care
Blisters.
Initial cleaning of the burn wound
Washing the burn wound with chlorhexidine solution is ideal for this purpose.
Topical agents
dressings with a non-adherent material such as Vaseline-impregnated gauze, 1% silver
sulphadiazin cream
1-AIRWAY: The first priority is the maintenance of the patient airway.
2-Breathing: Effective ventilation
3-Circulation
Put IV line and start I.V fluid
if burn is more than 15% (adult), and more than 10% (children) calculate the fluid
requirement by
Parkland formula.
Parkland formula = body wt. x % of TBSA x 4.
Type of fluid:
1-Crystalloid resuscitation.
Ringer’s lactate is the most commonly used crystalloid. Crystalloids
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are said to be as effective as colloids for maintaining intravascular
volume. In children, maintenance fluid must also be given. This is
normally dextrose–saline given as follows:
• 111 ml kg–1 for 24 hours for the first 10 kg;
• 51 ml kg–1 for the next 10 kg;
• 21 ml kg–1 for 24 hours for each kilogram over 20 kg body
2-Colloid resuscitation
Plasma Proteins should be given after the first 12
hours of burn because,
4-Manage other complicating life threatening injuries .
5-Cold water application
a-decreased tissue damage.
b-Decreased pain.
C-Stabilizes mast cells (decreases edema).
Pain relief in second degree (not third degree) burn which is less than 15%TBS.
6-Evaluate the burn wound and look for the most two important conditions:
a- inhalation injury
b- release of constricting eschar (Escharatomy) which lead to
decrease chest wall movement (respiratory embarrassment)
Extremity constriction (compartment syndrome or distal ischemia and necrosis).
7- Folleys Urinary Catheter
done in burn more than 25% TBSA.
UOP should be not less than 30-50 ml/hr(adult) and 0.5-1ml/kg body wt/hr in children.
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8- NGT
done in burn more than 25% TBSA. With suction for gastric decompression, because
there is chance of paralytic ileus.
9- Analgesic and Sedation
in major burn only IV not IM or SC morphine 0.2 mg/kg or into the drip.
10- Anti Ulcer Treatment
gastric or duodenal lesion occur within 48 hrs after burn, give prophylactic ranitidine
(H2 receptor antagonist) or give antiacids by NGT.
11-Tetanus Immunization
12-blood Transfusion
14- Oxygen Therapy
15- Careful monitoring
which includes
a-monitoring of the general condition or vital signs.
b-monitoring of the fluid resuscitation for adequate perfusion.
c- investigations for renal,metabolic and hematological condition.
16-Antibiotics (controversy)
sometime penicillin prophylaxis given in more than 10% burn to prevent hemolytic
streptococcal infection.
17- Physiotherapy and prevent bed sore.