58.17 Early excision and grafting for a full thickness burn

A logical method of treating a deep burn is to excise the dead tissue in the first few days before it becomes infected and then to graft it immediately, instead of waiting to deslough at about 14 days. Skilled surgeons in well equipped hospitals can do this in stages for burns of up to 30%. If you try it, you would be wise to use it in special sites only, such as the back of the hand, and in burns of less than 2% in which there is no shock.

There are difficulties: (1) Knowing which burns it is suitable for. You must be sure the burn is full thickness by the criteria in Section 58.12. If you excise and graft a partial thickness burn which is going to recover without grafting, you worsen the patient’s chances of recovery. You can easily sacrifice living tissues, and injure important structures, such as tendons and cutaneous nerves. (2) Severe bleeding is the main danger and can be fatal, so the burn must be small, and even so, you must have plenty of blood for transfusion. (3) Early excision and grafting is only practical early, before the slough separates, usually at 3 to 5 days, sometimes up to 7 days.

There are various methods of early excision and grafting. The one described below is the only one which deserves to be used more widely in district hospitals. It is often a very effective method for deep burns on the palm of the hand. If left to themselves these may take many weeks to heal.

THE EARLY EXCISION OF A FULL THICKNESS BURN

INDICATIONS This method is only indicated if all these indications apply. (1) You are sure the burn is full thickness. (2) You can do the excision within the first 3 days. (3) The burn is small, certainly less than 10% and preferably only 2%. (4) You have plenty of blood for transfusion. (5) You are a good skin grafter.

METHOD Use s scalpel or, better, bend the blade of a Humby knife and use it to shave away thin layers of burnt tissue until you reach a layer which you know is alive because it bleeds.

If the bed is suitable, graft the burn immediately, or by delayed primary grafting at 3 days.

If the bed is unsuitable, for example, if it is formed by dead bone, you may have to refer the patient for the wound to be covered with a flap. Alternatively, gouge down to healthy cancelleus bone, wait 3 days to allow granulations to start forming, and then graft.