ANTIBIOTIC COVER is essential if the patient’s slough or eschar is severely infected. If Streptococci are present, use penicillin, if Pseudomonas are present they may be sensitive to gentamicin. If possible do sensitivity tests.
INDICATIONS Full thickness burns only. (1) A constricting eschar needs immediate splitting as an emergency procedure. (2) Most other eschars are best removed at about 2 weeks. There is usually a clear line of demarcation for surgical desloughing at this time. (3) Fever (which is not malarial) and toxaemia.
ANAESTHESIA Full thickness burns have no sensation, so anaesthesia is theoretically unnecessary. But be kind and give the patient ketamine, or morphine. If he feels pain, either an escharotomy is not necessary because the burn is only superficial, or you are cutting in the wrong place.
SLOUGHECTOMY Clean the burnt areas with chlorhexidine. Use any convenient instrument, such as scissors, a scalpel, or an elevator. Or, open the gap between the blade and roller of a Humby knife and shave away the slough.
EMERGENCY ESCHAROTOMY Incise the eschar down the length of the patient’s limb; if necessary in two or more sites, and avoiding tendons and vessels. You may have to incise any burnt area, and cut across joints, so don’t be limited by Figure 58-12.
ROUTINE ESCHAROTOMY Cut very lightly partly through the tough thickened dermis. Thrust the points of artery forceps through into the subcutaneous fat, then separate them to open the incision. Like this, you will avoid cutting vessels. Pull off the tough stinking pieces of eschar. The patient’s wound will gape open, and bleed, perhaps for some hours, so watch him carefully.
CAUTION! (1) Don’t make deep cuts. (2) Never deslough more than 10% of the surface of his body at one time.
Bleeding may be troublesome. Control it with pressure and warm packs, or hydrogenperoxide (10 vol–%), and tie or undersew larger vessels. If necessary, apply haemostatic gauze. Raise his limb.
If the raw area is suitable (57.3), graft immediately. This is the best choice if it is practical.
If his burns are not clean or if there is excessive bleeding, either: (1) Apply an antibacterial dressing or vaseling gauze and send him back to the ward. Clean his wounds with saline baths three times daily for a week. Then bring him back to the theatre later for grafting. Or, (2) take skin grafts now, store them (57.8), and apply them a few days later in the ward when his wound is clean.
Alternatively, use soaks, as in the saline method (58.16).
