Cath Lab Digest

T he primary goal for burn wound management is to excise the devitalized tissue and close the wound as soon as possible. Secondary goals of wound care are to promote healing and to maintain function of the affected body part. These goals are accomplished by excising devitalized tissue, preventing wound infection and graft loss, and maintaining correct positioning and splinting throughout hospitalization.

In children, scald burns are common and in young children are best managed with conservative treatment for 2 to 3 weeks, which allows the wound either to heal or to present as a third-degree wound in need of surgical intervention. Once surgical intervention is determined to be necessary, special consideration must be made regarding children to prevent graft loss. Most graft loss is from friction or shearing. Preventing graft loss can be challenging in the adult population - it is almost impossible in the pediatric population.

Historically, graft fixation has been achieved by suturing (which is time-consuming) or stapling (which is painful when removed). Removing staples in children requires large amounts of analgesics and, at times, conscious sedation or general anesthesia. Usually, the patient returns from the operating room in a position that is maintained for 3 or 4 days. Any interaction with the patient during this time of graft immobilization requires creativity and care in order to prevent shearing of the graft. Children, who are usually active, cannot comprehend what is happening or why part of their body is immobilized, and become easily frustrated with the situation. Obtaining their cooperation for graft fixation and to prevent graft loss is next to impossible. They frequently react by pulling and tugging on their dressings. The graft also may be displaced during dressing changes for obvious reasons.

Studies have shown that graft fixation and dressing materials for split-thickness skin grafts must be porous to allow drainage of serosanguinous wound exudates and remain nonadherent to the graft. Ideally, the dressing material also should allow a care provider to view enough of the surgical wound to assess for infection. One particular dressing material (Mepitel, Molnlycke Health Care, Newtown, Pa.), which consists of a polyamide net impregnated with silicone gel, has proven to be an effective wound covering.

Case Report

Miss L is a 14-month-old African American child who received a 3% scald burn to her right lower extremity on October 25, 2003. She received a split-thickness skin graft to this area on November 24, 2003. The graft was meshed 2:1 and fixated in the OR without staples or sutures. The new silicone polyamide dressing material was placed over the graft and donor site and covered with an antimicrobial dressing (Acticoat, Smith and Nephew, Largo, Fla.). Burn compress dressings then were applied and Robnel catheters (red rubber catheters with small holes placed all along the catheter to allow solution to flow through) were placed medial and lateral to the lower extremity sand on top of the current dressing. The entire leg then was wrapped with Kerlix gauze (Tyco Health Care/Kendall, Mansfield, Mass.) and a posterior splint was made and secured with an ace wrap. The wound then was soaked with approximately 20 mL of 5% sulfamylon solution every 4 to 6 hours utilizing a Toomey syringe. The first dressing change was performed at 48 hours.

The dressing was removed down to the silicone dressing layer November 26, 2003, and the wound was assessed as healing normally without infection. The wound was redressed using the antimicrobial dressing (per manufacturer recommendations) over the silicone dressing and wrapped again with Kerlix gauze, posterior splint, and ace wrap. The sulfamylon soak was not utilized at this dressing change.