Arguably burn injured individuals are amongst the most susceptible to infection of any trauma group. They are hypercatabolic, immune compromised and have large wounds covered with necrotic tissue, inviting opportunistic pathogens.Multi-resistant wound flora is common place. Lack of skin function is likely to exacerbate all this problems. Wound control through damage limitation surgery is the keystone in this aspect.
Damage control is not a new term. It has originated from the US navy, referring to the ability of a ship to absorb damage while maintaining mission integrity and return to safe harbor. The damaged hull of a ship undergoes rapid assessment and adequqte, temporary repair to allow a return to the controlled environment of port. This concept gained wide acceptance n management of severely injured surgical patients by controlling bleeding and contamination further restricting physiological damage caused by the lethal triad namely hypothermia, acidosis, and coagulopathy. Damage control surgeries are protocols are defined as creating a stable anatomical and physiological environment to prevent patients from progressing to unsalvageable metabolic state. Staged procedures were used instead of complete and immediate repair, buying time for the damage propagated to other fields of surgery including thoracic, orthopedics and vascular surgery .This principle can be applied in management of patients with severe burns. There are four aspects of damage control surgery in burns; burn shock management, stabilizing and preparing the patient for theatre, limiting wound fluid loss maintaining tissue viability, preventing infection and early continuous enteral feeding keeping GI tract integrity, preventing bacterial translocation.
Damage control in burn surgery
Stage 1; patient selection
Stage 2; Emergency management of burn patient including; resuscitation stabilizing and preparation for theatre.
Stage 3; almost immediate excision of all necrotic tissue
Stage 4; Definitive staged burn wounds with auto graft or permanent skin substitute
Stage 5; Reconstructive procedures related to hypertrophic scars, keliods, and burn contractures.
Severe burn is devastating form of injury, and a significant risk in developing countries, traditionally are treated with dressings and topical antimicrobial agents until the eschar separate. The granulating wound would then be covered with spilt thickness skin graft. Patients with severe burns treated in this manner are more likely to die from sepsis due to massive release of inflammatory mediators from the burns wounds. This is further exacerbated by subsequent infection of this wound. Hospitals with smaller budget should be strong advocate of immediate excision, as once patients develop multi organ failure, they die quickly or consume large amount of resources and then they usually die.
Damage control surgery in burns saves lives. Early surgical excision reduces inflammatory response, further avoids progressive wound damage, protect against desiccation and serves as graft take test.
Combinations of early wound covered and early physiotherapy prevent scars and contractures.
Low hospital cost decrease staff workload, less dressings, less pain, less maintenance and shorter hospital stay.
AFIA NEGBLE ( Nurse, KATH)