From Acute Burns. Grunwald, Tiffany B.; Garner, Warren L. Plastic & Reconstructive Surgery. 121(5):311e-319e, May 2008.
by Joseph Ricci, MD
The Resident Reader Section contains many fantastic topics which are extremely pertinent to any plastic surgeon in training. Historically, plastic surgeons have been extremely active in the care of burn patients, however as there has been increased focus on the critical care aspect of the care of these complicated patients, many plastic surgeons have turned away from this area and have been supplanted by surgeons completing dedicated “burn fellowships.”
Contained within this collection are a series of articles which outline many of the current practice algorithms needed by plastic surgeons to care for burn victims. This set of articles covers not only the management of acute burn patients, but also covers how to tackle some of the unique reconstructive challenges present in these patients. Additionally, there are articles dedicated to the care of the pediatric burn patient. Although, these articles are not a substitute for formal critical care training, these articles lay the groundwork for plastic surgeons to build upon and can act as a reference for recent plastic surgical graduates who may be responsible for caring for these patients acutely in the community where there is no immediate access to a burn center.
The articles by Grunwald and Bezuhly review many of the essential principles in the care of burn patients, including: criteria for transfer to a burn center, initial management steps for non-burn center physicians to take before transferring a patient, the physiology of burns, fluid resuscitation and acute surgical management of burn wounds. For the plastic surgeon who will not be involved in the acute critical care aspect of these patients, but rather might be called upon by a burn surgeons for assistance with the acute wound management and initial reconstruction, these papers are well complimented by the articles by Orgill and Lee on acute burn reconstruction. The articles by Lee and Orgill describe much of the overall methods of burn reconstruction. Importantly, these articles highlight some of the more challenging situations that plastic surgeons may face when caring for these patients; specific scenarios which are relevant to burns on certain anatomical areas in which specialized reconstructive strategies are needed.
In the article by Orgill from May 2013, there is also an excellent section discussing the power of composite tissue allotransplantation as a potential treatment option for patients with extensive burns. In the two years since this article was published the indications for performing a transplant for reconstruction of a burn victim to replace “like with like” have probably gotten even stronger. The article by Lee similarly focuses on more cutting edge methods of reconstruction and in the article they make a compelling case for the use of Integra (a bilaminate permanent dermal replacement system made of bovine collagen and shark chondroitin-6-sulfate) as a skin substitute to treat lower extremity burns.
This collection of articles is rounded out by Armour’s article, which covers the acute care and reconstruction of pediatric burn injuries. This article expertly covers all of the material which was missing from the previous articles in this set. In addition to acute resuscitation and surgical treatment they discuss many aspects of burn care that are unique to the pediatric population. These include things like aggressive rehab, the difficulty with compliance and use of pressure garments, psychiatric considerations, and perhaps the most important challenge – limited donor sites for skin grafts.
Overall, the Resident Reader articles contained in the treatment of burns sections covers many of the key principles of treatment of both the adult and pediatric burn patient. It covers the acute burn management for the novice provider who finds himself/herself on call when a burn patient might present and their acute stabilization and treatment prior to transfer to a definitive burn center. Additionally, it covers in depth the acute reconstruction needs as well as specific challenges and solutions in burn reconstruction which may face any practicing plastic surgeon. Not only do these articles serve as a great initial reference for plastic surgeons but are a must read for all plastic surgeons in training.