making the latter optimal for smaller burns where functionality and cosmesis
take precedence.
Patients suffering from large TBSA burns, usually ≥ 20%, also benefit
from an aggressive surgical approach. These children tend to require serial
trips to the operating room given the extent of injury. Although autograft is the
substitute of choice in any thermal injury, patients with large burns will often
require skin substitutes given the limited availability of non-burned skin. Skin
substitutes can accelerate healing by allowing spontaneous reepithelialization.
These can be biological or synthetic substitutes. Alloderm, an acellular dermal
matrix derived from donated human skin, is an example of a biological
dressing. Its dermal template allows it to become incorporated into the existing
tissue, however, it requires the use of a thin skin graft. Proponents of Alloderm
have observed a decreased length of stay and decreased donor site healing
time.
Escharatomy
Burn patients may require escharatomies to relieve vascular
compromise or ventilatory impairment. Full thickness circumferential burns to
the extremities can produce constricting eschar that leads to edema, followed
by vascular compromise (venous congestion and arterial insufficiency)
prompting an escharatomy +/- fasciotomy. This compromise can produce pain,
paresthesia, pallor and/or pulselessness, although these signs frequently are