Conventional Warfare: Ballistic, Blast, and Burn Injuries

verting colostomies are not required either to achieve wound closure or to prevent wound infection. Diversion of the fecal stream usually results in significant anal stenosis, which then requires surgical correction. Skin Grafts. After a burn wound has been excised, optimal closure is accomplished by of cutaneous autografts. However, this is possible only when (a) the wound bed is unequivocally viable and available donor sites exist. In extensively burned patients, the size of the burn wound often exceeds that of the available donor sites. Meshed autograft skin is the most commonly used permanent covering after burn-wound excision. The most common expansion ratios arc although up to ninefold expansion is possible (Figures 11-9and 11-10). Because so long a time is required for the interstices of either sixor ninefold expanded grafts to re-epithelize, they are seldom employed. To prevent desiccation of the tissues underlying the open interstices of meshed cutaneous autografts, occlusive dressings soaked in either 0.5% silver nitrate solution or 5% mafenide acetate solution are applied until epithelial closure is complete. For widely expanded meshed autograft skin or meshed autograft skin over fat, overlays of cutaneous allograft, xenograft, or Biobrane have proven successful in both increasing graft take the time tn interstitial sure. In patients with smaller burns involving 30% TBSAB, covering the functional and cosmetically important areas such as the face, feet, neck, and ears may be accomplished with sheet grafts. The care of donor sites is critical. In extensively burned patients, theseareasmay need to bereharvested as soon as possible. Donor-site care should maximize re-epithelization and minimize trauma in an environment that promotes epithelial growth. Fine-mesh gauze remains the simplest, most inexpensive site dressing, and when re-epithelization has occurred beneath, the gauze is easily peeled from the wound. Using a synthetic substitute such as Duoderm as a donor-site dressing has decreased the healing time of donor but such dressings are expensive, more difficult touse, and will in all likelihood be unavailable in a wartime setting. When donor sites are limited, the burn wound is frequently closed temporarily, using material other than thc paticnt’s own goals of temporary wound coverage are to decrease the physiological impact of the open wound and to prevent bacterial colonization. Various biological dressings and skin substitutes now exist for achieving this goal. Cutaneous allograft, harvested from cadavers, is the most effective biological dressing and is the standard to which all other biologicaldressings and skin substitutes Fig. Whenacasualty’sdonor sites are limited, a meshed autograft,which can expand, allows a greater portion of the burned body surface to be covered.