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Combined
Burn
Therapy
Utilizing
Immediate
Skin
Allografts
and
0.5%
AgNO3
John
F.
Burke,
MD,
and
Conrado
C.
Bondoc,
MD,
Boston
DURING
the
last
few
years,
the
use
of
several
topically
applied
antibacterial
sub-
stances
has
been
shown
to
provide
an
ap-
proach
to
satisfactory
control
of
burn
wound
sepsis.
Clinical
experience
has
shown,
how-
ever,
that
even
with
successful
controlof
surface
infection,
the
overall
status
of
the
extensively
burned
patient
remains
precar-
ious
until
skin
coverage
is
accomplished.
It
appears
that
the
metabolic
demands
inher-
ent
in
maintenance
of
homeostasis
and
in
repair
of
damagedtissue,
if
carried
onover
a
long
period
of
time,
may
approach
a
magni-
tude
with
which
the host
cannot
cope.
Therefore,
the
rate at
which
the
burn
wound
is
closed
is
a
primary
factor
in
the overall
treatment
of
the
burned
patient.
In
order
to
avoid
longperiods
of
stress
produced
by
a
large
open
burn
wound,
a
number of
attempts
havebeen
made
topro-
duce
a
suitable
synthetic
material which
would
provide
a
temporary
skin
substitute.
Clinical
success
has
yet
to
be
achieved.
At
this
time,
the
only
successful
means
of
pro¬
viding
a
physiologic
"skin
surface"
which
will
reverse
the
extraordinary
metabolic
de¬
mands
on
the
burn
patient
is
the
use
of
skinitself.
There
is
good
reason
to
believe
that
for the
period
prior
to
sensitization
and
re¬
 jection,
split
skin
allografts
(homografts)
act
in
the
same
physiologic
way
as
auto-
grafts.
In
the late
stages
of
therapy,
consid¬
erable
experience
in
the
use
of
these allo¬
grafts
as
temporary
cover
for
areas
of
full-thicknessskin
loss
has
been
gained.
Al¬
though
this
may
be
life
saving,
the
late
use
of
allografts
to
cover
open
areas
following
slough
separation
in
full-thickness
skin
loss
leaves
much
to
be
desired.
This
type
of
skin
closureis
but
a
temporary
covering
to
be
re¬
 jected
by
the
patient
with
the
development
Submitted
for
publication
Feb
2,
1968.
From
the
Department
of
Surgery,
Harvard
Medi-
cal
School
and
the
General
Surgical
Services,
Mas-
sachusetts
General
Hospital,
Boston.
Reprint
requests
to
the
Department
of
Surgery,
Massachusetts
General
Hospital,
Boston
(Dr.
Burke).
of
sensitivity.
Success
depends
on
an
accu¬
rate
control
of
sepsis
not
always
present
even
with
the
topical
therapy
now
available.
Perhaps
most
important,
it
is
a
late
measure
designed
to
holdtheline
at
a
time
of
meta¬
bolic
crisis.
Nothing
isdone
to
alter
the
ini¬
tial
phase
of
the
burn
illness
or
to
increase
the
rate
of
healing
to
shortenthe
overall
pe¬
riod
of
this
illness.
With
an
eye
to
decreasing
this
period
of
healing,
it
is
now
reasonable
to
reexplore
the
possibilities
of
immediate
skin
closure.
The
control
of
burn
wound
infection
which
has
come
with
the
development
of
efficient
topi¬
cal
antibacterial
therapy
has
produced
im¬
portant
changes
in
both
the
clinical
state
of
the
patient
and
the
natural
history
of
the
burn
wound.
In
the
latter
area,
it
is
now
clear
that
the
spector
of
late,
unavoidable,
destructiveinfection
need
no
longer
inhibit
early
efforts
at
repair
of
the
burn
wound.
The
following
is
a
description
of
a
methodwhich
attempts
to
approach
immediate
burn
wound
closure
via
a
combination
of
the
in¬
fection
controlling
aspects
of
topical
0.5%
AgNOg
and
the woundclosure
potential
of
immediately
applied
skin
allografts
to
areas
of
second
and
third
degree
burn.
Materials
and
Methods
All
patients
admitted
to
this
study
were
as¬
sessed
immediately
upon
admission
to
the
hos¬
pital. Following
initial
management
of
the
burn
wound,
topical
0.5%
AgNO:i
therapy
was
car¬
ried
out
with
only
slight
modification
in
the
re¬
gime
as
published
by
Moyer
et
al.1
Systemic
management
was
carried
out
in
the
usual
fash¬
ion
using
plasma
containing
solutions.2
LocalTreatment
of
Burned
Areas.—Theburned
areas
were
cleaned
by
washing
all
oil
or
grease
from
the surface.
Loose
skin,
blebs,
and
foreign
material
were
debrided.
Viable
split-
thickness
cadaver
skin
allografts,
or
donor skin
allografts
from
parents
or
siblings,
were
imme¬
diately
applied
over
all
test-burn
areas
irre¬
spective
of
the
clinical
judgement
of
the
depth
 
of
burn.The
allografts
were
then
covered
with
AgNOa
dressings.
Control
areas
were
treated
with
topical
0.5%
AgN03
therapy
alone.
The
control
areaswere
selected
to
match
allografted
areas
anatomically
as
well
as
in
depth
ofburn
(ie,
hand
for
hand,
forearm
for
forearm, etc).
Allografts
were
applied
without
anesthesia
at
the
bedside.
These
were
secured
in
place
by
the
application
of
several
layers
of
wide
mesh
gauze
dressings
soaked
with
0.5%
AgN03.
The
topical
AgN03
therapy
was
carried
on
in
both
the
grafted
and
nongrafted
areas
in
exactly
the
same
way
as
described
above.
The
patient
and
the
dressings
were
then
covered
with
a
dry
blanket,
considerably
diminishing
surface
evap¬
oration
and,
therefore,
evaporative
heat
loss
from
the
wound
surface.
It
was
felt
important
that
the
dressings
were
kept
continuously
wet
with
AgN03
by
pouring
an
excess
of
the
solu¬
tion
on
to
the
dressings
every
two
hours.
Dress¬
ings
were
changed
daily
without
anesthesia.
Any
skin
allografts
removed
by
the
daily
dress¬
ing
change
were
replaced
with
fresh
grafts.
During
these
dressing
changes,
any
gentle
de¬
bridement
necessary
was
carried
out,
again
without
anesthesia.
Skin
grafts
were
allowed
to
remain
in
place
until
they
peeled
spontaneous¬
ly
off
areas
of
healed,deep
second-degree
burns
or
began
to
be
rejected
from
areas
of
third-de¬
gree
burns.
Split-Thickness
Skin
Allografts.—Split-thick¬
ness
human
skin
was
obtained
from
cadavers
within
eight
hours
of
death.
Patients
who
had
died
with
a
history
of
malignant
disease,
cur¬
rentinfectious
disease,
or
a
history
of
jaundice
were
not
used.
An
aseptic
technique
was
used
to
obtain the
grafts,
including
preparation
and
draping
of
donor
sites,
as
well
as
the
use
of
sterile
gowns,
instruments,
and
gloves.
A
Brown
dermatome
was
used
for
the removal
of
skin
(11/1000-inch
thickness)
after
which
the
skin
allografts
were
wrapped
in
sterile
sponges
soaked
in
normal
saline
solution,
placed
in
ster¬
ile
Petri
dishes
and
refrigerated
at
4
C
until
used.
Skin
for
grafting
was
not
kept
longer
than
two
weeks
before
use.
Results
Sixty-five
patients
with
second-
and
third-
degree
burns
involving
between
30%
to
85%
of
the
body
surface
were
treated
by
the
use
of
topical
0.5%
AgN03
in
combination
with
skin
allografts.
In
the
patients
studied,
heal¬
ing
of
partial-thickness
bums
(superficial
and
deep)
occurred
beneath
the
allografts
within
a
period
of
10
to
18
days
(Fig
1
and
2).
This
is
accomplished
by
reepithelializa-
tion
of
the
burn
surface
from
remaining
epi¬
thelial
elements.
Following
reepithelializa-
tion,
the
allograft
dried
and
separated
as
a
thin
scale.
There
was
no
clinical
evidence
of
rejection
of
allografts
covering
areas
of
par¬
tial-thickness
skin
loss
which
healed
sponta¬
neously.
Areas
of
full-thickness
injury
de¬
clared
themselves
by
the
end
of
the
first
week.
In
these
areas,
the
immediately
ap¬
plied
split-thickness
skin
allografts
did
not
take.
These
areas
were
debrided,
and
as
the
slough
separated
they
were
allografted.
As
soon
as
the
skin
allografts
began
to
take,
these
areas
were
autografted.
In
the
control
areas
treated
with
0.5%
AgN03
healing
of
partial-thickness
burns
proceeded
at
a
muchslower
rate.
It
was
not
possible
to
quantitate
the
difference
between
areas
in
each
group
requiring
an
autografi
for
final
closure.
There
was,
however,
strong
indication
that
small
areas
of
full-thickness
skin
loss
healed
considerably
faster
by
edge
migration
when
treated
with
a
combination
of
allografts
and
AgN03.
Early
in
the
study,
allografts
alone
were
used
without
AgN03.
In
these
patients,
con¬
siderable
sepsis
developed
in
the
cracks
and
spaces
between
grafts,
and
spread
to
destroy
the
adjacent
allografts.
This
technique
was
therefore
replaced
by
the
use
of
AgN03
di¬
rectly
over
the
allografted
areas
in
exactly
the
same
manner
as
is
used
in
ungrafted
areas.
The
following
case
reports
will
illustrate
the
clinical
course
of
patients
treated
with
combined
therapy.
Report
of
Cases
CASE
1.—A
56-year-old
white
man
sustained
75%
body
burns
following
an
industrial
acci¬
dent.
Burned
areas
included
the
face,
scalp,
ears,
neck,
anterior
and
posterior
trunk,
both
upper
extremities
including
hands and
fingers,
and
anterior
right
thigh
and
leg,
as
well
as
the
left
mid-leg
and
knee.
No
respiratory
tract
burn
was
noted.
It
was
initially
estimated
that
the
patient
hadsustained
a
40%
full-thickness
burn
with
the
remaining
burn
a
deep
second
degree.
Upon
admission,
after
initial
manage¬
ment
of
fluid
requirements
was
begun,
the
burn
wound
was
carefully
cleansed
and
blebs
re¬
moved.
Skin
allografts
were
immediately
ap¬
plied
over
the
burn
areas
on
the
anterior
chest
wall,
both
ears,
right
shoulder
and
arm,
elbows
and
dorsum
of
both
hands
and
fingers
(Fig
1).
 
Fig
1.—Thirty-six
hours
following
75%
to¬
tal
body-surface
burn.
Allografts
in
place
on
shoulders,
both
arms,
and
chest.
Fig
2.—Ninth
postburn
day
following
75%
body-surface
burn.
Skin
allografts
placed
im¬
mediately
following
admission
are
beginning
to
"flake"
off.
Under
these,
epithelial
re¬
generation
is
virtually
complete.
This is
most
prominent
in
area
of
left
forearm
and
right
upper
arm.
Fig
3.—Thirtieth
hospital
day
following
75%
total
body-surface
burn
showing
com¬
plete
healing
of
extensive
areas
of
partial-
thickness
burns
and
the
small
irregularities
of
full-thickness
burn
treated
by
immediate
allograft
and
0.5%
AgN03
therapy
on
face,
trunk,
and
both
upper
extremities.
of 00

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