Patient stability and the extent and depth of burn injury should determine the timing of burn surgery among the priorities of patient care. Small burns (<10 per cent TBSA) are rarely life threatening and risk of infection is usually low; therefore surgery should be delayed until it is clearly indicated and can be performed with minimal risk. The surgeon may elect to follow small burns of indeterminate depth for 10 to 14 days to permit separation of superficial eschar, which will either confirm or obviate the need for surgery. Such observation is justified provided that the patient is stable and ambulatory, wound care and pain control are adequate, and there is no evidence of infection. In most cases, wounds that have not separated after 14 days will benefit from excision and skin grafting. ( CD Fig,u,re,,,,4)
CD Figure 4. Separation of eschar. This photograph demonstrates a partial-thickness burn approximately 5 days after injury. Large sheets of eschar are separating during daily cleansing, and can be removed with a gauze pad. The translucent, irregular, and slightly granular tissue revealed beneath the separating eschar consists of dermis and epidermal "buds&3148; beginning to emerge from hair follicles and sweat glands. When this type of eschar separation is observed within 10 to 14 days of injury, it is safe to assume that the wound will heal without skin grafting.
With increasing extent of injury, obtaining rapid wound coverage becomes progressively more urgent as a means of preventing infection. Deep burns of 10 to 20 per cent TBSA should be excised within 1 to 2 weeks of injury; larger wounds should be removed as soon as the patient's medical status will allow. In treating truly major injuries (3 40 per cent TBSA), all but obviously superficial burns must be excised as the importance of removing eschar precludes observation of indeterminate wounds. Herndon (see Mullerefa/ 1996) has advocated complete removal of massive burns within 24 to 48 h of injury, but most experts limit each excision to 20 to
25 per cent TBSA; larger wounds are removed in a series of procedures over a period of 7 days. Even this more conservative approach means that patients are subjected to major operations within a day or two of injury, often before resuscitation and hemodynamic stability have been achieved. Careful planning and attention to perioperative care are critical for such procedures to be performed safely.
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