1. MANAGEMENT OF A SEVERELY
BURNT PATIENT
Dr Sunil Keswani
NATIONAL BURNS CENTRE
Navi Mumbai
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

2. Aim of burn care
•
•
•
•
Rescue
Resuscitate
Refer
Resurface
• Rehabilitate
• Reconstruct
• Review
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

3. INTENSIVE BURN CARE UNIT(IBCU)
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

4. INTENSIVE BURNS CARE UNIT(IBCU)
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

5. History
• Type of burn:
– Flame (open flame, closed space)
– Chemical (type of chemical)
– Scald (type of liquid)
– Electrical (voltage, arcing/flame, contact time)
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

6. FIRST-AID FOR BURNS
• Pour Water on Burns till the
burning sensation subsides
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

7. A: Airway
History & Physical: Inhalational injury
• Fire in a closed space.
• Full-thickness/ deep
chemical burns to face,
neck.
• Singed nasal hair.
• Carbonaceous sputum.
• Carbonaceous particles in
oropharynx.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

8. A: Airway
• Burned airways swell
rapidly.
• Intubate patient as
early as possible
before airway
swelling.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

9. A: Airway
• Indications for intubation:
– Oropharyngeal erythema/ swelling on direct
visualization.
– Change in voice, harsh cough.
– Stridor.
– Dyspnea, tachypnea.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

10. B: Breathing
• Circumferential fullthickness burns may impair
ventilation.
• Blast injuries can cause
pneumothorax, lung
contusions.
• Noxious chemical (plastic)
can cause a chemical
pneumonitis.
• Carbon monoxide poisoning
(if COHb > 15-40%
ventilate).
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

11. C: Circulation
•
•
•
•
•
•
BP, HR, color of unburnt skin
2 large bore I.V.s in unburnt skin
Draw bloodwork.
Insert urinary catheter.
Insert nasogastric tube.
Doppler exam of circumferentially burnt
extremities
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

12. ASSESSMENT OF BURNS
• TBSA(Total body surface area)
• Decides fluid requirements and nutritional needs
• Wallace’s rule of nines
• Lund and Browder chart
• DEPTH
• Dictates local and surgical wound management
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

13. ASSESSMENT OF BURN WOUND DEPTH
• Clinical-wound appearance,blanching,capillary return,degree of
fixed capillary staining,evaluation of retained light touch and
sensation
• Wound biopsy
• Measurement of tissue perfusion-Laser Doppler
Flowmetry,Indocyanine Green Video Angiography,Fluroscein
Fluoresecence
• Photooptical measurements—Reflection-optical Multispectral
Imaging,Fibreoptic Confocal Imaging,Polarisation Sensitive
Optical Coherence Tomography
• Thermography
• Radioisotopes and Nuclear Magnetic Resonance
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

14. Fluid resuscitation
•
•
•
•
Need to replace losses to maintain homeostasis.
Formulas are ONLY GUIDELINES.
Monitor physiologic parameters.
Maintain adequate tissue perfusion to prevent
increase in depth of burn.
• Too little fluid ► Hypotension ► renal failure, etc.
• Too much fluid ► Edema ► Tissue hypoxia
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

15. Fluid resuscitation
• Fluid resuscitation should be started when
– >15% TBSA burns in an adult
– >10% TBSA in children and elderly
• First 8-12 hrs: intravascular volume shifts to
interstitial space.
• Fast fluid boluses are of no benefit.
• Colloids: Questionable in first 24 hrs (capillary
leakage)
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

16. Fluid resuscitation
Parkland Formula
• Total fluid requirement in first 24 hrs =
4ml x TBSA burn (%) x body weight (kg)
50% given in first 8 hours from time of injury
50% given over next 16 hours.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

17. Pediatric Fluid resuscitation
• Use Parkland formula + MAINTENANCE fluid
• For maintenance fluid, hourly rate of
4 mL/kg for first 10 kg of body weight plus
2 mL/kg for second 10 kg of body weight plus
1 mL/kg for >20 kg of body weight
• End point: urine output of 1.0-1.5 mL/kg/hr
• Maintenance fluid given is D5W/E45 (child’s liver not
fully matured- limited glycogen stores).
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

18. Electrical injury resuscitation
• Fluid needs greater
• 9 mL x TBSA burn (%) x body weight (kg) in
first 24 hrs
• If myoglobinuria, may require bicarbonate
infusion to alkalinize urine to pH > 8
• End point: urine output of 1.5-2 mL/kg/hr
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

19. Antibiotic Protocol
• FRESH BURN
• Start with a 3rd gen Cephalosporin with an
aminoglycoside
• INFECTED OLD BURN
• Start with a semisynthetic Penecillin like Pipra
and Tazobactum or a Carbapenem
• LATER go by wound swabs culture and sensitivity
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

20. Pain Management
• Continuous infusion round the clock of
Tramadol 100mg
Ketamine 100mg
Midazolam 10mg
• In a 50cc syringe in a syringe pump
• Resting Pain-At 4-6cc per hour to start and then
titrate with pain response
• Procedural Pain-During dressing 30-40cc per hour
and titrate
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

21. Nutritional support
• Burns patient is hypercatabolic – up to 150200% above baseline.
• Nutrition needed for burns >20% TBSA.
• Curreri formula
– Adult: 25kcal/kg/day + 40kcal/ % TBSA burn
– Child: 60kcal/kg/day + 35kcal/ % TBSA burn
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

22. Nutritional support
• Calorie : Nitrogen = 100 : 1
• Protein requirement
– Adult: 2g/ kg/ day
– Child: 3g/ kg/ day
• Fat emulsion
– 4g/ kg/ day max.
• Carbohydrate (glucose)
– 6.2mg/ kg/ min. max.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

23. NUTRITION
• Burn patient caloric requirement 30005000calories per day
• Early feeding
• Nasogastric tube No 10
• Hourly tube feeding
Butter milk diet 1cal/cc
Eggs
4
Bananas
4
Sugar
4Tbs
Curd
1 litre
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

24. Initial burn wound management
• Early transfer to burn centre (within first 24 hours):
–
–
–
–
Remove smoldering, non-adherent clothes.
No debridement or topical agents needed.
Clean, dry sheets,
Wet dressing cause heat loss.
• If transfer is delayed > 24 hours:
– Unroof blisters >2 cm, cleanse with chlorhexidine
– Silver sulfadiazine cream OD or Povidone Iodine solution
and Vaseline gauze
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

25. Burn wound management
• Circumferential
extremity burns:
–
–
–
–
Edema under eschar
Remove all rings, jewelry
Elevate, active motion
Check skin color,
sensation, capillary refill,
Doppler pulses q1h
– Rule out hypotension,
arterial injury
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

26. Burn wound management
• Bedside escharotomy
• 3rd degree burns
insensate
• Use electrocautery
• Mid-medial or midlateral, across joints
• Recheck pulses - may
have to do opposite side
of limb
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

27. Fasciotomy In Burns
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

28. Burn wound management
Specific anatomical areas:
Face - watch for airway compromise
Eyes - fluorescein exam, copious irrigation,
antibiotic ointment,mydriatics
Ears - external canal, TM (children, perf in blast
injury)
Genitalia, perineum - insert Foley to stent urethra
 treat scrotal edema conservatively
 diverting colostomy NOT automatically indicated in perineal
burns
Dr. Sunil Keswani, National
Burns Centre, www.burnsindia.com,

29. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

30. SURGICAL TECHNIQUES-ACUTE BURNS
EARLY EXCISION
Tangential excision and grafting-within first
72 hrs
Cadaveric skin from SKIN BANK
DELAYED EXCISION
Fascial excision and grafting-after 72hrs
Cadaveric skin from SKIN BANK
Dr. Sunil Keswani, National Burns
Centre, www.burns-india.com,
nbcairoli@gmail.com

31. Dr. Sunil Keswani, National Burns
Centre, www.burns-india.com,
nbcairoli@gmail.com
Dermatome with blade

32. DERMATOME-HARVESTING GRAFT
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

33. Fascial excision
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

34. Integra and ACTICOAT
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

35. Skin grafting of extensive Burns
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

36. Case -2 skin grafting
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

37. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

38. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com

39. NATIONAL BURNS CENTRE
Burns Helpline:
+91 22 2779 3333
www.burns-india.com
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns
Centre, www.burns-india.com,
nbcairoli@gmail.com