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MANAGEMENT OF A BURN PATIENT
Dr sumer yadav
Aim of burn care
• Rescue
• Resuscitate
• Refer
• Resurface
• Rehabilitate
• Reconstruct
• Review
Principles of BURN MANAGEMENT
• Airway management-quick and appropriate
• Prompt and accurate fluid resuscitation
• Remova...
Which burn patients need
HOSPITALISATION?
• We go by the AMERICAN BURN ASSOCIATION
GUIDELINES
Management of the Patient With
a Burn Injury
6
• Burn care must be planned according to the burn depth
and local response,...
Table: phases of burn care
7
Phase Duration Priorities
Emergent or
immediate
resuscitative
From onset of injury to
complet...
INTENSIVE BURN CARE UNIT(IBCU)
INTENSIVE BURNS CARE UNIT(IBCU)
LEVELS OF ICU CARE
• Level - I – provides
monitoring, observation
and short term
ventilation.
• Level - II – Provides
Obse...
History
• Type of burn:
– Flame (open flame, closed space)
– Chemical (type of chemical)
– Scald (type of liquid)
– Electr...
A: Airway
History & Physical: Inhalational injury
• Fire in a closed space.
• Full-thickness/ deep
chemical burns to face,...
A: Airway
• Burned airways swell
rapidly.
• Intubate patient as
early as possible
before airway
swelling.
A: Airway
• Indications for intubation:
– Oropharyngeal erythema/ swelling on direct
visualization.
– Change in voice, har...
B: Breathing
• Circumferential full-
thickness burns may impair
ventilation.
• Blast injuries can cause
pneumothorax, lung...
C: Circulation
• BP, HR, color of unburnt skin
• 2 large bore I.V.s in unburnt skin
• Draw bloodwork.
• Insert urinary cat...
ASSESSMENT OF BURNS
• TBSA(Total body surface area)
• Decides fluid requirements and nutritional needs
• Wallace’s rule of...
Management of fluid loss and shock
Fluid Replacement Therapy:
• The total volume and rate of intravenous fluid
replacement...
Assessing adequacy of
resuscitation
• Peripheral blood pressure: may
be difficult to obtain – often
misleading
• Urine Out...
Conditions Leading to Burn Shock
21
Management of fluid loss and shock
Fluid Requirements:
• The projected fluid requirements for the first 24
hours are calcu...
Management of fluid loss and shock
Fluid Requirements:
• Adequate fluid resuscitation results in slightly
decreased blood ...
Fluid resuscitation
• Lactated Ringers - preferred solution
• Contains Na+ - restoration of Na+ loss is
essential
• Free o...
Guidelines and Formulas for Fluid
Replacement in Burn Patients
Consensus Formula
• Lactated Ringer’s solution (or other ba...
Guidelines and Formulas for Fluid
Replacement in Burn Patients
• The following example illustrates use of the
formula in a...
Guidelines and Formulas for Fluid Replacement in Burn Patients
Evans Formula
• 1. Colloids: 1 mL × kg body weight × % TBSA...
Guidelines and Formulas for Fluid
Replacement in Burn Patients
Brooke Army Formula
• 1. Colloids: 0.5 mL × kg body weight ...
Guidelines and Formulas for Fluid
Replacement in Burn Patients
Parkland/Baxter Formula
• Lactated Ringer’s solution: 4 mL ...
Guidelines and Formulas for Fluid
Replacement in Burn Patients
Hypertonic Saline Solution
• Concentrated solutions of sodi...
Pediatric Fluid resuscitation
• Use Parkland formula + MAINTENANCE fluid
• For maintenance fluid, hourly rate of
4 mL/kg f...
Fluid resuscitation
• Need to replace losses to maintain homeostasis.
• Formulas are ONLY GUIDELINES.
• Monitor physiologi...
Fluid resuscitation
• Fluid resuscitation should be started when
– >15% TBSA burns in an adult
– >10% TBSA in children and...
Fluid Management
• Start with RL in adults and Isolyte P in
children
• After 24 hrs start DNS
• If not adequate urine outp...
Electrical injury resuscitation
• Fluid needs greater
• 9 mL x TBSA burn (%) x body weight (kg) in
first 24 hrs
• If myogl...
Electrolyte Abnormalities
• HYPOKALEMIA- seen more often than
Hyperkalemia
• Commonest cause of non infective paralytic
il...
Electrolyte Abnormalities
• HYPOCALCEMIA-most commonly due to
Hypoalbuminemia
• Lowering of Ser Albumin by 1g/ml lowers Se...
Reducing the HYPERMETABOLIC
RESPONSE
• Temperature regulation
• Nutrition
• Pharamacological manipulation-Propranolol
40 m...
Effects of hypothermia
• Hypothermia may lead to acidosis/coagulopathy
• Hypothermia causes peripheral vasoconstriction an...
Prevention of hypothermia
• Cover patients with a dry
sheet – keep head covered
• Pre-warm trauma room
• Administer warmed...
Role of LMWH
• Incidence of Deep Vein Thrombosis is
significant enough to warrant routine use of
LMWH
• Incidence of Pulmo...
INTRAABDOMINAL HYPERTENSION
and
INTRAABDOMINAL
COMPARTMENT SYDROME
Abd compartment syndrome-
LAPAROTOMY
Nutrition
• Aggressive nutritional support to
counterbalance the effect of
Hypermetabolism and Protein catabolism
followin...
Nutritional support
• Calorie : Nitrogen = 100 : 1
• Protein requirement
– Adult: 2g/ kg/ day
– Child: 3g/ kg/ day
• Fat e...
Nutritional support
• Burns patient is hypercatabolic – up to 150-
200% above baseline.
• Nutrition needed for burns >20% ...
NUTRITION
• Burn patient caloric requirement 3000-
5000calories per day
• Early feeding
• Nasogastric tube No 10
• Hourly ...
BUTTERMILK DIET(BMD)
• Eggs- 4 /Protein
powders(Whey protein
or Soya protein)
• Bananas- 4
• Sugar- 4 Tbsf
• Curds (Yoghur...
Antibiotic Protocol
• FRESH BURN
• Start with a 3rd
gen Cephalosporin with an
aminoglycoside
• INFECTED OLD BURN
• Start w...
Pain Management
• Continuous infusion round the clock of
Tramadol 100mg
Ketamine 100mg
Midazolam 10mg
• In a 50cc syringe ...
Chest Physiotherapy
Limb Physiotherapy
Initial burn wound management
• Early transfer to burn centre (within first 24 hours):
– Remove smoldering, non-adherent c...
Procedures
• Tracheostomy
• Central line
insertion
• Escharotomy
• Debridement.
Dr. Sunil Keswani, National
Burns Centre, ...
Burn wound management
• Circumferential
extremity burns:
– Edema under eschar
– Remove all rings, jewelry
– Elevate, activ...
Burn wound management
• Bedside escharotomy
• 3rd degree burns
insensate
• Use electrocautery
• Mid-medial or mid-
lateral...
Esharotomy-LINES OF INCISION
Fasciotomy
• Pain
• Pallor-look at capillary refill
time-if less than 2 secs-
VENOUS OBSTRUCTION and
if more than 5 secs –...
Fasciotomy In Burns
Fasciotomy-methodology
Leg-FASCIAL COMPARTMENTS
Burn wound management
Specific anatomical areas:
Face - watch for airway compromise
Eyes - fluorescein exam, copious irr...
SURGICAL TECHNIQUES-ACUTE BURNS
EARLY EXCISION
Tangential excision and grafting-within first
72 hrs
Cadaveric skin from SK...
Early excision Vs Delayed excision
• Always early excision if patient comes early
enough and facilities exist
• Early enou...
Early Excision
• Within the first 3-5days
• After 5 days chances of Sepsis higher and
bleeding more
• 15% of BSA is excise...
Order of excision
• Areas easy and quick to excise: trunk and
legs
• Joints and throats
• Hands and face
Early Excision
• Blood Loss
– Clear pre-operative plan
– Excision prior to wound hyperemia
– Elevation of extremities
– To...
Early Excision
• Procedure (En Bloc)
– For deeper burns
– Skin and fat excised in one session
– Less time consuming
– Exci...
Meshed graft Vs Meek Micrografting
Vs Sheet Graft
• Acute burns always meshed or meek
micrografting for better takes
• Rec...
Dermatome with blade
DERMATOME-HARVESTING GRAFT
Fascial excision
Integra and ACTICOAT
Case -2 skin grafting
Cultured autologous keratinocytes
• Grown in vitro and then applied to wounds
• Take of cultured epithelial autografts dep...
Wound Closure
• Suggested Clinical Indications for CAE
– burn injuries >90% broad
– 70-90% more limited
– <70% no clear in...
PITFALLS IN BURN MANAGEMENT
• Early tracheostomy
• Prompt adequate resuscitation
• Infection control practices
• Pain reli...
PITFALLS IN BURN MANAGEMENT
• Escharotomy
• Fasciotomy
• Early excision and use of banked skin
• Fascial excison and use o...
TEAM APPROACH TO BURNS
• Plastic Surgeon
• General Surgeon
• Ophthalomologist
• ENT surgeon
• Intensivist
• Nephrologist
•...
thanks
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
management of a burn patient
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management of a burn patient

  1. 1. MANAGEMENT OF A BURN PATIENT Dr sumer yadav
  2. 2. Aim of burn care • Rescue • Resuscitate • Refer • Resurface • Rehabilitate • Reconstruct • Review
  3. 3. Principles of BURN MANAGEMENT • Airway management-quick and appropriate • Prompt and accurate fluid resuscitation • Removal of dead burnt skin and replacement with homograft(cadaveric skin from SKIN BANK) or biologic skin substitutes • Appropriate adequate nutrition • Good chest PT • Replacement of homograft with autograft or cultured skin(cultured keratinocytes)
  4. 4. Which burn patients need HOSPITALISATION? • We go by the AMERICAN BURN ASSOCIATION GUIDELINES
  5. 5. Management of the Patient With a Burn Injury 6 • Burn care must be planned according to the burn depth and local response, the extent of the injury, and the presence of a systemic response. • Burn care then proceeds through three phases: – Emergent/resuscitative phase (on-the-scene care), – Acute/intermediate phase, and – Rehabilitation phase. • Although priorities exist for each of the phases, the phases overlap, and assessment and management of specific problems and complications are not limited to these phases but take place throughout burn care.
  6. 6. Table: phases of burn care 7 Phase Duration Priorities Emergent or immediate resuscitative From onset of injury to completion of fluid resuscitation • First aid • Prevention of shock • Prevention of respiratory distress • Detection and treatment of concomitant injuries • Wound assessment and initial care Acute From beginning of diuresis to near completion of wound closure • Wound care and closure • Prevention or treatment of complications, including infection • Nutritional support Rehabilitati on From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment • Prevention of scars and contractures • Physical, occupational, and vocational rehabilitation • Functional and cosmetic reconstruction • Psychosocial counseling
  7. 7. INTENSIVE BURN CARE UNIT(IBCU)
  8. 8. INTENSIVE BURNS CARE UNIT(IBCU)
  9. 9. LEVELS OF ICU CARE • Level - I – provides monitoring, observation and short term ventilation. • Level - II – Provides Observation, Monitoring & Long Term Ventilation With Resident Doctors. • Level - III – provides all aspects of intensive care including invasive haemo dynamic monitoring & dialysis.
  10. 10. History • Type of burn: – Flame (open flame, closed space) – Chemical (type of chemical) – Scald (type of liquid) – Electrical (voltage, arcing/flame, contact time)
  11. 11. 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.
  12. 12. A: Airway • Burned airways swell rapidly. • Intubate patient as early as possible before airway swelling.
  13. 13. A: Airway • Indications for intubation: – Oropharyngeal erythema/ swelling on direct visualization. – Change in voice, harsh cough. – Stridor. – Dyspnea, tachypnea.
  14. 14. B: Breathing • Circumferential full- thickness 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).
  15. 15. 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, if necessary • Doppler exam of circumferentially burnt extremities
  16. 16. 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
  17. 17. Management of fluid loss and shock Fluid Replacement Therapy: • The total volume and rate of intravenous fluid replacement are gauged by the patient’s response. • The adequacy of fluid resuscitation is determined by: –Output totals of 30 to 50 mL/hour –systolic blood pressure exceeding 100 mm Hg and/or 19
  18. 18. Assessing adequacy of resuscitation • Peripheral blood pressure: may be difficult to obtain – often misleading • Urine Output: Best indicator unless ARF occurs • CVP: Better indicator of fluid status • Heart rate: Valuable in early post burn period – should be around 120/min. • > HR indicates need for > fluids or pain control • Invasive cardiac monitoring: Indicated in a minority of patients (elderly or pre-existing cardiac disease)
  19. 19. Conditions Leading to Burn Shock 21
  20. 20. Management of fluid loss and shock Fluid Requirements: • The projected fluid requirements for the first 24 hours are calculated by the clinician based on the extent of the burn injury. • Some combination of fluid categories may be used: –Colloids (whole blood, plasma, and plasma expanders) and – Crystalloids/electrolytes (physiologic sodium chloride or lactated Ringer’s solution). 22
  21. 21. Management of fluid loss and shock Fluid Requirements: • Adequate fluid resuscitation results in slightly decreased blood volume levels during the first 24 post-burn hours and restores plasma levels to normal by the end of 48 hours. • Oral resuscitation can be successful in adults with less than 20% TBSA and children with less than 10% to 15% TBSA. 23
  22. 22. Fluid resuscitation • Lactated Ringers - preferred solution • Contains Na+ - restoration of Na+ loss is essential • Free of glucose – high levels of circulating stress hormones may cause glucose intolerance
  23. 23. Guidelines and Formulas for Fluid Replacement in Burn Patients Consensus Formula • Lactated Ringer’s solution (or other balanced saline solution): 2–4 mL× kg body weight × % total body surface area (TBSA) burned. • Half to be given in first 8 hours; remaining half to be given over next 16 hours. 25
  24. 24. Guidelines and Formulas for Fluid Replacement in Burn Patients • The following example illustrates use of the formula in a management of a 70-kg patient with a 50% TBSA burn: • Steps –1, Consensus formula: 2 to 4 mL/kg/% TBSA –2, 2 × 70 × 50 = 7,000 mL/24 hours –3, Plan to administer: First 8 hours = 3,500 mL, or 437 mL/ hour; next 16 hours = 3,500 mL, or 219 mL/hour 26
  25. 25. Guidelines and Formulas for Fluid Replacement in Burn Patients Evans Formula • 1. Colloids: 1 mL × kg body weight × % TBSA burned • 2. Electrolytes (saline): 1 mL × body weight × % TBSA burned • 3. Glucose (5% in water): 2,000 mL for insensible loss • Day 1: Half to be given in first 8 hours; remaining half over next 16 hours • Day 2: Half of previous day’s colloids and electrolytes; all of insensible fluid replacement • Maximum of 10,000 mL over 24 hours. Second- and third-degree • (partial- and full-thickness) burns exceeding 50% TBSA are calculated • on the basis of 50% TBSA. 27
  26. 26. Guidelines and Formulas for Fluid Replacement in Burn Patients Brooke Army Formula • 1. Colloids: 0.5 mL × kg body weight × % TBSA burned • 2. Electrolytes (lactated Ringer’s solution): 1.5 mL × kg body weight × % TBSA burned • 3. Glucose (5% in water): 2,000 mL for insensible loss 28
  27. 27. Guidelines and Formulas for Fluid Replacement in Burn Patients Parkland/Baxter Formula • Lactated Ringer’s solution: 4 mL × kg body weight × % TBSA burned • Day 1: Half to be given in first 8 hours; half to be given over next16 hours • Day 2: Varies. Colloid is added. 29
  28. 28. Guidelines and Formulas for Fluid Replacement in Burn Patients Hypertonic Saline Solution • Concentrated solutions of sodium chloride (NaCl) and lactate with concentration of 250–300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired volume of urinary output. • Do not increase the infusion rate during the first 8 post burn hours. • Serum sodium levels must be monitored closely. • Goal: Increase serum sodium level and osmolality to reduce edema and prevent pulmonary complications. 30
  29. 29. 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/ iso-p (child’s liver not fully matured- limited glycogen stores).
  30. 30. 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► ►
  31. 31. 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)
  32. 32. Fluid Management • Start with RL in adults and Isolyte P in children • After 24 hrs start DNS • If not adequate urine output in 12 hrs start colloids FFP • More fluids required in Electric Burns and Inhalation Injury • Always central line (sometimes even thro burnt tissue) for initial resuscitation
  33. 33. 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
  34. 34. Electrolyte Abnormalities • HYPOKALEMIA- seen more often than Hyperkalemia • Commonest cause of non infective paralytic ileus • Serum K <3mEq/l KCl at 10mEq/hr • Serum K <2mEq/l KCl at 40mEq/hr • Daily Ser Electrolytes in first 3 days
  35. 35. Electrolyte Abnormalities • HYPOCALCEMIA-most commonly due to Hypoalbuminemia • Lowering of Ser Albumin by 1g/ml lowers Ser Calcium by 1g/ml • Alkalosis also lowers Ser Ca by increasing protein binding • Correction required only if symptomatic • Associated Hypomagnesemia needs simultaneous correction to prevent tetany and arrhythmias
  36. 36. Reducing the HYPERMETABOLIC RESPONSE • Temperature regulation • Nutrition • Pharamacological manipulation-Propranolol 40 mg BD and Oxandrolone 5mg BD • Early excision and homografting
  37. 37. Effects of hypothermia • Hypothermia may lead to acidosis/coagulopathy • Hypothermia causes peripheral vasoconstriction and impairs oxygen delivery to the tissues • Metabolism changes from aerobic to anaerobic serum lactate serum pH
  38. 38. Prevention of hypothermia • Cover patients with a dry sheet – keep head covered • Pre-warm trauma room • Administer warmed IV solutions • Avoid application of saline- soaked dressings • Avoid prolonged irrigation • Remove wet / bloody clothing and sheets • Paralytics – unable to shiver and generate heat • Avoid application of antimicrobial creams • Continual monitoring of core temperature via foley or SCG temperature probe
  39. 39. Role of LMWH • Incidence of Deep Vein Thrombosis is significant enough to warrant routine use of LMWH • Incidence of Pulmonary embolism is reduced significantly • Daltaparin or Enoxiparin • Fragmin or Clexane • This is stopped once patient is mobile
  40. 40. INTRAABDOMINAL HYPERTENSION and INTRAABDOMINAL COMPARTMENT SYDROME
  41. 41. Abd compartment syndrome- LAPAROTOMY
  42. 42. Nutrition • Aggressive nutritional support to counterbalance the effect of Hypermetabolism and Protein catabolism following Burns • ENTERAL feeding is preferred over PARENTERAL feeding
  43. 43. 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.
  44. 44. Nutritional support • Burns patient is hypercatabolic – up to 150- 200% above baseline. • Nutrition needed for burns >20% TBSA. • Curreri formula –Adult: 25kcal/kg/day + 40kcal/ % TBSA burn –Child: 60kcal/kg/day + 35kcal/ % TBSA burn
  45. 45. NUTRITION • Burn patient caloric requirement 3000- 5000calories 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
  46. 46. BUTTERMILK DIET(BMD) • Eggs- 4 /Protein powders(Whey protein or Soya protein) • Bananas- 4 • Sugar- 4 Tbsf • Curds (Yoghurt) -1000cc • Mixed with water to 1600cc
  47. 47. 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
  48. 48. 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
  49. 49. Chest Physiotherapy
  50. 50. Limb Physiotherapy
  51. 51. 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
  52. 52. Procedures • Tracheostomy • Central line insertion • Escharotomy • Debridement. Dr. Sunil Keswani, National Burns Centre, www.burns- india.com,
  53. 53. 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
  54. 54. Burn wound management • Bedside escharotomy • 3rd degree burns insensate • Use electrocautery • Mid-medial or mid- lateral, across joints • Recheck pulses - may have to do opposite side of limb
  55. 55. Esharotomy-LINES OF INCISION
  56. 56. Fasciotomy • Pain • Pallor-look at capillary refill time-if less than 2 secs- VENOUS OBSTRUCTION and if more than 5 secs – ARTERIAL OBSTRUCTION • Pressure • Pulselessnes • Paresthesia • Paralysis • Poikilothermia • Progression • Compartmental pressures above 25mm Hg warrant a FASCIOTOMY • There are devices to measure this pressure • Or use DOPPLER to decide
  57. 57. Fasciotomy In Burns
  58. 58. Fasciotomy-methodology
  59. 59. Leg-FASCIAL COMPARTMENTS
  60. 60. 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
  61. 61. 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
  62. 62. Early excision Vs Delayed excision • Always early excision if patient comes early enough and facilities exist • Early enough is upto 72 hrs postburn • Early excision decreases the chances of Sepsis and facilitates early moblisation and better and more predictable functional recovery. • Delayed excision is generally at 3 weeks or later
  63. 63. Early Excision • Within the first 3-5days • After 5 days chances of Sepsis higher and bleeding more • 15% of BSA is excised at a time • Coverage of excised area by Meshed Homograft is mandatory
  64. 64. Order of excision • Areas easy and quick to excise: trunk and legs • Joints and throats • Hands and face
  65. 65. Early Excision • Blood Loss – Clear pre-operative plan – Excision prior to wound hyperemia – Elevation of extremities – Tourniquet control – Dilute Epinephrine tumescent fluid – Epinephrine soaked sponges
  66. 66. Early Excision • Procedure (En Bloc) – For deeper burns – Skin and fat excised in one session – Less time consuming – Excision down to the natural cleavage plane – Down to fat or Fascia
  67. 67. Meshed graft Vs Meek Micrografting Vs Sheet Graft • Acute burns always meshed or meek micrografting for better takes • Reconstructive procedures like overgrafting and release of contractures always sheet grafting for better cosmesis • Meek micrografting gives wider coverage and more predictable takes than mesh grafting but more expensive
  68. 68. Dermatome with blade
  69. 69. DERMATOME-HARVESTING GRAFT
  70. 70. Fascial excision
  71. 71. Integra and ACTICOAT
  72. 72. Case -2 skin grafting
  73. 73. Cultured autologous keratinocytes • Grown in vitro and then applied to wounds • Take of cultured epithelial autografts depends on the wound bed • Expensive • Skilled labour and quality control, • 3–5 weeks to produce 1.8m2 confluent sheets of cells from a 2 cm2 biopsy • Fragile sheets • Blistering, infection, and contractures.
  74. 74. Wound Closure • Suggested Clinical Indications for CAE – burn injuries >90% broad – 70-90% more limited – <70% no clear indication
  75. 75. PITFALLS IN BURN MANAGEMENT • Early tracheostomy • Prompt adequate resuscitation • Infection control practices • Pain relief • Early enteral nutrition • Early mobilisation and Intensive chest PT • DVT prophylaxis
  76. 76. PITFALLS IN BURN MANAGEMENT • Escharotomy • Fasciotomy • Early excision and use of banked skin • Fascial excison and use of banked skin or autografts • Early rehabilitation- physical,social,psychological
  77. 77. TEAM APPROACH TO BURNS • Plastic Surgeon • General Surgeon • Ophthalomologist • ENT surgeon • Intensivist • Nephrologist • Anesthesiologist • Cardiologist • Psychiatrist Nurses Microbiologist Physiotherapist Occupational therapist Psychological Counsellor Social Worker Dietitian Prevention team
  78. 78. thanks
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