Pitfalls in Burn Management

PITFALLS IN BURN
MANAGEMENT
Dr Sunil Keswani

Cosmetic Surgeon and Burns Surgeon
NATIONAL BURNS CENTRE
Navi Mumbai

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

Aim of burn care
•
•
•
•

Rescue
Resuscitate
Refer
Resurface

• Rehabilitate
• Reconstruct
• Review

nbcairoli@gmail.com

nbcairoli@gmail.com

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)
nbcairoli@gmail.com

Which burn patients need
HOSPITALISATION?

• We go by the AMERICAN BURN ASSOCIATION
GUIDELINES
nbcairoli@gmail.com

Does a child with only head face
burns require hospitalisation?
• YES.
• The head face in a child constitues about 18%
BSA while in an adult it is 9 %!!
• Anything above 10% BSA in a child needs
hospitalisation
nbcairoli@gmail.com

How do we reduce INFECTION IN
BURNS?
• Hand washing
• Infection control measures like Isolation,Use
of disposables,Separate bedpan,stethoscope
and BP apparatus for each burn patient and a
1:1 nurse patient ratio.

nbcairoli@gmail.com

Philipp Ignaz Semmelweis
• Hungarian Physician
reduced the incidence
of Puerperal Fever in a
Vienna Hospital by
introducing the practice
of HAND WASHING with
chlorinated water

nbcairoli@gmail.com

Louis Pasteur
• French microbiologist
and chemist
• Germ theory of disease
• Founder of
Microbiology along with
Robert Koch
• Pasteurisation of milk
• Popularised the concept
of HAND WASHING
nbcairoli@gmail.com

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.

nbcairoli@gmail.com

BED STRENGTH
• IDEALLY 8 TO 12 BEDS.
• LARGER AREAS –
DIFFICULT TO
ADMINISTER AND
SMALLER AREAS NOT
BEING COST EFFECTIVE.
• 5 TO 8 BEDS PER 50
HOSPITAL BEDS FOR A
LEVEL III ICU / 10-16%
OF THE TOTAL NUMBER
OF HOSPITAL BEDS.
nbcairoli@gmail.com

BED SPACE & BEDS
• ALL SEPARATE CUBICLES
• 225 – 250 SQUARE FEET
PER BEDS
• BEDS - ADJUSTABLE, NO
HEAD BOARD, SIDE RAILS
AND WITH
WHEELS,REMOTE
CONTROLLED WITH
FACILITY FOR ALL
POSITIONING FOR
NURSING CARE AND
PHYSIOTHERAPY AND
EMERGENCY SITUATIONS

nbcairoli@gmail.com

Fluid Management
•
•
•
•

Fluids per hour=Wt(kg) x % of Burns divided by 4
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
• CVP above 10 cms water and inadequate uo Inj
Lasix
• More fluids required in Electric Burns and
Inhalation Injury
• Always central line (sometimes even thro burnt
tissue) for initial resuscitation
nbcairoli@gmail.com

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

nbcairoli@gmail.com

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
nbcairoli@gmail.com

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
nbcairoli@gmail.com

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
nbcairoli@gmail.com

Reducing the HYPERMETABOLIC
RESPONSE
• Temperature regulation
• Nutrition
• Pharamacological manipulation-Propranolol
40 mg BD and Oxandrolone 5mg BD
• Early excision and homografting

nbcairoli@gmail.com

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
nbcairoli@gmail.com

Role of Intermittent Compression
Device
• Intermittent
compression pump
along with LMWH
decreases the incidence
of DVT by as much as
50%

nbcairoli@gmail.com

Nutrition
• Aggressive nutritional support to
counterbalance the effect of
Hypermetabolism and Protein catabolism
following Burns
• ENTERAL feeding is preferred over
PARENTERAL feeding

nbcairoli@gmail.com

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

nbcairoli@gmail.com

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
Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com

Tracheostomy
• Head face neck
burns IMMEDIATE
TRACHEOSTOMY to
facilitate airway and
nursing


Chest Physiotherapy

nbcairoli@gmail.com

Limb Physiotherapy

nbcairoli@gmail.com

Fasciotomy

• Pain
• Pallor-look at capillary refill
• Compartmental
time-if less than 2 secspressures above
VENOUS OBSTRUCTION and
25mm Hg warrant
if more than 5 secs –
a FASCIOTOMY
ARTERIAL OBSTRUCTION
• Pressure
• There are devices
• Pulselessnes
to measure this
• Paresthesia
pressure
• Paralysis
• Poikilothermia
• We use DOPPLER
to decide
• Progression
nbcairoli@gmail.com

Fasciotomy-LINES OF INCISION

nbcairoli@gmail.com

Fasciotomy-methodology

nbcairoli@gmail.com

Leg-FASCIAL COMPARTMENTS

nbcairoli@gmail.com

Esharotomy
• Thick circumferential non-yielding
eschar warrants an ESHCAROTOMY


Esharotomy-LINES OF INCISION

nbcairoli@gmail.com

Esharotomy

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INTRAABDOMINAL HYPERTENSION
and
INTRAABDOMINAL
COMPARTMENT SYDROME

nbcairoli@gmail.com

Abd compartment syndromeLAPAROTOMY

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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
nbcairoli@gmail.com

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

nbcairoli@gmail.com

Order of excision
• Areas easy and quick to excise: trunk and
legs
• Joints and throats
• Hands and face

nbcairoli@gmail.com

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

nbcairoli@gmail.com

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

nbcairoli@gmail.com

Allograft
Classic benefits of allograft as a physiologic and
mechanical barrier:

• Reduction in water, electrolyte and protein
loss
• Reduction in energy requirements
secondary to the attainment of a closed
wound
• Reduction in wound infection rates
• Reduction in pain
• Conservation of autografts
• Improved general welfare and psychological
outlook of the patient
nbcairoli@gmail.com

Allograft
• Reduction in the number of bacteria under a
biological dressing
• Phagocytes within a wound use the fibrin
network established between the allograft and
the wound to trap and phagocytose bacteria
without the production of opsonins or antibody
• The effects of allografts in reducing bacteria
and promoting healing have proven beneficial

nbcairoli@gmail.com

Porcine Skin

nbcairoli@gmail.com

Porcine skin being meshed

nbcairoli@gmail.com

Differences Between Skin Substitutes
• Materials that are applied for short periods
then removed, to stimulate autologous healing
• Cell free material that encourage colonization
by autologous cells, to stimulate new skin
formation
• Cell containing skin substitutes: to provide
immediate functional replacement

nbcairoli@gmail.com

Integra
•
•
•
•

Most widely accepted synthetic skin substitute
Bilaminar structure
The median ‘take’ is 85%
Two-stage procedure, with a minimum interval
of 3 weeks between the application of the
Integra and the split-skin grafting
• Relatively expensive

nbcairoli@gmail.com

Integra

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Acticoat

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Fascial Excision

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Integra applied

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Covered with Acticoat

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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.

nbcairoli@gmail.com

Wound Closure
• Suggested Clinical Indications for CAE
– burn injuries >90% broad
– 70-90% more limited
– <70% no clear indication

nbcairoli@gmail.com

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
nbcairoli@gmail.com

MATERIALS & METHODS
Surplus cutting

nbcairoli@gmail.com

MATERIALS & METHODS
Positioning on plate.

nbcairoli@gmail.com

MATERIALS & METHODS
Dermatome cut through

nbcairoli@gmail.com

MATERIALS & METHODS
Adhesive Spraying

nbcairoli@gmail.com

MATERIALS & METHODS
Cork removing.

nbcairoli@gmail.com

MATERIALS & METHODS
Gauze expansion

nbcairoli@gmail.com

MATERIALS & METHODS
Gauze expanded.

nbcairoli@gmail.com

MATERIALS & METHODS
Micrograft positioning

nbcairoli@gmail.com

MATERIALS & METHODS
After gauze removal. 7th day.

nbcairoli@gmail.com

MATERIALS & METHODS
10th day wound care.

nbcairoli@gmail.com

MATERIALS & METHODS
Long term control.

POST-PHYSICAL REHABILITATION OUTCOME

nbcairoli@gmail.com

DISCUSSION
•
•
•
•
•
•
•
•

Reliable alternative.
Easy technique.
Larger expansions.
High integration.
Fast epithelization.
Better infection response versus mesh graft.
Easy to handle because of its pliability.
Comparative with mesh tecniques and functional
results studies are required in the future.

nbcairoli@gmail.com

NEED FOR PAIN RELIEF
•
•
•
•
•
•
•

PAIN IS A FORM OF STRESS AND PRODUCES ELEVATION IN STRESS
HORMONES AND CATECHOLAMINES.
PAIN RELIEF ADVANTAGES:SHORTER HOSPITAL STAY.
IMPROVED MORTALITY RATES
LESS CATABOLISM AND ENDOCRINE DERANGEMENTS.
FEWER THROMBOEMBOLIC COMPLICATIONS
PAIN FREE DRESSINGS MAKE PATIENTS MORE COMFORTABLE AND
DECREASES THE MORBIDITY AND MORTALITY.

nbcairoli@gmail.com

NEED FOR PAIN RELIEF
• Circumferential chest burns-pain restricts full
respiratory excursions ,atelectasis and pneumonias
• Pain prevents patients from eating well-nutrition
affected.
• Pain depresses the patient-psychosomatic problems
• Pain contributory to Post burn psychosis
• Pain-poor compliance during physiotherapy-poor
rehabilitation-poor functional outcome

nbcairoli@gmail.com

Mentosternal Contracture

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Homogrft and Autograft

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Penoscrotal burns

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PRE-OP

POST-OP

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CLINICAL USE OF
HOMOGRAFT
AT NBC

nbcairoli@gmail.com

Skin Bank and Skin Donation
DONATE SKIN AND SAVE A LIFE

nbcairoli@gmail.com

PATIENT
DETAILS
Patient Name- Neeta Parekh
Age- 48
Gender- Female
TBSA Of Burns- 35%
Degree Of Burns-2nd Degree
Areas Of Burns-chest, Both
Upper Extremities
Cause Of Burns-During Lighting
Diya

nbcairoli@gmail.com

ADMISSION FORM

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PHOTOS ON DAY OF ADMISSION

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EARLY BURN EXCISION

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APPLICATION OF HOMOGRAFT

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1ST DRESSING CHANGE OF HOMOGRAFT

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2ND DRESSING CHANGE OF HOMOGRAFT (4TH DAY)

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3RD DRESSING CHANGE OF HOMOGRAFT (6TH DAY)

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FOLLOW UP

nbcairoli@gmail.com

END RESULT

nbcairoli@gmail.com

PATIENT DETAILS
Patient Name- Ramsingh
Age- 52
Gender- Male
TBSA Of Burns- 55%
Areas Of Burns- Face ,Chest,
Both Upper Extremities,,
Lower Extremities.
Cause Of Burns- Explosion
nbcairoli@gmail.com

2NDDRESSING CHANGE OF HOMOGRAFT

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5TH DRESSING CHANGE OF HOMOGRAFT

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2ND DRESSING CHANGE OF HOMOGRAFT

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2ND STAGE TANGENTIAL EXCISION

nbcairoli@gmail.com

2ND DRESSING CHANGE OF HOMOGRAFT (4TH
DAY)

nbcairoli@gmail.com

TREATMENT GOING ON

BEFORE
TREATMENT

AFTER
TREATMENT
nbcairoli@gmail.com

PATIENT DETAILS

Patient Name- Yojana D.
Ghase
Age- 24
Gender- Female
TBSA Of Burns- 20%
Deep
Areas Of Burns- Chest,
Abdomen, Right Upper
Extremity, Lower Face .
Cause Of Burns-flame Burn.
nbcairoli@gmail.com

4TH DRESSING CHANGE OF HOMOGRAFT

nbcairoli@gmail.com

BEFORE AUTOGRAFTING
AUTOGRAFTING

nbcairoli@gmail.com

AFTER

PITFALLS IN BURN MANAGEMENT
•
•
•
•
•
•
•
•

Early tracheostomy
Prompt adequate resuscitation
Colloids after 12 hrs
Infection control practices
Pain relief
Early enteral nutrition
Early mobilisation and Intensive chest PT
DVT prophylaxis
nbcairoli@gmail.com

PITFALLS IN BURN MANAGEMENT
•
•
•
•

Escharotomy
Fasciotomy
Early excision and use of banked skin
Fascial excison and use of banked skin or
autografts
• Early rehabilitationphysical,social,psychological
nbcairoli@gmail.com

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
nbcairoli@gmail.com

Screening of patients

nbcairoli@gmail.com

Surgeries being performed in the previous camps

nbcairoli@gmail.com

Post- Operative care of the patients

nbcairoli@gmail.com

Skin Donation Helpline:

022 2779 3333

www.skindonation.in
www.burns-india.com
skinbanknbc@gmail.com

nbcairoli@gmail.com

Pitfalls in Burn Management

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