Pitfalls in burn management by Dr. Sunil Keswani, National Burns Centre, Airoli

transcript

PITFALLS IN BURN MANAGEMENT

Dr Sunil KeswaniCosmetic Surgeon and Burns Surgeon

NATIONAL BURNS CENTRENavi 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

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)

Which burn patients need HOSPITALISATION?

• We go by the AMERICAN BURN ASSOCIATION GUIDELINES

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

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.

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

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 WASHINGDr. Sunil Keswani, National Burns Centre,

www.burns-india.com, 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.

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.

Dr. Sunil Keswani, National Burns Centre,

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 SITUATIONSDr. Sunil Keswani, National Burns Centre,

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 Dr. Sunil Keswani, National Burns Centre,

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► ►

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/hrDr. Sunil Keswani, National Burns Centre,

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

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

Reducing the HYPERMETABOLIC RESPONSE

• Temperature regulation• Nutrition• Pharamacological manipulation-Propranolol

40 mg BD and Oxandrolone 5mg BD• Early excision and homografting

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

Role of Intermittent Compression Device

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

Nutrition

• Aggressive nutritional support to counterbalance the effect of Hypermetabolism and Protein catabolism following Burns

• ENTERAL feeding is preferred over PARENTERAL feeding

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

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

Tracheostomy

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

Chest Physiotherapy

Limb Physiotherapy

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

• We use DOPPLER to decide

Fasciotomy-LINES OF INCISION

Fasciotomy-methodology

Leg-FASCIAL COMPARTMENTS

Esharotomy

• Thick circumferential non-yielding eschar warrants an ESHCAROTOMY

Esharotomy-LINES OF INCISION

Esharotomy

INTRAABDOMINAL HYPERTENSIONand

INTRAABDOMINAL COMPARTMENT SYDROME

Abd compartment syndrome-LAPAROTOMY

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

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

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– Tourniquet control– Dilute Epinephrine tumescent fluid– Epinephrine soaked sponges

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

AllograftClassic 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 patientDr. Sunil Keswani, National Burns Centre,

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

Porcine Skin

Porcine skin being meshed

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

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

Integra

Acticoat

Fascial Excision

Integra applied

Covered with Acticoat

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.

Wound Closure

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

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

MATERIALS & METHODSSurplus cutting

MATERIALS & METHODSPositioning on plate.

MATERIALS & METHODSDermatome cut through

MATERIALS & METHODSAdhesive Spraying

MATERIALS & METHODSCork removing.

MATERIALS & METHODSGauze expansion

MATERIALS & METHODSGauze expanded.

MATERIALS & METHODSMicrograft positioning

MATERIALS & METHODSAfter gauze removal. 7th day.

MATERIALS & METHODS10th day wound care.

MATERIALS & METHODSLong term control.

POST-PHYSICAL REHABILITATION OUTCOME

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.

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.

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

Mentosternal Contracture

Homogrft and Autograft

Penoscrotal burns

PRE-OP POST-OP

CLINICAL USE OF HOMOGRAFT

AT NBC

Skin Bank and Skin DonationDONATE SKIN AND SAVE A LIFE

Patient Name- Neeta Parekh Age- 48Gender- FemaleTBSA Of Burns- 35%Degree Of Burns-2nd Degree Areas Of Burns-chest, Both Upper ExtremitiesCause Of Burns-During Lighting Diya

PATIENT DETAILS

ADMISSION FORM

PHOTOS ON DAY OF ADMISSION

EARLY BURN EXCISION

APPLICATION OF HOMOGRAFT

1ST DRESSING CHANGE OF HOMOGRAFT

2ND DRESSING CHANGE OF HOMOGRAFT (4TH DAY)

3RD DRESSING CHANGE OF HOMOGRAFT (6TH DAY)

FOLLOW UP

3RD DRESSING CHANGE OF HOMOGRAFT (6TH DAY)

FOLLOW UP

END RESULT

Patient Name- Ramsingh Age- 52 Gender- MaleTBSA Of Burns- 55%Degree Of Burns-2nd DegreeAreas Of Burns- Face ,Chest, Both Upper Extremities,, Lower Extremities.Cause Of Burns- Explosion

PATIENT DETAILS

ADMISSION FORM

EARLY BURN EXCISION

2NDDRESSING CHANGE OF HOMOGRAFT

5TH DRESSING CHANGE OF HOMOGRAFT

FOLLOW UP

EARLY BURN EXCISION

2ND DRESSING CHANGE OF HOMOGRAFT

FOLLOW UP

2ND STAGE TANGENTIAL EXCISION

TREATMENT GOING ON

BEFORE TREATMENT

AFTER TREATMENT

Patient Name- Yojana D. GhaseAge- 24 Gender- FemaleTBSA Of Burns- 20%Degree Of Burns-2nd Degree Deep Areas Of Burns- Chest, Abdomen, Right Upper Extremity, Lower Face .Cause Of Burns-flame Burn.

PATIENT DETAILS

ADMISSION FORM

EARLY BURN EXCISION

2ND DRESSING CHANGE OF HOMOGRAFT

4TH DRESSING CHANGE OF HOMOGRAFT

BEFORE AUTOGRAFTING AFTER AUTOGRAFTING

END RESULT

• 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

• Escharotomy• Fasciotomy• Early excision and use of banked skin• Fascial excison and use of banked skin or

autografts• Early rehabilitation-

physical,social,psychological

TEAM APPROACH TO BURNS

• Plastic Surgeon• General Surgeon• Ophthalomologist• ENT surgeon• Intensivist• Nephrologist• Anesthesiologist• Cardiologist• Psychiatrist

NursesMicrobiologistPhysiotherapistOccupational therapistPsychological CounsellorSocial WorkerDietitianPrevention team

Screening of patients

Surgeries being performed in the previous camps

Post- Operative care of the patients

Skin Donation Helpline:

022 2779 3333

www.skindonation.inwww.burns-india.com

skinbanknbc@gmail.com

Pitfalls in burn management by Dr. Sunil Keswani, National Burns Centre, Airoli

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