Burn update 2013 by Dr. Sunil Keswani, National Burns Centre, Airoli

SURGICAL MANAGEMENT IN BURNS

Dr S. M. KeswaniNational Burns CentreAiroli, Navi Mumbai

Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]

Procedures

• Tracheostomy

• Central line insertion

• Escharotomy

• Debridement.

Dr. Sunil Keswani, National Burns Centre, www.burns-

india.com, [email protected]

COMPARTMENT SYNDROME

• Signs and symptoms:– Unrelenting deep pain– Pallor– Progressive paresthesias– Progressive decrease, absence of pulse


Eshcarotomy

May limit chest excursion

Rule out other causes of respiratory distress

Incisions along anterior axillary lines, across costal margin to midline

Only burnt tissue divided, not fascia


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


Burn wound management

• If have loss of palmar arch pulse

+ Full-thickness burn dorsal hand

+ Normal radial and ulnar pulses

= Dorsal hand escharotomy


Finger escharotomies rarely indicated - consult accepting burn surgeon

Extremity compartment syndrome:–Edema beneath deep fascia–Seen in massive resuscitation, high

voltage injuries, delay in escharotomy (ischemia-reperfusion), crush

–Opening pressure >30 mmHg–Fasciotomy in OR



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 & METHODSAdhesive Spraying


MATERIALS & METHODSCork removing.


MATERIALS & METHODSGauze expantion


MATERIALS & METHODSGauze expanded.


MATERIALS & METHODSMicrograft positioning


MATERIALS & METHODSAfter gauze removal. 7th day.


Early Excision“Injured dermis

defends itself poorly against infection, so a program of slough excision with immediate grafting seems better than focusing on antibacterial measures.”Z. Janzekovic


Early Excision

• Definition:– Janzekovic- 3-5 days, rational

• not yet colonized• definitive tissue damage is established• prior to wound contraction

– Baumer and Henrich - 5-6 days– Davies- 7 days


Early Excision

• Criteria:– diagnosis of deep burns established– patient able to tolerate major surgery– normal coagulation parameters– adequate donor areas– +/- inhalation injury


Historical Perspective

• 1970’s: Janzekovic Tangential Excision– performed early before colonization– patients in better physical condition– improved scar quality– fewer contractures– shorter hospital stay– fewer dressing changes



• 1950’s: – Rare survival for burns >40%– Burn wound sepsis less of an issue

• 1950-70’s:– normal practice to wait for eschar separation– wound contraction– increased metabolic rate



• 1969: Introduction of SSD– decreased bacterial colonization of wounds– lower conversion rates to full thickness– increased tendency to watch and wait– prolonged period to eschar separation– large unsightly hypertrophic scars



• Value of early excision and grafting– 1980s - in otherwise healthy subjects– 20% TBSA– led to shorter hospitalization– early return to work– better cosmetic result– less expenditure



• No increase in overall blood loss• No increase in cumulative operating time



• Elderly Population (>50yrs)– advantages less clear– Decreased hospital stay – Fewer septic episodes– Early DONOR wound closure



• Pediatric Population:– <50%TBSANO significant change in

• 1- length of stay• 2-blood requirements• 3- mortality

– >50% TBSA• decreased mortality.



• Mesh Grafting– greater coverage with available auto graft– enhanced wound drainage– decreased number of procedures


Order of excision

• Areas easy and quick to excise: trunk and legs

• Joints and throats• Hands and face


Allograft

• In patients with massive burn injury, temporary coverage with allograft is essential

• Development of US Navy Skin Bank in Maryland in 1949 signified the emergence of modern day skin banking


Allograft• 1881 - First use of allograft by harvesting a suicide

victims skin to use for closure of a burn wound

• Large part initially took, during second and third weeks and “erysepelatous inflammation” resulted

• 1944 - Successful take of graft stored in vaseline gauze for 3 weeks at 4 - 7 C

• Use of allograft became standard in 1950’s when their use in extensive burns as a biological dressing was reported


Clinical Use of Homograft


Pre-Op photographs


Post-Op photographs


Post-Op healing


Case 2





Use of AutograftRelease of a SEVERE POST BURN

CONTRACTURE






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 ratesReduction in painConservation of autograftsImproved general welfare and psychological

outlook of the patientDr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]

Porcine Skin


Porcine skin being meshed


Integra


Integra


Acticoat


Fascial Excision


Integra applied


Covered with Acticoat


Alloderm

• Processed human cadaveric skin• Removed epidermis, extracted dermal cells• Template for dermal regeneration• Good take rates • Reduce subsequent scarring • Allowing grafting of an ultra-thin split-skin graft

as a one-stage procedure


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


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

• Composite Materials Strategy– Allograft skin with cultured autologous

epidermal cells (Cuano et al.)– Gelled collagen seeded with epidermal cells

and fibroblasts (Bell et al.)– Collagen-glycosaminoglycan (CAG) matrix

with epidermal cells and fibroblasts– Dermal matrix from fibroblasts on vicryl

meshDr. Sunil Keswani, National Burns Centre,

www.burns-india.com, [email protected]


www.skindonation.in Dr Sunil Keswaniwww.burns-india.com 98200 31881 [email protected] Donation Helpline: +91 22 27793333

THANK YOU

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Economy & Finance

Burn update 2013 by Dr. Sunil Keswani, National Burns Centre, Airoli