Management of a severely burnt patient by Dr. Sunil Keswani, National Burns Centre, Airoli

MANAGEMENT OF A SEVERELY BURNT PATIENT

Dr Sunil KeswaniNATIONAL BURNS CENTRE

Navi Mumbai

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

Aim of burn care

• Rescue• Resuscitate• Refer• Resurface

• Rehabilitate• Reconstruct• Review


INTENSIVE BURN CARE UNIT(IBCU)


INTENSIVE BURNS CARE UNIT(IBCU)


History

• Type of burn:– Flame (open flame, closed space)

– Chemical (type of chemical)

– Scald (type of liquid)

– Electrical (voltage, arcing/flame, contact time)



FIRST-AID FOR BURNS

• Pour Water on Burns till the burning sensation subsides

A: AirwayHistory & 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.


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, harsh cough.

– Stridor.

– Dyspnea, tachypnea.


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).


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



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


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

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► ►


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)


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.


Pediatric Fluid resuscitation

• Use Parkland formula + MAINTENANCE fluid• For maintenance fluid, hourly rate of

4 mL/kg for first 10 kg of body weight plus2 mL/kg for second 10 kg of body weight plus1 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).


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,

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

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 sensitivityDr. Sunil Keswani, National Burns Centre,


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


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


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.


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 litreDr. Sunil Keswani, National Burns Centre,


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 gauzeDr. Sunil Keswani, National Burns Centre,


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

• 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


Fasciotomy In Burns


Burn wound managementSpecific 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

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

india.com, [email protected]


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

[email protected]

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 72hrsCadaveric skin from SKIN BANK


[email protected]

Dermatome with blade

DERMATOME-HARVESTING GRAFT


Fascial excision


Integra and ACTICOAT


Skin grafting of extensive Burns


Case -2 skin grafting





[email protected]

NATIONAL BURNS CENTREBurns Helpline:

+91 22 2779 3333

www.burns-india.com [email protected]

Health & Medicine

Management of a severely burnt patient by Dr. Sunil Keswani, National Burns Centre, Airoli