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

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  • {"27":"Mortality at the MGH -\nearly excision and grafting instituted in 1976.\n","28":"Elderly Population\nHistorical controls (Dietch, 114 consecutive patients average age 68 years)\nhospital stay decreased 40-%\npreexisting medical conditions had no effect on survival\nEarly Donor site closure:\nRedundant skin of thighs and lower abdomen allows for direct excision and primary closure decreasing overall wound surface area.\n","56":"Processing is designed to leave a non-antigenic dermal scaffold, leaving basement membrane proteins intact\n","23":"Janzekovic, Zora (Yugoslavia)\nTangential Excision def’n:\nburned tissue excised layer by layer until a freely bleeding surface is obtained.\nQuickly became the standard excisional technique\nDebate remained - how much tissue to excise in one session.\n1978 proposed single session for full thickness burns 50%\nNo inhalation injury\n17-30 years old\nMortality decreased from 45% to 9%.\n","21":"Early Excision\nNational institutes of Health USA\n3-7 days.\n"}

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

  • 1. SURGICAL MANAGEMENT IN BURNS Dr S. M. Keswani National Burns Centre Airoli, Navi Mumbai Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 2. Procedures • Tracheostomy • Central line insertion • Escharotomy • Debridement. Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com,
  • 3. COMPARTMENT SYNDROME • Signs and symptoms: – Unrelenting deep pain – Pallor – Progressive paresthesias – Progressive decrease, absence of pulse Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 4. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 5. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 6. Burn wound management • If have loss of palmar = Dorsal hand arch pulse escharotomy + Full-thickness burn dorsal hand + Normal radial and ulnar pulses Finger escharotomies rarely indicated - consult accepting burn surgeonNational Burns Centre, Dr. Sunil Keswani, www.burns-india.com, nbcairoli@gmail.com
  • 7. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 8. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 9. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 10. MATERIALS & METHODS Surplus cutting Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 11. MATERIALS & METHODS Positioning on plate. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 12. MATERIALS & METHODS Dermatome cut through Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 13. MATERIALS & METHODS Adhesive Spraying Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 14. MATERIALS & METHODS Adhesive Spraying Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 15. MATERIALS & METHODS Cork removing. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 16. MATERIALS & METHODS Gauze expantion Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 17. MATERIALS & METHODS Gauze expanded. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 18. MATERIALS & METHODS Micrograft positioning Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 19. MATERIALS & METHODS After gauze removal. 7th day. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 20. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 21. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 22. Early Excision • Criteria: – diagnosis of deep burns established – patient able to tolerate major surgery – normal coagulation parameters – adequate donor areas – +/- inhalation injury Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 23. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 24. Historical Perspective • 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 25. Historical Perspective • 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 26. Historical Perspective • 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 27. Historical Perspective • No increase in overall blood loss • No increase in cumulative operating time Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 28. Historical Perspective • Elderly Population (>50yrs) – advantages less clear – Decreased hospital stay – Fewer septic episodes – Early DONOR wound closure Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 29. Historical Perspective • Pediatric Population: – <50%TBSA NO significant change in • 1- length of stay • 2-blood requirements • 3- mortality – >50% TBSA • decreased mortality. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 30. Historical Perspective • Mesh Grafting – greater coverage with available auto graft – enhanced wound drainage – decreased number of procedures Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 31. Order of excision • Areas easy and quick to excise: trunk and legs • Joints and throats • Hands and face Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 32. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 33. 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 Dr. Sunil their use in extensiveKeswani, National Burns Centre, burns as a www.burns-india.com, biological nbcairoli@gmail.com
  • 34. Clinical Use of Homograft Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 35. Pre-Op photographs Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 36. Post-Op photographs Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 37. Post-Op healing Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 38. Case 2 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 39. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 40. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 41. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 42. Use of Autograft Release of a SEVERE POST BURN CONTRACTURE Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 43. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 44. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 45. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 46. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 47. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 48. Porcine Skin Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 49. Porcine skin being meshed Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 50. Integra Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 51. Integra Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 52. Acticoat Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 53. Fascial Excision Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 54. Integra applied Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 55. Covered with Acticoat Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 56. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 57. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 58. 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. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 59. 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 mesh Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  • 60. www.skindonation.in www.burns-india.com Skin Donation Helpline: +91 22 27793333 Dr Sunil Keswani 98200 31881 smkeswani@gmail.com THANK YOU Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com