MANAGEMENT OF A SEVERELY
BURNT PATIENT
Dr Sunil Keswani
NATIONAL BURNS CENTRE
Navi Mumbai
Dr. Sunil Keswani, National Burn...
Aim of burn care
•
•
•
•

Rescue
Resuscitate
Refer
Resurface

• Rehabilitate
• Reconstruct
• Review

Dr. Sunil Keswani, Na...
INTENSIVE BURN CARE UNIT(IBCU)

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
INTENSIVE BURNS CARE UNIT(IBCU)

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
History
• Type of burn:
– Flame (open flame, closed space)
– Chemical (type of chemical)
– Scald (type of liquid)
– Electr...
FIRST-AID FOR BURNS

• Pour Water on Burns till the
burning sensation subsides

Dr. Sunil Keswani, National Burns Centre,
...
A: Airway
History & Physical: Inhalational injury
• Fire in a closed space.
• Full-thickness/ deep
chemical burns to face,...
A: Airway
• Burned airways swell
rapidly.

• Intubate patient as
early as possible
before airway
swelling.
Dr. Sunil Keswa...
A: Airway
• Indications for intubation:
– Oropharyngeal erythema/ swelling on direct
visualization.
– Change in voice, har...
B: Breathing
• Circumferential fullthickness burns may impair
ventilation.
• Blast injuries can cause
pneumothorax, lung
c...
C: Circulation
•
•
•
•
•
•

BP, HR, color of unburnt skin
2 large bore I.V.s in unburnt skin
Draw bloodwork.
Insert urinar...
ASSESSMENT OF BURNS
• TBSA(Total body surface area)
• Decides fluid requirements and nutritional needs
• Wallace’s rule of...
ASSESSMENT OF BURN WOUND DEPTH
• Clinical-wound appearance,blanching,capillary return,degree of
fixed capillary staining,e...
Fluid resuscitation
•
•
•
•

Need to replace losses to maintain homeostasis.
Formulas are ONLY GUIDELINES.
Monitor physiol...
Fluid resuscitation
• Fluid resuscitation should be started when
– >15% TBSA burns in an adult
– >10% TBSA in children and...
Fluid resuscitation
Parkland Formula
• Total fluid requirement in first 24 hrs =
4ml x TBSA burn (%) x body weight (kg)
50...
Pediatric Fluid resuscitation
• Use Parkland formula + MAINTENANCE fluid
• For maintenance fluid, hourly rate of
4 mL/kg f...
Electrical injury resuscitation
• Fluid needs greater
• 9 mL x TBSA burn (%) x body weight (kg) in
first 24 hrs
• If myogl...
Antibiotic Protocol
• FRESH BURN
• Start with a 3rd gen Cephalosporin with an
aminoglycoside
• INFECTED OLD BURN
• Start w...
Pain Management
• Continuous infusion round the clock of
Tramadol 100mg
Ketamine 100mg
Midazolam 10mg
• In a 50cc syringe ...
Nutritional support
• Burns patient is hypercatabolic – up to 150200% above baseline.
• Nutrition needed for burns >20% TB...
Nutritional support
• Calorie : Nitrogen = 100 : 1
• Protein requirement
– Adult: 2g/ kg/ day
– Child: 3g/ kg/ day

• Fat ...
NUTRITION
• Burn patient caloric requirement 30005000calories per day
• Early feeding
• Nasogastric tube No 10
• Hourly tu...
Initial burn wound management
• Early transfer to burn centre (within first 24 hours):
–
–
–
–

Remove smoldering, non-adh...
Burn wound management
• Circumferential
extremity burns:
–
–
–
–

Edema under eschar
Remove all rings, jewelry
Elevate, ac...
Burn wound management
• Bedside escharotomy
• 3rd degree burns
insensate
• Use electrocautery
• Mid-medial or midlateral, ...
Fasciotomy In Burns

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Burn wound management
Specific anatomical areas:

Face - watch for airway compromise
Eyes - fluorescein exam, copious ir...
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
SURGICAL TECHNIQUES-ACUTE BURNS
EARLY EXCISION

Tangential excision and grafting-within first
72 hrs
Cadaveric skin from S...
Dr. Sunil Keswani, National Burns
Centre, www.burns-india.com,
nbcairoli@gmail.com

Dermatome with blade
DERMATOME-HARVESTING GRAFT

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

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

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Case -2 skin grafting

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
NATIONAL BURNS CENTRE
Burns Helpline:

+91 22 2779 3333

www.burns-india.com
nbcairoli@gmail.com

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

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  • {"5":"History is taken on admission prior to airway swelling.\n","11":"Assessment of adequacy of circulation includes evaluation of BP, HR, skin color of unburned skin.\n2 large bore IV catheters are inserted in unburned skin to start fluid resuscitation.\nInsert a foley’s catheter & NG tube.\nBlood is drawn at the time of IV insertion.\nDoppler examination for circulation in a circumferential extremity burn.\n"}
  • Management of a severely burnt patient by Dr. Sunil Keswani, National Burns Centre, Airoli

    1. 1. MANAGEMENT OF A SEVERELY BURNT PATIENT Dr Sunil Keswani NATIONAL BURNS CENTRE Navi Mumbai Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    2. 2. Aim of burn care • • • • Rescue Resuscitate Refer Resurface • Rehabilitate • Reconstruct • Review Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    3. 3. INTENSIVE BURN CARE UNIT(IBCU) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    4. 4. INTENSIVE BURNS CARE UNIT(IBCU) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    5. 5. History • Type of burn: – Flame (open flame, closed space) – Chemical (type of chemical) – Scald (type of liquid) – Electrical (voltage, arcing/flame, contact time) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    6. 6. FIRST-AID FOR BURNS • Pour Water on Burns till the burning sensation subsides Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    7. 7. A: Airway History & 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. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    8. 8. A: Airway • Burned airways swell rapidly. • Intubate patient as early as possible before airway swelling. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    9. 9. A: Airway • Indications for intubation: – Oropharyngeal erythema/ swelling on direct visualization. – Change in voice, harsh cough. – Stridor. – Dyspnea, tachypnea. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    10. 10. B: Breathing • Circumferential fullthickness 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). Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    11. 11. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    12. 12. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    13. 13. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    14. 14. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    15. 15. 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) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    16. 16. 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. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    17. 17. Pediatric Fluid resuscitation • Use Parkland formula + MAINTENANCE fluid • For maintenance fluid, hourly rate of 4 mL/kg for first 10 kg of body weight plus 2 mL/kg for second 10 kg of body weight plus 1 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). Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    18. 18. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    19. 19. 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 sensitivity Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    20. 20. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    21. 21. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    22. 22. 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. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    23. 23. NUTRITION • Burn patient caloric requirement 30005000calories per day • Early feeding • Nasogastric tube No 10 • Hourly tube feeding Butter milk diet 1cal/cc Eggs 4 Bananas 4 Sugar 4Tbs Curd 1 litre Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    24. 24. 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 gauze Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    25. 25. 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
    26. 26. Burn wound management • Bedside escharotomy • 3rd degree burns insensate • Use electrocautery • Mid-medial or midlateral, across joints • Recheck pulses - may have to do opposite side of limb Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    27. 27. Fasciotomy In Burns Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    28. 28. Burn wound management Specific 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 burns Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com,
    29. 29. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    30. 30. 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 72hrs Cadaveric skin from SKIN BANK Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    31. 31. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com Dermatome with blade
    32. 32. DERMATOME-HARVESTING GRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    33. 33. Fascial excision Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    34. 34. Integra and ACTICOAT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    35. 35. Skin grafting of extensive Burns Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    36. 36. Case -2 skin grafting Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    37. 37. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    38. 38. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    39. 39. NATIONAL BURNS CENTRE Burns Helpline: +91 22 2779 3333 www.burns-india.com nbcairoli@gmail.com Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com

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