short description of burn & its management

1. worst trauma : spares nobody

2. should we worry?
 60-70 lakh cases/ year
 10% admitted
 3-4 lakh deaths/2nd only to RTA
 Regular increase in incidence
 Productive age group involved
 Higher Homicides and Suicides.

3. we should worry !

4. PRACTICAL GUIDELINES
 47 ̊ : Epidermal cells die
 65̊ : Collagen denatures
 60̊ : Water causes deep burn in 3sec
 70̊ : Water causes deep burns
in < 1 sec
 80̊ : Coffee from percolator
 180̊ : Cooking oil
 250̊ : Hot tar

5. what causes burns?
thermal

6. electrical

7. chemical

8. friction

9. treatment difficult & prolonged
Input > output
Results : The Best Is Average
Sequelae are crippling

11. first degree

12. second degree superficial
 Superficial Dermis
 Blistering
 Hypersensitive
 Blanch on pressure
 No surgery

13. second degree deep

14. third degree

15. CLINICAL IMPORTANCE
 All superficial burns heal early
 Deep burns heal by secondary
intention and complications
CRITICAL TIME FRAME :
3 WEEKS

16. early management : critical
 Survival
 Morbidity
 Function
 Aesthesis
 Cost
Not Convincing !??

17. first aid
 Move from site, Disconnect electrical contact
 “Drop & Roll”, Wet blanket
 Water, water & water
 Check for associated trauma
 Plan immediate evacuation to best possible
facility.

18. GUIDELINES
 Resuscitate : ABC, Sterile Dressing
 Prevent Hypothermia
 Refer all major burns
>10 % in children & elderly
Critical areas : Hands, face, genitalia
Chemical, electrical, inhalation burns
> 60 % ????
>20% in adults, all deep burns>10%

19. Airway

20. Breathing

21. Circulation
 Wide Bore Venous
Access
 Central line
: High volume
resuscitation
: CVP
: Nutrition

22. Dysfunction
Head Injury,
Associated
ailments,
Detailed
physical
examination

23. Diet & Drugs
 Protein Calorie Need >2-3 times
normal
Parenteral / Enteral
 Antacids
 Analgesics
 Antibiotics

24. 50% burn 70 kg adult:
3750 Kcal +225 g Protein
Ryle,s Tube Drip Feed : 2-3 ml/min
Calorie Protein
Curreri Formula
( any % )
Adults – 25 Kcal / kg +
40 Kcal / %
Child – 60 Kcal / kg
+ 35 Kcal / %
1 gm / kg + 3 gm /%
3 gm/ kg + 1 gm / %
Davis Formula
( upto 50 % )
Adults – 20 Kcal / kg
+ 70 Kcal / %
Child – 60 Kcal / kg
+ 35 Kcal / %
1 gm / kg + 3 gm /%
3 gm/ kg + 1 gm / %

25. Examination : % & Degree
Wallace Rule of
Nine

26. Lund Browder
Chart

27. Escharotomy

28. Fluid
Parkland Formula: Ringer Lactate
Day 1:
4ml x weight (kg) x % of burn ( max 50%)
Infusion :Half x first 8 hrs, half x next 16 hrs
Day 2 & later :
Reduce daily by 30-50 % maintaining urine>
1ml/kg/hr

29. Treatment : First degree Burn
 Avoid exposure to sun
 Antihistamines
 Analgesics
 Emollient lotions
 Heal in a week

30. Treatment : Second degree Burn
 Conservative
 Dressings
 Ancillary treatment, Analgesics, Antibiotics
 Prevent infection
 May need Grafting in second degree deep

31. collagen sheet

32. nanocrystalline silver

33. Third Degree Burn
 Skin has to be resurfaced
 Surgery is a must
 Split Skin Graft
 Homograft, Allograft
 Artificial Skin

34. Split Skin Graft
 Partial thickness skin removed from donor site
 Wound bed prepared
 Skin fixed
 Graft take by : Imbibation, Inosculation,
Capillary linkup and Consolidation
 Flap cover for special indications

35. traditional treatment

36. Limitations of Traditional Rx
 Severe Sepsis
 Organ Dysfunction
 Intensive nursing & care
 Extremely poor outcomes
 Costly

37. CRITICAL ISSUES
 Very accurate clinical examination
for burn depth and healing time
 Clinical ??? Usual accuracy 50%
 Technical advancements :
Biopsy,Vital dyes, Light reflectance,
Doppler, MRI
 When in doubt OPERATE

38. what,s new/ recycled
 Dressings
 Skin substitutes
 Growth Factors
 Enteral Hyperalimentation
 Immunomodulation
 Change in Surgical Approach

39. TANGENTIAL EXCISION & SSG
Z Janzekovic : Excise thin layers
of burned tissues till living tissue
and graft immediately
DICTUM : If Donor site available
prefer TE & SSG for all
indeterminate thickness burns

40. meshing
&
homograft

41. Skin Meshing
 Extensive
burns
 Inadequate
normal skin
availability

42. Meshed SSG

43. Graft Fixation

44. last decade: early tangential
excision & grafting
 Post burn Day 5-7
 After stabilization

45. EXCLUSION CRITERIA
BP > or < 40% of basic
Urine <0.75 ml/kg/hour
Pulmonary edema
No adverse affect on
mortality

46. ADVANTAGES
Increased survival : Mortality
: < 1/3
Hospitalization : <1/3
Lower costs and lesser
procedures
Minimal infection and morbidity
Better long term outcomes

47. DISADVANTAGES
 Donor skin availability and
extent of burns
 Bleeding : 20-50 ml/ % of deep
burn
 Golden period < 7 days of burns
 Operative risk

48. TE in Progress

49. Completed procedure

50. Drawbacks
 Extensive bleeding ( Hyperemic Phase)
 Limited to 10-20 % Excision at one sitting
 Higher Risk of Wound infection

51. 25 % burns
 Optd 5Th post burn day.
 Tangential Excision + Split Skin Graft

52. 7 weeks post op

53. present trend
 Immediate TE + SSG
 During phase of Compensated shock
 Upto 65 % excision with only nil / one unit
blood transfusion

54. 19 Yr old, 20% Burns
2 weeks before engagement

55.  Optd 14 hr post
burn
 TE & SSG for
deep burn,
Collagen for
superficial burn
 Healed one week
post op
 Discharged on day
of engagement

56. 80 % Electric Flash Burn

57. Survival with Minimal Disability

58. 20 yrs w/o AMC Pers :80% Burn

59. 19 yr : 90% Burns, Walked Home

60. Complications/Outcomes

61. hypertrophic scarring
 Itching,blistering
 Recurrent
ulceration
 Aesthetically
poor result

62. contractures
 Severe functional disability
 Repeated corrective procedures
 Poor end results

63. contractures

64. functional defecit
 Loss of sensory organs
 Gross disabilities

65. aesthesis

66. psychiatric disorders

67. prolonged morbidity

68. lifelong suffering

69. malignancy
 Repeated scar breakdown
 Marjolin’s ulcer

70. death
 40 yr female, flame
burn
 Covered by blanket -
15 min
 65% burn, 3rd deg
 Inhalation injury
 Ventilator x 3 day
 Refd with frank
septicemia day 7
 Expired

71. cost & care
 Daily treatment cost of severe burns in
Centres Rs 10,000/-
 Average stay 3-4 months
 Total 12,00000/-
 Daily recorded parameters > 150
 Nursing acts >250

72. shock room

73. treatment
room

74. burns centre chec

75. exceptions
DON’T
make the rule

76. where is the silver lining
 90% Burns are Preventable
 Prevention is at Primary Care Level
 First Aid Vital. Pour Running Water
for 20-30 min
 Stabilization and Early Transfer

77. treatment is a poor
substitute for
prevention