1. Surgical management of burn wounds includes debridement methods like chemical, mechanical, autolytic, and surgical excision. Early excision is preferred within 72 hours when possible. 2. Excision techniques include tangential and fascial excision. Escharotomy may be needed for circumferential burns to relieve pressure. 3. Following excision, wounds are closed with skin grafts or other skin substitutes. Long term rehabilitation addresses splinting, positioning and scar management to prevent contractures and promote healing.

1. SURGICAL MANAGEMENT OF BURN
WOUND

3. Airway / C-spine
Breathing
Circulation
Disability
Expose / Environmental controls

21. Chemical Mechanical
Autolytic Surgical

22. Chemical debridement:
digest necrotic tissue, denatured collagen, and other
proteinaceous materials to help shorten the time of
eschar separation.
require a moist environment within a specific pH range for
activation

23. • papaine-urea derivatives (Accuzyme, Health Point, Fort Worth,
Texas);
• collagenases (Santyl, Smith&Nephew, Largo, Florida);
• Fibrinolysin and deoxyribonuclease (Elase, Park-Davis division
of Warner Lambert Company, Morris Plains, New Jersey)
• Care must be taken when using the enzymatic agents over
joints, ligaments, blood vessels, bones, and facial burns
because of the potential for bleeding and damage to other
viable tissue

24. Mechanical debridement:
• using surgical forceps or scissors or a knife blade to lift gently
and remove all loose, necrotic tissue and any nonviable eschar

25. Autolyic debridement:
• allowing the patient’s natural defenses to digest and remove
any necrotic and nonviable tissue.
• Advantage: no action is taken that might cause further harm to
the patient or to other tissue.
• Disadvantage: slow; patient is subjected to further
hypermetobolic demands while the wounds remain open and
unattended

26. • Surgical debridement/ excision:
Tangential
Fascial

27. Early excision Vs Delayed excision
• Always early excision if patient comes early enough and
facilities exist.
• Early enough is upto 72 hrs postburn
• Early excision decreases the chances of Sepsis and facilitates
early moblisation and better and more predictable functional
recovery.
• Delayed excision is generally at 3 weeks or later
Assessment
Excision
Dressing Debridement Wound Closure Rehabilitation

28. • Within the first 3-5days
• After 5 days chances of Sepsis higher and bleeding more
• 15% of BSA is excised at a time
• Spaced apart (every 2 or 3 days)
• By one estimate excision of 1% burn area can result in 100
ccs blood loss
• The goal of early excision is to remove all de- vitalized tissue
and prepare the wound for skin grafting
Assessment Dressing
Early Excision
Debridement Wound Closure Rehabilitation

29. Toprevent blood loss
• Proper preoperative plan must be
present
• Excision prior to wound hyperemia
• Elevation of extremities
• Tourniquet control
• Dilute Epinephrine tumescent fluid
• Pressure dressings following the
excision
Assessment Dressing
Early Excision
Debridement Wound Closure Rehabilitation

30. Early Excision
•Indications:
• deep burns (dermal and
sub-dermal)
• significant size
• clinical diagnosis
• hands and feet
•Surgical principles
• preservation of life
• prevention of infection
• conservation of viable
tissue
• maintenance of function
• timely closure
Assessment Dressing Debridement Wound Closure Rehabilitation

31. • Areas easy and quick to
excise: trunk and legs
• Joints and neck
• Hands and face
Assessment Dressing
Order of Excision
Debridement Wound Closure Rehabilitation

32. •Neck
•Eyelids
•Lips
•Ears
•Hand & fingers
•Perineum & Gentials
Assessment Dressing
Special Care
Debridement Wound Closure Rehabilitation

33. Assessment
Humby
Skin
Grafting
Handle
Dressing Debridement Wound Closure Rehabilitatio
n

34. Goulian-type
Weck Knife
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

35. • Tangential excision
involves repeated
removing of very thin
slices (0.5 mm thick) of
burned tissue from the
zones of stasis and
coagulation.
Assessment Dressing
Tangential Excision
Debridement Wound Closure Rehabilitation

37. • Applies to deep dermal
burns & 3rd degreeburns
• Full-thickness burns
extending into the
subcutaneous tissue -
burned fat excised in a
similar manner until a plane
of healthy, yellow, bleeding
fat is found.
Assessment Dressing Debridement Wound Closure Rehabilitation

39. Tangential excision to achieve
surface with viable bleeding,
which are suitable for grafting
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

40. Advantages
Disadvantages
Good cosmesis
More wound
coverage methods
High blood loss
Difficult burn methods
depth evaluation
Assessment Dressing
Tangential Excision
Debridement Wound Closure Rehabilitation

41. Assessment Dressing Debridement
Fascial Excision
• Removes all layers of eschar and
underlying tissue to the level of
fascia.
• Excision to this plane minimizes
bleeding and provides a reliable,
clean, vascular bed.
• Recommended
-subcutaneous fat is burned
-selected large burns with >60%
BSA full-thickness who have high
risks for infection, blood loss, or
skin graft slough
Wound Closure Rehabilitation

42. Epifascial excision and
grafting with skin grafts
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

43. Assessment Dressing Debridement Wound Closure Rehabilitation

44. Advantages
Disadvantages
Easy burn depth
evaluation
Low blood
loss
Fewer grafting
possibilities
Injury to nerve &
joints
Assessment Dressing
Fascial Excision
Debridement Wound Closure Rehabilitation
Less time
consuming
Reliable graft
bed
High incidence of
distal edema
when there is
circumferential
excision
Poor cosmesis

45. Assessment Dressing Debridement Wound Closure Rehabilitation

46. • An escharotomy is a surgical procedure used to treat full
thickness (third-degree) circumferential burns.
• Full-thickness circumferential burn of an extremity or Trunk can
result in vascular compromise.
Assessment Dressing
Escharotomy
Debridement Wound Closure Rehabilitation

47. Eschar Inelasticity
Compartment
Syndrome
Compartment
Syndrome
Pressure >40
mm of Hg
Escharotomy
Assessment Dressing Debridement Wound Closure Rehabilitation

48. Assessment Dressing Debridement
Indications
1. Pain on passive extension
2. Pallor
3. Paresthesia
4. Poikilothermia
5. Paresis
6. Pulselessness
Wound Closure Rehabilitation

49. • Indicated when the
circulation is
compromised due to
increased pressure in the
burned limb and can not
be relieved by simple
elevation.
Assessment Dressing
Limb Escharotomy
Debridement Wound Closure Rehabilitation

50. Assessment Dressing Debridement
Chest Escharotomy
• Considered when a
circumferential burn of the
chest wall results in
respiratory compromise by
restricting normal chest wall
movement.
• Circumferential burns of the
abdomen may also cause
respiratory compromise by
restricting diaphragmatic
movement. E.g. Infants under
12 months
Wound Closure Rehabilitation

51. Anasthesia for children, Sedative & Analgesic for
adults
Incision 1 cm into unburned healthy tissue where
possible.
Upper limb should be in the supine position and the lower limb in the
neutral position
Assessment Dressing Debridement
Escharotomy Procedure
Wound Closure Rehabilitation

52. Incisions of the limbs are in the mid-axial lines between flexor and extensor
surfaces
For the chest, incisions along the mid axillary lines,
A transverse elliptical incision across the abdomen below the costal margin
Escharotomy Procedure (continued)
Running a finger along the incision
Assessment Dressing Debridement Wound Closure Rehabilitation

53. Ensure the adequacy of the incisions by reassessing the circulation or
respiration
Avoid the ulnar nerve and common peroneal
nerve
Escharotomy Procedure (continued)
Draw a line where you will make the incision
Assessment Dressing Debridement Wound Closure Rehabilitation

54. Line of Incisions
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

55. Plan the Incision
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

56. Incision using
Diathermy
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

57. Assessment Dressing
Check Incision
Adequacy
Debridement Wound Closure Rehabilitation

58. Separation of
Eschar
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

59. Dressing
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

60. Assessment Dressing Debridement
Fasciotomy
• Fasciotomy or fasciectomy
is a surgical procedure
where the fascia is cut to
relieve tension or pressure
commonly to treat the
resulting loss
of circulation to an area
of tissue or muscle.
• Done in Patients with
Electrical Burns
Wound Closure Rehabilitation

61. Assessment Dressing Debridement Wound Closure Rehabilitation

62. • After excision the wound, there is wound closure.
• Goals:
• Reestablish barrier (epidermis) to prevent bacterial invasion and
evaporative water loss
• Reconstitute the dermis to provide durability, pliability and
acceptable cosmetics.
Assessment Dressing
Wound Closure
Debridement Wound Closure Rehabilitation

63. Assessment Dressing
Skin Grafting
Debridement Wound Closure Rehabilitatio
n

64. According to thickness
• Full thickness skin graft
• Partial thickness skin graft
also called split thickness
skin graft
• Composite graft –skin
along with underlying
tissue is grafted
Assessment Dressing Debridement
Classification of skin grafting
Wound Closure Rehabilitation

65. • Skin graft including the
epidermis and part of the
dermis.
• Thickness depends on the donor
site and needs of the patient
• Can expand upto 9 times
• Frequently used as they can
cover large areas and the rate of
autorejection is low.
Assessment Dressing
Split-Thickness
Debridement Wound Closure Rehabilitation

66. •Immediate coverage of clean soft tissue defects
•Immediate coverage of burn defects
•Prevention of scar contracture.
Assessment Dressing Debridement
Indications
Wound Closure Rehabilitation

67. Contraindications
•Need to place the graft in areas where good cosmesis
or durability is essential
•Significant wound contraction could compromise
function.
Assessment Dressing Debridement Wound Closure Rehabilitation

68. • A full-thickness skin graft
consists of the epidermis
and the entire thickness of
the dermis
Assessment Dressing
Full Thickness
Debridement Wound Closure Rehabilitation

69. •Deep burn injuries
Assessment Dressing Debridement
Indications
Wound Closure Rehabilitation

70. Contraindications
•Recipient bed cannot sustain the graft.
•On avascular tissues
•Uncontrolled bleeding in the recipient bed
Assessment Dressing Debridement Wound Closure Rehabilitation

71. Dermatome-harvesting Graft
Assessment Dressing Debridement Rehabilitatio
n

72. Pre-Op wound
Application of Homograft
Day 3
Complete healing
Day 21
Assessment Dressing
Early excision and grafting
Debridement Wound Closure Rehabilitation

73. Skin flaps

74. Temporary wound covering:
1. Preventing wound desiccation
2. Decreasing bacterial proliferation on the
wound surface
3. Preventing further necrosis of viable elements
in the dermis
4. Assisting in the control of evaporative fluid
and heat loss through the open wound
5. Decreasing protein loss and wound exudate
6. Decreasing pain
7. Detecting exposed blood vessels, nerves,
and tendons
8. Facilitating joint motion
9. Stimulating wound healing
10. Preparing the wound bed for autograft skin

75. Cadeveric allograft Porcine allograft
Amniotic membrane

77. Acellular skin substitutes
Cellular Allogenic Skin Substitutes
Cellular Autologous Skin Substitutes
Biobrane
Integra
Alloderm
Transcyte
Apligraf
Dermagraft
Cultured Epidermal Autograft
Cultured Skin Substitutes
Assessment Dressing
Skin Substitutes
Debridement Wound Closure Rehabilitation

80. Assessment Dressing Debridement Wound Closure Rehabilitation

81. Rehabilitation
Splinting and Positioning
Scar Management
Assessment Dressing Debridement Wound Closure Rehabilitation

82. Splinting & Positioning
•Done to Prevent Contracture
•The positioning of the burn patient is vital in
bringing about the best functional outcomes in
rehabilitation
•Begin immediately after the injury occurs
•Positioning should be designed for the specific
individual’s needs
•Should not compromise mobility and function
Assessment Dressing Debridement Wound Closure Rehabilitation

83. Primary Splints
• acute phase and pre
grafting period
• used to position the
involved joints during
sleep, inactivity, or periods
of unresponsiveness.
Postural Splints
• Immediate post graft
phase
• Worn continuously for 5 to
14 days until the graft is
secure.
Assessment Dressing
Types Of Splinting
Debridement Wound Closure Rehabilitation

84. Follow up Splints:
• Chronic phase of burn care begins with wound closure.
• Dynamic splints (movable parts) are used to increase function.
• Provide slow steady force to stretch a skin contracture, or provide
resistive force for exercise.
Assessment Dressing Debridement Wound Closure Rehabilitation

86. • Reduces edema
• Maintains joint
alignment
• Maintains tissues
elongated
• Prevents contracture
formation
•Promotes wound healing
•Relieves pressure
•Protects joints, exposed
tendons and new
grafts/flaps
Assessment Dressing Debridement
Positioning Must Be
Designed In A Way That It:
Wound Closure Rehabilitation

87. General
Positioning
ToPrevent
Contracture
Assessment Dressing Debridement Wound Closure Rehabilitatio
n

88. Body Area Contracture Predisposition Preventive Positioning
*Neck Flexion Extension /Hyper ext.
* AnteriorAxilla Shoulder Adduction Shoulder Adduction
* Antecubital space Elbow flexion Elbow Extension
* Forearm Pronation Supination
* Wrist Flexion Extension- 30o
Dorsal/hand/finger
MCP Hyper extension IP Flexion,thumb
adduction
MCP Flexion-80o, IF Extension, thumb palmar
abduction
*
Palmar hand/finger Finger flexion, thumb opposition Finger extension thumb radial abduction
Hip Flexion, adduction external rotation Extension, abduction neutral rotation
* Knee Flexion Extension
* Ankle Planter flexion Dorsiflexion
* Dorsal toes Hyperextension Flexion
* Planter toes Flexion Extension
Assessment Dressing
Burn Patient Positioning:
Debridement Wound Closure Rehabilitatio
n

89. • Pressure therapy
• Silicone gel sheet
• Intra lesional injection
• Split skin graft
• Laser therapy
• Cryotherapy
• Radio therapy
• Combination therapy
• Elevation
• Itching
• Redness
Assessment Dressing Debridement
SCAR MANAGEMENT
Wound Closure Rehabilitation

90. Biblography
•Total burn care
•Journal of burn care and research
•Critical care nursing clinics of north
america.
•The New England Journal Of Medicine
•Schwartz Manual Of Surgery
•Wounds UK Vol 9
•Medscape