BURNS: Surgical Management

Alhad Naragude
Final Year M.B.B.S [BJMC PUNE]
Guided By
Dr. Pawan Chumbale
M.S, MCh Plastic Surgery [SASSOON HOSPITAL, PUNE]
BURNS

Surgical Management
Assessment
Dressing
Debridement
Wound
Closure
Rehabilitation

Assessment Dressing Debridement Wound Closure Rehabilitation

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.

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
• Draw blood sample
• Insert urinary catheter
• Insert nasogastric tube
• Clinical Examination of Extremities
• 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

Burns
Patient
Survival
Factors
Burns Size Burns Depth
Age
Presence Of Inhalational
Injury
Patient
Comorbidity

CLASSIFICATION

Dressing

Principles of dressing
• Full thickness and deep dermal burns require
antibacterial dressings to prevent infections prior to
surgery.
• Superficial burns require simple dressings as they heal
completely within 3 weeks
• Optimal dressings environment can make significant
difference in healing.

Healing
Prevent
Infection
Initial Focus

Tetanus
Prophylaxis

Debride Bullae
Excise Adherent Necrotic Tissue

Scrubbing Apply Antibiotic

Topical Antibiotic

Dress the burn with petroleum gauze and dry gauze

Daily treatment
•Change the dressing
daily
•On each dressing
change, remove any
loose tissue.
•Inspect the wounds for
discoloration or
haemorrhage, which
indicate developing
infection.

Types of Dressings For Different Degrees of
Burns
Superficial Burn
Protect the wound & Encourage
Re-epithelialization
• Topical Analgesic Cream
• Moisturising Cream
• E.g. Polyurethrane
Semipermeable Membrane,
Hydrocolloids & Retention
dressings
Polyurethrane
Semipermeable Membrane

Partial thickness burn
• Hydrocolloids
• Polyurethane films
• Biologic dressings
• Alginates
• Foams
• Antimicrobial products such as
products containing silver.
Hydrocolloid

Full thickness burn injuries
• Antimicrobial dressings
E.g. Silver Sulphadiazine cream
and Silver Nitrate Solution

Debridement
Excision
Escharotomy

Excision
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

Early Excision
• 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

Early Excision
To prevent 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

Early Excision
•Indications:
• deep burns (dermal and
sub-dermal)
• significant size
• clinical diagnosis
•Surgical principles
• preservation of life
• prevention of infection
• conservation of viable
tissue
• maintenance of function
• timely closure

Order of Excision
• Areas easy and quick to
excise: trunk and legs
• Joints and neck
• Hands and face

Special Care
• Neck
• Eyelids
• Lips
• Ears
• Hand & fingers
• Perineum & Gentials

Humby
Skin
Grafting
Handle

Goulian-type
Weck Knife

Tangential Excision
• Tangential excision
involves repeated
removing of very thin
slices (0.5 mm thick) of
burned tissue from the
zones of stasis and
coagulation.

• Applies to deep dermal
burns & 3rd degree burns
• 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.

Tangential excision to achieve
surface with viable bleeding,
which are suitable for grafting

Advantages
Disadvantages
Good cosmesis
More wound
coverage methods
High blood loss
Difficult burn methods
depth evaluation
Tangential Excision

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

Epifascial excision and
grafting with skin grafts

Fascial Excision
Advantages
Disadvantages
Easy burn depth
evaluation
Low blood loss
Fewer grafting
possibilities
Injury to nerve &
joints

Escharotomy
• 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.

Eschar Inelasticity
Compartment
Syndrome
Compartment
Syndrome
Pressure >40
mm of Hg
Escharotomy

Indications
1. Pain on passive extension
2. Pallor
3. Paresthesia
4. Poikilothermia
5. Paresis
6. Pulselessness

Limb Escharotomy
• Indicated when the
circulation is
compromised due to
increased pressure in the
burned limb and can not
be relieved by simple
elevation.

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

Escharotomy Procedure
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

Escharotomy Procedure (continued)
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
Running a finger along the incision

Ensure the adequacy of the incisions by reassessing the circulation or
respiration
Draw a line where you will make the incision
Avoid the ulnar nerve and common peroneal
nerve
Escharotomy Procedure (continued)

Line of Incisions

Plan the Incision

Incision using
Diathermy

Check Incision
Adequacy

Separation of
Eschar

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
• 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.

Skin Grafting

Classification of skin grafting
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

Split-Thickness
• 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.

Indications
• Immediate coverage of clean soft tissue defects
• Immediate coverage of burn defects
• Prevention of scar contracture.

Contraindications
• Need to place the graft in areas where good cosmesis
or durability is essential
• Significant wound contraction could compromise
function.

Full Thickness
• A full-thickness skin graft
consists of the epidermis
and the entire thickness of
the dermis

Indications
• Deep burn injuries

Contraindications
• Recipient bed cannot sustain the graft.
• On avascular tissues
• Uncontrolled bleeding in the recipient bed

Dermatome with blade

Dermatome-harvesting Graft
Assessment Dressing Debridement Rehabilitation

Early excision and grafting
Pre-Op wound
Application of Homograft
Day 3
Complete healing
Day 21

Skin Substitutes
Acellular skin substitutes
Cellular Allogenic Skin Substitutes
Cellular Autologous Skin Substitutes
Biobrane
Integra
Alloderm
Transcyte
Apligraf
Dermagraft
Cultured Epidermal Autograft
Cultured Skin Substitutes

Rehabilitation
Splinting and Positioning
Scar Management

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

Types Of Splinting
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.

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.

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

General
Positioning
To Prevent
Contracture

Burn Patient Positioning:
Body Area Contracture Predisposition Preventive Positioning
*Neck Flexion Extension /Hyper ext.
* Anterior Axilla 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

SCAR MANAGEMENT
• Pressure therapy
• Silicone gel sheet
• Intra lesional injection
• Split skin graft
• Laser therapy
• Cryotherapy
• Radio therapy
• Combination therapy
• Elevation
• Itching
• Redness

Anesthesiologist in Management of Burns
• Initial resuscitation of burns
• ICU management - sepsis/MOF
• General Anesthesia
-Early debridement
-Excision of granulation tissue/Skin Graft
-Change of Dressings
-Reconstructive plastic surgery: Post Burn Contracture

PBC Neck and Anesthesia Implications
• Reduced mouth opening
• Difficulty in introducing
airway devices via the oral
route
• Difficult mask seal

Acknowledgement
•Dr. Pawan Chumbale
•Dr. Nikhil Panse
•Dr. kalpana kelkar
•Dr. Surekha Shinde

Biblography
•The New England Journal Of Medicine
•Schwartz Manual Of Surgery
•Wikipedia
•Medsacpe

BURNS: Surgical Management

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