Post burn Contractures

1. BURN AND POST BURN
CONTRACTURE
DR SHRIKANT GHUGE

2. MAJOR PERIOPERATIVE CONCERN FOR BURN PATIENT
 Age of the patient
 Extent of burn injury
 Mechanism of burn injury
 Elapsed time from burn injury
 Associated injuries
 Inhalational injury
 Adequacy of resuscitation
 Airway patency
 Difficult vascular access
 Gastric statis
 Altered drug responses
 Altered mental status
 Pain/Anxiety
 Presence of organ dysfunction
 Presence of infection

9. American Burn Life Support (ABLS) indications for early
intubation include:
 Signs of airway obstruction (hoarseness, stridor, accessory respiratory
muscle use, sternal retraction)
 Extent of the burn (total body surface area burn > 40%–50%)
 Extensive and deep facial burns
 Burns inside the mouth
 Significant edema or risk for edema
 Difficulty swallowing
 Signs of respiratory compromise: inability to clear secretions,
respiratory fatigue, poor oxygenation or ventilation
 Decreased level of consciousness where airway protective reflexes are
impaired
 Anticipated patient transfer of large burn with airway issue without
qualified personnel to intubate en route

10. Onah’s classification of postburn contracture of
the neck
1) Mild anterior contracture
limited extension, full flexion to normal anatomic position
skin, subcutaneous tissue involved
2) Moderate anterior contracture
extension causes significant pull at uninvolved lower lip
skin, subcutaneous tissue involved
3) Severe anterior contracture
restricted extension, skin, subcutaneous tissue and strap muscles involved
4) Posterior contracture
neck held in extension, skin subcutaneous tissue involved

11. Problems in patients with healed burn
1) Distorted and reduced nasal opening
2) Narrow nasal passage
3) Distorted and reduced mouth opening
4) Restricted neck movement
5) Stiff submandibular space
6) Scar and contracture in front of neck
7) Larynx may be shifted from midline
8) Decreased oropharyngeal space
9) Distortion in anatomic alignment of oro-pharynx
pharynx and trachea
10) Cervical spine distortion
11) Fixed flexion neck deformity

12. POINTS TO BE KEPT IN MIND DURING PAC
1) Type of surgery
2) Time of burn and its duration
3) Cause of burn
4) Extent of burn
5) Assessment of airway
6) Technique of choice of anaesthesia
7) Starting IV lines

13. AIRWAY ASSESSMENT
1) Psychological preparation
2) Difficult mask ventilation
3) Difficulty laryngoscopy
4) Difficult intubation
5) Difficult supraglottic devices placement
6) Difficult surgical airway
7) Difficult extubation

14. AIRWAY ASSESSMENT

15. PREOPERATIVE INVESTIGATIONS
 Serum electrolytes
 CBC
 RFT
 Chest X ray (AP/Lateral view)
 ECG

16. AIRWAY MANAGEMENT
 Plan A- awake nasal FB/ Oral FB
 Plan B- Awake video laryngoscopy
 Plan C- SGAD under inhalational
 Plan D- Release of scar under Ketamine
 Plan E – Tumescent anaesthesia

17. AWAKE FIBREOPTIC NASAL INTUBATION
PREPARATION- ‘ADD TSP’
 Adequate explanation of need of procedure
 Decongestion of nasal passage using vasoconstrictors
 Drying up secretions by using glycopyrrolate
 Topicalisation of upper airway by nebulization, gargle and local spray
 Sedation and anxiolysis
 Preoxygenation-Perioxygenation

25. McKENZIE TECHNIQUE (MUCOSAL AUTOMIZATION DEVICE)

26. MUCOSAL AUTOMIZATION DEVICE (MAD)

27. ADMINISTRATION OF NEBULIZED LIGNOCAINE

28. GLOSSOPHARYNGEAL NERVE BLOCK

29. SURFACE ANATOMY OF SUPERIOR LARYNGEAL NERVE

30. TRANSLARYNGEAL BLOCK

31. DIFFICULT AIRWAY TROLLEY

33. TROUBLE SHOOTING DURING FIBREOPTIC
INTUBATION
Blurred view
Can not identify larynx
Bleeding
Can not remove fibreoptic
Can not pass tube

37. TUMESCENT LA
Solution for tumescent contains lignocaine, adrenaline, hyaluronidase,
and saline
FORMULA: 25ml of 2% lignocaine + hyaluronidase 1-2ml + 1 ml of 1 in
1,00,000 adrenaline + distilled water to a total volume of 100 ml.
Tumescent LA infiltrated along with incision line and into surrounding
areas.
The associated vasoconstriction was so complete that there was virtually
no blood loss during surgery.

39. PHARMACOKINETICS IN BURN

40. MUSCLE RELAXANT IN BURN PATIENTS
Musculoskeletal Injury in Burns :-
Damaged muscle →↑ acetylcholine
receptor density + Extra Junctional Receptors
↓
• ↓ sensitivity to nondepolarizing muscle relaxants
• potentially fatal elevations of K+ in response to succinylcholine.
Avoid succinylcholine after 24 hrs to 48 hrs Postburn and for at least 2 year
thereafter.

41. ROLE OF KETAMINE IN BURNS
1) Hemodynamic stability
2) Airway patency
3) Preserves hypoxic and hypercapnic responses
4) Decreases airway resistance