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: AirwayHistory & 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


BurnsPatientSurvivalFactors

Burns Size Burns Depth

Age

Presence Of Inhalational Injury

Patient Comorbidity


CLASSIFICATIONAssessment Dressing Debridement Wound Closure Rehabilitation

DressingAssessment Dressing Debridement Wound Closure Rehabilitation

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 AntibioticAssessment Dressing Debridement Wound Closure Rehabilitation

Topical AntibioticAssessment Dressing Debridement Wound Closure Rehabilitation

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 BurnProtect 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

Debridement

Excision

Escharotomy


ExcisionEarly 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 ExcisionAssessment Dressing Debridement Wound Closure Rehabilitation

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


Indications1. Pain on passive extension2. Pallor3. Paresthesia4. Poikilothermia5. Paresis6. 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


Dressing


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 GraftingAssessment Dressing Debridement Wound Closure Rehabilitation

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 SubstitutesAcellular skin substitutes

Cellular Allogenic Skin Substitutes

Cellular Autologous Skin Substitutes

BiobraneIntegraAlloderm

TranscyteApligrafDermagraft

Cultured Epidermal AutograftCultured 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 SplintingPrimary 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/fingerMCP 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

Restricted neck movement

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

THANK YOU

BURNS: Surgical Management

Health & Medicine

Transcript of BURNS: Surgical Management