Acute burns isshcon 2013 by Dr. Sunil Keswani, National Burns Centre, Airoli

Dr Sunil KeswaniPlastic Surgeon

NATIONAL BURNS CENTRE

Navi Mumbai

Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com

“Pour water on BURNS till the burning sensation subsides”

Relieves pain Decreases depth of

Dorsal skin similar to rest of skin -much thinner (tendons easily exposed)

Palmar skin markedly different -Thicker epidermis -Less mobile -No hair -No pigment

Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,

nbcairoli@gmail.com

PATIENT COMES EARLY(WITHIN 48 HRS)

PATIENT COMES LATE(AFTER 48 HRS)

Rupture the blister Evacuate the blister fluid by

gentle milking with saline soaked gauze

Cover with KOLLAGEN-M KOLLAGEN-M is just laid on

and covered with adequate layers of gauze to ensure there is no external soakage(“STRIKE THROUGH”)

Crepe Bandage

Gently clean with sterile saline soaked gauze

Apply a thick layer of 1% SILVER SULPHADIAZINE

Apply a non adherent lubricated dressing like Vaseline gauze or Jelonet

Cover with adequate layers of gauze

Crepe Bandage

PRE-APPLICATION POST-APPLICATION

SMALL BURN SIZE(TBSA<30%) AND DEFINITE 3RD DEGREE BURN

LARGE BURN SIZE(TBSA>30%) AND UNCERTAIN ABOUT DEPTH

Early excision and AUTOGRAFTING.

Timing-within first four days post-burn

Early excision and HOMOGRAFTING

Within first four days post- burn

Mobilisation instituted after second dressing ie 4th day

Homograft can be replaced by autograft if wound does not epithelialise under the homograft in 2 weeks time

Allow to heal on its own-give it time RARELY does it need resurfacing IF Resurfacing needed Full thickness grafts from groin -Good function -Hyperpigmented

nbcairoli@gmail.com

IF deeper vital structures are exposed ONLY then

Local flaps-transposition, advancement, cross finger, island flaps

Abdominal, groin flaps Free flaps

nbcairoli@gmail.com

INCISION LINES TYPES OF RELEASE INCISIONS

Mid axial incisions Carpal tunnel release Guyons canal release Digital incisions- Thumb and LF –radial

IF,MF,RF-ulnar

nbcairoli@gmail.com

8 P’S

Pain Pallor Pressure Pulselessnes Paresthesia Paralysis Poikilothermia Progression of the ischemia

Timely Appropriate Adequate-Hand compartments-Finger compartments

INTRINSIC TIGHTNESS TEST

MCP jt is passively extended and the PIP jt is passively flexed

Presence of SIGNIFICANT RESISTANCE is an indication of release of the intrinsic muscles

nbcairoli@gmail.com

PAIN MANAGEMENT PROTOCOL

Inj Ketamine 100mg Inj Tramadol 100mg Inj Midazolam 10mg All together in a 50cc

syringe pump starting at 4cc per hour and titrating with pain relief and can go up to 40cc per hour in heavy or apprehensive patients

PAIN RELIEVED- BETTER PATIENT COMPLIANCE FOR PHYSIOTHERAPY

Splints are given from Day 1

To be worn 24 hrs a day for a week

To be worn only at night after a week for the next 4 weeks

Light pressure bandaging

Elevation

Mobilisation instituted after second dressing (post grafting) ie. 4th day

Passive gentle ROM exercises

Active movements Preferably every 2

hourly by hand therapist and relatives

Limb PhysiotherapyDr. Sunil Keswani, National Burns Centre,

www.burns-india.com, nbcairoli@gmail.com

Once the wound heals and is well epithelialised pressure garments are worn which is roughly by the 21st PBD

To be worn 23 hours a day

Should be removed four times a day for cleaning and massage and more active movements

CHEMICAL BURNS

FIRST AID -Wash off the offending agent with copious water for adequate time to ensure minimum contact period between corrosive and the skin

Invariably DEEP (rarely superficial)

Alkali burns are generally deeper than Acid burns

Early excision and grafting

TAR BURNS

Tar not to be removed on Day 1-to be left alone and

dressed with thick layer of 1% Silver sulphadiazine/ Paraffin/ Cocoa butter

Tar will start coming off spontaneously by the 4th PB day

One could damage useful epithelium and deepen the depth of burn by attempting early removal of TAR

ELECTRICAL BURNS

Compartment Syndrome

Early adequate fasciotomy

Appropriate surgical intervention depending upon the damage-skin graft, flap cover, amputation.

Re-epithelialize within 2 weeks to minimize scarring

Optimize epithelialisation by Moist healing Minimize infections Biologic dressings Optimize costs

nbcairoli@gmail.com

FULL THICKNESS BURNS Autografts Finely meshed 2:1/Sheet grafts Medium thickness

nbcairoli@gmail.com

Exposed joints Immobilize(K-wires)

Exposed bones, tendons, joints Skin grafts do not suffice Flaps required

nbcairoli@gmail.com

Pre-Op wound

Application of Homograft Day 3

Complete healing Day 21

nbcairoli@gmail.com

Burns of the HAND can land up with severe dysfunction and morbidity

Simple TIMELY interventions can make a HUGE difference to outcome!!

Positioning, Early excision, Early mobilisation and TEAM APPROACH are the KEY to good outcomes in Acute HAND Burns

nbcairoli@gmail.com

THANK YOUBURNS Helpline:

022 2779 3333

www.burns-india.com

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