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SURGICAL MANAGEMENT IN
BURNS
Dr S. M. Keswani

National Burns Centre
Airoli, Navi Mumbai
Dr. Sunil Keswani, National Burns...
Procedures
• Tracheostomy
• Central line
insertion
• Escharotomy
• Debridement.
Dr. Sunil Keswani, National
Burns Centre, ...
COMPARTMENT SYNDROME
• Signs and symptoms:
– Unrelenting deep pain
– Pallor
– Progressive paresthesias
– Progressive decre...
Eshcarotomy
 May limit chest
excursion
 Rule out other causes of
respiratory distress
 Incisions along anterior
axillar...
Burn wound management
• Circumferential extremity
burns:
– Edema under eschar
– Remove all rings,
jewelry
– Elevate, activ...
Burn wound management
• If have loss of palmar
= Dorsal hand
arch pulse
escharotomy
+
Full-thickness burn
dorsal hand
+
No...
Extremity compartment syndrome:
– Edema beneath deep fascia
– Seen in massive resuscitation, high
voltage injuries, delay ...
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Meshed graft Vs Meek Micrografting
Vs Sheet Graft
• Acute burns always meshed or meek
micrografting for better takes
• Rec...
MATERIALS & METHODS
Surplus cutting

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
MATERIALS & METHODS
Positioning on plate.

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail....
MATERIALS & METHODS
Dermatome cut through

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail....
MATERIALS & METHODS
Adhesive Spraying

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
MATERIALS & METHODS
Adhesive Spraying

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
MATERIALS & METHODS
Cork removing.

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
MATERIALS & METHODS
Gauze expantion

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
MATERIALS & METHODS
Gauze expanded.

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
MATERIALS & METHODS
Micrograft positioning

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail...
MATERIALS & METHODS
After gauze removal. 7th day.

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairol...
Early Excision
“Injured dermis
defends itself poorly
against infection, so a
program of slough
excision with
immediate gr...
Early Excision
• Definition:
– Janzekovic- 3-5 days, rational
• not yet colonized
• definitive tissue damage is establishe...
Early Excision
• Criteria:
– diagnosis of deep burns established
– patient able to tolerate major surgery
– normal coagula...
Historical Perspective
• 1970’s: Janzekovic Tangential Excision
– performed early before colonization
– patients in better...
Historical Perspective
• 1950’s:
– Rare survival for burns >40%
– Burn wound sepsis less of an issue

• 1950-70’s:
– norma...
Historical Perspective
• 1969: Introduction of SSD
– decreased bacterial colonization of wounds
– lower conversion rates t...
Historical Perspective
• Value of early excision and grafting
– 1980s - in otherwise healthy subjects
– 20% TBSA
– led to ...
Historical Perspective
• No increase in overall blood loss
• No increase in cumulative operating time

Dr. Sunil Keswani, ...
Historical Perspective
• Elderly Population (>50yrs)
– advantages less clear
– Decreased hospital stay
– Fewer septic epis...
Historical Perspective
• Pediatric Population:
– <50%TBSA
NO significant change in
• 1- length of stay
• 2-blood requireme...
Historical Perspective
• Mesh Grafting
– greater coverage with available auto graft
– enhanced wound drainage
– decreased ...
Order of excision
• Areas easy and quick to excise: trunk and
legs
• Joints and throats
• Hands and face

Dr. Sunil Keswan...
Allograft
• In patients with massive burn injury,
temporary coverage with allograft is
essential
• Development of US Navy ...
Allograft
• 1881 - First use of allograft by harvesting a
suicide victims skin to use for closure of a burn
wound
• Large ...
Clinical Use of Homograft

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

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

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Case 2

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Use of Autograft
Release of a SEVERE POST BURN
CONTRACTURE

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,...
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Allograft
Classic benefits of allograft as a physiologic and
mechanical barrier:

Reduction in water, electrolyte and pro...
Porcine Skin

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

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

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

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

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

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

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

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

Processed human cadaveric skin
Removed epidermis, extracted dermal cells
Template for dermal regener...
Integra
•
•
•
•

Most widely accepted synthetic skin substitute
Bilaminar structure
The median ‘take’ is 85%
Two-stage pro...
Cultured autologous keratinocytes
• Grown in vitro and then applied to wounds
• Take of cultured epithelial autografts dep...
Wound Closure
• Composite Materials Strategy
– Allograft skin with cultured autologous
epidermal cells (Cuano et al.)
– Ge...
www.skindonation.in
www.burns-india.com
Skin Donation Helpline:
+91 22 27793333

Dr Sunil Keswani
98200 31881
smkeswani@gm...
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Burn update 2013 by Dr. Sunil Keswani, National Burns Centre, Airoli

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Burn update 2013 by Dr. Sunil Keswani, National Burns Centre, Airoli

  1. 1. SURGICAL MANAGEMENT IN BURNS Dr S. M. Keswani National Burns Centre Airoli, Navi Mumbai Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  2. 2. Procedures • Tracheostomy • Central line insertion • Escharotomy • Debridement. Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com,
  3. 3. COMPARTMENT SYNDROME • Signs and symptoms: – Unrelenting deep pain – Pallor – Progressive paresthesias – Progressive decrease, absence of pulse Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  4. 4. Eshcarotomy  May limit chest excursion  Rule out other causes of respiratory distress  Incisions along anterior axillary lines, across costal margin to midline  Only burnt tissue divided, not fascia Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  5. 5. Burn wound management • Circumferential extremity burns: – Edema under eschar – Remove all rings, jewelry – Elevate, active motion – Check skin color, sensation, capillary refill, Doppler pulses q1h – Rule out hypotension, arterial injury Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  6. 6. Burn wound management • If have loss of palmar = Dorsal hand arch pulse escharotomy + Full-thickness burn dorsal hand + Normal radial and ulnar pulses Finger escharotomies rarely indicated - consult accepting burn surgeonNational Burns Centre, Dr. Sunil Keswani, www.burns-india.com, nbcairoli@gmail.com
  7. 7. Extremity compartment syndrome: – Edema beneath deep fascia – Seen in massive resuscitation, high voltage injuries, delay in escharotomy (ischemia-reperfusion), crush – Opening pressure >30 mmHg – Fasciotomy in OR Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  8. 8. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  9. 9. Meshed graft Vs Meek Micrografting Vs Sheet Graft • Acute burns always meshed or meek micrografting for better takes • Reconstructive procedures like overgrafting and release of contractures always sheet grafting for better cosmesis • Meek micrografting gives wider coverage and more predictable takes than mesh grafting but more expensive Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  10. 10. MATERIALS & METHODS Surplus cutting Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  11. 11. MATERIALS & METHODS Positioning on plate. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  12. 12. MATERIALS & METHODS Dermatome cut through Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  13. 13. MATERIALS & METHODS Adhesive Spraying Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  14. 14. MATERIALS & METHODS Adhesive Spraying Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  15. 15. MATERIALS & METHODS Cork removing. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  16. 16. MATERIALS & METHODS Gauze expantion Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  17. 17. MATERIALS & METHODS Gauze expanded. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  18. 18. MATERIALS & METHODS Micrograft positioning Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  19. 19. MATERIALS & METHODS After gauze removal. 7th day. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  20. 20. Early Excision “Injured dermis defends itself poorly against infection, so a program of slough excision with immediate grafting seems better than focusing on antibacterial measures.” Z. Janzekovic Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  21. 21. Early Excision • Definition: – Janzekovic- 3-5 days, rational • not yet colonized • definitive tissue damage is established • prior to wound contraction – Baumer and Henrich - 5-6 days – Davies- 7 days Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  22. 22. Early Excision • Criteria: – diagnosis of deep burns established – patient able to tolerate major surgery – normal coagulation parameters – adequate donor areas – +/- inhalation injury Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  23. 23. Historical Perspective • 1970’s: Janzekovic Tangential Excision – performed early before colonization – patients in better physical condition – improved scar quality – fewer contractures – shorter hospital stay – fewer dressing changes Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  24. 24. Historical Perspective • 1950’s: – Rare survival for burns >40% – Burn wound sepsis less of an issue • 1950-70’s: – normal practice to wait for eschar separation – wound contraction – increased metabolic rate Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  25. 25. Historical Perspective • 1969: Introduction of SSD – decreased bacterial colonization of wounds – lower conversion rates to full thickness – increased tendency to watch and wait – prolonged period to eschar separation – large unsightly hypertrophic scars Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  26. 26. Historical Perspective • Value of early excision and grafting – 1980s - in otherwise healthy subjects – 20% TBSA – led to shorter hospitalization – early return to work – better cosmetic result – less expenditure Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  27. 27. Historical Perspective • No increase in overall blood loss • No increase in cumulative operating time Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  28. 28. Historical Perspective • Elderly Population (>50yrs) – advantages less clear – Decreased hospital stay – Fewer septic episodes – Early DONOR wound closure Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  29. 29. Historical Perspective • Pediatric Population: – <50%TBSA NO significant change in • 1- length of stay • 2-blood requirements • 3- mortality – >50% TBSA • decreased mortality. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  30. 30. Historical Perspective • Mesh Grafting – greater coverage with available auto graft – enhanced wound drainage – decreased number of procedures Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  31. 31. Order of excision • Areas easy and quick to excise: trunk and legs • Joints and throats • Hands and face Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  32. 32. Allograft • In patients with massive burn injury, temporary coverage with allograft is essential • Development of US Navy Skin Bank in Maryland in 1949 signified the emergence of modern day skin banking Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  33. 33. Allograft • 1881 - First use of allograft by harvesting a suicide victims skin to use for closure of a burn wound • Large part initially took, during second and third weeks and “erysepelatous inflammation” resulted • 1944 - Successful take of graft stored in vaseline gauze for 3 weeks at 4 - 7 °C • Use of allograft became standard in 1950’s when Dr. Sunil their use in extensiveKeswani, National Burns Centre, burns as a www.burns-india.com, biological nbcairoli@gmail.com
  34. 34. Clinical Use of Homograft Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  35. 35. Pre-Op photographs Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  36. 36. Post-Op photographs Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  37. 37. Post-Op healing Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  38. 38. Case 2 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  39. 39. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  40. 40. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  41. 41. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  42. 42. Use of Autograft Release of a SEVERE POST BURN CONTRACTURE Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  43. 43. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  44. 44. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  45. 45. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  46. 46. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  47. 47. Allograft Classic benefits of allograft as a physiologic and mechanical barrier: Reduction in water, electrolyte and protein loss Reduction in energy requirements secondary to the attainment of a closed wound Reduction in wound infection rates Reduction in pain Conservation of autografts Improved general welfare and psychological outlook of the patient Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  48. 48. Porcine Skin Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  49. 49. Porcine skin being meshed Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  50. 50. Integra Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  51. 51. Integra Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  52. 52. Acticoat Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  53. 53. Fascial Excision Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  54. 54. Integra applied Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  55. 55. Covered with Acticoat Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  56. 56. Alloderm • • • • • • Processed human cadaveric skin Removed epidermis, extracted dermal cells Template for dermal regeneration Good take rates Reduce subsequent scarring Allowing grafting of an ultra-thin split-skin graft as a one-stage procedure Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  57. 57. Integra • • • • Most widely accepted synthetic skin substitute Bilaminar structure The median ‘take’ is 85% Two-stage procedure, with a minimum interval of 3 weeks between the application of the Integra and the split-skin grafting • Relatively expensive Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  58. 58. Cultured autologous keratinocytes • Grown in vitro and then applied to wounds • Take of cultured epithelial autografts depends on the wound bed • Expensive • Skilled labour and quality control, • 3–5 weeks to produce 1.8m2 confluent sheets of cells from a 2 cm2 biopsy • Fragile sheets • Blistering, infection, and contractures. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  59. 59. Wound Closure • Composite Materials Strategy – Allograft skin with cultured autologous epidermal cells (Cuano et al.) – Gelled collagen seeded with epidermal cells and fibroblasts (Bell et al.) – Collagen-glycosaminoglycan (CAG) matrix with epidermal cells and fibroblasts – Dermal matrix from fibroblasts on vicryl mesh Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  60. 60. www.skindonation.in www.burns-india.com Skin Donation Helpline: +91 22 27793333 Dr Sunil Keswani 98200 31881 smkeswani@gmail.com THANK YOU Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com

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