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PITFALLS IN BURN
MANAGEMENT
Dr Sunil Keswani

Cosmetic Surgeon and Burns Surgeon
NATIONAL BURNS CENTRE
Navi Mumbai

Dr. Su...
Aim of burn care
•
•
•
•

Rescue
Resuscitate
Refer
Resurface

• Rehabilitate
• Reconstruct
• Review

Dr. Sunil Keswani, Na...
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
Principles of BURN MANAGEMENT
• Airway management-quick and appropriate
• Prompt and accurate fluid resuscitation
• Remova...
Which burn patients need
HOSPITALISATION?

• We go by the AMERICAN BURN ASSOCIATION
GUIDELINES
Dr. Sunil Keswani, National...
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
Does a child with only head face
burns require hospitalisation?
• YES.
• The head face in a child constitues about 18%
BSA...
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
How do we reduce INFECTION IN
BURNS?
• Hand washing
• Infection control measures like Isolation,Use
of disposables,Separat...
Philipp Ignaz Semmelweis
• Hungarian Physician
reduced the incidence
of Puerperal Fever in a
Vienna Hospital by
introducin...
Louis Pasteur
• French microbiologist
and chemist
• Germ theory of disease
• Founder of
Microbiology along with
Robert Koc...
LEVELS OF ICU CARE
• Level - I – provides
monitoring, observation
and short term
ventilation.
• Level - II – Provides
Obse...
BED STRENGTH
• IDEALLY 8 TO 12 BEDS.
• LARGER AREAS –
DIFFICULT TO
ADMINISTER AND
SMALLER AREAS NOT
BEING COST EFFECTIVE.
...
BED SPACE & BEDS
• ALL SEPARATE CUBICLES
• 225 – 250 SQUARE FEET
PER BEDS
• BEDS - ADJUSTABLE, NO
HEAD BOARD, SIDE RAILS
A...
Fluid Management
•
•
•
•

Fluids per hour=Wt(kg) x % of Burns divided by 4
Start with RL in adults and Isolyte P in childr...
Fluid resuscitation
•
•
•
•

Need to replace losses to maintain homeostasis.
Formulas are ONLY GUIDELINES.
Monitor physiol...
Electrical injury resuscitation
• Fluid needs greater
• 9 mL x TBSA burn (%) x body weight (kg) in
first 24 hrs
• If myogl...
Electrolyte Abnormalities
• HYPOKALEMIA- seen more often than
Hyperkalemia
• Commonest cause of non infective paralytic
il...
Electrolyte Abnormalities
• HYPOCALCEMIA-most commonly due to
Hypoalbuminemia
• Lowering of Ser Albumin by 1g/ml lowers Se...
Reducing the HYPERMETABOLIC
RESPONSE
• Temperature regulation
• Nutrition
• Pharamacological manipulation-Propranolol
40 m...
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Role of LMWH
• Incidence of Deep Vein Thrombosis is
significant enough to warrant routine use of
LMWH
• Incidence of Pulmo...
Role of Intermittent Compression
Device
• Intermittent
compression pump
along with LMWH
decreases the incidence
of DVT by ...
Nutrition
• Aggressive nutritional support to
counterbalance the effect of
Hypermetabolism and Protein catabolism
followin...
Nutritional support
• Burns patient is hypercatabolic – up to 150200% above baseline.
• Nutrition needed for burns >20% TB...
BUTTERMILK DIET(BMD)
• Eggs- 4 /Protein
powders(Whey protein
or Soya protein)
• Bananas- 4
• Sugar- 4 Tbsf
• Curds (Yoghur...
Tracheostomy
• Head face neck
burns IMMEDIATE
TRACHEOSTOMY to
facilitate airway and
nursing

Dr. Sunil Keswani, National B...
Chest Physiotherapy

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

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

• Pain
• Pallor-look at capillary refill
• Compartmental
time-if less than 2 secspressures above
VENOUS OBSTRU...
Fasciotomy-LINES OF INCISION

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

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

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

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
Esharotomy
• Thick circumferential non-yielding
eschar warrants an ESHCAROTOMY

Dr. Sunil Keswani, National Burns Centre, ...
Esharotomy-LINES OF INCISION

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
INTRAABDOMINAL HYPERTENSION
and
INTRAABDOMINAL
COMPARTMENT SYDROME

Dr. Sunil Keswani, National Burns Centre,
www.burns-in...
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
Abd compartment syndromeLAPAROTOMY

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Early excision Vs Delayed excision
• Always early excision if patient comes early
enough and facilities exist
• Early enou...
Early Excision
• Within the first 3-5days
• After 5 days chances of Sepsis higher and
bleeding more
• 15% of BSA is excise...
Order of excision
• Areas easy and quick to excise: trunk and
legs
• Joints and throats
• Hands and face

Dr. Sunil Keswan...
Early Excision
• Blood Loss
– Clear pre-operative plan
– Excision prior to wound hyperemia
– Elevation of extremities
– To...
Early Excision
• Procedure (En Bloc)
– For deeper burns
– Skin and fat excised in one session
– Less time consuming
– Exci...
Allograft
Classic benefits of allograft as a physiologic and
mechanical barrier:

• Reduction in water, electrolyte and pr...
Allograft
• Reduction in the number of bacteria under a
biological dressing
• Phagocytes within a wound use the fibrin
net...
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
Differences Between Skin Substitutes
• Materials that are applied for short periods
then removed, to stimulate autologous ...
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Integra
•
•
•
•

Most widely accepted synthetic skin substitute
Bilaminar structure
The median ‘take’ is 85%
Two-stage pro...
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
Cultured autologous keratinocytes
• Grown in vitro and then applied to wounds
• Take of cultured epithelial autografts dep...
Wound Closure
• Suggested Clinical Indications for CAE
– burn injuries >90% broad
– 70-90% more limited
– <70% no clear in...
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 expansion

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...
MATERIALS & METHODS
10th day wound care.

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.c...
MATERIALS & METHODS
Long term control.

POST-PHYSICAL REHABILITATION OUTCOME

Dr. Sunil Keswani, National Burns Centre,
ww...
DISCUSSION
•
•
•
•
•
•
•
•

Reliable alternative.
Easy technique.
Larger expansions.
High integration.
Fast epithelization...
NEED FOR PAIN RELIEF
•
•
•
•
•
•
•

PAIN IS A FORM OF STRESS AND PRODUCES ELEVATION IN STRESS
HORMONES AND CATECHOLAMINES....
NEED FOR PAIN RELIEF
• Circumferential chest burns-pain restricts full
respiratory excursions ,atelectasis and pneumonias
...
Mentosternal Contracture

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

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

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

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

POST-OP

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

POST-OP

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

POST-OP

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

POST-OP

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

POST-OP

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

POST-OP

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

POST-OP

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

POST-OP

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

POST-OP

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

POST-OP

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

POST-OP

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
CLINICAL USE OF
HOMOGRAFT
AT NBC

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Skin Bank and Skin Donation
DONATE SKIN AND SAVE A LIFE

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nb...
PATIENT
DETAILS
Patient Name- Neeta Parekh
Age- 48
Gender- Female
TBSA Of Burns- 35%
Degree Of Burns-2nd Degree
Areas Of B...
ADMISSION FORM

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
PHOTOS ON DAY OF ADMISSION

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
PHOTOS ON DAY OF ADMISSION

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

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
1ST DRESSING CHANGE OF HOMOGRAFT

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
2ND DRESSING CHANGE OF HOMOGRAFT (4TH DAY)

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail...
3RD DRESSING CHANGE OF HOMOGRAFT (6TH DAY)

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

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

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
1ST DRESSING CHANGE OF HOMOGRAFT

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
2ND DRESSING CHANGE OF HOMOGRAFT (4TH DAY)

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail...
3RD DRESSING CHANGE OF HOMOGRAFT (6TH DAY)

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

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

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
PATIENT DETAILS
Patient Name- Ramsingh
Age- 52
Gender- Male
TBSA Of Burns- 55%
Degree Of Burns-2nd Degree
Areas Of Burns- ...
ADMISSION FORM

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
PHOTOS ON DAY OF ADMISSION

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
PHOTOS ON DAY OF ADMISSION

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

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
1ST DRESSING CHANGE OF HOMOGRAFT

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
2NDDRESSING CHANGE OF HOMOGRAFT

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
5TH DRESSING CHANGE OF HOMOGRAFT

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

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

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
1ST DRESSING CHANGE OF HOMOGRAFT

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
2ND DRESSING CHANGE OF HOMOGRAFT

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
2ND STAGE TANGENTIAL EXCISION

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
2ND DRESSING CHANGE OF HOMOGRAFT (4TH
DAY)

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

BEFORE
TREATMENT

AFTER
TREATMENT
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcai...
PATIENT DETAILS

Patient Name- Yojana D.
Ghase
Age- 24
Gender- Female
TBSA Of Burns- 20%
Degree Of Burns-2nd Degree
Deep
A...
ADMISSION FORM

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
PHOTOS ON DAY OF ADMISSION

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

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

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
1ST DRESSING CHANGE OF HOMOGRAFT

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
2ND DRESSING CHANGE OF HOMOGRAFT

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
4TH DRESSING CHANGE OF HOMOGRAFT

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

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

AFTE...
END RESULT

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
PITFALLS IN BURN MANAGEMENT
•
•
•
•
•
•
•
•

Early tracheostomy
Prompt adequate resuscitation
Colloids after 12 hrs
Infect...
PITFALLS IN BURN MANAGEMENT
•
•
•
•

Escharotomy
Fasciotomy
Early excision and use of banked skin
Fascial excison and use ...
TEAM APPROACH TO BURNS

•
•
•
•
•
•
•
•
•

Plastic Surgeon
General Surgeon
Ophthalomologist
ENT surgeon
Intensivist
Nephro...
Screening of patients

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Surgeries being performed in the previous camps

Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@...
Post- Operative care of the patients

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

022 2779 3333

www.skindonation.in
www.burns-india.com
skinbanknbc@gmail.com

Dr. Sunil Keswani, ...
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Pitfalls in burn management by Dr. Sunil Keswani, National Burns Centre, Airoli

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Pitfalls in burn management by Dr. Sunil Keswani, National Burns Centre, Airoli

  1. 1. PITFALLS IN BURN MANAGEMENT Dr Sunil Keswani Cosmetic Surgeon and Burns Surgeon NATIONAL BURNS CENTRE Navi Mumbai Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  2. 2. Aim of burn care • • • • Rescue Resuscitate Refer Resurface • Rehabilitate • Reconstruct • Review Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  3. 3. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  4. 4. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  5. 5. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  6. 6. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  7. 7. Principles of BURN MANAGEMENT • Airway management-quick and appropriate • Prompt and accurate fluid resuscitation • Removal of dead burnt skin and replacement with homograft(cadaveric skin from SKIN BANK) or biologic skin substitutes • Appropriate adequate nutrition • Good chest PT • Replacement of homograft with autograft or cultured skin(cultured keratinocytes) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  8. 8. Which burn patients need HOSPITALISATION? • We go by the AMERICAN BURN ASSOCIATION GUIDELINES Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  9. 9. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  10. 10. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  11. 11. Does a child with only head face burns require hospitalisation? • YES. • The head face in a child constitues about 18% BSA while in an adult it is 9 %!! • Anything above 10% BSA in a child needs hospitalisation Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  12. 12. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  13. 13. How do we reduce INFECTION IN BURNS? • Hand washing • Infection control measures like Isolation,Use of disposables,Separate bedpan,stethoscope and BP apparatus for each burn patient and a 1:1 nurse patient ratio. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  14. 14. Philipp Ignaz Semmelweis • Hungarian Physician reduced the incidence of Puerperal Fever in a Vienna Hospital by introducing the practice of HAND WASHING with chlorinated water Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  15. 15. Louis Pasteur • French microbiologist and chemist • Germ theory of disease • Founder of Microbiology along with Robert Koch • Pasteurisation of milk • Popularised the concept of HAND WASHING Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  16. 16. LEVELS OF ICU CARE • Level - I – provides monitoring, observation and short term ventilation. • Level - II – Provides Observation, Monitoring & Long Term Ventilation With Resident Doctors. • Level - III – provides all aspects of intensive care including invasive haemo dynamic monitoring & dialysis. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  17. 17. BED STRENGTH • IDEALLY 8 TO 12 BEDS. • LARGER AREAS – DIFFICULT TO ADMINISTER AND SMALLER AREAS NOT BEING COST EFFECTIVE. • 5 TO 8 BEDS PER 50 HOSPITAL BEDS FOR A LEVEL III ICU / 10-16% OF THE TOTAL NUMBER OF HOSPITAL BEDS. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  18. 18. BED SPACE & BEDS • ALL SEPARATE CUBICLES • 225 – 250 SQUARE FEET PER BEDS • BEDS - ADJUSTABLE, NO HEAD BOARD, SIDE RAILS AND WITH WHEELS,REMOTE CONTROLLED WITH FACILITY FOR ALL POSITIONING FOR NURSING CARE AND PHYSIOTHERAPY AND EMERGENCY SITUATIONS Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  19. 19. Fluid Management • • • • Fluids per hour=Wt(kg) x % of Burns divided by 4 Start with RL in adults and Isolyte P in children After 24 hrs start DNS If not adequate urine output in 12 hrs start colloids FFP • CVP above 10 cms water and inadequate uo Inj Lasix • More fluids required in Electric Burns and Inhalation Injury • Always central line (sometimes even thro burnt tissue) for initial resuscitation Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  20. 20. Fluid resuscitation • • • • Need to replace losses to maintain homeostasis. Formulas are ONLY GUIDELINES. Monitor physiologic parameters. Maintain adequate tissue perfusion to prevent increase in depth of burn. • Too little fluid ► Hypotension ► renal failure, etc. • Too much fluid ► Edema ► Tissue hypoxia Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  21. 21. Electrical injury resuscitation • Fluid needs greater • 9 mL x TBSA burn (%) x body weight (kg) in first 24 hrs • If myoglobinuria, may require bicarbonate infusion to alkalinize urine to pH > 8 • End point: urine output of 1.5-2 mL/kg/hr Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  22. 22. Electrolyte Abnormalities • HYPOKALEMIA- seen more often than Hyperkalemia • Commonest cause of non infective paralytic ileus • Serum K <3mEq/l KCl at 10mEq/hr • Serum K <2mEq/l KCl at 40mEq/hr • Daily Ser Electrolytes in first 3 days Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  23. 23. Electrolyte Abnormalities • HYPOCALCEMIA-most commonly due to Hypoalbuminemia • Lowering of Ser Albumin by 1g/ml lowers Ser Calcium by 1g/ml • Alkalosis also lowers Ser Ca by increasing protein binding • Correction required only if symptomatic • Associated Hypomagnesemia needs simultaneous correction to prevent tetany and arrhythmias Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  24. 24. Reducing the HYPERMETABOLIC RESPONSE • Temperature regulation • Nutrition • Pharamacological manipulation-Propranolol 40 mg BD and Oxandrolone 5mg BD • Early excision and homografting Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  25. 25. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  26. 26. Role of LMWH • Incidence of Deep Vein Thrombosis is significant enough to warrant routine use of LMWH • Incidence of Pulmonary embolism is reduced significantly • Daltaparin or Enoxiparin • Fragmin or Clexane • This is stopped once patient is mobile Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  27. 27. Role of Intermittent Compression Device • Intermittent compression pump along with LMWH decreases the incidence of DVT by as much as 50% Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  28. 28. Nutrition • Aggressive nutritional support to counterbalance the effect of Hypermetabolism and Protein catabolism following Burns • ENTERAL feeding is preferred over PARENTERAL feeding Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  29. 29. Nutritional support • Burns patient is hypercatabolic – up to 150200% above baseline. • Nutrition needed for burns >20% TBSA. • Curreri formula – Adult: 25kcal/kg/day + 40kcal/ % TBSA burn – Child: 60kcal/kg/day + 35kcal/ % TBSA burn Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  30. 30. BUTTERMILK DIET(BMD) • Eggs- 4 /Protein powders(Whey protein or Soya protein) • Bananas- 4 • Sugar- 4 Tbsf • Curds (Yoghurt) -1000cc • Mixed with water to 1600cc Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  31. 31. Tracheostomy • Head face neck burns IMMEDIATE TRACHEOSTOMY to facilitate airway and nursing Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  32. 32. Chest Physiotherapy Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  33. 33. Limb Physiotherapy Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  34. 34. Fasciotomy • Pain • Pallor-look at capillary refill • Compartmental time-if less than 2 secspressures above VENOUS OBSTRUCTION and 25mm Hg warrant if more than 5 secs – a FASCIOTOMY ARTERIAL OBSTRUCTION • Pressure • There are devices • Pulselessnes to measure this • Paresthesia pressure • Paralysis • Poikilothermia • We use DOPPLER Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, to decide • Progression nbcairoli@gmail.com
  35. 35. Fasciotomy-LINES OF INCISION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  36. 36. Fasciotomy-methodology Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  37. 37. Fasciotomy-methodology Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  38. 38. Leg-FASCIAL COMPARTMENTS 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. Esharotomy • Thick circumferential non-yielding eschar warrants an ESHCAROTOMY Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
  41. 41. Esharotomy-LINES OF INCISION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  42. 42. Esharotomy Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  43. 43. INTRAABDOMINAL HYPERTENSION and INTRAABDOMINAL COMPARTMENT SYDROME 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. Abd compartment syndromeLAPAROTOMY Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  48. 48. 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 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  49. 49. 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 • Coverage of excised area by Meshed Homograft is mandatory Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  50. 50. 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
  51. 51. Early Excision • Blood Loss – Clear pre-operative plan – Excision prior to wound hyperemia – Elevation of extremities – Tourniquet control – Dilute Epinephrine tumescent fluid – Epinephrine soaked sponges Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  52. 52. Early Excision • Procedure (En Bloc) – For deeper burns – Skin and fat excised in one session – Less time consuming – Excision down to the natural cleavage plane – Down to fat or Fascia Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  53. 53. 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
  54. 54. Allograft • Reduction in the number of bacteria under a biological dressing • Phagocytes within a wound use the fibrin network established between the allograft and the wound to trap and phagocytose bacteria without the production of opsonins or antibody • The effects of allografts in reducing bacteria and promoting healing have proven beneficial Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  55. 55. Porcine Skin Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  56. 56. Porcine skin being meshed Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  57. 57. Differences Between Skin Substitutes • Materials that are applied for short periods then removed, to stimulate autologous healing • Cell free material that encourage colonization by autologous cells, to stimulate new skin formation • Cell containing skin substitutes: to provide immediate functional replacement Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  58. 58. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  59. 59. 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
  60. 60. Integra Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  61. 61. Acticoat Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  62. 62. Fascial Excision Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  63. 63. Integra applied Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  64. 64. Covered with Acticoat Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  65. 65. 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
  66. 66. Wound Closure • Suggested Clinical Indications for CAE – burn injuries >90% broad – 70-90% more limited – <70% no clear indication Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  67. 67. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  68. 68. 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
  69. 69. MATERIALS & METHODS Surplus cutting Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  70. 70. MATERIALS & METHODS Positioning on plate. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  71. 71. MATERIALS & METHODS Dermatome cut through Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  72. 72. MATERIALS & METHODS Adhesive Spraying Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  73. 73. MATERIALS & METHODS Adhesive Spraying Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  74. 74. MATERIALS & METHODS Cork removing. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  75. 75. MATERIALS & METHODS Gauze expansion Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  76. 76. MATERIALS & METHODS Gauze expanded. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  77. 77. MATERIALS & METHODS Micrograft positioning Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  78. 78. MATERIALS & METHODS After gauze removal. 7th day. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  79. 79. MATERIALS & METHODS 10th day wound care. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  80. 80. MATERIALS & METHODS Long term control. POST-PHYSICAL REHABILITATION OUTCOME Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  81. 81. DISCUSSION • • • • • • • • Reliable alternative. Easy technique. Larger expansions. High integration. Fast epithelization. Better infection response versus mesh graft. Easy to handle because of its pliability. Comparative with mesh tecniques and functional results studies are required in the future. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  82. 82. NEED FOR PAIN RELIEF • • • • • • • PAIN IS A FORM OF STRESS AND PRODUCES ELEVATION IN STRESS HORMONES AND CATECHOLAMINES. PAIN RELIEF ADVANTAGES:SHORTER HOSPITAL STAY. IMPROVED MORTALITY RATES LESS CATABOLISM AND ENDOCRINE DERANGEMENTS. FEWER THROMBOEMBOLIC COMPLICATIONS PAIN FREE DRESSINGS MAKE PATIENTS MORE COMFORTABLE AND DECREASES THE MORBIDITY AND MORTALITY. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  83. 83. NEED FOR PAIN RELIEF • Circumferential chest burns-pain restricts full respiratory excursions ,atelectasis and pneumonias • Pain prevents patients from eating well-nutrition affected. • Pain depresses the patient-psychosomatic problems • Pain contributory to Post burn psychosis • Pain-poor compliance during physiotherapy-poor rehabilitation-poor functional outcome Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  84. 84. Mentosternal Contracture Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  85. 85. Mentosternal Contracture Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  86. 86. Homogrft and Autograft Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  87. 87. Penoscrotal burns Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  88. 88. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  89. 89. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  90. 90. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  91. 91. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  92. 92. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  93. 93. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  94. 94. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  95. 95. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  96. 96. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  97. 97. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  98. 98. PRE-OP POST-OP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  99. 99. CLINICAL USE OF HOMOGRAFT AT NBC Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  100. 100. Skin Bank and Skin Donation DONATE SKIN AND SAVE A LIFE Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  101. 101. PATIENT DETAILS Patient Name- Neeta Parekh Age- 48 Gender- Female TBSA Of Burns- 35% Degree Of Burns-2nd Degree Areas Of Burns-chest, Both Upper Extremities Cause Of Burns-During Lighting Diya Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  102. 102. ADMISSION FORM Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  103. 103. PHOTOS ON DAY OF ADMISSION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  104. 104. PHOTOS ON DAY OF ADMISSION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  105. 105. EARLY BURN EXCISION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  106. 106. APPLICATION OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  107. 107. 1ST DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  108. 108. 2ND DRESSING CHANGE OF HOMOGRAFT (4TH DAY) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  109. 109. 3RD DRESSING CHANGE OF HOMOGRAFT (6TH DAY) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  110. 110. FOLLOW UP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  111. 111. FOLLOW UP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  112. 112. APPLICATION OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  113. 113. 1ST DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  114. 114. 2ND DRESSING CHANGE OF HOMOGRAFT (4TH DAY) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  115. 115. 3RD DRESSING CHANGE OF HOMOGRAFT (6TH DAY) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  116. 116. FOLLOW UP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  117. 117. FOLLOW UP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  118. 118. END RESULT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  119. 119. PATIENT DETAILS Patient Name- Ramsingh Age- 52 Gender- Male TBSA Of Burns- 55% Degree Of Burns-2nd Degree Areas Of Burns- Face ,Chest, Both Upper Extremities,, Lower Extremities. Cause Of Burns- Explosion Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  120. 120. ADMISSION FORM Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  121. 121. PHOTOS ON DAY OF ADMISSION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  122. 122. PHOTOS ON DAY OF ADMISSION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  123. 123. EARLY BURN EXCISION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  124. 124. APPLICATION OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  125. 125. 1ST DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  126. 126. 2NDDRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  127. 127. 5TH DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  128. 128. FOLLOW UP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  129. 129. EARLY BURN EXCISION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  130. 130. APPLICATION OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  131. 131. 1ST DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  132. 132. 2ND DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  133. 133. FOLLOW UP Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  134. 134. 2ND STAGE TANGENTIAL EXCISION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  135. 135. APPLICATION OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  136. 136. 2ND DRESSING CHANGE OF HOMOGRAFT (4TH DAY) Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  137. 137. TREATMENT GOING ON BEFORE TREATMENT AFTER TREATMENT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  138. 138. PATIENT DETAILS Patient Name- Yojana D. Ghase Age- 24 Gender- Female TBSA Of Burns- 20% Degree Of Burns-2nd Degree Deep Areas Of Burns- Chest, Abdomen, Right Upper Extremity, Lower Face . Cause Of Burns-flame Burn. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  139. 139. ADMISSION FORM Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  140. 140. PHOTOS ON DAY OF ADMISSION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  141. 141. EARLY BURN EXCISION Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  142. 142. APPLICATION OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  143. 143. 1ST DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  144. 144. 2ND DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  145. 145. 4TH DRESSING CHANGE OF HOMOGRAFT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  146. 146. BEFORE AUTOGRAFTING AUTOGRAFTING Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com AFTER
  147. 147. END RESULT Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  148. 148. PITFALLS IN BURN MANAGEMENT • • • • • • • • Early tracheostomy Prompt adequate resuscitation Colloids after 12 hrs Infection control practices Pain relief Early enteral nutrition Early mobilisation and Intensive chest PT DVT prophylaxis Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  149. 149. PITFALLS IN BURN MANAGEMENT • • • • Escharotomy Fasciotomy Early excision and use of banked skin Fascial excison and use of banked skin or autografts • Early rehabilitationphysical,social,psychological Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  150. 150. TEAM APPROACH TO BURNS • • • • • • • • • Plastic Surgeon General Surgeon Ophthalomologist ENT surgeon Intensivist Nephrologist Anesthesiologist Cardiologist Psychiatrist Nurses Microbiologist Physiotherapist Occupational therapist Psychological Counsellor Social Worker Dietitian Prevention team Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  151. 151. Screening of patients Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  152. 152. Surgeries being performed in the previous camps Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  153. 153. Post- Operative care of the patients Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
  154. 154. Skin Donation Helpline: 022 2779 3333 www.skindonation.in www.burns-india.com skinbanknbc@gmail.com Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com

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