Burns: Alhad Naragude Final Year M.B.B.S (BJMC Pune) Dr. Pawan Chumbale M.S, MCH Plastic Surgery (Sassoon Hospital, Pune)

BURNS
Alhad Naragude
Final Year M.B.B.S [BJMC PUNE]
Guided By
Dr. Pawan Chumbale
M.S, MCh Plastic Surgery [SASSOON HOSPITAL, PUNE]
Surgical Management
Assessment Debridement Rehabilitation
Dressing Wound
Closure
Assessment Dressing Debridement Wound Closure Rehabilitation
A: Airway
History & 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
Burns Size Burns Depth
Burns
Patient
Patient Survival
Age
Comorbidity Factors
Presence Of Inhalational
Injury
CLASSIFICATION
Dressing
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.
Initial Focus
Healing
Prevent
Infection
Tetanus
Prophylaxis
Debride Bullae
Excise Adherent Necrotic Tissue

Scrubbing Apply Antibiotic
Topical Antibiotic
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
Polyurethrane
Superficial Burn Semipermeable Membrane
Protect the wound & Encourage
Re-epithelialization
• Topical Analgesic Cream
• Moisturising Cream
• E.g. Polyurethrane
Semipermeable Membrane,
Hydrocolloids & Retention
dressings
Partial thickness burn
• Hydrocolloids Hydrocolloid
• Polyurethane films
• Biologic dressings
• Alginates
• Foams
• Antimicrobial products such as

products containing silver.
Full thickness burn injuries
• Antimicrobial dressings
E.g. Silver Sulphadiazine cream

and Silver Nitrate Solution
Debridement
Debridement
Excision
Escharotomy
Excision
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
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: • Surgical principles
• deep burns (dermal and • preservation of life
sub-dermal) • prevention of infection
• significant size • conservation of viable
• clinical diagnosis 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
Tangential Excision
Good cosmesis
Advantages
More wound
coverage methods
High blood loss

Disadvantages
Difficult burn methods
depth evaluation
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 Easy burn depth
evaluation
Advantages
Low blood loss
Fewer grafting
possibilities
Disadvantages
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.
Compartment
Eschar Inelasticity
Syndrome
Compartment Pressure >40

Escharotomy
Syndrome mm of Hg
Indications
1. Pain on passive extension
2. Pallor
3. Paresthesia
4. Poikilothermia
5. Paresis
6. 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)

Running a finger along the incision
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
Escharotomy Procedure (continued)

Draw a line where you will make the incision
Avoid the ulnar nerve and common peroneal

nerve
Ensure the adequacy of the incisions by reassessing the circulation or

respiration
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 Grafting
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
Assessment Dressing Debridement Rehabilitation
Dermatome-harvesting Graft
Early excision and grafting
Pre-Op wound
Application of Homograft
Day 3
Complete healing
Day 21
Skin Substitutes
Biobrane
Acellular skin substitutes Integra
Alloderm
Transcyte
Cellular Allogenic Skin Substitutes Apligraf
Dermagraft
Cultured Epidermal Autograft

Cellular Autologous Skin Substitutes
Cultured Skin Substitutes
Splinting and Positioning
Rehabilitation
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 Splinting
Primary Splints Postural Splints
• acute phase and pre • Immediate post graft
grafting period phase
• used to position the • Worn continuously for 5 to

involved joints during 14 days until the graft is
sleep, inactivity, or periods secure.
of unresponsiveness.
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
• Promotes wound healing
• Maintains joint
alignment • Relieves pressure
• Protects joints, exposed
• Maintains tissues
elongated tendons and new
grafts/flaps
• Prevents contracture
formation
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
MCP Hyper extension IP Flexion, thumb MCP Flexion-80o, IF Extension, thumb palmar
Dorsal/hand/finger adduction 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 • Elevation
• Silicone gel sheet • Itching
• Intra lesional injection • Redness
• Split skin graft
• Laser therapy
• Cryotherapy
• Radio therapy
• Combination therapy
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: Alhad Naragude Final Year M.B.B.S (BJMC Pune) Dr. Pawan Chumbale M.S, MCH Plastic Surgery (Sassoon Hospital, Pune)

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BURNS

Assessment Debridement Rehabilitation

• Fire in a closed space.

• Intubate patient as early as

• Indications for intubation:

• Change in voice, harsh cough.

• BP, HR, color of unburnt skin

Assessment Of Burn Wound Depth

Burns Size Burns Depth

Excise Adherent Necrotic Tissue

Dress the burn with petroleum gauze and dry gauze

• Antimicrobial products such as

Full thickness burn injuries

E.g. Silver Sulphadiazine cream

• Within the first 3-5days

• Areas easy and quick to

• Joints and neck

• Hands and face

• Applies to deep dermal

Tangential excision to achieve

High blood loss

Epifascial excision and

Low blood loss

• An escharotomy is a surgical procedure used to treat full

• Full-thickness circumferential burn of an extremity or Trunk can

Compartment Pressure >40

• Indicated when the

Incision 1 cm into unburned healthy tissue where

Escharotomy Procedure (continued)

For the chest, incisions along the mid axillary lines,

Escharotomy Procedure (continued)

Avoid the ulnar nerve and common peroneal

Ensure the adequacy of the incisions by reassessing the circulation or

Plan the Incision

• After excision the wound, there is wound closure.

Classification of skin grafting

• Full thickness skin graft

• Immediate coverage of clean soft tissue defects

• Immediate coverage of burn defects

• Prevention of scar contracture.

• Need to place the graft in areas where good cosmesis

• Significant wound contraction could compromise

• A full-thickness skin graft

• Deep burn injuries

• Recipient bed cannot sustain the graft.

• Uncontrolled bleeding in the recipient bed

Early excision and grafting

Cultured Epidermal Autograft

Splinting and Positioning

Splinting & Positioning

• used to position the • Worn continuously for 5 to

• 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

* Forearm Pronation Supination

Hip Flexion, adduction external rotation Extension, abduction neutral rotation

• Initial resuscitation of burns

• Difficult mask seal

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