Recomendados
Mais conteúdo relacionado
Mais procurados
Mais procurados (20)
Destaque
Destaque (20)
Semelhante a Burn update 2013 by Dr. Sunil Keswani, National Burns Centre, Airoli
Semelhante a Burn update 2013 by Dr. Sunil Keswani, National Burns Centre, Airoli (16)
Último
Último (20)
Burn update 2013 by Dr. Sunil Keswani, National Burns Centre, Airoli
- 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. Procedures • Tracheostomy • Central line insertion • Escharotomy • Debridement. Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com,
- 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. 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. 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. 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. 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. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 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. MATERIALS & METHODS Surplus cutting Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 11. MATERIALS & METHODS Positioning on plate. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 12. MATERIALS & METHODS Dermatome cut through Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 13. MATERIALS & METHODS Adhesive Spraying Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 14. MATERIALS & METHODS Adhesive Spraying Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 15. MATERIALS & METHODS Cork removing. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 16. MATERIALS & METHODS Gauze expantion Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 17. MATERIALS & METHODS Gauze expanded. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 18. MATERIALS & METHODS Micrograft positioning Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 19. MATERIALS & METHODS After gauze removal. 7th day. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Clinical Use of Homograft Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 35. Pre-Op photographs Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 36. Post-Op photographs Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 37. Post-Op healing Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 38. Case 2 Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 39. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 40. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 41. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 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. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 44. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 45. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 46. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 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. Porcine Skin Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 49. Porcine skin being meshed Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 50. Integra Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 51. Integra Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 52. Acticoat Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 53. Fascial Excision Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 54. Integra applied Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 55. Covered with Acticoat Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
- 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. 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. 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. 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. 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
Notas do Editor
- {"27":"Mortality at the MGH -\nearly excision and grafting instituted in 1976.\n","28":"Elderly Population\nHistorical controls (Dietch, 114 consecutive patients average age 68 years)\nhospital stay decreased 40-%\npreexisting medical conditions had no effect on survival\nEarly Donor site closure:\nRedundant skin of thighs and lower abdomen allows for direct excision and primary closure decreasing overall wound surface area.\n","56":"Processing is designed to leave a non-antigenic dermal scaffold, leaving basement membrane proteins intact\n","23":"Janzekovic, Zora (Yugoslavia)\nTangential Excision def’n:\nburned tissue excised layer by layer until a freely bleeding surface is obtained.\nQuickly became the standard excisional technique\nDebate remained - how much tissue to excise in one session.\n1978 proposed single session for full thickness burns <20%TBS, two sessions for those burns, 30-40% TBSA.\n1979 Jurkewiscz heading a consensus meeting for the American Burn Association recommended single session excision be limited to 30%BSA.\nReference:\nJanzekovic, Z: A new concept in the early excision and immediate grafting of burns. J Trauma 19:1103, 1970\n","57":"Inner layer is 2mm thick and is a combination of GAG and collagen fibers from bovine tissue\nInner layer has 70-200 nm pore size that allows fibrovascular ingrowth, after which it is designed to slowly biodegrade\nOuter layer is 0.009 inches thick polysiloxane polymer with vapor transmission characteristics similar to normal epithelium\n","24":"Eschar separation:\nFuelled by inflammatory response to injury and bacterial invasion. Enzymatic action leads to separation at the granulating interface.\n(Colebrook, 1950, Crews 1964).\nMediators- prostaglandins, thomboxane histamine, TNF.\nAdvantage- smaller wounds secondary to contraction but - higher incidence of contracture.\nDisadvantage- time consuming\nhigh evaporative water loss\nhigh metabolic demands, protein catabolism, weight loss.\nImmunosuppression, infection and sepsis\n","30":"Decreased procedures:\naverage number reduced from 4 to 1.5.\nEquivalent decrease in length of stay\n(Macmillan), 1970).\n","58":"such asburns, chronic leg ulcers, giant pigmented naevi,epidermolysis bullosa and neonatal scalp necrosis\nseparation from the tissue culture substrate using a proteolytic enzyme\nspontaneous blistering many months after grafting, increased susceptibility to infection, and contractures\nBovine serum proteins\nact as growth promoters\nDelayed loss of graft\ninitial take 64% declined to 47% at discharge for one study of 16 patients\nCost $2000-34 000 pr percent of definitive wound closure at discharge.\nBlistering\nassociated with high PGE2 and thromboxane levels suggesting an ongoing inflammatory response\nEffects of fibrin glues being evaluated with limited success\nFibrin-glue suspensionSome success has been achieved by applying cells together with fibrin glue, in a suspensionof growth medium or using a membrane for delivery.\nFibrin-glue sheets. Subconfluent cultured keratinocyteshave been grown on fibrin glue, and then transferred as asheet onto the wounds in three patients with excised fullthicknessburns. The fibrin was found to provide a satisfactorybarrier for 10 days, \n","20":"a wound must not be excised\nunless it can be immediately closed\nDoes early excision of large burns have any effect\non morbidity and mortality? A report by Cryer and\nothers4 notes markedly improved survival of patients\n41 to 60 years of age who have burns over 20% to\n65% TBSA and are treated with early excision and\ngrafting. Early wound closure may decrease overall\nmortality but does not change the morbidity pattern\nor cause of death of patients who die more\nthan 3 days postburn\n","59":"Cuano\nallograft provides coverage while the epidermal cell culture grows in vitro\nhost fibroblast migrate into the allograft dermal matrix replacing it\nBell\nLiving Skin Equivalent (LSE)\ndermal equivalent bovine collagen and neo-natal (foreskin) fibroblasts\noverlay of human epidermal cells\nGraftskin (tradename)\nDermagraft \napplied to wound and immediately autografted\ntake 70-90%\nno evidence of immunologic reaction to the neo-natal fibroblasts\ntested on 17 patients\n(age 31 range 9-69)\nburn size 23.8%TBSA\n","26":"Shorter hospitalization:\nlower rates of sepsis\nEarly studies excluded patients :\nolder than 55\nwith associated inhalation injury\nwith burns larger than 30%\nStudies in the mid eighties concluded that for burns larger than 30%TBSA, patients older than 30 years with inhalation injury the survival benefit was lost\nShriners Burn Institute - Galveston \nBurns >50%\nNo inhalation injury\n17-30 years old\nMortality decreased from 45% to 9%.\n","21":"Early Excision\nNational institutes of Health USA\n3-7 days.\n"}