SURGICAL TREATMENT AND MANAGEMENT OF

THE BURN PATIENT

ACUTE MANAGEMENT

• Primary survey
• A – Airway with cervical spine control
B – Breathing
C – Circulation
D – Neurological status and pain control
E – Environment (heat loss) control
F – Initiate fluid resuscitation
ACUTE MANAGEMENT

• Stop burn process

• Inhalation injury
• Circumferential chest wall contracture
• Burn shock
• Pain control
• Heat loss
PRIMARY SURVEY

• Type of burn (flame, scald, electrical, radiation, or chemical)

• A : inhalation injury  definitive airway
• B : Circumferential chest wall contracture  Burn escharotomy
• C : Shock resuscitation
• hemorrhagic shock
• ongoing losses from capillary leak due to inflammation
ESCHAROTOMY
PRIMARY SURVEY

• Rough estimate of % body surface area burned

• Route of IV access
peripheral intravenous access But if cannot be obtained then considered
- interosseous route
- Central venous catheter route
• Pain management as needed
• Catheterize patient or establish fluid balance monitoring
SECONDARY SURVEY

• Clean and dress wounds

• Assess the depth and TBSA burned, reassess, and exclude or treat associated
injuries
• Arrange safe transfer to specialist burns facility
BSA
DEPTH OF BURN
EPIDERMAL BURN
SUPERFICIAL PARTIAL THICKNESS BURN

Bleb Pink Moist Pain

DEEP PARTIAL THICKNESS BURN
FULL THICKNESS BURN
BURN INJURIES THAT SHOULD BE REFERRED TO A BURN UNIT
BURN CARE AND MANAGEMENT
WOUND CARE

• Depend on wound depth

• Superficial partial thickness burn : Wound dressings
• Deep partial thickness burn : Early excision and skin graft
• No systemic prophylactic antibiotics
• Promote development of fungal infections
BURN WOUND CLEANSING

• Bed side
- NSS, Forceps, Aspirate VS unroof blister

• Tub bath
- improvement of the burn surface (separation of the eschar, loose necrotic debris is
gently removed and pus evacuated)
- 1-2 times per week
• Shower bath
SUPERFICIAL PARTIAL THICKNESS BURN

• Topical antimicrobials
TOPICAL AGENTS AND DRESSINGS FOR
LOCAL BURN WOUND CARE

• Aggressive wound care that includes topical agents with antimicrobial

activity has been associated with a reduced incidence of invasive wound
infections
• There is no consensus on which agent or dressing is optimal for managing
burn wounds to prevent or control infection or enhance wound healing
COMMONLY USED AGENTS

• Antimicrobial ointments :
• Topical antimicrobial ointments,
• As single agents or combination agents, are commonly used for superficial burn wounds.
• Compared with silver sulfadiazine, the advantages of these are ease of application and of removal for
wound cleansing. In addition, these can be used in areas of sensitivity, such as on the face, ears, and
perineum

• Silver-containing agents
• Silver-containing agents slowly release ionic silver into the wound Activated silver has broad-spectrum
antimicrobial activity and may also have an anti-inflammatory benefit
SUPERFICIAL PARTIAL THICKNESS BURN

• Synthetic wound dressing

HYDROGELS

• Intrasite gel
• Indication : Dry/low to moderate exuding wounds
• Action : Rehydrate wound bed, Moisture control, Promote autolytic debridement
• Pros : easy to visualize wound base for preparing skin graft in deep well-
granulation tissue burn wound or almost fully recovered wound
• Cons : antimicrobial activity
HYDROCOLLOIDS

• Urgotul, Duoderm
• Indication : Clean, low to moderate exuding wounds
• Action : Absorb fluid, Promote autolytic debridement
• Pros : cost, non-stick pad, occlusive protection
ALGINATES

• Algisite
• Indication : Moderate to high exuding wounds
• Action : Absorb fluid, Promote autolytic debridement
• Pros : deep wound, high exudate
• Cons : conform ability to wound base, skin marceration, change with soak
HYDROFIBER

• AquacelAG
• Indication : Moderate to high exuding wounds
• Action : Absorb fluid, Promote autolytic debridement
• Pros : deep wound, easy to remove after absorption high exudate
• Cons : cost, conform ability to wound base
FOAMS

• Allevyn
• Indication : high exuding wounds
• Action : Absorb fluid, moisture control
• Pros : non-adherent, occlusive dressing, easy to apply and remove, change 3
days
• Cons : not apply in fingers, joints
NANOCRYSTALLINE SILVER DRESSING

• Acticoat
• Indication : moderate to high exuding wounds
• Action : high antimicrobial activity
• Pros : long duration 2-7 days, deep burn
• Cons : cost
SILICONE DRESSING

• Mepitel, Mepilex
• Indication : high exuding wounds, antimicrobial activity
• Action : absorb fluid, promote wound epithelialization
• Pros : easy to apply and remove
• Cons : cost
SURGICAL MANAGEMENT

• Burn wound excision

• Deep partial thickness burn
• Full thickness burn
• Escharotomy
• Deep partial thickness burn
• Full thickness burn
• Escharectomy
• Full thickness burn
SURGICAL TREATMENT

• Burns are common injuries with considerable morbidity and Mortality

• Early excision and grafting has been the standard care for decades.
• Since mid 70s most studies have shown that excision within 24 to 48 h after
injury is associated with decreased blood loss, infection, length of hospital
stay and mortality, and increased graft take
• Need for surgical intervention/debridement depends on the depth of the
injury.
• Full-thickness burns destroy all of the dermal elements;
• hence there are no epidermal cells left to regenerate the injured area.

• Partial thickness injuries allow epidermal cells to survive

• The dermal elements, such as sweat glands or hair folllicles to repopulate the injured
area.
WOUND CLOSURE AFTER MASSIVE WOUND
DEBRIDEMENT

• Burn wound closure > 40% BSA

• Delayed closure due to high incidence of bacterial colonization
• Meshed skin graft
• 1:3 – 1:4
• 0.012 – 0.020 inches
• MEEK skin graft
SUCCESSFUL BURN TREATMENT

• Early management and fluid resuscitation

• Control of infection
• Early closure of the burn wound
• Support of hypermetabolic response of the injury
THANK
YOU