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[Music] uh so good evening everyone i'm dr niveda and i welcome you all on behalf of netflix uh for a very interesting topic management of acute burns i think this is something that the man had to live with from the time he's invented fire uh and who better to talk about this topic than dr vinita puri who is the professor and a head of department plastic surgery at km hospital mumbai so mama i'll start your presentation and we can get started thank you so uh we'll begin right so uh ever since humans discovered fire burns have been occurring and its consequences are really devastating so uh i think burn care needs to keep pace with the rest of the medical world there is a lot more that can be done in burn care but at least uh what the the knowledge that is already available i think that needs to be spread to many more so now i said that the consequences are devastating and why did i say that that's because mortality is very high in burns even a patient who has 25 percent burns may succumb to the injuries because 20 anything more than 25 burns is considered a severe burn uh post burn post burn scarring is essential in any patient who is going to get deep burns they will be scarring and though deformities need not happen if the right treatment is taken but in our countries we see a large number of deformities so because of this scarring and deformities survivors often stop being useful members of society which is a very very uh huge consequence i think so there are many maybe who feel that isn't just saving life a priority and should be really border about late morbidity when you are treating the burn patients and i think this is probably a thought that may be happening and there could be many others who treat burns and think that can we really stop the burn deformities so uh now i'm going to show you a set of photographs and when you see all these patients these are the kind of patients that most uh plastic surgeons see in the outpatient department and if you see all these deformities you realize that these are our burn survivors so basically these patients have landed up they have gone to a doctor they have been treated uh in uh some place which has they have all been admitted sometime but they have landed up with these exceedingly severe deformities so what why is it that we are such a deformity capital of the of of the world i should say and we get an exceedingly very large number of post-burn uh contractors well burns is a problem of the poor and burn care at centers other than at government hospitals or municipal hospitals is very expensive and where the patients are concerned they feel that treatment at a government center is associated with the stigma of infection or of neglect now these problems are not just related to any one specific point but a multiple there are multiple factors for this so what are the patient problems well poverty is a very big issue as well as ignorance because there is lack of information so even somebody who gets a very small burn like a hand burn it feels like it's not too much it's barely half percentage of the body body surface area but it can lead to a huge deformity like contractures and it finally affects function now other issue is that because of poverty they have they probably don't have the money to go too far away places uh to get their treatment done because burn centers are inadequate in in it's not as though we have large number of burn centers in each district there is some amount of apathy also where they feel well uh anyway the wound has now healed secondarily and it's all right we will live with the deformities there is another issue and that is as i mentioned earlier that is of the primary care physician problems there is lack of burn care awareness and updates in the primary care physicians if you saw you saw all those photographs of the contractors you'll realize that all these patients have actually been treated by some doctor somewhere but we have even then landed up with so many contractors and these are very severe contractors which are very preventable uh we also have an issue of no real referral guidelines and uh referrals are occasionally late to the burn center and uh sometimes uh even larger percentages of burn when they start healing secondarily there is a feeling that anywhere they are healing so let's just keep them where we are and not refer them to a burn center for higher management what about burn specialist problems what about people like us who are actually treating one so uh ideally probably we should put in the effort to do some referral tracing and see where where the patient was treated earlier so that we can update the knowledge of at least that specific physician who treated so that the next patient would not land up with problems uh there is uh not adequate uh uh effort on our part uh to though there are many and our national burn uh the academy of burns our national organization is putting in a lot of effort uh to educate and empower the non-burn surgeons uh even then i think a lot more can be done uh in government hospitals uh the the units are also juggling with treating other patients so the and they're also juggling resources uh that they have uh private hospitals uh well they are able to give the optimum treatment only till the resources last and later after that the patients are then referred to government hospitals and there is also inadequate funding for research so we are not really able to do adequate research in the problem of births what are the system problems yes there's a very big system problem one is that we don't have a national burn registry and if if we as a country don't even know what is the actual load of burns how are we actually going to try to resolve the problem of of burn mortality and better management we don't have uh any known national guidelines for referral or treatment so i i have a few suggestions and i feel that it is very important to empower our primary care physicians whether they are the gps or the physicians and give them adequate knowledge about first aid the first 24 hour care and i think this first 24 hour care if it is given right then the patient will be able to go on for a better result when they are referred to the burn centers this can be done through regular cmes referral criteria should become more visible to everyone and we need to improve the knowledge of doctors regarding morbidity related to burns and the fact that severe morbidity is very preventable so i always say that post-burn scarring is inevitable no doubt in a deep ones but contractures are very much preventable so we need to empower the treating doctors with knowledge about simple measures to avoid the contractors and this is where the system is concerned that is the government is concerned i think they need to come up with hospitals and specific burn centers in each district so today's talk of mine is basically going to talk about the basic objectives of burn care which is one save life to prevent deformity and of course provide rehabilitation to our patients so starting out let's talk about the burn victim what is the first thing that a burn victim needs and that's first aid at the site so what is the purpose of the first state the first aid essentially in your burn patient should fulfill two main uh main purposes one it should prevent the condition of burn becoming worse and secondly the first state in some way should also make sure that later on it doesn't cause an infection so what is there it that the first thing that is needed is obviously to remove the patient from the source of the injury whatever is causing the burns after that you are going to stop the burning process on the patient so poor water the person can also the victim can drop on the ground and after that one can pack the flames off you have to make sure that the person does not run around the victim should not run around because that only fuels the flames of the garments and that whatever the person is wearing that is going to flame up even more once the flames are doused assess the clothes and remove the smoldering clothes otherwise all those clothes which are hot are going to continue to burn the skin or water on burns this pouring of water should be done for at least at least 15 to 20 minutes and it makes a lot of difference in fact you should keep continuing to pour water till the pain goes down a bit this is going to help you in a very big way because it also decreases the depth of burns so let me put it as simple as simply as this when we cook and you have a vessel in which you cook and you create heat the vessel also remains hot along with the uh structure along with whatever is inside the vessel in us in a similar way the skin itself after it gets burned is going to remain hot and that is going to continue to the burning process sort of continues inside the body and on that skin so it is very essential to reduce the temperature of the skin so this holds true for example even if you get a very simple kitchen burn or even a contact burn to a cooker or something like that it is very important to cool that area for 15 to 20 minutes and that goes a long way in reducing the depth of the burn don't use ice or ice packs because it basically eyes can cause further injury to the skin and in a colder climate of course it can cause hypothermia remember to remove all things like rings watches dwells bears etc like i mentioned about the clothes or the skin itself all of these retain heat so that will continue to give you a much deeper burn in that area secondly things like rings bangles kadas and all these can cause a tunic effect because edema is going to happen in all burns and then you will end up having distill ischemia now if if what has happened is scars then remove the soaked clothing again because it's a continuous source of heat and at that site itself if one can get some clean chatter or something like that wrap the burnt area in the victim with a clean sheet and then transfer this person from the road or from wherever the burns have happened happened to the hospital so once the patient once the victim reaches the primary center it could be a basic primary center or it could be a higher center or it could be a nursing home the first thing that needs to be done is a primary survey and us and then a secondary survey now what do you need to see the first thing that is need to be seen in any patient of trauma and we know that burns is trauma is to see whether there is any other trauma that is along with and this can very easily happen now for example if you have an electrical burn and the person actually falls from a height after getting a shock or sometimes you have a car accident and there is a burn so they can be a trauma of any variety so roll out primary trauma any other polytrauma after that it is really important for you to look at the abc like in any other trauma so you are going to take care of the airway breathing and circulation confirm that there is no hemorrhage that is happening obviously take control of the cervical spine after that check that there is no neurological problem that is there then when i say e events what i actually mean is again the same thing what if the person has been brought with smoldering clothes or with warm clothes or with chemicals yet on the body and maybe the rings and so all that kind of thing also needs to be taken taken care f is fluids it is very important in a higher percentage of burns to start immediately is to start iv fluids this can be in the form of ring galactic i will give you more details of the fluids ah later so you can catheterize the patient pass in a rice tube especially if the burns are more than 25 to 30 and when i say g you get your x-rays you give pain relief so you can remember all these points by a b c d e f g now uh the next thing that is needed to be done is once your patient is settled and you have you know your basic you've done your basic primary uh this you will now do a secondary survey now your secondary survey is going to do all the usual things like uh you use you check the head face neck you check the chest and the abdomen you make sure that there are no uh no problems in the in the chest and the abdomen you essentially check the perineum rectum vagina each and every part of the body needs to be checked as we would do in any other patient basically a very very detailed general examination needs to be done check all the limbs as well as do a neurological examination once the patient is well settled you have started the iv fluids you have done a secondary survey now you look at what are you going to do about the burn wound itself so uh we should remember that since it is actually had a flame so the burn wound is actually sterile at the time of burning so you don't need to do any extensive burn wound care immediately especially if you have to let us say you're already in a center and if you want to show it to seniors or a burn center is nearby then all you can do is just cover the patient with a clean sheet or with some plastic grips and you can arrange for transfer to the center but if your transfer is going to happen let us say after 24 hours or if you are only going to manage then it is better for you to clean every clean the burn wound remove all the dead tissue that is above and if the blisters have broken remove those blisters clean well and apply your whichever primary dressing you are going to be giving more often than not you are using one of the silver creams like silver sulfurizing and you can use that the most important thing to remember in this is do not give any dressing which is tight when an acute burn happens immediately edema is going to start so any dressing which feels even comfortable when you are giving it is essentially going to become tight very soon because edema is going to rise till at least 48 hours and after that the edema starts going down so you should also check your dressing um at regular intervals to make sure that you're not causing any compression this is very important because as it is you're going to have edema which is going on from inside that is going to compress upon the skin from inside and when you're going when you have a tight dressing that will give pressure from above so that skin which maybe was you know partial thickness will go on to become a deep thick full thickness wound the the other thing that you need to check on early is patients and relatives and make sure that you support and you reassure them well they will essentially be feelings of grief and loss and that needs to be uh taken care of what if it is an attempted suicide and the injury that is a it's 80 percent or a 90 burns this is essentially a mortal injury so we should allow our patient at that time we should allow our victims to meet with the patients and relatives so that they are able to have their last time with the victim so i will now talk about the referral criteria i think these referral criteria are something that all physicians should know anybody who is an mbbs doctor should know what are the referral criteria for burns because everybody i think just an mb based doctor can also manage the first 24 hours with fluids and the dressings but they should know when they need to send the patient to a burn center so burns more than 10 percent of body surface area and adults and more than 5 and children they should preferably be sent to a burn center if it is nearby full thickness burns more than five percent total body surface area then there are also burns and special areas like i mentioned the hand same way the hands the feet the genitalia the perineum the face near all major joints and the reason why we say that is that even if it's only a ten percent burn but if it involves these areas the deformities can be so horrendous that finally it leads to a very limitation of the uh of the uh of function in the patient then electrical burns and chemical burns burns which are associated with an inhalation injury how would you know that there is an inhalation injury uh well the face burns burns uh which are deep on the neck you may have suit around the nostrils around the lips all this will give you an idea that there is inhalation injury the face itself starts swelling up quite a bit in these patients then circumferential burns of the limbs of the chest and burns and extremes of ages because in the children and the elderly the mortality is much more also patients who have some pre-existing medical disorders they are obviously going to have a higher mortality so i think they would do better in a burn center and if there is any associated polytrauma with the patient again i think those patients would be better treated at a burn center or let us say in a higher center now in preparation for travel uh transfer what should you do you make sure that you put in two large bore cannulae through which i uh the iv is going on where the respiratory system is concerned now you see this photograph she is a lady who had only some 25 words but basically she had it of her hfn and the chest area and you can see obviously that her edema has already gone up quite a bit so one is that make sure that you have started oxygen in all such patients but also consider whether you want to do an endotracheal incubation in this patient before the journey is started so that it shouldn't happen if the journey is let us say two hours three years by that time the patient should not have gone into strider you give pain relief to the patient and put in a rice tube specially if the percentage of burn is anything more than 20 to 25 percent and document everything that you have done in your center let us say you are transferring a patient after 24 hours you make sure that all documentation is done as to how much fluids was given and any other drugs that may have been given to the patient regarding transfer talk to the referral center before sending any patient so that you make sure that they are that the bed is available and that the patient will be accepted at that spot so to summarize i think in preparation for transfer take care make sure that your patient if you feel that incubation is needed that is done uh put in a two large large bore iv lines put in a rice tube as needed do your dressing for the patient give pain relief essentially give the tetanus prophylaxis document all details and talk to the reference at referral center and only then you are going to transfer the patient so to summarize well you have your burns the first state is given from there patient goes to the receiving center there are primary and secondary surveys done and immediately the first 24 hours treatment it should be begun that is in the form of fluids dressings pain relief and in case an extraordinary is to be done i will talk about this after this after which if you feel that the patient meets the referral criteria you will send the patient to a burn center where definitive care can be given so now let's talk about fluids all of us know that fluids are essential because burn shock will will happen in any patient who is more than at least 20 25 burns so what are your goals of fluid management one you want to restore and maintain adequate tissue perfusion and oxygenation which will happen only if the intravascular volume is adequate you want to avoid any organ ischemia you want to preserve the viable tissue and you want to make sure that you are not contributing to the edema by giving excessive fluids right now with respect to formulas and solutions all the general surgeons i am sure out here would also uh uh you know know that a very large number of uh formulas have been uh have been suggested by different uh different people but what is most important is that you have to balance adequate resuscitation and not give too much also because the fluid overload is also not good so policies and and all the practices vary differently in different institutes however predominantly the practice has evolved from publications by charles baxter at parkland hospital at texas in which the publications which he did in 1960s so now what is the parkland formula in the parkland formula the first thing of course is that you count your time from the time the burn occurred and that is true in all the formulas because your fluid shift starts happening as soon as the burn has happened so you are giving a ring elected solution in the first 24 hours and the total volume is to be that is to be given over over 24 hours is 4cc per kg per percentage of burn so we realize that there are two things that we will need in this we need to know the weight of the patient and obviously we need to know what is the total body surface area burnt now whatever is the volume that comes by this calculation by doing 4 cc per kg per percentage you are going to divide it into two parts half of this volume is to be given in the first eight hours itself and you start counting your eight hours from the time of burns so let us say that the burn has happened at 12 noon in the afternoon but patient comes to you at four o'clock in the evening so from four to eight that means in the in the first eight hours itself you will give half the volume so if the calculated volume is ten liters five liters you will actually have to give in the next four hours so you give half the volume in the first eight hours and then you give the next half in the next 16 hours remember that whatever volume comes these are just suggested volumes so uh even though it's a so we cannot say that just because this volume is that we have to essentially give but we have to have some some criteria to decide whether you are actually overloading the patient or giving less to the patient so you need to adjust your infusion rate also according to the urine output in an adult you can maintain a urine output of half cc per kg per art so in a normal adult it would be let us say about 30 to 50 cc per hour and in children you can keep it at one cc per kg per hour so if the urine output is too much then you can reduce the volume in the next hour by 25 percent now as soon as you feel that the peristalsis begin you can of course begin oral intake and or start internal feeding and on day two basically you can include five percent dextrose on day two and again you have to adjust based on urine output very importantly ideally you have to start colloid infusions at the rate of 0.5 per cc per kg for the whole day so uh in case you have any excessive urine output or lesser urine output then don't vary the colloid but basically adjust your crystalloids so essentially give the colloids to the patient after day three you can just change it to maintenance fluids now as i mentioned many formulas exist with variations in the volume suggested also in the type of fluid whether crystalloids or colors and there is no single recommendation that you can say works the best each unit will manage on their own but it is very important to make sure that you do not over resuscitate because when you over resuscitate you will have excessive edema that can of course lead to problems of vascularity in the skin and it leads to higher sterotomies it also increases pulmonary complications at times you also have problems of uh abdominal tightness we also have to remember that all burns don't need the parkland formula for example let us say you have an adult burn of about 15 to 20 percent and the patient is also able to take adequate orally so you could do a that same volume part of it can be given in the form of oral rehydration so you would have to give much lesser iv fluids now we had mentioned it is four cc per kg per percentage of bonds how do you calculate your percentage of body surface area the wallace's rule of nine is very simple where the body basically all parts are like nine percent so your head neck is nine percent both the upper limbs are nine percent each the uh front and the back basically the front has two nines and the back has two lines same thing is true of the lower limb uh so basically there are uh 11 nines and that makes it very easy so you calculated by the nines another method is to use the palm of the burn victim so basically if you think this is the pump this is one percent of your own body approximately one percent so uh if you have got burns which are patchy it may get very difficult for you to calculate by the nine percent so you can use the uh you can use on an average about the palm of the patient to decide what would be the percentage of one finally uh in children since the surface area of the head neck is almost 18 percent and a one-year-old child so in children the lower limb have a lesser lesser percentage of surface so in children if the head neck is burned the whole of the head neck is one then that would be 18 and you would accordingly reduce nine percent and nine percent from the lower limb let me now talk about uh deep circumferential burns these are very important very important for us to think about in the first 24 hours so uh deep circumferential burns of the limbs of the chest and the abdomen can all cause a problem if you have deep circumferential burns in the limbs then you will end up with basically gangrene of the peripherals of peripheries and the chest and abdomen it obstructs your breathing so the patient will will have problems with respiration so tissues basically get constricted under the tight burnt skin and this happens because whenever you have a full thickness burn the skin basically become leathery so it becomes more like a so that sharp of the of the burnt skin uh becomes more like an armor so it's like if you have a chest burn which is it doesn't even have to be circumferential in fact according to me if it crosses the uh you know the anterior axillary line that let us say it goes from posterior axillary line all the way anterior and goes to the positive axillary line again so that behaves like an armor and it doesn't allow the chest to expand so that also can cause a problem and even in those cases you might have to do an esterotomy so um i don't know if you can really see this otherwise you could zoom in if you want to so the the drawing on the left basically is telling you that let us see if there is edema but if there is elastic skin then it will start expanding so even if there is some amount of edema let us say somebody has a protein problem and edema happens the skin keeps enlarging but what happens in burns now in burns what is happening is that this the the covering that is your skin becomes inelastic and it is going to start uh pressing upon the muscles in the forearm as well as all the arteries and then that is what is basically leading to the uh to the pressure on the vessel so the vessels will flatten out the muscles have a lot of pressure and finally when it crosses the capillary pressure you are going to have death of tissues hence it is very essential to release and this release is needed as early as possible so uh this is essentially a shadow tommy should be done in the first 24 hours so here you see this child we have done an escharotomy so even though there is increase in the compartment pressure the compartment pressure increases not because of fluid in the compartment itself person but because of an unyielding skin dead skin outside so just doing an escharotomy itself will release all the pressure and like you see in this skin you see that the minute you take an incision it immediately pops open and um the fluid starts coming out similarly again in this child and ashara tommy has been done i will now talk about uh definitive care okay so now let's say the definitive care at a burn center you could have sent the patient to a burn center you may be yourself treating the patient in your uh nursing home so one most important thing in definitive care is that it is essentially going to be multi-disciplinary where you're going to get in a lot of people who are going to be helping with burn care and we essentially do need need all that care in larger burns so the burn surgeon more often than not is usually the team leader and he or she would get in the intensivist or the anesthesiologist we often need to call upon a hematologist our chest medicine guys are uh more often than not helping us with our burn patient we need psychiatrists we need ophthalmologists nurses are a backbone of management of our burn patients dietitians are needed and exceedingly important other therapists because uh deformity prevention as i mentioned is a very important aim in burn burn management we also say that the team includes the patient and family of the patient because if we want to give good therapy and we need also caregiving in the form of especially in public hospitals then the family of the patient also becomes very much a part of the team of people who are managing i've also added msw because burn treatment is finally expensive so it is essential to have social workers also along with us who will be able to arrange for funds for the patient now aim of definitive care is to avoid mortality and morbidity so now what is a primary determinant of this mortality and morbidity one is of course age so if the patient is of a pediatric or of the geriatric age group then mortality is much higher in them the extent of burns anything more than 40 50 percent is uh has a very has a chance of very high high mortality similarly depth of birth so when we think of depth of burns depth of burns is very important because it is going to determine the patient's long-term appearance and function in the survivors so assessment is is very very crucial also because it is going to decide the management uh of the patient so now when we talk of uh uh management in general patients can be categorized into three broad groups for management and what are they superficial burns then indeterminate depth burns and deep partial of full thickness bonds so when we talk of superficial burns basically these are your first degree burns or you will have superficial second degree burns so ah the blue line out there is what is your superficial second degree which means that there is a decent amount of dermis tissue which is not burned so healing can happen by itself when we say indeterminate depth sometimes clinically you are not able to really evaluate how much of it is deep and how much of it is superficial or how deep it has gone so those we do classify finally as indeterminate and you have the third variety which is a deep partial and full thickness so the red line basically is telling you which is the level of the deep partial which is that it is almost a full thickness bone and it may have some very very tiny uh dermal elements in it only issue is that when you allow a wound to heal by itself beyond three weeks then you land up with a lot of scarring so deep partial and full thickness burns are combined as one type for management point of view so now when we say first degree burn this is what it is it's just a sunburn it is red arithmetic and it will heal by it itself there will be no blisters second degree burns you will have blisters it will be very very painful it will blanch also and these wounds will heal spontaneously within about 7 to 14 days and usually if the wound heals within 14 days it doesn't cause any cause any long-term scarring third degree burns are they will look white and they actually look white they become leathery they become hard and it is very it is painless and there will be no blisters in these patients and these patients are not going to re-epithelize and if any secondary healing happens in this then it is literally that it is secondary healing and it happens from the wound edges it is not really from below upwards and a fourth degree burn is when it goes beyond the subcutaneous tissue and when other organs like you are seeing in this electrical burn where muscles bone and these are involved in the burn now with respect to decisions superficial partial thickness burns essentially we will give conservative treatment we are not going to operate these patients and we will get a good result again deep partial and full thickness also it's a very simple decision no problem ideally we should be going ahead exercising the wound and doing a grafting in the patient where indeterminate debt burns are concerned those are the problem patients so more often than not we will give conservative treatment for some time till we can decide whether it is healing or whether we have to go ahead with excision so superficial burns as you see in these photographs basically we know that it will heal by proliferation of the skin appendages so whatever you do it is going to heal unless and until there is infection if there is infection you may convert a superficial burn to a deep burn which is what we want to avoid so you will use either of the two you will either use a definitive dressing like a topical antimicrobial cream or you will use some temporary skin substitute but your final outcome should be similar with both the treatments now this patient that you see here these this facial burn you see that all her burnt out partial skin has been removed it has been cleaned we have applied something called a collagen sheet and at 21 days you see that she has got good healing so your topical antimicrobial agents are basically going to help you to avoid infection and keep that area away from infection till the wound re-epithelizes but also remember that many of these topical agents actually um hamper epithelization so they slow down the epithelization i think it is much better to use synthetic or biological dressings which will help which also take care of infection because they basically give you a cover cover immediately they stick to the wound and then the healing happens from below upwards so this is how you would have a patient who would have conservative dressings completely dressings are given from top to bottom according to the uh area involved and this is how uh this is something called a collagen sheets i think uh these are to my mind these are a blessing for all burn patients we have been using collagen sheets for a very long time there are many brands of collagen sheets available in the form of dry collagen or wet collagen and once applied uh if it's a partial thickness burn then it separates by itself by healing below so these are all photographs you see this child again it was a firecracker burn and collagen sheets were applied the second photograph shows the collagen sheet you can it's a nice it's nice it dries up well and it sticks and doesn't come out and then healing happens and the last photograph is a six month later photograph and you can see how well he has healed and he has um almost no no scarring at all so indeterminate burns as i mentioned when it is indeterminate how do you manage basically it will be mixed so when it's mixed you're not very sure whether you want to go ahead and exercise because you could land up also excising some of the superficial ones which you don't want to do so it is a good idea to wait in these patients so what you could do is that you can wait for some time continue with your conservative management of either dressings or if you have given a replacement like collide and sheet and uh wait for about 14 days at 14 days you would get an idea whether the wound is going towards healing or it's not healing if you think that it is going to heal within seven days then you can continue with your conservative management if you feel that it is not going to heal it is starting to granulate then you should get go ahead and exercise even at that time and graft the patient let's now talk or talk about deep partial and full thickness ones this is really important because one deep burns obviously have a higher mortality too they have very high morbidity so a deep partial or a full thickness burns should essentially have a formal surgical approach so what happens in these patients since the dermis is destroyed uh it is going to take a very long time to heal if you are going to allow it to heal secondarily so you're going to finally land up with hypertrophic scar formation very poor cosmesis and function is also going to be poor and it takes a long time and hence it is essentially to go ahead with early accession of the dead tissue and skin autographing the final outcome which you will get with skin autographs is far better than that of the natural healing process in a full thickness burn or a deep partial thickness bond therefore the standard of treatment should be formal early excision of all the dead tissue and give a skin autograft in case it's something like an electrical burn or if it's a very very deep ones which occasionally happen in patients uh when they fall into a fire or if it's like let us say somebody's had calvin convulsions and fallen then you may also need to do flaps in the patient instead of just a skin graft so here you see a photograph two photographs of two different patients the one on the left was actually treated with early excision and skin graft you see that the area involved in the same but we did not allow her to have secondary healing whereas the one on the right has actually had secondary healing and you see that her area has not yet healed she's yet got that little bit of raw area which over many months has been gradually coming down so when she presented to us like this she came in with very severe neck contracture the axillas are contracted the chest the two breasts are completely joined together and she had not yet healed so ideally if this lady had been taken up for a removal of the granulation tissue and the skin had been replaced with a skin graft she would have had a good result what about timing for excision there are people across the world who are also doing immediate burn wound excision there are so there's some research which says that maybe an early burn moon accession will also help to keep the systemic inflammatory response down but here we are not really doing it that early we start our excisions after 48 hours so somewhere at 48 to 72 hours you can start your exhibition i am not giving too many details of how the exhibition should be done because this talk is more about a general outlook on once but when we do when we start doing our early accessions at 70 to us and let us say it's a 60 percent burst so you can do about 15 to 20 percent at any one time and keep repeating this uh excision every uh two days there are some centers in europe who are also doing a delayed serial burn wound accession and they started seven days now the next question that needs to be answered is that once you are doing your accession what kind of cover would you like to give so the cover could be either an autograph or you could put an allograft when you say an allograft you basically mean a homograph that means it's a caliber graft it's from another human but but when we use uh cadaver graph so when we use allograft when we use homograph they are essentially going to get it by the question question asked would be that why are we even putting an allograft base basically it divides time when we are exercising let us say you have a 60 burst and your exercise is 20 if you're going to take an autograph at the same time then you're creating more raw area so basically the in these patients take care of some time with autographs so with your homograph about 11 12 13 days a homograph stays well it sticks like a normal autograph so it gives us some more time before we can start harvesting autograph and lastly of course the cover could be a flap so here i've just shown a photographs where you see that wool coverage has been done with skin grafts on the left side and on the right side you are seeing some electrical ones in which large flaps have been uh used for wound cover so now the last thing that i would like to talk to you about is avoidance of deformity we have spoken about uh about everything that you want to do towards healing now uh i'm we'll be talking about avoidance of deformity so i've showed you some more photographs of the kind of deformities that we have seen and you see that these are really severe deformities which is not going to allow either a patient to walk or to see or to work with their hands so why is it that deformities happen well we mentioned that there is uh i had said that there is a demand that edema is happening because fluid creep happens from the intravascular to the extravascular space i am not really going into the pathology right now at first but this is what happens now when this edema fluid accumulates in this interstitial the tissue mechanics near joints uh basically is altered so the patient tries to take a position which is called as a position of comfort and invariably this position of comfort is diametrically opposite to the actual functional position of the of that certain joint and this is what leads to a problem so if we do not correct that position you are going to invariably lead to a deformity so how are we going to take care of this problem well there are two ways that it can be taken care of and that is with positioning and with the use of splints so what is the rationale basically contraction that is occurring within the substance of that burn wound or the scar is a continuous process fibroblasts are there and they're going to continue to do their contractile activities so wound is going to essentially shorten unless and until you give it some opposing force of it off if not of anything at least of equal magnitude to that of the contractual and hence it is necessary for us to use this opposing force during both the times while the acute process is going on as well as and this is really important as well as during the healing phase because the contractile forces are continuing to act even in the post healing phase so uh i will just in very quickly let you know about positioning so a positioning should be designed specifically for each and it should also not compromise mobility and function so whenever we talk of positioning and splints we have to make sure that we also make sure that that mobilization is also happening at alternate times from when you're not uh positioning for the head elevate the bed with blocks or you can if you're using a fowler bed then you can just basically give a head elevation if the neck is burnt essentially you make sure that you give 10 to 15 degrees of extension don't allow a pillow on the patient strictly no pillow should be given and instead there should be a bolster or something below the shoulders which will allow the head neck to be in extension and when we are giving a dressing essentially we have to use a neck collar at that time when the shoulder is concerned give a 90 degree of abduction make sure that you don't give excessive abduction because you don't want to pull on the brachial plexus or the vessels elbow keep the elbow in extension so now the thing is that even though flexion is a functional position usually contractures are happening in flexion and hence we keep it an extension other thing is that when bandaging is done make sure it's done in a figure of eight manner so that you can also allow mobility where the wrist and hand is concerned we have a proper functional position of the hand with the wrist and a little bit of extension mp joints inflation and the eyepiece in extension this is very essential simply because these are the commonest contractures that happen in the burn patients during bandaging uh make sure that all the webs are very well very you know you put in gauss pieces between the webs because web creep and these kind of uh deformities are very common and the fingers basically become like a burns induction is one of the very common uh problems uh hips are where the hips are concerned uh keep it in 10 to 15 degrees of abduction and keep the knees in extension keep the knees and extension but just avoid locking the knee so it can be 5 to ten degrees less foot and ankle uh you can keep the ankle in neutral uh position remember whether where the foot is concerned your heart surfaces are going to include venous stasis so you can cause ulcers in the heel so make sure that that is well uh padded so uh these are uh uh these are just photographs of splints applied i can uh i can show you a video can i have the video of splint please yes yes yes yeah so this is how we apply you see this patient and you see that she she was a high percentage she's a high percentage burn all the areas are uh are bandaged and uh you can see that this and this splint material is not really very expensive these are uh these are not really molded to the shape but just a shape has been given so you will see if you can notice on the left side also the knee is already splinted she's got a pulse ox and a foot so you know that she's a high percentage of burn so each and every body part is basically uh splinted according to the uh paths that are involved so if the patient is bedridden and a very like 50 to 60 percent of the body is affected mostly all the joints are uh are splinted can you go off the video and can have the presentation again yeah thanks okay so now you see this photographs and the one the photograph which is on the right is our word we are a public hospital so you can see this is not this is not really an ac board or anything like that and that's the photograph which is on the left that is from a center abroad and we do the best we can and we do make sure that our patients are well splinted and mobilized and positioned uh even in our body so now uh what about splints spoken about position and the last thing that i would like to talk about is splints so splints can be given an acute injury so basically splints are going to help your position so now an ideal splint ideally should be very lightweight low profile should be of the appropriate material and should allow for ventilation and should also be cosmetically appealing so ideally we should custom fabricate the uh the splints now but obviously when you're talking of uh more thermoplastic splints they are much more expensive but you could innovate now in in an acute uh uh in an acute condition where there are a lot of bandages also given you could like we have ourselves made sometimes you make a splint out of you could cut an iv bottle and you could put it in the neck or this gray splint that you're seeing is actually a pipe material you know the pipe which runs outside uh buildings gray color that can also be heated with a heat gun and it can be made into a splint so all kinds of things can be used the purpose is just that you are able to position the patient with so these are some splints as you see different kinds of lints have been used for different reasons across the face on the neck this is an upper limb and you see that axilla elbow all splints have been used these are thermoplastic splints which have been used in the hand and here you see different varieties of splints now if the groin is still burnt so you can see a kind of spika has been given and you know we have put something between the legs so that he doesn't bring the legs together and cause a contracture but there can also be complications if you use the splint improperly can cause pressure ulcers and you can reduce the range of motion so we have to always remember that if we are going to give positioning and we have figured this lens but we also need to essentially do range of motion exercises in all these patients i'm going to summarize before i summarize i think uh we have a quote yeah yeah yeah can you show the collagen video so that though imagine being applied i forgot at that time so here you see that the face is being cleaned and all the uh that tissue has been removed uh very often blisters are already broken and they're just lying loose and free collagen can you know so that the mouth opening is possible and once the collagen is applied after that we leave it to dry it takes about half an hour one hour at least in hours in our situation in bombay you can also put a fan and once it dries up it just sticks so only if it's a full thickness burn it is not really going to uh stay in place otherwise uh in 10 to 15 days good healing happens and you can get a very good result so i am very happy to use collagen sheets in all the burns which are vital thickness yeah maybe now have the poll and then and the presentation after that okay so we just have some very very simple questions i wasn't sure so um yeah so this is the first question poll question that you'll see on the screen and uh you'll have a couple of options so you have four options uh you can scroll on the screen and choose the right option and then submit the word wonderful so at least 77 so people were listening to the talk that's great uh the next one [Music] so the best first day for flame burn i think this will should hopefully get 100 result [Music] okay 87 the next one okay this is the sequence of resuscitation in any injury uh again there are four options to this so you can scroll on your screen and uh pick the right one [Music] yes so yeah i think for when to check everything breathing bleeding and then stabilize the night yeah so the correct answer was obviously the fourth answer where your abc is always first in all trauma yeah and the last one [Music] oh yes [Music] so now this we have had inadequate so here uh we have had very wrong answers the answer to this is that a homograft is always rejected right in us the skin graft that is put from another person is always rejected it is rejected somewhere at some times it takes two weeks to get rejected or whatever doesn't really take it's only in real in newborns uh when we put sometimes we take the mothers and it may be accepted so now i will summarize and i have two three slides now summarize from mortality point of view correct assessment of the total body surface area and the fluid calculation can help you reduce mortality because of the burn shock and right precautions during transport will help you uh give a better definitive care at the burn center surgical decisions which are made on time by uh understanding that the burn wound is deep and hence doing an early chronic closure can also help you reduce mortality and if your team multidisciplinary team works as a team very well and everybody comes in and does what is needed you will positively help reduce the mortality from fluids point of view it is very important for you to remember that where that many different institutes and units may have different uh fluid some people are giving it at four cc some people are giving it a three cc per kg per percentage but it is very important for you to remember that it is important to perfuse the tissues well and replace on time adequately and you have to give give the fluid in such a way that you do not over perfuse the patient so that is the next thing we have to remember and we have to remember and one hopes that with further research there will be some work where we will be able to actually blunt that whole systemic response which is happening which is what is actually causing mortality in our patients from wound care point point of view i'd like to summarize and say that assess the wound will assess the depth of the wall well leave blisters if they are unbroken then you can very much leave the blisters alone debride any vitalize tissue or debride any blister which is already broken use non adherent dressing then try and try and see to it that you don't change the dressing too often if you especially if you are able to use good dressing materials and you don't need to change it that often and dress the wound in such a way that you will allow movement that means overall joints you should be able to do a figure of your dressing go ahead with early access and grafting if there is burns and also go ahead with early scar management and patients from deformity prevention we must remember that the condition of burns along with its sequel are very highly preventable so we should kick into action early right from day one we should give position the right position and splints anti-edema and anti-deformity measures should be a mantra in all the patients and just like education can prevent burns only mobilization and positioning is going to be able to help you prevent a deformity in burns so to conclude i'd like to say that multi-disciplinary management will reduce mortality early wound coverage for being burns is going to help you reduce scarring in our patients positioning during acute management and in the immediate post-op phase will help you prevent deformities and exercises splints and pressure garments in the post healing trails will help you reduce scarring and deformities so i think the challenge of burns in india lies not just in the treat in the successful treatment of 100 burn but positively in the prevention of burns and the prevention of post-burn deformities thank you thank you ma'am uh wonderful very beautiful presentation uh so y'all can put in your queries the questions comment about the session in the comment section uh you can also use the raise hand feature so you will have this razor on the right hand side of your panels so you can use that to come up on stage so i'm seeing a question here from a gp who says dr ashwini who says that she's a gpa and if a patient comes to clinic with superfood burns and with a bubble should i puncture so i think that you don't need to puncture a blister if it is intact unless and until it is coming in the way of function so you can leave it alone and a blister fluid the fact that there is a blister means obviously it's a it's a superficial second degree burn and will it will heal uh the other thing is that if you feel it's a child and you want to give a dressing in that area then it is quite okay if you are doing it in a very sterile environment then you can puncture you can use one of the silver dressings and dress it and then not open it that means use one of the long lasting dressings that is the second if the blister has got punctured somewhere else outside in that case it is better to de-roof it and then give you a dressing do we need to give a tt injection for every bond patient even small superficial ones so it really depends if it's a kitchen bun obviously i mean it's one of those smaller ones you don't really don't need to also check whether they have taken the tte profile access so according to that you can give next [Music] i thought i'd seen one more question from someone else yes so this is a good question is the recent formula 2 cc per kg per or 4ml so when we talk of parkland we talk of 4ml but please remember always that it is really dependent on the urine output so uh you can very much use 2 cc per kg per percentage of burn and more often than not probably that may be adequate but if you are not throwing if the patient is not throwing out adequate amount of fluid you can increase the fluids uh there are many units who are now using three cc per kg per percentage of one there are also people who are adding on the colloids slightly earlier than 24 hours there are some centers who are doing that that can also help to keep your risk rights down electric burns yeah so electric ones there will be cardiac arrhythmias so uh in the first uh first 24 hours it is better if they are under the care of a physician and uh after that if they have not had a problem then it can be treated by the burn unit themselves but yes they should be under the care of a physician uh or let us say they are with us but basically uh it is good for you to keep up cardiac monitoring in them can we apply collagen on superficial burns early you have to apply it early ideally you have to apply it more like as soon as the patient comes to you clean up everything and apply the collagen sheet and it will and after that literally you can forget it and more often than not you would get good healing unless and until an infection happens and the collagen gets eaten up and then you would have a problem and then you would have to then do daily dressings if it is not healing any wound that does not heal by itself by 14 days i think you should get your uh you know your your tentacles up and say okay i may yet need to go ahead and graft so at 21 days if it is not he'll please go ahead and exercise that granulation tissue remove the granulation tissue and photograph so there could be someone who may then heal in four weeks but please remember that it is going to scar very badly and these patients are going to start healing from the periphery so then the scar is not nice or that you're going to get some amount of tissue which is which is going to tighten up and lead to some tissue shortening parkland can be used in the elderly also but again as i said please in the elderly specially as i said over i think that parkland formula basically more often than not over resuscitate the patient so in the elderly you have to be a little bit more careful maybe in the elderly i would be happier giving the lesser volume and then checking the urine output if you're not throwing out adequate you don't have to add on whenever you add fluids also you can just add 25 percent of whatever is the volume in the next or when you reduce also reduce 25 percent so have a method to your reduction how often to change collagen dressings you don't really need to change the collagen dressing at all once a collagen sheet is put um after that uh it will usually heal if it doesn't heal then uh and if let us say that your dressing gets soaked if you have put a dressing on top of the collagen then you can open it if the if it's dry beneath or if it's not that good then you could you could reapply a collagen if you want to i'm not very eager to apply reapply collagen then it is better to go ahead with either a long you get a lot of long acting silver dressings like uh maple x or uh bite bite energy uh silv silver there are many such blessings and these basically you can keep like maple exciting you can keep for seven days so you could replace that if it has got soaked and if it has got absorbed you can replace it with one of these dressings and you would not need to change it uh again and hopefully it will heal within 14 days so can we use normal saline to clean the wound i think you can even clean a burn moon with normal with soap and water and if it's very small somebody has asked whether you can use silver extreme yes you can if it's very small you can do a home management but make sure that you if it's in one of the special areas like the hand and all because we get too many children and too many people who who say that it was just that much it was not contracted earlier so it's very common they'll say that i wish i could have showed you more photographs but this talk was only about a general talk on an overview of burn management so i could not show you that many uh snaps so yes you can manage but not the burns in special areas any specific drug contraindicated not really not specifically that i know of [Music] ma'am would compromise yes again as i said any patient who has got home orbit conditions where you feel that uh where you feel that over-infusion can cause a problem if you want to keep the volume down even hypertonic saline is a good uh option in these patients but then you if you're going to use hypertonic saline and you cannot use it in an area where you don't have physician i mean then you need your physician to be there and to be able to take care of the problems that can happen also with the hypertonics any alternative to collagen sheet if not available actually there are so many varieties of if you are someone from india then um collagen sheets are available all over the country and different varieties are available so i think if you are someone who treats burns as a routine then you should probably get in touch with uh these com companies there's a sheet called uh collagen itself it's just called collagen ko it's i think with a company called urgo now it was a ucare product earlier nowadays uh one of the products that we use often and it's it's it gives good results i'm sure it's they market it all over the country it's not excessively expensive other option you can use this amniotic membrane but for that you would need to get it from the us a bank that would be even less easily available and of course your last option is using a homograph which is even lesser available because we don't have adequate number of skin banks in a country i think i'm done am i done with all the can we apply collagen yes you can apply collagen in the indeterminate burns any indication of injection ted globe i don't think unless and until you feel that the person has had a lot of contamination then it would be related to the trauma not to the burn if you see a person burning with clothes what should be done instantly yes absolutely water should be thrown unless and until it is an oil burn in which case you should not be throwing water otherwise you can fight the person should actually literally you can even let them lie down on the floor and try and pack the you know earlier they used to say put a blanket so obviously you cannot put the blanket and keep the blanket on because that retains it but you can pack the flame dry that question disappeared i think best is obviously you have to get the person away from the fire and then but pour water pour water pour water pour water it is one of the things that we keep repeatedly saying pour water pour water so it does two things one it is going to take care of the flames and more importantly it's going to cool the person how will you manage acid burns and inhalation one acid burns are a completely different uh however it's very difficult for me to tell you in one line how i will manage acid bones remember acid burns are very very very deep so you would more often than not if not you would more often than not need to go ahead and either excise it or allow it to separate and then graft it but it does lead to very severe deformities inhalation burns again are very different uh this one needs to go ahead you may be giving steroids you may need to uh do a trichostomy or an intubation and there are these are very specialized ones and genuinely very difficult for me to tell you in one line but remember that for all these patients you would essentially need multi-disciplinary care that means you need for an inhalation but we will need to take in the help of our chest physicians scorpio will need to be done sometimes washes need to be given many more questions do you want me to stop um well i think you've answered all there was one academic question and since you are into academics and i'll ask you there's one question here um by dr malik so what research can be done on this topic as a ug wonderful if it is someone who is willing to do research i want to say that we need to do some there has to be good research on two uh two things okay one is from the actual this there is a systemic inflammatory response that happens in burns right we have that movement of fluid that happens from the intravascular space to the extravascular space and that is what causes the burn shock if we can have if if there is something that can block that systemic response i think that will go a very very long way in management of burns that is from acute burns and the systemic problem the second research that we need to do is on normal substitutes now imagine a patient with 80 burns right so when people are broader able to save 80 90 percent people are even saving 95 body surface area burns but you need skin so uh so skin is taken you know one centimeter size skin is taken and that is actually grown in a lab but when the skin is grown it is more of epidermis and there is hardly any dermal element so the dermis is replaced using um products which are commercially available now these commercially available products though they are now available in our country we use them in some patients but they are exceedingly expensive so i think in our country we need to have some double uh normal substitute which is made in india and that will go a very long way uh to help our patients uh um uh when we have very large percentage of funds so i think we do have some uh you know limitations in when we manage because of finances and of course uh the uh you know the systemic i think somebody does a research yeah i think other than that most of the questions uh have uh been answered yeah antibiotics so ideally a fresh burn wound doesn't need uh antibiotics but you would need to depending on your situation i every place has their own antibiotic policy you can give broad spectrum uh we start with augmented but i think each place should have their own antibiotic policy it is not right to pick somebody else's antibiotic so you manage your antibiotics as well where first aid for acid burns are concerned again water is a good uh good idea in fact water in in burns in acid burns chemical burns needs to be poured for at least 45 minutes to one hour to be able to wash off with the best of for ability because the wash off is to be done done with almost all the questions in case we've missed any uh we'll get the questions to ma'am and we'll get the answers back to you um thank you so much ma'am uh for a wonderful session uh really in depth i know it was a very broad topic and you try to go into every bit of it and i'm sure the audience has really liked it and has learned a lot from your experience uh for the audience i have not had so many questions from uh even a plastic surgery audience more often than not it's a very good experience for me i i enjoyed speaking to audience which is let's say non-plastic surgery yeah thank you thank you so much audience uh for being patient and be here for such a long time and thank you once again ma'am so much and thank you volume good night bye everyone good night
Management of Acute Burns
Burns can be debilitating, life-threatening, and difficult to treat. Burn patients are classified according to the size, depth, and severity of their burns, as well as any accompanying injuries. For optimal results, a holistic and multidisciplinary approach to management is required. Physicians must understand the referral criteria for moving a patient to a tertiary care centre in order to provide the best possible care to their patients. Join us live on Medflix to hear from renowned Dr. Vinita Puri, Professor and Head of Department, Plastic Surgery at KEM Hospital in Mumbai, on her unique insights into the timely treatment of acute burns!
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