Management of Severe burns in middle income countries · Chandini Perera MD John Vandervord MD...
Transcript of Management of Severe burns in middle income countries · Chandini Perera MD John Vandervord MD...
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Management of Severe burns in Low/middle income countries
Chandini Perera MD John Vandervord MD
National Hospital of Sri Lanka, Colombo Royal North shore Hospital, St Leonards, NSW
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There is a higher incidence of burns in Low and middle Income countries
Burns, 2013 Dec;39(8):1599-605. doi: 10.1016/j.burns.2013.04.008. Epub 2013 May 8.
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There is a higher incidence of severe burns in low and middle income countries
Burns, 2013 Dec;39(8):1599-605. doi: 10.1016/j.burns.2013.04.008. Epub 2013 May 8.
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Burn Statistics Jan 2016-Dec 2016
Total admissions 700
Severe burn admission 317
Excision and grafting 470
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Burns are a public health issue in low and middle income countries
Journal of College of Medical Sciences-Nepal, Vol-11, No 4, Oct-Dec 015
Burns, 2013 Dec;39(8):1599-605. doi: 10.1016/j.burns.2013.04.008. Epub 2013 May 8.
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Definition of Severe Burn
A burn with over 25% TBSA full thickness burns
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SEVERE BURNS
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Challenges in management of Severe Burns in Low income countries
Lack of critical care ( ICU ,HDU )
Lack of isolation
Lack of skin substitutes
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How do we manage care in the face of challenges
Innovation and learning from survivors and scars
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Innovations
Acute care and Mx: of smoke Inhalation
Dressing techniques
Surgical techniques
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Burn survivors as teachers….
Extensive severe burns survive without medical or surgical intervention
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50% TBSA SURVIVAL WITHOUT MEDICAL INTERVENTION
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40 % TBSA SURVIVAL WITHOUT MEDICAL INTERVENTION
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SEVERE BURN CARE
3 PERIODS
The Acute Phase 24-48 hours
The First week-dressings /surgical Mx: of burn wound
After two weeks-Dressings / surgical Mx: of burn wound/non surgical Mx:
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The first 24-48hrs
Awake ,non ventilated, mobile patient, minimal narcotic usage
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24-48 hour management of Severe Burn
Less fluid and plasma in the resuscitation phase
2ml x %TBSA x Kg body weight
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Innovation in management of smoke inhalation
No Sedation
Early mobilization: Day 3
Physiotherapy interventions for management of inhalation injury
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Physiotherapy interventions in smoke inhalation
Positioning Neck (Cervical collar)
Nebulization using adrenaline, salbutamol, and heparin , n- acetyl cysteine
Bubbling bottle
Spirometer
Chest physiotherapy –tapping, percussion and coughing
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Chest Physiotherapy
Prop-up with oxygen therapy
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Using bubbling bottle
Mobilize the patient
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Management of the burn wound
3 Types
Surgical
The colonized burn wound
Non Surgical management
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Surgical management
3 Timings (Post burn period)
Early primary closure (First week)
Delayed primary closure group (after two weeks )
Late closure( after two months )
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Early surgical intervention group
Within the first week
Physiologically Stable patient
Adequate donor sites
Non colonized burn wound
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E.g. Early surgical intervention patient
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Delayed primary surgical group
After two weeks –one month
Associated severe smoke inhalation
Co morbid states e.g. Acute renal failure, Diabetes
Minimal donor sites
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Late primary closure group
After Two months
Colonized wound
Limited donor sites
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Non surgical group
Lack financial and psychosocial support
No donor sites
Dressings only
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Innovative Dressing technique
Special properties of dressing used for early and delayed primary closure group
Intrinsic splinting mechanism for neck, axilla, webs and breast
Facilitates active movements
Minimizes need for analgesics
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Dressing technique used to splint neck, axilla, web spaces
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Innovative Intervention for the colonized burn wound
Rotational antiseptics
Use of minimal or no IV antibiotics
Minimize use of blood and blood products
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Scars as teachers…....
Functional and aesthetic outcomes are superior in burns with primary healing contractures as opposed to outcomes following early surgical closure and contractures.
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Reconstruction of primary healed contracture
Before contracture release After contracture release
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Reconstruction of neck , bilateral axillae, left elbow release
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Scars as teachers…....
During Acute surgical intervention preservation of dermis is more important in certain areas than merely achieving early closure of the burn wound.
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Reconstruction vs Resurfacing
Surgical techniques of excision and grafting combined with plastic surgical techniques are used to preserve dermal element
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E.g.Early Excision and grafting Re-surfacing Technique( 6/12 post burn)
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Reconstruction vs resurfacing
Surgical techniques of excision and grafting combined with plastic surgical techniques are used to preserve dermal element
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Delayed primary closure technique Reconstructive technique 6/12 post burn
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Innovations in Surgical techniques in acute burn
Key to burn rehabilitation
Can control/ minimize secondary scar contracture
Creates both aesthetic and functional outcome
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Innovative concepts in the surgical technique
Preserve dermal areas for function and aesthetics
Incorporate plastic surgical techniques with grafting
Maximize on sheet grafts
Reducing the burn load facilitates healing in other areas of open wounds
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Importance of surgical technique
Prevents secondary contraction and deformity
Prevents post burn rehabilitation needs
Prevents need for costly secondary surgery
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Patient A
Female. 16 yrs. Old. 60%TBSA. Flame burn with accelerant, with inhalation injury.
Managed in a surgical ward of a peripheral hospital
Wounds managed with Silver sulphadiazine ointment.
Transferred to burns unit NHSL after 1/12 for late wound closure.
Colonized wounds managed with rotational antiseptics
Discharged home two months after late primary closure
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Patient A
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PATIENT B
Male, 19yr old , 60%TBSA , flame burn with accelerant Initial resuscitation in a peripheral general hospital Physiotherapy interventions for smoke inhalation Transferred after 48 hours to burns unit Wounds managed with Acticoat and special dressings technique Delayed primary closure after 2 weeks(reduce burn load) Discharged home one month after burn
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Patient B
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Late primary closure with plastic surgical technique
10days after grafting
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Delayed primary closure with plastic surgical procedures
10th day after grafting
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Functional and aesthetic outcome 14 days after burn
Neck extension and contour Movement and contour at axilla
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Reducing burn load 3 weeks after graft
Grafting the anterior chest Promoted healing of the back
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Innovations in Therapy of Severe Burn
Awake ,non sedated, mobile, securely dressed patient
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Positioning and therapy
Dressing provides splinting rather than static splint
Active movements rather than passive movements
Active Stretching/ sustained stretch
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Dressing technique splints/allows movement
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Active stretching exercises/sustained
stretch
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Post burn rehabilitation
Patients are discharged home
Home based therapy based on active movements
Scar support vs Pressure therapy
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Hand therapy using flour dough
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The future…......
Research ( scientific basis):
Alternative forms of management in acute and early phase of severe burns
Training in surgical techniques
For Low and middle income countries
Research in microbiology
For managing severe colonized burn wounds