Burn Management
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pepita, 6 years old, was thrown into a fire by another child two years earlier and sustained an 8% burn of her lower back. The burn was initially thought to be superficial, but, months later, the wound is still open and has never been grafted. Pepita cannot stand upright because she has flexion contractures of both hips and one knee. Instead, she has to crawl. Her groin was not burned, and the burn on her knee was only a minor one. Her contractures are the result of failing to ensure that she used her unburnt and minimally burnt limbs during the acute stage of her injury. She has now been abandoned by her family [1].
The devastating effects of burns are long lasting at both an individual and societal level. These impacts are compounded in resource-poor settings, where the human and material resources necessary to deal with this complex public health problem are lacking. Developing nations are disproportionately affected - 95% of the 322,000 global fire-related deaths in 2002 occurred in low to middle-resource countries [2]. A structured and comprehensive approach to burn care must be applied to resource-poor settings in order to improve outcomes.
A combination of improved management and prevention strategies has resulted in
important declines in morbidity and mortality in the developed world. A
recent
Unfortunately, without adequate resources in first-aid, acute surgical management and rehabilitation facilities, patients that do survive their burn injuries in developing countries often have poor, disfiguring and disabling long term outcomes. A Ghanaian study found that 18 % of childhood burns patients had suffered a physical impairment or disability [4].
As surgeons working in or supporting those who work in resource-poor countries, it is imperative that we understand the region-specific risk factors associated with burns, support preventative measures and provide rapid and appropriate resuscitation, surgical treatment and rehabilitation.
2.1. Etiology and epidemiology
In order to understand and overcome the challenges in the management and prevention of burns in low-income countries, a close look at the epidemiology and causal factors involved is required. It is also necessary to understand the local economic constraints and the available health-care infrastructure.
There exist numerous hospital or clinic-based studies describing
epidemiological characteristics of their burn population. Forjuoh has
published a review of 117 articles from 34 low and middle-income countries [5]. The majority of these studies dealt with the pediatric
population, with the highest incidence of burns occurring in infants and
toddlers (ages 0-4 years) who are dependant on others for their care. In
a study from
In many countries in
Most burns occur in the home, commonly in the cooking area, accounting for the
high proportion of scald burns, followed by flame burns. Combined, they account
for over 80% of all burns seen in low-income countries [4].
Electrical burns are also frequently seen in low-income areas where building
codes may be less stringent and homes may be built near high tension wires.
Although most studies report higher burn rates in urban settings, this could be
due to a publication bias, with few district hospitals having the means to
carry out and publish results [14] Given the lack of
first-aid resources and longer distances to travel to medical care in rural
settings, it is not surprising that outcomes are worse in these locations. This
is intuitively understood and is illustrated in a South African study showing
that the average pre-hospital delay was 42 hrs in rural
At a
population health level, the true magnitude of the problem is not well defined
with few standardized comprehensive statistical collection systems in many
low-income countries. Some authors suggest that the global estimated death rate
is a gross underestimation [14]. It is widely accepted that
the social and economic costs of burn injuries to low-income populations are
great and efforts to develop, evaluate, and implement prevention strategies
specific to the local cultural and economic settings are urgently needed.
Successful examples have been shown to work in developed countries such as
With over 2
billion people worldwide preparing meals using rudimentary traditional stoves
or open fires [5], much interest has been directed toward
developing safer domestic appliances and energy sources [14].
An example of such a strategy is the inexpensive redesigned flat kerosene lamp,
designed by burn surgeon Dr. Wijaya Godakumbura of
Recognizing the complexity of the issue and its regional challenges, the WHO,
in collaboration with international partner agencies, developed in 2008 an
evidence-based global strategy for burn prevention and care [5].
There are several processes involved in the local tissue responses after a
burn. An increase in vascular permeability leads to the loss of water,
electrolytes, proteins and heat [11]. The complement and
coagulation cascades are activated and this results in thrombosis and the
release of histamine and bradykinin. These mediators cause an increase in
capillary leak and interstitial edema in distant organs and soft tissue. In
addition, the activation of the inflammatory cascade can lead to immune
dysfunction. All of these responses increase the patient’s susceptibility to
sepsis and multiple organ failure [17]. These systemic
responses are significant once a burn exceeds 20 percent of the patient’s body
surface. Hypovolemia, immunosuppression, bacterial translocation from the gut,
and Acute Respiratory Distress Syndrome (ARDS) can ensue [11].
The rapid implementation of the ABCs of trauma management (airway, breathing, circulation) also applies to burns. The initial physical examination of the burn victim should focus on assessing the airway and the patient’s hemodynamic status, as well as estimating the size and depth of the burn. Airway edema can result in airway obstruction and death. One hundred percent oxygen should be administered from the outset. If there are any concerns about the adequacy of the airway, prompt endotracheal intubation is mandated [18]. In addition, signs of inhalational injuries should be quickly recognized.
If there are concerns of cervical spine injuries, nasotracheal intubation can
be performed because it has the advantages of decreased cervical spine
manipulation and the tube can be easily secured by suturing it to the nasal
septum. The disadvantage of nasotracheal tubes is that they tend to be of
smaller caliber, which are not as good for suctioning, and may increase the
risk of sinusitis. In difficult cases, fiber-optic bronchoscopy (if available)
can prove to be an invaluable tool in securing the airway. Vocal cords,
directly injured from smoke, may be resistant to usual topical anesthesia and
care must be exercised to avoid laryngospasm. Consideration should be
given to securing the tube to the teeth with wires (or heavy sutures), rather
than risking further damage to burned facial skin with tie-tapes.
Once the airway has been addressed, the next step is to place two large-bore
(at least 14 gauge) peripheral intravenous catheters through non-burned viable
tissue. If necessary, these catheters can be placed through burned skin because
the eschar is still sterile in the acute phase and more importantly, death can
result from delays in fluid resuscitation. A Foley catheter should be placed to
monitor urine output because this is the most straightforward and reliable
indicator of intravascular volume status in the majority of these patients.
Associated life-threatening injuries such as cardiac tamponade, pneumothorax,
hemothorax, and flail chest must be identified and treated quickly [18] Tetanus toxoid should also be administered routinely
to all burn patients, depending on immune status .
Quantifying the extent (figures 1&2) of the burn is crucial in determining subsequent management. Burns are dynamic injuries, and damage to the skin can continue for 24 to 48 hours after the initial injury due to edema, coagulation of small vessels, pressure, desiccation, and infection. Thus daily evaluation is of paramount importance in reassessing burn depth and success of excision [17].
Superficial burns (1st degree) are generally red, painful, and
involve the most superficial aspect of the skin; as such, they are not included
in the calculation of total body surface area (TBSA). These blanch to the touch
[19] and have an intact epidermal barrier. Examples include
sunburn or a minor scald from a kitchen accident. These burns will heal
spontaneously, will not require operative treatment, and will not result in
scarring. Treatment is aimed at comfort with the use of soothing topical salves
with or without aloe and oral non-steroidal anti-inflammatory agents. Surgery is
not required for these patients [20].
|
|
|
|
|
|
Figure 1: Burn Depth Burns are usually classified into superficial, superficial partial thickness, deep partial thickness and full thickness. Here we have given then letters A, B, C, D and E. [1]
Partial-thickness (2nd degree) burns involve the dermis and the epidermis. Partial-thickness injuries classified into two types: superficial and deep. All second-degree injuries involve some amount of dermal damage, and the division is based on the depth of injury into this structure.
Superficial dermal burns are erythematous, painful, may blanch to touch, and often blister.
Examples include scald injuries from overheated bathtub water and flash flame
burns from open carburetors. These wounds will spontaneously re-epithelialize
from retained epidermal structures in the rete ridges, hair follicles, and
sweat glands in 7–14 days. The injury will cause some slight skin
discoloration.
Deep dermal burns into the reticular dermis will appear more pale and mottled, will not blanch to touch, but will remain painful to pinprick. These burns will usually heal in 14–28 days by re-epithelialization from hair follicles and sweat gland keratinocytes, often with severe scarring. Some of these will require surgical treatment [20].
A full-thickness (3rd degree) burn generally is identified by a dry
and leathery appearance, although a plastic-like texture and a hemorrhagic or
purpuric pattern may also be seen. Classically, full-thickness burn
wounds have been described as insensate, although there is often mixed
distribution patterns which make sensation determination less reliable as
a defining characteristic [19].
Deep dermal and full-thickness burns require excision and grafting with
autograft skin to heal the wounds in a timely fashion[19],
thus minimizing morbidity from protein loss, sepsis, and contracture.
Since all the elements of the epidermis have been obliterated in full-thickness
wounds, healing can occur only through wound contraction and/or spreading
epithelialization from the wound edges. In a sizable wound, this process will
take weeks to months to years to complete. [21].
Fourth-degree burns involve other organs beneath the skin, such as fat, muscle, bone, and the brain.
In adults, the rule
of nines can be used to quickly estimate the size of a burn. The anterior and
posterior trunk is each l8%, each of the lower extremities is l8%, each upper
extremity is 9%, and the head is 9%. This is depicted clearly in Figure 2. Unfortunately, the rule of nines is somewhat
inaccurate in children and may overestimate burn size because the head accounts
for a greater portion of the body surface area (BSA). In a 2-year-old child,
this is 19% of the TBSA Diagrams such as the Lund and Browder charts (Figure 3) are more accurate and should be used for
calculating the burn size in children[18]. In small burns, the surface of
the patient’s hand can be used to estimate the extent of the burn; it represents approximately 1% of the
TBSA (from fingertips to wrist).
Patient selection is the key to improving the outcomes of burn injury within the resource constraints of a given environment. The mortality of a given size of burn injury increases in infants and the elderly. It is difficult to cite what size of burn constitutes a lethal injury as mortality varies so much around the world, but local experience will suggest what magnitude of injury is likely to be survivable given the treatments available. For patients with clearly lethal burn/inhalation injury it is humane to withhold fluid resuscitation and airway intervention and provide palliation with dressings and generous amounts of intravenous morphine. Depending on circumstances it may be prudent to ask a colleague to examine the patient and note their
Figure 3: Lund and Browder chart [11]
concurrence with the lethality of the prognosis. Patients with severe, but not clearly lethal burn injuries pose a difficult problem: they can consume an inordinate amount of scarce hospital resources (ICU days, total length of stay, dressing supplies, nursing and operating room time), and still die or have dreadful outcomes. Consultation and possible referral to a burn centre is helpful. Treatment with pain control, dressings, prevention of infection, nutritional support, good splinting and early mobilization of affected joints, and careful selection of patients for surgical intervention is a sound policy. Small but potentially disabling burns, especially in children, should be the main focus of surgical attention. It is in this group of patients that early surgery, meticulous graft care, splinting, pressure garments and aggressive physiotherapy will produce the most gratifying (and cost effective) outcomes.
The most commonly used formula for adults, for fluid resuscitation after a burn, is the Parkland formula. To calculate daily fluid requirements, a crystalloid solution at the rate of 4 mL/kg/%TBSA burn is given intravenously. The first half of the calculated amount of fluid is administered within the first 8 hours after the burn, and the remaining is given over the next 16 hours. In the first 24 hours post-burn, the initial resuscitation fluid is Lactated Ringers, which is isotonic to plasma.
In children, maintenance requirements must be added to the resuscitation
formula, and should be provide as a dextrose containing solution for infants
due to the risk of hypoglycemia if they are not drinking. The addition of
maintenance is less important in adults due to the large volumes and low risk
of hypoglycemia. One formula that accounts for the maintenance
requirements is the Shiners Burns Hospital SBH-Galveston Formula, which calls
for initial resuscitation with 5000 mL/m2 BSA burn/d + 2000 mL/m2 BSA/d of
Lactated Ringers solution [18]. See http://www.halls.md/body-surface-area/bsa.htm
to express BSA in M2. Again, the first half is
administered within the first 8 hours post-burn, and the remaining is given
over the next 16 hours.
Another option to intravenous fluids, in cases of less severe burns or where
intravenous solutions are at a premium, includes oral rehydration solution. The
WHO describes a method for preparation of an electrolyte-balanced solution [62]. Although very time consuming, IV fluids may also be
prepared on site at low cost [63].
It is important to remember that these are only guidelines, and the infusion volumes must be titrated on a regular basis. Urine output is the usual indicator of adequate resuscitation. Urine output in a child should be maintained at 1 mL/kg/h. In an adult, 0.5 mL/kg/h is sufficient (unless myoglobinuria is suspected in which case it should be over 2 mL/kg/h). It is essential to avoid over-aggressive resuscitation, which may lead to increased extravascular hydrostatic pressure and pulmonary edema. This is especially important in patients who have a cardiac history, as well as patients with a concomitant inhalation injury, because they will also have increased pulmonary vascular permeability. Administration of colloid or hypertonic solutions decreases the total amount of fluid requirements in the first 24 hours post-injury; however, no clear advantages in long-term outcomes over isotonic crystalloid resuscitations have been clinically documented. In general, crystalloid resuscitation with isotonic Lactated Ringers is the best option in the acute phase [18].
If a patient is having increased fluid requirements, it should raise suspicion
of concomitant inhalation injury, a delay in resuscitation, or another
associated injury. It must be reiterated that the most important thing is to
begin resuscitation as soon as possible after the time of injury.
Unfortunately, delays in adequate resuscitation are common and lead to
increased fluid requirements because of additive perfusion-reperfusion injury,
which lead to unnecessary loss of life [18].
With circumferential full thickness, or deep partial thickness burns, there must be a high index of suspicion for compartment syndrome. The decreased skin compliance does not accommodate the extreme edema from the inflammatory response. Swelling increases with fluid resuscitation and it is much better to release a limb with early escharotomies than to discover too late that compartment syndrome and myonecrosis have set in. The diagnosis of compartment syndrome in a burned patient is challenging. Pallor is difficult to determine because the eschar often is discolored, soot stained and can be pale and leathery or red and plastic-like to the touch. Most burn wounds are painful to the touch, unless an area of pure full thickness exists. Paresthesia and paralysis are late findings of compartment syndrome and are impossible to address in a patient that may be paralyzed or sedated. The absence of a pulse is similarly too late of a finding. Delayed escharotomies can lead to muscle necrosis and limb loss. Sufficient release can usually be noted as soon as the dermis is released, as the wound opens and subcutaneous tissue bulges out. Escharotomies may need to be done on any limb. (Figure 4) Escharotomy may be done with a scalpel or diathermy blade. While it is true that full thickness burns are usually insensate, it is not true that escharotomy can routinely be performed without some kind of pain control. Ketamine or fentanyl and versed are safe and effective. The incision should go through skin but not into fascia or muscle. The mid-medial and mid-lateral lines of each limb are incised. A small “T” where the incision meets normal skin will ease constriction at the end of the incision.
|
|
||
|
|
|
|
Thoracic escharotomies are also occasionally required for improving chest-wall
compliance and facilitate ventilation. This may require multiple incisions
across the chest, both longitudinally and transversely to allow full chest
expansion. Figure 4
shows possible thoracic escharotomy lines, but more lines may be required for
very deep constricting burns.
In electrical injury, the final extent of tissue injury can be difficult to
predict. Frequent assessments and surgical debridements are required often in
the face of progressive myonecrosis. With any high voltage electrical injury,
the index of suspicion for a deep injury should be high. The skin wound is not
a reliable indicator of the underlying damage. These injuries will require a
fasciotomy, with release of all muscle compartments to minimize muscle
damage. Patients should also be monitored for myoglobinuria which will
require treatment with increasing urine output, alkalinization of the urine,
and sometimes with very cautious use of diuretics. Untreated myoglobinuria can lead
to deposition in the glomerular tubules and renal failure.
Inhalation injuries are associated with severe burns and poor outcomes. A
retrospective review in Cape Town, South Africa found that inhalation injury
was present in 63% of severe burn patients (>30% TBSA), which resulted
in a mortality rate of 76% [21]. However, it is believed that
inhalation injuries are more frequently seen in high income countries due to
the high prevalence of house burns, where victims are confined to enclosed
spaces. Alcohol and smoking account for over half the deaths in developing
countries, so prolonged exposure to smoke may occur as a result of
intoxication. The prevalence of inhalational injury in low to middle income
countries is unknown, but suspected to be lower. The reason for differences in
prevalence is unclear, whether due to under diagnosis [20] or
a true difference given that the vast majority of burns occur outdoors.
Researchers have found prevalence rates of inhalational injury in South Africa
of 2.2 % of pediatric burn patients [19] and 14.5% of
adult burn patients [21].
Successful management of inhalation injuries relies on early suspicion and
resuscitation, as well as minimizing post-injury complications such as
bronchopneumonia and acute respiratory distress syndrome (ARDS).
In the early resuscitation phase (< 36hrs), it is key to suspect inhalation
injury, consider early intubation and empirically oxygenate these patients.
Patients who have had prolonged exposure to smoke (ie. trapped indoors), loss
of consciousness, flash burns with singed facial hair, carbonaceous sputum,
hoarseness should all be closely observed for impending airway obstruction.
Suspicion should also be high in patient with facial scald injuries, where
airway compromise is often misdiagnosed. Scald burns can be associated with
direct thermal injury to the upper airway from ingestion of hot liquids or
steam inhalation[19]. Intubation with a large endotracheal
tube (to enable suctioning) should be done in patients with stridor, increased
work to breathing, respiratory distress, hypoxia, hypercapnea, deep burns to
the face or edema/erythema of the oropharynx on laryngoscopic exam. Respiratory
distress may not develop for several hours, and intubation should be performed
in the case of transfer in high risk patients even in absence of stridor as
obstruction may progress quickly as a result of airway inflammation from injury
or edema from resuscitation [22].
Smoke inhalation injury is often associated with significant carbon monoxide
exposure, resulting in carboxyhemoglobinemia. Carbon monoxide poisonings
account for the majority of deaths, which occur at the scene or early in the
pre-hospital phase. Asphyxia or anoxic brain injury develop quickly; as the
oxygen-carrying capacity of the blood is decreased. The clinical manifestations
of carbon monoxide poisoning are non-specific and can include headache,
malaise, confusion, dyspnea, seizures and loss of consciousness. The diagnosis
of carbon monoxide poisoning may be hard to confirm, given its imprecise
presentation, unavailable carboxyhemoglobin levels, and misleading O2
saturation measurement. Conventional pulse oxymetry monitors are unable to
distinguish O2 saturation from CO saturation, and therefore the
patient may have a falsely normal O2 saturation reading. Patients
may also appear pink/red and well-perfused, classically described as “cherry
red”. PaO2 should be confirmed by blood gas if possible. Clinical
suspicion is the mainstay for diagnosis and treatment. Given poor
outcomes associated with neurologic findings or loss of consciousness in the
setting of carbon monoxide poisoning [23], administration of
high flow oxygen should be used liberally to reverse tissue hypoxia and to
accelerate the displacement of carbon monoxide (as well as cyanide) from their
binding sites. The half-life of carboxyhemoglobin can be decreased from 240
minutes to 75-80 minutes by using 100% FiO2 instead of
room air (21% FiO2) [24].
In the post-resuscitation phase (2-5 days) many competing factors can
contribute to exacerbate pulmonary insufficiency. Direct thermal injury or
exposure to bronchopulmonary toxins from smoke exposure can lead to airway
edema, inflammatory changes and activation of systemic inflammatory response,
as well as disruption of the muco-ciliary transport, increased capillary
permeability, mucosal necrosis and sloughing. As a result subsequent distal
airway obstruction, from atelectasis, edema and inflammatory debris, leads to a
high risk of bronchopneumonia; the most frequent complication seen in a cohort
of children with inhalational injuries in South Africa, seen in 32% of patients
[19]. Other compounding factors include non-cardiogenic
pulmonary edema secondary to aggressive fluid resuscitation in burn patients,
poor lung compliance and chest wall rigidity in the setting of trunk burns,
secondary ventilatory-associated lung injury from aggressive high tidal volume,
ventilator associated pneumonia, relative immunosuppression and the emergence
of multi-drug resistance [25].
Recent recommendations to minimize respiratory complications in burn patients
have been shown to improve outcomes in high income countries [25,
26]. These include using low tidal volume ventilation with
PEEP (positive end expiratory pressure) to maintain alveolar patency and
minimize baro-trauma, humidified oxygenation and elevating the head of the bed
to improve pulmonary toilet and judicious use of antibiotics based on bronchoalveolar
lavage cultures. Other interventions and treatments remain controversial
including early tracheostomy [27], adjunct inhalational
therapies (heparin or N-acetylcysteine) or other modes of ventilation.
Corticosteroids have been shown to be harmful in this patient population [28].
The final inflammatory-inflammation phase of injury (5 days and beyond)
persists until complete lung healing and burn wound closure, during which time
patients remain at risk for infectious complications.
Most patients do not suffer from long-term respiratory complications as a
result of their lung injury, with evidence of normal lung function seen in a
study at 4 years post-injury [29]. Rarely,
complications such as fibrosis and tracheal stenosis have been seen and should
be managed independently of the causal etiology.
Wound care is a fundamental pillar in the care of the burn patient, and an area
of evolution partially responsible for improved survival seen since the 1960s.
As a result of loss of dermal integrity, the burn wound loses its protective
barrier against invasion by micro-organisms and against evaporative losses.
Therefore, until complete re-epitheliazation occurs, the burn dressing serves a
number of functions: protection against micro-organism invasion, minimizing
metabolic losses, limiting the pain of exposed burn surfaces, containing messy
wound secretions, and hiding the burn to help prevent adverse psychological
responses [30]. Most of the practices used in modern burn units
are based on anecdotal or uncontrolled clinical observations. However, with the
introduction of topical antimicrobial prophylaxis, occlusive dressing, and improved
sterility as well as a goal of early wound closure, the incidence of burn wound
infections have steadily declined [31, 32].
Burn wound care requires an experienced eye and knowledge of the dressing options
available. Surgeons often lack the time to examine wounds as often as
they should so developing expertise in the nursing staff is important. If
dressings are changed each day by a nurse experienced in burns many problems
will be averted and if staff understand well the importance of both splinting
and early mobilization to prevent contracture functional results will improve.
The routine inspection of wounds by a knowledgeable person is at least as
important as the selection of the dressing material itself. This is the
advantage of a burn team.
Exposure Method: Leaving a burn open is a poor option but where dressings are
not possible it may be the only option. The patients is washed daily and
kept of clean dry sheets with another sheet or mosquito net draped over a frame
to reduce the pain from air currents and to reduce contamination from the
environment. Ambient temperature control is important to maintain
normothermia. Exposure is less painful for full-thickness burns than for
partial thickness burns but has little else to recommend it.
Tubbing:
Most modern burn units avoid the regular immersion of patients in water both
because they practice early excision and grafting and because of the high risks
developing resistant strains of bacteria in the tub environment and of patient
cross-infection. That said, tubbing can be helpful to clean the wounds
and gently remove eschar as it separates. When early wound infections
develop suspect the tub! Avoid the routine immersion of infected patients in filthy
bathtubs of cold water on the basis of ignorance and tradition.
Bland Dressings:
These provide a clean, moist wound healing environment, absorb exudates protect
from contamination and provide comfort at a fraction of the cost of antibiotic
dressings. Where antibiotic dressings are scarce bland dressings are a
very acceptable solution for burns. Expensive topical antibiotic
dressings may be reserved for infected wounds. Paraffin gauze is widely
available and can be manufactured locally. Honey and ghee dressings were first
advocated in Ayurvedic texts two thousand years ago and remain an excellent
choice for bland burn dressings. Mix two parts honey with one part ghee
(clarified butter) and pour over a stack of gauze dressings in a tray.
Cover and store. Vegetable oil or mineral oil may be substituted for
Ghee. Gauze sheets can be applied directly to the wound in a single layer and
covered with plain dry gauze to absorb exudates, then wrapped. Dressings
should be changed at least ever second day, or when soiled.
Antimicrobial dressing: There exist numerous topical antimicrobial agents that are
effective in delaying the onset of invasive wound infections, but none prevent
them entirely. This is why they must be used in conjunction with a goal of early
surgical wound closure when possible. A brief review of the agents most likely
to be available to low and middle income countries will follow. There are also
alternative synthetic wound coverings and newer silver-ionized agents that can
be used; however they are often very costly and inaccessible in low-income
countries. A more detailed review, as well as instructions for preparation, can
be found in these references [11, 33].
Table 1: Burn
Wound Dressings [Modified from Sabiston, 33]
|
Antimicrobial Salves |
|
|
Silver sulfadiazine (Flamazine, Silvadene) |
Broad-spectrum antimicrobial; painless and easy to use; does not penetrate eschar; deeply may leave black tattoos from silver ion; mild inhibition of epithelialization |
|
Mafenide acetate (Sulfamylon) |
Broad-spectrum antimicrobial; penetrates eschar well; may cause pain in sensate skin; wide application causes metabolic acidosis, therefore only suitable for small areas; mild inhibition of epithelialization. |
|
Bacitracin |
Ease of application; painless; antimicrobial spectrum not as wide as above agents |
|
Neomycin |
Ease of application; painless; antimicrobial spectrum not as wide |
|
Polymyxin B |
Ease of application; painless; antimicrobial spectrum not as wide |
|
Nystatin (Mycostatin) |
Effective in inhibiting most fungal growth; cannot be used in combination with mafenide acetate |
|
Mupirocin (Bactroban) |
More effective staphylococcal coverage; does not inhibit epithelialization; expensive |
|
Antimicrobial Soaks |
|
|
0.5% Silver nitrate |
Effective against all microorganisms; stains contacted areas; leaches sodium from wounds; may cause methemoglobinemia |
|
5% Mafenide acetate |
Wide antibacterial coverage; no fungal coverage; painful on application to sensate wound; wide application associated with metabolic acidosis, and therefore generally used for small high-risk areas such as cartilage coverage in nose and ears. |
|
0.025% Sodium hypochlorite (Dakin solution) |
Effective against almost all microbes, particularly gram-positive organisms; mildly inhibits epithelialization |
|
0.25% Acetic acid |
Effective against most organisms, particularly gram-negative ones; mildly inhibits epithelialization |
|
Synthetic Coverings |
|
|
OpSite |
Provides a moisture barrier; inexpensive; decreased wound pain; use complicated by accumulation of transudate and exudate requiring removal; no antimicrobial properties |
|
Biobrane |
Provides a wound barrier; associated with decreased pain; use complicated by accumulation of exudate risking invasive wound infection; no antimicrobial properties |
|
Transcyte |
Provides a wound barrier; decreased pain; accelerated wound healing; use complicated by accumulation of exudate; no antimicrobial properties |
|
Integra |
Provides complete wound closure and leaves a dermal equivalent; sporadic take rates; no antimicrobial properties. Allows for coverage with a very thin skin graft with no dermis. Very expensive product |
|
Biologic Coverings |
|
|
Xenograft (pig skin) |
Completely closes the wound; provides some immunologic benefits; must be removed or allowed to slough |
|
Allograft (homograft, cadaver skin) |
Provides all the normal functions of skin; can leave a dermal equivalent; epithelium must be removed or allowed to slough |
Silver sulfadiazine (SSD, Flamazine), is by far the most frequently used agent, given its broad antimicrobial coverage, painless application and minimal toxicity. It is better to apply the SSD to large gauze squares and to apply these to the wound than to attempt to cover the burn in an even coat of cream before applying the gauze. A very loose plastic or surgical glove containing silver sulfadiazine and gently secured with tape around the wrists is a simple and excellent hand dressing. Splints can be applied outside the bag and the fingers can easily be mobilized to reduce swelling and prevent stiffening.
There exist many other less expensive options worthy of mention. Honey has well
established antimicrobial properties, and has demonstrated effectiveness in
limited studies [34]. Tannins, as found in tea leaves, have
also been shown to have antibacterial properties and may reduce the incidence
of hypertrophic scarring [64, 65]. Amniotic
membrane, used as a biologic wound coverage has also been shown to be more
effective than nitrofurazone in decreasing the incidence of wound infection [35], as well as being cost-effective in reducing the length of
stay and increasing epithelialization [36]. Obvious caution
regarding the risk of disease transmission with the use of human tissue should
be used and comprehensive donor viral screening performed prior to wide-spread
adoption of this technique. Another innovative way to minimize cost yet still
provide an occlusive dressing to prevent dehydration has been
demonstrated in India with the use of Banana leaves [37].
Gore et al have shown an acceptable level of patient acceptance, in comparison
to potato peels. Both options provide wound protection and healing at a
fraction of the cost of conventional dressings.
If despite vigilance, an invasive wound infection becomes evident on serial
observations, one must consider altering the current treatment protocol. An
invasive wound infection can be determined by clinical expertise or suggestive
by wound cultures showing > 105 organism per gram or invasion
seen on tissue biopsy. Invasion of microorganism into viable tissues may lead
to progression of the burn or systemic sepsis. It should be noted that elevated
temperatures per se are not necessarily indicative of sepsis, but are common
secondary to the inflammatory component of the burn wound process. The same
organisms have been identified in serial wound cultures in both low and middle
income countries, with Staph aureaus, Proteus, Klebsiella, E.coli and Pseudomonas
being the most common. The problem of drug resistance is not confined to high
income countries [38]. A recent Nigerian study, looking at
serial wound cultures, concluded that systemic prophylactic antibiotics did not
reduce invasive infection, but may in fact select more virulent, resistant
strains of bacteria [39], a notion which has gained wide
spread acceptance. We should therefore guide our antimicrobial use by evidence
of invasive infection, organism culture and sensitivities when these are known.
Prophylactic antibiotics at the time of initial admission are not routinely
advised.
Severe burn wounds are known to induce systemic inflammatory response syndrome
(SIRS) through the release of a series of pro-inflammatory endotoxins,
exotoxins from infectious sources or from the wound itself. Although the exact
mechanism is not well understood, it is clear that there is a systemic response
which can lead to progressive infection, immuno-suppression, sepsis and
eventually multi-organ failure. Supportive measures are needed early in the care
of the severely burned patient to minimize the progression and attenuate the
hypermetabolic response to burn injury.
Early nutritional support is essential in burn patients, even more so in low-middle income countries where many patients present malnourished. Burn patients demonstrate levels of metabolism that can be as high as 200% normal and that are proportional to the severity of the burn. The metabolic rate does not return to normal until wound closure. Supporting this high metabolic rate with diets rich in carbohydrate and protein without overfeeding patients can decrease muscle wasting, and poor wound healing consequences of chronic malnutrition. Early feeding also avoids mucosal atrophy and bacterial translocation [40]. This is particularly important for intubated patients, for whom feeding is often not initiated at presentation, increasing the risk of bacterial sepsis. Strategies to achieve this goal include tube feeding, which should begin within 6 hours, weekly monitoring patients’ weights, and the creation of high protein high-caloric feeds from locally available produce. The frequency of the feeds should be adjusted to the severity of the burn (%TBSA) and the patient’s pre-existing nutritional status [11].
Unfortunately the prevalence of underlying disease in burn patients is common in low to middle income countries and may influence treatment options. A Liberian study found that 61% of their patients had underlying medical co-morbidities, including epilepsy, anemia as a result of malaria, or iron deficiency and malnutrition [41]. Anemia and malnutrition contribute to infectious complications in these burn patients; however grafting was possible, albeit delayed, in this study, with surgery being performed between 5-96 days (average 29.8 days) with reasonable graft take (mean 81%). There is no question that the benefits of early excision must be weighted against the risk of blood loss and physiological needs of these specific patients. However, new understanding of the potentially infectious complications of blood transfusion is emerging as a result of large prospective multi-centered ICU trials [42]. A recent multicenter retrospective cohort study that has shown an associated 13% rise in infectious complications per unit of blood transfused and an associated increased mortality rate even when accounting for burn severity [43]. This study underlined the importance of further research to establish appropriate transfusion guidelines. Strategies should be undertaken to minimize blood loss during surgery. Some techniques for minimizing blood loss are discussed in the surgical management.
Another important consideration in many low-income countries is the burn patient who is HIV positive. Until recently, little was known regarding clinical outcomes in this specific patient population. James et al conducted a study in a burn unit in Malawi [44], showing a 31% HIV prevalence rate in their adult burn population (34 of 112 patients) and in 3% of the pediatric burn patients (6 of 231 patients under the age of 15). The researchers found that HIV status was an independent risk factor for death, mostly from infectious complications with more marked immunosuppression, as indicated by a lower mean CD 4 count (383mm3 vs. 937 mm3 in HIV negative patients). They found no differences in bacterial cultures, need or outcome of skin grafting, transfusion or antibiotic requirements or length of stay. In a case-controlled study out of South Africa [45], no differences in mortality or morbidity was found when comparing 33 patients with and without HIV, when matched for age, sex, burn severity and inhalational injury. Two patients with clinical AIDS died of infectious complications leading the authors to conclude that HIV positive patients, without the stigmata of AIDS should be treated in the same manner with similar outcomes expected. Further research is needed to understand the effect of HIV on immunosuppression in its early stages of disease.
After hemodynamic stabilization, a burned patient’s priority of treatment
shifts to ‘burn-wound-management’[46]. Preoperatively,
several factors can pose a challenge to surgical patient care. In the
developing world, many of the burns present late, already infected, or the poor
general health of the patients makes them unfit for anesthesia. In addition,
blood loss can be significant in burn wound excision, especially since inflamed
and infected wounds tend to bleed more during tangential excision. Thus, burn
surgery can be dangerous in high risk patients where blood transfusion
facilities are not readily available.
The options for the surgical management of burns includes early tangential
excision and grafting for deep dermal burns and delayed escharectomy skin
grafting for full thickness skin loss [47]. Tangential
excision describes the sequential and layered excisions of devitalized tissues
to a vital bed, generally recognized by punctuate bleeding. An inadequately
excised wound is more likely to become infected and is unsuitable for graft
take, necessitating further surgery [19]. The use of
tumescence (discussed below) is good for decreasing blood loss from the burn
site; however it makes judgment of adequacy of excision and of hemostasis more
difficult. It can decrease blood loss to a minimal amount. Adequate debridement
must instead be determined by tissue quality, and not by punctuate
bleeding.
The exact timing for wound excision is debatable. It is often suggested that burn wounds should be excised and grafted if they are not expected to heal within 21 days of injury. This is especially true for key functional and esthetic locations such as the hands and face.[19]. The decision to perform extensive excisions in a single setting versus staged procedures is dependent upon the hemodynamic stability of the patient, the availability of resources, and the coordination of all parties involved in the care of the patient [19]. Conservative treatment of burn wounds, with silver sulfadiazine, followed by serial excision of the burn wound is currently the standard of care in many burn centers throughout the world. Burns are excised in areas of as much as 20% TBSA in one operative setting, and performing the entire excision of the burn wound in 10 days post-injury is the goal. All full-thickness burns can be excised first, so that deep dermal and indeterminate depth wounds are addressed later, preventing excision of potentially viable tissue. Early excision and grafting is the treatment of choice to potentially reduce scar contractures and hypopigmentation [47]. The disadvantages to serial excision are that the patient needs to return many times to the operative room, so that episodes of bacterial translocation, bacteremia, and cardiovascular instability are repeated. Other disadvantages include exaggerated blood losses, prolongation of the hypermetabolic response, and increased risk of infection and sepsis from remaining eschar in which bacteria proliferate.
Near-total wound excision has been advocated as an alternative to serial
debridement in massive burns. In near-total excision, all full-thickness and
partial-thickness burns are excised within 24 hours of admission, and the
excised wounds are covered with autografts and skin substitutes are used if the
burn exceeds the donor-site supply. Areas of the face are normally not excised
in the first operation. Near-total burn excision has dramatically improved
survival in massive burns [18]. However, it has been
postulated that the surgical trauma of immediate burn wound excision,
especially given the hemodynamic instability of burn patients during the first
72 h after the injury, may aggravate the inflammatory and catabolic responses,
leading to potentially fatal postoperative complications [18][47]. It should be clear that near-total wound excision is only
meant for massive burns, and allograft/autograft/xenograft must be available
for coverage, or the wounds would only have been converted to full thickness
open wounds.
8.1.
General Surgical Principles
The intent of burn wound operations is twofold: to remove devitalized tissue and restore skin continuity. For this process to take place and for the skin graft to take, four things are required:
- A viable wound bed
- No accumulation of fluid between the graft and the wound bed
- No shear stresses on the wound
- Avoidance of massive micro-organism proliferation
Surgical debridement is performed using a Goulian blade for small areas or
those with multiple irregular contours (e.g., hand or knee) and a Watson or
Humby blade for larger areas. Inexpensive alternatives have been proposed for
harvesting and debriding blades [48]. Burned tissue is
excised tangentially and sequentially until the wound has been excised down to
healthy dermis, fat, muscle, peritenon, or periosteum. The wound may then be
covered with an autograft, allograft, or synthetic skin substitute.
Graft depth should be adjusted in pediatric and geriatric populations for their
thinner reticular dermis layer. If using a powered dermatome, it should be set
at less than 10/1000th inch. The meshing pattern used for
wound closure depends on burn surface area and donor site availability.
Meshing of the skin graft has several advantages, including expanding the
square centimeters of coverage, allowing for drainage of fluid from under the
graft, and allowing for placement of the graft over contoured areas, such as
the knee or ankle. The disadvantage of the meshed skin graft includes a
permanent weave-like appearance of the healed scar site, and increased
contraction [17].
Many authors have described innovative methods for performing skin grafting in
resource-poor settings [49]. With minimal financial
resources, using readily available modified household or industrial materials a
surgeon is able to sharpen the Humby knife and use a pizza cutter for meshing
grafts [48, 50].
Methods of optimizing hemostasis and minimizing blood losses include meticulous attention to maintaining the patient’s core body temperature (operating in a warm environment, isolating surgical fields, warming intravenous fluids, warming humidified air circuits for anesthesia), the use of cautery, the application of topical epinephrine solutions or topical thrombin solutions, injecting dilute epinephrine tumescent solution below the eschar, and the use of topical fibrin sealants.
The use of tumescence and tourniquet in burn excision significantly reduces
intraoperative blood loss and facilitates accurate wound excision.
Epinephrine is diluted in saline to a concentration of 1:500,000 (2mg/l) and
large volumes are injected beneath the wound to be excised. Use a
concentration of 1:1,000,000 for children. The edges of the wound are scored
with a scalpel and the burned dead skin is sliced away with a grafting
knife. Tangential excision is continued to the point where the dermis
looks healthy, clean and pearly white, fat appears shiny and yellow with no
haem staining and small visible vessels have patency and flow. If the fat
does not look healthy consider excision down to the fascia which is possessed
of a better blood supply than the fat. Bleeding vessels are coagulated
and the wound is wrapped in adrenaline saline soaked gauze while natural
haemostasis takes place. Attention is the turned to the donor site and a
template of gauze from the excised wound is used to measure the area of skin to
be harvested. Adrenaline saline is injected beneath the donor site till the
skin is taught and blanched then it is harvested with the humby knife or power
dermatome. The donor wound is wrapped in adrenaline saline gauze while
attention returns to the burn site. When hemostasis is satisfactory the
grafts are applied and secured in place. Local anesthetic can also be added for
small wounds, with 20ml of 1% xylocaine added to 1 L of solution. The addition
of local anesthetic to the solution can decrease pain, reducing anesthetic
agents and narcotics during surgery but the toxicity of xylocaine exceeds that
of the adrenaline. A number of recent papers have addressed the safety of
high dose adrenaline tumescence during burn excision and are cited here to
placate anesthetic concerns. Atropine and ketamine are poor choices for tumescent
burn excision as the patient will be tachycardic and hypertensive even before
adrenaline infiltration is begun. Excision of burns from the extremities
under tourniquet control can minimize bleeding significantly
If possible, donor sites should be chosen that are inconspicuous and will have
a good color match for the wound bed. Donor sites may develop hypertrophic
scars and should not cross joints. Potential donor sites include the upper
thigh or the buttock, which remain hidden with normal clothing and the back,
which heals well but is technically difficult to harvest with a hand held
grafting knife. Selection of the donor site should also consider the color
match of the wounded area, which is most significant on the head and neck. A
number of types of donor site dressings are available. The first type is a
fine-mesh cotton gauze that may or may not be impregnated. Dressings of this
type include Scarlet Red and Xeroform, which have the advantage of low cost and
familiarity. These may need to be reinforced with more gauze initially that can
be removed in 24-48 hours, and the inner layer left intact. The adherent gauze
will start lifting in 1-2 weeks as the wound re-epithelializes. The edges can
be trimmed off as they spontaneously lift. An occlusive dressing such as
OpSite/tegaderm can also be used, but may require a few holes to drain seromas
[47].
Loss of dermis leads to significant scarring and wound contracture. There are a
number of dermis substitutes that can be used such as Integra and AlloDerm.
These products allow the use of a very thin partial thickness skin graft on top
of the dermis. These products require a very clean wound bed, and meticulous
cleanliness post-operatively to prevent infection. These two options are very expensive,
though, and are not mainstays of the armamentarium of burn surgeons in the
developing world.
Grafts must be held in place by sutures or staples. Some form of dressing is
required to hold grafts in place. In more mobile locations, a bolster dressing
may be placed on top of the graft. An inner layer that can maintain
moisture (petroleum jelly or mineral oil product) should be placed before
gauze. Grafts over joints will require casting/splinting for the time period
for grafts to take, usually 10-14 days. Dressings are left intact during the
time period.
8.2. Specific anatomic considerations
Particular anatomical regions require specific treatments. The head and neck region is well vascularized and this is protective against invasive infection. Excision and grafting of the face is ideally done in full aesthetic units (Figure 5). Early excision of eschar is not recommended in order to preserve any dermal and epidermal structures that may survive. Once the eschar separates in 10–14 days, the underlying wound can be grafted. The color of the skin in this area is relatively specific; therefore, autograft skin should be obtained from donor sites above the clavicles. The scalp is an excellent donor site for the face [21].
With regards to the breasts, keratinocytes are often found deep beneath the
skin. These will proliferate and facilitate wound closure if left in place. The
coloration of the areola is also very specific so the nipple/areolar complex should
not be excised.
The buttocks and perineum are in a very difficult position for skin grafts to
take, since the dressings applied are often soiled from excrement, and
cleaning, often shearing the grafts. It may be necessary to leave the patient
in the prone position at later operations after application of grafts to this
area while they adhere. In extreme cases, a temporary defunctioning colostomy
may be considered until the burn wounds in the perineum are closed.
The penis and scrotum have an excellent blood supply, so they will usually heal
in a timely fashion. The skin in this region occupies a highly important
function, so, in general, excision is avoided. In the case of a small burn to
the shaft of the penis, excision and primary closure akin to a circumcision can
suffice. The scrotum is also a very good donor site because it heals well, is
relatively hidden, and can be vastly expanded to provide a surprising amount of
donor skin.
The hands are very important in terms of function and cosmesis. Most burns of
the hand are limited to the dorsal surface as the hand is clenched during
injury. Unfortunately, sometimes the digits sustain a second injury associated
with diminished perfusion during resuscitation. Escharotomies along the axial
lines may salvage digits during resuscitation. Grafts placed on the hands
should either be unmeshed or meshed tightly at a 1:1 ratio to improve cosmesis.
Burns through to the extensor tendons can result in boutonniere deformities
even with complete wound closure due to sliding of tendons medial and lateral
around the proximal interphalangeal joint. Extension contractures at the
metacarpophalangeal joint are also common because the burn and subsequent
scarring are limited to the dorsal surface. For these two reasons, consideration
should be given to fixing the digits in extension at the proximal
interphalangeal joint and flexion at the metacarpophalangeal joint by insertion
of threaded Kirschner wires which are removed after complete wound healing, at
which time the position can be maintained easily with splints [21]
Burns to the palm of the hand should be treated conservatively with gentle
debridement, as they will often heal spontaneously because of the depth of the
skin. In the paediatric population contractures may develop, either in the
acute phase or, years later, as the scar growth is less than that of the normal
tissue.
For the feet, great care must also be taken with excision of full-thickness eschar in this area, because the extensor tendons are in very close proximity to the skin. Autograft skin applied to this area should be of a narrow mesh to avoid hypertrophic scarring, which can make it difficult to fit shoes. The toes require the same considerations as the fingers [21].
The goals of the rehabilitation process are to maximize function and appearance
of the scars. This is done by trying to counteract two main physiologic
processes, scar hypertrophy and contracture.
Hypertrophic scarring generally does not develop in burns that require less than 2 weeks to heal. Hypertrophic scarring develops in 33% of wounds that take less than 3 weeks to heal, but 78% of wounds that take more than 3 weeks. It also affects skin grafts. Hypertrophic scars are thickened, red, and raised scars which can often be very itchy. Unlike keloids, hypertrophic scars do not outgrow their boundaries. They will also generally remodel and regress over time, but this may take a number of years, and contractures may develop in the interim. Although children generally heal quickly, they are at higher risk of hypertrophic scarring if there is delayed healing. In addition, individuals with darker skin pigmentation are also at greater risk of hypertrophic scarring and keloids. Tangential excision and grafting of burns that require greater than 3 weeks to heal can help prevent or reduce hypertrophic scarring.
Scar compression is the mainstay of non-surgical hypertrophic scarring
prevention and management. This can be achieved with customized compression
garments, or with elastic tensor bandages. The goal is to have pressures of
approximately 25mmHg. If using tensor bandages, they must be wrapped from
distal to proximal, taking care not to cause ischemia or venous stasis.
Using tensors for compression over grafts should be initiated after grafts are
well healed, approximately 2-3 weeks after grafting. This should continue until
scar maturation, which can take up to 1-2 years, and is gauged by when the scar
is softened and stabilized.
Scar massage can also help with breaking down of excess scar tissue. This is
often done in combination with stretching exercises to prevent scar
contractures. Scar massage should be done 2-3 times per day with a
hypo-allergenic lotion or cream, or petroleum jelly (Vaseline).
Moisturizing and massaging the scars, which can be dry due to the lack of
glands in the scar tissue, may be sore at first, but usually becomes soothing,
and can help with the itchiness of the scars. Massaging must press hard enough
to blanch the pink scars. Maturation and flattening of the scars can take 1-2
years, particularly in children where the hypertrophic phase may be
longer. Most scars will eventually fade and lose their pink colour over
time, but the 1-2 year time frame may be longer.
Silicone gel sheets can also be beneficial. The exact mechanism is unknown, but
they appear to help soften the scar. To reap the benefits, they must be worn
for long periods (over 20 hours a day) to be beneficial. They can be placed
under compression garments, or simply taped on for areas not amenable to
compression. These can be washed daily and reused.
Joint contractures are one of the most challenging aspects of burn management, and are the main source of disability from thermal burns. Scar contracture is due to activity of the myofibroblasts which act to contract scars. When the scars are across joints, particularly flexion joints, these can lead to permanent flexion deformities. In addition, flexed positions are often positions of comfort during the acute phase of burn management, exacerbating the problem. To combat joint contractures, stretching and splinting is necessary. Stretching and range of motion exercises should be initiated from the beginning. With initial edema, movement may be a bit difficult but should be encouraged with daily exercises.
To combat joint contractures, stretching, careful positioning and splinting are
necessary. Necks should be hyperextended with a roll under the shoulders.
Axillae should be carefully positioned. Upper thigh/lower abdominal burns
require positioning to prevent flexion of the hips. Stretching and range of
motion exercises should be initiated from the beginning. With initial edema,
movement may be a bit difficult, but should be encouraged with daily exercises.
Contractures are the most debilitating residual stigma of burns, and high-risk patients (deeper burns over flexion joint surfaces) can easily be identified. Contractures are much easier to prevent than to fix. Once developed, can be very difficult to manage and correct. Elevation of the burned limb reduces edema and facilitates early joint mobilization. Where surgical treatment is limited by resource issues; hyperalimentation, good dressings, splinting and aggressive stretching can still make a big difference to patient outcomes. Equally, surgical results will improve dramatically with good post-operative splinting and early mobilization as soon as the grafts are solid.
Splinting should be considered when any loss of extension is noted across
elbows and knees. Hands should be splinted from the onset.[51]
Simple plaster slabs covered in elastic tube bandage or “stockinet” make
excellent volar hand splints, can be wrapped on with tensor bandages and are
re-usable till soiled. Splints are often applied overnight, allowing for
mobilization and function in the daytime.
There are numerous splinting techniques suggested. Both static and dynamic
splints can be used. Dynamic splints may be better for reversing any
contractures, as they may gain extension, not only maintain the gains during
therapy. However, they are significantly more costly to produce, and long-term
gains have not consistently been shown. Many local materials have been used to
produce inexpensive splints, including easily malleable aluminum sheets.
Neck collar braces, or custom thermoplastic splints may be used to prevent
flexion contractures, and stretches should include both extension and lateral
flexion. The splint should be properly padded to prevent pressure points. There
are also alternative splinting techniques for the neck [52].
Axilla contractures can be challenging to splint, with various materials used
for “airplane splints”. Because splinting in abduction can be uncomfortable and
awkward, this is sometimes neglected. However, the inability to abduct the arms
leads to significant morbidity, and it severely limits overhead activities [53]
The ankle can have contractures in both directions. Burns and scar contractures to the dorsum are more common, which must be combated with plantar flexion exercises and splints. However, the Achilles tendon may also become shortened with a prolonged planter flexion. For an ambulating patient, this is not a concern. However, for a patient who is bed-ridden, splinting should be initially for dorsiflexion to prevent Achilles tendon shortening.
Fingers and hands should be splinted in the position of safety (figure 6), with MCPs flexed and IPs extended. If there
is a severe burn over the palmer aspect of the MCP joints, the MP joints can
sometimes be splinted in extension, but it becomes very important to ensure
that daily exercises maintain good flexion of the collateral ligaments of the
MCP joint, which can tighten when in extension.
Oral burns, particularly commissure burns can lead to complications of
microstomia. These can be initially managed with mouth exercises, and
gradually increasing the amount of mouth opening. Splints can also be
fabricated to stretch the commissures [54].
Surgical release of burn contractures can involve local flaps for reorientation
of the scar, but often also include a skin deficit which must be filled with a
graft or flap. Skin grafts are also more prone to contractures, and aggressive
post-operative therapy much be implemented. Repeat surgeries may be
necessary. Thick (full thickness if the area is small enough) unmeshed grafts
offer less contracture. Alternatives include artificial dermal substitutes that
will allow decreased contracture with thinner split-thickness grafts. However,
dermal substitutes such as Integra, a bovine collagen product, are commercial
produced and extremely expensive. If skin or myocutaneous flaps are
possible, they offer the advantage of coverage with minimal contracture and
need for repeat surgery. These include both local flaps such as z-plasties and
transposition flaps, but also pedicled or free vascularized flaps. The surgeons
will require an armamentarium of possible flaps and grafts to apply to the
situation. Figure 7 gives a possible algorithm
for selective various surgical options [55]. Other general
principles include the release of more proximal contractures before distal ones
in limbs with multiple levels involved, such as elbow release followed by
wrist, then fingers. Certain anatomic areas are more prone to contractures and
have specific complications.
Neck
flexion is often associated with webbing of the neck. There is often a severe
shortage of skin,
and a significant size skin graft may be necessary for coverage of the defect
after release. Unless very minor, or featuring a narrow band of scar,
these are usually not amenable to z-plasties. Another challenge for severe neck
contractures is difficulty with intubation. The release of the neck may need to
be done under local anesthetic to allow for neck extension before initiation of
general anesthetic and reconstruction of the defect. If the injury is anterior
only, a good alternative for coverage of the neck is a pedicled latissimus
dorsi flap, which would provide normal skin coverage without risk of
contracture recurrence [56]. Contractures
in the hands include flexion contractures of the fingers and wrist, web space
narrowing of the digits, as well as hyperextension of the MCP joints. Finger
contractures can sometimes be released with z-plasties, if the burn area is
isolated to the central palmer aspect of each finger. If z-plasties are used,
care should be taken not to cause excess tension with closures leading to
finger ischemia. Release of prolonged flexion contractures can also have
ischemia from overstretching of shortened neurovascular bundles. Release
may need to be staged, or stretched post-operatively with therapy. Kirshner
wires may be beneficial for the first 1-2 weeks until the skin graft take is
reasonable. They also facilitate the fabrication of post-operative splints
which are best fashioned with the K-wires still in place. Web-space deepening
is particularly important in the first web-space. A 4-flap or 5-flap z-plasty (figures
8&9) will allow deepening
of the webspace and increased abduction of the thumb. A Axillary scar
contractures are also very common. These can at times be treated with a large
4-flap z-plasty, similar to for the first webspace, or multiple z-plasties or
V-Y plasties [58]. Alternatively, they can sometimes
also be managed with release and skin grafts. The use of skin grafts requires
post-operative splinting, often in airplane splints to prevent recurrence. An
alternative may be a Figure-of-8 splint which also helps to hold the graft in
place [59]. Recurrent or very tight contractures may be
amenable to local flaps if the burn is localized to the axilla with sparing of
chest or back tissue. These include latissimus dorsi, or pectoralis major/minor
myocutaneous flaps [60]. Release of
the scar may be insufficient for chronic contractures. Contractures may be
limited by deep structures, such as joint capsules, tendons, or nerves. Some of
these may be released or lengthened (such as tendons or joints), while others
may limit the release to limited stages serial casting/splinting
postoperatively. The exposure of tendons or nerves in the scar bed may require
a flap rather than graft coverage. Preservation of the peritenon on the
tendon/peritenon may allow for a primary skin graft to survive. However, if the
tendon is in an area that requires significant mobility, the skin graft may
tether the tendon leading to decreased mobility. Caution should be also taken
when putting a skin graft on an exposed nerve, as this may lead to
complications of neuromas, or hypersensitivity in the area. Eyelid
contractures can be released with skin grafts. Patients with eyelid burns must
be followed to watch for ectropion, which can lead to corneal abrasions. These
can be release with preferably full thickness skin graft placement. Thin
full-thickness skin can be harvested from the pre or post-auricular region if
available. Microstomia and commissure burns can be treated initially with
splinting and stretching exercises. Customized splints can be made, preferably
with the ability to slowly expand the mouth. With severe microstomia, a
commissureplasty using mucosa to recreate vermillion may be necessary [54]. Esselman et al. has a literature review of rehabilitation
evidence in burn management. [61] Many
accomplishments have been made in burn care over the past several decades, as
illustrated below (figure 10) [31].
Figure 10: Advances in Burn Care – A schematized
time line of important advances in burn care ICU=intensive care unit, LA50=survival
of half of patients, depending on the percentage of total body surface area
(TBSA) burned, Rx=therapy, TPN=total parenteral nutrition [31] Encouragingly, these have resulted
in steady improvements in mortality rates. An excellent
reference for burn surgeons in resource poor countries is the Burns
Manual, written by Dr E J van Hasselt. The most recent 2008 edition
should be made available to all surgeons. McMaster
University, Hamilton, Ontario, Canada Ying Y.
& Duncan MJ. Department
of Plastic Surgery, Children’s
Hospital of Eastern Ontario, Ottawa, Ontario, Canada
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55190
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55192
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55194
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55195
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55196
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55197
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55198
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55199
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55202
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55206 Click
here to join the Surgery in Africa Discussion Group 
5-flap z-plasty (also known as a double Z-plasty with V-Y advancement) allows
for more deepening, while a 4-flap allows for much greater lengthening. These
are used primarily in the 1st webspace. Deepening of the other
webspaces is often performed using techniques for congenital syndactyly, with a
skin flaps used to reconstruct the base of the webspace to prevent future web
creep. Skin grafts are often necessary to fill in the gaps on the sides of the
fingers[57].
This progress has also been noted in a number of centers in resource-poor
countries where a multi-disciplinary, global approach to the burn patient has
been embraced; from prevention to rehabilitation.
See Van Hasselt Burns Manual http://www.ptolemy.ca/members/library.htm. International
collaboration is also available and encouraged through organizations such as
Interburns, the International
Network for Training Education and Research in Burns, who run courses such as
Emergency Burn Care and other public awareness programs, http://www.interburns.org/index.htm
This review has demonstrated that specific changes in clinical practice can and
do improve outcomes. As medical professionals, we must not be paralyzed by the
magnitude of the task ahead. Instead we must think of each small step as a
significant improvement. With focused attention and the application of
evidence-based knowledge, we will see change both measurable and meaningful in
the treatment of burn patients.
The following recommendations capture the key elements of a simple, but
effective approach to better burn management tailored to developing countries:
Davey M. & Ayeni B.
1. King, M., et al. Primary
Surgery: Trauma 1990 [cited 2; Available from: http://ps.cnis.ca/wiki/index.php/Main.
2. The injury chartbook: A graphical overview of the global
burden of injuries. 2002, World Health Organization: Geneva.
3. McGwin Jr, G., C. JM, and F. JW, Long-term trends in
mortality accoding to age among adult burn patients. Journal of Burn Care
& Rehabilitation, 2003. 24: p. 21-5.
4. Forjuoh, S., B. Guyer, and H. Ireys, Burn-related physical
impairments and disabilities in Ghanian children: prevalence and risk
factors. Am J Public Health, 2001. 27: p. 291-26.
5. Forjuoh, S., et al., Risk factors for childhood burns: a
case-control study of Ghanaian children. J Epidemiol Community Health,
1995. 49: p. 189-93.
6. Barss, P. and K. Wallace, Grass-skirt burns in Papua New
Guinea. Lancet, 1983. 8327: p. 733-4.
7. WHO Burn Fact Sheet: WHO Injuries & Violence Prevention
Non-communicable diseases and mental health and the International Society for
Burn Injuries [cited; Available from: www.who.int/violence_injury_prevention/index.html.
8. Singh, D., et al., Burn mortality in Chandigarh zone: 25
year autopsy experience from a tertiary care hospital of India. Burns,
1998. 24(2): p. 150-6.
9. Gupta, R. and A. Srivastava, Study of fatal burn cases in
Kanpur (India). Forensic Science International, 1988. 37(81-9).
10. Peck, M.e.a., Burns and fires from non-electric
appliances fires in low- and middle-income countries Part II. A strategy
for intervention using Haddon Matrix. Burns, 2008. 34: p. 312-19.
11. Van Hasselt, E., Burns Manual: A manual for health
workers 2ed. 2008: Nederlandse Brandwonden Stichting. http://www.ptolemy.ca/members/library.htm
12. Daisy, S., et al., Socioeconomic and cultural influence
in the causation of burns in urban children of Bangladesh. Journal of Burn
Care & Rehabilitation, 2001. 22: p. 269-74.
13. Mock, C., et al. A WHO plan for burn prevention and care.
2008 [cited; Available from: http://www.who.int/violence_injury_prevention.
14. Damo, C., et al., Epidemiological data on burn injuries
in Angola: a retrospective study on 7230 patients. Burns, 1995. 21:
p. 536-8.
15. Chopra, M., H. Kettle, and D. Wilkinson, Pediatric burns
in rural South African district hospital. . South African Medical
Journal, 1997. 87(5): p. 600-3.
16. Werneck, G. and M. Reichenheim, Paediatric burns and
associated risk factors in Rio de Janeiro, Brazil. Burns, 1997. 23:
p. 478-83.
17. Grunwald, T. and W. Garner, Acute Burns. Plastic and
Reconstructive Surgery, 2008. 121(5): p. 311e-319e.
18. Ramzy, P., J. Barrett, and D. Herndon, Thermal Injuries.
Critical Care Clinics, 1999. 15(27).
19. Tenenhaus, M. and H. Rennekampff, Burn Surgery.
Clinics in Plastic Surgery, 2007. 34(4): p. 687-715.
20. Barret, J., Surgical Approaches to the Major Burn, in
Principles and Practice of Burn Surgery.
21. Wolf, S., The Major Burn, in Principles and
Practice of Burn Surgery.
22. Mitchell, M., H. Oliveira, and M.e.a. Kinsky, Enteral
resuscitation of burn shock using World Health Organization Oral Rehydration
Solution: a potential solution for mass casulty care. . Journal of Burn
Care Res., 2006. 27: p. 819.
23. Munson, M. and P. Mertons, A system for making hospital
solutions in the Third World. Tropical Doctor, 1988. 2: p. 54.
24. Indications and Instructions for Escharatomy. [cited;
Available from: http://www.health.nsw.gov.au/gmct/burninjury/docs/escharotomy_indications_instructions.pdf.
25. Godwin, Y.W., SH, Major burns in CapeTown: a modified
burns score for patient triage. Burns, 1998. 24: p. 58-63.
26. Whitelock-Jones, L., et al., Inhalation burns in
children. Pediatric Surgery International, 1999. 15: p. 50-55.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55200
27. Masanes, M., C. Legendre, and N.e.a. Lionet, Using
bronchoscopy and biopsy to diagnose early inhalation injury. Chest, 1995. 107:
p. 1365.
28. Mandel, J. and C. Hales. Smoke Inhalation.
2008 [cited; Available from: www.uptodate.com.
29. Seger, D. and L. Welch, Carbon monoxide
controversies: Neuropsychologic testing, mecanisms of tocixity, and
hyperbaric oxygen. Annals of Emergency Medicine, 1994. 24: p. 242.
30. Ipaktchi, K. and S. Arbabi, Advances in burn critical
care. Critical Care Medicine, 2006. 34(9(suppl)). http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55201
31. Weaver , L., et al., Carboxyhemoglobin half-life in
carbon-monoxide-poisoned patients treated with 100% oxygen at atmospheric
pressure. . Chest, 2000. 117: p. 801. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55204
32. Wahl , W., K. Ahrns, and M.e.a. Brandt, Bronchoalveolar
lavage in diagnosis of ventilator-associated pneumonia n patients with burns. .
Journal of Burn Care & Rehabilitation, 2005. 26: p. 57-61.
33. Monafo, Wound Care, in Total Burn Care, D.N.
Herndon, Editor. 2002.
34. Mann, R. and D. Heimbach, Prognosis and treatment of
burns. Western Journal of Medicine, 1996. 165: p. 215-20 http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55203
35. MacMillan, B., Burn Wound Sepsis -- a 10 year experience.
Burns, 1975. 2(1).
36. Gallagher, J., S. Wolf, and D. Herndon, Burns, in Sabiston
Textbook of General Surgery, C.e.a. Townsted, Editor. 2008.
37. Molan, P., The role of honey in the management of wounds.
J Wound Care, 1999. 8: p. 415-8.
38. Halkes, S., J. du Pont, and M.e.a. Hoekstra, The use of
tannic acid in the local treatment of bum wounds: intriguing old and new
perspectives. . Wounds, 2001. 13(4): p. 144-58.
39. Chokoto, L. and E. van Hasselt, The use of tannins in the
local treatment of burn wounds. . Malawi Medical Journal, 2005. 17(1):
p. 19-20.
40. Ghalambor, A., M. Pipelzadeh, and A. Khodadadi, The
Amniotic Membrane: A Suitable Biological Dressing to Prevent Infection in
Thermal Burns. Medical Journal of Islamic Academy of Science, 2000. 13(3):
p. 115-8.
41. Ramakrishnan, K. and V. Jayaraman, Management of partial
thickness burn wounds by amniotic membrane; a cost effective treatment in
developing countries. Burns, 1997. 23 (Suppl 1): p. 533-6. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55207
42. Gore, M. and D. Akolekar, Evaluation of banana leaf
dressing for partial thickness burn wounds. Burns, 2003. 29: p.
487-92. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55208
43. Ozumba, U. and B. Jiburum, Bacteriology of burn wounds in
Enugu. Nigeria Burns, 2000. 26: p. 178-80.
44. Ugburo, An evaluation of the role of systematic
antibiotic prophylaxis in the control of burn wound infection at the Lagos
University Teaching hospital. Burns, 2004. 30: p. 43-8. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55209
45. Herndon, D.N. and R. Tompkins, Support of the metabolic
response to burn injury. The Lancet, 2004. 363. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55210
46. Manktelow, A., Burn injury and management in Liberia.
Burns, 1990. 16: p. 432-6.
47. Corwin, H., A. Gettinger, and R. Pearl, The CRIT
Study: Anemia and blood transfusion in the critically ill. Current
clinical practicie in the United States. Crit Care Med, 2004. 32: p.
39-52. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55211
48. Palmieri, T., D. Caruso, and K.e.a. Foster, Effect of
blood transfusion on outcome after major burn injury: a multi center
sutdy. Crit Care Med, 2006. 34(6): p. 1602-7. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55213
49. James, J.e.a., The prevalence of HIV infection among burn
patients in a burns unit in Malawi and its influence on outcome. Burns,
2003. 29: p. 55-60. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55214
50. Edge, J., et al., Clinical Outcome of HIV positive
patients with moderate to severe burns. Burns, 2001. 27: p. 111-114.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55215
51. Prasanna, M., P. Mishra, and T. C., Delayed primary
closure of the burn wounds. Burns, 2004. 30: p. 169-75. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55216
52. Stevenson, J., et al., The establishment of a burns unit
in a developing country: collaborative venture in Malawi. British
Journal of Plastic Surgery, 1999. 52: p. 488-94. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55218
53. Bell, M. and M. Duncan, The Cutting Edge of Plastic
Surgery: How to Sharpen Your Humby Knife. Plastic and Reconstructive
Surgery., 1998. 101(3): p. 864-5. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55219
54. Bell, M., M. Duncan, and S. Shanhrokhi Ebrahimipour, Successful
Skin Grafting in Developing Countries. . Tropical Doctor, 2000. 30(3):
p. 149-51.
55. Bell, M. and M. Duncan, Need A Pizza Meshed Skin? A
Simple Expansion Device. Tropical Doctor, 1997. 27(4): p. 229.
56. Richard, R. and R.S. Ward, Splinting Strategies and
Controversies. Journal of Burn Care & Rehabilitation, 2005. 26(5).
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55220
57. Serghiou, M.A., A. McLaughlin, and D.N. Herndon, Alternative
Splinting Methods for the Prevention and Correction of Burn Scar Torticollis.
Journal of Burn Care & Rehabilitation, 2003. 24: p. 336-40. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55221
58. Manigandan, C., et al., A multi-purpose, self-adjustable
aeroplane splint for the aplinting of axillary burns. Burns, 2003. 29:
p. 276-9. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55222
59. Germann, G. and K. Philipp, The Burned Hand, in Green's
Operative Hand Surgery, D.e.a. Green, Editor. 2005.
60. Hashem, F.K. and Z.A. Khayal, Oral Burn Contractures in
Children. Annals of Plastic Surgery, 2003. 51(5): p. 468-71. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55223
61. Hudson, D. and A. Renshaw, An algorithm for the release
of burn contractures of the extremities. Burns, 2006. 32: p. 663-8.
http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55224
62.
63. Lee, W. and A. Salyapongse, Thumb Reconstruction, in Green's
Operative Hand Surgery, G.e. al, Editor. 2005.
64. Gulgonen, A. and K. Ozer, The correction of post-burn
contractures of the second through fourth web spaces. Journal of Hand
Surgery, 2007. 32A: p. 556-564. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55226
65. Lin, T.-M., et al., Treatment of Axillary Burn Scar
Contracture using opposite running Y-V-plasty. Burns, 2005. 31: p.
894-900. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55227
66. Obaidullah, H. Ullah, and M. Aslam, Figure-of-8 sling for
prevention of recurrent axillary contracture after release and skin grafting.
Burns, 2005. 31(283-9). http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55228
67. Hallock, G.G., A Systematic Approach to Flap Selection
for the Axillary Burn Contracture. Journal of Burn Care &
Rehabilitation, 1993. 14: p. 343-7.
68. Esselman, P., et al., Burn Rehabilitation--State of