What are the major causes of Burns?
- ELECTRICAL & LIGHTENING
Major causes of thermal burns are-
- Flame burns 80% in India,[in West scalds common]. Common in kitchens
Ghee, sugar solution, gravy cause deeper burns
- Steam causes deeper injury [pressure cooker]
- Thermal contact burns-hot utensils/irons/molten metal/coal tar. Epileptics
- Blasts- bombs/ Anars
- Friction burns
- Laser burns
Burns can be suicidal / accidental/ homicidal.
Bride burning is a uniquely Indian Cause
What is the incidence of Burns?
We do not have a central burn registry unlike American Burn registry but National Academy of burns –India did a survey over several years and found that 70 lakhs people get burns annually, 7lakhs need hospitalization, 2.5lakhs are crippled and 1.4 lakhs die annually.
Are Burns preventable?
Yes. Burns are a preventable cause of misery and death. The following factors are responsible-
- Kerosene lamps & stoves – aerosolized kerosene pumped under pressure and carbon choked burner holes suddenly ignites into a fireball called stove burst by the patient. Wick stoves better
- Clothes- loose clothes like sarees & dupattas
- Flammable fabrics-kids clothes have flammability standards abroad but no such standards in India
- Floor cooking
- Cigarette smoking- fire deaths because of cigarette smoke major cause in developed world-50 % Sweden, 33% Canada, 25% USA
- Hot liquids- do not keep on edge; keep water geysers below 124 F; do not leave kids in bathroom alone; Caution during Steam inhalation by patients esp. children & elderly
- Car radiator precautions – never open a hot radiator
- LPG leaks-check for leaky pipes, faulty regulators, open burners
LPG is heavier & settles low down and ignites with ignition
- Theatres- Major fires in theatres have caused much loss of life in the past
- Fire crackers-open spaces/light from distance-not in hand/ do not inspect unlighted crackers/ avoid ‘anars’ / do not leave children alone/keep water ready/community fireworks should be encouraged.
- Electric burns- Use standardized fire retardant cables.
What should be the first aid to burn patients?
It is important to pour water on burns except electric burns for at least 15 minutes- any water will do; do not waste time trying to search for cold water. . This cools down the temperature & prevents further damage. After that the patient should be wrapped in a clean cloth & shifted to hospital in all but the most minor burns. In electric burns, the source of electricity should be disconnected without coming in direct contact with the victim.
There is no need to apply creams on the burn area.
What are the Criteria for admission/ referral to burn unit?
In the triage area of hospital casualty depth and area of burns are assessed along with full examination and history taking. Depth is a function of temp of the agent and duration of contact and inverse relationship to thickness of skin (areas/age).Extensive burns more likely to be deep.
General criteria for admission are-
- Burns more than 10% TBSA in ages below 10 and above 50 yrs
- Burns more than 20% TBSA in others
- Third Degree burns more than 5% TBSA in any age group
- Burns involving areas of cosmetic and functional importance
E.g. face, hands, feet, genitalia major joints
- Circumferential burns
- Inhalational burns
- Electrical burns
- Chemical burns
- Burns with ass. Injuries
- Burns with pre existing disease
Burn centers have Burn surgeons, nurses, anesthesiologists, Respiratory therapists, dieticians, occupational &, physical therapists, psychosocial experts etc.
What is the Initial management-?
In the initial phase airway is secured. Fluids are started to compensate for losses. Goals of resuscitation are to restore plasma losses. A number are formulae are available to roughly calculate the fluid; Parkland formula is most popular. Escharotomy may be done to relieve tension in tight circumferentially burnt areas. Drugs to relieve pain are given as is tetanus prophylaxis. Urine catheter may be put to monitor urine output.
What is the Subsequent management?
The burn treatment in Delhi starts with dressings. A number of agents are available for dressings- silver sulfadiazine is a popular agent. Some areas like face, hands & and genitalia require special attention. Diagnosis & treatment of sepsis is integral part of wound management. Early Excision of deep burns & coverage with skin grafts is done in first week to reduce morbidity & mortality.
Nutrition is very important to prevent deficiencies. Blood or its components may have to be transfused to cover deficiencies. Stress ulcers are prevented by giving antacids. Physiotherapy and psychological support are also necessary
Late management and rehabilitation include modulation of post burn scar by pressure garments.
What are the goals of Burn wound management?
Superficial burns heal themselves. So create conditions which optimize re- epithelialisation. Dressings with paraffin help.
Deep burns will not heal them unless small. Therefore excise and graft at the earliest. If early grafting not done for some reason, then late grafting is done.
What is Burn survival & mortality?
LA50 –this is the percentage of burns associated with 50% mortality.
In US Army burn centre, presently it is 75% at 21 yrs, 65% at 40yrs.45% for adults over 40 and 71% for 0-14 yrs.
In 1950 the value for young adults was 43%.
Electrical contact burns are generally much more serious injuries.>
They require more vigorous resuscitation; there is a need for larger amount of fluids, greater need for fasciotomy, and a greater risk of amputations and mortality. Many of these patients will also require flaps for reconstruction.>
Chemical burns produce a much deeper level of injury at the site of acid or alkali contact. Generally the damage is deep and deformity disfiguring and reconstruction long and unsatisfactory
POST BURN DEFORMITIES & PRINCIPLES OF BURN RECONSTRUCTION
What are the Goals-?
Burn reconstruction requires a unique perspective because-
1. Reconstructive surgery following burn injury involves almost all aspects of plastic surgery in Delhi. The patient population includes children and adults. All areas of the body can be involved. Deep structures can be injured either acutely or secondarily.
2 The plastic surgeon in Delhi must thoroughly understand the processes of wound healing and contraction. The effect of time on the maturation of scars is of pivotal importance and requires patience and judgment on the part of the surgeon and patient. Correct timing of surgery is essential.
3. Donor sites are frequently compromised. Multiple operations are the rule. Multiple sites may be involved. Complete plan may take years to execute.
What are usual Patient Complaints after major Burns?
Reconstruction requested for-
- Feeling of tightness
- Contour problems
- Hypertrophic scars
- Contractures results from contraction across a flexural surface leading to tightness or actual limitation of movement. Burns cause tissue loss, wounds heal with contraction, and contractures result. Contractures can be either intrinsic or extrinsic. Intrinsic contractures result from injury or loss of tissue in the affected area, causing subsequent distortion and deformity of the part. Extrinsic contractures occur when tissue loss at a distance from an affected area creates tension that distorts the structure. Eyelid ectropion, for example, can result from either intrinsic or extrinsic contractures.
- Unstable scars and ulceration. It is not uncommon in this group of patients for hypertrophic scars to present with areas of open ulceration. This is almost always caused by chronic tension.
Burn reconstruction can be a long and frustrating battle with the deformities. Well-functioning support system, including nurses, therapists, psychosocial practitioners, and, hopefully, a supportive family are required for satisfactory outcome for what is often a long and arduous process.
What are the Fundamentals of burn reconstruction?
Burn injuries obviously vary greatly in severity and extent. Yet virtually all post burn deformities have similar components that must be addressed for reconstructive surgery to be successful.
Sequencing of surgeries is very important.
A prospective plan for reconstructive surgery should be worked out either with the patient and the patient’s family All reconstructive procedures should try to improve both the function and appearance of the operated area as much as possible.
Operations to improve essential function are the initial priority, but appearance, particularly of the face and hands should always be a consideration.
Because the patient’s priorities may be different from the surgeon’s, education, careful consultation, and mutual agreement are of extreme importance.
Role of contraction and tension should be understood. All burns of the second or third degree result in open wounds. Open wounds heal by contraction and epithelialization. Contraction may be decreased by early excision and grafting, but it is always present to some degree. Contraction leads to tension, and tension is one of the principal causes of hypertrophic scarring and unfavorable scarring in general. Understanding the role of tension in the evolution of post burn deformities is essential for their successful treatment.
For scars to mature as well as possible, tension must be eliminated.
Tension deforms normal body contours, and the resulting abnormal shape draws attention to the injured area. Relief of tension and restoration of normal contour by either release and grafting or Z-plasties is perhaps the most basic fundamental of all burn reconstruction.
The amount of tension in the skin following a burn injury is often not obvious, particularly to inexperienced surgeons. When releases are carried out and defects are created, the amount of tissue required to close the open defects can be surprising.
What is the timing of reconstruction?
As a general rule, burn reconstruction is best delayed until all wounds are closed, inflammation has subsided, and scars and grafts are mature and soft.
Early intervention – is the exception. It is useful in wounds such as open joints, or to prevent acute contractures from causing irreversible secondary damage. Examples of indications are eyelid contractures with exposure keratitis, cervical contractures causing airway issues, oral incompetence due to lip contracture dorsum of hand contractures and “fourth-degree burns,” such as in electrical injuries, where acute flap coverage is required.
What are the techniques used for burn reconstruction?
Reconstruction should not be focused on the excision of burn scars. It is fundamentally about the release of contractures and the correction of contour abnormalities and tightness.
Patients would like their scars to be “removed” and they want to “get on with their lives.” Most of the time, this is not in the patient’s best interest. Education of the patient and the patient’s family is essential in order to help guide them to the best possible outcome. The desire for “excision” can lead to iatrogenic deformities. A scar can only be traded for another scar of a different variety. A well settled mature burn scar may be better than a surgical scar.
So Contracture should be released not excised. This can be carried out with local tissue rearrangement such as Z-plasties or transposition flaps or they can be carried out by releases and skin grafting of the resulting defects. Releases can be performed by either incising scars or excising scars.
Choice of tissues to release tension
Skin grafts are pivotal in burn reconstruction. A few generalizations about their characteristics may be helpful.
A] Split-thickness skin grafts contract more than full-thickness skin grafts, have more propensity to wrinkle, and always remain shiny with a “glossy finish” look. Thick split-thickness skin grafts contract less and provide more durable skin coverage, but do not possess elastic properties. Meshed split-thickness grafts are rarely indicated in burn reconstruction surgery. The meshed pattern is permanently retained and has an unattractive “reptilian” appearance. Hyper pigmentation of grafts is a frequent problem in dark-skinned patients, particularly those of African descent.
B] Full-thickness skin grafts are reliable workhorses in facial burn reconstruction. The use of full-thickness skin grafts in other areas of burn reconstruction should be carefully considered on an individual basis. Full-thickness grafts are elastic, contract less, have a “matte finish” like normal skin, and create a durable, resilient, skin surface. Full- thickness grafts, however, require a good bed, primary closure or grafting of the donor site, and are best reserved for reconstruction of the head and neck or the hand.
C] Composite grafts from the ear are useful for complex facial burn reconstruction, but should only be used when there is adequate blood supply in the recipient bed.
They are pieces of skin and deeper tissues with intact blood supply. Advantages of flaps are elasticity, minimal contracture, excellent color and texture match. Post op splinting requirement is less. Disadvantage is donor site morbidity
Indications -Flaps, with or without tissue expansion, are useful for burn reconstruction.
Mandatory-They are mandatory for complex defects such as open joints or exposed vessels, or to provide tissue coverage that allows for later complex reconstruction, such as tendon or nerve grafting in the hand.. available for the correction of cervical contractures
Preferred-Special sites- axilla, web spaces
When contractures have a predominantly linear component and there is a relative excess of vascular, elastic tissue lateral to the contracture, the Z-plasty is simple, reliable, and has the least morbidity. Z-plasty minimizes the need for most postoperative therapy, including pressure garments, and the benefit of the procedure is prolonged. The relaxed scar tissue will continue to soften, flatten, and loosen for many months to years.
2] Z-plasties can be used on the narrower, linear, components of diffuse areas of hypertrophic scarring to separate islands of scar and restore elasticity. Contour abnormalities can be corrected at the same time. The relief of tension leads to improved maturation. Burn scar contractures are frequently diffuse, and excision is neither practical nor desirable.
Tissue expanders have transformed the treatment of post burn alopecia. Bald areas of 50% of the scalp or more can be successfully reconstructed, frequently requiring more than one expansion
Face transplant has been successful recently for hopeless cases.
What are non surgical methods to modulate burn scars?
Scar maturation can be enhanced by the use of
a] pressure garments
d]Steroid Creams & injections
e] Scar creams
f] Laser is effective in decreasing facial redness when used in this intermediate phase and seems to result in more favorable long-term scar maturation.