Acute burn injury

Almost 2 million people in the United States suffer from burns annually. A small percentage of these injuries are fatal, but all require some degree of medical attention. Burn injury is associated with anatomic, physiologic, endocrinologic, and immunologic alterations. These problems need to be identified and treated properly to prevent or minimize the extent of the damage. In recent years, advances in burn treatment have reduced morbidity and mortality and improved the quality of life for burn survivors. These advances have been made in the treatment of the acute injury, the quality of the initial resuscitation, the effectiveness of infection control, and the surgical decision making for improved short- and long-term outcomes.     

Psychological consequences of vertigo and the effectiveness of vestibular rehabilitation for brain injury patients

This research evaluated the effectiveness of a multidimensional psychological approach towards vestibular rehabilitation. The sample included 18 patients with vertigo due to acquired brain injury. Patients were assessed for vestibular disorder and referred to the therapy programme. They acted as their own controls. The therapy consisted of a behavioural exposure programme to movements and activities which provoked vertigo and anxiety in order to facilitate compensation of vestibular dysfunction and habituation to physical anxiety symptoms. Outcome measures included self-rating questionnaires and sway-monitor to assess vertigo and balance, emotional distress, vertigo handicap and coping strategies. This vestibular rehabilitation programme proved very effective and beneficial for the 18 patients, as their scores on measures of vertigo symptoms, handicap, emotional distress, physical flexibility and postural stability improved significantly post-therapy in comparison to no improvement during a waiting list period.     

Management of burn injury

Burns are a major cause of morbidity and mortality worldwide. Vulnerable people such as children, the frail and elderly, and the socially deprived are at particular risk. Most burns are caused by thermal injury to the skin, but electrical and chemical burns can be very severe. Fortunately, most burns are minor and superficial and can be managed by primary health care professionals. However, major and severe burns require in-hospital management from a team of surgeons and other specialists. Life-threatening conditions such as smoke inhalation airway damage and severe fluid loss should be addressed during the initial resuscitation. Prevention of further thermal damage by cooling is important along with prevention of secondary infection of burn injuries. A wide variety of dressings is available for the management of burns and expert nursing care is vital. Surgical intervention may be urgently required for fasciotomy or escharotomy in cases of compartment syndrome or circumferential burns, respectively. Debridement, skin grafting and reconstructive procedures will be required over the medium or long term for patients with severe or complex burns and should be planned with appropriate multidisciplinary expertize. The functional and psychological impact of major burn injury should not be underestimated.     

Immunomodulation following burn injury

Severe burn injury is accompanied by suppression of almost all the components of immunity; such suppression undoubedly contributes to infectious complications in the burned patient. There has now been substantial experimental progress made in devising approaches to prevent or minimize these immune defects; however, clinical application is still limited.     

Hyperglycaemia after burn injury

The effect of burn injury on blood sugar levels, serum insulin levels and glucose tolerance was studied in male rats. In the burned group (following 50 per cent surface burn injury), the blood sugar level was significantly increased after burn injury in comparison with control uninjured rats. Hyperglycaemia was blocked by injection of phentolamine (10 mg/kg) for 24 h or propranolol (50 micrograms/kg) 30 min before burn or if the animals were adrenalectomized 4 days before injury. Serum insulin levels were significantly decreased in the scalded rats and their glucose tolerance was impaired. Early hyperglycaemia probably arises as a result of adrenal medullary hyperactivity. The initial rise in blood glucose probably arises from glycogen breakdown, followed later by increased hepatic production of glucose. The 50 per cent body surface scald injury is followed, acutely, by a period of glucose intolerance. In part, this intolerance may be due to decreased serum levels of insulin. The inadequate response of insulin secretion in response to glucose loading may be due to inhibition of insulin secretion by pancreatic beta cells caused by elevated catecholamine levels, possibly in combination with the action of antagonists such as glucagon, which may be secreted in excess as a result of stimulation by catecholamines.     

Resuscitation burn card--a useful tool for burn injury assessment

It is well recognised that the initial assessment of body surface area affected by a burn is often over estimated in Accident and Emergency Departments. A useful aide-memoir in the acute setting is Wallace's "rule of nines" or using the patients' palmar surface of the hand, which approximates 1% of the total body surface area, as a method of assessment. Unfortunately, as with every system, limitations apply. Factors such as patient size and the interpretation of what is exactly the 'palmar surface' may significantly influence burn size estimations and subsequently fluid resuscitation. Our aim is to develop a simple, quick and easy reproducible method of calculating burn injuries for medical professionals in the acute setting. Worldwide, the dimensions of a credit card are standardized (8.5 cm x 5.3 cm), thus producing a surface area of 45 cm2. We created a resuscitation burn card (RBC) using these exact same proportions, upon which a modified body surface area (BSA) nomogram was printed. Knowing the patient height and weight, we calculated the surface area of the card as percentage of total body surface area (TBSA). On the opposite site of the RBC, a Lund and Browder chart was printed, as well as the Parkland formula and a formula to calculate paediatric burn fluid requirements. The plastic, flexible RBC conformed well to the body contour and was designed for single use. We used the resuscitation burn card in the initial assessment of simulated burns in a Regional Burn Centre and in an Accident and Emergency Department. The information present on the card was found to be clear and straightforward to use. The evaluation of burn extent was found to be more accurately measured than the estimation obtained without the RBC. The resuscitation burn card can be a valuable tool in the hands of less experienced medical professionals for the early assessment and fluid resuscitation of a burn.     

Flow cytometric measurement of rat lymphocyte subpopulations after burn injury and burn injury with infection

Increased infection rates in burned patients may result from a disproportionate increase in the suppressor subpopulations. Measurement of lymphocyte subpopulations is difficult in burned patients because gradient-purified cells are contaminated by nonlymphoid cells. The accuracy of flow cytometric subpopulation analysis was improved by restricting (gating) the analysis to cells with light-scatter intensity typical of lymphocytes. Blood was obtained 48 hours after burn from rats receiving no burns, 30% scald burns, or burns seeded with Pseudomonas aeruginosa to induce infection. Subpopulations were identified by monoclonal antibodies to T-lymphocyte antigens. Gating increased the values obtained for most subpopulations, but the relative differences between groups were unchanged. Burned and infected animals, but not animals burned only, had a decreased ratio of helper to suppressor lymphocytes (HSR) relative to control. A decreased HSR correlated with sepsis, but not with infection susceptibility. This suggests that a decrease in HSR may be a result of infection rather than a cause of susceptibility to infection.     

Bacteriological monitoring after burn injury

The most frequent and serious complication after burn injury is infection. Bacteriological monitoring of patients after burn injury is part of complex care. The algorithm of bacteriological checkups is set. Burned areas are microbiologically monitored by semi quantitative imprint method. Colonization is proportional to the length of patient's hospital stay. Resistance of the bacteria to antibiotics is usually higher in burn units than in other departments. That is why it is important to consider antibiotic treatment and strictly observe sensitivity by obtaining bacteriological results and current epidemiological situation. Burned patients are in danger of infection from the burned areas, respiratory tract, urinary tract and central venous catheters. Attending doctor should daily be in contact with the bacteriological laboratory.     

Inhalation burn injury in children

With advances in burn care, many children are surviving severe burn injuries. Inhalation injury remains a predictor of morbidity and mortality in burn injury. Inhalation of smoke and toxic gases leads to pulmonary complications, including airway obstruction from bronchial casts, pulmonary edema, decreased pulmonary compliance, and ventilation–perfusion mismatch, as well as systemic toxicity from carbon monoxide poisoning and cyanide toxicity. The diagnosis of inhalation injury is suggested by the history and physical exam and can be confirmed by bronchoscopy. Management consists of supportive measures, pulmonary toilet, treatment of pulmonary infection and ventilatory support as needed. This review details the pathophysiology, diagnosis, and management options for inhalation injury.     

Eyebrow reconstruction following burn injury

Facial burns represent between one-fourth and one-third of all burns. Absence of the eyebrows or distortions in their position alter the character of the face. Thus, eyebrow repair or reconstruction can be an important "finishing touch" in the overall reconstruction of a burned face. Generally, there are three ways to reconstruct the eyebrow: use of superficial temporal artery island flap; composite graft from scalp; and mini or micrografts from scalp. This report presents 20 patients reconstructed with the above techniques. Eleven patients (eight male and three female) with superficial temporal artery island flaps; seven patients (two male and five female) with composite grafts from scalp; and two patients (female) with minigrafts. The results suggest that superficial temporal artery island flaps were more suitable for males and composite graft for females who generally require thinner and less dense eyebrows. Our experience with minigrafts for burn alopecia has not been adequate. Here in this article, different methods of eyebrow reconstruction are presented with the greater emphasis on superficial temporal artery flap.     

Cold injury complicating burn therapy

The immediate application of cool water to a burn provides prompt relief of pain; however, we must become aware of the complications associated with the use of ice and ice water in this regard. Two cases of extremity ischemia secondary to burn wound therapy are reported with a discussion of patient care. The most important aspect of this injury is prevention.     

Addressing pain in burn injury

The pain associated with burn injury can be challenging to treat. It is frequently time consuming and resource dependent, and as a result is often poorly managed. The pain experienced is patient specific with numerous factors influencing the nature and the intensity of the pain. Many of these factors will alter during the course of treatment and rehabilitation. Pain assessment should be performed regularly with the aid of one of the scoring systems available. The management of burn pain should be tailored to the underlying cause (background pain, breakthrough pain, procedural pain, post-operative pain or chronic and complex pain associated with the healing process). Although opiates remain the mainstay of treatment of burn pain they are not always effective or appropriate. Non-opiate drug therapy should always be considered as it maybe more effective and better suited to treating the complex nature of burn pain. Non-pharmacological interventions are an important adjuvant to drug treatment. The most effective approach uses all of these methods, is flexible, has multidisciplinary input and is tailored to the individual patients needs.     

Cardiac output after burn injury

Cardiac output after burn injury has been measured by the non-invasive method of impedance plethysmography. An initial study of 143 normal subjects was undertaken in order to investigate variations in cardiac output with age. Fifteen patients were monitored during resuscitation after extensive burns. Fourteen patients showed a depression of stroke volume below the lower limits of the normal range, derived from the initial study on normal people.     

Comprehensive rehabilitation after burn injury

Comprehensive rehabilitation of patients after burn injury requires the organized application of sound, recognized principles. The basic concerns are the prevention of loss of joint motion, loss of muscle mass, and the prevention of anatomic deformities. Important considerations are starting the rehabilitative program as early as possible after injury and avoiding techniques that unduly immobilize the patient or parts of the body. The use of early active motion to the patient and all movable joints, along with appropriate positioning while at rest, is crucial to a successful program. Passive exercising along with the use of restraints and splints is necessary in certain patients.     

Psychological consequences of awareness and their treatment

Intraoperative awareness with subsequent recall is a rare but serious complication with an incidence of 0.1-0.2%. In approximately one third of the patients who have experienced awareness, late severe psychiatric sequelae may develop. The psychiatric symptoms in these patients fulfil the diagnostic criteria for post traumatic stress disorder. To prevent awareness as a negative outcome after anaesthesia, a thorough perioperative management of anaesthesia is necessary. The definite risk for post traumatic stress disorder following awareness indicates the necessity of postoperative clinical routines to identify awareness patients. The problem must be acknowledged. Professional psychiatric assessment and follow up should constitute standard practice. The treatments of choice are Eye Movement Desensitisation Reprocessing and Cognitive Behaviour Therapy.     

Tetanus following a burn injury

We report a case of tetanus following thermal injury in an 18-month-old girl who had been immunized with the usual triple vaccine and had received a booster dose for tetanus at 15 months of age. She had been admitted initially to a general district hospital and remained there for 10 days before being transferred to the University Hospital. Despite the unparalleled effectiveness and safety of tetanus toxoid, the administration of antitetanus serum (tetanus antitoxin) for patients with suspicious symptoms or wounds grossly contaminated with soil is often highly desirable. A schema of prophylaxis and management of patients with tetanus is provided.     

Electrical burn with visceral injury

A 37-year-old female patient suffered high voltage electrical injury with resultant exit wound on the left quadrant of the abdomen measuring 15 X 10 cm2 involving full thickness of the abdominal wall including the peritoneum. Early debridement and exploratory laparotomy was performed on the fifth post-burn day although the patient had no abdominal symptoms. All visceral organs were grossly normal. The peritoneum was closed and the wound covered with split thickness skin graft. On the twelfth post-burn day the anterior wall of the stomach sloughed and resulted in a 10 X 10 cm2 gastrocutaneous fistula. After 1 month of duodenostomy feeding via the fistula using a Foley catheter, the fistula was closed and was covered with greater omental flap and split thickness skin. Seventeen days later the patient was discharged following an uneventful recovery.