- •Preface
- •List of contributers
- •History, epidemiology, prevention and education
- •A history of burn care
- •“Black sheep in surgical wards”
- •Toxaemia, plasmarrhea, or infection?
- •The Guinea Pig Club
- •Burns and sulfa drugs at Pearl Harbor
- •Burn center concept
- •Shock and resuscitation
- •Wound care and infection
- •Burn surgery
- •Inhalation injury and pulmonary care
- •Nutrition and the “Universal Trauma Model”
- •Rehabilitation
- •Conclusions
- •References
- •Epidemiology and prevention of burns throughout the world
- •Introduction
- •Epidemiology
- •The inequitable distribution of burns
- •Cost by age
- •Cost by mechanism
- •Limitations of data
- •Risk factors
- •Socioeconomic factors
- •Race and ethnicity
- •Age-related factors: children
- •Age-related factors: the elderly
- •Regional factors
- •Gender-related factors
- •Intent
- •Comorbidity
- •Agents
- •Non-electric domestic appliances
- •War, mass casualties, and terrorism
- •Interventions
- •Smoke detectors
- •Residential sprinklers
- •Hot water temperature regulation
- •Lamps and stoves
- •Fireworks legislation
- •Fire-safe cigarettes
- •Children’s sleepwear
- •Acid assaults
- •Burn care systems
- •Role of the World Health Organization
- •Conclusions and recommendations
- •Surveillance
- •Smoke alarms
- •Gender inequality
- •Community surveys
- •Acknowledgements
- •References
- •Prevention of burn injuries
- •Introduction
- •Burns prevalence and relevance
- •Burn injury risk factors
- •WHERE?
- •Burn prevention types
- •Burn prevention: The basics to design a plan
- •Flame burns
- •Prevention of scald burns
- •Conclusions
- •References
- •Burns associated with wars and disasters
- •Introduction
- •Wartime burns
- •Epidemiology of burns sustained during combat operations
- •Fluid resuscitation and initial burn care in theater
- •Evacuation of thermally-injured combat casualties
- •Care of host-nation burn patients
- •Disaster-related burns
- •Epidemiology
- •Treatment of disaster-related burns
- •The American Burn Association (ABA) disaster management plan
- •Summary
- •References
- •Education in burns
- •Introduction
- •Surgical education
- •Background
- •Simulation
- •Education in the internet era
- •Rotations as courses
- •Mentorship
- •Peer mentorship
- •Hierarchical mentorship
- •What is a mentor
- •Implementation
- •Interprofessional education
- •What is interprofessional education
- •Approaches to interprofessional education
- •References
- •European practice guidelines for burn care: Minimum level of burn care provision in Europe
- •Foreword
- •Background
- •Introduction
- •Burn injury and burn care in general
- •Conclusion
- •References
- •Pre-hospital and initial management of burns
- •Introduction
- •Modern care
- •Early management
- •At the accident
- •At a local hospital – stabilization prior to transport to the Burn Center
- •Transportation
- •References
- •Medical documentation of burn injuries
- •Introduction
- •Medical documentation of burn injuries
- •Contents of an up-to-date burns registry
- •Shortcomings in existing documentation systems designs
- •Burn depth
- •Burn depth as a dynamic process
- •Non-clinical methods to classify burn depth
- •Burn extent
- •Basic principles of determining the burn extent
- •Methods to determine burn extent
- •Computer aided three-dimensional documentation systems
- •Methods used by BurnCase 3D
- •Creating a comparable international database
- •Results
- •Conclusion
- •Financing and accomplishment
- •References
- •Pathophysiology of burn injury
- •Introduction
- •Local changes
- •Burn depth
- •Burn size
- •Systemic changes
- •Hypovolemia and rapid edema formation
- •Altered cellular membranes and cellular edema
- •Mediators of burn injury
- •Hemodynamic consequences of acute burns
- •Hypermetabolic response to burn injury
- •Glucose metabolism
- •Myocardial dysfunction
- •Effects on the renal system
- •Effects on the gastrointestinal system
- •Effects on the immune system
- •Summary and conclusion
- •References
- •Anesthesia for patients with acute burn injuries
- •Introduction
- •Preoperative evaluation
- •Monitors
- •Pharmacology
- •Postoperative care
- •References
- •Diagnosis and management of inhalation injury
- •Introduction
- •Effects of inhaled gases
- •Carbon monoxide
- •Cyanide toxicity
- •Upper airway injury
- •Lower airway injury
- •Diagnosis
- •Resuscitation after inhalation injury
- •Other treatment issues
- •Prognosis
- •Conclusions
- •References
- •Respiratory management
- •Airway management
- •(a) Endotracheal intubation
- •(b) Elective tracheostomy
- •Chest escharotomy
- •Conventional mechanical ventilation
- •Introduction
- •Pathophysiological principles
- •Low tidal volume and limited plateau pressure approaches
- •Permissive hypercapnia
- •The open-lung approach
- •PEEP
- •Lung recruitment maneuvers
- •Unconventional mechanical ventilation strategies
- •High-frequency percussive ventilation (HFPV)
- •High-frequency oscillatory ventilation
- •Airway pressure release ventilation (APRV)
- •Ventilator associated pneumonia (VAP)
- •(a) Prevention
- •(b) Treatment
- •References
- •Organ responses and organ support
- •Introduction
- •Burn shock and resuscitation
- •Post-burn hypermetabolism
- •Individual organ systems
- •Central nervous system
- •Peripheral nervous system
- •Pulmonary
- •Cardiovascular
- •Renal
- •Gastrointestinal tract
- •Conclusion
- •References
- •Critical care of thermally injured patient
- •Introduction
- •Oxidative stress control strategies
- •Fluid and cardiovascular management beyond 24 hours
- •Other organ function/dysfunction and support
- •The nervous system
- •Respiratory system and inhalation injury
- •Renal failure and renal replacement therapy
- •Gastro-intestinal system
- •Glucose control
- •Endocrine changes
- •Stress response (Fig. 2)
- •Low T3 syndrome
- •Gonadal depression
- •Thermal regulation
- •Metabolic modulation
- •Propranolol
- •Oxandrolone
- •Recombinant human growth hormone
- •Insulin
- •Electrolyte disorders
- •Sodium
- •Chloride
- •Calcium, phosphate and magnesium
- •Calcium
- •Bone demineralization and osteoporosis
- •Micronutrients and antioxidants
- •Thrombosis prophylaxis
- •Conclusion
- •References
- •Treatment of infection in burns
- •Introduction
- •Clinical management strategies
- •Pathophysiology of the burn wound
- •Burn wound infection
- •Cellulitis
- •Impetigo
- •Catheter related infections
- •Urinary tract infection
- •Tracheobronchitis
- •Pneumonia
- •Sepsis in the burn patient
- •The microbiology of burn wound infection
- •Sources of organisms
- •Gram-positive organisms
- •Gram-negative organisms
- •Infection control
- •Pharmacological considerations in the treatment of burn infections
- •Topical antimicrobial treatment
- •Systemic antimicrobial treatment (Table 3)
- •Gram-positive bacterial infections
- •Enterococcal bacterial infections
- •Gram-negative bacterial infections
- •Treatment of yeast and fungal infections
- •The Polyenes (Amphotericin B)
- •Azole antifungals
- •Echinocandin antifungals
- •Nucleoside analog antifungal (Flucytosine)
- •Conclusion
- •References
- •Acute treatment of severely burned pediatric patients
- •Introduction
- •Initial management of the burned child
- •Fluid resuscitation
- •Sepsis
- •Inhalation injury
- •Burn wound excision
- •Burn wound coverage
- •Metabolic response and nutritional support
- •Modulation of the hormonal and endocrine response
- •Recombinant human growth hormone
- •Insulin-like growth factor
- •Oxandrolone
- •Propranolol
- •Glucose control
- •Insulin
- •Metformin
- •Novel therapeutic options
- •Long-term responses
- •Conclusion
- •References
- •Adult burn management
- •Introduction
- •Epidemiology and aetiology
- •Pathophysiology
- •Assessment of the burn wound
- •Depth of burn
- •Size of the burn
- •Initial management of the burn wound
- •First aid
- •Burn blisters
- •Escharotomy
- •General care of the adult burn patient
- •Biological/Semi biological dressings
- •Topical antimicrobials
- •Biological dressings
- •Other dressings
- •Exposure
- •Deep partial thickness wound
- •Total wound excision
- •Serial wound excision and conservative management
- •Full thickness burns
- •Excision and autografting
- •Topical antimicrobials
- •Large full thickness burns
- •Serial excision
- •Mixed depth burn
- •Donor sites
- •Techniques of wound excision
- •Blood loss
- •Antibiotics
- •Anatomical considerations
- •Skin replacement
- •Autograft
- •Allograft
- •Other skin replacements
- •Cultured skin substitutes
- •Skin graft take
- •Rehabilitation and outcome
- •Future care
- •References
- •Burns in older adults
- •Introduction
- •Burn injury epidemiology
- •Pathophysiologic changes and implications for burn therapy
- •Aging
- •Comorbidities
- •Acute management challenges
- •Fluid resuscitation
- •Burn excision
- •Pain and sedation
- •End of life decisions
- •Summary of key points and recommendations
- •References
- •Acute management of facial burns
- •Introduction
- •Anatomy and pathophysiology
- •Management
- •General approach
- •Airway management
- •Facial burn wound management
- •Initial wound care
- •Topical agents
- •Biological dressings
- •Surgical burn wound excision of the face
- •Wound closure
- •Special areas and adjacent of the face
- •Eyelids
- •Nose and ears
- •Lips
- •Scalp
- •The neck
- •Catastrophic injury
- •Post healing rehabilitation and scar management
- •Outcome and reconstruction
- •Summary
- •References
- •Hand burns
- •Introduction
- •Initial evaluation and history
- •Initial wound management
- •Escharotomy and fasciotomy
- •Surgical management: Early excision and grafting
- •Skin substitutes
- •Amputation
- •Hand therapy
- •Secondary reconstruction
- •References
- •Treatment of burns – established and novel technology
- •Introduction
- •Partial thickness burns
- •Biological membranes – amnion and others
- •Xenograft
- •Full thickness burns
- •Dermal analogs
- •Keratinocyte coverage
- •Facial transplantation
- •Tissue engineering and stem cells
- •Gene therapy and growth factors
- •Conclusion
- •References
- •Wound healing
- •History of wound care
- •Types of wounds
- •Mechanisms of wound healing
- •Hemostasis
- •Proliferation
- •Epithelialization
- •Remodeling
- •Fetal wound healing
- •Stem cells
- •Abnormal wound healing
- •Impaired wound healing
- •Hypertrophic scars and keloids
- •Chronic non-healing wounds
- •Conclusions
- •References
- •Pain management after burn trauma
- •Introduction
- •Pathophysiology of pain after burn injuries
- •Nociceptive pain
- •Neuropathic pain
- •Sympathetically Maintained Pain (SMP)
- •Pain rating and documentation
- •Pain management and analgesics
- •Pharmacokinetics in severe burns
- •Form of administration [21]
- •Non-opioids (Table 1)
- •Paracetamol
- •Metamizole
- •Non-steroidal antirheumatics (NSAID)
- •Selective cyclooxygenasis-2-inhibitors
- •Opioids (Table 2)
- •Weak opioids
- •Strong opioids
- •Other analgesics
- •Ketamine (see also intensive care unit and analgosedation)
- •Anticonvulsants (Gabapentin and Pregabalin)
- •Antidepressants with analgesic effects
- •Regional anesthesia
- •Pain management without analgesics
- •Adequate communication
- •Psychological techniques [65]
- •Transcutaneous electrical nerve stimulation (TENS)
- •Particularities of burn pain
- •Wound pain
- •Breakthrough pain
- •Intervention-induced pain
- •Necrosectomy and skin grafting
- •Dressing change of large burn wounds and removal of clamps in skin grafts
- •Dressing change in smaller burn wounds, baths and physical therapy
- •Postoperative pain
- •Mental aspects
- •Intensive care unit
- •Opioid-induced hyperalgesia and opioid tolerance
- •Hypermetabolism
- •Psychic stress factors
- •Risk of infection
- •Monitoring [92]
- •Sedation monitoring
- •Analgesia monitoring (see Fig. 2)
- •Analgosedation (Table 3)
- •Sedation
- •Analgesia
- •References
- •Nutrition support for the burn patient
- •Background
- •Case presentation
- •Patient selection: Timing and route of nutritional support
- •Determining nutritional demands
- •What is an appropriate initial nutrition plan for this patient?
- •Formulations for nutritional support
- •Monitoring nutrition support
- •Optimal monitoring of nutritional status
- •Problems and complications of nutritional support
- •Conclusion
- •References
- •HBO and burns
- •Historical development
- •Contraindications for the use of HBO
- •Conclusion
- •References
- •Nursing management of the burn-injured person
- •Introduction
- •Incidence
- •Prevention
- •Pathophysiology
- •Severity factors
- •Local damage
- •Fluid and electrolyte shifts
- •Cardiovascular, gastrointestinal and renal system manifestations
- •Types of burn injuries
- •Thermal
- •Chemical
- •Electrical
- •Smoke and inhalation injury
- •Clinical manifestations
- •Subjective symptoms
- •Possible complications
- •Clinical management
- •Non-surgical care
- •Surgical care
- •Coordination of care: Burn nursing’s unique role
- •Nursing interventions: Emergent phase
- •Nursing interventions: Acute phase
- •Nursing interventions: Rehabilitative phase
- •Ongoing care
- •Infection prevention and control
- •Rehabilitation medicine
- •Nutrition
- •Pharmacology
- •Conclusion
- •References
- •Outpatient burn care
- •Introduction
- •Epidemiology
- •Accident causes
- •Care structures
- •Indications for inpatient treatment
- •Patient age
- •Total burned body surface area (TBSA)
- •Depth of the burn
- •Pre-existing conditions
- •Accompanying injuries
- •Special injuries
- •Treatment
- •Initial treatment
- •Pain therapy
- •Local treatment
- •Course of treatment
- •Complications
- •Infections
- •Follow-up care
- •References
- •Non-thermal burns
- •Electrical injury
- •Introduction
- •Pathophysiology
- •Initial assessment and acute care
- •Wound care
- •Diagnosis
- •Low voltage injuries
- •Lightning injuries
- •Complications
- •References
- •Symptoms, diagnosis and treatment of chemical burns
- •Chemical burns
- •Decontamination
- •Affection of different organ systems
- •Respiratory tract
- •Gastrointestinal tract
- •Hematological signs
- •Nephrologic symptoms
- •Skin
- •Nitric acid
- •Sulfuric acid
- •Caustic soda
- •Phenol
- •Summary
- •References
- •Necrotizing and exfoliative diseases of the skin
- •Introduction
- •Necrotizing diseases of the skin
- •Cellulitis
- •Staphylococcal scalded skin syndrome
- •Autoimmune blistering diseases
- •Epidermolysis bullosa acquisita
- •Necrotizing fasciitis
- •Purpura fulminans
- •Exfoliative diseases of the skin
- •Stevens-Johnson syndrome
- •Toxic epidermal necrolysis
- •Conclusion
- •References
- •Frostbite
- •Mechanism
- •Risk factors
- •Causes
- •Diagnosis
- •Treatment
- •Rewarming
- •Surgery
- •Sympathectomy
- •Vasodilators
- •Escharotomy and fasciotomy
- •Prognosis
- •Research
- •References
- •Subject index
Hand burns
priate choice for local coverage when the donor site remains uninjured. An Allen’s test, as well as Doppler examination of the superficial palmar arch, should be performed prior to raising the flap to ensure adequate perfusion of the hand. Skin grafting of the donor site in the case of a fasciocutaneous flap or recipient site in the case of a fascial flap will be necessary. The distally based posterior interosseous flap is a fasciocutaneous flap harvested from the dorsal aspect of the forearm and does not disrupt either of the major blood vessels perfusing the hand [1]. Although the flap’s perfusing vessel is sometimes hypoplastic or absent, this flap is especially useful when there has been an injury to either the radial or ulnar artery.
Distant flaps. When local flaps are unavailable due to injury, distant flaps may be considered. The primary distant flaps used for hand coverage are the abdominal (random) or groin (pedicled) flaps [27]. In either case, a flap of Scarpa’s fascia, subcutaneous tissue, and skin is templated, raised, and sutured onto the hand. The hand is left in-situ for 2–3 weeks after which the flap is divided (Fig. 3). Vascularization of the flap can be determined, when in doubt, using indocynanine-green fluorescence video angiography [21]. A variant of groin or abdominal flaps may be performed in which only Scarpa’s fascia is transferred and skin grafted, leaving behind the groin or abdominal skin and subcutaneous tissue – the Crane procedure.
Free tissue transfer. Free tissue transfer may be necessitated when extensive burns prevent local or distant pedicled flaps. Numerous options exist including a contralateral radial forearm fascial flap, dorsalis pedis fascial flap, temporoparietal fascial flap, perforator flap (ex. thin anterolateral thigh perforator flap), and muscle flaps (ex. serratus anterior, rectus abdominus, or gracilis) [4, 13]. All have been used with success to provide durable, pliable coverage. Prior to considering a free tissue transfer, the viability of the recipient vessels must be evaluated to ensure that they have not also been damaged.
Skin substitutes
Skin substitutes may be useful in cases of extensive burn injury where there is limited donor site to allow
Fig. 3. A pedicled abdominal flap was used in this case to provide soft tissue coverage over exposed joints and tendons of the hand. In this case two separate flaps were used – one for the thumb and one for the digits
for the harvest of quality autografts for hand coverage. Skin substitutes are applied to the freshly excised wound bed and, as in the case of autograft, it is essential that the wound bed be viable and hemostatic prior to skin substitute placement. Depending on the skin substitute used, the autograft may be placed over the substitute in one operation or in a second procedure after the substitute has had adequate time to vascularize. Two popular skin substitutes are Integra (Integra Life Sciences, Plainsboro, NJ) which requires two procedures and Matriderm (Dr. Otto Suwelack Skin & Health Care AG, Billerbeck, Germany) which is a one-stage product. Each approach has relative benefits and drawbacks. A full discussion of skin graft substitutes is beyond the scope of this chapter; however, their use has been described in several small case series studies involving the hand [6, 11, 12, 16, 31].
Amputation
Severe burns of the hand may result in injuries for which salvage is either impossible or impractical. The ultimate goal of treatment of hand burns is optimization of function. The loss of a digit may provide the patient with a more favorable outcome when compared to an insensate, painful, and stiff finger.
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Delayed amputation is also sometimes required when all other treatments options have been exhausted or have failed. Length should be protected at all times. As is the case with all severe hand burns, realistic discussions about the goals of reconstruction should take place prior to embarking on a plan of treatment. In addition, an area of viable soft tissue on a digit which is to be amputated may be useful for coverage of other areas of the hand. For example, if the dorsal aspect of a digit is burned down through the tendon and joint, a filet flap from the volar aspect of the digit can be used to cover any exposed metacarpophalangeal joints or tendons.
Hand therapy
Hand therapy is an integral component in the treatment of any hand injury. Surgical management of hand burns without proper post-operative hand therapy – including splinting, edema management, and range-of-motion exercises – preferably led by an experienced burn therapist, is likely to result in suboptimal results. Hand therapy should begin within 24-hours of injury. Edema management is initiated with elevation and proceeds to compressive wraps. Custom compressive gloves and sleeves should be fitted to the patient when there is no longer concern for a shear injury [17]. Any hand which begins to assume a clawed posture should be splinted in the intrinsic plus position with the wrist in 30 degrees of extension, the metacarpophalangeal joints in 70–90 degrees of flexion, and the interphalangeal joint in full extension to 15 degrees of flexion. The first webspace should also be held in an abducted position. This posture will maintain the collateral ligaments in tension and help to avoid fixed contractures. Palm burns, which are at significant risk of flexion contracture, should be splinted with all joints in full extension. Range of motion exercises should be withheld in the acute phase of graft or flap healing, but should be initiated as soon as possible thereafter, usually after five days in the case of splitor full-thickness skin grafting. If prolonged splinting is required, range of motion exercises out of the splint should occur several times a day. Night time only splinting should be considered and independent therapy should be encouraged. Passive range of motion should be performed on intubated
patients daily. Patients should not be discharged from the hospital until they have demonstrated that they are self-sufficient with both hand therapy and wound care [20].
Secondary reconstruction
Even optimal care of burned hands may result in excessive scarring and contracture. Hand contractures may be categorized as digital, palmar, dorsal, or syndactyly [14] (Fig. 4). Secondary reconstructions include scar release, rearranging or lengthening scar, and replacing deficient tissues with grafts or flaps. Treatment of contracted tissue should be initiated after the scar has fully matured, often a period of 12 months. The patient must also be mentally prepared to return to the operating room and participate in postoperative rehabilitation. In case of pediatric patients, parental compliance must also be assured. However, in some cases of severe contracture, early release and grafting should be considered.
The approach to secondary reconstruction begins with defining the problem or functional deficit. A discussion of realistic goals and expectations should follow. Physical therapy should be initiated to both improve contracture and demonstrate future compliance. Coverage options, both local and distant, should be inventoried. If two hands require sur-
Fig. 4. Digital contractures of the burned hand extending from the palm to the digits
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Hand burns
gery, only one should be addressed at a time. Surgeries with competing post-operative needs, such as prolonged immobilization and early motion, should also be performed separately. Standard plastic surgery techniques such as Z-plasty and Z-to-Y flap release are commonly performed to release hand contractures The Z-plasty is particularly well suited for web spaces and the Z-to-Y flap release is appropriate for small, linear contractures. Full-thickness skin grafts may be required after the release or excision of scar to accommodate for increased excursion. In cases of long-standing contracture, consideration of Kirschner wire fixation in extension for 3 weeks may help to prevent recurrence of contracture.
References
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[30]van Zuijlen P, Kreis R, Vloemans A et al (1999) The progCorrespondence: Matthew B. Klein, M.D., M.S., FACS, David
nostic factors regarding long-term functional outcome |
and Nancy Auth-Washington Research Foundation, En- |
of full-thickness hand burns. Burns 25(8): 709–714 |
dowed Chair for Restorative Burn Surgery, Associate Director, |
[31]Wainwright D, Madden M, Luterman A et al (1996) University of Washington Burn Center, Program Director and Clinical evaluation of an acellular allograft dermal maAssociate Professor, Division of Plastic Surgery, Harborview trix in full-thickness burns. J Burn Care Rehabil 17(2): Medical Center, 325 9th Avenue, Box 359796, Seattle, WA
124–136 |
98104, USA, E-mail: mbklein@uw.edu |
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