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Innovation and clinical specialities: burns Figure 8: 4-Flap Z-plasty 63 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. Figure 9: 4-Flap Z-plasty 63 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 Deep structures 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 Burn TBSA, % 80 70 60 50 40 30 20 10 0 Penicillin Resuscitation Burn centres More antibiotics Ventiilators Topical Rx Skin banks TPN More antibiotics Early excision 1940 1950 1960 1970 1980 1990 Burn LA 50 Nutrition ICU Face 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 Conclusions Many accomplishments have been made in burn care over the past several decades, as illustrated below (Figure 10). 31 Encouragingly, these have resulted in steady improvements in mortality rates. This progress has also been noted in a number of centres in resource-poor countries where a multidisciplinary, global approach to the burn patient has been embraced; from Excision common Figure 10: Advances in burn xare – 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 prevention to rehabilitation. 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. 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 Hospital and Healthcare Innovation Book 2009/2010 65
Innovation and clinical specialities: burns 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. Recommendations The following recommendations capture the key elements of a simple, but effective approach to better burn management tailored to developing countries: ✚ Community leaders and burn surgeons must collaborate in developing local prevention strategies as well as community education strategies on immediate first aid steps for burn victims and the critical importance of early transportation to the nearest source of appropriate medical services. ✚ Medical personnel must be trained in resuscitation; including aggressive fluid resuscitation, monitoring for airway compromise, and high flow oxygen, all of which to be initiated within the first hours in the case of a major burn. The burns must be assessed for depth, size, need for escharotomy and risk of inhalation injury on presentation ✚ Both physiotherapy, including early active and passive movements and splinting for high risk joints and high protein, high caloric frequent feeds should be in place as of the first day. ✚ Wound care must be performed daily, with careful attention for signs of invasive infection. Appropriate analgesia, sterile conditions and topical antibiotics (SSD) should be used. ✚ Whenever possible, deep second degree burns and third degree burns should be grafted within 10 days of the injury. Techniques to minimize blood loss such as tumescence and tourniquets should be standard practice. ✚ Systemic antibiotics should be reserved for single-dose immediate pre-operative prophylaxis and treatment of invasive wound sepsis, tailored if possible to wound culture results and institutional resistance patterns. ✚ All practicing physicians and surgeons working in areas without a regional burn center should receive training in skin grafting. ✚ Blood transfusion should be limited to when physiologic need exists. ✚ Life-long seizure prophylaxis and patient education regarding the importance of compliance must be part of burn care prevention in all epileptic patients. ❏ Acknowledgement Reprinted with kind permission from Surgery in Africa Monthly Review – October 2008 Bimpe Ayeni, MD MPH is a fourth year Plastic Surgery resident at McMaster University in Hamilton, Ontario. He holds a Bachelor of Arts Degree from Yale University, a Masters in Public Health from Columbia University, and a Doctorate in Medicine from the University of Ottawa. References 1. 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. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55190 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. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55192 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. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55194 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. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55195 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. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55196 17. Grunwald, T. and W. Garner, Acute Burns. Plastic and Reconstructive Surgery, 2008. 121(5): p. 311e-319e. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55197 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. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55198 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. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55199 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 ventilatorassociated pneumonia n patients with burns. Journal of Burn Care & Rehabilitation, 2005. 26: p. 57-61. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55202 33. Monafo, Wound Care, in Total Burn Care, D.N. Herndon, Editor. 2002. 66 Hospital and Healthcare Innovation Book 2009/2010
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International Hospital Federation I
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Introduction Sterile Barrier System
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Contents Healthcare transformation
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International Hospital Federation H
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Introduction Introduction ERIC DE R
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Innovation and strategy 14 Creativi
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Company Profile: Wipak Medical Wipa
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Innovation in patient care: patient
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Innovation in patient care: patient
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C M Y CM MY CY CMY K with support f
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IHF reference IHF Governing Council
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IHF reference IHF Consultants Audit
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IHF reference JAPAN JAPAN HOSPITAL
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IHF reference KENYA THE NAIROBI HOS
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IHF Corporate Member Profiles GE He
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How Can Health Organizations Get th
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