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   Table of Contents - Current issue
January-December 2017
Volume 25 | Issue 1
Page Nos. 1-89

Online since Wednesday, December 13, 2017

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Models of a different kind p. 1
Vinita Puri
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Cadaver skin donation and skin bank p. 3
Madhuri Gore
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The management of postburn contractures of trunk, groin, and perineum: A review p. 6
Rajeev B Ahuja, Pallab Chatterjee
While the trunk is injured in about one-fifth of burn incidents, the groin and perineal contractures are relatively infrequent. Truncal and groin/perineal involvement with disfiguring and functionally restrictive contractures are usually seen in the setting of large surface area burn injuries. In a majority of cases, the treatment of truncal contractures is aimed at mitigating the effects of hypertrophic scarring. In groin/perineal contractures, the contractures are treated to restore movements that enable the important functions of excretion, squatting, and sexual intercourse. Many innovative local and regional flaps have been described to treat such contractures that provide a durable result. Even then, split skin grafting remains a valuable method to treat these contractures, especially for the severe ones. Although tissue expansion can be frequently used to provide color and texture-matched skin resurfacing after the release of truncal contractures, it is deemed unsuitable for groin/perineal contractures owing to high complications rates.
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Burn Care Unit, Tata Main Hospital, Jamshedpur p. 14
Prasenjit Goswami, Amit Kumar Sinha, Pankaj Kumar Sinha
Consequent to a big fire tragedy which occurred at a function on 3rd of March 1989 at Jamshedpur which left many people dead and an even more number of people with severe burn, a serious need was felt regarding having of a specialised burn care unit in the region. Foundation stone for the burn care unit (BCU) of TMH was laid on 19th December 1989. This self-sufficient unit became fully functional from August 1992 with 18 beds divided into two zones – Septic and Aseptic, and was headed by Plastic Surgeon Dr R Bharat, who served the department till his retirement in the year 2008. The present BCU has fifteen beds in separate cubicles and is provided with all the modern facilities such as modern critical care beds, wall mounted gas pipe lines and suction, monitors and Ventilators. Apart from its therapeutic endeavours, the department has constantly forayed into the realm of social responsibility by undertaking community awareness programmes on prevention of burns through its several outreach programs within the premises of the Tata Steel industrial areas as well as the community at large, in keeping with the Tata steel’s Corporate Social Responsibility.
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Could serum cytokines serve as predictors in outcome of thermal burn injuries p. 18
Ranjith J Babu, G. Karthikeyan, Nirmala Ponnambalam
Introduction: Thermal burns cause ample havoc to human beings. Multidisciplinary approach plays a pivotal role in reducing morbidity and mortality. Justifiably tailored intervention plays cardinal role to offset further systemic derangements. This study is undertaken to assess whether serum cytokines could serve as predictors in the outcome of thermal burn injuries. Materials and Methods: Prospective study was conducted in 30 patients during the period of January 2016 to December 2016. The use of proinflammatory cytokines interleukin-1B (IL-1B), interleukin-6 (IL-6) was quantitatively estimated on postburn day 4 and every 5 days thereafter. The proinflammatory cytokine levels were high in patients who had higher percentage total body surface area burns. Results: Temporal cytokine profiling revealed significant difference in the pattern of patients who survived with those who had a fatal outcome. Reduction in cytokine levels IL-1B, IL-6 in the survival group over the course of treatment and observation of incremental temporal expression in cytokine levels in the nonsurvival group indicate its recalcitrant nature on treatment and thereby dictate catastrophic outcome. Discussion: The local inflammation in thermal burns releases proinflammatory cytokines systemically which leads to progression in systemic inflammatory response syndrome which can prove detrimental. Conclusion: Temporal analysis of cytokines could serve as prediction analysis in the outcome of thermal burn injuries because this sequence goes awry with higher percentage of burn area. This could dictate morbidity and mortality which gain significance in the overall outcome of patient.
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Commentary to ‘Could serum cytokines serve as predictors in outcome of thermal burn injuries’ p. 23
Kuldeep Singh
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A simple mortality prognostic scoring system for burns p. 26
Pawan Agarwal, Sudhir Adalti, Vikesh Agrawal, Dhananjaya Sharma
Background: Several complex prognostic scoring systems are available for burn patients incorporating sophisticated investigations and use of global scales involved in the management of patients in intensive care unit. We constructed and validated a simplified scoring system for burn patients, which can be easily used in developing countries. Materials and Methods: One hundred and eighty-two consecutive patients with burns undergoing treatment at a teaching hospital in Central India were studied prospectively. Multiple logistic regressions were used to assess the predictive power of each prognostic variable. A simple scoring system was constructed using the four most powerful, but easy to calculate, prognostic factors. This system was then prospectively validated in the next 122 consecutive patients. Results: On multivariate analysis, total body surface area, percentage full thickness burn area, presence of inhalation burn, and serum creatinine were found significant predictors of mortality. Score was constructed using logit model using these four factors, which ranged from 4 to 20. Score correlated well with mortality; which increased with rising score. The mean score in survivors was significantly less than that in non-survivors (9.44 vs. 15.75; P < 0.0001). Cut off value of score ≥12 was associated with significantly higher mortality. The predicted and observed outcomes matched well. Conclusion: The Jabalpur prognostic scoring system for burns is effective for prognostication in selected group of patients with burn injuries. It is simple and user-friendly because it uses only four routinely documented clinical risk factors.
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Impact of nonscraping of granulation tissue on outcomes after skin grafting p. 33
Deepak Krishna, Shalabh Kumar, Upendra Sharma, Deepti Gupta
Context: Chronic granulating burn wounds are covered with split-thickness skin grafts (SSG) after scraping of granulation tissue. But scraping is associated with increased blood and protein loss, and time required for hemostasis. We, therefore, conducted a study to determine if scraping can be avoided. Aims: Comparison of outcome of SSG and blood loss in burn wounds treated with and without scraping of granulation tissue. Settings and Design: Prospective clinical study. Materials and Methods: Over a year, 30 adult patients, with healthy granulating postburn wounds of size at least 100 cm2 and 4 to 10-week duration, were included. Wounds were divided into two halves, with one-half grafted after scraping (Group A) and other without scraping (Group B). Intraoperative blood loss was calculated. Dressings were done at postoperative days 3, 5, 7, and 10. Graft take, complete wound-healing time, and regrafting requirement were assessed. Statistical Analysis: Unpaired t test for quantitative variables. Results: Mean graft take (87.21 ± 9.48 Group A; 86.58 ± 11.18 Group B) was similar in both groups. Average intraoperative blood loss was significantly lesser (Group A 54.58 ± 6.5 mL/100 cm2; Group B 10.2 ± 1.5 mL/100 cm2), and duration of complete wound healing was increased without scraping (14.66 ± 2.79 days Group A; 15.73 ± 3.13 days Group B). There was no requirement of regrafting in both groups. Conclusion: Scraping of wound bed is avoidable in selected patients, although at expense of marginally faster healing. Leaving the healthy granulation tissue intact does not affect overall graft take and is associated with decreased blood loss.
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Silver sulfadiazine versus sustained-release silver dressings in the treatment of burns: A surprising result p. 38
Shobhit Gupta, Naveen Kumar, Vinay K Tiwari
Introduction: In recent times, there has been an increased use of dressings containing silver. Although there are many studies showing the impact of sustained-release silver foam dressings on microbial assay, there is a scarcity of studies on clinical and economical parameters. This study highlights the comparison between sustained-release silver dressings and 1% silver sulfadiazine (SSD) with respect to patient comfort, its impact on wound healing, and cost estimation in patients with burns. Materials and Methods: This prospective observational study was conducted from 1st August 2015 to 31st December 2015. Patients with second-degree burns (scald and flame burns) covering 20–60% of the total body surface area and belonging to the age group from 18 to 60 years were selected. The patients were divided into the following groups on alternate basis: Group 1–dressing with 1% SSD; Group 2–dressing with sustained-release silver dressings. The following variables were used: pain during change of dressing using visual analogue scale (VAS) score, the percentage of wound healing on the 5th, 10th, 15th, and 20th days on the anterior and posterior trunk using graphs, duration of hospital stay, cost calculation accounting for dressings and hospital expenses. Results: Statistical analysis showed an advantage of sustained-release silver foam dressing over SSD with respect to reduced pain on the basis of VAS score on the 5th, 10th, 15th, and 20th days (7.47, 6.27, 3.8, and 3.87 in Group 1 vs. 4.4, 3.13, 2.53, and 1.93 in Group 2) with P < 0.005. In addition, statistically, wound healing was faster among the patients in Group 2 than those in Group 1 on the 10th, 15th, and 20th days (25.67, 39.27, and 64.53% vs. 22.07, 54.6, and 84.53% in Group 2) with P < 0.005. The patients belonging to Group 2 were discharged earlier (14.6 vs. 22.47 days) with P < 0.005. Surprisingly, accounting both hospital expenses and dressing cost, the patients belonging to Group 2 had lesser expense than those in Group 1. Conclusion: Comparative study shows that sustained-release silver foam dressing has faster wound healing, lesser pain with earlier hospital discharge than SSD, and lesser expenses when total hospital burden was accounted.
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An algorithmic approach to reconstruction of complex scalp defects in electric burns p. 44
Jonathan Victor, Naren Shetty, Narender Manickavachakan, Deevish Dinakara
Introduction: Reconstruction of scalp defects due to electrical burns poses a challenge to the reconstructive surgeon and a lot of controversy exists in decision making with regards to the timing of surgery, debridement of the underlying bone, choice of flap cover and the role of trephining. There also is a paucity of literature on this subject probably because of its rare incidence. Proper management of these cases could prevent serious complications like osteomyelitis of the underlying bone, epidural abscess and cosmetic disfigurement. Materials and Methods: The study was conducted at a tertiary care burn unit. A retrospective analysis was done of the patients with electrical burns involving the scalp, between 2010 and 2015. Results: In the study period there were 135 cases of electrical burns. Out of these 9 patients had electrical burns involving the scalp. Two patients with scalp defects in which the pericranium was intact after debridement were managed with skin grafts, 4 patients with moderate sized scalp defects were managed with local flaps, and in 3 patients free flaps were used to reconstruct large scalp defects. Literature search showed only two other similar case series with free flap reconstruction. We have proposed a management protocol for scalp defects in electrical burns based on our experience and a review of the available literature. Conclusion: Meticulous debridement of infected/non-viable bone is the key to a good outcome. In view of progressive tissue necrosis in electrical burns delayed reconstruction is preferred. Free flaps are the standard of care for extensive scalp defects. Local flaps and skin grafting can be used for smaller scalp defects. Secondary procedures are required for management of the alopecia and optimal cosmetic outcome.
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Single-stage reconstruction of high-voltage electric burns sequelae of volar forearm using nerve grafts, short tendon grafts and microvascular flap p. 52
Rayidi V.K. Rao, Pigilam Suma, Rangachari Srikanth, Manajeet Patil
Introduction: A total of 10 patients underwent single-stage reconstruction of high-voltage electrical burn sequelae at the distal forearm and volar wrist, in patients with complete loss of motor and sensory function of the hand; all 10 were operated using interposition tendon grafts for the flexor digitorum profundus, nerve grafts for the median and ulnar nerves and the anterolateral thigh flap (ALT) for coverage; in addition, the fascial component of the flap was used to wrap the repaired finger flexors. Materials and Methods: All the flaps survived, and eight of the 10 patients had S3 or S4 recovery of median nerve sensation. Results: The final outcome measurement was done by adopting a variant of the abbreviated upper extremity functional index. The mean value for this was 19 of a possible 40 points (range in 10 patients −7 to 28). Discussion: Single-stage reconstruction using short tendon grafts and nerve grafts is a useful procedure in high-voltage electrical burns. Conclusion: The use of the ALT with vascularised fascia permits early finger flexor activity suitable for activities of daily living.
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Epidemiological study of burn injuries and its mortality risk factors in a tertiary care hospital p. 62
Chirag A Bhansali, Giriraj Gandhi, Parag Sahastrabudhe, Nikhil Panse
Background: Burn injuries account for a significant cause of mortality and morbidity amongst the Indian population. Since prevention is more important than the treatment of such injuries, this study was undertaken to find out the exact epidemiological determinants of such injuries and thus to try and formulate effective preventive strategies. Aims and Objectives: To find out the epidemiological characteristics of burn patients in a tertiary care hospital. Materials and Methods: A Cohort review of patients admitted over a period of 3 years from January 2010 to September 2013 in the burns unit of our institute. Data were collected from hospital admission books which included age, sex, religion, Total body surface area burns, location, mode of burn and the cause of burns. Data were entered in MS EXCEL software and analysed. Results: There are 3179 patients included in the study. The mean age of patients was 28 years (SD=14.7 years) and overall male to female ratio was 0.6. The percent of Total body surface area for burned patients ranged between 1% and 100% and maximum number of patients were admitted with 30 to 50 % burns (27.5%) The median hospital stay was 5 days. There was a significant association between Total body surface area burns and hospital stay (P<0.001). 7.3% patients were discharged from the hospital after successful treatment. 1733 (54.51%) deaths were recorded. Death rate was higher amongst females as compared to males. Mortality rate was highest in age group of 12–26 years. There was a significant correlation between Total body surface area burns and mortality (P<0.001). Death rate was highest amongst patients with suicidal burns as compared to accidental and homicidal burns.75% patients died within 5 days of hospitalization. Conclusion: High mortality rate amongst patients is a major concern in the present scenario of health care towards burn injuries.
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Resistant Acinetobacter: A Booming Peril p. 67
Sathya Chandrasekaran, Ramesh Bellam Alagirisamy, Sathish Kumar Jayaraman, Mohan Jagannathan
Aim: The objective of the study was to find pathogens currently colonizing the wounds of patients admitted to burn intensive care unit (ICU) and to evaluate drug resistance among the common organisms. Materials and Methods: A retrospective analysis of bacterial isolates from the wounds of patients admitted to burn ICU in a tertiary care center. The study was conducted from November 2015 to April 2017. A total of 126 isolates were analyzed. Results: Pseudomonas and Klebsiella were the most common organisms followed by Acinetobacter. The antibiotic-sensitive patterns of these three common bacteria were analyzed. Statistical analyses were performed using one-way analysis of variance and post-hoc Tukey honest significant difference test. The study helped to infer that the multidrug resistance (MDR) of Acinetobacter is greater than that of Pseudomonas or Klebsiella and is significant (P < 0.05). Conclusion: The MDR seen in the isolates is a matter of concern. A study of bacterial isolates from the patients with burns and the sensitivity pattern of these isolates would assist to create or modify institutional drug policy.
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Burn injury in infants and toddlers: Risk factors, circumstances, and prevention p. 72
Sonal T Lal, Deepak J Bhatti
Aim: To study the risk factors and circumstances of burn injury in infants and toddlers. Materials and Methods: A retrospective study was conducted on children visiting the plastic surgery department with acute burns or postburn deformities in the year 2016. The children who sustained burns up to an age of 3 years were included. An analysis of data for their age, sex, type of burn injury, involved body part, seasonal variation, place of occurrence, time of the day, presence of guardians at the time of injury, and socioeconomic status was performed. Results: A total of 44 children were included in the study. Thirty-one were males and 13 were females. The majority of children (77.3%) belonged to the toddler age group (1–3 years). Scald was the most common burn injury (54.5%). The majority of burns (68.2%) were sustained in winters. Burns were most frequent in domestic settings (90.9%). 64.1% were kitchen accidents. Hands were the most commonly affected anatomical site (54%). Ninety percent of the burnt children belonged to low socioeconomic strata. Conclusion: Pediatric burns were seen more commonly among toddlers. Scalds were the most common form of burns. Male gender, domestic environment, winter season, and low socioeconomic strata were found to have an increased frequency of burns. Hands were the most commonly affected site. Focused burn prevention strategies consistent with local circumstances should be implemented for the prevention and better management of pediatric burn injuries.
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Complex airway after electric burns in the neck – A challenge for the anesthesiologist p. 76
Nitika Goel, Indumohini Sen, Kiran Jhangra, Mukesh Kumar
High voltage electric burns can cause massive damage to the body tissues. Direct contact with the live electric wires may result in severe damage of the underlying subdermal tissues. However, the superficial presentation is often misleading as most of the damage occurs under the skin. Very less literature has been found regarding the presentation of high voltage burns in head and neck region. We present a patient who sustained high voltage burns in the neck region resulting in massive damage of the underlying tissues. This lead to challenges for the anesthesiologist.
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Neonatal scalp necrosis: Long term sequelae and management: A case report p. 80
Mathangi Ramakrishnan, Rahul Yadav, Balasubramaniam Chidambaram, Ranganathan Jothi, Santosh M.R Kanangi, Gomathy Nayagam Karthikeyan, Venkatraman Jayaraman, Thangarajan Mathivanan, Rangasamy Ravi, Krishnamurty Ramachandran
Scalp necrosis in the neonate is not an unheard of entity. It however, poses a treatment challenge because the neonatal calvarium is not ossified, and the dura is in close association with the skin. The neonatal susceptibility to sepsis also compounds the issue. We present a case of neonatal scalp necrosis. The child was treated in the newborn period and was on a regular follow-up. The plastic surgery, pediatric neurosurgery departments together with the pediatricians were closely involved in the management. He subsequently developed new onset behavioral problems which, after ruling out other common neurosurgical aetiologies, was attributed to contractures in the split skin graft used in the neonatal period. He was operated on again, wherein a vascularized free flap (latissimus dorsi − LD flap) was used. His behavioral disturbances abated considerably post-surgery. We consider this case unique, as the long-term sequelae of neonatal scalp necrosis, and its management is rarely mentioned in literature. Further, the behavioral disturbances which could be attributable to the graft fibrosis were a feature worth mentioning. We would also like to highlight the need for multidisciplinary co-operation to achieve the best results in children.
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The role of regional block analgesia in the early functional recovery of burns in the hand p. 85
Sandeep Mehrotra, Amit Dua, Vikas Singh, Samiksha Mehare, Rakesh Kaundal
Patients with upper limb and hand burn suffer from a higher pain perception due to higher density of nerve endings and larger cortical representation compared to other regions. This unfortunately leads to reduction of movement, increasing edema and stiffness. This initiates a vicious cycle leading to prolonged morbidity and repeated interventions. In our burn centre we are routinely practicing regional supraclavicular analgesic blocks for hand burn. We have found this technique immensely beneficial in pain relief, promoting early healing with restoration of range of motion (ROM) and functional recovery.
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When the skin changes in severe acute malnutrition appear as burns p. 88
Zainab F Ibrahim, Ibrahim Aliyu
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