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   Table of Contents - Current issue
January-December 2016
Volume 24 | Issue 1
Page Nos. 1-80

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Ekla Chalo Re… (Walk alone…) p. 1
Vinita Puri
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Care of the burn wound: As I do it p. 3
Arvind Madhusudan Vartak
Skin covers the entire body. It is the most important protective organ. Since the burn injury is most painful of all injuries, dressings play an important part of the management. Dressing of the burn wound is very essential to provide pain relief, to promote early healing, to prevent contractures, and to help early mobilization. Many workers from time immemorial have used different types of dressings so as to provide desired results. I use sterile polyethylene drape as a dressing material after covering it with the first layer of gauze soaked in silver sulfadiazine cream. The results are encouraging as there is near total absence of pain experienced by patients and removal is totally pain-free without any bleeding. There is no need for escharotomies, and there is early removal of the slough with no contracture. The polyethylene drapes are easily available in the market, easy to store, available sterile, and totally cost-effective. They help reduce the hospital stay of the patient. The need of anesthesia for surgeries such as escharotomies and debridement is significantly reduced.
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Making of a burn unit: SOA burn center p. 8
Jayant Kumar Dash, Ipsa Mohapatra, Abhimanyu Sharma
Each year in India, burn injuries account for more than 6 million hospital emergency department visits; of which many require hospitalization and are referred to specialized burn centers. There are few burn surgeons and very few burn centers in India. In our state, Odisha, there are only two burn centers to cater to more than 5000 burn victims per year. This article is an attempt to share the knowledge that I acquired while setting up a new burn unit in a private medical college of Odisha.
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Commentary on making of a burn unit - SOA center p. 12
Shobha Chamania
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Assessment of biological response of lyophilized cadaveric skin allograft in post burn raw area and nonhealing ulcers p. 13
Pawan Agarwal, Anoop Jain, Dhananjaya Sharma
Introduction: Extensive full-thickness burns and major injuries resulting in extensive damage to the skin make spontaneous regeneration difficult and compromise patient survival. When a donor area is available, it is always preferable to proceed with autograft, which is considered to be the best option. However, if the affected region is extensive, donor area is not enough, or when medical condition of the patient does not permit immediate grafting with autologous skin; in such conditions lyophilized skin allograft can be used for temporary coverage of the wounds. Materials and Methods: In this prospective study, evaluation of biological response of lyophilized cadaveric skin allografting was done in 100 cases of thermal burn and nohealing ulcers. Results: In this study, 19% cases lyophilized skin grafts got rejected in 3 weeks, 65% in 1 month, and in 16% patients graft got rejected at the end of 2 months. Rejection is defined as when skin graft becomes hard and starts separating from wound edges and is finally totally detached from the bed. Out of 100 patients, wounds healed completely in 81 patients, while 19 patients required autografting. On pus culture examination out of 100 patients, 26% patients showed the presence of infection. Histopathological study was done on the 21st postoperative day and all those who survived skin graft showed infiltration of mononuclear cells, fibroblasts, keratinization, uniformly arranged collagen bundles, and angiogenesis at the junction of graft and graft bed. All grafts that were rejected, showed acanthosis, spongiosis, and degenerative changes in vascular walls. Neovascularization was not observed in these grafts. Conclusion: Lyophilized cadaveric allograft acts as mechanical and physiological barrier and the process of lyophilization helps in minimizing the immunoreactivity of the graft, therefore, rejection is not rapid. Lyophilized cadaveric allografts can be lifesaving in cases of severe burn.
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AQUACEL® Ag BURN glove and silver sulfadiazine for the treatment of partial thickness hand burns: A retrospective review p. 18
Moti Harats, Marie Jaeger, Rachel Anne Kornhaber, Josef M Haik
Background: Loss of hand function has a detrimental impact on the physical and psychosocial functioning of those with hand burns. Of prime importance is the maintenance of range of movement (ROM). Subsequently, an ideal hand dressing needs to allow for full ROM, be comfortable, and facilitate healing. However, hand burns present complex challenges for burn clinicians with the dressing of choice remaining controversial. Patients and Methods: This retrospective review was undertaken to determine the effectiveness of the AQUACEL® Ag BURN glove as compared to silver sulfadiazine (SSD; standard care) in patients with partial thickness hand burns. The average total body surface area % was 14.6% with an average age of 37 years. Eight hands were dressed with an AQUACEL® Ag BURN glove and eight were dressed with SSD. Results: Pain scores were reduced in those with the glove compared to those who were treated with SSD dressing. Mobility of the hand with the glove was reduced compared to the patients treated with SSD. The glove cost including outer dressings was $330 US, this is compared to $432 US for the SSD dressing based on the average reepithelization rate of 15 days, and translates into a financial saving of approximately $100 US per patient and further reduces workload and resources. Conclusion: The use of a hydrofiber silver impregnated glove for partial thickness hand burns, has clinical significance in the outpatient setting reducing the need for hospitalization, and the amount of dressing changes required.
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Papaya pulp for enzymatic wound debridement in burns p. 24
Rajshree C Jayarajan, Puthucode V Narayanan, Hirji S Adenwalla
Context: Early surgical debridement in burns has its disadvantages like extensive blood loss and long anaesthesia time and risks. Enzymatic wound debridement as an alternative to surgical debridement has been assessed for its effectiveness, safety and patient compliance. Aims: To assess the effectiveness and safety of papaya pulp as an enzymatic wound debriding agent in burns. Setting and Design: The study was conducted including 50 patients with second degree and third degree burns, age ranging from 15 to 60 years from January 2004 to December 2004 at the Burns Centre, Department of Plastic, Reconstructive and Burns Surgery, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India. Materials and Methods: A prospective study including 50 patients with second degree and third degree burns, age ranging from 15 to 60 years was carried out from January 2004 to December 2004 at the Burns Centre, Department of Plastic, Reconstructive and Burns Surgery, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India. There were 38 female and 12 male patients in the study group. Areas of burns ranging from 10% to 60% TBSA were included in the study. Daily dressings were done using autoclaved unripe papaya pulp smeared on potato peel dressing. The progress was assessed daily and application stopped when adequate debridement has been achieved or a maximum of 1 week. Statistical Analysis Used: None. Results: All 50 patients included initially completed the study. There were 38 females and 12 males. Papaya pulp was found to be a very effective debriding agent in all cases. Deep dermal wounds cleared up in 5 to 6 days and eschar in full thickness burns became loose by this period so that it needed minimal surgical debridement. The granulation tissue found following debridement with papaya pulp was pink and healthy. In patients who had to be taken up for grafting, a mild scraping was sufficient before placement of a graft. This has helped on reducing blood transfusions and has considerably reduced anaesthesia time. Conclusions: The use of papaya pulp results in 1. Early and complete non-invasive debridement, 2. Healthy granulation tissue, 3. Decreased blood loss and hence decreased number of blood transfusions in cases which have to be grafted, as excision is avoided. 4. Less operating time and hence less anaesthesia time.
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Management of postburn contractures of upper extremities: A general surgeon's perspective p. 29
Bharat Bhushan Dogra, Mahendra Kataria, Ashwani Kandari, Shamshad Ahmed, Abhishek Singh, Rohit Virmani
Introduction: Postburn contracture (PBC) is one of the common sequelae encountered after burns in general surgical practice. Surgical management of such deformities involves release of contracture followed by cover by skin graft or skin flap. Optimum management of PBCs has always been a challenge to the surgeon because of paucity of adequate healthy skin in the affected areas. Various operative techniques are available, and the surgeon has to decide which particular technique will be more suitable for a particular patient. We have employed the techniques of release by Z-plasty, and release and skin grafting in managing PBC involving upper extremity, and this study is based on our experience with these techniques. Aims and Objective: The study was carried out to evaluate the frequency of different PBCs involving upper extremities and comparing the relatively simpler techniques of release of contracture and cover by skin grafting and Z-plasty, which can be undertaken by a general surgeon as well. Materials and Methods: A total of 100 cases having PBC of upper extremities of more than 6 months duration were included in this study. Complex contractures of hands involving tendons and joints were excluded from this study. Linear contractures were managed by single or multiple Z-plasty techniques whereas patients having wider and dense scars were managed by release/excision of scar and cover by skin grafting. Observations: The mean visual analog score for patient satisfaction was 8.06 for Z-plasty group versus 5.33 for split skin grafting (SSG) group. The mean stay for patients who had undergone Z-plasty was 9.40 days as compared to 15 days for SSG. Conclusion: Contracture release with local flap cover was better technique in relation to patient satisfaction, recurrence of deformity, hospital stay, and time taken for rehabilitation.
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Etiology and characteristics of burn injuries in patients admitted at Burns Center, Civil Hospital Karachi p. 36
Muhammad Osama Anwer, Muhammad Uzair Abdul Rauf, Noorulain Chishti, Sanam Anwer
Background: Morbidity and mortality by burns are alarmingly high among the developing countries due to inadequate care facilities. Among these nations, Pakistan has one of the highest burn-related incidents. The dilemma is that most of these deaths and disabilities are curable and preventable. Therefore, there is an urgent need of creating an effective infrastructure to cut down these high number of cases. Methods: We conducted a cross-sectional study at Burns Center, Civil Hospital Karachi. Two hundred and seventy-five patients participated in the study. Data were analyzed using SPSS version 17.0. Results: Among these 275 patients interviewed 63.6% (n = 175) were males whereas 36.4% (n = 100) were females. The mean age of our participants was found to be 26.36 years. A large proportion of the population belonged to the urban areas, i.e. 76.4% (210), whereas only 23.6% (65) were from rural areas, with P = 0.001. About 63.6% of the burn injuries occurred at home (175) while 25.1% (69) got injured at the place of work. Most of the cases were found to be accidental 93.8% (258). About 53.1% (146) had <20% of the total body surface area effected, whereas 16.7% (46) had more than 40% burns. Conclusion: By introducing an effective awareness program regarding burns and teaching first aid techniques to general population, a high number of burn-related accidents could be prevented.
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Five-year epidemiological study of burn patients admitted in burns care unit, Tata Main Hospital, Jamshedpur, Jharkhand, India p. 41
Prasenjit Goswami, Pankaj Singodia, Amit Kumar Sinha, Tukulu Tudu
Introduction: Burn injury remains one of the biggest health concerns in the developing world and is a formidable public health issue in terms of mortality, morbidity, and permanent disability. The incidence of burn injuries is found all over India; detailed epidemiological studies from the eastern part of the country are sparse. Materials and Methods: We present an epidemiological study form the burn care unit (BCU) of Tata Main Hospital, Jamshedpur, Jharkhand, India of a period of 5 years from January 2009 to December 2013. Results: A total of 1975 burn patients were admitted in the BCU in this 5-year period. The mean age of all the patients included in the study was 29.16 years. There was a slight female predominance in this 5-year period. The overall male to female ratio was 1:1.05. The mean percentage total body surface area (TBSA) burn of all the patients over the period of 5 years was 42.5%. Flame burns were the most common form of burn, accounting for 65.16% of all burns. The overall mortality of the patients over 5 years was 40.8%. If the data are further classified, the overall mortality of patients up to 30% burns was 3.45%, with 30-60% burns was 42.3%, and above 60% burns was 91.8%. Conclusion: Analysis of the 5-year data fairly represents the epidemiological pattern of burns in this region, which has never been studied before and this study can serve as a pilot study for any burn care-related development in this region.
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Epidemiology of burns in teaching hospital of Northern India p. 47
Mumtazudin Wani, Mushtaq Ahmad Mir, Shabir Ahmad Mir, Ankush Banotra, Yawar Watali, Zahoor Ahmad
Background: There is no information on the pattern of outcomes among burn patients in relation to clinical aspects in India. Hence, the present study was undertaken in a burn unit to determine selected epidemiological variables, assess the clinical aspects (etiology, extent and anatomical location) and finally to analyze the outcomes in cases of burn injury. Materials and Methods: This prospective study was undertaken to analyze the patients admitted to the Burn Unit of Government Medical college Srinagar. The study was carried over a period 2 years from January 2013 to December 2014. Various variables including age and sex distribution, nature of burn injuries, Anatomical location, percentage of total body surface area burnt, depth of burns, Survival of expired patients and mortality were recorded and analyzed. Results: Highest incidence of burns was in the age group between 21 and 40 years; 61% patients were females and 39% were males; majority of our patients had burns in the range of 20 to 40% TBSA (total body surface area); mortality rate in our study was 36.82%; most common site of the burn injury was upper limb(30.19%);among patients who died those with TBSA burn of >60%, 41 to 60% and 31 to 40% succumbed within three, six and nine days respectively. Age ranged from 6 months to 93 years. Mean age of the patients was 31 years. Eighty percent patients belonged to rural areas and 20% belonged to Urban locality. Conclusion: People with low educational qualification should be taught about the proper and safe usage of modern appliances based on electricity, LPG or kerosene. People with psychiatric problems or low intelligence quotient (I.Q) should be helped by their care takers in avoiding the burn injuries and also devices with alarms should be used in their households. Fuel or electric devices should be checked by a trained person regularly (e.g once in month) to avoid usage of faulty devices.
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Collagen dressings in the management of partial thickness pediatric burns: Our experience p. 53
Mukta Waghmare, Hemanshi Shah, Charu Tiwari, Deepa Makhija, Jayesh Desale, Pankaj Dwivedi
Background: Burns in the pediatric patients are usually caused due to accidental spillage and scalding by hot liquids. These are usually partial thickness burns. Collagen dressings have a better outcome in the management of partial thickness burns. Methodology: One hundred patients <12 years of age were included in a retrospective study from January 2013 to 2016. Patients were analyzed in terms of age and sex of the patient, type of burns, duration of presentation, degree and percentage of burns, and complications. Results: The mean age of presentation was 4 years. Ninety-eight percent of children had burns secondary to scalding. Collagen was applied for all patients. Ninety-two patients had no complication. Eight patients had minor complications. Conclusion: Collagen sheet is very useful in first- and second-degree burns in children. It is well tolerated, provides multiple benefits, and it has fewer complications.
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A study of residual physical disability after a burn injury in patients admitted in tertiary care hospitals in Karnataka, India p. 58
Gowri Shankar, Vijaya A Naik
Introduction: Burn Injuries Are Among The Leading Causes Of Disability-Adjusted Life Years Lost In Low And Middle Income Countries. In India, About 6-7 Million People Suffer From Burn Injuries Every Year. Out Of Them, 7 Lakh Require Hospital Admission And 2.4 Lakh Become Disabled. Materials And Methods: A Prospective Study Was Conducted To Identify The Epidemiological Determinants For Residual Physical Disabilities In Burn Patients Admitted Between April 1St, 2004 And March 31St, 2005 In Two Tertiary Hospitals In Belagavi City, Karnataka, India. Out Of 316 Patients Admitted During The Study Period, 48 (15.19%) Had Residual Physical Disability At The Time Of Discharge. Data About Their Socio Demographic Profile, Total Burn Surface Area, Mode And Type Of Burn, Severity And Depth Of Burn And Type Of Disability Was Collected On A Pre Designed Proforma After Informed Consent. Data Was Analyzed By Percentages And Chi-Square Test. Results: Out Of 48 Patients With Residual Physical Disability Sustained After A Burn Injury, 15 (31.25%) Were Males And 33 (68.75%) Were Females. Maximum Number (70.83%) Were Between 15-44 Years Of Age. Majority (77.08%) Were From Rural Areas. It Was Observed That 62.5% Were Wearing Synthetic Clothes At The Time Of Burn. Majority (85.4%) Had Scar Contractures. Maximum Number (89.58%) Had Upper Limb Injury Followed By 47.9% With Chest Injury. Conclusion: Burn Injury Should Be Prevented At All Costs And Health Education Regarding Safety Measures Should Be Implemented In All Educational Institutions.
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Microbiological and quantitative analysis of burn wounds in the burn unit at a tertiary care hospital in Kashmir p. 62
Tahir Saleem Khan, Akram Hussain Bijli, Adil Hafeez Wani
Background: The burn wound represents a susceptible site for opportunistic colonization by organisms of endogenous and exogenous origin. The present study was undertaken to analyze the microflora of burn wounds of the burn patients from a tertiary care hospital in Kashmir, India. Materials sand Methods: The study included all patients with acute burns admitted from January 2010 to December 2011 (2 years). The standard techniques, as practiced during collection of microbiological specimens, were used during wound swab/biopsy collection. Results: 74.19% of swab cultures yielded single isolates. On swab culture, Pseudomonas aeruginosa was the commonly isolated organism (46.86%). Staphylococcus aureus was the most common isolate isolated during 1st postburn week (30.86%). 258/288 (89.58%) blood cultures were sterile. 8/58 (13.79%) blood cultures were positive during the second postburn week. S. aureus was the most common organism grown on blood culture (44.44%). P. aeruginosa was mostly sensitive to polymyxin B (86.0%), amikacin (40.0%), and ciprofloxacin (37.3%), respectively. S. aureus was most commonly sensitive to linezolid (85.0%) and vancomycin (78.8%%) whereas Acinetobacter spp. was sensitive to polymyxin B (65.3%), piperacillin/tazobactam (44.9%), and amikacin (38.8%). Patients (27.27%) who showed local signs of burn wound infection and positive blood culture were subjected to burn wound biopsy. 93.33% of patients who had counts >105 colony-forming unit/g of tissue showed significant association with local signs of burn wound infection and positive blood culture for any organism. Conclusion: The microbiological surveillance of burn wounds needs to be continued for a rational antibiotic policy and prevention of emergence of resistant organisms. Burn wound biopsy culture is an effective tool for quantitative analysis of burn wounds; however, subjecting this biopsy to histological examination is more predictable of burn wound infection and its correlation with burn wound sepsis.
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An appraisal of antibiotic sensitivity pattern and drug utilization in burn patients p. 69
Janki Raj Chauhan, Sarvajeet Khare, Prem Lal, Vijayanarayana Kunhikatta, Girish Thunga, Sreedharan Nair, Narayanthu Chellappanpilla Sreekumar
Aim: To analyze the antibiotic sensitivity and resistance pattern and antibiotic consumption in defined daily dose (DDD)/100 bed days (BD). Materials and Methods: Burns patients admitted from January 2013 to December 2013 were identified retrospectively from medical record department registry using the International Classification of Diseases-(ICD) Codes T 30.1-39.9. Patient demographics, total body surface area (TBSA) of burn, treatment chart, hospitalization days, and antibiotic sensitivity/resistance profile were recorded. Cumulative sensitivity/resistance pattern of isolated microorganisms against various antibiotics was calculated (in percentage) from culture sensitivity reports. Total use of antibiotics in burn patients was calculated as DDD/100 BD using antibiotic consumption calculator-WHO ABC Calc version 3.1. Results: Of total 159 burn patients, the main cause of burns in these patients was thermal (81.8%). Cefoperazone-sulbactam (54.7%) was the most frequently prescribed antibiotic followed by amoxicillin-clavulanic acid (34%). Totally, 82 bacterial isolates were obtained, among which Pseudomonas aeruginosa (31.6%) was the most common organism. P. aeruginosa was sensitive to rifampicin and erythromycin but resistant to clindamycin. The DDD/100 BD was highest for parenteral cefoperazone (40.21). Conclusion: Proper antibiogram and DDD will facilitate conceptualizing and developing drug policies for improved patient outcomes in burns.
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Treatment of pediatric burn patient having glucose-6-phosphate dehydrogenase deficiency p. 74
Vijay Y Bhatia, Sankit D Shah, Harshil Y Ravalji, Deepa Banker
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common red cell enzymopathy found in humans. It clearly has an X-linked recessive inheritance with its prevalence varying from 0% to 27% in a different caste, ethnic, and linguistic groups. This deficiency may result in hemolytic anemia during stress, infection, and use of certain drugs. The use of topical silver sulfadiazine can produce hemolysis in patients having G6PD deficiency. Here, we describe one case successfully treated of pediatric burn of 25% of body surface area who was a known case of G6PD deficiency.
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Electrical injury of external genitalia and reconstruction with gracilis muscle flap p. 78
Jyoshid R Balan
The high-voltage electrical injury is not uncommon, but the involvement of the genitalia and the perineum is rare. Our patient is a 29-year-old female with electrical injury from a high-tension wire and had injury to the perineum, genitalia, and lower limbs with negligible involvement of the upper limbs. There was a loss of the lower half of the labia majora and she had a tissue defect on the left side of the perineum. The reconstruction was performed with the use of pedicled gracilis flap with a good outcome.
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