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   Table of Contents - Current issue
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January-December 2019
Volume 27 | Issue 1
Page Nos. 1-116

Online since Friday, January 17, 2020

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EDITORIAL  

Prevention of burns p. 1
Vijay Kumar
DOI:10.4103/ijb.ijb_32_19  
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GURU SPEAK Top

Challenges in setting up a skin bank at GMC Nagpur p. 3
Surendrakumar B Patil
DOI:10.4103/ijb.ijb_29_19  
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KNOW YOUR BURN UNIT Top

Burn Unit at ABVIMS and Dr. Ram Manohar Lohia Hospital, New Delhi, India p. 5
Rakesh Kumar Srivastava, Vaddi Suman Babu, Mukesh Kumar Sharma
DOI:10.4103/ijb.ijb_30_19  
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REVIEW ARTICLE Top

Management of postburn axillary contractures Highly accessed article p. 8
Rajeev B Ahuja, Pallab Chatterjee
DOI:10.4103/ijb.ijb_18_18  
Many epidemiological studies have revealed the incidence of axillary contractures next only to elbow contractures as sequelae to burn injury. Even if it may be possible to prevent adduction contracture of the axilla through early splinting and range of motion exercises that counteract the position of comfort, it continues to pose a frequent problem to burn surgeons. In the increasing degree of severity, axillary contractures may involve one or both axillary folds and also involve the hair-bearing dome of the axilla. Unless severe functional disability is present, we recommend a minimum 6-month wait following wound healing to allow for scar maturation to achieve better results. In milder presentations, it may be possible to perform Z-plasties, Y–V plasties, or many other local flaps on isolated axillary bands, with the caveat that if the contractile bands are in the midst of scarring, such linear contractures may only be effectively released and resurfaced with skin grafts. While the innovative use of local skin flaps must be encouraged, we recommend a low threshold of using acceptable thickness skin grafts for coverage. Controversy exists on the best technique for axillary resurfacing in severe cases of axillary involvement. While it is relatively simple and expeditious to release the contracture and cover the extensive defect with skin grafts, it requires meticulous postoperative regimen of splinting and physiotherapy. In selected cases, uninvolved adjacent scapular and back areas allow for many fasciocutaneous and myocutaneous flaps for durable long-term results. Free flaps, traditionally less popular in this region, may be an alternative option if areas adjacent to axilla are also involved.
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ORIGINAL ARTICLES Top

The role of comorbidieites in the prognosis of thermal burns p. 16
Abhinav Aggarwal, Ravi Kumar Chittoria, Vinayak K Chavan, Saurabh Gupta, Chirra Likhitha Reddy, Padmalakshmi Bharathi Mohan, Imran Pathan, K Shijina
DOI:10.4103/ijb.ijb_10_19  
Context: Burn injury is a complex trauma with multiple changes in physiology of the patient. Assessing prognosis of the burn patient is a subject of debate with various prognostic scores available. The presence of inhalational injury and percentage (total body surface area) of thermal burns are the most important factors affecting the outcome of the burn patient. The role of comorbidities is another very important factor and its importance cannot be undermined, especially with massive fluid shifts associated with resuscitation and body catabolism in the rehabilitative stage, respectively. Charlson Comorbidity Index (CCI) is an attractive scale that has stood the test of time as a scale to measure objectively the severity of comorbidities on the prognosis. Aims: The aim of the study was to understand the role of comorbidities have on the outcome of thermal burns. Materials and Methods: This was a retrospective analysis of burn patients admitted in the burns center over the past 1 year fulfilling the inclusion criteria. Descriptive analysis of patient records was done. Results: A total of 18 patients with comorbidities admitted in the burns center fulfilling the above-said inclusion criteria. Ten patients survived, while eight patients succumbed to the burn injuries. The average CCI of the survivor group was 2.2 (range: 1–4), whereas the mean CCI of the nonsurvivor group was 3.5 (range: 2–6). Conclusion: Comorbidities do have an impact on the prognosis of a burn patient, and objective assessment of prognosis of the burn injury must include the CCI as a tool to predict the outcome correctly and reliably.
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Bilateral unexpanded supraclavicular flaps for single-stage resurfacing of anterior neck contractures p. 20
Reuben Fernando De Sousa
DOI:10.4103/ijb.ijb_11_19  
Context: Anterior neck scar contracture causes functional and esthetic deformity which is difficult to conceal. Supraclavicular flap is an accepted modality for neck scar reconstruction but has limitations of reach and skin deformation if used as a pedicled flap. Island flap and propeller modification can allow primary closure of donor site. Aims: The aim of the study is to assess the efficacy of bilateral supraclavicular unexpanded flaps in single-stage release and resurfacing of anterior neck contractures. Subjects: Seven cases of anterior neck contracture were operated with release and flap cover. Grades of contracture treated were Onah 2b, 2c, 3b and 3c. Methods: All cases underwent single stage release and resurfacing with bilateral propeller island supraclavicular flaps. Patients were followed up fo an average 30+/- 10 months using extension angle to check for recurrence. Results: All cases achieved satisfactory cosmesis at 1year followup. The average increase in neck extension angle achieved at 1 year was 22.9° ± 10°. No recurrence of contracture was noted. One flap had partial necrosis requiring skin graft. Two cases had axilla scarring requiring graft closure for donor site. Average flap length was 14.4 ± 1.7 cm. Average flap width was 7.1 ± 1 cm. Conclusions: Bilateral supraclavicular flaps can be used to resurface anterior neck contractures in a single stage with acceptable donor-site morbidity.
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Management of Acinetobacter baumannii infection of burn wound with the evidence of sepsis p. 30
K Mathangi Ramakrishnan, Bala Ramachandran, KG Ravikumar, K Ravikumar, Sulochana Putli, V Jayaraman, Mathivanan , Ravi , Arumugam Ganamani, Mary Babu
DOI:10.4103/ijb.ijb_12_19  
Introduction: Acinetobacter baumannii infection of a burn wound is a serious infection causing significant morbidity and mortality. Clinical Presentation: Acinetobacter can cause wound colonization, infection, invasive sepsis, and with or without septic shock. We present a series of five cases and management. Prompt medical and surgical treatments are essential to improve the outcome. Conclusion: Awareness of the presence of infection and detection of local sensitivity pattern of the organism will lead to initiation of the correct antibiotic.
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A unique association of an ancient Indian custom of body roasting and the postpartum psychosis responsible for the occurrence of major burns: A case report and challenges posed by postpartum psychosis in the treatment of burns p. 35
Hemant A Saraiya
DOI:10.4103/ijb.ijb_13_19  
Introduction: We report a unique association of an ancient Indian custom of postdelivery mother roasting and postpartum psychosis responsible for the causation of major burns. Materials and Methods: A 20-year-old postpartum female reported with 40% second- and third-degree total body surface area burns. The combination of the ancient Indian custom of mother roasting and postpartum psychosis led to these major burns. The conventional treatment of burns in the form of IV fluids, antibiotics, and dressings with silver sulfadiazine creams was carried out. The psychiatrist was consulted, and the antipsychotic medicines were started for an altered behavior. One month after the burns, she developed deep-vein thrombosis with venous gangrene of the left leg for which she required a below-knee amputation. She required 45 days of hospitalization and six surgical procedures in the form of debridement and split-thickness skin grafting. Problems such as hypotension, noncooperation due to the wild swing in the moods were overcome by proper fluid and electrolyte management, an adjustment in antipsychotic medicines, appropriate postoperative care, and chest physiotherapy. Results: One year of follow-up showed good stable scars. At present, she can perform all domestic as well as labor work on the farm, with the help of a below-knee prosthesis. There is no element of psychotic behavior at present. Conclusion: This case report sheds light on an ancient Indian custom of mother roasting and postpartum psychosis and its dangers in contracting severe burn injuries. Challenges posed by postpartum psychosis in the treatment of burns have been discussed.
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Reverse radial forearm perforator plus flaps for the reconstruction of postelectrical burn sequelae of hand and forearm defects p. 40
Pradeoth Mukundan Korambayil, Prashanth Varkey Ambookan, Vinoth Kumar Dilliraj, Rameela Ravindran Karangath
DOI:10.4103/ijb.ijb_15_19  
Background: The reverse radial forearm perforator flaps are useful in softtissue reconstruction of the hand and forearm. Certain modifications in the flap and usage of hyperbaric oxygen therapy as an adjunct in reconstruction could aid in better outcome of the surgical procedure. The conventional reverse radial artery forearm flap incorporates the radial artery along with its venae commitants along with the flap providing less chances of venous congestion. The per-foratoronly flap may cause a twist in a pedicle which may not affect the artery much, but a small increase in pressure may obstruct the tiny veins running along with the perforator resulting in chances of venous congestion which is a common problem in propeller or perforator flaps. This can be overcome by designing a flap with adequate venous outflow and reducing the postoperative inflammatory edema to prevent pressure to the tiny perforators with arterial and venous components. Aims and Objectives: To focus on flap harvest in a perforator plus model to increase the venous outflow and use of hyperbaric oxygen therapy as an adjunct to prevent the inflammatory edema on the perforator vessels. Materials and Methods: Reverse radial artery perforator plus flaps used for the reconstruction of hand and forearm soft-tissue loss in a series of patients due to electrical burns. We used hyperbaric oxygen therapy as an adjunct for reconstruction. Results: No flap related complication in the series. One patient developed venous congestion at the distal tip region which settled without any further intervention. Conclusion: Defects of the hand and forearm due to the electrical burns could be effectively managed with radial forearm perforator plus flap with allowing adequate venous outflow, and hyperbaric oxygen therapy as an adjunct in electrical burns.
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Self-inflicted chemical burns caused by depilatory cream use: The price of beauty Highly accessed article p. 44
Rachel H Park, Trevor C Hansen, Derek E Bell
DOI:10.4103/ijb.ijb_17_19  
Objective: The objective was to study and describe the presenting patient characteristics for those with chemical burns acquired from hair removal beauty products. Methods: Retrospective single-center chart review was done to identify all burn injuries caused by the use of depilatory cream use. Results: A total of seven patients who acquired burn injuries due to depilatory cream use were identified. Six were female and one was male. Patients' age ranged from 3 to 43 years, with a mean age of 27.2 years. Total body surface area of the burns ranged from 0.18% to 0.79% including first- and second-degree burns; none of the patients acquired third-degree burns. Most of the injuries involved groin and pubic area. All patients were treated with wound care, and none required inpatient care. All of the patients who presented to follow-up visits showed re-epithelialization and good healing. Conclusion: Depilatory cream is a corrosive chemical hair removal agent that can lead to unintended chemical burns if used improperly. Burn-care provider, as well as other health-care providers, should be aware of this unusual cause of chemical burn and educate their patients appropriately.
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Experiences of burn patients in Ghana: A qualitative study at the Korle-Bu Teaching Hospital in Accra p. 49
Lily Yarney, Elizabeth Yeboah, Rachael Hansen-Garshong
DOI:10.4103/ijb.ijb_18_19  
Background: Statistics on the trends of burn injuries in Ghana, Africa, and the world at large indicate unacceptable number of lives lost through burns. Aside these deaths, individuals who survive suffer lots of physical and psychological burdens as a result of long hospitalization and pain from the regular wound dressing, and physical deformities in severe cases. This study focused on the sources of burns, types of burns, how burns are managed, and the effects of burns on victims to enable an empirical basis for formulating preventive educational materials for awareness creation and preventive education. Methodology: We employed a case study design and purposively selected 20 participants made up of 15 adults and 5 caregivers of children with burns who were receiving treatment at the Reconstructive, Plastic Surgery, and Burns Centre of the Korle-Bu Teaching Hospital in Accra for the study. In-depth interviews were conducted with participants to ascertain the type and sources of burns incurred, and their experiences with the study facility and living with the consequences of burns. Recorded interviews were transcribed and analyzed based on themes with the study objectives as a guide. Results: The majority of participants had third-degree burns from explosive sources either at their place of residence or the work-place. The physical and psychological effects of burns have been unbearable. Their encounter with the study facility has been pleasant with few challenges related to the cost of treatment, some personnel, and waiting time. Conclusion: Massive education on burns and the prevention of accidental burns in Ghana is needed. Training of more personnel to handle patients in a professional manner and cost of care of burn patients should be placed on the agenda of all relevant stakeholders in the country.
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Surface pH and acute burn wound healing p. 57
Tejaswini Divakar, Rakesh Kumar Srivastava
DOI:10.4103/ijb.ijb_19_19  
Context: There is a lacuna in our knowledge to objectively assess the progression of healing in an acute burn wound. Aim: This study aims to validate if a trend in changes of wound surface pH can be used as a reliable indicator to prognosticate wound healing in acute thermal burns. Materials and Methods: Hospital-based longitudinal observational study was conducted in the department of burns of a tertiary care center. One hundred and twenty-three patients with acute thermal burns in the age group of 15–60 years with total burn surface area between 30%–60% were included in the study. Surface pH of wound from a specific area of dimension 10×10 cm was measured on day 1, 3, 5, 7, 9, 11, 13, and 15 using HANNA HI 99181 pH meter and the trend of wound surface pH level changes over time was observed. Wound healing was clinically assessed by wound grading chart on day 7 and 15. Results: The trend of reducing pH values had a negative correlation coefficient of - 0.95 with improved wound healing, and the trend of increasing pH values had a positive correlation coefficient of 0.74 with deteriorating wound. This is statistically highly significant with P < 0.0001. Conclusion: The analysis showed that the trend of change in pH value over time has high statistical significance with wound healing in burns patients with reducing trend, i.e., toward slightly acidic pH being associated with better wound healing and increasing trend, i.e., toward alkalinity suggesting worsening of wounds. Hence, wound surface pH can be used as a reliable indicator to prognosticate wound healing in acute thermal burns.
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Epidemiological study of burn admissions in a tertiary burn care center of Bihar, India p. 63
Vidyapati Choudhary, Pranav Kumar, Prakash Kumar, Purushottam Kumar, Sanjay Kumar
DOI:10.4103/ijb.ijb_21_19  
Background: 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. Aims and objectives: To study the epidemiological aspects of burn admission in a tertiary care burn centre of Bihar. Materials and Methods: This study is a retrospective hospital based observational study, being conducted at Patna Medical College Hospital (PMCH), Patna from 1.1.2018 to 31.12.2018. All burn patients (n = 1431) admitted during this period were included in this study. Results: In our region, burn admissions showed 2 seasonal peaks (April, May) & (Nov, Dec). Females of age 20-39 years were most commonly affected. Accidental injuries were more common than suicidal & homicidal cases. Flame burn leaded the cause followed by electric burn. Most burn victims belonged to rural background & low socio-economic strata. Kitchen was the most common place & kerosene oil most common agent causing burn. Majority of patients presented late to our hospital i.e. after 4 hours. In our scenario, mortality of burn patients with total body surface area (TBSA) > 60% was 95%. Conclusion: Young females of rural background & low socio-economic strata are the commonest victim of burn injuries. Majority of cases are accidental thermal burn. Mortality rate is high in patients with TBSA > 60%. Appropriate preventive & therapeutic measures need to be taken in terms of social education & provision of quality healthcare to reduce the incidence & improve the survival outcome of burn patients.
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Changing trends in electrical burn injury due to technology p. 70
Gurudayal Singh Kalra, Amit Sharma, Nikita Gulab Rolekar
DOI:10.4103/ijb.ijb_22_19  
Background: Electrical burn injuries result from accidental contact with exposed parts of electrical appliances, wiring, or lightning strikes. The purpose of this study was to analyze the mode of electric burn injuries occurring in the current technological world. Materials and Methods: A retrospective analysis of 3-year experience of electric burn injury case admitted in the burn unit of our institute was conducted from April 2016 to March 2019. Of the total 3983 patients, 914 patients were of electric burn injury. All age groups of patients were included, with exclusion of thermal, flame, and scald burn patients. We evaluated the variables according to age, sex, total burn surface area, injury type, and mode of injury. Results: Out of 914 cases, we had admitted 329 cases from February 2016 to August 2017 (Group 1) and 585 cases admitted from September 2017 to March 2019 (Group 2). Seven hundred sixty-nine cases were male and 145 were female. Group 1 had 187 cases in the age group of 40–59 years. While in Group 2, 226 cases were in the age group of 20–39 years. About 40.7% of the cases had electric burn due to working over electric pole in Group 1, while in Group 2, 19.65% cases had electric burn due to malfunctioning of appliances and 2.7% cases had smartphone electric burn injury. About 3.9% of the cases had electric burn due to working or taking selfies near electric train. Conclusion: In this technology era, the use of electric current in various appliances leads to increase the risk of electric burn injury, and these injuries can be prevented by education and safety measures to reduce the incidence of electrical injuries.
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Burn scenario in a single North-Eastern State of India: A 5-year retrospective study p. 73
Samuel Lalruatfala Sailo, Saia Chenkual, Vanlalhlua Chawngthu, Richard Lalramhluna Chawngthu
DOI:10.4103/ijb.ijb_23_18  
Introduction: The exact figure of burn injuries is still unavailable in many states of India. Some northeast Indian states with their unique social structure, hilly terrain, and practice of shifting (Jhum) cultivation the pattern of burn injuries in these states may be different. Materials and Methods: The burn records between March 2012 and April 2017 were retrospectively studied from all the district and private hospitals of the state. The demographic profiles, etiologies, delay in admission, percentage, and degrees of burn, hospital days, managements, and outcome on a single hill state of India were reviewed and analyzed. Results and Observations: The total number of patients studied was 450 with a mean age of 18.94 years. There were 281 male (62.4%), 168 female (37.3%), and one missing sex data, out of which 17 (4.2%) expired. Majority of the admission were in the winter season. The most common etiology was scald burn (55%). Suicidal intent was recorded in 8 patients (1.8%). The mean percentage of burn was 21.72%. Conclusion: The pattern of burn cases in the state showed marked variance from studies of other larger states of the country. Lifestyle modification, improving living standard, and active NGO participation seem to influence the low incidence of burn in the state.
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Role of infrared thermography in the assessment of burn wounds treated with and without hyperbaric oxygen therapy p. 78
Pradeoth Mukundan Korambayil, Prashanth Varkey Ambookan, Rameela Ravindran Karangath
DOI:10.4103/ijb.ijb_23_19  
Aim: The aim is to study the role of infrared thermography in the assessment of burns wound treated with and without hyperbaric oxygen (HBO) therapy. Burn wound progression is assessed with clinical evaluation and infrared thermography for the patients subjected to HBO therapy with controls. Materials and Methods: This study was carried out in the plastic surgery department, from November 2018 to February 2019. A total of 21 patients with Burns were subjected to clinical evaluation and thermographic study. All patients were treated according to standard burns treatment protocol, and photographic data of clinical and thermographic imagings were sequentially recorded. These clinical and radiographic images were preserved for analysis. In 10 patients, HBO therapy was used as an adjunct for burns wound management and results were evaluated and rest of the patients was used as control. Results: Of 21 patients, with all patients' burns patients assessment done clinically and infrared thermography, 10 patients were subjected to hyperbaric therapy in random fashion and 11 patients were not subjected to HBO therapy. The duration of wound healing and wound progression to deeper planes were reduced in the patients subjected to hyperbaric therapy, which was evident both clinically and, by thermographic assessment. No complications were noted in patients subjected to HBO therapy. Conclusions: Infrared thermography can be used in association with clinical examination to assess the various types of burns wound and could be utilized for understanding the dynamic changes that happen in burns wound due to changes in the treatment protocol with evolving adjunct managements.
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Management of postburn flexion contracture of the proximal interphalangeal joint of the finger by distraction histiogenesis and release and skin grafting: A comparative study p. 85
Sanjay Kumar, Sharadendu Sharma, Harish Sharma
DOI:10.4103/ijb.ijb_3_19  
Introduction: Flexion contractures of the fingers cause functional and esthetic problems to a burn patient. Various methods of reconstruction have been described, but the usual treatment for these contractures is release and split-skin graft. In this study, technique of distraction histiogenesis was used for the treatment of finger contracture. Methods: In this study, sixty patients of postburn contracture of proximal interphalangeal (PIP) joint of the hand due to volar skin burns were taken. Thirty patients were treated with distraction technique and thirty patients with release and split-skin grafting. The average age of patient is 20 years. Results: Both techniques showed improvement in range of motion at PIP joint. Esthetic result was also assessed using score on the Visual Analog Scale, with better score in distraction histiogenesis. There was no recurrence of contracture at 6 months follows-up. Conclusion: Technique of gradual distraction histiogenesis is safe for treating long-standing flexion contracture of the finger without risk of neurovascular compromise to finger.
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Portable indocyanine green perfusion assessment: An adjunct to visual assessment in burn wound healing in second-degree burns p. 90
Pradeoth Mukundan Korambayil, Prashanth Varkey Ambookan, Rameela Ravindran Karangath
DOI:10.4103/ijb.ijb_5_19  
Aim: To identify perfusion differences between the areas of different depths and to evaluate the potential of portable indocyanine green (ICG) perfusion assessment to determine the likelihood of healing in burns compared with visual assessment. Materials and Methods: This interventional study was carried out at the burn unit and plastic surgery department, from April 2017 to September 2017. A total of 20 patients with superficial and partial thickness burns <15% for whom the burn assessment was done with portable ICG perfusion assessment and visual assessment were included in the study. The results regarding the excision of burn wound and burn wound healing were compared. Results: Of 20 patients, 14 patients did not have any discrepancy with the clinical findings and ICG perfusion assessment. The findings of five patients appeared clinically deep, but perfusion was present which did not require surgical intervention. One patient had patchy perfusion and finally required surgical correction. Conclusion: ICG perfusion assessment appeared to be effective in preventing surgical intervention in patients by differentiating deep to superficial second-degree burns. Proper clinical assessment and ICG perfusion assessment as an adjunct can improve the outcome of burn wound.
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Epileptic burn injuries in Kashmir valley: Is “Kangri” a boon or bane? p. 95
Peerzada Umar Farooq Baba, Shiv K Sharma, Adil Hafeez Wani
DOI:10.4103/ijb.ijb_6_19  
Background: During seizure attacks, patients may suffer severe trauma such as deep burns, limb fractures, and head-and-neck injuries. Most burns in epileptic patients occur during major seizures. Such burns are always full-thickness. Because of extreme cold conditions people in Kashmir valley, especially in rural areas use Kangri to keep themselves warm. This Kangri which is already notorious for causing Kangri cancer has an additional disadvantage in causing deep burns mainly to the hands in epileptic patients. Objective: (1) To analyze the epidemiological data of burnt hospitalized epileptic patients. (2) To determine the frequency, causes, and consequences of burns in patients with epilepsy stressing on Kangri burns in epileptics. (3) To determine the various preventive measures to reduce the incidence of such injuries. Materials and Methods: This was a retrospective study conducted in the Department of Burns, Plastic, and Reconstructive Surgery at Sher-e-Kashmir Institute of Medical Sciences, Srinagar, India, from January 2005 to December 2018. All epileptic patients with burns admitted in the hospital were included in the study. Results: Of 157 patients, 67 (43%) were in the age group of 16–30 years. The mean age was 32.7 years. Majority of the patients 99 (63%) were female. One hundred and two (84%) patients belonged to rural areas. Kangri was the most common etiological agent of epileptic burns in 99 (63%) patients. Eighty-four (53%) had sustained full-thickness burns and total body surface area involved was up to 5% only. The most common site of burns was hands 88 (56%). Amputation of the gangrenous digits/hands was the most common surgery performed in 39 (25%) patients. Complication in burnt epileptic patients was loss of a body part 47 (44%) followed by contracture (32.4%), wound infection (22%), and loss of vision in 1 (0.6%) patients. There was no mortality in our series. Conclusion: Epileptic patients should avoid high-risk situations like working alone in kitchen. Kangri should be replaced by alternative simple and safe warming devices.
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CASE REPORTS Top

Securing airway in a burn patient with inhalation injury – A narrow escape p. 102
Utsav Acharya, Santosh Bikram Bhandari
DOI:10.4103/ijb.ijb_16_19  
Inhaltion injury is one of the major determinants of the outcome, morbidity and mortality in burn patients. Early intervention to secure the airway in a suspected inhalation injury proves vital in the management and outcome of such patients. Failure to identify such cases will push the attending physicians into a vortex and the patients will succumb to the injury. High degree of suspicion and the ability to identify airway burns is a must for all physicians involved in the management of burn patients. Here we present a case of inhalation injury where airway management was delayed by a few hours due to technical and logistic issues, where in we had a very hard time securing the airway.
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Endotracheal tube anchoring to the maxilla in an edentulous patient with a facial burn p. 105
Masaki Fujioka, Kiyoko Fukui
DOI:10.4103/ijb.ijb_30_18  
Securing an endotracheal tube for the patients with facial blistering due to burns is problematic. Unstable fixation may cause dislodging of the tube. Various improvements have been reported to overcome this problem. However, they are not considered practical, because all methods require a special instrument, which may be impossible to obtain in emergent situations. In this report, we present a simple and easy technique to directly secure an endotracheal tube to the maxilla. A 64-year-old man sustained a scaled burn involving 10% of the total body surface area to the face and both hands. He also had inhalation injury and underwent immediate intra-tracheal intubation at a nearby hospital. As the patient's face was covered with blisters, the fixation of the tube to the skin was unstable. Also, the patient had no teeth to fix the tube. Thus, we directly fixed the endotracheal tube to the maxilla. A drill hole was made in the alveolar process of the maxilla using a Kirschner wire and hand-hold drilling instrument, and a nylon line was threaded through the hole and tied around the endotracheal tube. The tube was anchored securely until extubation for seven days. We describe a simple method to secure an endotracheal tube to the maxilla in a toothless patient who sustained facial burn, without any special instruments. Our procedure may be a favorable option for such patients who require immediate oral intubation.
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Rare leiomyosarcoma in a burn scar p. 108
Inampudi Sravya, Joseph Thomas, NC Sreekumar, Bhavna Nayal
DOI:10.4103/ijb.ijb_9_19  
Leiomyosarcomas presenting as a cutaneous malignancy in a burn scar are rare due to scarce mesenchymal elements within the cutaneous tissues. We here present a case of a 73-year-old woman with a past history of burns, came with a recurrent ulceroproliferative lesion in the right lumbar region over previous burn scar. She had a history of a similar lesion in the same region 1 year ago, for which wide local excision and grafting were done, and histopathology revealed as sarcomatoid carcinoma. Examination revealed multiple right axillary lymph nodes. Evaluation was done with contrast-enhanced computed tomography to rule out systemic metastasis. She was managed surgically with wide local excision, right axillary dissection, and split skin grafting. She had aggressive local recurrence along with lung metastasis within 6 months and was lost to follow-up. This report presents the second case of leiomyosarcoma arising in a burn scar on the right flank.
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An unusual combination of complications in a pediatric burn patient with successful outcome p. 112
Santhy Mohanachandran Nair, John Oommen, VT Chandrabose, Hafiz Muhammed, Kader Kalathingal, Anand Sivadasan, Subin Joseph, Rajesh Vardhan Pydi, Srivatsa M Shet, Srikant Samantaray
DOI:10.4103/ijb.ijb_25_18  
Accidental burns is one of the most commonly encountered condition in our society. Women and children are often affected. The case being discussed is of a burn victim who had a series of unexpected and rare life-threatening complications. The child developed complications of actively bleeding duodenal stress ulcer, deep-vein thrombosis, and heparin-induced thrombocytopenia with thrombosis in addition to bacterial sepsis, during the hospital stay. All the complications that the child endured were unfortunate though not uncommon, and with the help of accurate diagnosis, treatment, and multidisciplinary team approach, we were able to save the child and enable him to lead a normal life.
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LETTER TO EDITOR Top

Serum cytokines serve as predictors of thermal burn injuries p. 116
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/ijb.ijb_29_18  
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