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Wednesday, June 2, 2010

MAJOR BURNS : SURVIVAL FACTORS

Dear doctor,

One of my relatives who is in his 20th year is severely burnt (86 %) by a house fire 2 days ago and he is in Iraq now. His relatives are trying to bring him to UK for treatment and I think that it will not make any difference for his survival and may even make his condition worse by exposing him to pathogens in the plane and outside. I just want to ask you whether he has a chance of surviving or not please. He is also severely swollen now. Please answer me ASAP.
With best regards,
H Abdulla.

Dear Mr. Abdulla,


Thank you very much for the question. I am sorry that your relative suffered a major burn. You have raised quite a number of issues by your question which relatives of patients with major burns as well as burn professionals are often forced to ask. Let us consider in detail the factors that will influence the survival or outcome of burn management in patients with major burns.







Age
Is age an important factor in healing or outcome of ''major burn'' patients?


Age in general, is an important factor in wound healing as well as healing of burn wounds. http://asktheburnsurgeon.blogspot.com/2010/04/part-ii-wound-healing-why-wounds-fail.html


1. As we grow old, the wound healing processes as well as the ability of our cells to multiply and form new cells are reduced.
2. As we grow older our immune mechanisms grow weaker and our ability to fight infection decreases


With age
Only wisdom profits
Rests are all losses

3. While the mind becomes wise with age we attract a lot of diseases- diabetes, hypertension, ischemic heart disease, atherosclerosis, venous insufficiencies etc. All these conditions hamper the healing of burn wounds as well as cause problems in the management of burn patients.


Percentage of Burn
Is the percentage of burn an important factor in the outcome (prognosis) of burn patients?


As we discussed in http://asktheburnsurgeon.blogspot.com/2009/11/dear-charulata-you-have-raised-three.html the total area of burn (percentage of burn) will show us if it is a minor, moderate or major burn. Major burn patients (>40% burn) have more problems and have more complications (morbidity)such as fluid resuscitation problems, more infection rates, as well as high death rate (mortality) as compared to patients with minor or moderate burns.


What is the Baux Index?


The Baux index is an old method which helps in a simple way to assess the prognosis (outcome) in burn patients.


Baux index = Age + % Burn


The higher the Baux index, the poorer the prognosis.


In recent times, this is not considered accurate, because the Baux index is based on limited number of variables: age and percentage of burn. With the vast advances in burn care that have taken place, even patients with high Baux index survive.


Depth of burn
Does the depth of the burn influence the outcome in a burn patient?


In patients with minor burns even if the burns are deep, there is adequate normal skin (unburnt area) on the patient’s body that is available for skin grafting (a surgical procedure in which the badly burnt skin is removed and replaced by normal skin taken from the patient’s own body). However when a large area of body has deep burns( like >80% ) then the availability of normal skin (<20%) for the purpose of skin grafting becomes less and this make the management of deep burns difficult and the outcome worse. For example if all the body is burnt except the head and face- one wouldn’t want to harvest skin grafts from the face so that the normal skin available for skin grafting is limited. If the patient has a major burn (>80%) but most of the burns are superficial: this is good news because the superficial burns will heal and only small area with deep burns will need skin grafting and adequate normal skin will be available for this procedure.

Associated disease
If a burn patient has any associated diseases, will it influence the outcome or prognosis?


When a burn patient is resuscitated he may need large volume of intravenous fluid in the resuscitation phase (first 48 hours) because


1. When the skin and tissues are burnt, toxins are released that make the blood vessels (capillaries) to leak fluid outside (into the interstitial spaces) which causes severe swelling or edema. If this fluid is not replaced, the patient will end up in shock and die. Sometimes the fluid requirement may be more than 20 liters in the first 24 hours of the burn. This explains why your relative appears all swollen up. But within 24 hrs (>8 hrs) the capillaries begin to regain their integrity and the leak is reduced.

For example Fluid requirement for a 80 kg man with 86% burns


According to Parkland formula- (4 X %burn X body weight) ml


80 X86X4= 27,520ml or 27.5 liters in the first 24 hours


Half this volume should be given in the first 8 hours=13,760


One eighth of this volume should be given per hour for first 8 hours and one sixteenth per hour in the next 16 hours


That means 1720 ml or 1.72 liters need to be given per hour in the first 8 hours


which is quite a lot of fluid!!!


And 860 ml per hour in the next 16 hours.


This requirement becomes higher as the percentage of burn and weight of the patient increases; only 4 is the constant in this formula.


Imagine now if this patient has a heart disease or has hypertension or renal disease or renal failure- and you try to give him this large volume of fluid, the patient will develop new complications from heart failure or pulmonary edema and may die not from burn but from disease he had before the burn. Since the body is unable to excrete (pass out) this large amount of fluid, patients with preexisting diseases are very delicate and need advanced care facilities to manage their major burn. This patient therefore needs to be managed by an experienced burn care team in an intensive care unit.

If the patient has diabetes then he is predisposed to infection as we discussed in http://asktheburnsurgeon.blogspot.com/2010/04/part-ii-wound-healing-why-wounds-fail.html


The burn itself reduces a patient’s immunity and exposes him to infection. Further the large amount of burnt dead skin (eschar) is a good bed for microorganisms to grow. These factors will increase the complications (morbidity) and make the management of a burn patient with diabetes difficult.

Facilities available at a burn centre
What about the facilities available at a burn center- does this influence the outcome treatment?


The management of burn patients with major burns (>40 %) is a complicated affair and the outcome of the patient depends greatly on the facilities available at the centre that he is admitted to. The burn surgeon who heads the team must first of all be an experienced surgeon. He must be cool, calm and composed and make mature decisions after discussion with his team of surgeons and burn care professionals. The burn surgeon and his team must not give up at any stage and must fight to the end to save the patients life: ethical discussions and decisions must be left to ethical committees.


Ego must be last
The patient first
For if there is no patient
What worth be a burn unit?

Smoke inhalation
Is the outcome affected if the patient has inhaled a lot of smoke?


Definitely when a fire breaks out and the person is exposed to a lot of smoke and fumes, he may suffer injury to his lungs in addition to the burn – an injury referred to as ‘smoke inhalation injury’. Now this burn patient has two problems

1. The burn itself
2. The lung injury from ‘smoke inhalation’.


Obviously his management will be more difficult as the burn surgeon has to focus on the burnt area as well as manage his lung injury and this patient may die from lung damage though the burn areas may all be healed.


For those who are wondering what a burn team is, a list of professionals that are needed to make a complete team is given below:

Burn unit director
Staff surgeons
Nurse manager
Nursing staff
Physical therapist
Occupational therapist
Physician extenders
Surgical assistant
Physician assistants
Nurse practitioners
Social workers
Dietitian
Pharmacist
Respiratory therapist
Clinical psychologists


Besides this, the following specialist must be available for consultation: orthopedic surgery, cardiology neuro- surgery, cardiothoracic surgery, plastic surgery, ophthalmology, neurology, hematology, otorhinolaryngology, General surgery urology, pediatrics,, radiology, psychiatry, obstetrics/ gynecology, gastroenterology, anesthesiology, infectious disease, Nephrology and Pathology.


An advanced fully equipped burn intensive care unit along with an intensivist trained in burns must be available at all times to take care of the burn patient where the patient can be admitted, resuscitated, monitored with invasive and non invasive methods, intubated and mechanically ventilated in case of severe inhalation injury or otherwise, where massive dressing changes can be done under general anesthesia if needed, where emergency escharotomies, tracheotomies and other procedures can be carried out and where all infection control procedures are strictly enforced. The patient’s survival also depends on whether a number of other facilities are available as outlined below:


1. Why are blood and blood products important for survival of a patient with major burns?


Burn patients are potential candidates for blood transfusions from many causes and at different stages of treatment. Severe burns itself damages and destroys the skin and tissues and cause a fall in the hemoglobin. Burn surgery can itself lead to significant blood loss which will need to be replaced. The resuscitation phase in burn patients may need colloid administration; fresh frozen plasma and albumin may be needed in large quantities. Massive dressing changes in operated patients can cause blood loss. If the patient has severe septicemia (blood bone infection) and ends up in DIC (disseminated intravascular coagulation) this will again require a large amount of blood and blood products including platelets.

2. Why is the availability of newer antibiotics important?


Burn patients are potential candidates for severe infection since they have a lot of dead tissue and skin (eschar) which is a good bed for germs or microorganisms. In addition they have a reduced immunity from the massive burn. Death from septicemia is one of the major causes of mortality in burns. Burn patients suffer infection from variety of strong bugs with sometimes are resistant to many antibiotics (multi drug resistant organisms or MDRO) like

1. Methicillin resistant staphylococcus aureus (MRSA)
2. Vancomycin resistant organisms (VRO)
3. Extended spectrum beta- lactamase (ESBL)
4. acinobacter baumanii (Few strains are MDRO)


The availability of culture facilities and highly specific powerful antibiotics like vancomycin, tiecoplanin, meropenem, linezolid and others is crucial to the survival of a burn patient with infection.


Burn patients are also prone to fungal infections and availability of fungus culture facilities as well as newer anti fungal agents are essential to the survival of patients with major burns.

Nutrition
Why is nutrition an important factor in the prognosis or survival of burn patients?


Patients with major burns are in a catabolic phase and their survival will depend on the burn team’s effort to push the patient to an anabolic phase. The nutritionist will need to prepare feeding mixtures that are high in calories, proteins, fats and have minerals and vitamins as additives. If hyperalimentation (gut feeding) is not possible then parental nutrition (through intravenous lines) must be available. Thus we observe that the availability of blood, blood products, antibiotics, antifungal agents and nutritional support are crucial to the survival of patients with major burns.

Treatment options
What are the treatment options available at the centre to which the patient is admitted?
Even if all the factors that have been discussed are positive, and the patient survives through the resuscitation phase, overcome the inhalation injury, is protected for infection and sepsis; the final outcome will depend on whether the burn surgeon can cover the deep burnt areas with skin obtained from the patient itself. This is quite a difficult and daunting task in patients with major burns who have severe shortage of unburnt skin, but if we have God’s grace and the treatment options mentioned below, the patient can be saved:

1. Skin bank
2. Skin substitutes
3. Meek grafting
4. Skin culture (Keratinocyte culture)


Each of these options will need to be discussed in detail in a future article.


So Mr. Hassan the survival of your relative will depend on all the factors that have been discussed. Managing a patient with major burn is a complex affair and though all these factors may be favorable to the patient, if the treatment options are not available for your patient in Iraq, then shifting him to a advanced burn care facility as in UK will be beneficial and can save the life of your relative. Unfortunately, patients in most of the underdeveloped and developing countries face the same problem and their relatives are often in a dilemma wondering where they should shift the patient to get better treatment. As for acquiring infection during the travel, I don’t think this should cause any worry since this usually does not happen if adequate precautions are taken and travel protocols are observed.


The field of burns may not be attractive to many, but for those who toil and focus on the burn patient, it is worthwhile. It is sad that most of the facilities we have discussed are not available to a large number people around the globe, especially in underdeveloped and developing countries and burn patients whose lives can be saved die a painful and miserable death. We at asktheburnsurgeon hope that this trend will change: more surgeons will join this stream, more research and funding will come in, more governments will take burn as a serious issue and the right of a burn patient to get proper treatment and survive is recognized in all countries.

May God help us in this endeavor!

With best regards
++asktheburnsurgeon


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