SUMMARY. The objective of this study was to document that treatment of a critically burned patient could be, although with some problems, ultimately very successful. The commonplace of such successful therapy is certainly not only current, up-to-date and most intensive care, but also good teamwork and professionalism of the whole team in the specialized workplace- Burn and Reconstructive Surgery Departments of the Faculty Hospital in Brno.
Eire Erfolgreiche Behandlung eines ernstlich verbrannten Patienten wird in dem Beitrag beschrieben. Unerlassliche Voraussetzung fur erfolgreiche Therapie ist Verwendung von modernsten Behandlungsweisen and ein perfektes Zussamenspiel and Professionalitat des Arbeitskollektiven an der Kinik der Verbrennungen and rekonstruktiver Chinurgic des Fakultatskrankenhauses in Brunn
Key words: electrical burn, tracheotomy, dressing change, necrectomy, auto-transplantation, meshed skin graft, rehabilitation, scar reconstruction
Electric burn is not a very common injury. Nevertheless therapy of electric burn patient is one of the most complicated, particularly if deeper tissues are involved besides skin. This damage is due to electrical current passing through the organism. Although only 4°/ of all burns are electric burns, because of its severity these are the most serious ones. Individual tissues resist electrical current differently and tend to be damaged in various degrees. After burn injury there is necrosis at the entrance and exit sites and damage likely to be also in deep structures. During arc burn there is burn damage to the skin surface, as after any other thermo-injuries.
We would like to introduce therapy of a patient who sustained extensive burns. This patient was successfully treated at our department between May 16, 2002 and September 18, 2002. On May 16, 2002 our patient suffered work related injury. Patient has been ordered by his boss to paint switch cupboard of high voltage. At the beginning of his work the electrical current has been switched off. In the middle of the work our patient interrupted work and left for a break.
During that time staff' shift has changed at the switch room. The new shift had noticed that the switch cupboard was switched off' and without hesitation returned the handle to the usual position. After his break our young man wanted to complete his job, unfortunately was only able to touch the device once. Mechanism of the injury was high voltage electrical current of 10.000 volts. The patient sustained II b III degree burn of 83% of his body surface. Entrance wound site was at right wrist, exit wound site at right lateral ankle. Ambulance was called to the site and its staff found patient with extensive burns, but conscious, alert and cooperative. Patient was medically attended; including orotracheal intubation and appropriate therapy was initiated. Patient was transported by medical first aid service directly to the Burn center in Brno. The admission was standard via the operation room (Fig. 1).
<% immagine "Fig. 1","gr0000002.jpg","Burn wound dressed in the operation theatre.",230 %>The findings were that in addition to the extreme burns to 83% of a body surface, electrical current passed through with entrance wound in the area of right wrist, exit wound at right lateral ankle. Distal parts of these extremities where white, cold and in semi flexed positions in elbow and knee joints. There was circular burn wound at the right wrist. Larger area was damaged at the exit site at right ankle, with irregular edges.
For these reasons release incisions of the skin and extensive fasciotomies were performed on the palmar side of right upper extremity including discision of the palmar carp ligament. Additional incisions and fasciotomies were performed at the right lower extremity. After that both extremities got adequate perfusion and were comparable to contra lateral extremities. Patient was then transferred to critical care unit to continue with complex and intensive care. The chance to survive was small. From the surgical perspective it was necessary to manage significant imbalance between donor sites and sites that needed to be transplanted. For that reason we have approached parents of our young patient to find out whether any members of the family would be able and willing to help by donning skin for temporary coverage for the patient. This was to overcome difficult time while patient didn't have enough own skin. At our department xenografts are not used anymore, because of the danger of transmission of retrovirus from pigs. Also cadaver grafts are not without risk since there is often not sufficient overall evaluation of the patients.
At the same time we have informed our tissue bank about possible necessity to withdraw large amounts of keratinocytes from their reserve. The purpose of the use of keratinocytes was to speed up the healing of the areas with 111" degree burn, possibly donor sites.
Necrectomies were performed in stages and in combination of sharp surgical and enzymatic chemical debridement. The debridement was performed in appropriate extent in order not to disturb the balance of the internal environment.
Tracheotomy was performed the fourth day of the hospital stay because of expected long-term therapy. Inferior tracheotomy is at our workplace standard access to the respiratory system of patient with severe burns. This approach is also used for continuing therapy at the intensive care and offers several advantages including better respiratory hygiene, oral care, reduces risk of unwanted extubation during positioning of the patient and prevention of aspiration. Unfortunately there are also disadvantages. For example chance of secondary pneumonia or micro aspiration. According to our statistic monitoring since 1994, when we started to prioritize tracheotomy in treatment of extensive thermic traumas, we didn't notice a single complication during the follow-up care. During later reconstructive surgeries performed in general anesthesia, we have not recorded any complications including stenosis of the trachea and the like.
Before the end of the third week all necrotic tissue was cleared away, as mentioned above, sharply or chemically with the use of benzoic acid. Sharp surgical necrectomy was used where benzoic acid wouldn't be effective or deep and large areas were involved.
Simultaneously sutures of the fasciotomies where performed on the palmar side of right upper extremity, including discissed palmar carp ligament, sutures to fibular side of the right lower extremity and sutures of the release incisions on patient's neck and chest.
Subsequent auto-transplantations where limited by the size of the donor sites. Areas were transplanted with dermoepidermal grafts meshed in 1:3 ratio. The exception was patient's face, where we used unmeshed grafts and in the area around penis where we used grafts meshed in 1:1,5 ratio. Air dermatomes usually thinner than 4-6 micrometers where used for the graft collection, so that subsequent healing process allowed repeated collection. Donor sites had to heal quickly, so they could be used repeatedly again soon. These donor sites were used three times. Area on the left side of the patients chest was eventually also used as a donor site. This area healed conservatively in the extent of 2%0 of the surface. Regular redressing was performed in the operating room. Triple disinfection was performed during redressing, when we used the convenience of cooperation with the microbiological center. All transplanted areas healed one hundred percent and no repeated transplantation was needed. The frequency of dressing change in the operation room has been following patient's needs. Maximum importance during treatment was on complete microbiological screening, specific use of antibiotics according to sensitivity and fast and efficient change of the internal environment. Overall we all use the same range of medications, but the timing of the use of the medica- ulcerative colitis, we have started massive antitions is important.
Wet dressing is ideal environment for the growth of gram-negative microorganisms, so we didn't leave the dressing on for more than 48 hours. During the whole treatment patient didn't develop burn wound sepsis. Hyperpyrexia lasted up until necrectomies were completed. Patient didn't have any other serious and severe complications, including respiratory complications.
We would like to mention one complication. It was appearance of massive diarrheas with mucous secretions, which during one day changed to excretion of just mucus. To prevent hemorrhagic ulcerogenic therapy. Ulcerative colitis was a fatal complication in several previously treated patients. The third day with this therapy, stool was without any mucus.
Another problem, that didn't threaten the patient's life, but was uncomfortable for the patient was, repeated impetigo in the areas with II b degree in patients face. After several days, when patient's face healed and dressing was removed, pustules erupted and spread. Newly epithelized areas eroded. Complete healing appeared after treatment with specific antibiotics. Patient was transferred to standard unit after 92 days of hospitalization in intensive care. At this time skin sensitivity of bacterial strain. On these pillars we was renewed, there were minimal granulations and these quickly epithelized. Pt has been participating in rehabilitation and during the transfer has been mobilizing out of bed and ambulating. Patient has had minimal weight loss and coped well with terminal stages of the therapy (Fig. 2, 5).
<% immagine "Fig. 2","gr0000003.jpg","Taken shin Graft.",230 %> <% immagine "Fig. 3","gr0000004.jpg","Reconstructed contractures in axilla region.",230 %> <% immagine "Fig. 4","gr0000005.jpg","Reconstructed contractures in axilla region.",230 %> <% immagine "Fig. 5","gr0000006.jpg","Taken skin graft.",230 %>These included application of soft cosmetic laser and 1. phase of reconstructive surgeries (Fig. 3, 4). At this point of a hospital stay, partial contractures in both axillae were already released. Subsequent healing of the reconstructed sites was without problems. After several home visits, patient was finally discharged after 123 days of hospital stay.
Needless to say, that we have so far not encountered such a positive progress in treatment of alike serious thermic trauma. Majority of patients would probably survive with very severe complications that would possibly lead to death.
Pillars of successful treatment were frequent and regular dressing changes, well tried multiple disinfections of surfaces and a use of accurate one or more antibiotics, picked up according to the could build series of soon enough performed necrectomies and repeated gentle auto grafts. These consequently led to reconstruction of the patient's skin. Intensive physiotherapy, carried out during the whole hospitalization, has helped patient to return quickly and completely to a regular life. This whole successful work couldn't have been created without liaison of all therapy components together with professionalism of the whole medical team.
The above case report was created as acknowledgements to the medical team of our Clinic, to the nursing staff and to all personnel that participated in the therapy. Our treatment and everyday work couldn't be successful without their highly educated and very human approach.
Address for correspondence:
R. Mager
Department of Burn and Reconstructive Surgery
Faculty Hospital Brno
Jihlavska 20
625 00 Brno
Czech Republic
E-mail: rmager@fnbrno.cz