Ask The Burn Surgeon +For Free+

Face Burns

2011-08-22T06:49:00.000-07:00

Dear doctor,

Sunday evening my Dad was going to barbeque dinner. There was a leak in the propane tank and there was a flash when he lit the bbq that burned his arms, hands, legs, and face. His hair caught on fire, most of his beard and hair is now gone. Eyelashes and eyebrows are gone as well. He was immediately taken to the ER where they gave him morphine for the pain. This made him vomit and his blood pressure dropped to 58/27. They intubated him as a precautionary measure and his blood pressure was stabilized. They then moved him to a burn unit in a hospital in SF.

After examining him that night, they said that most of his burns are 1st and 2nd degree. They extubated him late Monday morning and lifted his diet restrictions. Their main concern is infection at this point and his left leg. This area saw the worst damage and they are observing him for 2-3 days to see if he will need surgery.

I read your information on 2nd degree burns and feel that it was extremely well written and understandable for the lay person. Thank you so much for that. The history with my Dad is that he had a staphylococcus infection 4 years ago and endocarditis. He had 50% damage to his heart at that time due to a previous heart attack and the damage from the infection. He had a quadruple bypass 10 years ago and as of the last appointment a month ago the bypasses are holding. They did say that he is in the beginning stages of liver failure last month as well as congestive heart failure. He is 62 years old.

His blood pressure has been holding steady after that initial drop and he said that he isn't in any pain right now. He is an 8 hour drive away from me right now and they tell me that he is stable, but I can't help but feel that any surgery on him at this point would be very rough on him. Today is the second day of observation and I am planning on heading down to be with him either later today or tomorrow.

My question is, are my concerns warranted? I feel silly because they say he is stable and to not come, but my gut tells me otherwise. I'm sure by the time you read this I will already be there; I guess I just wanted some reassurance. I am worried that his previous health issues
will make this current trauma worse.

Sorry to take up your time, I just found a lot of comfort in your posts and hoped you might have a thought or two.

Sincerely,
Lori

Dear Ms. Lori,

Thank you very much for you question. I am sorry to hear that your father had a burn accident. We are sorry for the delay in replying because we have a lot of queries waiting. The superficial loss of hair is not significant since one can have the hair burnt and lost from the fire and heat, though the skin may not be burnt. Some patients react to morphine by vomiting and lowering of the blood pressure this usually gets controlled once corrective measures or medication are given.

That he was intubated appears more of a prophylactic measure since they extubated him within 24 hours and he appears to be stable. Also the fact that the BbQ must likely have been in an open space means that inhalation injury to the lungs are unlikely. Most of his burns were 1^st and 2^nd degree burns- as you said- 1^st degree burns- should not be of any worry- it’s like sunburn and will heal quickly. For the 2^nd degree burn areas it will depends on whether they are superficial or deep. From what you describe and by the history I feel it may be a 2^nd degree superficial burn which will heal, but we can’t be sure till we examine the burn itself.

In view of his medical illnesses prophylactic antibiotic coverage should be discussed with his treating surgeon and may be a good idea. A physician should also be involved to manage his medical problems (heart and liver problems). Finally the area of the deep burn if present may be small as I presume from your description. Good timely analgesics should be helpful along with local dressings and care of the wound. An ophthalmologist should also check his eyes to rule out any burn injury to the eye which is quite common in patients with face burns.

I hope he recovers quickly and that he may not need any surgery by God’s grace.

With best regards,

asktheburnsurgeon+

Lori wrote to us again…..

Dear doctor,

Thank you so much for your response. You are correct that the bbq was in an open area. He was lucky because he shut his eyes and mouth before there was any damage to his lungs or eyes.

An update on my Dad. The enzyme cream that they used to eat away at the dead tissue is working really well. They do not believe that surgery will be necessary for now. He is continuing with the debridment baths every day for now, which have become very painful for him, but they are working. There has even been talk about discharge this weekend. We are so grateful that he is progressing so well. Seeing the other patients in the burn unit made me realize how lucky he was.

Thank you again for your response. Of course you can put this up on your website. The posts on there helped me at a time when I had no idea which way this would go. If our story can help someone else, please use it.

Thank you again,
Lori

102 Burn Pictures- Learning through Pictures +

2011-04-23T07:28:00.000-07:00

The visual presentation of burns and burn problems is critical to the understanding of burn management. We at Ask The Burn Surgeon present a series of burn pictures and videos that should help the reader understand and learn more about burns as well as create burn awareness. One should look at the pictures and try to identify the post burn day, the cause of burn (in some cases), the depth of the burn, healing or non healing burn wounds, the need for surgery, skin grafting or flap reconstuction and the presence of infection. We have provided only a heading for the burn pictures as the page is still under construction and as we add more pictures and videos, we encourage our readers to ask questions freely, which will be answered in detail on this site regarding any picture or patient. Please quote the image number to identify the image.

All photos and material presented here unless otherwise stated, is the property of asktheburnsurgeon. Copyright and other intellectual property laws protect these materials. Reproduction or retransmission of the materials, in whole or in part, in any manner, without the prior written consent of the copyright holder, is a violation of copyright law. A single copy of the materials available may be made, solely for personal, noncommercial use. Individuals must preserve any copyright or other notices contained in or associated with them. Users may not distribute such copies to others, whether or not in electronic form, whether or not for a charge or other consideration, without prior written consent of the copyright holder of the materials. Contact information for requests for permission to reproduce or distribute materials: asktheburnsurgeon@yahoo.com

1) 2 months post burn, hypertrophic scar nose , 047

2) 2nd degree burns, lower abdomen, genitalia, groin and thighs 038

3)2nd degree burns hand, wrist , healing 089

4) 2nd degree burns hand, wrist and forearm 191

5) 2nd degree deep burns hand, 3rd week post burn 082

6) 2nd degree deep burns, hands, third week post burn 080

7) unhealed2nd degree deep burns, healed 2nd degree

superficial burns, 3rd week post burn 005

8) 2nd degree deep burns healing with hypertrophic scar formation 069

9) 2nd degree deep burns healing with hypertrophic scar formation,

unhealed small areas of 3rd degree burn index finger and hand 068

10) 2nd degree deep burns with 3rd degree burns of inner thigh 023

11) 2nd degree deep burns, flamazine dressing day 5, 125

12) 2nd degree foot burns, healing, 18th post burn day 151

13) 2nd degree superficial burn

14) coal tar burns, 2nd degree superficial burn

healed, 22 days post burn 143

15) 2nd degree superficial burns 1

16) 2nd degree superficial burns healed,

small lenear strip of 2nd degree deep burn unhealed (2)

17) 2nd degree superficial burns of the hand , wrist and forearm 054

18) 2nd degree superficial burns, hand, 055

19) 2nd degree superficial burns, both hands, 053

20) 3rd degree burns, untreated, needs skin grafting 029

21) 3rd week, 2nd degree deep burns of the hand and forearm, 104

22) 5 months post burn, hypertrophic scars, post burn scar,

after chemical burns, deep 2nd degree burns, 161

23) 28 day post burn, second degree deep burn dorsum hand,

unhealed, rest second degree superficial burns healed, 075

24 ) both thighs 2nd degree deep burns periphery and

3rd degree burns central area, needs tangential excision

of the burn eschar and skin grafting 134

25) burn dorsum hand, unhealed, need surgery - skin grafting ,

rest second degree superficial burns healed 074

26) burn dorsum hand unhealed, rest second degree

superficial burns healed 076

27) burn eschar breakdown, untreated, 3rd degree burns 031

28) chemical burns, deep second degree burns, healed, day 34, 116

29) coal tar burns, bitumen burns, hands- day one, 144

30) day14, second degree deep and superficial burns,

electrical flash burns, knee, calf, leg, 137

31) day 2 mixed 2nd degree superficial and deep burns 019

32) day 2 post burn, mixed 2nd degree superficial and deep burns 018

33) day 3 , second degree burns palm, hand wrist and forearm,108

34) day 3 , second degree burns palm, hand wrist and forearm, 109

35) day 3, face burns, neck burns, scalds,

2nd degree superficial burns 166

36) day 5, 2nd degree deep burns of the hand 060

37) day 5, deep second degree burns hand and fingers 182

38) day 10, second degree superficial burns, ankle burns, 155

39) electrical flash burns, day 10, second degreee burns,

hand, wrist, 112

40) day 16 , second degree superficial burns,

scald burns , healing 168

41) day 18, second degree superficial burns hand and fingers

healing 077

42) day 18, second degree superficial burns,

scald burns , healing 170

43) day 20, healing hand burns 129

44) day 23 , 2nd degree deep burns 081

45) day 24, healing second degree superficial and

patchy deep burns , hand , fingers, 072

46) day 25 , third degree burns neck, was treated

elsewhere by mebo dressing, should undergo surgery,

excision and skin grafting 043

47) day 28 post burn, 2nd degree deep burns healing,

granulation tissue, 067

48) deep 2nd degree burns

49) deep 2nd degree burn - day three after the burn 096

50) deep 2nd degree burns hand 098

52) deep 2nd degree burns hand 097

53) deep 2nd degree burns hand and wrist 092

54) deep 2nd degree burns of the hand, palm and forearm- day 2, 107

55) deep 2nd degree burns with some areas of third degree burns 101

56) deep burns , skin grafted , mesh graft, needing graft care 059

57) deep dermal burns, 2nd degree deep burns hand dorsum, forearm and arm 099

58) deep dermal burns, 2nd degree deep burns hand, wrist 100

59) deep dermal, 2nd degree deep burns , hand 065

60) deep second degree and third degree burns chest , untreated, with granulation tissue and scar hypertrophy, 044

61) deep second degree burns and third degree burns, 040

62) deep second degree burns forearm 180

63) deep second degree burns upper arm 176

64) deep second degree burns, flame burns, 139

65) deep second degree burns, third degree burns 041

66) electrical burns, post burn contractures, mpj extension contracture, with post burn scarring , skin graft dorsum hand, 114

67) electrical flash burns, forehead burns, third degree unhealed , day 28, granulation tissue, rest second degree healed, 046

68) face burns 2nd degree 020

69) face burns, chest burns, deep second degree, healed, hypertrophic scarring, post burn scars, 045

70) fingers, hand and forearm, 2nd degree burns - superficial and deep 193

71) flame burns, 2nd degree burns healed with pigmentation 085

73) flame burns, 2nd degree palm burns 194

74) flame burns, day 12, abdomen , groins, genetalia, flamazine dressing, 042

75) flame burns, day 24 , deep second degree burns. needs surgery , excision of wound and skin grafting 157

76) flame burns, deep second degree burns hand 102

77) flame burns, fire burns, day 3, second degree burns hand and fingers, 111

78) granulation tissue , need skin graft 173

79) hand and forearm burns 124

80) hand and forearm burns 190

81) hand and forearm burns 123

82) hand burns 130

83) healed second degree burns, deep on the fingers, with hypertrophic scarring 118

84) healed 2nd degree burns with hypo pigmentation 083

85) healed 2nd degree degree burns with scarring 087

86) healed 2nd degree degree burns with scarring and hypopigmentation and hyper pigmentation 088

87) healed 2nd degree degree burns with scarring and pigmentation 084

88) healed 2nd degree degree burns with scarring and pigmentation 086

89) healed 2nd degree burns with hypo pigmentation 078

90) healed 2nd degree burns with hypo pigmentation 079

91) healed burns, second degree burns, legs, 24 days, 189

92) healed hot oil burns, scald burns day 18, 153

93) healed mixed 2nd degree superficial and deep burns 011

94) healed mixed 2nd degree superficial and deep burns 012

95) healed palm burns, chemical burns, day 22, 110

96) healed post burn hypopigmentation, full function, hand and wrist burns, 184

97) healed second degree burns foot dorsum 22 days post burns 150

98) healed second degree burns left forearm and wrist, 18 day post burns, 167

99) healed second degree burns of both hands following coal tar burns 144

100) healed second degree burns of the right arm, forearm, elbow, wrist and hand 177

101) healed second degree burns right shoulder and right arm at 3 weeks 146

102) Healed second degree burns of the forearm at 3 weeks

@Asktheburnsurgeon +

Burn conferences and meetings -2011.

2011-02-19T19:02:00.000-08:00

Dates of burn conferences and meetings for 2011 have been updated. You can also follow them on the right as links. Please send us your dates for meetings and conferences that are not included here and we shall post them on this site.

American burn association meeting

http://www.blogger.com/goog_2012515613

World burn congress meeting

http://www.phoenix-society.org/programs/worldburncongress/wbc2011/

Nordic Burn Meeting

http://www.nbm2010.com/

British Burn Association Annual Meeting

http://www.britishburnassociation.org/annual_meeting/detail/annual_meeting_2011

Congress of the ISBI

http://events-world.net/EventInfo.asp?i=217

Meeting of the Australian and New Zealand Burns Association http://www.cdesign.com.au/anzba2011/program.html

Annual Southern Region Burn meeting
http://www.facebook.com/group.php?gid=86660892598

north American burn society meeting

http://nabsociety.org/site/?page_id=7

Canadian Burn Survivors Conference

http://www.canadianburnsurvivors.ca/

asktheburnsurgeon+

Steam burns to the face, help!!!!!

2011-02-02T06:42:00.000-08:00

Dear doctor,

I had burns on my face 5 days back from pressure cooker steam & its contents. I had a blister which got popped while applying water immediately after the accident. Fluid was seen oozing from that spot. Now the skin appears to be a little pink. I wish to ask if that would scar to white. How can I avoid or reduce that?
There are some areas that have become brown on second day. Doctor said I should apply Mupirocin for a week & then continue on Vaseline to keep it moisturized. It seems to be not serious injury. I wish to ask if the pink area would scar.
Please help!
Regards,
Ruhi Surve.

Dear Ruhi
Thank you very much for your question. I am sorry to hear that you had a steam burn. The normal body temperature is 37 c or 98.4 f. Hence the body can withstand a few degrees more or less. However at temperatures of 40-44 c or 104 to 111.2 f the tissues suffer damage. The cellular proteins denature and even the cellular enzymes and pump mechanisms stop functioning. Over 44 c or 111.2 f it is difficult for the cells to repair this damage. One has to be careful when temperatures cross 40 c as burns can result.

Steam results when water heated to 100 deg c changes to vapour form. However with increased pressures as in a pressure cooker, higher temperatures than 100 deg c can result and therefore steam from a pressure cooker can cause severe burns. Besides this, the steam can be accidently inhaled and result in damage to the lungs, a condition called as inhalation injury. When the face is exposed to the steam, the delicate tissues of the eyes may suffer damage or burns and therefore the eyes need to be examined to make sure they are not damaged in any way.

Cold running water is the best way to treat a burn as soon as it occurs. Hold the burn area under the cold running water till pain subsides for a few minutes (water conducts the heat away from the skin). For big severe burn areas one should be careful and avoid immersing in cold water as this can result in hypothermia (lowering of body temperature) and shock. Application of ice should be avoided for reasons of hypothermia as well as to prevent causing a cold burn (frostbite). For the face one could splash cold water on the face as well as apply cold soaks.

From your history it appears that there was a blister and that the blister broke and released some fluid. This is a sign of a second degree superficial burn. Further it showed an area which is pink and probably blanching, again a sign of a 2nd degree superficial burn. Also you don’t seem to have inhaled the steam or suffered injury to your eyes.

So relax, your burns don’t appear to be serious, and do the following:
You need to clean it with a dilute antiseptic solution or sterile saline thrice a day and apply an antibiotic ointment like Neosporin or fusidic acid ointment. You can also take some pain killers like ibuprofen, paracetamol, diclofenac sodium etc, though in a day or two the pain should reduce considerably. The burn should heal in about two weeks.
Don’t start applying moisturiser cream till the burn is healed totally.
Avoid sunlight as there can be pigmentation and use a sunscreen when you travel outside.
If the pain increases along with redness of normal skin and swelling around the burn, consult your doctor as you may need antibiotics to treat the infection.
Don’t worry about the scars as I feel it is a superficial burn and should heal without scarring by God's grace. You may have some redness or hyperaemia which should go away. Sometimes you may have pigmentation which will need lightening creams.
Please be careful with the pressure cooker as serious burns can result and do read other related articles:
management of 2nd degree superficial burn http://asktheburnsurgeon.blogspot.com/2010/01/management-of-2nd-degree-superficial.html
Burn area estimation
http://asktheburnsurgeon.blogspot.com/2009_11_22_archive.html
Degree of burns, Avoid burns in kitchen
http://asktheburnsurgeon.blogspot.com/2009/11/1.html

wishing you a speedy recovery,
With best regards,
asktheburnsurgeon+

Healthcare-Associated Infections (HAIs)

2011-01-31T20:46:00.000-08:00

When an individual falls sick and approaches a health care setting, he rarely realises that he may acquire a new illness. Infections or diseases that are transmitted or acquired in a health care setting are referred to as Healthcare-Associated Infections or HAIs. As health care providers we have a responsibility towards our patients and it is imperative that we do not subject the patient to a new infection that could be fatal. Every year, thousands of patients die due to HAIs and millions are spent to tackle this problem.

Kimberly-Clark Health Care has launched a website "Not on My Watch" (http://www.haiwatch.com/ , http://haiwatchnews.com/ ), that provides tools and information to help health care professionals and facilities eliminate HAIs. Readers of ‘Asktheburnsurgeon For Free’ should visit this site and gain information and knowledge that will help counter HAIs.

It is time that we seriously dwell on the subject of HAIs, before it is too late. Every centre or health care provider must collect data related to HAIs and send it to a central agency which can put them together, analyse it and suggest ways to counter HAIs. We must avoid the indiscriminate use of antibiotics and focus on ways to prevent cross infection. We must never forget that the enemy consist of billions and billions of bugs and microbes that are perpetually scheming against our patient. If we are able to get together on a global level and fight this menace, I am sure we will be able to control HAIs.

asktheburnsurgeon+

Iodine burns!!!

2011-01-24T20:40:00.000-08:00

Hello doctor,

Two days ago I was bit by a tick in my yard. I pulled the nasty little bug off and was rid of it quickly. I had a bit of a welt so I treated it quickly with a warm vinegar compress and have been eating raw garlic for antibiotics. This morning the welt is a bit irritating, so I decided to put some iodine on a small piece of gauze and tape it to the area while I got ready for work- I felt it sting and thought nothing of it except that is was obviously a good antiseptic-but then my skin felt like it was on fire, so when the bandage came off all the iodine in the gauze was of course in my skin and I do not ever remember iodine burning like this, but the skin is on the stomach area and is more sensitive. I have put some antibiotic and zinc ointment on it. Will this cause me more of a problem? I am sure it killed any of the saliva from the tic.

Thank you for your time.
Catherine

Dear Catherine,

Thank you very much for your letter and we are sorry for the delay due to a huge backload of queries.
Iodine, discovered by Bernard Courteous in 1811, is quite an irritant to the skin and in general one should avoid applying iodine directly over the skin. The application of iodine solution causes pain, irritation and skin discolouration. Since 1949 the development of iodophores (povidone, iodine and cadexomer iodine) helped form safer and less painful preparations. In the old days we used iodine, but now this has been replaced by povidone- iodine. Some patients can develop an allergic reaction to iodine (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue). Others can end up with a chemical burn if the iodine is used in higher concentrations.
In your case the tick bite itself could end up in skin inflammation and infection that could give a similar picture. In case it appears like a chemical burn, then one should treat it like a burn. You need to clean it with a dilute antiseptic solution or sterile saline thrice a day and apply an antibiotic ointment like Neosporin or fusidic acid ointment. You can also take some pain killers like ibuprofen, paracetamol, diclofenac sodium etc, though in a day or two the pain should reduce considerably. You may also use closed daily dressing if this is more convenient. The affected site should be watched for any sign of infection as this is a tick bite and antibiotics should be started if this happens. Once the area heals use a bland skin moisturizer to nourish the new skin and use a sunscreen to avoid pigmentation (darkening) of the new skin from sun exposure. If allergy is the cause then a steroid cream can be added. However tick bites can cause acute infection, as well as other disease like tularaemia and I feel that your physician needs to decide whether you need to prophylactically treat this with antibiotics. A visit to your doctor will be helpful as this advice is given without actually seeing you in person.

You should also read these related articles;
Management of 2nd degree superficial burns- (2nd degree burns)
http://asktheburnsurgeon.blogspot.com/2010/01/management-of-2nd-degree-superficial.html
tick bite management
http://www.emedicinehealth.com/ticks/article_em.htm

Wishing you a speedy recovery,
Asktheburnsurgeon+

What is Duoderm?(wound dressings)

2011-01-20T21:44:00.000-08:00

Dear doctor, my husband has been bedridden for the past two years following an accident when he was hit by a drunk driver. He’s been having a bedsore for 3 months on his lower back. The doctor recently changed his wound dressing to Duoderm. Doc, what is Duoderm and will it help heal his wound? Thanks,

Clare P
Texas.

Thank you very much Mrs Clare for the question. I am sorry your husband had this injury and is bedridden. To understand wound dressings better it will be helpful to go through our previous article where we described different wounds and what dressings to choose in order to heal them:

How to choose wound dressings? (Wounds, wound healing, wound dressings) - http://asktheburnsurgeon.blogspot.com/2010/10/how-to-choose-wound-dressings-wounds.html

Duoderm is a hydrocolloid dressing agent which is made up of microgranular suspension of natural and synthetic polymers like pectin or gelatine that is placed in an adhesive matrix. As the wound exudate is absorbed, the dressing granulates in the Duoderm changing from a semi hydrated state to a gel state. The wound is therefore kept moist all the time and this helps wound healing. The exudate is also absorbed so that frequent dressing changes are not required.

Duoderm is produced by Convatec and provided as sterile sheets which should be cut and applied over the wound. There should be an overlap of 2 cms beyond the skin margins- so that adhesive Duoderm will not allow exudate to pass through and no additional dressings are required before applying Duoderm. One must clean the wound thoroughly and pat the skin around to make it dry so that the Duoderm patch will adhere well. Duoderm is good for dry necrotic wounds or for wounds that have little exudate. It can also be applied over granulating wounds or small ulcerated areas that break down by repeated dressings.

Duoderm should be avoided in patients who have shown pervious allergy to it or its components. For dry or in very lightly exuding wounds, the dressing can be left in place for more than 3-5 days. If the exudate starts to leak, more frequent dressings will be needed.

There are other hydrocolloid dressings which work on a similar principle like:

Granuflex

Combiderm

Tegasorb

Comfeel

When using Duoderm dressing, one should take care to see that the wound does not develop infection which may go unnoticed. If this happens, then one must use dressings with antimicrobial agents along with specific antibiotics if needed.

The application of Duoderm helps to keep the wound moist and promotes wound healing but as with all wound dressings deciding which dressing to apply over a particular wound is the most important factor that will determine if a wound will heal rapidly.

So Ms Clare I hope that your doctor has chosen the right wound dressing and that your husband’s wound will heal rapidly.

With best regards,

Asktheburnsurgeon+

How to choose wound dressings? (Wounds, wound healing, wound dressings)

2010-10-22T21:35:00.000-07:00

Dear doctor,

I read your article on ‘Wound Healing’, however you have not described anything on Wound dressings. I am often confused when different doctors advise different dressings for the same wound. Can you tell me how wound dressings are decided?

Nancy A,

Medical student,

Illinois, USA

Dear Nancy,

Thank you very much for your letter. Wound healing is a complex process and was exhaustively described in

1. Wound healing, scars, mature scars, hypertrophic scars, keloids
http://asktheburnsurgeon.blogspot.com/2010/03/wound-healing-scars-mature-scars.html

2. Part II: Wound healing: why wounds fail to heal, factors affecting wound healing, chronic wounds, non healing wounds.

http://asktheburnsurgeon.blogspot.com/2010/04/part-ii-wound-healing-why-wounds-fail.html

Wound dressings must be selected according to the nature of the wound. A wide variety of wound dressings are available and choosing the ideal one is critical to the healing of the wound.

An optimal wound dressing:

1)Must promote normal wound healing process (epithelisation)

2) Must absorb the discharge or exudate from the wound

3)must help the wound clear away the dead tissue in the wound (autolytic debridement)

4) Must not damage the normal surrounding skin.

5)Must destroy the bacteria in the wound.

A wound in general must be kept moist, since drying will lead to cell and tissue death. If a wound is producing a lot of exudate (discharge), a dressing which is highly absorptive will help to prevent the wound from being soggy and wet. It will also avoid maceration of the skin. If a wound is showing local signs of infection, then a wound dressing which has antibacterial incorporated into it will be helpful.

Some wounds may have dead tissue in them that may appear pale, grey, black or white in colour. The presence of dead tissue hampers the normal wound healing process and such a wound will never heal unless this dead tissue is removed by the use of dressing with enzymatic preparations or by the surgeons knife (a process called debridement)

If a wound is dry then a dressing which will prevent moisture to pass through and provide a moist environment will help the normal wound healing process and epithelialisation.

A wound that is clean and showing signs of healing like good epithelisation (growth of skin cells) will need less frequent dressings since changing the dressing frequently will damage the delicate new epithelial cells.

If a wound is badly contaminated or infected and producing a lot of discharge then it is important that frequent dressing changes be made to keep the wound clean and promote healing.

Infected wounds must have culture study to know the organisms or germ causing the infection and appropriate antibiotics must be give for the same.

Some wounds are small and may heal spontaneously. Some wound are large and will need new skin to applied over them (Skin grafting) to heal, otherwise they will remain as non-healing wounds. To make the wound ideal for skin grafting and promote good granulation tissue (new blood vessels and cells) - dressing which have hypertonic saline impregnated in them can be used.

Some wounds are not dry or exudative (producing too much discharge). A polyvinyl film dressing which in impermeable to bacteria but allows oxygen and moisture to pass through partially can be used. However one must be cautious as polyvinyl film dressing can cause skin maceration especially in those who sweat a lot or live in humid areas.

Some wounds are large and cannot heal spontaneously. These wounds may need the help of dressings supported by negative pressure suction (Vac therapy) which will help to decrease the bacteria, increase the blood supply, increase the granulation tissue, reduce the size of the wound and prepare the wound for skin grafting.

Types Of Wounds

Dry wounds

Exudative wounds

Neither dry nor wet wounds

Infected wounds

Sloughy wounds

Hyper granulating wounds

Poorly granulating wounds

Different dressing materials that are presently available in the market for different wounds will be described in detail in a future article.

Asktheburnsurgeon+

Burn videos links on the web (how to treat sunburns, electrical burns, road accidents and burns, infection and burns, how to treat minor burns and scalds, first aid and minor burns, plastic surgery and burns, MRSA, antibiotics)

2010-09-24T20:42:00.000-07:00

Dear Burn surgeon,

I found your website very informative. I saw a number of burn videos on YouTube but I was confused as there are no explanations many times. Could you suggest some good videos and advice?

Katie Jones,

Barbados

Dear Katie,

Thank you very much for appreciating our site. Asktheburnsurgeon is specifically written in a manner that both lay persons as well as burn professionals will understand burn management and is aimed at creating burn awareness and simplifying burn treatment in the community. There are a number of burn related videos available on the web which can be helpful. We have put together a few links below- and included our thoughts and comments on the video.

(Asktheburnsurgeon has no financial or other interest in the video links displayed on this page)

Electrical burns

There are two types of electrical injuries

1) caused by electrical flash

2) caused by direct electrical current

The electrical flash burn causes a burn injury, and in this type of accident the electric current does not touch or pass through the victim’s body. A flash or flame only affects him and he can be treated as a flash/ flame burn victim. On the other hand, in the direct electrical current injury patient, the electrical current passes through the body and this patient must be admitted and monitored in a burn ward as he may manifest problems and complications associated with direct electrical injuries even where no apparent injuries are evident. This is because the electrical injury affects the heart and severe changes in heart rhythm (arrhythmia) can lead to death if the patient is not kept under observation. Further other injuries like muscle damage and myoglobinuria (release of muscle protein in urine) which can block and damage the kidney may occur. Again, muscle damage may lead to compartment syndrome (tissue edema or swelling which causes reduced blood flow and ischemic injury).

Staffs who work with electrical lines and devices must be careful to avoid burns. Rescue officials have to make sure that all electrical currents have been switched off and it is safe for both the rescuer and the victim. Backup, ambulances and first aid experts in CPR, burns and injury managements must always be available in any rescue effort, if mishaps are to be prevented.

Electric burns will be discussed as a full article in a later issue.

Asktheburnsurgeon+

‘Wonder why some people make offensive comments at others misfortunes’

The following video link shows a rescue official getting electrocuted while trying to rescue a person who is on top of a high voltage electric pole.

http://www.youtube.com/watch?v=BtQtRGI0F2Q&feature=related

HOW TO TREAT SUNBURNS

has already been explained in our previous blog

http://asktheburnsurgeon.blogspot.com/2010/09/how-to-treat-sunburns-management-of-1st.html

The following video link tells you how to take care of sunburns.

1.How to protect your kids from sunburn

http://www.youtube.com/watch?v=4eyRQWwHZl8&feature=channel

2. Child Care & First Aid : How to Treat a Sunburn

http://www.youtube.com/watch?v=fon8W-hOCW8&feature=related

3. How to Treat a Sunburn

http://www.youtube.com/watch?v=4NPNS9lj73I&feature=related

Road accidents and burns.

http://www.youtube.com/watch?v=L1akPA1BxSI&feature=related

This video link shows a movie clip scenes where multiple road accidents occur simultaneously. To avoid accident and burn injuries, please read our previous article.

24 tips from asktheburnsurgeon on-How to avoid road accidents and burns at

http://asktheburnsurgeon.blogspot.com/2010/07/24-tips-from-asktheburnsurgeon-on-how.html

First aid and minor burns

This video link tells you about the first aid management of minor burns. Please read our detailed article on first aid and burn prevention before you follow other links

FIRST AID IN BURNS-FLAME BURNS, SCALD BURNS, CHEMICAL BURNS AND ELECTRICAL BURNS
http://asktheburnsurgeon.blogspot.com/2010/01/first-aid-in-burns-flame-burns-scald.html

Burn Prevention

http://asktheburnsurgeon.blogspot.com/2009/12/burn-prevention-1.html

+How To Treat Minor Burns & Scalds

http://www.videojug.com/film/how-to-treat-minor-burns-and-scalds%20%20

Handling Burns
http://www.youtube.com/watch?v=JBBvSkhhJ-I&feature=related

Case 2 - Accidental flame burns
http://www.youtube.com/watch?v=fMjfDIT1jLc&feature=related

How to treat a burn - How to treat burns at home
http://www.youtube.com/watch?v=SBfdDe_5O8A&feature=related

First Aid Tips : How to Treat Second & Third-Degree Burns
http://www.youtube.com/watch?v=CJt7XySKqYI&feature=channel

First Aid Tips : How to Treat Mouth Burn
http://www.youtube.com/watch?v=nKOpAgOm21Q&feature=channel

how to Treat a Chemical Burn
http://www.ehow.com/video_5226140_treat-chemical-burn.html

Management of Patients with Burn Injury-http://www.authorstream.com/Presentation/lizb003-213735-management-patients-burn-injury-sum-09-notes-education-ppt-powerpoint/

Nurse TV: Burns Unit

http://www.icyou.com/video-source/doctors-and-experts/nurse-tv-burns-unit+

Burn Survivor
http://www.youtube.com/watch?v=RJqBiyf5D2Q&feature=related

Plastic Surgery And Burns
http://www.youtube.com/watch?v=xlvc7Rn93Pg&feature=related

Burns can lead to severe contractures and limitations of joint movements, but with the recent advances in tissue transfers and microsurgery, it is possible to correct severe deformities and let patients lead normal life styles. The following video link shows a young girl who suffered burns to her leg, walking after she underwent surgical corrections. Burn surgery will be discussed as a full article in the future.
‘There is always light in the end of the tunnel’
Asktheburnsurgeon+

Electrical burns
http://www.youtube.com/watch?v=q98YAo0vrio

Burns - First Aid
http://www.youtube.com/watch?v=v2mY1h0BdTw

first aid - Dealing with burns
http://www.youtube.com/watch?v=t5HRdE3MmPI&feature=related

Live Burn Mishap
http://www.youtube.com/watch?v=nvHBnRgAO3o&feature=related

How the Body Works : When the Skin is Cut
http://www.youtube.com/watch?v=fAOti396K_4&feature=related

Basic First Aid Tips : How to Treat Burn Blisters
http://www.youtube.com/watch?v=pwRCn_lkxeQ&feature=channel

First Aid – Burn
http://www.youtube.com/watch?v=hrqK3rZKQ00&feature=channel

How To Treat Someone For Shock
http://www.youtube.com/watch?v=979NvgoUeVk&feature=related

Why are burn patients prone to infection?

Infections and burns.

Burn patients are prone to infections because

1)   They carry a lot of dead burnt tissue (Eschar) which is a good bed for microorganisms to grow
2)   Burn patients are immucompromised or they have a low immunity, so that their body is unable to defend itself from attack by various germs.
3)   Besides burn to the skin, inhalation of smoke or smoke inhalation injury damages the lungs and makes them prone to lung infections.
4)   Monitoring of burn patients may involve insertions of intravenous lines, central venomous lines, Foley catheter, arterial lines, schwan ganz catheter and others. Sometimes theses lines are passed through burnt areas as there are no un-burnt areas to do so. These lines are a potential source of infection. So also is the Foley’s catheter or urinary catheter which can causes urinary tract infection that can be serious if untreated.

5)   Burn patients need to have dressing changes for their burn areas regularly and this can be a source of infection, if infection control protocols are not observed by the attending staff during the dressing changes. In fact, infection control protocols need to be strictly observed from the time of admission, to the time of discharge from the hospital.
6)   Burn patients tend to be infected sometimes by multiple organisms. The use of some antibiotics have be shown to kill the organisms against which they are effective, but sometimes their use promotes the growth of other organisms which attack the burn patient.

7) The indiscriminate use of antibiotics promotes the development of 'antibiotics resistance’ where the organisms are able to survive and grow in the presence of powerful antibiotics. Hence all antibiotics should be used with extreme caution after studying the microbiology and culture/ sensitivity of the microorganism that have infected the burn patient.

The following video links give you a brief idea about burn infection, MRSA and antibiotic resistance.

Antibiotics - Dangerous or Safe?
http://www.youtube.com/watch?v=YiZJMTjd_54

Antibiotic Resistance
http://www.youtube.com/watch?v=yG2PWCJnX2Q&feature=related

MRSA - Why, How & What Happened ?
http://www.youtube.com/watch?v=WaxoyAsWWCA&feature=related

MRSA Can Kill You! What You Need To Know!
http://www.youtube.com/watch?v=dBDZPnbCXBE&feature=related

MRSA: Methicillin-resistant Staphylococcus Aureus
http://www.youtube.com/watch?v=VZ3ImVUFT48&playnext_from=TL&videos=PSywr2Wk35E&feature=rec-LGOUT-exp_stronger_r2-2r-10-HM

asktheburnsurgeon+

How to treat sunburns? (Management of 1st degree burns)

2010-09-23T23:26:00.001-07:00

Dear burn surgeon, last weekend we spent a long time on the beach and my daughter had sunburn on her face. Now the skin is peeling off and I am wondering if we did not treat her well and is she going to have a scar?

Mrs Mabel

California.

USA

Sunburns is usually a first degree burn and does not need special physician care as first degree burns does not cause fluid loss and is not included in the calculation of burn percentage for fluid resuscitation. The patient usually has been exposed to sunlight for a long time as on the beach. The skin shows redness and when you press your fingertip on this area, there is blanching (skin becomes pale and pink again). The outermost layer of skin (epidermis) is intact but red. If there is blistering of skin then this is a 2^nddegree superficial burn and the management will be different as we have seen before..

Management of 2nd degree superficial burns- (2nd degree burns)
http://asktheburnsurgeon.blogspot.com/2010/01/management-of-2nd-degree-superficial.html

However patients with sunburns may have severe dehydration and should take plenty of fluid orally like water, juices or oral rehydration preparations. For small areas of sunburn, one should cover the area with a piece of cloth soaked in cold water. This will ease the pain and one can combine it with regular analgesics like ibuprofen, paracetamol, aspirin, diclofenac sodium etc. For burns that are extremely painful, a local anaesthetic like xylocaine can help. Avoid aspirin in children. For larger areas one can take a cold shower or soak in a bath tub. In children, this should be avoided for fear of hypothermia (abnormal lowering of body temperature). This can be followed up with applications of mild lotions or Aloe Vera preparations, or moisturisers. One should wear light and loose cotton clothing to avoid irritation of the burn area.

To avoid sunburns one should use a sunscreen with a SPF (sun protection factor) more than 25. If you are a fair complexion person, use one with an SPF greater than 45 to prevent sunburns. This burn usually heals in a week’s time.

First degree burns do not cause a scar normally and as the healing takes place the damaged epidermis may peel of slowly revealing the new epidermis underneath. Protect this new skin from sunlight by using a sunscreen and avoid direct bright sunlight for a few weeks.

So don’t worry Mrs. Mabel, your daughter should be fine by God’s grace.

Asktheburnsurgeon+

Burns in the OR and how to avoid them.

2010-09-16T08:24:00.000-07:00

Doctor my wife had back surgery and the next morning the nurse while checking her incision asked her how she burned her buttock because she had large blisters on it. She said she hadn't burned her buttock. The blisters burst that evening and they treated her with topical ointment. They kept her a 2 days longer then they had originally told her she would be able to go home. I took her to the family doctor and he just wasn't sure but thought they were 2nd and 3rd degree burns and prescribed Silvadene ointment which seemed to help it heal faster.
They won't give a explanation of the blister other then to say she scooted on her buttock and they were bed sores. She had these less then 24 hours after surgery and only was lying on her side in the bed.

Please give us your opinion.
Thanks for your help Sir,

J.B.

Dear Mr JB,
Thank you very much for your letter. I am sorry to hear your wife had a possible burn in the theatre. From the history it appears that this resulted after the operation. Whether it occurred in the theatre or afterwards in the ward prior to being noticed the next morning is difficult to say.
If it is did occur it the theatre, there are a few causes that can lead to this clinical presentation:-

1. Allergy to the scrubbing agent

Some patients are allergic to the skin scrubs or antiseptic that are used to clean the skin prior to surgery: like betadine , hibiscrub or cetrimide solution.
I have seen quite a few of these in some unfortunate patients. However they are usually 2nd degree superficial burns- with blistering on the following day and often tend to heal with conservative treatment i.e. dressings and local wound care.
Patients going to the OR must specifically be asked for any allergy to chemical and scrub agents.

2. Bedsores/ pressure sores.
Sometimes the patient is put in a particular position during surgery and due to the long hours of surgery pressure areas may show redness and blistering. Often this pressure area is superficial and tends to heal well with local wound care. Surgeons and OR staff must take great care to monitor pressure areas and change them if possible or provide extra padding.

3. Thermal Burns.
Electrocautery is used during surgery for the purpose of cutting tissue and coagulating blood vessels to control bleeding. When a monopolar cautery is used a cautery pad is applied over some part of the body to complete the circuit for the device to function. If for any reason there is a malfunction a burn may result over the area and skin pad to which it has been applied. If this is discovered early the burn may be superficial but often this is noticed when the pad has been removed after surgery and by this time the burn is normally a deep burn as every time the surgeon uses his cautery, probably the skin gets a burn. Deep burns of this kind often need surgical excision and skin grafting to heal the wound.

4. Thermal burns for the O.T lights.
In the past the lights used in the operation theatre generate a lot of heat and focusing the light on a area of skin for a long surgery sometimes resulted in a burn. In some patient who had a sensitive skin it formed a 2nd degree burn while in others it resulted in a 1st degree burn akin to a sunburn.
In recent times the quality of the OR lights have improved significantly and rarely does one see a burn for this source.

5.Thermal burns from materials used during surgery
Sometimes accidental burns can result from any hot materials used during surgery. If hot water is used for any purpose such as to soften a thermoplastic elements or otherwise and falls accidentally on the patient, a burn can result . This depends on the type of surgery and techniques used there in. However this is quite rare as surgeons and OR staff are extremely cautious when it comes to procedures that can cause burns in patients. High speed drills and mechanical devices should be used with care to avoid friction burns.

6. Lasers.
The use of laser can sometimes result in burn on the patients depending on the skin sensitivity, type of laser , intensity of the laser, the laser machine and the surgeons experience. Laser machines should be used carefully and always a test patch should be carried out before the complete procedure is undertaken.

7. Sticking tape allergy.
Many patients show allergy to skin tapes that are applied after the surgery is over. Prior history and allergy to skin tapes should be asked for. Similarly use tapes that are hypoallergenic and light on the skin. However these appears as redness or blistering when the tapes are removed and settle down and heal with local wound care.

I have put together a number of circumstances that can lead to burn like presentation in operation theatre. However surgeons and OR staff are well trained and take great care in preventing accidental injuries to patients entering the theatre. I hope that this reply is used only for educational purposes and is not for purposes of litigation or otherwise. Creating awareness among patients and medical professionals will help decrease these unfortunate OR incidents.

Asktheburnsurgeon.+

Is the abnormal becoming the ‘norm’(al)?

2010-09-04T02:23:00.000-07:00

When Edmund Hillary and Sherpa Tensing scaled Mount Everest in 1953, it was glorious moment in the history of mankind. Human abilities were pitted against nature, in a test of strength, determination and grit. In their success we rejoiced and applauded them and transformed them into heroes overnight. Over the past few decades human values, customs, traditions and perceptions have changed. In my youth, riding a bicycle meant going round the country side and enjoying the beautiful scenic views, the fields, the mountains, meadows, waterfalls, and lakes. We came home refreshed and ready to take on the next day. Ask any child today, what bicycle he wants and he will reply- one which can go up a mountain terrain or down the stairs, kerbs, planks and more. Simple old fashioned fun has been replaced by adventure’? To design a vehicle or device that will go up or down a mountain is ‘normal behaviour’, but to take a bicycle, motorbike or car and attempt this task is insane and abnormal even if it is disguised as an ‘adventure sport’! Abnormal venture promoters must be discouraged but the spirit of adventure must prevail within normal limits.

In the old days, pets were kept for fun- the pets had fun, the keeper enjoyed it and the people around admired the pets. This was supposed to be the principle and norm. Pets then were cats, dogs or birds that were safe and adorable. Visit any pet shop today and you will feel like you are on a safari- snakes, spiders, garials and others that will frighten you and make sure that you will never visit your friend who has one of them. Today’s TV programs on wild animals, show men playing with crocodiles, elephants, komodo dragons and snakes- we who encourage them and cheer them are responsible for their mishaps and deaths.

The Guinness world records have slowly turned from the normal to abnormal. For why should a man walk on his hands when he has legs or why should a man lie distressed in a tub of snakes when he can lie peacefully in bed? We have started to be abnormal to create records and society has started to promote these records- or abnormal events.

In the Roman era gladiators killed each other in an arena where spectators cheered. It took us some time to do away with this inhuman and abnormal sport. In present times we still have remnant of this sport – Boxing – where boxers attempt to bring their opponents down by hitting them. We stand around and enjoy this barbaric bloody sport, little realising the pain and suffering they go through and the brain injury which they suffer that will last a life time.

When Steve Irving died from the barb of a sting ray in Australia, it was a signal that the world ignored. We watched, shocked, petrified and guilty. Wild animals are supposed to live in the wild. We are part of their food chain. To take a tiger, a lion, a snake or any wild animals and try to live in harmony with it is wrong and ‘abnormal’ and can be likened to taking a guest to KFC and asking him not to eat the chicken!

For those who believe in religion, God made Adam and Eve to care, love, support and procreate. God did not make two Adams or two Eves. For the atheist, science confirms that men and women were made to be with each other, the anatomy supports this fact and if it were not so, man would have become extinct.

In 1993, when bill Clinton tried to lift the ban on homosexuals serving in the army through his ‘don’t ask don’t tell’ policy, he was attempting to legalise and normalise the ‘abnormal’. Since the evolution of mankind the ‘abnormal’ has always survived on the periphery. Our forefathers knew it but ignored and often turned a blind eye to it, but never accepted it as normal. Hitler used his mental abilities to wipe out a part of the human race but with the same Einstein solved the mysteries of the universe and unified the many branches of science with his ‘theory of relativity’. When rulers and nations join this band of accepting the ‘abnormal’ as ‘normal’ the end result can be catastrophic.

The use of alcohol in medicine, as an appetizer or accompaniment to food, or at a party can be considered normal but to get drunk everyday, loose ones senses and end up doing all sorts of things that one does not remember in the morning- has become the ‘norm’. Simple old fashioned partying has been replaced by drink, drugs and sex.

Promiscuity, alcohol, drugs, prostitution, gambling, homosexuality and more- we are promoting as the ‘norm’ and our children have begun to accept them as the normal. Artist paint with blood and body fluids and promote them as ‘art’. We have legalised prostitution in the hope of protecting our women. But did we really achieve what we aimed for? Perhaps we pushed more of them into this arena.

Cloning has been a dream for many scientists. Cloning of cell, tissue and organs is beneficial. Many diseases that cannot be treated successfully can be cured by replacing the cells, tissues or organs themselves. Dolly proved that cloning an animal was possible but showed the world that we understood very little of the many abnormalities- physiological and anatomical that would occur in this process.

Our scientists are attempting to clone human beings- they did not perfect this technique in animals?

Do we want to create abnormal babies and then decide whether they should live or die? Who gives us the right to play the terminator?

Creating ‘scientific wonders’ and ‘medical first’ has been a craze among our learned scientists. But to let a woman deliver at the age of 63 years and face the possibility of her dying at anytime in the near future leaving behind a motherless child, borders on the absurd. Besides we are nowhere with our creams, lotions, capsules and elixirs in our quest for living eternally.

As scientists, we sometimes plagiarise, copy research work, and put ourselves in papers we never contributed to: did we stop for a moment and think- what are we doing?

Scientists should be scientific and follow normal and accepted scientific methods. Their work and research must culminate into something that is not only scientifically accurate but also socially and morally acceptable.

As businessmen prosper and their businesses flourish, their principles change from normal to abnormal- for the men who make 5%, 50%, 500% or a 5000% profit on the same item they sell, all strongly believe that they are doing legitimate business.

Where do we draw the line which separates business and cheating?

Can we apply the same standards to the medical profession? We would definitely be charged with fraud and cheating!

A child is born innocent, but as he grows up, he observes that the evil and corrupt prosper, they become powerful, suppress the meek and appear successful. He begins to think that this is the ‘normal’ way of life. His thought processes and actions function is this direction. Unless he is made to realise the truth and learn to filter the right from the wrong, the normal from the abnormal, he will end up being part of the cesspool of corruption. In our fast life results and goals are stressed upon, the path is ignored. We need to teach our children that along the way we need to support and encourage our colleagues rather that to put them down. The path we take is as important as achieving the goal.

For what did Ben Johnson achieve? Though he won the race, he lost everything that he appeared to have gained.

For what did Saddam, the dictator of Iraq, gain when he plundered his nation and massacred his opponents? Cornered in a rat hole, he was hung like a criminal.

When bill Clinton became the president of the United States of America, he achieved the ultimate goal that few people could dream off. As he sat in power in the white house, he indulged in an ‘abnormal affair’ that destroyed his career and reputation and put him to indescribable shame.

Our forefathers lived in the wild; they were lawless but realized that normal values had to be set up if they and their future generations had to survive. They established a society based on these values, the normal was separated from the abnormal, so that every individual in the society knew when something seemed wrong. We are reversing the cycle, going downhill, from civilised to uncivilised, from culture to cultureless, from normal to abnormal; in vain did our forefathers struggle!

This trend has to be changed and the responsibility lies on the rulers of this nation, on the teachers, on the parents and on each one of us; to turn around tell our folks and children- let us do the normal, if not for us, for our future generations to whom we are accountable. We are living in an era which has the best of everything: from the first invention- the wheel to the best invention-electricity. We have travelled afar from the Stone Age to the Space Age, from unknown to the known, from darkness to light.

Let us not destroy what we have gathered so far in our journey through time. If we start discouraging the abnormal, the idea will sink into our kids; though it will take time, the results will be acquired, slowly but surely. Let our conscience be our judge.

We must act now!

Good must overcome the evil,

Right must replace the wrong,

Normal must replace the abnormal.

+asktheburnsurgeon.

How to avoid propane gas barbeque grill burns and explosions

2010-08-26T05:15:00.000-07:00

Dear doctor,

Sunday evening my Dad was going to barbeque dinner. There was a leak in the propane tank and there was a flash when he lit the barbeque that burned his arms, hands, legs, and face. His hair caught on fire, most of his beard and hair is now gone. Eyelashes and eyebrows are gone as well.

He was immediately taken to the ER where they gave him morphine for the pain. This made him vomit and his blood pressure dropped to 58/27.

They intubated him as a precautionary measure and his blood pressure was stabilized. They then moved him to a burn unit in a hospital in SF. After examining him that night, they said that most of his burns are 1st and 2nd degree. They extubated him late Monday morning and lifted his diet restrictions. Their main concern is infection at this point and his left leg. This area saw the worst damage and they are observing him for 2-3 days to see if he will need surgery.

I read your information on 2nd degree burns and feel that it was extremely well written and understandable for the lay person. Thank you so much for that.

The history with my Dad is that he had a staph infection 4 years ago and endocarditis. He had 50% damage to his heart at that time due to a previous heart attack and the damage from the infection. He had a quadruple bypass 10 years ago and as of the last appointment a month ago the bypasses (sp) are holding.

They did say that he is in the beginning stages of liver failure last month as well as congestive heart failure. He is 62 years old. His blood pressure has been holding steady after that initial drop and he said that he isn't in any pain right now.

He is an 8 hour drive away from me right now and they tell me that he is stable, but I can't help but feel that any surgery on him at this point would be very rough on him. Today is the second day of observation and I am planning on heading down to be with him either later today or tomorrow.

My question is, are my concerns warranted? I feel silly because they say he is stable and to not come, but my gut tells me otherwise. I'm sure by the time you read this I will already be there, I guess I just wanted some reassurance. I am worried that his previous health issues will make this current trauma worse.

Sorry to take up your time, I just found a lot of comfort in your posts and hoped you might have a thought or two.
Sincerely,
Lori

Dear Ms. Lori,

Thank you very much for you question. I am sorry to hear that your father had a burn accident. We are sorry for the delay in replying because we have a lot of queries waiting. The loss of hair is not significant since one can have the hair burnt and lost from the heat though the skin may not be burnt.

Some patients react to morphine by vomiting and lowering of the blood pressure this usually gets controlled once corrective measures or medication are given. That he was intubated appears more of a prophylactic measure since they extubated him within 24 hours and he appears to be stable. Also the fact that the BBQ must likely have been in an open space means that inhalation injury to the lungs are unlikely.

Most of his burns were 1st and 2nd degree burns- as you said- 1st degree burns- should not be of any worry- it’s like sunburn and will heal quickly.

For the 2nd degree burn areas it will depends on whether they are superficial or deep. From what you describe and by the history I feel it may be a 2nd degree superficial burn which will heal, but we can’t be sure till we examine the burn itself.

In view of his medical illnesses and cardiac problems prophylactic antibiotic coverage should be discussed with his treating surgeon and may be a good idea.

A physician should also be involved to manage his medical problems. Finally the area of the deep burn if present may be small as I presume from your description.

Good timely analgesics should be helpful along with local dressings and care of the wound.

An ophthalmologist should also check his eyes to rule out any burn injury to the eye which is quite common in patients with face burns.

I hope he recovers quickly and that he may not need any surgery by God’s grace.

With best regards,
asktheburnsurgeon+

Dear doctor,
Thank you so much for your response. You are correct that the BBQ was in an open area. An update on my Dad.

The enzyme cream that they used to eat away at the dead tissue is working really well. They do not believe that surgery will be necessary for now. He is continuing with the debridement (sp) baths every day for now, which have become very painful for him, but they are working.

There has even been talk about discharge this weekend. We are so grateful that he is progressing so well. Seeing the other patients in the burn unit made me realize how lucky he was.
Thank you again for your response. Of course you can put this up on your website. The posts on there helped me at a time when I had no idea which way this would go. If our story can help someone else, please use it.

Thank you again.
Lori

Dear Ms Lori
Thank you very much for the reply and it is nice to know that dad is recovering. Burns can be very painful physically and psychologically depressing. Yet the support that friends and family can provide will help the patient overcome his burns and it is nice to know that your dad has a wonderful daughter like you to take care of him. Following the tips below may help to prevent burns in other propane barbecue grill users.

How to avoid propane barbeque grill burns
- from asktheburnsurgeon

Propane is highly inflammable gas which is commonly used as fuel for stoves, barbeques and others. LPG or liquefied petroleum gas is a mixture of propane and butane and is used commonly as cooking gas or vehicle fuel. Use of propane gas barbeque grills can result in burn or explosion injuries. Following simple safety precautions will help to avoid serious accidents.

1. Buy your gas tanks only from approved dealers who believe in high safety standards.

2. Make sure that all the valves and hoses are safe and undamaged and check them regularly.

3) Use propane tanks that have the ‘Overfill prevention device’ which will help to avoid leaks and accidents.

4) Using leak proof devices that detect leaks and shut off the gas supply can make BBQ grills extremely safe.

5) Keep the tanks upright and while transporting the tank secure it safely so that it doesn’t move or roll around and get damaged.

6) Use the barbeques with a minimum clearance at least 10 feet from any building- avoid rooftops, terraces or even balconies.

7) Barbequing within a closed space or home can result in carbon monoxide poisoning.

8) Avoid storing spare propane gas tanks indoors or near a store or grill.

9) Prevent children from being near the barbeque tanks and grill.

10) Make sure the regulator of your barbeque grill is not faulty lest the flame will be inadequate or an explosion can result with too much compressed gas.

11) Check the spark ignition regularly to see if it is generating a spark, if not the gas may be released without being ignited and can result in a fire or explosion.

12) Turn off the propane tank after use to avoid leak and accidents.

13) Water should be readily available nearby in case of a fire while using the grill.

Grill time now folks- and safe grilling.
Asktheburnsurgeon+

24 tips from asktheburnsurgeon on-How to avoid road accidents and burns

2010-07-13T21:53:00.000-07:00

Every year, thousands of people die from road accidents and burns. The sad fact is that most of these accidents can be avoided. Asktheburnsurgeon presents 24 tips on how to avoid road accidents and burns.

1. Drive only when you are well trained, confident and have a valid driving license.

2. Do not drive under the influence of alcohol, drugs or medication that will affect your driving. You are putting you life and the valuable lives of others at risk.

3. While driving avoid eating, drinking, smoking or using a cell phone.

4. Do not let children or passengers distract you while driving.

5. Drive carefully and follow the traffic rules.

6. Avoid over speeding- you tend to loose control and may cause an accident while over speeding. Reduce your speed especially during adverse weather conditions like sleet, snow, rain and ice. Drive carefully if the road is under repair.

7. Stick to your lane while driving, change lanes only when you want to take a new road.

8. Forget the ‘me first’ attitude and let others cross if needed.

9. Drive to reach your destination and not to race other cars – ‘racing is for race courses’.

10. Before changing lanes look in the side and rear mirrors. Don’t forget the ‘blind spot’ if your car has one, so turn your head and look if any cars are approaching.

11. Avoid being close to large sized vehicles like trailer vans and tractor- trailer rigs. The drivers of these vehicles have a poor vision due to the immense size of the vehicle and can cause serious accidents if you are nearby.

12. Honk when you are in danger or see a dangerous situation developing so that other drivers are also aware of it.

13. Do not carry inflammables in your car like petrol, turpentine or other chemicals which can convert your car into a potential bomb.

14. Never take your eyes off the road while driving –except when you have parked or stopped your vehicle.

15. Keep a ‘first aid’ kit in your car. Having a burnshield or other dressing, fire extinguisher, a large can of water, and a cell phone to call when in trouble can be of great help if you have an accident.

16. Be careful in parking lots- there is always someone crossing or coming out unexpectedly and that could be dangerous.

17 Never drive without your seatbelts on. Seatbelts prevent you from being thrown around or outside your vehicle and injuring yourself in case of an accident.

18. While driving at high permissible speeds, keep a safe distance from the vehicle in front. If the car behind is too close, put your hazard lights on to signal him about the ‘clear and imminent danger’.

19. Car radiator burns are common in hot summers. If you have to tinker with your hot radiator- be careful as you open the lid the hot water can splash and cause severe burns- wait till it cools down or get a car mechanic to repair your car.

20. Long drives can be boring and the monotony may put you to sleep. Have a driving partner who will replace you and prevent you from sleeping.

21. While driving, avoid being a navigator and checking maps and locations- doing both can lead to accidents.

22. Service your vehicle regularly; also see that the tires, breaks and windshield wipers are in good condition. Having a ‘flat tire’ or a ‘burst tire’ while driving can lead to serious accidents. Faulty breaks and non functional wipers can be disastrous.

23. Be careful at traffic signals- there is always someone passing through the yellow light or crossing the red light which could lead to a major accident. So watch out even if you have the green light.

24. Before you start driving

Pray that you reach safely

After you reach your destination

Thank God for being merciful

Drive safely and avoid accidents and burns.

Asktheburnsurgeon +

MAJOR BURNS : SURVIVAL FACTORS

2010-06-02T19:33:00.000-07:00

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

keywords : major burn
tag: major burn

BURN- What does 'burn' mean to you?

2010-05-14T21:01:00.000-07:00

The word ‘burn’ conjures diverse vivid images in the human brain. As a child the word ‘burn’ reminded me of the fires I had seen and the hours I had spent trying to ‘burn’ small bits of paper with a magnifying glass waiting for a whiff of smoke to appear. As a school boy ‘burn’ meant ‘campfires’- collecting twigs and branches of wood and setting them afire, spending the night in the woods with friends

sweet memories that elevate your mood in the worst of depressions…

In school ‘burn’ meant ‘burning the midnight oil’ in the hope of improving our grades. For a teenager, ‘burn’ means to burn a movie, song or CD.

College and youth were all about a ‘burning’ desire to meet the one who would be your soul mate.….

‘As their eyes met, her heart fluttered, love seemed so intense that it would ‘burn’ a hole in her heart’

For those who wrote poetic love notes ‘burn’ meant ‘Robert Burns’ the famous Scottish poet who was known to be an icon of romance in his times.

Thou art sweet

As the smile when fond lovers meet

And soft as their parting tear

Robert Burns

The work place brings in a new form of ‘burn’ to our minds. Meetings, board rooms and conferences, not to forget the ‘pesky boss’ who will give you a ‘heartburn’ and tons of antacids won’t reduce this burn. As one gets married and the kids come, the word ‘burn’ takes a new meaning- picnics and weekends… ‘burning’ the coals- barbequing on the beaches. In Nevada's Black Rock Desert, thousands of people gather once a year to create a City that is dedicated to community, art and free self-expression- ‘the burning man’

All ‘free’ expressions must be ‘bound’ within the norms of society, for if we cross the limits, we face the risk of becoming ‘antisocial’ and the very purpose for which it was created will be defeated.

For men of sport ‘burn out’ at an early age is something that they would like to avoid. For those who love music ‘burn’ reminds them of Usher’s rap

Let it burn

Gotta let it burn

For movie buffs ‘burn’ is the 1969 Italian film ‘Burn’ (Queimada) starring Marlon Brando and directed by Gillo Pontecorvo who persuades the black slaves to fight for their liberation from slavery. When one approaches middle age and the ‘fat’ catches up, workouts become an obsession-‘burning’ the calories becomes the sole aim in life. History taught us how Nero fiddled when Rome was ‘burning’ and how a woman jumped into the ‘burning’ pyre of her dead husband, a custom termed ‘Sati’. Religion tells that how the good will is saved and how the bad will ‘burn’ in hell and there will be ‘bitter lamentations’ and ‘gnashing of teeth’. In recent times, the print and the electronic media have brought to us visions of ‘burning’ wild fires and volcanoes with heroic reporters attempting to spend the night within the volcano itself!

wonder why reporters often force us to believe that this is going to be their last report…..

CNN brought wars, bombs, missiles and ‘burning cities’ right into the living room where people watched innocent men, women and children maimed and dying, all while sipping their morning coffee.

they did not believe him when he said the media made him insensitive......

As a burn surgeon, the word ‘burn’ loses all meaning of fun, pleasure, romance or the thrill of the work place. ‘Burn’ means the pain and the suffering of the burn patient, the weeks or months of hospitalization in a major burn, deformities and scars that sometime lasts for a life time, physical and psychological trauma that will change life drastically, hours spent in the operation theatre trying to resurface the burn wound, skin grafts, flap, painful dressings and months of physical and occupational therapy trying to rehabilitate the burn patient so that they will ultimately go back to society and live and work as normal individuals. ‘Burn’ means informing the patient’s family and relatives with a heavy heart when the patient is critical or has expired.

The burn surgeon develops an unique bonding with his burn patient that last beyond the treatment period and experiences emotional ups and downs as his patient sways between life and death. Every burn patient teaches him that life is so fragile and sweet to squander away and if we could look at the good side of life, it would end up being meaningful; bringing in a sense of contentment and fulfilment. ‘Burn’ at the same time can be service and support, compassion and love, fun and frustration, anger and dejection, despair and loss, success and failure and much more……
But at the end of the day, a twinkle in a child’s eye, a warm handshake or a smile on a patient’s face when he is healed and returns home to his family and friends, compensates for all other meanings of the word ‘burn’ and energizes us to go back with the same vigour and zest that we started out with our first burn patient!

+@asktheburnsurgeon

Wound and Smoking

2010-05-04T19:40:00.000-07:00

Wound, Wound healing and Smoking

In the last article:

http://asktheburnsurgeon.blogspot.com/2010/04/part-ii-wound-healing-why-wounds-fail.html We discussed in detail 'why wounds fail to heal'. Here an original poem from asktheburnsurgeon is presented to encourage smokers to give up smoking in an effort to help wounds heal.

The Cigar

Walking down the alley
Saw a plume of smoke
Stood a little while
Oh, what was on fire?

Out of the bushes
Arose an elfin man
Behold a wicked cigar
Held firmly in his hand

Smoking and puffing
Huffing and coughing
Dragging in the fumes
Blowing rings in tunes

Watching the folks around
Atop his surreal world
Little did he realise
One day would be his demise

The cigar he admired
The smoke he cherished
Freely had he received
Dearly had he paid

Wound and ulcer
Disease and cancer
Qualms and tears
Agony and torments

Cried he in despair
Alas! my love
Brutus you are!
Why thou stab me?

As cigar and smoke, disappeared
Behind the bramble bushes
‘The enemy is within’ I lingered
Walking down the alley

+@asktheburnsurgeon+

Part II: Wound healing: why wounds fail to heal, factors affecting wound healing, chronic wounds, non healing wounds.

2010-04-25T10:12:00.000-07:00

In part 1- wound healing http://asktheburnsurgeon.blogspot.com/2010/03/wound-healing-scars-mature-scars.html

we discussed the normal wound healing process and why scars result. However some wounds fail to heal and there are number of factors that hamper the normal wound healing process. It is important for us to recognize this so that we can address the problem. This article deals with: ‘why wounds fail to heal’ and answers questions that have been sent by the readers.

Dear Doctor, I have a wound on my leg for the last two months. My diabetes is under control but my doctors say I need to undergo surgery to clean the wound. Doctor, can’t we just keep dressing the wound and get it to heal without surgery? I am scared of being cut up.
Sandra F,
Chicago, USA.

A large number of patients go around from doctor to doctor with chronic nonhealing wound though their diabetes and other contributing factors are corrected. A look at this wound may show dead and devitalized tissue (slough, necrotic tissue) that releases endotoxins, which hamper the healing process (decreases epithelisation and fibroblast activity). Further a large number of traumatic wounds have some foreign bodies- like sand, dirt, glass pieces and others that get embedded within the wound during the accident. The presence of foreign bodies in the wound has been scientifically shown to increase the incidence of wound infection- which again hampers wound healing as we have already seen. Therefore it is logical that all the dead tissue and foreign bodies must be removed from the wound to help the healing process. Sometimes the cause of a non healing wound is an underlying bony infection (osteomyelitis) or infected fracture site that is constant discharging material (pus, serous fluid) that prevents the overlying wound from healing.

In all these cases the body can do nothing to heal the wound and we need external aid (see figure: why wounds fail to heal? at the end of this article)

Why call in the general surgeon?
He will debride (remove all dead tissue) and clean up the wound using his knife.

Why call the orthopedic surgeon?
He will manage the underlying bone problem. He will treat the bone infection or the dead bone which prevents the wound from healing.

Why call the vascular surgeon?
If the blood flow to the limb or wound area is decreased or stopped due to diseased blood vessels, the vascular surgeon will evaluate (Doppler study / angiogram- will help to find if the blood vessels are patent and functioning) and repair these blood vessels to increase the blood flow (angioplasty or arterial bypass grafting) thereby removing the blockage and increasing the lumen of blood vessels or replacing the damaged or blocked blood vessels by a new blood vessel from the person’s own body or by using an artificial graft. The same is true for peripheral vascular diseases of the blood vessels that result in the poor blood supply to the wound.

Besides treating diabetes, can a physician help in wound healing?

We often feel that wounds are a surgeon’s domain. This is true to a great extent but in a number of patients there are a lot of general conditions and diseases of the body that affect the wound healing locally.
In many patients the local factors in and around the wound appear not to be the cause of poor wound healing. These patients fail to realize that cause of their poor wound healing lie elsewhere. In patients with cardiac failure the heart is unable to pump the blood efficiently. The blood flow to the wound is poor and oxygen delivery to the tissue is decreased both of which impairs wound healing as we have discussed in detail. Further since the heart pump is ineffective, the back pressure (increased pressure in veins) cause more swelling (edema) of the tissues (and wound area). Tissue edema can also result in patients with renal failure where the kidneys fail to excrete the body wastes and urine.

This swelling or edema is bad because
a) It prevents good oxygenation of wound.
b) It prevents the smooth flow of ‘worker cells’, ‘specialist cells’, growth factors and other repair materials into the wound area (refer part I wound healing http://asktheburnsurgeon.blogspot.com/2010/03/wound-healing-scars-mature-scars.html
A physician, cardiologist or a nephrologist will need to assess and help to correct these problems.

The same mechanism is true for patients with varicose veins.One of my patients, a healthy gentleman of 35 years, was going around with an accidental injury and wound on his leg for months. He had been on treatment for his diabetes (mild), and then treated with antibiotics, thinking it was infection till we evaluated his leg veins and found that he had underlying varicose veins without any apparent complaints, which was preventing the wound from healing. As the back pressure increases in the blood vessels some of the constituents of blood that normally does not pass through the wall (off capillaries) now filter out by pressure. This build up of fibrin, haemosiderin and fluid in the tissues cause firm swelling of the limb (induration) that is typically seen in blood outflow disorders (venous insufficiency).Why call the Plastic surgeon?
Well, when large area of skin or tissue is lost the body cannot replace it. The human body only repairs the tissue – it cannot regenerate tissues. Therefore we need to replace skin or tissue loss from other areas of the human body by skin grafts or flaps (skin, fat, fascia, bone muscle etc): a plastic surgeon’s domain.

The plastic surgeon works on two basic principles:
1) What is the defect (tissue that needs to be replaced like skin, fat, bone, muscle, etc)
2) Replace the lost tissue by the same
This is simple to understand: if your son has lost his shoes, you have to replace them with a new pair of shoes. You can’t buy him a pair of gloves instead!!
Once the wound is cleaned of all dead tissue, we need to evaluate the defect and the missing tissue. The next step is to replace it. If skin is lost- replace skin, if muscle is missing- replace muscle, if bone is missing –replace with bone and so on.
I hope this answers your question Ms Sandra. So go ahead and let your surgeon handle your wound.Why is blood supply to the wound area important?
Blood vessels are like roads that lead ‘to and fro’ the damaged wound sites (see figure at end of article). The body sends workers and supplies to repair the damaged site by these blood vessels. Further adequate oxygen (carried by red blood cells) cannot reach the wound site and good oxygenation is required for proper functioning of all cells. If blood supply to the wound area is decreased from any reason then the ‘worker cells and specialist cells’ as well as nutrients and repair materials cannot easily reach the wound to begin the process of repair and healing effectively.

Why do patients with diabetes have poor wound healing?

castor f

Brussels.

Thank you very much for your question Mr. Zubin.
There are two issues that need to be addressed with respect to your burn
1) Diabetes
2) SmokingAs we have discussed earlier, uncontrolled diabetes can be a great enemy of wound healing. If your diabetes is not under control you need to be seen by a physician or a diabetologist who will put you on proper medications to control the blood sugar. Smoking hampers wound healing and in fact the use of tobacco in any form must be avoided. This is because use of tobacco releases nicotine which in turn causes the blood vessels to contract (vasoconstriction) and reduce the blood flow to the wound. Similarly it also increases the platelet adherence (blood cells that stick together or clump together) which again diminishes the blood flow; all of which will lead to poor wound healing as already discussed. I understand that to quit smoking suddenly may be difficult, but you could reduce your frequency of smoking, or at least stop during the time your wound needs to heal.

A non healing wound is often a pointer to the onset of diabetes or undetected underlying diabetes.

If the wound is infected, how will it affect the wound healing?
Robin green,uk

When germs or microorganisms attack a wound and cause infection, they hamper the normal wound healing process. Some of them release toxin, damage the tissues, degrade growth factors, increase the collagen break down and also reduce the epithelisation: processes that are necessary to heal the wound. Even if the wound heals, in the presence of infection the chance of scar formation is higher. Further surgical procedure like skin grafting and flap that are carried out to heal the wound, which may be technically perfect may fail in the presence of infection. The skin graft fails to stick to the wound bed, floats or is eaten up. The skin flap may show inflammation and even areas of necrosis (tissue death).

What is atherosclerosis and how does it affect wound healing?

Atherosclerosis is a condition usually seen in elderly individuals where blood flow is reduced due to the narrowing of the lumen of the blood vessels from abnormal depositions (atheromas) in the vessel wall. This result in reduced blood supply to the wound area which in turn hampers wound healing.

Should we use antibiotics if culture of wound fluid will show microorganisms?
Well, one has to understand difference between wound colonization and wound healing. In wound colonization the germs are just visitors and don’t really damage the tissue, though they do have a potential to cause infection (become illegal residents). We avoid antibiotics in these cases and use local antimicrobial agents and dressings to cleanse the wound. However in wound infection, the germs have now become illegal residents of the wound and seek to damage and destroy tissue and prevent wound healing. These wound show signs of infection like redness, swelling (cellulitis), and foul smelling discharge; lacks peripheral epithelisation, has poor granulation, looks unhealthy and shows poor healing. In such cases we can start appropriate antibiotics based on the germs (organism) we culture from the wound.To confirm wound infection one can find the concentration of organism per gram of tissue (tissue culture) ; more than 10 to the power of 5 organisms is considered wound infection. We don’t do this commonly as clinical signs and symptoms are fairly accurate to know if the wound is infected.Doctor, if the patient has taken antibiotics can wound infection persists?
Sunil P. Calcutta

Yes, that often happens because:
1. Different germs or microorganisms are sensitive/ resistant to different antibiotics that are used to kill a specific germ. Therefore culturing the microorganism from the wound is very helpful and important.
2. Sometimes the wound may be infected with more than one germ, so that we may need a combination of antibiotics to treat the infection.
3. Also it is a good habit to repeat the wound cultures on weekly basis to know if new organisms are isolated or resistant micro bacteria are present so that we can attack these invaders. In major burn patients these issues are extremely important as the microbial pattern keeps changing due to a lot of dead tissue (burn eschar).

Doctor, I am a chain smoker and a diabetic. I suffered a 2nd degree burn on my left arm and its taking ages to heal. I just can’t quit smoking as my doctor advises. what should I do?

Zubin S
New Orleans USA

Why is nutrition an important factor in wound healing?Stella Q
scotland

This is easy to explain. For any tissue or body cell to repair and heal- proteins are needed. Amino acids (proline, glycine, lysine, etc) the building blocks for proteins are extremely crucial for cell function and repair. For repairing the cell wall fatty acids are needed. Vitamins and minerals play a great role in many chemical reactions that occur during various body metabolic processes.
For example,
Vitamin A (retinoic acid) – important for collagen production and epithelisation (surface cell growth).
Vitamin E (alpha tocopherol) – antioxidant that destroys free radicals and helps healing.
Vitamin C (ascorbic acid) – Helps collagen formation
Iron, copper – helps collagen formation.
Zinc- zinc is a constituent of many enzymes treated for wound healing as well as it is a potent antioxidant

If the patient has anemia (low hemoglobin), this will affect the oxygen carrying capacity of blood and the wound will get less oxygen resulting in poor healing. Albumin is another protein in the blood that is important for wound healing. Low levels of albumin can be detrimental to the wound healing process and should be corrected. In a patient with a non healing wound these factors need to be treated aggressively as they all contribute to non- healing.

Doctor, you said the growth factors play a big role in wound healing. Why don’t we supply them directly into the wound and hasten the healing?
Sr. Mabel
Minneapolis, USA

We are still learning about the growth factors and our knowledge about them is limited. Here are few examples of growth factors.

: Vascular endothelial growth factor (VEgF)
: Tranforming growth factor β (TGF β)
: Epidermal growth factor (EGF)
: Insulin like growth factor (Ig F-1)
: Fibroblast growth factor (FGF)
Platelet derived growth factor (PGF)
: Tumor necrosis factor (TNF-α)

These are basically proteins but the body uses them to signal various activities like getting the ‘worker cells’ and ‘specialist cells’ to reach the wound site, encourage cells to start multiplying at the site (epithelisation), increase the blood flow by new blood vessel formation (angiogenesis) and stimulate fibroblast and other cells to repair the damaged area by collagen and ground substance formation. Their commercial production and use is still experimental and the first growth factor to reach the market is the platelet derived growth factor (PDGF) (regranex gel) (Becaplermin) developed by Johnson and Johnson. We need to develop the whole array of growth factors and see how effectively they will help wound healing. I think it will take sometime till we are able to use growth factors on a regular basis effectively.

Doctor, can pressure cause ulcer or wounds?

Yes, when you apply pressure over an area of the body which is greater than the pressure within the blood vessels, the blood flow will diminish- this will reduce the oxygen supply and affect the metabolism and normal healing process which will ultimately result in breakdown of tissue and ulcer or wound formation. Such pressure ulcers commonly occur over the bony sites-(sacrum, shoulder blades, heel, back of head) in bedridden patients who are unable to move regularly to prevent sustained pressure over any particular area of the body. In these patients frequent change of position, maintaining hygiene, improving nutrition, using special mattress and beds to prevent sustained pressure over any specific site will help to prevent formation of pressure ulcer and also to heal them. However if a large nonhealing pressure ulcer should occur, you will need ‘external aid’ to heal them (see check list at end of article: why wounds fail to heal).

Doctor, my father has a non healing wound that appeared without any apparent cause on his leg. He is not diabetic and is generally healthy. Can any infection start such a wound?
Gunther P
Berlin

This is an interesting question- a number of times we are unable to find the exact cause of the non healing wound. There are some infections that cause wounds or ulcers primarily. Yaws is a disease caused by a bacterium called a spirochete (a spiral-shaped type of bacteria). The bacterium is scientifically referred to as Treponema pertenue which can result in an ulcer. Mucormycosis is a disease caused by a fungus that can result in sinuses, abscesses and ulceration. Cutaneous anthrax (affecting the skin) is a disease caused by germ (bacillus) called Bacillus anthracis that can cause a skin wound. Actinomycosis is a disease caused by a germ (anaerobic bacteria) in individuals who have lowered immunity and results in sinuses and skin ulcers. Each of these diseases has investigations that will help to confirm the diagnosis.
Sometimes the ulcer or wound may be the manifestation of an undetected disease in the human body. Pyoderma gangrenosum, a condition, which starts like a small swelling and then ends up as an ulcer often reveals underlying diseases like hepatitis, myeloma, systemic lupus erythematosis and others. There are other rare causes of wounds which like necrobiosis lipiodica, calciphylaxis, sickle cell ulcers etc. Please read this full article to check out the other causes including cancer that have been discussed.

Doctor, can any medication cause an ulcer or wound?
Rose A
Argentina

Well we rarely think of such a possibility. However anticoagulants like heparin or warfarin which are medications that reduce the blood coagulation ability (clotting) can induce skin necrosis (areas of skin destruction) that can end up as wounds.

Dear Doctor, my mother has an ulcer on the face that keeps on breaking down and does not heal for the past one year. The doctor says it may be a cancer as mom is 85 years old. What do you think?

Patterson J
Sydney, Australia

Thank you for your question. Yes, one of the causes of an ulcer or wound that fails to heal and keep on slowly increasing may be cancer or malignancy. The cancerous cells multiply from some signals and body is unable to stop this multiplication. However they increase and reach a stage where the blood flow cannot reach the cells adequately and so some of the cells start to die or form an ulcer or wound. While a cancer or malignancy can end up as an ulcer, a chronic wound can sometimes end up developing a cancer possibly due to the tissue being repeatedly damaged in the wound which excites the cells to multiply rapidly. Sometimes when there is a long standing scar (scar of many years) following burns or any other causes which is unhealthy (skin tends to breakdown often) a cancer can develop. This cancer that develops in the scar tissue or wound is called ‘Marjolins ulcer’.

When a cancer is suspected often a ‘biopsy’ will confirm it. The surgeon will either take a small part of the wound edge (incision biopsy) or if the ulcer is small –completely excise (excision biopsy) the ulcer. The pathologist can examine the tissue immediately while the surgery is ongoing – (frozen section) and give the surgeon a clue that the tissue is malignant or not. This will help the surgeon to decide how much area (free margin) he should excise (cut out) around the wound, as well as the depth, so the cancer is completely excised. In other cases the surgeon may decide to excise the wound and get the definite biopsy report (paraffin section) after a week or two with all tests confirming the nature and diagnosis of the cancer. So Mr. Patterson, if your doctor wants to go ahead with surgery, let him, as this will help the diagnosis and treatment. Sometimes you have to trust your surgeon!Dear doctor, Can radiation lead to poor wound healing?Alan Sebastin, Uk.

This is a common question asked by patients of cancer who undergo radiation and have skin ulcer or scar that breakdown and don’t heal. Radiation damages the blood supply in the radiated skin by causing direct destruction of the vessels and by causing clotting in the blood vessels (thrombosis and necrosis). Some also affect the DNA directly which prevents the cells from multiplying (cell proliferation).
The hair follicles and fat cells are destroyed and the skin becomes thin (atrophic). These factors cause skin to breakdown and form radiation ulcers or wounds with poor wound healing.

Dear doctor, can emotional stress influence wound healing?

Well, when we suffer an injury or have a wound, most of us get depressed or undergo stress. It has been shown by that emotional stress hampers wound healing by increasing the blood pressure and blood levels of cortisol( steroids) , which in turn decreases our immunity.
So guys sit back and relax when you have a wound (let the surgeon undergo stress!)

Dear Doc, what is lymphedema? Can it impair wound healing?

While obstruction of veins can cause back pressure and swelling of the limbs, sometimes the drainage of tissue fluid (lymph) itself may be blocked or hampered leading to severe swelling of limbs (lymphedema). This is commonly seen when surgeons remove the lymph nodes in the axillary region (armpit) following cancer of the breast and the arm gets swollen. Sometimes diseases like filariasis(elephantiasis) block the lymphatic system, similarly causing lymphedema or swelling.
In these cases if ulcers or wounds occur from any cause in these odematous limbs, their healing will be hampered.
solving the mystery through simple exclusion, till the culprit is finally found and then exclaiming

a) In diabetics the fine and big blood vessels that supply the wound are diseased (diabetic angiopathy) so that the blood flow to the wound is diminished.
b) Further the disease affects the nerves (peripheral diabetic neuropathy) and this leads to increased tissue pressure as the pain sensations that tell us to relieve the pressure are affected or absent. In fact sensory loss or inability to feel pain sensation from any cause like nerve injury can result in ulcers or wounds that progress and don’t heal. As the person does not realize or feel the pain he fails to prevent repeated injury to himself.
c) The immune system is affected in diabetes (decreased neutrophil function) so that there is a greater chance for germs (microorganisms) to attack the wound and cause infection.
Many patients present with non healing wounds without prior history of diabetes.

Does age affect wound healing?

Yes as we discussed before, fetal tissues( when baby in the womb) when injured heal perfectly- because these tissues have the ability to regenerate.
At birth we loose this ability and our tissue can only repair- not regenerate new tissues or organs.
When we become old ( old age) our skin is easily damaged. The ability of cells in old age to multiply is reduced. These factors lead to poor wound healing in old age.
(There is still hope: our anti aging scientist are seriously involved in finding the secrets to eternal youth.)

Dear doctor, if our immunity is lowered from any reason, will it affect wound healing?

Immunity deals with our ability to fight infection. Diseases like AIDS ( Acquired immune deficiency syndrome) directly attack the immune system and destroy it so that the immunity of these patients is impaired. Similarly taking steroids for long term (for any reason) can reduce the immunity again. Diabetes and malnutrition are other causes for decreased immunity as we discussed. If these patients have wounds obviously the healing will be hampered.

The checklist: why wounds fail to heal? from @asktheburnsurgeon

Sometimes finding the exact cause of a non healing wound can end up like an Agatha Christie novel where every character appears to be the culprit.

.......Was it Jane or Jack?... The killer knife which had ‘to Jane with love’ embossed in gold on the woodwork…. had been stolen from Sarah’s kitchen a month back……. was found in Jack’s drawer…… in a villa that was owned by Tim…. who had invited Michael, Peter &Stella for dinner….. On the night of murder…. the cook Burt who had recently changed his profession from being a butcher…...

The surgeon dealing with a non-healing wound has to be like Agatha Christie gathering all the characters in the plot; he should be Sherlock Holmes

‘'Elementary, my dear, Watson, elementary’’

I have gathered the characters responsible for chronic, delayed and non healing wounds and prepared a check list. While searching for causes of wounds or ulcers, the dictum is

''look for common disease or conditions and then if you are unable to find the cause or heal the wound, start looking for the rare ones''
When you are faced with a troublesome wound, look up the characters in the list that are likely to play a role in your patient’s wound, investigate each one, till you find the exact culprit. In this article I have tried to cover most of the common causes and I hope the reader will find the check list- ‘why wounds fail to heal’ helpful in treating their patients. Readers are welcome to send in their comments.

With best regards,
+@Asktheburnsurgeon

Topics discussed in this article: why wounds fail to heal, chronic wounds, diabetic wound, infected wound, pressure ulcers, cancer, malignant wound, radiation ulcers, peripheral vascular diseases, vasculitis, wound infection, foreign bodies in wounds, varicose veins, venous ulcers, Deep vein thrombosis, lymphedema, renal failure, cardiac failure, anthrax, yaws, mucormycosis, actinomycosis, debridement, skin graft, flap cover, bone infection, thrombosed blood vessels, low hemoglobin, low albumin, low oxygenation, malnutrition, vitamin mineral deficiency, smoking, steroids, aging, immunocompromised – AIDS, immune suppression, medical illnesses, emotional stress, self induced wounds, non healing wounds.

keyword: wound, wounds

Chemical Burn From Tea Tree Oil- Management.

2010-04-01T08:21:00.000-07:00

Hi,

I used pure tea tree oil on a small pimple on my cheek yesterday night and today morning I woke up to find the pimple is flattened but I have got a red chemical burn of the size of a coin on my cheek. The area is all red, raw and weeping. It’s not painful as such but when I washed my face it stung and burnt like it’s on fire. I have never had chemical burns before and totally at a loss about what steps should I take, like should I use antiseptic creams (like Savlon etc) on it or just leave it as it is. Though it’s watery and raw, when I am moving my face muscles (to talk or to eat) I can feel the stretch on that part as if it's very dry. Please do let me know what steps I should take.
Thanks
+Dia

Dear Dia
Thank you very much for the question. Tea tree oil is derived from the leaves of the Melaleuca alternifolia, a plant commonly found in Australia and used by the Australian aborigines. It appears that the leaves were used sometime to make tea and hence the name. It is used regularly as an alternative medicine in a variety of conditions like boils, dandruffs, acne, athletes’ foot and others. Tea tree oil is effective against germs and fungus because of the presence of terpenoids like terpenin-4-ol. It has also been used in allopathic medicine and in the treatment of burns. Studies have shown the cytotoxicity of tea tree oil against human fibroblast and epithelial cells and therefore it has been suggested that tea tree oil should not be used on burn wounds ( see reference below-1). I am not sure if you have used tea tree oil before as some individuals may have allergy to the tea tree oil and present with dermatitis like picture with rashes, itching and blisters or serious allergic reactions rarely. When used in undiluted form it can result in a chemical burn showing redness, skin irritation, itching and blistering.

It appears that you have used the tea tree oil in its pure form which has resulted in your skin blistering and breaking down. In any case your description appears similar to a superficial 2nd degree burn.
http://asktheburnsurgeon.blogspot.com/2010/01/management-of-2nd-degree-superficial.html describes in detail the management of 2nd degree superficial burn.

Dia, you need to clean it with a dilute antiseptic solution or sterile saline thrice a day and apply an antibiotic ointment like Neosporin or fusidic acid ointment. Avoid direct sunlight over the affected site as it can aggravate the problem. You can also take some pain killers like ibuprofen, paracetamol, diclofenac sodium etc, though in a day or two the pain should reduce considerably.
Since you have acne and possibly a higher skin bacterial load the affected site should be watched for any sign of infection and antibiotics may be started if this happens. Once the area heals use a bland skin moisturizer to nourish the new skin and use a sunscreen to avoid pigmentation (darkening) of the new skin from sun exposure. A visit to your doctor will be helpful as this advice is given without actually seeing you in person.

Wishing you a speedy recovery,
Asktheburnsurgeon

Related articles and sites
1)Allergy to tea tree oil: retrospective review of 41 cases with positive patch tests over 4.5 years.
Rutherford T, Nixon R, Tam M, Tate B.
Australas J Dermatol. 2007 May;48(2):83-7.

2)Does tea tree oil have a place in the topical treatment of burns?
Faoagali J, George N, Leditschke JF.
Burns. 1997 Jun;23(4):349-51.

3)Melaleuca oil (tea tree oil) dermatitis.
Knight TE, Hausen BM.
J Am Acad Dermatol. 1994 Mar;30(3):423-7.

List of burn care facilities and centres in Brazil

2010-03-19T22:50:00.000-07:00

Dear Doc,
I am trying to find a listing of burn centres in Brazil. I have tried searching on the internet but my inability to read or speak Portuguese has severely limited my search capabilities. Does this organization know of burn centres in Brazil? If so, can you please send me the names and contact information for them?

Kind regards,
+Douglas Emery

Dear Mr Douglas Emery,
Thank you very much for your question. The list of burn centres in the USA and Canada are available from the links to the right. We are also trying to compile a list of burn centres in different countries all over the world as this will be very helpful to burn patients seeking burn care as well as for burn professionals looking for research, employment, scientific interactions and advancing the science and burn care.
We encourage readers to send us names or list of burn care centres or facilities in their country or state and we shall put them up on our website. Please note that this list is not an advertisement and asktheburnsurgeon in no way verifies or endorses the quality of burn care or facilities available at these centres.
Some of the burn care facilities and centres in brazil are given below.

I hope this answers your question.
@asktheburnsurgeon.

Burn centers and facilities in Brazil.

Children's Hospital
R Meri Ubirajara, 205 Victoria St. Lucia
Zip Code: 29055120
(27) 3324-1566
(27) 3137-2402

Surgery Service Pratique Burns and the Santa Casa de Campo Grande
A: Eduardo Santos Pereira, 88 - Bairro São Farncisco
Tel: (67) 3322-4000

Plastic Surgery Services of San Rafael
Av San Rafael, 2152 San Marco Salvador
Zip Code: 41256900
(71) 399-6111
(71) 393-1021

Emergency Unit Dr. Armando Lages
Av Siqueira Campos, 2095 Trapiche da Barra Maceio
CEP :57010-000
(82) 221-5009

REAL PORTUGUESE HOSPITAL OF CHARITY IN LEG
AV. Agamenon Magalhães S / N - Recife
(81) 3416-1122

Burns Unit of Hospital São Marcos
Av Portugal, 52 Boa Vista - Recife
Zip Code: 52010010
(81) 3217-4589

Burns Unit of Hospital Restoration
Av Agamemnon Magalhães, s / n Derby - Recife
Zip Code: 52010040
(81) 3421-5444

Santa Casa de Marília
Av Vicente Ferreira, 828 Maria Izabel - Marilia
Zip Code: 17515900
(14) 4335644

First Aid for Burns
Rua 5, No 439 Setor Oeste Goiania
Zip Code: 74115060
(62) 224-4130
(62) 225-8603

Vitória Apart Hospital
BR 101 Norte, s / n º Carapina Sierra
Zip Code: 29161900
(27) 3348-5563
(27) 3348-5516

Hospital Association Santa Rosalia
High Street from the Cathedral, s / n Centro Teofilo Otoni
Zip Code: 39800000
(33) 3529-1500
(33) 3529-1509

Santa Casa de Misericordia de Juiz de Fora
Barão do Rio Branco, 3353 - Alto dos Passos Juiz de Fora
Zip Code: 36021630
(32) 3229-2222
(32) 3216-2557

Santa Casa de Santos
Rua Cláudio Luiz da Costa, 50 Jabalpur - Santos
Zip Code: 11075101
(13) 3202-0600
Brotherhood of Santa Casa de Misericordia de Sao Jose dos Campos
Street Dolzani Ricardo, 620 - Centro
CEP: 12210-110 - São José dos Campos - SP
Phone: (12) 3876-1999
Dr. Gilka Barbosa Lima Nery

Clínica São Vicente
Rua João Borges, 204 Gavea - Rio De Janeiro
HFAG Hospital Air Force Galleon
Galleon Road, 4101 - Rio De Janeiro
Zip Code: 21941000
(21) 2468-5100

Hospital das Clinicas de Sao Paulo
Rua Dr. Eneas de Carvalho Aguiar, 225 Cerqueira Cesar - Sao Paulo
Zip Code: 05403900
(11) 3069-6238

Hospital Emergency and Trauma Senador Humberto
Av Orestes Lisbon, s / n Set Pedro Gondim - Joao Pessoa
Zip Code: 58031090
(83) 216-5702
(83) 218-7777

Hospital Dorian Silva
Av Chopin, s / n Hospital Laranjeiras Serra
Zip Code: 29165240
(27) 3328-3611
(27) 3138-8907

Base Hospital of Bauru
Of course Bishop Street, 888 Center - Bauru
Zip Code: 17100010
(14) 235-3535

Hospital for State Civil Servants
Rua Pedro de Toledo, 1800 - 5th floor Ibirapuera - Sao Paulo
Zip Code: 04025000
(11) 5088-8001
(11) 5088-8929

Hospital Defects Face
Rua Moreira Guimarães, 699 Indianapolis - Sao Paulo
Zip Code: 04074031

Teaching Hospital Padre Albino
Bethlehem Street, 519 Center - Catanduva
CEP: 15800000
(17) 531-3000
(17) 531-3035

Clinical Rayana
Av Bosque da Saúde, 171 Grove Health - Cuiaba
Zip Code: 78060310

State General Hospital
Avenida Vasco da Gama s / n Brotas Salvador
(71) 276-8987
(71) 276-8988

Hospital Sao Camilo
Rodovia BR 522, Km 02, Estrada Mataripe s / n Candeias
CEP: 43800000 (71) 601-1906 (71) 601

Hospital Infantil Joana de Gusmão
Rua Rui Barbosa, 152 Agricultural - Florianopolis
Zip Code: 88025301
(48) 251-9000

Hospital Municipal de San José de Joinville
Getúlio Vargas, 232 Centro - Joinville
Zip Code: 89202000
(47) 441-666

Emergency Hospital of Porto Alegre
Largo Teodoro Hertz, s / n Bom Fim - Porto Alegre
Zip Code: 90040192
(51) 3316-9888

Service Burns Hospital Cristo Redentor
Rua Domingos Rubbo No. 20
Bairro Cristo Redentor Porto Alegre
Santa Casa de Presidente Prudente
Av Wenceslau Brás, Vila Euclides 05 - Presidente Prudente
Zip Code: 19014240
(18) 226-1355

Evangelical Hospital in Curitiba
Rua Augusto Stefeld, 1908 - 5th floor - Curitiba
Zip Code: 80730150
(41) 322-4141
(41) 323-2411

General Hospital of Vila Penteado
Av Minister Petronio Portela, 1642 - Sao Paulo
Zip Code: 02802120
(11) 3796-9911

Santa Casa de Limeira
Av Antonio Ometo, 675 Vila Claudia - Limeira
(19) 3445 3735

University Hospital of Juiz de Fora
Rua Dom Lush, Alto dos Passos - Juiz de Fora
Zip Code: 36026390
(32) 3215-8282

Brotherhood of Our Lady of Mercy Holy House Car
Square Alves Honorato, 22 Center - Montes Claros
Zip Code: 39400103
(38) 3229-2401

John XXIII Hospital FHEMIG
Alfredo Balena, 400 - Belo Horizonte
Zip Code: 30130100
(31) 3239-9245
(31) 3239-9060

Holy House of Mercy Our Lady of Fatima
Avenida Jose Bonifacio, 569 Centro - Araraquara
Zip Code: 14801150
(16) 236-2600

Burns Hospital
Av Divine Eternal Father, No. 950 Gois Vila Vila Boa
Zip Code: 77370120
(62) 327-0735
(62) 327-0889

Hospital Municipal Souza Aguiar
Republic Square, 111 Centro - Rio De Janeiro
Hospital Pedro II
Prado Street, 325 Santa Cruz - Rio De Janeiro
(21) 3395-0123

Hospital das Clinicas FMUSP
Rua Bernardino de Campos, 1000 Higienópolis - Ribeirao Preto
Zip Code: 14015130
(16) 602-1000

Hospital Regional da Asa Norte
NMHSs Q. 01 Bloco A Brasilia Asa Norte
Zip Code: 70710905
(61) 325-4243
(61) 326-5769

Related sites and articles:

Benaim F, Artigas Nambrard R . Burns. 1999 May;25(3):250-5. Development in the treatment of burns in South America during the last decades.

Piccolo NS. J Burn Care Rehabil. 2002 Nov-Dec;23(6):385-400. The 2002 Everett Idris Evans Memorial Lecture. Burn care in Brazil: ideas from the past, trends of the present, and hopes for the future.

(Please copy and paste the links in your browser to open the site)

Brazilian burn society
http://www.sbqueimaduras.com.br/sbq/

PART 1 - Wound healing, scars, mature scars, hypertrophic scars, keloids

2010-03-10T08:44:00.000-08:00

Doctor, I have a painful scar on my left leg following an accident two years ago. It is very embarrassing as I am forced to wear long skirts to cover my legs. My sister was involved in the same accident but all her wounds healed well without any scar. Why did my wound form scars?
Mrs. Silvie B +
Orlando

Thank you very much Mrs. Silvie for your question. I am sorry to hear about your accident. There are four issues that need to be explained to help understand your problem.
1.How does a wound heal?
2.why we need to understand wound healing
3. Types of scars that can result when wound heal?
4. Various factors that can determine whether a scar will result.
5. management of scars, hypertrophic scars and keloids.

As human beings, we tend to falter and fall (physically and mentally as well), and when that happens we suffer cuts, bruises burns and other injuries. Every day we use sharp objects like knives, razors, saws etc and accidently cut ourselves. Children injure themselves while playing. The world is full of glass, metals, chemicals, electricity, machines and others - sources of injuries and burns; we have now come to accept them as part of our everyday life. While we can be careful and reduce the incidence of injuries we can never completely eradicate them like polio or small pox.

‘Even a beautiful rose –hides a lowly thorn.’

The point of this entire introduction is that when injuries result we often ask

‘why did this happen to me?’

We need to put aside this question and turn to the important issue- managing the injury and its complication.

First of all how does a normal wound heal?
When the skin is cut or injured the first protective body mechanism is to stop the flow of blood by contraction of the blood vessels and forming blood clots (haemostasis). Once this is done the body decides to repair the damage. It does this by sending certain cells to the area of damage (macrophages, neutrophils, monocytes and lymphocytes). These ‘worker cells’ do the following
- They clear the wound of debris and dirt
- They fight infection
- They send signals to bring in ‘specialists’ who will rebuild the damaged tissue.

Growth factors are chemical substances released by a lot of cells (macrophages, platelets, endothelial cells, fibroblasts, lymphocytes) that encourage and promote various activities needed to heal a wound like –cell multiplication, matrix synthesis, blood vessel growth. A lot of studies are underway to determine if we can externally add some growth factor and influence or encourage or hasten the wound healing and avoid scar formation.

The next step is to start rebuilding the damage and so the wound needs some ‘specialist cells’ called fibroblasts. These cells lay down a strong scaffold with collagen fibers and ground substance or matrix which will provide a basic structure and strength to the healed area. New blood vessels (angiogenesis) form and grow into the healing area to bring in more ‘workers and specialist cells’ to rebuild the damage. During this time some worker cells are repairing the skin surface (called epithelisation). This hyperactivity (proliferative phase) is needed in the initial phase to repair the wound. This phase of repair (3-4 weeks) then slows down and the body starts to focus on remodeling the tissues (remodeling phase) so that they will start to look like normal skin. Remodeling of the tissues can go on up to a year.

During the repair –a lot of collagen (scaffold) and ground substance(cementing substance, extra cellular matrix) is laid down to strengthen the wound and during the remodeling stage the extra collagen is removed or replaced to get the end result to resemble normal skin. These are also some specialist cells called myofibroblast that cause the wound size to decrease by contracting the wound edges. As long as these process are going on normally there may be no scar or a fine mature scar may develop.

When the baby is in the womb (in utero), wounds heals without scarring, but we lose this ability after birth. We are still unable to understand why exactly fetal wounds heal without scars. However when there is an imbalance of the repair phase, and the remodeling phase i.e. when the fibroblast cells in the remodeling phase lay down too much collagen and the body is slow to remove it- the problem starts to manifest in the form of a hypertrophic scar or keloid. Beside the liver which minimally regenerates tissues, we don’t have the capacity to regenerate limbs or organs as we see in lizard which can regenerate the whole tail that is lost.

figure: showing the stages of wound

healing and how scars result.

Why do we need to understand wound healing?
Wound healing is a complex process. As we have discussed, there are four phase or stages of wound healing. Understanding the stages helps us to realize that wounds take time to heal and that we need to be patient. It also helps us to look closely at wound healing and our researchers and doctors can work on various parameters to hasten wound healing. We can evolve and develop better wound care products like different wound dressings for better wound management. Growth factors play a very important role and studies are underway to introduce growth factors into the wound and hasten wound healing. By studying the healing process in different types of wounds and ulcer like diabetic wound, surgical wounds, pressure sores, burn wounds, acute, chronic and non healing wounds, venous ulcers etc we are able to individualize treatment for each case and help the patients have a faster recovery.

We now understand non healing wounds and ulcers in a better way and treat them. Wound care companies are involved in serious research trying to outdo their competitors by providing the best wound care products. Newer techniques in wound management like VAC( vacuum assisted healing),enzymatic wound debridement, hyperbaric oxygen therapy, maggot therapy, growth factor therapy, skin substitutes, advanced wound dressings, keratinocyte culture (skin culture) have all developed from our understand of wound healing. Even plastic surgeons, burn surgeons, general surgeons and others decide how and when to interfere surgically to heal a wound through their understanding of the wound healing processes. In addition we are now able to establish wound assessment and wound care guidelines for proper wound management.

Following a minor injury the skin heals without any visible mark. If this was not the case, our body would be a museum of scars as we suffer minor injuries almost daily that we hardly notice.

So then what exactly is a scar?

The word scar simply means any visible mark left on the skin or mucosa in the process of healing of any injury or wound.

What are the types of scar?
There are four Scenarios:
1. No scar
2. Mature scar
3. Hypertrophic scar
4. Keloidal scar

What are mature scar?
Mature scar are scars that develop in the course of wound healing. These scars are not physically troublesome- they do not cause pain, itching, are not thickened or red in colour and do not tend to grow in size. The main problem with this scar are they are they are a cosmetic problem especially when they are on the exposed parts like face, arms, or legs.

In this article we have tried to explain how a wound heals and why scars result.

In the next article we shall consider
- Factors that influence wound healing and scar formation
- Type of scars that result when wounds heal
- Management of scars, hypertrophic scars and keloids.
Keep reading @ ask the burn surgeon.

Related sites:

Wound Healing Society - What's Happening Now
http://www.woundheal.org/

Canadian Association of Wound Care
http://www.cawc.net/

WUWHS - World Union of Wound Healing Societies
http://www.wuwhs.org/

Betadine ointment, Povidone- iodine, does betadine cause chemical burn or allergy?

2010-03-04T20:02:00.000-08:00

Doc, I used betadine ointment on my 4 month old son who had a burn with hot water and I found the normal skin around the burn became red. Does betadine cause a skin burn?

+Kessler B
Germany

Thank you very much for the question. I am sorry that your baby had a burn. Let me give you a little detail about the ointment you used.
Betadine (Mundipharma, Switzerland) is a broad spectrum microbicide ( works against a lot of microorganisms, germs, virus, protozoa, spores, fungi and yeast) used regularly in wound care and wound management. Betadine is the trade name and the actual active substance in it is povidone – iodine. Iodine as an element was discovered in 1811 and the application of iodine solution caused pain, irritation and skin dicolouration. Since 1949 the development of iodophores (povidone, iodine and cadexomer iodine) helped form safer and less painful preparations.In the old days we used iodine, but now this has been replaced by povidone- iodine. Betadine can be used as an antiseptic for burn wounds, infected wounds, surgical wounds, leg ulcers, minor cuts and skin grazes. It is also used as a pressure sore cream in the management of bedsores. Burn Surgeons use it to kill the bacteria or germs and prepare the skin prior to making a surgical incision by painting the skin with betadine lotion. Betadine helps in wound healing by controlling and preventing infection when used as a dressing for burns wounds in burn management.

Betadine should not be used in patients with allergy to iodine as severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue)can occur. Since it contains iodine it should be avoided in patients with hyperthyroidism or increased activity of the thyroid gland or in patients with thyroid disease. Similarly we should be very cautious of its use in newborn babies and infants as the iodine can be absorbed through the unbroken skin. It should also be avoided in pregnant and lactating women as well as in elderly patients and patients with kidney dysfunction. One should avoid combining the use of povidone iodine with other ointments since it reduces the efficacy or can even damage the skin. While using this ointment the thyroid function test if carried out concomitantly, will show wrong results. Betadine can cause pain in some patients and can also reduce the immunity in others. Betadine is only for external application and should not be ingested or applied in the eye. Betadine or povidone -iodine, a wound care product is available in the following forms: betadine ointmint, betadine lotion, betadine solution, betadine gel, betadine powder, betadine aerosol, betadine paint, betadine mouthwash, betadine surgical scrub, betadine suppository and betadine skin cleanser.

Does it really cause a burn?

More than 13 cases of povidone-iodine–induced burn has been reported in the medical literature. This occurs when the povidone-iodine has not been allowed to dry or has been trapped under the body of a patient in a pooled dependent position. The burn is usually seen immediately after the procedure or on the next day, and typically heals with minimum scarring within 3–4 weeks with conservative treatment. The commonly postulated mechanism is a chemical burn due to irritation coupled with maceration, friction, and pressure. If betadine causes the chemical burn, I don’t really see what maceration, friction and pressure has to do with it. But that’s the way, whether from allergy or chemical burn, betadine can cause a skin burn which needs to be kept in mind.
As with the use of any ointment one can have an allergic reaction which is often taken as a chemical burn since betadine is a chemical and the skin reaction looks like a burn. Severe allergic reactions or hypersensitivity can easily be differentiated easily based on the symptoms mentioned previously. Infants have a delicate skin and one should try diluting the betadine before use, the first time and the slowly increase the concentration to make sure there is no allergy or chemical burn. Also its use should be limited to a very short period and physician supervision is recommended.

How do we treat it?
Well, stop using the ointment and change to Neosporin, fusidin or other ointments on the unburnt areas which show this chemical burn or allergy. Sometimes the use of steroids creams may help to treat the allergy element, but each case has to be judged and treated accordingly by the supervising physician. For the burnt areas use other ointments that are available for burn management. You can check these in the previous articles:
Management of 2nd degree superficial burns- (2nd degree burns)
http://asktheburnsurgeon.blogspot.com/2010/01/management-of-2nd-degree-superficial.html
Management of 2nd degree burns (deep), Skin grafting
http://asktheburnsurgeon.blogspot.com/2010/02/management-of-2nd-degree-burns-deep.html

I hope this answers your queries and I wish your son a speedy recovery.
With best regards,
asktheburnsurgeon@yahoo.com

Research grants, fellowships and scholarships for researchers, burn survivors and medical specialities

2010-02-26T21:32:00.000-08:00

1) Dear doc, I am interested in doing research work in the burn field, could you help me gather some grants for this?
+ Steven J
Detroit, USA

2) Dear burn surgeon, I suffered severe burns last year and now though all the burns have healed my doc says I need pressure garments (compression garments). I am presently unemployed. Do you know any organisations that can help?
Name withheld,
Portland, USA

Thank you very much for your letters. There are a number if associations and foundations that help researchers and burn survivors to do research, pay for education as well as support therapy, pressure garments etc. There are also a number of fellowships programs that you can enrol for. The easiest way is to find out the burn association society or foundation that functions in your state and then approach the directly. If you are a researcher, they will ask you details of the project that you will research in. if you convince them you can get a grant. If you are a burn survivor you need to show proof of your burn accident (medical certificate) and convince them about the need for a grant. Here are a few that could be of help and I hope you get your grant. A number of general research grants, fellowships, scholarship programs, foundations and organisations are also given to help the readers.

(Please copy and paste the links in your browser to open the site)

For burn patients and survivors seeking grants for education or pressure garments these may be of help.
Compression Garment Grant application
http://www.knapp-burn.org/pdffiles/Garments.pdf

John Benet Shavian Educational Grant
http://www.knapp-burn.org//pdffiles/GrantApp.pdf

Spiegel Burn Foundation
http://www.spiegelburnfoundation.com/wbc.html

Children’s Burn Foundation
http://www.childburn.org/recovery/requestservices.html

United States Burn Support Organization
http://www.usburn.org/

Northwest Burn Foundation
http://www.nwburn.org/index.htm

FOUNDATION FOR BURNS AND TRAUMA
www.azburn.org/

Wisconsin Burn Survivors Network
http://www.healtheburn.org/index.html

For those seeking burn grants for education or research grants these sites may be of help

The American Burn Association
http://www.ameriburn.org/about_awards.php

British Burn Association
http://www.rdfunding.org.uk/Queries/ListGrantDetails.asp?GrantID=10928

burn institute of san dingo provides research grants
http://www.burninstitute.org/research/application.html

The international association of fire fighters (IAFF) Burn Foundation provides grants for research projects
http://burn.iaff.org/grants.shtml

The St. Joseph Community Health Foundation
http://www.stjosephhealthfdn.org/index.php?option=com_content&view=article&id=72&Itemid=71

Spiegel Burn Foundation
http://www.spiegelburnfoundation.com/links.html

fire-fighters burn institute
http://ffburn.org/

Royal Children's Hospital Foundation
http://www.workingwonders.com.au/competitive-grants/

money for medical students
http://www.money4medstudents.org/content.asp?id=581

The University of Iowa Hospitals and Clinics (UIHC)
http://www.healthcare.uiowa.edu/surgery/burn-fellowship.html

Trauma and Burns Research Fellowship - UCSF
http://www.surgery.ucsf.edu/research/fellowsh.html

the American burn association has a wonderful collection of burn fellowships that are available throughout the united states
http://www.ameriburn.org/Fellowshipsfinal.pdf

General medical grants and fellowships covering undergraduates, postgraduates in all fields: surgery, medicine, gynaecology, transplantations, oncology, plastic surgery, cardiology, vascular surgery, cardiothoracic surgery, neurology, basic sciences anatomy, physiology,biochemistry pathology, microbiology, pharmacology and many others are given below

Alpha Kappa Alpha Educational Advancement Foundation
http://www.akaeaf.org/
A.P. Giannini Foundation Research Fellowship -($37,000, 1-3 yrs)
http://www.apgianninifoundation.org/
American Institute of Physics
Congressional Science Fellowships
http://www.aip.org/gov/cf.html
Stanford Post-doctoral Fellowships
http://postdocs.stanford.edu/scholars/fellowships_SoM.html
American Institute of Physics
State Department Science Fellowship Program
http://www.aip.org/gov/fellowships/sdf.html
Nina Starr Braunwald Career Development Award
http://www.tsfre.org/Awards/NinaBraunwald.html
Balfour Fellowship
http://www.nif-inc.net/scholarships/lloyd_balfour/
Katherine McCormick Travel and Fellowship Awards
http://postdocs.stanford.edu/scholars/fellowships_SoM.html
Boren Graduate Fellowships
http://www.borenawards.org/boren_fellowship
Brigham's Research Funding Site
http://www.brighamandwomens.org/surgery/research/FundingSurgicalResidents.aspx#OtherFunding
College Community Partnerships
http://www.oup.org/files/pubs/foundations.pdf
NIH NRSA - ($30,000, 2 yrs mandatory, 10 page proposal)
http://grants.nih.gov/training/nrsa.htm
College Scholarships and Graduate Fellowships
http://groups-beta.google.com/group/fellowships
Soros Fellowships for New Americans
http://www.pdsoros.org/
Walter V. and Idun Berry Fellowship Program
http://postdocs.stanford.edu/berry/
Collegiate Inventors Competition
http://www.invent.org/collegiate/
Ruth L. Kirschstein National Research Service Award:
http://grants.nih.gov/training/nrsa.htm
California Institute for Regenerative Medicine (CIRM) Grant:
http://stemcell.stanford.edu/cirm/
Committee on Institutional Cooperation (CIC)
Minority Graduate Application Fee Waiver
http://www.cic.net/Home/Students/FreeApp/Introduction.aspx

UCSF's Research Funding Opportunities
http://www.research.ucsf.edu/cg/funding/cgFunding.asp
Society of University Surgeons Fellowship -($30,000, 1-2 yrs, 10 page proposal)
http://www.susweb.org/forms/fellowship.htm
Committee on Institutional Cooperation (CIC)
Traveling Scholar Program
http://www.cic.net/Home/Projects/SharedCourses/TScholar/Introduction.aspx
Robert Wood Johnson Clinical Scholars Program: -- Peter Schilling
http://rwjcsp.stanford.edu/
(Jack Kent) Cooke Foundation
Graduate Scholarship Program
http://www.jkcf.org/scholarships/graduate-scholarships/
NIH Loan Repayment Program
http://www.lrp.nih.gov/about/lrp-clinical.htm
Stanford Dean's Fellowship
http://postdocs.stanford.edu/scholars/fellowships_dean.html
Council of Graduate Schools
Fellowships and Financial Aid
http://www.cgsnet.org/Default.aspx?tabid=163
Kellogg Health Scholars Program:
http://www.cfah.org/programs/healthscholars/index.cfm
e-Scholar
http://www.studentjobs.gov/e-scholar.asp
Stanford Vascular Medicine and Biology Training Grant
http://cvmedicine.stanford.edu/vascularmedicine/training/
UCSF's Research Funding Opportunities
http://www.research.ucsf.edu/cg/funding/cgFunding.asp
FedMoney.org
Student Financial Aid : Fellowships
http://www.fedmoney.org/grants/0-fellowships.htm
Bayer Fellowships in Blood Conservation
http://www.bayerfellowship.com/

American Philosophical Society: $50,000/yr
http://www.amphilsoc.org/grants/daland.htm
Finding and Applying for Grant Opportunities (HUD)
http://www.oup.org/files/egrants/egrantsbrochure.pdf
Gastrointestinal Training Grant - UCSF: ~$40,000/yr
http://www.surgery.ucsf.edu/research/fellowsh.html
(Harry Frank) Guggenheim Foundation Dissertation Fellowships
http://www.hfg.org/df/guidelines.htm
American College of Surgeons
ACS Resident Research Scholarship - 2007($30,000, 2 yrs, 3 page proposal)
Juvenile Diabetes Research Foundation Postdoctoral Fellowship (need to navigate to PDF from main webpage):
http://www.jdrf.org/index.cfm?page_id=103207
NOAA Student Opportunities
http://www.oesd.noaa.gov/noaa_student_opps.html
Association for Academic Surgery
http://www.aasurg.org/awards.htm
North Carolina State University Graduate School
Nationally Competitive Graduate Fellowships
http://www.fis.ncsu.edu/grad_fellows/index.html
American Association for Hand Surgery Research Fellowship: $5000 - Application Due:11/1/2007
http://www.handsurgery.org/grants/research.asp
Fresh Start Fellowship - Pedi Reconstructive Surgery: $5000 - Application Due:11/1/2007
http://www.plasticsurgery.org/PSEF/research/?CFID=48088497&CFTOKEN=77079335
Post-Docs.Com Fellowships Page
http://www.postdocjobs.com/jobseekers/fellowships.shtml
PSEF and ASERF Basic Research Grants:
http://www.plasticsurgery.org/PSEF/research/?CFID=48088497&CFTOKEN=77079335
(Bill) Raskob Foundation
http://www.billraskob.org/
Plastic Surgery Education Foundation Research Grant:
http://www.plasticsurgery.org/medical_professionals/research/index.cfm#two
American Society of Transplantation
http://www.a-s-t.org/awards/navawards.htm
PSEF Lyndon Peer Fellowship - Cleft Lip & Palate or Craniofacial Recon
http://www.plasticsurgery.org/PSEF/research/?CFID=48088497&CFTOKEN=77079335
TSFRE (Thoracic Surgery Foundation Research and Education)
http://www.tsfre.org/Awards/Fellowships.html
American Heart Association
http://www.americanheart.org/presenter.jhtml?identifier=9713
PSEF Scientific Essay Contest
http://www.plasticsurgery.org/PSEF/research/?CFID=48088497&CFTOKEN=77079335
National Institute of Health Surgical Oncology Fellowship -- Peter Peng
http://www.training.nih.gov/webforms/trainingprograms/application/physicanAds.aspx?AdID=TP-77National Kidney Foundation
http://www.kidney.org/professionals/research/
International Society for Heart and Lung Transplantation
http://www.ishlt.org/awards/awardResearchApp.asp
American Heart Association (Western States Affiliate)
http://www.americanheart.org/presenter.jhtml?identifier=2493
American Society of Transplant Surgeons
http://asts.org/Awards/AnnualAwardsEligibility.aspx
michigan state university
http://staff.lib.msu.edu/harris23/grants/3gradinf.htm

+ asktheburnsurgeon@yahoo.com

2010-02-06T18:36:00.000-08:00

Plastic Surgeon

I write, am not a writer,
I paint, am not a painter,
I mould, am not a sculptor,

I perform, am not an artist,
I cook, am not a chef,
I stitch, am not a tailor,

I think, am not a philosopher,
I plan, am not a strategist,
I direct, am not a manager,

I am, what I am,
The human body,
I cut and sew,

Endowed by a gift,
Bestowed on few,
Thank you, lord almighty!

@asktheburnsurgeon+

Management of 2nd degree burns (deep), Skin grafting

2010-02-05T07:00:00.000-08:00

My son burnt his hand while playing with a fire cracker and the doctor says he has a 2nd degree deep burn and will need new skin (skin grafting). Can you please explain what all this means?
Mrs. S Kempinsky+
Germany.

Thank you Mrs. Kempinsky for your question. I am sorry your son has a burn that appears like a deep 2nd degree burn. Before I discuss this question, to understand 2nd degree deep burns as well as its management, please see my previous articles as links on the right side:
1) Degree of burn
2) Management of 2nd degree superficial burns

The picture on the right (fig 1) shows the right hand of a gentleman who suffered flame burns over the fingers and the dorsum of the right hand. You will notice that the epidermis or the outer layer of the skin has peeled off or removed over the dorsum of the hand. The fingers still have part of the epidermis which is dead and falling off. The dermis is exposed on the dorsum of the hand –
1) It appears pale
2) Non blanching (becoming pale on pressure).
3) There is some small dark blood stained area in addition.
4) There are no hair follicles.
5) However this burn area is not charred, hard, dry, leathery as in a 3rd degree burn.
This burn has all features of a 2nd degree deep burn which actually destroys the epidermis and the deeper layers of the dermis. Some dermis still survives.

Why is there no blanching on pressure?It does not blanch on pressure and appears pale because the superficial dermal vessels are damaged, burnt or coagulated.

Why is there less pain compared to a 2nd degree superficial burn?Pain is less because the superficial nerve endings are also damaged in the deep dermal burns.

Now look at the fingers- they are less burnt as compared to the dorsum of the hand and they have more features of a 2nd degree superficial burn (refer to blog on 2nd degree superficial burn to avoid repetition)

How do we go about this burnt hand?First of all this burn is to be handled by a burn professional (don’t treat him by surfing the web). The burn professional will handle these issues
1. Admission to ward
2. Pain
3. Infection
4. Care of the burn wound
5. Routine tests, splinting, physiotherapy, elevation of the hand.

Does he need to be admitted to the burn ward?
Well this is a deep 2nd degree burn of a critical area- the hand- if improperly treated will lead to loss of function of the hand. It is therefore important to admit this gentleman to the ward and treat him as an inpatient.

How do we manage pain?By using analgesics like paracetamol, ibuproffen, Diclofenac sodium, mafenemic acid, tramadol, morphine or pethedine- all depending on the severity of the pain, pain tolerance and other area of burns if present.

Should we use antibiotics?
This is a common question and the answer is simple. Should we inflate the air bag while going for a drive- fearing an accident?? (Sounds stupid!). Similarly we do not normally give antibiotics unless we see infection of the burn area or systemic signs of infection like fever, raised white cell count ,etc.

What we should do?1. Take a swab from the burn wound to culture and check for sensitivity if any organisms are present. This will give us a base line idea and a chance to use the correct antibiotic if infection should occur sometimes.
2. We do give antibiotics prophylactically when fearing an infection or anticipating an infection as in severe diabetic patients or immune compromised patients.
3. Do tell the doctor if you are allergic to any antibiotics.

How do we take care of the burn wound?
This again needs the burn professional. The nurse will clean the area with sterile saline solution. She will debride (cut out) all the dead epidermis and clean the burn wound thoroughly. She will then cover it with an ointment or cream.

Which ointment should I use?For a 2nd degree deep burn I often prefer flamazine (Silver sulphadiazine). It is soothening causes less pain and kills microorganism if present. One can use betadine solution or ointment (povidone iodine) which is good; kill’s microorganisms but sometimes the patient complains of pain more with the use of betadine.

What about Flammacerium?
Flammacerium has Cerium Nitrate Hexahydrate and Silver Sulfadiazine. After application it forms a hard shell over the burn area. When you change the dressing it is difficult to remove the shell completely. This is good when you are treating superficial 2nd degree burn and are sure that burn area will heal and not need any surgery. But in a burn as in fig 1 we know that it may not heal and will need to be reviewed on a regular basis. So avoid flammacerium in burns that will need to be regularly reviewed to decide about surgery or skin grafting.

It is good to put a layer of sofratulle or Vaseline gauze before you apply flamazine or betadine, this helps to prevent the gauze dressing from sticking to the burn wound and causing pain when you change the dressing the next day.
Use these layers over the burn wound
1. Sofratulle or Vaseline gauze
2. Flamazine/ Betadine
3. Gauze bandages
4. Crepe bandages

This is very important. Splinting will support the hand and maintain a functional position of the hand and cause less pain.

Should we splint the hand?

Why should we elevate the hand?Elevation of the hand by pillows or other support will help to reduce the edema (swelling) of the hand and relive pain and accelerate healing by increasing the circulation.

How often should we dress the wound?
Dressing the wound daily is a good idea in 2nd degree deep burns- if you wait longer they become soggy and foul – from all the discharge.

Does this hand need physiotherapy?

Definitely! We should start physiotherapy very early in burn patients- both active ( done by the patient himself) and passive movements ( movement assisted by other hand or by a therapist) should be encouraged, this will help to retain the movements of all joints and the functions of the hand, otherwise the joints will become stiff and it will delay the patient from returning to work.

What else will the burn surgeons do?
Well he will see if you have any additional illness which will hamper the wound healing or needs treatment while you are admitted in the ward such as diabetes, asthma and hypertension. He will ask for some investigations like
1. Complete blood count
2. Electrolytes- Na, K
3. Blood sugar
4. Blood urea
5. Serum creatinine
6. Liver function test
7. Serum Albumin
8. Serum protein
9. Chest X ray- this will serve as a base line especially if you have suffered smoke inhalation injury.
10. ECG if you are above 40 year.

Once all this has been done we come to the most important issue- will this burn heal??Yes by God’s Grace!

How will this burn wound heal?Well, to start with this is a 2nd degree deep burn( on the dorsum of the hand). The 2nd degree deep burn affects the deeper layer of the dermis (though not the whole dermis- as in 3rd degree burns). As the deeper layers of the dermis are destroyed- the hair follicles, sebaceous glands and the sweat glands are also damaged. It is therefore difficult for the new skin to form as the regenerative epithelial elements are damaged.

Will it never heal without surgery? Is the next question that the patient will ask.This burn wound may heal over a period of time- that’s how God made the human body. But when deep 2nd degree deep burns heal, the healing occurs with the formation of abnormal scar tissue (not normal skin). This scar tissue will have the following problems.
1. It will hypertrophy (become thick and large)
2. It will cause itching and pain.3. Most important it will restrict mobility and result in what are called contractures. I hope to explain scar / keloids/ contractures in a future blog.

The gentleman with the hand burn actually refused to undergo surgery and went home against medical advice. The picture on the right (figure- 2) shows his hand after 4 weeks when he came back to my clinic.
The burn on the fingers- which we diagnosed as 2nd degree superficial burns had healed, while the 2nd degree deep dermal burn on the dorsum of the hand failed to heal. It we wait further, the dead white tissue (eschar) seen will slowly disappear and will be replaced by raw red body tissue called granulation tissue that consists of body cells, fibroblasts and fine blood vessels( capillaries)- but no skin!

Now that we are convinced that the burn wound needs help to heal the answer is quite simple, if skin is damaged- replace it.

How can we replace damaged skin?By a simple procedure called skin grafting in which the skin from one part of the healthy body is removed and applied over the area lacking skin.

Can we use a person’s skin for another one?
This is a common question asked by mothers whose children are burnt. However this is not possible as it will only be a temporary measure and in about two to three weeks the skin will be rejected.

Doc, you guys are doing kidney and heart transplantation and you can’t do a simple skin transplant for my hand?
Well kidney and heart transplantations are highly complicated procedures and need lifelong immunosuppressives (drugs that will decrease your immune response so that the body will not reject the heart or kidney). These procedures can be fatal and one can die! Skin transplantation is neither feasible nor advisable in burns as of now. Presently, face transplantation is still in its infancy and not commonly done. Skin grafting is a simple procedure that does away with all these problems.

Do you take the whole skin?
No, only the part or upper layer of the skin. You know the skin has two layers- epidermis and dermis. In skin grafting we use a blade fixed to a device – called the Humby’s knife or an electric device called a dermatome and remove only epidermis and part of the dermis – called a split thickness graft. This will help the donor area of the body from which the skin graft has been taken to heal by itself in about two weeks. There will be some pain in the donor site which can be managed by analgesics like paracetamol, ibuprofen, mefenemic acid or injectables like pethedine or morphine depending on the pain tolerance and pain itself.

Figure 3 on the right shows the skin grafting of the right hand which has fully healed. The graft was taken from the thigh a common area as it is well hidden , but you can suggest the area that you want the graft to be taken from. The function is well maintained and the fingers can be flexed and extended. The problem of color match exists but they settle down over a period of time. Time is a great healer and burn surgeons as well as plastic surgeons rely on time a lot!!!!

So ms kempinsky I hope this answers your question and I wish your son a speedy recovery.

Asktheburnsurgeon.