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220 Burns

• burn wound impetigo. children being ostracised from society. Unable to attend school or other
Burn wound sepsis can be difficult to distinguish from the usual social activities, children may be unable to develop to their potential,
hyperdynamic, hyperthermic, hypermetabolic postburn state. Blood unable to fit into society, and unable to pursue their dreams. Such
cultures are commonly negative, and fever spikes are frequently not children are at risk of posttraumatic stress disorder (PTSD) and other
proportional to the degree of infection. psychological disorders; psychological assessment and treatment are
Clinical diagnosis of sepsis is made by meeting at least three of the important components of rehabilitation from major burn injury.
following criteria: Prevention
5
• burn wound infection (>10 organisms/gm tissue with histologic or An old adage holds that “prevention is better than cure”. Nowhere else
clinical evidence of invasion); is this proverb more applicable than in trauma, and more specifically
• thrombocytopaenia (<50,000 or falling rapidly); in burn injuries. The majority of burn injuries occur among the poor
urban populations living under deplorable conditions. Poor infrastruc-
• leukocytosis or leukopaenia (>20,000 or <3,000); ture, including overcrowding, poorly planned housing, and no water
• unexplained hypoxia, acidosis, or hyper- or hypoglycaemia; access points, lead to rapid spread of fires in these shanty communi-
ties. Provision of appropriate housing and decent living conditions are
• prolonged paralytic ileus;
important steps in reducing the scourge of burns to children
• hyper/hypothermia (>39°C or <36.5°C); Education and government action will likely be needed to abolish
child labor practices that place children at greater risk of burn injuries
• positive blood cultures;
(e.g., underage children who handle fires or hot liquids while cooking).
• documented catheter or pulmonary infection; Fire drills in schools should be implemented to help avoid deaths
among schoolage children, particularly in boarding schools. Finally,
• altered mental status; and
first aid should be taught, which will minimise the burn injuries when
• progressive renal failure or pulmonary dysfunction. they do occur.
Noninfective Complications Ethical Issues
Noninfective complications may include any of the following: The management of paediatric burn injuries in the African environment,
• contractures—positioning and physiotherapy are preventive manoeu- especially in rural areas, may be complicated by traditional beliefs
vres; and practices. Many traditional therapies, such as raw egg mixtures,
flour, and liquid paraffin, among other practices, remain harmful and
• hypertrophic scars and keloids—early wound closure and appropri-
ate scar management are important in the functional and cosmetic delay appropriate care. Consistent education is urgently needed to both
outcomes; prevent these injuries and improve their outcomes, should they occur.
Child abuse by guardians must also be considered where unusual
• smoke inhalation syndrome; burn injury patterns or suspicious histories are presented, and
appropriate safety measures must be undertaken.
• sterile multiorgan failure;
Evidence-Based Research
• anaemia;
Table 33.5 presents a comparative study of the use of a biosynthetic
• malnutrition;
skin replacement versus cryopreserved cadaver skin to temporarily
• Curling’s ulcers—H blockers or proton pump inhibitors are effec- cover excised burn skin.
2
tive in protecting against gastric ulceration and bleeding; and Table 33.5: Evidence-based research.
• thrombo-embolic complications—estimated to affect between 0.4% Title A multicentre clinical trial of a biosynthetic skin replacement,
and 7% of burn patients. Dermagraft-TC (DG-TC), compared with cryopreserved
human cadaver skin for temporary coverage of excised burn
Additionally, long-term complications of burn scars include skin wounds
dyspigmentation, hypertrophic scars, keloid, and chronic nonhealing Authors Purdue GF, Hunt JL, Still JM Jr, et al.
or unstable scars that may degenerate into squamous cell carcinomas Institution Department of Surgery, University of Texas, Southwestern
(Marjolin’s ulcers). Cutaneous horns may also develop from burn scars. Medical Center, Dallas, Texas, USA
Alopecia and burn syndactylys, digit or limb amputations, corneal Reference 9063788 (PubMed ID)
perforations, and blindness are other possible postburn complications.
Problem Coverage of excised burn skin.
Prognosis and Outcomes Intervention Biosynthetic skin replacement.
Prompt and appropriate treatment of burn injuries, including resuscita-
Comparison/ Randomised controlled trial, comparative study.
tion and appropriate wound care, have led to a reduction in morbidity control (quality
and mortality. Poor outcomes are the result of inadequate early man- of evidence)
agement. Inadequate fluid resuscitation may lead to renal failure and Outcome/effect DG-TC was equivalent or superior to allograft with regard
needless death. Inappropriate triaging of patients leads to a waste of to autograft take at post-autograft day 14. DG-TC was also
resources as well as the deaths of otherwise salvageable patients. Poor easier to remove, had no epidermal slough, and resulted
surgical wound management leads to wound infection, delay in wound in less bleeding than did allograft, while maintaining an
closure, prolongation of the inflammatory/hypermetabolic phase, and adequate wound bed. Overall satisfaction was better with
DG-TC.
significant malnutrition, especially in the child. Historical Improvement in burn care, surgical technique of covering
Delayed wound closure, with wound healing by secondary intention, significance/ wounds and its quality.
leads to unsightly scars, dyspigmentation, keloids, and contractures. comments
Resultant low self-esteem coupled with limited mobility may lead to