Vk Tiwari

Burn wound: How it differs from other wounds?

Management of burn injury has always been the domain of burn specialists. Since ancient time, local and systemic remedies have been advised for burn wound dressing and burn scar prevention. Management of burn wound inflicted by the different physical and chemical agents require different regimes which are poles apart from the regimes used for any of the other traumatic wounds. In extensive burn, because of increased capillary permeability, there is extensive loss of plasma leading to shock while whole blood loss is the cause of shock in other acute wounds. Even though the burn wounds are sterile in the beginning in comparison to most of other wounds, yet, the death in extensive burns is mainly because of wound infection and septicemia, because of the immunocompromised status of the burn patients. Eschar and blister are specific for burn wounds requiring a specific treatment protocol. Antimicrobial creams and other dressing agents used for traumatic wounds are ineffective in deep burns with eschar. The subeschar plane harbours the micro-organisms and many of these agents are not able to penetrate the eschar. Even after complete epithelisation of burn wound, remodelling phase is prolonged. It may take years for scar maturation in burns. This article emphasizes on how the pathophysiology, healing and management of a burn wound is different from that of other wounds.

Changing pattern of fungal infection in burn patients.

Invasive fungal burn wound infection is an important emerging cause of late onset morbidity and high mortality in patients with major burns. Following a pilot study done in our unit in 1 year, i.e. January 2008-March 2009 in 71 patients where 28% (20 patients) of the burn wound biopsies from suspected cases showed fungal wound invasion (FWI), a detailed study was planned in order to study the epidemiology of fungal infection in burns in our unit wherein routine wound biopsies in 100 patients were sent on 7th, 14th and 21st postburn day over a one year period (July 2009-June 2010). 12 patients (12%) were diagnosed with FWI on culture. This was then followed by another study in a 9 month period (July 2010-March 2011) when wound samples for only 36 patients in whom there was clinical suspicion of fungal infection were sent. 16 of these patients were diagnosed with fungal wound invasion (FWI) thus establishing an incidence of 44% from suspected cases. These studies showing the increase in fungal infection in our unit have therefore made us wiser, increased our awareness and our accuracy in diagnosing this uncommon infection in extensive burns where patient is not only severely immunocompromised but also has many other risk factors making them more vulnerable to fungal invasion. Another glaring fact which emerged from these studies was the rising incidence of nonalbicans Candida infection compared to Candida albicans, especially C. tropicalis and C. krusei which are more severe in nature and associated with a higher mortality. This signifies that there is a shift of FWI in burns from commensal organism, i.e. C. albicans to pathogenic nosocomial organisms, i.e. C. nonalbicans.

Fungal infections in burns: Diagnosis and management

Burn wound infection (BWI) is a major public health problem and the most devastating form of trauma worldwide. Fungi cause BWI as part of monomicrobial or polymicrobial infection, fungaemia, rare aggressive soft tissue infection and as opportunistic infections. The risk factors for acquiring fungal infection in burns include age of burns, total burn size, body surface area (BSA) (30–60%), full thickness burns, inhalational injury, prolonged hospital stay, late surgical excision, open dressing, artificial dermis, central venous catheters, antibiotics, steroid treatment, long-term artificial ventilation, fungal wound colonisation (FWC), hyperglycaemic episodes and other immunosuppressive disorders. Most of the fungal infections are missed owing to lack of clinical awareness and similar presentation as bacterial infection coupled with paucity of mycology laboratories. Expedient diagnosis and treatment of these mycoses can be life-saving as the mortality is otherwise very high. Emergence of resistance in non-albicans Candida spp., unusual yeasts and moulds in fungal BWI, leaves very few fungi susceptible to antifungal drugs, leaving many patients susceptible. There is a need to speciate fungi as far as the topical and systemic antifungal is concerned. Deep tissue biopsy and other relevant samples are processed by standard mycological procedures using direct microscopy, culture and histopathological examination. Patients with FWC should be treated by aggressive surgical debridement and, in the case of fungal wound infection (FWI), in addition to surgical debridement, an intravenous antifungal drug, most commonly amphotericin B or caspofungin, is prescribed followed by de-escalating with voriconazole or itraconazole, or fluconazole depending upon the species or antifungal susceptibility, if available. The propensity for fungal infection increases, the longer the wound is present. Therefore, the development of products to close the wound more rapidly, improvement in topical antifungal therapy with mould activity and implementation of appropriate systemic antifungal therapy guided by antifungal susceptibility may improve the outcome for severely injured burn victims.

Kite-flying: a unique but dangerous mode of electrical injury in children

A retrospective study was conducted to evaluate the cause of a sudden rise in number of pediatric admissions with electrical injuries at our centre during the year 1998. In evaluating the cause, six out of twelve admissions were found to be related to kite-flying which is a popular sport during the months of June, July, August and September. In two out of six cases current travelled directly through the string of the kite. In two others, flame burns occured following ignition of clothing. Another patient had contact with wire through a metal rod. In the last case, arcing pulled the hand of the patient leading to direct contact with wire. The average burns size was approximately 31% body surface area (BSA), with all patients having burns over the palmar aspect of at least one hand. No patient required amputation for the injuries. In this article, attention has been focussed on the various modes of electrical injuries associated with kite-flying and some measures have been advised to avoid such accidents.

Epidemiological and clinico-mycological profile of fungal wound infection from largest burn centre in Asia.

The current study was conducted to know the incidence, predisposing factors, spectrum, clinical profile and antifungal susceptibility (AFS) of fungal wound infection (FWI) in burn patients. Of a total of 71 patients, 20 (28.2%) emerged with the diagnosis of FWI. Fungal pathogens in this study were Candida tropicalis (14%), Candida parapsilosis (5.6%), Aspergillus niger (2.8%) and one each of Candida albicans (1.4%), Candida glabrata (1.4%), Syncephalestrum (1.4%) and Fusarium solani (1.4%). All patients with mould infections expired before the mycological culture results could be conveyed to clinicians. Of the yeasts isolated in the study, one each of C. tropicalis and C. albicans showed cross‐resistance to azoles. All the moulds were susceptible to amphotericin B. This study depicted that fungal invasion is associated with a high mortality, burn size 30–60% and high incidence of inhalational injury. Fungal invasion was detected on an average of 14 days after injury. Association of use of four classes of drugs – aminoglycosides, imipenem, vancomycin and third generation cephalosporins and use of total parenteral nutrition was observed. Expedient laboratory diagnosis of FWI and appropriate systemic antifungal therapy guided by AFS may improve outcome for severely injured burn victims.

Orbicularis oris musculomucosal flap for anterior palatal fistula

Anterior palatal fistulae or residual anterior clefts are a frequent problem following palatoplasty. Various techniques have been used to repair such fistulae, each having its own advantages and disadvantages. We have successfully used orbicularis oris musculomucosal flap to close anterior fistula and residual clefts in 25 patients. This study shows the superiority of this flap over other techniques because of its reliable blood supply, easy elevation and transfer to fistula site and finally because it is a single-stage procedure.

The dartos musculocutaneous flap

Six dartos musculocutaneous flaps have been used to resurface proximal penile defects. The vascular anatomy of the flap, surgical technique and complications are described in detail.

The social construction of 'dowry deaths'

The classification of cause of death is real in its consequences: for the reputation of the deceased, for her family, for those who may be implicated, and for epidemiological and social research and policies and practices that may follow from it. The study reported here refers specifically to the processes involved in classifying deaths of women from burns in India. In particular, it examines the determination of ‘dowry death’, a class used in India, but not in other jurisdictions. Classification of death is situated within a framework of special legal provisions intended to protect vulnerable women from dowry-related violence and abuse. The findings are based on 33 case studies tracked in hospital in real time, and interviews with 14 physicians and 14 police officers with experience of dealing with burns cases. The formal class into which any given death is allocated is shown to result from motivated accounting processes representing the interests and resources available to the doctors, victims, victim families, the victim’s husband and his family, and ultimately, the police. These processes may lead to biases in research and to injustice in the treatment of victims and alleged offenders. Suggestions are made for methods of ameliorating the risks.

Police investigations: discretion denied yet undeniably exercised

Police investigations involve determining whether a crime has been committed, and if so what type of crime, who has committed it and whether there is the evidence to charge the perpetrators. Drawing on fieldwork in Delhi and Mumbai, this paper explores how police investigations unfolded in the specific context of womens deaths by burning in India. In particular, it focuses on the use of discretion despite its denial by those exercising it. In India, there are distinctive statutes relating to womens suspicious deaths, reflecting the widespread expectation that the brides family will pay a dowry to the grooms family and the tensions to which this may on occasion give rise in the early years of a marriage. Often, there are conflicting claims influencing how the womans death is classified. These in turn affect police investigation. The nature and direction of police discretion in investigating womens deaths by burning reflect in part the unique nature of the legislation and the particular sensitivities in relation to these types of death. They also highlight processes that are liable to be at work in any crime investigation. It was found that police officers exercised unacknowledged discretion at seven specific points in the investigative process, with potentially significant consequences for the achievement of just outcomes: first response, recording the victims ‘dying declaration’, inquest, registering of the ‘First Information Report’, collecting evidence, arrest and framing of the charges.

Firecracker injuries during Diwali festival: The epidemiology and impact of legislation in Delhi

Setting and Design: A hospital-based retrospective study of firecracker-related injuries was carried out at a government sponsored hospital in Delhi. Materials and Methods: 1373 patients attended the emergency burn care out-patients clinic during 2002–2010 pre-Diwali, Diwali and post-Diwali days. Every year, a disaster management protocol is revoked during these 3 days under the direct supervision of the Ministry of Health and Family Welfare, Government of India. Results: There was an increase in the number of patients of firecracker-related injuries in Delhi national capital region from the year 2002 to 2010, based on the hospital statistics. During the study period, the hospital received approximately one patient with firecracker-related injury per 100,000 population of the city. 73.02% of the victims were 5–30 years old. Majority (90.87%) of them sustained <5% total body surface area burn. Conclusions: In spite of legislations and court orders, the number of patients is on the rise. The implementation agencies have to analyse the situation to find a way to control this preventable manmade accident. Websites, emails, SMS, social sites, etc. should be used for public education, apart from conventional methods of public awareness.