An Outcome Analysis of Fibrin Sealant versus Staples for Fixation of Split-Thickness Skin Grafts.

Background Skin grafting plays a vital role in post-burn and post-traumatic wound management. Split-thickness skin grafts (STSG) are traditionally fixed using staples or sutures, which have tedious application and their removal necessitates painkillers, medical equipment, and human intervention. As an alternative, fibrin sealant is a biological tissue adhesive, composed of thrombin, calcium, and fibrinogen. Fibrin sealant promotes hemostasis and acts as a biological adherent. Objective The aim of this study was to evaluate the outcomes (graft take, wound healing and complications) of fibrin sealant and staples for STSG fixation. Methods It is a randomized controlled trial on 40 patients with wounds of minimum 400 cm 2 . Wound area was divided into equal halves and randomly allocated to the study group or control group. In the study group, 4 mL per 200 cm 2 of fibrin sealant was sprayed followed by STSG application. In the control group, STSG was fixed with only skin staples. Evaluation was done on postoperative days 3, 5, 15, and 30 for graft take, hematoma/seroma, infection, and complete wound healing. Results The mean graft take was significantly higher ( p -value < 0.05) in the study group than in the control group (91 vs. 89%). No seroma or hematoma formation was seen in either group. Complete wound healing was seen in more patients in the study group, but the difference was statistically insignificant. Conclusion Fibrin sealant is an excellent alternative to staples for skin grafting, with the advantage of better graft take and being free of pain that is incurred during staple removal.

Firecracker Powder: A Unique Source of Burn Injuries.

Firecrackers are a common cause of burns in India; large-scale use of firecrackers is seen during the festival of Diwali, and patients of all age groups present with varying patterns of firecracker burns. With the recent ban of firecrackers in some parts of the country, we have noticed a new emerging cause of burns during Diwali where patients were attempting to prepare firecrackers at home using Gandhak (sulfur) and potash by mixing the materials in a pipe gun. Explosion of this powder leads to varying degree of burns, and this series reports 12 such cases who presented to a tertiary care burn unit in North India during the 2022 festival of Diwali.

New fluid therapy protocol in acute burn from a tertiary burn care centre.

BACKGROUND: Ringer lactate is the main fluid for resuscitation of acute burns. However it is not a complete fluid alone, as it does not take care of sugar and electrolyte balance adequately. This study has been carried out to compare the use of Ringer lactate (RL) alone and combination of RL with Dextrose Normal Saline (DNS) as fluid replacement therapy in acute burn. OBJECTIVE: To assess the biochemical parameters with the use of DNS as maintenance fluid in combination with Ringer lactate as resuscitation fluid in acute burns resuscitation. METHOD: A prospective randomized control study has been carried out by enrolling 200 patients into 2 groups, treated in ICU and resuscitated by using Modification of Brooke's formula (2mL/kg/% TBSA for resuscitation plus 2500mL maintenance). Group A received RL for resuscitation and DNS as maintenance in 1st 72h of burns. Group B received RL only for 1st 72h. The effects of this on various blood parameters were studied. RESULTS: Mean value of sodium at 24h was 137.79±3.89 in group A and was 133.2±4.57 (p<.0001) in group B. The sodium levels remained in range of 137-138 (p<.0001) in group A with only 22% patients showing lower range of sodium levels, whereas, there was a falling trend (p<.0001) of sodium levels in group B on subsequent days with 54.00% (p<.0001) showing hyponatremia on 1st day which increased to 76% on 3rd day. Mean values of early morning random blood sugar (RBS) levels in group A remained between 165.5±65.51mg/dL-115.82±32.52mg/dL on all 3days but in group B there was a falling trend from 127.49±46.11mg/dL to 102.84±22.92mg/dL by 3rd day. Thus, there was significant difference in levels of sodium and RBS in patients receiving DNS as maintenance fluid in addition to RL in acute phase. CONCLUSION: RL is not an ideal fluid for maintenance as it is low in sodium (130mEq/L) as well as potassium (4mEq/L) in view of daily electrolyte requirement. There is no glucose content in it to provide calories. Therefore, DNS should be added as daily maintenance fluid with RL as replacement for evaporative losses following burns.

A qualitative study of the background and in-hospital medicolegal response to female burn injuries in India.

BACKGROUND: Most burns happen in low- and middle-income countries. In India, deaths related to burns are more common in women than in men and occur against a complex background in which the cause - accidental or non-accidental, suicidal or homicidal - is often unclear. Our study aimed to understand the antecedents to burns and the problem of ascribing cause, the sequence of medicolegal events after a woman was admitted to hospital, and potential opportunities for improvement. METHODS: We conducted semi-structured interviews with 33 women admitted to two major burns units, their families, and 26 key informant doctors, nurses, and police officers. We used framework analysis to examine the context in which burns occurred and the sequence of medicolegal action after admission to hospital. RESULTS: Interviewees described accidents, attempted suicide, and attempted homicide. Distinguishing between these was difficult because the underlying combination of poverty and cultural precedent was common to all and action was contingent on potentially conflicting narratives. Space constraint, problems with cooking equipment, and inflammable clothing increased the risk of accidental burns, but coexisted with household conflict, gender-based violence, and alcohol use. Most burns were initially ascribed to accidents. Clinicians adhered to medicolegal procedures, the police carried out their investigative requirements relatively rapidly, but both groups felt vulnerable in the face of the legal process. Women's understandable reticence to describe burns as non-accidental, the contested nature of statements, their perceived history of changeability, the limited quality and validity of forensic evidence, and the requirement for resilience on the part of clients underlay a general pessimism. CONCLUSIONS: The similarities between accident and intention cluster so tightly as to make them challenging to distinguish, especially given women's understandable reticence to describe burns as non-accidental. The contested status of forensic evidence and a reliance on testimony means that only a minority of cases lead to conviction. The emphasis should be on improving documentation, communication between service providers, and public understanding of the risks of burns.

Preputial flap as an adjunct to groin flap for the coverage of electrical burns in the hand.

High voltage electrical contact to hand result in injuries at multiple levels that may require more than a single flap for effective coverage. We present here a simple technique to utilise preputial flap as an adjunct to groin flap in cases where simultaneous coverage was required at more than one site in hands. In the past two years, 15 patients with unilateral involvement of hands due to electrical contact injury underwent this procedure. In addition to a comfortable position of the hand, stable and purposeful coverage at the wrist and various areas of hands was achieved in all the patients and none had flap failure. Minor complications related to penile erection were encountered that resulted in partial wound dehiscence that was managed with resuturing, pain relief and temporary suppression of erection. In our opinion, preputial flap is a good addition in our armamentarium to be used alongside groin flap for effective coverage of more than a single site requiring flap cover in electric injuries of the hand.

Recent advances in topical wound care.

There are a wide variety of dressing techniques and materials available for management of both acute wounds and chronic non-healing wounds. The primary objective in both the cases is to achieve a healed closed wound. However, in a chronic wound the dressing may be required for preparing the wound bed for further operative procedures such as skin grafting. An ideal dressing material should not only accelerate wound healing but also reduce loss of protein, electrolytes and fluid from the wound, and help to minimize pain and infection. The present dictum is to promote the concept of moist wound healing. This is in sharp contrast to the earlier practice of exposure method of wound management wherein the wound was allowed to dry. It can be quite a challenge for any physician to choose an appropriate dressing material when faced with a wound. Since wound care is undergoing a constant change and new products are being introduced into the market frequently, one needs to keep abreast of their effect on wound healing. This article emphasizes on the importance of assessment of the wound bed, the amount of drainage, depth of damage, presence of infection and location of wound. These characteristics will help any clinician decide on which product to use and where,in order to get optimal wound healing. However, there are no 'magical dressings'. Dressings are one important aspect that promotes wound healing apart from treating the underlying cause and other supportive measures like nutrition and systemic antibiotics need to be given equal attention.

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.

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.

Sternal cleft in a neonate- repaired with silastic block and pectoralis major flaps.

Sternal Cleft is a rare variety of congenital malformation seen in neonates. It is a potentially life threatening condition that may be associated with developmental anomalies of other visceral structures. Very few cases have been reported of this condition and experience with regard to time for intervention and management is limited. The authors report a case of partial sternal cleft, without any associated anomaly that had successful outcome after surgical reconstruction.

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.

Starplasty: an ideal method for correction of occluded external nares following burns.

Correction of any closed ostium following either burns or any other trauma by release and split skin grafting is not very successful in the long run because of restenosis of the ostium by contraction of the graft. It is very difficult to maintain the patency by any kind of prosthesis. For this reason we have devised a new technique called 'starplasty', which is simple and effective in opening occluded external nares without any chances of restenosis.