Burns Management In Tertiary Health Care Centre

In rural places of our country, burns have become frequent accidents due to the use of loor-based stoves & kerosene lamps. Suicides due to burns are also quite usual in our country. The objective of this study is to evaluate the necessity of early excision of the burnwound and skin grafting to decrease the morbidity, mortality, complications of burns and stay at the hospital. Calculate pressure garment ef icacy in preventing burn scar and contracture formation. To lay out cost-effective management for patients at rural hospitals. 50 patients were included in this study presenting with burn injuries, admitted in the department of plastic surgery from June 2019 to December 2020. In a recent study, Females (52%) suffered more as compared to males. Scalds were the prime root cause of the burns constituting the 52% of the cases. Infections of Burn wound was seen in 20 patients (40%). Pseudomonas was prime organism isolated. Wound excision was required in 19 patients (38%). Around 6 to 12 days, elapsed between the injury to the surgical excision. 19 patients required (38%) coveringofwoundpermanentlywith STSG. Themean admission period in hospital for burns of 41-60% was 62 days, 33.4 days for 21-40% burns and 19.6 days for <20%. Amongst 50 patients, 3 died accounting to 6% of overall cases. This study concluded that initiation of resuscitation with untimely wound excision and permanent coverage with grafting can bring signi icant fall inmortality, painful debridements, limiting complications, decreasing the duration of stay at a hospital, curtailing the cost of health care and time apart from work.


INTRODUCTION
Considering the injuries caused from ire, we can conclude that ire is a blessing and also a curse to mankind.
Burns injuries are frequent accidents in both developed and developing Countries as their predisposing causes are universal (WHO, 2002). They are simplest in extreme of ages. Children are injured because they have not learnt about these environmental dangers. Elderly become victims when they forget the dangers or don't have the strength or capability to avoid it. In India maximum thermal accidents take place at home, particularly at the time of cooking, due to substandard cooking stoves, substandard housing, kerosene lamps & stoves.
The clinical compass of burn care constitutes luid as well as surgical intervention, electrolytes management, cardiopulmonary support, nutritional support and wound management. These cant be looked upon & treated as different units without interpretation of complete disease process. Therefore it needs an integrated approach. The likelihood of dis igurement, death and emotional trauma due to burns is a devastating experience to the victim & his/her family. Proper initial management can salvage many such unfortunate victims. (COL.BB.Dogra, 2001) Unfortunately, without necessary facilities in irstaid, surgical management and facilities in rehabilitation, patients who survive injuries, usually have disabling long term outcomes. A Ghanaian study found that 18% of childhood burns patients had suffered a physical impairment or disability. (McLoughlin, 1990) Burn injuries and their related morbidity, disability and the mortality denote a public health problem and increasing prevalence in the developing countries. (Forjuoh et al., 1996). Burn injury survival ratio has improved over the past few decades. In 1950's and early 1960's surviving from 30% TBSA burn injury irrespective of age was nearly unprecedented. Burn injuries represent an extremely stressful experience and constitute a major concern in the paediatric age group. (Cheng et al., 1990) The multiplicity of the methods and the difference in the opinion in the management of burns show that we have not yet mastered the question of management. (Forjuoh et al., 1996) Aims and Objectives 1. The objective of this study is to evaluate the necessity of early excision of the burn wound and skin grafting to decrease the morbidity, mortality, complications of burns and stay at the hospital.
2. Evaluate pressure garment usefulness in preventing post burns scar hypertrophy and the formation of contracture.
3. To lay out cost-effective management to patients in the hospital.

MATERIALS AND METHODS
Patients admitted with burn inury of varying percentage to Krishna Hospital, Karad between June 2019 to December 2020.
Patients who happen to be successfully resuscitated and remained in hospital till the treatment was complete & able to follow up for a reasonable period were selected in the study group.
Random selection of 50 patients was done from 150 total burns admissions in Krishna Hospital & Medical Research Centre, Karad between June 2019 to December 2020.

Inclusion criteria
Burn injury upto 80% of TBSA

Exclusion criteria
Burn injury > 80% of TBSA Burn injury correlated with comorbidities like diabetes & immunosuppression.

History and examination
History was taken giving special attention to the following: Routine investigations were performed in every patient along with culture and sensitivity of pus for infected burn wounds.

Management plan
Post admission, irstly securing a peripheral venous line with a wide bore venous cannula was done.
Percentage of burns injury was calculated with the help of 'Rule of 9' and compared along with Lund & Browder chart and accordingly, luids were administered using the Parklands formula.
To all of the patients, anti-tetanus prophylaxis along with prophylactic antibiotic was given & wound swab for culture sensitivity was sent. In initial 24 hours plasma expanders as well blood transfusion weren't given. After 24 hours, plasma expanders, 20% albumin & blood transfusion were given only after analysing the general state of the patient and blood values.
Oxygen support with a mask was given to every patient suspected to have an inhalational injury. The bladder was catheterized in every patient having burns >30%TBSA. Ryles tube was inserted, and patients were advised to remain NBM whenever paralytic ileus was suspected.
After improvement of general condition & initial resuscitation, the wound was cleaned using the normal saline. Silver sulfadiazine with chlorhexidine gluconate cream were applied as the topical antibiotics. Second-degree burns were managed conservatively using closed dressings. In affording patients, collagen dressing was used.
Burns injury of third-degree were excised at the earliest opportunity and permanent wound covering was performed by taking an autologous STSG in one or multiple settings depending upon donor site availability. 5 days later, graft wounds were inspected & pressure dressings along with physiotherapy were initiated. Donor site dressing was not disturbed until dressing falls by itself.
For delayed complications like hypertrophic scar & keloids treatment included the pressure garments as well as intralesional steroid injections. In cases who developed residual contractures, 'Z' plasty was performed.
Patients with electrical burns ECG along with strict monitoring of the cardiac status was done.
Patients were mobilised as early as possible, rehabilitated & discharged post complete recovery. For patients with burn injuries of second and third degrees who underwent skin grafting were advised to utilise pressure garments until 6 months minimum. At the time of death of a patient, an effort was made to manifest cause of the death.

Use of pressure garments
47 cases were advised to utilise pressure garments for a minimum duration of 6 months. Most patients were well co-operative. Only 14% of cases (7 patients) developed the residual contractures. All 7 cases went through reconstructive surgeries.
Only 3 cases in the present study developed hypertrophic scars. (Naveen et al., 2013) series 65% of the study group developed the late complications by like hypertrophic scars, keloids, and post-burn contractures. He didn't use the pressure garments.

CONCLUSIONS
The study concluded that initiation of resuscitation with untimely wound excision and permanent coverage with grafting can bring signi icant fall in mortality, painful debridement, limiting complications, decreasing the duration of stay at a hospital, curtailing the cost of health care and time apart from work.