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Case

Shoulders, back and buttocks

This example shows a 9-year-old girl with a severe burn of the posterior trunk. Most of the deep burn injuries affecting the posterior of the trunk, encountered in rural Tanzania, were caused by burning clothes, a cause of severe mortality and morbidity in patients. Patients with a TBSA burned > 40% have a high mortality risk in low-resource settings.

Medical history

The patient’s clothes caught fire when she accidentally made contact with an open fire while working on the land. She panicked and started running and her friends and family rushed to help her. They brought her to a small, local clinic where she received only fluid therapy. Four days post-injury she arrived at Haydom Lutheran Hospital.

Physical examination

The patient had edema and 39% of her total body surface area (TBSA) had been burned. The affected areas include the posterior neck, upper arms, back, and buttocks/upper legs. The patient weighed 19.2 kg. She had dry and sunken eyes, a dry mouth, reduced skin elasticity, and decreased urine output.

Conservative management

To manage the fluid levels in the patient, medical providers used intraosseous fluid therapy and closely monitored the patient's urine output. Antibiotics were administered due to the presence of a fever. To aid in the healing process, the patient underwent daily soaking and dressing changes, and received pain management through ketamine or tramadol as available. Additionally, to maintain a healthy hemoglobin level, the patient received 3 units of blood in the first weeks of daily soaking.

Due to the large area affected by the burn and the rural setting, medical providers performed staged delayed grafting on the patient. After three weeks of daily soaking, the patient was ready for the first round of grafting (Photo 3).

Surgery

Surgery 1

During the first surgery the arms and the shoulders were grafted after carefully removing the eschar (Photo 4). Skin was taken from the donor site on the anterior of the upper legs and the scalp (Photo 5). The grafts took well (Photo 6).

Surgery 2 and 3

In the delayed staged grafting strategy a second session (Photo 7) and a third session (Photo 8) of skin grafting were needed to close the wounds.

Postoperative care

Tetracycline ointment mixed with Vaseline was applied to both the donor and acceptor sites and covered with dry gauzes. The wound was then secured with a circular bandage. After four days, the wound was inspected for any signs of infection. To prevent infection, it is important to not cover the wound too heavily with bandages. Both the patient and their parents were instructed on the importance of avoiding shearing forces, which can cause the skin graft to fail. The patient also received physical therapy while on the ward.

Outcome

The wounds gradually healed and the patient became stronger day by day. After six months she was finally discharged from the hospital (as seen in Photo 9).

In cases of severe burn injuries with a large percentage of total body surface area (TBSA) burned, patients are at risk of several life-threatening complications, such as:

  • Fluid loss/dehydration
  • Acute kidney injury (pre-renal)
  • Electrolyte imbalance (due to fluid loss)
  • Anaemia
  • Sepsis (due to necrosis and eschar formation, which reduces the skin's barrier function)
  • Acute malnutrition (increased anabolism is needed for wound recovery)
  • Failure of the take of the split skin graft
  • Infection and skin necrosis at the donor site (In this case, the child developed folliculitis on the scalp where the skin was taken)
  • Development of contractures

Lessons learned

Insights in Burn Care: Doctors acquired significant insights in burn care during the treatment of this patient. They emphasized the critical importance of fluid management for late-admission burn victims, recognizing its pivotal role in optimizing patient outcomes. Additionally, they underscored the value of implementing a staged grafting strategy to enhance stabilization and treatment planning, ultimately facilitating more effective wound healing. Moreover, the utilization of ketamine during daily soaking and dressing emerged as a beneficial practice, contributing to improved patient comfort and management.

Exploring New Techniques: Local doctors also explored innovative techniques, such as utilizing the scalp as a donor site for skin grafts, particularly in children with extensive burns. This approach, leveraging the relatively ample surface area of the scalp, showed promise in enhancing treatment efficacy. However, they cautioned against overlooking the heightened risk of complications, such as folliculitis, especially in children with darker skin tones.

Patient and Caregiver Experience: Initially, the patient endured considerable pain during transport to the hospital and the mother initially held little hope for her child's recovery. Over the course of the seven-month hospitalization period, a strong bond developed between the patient and the hospital staff, fostering an environment of trust and support. Ultimately, the patient expressed deep gratitude for the care received, reflecting the positive impact of compassionate and comprehensive healthcare delivery.

Case

Shoulders, back and buttocks