Trunk, arms and legs
This case highlights the challenges of treating burn injuries in resource-limited settings. The patient, a 6-year-old boy, sustained burns from hot water and was treated at a hospital that specializes in mother and child care in Pujehun, Sierra Leone. Despite the odds and limited resources, the child survived his injuries.
Medical history
The 6-year-old boy was playing outside when he stumbled over a large pot of boiling water in his family's hut and fell into it. His mother immediately took him to a primary health unit and he was transported by ambulance to the hospital. He arrived at the hospital just over three hours after the incident.
Physical examination
Primary Survey
The patient was assessed using primary survey and resuscitation principles as follows:
A: Airway was patent (open)
B: Chest movements were symmetrical and unrestricted, breath sounds were normal, respiratory rate was 24/min, and oxygen saturation was 99% without the use of oxygen (as it was not available).
C: No signs of internal or external bleeding, no signs of shock. Pulse rate was 116 bpm, hemoglobin level was 12.1 g/L. Two intravenous lines were established.
D: Patient was alert, pupils were equal and responsive to light, no signs of lateralization. (Glucose strips were not available.)
E: Temperature was 35.3°C, weight was 16.5kg.
Wound Inspection
The patient's clothing was removed revealing burns on the front and back of the trunk, both arms, thighs, and buttocks. Using the rule of nines modified for a 6-year-old child, the total body surface area burned was calculated to be 39%. (Photos 2 and 3)
Wound Treatment
The wounds were dressed with Silver Sulfadiazine (SSD) and sterile gauzes, which were changed daily (as seen in Photo 4). To treat hypothermia, the patient was covered with blankets (as seen in Photo 5).
Fluid Resuscitation
Fluid resuscitation was necessary as the burns were ≥ 10% TBSA.
Pain management
Pain management was done using paracetamol and intravenous morphine. Unfortunately, oral laxatives were not available.
Tests
Additional tests were not readily available, only hemoglobin could be checked (12.1 g/dl). The patient was screened for malaria; the rapid diagnostic test came back negative.
Tubes
A urinary catheter was placed to monitor urine output. Nasogastric tubes were scarce and one was not placed.
Conservative management
The patient stayed in the hospital for more than two months.
Post-Injury Day 1:
The injury was sustained less than 24 hours prior. The patient was receiving fluid resuscitation and maintenance fluids, with no signs of fluid overload. Unfortunately, urinary output was not recorded. The closed wound treatment continued with daily dressings using silver sulfadiazine. Since no duodenal or gastric tube was available, the patient was encouraged to eat carbohydrate and protein-rich foods, such as peanut-based paste and eggs.
Post-Injury Day 3:
The child developed a fever of 39.0°C, which was most likely due to the systemic reaction to the large burn wounds. Although there were no signs of infection in the wounds, an infection could not be ruled out and systemic antibiotics were started. Blister removal was also performed in the operating theatre (Photo 7).
Post-Injury Day 3 - 10:
During these days, the child was weak and had a fluctuating fever. He was unable to take oral fluids. His chest was clear, but the blood film for malaria was positive. There were no signs of wound infection (Photo 8). The possible causes of the fever included a persistent systemic reaction to the large burn surface area, a urinary tract infection, or malaria. The treatment was switched to broad-spectrum antibiotics and malaria medication was added.
Post-Injury Day 11 - 13:
The child had lost weight and was down to 11kg (from 16.5kg at admission). (Photo 9) The fever had subsided, and signs of wound healing were present (Photo 10). The malnourished child was encouraged to eat protein-rich foods and instructed to do active and passive movements.
Post-Injury Day 15 - 17:
The child was eating and drinking well and had started walking. Wounds on the arms and a large portion of the back and legs had healed (Photo 10). The wounds on the buttocks, lower back, and abdomen were still present. The anterior trunk showed scattered pigmentation at the edges of the wound, where re-epithelialization had already taken place. The lower abdomen and the wounds in the groin and hip area showed a pale wound bed (Photo 11). Debridement of the remaining dead tissue and skin grafting would have been beneficial to reduce the risk of contractures in the hip, but due to a lack of experience and equipment, conservative management was continued.
Surgery
No surgery was provided in this case.
Outcome
The patient's wounds took time to heal. As he lived far away, he had to stay in the hospital until his wounds were mostly closed. After two months of being discharged, the patient still had wounds on his buttocks and groin, affecting about 4% of his total body surface area (Photos 12 and 13).
Four months after the burn, the patient was doing well. The wounds on his buttocks still remained but were covered in crusts (Photo 14). There were no signs of contractures, and he was able to walk with ease.
Lessons learned
Proper documentation of fluid resuscitation is crucial in the management of burn patients, although it can pose challenges. Consider implementing a standardized resuscitation form in patient files to ensure accurate and consistent recording of fluid administration.
Fever is a common occurrence in burn patients, and it is essential to determine the underlying cause. In this case, the child likely contracted malaria during their hospital stay. It is important to be aware that hospital wards in areas where malaria is endemic can serve as hotspots for transmission. Whenever possible, utilize bed nets to minimize the risk of mosquito bites and malaria infection.
Malnutrition is highly prevalent among patients with extensive burns. To support wound healing, it is important to promote a diet rich in protein, such as peanut-based paste and eggs, during the early stages of recovery. Peanut paste, in addition to being protein-rich, is also high in fiber, which can help prevent constipation when laxatives are not readily available. Encouraging adequate oral fluid intake and mobilization is also crucial in preventing constipation.
Surgical debridement and skin grafting are vital procedures in burn management worldwide. In the case described, the patient survived and did not develop contractures due to the diligent efforts of a dedicated medical team providing conservative burn care. However, it is important to note that complete wound healing had not been achieved even after four months, highlighting the complex and time-consuming nature of burn recovery.
Physiotherapy plays a pivotal role in preventing contractures. In situations where formal physiotherapy services may be unavailable, the involvement of supportive relatives or caregivers becomes crucial. Early initiation of passive and active mobilization exercises, under guidance, can contribute significantly to preserving joint mobility and preventing the development of contractures.
By incorporating these lessons learned into burn care practices, healthcare providers can enhance patient outcomes and improve the overall management of burn injuries.
