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Case

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 1 and 2)

Wound Treatment

The wounds were dressed with Silver Sulfadiazine (SSD) and sterile gauzes, which were changed daily (as seen in Photo 3). To treat hypothermia, the patient was covered with blankets (as seen in Photo 4).

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 5).

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 6). 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 7) The fever had subsided, and signs of wound healing were present (Photo 8). 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 9). 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 10 and 11).

Four months after the burn, the patient was doing well. The wounds on his buttocks still remained but were covered in crusts (Photo 12). There were no signs of contractures, and he was able to walk with ease.

Lessons learned

Accurate Documentation of Fluid Resuscitation: Proper documentation of fluid resuscitation is paramount in burn patient management, albeit presenting challenges. Introducing a standardized resuscitation form in patient records can ensure precise and consistent recording of fluid administration, streamlining the process and enhancing patient care.

Managing Fever in Burn Patients: Fever is a frequent occurrence in burn patients, warranting thorough investigation into its underlying cause. In the described case, the child likely contracted malaria during their hospitalization. Awareness should be raised regarding the potential for hospital wards in malaria-endemic areas to serve as transmission hotspots. Implementing preventive measures such as bed nets can mitigate the risk of mosquito bites and subsequent malaria infection.

Addressing Malnutrition: Malnutrition is prevalent among patients with extensive burns and significantly impacts wound healing. Emphasizing a diet rich in protein, including peanut-based paste and eggs, during the early stages of recovery can support healing processes. Peanut paste, being both protein-rich and high in fiber, also aids in preventing constipation, particularly when laxatives are not readily accessible. Encouraging adequate oral fluid intake and mobilization further contributes to preventing constipation and supporting overall recovery.

Understanding the Importance of Surgical Intervention: Surgical debridement and skin grafting are indispensable procedures in burn management globally. While the patient described in the case avoided contractures due to meticulous conservative care provided by a dedicated medical team, complete wound healing remained elusive even after four months. This underscores the intricate and time-intensive nature of burn recovery, emphasizing the ongoing challenges in achieving optimal outcomes.

Role of Physiotherapy in Preventing Contractures: Physiotherapy plays a crucial role in mitigating the risk of contractures in burn patients. In settings where formal physiotherapy services may be limited, the involvement of supportive relatives or caregivers becomes pivotal. Early implementation of passive and active mobilization exercises, guided by healthcare professionals, significantly contributes to preserving joint mobility and averting contracture development.

By incorporating these lessons learned into burn care practices, healthcare providers can enhance patient outcomes and improve the overall management of burn injuries.

Case

Trunk, arms and legs