Case 6-2004 — A 35-Year-Old Woman with Extensive, Deep Burns from a Nightclub Fire
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《新英格兰医药杂志》
Presentation of Case
A 35-year-old woman sustained extensive burns and was possibly trampled in a nightclub after a pyrotechnics display set fire to the building. At the scene, she was responsive but confused and agitated.
Hour 2
Ninety minutes after the start of the fire, the patient arrived in the emergency department of another hospital. She was disoriented and in moderate distress, and she was coughing up soot and having trouble breathing. There were burns on her face, chest, back, and arms and legs. The nasal hair was singed. She was sedated, and the trachea was intubated. The carboxyhemoglobin level was 28 percent. The results of other laboratory tests are shown in Table 1, Table 2, and Table 3. A nasogastric tube, Foley catheter, and left femoral triple-lumen catheter were placed, and 2 liters of normal saline was administered; thereafter she received continuous fluid resuscitation. A diphtheria–tetanus vaccine booster was administered. A chest radiograph and computed tomographic scans of the neck, head, abdomen, and pelvis showed no abnormalities.
Table 1. Arterial-Blood Gas Values and Ventilatory Information.
Table 2. Hematologic and Coagulation Laboratory Data.
Table 3. Blood Chemical Values.
Hours 3 through 6
The patient was admitted to the intensive care unit. The blood pressure was 154/84 mm Hg, the pulse 92 beats per minute, and the respiratory rate 16 breaths per minute while she was receiving mechanical ventilatory support. Second- and third-degree burns to the skin had been estimated by various observers to involve 30 to 60 percent of the body-surface area. The arms and legs were cold but not edematous. A right femoral arterial catheter was placed.
The fingers were débrided, the hands and back were cleansed with saline, and silver sulfadiazene cream and dressings were applied. The compartments of her hands and forearms were initially soft, and splints were applied. Bronchoscopy performed at the bedside 4 hours and 30 minutes after the fire revealed carbonaceous material in the airways leading to all the lobes of the lungs. The tracheobronchial mucosa was inflamed and friable.
Hour 11
Because the burn unit at the Massachusetts General Hospital had reached capacity while other victims of the same fire were treated, the patient was transported to the adjacent Shriners Hospital for Children in Boston (a burn center affiliated with this hospital) and arrived there 11 hours after she had sustained her burn injuries. According to a family member, she had no medical problems except for an allergy to amoxicillin. She did not smoke and occasionally drank alcohol. She was divorced and had two children. Medications and fluids given during the transfer were Ringer's lactate solution, intravenous morphine (10 mg per hour), and intravenous propofol (titrated for comfort). Fluid intake and output are listed in Table 4.
Table 4. Fluid Intake and Output.
On examination, the patient was sedated and had an endotracheal tube in place; she responded to questions by nodding her head. She moved her arms and legs in response to pain. The blood pressure was 152/98 mm Hg, the respiratory rate 18 breaths per minute with mechanical ventilatory support, and the pulse 98 beats per minute, and the temperature ranged from 34.1°C to 35.6°C. The chest and heart were normal on auscultation. The abdomen was normal. There were third- and fourth-degree burns (extending into subcutaneous tissue, fascia, muscle, or bone) over 40 percent of her body, including the head, neck, shoulders, upper torso, arms, hands, and right knee (Figure 1A and Figure 1B). Doppler ultrasonography showed that the pulses in the digits were minimal or absent. The results of laboratory tests are shown in Table 1, Table 2, and Table 3. A chest radiograph showed bilateral, predominantly central, lung opacities, a finding compatible with the presence of early pulmonary edema or inhalation injury (Figure 2A). Opiates, benzodiazepine, ranitidine, and warmed fluids were administered intravenously. She was placed in a warm, bacteria-controlled nursing unit.
Figure 1. Photographs of the Patient's Burn Wounds and Grafts.
There is a deep burn on the top of the head, with charring of the bone (Panel A). Burns on the side of the head, neck, and face have been débrided. The skin of the left shoulder (Panel B) is blackened, and wounds extend to the fascial level. The burned skin on the left forearm and the dorsum of the left hand have been removed (Panel C); the burns on the fingers are left for later débridement and grafting. A split-thickness skin allograft has been applied to the left forearm and hand (Panel D).
Figure 2. Chest Radiographs.
A radiograph obtained on the first day after the fire (Panel A) shows perihilar air-space disease, indicating the presence of early pulmonary edema. On the third day (Panel B), the appearance of widespread bilateral consolidation probably represents the development of the acute respiratory distress syndrome. A plain-film radiograph obtained on the seventh day, five days after the start of nitric oxide therapy (Panel C), shows partial resolution of the bilateral lung opacities. L denotes the left side.
Examination of the eyes by an ophthalmologist disclosed 3+ edema of both lower lids, with singed lashes, bilateral conjunctival chemosis, and a small epithelial defect in the right cornea, indicating thermal keratitis. There was no rupture of the globes and no compartment syndrome. Erythromycin and lubricating ointments were administered.
Hour 15
Fifteen hours after the fire, the arms and the hands had become firm, and the patient was taken to the operating room. The skin of the arms and hands was charred and leathery, with thrombosed vessels in the subcutaneous fat. Escharotomies and fasciotomies were performed on the left wrist and hand, and escharectomies and grafting with cadaveric skin were performed on both shoulders, the left upper arm, and the right arm and hand (Figure 1A and Figure 1B). Blood flow was detectable by Doppler ultrasonography in the palmar arch and digital pulp after the surgery.
Ringer's lactate solution and albumin were administered intravenously; silver sulfadiazene was applied to the face, mafenide acetate to the ears, and silver nitrate to the trunk, arms, and legs. Norepinephrine was administered in titrated doses beginning at 5 μg per minute. The temperature ranged from 36.9°C to 37.7°C, and abundant black material was suctioned from the endotracheal tube. Specimens from the wounds, urine, and catheters were sent for culture.
During the night and throughout the next day, increased pressures were needed in the ventilator circuit as adjustments were made to maintain the arterial oxygen saturation at 96 percent with the fraction of inspired oxygen at 0.50 to 0.70 (Table 1). The temperature was 38.3°C. Hypotension developed, necessitating increased vasopressor support. Dalteparin therapy (5000 U per day) was started.
Days 2 and 3
On the second day after the burn injuries had been sustained, the maximal temperature was 38.3°C, the systolic blood pressure ranged from 94 to 127 mm Hg, the diastolic blood pressure ranged from 48 to 69 mm Hg, the heart rate ranged from 112 to 134 beats per minute with premature atrial contractions, and the respiratory rate was set at 20 breaths per minute, without spontaneous breathing. The central venous pressure was 5 to 10 mm Hg.
On the third day, excision and allografting of the skin of the dorsum of the left hand (Figure 1C and Figure 1D), the left arm, and the upper back were performed. A deep burn on the back that was charred and wooden in consistency was excised; the excision included the involved fascia. The remaining eschar on the left arm and hand was excised. The deeply burned digits were not débrided.
The oxygen saturation decreased from 98 percent while the fraction of inspired oxygen was 0.80 to 0.90 and to 93 percent while the fraction of inspired oxygen was 1.00, with a peak inspiratory pressure of 44 cm of water and a peak end expiratory pressure of 18 cm of water (Table 1). The maximal temperature was 38.9°C, and the central venous pressure increased to 15 to 20 mm Hg. Copious black material was suctioned from the endotracheal tube. Four hours after the procedure, the arterial oxygen tension was 61 mm Hg, and the oxygen saturation 90 percent (Table 1) while the patient was breathing 100 percent oxygen. A chest radiograph showed diffuse bilateral interstitial infiltrates, a finding consistent with the development of the acute respiratory distress syndrome (Figure 2B). Nitric oxide therapy administered by inhalation (20 ppm) was started, and rapid improvement in oxygenation followed (Table 1).
Days 4 and 5
On the fourth day after the fire, a culture of a skin wound was positive for methicillin-sensitive Staphylococcus aureus, and antibiotics were administered as part of perioperative coverage. On the fifth day, disseminated intravascular coagulation developed (Table 2), with bleeding into the airway, which was controlled with a platelet transfusion. Additional specimens were sent for culturing, and the antibiotic coverage was broadened to treat possible gram-negative sepsis.
Weeks 2, 3, and 4
During the second week after the fire, the patient's respiratory status improved, with clearing of the infiltrates on the chest radiographs (Figure 2C); the nitric oxide was discontinued. The coagulopathy resolved. On the eighth day, fever developed and the white-cell count was elevated; wound and sputum cultures were positive for methicillin-sensitive S. aureus. The catheters, including the Foley catheter, were replaced, and the patient completed a 12-day course of antibiotics. During the same week, the first of seven definitive wound-closure procedures (described below) was performed.
During the third and fourth weeks after the fire, the patient's temperature reached 39.1°C, and a sputum culture grew Pseudomonas aeruginosa, despite the continued clearing of the pulmonary infiltrates observed on chest radiographs. Vancomycin and ceftazidime were administered, and the fever resolved. On day 27, the trachea was extubated, but it was reintubated later that day because of fatigue and the accumulation of secretions.
Month 1
On day 30 after the patient had sustained her burn injuries, she was transferred to this hospital, and a tracheostomy was performed. During the next five weeks, she underwent multiple excision and grafting procedures as well as physical, occupational, and speech therapy. Wound closure was complicated by the extreme depth of the burns, most of which extended to the subcutis, muscle, and bone. The narcotics administered intravenously for pain control were gradually discontinued and replaced with orally administered methadone. She required prolonged antibiotic treatment for pneumonia due to P. aeruginosa and for wound infections with staphylococcus species (including methicillin-sensitive and methicillin-resistant S. aureus).
On day 62, decannulation of the tracheostomy was followed by a good return of the voice. A follow-up ophthalmologic examination documented a left corneal scar and slight lagophthalmos in the left eye due to lid retraction. She was discharged to a rehabilitation hospital on day 70 after the fire.
Discussion of Management
Dr. Robert L. Sheridan: Progress in burn care has been heavily influenced by disasters. The Triangle Shirtwaist Factory fire of 1911 highlighted the dangers of crowded buildings with inadequate exits. The Rialto Concert Hall fire of 1930 led to a better understanding of burn resuscitation.1 The Hartford Circus fire of 1944 emphasized the need for regional planning to distribute multiple burn casualties.2 The Cocoanut Grove nightclub fire of 1942 resulted in legislation to improve public safety, with such measures as outward-opening exit doors for public places.3 Experience during the Vietnam War showed that immediate evacuation to capable resuscitation facilities improved clinical outcomes. Experience during the first Gulf War showed that successful planning for surges in the need for high-level burn care is possible.
In the era of the Cocoanut Grove fire, survival with burns over 30 percent of the body was not generally possible.4 Until surprisingly recently, patients with serious burns, such as the patient under discussion, were treated with comfort measures only, since even if they could be saved, it was assumed that their quality of life would be so poor that treatment would be unethical.5 However, both the rate and quality of survival after serious burns have increased dramatically during the past 20 years.6,7 Burn care can be roughly organized into four clinical phases: first, initial evaluation and resuscitation; second, initial burn excision and biologic closure; third, definitive wound closure; and fourth, rehabilitation and reconstruction.
Resuscitation and Critical Care of Patients with Burns
Dr. John T. Schulz: This patient's initial care was directed at stabilization of her airway, breathing, and circulation.8 The history and physical examination suggested a diagnosis of smoke-inhalation injury, which can be accompanied by severe hypopharyngeal and laryngeal edema and which is thus an indication for airway protection. Additional indications for intubation included the extensive, deep burns to her upper body and her clouded mental status. The local and systemic capillary leak accompanying these burns would soon have caused sufficient pharyngeal edema to close her airway.9 The sedatives and analgesics required to manage her pain and distress would soon suppress her respiratory drive and eliminate airway-protective reflexes. Early intubation was lifesaving.
Once the patient's trachea had been intubated, her breathing was supported by mechanical ventilation. Early arterial-blood gas analysis showed excellent gas exchange but clinically significant metabolic acidosis. Metabolic acidosis suggests the presence of ischemia, which can be caused by hypoperfusion due to volume depletion or pump failure. However, the initial carboxyhemoglobin level of 28 percent suggested ischemia at the molecular level, since carbon monoxide prevents oxygen from binding to hemoglobin. The patient received 100 percent inspired oxygen to treat carbon monoxide intoxication. Although we consider hyperbaric therapy for carboxyhemoglobin levels greater than 25 percent, the condition of patients with severe burns is usually too unstable for them to receive such treatment.10,11
Hypovolemia undoubtedly contributed to the patient's initial acidosis. Large burns evoke a systemic capillary leak: plasma and proteins flood into the interstitium, creating massive edema and emptying the vasculature. Since there is no known way to reverse this process, treatment involves pouring fluid containing crystalloid or colloid into the circulation as fast as it leaks out.12 The initial need for fluid varies directly with the size of the burn (hence the importance of estimating the percentage of body-surface area burned) and the size of the patient. Extensive clinical experience has validated the use of the modified Brooke formula for the initial estimation of resuscitation needs (2 to 4 ml multiplied by the total burned area of the body surface , multiplied by the body weight , with half of this amount given in the first 8 hours after presentation and the remaining half in the next 16 hours).8 Any formula is only a starting point, however; ongoing monitoring is essential to ensure that resuscitation is sufficient to support adequate urine output (0.5 to 1.0 ml per kilogram of body weight per hour) and hemodynamic stability. Smoke-inhalation injury increases volume requirements by up to 50 percent.13,14
Considering this patient's weight, the size of her burns, and her inhalation injury, an initial estimate of her maximal fluid requirement would fall in the range of 18 liters during the first 24 hours after presentation. On day 1, when she arrived at the first hospital, she probably had a fluid deficit of at least 1 liter (Table 4). Adequate initial resuscitation and elimination of carboxyhemoglobin (i.e., correction of the carbon monoxide intoxication) were reflected in early resolution of her metabolic acidosis. The resuscitation fluid was delivered by central venous catheters, which were preferentially placed through unburned skin.
Once the patency of the airway and the stability of breathing and circulation had been ensured, the patient underwent other standard interventions for burn care: administration of a diphtheria–tetanus vaccine booster (without immune globulin, which is added if there is no history of immunization), a radiologic workup for trauma because of the possibility that she had been trampled at the nightclub,15 dressing of her wounds with a topical antimicrobial agent,16 and bronchoscopy to confirm the smoke-inhalation injury.17
On arrival in Boston 11 hours after her injury, the patient had mild hypothermia. Hypothermia is a common problem in burned patients. Fluids should be warmed, and wet dressings should never be applied before transport. She responded to passive rewarming measures. Prophylactic measures against deep-vein thrombosis and gastric ulcers were started.
On day 3 after the fire, the patient's pulmonary gas exchange began to deteriorate rapidly because of intrapulmonary ventilation–perfusion mismatching, which resulted in a potentially lethal physiological shunt. Nitric oxide, a potent, short-acting vasodilator, was administered through the airway and resulted in rapid improvement.18
Even with adequate caloric feeding, patients with burns may lose muscle mass during their illness because hypercatabolism results in the consumption of muscle protein.19 In this case, as is our practice, we began hyperalimentation with high levels of nitrogen immediately, with transition to feeding through a postpyloric tube as soon as it was tolerated by the patient. Nutrition was maintained perioperatively by total parenteral nutrition.
Dr. McGinnis, can you show us the thoracic imaging studies?
Dr. Paul J. McGinnis: A radiograph obtained on day 1 shows bilateral, predominantly central, lung opacities (Figure 2A) — findings that are compatible with early pulmonary edema and that are characteristic of smoke-inhalation injury. By day 3, the pulmonary opacities have worsened and are more diffuse, indicating the development of the acute respiratory distress syndrome (Figure 2B). By day 7, after five days of nitric oxide therapy, progressive clearing of the pulmonary opacities is evident (Figure 2C).
By day 18, despite a sputum culture that was positive for P. aeruginosa, a chest radiograph showed improvement of the pulmonary opacities, with no evidence of developing air-space disease. Plain-film radiographic findings are nonspecific for nosocomial infection with pseudomonas in patients with the acute respiratory distress syndrome who are receiving mechanical ventilation.20
Surgical Treatment of Burns
Dr. Sheridan: There are five general classes of burn operations: decompression procedures, excision and biologic closure operations, definitive closure procedures, burn reconstructive procedures, and general supportive procedures. This patient required operations in each of these categories. Surgical management of burn wounds before colonization of the eschar by bacteria and septic liquefaction, which otherwise are inevitable, is at the heart of the improved outcomes seen in recent decades in patients with burns.21
Prompt recognition of imminent ischemia in the limbs or constriction of the chest and abdominal wall is essential to prevent ischemic necrosis of the limbs and difficulty with ventilation as a consequence of soft-tissue hypertension.22 Escharotomies and fasciotomies are performed to release the compression caused by the rigid burned tissue and the edematous unburned tissue below it. These operations are performed on the limbs, chest, and abdomen. Occasionally, laparotomy is needed for abdominal decompression. In this patient, escharotomies were performed on the torso, arms, and legs and fasciotomies on the arms in order to restore a pulse in her digits and to facilitate ventilation. The burns on her face, arms, hands, and torso were excised within five days after the injury and covered with human allograft (Figure 1A, Figure 1B, Figure 1C, and Figure 1D). Closure of the skull wound required removal of portions of the burned outer table of the skull.
These operations have a reputation for being bloody and physiologically stressful. However, with attention to the details of intraoperative critical care, heating of the operating room to prevent hypothermia and associated coagulopathy, and use of techniques to minimize operative blood loss, these operations are well tolerated and greatly improve the outcome. Ideally, wounds generated during these procedures are covered immediately with autografts. However, when wounds are very large or when a patient is in unstable condition, it is often more prudent to use temporary membranes, such as the allograft used in this case.23
Definitive wound-closure operations are performed later and involve the replacement of temporary membranes with permanent grafts, usually split-thickness autografts, and definitive surgery for wounds of small but complex areas, such as the digits, face, and genitals. These areas are small enough that they are not likely to cause overwhelming sepsis if left to slough spontaneously, and they require a disproportionate amount of time and amount of skin graft in the operating room, so they are typically deferred until the patient's condition is stable and larger wounds have been closed. In the current case, the patient's deeply burned digits were definitively closed with sheet autografts in the weeks after her initial therapy, and range of motion was maintained with a program of hand therapy and splinting. Kirshner wires for internal fixation of the digits were used selectively.
Reconstructive operations begin as soon as functional progress is impeded by contractures. Contractures that limit physical function are given priority, but aesthetic problems that limit social reintegration are also considered to be early surgical priorities. The contracted tissue is replaced with split-thickness or full-thickness skin or flaps. In the patient under discussion, reconstruction began with correction of dorsal hand contractures (Figure 3A) and release of a tight contracture of the posterior surface of the neck (Figure 3B). The patient also had a flexion deformity of the proximal interphalangeal joint from destruction of the dorsal extensors and volar migration of the lateral bands, known as a boutonnière deformity. This problem will be addressed at a later date and may require fusion of the joint.24
Figure 3. Photographs Taken after the Performance of Definitive Excision and Grafting Procedures.
The allograft of the left forearm and hand (Panel A) has been replaced by split-thickness sheet autographs. A flexion (boutonnière) deformity of the first proximal interphalangeal joint has developed. The burned skin on the head and neck has been replaced by autografts (Panel B). A small open wound remains on the top of the head. The left external ear is mostly absent. A hypertrophic scar limits the range of motion of the neck.
Finally, patients with burns require a predictable set of supportive general surgical operations that include vascular access, tracheostomy, gastrostomy, cholecystectomy, and abdominal procedures.25 A high index of suspicion for clinically significant abdominal complications is an important part of burn-related intensive care.26 This patient required multiple vascular-access procedures and bronchoscopies to irrigate and suction thick secretions as well as a tracheostomy.
Rehabilitation of Patients with Burns
Dr. Colleen M. Ryan: The goals of burn treatment in a comprehensive burn center extend beyond survival to encompass rehabilitation and recovery. The survival rate among patients with massive burns improved during the 1970s and 1980s.27 Now that patients with massive burns survive, the new population of patients surviving large burn injuries is expanding.
This patient was discharged from the hospital 10 weeks after the fire. Whereas her survival was predicted by objective probability estimates, her hospitalization was much longer than that predicted according to burn size alone.27 The prolonged hospital stay was indicative of the severity of her inhalation injury and the extreme depth of her burns. She was discharged home from the rehabilitation facility 16 weeks after the fire.
Nine months after the fire, this patient has many of the symptoms and impairments that may be seen after severe burns (Table 5). She has a small open wound on her head that will contract and close over time. In addition, she has lost most of her left external ear (Figure 3B). She needs to protect her ear canal while showering and use straps to retain eyewear. Options for future reconstruction of the ear include composite grafts28 or a prosthesis. She has near-total alopecia, which she conceals with scarves and wigs (Figure 4A and Figure 4B).
Table 5. Common Long-Term Disabilities in Patients with Burn Injuries.
Figure 4. Photographs of the Patient 10 Months after the Fire.
There is near-total alopecia (Panel A). The ectropion of the left eyelid has been successfully released. With the use of makeup and a wig (Panel B), a good cosmetic result is achieved. The patient is able to write (Panel C), despite the contracture of her left index finger, which has yet to be fully corrected.
An important problem for this patient has been hypertrophic scarring, which has resulted in dry skin and areas susceptible to injury from minor trauma, cold, and sun exposure. The scars have resulted in contractures of her neck, left eyelid, hands, and arms and were initially pruritic and painful. Hypertrophic scars after burns cause symptoms that are more serious than the obvious aesthetic deformity; however, these symptoms generally resolve over a period of several months. Itching may interfere with sleep. Some patients report persistent discomfort from the thickness and nonpliability of scars. Our patient reported burning, lancinating, or "pins and needles" pain, which is not uncommon.
Pruritic scars often respond to topical doxepin hydrochloride as well as diphenhydramine hydrochloride, cool water, or milk-and-oatmeal baths. Pain-related symptoms respond poorly to narcotics. Gabapentin and triamcinolone acetonide injections are sometimes useful. Topical silicone pads can help flatten scars and reduce redness. Pressure garments worn 23 hours a day have a long anecdotal history in the treatment of burn scars, but little information exists as to whether the resulting flattening and reduced erythema of the scars translates into a permanent effect that is superior to the partial spontaneous involution of the scars with time. These garments protect the fragile scars from minor trauma, and many patients, such as this one, find them comfortable and rely on them. With these treatments, in combination with the expected course of spontaneous resolution, the patient's scar symptoms have improved over the past several months.
Hypertrophic scars positioned across a joint can interfere with range of motion. This patient had a contracture of the posterior surface of the neck; surgical release, performed two months after discharge, has resulted in substantial improvement. Ectropion, or eyelid retraction resulting in an inability to close the eyelid and potential corneal ulcerations due to exposure, also developed. She has had two releases of her left upper eyelid. Good eyelid apposition is maintained with the use of this procedure, without disruption of the tarsal margin.29
Exceptionally severe burns of the hands and the head were characteristic of the patients injured in this fire. Some patients had no remaining viable tissue in the arms and required amputations. This patient fortunately did not require amputation, but the burns extended into some of her tendons and finger joints. Scarring and contractures have limited the function of her hands. The management of hand burns24 in this case involved early escharotomy to preserve blood flow to the digits, splinting in a position of function, passive range-of-motion exercises, and excision and placement of split-thickness skin grafts as soon as possible. Active range-of-motion exercises were begun as soon as her condition allowed. Despite all these measures, the proximal interphalangeal joint of the left index finger rapidly assumed a 90-degree flexion deformity (Figure 3A). The patient's hand function improved with surgical release of contracted soft tissues and grafting of the dorsum of both hands one month before her discharge from the rehabilitation facility, but she clearly will face a number of reconstructive procedures on her hands in the future. Despite the deformities, she is beginning to adapt and compensate. She reports being able to use a computer keyboard and is able to write with her left hand (Figure 4C). The strength of her right hand is still limited, but she can now carry a handbag. She can open a jar with her left hand but not with her right hand.
Heterotopic ossification is a less common but debilitating complication of burn injuries. In this case, posterior medial heterotopic ossification resulted in severe ankylosis of the patient's right elbow, which became fixed in 40-degree flexion. Dr. Jesse Jupiter resected the heterotopic bone and performed ulnar-nerve transposition. So far the patient has gained flexion of up to 70 degrees, and she is currently undergoing physical therapy. May we see the radiographs of the elbow?
Dr. McGinnis: A radiograph of the right elbow (Figure 5A) obtained during the second month after the fire shows a large area of heterotopic bone posterior to the distal humerus. A radiograph taken after surgery (Figure 5B) shows that the heterotopic bone has disappeared.
Figure 5. Radiographs of the Right Elbow.
A radiograph obtained during the second month after the fire (Panel A) shows heterotopic bone posterior to the distal humerus. A radiograph obtained after surgery (Panel B) shows resection of heterotopic bone with improved extension of the elbow. R denotes the right side.
Dr. Ryan: A staff psychiatrist evaluates all patients with major burns and screens them for sleep disturbances, adjustment disorders, and post-traumatic stress disorder. This patient has excellent coping abilities and excellent family support and attends long-term follow-up in our comprehensive outpatient burn program. All these characteristics have been shown to correlate with good recovery.7,30 She hopes to return to work as a medical secretary once the recovery of her hand function has progressed. She is interactive, maintains a courageous and positive attitude, and has reached several milestones in regaining her quality of life. She participates fully as a parent of her children and is dealing with the loss of friends in the fire.
Dr. Nancy Lee Harris (Pathology): I would like to ask the patient to comment on her experience.
The Patient: There is so much I remember about that awful night and so many things I will never know. I do not know who pulled me out of the burning building and do not remember being brought to the hospital. I awoke weeks later, and nothing seemed real. I could not believe I had lived through the fire and only very slowly began to remember everything that had happened. I appreciated the compassion and care of the nurses in changing my dressings twice a day and just being there when I was depressed. I have never seen such dedication and teamwork.
Being a burn victim has taken away many of the things I enjoyed in life. I still struggle with many things, such as the fact that I will never have my own hair again and that I have lost my ear. I want to be me again, so with the help of my doctors, nurses, and therapists I am on the road to recovery. The first time I was able to shower by myself or tie my own shoes was a big accomplishment. Every day I make sure I accomplish something new and then go to bed at night peacefully. I have decided not to waste another minute dwelling on what happened and whose fault it was and to enjoy the second chance I have been given.
We are indebted to the patient and her family and have been privileged to witness their courage in her recovery.
Source Information
From the Burn and Trauma Services (R.L.S., J.T.S., C.M.R.) and the Department of Radiology (P.J.M.), Massachusetts General Hospital; the Shriners Hospital for Children (R.L.S., J.T.S., C.M.R.); and the Departments of Surgery (R.L.S., J.T.S., C.M.R.) and Radiology (P.J.M.), Harvard Medical School — all in Boston.
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Related Letters:
Case 6-2004: Severe Burns from a Nightclub Fire
Borron S. W., Mégarbane B., Baud F. J., Sheridan R., Schultz J., Ryan C.(Robert L. Sheridan, M.D.,)
A 35-year-old woman sustained extensive burns and was possibly trampled in a nightclub after a pyrotechnics display set fire to the building. At the scene, she was responsive but confused and agitated.
Hour 2
Ninety minutes after the start of the fire, the patient arrived in the emergency department of another hospital. She was disoriented and in moderate distress, and she was coughing up soot and having trouble breathing. There were burns on her face, chest, back, and arms and legs. The nasal hair was singed. She was sedated, and the trachea was intubated. The carboxyhemoglobin level was 28 percent. The results of other laboratory tests are shown in Table 1, Table 2, and Table 3. A nasogastric tube, Foley catheter, and left femoral triple-lumen catheter were placed, and 2 liters of normal saline was administered; thereafter she received continuous fluid resuscitation. A diphtheria–tetanus vaccine booster was administered. A chest radiograph and computed tomographic scans of the neck, head, abdomen, and pelvis showed no abnormalities.
Table 1. Arterial-Blood Gas Values and Ventilatory Information.
Table 2. Hematologic and Coagulation Laboratory Data.
Table 3. Blood Chemical Values.
Hours 3 through 6
The patient was admitted to the intensive care unit. The blood pressure was 154/84 mm Hg, the pulse 92 beats per minute, and the respiratory rate 16 breaths per minute while she was receiving mechanical ventilatory support. Second- and third-degree burns to the skin had been estimated by various observers to involve 30 to 60 percent of the body-surface area. The arms and legs were cold but not edematous. A right femoral arterial catheter was placed.
The fingers were débrided, the hands and back were cleansed with saline, and silver sulfadiazene cream and dressings were applied. The compartments of her hands and forearms were initially soft, and splints were applied. Bronchoscopy performed at the bedside 4 hours and 30 minutes after the fire revealed carbonaceous material in the airways leading to all the lobes of the lungs. The tracheobronchial mucosa was inflamed and friable.
Hour 11
Because the burn unit at the Massachusetts General Hospital had reached capacity while other victims of the same fire were treated, the patient was transported to the adjacent Shriners Hospital for Children in Boston (a burn center affiliated with this hospital) and arrived there 11 hours after she had sustained her burn injuries. According to a family member, she had no medical problems except for an allergy to amoxicillin. She did not smoke and occasionally drank alcohol. She was divorced and had two children. Medications and fluids given during the transfer were Ringer's lactate solution, intravenous morphine (10 mg per hour), and intravenous propofol (titrated for comfort). Fluid intake and output are listed in Table 4.
Table 4. Fluid Intake and Output.
On examination, the patient was sedated and had an endotracheal tube in place; she responded to questions by nodding her head. She moved her arms and legs in response to pain. The blood pressure was 152/98 mm Hg, the respiratory rate 18 breaths per minute with mechanical ventilatory support, and the pulse 98 beats per minute, and the temperature ranged from 34.1°C to 35.6°C. The chest and heart were normal on auscultation. The abdomen was normal. There were third- and fourth-degree burns (extending into subcutaneous tissue, fascia, muscle, or bone) over 40 percent of her body, including the head, neck, shoulders, upper torso, arms, hands, and right knee (Figure 1A and Figure 1B). Doppler ultrasonography showed that the pulses in the digits were minimal or absent. The results of laboratory tests are shown in Table 1, Table 2, and Table 3. A chest radiograph showed bilateral, predominantly central, lung opacities, a finding compatible with the presence of early pulmonary edema or inhalation injury (Figure 2A). Opiates, benzodiazepine, ranitidine, and warmed fluids were administered intravenously. She was placed in a warm, bacteria-controlled nursing unit.
Figure 1. Photographs of the Patient's Burn Wounds and Grafts.
There is a deep burn on the top of the head, with charring of the bone (Panel A). Burns on the side of the head, neck, and face have been débrided. The skin of the left shoulder (Panel B) is blackened, and wounds extend to the fascial level. The burned skin on the left forearm and the dorsum of the left hand have been removed (Panel C); the burns on the fingers are left for later débridement and grafting. A split-thickness skin allograft has been applied to the left forearm and hand (Panel D).
Figure 2. Chest Radiographs.
A radiograph obtained on the first day after the fire (Panel A) shows perihilar air-space disease, indicating the presence of early pulmonary edema. On the third day (Panel B), the appearance of widespread bilateral consolidation probably represents the development of the acute respiratory distress syndrome. A plain-film radiograph obtained on the seventh day, five days after the start of nitric oxide therapy (Panel C), shows partial resolution of the bilateral lung opacities. L denotes the left side.
Examination of the eyes by an ophthalmologist disclosed 3+ edema of both lower lids, with singed lashes, bilateral conjunctival chemosis, and a small epithelial defect in the right cornea, indicating thermal keratitis. There was no rupture of the globes and no compartment syndrome. Erythromycin and lubricating ointments were administered.
Hour 15
Fifteen hours after the fire, the arms and the hands had become firm, and the patient was taken to the operating room. The skin of the arms and hands was charred and leathery, with thrombosed vessels in the subcutaneous fat. Escharotomies and fasciotomies were performed on the left wrist and hand, and escharectomies and grafting with cadaveric skin were performed on both shoulders, the left upper arm, and the right arm and hand (Figure 1A and Figure 1B). Blood flow was detectable by Doppler ultrasonography in the palmar arch and digital pulp after the surgery.
Ringer's lactate solution and albumin were administered intravenously; silver sulfadiazene was applied to the face, mafenide acetate to the ears, and silver nitrate to the trunk, arms, and legs. Norepinephrine was administered in titrated doses beginning at 5 μg per minute. The temperature ranged from 36.9°C to 37.7°C, and abundant black material was suctioned from the endotracheal tube. Specimens from the wounds, urine, and catheters were sent for culture.
During the night and throughout the next day, increased pressures were needed in the ventilator circuit as adjustments were made to maintain the arterial oxygen saturation at 96 percent with the fraction of inspired oxygen at 0.50 to 0.70 (Table 1). The temperature was 38.3°C. Hypotension developed, necessitating increased vasopressor support. Dalteparin therapy (5000 U per day) was started.
Days 2 and 3
On the second day after the burn injuries had been sustained, the maximal temperature was 38.3°C, the systolic blood pressure ranged from 94 to 127 mm Hg, the diastolic blood pressure ranged from 48 to 69 mm Hg, the heart rate ranged from 112 to 134 beats per minute with premature atrial contractions, and the respiratory rate was set at 20 breaths per minute, without spontaneous breathing. The central venous pressure was 5 to 10 mm Hg.
On the third day, excision and allografting of the skin of the dorsum of the left hand (Figure 1C and Figure 1D), the left arm, and the upper back were performed. A deep burn on the back that was charred and wooden in consistency was excised; the excision included the involved fascia. The remaining eschar on the left arm and hand was excised. The deeply burned digits were not débrided.
The oxygen saturation decreased from 98 percent while the fraction of inspired oxygen was 0.80 to 0.90 and to 93 percent while the fraction of inspired oxygen was 1.00, with a peak inspiratory pressure of 44 cm of water and a peak end expiratory pressure of 18 cm of water (Table 1). The maximal temperature was 38.9°C, and the central venous pressure increased to 15 to 20 mm Hg. Copious black material was suctioned from the endotracheal tube. Four hours after the procedure, the arterial oxygen tension was 61 mm Hg, and the oxygen saturation 90 percent (Table 1) while the patient was breathing 100 percent oxygen. A chest radiograph showed diffuse bilateral interstitial infiltrates, a finding consistent with the development of the acute respiratory distress syndrome (Figure 2B). Nitric oxide therapy administered by inhalation (20 ppm) was started, and rapid improvement in oxygenation followed (Table 1).
Days 4 and 5
On the fourth day after the fire, a culture of a skin wound was positive for methicillin-sensitive Staphylococcus aureus, and antibiotics were administered as part of perioperative coverage. On the fifth day, disseminated intravascular coagulation developed (Table 2), with bleeding into the airway, which was controlled with a platelet transfusion. Additional specimens were sent for culturing, and the antibiotic coverage was broadened to treat possible gram-negative sepsis.
Weeks 2, 3, and 4
During the second week after the fire, the patient's respiratory status improved, with clearing of the infiltrates on the chest radiographs (Figure 2C); the nitric oxide was discontinued. The coagulopathy resolved. On the eighth day, fever developed and the white-cell count was elevated; wound and sputum cultures were positive for methicillin-sensitive S. aureus. The catheters, including the Foley catheter, were replaced, and the patient completed a 12-day course of antibiotics. During the same week, the first of seven definitive wound-closure procedures (described below) was performed.
During the third and fourth weeks after the fire, the patient's temperature reached 39.1°C, and a sputum culture grew Pseudomonas aeruginosa, despite the continued clearing of the pulmonary infiltrates observed on chest radiographs. Vancomycin and ceftazidime were administered, and the fever resolved. On day 27, the trachea was extubated, but it was reintubated later that day because of fatigue and the accumulation of secretions.
Month 1
On day 30 after the patient had sustained her burn injuries, she was transferred to this hospital, and a tracheostomy was performed. During the next five weeks, she underwent multiple excision and grafting procedures as well as physical, occupational, and speech therapy. Wound closure was complicated by the extreme depth of the burns, most of which extended to the subcutis, muscle, and bone. The narcotics administered intravenously for pain control were gradually discontinued and replaced with orally administered methadone. She required prolonged antibiotic treatment for pneumonia due to P. aeruginosa and for wound infections with staphylococcus species (including methicillin-sensitive and methicillin-resistant S. aureus).
On day 62, decannulation of the tracheostomy was followed by a good return of the voice. A follow-up ophthalmologic examination documented a left corneal scar and slight lagophthalmos in the left eye due to lid retraction. She was discharged to a rehabilitation hospital on day 70 after the fire.
Discussion of Management
Dr. Robert L. Sheridan: Progress in burn care has been heavily influenced by disasters. The Triangle Shirtwaist Factory fire of 1911 highlighted the dangers of crowded buildings with inadequate exits. The Rialto Concert Hall fire of 1930 led to a better understanding of burn resuscitation.1 The Hartford Circus fire of 1944 emphasized the need for regional planning to distribute multiple burn casualties.2 The Cocoanut Grove nightclub fire of 1942 resulted in legislation to improve public safety, with such measures as outward-opening exit doors for public places.3 Experience during the Vietnam War showed that immediate evacuation to capable resuscitation facilities improved clinical outcomes. Experience during the first Gulf War showed that successful planning for surges in the need for high-level burn care is possible.
In the era of the Cocoanut Grove fire, survival with burns over 30 percent of the body was not generally possible.4 Until surprisingly recently, patients with serious burns, such as the patient under discussion, were treated with comfort measures only, since even if they could be saved, it was assumed that their quality of life would be so poor that treatment would be unethical.5 However, both the rate and quality of survival after serious burns have increased dramatically during the past 20 years.6,7 Burn care can be roughly organized into four clinical phases: first, initial evaluation and resuscitation; second, initial burn excision and biologic closure; third, definitive wound closure; and fourth, rehabilitation and reconstruction.
Resuscitation and Critical Care of Patients with Burns
Dr. John T. Schulz: This patient's initial care was directed at stabilization of her airway, breathing, and circulation.8 The history and physical examination suggested a diagnosis of smoke-inhalation injury, which can be accompanied by severe hypopharyngeal and laryngeal edema and which is thus an indication for airway protection. Additional indications for intubation included the extensive, deep burns to her upper body and her clouded mental status. The local and systemic capillary leak accompanying these burns would soon have caused sufficient pharyngeal edema to close her airway.9 The sedatives and analgesics required to manage her pain and distress would soon suppress her respiratory drive and eliminate airway-protective reflexes. Early intubation was lifesaving.
Once the patient's trachea had been intubated, her breathing was supported by mechanical ventilation. Early arterial-blood gas analysis showed excellent gas exchange but clinically significant metabolic acidosis. Metabolic acidosis suggests the presence of ischemia, which can be caused by hypoperfusion due to volume depletion or pump failure. However, the initial carboxyhemoglobin level of 28 percent suggested ischemia at the molecular level, since carbon monoxide prevents oxygen from binding to hemoglobin. The patient received 100 percent inspired oxygen to treat carbon monoxide intoxication. Although we consider hyperbaric therapy for carboxyhemoglobin levels greater than 25 percent, the condition of patients with severe burns is usually too unstable for them to receive such treatment.10,11
Hypovolemia undoubtedly contributed to the patient's initial acidosis. Large burns evoke a systemic capillary leak: plasma and proteins flood into the interstitium, creating massive edema and emptying the vasculature. Since there is no known way to reverse this process, treatment involves pouring fluid containing crystalloid or colloid into the circulation as fast as it leaks out.12 The initial need for fluid varies directly with the size of the burn (hence the importance of estimating the percentage of body-surface area burned) and the size of the patient. Extensive clinical experience has validated the use of the modified Brooke formula for the initial estimation of resuscitation needs (2 to 4 ml multiplied by the total burned area of the body surface , multiplied by the body weight , with half of this amount given in the first 8 hours after presentation and the remaining half in the next 16 hours).8 Any formula is only a starting point, however; ongoing monitoring is essential to ensure that resuscitation is sufficient to support adequate urine output (0.5 to 1.0 ml per kilogram of body weight per hour) and hemodynamic stability. Smoke-inhalation injury increases volume requirements by up to 50 percent.13,14
Considering this patient's weight, the size of her burns, and her inhalation injury, an initial estimate of her maximal fluid requirement would fall in the range of 18 liters during the first 24 hours after presentation. On day 1, when she arrived at the first hospital, she probably had a fluid deficit of at least 1 liter (Table 4). Adequate initial resuscitation and elimination of carboxyhemoglobin (i.e., correction of the carbon monoxide intoxication) were reflected in early resolution of her metabolic acidosis. The resuscitation fluid was delivered by central venous catheters, which were preferentially placed through unburned skin.
Once the patency of the airway and the stability of breathing and circulation had been ensured, the patient underwent other standard interventions for burn care: administration of a diphtheria–tetanus vaccine booster (without immune globulin, which is added if there is no history of immunization), a radiologic workup for trauma because of the possibility that she had been trampled at the nightclub,15 dressing of her wounds with a topical antimicrobial agent,16 and bronchoscopy to confirm the smoke-inhalation injury.17
On arrival in Boston 11 hours after her injury, the patient had mild hypothermia. Hypothermia is a common problem in burned patients. Fluids should be warmed, and wet dressings should never be applied before transport. She responded to passive rewarming measures. Prophylactic measures against deep-vein thrombosis and gastric ulcers were started.
On day 3 after the fire, the patient's pulmonary gas exchange began to deteriorate rapidly because of intrapulmonary ventilation–perfusion mismatching, which resulted in a potentially lethal physiological shunt. Nitric oxide, a potent, short-acting vasodilator, was administered through the airway and resulted in rapid improvement.18
Even with adequate caloric feeding, patients with burns may lose muscle mass during their illness because hypercatabolism results in the consumption of muscle protein.19 In this case, as is our practice, we began hyperalimentation with high levels of nitrogen immediately, with transition to feeding through a postpyloric tube as soon as it was tolerated by the patient. Nutrition was maintained perioperatively by total parenteral nutrition.
Dr. McGinnis, can you show us the thoracic imaging studies?
Dr. Paul J. McGinnis: A radiograph obtained on day 1 shows bilateral, predominantly central, lung opacities (Figure 2A) — findings that are compatible with early pulmonary edema and that are characteristic of smoke-inhalation injury. By day 3, the pulmonary opacities have worsened and are more diffuse, indicating the development of the acute respiratory distress syndrome (Figure 2B). By day 7, after five days of nitric oxide therapy, progressive clearing of the pulmonary opacities is evident (Figure 2C).
By day 18, despite a sputum culture that was positive for P. aeruginosa, a chest radiograph showed improvement of the pulmonary opacities, with no evidence of developing air-space disease. Plain-film radiographic findings are nonspecific for nosocomial infection with pseudomonas in patients with the acute respiratory distress syndrome who are receiving mechanical ventilation.20
Surgical Treatment of Burns
Dr. Sheridan: There are five general classes of burn operations: decompression procedures, excision and biologic closure operations, definitive closure procedures, burn reconstructive procedures, and general supportive procedures. This patient required operations in each of these categories. Surgical management of burn wounds before colonization of the eschar by bacteria and septic liquefaction, which otherwise are inevitable, is at the heart of the improved outcomes seen in recent decades in patients with burns.21
Prompt recognition of imminent ischemia in the limbs or constriction of the chest and abdominal wall is essential to prevent ischemic necrosis of the limbs and difficulty with ventilation as a consequence of soft-tissue hypertension.22 Escharotomies and fasciotomies are performed to release the compression caused by the rigid burned tissue and the edematous unburned tissue below it. These operations are performed on the limbs, chest, and abdomen. Occasionally, laparotomy is needed for abdominal decompression. In this patient, escharotomies were performed on the torso, arms, and legs and fasciotomies on the arms in order to restore a pulse in her digits and to facilitate ventilation. The burns on her face, arms, hands, and torso were excised within five days after the injury and covered with human allograft (Figure 1A, Figure 1B, Figure 1C, and Figure 1D). Closure of the skull wound required removal of portions of the burned outer table of the skull.
These operations have a reputation for being bloody and physiologically stressful. However, with attention to the details of intraoperative critical care, heating of the operating room to prevent hypothermia and associated coagulopathy, and use of techniques to minimize operative blood loss, these operations are well tolerated and greatly improve the outcome. Ideally, wounds generated during these procedures are covered immediately with autografts. However, when wounds are very large or when a patient is in unstable condition, it is often more prudent to use temporary membranes, such as the allograft used in this case.23
Definitive wound-closure operations are performed later and involve the replacement of temporary membranes with permanent grafts, usually split-thickness autografts, and definitive surgery for wounds of small but complex areas, such as the digits, face, and genitals. These areas are small enough that they are not likely to cause overwhelming sepsis if left to slough spontaneously, and they require a disproportionate amount of time and amount of skin graft in the operating room, so they are typically deferred until the patient's condition is stable and larger wounds have been closed. In the current case, the patient's deeply burned digits were definitively closed with sheet autografts in the weeks after her initial therapy, and range of motion was maintained with a program of hand therapy and splinting. Kirshner wires for internal fixation of the digits were used selectively.
Reconstructive operations begin as soon as functional progress is impeded by contractures. Contractures that limit physical function are given priority, but aesthetic problems that limit social reintegration are also considered to be early surgical priorities. The contracted tissue is replaced with split-thickness or full-thickness skin or flaps. In the patient under discussion, reconstruction began with correction of dorsal hand contractures (Figure 3A) and release of a tight contracture of the posterior surface of the neck (Figure 3B). The patient also had a flexion deformity of the proximal interphalangeal joint from destruction of the dorsal extensors and volar migration of the lateral bands, known as a boutonnière deformity. This problem will be addressed at a later date and may require fusion of the joint.24
Figure 3. Photographs Taken after the Performance of Definitive Excision and Grafting Procedures.
The allograft of the left forearm and hand (Panel A) has been replaced by split-thickness sheet autographs. A flexion (boutonnière) deformity of the first proximal interphalangeal joint has developed. The burned skin on the head and neck has been replaced by autografts (Panel B). A small open wound remains on the top of the head. The left external ear is mostly absent. A hypertrophic scar limits the range of motion of the neck.
Finally, patients with burns require a predictable set of supportive general surgical operations that include vascular access, tracheostomy, gastrostomy, cholecystectomy, and abdominal procedures.25 A high index of suspicion for clinically significant abdominal complications is an important part of burn-related intensive care.26 This patient required multiple vascular-access procedures and bronchoscopies to irrigate and suction thick secretions as well as a tracheostomy.
Rehabilitation of Patients with Burns
Dr. Colleen M. Ryan: The goals of burn treatment in a comprehensive burn center extend beyond survival to encompass rehabilitation and recovery. The survival rate among patients with massive burns improved during the 1970s and 1980s.27 Now that patients with massive burns survive, the new population of patients surviving large burn injuries is expanding.
This patient was discharged from the hospital 10 weeks after the fire. Whereas her survival was predicted by objective probability estimates, her hospitalization was much longer than that predicted according to burn size alone.27 The prolonged hospital stay was indicative of the severity of her inhalation injury and the extreme depth of her burns. She was discharged home from the rehabilitation facility 16 weeks after the fire.
Nine months after the fire, this patient has many of the symptoms and impairments that may be seen after severe burns (Table 5). She has a small open wound on her head that will contract and close over time. In addition, she has lost most of her left external ear (Figure 3B). She needs to protect her ear canal while showering and use straps to retain eyewear. Options for future reconstruction of the ear include composite grafts28 or a prosthesis. She has near-total alopecia, which she conceals with scarves and wigs (Figure 4A and Figure 4B).
Table 5. Common Long-Term Disabilities in Patients with Burn Injuries.
Figure 4. Photographs of the Patient 10 Months after the Fire.
There is near-total alopecia (Panel A). The ectropion of the left eyelid has been successfully released. With the use of makeup and a wig (Panel B), a good cosmetic result is achieved. The patient is able to write (Panel C), despite the contracture of her left index finger, which has yet to be fully corrected.
An important problem for this patient has been hypertrophic scarring, which has resulted in dry skin and areas susceptible to injury from minor trauma, cold, and sun exposure. The scars have resulted in contractures of her neck, left eyelid, hands, and arms and were initially pruritic and painful. Hypertrophic scars after burns cause symptoms that are more serious than the obvious aesthetic deformity; however, these symptoms generally resolve over a period of several months. Itching may interfere with sleep. Some patients report persistent discomfort from the thickness and nonpliability of scars. Our patient reported burning, lancinating, or "pins and needles" pain, which is not uncommon.
Pruritic scars often respond to topical doxepin hydrochloride as well as diphenhydramine hydrochloride, cool water, or milk-and-oatmeal baths. Pain-related symptoms respond poorly to narcotics. Gabapentin and triamcinolone acetonide injections are sometimes useful. Topical silicone pads can help flatten scars and reduce redness. Pressure garments worn 23 hours a day have a long anecdotal history in the treatment of burn scars, but little information exists as to whether the resulting flattening and reduced erythema of the scars translates into a permanent effect that is superior to the partial spontaneous involution of the scars with time. These garments protect the fragile scars from minor trauma, and many patients, such as this one, find them comfortable and rely on them. With these treatments, in combination with the expected course of spontaneous resolution, the patient's scar symptoms have improved over the past several months.
Hypertrophic scars positioned across a joint can interfere with range of motion. This patient had a contracture of the posterior surface of the neck; surgical release, performed two months after discharge, has resulted in substantial improvement. Ectropion, or eyelid retraction resulting in an inability to close the eyelid and potential corneal ulcerations due to exposure, also developed. She has had two releases of her left upper eyelid. Good eyelid apposition is maintained with the use of this procedure, without disruption of the tarsal margin.29
Exceptionally severe burns of the hands and the head were characteristic of the patients injured in this fire. Some patients had no remaining viable tissue in the arms and required amputations. This patient fortunately did not require amputation, but the burns extended into some of her tendons and finger joints. Scarring and contractures have limited the function of her hands. The management of hand burns24 in this case involved early escharotomy to preserve blood flow to the digits, splinting in a position of function, passive range-of-motion exercises, and excision and placement of split-thickness skin grafts as soon as possible. Active range-of-motion exercises were begun as soon as her condition allowed. Despite all these measures, the proximal interphalangeal joint of the left index finger rapidly assumed a 90-degree flexion deformity (Figure 3A). The patient's hand function improved with surgical release of contracted soft tissues and grafting of the dorsum of both hands one month before her discharge from the rehabilitation facility, but she clearly will face a number of reconstructive procedures on her hands in the future. Despite the deformities, she is beginning to adapt and compensate. She reports being able to use a computer keyboard and is able to write with her left hand (Figure 4C). The strength of her right hand is still limited, but she can now carry a handbag. She can open a jar with her left hand but not with her right hand.
Heterotopic ossification is a less common but debilitating complication of burn injuries. In this case, posterior medial heterotopic ossification resulted in severe ankylosis of the patient's right elbow, which became fixed in 40-degree flexion. Dr. Jesse Jupiter resected the heterotopic bone and performed ulnar-nerve transposition. So far the patient has gained flexion of up to 70 degrees, and she is currently undergoing physical therapy. May we see the radiographs of the elbow?
Dr. McGinnis: A radiograph of the right elbow (Figure 5A) obtained during the second month after the fire shows a large area of heterotopic bone posterior to the distal humerus. A radiograph taken after surgery (Figure 5B) shows that the heterotopic bone has disappeared.
Figure 5. Radiographs of the Right Elbow.
A radiograph obtained during the second month after the fire (Panel A) shows heterotopic bone posterior to the distal humerus. A radiograph obtained after surgery (Panel B) shows resection of heterotopic bone with improved extension of the elbow. R denotes the right side.
Dr. Ryan: A staff psychiatrist evaluates all patients with major burns and screens them for sleep disturbances, adjustment disorders, and post-traumatic stress disorder. This patient has excellent coping abilities and excellent family support and attends long-term follow-up in our comprehensive outpatient burn program. All these characteristics have been shown to correlate with good recovery.7,30 She hopes to return to work as a medical secretary once the recovery of her hand function has progressed. She is interactive, maintains a courageous and positive attitude, and has reached several milestones in regaining her quality of life. She participates fully as a parent of her children and is dealing with the loss of friends in the fire.
Dr. Nancy Lee Harris (Pathology): I would like to ask the patient to comment on her experience.
The Patient: There is so much I remember about that awful night and so many things I will never know. I do not know who pulled me out of the burning building and do not remember being brought to the hospital. I awoke weeks later, and nothing seemed real. I could not believe I had lived through the fire and only very slowly began to remember everything that had happened. I appreciated the compassion and care of the nurses in changing my dressings twice a day and just being there when I was depressed. I have never seen such dedication and teamwork.
Being a burn victim has taken away many of the things I enjoyed in life. I still struggle with many things, such as the fact that I will never have my own hair again and that I have lost my ear. I want to be me again, so with the help of my doctors, nurses, and therapists I am on the road to recovery. The first time I was able to shower by myself or tie my own shoes was a big accomplishment. Every day I make sure I accomplish something new and then go to bed at night peacefully. I have decided not to waste another minute dwelling on what happened and whose fault it was and to enjoy the second chance I have been given.
We are indebted to the patient and her family and have been privileged to witness their courage in her recovery.
Source Information
From the Burn and Trauma Services (R.L.S., J.T.S., C.M.R.) and the Department of Radiology (P.J.M.), Massachusetts General Hospital; the Shriners Hospital for Children (R.L.S., J.T.S., C.M.R.); and the Departments of Surgery (R.L.S., J.T.S., C.M.R.) and Radiology (P.J.M.), Harvard Medical School — all in Boston.
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Related Letters:
Case 6-2004: Severe Burns from a Nightclub Fire
Borron S. W., Mégarbane B., Baud F. J., Sheridan R., Schultz J., Ryan C.(Robert L. Sheridan, M.D.,)