[New Aspects of Burn Management] #2. Emergency Care of Burn

In the emergency care of patients with severe burns requiring hospitalization, the top priority is to assess the general condition, as with other trauma patients, in the following manner:

First, upon the patient’s arrival, history-taking and physical examinations should be completed, and the airway should be maintained by placing the patient in a comfortable position conducive to proper breathing. Patients with difficulty breathing due to inhalation burns or burns to the upper airway should be provided with a 100% oxygen mask until the arterial blood gas level has returned to normal. If the difficulty in breathing continues, endotracheal intubation should be carefully considered. Because endotracheal intubations, which are relatively easy to perform immediately after the patient has arrived, can become quite difficult to perform after administering a considerable amount of fluid to the patient in the course of treatment, it is recommended that preparations for endotracheal intubations be kept ready and available.



Second, fluid therapies should be applied to assist in maintenance of normal systemic circulation, and a blood vessel should be secured to allow for immediate treatments in case of emergency.

Third, the examination for the presence of other traumas or injuries should be completed. In the case of injuries resulting from falls from a tall building due to fire, head injuries, chest injuries including pneumothorax, spinal injuries, intra-abdominal injuries including ruptured viscus and hemoperitoneum, and excessive hemorrhage due to pelvic and long bone fractures should be evaluated using x-ray and CT scans. Patients with burns may have generally low blood pressures; however, if there is extensive hypotension or systemic hypovolemia in the early phases for some other unaccountable reason, the possibility of other injuries should be investigated. When transferring the patient to a special burn center, injuries other than severe burns should be treated and the airway should be stabilized prior to transfer.

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Criteria for admission to a burn center or hospital with a specialized burn treatment facility

Fourth, history-taking and physical examinations should be re-performed. If the burn was caused by fire in a building, witnesses and the rescuer should be questioned about the any possibilities of the patient having been in an enclosed space to eliminate or confirm the possibility of inhalation burn. Past history of other diseases, currently used drugs, and allergic symptoms including hypersensitivity should also be investigated. Physical examinations should be performed after the patient is completely undressed in order to enable examination of injuries in all parts of the body. When the patient is transferred from another hospital, it is important to obtain accurate data on the amount and type of the pretreatment fluid as the basis of further fluid therapy.

Tracheostomy to maintain the airway in a patient with severe facial burn accompanied by inhalation burn

 Escharotomy to prevent compartment syndrome from circumferential burn of the right upper arm

Emergency care of inhalation burns

Indications of inhalation burns include severe burns to the face and neck, singed hair on the head and of the nostril and face, deposition of carbonaceous materials in the pharyngeal area, and carbonaceous sputum. The inhalation burn is one of the main causes of death among burn patients, and increases mortality to 30-40%. In the case of suspicion of an inhalation burn, early endotracheal intubation is ideal in preventing respiratory distress. While the diagnosis may not be clinically certain, inhalation burns should be suspected if the patient has suffered burns in an enclosed space. Carboxyhemoglobin levels (COHb) of 10% or more detected by arterial blood gas analysis may also be a key factor in the diagnosis.

Additionally, carbon monoxide poisoning may induce headache and nausea at levels of 10-20% COHb, dizziness and weakness at 20-30%, and coma and eventually death at levels near 50%. 100% oxygen therapy is the most essential method of treatment.



Treatment plan

1) History-Taking & Physical Examination

Location and environment where the patient suffered injury, cause of burns, amount of fluid administered in another hospital, and presence of wound treatment are important elements for accurate and rapid emergency care as they allow for effective assessment of any injuries or conditions that may have been missed in patients, thereby condensing time spent for examination and prevalence of severe injuries or complications.



2) Escharotomy to relieve respiratory and circulatory distress

① In the case of circumferential burns of the limb and chest, thick and inflexible circumferential eschars of the chest may cause respiratory distress. Incisions should be made starting from the middle of each of the bilateral clavicles down in a vertical line to the subcostal margin (see following figure). If the burn is moderate, the resultant eschar can be relieved by performing escharotomies along the bilateral anterior axillary lines. Circumferential eschars of the limbs, and especially of the hands may increase distal blood pressure and block the bloodstream, causing distal limb necrosis or compartment syndrome. The escharotomy should be made for the full depth of and along the full length of the eschar so that the subcutaneous tissues are sufficiently exposed. Fasciotomy should be performed for the fascial compartments of the limb.

 Locations of escharotomy to prevent compartment syndrome

 Table 1. Fluid resuscitation formulas for adult patients with burns

② Indications for escharotomy

a. cyanosis

b. impaired capillary refill

c. progressive alterations neurologic status, paresthesia, or deep tissue pain,

d. loss of a palpable pulse, absence of Doppler pulses, compartment pressure ≥30mmHg.

After escharotomy, presence of blood circulation in the distal areas should be confirmed. If blood circulation is not improved after escharotomy, further assessment for other causes of inefficient circulation such as insufficient fluid therapy should be completed.

 Table 2. Fluid resuscitation formulas for children patients with burns

3) Prevention and treatment of burn shock

The cause of burn shock is complex in most cases. In the early phases of burn injury, capillary permeability increases, inducing hypotension, and a maximal edema can develop in 12-24 hours. Vectors, such as Vasoactiveamines, prostaglandins and leukotrienes, are known to increase capillary permeability. Furthermore, burned tissues affect surrounding unburned tissues as well by increasing sodium concentration in the cells and inducing cellular edema. An IV line should be secured and sufficient fluid replacement should be performed according to the proper formula and the patient’s clinical symptoms.



4) To monitor fluid resuscitation, a catheter should be inserted and urine output per hour should be measured. The monitored urine output should be maintained at 0.5~1ml/kg/hr for adults, 1~1.5ml/kg/hr for children, and 1.5ml/kg/hr for infants. Proper fluid resuscitation should be based on the amount of fluid infused per hour, and rapid bolus infusions should be attempted only in cases with severe hypotension or little urine output as it may cause disruptions in continuous and accurate fluid therapy. Burns covering 20% or more of the TBSA require a nasogastric tube insertion to prevent ileus and vomiting.

- To be continued -

▶ Previous Artlcle : #1. Diagnosis & Classification of Burns

[Laser Resurfacing] #2. Total Rejuvenation

Lasers are definitely effective for rejuvenation, and various lasers are being used for the purpose. ‘Juvenile’ means young and ‘rejuvenation’ means becoming young again. This word can be easily confused with ‘anti-aging’, which means preventing the process of aging, slightly different from rejuvenation. Anti-aging is mostly focused on medical treatments, such as hormone therapy, prevention and treatment of metabolic diseases and aging-associated diseases. On the other hand, rejuvenation is a more aggressive method to turn back the youth. Everybody is bound to experience the aging process when they grow old; people lose confidence in their appearance and don’t even want to look at themselves in the mirror or take a picture. People think of facial wrinkles first among the aging process, but aging is related not only to the facial skin but also to other physical changes, including subcutaneous fat, musculoskeletal system, hormone and metabolic change, as well as psychological and social changes.

Aging epidermis of the facial skin becomes withered, shows lentiginosis, age spot and blemishes, and melanin pigment is increased, making the skin color more yellowish than in the younger age. Dermis also becomeswithered, thin and less resilient, the appendages become atrophied, and the skin is dried. Resilient skin contains a lot of collagen fibers, but aging skin has a thick degenerated elastic tissue layer (elastosis). The subcutaneous fat also becomes atrophied and thin in parts, not as evenly distributed as in the younger age, and the facial skin adheres to the muscle, forming deep wrinkles. Nasolabial folds between the cheeks and lips or glabellar frown lines between the eyebrows are deepened. The face also becomes partially sagged, making nasolabial folds, jowl, marionette line and dark circles under eyes. There are retaining ligaments in the face that supports skin and soft tissues; aging face becomes sagged due to the gravity, with the exception of the areas with retaining ligaments. The forehead, eyelids, cheeks and jowl also becomes sagged.



The musculoskeletal system also changes; muscles are generally reduced, the bone is reduced in parts, the alveolar bone becomes atrophied and the mouth is puckered. The bone is not constantly fixed but partly absorbed and partly accumulated by new calcium, keeping the balance. When more bone is absorbed then generated, the bone becomes smaller. Aged people have reduced hormone and metabolic change. Growth hormones are necessary not only for growth but also for the maintenance of the body; growth hormone plateaus around the age of 16 and decreases to 20% of the maximum level at the age of 60.



Despite the lack of understanding on the accurate reason of aging, there are several theories explaining the reason of aging. The first theory argues that exposure to harmful environments, such as pollution, alcohol, cigarette, overwork and stress, triggers early aging. Programmed aging theory states that aging is imprinted on DNAs and cells are programmed to divide a certain number of times. Aged cells should go through apoptosis, and denaturized cells may turn into a carcinoma. Aging by DNA changes has been partially demonstrated by experiments.

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Before and after laser skin resurfacing (Left, before; right, after)

Aging becomes accelerated in old people by hormone and metabolic changes. Anti-aging medicine focuses on medication to maintain hormone and metabolism in younger people.

Aging also leads to psychological and emotional changes; aging people has decreased memory ability, depressed mood, loss of confidence, psychological withdrawal, contributing the increased risk of depression.

As aging includes all these physical, psychological and social changes, total rejuvenation should bring all possible measures to recover youth.

In plastic surgery, face lifting is the most traditional but invasive method. For lessinvasive methods, other procedures such as forehead lift by minimum incision or endoscopy are available. Blepharoplasty is commonly performed for sagged eyelids in middle-aged patients.



Among laser therapies, ablative laser is an invasive method because it requires more than 1 month recovering the ablated skin. Non-ablative infrared low-output lasers are non-invasive, and fractional lasers are less invasive. As for the effectiveness, the ablative laser is the most effective; while the infrared low-output laser is weak and the fractional laser yields moderate effectiveness.

As the saying ‘no pain, no gain’, the ablative laser provides the most dramatic effect but erythema and pigmentation last for about 1-2 months making the facial color uneven. The infrared low-output laser does not cause a discomfort in social life but provides less effect. The fractional laser is recently popular because it has the advantages of both the ablative and non-ablative lasers, providing considerable effect with -less discomfort

Rejuvenation Methods

As aged face has atrophied subcutaneous fat, face lifting with fat grafting can recover facial volume and rejuvenate the face. Filler injection can be handy when injecting small amount of fat instead of fat graft. A simple method of relieving wrinkles is to inject botulinum toxin, which paralyzes facial expression muscles. However, the anatomy and physiology of the facial muscles should be fully understood to achieve a proper effect, and misuse may lead to side effects, such as ptosis or long-term inappropriate facial expression around the mouth.

Other methods of total rejuvenation include exercise and diet therapy; exercise increases the level of growth hormone, enhances muscular strength and is very helpful for mental health. Bad eating habits and social habits can be improved, and psychology consultation and psychiatric drug treatment can be also helpful, if necessary, to maintain young and healthy mental status. Aging occurs in every part of human body. Therefore, just one method is not enough for rejuvenation and multiple methods selected according to the patient’s needs are most recommended.



Among laser therapies for rejuvenation, ablative laser is most effective. After removing the aged epidermis, the skin is regenerated with more regular and thicker epidermal cells and reduced melanin pigments. The ablated dermis also regenerates to thicker collagen fiber layers, enhancing the skin resilience. Among ablative lasers, CO₂ laser is appropriate for deep ablation but is invasive, while Er:YAG laser is safe and induces less erythema and pigmentation. Among non-invasive lasers, low-output infrared laser and IPL are available, although the expected extent of rejuvenation is not enough to improve wrinkles. The fractional laser can achieve rejuvenation effect by delivering micro-thermal zones to the skin, but the effect is weak and requires repeated treatments. Ablative fractional laser is an intermediate form between the ablative laser and the fractional laser, and the micro-ablative column causes less discomfort in social life. Radiofrequency and ultrasound can also increase the elasticity of the dermis without peeling the skin.

.

Reference: Laser Plastic Surgery, Koonja Publishing, 2008, Seoul

- To be continued -

▶ Previous Artlcle : #1. History of Laser Resurfacing

▶ Next Artlcle : #3.Lasers for Skin Resurfacing and Their Effects

[Case Series in Dermatologic Surgery] #2. Pigmented Basal Cell Carcinoma on the Face Mimicking a Nevus

Case

▶ Patient: a 43-year-old female

▶ Chief complaint: Bleeding black spot (which lasted for 3 years).

▶ Past medical history and family history: The patient received CO₂ laser 3 times for a year at a private clinic.

▶ Skin findings: Black nodule was observed at the tip of the nose (Figure 1).

▶ Histology findings: Basal cell carcinoma of pigmented, nodular type was diagnosed by punch biopsy (Figure 2).

▶ Surgical finding: Mohs surgery of the first stage with 4mm margin was performed, and the patient has been completely recovered without recurrence. Mohs surgery will be described in details in the following case series.

Figure 1. Black nodule at the right tip of the nose

Figure 2. Asymmetric proliferation of basal cell infiltrating the full thickness of the dermis with nodule formation

Figure 3. Episcopy finding: 6-mm sized, irregular punctuated proliferation with asymmetric color and shape

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Study on the diagnostic process ①

Excluding the differential diagnoses to be made by visual inspection with experienced eyes (macroscopic examination) (Table 1), the necessity for histology should be determined and the diagnosis should be confirmed by histology. In order to reduce errors in visual inspection and to determine the necessity of histology, the following objective approach should be exercised in addition to the intuitive approach than depends on experiences.

Noninvasive objective diagnostic approach for pigmented lesions on the face

1. Macroscopic observation– the lesions should be analyzed and diagnosis should be made according to the following ABCD rule.

1) Asymmetry extension: One half doesn’t match the other

2) Border Irregularity: Blurred, Notched, Ragged

3) Color: Pigmentation not uniform, Brown, Black, Tan, Red, White, Blue

4) Diameter/Difference (family resemblance) :> 6mm is significant

2. Diagnosis using Dermoscopy, Dermatoscopy, Episcopy: Characteristic findings of pigmented basal cell carcinoma on clinical photographs and on dermoscopy (see picture below) should be acquainted and diagnosis should be made considering racial difference.

Asian (Korean F/37)

Caucasian

1) Typical characteristic findings of basal cell carcinoma: Ulceration, Ovoid blue nest of pigmentation, Spoke-wheel structure, Arborizing telangiectasia, Maple-leaflike areas.

2) Asymmetry of color and structure, multicomponent global pattern, irregular brown globules, irregular streaks, irregular bluish-black blotch and regression are findings detectable in malignant melanoma and require differentiation. Spoke-wheel structure, on the other hand, does not appear in malignant melanoma and is often detected in basal cell carcinoma, allowing the diagnosis of basal cell carcinoma. Globules mean a melanotic lesion.

3) Recent studies reported more varied findings for darker pigmentation, and dermoscopy specialists made accurate (98% sensitivity) and reliable (87%) diagnoses (JAAD 2010;62:67-75).

Study on the diagnostic process ②

Pigmented basal cell carcinomas grow in superficial or nodular shape, and grey, blue or brown colors are observed in all or part of the lesion. Therefore, differentiation with malignant melanoma is a necessity in Caucasian patients and histology should be performed always before removal. On the other hand, early phase lesions are very similar to typical melanocytic nevus among Asians including Koreans, rendering the lesion very easy to be missed, as often experienced recently. According to the medical history, most patients removed the nevus for aesthetic purpose but experienced recurrence several time. During aesthetic nevus removal, it is hard to differentiate among malignant melanocytic nevus, dysplastic nevus, malignant pigmented basal cell carcinoma as in the above case, and early stage malignant melanoma with the naked eye. Among non-white Asians, pigmented lesions on the face are mostly common lesions, including pigmented nevus such as freckles, melanocytic nevus, seborrheic keratosis, solar lentigo and sebaceous hyperplasia, making it easily removed based on simple clinical determination without detailed differentiation (Table 1). On the other hand, it is a necessity to differentiate black spots in Caucasians with malignant melanoma, because the differentiation is forensically important in Western countries including the US. Therefore, periodic skin examination of the whole body by a dermatologist and an approach for early detection, such as histology for suspicious lesions, are established as a standard practice guideline. However, malignant melanoma on the face is very rare in non-white Asians including Koreans. When a black spot is present on the exposed area of the face, as in the above case, more common pigmented basal cell carcinoma should be suspected first before malignant melanoma.

Pigmented basal cell carcinoma is common among Asians because of the activity of melanin pigment cell and the difference of melanin pigment cell in the melanosome. When examining a patient chiefly complaining of pigmentation or a nevus, close macroscopic examination using an objective approach should be performed before conducting a procedure unlike in the past. Currently available methods for early differentiation of benign and malignant lesions (actinic keratosis, Bowen’s disease, keratoacanthoma, basal cell carcinoma, squamous cell carcinoma, etc.) are macroscopic examination using the ABCD rule and finding microscopic subclinical infiltration change using noninvasive dermoscopy. Knowledge and understanding gained from cases as above would be of great help in detecting clinical characteristics certainly distinguishable from typical nevus, so as to prevent unnecessary procedure, surgery or inappropriate treatment, and in performing histology in the early phase, so as to recover the lesion by early diagnosis and treatment without missing early skin cancer, such as melanoma.

References

1. Jae Hong Park, Jeung Tae Jeong, Hae Jun Song, Chil Whan Oh, Il Hwan Kim. Case Report : Diagnostic Trial of Epiluminescence Microscopy in Two Cases of Pigmented     Basal Cell Carcinomas. Annals of Dermatology.2001;39(10):1127~1132.

2. Peris K, Altobelli E, Ferrari A, Fargnoli MC, PiccoloD, Esposito M, et al. Interobserver agreement on dermoscopic features of pigmented basal cell carcinoma. Dermatol Surg 2002;28:643~5.

3. Telfer NR, Colver GB, Morton CA. Guidelines for management of basal cell carcinoma. Br J Dermatol2008;159:35~48.

4. Altamura D, Menzies SW, Argenziano G, Zalaudek,Peter Soyer. Dermatoscopy of basal cell carcinoma: Morphologic variability of global and local features and accuracy of diagnosis. J Am Acad Dermatol2010;62:67~75.

- To be continued -

▶ Previous Artlcle : #1. Epidermal Cyst Surgery

▶ Nest Artlcle : #3. The Most Effective Method for Surgical Treatment of Earlobe Keloid and Prevention of Its Recurrence