1 International Journal of Scientific Study | March 2021 | Vol 8 | Issue 12 Hyperbaric Oxygen for Thermal Burn and Electrical Burn Wound Healing – A Case Report M. Mohamed Arafath, R. Viswanathan 1 Consultant, Department of General Medicine, Shifa Hospitals, Tirunelveli, Tamil Nadu, India, 2 Senior Consultant, Department of General Medicine, Shifa Hospitals, Tirunelveli, Tamil Nadu, India the patient’s eventual reconstruction and rehabilitation, that is, to return the patient to society as a functional human being is as aesthetically acceptable as possible. [9] Hyperbaric oxygen therapy (HBOT) is an adjunctive therapy that has been proposed to improve outcomes in thermal burns. HBOT is the therapeutic administration of 100% oxygen at environmental pressures >1 atmosphere absolute (ATA). Administration involves placing the patient in an airtight vessel, increasing the pressure within that vessel, and administering 100% oxygen for respiration. In this way, it is possible to increase the partial pressure of oxygen to the tissues significantly. Typically, treatments involve pressurization to between 1.5 and 3.0 ATA, for periods between 60 and 120 min once or more daily. It has been suggested since 1965 that HBOT might improve the outcome following thermal burns. [10] HBOT has been shown to reduce edema and preserve microcirculation in many injury models, including burns, vasoconstriction with enhanced oxygen delivery, a direct osmotic effect, and the inactivation of white cell adhesion. [11] HBOT also exerts beneficial effects on infections in hypoxic tissues through a variety of mechanisms. [12] HBOT is associated with some risk of adverse effects, including damage to the ears, sinuses, and lungs from the impact of pressure, temporary worsening of shortsightedness, claustrophobia, INTRODUCTION During the last 30 years, the death rate from burn shock has declined dramatically. The primary concern in managing burns is no longer simply the patient’s survival but also includes morbidity and long-term rehabilitation, and reconstructive problems. In deep burns, necrotic skin serves as an excellent culture medium for micro-organisms to increase, and invasive infection will inevitably ensue if the lesion is not promptly resurfaced. In the case of extensive deep burns, after removing the burn wound eschar, it is impossible to cover the exposed wound completely with autografts because of the scarcity of donor sites. A variety of biosynthetic and biological dressings can serve as a temporary wound closure with different acceptability degrees. [1-3] The correlation between burn severity and the magnitude of the impairment of host resistance is well documented. [4-8] An important goal in the course of treatment of the burn patient is to facilitate the outset of Case Report Abstract Contact electrical burns are more severe than others form of contact burn injury. Burns are a difficult treatment challenge and ideally the province of specialized units with high-volume workloads. Such units do not exist in most parts of the world. Early treatment can positively influence the mortality rate. It involves appropriate fluid resuscitation, usually involving the attainment of resuscitation targets using consensus formulas for initial fluid administration and topical agents to control pain, limit direct fluid losses, and slow bacterial growth. Over the past two decades, early closure of full-thickness wounds has improved the outcome from extensive burns by preventing wound colonization and infection. Temporary skin substitutes are widely employed on a similar rationale when formal closure is not an option. Hyperbaric oxygen therapy consists of intermittently administering 100% oxygen at pressures >1 atmosphere in a pressure vessel. This technology has been used to treat various disease states and has been described as helping patients who have sustained burns. Key words: Hyperbaric oxygen therapy, Electrical injuries, Burns Access this article online www.ijss-sn.com Month of Submission : 01-2021 Month of Peer Review : 01-2021 Month of Acceptance : 02-2021 Month of Publishing : 03-2021 Corresponding Author: Dr. R. Viswanathan, Department of General Medicine, Shifa Hospitals, Tirunelveli, Tamil Nadu, India. Print ISSN: 2321-6379 Online ISSN: 2321-595X
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11 International Journal of Scientific Study | March 2021 | Vol 8 | Issue 12
Hyperbaric Oxygen for Thermal Burn and Electrical Burn Wound Healing – A Case ReportM. Mohamed Arafath, R. Viswanathan1Consultant, Department of General Medicine, Shifa Hospitals, Tirunelveli, Tamil Nadu, India, 2Senior Consultant, Department of General Medicine, Shifa Hospitals, Tirunelveli, Tamil Nadu, India
the patient’s eventual reconstruction and rehabilitation, that is, to return the patient to society as a functional human being is as aesthetically acceptable as possible.[9]
Hyperbaric oxygen therapy (HBOT) is an adjunctive therapy that has been proposed to improve outcomes in thermal burns. HBOT is the therapeutic administration of 100% oxygen at environmental pressures >1 atmosphere absolute (ATA). Administration involves placing the patient in an airtight vessel, increasing the pressure within that vessel, and administering 100% oxygen for respiration. In this way, it is possible to increase the partial pressure of oxygen to the tissues significantly. Typically, treatments involve pressurization to between 1.5 and 3.0 ATA, for periods between 60 and 120 min once or more daily. It has been suggested since 1965 that HBOT might improve the outcome following thermal burns.[10] HBOT has been shown to reduce edema and preserve microcirculation in many injury models, including burns, vasoconstriction with enhanced oxygen delivery, a direct osmotic effect, and the inactivation of white cell adhesion.[11] HBOT also exerts beneficial effects on infections in hypoxic tissues through a variety of mechanisms.[12] HBOT is associated with some risk of adverse effects, including damage to the ears, sinuses, and lungs from the impact of pressure, temporary worsening of shortsightedness, claustrophobia,
INTRODUCTION
During the last 30 years, the death rate from burn shock has declined dramatically. The primary concern in managing burns is no longer simply the patient’s survival but also includes morbidity and long-term rehabilitation, and reconstructive problems. In deep burns, necrotic skin serves as an excellent culture medium for micro-organisms to increase, and invasive infection will inevitably ensue if the lesion is not promptly resurfaced. In the case of extensive deep burns, after removing the burn wound eschar, it is impossible to cover the exposed wound completely with autografts because of the scarcity of donor sites. A variety of biosynthetic and biological dressings can serve as a temporary wound closure with different acceptability degrees.[1-3] The correlation between burn severity and the magnitude of the impairment of host resistance is well documented.[4-8] An important goal in the course of treatment of the burn patient is to facilitate the outset of
Case Report
AbstractContact electrical burns are more severe than others form of contact burn injury. Burns are a difficult treatment challenge and ideally the province of specialized units with high-volume workloads. Such units do not exist in most parts of the world. Early treatment can positively influence the mortality rate. It involves appropriate fluid resuscitation, usually involving the attainment of resuscitation targets using consensus formulas for initial fluid administration and topical agents to control pain, limit direct fluid losses, and slow bacterial growth. Over the past two decades, early closure of full-thickness wounds has improved the outcome from extensive burns by preventing wound colonization and infection. Temporary skin substitutes are widely employed on a similar rationale when formal closure is not an option. Hyperbaric oxygen therapy consists of intermittently administering 100% oxygen at pressures >1 atmosphere in a pressure vessel. This technology has been used to treat various disease states and has been described as helping patients who have sustained burns.
Key words: Hyperbaric oxygen therapy, Electrical injuries, Burns
Access this article online
www.ijss-sn.com
Month of Submission : 01-2021 Month of Peer Review : 01-2021 Month of Acceptance : 02-2021 Month of Publishing : 03-2021
Corresponding Author: Dr. R. Viswanathan, Department of General Medicine, Shifa Hospitals, Tirunelveli, Tamil Nadu, India.
Print ISSN: 2321-6379Online ISSN: 2321-595X
Arafath and Viswanathan: Hyperbaric Oxygen for Thermal Burn and Electrical Burn
22International Journal of Scientific Study | March 2021 | Vol 8 | Issue 12
and oxygen poisoning. Although serious adverse events are rare, HBOT cannot be regarded as an entirely benign intervention.
CASE 1
A 27 years old male patient was admitted with electrical burn involving 50% of total body surface area involving a right upper limb, back, lower limb, and chest. Past medical history reveals no known comorbidities.
The patient was assessed clinically; relevant investigations were done. Opinion from plastic surgeon was obtained before the procedure.
The patient underwent a dorsal slit and cauterization procedure and burns treatment modalities. Two units of blood transfusion done and two units of fresh frozen plasma and four sittings of HBOT were given and continued as indicated. Antiseptic techniques were rigorously followed in dealing with the patient.
CASE 2
A 51-year-old male patient was admitted to our hospital with the chief complaint of a burning sensation over the site of the wound after 5 days of treatment. No previous medical history of diabetes, hypertension, and bronchial asthma or tuberculosis.
On local examination, a 1st degree burn wound was seen in both the right and left lower limb. However, the right lower limb was healed better than the left lower limb, and a hot blister was noted in the left and right lower limb. After first-aid measures in the emergency room, the patient was kept under intensive care to monitor his vital signs. All the necessary investigations were performed and plastic surgeon opinion was obtained.
The patient underwent collagen application under intravenous sedation. Antibiotic and other post-operative medicaments were given. Healing was uneventful. The patient was symptomatically improved and hence discharged. Early oral intake was encouraged and advised to take a high-protein high-calorie diet supplemented with the parenteral administration of intralipid and an essential amino acid formula to reach the calculated daily calorie needs. Parenteral and subsequently oral polyvitamins, minerals and trace element formula were continued. Burn wound debridement with hydrotherapy was initiated and continued with wound flora monitoring. Antiseptic techniques were rigorously followed in dealing with the patient.
Figure 1: Pre-operative wound
DISCUSSION
The burn is one of the most severe types of injuries the human body encounters. Its significant consequences are not only mortality but also the tremendous morbidity and
Figure 2: Mid operative wound
Figure 3: Post-operative wound
Arafath and Viswanathan: Hyperbaric Oxygen for Thermal Burn and Electrical Burn
33 International Journal of Scientific Study | March 2021 | Vol 8 | Issue 12
the cost factors that are involved. In extensive burns, the health care personnel priorities at the time of injury are survival, functionality, and cosmetics.[13,14]
The primary rationale for using HBOT is that it increases tissue oxygen tension in hypoxic tissue to higher levels, making the host responses work. With HBOT, arterial blood oxygen contents are increased; plasma and tissue oxygen tension increase 10-fold. HBOT could be effective in fighting against necrosis, infection, and tissue loss in thermal burns.[15] Hence, it could be expected to be effective in electrical burns. However, in thermal burns, some studies have shown little to no benefit with HBO therapy.[16,17]
A Cochrane review was published in 2004[18] that looked at a total of two small randomized trials of HBOT in thermal burns. The main effect is the success of grafts with additional HBOT. It was reported in a low-quality randomized study with a risk ratio of 1.75 (0.53, 5.76) for HBOT.[18]
HBOT has demonstrated utility in the salvaging compromised grafts/flaps,[19] and animal models suggest the benefits of hyperbaric oxygen as a preconditioning stimulus in setting ischemic/reperfusion, including flap preparation to improve survival, by attenuating the inflammatory response and increasing flap perfusion.[20]
Hyperbaric oxygen does have the potential to increase skin grafts success in burns. More studies must be conducted to adopt this therapeutic tool into routine practice, especially in electrical burns. The benefits could have been much more significant if HBOT had started earlier, preferably within the first 24 h following injury[17] and as post-surgical conditioning of amputation and flap coverage.
Current data show that HBOT, when used as an adjunct in a comprehensive program of burn care, can significantly improve morbidity and mortality, reduce the length of hospital stay, and lessen the need for surgery. It has been
Figure 4: Pre-operative wound
Figure 6: Mid operative wound
Figure 5: Mid operative wound
Figure 7: Post-operative wound
Arafath and Viswanathan: Hyperbaric Oxygen for Thermal Burn and Electrical Burn
44International Journal of Scientific Study | March 2021 | Vol 8 | Issue 12
demonstrated to be safe in the hands of those thoroughly trained in rendering HBOT in the critical care setting and with appropriate monitoring precautions. Careful patient selection and screening are mandatory [Figures 1-7].
REFERENCES
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2. Achauer B, Black K, Waxman K, Hewitt C, Martinez S, Ott R, et al. Long-term skin allograft survival after short-term cyclosporin treatment in a patient with massive burns. Lancet 1986;327:14-5.
3. Robson MC, Samburg JL, Krizek TJ. Quantitative comparison of biological dressings. J Surg Res 1973;14:431-4.
4. MunsterAM,HoaglandHC,PruittBAJr.Theeffectofthermalinjuryonserum immunoglobulins. Ann Surg 1970;172:965-9.
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6. EureniusK,BrouseRO.Granulocytekinetics after thermal injury.AmJClin Path 1973;60:337-40.
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11. Hills BA. A role for oxygen-induced osmosis in hyperbaric oxygen therapy. Med Hypotheses 1999;52:259-63.
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13. Li H, Tan J, Zhou J, Yuan Z, Zhang J, Peng Y, et al. Wound management and outcome of 595 electrical burns in amajor burn centre. J SurgRes2017;214:182-9.
14. HueiTJ,YussofSJ,LipHT,SalinaI.Casereportofahighvoltageelectricalinjuryandreviewoftheindicationsforearlyfasciotomyinlimbsalvageofanelectricallyinjuredlimb.AnnBurnsFireDisasters2017;30:150-3.
15. CianciP,SatoRM,FaulknerJ.Adjunctivehyperbaricoxygentherapyinthetreatment of thermal burns. Undersea Hyperb Med 2013;40:89-108.
16. Weitgasser L, Ihra G, Schäfer B, Markstaller K, Radtke C. Update onhyperbaric oxygen therapy in burn treatment. Wien Klin Wochenschr 2021;133:137-43.
17. EdwardsM,Cooper JS.Hyperbaric treatment of thermal burns. In: StatPearls.TreasureIsland,FL:StatPearlsPublishing;2020.
18. Villanueva E, Bennett MH, Wasiak J, Lehm JP. Hyperbaric oxygen therapy for thermal burns. Cochrane Database Syst Rev 2004;3:CD004727.
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20. Hentia C, RizzatoA, Camporesi E,Yang Z,Muntean DM, Săndesc D,et al. An overview of protective strategies against ischemia/reperfusion injury: The role of hyperbaric oxygen preconditioning. Brain Behav2018;8:e00959.
How to cite this article: Arafath MM, Viswanathan R. Hyperbaric Oxygen for Thermal Burn and Electrical Burn Wound Healing – A Case Report. Int J Sci Stud 2021;8(12):1-4.
Source of Support: Nil, Conflicts of Interest: None declared.
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