Editor-in-Chief
Sujata Sarabahi MS MCh DNB MNAMS
Assistant Professor and Specialist Plastic Surgeon Department of Burns, Plastic, Maxillofacial and Microvascular Surgery Vardhman Mahavir Medical College and Associated Safdarjung Hospital,
New Delhi, India
Editors
VK Tiwari MS MCh
Professor and Senior Specialist Plastic Surgeon Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Vardhman Mahavir Medical College and Associated Safdarjung Hospital,
New Delhi, India
Arun Goel MS MCh FICS
Senior Specialist Plastic Surgeon and Head of Unit Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Lok Nayak Hospital and Associated Maulana Azad Medical College,
New Delhi, India
LC Gupta MD (Radiology) DMRE MD (PSM) FAMS DSc (Hon.)
Retd. Director Medical, Border Security Force,
India
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Principles and Practice of Burn Care
© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
First Edition: 2010
9788184488098
Typeset at JPBMP typesetting unit
Printed at
To
My Parents who Made me What I am Today
To
My Husband whose Constant Moral Support Gave me The Base on Which I Worked
To
My Children, Rohan and Arushi whose Patience and Love Helped me to Continue
To
My Father in Law who Inspired me To Write this Book and his Constant Encouragement Helped me Finish the Book
To
My Mother in Law whose Support Enabled me to Undertake this Venture and last but not the least To My Sister for her Love and Encouragement
7Contributors
- Amitabh Singh ms, dnb, mch
- Consultant Plastic Surgeon, Fortis Hospital
- New Delhi, India
- Anil Chadha ms, mch
- Medical Director and Consultant Plastic Surgeon
- Gujarat Medical Research Centre and Rajasthan Hospital
- Ahmedabad, Gujarat
- Formerly Professor and Head
- Department of Burns and Plastic Surgery
- BJ Medical College and Medical Superintendent
- Civil Hospital, Ahmedabad, India
- Arun Goel ms, mch, fics
- Senior Specialist Plastic Surgeon and Head of Unit
- Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Lok Nayak Hospital and Associated Maulana Azad Medical College
- New Delhi, India
- Arvind Vartak mbbs, ms, mch
- Honorary Plastic Surgeon and Head of Department of Plastic Surgery, Ben Jerbai Wadia Hospital for Children and Institute of Child Health, Parel, Mumbai
- Masina Hospital, Byculla, SL Raheja Hospital
- Mahim, Mumbai, Maharashtra, India
- Atul Kumar Shah ms, mch, mphil, llb, pgdip
- Medical Law and Ethics, Burns Specialist and Medicolegal Consultant, Mahi Hospital Baroda
- Gujarat, India
- B Karthikeya Prabhu msc, phd
- Young Scientist, DST-SERC Fast Track Project
- Biomaterials Division, Central Leather Research Institute (CLRI), TICEL-BIOPARK, Taramani Main Road
- Taramani, Chennai, Tamil Nadu, India
- BC Shankar ms
- Consultant Plastic Surgeon, Mumbai
- Ex-Associate Director of Biomedical Group
- Bhabha Atomic Research Centre (BARC), Mumbai
- Maharashtra, India
- Chandrakant md
- Formerly, Head, Department of Forensic Medicine
- Safdarjung Hospital, New Delhi, India
- Deepak Nanda ms, mch
- Specialist and Assistant Professor, Dept of Burns, Plastic, Maxillofacial and Microvascular Surgery
- Vardhman Mahavir Medical College and Associated
- Safdarjung Hospital, New Delhi, India
- Deepthi Nair md
- Senior Specialist and Associate Professor of Microbiology, Department of Microbiology, Safdarjung
- Hospital and Vardhman Mahavir Medical College
- New Delhi, India
- Harish Chellani md
- Senior Pediatrician, Department of Pediatrics, Safdarjung Hospital and Vardhman Mahavir
- Medical College, New Delhi, India
- Hemant Haldavnekar mbbs
- Industrial Medicine Specialist, Bhabha Atomic Research
- Centre (BARC), Mumbai, Maharashtra, India
- Indu Chadha md
- Professor, Department of Anesthesiology
- BJ Medical College and Civil Hospital
- Ahmedabad, Gujarat, India
- JC Suri md, dtcd, dnb, fnccp
- Professor and Head of Respiratory Medicine
- Vardhman Mahavir Medical College and Safdarjung Hospital
- Karoon Agrawal ms, mch
- Professor and Head of Plastic Surgery, Jawahar Lal
- Nehru Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
- MK Sen dtcd, md, fnccp
- Senior Chest Physician and Associate Professor
- Safdarjung Hospital and Associated Vardhman Mahavir
- Medical College and Safdarjung Hospital
- New Delhi, India
- Madhuri A Gore ms
- Professor and Head of Surgery, Lokmanya Tilak
- Medical College and General Hospital
- Sion, Mumbai, Maharashtra, India
- Mamta Sikroria ms, mch
- Senior Deputy Director and Head
- Department of Burns and Plastic Surgery
- JLN Hospital and Research Centre Bhilai
- Chhatisgarh, India
- Mary Babu
- Ex-Head and Director Grade-Scientist ‘G’ Biomaterials
- Division, Central Leather Research Institute (CLRI)
- Chennai, Tamil Nadu, India
- N Shanmuganathan m Pharma, PhD
- Assistant Professor, Department of Pharmaceutics
- Sri Ramachandra College of Pharmacy
- Sri Ramachandra University
- Porur, Chennai, Tamil Nadu, India
- PR Bongirwar mbbs
- Industrial Medicine Specialist
- Bhabha Atomic Research Centre (BARC)
- Mumbai, Maharashtra, India
- PK Bilwani ms, mch
- Director, Gujarat Burns Hospital and Research Centre
- Hon. Professor of Plastic Surgery, NHL Muni Medical
- College and KM School of Postgraduate Medicine
- Ahmedabad, Hon Plastic Surgeon, LG Hospital
- Ahmedabad, Gujarat, India
- PK Verma md
- Reader in Anesthesia and Senior Specialist, Department of Anesthesiology and Intensive Care
- Vardhman Mahavir Medical College and Safdarjung
- Hospital, New Delhi, India
- Pramod Kumar ms, mch, dnb
- Professor and Head, Department of Plastic Surgery
- Kasturba Medical College, Manipal, Karnataka, India
- PS Bhandari ms, mch
- Senior Specialist Plastic Surgeon and Head of Unit
- Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Lok Nayak Hospital and Associated Maulana Azad Medical College
- New Delhi, India
- Rajiv Kohli md, ficp
- Physician and Nephrologist, Head, Dialysis Unit
- Lok Nayak Hospital and Associated Maulana Azad
- Medical College, New Delhi, India
- Rakesh Kain ms, mch
- Assistant Professor and Specialist Plastic Surgeon, Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Vardhman Mahavir Medical
- College and Associated Safdarjung Hospital
- New Delhi, India
- Ravi Chittoria ms, mch, dnb, mnams
- Head, Department of Plastic Surgery, Sri Venkateswara
- Institute of Medical Sciences, Tirupati
- Andhra Pradesh, India
- Ravindra Tah ms, mch
- Consultant Plastic Surgeon, Deepak Hospital and Apollo
- Hospital, Ludhiana, Punjab, India
- RP Narayan ms, mch, fics
- Professor and Head, Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Vardhman
- Mahavir Medical College and Associated Safdarjung
- Hospital, New Delhi, India
- S Raja Sabapathy ms, mch, dnb (Plastic Surgery), frcs (Edin), mnams
- Director, Ganga Hospital
- Head, Department of Plastic Surgery, Hand and Microsurgery and Burns, Ganga Hospital, Coimbatore
- Tamil Nadu, India
- Sameek Bhattacharya ms, dnb (Plastic Surgery), fics, mnams
- Assistant Professor and Specialist Plastic Surgeon
- Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Vardhman Mahavir Medical
- College and Associated Safdarjung Hospital
- New Delhi, India
- Sarla Passi
- Department in Physiotherapy
- Postgraduate in Rehabilitation
- Presently, Practising Physiotherapist, New Delhi
- Ex-Incharge, Physiotherapy
- Department of Burns and Plastic Surgery
- Safdarjung Hospital, New Delhi, India
- Savita Arora ms, mch
- Assistant Professor and Specialist Plastic Surgeon
- Dept of Burns, Plastic, Maxillofacial and Microvascular
- Surgery, Vardhman Mahavir Medical College and Associated Safdarjung Hospital, New Delhi, India
- Shailesh Ranade ms, mch
- Consultant Plastic Surgeon, Bhatia Hospital
- Mumbai, Maharashtra, India
- Shankar Sriniwasan ms, mch
- Plastic Surgeon, Wadia Hospital for Children, Parel
- Hiranandani Hospital, Powai
- Mumbai, Maharashtra, India
- SP Bajaj ms, mch, frcs
- Formerly Professor and Head
- Department of Burns, Plastic, Maxillofacial and Microvascular Surgery Safdarjung Hospital
- New Delhi
- Consultant Plastic surgeon, Jaipur Golden Hospital
- New Delhi, India
- Sugandha Arya md
- Specialist Pediatrician, Safdarjung Hospital
- New Delhi, India
- Sujata Sarabahi ms, mch, dnb (Plastic Surgery), mnams
- Assistant Professor and Specialist Plastic Surgeon
- Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Vardhman Mahavir Medical
- College and Associated Safdarjung Hospital
- New Delhi, India
- VK Tiwari ms, mch
- Professor and Senior Specialist Plastic Surgeon
- Department of Burns, Plastic, Maxillofacial and Microvascular Surgery Vardhman Mahavir Medical
- College and Associated Safdarjung Hospital
- New Delhi, India
It gives me a great pleasure to write a foreword for this book entitled Principles and Practice of Burn Care, which has been ably compiled and edited by Dr Sujata Sarabahi, Dr VK Tiwari, Dr Arun Goel and Dr LC Gupta.
Sufferings of the World Wars have given some precious dividends of today. Efforts and contributions of Sir Harrold Gillies in various fields of Plastic Surgery including his invaluable contributions in burns outshine till this day. The unfortunate victims of burns are crippled, deformed, handicapped and disfigured and socially unacceptable. These poor patients are shoved into dark and smelly corners of the surgical wards of hospitals and left to die or scar in their own serum and sepsis. Being treated at general hospitals without skin grafting, most of them land up with horrible deformities and scars.
The magnitude of problem in a developing country like ours is a colossal challenge. We still do not have a central burn registry, which means that the magnitude of the problem is yet not fully understood, appreciated and defined. National Academy of Burns—India (NABI) conducted a survey over several years and found that about 7 million (70 lakhs) people get burnt annually, 7 lakhs need hospital admission, 2.5 lakhs get crippled with deformities and 1.4 lakhs die annually. The facilities for treatment are from meager to non-existent in some parts of the country. The progress has been no happy fluke, but a personal response to the challenge by a very few in the country. The research of some workers on the physiology and pathology of this trauma has given us valuable new insights; others have had the vision to see how new understandings could be translated into useful techniques, while yet others have responded to the clinical challenge by commitment of their lives to the delivery of burn care and to burn prevention.
Historically speaking, the first dedicated burn unit was started in India under my guidance in the Department of Burns, Plastic and Maxillofacial surgery at Safdarjung Hospital, New Delhi in 1963 and this department went on to become the largest burn care unit in Asia. This unit has been an example of commitment and dedication to the cause of optimum burn care in the country. Over the years, the details of treatment have been changing and facilities improved and advanced with progress in the world by various subsequent heads of the department. It is a matter of great pride that this book also comes from the same department where the story started in a barrack of a hospital designed for wartime casualties. The journey for this department has been long and arduous and I am happy to say that it has enjoyed the status of excellence all this while.
The editors are to be congratulated on recording in this volume entitled Principles and Practice of Burn Care, the views of several authors covering the entire country. This book has been divided into 7 sections, depending on the various situations in managing burns and has contributions from eminent specialists involved in burn care and research. Each section has chapters relevant to clinical management of the burn patient. The book is comprehensive and yet makes for easy reading. I am sure the students and doctors will find here the important practical information they need to give safe and thorough care to their burn patients.
I also hope that this book will be used in other developing countries especially by those who work in peripheral district hospitals and private medical practitioners with limited means. The basic essential to start a unit, is to have a committed staff who are ready to be spent for the sake of those in their care. The book will provide them with knowledge they need.
I wish this book a great success.
JL Gupta
Consultant in Burns, Plastic and Maxillofacial Surgery,
Formerly, Head of Department of Burns, Plastic and Maxillofacial Surgery, Safdarjung Hospital, New Delhi
Professor of Plastic Surgery, University of Delhi
Patron, National Academy of Burns – India
13Preface
Burns is the most serious injury ever inflicted on mankind. This appears to be the price of civilization which man is paying today. India is amongst the few countries of the world where the incidence of burns is showing a rising trend even though it is on the decline in the Western world. Management of burns is difficult and time consuming. Apart from being a costly treatment, it is also a heart-breaking experience for any specialist treating a burn victim and rehabilitating him back to the society is equally difficult.
Over the centuries, we have discovered how to use new technological innovations and scientific advances to the greater advantage of victims of burns, fire, bomb blast and other terrorist crimes. However, in view of the continuously changing circumstances, it becomes imperative for burn surgeons, physicians and other para-medicals to constantly learn to change and accept changes and keep themselves updated at all the times with the new skills and techniques in the management of burn patients. We cannot afford to remain silent, inactive or resilient even in the treatment of minor accidental burn cases which otherwise receive scant attention by the hospital staff possibly because they are not dangerous to life or due to lack of interest on their part.
In the 21st century we are learning to evaluate new products and technologies more realistically. In short we are re-discovering the wisdom of our ancestors and learning to value the efforts made by others so far in modifying and improving our methods and skills in burn care. Regular studies and continuous research in various fields have proven to be the right investment in improving every aspect of human life—so why not for burn injury?
Though a burn specialist treats burn patients, but the modern treatment of major burns depends upon multidisciplinary team approach which includes anesthetist, medical specialist, pulmonologist, nutritionist, physiotherapist and occupational therapist. Each of them helps in providing a holistic approach towards treating and rehabilitating a burn patient.
This book brings together the knowledge and clinical experience of many of the specialists from all over the country, who have made outstanding contributions in the field of burn care. An attempt has been made to deliver comprehensive information about the treatment of a burn victim in all its aspects from the experiences and expertise of these surgeons and physicians serving in the battlefield of burns, i.e The Burn Units; thus gaining and giving opportunities to learn from the best. This book emphasizes not only on the treatment and rehabilitation of burns but also the pathophysiology of burns and its prevention. It was not an easy task and required constant follow up to get others associated in producing this book.
I am thankful to all the contributors who are experts in their own fields for sharing their knowledge and experiences which have been reflected in their contributions, which I am sure will be beneficial to all the postgraduate and practicing burn surgeons who will be reading this book.
I have personally inserted photographs of many interesting cases in various chapters in addition to the photographs provided by the contributors in order to make the topic more interesting and easy to comprehend.
A book of this magnitude cannot be brought out single handedly. Dr Arun Goel, Dr VK Tiwari and Dr LC Gupta have been associated in editing this book and their help and support cannot be acknowledged in words. Without them, it would not have been possible to bring out this book which is complete in every sense, whether it is in the text content, pictorial depiction or practical case management protocol.
I am grateful to Dr SP Bajaj, who has been my guide and a father figure in burn management in India, for his valuable suggestions and encouragement at every step.
I am also thankful to my residents specially Dr Jeethendran Iyer for providing help in procuring the case photographs and Dr Geetika Khanna for providing the histological slides.
I must especially thank my publisher M/s Jaypee Brothers Medical Publishers (P) Ltd. especially Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director, Publishing) for having recognized the merits of the presented material and to have come forward enthusiastically for publishing the book.
Lastly, I am thankful to my family for their moral support in helping me complete this book.
JAI HIND and Good Luck to my readers whoever and wherever they are.
Sujata Sarabahi