Severe burn injury is a serious pathology leading to significant morbidity and mortality that has considerable economic impacts.1 Wound repair is key to treating patients with severe burns. If large wounds remain open, systemic infection and multiple organ dysfunction syndrome can occur, threatening the lives of patients. Moreover, severe infections, organ dysfunction, and bone exposure make wound repair more difficult and usually require multidisciplinary collaboration. Wound repair methods mainly include dressing changes, skin grafts, and flap repair. In recent years, negative-pressure wound therapy (NPWT), cellular and/or tissue-based products (CTPs), and platelet-rich plasma (PRP) have been increasing in popularity as treatments for refractory wounds.2–4 For deep burn wounds that are difficult to repair, a single form of treatment is usually ineffective. This article reports a rare case of burn injury that required diverse treatments.
The patient signed informed consent forms and authorized the authors to publish his clinical data and images in this case report.
A 29-year-old man fell asleep while using charcoal as a source of heat, experienced carbon monoxide poisoning, and lapsed into a coma for an unknown amount of time. He fell into the charcoal fire and was found approximately 3 hours later. He was taken to the burn unit in the department of surgery at the local central hospital for treatment. Two days after the injury, the patient experienced pneumothorax and acute renal failure, which were treated with thoracic drainage and continuous renal replacement therapy (CRRT). He was transferred to the authors’ department for further treatment on the fourth day after injury. He had no history of underlying disease.
On admission, the patient’s vital signs were stable. Physical examination revealed that the burn wounds were distributed on the right anterior and posterior torso, bilateral hips, bilateral lower limbs, and upper right limbs, with a 17% total burn surface area (TBSA). Most of the burn wounds were covered with hard, black, leather-like eschar. Deep necrotic fascia and muscle tissue were visible (Figure 1). The blood supply to distal limbs was acceptable, and his skin was warm. The patient’s diagnoses on admission were as follows: (1) thermal burns (from charcoal flame, 17% TBSA; deep second-degree burns, 2% TBSA; third-degree burns, 15% TBSA), (2) acute renal failure, and (3) bilateral lower lung infection. The patient’s visual analog scale score for pain was 7. Analgesic medications such as flurbiprofen and tramadol were used in succession to relieve his pain. Once the shock window had passed, the patient received enteral and partial parenteral nutrition without additional fluid resuscitation.
On the third day after admission, computed tomography and MRI of the chest and abdomen were performed and showed a right pneumothorax, bilateral lower lung infection, and bilateral pleural effusion; a right abdominal wall soft tissue defect, suspected right chest wall soft tissue defect into the abdominal cavity, and blood effusion in the pelvis; and multiple muscle injuries on the right chest wall, hips, and pelvic cavity.
On the fourth day after admission, a multidisciplinary team convened to formulate treatment plans that included wound treatment, CRRT, infection control, respiratory support, nutrition, and rehabilitation. Conservative debridement was necessary because the right abdominal wall defect possibly penetrated into the abdominal cavity. Providers agreed to apply NPWT, CTPs, skin grafts, or flap repairs as needed based on the condition of the patient’s large wounds. Because his renal function remained poor (probably because of denatured proteins from rhabdomyolysis), CRRT was provided 12 hours a day (in continuous venovenous hemodiafiltration mode) for nearly 2 weeks until renal function recovered. The enteral and parental nutrition calorie intake was about 2,000 to 2,200 kcal per day. Multidisciplinary rehabilitation treatments were provided in the burn ICU, including anticontracture positioning, passive and active range-of-motion exercises, transfer training, and tilt table training under the guidance of rehabilitation therapists. Meanwhile, psychological interventions such as rational-emotional therapy and music therapy were provided to the patient to reduce anxiety and depression.
On the sixth day after admission, the patient underwent escharectomy under general anesthesia. The intraoperative findings revealed necrosis of most of the right chest muscles (including his intercostal muscles) and part of the ribs and exposure of part of the pleura. With the assistance of thoracic surgeons and general surgeons, conservative debridement was performed to better protect the tissues in the chest cavity. Most of the abdominal muscles were necrotic, including the external and internal oblique muscles and most of the rectus abdominis. The iliac bone was partially necrotic. The muscles and soft tissues near the peritoneum were preserved to avoid entry into the abdominal cavity. After debridement, the exposed peritoneum was covered with xenogeneic dressings (porcine peritoneum; Figure 2), and then NPWT was applied to seal the surgical wound (Figure 3).
On the 12th day after admission, physical examination revealed that the wounds on the patient’s abdomen were well covered by the xenogeneic dressings, with red granulation visible in the wound bed. On the 17th day after admission, the sixth intercostal arteries in the right chest wall hemorrhaged, and the wounds were covered with allogeneic skin patches after the hemorrhagic blood vessels were sutured (Figure 4). Forty-four days after admission, the patient underwent debridement and meshed skin grafting under general anesthesia to close the wounds on his torso and part of the lower extremity (Figure 5).
On day 65, with the assistance of thoracic surgeons, the right necrotic ribs (6-12) were removed. The chest wall was ruptured (1 × 1 cm), and the right lung tissue was visualized through the rupture, which was then repaired with sutures. An autologous meshed dermal scaffold harvested by an air-driven dermatome was used to cover the chest wall wound, and the epidermal skin sheet was placed in situ to cover the donor area. Next, NPWT was placed on top of the dermal scaffold (Figure 6).
On day 103 after admission, the right necrotic iliac bone was excised, and the surgical wound was covered with preprepared autologous dermal scaffold and then dressed for NPWT. On day 115 after admission, a sural neurovascular flap was used to repair the right heel wound. A refractory sinus tract on the right chest wound persisted, even with continuous dressing change. Therefore, on day 179 after admission, autologous PRP was injected into the thoracic sinus tract, which healed 2 weeks later. On the 195th day after admission, the patient was discharged when his kidney and lung functions had recovered, and all the wounds had healed (Figure 7).
Severe burn injuries are the most traumatic and physically debilitating injuries, affecting most organ systems and leading to significant morbidity and mortality, often complicated by shock, systematic infection, multiple organ dysfunction syndrome, and hypertrophic scarring.5–7 A pivotal step in the early treatment of severe burns is IV fluid resuscitation, after which surgical management and nutrition supplementation for wound healing is critical.8,9 Rapid, effective treatment for complications after burns can shorten the wound repair time and improve patient prognosis. Early acute kidney injury is a common complication, mainly because of hypovolemia, increased inflammatory mediators, mechanical tissue destruction, release of denatured proteins, and cardiac dysfunction.10 Evidence shows that CRRT has significantly improved mortality among burn patients with acute kidney injury and should be initiated early if renal function continues to worsen.11,12
Dressing changes, excision and grafting, or physical therapy can cause pain that is equivalent to or worse than the pain of an initial burn injury.13,14 Good pain control is the foundation of efficacious burn care and results in better wound healing.15 Interdisciplinary rehabilitation aims to prevent scarring, contractures, psychological issues, and so on. Long-term and effective rehabilitation facilitates patients’ successful return to work and their daily lives.16–18
The patient in this case report suffered from carbon monoxide poisoning and lengthy thermal exposure, which resulted in a large area of deep burns. After the injury, pneumothorax and acute renal failure made treatment extremely difficult. In the early period following the injury, thoracic closed drainage, respiratory support, CRRT, anti-infection measures, and pain management were performed to gradually improve organ function and lay a good foundation for deep wound repair. Further, a comprehensive rehabilitation program was implemented from initial admission to facilitate long-term recovery.
Timely wound closure is key to the successful treatment of patients with severe burns. Skin graft and flap repair are common methods of wound repair.19,20 However, for some complex wounds, especially those that require conservative debridement and present with infection and secondary necrosis of deep tissues, skin grafts or flap repair may not be suitable. Certain advanced treatments such as NPWT and CTPs can promote granulation tissue growth and wound healing; for example, NPWT produces significant effects by shortening wound healing time and reducing infections.21
Further, an allogeneic skin patch with good biologic activity is the first choice of CTP and provides complete skin barrier function to prevent bacterial invasion and water, electrolyte, protein, and heat loss. It can control wound infection with good analgesic and hemostatic support, establish blood supply, induce granulation tissue growth, and provide a scaffold for autogenous skin to repair the wound.22,23 Acellular dermal matrices have been widely used to repair tissue defects.24 An allogeneic acellular dermal matrix has limited tissue sources and is associated with a risk of transmitting viral diseases. Heterogeneous dermis has a wide range of sources, but it is complicated to prepare and may induce an immune response.25,26 Autologous dermal tissue is easy to obtain and does not cause immune rejection, with good biocompatibility and low costs.27 An autologous dermal scaffold can promote interstitial fluid permeation and microvascular regeneration, and it can distribute the dermal matrix uniformly, thereby improving the survival and long-term effects of consequent skin grafts. An epidermal layer is used to cover wounds in situ, ensuring rapid healing of the donor area. However, there are currently few clinical reports of autologous dermal scaffold grafting for deep burn wounds.
To date, PRP has been widely used for chronic wounds. Its mechanism is based on the increased concentration of growth factors released from concentrated platelets and the secretion of proteins to promote the healing process. Platelet-rich plasma can promote blood vessel and dermal regeneration, improve the survival of skin grafts, and accelerate re-epithelialization in burn wounds.28,29
This case patient underwent 8 months of treatment that included 13 operations. The large deep wounds were extremely difficult to repair. Therefore, diverse treatments including conservative debridement, allogeneic and xenogeneic dressings, autologous dermal scaffold graft, NPWT, and PRP were used successfully to repair the wounds.
Patients with burns are often managed by a multidisciplinary team consisting of burn surgeons, critical care specialists, experienced nurses, anesthesiologists, and allied medical professionals such as physiotherapists, occupational therapists, psychologists, dietitians, and social workers. This team can formulate a scientific and individualized treatment program to improve patient prognosis.30 In this case, the patient received a series of treatments from the multidisciplinary team after admission, and providers requested multidisciplinary experts from other surgical departments (thoracic surgery, general surgery) to assist in the operations to reduce the risk of complications, shorten treatment time, and ensure efficacy.
Long-term follow-up of the patient is required to understand the final result of all treatments. Optoelectronic treatment for hypertrophic scars, such as laser therapy, may improve outcomes.
Wound healing is crucial for successful treatment of patients with severe burns, and fluid resuscitation, nutrition, pain control, and rehabilitation play important roles in supporting this objective. Integrating diverse treatments, such as NPWT, CTPs, skin grafts, flap transposition, and PRP, is markedly beneficial for complicated burn wounds.
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