Extensive burn case study NEJM.pdf - SASSiT

The new england journal of medicine 

case records of the massachusetts general hospital 

Founded by Richard C. Cabot 

Nancy Lee Harris, m.d., Editor 

Jo-Anne O. Shepard, m.d., Associate Editor 

Sally H. Ebeling, Assistant Editor 

Stacey M. Ellender, Assistant Editor 

Christine C. Peters, Assistant Editor 

Case 6-2004: A 35-Year-Old Woman 

with Extensive, Deep Burns from a Nightclub Fire 

Robert L. Sheridan, M.D., John T. Schulz, M.D., Ph.D., Colleen M. Ryan, M.D., 

and Paul J. McGinnis, M.D. 

presentation of case 

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. 

N Engl J Med 2004;350:810-21. 

Copyright © 2004 Massachusetts Medical Society. 

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 Tables 1, 2, and 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. 

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. 

810 

n engl j med 350;8 www.nejm.org february 19, 2004 

Downloaded from www.nejm.org by MARTIN BRAND MD on December 28, 2007 . 

Copyright © 2004 Massachusetts Medical Society. All rights reserved.


Table 1. Arterial-Blood Gas Values and Ventilatory Information. 

Variable Day 1 Day 2 Day 3 

4 hr 

after 

operation 

1 hr after 

start of 

nitrous 

oxide 

3 hr after 

start of 

nitrous 

oxide 

2 hr 4.5 hr 7.5 hr 13 hr morning noon evening 

end of 

operation 

pH 7.1 7.16 7.35 7.25 7.30 7.36 7.28 7.28 7.31 7.34 7.35 

36 53 31.7 49 53 45 59 55 56 50 49 

Partial pressure of carbon 

dioxide (mm Hg) 

Partial pressure of oxygen 274 312 73.6 146 65 121 77 65 61 173 83 

(mm Hg) 

Bicarbonate (mmol/liter) 12 18.5 17.1 21 25 24 27 28 28 24 

Oxygen saturation (%) 98.9 96.1 100 96 100 95 93 90 99 98 

Fraction of inspired oxygen 1.00 1.00 0.65 0.50 0.60 0.70 0.70 1.00 1.00 1.00 0.80 

Peak end expiratory 

5 5 12 8 15 15 13 18 16 16 16 

pressure (cm of water) 

Peak inspiratory pressure 

26 40 39 37 44 45 45 45 

(cm of water) 

Carboxyhemoglobin 28.0 7.0 3.2 1.3 

(% of total hemoglobin) 

Lactic acid (mmol/liter) 4.6 1.7 

Osmolality (mOsm/kg) 283 

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. 

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 (Fig. 1A and 1B). Doppler ultrasonography 

showed that the pulses in the digits 

Table 2. Hematologic and Coagulation Laboratory Data.* 

Variable Day 1 Day 3 Day 5 Day 6 

Hematocrit (%) 44.0 43.5 31.4 26.9 28.9 

Hemoglobin (g/dl) 15.0 14.9 10.5 9.1 9.5 

White cells (per mm 3 ) 19,200 28,100 16,500 9,800 9,100 

Differential count (%) 

Neutrophils 75 74 92 

Band forms 20 

Lymphocytes 11 4 5 

Monocytes 4 2 2 

Eosinophils 11 0 1 

Platelets (per mm 3 ) 359,000 209,000 125,000 59,000 95,000 

Prothrombin time (sec) 12.8 13.6 17.0 16.0 

Partial-thromboplastin 

time (sec) 

25.1 38.0 71.3 39.2 

* Because of rounding, not all percentages total 100. 


811 




Table 3. Blood Chemical Values.* 

Variable Day 1 Day 26 Day 47 

Glucose (mg/dl) 246 105 125 127 

Bilirubin (mg/dl) 

Total 1.0 2.9 0.8 0.5 

Direct 1.1 0.4 0.3 

Phosphorus (mg/dl) 2.8 2.9 3.3 

Protein (g/dl) 

Total 4.3 5.1 6.8 

Albumin 3.3 2.0 1.3 2.3 

Globulin 2.3 3.8 4.5 

Sodium (mmol/liter) 135 137 137 144 

Potassium (mmol/liter) 4.2 4.2 4.1 3.5 

Chloride (mmol/liter) 106 114 111 107 

Carbon dioxide (mmol/liter) 16 23.9 26.1 30.6 

Magnesium (mmol/liter) 0.6 1.0 0.8 

Urea nitrogen (mg/dl) 15 12 15 21 

Creatinine (mg/dl) 1.5 1.0 0.4 0.7 

Calcium (mg/dl) 7.2 8.8 

Creatine kinase (U/liter) 436 

Alkaline phosphatase (U/liter) 52 54 431 686 

Aspartate aminotransferase (U/liter) 82 320 128 200 

Alanine aminotransferase (U/liter) 54 200 155 375 

Lipase (U/liter) † 3.6 7.1 

Amylase (U/liter) 83 47 

Thiocyanate (mg/dl) 0.4 

Alcohol level (mg/dl) 49 

Urine test for human chorionic 

gonadotropin 

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 (Fig. 1A and 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, in- 

Negative 

* To convert the values for glucose to millimoles per liter, multiply by 0.05551. 

To convert the values for bilirubin to micromoles per liter, multiply by 17.1. To 

convert the values for phosphorus to millimoles per liter, multiply by 0.3229. 

To convert the values for magnesium to milliequivalents per liter, divide by 0.5. 

To convert the values for urea nitrogen to millimoles per liter, multiply by 0.357. 

To convert the values for creatinine to micromoles per liter, multiply by 88.4. 

To convert the values for calcium to millimoles per liter, multiply by 0.250. To 

convert the value for thiocyanate to millimoles per liter, multiply by 0.1722. 

† The normal range is 1.3 to 6.0 U per liter. 

were minimal or absent. The results of laboratory 

tests are shown in Tables 1, 2, and 3. A chest radiograph 

showed bilateral, predominantly central, lung 

opacities, a finding compatible with the presence 

of early pulmonary edema or inhalation injury 

(Fig. 2A). Opiates, benzodiazepine, ranitidine, and 

warmed fluids were administered intravenously. 

She was placed in a warm, bacteria-controlled nursing 

unit. 

Table 4. Fluid Intake and Output. 

Variable Day 1 Day 2 

0–12 

hr* 

* These values are estimates. 

† These values are averages. 

13–24 

hr 

1–12 

hr 

13–24 

hr 

Fluid intake (ml) 

Crystalloid 11,000 8,447 2054 1320 

Hyperalimentation 210 1260 1260 

Albumin 1,500 1200 1200 

Total 11,000 10,157 4514 3780 

Fluid output (ml) 

Urine 1,210 2,340 2985 1815 

Other† 25 25


A 

B 

C 

D 

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). 

creased 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 (Fig. 1C and 

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 ar- 


813 




A B C 

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. 

terial 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 (Fig. 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 gramnegative 

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 (Fig. 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 

814 





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 [as 

a percentage], multiplied by the body weight [in kilograms], 

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 


815 




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 smokeinhalation 

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 (Fig. 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 (Fig. 2B). By day 7, after five 

days of nitric oxide therapy, progressive clearing of 

the pulmonary opacities is evident (Fig. 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 (Fig. 1A, 1B, 1C, and 

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 tech- 

816 





niques 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 splitthickness 

or full-thickness skin or flaps. In the 

patient under discussion, reconstruction began with 

correction of dorsal hand contractures (Fig. 3A) and 

release of a tight contracture of the posterior surface 

of the neck (Fig. 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 

Finally, patients with burns require a predictable 

set of supportive general surgical operations that 

A 

B 

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. 


817 




Table 5. Common Long-Term Disabilities in Patients 

with Burn Injuries. 

Disabilities affecting the skin and soft tissue 

Hypertrophic scars 

Susceptibility to minor trauma, chemicals, or cold 

Dry skin 

Contractures 

Itching and neuropathic pain 

Alopecia 

Chronic open wounds 

Skin cancers 

Orthopedic disabilities 

Amputations 

Contractures 

Heterotopic ossification 

Metabolic disabilities 

Heat exhaustion 

Obesity 

Psychiatric and neurologic disabilities 

Sleep disorders 

Adjustment disorders 

Post-traumatic stress syndrome 

Depression 

Neuropathy and neuropathic pain 

Long-term neurologic effects of carbon monoxide 

poisoning 

Anoxic brain injury 

Long-term complications of critical care 

Deep-vein thrombosis, venous insufficiency, or varicose 

veins 

Tracheal stenosis, vocal-cord disorders, or swallowing 

disorders 

Renal or adrenal dysfunction 

Hepatobiliary or pancreatic disease 

Cardiovascular disease 

Reactive airway disease or bronchial polyposis 

Preexisting disabilities that contributed to the injuries 

Substance abuse 

Risk-taking behavior 

Untreated or poorly treated psychiatric disorder 

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 (Fig. 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 grafts 28 or a prosthesis. She has neartotal 

alopecia, which she conceals with scarves and 

wigs (Fig. 4A and 4B). 

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 

818 





A B C 

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. 

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 

burns 24 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-ofmotion 

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 (Fig. 

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 (Fig. 

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 

(Fig. 5A) obtained during the second month after 

the fire shows a large area of heterotopic bone posterior 

to the distal humerus. A radiograph taken 


819 




A 

B 

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. 

after surgery (Fig. 5B) shows that the heterotopic 

bone has disappeared. 

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. 

references 

1. Underhill FP. The significance of anhydremia 

in extensive superficial burns. JAMA 

1930;95:852-7. 

2. O’Nan S. The circus fire: a true story. 

New York: Doubleday, 2000. 

3. Saffle JR. The 1942 fire at Boston’s 

Cocoanut Grove nightclub. Am J Surg 1993; 

166:581-91. 

4. Artz CP, Moncrief JA. The burn problem. 

In: Artz CP, Moncrief JA, eds. The treatment 

of burns. 2nd ed. Philadelphia: W.B. 

Saunders, 1969:1-21. 

5. Linn BS, Stephenson SE Jr, Bergstresser 

PR, Smith J. Are burn units the best places to 

treat burn patients? J Surg Res 1977;23:1-5. 

6. Sheridan RL, Remensnyder JP, Schnitzer 

JJ, Schulz JT, Ryan CM, Tompkins RG. Current 

expectations for survival in pediatric 

820 





burns. Arch Pediatr Adolesc Med 2000;154: 

245-9. 

7. Sheridan RL, Hinson MI, Liang MH, et 

al. Long-term outcome of children surviving 

massive burns. JAMA 2000;283:69-73. 

8. Sheridan RL. Comprehensive treatment 

of burns. Curr Probl Surg 2001;38:657-756. 

9. Monafo WW. Initial management of 

burns. N Engl J Med 1996;335:1581-6. 

10. Sheridan RL, Shank ES. Hyperbaric oxygen 

treatment: a brief overview of a controversial 

topic. J Trauma 1999;47:426-35. 

11. Weaver LK, Hopkins RO, Chan KJ, et al. 

Hyperbaric oxygen for acute carbon monoxide 

poisoning. N Engl J Med 2002;347: 

1057-67. 

12. Shirani KZ, Vaughan GM, Mason AD Jr, 

Pruitt BA Jr. Update on current therapeutic 

approaches in burns. Shock 1996;5:4-16. 

13. Warden GD. Burn shock resuscitation. 

World J Surg 1992;16:16-23. 

14. Cartotto RC, Innes M, Musgrave MA, 

Gomez M, Cooper AB. How well does the 

Parkland formula estimate actual fluid 

resuscitation volumes? J Burn Care Rehabil 

2002;23:258-65. 

15. Rosenkranz KM, Sheridan RL. Management 

of the burned trauma patient: balancing 

conflicting priorities. Burns 2002;28: 

665-9. 

16. Mayhall CG. The epidemiology of burn 

wound infections: then and now. Clin Infect 

Dis 2003;37:543-50. 

17. American Burn Association. Inhalation 

injury: diagnosis. J Am Coll Surg 2003;196: 

307-12. 

18. Sheridan RL, Hurford WE, Kacmarek 

RM, et al. Inhaled nitric oxide in burn 

patients with respiratory failure. J Trauma 

1997;42:629-34. 

19. Yu YM, Tompkins RG, Ryan CM, Young 

VR. The metabolic basis of the increase in 

energy expenditure in severely burned 

patients. JPEN J Parenter Enteral Nutr 1999; 

23:160-8. 

20. Winer-Muram HT, Jennings SG, Wunderink 

RG, Jones CB, Leeper KV Jr. Ventilator-associated 

Pseudomonas aeruginosa pneumonia: 

radiographic findings. Radiology 

1995;195:247-52. 

21. Thompson P, Herndon DN, Abston S, 

Rutan T. Effect of early excision on patients 

with major thermal injury. J Trauma 1987; 

27:205-7. 

22. Sheridan RL, Tompkins RG, McManus 

WF, Pruitt BA Jr. Intracompartmental sepsis 

in burn patients. J Trauma 1994;36:301-5. 

23. Sheridan RL, Tompkins RG. Skin substitutes 

in burns. Burns 1999;25:97-103. 

24. Sheridan RL, Hurley J, Smith MA, et al. 

The acutely burned hand: management and 

outcome based on a ten-year experience 

with 1047 acute hand burns. J Trauma 1995; 

38:406-11. 

25. Palmieri TL, Jackson W, Greenhalgh 

DG. Benefits of early tracheostomy in 

severely burned children. Crit Care Med 

2002;30:922-4. 

26. Iliopoulou E, Markaki S, Poulikakos L. 

Autopsy findings in burn injuries. Arch Anat 

Cytol Pathol 1993;41:5-8. 

27. Sheridan RL. Burn care: results of technical 

and organizational progress. JAMA 

2003;290:719-22. 

28. Ryan CM, Schoenfeld DA, Thorpe WP, 

Sheridan RL, Cassem EH, Tompkins RG. 

Objective estimates of the probability of 

death from burns. N Engl J Med 1998;338: 

362-6. 

29. Ryan CM, Malloy M, Schulz JT III, Sheridan 

RL, Tompkins RG, Donelan MB. Outcome 

following ectropian release in adults 

with major burn injury. J Burn Care Rehabil 

2002;23:Suppl:S156. abstract. 

30. Willebrand M, Andersson G, Kildal M, 

Ekselius L. Exploration of coping patterns in 

burned adults: cluster analysis of the coping 

with burns questionnaire (CBQ). Burns 

2002;28:549-54. 

Copyright © 2004 Massachusetts Medical Society. 

35-millimeter slides for the case records 

Any reader of the Journal who uses the Case Records of the Massachusetts General Hospital as a medical teaching 

exercise or reference material is eligible to receive 35-mm slides, with identifying legends, of the pertinent x-ray films, 

electrocardiograms, gross specimens, and photomicrographs of each case. The slides are 2 in. by 2 in., for use with a 

standard 35-mm projector. These slides, which illustrate the current cases in the Journal, are mailed from the Department 

of Pathology to correspond to the week of publication and may be retained by the subscriber. Each year approximately 

250 slides from 40 cases are sent to each subscriber. The cost of the subscription is $450 per year. Application forms for 

the current subscription year, which began in January, may be obtained from Lantern Slides Service, Department of 

Pathology, Massachusetts General Hospital, Boston, MA 02114 (telephone 617-726-2974). 

Slides from individual cases may be obtained at a cost of $35 per case. 


821 



New England Journal of Medicine 

CORRECTION 

Case 6-2004: A 35-Year-Old Woman with Extensive, 

Deep Burns from a Nightclub Fire 

Case 6-2004: A 35-Year-Old Woman with Extensive, Deep Burns 

from a Nightclub Fire . On page 811, in Table 1, the headings of the 

last two columns should have read ``nitric oxide,´´ rather than ``nitrous 

oxide,´´ as printed. 

N Engl J Med 2004;351:408-a

Extensive burn case study NEJM.pdf - SASSiT

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?