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When the skin is burned, contracture scars may form, these contracture scars will affect the range of motion in the affected area and one of the methods used for scar treatment is Z-plasty.

Z-plasty is a surgical procedure used to improve the functional and/or cosmetic appearance of the scars.

Cosmetic Z-plasty is the repositioning the scar so that it more closely conforms to the natural lines and creases of the skin, where it will be less noticeable.

Functional Z-plasty is the lengthening of the scar to relieve the tension caused by that scar. This procedure can be used as one of the treatment methods for burn contracture scars.

Z-plasty procedure is done by making a Z shape incision in a way that the part of the scar that needs lengthening or re-aligning is running with the central limb of the Z shape. The flaps of skin formed by the other line of the Z are rotated and sewn into a new position.

Z-plasty may be used in other conditions such as closing cutaneous defects, correcting stenosis such as external auditory canal stenosis and other conditions.

Complications of Z-Plasty may include wound infection, necrosis (death) of the flap, formation of haematoma under the flap and others.

Several factors may affect the success of Z-plasty procedure one of which is the medical history of the patient. Patients with risk factors that affect the blood supply to the skin like diabetes, or other medical problems relating to the skin may preclude Z-plasty as an option.

Scars left after Z-plasty procedure may take a long time to reach their final appearance. You have to keep in mind that when Z-plasty is used for cosmetic reasons, it will not make the scar go away but it will make it less obvious.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Keloid scar is a benign scar composed of dense fibrous tissue formed as a result of an abnormal healing process in response to skin injury, extending beyond the original borders of the wound or inflammatory response. There is little to be done to prevent them and even with its removal there is a possibility of keloid recurrence. Keloid scar may affect the patient both physically and emotionally as it may become a cosmetic problem depending on its location on the body.

Keloid scar can happen in any age and can affect both sexes. The incidance of keloid scar varies among different races, it’s more common among blacks, hispanics and Asians and less common in Caucasians for unknown reasons. Both genetic and enviromental factors play a role in the formation of keloid scar. Keloid scar may form following skin inflamation such as acne vulgaris or skin injury such as second and third degree burns. Keloid may happen may appear months after skin inflammation or trauma but may take up to a year to develop.

Keloid scar can present as a firm nodule which can be skin coloured, hypopigmented (lighter in colour) or erythematous (red in colour) and is often located at the site of the injury (such as burn), wound which could be surgical or non-surgical or other lesion. Most common locations of keloid scar include the shoulders, , chest, sternal area, earlobes and back of the neck. Symptoms of keloid scar may include pain, itching and mobility limitalion if it is located over a joint area.

See also: Hypertrophic scars, Contractures, Burns and itching, Occupational therapy and third degree burns, Prevention and dealing with scars, Physical therapy and third degree burns, Scar massage, Psychological consequences of burns, Compression garments.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Trade names include Silvadene, SSD AF, Thermazene.

Silver Sulfadiazine topical cream is a sulfa drug that is used in the prevention or treatment of skin infections in patients with second and third degree burns; it can also be used for other conditions that will be determined by your doctor. Silvadene has anti-bacterial and anti-fungal properties that work by killing bacteria or fungi and is for external use only.

Before using this drug tell your doctor:

  • About any previous allergy to this drug, any allergy to sulfa drugs or other medications.
  • About any other medications you are using whether they are prescription or over-the-counter.
  • If you are pregnant or breast feeding.
  • If you have liver or kidney disease as smaller doses may be needed.
  • If you have an enzyme deficiency disease known as glucose-6-phosphate dehydrogenase deficiency (G6PD) because of the increased risk of hemolysis.

Follow the instructions given to you by your doctor for using Silvadene. When using Sivadene:

  • Wash your hands thoroughly and wear sterile gloves.
  • Cover the cleaned burned area with a thin layer of about 1/16 inch of the Silvadene once or twice a day as recommended by your doctor.
  • The burned area should be kept covered with the medicine at all times.
  • Reapply the medicine to the burned area if for any reason it becomes uncovered.
  • The area treated can be left uncovered or may be covered with dressing (consult your doctor).

Side effects of Silvadene include:

  • Burning sensation on the treated area and itching, contact your doctor if they don’t go away or if they become severe.
  • Skin rash, this may indicate allergy to the drug, contact your doctor.
  • Dark skin discoloration.
  • Rare side effects may include increased skin sensitivity to sunlight, fever, bloody urine, decreased or painful urination, unusual bleeding or bruising, sore throat, unusual weakness, shortness of breath. You have to contact your doctor immediately if you develop any of these symptoms.

Silvadene is not used for premature infants or infants less than two months of age as it may cause liver problems for infants.

Contact your doctor if you notice signs and symptoms of infection or if an infection worsens (see skin infection).

Keep the medicine out of reach of children and follow your doctor’s orders regarding the use of this medication and the duration of use. Don’t stop using Silvadene unless you have been told to do so by your doctor.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Some burns can heal without leaving any scars while other burns can leave wound scars after healing. Among the factors that determine the formation of scars is wound severity, superficial minor burns leave no scars when healing while deep severe burns such as second and third degree burns may leave scars after healing. when scars are formed whether they are hypertrophic or Keloids they may be difficult to treat. Cosmetic appearance of the scar form the patient’s main concern despite that hypertrophic scars and keloids may also cause pain, pruritus and pressure and/or contractures.

Treatment of scsars:

Treatment of scars may not be easy and there is a possibility of recurrance of scars even after treatment. Theraputic methods may include:

  • Surgery
  • Pressure garments
  • Massage therapy
  • Laser therapy
  • Cryosurgery therapy
  • Radiation therapy
  • Creams, Pasts and Gels
  • Silicone sheets

Pressure Garment:

Pressure garment is one of the methods used to treat burn scars. After being prescribed by the treating doctor, the Occupational therapist (OT) will take the exact measurements and the garments will be custom-made for the patient. Pressure garments are to be worn at all times day and night except during bathing and dressing changes. There should be two properly fitting sets of garments to alternate between them.

Ask your doctor about any question you have. Wash the garments eith by hand or by machine. For hand washing let the garment soak in warm water and laundry detergent for several minutes then rinse them well with clean warm water, roll the garment in a towel to soak up the extra water and leave them to be air dries. Aviod putting the garments in the dryer on in front of a heater or in the sunlight as this may destroy them and. For machine washing put the garment and laundry in warm water, put the washer on the gentle cycle and the air dry them. Avoid using hot water, dishwashing soap, bleach or cloth dryer and these may cause garment damage.

The doctor should be contacted if:

  • The garment is too tight or become loose.
  • There is swelling or redness or tingling sensation.
  • There is signs of wound infection such as fever, increase redness, increase pain, increase swelling, foul smelling dischage and bleeding.

For children, they have to be seen every three months as they may need to be measured for a new garment because the child’s body size is always changing.

As keloid scars differ in shape, size and causation from one person to another, the response to treatment also differ among different individuals therefore what might work for one person may not work for you and vise versa.

The combination of two or more treatment methods is usually more effective than using one method by itself and the recurrence is less when combining two or more methods together.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Skin graft is the process by which a non healing wound or a burn wound is covered by a piece of skin taken either from the patient himself/herself or from cadavers or animls. this procedure is done surgically. Skin graft is either used a temporary wound cover or a permanent one. Some wounds such as third degree burns if left to heal on their own can lead to scarring and contractions.

As the skin is the largest organ in the body and among its functions is playing a major role in protecting the body from fluid loss and help in preventing harmful micro organisims such as bacteria and varuses from entering the body and causing infections therefore its important to cover third degree burns with skin graft as soon as possiblee as uncovered third degree burns are more liable for wound infections and fluid loss from the burn area .

Skin graft is a surgical procedure that is not used for wounds that can heal on itself such as first and second degree burns, it’s used for large and non healing wounds. The skin used for grafting can be taken from another area of the patient body if there is enough undamaged healthy skin available and if the general condition of the patient permit to undergo an additional surgery. This type of graft is call autograft. Another type of skin graft is called Autograft where the skin is obtained from another person who is usually a donor cadaver in which the skin is frozen and stored to be available for use. The last last type of skin graft is called Xenograft where the skin is obtained from an animal which is usually a pig. Autograft can be used as a perminant covering to the damaged area while Allograft and Xenografts are temporary ones as they will be rejected by the immune system of the patient after a short period of time and need to be replaced by Autograft.

Skin grafts can aslo be classified according to the thickness of the graft as Partial (split) thickness skin graft and full thickness skin graft. Split thickness skin graft is used for wounds which are not very deep where the epidermis and a small thickness of the dermis is used, the graft reciever area usually heals within several days. Full thickness autograft skin graft involves both the epidermis and dermis, it provides less contraction and better contour at the reciepiant site but the wound at the donor site will be larger, requires more medical attention and often needs a split thickness skin graft to cover it.

Skin graft need to be taken care of for several months with Ace bandage or stocking even after healing to decrease the risk of contracture. Patients with grafts on their legs need to stay in bed for several days for the grafts to heal. Grafts should be kept moist and be lubricated daily for two to three months with a bland oil such as mineral oil to prevent dryness, itching and cracking of the area as the grafted skin does not contain sebaceous (oil) glands or sweat glands. As with any surgical procedure, skin graft surgery risks my include infection, bleeding, anesthesia complications and graft failure. A successful graft provides a great improvement in the burn wound quality and can may prevent serious burn wound complications such as infections and contractures.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Patients with small partial thickness burns can be treated as outpatients. Adults with less than 15% body surface area (BSA) partial thickness burns and children with less then 10% body surface area partial thickness burns can be candidates for outpatient treatment.

Treatment:
A- Emergency treatment:

  • The first thing to do to minimize the injury is removing the person from the source of heat and remove any burned or tight clothes, jewelry and any plastic coverings that may retain heat causing deeper injury.
  • Run cool (not cold) water over the burned areafor at least 15 minutes.Aviod using ice, butter or other types of grease as it may cause more damage.
  • For chemical burns, if the chemical that caused the burn is dry then it should be brushed off the skin by a person wearing gloves. If the chemical is wet, it should be flushed the affected area with cool running water for at least 20 minutes. You have to call the poison control center specially if the chemical substance was swallowed then call 911.
  • Tetnas prophylaxis is only indicated when the burned patient is a child and he/she is not up to date with the immunization schedule or if the burned patient is an adult whose last tetnus immunization was more than 10 years ago.

B- Non Emergent Treatment:

  • Use soap and water to clean the wound
  • Don’t open blister, leave them intact as opening the blisters may lead to infection
  • If the burn is on the face, apply bacitracin, neomycin or other similar agents. Protect the affected area of the face from the exposure to sun.
  • If the burns are on the trunk and/or extremities, apply 1% silver sulfadiazine or other iodine creams and cover the area with a clean dressing. The patinet and the family should be given instructions on how clean and care for the wound.
  • Follow up outpatient appointments should be scheduled for the patient to follow up the healing process.
  • Pain relief medications such as acetaminophen and anti-itching medications such as benadryl are given to the patient with teaching on how to use the medicine. Pain medicine should be taken approximately 30 minutes before dressing change. Emolient cream shoud be used once the burn wound is heald to lubricate the area, decrease itching and protect the skin.
  • Burned areas should be protected from sun exposure by using protective clothes and sun screens for at least one year after healing, also avoid going out in the sun peak hours. Patients should also be instructed about the importance of balanced nutrition and wound healing
  • (see also how to care for your burn following hospital discharge)

Infection Prevention:

  • Patients and their families when discharged home should be tought and given written instructions on how to do home wound care and dressing change in an asepic technique.
  • Hand wash both bofore and after wound care is an important step in decreasing the incidance of infection. Places where wound care is done should be cleaned before and after they have been used.
  • Patients and their families should be tought the sings and symptoms of wound infection including fever, increased pain and/or tenderness, increased redness, increased swelling, increased warmth in the area around the wound, bad odor drainage from the wound, wound dehiscence (opening of the edges of the wound)

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Not all burn patients need to be admitted to the hospital for treatment as some of these burn patients can be treated as outpatients including first degree burns and some second degree burns. Small partial thickness burns can be treated in an outpatient setting. Adults with les than 15% body surface area partial thickness burns and children with less than 10% body surface area partial thickness burns can usually be treated safely as outpatients. These patinets after being treated they should have a supportive home enviroment. Abuse or neglect has to be excluded specially with children, smoke inhalation should also be excluded as it is one of the major causes of dealth in burned patients.

What type of burns are eligible to be treated in an outpatient setting:

  • Adults with less than 15% body surface area partial thickness burns and children with less than 10% body surface area partial thickness burns.
  • No or minimal underlying medical conditions.
  • No smoke inhalation with adequate airway.
  • No added injury or trauma.
  • No evidence of neglect or abuse
  • No circumferential burns (burns that go all the way around a body part) see also Escharotomy
  • Ability to drink enough amount of fluids (to avoid hypovolemic shock)
  • No or minimal involvement of the face, hands, joints and the genitalia as involvement of these areas my lead to scars and contractures
  • No chemical burn injury as patients with chemical burns need to be admitted to the hospital
  • The presence of supportive home enviroment in which the patient and his/her family can follow the plan of care. See also Burn wound care at home

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Cyanide is a toxic chemical substance that is found in a gas or a salt form. The gaseous form is colorless with a bitter almonds odor. Cyanide can be ingested by mouth, inhaled or absorbed by the skin.

Cyanide is used in the synthesis of some plastic items; it can be used in cleaning metal as well as in other industrial or laboratory settings. Cyanide is also naturally present in some pits and seeds of fruits such as apricots and almonds but it’s in a small amount. Nitroprusside is a drug that may lead to cyanide toxicity if it’s given in an improper dose. During a house fire, cyanide gas is produced due to the combustion of common household materials. Inhalation of cyanide leads to cyanide poisoning. Cyanide can be used in chemical warfare and poisoning.

Cyanide simply works by decreasing the oxygen content of the blood by causing a chemical change that prevent oxygen from getting into the hemoglobin of the red blood cell and this will lead to tissue hypoxia.

Signs and symptoms of cyanide poisoning:

  • Headache.
  • Dizziness.
  • Faintness.
  • Flushing.
  • Nausea.
  • Vomiting.
  • Bitter almond smell
  • Rapid breathing.
  • Rapid heart rate (tachycardia).
  • Abdominal pain.
  • Weakness.
  • Fainting.
  • Confusion.

Poisoning with large amount of cyanide may lead to:

  • Convulsions.
  • Paralysis.
  • Coma (loss of consciousness).
  • Shock.
  • Cardiac arrhythmia.
  • Respiratory arrest (stop breathing).
  • Cardiovascular collapse.
  • Death

.

Diagnosis:

Diagnosis will depend on the history of exposure to cyanide and the symptoms of the patient if they are present.

Treatment:

  • Seek medical attention as soon as possible.
  • The success of the treatment depends on the time between the exposure and treatment and on the concentration of the exposure.
  • Move away from the area where cyanide gas is present to an area with fresh air.
  • Don’t induce vomiting if cyanide has been swollen.
  • The antidote for cyanide is the administration of amylnitrate followed by the administration of sodium thiosulfate. A new approved antidote is Hydroxocobalamin.
  • Treatment in the hospital will depend on the condition of the patient including airway management, oxygen supplementation, cardiopulmonary resuscitation, intravenous fluids and other medications depending on the situation.
  • In cases where poisoning was due to Nitroprusside (antihypertensive drug) in a hospital then the drug should be discontinued.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Debridement is defined as the process of removing dead tissue and contaminated material from and around a wound to expose healthy tissue.

When the skin gets burned and tissue dies, the dead tissue will naturally fall of as part of the healing process of the skin. In other cases where the burns are more severe, wound debridement will be needed. Dead tissue is a good medium for bacteria to grow and that is why it is important to remove it (bacteria can lead to infection).

Debridement methods are:

Surgical, Chemical, Mechanical and Autolytic.

The wound will be assessed to determine: the best debridement method by examining the depth, extent and location of the wound; whether it lies close to other structures like bones, the risk of infection and antibiotic use, and the type of pain management that will be used during and after the procedure.

  • Surgical debridement:
  • This is done using scalpels, forceps, scissors and other instruments to cut dead tissue from the wound. It is the most effective method used if the wound is large, has deep tissue damage, and may be done if the wound debridement is urgent. The wound will be cleaned with saline and then the dead tissue will be cut, this method may need to be repeated more than once and sometimes skin grafts may need to be transplanted into the debrided site.

  • Mechanical debridement:
  • This is done by applying a saline moistened dressing over the wound and allowing it to dry and adhere to the dead tissue, when the dressing is removed the dead tissue will be pulled with it, this method is one of the oldest and can be very painful.

  • Chemical debridement:
    This is done by using enzymes and other compounds to dissolve dead tissue in the wound.
  • Autolytic debridement:
  • This method involves using dressings that retain wound fluids, allowing the body itself to naturally get rid of the dead tissue. This method is not used if the wound is infected or quick treatment is needed, it takes more time than the other methods and is a good method if the body cannot tolerate more forceful treatment.

Debridement is done under general or local anesthesia, pain medications may be given if there is pain.

It is important to take good care of the debrided burned area by keeping the wound and the dressing clean and dry. Contact the doctor if there are signs of infection (discharge from the wound, color change, swelling, redness, increasing pain, excessive bleeding, fever and chills).

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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The incidance of burns during pregnancy are more common in developing countries then developed countries. Treatment of burns during pregnency may not be easy as during treatment both the wellbeing of the mother and the baby has to be taken into consideration. Topical and systemic treatment of burns in pregnant women may cause serious effects on the health of the fetus including fetal malformations.

Treatment of burns in pregnant women may include:

  • Monitoring of the mother and the fetus by frequent ultrasounds, fetal heart monitoring, measuring blood clotting factors on a daily bases and other tests as needed.
  • Determining the gestational age, the extent of the burn and other associated maternal illnesses.
  • Preventing hypovolaemic shock by adequate fluid replacement and maintenance of blood pressure.
  • Using safe drugs that won’t affect the mother and the fetal development.
  • Semi sitting position can improve the oxygenation of thr pregnant woment.
  • First degree burns are superfecial involving the epidermis. The skin is painful and red, it heals without any reidual scarring.
  • Second degree burns involve the epidermis and part of the dermis . The skin is painful and healing may leave scarring depending on the depth of the burn.
  • Third degree burn is a full thickness burn which is painless due to the destruction of the neves. It heals with scarring.
  • Treatment of burns is more difficult in the first trimester of pregnancy because of the high risk of abortion.
  • If there is smoke inhalation of the mother mechanical ventilation support should be started as soon as possible.
  • All burned females of childbearing age should be tested for pregnancy.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.