Lise Deguire, author of Flashback Girl: Lessons on Resilience from a Burn Survivor

It is an honor to share how Jill Krystofinski changed my life. I was burned, third degree, on two-thirds of my body in 1967, when I was four years old. Back in those days, anesthesia was given by force, with a mask held down on a child until they fell asleep. Also, because of my many operations, my veins have become scarred and resistant to IV insertion. I had over 40 surgeries, each of one of which frightened me to my core.

Recently, I began to have laser treatments and I was terrified. As much as I wanted the new treatments, IV insertions were painful, often requiring numerous attempts. The mere smell of the rubber mask panicked me. And I vomited repeatedly after every procedure. But not after I met Jill.

Jill worked on one of my operations and saw how scared I was. She reached out to me the day after and said, “I want to understand everything that makes surgery hard for you. We are going to make this better, so it just feels like going to the dentist.” Tearfully, I explained all my issues and she solved every one of them, painstakingly, diligently and with warmth and care. Now IV insertion is a piece of cake. I don’t even see the mask. No more nausea. No pain at all.

I cannot recommend Jill Krystofinski highly enough. She is that rare person who is both highly gifted, and who also has a big heart. I never thought that I could have pain-free, anxiety- free surgery, given my years of trauma. But Jill made that happen.

Last year, I spoke at the World Burn Congress, and told people about Jill. I saw some many people in the audience sigh and shake their heads, wishing they too had a Jill in their life, to make their burn care easier. All I can say is, if you are lucky enough to have access to Jill Krystofinski’s skills, you are very lucky indeed.

Lise Deguire, author of Flashback Girl: Lessons on Resilience from a Burn Survivor

The Venturi Principle’s (Effect) Demonstrated within Burn Surgery

Early debridement and depth-specific coverage are currently the standard in the surgical treatment of burns. Prerequisites are exact determination of the depth and accurate debridement. It is essential to preserve and protect vital tissue.

The Versajet® is a hydro surgical system employing a jet of water by which tissue is simultaneously cut, ablated, and suctioned. The wound is rinsed without significant aerosolization. The consistency of the working tip and the velocity of the water jet create a vacuum below the incision window. This aspirates, cuts and suctions the tissue.

  1. As the handpiece is held parallel to the wound the high-pressure water jet acts as a scalpel.

  2. When the working tip is tilted slightly the scalpel effect of the water jet is reduced while the rinsing and suction effect is enhanced.

  3. The quantity of ablated tissue is determined by the pressure settings at the console (1-10), the pressure exerted by the surgeon, and the speed at which the handpiece is moved on tissue.

  4. The console is operated by a foot pedal.

The Versajet® system is based on the Venturi principle:

A thin high-velocity jet of water consisting of sterile saline is discharged from a 0.12-mm nozzle into a suction tube.

Venturi Meter or Venturi Tube

The static pressure in the first measuring tube (1) is higher than at the second (2), and the fluid speed at “1” is lower than at “2”, because the cross-sectional area at “1” is greater than at “2”.

https://www.intechopen.com/books/skin-grafts/hydrosurgery-system-in-burnsurgery-indications-and-applications

The Venturi Principle

The Venturi Effect was discovered by Italian physicist Giovanni Battista Venturi who lived between 1746 and 1822.

When flowing through a constricted area of a pipe, a fluid's velocity increases and its static pressure decreases. This principle is known as the Venturi effect.

The Venturi Principle Explained

In its simplest form the Venturi Effect is perfectly illustrated with fluid flowing through a pipe which then narrows. You might be mistaken for assuming that as the pipe narrows and the fluid is forced through the narrow section there would be a buildup of pressure because of the fluid behind pushing forward. This is where the Venturi Effect comes into play because while the water is forced through the narrow section of pipe it increases in velocity and there is a reduction in pressure. Once the pipe opens up again to the original size the fluid reduces in velocity and the pressure returns to the previous level.

The mathematical formula to explain this is known as the Bernoulli equation and while the formula is fairly technical the practical examples of the Venturi Effect are man

https://www.engineeringclicks.com/the-venturi-effect-explained/

One example that almost everybody has experienced is when the thumb is placed at the end of a garden hose. The water’s velocity increases when you place your thumb over the water, introducing a decrease in the hose cross-section. The pressure increases over the smaller surface area, while the narrow flow then creates a vacuum in the water. The fluid’s kinetic energy increases results in a pressure decrease.

Examples of Venturi Principle

  • Atomizers disperse perfume or spray paint (i.e. from a spray gun)

  • Carburetors use the effect to suck gasoline into an engine's intake air stream

  • Wine aerators infuse air into wine as it is poured into a glass

  • Protein skimmers filter saltwater aquaria

  • Automated pool cleaners use pressure-side water flow to collect sediment and debris

  • Clarinets use a reverse taper to speed the air down the tube, enabling better tone, response and intonation

  • Industrial vacuum cleaners use compressed air

  • Injectors (also called ejectors) are used to add chlorine gas to water treatment chlorination systems

  • Sandblasting nozzles accelerate and air and media mixture.

  • Bilge water can be emptied from a moving boat through a small waste gate in the hull. The air pressure inside the moving boat is greater than the water sliding by beneath.

  • A scuba diving regulator is used to assist the flow of air once it starts flowing

  • In recoilless rifles to decrease the recoil of firing

  • The diffuser on an automobile

  • Race cars utilizing ground effect to increase downforce and thus become capable of higher cornering speeds.

  • Foam proportioners used to induct firefighting foam concentrate into fire protection systems

  • Trompe air compressors entrain air into a falling column of water

This article is for educational purposes only. I do not have any affiliation with Versajet/Smith and Nephew. I have nothing to disclose.

Amish Burn & Wound Ointment with Burdock Leaves for the Treatment of Burns

Amish live in small rural communities where strong family and social ties allow them their own distinctive and separate way of life. The family is the heart of Amish community, individual identity and spiritual life. Amish live without cars, electricity, telephones, televisions or computers. They rely upon wood burning stoves for heat and cooking as well as using the horse and buggy for transportation. Evidence has shown that the Amish people are at a higher risk for burns and wounds as a result of their rural lifestyle.

When an Amish adult or child is burned, the family turns to the community healers. As part of their treatment, these healers apply an ointment called B & W, short for burn and wound ointment. Honey is one of its main ingredients, along with olive oil, wormwood, myrrh and other plant-based substances. After the ointment is applied, the wound is wrapped in (previously steamed) burdock leaves, which are then secured with gauze.

The History of B & W Ointment

B & W ointment was developed in the early 1990s after an Amish toddler (son of John Keim) was injured in an accident involving boiling water. John Keim who was an Amish alternative practitioner; needed a therapy to treat his son’s burns. A therapy that would relieve pain and stimulate healing. It was after Mr. Keim had gone into the woods to meditate and seek Divine guidance, that his attention was drawn to big plantain leaves. Keim believed they would serve as an ideal non-stick barrier between the salve he had applied to his son’s body and the gauze body wrap. After using many different types of leaves, the Burdock became his treatment of choice because of the size and availability of the leaves.

The Burdock Plant

Burdock Plant

Burdock is a common plant that can reach heights of six feet with heart-shaped leaves. At maturity the plant produces burs that commonly attach to clothing or animal fur (“sticker bushes”). Burdock is believed to have a high content of vitamins and minerals and is available in diverse preparations including pills, tinctures, teas, or dried roots. Burdock leaves are harvested when they are slightly larger than an adult’s hand. They are dried in a warm, dark place for four to seven days. They are then stored in a plastic container with a tight lid until needed, at which time they are rehydrated with boiling water.

Burn & Wound Ointment (B & W)

The main ingredient, and possibly the active ingredient, is honey. Remember that honey was recommended for burn treatment as far back as in ancient Egyptian times.

An Eight Pound (128 oz) Container of B & W Ointment

B&W Ointment

The Application Process

The Prepared Burdock Leaves

Burdock Leaves

The B & W Ointment is Applied to the Prepared Burdock Leaves

B&W Ointment

The Preparation is then Applied to the Burn Injured Patient

Burn Injured Patient

The Claim Made with the B&W Treatment:

  • Painful burns are rendered non-painful.

  • Healing is faster.

  • Painful debridement is not necessary.

  • Skin grafting is not necessary.

  • Scarring seldom occurs.

  • Latrogenic harm from hospitals is avoided.

  • Patients can be treated at home at much less expense.

Possible Side Effects

This treatment is not without side effects. In many of the case histories, patients developed rashes, redness, red pimples, prickliness, and hives, interpreted as reactions to burdock leaves or to the ointment itself, requiring substitution or alternation with lettuce leaves, grape leaves, flaxseed paste, bag balm or other natural products. One of the biggest dangers in burns is infection. Through his published books on burn care, Keim tells patients not to worry about fever. He says fever is perfectly normal and part of the healing process but you should watch for a bad smell to detect infection. Fever can be treated with vitamin C powder.

Scientific Data & Research

Keim refined his product for over two decades, however, the evidence remains subjective. There are no official records of his work, no randomized control trials. Recently the Amish have enlisted the cooperation of doctors who are now allowing them to use the B&W treatment in the hospital under supervision. However, there is very little research to base any recommendations upon.

Two Quoted Articles Below

Seeking Common Ground UMHS works with Amish and Mennonite communities toward a culturally sensitive approach to burn treatment.

By Sara Talpos

“Determining how to standardize the ointment and leaves in order to achieve FDA approval of the study. Herbal supplements are difficult to test: Their chemical makeup varies depending on when and where harvesting occurs. Ideally, Skyles would like to buy standardized sources before compounding the B&W ointment in the pharmacy. The burdock leaves are trickier. Wang and Skyles acknowledge that the leaves work as an occlusive dressing, but the Plain community believes the leaves also contain an active component that seeps into wounds and provides pain relief. They want the leaves simmered or scalded in order to preserve the active component. These heating methods, however, do not kill all bacteria, and so may pose a risk to the patient.”

http://www.med.umich.edu/surgery/icam/seeking_common_ground.html

Amish Burn Ointment and Burdock Leaf Dressings: Assessments of Antimicrobial and Cytotoxic Activities

Journal of Burn Care & Research, Volume 35, Issue 4, July-August 2014, Pages e217–e223, Published:01 July 2014

Neither DI nor BL extracts demonstrated antimicrobial activity against any of organisms tested. The DI extract inhibited growth of both keratinocytes and fibroblasts at the 0.1% concentration. The 0.1 and 0.03% concentrations of the BL extract were cytotoxic to both keratinocytes and fibroblasts. Although tests for microbial growth from the at-use preparation of the ABO were negative, extracts of the DI and BL did not demonstrate any antimicrobial activity. Additionally, both extracts inhibited the growth of skin cells in vitro at higher concentrations. These results suggest caution in the use of ABO and BL dressings if there is more than a minimal risk of complications from the burn injury.”

https://doi.org/10.1097/BCR.0b013e3182a23228

References

https://doi.org/10.1097/BCR.0b013e3182a23228

https://sciencebasedmedicine.org/amish-home-burn-treatment-bw-salve-and-burdock-leaves/

https://www.ncbi.nlm.nih.gov/pubmed/24043243

https://www.ncbi.nlm.nih.gov/pubmed/24668061

https://www.ncbi.nlm.nih.gov/pubmed/28426569] 

Burn Aid
Comfort for the Burned Wounded

Understanding Acute Burn Injury as a Chronic Disease

“While treatment for burn injury has improved significantly over the past few decades, reducing mortality and improving patient outcomes, recent evidence has revealed that burn injury is associated with several secondary pathologies, many of which arise long after the initial injury has healed. Population studies have linked burn injury with increased risk of cancer, cardiovascular disease, nervous system disorders, diabetes, musculoskeletal disorders, gastrointestinal disease, infections, anxiety and depression. The wide range of secondary pathologies indicates that burn can cause sustained disruption of homeostasis, presenting new challenges for post-burn care. Understanding burn injury as a chronic disease will improve patient care, providing evidence for better long-term support and monitoring of patients. Through focused research into the mechanisms underpinning long-term dysfunction, a better understanding of burn injury pathology may help with the development of preventative treatments to improve long-term health outcomes. “

Chronic Disease

“While acute clinical treatment for burns has improved significantly over the past few decades resulting in significantly higher rates of survival, there is increasing evidence of lifelong impacts of burn injury. Recent findings suggest burn injury can be considered a chronic disease, with secondary morbidity most likely linked to sustained changes to immune function. Future studies to understand the mechanisms involved will be critical to change clinical treatment pathways and reduce the long-term burden of burn injury for patients.”

Burns and Trauma 

Published: 16 September 2019

https://doi.org/10.1186/s41038-019-0163-2

A Review of Cultured Epidermal Cells (CEA)

Skin Substitutes

     A Swiss surgeon, Jaques Louis Reverdin, has been credited as performing the first skin autograft, in 1869, using a ‘pinch-graft’ technique. Although procurement methods have evolved, the split-thickness autograft remains the standard of care. Although reliable in experienced hands, this definitive solution to the open wound has substantial drawbacks, particularly donor site morbidity and availability. Unfortunately, despite decades of work, currently available alternatives are even more imperfect. A reliable permanent skin substitute will revolutionize the care of patients with burns and other difficult wounds.

The Perfect Skin Substitute Criteria for Autologous Split-Thickness Skin Would be:

  1.   Prevents water loss

  2.   Barrier to bacteria

  3.   Inexpensive

  4.   Long shelf life

  5.   Can be applied in one operation

  6.   Does not become hypertrophic

  7.   Flexible

  8.   Conforms to irregular wound surfaces

  9.   Can be used ‘off the shelf’

  10. Does not require refrigeration

  11. Cannot transmit viral diseases

  12. Does not incite inflammatory response

  13. Durable

  14. Easy to secure

  15. Grows with a child

Advances in Wound Closure

  1. Cultured Epidermal Cells (CEA)

  2. Dermal Analogs

  3. Composite Substitutes

Cultured epidermal autograft (CEA)

Cultured epidermal autograft (CEA) is an important tool in the management of patients with massive burns. In full-thickness burns involving more than 90% TBSA it may be the only choice, given that procurement of the uninvolved skin will not be sufficient to cover the patient’s wound.

SKIN

 For over 20 years it has been possible to culture vast numbers of epithelial cells from a small skin biopsy, and this has led to the widespread clinical use of cultured epithelial grafts to cover burn wounds.  Epithelial cells are procured from a full thickness skin biopsy, the cells being separated with trypsin. The resulting epithelial cell suspension is cultured in medium containing fetal calf serum, insulin, transferrin, hydrocortisone, epidermal growth factor, and cholera toxin, overlying a layer of murine fibroblasts that have been treated with a nonlethal dose of radiation that prevents them from multiplying. Colonies of epithelial cells expand into broad sheets of undifferentiated epithelial cells.  These cells are separated from the culture vessel with trypsin and taken to secondary culture using the same techniques until confluent thin sheets of undifferentiated cells are obtained. The resulting sheets are removed from the dishes after treatment with dipase, which digests the proteins attaching the epithelial cells to the dish. The sheets of epithelial cells are attached to a petrolatum gauze carrier to ease handling.

The final product takes approximately 3 weeks to be ready for grafting and consists of sheets of keratinocytes, 2–8 cells thick.

When epithelial cultures were first used in patients with large burns it was hoped that they would provide the definitive answer to the clinical problem of the massive wound.   With more frequent use of epithelial grafts, specific liabilities have become apparent including suboptimal engraftment rates and long-term durability. However, when faced with a very large wound and minimal donor sites, epithelial cell wound closure is a useful adjunct to split-thickness autograft, their liabilities and expense becoming more acceptable as wound size increases.

Many of the imperfections associated with epithelial cell wound closure may be attributed to the absence of a dermal element.  Epithelial grafts are now commercially available. Application is generally most successful in wounds from which vascularized allograft has been removed.  Despite scattered cases, application of cultured epithelial grafts onto synthetic dermal analogs has not been shown effective.

Source: Herndon, D. N. (2018). Total burn care. Edinburgh: Elsevier.

ERAS: Not the Complete Answer for the Burn Patient

Although a multidisciplinary approach including nonpharmacological modes of management are essential, pharmacological treatment remains the cornerstone of pain control in patients with burn injuries. Drug and dose selection must be made in the context of systemic changes that evolve over time and alter pharmacokinetics and pharmacodynamics. Opioids are the mainstay of therapy but are associated with certain adverse effects such as opiate induced hyperalgesia. A newly appreciated problem, neuropathic painis characterized by burning and itching in the areas of newly regenerating skin and at amputation site. Effective pharmacological analgesia requires the concomitant treatment of anxiety, depression and PTSD with anxiolytics and antidepressants to control the pain syndrome following burn injury.  Pain protocols facilitate the systematic pain management. New non pharmacologic approaches such as virtual reality now have demonstrated effectiveness. Burn pain comprises background, breakthrough, procedural and postoperative pain. Each type of pain requires different drugs, doses, or strategies.

https://expertconsult.inkling.com/read/herndon-total-burn-care-5e/chapter-64/management-of-pain-and-other

 We will discuss reasons for the controversial issues for eras and it’s controversies in our next blog.

The Dangers of Beta-Blockers and Epinephrine In the Burn Patient

Unopposed Alpha Vasoconstriction/Unopposed Alpha Agonism

What causes the hypertensive reaction? 

In the absence of beta-blockade, a systemic dose of epinephrine does not have much effect on mean blood pressure because it has both alpha-adrenergic effects (producing vasoconstriction) and beta-adrenergic effects (producing vasodilation). If a patient on a non-selective beta-blocker receives a systemic dose of epinephrine, the non-selective beta-blocker prevents vasodilation, leaving unopposed alpha vasoconstriction (also termed unopposed alpha agonism). The hypertensive reaction can be considerable, with a systolic pressure well over 200 mm Hg.

Do all beta-blockers increase the risk of acute hypertension? 

No. Cardio-selective beta-blockers, such as acebutolol, atenolol, betaxolol, bisoprolol, esmolol, and metoprolol, would not be expected to cause hypertensive reactions following a systemic dose of epinephrine. This is because cardio selective beta-blockers have little effect on the beta-adrenergic receptors in the arterioles. Nonetheless, one should consider the possibility of an interaction of epinephrine with cardio-selective beta-blockers if plasma concentrations of the beta-blocker are elevated due to large doses or other factors. 
Is the dose of the epinephrine important? 
Yes. The small amounts of epinephrine (combined with local anesthetics) that may be used in routine are unlikely to be a problem.

Specific Anesthesia Considerations for the Burn Patient Undergoing Surgery, Regarding Beta-Blockade & Epinephrine Administration

Tangential excision is the meticulous removal of burned skin while preserving the underlying viable tissue. Bleeding is intentionally created by burn surgeons to not only remove the burned tissue but also to ensure an adequate vascular bed is present for the grafting and healing process. Once the surgical area is successfully excised and bleeding is established, the epinephrine soaked telfa pads are applied to achieve hemostasis. The epinephrine soaked telfa’s are created by the scrub nurse/tech. She/he soaks approximately 30 to 50 telfa’s in one liter of warmed normal saline mixed with 90 mg of epinephrine. It is not uncommon for three or four liters of the saline and epinephrine mixture to be applied to the wound bed(s) by the surgeon during the case. Think of what one mg of epinephrine does when administered. Now 270 to 360 mgs of epinephrine are being applied to a fresh, bleeding vascular bed. If an adequate and balanced anesthetic is not achieved prior to the application of the epinephrine soaked telfa’s, profound hypertension and tachycardia may result. If this occurs consider increasing narcotic administration, increasing volatile agent/TIVA delivery and/or asking the surgical team to remove the telfa’s until acceptable hemodynamics are achieved before continuing. Cardio-selective beta-blockers have their place, but should not be the first line of attack to correct this abnormal hemodynamic situation. If you do decide to commit to a vasoactive agent, consider its half-life, since the epinephrine effects are usually gone within 60 to 90 minutes after surgical application.


Horn, J. R., PharmD, FCCP, & Hansten, P. D., Pharm D. (2009, May 15). The Dangers of Beta-Blockers and Epinephrine. Retrieved November 4, 2018, from https://www.pharmacytimes.com/publications/issue/2009/2009-05/druginteractionsbetablockers-0509