A 53-year-old female patient has got burned when handling a propane-butane gas cartridge that exploded at her kitchen. The patient sustained 16% TBSAB (Total Body Surface Area Burned) to face, neck, trunk, both hands and right thigh associated with severe inhalation trauma. The burn depth was diagnosed clinically as mixed deep dermal/third degree of 12% TBSAB (third-degree burns at hands, neck and lower part of the face, total 6%) and superficial burns of 4% TBSAB (Fig. 1). Because of inhalation injury, the patient was intubated immediately at admission. There was an extensive edema of the epiglottis and a huge mass of carbon blacks in examined airways. Shortly after admission, despite adequate fluid replacement therapy, the patient s circulation became unstable. High doses of circulatory support drug (norepinephrine) were needed for the restoration of normal blood pressure although there were not any cardiac or other internal diseases in the patient s medical history. In that condition early surgical intervention was risky and it was replaced by enzymatic debridement.
The enzymatic debridement of the deep burn areas at the face, neck, both hands and trunk (total 8% TBSA), was performed 17 h post-injury using bromelain-derived proteolytic enzymes mixture gel. The procedure was accomplished according to the manufacturer s instructions. We added just one more step, protection of the orbital area and outer ear canal with medical-grade sterile vaseline. Single debridement efficacy was 95% on the face, neck and trunk and 90% on both hands. (Fig. 2) In the high-risk patient with unstable circulation enzymatic debridement proved to be safe and effective.
All the debrided wounds were covered temporarily by cryopreserved porcine xenografts. The porcine xenografts were standardly processed in the Central Tissue Bank at Department of Burns and Reconstructive Surgery, University Hospital, Bratislava. Healing by epithelization under the xenografts of most of the wounds including face area was achieved within 5 weeks. Only 2,5% TBSA of the debrided areas on both hands and neck were full-thickness deep burns. Full-thickness burns were closed by split-thickness autografts after patient stabilization, fifteen days after the debridement. The patient was discharged from our department 5 weeks after injury with all burned areas healed.
We followed-up the patient for 20 months after the injury (Fig. 3). The quality of scars after spontaneous healing at the patient s face and neck was satisfying with good aesthetical and functional outcome. Only a few sebaceous cysts formed at the patient s chin. The scars after skin grafting at the patient s left hand were also satisfying with full function of the hand. Only one scar contracture formed in the grafted area at the patient s right hand, which limited the flexion of the little finger and the index finger. The patient was readmitted 20 months post-injury for the contracting scars revision. Scar contractures of the 2 above-mentioned fingers of her right hand have been released using Z-plasties. Sebaceous cysts from the chin have been removed as well. The patient was discharged after 2 days and did not come back for follow-up anymore.