Chronic Pain Following Physical and Emotional Trauma: The Station Nightclub Fire

Objective: The purpose of this study was to evaluate factors associated with chronic pain in survivors of a large fire, including those with and without burn injury. Methods: This study employed a survey-based cross-sectional design to evaluate data from survivors of The Station nightclub fire. The primary outcome measure was the presence and severity of pain. Multiple linear regressions with a stepwise approach were used to examine relationships among variables. Variables considered included age, gender, marital status, burn injury, total body surface area, skin graft, pre-morbid employment, time off work, return to same employment, depression (Beck depression inventory, BDI), and post-traumatic stress (impact of event scale – revised). Results: Of 104 fire survivors, 27% reported pain at least 28 months after the event. Multiple factors associated with pain were assessed in the univariate analysis but only age (p = 0.012), graft (p = 0.009), and BDI score (p < 0.001) were significantly associated with pain in the multiple regression model. Discussion: A significant number of fire survivors with and without burn injuries experienced chronic pain. Depth of burn and depression were significantly associated with pain outcome. Pain management should address both physical and emotional risk factors in this population

Prehospital treatment of burns: A qualitative study of experiences, perceptions and reactions of victims

Background The manner in which burns are initially managed, at an incident scene, can affect the extent and depth of burn wounds and their final prognosis. The aim of this study was to understand people's experiences, perceptions and reactions towards the initial management of burns and fire accidents in Ardabil Province, Iran. Methods In a qualitative study, 48 burn victims accompanied by their caregivers were enrolled. Focus group discussion (FGD) was used to collect data. All the interviews were recorded, transcribed and analysed using content analysis method. Results Four categories of information were retrieved in this study, including fire control, scald and burn wound management, seeking medical consultation and severity indicators. Uncertainty regarding what to do when someone catches fire was an evident finding that was explored through the discussions. The results revealed that transferring the patient to the hospital most often takes place after initial treatments administered at home. People believed that cooling a burn wound for a time longer than a few seconds may harm the wound. A strong belief in the efficacy of traditional remedies was disclosed when the statements of participants revealed that traditional or home-made remedies were widely used either to control pain immediately after burn and later during the wound repair process to accelerate the repair or to control the infection and prevent oedema and scar. Among these remedies, pennyroyal and grated potatoes seemed to be the most popular ones. Pennyroyal was thought to prevent infection and potatoes were used to relieve pain. People doubted the capability of health-care workers who work in rural health houses. People considered electrical burns and burns on the chest to be the most severe types of burns. Conclusion Inappropriate perceptions regarding initial management of burns existed among the participants that should be addressed in future quantitative research or through developing programmes on secondary prevention of burns. Keywords • Burn; • Injury epidemiology; • Home remedies; • Injury; • Fire accident; • Qualitative study; • Traditional remedies; • Secondary preventio

Branding Practices on Four Dairies in Kantale, Sri Lanka.

Hot-iron branding is illegal in Sri Lanka, but is still commonly used to identify dairy herds in extensive farming systems, which are primarily located in the countrys Dry Zone. Despite the negative welfare implications of this practice, there is no written documentation of branding in this region. We observed branding on four smallholder farms in Kantale, Eastern Province to understand the welfare implications associated with the procedure and challenges limiting the uptake of more welfare-friendly alternatives, such as ear tagging. Areas of welfare concern included the duration of restraint, the size and location of the brand, and the absence of pain relief. Animals were restrained with rope for an average duration of 12 min (range 8⁻17 min). Farmers used multiple running irons to mark their initials and, in some cases, their address, with the largest brands extending across the ribs and hip. Three farmers applied coconut or neem oil topically to the brand after performing the procedure. No analgesics were given before or after branding. Farmers reported that poor ear tag retention in extensive systems and theft were the main factors impeding the uptake of alternative forms of identification. Branding is also practiced as part of traditional medicine in some cases. Given the clear evidence that hot-iron branding impairs animal welfare and there is no evidence that this can be improved, alternative identification methods are needed, both in Sri Lanka, as well as in other countries engaging in this practice

Grip and muscle strength dynamometry in acute burn injury: Evaluation of an updated assessment protocol

External stabilization is reported to improve reliability of hand held dynamometry, yet this has not been tested in burns. We aimed to assess the reliability of dynamometry using an external system of stabilization in people with moderate burn injury and explore construct validity of strength assessment using dynamometry. Participants were assessed on muscle and grip strength three times on each side. Assessment occurred three times per week for up to four weeks. Within session reliability was assessed using intraclass correlations calculated for within session data grouped prior to surgery, immediately after surgery and in the sub-acute phase of injury. Minimum detectable differences were also calculated. In the same timeframe categories, construct validity was explored using regression analysis incorporating burn severity and demographic characteristics. Thirty-eight participants with total burn surface area 5 – 40% were recruited. Reliability was determined to be clinically applicable for the assessment method (intraclass correlation coefficient \u3e0.75) at all phases after injury. Muscle strength was associated with sex and burn location during injury and wound healing. Burn size in the immediate period after surgery and age in the sub-acute phase of injury were also associated with muscle strength assessment results. Hand held dynamometry is a reliable assessment tool for evaluating within session muscle strength in the acute and sub-acute phase of injury in burns up to 40% total burn surface area. External stabilization may assist to eliminate reliability issues related to patient and assessor strength

The Pattern of Oral and Maxillofacial Injuries Among Patients Attending Muhimbili National Hospital, Dar es salaam, Tanzania

To determine the pattern of oral and maxillofacial injuries among patients attended at the Muhimbili National Hospital, Dar es Salaam, Tanzania. Descriptive cross-sectional hospital based study. The study was done at oral and maxillofacial surgery firm and emergency medicine department of Muhimbili National Hospital (MNH). All patients who attended the Oral and Maxillofacial Surgery firm and Emergency Medicine departments of MNH for treatment of oral and maxillofacial injuries during the period of the study and consented were included in the study. An interview of the patients with oral and maxillofacial injuries was done through structured questionnaire to obtain relevant information from the patient. Social-demographic information (age, sex, address, education level and marital status), patient’s main complaint, type of injury, place where injury took place, cause of injury, general condition of patient immediately after injury and afterwards and the time interval from injury to reporting to hospital were recorded. Clinical findings were recorded as follows: type of injury, site of injury, single or multiple, soft tissue or hard tissue injury. Soft tissue injuries were categorized as bruises, abrasions, cut wound, contusion, lacerations, avulsions, and burn. Hard tissue injury was categorized as fracture of facial bones such as nasal bone, maxilla, mandible, zygoma, frontal palatal and orbital bones. Accompanying injuries to the TMJ were also recorded. Radiological investigations including plain skull radiography (posterior anterior view, Water’s view, submental vertex view), orthopantomograph and where necessary a computed tomography (CT) were ordered. The interpretation of the radiological investigations was done by the principal investigator with the assistance of an experienced clinician and was recorded in a special form as fracture or no fracture, site and type of fracture. Treatment offered and treatment outcomes were also recorded. For admitted patients the number of days spent in hospital was recorded against the type of injury and treatment done. The data was entered into computer and analysis was done using Statistical Package for Social Sciences programme (SPSS) Version 15. Association of maxillofacial injury parameters vii (demographic factors, aetiology, treatment and complications) and type of injuries was evaluated using Chi –square test (X2). Significant level p<0.05 was used to draw out conclusion. A total of 137 patients, 123 (89.8%) males and 14 (10.2%) females with the male- female ratio of 9:1 were included in this study. The age range was from 4 to 70 years with a mean age of 30.13 years. The 21-30 and 31-40 years age groups were the most affected. Road traffic accidents (RTA) were the most (64.2%) common causes of oral and maxillofacial injuries. The most common soft tissue injury was laceration in 63 (26.9%) patients followed by bruises in 57 (24.4%) and cut wounds in 54 (23.1%). Ninety-three patients (67.9%) had sustained fractures of either the mandible, mid face or both and of those 93 patients who sustained fracture, most had mandibular fractures 42 (45.2%). All patients received basic resuscitation procedures, for stabilization of the patient. Almost all (97.8%) patients with oral and maxillofacial injuries were given analgesics for pain control and prophylaxis antibiotics (96.4%). Surgical wound debridement and wound suturing were the most (62.8% and 53.3% respectively) common treatment for soft tissue injuries, while intermaxillary or mandibulomaxillary fixation was the most (51%) common hard tissue injuries treatment. A total of 27 (19.7%) patients suffered some complications after treatment. Infection was the most (59.3%) common complication followed by malunion (33.3%). This study showed that road traffic accidents were the most common cause of maxillofacial injuries. Assaults/interpersonal violence were the second most common cause of maxillofacial trauma. These findings should alert the authorities, particularly the government and the road safety commission to the need for improvement of our roads, enforcement of existing traffic laws, and improvement of socio-economic conditions of the general population

Classification of pain and its treatment at an intensive care rehabilitation clinic

Introduction Treatment in an Intensive Care Unit (ICU) often necessitates uncomfortable and painful procedures for patients throughout their admission. There is growing evidence to suggest that chronic pain is becoming increasingly recognised as a long term problem for patients following an ICU admission [1]. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) is a five week rehabilitation programme for patients and their caregivers after ICU discharge at Glasgow Royal Infirmary. This study investigated the incidence and location of chronic pain in patients discharged from ICU and classified the analgesics prescribed according to the World Health Organization analgesic Methods The InS:PIRE programme involved individual sessions for patients and their caregivers with a physiotherapist and a pharmacist along with interventions from medical, nursing, psychology and community services. The physiotherapist documented the incidence and pain location during the assessment. The pharmacist recorded all analgesic medications prescribed prior to admission and at their clinic visit. The patient’s analgesic medication was classified according to the WHO pain ladder from zero to three, zero being no pain medication and three being treatment with a strong opioid. Data collected was part of an evaluation of a quality improvement initiative, therefore ethics approval was waived. Results Data was collected from 47 of the 48 patients who attended the rehabilitation clinic (median age was 52 (IQR, 44-57) median ICU LOS was 15 (IQR 9-25), median APACHE II was 23 (IQR 18-27) and 32 of the patients were men (67 %)). Prior to admission to ICU 43 % of patients were taking analgesics and this increased to 81 % at the time of their clinic visit. The number of patients at step two and above on the WHO pain ladder also increased from 34 % to 56 %. Conclusions Of the patients seen at the InS:PIRE clinic two-thirds stated that they had new pain since their ICU admission. Despite the increase in the number and strength of analgesics prescribed, almost a quarter of patients still complained of pain at their clinic visit. These results confirm that pain continues to be a significant problem in this patient group. Raising awareness in primary care of the incidence of chronic pain and improving its management is essential to the recovery process following an ICU admission

Ultrasound-Guided Lateral Femoral Cutaneous Nerve Cryoneurolysis for Analgesia in Patients With Burns.

Autologous skin grafting from the thigh is frequently required for treatment of burns and is associated with intense pain at the donor site. Local anesthetic-based (LA) nerve blocks of the lateral femoral cutaneous nerve (LFCN) have been demonstrated to provide analgesia when the graft is taken from the lateral thigh. However, the duration of these single injection blocks has been reported to average only 9 hours, whereas the pain from the procedure lasts days or weeks. Continuous LA nerve blocks can also be used to provide analgesia during serial debridement of burns, although this requires placement of a perineural catheter which may increase infection risk in a population with an increased susceptibility to infection. Cryoneurolysis of the LFCN can potentially provide analgesia of the lateral thigh for skin graft harvesting or serial burn debridement that lasts far longer than conventional LA nerve blocks. Here, we present a series of three patients who received a combination of a LA nerve block and cryoneurolysis nerve block of the LFCN for analgesia of the lateral thigh. Two of these patients had the blocks placed before harvesting a split thickness skin graft. The third received the blocks for outpatient wound care of a burn to the lateral thigh. In all cases, the resulting analgesia lasted more than 1 week. A single cryoneurolysis block of the LFCN successfully provided extended duration analgesia of the lateral thigh for autologous skin graft donor site or wound care of a burn in three patients

A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries.

Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P &lt; .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG

Thermal Burns and Smoke Inhalation Injuries

In this pathophysiology paper, the reader is presented with a profile of an elderly patient who recently suffered thermal burns and smoke inhalation injuries as a result of a nursing home fire. This patient’s severe burns were classified as deep partial-thickness and full-thickness and her total body surface area (TBSA) of burns was over 15%. This paper details the different types of burns, the varying clinical manifestations of thermal burns, smoke inhalation injuries, laboratory values associated with burns, and the multitude of treatment necessary for each stage of burn management. Wound healing is described as well as potential risks and complications associated with burns. Suggestions for nursing care are also given in order to properly care for a patient similar to the one in this profile