Heparin is a Wonderful New Therapy for Burns
by Dr. James Howenstine, MD
Conventional therapy for burns has always produced a nightmarish illness
for patients. Patients, who are treated with multiple skin grafting procedures,
are in severe pain from dressing changes and the frequent need to remove
devitalized infected tissue. Potent narcotics are a necessity to permit
these needed surgical procedures. The lack of ability to prevent contractures
often produces dysfunctional limbs and the ugly scars resulting from severe
burns are an ongoing reminder of this lengthy painful illness.
Roger Tilton's wife, Pat, sustained a scalding burn involving her hand
and forearm. She was cared for by the world's leader in burn therapy Dr.
Michael J. Saliba, Director of the Saliba Burns Institute, in San Diego,
Cal. Dr. Saliba proceeded to place heparin solution on the open burn wounds
and into the burn blisters. The pain originating from the burn surfaces
and blisters was gone in a minute. Deep burn pain was promptly resolved
by an injection of heparin into a layer of fat below the skin where it
is slowly absorbed. Additionally heparin was given by an intravenous infusion.
Dr. Saliba then sprayed heparin over the burn surfaces two or three times
over a 15 minute period. He proceeded to tape bandages loosely over the
burn areas. Heparin was continued by daily injection for a few days and
was applied to the burn surfaces twice daily in diminishing amounts until
final healing was accomplished. Complete healing was present in 2 weeks
without scarring.
Why Does Heparin Help Burns?
More than 40 years of meticulous research has gone into the development
of this therapy. Dr. Saliba knew that the body is able to heal small burns
by itself. He theorized that perhaps these same methods might permit healing
of larger burns if the detrimental punishment of surgery was avoided.
The primary focus was directed toward finding therapies that would increase
the blood flow to the burn site. Persons burning a finger are often observed
to shake the finger vigorously. This increases the blood flow to the finger
so healing gets started and the pain diminishes.
The primary use of heparin relates to it's ability to prevent clotting
of blood. Dr. Saliba and his colleagues began experiments in animals which
clarified the precise mechanisms whereby heparin permitted more blood
to reach burned tissues. This results in stopping burn damage, easing
pain and initiating the growth of normal healthy unscarred skin. This
process proceeds in a painless manner until the old burnt skin is sloughed
off like a snake sheds a skin.
Burns can be produced by fires, steam, water, subzero freezing, electricity,
caustics and explosions. Depending on the temperature, duration and area
exposed burns destroy increasing larger groups of cells because of blood
clotting and inflammatory changes.
Inhalation of hot smoky air damages the lungs. This injury can be completely
resolved by aerosolized heparin. Smoke inhalation is the leading cause
of death from fires. Respiratory Technician, Ron Meek, of Galveston, Texas
reports that heparin has reduced the mortality rate from inhalation burns[1]
in his hospital to 12 %, probably the lowest in the world.
Electrical charges leave damaged tissues where the electrical charge enters
and exits the body. Heparin has recently been found to be effective in
healing the deep injuries caused by electrical burns. This is saving many
limbs from amputation.
After the initial burn injury toxins are released from the dead cells
killed by the burn and lack of oxygen consequent to blood clots. . These
toxins may injure muscles, nerves and institute gangrenous changes in
extremities. Surgeons have combated this progression of burn injury by
excising burned tissue. They then proceed to do skin grafting and reconstructive
surgery but unfortunately gangrene may be the ultimate outcome particularly
in cases of electrical accidents.
An unfortunate complication of surgery may be an enhanced possibility
for infection. Also surgery often requires blood transfusions, reduces
the mobility of the patient and requires long courses of narcotics to
control pain. The hindered mobility interferes with the body's ability
to heal itself.
Heparin is not expensive. When burns are treated medically with heparin
long hospitalizations do not occur. The average cost of a burn hospitalization
treated surgically runs hundreds of thousands of dollars. The cost of
burn care with heparin is a tenth or less of other methods.
Burns Are A Nutritional Disaster
A burn leaves large areas of denuded skin that continuously weep large
quantities of protein rich fluid from the body. Conventional therapy of
burns attempts to decrease this protein loss by skin grafting. These grafts
are often imperfect because of loss of blood supply to portions of the
graft with resulting infection of the skin. Invariably antibiotics are
administered in an attempt to control skin and other infections (lungs,
intravenous lines etc.). Antibiotic therapy kills the sensitive intestinal
bacteria. This causes impaired absorption of nutrients and diminished
production of critically important immune cells by the intestinal membranes
(up to 50 % of the body's immune cells are normally produced by
the intestinal lining cells). Burn patients have massive protein needs
to heal incisions, restore body protein losses and create new skin, subcutaneous
tissue and maintain body protein stores. Even intravenous hyper-alimentation
through large vascular catheters has difficulty keeping up with protein
losses and creates a new source (catheter) for serious infection. There
may be difficulty controlling blood sugar values and this increases the
risk for infections because white blood cells have impaired ability to
kill bacteria and tumor cells for 6 to 8 hours after exposure to elevated
sugar values..
Dr. Saliba's Research
Dr. Saliba's research learned that heparin limited the size of
the destructive effects of the burn. Experimental burns did not increase
in size or depth whereas burns not treated with heparin became deeper
and larger. The initial size was the maximum size. Burns treated with
heparin also avoided swelling, warmth and redness (no inflammation). These
beneficial changes decreased the possibility of infection and led to earlier
healing. Pain medicines were not needed. Decreased swelling led to fewer
surgical procedures. Blood flow was increased to both burned and non-burned
areas. The most amazing and unexpected result was that the new skin was
smooth, comfortable and had no shortening of length (contracture). Contractures
cause problems with movement and function.
Medical therapy of burns avoids the inherent pain of surgery and the risks
of blood transfusions. The risks of infection in burn patients are essentially
avoided by heparin therapy. Dr. Saliba states "In medical school
I hated burns, and swore I would never treat them. Well, not only have
I treated a great many, but it seems we have improved our results through
the addition of heparin. The deep satisfaction we doctors feel in seeing
our patients pain abate and scars and amputations minimized is beyond
description, and reward beyond imagining. But I still hate burns!"
Dr. Saliba has traveled all over the world to personally train surgeons
in how to use heparin therapy. Many articles about heparin burn therapy
have been published in fine medical journals. Despite this wealth of information
many burn centers are still following surgical modes of therapy.
India has a large problem with self-immolation practiced by new widows.
Dr. K.M. Ramakrishnan of Madras reports the successful therapy of hundreds
of seriously burned patients using heparin. In one case a hopelessly burned
woman was saved from certain death by a massive infusion of heparin, far
beyond any dosage previously used.
Nurses and pediatricians have become enthusiastic about heparin burn therapy.
The difficult problem of pain control is solved and children no longer
face multiple operations.
Major burn centers in India, Russia, Bulgaria, Brazil, El Salvador, China,
Mexico, Canada, Haiti, Korea and Oman have switched to heparin burn therapy.
Heparin is ideal for nations with limited funds, lack of debriding equipment
and lack of expensive isolation wards for burn infections.
What Patients Are Not Suitable For Heparin Therapy?
There are some patients who are not suitable candidates for heparin
therapy:
- Patients who are actively bleeding must not take heparin
- Patients with very low platelet counts are at risk for bleeding which
heparin could make worse.
- Allergy to heparin
- Traumatic injury which makes bleeding likely
- Patients with a personal or family history of bleeding disorder would
need an emergency hematology evaluation
- Active duodenal or stomach ulcer
- Large doses of heparin should be avoided if the burn occurred more
than 2 days previously
Heparin therapy can be commenced anywhere and the sooner the therapy
is instituted the better the end result. Heparin could save many lives
in large scale thermal disasters (nuclear bombing). Military personnel
should be trained in how to rapidly evacuate burn patients to triage centers
where heparin can be promptly started..
If Dr. Saliba's Burn Program With Heparin Is So Great Why Has It Not
Been Universally Accepted?
The use of heparin therapy has dramatically changed the course of severe
burn therapy. Patients are now going home in a month instead of three
months. There are no ugly permanent burn scars. Heparin is not expensive.
The average cost per patient stay has fallen from hundreds of thousands
of dollars for surgically treated burn to about one tenth this amount.
Additionally, some severe burn patients are surviving what would have
been fatal burns. Why has this obviously superior therapy not become standard
care in all burn centers?
Dr. Saliba's research still remains largely unknown. No pharmaceutical
firm will make large sums of money from heparin as it's patent has
expired. Burn centers are run by surgeons who will surely be doing less
surgery if heparin burn therapy becomes widely accepted. There has been
no scientific evidence presented at any international symposia refuting
Dr. Saliba's findings.
If you know of a patient who has experienced a severe burn try to see
that they end up in a facility that does use heparin for burns.
Footnotes:
1. Tilton, Roger A Burning Issue Townsend Letter for Doctors & Patients
October 2005 #267 pg 66-70
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