Heparin is a Wonderful New Therapy for Burns
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 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.
1. Tilton, Roger A Burning Issue Townsend Letter for Doctors & Patients October 2005 #267 pg 66-70