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Volume X

Number 2

June 1997

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(M. Kadry - Egypt)
This paper considers various aspects of co-operation in the Mediterranean area with regard to fire disasters. The importance -f pieparedness, education, and training is stressed: we should not wait passively for the next natural disaster to strike, but rather mobilize knowledge and technological know-how and give a positive response to the strong political interest and commitment to the inter community. A survey is made of the various organizations involved in the international response to disasters, with particular refeicocc to the Mediterranean Club for Burns and Fire Disasters (MBQ. It is possible to prevent many natural and all man-made disasters. 'I'lie MBC has compiled a list of volunteer task forces willing to intervene in the event of a disaster. Efficient planning can always reduce the impact of a disaster.
(P.Y. Gueugniaud, M. Jauffray, M. Bertin-Maghit, C. Bouchard, F. Durand, J.M. Fonrouge, P. Petit - France)
Massive fluid resuscitation is required after severe burn injury. This leads to extensive oedema which can affect not only the burned skin but also unburned areas and vital organs such as the heart and lungs. Cerebral oedema has never been systematically investigated in burn patients, and burn encephalopathy remains a well-known but unexplained complication. A prospective study was conducted on early intracranial and cerebral perfusion pressures in severely burned patients with a percentage of total burn surface area (T13SA) over 60% and a unit burn score (UBS) of up to 220. Intracranial pressure monitoring was set up as soon as possible with an epidural screw and recorded over a period of five days. Thirty-two patients were successively included (age = 37 14 years; TBSA = 68 19%; UBS 258 73). Markedly abnormal cerebral pressure data were observed, mainly between days 1 and 3 post-burn: intracranial pressure peak values increased to 31.4 10.4 mm Hg on day 2 post-burn. Cerebral perfusion pressures dropped to critical values also on day 2 post-burn (41.0 10.2 min Hg). Eighteen patients were discharged alive (56%). A comparison between survivors and non-survivors showed that non-survivors always presented higher intracranial perfusion pressures and lower cerebral perfusion pressures than survivors. The significance between survivors and non~survivors over the five days of monitoring was calculated by a variance analysis for repeated measures. The intracranial pressure average was slightly above significant levels (p = 0.06). Cerebral perfusion pressure differences were statistically significant as regards both minimum recorded values (p = 0.009) and average values (p = 0.02), whereas mean arterial pressures were not significantly different (p = 0. 12). These data suggest that very severely burned patients suffer cerebral oedema capable of inducing abnormal intracranial pressure. During this initial massive fluid resuscitation, intracranial hypertension and haemodynamic instability may lead to deleterious cerebral hypoperfusion. It is concluded that the use of therapy for cerebral oedema combined with catecholamines may be useful in the limitation of cerebral perfusion after extensive burn injury.
(N.I. Atyasov - Russia)
The intraportal injection method (injections in the venous bed through recanalized umbilical vessels is rarely used in the treatment of burn patients suffering from post-burn complications. This work presents a study of this method for the treatment of deep burns. It was found that haemostasis disorders, intra- and extracorporeal circulation malfunctions, hypoxia, capillary hyperpermeability, and hepatic lymph hyperproduction increase portal vein pressure. The degree of portal hypertension and blood and lymph deposition in the regional system depends on the area and depth of the burn, the patient's age, and the time period after the burn. The present report provides a detailed description of the surgical management of 554 patients aged up to 81 years with deep burns in up to 85% total body surface area, together with experimental data. Patients treated with intraportal infusions achieved stable nonspecific immunity sooner than patients treated with standard methods. It is therefore concluded that infusion therapy has profound therapeutic possibilities in the treatment of burn disease.
(Shi-Hui Zhu, Shi-Kang Liu, Sheng-De Ge - People's Republic of China)
A comparative study was performed to evaluate the effects of resuscitation with hypertonic sodium lactate and dextran (HLD, Na+ 250 mmol/l sodium lactate with 6% dextran 70) and with lactated Ringer's solution (LR) on cardiac function, lipid peroxide level and heart tissue SOD activity. Dogs with 35% TBSA third-degree burns received I h post-burn either HLD resuscitation (19.6 inl/kg/3h; 14LD group, N' = 6) followed by LR 6 mllkgl% TBSA or LR resuscitation (10 ml/kg/% TBSA; LR group, N' = 6). The results ,Jiowed that the cardiac index was much higher in the HLD group than in the LR group 4, 8, 12 and 24 h post-burn. Cardiac contractility and relaxation were higher in the HLD group than in the LR group 12 and 24 h post-burn. The MDA level in heart tissue was much lower in the HLD group (17,41 ? 2.82 mmol/g) than in the LR group (32.43 ? 5.62 mmol/g) (p <0.01). Heart tissue SOD activity was much higher in the HLD group (157.49 ? 32.23 p/g) than in the LR group (46.88 ? 16.28 p/g) (p <0.01). These results suggest that HLD resuscita(ion may be beneficial in improving post-burn cardiac function and in attenuating post-burn oxidant-induced lipid peroxidation in the heart not only because of its oxygen-free radical scavenger but also because of its stimulation of heart tissue SOD activity.
(A. Mabrouk, R.R. Mabrouk, M. Sabry, S.F. Fedawy - Egypt)
The defects causing immunosuppression after burn injury are still very much under consideration. IL-6, CD3, and its subsets CD4 and CD8 were determined in 40 patients on the fourth day after burn injury. The results were compared with those of 20 normal healthy controls and correlated with total body surface area (TBSA), sepsis, mortality, and liver and kidney function tests. The results demonstrated I lie elevation of IL-6 compared with controls and its significant correlation with TBSA, mortality, sepsis, and liver function tests. CD3 and C D4 were significantly decreased compared with controls. CD3 was significantly correlated with T13SA, death, ALT, TP, alburnin, BUN, and creatinine. CD4 was significantly correlated with T13SA, AST, and alburnin. CD8 not significantly different from the control group and was correlated only with mortality, ALT, and BUN. It may thus be concluded that IL-6 and to some extent CD4 play an important role in the development of the immune response and clinical manifestations after burn injury.
(K. Troshev, D. Markov - Bulgaria)
There is a significant similarity between wound zones after chemical injuries with NaOH, H2SO4, and HCI and after burn trauma. The morphological differences are not significant either with regard to experimental and control groups or to different causes. This is confirmed by investigations we have conducted on other kinds of wounding. After chemical injury to the skin nonspecific processes occur in the wound zone. There is no difference in their character and dynamics from other skin injuries. Some different metabolic processes may take place, but these were not investigated in the present study. The same diagnostic and therapeutic problems and possibilities exist after chemical injuries as after other kinds of burns.
(O. Hadjuski, M. Lesseva, N. Tzolova - Bulgaria)
Silver sulphadiazine, used for the first time by Fox in 1968, is now the drug of choice for local treatment of burn wounds, and Flamazine, its most popular compound, meets most of the criteria for the ideal local agent. The aim of this study was to establish the efficacy of Flamazine in the prevention of bacterial infection and in burn treatment. The study concerned 50 hospitalized patients of either sex, aged between 1 and 76 years, with second- and third-degree burns in 5 to 70% T13SA. The bacteriological results of Flamazine application in 35 patients are presented. Both the open and the closed methods were used for Flamazine application. All the patients were treafed successfully. In deep burns the eschars were soft, slightly moist, metal grey in colour, and with no inflammation area in or around them or any bacterial growth, this making it possible to perform early surgical necrectomy. A good process of epithclialization initiated after debridement of superficial burns. In 27 patients (77.0%) the wounds remained without bacterial growth from the time of the patients' admission until they were operated on or until epithelialization. The bacteriological results were evaluated as very good in 31 cases (88.5%) and good in four (11.5%), with no unsatisfactory result. It is concluded that local treatment with Flamazine is very important for the favourable course and outcome of the burn disease as it prepares deep burns for early operative treatment and promotes rapid epithelialization of superficial burns.
(M. Rouabhia - Canada)
Tissue culture research has recently led to significant breakthroughs in several medical fields. Autologous epidermal substitute transplantation for burn coverage and damaged skin replacement is an example of such biotechnological progress. This approach has already saved many lives. However, the main drawback to this treatment remains the time required for patient keratinocyte growth before grafting. In order to overcome this problem, I have devised a new cell culture method for rapid graftable epidermal substitute production. These epidermal substitutes, composed of two keratinocyte populations, were grafted onto an experimental model to assess their potential on generating functional skin. A hairless mouse was chosen as a model for this heterologous epidermal substitute grafting. A comparative study was carried out between the heterografts and the homogeneous implants. Morphological, histological and immunohistochemical analyses showed that heterologous epidermal substitutes led to successful graft take and functional skin regeneration. Indeed, in situ analysis of the newly generated cutaneous tissue indicated good structural organization, including the deposition of a continuous basement membrane and a well -v ascularized neodennis. These data suggest the potential use of these heterologous epidermal substitutes for clinical improvements in massive burn management.
(G. Magliacani, M. Stella, C. Castagnoli, C. Trombotto, S. Ondei, M. Calcagni - Italy)
Pathological scarring continues to represents a major challenge for reconstructive surgeons. its anatomopathological classification is poorly defined and the relative epidemiological data are controversial. Our research group has therefore drawn up a classification chart on the basis of the morphological aspects of pathological scars. Hypertrophic scarring, the burn sequela most frequently observed in our case records, is characterized by the onset of typical clinical features which after a variable time course of activation undergo a phase of remission. The factors that produce this progressive radical change in the scars are not clear. It has recently been suggested that immunological factors may play a major role in the pathogenesis of hypertrophic scars. In order to have a better understanding of the pathophysiological factors involved, we studied active hypertrophic scars by means of immunohistochemistry. Among the wide range of cytokines, only interferon y was highly expressed in active hypertrophic scars on lymphocytes; it was less expressed in the remission phase and in control samples. The management of abnormal wound response can be considered appropriate only if it aims at the prevention or minimization of pathological scarring, and the results can be considered satisfactory only if the therapy is successful in specific anomalies related to particular lesions and in strict correlation with the scarring evolution phase. It is therefore indispensable to adopt a common clinical classification as this will provide better correlation between the clinical and the biological situation and a better interpretation of the mechanisms responsible for hypertrophic scarring.
(I. Gokalan, F. Ozgur, E. Mavili, G. Gorsu - Turkey)
Over a 15-year period (1978-1993), 123 procedures were used to reconstruct post-burn face deformities in 108 patients. Some of the reconstructions were essential procedures, such as neck, microstomia and eyelid ectropion release, by means of skin grafts, Zplastics, or local flaps. As these were the initial steps of burned face repair, they were performed as early as possible, sometimes without waiting for scar maturation. As an aesthetic procedure resurfacing of the face was performed by dermabrasion and skin grafting. In some patients expanded skin flaps or free flaps were used. Hair-bearing skin grafts or hair-bearing skin flaps pediculed by temporal fascia were used for eyebrow reconstruction, local flaps or forehead flaps for nasal reconstruction, and hair-bearing skin flaps from the temporoparietal region for moustache reconstruction. Ear reconstruction was a difficult procedure, because of the poor quality of the skin; the best results were obtained when the ear was reconstructed by costal cartilage frames covered with temporal fascia and skin grafts.
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