Introduction

The burn trauma has become ever more evident during the process of the technological development of modern society. The epidemiological and historical acknowledgement of disasters and injuries in groups of people has increased the awareness of medical opinion and of a variety of different institutions, with the ultimate aim of the improvement of organizational and administrative measures for a better prevention policy.',' At the same time, scientific conclusions drawn during and after the treatment of single cases have built up a store of valuable experience and useful background knowledge for future cases, thus contributing to the proper orientation of medical staff.
The concern for a more efficient approach to disasters, or to burns in groups of people, has always inspired discussions in congresses, conferences and symposiums. We present here our data on burns that have occurred in groups of people in Albania in the last twenty years and we offer some modest conclusions that we consider valuable for the current situation as well as for the future, in corrformity with the technical and industrial progress and therapeutic possibilities of our country.

The period concerned goes from March 1974 to October 1995, during which time fifteen cases of burns in groups of people occurred in various parts of Albania. The description of the cases will be given in chronological order, citing the month, year and geographical location of the accident, the site and the type of burning agent, the number of injured persons, burn extent and depth, number f survivors, overall results, and final conclusions.

March 1974 - Shkoder
- Artisan business - fire caused by diluent
- 5 adults burned: one 80% BSA, four 15-25% BSA deep II-III degree
- Outcome: 4 recoveries, 1 death

April 1975 - Korce
- Coal-mine - fire due to methane gas explosion
- 6 adults burned: 40-50% BSA III degree
- Outcome: 2 recoveries, 4 deaths

July 1976 - Berat
- Dwelling-house - fire due to benzine
- 2 children, 2 adults burned: 80-90% BSA III degree
- Outcome: fatal

June 1978 - Elbasan
- Metallurgical plant - fire due to furnace slag and clinker
- 7 adults burned: 80-90% B SA burned III degree
- Outcome : fatal

August 1978 - Elbasan
- Metallurgical plant - explosion during soldering
- 8 adults burned: 100% BSA III degree
- Outcome: fatal

July 1980 - Tirana
- Paint factory - fire caused by diluent ignition
- 6 adults burned: 15 -20% BSA deep II-III degree
- Outcome: recovered

July 1980 - Elbasan
- Metallurgical plant - explosion during casting of molten metal
- 6 adults burned: two 15%, four 45-50% BSA III degree
- Outcome: 5 recoveries, I death

December 1980 - Berat
- School - fire caused by explosion of stove
- 20 children burned: 10-15% BSA deep II-III degree
- Outcome: recovered

December 1981 - Fier
- Geological enterprise - flame in oilwell
- 9 adults burned: 15-20% BSA deep 11-111 degree
- Outcome: recovered

October 1982 - Elbasan
- Metallurgical plant - explosion during casting of molten metal
- 12 adults burned: 90- 100% B SA deep 11-111 degree
- Outcome: fatal

January 1983 -Tirana
- Coal-mine - fire due to methane gas explosion
- 5 adults burned: 20-25% BSA deep II-III degree
- Outcome: recovered

March 1988 -Tirana
- Bread factory - flame caused by short circuit
- 5 adults burned: 15-20% BSA deep II-III degree
- Outcome: recovered

November 1990 - Memaliaj
- Coal-mine -fire caused by methane gas explosion
- 7 adults burned: two 80%, one 50%, four 25-50% BSA deep II-III degree
- Outcome: 5 recoveries, 2 deaths

May 1994 -Elbasan
- Dwelling-house - fire caused by benzine barrel explosion
- 3 children, one adult burned: 80-100% BSA III degree
- Outcome: fatal

October 1995 - Korce
- Garbage processing factory - explosion
- 6 adults burned: one 45%, three 20-25%, two 1015% BSA deep II-III degree
- Outcome: see below

The last group of victims consisted of six adults injured in October 1995 in the town of Korce, after an explosion in a garbage processing factory. The burns involved 45% BSA in one patient, 20-25 % in three patients, and 10-15% in two patients, mainly deep dermal and III degree burns. The burns were located primarily in the upper half of the body, including in all cases the head and upper limbs, as well as portions of the trunk. The patient with 45% BSA burns was 19 years old, while the others varied in age between 35 and 48 years. Soon after the explosion (within four hours), all the patients were transferred by helicopter to our burn unit, in the care of a resuscitation team with all necessary equipment for cardiopulmonary resuscitation; fluid therapy was initiated at the same time.
The rate of intravenous infusion was adjusted in order to maintain normal urinary output. With this objective the rate was increased and, in the end, the Parkland formula coefficient which guided our fluid therapy was 6, instead of 4. Fresh frozen plasma was started in the third eighthour period of the first day, and in the following days therapy was completed with antibiotics, human alburnin, electrolytes, intralipid vitamins, immunoglobulin, antacids, and blood transfusions, according to need.
The laboratory data revealed the following:

• high haernatocrit (58-60%), gradually reducing to normal values after day 2 post-burn
• hypokalaernia (3-3.3 mmol/1), corrected after day 2
• hypoproteinaernia (4.2-4.4 grldl), reducing to the lower end of the normal range on the fifth after initiation of therapy
• hyperglycaemia (150-200 mgldl), which persisted until the last day of hospital stay; after endocrinological consultation this was considered to be of stress origin

With regard to local care, silver sulphadiazine was the mainstay of antimicrobial therapy. Neomycin-impregnated gauzes were used in more superficial burns and Mercurochrome in cases of burns of the ear or mucous membranes. Staphylococcus aureus was isolated in cultures obtained from the burn wound, except in the case of the most extensively burned patient, in whom Pseudomonas aeruginosa was isolated.
Thanks to the intensive general care, all the patients succeeded in overcoming the septic phase, and by the beginning of the second week there was an obvious reduction of the burned area because of epithelialization beginning on the head. By the third week, all the patients had been subjected to several plastic interventions in order to cover the burn wounds; necrectomy was performed in these areas - generally on the limbs - where the eschar still adhered, and meshed-skin autografts were used to cover the wounds definitively. The grafts took well, enabling us to re-operate on the patient with 45% BSA burns by the fifth week.
At the end of treatment in this group, which suffered no fatal outcomes, the average duration of hospital stay was 28 days. Hospital stay lasted 50 days in the case of the most extensively burned patient.

Discussion and conclusions

From the geographical point of view, these accidents occurred predominantly in the inland parts of Albania, where most of our industry is concentrated.
Medical facilities are more numerous in the vicinity of important industrial centres, which can provide not only emergency care but also treatment for injured persons until the arrival of specialists. It is very important that the personnel working in such places should be well qualified and possess the ability to control emergency situations in the event of disasters or casualties in groups of people.
It would be better if resuscitation teams were permanently present in these industrialized districts, ready to intervene promptly at the site of the accident. The objective of these teams should be to offer qualified medical care straight from the first moments of contact with the patient, after he/she is taken away by firemen from the place of the accident. Oxygen delivery and the establishment of an intravenous line in all these injured patients enable them to be transported to a more specialized facility, or to be examined in a district hospital for other problems that may arise.` It must be understood that the pres~ ence of rescue teams is mandatory - in the selection of patients according to the severity of their injuries, in the organization of first aid, and in the rescue of a considerable number of victims, thus having an important impact on the overall mortality rate.
The assessment and classification of patients in different categories based on their prognosis facilitates the work of the burns team, allowing them concentrate on each case and to act in accordance with the severity of the injury and the need for surgical intervention. In this second stage of treatment, a re-estimation has to be performed in order to calculate possible losses and to decide on therapeutic measures to prevent them.
A survey of the industrial plants that were the sites of the accidents reveals that the workers most exposed to this kind of injury were those in the metallurgical industry and in coalmines. Burns in groups of people caused by explosions during metal melting and burns due to furnace flares emphasize the importance of the observance of safety regulations and of the correct assessment of every step of the technological process. Disregard of any of these steps can have disastrous consequences not only for the person directly involved but also for co-workers in the immediate vicinity.
In coal-mines, a recurrent problem is explosions due to the ignition of methane gas. Flames engulfing an entire gallery are caused by the careless use of matches and lighters, or by sparking or short-circuiting after breakdowns or malfunction of various types of apparatus. The insistence by technical engineering staff on absolute observance of all safety regulations, together with careful checking and repair of equipment, and substitution, if necessary, with new equipment when beyond repair, could prevent the occurrence of such accidents in high-risk industrial zones.
If we consider the location of these burns it can be seen that, besides involving large areas of body surface, they were mainly located in critical areas such as the head, torso and upper limbs, in association with inhalation injuries. Locally, the wounds presented a typical aspect: considerable exudation in areas of deep dermal burns, singeing of nasal hair and mucosal membranes, and typical oedema, even at some distance from the area directly involved. With this kind of local condition and general restlessness, and with increasing demands for fluids, it was necessary to enhance fluid administration with Ringer's lactate, in order to reach amounts exceeding those recommended by Parkland's formula. This is a reasonable approach, especially in the event of a weak response by the patient to fluid therapy, with decreased urinary output, or in the case of delayed initiation of fluid administration. This is of course just a clinical guideline and must on no account lead to pulmonary overload.
Statistically, 77.2% of the patients in all fifteen groups were adults, the other 22.8% being children. In the latter group, the site of the accident was a dwelling-house or school. The incidence of burns is low in the home environment but increases considerably for groups of children in schools, kindergartens or day-nurseries. These tragic events must be prevented by training teachers and all other school staff, by insisting strictly on proper order, and by continuously warning children about the hazards of electric current, fuel, and the heating appliances that are widely used in school environments. Technicians should bear in mind that the appliances used in such areas must be chosen according to the age groups of the children and be installed some distance out of children's reach.
The above data show that the most important conclusion in all these groups is that mortality did not exceed 40%. This means, first of all, that the burn agent is not always fatal - it may spare human lives, offering an opportunity to act. Secondly, the extent and depth of thermal injuries are not always at the limit of incompatibility with life, and allow possibilities for the survival of more than half of the members of an injured group. Thirdly, there should be awareness of all the above figures, conclusions and concepts regarding disasters and emergency medical care not only on the part of medical opinion but also by all those required to face such situations, including firemen, first-aid workers, rescue team transporters, industrial and medical institution staff, and others." The final aim in ble, responding to such cases with preparedness, strength cases of disaster is to save as many human lives as possi- and conviction.

RESUME. Cet article présente les données relatives aux brûlures qui se sont produites en Albanie pendant les derniers vingt ans. Les Auteurs, pour ce qui concerne les groupes de patients atteints, considèrent en particulier le type d'agent qui a causé la brûlure, son extension et sa profondité, et les résultats finals du traitement médical. Les Auteurs décrivent en majeur détail la thérapie d'un groupe de patients qui ont été suivis récemment, en octobre 1995, après une explosion qui s'est produite pendant le traitement de déchets de fabrication à Torca. Les Auteurs concluent en soulignant l'importance de la thérapie de réanimation avec des régimes complémentaires de liquides qui dépassent les quantités prévues par les formules normales. Ce besoin augmenté dépend principalement de la localisation des brûlures dans des zones critiques du corps mais aussi du retard dans le commencement de la thérapeutique liquidienne. La mortalité globale dans ces groupes de patients confirme les dangers auxquels ils sont exposés. Il faut instituer des mesures organisées pour prévenir et gérer ces accidents, avec la collaboration minutieuse de disciplines différentes, si nous voulons réduire au minimum les pertes humaines.

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