Volume XII

Number 4

December 1999

ANALYSIS AND OUTCOMBE OF 835 BURN INJURY ADMISSIONS TO THE BURN UNIT, KING FAHD HOSPITAL, AL-KHOBAR, SAUDI ARABIA
Faidaak H.A., Ballal S.G., Hegazi M., Al-Hoqail R., Al-Awad N. - Saudi Arabia
The objective of this study was to determine the magnitude of the problem of burns suffered by patients admitted to the burns unit at King Fahd Hospital of the University (KFLIU) in Saudi Arabia and to suggest possible measures to reduce their incidence.
Burn patients reporting to the KFHU emergency room and admitted to the burns unit during the period between May 19:~3 and April 1994 were analysed. A total of 835 (558 males, 277 females) burn patients were admitted over the 11 yr. Of these, 65.2% (546) were Saudis and the rest non -Saudis. The age ofthe injured ranged from 2 months to 80 yr; children aged under 5 yr (pre-school) constituted 39.0% (324) of all cases. Of the children, 58.3% (183) were male. The hospital stay ranged from as short as zero (deceased) to 21 months (a male child aged 3.5 yr). Domestic burns accounted for the ma ority of cases in the 11 -yr period (87.0%). The lowest annual rate of domestic burns was 80%, during the year 1985, and the highest 93%, in 1993. Scalding, in the majority of cases due to hot liquids, accounted for 52.4% (439) ofall burns, followed by flame, 36.9% (309), electricity, 4.4% (37), and chemical burns, 2.4% (20). The causes ofthe remaining 32 burns (3.8%) were not specified in the patient's record. The total body surface area affected ranged from 1 % to 100~'(,. Of' all the burn patients admitted to the unit, 7.0% (59) discharged themselves against medical advice. The mortality rate was 5.9% (49 deaths). This study showed that pre-school children formed a sizeable proportion of the injured, a finding that underlines the special attention required by this age group. Burns by hot liquids (water, coffee, tea, soup, oil) were the commonest, which again stresses the need for more attention in the home. A health education programme directed towards safety against domestic burns has much to commend it.

THE CLINICAL SIGNIFICANCE OF THE SIRS SCORING SYSTEM IN SEVERELY BURNED PATIENTS
Wang G.-Q., Xia Z.-F, Yu B.-J., Ge S.-D., Chen Y.-l., Liu S.-K. - Republic of China
In order to evaluate the contribution of four individual factors (respiratory rate, heart rate, body temperature, and white blood cell count) to the diagnosis of the systemic inflammatory response syndrome (SIRS) in patients with burn trauma, a multiple regression analysis was performed between the S1RS score and the organ dysfunction score. The relationship between the number of days of SIRS with regard to the different criteria and organ dysfunction was also analysed. In relation to the criteria of burn patients with severe SIRS, the concentrations of T3 and T4 in the serum were detected by radioinummoassay. The results showed that the four factors made a different contribution to the occurrence of organ dysfunction. The order of importance of the factors, from large to small, was as follows: respiratory rate, heart rate, body temperature, white blood cell count. Severe SIRS was responsible for organ dysfunction. T3 and T4 concentrations in burn patients with severe SIRS were significantly lower than those in burn patients with nonsevere SIRS. The SIRS score can therefore be used as a predictor of organ dysfunction.

INVASIVE BURN WOUND INFECTION
Ail-Akayled A.T. - Jordan
Objective: The aim of this study was to determine the aetiological factors, causative micro-organisms, mortality rate, and antimicrobial therapy in cases of invasive burn wound infection.
Methods: This is a retrospective study of 67 patients who presented invasive burn wound infection, representing 8.98% of the total number of burn patients admitted to three military hospitals in the south of Jordan from June 1990 to May 1998. Results: Children and the elderly were found to be the most commonly burned patients who developed invasive burn wound infection. Third-degree burns were found in 38.7% of the patients with burn wound infection. The most commonly isolated micro-organisms (50.8%) were fungi. Amputation was performed during treatment in 26.9% of the patients with invasive burns and only 29 patients out of the entire group survived. Conclusion: The factors found to be mainly implicated in invasive burn wound infection were burn extent and depth, and patient age. Antifungal therapy should be considered in every patient suffering from invasive burn wound infection.

TRENDS AND STRATEGIES FOR INFECTION CONTROL IN A NEW BURNS CENTRE
Melandri D., Morri M., Polverelli M., Pierleoni M., Arcangeli E, Landi G. - Italy
Despite the significant advances made in the last 40 years in the treatment of burn patients, infections continue to represent a serious complication of burn injuries and a stimulating challenge for medical staff. The general arrangement of a new burns centre in Cesena was carefully planned in order to achieve a significant reduction in the risk of infection and to keep the microbial environment to a minimum. Special architectural structures were used to achieve satisfactory isolation from the external environment. There are separate entrances for burn unit staff, patients, equipment, and visitors. Air-handling systems have been installed, with a larninar airflow room and the choice of multiple centralized air-conditioning units for patients, staff, and the operating theatre. All rooms are provided with a bath in order to minimize the risk of cross-infection, which is traditionally associated with hydrotherapy. For the same reason, all rooms have an anteroom that functions as a further filter area for the staff. Microbiological checks are carried out on a frequent basis both on air samples and on surface swabs in order to monitor the level of microbial contamination inside the unit.

PERICARDIAL EFFUSION: A RARE COMPLICATION OF THERMAL BURN
Barr J., Sagi A., Glesinger R., Rosenberg L. - Israel
The heart is rarely affected by thermal injury, but here such a case is presented. Following severe burns a 28-yr-old woman suffered from pericardial effusion together with ARDS and sepsis. She had sustained 30% TBSA second- and third-degree burns in the face, neck, chest, arms, hands, abdomen, and thighs. Two days after admission the patient underwent tangential excision and skin grafting in the hand. The patient eventually developed ARDS, and in the second week post-burn her blood cultures were positive for Acinetobacter and enterococei. The patient was treated with intravenous imipenem, which according to sensitivity was later replaced by ampicillin and Garamycin. It was decided not to drain the pericardium but rather to continue conservative treatment with aspirin, antibiotics, and respiratory support. The patient's condition gradually improved and two months after admission she was discharged with all wounds closed. At follow-up several months later, she was free of respiratory complaints.

SEVEN-YEAR EXPERIENCE IN THE TREATMENT OF BURN PATIENTS WITH ALLOGENIC CULTURED KERATINOCYTES
Smirnov S.V., Vasiliev A.V., Paramonov B.A., Loginov L., Kiseliov I.V., Danilova T.l., Terskikh V.V. - Russia
This study was conducted over a period of seven years (1992-98) in burn units at the Sklifosofsky Research Institute of Emergency Care (Moscow) and the Military Medical Academy (St Petersburg). Sixty transplants were performed in 48 patients with second- and third-degree burns and donor sites. Allotransplantation was found to have a beneficial effect on wound healing. We suggest that, after grafting, allogenic keratinocytes activated by in vitro cultivation may produce a reparative environment necessary for the proliferation and migration of recipient keratinocytes.

EARLY TANGENTIAL EXCISION WITH THE GUIDANCE OF METHYLENE BLUE APPLICATION
Celikoz B., Deveci M., Nisanci A. - Turkey
The difficulty of distinguishing devitalized tissues from vital tissues in the early post-burn period has long been a deterrent to adequate debridement. Clinical observation is still the only standard method for estimating what is to be excised, but it cannot reliably identify the critical zone of vascular stasis that separates necrotic from viable tissue. In our present clinical study we have evaluated the reliability of a practical method in which methylene blue is used to predict burn depth. The mechanism underlying this procedure exploits the metabolism of methylene blue in vital tissues, where it is converted into leucomethylene by the enzyme reductase. Pre-operative application of methylene blue enabled us to make an accurate prediction of the depth of thermal injuries while performing early tangential excision. The mean value of graft take rates was found to be 98% in all patients treated by skin grafting following tangential excision performed with the method of pre-operative methylene blue application. Acceptable wound healing, increased graft survival, and diminished intra-operative blood loss appear to be the main advantages provided by this procedure compared with conventional early tangential excision. In conclusion, we highly recommend performing early tangential excision with the guidance provided by the application of methylene blue.

ABDOMINAL WALL RECONSTRUCTION IN AN ELECTRICAL BURN WITH A MYOCUTANEOUS TENSOR FASCIAE LATAE ISLAND FLAR CASE REPORT
Cavadas P.C. - Spain
High-voltage electrical injuries often cause full-thickness defects in the abdominal wall, which are difficult to reconstruct. A case is reported of periumbilical reconstruction using a tensor fasciae latae (TFL) myocutaneous flap in an 8-yr-old boy who had sustained severe electrical injuries. The operative procedure is described, in which a right TFL myocutancous island flap was used. The treatment described led to satisfactory results.

MASS DISASTERS. BULGARIAN COMPLEX PROGRAMME FOR MEDICAL CARE FOR PATIENTS WITH BURNS AFTER FIRE DISASTERS
Hadjiiski O. - Bulgaria
A medical programme for action in the event of mass burns is described. It is the result of the observation of 20 mass accidents, with 155 victims, that occurred in Bulgaria in the period 1990-97. The programme is in line with the recommendations of similar programmes such as that of the Mediterranean Club for Burns and Fire Disasters and with national demands for such programmes. The programme is in two parts. It includes pre-hospital management at the place of the accident - non-medical medical aid, first medical aid, and pre-hospital transport - and hospital treatment in hospitals not specialized in burns, inter-hospital transport, and treatment in specialized burns centres.

EXTENSIVE KELOIDS IN THE AURICLE - SURGICAL TREATMENT BY MEANS OF AUTOLOGOUS GRAFTS
Masellis M., Ferrara M. M. - Italy
This article considers two cases of keloid formation in the auricle. Keloids usually affect the dermis and are characterized by the presence of thick collagenous fibres of vitreous and hyalinized aspect. Some related fibroblasts are also present. ln the early stages the formations tend to be more vascularized, especially in peripheral zones, while in the more mature phase they are more hyalinized. The removal of an ample keloid, as in the cases reported here, and the repair of an exposed area with a dermo-epidermal full-thickness skin graft cause both general and specific modifications in the healing process. The removal of an ample keloid, as reported here, and the repair of an exposed area with a denno-epidermal full-thickness skin graft cause both general and specific modifications in the healing process. The surgical techniques employed are described and the various problems involved are considered. Although only two cases are considered, the experience obtained makes it possible to repropose the treatment of keloids with the free skin graft technique, at least in cases located in the auricle, without the supplementary assistance of medical or physical therapy.