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Volume XIII

Number 2

June 2000

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SUMMARIES

67 MORTALITY OF THE PAEDIATRIC BURN POPULATION TREATED AT THE VIRGEN DEL ROCIO UNIVERSITY HOSPITAL, SEVILLE, SPAIN IN THE PERIOD 1968-1999
(Gomez-Cia T., Franco A., Mallen J.M., Gimeno M.A., Fernandez-Mota A., Marquez T., Portela C., Lopez I. - Spain)
Changes in medical treatment protocols have led to a significant reduction in the mortality of the paediatric population treated at the Burn Unit of the Virgen del Rocfo University Hospital in Seville (Spain) in the last 30 yr. An analysis was made of the probability of death in two groups of patients under 9 yr with burns in:5 45 % body surface area: Group A (1451 admissions between 1968 and 1977) and Group B (312 patients admitted between January 1993 and January 1999). In Group A, approximately one-hundredth of the patients admitted with the above characteristics died, while in Group B the mortality rate was one in three hundred. The findings in these two groups of patients during the two periods are compatible with those published by other authors. Some changes in the clinical protocols might explain the improvements achieved, e.g., resuscitation therapy adapted to each individual case, with early use of colloids; strict hypercaloric and hyperproteic nutrition; early escharectomy and subsequent closing of the wound.
73 TREATMENT AND MORTALITY TRENDS AMONG MASSIVELY BURNED PATIENTS
(O'mara M.S., Caushaj R, Goldfarb I.W., Slater H. - Usa)
Despite advances in burn care techniques, there remains a trend towards therapeutic failure in patients who sustain burns in more than 60% total body surface area (TBSA). Predictors of survival that have been seen include age, burn size, amount of full-thickness burn, inhalation injury, mechanism of burn, timing and appropriateness of resuscitation, and concurrent complications. We reviewed the data of patients with 60% or greater TBSA burns seen at our Burn Trauma Unit over the past five years. The purpose of this was to evaluate our practices as well as the success of current therapy. During the time period reviewed 39 patients were admitted with this significant level of injury. They were all treated with appropriate resuscitation and early excision and grafting. All available demographic, historical, therapeutic, and outcome data were gathered. Statistical analysis was undertaken to identify variables, which presented significant differences between the group of survivors and that of patients who died. Of the 39, 28 patients succumbed. Larger burns, more full-thickness burns, inhalation injury, the need of escharotomy, and anuria/oliguria were all associated with a decreasing chance of survival. Delay in arrival at the burn trauma unit was also associated with poor outcome, as was earlier first operative excision. Greater burns severity led to basic malfunctioning of the physiological response, as seen in the inadequate effect of resuscitation: essentially, the more extensive the burn the higher the likelihood of mortality. The key to improving our ability to treat massively burned patients seems to lie in be;ter and prompter resuscitation, better treatment of pulmonary injury, and better understanding of how to halt the underlying deteriorating physiological process in more severe burns.
77 ACUTE RENAL FAILURE IN SEVERE BURNS. CONCLUSIONS AFTER ANALYSIS OF DEATHS DURING 1998
(Belba M. Belba G. - Albania)
This article focuses on the presence of acute renal failure (ARF) in deceased patients during 1998. We describe the clinical situations in which ARF occurs. These include burn shock, massive necrotic tissue (especially in electrical and chemical), burns, endotoxic shock from gram-negative bacteria, and hypercatabolic states with multiple organ failure. We believe that there are two essential aspects that medical staff must keep in mind in the treatment of severe burns - prevention and the treatment of ARF.
81 GASTROINTESTINAL HAEMORRHAGE IN BURN PATIENTS - THE EXPERIENCE OF A BURNS UNIT IN SAUDI ARABIA
(Fadaak H.A. - Saudi Arabia)
Gastrointestinal (G1) ulceration complicated by haemorrhage used to be a potentially lethal complication of major thermal injury. Prophylactic treatment with antacids or H2-receptor blockers has dramatically reduced the incidence in many burn units. Early enteral feeding has recently been shown to be an effective additional measure in stress ulcer prophylaxis. Our experience with stress ulcer prophylaxis at the King Fahd Hospital of the University Burns Unit (Saudi Arabia) in the management of 1040 patients over 14 yr is described in this paper. The overall mortality was 5.38% (56 cases). Of the total admissions, nine patients developed G1 bleeding (0.86%). The group with significant burns, i.e. burns in more than 20% total body surface area, suffered GI bleeding in 3.28% of cases. The commonest presentation was melaena during the terminal stages of septicaemia. Surgical intervention to control bleeding was required in two out of the nine cases. Of the seven other patients who died owing to thermal injury, massive bleeding was directly responsible for death in only one patient. While septicaemia is a risk factor, it seems that prophylaxis with H2-receptor antagonists and early enteral feeding significantly reduced the incidence of bleeding in this series.
84 THE COMPLICATIONS OF BURNS IN THE NEWBORN PERIOD
(S. Golubovic Z., Parabucki D., Jawic G., Zamaklar D., Najdanovic Z., Rakic I. - Yugoslavia)
Over a four-yr period we treated five children under one month of age for severe burns. All the burns were of iatrogenic origin. The injury mechanisms were: 1. bathing the child in water that was too hot; 2. use of a hot water bottle to increase the temperature in the incubator (two cases); 3. use of a hot water bottle without an incubator; 4. incorrect fitting of the thermocautery electrode to the child's crura. In all but one of the patients we used the method of tangential excision after definite demarcation of the necrotic surface. To cover the burn areas we used homograft skin from the parents and subsequently free skin transplants from the babies themselves. On the basis of our experience we consider it imperative to treat burns in neonates following the same principles as in older children. Sepsis was a major complication in one case but was adequately treated with antibiotics. Later complications were post-osteomyelitis sequelac and contractures in scars in the groin region.
87 THE SYSTEM OF ACTIVE SURGICAL MANAGEMENT OF SEVERELY BURNED PATIENTS WITH DEEP BURNS AND COMBINED INJURIES (BURN AND BLOOD LOSS)
(Atyasov N.I. - Russia)
Purpose-oriented infusion therapy and intensive treatment proved to be successful in restoring skin coverage in a cohort of over 3000 severely burned patients prior to the development of irreversible changes. Owing to the enhancement of the body's defensive mechanisms it became possible: to shorten the period of wound cleansing of necrotic tissues; to accelerate the local treatment of wounds in the presence of daily dressings in the pre-operative period and speed up the healing of donor sites by means of improved reparative processes; to shorten the time gap between repeated surgical operations, thus achieving a maximum overall gain in time, which was extremely important for the patient's recovery; to minimize the detrimental effect of autoinununization on graft take by reducing the number of repeated surgical interventions (in the presence of infusions that increase in volume up to a maximum level, as the patient's state improves); and to prevent the increasing threat of peri-operative shock by performing preventive infusions under pressure at the most traumatic moments. It was found opportune to cover the wounds with large-sized, closely adjoining skin flaps, a procedure that yielded better functional and cosmetic results and helped to restrict indications of allogenic and meshed grafts. The system was developed in fifty-two dissertation papers, and its implementation in clinical practice helped to save the lives of patients previously regarded as doomed to die.
92 INTERDIGITAL BRIDGING FOR TREATMENT OF THE BURNED HAND
(Ullmann Y.,Lerner A.,Shtein H.,Peled I.J. - Israel)
A simple method is presented for bridging between burned fingers in order to keep the webs open during and after surgery. This "trick" can be tried when Kirschner wires are used during surgery for stabilization of the interphalangeal and metacarpophalangeal joints. Horizontal wires are connected to the free ends of the intradigital wires by means of bone cement. Stabilization of the skin grafts is easier, fewer bandages are needed, and good preservation of the webs can be achieved. Our experience is based on the patient described and on four others, in whom the method was used to treat burned hands.
94 L'EXPANSION TISSULAIRE DANS LE TRAITEMENT DES SEQUELLES DE BRULURES DE L'EXTREMITE CEPHALIQUE
(Adouani A., Zili H., Landoulsi A., Mouafak M., Lasta S. Brahem H., Zairi L, Moktar M., Seghir M. - Tunisie)
L'expansion tissulaire a enrichi l'arsenal therapeutique en chirurgie reparatrice. L'etude d'une serie de 57 cas de sequelles de brulures de l'extremite cephalique, traitues par l'expansion tissulaire, permet de degager que ce procede donne des resultats satisfaisants au niveau du cuir chevelu, mais moins interessants au niveau de la face et du cou, essentiellement pour des raisons anatomiques.
98 PIEDMONT FOUNDATION OF STUDIES AND RESEARCH ON BURNS: THE LAST THREE YEARS OF RESEARCH ACTIVITY
(Teich Alasia S. - Italy)
An account is given of the main activities of the Piedmont Foundation of Studies and Research on Burns. The results of latest research are presented, together with important developments in the field of pathological scarring, new methods of skin cryoconservation, and peripheral sensory nerve regeneration after extensive burns. All the Foundation's efforts endeavour to promote close and productive links between researchers and clinicians in the field of burns in order to achieve significant advances in this important field of medical science.
101 THE EFFECT OF THE DELAY PHENOMENON ON THI.P ZONE OF STASIS,11N BURNS: AN EXPERIMENTAL STUDY IN RABBITS
(Isik S., Kopal C., Karakalioglu O., Selmanpakoglu N. - Turkey)
Twenty-five New Zealand white rabbits (weight 3.0 0.5 kg) were used to study the destiny of skin responding to ischaernia in experimental burns. In the first group, dorsal delay flaps (4 x 10 cm) with the caudal pedicle (N5) were elevated in two stages and sutured to their donor sites. On day 7 of elevation, dorsal acute flaps the same size were elevated counterlaterally to the delay flaps. The extent of the distal necrotic areas was calculated one week later. In the second group, delay flaps were elevated and rows of burns were created in the distal half of the flap (N10). A probe (0.5 x 1 cm of each) was heated in boiling water and applied four times on the skin for 20 sec in such a fashion that a cross-shaped interspace area (0.5 cm, in width) was achieved. The same pattern of burn was created on the normal skin next to the flap. In the third group, delay flaps and acute flaps were elevated in the abovementioned fashion and the same pattern of burn was created in the distal halves of the flaps. Tests, including laser Doppler flowmetry, nuclear irnaging, and autoradiography, were performed on days 1 and 7 post-burn. In the first group, the average necrotic area in the acute flaps was 310.4 mm2, and all the delayed flaps survived. Burn rows were then created 2 cm proximally to the distal edges of the flaps in groups 2 and 3. In group 3, the distal necrosis of the acute flaps was significantly increased to 774 138 mm2 on day 7. The laser Doppler flowmetry measurements revealed decreased distal circulation in the acute flaps, and 4.5 2.2 perfusion units in the delay flaps on day 7 post-burn. The amount of necrotic change in burned areas in group 2, as calculated from autoradiographies, was found to be 316 62 mm2 in normal skin and 274 45 mm2 in delay flaps on day 7. In group 3 the amount was 288 54 mm2 in delay flaps and 680 41 mm2 in acute flaps. To conclude, it seems that the mechanism involved in the saving of ischaemic tissues does not significantly save the zone of stasis in burns.
107 RESUSCITATION APPROACH AND CLINICAL EVALUATION IN BURNS VICTIM AFTER MASS ACCIDENTS - PART TWO. HAEMATOLOGICAL STUDY AND ANALYSIS
(Hadjiiski O., Rashkov V., Emanuilov L., Lubomirov M. - Bulgaria)
This study continues our exploration of the treatment of patients with burns suffered in mass accidents (Part One was published in the March 2000 issue of Annals of Burns and Fire Disasters). We observed the changes in various laboratory parameters, such as the dynamic of the haemoglobin and haematocrit levels, proteins, potassium, sodium, and the acid-base balance related to the application of Baxter's modified scheme in the treatment of burn patients in the first three days post-burn. Our results show a normalization of haematocrit and protein levels, plus a stable electrolyte balance and satisfactory normalization of the acid-base level.
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