Volume XIV

Number 2

June 2001

NON-ACCIDENTAL PAEDIATRIC BURNS IN JORDAN
(Haddadin K.J., Amayreh W.M. - Jordan)
Objectives: This is a retrospective study of all suspected non-accidental paediatric burns treated at the Burn Unit of Farah Royal Jordanian Rehabilitation Centre between 1 January 1993 and 31 December 1999. Guidelines for medical personnel facing a situation of suspected child abuse in our society are highlighted. Materials and methods: Over the 7-yr period of the study, all paediatric burn patients admitted to our unit were scrutinized for the possibility of child abuse as a cause of burning. Burns judged to be highly suspicious or confirmed non-accidental in nature were analysed. Results: Fifteen patients (6 male, 9 female), all under the age of 6 yr, burns judged to be non-accidental in nature. The incidence of non-accidental injuries in this age group, among burn admissions over the 7-yr period of the study, was 15/292 (5%). Three of these patients (20%) had associated medical conditions prior to the burn. Seven patients (47%) were taken to hospital at least 24 h after the injury. The majority of patients had deep burns and 11 patients (73%) required surgery. The majority of burns in this series involved the lower extremities, buttocks, and perineum. There was one death in the whole group and three patients were lost to hospital follow-up after discharge. Conclusion: Increased awareness among medical personnel of the possibility of non-accidental burns as a manifestation of child abuse is stressed. Notification and early referral of children with such burns to specialized burn units regardless of total body surface area burn or burn depth are recommended, where the expertise and support necessary for management and follow-up of such patients are available.

BURNS IN GROUPS OF PEOPLE, DEFINITION, STATISTICS, AND MEDICAL MANAGEMENT
(Belba G., Mingomataj L., Belba M., Isaraj S. - Albania)
The concept of burns in groups of people lies between that of burns in a single person and that of mass fire disasters. We give a definition of the term with regard to the number of persons injured by the thermal agent. The places where such burns most commonly occur are reported, and it is observed that some working sites are especially dangerous, such as metallurgical industry plants, coal mines, business enterprises, and factories. Neglect of technological processes leads to very severe consequences. Professional incompetence, technical failures, and lack of maintenance are the main reasons for such burns. Carelessness in handling various household appliances leads to the same outcome, causing burns in houses, schools, and kindergartens. We present statistical data indicating the incidence of burns in groups of people in recent years in Albania. The most important conclusion to be drawn is that these burns are not as fatal as burn catastrophes and mass burns. Medical teams must take advantage of this fact and save human lives through better management of the situation and by being technically prepared in advance, on the basis of a detailed strategy.

A BRIEF CLINICAL REVIEW OF THE TREATMENT OF 36 CASES OF BURN PATIENTS INJURED BY GAS EXPLOSION
(Xusheng Liu, Tian Tong, Tang Ao, Li Jiang, Yang Zongcheng - People's Republic of China)
In order to highlight the characteristics of the diagnostics and treatment of patients injured by gas explosion, with a view to providing references for the future improvement of treatment, an analysis was made of the gender, age, burn wound area and location, admission time to hospital after injury, blood gas analysis, blood routine, renal function, serum cardiac and hepatic enzymes, the identification of burn wound bacteria and sensitive antibiotics, mortality, and the duration of hospitalization time in 36 patients injured by gas explosion. Certain indices observed in deceased patients were compared with those observed in surviving patients. Gas explosion injury accounted for 0.8% of all burn patients (often male youths) in the period considered. The four main findings were: 1. The burn wound area was usually less than 50% TBSA. Shallow wounds (superficial and deep-partial second-degree burns) were often seen, with little involvement of internal organs. 2. In the three fatal cases, the burn wound and third-degree burn areas and the incidence of inhalation and internal organ injury were more marked than in surviving patients. 3. The six suspected cases of inhalation injury were subjected to tracheostomy, leading to improvement in ventilatory function and prevention of suffocation. 4. Hospitalization time was positively related to operation times. In conclusion, gas explosion injury occurred in special circumstances with high on-the-scene mortality. On-the-spot rescue treatment is of great importance. Tracheostomy is recommended in cases of suspected inhalation injury, and early operation on candidate patients is advocated.

IATROGENIC BURNS IN CHILDHOOD
(Dyakov R., Hadjiiski O. - Bulgaria)
Iatrogenic burns are rare in childhood, but they include all four aetiological burn types: chemical, thermal, electrical, and radiological. We report 22 iatrogenic burns observed in 2216 children treated over a period of 10 years. The chemical burns that occurred in our clinic were caused by seepage of alcohol solutions during an operation, when the patients spent 60 to 180 min lying on solution-soaked operative linen. These burns were I or IIA degree and covered 0.5 to 4% TBSA. Re-epithelialization took 7-14 days, after topical treatment. Thermal and electrical burns also ranged from 0.5 to 4% TBSA. In all cases, the excoriated wound surfaces were covered with free split-thickness skin autografts 0.15 to 0.3 mm thick. A complicated case is discussed of a new-born that necessitated flap rotation to cover a naked elbow joint. We conclude that most often iatrogenic burns in children are associated with misuse or failure of medical equipment and with mistakes in paediatric medical care.

ACUTE RESUSCITATION OF BURN INJURY: HAES-STERIL VERSUS LACTATED RINGER’S SOLUTION
(Al-Hawary S.E., Abdel Razek E.M., Belal T.H., Mandoor E. - Egypt)
Thermal injuries cause many complications and deaths. Most burned patients have reduced plasma volume and expanded interstitial water. Haes-Steril is used for medium-term expansive volume replacement therapy to achieve a more rapid and profound improvement of haemodynamic variables. The current study compared the effects of acute fluid therapy using lactated Ringer’s solution and Haes-Steril 10% on haemodynamic variables, volume oxygen consumption, and renal function in burn patients. The study comprised 40 patients with burns greater than 15% of total body surface area allocated in two groups receiving either lactated Ringer’s solution or Haes-Steril 10%. Comparison of the results of the two groups studied showed a non-significant (p > 0.05) difference with regard to heart rate and mean arterial blood pressure but showed a significant (p <0.05) increase of central venous pressure, cardiac output, cardiac index, and VO2 in patients in the Haes group compared with the lactated Ringer’s group. Serum lactate and plasma endothelin-1 levels were decreased in both groups at the end of study period and were significantly correlated with increased cardiac index. Serum creatinine was significantly decreased, and the creatinine clearance rate was significantly increased in patients in the Haes group compared with those in the lactated Ringer’s group. We conclude that Haes-Steril 10% can improve the overall haemodynamic situation of burn patients and that serum creatinine can be used as a predictive factor for improvement.

IMMUNOLOGY OF BURN INJURY - AN OVERVIEW
(Atiyeh B.S., Al-Amm C.A. - Lebanon)
Major injury due to trauma and burns and injury causing massive haemorrhage have been demonstrated to increase susceptibility to infectious complications and related multiple organ failure primarily because of a suppressed immune system. This is an interesting phenomenon that is still incompletely understood. Why should it be that just when an individual is injured and most needs to be able to resist infection, there is immunosuppression? Various components of the complex immune system have been incriminated, including neutrophil dysfunction, abnormality in opsonic activity, depletion of the complement cascade, helper cell dysfunction, macrophage dysfunction, production of soluble immunosuppressive substances, stress-associated hormones, and an increase in the prostaglandin E2 (PGE2) level. The most recent evidence suggests that the immunosuppression is the result of T-cell dysfunction with failure of interleukin-2 production. This may be only an endpoint of macrophage hyperactivity and activation of a pro-inflammatory cascade including prostaglandins and reactive nitrogen intermediates with the aberrant production of what is called “garbage” non-specific immunoglobulin G1.

A CHINESE SESAME-OIL-BASED OINTMENT FOR BURNS COMPARED WITH BACITRACIN OINTMENT - AN ANIMAL TRIAL
(Kogan L., Lebenthal A., Breiterman S., Eldad A.. - Israel)
Moist exposed burn ointment (MEBO) is a sesame-oil-based ointment for burns produced in China. An animal trial was carried out in a guinea-pig model to compare MEBO treatment with 1% bacitracin ointment in contact burns. Forty female guinea-pigs sustained contact burns inflicted by means of a brass cylinder heated to 60 °C. Some of the wounds were treated with MEBO and some with 1% bacitracin ointment. Follow-up included wound biopsies and planimetry. No differences were demonstrated in the rate of wound healing when wound planimetry was analysed. There was no statistically significant difference in the histological wound-healing patterns.

ROLE OF LEUKOTRIENES IN THE PHYSIOPATHOLOGY OF THE RESPONSE TO EXPERIMENTAL BURN
(Santos X., Castilla C., Martín M., Arroyo C., Navarro L., Deiros L. - Spain)
The present study investigates how inhibition of the leukotrienes modifies the acute physiopathological response of the burned organism in the hypovolaemic shock phase, characterized by significant haemoconcentration. We studied the variations in haemoglobin and haematocrit both in the normal course of the general disease and in that in which the leukotrienes have been inhibited. Wistar rats were used to compare the possible effects of the leukotriene inhibitor ICI-198,615. The rats were divided into two groups (control and anti-leukotriene), treated with saline solution and the drug respectively in the first minutes after receiving a scald burn. The data were obtained by taking three blood samples from each animal (baseline, 15 min, and 60 min) in order to measure the variations in haemoglobin and haematocrit. Statistically significant differences between the two groups were observed in the average haematocrit and haemoglobin increases 15 min post-burn (p <0.05). These results prove the participation of leukotrienes in the extravasation that takes place during the first stages of the general disease in burn patients. We also deduce that the drug has an early maximum activity as its effects are apparent in the first 15 min post-burn, but not at later intervals.

PERMANENT PARAPLEGIA IN AN ELECTRICAL BURN PATIENT FOLLOWING SPINAL ANAESTHESIA (CASE REPORT AND REVIEW)
(Bozkurt M., Deveci M., Sengezer M. Gülhane - Turkey)
Spinal anaesthesia is frequently used in the reconstruction of burned lower extremities and presents well-known complications. Neurological damage following spinal anaesthesia is sometimes irreversible; though rare, it is occasionally seen. We present a case report of permanent motor paraplegia in an electrical burn patient who was operated on for stump revision 6 months post-injury. Neurological examination and EMG suggested a cauda equina/conus lesion due to spinal anaesthesia. The pathophysiology of electrical spinal injury is still unclear. In conclusion, when spinal anaesthesia is performed on high-tension electrical injury patients, hidden and delayed neurological damage must be considered.

CULTURED AUTOLOGOUS FIBROBLAST AND KERATINOCYTE GRAFTS: APPLICATIONS IN PLASTIC SURGERY
(Scalise A., Pierangeli M., Di Benedetto G., Sperti V., Bertani A. - China)
This paper presents the multiple possible uses of a new strategy in wound healing. This novel technique consists of the separate cultivation in vitro of autologous fibroblasts and keratinocytes obtained from a cutaneous biopsy from the patient. The biopsy technique permits the resolution of pathologies frequently encountered in plastic surgery such as burns, ulcers in diabetic patients, ulcers in patients with venous insufficiency, and ulcers due to traumas.