Volume XVI

Number 4

December 2003

FLUID RESUSCITATION OF BURN PATIENTS IN BANGLADESH - “DHAKA FLUID THERAPY”, AN ALTERNATIVE APPROACH
(Bari Md. Shahidul, Choudhury Md. Iqbal Mahmud, Shimul Farahid Zeba, Khan Aleem-Al-Razee - Bangladesh)
Whether a colloid solution or an exclusively crystalloid solution or a mixture of crystalloid and colloid solutions should be preferred for the treatment of burn shock has been a topic of discussion for many years. Consequently there are many different formulas. Among them, the Parkland formula is widely used. Our formula is based on crystalloid solutions and is administered as 3-4 ml ¥ kg ¥ percentage of total body surface area (TBSA) burn = ml of Hartmann’s solution in the first 24 h post-burn. Half of the estimated volume is given in the first 8 h and a quarter of the volume in the second 8 h; the remaining quarter is given in the third 8 h. In the second 24 h post-burn, a slightly hypertonic fluid is infused (5% dextrose saline) in adults and half-strength dextrose saline in infants and children. The volume of infusion is adjusted to obtain a urine output of 0.5-1.5 ml/kg/h. Patients below 12 yr with more than 10% TBSA burn and over 12 yr with more than 15% TBSA burn were included in the study, while patients with inhalation injury and superficial burns, and those admitted to hospital 12 h after the burn accident were excluded. The patients were divided into five groups on the basis of extent of the burn area, and the results were analysed in relation to fluid intake and urine output, haemoglobin and haematocrit level in the first three days, the dynamics of the plasma Na+ and K+ level in the first five days, and the outcome of treatment on the basis of extent of the burn surface, the age of the patient, and the time lag between the burn accident and initiation of resuscitation. The cost of the fluid infused for resuscitation was also calculated. To compare our treatment and to differentiate it from others, as also for further evaluation, we named this formula “Dhaka fluid therapy” for burn management.

PAN-ANTIBIOTIC RESISTANCE AND NOSOCOMIAL INFECTION IN BURN PATIENTS: THERAPEUTIC CHOICES AND MEDICO-LEGAL PROBLEMS IN ITALY
(Bollero D., Cortellini M., Stella M., Carnino R., Magliacani G., Iorio M. - Italy)
Many successes have been achieved in the care and treatment of burn patients in recent years, with a significant improvement in outcome. Sepsis and related problems are the major cause of death in these patients and represent an outstanding problem, also in view of the emergence of polyantibiotic-resistant germs. With regard to gram-positive organisms, the identification of methicillin-resistant Enterococci and Staphylococci does not constitute an insoluble problem, given the sustained sensitivity to glycopeptides (vancomycin, teicoplanin). More problems occur with gram-negative germs: in recent years the isolation in burn units of polyresistant Pseudomonas aeruginosa, Stenotropomonas maltophilia, and Acinetobacter baumannii has become more frequent. In some cases, an in vitro resistance to all antibiotics tested has been observed. In these cases, the difficulty of deciding on appropriate therapy has led us to consult an infectivologist. In this article, together with our approach to these pan-resistant infections, we wish to consider the medico-legal aspect of the problem, underlining the fact that all clinics involved in burn treatment frequently have to take important decisions regarding strategies against polyantibiotic-resistant germs. These strategies have not yet been standardized either by infectivologists or by medico-legal physicians.

METHICILLIN-RESISTANT STAPHYLOCOCCUS EPIDERMIDIS INFECTION INSENSITIVE TO TEICOPLANIN.A CASE REPORT AND A REVIEW OF THE LITERATURE
(Keramidas E., Rodopoulou S., Iconomou T., Tsati E., Ioannovich J. - Greece)
High-voltage electrical injuries are unique with respect to long-term morbidity and overall outcome. Depth of injury and potential complications are related to the intensity of the current that passes through the patient. Necrotic tissue located on the skin or in the muscles, nerves, and vessels offers a favourable environment for the development of serious infections caused by various bacteria. A patient who developed septic shock from a methicillin-resistant Staphylococcus epidermidis (MRSE) resistant to teicoplanin, following a serious high-voltage electrical injury, is presented. Coagulase-negative staphylococci are now increasingly recognized as nosocomial pathogens. MRSE is broadly recognized to be sensitive to glycopeptide treatment. MRSE resistant to teicoplanin and vancomycin has already been reported in the literature in a few patients but not after a burn injury.

MULTIDRUG-RESISTANT STAPHYLOCOCCUS AUREUS ISOLATED FROM INFECTED BURNS SENSITIVE TO HONEY
(Subrahmanyam M., Hemmady A.R., Pawar S.G. - India)
Twenty-eight strains of coagulase-positive Staphylococcus aureus isolated from infected burn wounds were found to be resistant to routinely used higher antibiotics in our hospital. Using an agar incorporation technique, the sensitivity of these strains to honey was tested by the method of minimum inhibitory concentration. All the tested strains of Staphylococcus aureus showed inhibition with honey at concentrations of 25%. The present study shows that in burn wounds infected by multidrug-resistant Staphylococcus aureus, honey may be useful for controlling infection.

EXPANSION CUTANEE DANS LES SEQUELLES DE BRULURE
(Ezzoubi M., Ettalbi S., Fassi Fihri J., El Mounjid S., Benbrahim A., Bahechar N., Boukind E.H. - Maroc)
L’expansion cutanée représente un progrès considérable dans le traitement des séquelles de brûlures. Ce travail est une étude rétrospective portant sur une série de 90 cas traités de janvier 1999 à décembre 2002 au Service des Brûlés et de Chirurgie Plastique du CHU Ibn Roch de Casablanca, destinée à étudier les résultats de cette technique en fonction du siège des séquelles et du nombre de prothèses implantées. L’âge moyen des patients a été de 22 ans, avec un sex ratio de 1,4. Le siège prédominant des séquelles est l’extrémité céphalique avec 75,5% des cas. Sur 136 prothèses mises en place, 36 ont du être retirées précocement, et ce le plus souvent à cause de l’exposition du ballon (14% des cas étudiés). Le résultat final a été jugé excellent dans 50% des cas, avec les meilleurs résultats au niveau du scalp.

ORGANIZATION AND PURPOSES OF A BURNS CENTRE SKIN BANK
(Melandri D. - Italy)
This paper considers the organization and purposes of a skin bank in a burns centre. The advantages and disadvantages of homologous skin for grafting are considered, and the history of skin transplants for burn repair is reviewed. The organizational aspects are also considered. Methods of finding, removing, and storing skin are described, together with the use of cryoconservation. The risk of the transmission of disease by infection is a constant presence, but can be overcome by careful screening. The Cuono technique has proved to be a very useful grafting technique. Skin banks play an important role, especially when autografts are not available.

BURN INJURIES ASSOCIATED WITH THE WATER TANK OF MOTOR FARMING TRICYCLES IN CHINA
(Xin-long Chen, Yan Ping Li, Dan-Ping Zhang, Pin Zhang, Wei Zhang - People’s Republic of China)
Burns caused by the water tank of motor farming tricycles have not hitherto been reported. We performed a retrospective study of such burns in 126 patients with complete records in rural areas of China. The majority of the patients were unmarried (59.5%), young (55.6% between 20 and 40 yr), and male (male-to-female ratio, 9:1). The burn accidents occurred mostly (66.7%) during busy spring and summer seasons. The major category of injury mechanism was identified as that of motor-tricycle-related burns caused by hot water (70-100 °C) from the water tank in traffic accidents. Overloading may have been one of the most important causes of the accidents. The burn wounds were located mostly (64.3%) in the buttocks and lower extremities (especially the thigh), and usually took 3-4 weeks for complete healing. Most of the patients presented a moderate burn area (20-50% TBSA) and deep partial-thickness or full-thickness burns. For the purpose of prevention of these injuries and improvement of patient prognosis, a number of recommendations are made

CONTAMINATED KEROSENE BURNS DISASTERS IN LAGOS, NIGERIA
(Oduwole E.O., Odusanya O.O. Sani A.O., Fadeyibi A. - Nigeria)
A longitudinal study was conducted of patients who sustained thermal burns resulting from the use of contaminated kerosene and were seen at an emergency medical centre in Nigeria over a seven-week period between October and November 2001. Burns of at least 10% in children and 15% or more of the body surface area in adults were classified as major. Most patients were managed with open dressings, systemic antibiotics, intravenous fluids, or oral fluids depending on the severity of the burns. One hundred and thirty-nine patients were seen; 83 (59.7%) were females and 56 (40.3%) were males. Ninety-three (67.6%) were older than 15 years of age and 46 (33.0%) were children. The mean age was 23.4 ± 14.1 yr. Most of the burns (96.4%) resulted from the use of hurricane lamps. The mean burn surface was 24.1 ± 21.3%. The upper limb was the most frequently affected region of the body. Eighty-six (61.9%) of the patients had major burns, of whom 18 died, giving a case fatality rate of 12.9%. All the dead patients had major burns (p = 0.0009) and burned body surface area greater than 15% (p = 0.00001). Contaminated kerosene is associated with high mortality, and more care is needed in its storage, distribution, and use.  

TREATMENT OF SEVERE BURNS ON BOARD SHIP IN SEA DISASTERS
(Becker D. - Germany)
Nowadays international trade is expanding enormously, and this will involve more and more seagoing trade. In this age of globalization, numerous large ships sail in every possible condition, under various flags, and with hired crews. The crewmembers often come from the developing countries and may be untrained and ignorant of the rules of seafaring life. In the event of disasters at sea such sailors may be lost or severely injured. It is necessary to inaugurate new basic principles for saving lives in sea disasters, when conditions are very different from those on shore. Severely burned patients are in immediate danger for their lives and final outcome. The treatment of burns depends on appropriate first aid, which improves the outcome. But in sea disasters first-aid measures may be insufficient as crew members have to be winched off the wreck whether they are injured or not. New principles are outlined, as also the necessity of a centralized installation by the World Health Organization. Knowledge of these special measures for the particular conditions operative in sea disasters must be transmitted to all seafarers, researchers, and captains of ship. In this way the patients - often young men - can look forward to better fortune.

CASE REPORT: EARLY ARISING MARJOLIN’S ULCER IN THE SCALP
(Çelik E., ErogŠlu S., KaracaogŠlan N., Uzunismail A. - Turkey)
Chronic wounds and scar tissues are prone to an increased risk of skin cancer. In 1828 Jean-Nicholas Marjolin described the occurrence of tumours in post-traumatic scar tissue. The commonest type of carcinoma arising from Marjolin’s ulcer is squamous cell carcinoma. The latent period between the injury and the appearance of cancer is 25-40 years. Early arising Marjolin’s ulcer has rarely been described in the literature. In this case report, we present such a case of an early appearance of Marjolin’s ulcer.

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