Volume XVIII

Number 2

June 2005

OUR EXPERIENCE IN THE TREATMENT OF BURN SHOCK BY HYPERTONIC LACTATED SALINE SOLUTION
(Belba M. - Albania)
Hypertonic salt solutions have for many years been known to be effective in the treatment of burn shock. Rapid infusion of a high concentration of sodium (250 mEq/l) produces positive effects by reducing fluid shifts, decreasing tissue oedema, and causing fewer attendant complications. This study presents data on 20 patients with severe burns who were resuscitated with hypertonic lactated saline (HLS) solution. The resuscitation regime used was that proposed in the USA and subsequently also in Europe. The fluid formula is based only on calculating fluid requirements for the first hour of therapy. Further adjustments of fluid requirements are based mainly on urine output. During the first hour of fluid therapy the amount of HLS given (ml) is 0.5 x percentage TBSA x kg body weight. This regime is recommended for resuscitation both of children, taking into consideration that urine output should be 1 ml/kg body weight/h, and of adults and the elderly, in whom an amount of 35 ml of urine per h is considered optimal and reflects sufficient vital organ perfusion. In order to control the administration of fluid volumes, we calculated fluid and sodium balances. Fluid load was 2.3 ml/kg/%; sodium load, 0.6 mEq/kg/%; net fluid accumulation, 20-30 ml/kg; and sodium retention, 56 %, associated with high natriuresis. We observed a high volume load in the first hour and in the first four hours of therapy, which regressed after lower fluid loads. During resuscitation the clinical and laboratory criteria were maintained within acceptable limits. Our clinical experience indicates that during burn shock resuscitation with HLS solution, the amount of fluid can be reduced, compared to conventional formula. Early administration of high sodium and fluid loads in the first four hours may decrease the total fluid load in the first 24 hours post-burn. A hypertonic regime requires careful observation and calculations. Resuscitation with HLS solution is a valuable regime in the treatment of severe burn patients that is also applicable in other similar clinical conditions.

BURN WOUND INFECTIONS AND ANTIMICROBIAL RESISTANCE IN TEHRAN, IRAN: AN INCREASING PROBLEM
(Rastegar Lari A.R., Alaghehbandan R., Akhlaghi L. - Iran)
Pseudomonas aeruginosa and Staphylococcus aureus remain the most important pathogens and are frequently the cause of burn wound infections in our centre. This is a particular problem in high-risk and long-stay patients and can lead to epidemics of infection in hospital settings. This study analysed P. aeruginosa and S. aureus infections in Tohid Burn Centre, Iran, in order to estimate their frequency and antibiotic susceptibilities. Out of 6704 strains examined, 4904 and 688 were found respectively to be P. aeruginosa and S. aureus in the period March 1995-September 1999, in burn patients hospitalized in this burn centre. Antimicrobial susceptibility was determined by the disk diffusion method outlined by the National Committee for Clinical Laboratory Standards. The overall frequencies of P. aeruginosa and S. aureus were respectively 73.1% and 10.3%; the remaining 16.6% consisted of other organisms. The frequency of P. aeruginosa resistance to ciprofloxacin, amikacin, and gentamicin was over 85%. The rate of S. aureus resistance to cloxacillin and cephalexin was 90%. P. aeruginosa and S. aureus were thus the commonest organisms in this centre. High frequency rates of resistance to these micro-organisms were found in this study. It is necessary to limit the use of antimicrobial agents in our epidemiological setting.

EFFECT OF EARLY NUTRITIONAL SUPPORT ON CLINICAL COURSE AND SEPTIC COMPLICATIONS IN PATIENTS WITH SEVERE BURNS
(Tancheva D., Hadjiiski O. - Bulgaria)
Retrospective and prospective analyses of methods for nutritional support were carried out to assess their efficiency in covering the calculated caloric and protein needs of patients with severe burns. The energy and protein needs of the patients in Group 1 (study group) with nutritional support started 24 h after the thermal trauma were determined by the Toronto formula or by means of indirect calorimetry. Nutritional support of patients in Group 2 (control group) were initiated on day 4 post-trauma. The patients in the two groups were similar in respect to age, gender, body surface area burned, and injury severity score. We found statistically significant differences in the metabolic response of both groups as measured by nitrogen balance, serum proteins, and absolute lymphocyte count. Significant differences were also registered in body weight loss, number of positive haemocultures, and the complications rate.

THE VALUE AND PROGNOSTIC ROLWE OF THE CT SCAN VERSUS CHEST RADIOGRAPHY IN THE FOLLOW-UP OF INTUBATED BURN PATIENTS WITH POSSIBLE INHALATION INJURY
(Spyropoulou G.A., Iconomou T., Tsagarakis M., Tsoutsos D. - Greece)
The admission and follow-up chest radiographs as well as the follow-up CT scans of 13 burn patients admitted to our clinic requiring ventilatory support were analysed for signs of inhalation injury and pulmonary complications. The findings were compared with the results of the clinical examination, the blood gas tests, and bronchoscopy. Eleven out of the 13 patients underwent bronchoscopy revealing inhalation injury. The CT scan detected pleural effusion in two patients with a normal chest radiograph. In two patients the CT scan detected asymmetrical expansion between the right lung and the left. In one patient soft tissue oedema made evaluation of the chest radiograph impossible, while the CT revealed bilateral pleural effusions and consolidations or atelectasis in both the lower lobes. In one patient the CT scan detected oedema of consolidatory pattern in every lobe (superior-middle-inferior), while the image in the chest radiograph was not similar. CT identified an area of consolidation in one patient in the right middle lobe with a normal chest radiograph. The results of the CT scan correlated with the clinical course and blood gas determinations, while similar findings in the chest radiograph were observed at a later stage. In conclusion, compared to chest radiographs, the CT scan often yielded additional information in the follow-up of intubated burn patients with inhalation injury. It can be performed in order to confirm and/or more precisely define the full extent of lung injury and is also feasible in patients who are critically ill and hard to move.

ULTRASTRUCTURAL DIFFERENTIATION OF ABNORMAL SCARS
(Meenakshi J., Jayaraman V., Ramakrishnan K.M., Babu M. - India)
Aim: To evaluate the differences between keloid and hypertrophic scars by biochemical and ultrastructural techniques. Method: Over 1000 patients with different types of scars were studied and followed up for a period of 20 years. The histochemical and biochemical analysis with respect to the composition of the extracellular matrix of the dermis was conducted. At the ultrastructural level, collagen deposition and assembly were studied using electron microscopy. The rate of proliferation and metabolic activity of the dermal fibroblasts isolated from the normal skin and scar biopsies were studied to assess the cause of excess matrix deposition in scar tissues. Results: Evaluation of different types of scars showed that both keloid and hypertrophic scars have excess matrix deposition in terms of collagen and proteoglycans. Keloid shows a high amount of acid-soluble collagen. The assembly of collagen fibrils is also abnormal in keloids. Studies on the proliferation and metabolic activity showed that keloid fibroblasts have a higher rate of proliferation and metabolic activity than fibroblasts from hypertrophic scars and normal skin. Finally, keloid fibroblasts show high and intense staining for the endoplasmic reticulum, suggesting a possible reason for high activity of these fibroblasts. Conclusion: Keloids and hypertrophic scars show distinct ultrastructural patterns of both collagen deposition and assembly. These parameters could be refined by further research, and they would thus serve as a useful tool for surgeons to distinguish different types of scars and adopt suitable therapeutic strategies.

THE ROLE OF THE NURSE IN THE REHABILITATION OF PATIENTS WITH RADICAL CHANGES IN BODY IMAGE DUE TO BURN INJURIES
(Aacovou I. - Cyprus)
Burn injuries are among the most serious causes of radical changes in body image. The subject of body image and self-image is essential in rehabilitation, and the nurse must be aware of the issues related to these concepts and take them seriously into account in drafting out the nursing programme. This paper defines certain key words related to body image and discusses the social context of body image. Burn injuries are considered in relation to the way each of these affects the patient’s body image. The aim of nursing is defined and the nurse’s role in cases of severe changes in body image due to burn injuries is discussed.

APPLICATION OF A FOUR-DIMENSIONAL MATHEMATICAL MODEL IN THE ESTABLISHMENT OF AN EARLY POST-BURN CEREBRAL OEDEMA MODEL IN SEVERELY BURNED DOGS
(Haitao L., Dajun Y., Kaifa W., Xiuwu B., Jiansen S., Zongchen Y. - People’s Republic of China)
The aim of this study was to explore the spatiotemporal development of cerebral oedema in the early stage of severe burn (50% TBSA, third degree), using a four-dimensional (4D) mathematical model. Twenty-six male mongrel dogs were randomly divided into control and 6, 12, 18, and 24 post-burn hour (PBH) groups. The manifestation of magnetic resonance imaging (MRI) and histopathology, changes of brain water content, and intracranial pressure were observed in each group respectively. A 4D mathematical model was established on the basis of the results of MRI scanning. Two turning points (6 and 18 PBH) and three phases of pathological change were displayed by the 4D mathematical model of cerebral oedema in the early stage of severe burn. The first phase was in the subclinical period, and effective treatment should therefore be performed as quickly as possible in order to prevent deterioration of post-burn cerebral oedema. The second phase (6-18 PBH), with pathological characteristics of cytotoxic cerebral oedema, was in the apoptosis period. The third stage (18-24 PBH) was the danger period of cerebral oedema. Intracranial pressure increased rapidly owing to the limitation of the cranial cavity. As a result, cerebral hernia could easily occur. An S-shape curve in the pathological process of cerebral oedema occurred in the early post-burn stage following severe burn.

BURNS AND FIRE DISASTERS
(Castana O., Makrodimou M., Michelakis D., Tsandoulas Z., Alexakis D. - Greece)
A fire disaster took place on New Year’s Eve 2003 in a small closed environment as the result of a Molotov cocktail bomb attack. Seven persons suffered burns, two of whom died and five were hospitalized. The aim of this paper is to focus on the consequences of such explosions, which are numerous and cause extensive burns with fewer though more severe injuries when they occur in a closed environment than fire disasters in an open environment.

VARIETE TECHNIQUE DU LAMBEAU SURAL DANS LES BRULURES PROFONDES DU PIED
(Ezzoubi M., Ettalbi S., Elmounjid S., Fassi J., Benchamckha F.Y., Sakhi M., Boukind E. - Maroc)
Les couvertures des pertes de substance de la jambe, du talon et du pied font souvent appel au lambeau sural, qui reste, de part ses dimensions, une indication limitée. Les Auteurs présentent, à travers deux cas cliniques, une variété technique pour la levée du lambeau sural, permettant d’obtenir des palettes cutanées de grande surface avec une bonne sécurité vasculaire. C’est un lambeau fasciocutané remontant jusqu’à un centimètre du creux poplité et incluant, lors de la levée, l’aponévrose, le nerf sural, la petite veine saphène et le nerf sural latéral.

CASE REPORT: SURGICAL TREATMENT OF A BURNS CASE OF 40% TBSA
(Buja Z., Shabani A., Zatriqi V., Terziqi H., Bukoshi Z., Berisha A., Arifi H. - Kosovo)
We describe the case of a two-year-old boy with massive burns. After the period of shock and sepsis, very successful four-phase operative treatment was performed, with combined skin grafting homograft plus autograft. With regard to the four surgical interventions, in the first two we used the above combined method, while in the other two we used grafting only with skin autograft. We also used the donor region of the epicranial scalp.

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