PROTOCOL FOR THE TREATMENT OF BURN PATIENTS ADMITTED INTO THE BARI BURN 'CENTRE

Brienza E., Di Lonardo A., Calvario A., Parisi D.

Polychair institute for Emergency Surgery and Plastic Surgery, Bari, Italia

SUMMARY. The definition of a therapeutic protocol for treatment of the bum patient depends on the patient's general clinical conditions and varies according to the gravity of the lesions. f, This assumption means that upon admission patients must be observed and allocated to risk classes defined on the basis of a predetermined prognostic index.
Such a procedure has been adopted at the Burns Unit attached to the Chair of Plastic Surgery in Bari University, enabling us to define a more or less codified therapeutic approach in the intensive and progressive phase of the patient's treatment. There is thus a different approach to patients belonging to the different risk classes, as distinguished after the first observation.
On the basis of our ten-year experience, and of statements in the literature, and notwithstanding the unpredictable clinical modifications that are peculiar to the bum illness, the definition of this protocol offers us preventive and therapeutic solutions with an improvement in prognostic assessment and in the quality of recovery.

The considerable difficulties concerning burn patient treatment have induced the experts to make several attempts to define an "ideal" therapeutic protocol.
Such a scheme, besides unifying the different positions that have been adopted in the various Burn Centres, could represent a substantial reference point even for non-experts or for those who are interested in such a pathology for the first time.
In these two last cases however it is necessary to underline that besides any therapeutic protocol the availability of appropriate structures and of qualified medical and paramedical stafT is important.
The therapeutic protocol that is currently adopted in the Burn Centre in Bari represents the result of a rigorous critical analysis of the activity carried out for over ten years, and of the comparison between the results achieved and those of the latest experiences referred to in the international literature.
The basic element our therapeutic scheme is founded upon is the subdivision, at the first observation, of the burn patients in 4 risk classes of growing gravity, determined in accordance with a pre-established prognostic index (Tab. 1).
Such a classification makes it possible, on one hand, to programme a therapeutic approach, differentiated for the separate classes, and on the other hand, by identifying groups of patients with the same kind of lesions, it permits a statistically precise and reliable derivation of the results.

Ist Observation: in the first place the patient's "risk class" is determined. The gravity of the lesion is defined in accordance with a pre-established prognostic index (Tab. 1) which considers two kinds of factors: a) Factors relative to the patient: - Age - Physical constitution - Associated disease (physical or psychological) - Immunological system in order b) Factors relative to the lesions:

• % of total extent
• % of deep burns
• Sites of lesions
• Interval between burn and hospitalization
• Associated lesions (burn of respiratory tract, trauma, etc.).

A score is ascribed to each factor (Tab. 1) and the mathematical combination of each score gives the possibility of defining the "risk class":
Class 1 50-100 ambulatory burns
Class II 100-150 partial-full thickness burns
Class III 150-200 partial-full thickness burns
Class IV 200 full thickness burns

The therapeutic scheme changes in accordance with the gravity of the lesion. We can distinguish three categories of burn patients:

1. ambulatory patients (Class 1)
2. medium-grave (Class 11-111) (hospitalized)
3. grave (Class IV) (hospitalized).

The patients belonging to one class, in accordance with subsequent observations, can be allocated to different classes because of the appearance or resolution of complications.

Patients do not present systemic problems so we essentially pay attention to the topical treatment of the small cutaneous lesions.

1. Cutaneous injury evaluation
   Aetiology of the lesions: physical agents chemical agents electrical agents Semeiotics of the lesions (evaluation of the thickness) Signs of bacterical contamination (presumed or in course). We proceed, as is usual in the case of presumed infection, to a cultural test by a cutaneous tampon.
2. Topical ambulatory treatment of the wounds
   Cleansing: antiseptic and detergent brands (chlorhexidine) physiological solution. Dressing: fastened dressing with differentiated therapies according to the kind of wound.

1. Superficial and partial thickness uninfected burns sterile dressing - topical Mercurochrome - vaseline gauze - sterile gauzes and isolation by sterile cotton-wool - bandages
2. Superficial and partial thickness burns (with presumed pollution) or deep with small eschar burns medication by enzymatic and antibacterial ointment.

The sterile dressing is changed every other day, and the medication twice a day. Small areas of necrotic tissue are removed surgically.
The phlyctenae are cleared of their content 3/4 days after the burns only if they remain undamaged and without any sign of infection.
The hyperbaric chamber is very useful for the therapy of the partial thickness and deep burns concerning inferior and superior boxes; the treatment is affected twice a day for an hour each session.
When healing has occurred, great attention is paid to the evolution of the cicatricial results.
In the case of partial thickness, deep and small extension lesions that heal spontaneously, an elastic anatomical sheath for the mechanical compression of the scars is prescribed.

The patient is in a shock hypovolaemic state, observed a few hours after the trauma.
The treatment is characterized by a systemic and topical approach.

Re-equilibrium of the electrolytic and proteic decompensation: realized under the direction of an instrumental and laboratory monitor in the first 48-72 h (C.V.P., E.C.G., chest XR, haematochemical text every 6 h: monitor of the diuresis with computerized balance of the water loss).
Therapy: isotonic hypertonic electrolytic solutions are alternated with lactate and acetate Ringer's solutions in a defined amount in accordance with the extent (modifiable 9 Rule) of the hypovolaemic state and electrolytic imbalance.
Systemic anti-stress ulcer prophylaxis: anti H, specified antagonist.
Anti-thrombotic prophylaxis: heparin, AT 111 upon dosage.
Nutritional therapy: N.T.P. precocious after 72 h, enteroparental nutrition - enteral nutrition, which is made in the next stage. The nutritional therapy is effected under the direction of a monitor of the nitrogen balance of the patient's metabolic equilibrium.
Immunostimulant therapy: cycles of treatments with immunoglobulins or of thymic hormone extract and plasmatic cryoprecipitate according to therapeutic periodical, defined in accordance with precise haernatochemical immunologic pictures.
Short-term antibiotic: the choice of the antibiotic depends on the microbiological analysis of the wounds.

Daily bath of the patient.
Cleansing of the wounds by disinfectant soap (based on chlorhexidine) solutions and subsequent cleansing by physiologic solution. Dressing: fastened dressing is prevalently practised.
The most commonly used topical disinfectants are:

• Silver sulphadiazine ointment
• lodatepolyvinyl pyrrolidone
• Liquid silver nitrate at 0.5%
• Mercurochrome
• Silver salt
• Enzymatic ointments.

The choice of every topic disinfectant is relative to the characteristic of the lesions (eschar, fibrin, etc.) and to microbiological efficacy (topicgram).

Surgery is performed early, within the tenth day from the thermic trauma, for quite deep lesions. It is preferable, to operate first on areas with retracting cicatrices in evolution with a potential functional deficit (face, neck, hands).
There are two stages:

1. surgical escharectomy of the wound
2. covering of bloody areas with dermo-hypodermic autogenous grafts, upon haemostatic from human fibrin sealant acting as biological sealant.

The first dressing, subsequent to the surgical operation, is applied after the third day. Motor rehabilitation can begin on the sixth-seventh day. When healing has occurred, "elastic" creams and elastic anatomical sheaths, to limit the cicatricial evolution of the lesions, are prescribed before dismissal of the patient.

Critical patients, owing to the extent of their lesions and/or to their grave systemic condition, belong to this class.
Topical and systemic treatment does not differ from that already described for classes II and III.
What distinguishes these patients' treatment is the surgical approach deriving from the cutdown of areas for the autologous epidermic cultures. After choosing the patient to undergo the treatment, a rhombus-shaped full-thickness cutaneous biopsy is effected, about 10 cml. From this the cultures are grown.
Surgical operations are effected every seven days until the 28th day after the biopsy, when it is possible to implant the cultures. As said above, the graft area cutdown is very important, because these cultures are very feeble. At the moment of reconstruction these areas have to be without any kind of pollution, with a homogeneous surface, vascularized and unbloody (careful haemostasia is necessary). To attain these aims, we perform an escharectomy as far as the muscular fascia (superior and inferior boxes), use high-porosity, cutaneous, biological substitutes, reduce the hydroprotein losses and prevent bacterial pollution.
On the area of the culture graft a human fibrin sealant is applied by means of an atomizer, in order to facilitate the take. It is important to add, with regard to the prevention of infection, that we perform a microbiological depistage of the patients, of the staff and of the hospital environment, as it is useful for the qualitative and quantitative identification of the existing bacterial strains, in order to define appropriate therapies and/or vaccine-prophylaxis.

RÉSUMÉ. La définition d'un protocole thérapeutique pour le traitement du brûlé dépend des conditions cliniques générales du patient et elle se modifie selon la gravité des lésions. Il suit de là que les patients, au moment de l'hospitalisation, doivent être observés et assignés à des classes de risque définies sur la base d'un indice prognostique prédéterminé. Cette procédure a été adoptée au Centre des Brûlés attaché à la Chaire de Chirurgie Plastique de lUniversité de Bari, et elle nous a permis de définir une approche plus ou moins codifiée dans la phase intensive et progressive du traitement du patient. Il y a donc une approche différente selon les différentes classes de risque des patients, définies dès la première observation. Sur la base de notre expérience pendant 10 ans, et des résultats dans la littérature, et malgré les modifications cliniques imprévisibles qui sont typiques des brûlures, la définition de ce protocole nous offre des solutions préventives et thérapeutiques, ainsi qu'une amélioration de l'évaluation prognostique et da la qualité de la guérison.

BIBLIOGRAPHY

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