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Volume II |
Number 1 |
March 1989 |
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SUMMARIES
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REGARD RAPIDE SUR LES DEBUTS DE LA REHYDRATATION DES GRANDS BRULES
(Masse C. - France)
Les résultats du traitement des brûlures étendues ont commencé à s'améliorer à partir du moment où la thérapeutique liquidienne de remplacement est devenue une pratique courante. Un regard sur les lenteurs, les hésitations, les réticences qu'il fallut vaincre est une bonne illustration des obstacles rencontrés par la médecine pour progresser. Ainsi, le domaine de la brûlure, qui est déjà un champ privilégié pour l'étude quasi -expérimentale de tant de phénomènes physio-pathologiques, l'est-il aussi pour une meilleure compréhension de l'Histoire de la Médecine.
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STATISTICAL RETROSPECTIVE ANALYSIS OF BURN PATIENTS ADMITTED TO AUBMC BETWEEN 1982-87 (TOWARDS A CHANGING FUTURE IN BURN MANAGEMENT)
(Jiz F, Kaddoura 1, Saba M. - Lebanon)
Between the years 1982 and 1987, 330 cases of bum patients were admitted to the American University of Beirut Medical Center (AUBMC). A statistical analysis of these cases was performed. A retrospective study was carried out to analyse the incidence, bum aetiological factors, mode of treatment, hospital stay and mortality as related to the extent and the depth of the injury. This basic review will be the nidus for a future double blind prospective study over the coming two years using the "modem" early excision of bum. eschars and early grafting which has been implemented at the AUBMC since July 1987, the beginning of a uniform burn protocol management.
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SUICIDE ATTEMPTED BY BURNING
(Haberal M., Oner 1, GOlay K, Bayraktar U., Bilgin N. - Turkey)
Sixteen patients who had attempted suicide by burning were admitted to Hacettepe Univerity Hospital Burn Center over the 9 years' period. Five of these patients were psychiatric and two of them had previously attempted to commit suicide. The mean age was 32 years and th4 overall mortality rate was 50%. This study shows that suicide by self-burning is giving a serious problem with high mortality rate. Therefore, prevention and education are involved in this matter.
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EPIDEMIOLOGY OF ELECTRICAL BURNS IN OUR CENTRE
(Haberal M., Kaynaroglu V., Oner 1, G0lay K, Bayraktar U., Bilgin N. - Turkey)
Of the 811 patients who were admitted to our Bum Centre from January 1, 1980 to January 1, 1988, 137 (16.90%) had electrical bums, not including 7 flash bums, 2 lightning and 1 bum from electrical stove. Of these 137 patients, 94 (68.60%) were over 15 years old with mean age 26.8 years (16 to 48 years). 84 (89.36%) were males and 10 (10.64%) were females. 43 (31.40%) patients were under 15 years old with mean age 11.2 (1 to 15), 39 (90.70%) were males and 4 (9.30%) were females, the majority being 11 to 15 years old. 53 (38.69%) of the patients were injured with house current (220-400 volts) and 84 (61.31%) with high tension (100-134,000 volts). The occupations of the patients over 15 years old could be classified as follows: 40 (42.35%) electricians, 23 (23.5%) blue collar workers, 9 (10.58%) farmers, 7 (7.44%) housewives, 7 (7.44%) teachers and 8 (8.56%) others including 2 students, 2 chafreurs, 1 pharmacist, 1 pensioner, 1 engineer and 1 shoemaker. All of these patients came from throughout the country. Following routine resuscitation and local wound care, including fasciotomy and debridement, the patients were observed closely.
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A PROPOS DE LA CONDUITE A TENIR CHEZ LES ACCIDENTES ELECTRIOUES PORTEURS DE BRULURES GRAVES
(Cabanes J. - France)
La pratique, de part des Médecins d'Electricité-Gaz de France, de recommander aux secouristes de donner à boire aux accidentés électriques porteurs de brûlures graves une solution salée et alcaline isotonique a été supprimée parce que cette technique était insuffisante pour assurer une réhydratation et une alcalinisation correctes. En outre elle n'était pas sans danger car elle pouvait entraîner des troubles de la déglutition et comportait un risque si une anesthésie devenait nécessaire. Aujourd'hui le transport des accidentés est plus rapide, comme par exemple par l'hélicoptère, et cette technique n'est guère nécessaire, sauf peut-être pour les accidents dans des sites difficiles d'accès.
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ESSAI D'UN PROTOCOLE STANDARD DE TRAITEMENT DES ENFANTS BRULES A ALGER
(Bouayad Agha R. - Algérie)
En 1987, tous les enfants brûlés à Alger ou ses environs ont été reçus dans le même service. Le traitement standard rapporté a concerné en moyenne 40 enfants par jour dont un cinquième étaient brûlés depuis 1 à 24 heures. 14.843 pansements et soins ont été fournis à titre externe en un an et 238 enfants ont été hospitalisés.
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PROTOCOL FOR THE TREATMENT OF BURN PATIENTS ADMITTED INTO THE BARI BURN 'CENTRE
(Brienza E., Di Lonardo A., Calvario A., Parisi D. - Italy)
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.
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EMERGENCY AND LOCAL THERAPY
(Dayoub A., Barakat 0. - Syria)
After burn injury, all patients are in pain, the degree of which varies, and they are irritable and restless. So measures for the relief of pain should be taken. The wound surface should be covered with sheets or clean clothes. When transportation of the patient is deemed necessary, it should be carried out as quickly as possible under the prerequisite of safety. During transportation, the patient should be laid crosswise if possible, or in a position with the feet toward the direction of travel.
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PARKLAND FORMULA AS A GUIDE FOR RESUSCITATION
(loannovich 1, Alexakis D., Parker 1, Mantas N. - Greece)
During a two-year period (1987-1988) 180 patients with bum injury were admitted to our clinic for acute care, 64 of them (35.5%) considered to be major injuries (over 25% T13SA), requiring fluid resuscitation. In this series all admissions were included, regardless of age, concomitant injuries or pre-existing diseases. Initial resuscitation was accomplished using the Parkland formula as a guide for resuscitation. This formula employs Ringer's lactate alone for the first 24 hour period giving a total amount of 4 ml/kg/% burn area. For the second 24 hour period it employs plasma at the amount of 0.5 ml/kg/% bum area and 5% glucose in an amount enough to maintain adequate. urine output. After the initial resuscitation, fluids were limited to the maintenance solutions. The efficacy of initial therapy was estimated by the determination of.. a) the accuracy of the resuscitation guides; b) the response of various organ systems (cardiovascular system, urinary system, pulmonary system, the balance of fluids and electrolytes; c) early mortality; and d) the complications encountered during the entire first, week post-burn period. According to our results the Parkland resuscitation formula provides a satisfactory urinary output, diminishes the development and accelerates the regression of the oedema. Thus it minimizes the possibility of renal failure and brain oedema. It contributes also to good electrolyte balance and is less expensive than the other formulae. On the other hand it necessitates large amount of fluids, which need a well organized team work with the nursing staff and a close monitoring of the clinical and laboratory paremeters for the control of the massive fluid infusion.
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A SUGGESTED MEDITERRANEAN STANDARD BURN THERAPY MANUAL
(Kaddoura 11. - Lebanon)
In order to standardize the basic treatment of the burn patient, it is mandatory to eliminate unnecessary variables such as techniques of fluid resuscitation, colloid administration, topical antibiotic therapy, hydrotherapy, antacid administration, hyperalimentation, etc.. For that reason a burn manual was designed at AUBMC. It is taken for granted that it might not be the ideal protocol and therefore it will be reevaluated every two years so that new scientific data may be integrated into it. The manual was intended to be simple and workable. Thus it starts with the means of referral to the bum,unit, the physical examination, the initial fluid resuscitation (Parkland Formula) and diagnosis of inhalation injury. The extent of burn diagram is filled, and wounds are cleaned in the hydrotherapy and dressed. No colloids are given until 8 hours post burn when capillary integrity is restored. Diuretics are avoided whenever possible and prophylactic antibiotics are not given until cultures show pathogenic organisms with high counts. In burns above 30% B.S.A. our patients receive cryoprecipitate 4 units per day to replace reduced levels of factors 1, V and VIII and fibronectin. They are also given heparin and persantin to moderate platelet consumption problems. The use of NG feeding or hyperalimentation and antacids is discussed. The indications for early excision are reviewed together with the use of biologic dressings. The manual concludes by reviewing the responsibilities of the bum team, the indications for consultation, guidelines for medical orders and Lund and Browder charts that are filled upon admission and refilled on a weekly basis to document the patient's burn wounds status.
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FLUID RESUSCITATION IN THE EMERGENCY PHASE AT THE TURIN BURNS CENTRE
(Magliacani G., Bormioli M., Stella M., Ferrero R., Merlino G. - Italy)
All fluid resuscitation techniques in use today give satisfactory results for survival, but the experience of the Turin Bums Centre, confirmed by other clinical and experimental research, shows how the various solutions employed in resuscitation treatment in the emergency phase can have different effects. Although the sodium intake in the various methods is more or less constant (0.4-0.6 mEq/kg/burn percentage), it is important to consider the physiopathological significance of the resuscitation achieved by the various techniques in order to make the best use of the particular characteristics of each single technique. There is no justification for the application of a standard formula, even if this is adjusted during therapy. It is preferable to base therapy closely on the individual clinical case and in particular to modify it by varying as necessary the sodium content in the solution rather than the velocity and the quantity of the fixed sodium content infusion. In order to facilitate the choice of the most suitable fluid regimen for each individual patient and to eliminate the limits imposed by the single formula method, a series of pathological conditions are indicated that can best be treated with different approaches, as shown by a comparison of various parameters, e.g. diuresis, oedema, cardiac output, extrarenal water loss and proteinaemia.
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PREVENTION AND TREATMENT OF ACUTE RESPIRATORY INSUFFICIENCY IN THE BURN PATIENT
(Manni C, Arcangeli A. - Italy)
In cases of severe burning the pulmonary damage causing respiratory insufficiency may result from a double mechanism: direct toxic activity on bronchial and alveolar epithelium from the gases and fumes caused by combustion or by explosion; or indirect metabolic derangement induced by multiparenchymal failure resulting from the severe effect of heat on the tissues. In both cases the clinical picture is almost identical and coincides with the pattern of ARDS.
Dyspnoea, cyanosis, restlessness and severe hypoxaemia resistant to 02 treatment are the typical symptoms. Chest XR shows interstitial or interstitial-alveo tar diffuse oedema. Prevention is difficult and consists mainly of 02 administration, humidification of respiratory gases and prompt correction of the metabolic derangements.
As soon as clinical manifestation of respiratory failure becomes evident the patient must be immediately transfered to the I.C.U. where respiratory assistance is promptly adopted: PEEP and in less severe cases CPAP. If the hypoxaemia is associated with a significant reduction of current volume, endotracheal intubation and mechanical ventilation are needed.
In addition to the specific ventilatory assistance, all the measures to prevent the negative evolution of the metabolic derangements are fundamental. Particular attention must be paid to caloric and hydroelectrolyte balances and to monitoring of the kidney and heart functions.
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