SUMMARY. As is predictable, mortality and morbidity among geriatric patients are higher in patients with major burns. Decreased radiopulmonary reserves and malnutrition characterized by protein/energy deficiency and ageing of skin are predisposing factors which increase mortality and morbidity. In this study, we present a 90-yr-old patient with 46% total body surface area of 2nd-3rd degree burns. We had to overcome difficulties which can be seen in elderly patients and which succeeded in our treatment.
Geriatric patients, usually defined as those older than 65 years of age, comprise approximately 10% of the major burns population.1 Burns in this age group constitute more serious injuries than in the general population and burns larger than 30% total body surface area (TBSA) cause an extremely high mortality. Co-morbid factors are responsible for this increase in morbidity and mortality.2 Elderly people have thinner skin, poorer microcirculation, and increased susceptibility to infection3,4 and the rate of burn shock, inhalation injury, pulmonary pathology, septicaemia and renal failure is higher than in younger people. If we compare the number of elderly burn patients over 80 years old with those between 65 and 80 we can see that both these groups are small, but the survival rate, especially in patients with more than 40% TBSA burns, is very low.
In this article we present a 90-yr-old patient who presented challenging difficulties in therapy and care.
A 90-yr-old male patient was admitted to our burns centre after a water heater blast accident at home. Altogether 46% TBSA was burned by flame (2nd-3rd degree). The regions affected were the face, posterior neck, posterosuperior trunk, right anterosuperior trunk, the right lumbar and dorsal side of both upper extremities and both lower extremities (Figs. 1-3).
<% immagine "Fig. 1","gr0000065.jpg","The patient on admission, front view.",230 %> <% immagine "Fig. 2","gr0000066.jpg","Side view.",230 %> <% immagine "Fig. 3","gr0000067.jpg","Back view.",230 %>After sedation with 2 mg midazolam i.v. and 50 mg ketamine i.v., the burned areas were scrubbed with distilled water and 7.5% povidine iodine in our washroom. The wounds were closed with 0.5% chlorhexidine acetate and petrolatum gauze. After the initial dressing, the patient was taken to the intensive care unit and fully monitored with central venous, arterial, urinary, and nasogastric catheterization. On day 1, fluid resuscitation was administered according to the Parkland formula, i.e. 4 ml/kg/% TBSA. Crystalloid (Ringer’s lactate) was preferred. The speed of the fluid resuscitation was monitored in relation to urine output and central venous pressure. Dressings were changed daily.
Respiratory support was ensured by postural drainage, respiratory, and Tri-flow exercises, plus cold vapour. Fluid replacement was continued in order to maintain urine output at 0.5-1 cc/kg. Periodically, quantitative and exfoliative wound, urine, and haemocultures were taken. Sefoperazon + Sulbactam 1 g twice daily were initiated owing to high fever on day 3 post-burn. Acinetobacter baumanii was isolated in the haemoculture on day 8. Appropriate antibiotherapy with a sensitive antibiotic was performed. Following the onset of gastroenteritis on day 10, the oral nutritional support solutions were suspended and total parenteral nutrition was commenced. Pseudomonas aeruginosa was isolated in the wound culture on day 17 post-burn, and meropenem and amikacin were given for respectively 32 and 7 days. At the same time silver-coated dressings were applied (Acticoat, Smith and Nephew, USA).6,7 Following subdermal epinephrine infiltration, debridement and grafting were performed in 25% TBSA on post-burn day 19. An intensive physical therapy and exercise programme was initiated after post-operative day 7.
We assessed the patient’s hypotensive and oliguric state on day 26, and therapy with an inotropic agent (dopamine, 2 mg/kg/min) was initiated. After ten days’ therapy this state diminished and inotropic therapy was terminated.
Altogether the patient was hospitalized for 40 days, after which he was discharged as cured (Figs. 4-6).
<% immagine "Fig. 4","gr0000068.jpg","The patient on discharge.",230 %> <% immagine "Fig. 5","gr0000069.jpg","The patient on discharge.",230 %> <% immagine "Fig. 6","gr0000070.jpg","The patient on discharge.",230 %>Although burn treatment has improved during the past few years with the advent of better topical treatments, improved resuscitation, and early burn eschar excision, the prognosis still remains poor for older adult patients, and burn injuries rank forth among the causes of injury-related deaths in the geriatric age group. Mortality in young adults with an 80% TBSA burn is 50%; in persons aged 60-70 yr, a 35% TBSA burn has 50% mortality, and in persons over 70 a 20% TBSA burn will have 50% mortality.
Pre-morbid conditions such as chronic obstructive pulmonary disease (COPD) and coronary artery disease may lead to longer hospital stay, increased ventilation requirements, and elevated complication rates. Agarwal et al. demonstrated that the greater fluid requirements in elderly burn patients led to an increase in congestive heart failure, pulmonary oedema, and pneumonia.
The mortality rate also increases owing to an impaired response to infection and sepsis, as also to decreased ability to tolerate prolonged stress and physiological insult.11-16 The deficient nutritional state seen in elderly burned patients may also cause impaired wound healing.
Materials used for the purpose of smoking and stoves are reported as frequent sources of injury in older persons, who are most frequently burned during the course of routine daily tasks. In our case the burn was a flame burn.
Physical and physiological differences such as diminished manual dexterity, vision, and hearing, decreased mobility and judgement, and slower reaction times cause injuries in this age group.18 Because of the diminished reaction time, the severity of burn injuries and the incidence of inhalation injury increase in the geriatric population, and this reduces the size of survivable burn injuries.
Prolonged immobilization and ongoing physiological stress contribute to the significant morbidity related to inhalation injury. Elderly people have decreased pulmonary reserves for gas exchange and lung mechanics and they are prone to pulmonary failure, which is a major cause of death in all burns.
Even when inhalation injury symptoms are totally absent, the early administration of humidified oxygen and nebulization and the use of mycotic agents, position changes, chest physiotherapy, and early ambulation discourage the development of pulmonary problems or attenuate their clinical course in burns caused by flame. In the case we describe, even though there were no signs of inhalation injury, thanks to the early application of respiratory physiotherapy we did not have to treat pulmonary problems.
In elderly people there are several well-recognized risk factors with age, such as chronic illnesses, cardiovascular disease, and decreased pulmonary reserve. The major causes of mortality and morbidity in the elderly following thermal injury are not the burn, but rather alterations due to concomitant disease processes. In this age group, pre-morbid states like COPD and coronary artery disease prolong hospitalization time and increase the need of ventilation support due to the complications.
In elderly people fluid resuscitation is important. These people, like children, are volume-sensitive and may be at risk of hypotensive renal damage. It is advocated that resuscitation fluid should be administered to elderly people with injuries of more than 5% TBSA burns.
Resuscitation solutions should be initiated at a rate of 3-4 ml/kg/% burn and titrated to specific outcome parameters, evaluating any evidence of systemic overload or underhydration. Adequacy of resuscitation should be surmised at 30-50 ml/h urine output, clear mentation, and appropriate blood pressure.
Even after surviving the earliest days of trauma, an oliguric and hypotensive state can be interfaced at any time during therapy, as in our patient, who presented such a condition on day 26 post-burn.
Wound healing is of great concern in older people. There are significant changes in the skin with ageing that are responsible for the greater percentage of deep burns in the elderly, e.g. progressive thinning of the dermis and epidermis. Many factors cause a greater amount of deep burns and a decrease in healing in all phases, such as decreased epidermal turnover and a decrease in skin appendages, vascularity, collagen and matrix, fibroblast, and macrophage levels.20-22 These unfavourable factors cause a delay in epithelialization, an increase of burn depth, especially in second-degree burn areas, and healing problems at the donor site. In the case reported, areas that did not epithelialize spontaneously were grafted on post-burn day 19.
One such problem, protein energy malnutrition (PEM), has been reported to be present in at least one-third (30-60%) of elderly patients admitted to hospital. PEM has also been found to be three to four times more likely in patients over 65 years of age than in younger patients.23-25 Malnutrition and involuntary weight loss have been shown to be major risk factors for increased infection, impaired wound healing, and overall disability, the major reason being a loss of body protein and lean body mass. Mortality and morbidity rates seem to be accentuated owing to the addition of a post-burn catabolic state to an existing body protein and energy deficit.26-28 By giving our patient a high-energy, calorie-rich diet after day 2 post-burn we prevented him from developing a state of protein and energy malnutrition.
Elderly patients need to be aggressively managed to avoid early loss of function or muscle strength, which will be difficult to recover. These patients are capable of restoring muscle strength with resistance exercise and should not be managed conservatively.29 As with children, providing support and guidance for the family or caretakers is an integral part of care. We performed muscle physiotherapy, beginning with range of motion exercises on post-operative day 10, plus muscle strength exercises.
As a result, despite the high mortality seen in elderly burned patients, it is possible - with early respiration physiotherapy, fluid resuscitation without overload or underhydration, challenge of infection, early surgery, and post-operative physiotherapy - high mortality and morbidity rates can be decreased in this age group.
RÉSUMÉ. Comme on peut prévoir, le taux de mortalité et de morbidité chez les patients gériatriques est plus élevé quand ils sont atteints de brûlures importantes. Les réserves radiopoumonaires diminuées et la malnutrition caractérisées par l’insuffisance protéinique/énergétique et le vieillissement de la peau sont des facteurs prédisposant qui augmentent la mortalité et la morbidité. Les Auteurs présentent dans cette étude le cas d’un patient de 90 ans atteint de brûlures de deuxième et troisième degré. Ils ont du surmonter les difficultés que l’on peut avoir chez les patients d’un certain âge, et notre traitement a eu succès.