REHABILITATION OF BURNED PATIENTS WITH BILATERAL ABOVE-KNEE AMPUTATIONS

Bilateral above-knee amputation in burn patients is a rare occurrence - only six cases were found in a retrospective investigation of 5018 burn patients admitted to the Michigan Bum Center over a 28-year period. Four of the six patients survived the trauma. The records of the survivors were reviewed for information pertaining to age, sex, circumstances of injury, extent of burn, concurrent injuries, complications, level of function at last contact, marital and vocational status, and psychosocial adjustment. Recovery was found to have been time-consuming and costly, The surviving patients were wheelchair-bound, unemployed but socially active, relatively well adjusted and they stated that they were satisfied with their lives. As these patients suffer from hypertrophic scarring, polyneuropathy, and heterotopic bones, they clearly require a creative, extensive and comprehensive rehabilitation programme. If these services are efficiently provided they can make the necessary adjustments and resume active, productive and relatively happy lives.

Prasad J.K., Bowdwen M.L., McDonald K., Thomson P.D. Burns, 16: 297-301, 1990.

A topical agent commonly used in burn wound care is an ointment containing 10% polyvinylpyrrolidone-iodine (PVP-1) in a water-soluble base at a pH of 2.43 which yields 1% available iodine. However, this formulation presents a number of problems (viscosity, elevated serum iodine levels, depressed thyroid function and metabolic acidosis, unsuitability in unstable patients with impaired renal function, short period of antibacterial efficacy, non-effectiveness at intra- and subeschar level). In an attempt to overcome these problems a new formulation of 5% PVP-I in an oil/water emulsion cream was developed. Experiments in rats showed that the new formulation met specific criteria: it was very effective in terms of rapid penetration, rapid killing and sustained antibacterial effect; the cream spread easily and washed readily off the skin. Pharmacodynamic studies will be necessary to determine whether the decreased concentration and change in carrier base will influence iodine absorption. Until such studies have been performed it is recommended that generalized usage should be avoided in large burns and in unstable patients with impaired renal function.

De Wet P.M., Rode H., Cywes S. Burns, 16: 302-306, 1990.

This paper describes a case involving the use of midazolam (a short-acting benzodiazepine with anxiolytic, sedative, hypnotic, anticonvulsant, muscle-relaxant and antegrade amnestic effects). A 4-year-old child sustained 80% T13SA burns in a house fire. Because of his state of agitation and his unwillingness to cooperate, a difficult problem arose when it was found necessary to insert a new central venous catheter to replace one that was not functioning. Peripheral venous access was not available. Morphine sulphate 2 ing intramuscularly and midazolam (5 mg/ml) 3 ing (0.17 mg/kg) were administered by intranasal drip. The patient became less agitated and more cooperative, and in this state of sedation (the patient was sleepy but responsive to verbal commands) it was possible to insert the new central venous catheter. There were no demonstrable adverse local or systemic effects.

Rice T.L., Kyff J.V. Bums, 16: 307-308, 1990.

The Bashkir train-gas pipeline disaster occurred in June 1989. At least 400 people were killed when a pipeline exploded as two trains were passing. This article describes the care given to 26 children burned in the accident, as provided by resident Soviet physicians at Children's Hospital 9, Moscow, with the assistance of an invited US team. The methods of burn therapy adopted at this hospital provide for successful wound care, with an emphasis on avoiding invasive infection, and result in wounds that after spontaneous separation of eschar will readily accept grafts. During the two weeks of joint Soviet/US effort, mutualunderstanding fostered the acceptance of the value of techniques and methodologies of surgeons from both countries.

Remensnyder J.P., Ackroyd F.P., Astrozjnikova S., Budkevitch L.G., Buletova A.A., Creedon C.M., Lankina L., Lybarger P., Okatyev V., Prodeus P.P., Reinke K., Ruslan K., Salvo P.M., Tuohy C.B., Vasileva L., Vozdvidzensky S.

Bums, 16: 329-332, 1990.

Seven months after a US team of surgeons an'&nurses were invited to Children's Hospital 9, Moscow, to assist their Soviet colleagues in the care of children burned in the Bashkir disaster in June 1989, they were invited to return in order to participate in the evaluation of the treatment given. It was found that the major sequelae suffered by the 25 children were hepatitis, cardiomyopathy and severe emotional disorders. The Soviet and US teams worked together on reconstructive surgery for bum scars during a 2-week period of mutual instructive cooperation.

Remensnyder J.P., Ackroyd F.P., Astrozjnikova S., Budkevitch L.G., Buletova A.A., Creedon C.M., Lankina L., Lybarger P., Okatyev V., Prodeus P.P., Ruslan K., Salvo P.M., Tuohy C.B., Vasileva L., Vozdvidzensky S.

Bums, 16: 333-336, 1990.

After the methane/propane pipeline explosion that destroyed two passenger trains in the Bashkirian Republic of the Soviet Union in June 1989, causing 400 immediate deaths and over 800 casualties, mostly with thermal injuries, 150 patients were treated by a combined Soviet-US team of physicians and nurses. Twenty-six of the patients underwent excision and grafting of their burn wounds. Antibiotics provided by the US team proved effective in treating organisms that were resistant to locally available antibiotics, The joint work of the Soviet and 'US medical personnel during this unprecedented disaster demonstrated the efficacy of international cooperation. In planning for the care of victims of future disasters, such international cooperation should be included.

Kulyapin AN., Sakhautinov V.G., Temerbulatov V.M., Becker W.K., Waymack J.P.

Bums, 16: 337-342, 1990.

ROLE OF NEUTROPHILS IN THE INTESTINAL ALTERATIONS ASSOCIATED WITH THERMAL INJURY

An examination was made of the role of neutrophils in the alterations observed in rat intestine after the animals, were subjected to a 40% surface area scald injury. There was no histological evidence of neutrophilia in the intestinal tissue, and myeloperoxidase activity in mucosal scrapings was not elevated. The distribution of labelled human neutrophils injected into the burned rats did not show any enhancement of intestinal uptake. There was however an increase in pulmonary uptake. These data would suggest that neutrophil migration is possibly not involved in the alterations in small intestinal function and morphology observed in burn trauma in rats but may be a contributory factor in lung damage 'secondary to thermal injury.

Trop M., Schiffrin E.J., Carter E.A. Burns, 16: 343-346, 1990.

A skin graft alone may not be sufficient for the wound management of the burned elbow. Local fasciocutaneous flaps may provide a better source for vascular tissue than distant pedicle flaps or microsurgical tissue transfers. "Random" fasciocutaneous flaps do not require location of any discrete vessel, but have to be designed to parallel the longitudinal axis of perifascial circulation in the upper extremity. There is therefore no need to violate any vessel in the major extremity, so that muscle function is well preserved. It is probably advisable to limit excision -to-fascia techniques for bum escharectomy in the elbow region, because if the fascia remains intact, the overlying skin-grafted subcutaneous fat will survive flap transposition as a fasciocutaneous flap. The advantage of local flaps is that they permit earlier rehabilitation, and donor defect is restricted to the ipsilateral extremity, which is already damaged.

Hallock G.G. J. Bum Care Rehabil., 12: 26-32, 1991.

The question of when post-graft ambulation can be safely resumed in burn patients is considered here. Twenty-two patients with lower-extremity grafting were randomly divided into three groups and dangling protocol was initiated on post-operative day 6, 8 or 10. A five-point scale was devised to evaluate the grafts at six stages. No significant difference in scores was found in the three groups. Total hospital stay was significantly shortened by early ambulation, with no adverse effect on the quality of graft take. Careful mobilization on post-operative day 6 appears to be safe for sedated patients when lower-extremity skin grafts have been performed. performed to determine the effects on the immune response of changes in dietary lipids before burn injury in rats. It was found that neutrophil action in rats is not altered by diets high in either fish or safflower oil before burn injury. Safflower oil diets for 2 weeks, but not for 6 weeks, before burn injury marginally improved serum opsonization.

Peck M.D., Ogle C.K., Alexander J.W., Babcock G.F. J. Burn Care Rehabil., 12: 43-45, 1991.

Schmitt M.A., French L., Kalil E.T.

J. Burn Care Rehabil., 12: 33-37, 1991.

TRAINING FOR HEALTH DISASTERS: THE EUROPEAN CENTRE FOR DISASTER MEDICINE ENHANCEMENT OF HUMORAL IMMUNITY BY HETEROLOGOUS LIPID PEROXIDATION PRODUCTS RESULTING FROM BURN INJURY

Lipid peroxidation products (conjugated dienes) were extracted from the plasma of scalded rats and injected intraperitoneally into mice before immunization of the mice with sheep erythrocytes. It was shown by 5-day plaque-forming cell assays that mice receiving conjugated dienes from the plasma of burned rats had enhanced specific immunoglobulin Mantibody production compared to mice injected with dienes from normal rat plasma or sheep erythrocytes alone. The findings suggest that the humoral immune response may be modulated by lipid peroxidation products in the plasma of burned animals.

Thomson P.D., Till G.O., Prasad J.K., Smith D.J. jr.

J. Burn Care Rehabil., 12: 38-40, 1991.

In the light of previous studies indicating that vitamin E acetate given by gavage to mice before thermal injury can improve survival from subsequent infection, it was decided to test the efficacy of aqueous vitamin E given parentally after burn injury. The

experimental findings confirmed other results in the literature showing that vitamin E acetate does not alter outcome from subsequent infection in burned mice.

Peck M.D., Alexander J.W.

J. Burn Care Rehabil., 12: 41-42, 1991.

The experiments described in this article were

The aim of the European Centre for Disaster Medicine (CEMEC) is to promote the prevention and mitigation of the effects of natural and technological disasters through research, training and international collaboration, in particular among the countries of Europe. Through permanent mechanisms and in cooperation with the Council of Europe, the World Health Organization, the Office of the United Nations Disaster Relief Co-ordinator, universities, civil protection associations and other specialized bodies, it thus brings its humanitarian and scientific contribution to the efforts of society against the suffering and destruction caused by disasters.

Gunn S.W.A., Manni C. Disaster Management, 2, 2, 1989.

Growth factors such as transforming growth factor-beta (TGF-beta), platelet derived growth factor (PDGF) and platelet activating factor (PAF) are potent wound-healing promoters which accelerate repair by various mechanisms. TGF-beta, a chemotactic factor, increases synthesis of extracellular matrix and stimulates granulation tissue. It was demonstrated that a single topical dose of TGF-beta increased the wound breaking strength 'in normal models of tissue repair as also in models of impaired wound repair, characterized by severe rfionocytopenia. I'DG17, a chemotactic agent for inflammatory cells, with mitogenic activity, has the effect of activating monocytes and stimulating collagen production, and it was found to induce a significant increase in the wound breaking strength with effects lasting up to 47 days. Unlike TGF-beta, I'DG17 was active only in normal models of wound healing and its effect depended on the presence of macrophages. PAF is a glycerophospholipid, which chemotaxes and activates macrophages, but differs from growth factors in that it lacks mitogenetic activity. One topical dose of PAF was sufficient to cause significant decreases in the wound breaking strength and to promote macrophage migration.

Cromack D.T., Porras-Reyes B., Mustoe T.A. Supplement to The Journal of Trauma, 30, 12: S129-SI33, 1990.

The purpose of this article is: first, to recount some historical perspectives in the evolution of the understanding of trauma; second, to document recent data on the continuing and enlarging magnitude of the problem; third, to indicate some recent assessments which would point the way to more research in the spectrum of injuries, including everything from prevention through basic biological research to rehabilitation; and, finally, to discuss the , present status of some basic biological research in terms of its possible effectiveness and the indications for potential advances in this field.

Shires G.T. Supplement to The Journal of Trauma, 30, 12: S I 07-S 115, 1990.

In the last 20 years great strides have been made in wound healing, and newly verified mechanistic details are reducing wound complications and assisting recovery from injury. As understanding has increased, so has complexity, and this has given rise to an interesting problem. It is now difficult to define healing. Various clinical wounds have relatively little in common, and surgeons' expectations of healing vary, some being concerned with burns, others with fractures. Sbme surgeons want healing to be strong, others want it to be visible, etc. However, by conceiving of healing as an interacting sequence of components, much of this confusion can be overcome. This article is written in terms of the components of repair to demonstrate the logic of this contention.

Hunt T.K.

Supplement to The Journal of Trauma, 30, 12: S122-S128, 1990.