Ann. MediL Burns Club - vol. VIII - n. 1 - March 1995

The question whether burn blisters should be debrided and the fluid evacuated has long been debated. It is widely believed that large blisters should be debrided because the burn blister fluid contains substances that may interfere with the healing of the underlying wound. Agreement is not however universal and burn wounds with small blisters are found to heat better if left intact. In order to have a better understanding of the problems involved, it was decided to study the calcium binding protein calmodulin in human burn blister fluid and its role in the mitogenicity of this fluid in the culture of human keratinocytes, fibroblasts, and mouse 3T3 fibroblasts. Calmodulin levels in blister fluid were found to be three times greater than in serum (p < 0.005), while epidermal growth factor and plateletderived growth factor concentrations were significantly lower (p < 0.001). Affinity chromatography, Western blotting, and inummostaining were used to identify calmodulin biochemically. When calmodulin was inhibited by an antagonist or an antibody to calmodulin the mitogenic activity of blister fluid was reduced. These in vitro studies indicate that burn blister fluid may favour wound healing, and that locally released calmodulin contributes to this effect. It may therefore be advisable in certain cases to leave burn blisters intact.

Wilson Y., Goberdhan N., Dawson R.A., Smith J., Freedlander E., MacNeil S.
J. Burn Care Rehabil., 15: 303-14, 1994.

THE RESPONSE IN HEAT PRODUCTION, PLASMA CATECHOLAMINES, AND BODY TEMPERATURE OF BURNED RATS TO HYPOTHALAMIC TEMPERATURE D I S PLACEMENT

Experimental rats were implanted with two thermodes and a thermocouple reentry tube in the preoptic anterior hypothalamus (POAH). Simultaneous direct and indirect calorimetry was performed, during the ninth to eleventh post-burn interval, at ambient temperatures of 22 and 28 'C. For the purposes of catecholamine assay, blood was drawn during calorimetry at baseline and near the end of each period of displacement of the POAH temperature. POAH cooling caused a significant increase in heat production and plasma epinephrine and norepinephrine concentrations for both burn and control groups at 22 and 28 C (p < 0.05 in all cases). Heat production showed consistent negative linear correlation with POAH temperature. Plasma epinephrine values correlated with POAH temperature only for the controls at 28 'C ambient temperature, while norepinephrine had significant linear correlation with heat production for all groups and significant negative linear correlation with POAH temperature. These findings would suggest that norepinephrine is more important than epinephrine in the maintenance of post-burn hypermetabolism in this particular rat burn model and they also demonstrate that the hypermetabolism is appropriately responsive to perturbation of PAOH.

Caldwell F.T. Jr, Graves D.B., Wallace B.H, J. Burn Care Rehabil.,
15: 315-22, 1994.

EVALUATION OF TREATMENT MODALITIES IN PERIORAL ELECTRICAL BURNS

The purpose of this study was to compare three modalities of the treatment of perioral electrical burns in children. A retrospective analysis was undertaken of 29 patients (mean age 3 years; minimum follow-up I year) who had sustained perioral electrical burns. The patients were divided into three groups: no surgery and no splint (group 1); no surgery and splint therapy alone (group 2); and oral commisuroplasty and a special splint design presented in the article (group 3). Subjective evaluation of standard photographs was performed by six surgeons who gave points on the basis of the following parameters: lip length, scar, vermilion quality, and lip roll. Group 2 patients were judged to have a less noticeable scar and more normal lip parameters. Groups I and 3 had a similar percentage of scar involvement and overall poor subjective scores. All the evaluators considered that commisuropathy (group 3) improved the patients' appearance compared with no surgery and no splint (group 1). The application of the easily constructed splint alone therefore proved to yield the best cosmetic results.

Barone C.M., Hulnick S.J., De Linde L.G., Sauer J.B., Mitra A.
J. Burn Care Rehabil., 15: 335-40, 1994.

HOT TAR BURNS: TWENTY-SEVEN HOSPITALIZED CASES

The purpose of this study was to 'evaluate the incidence and problem of hot tar burns as they are managed in a county hospital burn unit. A survey was made of 27 consecutive patients (26 male) requiring admission to a burn unit in Atlanta, Georgia, USA. All the accidents occurred on a worksite and involved active young persons (mean age 33.7 years). The mean burn size was 13.1% TBSA, mainly in the upper extremities and hands. Nearly all the patients made a good recovery: of the two patients who died, one was completely immersed in hot tar, sustaining 80% TBSA burns, and the other sustained 49% TBSA burns, mostly full-thickness, and had suffered previously from heart disease. Hot tar burns are fully pN~ictable and can easily be prevented by avoiding unsaf~ practices and/or equipment.

Renz B.M., Sherman R. J. Burn Care Rehabil.,
15: 341-5, 1994.

ALCOHOL DISORDERS AMONG PATIENTS WITH BURNS: CRISIS AND OPPORTUNITY

A study was.made of 442 patients admitted to the Burn Centre in Tampa, Florida, USA and it was found that I I% were also diagnosed as having an alcohol use disorder. The injuries in these patients were judged to be preventable in all cases but one. The average length of hospital stay was 9 days longer than average, involving considerable extra cost. However, fewer than half of the alcohol abusers were referred elsewhere for treatment of their underlying condition. A valuable opportunity was thus lost to help these patients to achieve abstinence. Without such intervention these patients are very likely to re-experience trauma at the cost of significant morbidity, mortality and expense.

Powers P.S., Stevens B., Arias F., Cruse~ C.W., KriZek T., Daniels S.
J. Burn Care Rehabil., 15: 386-91, 1994.

EARLY BURN WOUND EXCISION AND SKIN GRAFTING

This article provides a history of early burn wound excision and grafting and considers the state of the art. The different types of excision (fascial, tangential, sequential) are described, as well as escharectomy. The criteria for the selection of patients, which depend on the depth and extent of the burns, are indicated. Operative techniques are also described. The advantages of the correct use of early burn wound excision and closure are a reduction in the risk of infection, diminished hospitalization time, more effective management of pain, the early institution of physical therapy, and reduced scarring.

Although split-skin grafting is a relatively simple and reliable procedure for the closing of burn wounds, there are occasions when a temporary skin substitute may be indicated. The advantages of temporary skin substitutes are listed and described, and the qualities of the ideal skin substitute considered. Skin substitutes can be either biological (homo- or heterografts, amniotic membrane, colla~ gen) or synthetic (films, foams, gels, sprays, composites). The various advantages and disadvantages are compared. All these materials have come to play a vital role in the management of patients with extensive burns in whom the available donor sites are limited.

Burns in certain areas of the body are very important for aesthetic andlor functional reasons and pose unusual problems for their management. This afficle considers the special features involved in the management of burns in these areas. Face burns are particularly important as they involve that part of the body that gives a person his or her personality. It is the site of the senses of sight, hearing, taste and smell. It is also exposed and burn scars are therefore difficult to conceal. The special problems of car burns are considered in detail. Perineum and hand burns are also dealt with.

The particular problems presented by chemical burns are considered. These injuries account on average for 3 to 5% of all patients admitted to a major burns unit. The common modes of injury are described together with the resulting pathophysiology. The different kinds of chemical agent are classified according to their mechanism of action, with special reference to certain chemicals that cause various forms of systemic toxicity. The clinical features are described, together with management in its successive phases - first aid, initial mangement and definitive care. Specific measures are necessary for certain burn agents, e.g. hydrofluoric acid, phenol, Portland cement, petrol (which may lead to lead poisoning), and hot coal tar (this is in fact a thermal burn but noxious chemicals may be used to remove the tar).

An examination was made on day 3 post-burn of the proliferative and phenotypic characteristics of cells in regional lymph nodes that drain burn injury. This is the moment of maximum spontaneous proliferation and of interleukin-2 and accessory cytokine (IL- I and IL-6) production. The importance of IL-I in the spontaneous proliferation of draining lymph node (DLN) cells was shown by stimulation of IL-2-driven proliferation by recombinant IL-1 in vitro and by susceptibility of unstimulated proliferation to anti-IL-1 antibodies. Requirements for IL-6 in DLN cell proliferation was less marked. Cell surface phenotyping presented a slightly increased percentage of CD25+ cells in the blast cell population of freshly isolated DLN cells post-burn, which increased further during cultivation. It was possible to demonstrate enrichment in CD8+ cells on day 3 post-burn, but no change in total cell population and CD4+ cells was noted. This was however preceded by a marked percentage decrease of total T cells and CD4+ cells and by increases of B cells and MHC class ll+ cells on day I post-burn. The inhibition of DLN cell proliferation by anti-MHC class 11 antibodies suggested that this proliferation was class 11 MHC dependent. The question of the contribution of cell pro.liferation and/or cell influx to day 3 post-burn DLN cell activity is considered.

HAEMATOLOGY REPORTS OF ROUTINE BLOOD FILMS IN PATIENTS WITH BURNS.

Ninety-nine periDheral blood films from 27 patients with skin burns admitted to a hospital in Birmingham, England, were studied blind, in a retrospective study. It was found that abnormalities of the granular leucocyte series were commoner in more extensive burns and that they usually preceded bacteriological evidence of wound pathogens or a clinical decision to take a blood culture. A prospective study would appear to be necessary to determine the possible clinical value of reporting such granulocyte abnormalities. Abnormalities of the myelo-monocytic and lymphocyte cell lines were sufficiently frequent to allow fundamental research of possible relevance not only to patients with burns but also in other host responses such as in sepsis, malaria or AIDS.

SIMILAR ECTOPIC EXPRESSION OF ICAM-1 AND HLA CLASS II MOLECULES IN HYPERTROPHIC SCARS FOLLOWING THERMAL INJURY

Hypertrophic scars are long-term secondary consequences of thermal injury, appearing as reddish, tense, pruritic and painful masses. The pathogenesis of this condition is not fully understood, although in previous studies the authors of this article have shown that HLA Class 11 antigens are expressed by keratinocytes and fibroblasts in hypertrophic scars. In the light of the potential role of immunological events in the pathogenesis of hypertrophic scars, the present study considers hypertrophic scars for the expression of intercellular adhesion molecule-I (ICAM-1), a molecule that plays an important role in immunological phenomena. The technique of immunoperoxidase staining with anti-ICAM-1 MoAb in 10 hypertrophic sear samples detected the molecule on epidermal keratinocytes and on about 30% of fibroblasts at the site of lymphoid infiltration. The expression of ICAM-1 in hypertrophic scars was similar to that of HLA Class 11 antigens. The concomitant expression of ICAM-1 and HLA Class 11 by keratinocytes is known to enhance their antigen-presenting properties. The findings of the present study thus support the possibility that immunological events play a part in the disruption of the normal process of wound healing and tissue remodelling, which results in hypertrophic scarring.

Castagnoli C_ Stella M_ Magliacani G_ Ferrone S., Momigliano Richiardi P.
Burns, 20: 430-3, 1994.