|Ann. Medit. Burns Club - voL V111 - n. 2 - June
A BIOCHEMICAL AND HISTOLOGIC RATIONALE
FOR THE TREATMENT OF
Hydrofluoric acid (HF) is highly corrosive. In dilute form (20%) it is an excellent agent for removing rust stains and is a common ingredient in several household rust removers and heavy-duty cleansers. It is thus commonly found in the home and represents a potential danger to children if inadequately or carelessly stored. Exposure to dilute and concentrated HF solutions can lead to severe pain and tissue necrosis. Local treatment with topical cal-, cium gluconate and subdermal injections of 0.5 ml 10% solution of calcium gluconate per cm' of affected tissue is often advocated but this does not relieve pain. There are also several reports of massive soft-tissue loss after such therapy. In view of these considerations it was decided to study the microscopic effects on the distal arterial tree of the intra-arterial infusion of calcium gluconate. Experiments conducted in rats showed that the incidence of microperforations in the intima and media of rat aorta increased with the concentration of calcium gluconate. It is therefore concluded that intra-arterial infusions should be reserved for only the most severe cases of HF burns that are not responsive to local therapy.
Dowback G., Rose K., Rohrich R.J. J. Burn Care Rehab., 15: 323-7, 1994.
HISTOLOGIC ASSESSMENT OF LOW VOLTAGE
The present investigation was designed to answer some of the questions asked by physicians facing a patient with burns, namely: Is the necrosis really progressive? When and at what level should initial debridement be performed? An experimental protocol was therefore carried out on pigs, which are an excellent animal model because of the morphological similarities between their cutaneous system and that of human skin. Identical low-voltage electrical burns were inflicted in order to examine clinically and histologically the evolution in time of this kind of burn. A clinical lesion in the form of a rosette was observed, composed of three zones: a central carbonized zone, a pale ischaernic intermediate zone, and an erythernatous peripheral zone. Microscopy showed vascular thrombosis in the intermediate and peripheral zones in addition to necrosis of the central zone. These vascular lesions can be classified in three stages, according to the degree of vascular damage. The evolution of the lesions was stabilized at 72 hours postburn. These observations are important with regard to surgical treatment, particularly debridement, on day 3 postburn, when the prognosis of the intermediate and peripheral zones must be taken into consideration.
Roug6 D., Polynice
A_ Grolleau J.1------Nicoulet B., Chavoin J.P., Costagliola M.
EVALUATION OF GRAFTSKIN* COMPOSITE GRAFTS ON FULL-THICKNESS WOUNDS ON ATHYMIC MICE
Graftskin is a composite, cultured skin substitute designed to function as a permanent skin replacement for fullthickness wounds. It is composed of human fibroblasts that condense a bovine collagen lattice; the lattice is then seeded with cultured human keratinocytes. The collagen lattice containing fibroblasts is designed as a living dermal template, and the overlying human keratinocytes form the epidermal component of this composite skin replacement. Graftskin was used to close full-thickness wound defects on the dorsum of 24 athymic mice, which lack effective T-cell immunity to reject the human cells. The wounds were biopsied and examined at time intervals of 6, 15, 36 and 60 days after graft placement. The results of the experiment showed that Graftskin formed a structurally complete skin replacement within one week of positioning on full-thickness wounds on athymic mice, and effective skin coverage was provided for the entire 60-day observation period after grafting.
* Organogenesis, Inc., Canton,
RISK OF ALUMINUM ACCUMULATION IN
PATIENTS WITH BURNS
In view of the fact that aluminium may be a factor in the development of the aplastic lesions frequently observed in the bones of burn patients, research was undertaken to identif, all, the sources of alumini.um used in the management of Such patients, with the goal of determining ways of reducing the potential burden of this element. Various fluids, creams and medication materials were assessed and classified according to their route of administration: cutaneous, enteral or parenteral. Cutaneous exposure to aluminium was found to be greatest from baths, which provided up to 8 ing aluminium. The dynamics of aluminium entry into the blood via a damaged skin barrier is not however clear. Enteral exposure to aluminium is no greater than dietary sources. Parenteral sources of the element (especially 25% human serum albumin and calcium gluconate) provide the most significant risk of loading because of direct introduction of aluminium into the circulation. Substitution with a different brand of albumin and calcium chloride can reduce the parenteral aluminium load by up to 95% and thus much reduce the role of aluminium in the pathogenesis of aplastic bone lesions.
Klein G.L., Herndon
D.N., Rutan T.C., Barnett J.R., Miller N.L., Alfrey A.C.
A PROSPECTIVE COMPARISON
OF A NEW, SYNTHETIC DONOR SITE
This study considers the results of a prospective study carried out to compare the treatment of bilateral skin graft donor sites with either a new, synthetic donor site dressing, Wound Contact Layer (WCL) (a hydrocolloid with a fabric backing, manufactured by Convatec, Princeton, N.J., USA), or Xeroform (a petroleum-impregnated gauze, manufactured by Cheseborough-Ponds, Greenwich, Conn., USA). Thirty-eight patients were included in the study. Wounds were assessed by time of healing, pain, and patient preference. Mean results showed that wounds treated with WCL healed in 7.9 days compared with 10.2 days for Xeroform (p > 0.001), and the WCL-treated wounds were more completely epithelialized. The synthetic dressing appeared to be less painful than the gauze dressing. WCL had fewer treatulent-related adverse experiences than Xeroform and was judged by patients to be superior as regards comfort, pain relief, cosmetic appeal, ease of ambulation, and overall acceptance.
Hickerson W.L., Kealey G.P., Smith D.J. Jr, Thomson P.D. J. Burn Care Rehabil., 15: 359-63, 1994.
USES OF COBAIN*
SELF-ADHERENT WRAP IN MANAGEMENT OF POSTBURN HAND
Two cases (referring to a 23-year-old man and a 13month-old child) are presented of the post-surgical use of Coban, a self-adherent elastic wrap. Coban applies snugly without loosening. It does not stick to underlying tissue and is therefore excellent for early post-operative management of full- and split-thickness hand grafts. Coban decreases post-operative oedema, permits earlier mobility, and facilitates accurate measurements for the fitting of pressure garments. Wounds can be covered with Coban when the grafts are largely adherent and vascularized; it can be wrapped directly over the graft, over an ointment/adaptic dressing, or over gauze padding for extra protection, i.e. as a "soft splint". The wrap is changed daily, a procedure that family members readily learn. Coban encourages early, protected, active range of motion and the early use of custom-made pressure garments.
3M HealthCare, St. Paul, Minnesota
CYTOSKELETAL ACTIN: THE'llISIFLUENCE OF
MAJOR BURNS ON NEUTROPHOL
Among patients who sustain major trauma, those surviving beyond 48 h most frequently die of sepsis and multiple organ failure. Such patients, especially burn patients, become markedly hypermetabolic and are in negative nitrogen balance at the moment of their death. It is clear that the polymorphonuelear white blood cells become functionally impaired. The purpose of this research was to assess the influence of major burns on neutrophil structure and function. It was speculated that leucocyte dysfunction might in part he related to the overall systemic catabolism of actin stores. This hypothesis was investigated by making a comparison between the functions and the cytoskeletal structure of neutrophilic leucocytes from normal control adults and from victims of fresh, major, thermal injuries. The results of the research, performed in relation to ten patients admitted to a burns centre in South Africa in 1992, confirmed that major thermal injuries cause several forms of neutrophil dysfunction. The numerically significant reduction in cytoskeletal actin may be central to some of the neutrophil dysfunctions that were observed. The mechanism by which this occurs is not yet however clear.
de Chalain T.M.B., Bracher M., Linley W., Gerneke D., Hickman R. Burns, 20: 416-21, 1994.
G-HAEMOLYTIC STREPTOCOCCAL INFECTIONS IN BURNED PATIENTS
The purpose of this study was to inves tigate B-haemolytic streptococcal infections at a Bulgarian burns centre during a 12-month period. It has long been recognized thatl the group A B-haemolytic streptococcus (Streptococcus pyogenes) is very destructive to healing epithelium and new skin grafts. In the period March 1991 - March 1992, 117 B-haemolytic streptococcal strains were isolated in 114 burn patients. On the basis of their serogroup, 64 strains (54.7%) were group A; the percentages of groups B, G, C and F were respectively 29.1, 7.7, 4.25 and 4.25. Antibiotic sensitivity tests indicated the presence of some differences among the serogroups, especially between groups A and B. Although group A was the major strain found, it is.clear that for successful treament of f3-haemolyiid'st~eptocOccal infections in burns it is important to consider the role of non-group A B-haemolytic streptococci, which in this study amounted to 45.3%.
Lesseva M., Girgitzova B.P., Bojadjicv C. Burns, 20: 4Z2-5, 1994.
AGAR WELL DIFFUSION ASSAY TESTING OF
In a previous report the authors of this article showed that microbial susceptibility to antimicrobials in concentrations non-toxic for human cells in culture could be tested using the wet disc topical antimicrobial assay. This new report compares wet disc assay and agar well diffusion on the basis of tests of the susceptibility of Pseudomonas aeruginosa isolates ftoin burn patients to concentrations of Polymixin B nQn-toxic for cultured cells. Both types of assay were performed.on, the same plates. The results showed no differences. FuTther agar well diffusion assay testing demonstcated that susceptibility/resistance could be shown when tes",g sevetal antimicrobials in concentrations non-toxic for cut~ cells against various bacteria isolated from bum patients. It is therefore clear that the more familiar agar well diffusion as well as the wet disc assay can be used to test microbial sensitivity to these concentraions of antdmbids.
Holder I.A., Boyce S.T. -Burns, 20: 42(à-9,1994.
AN AUDIT OF NON-ACCIDENTAL INJURY IN BURNED CHILDREN
The relevant literature suggests that non-accidental injury in burned children is higher than one might expect (one report found a rate of 25%). Also high is the repeat injury rate following non-accidental injury. A retrospective follow-up review was conducted for all patients admitted to an English paediatric burns unit over a 47-month period, in order to ascertain the exact incidence of non-accidental injury. The incidence, of confirmed abuse was about 3% (this figure includes intentional injury and neglect). The repeat injury rate was extremely low. The reasons for the low figures compared with other reports are considered: possible differences in the definition of non-accidental injury, differences in population make-up, or simply that burn injury is a relatively uncommon form of non-accidental injury in that particular part of England (Devon and Cornwall).
Hobson M.I., Evans J., Stewart I.P. Burns, 2Q: 442-5, 1994.
EARLY TANGENTIAL EXCISION AND SKIN
GRAFTING AS A ROUTINE METHOD OF
This retrospective study assesses the feasibility of routine early tangential excision of burn wounds and skin grafting in a developing country (India) - "early" is defined as on or before day 5 post-burn. An analysis was carried out of mortality, morbidity and hospital stay in 90 burn patients with deep partial skin loss burns who underwent early tangential excision and skin grafting. The overall survival rate was 86.5%. Children U nder the age of 14 years with burns of 40% or less total body surface area (T13SA) had no mortality, 93.5% of adults with burns in 60% or less T13SA survived, while adults with more than 60% TI1SA burns all died. Morbidity for contractures and hypertrophic scars was nil or minimal. The mean hospital stay for adults with minor burns was 18.7 days and with major burns 30 days. It is concluded that in developing countries early tangential excision and skin grafting can be performed routinely for all minor burns and for major burns treated in a well-equipped burns centre, but not for very extensive burns until biological skin substitutes are more widely available.
Prasanna M., Singh K., Kumar P. Burns, 20: 446-50, 1990.
RADIATION INJURYRadiation injury is becoming an increasing hazard in our modern life. Industrial accidents, nuclear disasters and warfare, even space travel, are all possible sources of exposure to radiation. Radiation may also be used in medicine, for diagnostic and therapeutic purposes. An understanding of the biological effects of radiation on the human body is an essential prerequisite for the improvement of protective measures and for better management of the injury when it occurs. Radiation injures the haemopoietic stem cells of bone marrow to produce leukopenia, thrombocytopenia and anaemia. The article considers the amounts of radiation that cause injury, and the effects on different organs and systems. There are sections on carcinogenesis, genetic effects, radiodermatitis, radiation cancer, and osteOradionecrosis. Methods of management are also discussed.
Kumor R, Jagetia G.C. Indian J. Burns, 2: 24-33, 1994.
BURNS IN CHILDREN
In view of the statistical finding that in children injury due to burns is second only to motor accidents as a cause of fatality, and also considering the high rate of physical ;~nd psychological sequelae among children who survive burns, it is clear that every effort must be made to prevent this kind of accident. This article gives a clear account of the mode of injury, first aid, the assessment of burn injury, initial management, fluid therapy, nutrition, the management of sepsis, and the management of the burn wound.
Goel A., Ahuja R.B. Indian J. Burns, 2: 34-40, 1994.
BURNS IN PREGNANCY
Thermal injury during pregnancy presents special difficulties for both the gravid woman and the unborn child. The physiological response to maternal injury is self-preservation at the expense of the foetus. Foetal well-being after a burn trauma therefore depends on energetic and proper treatment of the mother. Particular attention must be paid to hypotension and hypovolaemia, hypoxia, septicaemia, dilutional hyponatraemia and any drug-related problems. Pregnancy following burns is also considered, as also burns of the breast and possible problems of lactation.Pandya N. Indian J. Burns, 2: 41-44, 1994.