Ann. Medit. Burns Club - vol. VIII - n. 3 - September 1995

INTERNATIONAL ABSTRACTS

HISTORICAL NOTES ON THE USE OF PRESSURE IN THE TREATMENT OF HYPERTROPHIC SCARS OR KELORDS

This interesting and wide-ranging article considers descriptions in the literature of deforming scars and contractures. Apart from some uncertain allusions in occasional ancient sources, the first known specific reference was in The Works of Ambrose Parey (1678). Other landmarks in the literature were Retz's Treatise on Skin Disease and Things of the Mind (1790) and various works ~1806-1817) by Alibert, who coined the term "keloid". Rayer, in 1835, was the first to describe a keloid developing from a burn scar. At this time, the use of pressure as a therapeutic method was already prescribed, and many references are to be found to this kind of treatment throughout the nineteenth century. However, the use of pressure in the treatment of hypertrophic scars or keloids only gained universal support after the pioneer work at the Shriners Burns Institute at Galveston in the USA, which led to the use of pressure, positioning, splinting, exercise and pressure garments as standard treatment modalities in burns centres. The development of these techniques and the devices designed are described.

EARLY DIAGNOSIS OF STAPHYLOCOCCAL TOXAEMIA IN BURNED CHILDREN

The diagnosis of toxic shock syndrome in burned children is made on clinical grounds supported by haematological and biochemical tests: there is a prodromal 24-48 h period with diarrhoea, vomiting, general malaise, pyrexia, tachycardia and tachypnoea, together with a drop in the white cell count and haemoglobin concentration prior to the shock phase, which has its onset 3-4 days post-burn. If shock occurs the mortality rate is usually in the region of 50%. A retrospective review is made of six burned children with a clinical diagnosis of toxic shock syndrome observed in a 2-year period. With careful treatment such patients can recover and in fact these six children all survived. The modalities of their treatment are described. It is pointed out that early diagnosis of staphylococcal toxaemia and prompt specific treatment prior to the development of shock is likely to reduce mortality. The term "staphylococcal toxaemia" emphasizes the need to treat this condition in burned children before the development of shock, with its high mortality risk.

This paper describes a psychiatric liaison service in a burns unit, with a review of the results achieved in the first year. A definition of the objectives of the service is followed by a discussion of the ways in which contact can be maintained between the psychiatrist and the bums team. The referrals observed are divided into three diagnostic categories. Although diagnostic criteria may not be achieved in all patients, the burns team still benefits from any help in the management of cases presenting psychological disturbances. It is now fairly well established that attentive care of the psychological status of medical and surgical patients improved their physical outcome: the provision of effective liaison psychiatry services is a sensible statagem in terms of patient health, staff satisfaction and the rational allocation of resources.

Antebi D. Burns, 19: 43-6, 1993.

A retrospective study is presented of 629 burn cases treated between January 1989 and August 1990 in the new Burn Unit opened in Jaipur (the "Pink City"), India, in April 1988. The data analysed refer to age, sex, cause of burn, and related mortality. Further information concerns socioeconomic and marital status, place of burn, family size, type of bum, time of accident and time delay between injury and hospital admission. Adolescents and young adults (11-40 years) constituted 64.8% of the patients. The male/female ratio was 54 to 46. Domestic bums represented 82.65% of the total. The majority of the patients belonged to low or lower middle socio-economic strata, with large families. The vast majority (95.5%) of the accidents were accidental in nature. The overall mortality rate was 48.3% (20.1% in children), flame burns being the most dangerous (mortality rate 62.1%). In patients with over 40% TBSA burns the mortality rate was about 80%; there were no survivors among patients with more than 70% burns.

LABORATORY DATA FROM THE SURVEILLANCE OF A BURNS WARD FOR THE DETECTION OF HOSPITAL INFECTION

After an alarming increase was observed in the infection rate in a Burns Unit in Bombay, India, it was decided to carry out a programme of bacteriological surveillance and analysis of wound sepsis. This was done for a l-year period (January-December 1988). Various sources of infection were thus discovered, including a contaminated disinfectant container and transient pathogenic flora on a staff member involved in changing dressings. The most common pathogen isolated from infected wounds and from the blood of patients developing sepsis was Pseudomonas aeruginosa. A number of changes were implemented in procedure and the infection rate dropped considerably. This underlines the importance of strict vigilance by all personnel involved in the care of burned patients, in order to reduce the incidence of hospital infection and thus to shorten hospital stay.

The threat of legionnaires' disease, particularly in hospitals and other health-care premises, is so real that building services engineers are recommended - and in some countries required by national legislation - to store and operate hot water systems at a temperature of 60 'C. The causative organism of the disease, Legionella pneumophila, which can be fatal to inummosuppressed persons and those with chronic respiratory conditions, can colonize hot water systems but is killed off by temperatures above 50 'C. The high water temperature is evidently a risk and serious scaldings may result if adequate water mixing devices are not installed to coot the water before normal use for washing or bathing. Three such hotand-cold water blending devices are compared (Aquamix Mixing Valve, Horne 15 Thermostatic Mixing Valve and Taco Automatic Tempering Valve). It was found that while all three operated satisfactorily in normal supply conditions, only the most expensive (the Horne model; cost US$ 194) was consistently able to shut off the hot water in the event of failure of the cold water supply. As this is not a negligible risk, especially where young children and handicapped persons are concerned, it is recommended that the cheaper tempering valves, which in certain circumstances may be inefficient, should not be installed.

ACUTE ADRENAL INSUFFICIENCY IN THE BURN INTENSIVE CARE UNIT

Unsuspected acute adrenal insufficiency can underlie a confusing and stormy intensive care unit course in the bum patient because the haemodynamic picture is identical to that seen with sepsis. The possibility of acute adrenal insufficiency should be considered in burn patients who develop unexplained hypotension, delirium and fever - especially when accompanied by hyponatraemia and hyperkalaemia. The case histories are given of two such patients who were diagnosed antemortern but successfully treated with replacement therapy. The aetiology, presentation, diagnosis and treatment of acute adrenal insufficiency in the intensive care unit is reviewed.

OCULAR CHEMICAL BURNS - CLINICAL AND DEMOGRAPHIC PROFILE

CARDIAC ABNORMALITIES IN CHILDREN WITH BURNS: AN AUTOPSY ANALYSIS

This study was undertaken after the observation of several recent cases of endocarditis -related deaths at the Cincinatti Shriners Burns Institute. Autopsy reports of all burn-related deaths between 1964 and 1992, 212 in all, were reviewed for cardiac disease (86 cardiac, 126 non-cardiac). Cardiac abnormalities were classified as infectious, acquired and congenital. Longer periods of hospitalization were related to cardiac abnormalities and there was a comparatively high rate among female patients. It would seem that improved burn management has led not only to improved survival but also to increased duration of hospitalization of patients who will ultimately die of their burns. The incidence of endocarditis and the cardiac manifestations of multiple organ failure have increased because patients are kept alive longer. A case study is included.

Albertson A., Greenhalgh D.G., Breeden M.P., Warden G.D. J. Bum Care Rehabil., 15: 401-4,1994.

The treatment of paediatric facial burns varies considerably from burns centre to burns centre. Many facilities prefer to wait until the eschar separates in order to reduce blood loss and allow accurate determination of which portions of the face are going to heal. Early excision in young patients presents certain difficulties but the possible benefits have led us to prefer this technique. A large series of paediatric face burns is described, with reference to management, the issue of the timing of grafting, airway management, and post-operative graft treatment. Patients underwent grafting on average 12.7 days post-burn. Procedures were performed in two stages. The grafts were dressed open. No episodes of acute airway decompensation were recorded and no patient required regrafting. The results showed that early excision and grafting of facial burns can be carried out safely in burned paediatric patients.

Housinger T.A., Hills L, Warden G.D. J. Burn Care Rehabil., 15: 408-11, 1994.

A COMPARISON OF PSYCHOLOGIC FUNCTIONING IN CHILDREN AND ADOLESCENTS WITH SEVERE BURNS ON THE RORSCHACH AND THE CHILD BEHAVIOR CHECKLIST

Although depression in severely burned children and adolescents is a common reason given on referrals requesting psychological services, there is disagreement in the literature regarding the incidence of the emotional problems suffered by these patients. Some of the differences in empiric outcomes are due to the type of assessment instrument used to determine emotional problems. These considerations relate to a study carried out on 12 severely burned children and adolescents with psychological problems, the incidence of which was examined through four similar scales on the Children's Behavior Checklist and the Rorschach. No correlations were found for any of the pairs (Withdrawn-Isolation Index, Somatic C omp I aints -Anatomy + X-ray, Anxious/Depressed-Depression Index, and Thought Disorder- Schizophrenic Index). The discrepancies were explained as both accurate reflections of patients' personalities and function of the type of assessment instrument used to determine the psychological problems. The results of this admittedly limited survey suggest the lack of good objective psychological assessment tools available to this population and the need for experienced professionals to interpret results in the light of their personal knowledge of the patient.

EURO SKIN BANK: LARGE SCALE SKIN-BANKING IN EUROPE BASED ON GLYCEROL-PRESERVATION OF DONOR SKIN

The Euro Skin Bank, originally founded in 1976 as the Dutch National Skin Bank, operates on a non-profit-making basis. Since 1984 it has used glycerol as a preservant for skin allografts from cadaveric donors. In 1992 the Bank began to operate on an international scale and the Euro Skin Bank was thus instituted. This article deals with the Bank's work: the procurement of skin, processing and preservation, quality control, distribution, and application. A number of considerations are made about possible future developments. Skin donors must meet a number of general and specific criteria, which are described in detail.

PSYCHOLOGICAL AND PHARMOCOLOGICAL ASPECTS IN PATIENTS IN BURN UNITS

This study, based on the experience of the Plastic Surgery Department and Burns Unit of the Ca' Niguarda Hospital, Milan, proposes a four-stage classification (1 - emergency; 2 - defence; 3 - confrontation, 4 - re-introduction) in the psychological progression of burned patients. From the moment of their admission to a Burns Centre, patients have to adapt to different psychodynamic situations. They have passed from a state of welfare to a condition in which their life is at risk, with the knowledge that they will forever bear indelible scars. During the long evolution of the disease the plastic surgeon becomes the principal landmark for the patients. The purpose of this article is to provide the plastic surgeon with guidelines of psychological and pharmacological therapy in order to Prevent negative reactions and to improve the patients' general state.

ANALYSIS OF BACTERIURIA IN PATIENTS WITH BURNS

The purpose of this prospective study of bacteriuria in burn patients was to investigate the incidence of uroinfections, their sources and possible causes, and their impact on clinical conditions and the final outcome. Over a 2-year period during which a total of 607 patients were treated, a detailed analysis was made of bacteriuria in 148 burn patients, selected on the basis of the following criteria: case history of renal pathology; clinical findings of uroinfection; patients with transurethral catheters. Out of the total number of 607 patients, urine infection was found in 46 patients (7.6%), constituted by community acquired uroinfection (CAU) in 39.1% of cases and hospital acquired uroinfection (HAU) in the remaining 60.9%. Eight patients had bacteriuria secondary to generalized bacterial infection (CBI) and 11 presented candiduria associated with massive antibacterial therapy. CAU was mostly caused by the common uropathogens (E. coli, Citrobacter and Proteus sp.) and HAU by multiresistant hospital strains (Pseudomonas aeruginosa, Klebsiella sp., Acinobacter sp. and Serratio sp.). It was confirmed that transurethral catheterizations are factors associated with the development of the exacerbation of life-endangering chronic uroinfections. The causes of death in the 20 fatalities were analysed. The need is emphasized of strict monitoring of bum patients at risk for uroinfection and of thorough preventive measures.

Lesseva M.l., Hadjiski O.G. Bums, 21: 1, 3-6.

EVALUATION OF EARLY ENTERAL FEEDING IN CHIL. DREN LESS THAN THREE YEARS OLD WITH SMALLER BURNS (8-25 PER CENT TI3SA)

This study evaluates the safety and efficacy of early enteral nasogastric (NG) feeding of high protein content in children under three years old with burns of 8-25% TBSA. An attempt was also made to validate existing mathematical formulae for estimating energy requirements in young children with smaller burns. It was found that the ten burned children studied were able to to tolerate high protein intake without detrimental effects. Gastrointestinal complications were low. The children needed about two weeks of supplemental NG feeding which provided two-thirds of total energy intake and three-quarters of protein intake. It was found that recommended daily allowance requirements for energy are adequate for supporting such children. However, nutritional support which provides three times the amount of recommended daily allowances may be necessary to support visceral protein synthesis. The high-level protein intake had no short-term deleterious effect liver or renal function.

Trocki 0., Michelini J.A., Robbins S.T., Eichelberger M.R. Bums, 21: 1, 17-23.