MANAGEMENT OF SEVERELY BURNED PATIENTS A STUDY OF 684 SEVERELY BURNED PATIENTS ADMITTED IN THE LAST SIX YEARS TO THE BURN AND PLASTIC SURGERY CENTRE, TRIPOLI, LIBYA

Zaidi M.M., Abussetta A.A., Franka MR, Shahata G, Traikov E, Uyang L.

Burn and Plastic Surgery Centre, Tripoli, Libya

SUMMARY. Between 1 January 1989 and 31 December 1994 684 severely burned patients were admitted to the Intensive Care Unit (ICU) in the Burn and Plastic Surgery Centre in Tripoli (Libya). The ICU is an isolated department with nine beds (three single isolated beds, plus six others), with separate operating theatres and five air-fluidized beds. The Unit is staffed by four anaesthesiologists from the Anaesthesia Department together with three burn surgeons working exclusively in the Unit, as well as specially trained nurses. All facilities for non-invasive monitoring are available for the nine beds. As in the central control unit, dialysis is available in the ICU if required.

Criteria for admission to the Intensive Care Unit

1. Severe burns in more than 30% TBSA
2. Bums in extremes of ages
3. Bums with smoke inhalation
4. High-voltage electric burns
5. Bums associated with other medical problems

Materials and methods

In the 6-year period between 1 January 1989 and 31 December 1994, 684 patients, including 249 with smoke  inhalation, were admitted to our ICU. All patients were managed by the Evans formula, modified in children, as follows:

1. Ringer's lactate 1 ml/kg/% TBSA/24 h
2. Plasma protein 1 ml/kg/% TBSA/24 h
3. Dextrose saline according to body weight
4. (half of this amount is given in the first 8 hours)

All patients with smoke inhalation or suspected smoke inhalation are either immediately intubated or prepared for intubation.
All patients are bathed in the emergency room after stabilization and before admission to the ICU. Escharotomy is also decided if there is a deep burn around the extremities or the chest wall. Analgesia and sedation are usually initiated in the emergency room.
In most cases wound management is performed by early excision 12 hours post-burn.
Surgery is completed in the first nine days post-burn in patients with a moderate percentage of burned body surface area. Temporary wound closure is performed with homoskin graft (usually from volunteer donors), xenograft (prepared from sheep), or synthetic skin substitute (Biobrane). Nutrition is initiated after 12 hours either orally or by nasogastric tube with parenteral caloric support. We analyse our patients according to age (Table I), sex (Table II), percentage burn (Table III), cause of burn (Table IV% presence of smoke inhalation and related mortality (Table V~, and the mortality rate for patients admit ted to the ICU (Tables VI, VII). We also analyse the direct cause of death in each group and describe our methods of dealing with smoke inhalation.Smoke inhalation is suspected in cases of flame burn in closed spaces, burned face, soot in the nostrils or sputum, stridor, hoarseness or loss of voice, and respiratory insufficiency. We diagnose smoke inhalation by:

• history (fire in closed spaces)
• physical findings (facial burns, ocular irritation, sooty sputum, stridor and respiratory insufficiency)
• laboratory investigations (arterial blood gases, carbon monoxide rate)
• pulmonary function tests (reduction of forced expiratory volume)
• fiberoptic bronchoscopy (showing level of injury)

We achieve better oxygenation in patients suffering from smoke inhalation by increasing P02 and improving perfitsion ventilation.
Systemic toxication is treated as shown below.

Initial treatment consists of an aggressive approach to upper airway maintenance and pulmonary support by:

• nasal endotracheal tube for bronchial lavage and adequate oxygenation
• connection to ventilator with 5 cm water PEEP to maintain airway patency and adequate functional residual capacity
• bronchodilators such as sulbotamol (Ventoline) via aerosol
• Lasix to minimize pulmonary oedema
• antibiotics to prevent secondary infection
• Ca channel blockers (e.g. Verapamil) to improve the vascularity of pulmonary and tracheal membranes

Table I shows that most of the patients admitted to the ICU in the six-year period were over 14 years of age. There were however also paediatric patients - we admitted 18 infants aged less than one year, mainly suffering from scald burns. The majority of the patients were males, owing to the fact that most of the cases were related either to flame burns or high-voltage electric burns caused by accidents at work (Fig. 1, 2, 3, 4).
Out of all patients admitted to the ICU, 249 complained of smoke inhalation, requiting special management. The mortality rate was about 40% of the whole population, and was related to the percentage of TBSA burned. In the entire series, only five patients out of 54 with TBSA percentage over 80% survived, and three of these presented smoke inhalation.

Fig. 1 - Mortality rate in relation to TBSA burned Fig. 2 - Causes of death. Fig. 3 - Overall distribution of patients by sex. Fig. 4 - Distribution of patients by sex by year.

The mortality rate was low when the percentage TBSA burned was less than 50%. In patients with TBSA burned between 51% and 80%, there was a major improvement in the mortality rate in the six-year period (Table VII). Not many patients died in the resuscitation phase, 4 most of the deaths occurring after the second week secondary to septicaernia, multiorgan failure, and bleeding from the gastrointestinal tract. Two of the deceased patients were pregnant, which suggests that severe burns associated with pregnancy result in high mortality (we intend to study this phenomenon in further studies). In the six-year period, our experience was that bleeding from the gastrointestinal tract was a real problem. We lost five patients as a result of gastrointestinal bleeding. These were not possible candidates for laparotomy, be cause of their general condition. As a routine measure we treat all our patients prophylactically against bleeding.
As shown in Table V and VI, 53 out of 54 patients with more than 81% TBSA burns also complained of smoke inhalation. The majority of these died. Some of these patients were admitted after two major tragedies which occurred in Lybia - one a Korean airline crash near Tripoli in 1990 and the other a fire during a wedding reception in 1992. The Tripoli Burn and Plastic Surgery Centre takes patients from all over Lybia, which has a population of around five millions in an area of 2,000,000 kin'. Some patients were transferred late from other hospitals after inappropriate early post-burn management.

Conclusions

• The incidence of severe burns is increasing in thirdworld countries as a result of economic progress. The number of cases and the severity of burns are increasing, and this requires a national programme of prevention and management. Regional co-operation in this field is also essential.

• Mortality could be decreased by improving burn services and developing specialized burn units. Our experience is that the treatment of burns in general surgery departments fails to provide the necessary facilities, while some physicians tend to prefer straightforward general surgery to the complex management of difficult burns. We feel very strongly that proper resuscitation in the early postburn phase is decisive in the outcome of treatment. Many patients die because of improper management during the resuscitation phase, and this requires education of the medical personnel in general hospitals with regard to burn problems, clear management plans, charts, guidelines to the transfer of patients, etc. Emergency departments must be in a condition to provide all this. Early transfer to burn units of patients in better condition will reduce the morta~ lity rate.

• It was proved that early surgical management of the wound considerably improved our results.

• Early nutritional support (oral with parental nutrition) had a major effect on our results and we therefore consider it essential.

RESUME. Dans la période 1 janvier 1989 - 31 décembre 1994 684 grands brûlés ont été admis au service de réanimation du Centre de Brûlés et de Chirurgie Plastique à Tripoli (Libye). Le service de réanimation est un secteur isolé avec neuf lits (trois lits seuls isolés, plus autres six), avec ses salles d'opération et cinq lits à air fluidisé. Le personnel du service de réanimation se compose de quatre anesthésiologistes du Service d'Anesthésie, trois chirurgiens spécialistes des brûlures qui travaillent exclusivement pour le service de réanimation, et des infirmiers spécialisés. Toutes les opérations du monitorage non-invasif sont disponibles pour tous les neuf lits. Au besoin la dialyse peut être pratiquée dans le service, comme dans l'unité centrale de contrôle.

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