SUMMARY The Centre for Burns can help by its means (material, technical and personal) in the treatment of burns with extensive and deep losses of the skin cover and Cher tissue structures and in some affections with a different etiology (non-thermie affections). Indicated for admission are, in particular, extensive exfoliative affections - StevensJohnson's syndrome (SJS), Lyell's syndrome - toxic epidermal necrolysis (TEN) and staphylococcal scalded skin syndrome (SSSS), deep skin and tissue affections associated with fulminant purpura (PF), possibly other affections (epidermolysis bullosa, posttraumatic avulsions etc.). The similarity with burn injuries with loss of the skip cover grade II is typical, in particular in exfoliative affections with a need for adequate fluid replacement in the acute stage and aseptic surgical treatment of the affected area from the onset of the disease. In conditions leading to full thickness skin loss, in addition to general treatment rapid plastic surgical interventions dominate.
Die nicht-thermische Beschâdigungen der Hautdeckung
Broe L., Kripner J.
Das Verbrennungszentrum kann mit seinen Mitteln (im material-technischen und personellen Sinne) und seinen Erfahrungen bel L&sung der ausgedehnten und tiefen Verluste der Hautdeckung und weiterer Gewebestrukturen und auch bei einigen Beschâdigung anderer Etiologie (nicht-thermischen Beschâdigungen) helfen. Zur Aufnahme werden vorwiegend die ausgedehnten exfoliativen Beschâdigungen indiziert - das Steven's-Johnson's Syndrom (SJS), das Lyell's Syndrom - eine toxische ephidermale Nekrolise (TEN) und das Staphylococcal Scalded Skin Syndrome - staphylokokisches Syndrom der verbrühten Haut (SSSS), tiefe Haut- und Gewebebeschâdigungen beim fulminanten Purpurausschlag (PF), bzw. weitere Beschâdigungen (Epidermolysis bullosa, posttraumatische Avulsion usw.). Die Âhnlichkeit mit einer Verbrennungsverletzung mir Verlust der Hautdeckung vom II. Grad ist besonders charakteristisch für die exfoliativen Beschâdigungen, wo die entsprechenden Flüssigkeitersâtze in der akuten Phase und die eigene sterile chirurgische Behandlung der beschâdigten Flâche vom Beginn der Krankheit notwendig sind. In Fâllen, die zu dem Hautverlust in voller Dicke führen, ist neben der Ganzbehandlung die mbglist schnelle plastisch-chirurgische Lüsung von dominanter Bedeutung.
Key words: non-thermie affection of the skin cover, Stevens-Johnson sy, Lyell sy, staphylococcal scalded skin syndrome, meningococcal sepsis
The similarity of some non-thermie affections of the skin cover with burn injuries from the aspect of general and local treatment is an indication for treatment at a burn department. This applies to the following conditions:
- Stevens-Johnson's syndrome (SJS),
- Lyell's syndrome - toxic epidermal necrolysis(TEN),
- staphylococcal scalded skin syndrome (SSSS), - extensive necrotic affections such as purpura fulminans (PF).
In the initial stages of exfoliative skin affections, it is often difficult to establish a diagnosis and to foresee the further development of the disease. Early diagnosis based on epidemiology, anamnestic data, the clinical picture and, in particular, histology is important for the initiation of aimed ATB therapy.At the paediatric intensive care unit of the Prague Burn Center during the past three years five patients with non-thermie affections of the skin were hospitalized, Le. 2 % of the total number of children admitted to the unit. The number comprised three cases with exfoliative affections of the skin (SJS, TEN and SSSS), and two children were admitted due to ischaemic skin and tissue changes after meningococcal sepsis.Meningococcal sepsis is an acute inflammatory disease caused by Neisseria meningitidis. Thirteen serotypes are described, serotypes A, B, C, W, Y being pathogenic. It affects younger age groups: 46 % of the cases have been found in children under two years. Clinical manifestations includ pharyngitis, febrile temperatures or hypothermie, manifestations of altered circulation and shock, skin lesions - petechiae, dermalActa chirurgiae plasticae haemorrhages or necroses, fulminant purpura being typical. These skin changes are caused by manifestations of acute vasculitis with fibrin deposits in the arterioles and capillaries and the development of the procoagulation stage of a haemostatic disorder with microvascular multiorgan microthrombotization. These mechanisms affect all organs with an ample capillary network (lungs, CNS, kidneys, adrenals). Subsequently, secondary activation of fibrinolysis occurs with manifestations of haemorrhagic diathesis within the framework of disseminated intravascular coagulopathy, severe multiorgan dysfunction, manifestation of septic shock and possibly death. Vascultitis may lead to extensive skin changes and subsequent loss of the skin cover. Secondary infections leading to extension of skin necroses and the development of gangrene are frequent. An inevitable therpeutic intervention in diseases that involve loss of the skin cover is necrectomy of the affected skin and dermoepidermal transplantation. In cases of deep affection and necrosis of tissues of the extremity, or in cases of a vascular necrosis of the bones in which secondary skeletal deformities develop, sometimes amputation of the affected part of the extremity is inevitable. This is why we consider collaboration of the intensive care specialist and a surgeon specialized in burns an essential prerequisite in the treatment of conditions involving damage and loss of the skin cover to prevent deeper penetration of necroses and their secondary infection in the initial stage of treatment.The course of these diseases is demonstrated by two examples.
| <% immagine "Fig. 1","gr0000027.jpg","Necrotic changes on the forearm and gangrene of distal phalanges of the right hand. ",230 %> |
<% immagine "Fig. 2","gr0000028.jpg","Condition after amputation of distal phalanges of the tnd - 5tn fingers of the right hand and after autotransplantation of the defect",230 %> |
| <% immagine "Fig. 3a","gr0000029.jpg","",230 %> | <% immagine "Fig. 3b","gr0000030.jpg","",230 %> |
Fig. 3. Necrotic areas on the right lower extremity (a), condition after autotransplantation (b).
In the first case (Figs 1-3) a 5-month-old boy was involved, who in the first stage of treatment was subfebrile and apathie, but already in the course of the night he developed haemorrhagic manifestations on the skin and signs of haemorrhage into the GIT.
The emergency medical service referred the child to a paediatric hospital department where he developed the following symptoms: progressive impairment of consciousness, extensive skin suffusions with a maximum on the extremities and cardiopulmonary insufficiency.
Without ensuring i.v. access and adequate ventilation and circulation support, the patient was transferred to the intensive care and resuscitation department of a higher grade paediatric department. There he was admitted in a moribund condition, GCS3, with severe cardiac decompensation and with anuria, therefore comprehensive resuscitation care incl. pharmacological resuscitation of the circulation was started. With regard to considered possibilities of continuous elimination methods, the child was transfered to the intenputation of the fingers.
The patient was at the guru Center for 29 days. The defects incl. those grafted, healed completely, and the child was transferred to the paediatric department.
<% immagine "Fig. 4","gr0000031.jpg","Deep necroses on the lower and upper ,extremities (situation on admission).",230 %>| <% immagine "Fig. 5","gr0000032.jpg","Focal necroses on the gluteal region. ",230 %> |
<% immagine "Fig. 6","gr0000033.jpg","Healing defects on gluteal region - alter autotransplantation.",230 %> |
| <% immagine "Fig. 7a","gr0000034.jpg","",230 %> | <% immagine "Fig. 7b","gr0000035.jpg","",230 %> |
Fig. 7a, b. Patient with healed areas.
The second patient (Figs 4-7) was a seven-year-old girl symptomatically treated as an outpatient suffering from myalgia, arthralgia, lever and haemorrhagic skin manifestations. After three days she was admitted to the paediatric department where her general condition deteriorated: her consciousness was impaired, intubation and artificial pulmonary ventilation was necessary, and she developed septic shock. Artificial
pulmonary ventilation was introduced for ten days, pharmacological support of the circulation along with continuous venovenous haemodiafiltration until renal functions improved and the myoglobin level declined. On the second day in
hospital she developed v.s. compartment syndrome of the right leg, which was confirmed by an sive and resuscitation care unit of the Clinic for Children and Adolescents in Prague. On admission multiple suffusions in the whole body, necrotic extremities and extensive perigluteal ischaemic changes developed. The patient was hospitalized for 15 days, incl. six days on artificial pulmonary ventilation; the affected areas were treated in collaboration with the Burn Center. After stabilization of his condition, the boy was transferred for treatment of the skin lesions to the Burn Center, Faculty Hospital Prague 10, with the diagnosis of local skin defects: 17 % grade IIa-b and 8 % grade III. There the patient was subjected to several surgical operations: necrec- 7a) tomy, allotransplantation, autotransplantation and am-
Acta chirurgiae plasticae assessment of the tissue pressure. Fasciotomy on the inner and outer side of the leg was performed and the posterior peroneal space was opened. For treatment of ischaemic skin lesions, the patient was transferred to the Burn Center, Faculty Hospital Prague 10, with an affection of 20 % (15 % gr. III, 5 % gr. IIb) in the area of the upper and lower extremities and in the gluteal region. Surgical procedures: necrectomy, xenotransplantation, autotransplantation, removal of the necrotic left patella, reposition flap in the area of the left knee, tubular flap on the right upper extremity. The total period in hospital was 24 weeks, on discharge restricted mobility of the elbows, bilateral paresis of the nn. peronei, on the right lower extremity partial loss and fibrosis of muscles of the right leg.
The approach to the treatment of children with exfoliative affections is similar to that of patients with burns with grade II skin affections. In addition to discontinuing all medication apart from essential drugs in SJS and TEN and antistaphylococcal ATB, therapy in a child with suspected SSSS comprised the following basic therapeutic protocol:
The 8th Congress of the Polish Society of Plastic, Reconstructive and Aesthetic Surgery will be held in Lddz, October 11 through 13, 2001.
For further information please contact the Department of Plastic Surgery Medical Academy of IJodz, Kopcinskiego Str. 22, 90-153 Eôdz, Poland.Tel./fax: 0-48-42-678-66-62
President of PSPRES Ass. Prof. Andrzej Zielànshi
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riquadro "Address for correspondence:
Ludomir Broz, M. D. Srobâroua 50 100 34 Prague 10 Czech Republic phone: +420 2 6716 3362 e-mail: broz@fnhv.cz
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