Treatment strategies for mass burn casualties

Background Mass burn casualties are always a great challenge to a medical team because a large number of seriously injured patients were sent in within a short time. Usually a high mortality is impending. Experiences gained from successful treatment of the victims may be useful in guiding the care of mass casualties in an armed conflict. Methods Thirty-five burn victims in a single batch, being transferred nonstop by air and highway from a distant province were admitted 48 hours post-injury. All patients were male with a mean age of （22.4±8.7） years. The burn extent ranged from 4% to 75% （（13.6±12.9）%） total body surface area. Among them, thirty-two patients were complicated by moderate and severe inhalation injury, and tracheostomy had been performed in 15 patients. Decompression incisions of burn eschar on extremities were done in 17 cases before transportation. All the thirty-five patients arrived at the destination smoothly via 4-hour airlift and road transportation. Among them, twenty-five patients were in critical condition. Results These thirty-five patients were evacuated 6 hours from the scene of the injury, and they were transferred to a local hospital for primary emergency care. The patients were in very poor condition when admitted to our hospital because of the severe injury with delayed and inadequate treatment. Examination of these patients at admission showed that one patient was suffering from sepsis and multiple organ dysfunction syndrome. Dysfunction of the heart, lung, liver, kidney, and coagulation were all found in the patients. Forty-eight operations were performed in the 23 patients during one month together with comprehensive treatment, and the function of various organs was ameliorated after appropriate treatment. All the 35 patients survived. Conclusions A well-organized team consisting of several cooperative groups with specified duties is very important. As a whole, the treatment protocol should be individualized, basing on the extent of the injury and the care that the patient had received at the spot. During airlift, the stretchers should be arranged perpendicular to the longitudinal axis of the cabin. The treatment protocol in our hospital consisted mainly of prompt effective relief of all life-threatening complications, followed by early closure of burn wounds, appropriate use of anti-infection therapy, emphasis on nutritional support, correction of metabolic disorders, alleviation of immunosuppression, correction of coagulopathy, and effective support and protection of organ function.     

CHANGES OF IMMUNE FUNCTIONS AFTER RADIATION, BURNS AND COMBINED RADIATION-BURN INJURY IN RATS

The changes ot several immune functions were observed in rats after they were inflicted with 6 Gy gamma rays irradiation, 15% TBSA full thickness hrun and the combination of the 2 injuries. It was found that the ftmcldons of thymocytes and epienocytes suffered the most severe suppressinn in the 24th to 72nd hour after radiation injury and began to recover on the 7th day. In the rats with burn injury, the suppression on thymocytes and splenocytes were significantly less severe than that after radiation and recovered more rapidly. The effects of combined rediation-bura injury showed several characteristics. The suppression on the thymocytes was more severe with slower recovery as compared with that after single radiation injury only. The suppression on the splenocytes as a whole was similar to that after single radiation injury, but in the early stage after combined injury, the suppression was far more severe than that after radiation. Escharectccny and skin grafting on the burn wounds on the lst day after combined injury could accelerate the recovery on both the thymocytes and eplenocytes. Our findings indicated that the severity of the suppression on the immune functions due to combined radiadon-burrt injury might depend on the size of the burn wounds.     

Clinical characteristics and treatment of combined burn-blast injury

Objective To further improve the treatment of combined burn-blast injury, elucidate its clinical characteristics and sum up treatment experiences. Methods Five cases with combined brnm-blast injury transferred for three times were admitted from a remote area to our burns institute 77 hours after injury on June 7,2005. The burn extent was （89.6±7.2）% （80%-97%） TBSA, with （83.4±7.3）% （75%-92%） TBSA full-thickness injury.     

Redox factor-1 may mediate the repair of multiple organ injuries after liver transplantation

AIM: To examine the relationship between multiple-organ injuries and expression of redox factor-1 (Ref-1) in the early period after liver transplantation. METHODS: A total of 150 adult male Wister rats were divided randomly into three groups: liver transplantation, sham surgery, and untreated control. After liver transplantation, animals were sacrificed at different time points. Hepatic and renal functions were analyzed by serology. Histology, apoptotic levels, and Ref-1 expression were examined by immunohistochemistry in the liver, kidneys, intestines, and lungs. RESULTS: Serum levels of alanine aminotransferase and aspartate aminotransferase peaked 6 h after liver transplantation and decreased appreciably after 12 h in the transplantation group, suggesting that the degree of liver injury in the early period after transplantation peaked at 6 h and then decreased. Pathological analyses showed that hepatic tissues were more severely injured in the transplantation group than in the sham and untreated groups. A considerable number of infiltrating inflammatory cells was observed around the portal vein in the transplantation group. Injuries to the kidneys, intestines, and lungs were milder after liver transplantation. Apoptotic levels increased after liver transplantation in all four organs examined. Ref-1 expression was higher in the transplantation group in the early period after liver transplantation than in the sham surgery and untreated control groups. CONCLUSION: Ref-1 expression induced by ischemia–reperfusion injury may have a critical role in repairing multiple-organ injuries after liver transplantation.     

A study on mitochondrial respiratory dysfunction and lipid peroxidation in the liver after radiation,burn,and combined radiation-burn injuries in mice

Male mice were subjected to 6 Gy total body irradiation,20% TBSAfull-thickness burns,or combined radiation-burn injury and lipid peroxides(LPO),vita-min E,sulfhydryl group,respiratory control ratio(RCR),ADP/O ratio,and cytochromeoxidase activity of the liver mitochondria were determined in the first 9 d postinjury.Theresults are as follows:(1)LPO level increased in the early postinjury stage after combinedradiation-burn injury,on the 5th-7th day after irradiation and on the 7th day postburn.(2)Vitamin E level decreased significantly in the two groups of radiation and burn inju-ries but showed no significant decrease after combined injury.(3)The sulfhydryl groupshowed a tendency to increase in all the 3 groups.(4)The activity of cytochrome oxidaseincreased significantly on the 7th day after radiation but decreased considerably in theburn and combined injury groups.(5)RCR and ADP/O ratio decreased more significantlyin the combined injury group than in either the radiation group or the burn group.These facts suggest that the respiratory dysfunction of the liver mitochondria results mostprobably from the damage on the mitochondrial membrane due to lipid peroxidation.     

ANALYSIS OF CAUSES OF DEATH IN AGED BURNED PATIENTS

From August 1st 1976 to July 31st 1986, thirty—six (32.7%) of the 110 burn patients over the age of sixty—five admitted to the Bum Center, Ruijin Hospital died in hospital. Significant differences related to the total bum surface area (TBSA) and full-thickness burn size were observed between the survivors and the non-survivors. Among the causes of death, pre-existing cardio-pulmonary diseases and associated inhalation injury were particularly important since pneumonia was considered as a primary cause of death in 13 patients, myocardial in 2, cor pulmonale and heart failure in 2. Cautious in fluid resuscitation, early exisian of deep burn wound and grafting, prevention and treatment of a variety of life-threatening complications, and nutritional support appeared to be beneficial in decreasing the mortality of aged burn patients.     

Experimental studies on the treatment and pathological basis of combined radiation and burn injury

Objective To investigate therapeutics for and the pathological basis of combined radiation and burn injuriesMethods Combined radiation and burn injuries on mice and rats were inflicted by γ ray irradiation from a (60)Co source and thermal radiation from a 5 kW bromotungsten lampResults The dysfunction of myocardium played an important role in the development of early stage shock. Transfusion of irradiated (in vitro, 20 Gy) or stored (4℃, 7 days) blood after irradiation was done to promote the success of allo-transplantation of bone marrow. Decrease of IL-4 mRNA expression was the molecular basis of depression of intestinal mucosa immune and intervention of IL-4 showed an antagonistic effect on enterogenic infection. A new lipid component extracted from burn eschar was documented for the first time and its toxic effects were elucidated. The survival rate of alloskin grafts after removal of burn eschar from the recipient animals was obviously increased in combined injury due to reduction of immune rejection activity by the radiation effect. In contrast, in animal models with simple burn, the alloskin grafts were all rejected within ten days after the procedure. A successful therapeutic result (survival rate: 92% for 30 days and 67% for 100 days) was obtained by comprehensive management of treated animals, while the untreated control animals all died within 3-7 days after injury. Conclusion The pathogenesis of injury caused by simultaneous radiation and burn is extremely complicated and the treatment is very difficult. A comprehensive management program consisting of several therapeutic measures aimed at key links of the pathogenesis may achieve significantly improved results.     

Successful treatment of invasive burn wound infection with sepsis in patients with major burns

Objective To investigate the clinical characteristics of invasive burn wound infection wit h sepsis in patients with major burns and to summarize the successful experience s in the treatment of such patients. Methods Eight patients with major burns, complicated by invasive burn wound infection an d sepsis were consecutively admitted to our hospital from September 1997 to Octo ber 1998.Among them, 6 patients developed multiple organ dysfunction syndrome (MODS) and 2 developed septic shock.The plasma concentrations of IL-6, IL-8, TNFα and lypopolysaccharide (LPS) were assayed before and after surgical inter vention, as well as when the patient’s vital signs became stable.Results The patients’ conditions usually deteriorated abruptly when extensive invasive b urn wound infection emerged.While multi-microbial infection was usually found , Pseudomonas aeruginosa was the predominant bacteria isolated from the sube schar tissue.The plasma concentrations of IL-6, IL-8, TNFα and LPS before s urgical intervention were significantly higher than those after surgical interve ntion (P<0.05).The lowest levels of the inflammatory mediators were obser ved when the patients’ conditions became stable, and the values were signifi cantly lower than those before surgical intervention (P<0.001). Conclusion Since the main cause of burn wound sepsis is the presence of a large area of i nfected burn wound, they should be excised and covered as early as possible.LP S and pro-inflammatory mediators play an important role in the pathogenesis of burn sepsis.Although favorable results should be attributed to comprehensive t reatment, we believe that early, aggressive and thorough surgical excision of in fected burn wounds, followed by sound and complete coverage of the area, play a crucial role.     

NITRIC OXIDE SYNTHESIS IN MYOCARDIUM FOLLOWING BURN INJURY IN RATS

The nitric oxide and cyclic GMP production in myocardium early after burn injury in tats were investigated. Nitric oxide synthase activity was measured in cytosols from the left ventricular wall of burned rats.Cytosols from the control group animals were shown to contain mainly Ca^2 dependent nitric oxide synthase (cNOS) with small amount of Ca^2 independent nitric oxide synthase (iNOS). Following burn injury,there was a marked increase in iNOS activity with a peak at 8h post-butyl, however, myocardial cNOS activity was found to decline obviously. Parallel to iNOS induction there was a significant increase in myocardial nitric oxide and cyelic GMP production. All these chenges were alleviated by treatment of the rats with dexamethasone. Since increases in cyclic GMP levels in the heart were associated with reduced myocardial contractility, it is possible that enhanced production of nitric oxide by a Ca^2 independent NO synthase accounts, at least in part, for the depression of myocardial contractility seen in burn animals and patients.     

Multiple organ dysfunction syndrome due to ingestion of fish gall bladder

Objective To investigate changes in renal function, urine N- acetyl- β- D- glucosaminidase enzyme (N- AG), liver function, myocardial enzymes, the pathology of renal damage and the mechanism of acute renal failure (ARF) associated with fish gall bladder poisoning.Methods Eleven patients with acute fish gall bladder poisoning were consecutively admitted to our hospital from September 1997 to October 1999. Renal function, urine N- AG enzyme, liver function, and myocardial enzymes were assayed before and after treatment. One patient consented to a kidney biopsy and the pathology of renal damage was observed under light and electron microscopes.Results All patients had multiple organ dysfunction syndrome (MODS) and 11 patients suffered from ARF. Ten patients had liver dysfunction, ten patients had poisonous myocarditis, and 8 patients had gastrointestinal dysfunction. Renal function, urine N- AG enzyme, liver function, and myocardial enzymes were significantly improved after treatment compared with those of before treatment (P<0.05). Kidney biopsy showed that the main damage site was the proximal renal tubule. All eleven patients recovered and were discharged from the hospital.Conclusions Ingestion of fish gall bladder leads to kidney damage, as well as liver, heart and gastrointestinal tract injury. The mechanism of acute renal function failure is the serious tubular damage, confirming the location of kidney damage. Necrosis of the proximal tubules plays an important role in the development of ARF. Immediate hemodialysis is the most effective treatment.     

特重烧伤患者肺部感染的治疗

目的:探讨特重烧伤伴吸入性损伤患者的肺部感染有效的治疗方法。方法:总结6例特重烧伤伴吸入性损伤和肺爆震伤患者的肺部感染的临床资料。结果:6名伤员在伤后3.5~6 d内出现肺部感染,其中5名需气管切开及呼吸机辅助通气,3例接受机械通气2.5 d后出现肺部感染。经过综合治疗,所有患者的肺部感染均得到治愈。结论:早期合理应用抗生素,防治呼吸机相关性肺炎,应用纤维支气管镜检查及治疗,加强呼吸道管理和营养支持,积极处理创面都是治疗特重度烧伤伴吸入性损伤患者的肺部感染的有效方法。     

鞭炮爆炸烧伤的临床特点

目的:探讨鞭炮爆炸烧伤的临床特点和治疗方法,以求提高治愈率。方法:通过对临床患者的前瞻性规范治疗和回顾性观察,进行比较分析。结果:鞭炮爆炸烧伤多发生在暴露部位,以深度烧伤为主,常常合并有吸入性损伤、复合伤、火药中毒,发生休克的机会较高,病死率高,全身侵袭性感染的主要细菌是肠道杆菌科的细菌和绿脓杆菌。结论:鞭炮爆炸烧伤是以烧伤病理变化为主的复合伤,出现功能障碍最常见的器官是肺脏,应特别注意呼吸功能支持,创面早期手术效果好。     

大鼠超压冲击伤和烧冲复合伤肺出血的量化研究

本文用图象分析方法测量了冲击伤、烧伤和烧冲复合伤大鼠伤后不同时间肺出血情况。结果,冲击伤速发死亡大鼠平均肺出血体积和出血积分显著高于存活动物(P<0.01);单冲和烧冲组大鼠于伤后2、12 h肺出血明显,24 h出血体积有所增加,至72 h出血已明显吸收。单烧组无出血。实验结果表明,超压冲击伤肺出血是速发死亡的主要原因,活存动物在24 h内可能有续发性肺出血,烧冲复合伤时肺出血吸收速度较单冲减慢。文中初步讨论了以肺出血体积和积分划分伤情分度的标准。     

内皮素和一氧化氮在烧冲复合伤肺损伤中作用的研究

目的 探讨内皮素（ＥＴ）和一氧化氮（ＮＯ）在大鼠烧冲复合伤肺损伤中的作用机制。方法 大鼠烧冲复合伤后给予ＥＴ受体（ＥＴＲ）拮抗剂和Ｎ 酶（ＮＯＳ）抑制剂治疗，检测与肺损伤密切相关的指标的变化。结果 烧冲复合伤大鼠血清和肺组织氧自由基丙二醛（ＭＤＡ）含量、肺组织弹力纤维（ＥＦ）和血管性血友病因子（ｖＷＦ）含量均出现了显著变化（Ｐ〈０．０５），给予ＥＴＲ拮抗剂和ＮＯＳ抑制剂治疗分别可减轻和加重这些指标     

小儿烧伤脓毒症53例的治疗体会

目的总结小儿烧伤脓毒症的防治经验。方法 2006年1月～2010年12月我院收治小儿烧伤1106例,发生脓毒症53例。对53例患儿脓毒症的发生原因、防治措施进行分析和总结。结果脓毒症发生率4.8%,休克、感染、吸入性损伤、营养不良等是脓毒症发生的主要原因;经积极抗休克治疗、加强创面处理和抗感染、脏器功能保护、营养支持等综合治疗,治愈45例,转院1例,死亡7例,病死率13.2%,主要死因是脓毒症并发的MODS。结论提高对小儿烧伤脓毒症的认识、积极有效复苏、对深度烧伤创面早期切（削）痂植皮、及时切除感染灶、合理使用抗生素、加强脏器功能保护和营养支持等综合治疗,能有效提高小儿烧伤脓毒症的治愈率。     

成批中重度烧伤患者长途转送后的救治

目的:分析成批危重烧伤患者长途转运后并发症及总结其救治经验。方法:两批烧伤中的重度烧伤患者13名,分别于伤后3 d和4 d由外地长途空运转入,烧伤面积75％±25％,Ⅲ度烧伤面积63％±34％且有中度吸人性损伤;入院时所有患者已出现创面溶痂,大部分患者分别或同时有休克、严重高钠血症、白细胞总数低、低蛋白血症、应激性溃疡出血等并发症。治疗措施包括:①入院后尽快行相关检查,掌握病情;尽快处理休克和严重高钠血症等危及生命并发症。②尽快手术封闭创面。③加强抗感染治疗的同时,积极实施器官功能及免疫支持。结果:入院后并发症得到迅速纠正,大部分患者顺利恢复。5例Ⅲ度烧伤面积≥95％患者伤后2周左右始出现脓毒症和器官功能不全。经积极对症处理和器官支持等治疗3例治愈,2例分别因自体皮极度匮乏和急性乙型肝炎而死亡。结论:成批烧伤中的危重患者长途转运后极易出现危及生命的并发症;掌握并发症发生特点并及早处理是成功救治的关键。     

烧冲复合伤早期输液治疗的实验研究

1.本文报告了狗40％Ⅱ~-～Ⅱ~+烧伤合并中度以上肺冲击伤时,早期静脉输液对肺部的影响。共用122只狗,有相应烧冲、单烧、单冲对照组。 2.实验结果表明,按临床输液公式较晚而较快地静脉补给液体,未见有肺出血加重,肺水肿的发生率和中度以上的比例虽较对照组略高,但差别无统计学意义。 3.据实验结果,结合临床资料,认为在烧冲复合伤时,在监测尿量和胸部体征变化的条件下,应补充足量的液体。     

CHANGES OF IMMUNE FUNCTIONS AFTER RADIATION，BURNS AND COMBINED RADIATION－BURN INJURY IN RATS

ＣＨＡＮＧＥＳＯＦＩＭＭＵＮＥＦＵＮＣＴＩＯＮＳＡＦＴＥＲＲＡＤＩＡＴＩＯ，ＢＵＲＮＳＡＮＤＣＯＭＢＩＮＥＤＲＡＤＩＡＴＩＯＮ－ＢＵＲＮＩＮＪＵＲＹＩＮ　ＲＡＴＳＹａｎＹｏｎｇｔａｎｇ（阎永堂）；ＲａｎＸｉｎｚｅ（冉新泽）ａｎｄＷｅｉＳｈｕｑｉｎｇ（...     

合并休克期呼吸心跳骤停的大面积烧伤救治体会

目的：回顾总结救治1例合并休克期呼吸心跳骤停的大面积烧伤的成功救治经验。方法：对1例火焰烧伤总面积96％TBsA（深Ⅱ度4％;Ⅲ、Ⅳ度92％）合并吸入性损伤、休克期（伤后27h）呼吸心跳骤停的患者,早期重要治疗包括合理的补液治疗,早期气管切开,心肺复苏治疗;早期切痂手术,自体微粒皮、异体大张皮覆盖创面;此外,营养支持、抗感染治疗也贯穿了治疗整个过程。结果：患者在休克期出现呼吸心跳骤停,经过及时、成功的心肺复苏治疗,在密切监测生命指标的前提下,采取早期分二次切痂自体微粒皮、异体大张皮移植;由于自体皮源的缺乏,后期分11次手术自体皮移植封闭创面,经过128天创面愈合,治愈出院。结论：对于休克期出现呼吸心跳骤停的大面积深度烧伤的患者,个体化的补液治疗、及时有效地心肺复苏是救治成功的前提;在心肺复苏之后,选择合适的手术时机,重视围手术期的治疗,早期切痂手术,自体微粒皮、异体大张皮覆盖创面仍然是可行的,并且对稳定病情,减少并发症非常重要。同时,积极营养治疗并且尽早向肠内营养过度,防治感染,及时有效利用有限的自体皮源封闭创面同样必不可少。