湿润烧伤膏治疗烧伤总面积>50%TBSA患者的疗效观察

目的观察应用湿润烧伤膏治疗大面积烧伤患者的疗效。方法1991年6月-2003年12月，将笔者单位收治的入院前曾用湿润烧伤膏治疗烧伤总面积〉50％TBSA的患者298例作为观察组；随机抽取同期大面积烧伤患者300例作为对照组，其创面应用磺胺嘧啶银（SD—Ag）冷霜治疗。观察两组患者的细菌培养情况、主要伤情变化及病死率。结果观察组培养出菌株1506株，主要伤情变化9种1679例次，病死率20．8％；对照组培养出菌株353株，主要伤情变化9种518例次，病死率4．7％。两组主要伤情变化及病死率问比较，差异有统计学意义（P〈0．01）。结论采用湿润烧伤膏治疗大面积烧伤患者，其疗效不及SD—Ag冷霜。     

Long-term survival among elderly after burns compared with national mean remaining life expectancy

IntroductionAs compared to younger adults, older people have a greater risk of domestic accidents, such as burns, and their prognosis is worsened by a diminished physiological ability to face a thermal trauma. The in-hospital mortality is adversely affected by old age and burn size, whereas less is known about the long-term-survival in elderly patients who survive a burn injury. The aim of this study was to investigate if elderly burn patients after discharge from a Swedish National Burn Centre have a shorter remaining life compared to the national population, by using calculated remaining Life Expectancy (rLE).MethodsIn this retrospective study we included all patients who were admitted for burns to the Linköping Burn Centre during 1993–2016 and who were 60 years or older and alive, at the time of discharge. The control group was extracted from Statistics Sweden, the national statistics database, and consisted of all individuals from the Swedish population matched for each patient in the study group, by sex and age at the year of discharge. The proportion who died before reaching the rLE was compared between the study population and the control group by calculating risk ratio.ResultsThe study group consisted of 111 former patients and 77 of them (69%) died before reaching the rLE, with mean 4.7 years of life lost (YLL), which was 33% more than that (52%) of the control group (RR 1.33, 95% CI 1.18–1.51). Burn related factors, such as TBSA % or FTB % were not found to account for this effect.ConclusionWe found that the long-time survival of elderly patients after burns is shorter than that of a national control, the magnitude of which is quantitatively important. The current study does not support that burn related factors account for this effect and the reason should therefore be sought in other factors, such as e.g., co-morbidity or psychosocial issues.     

Sympathetic skin response in electrical burn injury

BackgroundElectrical burn has been reported to be highly associated with peripheral neuropathy. This study was designed to evaluate the sympathetic skin response (SSR) of electrical burn patients to determine whether the sympathetic nervous system is involved in these patients.Materials and methodsThe sympathetic skin response of 28 patients, suffering from electrical burn injury (divided into two groups of high voltage and low voltage exposure) was compared with that of 28 matched subjects, who had never experienced electrical burn. Bilateral palmar and plantar latency and amplitude of SSR were recorded in response to Median and Tibial nerve electrical stimulation.ResultsSSR in all recording sites of the electrical burn patients compared showed significantly more prolonged latencies and reduced amplitudes, with their counterparts in the control group with no significant difference between the high voltage and low voltage electrical burns. There was no significant difference in SSR latency, between the entry and exit sites of the electrical current. The SSR amplitude however, showed more reduction in right hand than the left one, in whom the electrical current had entered the body from the right hand. The time lapse between the electrical burn and the SSR study was shown to play no role in the results.DiscussionIncreased SSR latency in electrical burn injury may be a sign of autonomic nervous system involvement, through systemic responses to electrical burn.     

Serum transthyretin levels in patients with burn injury

We examined serum transthyretin levels after thermal injury in a longitudinal study of 61 patients with burn injury from day 2 to day 28 after trauma. All the patients had a maximal decrease in transthyretin levels between days 6 and 8. Transthyretin values remained lower during the recovery phase in patients who died than in patients who survived. In addition, persistently low transthyretin values were associated with sepsis in the survivors. Finally, transthyretin levels were only slightly dependent on the extent of the burn injury. These results emphasize the interest of transthyretin monitoring in patients with burn injuries.     

Elevated cytokine levels in peritoneal fluid from burned patients with intra-abdominal hypertension and abdominal compartment syndrome

BACKGROUND: Burn patients with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) undergo vigorous resuscitation and accumulate peritoneal fluid (PF) that is a plasma ultra-filtrate. This study compared antithrombin (AT) and cytokine levels in burn patient plasma and peritoneal fluid (PF). METHODS: Twenty-nine patients were studied: 22 developed IAH and 9 progressed to ACS. Burn + inhalation injury was present in 22 patients; 5 had burn only and 2 had inhalation only. Sixteen patients died: of these, 9 survived less than 48 h due to the severity of their injuries. Flow cytometry utilized the Cytometric Bead Array kit for Human Th1/Th2 cytokines. AT levels were determined by the Accucolor method spectrophotometrically. RESULTS: All cytokine levels were significantly elevated in burn plasma and PF compared to normal plasma, p < 0.001. AT plasma levels were decreased compared to normal. AT and cytokines were present in peritoneal fluid of burn patients with IAH and ACS. Patients who died had decreased plasma levels of AT and increased IFN-gamma, IL-10, IL-6, IL-4, IL-2 peritoneal fluid levels compared to survivors. CONCLUSIONS: Peritoneal fluid may be a reservoir for cytokines during initial resuscitation and contributes to homeostatic perturbations in burn patients.     

The effects of human burn injury on urinary nitrate excretion

Different studies have demonstrated both an increase and a decrease in the biosynthesis of nitric oxide (NO) during the first 2 days following experimental and human burn trauma. This study investigated changes in urinary nitrate excretion in humans following thermal injury in order to determine the temporal relationship between NO release and the initial injury. Urinary nitrate was measured in daily 24-h urine collections taken on days 1-7 following burn injury from 15 patients. The control group consisted of 11 healthy, age- and sex-matched patients who kept a nitrate-restricted diet for five days prior to collection of a single 24-h urine sample. The burns group had a mean age of 41.9 +/- 19.4 (mean +/- S.D.) years and a mean total burn surface area (TBSA) of 30.2 +/- 24.9% (mean +/- S.D.). In the burn injured patients, urinary nitrate levels peaked at day 4 and a 2-fold increase relative to day 1 was observed. Urinary nitrate levels were significantly higher in the burns group than the control group on days 4 and 5 only (p < 0.05 for both days). There was no correlation between TBSA and the measured urinary nitrate levels. This study confirms that the biosynthesis of NO is increased during the first week following burn trauma and establishes that the renal elimination of the by-products of NO metabolism is not increased during the first three days after injury. Notwithstanding the potential effects of burns on nitrate distribution, our findings may reflect a delay in the release of NO following the initial insult.     

烧伤对垂体—睾丸轴影响的临床研究

OBJECTIVE: To investigate the effects of burn trauma on pituitary-testis axis. METHODS: The changes in serum estradiol(E2), testosterone(T), luteinizing hormone(LH), and follicle stimulating hormone(FSH) levels were dynamically investigated by RIA in 30 days after thermal injury in 28 burnt men. RESULTS: The serum FSH, LH, and T levels significantly decreased after injury, and there was some increase from PBD(postburn day) 14 to 30. In patients in group II and III (BSA > 30% TBSA), not all of their FSH, LH, and T levels reached the normal control on the PBD 30. Serum E2 levels were elevated after injury, then returned gradually to normal. In three patients who died, their mean T levels were significantly lower than patients who survived, but mean E2 levels were significantly higher than that of survivors. CONCLUSION: The activity of pituitary might be depressed after burn trauma. The imbalance between E2 and T might play a role in the processes of immuno-depression after injury. The changed extent of E2 and T levels was correlated to burn size. They could be sensitive indicators of burn stress.     

Locomotion of neutrophil granulocytes from patients with thermal injury. Identification of serum-derived inhibitors

Seven variables related to the migration of the PMN have been evaluated in a consecutive study of 33 thermally injured patients. Random migration and chemotactic response of the isolated PMN showed both depressed and enhanced cellular function as compared to a reference group. No apparent relation to burn size was seen. A chemokinetic ratio was constructed to investigate the responsiveness of the patient PMN to chemokinetically active serum factors. Significant reductions in the chemokinetic ratio were observed during the first 8 days after injury both in major (≥40 per cent) and in minor (<40 per cent) burns with the heaviest reductions seen in the major burn group. An inverse and significant (P<0?02) relationship was found between skin burn area and the chemokinetic ratio.Serum obtained during the first 1–2 weeks after injury contained increased amounts of heat-labile chemokinetic activity with significantly higher amounts in the major burns. Heat treatment (56°C for 30 min) of the sera revealed a reduced amount of heat-stable chemokinetic activity most apparent in the sera from patients with major burns. The reduction during the first 1–2 weeks was in most cases shown to be due to a deficiency of stimulatory activity whereas the reduction during the subsequent weeks predominantly was due to the presence of cell-directed inhibitors. Two kinds of cell-directed inhibitors of PMN migration have been identified. Both were heat stable and revealed no chemotactic activities. One interfered with the chemotactic response of the PMN and had an apparent molecular weight of 20–30 000. The other inhibited both the chemotactic response and random migration of normal PMN. This migration inhibitor was eluated from a Sephacryl S-200 column mainly at a molecular weight of 150–300 000 dalton. Four of 8 patients who died developed migration inhibitory activity in their sera. One patient with migration inhibitory activity has survived possibly due to plasmapheresis. This study shows the variety of dysfunction in mechanisms involved in PMN migration. Some appear to be primarily of cellular origin but most seem to be found in the environment i.e. in plasma. The study of these variables may provide a basis for a more successful treatment of thermally injured patients including measures such as plasmapheresis, plasma or granulocyte transfusions.     

Gunpowder explosion burns in fireworks factory: causes of death and management

The mortality rate of gunpowder explosion burns from fireworks factory accidents was high. The aim of this study was to evaluate the impact of different managements on outcome of these burns patients and to optimize treatment measures and decrease the morbidity and mortality. During the period from January 1987 to December 1999 in our center, 44 patients burned in gunpowder explosions died. Fifty sex-, age-, TBSA- and full-thickness-matched patients who survived were selected randomly as a comparison group. Data on time and causes of death, fluid resuscitation, and management of inhalation injury, associated injuries and wound were collected. Half of the deaths occurred during the first week after burn. The commonest cause of death was sepsis (27 patients), followed by MODS (11 patients), then hypovolaemic shock (4 patients) and pulmonary infection (2 patients). Thirty-six dead patients and 10 surviving patients had received insufficient fluid resuscitation and developed severe shock. Prophylactic tracheotomy was undertaken in 15 patients, of whom 6 died. Thirty-two patients had undergone emergency tracheotomies, of which 29 died. All associated injuries had been well-managed and no death was related to associated injuries or their complications directly. In the group of patients who died, 20 had undergone early excision (within 1 week of injury) and grafting. The number of patients in the survivor group who underwent early excision and grafting was 31. These results indicate that the sepsis and MODS are the two commonest causes of death for the patients who sustained burns by gunpowder explosions in fireworks factory. The optimal managements of this type of burn are as follows: (1) sufficient fluid resuscitation and invasive monitoring if necessary; (2) prophylactic tracheotomy and mechanical ventilation for the patients whose upper-airway edema is present or airway patency is threatened; (3) early excision and grafting of lager-deep wounds and covering with allograft with microautograft (1:10); (4) life-threatening associated injuries must be treated immediately after admitting.     

Patients with a head injury who "talk and die" in the 1990s

BACKGROUND: Patients who "talk and die" after head injury may represent a group who suffer delayed and therefore potentially preventable complications after injury. We have compared the clinical and pathologic features of patients who talk and die with those who "talk and live" after head injury. METHODS: Data collected prospectively by the Scottish Trauma Audit Group were used to identify patients with a head injury and classify them according to verbal response at admission to hospital. All "talking" patients in the catchment area of a regional neurosurgical center were selected and those who died were compared with those who survived. RESULTS: Seven hundred eighty-nine talking patients were identified. Seven hundred twenty-seven patients survived and 62 died. Patients who talked and died were older, had more severe extracranial injuries, had lower consciousness levels, and reached theater more quickly than those who talked and lived. Thirty-one of the patients that died had extra-axial hematomas. CONCLUSION: Even with increased availability of computed tomographic scanning, some patients still talk and die after head injury.     

Clinical outcome of HIV positive patients with moderate to severe burns

Human immunodeficiency virus (HIV) infection is a world wide and growing problem. Little is found in the literature concerning the treatment and outcome of patients suffering from HIV infection who are treated for burns. The aim of this study was to assess whether the outcome of HIV positive patients suffering from burn wounds differed from those who do not have HIV infection. Thirty three patients formed the HIV positive study group. HIV negative controls were matched for age, degree of burns, sex and inhalation injury. The mean age of the patients was 31.6 years and the mean total body surface burn was 26.4%. There was no significant difference in the outcome of the two groups in terms of mortality or treatment parameters measured. Two patients had stigmata of AIDS (tuberculosis) and both died. One patient, with a CD4 count of 228, developed severe necrotizing fasciitis. In keeping with other studies looking at the outcome of HIV positive patients in an Intensive Care Unit setting, we concluded that a HIV positive patient, who suffers from a burn wound and has no stigmata of AIDS, should be treated similarly to a HIV negative patient.     

Assault by burning--a reappraisal.

Assault by burning is a serious form of trauma that often results in higher incidence of inhalation injury, longer intensive care unit (ICU) and hospital stay, and higher mortality rate than is observed in the general burn population. We evaluated the epidemiology and outcome of assault burn victims treated in a tertiary burn center over a 6-year period. Among the 1063 acute burn patients who had been admitted to the Burns Unit between March 1993 and February 1999, 28 (2.6%) had assault burn injuries either by scald, chemical or fire. The mean extent of burn was 21.9%+/-20.8% (range 2-90%) total body surface area and the mean length of hospital stay was 65.2+/-107.3 days (range 1-565). Nineteen out of 25 patients (67.9%) underwent 76 operations. Nine patients had inhalation injuries requiring intubation and ICU admission. Three patients died in the series, which yielded a mortality rate of 10.7%. Compared to the general burn population, the assault burn group had significantly larger burn size (P<0.001), higher incidence of inhalation injury (P<0.001), longer ICU and hospital stay (P<0.001), and higher mortality rate (P<0.005). When these 28 victims were grouped according to the type of assault burn injury into a fire group, chemical group and scald group, all the 9 ICU admission and the 3 mortalities belonged to the fire group. Assault by fire resulted in larger burn size (P=0.03), more inhalation injury (P<0.001) and longer ICU stay (P=0.02). Although the fire group had a longer hospital stay and higher mortality rate, this was statistically insignificant.     

Ligustrazine attenuates acute lung injury after burn trauma

Acute lung injury is a common complication in patients with extensive burns in which the burned area exceeds 30% of the total body surface area (TBSA). This study was undertaken to evaluate the effect of Ligustrazine on burn-induced lung injury as well as the release of interleukin-8 (IL-8) in rats to characterize the role of Ligustrazine and IL-8 in lung injury after burn trauma. Sprague-dawley rats were divided into three groups: (1) sham group, rats who underwent sham burn; (2) control group, rats given third-degree burns over 30% TBSA and lactated Ringer solution for resuscitation; and (3) Ligustrazine group, rats given burn injury and lactated Ringer's solution with Ligustrazine inside for resuscitation. Pulmonary injury was assessed at 24 h by pulmonary capillary permeability determined with fluorescein isothiocyanate-labeled albumin and lung histologic analysis, and lung myeloperoxidase (MPO) activity as well as lung wet/dry weight ratio. The IL-8 levels were measured in serum by enzyme-linked immunosorbent assay. These studies showed that burn trauma results in increased pulmonary leakage permeability and lung wet/dry ratio, elevated serum IL-8 levels and MPO activity, and worsened histologic condition. Ligustrazine inhibited these changes, prevented burn-mediated lung injury, and the production of IL-8. This will likely provide further evidence for ligustrazine as a therapeutic strategy in burn-induced lung injury.     

The response of immunoglobulins to infection after thermal and nonthermal injury

Traumatic and thermal injuries are leading causes of mortality and morbidity due to their high incidence of infection. Host defense is vital to recovery in these patients yet incompletely understood. On days 1, 7, and 14, serum immunoglobulins of the IgA, IgG, and IgM classes were measured in 46 consecutive patients who sustained severe trauma with an injury severity score of at least 20. The patients were divided into four groups: 1) an uneventful recovery group (n = 11) of nonthermal trauma patients who did not become infected; 2) an infected nonthermal group without splenectomy; 3) an infected group of burn patients; and 4) 12 patients who underwent splenectomy of which nine became infected following nonthermal trauma. In each patient group, IgA, IgG, and IgM were all reduced, and group 1 had a steady return to normal range. Group 2 patients exhibited supranormal responses in all 3 classes at one week and supranormal IgA and IgG responses at two weeks. In contrast, both infected burn and splenectomized patients had markedly reduced IgG and IgM levels compared with the group 2 patients (P less than 0.05). Splenectomy sharply reduced IgM response to infection at 7 and 14 days compared with nonsplenectomized infected posttraumatic patients. Immunoglobulin response after trauma depended on the type of injury, presence of infection, splenic function, and type of immunoglobulin. Recognition of immunoglobulin deficiencies in both the burn and splenectomized patient may permit focused therapy, such as specific replacement of these proteins.     

Accident proneness and impulsiveness in an Italian group of burn patients

There is controversy about the existence of a predisposition to burn incidents (accident proneness). Our objective was to examine, in a group of burn patients, the conditions or "unconscious" subjective predisposition, the presence of impulsiveness that may have contributed to bringing about the "burn" event, and to assess the presence of psychiatric diagnoses and specific characteristics of temperament. 25 consecutive burn patients were interviewed by using specific psychometric tests. The sample was divided into two groups: "control" group (N=10), composed of subjects who had accidentally been involved in the incident and "case" group (N=15) composed of subjects who had very likely and more or less "knowingly" put themselves at risk of injury. We observed a marked statistically significant difference with case group subjects appearing to be more impulsive than the ones in control group. Higher levels of impulsiveness may predispose case group patients to a greater risk of burn. Our survey also seems to reveal a relationship between impulsiveness and the proneness of some subjects to burns.     

Radiological manifestation of pulmonary complications in deceased intensive care burn patients

The chest radiographs of 46 burn patients who died in the burn intensive care unit (BICU) were retrospectively analyzed to study the spectrum of pulmonary complications and their contribution to patient's mortality. There were 25 male and 21 female patients and their mean ages were 34 and 30 years, respectively. Forty-three patients had flame burns, two chemical, and one scald with a mean total burn surface area (TBSA) of 71%. Thirty-six of them had inhalation injury and of these 25 patients developed septicaemia. Out of these 46 patients, 39 had a total of 60 pulmonary complications on various postburn days. The commonest complications were consolidation (28.3%) and adult respiratory distress syndrome (ARDS) (26.7%) mainly due to inhalation injury and/or following septicaemia. The majority of these complications (46.7%) occurred in the late phase (postburn day 5 onwards). Forty-one (89.2%) patients died due to multi-organ failure (MOF) and a good number of them had secondary respiratory failure. The flame burn patients with large TBSA, presence of inhalation injury, and occurrence of septicaemia, are at risk for pulmonary complications that equally affect adult males and females. Pulmonary complications irrespective of the cause significantly contribute to the mortality. This study suggests that serial chest X-rays done in BICU form an important diagnostic tool for pulmonary complications from postburn day 1 onwards, and is useful for subsequent monitoring of the treatment. All burn intensive care units may not be privileged to have a full time radiologist, and intensivist. Therefore, the burn surgeon needs to metamorphose into an intensivist and double as a burn radiologist for early detection and quick treatment if his surgical skills are to be adequately rewarded.     

The total number of burn injuries in a Scandinavian population—a prospective analysis

During the period 1 September 1982 to 31 August 1983 the total number of burn injuries in the municipality of Copenhagen was recorded prospectively. The social changes and the constitution of the population are illustrated.

The total number of burn injuries showed a decrease of 33 per cent compared to the investigation in 1974/75. Scalds are still the most frequent cause of burn accidents, small children are especially vulnerable. Seventy-two per cent of all accidents occurred at home. Only a few patients required ‘antishock’ therapy. No patients with work-related burn injuries died.

Preventive measures have eliminated or reduced the number of some types of thermal injury.     

Changes in circulating levels of interleukin 6 in burned patients

Interleukin 6 (IL-6) levels in serial serum samples of 10 burned patients were analyzed. The total body surface areas (TBSA) of the burn injury varied from 30 to 85%. Among these 10 patients, five recovered and the other five, who were septic, expired. A significant difference in serum IL-6 values on admission (5-13 h postburn) was found (p < 0.05) between patients who survived or died from burn injury as analyzed by the Wilcoxon's rank sum test. In addition, a significant difference in serum IL-6 on admission was also found (p < 0.05) between patients with TBSA of greater or less than 50%. Afterwards, an initial peak serum IL-6 response was detected within 4 days postburn. Significant differences in the peak serum IL-6 levels were not found between patients with TBSA of greater or less than 50% and patients who survived or expired from burn injury. In the survivors, serum IL-6 remained low, while IL-6 increased markedly starting at about one to two weeks postburn in four of the five nonsurvivors with proven sepsis. Except for the patient who expired 42 days postburn, the maximum serum IL-6 values of the other four nonsurvivors were all greater than those of the five survivors from burn injury. Significant correlation (p < 0.05) relating the change in serum IL-6 and body temperature was observed in only two (one survivor and one nonsurvivor) of the ten patients. Changes in serum IL-6 were also compared with changes in circulating TNF-alpha and IL-8 determined previously. A similar pattern in the dynamic changes of circulating TNF-alpha, IL-8 and IL-6 was observed in the individual burned patient. An increase in serum levels of all three cytokines was detected postburn. Serum levels of three cytokines were significantly higher in the septic patients, who all died. It was considered that all three cytokines analyzed may play a significant role in the pathophysiology of sepsis in burned patients.     

The use of temporary diverting colostomy to manage elderly individuals with extensive perineal burns

The regimen of burn treatment for five elderly individuals who had sustained burns that had involved the perineum included formation of colostomy to divert fecal passage. The inclusion of diverting colostomy in this group of patients had made the management of burn wound that had included eventual skin grafting technically easy. A total of 168 patients were admitted to the Burn Unit at the Kagoshima City Hospital between 1997 and 2000. There were 36 patients who had perineal involvement. Of these, there were five elderly patients aged 60 years or older. There were two men and three women who were between 60 and 81 years of age. The mean age was 72 years. The total body surface involvement varied between 7 and 55% with an average body surface involvement of 30%. The sigmoid colon was as the colostomy site. Although, two patients died of injury, the morbidities associated with colostomy procedure were nil.