A policy of early excision and grafting in elderly burn patients shortens the hospital stay and improves survival

Early excision and grafting of the burn wound appears to shorten the hospital stay and decrease mortality in children and adults. However, whether an early surgical approach is safe in elderly burn patients has not been resolved. To answer this question we carried out a prospective study of early surgery in 114 consecutive patients over the age of 50 years. Patients were generally operated on between post-burn days 2 and 5. The mean age of the patients was 68 years, with a burn size of 22 per cent, of which 13 per cent was full thickness skin loss. The mean hospital stay of the surviving patients was reduced by 40 per cent compared to national averages (P less than 0.001). The mortality rate for the entire group of patients was 17 per cent, with 2 deaths in the 65 patients with burns less than 20 per cent total body surface area (TBSA). Although the mortality rate for patients with burns greater than 20 per cent TBSA was 35 per cent, this was less than predicted (P less than 0.05). The improvement in survival appeared to be due to a decrease in the incidence of lethal burn wound infections.     

Determinants of death following burn injury

BACKGROUND: Burn care has changed considerably. Early surgery, nutritional support, improved resuscitation and novel skin replacement techniques are now well established. The aim of the study was to establish whether changes in management have improved survival following burn injury and to determine the contributory factors leading to non-survival. METHODS: This was a retrospective outcome analysis of data collected from a consecutive series of 4094 patients with burns admitted to a tertiary referral, metropolitan teaching hospital between 1972 and 1996. RESULTS: The overall mortality rate was 3.6 per cent. This decreased from 5.3 per cent (1972--1980) to 3.4 per cent (1993--1996) (P = 0.076). The risk of death was increased with increasing burn size (relative risk (RR) 95.90 (95 per cent confidence interval 12.60--729.47) if more than 35 per cent of the total body surface area was burned; P < 0.001) increasing age (RR 7.32 (3.08--17.42) if aged more than 48 years; P < 0.001), inhalation injury (RR 3.61 (2.39--5.47); P < 0.001) and female sex (RR 1.82 (1.23--2.69); P = 0.003). Operative intervention (RR 0.11 (0.06--0.21); P < 0.001) and the presence of an upper limb burn (RR 0.53 (0.35--0.79); P = 0.002) decreased the risk. CONCLUSION: Modern burn care has decreased the mortality rate. Increasing burn size, increasing age, inhalation injury and female sex increased, while operative intervention and an upper limb burn decreased, the risk of death. Presented to the 10th Congress of the International Society for Burn Injuries, in Jerusalem, November 1998     

Anaphylatoxin formation in plasma and burn bullae fluid in the thermally injured patient

Plasma anaphylatoxins (C3a and C5a) were measured in 19 thermally injured patients with a mean total burned surface area of 39 per cent (range 10-90 per cent) of partial and full skin thickness loss. Extensive burns were associated with increased anaphylatoxin activity. Patients with greater than 50 per cent burned surface area had higher plasma C3a and C5a concentrations than patients with 10-25 per cent burns (P less than 0.001) 1 week after injury. Six out of seven patients with greater than 50 per cent burned surface area developed adult respiratory distress syndrome (ARDS) and four out of seven bacteraemia. Twelve patients had 10-25 per cent burns and none of them developed ARDS or bacteraemia. The mean C3a concentration per millilitre of fluid from the burn bullae from nine different individuals was 2570 +/- 260 ng/ml. The C5a content in fluid from the bullae did not differ from the corresponding plasma range. Increased anaphylatoxin activity might explain extensive extravasation of fluid in burned patients. This increase might also be one reason for leukocyte accumulation in burned areas.     

Long-term experience with 1 per cent topical silver sulphadiazine cream in the management of burn wounds

Three hundred and forty-two patients with 10–50 per cent body surface area burns were studied prospectively over the 5-year period from 1982 to 1986 for the effectiveness of topical 1 per cent silver sulphadiazine. Various parameters were studied including: (i) healing time of deep partial skin thickness burns, (ii) eschar separation time, (iii) conversion rate of deep dermal burns to full skin thickness burns, (iv) burn wound surface bacterial flora and their changing pattern over the years, (v) incidence of invasive sepsis and (vi) overall mortality. There was a remarkable decrease in the time taken for the healing of deep dermal burns, and the conversion rate of deep dermal burns to full skin thickness was significantly reduced. Eschar separation was delayed considerably. There was a total change in the predominent surface micro-organisms from Staph. aureus, which was predominant in 1982, to pseudomonas species and klebsiella in 1986. Moreover, there was the emergence of a new variety of micro-organism within the last 2 years. The incidence of invasive infection and overall mortality was significantly reduced.     

Peripheral neuropathy in burn patients

Neuropathy in burn patients is frequently overlooked. This study aimed at looking for neuropathies among burn patients. It included 55 burn patients, whether symptomatic or asymptomatic, with variable depths of burn at different stages. Their ages ranged from 8 to 55 years with a mean age of 23.6 ± 11.1 years. All patients were submitted to clinical examination, electromyographic and motor conduction velocities of burned and unburned limbs. Serum electrolyte, blood urea and creatinine were measured for all patients. Sixteen patients (29 per cent) had peripheral neuropathy. Only six had symptoms and signs of peripheral neuropathy. The most frequently diagnosed neuropathy in this study was mononeuritis multiplex in nine patients (56 per cent), then generalized distal axonal neuropathy in five patients (31 per cent) and entrapment neuropathy in two patients (13 per cent). In patients with mononcuritis, 29 nerves were affected, 24 nerves related to the site of the burn and five nerves were away from the site of the burn. All the entrapment neuropathy developed after wound healing. Age above 20 years, electric burns, burns involving full thickness of the skin and a surface area of more than 20 per cent were associated with a significantly higher prevalence of neuropathy. Other parameters were not found to be significant in the development of neuropathy.     

Long-term psychosocial adjustment in patients with severe burn injuries: a follow-up study.

An investigation of the long-term psychosocial adjustment of patients with severe burn injuries is presented. In the selected 13-year period (1968-80) 46 patients fulfilled the entry criteria: burns covering more than 30 per cent body surface area (deep dermal or full skin thickness). Seventeen patients died early and one later. Of the remaining 28 patients, contact was made with 25 (89.3 per cent) who all participated. The observation time ranged between 7 and 21 years. The patients received a semi-standardized interview adjusted for age at the time of burn injury, a psychiatric interview and a physical examination to assess the permanent character and functional loss. The principal findings were: no correlation could be found between degree of disfiguration/function loss and the long-term psychosocial adaptation after severe burn injuries. The determinant factor was the premorbid psychiatric/psychological integration and, to some extent, support from staff and relatives.     

Work-related burns: a 6-year retrospective study

During the 6 years from July 1984 to May 1990, 193 patients (30.2 per cent of all patients) were admitted to our regional adult burn centre, for treatment of work-related burn injuries. The median age of patients was 32.5 years (range 18-64 per cent), and 94 per cent were males. Fifty-nine per cent of the patients came from metropolitan Toronto, and 40 per cent from rural Ontario. Most of the patients (97.3 per cent) were referred to the burn centre within 24 h of their injury. The most common aetiology was electrical injury (29.5 per cent), followed by flame (24.4 per cent), contact (10.4 per cent), flash (9.8 per cent), tar and asphalt (9.3 per cent), scald (7.8 per cent), chemical (5.1 per cent), steam (4.7 per cent) and grease (1 per cent). Within the electrical burn group, about one-half were flash burns, one-quarter were clothing fire injuries, and one-quarter were contact injuries. These occupational burns tended to be extensive injuries. The median body surface area (BSA) was 16.5 per cent, with a median full thickness (FT) component of 5.0 per cent. The average length of stay was 20.0 days. Inhalation injury requiring intubation occurred in 14.8 per cent of patients. Sepsis--confirmed by positive blood cultures--developed in 14 per cent of the patients, at an average time of 8.8 days postburn. Staphylococcus aureus was the commonest organism isolated from blood cultures. Pneumonia occurred in 6.3 per cent of patients. A total of 207 surgical procedures was performed on 113 of the 193 patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Causes of death in aged burn patients: analysis of 36 cases

Over a 10-year period 110 patients over the age of 65 years were admitted to the Burn Center, Rui Jin Hospital and 36 (32.7 per cent) died. Significant differences between the survivors and non-survivors were related to the total burn surface area and full skin thickness burn size. Among the causes of death, pre-existing cardiopulmonary diseases and associated inhalation injury were particularly important since pneumonia was considered as a primary cause of death in 13 patients, myocardial disease in two, cor-pulmonale and heart failure in two. Care of the early fluid resuscitation, early excision of deep burn wounds and grafting, prevention or treatment of a variety of life-threatening complications, and nutritional supplementation appeared to decrease the mortality of aged burn patients.     

Epidemiological pattern of adult burn injuries

An epidemiological survey of 411 patients over a period of five and a half years is analysed. There were no yearly trends but there was a slight increase in the number of female burns during the survey. There were 293 males, 71.3 per cent and 118 females, 28.7 per cent. The majority of the burns occurred in the younger age groups and reflect the cause of the injury. Approximately one-half of the injuries were burns of less than 10 per cent and three-quarters were of less than 20 per cent. The most extensive burns were caused by petrol and clothes fires. Predisposing conditions were present in 23.8 per cent of the patients, with alcohol abuse figuring prominently. Epilepsy was present in 2.7 per cent of the patients. The major predisposing conditions, causes and complications of the burn injuries are discussed. Burn infection occurred in 18.2 per cent of the patients and septicaemia in 3.5 per cent. There was a mortality rate of 8.3 per cent and the average length of hospital stay was 22.9 days. While these burns are mainly preventable it is difficult to see how this can be fully achieved.     

Profile of the paediatric burn patient in a Canadian burn centre.

Five hundred and eighty-three children (0-18 years old), consisting of 33.4 per cent of all burn inpatients, were admitted to the University of Alberta Hospitals over an 11-year period (January 1978 to December 1988). Demographic and outcome variables, in addition to aetiological factors, were examined. 48.4 per cent of burns occurred in children less than 4 years of age, with males predominating in every age group (P less than 0.001). Children had smaller burns, a higher incidence of scalds, less inhalation injuries and a lower mortality compared to adult burn patients admitted over the same time period (P less than 0.05). There was a low incidence of confirmed child abuse by burns (1.4 per cent). High-risk environments identified were the home (74.6 per cent of burns) and recreational settings (12.4 per cent of burns), mainly occurring around campfires. Native children were overrepresented in the burn population compared to the general population by a factor of approximately 10:1. Scald prevention, high-risk environments (home and recreational), high-risk populations (male and natives) and unsafe practices with flammable liquids (petrol in particular) should be emphasized in paediatric burn prevention programmes.     

The last 10 years in a burn centre in Ankara, Turkey: an analysis of 5264 cases

This is a retrospective study analysing 5264 patients treated in the burn centre at Gülhane Military Medical Academy from 1 January 1986 to 31 December 1995. Our burn centre is not only the firs, but one of the best established and supported in Turkey. Our present study has the largest patient group of other previously published studies from Turkey. Of the total patients studied, 4464 patients had minor burns and were treated on an outpatient basis and 800 patients had moderate to major burns. Although our centre is in a military area in Ankara, only 1047 (20 per cent) patients were military personnel and the military-related burn causes comprised only 6 per cent of the total. The remaining 4217 (80 per cent of the total patients) were civilians. Flame injuries were also more frequent in military patients than civilians. Minor burns were most common in the age group 0–10 years old (40 per cent) and moderate to major burns in the age group 21–30 years (54 per cent). Scalds were the main cause of paediatric burns. Male patients were dominant. The overall mortality among inpatients was 18.2 per cent and mean total body surface area (TBSA) was 57.6 per cent in patients who died. 134 patients demonstrated inhalation injury and 82 per cent of these patients died. The epidemiological pattern of our patients is similar to that in other studies from developed countries, although some ethnic causative factors could be found. Our study indicates that emergency measures should be taken to prevent flame injuries at military barracks and industrial workplaces and scalding accidents to children at home and throughout the country.     

Combination alkali/thermal burns caused by 'black liquor' in the pulp and paper industry.

Three patients are presented, who sustained a unique type of burn injury while working in the pulp and paper industry in Canada. These patients suffered combination chemical (pH 11-13) and thermal (85-95 degrees C) injuries, when they were exposed to 'black liquor'--a solution which is used in the pulp and paper industry to convert wood chips to pulp. Black liquor can rapidly cause devastating thermal-corrosive burns to the skin, eyes, lungs, and upper gastrointestinal tract. One patient sustained a relatively minor, full skin thickness 3 per cent body surface area (BSA) injury to both feet and lower legs. The second patient, who was sprayed with the heated black liquor solution, sustained a full skin thickness injury to 40 per cent BSA and also suffered virtual loss of vision in one eye. The third patient, who was also sprayed with the solution, sustained a 98 per cent full skin thickness burn and severe inhalation injury, and died during day 1 postburn. Photographic documentation of all three patients is presented. The principles of treatment of this type of burn injury are reviewed. All of these burns were preventable.     

Occupational burn injuries

The epidemiology of occupational burns injuries in a well-defined population is analysed. Although a total of 371 persons sustained an injury, only a few were inpatients and just one required anti-shock treatment. The mean burn surface area was 0.66 per cent and 14 patients had full thickness burn injuries. There were no deaths. Men were found to be more prone than women to injury, especially young workers. The distribution by categories of work and causes of burn are illustrated. Scalds and contact burns were dominant, particularly in restaurants. The work by the National Labour Inspection is acknowledged.     

A comparison of conservative versus early excision. Therapies in severely burned patients.

Early excision and grafting of small burn wounds is a generally accepted treatment. Early excision of burn injuries greater than 30% total body surface area (TBSA) in adults, however, has not been universally accepted. In this study, 85 patients whose ages ranged from 17 to 55 years with greater than 30% total body surface area (TBSA) burns were randomly assigned to either early excision or topical antimicrobial therapy and skin grafting after spontaneous eschar separation. Mortality from burns without inhalation injury was significantly decreased by early excision from 45% to 9% in patients who were 17 to 30 years of age (p less than 0.025). No differences in mortality could be demonstrated between therapies in adult patients older than 30 years of age or with a concomitant inhalation injury. Children (n = 259) with similar large burns treated by early excision showed a significant increase in mortality with increasing burn size and with concomitant inhalation injury (p less than 0.05). The mean length of hospital stay of survivors was less than one day per per cent of TBSA burn in both children and adults.     

Hand burns in children under 5 years of age

In order to evaluate the epidemiology and functional results of hand burns in young children, 92 consecutive patients (126 hand burns) under age 5 years admitted to a Burn Center were reviewed. Scald burns (49 per cent) were most common, followed by flame (34 per cent), contact (14 per cent) and electrical burns (3 per cent). The child was left unattended by an adult in 53 per cent of cases and documented abuse was present in 6 per cent. The mean total body surface area (TBSA) burned was 17 per cent, and 77 patients (85 per cent) had additional burns in other areas (arms 34 per cent, legs 31 per cent, chest 29 per cent and face 27 per cent).

Palmar burns occurred in 24 hands (19 per cent), dorsal in 41 (33 per cent), while both surfaces were burned in 61 (48 per cent). Joints involved included the MP in 96 (76 per cent). PIP in 87 (69 per cent) and DIP in 80 (63 per cent). The depth was superficial partial thickness in 53 (47 per cent), deep partial in 55 (44 per cent), and full thickness in 18 hands (14 per cent); a total of 29 hands were grafted (15 deep partial and 14 full thickness). Escharotomies were required in 12 hands (9 per cent) (9 flame and 3 scald) and partial amputation of digits was required in 3 (2 per cent).

Follow-up was available in 46 hands from 7 to 120 months (mean 39 months). Partial thickness burns (34) healed with normal (32) or near-normal (2) hand function and developmental delay occurred in one patient. Hand function in 12 full thickness burns was normal in 9, decreased in 3 with developmental delay in 2 patients. The number of reoperations required per hand burned after hospital discharge varied with age (2 years and under 1.2 vs. over 2 years 0.6), depth (deep partial 0.4 vs. full thickness 1·6) and surface involved (palmar 1.3 vs. dorsal 0.1 vs. both 1.5), indicating that children under 2 years with full thickness palmar burns are at increased risk of developing burn scar deformities requiring surgical correction. Although 24 total reoperations were required in 25 deep partial and full thickness hand burns, residual burn scar deformities were present in only 2 hands at follow-up (1 boutonniere and I web space contacture).

It is concluded that the overall outcome of hand burns in this age-group is good and developmental delay is rare with proper acute management and prompt surgical correction of burn scar deformities.     

镇江地区五年来职业烧伤回顾性调查

对镇江地区1986～1991年221例职业烧伤病例进行了分析总结。本组平均年龄31.2岁,男性占83.4%,79.6%的病人在伤后24 h 内入院。首位致伤原因为火焰(33%)。平均烧伤面积17.1%,平均Ⅲ度面积8.1%。8.1%的病人并发吸人性损伤。本组死亡率为1.8%。平均住院时间34.3天,平均住院费用3千余元。文章强调对职业烧伤的现场急救和正确的早期处理,讨论了降低职业烧伤发病率的初步设想,旨在为劳保部门和其它地区职业烧伤研究提供参考。     

Some problems in blood transfusions in burn patients

A decrease in the blood volume and its components was found in 65 burn patients, graded in 3 groups according to the degree of the injury and the burned surface area. The blood volume is restored after the first 24 hours in patients with superficial burns. The RBC volume, however, is not restored and demonstrates a tendency to decrease during the shock phase in patients with moderate and severe burns. These patients need the first blood transfusion about the twenty-fourth hour after the injury.Antileucocyte iso-antibodies in 66 per cent, antierythrocyte antibodies in 24·5 per cent and anti-platelet antibodies in 5·6 per cent were demonstrated in burn patients who had received multiple blood transfusions. The iso-immunization may be avoided using leucocyte and erythrocyte compatible blood. This is a way to avoid the post-transfusion reactions and the danger of early rejection of allotransplanted skin grafts.     

镇江地区五年来职业烧伤回顾性调查

对镇江地区１９８６～１９９１年２２１例职业烧伤病例进行了分析总结。本组平均年龄３１．２岁，男性占８３．４％，７９．６％的病人在伤后２４ｈ内入院。首位致伤原因为火焰（３３％）。平均烧伤面积１７．１％，平均Ⅲ度面积８．１％。８．１％的病人并发吸入性损伤。本组死亡率为１．８％。平均住院时间３４．３天，平均住院费用３千余元。文章强调对职业烧伤的现场急救和正确的早期处理，讨论了降低职业烧伤发病率的初步设想，旨在为劳保部门和其它地区职业烧伤研究提供参考。     

A quantitative assessment of blood loss in burn wound excision and grafting

A prospective study was performed that allowed a quantitative estimation of blood loss in excision and grafting of adult burn injuries. The average value for blood loss was 9.2 per cent of the patient's estimated blood volume or 387 ml per 1 per cent burn excised and grafted. There was no exponential increase in blood loss as the percentage excised and grafted increased apart from proportionality and there was no statistical difference between males and females for burns excised and grafted days 1–14 after injury or greater than 14 days after injury. It was therefore concluded that a useful working figure is 400 ml whole blood or 10 per cent of patient blood volume is lost per 1 per cent full thickness burn excised and grafted for an adult. These values do not apply to the very young, the very old and those patients who have bleeding disorders, and when using various methods to limit blood loss. This figure allows adequate cross-matched whole blood to be available preoperatively.     

Survival of an infant with massive thermal injury: a case report

Survival of infants with greater than 80 per cent body surface area burns has not been well documented. Survival of a 4-month-old infant with 80 per cent full skin thickness flame injury is reported. Data from the National Burn Information Exchange showed that there were 2266 infants under 8 months of age treated for burns in reporting hospitals. Only four children of the 2266 were treated for full skin thickness thermal injury covering more than 80 per cent TBSA and none survived except for the child reported here. It was felt that early aggressive excision of the burn eschar was an important factor leading to the survival of this infant. Complex rehabilitation issues related to developmental issues as well as physical and psychosocial needs were identified and addressed throughout her time in hospital by a multidisciplinary team to ensure the best possible quality of life.