Präklinische Versorgung einer lichtbogenbedingten schweren Verbrennung an einer Bahnoberleitung

Severe burns due to electrical accidents occur rarely in Germany but represent a challenge for emergency physicians and their team. Apart from extensive burns cardiac arrhythmia, neurological damage caused by electric current and osseous injury corresponding to the trauma mechanism are also common. It is important to perform a survey of the pattern of injuries and treat acute life-threatening conditions immediately in the field. Furthermore, specific conditions related to burns must be considered, e.g. fluid resuscitation, thermal management and analgesia. In addition, a correct strategy for further medical care in an appropriate hospital is essential. Exemplified by this case guidelines for the treatment of severe burns and typical pitfalls are presented.     

Pathophysiology of nerve regeneration and nerve reconstruction in burned patients

In extensive burns peripheral nerves can be involved. The injury to the nerve can be direct by thermal or electrical burns, but nerves can also be indirectly affected by the systemic reaction that follows the burn. Mediators will be released causing a neuropathy to nerves remote from the involved area. Involved mediators and possible therapeutic options will be discussed. In burned patients nerves can be reconstructed using autologous nerve grafts or nerve conduits. A key factor is an adequate wound debridement and a well-vascularized bed to optimize the outgrowth of the axons. Early free tissue transfers have shown promising results.     

Management of acute calvarial burns in children

BACKGROUND: Although rare, head burns involving the calvarium are a serious complication of burns and electrical injury, and present therapeutic challenges to the surgical burn care team. We evaluated our experiences and compared available strategies to address this challenge. METHODS: Records of all burned children between January 1986 and December 2000 were reviewed. Twenty-seven children (15 boys and 12 girls) with scalp burns extending at least into the outer table of bone were identified and compared with a matched group of 30 patients admitted for acute thermal burns without skull injury. RESULTS: Flame burn was the injury mechanism in 78% of these patients and electrical injury was the injury mechanism in 22%. The incidence of calvarial burns in our patient population was 1.2% for thermal burns and 5.6% for electrical injuries during the study period. The age distribution was biphasic, with maximums in infancy for thermal burns and in puberty for electrical injuries. Eight of 27 patients (29.6%) developed full-thickness calvarial bone defects. In 23 patients, calvarial burn wound coverage was achieved with bone debridement and immediate or delayed placement of autograft skin. In four patients (all with electrical injury), local scalp flaps were required for closure. The length of hospital stay and overall number of acute operative procedures significantly increased for patients with calvarial burns. CONCLUSION: Acute calvarial burns are safely managed by bone debridement in combination with staged autografting or early flap coverage. Although flap coverage reduces the number of required procedures, the extensive wound size in thermal burns restricts acute flap procedures primarily to electrical injuries. Compared with patients without skull injury, length of hospital stay and the number of acute operative procedures are tremendously increased in patients with calvarial burns.     

Critically ill polyneuropathy associated with burns: a case report

A severe sensorimotor peripheral neuropathy is reported in a patient with burns covering 35 per cent of the body surface area, severe sepsis and acute renal failure. It presented as difficulty in wearing the patient from a ventilator. Attention is drawn to the condition of critically ill polyneuropathy which has been recently noted in severe illnesses and sepsis. From a search of the literature we believe this to be the first report of this condition in association with thermal injury.     

Brachial plexus traction injuries.

Brachial plexus traction injuries most frequently occur following acute flexion or extension of the neck. The symptomatology following this injury may be defined clearly into the anatomic patterns of upper trunk, lower trunk, posterior cord, medial cord, and lateral cord radiations. This injury is the most common cause of the neurogenic form of thoracic outlet syndrome and is frequently seen in conjunction with cervical spine disease as well as peripheral entrapment syndromes of the ulnar, radial, and medial nerves.     

The "Friday Mass" burns of the feet in Saudi Arabia

Twelve cases of feet burns sustained because of standing or walking barefoot on the street following the "Friday Mass" were included in a prospective study. All injuries occurred during the summer months when the ground temperature is estimated to be in the range of 50-60 C. There were 2 children and 10 adults. Eight out of the 10 adults were diabetics with significant peripheral neuropathy. Non-diabetic patients with intact sensibility of the feet developed second degree burns that mainly involved the anterior part of the soles. On the other hand. diabetic patients with peripheral neuropathy developed deep burns that involved the entire weight-bearing area of the sole. Furthermore, in one diabetic patient with superimposed significant peripheral vascular disease this burn injury induced toe pulp necrosis. Treatment and prevention of these burns are discussed.     

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.     

Phagocytosis in experimental burns

The variations of phagocytic activity have been measured during a 9-day period following experimental burns. The burns are of an intermediate type; necrosis develops within 2 to 4 days after thermal trauma and covers up to 10% of total body surface.Phagocytic activity has been measured in peripheral blood, spleen, and liver by measuring both clearance of bacteria and the bactericidal index of the macrophages.Shortly after burn trauma, a considerable inactivation of the bactericidal index has been noticed. The decrease of the phagocytic activity of macrophages in the liver and peripheral blood is important but transient; the decrease of the phagocytic activity of splenic macrophages is drastic and persists unimproved for at least 9 days following burn injury.     

Lipoma causing a posterior interosseous nerve syndrome

. Posterior interosseous nerve syndrome is an entrapment neuropathy of the deep terminal branch of the radial nerve – the posterior interosseous nerve – at the radial tunnel. Radial neuropathy without prior injury or other obvious etiology occurs frequently. However, sometimes previous trauma, surgery, or tumors over the radial nerve contribute to chronic entrapment and can produce the classic syndrome. In this report we describe an unusual case of a 68-year-old-woman with a chronic posterior interosseous nerve syndrome due to a lipoma. The patient had poor recovery after surgery, despite splinting and rehabilitation physiotherapy, mainly because of the long duration (2 years) and severity of the compression neuropathy.     

Nerve and muscle disorders and their sequelae

A number of diseases of the nervous system, especially upper neuron lesions, produce ankle and foot deformities. Such deformities can be the single most important reason why some patients become nonambulatory. This article reviews the impact of upper motor neuron lesions such as traumatic brain injury, stroke, multiple sclerosis, neurodegenerative disorders, and low motor neuron lesions such as peripheral nerve injury, neuropathy, entrapment syndromes, and muscle diseases. This article also reviews diagnostic tests including EMG and nonsurgical management.     

Multiple trauma and the burn patient

Multiple trauma greatly complicates the care of the burn patient, whereas a burn often complicates the diagnosis and treatment of the trauma patient. One hundred seventy-six of 3,550 consecutive acute burn admissions received nonburn trauma. The majority of injuries were sustained in motor vehicle accidents (70), escaping fire (32), electrical burns with falls (24), scald burns associated with assault (22), and explosions (18). Eighty patients received orthopedic injuries, including major (47), minor (25), and multiple (28) fractures, 10 dislocations, and 4 open joints. Soft-tissue injury occurred in 91 patients, head injury in 30, thoracic trauma in 27, and abdominal injury in 15. Unstable orthopedic injuries were major contributors to morbidity. Early internal and external fixation permitted optimal mobilization and wound care. Awareness of the potential for multiple injuries and the team approach to these injuries are the most important factors in appropriate care.     

Assessment of burn injury in the accident and emergency department: a review of 100 referrals to a regional burns unit.

Accurate assessment of the extent of thermal injury in the accident and emergency (A&E) department is essential if appropriate resuscitation and referral to a specialist unit is to occur. However, review of 100 referrals to a regional burns unit confirms that assessment is often inaccurate, and usually undertaken by no one more senior than a casualty officer, leading to suboptimal treatment and referral. Severe thermal injury should be assessed by a team of senior doctors, according to the major trauma protocol, and casualty officers should receive better training in the assessment of less extensive burns.     

The importance of a multidisciplinary approach in the treatment of mutilating electrical injury: a case study

Electrical burns are not ranked among the most frequent type of injuries, but they have the most devastating potential of all thermal injuries and often cause lifelong stigmatization. Those primarily affected are young males: work injuries predominate. An electrical burn is a specific nosological unit that has multiple acute and chronic abnormal manifestations. In this study we describe the case of a young man who suffered an electrical injury after contact with a high-voltage line (22,000 volts) while paragliding. This contact was followed by a 10 m fall. In our work we present the need for multidisciplinary cooperation along with the opportunities, problems and risks that accompany the treatment of this type of injury.     

Trauma der Wirbelsäule und Bandscheibe

In the literature, the association between chronic pain syndromes of the spine and sustained "trifle trauma" is a matter of controversy. "Trifle trauma" is identified as a contusion, compression and/or sprain without a definite, acute imaging sign of injury to the bone, the disk or the ligaments of the spine. Most of the time, striking isolated changes to the intervertebral disks are interpreted as preexisting without relevance to an acute injury. However, complex chronic pain syndromes causing permanent and significant functional limitations in daily life and work may occur. Besides the diagnostic and therapeutic challenge for the treating physician, the expert confronted with compensation claims very often has to answer questions as to whether "trifle trauma" of the spine may lead to significant and permanent functional limitations or loss with chronic pain syndromes, and what the importance of possible isolated changes in intervertebral disks is. The data from literature dealing with this topic is contradictory and deficient. In this article, we critically examine the causality between "trifle trauma" to the spine and possible permanent chronic complaints based on currently available data from the literature in order to support the process of decision making in questions of litigation and controversial compensation claims.     

Imaging of peripheral nerve lesions

The imaging of peripheral nerve lesions remains limited to the radiographic demonstration of secondary skeletal lesions in birth trauma, reflex sympathetic dystrophy, neuropathic arthropathy, leprosy, and congenital indifference to pain. Nerve root avulsions can be imaged directly and the newer imaging modalities now allow delineation of lesions that previously could not be studied using conventional radiography. The ability of ultrasound, CT, and MRI to differentiate soft tissue structures makes it possible, in many instances, to study the primary abnormality in trauma, nerve entrapment syndromes, and tumors. With fractures, the possibility of trauma to adjacent nerves can only be inferred on the radiographs, while the role that peripheral nerve injury plays remains controversial in other entities, such as amputation with replantation. Imaging of peripheral nerve lesions remains in its infancy. With further refinement in the signal-to-noise ratio made possible by advances in MRI technology, we may be optimistic about future imaging of peripheral nerve pathology.     

The prevalence of hereditary neuropathy with liability to pressure palsies in patients with multiple surgically treated entrapment neuropathies

PURPOSE: Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal-dominant peripheral neuropathy that results from deletion of a 1.5-Megabase pair (Mb) segment of the short arm (p) of chromosome 17. Hereditary neuropathy with liability to pressure palsies increases susceptibility of peripheral nerves to pressure and trauma and can be associated with symptoms at multiple anatomic entrapment sites. Many patients present with multiple upper-extremity entrapment neuropathies and the etiology is uncertain. We hypothesized that some of these patients have an underlying hereditary neuropathy. The purpose of this study was to determine the prevalence of HNPP in patients with multiple surgically treated upper-extremity entrapment neuropathies. METHODS: The inclusion criterion for the study was history of more than 1 carpal tunnel release and/or ulnar nerve transposition. The exclusion criteria were history of diabetes or history of Charcot-Marie-Tooth neuropathy. Fifty-nine patients were in the study group. Two patients known to have the 17p11.2 deletion were used as controls. Genomic DNA was extracted from peripheral blood. Each sample was genotyped using polymerase chain reaction (PCR) amplification with short tandem repeat polymorphism markers within the 1.5-Mb region of 17p deleted in HNPP. Markers were scored as homozygous or heterozygous after resolution by polyacrylamide gel electrophoresis and silver staining. RESULTS: The 2 control patients were homozygous for 11 markers. None of the 59 study patients were homozygous for all markers tested in the deleted region. No study patient had the 17p deletion diagnostic for HNPP. Based on the sample size of 59 patients the 95% confidence interval for the prevalence of the 17p11.2 deletion in this population is 0% to 5%. CONCLUSIONS: We found no evidence for an association between HNPP and patients who have multiple surgical releases for upper-extremity entrapment neuropathies.     

Isolated medial foot compartment syndrome after ankle sprain

Foot compartment syndrome is a serious potential complication of foot crush injury, fractures, surgery, and vascular injury. An acute compartment syndrome isolated to the medial compartment of the foot after suffering an ankle sprain is a rare complication.We report the case of a 31-year-old man who developed a medial foot compartment syndrome after suffering a deltoid ligament rupture at ankle while playing football. The patient underwent a medial compartment fasciotomy with resolution of symptoms.Compartment syndromes of the foot are rare and have been reported to occur after severe trauma. But, there are some reports in the literature of acute exertional compartment syndrome. In our case, the compartment syndrome appeared after an ankle sprain without vascular injuries associated.     

Crush injuries of the foot in the industrial setting

Over the years patients with relatively minor compressive injuries seem to have a different morbidity, largely because of a constellation of neurologic findings, including dysesthesia and hyperesthesias. These are usually multifocal, and often extend far beyond the point of impact of the crushing force. Neuroischemia may play a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This direct trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated pain syndrome. For the injured worker, these problems seem to be magnified. Early recognition of the extent of injury, the zone of injury, and the need for early soft tissue coverage is essential. With expeditious treatment, wound coverage, treatment of compartment syndromes, and early aggressive rehabilitation, many of the complications of these injuries, including chronic pain syndromes, can be minimized.     

Neurosurgical approaches to pain treatment

In a multidisciplinary approach to the management of chronic pain, neurosurgical methods are an indispensable part of the therapeutic armamentarium. With the exception of percutaneous interventions for trigeminal neuralgia and facet joint syndromes, most ablative pain surgery procedures (neurotomy, rhizotomy, sympathectomy, etc.) have been replaced by neuromodulatory approaches such as electrical stimulation of the central nervous system (CNS). However, cordotomy is still a valuable operation for certain forms of cancer related pains (Pancoast's syndrome, breakthrough pain) which are relatively resistant to pharmacotherapy. Another example of ablative surgery is the dorsal root entry zone (DREZ) operation, which is generally the only treatment option for pain due to root avulsion and segmental pain in spinal cord injury. Spinal cord stimulation (SCS) has proven to be most useful for the management of pain following peripheral nerve injury (including complex regional pain syndromes) and rhizopathy. For these conditions which are otherwise often therapy resistant, SCS may produce substantial and long-lasting pain relief in 60-70% of the patients. Considering that such pains are common and the fact that SCS has been shown to be cost-effective, this treatment is no doubt at present underused. Complications and side-effects are very rare. SCS has also been found to be useful for pain in peripheral vascular disorders and angina pectoris. In the latter condition the overall results are favorable in about 80% of patients with a significant reduction of the frequency and severity of angina attacks and the need for nitrates. Stimulation of the motor cortex is a novel and promising treatment of central, post-stroke pain and painful trigeminal neuropathy.     

The impact of severe burns on skeletal muscle mitochondrial function

Severe burns induce a pathophysiological response that affects almost every physiological system within the body. Inflammation, hypermetabolism, muscle wasting, and insulin resistance are all hallmarks of the pathophysiological response to severe burns, with perturbations in metabolism known to persist for several years post injury. Skeletal muscle is the principal depot of lean tissue within the body and as the primary site of peripheral glucose disposal, plays an important role in metabolic regulation. Following a large burn, skeletal muscle functions as and endogenous amino acid store, providing substrates for more pressing functions, such as the synthesis of acute phase proteins and the deposition of new skin. Subsequently, burn patients become cachectic, which is associated with poor outcomes in terms of metabolic health and functional capacity. While a loss of skeletal muscle contractile proteins per se will no doubt negatively impact functional capacity, detriments in skeletal muscle quality, i.e. a loss in mitochondrial number and/or function may be quantitatively just as important. The goal of this review article is to summarise the current understanding of the impact of thermal trauma on skeletal muscle mitochondrial content and function, to offer direction for future research concerning skeletal muscle mitochondrial function in patients with severe burns, and to renew interest in the role of these organelles in metabolic dysfunction following severe burns.