An analysis of burn mortality: a report from a Spanish regional burn centre

This paper reports an analysis of the mortality rates and related factors in our Burn Centre, based on 710 patients treated between 1985 and 1988. The average age of the patients was 23.8 years and the average burn size was 14 per cent of the body surface area. Burning injury affected mainly men (66 per cent), and their mortality rate was higher than that of women. The overall mortality rate was 6.6 per cent, the average age of the fatally injured patients being 54 years. We confirm that mortality in burned patients is closely related to: age (51 per cent of the patients were over 60 years of age); burn size (68 per cent of the patients had burns covering more than 30 per cent TBS); burn depth (57.4 per cent had full skin thickness burns); inhalation injury (present in 66 per cent of the fatally injured); and associated risk factors. The main cause of the burning injury was flames, chiefly from domestic accidents. The average survival time for the fatally injured patients was 10 days. Finally, our expected mortality followed a linear regression model, the LA50 for patients with only full skin thickness burns was 50 per cent.     

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.     

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.     

Extensive deep neck burns

A total of 1402 patients were treated in the Nuffield Burns Unit between 1960 and 1970. There were 51 deaths (3·3 per cent); 40 were anticipated from mortal burns (Bull, 1954), 5 from pulmonary embolism and 1 each from airway burn, diffuse adrenal haemorrhage, septicaemia, coincidental rupture of an aortic aneurysm, toxic nephritis and hepatitis.Of the 1402, 218 (15·8 per cent) had burns involving the neck and adjacent areas; 29 of these 218 had extensive whole skin loss of the neck and adjacent skin.     

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.     

Composite grafts of autogenic cultured epidermis and glycerol-preserved allogeneic dermis for definitive coverage of full thickness burn wounds: case reports

In patients with extensive deep burns and scarce donor sites autogenic cultured epithelialgrafts (auto-CEG) have become a real alternative. In deep burns the ‘take’ rate of auto-CEG applied directly on subcutaneous fat, fascia or muscle is unreliable and frequently disappointing. The auto-CEG seems to need a dermal base. Improved results have been reported when auto-CEG were applied to the dermal base of a viable cryopreserved donor skin. We extended this principle by using the dermal layer of non-viable glycerol-preserved donor skin (GPDS). We report on two patients with deep burns of 55 and 80 per cent TBSA in whom we used the composite grafting of auto-CEG on non-viable allogeneic dermis from GPDS. The estimated ‘take’ rates were 70 and 77 per cent. The grafted areas remained stable for 4 and 8 months respectively. The two-layer skin substitute gave a permanent cover for full thickness burn wounds of higher quality and better ‘take’ rate than previous results, where the auto-CEG had been grafted directly onto the debrided wounds.     

Polyurethane film (Opsite) vs. impregnated gauze (Jelonet) in the treatment of outpatient burns: a prospective, randomized study

As it has been shown that re-epithelialization of partial skin thickness wounds can be accelerated if the wound is kept moist, a prospective, randomized clinical study compared the water vapour-semipermeable polyurethane film, Opsite, with the conventional impregnated gauze dressing, Jelonet, in the treatment of outpatient partial skin thickness burns. Fifty-five patients were included: 30 were treated with the polyurethane film and 25 with the conventional dressing. The patients were followed at regular intervals until healing had occurred and were seen 3 months later for evaluation of residual scars and pigmentation. The burns treated with polyurethane films healed with a median of 10 days, while the conventionally treated burns healed with a median of 7 days (P greater than 0.05). Residual scars were noted in 21 per cent of the patients treated with polyurethane films and in 8 per cent treated conventionally (P greater than 0.05). Prophylactic methods should be publicly stressed since one-quarter of the patients were children of 3 years or less who were scalded by split hot liquids. Furthermore the patients' wounds were only briefly cooled before attending medical care. With small burns we advise that cooling should be prolonged until the pain fades then professional assistance should be sought.     

Morbidity, mortality and local recurrence following regional node dissection for melanoma

Eighty-six patients who underwent regional node dissection (RND) for melanoma were reviewed with respect to short and long term postoperative morbidity, mortality and local recurrence rate. Twenty-eight per cent of dissections were prophylactic and seventy-two per cent therapeutic. There were significant wound related complications which tended to delay hospital discharge, in particular following axillary and groin dissections, but symptomatic long term complications were infrequent. The postoperative mortality rate was 1.2 per cent. Local recurrence in RND scars was particularly common in the neck (33 per cent). RND for melanoma is a safe procedure, with significant short term but relatively little long term morbidity. Both recurrence and morbidity should be borne in mind when considering patients for prophylactic RND. Surgeons should be prepared to use axial or myocutaneous flaps where extensive skin resection is necessary. A controlled trial of prophylactic antibiotics would be useful to try to reduce the incidence of wound infection.     

Face burn reconstruction--does early excision and autografting improve aesthetic appearance?

Despite improvements in functional rehabilitation secondary to better control of scar and contractures, aesthetic rehabilitation of the extensively burned face has remained a difficult problem. This study was undertaken to evaluate both technique and aesthetic results of early excision and split thickness autografting (STAG) of full skin thickness face burns. Twenty-five patients with full skin thickness face burns were operated on between days 4 and 14 post-burn. Thirteen patients had excision and STAG in one stage. Twelve patients had a two-stage procedure-excision and coverage with a biological dressing followed 24-72 h later by STAG. Seven of these patients had a pressure dressing in the form of a silicone face mask applied at the second stage. Early cosmetic results were encouraging in all patients. Twenty-five per cent of patients later required either contracture release or skin resurfacing. Preliminary results are encouraging and warrant evaluation by surgeons at other centres. When early excision of full skin thickness face burns is undertaken, cautious optimism as to the ultimate aesthetic result, both by the surgeon and the patient, is advisable.     

Preliminary report on the use of a new hydrocolloid dressing in the treatment of burns

Twenty-four patients who were referred to our outpatient clinic for treatment of burns were included in a study to evaluate the clinical effectiveness of a new hydrocolloid dressing (HCD). The depth of their burns ranged from superficial partial thickness to full thickness burns and the average size was 1.63 per cent of the total body surface. Seven patients had similar burns on other areas of their body which served as control areas. In six patients healing occurred slightly faster in the HCD treated wounds as compared to silver sulfadiazine (1 per cent), and at least as fast as compared with human allografts in these patients. Two patients were removed from the study; in the remaining non-control group (15 patients) healing progressed rapidly and the patients reported the treatment to be very comfortable. Follow-up visits after 1, 3 and 6 months showed excellent healing and there were no signs of hypertrophic scarring.     

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.     

Treatment of toxic epidermal necrolysis and a review of six cases

Six cases of drug-induced toxic epidermal necrolysis treated in a burns unit are presented. The mean skin loss was 67.3 per cent of the total body surface area. Two patients developed renal failure and two had ocular symptoms. The mortality rate was 50 per cent, with two patients dying from septicaemia and one from respiratory and renal failure. The diagnosis of toxic epidermal necrolysis can be confirmed by skin biopsy. We recommend that this disease is treated in a burns unit so that both adequate wound care and essential intensive supportive treatment can be given. Antibiotics are indicated only for specific infections such as septicaemia or pneumonia. Steroids have been shown to increase greatly the mortality from septic complications and are not recommended. The mortality ranges from 10 per cent to 70 per cent and bad prognostic factors include increasing age, greater than 50 per cent of body surface skin loss and neutropenia.     

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.     

Burns due to cooking oils--an increasing hazard

From July 1967 to June 1981, the proportion of all burns patients admitted to the Royal Brisbane Hospital Burns Unit, who were burnt by hot cooking oil or fat, rose 5.1 per cent during the first five years of the study, to 11.3 per cent during the last four years, probably due mainly to the rising popularity of cooking food in hot oil, but also probably due partly to the changing patterns of how cooking oil is used. Sixty-two of the 112 patients sustaining hot cooking oil or fat burns over the 14-year period, were males (55 per cent), and 50 were females (45 per cent). Patients of all ages were involved, but there was a notable increase in the proportion of 30-39 year-olds and a notable decrease in the proportion of those aged 60 years and older. The vast majority of these burns occurred in the domestic situation, and this majority increased over the 14 years, may be explained by changes in the of industrial cooking. The notable increase in the ratio of deep partial/full thickness burns in the series, over the fourteen years, may be explained by changes in the relative amounts of cooking done with different types of fats and oils, which have differing physico-chemical properties, although the proportion of patients receiving skin grafts did not alter much with time, reflecting the increasing tendency to graft burns. Ninety-six per cent of the patients in the series sustained burns of less than 20 per cent of their body surface area, and the proportion suffering burns of 1 per cent or less in area has risen markedly. No deaths directly resulted, and predisposing factors to burn injury were remarkably absent. The majority of patients sustained burns to their hands, reflecting the situation in which most of these burns occur, that is, spilling a carried vessel of ignited cooking oil. Prevention by greater consumer education is recommended.     

Analysis of survival and disease control in stage I melanoma of the head and neck

From 1958 through 1969, 357 patients were treated for melanoma of the head and neck. Of these, 166 had invasive, clinical stage I disease. All patients had wide local excision of the primary. Elective regional node dissection was performed in sixty-nine patients and in the remaining ninety-seven observation only was elected. Retrospective analysis of these 166 patients considered (1) survival and disease control, (2) sites and timing of failures, and (3) the effect of sex, site, type of biopsy, skin grafting, and regional node dissection on disease control and survival. More than 80 per cent of the local recurrences developed within the first twenty-four months. Similarly, in the patients not undergoing initial neck dissection, 80 per cent of those who subsequently had clinically positive regional nodes did so within twenty-four months. In the sixty-nine patients undergoing elective regional node dissection, the survival rate was 33.5 per cent at five and ten years in those with histologically positive nodes. Those patients with elective neck dissections having histologically negative nodes had a survival rate of 75.8 and 67.1 per cent at five and ten years, respectively.     

Prevention and management of contractures in patients with burns of the neck

Two hundred patients with neck burns were analyzed to determine the incidence of contractures. It was found that only 8 per cent of patients with second degree burns had contractures, all of which were mild. Both the overall incidence of cervical contractures in patients with third degree neck burns and their severity can be decreased by the use of a custom-formed isoprene splint. Splinting should begin as soon as possible after the burn and continue until scar maturation is complete.     

Cryopreserved cadaveric allografts for treatment of unexcised partial thickness flame burns: clinical experience with 12 patients

Partial thickness burns (PTB) usually heal within 3 weeks. Prevention of infection and desiccation of the wounds are crucial for optimal healing. Early tangential excision of the burn eschar and allografting prevent deepening of the burns, and are therefore advocated for treatment with the best functional and aesthetic results. For superficial partial thickness burns (SPTB) conservative use of topical antimicrobial agents with frequent dressing changes are implemented. We compared the conservarive treatment for PTBs and SPTBs to grafting cryopreserved cadaveric allografts with no prior excision.

Twelve patients with flame PTB areas were allografted after mechanical debridement without excision of the burn wounds. The allografts were cadaveric skin cryopreserved by programmed freezing and stored at −180°C for 30–48 months. Matching burns for depth and area were treated with silver sulfadiazine (SSD) one to two times daily until healing or debridement and grafting were required.

It was found that 80 per cent of the cryopreserved allografts adhered well and 76 per cent of the treated areas healed within 21 days, whereas only 40 per cent of the SSD-treated burns healed within 21 days.

Partial thickness burns can be treated successfully with viable human allografts (cryopreserved cadaveric skin) with no prior surgical excision. The burn wounds heal well within 3 weeks. For deep partial thickness burns (DPTB) treatment with allografts has no advantage if they have not been previously excised.     

DuoDERM hydroactive dressing versus silver sulphadiazine/Bactigras in the emergency treatment of partial skin thickness burns.

The study compared DuoDERM Burn Pack Hydroactive Dressings (DHD) with silver sulphadiazine/Bactigras dressings (SSD/Bactigras) in the outpatient management of small partial skin thickness burns. Forty-eight patients were entered into the study, and randomly allocated into either the DHD or SSD/Bactigras group. Burn wounds were followed until complete re-epithelialization occurred. There were no statistical differences between the groups, either with respect to their composition or characteristics of healing in days, and patients' subjective responses to treatment. However, application was easier in the DHD group (93 per cent), compared with 71 per cent in the SSD/Bactigras group (P = 0.0009), and the SSD/Bactigras were easier to remove (96 per cent) versus DHD (66 per cent, P = 0.0004). Furthermore, the DHD group had significantly less dressing changes; a mean of three changes per subject in the DHD group compared with eight in the SSD/Bactigras group (P = 0.117). Two burn wounds became infected in the DHD group, and one in the SSD/Bactigras group. In this study both modalities were found to be equally suitable and effective for small partial skin thickness burns.     

Use of topically applied silver sulphadiazine plus cerium nitrate in major burns

All patients hospitalized between May 1987 and June 1988 suffering from burns covering over 50 per cent of the body surface area were treated by topical application of a cream containing cerium nitrate (0.05 M) and silver sulphadiazine (0.03 M) (CN + SSD). Eleven patients were included in this series, with a mean age of 35 years (range 22-65), a mean total burn size of 78 per cent (range 50-96 per cent) and full skin thickness covering a mean of 48 per cent (range 10-91 per cent). Eight patients survived (73 per cent) (mean age 36 years; mean total burn surface 73 per cent; mean full skin thickness burn surface, 38 per cent). These results are far better than those obtained in our Unit where a survival rate of 34 per cent was obtained in a comparable series of patients treated before 1987. Sixty positive blood cultures were obtained, which included a large variety of organisms with a slight predominance of Staph. aureus, Candida albicans and Ps. aeruginosa. Wound cultures were positive in 72 per cent of swabs and showed a predominance of Ps. aeruginosa (59 per cent of all the strains isolated). Even if CN + SSD appears in this series not to be very efficient in preventing wound colonization and septic complications, it permitted a very high survival rate in the treated patients, taking into account the extreme severity of the injuries. This beneficial effect is probably the consequence of the protective action of the yellow-green eschar formed by CN + SSD.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cement burns and their treatment.

Twenty patients with cement burns presenting to Stoke Mandeville Hospital Burns Unit between 1981 and 1989 are described. They represent 1.8 per cent of the total adult patients treated at this unit. Fifteen (75 per cent) had surgery for full thickness skin burns. A questionnaire sent to all the accident and emergency officers employed within the catchment area of the Burns Unit at Stoke Mandeville Hospital showed important gaps in their knowledge of the subject. It is suggested that further publicity be given to this uncommon but potentially serious injury.