特重度烧伤早期处理与意义

目的:探讨特重烧伤早期处理与意义。方法:入院后全部立即建立快速有效静脉通道(包括两路以上周围静脉穿刺,静脉切开,股静脉穿刺),应用烧伤治疗机,早期环痂切开减张,改善肢体血液循环,气管切开,改善通气功能16例。6d内行大面积切(削)痂,大张异体皮覆盖自体“邮票”皮或微粒皮,手背及关节功能部位用大块自体皮移植。结果:本组患者除4例合并重度吸入性损伤死亡,3例休克期过后送外院治疗,其余患者均痊愈出院。结论:尽快建立有效静脉通路,快速足量补充循环血量,及时行气管切开改善通气及环痂切开减张,早期切(削)痂植皮是早期治疗特重烧伤患者的关键。     

烧伤并吸入性损伤患者气管切开的气道护理

烧伤合并吸入性损伤是一种严重烧伤。死亡率在45％～75％。是影响烧伤患者救治成功的三大主要因素之一。早期观察、正确分析、细心护理,在积极抗休克、抗感染的同时做好呼吸道管理,可防止并发症的发生,提高吸入性损伤的治愈率。本院烧伤中心2005年1月-2008年10月共收治严重烧伤合并吸入性损伤患者106例,经气管切开后合理的气道护理,取得满意效果,报告如下。     

严重烧伤合并重度吸入性损伤28例临床护理

对28例严重烧伤合并重度吸入性损伤患者给予精心护理,包括抗休克、气道管理、面、颈部护理、严格执行消毒隔离制度及心理护理。结果本组气管切开16例,应用呼吸机11例,气管切开时间12～2td,治愈19例,死亡9例。认为对严重烧伤合并重度吸入性损伤患者给予精心护理的同时做好呼吸道管理至关重要,它可有效预防肺部并发症的发生。     

成批特重度烧伤合并吸入性损伤行气管切开病人气道的特点及护理

[目的]总结成批特重度烧伤合并吸入性损伤行气管切开病人气道的特点及护理。[方法]回顾性分析5例成批特重度烧伤合并吸入性损伤行气管切开病人的临床资料。[结果]1例大面积烧伤95%伴重度吸入性损伤早期因脑缺氧、脑损伤,现病人昏迷,继续使用气管切开插管,呼吸机辅助呼吸,创面愈合,1例大面积烧伤97%伴重度吸入性损伤早期因多器官功能障碍综合征(MODS)死亡,其余3例顺利拔除气管切开插管,后期创面愈合,痊愈出院。[结论]通过正确有效的气道护理可维持有效的呼吸、减少气道的损伤、降低翻身床使用过程中管道滑脱的几率、减轻病人的痛苦,从而达到更高的护理质量。     

大面积烧伤61例合并吸人性损伤治疗体会

目的探讨大面积烧伤合并吸入性损伤的治疗。方法统计6l例大面积烧伤合并吸入性损伤并进行分类总结。结果小儿吸入性损伤死亡率高于成人。由于发育小儿呼吸功能较成人差，气管、支气管较成人狭窄，尤其吸入性损伤早期局部渗出、水肿、很容易造成呼吸道梗阻死亡。特别注意的是，对严重吸入性损伤患者，即使气管切开通气，在脱落和修复期仍容易发生呼吸道梗阻。     

严重烧伤合并重度吸入性损伤28例临床护理

对28例严重烧伤合并重度吸入性损伤患者给予精心护理,包括抗休克、气道管理、面、颈部护理、严格执行消毒隔离制度及心理护理.结果本组气管切开16例,应用呼吸机11例,气管切开时间12～21 d,治愈19例,死亡9例.认为对严重烧伤合并重度吸入性损伤患者给予精心护理的同时做好呼吸道管理至关重要,它可有效预防肺部并发症的发生.     

保护性机械通气在烧伤合并重度吸入性损伤救治中的护理

为减少重度吸入性损伤相关的肺损伤的发生，我科2006年7月～2008年8月对收治的10例烧伤合并重度吸入性损伤患者采用早期气管切开低潮气量、低PEEP和允许“高碳酸血症”保护性机械通气措施，取得良好的效果。现报告如下。     

大于90%总体表面积Ⅲ度烧伤患者的治疗体会

Ⅲ度烧伤面积>90%总体表面积者治疗极其困难,救治成功率不高.近10年来我科治愈4例Ⅲ度烧伤面积>90%患者,最严重者为烧伤总面积达98%、Ⅲ度烧伤占95%、合并重度吸入性损伤者,经全力救治后痊愈,报告如下.     

大面积烧伤并吸入性损伤患者28例临床分析

目的总结大面积烧伤并吸入性损伤患者的早期处理及治疗经验。方法回顾性分析28例大面积烧伤并吸入性损伤患者的临床资料。结果 28例患者中合并轻度吸入性损伤4例,中度吸入性损伤23例,重度吸入性损伤1例;给予加强气道管理、纤维支气管镜辅助、营养支持、抗感染、个体化液体治疗及创面治疗后,4例轻度损伤患者7d后痊愈出院,16例中度患者住院15d后出院,7例中度患者在28d出院,1例重度损伤患者死于呼吸窘迫综合征导致的多器官功能衰竭。结论对大面积烧伤并吸入性损伤患者应早期给予气道管理、纤维支气管镜辅助、营养支持、抗感染、个体化液体治疗的综合治疗措施。     

重度烧伤治疗体会

目的总结5年来我院治愈29例重度烧伤患者的经验。方法（1）抗休克治疗；（2）吸入性损伤处理；（3）创面处理。结果29例重度烧伤患者，经过全身抗休克、抗感染等综合治疗，深度创面进行手术切削痂植皮，合并吸入性损伤患者及时行气管切开，均取得了满意临床效果。结论（1）及时有效补充血容量是休克期治疗的关键。（2）重度吸入性损伤入院时，必须给予气管切开，高浓度吸氧，及时气道湿化雾化治疗。（3）休克期切削痂的植皮，可以减少毒素吸收和全身感染机会，减少输液输血量，提高治愈率，缩短住院时间。（4）合理使用抗生素。（5）重视早期肠道营养。     

Social support correlates with survival in patients with massive burn injury

Large burn size, inhalation injury, age, and associated trauma increase the rate of mortality after burns. However, not all patients with large burns and significant risk factors die. In this study, we wanted to determine other presenting factors that might indicate a survival benefit for burn patients with large burns. We reviewed charts of 36 patients with burns > or =60% TBSA that were aggressively resuscitated at the University of Washington Burn Center from 1990 to 2000 to determine whether survivors of large burns exhibit presenting variables that predict survival. Patients who had comfort care measures initiated at admission were excluded from this analysis. Survivors (n = 16) and nonsurvivors (n = 20) had no significant differences in age, total burn size, inhalation injury, or need for escharotomy. Full-thickness burn size was significantly smaller for survivors (58%) than for nonsurvivors (73%; P = .02). Survivors (81%) were more likely than nonsurvivors to have social support (35%; P = .007). A full-thickness burn > or =80 % TBSA was the only variable uniformly associated with mortality, suggesting that patients who survive large burns have a partial-thickness component that heals without surgery. The difference in degree of social support was one unique distinction that may impact patient survival and is worth further investigation.     

Carotid rupture following electrical injury: a report of two cases

Electrical injuries often result in extensive tissue damage where vascular damage may occur and result in thrombosis and spontaneous rupture of blood vessels. Rupture of the brachial, radial, ulnar, internal mammary, and obturator arteries has been reported in the literature. The authors present two cases of carotid artery rupture following high-voltage electrical injuries. The first case is a 21-year-old man who was climbing a fence near a high-voltage power line when a gold chain he was wearing around his neck caught on the power line, resulting in a 10% circumferential electrical injury to his neck. He presented with visible arterial bleeding from the large neck wound and was taken to the operating room, where a 1-cm laceration to the carotid artery was repaired with a vein patch. On the second postoperative day, the patch dislodged, and a spontaneous rupture of the common carotid artery occurred. The damaged artery was subsequently ligated. The patient recovered with no neurological sequelae. The second case is a 43-year-old man who suffered a high-voltage injury while working on an electrical panel, resulting in a 50% TBSA full-thickness burn to the face, scalp, trunk, and extremities. Four weeks after admission, a latissimus dorsi myocutaneous free flap was used for coverage of exposed outer table of the skull. Intraoperatively, the carotid artery spontaneously ruptured proximal to where the dissection was being carried out. The patient recovered with no neurological sequelae. High-voltage electrical injury results in significant damage to blood vessels via a number of mechanisms. Rupture of a major vessel is a rare, life-threatening sequelae of electrical injury.     

Influence of injury characteristics and payer status on burn treatment location in Washington state.

The provision of optimal burn care is a resource-intensive endeavor. The American Burn Association has developed criteria to help guide the decision to refer a patient to a burn center for definitive injury care. The purpose of this study was to compare the patient and injury characteristics of patients admitted to the single verified burn center in Washington State with those treated at other facilities in the state. We performed a retrospective review of all patients admitted to a hospital with a burn injury in Washington State from 1987 to 2005 using the state's discharge database (Comprehensive Hospital Abstract Reporting System). Patient and injury factors of patients admitted to the state's single verified burn center or at other hospitals were compared. Multivariate poisson regression was used to calculate the relative risk of injury and patient factors that were significantly associated with admission to the verified burn center. From 1987 to 2005, a total of 16,531 patients were admitted to a Washington State hospital after burn injury. Of these patients, 8624 (52.2%) were treated definitively at the University of Washington Burn Center. Patients treated at this verified center had larger overall burn size (7.4% vs 4.5% TBSA, P < .001), higher percent full-thickness burn (4.3% vs 1.2%, P < .001), and higher rates of inhalation injury (2.3% vs 1.5%, P = .005). Uninsured status (relative risk = 1.46, 95% confidence interval = 1.4-1.5) was also significantly associated with treatment at the verified burn center. Injury severity and payer status were both found to be independent predictors of treatment at the single verified burn center in Washington.     

Early pulmonary immune hyporesponsiveness is associated with mortality after burn and smoke inhalation injury

This prospective study aims to address mortality in the context of the early pulmonary immune response to burn and inhalation injury. The authors collected bronchoalveolar lavage fluid from 60 burn patients within 14 hours of their injury when smoke inhalation was suspected. Clinical and laboratory parameters and immune mediator profiles were compared with patient outcomes. Patients who succumbed to their injuries were older (P = .005), had a larger % TBSA burn (P < .001), and required greater 24-hour resuscitative fluids (P = .002). Nonsurvivors had lower bronchoalveolar lavage fluid concentrations of numerous immunomodulators, including C5a, interleukin (IL)-1β, IL-1RA, IL-8, IL-10, and IL-13 (P < .05 for all). Comparing only those with the highest Baux scores to account for the effects of age and % TBSA burn on mortality, nonsurvivors also had reduced levels of IL-2, IL-4, granulocyte colony-stimulating factor, interferon-γ, macrophage inflammatory protein-1β, and tumor necrosis factor-α (P < .05 for all). The apparent pulmonary immune hyporesponsiveness in those who died was confirmed by in vitro culture, which revealed that pulmonary leukocytes from nonsurvivors had a blunted production of numerous immune mediators. This study demonstrates that the early pulmonary immune response to burn and smoke inhalation may be attenuated in patients who succumb to their injuries.     

Burns caused by automobile radiators: a continuing problem.

In spite of the fact that injury warning labels have been placed on radiator caps for the last 15 years, automobile radiator scald burns continue to be a burn prevention problem. The temperature of radiator fluid may be as high as 100 degrees F to 250 degrees F in a properly functioning car and higher in an overheated vehicle. From 1974 to 1990, 100 patients with burns that were caused by automobile radiators have been admitted to the Parkland Memorial Hospital Burn Unit (1.5% of acute admissions). Eighty-two percent of the injuries occurred in the summer months, and 93% of the patients were male. Mean age was 31 +/- 17 years (range, 8 months to 79 years), and mean burn size was 11.3% total body surface area (TBSA) (range, 1% to 32%) with a mean full-thickness burn size of 0.6% TBSA. Length of stay was 7 +/- 7.4 days (range, 1 to 38 days). Burns to the face, neck, and trunk necessitated most admissions. Although there were no deaths, five patients required intensive care for airway monitoring; mean length of stay was 6 days. One patient required endotracheal intubation for a total of 11 days. Ten patients required one or more skin grafting procedures, and three patients required burn resuscitation. Four patients sustained minor ocular injuries. A subgroup of patients demands special review: 10 children younger than 10 years of age (mean age, 4.1 years) of which 70% were boys. Mean burn size was 15.5% TBSA; mean full-thickness burn size was 2.4% (four times larger than the mean burn size for the adult population).(ABSTRACT TRUNCATED AT 250 WORDS)     

Microalbuminuria in acute burn injury.

Microalbuminuria is a known finding in inflammatory states. We hypothesized that urinary albumin/creatinine ratio (ACR) would correlate with injury severity and resuscitation demands after acute burns. This pilot study evaluated 30 adults admitted within 12 hours of injury with burns > or =10% total body surface area burn injury (TBSA). The urinary ACR was calculated for each patient at 7 to 12 hours, 19 to 24 hours, and 43 to 48 hours following burn injury. Microalbuminuria was defined as a urinary ACR > or =20 mg/g. Study patients (23 males, 7 females) had a mean age of 42.9 + 14.0 years and a median TBSA burn injury of 18.8%. Inhalation injury was present in 10 of the study patients, and all patients with inhalation injury had microalbuminuria at the time of admission. One study patient died. Median time from burn injury to resuscitation was 30 hours, and the median fluid requirement was 4.2 ml/kg/%TBSA. Microalbuminuria was not uniformly present in burn-injured patients during the first 48 hours after injury. ACR values early in the hospital course correlated with higher lactate concentrations early after burn injury. However, ACR correlated with neither injury severity nor resuscitation demands after burn injury during any studied time range. Microalbuminuria does not have apparent clinical utility in burn-injured patients, and other markers of injury severity and resuscitation demands should be sought.     

Cost-effective use of helicopters for the transportation of patients with burn injuries

We performed a retrospective review to analyze the use of helicopters for the transportation of patients with burn injuries to determine whether a more cost-effective approach could be developed without impairing the quality or delivery of health care. Charts were reviewed for all patients with burn injuries who were transported by helicopter to our hospitals during a 2-year period. Patients with inhalation injuries, with burn injuries received more than 24 hours before admission or more than 200 miles from our burn center, with more than 30% total body surface area (TBSA) burned, or with associated trauma injuries were excluded. Control patients with burn injuries who were transported by ambulance were identified and matched to the patients with burn injuries transported by helicopter for the percentage of TBSA burned, the percentage of third-degree burns, transport mileage, and age. The outcome was evaluated by comparison of length of stay, days on ventilator, and mortality rate. Comparisons were performed with Student t test. The transportation charge was determined for the patients transported by helicopter who we believed were eligible for transport by ambulance. Forty-seven of 85 patients transported by helicopter matched the inclusion criteria and had survived. There was no statistically significant difference between the percentage of TBSA burned, the percentage of third-degree burns, length of stay, days on ventilator, age, or transport mileage. There was, however, a significant difference in the time from the injury to admission to the hospital, as well as in the charge for transportation. Patients who had less than 30% TBSA thermal cutaneous injuries without evidence of inhalation injury, and who are less than 200 miles from a burn center may be safely transported by ambulance. Ambulance transportation may take additional time; however, stricter protocols for helicopter transportation of patients with burn injuries will result in potentially substantial savings without affecting outcomes for patients.     

Delayed brain atrophy after electrical injury

We report a case of delayed brain atrophy after electrical injury. A 12-year-old boy sustained extensive burns by touching a high-voltage power line. The burn area comprised more than 60% TBSA, and he subsequently underwent several surgical procedures. Two months later, he suddenly developed seizures. Initial findings on magnetic resonance imaging showed diffuse cortical damage in the left brain. Two months later, motor aphasia appeared, and a second magnetic resonance imaging scan showed atrophy in the left temporal and frontal lobes. Owing to speech rehabilitation, the patient gradually recovered his capacity for speech. Eight months later, his speech was almost perfect. We believe that because the patient was young, early speech rehabilitation was effective.     

Ocular changes from electrical burn injuries. A literature review and report of cases.

One hundred fifty-nine consecutive patients with high-voltage burns were retrospectively reviewed to determine the ocular sequelae of these injuries. Five patients had ophthalmic changes (two had recurrent iritis, eight had cataracts, two had macular holes, and one had central retinal artery occlusion). All four patients with cataractous changes had characteristic anterior subcapsular opacifications, except for one patient who presented with a dense white opacified lens. All had bilateral lenticular changes in which the denser cataract developed earlier than the contact wound and ipsilateral to it. Central retinal artery occlusion has not been previously reported as a complication of electrical burns. Macular holes, formerly believed to be rare in these injuries, were found in two of the five patients. Ocular complications from electrical burn injuries are uncommon. Although a number of these ocular changes occur immediately after injury, many of the visually impairing changes develop days and even years after a severe electrical burn injury; thus, careful follow-up is mandated.     

Admission chest CT complements fiberoptic bronchoscopy in prediction of adverse outcomes in thermally injured patients

In burned patients, inhalation injury can result in progressive pulmonary dysfunction, infection, and death. Although bronchoscopy is the standard for diagnosis, it only assesses the proximal airway and does not provide a comprehensive analysis of pulmonary insult. Chest radiographs have not been proven helpful in diagnosis of inhalation injury. Our hypothesis is that a CT scan alone or in conjunction with bronchoscopy can be used as a prognostic tool for critically ill burn patients, especially those with inhalation injury. The authors performed a retrospective study of all patients admitted to the U.S. Army Institute of Surgical Research Burn Center between 2002 and 2008 with chest CT within 24 hours of admission. They divided subjects into two groups, those with evidence of inhalation injury on bronchoscopy and those without. They used a radiologist's score to assess the degree of damage to the pulmonary parenchyma. The primary endpoint was a composite of pneumonia, acute lung injury/acute respiratory distress syndrome, and death. The inhalation injury group consisted of 25 patients and the noninhalation injury group of 19 patients. Groups were not different in age, TBSA burned, and percentage full-thickness burn. By multiple logistic regression, detection of inhalation injury on bronchoscopy was associated with an 8.3-fold increase in the composite endpoint. The combination of inhalation injury on bronchoscopy and a high radiologist's score was associated with a 12.7-fold increase in the incidence of the composite endpoint. Admission CT assists in predicting future lung dysfunction in burn patients.