Rehabilitation of the burn patient

A successful outcome to the management of the significantly burned patient requires a team approach. Although at one time survival alone was considered a sufficient indicator of success, the quality of that survival now must be closely assessed prior to self-congratulations. The burn team, in addition to the usual medical personnel, requires occupational and physical therapy, as well as rehabilitation medical specialists, whose goals are to preserve function and restore independence. Burn care that does not emphasize these goals from the first day of injury, and extended well beyond initial discharge from the hospital, does not match contemporary standards of excellent care.     

Respiratory care of the burn patient

The vast majority of respiratory disorders in thermally injured patients arise from associated inhalation injuries. The major forms of these injuries are carbon monoxide poisoning, injury to the upper airway, and pulmonary parenchymal damage. One hundred per cent oxygen, initiated at the scene of the accident, is the single most effective treatment of carbon monoxide toxicity, which must be assessed by carboxyhemoglobin determinations. Respiratory tract damage is identified by fiberoptic bronchoscopy and xenon ventilation-perfusion scintigrams. The compromised airway is protected by tracheal intubation, and respiratory failure is treated with assisted ventilation and supplemental oxygen. Pulmonary infection requires specific antibiotics based on isolated organisms and their sensitivities to antimicrobials. The upper respiratory tract of patients requiring long-term intubation should be assessed by fiberoptic bronchoscopy and other modalities to prevent fatal late airway occlusion.     

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.     

Vasopressin for the septic burn patient

BACKGROUND: Exogenous arginine vasopressin (VP) has been increasingly used in the hemodynamic management of critically ill patients with septic shock, but its use in septic burn patients has not been systematically examined. PURPOSE: To review our experience with the use of VP in septic burn patients. METHODS: Retrospective review of all patients who received VP at a tertiary care adult regional burn centre. Only patients who strictly met the American College of Chest Physicians/Society of Critical Care Medicine Consensus Criteria for sepsis at the time of VP initiation were analysed. RESULTS: There were 30 septic burn patients treated on 43 distinct occasions with VP. This group had a mean (+/-S.D.) age of 49+/-19 years, a mean % TBSA burn of 41+/-15% and a 37% incidence of inhalation injury. A significant increase in mean arterial pressure (MAP), a significant decrease in heart rate (HR), and a trend towards increased urine output (UO) occurred following initiation of VP. When VP was added to an existing infusion of norepinephrine (NE), there was a significant NE sparing effect. VP was implicated in the death of one patient who developed diffuse upper gastrointestinal necrosis while on VP. Other complications in patients treated with VP included peripheral ischemia (2), skin graft failure (1) and donor site conversion (1). In all complications, VP had been administered in combination with prolonged NE infusions (mean of 10 microg/min over a mean of 177 h). CONCLUSION: VP is a useful adjunctive pressor that spares NE requirements in septic burn patients, but its use is not without risks, particularly when VP is combined with sustained moderate to high infusions of NE.     

Myocardial depression in the burn patient

Myocardial depression and heart failure are frequent complications in critically ill burn patients. The physiopathology is complex and involves the activation of inflammatory pathways, ischemia-reperfusion, oxidative stress and endothelial lesion. Diagnosis should be made early by means of hemodynamic monitoring. Treatment is accomplished by inotropics that act on different pathways of the contractile function and immune response associated with antioxidants and allopurinol.     

Management of the high-risk pediatric burn patient

BACKGROUND/PURPOSE: Inhalation injury, flame burn exceeding 30%, and age under 48 months all have been cited as independent risk factors for mortality; the combination of all 3 risk factors is unusual. The authors have experienced an overall reduction in mortality rate and chose to examine this high-risk group to define techniques useful in improving outcome in pediatric burns. METHODS: A review was done of children with all 3 risk factors over a recent 9-year interval. All were treated with a system of care emphasizing precise fluid repletion, early wound excision and closure, and avoidance of injurious pulmonary inflating pressures and concentrations of oxygen. Data are expressed as mean +/- SD. RESULTS: There were 26 children admitted with all 3 risk factors. Their average age was 2.1 +/- 1.1 years (range, 5 weeks to 3.7 years), and burn size was 61% +/- 21% (range, 30% to 98%) of the body surface. All required mechanical ventilation for an average of 28 +/- 4.5 days (range, 7 to 74 days). Two children underwent tracheostomy; all others were treated with protracted oral intubation. Inhaled nitric oxide (NO) was used in 3 children, all of whom were considered for extracorporeal membrane oxygenator (ECMO) support, although none went on to ECMO. Only 7 children (27%) never had any bacteremia. Ventilator-related pneumonia occurred in 8 children (31%). Total lengths of stay, including acute and rehabilitation hospitalizations, averaged 105 +/- 10 days (1.87 +/- 0.2; range, 0.66 to 4.8 days per percent burn). After exclusion of 1 child with a 98% third-and fourth-degree burn, pre-hospital cardiac arrest, and anoxic brain injury who had support withdrawn at 6 hours, all children survived to discharge; 23 followed up in our clinic currently are alive and well with no overt residual respiratory insufficiency. CONCLUSION: A high rate of survival can be expected in young children with large burns and inhalation injury.     

Determination of catabolism in the burn patient

Summary Quantitative data on protein catabolism employing urea production rate (PU) and the Bistrian index (BI) have been obtained in 8 patients with deep dermal burn injuries involving up to 80% of body surface. The advantages of these tests are demonstrated in the individual patient. Mean values of the PU and BI are especially high during the second and third week after injury and decrease to nearly normal values in the fourth week. Additional rises of PU and BI are sometimes caused by operative stress. Peak values were found in cases with high voltage injuries. A special nutritional regimen is presented to keep catabolism low. PU and BI are simple tests to monitor protein loss and can easily be carried out in any hospital.     

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.     

Venous thromboprophylaxis in burn patient

Few studies deal with thromboembolic complications in burn patients. The review of the literature and current practice in burn centres point out low, average and high-risk patients, according to the characteristics of the burns wounds. In case of average risk, low molecular weight heparin prophylaxis is suggested. In high risk patients, low molecular weight heparin therapy or continuous intravenous heparin are recommended. This prevention should be continued until the recovery of a normal mobility and complete resolution of inflammation.     

Quality of life of the Spanish burn patient

This is a study of the quality of life as performed on a sample of 115 Spanish patients treated for burns in the Burn Care Unit of the Alicante General Hospital. Through the application of the sole existing scale for measuring quality of life specific to burn patients, the following percentages of alterations were obtained: 9.7% in physical domains; 14.2% in body image; 27.4% in psychological domains; and 22.5% for the complete scale. Results similar to those published by the original authors of the scale have been encountered by us and we are now able to confirm that the questionnaire "adapted and validated" in Spanish is equally capable of measuring changes in quality of life of the group studied herein.     

Evaluation of exercise techniques in the burn patient

A programme for maintaining range of joint motion during the course of burn treatment is described, including the use of splinting, passive range of motion exercises and hydrotherapy, accompanied by a data collection form used in the prospective evaluation of the treatment.     

The elderly burn patient.

During a 16-year period, 547 patients who were older than 64 years of age with a mean total body surface area (TBSA) (third-degree burns) of 25% were treated. Etiologies were flame/flash in 81% of patients, scald in 11%, solids in 7%, and electrical/chemical in 1%. Seventeen percent of patients had significant causal factors. An inhalation injury was present in 13% of patients, and the mortality in these patients was 100%. Burn excision was performed 239 times in 165 patients. The majority of excisions were for full-thickness burns. Excision did not improve overall survival in patients with third-degree burns of 0% to 10%, but the length of stay (LOS) in excised and nonexcised survivors was improved (9 versus 21 days, respectively). The LOS and survival were not significantly different in patients with burns between 11% and 20%. Postburn complications occurred in 28% of patients. Overall mortality was 50% (mean age: 77 years; TBSA: 40%). There were no survivors with over 47% TBSA burns. The leading cause of death was pulmonary sepsis. Most surviving patients returned to a satisfactory lifestyle after discharge.     

Timing of burn therapy in the pediatric patient

The physician embarking on the long-term management of burned children must have a very strong and honest relationship with the patient and family or guardians and must use all available resources, including physical and occupational therapists, social workers, and others, over the course of the effort. There is rarely an end-point in the rehabilitation of a burned child, and the surgeon must be aware of the effects of growth, have state-of-the-art knowledge of reconstructive techniques, and ideally have adequate experience to predict the effects of therapy over many years. This experience often can be gained only from senior surgical colleagues who have the advantage of experience following years of observing wounds heal and operations mature. The timing of many facets of pediatric burn care is, in many ways, abstract and based on intense clinical acumen and physical examination. However, it is imperative that the physician develop a treatment timetable based on the principles of contemporary burn care.     

Peripheral neurological problems in the acute burn patient

Electromyographic and nerve conduction data in evaluation of 66 burn patients revealed a 29 per cent incidence of peripheral polyneuropathy. Patchy myopathic findings, probably related to multiple injections, were noted in the proximal muscles of 22 patients. Entrapment mononeuropathies of the ulnar, median and peroneal nerver were found. These neuromuscular abnormalities produce clinical motor and sensory deficits which limit rehabilitation in the burned patient, and further work is immediately needed to determine the pathophysiology of these abnormalities.