Effect of intravenous infusion on development of pulmonary oedema after inhalation injury

Last year, after a systematic search of pathological and pathophysiological changes of inhalation injury in dogs, we recorded severe pulmonary oedema as early as 2 h postburn (the earliest monitoring time designed in experiment) on dogs inflicted with both body surface and severe respiratory burns without any fluid replacement during the whole course of experiment. In an analysis of cases admitted into our burn centre in the past ten years, we also found that there was no definite relationship between the incidence and severity of pulmonary oedema occurring in severe burn patients and the amount of fluid infused in the early burn phase. These facts led us to the following experiment designed to study the effect of intravenous infusion on development of pulmonary oedema after severe burns complicated with inhalation injuries.     

Vascular injuries in electrical burns —the pathologic basis for mechanism of injury

These studies present a more complete picture of the pathological changes in injured arteries obtained from patients with electrical injuries affecting the upper extremity. The specific characteristics of vascular injury by electric current proceed from relatively mild to severe in the order of the intima, adventitia and whole-thickness. Vascular injury by electricity is a thermal process extending from the interior to the exterior.     

Clinical and histological observations on the application of intermingled auto-and porcine-skin heterografts in third degree burns

Escharectomy and skin grafting with both homograft and porcine skin has become an effective method in treating massive third degree burns. Seventeen patients and 21 operations of intermingled transplantation of auto- and fresh porcine skin heterografts after escharectomy of the severe burn wounds have been carried out since March 1973. Clinical and histological data are summarized, among which we observed the 'fusing phenomena' of auto- and porcine skin heterografts in 6 patients. Vascularization, 'turning red', viability and rejection as well as ways to improve the results of the grafting method are discussed. No vascular communication between fresh porcine skin and the host wound has been observed during the early postoperative period. The cause of 'turning red' is a reddish transudation between the graft and the host wound seen through the thin porcine skin. Based on histological observations, porcine skin is viable after transplantation. With nutritional support apparently coming from the underlying plasma and tissue fluid. Eventually the process of rejection is similar to that of homograft Better results are found with porcine skin grafts 0.4-0.5 mm in thickness placed 0.5-0.75 cm apart. In order to avoid large sloughing wound surfaces less than 20 per cent area of porcine skin coverage is advisable.     

Prevention of stress ulcer bleeding with cimetidine in severe burns

This paper presents clinical observations on the preventive effect of cimetidine for stress ulcer bleeding in severe burns. It shows that gastrointestinal bleeding after severe burn is significantly reduced, and the incidence of acute gastro-duodenal ulcer lowered by administration of cimetidine.     

Keys to successful second toe-to-hand transfer: a review of 30 cases

Thirty cases of second toe-to-hand transfers are reported in which there were no failures. Factors judged to be important in these successful results include the careful choice of the donor site, distal to proximal exposure of first metatarsal artery, ensuring adequate perfusion of the toe before severing its vessels, and meticulous postoperative care.     

Free transplantation of sub-axillary lateral thoraco-dorsal flap in burn surgery

Free transplantation of subaxillary lateral thoracodorsal flap is recommended. The thoraco-dorsal artery and its accompanying veins may nourish and drain a large musculo-cutaneous flap. The calibres of both the artery and the veins are big enough to be anastomosed to the recipient vessels using the naked eye. The donor area can be closed by first intention suture without interfering with the functional recovery of the donor area. Both the functional and cosmetic results after free transplantations of this flap are good.In acute electrical or other deep burns, this flap can be used to prevent infection, to protect the deep vital structures, and to lessen the amputation rate. A better condition is created for functional recovery and facilitating reconstructive surgery.The muscular branch of the thoraco-dorsal artery was always present in our 50 patients whereas only 20 cases (40 per cent) had an independent cutaneous branch which nourishes the flap. We stress the point of preserving and using the muscular branch as the main blood vessel to be anastomosed for this free flap.     

Histopathological and ultrastructural changes in liver tissue from burned patients

Histopathological studies were made on samples of liver and spleen tissue taken post mortem from 59 patients with severe burns. Samples from 8 patients were also studied using the transmission electron microscope. The main pathological findings were degeneration and necrosis of hepatic cells and proliferation of Kupffer cells showing active phagocytosis. Their causes in relation to the time of death after burning and severity of injury have been discussed. The proliferation of Kupffer cells may be a compensatory reaction to the severe splenic injury seen in the patients.     

Changes in lymphocyte response to phytohaemagglutinin and serum immunosuppressive activity after thermal injury

The present study consisted of two parts. In part one, 14 cases were divided into an invasive infection group (4 cases) and a non-invasive infection group (10 cases). A total of 68 assays for lymphocyte responses to PHA stimulation were carried out. The invasive infection group showed a significantly suppressed lymphocyte response, which occurred during invasive infection but neither before nor after the infection. The extent of third-degree burns was statistically significant between these two groups (P less than 0.05), but no significance was found between the total body surface area burned. In part two, 18 burn patients were studied for serum immunosuppressive activity. Both invasive infection cases and non-invasive infection cases showed serum immunosuppression during the course of the study and no significant difference was found between these two groups (P greater than 0.05). It is concluded that the extent of third-degree burn and the complicated systemic infection contribute to the impairment of lymphocyte responses to PHA stimulation, while the post-burn serum immunosuppression is unrelated to the occurrence of systemic infection.     

Clinical characteristics and operative treatment of postburn stress ulcers

Stress ulcers are one of the complications of severe burns. As there is often profuse bleeding into the alimentary tract, its early diagnosis and prompt treatment are of the utmost importance. From 1958 to 1980 we encountered 91 cases of postburn stress ulcers among whom 12 were treated operatively because of severe haemorrhage.     

Early vascular grafting to prevent upper extremity necrosis after electrical burns

Presented in this paper are the surgical considerations in the management of 8 electrically injured patients, with special reference to the care for wrist damage associated with impaired blood flow, and the prospect for effective recovery.Sound surgical principles, such as early diagnosis and repair of artery damage, complete débridement of dead tissue, and effective wound closure, in conjunction with intensive general treatment and overall planning, are necessary for maximally rehabilitated limbs.The electrically injured seem to have benefited a great deal from the procedures outlined, with a lowered incidence of amputation and a better functional recovery.     

Clinical evaluation of extensive excision of burn eschar in the presence of septicaemia--analysis of 32 cases

This paper reports 32 cases of burn septicaemia undergoing extensive escharectomy in our hospital during the years 1969-1980. The total burn area averaged 66.4 per cent, and that of full-thickness burn 49.8 per cent of the body surface area. Septicaemia was controlled in 18 cases postoperatively (56.3 per cent). The extent of each escharectomy averaged 23.3 per cent TBS, with a maximum of 42 per cent TBS in the survivors. Delayed excision of eschar and incomplete excision of the main infected lesions were the principal causes of 15 deaths (57.4 per cent). Identification of the main nidus of infection, its cause, the need for operation, the time for operation, the extent of excision at each operation, the type of wound coverage and the supportive treatment have been discussed. It is believed that with proper perioperative management, extensive escharectomy can be performed in the presence of septicaemia and many lives can be saved as long as there are convincing indications for such operations.     

The intermingled transplantation of auto- and homografts in severe burns

A brief history of the method using intermingled transplantation of auto- and homografts to treat extensive third-degree burns is reviewed. Through constant practice and improvement during the past 12 years this has become an effective method in lowering the mortality rate when treating extensive third-degree burns. The pathophysiological basis of the present method is as follows: accompanying the host rejection process, after intermingled transplantation, the autoepithelium creeps quickly in between the epidermis and dermis of the homograft. The homodermis degenerates and is absorbed under the intact auto-epidermis. This provides an auto-epidermal protection of the wound throughout the course. The sandwich phenomenon, the rejection episode and the rate of the homodermis are the main topics discussed in this paper.     

Catecholamine excretion in burns in children

The excretion pattern of adrenaline and noradrenaline in children with burns has been studied and compared with that of a number of controls of similar age. Very high outputs of both catecholamines were found in the more extensively burned children, and the output of adrenaline increased relatively more than did that of noradrenaline, though the output of noradrenaline was always quantitatively greater.

The relatively high output of adrenaline may be related to the environmental temperature in which the children were nursed. The evidence for and possible causes of partial failure of adrenaline production in burns are also discussed.     

Serum and erythrocyte amino acid pattern: studies on major burn cases

Venous serum amino acids were measured in 13 patients with major burns. Erythrocyte amino acids and plasma cortisol, blood sugar and urine catecholamine were measured in two representative subgroups respectively. After burn injury, serum proline, glycine, valine, isoleucine and arginine were significantly decreased; phenylalanine, cysteine, methionine, leucine, glutamate, alanine, aspartic acid and tyrosine were significantly increased. Histidine and lysine fluctuated. This serum amino acid profile is considered as a specific pattern for major burns. Serum phenylalanine was markedly elevated in the hypermetabolic burn patients, its fluctuation coincided with the burn course and was negatively correlated with serum albumin level (P<0·001). These findings suggest that the ratio of phenylalanine tyrosine is a useful clinical parameter for assessing the patient's nutritional condition. Twenty-three simultaneous determinations of both serum and erythrocyte amino acid concentrations show similar changes, suggesting that the serum amino acid profile might reflect the change of total free amino acid pool. After burn injury, plasma cortisol, blood sugar and urine catecholamine were elevated as well as urine urea nitrogen. However, although the first three returned to normal by the end of the second week post burn, urine urea nitrogen remained high. This indicates that there are other factors controlling nitrogen loss in patients with major burns. it is also postulated that, due to the abnormal amino acid pattern revealed after major burns, the constituents of commercially available amino acid solutions should be modified.     

Burns during pregnancy: An analysis of 24 cases

Twenty-four cases of burns in pregnant women are described. The relationship between the burn area, gestational age at treatment and prognosis is analysed. Active treatment is advocated.     

The problem of euthanasia and dysthanasia in burns

The authors discuss basic approaches to the problem of defining euthanasia. The definition should maintain the distinction between active and passive and between voluntary and involuntary euthanasia. Some of the recent views of the ethical and moral aspects are mentioned, as well as the reasons for terminating resuscitation in persons who suffer ‘brain death’ (permanent central nervous system) dysfunction. This problem is a matter of great urgency particularly in the burn centres, dealing with old patients. The authors base the discussion on their clinical experience showing that it is sometimes better that a person should die than continue living in certain desperate states, such as unbearable suffering, severe debilitation, permanent coma etc.However, the problem of euthanasia is in conclusion considered as an open system of question, where the answers are not unanimous. They are complicated with respect to the ethical, forensic aspects and also to the peculiarities of psychology.     

Hyperbaric oxygen in severe burns

A paired control study of the effect of hyperbaric oxygen (HBO) on the treatment of severe burns failed to reveal either a deleterious or salutary effect on mortality. Treatment had a deleterious effect on renal function and resistance to bacterial infection.     

Chromic acid burns and acute chromium poisoning

The problems encountered during the treatment of a patient with burns covering 40 per cent of the body surface caused by hot chromic acid and the resulting chromium poisoning are described. Anuria developed on the second day after injury and the patient died on the sixth day.     

The burned child — scarred for life?: A study of the psychosocial impact of a burn injury at different developmental stages

Several studies examining the psychosocial adjustment of child burn victims have resulted in contradictory conclusions, possibly because of their diverse methodology and poorly defined outcome measures. Using a standardized behaviour rating scale this study found that adolescent burn victims show a markedly poorer psychosocial adjustment when compared with younger burned children. Visible burns, emotional distress in the mother, and multiple home moves were all associated with poorer psychosocial adjustment in adolescence for burned children.     

Prevention of gastrointestinal bleeding in burns: the effects of cimetidine or antacids combined with early enteral feeding

The efficacy of prophylactic therapy with cimetidine or antacids combined with early enteral feeding to prevent gastrointestinal bleeding in patients with severe burns was evaluated. Fifty patients with burns exceeding 30 per cent of the total body surface area (TBSA) were divided into two groups, each of them treated by one of these agents in combination with early feeding. Bleeding was not encountered in either group. It is assumed that the combination of either agent with enteral feeding early in the post-burn course equally protected against gastrointestinal bleeding. Because of the ease and lack of side-effects of cimetidine in this series, its use was preferable.