D.M. Jackson

Tangential excision and grafting of burns: The method, and a report of 50 consecutive cases

Summary The role of tangential excision and grafting in the treatment of analgesic burns and the safety of the method have been discussed. The operative procedure has been described in detail. A study of 50 consecutive cases treated in this way has been undertaken, which has confirmed that the procedure can attain earlier wound closure without increased mortality, associated with reduced areas of bacterial colonisation and less scarring.

In search of an acceptable burn classification

Summary The need for an international classification of the depth of burns and the requirements of such a classification are stated. A suggested classification is offered for consideration, and an attempt made to show where it fits and where it fails to meet the requirements.

Topical chemoprophylaxis: Trials in silver phosphate chlorhexidine, silver sulphadiazine and povidone iodine preparations

Abstract A controlled trial showed that 1 per cent silver sulphadiazine (SSu) cream applied daily (or at intervals of 2 or 3 days) to burns had greater prophylactic value against Pseudomonas aeruginosa than a cream containing 0.4 per cent silver phosphate with 0.2 per cent chlorhexidine gluconate (SPCI). In another controlled trial, SSu cream had greater prophylactic value against Staphylococcus aureus , P. aeruginosa, proteus species and miscellaneous coliform bacilli than a 10 per cent povidone iodine (PVP-I) cream. It was inferred, from the results of an earlier trial, that silver nitrate chlorhexidine (SNCI) cream would be more effective than SPCI cream as a prophylactic agent against P. aeruginosa , apparently because of the greater solubility of silver nitrate; for this reason, SNCI cream was judged to be an appropriate substitute for SSu cream when sulphonamide-resistant Gram-negative bacilli were predominant in the ward. A trial of 10 per cent povidone iodine and 0–5 per cent silver nitrate solutions applied 6 hourly to exposed bums of the face, compared with no topical application, showed that both solutions reduced bacterial colonization of the burns, but there was no significant reduction in colonization by individual pathogens.

Local chemoprophylaxis for burns with gentamicin and other agents.

Abstract In a series of controlled prophylactic trials of antibacterial creams on burns of less than 30%, a cream containing 0.5% silver nitrate had a significant prophylactic action against Pseudomonas aeruginosa when compared with an inactive control cream (containing penicillin), but no significantly greater prophylaxis was obtained against Ps. aeruginosa by the addition of chlorhexidine gluconate (0.2%) or of gentamicin sulphate (0.1%) to the silver-nitrate cream; gentamicin cream was as active in prophylaxis against Ps. aeruginosa as silver-nitrate/gentamicin cream. Prophylaxis against Proteus spp. followed a similar pattern, but the addition of gentamicin significantly added to the prophylactic value against Proteus spp. of the cream containing silver nitrate. Unlike these organisms, Staphylococcus aureus was not acquired less often by burns treated with silver-nitrate cream than by those treated with penicillin cream; significant prophylactic effects against Staph. aureus were, however, obtained by the addition of gentamicin and (to a smaller degree) of chlorhexidine to the silver-nitrate cream. Both silver nitrate and gentamicin seemed to have a prophylactic effect against miscellaneous gram-negative bacilli, but this did not quite reach statistical significance. The proportion of swabs that yielded no bacterial growth was significantly greater in the series taken from burns treated with silver-nitrate cream (26%) than from those treated with penicillin cream (4.4%), and in the series from burns treated with silver-nitrate/gentamicin and gentamicin creams (62% and 54% respectively) than in the series from burns treated with silver-nitrate cream. There was no significant emergence of gentamicin or silver-nitrate-resistant bacteria in burns during these trials.

Topical chemoprophylaxis for burns: Trials of creams containing silver sulphadiazine and trimethoprim

Controlled trials showed that creams containing silver sulphadiazine, silver nitrate with trimethoprim, sulphadiazine with trimethoprim, and silver sulphadiazine with trimethoprim applied to fresh burns had prophylactic effects against bacterial colonization comparable with and in some respects (e.g., activity against Staphylococcus aureus ) superior to that of 0.5 per cent silver nitrate cream. Some trimethoprim-resistant staphylococci and Gramnegative bacilli emerged during the trial, and trimethoprim was therefore considered unsuitable for routine prophylactic use. The addition of trimethoprim to silver sulphadiazine did not increase the prophylactic effect of the application, in spite of some in vitro evidence of synergy. No sulphadiazine-resistant organisms were found to emerge, and no obvious toxic or allergic reactions were observed. Silver sulphadiazine cream was well tolerated by patients and considered to be a suitable agent for prophylactic use. Bacteria sensitive to silver nitrate and resistant to sulphadiazine or sensitive to sulphadiazine and relatively resistant to silver nitrate were all sensitive to silver sulphadiazine. From this it was inferred that silver sulphadiazine acts by virtue of both its antimicrobial components. Silver ions were absorbed by bacteria from silver sulphadiazine, as from silver nitrate solution, in nutrient broth. In an interim assessment of a controlled therapeutic trial, silver sulphadiazine cream applied to burns infected with Pseudomonas aeruginosa appeared to have some therapeutic value.

A historical review of the use of local physical signs in burns

Summary The use of physical signs to describe and classify burns has been reviewed from earliest times to the present day. During the last 30 years a number of methods have been studied for diagnosing partial and full-thickness skin destruction. These are enumerated, and the opinion is advanced that sensitivity to pin-prick is the best and simplest guide we have as to whether the deepest epithelial elements in the skin are alive or not.

Burns of bone: can these bones live?

Abstract In the first paper the history of the management of burns of bone has been described with reference to the principle papers. The aetiology and incidence of the injury has been recorded and illustrated from a series of cases treated in Birmingham over the last 25 years. In the second paper the results of treating these patients have been assessed using the criteria of operations required, healing time and mortality. Wound closure with free grafts after bone excision, and with skin flaps with or without excision have been described, and the factors favouring each method discussed. Finally, early cover with skin flaps over dead bone is encouraged.

Bone and joint changes following burns

Summary Changes occurring in bones and joints following burns are described. Clinically they are often associated with limitation of movement, and they are of importance radiologically because they may be wrongly attributed to other diorders unless their association with burns is recognised.

Preservation of sight after complete destruction of the eyelids by burning

Abstract The destruction of the upper and lower eyelids by burning may present the surgeon with an urgent problem of preparing skin flaps to save the eyes. The outlook will become more serious if the eyes themselves are damaged, but even if the corneas become severely scarred it may be possible to restore sight by the use of a keratoprosthesis. A successful, illustrative case is reported.

ACUTE HEINZ-BODY ANÆMIA IN BURNED PATIENTS

Abstract Haemolytic anaemia associated with many Heinz bodies and necessitating large blood-transfusions is described in three extensively burned patients, two of whom were young children. It was delayed in onset. Anaemia improved and Heinz bodies disappeared when drugs were discontinued—cloxacillin, probenecid, and aspirin in one case; cloxacillin, ampicillin, aspirin, and digoxin in another; and gentamicin and carbenicillin in the third. Follow-up studies in the two survivors revealed no deficiency in glucose-6-phosphate dehydrogenase or other enzymes concerned with aerobic glycolysis. The burns in two patients were treated locally with silver nitrate, and they became infected with Pseudomonas œruginosa in the three patients. Two patients had episodes of unexplained cyanosis, and methaemoglobinaemia has been found in other burned patients. Though the haemolytic process seems to have been aggravated or precipitated by drugs, multiple factors may have been concerned in predisposing the red blood-cells to oxidative degradation, including the residual effects of heat, bacterial infection, and local therapy with silver nitrate. The condition may be an overt manifestation of a more frequent red-blood-cell disorder induced by burning, complications, and therapy.