Hj Klasen

A historical review of the use of silver in the treatment of burns. II. Renewed interest for silver

In 1965, Moyer revived interest in silver nitrate solution. He concluded on the basis on in vitro and in vivo studies that a 0.5% solution represented the lowest concentration at which antibacterial action (against Staphylococcus aureus, haemolytic streptococci and generally against Pseudomonas aeruginosa and E. coli) was obtained. Mafenide acetate was introduced a short time after the reintroduction of silver nitrate, followed a few years later by silver sulphadiazine. Thus, in a short period of time three medicaments appeared on the market which represented a radical change in the topical treatment of burns. The action of silver sulphadiazine has been intensively studied. Since silver sulphadiazine does not offer sufficient protection to prevent or retard the growth of gram-negative bacteria in patients with burns covering more than 50% of body surface, Monafo introduced the combined preparation silver sulphadiazine and cerium nitrate. Although various attempts have been made to develop more effective silver compounds, so far silver sulphadiazine still remains the most widely used substance of this type.

Major trauma in young and old : What is the difference?

OBJECTIVE To evaluate the differences in mortality and long-term outcome between young and elderly patients with multiple injuries. DESIGN Retrospective and descriptive. MATERIALS AND METHODS Over a 5-year period (from January 1985 to January 1990) all the consecutive young (20 to 29 years, n = 167) and elderly (> or = 60 years, n = 121) patients with an Abbreviated Injury Scale score/Injury Severity Score of > or = 16 treated at the University Hospital Groningen (the Netherlands) were reviewed. Age, sex, mechanisms of injury, Abbreviated Injury Scale score, Injury Severity Score, mortality, duration of artificial ventilation, hospitalization, and intensive care treatment and discharge destination were analyzed. Long-term outcome was determined using the Glasgow Outcome Scale. MEASUREMENTS AND MAIN RESULTS Motorized vehicles were the leading cause of injury in both groups. Mortality in the young was lower than in the elderly (19.6% versus 38.8%); all elderly with an Injury Severity Score of > or = 50 died. Nearly all deaths in young and elderly were caused by severe brain injuries (83.8% versus 74.4%). Deaths related to multiple organ failure were not observed in the young and were rare in the elderly. The surviving young and elderly could be discharged home in equal percentages and their functional outcome 2 years after injury did not differ essentially. CONCLUSION We did not find any valid argument to treat severely injured elderly patients any differently from their younger counterparts, which implies that the increased trauma care cost is also justified for severely injured elderly.

A review on the nonoperative removal of necrotic tissue from burn wounds

The study of nonoperative debridement of burns got underway during the Second World War. A large number of substances such as enzymes of plant origin, acids and proteolytic enzymes of bacterial origin were examined since. The proteolytic enzymes derived from filtrates of C. histolyticum and B. subtilis have attracted the greatest interest. Although enzymatic debridement would seem at first sight to be an attractive form of treatment, unfortunately the results are highly variable.

Keraunoparalysis, a 'specific' lightning injury

Lightning paralysis or keraunoparalysis, a transient paralysis associated with extreme vasoconstriction and sensory disturbances of one or more extremities as a result of lightning impact is described in two patients.

SELECTIVE INTESTINAL DECONTAMINATION FOR PREVENTION OF WOUND COLONIZATION IN SEVERELY BURNED PATIENTS - A RETROSPECTIVE ANALYSIS

In this study the effect of selective intestinal decontamination of the digestive tract (SDD) on wound colonization was investigated. Ninety-one patients with at least 25 per cent total burned surface area (TBSA) were included in this study. All patients received oral polymyxin. In 63 patients oral co-trimoxazole and amphotericin B were added to the regimen. The addition of co-trimoxazole decreased the incidence of Enterobacteriaceae wound colonization from 71 per cent to 11 per cent (P less than 0.005). Colonization with Proteus was eliminated in patients treated with co-trimoxazole, compared with an incidence of 36 per cent in the group treated with polymyxin alone (P less than 0.001). The addition of amphotericin B decreased yeast colonization of the burn wound from 39 per cent to 10 per cent (P less than 0.005). A close relation was observed between burn wound colonization and colonization of the gastrointestinal tract. No resistant bacterial strains emerged during the period of study. These results suggest that SDD is an effective method for prevention of wound colonization. Further controlled studies are needed to establish the role of SDD in preventing burn wound colonization and wound sepsis.

CORRECTION OSTEOTOMIES OF PHALANGES AND METACARPALS FOR ROTATIONAL AND ANGULAR MALUNION - A LONG-TERM FOLLOW-UP AND A REVIEW OF THE LITERATURE

Correction osteotomies of nine phalanges and six metacarpals for rotational and angular malunion were performed in 15 patients ranging from 20 to 75 years of age and followed a mean period of 4.5 years, ranging from 1 to 11 years. Full correction of the preoperative deformity was achieved in 13 of the 15 patients (87%), bony union in 100%, and no loss of preoperative range of motion was observed, except in one patient who underwent additional arthrodesis. A high satisfaction rate was seen among 13 of the 15 patients. These results underline that osteotomies of phalanges and metacarpals for angular and rotational malunion can have significant functional benefits for the well-being of patients.

Fracture of the thumb sesamoid bone: a report of three cases and a review of the English-language literature

Fracture of the sesamoid bone of the thumb is a rare injury. In this report three additional cases with fracture of an ulnar sesamoid bone of the thumb are reported. The anatomic considerations, the mechanisms of injury, the differential diagnoses, and management are discussed with the English-language literature.

DORSAL CARPOMETACARPAL DISLOCATION OF THE INDEX FINGER - A REPORT OF 3 CASES AND A REVIEW OF THE ENGLISH-LANGUAGE LITERATURE

Isolated dorsal carpometacarpal dislocation of the index finger is a rare injury. We treated three patients with such an injury; two cases by delayed open reduction and internal fixation, and one case by direct closed reduction and internal fixation. Satisfactory functional results were obtained in two of the three cases (follow-up of 4 and 2 years, respectively). Anatomic factors, the mechanisms of injury, and management as discussed in the English-language literature are reviewed.

Bacterial translocation in D-galactosamine-treated rats in a burn model.

Bacteria and endotoxins can pass through the gut barrier under certain conditions. This process of bacterial translocation (BT) may occur after thermal injury in animals and is thought to play a role in the pathogenesis of septic complications in severely burned patients. The current study was performed to determine the role of endotoxin-related cytokines in the pathogenesis of burn-induced BT. Wistar rats were used in which enhanced sensitivity to TNF/LPS reactions was achieved by treatment with galactosamine (GalN). The GI tracts of these rats were antibiotic decontaminated with oral bacitracin and neomycin and were colonized with a neomycin resistant (NR)-Escherichia coli strain. The rats were divided into four groups, 30 per cent TBSA scald with GalN (Burn+GalN) pretreatment; 30 per cent TBSA scald without GalN (Burn); or sham injury with (GalN) and without GalN (Sham) pretreatment. On day 2, the animals were killed and liver, spleen, lung, heart and the peritoneal cavity were cultured. Blood samples were taken and the concentrations of LPS, TNF, IL-6 and ALAT were determined. Mortality was significantly increased in the Burn+GalN group compared to the other groups. In all groups, the incidences of BT were increased compared to the sham-treated group, although BT was most pronounced in the Burn+GalN group. In the latter group it was accompanied by highly elevated IL-6 and ALAT levels. The results of this study suggest that endotoxin mediators like TNF and IL-6 could play a role in the phenomenon of BT and that the function of the liver is an important clearing mechanism.

Power take-off injuries

Accidents with power take-off mechanisms often cause very serious injuries. In this study the clinical data and circumstances of the accidents of 14 patients who suffered a power take-off accident were analysed. From a total of 38 fractures, three primary and three secondary amputations were necessary. Fifty per cent of the accidents were due to human negligence, indicating the need not only for better safety shields but also for improved safety practices.