Hugh A. Frank

The inter-rater reliability of estimating the size of burns from various burn area chart drawings

The accuracy and variability of burn size calculations using four Lund and Browder charts currently in clinical use and two Rule of Nines diagrams were evaluated. The study showed that variability in estimation increased with burn size initially, plateaued in large burns and then decreased slightly in extensive burns. The Rule of Nines technique often overestimates the burn size and is more variable, but can be performed somewhat faster than the Lund and Browder method. More burn experience leads to less variability in burn area chart drawing estimates. Irregularly shaped burns and burns on the trunk and thighs had greater variability than less irregularly shaped burns or burns on more defined anatomical parts of the body.

B-mode ultrasonic echo determination of depth of thermal injury

A high-resolution high-frequency prototype B-mode ultrasonic scanning device was utilized to determine the depth of burn in a pilot study of five burned patients. Comparisons with clinical evaluations and histopathological studies of burn wound biopsies of the same burned areas failed to show any substantive improvement in predicting the depth of burn by ultrasonic scanning techniques. Current ultrasonic scanning is of no practical value to the burn surgeon for differentiating precisely between the depth of a deep dermal burn and a full skin thickness thermal injury.

An analysis of factors which predict mortality in hospitalized burn patients

Numerous studies have described the relationship between the size and depth of burn, age and burn patient mortality. Recent studies have examined the effect of other factors upon burn mortality and have proposed burn severity indexes based on statistical models. Data from 854 patients treated in the San Diego Burn Treatment Centre were analysed using multiple logistic regression. Many variables were associated with mortality, even when adjustments were made for burn size and depth. Several predictive models were constructed using those variables. The admission white blood count, admission serum osmolality, the involvement of inflammable liquid and the presence of pre-existing mental disorders, circulatory disease and digestive disease were found to have significant effects upon mortality when incorporated in a predictive model with age, size of partial-thickness burn and size of full-thickness burn. These results have implications for the construction and use of burn severity indexes.

Viability of frozen allografts

The use of meshed skin grafts allows an evaluation of the biologic properties of stored tissues such as skin. Frozen allograft may serve as an excellent biologic membrane, but it is not a satisfactory product for longer term allografting (intermediate allografting). The method of thawing (microwave oven versus water bath) appeared to have little effect on the ultimate viability and outcome of the frozen allograft.

Successful use of a bulk laxative to control the diarrhea of tube feeding.

The greatly increased nutritional demands of the severely burned patient frequently require the use of tube feeding for enternal hyperalimentation. At a time when general patient morale is low and motivation needs to be maximally maintained, there is nothing so dispiriting as the distress of a painful perianal region and uncontrollable liquid stools. Attempts to control the diarrhea which frequently accompanies tube feeding by changing the formula or the method of administration or a wide variety of constipating drugs have all met with very limited success. Based on the clinical observation of a noted gastroenterologist (Bockus), we have administered a mucilagenous hydrophilic colloid bulk laxative (Metamucil) to patients on tube feeding formulae. The dosage and frequency are adjusted to individual patient needs, but average 7 g per liter of liquid formula. The results have been dramatic; namely, the virtual elimination of the diarrhea problem in our burn patients on enteral hyperalimentation by gastric tube feeding. Colonic transit time increases. The stools become formed but soft, cohesive but not adhesive. Perianal irritation does not occur. Neither does soilage of wound, dressings, or bed. No rebound constipation or obstructive symptoms have been encountered. We attribute this response to the same water binding mechanism that allows these colloids to prevent chronic constipation. Our patients may be given as much as 5,000 to 6,000 calories of tube feeding per day. Our patients are not distressed by diarrhea. Our nursing staff is relieved of the burden that entails.

Clinical skin banking: a simplified system for processing, storage, and retrieval of human allografts.

A simplified procedure for the harvest and preservation of human allograft skin for burn treatment is outlined. In establishing a skin bank to serve the San Diego County Regional Burn Treatment Center, our primary goals were to deliver a low-cost product, monitored to be free of significant bacterial contamination. Our own innovations include the use of Falcon 2070 tubes as packaging material, and the use of microwave energy for the safe, rapid thawing of liquid nitrogen stored tissue.

The early treatment and reconstruction of eyelid burns.

Eyelid burns occurred in 67% of the 210 patients with facial burns admitted to the San Diego Regional Burn Center between 1 December 1977 and 30 June 1982. Evaluation of 48 surviving patients with significant eyelid injury demonstrated the safety and effectiveness of early excision and grafting of eyelid burns. Tarsorrhaphies were found not to be useful in preventing ectropion and resulted in deformity of the lid margins. Our technique employing early excision and grafting and reconstruction of eyelid burns is illustrated.

Analysis of 585 burn patients hospitalized over a 6-year period Part II: aetiological data

In a population of 585 burn patients from a well-defined urban area, the contribution of a number of factors to the occurrence of the burn injury is examined. These are: place where burned; activity of the patient at the time; contribution of various appliances and materials; the influence of clothing on the extent of the injury. These findings should prove helpful in future efforts at burn prevention.

Behavioural factors in burn mortality and length of stay in hospital

Abstract Numerous studies have examined the effects of burn size and depth, age, concomitant injury, and illness upon burn patient mortality and duration of stay in hospital, and other studies have stressed the importance of psychosocial factors in the causation of burns. However, scant attention has been given to the effects of psychosocial factors on burn mortality and length of stay in hospital. Data on psychiatric diagnoses, substance abuse, and factors in severity of injury were abstracted from the charts of patients admitted to the San Diego Regional Burn Treatment Center. Mortality data were analysed using logistic regression. After adjusting for severity of the burn injury, statistically significant increases in mortality are associated with the diagnosis of character or personality disorder, schizophrenia, alcohol intoxication at the time of injury, and a variable indicating a psychiatric diagnosis or severe undiagnosed problems. Comments on individual charts suggest that overtly self-destructive behaviour during treatment caused the increased mortality. Data on duration of stay in hospital among survivors were analysed using multiple linear regression. After adjusting for severity of injury, significantly longer stays are associated with suicidal intention, diagnosis of character or personality disorder, schizophrenia, senility and a variable indicating a psychiatric diagnosis or severe undiagnosed problems. Overtly self-destructive behaviour, treatment of psychiatric problems, and the inability of some patients to care for themselves may each contribute to the longer stay in hospital.

Analysis of 585 burn patients hospitalized over a 6-year period Part III: psychosocial data☆

We have examined the physical and psychosocial aberrations found in a series of 585 hospitalized burn patients. The implications of this data have been discussed as they apply to identifying persons at high risk for burn injury, and as they apply to estimation of the prognosis in severe burn injury. This is a step towards identifying a psychosocial profile for the evaluation of burned patients.