John A. Moncrief

PSEUDOMONAS BURN WOUND SEPSIS. I PATHOGENESIS OF EXPERIMENTAL PSEUDOMONAS BURN WOUND SEPSIS.

Summary The bacteriologic and clinicopathologic features of experimental Pseudomonas burn wound sepsis display an orderly sequence of progression. There is initial supraeschar and intrafollicular (hair) bacillary localization followed by more widespread intraeschar colonization. By the fourth and fifth days, bacilli have invaded to the junction of the burned and viable tissue, and at this time a low grade bacteremia becomes evident. Bacteria then invade to the zone of viable granulation tissue. During the terminal phase of the disease, the bacterial invasion front destroys the granulation tissue zone and invades the deeper tissues. This is associated with a rise in pseudomonad count in the blood stream and the appearance of visceral hematogenous lesions, leukopenia and hypothermia. The hematogenous lesions not infrequently show Pseudomonas vasculitis similar to that seen in the human disease. The details of the bacteriologic and clinicopathologic findings of burn wound sepsis in the rat are discussed in relation to its human counterpart.

CONTROL OF EXPERIMENTAL AND CLINICAL BURN WOUND SEPSIS BY TOPICAL APPLICATION OF SULFAMYLON COMPOUNDS

The successful control of burn wound sepsis by use of Sulfamylon burn cream has greatly altered the management of the burn wound and its prognosis. The character of the healing wound has altered, with persistence of eschar now seen, due to suppression of microbial debriding action. This problem has been resolved by discontinuing therapy and applying dressings if necessary to hasten eschar separation. The use of a water soluble base, which is 62% water, has resulted in a decrease in evaporative water loss, with a consequent reduction in the metabolic load on the patient. This is evident in the reduction of weight loss in the post‐burn period. The control of local sepsis appears to add to this gain, since it too represents a decrease in metabolic demand. The survival of epithelial islands in deep dermal burns which had previously been converted to full‐thickness injury by infection has resulted in healing of such injuries without resort to skin grafting. The hydrotherapy procedures permit a daily gentle debridement of matured eschar, and a consequent reduction in the frequency of surgical debridement has occurred. The reduction in the need for general anaesthetic has simplified wound management and minimized weight loss due to cancelled meals.

PSEUDOMONAS BURN WOUND SEPSIS. II HEMATOGENOUS INFECTION AT THE JUNCTION OF THE BURN WOUND AND THE UNBURNED HYPODERMIS.

Summary Pseudomonas septicemia was produced in rats and the occurrence of hematogenous infection to the junction of the viable hypodermal tissue and burn eschar was studied. Hematogenous burn wound infection did occur, but was uncommon under experimental conditions which most closely paralleled those present in human Pseudomonas burn wound sepsis.

Gastrointestinal complications in burns

Abstract Complications involving the gastrointestinal tract are commonly seen in thermal injuries and are present in a variety of forms. To date, 322 complications have been documented in 1,291 cases, an over-all incidence of 24.9 per cent. The paralytic ileus frequently accompanying burns requires nasogastric intubation. Esophageal stricture and erosion can result unless tubes are removed as soon as possible. Curlings ulceration of the stomach and duodenum is the most prevalent problem and is related to the magnitude of the burn and to a decrease in mucus production by the stomach. Ordinary therapeutic measures commonly used in the treatment of peptic ulcer have not been effective. Perforation and severe hemorrhage require hemigastrectomy and vagotomy; lesser procedures have not been effective. Nine cases of acute cholecystitis, seven occurring without the presence of calculi, have been seen. Cholecytectomy is the treatment of choice. Several cases of hemorrhagic pancreatitis have occurred, and at autopsy subclinical pancreatitis is a frequent finding. Nonoperative treatment is recommended. Four cases of severe weight loss with duodenal obstruction by the superior mesenteric artery have been successfully managed by duodenojejunostomy. Involvement of the small and large intestine has been recorded in thirty-three instances and usually represents sequelae of low flow states or sepsis associated with thermal injury. Conventional treatment is effective. The presence of a burn makes diagnosis more difficult, thereby delaying treatment. Thus, a keen awareness of the potential hazard of gastrointestinal complications after thermal injury is the key to successful management.

Current trends in burn research Part I

Abstract Research related to thermal injury, both clinical and laboratory, has been exceedingly active in the past several years. Attempts have been and are being made to arrive at a more thorough understanding of the pathophysiological changes pursuant to burns, with the concomitant development of more physiological means of altering these deleterious effects. Problems related to skin grafting have been similarly scrutinized; a greater interest has been displayed in the physiology and biochemistry of the skin, and early steps have been taken to develop a satisfactory skin substitute. The most significant result of research in burns in recent years has unequivocally been the development of means of controlling burn-wound sepsis, thereby preventing bacterial invasion, and significantly improving survival in the burned patient.

Safeguards in the use of topical mafenide (Sulfamylon) in burned patients

Abstract Some practical guidelines are suggested for the use of Sulfamylon Acetate burn cream in major thermal injury. Knowledge and experience with the complications of this drug have permitted evolution of safeguards which lessen the incidence and minimize the severity of allergic and metabolic phenomena. Awareness of incipient acidosis and corrective measures may prevent fatal metabolic derangements. The usefulness of Sulfamylon Acetate burn cream is related to the ability of the surgeon to anticipate and prevent its complications.

In vitro determination of tetanus immunity.

Abstract : Four in vitro methods for the determination of tetanus immunity are discussed, including a new test which utilizes a passive latex agglutination technique. Of these tests, the passive latex agglutination technique appears to have the greatest potential for practical clinical value since it utilizes a relatively stable antigen and can be performed inexpensively in any well- equipped clinical laboratory within a matter of hours. The results obtained by the test may be valuable as a guide for the rational selection of the optimal type of therapy for tetanus prone individuals, both when a definite history of past immunization is obtained and when no history is available.

Reactions to Injury and Burns and Their Clinical Importance

This small text, written by one of the few premier pathologists interested in the subject of trauma, including burns, has the avowed purpose of providing information directed to medical students in their later years and to postgraduate students of pathology and surgery. The information is a compilation of the data available at the time of publication, including the international literature and the authors wealth of experience, which covers 25 years in the Birmingham Accident Hospital. While the bibliography is adequate, the reader cannot determine whether the statements are derived from personal experience or from the literature survey, and thus documentation of some of the more controversial statements is difficult to grasp immediately. In spite of this minor deficiency, the book presents the subject matter thoroughly, yet in a concise and readable fashion. The volume of information in this fine text is such that rapid scanning is not possible, and careful

Curling??s ulcer: a clinical-pathology study of 323 cases

Curlings ulcer: a clinical-pathology study of 323 cases B A Pruitt;F D Foley;J A Moncrief; Plastic and Reconstructive Surgery

Homograft Skin: A Versatile Biologic Dressing

The most important step during the recovery of the burn patient is the conversion of the open wound to a closed wound. The covering may be from regeneration of skin from residual epidermal elements or by the application of autograft. In large or untidy wounds, attempts have been made to use substitutes for the patient’s own skin. Although artificial substances have been tested, none has been more effective than skin itself in providing protection of the open wound and in controlling bacterial growth. Homograft skin was applied as early as 1881 for treatment of a lightning victim, but not until the mid-twentieth century did enthusiasm for its use begin to develop.’-’ The homograft skin was allowed to remain in place until the rejection phenomenon resulted in slough.’ It became evident that the rejection period was unsatisfactory because it resulted in a febrile, irritable and anorectic patient whose wounds again were open, unhealthy, edematous and