Sally Abston

A comparison of conservative versus early excision. Therapies in severely burned patients.

Early excision and grafting of small burn wounds is a generally accepted treatment. Early excision of burn injuries greater than 30% total body surface area (TBSA) in adults, however, has not been universally accepted. In this study, 85 patients whose ages ranged from 17 to 55 years with greater than 30% total body surface area (TBSA) burns were randomly assigned to either early excision or topical antimicrobial therapy and skin grafting after spontaneous eschar separation. Mortality from burns without inhalation injury was significantly decreased by early excision from 45% to 9% in patients who were 17 to 30 years of age (p less than 0.025). No differences in mortality could be demonstrated between therapies in adult patients older than 30 years of age or with a concomitant inhalation injury. Children (n = 259) with similar large burns treated by early excision showed a significant increase in mortality with increasing burn size and with concomitant inhalation injury (p less than 0.05). The mean length of hospital stay of survivors was less than one day per per cent of TBSA burn in both children and adults.

Effect on mortality of inhalation injury.

A retrospective analysis of 1,018 consecutive admissions with cutaneous burn injury over 32 months was carried out. Mortality probabilities as related to age, per cent TBSA burn, and presence of inhalation injury are presented. Incidence of and mortality from inhalation injury both rose with increasing burn area. The incidence of inhalation injury also rose with advancing age; mortality was lowest in the 5- to 14-year old age group and highest in those more than 59 years of age.

Determinants of mortality in pediatric patients with greater than 70% full-thickness total body surface area thermal injury treated by early total excision and grafting

Recent advancements in burn care have improved the survival rates of victims with severe burn injuries. The total mortality rate in a series of 1,057 pediatric patients admitted to Shriners Burns Institute Galveston Unit between 1982 and 1986 was 2.7%. The burn size resulting in a 50% death rate was 95% of the total body surface area (TBSA). In this study 19 survivors and 13 nonsurvivors with greater than 70% full-thickness TBSA burn injuries were compared. All survivors were adequately resuscitated upon arrival 11% sustained an inhalation injury. Forty-six per cent of the nonsurvivors sustained an inhalation injury; 31% were not initially adequately resuscitated. The presence of preadmission shock and inhalation injury were early determinants of mortality with secondary renal, pulmonary, or cardiovascular collapse being the later predictors of mortality in these massively burned pediatric patients.

Failure of TPN supplementation to improve liver function, immunity, and mortality in thermally injured patients.

Hypermetabolism with negative nitrogen balance and immune deficiencies characterize the systemic response to major thermal injury. Patients with burns greater than 50% of the total body surface area (TBSA) initially have poor gastrointestinal function, making it difficult to deliver sufficient enteral calories to meet nutritional requirements. Controversy has developed over whether to supplement oral alimentation with total parenteral nutrition (TPN) early in their treatment. This study randomly assigned 28 patients with burns greater than 50% TBSA to receive TPN supplementation or no TPN supplementation in the first 10 days postburn. Patients receiving TPN supplementation had significantly lower T-cell helper-to-suppressor cell ratios than the unsupplemented group. However, there was no difference in mortality between the groups (eight in each). All patients who died developed hepatomegaly associated with fatty infiltration cholestasis and antemortem liver function abnormalities, indicating that this syndrome is the result of burn injury itself, not TPN.

The Quality of Life after Major Thermal Injury in Children: An Analysis of 12 Survivors with 80% Total Body, 70% Third-degree Burns

Twenty-one children admitted between December 1981 and May 1985, with greater than 80% total body surface area burn (TBSAB), underwent total excision and grafting of all of their wounds within 72 hours of injury. Twelve survivors (with an average TBSAB of 89%, 82% third degree) were studied in detai

Improved myocardial oxygen utilization following propranolol infusion in adolescents with postburn hypermetabolism.

The purpose of this study was to determine if propranolol (0.5 mg/kg and 1 mg/kg), administered intravenously (IV) at the height of the postburn hypermetabolic response, would decrease myocardial oxygen requirements, without adversely affecting overall oxygen delivery or total body oxygen consumption. To test this hypothesis, six nonseptic patients age 17 +/- 3 years with burns over 82% +/- 11% total body surface area were given propranolol with continuous hemodynamic monitoring. Propranolol was administered to these patients 20 +/- 15 days postburn. Two clinically derived indices of myocardial oxygen consumption, pressure-work index (PWI) and rate-pressure product (RPP), were used to estimate the energy expenditure of the working heart. Both PWI and RPP were significantly decreased from baseline after 0.5 mg/kg propranolol, 31% for PWI (P less than .001) and 30% for RPP (P less than .01). Similarly, a decrease from baseline was seen after 1.0 mg/kg propranolol, 32% for PWI (P less than .001) and 35% for RPP (P less than .01). Cardiac index (L/min/m2) demonstrated no significant change [7.4 +/- 1.1 (prepropranolol), 6.5 +/- 1.3 (after 0.5 mg/kg propranolol), and 6.8 +/- 1.0 (after 1.0 mg/kg propranolol)] and exceeded the upper limits of normal (hyperdynamic state) throughout the study. Oxygen delivery index (962 +/- 209 mL/min/m2) and oxygen consumption indices [(254 +/- 78 mL/min/m2 by Fick method and 236 +/- 78 mL/min/m2 by inspired and expired gases)] were elevated at baseline and unaffected by propranolol. The decrease in PWI and RPP was achieved mainly by propranolols effect to lower both heart rate and BP.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic Rate Alterations in Early Excision and Grafting versus Conservative Treatment

This study was done to determine whether early massive excision and grafting would decrease the hypermetabolic response that characterizes burn injury. Thirteen consecutively admitted adult males with burns over more than 45% of the total body surface area (TBSA) were randomly assigned to one of two treatment groups. One group was treated by excising the burn within 72 hours of injury and grafting with autograft overlaid with cadaveric allograft or cadaveric allograft alone depending on available donor sites and size of recipient areas. The second group was treated conservatively with daily hydrotherapy and twice daily applications of topical antimicrobial agents until granulating beds could receive autografts. Resting energy expenditure (REE) was calculated from measurement of vO2 and vCO2 at the patients bedside. The responses of the two groups were comparable: the REE was approximately 20-30% above the predicted basal metabolic rate (BMR). Excisional therapy did not markedly decrease the hypermetabolic response to burn injury.

Prevention of upper gastrointestinal hemorrhage in 582 burned children

In 582 burned children, neutralization of gastric acid and reduction of psychic stress were utilized to reduce upper gastrointestinal ulceration and hemorrhage. While receiving milk, diazepam, and psychologic support, two children required operation. Two of the children who died without clinically apparent gastrointestinal disease had ulcers discovered at autopsy. We conclude that a prophylactic regimen that reduced the amount of acid bathing the gastroduodenal mucosa, provides adequate calories, and minimizes psychic stress is useful in preventing gastrointestinal hemorrhage after burns.

Comparison of fresh, frozen and lyophilized porcine skin as xenografts on burned patients

Summary This study evaluated the differences between commercial porcine skin (fresh-frozen or frozen-irradiated and lyophilized) and the fresh porcine skin that is currently in use at our Burn Hospital. The different preparations of skin were evaluated by various clinical criteria including weight gain of the patient, relief of pain, joint movement, ease of application, development of sepsis and preparation of the granulation bed. We also did a cost accounting to compare the difference in price between commercial and fresh porcine skin. In addition, the development of anti-porcine antibodies after sequential xenograft applications were evaluated and the implications of this antibody response are discussed. From the data obtained it is felt that the commercial preparations of frozen porcine skin are a suitable alternative to fresh porcine skin for treatment of the burned patient.

Gasoline explosions, gasoline sniffing: an epidemic in young adolescents.

One hundred twenty-two patients between the ages of 10 and 15 were admitted to the Shriners Burns Institute between July 1981 and November 1984. Seventy-five of the 122 patients sustained burns as a direct result of liquid gasoline explosions. Thirty patients had thrown gasoline on a fire and 17 others admitted to having ignited gasoline with a match. During admission interviews, none of the patients admitted to gasoline sniffing; however, 19 patients were subsequently found to have been sniffing gasoline at the time of the accident. All of the patients with gasoline burns sustained much larger burns, had longer hospitalizations, and required more surgery than did patients burned by other means. Similarly, the 19 patients who had been sniffing gasoline had larger burns, had longer hospital stays, and required more surgery than did those injured by gasoline in other accidents. The most common cause of thermal injury in the ten-to-15 year age group is a gasoline-related accident. The histories of a large number of these adolescents may be compatible with explosions related to gasoline sniffing. Educational efforts relating to the explosive nature of the substance and the dangers of gasoline sniffing are warranted.