Burn Therapy Research Articles

Measurements of quality of life: then and now

Reviewing the burn literature of 25 years ago, one is struck by the excitement caused by the reduction of mortality rates as a result of the scienti®c approach to the problems of burn pathophysiology. Today, however, perhaps no single aspect of burn therapy has seen as much change over the last 25 years as the advent of functional and psychological outcome measurements and, foremost among these, measurements of quality of life. There were some very early studies of psychological complications. Neuropsychiatric problems arising from the Coconut Grove disaster had been reported as early as 1943 by Adler [1] and by Cobb and Linderman [2]. During the early days of organization of institutions and individuals interested in the burn problem, which included the establishment of the International Society for Burn Injuries, the American Burn Association and the publication of the journal Burns, outcome managements were little in evidence. There is some consideration of the prevention of burns, but no discussion of outcomes in the 1964 Bahama Conference [3]. In the second edition of the classic `The Treatment of Burns' [4], there is an excellent chapter entitled `Nursing Care and Psychological Considerations' in which emotional factors and adaptive mechanisms are discussed and the sta€ exhorted to be considerate and attentive to the tremendous psychological needs of inpatients. There is, however, no patient follow-up nor any attempt at analysis of the factors that play a part in psychological complications. The 1968 New York Academy of Sciences meeting devoted to the early treatment of severe burns [5] was probably the ®rst comprehensive meeting devoted to the science of burn care, but there is no mention of outcomes. An early article on outcome problems was published in the psychiatric literature in 1953 [6]. The annual reports of the USA Institute of Surgical Research [7], has contained analysis of range of movement following physical therapy and in one year 231 patients were followed from initial admission until discharge with investigations of range of movement; but there are very little additional data. The ®rst consideration of return to work is contained in an article in the ®rst issue of The Surgical Clinics of North America to be devoted to burns [8]. Thus, at this early stage already, the importance of physical medicine rehabilitation to burn therapy was beginning to be emphasized. In the same issue of the Surgical Clinics the National Burn Information Exchange questionnaire [9] asks respondents to `list physical impairments resulting from the burn injury present at the time of discharge'; however there is no follow-up, so this was an early one-time assessment only. In this atmosphere of scienti®c endeavor it is highly praiseworthy that the ®rst issue of `Burns' did in fact contain an excellent paper on the psychological e€ect of burns by Mr. Douglas Jackson [10]. Mr. Jackson in this article references Cobb and Adler's work on the Coconut Grove ®re and extends these with observations of his own. Thus, even in the ®rst issue, this journal ful®lled its role as representing a holistic approach to burn therapy.

A new technology in burn therapy

Nurses caring for severely burned patients need to know not only a burn injury's multisystem consequences, but also the effects and expected outcomes of burn treatment. Excision and grafting remain the primary interventions to promote wound healing, but severely burned patients may have little or no skin available for autograft harvesting. INTEGRA artificial skin, a commercial dermal regeneration template, is a new option for complete physiologic wound closure in a variety of clinical situations. This article reviews the physiologic effects, complications, and expected outcomes of INTEGRA artificial skin and compares it with other methods of closing burn wounds.

Effect of growth hormone therapy in burn patients on conservative treatment

Evaluation of growth hormone therapy in burns is limited and none is reported from developing countries where burns still carry high mortality. We analysed serial observations on the clinical and biochemical profiles in 13 patients with second and third degree burns who received recombinant human growth hormone (rhGH) (0.5 IU/kg body wt) for 2 weeks in addition to standard conservative treatment and in 9 patients who were managed with standard conservative treatment only. The two groups of patients had burns, comparable in extent and severity. Additional rhGH treatment resulted in improved wound healing ( p<0.001), delayed separation of eschars ( p<0.01), increase in haemoglobin ( p<0.05), serum albumin ( p<0.01), calcium ( p<0.05), phosphorus ( p<0.001), glomerular filtration rate ( p<0.05) and 7 fold elevation in IGF-1. Also, a reduction in weight loss ( p<0.01), nitrogen production rate ( p<0.05), catabolic index ( p<0.01), duration of sepsis ( p<0.01) and hospital stay by 40% ( p<0.01) was noted with rhGH therapy. Transient hypercalcemia (3 patients), albuminuria (2 patients) and elevated blood glucose (one patient) were noted in the rhGH treated group not necessitating any specific therapy. Mortality in rhGH treatment group was 8.3% compared to 44.5% in the “no rhGH” treatment group. These observations suggest significant benefits of short term rhGH treatment in burn patients on conservative management.

The comparison of early fluid therapy in extensive flame burns between inhalation and noninhalation injuries

Over the last half century, advances in treatment have changed the principal cause of death in burn patients from burn shock and wound sepsis to pulmonary sepsis, of which inhalation injury has always played a key role in morbidity and mortality. Even though Navar et al., Am. J. Surg. 1985;150:716–720 have noted that patients with inhalation injury had a mean fluid requirement of 5.8 ml/kg/% burn to achieve resuscitation from early burn shock, while patients without inhalation injury required only a mean fluid of 4.0 ml/kg/% burn, to achieve successful resuscitation in inhalation injured patients with minimum but adequate fluid has always been a challenge. To further define the difference of early fluid therapy between inhalation and noninhalation in extensively burned patients, a retrospective analysis was carried out in the Tri-Service General Hospital. Sixty-two flame burned patients (aged from 16 to 81 years-old with a mean age of 33.2±15.1 years; with burn size ranging from 30% to 98% TBSA with a mean burn size of 60.5±22.7%; 26 with inhalation injury; noninhalation 36) were reviewed during a 5-year period. The Parkland formula is the initial choice of fluid regimen with 4 ml/kg/% burn and the amount of replacement is monitored by urine output and is titrated to maintain urine output between 0.5 and 1.0 ml/kg/h. The mean amounts of fluid requirements of both inhalation and noninhalation burned patients were 3.1±1.0 and 2.3±0.8 ml/kg/% burn respectively ( p<0.05). Our study showed less fluid requirement for both inhalation and noninhalation injured patients in comparison with the Navar study and Parkland predictions in the first 24 h postburn. Furthermore, the inhalation injured patients definitely required volumes of fluid in excess of those required in noninhalation injured cases.

Oral fluid therapy in paediatric burns (5–10%): an appraisal

Fluid therapy by the oral route is the accepted method of treatment for smaller burns in children (less than 10%). [Settle JAD. Burns—the first five days. Essex: Smith and Nephew Pharmaceuticals Ltd, 1986.] A phone survey was carried out of all the hospitals in the United Kingdom that manage burns, to record their oral fluid therapy practices for burns (5–10% BSA) in paediatric patients. Included in the survey was an assessment of the uniformity of the contents of the fluids, their palatability and acceptance by patients and any side-effects from this form of treatment. There appears to be no uniformity in policies regarding fluid therapy in children with this percentage of burns. Treatment ranged from a formula guided resusciation therapy (as practised generally with large burns) to a ‘drink as you like’ policy. Fluids used varied from electrolyte to non-electrolyte containing solutions and fruit juices and were, therefore, markedly different in content. The electrolyte solutions were reported as being non-palatable unless flavoured with fruit juices. No complication was reported although one unit queried a possible case of fluid overload. Potential complications from this mode of therapy are discussed. The cost implications of using various fluid types are also presented.

Apoptosis of hair follicle cells in the second-degree burn wound unders hypernatremic conditions

Progressive burn wound necrosis is an important factor as a cause of delayed healing during clinical therapy of burns. Among the causes of progressive necrosis have been attributed an insufficient blood supply or a dehydration at the zone of stasis just beneath the zone of coagulation. In a previous study evidence was presented that hypernatremia, an osmotic injury, may act to promote progressive tissue or cell death of the superficial dermal wound resulting from a heat injury. To test this hypothesis pathological features of cell death in the second-degree burn wound in the rat with hypernatremia were investigated and evidence for apoptosis in hair follicle cells was observed. Rats in the hypernatremic group were administered 10 ml of hypertonic sodium solution (850 meq 1 −1) and the control rats were treated with 10 ml of hyponatremic solution (100 meq 1 −1) to prevent hypernatremia. After 24 h postburn the average incidence of hair follicles (ratio to the normal skin) in the hypernatremic group was 30.1±11.6 per cent and significantly lower when compared with the control group (87.6±6.0 per cent). The numbers of hair follicles were studied by haematoxylin and eosin stain, and the apoptotic process was investigated by an immunochemical assay and electron microscopy.

Mortality in Burned Children With Acute Renal Failure

During the past 13 years, mortality from acute renal failure in burned children has been on the decline. To determine which new burn therapies contributed to the decrease in mortality. The medical records of burned children admitted from February 1966 to January 1997 were reviewed, and the outcome of changes in the treatment of burned children were compared. Sixty children with acute renal failure were identified. These children were divided into those admitted from 1966 to 1983 (n=24) and those admitted from 1984 to 1997 (n=36). They were compared with matched control subjects from the same period without renal failure. Values are presented as means+/-SEMs. Statistical analysis was by the Student t test or chi2 analysis. Mortality rates in burned children with acute renal failure decreased from 100% before 1983 to 56% after 1984 (P<.001). The time between a burn injury and the initiation of intravenous fluid resuscitation was 8.6+/-1.7 hours before 1983 compared with 3.0+/-0.5 hours after 1984 (P<.005). The time between a burn injury and complete early wound excision decreased from 228+/-37 hours before 1983 to 40+/-7 hours after 1984 (P<.001). The incidence of sepsis decreased from 71% to 44% in these periods (P<.05). After 1984, survivors had a shorter time delay for fluid resuscitation than nonsurvivors (1.7+/-0.5 hours vs 4.8+/-0.9 hours; P<.005) and a lower incidence of sepsis (19% vs 60%; P<.05). From 1984 to 1997, burned children with acute renal failure who did not require dialysis had significantly shorter delays for fluid resuscitation (2.2+/-0.5 hours vs 4.4+/-0.9 hours) and complete wound excision (29+/-6 hours vs 49+/-7 hours) compared with those requiring dialysis (P<.05 for both). Early adequate fluid resuscitation, early wound excision, and better infection control may reduce mortality in burned children with acute renal failure.

Myocardial effects of isoflurane in healthy infants and small children

In paediatric healthy patients and in real peroperative conditions, the cardiovascular effects of isoflurane have been poorly described. We have evaluated the myocardial effects of 1% end-expired concentration (EEC) of isoflurane in 25 healthy infants or small children undergoing superficial surgical therapy for small burns with a continuous aortic blood flow echo-Doppler device. Aortic blood flow (ABF) was measured with a small oesophageal probe specially designed for infants. The aortic flowmeter was connected with satellite devices to visualize the haemodynamic profile variations during the isoflurane inhalation period. Isoflurane significantly decreased ABF and increased pre-ejection period/left ventricular ejection time (PEP/LVET), when compared with control values previously recorded 5 min after induction with halothane-fentanyl and atracurium (respectively, 80 +/- 7%, mean +/- SD; P < 0.001 and 111 +/- 11%; P = 0.017, 5 min after EEC of isoflurane reached 1%, then respectively, 75 +/- 12%; P < 0.001 and 119 +/- 16%; P < 0.001, at the end of the isoflurane inhalation period). These variations reversed to a great extent when isoflurane was switched off (97 +/- 17% for ABF; P = 0.08 and 105 +/- 12% for PEP/LVET; P = 0.75). Among the usual parameters, 1% EEC of isoflurane caused no significant changes in heart rate, moderately decreased mean arterial pressure (successively, 88 +/- 12%; P = 0.045 and 87 +/- 19%; P = 0.049), but belatedly decreased end-tidal CO2 pressure (87 +/- 11% at the end of the inhalation period (P < 0.001) which persisted 5 min after isoflurane was turned off (90 +/- 11%; P < 0.001)). These findings suggest that isoflurane can transiently depress cardiac function in healthy infants.

Hyperbaric oxygen therapy for deep second degree burns: an experimental studyin the guinea pig

Most previous animal studies reporting improved epithelialisation and healing of burn wounds under hyperbaric oxygen (HBO) did not include the conventional treatment with topical antibiotics as part of the protocol, and did not compare the effectiveness of HBO therapy with that of normobaric 100% oxygen (NO). The purpose of our study was to compare the results of combined treatment with HBO + silver sulfadiazine (SS) and those of treatment with NO + SS or SS alone. Deep second degree burns were produced on the depilated backs of 54 guinea pigs using a validated burn protocol. The animals were assigned to three treatment groups: HBO + SS, NO + SS, and SS. Dressings were changed daily. HBO was administered at 2 atmospheres absolute (ATA) for 90 min BID, and NO for 90 min BID. The parameters compared among the groups were laser Doppler flowmetry, and burn wound contracture and re-epithelialisation data derived from computerised planimetry of photographs of the wound. No differences in laser Doppler flowmetry results or the magnitude of contracture were found between the groups. Significantly increased re-epithelialisation was observed under NO + SS starting 10 days after the burn (P = 0.02, ANOVA). This significance stems from the difference between the HBO + SS and NO + SS groups (Tukey test). These data indicate that excessively high levels of tissue PO2 might compromise burn healing, and explain our results. A further study comparing combined treatment using a milder HBO protocol + SS and NO + SS is indicated in the search for the optimal HBO regimen.

Burn therapy with physiologically moist environments

Burn therapy with physiologically moist environments

BURN PAIN: Evaluation and Management

Burn injury is one of the most painful conditions an individual may ever experience. Each year in the United States, approximately 1.5 million people suffer a burn injury. 4 Of these, 500,000 people are seen in an emergency department, and more than 50,000 are admitted to the hospital. 4 Approximately 5500 deaths per year are attributed to the complications of burn injury. 4 All of these individuals have pain associated with burn injury. Minor burn injuries have fewer physiologic consequences but may be equally painful. The pain following a burn is initially related to the magnitude and type of tissue and nerve damage sustained and the resultant inflammatory process (see the articles by Sorkin and Yaksh and Chaplan). In addition, treatment-related pain arises from escharotomies, intravenous line placement, skin graft procedures, and other burn therapy. Pain may be made worse by psychological factors, including fear of pain or disfigurement, anxiety related to loss of control, distress of losing family members or material possessions at the time of the injury, and development of depression. 7 A comprehensive interdisciplinary team approach to management of burn-related pain is essential for maximizing a patient's functional outcome while minimizing psychological distress and facilitating community reentry. A combination of pharmacologic, procedural, physical, and psychological pain-relieving treatments needs to be employed. In addition, the physician needs to recognize and address the special needs of the pediatric burn population.

Acetobacter cellulosic biofilms search for new modulators of cellulogenesis and native membrane treatments

Since natural substances like pseudoxanthins exert a positive effect on the cellulogenic ability of Acetobacter xylinum when producing cellulosic pellicles suitable for skin burn therapy, new defined and complex modulators were sought. Ca2+ and Mg2+ (4 mM) were strongly stimulatory. Na+ had no effect and K+ was inhibitory. Ammonium dihydrogen phosphate (0.12 g/L) ensured the same nitrogen supply as the same concentration of yeast extract as measured by cellomembrane dry wt./yield albeit higher yeast extract supplies produced thicker membranes. Corn steep liquor (CSL) was also progressively beneficial from 0.125 to 0.5 mL/L, and this yield could be further improved by the combination of CSL with a tea infusion (source of caffeine). Uridine (precursor for UDP-Glc, sugar donor in cellulose biosynthesis), guanine, guanosine, and its butirylated derivatives (precursors for the positive modulator of cellulose synthetase, di-cGMP) resulted in only moderate stimulation. Sodium phytate and betaine were also slightly stimulatory. The fibrilar product from a new Acetobacter isolate (Ax-M) was characterized as cellulose by comparison with the solid-state(13)C-NMR of algal cellulose. Its X-ray diffractogram was a confirmatory analysis. After incorporation of tamarind xyloglucan to previously air-dried cellulosic pellicles, diffractometry displayed only slight differences. Mercerized (5M NaOH) fresh cellulosic biofilms underwent drastic size reduction (3.5-fold), turning compact nut still flexible if maintained wet.

Povidone-iodine in antisepsis--state of the art.

The natural element iodine has been used for more than 150 years to prevent infection and treat wounds. Yet only due to the development of iodophors has it become possible to use this highly efficient microbicide in a wide range of medical applications. The antimicrobial spectrum is universal. Its efficiency against clinically and epidemiologically significant new pathogens, such as methicillin-resistant Staphylococcus aureus and Enterococcus sp. has also been validated. No development of resistance has been determined. New data are also available on the excellent local tolerability of Betaisodona (povidone-iodine) preparations. On these grounds, a number of clinical fields exist in prophylaxis and therapy, for either once only or repeated applications: the disinfection of hands and skin, mucosa antisepsis, intra- and postoperative wound treatment, therapy of skin infections, burns and chronic wounds.

The treatment of minor burns in rural Alabama emergency departments

The purposes of this descriptive survey were to determine the treatments for minor burns in rural Alabama emergency departments, to assess how closely those treatments correspond with recommendations for burn therapy noted in the literature, and to identify specific deficits in the burn research literature. A descriptive survey consisting of open-ended questions was used to gather data on current practices for treating outpatient burn wounds. A researcher-developed questionnaire organized into seven categories of burn care was pilot-tested in an urban burn center; the questionnaire was then mailed to 96 rural Alabama hospitals, addressed to the ED nurse manager. The seven categories--initial cooling, analgesics, cleansing agents, topical antimicrobial therapy, wound dressings, blister debridement, and referrals--were identified from both major and minor burn care literature, because little research has been published about minor burns. Simple frequencies were used to analyze results from the 20% (n = 21) of the sample that responded. Seven categories of burn care are common to all respondent facilities, with wide variation in the details. Most practices proceed logically from the treatments recommended for major burn care, with a few notable and potentially dangerous exceptions, but there is no definitive research available to guide the clinician in the care of outpatient burns. Research questions were generated that can provide direction for measurement of outcomes in the care of minor burns treated on an outpatient basis.

The treatment of hydrofluoric acid burns.

Hydrofluoric acid is a colourless or almost colourless, fuming liquid having a highly caustic and corrosive effect on organic tissue. Many kinds of hydrofluoric acid in concentrations are used in Industrial processes and laboratory uses because of its useful chemical properties. Hydrofluoric acid causes severe and painful burns to the skin and eyes. In this paper, the immediate symptoms, the typical treatments in the literature, first aid and therapy of hydrofluoric acid burns are reviewed.

Hemodynamic effects of delayed initiation of antioxidant therapy (beginning two hours after burn) in extensive third-degree burns.

The hemodynamic effects of the delayed initiation of antioxidant therapy with high-dose vitamin C were studied in 12 guinea pigs with third-degree burns over 70% of their body surface area. All animals were resuscitated with Ringer's lactate solution (RL) according to the Parkland formula (4 ml/kg/% burn during the first 24 hours) from 1/2 to 2 hours after burn, and the infusion rate was reduced thereafter to 25% of that of the Parkland formula. The vitamin C group (n = 6) received RL with vitamin C (14 mg/kg/hr), and the control group (n = 6) received RL only. The 24-hour fluid intake for each group was 32.5% of the Parkland formula volume. Burn wound edema in the vitamin C group was significantly less than that in the control group. The vitamin C group maintained adequate hemodynamic stability as determined with hematocrit and cardiac output values, but the control group did not. Even though the initiation of the vitamin C administration is delayed until 2 hours after burn, the hourly infusion rate of the resuscitation fluid can be reduced to 25% once it is started. Thus antioxidant therapy with adjuvant vitamin C administration may be applicable to the clinical setting in which a patient with burns arrives at the burn care facility a few hours after the burn injury occurred.

Burn therapy

Burn therapy

Regional and institutional variation in burn care.

In reviewing the literature on burn therapy and observing clinical burn care, we noted differences among institutions and individual experts in several areas. To study variation in burn care, we surveyed the 140 burn centers listed by the American Burn Association to determine how burn care is currently administered in the United States and Canada. Responses were obtained from 83 hospitals (60%). The survey addressed resuscitation, operative and nonoperative wound care, medications, antimicrobial agents, and pain control. The major influence on care appeared to be the experience of the director (considered "very influential" in 85%) compared with the literature ("very influential" in 12%) and habit/what works for us ("very influential" in 48%). The Parkland formula was used "always" or "often" by 78%, and the Brooke formula "never" by 81% of respondents. Lactated Ringer's solution was the most popular initial fluid, and most (78%) respondents changed fluids after 24 hours. However, the fluids used in the second 24 hours varied equally among several choices. The use of colloids also varied without a set pattern. Furosemide (Lasix) and nonsteroidal antiinflammatory drugs were used "rarely" or "never" by 67% of centers in the acute stage. H2 blockers were used for gastritis prophylaxis "always" or "often" in 60% (vs 53% for antacids and 20% for sucralfate [Carafate]). Tube feedings were started on day 1 after burn injury "always" by less than 30% of centers. Total parenteral nutrition was not commonly used. Most centers use of silver sulfadiazine on the body and hands, but facial topical antimicrobial therapy varied.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurocardiac toxicity of racemic D,L-lactate fluids.

Racemic D,L-lactate has long been used in burn therapy as Ringer's lactate and in peritoneal dialysis fluid for treatment of renal failure. The D-lactate component of this racemic mixture is known to cause two forms of neurological toxicity in patients: encephalopathy and, in a subset of the population, panic reaction. Here we demonstrate that coma, similar in degree to that produced by blood levels of 75 mM ethanol was induced in rats by the intraperitoneal infusion of sodium D-lactate sufficient to raise serum D-lactate concentration to 25 mM, whereas infusion of equal quantities of sodium L-lactate produced no observable neurological effect. We further demonstrate that the intravenous infusion of racemic D,L-lactic acid into 48-hour fasted rats produced serious disturbances of cardiac rate and rhythm leading to death. When serum D-lactate concentration had reached 1-2 mM there was bradycardia, at 2-3 mM prolongation of QT interval, at 6-7 mM AV block with ectopic escape rhythms, and at 11 mM death in ventricular standstill or fibrillation. In contrast, intravenous infusion of L-lactic acid to blood levels of 25 mM failed to produce any change in cardiac rhythm. On the other hand, the isolated working heart, free of influence from the central nervous system, displayed no change of cardiac rhythm or physiological function when perfused with 25 mM sodium D,L-lactate.

Molecular and Cellular Studies of Hyaluronic Acid-Modified Liposomes as Bioadhesive Carriers for Topical Drug Delivery in Wound Healing

Liposomes, modified into bioadhesive systems by the covalent anchoring of hyaluronic acid (HA) to their surface, were investigated for their abilities to act as site-adherent and sustained-release carriers of drugs for the topical therapy of wounds and burns. Epidermal growth factor (EGF) served as the test drug for growth factors and monolayers of the A431 cell line served as models of the in vivo designated targets. The hyaluronic acid was radiolabeled to carry 3H, through a deacetylation-reacetylation procedure, yielding specific activities in the range of 1 × 106 dpm/mg. The HA was bound to the surface of the liposomes, using carbodiimide to crosslink its carboxyl residues to amine residues at the liposomal surface. The latter was provided through the inclusion of phosphatidylethanolamine in the liposome formulation. Varying the initial HA/lipid ratio over the range 1-500 mg HA/mmol lipid, it was found that the increase in bound HA was linear, providing up to 80 mg HA/mmol lipid. The HA-modified, but not the nonmodified, liposomes were found to bind with high affinity (ΔG° in the range of −7 to −9 Kcal/mol) to monolayers of the A431 cell line. The HA-modified liposomes were found to encapsulate EGF at high yields (% encapsulation, >87) and to act as sustained-release depots, the rate constant for the release of the encapsulated EGF in the range of 1.4 × 10−3 h−1. Taking all of these findings together, it is concluded that these liposomes are bioadhesive sustained-release carriers of drugs, as desired, meriting further cellular and in vivo studies.