Cent Of Body Surface Area Research Articles

Burns during pregnancy

Eight cases of burns during pregnancy were treated in Kuwait during the last 3 years. In all burns above 30 per cent body surface area (BSA), abortion, premature labour and intrauterine fetal death are ever-present complications and the survival of the foetus in burns above 50 per cent BSA is uncommon. Nearly all these complications occur during the first week after the burn. For patients in the second and third trimesters of pregnancy with burns above 50 per cent BSA the prognosis is usually poor unless the pregnancy is terminated within 24–48 h after the burn.

Burn area measurement by computerized planimetry.

A microcomputer system was developed which allows the user to draw the contour of a burn on a diagram on the computer screen. The per cent body surface area is then determined by direct area measurement by the computer. A total of 148 weekly burn diagrams ranging from 1% to 71% (mean, 23.7%) body surface area burn in 59 patients were analyzed using this system. Excellent correlation between the computer system and the manual Lund and Browder chart method (correlation coefficient, 0.962; p less than 0.0001) was obtained. Computerized planimetry provides a rapid, simple method of recording data and calculating total per cent burn which compares well with the manual Lund and Browder diagram.

The toxic shock syndrome in a burn victim

A case of toxic shock syndrome (TSS) in a 6-year-old boy with a 5 per cent body surface area partial thickness scald burn is reported. Biobrane® was the wound dressing used initially. The clinical and laboratory characteristics of the syndrome are listed. The syndrome is caused by an exotoxin of Staph. aureus and can occur in the absence of invasive infection. The syndrome, first described in menstruating women who used tampons, has occurred in patients with a variety of wounds. Reports of the TSS syndrome in burn victims are limited to children whose wounds were covered. Children are most vulnerable to the development of TSS because of their limited prior exposure to the toxin.

Maximal activities of glutaminase and some enzymes of glycolysis and ketone body utilization and rates of utilization of glutamine, glucose and ketone bodies by intestinal mucosa after burn injury

1. 1. The effects of burn injury (33 per cent of body surface area) on the activities of key enzymes in the metabolism of glucose, glutamate and ketone bodies in the epithelial cells of the small intestine and the rates of utilization of glucose, glutamine and ketone bodies by isolated enterocytes have been investigated. 2. 2. Burn injury decreased the maximal activities of hexokinase and 6-phosphofructokinase and increased those of glucose 6-phosphatase plus fructose bisphosphatase (in duodenum, jejunum and ileum) over the first 5 days post-injury. 3. 3. After injury there are decreases in the rates of glucose utilization and lactate formation by incubated enterocytes. 4. 4. The maximal activities of citrate synthase and oxoglutarate dehydrogenase were increased during the first 5 days post-injury, whereas the ketone-body-utilizing enzymes were unchanged. 5. 5. An increase in the maximal activity of phosphate-dependent glutaminase was observed during the whole of the post-injury period studied (20 days). 6. 6. After burn injury there is an increased rate of glutamine utilization and increased rates of formation of glutamate and alanine by incubated enterocytes.

Anaphylotoxin levels following thermal injury

Following thermal injury, anaphylotoxins (C 3a and C 5a) are generated by complement activity. We measured C 3a and C 5a levels serially in 18 seriously burned patients (mean burn size= 37.9 per cent body surface area) over the initial 3 weeks following injury. Values for C 3a were significantly increased when compared with normal controls, with maximum levels during the second week, while C 5a levels were slightly elevated initially. These levels did not correlate with the extent of tissue injury, the development of septic complications or the clinical outcome. However, it appears likely that C 3a and C 5a may be responsible for some of the pathophysiological alterations observed following thermal injury.

Oral hyperalimentation and the prevention of severe weight loss in burned patients

It is well known that the marked hypermetabolic response of the human body to thermal injury requires aggressive nutritional support. In order to minimize catabolic conditions resulting in severe weight loss, an oral hyperalimentation regimen has been successfully implemented in the burns unit of Tygerberg Hospital, Cape Town. Ninety-eight patients with deep burns, varying from 20 per cent to more than 60 per cent of body surface area, were included in this study. The results indicated a general increase in the percentage of patients who gained weight from week to week after week 2 post-burn in all burns categories. An exception was the 60 per cent and more burns category in which an increasing number of patients lost weight until week 4 post-burn. The results of this study and the apparent discrepancy in the above 60 per cent category are presented.

Fluid retention and burn survival.

The relationship between retained fluid and survival has previously been reported from our burn unit. Two hundred thirty cc/kg lean body mass accurately delineated survivors from nonsurvivors. Our previous study did not account for fluid lost through the burn wound. This study was undertaken to evaluate fluid retention per square meter of body surface area which has been corrected for fluid loss from the burn wound using a formula suggested by Mason et al. Data collected from 95 adult patients with burns greater than or equal to 20% body surface area burn (mean age, 42.4 years; mean burn size, 37.7%), who were admitted to our burn unit between January 1978 and September 1985, were evaluated. All patients included in the study were adequately resuscitated and survived the initial 48 hours. A calculation of the total fluid retained during the first 48 hours postburn and estimation of fluid loss from the burn wound were made. A comparison was made between lean body retained fluid and surface area retained fluid. A positive correlation (r = 0.921; p less than 0.001) was demonstrated between these two methods of assessing fluid retention. Fluid retention determined by either method resulted in a higher correlation with survival than any single predictor (age, per cent body surface area burned) of burn survival. Surface area fluid is as accurate as lean body fluid in predicting survival. Additionally, we determined that for the first 48 hours postburn, 4,425 cc fluid retained per meter square body surface area accurately differentiated survivors from nonsurvivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Fluid retention during the first 48 hours as an indicator of burn survival.

The quantity of fluid retained during the first 48 hours of resuscitation has been suggested as an indicator of burn severity and mortality (13). In this study of 82 adult burned patients with more than 20% total body surface burns we found that the net fluid retention during the first 48 hours of resuscitation was a predictor of burn mortality and additionally 230 cc of retained fluid per kilogram of lean body mass in the initial 48 hours postburn was an excellent means for separating survivors from nonsurvivors. Fluid retention as an indicator of burn severity and mortality was compared to other methods of predicting burned patient mortality. Parameters evaluated included the per cent body surface area burned, per cent full thickness burn, presence or absence of inhalation injuries, sex, age, and ultimate outcome. The Abbreviated Burn Severity Index (ABSI) (14) was determined for each patient using these data. A comparison was made between fluid retention data, per cent body surface area burned, and the calculated Abbreviated Burn Severity Index and patient mortality. The power of each variable to predict mortality was evaluated by stepwise regression analysis. From this analysis net fluid retention during the first 48 hours of resuscitation was as accurate as the Abbreviated Burn Severity Index and was a better predictor of mortality than individual components of that Index.

Neutrophil granulocyte functions in severely burned patients

Burns wound sepsis is not only the most common but also the most severe complication following extensive thermal injury. One conceivable explanation of this problem is a reduced capacity of the polymorphonuclear neutrophil leucocytes of these patients to combat the invading microbes. Fifty patients (42 male and 8 female) with deep dermal burns, covering 20–90 per cent of the total body surface area, were investigated from immediately after the injury until death or until healing of the wounds. The following functions of the neutrophil granulocytes were studied: (1) chemotaxis and random migration utilizing a modified Boyden chamber technique, (2) phagocytosis of Staph. aureus and IgG-coated latex particles, (3) bactericidal capacity, e.g. killing of Staph. aureus and (4) the neutrophil granulocyte content of: myeloperoxidase, lactoferrin, and chymotrypsin-like cationic protein. The presence of stimulators and inhibitors of the granulocyte functions was studied using gel filtration of the patient's serum on Sephacryl gel columns. Sera from all patients obtained within the first 1–3 days post-burn contained significantly increased amounts of heat-labile chemokinetic stimulating activity. Sera obtained between days 4 and 10 after injury contained significantly decreased amounts of heat-stable chemokinetic stimulating activity. Reduced chemokinetic activity was found during the third and fourth weeks following major burns (⩾40 per cent) due to the presence of one or both heat-stable chemokinetic inhibitory activities. During the second week post-burn patients with burns larger than 40 per cent of the body surface area who showed an inhibition of chemotaxis, also had defects in phagocytosis, and often impaired bactericidal capacity concomitant with lower contents than normal of the granular enzymes. A hyaluronic acid preparation in low concentrations was found to counteract the migration inhibitory effect demonstrated in vitro in sera from patients with severe burns. Based upon these results a series of patients with severe burns and impaired functions of the neutrophil granulocytes have been treated with small amounts of this hyaluronic acid preparation subcutaneously. Very promising results have been noticed, similar to those found in vitro.

Acute renal failure in a burn patient: the advantages of continuous peritoneal dialysis

An 8-year-old girl sustained 65–70 per cent body surface area burns when her clothes caught fire. Two weeks later, she developed acute renal failure (ARF) and needed dialysis therapy. The extensive, infected burn area prevented the establishment of a safe vascular access for haemodialysis. Continuous peritoneal dialysis proved to be a valid alternative form of treatment and even had advantages over haemodialysis. Large amounts of fluids, calories and electrolytes could be administered via the peritoneal route. This facilitated the treatment of the catabolic state of the uraemic burn patient and served to correct the electrolyte losses via the skin. Peritoneal dialysis is a valuable adjunct to the treatment of acute renal failure in burn patients who need renal replacement therapy.

Plasma palmitate turnover in subjects with thermal injury.

Using a continuous infusion of [1-13C] palmitic acid tracer, plasma palmitate turnover was measured 14 times in nine bandaged, thermally injured adults. Plasma glucose (102 +/- 4 mg/dl), insulin (21 +/- 4 microU/ml), and glucagon (296 +/- 34 pg/ml) levels were significantly elevated compared with values in uninjured controls. Circulating plasma epinephrine (67 +/- 11 pg/ml) and norepinephrine (219 +/- 57 pg/ml) levels were more than twofold their respective control values of 261 +/- 4 pg/ml and 211 +/- 7 pg/ml but less than the previously defined plasma threshold levels for lipolytic effects of these catecholamines as circulating hormones. Plasma palmitate and free fatty acid concentrations, 113 +/- 8 and 452 +/- 38 microM, respectively, were not different from control values but palmitate flux (2.66 +/- 0.28 mumol kg-1 min-1) and free fatty acid turnover calculated therefrom (10.53 +/- 1.13 mumol kg-1 min-1) were significantly elevated compared to the control rates. While palmitate turnover significantly correlated with plasma palmitate concentration and with per cent body surface area burned, there was no relationship between palmitate flux and circulating epinephrine or norepinephrine levels. These data raise new questions about the relative catabolic roles of catecholamines in bandaged, thermally-injured patients.

Effect of a protein-free haemodialysate on tissue respiration and healing of burns

Investigations were carried out in three groups of rats (10 rats per group) sustaining partial skin thickness burns covering 2.2 per cent of body surface area. Thirty minutes after burning animals received: Group I, 1 ml Solcoseryl, IP; Group II, 1 ml normal saline, IP; Group III, no treatment (controls). Two hours after burning tissue respiration and the tissue concentrations of potassium, magnesium, calcium and sodium ions were measured in biopsies from the burn wounds. It was found that early post-burn administration of Solcoseryl significantly inhibited the secondary destructive processes and accelerated the regeneration of damaged tissue.

Delirium in burn patients isolated in a plenum laminar air flow ventilation unit

The incidence of psychological morbidity associated with delirium was compared between burn patients isolated in a bed-size plenum laminar air flow ventilation unit (PLAFVU) and matched control burn patients treated in standard open cubicles. In patients with burn sizes of less than 60 per cent of body surface area, delirium developed in 40 per cent of the patients treated in the PLAFVU, but only in 7 per cent of the matched control patients (P = 0.04). Most of the patients with burn sizes of 60 per cent or greater exhibited delirium regardless of the method of treatment. The development of psychological morbidity was more strongly associated with treatment in the PLAFVU than with common causes such as hyponatraemia or septicaemia. The present study suggests that in the majority of burn patients, i.e. those with less than 60 per cent burns, the development of psychological morbidity may in fact be influenced by types of treatment which affect patient psychology, rather than being solely the result of physiological derangements.

The role of surgery in chromic acid burns: Our experience with two patients

Two patients with chromic acid burns are described, one having a 10 per cent body surface area (BSA) burn, the other a 70 per cent BSA burn. Hexavalent chromium, being more mobile physiologically, is more toxic than trivalent chromium. Both, however, are readily absorbed through burned skin, and cause renal failure. For this reason, emergency excision of burned areas has been advocated as first line treatment. However, this is not always feasible as, for instance, when the size of the burn is large, and is of uncertain value when patients are referred late.

Correlation of quantitative burn wound biopsy culture and surface swab culture to burn wound sepsis

The present study includes seventeen patients with second and third degree fresh burns involving 15–50 per cent total body surface area (TBSA). Surface swabs and quantitative burn wound biopsy cultures were obtained during postburn weeks 1,2 and 3 and correlation was studied. To obtain bacterial counts the technique described by Loebel et al. (1974) was used. The patients were divided in two groups depending upon burn body surface area involved. The first group includes five patients with burns between 15–29 per cent body surface area and the second group includes the rest of the twelve patients with burns between 30–50 per cent body surface area. No patient from group I showed any sign or symptom of sepsis whereas seven patients from group II developed sepsis and three died. These three patients showed positive blood culture at the time of death. Of the 48 cultures obtained in all the patients over 3 weeks, 7 cultures showed differences between swab and biopsy cultures. Genticyn was the most effective drug against Gram-negative organisms.

Actual problems of immunoprophylactic and immunotherapy of burn infection

Staphylococcal anatoxin which has a systemic therapeutic effect, improving burn wound condition and increasing humoral and cellular immunity was used for the prevention of staphylococcal infection among patients with deep burns of up to 15 per cent of body surface area as a component of their therapy. The patients with burns of over 15 per cent of their body surface were treated with hyperimmune antistaphylococcal plasma which had a clinical effect and decreased mortality in the group of severely burned patients by more than two fold. On our model of general wound infection from 5 most frequently observed serotypes of Pseudomonas aeruginosa we have got multicomponent cellfree vaccine pyoimmunogen with marked protective effect in experiments. This vaccine protected 80–85 per cent of animals in comparison with 90–95 per cent mortality in experiment. Preliminary clinical data speak for the high preventive and medical effect of pyoimmunogen and anti- Ps. aeruginosa hyperimmune plasma.

Effects of early hypnosis on the cardiovascular and renal physiology of burn patients

Sixteen patients with body surface area (BSA) burns of 4 per cent to 83 per cent, with whom single hypnotherapeutic interventions were attempted 5·3±3·4 h post burn, were compared to 16 matched controls. Ten physiological parameters related to fluid volume and haemodynamics were recorded on the first two post burn days. The only significant difference discovered was elevated urine output 0–48 h post burn in successfully hypnotized patients ( P=0·01). This difference was inversely related ( r=−0·94, P=0·009) to burn size from a 10 per cent BSA burn (3·9 litres/48 h) to a 35 per cent BSA burn (1·6 litres/48 h). A statistically suggestive ( P=0·13) increase in urine output occurred in patients in whom hypnotic trance induction was unsuccessfully attempted. Patients with BSA burn sizes ≥ 50 per cent, who presented with significant physiological stress and hypovolemia, were found not to be susceptible to hypnotic trance induction, and derived no physiological benefit. Attempted hypnotherapeutic intervention per se, with its psychotherapeutic component, may act only to reduce affective or psychological stress and anxiety. This psychological stress reduction apparently facilitates the loss of retained fluid in patients with small burns by a mechanism which is overwhelmed by the physiological stress of a major burn injury.

Pulmonary candidiasis complicating a severe burn treated with miconazole

A 3 3 4 -year-old boy received a 50 per cent body surface area burn in a house fire. On the eighteenth day post burn he was moribund and a diagnosis of pulmonary candidiasis was made following tracheal cultures and X-ray changes after a period of progressive deterioration during which he had received multiple antibiotics and assisted ventilation. Treatment of this pulmonary candidiasis was with intravenous miconazole. The child's clinical condition rapidly improved over the following 24–48 hours and the X-ray changes resolved. He was subsequently discharged fully healed.

The post-scald metabolic response in the growing rat: Evidence for a transient phase of muscle protein breakdown

Growing male rats were studied for 16 days following a full-thickness 30 per cent body surface area dorsal scald. Weight gain post scald was reduced despite normal food intake. Evaporative weight loss increased after the injury and remained elevated. Oxygen consumption also increased and was significantly correlated with evaporative loss in injured rats although not in controls. Plasma branched-chain amino acid concentrations and urinary Nr-methylhistidine excretion were increased over the first 72 h after injury, and were associated with net loss of muscle protein. Plasma branched-chain amino acids fell below control levels 5–7 days after scalding as muscle protein content increased. It was concluded that a 30 per cent scald in the growing rat leads to a transient ‘flow’ phase with net muscle protein breakdown, followed by a more prolonged period of hypermetabolism which is due largely to increased evaporative heat loss.

Some aspects of post-treatment adjustment in severely burned children

The post-treatment adjustment of 25 children who had sustained a burn of more than 30 per cent body surface area is discussed. They were visited at home between 2 and 11 years after the accident to ascertain whether there were any long term effects, whether they were attending school with benefit or were successfully employed. Good adjustment was found in 12 per cent of the sample, with 60 per cent reasonably adjusted and 28 per cent poorly adjusted. Aggression, withdrawal and depression were found to be the most common emotional after-effects of the trauma in addition to the physical disfigurement. The findings of this study have resulted in the adoption of a new attitude towards the aftercare of the severely burned child and suggestions for future follow-up are made.