A method of meshing large sheets of split skin using the Zimmer dermamesher with a standard carrier is described.
Early re-surfacing of burn wounds remains the ideal but is limited by the availability of skin graft donor sites. Cultured grafts overcome these problems and autologous keratinocytes can be grown in culture and placed on a dermal substitute, but this results in delay and requires two operations. We developed an organotypic skin substitute, which achieves cover in one procedure, and have previously found allogeneic cell survival up to 2.5 years after grafting onto clean elective wounds (tattoo removal). Here, we report a short series using the same model applied to burns patients with less than 20% total body surface area affected. The skin substitutes consisted of allogeneic dermal fibroblasts embedded in a collagen gel overlain with allogeneic epidermal keratinocytes, and were grafted to patients with tangentially excised burns. A side-by-side comparison with meshed split-thickness autografts was performed. No grafts became infected. The allogeneic skin substitute showed little effective take at 1 week, and by 2 weeks only small islands of keratinocytes survived. These sites were subsequently covered with meshed split-thickness autograft, which took well. It is concluded that further development of this model is needed to overcome the hostile wound bed seen in burns patients.
A technique of buried chip skin grafting for perianal burn injury is described. Small chip skin grafts are buried in the granulating wound around the anus and this procedure achieves epithelialization of the perianal and perineal wound within about 5 or 6 cm laterally from the middle with extremely small amounts of skin graft. Graft survival is not disturbed by stools or gently wiping of the wound to remove stools, as grafts are buried in the holes. If infection occurs soon after the operation, graft survival does not appear to be affected because the grafted holes show good drainage. This procedure is considered to be very useful for treating perianal or perineal granulating wounds in extensively and deeply burned patients who have limited autograft donor sites.
Cognitive and behavioural pain control coping techniques were studied in a sample of burn clinic outpatients. Forty-four subjects of generally low socioeconomic status were recruited for the study. TBSA average 8 per cent, the mean subject age was 38.1 years, and subjects reported experiencing pain during half their waking hours the previous week. The Burn Pain Questionnaire (BPQ) was used to assess the reported frequency of use and effectiveness of eight behavioural and seven cognitive coping strategies for average and severe levels of pain. The BPQ was also used to assess pain duration as a correlate of the efficacy of coping techniques. The results indicated that three behavioural techniques (listening to TV/radio/stereo, sleeping, talking about pain) and one cognitive technique (thinking about something else) were rated as effective by the majority of subjects for average levels of pain. None of the techniques were rated by subjects as useful with sever pain. Use of two behavioural approaches (use of TV/radio/stereo, talking) and two cognitive approaches (concentrating attention, imagining self elsewhere) were significantly correlated with increased pain duration. Results are discussed in terms of tailoring psychological pain control techniques to the individual needs of the patient.
This paper presents the results of the analysis of clinical data from a series of 132 thermally injured patients with 214 burned hands. The objective was to identify the factors affecting the pathogenesis of postburn hand deformities. The study indicates that deep burns have the worst prognosis and that circumferential burns are always followed by secondary sequelae. The incidence of secondary hand deformity rises sharply when the burn affects more than 25 per cent of the total body surface area (TBSA). Given the same physical therapy programme, early tangential excision and immediate grafting yield better results than conservative treatment. The results underline the role of patient motivation in maximal hand rehabilitation.
Between 1977 and 1986, 1598 patients were admitted to the Firefighters' Burn Unit of the University of Alberta Hospital in Edmonton, Alberta. One hundred and twenty-five (7.8 per cent) of these patients were Treaty Indians or Metis compared to 4.2 per cent of the general population in the same given area. The data show native people suffered larger total body surface area (TBSA) burns, were hospitalized on average 16.9 days longer and required 0.7 more operations than their non-native counterparts. Natives are also three times more likely to remain within the health care system as inpatients for rehabilitation after acute burn management has been completed. Mortality rates as a result of these burns were similar for natives (4.8 per cent) and non-natives (4.3 per cent). This review indicates that the native population is at higher risk of suffering burn injury even after adjusting for certain demographic variables, consequently impacting the utilization of the health care system.
Alterations in the epidermis and dermis after a scald burn (deep dermal wound) are sonographically displayed by different echo reflections. Histological slide preparations from various layers of healthy skin were studied to check the ultrasound analysis. Echo reflections of high and low density showed a close correlation to real anatomical structures in the histological slides. The 10-MHz B scan allows the differentiation of 0.1 mm. Heat causes an increase in dermal thickness of between 50 and 100 per cent for the period between 1 and 6 h after injury. Identifying the layers corresponding to the histological slides makes it is possible to measure the distance between the interfaces. This improves the quantitative assessment of both the depth and the area of thermal injury.
Successful treatment of severely burned patients with the Chinese method of intermingled skin grafting has raised questions concerning the pathophysiological and immunological mechanisms which allow the survival of mixed allogeneic and autologous tissue. In creating a rat model and measuring systemic immunological status by means of mixed lymphocyte reactions (MLR) and histology, we found comparable levels of sensitization in intermingled and allografted rats; however, allografts were rejected and intermingled graft survival was significantly prolonged. We interpret our results to indicate that the survival of intermingled grafts is dependent upon an as yet undefined local protective effect exerted by the presence of auto-skin islands in the allotypic portion of intermingled grafts.
This report describes the burns caused by an electric hot plate which is used by orthodox Jews for keeping food and liquids warm during the Sabbath (Saturday). An illustrative case is presented and the preventable aspects of this particular burn are discussed.
From January 1979 to January 1987, 125 patients were treated in our Centre for various electrical injuries. Among them, 85 patients were over 15 years of age (89.4 per cent were males and 10.6 per cent females) and 40 patients were below 15 years of age (92.5 per cent were males and 7.5 per cent females). Electricians were the most frequently injured in the over 15-year-old age-group, whereas most patients under 15 years old were students. We focused our study on five patients with multiple and severe electrical injury. Two of these patients were injured while erecting TV aerials, two were injured at work and the other one was working on a house roof. Despite all our efforts extensive limb amputations were required. Following complete healing, we fitted prostheses to the amputation stumps. All the patients have now returned to society as capable individuals, two of them to their previous occupations and the other three with new occupations. Our experience with five patients showed that patients with severe electrical injury and multiple amputations have a reasonable chance of recovery. Rehabilitation therapy must be given as early as possible after the electrical injury so that the patients may return to their normal place in society.
As a temporary dressing on scald wounds in children Omiderm was tried in 10 consecutive patients. Omiderm is a thin, transparent, hydrophilic polyurethane membrane, permeable to water and oxygen. It was applied on the wound when exudation was declining, about 4–10 hours postburn. The dressing formed a crust with the wound exudate and was removed when the wound had reepithelialized or at day 14 postburn before split skin grafting of the wound if the wound had not yet healed. The dressing had no advantages nor disadvantages compared to conventional exposure treatment with regard to healing time, rate of bacterial contamination, need for split skin grafting, quality of scars on spontaneously healed areas nor comfort to the patients.
A prospective, randomized trial of 32 patients with partial skin thickness burns is reported comparing E—Z Derm with Jelonet as a burn dressing. The bacterial colonization rate, need for surgical treatment, time for spontaneous healing, analgesic requirements and frequency of dressing changes were assessed in each group. No statistically significant differences were found between the two groups, for any of these factors.
In the search for a good temporary donor site dressing two synthetic products were compared in a randomized controlled clinical trial: Duoderm, a double layer dressing with an inner hydrocolloid polymer complex layer and an outer layer of polyurethane foam, impermeable to water and oxygen, and Omiderm, a hydrophilic polyurethane transparent membrane, permeable to water and oxygen. Sequence analysis showed that the trial could finish when eight patients had been treated. The Duoderm dressing resulted in solid re-epithelialization almost 3 days earlier than Omiderm, and it was more comfortable for the patients. Neither the Duoderm-treated nor the Omiderm-treated donor sites showed any signs of clinical infection. Due to fluid accumulation beneath the dressing during the first postoperative days the Duoderm dressing had to be changed more often than the Omiderm.
The development of glycerol-preserved donor skin by the Dutch National Skin Bank has led to the clinical use of this skin in 57 patients with partial thickness burns treated in the Burns Centre of the Red Cross Hospital in Beverwijk. Practical aspects, as well as clinical results, are presented in this article, leading to the conclusion that glycerol-preserved donor skin is a very easy to store and easy to use as an alternative for the ‘conventional’ cryopreserved donor skin.
In a randomized controlled clinical trial (RCCT) the healing rate, infection and late cosmetic/functional results were investigated in 48 children admitted to hospital with scalds. They were treated with either exposure treatment (EP) or lyophilized allograft (LA). Healing rate was improved with LA treatment. The infection tendency was identical within the two groups. Late cosmetic/functional results were superior, with LA treatment compared to exposure treatment but only in the subgroup of superficial dermal scalds.
This study examines the ability of junior doctors to initiate the management of burned patients. One hundred and twenty-four junior doctors were assessed using a questionnaire. Eighty per cent of the sample had had undergraduate lectures on the subject and 43 per cent had experience of managing patients with major burns. Despite this only 3 per cent could correctly carry out all the steps necessary to estimate the fluid requirements of a burned patient. Theoretical knowledge of the 'Rule of Nines' was adequate but 10 per cent of the sample made mathematical errors when supplied with a burns formula and the appropriate values. We suggest that postgraduate instruction be given to junior staff and that burns charts include details of a burns formula and an illustrative example of the calculation required.
This study quantitatively assessed the topical effects of Meshushit, a new herbal compound, on the healing process of experimental deep partial skin thickness burns over 27 days. To symmetrical circular burns were inflicted on the back of 15 animals by aluminium templates. The Meshushit and its control vehicle containing 0.1 per cent gentamycin or the control vehicle plus antibiotic alone, were applied topically to randomly selected burns at equal time intervals. Epithelialization and contraction were assessed on postburn days 6, 10, 15, 18, 22 and 27 using a computerized planimeter. The newly formed granulation tissue was assessed histologically on postburn day 27, while the hair follicles were counted in the same sections. Student's t test was used to differentiate the rates of contraction and epithelialization; hair follicle counts and the thickness of the newly formed granulation tissue. None of the animals died during the experiment. The epithelialization and contraction rates did not differ significantly between the test groups. The Meshushit-treated wounds showed a significantly thicker granulation tissue layer as compared to its control (828.72 +/- 46.39 microns vs. 540.78 +/- 37.81 microns, P less than 0.01). The count of hair follicles was significantly higher in the Meshushit-treated burns (23.38 +/- 1.84 vs. 3.76 +/- 0.35, P less than 0.001). It is concluded that the herbal Meshushit ointment enhanced the newly formed granulation tissue and preserved better the hair follicles in the present burn wound model. It is suggested that these findings are due to the preservation of the dermal microcirculation.
This paper describes the treatment of patients with thermal injury in Jordan University Hospital. Between 1976 and 1980 inclusive 338 patients were treated in general surgical wards. More recently a new specialized burn unit has been built and between April 1985 and July 1986, 100 patients have been treated in this new unit. Compared with the earlier study there has been an increase in the number of patients admitted with more severe burns. Among these 100 patients scalds and fire-burn injury have a nearly equal incidence. Small children are especially vulnerable. The mortality rate, the incidence of disability and the duration of stay in hospital has decreased compared with the previous study.
Serum suppressive factors were proved to be present and considered to be one of the causes to bring about the suppression of body defence following thermal injury. As a preliminary step to ascertain the presence of immunosuppressive substances, we tried to find out any abnormality in the postburn serum proteins by comparison of burned and normal sera by means of immuno-precipitation-in-gel. Results of SDS-polyacrylamide gel electrophoresis, crossed immunoelectrophoresis, tandem crossed immunoelectrophoresis, and fused rocket immunoelectrophoresis showed that differences of precipitation bands or peaks existed between burned and normal sera, and abnormal constituents with relatively low molecular weight were present in the burned serum.
