sEpTEMBER 1977 F I S I O T E R A P I E 3 THE CHANGING FACE OF BURNSt J. W. V A N D E R SPU Y, M .B., B.Ch., F.C.S. (S.A.)* - Oorsig van nuw e verw ikkelinge in die behandeling H b ra n d w o n d e w o r d gegee. Gespesialiseerde eenhede fan r a se p tie se behandeling in isolasie m o o n tlik is en " ‘fer insiS ,n d 'e ontw rigte fisiologie as gevolg van ndw°nd-traum a ls verantw oordelik vir die verbeterde P a n o s e vir brandw ond-pasiente. E ffektiew e vloeistof- Pr°aDie gedurende die skokfase; die instelling van hiper- tef n e n t a s i e : hernude belangstelling in die lokale letsel; rb e terd e verloorplantingstegniek; problem e ondervind vC geva lle m et brandw onde as gevolg van elektrisiteit; ll!-„ belangrikheid van die gepaardgaande respiratoriese kade en die gebruik van eskarotom ie w ord ko rtliks be- nreek■ D ie belang van goeie eerstehulp behandeling word beklem toon. One hundred years ago the fate of a severely b u rn t natient was a dismal one. A t th a t tim e im p o rtan t b re a k ­ throughs were being m ade in m any fields of surgical en d eav o u r. L ister’s w ork on asepsis had m ade its im pact and rocked th e surgical world. Sepsis had to be pre­ vented. B urn cases were an im p o rtan t source o f sepsis and they were consequently m oved out of the teaching hospitals to quieter byw aters like the J a n ito r’s H ouse in Edinburgh. In these places they pursued th eir pitiful course of pain, sepsis, and often death. M ortality was high and m orbidity lam entable. This century saw th e progressive advent o f intravenous fluid therapy resulting in a m arked decrease in m ortality. S k in g ra ftin g t e c h n i q u e s w e r e im proved and a second appreciable decrease in m ortality o ccu rred when better topical applications w hich could p enetrate th e slough came on to the m arket. T his im proved the outlook for the burnt patient. N evertheless, as recently as 20 years ago, the statem ent was m ade t h a t th e m ortality in large burns equated roughly to th e percentage of body s u r f a c e that had b e e n bu rn t, indicating t h a t a 60% b u rn had a n expected m ortality risk of 60% . Since th en m ajo r advances have been m ade, m any of hem in the last decade. F igures for m ortality and morbidity decreased m arkedly and th e R ed Cross Memorial H ospital has recorded an an n u al m ortality of 0,7% fo r com plicated p aediatric b u rn s adm itted to its Burn U nit, while th e teaching hospitals o f W itw atersrand University have halved the hospitalisation tim e fo r severe burns from 5 weeks to 2 | weeks. What b ro u g h t ab o u t this change in prognosis in recen t years? As I see it, two factors have been responsible: A. T h e establishm ent o f specialised b u rn units w here patients can be m anaged aseptically and in relative or com plete isolation. B. Better understanding of th e deranged physiology fol­ lowing m ajo r b u rn tra u m a , w ith therapeutic m easures geared accordingly. tPaper presented at Post-registration C ourse preceding the 12th N atio n al C ouncil M eeting o f the South A frican Society of Physiotherapy, M ay 1977. ’Senior Surgeon, A ccident U nit, G ro o te Schuur H ospital, Cape T ow n and D ep artm en t o f Surgery, U niversity of Cape Town. C ertain aspects of m anagem ent th a t have undergone change or th a t have received new em phasis in re c e n t years will be discussed briefly, as these fo rm th e basis ■ of cu rre n t b u rn therapy. Intravenous fluid therapy in the shock phase: T he large b u rn loses vast am ounts o f fluid and plasm a protein from th e surface and this is lost to the 1 body. T h e loss goes fu rth e r however. T h e fluid is also seques­ trated into th e tissues deep to th e b u rn t skin in the form of oedem a fluid. Should the p atien t becom e severely shocked and acidotic, fu rth e r intricate fluid shifts m ay occur into healthy tissues th ro u g h o u t the body and lead to additional loss of intravascular volum e an d electrolyte disturbances. R ed blood cells are dam aged in two ways: som e are trapped and b u rn t in th e dam aged areas; others are therm ally dam aged less critically, w eakened and sub­ sequently rem oved from th e circulation and b ro k en dow n by th e body. T his results in anaem ia, usually m anifest a few days after th e burn. U ntil recently these changes w ere com bated by tne use o f “ th ick fluids” like plasm a and blood during the shock phase, w hich lasts fo r at least the first 24 hours. T h e ratio n ale was replacem ent o f the plasm a and red cell loss. This tended to cause a blood o f high viscosity w hich did not circulate optim ally through th e constricted capillaries of the shocked patient. T h ere was also o ften a delay in resuscitation while one was w aiting to obtain plasm a and blood, thus aggravating shock. T h e tendency now is to start intravenous therapy with balanced salt solutions like Plasm alyte B and R inger lactate, which are im m ediately available and m ore physiological. T hey app ear to prom ote b etter circulation thro u g h th e narrow ed capillaries and prom ote early and adequate u rin ary output. If necessary, acidosis is treated with intravenous sodium bicarbonate. P lasm a and blood are used subsequently w hen necessary, i.e. they are used m ore and m ore in the second ro u n d o f the fight ra th e r th a n the first. T h e advent o f hyperalim entation: T h e p atient w ith a large b u rn requires up to th ree times the n orm al caloric intake to m aintain n o rm al function in the face o f a m arkedly raised basal m etabolic rate. N orm al diet and th e custom ary intravenous fluids can n o t supply the need. T his produces a state of relative starva­ tion and the patient loses weight, as he utilises his body proteins as energy substrate. T h e end result is o ften a w asted p atient w ith low resistance to infection and poor response to skingrafting procedures. E ven te n years ago these cases could be seen in m ost hospitals. H yperalim entation basically m eans th e supplem enta­ tion of ord in ary caloric intake by the adm inistration of special high-calorie substances. T h ere are tw o types of hyperalim entation, o ral and intravenous. In o ral hyperalim entation the p atient can take an ordinary diet b ut this will not provide adequate calories. In these cases th e p atient is given a high protein, high carbohydrate diet and to this is added as m any eggs as possible as well as additives like C aloreen. One egg contains 60-70 calories and is also high in p rotein content. In this way one can easily double th e caloric intake. Intravenous hyperalim entation is used on patients who are unable to take food by m outh. It can also be used as a supplem ent to o ra l feeding. O rdinary intravenous fluids a re low in caloric content and consequently fluids like A m igen an d In tralip id are used, containing protein and lipid concentrates. C oncentrated dextrose solutions R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 4 can also be used but m ust be given by a central venous catheter because peripheral veins are sclerosed. Long­ term intravenous hyperalim entation is technically com ­ plicated and is not w ithout side-effects. W hat hyperalim entation has achieved is to keep the p atient w ith a large b u rn in nutritional balance and to prevent the wasting and protein depletion th a t occurred in the past. Renewed interest in the local lesion: U ntil recently the emphasis in b u rn m anagem ent was on fluid therapy. Sloughs were rem oved by dressing techniques w hich usually took about three weeks. T hen the granulating defect was covered w ith skingraft. O ver the last few years th ere has been a renewed interest in the local lesion for two reasons: Slough tends to have an adverse effect on viable skin cells lying below the slough, and in this w'ay a partial-thickness b u rn may be rendered full­ thickness. In addition slough tends to get infected. T his sepsis puts an added strain on the patient, may delay g raft­ ing and can cause septicaem ia. This concept gave rise to two im portant develop­ ments: 1. B etter topical applications w ere developed which can p enetrate into the slough and have good antibacterial properties, e.g. M afylon, Flam azine and Betadine. 2. E arly surgical desloughing o f dead tissue w'as fol­ lowed by skingrafting. T h e early results of this are prom ising as it minimises sepsis and also provides early skin cover, thereby decreasing hospitalisation time. T heoretically this should be done in the acute phase but we p refer to w ait until a fte r the fifth day when the p atien t is metabolically stable. Improved techniques in skingrafting: It is now established th a t one needs m ore than good technique fo r optim al results in skingrafting procedures — th e p atient and the recipient a rea should be well- prepared. T h e nutritional state, haem oglobin level and bacteriological state m ust be adequate and th e g ran u la­ tions healthy and free of beta-haem olytic streptococci. Once this point has been reached th e scene is set for a good result and additional techniques becom e im portant in achieving full “ ta k e ” of a graft: 1. We alm ost routinely use meshed skin because the multiple perforations allow secretions to drain ra th e r than to lift the graft off its bed. This has im proved g raft “ ta k e ” considerably. ' 2. In grafting large areas it is best to take enough skin to cover about 10% of the body surface area, process and apply it and dress the a rea concerned. T hen the process is repeated for an o th er similarly-sized area until th e w ound has been covered. T his staggers the blood loss and also allows one to term inate th e p ro ­ cedure at any stage should th e p atien t becom e too cold from exposure; heat loss from granulating areas can be considerable in small children in a cool theatre. 3. T h e use o f biological dressings like cadaver skin, pigskin and hum an am nion has proved valuable in providing tem porary cover in large burns w here the p a tie n t’s own undam aged skin is not adequate in size to allow skin grafting in one session. They are also useful in clearing sepsis from granulating areas. Better appreciation o f electrical burn problems: W hat m atters in an electrical b u rn is not the skin dam age (w hich is usually localised) but the dam age done to the subcutaneous stru ctu res thro u g h which the cu rren t is conducted. T h e crux is th a t skin dam age may be insignificant and yet th e deeper tissues can be exten- SEPTEMBER, 1977 sively dam aged. C u rre n t follows the p ath o f l sistance and will be conducted preferably alonr. 1 r(-‘- next along blood vessels and ultim ately via musrl n®rVes Skin has a high electrical resistance, thus explain' t,SSU(; it is not often involved betw een en tran ce and ex it"8 whv Any p atien t w ith any electrical burn should E°lnis" mitted and observed for at least 24 hours h atl' insignificant the injury looks initially. E speciallv°^eV(;r injury was due to a high-tension cu rren t he ma tlu' need surgery to decom press muscle co m p artm en t 'Vel1 resect dead muscle. H e m ay also develop shock a i an<1 haem oglobinuria and renal failure. ’ CId°sis, It is to be noted th a t th e extent of damage often becomes apparent afte r a few hours. onL' Greater awareness o f associated respiratory damap D am age to the airw ay and lungs m ust be su sn ^ t , in any p atient w ith flame burns especially if the h occurred in an enclosed space w here fum es from burn*^n paint, etc., could have been inhaled in addition to hnt air. T h e risk rises if the face itself was b u rn t and r even fu rth e r if the insides o f the nostrils and the n» ■ hairs have been dam aged. If bronchospasm , stridor I copious airw ay secretions are also present, the diaenn- is virtually made. Restlessness and anxiety (due i hypoxia) may be the first indication of respirator’ dam age, how ever, and in this type of case blood «I analysis is essential. It should be emphasised that th* initial chest radiograph is usually norm al as the radio" logical changes take 12-24 hours to develop. A normal chest radiograph in the early phases does not excli.H,. the condition. A severe, rapidly progressive bronchopneum onia soon develops and unless early and expert respiratory care is given the pulm onary dam age is often fatal. This is one o f the phases o f burn m ortality which has undergone a considerable change as a result of the advent of R espiratory Intensive C are U nits in o u r big hospitals. A lm ost h alf of these patients now survive. T h e essence is to suspect and diagnose respiratory dam age as soon as possible so th at effective management can start early. The free use o f escharotomy: Full-thickness b u rn t skin contracts. If the burn is circum ferential on the tru n k a to u rn iq u et type of con­ striction can be caused, producing respiratory restriction. In the limbs, circulatory em barrassm ent can be caused in a sim ilar way. In such cases it is m ost im portant to decompress th t p a rt concerned by incising the burnt skin (eschar) longitul dinally. T h e edges will separate and th e compression i? relieved. T h e procedure is painless as the dead skin is insensitive. M any digits, limbs and patients have probably been saved by this simple measure. N ew techniques to minimise scar formation and contracture: Proper positioning o f the b u rn t patient, together with early and adequate m ovem ents, elevation of the burnt part, good grafting technique and compressive therapy to minim ise scar hypertrophy have been reviewed in this Jo u rn al by H . M axwell and by Susan K eays (1 and 2). Adequate first-aid measures: G ood first-aid m anagem ent is most im portant. The basic rules are: 1. Rem ove the dam aging agent. W ash chemical burns w ith running w ater; in flame burns, w rap the person in a blanket to extinguish the flames and then re­ move th e blanket and clothes so th a t the heat can dissipate; if clothes are alight, get the patient to lie dow n to save his face and lungs — flames spread upwards. C ontinued on page ■- P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )