Burns - experiences with consecutive cases treated at the Philippine General Hospital · Rare Periodicals

Title

Burns - experiences with consecutive cases treated at the Philippine General Hospital

Creator

Laico, Jaime E.

Ibay, Jr., Roman S.

Language

English

Source

Volume XV (4) April-June 1959

Year

1958

Subject

Burns and scalds -- Treatment

Philippine General Hospital

Medicine -- Periodicals

Rights

In Copyright - Educational Use Permitted

Fulltext

BURNS: EXPERIENCES WITH CONSECUTIVE CASES TREATED AT THE PHILIPPINE GENERAL HOSPITAL JAIME E. LAICO, MJD, f.P.CS. u>d ROMAN S. IBAY, JR, MJO. Department of Surgery, College of Medicine University of the Philippines Burns constitute one of our most serious emergencies and it is imperative for every physician in the genera) practice of medicine or surgery to be able to render satisfactory care to a victim of thermal trauma. It has been said that for a bum case to have a fair chance to live, proper care must be given during the first 24 hours. To bring out points in the manage ment of burns, we are presenting 50 cases of burns treated over a period of six months in 1957 in the surgical wards of the Philippine General Hospital. CLASSIFICATION OF CASES (1) Sen: — Of the 50 cases, 28 were males. (2) Age: — The age distribution was as follows: 30 cases 10 years of age and less; 12 cases between 11 and 30 years; and 8 eases 31 years old and over. (3) Etiology: — In 37 cases, the bums were caused by fire. The flammable agents involved were: Gasoline — 8 cases Kerosene — 7 cases Floor wax — 7 cases Others — alcohol, sawdust, bagasse lightning, housefire, candle Scalding was responsible in the remaining 13 cases. 235 236 ACTA MEDICA PHIL1PPINA (4) Extent:— Extent of Bums No. of Cases 0 — 10% 3 11 — 30% (moderate) 30 31 — 50% (severe) 9 51 — 70% (overwhelming) 7 Over 70% 1 (5) Case Fatality: — Extent of Burns 0 — 30% 31 — 60% 61 — 70% 71% above (6) Time of Death:— Within 24 hour* After 24 hours (7) Hospital Stay:— Less than a month 1 month—4 months Above 4 months Cases still in the wards No, of Cases Death 33 0 9 3 7 4 1 1 6 deaths 2 deaths 30 cases 10 cases 3 cases 7 cases (8) Skin Grafting: — Done in 7 eases. DISCUSSION We noted that moat of the cases were children. Males and females were almost equally represented. All the adult patients came from the laboring class. There were more bums due to fire than due to scalding. One of the agents was floor wax which is not regarded by many as inflammable. Other types of bums not seen by us were electrical, friction, chemical and irradiation burns. It seems that these occur infrequently or usually minor as not to require hospitalisation. The moderately severe burns (11-30%) constituted more than half of the admissions and the most severe was a young lady with 75% bums. Above this extent, cases probably do not reach the hospital anymore. MANAGEMENT OF BURNS 287 It is important to note that nearly half of the cases with severe and overwhelming burns died; this should emphasize how serious a bum ease can be. Most of those who died, died within 24 hours after the accident. The chances for survival decreases inversely as the extent of burns. It is also signifi cant that no case with extent less than 30% died, regardless of the depth of trauma, Cortone did not feature prominently in our management as most of the patients could not afford the drug. However, there is justification for its use. MANAGEMENT OF BURNS We have divided our management into early and late phases. EARLY PHASE: This period cavers the period of two weeks after the accident, at which time spontaneous healing of the superficial 2nd degree burns is more or less complete. The management consisted of: 1. Fluids: By far, this is the most important item in-the treatment especially during the first 24 hours. We calculated it in accordance with the Evans formula (modified): Ice. x percentage of burns x weight in lbs.=f)uids/day 30-40% of the total fluids is colloids divided equally for blood and plasma. 60-70% is given as dextrose in water or normal saline or Ringers Lactate Solution. The administration of fluids was done by the rule of thumb: 1/2 is given within the first 8 hours 1/4 for the next 8 hours 1/4 for the last 8 hours For the more superficial 2nd degree burns, 30% colloids was sufficient and 40% was given to the deeper cases. Of the fluids, there is nothing more important than whole blood for there is from the beginning a masked or hidden bum anemia due to the destruction of red cells by the heat at the time of burning even when the RBC, hemoglobin and hematocrit read ings are high. Furthermore, there is a decrease in blood vo as ACTA MEDIC* FHIL1PPINA lume due to the exudation of plasma to the burned areas. However, in the series, practically atl could not be given ade quate blood replacement. 2. Antibiotics:— These were given as prophylaxis against infection, for a burned surface is very weak and susceptible to micro-organisms. Penicillin (400,000 U) daily was usually sufficient for the mild cases, but broad spectrum antibiotics were given for the more extensive cases. 3. Tetanus antitoxin:—Given routinely in a single dose of 1,500 U. 4. Cortone and ACTH; These should be given as much as possible as the stress factor in bums is great. Autopsies of cases reported in literature have shown the adrenals to be similar to that in Addison’s disease. In its administration, the fluids calculated according to the Evans formula need no correction. Dose for cortone in adults is usually 50 mg. every 8 hours. In the 8 cases that died, it was only those given cortone which lived up to the Sth and 6th days while those who did not receive it died within 24 hours. 5. Antihistaminics: The release of histamine bodies from the burned area is so great that the administration of antiallergens seems imperative. Doses of 50 mg. every 8 hours given as Benadryl or any equivalent was sufficient 6, Tracheostomy: This was resorted to in respiratory and severe facial burns with respiratory tract obstruction. This happens in cases where the accident occurs in a close compart ment as a garage. Most often, dyspnea is interpreted as due to pulmonary edema and burns of the respiratory tract which could prove fatal is overlooked. Tracheostomy should be per formed without hesitation in such cases. 1. Dressings: Exposure therapy may be resorted to, but we commonly used dressings. The choice of method depends much on the environment in the hospital and the extent of the burns. In all our cases, we have used vaselinized gauze for the first dressing with a libera) amount of covering. Usual ly analgesics as demerol or morphine was enough to deaden the pain. Pain should be differentiated from anxiety as one may tend to give an overdose of the drugs. MANAGEMENT OF BURNS 239 8. Other Pointe: An indwelling catheter to measure the output and indirectly the blood pressure should be inserted. The development of the earliest signs of pulmonary edema is an urgent indication for reduction in the rate of fluid adminis tration. Burn shock is usually either cured or markedly im proved or will cause death of the patient before the 48 hours period is completed. Partial thickness burns of less than 20% did not ordinarily require intravenous therapy as the patient could retain oral fluids. Burns of over 50% had their fluids calculated on the basis of 50% to prevent overtreatment. As a further precau tion, a total of 10,000 cc. in the first 24 hours was the maximum given. After the first 24 hours, the fluids may be reduced depend ing on the capacity of the patient to tolerate food by mouth, urinary output, hematocrit levels and general progress of the patient. Burns of the first and superficial second degree with blis ter formation usually healed within two weeks similar to the donor site for skin grafting. Thus 60% of our patients stayed less than a month in the hospital. A complication one should guard against is infection which may convert a partial thick ness bum to one of full thickness, thereby prolonging the heal ing time and hospital day. This healing period is the “lull that follows the storm" in superficial burns, but in large deep bums the patient may show a steady decline until death or until covered with skin, whichever occurs first. LATE PHASE: 1, Dressing: Probably this is the most important pro cedure during the later part as on it depends the speed of healing of the wound. Careless dressing may introduce infection which may lead to other systemic complications. Thus, it is advisable to change the dressings every four days or else mag gots may set in. In the hospital, we washed the wound gently to avoid bleeding, using phisoderm followed with permanganate or salt solution. Sulfa locally and furacin ointment for the gram 240 ACTA MEDICA PH1L1PP1NA negative bacilli was found to be effective, but one should be on the alert for allergy to these drugs. Thick dressings were not necessary inasmuch as the dressings were changed fre quently. We could hardly institute exposure treatment in the emergency wards as the environment is unfavorable to this method. 2. Skin Grafting: This was done for cases where epithelization did not occur due to the depth and extent of burns. Furthermore, spontaneous healing should not be regarded as good in cases where there is full thickness loss of skin as it leads to the more serious condition namely, contracture. Craft ing was done either as a temporary dressing or as a permanent skin covering. Only 7 of our cases required skin grafting. Some of the patients had so extensive burns that not enough skin was available. It was in these cases where homografting and cadaver skin grafting became heroic measures. The skin dressing usually stayed only 2-10 weeks but this period was important as it gave the patient a respite from pain, dressings and electrolyte losses besides serving as a stimulus for epithefization. During this time also, the patient was built up with blood and tonics to be ready for the final stage when she could provide for a permanent covering with her own skin. The criterion for this period included hemo globin and blood count levels and a good albumin-globulin ra tio. Needless to say, the systemic condition must be good. Autografting was done in the form of stamp grafts or if skin is adequate, total covering of the raw area after slicing off the granulation tissue is preferred. For areaa where se condary contracture of thin grafts was undesirable as in the face and neck, repair by the sliding flap, tube or pedicle flap was resorted to for cosmetic reasons. 3. Other Measures: Fluids were not important in the later phase, except blood and plasma, as patients tolerate oral in take well. Vitamins were given in high doses and antibiotics were maintained at a high level, A part of management often forgotten is psychotherapy and one should take special efforts to improve the morale of the patient. MANAGEMENT OF BURNS 241 In conclusion, we have received encouraging results in our management of burns and nothing is more gratifying than seeing a patient crippled by burns recover and return to bis place in society. REFERENCES ALLEN, S.: The Treatment of Bums, Sure. Clinics of N.A. (Feb.) 1S52. pp. 336-S40. AMSPACHER, H.: The Early Management of Burna, Surg. Clinics of N.A. (Oct) 1956, pp. 1366-1997. BARSKY, A. J.: Principles and Practice of Plastic Surgery, I960, William & Wilkins Co., pp. 114-120. BROWN, J., and McDOWELL, F.: Skin Grafting, Lippincott, 1949 Ed. CHRISTOPHER, F.: Textbook of Surgery, (1949) Saunders, V. Ed. pp. 88-98. CONWAY, H.i Principles of Wound Healing with Indications for two of the Several types of Skin Grafts, Surg. Clinics of N.A. (April), 1952. pp. 419-443. HARKINS, H. N.: Management of the Patient with Severe Buras, Surg. Clinics of N.A. (Oct.), 19S4, pp. 1813-1320. ROYSTER, P.: Presenting Trauma to the Lay Audience, Surg. Clinics of N.A. (Oct), 1956, pp. 1185-1187.

pages

235-241

Burns - experiences with consecutive cases treated at the Philippine General Hospital

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