The acutely burned hand: management and outcome based on a ten-year experience with 1047 acute hand burns.

Optimal hand function has a very positive impact on the quality of survival after burn injury. Over a 10-year period, 659 patients with 1047 acutely burned hands were managed at the Sumner Redstone Burn Center of the Massachusetts General Hospital. Our approach to acutely burned hands emphasizes ranging and splinting throughout hospitalization, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. This approach is associated with normal function in 97% of those with superficial injuries and 81% of those with deep dermal and full-thickness injuries requiring surgery. Although only 9% of those with injuries involving the extensor mechanism, joint capsule, or bone had normal functional outcomes, 90% were able to independently perform activities of daily living.

Significant reductions in mortality for children with burn injuries through the use of prompt eschar excision.

During the past 19 years, mortality due to burn injuries has markedly declined for children at the Boston Unit of the Shriners Burns Institute (SBI), dropping from an average of 9% of SBI admissions during 1968-1970 to an average of 1% during 1981-1986. Detailed statistical analysis using logistic regression was necessary for determining whether this decline in mortality was explained by changes in patient characteristics, such as age or burn size, which are known to strongly influence the outcome of burn injuries. This dramatic decline in mortality during the past 19 years was not the result of change in the age of the patients or their burn sizes; rather, it may be attributed to improvements in burn care. Results of this statistical analysis indicated that, for burn injury patients whose ages ranged from 11 days to 19 years, age had no demonstrable effect on survival from a burn injury. Children survived burn injuries at least as well if not better than the young adult (20-29 years of age). Also, infants (less than 1 year old) survived as well as other children (2-19 years old). Dramatic improvement in survival occurred in patients with burns covering more than 50% of the body surface area. Since 1979, mortality has been essentially eliminated for patients with burn sizes less than 70% of the total body surface area (of 296 patients with burns covering 15-69% of the total body surface area, only two patients died). During the period 1979-1986, 29 of 37 patients (78%) survived an 80% or greater total body surface area thermal injury.

Prompt eschar excision: a treatment system contributing to reduced burn mortality. A statistical evaluation of burn care at the Massachusetts General Hospital (1974-1984).

Mortality at the Adult Burn Center of the Massachusetts General Hospital (MGH) has declined from 24% in 1974 to an average of 7% for 1979-1984. From 1974 to 1976, prompt eschar excision and immediate wound closure therapy was initiated and standardized. After 1976, this therapy was the standard treatment. Detailed statistical analysis is necessary to determine the influence of this treatment on the improved survival. Therefore, logistical regression analysis was used to examine the influence of variables such as burn size, age, and treatment on mortality for 1103 patients during 1974-1984. Survival rates during the treatment development phase (1974-1977) were compared to the survival rates of the last 5 years of standardized excisional treatment (1979-1984). Survival rates for the standardized excisional treatment were also compared to the results of previously published studies from this hospital that were probit analyses of burn mortality for 1939-1955 and 1955-1970. This latter comparison provided 45 years' experience with burn mortality at a single institution. Results of the statistical analysis of the survival data from 1974 to 1984 indicate that mortality strongly depends on burn size, age, and treatment (p less than 0.001 for each independent variable). In addition, length of stay (LOS) for the total group decreased significantly from 32 to 22 days. The improved survival for 1974-1984 occurred independently of changes in the annual distributions of burn size, age, or sex. Comparison of survival rates shows improved survival during standardized excisional treatment when compared to the treatment development phase. The most extensive increases in survival during 1974-1984 were seen in the treatment of elderly patients and patients with massive burn injuries. Survival for the period 1974-1984 was markedly improved as compared to the 1939-1970 published experiences.

Clinical trials of amniotic membranes in burn wound care.

Four test conditions of increasing complexity were used to evaluate the clinical efficacy of amniotic membranes as biologic dressings on donor sites and burn wounds in children. These were the clean-skin donor-site wound, the uncontaminated shallow partial-thickness burn wound, the bed of freshly excised full-thickness wounds, and the granulating surface of colonized burn wounds. The rate of epithelialization under amniotic membranes was the same as that under 5% scarlet red ointment or 0.5% silver nitrate solution dressings. Preservation of a healthy excised wound bed and maintenance of a low bacterial count in contaminated wounds paralleled the experience with human allograft dressings despite technical difficulties and the absence of vascularization of amniotic membrane and its fragile structure. Tentative conclusions are drawn as to the mechanisms by which biologic dressings exert their beneficial effects.

Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury.

A bilayer artificial skin composed of a temporary Silastic epidermis and a porous collagen-chondroitn 6-sulfate fibrillar dermis, which is not removed, has been used to physiologically close up to 60% of the body surface following prompt excision of burn wounds in ten patients whose total burn size covered 50--95% body surface area (BSA). Following grafting, the dermal portion is populated with fibroblasts and vessels from the wound bed. The anatomic structure of the artificial dermis resembles normal dermis and serves as a template for the synthesis of new connective tissue and the formation of a "neodermis," while it is slowly biodegraded. This artificial skin has physiologically closed excised burn wounds for periods of time up to 46 days before the Silastic epidermis was removed. At the time of election when donor sites are ready for reharvesting, the Silastic epidermis is removed from the vascularized artificial dermis and replaced with 0.004 autoepidermal graft in sheet or meshed form. Clinical and histologic experience in a relatively short follow-up period (2--16 months) indicates that "neodermis" retains some of the anatomic characteristics and behavior of normal dermis, thus promising improvement in the functional and cosmetic results, as well as providing physiologic function as a skin substitute. The artificial skin is easily sterilized and stored at room temperature, capable of large scale production, and immediately available for grafting, indicating its potential for easy and relatively economic use in the burn patient.

The contribution of a bacterially isolated environment to the prevention of infection in seriously burned patients.

A new system of patient protection from bacterial crossinfection called the Bacteria Controlled Nursing Unit (BCNU) is described, based on strict environmental control of a 6 x 10 foot area surrounding the patient's bed rather than the entire patient room or isolation ward, plus the ability to deliver all medical care without entering the protective environment and maintaining all monitoring, life support, and i.v. equipment outside the controlled environment. The clinical effectiveness of this system in the treatment of burn patients has been studied and compared with the effectiveness of single room isolation on a burn isolation ward and conventional isolation techniques on an open burn ward. The studies show that the BCNU is significantly more effective in preventing bacterial cross-contamination than conventional precautions (3.8% vs. 13.1%, P < 0.001; and 8% vs. 22.8%, P < 0.001) over a two and four week period. The studies also indicate that there was a significant increase in the probability of infection occurring following cross-contamination than occurring after auto-contamination (65% vs. 39%, P < 0.005), emphasizing the importance of preventing cross-contamination in reducing the overall infection rate in seriously burned patients. Clinical evaluation of the unit proved it to be compatible with intensive nursing and medical care without increasing the nurse to patient ratio. The unit provided sufficient control of bacterial cross-infection to allow reduction in mortality and improvement in the effectiveness of burn care through routine prompt excision of burn eschar and immediate wound closure to be carried out in severe and massively burned patients without a limiting threat of bacterial burn wound sepsis.

Primary surgical management of the deeply burned hand in children.

Primary burn excision with immediate wound closure by skin grafting was used as the initial definitive treatment for deep burns of the hand in 30 consecutive children. The results are compared with an additional group of 30 children whose burns were treated with AgNO3 alone. There is a significant difference in all categories examined between the excised and the nonexcised group. Hand deformities, secondary reconstructive procedures, and morbidity were significantly reduced in the excised group. Excision provided improved functional and cosmetic results.

Immunosuppression and temporary skin transplantation in the treatment of massive third degree burns.

A method of burn treatment (immunosuppression and temporary skin transplantation) for patients suffering from massive third degree burns is evaluated. The method is based on the prompt excision of all dead tissue (burn eschar) and immediate closure of the wound by skin grafts. Total wound closure is achieved before bacterial infection or organ failure takes place by carrying out all initial excision and grafting procedures within the first ten days post burn and supplementing the limited amount of autograft with allograft. Continuous wound closure is maintained for up to 50 days through immunosuppression. Both azathioprine and ATG have been used but ATG is preferred. During the period of immunosuppression, allograft is stepwise excised and replaced with autograft donor sites regenerate for recropping. Bacterial complications are minimized by housing the patient in the protected environment of the Bacteria Controlled Nursing Unit. Intensive protein and calorie alimentation are provided, and 0.5% aqueous AgNO3 dressings are used. A swinging febrile illness has been associated with large areas of allograft rejection. Eleven children have been treated and seven have been returned to normal, productive schooling.

The Control of Burn Wound Sepsis with 0.5% Silver Nitrate.

Recent adoption of 0.5% silver nitrate dressings as a topical treatment of the burn wound at the Massachusetts General Hospital and other centres has led to an impressive reduction of infection. Infection is the major cause of the mortality in burns today. The use of topical silver nitrate is described, together with a report of the problems associated with such therapy. It is concluded that topical silver nitrate therapy represents a major advance in the care of the burn wound.