Pain and anxiety during burn dressing changes: concordance between patients' and nurses' ratings and relation to medication administration and patient variables.

Few studies have examined the various factors related to pain during burn dressing changes. Patients' and nurses' ratings of pain and tension were obtained during 107 burn dressing changes among 11 burned patients. As found in previous studies, there was little concordance between nurses' and patients' ratings. Both nurses' and patients' ratings of pain were positively related to amount of analgesic medications administered, whereas amounts were inversely related to patients' reports of pain in a subsample of dressing changes in which anxiolytics were administered. However, these relationships failed to reach statistical significance. Multiple regression analyses revealed that ratings of tension during the procedure were significantly related to overall and worst pain, whereas amount of analgesics and anxiolytics given, postburn day, and total body surface area were not. Exploratory correlations suggested that ability to accurately discriminate between painful episodes, social desirability, and trait anxiety may be factors that significantly influence self-report of pain and might be worthwhile to study more systematically in the future. Implications for burn pain control and suggestions for future research are presented.

A retrospective review of the burn intensive care unit admissions for a year.

One hundred twenty-three patients who were admitted to the University of Florida burn intensive care unit during a 1-year period were included in this retrospective study. The average age of the patients was 28 years (range 3 months to 90 years), and the average size of the total body surface area burned was 18%, with 7% full-thickness burns. The average hospital stay of each patient was 17.46 days. One hundred twelve operations were carried out in the burn unit's operating room with a circulating nurse from the registered nursing staff of the burn intensive care unit. No major complications occurred during the procedures. There were 1689 hydrotherapies and 2496 splint days. No significant loss of function of the patients' extremities developed while the patients were in the burn intensive care unit after the 112 debridement and skin grafting procedures were done. During the year, 365 follow-up examinations were done on previously discharged patients in the outpatient clinic area of the burn intensive care unit, which gave the doctors, registered nurses, and therapists an opportunity to determine their patients' progress. During the past year 537 separate pieces of compression garments were fitted.

Eugene Tubbs Burn Intensive Care Unit. University of Florida Shands Hospital.

A four-year update is reported on the Eugene Tubbs Burn Intensive Care Unit at the University of Florida Shands Hospital. Flame (68%) and scald (18%) burns have remained fairly constant over the period. There were 123 inpatients and 356 outpatient visits this past year with an infection rate of 21%. Seventeen patients were age 50 or older and the average body surface area involved of the 9% mortality group was 57.4%. The advantage of a burn team working in a specially designed unit is emphasized.

An anesthetic technique to fabricate a pressure mask for controlling scar formation from facial burns.

An anesthetic technique, involving nasotracheal intubation, after mask induction with halothane, nitrous oxide, and oxygen, is described for use during fabrication of a contoured facial pressure mask. Rationale and benefits are discussed, and particular emphasis is placed on the potential problems of the commonly used ketamine-based technique.

Carbon dioxide laser burn of laryngotracheobronchial mucosa.

A CO2 laser fire in the laryngotracheobronchial tree occurred because of an increase in fraction of inspired oxygen to greater than 40%. An endotracheal tube was ignited and caused a severe burn of respiratory mucosa that required treatment in a burn intensive care unit. The patient had surprisingly few immediate respiratory complications and was discharged from the hospital 25 days after the burn.

Current concepts in management of the burned patient.

Management of the burned patient requires great skill and understanding of the burn wound. Knowledge of the wound has increased rapidly over the past few years and management of patients has progressively changed. The resuscitation formulae are widely recognized and "burn shock" rarely occurs in the acute phase. More often the patient receives excessive amounts of fluid due to over-estimation of the body surface involved.

Purpura fulminans.

The purpose of this article is to call attention to an unusual syndrome that may lead to a major loss of soft tissue, limb, and life. The application of principles learned from trauma and burn care may substantially reduce the morbidity and mortality, which in the past have been associated with purpura fulminans.

Breast cancer in a patient with silicone breast implants after 13 years.

The patient described in this article is a 45-year-old woman who developed an infiltrating ductal carcinoma in her left breast next to a Silastic mammary implant that had been used for augmentation some 13 years previously. She underwent a modified radical mastectomy and removal of the silicone prosthesis with an axillary lymph node dissection. Twenty-six axillary lymph nodes were negative for metastatic disease. The 165-gram silicone gel prosthesis was surrounded by a thin fibrous capsule with an attached 1-cm carcinoma that did not invade the fibrous capsule. It appeared that the capsule presented a barrier to the invading ductal carcinoma. The fibrous capsule surrounding the Silastic implant may have altered the spread of the breast cancer without being related to its genesis.

Early bronchoscopy as a predictor of ventilatory support for burned patients.

Twenty-seven burned patients who had facial burns, hoarseness, or evidence of carbonaceous sputum or had been in a smoke-filled enclosed space underwent fiberoptic bronchoscopy at the time of admission. Airway severity was indexed (grades 1-5, grade 5 being the most severe). Fifteen nonsurvivors had a bronchoscopic index of 3.2 +/- 1.6 and 12 survivors an index of 3.4 +/- 1.2 (p greater than 0.05). No patient died of respiratory complications. Bronchoscopic index correlated poorly with the level of positive end expiratory pressure required to maintain oxygenation in any patient (r = 0.50). Likewise, bronchoscopic index did not correlate with duration of intubation in any survivor (r = 0.33). Immediate bronchoscopy after burn injury neither indicates the level of respiratory support that will be required nor predicts its duration.

Adjuvant chemotherapy.

At present, adjuvant chemotherapy exerts no significant impact on long-term survival and only occasionally provides brief palliation in head and neck cancer. The major contribution of chemotherapy has been in the preoperative period, when therapy for advanced squamous cell carcinoma may render some patients candidates for curative operations or radiotherapy. This article discusses the use of single-agent chemotherapy, combination chemotherapy, and combination irradiation and surgery as well as the advantages of adjuvant chemosurgery.