Ten-year Brisbane experience in petrol burns: a preventable health burden.

Petrol is one of the most widely used and freely available fuels in use in developed countries today. This study examines the clinical details and demographics of adults with petrol burns over a 10-year period with a view to identifying any trends. The majority of petrol burns were due to human error and thus theoretically preventable. This study determined that the young male (aged 16-25) is most at risk, mainly through the misuse of petrol. The best method of prevention of these burns might be education targeting this group of population. This study provides a basis upon which effective intervention programmes can be designed.

Quinazoline antifolate thymidylate synthase inhibitors: replacement of glutamic acid in the C2-methyl series.

The synthesis of a series of analogues of the potent thymidylate synthase (TS) inhibitor N-[4-[N-[(3,4-dihydro-2-methyl-4-oxo-6- quinazolinyl)methyl]-N-prop-2-ynylamino]benzoyl]-L-glutamic acid (ICI 198583, 1) is described in which the glutamic acid residue has been replaced by other alpha-amino acids. Most of these analogues were prepared by coupling of tert-butyl-4-(prop-2-ynylamino)benzoate (37) with 6-(bromomethyl)-3,4-dihydro-2-methyl-4-oxoquinazoline (34) followed by deprotection of the tert-butyl ester to the acid and azide-mediated coupling to the appropriate amino acid or amino acid ester. In cases where the amino acid ester was unreactive with the acid azide, a modification was used in which the quinazolinone moiety was protected as its 3-(pivaloyloxy)methyl derivative. This permitted the generation of the more reactive acid chloride of the p-aminobenzoate unit. In general these modifications result in compounds that have equivalent potency to 1 as inhibitors of isolated TS except where the amino acid lacks a lipophilic alpha-substituent. These compounds appear to require the reduced folate carrier (RFC) for transport into cells, but since they are not converted intracellularly into polyglutamated forms, they have a lower level of cytotoxicity compared to 1. The removal of the alpha-carboxylic acid has given a second set of analogues of 1 which contain simple alkyl amide, benzyl, substituted benzyl, and heterocyclic benzyl amide derivatives. These are considerably less potent than 1 as TS inhibitors but display 1-10 microM cytotoxicities due to the fact that they do not require RFC transport and can presumably readily enter cells by passive diffusion through the cell membrane. Molecular modeling and NMR studies indicated that the incorporation of, respectively, 7-methyl and 2'-fluoro substituents would favor the optimum conformation of these molecules for interaction with the TS enzyme. Accordingly, these substituents were incorporated into selected examples to give the series of analogues 47-55. These all show enhanced (approximately 10-fold) inhibition of TS compared to their unsubstituted counterparts. In the substituted benzylamides (51, 52) and heterocyclic benzyl amides (53-55) the ability to enter cells by passive diffusion results in highly potent (< 1 microM) cytotoxic agents.

Are thermolabile splints a source of nosocomial infection?

The aim of this study was to determine whether thermolabile splints used on burned patients became colonized with microbes from the underlying burn or were capable of contaminating burn wounds, and to determine whether the current thermoplastic splint decontamination regimen was effective at removing contaminating bacteria. One hundred and thirty-one standardized swab samples were collected from 28 splints before and after cleaning, and from burn wounds of 10 patients. Qualitative bacterial cultures and identification of isolates were performed. Just over one third of all splints sampled before cleaning were contaminated with bacteria. This compared with over half of the burn wound samples and 17% of the splints sampled after cleaning. Most of the isolates were Gram-positive species including coagulase-negative staphylococci (18), Staphylococcus aureus (12), Bacillus spp. (17) and one isolate of viridans streptococcus. Only five Gram-negative isolates were detected. On only one occasion did the wound and the splint before cleaning have the same organism isolated. Cold disinfection every 24 h was adequate to decontaminate thermolabile splints used on burn patients provided the burn bacterial count was low and care was taken to handle the splints in order to avoid re-contaminating them with health care workers' flora. Thermolabile splints could be a source of burn colonization microbes, but with adequate ward cleaning they were not found to be a problem in our practice.

Development of chiral high performance liquid chromatographic assays for the enantiomers of 8-hydroxy-(di-n-propylamino)tetralin and three 8-keto-pyrrole-substituted analogues.

Two chiral HPLC methods using protein-based stationary phases for the analysis of 8-hydroxy-(di-n-propylamino)tetralin and three 8-keto-pyrrole analogues are presented. Efficient solid-phase extraction enabled quantification of 0.02 microgram ml-1 of the 8-keto-pyrrole analogues from 500 microliters rat hepatocyte suspensions, and 0.2 microgram ml-1 to be measured from 50 microliters of rat plasma using UV detection at 315 nm.

A quantitative assessment of blood loss in burn wound excision and grafting.

A prospective study was performed that allowed a quantitative estimation of blood loss in excision and grafting of adult burn injuries. The average value for blood loss was 9.2 per cent of the patient's estimated blood volume or 387 ml per 1 per cent burn excised and grafted. There was no exponential increase in blood loss as the percentage excised and grafted increased apart from proportionality and there was no statistical difference between males and females for burns excised and grafted days 1-14 after injury or greater than 14 days after injury. It was therefore concluded that a useful working figure is 400 ml whole blood or 10 per cent of patient blood volume is lost per 1 per cent full thickness burn excised and grafted for an adult. These values do not apply to the very young, the very old and those patients who have bleeding disorders, and when using various methods to limit blood loss. This figure allows adequate cross-matched whole blood to be available preoperatively.

Colonic pseudo-obstruction in burns patients.

Acute pseudo-obstruction is a rare complication in burns patients. An awareness of the factors implicated in its pathogenesis such as prolonged bed rest, narcotic medications, hypokalaemia, sepsis and surgery (all commonly associated with burns patients) is essential if this condition is to be avoided. Early diagnosis, prokinetic and cathartic agents, and aggressive endoscopic intervention are essential to halt the progression of caecal dilatation. Excisional surgery and stoma formation are necessary for salvage of complicated colonic pseudo-obstruction.

Vibrio cholerae non-O1 primary septicaemia following a large thermal burn.

A case of primary septicaemia with a Vibrio cholerae not agglutinable with O group 1 sera is reported in a burn patient. This appears to be the first reported case of this organism causing infection in a burn patient. The case is discussed, highlighting the difficulties encountered in treating this unexpected organism and the course of the infection in this patient. It is probable that the organism was obtained during first aid for the burn wound.

Measuring pressure under burns pressure garments using the Oxford Pressure Monitor.

Pressure garments are used extensively in the treatment of hypertrophic scarring following burn injuries. The Oxford Pressure Monitor was used to measure garment-scar interface pressure (mmHg) using a number of fabric types over various body parts. The results indicate a wide range of pressure values between different garments and body parts with the greatest pressures found over the dorsum of hands and feet. The problems of achieving 'optimal pressure' over hypertrophic scarring are discussed with emphasis on the need for more accurate measuring equipment.

Chryseobacterium in burn wounds.

Chryseobacteria are gram negative organisms, formerly known as Flavobacteria, which rarely cause infections of burn wounds. This article documents three cases of Chryseobacterium infection in burn wounds and adds to the other two cases that have been reported in English literature. Two patients died, with one of the deaths linked to a Chryseobacteria bacteraemia. In two patients, there was an associated history of first aid treatment with untreated water. Patients whose burn wounds are suspected to be infected with Chryseobacterium require wound excision and coverage in combination with antibiotic therapy such as ciprofloxacin, vancomycin and rifampicin.

Aeromonas wound infection in burns.

Infection of burn patients with the Aeromonas organism is an uncommon event. This paper documents four cases of Aeromonas hydrophila and one case involving both A. hydrophila and A. caviae occurring in burn patients between 1990 and 1998 at the Royal Brisbane Hospital burns unit. The organism was isolated from either skin swabs, tissue samples, blood cultures or cultured lines. In all patients there was a history of immersion in water immediately post burn. There is one case of invasion and destruction of deeper tissues and one fatality. Appropriate management requires a high index of suspicion if a history of immersion in untreated water post burn is given and the treatment involves aggressive excision and antibiotic therapy.

Self-inflicted burns.

Self-inflicted burns are a regular source of admissions to burns units world wide. This study examines the characteristics and outcomes of those who deliberately burn themselves. The medical records of all patients admitted to the Royal Brisbane Hospital Burns Unit and identified as having suffered a self-inflicted burn between 1990 and 1995 were reviewed. The records of patients who doused themselves with flammable liquid between 1984 and 1995 were examined as a separate group. Of 1072 admissions there were 44 cases (4.1 per cent) of deliberately self-inflicted burns. Average age was 30 yr with an average total burn surface area (TBSA) of 30 per cent (range 1-98 per cent). Schizophrenia, depression and personality disorder were diagnosed in 71 per cent. Alcohol intoxication was common in the rest. Suicide attempters were almost all male and the majority (60 per cent) were diagnosed with a major psychiatric illness. Self-mutilators suffered much less serious burns and none died. Self-inflicted burns accounted for 24 per cent of burns admitted to the intensive care unit. Self-immolation with flammable liquid resulted in severe burns with a 45 per cent mortality. A number of differences was demonstrated between those patients who had attempted suicide and those who had deliberately burnt themselves without suicidal attempt. Self-immolators constitute a considerable proportion of major burns admitted to this unit.

Hydrofluoric acid burns.

OBJECTIVE: The purpose of this article is to report our experience with hydrofluoric acid (HF) burns and to present our management guidelines for these burns, which include a novel way of delivering calcium combined with dimethyl sulphoxide (DMSO) for cutaneous burns. METHOD: We reviewed our institutional experience from 1977 to 1999 for patients presenting with burns caused by hydrofluoric acid and collected data on age, sex, burn size, anatomical site, method of contact, surgical procedure, and outcome. RESULTS: Of a total of 2310 admissions, 42 HF burns patients were identified during the study period. The average age was 34 years. There were 35 males and 7 females. Seventy-four percent of cases received burns to the upper limb. Median burn size was 1% of the total body surface area. Seventeen percent of patients required a surgical procedure. In 24% of cases, the method of contact was work related and 40% were injured using cleaning products at home or on boats. No deaths were recorded. CONCLUSION: HF injury is uncommon but problematic burns often requiring surgery. RECOMMENDED MANAGEMENT: In cases of cutaneous exposure, treatment should commence immediately with 30 min lavage followed by application dimethyl sulphoxide 50% + calcium gluconate 10% in surgical jelly. If hand or forearm is affected, regional intravenous calcium 'Bier's block' using 40 ml 10% calcium gluconate with 5000 U heparin in total final volume of 40 ml may be indicated. Subcutaneous infiltration may be indicated for elsewhere at 0.5 ml/cm(2) burn of 10% calcium gluconate. Persisting pain may require nail removal or arterial calcium infusion.

Pattern of burn injury in hang-glider pilots.

High-voltage electrical injury has been well documented in a number of situations, such as the occupational hazard of linesmen and construction workers, and in the context of overhead railway power lines. Two cases of hang-glider pilots contacting 11,000-volt power lines have recently been treated in the Royal Brisbane Hospital Burns Unit. They demonstrate an interesting pattern of injury, not described in current burns literature, involving both hand and lower abdominal burns. Both patients sustained full-thickness patches of burn injury, with underlying muscle damage and peripheral neurological injury. This distribution of injury seems to be closely related to the design of the hang glider.

Burn injuries in the elderly.

This study has shown that elderly males were more likely to be admitted to the Royal Brisbane Hospital Burns Unit than females. No high-risk period of the day, week or year could be identified for this group. Flame burns and scalds were most common as was the association with cooking and bathing activities. Predisposing factors were found to be common in the elderly burn population. Prevention programmes need to be directed to the home with safer cooking facilities and lower temperature or temperature outlet controls to lessen bathing scalds, as these patients found it difficult to escape a hot bath. Mortality rates were related to the percentage total body surface area burned and inhalation injury, and were well predicted by the Burn Severity Index. Complications were mainly pneumonias and venous thrombosis and reflect the need in this age group of maintaining active mobility and a quick resolution of the burn injury. Good nutrition, often lacking in this age group, must be maintained, along with meticulous wound care if infection is to be prevented. Early wound coverage is vital to prevent sepsis. Our approach is towards an early skin grafting programme while the patient is fit. This is aggressive, with as much skin coverage as possible, before the patient's condition deteriorates. Every effort is made to maintain the patient's health as near normal as possible. However, if deterioration occurs, then the patient is supported and grafting delayed until the patient is again fit for surgery. When this study was undertaken, it was hoped that an answer to the controversial subject of early versus late surgery could be answered.(ABSTRACT TRUNCATED AT 250 WORDS)

Cicatricial, postburn ectropion and exposure keratitis.

Exposure keratitis can lead to infectious keratitis, corneal perforation, blindness and disfigurement. Chronic exposure of the cornea can occur following facial burns that cause eyelid ectropion. This complication can be difficult to diagnose in the unconscious patient. Five patients have undergone lid ectropion release to 11 eyelids in the early postburn period over the past 5 years. One patient required repeat release. Full-thickness skin grafts were used for the lower eyelid and no graft failure occurred. Operations were performed between 30-50 days postburn. Plastic wrap was used in one patient as a temporary dressing to maintain corneal hydration until surgery could be performed. All the patients were noted to have exposure keratitis on ophthalmological review. Patients most at risk are those with large area burns that include the face, who require prolonged intensive care support. It is important to look out for the development of eyelid ectropion, which should be corrected when first diagnosed to prevent disabling, sight-threatening eye injury.

Epidemiology of burns due to domestic flammable agents.

An analysis of the epidemiological factors relating to domestic flammable agents has shown that 17.7 per cent of admissions over a 5-year period were involved in domestic flammable injuries; 87.7 per cent of the patients were male, with 38.9 per cent being young males between 12 and 19 years old. Petrol and diesel accounted for 56.8 per cent of the burns and the average body surface area burned was 17.7 per cent. Most commonly the face, hands and limbs were burned, and the average length of stay was 18.25 days, 69.2 per cent of the burns were due to human error and were thus potentially preventable, 21.2 per cent had predisposing conditions with 8.9 per cent being due to alcohol. It was considered that the strategies to prevent these burns injuries should be aimed particularly at young males.

Preventing morphological disturbances in burn-scarred children wearing compressive face garments.

Continuous external compression in the form of elasticized garments is a well-accepted and substantiated form of management for postburn hypertrophic scarring. Children who have sustained deep partial thickness and/or full skin thickness burns to the face and head are frequently prescribed elasticized compressive face garments in the post-acute stage of their recovery. Recurrent concerns expressed by parents prompted investigation into the frequency of sleep disturbances, such as snoring subsequent to the application of face garments, and the possibility of changes to the developing dentition. This preliminary study utilized a single case design to demonstrate the effectiveness of a bimaxillary mouthguard in circumventing such problems.

Management of extravasation injuries.

BACKGROUND: Various agents have been implicated in causing tissue necrosis after intravenous infusions have extravasated. These include solutions of calcium, potassium, bicarbonate, hypertonic dextrose, cytotoxic drugs and antibiotics. Views on management of these injuries differ, and range from a non-operative conservative approach to early debridement and grafting. METHODS: A retrospective review was undertaken of the hospital files of patients with extravasation injuries seen in three Australian hospitals. Nine patients were identified, and their management and long-term follow up are reported. RESULTS: Age ranged from 17 days to 60 years. Two patients received their injuries from solutions containing isotonic dextrose/saline. The other seven patients received injuries from a variety of solutions including calcium gluconate (n = 1), parenteral nutrition (n = 1), sodium bicarbonate (n = 1), immunoglobulin (n = 1), gentamicin and penicillin (n = 1), flucloxacillin (n = 1), and the chemotherapeutic agents epirubicin and cyclophosphamide (n = 1). The sites involved included the dorsum of the right foot (n = 3), the dorsum of the left foot (n = 3), the right groin (n = 1), the right hand (n = 1) and the left hand (n = 1). Four patients were managed by delayed debridement and split skin grafting, while five were treated non-operatively. Prolonged scar management was necessary in seven of the nine patients. Final results were satisfactory in all patients who received skin grafting and in all patients who were managed conservatively. CONCLUSIONS: Management of extravasation injuries should be conservative if possible. Delayed debridement and split skin grafting is required if the area of skin loss is extensive. Scar management remains a problem. Prevention of these injuries with the education of both medical and nursing staff remains the ultimate aim.

Foam ear protectors for burnt ears.

Foam ear protectors were developed at the Royal Brisbane Hospital for use with selected patients with burns to the ears. The protectors assist in preventing pressure necrosis of the ear and damage to skin grafts. They permit visualization of the ears after grafting and allow the patient to sleep in a side-lying position if desired.

Self-inflicted burn injuries: an 11-year retrospective study.

The burns unit at the Royal Brisbane Hospital accepted a total of 2275 admissions from 1986 to 1996. During this 11-year period, 65 cases of self-inflicted burn injury were treated, which made up 2.9% of the total number of admissions. A mortality rate of 21.5% (14 patients) is noted, with all patients dying after admission to the hospital. A common feature of people that self-inflict burn injuries is a psychiatric history, with many patients having histories of self-harm or suicide attempts. Two distinct groups were identified--those with suicidal intent and those with intent of self-harm. Those patients with self-inflicted injuries have an increased mean of 31.4% total body surface area burned as compared with those patients whose injuries are accounted for as accidental, which have a mean total body surface area burned of 10%. Additionally, the mean length of stay in the hospital for patients with self-inflicted injuries was 40 days for acute injuries, which is prolonged; the mean length of stay for acute injuries that were not self-inflicted was 14 days. This investigation discovered 3 cases of repeated self-inflicted burn injury.