An analysis of resuscitative requirements of petrol (gasoline) burns

Bums (1992) 18,(2), 141-144

Printed in Great Britain

141

An analysis of resuscitative requirements (gasoline) burns*

of petrol

C. L. Hankins’, M. E. Hackett’*” and S. Varma’ ‘The Plastic Surgery Department, Royal Infirmary, Leicester, UK

St Andrews

Hospital, Billericay, Essex and ZThe Plastic Surgery Department,

A retrospective study was carried out to confirm the clinical impression that petrol (gasoline) burns had a greater resuscitafion requirement than other types of thermal injury. A total of 450 admissions to the St Andrews Hospital Regional Bum Unit from 1982to 1988 were reviewed. Patients with pre-existing cardiovascular disease, respiratory disease, inhalation injury and fatalities occurring within the first 72 h of admission were excluded from the study. Forty-four pafients mef all requirements for inclusion within the study. 7hese 4~ patients consisted of 15 with petrol burns and 29 with non-petrol burns, all of whom were resuscifated using the modified Muir and Barclay formula, with adjustments made on the basis of clinical and laboratory monitoring. Comparison of resuscitation requirements of the fwo groups by the Wilcoxon E&k Sum Test showed that the petrol burns group had a signiticantly greater fluid resuscitation requirement (P< 0.01).

Introduction The modified Muir and Barclay formula is the most commonly used guide for bums resuscitation in the UK. It has been our clinical impression that petrol (gasoline) flame bums, particularly those involving a high proportion of full skin thickness injury, require a significantly greater amount of fluid resuscitation than that predicted by the modified Muir and Barclay formula (Watson et al., 1977). The aim of this study was to determine if petrol bums requiring resuscitation constitute a clinically distinct group in terms of fluid resuscitation requirements.

Materials and methods This retrospective study included all admissions to the St Andrews Hospital Bums Unit between 1982 and 1988. Only those patients requiring formal fluid resuscitation were considered for inclusion in the study. By definition, these were patients with partial or full skin thickness thermal injury covering more than 15 per cent of the total body surface area (TBSA) in adults or more than 10 per cent TBSA in children less than 12 years of age. In order to minimize extraneous factors influencing resuscitation requirements, all patients with pre-existing cardiovascular disease, respiratory disease, inhalation injury or those who died within the first 72 h of admission were excluded from the study.

To be included in the study as a petrol bum, the patient must have sustained his/her bums via direct contact of petrol with the skin which was then subsequently ignited. All patients included in the study were resuscitated by the modified Muir and Barclay Formula, in which 4.5 per cent human albumin solution and normal saline were used for resuscitation and maintenance fluid requirements respectively: Predicted fluid requirement Resuscitation period

(0 1992 Butterworth-Heinemann 03054179/92/020141-04

Ltd

%TBSA burned x wt (kg)

= 4/3 (

2

>

TBSA = total body surface area *The formula is designed to give equal volumes of resuscitation fluid in six successive periods of 4, 4, 4, 6, 6 and 12 h postbum. Adjustments were however made, dependent on clinical and laboratory monitoring. The patients were monitored using Marquette 7000 series monitors (Marquette Electronics; Milwalkee, Wisconsin, USA). Basic parameters of pulse rate, ECG, non-invasive blood pressure, pulse oximetry and temperature (skin and rectal) were measured on all patients. All patients were catheterized, with urinary output being measured hourly. Tables I and II indicate the urinary output for each resuscitation period for petrol and non-petrol bums respectively. Invasive techniques for central venous and pulmonary capillary wedge pressures used disposable pressure transducers (Spectramed). Cardiac output was measured using the thermodilution technique with thermodilution pulmonary artery catheters. Daily body weights were not routinely measured. The total predicted fluid resuscitation requirements (PREDRES) according to the modified Muir and Barclay formula and the actual amounts of fluid given (ACTRES) for all six resuscitation periods were determined for both the petrol and non-petrol groups. The difference of ACTRES minus PREDRES of the petrol and non-petrol groups were compared and analysed by the Wilcoxon Rank Sum Test (Bourke et al., 1985).

Results of 450 patients were reviewed, 119 of whom fluid resuscitation. After excluding those patients who did not fulfil the criteria discussed above, a total of 44 A total

“This pager is dedicated to the memory of Mr Michael E. Hackett, FRCS, who died in 1991.

Leicester

required

Bums (1992) Vol. IS/No.

142

Table I. Urinary output/resuscitation

period for petrol bums*

1

2

3

4

5

6

Urinary output OWWh)

320 120 475 275 0 420 120 580 215 245 220

363 106 280 252 225 152 76 141 85 138 135

221 104 515 145 140 142 132 410 115 129 195

228 195 361 99 289 298 150 302 176 285 139

192 337 268 235 250 325 101 175 377 184 115

396 453 782 880 478 538 448 770 326 656 231

0.7 0.5 0.9 0.7 0.5 0.8 0.5 0.9 0.7 0.5 0.4

6

Urinary output (ml/kg/h)

517 1580 1450 468 520 606 960 432 446 388 828 1390 1375 445 361 267 875 625 1206 681 456 780 1575

0.7 1.7 1.8 0.5 0.5 0.8 0.9 0.9 0.8 0.7 1.0 1.4 1.6 0.4 0.5 0.5 1.3 0.8 0.9 0.9 0.5 0.8 1.6

Resuscitation period Patient A.T. B.H. A.K. ST. S.W. D.A. M.C. J.R. D.H. R.S. E.8. *Data

regarding

urinary

output

for A.S., J.B., Z.F. and S.W. not available.

Table II. Urinary output/resuscitation

period for non-petrol bums* Resuscitation period

Patient

1

L.E. J.G. B.G. S.K. R.B. B.C. R.C. A.K. P.B. R.B. T.C. T.H. A.B. F.H. M.E. J.F. J.B. F.S. E.S. J.G. J.S. M.P. S.W. *Data

2

100 580 0 5 22 0 125 910 0 355 265 400 0 155 400 100 0 180 0 233 132 133 150 regarding

urinary

ouptut

2

230 315 280 132 290 0 82 500 34: 105 290 400 51 87 111 450 372 0 320 137 150 230 for A.C.,

3

4

5

155 220 800 81 190 210 193 194 600 175 102 115 400 190 114 92 750 400 475 218 87 138 364

230 287 1200 150 175 645 244 302 633 205 600 752 400 207 143 145 600 364 350 187 187 83 1075

240 852 750 310 275 508 860 223 290 305 990 652 475 184 290 234 520 305 450 356 205 565 765

K.B., D.K. and P. J. not available.

patients met all the requirements for inclusion in the study. There were 15 petrol burns, and 29 non-petrol bums. The petrol group (Tablelu) contained 14 males, mean age 28 years (range 1 l-58 years) and one female of 30 years of age. In the non-petrol group (Table IV), there were 24 males, mean age 35.25 years (range 19-SS), and five females, mean age 46.6 years (range 30-78 years). Comparison of the difference between the actual and predicted fluid resuscitation requirements (ACTRES - PREDRES) of the petrol and non-petrol groups by the Wilcoxon Rank Sum Test indicated that the petrol burns group had a requirement resuscitation fluid significantly greater (P < 0.01).

Discussion Petrol burns have been reported as being more prevalent in males. Patients having sustained petrol burns have been

reported as having larger bums, requiring more surgery and having a longer hospital stay than patients burned by other means (Cole et al., 1986). Immersion in or extensive skin contact with petrol, without ignition, has been reported to result in partial skin thickness injury (Hunter, 1968; Walsh, 1974; Simpson and Cruse, 1981; Hansbrough et al., 1985; Stewart, 1985; Cole et al., 1986; Stykes et al., 1986). Resuscitation fluid requirements in petrol bums do not appear to have been reported previously. Our study shows an increased resuscitation requirement which is greater than that predicted by the modified Muir and Barclay Formula. Although the reasons for this increased requirement are not known, it is more likely related to the chemical composition of petrol. Petrol is a complex mixture of alkanes, cycloalkanes and hydrocarbons (Simpson and G-use, 1981; Stewart, 1985). In particular, the hydrocarbon component has been incriminated as being primarily responsible for tissue damage. This

Hankins et al.: Resuscitative requirements for petrol burns

143

Table III. Petrol bums

Age Patient

w

A.T. B.H. A.K. S.T. SW. A.D. M.C. J.R. A.S. D.H. J.B. Z.F. SW. R.S. E.B.

24 27 43 21 23 16 22 30 11 12 42 58 26 28 44

Weight

TESA

Sex

(kg)

(%)

(ml)

(ml)

M M M M M M M F M M M M M M M

67 69 87 78 77 63 62 70 32 55 68 79 83 99 71

45 75 20 60 18 34 40 17

12060 20 700 6960 18720 5544 8568 9920 4760 5120 5720 10336 11060 5312 6336 12496

12246 23831 4669 21278 5577 10660 17086 4015 5348 6305 23 288 12461 5773 11 881 17624

z: 38 35 16 16 45

PREDRES

ACTRES

Table IV. Non-petrol bums Weight

TBSA

Sex

(kg)

(%)

(ml)

(ml)

M M M F M M M M M M M M M M M M M F M F M M M M M M F F M

61 67 70 70 85 70 73 70 85 110 79 92 73 72 83 73 54 85 83 56 66 53 78 80 78 64 66 67 73

45 38 15 41 21 16 42 20 50 20 41

10980 10184 4200 11480 7140 4480 12264 5600 17000 8800 12956 5888 6424 9216 4980 4380 3672 6800 6640 8960 6072 5300 9672 16000 6864 6144 9504 9380 8468

9902 5541 3152 13068 6820 3605 11 357 2906 12048 8342 4978 4583 6025 8590 4791 3700 3221 3360 9874 9757 5034 6630 8297 13599 6001 5233 6757 6468 5935

Age Patient

k)

L.E. J.G. B.G. SK. R.B. B.C. R.C. A.C. K.B. C.B. A. K. D.K. P.B. R.B. T.C. T.H. A.B. F.H. M.E. J.F. J.B. C.B. P.J. F.S. E.S. J.G. J.S. M.P. S.W.

19 31 42 39 38 42 27 25 37 26 22 21 54 21 43 22 39 78 32 53 59 39 40 55 57 26 33 30 29

hydrocarbon component in petrol has also been incriminated in the pathogenesis of endothelial cell damage which is the common pathway of injury to the lungs, liver, spleen and kidneys reported in immersion/extensive skin contact, non-ignition injuries (Walsh, 1971; Simpson and Cruse, 1981; Hansbrough et al., 1985). Due to the aliphatic nature of its constituents, petrol dissolves lipid compounds readily. This property allows percutaneous absorption in animals, distribution of the compound within the subcutaneous fat and disruption of cell membranes (Hansbrough et al., 1985). This membrane disruption may result in increased membrane permeability, fluid loss and therefore be the underlying mechanism of the

:; 32 15 15 :i 20 40 23 25 31 50 22 24 36 35 29

increased fluid requirement study.

PREDRES

ACTRES

of petrol burns observed

in this

Conclusion It is concluded that petrol bums have a statistically significant greater fluid resuscitation requirement than other types of thermal injury. Although the mechanism of this increased requirement has not been investigated, it is very likely due to the lipid solubility of the petrol prior to ignition, resulting in destabilization of cell membranes. This in turn would result in greater membrane permeability, increased fluid loss and an increased fluid resuscitation requirement.

Bums (1992) Vol. lS/No.

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References Bourke G. J., Daly L. E. and McGilray J. (1985) Inhpretation and Uses of Medical Statistics, 3rd edn. Cole M., Hemdon D. N., Desai M. H. et al. (1986) Gasoline explosions, gasoline sniffing: an epidemic in young adolescents. 1. Burn Care Rehabil. 7, 532. Hansbrough J. F., Zapata-Sirvent R., Dominic W. et al. (1985) Hydrocarbon contact injuries. J. Trauma 25, 250. Hunter G. A. (1986) Chemical burns of the skin after contact with petrol. Br. 1. Pk&. Surg. 21, 337. Simpson L. A. and Cruse C. W. (1981) Gasoline immersion injury. Plasl. Recondr. Surg. 67, 54. Stewart C. E. (1985) Chemical skin bums. Am. Fum. Physician 31, 149.

2

Stykes R. A., Mani M. M. and Hiebert J. M. (1986) Chemical bums: retrospective review. 1. Burn Care Rehbil. 7,343. Walsh W. A. (1974) Gasoline immersion bum. N. Eng2.I. Med. 29, 830. Watson, J. S., Walker, C. C. and Sanders, K. (1977) A comparison between dried plasma and purified protein fraction in the resuscitation of bum patients. Burns 3, 108.

Paper accepted

3 October

1991.

Correspondence should be addressed to: Dr C. L. Hankins, Department of Surgery, University of Virginia, Charlottesville, Virginia 22908, USA.

Jerusalem International Meeting on Burn Injuries Jerusalem, Israel, 8-12 June 1992 Endorsed by: International Society for Bum Injuries Israel Bum Association Israel Society for Plastic, Reconstructive

and Esthetic Surgery

Topics will include: care and resuscitation Smoke inhalation and airway thermal injuries The bum wound Infection and immunology Skin substitutes Nursing

Primary

PT/OT Pain Control Mass casualty Metabolism and nutrition Deadline for receipt of abstracts: 1 February 1992.

The best abstract will receive ‘The Williams F’kzefor Btim Research’.Juniors or young seniors (specialists for less than 5 years) will be eligible. Further information from: Dr A. Eldad, Chairman, Organizing Committee, P.O. Box 50006 Tel Aviv 61500, Israel.