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Conservative approach to the elderly patient with burns
Conservative Approach to the Elderly Patient With Burns
Terry Housinger, MD, Salt Lake City, Utah Jeffrey Saffle, MD, Salt Lake City, Utah Scott Ward, RPT, Salt Lake City, Utah Glenn Warden, MD, Salt Lake City, Utah
The treatment of elderly patients (more than 60 years of age) with burns remains a challenging problem. Age, general disability, and significant underlying disease contribute to a mortality of 50 percent after full-thickness burns of 10 to 14 percent in this population [I]. Poor healing of donor sites, graft loss due to inadequate vascular supply, and the risks of general anesthesia and prolonged hospitalization make operative treatment of burn wounds hazardous and difficult. Returning these patients to meaningful life-styles can often be accomplished without surgical wound coverage. A selective conservative approach to the elderly burn patient has been developed at our center. This report retrospectively analyzes our results with this type of care. Matertat and Methods From 1978 through 1983,55 patients older than 60 years of age were admitted to the bum center. The mean age of these patients was 72 years (range 60 to 93 years, Table I). The mean total body surface area burned was 24 percent, of which a mean of 13.3 percent was full-thickness injury. Thirty-nine patients were injured in fires, and 16 patients were injured by scalding or other causes. As a result of the treatment these patients received, they were divided into three groups. Seventeen patients died in the early postbum period, 15 patients underwent one or more operative procedures to attain wound coverage, and 23 patients were treated by a policy of conservative management. The 17 patients who died early were all severely injured, with a mean burn size of 51.3 percent of the total body surface area. Nine of these patients also had significant inhalation injuries documented by xenon-133 scanning or bronchoscopy. Patients died a mean of 4.6 days postburn, usually from some combination of intractable shock, respiratory failure, and cardiovascular collapse. In many instances, the severity of the injury led to an anticipated mortalitv approaching certainty using standard survival ntemomWn Bum Center, University of FromtheDqrtm&tofSugery.I Utah school of Medlclne, San Lake city, Utah.
R~for~lnts~be~~toJetfreySaffle,M),De-
parbnaliofsurgery, unlvam@ Of Ut8h Medbl
Center. 50 North Madlcal Drive, 3dt I.&e City, Utah 34132. Presented at the 36th Annlml Mesthg of the southwestern Surgical Ccqress, Honolulu, Hawaii, April 21-29, 1994.
vohmo 143, Dmcembu 1994
statistics [1,2]. This knowledge, plus awareness of the frequently poor quality of the patient’s life-style before injury, led to the decision by the burn team, in consultation with family members, not to pursue aggressive care. Only two patients in this group had burns of less than 20 percent of the total body surface area. One of the patients was an elderly man who was transferred to the bum center with ongoing burn wound sepsis, and the other patient had severe heart disease and dementia, and died from cardiac arrest. Patients were selected for conservative management based on overall assessment of their general health and the presence of significant underlying illnesses that would make operation and long hospitalization prohibitively risky. These patients had a variety of ongoing medical problems (Table II), averaging 1.5 significant illnesses each. Patients demonstrating generalized debility in the absence of specific underlying illness were also considered for conservative management. Other factors considered in this decision included the quality of the patient’s life-style before injury and the seriousness of their thermal injury. For some patients, location or depth of burn wounds mandated surgery, however risky, in order for the patient to have any chance of survival. In many cases, the decision to pursue conservative treatment included acceptance of the possibility of moderate contractures or scarring that would nonetheless permit the patient to return home. Conservative management emphasized four main pointi education of the patient and family (or skilled nursing facility) in proper burn wound care, the need for maintenance of adequate nutrition during healing, return to normal activities as soon as possible, and close follow-up at the burn center on an outpatient basis. Wound care consisted of twice daily cleansing of the wound with a gentle soap, application of a gentle topical antibiotic ointment (Neosporine, Burroughs-Wellcome, Research Triangle Park, NC) and loose coverage with a nonstick material (Adapti@, Johnson and Johnson, New Brunswick, NJ), and gauze wraps. Initially, patients returned to the burn center daily for dressing changes and wound inspection. As healing progressed, patients were seen less frequently. Follow-up continued until wounds were healed and the specialized services ,of the center could be supplanted by the family members or nursing staff. In some cases, patients were temporarily placed in a skilled care facility until some wound healing had occurred; in a few cases preexisting 817
al
Housinger
et
TABLE I
Classifications of Patlents According to Treatment Modal0
Number of patients Age (yr) Burn size (% TBSA) Full-thickness burn (% TBSA) Underlying illnesses (per patient) Mortality Number Percent
Conservative
Operative
Early Death
Total
23 74 (60-88)’ 11.2 (4-40) 4.8 (O-20) 1.4
15 68 (61-91) 13.3 (1.5-47) 8.9 (0.5-42) 0.87
17 75 (60-93) 5 1.3 (5-87) 28.7 (l-60) 1.8
55 73 24 13.3 1.4
2 8.6
2 13
17 100
21 38
l Values in parentheses indicate the range. TBSA = total body surface area.
disability or problems related to the burn wound necessitated permanent nursing home placement. The 15 patients managed operatively were, in general, healthier and younger than those treated conservatively (Tables I and II). Burn wounda, particularly full-thickness injuries, were slightly larger in this group compared with those managed without surgery. Operative management consisted of one or two stage excision and grafting procedures or amputations [3]. Every effort was made to support these patients during hospitalization with nutritional, cardiovascular, and pulmonary care. Early physical therapy and return to normal activity were encouraged as soon as possible after surgery. After grafting, patients were subjected to the same forma of physical therapy and outpatient management as those treated conservatively. Wound healing was evaluated by physicians and physical therapists at the time of discharge and during follow-up visits to the clinic. Results were considered excellent or good when affected areas attained complete skin coverage, with function equal or close to normal, satisfactory when resulting disability did not interfere significantly with activities of daily living; and poor when results interfered with routine activities. Results Conservatively managed patients had a mean hospital stay of 10.5 days (range 1 to 60 days). During hospitalization, there were nine significant complications (39 percent morbidity), including one stroke, four episodes of congestive heart failure, one case of TABLE II
Underlying Illnesses Conservative
Coronary artery disease Peripheral vascular disease Heart failure Arrhythmias fiypertension Venous thrombosis Chronic obstructive pulmonary disease Diabetes Neurofogic disorder or dementia Artbrltis Total
818
Operative
pneumonia, an episode of glucose intolerance requiring continuous insulin infusion, and an episode of sepsis. Two patients died (8 percent); one from heart failure and one from sepsis. In the surviving patients, the wounds healed in an average of 3.2 months (range 1 to 10 months). There were no burn wound infections after discharge. Nineteen of the 21 surviving patients (90 percent) were able to return to their place of residence, and two patients who had previously lived at home required nursing home placement. Functional results were described as excellent or good in 18 of the 21 patients (86 percent) and were satisfactory in the other 3. Operative patients had a mean hospital stay of 17.8 days (range 5 to 43 days). This group had 12 significant in-hospital complications (80 percent), including 4 cardiac complications, 5 infections,. 2 neurologic complications, and 1 episode of glucose intolerance. Mortality was 13 percent (two patients). One death was due to myocardial infarction and the other was due to respiratory arrest after amputation of a severely injured forearm. Surviving patients attained wound healing in a mean time of 1.5 months. Two patients, however, had poor graft take and required up to 3 months for the wounds to heal. Twelve of these 13 patients (92 percent) were able to return to their residence and 1 patient required nursing home placement. Seventy-seven percent of those operated on (10 patients) had good or excellent functional results, and the remaining 23 percent had poor results. The latter group included two patients who required amputation. Comments
5 2 3 4 5 1 5
! 0 2
1 6 2
l0
9A
12
: 1
The management of elderly patients with thermal injuries has received little attention in the literature. In younger patients, emphasis has been placed on early excision and grafting as a means of attaining superior functional results, decreasing hospital stay, and promoting earlier return to a productive life-style [2]. In healthy older patients as well, this philosophy is probably appropriate. Deitch and Clothier [4] reported a series of patients older than 50 years of age,
The American Journal of Surgery
Elderly Patients With Burns
in whom a policy of routine early excision and grafting of burn wounds was generally successful. For many elderly patients, however, such an aggressive philosophy may be inappropriate. The patients reviewed here were much older than those in the review of Deitch and Clothier. In addition, most had significant preexisting medical problems, including cardiac and pulmonary disease, diabetes, or neurologic impairment. Such patients tolerate the stress of major operative procedures poorly, and the dangers associated with general anesthetic, blood loss, and harvesting of donor sites can be prohibitively risky. In addition, the skin of elderly patients undergoes extensive thinning and atrophy, leading to difficulty with donor site healing, and poor vascularity of the graft bed can cause grafting failure [5]. Hospitalization, particularly the bed rest that is necessary after surgery, can contribute to disorientation, aspiration, ileus, and myocardial infarction. Finally, the goals of early excision and grafting of burn wounds require careful interpretation when applied to elderly patients. Many of these patients have relatively restricted life-styles that do not require great mechanical strength or dexterity. A healed burn wound that would leave an unacceptable scar or cause unacceptable impairment to a young person may be no more than a slight nuisance in an elderly patient. Similarly, a wound that requires 2 months to heal would be catastrophic if permitted to disable a young worker, but might again be acceptable in someone who is less active and who can restrict daily living to include meticulous burn wound care. For all of these reasons, we have adopted the policy of selective conservative therapy for the elderly burn patient. This study demonstrates that a policy of early mobilization and discharge and vigorous outpatient follow-up can be successful in a subgroup of elderly burn victims. Hospital stay was reduced in these patients, complications were minimized, and acceptable functional results were obtained. Wounds took a relatively long time to heal, but the fact that 90 percent of patients returned to their normal lifestyles bespeaks the success of this treatment. Which patients should be selected for a particular form of therapy, however, is not always clear. To begin with, many elderly patients die from relatively minor thermal injuries, a fact that is clearly apparent in national statistics [I ,2]. For elderly patients with massive burns, death is essentially certain, and a nonaggressive approach emphasizing sedation and pain control is warranted. These patients are reported separately here, since their inclusion under “conservative” management would prejudice our results in a misleading way. In addition, the operative and conservative groups are not strictly comparable. Surgical patients were younger and generally in better health, but some patients, even though quite
volume148,Decombr 1984
debilitated, were treated surgically because the burn wounds were not amendable to conservative management. The first criteria in selecting patients for conservative therapy, therefore, is the presence of a wound that can be permitted to heal primarily, even if this means a prolonged healing time or some degree of functional or cosmetic impairment. In addition to the size and type of wound, careful analysis of the support systems available to these patients is an essential part of the decision-making process. The ability to follow such patients in an outpatient setting is mandatory for achieving acceptable physical therapy, good nutrition, and acceptable wound healing. On occasion, outpatient management is facilitated by short-term admission to a nursing care facility, followed by eventual discharge home. The management of elderly burn patients remains challenging and controversial. As a result of this study, however, we believe that not all patients must be committed to aggressive therapy. The selective use of conservative treatment remains an acceptable alternative that can salvage such patients and return them to a functional life-style. Summary A retrospective analysis of 55 elderly patients (more than 60 years of age) was undertaken to compare results of conservative management to standard operative treatment. Thirty-one percent of the patients died early from their injury. Twenty-three patients were treated without operation, with emphasis on careful outpatient wound care and physical therapy. The remaining 15 patients required excision and grafting of burn wounds or amputation. Conservatively managed patients had fewer complications, a shorter hospital stay, and functional results equal to the operative group. These results suggest that many elderly burn patients can be managed without operation with good outcome and lessened morbidity. References 1. Feller I, TholenD, CornellRG. Improvementsin bum care, 1965 to 1979. JAMA 1980;244:2074-8. 2. CurreriP, LuterrnanA, Braun0, ShiresGT. Bum lnjuwanalysls of survivalandhospitalization time for 937 patients.Ann Surg 1980;192:472-8. 3. WerdenqSaffleJ,KravitrM.A~~technkluetorexcieion and graftingof burnwounds.J Trauma 1982;22:98-103. 4. Deitch E, ClothierJ. Burnsin the elderly:an early surgicalappreach. J Trauma 1983:23:891-4. 5. GllchrestB. Age-aswciated changesIn the skin. J Am Gerlatr Sot 1982;30:139-43.
Dlscussion MacDonald Wood (Phoenix, AZ): The authors have demonstrated the morbidity of a thermal burn in the elderly patient. By comparison, at the Maricopa Medical
819
liouslnger et al
Center Burn Unit in Phoenix, we have admitted 540 burn patienta, with a mortality of 4.6 percent over the past 3 years. Sixty-three patients were older than 60 years, with a threefold increase in mortality rate. Two thirds of our burn patients older than the age of 30 years died. With a burn surface area greater than 30 percent, the mortality rate was 50 percent. The average hospital stay was 20 days, with the majority leaving the hospital in less than 3 weeks. The average total burn surface area was 14 percent. Five patients had autografts. These patients had a larger total burn surface area and a slightly longer hospital stay. There was only one death. This low mortality rate probably reflects our conservative selection of patients for grafting. Our patients died from inhalation injury and of pulmonary or cardiovascular complications and had an average burn surface area of 35 percent. In addition to the deaths, the complications were primarily pulmonary, with hypertension, heart failure, myocardial infarction, psychoses, and burn wound infection adding to the care problems. Of great concern is the cause of the burn. In two thirds
820
of our patients, the burns were due to flame. Drinking and smoking were associated with some. We have a mobile, elderly population in the Phoenix area with campers, trailers, mobile homes, and vans. Many of the fires occurred in these quarters and were due to faulty propane connections and misuse of gasoline. We are working with fire departments to try to provide better education on the care of the mobile living area and to initiate improved inspection. Dr. Housinger, what has been the experience in Salt Lake City? I commend you and your co-workers on an excellent report. I also concur with the conservative approach. Terry A. Housinger (closing): We are involved with some education processes to help the elderly patient recognize the dangers associated with such things as smoking in bed and smoking while drinking. Other than that, we do not have any elderly education program at the present time.
ma
harkm
Journal 04 Suwry
Terry Housinger, MD, Salt Lake City, Utah Jeffrey Saffle, MD, Salt Lake City, Utah Scott Ward, RPT, Salt Lake City, Utah Glenn Warden, MD, Salt Lake City, Utah
The treatment of elderly patients (more than 60 years of age) with burns remains a challenging problem. Age, general disability, and significant underlying disease contribute to a mortality of 50 percent after full-thickness burns of 10 to 14 percent in this population [I]. Poor healing of donor sites, graft loss due to inadequate vascular supply, and the risks of general anesthesia and prolonged hospitalization make operative treatment of burn wounds hazardous and difficult. Returning these patients to meaningful life-styles can often be accomplished without surgical wound coverage. A selective conservative approach to the elderly burn patient has been developed at our center. This report retrospectively analyzes our results with this type of care. Matertat and Methods From 1978 through 1983,55 patients older than 60 years of age were admitted to the bum center. The mean age of these patients was 72 years (range 60 to 93 years, Table I). The mean total body surface area burned was 24 percent, of which a mean of 13.3 percent was full-thickness injury. Thirty-nine patients were injured in fires, and 16 patients were injured by scalding or other causes. As a result of the treatment these patients received, they were divided into three groups. Seventeen patients died in the early postbum period, 15 patients underwent one or more operative procedures to attain wound coverage, and 23 patients were treated by a policy of conservative management. The 17 patients who died early were all severely injured, with a mean burn size of 51.3 percent of the total body surface area. Nine of these patients also had significant inhalation injuries documented by xenon-133 scanning or bronchoscopy. Patients died a mean of 4.6 days postburn, usually from some combination of intractable shock, respiratory failure, and cardiovascular collapse. In many instances, the severity of the injury led to an anticipated mortalitv approaching certainty using standard survival ntemomWn Bum Center, University of FromtheDqrtm&tofSugery.I Utah school of Medlclne, San Lake city, Utah.
R~for~lnts~be~~toJetfreySaffle,M),De-
parbnaliofsurgery, unlvam@ Of Ut8h Medbl
Center. 50 North Madlcal Drive, 3dt I.&e City, Utah 34132. Presented at the 36th Annlml Mesthg of the southwestern Surgical Ccqress, Honolulu, Hawaii, April 21-29, 1994.
vohmo 143, Dmcembu 1994
statistics [1,2]. This knowledge, plus awareness of the frequently poor quality of the patient’s life-style before injury, led to the decision by the burn team, in consultation with family members, not to pursue aggressive care. Only two patients in this group had burns of less than 20 percent of the total body surface area. One of the patients was an elderly man who was transferred to the bum center with ongoing burn wound sepsis, and the other patient had severe heart disease and dementia, and died from cardiac arrest. Patients were selected for conservative management based on overall assessment of their general health and the presence of significant underlying illnesses that would make operation and long hospitalization prohibitively risky. These patients had a variety of ongoing medical problems (Table II), averaging 1.5 significant illnesses each. Patients demonstrating generalized debility in the absence of specific underlying illness were also considered for conservative management. Other factors considered in this decision included the quality of the patient’s life-style before injury and the seriousness of their thermal injury. For some patients, location or depth of burn wounds mandated surgery, however risky, in order for the patient to have any chance of survival. In many cases, the decision to pursue conservative treatment included acceptance of the possibility of moderate contractures or scarring that would nonetheless permit the patient to return home. Conservative management emphasized four main pointi education of the patient and family (or skilled nursing facility) in proper burn wound care, the need for maintenance of adequate nutrition during healing, return to normal activities as soon as possible, and close follow-up at the burn center on an outpatient basis. Wound care consisted of twice daily cleansing of the wound with a gentle soap, application of a gentle topical antibiotic ointment (Neosporine, Burroughs-Wellcome, Research Triangle Park, NC) and loose coverage with a nonstick material (Adapti@, Johnson and Johnson, New Brunswick, NJ), and gauze wraps. Initially, patients returned to the burn center daily for dressing changes and wound inspection. As healing progressed, patients were seen less frequently. Follow-up continued until wounds were healed and the specialized services ,of the center could be supplanted by the family members or nursing staff. In some cases, patients were temporarily placed in a skilled care facility until some wound healing had occurred; in a few cases preexisting 817
al
Housinger
et
TABLE I
Classifications of Patlents According to Treatment Modal0
Number of patients Age (yr) Burn size (% TBSA) Full-thickness burn (% TBSA) Underlying illnesses (per patient) Mortality Number Percent
Conservative
Operative
Early Death
Total
23 74 (60-88)’ 11.2 (4-40) 4.8 (O-20) 1.4
15 68 (61-91) 13.3 (1.5-47) 8.9 (0.5-42) 0.87
17 75 (60-93) 5 1.3 (5-87) 28.7 (l-60) 1.8
55 73 24 13.3 1.4
2 8.6
2 13
17 100
21 38
l Values in parentheses indicate the range. TBSA = total body surface area.
disability or problems related to the burn wound necessitated permanent nursing home placement. The 15 patients managed operatively were, in general, healthier and younger than those treated conservatively (Tables I and II). Burn wounda, particularly full-thickness injuries, were slightly larger in this group compared with those managed without surgery. Operative management consisted of one or two stage excision and grafting procedures or amputations [3]. Every effort was made to support these patients during hospitalization with nutritional, cardiovascular, and pulmonary care. Early physical therapy and return to normal activity were encouraged as soon as possible after surgery. After grafting, patients were subjected to the same forma of physical therapy and outpatient management as those treated conservatively. Wound healing was evaluated by physicians and physical therapists at the time of discharge and during follow-up visits to the clinic. Results were considered excellent or good when affected areas attained complete skin coverage, with function equal or close to normal, satisfactory when resulting disability did not interfere significantly with activities of daily living; and poor when results interfered with routine activities. Results Conservatively managed patients had a mean hospital stay of 10.5 days (range 1 to 60 days). During hospitalization, there were nine significant complications (39 percent morbidity), including one stroke, four episodes of congestive heart failure, one case of TABLE II
Underlying Illnesses Conservative
Coronary artery disease Peripheral vascular disease Heart failure Arrhythmias fiypertension Venous thrombosis Chronic obstructive pulmonary disease Diabetes Neurofogic disorder or dementia Artbrltis Total
818
Operative
pneumonia, an episode of glucose intolerance requiring continuous insulin infusion, and an episode of sepsis. Two patients died (8 percent); one from heart failure and one from sepsis. In the surviving patients, the wounds healed in an average of 3.2 months (range 1 to 10 months). There were no burn wound infections after discharge. Nineteen of the 21 surviving patients (90 percent) were able to return to their place of residence, and two patients who had previously lived at home required nursing home placement. Functional results were described as excellent or good in 18 of the 21 patients (86 percent) and were satisfactory in the other 3. Operative patients had a mean hospital stay of 17.8 days (range 5 to 43 days). This group had 12 significant in-hospital complications (80 percent), including 4 cardiac complications, 5 infections,. 2 neurologic complications, and 1 episode of glucose intolerance. Mortality was 13 percent (two patients). One death was due to myocardial infarction and the other was due to respiratory arrest after amputation of a severely injured forearm. Surviving patients attained wound healing in a mean time of 1.5 months. Two patients, however, had poor graft take and required up to 3 months for the wounds to heal. Twelve of these 13 patients (92 percent) were able to return to their residence and 1 patient required nursing home placement. Seventy-seven percent of those operated on (10 patients) had good or excellent functional results, and the remaining 23 percent had poor results. The latter group included two patients who required amputation. Comments
5 2 3 4 5 1 5
! 0 2
1 6 2
l0
9A
12
: 1
The management of elderly patients with thermal injuries has received little attention in the literature. In younger patients, emphasis has been placed on early excision and grafting as a means of attaining superior functional results, decreasing hospital stay, and promoting earlier return to a productive life-style [2]. In healthy older patients as well, this philosophy is probably appropriate. Deitch and Clothier [4] reported a series of patients older than 50 years of age,
The American Journal of Surgery
Elderly Patients With Burns
in whom a policy of routine early excision and grafting of burn wounds was generally successful. For many elderly patients, however, such an aggressive philosophy may be inappropriate. The patients reviewed here were much older than those in the review of Deitch and Clothier. In addition, most had significant preexisting medical problems, including cardiac and pulmonary disease, diabetes, or neurologic impairment. Such patients tolerate the stress of major operative procedures poorly, and the dangers associated with general anesthetic, blood loss, and harvesting of donor sites can be prohibitively risky. In addition, the skin of elderly patients undergoes extensive thinning and atrophy, leading to difficulty with donor site healing, and poor vascularity of the graft bed can cause grafting failure [5]. Hospitalization, particularly the bed rest that is necessary after surgery, can contribute to disorientation, aspiration, ileus, and myocardial infarction. Finally, the goals of early excision and grafting of burn wounds require careful interpretation when applied to elderly patients. Many of these patients have relatively restricted life-styles that do not require great mechanical strength or dexterity. A healed burn wound that would leave an unacceptable scar or cause unacceptable impairment to a young person may be no more than a slight nuisance in an elderly patient. Similarly, a wound that requires 2 months to heal would be catastrophic if permitted to disable a young worker, but might again be acceptable in someone who is less active and who can restrict daily living to include meticulous burn wound care. For all of these reasons, we have adopted the policy of selective conservative therapy for the elderly burn patient. This study demonstrates that a policy of early mobilization and discharge and vigorous outpatient follow-up can be successful in a subgroup of elderly burn victims. Hospital stay was reduced in these patients, complications were minimized, and acceptable functional results were obtained. Wounds took a relatively long time to heal, but the fact that 90 percent of patients returned to their normal lifestyles bespeaks the success of this treatment. Which patients should be selected for a particular form of therapy, however, is not always clear. To begin with, many elderly patients die from relatively minor thermal injuries, a fact that is clearly apparent in national statistics [I ,2]. For elderly patients with massive burns, death is essentially certain, and a nonaggressive approach emphasizing sedation and pain control is warranted. These patients are reported separately here, since their inclusion under “conservative” management would prejudice our results in a misleading way. In addition, the operative and conservative groups are not strictly comparable. Surgical patients were younger and generally in better health, but some patients, even though quite
volume148,Decombr 1984
debilitated, were treated surgically because the burn wounds were not amendable to conservative management. The first criteria in selecting patients for conservative therapy, therefore, is the presence of a wound that can be permitted to heal primarily, even if this means a prolonged healing time or some degree of functional or cosmetic impairment. In addition to the size and type of wound, careful analysis of the support systems available to these patients is an essential part of the decision-making process. The ability to follow such patients in an outpatient setting is mandatory for achieving acceptable physical therapy, good nutrition, and acceptable wound healing. On occasion, outpatient management is facilitated by short-term admission to a nursing care facility, followed by eventual discharge home. The management of elderly burn patients remains challenging and controversial. As a result of this study, however, we believe that not all patients must be committed to aggressive therapy. The selective use of conservative treatment remains an acceptable alternative that can salvage such patients and return them to a functional life-style. Summary A retrospective analysis of 55 elderly patients (more than 60 years of age) was undertaken to compare results of conservative management to standard operative treatment. Thirty-one percent of the patients died early from their injury. Twenty-three patients were treated without operation, with emphasis on careful outpatient wound care and physical therapy. The remaining 15 patients required excision and grafting of burn wounds or amputation. Conservatively managed patients had fewer complications, a shorter hospital stay, and functional results equal to the operative group. These results suggest that many elderly burn patients can be managed without operation with good outcome and lessened morbidity. References 1. Feller I, TholenD, CornellRG. Improvementsin bum care, 1965 to 1979. JAMA 1980;244:2074-8. 2. CurreriP, LuterrnanA, Braun0, ShiresGT. Bum lnjuwanalysls of survivalandhospitalization time for 937 patients.Ann Surg 1980;192:472-8. 3. WerdenqSaffleJ,KravitrM.A~~technkluetorexcieion and graftingof burnwounds.J Trauma 1982;22:98-103. 4. Deitch E, ClothierJ. Burnsin the elderly:an early surgicalappreach. J Trauma 1983:23:891-4. 5. GllchrestB. Age-aswciated changesIn the skin. J Am Gerlatr Sot 1982;30:139-43.
Dlscussion MacDonald Wood (Phoenix, AZ): The authors have demonstrated the morbidity of a thermal burn in the elderly patient. By comparison, at the Maricopa Medical
819
liouslnger et al
Center Burn Unit in Phoenix, we have admitted 540 burn patienta, with a mortality of 4.6 percent over the past 3 years. Sixty-three patients were older than 60 years, with a threefold increase in mortality rate. Two thirds of our burn patients older than the age of 30 years died. With a burn surface area greater than 30 percent, the mortality rate was 50 percent. The average hospital stay was 20 days, with the majority leaving the hospital in less than 3 weeks. The average total burn surface area was 14 percent. Five patients had autografts. These patients had a larger total burn surface area and a slightly longer hospital stay. There was only one death. This low mortality rate probably reflects our conservative selection of patients for grafting. Our patients died from inhalation injury and of pulmonary or cardiovascular complications and had an average burn surface area of 35 percent. In addition to the deaths, the complications were primarily pulmonary, with hypertension, heart failure, myocardial infarction, psychoses, and burn wound infection adding to the care problems. Of great concern is the cause of the burn. In two thirds
820
of our patients, the burns were due to flame. Drinking and smoking were associated with some. We have a mobile, elderly population in the Phoenix area with campers, trailers, mobile homes, and vans. Many of the fires occurred in these quarters and were due to faulty propane connections and misuse of gasoline. We are working with fire departments to try to provide better education on the care of the mobile living area and to initiate improved inspection. Dr. Housinger, what has been the experience in Salt Lake City? I commend you and your co-workers on an excellent report. I also concur with the conservative approach. Terry A. Housinger (closing): We are involved with some education processes to help the elderly patient recognize the dangers associated with such things as smoking in bed and smoking while drinking. Other than that, we do not have any elderly education program at the present time.
ma
harkm
Journal 04 Suwry