Experiences with the exposure method in the management of burns in a developing tropical country

Burns,

5, 105-l

06

Printed

in Great

1 Ofi

Britain

Experiences with the exposure method in the management of burns in a developing tropical country J. T. Fernando Burns and Plastic

Surgery

Unit, General

INTRODUCTtON SRI Lanka, with an area of about 22 000 square miles and a population of 14 million, has an incidence of over 10 000 burn injuries every year. Situated between 6” and 9” above the Equator, the temperature in the coastal regions varies between 80 “F and 90 “F. Humidity ranges between 60 per cent and 90 per cent. The humidity and temperature studies were made from Mason’s wet and dry bulb thermometer. Encouraged by the work of Wallace (1951), Barr et al. (1968), and of Sorenson and Thomsen (1968), the author employed the exposure method in the management of burns in 2 district hospitals in 2 different coastal towns between 1964 and 1970, and later from 1975 onwards in a burns unit in the General Hospital in Colombo, which is also on the western coast. PATIENTS AND METHODS AND RESULTS Between 1964 and 1967, of 436 patients seen, 268 (61 per cent) were subjected to the exposure method. These were the patients seen within the first 48 h after burns. The wound was cleaned thoroughly with chlorhexidine cetrimide (1 in 30), and then with sterile saline, and the patient was left exposed to the air in the open ward under a mosquito net. All patients were given systemic broad spectrum antibiotics for the first week, which was later altered according to culture reports. In the coastal town where these patients were treated the average temperature in the shade was 83 “F and the humidity ranged between 62 per cent and 90 per cent. Eschar formation took 6 days on average.

Hospital,

Colombo,

Sri Lanka

However, when the humidity was low (65 per cent) during the dry months of the year, eschar formation occurred in 3 days. During the monsoons, when it was moist and the humidity close to 90 per cent, eschar formation took as long as 8 days. Out of 268 patients treated, 182 (67 per cent)--41 per cent of the total number-were cured within 20 days. The balance, 86 patients, exhibited different degrees of wound infection resulting in the delay in wound healing. There were 20 deaths among these (9.2 per cent). The causes of death were septicaemia, renal failure and bronchopneumonia. Between January 1968 and October 1970 the author took over the surgical duties in a district hospital in another coastal town in a drier area. The temperature here was 88 “F and the humidity ranged between 60 per cent and 75 per cent. Out of 225 patients, 166 (73.7 per cent) were subjected to exposure. The same methods used in the earlier institution were adopted. Eschar formation there occurred within l-4 days, the average being 2 days. The number of patients cured within 20 days was 130 (78 per cent), which was 57.7 per cent of the total. Encouraged by the results of the exposure method in the two district hospitals and by the fact that results were better in the warm and dry environment, it was decided to adopt the exposure method, with modifications, in the burns unit in Colombo, which is the first bums unit in Sri Lanka. One such modification was the use of topical chemoprophylaxis combined with exposure, when there was evidence of gross infection. The other was to blow a stream of warm air over the patient to reduce the humidity to

106

Burns

Vol. ~/NO.

1

60 per cent when the atmospheric humidity was every burn surface tends to get contaminated with over 85 per cent. The average temperature in the different types of organism in the environColombo is around 85 “F and the humidity ment, the chief among these being Pseudomonas varies between 62 per cent and 90 per cent. The pyocyanea, Escherichia colt’, proteus and staphylohumidity was lowest and stood at 62 per cent coccus. However, a burn surface can still conat 3 p.m. and highest being in the range of 86 tinue to recover and manifest the healing proper cent at 6 a.m. During rainy weather, the cessin spite of such contamination, if satisfactory humidity at 6 a.m. went up to 90 per cent. conditions are provided to minimize bacterial Although the General Hospital, Colombo, proliferation. It was our clinical impression that admits over 400 patients every year, only those bacterial proliferation was considerably reduced patients with extensive burns (over 10 per cent when the air around the patient was warm and burns), or where the face or hands were in- dry. Systemic antibiotics also contributed to convolved, were sent to the burns unit for treatment. trol of bacterial proliferation. Between September 1975 and December 1976, 304 such patients were sent to the burns unit. CONCLUSION Exposure without topical chemoprophylaxis was The exposure method was adopted in the early employed when the patients were seen within 5 1960s more by force of circumstances, owing to days of the injury. There were 76 patients in this lack of material resources, as Sri Lanka is a degroup, being 25 per cent of the total. Sixty-two veloping country. Seeing the results of Barr et al. (81 per cent) were cured in 20 days. (1968), it was realized that this was a safe method, When patients were seen later than 5 days after in addition to being a convenient and cheap one. injury, the burn wound was invariably infected, However, the lowest humidity recorded in our and topical chemoprophylaxis of one form or serieswas 62 per cent and the highest temperaanother was necessary to control infection. Ex- ture was 88 “F. In our experience, reasonably posure, combined with 0.5 per cent silver nitrate good results can be expected from the exposure dressings, was used when the burn was over 5 method if it is adopted within 5 days of the injury, days old and clinically partial thickness. Such even though it is used in an open ward with no burns were invariably infected. The method of sterile air or facilities for the isolation of the silver nitrate dressings adopted was the applica- patient. Topical chemoprophylaxis is required tion of two layers of gauze impregnated with the when the patients come late for treatment and lotion. Usually this was sufficient to overcome the there is gross infection. infection and dry the surface of the burn. Eightytwo patients (27 per cent) were thus treated; 69 (84 per cent) were cured in 20 days. When the burn was over 5 days old and full thickness, or if it REFERENCES involved pyo-prone areas (thigh and buttocks), Barr P. O., Birke G., Liljedahl S.-O. et al. (1968) Oxygen consumption and water loss during treatexposure was combined with Sulfamylon cream meni of burns with warm dry air. Lancer 1, 164. (mafenide). Ninety-eight (32.3 per cent) were Sorensen B. and Thomsen M. (1968) The Burns Unit thus treated, and 63 (65 per cent) were cured in 20 in Copenhagen, I. Principlesof treatment. &and. days. J. Plast. Reconstr. Surg. 2, 3. Wallace A. B. (1951) Exposure treatment of burns. DISCUSSION Lancet 1, 501. In our analysis of the results of the exposure method, no attempt is made to analyse and compare the rate of wound infection. It is felt that