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Pulmonary injury in children
Burns, 6,6 l-66
61
Printedin Great Britain
Abstracts CLINICALSTUDIES
Assessment
Pulmonary
Conventional pulse echo ultrasound equipment was modified to provide resolution capable of distinguishing the interfaces in burned skin. The identifrcation of these interfaces allowed a quantitative assessment of the depth of a bum. Partial- and full-thickness skin loss bums in two patients were correctly identified, as they almost certainly would have been using the standard pinprick test carried out by a surgeon expert in the treatment of bums. The ultrasound technique is non-invasive and accurate making it highly acceptable for clinical use; but it requires an expert operator. Kalus A. M., Aindow J. and Caulfield M. R. (1979) Application of ultrasound in assessing bum depth. Lancet 1, 188.
injury in children
Basic concepts have evolved from a 15-year experience in the management of 101 children with inhalation injuries. Progression through 3 distinct clinical stages was often noted, i.e. bronchospasm (l-12 h post bum), pulmonary oedema (6-72 h) and bronchopneumonia (after 60 h). Successful outcome appeared to depend upon treatment that conformed to the pathophysiological state present. Pulmonary toilet should be both thorough and aseptic, and tracheotomy should be reserved for true glottic or supraglottic airway obstructions. There should be sharp division of strangulating or suffocating constrictions caused by cervical or thoracic eschars. Ventilators should be used primarily to maintain arterial Pao, above 60 mmHg and to reverse otherwise intractable pulmonary oedema. If corticosteroids are to be given they should be administered as a single intravenous bolus and only for overt bronchospasm. Parenteral antibiotic therapy should be given prophylactically only after sputum smears and cultures have indicated established pneumonia. Stone H. H. (1979)Pulmonary bums in children. J. Pediat. Surg. 14,48. Early laminar excision Clinical observations suggest that topical applications of silver sulphadiazine do not penetrate the large mass of devitalized eschar tissue in concentrations sufficient to prevent bacterial infection becoming established in the deeper levels of the wound. Bactericidal concentrations of silver sulphadiazine only exist in the outer I .5 mm of tissue. Early laminar excision takes advantage of this fact by the stepwise excision of layers of eschar with an electric dermatome. This is performed under general anaesthesia within the first 72 h of burning until the thickness of the devitalized tissue is reduced to less than 1.0 mm. Silver sulphadiazine is then capable of penetrating in bactericidal concentrations down to viable healthy tissue and greatly enhanced control ofbum wound sepsis is achieved. Lloyd J. R. and Hight D. W. (1978) Early laminar excision: improved control of bum wound sepsis by partial dermatome debridement. J. Pediut. Surg. 13, 698.
of burn depth
Colonic obstruction in burns Five out of 529 bum patients showed pseudoobstruction of the colon over a 2-year period. All patients had classic non-painful abdominal distention. Infection was the most common associated problem and may have been the triggering mechanism in these patients. After confnmation of the colonic dilatation on a plain abdominal X-ray, distal obstruction was ruled out by contrast enema. Occasionally. Gastrografm enema seemed to ameliorate the distention. Conservative medical management should be attempted initially. Colonoscopy should be used as soon as possible. Exploratory laparotomy and tube caecostomy are usually adequate when surgical decompression is necessary. Patients who have accompanying small-intestinal distention seemed to tolerate this condition better, possibly due to the decompressing effect of an incompetent ileocaecal valve. ‘Hinge type’ bends, which occur in time at both hepatic and splenic tlexures become obstructing in themselves, and can be a barrier to conservative treatment. Lescher T. J., Teegarden D. K. and Pruitt B. A. (1978) Acute pseudo-obstruction of the colon in thermally injured patients. Dis. Colon Rectum 21, 618. Grafting hand burns Sixty patients with deep, dermal, dorsal hand and finger bums have been treated by tangential excision
61
Printedin Great Britain
Abstracts CLINICALSTUDIES
Assessment
Pulmonary
Conventional pulse echo ultrasound equipment was modified to provide resolution capable of distinguishing the interfaces in burned skin. The identifrcation of these interfaces allowed a quantitative assessment of the depth of a bum. Partial- and full-thickness skin loss bums in two patients were correctly identified, as they almost certainly would have been using the standard pinprick test carried out by a surgeon expert in the treatment of bums. The ultrasound technique is non-invasive and accurate making it highly acceptable for clinical use; but it requires an expert operator. Kalus A. M., Aindow J. and Caulfield M. R. (1979) Application of ultrasound in assessing bum depth. Lancet 1, 188.
injury in children
Basic concepts have evolved from a 15-year experience in the management of 101 children with inhalation injuries. Progression through 3 distinct clinical stages was often noted, i.e. bronchospasm (l-12 h post bum), pulmonary oedema (6-72 h) and bronchopneumonia (after 60 h). Successful outcome appeared to depend upon treatment that conformed to the pathophysiological state present. Pulmonary toilet should be both thorough and aseptic, and tracheotomy should be reserved for true glottic or supraglottic airway obstructions. There should be sharp division of strangulating or suffocating constrictions caused by cervical or thoracic eschars. Ventilators should be used primarily to maintain arterial Pao, above 60 mmHg and to reverse otherwise intractable pulmonary oedema. If corticosteroids are to be given they should be administered as a single intravenous bolus and only for overt bronchospasm. Parenteral antibiotic therapy should be given prophylactically only after sputum smears and cultures have indicated established pneumonia. Stone H. H. (1979)Pulmonary bums in children. J. Pediat. Surg. 14,48. Early laminar excision Clinical observations suggest that topical applications of silver sulphadiazine do not penetrate the large mass of devitalized eschar tissue in concentrations sufficient to prevent bacterial infection becoming established in the deeper levels of the wound. Bactericidal concentrations of silver sulphadiazine only exist in the outer I .5 mm of tissue. Early laminar excision takes advantage of this fact by the stepwise excision of layers of eschar with an electric dermatome. This is performed under general anaesthesia within the first 72 h of burning until the thickness of the devitalized tissue is reduced to less than 1.0 mm. Silver sulphadiazine is then capable of penetrating in bactericidal concentrations down to viable healthy tissue and greatly enhanced control ofbum wound sepsis is achieved. Lloyd J. R. and Hight D. W. (1978) Early laminar excision: improved control of bum wound sepsis by partial dermatome debridement. J. Pediut. Surg. 13, 698.
of burn depth
Colonic obstruction in burns Five out of 529 bum patients showed pseudoobstruction of the colon over a 2-year period. All patients had classic non-painful abdominal distention. Infection was the most common associated problem and may have been the triggering mechanism in these patients. After confnmation of the colonic dilatation on a plain abdominal X-ray, distal obstruction was ruled out by contrast enema. Occasionally. Gastrografm enema seemed to ameliorate the distention. Conservative medical management should be attempted initially. Colonoscopy should be used as soon as possible. Exploratory laparotomy and tube caecostomy are usually adequate when surgical decompression is necessary. Patients who have accompanying small-intestinal distention seemed to tolerate this condition better, possibly due to the decompressing effect of an incompetent ileocaecal valve. ‘Hinge type’ bends, which occur in time at both hepatic and splenic tlexures become obstructing in themselves, and can be a barrier to conservative treatment. Lescher T. J., Teegarden D. K. and Pruitt B. A. (1978) Acute pseudo-obstruction of the colon in thermally injured patients. Dis. Colon Rectum 21, 618. Grafting hand burns Sixty patients with deep, dermal, dorsal hand and finger bums have been treated by tangential excision