Background pain in burn patients: routine measurement and recording of pain intensity in a burn unit.

It goes without saying that pain following a burn must be treated but it is not so evident to measure and document the intensity of pain and the efficacy of treatment. Since 1994 the authors have routinely measured background pain, that is, at rest, along with temperature and pulse rate. For analysis and quality assessment a relational database programme is used in the ward. In this paper the authors' experience is reported from a consecutive series of 98 patients with burn injuries who assessed the intensity of pain on a visual analogue scale. There were great intra- and inter-individual variations in pain intensity. Highest values were found during the first week of treatment when female patients experienced pain more intensively than male. For other time periods there was no statistical significant difference between the sexes. Pain intensity and severity of burn was not related except during the second week when patients with major burns had a tendency to express more pain than moderate burns. Measurement of background pain along with other routine registrations is easy and not time-consuming. Patients needing intensified pain treatment can be identified. For research and quality assessment a computerized patient register is of great help.

Rehabilitative, psychiatric, functional and aesthetic problems in patients treated for burn injuries--a preliminary follow-up study.

Patients consecutively treated for burn injuries for four or more days during 1994 were examined one year after admission by a plastic surgeon, a specialist in rehabilitation medicine and a psychiatrist. Of thirty-nine such patients treated, two were dead, 11 did not present and six thought they had no remaining problems. Aesthetic and functional problems were present in 16 patients, in 11 reconstructive surgery given in one or more sessions was judged to have improved the condition. Of eighteen patients referred to a rehabilitation medicine specialist, 14 were assessed. Nine of these had functional impairments in the burn-injured body regions. A majority had functional impairments, persistent decrease in range of upper extremity motion, reduced muscle force, altered sensibility and itch. One patient suffered from pain. Three patients had occupational handicaps. Work disability occurred in two patients and further two were in need of vocational counselling due to the burn injury. In a subgroup of 11 patients four fulfilled criteria for one or more personality disorders, and two of these also suffered from major depression. Quality of life assessed with the SF-36 was lower than in a normal population. Some of the patients had psychiatric disease and personality disorders. Although rehabilitation started early in the acute phase of treatment, rehabilitation medicine function-increasing measures were needed in several cases. Individual rehabilitation programmes based on the patient's particular features and needs are recommended. The findings support the idea of a multidisciplinary approach for patients with burn injury and indicate that a subgroup of burn injury patients have functional impairments and/or disabilities which can probably be improved with reconstructive surgery and rehabilitation.

Impairment of renal function after treatment of a burn patient with diclofenac, a non-steroidal antiinflammatory drug.

Due to pain from infected 12 per cent TBSA flame injuries a 71-year-old female was treated with a non-steroidal antiinflammatory drug (diclofenac), thereby inhibiting the synthesis of prostaglandins, and developed transient impairment of renal function. This case report indicates that prostaglandins may be required to modulate the late responses after burns or other major trauma, especially when infected.

Early excision and skin grafting of selected burns of the face and neck.

Since 1979, 16 patients with facial and neck burns have been treated with excision and skin grafting within the first 4 days of injury. The injuries were tangentially excised and immediately covered with split-thickness skin grafts. Detailed consecutive results are presented. The patients can be divided into three groups. Group 1 consisted of small subdermal or circumscribed deep dermal burns of the face (n = 8). Healing was quick. Some patients developed signs of overgrafting. As a late result, unevenness and discoloration were seen. Group 2 consisted of mixed deep dermal and subdermal burns of the face and neck (n = 5). Usually, minor areas had to be regrafted. Some patients developed hypertrophic scars at border areas. In the completely excised and grafted area, the skin was smooth, pliable, and discolored. Group 3 consisted mostly of subdermal burns of the face and neck (n = 3). The surgical trauma was significant. Small areas had to be regrafted. Ectropion and microstomia developed. It is concluded that in selected cases of deep dermal and subdermal burns, early excision and skin grafting will result in faster healing and less scarring than expectant treatment.

Direct mounting of cultured epidermal grafts. A way to enhance the transplantation area.

Cultured epidermal grafts were prepared in a new way, not allowing the epidermal sheets to shrink before mounting. Using this procedure, the graft area was increased by about 100%. Furthermore, this procedure is also quicker than the conventional technique. The directly mounted grafts take just as well as conventionally prepared grafts and their macroscopical and histological appearances are similar.

Effects of capsaicin pretreatment on the inflammatory response to scalding injury in the rat.

The oedema formation after scalding injury to the rat paw was studied by means of the Evans blue exudation technique. An early and a delayed oedema formation were demonstrated after severe and light scalding, respectively. It was shown that the delayed, but not the early, form was reduced by capsaicin pretreatment, suggesting an involvement of chemosensitive primary sensory neurons in this reaction.

Reinnervation of experimental superficial wounds in rats.

Sensory reinnervation of a superficial skin wound in the rat was studied by labeling sensory axons with anterogradely transported wheat germ agglutinin-horseradish peroxidase. Reinnervation starts after 3 days from the edge of the wound as well as from beneath the wound. About 2 weeks after the production of the wound, some hyperinnervation appears to be present, but after a few additional weeks, the innervation pattern is essentially normal. The results indicate that structural recovery of sensory axons is rapid and probably complete when skin wounds heal with no or minimal scar formation.

Decreased survival of experimental critical flaps in rats after sensory denervation with capsaicin.

The role of capsaicin-sensitive primary sensory neurons on the survival of experimental critical flaps was studied in the rat. Pretreatment with capsaicin, which depletes neuropeptide transmitter content from primary sensory neurons, caused a dramatic decrease in flap survival area compared to normal animals. In contrast, pretreatment with reserpine, which depletes catecholamines from adrenergic neurons, including the sympathetic post-ganglionic fibers, resulted in a significant increase in the survival area. It was concluded that both capsaicin-sensitive primary sensory neurons and sympathetic postganglionic adrenergic neurons play a role in systemic vascular regulation and that intact primary sensory neurons are of importance for the survival of ischemic tissue.

Sensory neuropeptides contribute to oedema formation in experimental burns.

The role of primary sensory neuropeptides in experimental burns was investigated. It was shown that after scalding, substance P-like immunoreactivity is released into the lymphatic fluid of dogs. Substance P, injected intravenously, was shown to cause dose-dependent oedema formation in rat skin, as measured with the Evans blue-technique. Furthermore, capsaicin pretreatment, which depletes the neuropeptide content of primary sensory neurons, was shown to inhibit late oedema formation in rats.

The surgical treatment of acute facial burns.

Over a five-year period selected patients with acute facial burns have been treated with early excision and skin grafting. Guidelines on the experience gained are outlined. On admission a tentative diagnosis of the depth of the burn was made and saline dressings were applied. When the patient was considered to be out of immediate danger the wounds were re-examined under anaesthesia following surgical cleaning. Deep dermal and subdermal burns of the face in patients without potentially fatal injuries were tangentially excised (or were subjected to dermabrasion) and covered with skin grafts within the first three days. Deep dermal and subdermal burns combined with potentially fatal injuries were treated conservatively. Early excision and skin grafting performed under optimum conditions give excellent functional and good aesthetic results.

Sensibility after burn injury.

Thresholds for touch, temperature, pain and two-point discrimination were examined in 27 healthy subjects and in 36 burn patients. Three groups of injuries were examined; superficial dermal burns, which were allowed to heal spontaneously, deep dermal and subdermal burns treated by either early or late excision and skin grafting. Uninjured areas on the contralateral side served as control. In spontaneously healed superficial burns, the sensibility recovered to normal, except for touch. In deep dermal or subdermal burns all thresholds were significantly higher than in the corresponding control areas. There was no recovery beyond one month after the injury. The sensibility was better on the upper than on the lower extremities and also in deep dermal than in subdermal burns. There was no significant difference in sensibility between burns excised and grafted early or late, respectively. The results indicate that current treatment of deep dermal and subdermal burns is not followed by complete recovery of cutaneous sensation. Furthermore, even superficial burns results in incomplete recovery of touch sensibility.

Release of substance-P-like immunoreactivity in dog paw lymph after scalding injury.

The level of substance-P-like immunoreactivity (SPLI) in dog paw lymph was determined before and after scalding injury of the paw. At basal conditions, no SPLI could be detected in the paw lymph. Scalding induced an immediate increase of the SPLI-levels. Within 5-10 min after the scalding injury the levels increased up to 28 fmol ml-1 and then gradually decreased within 30-90 min after the injury. It is suggested that scalding injury results in release of substance P from sensory nerve endings, and that this release may contribute to the inflammatory response to scalding injury and, possibly, also wound healing.

Sensory and autonomic innervation of non-hairy and hairy human skin. An immunohistochemical study.

Non-hairy and hairy human skin were investigated with the use of the indirect immunohistochemical technique employing antisera to different neuronal and non-neuronal structural proteins and neurotransmitter candidates. Fibers immunoreactive to antisera against neurofilaments, neuron-specific enolase, myelin basic protein, protein S-100, substance P, neurokinin A, neuropeptide Y, tyrosine hydroxylase and vasoactive intestinal polypeptide hydroxylase and vasoactive intestinal polypeptide (VIP) were detected in the skin with specific distributional patterns. Neurofilament-, neuron-specific enolase-, myelin basic protein-, protein S-100, neuropeptide Y-, tyrosine hydroxylase- and vasoactive intestinal polypeptide (VIP)-like immunoreactivities were found in or in association with sensory nerves; moreover, neuron-specific enolase-, myelin basic protein-, protein S-100, neuropeptide Y-, tyrosine hydroxylase- and vasoactive intestinal polypeptide (VIP)-like immunoreactivities occurred in or in association with autonomic nerves. It was concluded that antiserum against neurofilaments labels sensory nerve fibers exclusively, whereas neuron-specific enolase-, myelin basic protein- and protein S-100-like immunoreactivities are found in or in association with both sensory and autonomic nerves. Substance P- and neurokinin A-like immunoreactivities were observed only in sensory nerve fibers, and neuropeptide Y- and tyrosine hydroxylase-like immunoreactivities occurred only in autonomic nerve fibers, whereas vasoactive intestinal polypeptide (VIP)-like immunoreactivities was seen predominantly in autonomic nerves, but also in some sensory nerve fibers.

Distribution of neurofilament-immunoreactive nerve fibers in human skin.

Neurofilament immunoreactive nerve fibers were demonstrated in human skin using indirect immunohistochemical technique with antibodies to neurofilament polypeptides. Neurofilament-positive fibers were seen as free nerve endings in the epidermis and in dermal papilla, in Meissner's corpuscles and as fibers crossing in the dermis. Strongly fluorescent nerve fibers were also seen around hair follicles, sweat gland ducts and sometimes in relation to blood vessels. From the distribution pattern it was concluded that predominantly sensory nerve fibers were labelled and that this technique may be used to study reinnervation of cutaneous sensory nerves following traumatic injuries and surgical procedures.

Localization of substance P-immunoreactive nerve fibers in the human digital skin.

Substance P-immunoreactive nerve endings were localized in human digital skin by the use of indirect immunohistochemical technique. It was found that substance P-like immunoreactivity was present in free nerve endings in the dermal papillae and in the epidermis. Some Meissner's corpuscles also contained substance P positive nerve endings. Furthermore, substance P-immunoreactive nerves were localized in close connection to sweat gland ducts and blood vessels. The functional significance of these findings was discussed with regard to pain mediation and inflammatory response.

Burns unit in Stockholm: a report on patients treated 1971--1975 for acute burn injuries.

A review of 297 burn patients treated 1971--1975 is presented to illustrate burn problems in a West European, mainly urban population. Patients were treated by exposure and warm dry air. Tubbing usually started five days after injury. Sequential wound revisions were performed. Surgical excision was usually delayed until days 14--21. Autografting was performed as soon as possible. For temporary cover homografts were frequently used. The majority of the patients were adults. Twelve per cent were older than 65 years. The patients revealed many social problems. Cardiopulmonary disease, mental disorder and alcohol or drug addiction were fairly common. The most common cause of the burn was fire and a majority of the patients sustained injuries in leisure time. 28% were classified as due to accident. 43% were considered diagnosed in 17 patients (5.7%). Five patients died due to septicemia.