WORK AND QUALITY OF LIFE AFTER BURNS: SMALL BURNS, BIG CONSEQUENCES.

The objective of this study is to assess the quality of life and how to return to work after burns in adults. We conducted a monocentric, observational, prospective and open study in an intensive care burn unit. Patients aged between 18 and 65 years old were enrolled. Quality of life was assessed with Burn Specific Health Scale-Brief (BSHS-B). A total 118 patients were included with one delayed death. There were 55 flame burns. Median age was 39 years, median total burn surface area (TBSA) was 5% and median length of stay was 11 days. After management in the intensive care burn unit, 84 patients were discharged home and 33 to a rehabilitation care department. We sent 117 queries and got 56 answers. Median BSHS-B score ratio was 142/160. The most impacted items were heat sensitivity, body image, treatment regimens and work. Simple abilities were also affected with up to 28% of patients having difficulties with everyday actions such as cleaning oneself. Regarding return to work, 32% of workers lost their full-time job and 18% were downgraded as disabled. The outcome was worse for those patients who had to go to rehabilitation. Our data suggest that even small burns may strongly impact quality of life and limit the ability to return to work. Our results are consistent with previous published studies, which found greater alteration of quality of life with larger TBSA. These results call for care in specialized centers even for limited burns, especially in the case of functional area involvement.

Le but de ce travail est d'évaluer la qualité de vie et le retour au travail après brûlure chez des adultes. Il s'agit d'une étude monocentrique, observationnelle, prospective et ouverte menée dans un CTB auprès de patients de 18 à 65 ans. La qualité de vie a été évaluée en utilisant l'échelle BSHS-B (Burn Specific Health Scale-Brief). Nous avons inclus 118 patients dont 55 brûlés par flamme, 1 d'entre eux est décédé secondairement. En médianes, l'âge était de 39 ans, la surface atteinte de 5 % et la durée de séjour de 11 jours. Après leur hospitalisation en USI, 84 patients sont rentrés chez eux et 33 ont été transférés en SMR. Nous avons reçu 56 réponses aux 117 questionnaires envoyés. Le BSHS-B médian était de 142/160. Les variables les plus impactées étaient la sensibilité à la chaleur, l'image corporelle, les contraintes liées au traitement et le travail. Vingt-huit pour cent des patients étaient gênés pour les actes de la vie courante comme l'hygiène corporelle. En ce qui concerne le travail, 32 % des patients avaient perdu leur emploi et 18 % étaient considérés comme des travailleurs handicapés. Les suites étaient pires chez les patients ayant eu besoin de rééducation. Cette étude suggère que même de petites brûlure peuvent retentir fortement sur la qualité de vie et limiter les capacités de travail, à l'instar d'études précédentes, qui s'intéressaient à des patients atteints sur de plus grandes surfaces. Ceci prouve la nécessité du traitement en CTB de patients même peu atteints, en particulier si une zone fonctionnelle est atteinte.

Estimation of blood loss during adult burn surgery.

INTRODUCTION: Large burns excision and graft can produce major blood loss. The main objective of this study is to evaluate the blood loss in relation with the excision size in square centimeters (cm2) in adults. PATIENTS AND METHODS: We conducted a monocentric, observational, prospective and open study in a burn intensive care unit. Patients aged-over 18 with burn wounds excision and autografting covering at least 5% of total body surface area (TBS) were enrolled. Blood loss was evaluated with Mercuriali formula. RESULTS: 139 procedures were evaluated: median graft size was 1637cm2, median blood loss was 0.8ml/cm2 excised and grafted skin and median total blood loss was 1444ml. 84 procedures (i.e. 60.4%) required transfusion. 66 procedures concerned upper limbs, 75 lower limbs, 17 head and 72 trunk. 126 procedures used tangential excision, 10 used fascia excision and 3 used the two techniques. Patients with comorbidities (ASA score 3 or 4) had more bleeding (p=0.001). CONCLUSION: The results that were obtained, i.e. approximately 0.8ml/cm2 of excised and grafted skin, are similar to those of other published studies, which concerned specific populations such as pediatrics. Determining blood loss in one centre can help physicians to calculate the excisable area without any transfusion. However, blood loss can vary widely between patients and one must consider individual clinical situation to provide safe surgery.

[The pain from burns]. / La douleur du brûlé.

The painful events associated with the treatment of a severe burn can, because of their long-lasting and repetitive characteristics, be one of the most excruciating experiences in clinical practice. Moreover, burn pain has been shown to be detrimental to burn patients. Although nociception and peripheral hyperalgesia are considered the major causes of burn pain, the study of more hypothetical mechanisms like central hyperalgesia and neuropathic pain may lead to a better understanding of burn pain symptoms and to new therapeutic approaches. Continuous pain and intermittent pain due to therapeutic procedures are two distinct components of burn pain. They have to be evaluated and managed separately. Although continuous pain is by far less severe than intermittent pain, the treatment is, in both cases, essentially pharmacological relying basically on opioids. Because of wide intra- and inter-individual variations, protocols will have to leave large possibilities of adaptation for each case, systematic pain evaluation being mandatory to achieve the best risk/benefit ratio. Surprisingly, the dose of medication decreases only slowly with time, a burn often remaining painful for long periods after healing. Non pharmacological treatments are often useful and sometimes indispensable adjuncts; but their rationale and their feasibility depends entirely on previous optimal pharmacological control of burn pain. Several recent studies show that burn pain management is inadequate in most burn centres.

Clinical pharmacokinetics of ciprofloxacin in patients with major burns.

OBJECTIVE: To better master the use of ciprofloxacin (CPF) in burn patients, a clinical study, including pharmacokinetics in serum and urine, was undertaken in a pathophysiologically homogeneous population of major-burn subjects. METHODS: Twelve major-burn patients who were infected with Pseudomonas aeruginosa, enterobacteria and gram-positive cocci, received CPF (600 mg t.i.d.). The mean body surface area affected by third-degree burns was 31.8 +/- 14.5%. Two series of blood samples were drawn after the first and seventh doses; urine was collected during the first infusion. Levels of CPF in serum and urine were measured by means of high-performance liquid chromatography. A non-compartmental method was used for kinetic and graphic analysis of concentration-time pairs. RESULTS: No adverse effects were noted. Trough concentrations measured on day 3 (mean +/- SD) were above the minimum inhibitory concentration (MIC) for the organism responsible for infection; i.e., 2.0 +/- 1.2 microg. ml(-1), and maximum concentrations were high 9. 9 +/- 3.4 microg. ml(-1). An area under the concentration-time curve (AUC)/MIC ratio above 125 SIT(-1) (where SIT is the serum inhibitory titer), which has been strongly correlated with clinical response and time to bacterial eradication, was achieved in 11 patients with a MIC of 0.5 microg. ml(-1). There was a statistically significant difference between C(min) and AUC determined on day 1 and day 3. In contrast to healthy volunteers, CPF clearance rates were notably decreased. CONCLUSION: The pharmacokinetics of CPF was altered in major-burn patients. The recommended dosage regimen for administration of CPF, i.e. 600 mg t.i.d. shows no adverse effects and a good microbiological efficacy.

Randomised comparison of thalidomide versus placebo in toxic epidermal necrolysis.

BACKGROUND: Toxic epidermal necrolysis (TEN) is associated with a 30% death rate. Tumour necrosis factor alpha (TNF-alpha) has been implicated in the pathogenesis of TEN. Thalidomide is a potent inhibitor of TNF-alpha action. We did a double-blind, randomised, placebo-controlled study of thalidomide in TEN. METHODS: The patients received a 5-day course of thalidomide 400 mg daily or placebo. The main endpoint was the progression of skin detachment after day 7. Secondary endpoints were the severity of the disease, evaluated with the simplified acute physiology score (SAPS), and the mortality. TNF-alpha and interleukin 6 were measured. FINDINGS: The study was stopped because there was excess mortality in the thalidomide group--ten of 12 patients died compared with three of ten in the placebo group (Fisher's exact test with Katz's approximation, relative risk=2.78, p=0.03). After adjustment for SAPS, mortality remained significantly higher in the thalidomide group than in the placebo group (exact logistic regression mid-p=0.007; 95% CI for odds ratio 2.7 to infinity). Plasma TNF-alpha concentration was higher in the thalidomide group than the placebo group on day 2, though the difference was not significant (Wilcoxon rank-sum test p=0.07). INTERPRETATION: Even though few patients were included, our data suggest that thalidomide is detrimental in TEN, possibly because of a paradoxical enhancement of TNF-alpha production.

Extensive burns caused by the abusive use of photosensitizing agents.

Psoralens are photosensitizing agents used in dermatology as reinforcements in psoralen ultraviolet A-range therapy. We report observations of 14 young women hospitalized for severe burns caused by abusive use of psoralens. The burns were of superficial and deep second-degree depth and covered more than 76% of the body surface on average. All patients needed fluid resuscitation. Hospital stay was 11 days on average. Healing was obtained without skin grafting in all cases. Among the six patients who responded to the mailed questionnaire, negative effects are now present in all patients as inflammatory peaks. Two patients have esthetic sequelae such as dyschromia and scars. The misuse of photosensitizing agents poses many problems. These accidents are very expensive. The largeness of the burned surface can involve a fatal prognosis. And finally, one can suspect that a much larger portion of the population regularly uses these products without any serious accident. In this case carcinogenesis can be expected.

[Treatment of pain in children burns]. / Traitement de la douleur de l'enfant brûlé.

Burn injury is considered by children as one of the most painful traumas (just after bone factures). Burn pain in children can and must be controlled as well as for adult patients, with almost identical techniques. Continuous pain from injury and intermittent pain caused by therapeutic procedures must be evaluated and treated separately. Due to very high levels of nociception, satisfactory management of procedural pain requires the use of opioid therapy. Non pharmacological methods are meaningless if pharmacological treatment is not optimal.

[Treatment of burns in infants]. / Traitement des brûlures du nourrisson.

Because of the potential severity of their residual deformities, burn injuries in infants justify an early management in specialized centres when they cover more than 5% of body surface and in every case when hands, face, or external genitalia are concerned. Cooling with cold water is the first aid treatment to be performed as early as possible after the injury. The treatment in specialized centres must be both general and surgical. General treatment includes fluid and electrolyte therapy, temperature control, appropriate nutrition and pain suppression. Pain suppression is a major part of the treatment and morphine must be largely used. Surgical treatment starts as soon as the patient arrives in the centre and is eventually performed under general anesthesia: all the burned areas are covered with occlusive dressings. Infections are prevented by systematic cultures and adjusted antibiotic therapy. A vigorous rehabilitation program must be instituted as soon as possible: massages, compressive clothes, splints, physical therapy, plastic surgery. Primary prevention by sustained parental education is important in order to reduce the frequency of burn injuries in infants.

Salvage of extensively burned upper limbs by a pedicled latissimus dorsi flap.

Very deep burns of the arm and elbow lead to soft tissue necrosis and infection with exposure of important structures. Aggressive debridement should be performed as early as possible to cut the vicious circle, and the defect, which may be extensive, should be covered by well-vascularized tissues. The reliability and versatility of the pedicled latissimus dorsi muscle or musculocutaneous flap make it our first choice in the management of this problem. A retrospective study of three patients for whom salvage of the upper limb has been achieved by the use of a pedicled latissimus dorsi flap is presented, illustrating the advantages of this technique.

Pain in burn patients.

While severe pain is a constant component of the burn injury, inadequate pain management has been shown to be detrimental to burn patients. Pain-generating mechanisms in burns include nociception, primary and secondary hyperalgesia and neuropathy. The clinical studies of burn pain characteristics reveal very clear-cut differences between continuous pain and pain due to therapeutic procedures which have to be treated separately. Some of the main features of burn pain are: (1) its long-lasting course, often exceeding healing time, (2) the repetition of highly nociceptive procedures which can lead to severe psychological disturbances if pain control is inappropriate. Pharmaco-therapy with opioids is the mainstay for analgesia in burned patients, but non-pharmacological techniques may be useful adjuncts. Routine pain evaluation is mandatory for efficient and safe analgesia. Special attention must be given to pain in burned children which remains too often underestimated and undertreated. More educational efforts from physicians and nursing staff are necessary to improve pain management in burned patients.

[Previously expanded full-thickness skin grafts. Technical principles. Indications in the repair of sequelae of burns. Apropos of 22 cases]. / Les greffes de peau totale préalablement expansée. Principes techniques. Indications dans la réparation des séquelles de brûlures. A propos de 22 cas.

Burns raise difficult repair problems. Previously expanded full-thickness skin grafts represent a good solution in many situations. Based on their experience of 22 cases, the authors present a review of the various indications for this technique.

Visual analogue thermometer: a valid and useful instrument for measuring pain in burned patients.

This study assessed the psychometric qualities of a new pain rating instrument--the visual analogue thermometer (VAT)--which was developed to measure pain in burned patients. The validity and utility of the VAT was assessed and compared with a conventional numeric (NUM) and adjective pain scale (ADJ) with a group of 103 burned patients and 51 nurses. Analyses of the results support the concurrent and construct validity of the VAT as a pain measure. Furthermore, the VAT gave more sensitive and precise pain measures than the ADJ and/or NUM scales. No major difference between the three scales emerged in the patients' preference. The same was true for the nurses' evaluation except for those who had more clinical experience with the VAT and who tended to prefer this scale for its accuracy and ease of utilization. The VAT appears to be a valid, sensitive and clinically useful tool to measure pain in burned patients. A systematic pain assessment procedure which can be easily implemented in burn care facilities is presented.

[Child victims of house fires in France. Mortality, morbidity, prevention]. / Enfants, victimes d'incendies d'habitations en France. Mortalité, morbidité, prévention.

Children injuries by house fires in France are the cause of a severe mortality (sixty deaths in average each year) and of a morbidity for the survival due to smoke toxicity (oxygen deprivation and inhalation of toxic gases--CO and HCN) and to thermal burns. Epidemiological studies show that young children (0 to 4) are specially concerned by this threat and that the deaths occurred more often in some part of France (Nord-Pas-de-Calais Region). A special strategy for this prevention should be applied in France, the same available in USA, Sweden and UK, including information on the behavior one should have with children: never leave them alone and escape with them as soon as possible out of the smoke. The usefulness of smoke detectors should be confirmed by French administration and recommended to the public, since they have had effective results in other countries.

[Forum on tissue expansion. Expansion of the scalp. Surgical techniques and clinical applications]. / Forum: l'expansion tissulaire. L'expansion du cuir chevelu. Techniques chirurgicales et applications cliniques.

Repair of all forms of alopecia is one of the principal applications of scalp expansion. The authors have inserted 400 expansion prostheses, including 20 in the scalp. The surgical technique, choice of material and various types of flaps are described and illustrated by clinical cases of extensive alopecia.