今日の臨床サポート

熱傷

著者: 大塚正樹 中東遠総合医療センター皮膚科・皮膚腫瘍科

監修: 戸倉新樹 掛川市・袋井市病院企業団立 中東遠総合医療センター 参与/浜松医科大学 名誉教授

著者校正/監修レビュー済:2022/07/20
参考ガイドライン:
  1. 日本皮膚科学会:熱傷診療ガイドライン第2版
  1. 日本熱傷学会:熱傷診療ガイドライン第3版
患者向け説明資料

概要・推奨   

  1. 熱傷深度の推定方法として、臨床症状による分類を推奨する(推奨度2)
  1. 熱傷面積の推定方法として、9の法則、5の法則およびLund & Brodwerの法則、手掌法がある(推奨度2)
  1. 熱傷の重症度判定のツールとして、Artzの基準を用いることを推奨する(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
大塚正樹 : 特に申告事項無し[2022年]
監修:戸倉新樹 : 講演料(マルホ,サノフィ,協和キリン),原稿料(医学書院)[2022年]

改訂のポイント:
  1. 定期レビューを行い、引用文献の追加に伴い内容のupdateを行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 熱傷は熱による外傷であり、軽症例を含めると日常診療的によく遭遇するありふれた疾患である。
  1. 重症であれば組織障害は皮膚にとどまらず、全身の臓器に及び、生命に重篤な影響を及ぼすため、局所治療だけでは救命できないことも多い。
  1. 厚生労働省人口動態調査では2021年熱傷による年間死亡者数は10万人あたり0.8人で、減少傾向にある。
  1. 重症熱傷は、急性期、感染期、回復期に分けられ、病期に応じた治療が必要となる。
  1. 輸液療法、呼吸管理、栄養管理などの全身療法、外用療法や手術療法などの局所療法、リハビリテーションや精神管理も重要である。
問診・診察のポイント  
  1. 熱傷の深度を臨床所見から推定する
 
 
  1. 熱傷の面積を9の法則、5の法則、Lund & Browderの法則から推定する。

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文献 

D Heimbach, L Engrav, B Grube, J Marvin
Burn depth: a review.
World J Surg. 1992 Jan-Feb;16(1):10-5.
Abstract/Text Despite the plethora of technologic advances, the most common technique for diagnosing burn depth remains the clinical assessment of an experienced burn surgeon. It is clear that this assessment is accurate for very deep and very shallow burns. But since clinical judgment is not precise in telling whether a dermal burn will heal in 3 weeks, efforts to develop a burn depth indicator are certainly warranted to accurately determine which dermal burns to excise and graft. This review summarizes the considerable literature in which a variety of techniques to determine burn depth have been used.

PMID 1290249
A B WALLACE
The exposure treatment of burns.
Lancet. 1951 Mar 3;1(6653):501-4.
Abstract/Text
PMID 14805109
T G BLOCKER
Local and general treatment of acute extensive burns. The open-air régime.
Lancet. 1951 Mar 3;1(6653):498-501.
Abstract/Text
PMID 14805108
R J Perry, C A Moore, B D Morgan, D L Plummer
Determining the approximate area of a burn: an inconsistency investigated and re-evaluated.
BMJ. 1996 May 25;312(7042):1338.
Abstract/Text
PMID 8646048
T R Nagel, J E Schunk
Using the hand to estimate the surface area of a burn in children.
Pediatr Emerg Care. 1997 Aug;13(4):254-5.
Abstract/Text OBJECTIVE: Estimation of the surface area involved is vital to evaluation and treatment of burns. Common teaching suggests the palm approximates 1% of the total body surface area (TBSA). However, early century literature suggests the palmar surface of the entire hand approximates 1% of the TBSA. We sought to determine whether the palm or the entire palmar surface of the hand approximates 1% TBSA in children.
DESIGN: A prospective, convenience sample.
MATERIALS AND METHODS: Using height, weight, and standard nomograms, body surface area was determined. A photocopy of the hand was used to determine the surface area of the palm and the entire palmar surface of the hand.
RESULTS: In 91 children, the mean percent of the TBSA represented by the entire palmar surface was 0.94% (95% confidence interval (C.I.) 0.93-0.97), and the mean percent of the TBSA represented by the palm was 0.52% (95% C.I. 0.51-0.53).
CONCLUSION: The entire palmar surface of a child's hand more closely approximates 1% TBSA, while the palm approximate 0.5% TBSA.

PMID 9291511
Dilip D Madnani, Natalie P Steele, Egbert de Vries
Factors that predict the need for intubation in patients with smoke inhalation injury.
Ear Nose Throat J. 2006 Apr;85(4):278-80.
Abstract/Text Early identification of smoke inhalation patients who will require intubation is crucial. We conducted a retrospective chart review to identify predictors of respiratory distress in patients who present with smoke inhalation injury. Our study involved 41 patients who had been treated in the emergency room at a regional burn center. Eight of these patients required intubation. Intubation was positively correlated with physical examination findings of soot in the oral cavity (p < 0.001), facial burns (p = 0.025), and body burns (p = 0.025). The need for intubation was also predicted by fiberoptic laryngoscopic findings of edema of either the true vocal folds (p < 0.001) or the false vocal folds (p < 0.01). No statistically significant correlation was found between intubation and any of the classic symptoms of smoke inhalation: stridor, hoarseness, drooling, and dysphagia (all p = 1.0). Also, multivariate analysis revealed that facial burns correlated significantly with edema of the true vocal folds (p = 0.01) and body burns correlated significantly with edema of both the true (p = 0.047) and false (p = 0.003) vocal folds. We conclude that patients with soot in the oral cavity, facial burns, and/or body burns should be monitored closely because these findings indicate a higher likelihood of laryngeal edema and the need for intubation.

PMID 16696366
American Burn Association
Inhalation injury: diagnosis.
J Am Coll Surg. 2003 Feb;196(2):307-12.
Abstract/Text
PMID 12632576
B Venus, T Matsuda, J B Copiozo, M Mathru
Prophylactic intubation and continuous positive airway pressure in the management of inhalation injury in burn victims.
Crit Care Med. 1981 Jul;9(7):519-23.
Abstract/Text Burn mortality statistics are influenced by age and degree of total surface body burn. The addition of an inhalation injury to a cutaneous burn results in a significant increase in mortality rate. Nine hundred fourteen patients with acute thermal injury were screened for positive history of burn in a closed space, facial or oropharyngeal burn, singed nasal vibrisae, carbonacious sputum, and clinical signs of upper airway involvement. On admission, 84 patients (9.2%) had more than one of the previously mentioned factors. They were prophylactically intubated and placed on optimum level of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV). The mortality rate among patients without inhalation injury was 7.1%, while 54.7% of patients with inhalation injury died. Comparison of burn patients with inhalation injury to those without pulmonary involvement at the same age group and with the same percentage of burn showed significantly higher mortality rate in patients with inhalation injury. The main cause of death in the first 72 h postburn (stage 1) in patients without inhalation injury was peripheral shock (10.1%) and in patients with inhalation injury was peripheral shock (15.2%) and cardiac failure (10.8%). No pulmonary related death occurred in this stage. In 3-10 days postburn period (stage 2), burn wound sepsis (10.1%) and cardiac failure (11.8%) were the major causes of death in patients with inhalation injury. In patients with inhalation injury, pulmonary sepsis (26%) was the major cause of death in this stage. Major causes of death after 10 days postburn (stage 3) in patients without inhalation injury were pulmonary sepsis (20%) and burn wound sepsis (22%). In patients with inhalation injury, burn wound sepsis (21.7%) was the main cause of death. These data suggest that prophylactic intubation and CPAP therapy in burn patients with suspected inhalation injury prevent pulmonary related death in early stage of burn. Irrespective of presence of inhalation injury, sepsis originating from the wound or respiratory tract is the main cause of death in the late stage of burn.

PMID 7016441
Shawn Moshrefi, Clifford C Sheckter, Kimberly Shepard, Clifford Pereira, Drew J Davis, Yvonne Karanas, Danielle H Rochlin
Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury.
J Burn Care Res. 2019 Apr 26;40(3):341-346. doi: 10.1093/jbcr/irz016.
Abstract/Text The decision to intubate acute burn patients is often based on the presence of classic clinical exam findings. However, these findings may have poor correlation with airway injury and result in unnecessary intubation. We investigated flexible fiberoptic laryngoscopy (FFL) as a means to diagnose upper airway thermal and inhalation injury and guide airway management. A retrospective chart review of all burn patients who underwent FFL from 2013 to 2017 was performed. Their charts were reviewed to determine the indications for FFL including the historical data and physical exam findings that indicated airway injury as well as patient age, TBSA, type and depth of burn injury, carboxyhemoglobin level, and clinical course. Fifty-one patients underwent FFL, with an average TBSA of 6.5% (range 0.5-38.0%) and carboxyhemoglobin level of 3.5%. Burn mechanism was flame (35.3%) or flash (51.0%), with 50% occurring in enclosed spaces. In all cases, the decision to perform FFL was based on physical exam findings meeting criteria for intubation, including facial burns, singed nasal hairs, nasal soot, voice change, throat pain or abnormal sensation, shortness of breath, carbonaceous sputum, wheezing, or stridor. Based on FFL, 9 patients (17.7%) were treated with steroids, 28 patients (54.9%) received supportive care, and 6 patients (11.8%) had repeat FFL for monitoring. One patient was intubated after repeat FFL examination. All patients who underwent FFL met traditional criteria for intubation based on exam, however 98% were monitored without issues based on FFL findings. FFL is a valuable tool that can lead to fewer intubations in acute burn patients with a stable respiratory status for whom history and physical exam suggest upper airway injury.

© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
PMID 31222272
Kazuki Matsumura, Ryo Yamamoto, Tomohiro Kamagata, Tomohiro Kurihara, Kazuhiko Sekine, Kiyotsugu Takuma, Kenichi Kase, Junichi Sasaki
A novel scale for predicting delayed intubation in patients with inhalation injury.
Burns. 2020 Aug;46(5):1201-1207. doi: 10.1016/j.burns.2019.12.017. Epub 2020 Jan 22.
Abstract/Text BACKGROUND: Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score.
METHODS: We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries.
RESULTS: Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems.
CONCLUSIONS: We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.

Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.
PMID 31982185
R H J Baker, M A Akhavani, N Jallali
Resuscitation of thermal injuries in the United Kingdom and Ireland.
J Plast Reconstr Aesthet Surg. 2007;60(6):682-5. doi: 10.1016/j.bjps.2006.09.003. Epub 2007 Feb 7.
Abstract/Text The purpose of this study was to examine the consistency of burns resuscitation practice throughout UK and Ireland. Twenty-six Burns Units were identified via the National Burn Bed Bureau and surveyed via a postal questionnaire. Twenty-three units returned a completed questionnaire, covering all of the units treating children and 17 out of 20 units that treat adults. Nearly all of the Burns Units commence fluid resuscitation at 10% total body surface area of burn in children and 15% total body surface area of burn in adults. The estimated resuscitation volume is calculated using the Parkland or the Muir and Barclay formula in 76% and 11% of units, respectively. The most commonly used resuscitation fluid is Hartmann's solution. No unit uses blood as a first line fluid. Resuscitation is discontinued after 24h in 35% of units and after 36 h in 30% of units. Approximately half of the units do not routinely change the type of intravenous fluid administered after the initial period of resuscitation. This survey illustrates that resuscitation of thermally injured patients in UK and Ireland Burns Units is fairly consistent with a shift towards crystalloid resuscitation.

PMID 17485059
Tam N Pham, Leopoldo C Cancio, Nicole S Gibran, American Burn Association
American Burn Association practice guidelines burn shock resuscitation.
J Burn Care Res. 2008 Jan-Feb;29(1):257-66. doi: 10.1097/BCR.0b013e31815f3876.
Abstract/Text
PMID 18182930
Bishara S Atiyeh, S William Gunn, Shady N Hayek
State of the art in burn treatment.
World J Surg. 2005 Feb;29(2):131-48. doi: 10.1007/s00268-004-1082-2.
Abstract/Text Optimal treatment of burn victims requires deep understanding of the profound pathophysiological changes occurring locally and systemically after injury. Accurate estimation of burn size and depth, as well as early resuscitation, is essential. Good burn care includes also cleansing, debridement, and prevention of sepsis. Wound healing, is of major importance to the survival and clinical outcome of burn patients. An ideal therapy would not only promote rapid healing but would also act as an antiscarring therapy. The present article is a literature review of the most up-to-date modalities applied to burn treatment without overlooking the numerous controversies that still persist.

PMID 15654666
G D Warden
Burn shock resuscitation.
World J Surg. 1992 Jan-Feb;16(1):16-23.
Abstract/Text The goal of fluid resuscitation in the burn patient is maintenance of vital organ function at the least immediate or delayed physiological cost. To optimize fluid resuscitation in severely burned patients, the amount of fluid should be just enough to maintain vital organ function without producing iatrogenic pathological changes. The composition of the resuscitation fluid in the first 24 hours postburn probably makes very little difference; however, it should be individualized to the particular patient. The utilization of the advantages of hypertonic, crystalloid, and colloid solutions at various times postburn will minimize the amount of edema formation. The rate of administration of resuscitation fluids should be that necessary to maintain satisfactory organ function, with maintenance of hourly urine outputs of 30 cc to 50 cc in adults and 1-2 cc/kg/% burn in children. When a child reaches 30 kg to 50 kg in weight, the urine output should be maintained at the adult level. With our current knowledge of the massive fluid shifts and vascular changes that occur, mortality related to burn-induced hypovolemia has decreased considerably. The failure rate for adequate initial volume restoration is less than 5% even for patients with burns of more than 85% of the total body surface area. These improved statistics, however, are derived from experience in burn centers, where there is substantial knowledge of the pathophysiology of burn injury. Inadequate volume replacement in major burns is, unfortunately, common when clinicians lack sufficient knowledge in this area.

PMID 1290260
W W Monafo
Initial management of burns.
N Engl J Med. 1996 Nov 21;335(21):1581-6. doi: 10.1056/NEJM199611213352108.
Abstract/Text
PMID 8900093
George Kramer, Steve Hoskins, Nick Copper, Jiin-Yu Chen, Michelle Hazel, Charles Mitchell
Emerging advances in burn resuscitation.
J Trauma. 2007 Jun;62(6 Suppl):S71-2. doi: 10.1097/TA.0b013e318065aedf.
Abstract/Text
PMID 17556988
C R Baxter, T Shires
Physiological response to crystalloid resuscitation of severe burns.
Ann N Y Acad Sci. 1968 Aug 14;150(3):874-94.
Abstract/Text
PMID 4973463
C R Baxter
Problems and complications of burn shock resuscitation.
Surg Clin North Am. 1978 Dec;58(6):1313-22.
Abstract/Text The problems and complications of the fluid resuscitation phase of the treatment of major thermal burns are many and varied. Emphasis has been placed on the most important organ system responses commonly observed in the first week after injury. The efficacy of treatment and the lack of available treatment are outlined. The mechanical complications occurring from poorly selected and monitored fluid administration sites, complications of monitoring, problems of constrictive edema (usually in the extremities), airway problems, respiratory care, and innumerable other technical aspects were purposely omitted. While these problems and complications are extremely important and occur commonly in our experience, they are in the realm of technical performance of good emergency and intensive care medicine and their optimal management does not affect the problems and complications of the residual organ systems.

PMID 734611
C Holm, M Mayr, J Tegeler, F Hörbrand, G Henckel von Donnersmarck, W Mühlbauer, U J Pfeiffer
A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation.
Burns. 2004 Dec;30(8):798-807. doi: 10.1016/j.burns.2004.06.016.
Abstract/Text BACKGROUND: Ever since Charles Baxter's recommendations the standard regime for burn shock resuscitation remains crystalloid infusion at a rate of 4 ml/kg/% burn in the first 24h following the thermal injury. A growing number of studies on invasive monitoring in burn shock, however, have raised a debate regarding the adequacy of this regime. The purpose of this prospective, randomised study was to compare goal-directed therapy guided by invasive monitoring with standard care (Baxter formula) in patients with burn shock.
PATIENTS AND METHODS: Fifty consecutive patients with burns involving more than 20% body surface area were randomly assigned to one of two treatment groups. The control group was resuscitated according to the Baxter formula (4 ml/kg BW/% BSA burn), the thermodilution (TDD) group was treated according to a volumetric preload endpoint (intrathoracic blood volume) obtained by invasive haemodynamic monitoring.
RESULTS: The baseline characteristics of the two treatment groups were similar. Fluid administration in the initial 24h after burn was significantly higher in the TDD treatment group than in the control group (P = 0.0001). The results of haemodynamic monitoring showed no significant difference in preload or cardiac output parameters. Signs of significant intravasal hypovolemia as indicated by subnormal values of intrathoracic and total blood volumes were present in both treatment groups. Mortality and morbidity were independent on randomisation.
CONCLUSION: Burn shock resuscitation due to the Baxter formula leads to significant hypovolemia during the first 48 h following burn. Haemodynamic monitoring results in more aggressive therapeutic strategies and is associated with a significant increase in fluid administration. Increased crystalloid infusion does not improve preload or cardiac output parameters. This may be due to the fact that a pure crystalloid resuscitation is incapable of restoring cardiac preload during the period of burn shock.

PMID 15555792
Jason Wasiak, Heather Cleland, Fiona Campbell
Dressings for superficial and partial thickness burns.
Cochrane Database Syst Rev. 2008 Oct 8;(4):CD002106. doi: 10.1002/14651858.CD002106.pub3. Epub 2008 Oct 8.
Abstract/Text BACKGROUND: An acute burn wound is a complex and evolving injury. Extensive burns produce, in addition to local tissue damage, systemic consequences. Treatment of partial thickness burn wounds is directed towards promoting healing, and a wide variety of dressings is currently available. Improvements in technology and advances in understanding of wound healing have driven the development of new dressings. Dressing selection should be based on their effects of healing, but ease of application and removal, dressing change requirements, cost and patient comfort should also be considered.
OBJECTIVES: To assess the effects of burn wound dressings for superficial and partial thickness burns.
SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (Searched 29/5/08); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 2 2008; Ovid MEDLINE - 1950 to May Week 3 2008; Ovid EMBASE - 1980 to 2008 Week 21 and Ovid CINAHL - 1982 to May Week 4 2008.
SELECTION CRITERIA: All randomised controlled trials (RCTs) that evaluated the effects of burn wound dressings for superficial and partial thickness burns.
DATA COLLECTION AND ANALYSIS: Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion.
MAIN RESULTS: A total of 26 RCTs are included in this review and most were methodologically poor. A number of dressings appear to have some benefit over other products in the management of superficial and partial thickness burns. This benefit relates to time to wound healing, the number of dressing changes and the level of pain experienced. The use of biosynthetic dressings is associated with a decrease in time to healing and reduction in pain during dressing changes. The use of silver sulphadiazine (SSD) as a comparator on burn wounds for the full duration of treatment needs to be reconsidered, as a number of studies showed delays in time to wound healing and increased number of dressing applications in patients treated with SSD dressings.
AUTHORS' CONCLUSIONS: There is a paucity of high quality RCTs on dressings for superficial and partial thickness burn injury. The studies summarised in this review evaluated a variety of interventions, comparators and clinical endpoints. Despite some potentially positive findings, the evidence, which largely derives from trials with methodological shortcomings, is of limited usefulness in aiding clinicians in choosing suitable treatments.

PMID 18843629
Saruta Wattanaploy, Kusuma Chinaroonchai, Nantaporn Namviriyachote, Pornprom Muangman
Randomized Controlled Trial of Polyhexanide/Betaine Gel Versus Silver Sulfadiazine for Partial-Thickness Burn Treatment.
Int J Low Extrem Wounds. 2017 Mar;16(1):45-50. doi: 10.1177/1534734617690949. Epub 2017 Feb 1.
Abstract/Text Silver sulfadiazine is commonly used in the treatment of partial-thickness burns, but it sometimes forms pseudo-eschar and delays wound healing. Polyhexanide/betaine gel, a new wound cleansing and moisturizing product, has some advantages in removing biofilm and promotes wound healing. This study was designed to compare clinical efficacy of polyhexanide/betaine gel with silver sulfadiazine in partial-thickness burn treatment. From September 2013 to May 2015, 46 adult patients with partial-thickness burn ≥10% total body surface area that were admitted to the Burn Unit of Siriraj Hospital within 48 hours after injury were randomly allocated into 2 groups. One group was treated with polyhexanide/betaine gel, and the other group was treated with silver sulfadiazine. Both groups received daily dressing changes and the same standard care given to patients with burns in this center. Healing times in the polyhexanide/betaine gel group and silver sulfadiazine group were 17.8 ± 2.2 days and 18.8 ± 2.1 days, respectively ( P value .13). There were no significant differences in healing times, infection rates, bacterial colonization rates, and treatment cost in both groups. The pain score of the polyhexanide/betaine gel group was significantly less than the silver sulfadiazine group at 4 to 9 days after treatment ( P < .001). The satisfactory assessment result of the polyhexanide/betaine gel group was better than that in the silver sulfadiazine group. These data indicate the need for adequately designed studies to elicit the full potential of polyhexanide gel as a wound dressing for partial-thickness burn wounds.

PMID 28682677
Sadanori Akita, Kozo Akino, Toshifumi Imaizumi, Akiyoshi Hirano
Basic fibroblast growth factor accelerates and improves second-degree burn wound healing.
Wound Repair Regen. 2008 Sep-Oct;16(5):635-41. doi: 10.1111/j.1524-475X.2008.00414.x.
Abstract/Text Second-degree burns are sometimes a concern for shortening patient suffering time as well as the therapeutic choice. Thus, adult second-degree burn patients (average 57.8 +/- 13.9 years old), mainly with deep dermal burns, were included. Patients receiving topical basic fibroblast growth factor (bFGF) or no bFGF were compared for clinical scar extent, passive scar hardness and elasticity using a Cutometer, direct scar hardness using a durometer, and moisture analysis of the stratum corneum at 1 year after complete wound healing. There was significantly faster wound healing with bFGF, as early as 2.2 +/- 0.9 days from the burn injury, compared with non-bFGF use (12.0 +/- 2.2 vs. 15.0 +/- 2.7 days, p<0.01). Clinical evaluation of Vancouver scale scores showed significant differences between bFGF-treated and non-bFGF-treated scars (p<0.01). Both maximal scar extension and the ratio of scar retraction to maximal scar extension, elasticity, by Cutometer were significantly greater in bFGF-treated scars than non-bFGF-treated scars (0.23 +/- 0.10 vs. 0.14 +/- 0.06 mm, 0.59 +/- 0.20 vs. 0.49 +/- 0.15 mm: scar extension, scar elasticity, bFGF vs. non-bFGF, p<0.01). The durometer reading was significantly lower in bFGF-treated scars than in non-bFGF-treated scars (16.2 +/- 3.8 vs. 29.3 +/- 5.1, p<0.01). Transepidermal water loss, water content, and corneal thickness were significantly less in bFGF-treated than in non-bFGF-treated scars (p<0.01).

PMID 19128258
S P Pegg, K Ramsay, L Meldrum, M Laundy
Clinical comparison of maphenide and silver sulphadiazine.
Scand J Plast Reconstr Surg. 1979;13(1):95-101.
Abstract/Text A series of 645 consecutive burn injuries are analysed. There were 175 patients in the control group, 156 in the Maphenide (Sulfamylon) group and 314 in the Silver Sulphadiazine (S. S. D.) group. The Maphenide group and S.S.D. group are compared statistically with the control group. S.S.D. proved superior in relation to clinical infection rate and culture rate in reduction of Pseudomonas and Staphylococcus. Other culture rates were analysed. There were significant reductions in both groups for E. coli and Candida albicans. Pneumonias were significantly increased in both groups and the mortality rate reduced with S.S.D. Overall S.S.D. gave better results than Maphenide.

PMID 451487
X Z Li, H Nikaido, K E Williams
Silver-resistant mutants of Escherichia coli display active efflux of Ag+ and are deficient in porins.
J Bacteriol. 1997 Oct;179(19):6127-32.
Abstract/Text Silver-resistant mutants were selected by stepwise exposure of silver-susceptible clinical strains of Escherichia coli, two of which did not contain any plasmids, to either silver nitrate or silver sulfadiazine. These mutants showed complete cross-resistance to both compounds. They showed low-level cross-resistance to cephalosporins and HgCl2 but not to other heavy metals. The Ag-resistant mutants had decreased outer membrane (OM) permeability to cephalosporins, and all five resistant mutants tested were deficient in major porins, either OmpF or OmpF plus OmpC. However, the well-studied OmpF- and/or OmpC-deficient mutants of laboratory strains K-12 and B/r were not resistant to either silver compound. Resistant strains accumulated up to fourfold less (110m)AgNO3 than the parental strains. The treatment of cells with carbonyl cyanide m-chlorophenylhydrazone increased Ag accumulation in Ag-susceptible and -resistant strains, suggesting that even the wild-type Ag-susceptible strains had an endogenous Ag efflux activity, which occurred at higher levels in Ag-resistant mutants. The addition of glucose as an energy source to starved cells activated the efflux of Ag. The results suggest that active efflux, presumably coded by a chromosomal gene(s), may play a major role in silver resistance, which is likely to be enhanced synergistically by decreases in OM permeability.

PMID 9324262
Bishara S Atiyeh, Michel Costagliola, Shady N Hayek, Saad A Dibo
Effect of silver on burn wound infection control and healing: review of the literature.
Burns. 2007 Mar;33(2):139-48. doi: 10.1016/j.burns.2006.06.010. Epub 2006 Nov 29.
Abstract/Text Silver compounds have been exploited for their medicinal properties for centuries. At present, silver is reemerging as a viable treatment option for infections encountered in burns, open wounds, and chronic ulcers. The gold standard in topical burn treatment is silver sulfadiazine (Ag-SD), a useful antibacterial agent for burn wound treatment. Recent findings, however, indicate that the compound delays the wound-healing process and that silver may have serious cytotoxic activity on various host cells. The present review aims at examining all available evidence about effects, often contradictory, of silver on wound infection control and on wound healing trying to determine the practical therapeutic balance between antimicrobial activity and cellular toxicity. The ultimate goal remains the choice of a product with a superior profile of infection control over host cell cytotoxicity.

PMID 17137719
Abstract/Text Topical antibacterial treatment is of major importance in the burn patient. Silver sulfadiazine is an effective agent with low toxicity and few side effects. Deposition of silver in tissues, and absorption of sulfadiazine are both minimal. Present and future problems are represented by the emergence of resistant Gram negative bacilli, including Pseudomonas aeruginosa. The development of related metal sulfadiazines to be used against resistant bacteria is on an investigational stage, and clinical trials are few. Silver sulfadiazine may be used in a variety of other conditions than burns.

PMID 6377481
K Kobayashi, H Ikeda, R Higuchi, M Nozaki, Y Yamamoto, M Urabe, S Shimazaki, A Sugamata, N Aikawa, N Ninomiya, H Sakurai, Y Hamabe, N Yahagi, H Nakazawa
Epidemiological and outcome characteristics of major burns in Tokyo.
Burns. 2005 Jan;31 Suppl 1:S3-S11. doi: 10.1016/j.burns.2004.10.007.
Abstract/Text The Tokyo Burn Unit Association (TBUA) was established in 1983 funded by the Tokyo Metropolitan Government, and is organized by 13 burn units in Tokyo. TBUA covers more than 90% of severe burn patients occurring in Tokyo, and all of the cases are registered according to the burn injury registration format. The purpose of this study is to analyze the registered data and to elucidate epidemiological and outcome characteristics of major burn injuries in Tokyo. The total of 6988 hospitalized patients had data for epidemiological analysis, and 6401 patients had complete data for outcome analysis as well, and were included in this study. The characteristic profiles for the analysis included age, sex, cause of burns, inhalation injury, %BSA, burn index (BI), length of burn unit stay, and outcome, and were analyzed by age groups. The mean age of the patients was 40.4 years, and 63% of them were male. It was noteworthy that 25% of the total patients were elderly patients over 60 years of age. Flame was the most common cause making up 45.6% followed by scalding (32.0%). The overall mortality rate was 15.4%. Inhalation injury was accompanied in 27.3% of burn patients. The mortality rate was 34.6% with inhalation injury, and 8.2% without inhalation injury. Causes of death showed that multiple organ failure made up 36.9% of total mortality, followed by sepsis 25.2 and shock 19.0%. The burn size (%BSA and BI) and inhalation injury were the factors for high mortality rate in all age groups whereas age was a predictor for high mortality in the patients older than 16 years of age. Gender was not a factor for high mortality in any age group. The mortality rate showed mildly decreasing tendency since 1995 for which implementation of skin bank was thought to be responsible.

PMID 15649614
Young Hwan Choi, Young Soon Cho, Jong Ho Lee, Yanghwan Choi, Soo Young Noh, Seungchoon Park, Changmin Sung, Jin Kyu Lim, Jongdae Kim, Jae Jun Shin, Banseok Yang, Jiyun Jeong, Huan Chun, Kwang Jo Kim
Cadaver skin allograft may improve mortality rate for burns involving over 30% of total body surface area: a propensity score analysis of data from four burn centers.
Cell Tissue Bank. 2018 Dec;19(4):645-651. doi: 10.1007/s10561-018-9715-0. Epub 2018 Jul 31.
Abstract/Text Cadaver skin is used for temporary wound covering, but there is insufficient evidence regarding its clinical usefulness in patients with major burns. We aimed to analyze the effect of cadaveric skin allograft on mortality rates in patients with burns involving > 30% of total body surface area (TBSA). Our study included 1282 patients with > 30% of TBSA burned admitted to four hospitals in Korea between June 1, 2008 and December 31, 2016. Of these, 698 patients underwent cadaver skin allograft (cadaver group), and 584 were treated with conventional treatment (non-cadaver group). We corrected the differences between the two groups using propensity score matching, and generated 474 propensity score-matched pairs. Overall 90-day in-hospital mortality rate among all patients was 35.3% (453/1282). There was a significant difference in 90-day in-hospital mortality between the two groups for both unmatched [cadaver vs. conventional, 31.7 vs. 39.7%; difference, 8.0; 95% confidence interval (CI) 2.8-13.3] and propensity-matched groups (37.8 vs. 47.3%; difference, 9.5; 95% CI 3.2-15.8). Logistic regression analyses showed a significant association between cadaver skin allograft and lower 90-day in-hospital mortality in the propensity-matched groups (odds ratio, 0.42; 95% CI 0.29-0.62). Patients with major burns who underwent cadaver skin allograft had a lower mortality rate compared to those who did not. Cadaver skin allograft may improve the survival of patients with major burns, especially in the early phase of injury.

PMID 30066103
Alvin Chua, Colin Song, Andrea Chai, Lennard Chan, Kok Chai Tan
The impact of skin banking and the use of its cadaveric skin allografts for severe burn victims in Singapore.
Burns. 2004 Nov;30(7):696-700. doi: 10.1016/j.burns.2004.03.016.
Abstract/Text The skin banking programme was set-up in Singapore in 1998 to provide a ready source of allografts for patients with severe burns. The process and problems in establishing a local skin bank will be described together with a retrospective review of skin allograft recipients to determine the efficacy of the programme. For the skin bank set-up, pertinent issues related to legislation, methods, logistics, quality assurance and donation rate are discussed. In this retrospective review, a comparison between patients who had early complete excision with skin allograft transplantation and those who received conventional staged excision and coverage, was analysed in terms of clinical profile and outcome using statistical methods. The former group presented a significant reduction of mortality rate and hospital stay by 29% and 10 days, respectively. The establishment of the skin bank has helped in the management of severe burn patients by facilitating early excision and allografting. In a Burn Centre, therefore, it is essential to have an ample supply of skin allograft for burn victims in readiness for mass disaster situations.

PMID 15475145
Hajime Matsumura, Asako Matsushima, Masashi Ueyama, Norio Kumagai
Application of the cultured epidermal autograft "JACE(®") for treatment of severe burns: Results of a 6-year multicenter surveillance in Japan.
Burns. 2016 Jun;42(4):769-76. doi: 10.1016/j.burns.2016.01.019. Epub 2016 Mar 2.
Abstract/Text BACKGROUND: In the 1970s, Green et al. developed a method that involved culturing keratinocyte sheets and used for treatment of burns. Since then, the take rate of cultured epidermal autograft (CEA) onto fascia, granulation tissue, or allografts has been extensively reported, while that on an artificial dermis in a large case series is not. Moreover, the contribution of CEA to patient survival has not been analyzed in a multicenter study.
METHODS: We conducted a 6-year multicenter surveillance on the application of the CEA "JACE(®") for treatment of burns >30% total body surface area (TBSA) across 118 Japanese hospitals. This surveillance included 216 patients and 718 graft sites for efficacy analysis. The CEA take rate at 4 weeks after grafting was evaluated, and safety was monitored until 52 weeks. In addition, the survival curve obtained in this study and the data obtained from the Tokyo Burn Unit Association (TBUA) were compared.
RESULTS: The mean CEA take rates at week 4 were 66% (sites) and 68% (patients), and the rate on the artificial dermis was 65% for 226 sites. CEA application combined with wide split-thickness auto or patch autograft increased the CEA take rate. On comparison with the data obtained from the TBUA, which included data on individuals with burns of the same severity, CEA application was found to contribute to patient survival until 7 weeks after burn.
CONCLUSIONS: We reported the take rate of CEA based on a 6-year multicenter surveillance. From our results, we found that the application of CEA is a useful treatment for the patients with extensive burns.

Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.
PMID 26948957
Curtis J Donskey
The role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens.
Clin Infect Dis. 2004 Jul 15;39(2):219-26. doi: 10.1086/422002. Epub 2004 Jun 25.
Abstract/Text The intestinal tract provides an important reservoir for many nosocomial pathogens, including Enterococcus species, Enterobacteriaciae, Clostridium difficile, and Candida species. These organisms share several common risk factors and often coexist in the intestinal tract. Disruption of normal barriers, such as gastric acidity and the indigenous microflora of the colon, facilitates overgrowth of pathogens. Factors such as fecal incontinence and diarrhea contribute to the subsequent dissemination of pathogens into the health care environment. Selective pressure exerted by antibiotics plays a particularly important role in pathogen colonization, and adverse effects associated with these agents often persist beyond the period of treatment. Infection-control measures that are implemented to control individual pathogens may have a positive or negative impact on efforts to control other pathogens that colonize the intestinal tract.

PMID 15307031
Anantha Padmanabhan, Mark Stern, Judith Wishin, Mari Mangino, Karen Richey, Mary DeSane, Flexi-Seal Clinical Trial Investigators Group
Clinical evaluation of a flexible fecal incontinence management system.
Am J Crit Care. 2007 Jul;16(4):384-93.
Abstract/Text BACKGROUND: Management of fecal incontinence is a priority in acute and critical care to reduce risk of perineal dermatitis and transmission of nosocomial infections.
OBJECTIVE: To evaluate the safety of the Flexi-Seal Fecal Management System in hospitalized patients with diarrhea and incontinence.
METHODS: A prospective, single-arm clinical study with 42 patients from 7 hospitals in the United States was performed. The fecal management system could be used for up to 29 days. The first 11 patients (all from critical care) underwent endoscopic proctoscopy at baseline; 8 of these had endoscopy again after treatment. The remaining 31 patients (from critical or acute care) did not have endoscopy.
RESULTS: Rectal mucosa was healthy after use of the device in all patients who had baseline and follow-up endoscopy. Physicians and nurses reported that the system was easy to insert, remove, and dispose of; its use improved management of fecal incontinence; and it was practical, caregiver- and patient-friendly, time-efficient, and efficacious. Skin condition improved or was maintained in more than 92% of patients. Patients' reports of discomfort, pain, burning, or irritation were uncommon. Adverse events were reported for 11 patients (26%). Death (considered unrelated to study treatment) occurred in 5 patients, 2 patients had generalized skin breakdown, and 1 patient had gastrointestinal bleeding after 4 days of treatment.
CONCLUSIONS: The fecal management system can be used safely in hospitalized patients with diarrhea and fecal incontinence. Additional well-designed, controlled clinical trials may help to measure clinical and economic outcomes associated with the device.

PMID 17595371
Jane Echols, Bruce C Friedman, Robert F Mullins, Zaheed Hassan, Joseph R Shaver, Claus Brandigi, Joan Wilson, Laura Cox
Clinical utility and economic impact of introducing a bowel management system.
J Wound Ostomy Continence Nurs. 2007 Nov-Dec;34(6):664-70. doi: 10.1097/01.WON.0000300279.82262.07.
Abstract/Text PURPOSE: The primary objective of this study was to compare rates of urinary tract and soft tissue infections in critically ill burn patients before and following introduction of a Bowel Management System (BMS). We also analyzed the economic impact of the BMS as compared to reactive management of fecal soiling via cleansing and dressing changes.
METHODS AND MATERIALS: A retrospective case-matched before-after study was completed. Critically ill burn patients using a BMS were matched with similar patients managed before introduction of the device based on gender, total body surface area burned, burn location, ventilation days, and hospital length of stay.
RESULTS: Reductions in hospital-acquired urinary tract infections and skin and soft tissue infections were observed after introduction of the BMS. Despite its initial cost, it proved more cost effective than a reactive bowel management strategy based on cleansing and dressing changes when fecal soiling occurs.
CONCLUSIONS: Proactive use of a bowel management device appears to reduce some infectious sequelae in a complicated burn care population and proved cost-effective for our facility.

PMID 18030107
Anil Keshava, Andrew Renwick, Peter Stewart, Ann Pilley
A nonsurgical means of fecal diversion: the Zassi Bowel Management System.
Dis Colon Rectum. 2007 Jul;50(7):1017-22. doi: 10.1007/s10350-006-0882-x.
Abstract/Text PURPOSE: Patients with perineal burns and immobile hospitalized patients with severe excoriation from incontinence caused by excessive diarrhea pose difficult management problems, frequently requiring stoma formation. The Zassi Bowel Management System (Zassi Medical Evolutions, Fernandina Beach, Florida) multichannel intrarectal catheter was evaluated for its safety and its ability to divert feces away from perineal skin to allow wound and skin healing.
METHODS: A prospective cohort study was conducted on inpatients from the Burns and Geriatric Units. Patients with previous rectal disease were excluded. Perineal skin and wound healing was measured before and after tube insertion by using the perianal disease activity index score. Data regarding patient comfort, wound contamination, dressing changes, bed linen changes, and adverse events were collected. Proctoscopy was performed before and after tube insertion.
RESULTS: Twenty-two tubes were inserted in 20 patients (7 perineal burns, 13 severe perineal excoriations). Mean perianal disease activity index scores reduced from 14 to 6.4 (P<0.0001) after tube insertion. Mean dressing changes reduced from 3.3 to 1.5 times per day (P<0.01), and mean bed linen changes in the incontinent patients reduced from 9.3 to 1.2 times per day (P<0.0001). Mean duration of rectal intubation was 14 days. Proctoscopy after tube removal was normal in all cases. One patient developed a superficial ulcer on the buttock from retention strapping.
CONCLUSIONS: The Zassi Bowel Management System tube allows diversion of feces away from the perineum for wound healing. It is safe, effective, and may help avoid stoma formation.

PMID 17431722
J Bordes, P Goutorbe, Y Asencio, E Meaudre, E Dantzer
A non-surgical device for faecal diversion in the management of perineal burns.
Burns. 2008 Sep;34(6):840-4. doi: 10.1016/j.burns.2007.11.009. Epub 2008 Apr 18.
Abstract/Text BACKGROUND: Burns to the perineal, buttock and upper thigh areas are frequently exposed to continual faecal contamination which results in sepsis, graft loss, delayed wound healing and shrinkage of scars. A temporary diverting colostomy may be required. Two specifically designed intrarectal catheters were evaluated for their safety and ability to divert faeces away from the burn and allow wound healing.
METHODS: A prospective study was conducted involving patients at the burns centre. Either the Zassi Bowel Management System or the Flexi-Seal Fecal Management System were used. These differed only in the presence of a specific intraluminal balloon in the Zassi system to facilitate retention of infused irrigates. Data regarding skin graft success, wound contamination and adverse events were collected.
RESULTS: The study included eight participants, five of whom were treated successfully without colostomy. Four participants experienced complications, comprising one bowel occlusion, one anal ulceration and two reversible cases of anal atony.
CONCLUSION: A specifically designed intrarectal catheter can divert faeces to allow wound healing, and may avert colostomy. More studies are necessary to evaluate safety.

PMID 18395989

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