今日の臨床サポート

重症熱傷

著者: 大高俊一 国際医療福祉大学成田病院 救急科

監修: 志賀隆 国際医療福祉大学 医学部救急医学/国際医療福祉大学病院 救急医療部

著者校正/監修レビュー済:2021/10/27
患者向け説明資料

概要・推奨   

  1. 初期輸液には晶質液(乳酸リンゲルなど)を使用することが勧められる(推奨度1)。
  1. ABLSでは輸液過剰による浮腫によって、臓器血流障害を来すなどの理由により、24時間の初期輸液量は、4ml×kg×%TBSAより2ml×kg ×%TBSAとする初期輸液量を推奨している(推奨度1)。
  1. 輸液量は尿量を指標として調節を行い、0.5ml/kg/時以上を目標とすることが推奨される(推奨度1)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
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。
※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、実際の保険適用の査定において保険適用及び保険適用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用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:
大高俊一 : 未申告[2021年]
監修:志賀隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 熱傷診療ガイドライン改訂第3版(2021年7月)の発行に伴い改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 重症熱傷とは、あらゆる熱源が原因となり、皮膚および皮下の組織を変性させ損傷させるものである。
  1. 小児・成人女性は家庭内での受傷が多く、成人男性は屋外・仕事中に受傷することが多い。重症熱傷の原因としては火炎・火災によるものが多い。自殺目的・虐待の事例も報告がある。
  1. 重症熱傷では、熱傷創を含めた組織の血管透過性亢進により循環血液量の減少、末梢血管抵抗の上昇、心拍出量低下により熱傷ショックに至る。
問診・診察のポイント  
  1. 熱傷は外傷の一種であり、基本はJATECと同様の手順で進める。Airway Maintenance with Cervical Spine Protection(A)、Breathing and Ventilation(B)、Circulation and Cardiac Status(C)、Disability, Neurological Deficit and Gross Deformity(D)、Exposure and Environmental control(E)の順で行う[1]
  1. A・B:気道確保・酸素投与を行う。気道熱傷の合併を考慮する。顔面の熱傷がある場合、嗄声やストライダーに注意する[2]。気管支鏡も検討する[3]。頚椎保護を行う。
  1. C:血圧・心拍数を確認し輸液路を確保する。非熱傷部位の皮膚色調を確認する。

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文献 

著者: Dilip D Madnani, Natalie P Steele, Egbert de Vries
雑誌名: 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  Ear Nose Throat J. 2006 Apr;85(4):278-80.
著者: American Burn Association
雑誌名: J Am Coll Surg. 2003 Feb;196(2):307-12.
Abstract/Text
PMID 12632576  J Am Coll Surg. 2003 Feb;196(2):307-12.
著者: J R Saffle, B Davis, P Williams
雑誌名: J Burn Care Rehabil. 1995 May-Jun;16(3 Pt 1):219-32; discussion 288-9.
Abstract/Text This article reports outcomes of 6417 patients treated during 1991-1993 in 28 burn centers. Data were gathered by use of the ABA's computerized patient registry. Mean burn size was 14.1% total body surface area. There were 6087 survivors (95.9%); mortality rate among patients with inhalation injury was 29.4%. A probit analysis was used to construct a series of survival curves; the LA50 (which is defined as the burn size lethal to 50% of patients) for young adults was 81% total body surface area. Mean length of hospital stay was 13.5 days. Total mean charges were $39,533, with resource utilization related to clinical comorbidity factors and length of stay. No reliable method could be found to predict survival on admission. Mean charges for the most intensive diagnosis-related group (No. 472) exceeded $198,000 per patient. Pooled data and related summary statistics used in this study have some limitations, which are discussed. Additional accurate information regarding the outcomes of thermal injury treatment is needed by the burn care community.

PMID 7673300  J Burn Care Rehabil. 1995 May-Jun;16(3 Pt 1):219-32; di・・・
著者: G E O'Keefe, J L Hunt, G F Purdue
雑誌名: J Am Coll Surg. 2001 Feb;192(2):153-60.
Abstract/Text BACKGROUND: The primary objective of this study was to determine an objective method for estimating the risk of mortality after burn trauma, and secondarily, to evaluate the relationship between gender and mortality, in the setting of a quantifiable inflammatory stimulus. Previously reported estimates of mortality risk after burn trauma may no longer be applicable, given the overall reduction in case-fatality rates after burn trauma. We expect that future advances in burn trauma research will require careful and ongoing quantification of mortality risk factors to measure the importance of newly identified factors and to determine the impact of new therapies. Conflicting clinical reports regarding the impact of gender on survival after sepsis and critical illness may in part, be from different study designs, patient samples, or failure to adequately control for additional factors contributing to the development ofsepsis and mortality.
STUDY DESIGN: Data from the prospectively maintained burn registry for patients admitted to the Parkland Memorial Hospital burn unit between January 1, 1989 and December 31, 1998 were analyzed. Logistic regression was used to generate estimates of the probability of death in half of the study sample, and this model was validated on the second half of the sample. Risk factors evaluated for their relationship with mortality were: age, inhalation injury, burn size, body mass (weight), preexisting medical conditions, nonburn injuries, and gender.
RESULTS: Of 4,927 patients, 5.3% died. The best model for estimating mortality included the percent of total body surface area burned; the percent of full-thickness burn size; the presence of an inhalation injury; age categories of: < 30 years, 30 to 59 years, > or = 60 years; and gender. The risk of death was approximately two-fold higher in women aged 30 to 59 years compared with men of the same age.
CONCLUSIONS: We have provided a detailed method for estimating the risk of mortality after burn trauma, based on a large, contemporary cohort of patients. These estimates were validated on a second sample and proved to predict mortality accurately. We have identified an increased mortality risk in women of 30 to 59 years of age.

PMID 11220714  J Am Coll Surg. 2001 Feb;192(2):153-60.
著者: Z Aziz, S F Abu, N J Chong
雑誌名: Burns. 2012 May;38(3):307-18. doi: 10.1016/j.burns.2011.09.020. Epub 2011 Oct 24.
Abstract/Text Silver preparations are commonly used for burns, but evidence of their effectiveness remains poorly defined. The aim of the study was to evaluate the effectiveness of silver-containing dressings and topical silver for preventing infection and promoting healing in burns wounds through a meta-analysis of the available evidence. The Cochrane Central Register of Controlled Trials and relevant databases were searched. Drug companies and experts in this field were also contacted. Randomised controlled trials (RCTs) of silver dressings or topical silver (used with dressings) compared with non-silver dressings were eligible for inclusion. We identified 14 RCTs involving 877 participants. One small trial of a silver-containing dressing showed significantly better healing time compared to the control [MD -3.6; 95% CI -4.94 to -2.26 for partial thickness burns and MD -3.9; 95% CI -4.54 to -3.26 for superficial burns]. Topical silver showed significantly worse healing time compared to the non-silver group [WMD 3.96; 95% CI 2.41-5.51] and showed no evidence of effectiveness in preventing wounds infection [WMD 2.48; 95% CI 0.39-15.73]. Our review suggests that silver-containing dressings and topical silver were either no better or worse than control dressings in preventing wound infection and promoting healing of burn wounds.

Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.
PMID 22030441  Burns. 2012 May;38(3):307-18. doi: 10.1016/j.burns.2011・・・
著者: A O Ugburo, O A Atoyebi, J O Oyeneyin, G O A Sowemimo
雑誌名: Burns. 2004 Feb;30(1):43-8.
Abstract/Text A prospective study was carried out on 61 patients to evaluate the role of systemic antibiotic prophylaxis in the control of burn wound infection. The patients were randomised into three groups: group 1 (n=21) received ampicillin and cloxacillin; group 2 (n=20) received erythromycin and genticin and a control group (n=20) received no systemic chemo prophylaxis. The burn wounds were similarly managed. Wound colonisation was determined from surface wound swab cultures and wound infection was determined from wound biopsy cultures and histopathology. The colonisation time (days) for the groups was 2.90+/-0.92, 3.15+/-0.77 and 3.05+/-0.83 for groups 1 and 2 and the control, respectively. The commonest organism isolated from contaminated wounds was Staphylococcus aureus. Wound infection was established in 5.70+/-1.70, 5.75+/-1.62 and 5.6+/-1.90 days for group 1, group 2 and the control group, respectively. There was no significant difference between wound infection time of control and group 1 nor was there such difference between the control and group 2 (P>0.05). The commonest organism infecting burn wounds in all the groups was Pseudomonas aeruginosa followed by S. aureus. There was however a significant difference between the treatment groups and the control (P<0.05) with regard to the percentage of infected wounds that grew P. aeruginosa, compared to those that grew S. aureus. It was concluded that systemic antibiotic prophylaxis is of no value in controlling burn wound sepsis, and might even favour the growth of P. aeruginosa in the burn wounds.

PMID 14693085  Burns. 2004 Feb;30(1):43-8.
著者: Tomer Avni, Ariela Levcovich, Dean D Ad-El, Leonard Leibovici, Mical Paul
雑誌名: BMJ. 2010 Feb 15;340:c241. Epub 2010 Feb 15.
Abstract/Text OBJECTIVE: To assess the evidence for prophylactic treatment with systemic antibiotics in burns patients.
DESIGN: Systematic review and meta-analysis of randomised or quasi-randomised controlled trials recruiting burns inpatients that compared antibiotic prophylaxis (systemic, non-absorbable, or topical) with placebo or no treatment.
DATA SOURCES: PubMed, Cochrane Library, LILACS, Embase, conference proceedings, and bibliographies. No language, date, or publication status restrictions were imposed. Review methods Two reviewers independently extracted data. The primary outcome was all cause mortality. Risk or rate ratios with 95% confidence intervals were pooled with a fixed effect model if no heterogeneity was present.
RESULTS: 17 trials were included. Trials that assessed systemic antibiotic prophylaxis given for 4-14 days after admission showed a significant reduction in all cause mortality (risk ratio 0.54, 95% confidence interval 0.34 to 0.87, five trials). The corresponding number needed to treat was 8 (5 to 33), with a control event rate of 26%. Perioperative non-absorbable or topical antibiotics alone did not significantly affect mortality. There was a reduction in pneumonia with systemic prophylaxis and a reduction in wound infections with perioperative prophylaxis. Staphylococcus aureus infection or colonisation was reduced with anti-staphylococcal antibiotics. In three trials, resistance to the antibiotic used for prophylaxis significantly increased (rate ratio 2.84, 1.38 to 5.83). The overall methodological quality of the trials was poor.
CONCLUSIONS: Prophylaxis with systemic antibiotics has a beneficial effect in burns patients, but the methodological quality of the data is weak. As such prophylaxis is currently not recommended for patients with severe burns other than perioperatively, there is a need for randomised controlled trials to assess its use.

PMID 20156911  BMJ. 2010 Feb 15;340:c241. Epub 2010 Feb 15.
著者: C R Baxter, T Shires
雑誌名: Ann N Y Acad Sci. 1968 Aug 14;150(3):874-94.
Abstract/Text
PMID 4973463  Ann N Y Acad Sci. 1968 Aug 14;150(3):874-94.
著者: C R Baxter
雑誌名: 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  Surg Clin North Am. 1978 Dec;58(6):1313-22.
著者: Pablo Perel, Ian Roberts
雑誌名: Cochrane Database Syst Rev. 2012 Jun 13;6:CD000567. doi: 10.1002/14651858.CD000567.pub5. Epub 2012 Jun 13.
Abstract/Text BACKGROUND: Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids.
OBJECTIVES: To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.
SEARCH METHODS: We searched the Cochrane Injuries Group Specialised Register (searched 16 March 2012), Cochrane Central Register of Controlled Trials 2011, issue 3 (The Cochrane Library), MEDLINE (Ovid) 1946 to March 2012, Embase (Ovid) 1980 to March 2012, ISI Web of Science: Science Citation Index Expanded (1970 to March 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to March 2012), PubMed (searched 16 March 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles.
SELECTION CRITERIA: Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials in pregnant women and neonates.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment.
MAIN RESULTS: We identified 74 eligible trials; 66 of these presented mortality data.Colloids compared to crystalloids Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 21 trials compared hydroxyethyl starch with crystalloids, n = 1385 patients. The pooled RR was 1.10 (95% CI 0.91 to 1.32). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65).Colloids in hypertonic crystalloid compared to isotonic crystalloid Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR was 0.91 (95% CI 0.71 to 1.06).
AUTHORS' CONCLUSIONS: There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.

PMID 22696320  Cochrane Database Syst Rev. 2012 Jun 13;6:CD000567. doi・・・
著者: F Bunn, I Roberts, R Tasker, E Akpa
雑誌名: Cochrane Database Syst Rev. 2004;(3):CD002045. doi: 10.1002/14651858.CD002045.pub2.
Abstract/Text BACKGROUND: Hypertonic solutions are considered to have a greater ability to expand blood volume and thus elevate blood pressure and can be administered as a small volume infusion over a short time period. On the other hand, the use of hypertonic solutions for volume replacement may also have important disadvantages.
OBJECTIVES: To determine whether hypertonic crystalloid decreases mortality in patients with hypovolaemia.
SEARCH STRATEGY: We searched MEDLINE, EMBASE, The Cochrane Controlled Trials Register and the specialised register of the Cochrane Injuries Group. We checked reference lists of all articles identified and searched the National Research Register.
SELECTION CRITERIA: Randomised trials comparing hypertonic to isotonic and near isotonic crystalloid in patients with trauma, burns or undergoing surgery.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data and assessed the quality of the trials.
MAIN RESULTS: Fourteen trials with a total of 956 participants are included in the meta-analysis. The pooled relative risk (RR) for death in trauma patients was 0.84 (95% confidence interval [CI] 0.69-1.04); in patients with burns 1.49 (95% CI 0.56-3.95); and in patients undergoing surgery 0.51 (95% CI 0.09, 2.73). In the one trial that gave data on disability using the Glasgow outcome scale, the relative risk for a poor outcome was 1.00 (95% CI 0.82, 1.22).
REVIEWERS' CONCLUSIONS: This review does not give us enough data to be able to say whether hypertonic crystalloid is better than isotonic and near isotonic crystalloid for the resuscitation of patients with trauma, burns, or those undergoing surgery. However, the confidence intervals are wide and do not exclude clinically significant differences. Further trials which clearly state the type and amount of fluid used and that are large enough to detect a clinically important difference are needed.

PMID 15266460  Cochrane Database Syst Rev. 2004;(3):CD002045. doi: 10.・・・
著者: Jennifer Blumetti, John L Hunt, Brett D Arnoldo, Jennifer K Parks, Gary F Purdue
雑誌名: J Burn Care Res. 2008 Jan-Feb;29(1):180-6. doi: 10.1097/BCR.0b013e31815f5a62.
Abstract/Text Controversy has continued regarding the practicality and accuracy of the Parkland burn formula since its introduction over 35 years ago. The best guide for adequacy of resuscitation is urine output (UOP) per hour. A retrospective study of patients resuscitated with the Parkland formula was conducted to determine the accuracy (calculated vs. actual volume) based on UOP. A review of burn resuscitation from a single institution over 15 years was conducted. The Parkland formula was defined as fluid resuscitation of 3.7 to 4.3 ml/kg/% total body surface area (TBSA) burn in the first 24 hours. Adequate resuscitation was defined as UOP of 0.5 to 1.0 ml/kg/hr. Over-resuscitation was defined as UOP > 1.0 ml/kg/hr. Patients were stratified according to UOP. Burns more than 19% TBSA were included. Electrical burns, trauma, and children (<15 years) were excluded. Four hundred and eighty-three patients were reviewed. Forty-three percent (n = 210) received adequate resuscitation. Forty-eight percent (n = 233) received over-resuscitation. The mean fluid in the adequately and over-resuscitated groups was 5.8 and 6.1 ml/kg/%, respectively (P = .188). Mean TBSA and full thickness burns in the adequately and over-resuscitated groups were 38 and 43%, and 19 and 24%, respectively (P < .05). Inhalation injury was present in 12 and 18% (P = .1). Only 14% of adequately resuscitated and 12% of over-resuscitated patients met Parkland formula criteria. The mean Ivy index in the adequately and over-resuscitated groups was 216 and 259 ml/kg (P < .05). There was no significant difference in complication rates (80 vs. 82%) or mortality (14 vs. 17%). The actual burn resuscitation infrequently met the standard set forth by the Parkland formula. Patients commonly received fluid volumes higher than predicted by the Parkland formula. Emphasis should be placed not on calculated formula volumes, as these should represent the initial resuscitation volume only, but instead on parameters used to guide resuscitation. The Parkland formula only represents a resuscitation "starting" point. The UOP is the important parameter.

PMID 18182919  J Burn Care Res. 2008 Jan-Feb;29(1):180-6. doi: 10.1097・・・
著者: Dennis P Orgill, Nelson Piccolo
雑誌名: J Burn Care Res. 2009 Sep-Oct;30(5):759-68. doi: 10.1097/BCR.0b013e3181b47cd3.
Abstract/Text Experienced clinicians treating burns recognize the need for escharotomy and decompressive therapies. The burning process causes the integument to become stiff, and the underlying tissues can swell during the fluid resuscitation process. We reviewed the literature that supports the current clinical practice of decompressive therapies following burn injury.

PMID 19692906  J Burn Care Res. 2009 Sep-Oct;30(5):759-68. doi: 10.109・・・
著者: E A Deitch
雑誌名: Burns Incl Therm Inj. 1985 Dec;12(2):109-14.
Abstract/Text Early excision and grafting of the burn wound appears to shorten the hospital stay and decrease mortality in children and adults. However, whether an early surgical approach is safe in elderly burn patients has not been resolved. To answer this question we carried out a prospective study of early surgery in 114 consecutive patients over the age of 50 years. Patients were generally operated on between post-burn days 2 and 5. The mean age of the patients was 68 years, with a burn size of 22 per cent, of which 13 per cent was full thickness skin loss. The mean hospital stay of the surviving patients was reduced by 40 per cent compared to national averages (P less than 0.001). The mortality rate for the entire group of patients was 17 per cent, with 2 deaths in the 65 patients with burns less than 20 per cent total body surface area (TBSA). Although the mortality rate for patients with burns greater than 20 per cent TBSA was 35 per cent, this was less than predicted (P less than 0.05). The improvement in survival appeared to be due to a decrease in the incidence of lethal burn wound infections.

PMID 3912029  Burns Incl Therm Inj. 1985 Dec;12(2):109-14.

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