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BURN PATIENTS MANAGEMENT IN DISASTER SITUATIONS

Advances in trauma and burn management over the past three decades have resulted in improved
survival and reduced morbidity from major burns. Improved results in survival are due to advancements
in resuscitation, operative techniques, infection control, and nutritional/metabolic support. A burn injury
implies damage or destruction of skin and/or its contents by thermal, chemical, electrical, or radiation
energies or combinations thereof. Thermal injuries are by far the most common and frequently present
with concomitant inhalation injuries. A chemical burn is a special type of burn injury, caused by a
chemical agent, which can be acids alkalis and organic compound ( like phenol, white phosphor,
napalm, mustard gas). Most acids produce a coagulation necrosis by denaturing proteins, and form a
coagulum (eg, eschar) that limits the penetration of the acid. On the other side, bases typically produce
more severe injuries known as liquefaction necrosis. This involves denaturing of proteins as well as
saponification of fats, not limiting tissue penetration. Electrical burns can be classified into categories,
and any combination of these categories may be present on an electrical burn victim: A burn produced
by contact with a power source of 500 volts or less is classified as a low-voltage burn. High voltage burn
is very severe as the victim makes direct contact with the high voltage supply and the damage runs its
course throughout the body. Exterior injuries are misleading as most of the damage occurs underneath
the skin. Arc burn - this type of burn occurs when electrical energy passes from a high-resistance area to
a low-resistance area. No contact is required with an arc burn as the electricity ionizes air particles to
complete the circuit. Flash burns are caused by electrical arcs that pass over the skin. The intense heat
and light of an arc flash can cause severe burns.
Burn treatment we can separated on first aid, general medical aid and surgical management. First aid
implies first removal of burn cause, then removal from closed space, removal off all constrictive things
like jewelry, elevation of extremities , warming on patient. Analgesia is very important part, then
bandage for burns. In general medical aid in the first place is prevention and therapy of the burn shock,
with resuscitation and maintain normal hemodynamic balance, cardiotonic therapy, oxygenation and
control breath functions. Also nutrition and general care of patients and so decubital care are very
important.
Procedures in burn management: first detailed anamnesis, severity determinations, surgical debridement
in aseptic conditions, water cooling on 20-22 C, wound washing, specially at chemical injuries . It is
important to removal devitalized tissue, also antibacterial drugs, antitetanus blisters. Bandage with five
layers of gausses. In first 24-48 hours we use modified brooks formula, there in first 24 hours only
crystaloids (2mL x TT x %TBSA), and in next 24 h coloids ( 0,3-0,5 x kg x %TBSA) and 5% glucosae.
Complete closure of the burned wound in short period with maximal functional and aesthetic results is the
golden principle in burn management. Main problem in burn wound coverage is extensive burn wounds and
insufficient donor sites. Burn wound coverage includes: autotransplants (unmeshed, meshed), homotransplants
(volunteers, cadaveric), hetrotransplants, biological dressing, and epithelial cell culture, synthetic skin.

This is retrospective analysis encompassed 200 patients treated in our Clinic during ten-year period. The

study group included 160 male (80%) and 40 female patients (20%). The youngest patient was 4, the
oldest 94, and average age was 42 years. TBSA was from 0.5 % till 100%. The most common causes
were found to be flame in 42%, then boiling water in 26%, electricity in 10%, and chemical substances
in 7%. The most often localization included lower extremities 20%, hands 16% and upper extremities
15%, which were treated conservatively in 90 (45%), and surgically in 110 (55%) cases.
In eight burned patients, it was impossible to cover electrical burns neither with skin grafts nor with
local flaps due to tissue destruction. Delayed or secondary microvascular flap procedure was
performed to cover those tissue defects. Defects of the whole half of the face were treated with the
free scapular flaps. Latissimus dorsi musculocutaneous flaps were the choice of treatment for lower leg
defects in three cases and free scapular flap in one case. Complications developed in 45 (22.5%) cases.
From total number of patients 6 % died and 94% cured from burn trauma.
The morbidity and mortality rate, the prognosis and treatment outcome proved to be directly
associated with the burned surface area, deepness of the burned skin, the patients age and his/her
general health condition, kind of injury, complications and other factors as well. Due to the growing
number of burn patients, we experienced great difficulties in providing timely diagnosis and prompt
treatment for such patients.

MICROVASCULAR TISSUE TRANSFER IN THE TREATMENT OF BURNS


Microvascular tissue transfer could be used in the phase of covering of the burn wounds, or in the
phase of correction of the postburned sequels. : We operated eight patients with burns by using free
flaps in Military Medical Academy. The treatment of the deep burn wounds implies excision and skin
grafting. If the vital structures are exposed, the burned surfaces should be covered with skin flaps.
In eight burned patients (one patient on head, two on neck, two at forearm, and tree at lower leg)
it was impossible to cover those defects neither with skin grafts nor with local flaps due to tissue
destruction. The tissue defects were covered by using microvascular flaps as a delayed or secondary
procedure. The youngest patient was 18, the oldest 59, and average age was 31,1 years. There were
tree tipes of free flaps : scapular (2), scapular with parascapular (3) and latissimus dorsi (3) flap.
For the defect of the whole half of the face we used free scapular flap, and for the lower leg defects we
used latissimus dorsi musculocutaneous flap in three cases and free scapular flap in one case. For the

defects on forearm we applied latissimus dorsi flap and scapular flap. In two patients with burns of the
face and neck we applied scapular and parascapular flaps. After four corrections of the contracture of
the neck with skin graft, in second patient we applied preexpanded scapular and parascapular flap and
obtain permanent correction of the necks contracture.
For microvascular anastromosis were used end to end (5 artery, 8 vein) and end to side (3 artery and 5
vein) anastomosis. For resipiant arteries were used a. poplitea, a tibialis posterior, a radialis, a facialis,
a carotis externa. At 25 % of cases (2) we needed revision because of venous thrombosis, and there
were doing thrombectomy and reanastomosis.
Our experiences in the treatment of those burned patients indicated the possibility of applying the free
flaps in the early phase of the covering of the exposed deep structures, and in later reconstructive
phase for corrections of postburned sequelas also.