The expression of HLA-DR on blood CD14+ monocytes on day 1 (38.15%±15.63%) was significantly lower than the normal (71.25%±10.56%, P<0.01), and then decreased sharply on day 28 (23.31%±14.34%).
On admission, all the patients showed tachycardia (104 - 146 beats/min). The CK-MB increased during day 1 to 3, and then decreased gradually. and the ANP was remarkably abnormal during days 1-7 in all the patients. One patient had a small amount of tricuspid regurgitation as shown by color ultrasonography. The levels of ALT and Tbil were persistently higher than the normal from day 5 to 35. Although there were no significant changes in BUN and Cr during the whole course, persistent hematuria and proteinuria were found from day 1 to 28. The levels of amylase in blood and urine, and blood lipase were significantly increased on day 1 to 5 (Table 3). Weak bowel sound and abdominal distention were found in all the patients on day 1 to 5.
Four of the five patients survived, the other (96% TBSA), who had compound comminuted fracture of the left leg, with exposure of the upper left tibia and moderate inhalation injury, died of septic shock 23 hours after the admission. The pathological results of the lung, heart, and liver of the died patient are shown in Figs. 5-7.
Clinical characteristics of burn-blast combined injury
In patients with burn-blast combined injury, which is caused by thermal energy and shock waves, massive burn could induce a cascade of complications, including stress ulceration, systemic inflammatory reaction, sepsis, and even multiple organ dysfunction syndrome; in addition, shock wave produced by a strong detonation of explosives may cause further injury to the parenchymatous and hollow organs.2-6
Besides skin burns, severe dysfunction of the heart, liver, lungs, pancreas, and coagulation occurs early and lasted for a rather long time in the patients with burn-blast combined injuries. In our patients, hypotension with unknown reasons, showing decreased response to vasoactive drugs, was observed in 2 during the treatment; and assisted ventilation was performed in 3 because of dyspnea and hypoxemia on admission (2) or repeated attacks of dyspnea (1). Dysfunction of the liver developed early after admission and recuperated quite slowly. The pathological results in the dead patient show that the lungs, liver, and heart were all damaged severely after a burn-blast combined injury. In the survived patients, different degrees of pleural effusion were found, and two of them had ascites. In two patients, fibrobronchoscopy revealed mucosal congestion and edema, and chest X-ray demonstrated high density and ground-glass shadows, indicating that the injuries were not only produced by smoke or flame inhalation, but also by blast wave.
In all of our patients, signs of hypercoagulability were found on admission. Plasma protamine paracoagulation test was positive in two patients, who had significant changes of coagulation function. The expression of HLA-DR on CD14+ monocytes was remarkably decreased in all the patients, indicating long-term immunodeficiency. In the dead patient, the expression of HLA-DR on monocytes was only 35.79% on admission, while the normal value should be 71.25%±10.56%.
On account of the complicated pathological conditions involved in burn-blast combined injury, it seemed to be even more important to enhance the stamina of patients to the operative assaults, since there are mutiple injuries to organs and systems. All the derangements should be corrected as much as possible to enable the patients to withstand the surgical interventions.
In this series, the five patients were transferred to our department 77 hours after they had been preliminarily treated in other hospitals. Based on the characteristics of burn-blast combined injury, the following measures were taken immediately.
First of all, we protected and improved the organ functions and treated life-threatening complications immediately. Homeostasis was restored and maintained by correcting severe hypoproteinemia, acid-base imbalance, and electrolyte disturbance. Diffuse intravascular coagulation was prevented by using low molecular weight heparin (5000 U × 2-4 times/d) in patients with positive plasma protamine paracoagulation test and abnormal coagulation state.7 In the patients with a tendency of bleeding, prothrombin complex, fibrinogen, and platelets were used to enhance coagulation capability, then vitamin K1 was injected as well. A large dose of ulinastatin (600 000 U × 4 times/d) was used to suppress inflammatory response and the effects of leaked pancreatic enzymes.8 Cardiac tonics, including lanatoside C and 1, 6-phosphofructose, were used to improve the heart function, while reduced glutathione and glucuronlactone, etc., were used to protect the liver function. H2-receptor blocking agents and proton pump inhibitors were used to inhibit gastric acid secretion to prevent stress ulcer. Two of our patients with respiratory failure received protective assisted ventilation to reduce ventilation-associated lung injury, with the inspiratory pressure controlled at 30-35 cmH2O, tidal volume 6-8 ml/kg, and PEEP <15 cmH2O, a permissible hypercapnia was maintained as well.8 Since the patients had blast injury and inhalation injury, fibrobronchoscopy was performed to identify the extent of inhalation injury, and frequent tracheobronchial toilet and moistening of the airway by nebulization were used to prevent lung infection.
Early removal of burn eschar and closure of the burn wound were then carried out as soon as possible to prevent serious complications and aggravated organ dysfunctions subsequent to blast injury. 7,9 Escharectomy followed by mixed allogeneic and autologous micro-skin grafting was performed on the extremities or other parts of the body at 12 to 16 hours after admission. The mean extent of each excision was 55%±8% of TBSA. During and after the operation, the vital signs of the patients were relatively stable, and the main risk factor of pathophysiological changes in the later stages of burn injury were eliminated laying a foundation for the correction of existing morbid condition.
After the operations, antibiotics and immunotherapy were used to prevent and treat infections and sepsis. In our series, the persistent low level of HLA-DR expression on CD14+ monocytes suggested immunodeficiency, implicating a high risk of infection and sepsis.9-11 Special attentions should be given to such conditions, and full range immunotherapy, including immunoglobulin, panaxan, and thymic peptide, must be administered to the patients. Considering the immunosuppression in the patients, broad-spectrum antibiotics were used for the prophylaxis and control of infection before we obtained the results of culture of patients' excretion or blood, and then the doses of the antibiotics were adjusted timely according to the results of bacterial culture and the sensitivity tests. Prophylaxis of fungus infection was also important, especially in the patients with long-term use of antibiotics. In addition, Swan-Ganz catheter, indwelling venous lines, or urethral catheters should be retained as short as possible to reduce the incidence of iatrogenic infections.12-14
Nutritional support and regulation of metabolism are also very important for the patients. The body's response to burn injury is characterized by extensive changes in metabolism. Metabolic responses, including increased basal metabolic rate, nitrogen metabolism, and proteolysis,15-17 lead to increased energy expenditure and futile substrate cycling, resulting in depletion of nutritional and functional fat and protein stores, ending in a breakdown of functional structural proteins and organ dysfunctions.18-20 Therefore, nutritional surveillance and sufficient supplementation are imperative for accelerating patients' rehabilitation and reducing incidence of complications. In our patients, cardio-respiratory diagnostic system (Medical Graphics Co., USA) was used to monitor the resting energy expenditures, which is helpful for modulating required amount for each patient to meet his daily caloric requirements. In the early stage (within 7 days after injury), parenteral nutritional supply plays a key role in providing adequate nutrients for the patients; 7-10 days after injury, enteral feeding gradually becomes the main route to supply nutrients. However, a duodenal feeding tube should be inserted immediately on admission for enteral feeding. Moreover, fluid nutrients (Fresubin, 1.5 Kcal/ml) should be introduced to the patients continuously with a micro-pump to assure that they can tolerate the feeding, and recombinant human growth hormone (0.2 IU/kg/d) can be used to accelerate protein synthesis and wound healing in the late stage. Blood sugar level must be strictly controlled within 5-8 mmol/L by giving insulin intravenously via a micro-pump.21-24
Constant evaluation of patient's condition is necessary for modification of therapy. The morbid condition of patients with severe burn-blast combined injury maybe insidious because of the existence of blast injury. Obvious symptoms and signs might not be found till severe complications appeared. Thus, constant evaluation may help to detect the changes of patients' condition timely, so that appropriate alterations in the therapeutic measures can be taken immediately.25-27
Since the condition of the patients with burn-blast combined injuries is more complicated than that in burned patients, consultation of medical experts of different disciplines may contribute to correct diagnosis and perfection of treatment strategy.
Finally, we would like to stress the importance of psychotherapy for mental depression in the patients with massive burns, who have to face the intractable symptoms, and a long-drawn course of recovery.28-31 Therefore, psychotherapy, including brief psychological counseling and musicotherapy, should be carried out soon after admission. It is often helpful to give reassurance that suffering could diminish on its own, particularly if the patient has no premorbid history of depression or anxiety. In addition, drugs, such as oryzanol, may also be necessary to help patients sleep.
In conclusion, burn-blast combined injury may cause multiple organ dysfunctions, especially coagulopathy. Proper judgment of patients' condition, energetic anticoagulant treatment, early closure of burn wounds, rational use of antibiotics, nutritional support, intensive insulin treatment, timely and effective support and protection of organ functions are the most important contributory factors in successful treatment of burn-blast combined injuries
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Keywords:© 2007 Chinese Medical Association
burn-blast combined injury; treatment