114 I THE
Tropical Doctor, July I976
PROBLEM OF BURNS IN CENTRAL AFRICA
The problem of burns in Central Africa J. M.
Auchincloss, MB, ChB, DA G. Frank Grave, MB, BS (Lond.), FRCS (Edin.)
Department of Surgery, Mpilo Central Hospital and United Bulawayo Hospitals (Box 2096, Bulawayo, Rhodesia)
TROPICAL DOCTOR,
1976, 6, 114-117
A burned child is an emergency admission. It is also an admission of failure in preventive medicine. Ninety per cent of our burn admissions in children should be prevented as they are almost all caused by domestic accidents associated with open cooking fires in huts or accidental fires during the dry, winter season. Mpilo Hospital is an Boo-bed hospital complex serving the African population of Western Rhodesia. It provides all necessary specialist services to a population of almost two million people. The surgical services, as described elsewhere (Grave 1972), have been developed along accepted modern guidelines to provide facilities for our many emergency admissions, as well as a growing demand for routine treatment in the surgical field. Burned patients are admitted at an average rate of about 20 per month. Our death rate for burns is 7.3%; this figure is higher than that for head injuries (6%) and almost double the death rate for general surgical admissions for trauma, which is 3.7%) (see Table I).
Table I. Five year survey of surgical in-patients 1970-74 (incl.) and comparative mortality
All Trauma Non-trauma Burns
No. of cases 18,649 12,483 6,166 1,046
No. of deaths 1,031 465 566 76
Mortality rate 0/
5·510 3·7% 9.2% 7·3%
The majority of our burn admissions are infants and children. Since the early 1960s we have concentrated our efforts for their treatment by providing isolation accommodation at Mpilo where special nursing and medical care can be given.
Fig.
I.
Plan of Mpilo Hospital burns isolation unit.
In 1973 this facility was increased by converting a ward kitchen into a ry-bed burn isolation unit (Fig. I). This provides five wards of three beds each, and a dressing and resuscitation room. All rooms are heated by 3 kW hot-air space heaters which maintain the rooms at 75 - 80°F. This ambient temperature is most necessary in the Rhodesian winter as night temperatures drop below freezing at the time when we have our greatest number of burn admissions. Our management of the burn patient is carried out along conventional lines beginning with the original assessment and ending with the completion of any follow-up procedures. ASSESSMENT
In the initial assessment the following data should be recorded not only to initiate correct therapy but also for research programmes or statistical analysis: (i) age of patient, (ii) sex of patient, (iii) aetiology of burn, (iv) depth of burn, (v) area of burn, expressed as percentage of total body surface area (TBSA), (vi) its site, and (vii) date and time of burn. The presence or absence of infection at the initial visit should also be noted for this greatly affects therapy and if present is probably an indication for admission. The depth of the burn is assessed on its appearance and response to pin-prick sensitivity. Epidermal burns are characterized by local erythema only and respond to pin-prick. Superficial dermal and deep dermal burns are characterized by the formation of blisters which, when denuded, reveal a red, oedematous surface with profuse exudate. The response to pin-prick is usually normal but there may be diminished response in deep dermal burns or it may
Tropical Doctor,July I976 be diminished by increasing local oedema. This test therefore is not infallible. Full thickness burns are usually pale, dry, and depressed and may show frank charring and superficial vascular coagulation (this latter appearance is diagnostic of a full thickness burn). Obviously infected burns are easy to recognize; the presence of pus and local cellulitis is unmistakable. Regional lymphadenopathy and systemic disturbances may also be present. The area of the burn is most conveniently estimated in larger burns by the use of standard or modified Berkow charts and tables (Lynch 1973). These tables are unsurpassed for recording the anatomical distribution of burn wound(s). In smaller burns it is helpful to remember that the size of the patient's open palm is roughly equivalent to 1 % TBSA. When our initial assessment and recording is completed, the next question to be asked is "inpatient or out-patient treatment ?".
CRITERIA FOR ADMISSION
Criteria for admission of patients for systemic and/or local care of the burn wound are variable. What is applicable to an adult in an urban Western community is often not applicable to a child from a rural tribal population. Common sense must prevail. The following is a suggested list of criteria for inpatient admission and treatment: all burns exceeding 15% TBSA in adults or 10% in children; 2. all full thickness burns exceeding 2% TBSA; 3. all full thickness burns involving priority areas-hands, face, joint-flexures, and circumferentiallimb burns; 4. all eyelid burns, electrical burns, infected burns and suspected respiratory tract burns. 1.
OUT-PATIENT MANAGEMENT
Out-patient burns are managed on a regime which provides maximum results with a minimum number of out-patient attendances (Auchincloss 1975). Epidermal burns require no treatment apart from pain relief and an eventual application of antiseptic soothing creams. Dressings are unnecessary and if the patient is reassured and given some estimate of recovery time (within 10 days), no follow-up is needed. Superficial.and deep dermal burns are often difficult to distinguish initially but are both treated with the "standard burn dressing". Under aseptic conditions the burnt area is thoroughly cleaned with chlorhexidine/cetrimide solu-
THE PROBLEM OF BURNS IN CENTRAL AFRICA
I 115
tion and all the blistered and raised epidermis is removed using fine, pointed scissors; any fluid exudate is thus freed and any coagulated exudate is gently removed using a moist gauze swab. The burn is dried and reassessed for depth. The standard burn dressing is then applied; it consists of (a) a single layer of Vaseline gauze without any overlap of the gauze pieces, (b) several layers of opened cotton gauze swabs, (c) a conforming cotton bandage wound firmly - but not tightly - in place, to hold the underlying layers while subsequent layers are added, (d) several layers of bulky wool, held in place with (e) a firmly applied crepe bandage to produce a pressure effect on the underlying layers. Such a dressing, if applied correctly, is non-adherent, pain relieving, occlusive, and while exerting pressure also acts as a splint for the injured part. Lower limbs should be rested and elevated and upper limbs should be supported in a sling. This method is difficult to use in burns involving the axillae, groins, perineum, neck and face, and unless such burns are small they should be treated by exposure and usually require admission. Burns to be treated by exposure are cleaned and debrided as above and may also have a covering of silver sulphadiazine cream. Full thickness burns of less than 2% TBSA may be suitable for immediate or delayed excision and grafting. Small burns can be treated by elliptical excision and direct closure of the defect. The standard burn dressing is a suitable cover for full thickness burns prior to delayed excision. Controversy still exists as to the optimal time for excision and grafting; in general it is still true "the earlier the better". Well demarcated, obviously full thickness burns can be excised immediately and grafted if the patient's general condition is suitable. Mixed depth burns are best treated with the standard burn dressing until the partial thickness element is healed (10 - 21 days), and the full thickness element is well defined. Infection must be avoided by aseptic technique. All burn wounds, whether managed as outpatients or in-patients, must receive anti-tetanus prophylaxis since tetanus in burns is almost universally fatal (Lynch 1973). It is our policy to administer a booster dose of toxoid (Tetanol) to previously immunized patients, and ATS plus a course of toxoid to those who are not. In our opinion antibiotics are not initially required for out-patients with clinically uninfected burns. With this standard burn dressing the majority of partial thickness (i.e, superficial dermal and deep dermal) burns will be healed on the first return visit after 10 days. The dressing should not be changed during the
116
I THE PROBLEM OF BURNS IN
Tropical Doctor,July I976
CENTRAL AFRICA
first 10 days unless it becomes wet from without or within or unless symptoms and signs of infection supervene. Changing the dressing not only provides extra work for nursing and medical staff but may introduce infection and almost certainly damages regenerating epithelium. When the dressing becomes wet during the initial 10 days, only the outer crepe bandage and the outer layer of wool should be removed and reapplied with the addition of extra wool layers if the wetting is from within. After 10 days the dressing is removed carefully, layer by layer; if the Vaseline gauze can be removed easily, healing is almost certainly complete and the patient can be discharged without the need for further dressings or follow-up. If delay in healing occurs, general factors such as malnutrition, diabetes, steroid therapy, and malabsorption syndromes must be sought. Infection with pyogenic organisms is a more likely cause; by destroying remaining epithelial elements it may convert a partial burn into a full thickness loss. If the first and second causes for delayed healing can be excluded (the presence- of either of these is probably an indication for admission), the burn wound is either re-dressed with the standard burn dressing for a further 10 days or managed by daily
dressing with silver sulphadiazine cream covered with a light occlusive dressing. In a previous survey (Auchincloss 1975) 90% of patients treated on this regime were healed within 20 days of the initial burning. IN-PATIENT MANAGEMENT
Once the decision to admit a burnt patient has been made, treatment must start immediately. In a severe burn delay can be fatal. The following scheme is useful: (a) evaluation, (b) control of airway, (c) analgesia or sedation, (d) fluid replacement, (e) tetanus prophylaxis, (f) antibiotics, (g) nutritional requirements, (h) physiotherapy, (i) local wound management. The assessment differs in no way from that for out-patients. Evaluation of the patient's condition and classification and recording of burns can be carried out at the same time as therapy is initiated. Establishment and maintenance of an adequate airway is high on the list of priorities especially in burns around the face and neck with possible respiratory tract burns; tracheal intubation, bloodgas analysis, oxygenation, intermittent positive pressure ventilation and steroids may be indicated in severe cases. Tracheotomy - particularly through a burn wound - is meddlesome, dangerous, and not recommended (Blocker et al. 1967). Analgesia or sedation is required for most burnt patients. Morphine sulphate can be given to both adults and children (10 mg for adults, 0.5 mg per year of age to children) and must be given intravenously to ensure complete absorption.We have also used tilidine hydrochloride (Valoron) drops orally in infants with satisfactory results. Fluid replacement therapy is initiated and a programme of fluid and nutritional requirements is calculated using a well-known formula. This replacement should be monitored by attention to urine output (via an indwelling catheter for accuracy), regular Hb and haematocrit estimations and the measurement of central venous pressure (see Fig. 2). Tetanus prophylaxis as described above is started immediately. It is our practice to give penicillin to all burns requiring admission to hospital, in order to Fig. 2. Burns are recorded by area on the simple body supplement tetanus prophylaxis and to eliminate chart which also carries the formula for colloid streptococci from the patient's upper airway. Culture replacement. Volume of fluid to be given in each of the wound surface should be made on admission and repeated regularly thereafter. Antibiotics are • iod Weight in Kg X % area m1s. Perto = reserved for clinical infections and selected in 2 accordance with sensivity tests on the organisms . Weight in kg responsible. Expectedurme output = mls/hour Patients with extensive burns are not allowed any 2
Tropical Doctor, July rrJ7n
oral intake for the first 24 hours to diminish the risk of ileus and acute gastric dilatation so often seen in these patients. Thereafter oral intake is begun cautiously and expanded to provide the required high protein, high calorie diet. Parenteral vitamin supplements are often needed. The importance of physiotherapy is often underestimated. Careful positioning of the patient and daily exercises designed to put burnt limbs through a full range of active or passive movement will speed rehabilitation and may prevent subsequent deformities. In this respect the use of lightweight splints for hands, limb joints, and the neck are of proven benefit. Management of the local burn wound varies from centre to centre but in the Central African climate exposure therapy is particularly suitable; partial thickness burns are all re-epithelialized in about 14 days. Full thickness injuries are grafted on about the twenty-first day. We use the Davis electric dermatome and, where necessary, mesh all grafts for large burn areas using the Zimmer mesh dermatome. In conjunction with the exposure method and for infected late burns (seen more frequently than in Western countries owing to delay in seeking or reaching medical help), we were using 0.5% silver nitrate soaks for local burn care. This is a useful method of treatment but at the time of writing we have adopted the use of silver sulphadiazine cream prepared by our own pharmacy (Drake and Froese 1975) but also manufactured commercially (Flamazine Cream: Smith & Nephew). Its bacteriostatic properties are similar to those of silver nitratebeing particularly useful against Pseudomonas infections - in addition to which (a) nursing is more convenient, (b) it is non-irritant, thus giving it full
THE PROBLEM OF BURNS IN CENTRAL AFRICA
I II7
patient acceptability, and (c) there is no staining of skin or fomites which occurs in the use of silver nitrate. Our clinical impression is that it is superior topical application. It is applied directly to the burn surface with the sterile, gloved hand as a layer 1-2 mm thick and, if needed, can be covered with a light gauze and cotton bandage dressing. All our patients are nursed on polyurethane foam sheeting; this provides a comfortable non-stick surface which is also utilized as a dressing or splint to elevate burned limbs. Prevention of burns is theoretically very attractive but most difficult in a rural population who rely almost entirely on open fires for cooking and heating. Out efforts in this direction are all being made by way of education of women. We have health education officers in the rural areas who visit women's clubs, clinics, and schools. When opportunities arise they stress the dangers to children of accidents in the home involving open fires, hot fluids, and inflammable clothing. This approach will take a very long time to produce tangible results. We hope that these notes will be read by our colleagues in other tropical areas to whom the problem of burned children is a daily challenge. ACKNOWLEDGEMENT
We wish to acknowledge permission of the Secretary for Health of Rhodesia to offer this article for publication. REFERENCES
Auchincloss, J. M. (1975). Brit. J. din. Pract., 29, 251. Blocker, T. G. (1963). Sth med. J., 56, 382. Drake, D. J., and Froese, E. H. (1975). Cent. Afr. J. Med., 21, 71. Grave, G. F. (1972). Ann. roy. Coli. Surg. Engl., 51, 332. Lynch, J. B. (1973). "Thermal Burns" in Plastic Surgery. 2nd ed. Ed. Grabb, W. C. and Smith, J. W. Boston, Mass.: Little, Brown & Co.
Book Review Laboratory Techniques in Brucellosis By G. G. Alton, Lois M. Jones, and D. E. Pietz. (Geneva: World Health Organization, 1975. Monograph Series No. 55, znd edition, pp. I6].)
Brucellosis remains a world problem of both public health and economic importance, and its control depends largely on close collaboration between wellequipped laboratories using standardized methods and medical and veterinary services. Eight years have elapsed since the publication of the first edition of this monograph. In this second edition all the chapters have been revised and brought up to date and new chapters on Brucella ovisand Brucella canis have been added. The chapter on
bacterial methods contains a valuable new section on the precautions to be taken in handling infectious Or potentially infectious materials. The chapter on serological methods has been expanded to include methods for preparing and standardizing antigens, since these methods are widely used in some parts of the world. The use and limitations of allergic tests are fully discussed, together with a description of the nature of the allergens and details of their production and use. The new chapters on Brucella ovis and Brucella canis discuss the diagnostic procedures, both clinical and serological, and describe the methods of isolating and identifying the two organisms.
Tropical Doctor, July I976
PROBLEM OF BURNS IN CENTRAL AFRICA
The problem of burns in Central Africa J. M.
Auchincloss, MB, ChB, DA G. Frank Grave, MB, BS (Lond.), FRCS (Edin.)
Department of Surgery, Mpilo Central Hospital and United Bulawayo Hospitals (Box 2096, Bulawayo, Rhodesia)
TROPICAL DOCTOR,
1976, 6, 114-117
A burned child is an emergency admission. It is also an admission of failure in preventive medicine. Ninety per cent of our burn admissions in children should be prevented as they are almost all caused by domestic accidents associated with open cooking fires in huts or accidental fires during the dry, winter season. Mpilo Hospital is an Boo-bed hospital complex serving the African population of Western Rhodesia. It provides all necessary specialist services to a population of almost two million people. The surgical services, as described elsewhere (Grave 1972), have been developed along accepted modern guidelines to provide facilities for our many emergency admissions, as well as a growing demand for routine treatment in the surgical field. Burned patients are admitted at an average rate of about 20 per month. Our death rate for burns is 7.3%; this figure is higher than that for head injuries (6%) and almost double the death rate for general surgical admissions for trauma, which is 3.7%) (see Table I).
Table I. Five year survey of surgical in-patients 1970-74 (incl.) and comparative mortality
All Trauma Non-trauma Burns
No. of cases 18,649 12,483 6,166 1,046
No. of deaths 1,031 465 566 76
Mortality rate 0/
5·510 3·7% 9.2% 7·3%
The majority of our burn admissions are infants and children. Since the early 1960s we have concentrated our efforts for their treatment by providing isolation accommodation at Mpilo where special nursing and medical care can be given.
Fig.
I.
Plan of Mpilo Hospital burns isolation unit.
In 1973 this facility was increased by converting a ward kitchen into a ry-bed burn isolation unit (Fig. I). This provides five wards of three beds each, and a dressing and resuscitation room. All rooms are heated by 3 kW hot-air space heaters which maintain the rooms at 75 - 80°F. This ambient temperature is most necessary in the Rhodesian winter as night temperatures drop below freezing at the time when we have our greatest number of burn admissions. Our management of the burn patient is carried out along conventional lines beginning with the original assessment and ending with the completion of any follow-up procedures. ASSESSMENT
In the initial assessment the following data should be recorded not only to initiate correct therapy but also for research programmes or statistical analysis: (i) age of patient, (ii) sex of patient, (iii) aetiology of burn, (iv) depth of burn, (v) area of burn, expressed as percentage of total body surface area (TBSA), (vi) its site, and (vii) date and time of burn. The presence or absence of infection at the initial visit should also be noted for this greatly affects therapy and if present is probably an indication for admission. The depth of the burn is assessed on its appearance and response to pin-prick sensitivity. Epidermal burns are characterized by local erythema only and respond to pin-prick. Superficial dermal and deep dermal burns are characterized by the formation of blisters which, when denuded, reveal a red, oedematous surface with profuse exudate. The response to pin-prick is usually normal but there may be diminished response in deep dermal burns or it may
Tropical Doctor,July I976 be diminished by increasing local oedema. This test therefore is not infallible. Full thickness burns are usually pale, dry, and depressed and may show frank charring and superficial vascular coagulation (this latter appearance is diagnostic of a full thickness burn). Obviously infected burns are easy to recognize; the presence of pus and local cellulitis is unmistakable. Regional lymphadenopathy and systemic disturbances may also be present. The area of the burn is most conveniently estimated in larger burns by the use of standard or modified Berkow charts and tables (Lynch 1973). These tables are unsurpassed for recording the anatomical distribution of burn wound(s). In smaller burns it is helpful to remember that the size of the patient's open palm is roughly equivalent to 1 % TBSA. When our initial assessment and recording is completed, the next question to be asked is "inpatient or out-patient treatment ?".
CRITERIA FOR ADMISSION
Criteria for admission of patients for systemic and/or local care of the burn wound are variable. What is applicable to an adult in an urban Western community is often not applicable to a child from a rural tribal population. Common sense must prevail. The following is a suggested list of criteria for inpatient admission and treatment: all burns exceeding 15% TBSA in adults or 10% in children; 2. all full thickness burns exceeding 2% TBSA; 3. all full thickness burns involving priority areas-hands, face, joint-flexures, and circumferentiallimb burns; 4. all eyelid burns, electrical burns, infected burns and suspected respiratory tract burns. 1.
OUT-PATIENT MANAGEMENT
Out-patient burns are managed on a regime which provides maximum results with a minimum number of out-patient attendances (Auchincloss 1975). Epidermal burns require no treatment apart from pain relief and an eventual application of antiseptic soothing creams. Dressings are unnecessary and if the patient is reassured and given some estimate of recovery time (within 10 days), no follow-up is needed. Superficial.and deep dermal burns are often difficult to distinguish initially but are both treated with the "standard burn dressing". Under aseptic conditions the burnt area is thoroughly cleaned with chlorhexidine/cetrimide solu-
THE PROBLEM OF BURNS IN CENTRAL AFRICA
I 115
tion and all the blistered and raised epidermis is removed using fine, pointed scissors; any fluid exudate is thus freed and any coagulated exudate is gently removed using a moist gauze swab. The burn is dried and reassessed for depth. The standard burn dressing is then applied; it consists of (a) a single layer of Vaseline gauze without any overlap of the gauze pieces, (b) several layers of opened cotton gauze swabs, (c) a conforming cotton bandage wound firmly - but not tightly - in place, to hold the underlying layers while subsequent layers are added, (d) several layers of bulky wool, held in place with (e) a firmly applied crepe bandage to produce a pressure effect on the underlying layers. Such a dressing, if applied correctly, is non-adherent, pain relieving, occlusive, and while exerting pressure also acts as a splint for the injured part. Lower limbs should be rested and elevated and upper limbs should be supported in a sling. This method is difficult to use in burns involving the axillae, groins, perineum, neck and face, and unless such burns are small they should be treated by exposure and usually require admission. Burns to be treated by exposure are cleaned and debrided as above and may also have a covering of silver sulphadiazine cream. Full thickness burns of less than 2% TBSA may be suitable for immediate or delayed excision and grafting. Small burns can be treated by elliptical excision and direct closure of the defect. The standard burn dressing is a suitable cover for full thickness burns prior to delayed excision. Controversy still exists as to the optimal time for excision and grafting; in general it is still true "the earlier the better". Well demarcated, obviously full thickness burns can be excised immediately and grafted if the patient's general condition is suitable. Mixed depth burns are best treated with the standard burn dressing until the partial thickness element is healed (10 - 21 days), and the full thickness element is well defined. Infection must be avoided by aseptic technique. All burn wounds, whether managed as outpatients or in-patients, must receive anti-tetanus prophylaxis since tetanus in burns is almost universally fatal (Lynch 1973). It is our policy to administer a booster dose of toxoid (Tetanol) to previously immunized patients, and ATS plus a course of toxoid to those who are not. In our opinion antibiotics are not initially required for out-patients with clinically uninfected burns. With this standard burn dressing the majority of partial thickness (i.e, superficial dermal and deep dermal) burns will be healed on the first return visit after 10 days. The dressing should not be changed during the
116
I THE PROBLEM OF BURNS IN
Tropical Doctor,July I976
CENTRAL AFRICA
first 10 days unless it becomes wet from without or within or unless symptoms and signs of infection supervene. Changing the dressing not only provides extra work for nursing and medical staff but may introduce infection and almost certainly damages regenerating epithelium. When the dressing becomes wet during the initial 10 days, only the outer crepe bandage and the outer layer of wool should be removed and reapplied with the addition of extra wool layers if the wetting is from within. After 10 days the dressing is removed carefully, layer by layer; if the Vaseline gauze can be removed easily, healing is almost certainly complete and the patient can be discharged without the need for further dressings or follow-up. If delay in healing occurs, general factors such as malnutrition, diabetes, steroid therapy, and malabsorption syndromes must be sought. Infection with pyogenic organisms is a more likely cause; by destroying remaining epithelial elements it may convert a partial burn into a full thickness loss. If the first and second causes for delayed healing can be excluded (the presence- of either of these is probably an indication for admission), the burn wound is either re-dressed with the standard burn dressing for a further 10 days or managed by daily
dressing with silver sulphadiazine cream covered with a light occlusive dressing. In a previous survey (Auchincloss 1975) 90% of patients treated on this regime were healed within 20 days of the initial burning. IN-PATIENT MANAGEMENT
Once the decision to admit a burnt patient has been made, treatment must start immediately. In a severe burn delay can be fatal. The following scheme is useful: (a) evaluation, (b) control of airway, (c) analgesia or sedation, (d) fluid replacement, (e) tetanus prophylaxis, (f) antibiotics, (g) nutritional requirements, (h) physiotherapy, (i) local wound management. The assessment differs in no way from that for out-patients. Evaluation of the patient's condition and classification and recording of burns can be carried out at the same time as therapy is initiated. Establishment and maintenance of an adequate airway is high on the list of priorities especially in burns around the face and neck with possible respiratory tract burns; tracheal intubation, bloodgas analysis, oxygenation, intermittent positive pressure ventilation and steroids may be indicated in severe cases. Tracheotomy - particularly through a burn wound - is meddlesome, dangerous, and not recommended (Blocker et al. 1967). Analgesia or sedation is required for most burnt patients. Morphine sulphate can be given to both adults and children (10 mg for adults, 0.5 mg per year of age to children) and must be given intravenously to ensure complete absorption.We have also used tilidine hydrochloride (Valoron) drops orally in infants with satisfactory results. Fluid replacement therapy is initiated and a programme of fluid and nutritional requirements is calculated using a well-known formula. This replacement should be monitored by attention to urine output (via an indwelling catheter for accuracy), regular Hb and haematocrit estimations and the measurement of central venous pressure (see Fig. 2). Tetanus prophylaxis as described above is started immediately. It is our practice to give penicillin to all burns requiring admission to hospital, in order to Fig. 2. Burns are recorded by area on the simple body supplement tetanus prophylaxis and to eliminate chart which also carries the formula for colloid streptococci from the patient's upper airway. Culture replacement. Volume of fluid to be given in each of the wound surface should be made on admission and repeated regularly thereafter. Antibiotics are • iod Weight in Kg X % area m1s. Perto = reserved for clinical infections and selected in 2 accordance with sensivity tests on the organisms . Weight in kg responsible. Expectedurme output = mls/hour Patients with extensive burns are not allowed any 2
Tropical Doctor, July rrJ7n
oral intake for the first 24 hours to diminish the risk of ileus and acute gastric dilatation so often seen in these patients. Thereafter oral intake is begun cautiously and expanded to provide the required high protein, high calorie diet. Parenteral vitamin supplements are often needed. The importance of physiotherapy is often underestimated. Careful positioning of the patient and daily exercises designed to put burnt limbs through a full range of active or passive movement will speed rehabilitation and may prevent subsequent deformities. In this respect the use of lightweight splints for hands, limb joints, and the neck are of proven benefit. Management of the local burn wound varies from centre to centre but in the Central African climate exposure therapy is particularly suitable; partial thickness burns are all re-epithelialized in about 14 days. Full thickness injuries are grafted on about the twenty-first day. We use the Davis electric dermatome and, where necessary, mesh all grafts for large burn areas using the Zimmer mesh dermatome. In conjunction with the exposure method and for infected late burns (seen more frequently than in Western countries owing to delay in seeking or reaching medical help), we were using 0.5% silver nitrate soaks for local burn care. This is a useful method of treatment but at the time of writing we have adopted the use of silver sulphadiazine cream prepared by our own pharmacy (Drake and Froese 1975) but also manufactured commercially (Flamazine Cream: Smith & Nephew). Its bacteriostatic properties are similar to those of silver nitratebeing particularly useful against Pseudomonas infections - in addition to which (a) nursing is more convenient, (b) it is non-irritant, thus giving it full
THE PROBLEM OF BURNS IN CENTRAL AFRICA
I II7
patient acceptability, and (c) there is no staining of skin or fomites which occurs in the use of silver nitrate. Our clinical impression is that it is superior topical application. It is applied directly to the burn surface with the sterile, gloved hand as a layer 1-2 mm thick and, if needed, can be covered with a light gauze and cotton bandage dressing. All our patients are nursed on polyurethane foam sheeting; this provides a comfortable non-stick surface which is also utilized as a dressing or splint to elevate burned limbs. Prevention of burns is theoretically very attractive but most difficult in a rural population who rely almost entirely on open fires for cooking and heating. Out efforts in this direction are all being made by way of education of women. We have health education officers in the rural areas who visit women's clubs, clinics, and schools. When opportunities arise they stress the dangers to children of accidents in the home involving open fires, hot fluids, and inflammable clothing. This approach will take a very long time to produce tangible results. We hope that these notes will be read by our colleagues in other tropical areas to whom the problem of burned children is a daily challenge. ACKNOWLEDGEMENT
We wish to acknowledge permission of the Secretary for Health of Rhodesia to offer this article for publication. REFERENCES
Auchincloss, J. M. (1975). Brit. J. din. Pract., 29, 251. Blocker, T. G. (1963). Sth med. J., 56, 382. Drake, D. J., and Froese, E. H. (1975). Cent. Afr. J. Med., 21, 71. Grave, G. F. (1972). Ann. roy. Coli. Surg. Engl., 51, 332. Lynch, J. B. (1973). "Thermal Burns" in Plastic Surgery. 2nd ed. Ed. Grabb, W. C. and Smith, J. W. Boston, Mass.: Little, Brown & Co.
Book Review Laboratory Techniques in Brucellosis By G. G. Alton, Lois M. Jones, and D. E. Pietz. (Geneva: World Health Organization, 1975. Monograph Series No. 55, znd edition, pp. I6].)
Brucellosis remains a world problem of both public health and economic importance, and its control depends largely on close collaboration between wellequipped laboratories using standardized methods and medical and veterinary services. Eight years have elapsed since the publication of the first edition of this monograph. In this second edition all the chapters have been revised and brought up to date and new chapters on Brucella ovisand Brucella canis have been added. The chapter on
bacterial methods contains a valuable new section on the precautions to be taken in handling infectious Or potentially infectious materials. The chapter on serological methods has been expanded to include methods for preparing and standardizing antigens, since these methods are widely used in some parts of the world. The use and limitations of allergic tests are fully discussed, together with a description of the nature of the allergens and details of their production and use. The new chapters on Brucella ovis and Brucella canis discuss the diagnostic procedures, both clinical and serological, and describe the methods of isolating and identifying the two organisms.
