

Good to know
For anyone who wants to delve deeper into the topic, here are the basics on prevention, the history of burn medicine, burn medicine today, the burn wound itself, and its epidemiology.
Precaution
With greater awareness of the risks, many fire accidents could be avoided. Workplace safety measures have had a significant positive impact in recent decades. Only one-third of our injured patients are admitted from the workplace. Thanks to our outstanding emergency services and a dense network of specialized facilities, anyone suffering from a severe burn injury can now count on receiving state-of-the-art, internationally accredited treatment. An interdisciplinary treatment group led by a plastic surgeon guarantees optimal primary treatment and rehabilitation. Specialists from Germany, Austria, and Switzerland collaborate within the German-speaking Working Group for Burns, sharing their experiences. A number of research projects aim to solve remaining problems and further improve treatment outcomes.
The Burn Wound
The skin is the body's boundary with the environment. It consists of the epidermis, the dermis, and the subcutaneous tissue. If the skin is heated above a critical temperature, this tissue is burned. The severity of the burn depends primarily on the temperature, the duration of exposure, and the conductivity of the tissue. The pathophysiology of burns is characterized by: *Generalized edema *Increased permeability of the blood vessels *During the first 24–36 hours *Degenerative processes in the area of the burn wound *Wound infection due to reduced immune function *Increased energy metabolism due to increased energy requirements *Complications in the area of vital organs such as the lungs or kidneys Three essential features are characteristic of burn wounds: *Damage to the blood capillaries; This leads to excessive plasma loss, which in turn can trigger burn shock. *Dead tissue that provides an ideal breeding ground for bacteria. *Extension of the wound over a large area of the body, providing an unprotected, extensive opening for invasive infection. Histomorphologically, three zones can be distinguished in burns. The central zone is the zone of necrosis. Adjacent to this is the zone of stasis, which transitions into a zone of hyperemia. In the stasis zone, burn-induced capillary damage occurs, leading to increased vascular permeability. Blood components that normally do not penetrate the vessel wall can now leak into the surrounding tissue. The result is burn edema. This process leads to hypovolemic shock in severe burns. The inflammatory reaction of a burn wound is characterized by: *Local hyperthermia *Redness *Swelling *Pain *Loss of function A variety of inflammatory mediators interact in this process. However, it is still unclear how this inflammatory process is initiated and how these various mediators ultimately interact. In cases of extensive thermal injury, local edema develops beyond the local edema, leading to generalized edema, which also affects the gastrointestinal tract.
History of Combustion Medicine
"It is generally assumed that if two-thirds of the body surface is burned, even to the first degree, death occurs fairly quickly..." wrote Theodor Billroth in 1876. Erich Lexer's 1952 textbook of surgery states that any burn affecting 50% of the body surface almost always leads to death, and a 1964 publication reports that burns affecting more than 70% of the body surface are rarely survived. Survival from extensive, severe burns is a recent gift. Today, extreme approaches to the treatment of burn injuries are being taken by better control of shock, improved intensive care, especially during the first three days, advanced medical technology, and, last but not least, early necropsy. Burns have probably existed since time immemorial. For centuries, all peoples and cultures have used a wide variety of remedies for the local treatment of burns. The Egyptian Ebers Papyrus (1550 BC) contains a recipe made from black mud and boiled cow dung, which is supposed to treat burns on the first day, and then in the following days with various ointments, usually containing animal dung and animal fats. The benefits of cold applications after burns were already praised in Arabic medicine. This measure, still practiced today, gained particular prominence at the dawn of the modern era thanks to the Englishman James Earle (1755–1817). Earle's publication appeared in 1799, in which he described numerous cases of successful burn treatment with ice as an antidote. Other physicians of past centuries – including the great surgeon Ambroise Pare (1510–1590) – held the view that burns had to be cauterized with heat. In 1607, the first book exclusively dealing with burns was published in Basel under the title "De Combustionibus." Although the author Fabricius Hildanus (1560–1634) added nothing to existing treatment, Hildanus was the first to describe three different degrees of burns. This book includes two interesting illustrations of the treatment of a cicatricial contracture in a child, along with a detailed description. Six months after the injury, Hildanus incised these scars and corrected the deformity with the help of leather thimbles. "And with divine help, the hand was completely restored..." The "Burn House" of the Royal Infirmary in Surgeons Square in Edinburgh was the first hospital for burn victims. It was designated for this purpose in 1850 at the instigation of the famous surgeon James Syme (1799–1870). One can only speculate about Syme's motives for this decision. Was it the unpleasant smell from the burned patients, or did he decide to take this step because the hospital, like all hospitals of the time, was plagued with septicemia and erysipelas? However, the connection between nature and the treatment of infections was not clarified until Syme's famous son-in-law, Joseph Lister (1827–1912). Until the turn of the 20th century, little progress had been made in burn treatment. Only noteworthy were the open treatment method first advocated by W.T. Copeland of Alabama in 1887 and the "continuous bath" of the Viennese dermatologist Ferdinand von Hebra (1816–1880). In the 19th century, nothing could be found in textbooks or journals about burn physiology or general systemic treatment. The causes of rapid death after burns were completely unknown. A wide variety of hypotheses were discussed. It was assumed that simultaneous irritation of almost all nerve endings by the burn led to overstimulation of the central nervous system and ultimately to paralysis. Fatal blood poisoning of the organism due to the loss of skin perspiration, or intense phlogistic or septic intoxication, were also discussed as possible causes of death. Interestingly, the Frenchman Giullaume G. Dupuytren (1777–1835) had already observed an abundance of blood in the organs during the autopsy of burn victims, which, however, led him to the erroneous therapeutic conclusion of prescribing bloodletting and diuretics for burns. It was not until 1862 that H. Baraduc from Paris suggested giving burn victims plenty of fluids, as he had observed increased blood viscosity after burns. The pioneers of systemic treatment of burn shock were Reiss (1880) and the Italian dermatologist Tommasoli (1892), who administered saline infusions to their patients. The outstanding work "The Treatment of Burns and Skin Grafting" by Haldor Sneve of St. Paul, published in 1905, is rightly considered the first modern treatise on the treatment of burn shock.
Epidemiology
In the Federal Republic of Germany, it was previously estimated that there were 16,000 severe burn injuries per year, of which approximately 1,800 required intensive care. Epidemiological data are still not centrally recorded. The German-speaking Working Group for Burns has addressed this problem and annually collects data from most burn centers in Germany, and increasingly also from centers in Austria and Switzerland. According to data from the National Burn Information Exchange in the USA, the overall survival rate is showing an upward trend, and hospital stays have been significantly reduced. Studies of approximately 38,000 patients have shown that the rapid wound closure through surgical procedures, among other factors, has contributed to the significant increase in the overall survival rate. Our Burn Center has treated an average of 120 patients requiring intensive care over the past ten years. Approximately 30% of these patients suffer work-related or commuting accidents; the remaining accidents primarily occur at home. Eight percent of patients committed confirmed suicide. The average length of stay in the intensive care unit for this entire patient population is 16–17 days. The greater Munich area accounts for approximately 50% of the catchment area; almost 30% of patients come from the greater Bavaria area, and the remaining patients come from other German states and from abroad.
Combustion medicine today
Burn medicine changed suddenly in 1975 with the sensational work of Rheinwald and Green, who were the first to report on multiple passages of skin cultures. The now-discovered epithelial growth factor (EGF), which Rheinwald and Green used in their medium, likely played a significant role in this enormous advance. Using this method, it has already been possible to replace 70% to even 80% of burned skin in isolated cases. However, these promising results should not obscure the fact that such replantations still pose significant problems today. There is still no ideal temporary skin substitute that creates the conditions for unhindered healing of epidermal transplants after burn injuries. These transplants still lack important skin appendages such as sweat glands and hair follicles. The future will show how research will meet this challenge. The transition from initial treatment of a burn victim to plastic reconstruction is fluid and begins within the first few days after the accident. Providing around-the-clock care for a severely burned victim requires a high degree of physical, mental, and emotional commitment from the attending physicians, nurses, physical and occupational therapists, and psychologists. The personnel, space, equipment, organizational, and financial resources required exceed those of a standard intensive care unit by four to five times. Weeks or months pass before a burn victim can be discharged home or return to work. Scar contractures occasionally require reconstructive surgery even years later. Despite optimal treatment, permanent damage and visible scars, even disfigurement, remain.
More to come...
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