Burn Care: Infection and Smoke Inhalation EVERY YEAR in the United States nearly two million persons suffer burns that need medical attention. Of these, 130 000 are hospitalized, 70 000 require intensive care costing more than $300 million, and 10 000 die. Because of advances during the past decade in treatment in the major burn centers of patients with extensive burns, the survival of patients with burns up to 65% of body surface area has improved as much as 50%. Treatment differs widely even in specialized centers and because doctors who treat burns outside of these centers may be unaware of the best therapeutic measures, the National Institute of General Medical Sciences decided to hold a consensus meeting to delineate those measures that are beneficial, harmful, or of doubtful value, to define areas for future research, and to distribute this information to physicians and the public. The topics covered were fluid resuscitation, control of infection, metabolic balance, smoke inhalation, and the use of excisional therapy and biological coverings. The consensus findings on control of infection and smoke inhalation are emphasized here because of their pertinence to internists. Infection continues to be the cause of 75% of all deaths after thermal injury. Consensus was reached on six topics. First, topical antimicrobial therapy is one of the most important measures in the prevention and treatment of burn-wound infection. Second, routine microbial monitoring of the burn wound is necessary. Whether this testing should be qualitative or quantitative has not been established at present. Third, good nutrition is beneficial to both specific and nonspecific host defense mechanisms; no controlled clinical study has been done, however, to prove this impression, and a study in burned mice has

shown no advantage of high protein diet over an adequate protein diet (1). Fourth, the use of specific and, perhaps, nonspecific gram-negative (Pseudomonas) vaccines appears promising from the results of uncontrolled clinical trials (2, 3), animal experimentation (4), and a controlled study of burned patients in progress in India (5). Fifth, in the organization of burn care, it is critical to assess the high-risk patient, that is, the one who is very old or very young with deep full thickness injury and with serious associated diseases. Sixth, proper clinical trials are of the utmost importance. N o consensus was reached on three questions. Is a barrier system indispensable in the care of burned patients? Should systemic antibiotics, such as penicillin, be given during the first 5 days after burn injury or as a prophylactic measure before and after operative procedures without evidence of systemic infection? Can some current laboratory test predict survival of the burned patient? There was agreement that research is badly needed in five problems: first, variations in functions of neutrophils, lymphocytes, and macrophages after burn injury; second, the evaluation of immunoregulator agents in burned animals; third, nutritional difficulties in burned animals and humans; fourth, mediation of inflammation in normal and burned subjects; and fifth, passive immunization (that is, Pseudomonas) in burned patients. In the session on smoke inhalation, it was pointed out that smoke inhalation without a burn is essentially no problem, since the patient dies immediately or usually survives. In the presence of a burn, however, delayed mortality is high, and much more experimental work needs to be done to develop a rational therapy. ConsenEditorial Notes

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sus was reached on these points: First, immediate therapy with oxygen is critical to prevent damage due to carbon monoxide poisoning. Because of the anoxia suffered by the patient, the physician should always be suspicious of a concomitant myocardial infarction. Second, there is a need for a universal classification of inhalation injury, and the etiologic agents producing the smoke must be an integral part of that classification. Third, diagnosis depends on the site affected in the respiratory tract. Fiberoptic bronchoscopy is recommended for the upper airways, but a simple and fast method to diagnose parenchymal damage should be developed. Fourth, steroids should not be used in the treatment of pulmonary damage with cutaneous burns; a double-blind, controlled clinical study has shown a four-fold greater mortality in patients treated with steroids than in control subjects (6). The consensus-type conference has educational value for physicians at all levels of sophistication, but the recommendations must not be allowed to become dogma or

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to obscure the urgent need for further research. ( K E H L MARKLEY, M.D.; Laboratory of Biochemical Pharmacology, National Institute of Arthritis, Metabolism, and Digestive Diseases; Bethesda, Maryland) References 1. M A R K L E Y K, SMALLMAN E, T H O R N T O N SW: The effect of diet protein

on late burn mortality. Proc Soc Exp Biol Med 135:94-99, 1970 2. FELLER I, PIERSON C: Pseudomonas vaccine and hyperimmune plasma for burned patients. Arch Surg 97:225-229, 1968 3. A L E X A N D E R JW, F I S H E R MW, M A C M I L L A N BG: Immunological con-

trol of Pseudomonas infection in burn patients: a clinical evaluation. Arch Surg 102:31-35, 1971 4. M I L L I C A N RC, E V A N S G, M A R K L E Y K: Susceptibility of burned mice to

Pseudomonas aeruginosa and protection by vaccination. Ann Surg 163:603-610, 1966 5. J O N E S RJ, R O E EA, G U P T A JL: Low mortality in burned patients in a

pseudomonas vaccine trial. Lancet 2:401-403, 1978 6. MOYLAN JA, C H A N CK: Inhalation injury—an increasing problem. Ann Surg 188:34-37, 1978 © 1 9 7 9 American College of Physicians

February 1979 • Annals of Internal Medicine • Volume 90 • Number 2

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