Article 3

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=88 BGCOLOR="#006699" TEXT="#080000"> <div> carbonics GmbH  -  <FONT SIZE="4" COLOR="#FFFFFF" FACE="Tahoma" >Carbon Wound Dressings</FONT></div> <div> <A HREF="anfang98.htm" TARGET="_top" TITLE="Medical"><U>Medical</U></A>   ·   <A HREF="id153.htm" TARGET="_top" TITLE="Products"><U>Products</U></A>   ·   <A HREF="id154.htm" TARGET="_top" TITLE="Case Studies / Publications"><U>Case Studies / Publications</U></A>   ·   <A HREF="id155.htm" TARGET="_top" TITLE="Contact"><U>Contact</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=20,625% BGCOLOR="#006666" TEXT="#080000"> <bR> <div> <A HREF="id156.htm" TARGET="_top" TITLE="Case Study 1: Lower Leg"><U>Case Study 1: Lower Leg</U></A></div> <div> <A HREF="id157.htm" TARGET="_top" TITLE="Case Study 2: Face"><U>Case Study 2: Face</U></A></div> <div> <A HREF="id158.htm" TARGET="_top" TITLE="Case Study 3: Legs"><U>Case Study 3: Legs</U></A></div> <div> <A HREF="id159.htm" TARGET="_top" TITLE="Case Study 4: Stump Infection"><U>Case Study 4: Stump Infection</U></A></div> <div> <A HREF="id172.htm" TARGET="_top" TITLE="Varicose Ulcers"><U>Varicose Ulcers</U></A></div> <div> <A HREF="id160.htm" TARGET="_top" TITLE="Article 1"><U>Article 1</U></A></div> <div> <A HREF="id161.htm" TARGET="_top" TITLE="Article 2"><U>Article 2</U></A></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c8ffffff00.gif" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Article 3</B></div> </td> <td valign="top" height=392 BGCOLOR="#FFFFFF" TEXT="#080000"> <div>      <FONT SIZE="3" COLOR="#000000" FACE="Arial" ><IMG SRC="179b0210.jpg" border=0 width="176" height="33" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></FONT></div> <bR> <div> <B>Modern Standards in the Treatment of Severly Burn-Injured Patients</B></div> <bR> <div> <B>C. Krawehl-Nakath, N. Seidensticker</B></div> <div> <B>German Armed Forces Central Hospital Koblenz</B></div> <div> <B>Department XIV Trauma Surgery/Burn Unit</B></div> <bR> <div> <B>INTRODUCTION</B></div> <div> A burn injury involves more than skin damage. The attending physician is faced with a variety of problems manifesting themselves in the entire organism of the burn patient. Additionally, extreme physical strain and emotional stress are put not only on the patient but on nursing personnel and</div> <div> physicians as well.</div> <bR> <div> The success or failure of the treatment of a burn patient depends on several factors. They are: the type and extent of burn care applied; presence of an accompanying inhalation or mechanical injury, the general state of health and the age of the patient. A good end result is in 1 year possible if all possible</div> <div> therapeutic resources are brought into use. </div> <bR> <div> The survival rate of patients with serious burn injuries has been optimized through</div> <bR> <div> a) more effective application of shock therapy;</div> <div> b) more effective use of intensive care units equipped with modern medical equipment;</div> <div> c) operative treatment of the destroyed skin at an early stage;</div> <div> d) plastic skin grafting (with homografts, allografts).</div> <bR> <div> <B>BURN INJURIES</B></div> <div> Skin performs an important protective function against the negative environmental effects of mechanical, chernical, biological, etc. origin. Moreover, it prevents the loss of body fluid and provides a wide spectrurn of sensations through the sense of touch. Histomorphologically the depth of the tissue destruction, can be divided into three zones [35, 49] :</div> <bR> <div> 1) hyperamic zone</div> <div> 2) stasis zone</div> <div> 3) necrotic zone</div> <bR> <div> In the stasis zone of the burn wound, the capillaries are damaged. As a result, the permeability of vessels is increased (the so called Capillary Leak Syndrome).This provides ideal conditions for the discharge of plasma which in turn triggers the pathophysiological shock mechanism.[17, 19].</div> <bR> <div> The following three features are characteristic for the burn injury:</div> <bR> <div> 1) damnage ot the blood capillaries, leading to the extensive loss of body fluids and plasma;</div> <div> 2. necrosis of the burnt tissue, providing an ideal environment for the development of bacteria and fungi. In addition to infection of the wound, a danger of sepsis of the whole organism also exists.</div> <div> 3) development of Systematic Inflammation Response Syndrome (SIRS) that can evolve into  MultiOrgan     Dysfunction Syndrome (MOOS).</div> <bR> <div> This inflammatory reaction, largely based on an extensive disorder of the immune system, is caused bya large number of mediators that are produced in the cells and in the blood. The mediators are responsible for the development of organ dysfunction, organ failure and finally death as well </div> <div> [10,16,17, 21,31,33,43].</div> <bR> <div> <B>Depth of burn injury</B></div> <div> The depth of burn injuries is commonly classified in four degrees [35, 49]: </div> <bR> <div> First degree burn injury:           </div> <div>                superficial burn injuries involving only the epidermis, </div> <div>                with local erythema;</div> <bR> <div> Second degree burn injury(a):     </div> <div>                skin damage is not deep, blisters are formed; </div> <div>                the wound bottom is hyperemic and whitens upon pressure.</div> <div>                Normal skin elasticity decreases owing to the development of edema.</div> <div>                The wound is characterized by pain sensitivity to touch and a tendency</div> <div>                to bleed. Skin appendages are not destroyed.</div> <bR> <div> Second degree burn iniury (b):      </div> <div>                the burn injury is deeper and is characterized by blistering; </div> <div>                whitish zones with red edges can be distinguished on the wound; </div> <div>                the wound does not whiten upon pressure. Pain sensibility is very low </div> <div>                or absent. Hair can be easily removed from the skin.</div> <bR> <div> Third degree burn injury:</div> <div>                 the burn injury destroys all skin structures; skin appendages are </div> <div>                damaged as well; the wound appears white; there is no sensation in </div> <div>                the wound area.</div> <bR> <div> Fourth degree burn injury:</div> <div>                 not only the skin but the subcutaneous tissue, fasciae, tendons, </div> <div>                muscles and bones have a brown-black leathery consistence.</div> <bR> <div> The assessment of the depth of the burn wound is usually performed in a hospital, and depends on the experience of the attending physician. Due to the changes in the appearance of the wound that take place within several days post-trauma, erroneous estimations can occur often. Therefore, control of the so called "burn maps" should be performed regularly [17,49].</div> <bR> <div> Recently developed laser reflection measurements of the depth of the tissue damage, along with ultra-sonic methods for capillary blood flowmeasurements, allow a more precise assessment of the depth of the burn injury [2, 3, 5, 15, 41] .</div> <bR> <div> <B>Area of burn injury</B></div> <div> The estimation of the extent of burn injury can be done in accordance with two different rules of thumb:</div> <div> According to the first and rather simple one, it is assumed that the surface of the patient's palm makes up approximately 1% of his total body surface. This method is suitable at the place of accident where a rough estimation of the seriousness of the burn injury is sufficient. First degree burn injuries are not measured in this manner.[17, 49]. The second method is more precise and is done according to Wallace's Neuner rule [17,35,49].</div> <bR> <div> The following wounds must be treated in burn centers [24,48]:</div> <bR> <div> 1) second and third degree burns on the face and hands;</div> <div> 2) second degree burns if 20% of the total body surface is damaged</div> <div>    (for children 15%);</div> <div> 3) third degree burns if 10% of the total body surface is damaged </div> <div>    (for children 10%);</div> <div> 4) inhalation traumas;</div> <div> 5) electrical burns.</div> <bR> <div> The same rules count for scalding, chemical and radiation injuries. Patients in question should be referred to a burn center either directly through a regional ambulance service or through the switchboard of the Burn Care Center for Seriously Injured Patients in Hamburg (tel. 040-28823998, 28823999,fax 040-24865647) that is staffed twenty-four-hours a day. From almost every site in Germany, the nearest burn center can be reached by air within 30-60 min.</div> <bR> <div> <B>Emergency care</B></div> <div> In addition to the initial patient history, personal data should be registered. As a rule, a severely burn injured patient is able to provide information about himself. If a patient is burnt to an unrecognizable state, the identification will be difficult [24, 48] .</div> <bR> <div> After data registration, an infusion treatment with Ringerslactate should begin in order to prevent shock. Two-three infusions are generally sufficient. The extent of the burn injury is estimated according to the "palm method" or Neuner's rule (see above). The next step is the calculation of the fluid requirernents according to the Baxter's Parkland formula [18,24,35,49].</div> <bR> <div> 4 ml x kg KG 1 x % VKOF2</div> <div> 6-8 ml x kg KG x % VKOF (injured children)</div> <div> 8 mi x kg KG x% VKOF (electrical current injury)</div> <bR> <div> VKOF = Burned Body Surface</div> <bR> <div> Since it is difficult to calculate the exact infusion dosage at the site of the accident, the following rule of thumb has proved itself worthy. For the volume substitution, adults receive one litre of lactated ringers rapidly infused. Later, one litre/hour until the patient arrives at the hospital. During the initial phase of treatment, doses of colloids and corticosteroids are contraindicated [24, 49] .Because of the capillary leakage, colloids will be transported to the tissues, deposited there and promote the forming of an edema. Coricosteroids do not hinder an edemna and should thus only be administered in the case of an inhalation trauma or prior to intubation in the form of aerosol dosages.</div> <bR> <div> Intubation and artificial respiration should be performed in case of unconsciousness and in case of evident inhalation traumas. In all other cases, the administration of, for example, Ketanest - Dormicum is sufficient medication for the duration of the transportation of a patient to the hospital/burn centre where he receives the adequate treatment.</div> <bR> <div> Dry burn injuries should be covered with a sterile dressing or burn packs. In order to prevent a drop in body temperature, the patient should be covered with blankets. All applied measures should be properly  registered before the patient is transported to the burn centre [24].</div> <bR> <div> <B>Hospitalisation and Emergency Treatment</B></div> <div> A burn care center can provide a burn-injured patient with the optimal treatment in terms of adequate equipment and skilled personnel [17,49]. Treatment begins after the patient is brought to the intensive care unit. Here, the patient is undressed and weighed. During the warm bath, the following intensive care measures should be taken:</div> <bR> <div> -control of the state of the central intra-venous and/or intra-arterial inlets;</div> <bR> <div> -either transurethai or supropubic catheterization of the urinary bladder;</div> <bR> <div> -routine laboratory blood analysis including infection-serology with HIV-Test;</div> <bR> <div> -smears of all body orifices and of burn injured zones for bacteriological analyses; in the cose of  </div> <div>   intubated patients, the laboratory analysis of tracheal secretion should be also performed;</div> <bR> <div> -intubation and narcosis during medical cleansing both including wound debridement;</div> <bR> <div> -assessment and "mapping" of the burn injury;</div> <bR> <div> -making a decision on the expediency of escharotomy in the case of circular burn injuries;</div> <bR> <div> -laryngobronchoscopy in case of inhalation traumas.</div> <bR> <div> <B>Standardised Clinical Treatment</B></div> <div> After the necessary debridement has been performed, the patient should be placed on sterile sheets in a plastic foam bed. In order to minimize the drop in body temperature, the temperature in the intensive burn care box is kept at 32°C with humidity at 60-70%. The required fluid substitution calculated according to Baxter's Parkland formula (taking into account the amount administrated previously) should be performed. One half of this dosage should be administered within the first eight hours.</div> <div> The assessment of the amount of fluid replacement required in the first 24 post-trauma hours, using the so called Ludwigshafen model, is simpler [17]. The required amount is calculated as</div> <bR> <div> <B>% VKOF x kg KG = lactated Ringers/time interval</B></div> <bR> <div> and is given over two 4-hour time intervals and over two 8-hour time intervals. A good indicator of adequate shock treatment is the urine production per hour; it should not fall under less then 50 ml/hour [24, 49].</div> <bR> <div> The care of the patient in an intensive burn care unit is generally the same as in otherintensive care units [17,24,49]:</div> <bR> <div> -EKG, Pulse and RR monitoring</div> <div> -CVP-measurements</div> <div> -urine production per hour</div> <div> -routine laboratory analyses</div> <div> -x-Ray examination of the thorax;</div> <div> -ultrasonic examination of the abdomen;</div> <div> -consultation with an ophthalmologist and/or otorhinolaryngologist.</div> <bR> <div> The first days post trauma are marked by the development of edema and disturbances in the electrolyte and nutritive balances. Infusions with Ringer's solution are administered during the first two days post-trauma. By patients with more than 30% body surface affected, we begin substitution of the lost proteins as early as 18 hours post trauma. We prefer to administer a pooled serum protein solution that contains immunoglobulin, blood clotting factors, and transport and inhibition proteins. Attention must be also paid to the compensation of the acid-base balance, the replacement of vitamins, trace elements and free radicals. In our opinion, an initial prophylactic antibiotic therapy is contraindicated since it can promote the development of multiple resistant bacteria [7,49] .</div> <bR> <div> Laryngobronchoscopy provides information about the extent of an inhalation injury, which complicates the prognosis in terms of a successful therapy. [38,40].</div> <bR> <div> <B>EFFECT OF THE BURN INJURY ON THE ENTIRE ORGANISM</B></div> <bR> <div> <B>1. CENTRAL NERVOUS SYSTEM</B></div> <div> According to the modern scientific knowledge regarding burn Injuries, the central nervous system is endangered during the edemous phase. However, in our burn center, no cases of neurological disturbance in the initial period of the burn injury were registered. A danger of brain damage exists during artificial respiration when the oxygen saturation in the blood periodically drops. This can lead to a</div> <div> weakening of concentration, cognitive restrictions, amnesia, etc. [32, 49] .</div> <bR> <div> <B>2. RESPIRATORY SYSTEM</B></div> <div> The massive fluid loss caused by the capillary leakage directly after the burn injury as well as the high intra-vascular volume after the abatement of the edemous period from the second day post-trauma forward, put an enormous strain on the heart and on the circulatory system. In addition to the lengthening of the oxygen diffusion routes in the lungs during the edemous phase, a flushing due to an existing inhalation trauma with damnage to the alveolus can cause a reduction of the gas exchange surface [38, 40] .The artificial respiration methods involving high oxygen content and pressure should take these facts in consideration. The optimal method of artificial respiration should be chosen through an assessment of the results of regularly carried out pulmonary pressure measurements and blood gas tests. The further course of treatment can be complicated through the appearance of sepsis, which can also appear in the lungs [10,19,33].</div> <bR> <div> In the case of bed-ridden patients requiring nasal or oral artificial respiration, a tracheotomy could become necessary after multiple weeks of treatment. In this situation, it is important to keep in mind that the surgical procedure increases the risk of additional infection. The development of Adult Respiratory Distress Syndrome (ARDS) is another complication that can negatively affect the healing process. Here, in addition to antibiosis, the patient should bedded in a special rocking-bed (for example, KCI Rotorest) .This procedure is performed alternatively to bedding the patient face down in a foam rubber bed. This way, the ventilation of the lung is optimized. In a rocking-bed, the lateral inclination should be up to 60° with a frequency of 10 minutes per side). In order to maintain the physiological diuresis, the restricted fluid regime during infusion treatment should be kept.There are two alternative methods of treatment of ARDS: Extracorporal Membrane Oxygenation (EMO) and Extra Corporal CO2 Elimination (ECCO).</div> <bR> <div> In our clinic, venous-arterial EMCO and ECCO are performed in collaboration with the department of heart surgery.</div> <bR> <div> <B>3. GASTROINTESTINAL SYSTEM</B></div> <div> Inflammation following a burn injury affects the entire organism, including the digestive tract. The potential development of edema, atoni and paralysis requires that enteral nutrition through a gastric/duodenal tube should begin from the sixth hour post trauma on. This measure is aimed at</div> <div> maintaining the function of the gastrointestinal system and at preventing peritonitis [4, 12, 13,47] .</div> <bR> <div> We prefer enteral feeding with the help of a nutritional pump through a transnasal gastric silicon tube. The administered quantity should begin with 25 ml/hour, a step up to 100 ml/hour on the third day post-trauma and be kept at this level. The supplied caloric value of 2500-3000 Kcal is calculated tor every patient individually depending upon height, body weight and age [17].</div> <bR> <div> As a prophylaxis against atrophy of the small intestinal villi, an extra 50 mg/day of glutathione should be administered. Attention should be paid not only to the enteral nutrition of a patient but to regular bowel movements as weil. These can be supported through the administration of Propulsin@, Laktulose and/or SAB Simplex at the begin of the enteral nutrition therapy. Sphincter dilation, reduced pressure clysma and colon massage can be also applied agoinst intestinal atonia. Should the above mentioned treatment methods be insufficient, intra-venous administration of parasympathomimetic medications (Neostigmin) can become necessary.</div> <bR> <div> Since burn injuries induce hypermetabolism and negative nitrogen balances, catabolic metabolism, reduced protein levels and increased metabolic activity can result. If the enteral nutrition as it is described above is not possible, the parenteral supply of amino acids, carbohydrates and lipids</div> <div> for the regulation of energy and fluid balance is necessary.</div> <bR> <div> <B>4. RENAL SYSTEM</B></div> <div> The function of the kidneys is put under strain by low intravascular and oncotic pressure caused by protein loss and consequently by a higher concentration of urinary substances. In case of severely burn injured patients an urine output of at least 50 ml per hour can be considered as a guideline for sufficient kidney function. During the first days post-trauma the kidney function could be reduced. Because a cleansing of the burn edema is desirable from the second day post-trauma on, administration of diuretics can become necessary in order to maintain an adequate fluid level. The risks of an iatrogenic nephropathia should becarefully weighed. [43].</div> <bR> <div> On the basis of our own experience, we consider the application of uninterrupted venovenous hemodiafiltration in case of burn injures when more than 30% of the body surface is damaged. </div> <div> Thus, the tubuli damage caused by radicals and toxic by-products is prevented and fluid balance is restored more easily.</div> <bR> <div> <B>5. HEMATOLOGICAL SYSTEM</B></div> <div> A reversible drop of hemoglobin and hematocrits in blood is present at the initial stage of burn shock treatment. On the other hand the capillary leakage leads to the release of mediators out of the damaged tissue which increase the water and protein permeability of the vascular system. This results in a non-reversible protein loss.Thus, the protein replacement in case of patients with burns greater than 30% body surface has to begin from the 18th hour post-trauma hour on [17].</div> <bR> <div> A loss of blood and plasma at the beginning of surgical treatment of a burn injured patient is to be expected. In order to prevent hematopenic shock, blood and plasma substitutes with a ratio of 2 : 1 should be administered before and during the surgical treatment. The substitution of AT III, Factor XIII and blood clotting factors can be a live-saving measure.</div> <bR> <div> <B>6. TOPICAL TREATMENT</B></div> <div> Since 1996, topical treatment of burn injuries has been performed in our clinic according to the so called "Koblenz Model". This method of treatment has proven itself in the ambulance service of the German Armed Forces due to its simplicity. It is also recommended for application during military actions.</div> <div> After hospitalization of a severely burn injured patient and after the necessary debridement, the disinfection of the wound is performed with povidone-iodine; in case iodine allergy, the wound is disinfected with silver-sulphadiazine [8,20,23,46].</div> <bR> <div> Then the wound is covered with a dry dressing Sorusal manufactured from carbon fiber fabrics, which is fixed to the wound with a mull bandage [25,44]. Since the surface of the burn injury tends towards pronounced exudation during the first 24-48 hours post-trauma, Sorusal, being an extremely high absorbing dressing is the optimal covering for the wound. As soon as the dressing becomes soaked, it has to be changed under sterile conditions. Our experience shows that the first dressing change is expected after 6-8 hours. After the removal of the soaked dressing, the wound has to be disinfected again and covered with another Sorusal dressing. </div> <bR> <div> As soon as the wound no longer exudes, the treatment with Sorusal dressings should be replaced by the treatment with wet (impregnated with medication) Legius dressings. The wound should again be disinfected under sterile conditions with povidone-iodine and then covered with a carbon fiber dressing Legius, impregnated with 1:5 diluted povidone-iodine. The dressing is fixed to the wound with mull bandages. Thereafter, the dressing should be soaked with diluted povidone-iodine once every 6 hours and changed every other day. This way, a long-term disinfection of burn injuries is achieved and the risk of wound infection is minimized. If the dressing adheres to the wound, it can be removed easily through the application of saline solution. In case of infection caused by Pseudomonas aeruginosa, wound treatment with 1% acetic acid solution was found to be effective.</div> <bR> <div> Owing to its woven structure, the above described carbon fiber dressing is hygroscopic. It is chemically inert and not cytotoxic. No side effects are known. Treatment of burn injuries with these medical dressings is anti-bacterial, thus diminishing the risk of infection. During treatment, surface burn injuries reepithelialise spontaneously. Another important advantage of this method of treatment is the easily performed assessment of the depth of the tissue damage as compared to treatment with ointments when such an assessment is hindered by coating on the wound surface. Moreover, the dressing change is painless. This method of treatment is easy to handle, is economical and saves dressing material [25,44].</div> <bR> <div> <B>7. SURGICAL WOUND TREATMENT</B></div> <div> Burn injuries of the second (b) and third degree must be treated surgically. In our clinic this is done during the third -fifth day post trauma. During this time, the burn edema abates or is already abated.</div> <div> As a rule, the damaged areas of second (b) degree burn injury are necrectomized tangentially while third degree burn injuries are necrectomized epifascially. Necrectomy is coupled with meshed split-skit graft technique. The transplant is fixed with skin clips and afterward with oil dressing, compresses and if necessary, a buttoning foam rubber bandage.</div> <bR> <div> In case of facial and wrist burns (for example, eyelids, fingers), full-thickness skin grafts and/or unmeshed split-skit grafts (for example, back of the hand, extensor sides of fingers, face) are transplanted for optimal functional and cosmetic results. The transplants should be carefully sutured with absorbable suture material and applied as described above.</div> <bR> <div> As a rule, 10-15% of the damaged body surface can be treated and subjected to transplantation at one sitting. In favorable cases, the procedure is completed within fourteen days. In the case of extensive and deep burn injuries, mesh-grafts with large expansion ratios (1 :6, 1 :9) of foreign tissue preserved in glycerol (holland skin), can be transplanted using a "sandwich" technique. Foreign tissue provides protection against unfavorable environmental conditions and results in a step-by-step epithelization of the wound. This results in the gradual removal of the foreign skin layers [34, 42]. The final results regarding the scar quality, are, however, assessed as problematic.</div> <bR> <div> If no adequate split-skin grafts are available for transplantation, alternative methods, for example the cultivation of eratinocytes from an approximately 3 x 5 cm large skin graf t, are recommended.</div> <div> Then, the tissue culture should be cultivated and applied to the necrectomied areas as keratinocyte-sheets or keratinocyte-suspensions. These are single-layer tissue strips that consist only of epidermal cells [28, 34, 36, 37, 39].</div> <bR> <div> Research activity is now aimed at growing multiple-layer tissue strips that conform more closely to the normal skin structure. However, clinical results are not yet available[27].</div> <bR> <div> Another alternative for transplantation is a dermis-substitute INTEGRA@ [22, 42]. This is a foil consisting of bovine collagen, chondroitin-6-sulphate gained from shark cartilage, and a silicon layer. It can protect the necrectomic wound for up to six weeks. During this time, fibroblasts grow into the foreign matrix and build an extra-cellular dermis structure. After peeling off the silicon foil, an extra thin split-skin graft can be transplanted onto this structure.</div> <bR> <div> After surgical treatment, the patient is placed in a foam rubber bed. In cases where transplanted areas and necrectomic areas are on the patient's back and/or buttocks, the patient should be placed in a micro-glass ball bed for at least five days in order to ease the strain on the operated areas. The ability to individually regulate the ternperature makes it possible to establish a "dry climate" which helps to prevent the development ot bacteria on the wound.</div> <bR> <div> <B>PHYSIOTHERAPY / ERGOTHERAPY</B></div> <div> In addition to the above described treatment, physiotherapy and ergotherapy are important constituents in the treatment measures of a seriously burn injured patient. The healthy functioning of the joints or the restoration of their functions is crucial tor the recovery of the patient. Regular pulmonary physiotherapy and inhalation therapy can also contribute to the success of the healing process. This treatment should be started as early as possible. In our clinic, we begin with this treatment at the third day post-trauma.</div> <bR> <div> After necrectomy and transplantation operations on the affected joints and limbs, physiotherapeutic treatment can begin on the third day post-op.</div> <bR> <div> <B>PSYCHOLOGICAL ASSISTANCE</B></div> <div> The psychological treatment of patients with burn injuries should begin directly after the awakening from narcosis or after artificial respiration. Psychologists with experience in burn injury assistance are able to alleviate only a small portion of the patient's suffering. The attending physicians and nursing personnel should be trained in psychological attendance as well. Due to the patient's changed appearance, he/she will rernain in conflict with himself for the rest of his life. The traumatic event has a very strong psychological effect on the patient.</div> <bR> <div> The main task ot a psychologist is to help the patient to overcome Posttraumatic Stress Disorder (PTSD). In other words, fear and despair, searching for a way of gaining control over stress and pain, learning to accept the changed appearance, finding a new identity and gaining self-confidence [14, 30] .</div> <bR> <div> It is essential to begin therapeutic procedures as early as possible in order to achieve better results. Relatives, friends and self-help groups should also be involved in the therapeutic activity.</div> <bR> <div> <B>POST- TREATMENT</B></div> <div> The surgical treatment of burn injuries should be completed no later than the 14th day post-trauma. This advancing treatment is aimed at covering the surface the wound and, thus, minimizing the risk of infection and sepsis. Following the surgical treatment is a stage of treatment that is lengthy and</div> <div> expensive but crucial in order to minimize scarring. This compression treatment involves the application of custom-made compression suits. The treatment requires at least one year. At the same time, this treatment reduces the itching in the scarred areas which can cost the patient sleepless nights. In our view, the usage of silicon-sheets or gel-sheets is worth applying in the treatment of scars. The maturation of scars advances quicker, and the scars have a softer consistence. The daily medical care of scars is completed with treatment with the respective ointments and lotions, for example, Bepantol-Lotion, Panthenol ointment, Calendula ointment, Synchroline-Terproline, etc.</div> <bR> <div> In addition to the physiotherapeutic methods described above, the wearing of splints over contractures can become necessory [26, 29] .The psychological follow-up of the seriously burn injured patient is as important as the appearance of the patient [9].</div> <bR> <div> <B>FOLLOW-UP</B></div> <div> One should take into consideration that a seriously burn injured patient is a lifelong patient. A long-term follow-up succeeds clinical treatment; after rehabilitation in a hospital, the patient is faced with an expensive and, at the moment, bothersome scar treatment.</div> <bR> <div> Moreover, further surgical corrections for optimum recovery of appearance and function are necessary. This treatment is performed in a hospital. One of the methods used in the correction of scars is plastic surgery (scar corrections with and without tissue expansion, free skin flap technique and laser surgery) [1].</div> <bR> <div> In addition to the above mentioned procedures, professional and social reintegration is the most important process for the burn patient .</div> <bR> <div> <B>LITERATURE</B></div> <bR> <div> 1. Achauer, B.M.: Burn Reconstruction. Thieme Medical Publishers Inc. NewYork 1991</div> <div> 2. Alsbjorn,B., Micheels, J., Sorensen, B.: Laser doppler flowmetry measurements of superficial dermal, deep dermal and subdermal bums. Scand. J. Plast. Reconstr. Surg.18, 75-19,1984</div> <div> 3. Atiles, L. et al.: Laser doppler flowmetry in burn wounds. Journal of Burn Care 16,4,388-393,1995</div> <div> 4. Bastlan, L. et al.: Praktikabilität und Komplikationen bei der frühzeitigen enteralen Ernährung schwerstpolytraumatisierter Patienten über Duodenalsonden. Unrallchirurg 99,642-649,1996</div> <div> 5. Bauer, J.A.,Sauer, T.: Cutaneous 10 MHz ultrasound scan aIlows the quantitative assessment of burn depth.BURNS 15,49-51,1989</div> <div> 6. Bellomo, R.,Tipping, P., Boyce, N.: Continuous veno-venous hemofiltration dialysis removes cytokines from the circulation or septlc patients. Crit. Care Med. 21,4,522-526,1993</div> <div> 7. Berger,M.M., Chiolero,R.: Relations between copper, zinc and selenium intakes and malondialdehyde excretion after major burns. BURNS 21,7, 501-512,1995</div> <div> 8. BischolJ, M. et al.: Sinnvoller Einsatz von Externa bei der Behandlung von Wundinfektionen. </div> <div> Akt. Traumatol. 28, 181-188,1998</div> <div> 9. Blalock, S.J. et al.: Measuring health status among survivors of burn injury: revisions of the burn specific health scale. Journal of Trauma 36,4, 508-515,1994</div> <div> 10. Bone, R. et al.: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.Chest 101,1644-1655, 1992</div> <div> 11. Cotrelli, Mehta: Cytokine kinetlcs in septlc ARF patients on continuous veno-venous hemodialysis (CVVHD) .25th Ann.Meeting of ASN/Washington, Nov.15-18, 1992</div> <div> 12. Davies, M.P., Ward,D.J.: Long-term gastrointestinal problems in burn patlents. </div> <div> BURNS 19, 5,423-425,1993</div> <div> 13. Deitch, E.A., Specian, R.D., Berg, R.D.: Endotoxin induced bacterial translocatlon and mucosal permeability: role or xanlllinoxidase, complement actlvation and macrophage products. </div> <div> Crit.Care Med. 19,185-191,1991</div> <div> 14. Dorfmüller, M.: Psychologische Betreuung und Nachsorge Schwerbrandverletzter. </div> <div> Unfallchirurg 98, 213-211, 1995</div> <div> 15. Essex, T.J.H., Byme, P.O.: A laser doppler scanner for imaging blood flow in skin.</div> <div>  J.of Biomedical Eng. 13 (May) 189-194,1991</div> <div> 16. Ganser, M.P. et al.: Septic shock: pathogenesis. The Lancet 338, Sept.21,1991</div> <div> 17. Germann, G.,Hartmann, B., Wentzensen, A.: Behandlung Schwerbrandverletzer. </div> <div> Aus: Oestem,H.J., Probst,J. Unfallchirurgie in Deutschland, Kap.51, Springer Verlag 1997</div> <div> 18. Germann, G., Steinau, U.: Aktuelle Aspekte der Verbrennungsbehandlung. </div> <div> Zentralbl Chir 118, 290-502, 1995</div> <div> 19. Groeneveld, A-B.J.: Septic shock and multiple organ failure: treatment with hemofiltration? </div> <div> Intensive Care Medicine 16, 489-490, 1990</div> <div> 20. Hartmann, A., Soldan, A.: Zur vertikalen Penetration wäßriger Polividon-Jod-Hautdesinfektionsmittel in die Haut des Menschen. Z.Hautkr. 67, 1085-1089, 1992</div> <div> 21. Harnsbrough, J.F., Zapata-Sirvent, R., Hoyt, D.: Postburn Immune suppression: an inflammatory response to the burn wound J.Trauma 50, 671-675, 1990</div> <div> 22. Heimbach, D.M.: Early burn excision and grafting.</div> <div> Surg.Clin.North Amer. 67, 95-107, 1987</div> <div> 25. Kallenberger,A., Kallenberger, Chr., Willenegger, H.: Experimentelle Untersuchungen zur Gewebeverträglichkeit von Antiseptika. Hyg.Med.,Sonderdruck, 10, 5-15, 1991</div> <div> 24. Klammer, H.L.: Die Versorgung des Brandverletzten unter Katastrophenbedingungen. </div> <div> Schriftenreihe der Bayerischen Landesarztekammer Bd.58, 198-210, 1981</div> <div> 25. Krawehl-Nakath, C., Brockmann, M., Scholten, S.: Die Behandlung der Verbrennungswunde mit einem Kohlefasertuch -Sorusal, Legius -ein neues Behandlungsprinzip</div> <div> 28.Jahrestagung der Vereinigung der Deutschen Plastischen Chirurgen, </div> <div> Würzburg, 24.-25. September 1997</div> <div> 26. Lambert, K.: Krankengymnastik bei Schwerbrandverletzten. Unfallchirurg 98,209-212,1995</div> <div> 27. Lanza, R.P., Langer, R., Chick, W.L.: Principles of Tissue Engineering.</div> <div> Academic Press. R.G.Landes Company, Austin, Texas, USA, 1997</div> <div> 28. McAree, K.G., Klein, R.L., Boeckmann, C.R.: The use of cultured epithelial autografts in the wounds of severely burned patients. J. of Pediatric Surgery 28, 2, 166-168, 1995</div> <div> 29. Nickerl, U., Resag, I.: Ergotherapie bei Schwerbrandverletzten. </div> <div> Unfallchirurg  98, 204-208, 1995</div> <div> 30. Powers, P.S. et al.: Posttraumatlc stress disorder in patients with burns. </div> <div> Journal of Burn Care & Rehabilitation 15, 2, 147-155, 1994</div> <div> 31. Pruitt, B.: Complications of thermal injury.</div> <div> Clin.Plast.Surg. 1, 667-691, 1974</div> <div> 32. Pruitt, B.: Management of bums in the multiple injury patient. </div> <div> Surg.Clin. of North America 50, 6, 1283-1300, 1970</div> <div> 33. Regel, G. et al.: Humorale und zelluläre Veränderungen der unspezifischen Immunabwehr nach schwerem Trauma. Unfallchirurg 92, 314-320, 1998</div> <div> 34. Schlozer, 'lV.A. et al.: Composite grafts of autogenic cultured epidermis and glycerol-preserved allogenic dermis for definitive coverage of full-thickness burn wounds: </div> <div> case reports. BURNS 20, 6, 503-507,1994</div> <div> 35. Steen, M.: Die Verbrennung -Klinik und Pathophysiologie. Beilage zu Mitteilungen der Deutschen Gesellschaft für Chirurgie. Heft 4, 17a-27, 1994</div> <div> 36. Still, J.M.Jr., Orlet, H.K., Law, E.J.: Use of cultured epidermal autografts in the treatment of large burns.BURNS 20, 6, 539-541, 1994</div> <bR> </td> </tr></table></body>