First goal: prevent deaths from shock


East Baltimore Fire

May 23, 2007|By Chris Emery | Chris Emery,Sun reporter

As the victims arrived at Maryland's only specialized burn unit yesterday, the first concern of the medical team was ensuring that they didn't die of shock before doctors got a chance to tend to their burns.

"Our bodies normally take care of small wounds with no problem," said Dr. Robert Spence, director of burn reconstruction for the Johns Hopkins Burn Unit. "But a severe burn can send a person into shock."

A child and four adults, five of the seven injured in an East Baltimore house fire that killed six people, were taken to the burn unit at Johns Hopkins Bayview Medical Center, Spence said. Two of the adults were in critical condition last night.

Another child and another adult were taken to Johns Hopkins Hospital, Spence said. The adult was in critical condition last night.

Spence, 60, who led the Hopkins medical team treating the adults, said their injuries included deep burns on their hands and faces. A large portion of one patient's body was also burned.

"It runs the spectrum," he said of the injuries.

Although privacy laws prevented Spence from discussing treatment of specific patients, he described the care people receive in the minutes, days and weeks after being burned.

In the United States, about 25,000 burn victims are taken to specialized burn centers annually, according to the American Burn Association. The Hopkins unit sees about 400 burn patients a year.

Adult patients are typically taken to the burn center if they have second-degree burns over more than 15 percent of their bodies, and children are taken there if they have burns over 10 percent of their bodies. Deep burns to the hands, feet, face and groin also warrant specialized care.

Severe burns pose special challenges.

"When you are burned to that extent, it's not only that your skin is damaged and will eventually have to be replaced or heal," Spence said, "but that the body also goes into an intense inflammatory response."

The body normally reacts to an injury by flooding the damaged region with fluids. But that response can be deadly for burn victims, doctors say, because the heavy release of fluids from the blood stream can send them into shock.

To prevent that, patients with burns over 60 percent to 70 percent of the body may receive nearly six gallons of fluid intravenously over their first day in the burn center, Spence said.

The problem of swelling tissues is compounded by the contraction of the surrounding skin in severe burns. That causes pressure to build, which can cut off blood flow to the feet and hands and lead to amputations.

To avoid that, doctors make incisions in the skin to allow it to break open and release the fluid, Spence said.

Severely burned patients are also put on respirators to prevent death from lung damage and to allow doctors to sedate them.

Lung injuries can result from burns to the upper respiratory tract or from inhaling noxious gases released by burning plastics and other materials. The gases can also poison patients and cause their windpipes to swell shut.

With so many advances in treating skin burns over recent years, Spence said, a patient's survival often depends on the severity of lung damage.

Historically, many burn victims died of infection within 48 hours, but the development of penicillin sharply improved their chances in the 1940s. The same was true of antibiotic creams, developed in the 1960s, that could be applied directly to the skin.

But first, wounds must be cleared of burned tissue, a process so traumatic that no more than 20 percent of the damaged tissue is removed at one time.

"We essentially shave down the dead tissue and get to bleeding tissue, and that tells us the tissue is alive," Spence said.

Doctors apply skin grafts as a temporary measure to allow the victim's own skin to grow back. The graft skin can come from the patient's body or, in cases where little intact skin remains, from a deceased donor.

A newer technique, used for patients with burns over most of their bodies, involves using a small amount of the victim's skin that is cultured in a laboratory.

"Within three weeks, the lab can have skin cells to cover the whole body," Spence said.

The cells are used to provide a thin skin graft.

"It's very expensive and difficult to work with, but it does save lives," Spence said.

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