Amputation As A Life-Saving Measure In The Burn Patient
John H. Winkley, M.D. Donald J. Gaspard, M.D. Louis L. Smith, M.D., F.A.C S.
The above report was abstracted from an article appearing in the Journal of Trauma, Vol. 5, No. 6, 1965.
In an attempt to assess the lethal factors associated with extremity burns, a study was made of the records of the Los Angeles County General Hospital Burn Service for a three-year period between September 1961 and September 1964. Cases selected were those where a major burn of one or more extremity was the prominent feature. Excluded were patients whose nonextremity burns comprised more than half the total area involved, those with definite respiratory tract burns, and those with digital amputations only.
Of the 487 admissions to the Burn Service during the study period whose major problem was full-thickness burns, 18 met the criteria cited. The patients were divided into two groups: those amputated as a lifesaving measure (Group I) and those not amputated (Group II). By chance, each group contained nine patients (Table 1 ).
Table 2 compares the two groups. The average age in Group I was 51, in Group II, 35. Despite the relative youth of the latter group, only one patient survived-a mortality rate of 89%. The two deaths in Group II occurred in patients with burns of 42 and 65 percent of body surface area respectively-the extreme upper limits of the study criteria. On the average, amputations were performed about the 12th postburn day- about a week, on the average, before the nonamputated patients died. Although no "golden period" is implied for amputation, it obviously must be performed prior to the onset of those events that statistically are known to be highly lethal. The following factors were associated with patient mortality.
1. Evidence of sepsis. Of the ten deaths in Groups I and II, the clinical impression was death due to gram-negative sepsis in nine and probable septicemia complicated by severe delirium tremens in the tenth. An open, necrotic wound in a debilitated patient presents an excellent opportunity for sepsis to occur. Every patient in the series had numerous wound cultures that invariably grew out gram-negative organisms.
In vitro isolation of these organisms from the blood was a continuing problem. The low incidence of positive blood cultures in the series (only two patients had positive results, one Pseudomonas, one Paracolon) probably reflects inadequate frequency of collection of specimens, as well as difficulty in obtaining laboratory growth of organisms obtained from patients receiving large doses of systemic antibiotics. Penicillinase was not routinely added to cultures in this series.
After successfully navigating the acute burn phase, with its subsequent diuresis, pulse rates increased and temperature spikes of 103 to 105 F were common. The patients became progressively anorexic and apathetic; oral hydration increased. Disorientation and inability to actively cooperate compounded the problem. In several patients the toxic state was heralded by frankly psychotic behavior. Ileus and abdominal distention with vomiting further complicated fluid and electrolyte balances. Hyperventilation due to fever, superimposed on the acidosis of tissue destruction and the patient's general catabolic state, served to complicate the acid-base balance. Leukocytosis, although not marked, was a constant finding. Blood pressures were unstable, urine outputs frequently were less than 20 ml per hour, and as a final event, shock unresponsive to heroic measures occurred.
2. Likelihood of hemorrhage. The depth of thermal injury may be difficult to judge. It was not unusual in the series to find thermal injury of muscle and, less often, bone-especially in thin patients or when areas notably lacking in subcutaneous tissue were burned, such as about joints or the anterior surface of the tibia.
It is unwise to assume a burn is simply full-thickness until one can be sure deeper structures are not also involved. Hemorrhage from necrotic vessels can present a complex technical task for the surgeon, who may experience great difficulty finding tissue suitable for ligation if salvage of the extremity is to be accomplished.
3. Evidence of extensive non-viability of the burned extremity (and hence subsequent sepsis). Of importance in the assessment of the severely burned extremity is the maximal functional result possible. Early surgical debridement of extensively burned extremities will result in a more rapid determination of the depth of burn, obviously earlier removal of necrotic tissue, and more rapid appraisal of the functional restoration possible. In this regard, primary excision and early grafting of extremity burns appears to be a worthwhile procedure. However, excision and immediate grafting has frequently been followed by loss of graft and a realization that the necrotic tissue extended much deeper than originally thought.
Until the depth of the burn is accurately assessed, no estimate of distal extremity viability can be made. The earlier this determination is made, the more rational is the decision to attempt to salvage the limb or elect amputation, and the lower will be the risk of intervening sepsis. A vigorous diagnostic approach is advocated.
Comments and Conclusions
From the authors' experience, early and extensive debridement to remove the source of infection in burn cases has had little effect on mortality. The severely burned extremity provides an opportunity to remove the entire source of septicemia surgically, thereby remarkably lowering the mortality rate. Apparently the reason why septicemia is not satisfactorily treated in the burned patient is that the source of infection is more extensive than it is, for example, in the patient with septicemia secondary to pneumonia or subacute bacterial endocarditis.
Although the authors are not dissuaded from attempting to save deeply burned extremities on the basis of this small group of patients, they do point out the possible sequelae of such a venture-sepsis, hemorrhage, and nonviability. More important, they state, is the early assessment of these factors and the decision to amputate sooner rather than later.