breast cancer ovarian ablation significantly improves long-term survival(a). It is useful
in advanced, metastatic disease to induce regression or delay spread. If no response is obtained, second-line agents (aminoglutethamide, progestagens) can be used.
Pain relief and counselling
Oral opiates, non-steroidal agents, radiotherapy and steroids (for cerebral involvement) should be used liberally when the disease advances and symptoms develop. Drainage of effusions and ascites may be beneficial. Councelling and contact with a hospice are helpful in the late stages of disease.
Breast screening
Evidence that breast screening reduces mortality from breast cancer in women in New York, Holland and Sweden has resulted in the UK breast screening programme offered to women aged 50–64. No clear survival advantage has yet been seen in the UK, although more early tumours are being detected and treated. A considerable increase in work load has resulted and women are unecessarily alarmed when mammograms are falsely positive.
Treatment of high-risk groups
Studies are underway to examine the protective effect of tamoxifen in patients at high risk of developing breast cancer by virtue of their family history.
Further reading
Dixon JM, Mansel RE. The breast. In: Burnand KG, Young AE (eds). The New Aird’s Companion
in Surgical Studies (2nd Edn). London: Churchill Livingstone, 1998:631–663.
Early Breast Cancer Trial Lists Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet, 1998; 351:1451–1467.
Early Breast Cancer Trial Lists Collaborative Group. Polychemotherapy for early breast cancer: an overview of the randomised trials. Lancet, 1998; 352:930–942.
Early Breast Cancer Trial Lists Collaborative Group. Favourable and unfavourable effects on long- term survival of radiotherapy for early breast cancer: an overview of the randomised trials.
Lancet, 2000; 255:1739–1740.
Krag DN, Harlow S, Weaver D, Ashicaga T. Radiolabelled sentinel node biopsy: collaborative trial with the national cancer institute. World Journal of Surgery, 2001; 25:823–828.
Related topics of interest Benign breast disease (p. 45); Screening (p. 293).
BURNS
Christopher Lattimer, Omar Faiz
Burn injuries often result in profound physical and metabolic insult. Those most at risk include alcoholics, epileptics, drug addicts and the mentally handicapped. Children under six are most liable to scald injuries from bath water, hot drinks and kettle spills. The mortality associated with severe burn injury reaches 90% in patients: with>40% surface area burns; over 60 years of age; and those with concomitant inhalation injury(a).
Treatment involves an aggressive approach, with close collaboration between the intensivist, plastic surgeon and microbiologist, to curb mortality from fluid loss and sepsis.
Fluid replacement
A burn results in a substantial loss of fluid, protein, blood and heat. The percentage of total body surface area burnt (%TBSA), and consequently the severity of the injury, is estimated from the Wallace Rule of Nines chart. One per cent of the patient’s TBSA is represented by the palmar surface area of the subject’s hand. Adults suffering a burn greater than 15% surface area, or children greater than 10%, require admission and fluid resuscitation. The Muir and Barclay regime calculates fluid replacement requirement during the first 36 hours. Each of the six time periods requires an equal volume of fluid replacement in addition to normal requirements.
Period 1 2 3 4 5 6
Duration (hours) 4 4 4 6 6 12
This formula is only a guide which must be adjusted according to regular measurement of haemoglobin, haematocrit, electrolytes and urinary output. Another regime commonly used is the Parkland formula which suggests an approximate guide to fluid resuscitation over the first 24 hours of 4 ml/kg of body weight/% area of surface burn. Severe burn injuries predispose to a generalized increase in vascular permeability (including ARDS) with a concomitant decrease in cardiac output. The latter changes have been attributed to the release of inflammatory mediators, such as IL-6 and TNFα, and the humoral response
to burn injury. It was previously believed that crystalloids exacerbate the latter complications and should be avoided. In consequence, albumin has been the mainstay of resuscitation for major burn injuries. Recently, systematic reviews have raised doubts over the safety of colloid resuscitation (particularly albumin) and a universal protocol for acute fluid resuscitation in burn injuries is yet to be agreed(a).
Analgesia
Intravenous morphine is the most appropriate analgesic and can be administered from a patient-controlled analgesia system. Cool water (uncovered ice is harmful) is an effective analgesic for smaller burns and has been demonstrated to reverse tissue damage(b). Rectal
paracetamol is useful for pyrexia in children.
Sepsis
Burnt surfaces provide an excellent culture medium for bacteria. Colonization is rapid and the associated immunosuppression with large burns makes septicaemia a common complication. Staphylococcal, Pseudomonas and Candida organisms are the commonest wound offenders. Severely burnt patients should be isolated and barrier nursed. Intravenous antibiotics are required for septic episodes (including: septicaemia, pneumonia, UTI or cellulitis) but should never be administered prophylactically as this practice favours colonization with resistant strains thereby complicating the treatment of established infections. Signs of sepsis can be subtle as core temperature is often elevated in severely burnt patients. These may include: changes in clinical condition or mental status; either elevation or depression of the white cell count (WCC); acidosis; hypoxia; thrombocytopenia or hyperglycaemia. Regular cultures of the urine, sputum, wound and blood are taken to determine appropriate antibiotic therapy.
Nutrition
All burns require high-energy dietary supplementation to facilitate healing. In severely burnt patients basic metabolic rate can double leading to severe catabolism. Fine-bore nasogastric feeding should be used for patients with large burns as it can deliver essential nutrition, as well as bolstering the gut mucosal barrier to infection. Parenteral feeding lines present a high risk of infection and are consequently best avoided. A dynamic ileus, acute gastric dilatation and stress (Curling’s) ulceration frequently follow major burn injuries and prophylactic measures should be taken to avoid them.
Open or closed therapy?
Burns of the face and perineum as well as all superficial burns should be treated by exposure. A dry eschar discourages bacterial colonization and often separates
spontaneously after two weeks. Closed treatment involves covering the burn with Vaseline gauze and leaving the inner layers undisturbed for 10 days. Bums are often covered with topical silver sulfadiazine—an agent with broad antibacterial activity. All closed treatments moisten the eschar thereby preventing spontaneous separation. Surgical debridement under general anaesthesia is consequently required.
Surgery
The surgical approach depends upon the extent and depth of the burn. A general guide to depth identification is tabulated below.
Depth Sensation Blistering Colour Healing
Superficial (First degree)
Painful Often Pink Regeneration
Deep dermal (Second degree)
Analgaesic Occasional White/yellow Repair Full thickness
(Third degree)
Anaesthetic None Grey/olive Contraction
Superficial burns heal by regeneration from undamaged keratinocytes in hair follicles, sebaceous glands and sweat glands. Deep dermal burns mostly heal by repair but are capable of some regeneration from the deeper situated sweat glands. The latter burns are treated by tangential excision (shaving) using a skin graft knife between the third and fifth day to preserve the deeper dermis that would otherwise die. This occurs as the interface between viable and non-viable tissue deepens from the time of injury due to thrombosis of the surrounding microcirculation. Grafts take well on this prepared surface. The application of temporary synthetic skin substitutes may also be used for superficial and dermal burn injuries where spontaneous healing is possible. Their use has been shown to significantly reduce healing time(b). Full thickness burns require excision and
skin cover. If small (1–2 cm), the surrounding skin can be sutured directly over the defect. Full thickness burns over the face, palms and pressure areas or over denuded perichondrium, periosteum or paratenon require full thickness skin cover. Larger defects are covered with allogenic meshed split skin grafts. In extensively burnt patients the paucity of available donor sites complicates management.
Escharotomy
Deep circumferential burns of the chest or limbs require urgent relieving incisions (escharotomies) to prevent respiratory or vascular compromise.
Inhalation injuries
Inhalation injuries are suspected from the appearance official oedema, singed nasal hair and oropharyngeal carbon staining along with stridor and bronchospasm. Inhalation injury comprises three main mechanisms which commonly occur together. These include: carbon monoxide (CO) poisoning; airway heat injury; and inhalation of toxic gases released from the incomplete combustion of synthetic materials such as plastic furnishings, paints and fabrics. Treatment comprises: airway maintenance (occasionally emergency tracheostomy); humidified oxygen; and bronchodilators. CO levels should be monitored in the patient with suspected inhalation injury.
Electrical burns
Electrical burns are usually much deeper, and more extensive than the skin wounds might suggest. Current flows preferentially along nerves, muscle and blood vessels as the latter present less resistance than the skin. The current is transferred into heat energy in vivo with resultant protein denaturation and tissue destruction.
Arrhythmias, compartment syndrome and myoglobinuria complicate electrical burn injuries and require early and aggressive treatment. Wounds should be debrided early and may require subsequent excision of necrotic tissue prior to eventual grafting.
Acid/alkalis burns
Acid burns damage tissues by coagulative necrosis and alkaline burns (e.g. cement) damage by, more prolonged, colliquative necrosis. Treatment of chemical burns consists of immediate immersion in running water until wound pH has returned to normal. This process can take several hours with alkaline burns.
Aftercare
Severe burn injury patients often require multiple plastic surgical procedures for scar revisions and release of skin contractures. Unfortunately, rehabilitation can take years and, due to hypertrophic scarring, total cosmetic resolution is often not achieved. This can have a profound psychological impact on the patient and highlights the need for counselling as part of the rehabilitation process.
Further reading
Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: a systematic review of randomised controlled trials. British Medical Journal 1998;
317:235–240.
Muller MJ, Herndon DN. The challenge of burns. Lancet, 1994; 343(8891): 216–220.
Robson MC et al. Prevention and treatment of postburn scars and contracture. World Journal of
Surgery, 1992; 16:87.
Related topics of interest
Fluid replacement (p. 127); Multiple organ failure (p. 227); Nutrition in the surgical patient (p. 233).