War Surgery and Medicine
SECOND WORLD WAR
SECOND WORLD WAR
Classification of Burns
Before the Second World War burns were classified into many categories depending on the depth of the burn in relation to the different layers of the skin, commencing with the hyperaemia of the skin and extending to the complete destruction of all skin layers. For practical purposes this was of little or no use, and a simple classification of burns into (1) superficial (partial skin loss), and (2) deep (complete skin loss) was adopted and proved quite satisfactory.
Burns accounted for about 10 per cent of all army casualties, and accidental burns were two-thirds of the total. The most common cause was the use of petrol for lighting fires and also as fuel, such as in the Benghazi boiler used for making tea. In spite of repeated warnings petrol was recklessly used by the troops. Non-accidental burns casualties were seen in personnel of armoured cars and tanks.
In the early period of the war in the Middle East first-aid treatment consisted in treatment of the severe shock generally experienced in these cases, and the covering over of any exposed part of the burnt area with sterile dressings. Shock was relieved by warmth from blankets, by copious warm drinks, and by the relief of pain through moderately large doses of morphia. Later, sterile vaseline gauze and tulle gras were supplied to the field units, and these dressings were utilised as a primary dressing for any exposed burn. Plasma and serum were also available, and were administered even in the RAP in the serious cases before evacuation to the forward operating centre.
It was realised from the beginning of the war that severe shock was always present in any extensive burn, and that if more than a third of the surface of the body was affected the prognosis was grave. The treatment at the forward operating centre, either the CCS or an MDS, was at first the continuance of the first-aid treatment of warmth, free fluids, and morphia, with the addition of intravenous glucose saline, especially when vomiting was present. Blood transfusion was made available in the Middle East and steadily became the regular treatment for shock in wounded cases. It was not given to patients suffering from shock associated with burns in the same way, as it was realised that in burns it was not whole blood loss that was responsible for the condition of shock page 342 seen in these cases. Marked haemoconcentration of the blood in severe burns had been recognised prior to the war, and this led to the use of plasma instead of whole blood as the logical treatment for shock in burns cases. It had been known for a long time that there was considerable loss of plasma from the burnt surface, and it had more recently been recognised that there was also a great loss into the tissues around the burnt area. This loss had been estimated at 70 per cent of the total blood volume when one-sixth of the body surface was burnt. The loss from the surface had been one reason for the popularity of the tannic acid treatment, which had largely prevented this loss. The development of severe shock in spite of the tanning showed that the surface loss was not of major importance, and research clearly proved this to be true.
Other causes were thought to be partly responsible for shock, particularly the absorption of histamine substances from the damaged tissues, and the marked reaction from the destruction of skin. Research, however, did not disclose the presence of any histamine bodies, and the loss of plasma was held to be the main contributory factor in the production of shock, which was responsible for nearly 90 per cent of the deaths from burns.
The symptoms of shock were similar to those experienced in wounded cases suffering from loss of whole blood. There was the same fall of blood pressure, the rapid pulse, subnormal temperature, and cold clammy skin. Intravenous plasma was the logical treatment and was advised by Sir Harold Gillies and Rear Admiral Wakeley during the first year of the war. Sufficient supplies of plasma were made available in the Middle East for the treatment of burns, and plasma very soon became established as the routine treatment of shock in burns cases and remained so throughout the war. By July 1942 it was noted that the importance of shock was being more and more realised, and that the haemoconcentration associated with loss of blood plasma into the tissues was considered to be the most important factor demanding treatment. It was then found that large quantities of up to 5 to 7 pints of plasma or serum might be needed and that at first it should be given quickly. This was stressed in December 1942 by Major-General Ogilvie, who advocated the giving of 3 pints quickly in severe cases, a pint in every five minutes, and 8 to 10 pints in the first forty-eight hours. He also advised the giving of a pint of blood to every 2 pints of plasma when any considerable bleeding had occurred. In the absence of plasma or serum, whole blood was given in preference to salines or glucose during the first forty-eight hours, but in smaller quantities.
The giving of large quantites of fluid was advised to ensure a urinary output of at least 700 cc., but preferably 1500 cc.page 343
In 1943 the Burns Sub-Committee of the Medical Research Council War Wounds Committee carried out experiments with regard to fluid loss. The amount of plasma required in relation to the haemoglobin was determined as:
|Haemoglobin (Per Cent)||Plasma Required|
Another method was by use of a haematocrit; 100 cc. plasma were given for every point the haematocrit reading was above 45, plus 25 per cent for every gramme the blood protein was below 6 gm. per 100 cc.
Later research in the United States showed that in severe burns the blood volume might be decreased by at least 2 litres, and the tissue volume by 6 to 10 litres by dehydration, loss of fluid from the surface, and oedema into the tissues. Replacement fluid of 800–1500 cc. was needed in the first forty-eight hours, equal quantities of plasma and saline being advised, as well as fluid by the mouth. A urinary output of 1500–2000 cc. a day was aimed at.
During 1944 the overwhelming importance of shock in the first forty-eight hours was more and more realised, and the primary treatment was concentrated on its relief by the administration of large quantities of plasma and general fluids, with rest and freedom from pain ensured by morphia. It was also realised that evacuation should not be undertaken till shock had been completely relieved. This routine continued till the end of the war.