Diagnosis of burn depth using laser-induced indocyanine green fluorescence: a preliminary clinical trial.

Clinical assessment of burn depth is frequently inaccurate. In order to effectively plan the treatment of burn wounds, an accurate diagnosis of burn depth is desirable. A new method for evaluating the depth of burns by imaging the blood flow through the burned tissue using fluorescence from intravenously injected indocyanine green (ICG) dye illuminated with a 785-nm, near-infrared diode laser array was evaluated. Nine patients and 15 individual burn sites were studied. Five sites were classified by the ICG study as superficial second degree, four were deep-dermal second degree, and six were third degree. Etiology of the injuries included flame, contact burns, and scalds. The date postburn of the study ranged from 1 to 11 days. In all cases, the relative fluorescence levels (e.g. superficial second-degree burns yielded relatively bright fluorescence, third-degree burns appeared much darker than surrounding normal skin) were found to correlate well with actual burn depth as determined by histologic examination of biopsies and intraoperative clinical assessment.

Primary excision of the burn wound.

Early excision of burn eschar and wound closure significantly improves survival following major burn injury. Immediate primary excision performed by burn-experienced surgeons in dedicated burn care facilities can reduce further morbidity and mortality, length of hospital stay and medical costs. Burn care at the millennium is evolving rapidly into a subcategory of trauma surgery, with burn patients increasingly being viewed as victims of major trauma who benefit most from immediate and definitive surgical correction of their injuries.

A regional medical center's experience with burns of the elderly.

For a 10-year period, the cases of 236 patients aged 60 years old or older were evaluated with regard to mortality and length of hospital stay. Multiple variables were evaluated. Total mortality for the entire group was 41.9%. Mortality was adversely affected by increased age and the development of complications after admission. Larger burn size increased mortality when it was considered in association with the presence of inhalation problems sufficiently severe to require a ventilator. Mean length of stay for survivors was 34.04 days. Length of stay (LOS) was increased in association with larger burn size, preexisting medical problems, and the development of complications after admission. The increase in the number of elderly patients as part of the in-hospital burn population mandates evaluation of this growing group.

A multicenter clinical trial of a biosynthetic skin replacement, Dermagraft-TC, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds.

This multicenter study compared the use of a biosynthetic human skin substitute with frozen human cadaver allograft for the temporary closure of excised burn wounds. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) consists of a synthetic material onto which human neonatal fibroblasts are cultured. Burn wounds in 66 patients with a mean age of 36 years and a mean burn size of 44% total body surface area (28% total body surface area full-thickness) were surgically excised. Two comparable sites, each approximately 1% total body surface area in size, were randomized to receive either DG-TC or allograft. Both sites were then treated in the same manner. When clinically indicated (> 5 days after application) both skin replacements were removed, and the wound beds were evaluated and prepared for grafting. DG-TC was equivalent or superior to allograft with regard to autograft take at postautograft day 14. DG-TC was also easier to remove, had no epidermal slough, and resulted in less bleeding than did allograft while maintaining an adequate wound bed. Overall satisfaction was better with DG-TC.

Long thoracic nerve injury due to an electric burn.

A 19-year-old white man was burned over 7.5% of his body when he sustained an electric injury from a transformer. There was no associated fall or loss of consciousness. Debridement and grafting were required. The patient had some transient weakness of the muscles of his right arm associated with lower cervical nerve-root injury. This subsequently improved. He also was found to have paralysis of the serratus anterior muscle, with winging of the scapula due to long thoracic nerve injury. This has not improved. A surgical procedure suggested to improve function of the shoulder was rejected by the patient. This is only the second case reported of long thoracic nerve injury due to an electric burn of which we are aware.

Decreasing length of hospital stay by early excision and grafting of burns.

All acutely burned patients admitted to one surgeon's practice during a 1-year period were considered for burn excision and grafting. A total of 222 patients were enrolled; 57 did not have surgery. In all, 130 patients having surgery within 24 hours after admission were compared with 48 patients having excision later than this. Sex, age, burn size, number of operative procedures, and number of deaths were not significantly different statistically. The proportion of acute readmissions was not significantly different. The patients in the early excision group had a significantly shorter hospital stay for the first admission and for total length of stay for acute care, since if the length of stay for the first acute admission was added to the duration of hospitalization at any second acute admission, the early excision group again had a significantly shorter total length of stay. It appears that early burn excision (defined as within 24 hours of admission in this series) results in a reduced length of hospital stay without adverse effects on clinical outcome.

Burn due to a sawdust explosion.

Burns due to explosions of various types of inflammable dust have been reported, including coal dust, flour and grain dust. A 33-year-old worker was burned over 33 per cent of his body surface area in a sawdust explosion. Recovery was uneventful. This is the first reported case due to this mechanism as far as we have been able to ascertain.

Burns due to flammable solvents ignited with floor buffers.

Three patients, employed by janitorial service agencies, were burned severely while buffing floors. A solvent to remove floor lacquer was used in one case, and a solvent to remove glue that held carpet to the floor was used in the other two cases. The solvent used in each case is flammable and was ignited when a floor buffer was used near it. The floor buffers are specifically labeled as unsafe to operate near flammable liquids. The patients' injuries were severe. All three patients survived. This represents a rather unusual and unsafe industrial practice that should be avoided.

An evaluation of excision with application of autografts or porcine xenografts within 24 hours of burn injury.

An evaluation of feasibility and safety of excising burn wounds within 24 hours of injury was carried out. Over a 2-year period, 124 patients were admitted and taken to the operating room within 24 hours of initial burn injury. All cases were from one surgeon's practice. There were 99 males and 28 females. Age ranged from 8 months to 93 years. Burn size ranged from 0.5% to 70%, with a mean of 17.59%. Time from injury to surgery varied from 2 hours 10 minutes to 23 hours 40 minutes, with a mean of 14.42 hours. All patients admitted within 24 hours of injury were considered for immediate excision. Patients admitted too late in their course to receive excision within 24 hours were not included in the evaluation. Second-degree burns were treated with tangential debridement and porcine xenografts. If third-degree burns were obviously present, electrocautery excision was carried out followed by cadaver grafting or autografting as appropriate. Blood loss ranged from 0 to 2000 cc (mean, 215.08 cc) for the first surgery. The mean number of operations per patient was 1.72. Very large burns underwent staged procedures. There were five deaths (4.0%) in the group. There were no operative deaths. Twenty-three patients required readmission for further treatment, usually including surgery. It appears that excision within 24 hours of injury is safe. There is the obvious benefit of a reduced hospital stay by decreasing the time to surgery and the theoretical advantage obtained by early removal of sources of infection.

Management of candida septicaemia in a regional burn unit.

Sepsis due to candida infection is a major cause of mortality and morbidity on our unit. Over a period of 3 years and 4 months, 29 cases of candida septicaemia, diagnosed by blood cultures, were encountered at the burn unit at Augusta Regional Medical Center. Factors known to predispose to fungal sepsis were present in all cases. All patients had large burns (14-98 per cent total body surface (TBSA) with a mean of 48.3 per cent). All but one patient had at least one central venous line. Respiratory problems requiring ventilator support were present in 24 patients. Sixteen patients had Candida albicans sepsis, two in association with another fungal sepsis. Candida parapsilosis was encountered in nine patients, one in combination with another species. Four patients had Candida tropicalis. Amphotericin B was prescribed therapeutically in 25 patients, in seven together with fluconazole. Two patients received fluconazole only and two received no antifungal therapy. There were eight deaths all attributed to sepsis and all of whom had multiple organ failure. Five of those who died had completed a course of amphotericin B therapy, two were receiving treatment at the time of death, and one patient died before culture data became available. Early and aggressive therapy is advised and amphotericin B appears to be the drug of choice.

Development of an epidural abscess following staphylococcal septicemia in an acutely burned patient: case report.

A 57-year-old black female burned in a house fire sustained 22.5% total body surface area burns. On postburn day 45, she developed Staphylococcus aureus septicemia, and vancomycin was begun. On postburn day 50, quadriplegia developed. Magnetic resonance imaging revealed an anterior cervical mass, and cervical drainage of a staphylococcal cervical abscess was conducted. Antibiotics were continued. The patient regained almost complete neurologic function and was discharged doing well.

Experience with burns of the eyes and lids in a regional burn unit.

During a 3-year period 1527 patients with burns were admitted to a regional burn unit in Augusta, Georgia. Two hundred thirty patients (15.06%) were referred for consultation by an ophthalmologist. Thirty-two patients had preexisting ophthalmic problems that were believed to warrant consultation. One hundred eighty-nine patients were seen because of facial burns. Of these, 143, or 9.36%, had burn injuries of the eyes or lids that required care. Lid involvement was encountered in 122 (7.98%) cases. In 78 cases lid involvement was bilateral (in the remainder, unilateral). In 61 cases thermal or chemical burns to the conjunctiva or lens were present. Skin grafts to the lids were required for acute care in 11 instances. Tarsorrhaphies were done in 11 instances. In one case the lids were essentially destroyed, and extensive reconstruction with flaps was needed. Late reconstruction with grafting of the lids was done in five cases. In three eyes (two patients) enucleation was eventually required. Ten patients without burns who had toxic epidermal necrolysis were also treated on the unit. Consultation with an ophthalmologist is believed to be important in patients with significant ocular or periocular injury. The importance of maintaining moisture to the globe is stressed.

A comparison of susceptibility to five antifungal agents of yeast cultures from burn patients.

Patients with significant degrees of immunocompromise, such as cancer, AIDS and large burns, who have received significant amounts of antibiotics, may develop infections with yeast organisms. Over a 3-year period, all patients with positive fungal blood cultures and most wounds of patients with large burns considered to be a risk of yeast infection were selected and tested for their susceptibility to five antifungal agents, amphotericin B, ketoconazole, miconazole, diflucan, and 5-fluorocytosine. In all, 244 specimens of yeast were tested: 142 Candida albicans, 52 Candida parapsilosis, 26 Candida tropicalis and 13 Trichosporon beigelii. A limited number of other isolates of Candida (12) were also encountered. All Candida organism were sensitive to amphotericin B. There was wide variation in regard to the susceptibility to the other four agents, with C. albicans and C. tropicalis being largely resistant to miconazole and ketoconazole. T. beigelii was recovered in 13 patients. One-half of these organisms was resistant to amphotericin B. Awareness of variations in species and susceptibility are helpful in the selection of appropriate therapeutic antifungal agents.

A double-blinded prospective evaluation of recombinant human erythropoietin in acutely burned patients.

OBJECTIVE: To evaluate the effects of recombinant human erythropoietin (r-HuEPO) in attempting to prevent anemia in acutely burned patients. DESIGN: Prospective double-blind randomized study of 40 patients. METHODS: Patients with burns from 25% to 65% total body surface were enrolled. r-HuEPO or a placebo was begun within 72 hours of admission. Cell blood count, reticulocyte counts, transfusion requirements, and blood loss were measured. Comparison was carried out by the unpaired t test. MAIN RESULTS: There was no statistically significant difference in hemoglobin, hematocrit, reticulocyte count, ferritin, serum iron, total iron blinding capacity, or transfusion requirements. In patients with burns from 25% to 35%, the reticulocyte counts were statistically significantly higher. CONCLUSION: In our work the administration of r-HuEPO in acutely burned patients did not prevent the development of postburn anemia or decrease transfusion requirements. Increased erythropoiesis in smaller burns (25% to 35%) was observed and may indicate a reason for further study.

Use of cultured epidermal autografts in the treatment of large burns.

Mortality in patients with large areas of full skin thickness burns is, in part, due to complications developing during the period of prolonged delay required to obtain enough wound healing to permit skin grafting from limited donor sites. Cultured epithelial autograft (CEA) has become available as an alternative measure to the use of expanded skin autografts and regrafting. Small biopsies are taken and transported to the laboratories of BioSurface Technology where keratinocytes are grown to cover large areas during a 3-week period. The cultured keratinocytes are then available on petroleum jelly gauze which is applied to the patient. The gauze is used as a temporary dressing. To date, 37 patients have been biopsied. Grafts have been applied in 15. Graft 'take' averaged 71.5 per cent at our institution. Two of the patients grafted with CEA died of sepsis. One patient had a 100 per cent loss of the CEA grafts. In 12 patients, the use of CEA probably contributed significantly to wound coverage and survival. Such grafts are more susceptible to mechanical loss than routine autograft, although long-term coverage after several years is considered to be satisfactory. The cost of the process is high.

Trichosporon beigelii septicaemia in a burn patient.

A patient with Trichosporon beigelii sepsis secondary to a 31 per cent burn is reported. Good results were obtained by treatment with amphotericin B. No other reports of septicaemia due this organism in burn patients have been found by us, although the organism has been reported as a cause of sepsis in cancer patients.

Enterococcal infections as a cause of mortality and morbidity in patients with burns.

Enterococcal sepsis is a significant cause of death on our burn unit. In a 3-year period, enterococci were responsible for 11% to 13% of all infections. Bacteremias with enterococci ranged from 4.2% to 2.1% per year. Sixty-four percent of enterococcal bacteremias were polymicrobial. Septic deaths associated with enterococcal sepsis ranged from 20% to 10.3%. Antibiotic resistance to enterococci appears to be increasing.

Candida parapsilosis sepsis in patients with burns: report of six cases.

Six patients with burns who had Candida Parapsilosis septicemia were encountered during a 3-year period at a regional burn unit. Four patients treated with Amphotericin B survived; two untreated patients did not. Candida Parapsilosis seems to be increasing in frequency at our unit. The organism is somewhat more resistant to antifungal agents than are other Candida species.

Caecal perforation due to colonic ulcer in a burn patient.

Non-specific ulcers of the colon are occasionally reported as a cause of perforation of the colon. No previous cases have been reported in burn patients as a cause of perforation, although cases of haemorrhage have been cited. A 42-year-old black-skinned female with a 26 per cent TBSA burn developed a caecal perforation from this cause. Treatment with caecostomy patient recovered successfully.