Choosing wisely in burn care.

BACKGROUND: The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices. METHODS: The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™. RESULTS: Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations. CONCLUSIONS: The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

Flap coverage for necrotising soft tissue infections: A systematic review.

BACKGROUND: Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas. METHODS: A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate. RESULTS: After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%. CONCLUSION: Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.

A survey of risk factors for burns in the elderly and prevention strategies.

Elderly burn patients suffer from greater morbidity and mortality than younger patients with similar burn extents. The purpose of this study was to identify risk factors for burn injuries in the elderly to develop an effective preventive program. A cross-sectional survey was conducted among 20 elderly (> or =65 years of age) burn survivors on the circumstances surrounding their burn injury and on burn prevention. A control group of 20 nonburned elderly completed a similar survey only on burn prevention. The majority of burned subjects believed that their injury was preventable (85%). The home was the commonest location for burn injury (70%), and scalds (50%) and flame burns (25%) were the most common etiologies. Most subjects felt that a burn prevention program would be useful (95%) and television, news, and posters were the preferred sources of prevention information. Compared with the burn group, the control group had more risk factors for burn injury. However, the control group also took more active preventive measures. Burn prevention campaigns for elderly should focus on reducing flame and scald burns that occur in the home, preferably using television, news, and poster media.

Early clinical experience with high-frequency oscillatory ventilation for ARDS in adult burn patients.

Lung protective ventilation strategies are recommended in acute respiratory distress syndrome to avoid ventilator associated lung injury, a recently characterized complication of mechanical ventilation. High-frequency oscillatory ventilation (HFOV) is an unconventional ventilation strategy which may achieve this goal. We reviewed our experience with HFOV in six severely burned patients with acute respiratory distress syndrome. The mean age (+/- SD) of the patients was 34 +/- 13 years, and the mean TBSA burn was 52 +/- 10%, with a mean full-thickness injury of 49 +/- 12%. HFOV was initiated as "rescue therapy" in three patients with oxygenation failure (mean PaO2/FIO2 ratio of 71 +/- 8 and mean oxygenation index [OI] of 42 +/- 3) that was unresponsive to conventional ventilation (mean FIO2, 1.0 +/- 0; mean positive end expiratory pressure, 14.8 +/- 2.8 cm H2O; and mean inhaled nitric oxide, 20 +/- 0 ppm). In the other three cases, HFOV was initiated "prophylactically" as a lung protective ventilation strategy in an attempt to prevent further respiratory deterioration. All six patients showed a rapid and substantial improvement in oxygenation after initiation of HFOV, with significant improvements in the PaO2/FIO2 and OI by 12 hours (P = 0.02). In four patients HFOV was also used during anesthesia and surgery, where a total of 10 procedures involving a mean excision and closure of 15 +/- 7% TBSA burns was performed. Five of the six patients died, but none died because of oxygenation failure. In three patients death resulted from sepsis and multiple organ dysfunction syndrome; their mean PaO2/FIO2 was 107 +/- 31 and their mean OI was 30 +/- 11 immediately before death. Two patients with multiple organ dysfunction syndrome died after withdrawal of life support; their mean PaO2/FIO2 and OI were 178 +/- 31 and 18 +/- 2 respectively, at the time of this decision. Although HFOV had no impact on mortality, it played a useful role in the supportive management of burn patients with severe oxygenation failure unresponsive to conventional ventilation. Importantly, HFOV allowed surgery to proceed in patients who may have otherwise been too unstable to go to the operating room. As far as we are aware, this is the first report of the use of intraoperative HFOV in burn patients.

The use of silver coated dressings on donor site wounds: a prospective, controlled matched pair study.

Acticoat, a new silver-coated dressing, produces a moist healing environment along with the sustained release of ionic silver for improved microbial control. These properties suggest that Acticoat might be a useful donor site dressing. However, there are no human studies which assess Acticoat for this use. The purpose of this study was to compare the healing of human skin graft donor sites dressed with Acticoat, to the healing of those dressed with Allevyn, an occlusive moist-healing environment material, which is our standard donor site dressing. In burn patients who had undergone burn excision and grafting, identical side-by-side split thickness donor site wound pairs were dressed with Allevyn and Acticoat. Re-epithelialization was directly assessed daily by a single observer from post-operative day 6 onward, and by four independent observers who rated the extent of re-epithelialization by viewing standardized digital images of the wounds that had been obtained on post-operative days 6, 8, 10,and 12. Donor sites were swabbed for bacterial culture on days 3, 6, and 9. Subsequently, each study donor site scar was rated by a blinded observer using the Vancouver Scar Scale at 1, 2, and 3 months. Sixteen paired sites in 15 patients (3 female, 12 male) were studied. Donor sites dressed with Allevyn were >90% re-epithelialized at a mean of 9.1+/-1.6 days while donor sites dressed with Acticoat required a mean of 14.5+/-6.7 days to achieve >90% re-epithelialization (P=0.004). The Allevyn sites had significantly greater estimated re-epithelialization at days 6, 8, 10 and 12 than the Acticoat sites based on the observations of the digital images. There were no significant differences in the incidence of positive bacterial cultures with either dressing at days 3, 6, and 9. Donor sites dressed with Acticoat had significantly worse scars at 1 and 2 months but this difference resolved by 3 months. Our findings do not support the use of Acticoat as a skin graft donor site dressing.

Minimizing blood loss in burn surgery.

BACKGROUND: Significant blood loss continues to plague early tangential excision of the burn wound. Although various techniques to reduce intraoperative blood loss have been described, there is an absence of uniformity and consistency in their application. Furthermore, it is unclear whether these techniques compromise intraoperative tissue assessment and wound outcome. The purpose of this study was to evaluate the effects of a comprehensive intraoperative blood conservation strategy on blood loss, transfusion requirements, and wound outcome in burn surgery. METHODS: An intraoperative blood conservation strategy (CONSV) that included donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and limb tourniquets was prospectively evaluated and compared with a historical control group (HIST) where only topical adrenaline and thrombin were applied to donor sites and excised wounds. RESULTS: Estimated blood loss was reduced from 211 +/- 166 mL per percentage body surface area excised and grafted in the HIST group to 123 +/- 106 mL in the CONSV group (p = 0.02). Similarly, the intraoperative transfusion requirement in the HIST group was reduced from 3.3 +/- 3.1 units per case to 0.1 +/- 0.3 units per case in the CONSV group (p < 0.001). There was no compromise in wound outcome in the CONSV group, which had a mean skin graft take rate of 96 +/- 4.2%. CONCLUSION: The application of a strict and comprehensive intraoperative blood conservation strategy during burn excision and grafting resulted in a profound reduction in blood loss and transfusion requirements, without compromising wound outcome.

Herpes simplex virus infection in a paediatric burn patient: case report and review.

Herpes simplex virus (HSV) infection in the burn patient is thought to occur relatively frequently. Most commonly, children with significant burns, particularly involving the head and neck, are affected. Burn related immunosuppression is thought to allow reactivation of latent HSV in most cases, although primary HSV infection has been recognized. Clinical manifestations vary from asymptomatic viral shedding, to prolonged fever with eruption of vesicles, to rare cases of systemic visceral dissemination. Healing partial thickness wounds and donor sites are most prone to infection. Laboratory confirmation of HSV infection relies on direct demonstration of the virus and/or observation of a rise in antibody titer. Treatment of an established HSV infection includes use of IV Acyclovir, meticulous wound care, and efforts to prevent nosocomial spread. The vast majority of cases resolve without sequelae unless complicated by systemic, multiorgan HSV infection.

The 2000 Moyer Award. The relevance of base deficits after burn injuries.

The relevance of an elevated base deficit (BD) during the fluid resuscitation of a thermally injured patient is not completely understood. After nonthermal trauma, early elevation of the BD represents insufficient cellular perfusion and is ultimately associated with a higher incidence of organ dysfunction and death. However, this relationship has not been completely examined after burn injuries. The purpose of this study was to determine if elevation of the BD during burn resuscitation was associated with potential consequences of malperfusion, such as systemic inflammatory response syndrome, acute respiratory distress syndrome, and multiple organ dysfunction. The records of 72 patients with burn injuries (mean age, 46 +/- 17 years; mean total body surface area burned, 44% +/- 18%) who required fluid resuscitation on admission to an adult regional burn center were analyzed. Patients with a mean BD of less than -6 mmol/L during the first 24 hours were compared with patients with a mean BD of more than -6 mmol/L. Despite adequate resuscitation with good maintenance of urinary output, the patients in the group with a mean BD of less than -6 mmol/L had more florid systemic inflammatory response syndrome (P = .004), had more prevalent acute respiratory distress syndrome (P = .012), and experienced more severe multiple organ dysfunction (P < .001) compared with patients in the group with a mean BD of more than -6 mmol/L. The results suggest that abnormal elevation of the BD after burn injuries represents a malperfusion state, which may not be recognized if only "traditional" parameters, such as UO, are followed. Furthermore, this state appears to be related to the onset of more severe systemic inflammation and organ dysfunction.

The use of inhaled nitric oxide as adjuvant therapy in patients with burn injuries and respiratory failure.

Inhaled nitric oxide (NO) is a relatively new modality in the management of acute respiratory distress syndrome. The purpose of this study was to examine our experience with inhaled NO in 10 adult patients with burn injuries and acute respiratory distress syndrome-related oxygenation failure. The patients had a mean age of 50 +/- 19 years and a mean burn size of 41% +/- 20% of the total body surface area. Seven patients died and 3 survived. The survivors and nonsurvivors did not differ with respect to age, burn size, pre-NO ventilator settings, or indices of oxygenation including PaO2, oxygen saturation in arterial blood, PaO2/fraction of inspired oxygen (FIO2) ratio, and alveolar-arterial oxygen tension difference. The concentration of NO administered ranged between 5 ppm and 30 ppm. PaO2, oxygen saturation in arterial blood, and the PaO2/FIO2 ratio increased in all patients. Although it was not statistically significant, survivors tended to have a more vigorous and sustained response than non-survivors; this was best exemplified by the change in PFR. During the first hour of therapy, the PaO2/FIO2 ratio increased from 64.3 +/- 12.7 to 231.8 +/- 154.5 in survivors and from 93.9 +/- 44.0 to 161.5 +/- 81.8 in the nonsurvivors. After 12 hours of therapy, the PaO2/FIO2 ratio was 306.2 +/- 333.7 in the survivors and 178.9 +/- 69.9 in the nonsurvivors. There were no complications associated with the use of inhaled NO. Although a stronger early response to NO seems to occur in survivors, we cannot definitely conclude that the early response pattern is predictive of recovery. Nonetheless, we believe that inhaled NO has a useful role in the treatment of patients with burn injuries and severe acute respiratory distress syndrome-related oxygenation failure.

The gas fireplace: a new burn hazard in the home.

Gas fireplaces have become popular in recent years. This article presents the first reported case of a burn injury from contact with the glass front of a gas fireplace. An investigation of the surface temperature of the glass fronts of gas fireplaces was undertaken to clarify the risks posed by these units. Surface temperature measurements of the glass fronts of 3 common gas fireplace models were obtained using a thermocouple probe. Glass temperatures reached 200 degrees C within 6.5 minutes of ignition, climbing to 245 degrees C at 14 minutes after ignition. Glass temperature continued to rise beyond this point, but it could not be monitored because the adhesives securing the thermocouple probe melted. Glass temperatures of 50 degrees C were recorded at 30 minutes after the unit was shut off. The temperatures of the glass fronts of glass fireplaces are sufficient to cause cutaneous burns within seconds of contact both while the fireplace is in use and up to one half hour after it has been turned off. Current industry safety standards are not directed at the prevention of contact burns. We recommend that (1) mechanical guards be installed to create a barrier in front of the glass; (2) strict warning labels be applied to the units and ignition switches; and (3) burn prevention information be distributed with the owner's manual for these products.

Acute bacterial endocarditis following burns: case report and review.

Acute bacterial endocarditis (ABE) is a rare but deadly complication following major thermal injury. Typically the presentation is silent, with persistent fever and positive blood cultures being the only consistent findings. Fibrin-platelet vegetations on the valvular endocardium are thought to be seeded during bacteremic episodes. Manipulation of the burn wound is probably the most likely source of bacteremia, with Staphylococcus aureus and Gram-negative bacilli being the most commonly implicated bacteria. In addition to causing local damage to a valve or the myocardium, infected vegetations may dislodge septic emboli systemically. Diagnosis is most easily obtained by echocardiography. Treatment usually involves prolonged administration of intravenous antibiotics. In rare circumstances, valvular resection and replacement may be indicated.

Narrow resection of cutaneous melanoma.

BACKGROUND: There has been a progressive reduction in the extent of resection of primary cutaneous melanoma. Although overall survival appears to have been unaffected by this trend, the effect of narrow resection on local recurrence is not entirely clear. OBJECTIVE: To examine the relationship between narrow resection margins and local recurrence of primary cutaneous melanoma. METHODS: Primary melanoma, 104 cases, treated by surgical resection were reviewed retrospectively. RESULTS: "Thin" (< 1 mm) melanomas (31 cases) were resected with a mean margin of 0.87 cm; "intermediate" (1-4 mm) melanomas (37 cases) were resected with a mean margin of 1.26 cm; and 14 "thick" (> 4 mm) melanomas were resected with a mean margin of 1.25 cm. Local recurrence rates were 6.5%, 16.2%, and 42.9%, respectively. In the "intermediate" group, two local recurrences occurred in melanomas < 2 mm thick despite use of margins of 1.7 cm and 2.4 cm. CONCLUSIONS: The results to not support the use of excessively narrow resection margins around primary cutaneous melanoma. Additionally, we question the true safety of currently accepted 1 to 2 cm margins for 1 to 2 mm thick melanomas.

Continuous infusion of epidural morphine in frostbite.

After frostbite injury, the phases of rewarming and progressive injury may cause intense pain for the patient. Although parenteral narcotic agents are the usual method of pain relief, they have well-described adverse effects such as heavy sedation, respiratory depression, and nausea and vomiting. In frostbite injury of the lower extremities, epidural blockade has the potential to provide good pain relief with fewer of those complications. However, the associated sympathetic blockade is believed by many clinicians to be of no benefit and by some to be potentially harmful. Epidural narcotics have the selective advantage of providing analgesia without sympathetic blockade. In this case report, the use of continuous epidural morphine during the first 24 hours after severe bilateral frostbite injury to the feet is described. The technique provided effective pain control, and no complications occurred. To our knowledge, use of continuous epidural morphine after frostbite injury has not been reported previously. Further use of this technique will be required to clarify its efficacy.

Chemical burns.

OBJECTIVES: To report a burn unit's experience with chemical burns and to discuss the fundamental principles in managing chemical burns. DESIGN: A chart review. SETTING: A burn centre at a major university-affiliated hospital. PATIENTS: Twenty-four patients with chemical burns, representing 2.6% of all burn admissions over an 8-year period at the Ross Tilley Regional Adult Burn Centre. Seventy-five percent of the burn injuries were work-related accidents. Chemicals involved included hydrofluoric acid, sulfuric acid, black liquor, various lyes, potassium permanganate and phenol. RESULTS: Fourteen patients required excision and skin grafting. Complications were frequent and included ocular chemical contacts, wound infections, tendon exposures, toe amputation and systemic reactions from absorption of chemical. One patient died from a chemical scald burn to 98% of the body surface area. CONCLUSIONS: The key principles in the management of chemical burns include removal of the chemical, copious irrigation, limited use of antidotes, correct estimation of the extent of injury, identification of systemic toxicity, treatment of ocular contacts and management of chemical inhalation injury. Individualized treatment is emphasized.

Two devastating complications of carpal tunnel surgery.

Two devastating complications of carpal tunnel release are presented. In 1 patient, the median nerve was completely transected; in another, massive necrosis of the palm required free flap coverage.

The rectus femoris myocutaneous flap for closure of difficult wounds of the abdomen, groin, and trochanteric areas.

The rectus femoris myocutaneous flap has proved to be an effective means of closing particularly difficult wounds in 2 patients. One patients had a massive defect in the lower abdomen, pubic, and right groin area after the radical resection of a recurrent pleomorphic liposarcoma of the spermatic cord. The second patient presented with a huge, right greater trochanteric wound measuring 15 cm in diameter. Both patients progressed to relatively uneventful primary healing.

An unusual facial injury highlighting the basics of diagnosis in maxillofacial trauma: a case report.

The authors present an unusual and bizarre missile type of maxillofacial injury in a 7-year-old girl, who was struck in the middle of her face by an iron hook. The area between her forehead and upper lip was obliterated, making a clinical and radiologic diagnosis impossible. The authors review the current diagnostic methods used in maxillofacial trauma, including standard and computed tomography, to emphasize the importance of a correct preoperative diagnosis in the management of maxillofacial injuries.

Managing human bite infections of the hand.

Human bite injuries of the hand may become complicated and therefore demand an organized approach to management. Thirty-two patients with human bites to the hand, admitted to Toronto's Wellesley Hospital between 1981 and 1985, were analyzed. The history and etiology, delay before presentation, microbiology results versus time from injury, and treatment regimens were reviewed. Streptococci appeared to be early pathogens and staphylococci later pathogens. However, a prospective study with serial aerobic, anaerobic, and 10% CO(2) cultures is needed to confirm these findings. Lack of organization in management was the most notable finding. Inpatient therapy with intravenous antibiotics usually is required. Treatment should revolve around the mnemonic 'ODD BITES': open treatment; debridement; drugs (antibiotics); bloodwork (leukocyte count); irrigation; tetanus prophylaxis; exploration (including X-rays); and swab (for culture and sensitivity).