Fascial incisions heal faster than skin: a new model of abdominal wall repair.

BACKGROUND: Optimal healing of the fascial layer is a necessary component of complete abdominal wall repair. The majority of acute wound healing studies have focused on the dermis. We designed a model of abdominal wall repair that, to our knowledge, for the first time simultaneously characterizes differences in the wound healing trajectories of the fascia and skin. METHODS: Full-thickness dermal flaps were raised on the ventral abdominal walls of rats, and midline fascial celiotomies were completed. The dimensions of the flap were developed so as to have no detrimental effect on skin healing. The dermal flaps were replaced so that the fascial incisions would heal separately from the overlying skin incisions. Animals were killed 7, 14, and 21 days after operation and fascial and dermal wounds were harvested and tested for breaking strength. Fascial and dermal wounds were also compared histologically for inflammatory response, fibroplasia, and collagen staining. RESULTS: Fascial wound breaking strength exceeded dermal wound breaking strength at all time points (9.16 +/- 2.17 vs 3.51 +/- 0.49 N at 7 days, P <.05). Fascial wounds also developed greater fibroblast cellularity and greater collagen staining 7 days after the incision. There was no difference in wound inflammatory response. CONCLUSIONS: Fascial incisions regain breaking strength faster than simultaneous dermal incisions. The mechanism for this appears to involve increased fascial fibroplasia and collagen production after acute injury.

Early decortication after thoracic trauma.

Twenty-three patients who sustained either blunt or penetrating thoracic trauma underwent early decortication after failure of chest tube drainage. Patients were divided into two groups: (1) ten with isolated chest injuries were compared with (2) 13 with chest trauma and other associated major injuries. Group 1 patients had earlier decortication (10.3 days), rapid recovery (home in 6.1 days), and little morbidity. Group 2 patients had later decortications (19.3 days), higher incidence of infected clot, yet were home in 9.8 days after thoracotomy. Early decortication is advocated as a safe and expedient means of dealing with the complications of traumatic pneumothorax and hemothorax.

Emergency intravenous pyelography in the trauma patient. A reexamination of the indications.

Because of the high incidence of abnormal intravenous pyelograms (IVPs) in victims of blunt trauma undergoing resuscitation, a retrospective review of the Trauma Registry at the University of California, San Diego Medical Center, was undertaken to evaluate the indications for ordering this test. The charts of 216 patients were reviewed, all of whom had formal IVPs (four films) done as an emergency procedure at the time of admission. In this study, special attention was directed toward comparing both the degree of hematuria and the anatomic site of injury with the results of the IVP. A total of 20 renal injuries was detected by IVP. Of these injuries, all but one had hematuria that was greater than 50 red blood cells per high-power field. All but one of the abnormal IVPs were associated with obvious abdominal injuries. The results of the IVP influenced the clinical course of only one patient in the entire series. We conclude that the use of the formal IVP (four films) in the resuscitation phase of treating the multiply traumatized patient be reserved for those patients with penetrating abdominal injury or with hematuria consisting of greater than 50 red blood cells per high-power field. For any major blunt abdominal trauma without significant hematuria, a more simple and rapid study (one-shot IVP) to demonstrate bilateral nephrograms is probably adequate to rule out occult renal artery thrombosis.

Management of burns of the head and neck.

Burns of the head and neck with or without respiratory tract injury remain a serious and complex problem. Care of patients with this injury requires astute frequent clinical examinations, repeated laryngoscopy or flexible bronchoscopy, and serial laboratory investigations. Superb monitoring and care by the entire burn team with frequent dialogue among the individuals with specialized knowledge, mature clinical judgement in regard to therapy, the long-term follow-up help burn victims survive the injury and achieve the best possible functional ability and cosmetic appearance. There are no simple answers or rote decisions in the management of these injuries. The challenge requires the most innovative and creative care coupled with large amounts of hard work. Many of the recent advances in the management of burns of the head and neck have permitted these patients to survive and have helped them to return as functioning members of society.

Viability of frozen allografts.

The use of meshed skin grafts allows an evaluation of the biologic properties of stored tissues such as skin. Frozen allograft may serve as an excellent biologic membrane, but it is not a satisfactory product for longer term allografting (intermediate allografting). The method of thawing (microwave oven versus water bath) appeared to have little effect on the ultimate viability and outcome of the frozen allograft.

Nutritional considerations for the burned patient.

The metabolic response to injury is one of marked catabolic hormonal predominance resulting in hypermetabolism and protein wasting. Energy expenditure increases with increasing severity of injury, but reaches a maximum of twice resting energy expenditure when 50 per cent TBSA is burned. We agree with the nutritional recommendations of the group at the Boston Shriner's Burn Institute and the Massachusetts General Hospital. These include providing calories at twice the resting energy expenditure, as predicted by the Harris-Benedict equations, for patients with greater than 30 per cent BSAB; protein is provided at 2.5 gm per kg per day based on ideal body weight. It is important to recognize that these are optimal goals, but their attainment must be governed by safety considerations for the patient. It is probably safe to supplement intake with a multivitamin and vitamin C, as well as zinc, but our understanding of micronutrient therapy for stressed patients is rudimentary.

The synergistic relationship between a level I trauma center and a regional pediatric trauma center.

A regional pediatric trauma center and a level I trauma center with pediatric commitment in the same city developed a synergistic relationship addressing all aspects of care for pediatric trauma patients. Although it is unlikely that this model could be used in its entirety by all similar institutions, the principles may prove helpful in creating guidelines and relationships. Categorization, optimal use of resources, timely transportation of seriously injured children to the appropriate facility, and maintaining urgent care capabilities of each institution to care for seriously injured children are imperative. The combined effort resulted in our level I trauma center being verified by the American College of Surgeons and designated by our state Health Department as meeting all the criteria for pediatric trauma care. This experience should encourage every pediatric trauma center located in a children's hospital to become a regional pediatric trauma center. The real benefit from the relationship is that injured children receive optimal care at both institutions.

Epidemiology, classification, initial care, and administrative considerations for critically burned patients.

The care of major burn injuries is a critical care endeavor from the initial evaluation and admission until the patient is discharged from the burn intensive care unit. A thorough history and physical examination are essential and require expertise to classify each burn injury. The initial treatment of the burn must address stopping the burning process, insuring a patient airway, assessing inhalation injury, initiation of adequate fluid and electrolyte resuscitation, appropriate wound care, and institution of ancillary care, such as insertion of nasogastric tubes and urinary catheters, narcotic dosage, tetanus prophylaxis, laboratory studies, and environmental temperature control. Critical care units must be designed, equipped, and staffed to facilitate the safe and effective care of burned patients. A well trained and experienced multidisciplinary burn team under the direction of a surgeon who specializes in burns is essential to the ultimate outcome of the seriously burned patient. Effective communication among the burn team and with the burned patients requires formal protocols for general treatment as well as dynamic individualized care based on careful comprehensive observations and monitoring. The prognosis for these critically injured and ill patients depends on attention to every detail of their care, which can only be accomplished in a sophisticated critical care atmosphere with personnel skilled in intensive care techniques.

Building a balanced scorecard for a burn center.

The Balanced Scorecard provides a model that can be adapted to the management of any burn center, burn service or burn program. This model enables an organization to translate its mission and vision into specific strategic objectives across the four perspective: (1) the financial perspective; (2) the customer service perspective; (3) the internal business perspective; and (4) the growth and learning perspective. Once the appropriate objectives are identified, the Balanced Scorecard guides the organization to develop reasonable performance measures and establishes targets, initiatives and alternatives to meet programmatic goals and pursue longer-term visionary improvements. We used the burn center at the University of Colorado Health Sciences Center to test whether the Balanced Scorecard methodology was appropriate for the core business plan of a healthcare strategic business unit (i.e. a burn center).

The inter-rater reliability of estimating the size of burns from various burn area chart drawings.

The accuracy and variability of burn size calculations using four Lund and Browder charts currently in clinical use and two Rule of Nine's diagrams were evaluated. The study showed that variability in estimation increased with burn size initially, plateaued in large burns and then decreased slightly in extensive burns. The Rule of Nine's technique often overestimates the burn size and is more variable, but can be performed somewhat faster than the Lund and Browder method. More burn experience leads to less variability in burn area chart drawing estimates. Irregularly shaped burns and burns on the trunk and thighs had greater variability than less irregularly shaped burns or burns on more defined anatomical parts of the body.

Liquid-propane freeze injury: a case history.

Exposure of skin to liquid propane causes a severe freeze injury. This cutaneous injury has the appearance of a partial-thickness thermal injury of indeterminate depth, but the deep tissue damage is greater than is at first apparent. A case history is presented that illustrates the severity of this particular mechanism of injury and the need for adequate safety precautions.

The impact of thermal injury.

From data collected by the Regional Burn Treatment Center at UCSD in San Diego and Imperial Counties in California, the incidence and economic cost of thermal injuries are extrapolated to the entire United States in order to estimate the impact of thermal injury on the public health.

Developing a regional and national burn disaster response.

The supplement on burns by the National Disaster Medical System (NDMS) requires an evaluation of burn centers' and burn hospitals' capabilities for treating seriously burned victims. The American Burn Association (ABA) and its members, as experts in burn care, should take the lead in working with local, state, and federal disaster planners. Proposals based on standards adopted by the ABA support classification of facilities (levels I, II, III), identify minimum and maximum bed availability, require minimum training for personnel (e.g., ABLS), and encourage enrollment of all burn centers and burn hospitals as contract hospitals in the National Disaster Medical System. Periodically, the ABA should verify that the burn care facilities identified in the disaster plan meet its standards. Once the burn disaster system is developed, drills should be held locally on a regular basis and nationally on an annual basis.

Computer-drafted pressure support gloves.

Using computer-drafted pressure support gloves during a six-month period, we greatly increased our accuracy of fit. Only eight alterations were required out of 214 gloves manufactured, and none of the alterations was due to computer error. Our time to calculate and lay out patterns decreased by a 4:1 ratio, thus reducing a two-hour time period to one-half hour per glove. The cost of hardware and software was offset by reduced labor costs over a period of approximately eight months. Use of the computer was cost effective, produced error-free patterns, and allowed better control of pattern consistency.

The protection against and treatment of a liquid propane freeze injury: an experimental model.

Liquid propane causes a severe, deep thermal injury in unprotected tissue. Delayed surgical intervention, as for thermal burns, has been the gold standard of treatment. An animal model of liquid-propane injury was devised to document injury, to demonstrate a better method of protection, and to define an appropriate management protocol. Twenty-eight rats were classified into four groups: unprotected tissue (n = 8), skin covered with wool (n = 8), skin covered with Neoprene (Wm. H. Horn & Brothers Inc., Philadelphia, Pa.) (n = 8), and skin covered with wool plus Neoprene (n = 4). Each group was subdivided into two exposure times: 6 seconds and 30 seconds. The mean temperatures +/- standard error of the mean of the various tissue levels initially and at 6 and 30 seconds of exposure were determined. Histologic examination demonstrated that full-thickness tissue necrosis occurred in unprotected and wool-covered tissue. Areas that were covered with Neoprene showed intact skin and subcutaneous tissue with underlying muscle necrosis. Examination of the tissue that was covered with wool plus Neoprene showed no histologic damage. There was no sign of tissue regeneration at the wound periphery, and there was no histologic difference in any group, whether the examination took place at 1 or 5 days after injury. This study demonstrated that the best form of protection appears to be a wool glove liner covered with a Neoprene glove. The histologic evidence suggests that a liquid-propane injury to unprotected tissue should be managed aggressively with early excision and grafting.

Prevalence of postburn depression following burn injury.

We examined the prevalence of depression after burn injury in 139 adults treated at a major burn center. Interviews were held from one to eight years following the burn. Our subsample, taken from 882 patients treated over a six-year period, comprised all patients with 30% total body surface area burns and a random sample of those with burns of lesser severity. We considered 17 possible predictors of depression (including the severity and placement of the burn and the patient's age, educational background, medical history, employment status, income level, and emotional and psychiatric history). We found that it is the person, rather than the injury, that best predicts postburn depression. The factor most strongly linked with depression was a past history of emotional disturbance. However, after being burned, a significant number of even previously well-adjusted patients show clinical postburn depression.

Bioassay of thermal protection afforded by candidate flight suit fabrics.

The United States Army Aeromedical Research Laboratory (USAARL) porcine cutaneous bioassay technique was used to determine what mitigating effect four thermally protective flight suit fabrics would have on fire-induced skin damage. The fabrics were 4.8-ox twill weave Nomex aramide, 4.5-oz stabilized twill weave polybenzimidazole, 4.8-oz plain weave experimental high-temperature polymer (HT4), and 4.8-oz plain weave Nomex aramide (New Weave Nomex or NWN). Each fabric sample was assayed 20 times in each of four configurations: as a single layer in contact with the skin; as a single layer with a 6.35 mm (0.25 in) air gap between fabric and skin; in conjuction with a cotton T-shirt with no air gaps; and, finally, in conjuction with a T-shirt with a 6.35 mm air gap between T-shirt and fabric. Bare skin was used as a control. A JP-4 fueled furnace was used as a thermal source and was adjested to deliver a mean heat flux of 3.07 cal/cm2/s. The duration of exposure was 5 s. Four hundred burn sites were graded using clinical observation and microscopic techniques. Used as single layers, none of the fabrics demonstrated superiority in providing clinically significant protection. When used with a cotton T-shirt, protection was improved. Protection improved progressively for all fabrics and configuration when an air gap was introduced. The experimental high-temperature polymer consistently demonstrated lower heat flux transmission in all configurations, but did not significantly reduce clinical burns.

Effect of fiber and dye degradation products (FDP) on burn wound healing.

Upon exposure to the thermal environment of an aircraft fire, many fire retardant fabrics off-gas fiber and dye degradation products (FDP). Condensation of these products on human skin raises questions concerning possible deleterious effects on burn wound healing. A porcine bioassay was used to study the physiological effects of FDP. Selected areas of living skin, protected by dyed aromatic polyamides and polybenzimidazole fabrics, were exposed to a thermal source adjusted to simulate a postcrash JP-4 fuel fire. Burn sites contaminated with FDP were evaluated by clinical observation ane to begin epithelialization, time to closure of an open wound, and the amount and type of cicatrix formation. The experiment showed that each fabric has unique off-gasing products. The greatest amount of FDP was deposited on the skin when the skin was covered by a single layer of shell fabric separated by a 6.35-mm air gap. The presence of an intervening cotton T-shirt decreased the amount of FDP deposited on the skin. We found no evidence that FDP caused alterations in wound healing.

Major burns. What to do at the scene and en route to the hospital.

Patients with major burns should be transported by whatever conveyance seems appropriate to a facility capable of caring for such injuries. At the scene of the accident and en route to the hospital, adherence to standard principles of trauma care allows optimal resuscitation. Once rescuers have assessed the depth and extent of burns and conferred with hospital personnel, they need to do relatively little in the way of initial wound treatment except to prevent further injury and decrease pain. Careful, concise documentation is necessary to assure a continuum of good patient care.