The Krampus and the Old, Dark Christmas-Full-thickness Contact Alkali Burn With Soot, Milking Grease and Baby Oil.

A chemical alkali burn caused by ash and soot is quite rare, resulting from its high pH-value, and underestimated in its potential to cause injury. In folkloric medicine, ash was purportedly used to relieve pain. We present an unusual case of a 27-year-old man who used a self-mixed cream of soot of wooden pellets, milking grease and baby oil to blacken his face and hands for a traditional Krampus procession.

Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo. / Opções de tratamento cirúrgico em lesões cutâneas por extravasamento acidental de drogas: experiência do Hospital das Clínicas da Faculdade de Medicina da USP.

OBJECTIVE: to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs. METHODS: we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization. RESULTS: we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions. CONCLUSION: in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

OBJETIVO: relatar a experiência da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no tratamento de lesões cutâneas por extravasamento acidental de drogas. MÉTODOS: foram incluídos os pacientes com lesões por extravasamento de drogas num período de 18 meses. Os seguintes parâmetros foram avaliados retrospectivamente: idade, diagnósticos durante internação e comorbidades, níveis séricos de albumina e hemoglobina, local de internação, droga envolvida, segmento anatômico acometido, conduta terapêutica e óbito durante internação. RESULTADOS: foram acompanhados 14 pacientes. A principal droga envolvida foi a noradrenalina (21%). Todos os pacientes foram submetidos a desbridamento da necrose tecidual. Três pacientes foram submetidos a retalhos após preparo do leito com terapia por pressão negativa, com bons resultados. Sete pacientes não tiveram tratamento definitivo de suas lesões por falta de condições clínicas. CONCLUSÃO: o tratamento definitivo por meio de retalhos se mostrou adequado para os casos de feridas por extravasamento de drogas em tecido subcutâneo, quando há exposição de estruturas nobres, em pacientes com condições clínicas favoráveis.

Opções de tratamento cirúrgico em lesões cutâneas por extravasamento acidental de drogas: experiência do Hospital das Clínicas da Faculdade de Medicina da USP / Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo

RESUMO Objetivo: relatar a experiência da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no tratamento de lesões cutâneas por extravasamento acidental de drogas. Métodos: foram incluídos os pacientes com lesões por extravasamento de drogas num período de 18 meses. Os seguintes parâmetros foram avaliados retrospectivamente: idade, diagnósticos durante internação e comorbidades, níveis séricos de albumina e hemoglobina, local de internação, droga envolvida, segmento anatômico acometido, conduta terapêutica e óbito durante internação. Resultados: foram acompanhados 14 pacientes. A principal droga envolvida foi a noradrenalina (21%). Todos os pacientes foram submetidos a desbridamento da necrose tecidual. Três pacientes foram submetidos a retalhos após preparo do leito com terapia por pressão negativa, com bons resultados. Sete pacientes não tiveram tratamento definitivo de suas lesões por falta de condições clínicas. Conclusão: o tratamento definitivo por meio de retalhos se mostrou adequado para os casos de feridas por extravasamento de drogas em tecido subcutâneo, quando há exposição de estruturas nobres, em pacientes com condições clínicas favoráveis.

ABSTRACT Objective: to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs. Methods: we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization. Results: we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions. Conclusion: in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

[Hydrofluoric acid burns of the hands in the home environment: correct therapeutic approach]. / Le ustioni delle mani da acido fluoridrico in ambiente domestico: corretto approccio terapeutico.

The broad market penetration of products with components used primarily in the industrial sector requires the precise knowledge of their mechanism of action in order to perform a correct therapeutic approach. The article reports on three cases of domestic hydrofluoric acid burn that came to our Plastic Surgery Unit over the last three years. The treatment options are discussed in detail with emphasis on the importance of a constant update about such emerging diseases.

Extravasation injuries: a review.

Extravasation injuries are common emergencies in clinical practice. If they are not recognized and treated promptly, they can lead to deleterious functional and cosmetic outcomes. There is a vast range of agents involved in these injuries and marked paucity of evidence to support their specific management. Following an extensive literature review, we outline management principles for clinicians involved in the care of patients with extravasation injuries. Key parameters in deciding appropriate management plans include the volume/toxicity of the agent, the necrosis interval of the injury, patient-related factors, as well as the facilities and expertise available in the setting of individual cases of extravasation.

[Soft-tissue defects on the dorsum of the hand by extravasation of the cytostatic agents: surgical options of treatment]. / Weichteildefekte an der Streckseite der Hand durch Paravasate im Rahmen systemischer Chemotherapien - chirurgische Therapieoptionen.

Systemic treatment with chemotherapeutic agents is often applied by infusions over peripheral vein cannulae located on the hands and lower arms. Dislocation of the cannulae or vein perforation causes an extravasation of the cytostatic agent. This complication occurs in approximately 0.1 - 6 % of intravenous treatments and is rarely noticed before administration of greater volumes. Depending on the tissue toxicity of the administered substances, the extravasation results in tissue damage of different extents. In a few cases, only conservative therapy is required. The majority of patients, however, needs immediate surgical therapy. The reason for this is the severe tissue damage caused by the chemotherapeutic agent that accumulates in the subcutaneous fat where it destroys the connective and fat tissue, nerves, vessels, tendons and muscles, impairing the functionality of the entire hand and arm. In very severe cases, partial or complete amputation of the extremity is the only treatment. The application of antidotes has been discussed controversially and is not a standard procedure. In the past 11 years, 18 patients with extravasations of chemotherapeutics on the dorsum of the hand were admitted to our department. After radical debridement no primary closure of the resulting defect was advisable in the first operation. In all cases we could later perform a stable wound closure. In our opinion, this two-step procedure with primary radical debridement, temporary wound coverage and later wound closure should be performed regularly.

Management of hand-foot syndrome induced by capecitabine.

INTRODUCTION: Capecitabine (Xeloda) is a systemic prodrug of 5-fluorouracil (5-FU), which is administered in an oral formulation. Hand-foot syndrome (HFS) has proven to be a chronic dose-limiting toxicity of capecitabine, leading to significant morbidity in patients receiving this agent. The purpose of this review is to define the pathophysiology, risk factors, incidence and management of capecitabine-induced HFS. METHODS: Literature for this review article was collected from the following databases: PubMed, CINAHL, and the proceedings of the American Society of Clinical Oncology (ASCO) confined to the years 1995-2006. The following key terms were used in the search: hand-foot syndrome, palmar-plantar erythrodysesthesia, capecitabine, Xeloda, colorectal cancer, and metastatic breast cancer. RESULTS: HFS associated with capecitabine is a serious dose-limiting toxicity. Incidence of grade 3/4 toxicity is of extreme significance, and introduces the need for dose reductions and/or interruptions in capecitabine therapy. Drug-related therapies studied include topical emollients and creams, systemic and topical corticosteroids, nicotine patch, vitamin E, pyridoxine, and COX-2 inhibitors. However, due to the lack of randomized, controlled trials with these therapies, the current mainstay of treatment for the management of this toxicity is interruption of therapy and, if necessary, dose reduction. CONCLUSION: Treatment interruption or dose reduction remain the only methods shown to effectively manage HFS, but supportive measures to reduce pain and discomfort and prevent secondary infection are very important. Many other prophylactic and treatment strategies have been investigated, with pyridoxine and COX-2 inhibitors being the most promising in case reports and retrospective studies; therefore, prospective, randomized, controlled trials are needed to prove their efficacy.

Musculoskeletal injury associated with fluoroquinolone antibiotics.

With the expanded use of fluoroquinolones and increasing number of reports of tendon injury linked to these agents, clinicians must be aware of the frequency and strength of this association. In the past, pefloxacin and ciprofloxacin were most frequently implicated, but tendon injury is reported with most fluoroquinolones. As many as half of patients with fluoroquinolone-associated tendinopathy experience tendon rupture, and almost one third have received long-term corticosteroids. Tendon injury is mostly reported in the lower extremities, but injury in the upper extremities, including the hand, has also been reported. Management is similar regardless of the location of the injury. Use of fluoroquinolones requires careful patient assessment and follow-up in view of this complication with potential for sequelae.

Injury caused by self-inoculation with a vaccine of a Freund's complete adjuvant nature (Gudair) used for control of ovine paratuberculosis.

OBJECTIVE: To document the occurrence and consequences of accidental self-inoculation of vaccinators (producers, farm employees, contractors) with the recently registered Gudair vaccine for the control of ovine paratuberculosis in Australia. DESIGN AND PROCEDURE: A survey of the first 50 primary producers permitted to use the vaccine in sheep and a description of six cases of accidental self-inoculation for which medical attention was sought, and which occurred after the vaccine became widely available. RESULTS: The survey recorded that, of 37 respondents vaccinating 155,523 sheep, there were 21 incidents of exposure to the vaccine, an overall rate of one incident per 7406 vaccinations. In five of these incidents there was only superficial skin contact with vaccine; in 16 there was needle penetration without vaccine injection. There were no reports of self-inoculation with vaccine. Six cases of self-inoculation with Gudair vaccine that required medical intervention are described. Of these five were in males and one in a female; four involved injection of vaccine into the leg and single cases involved a foot or hand. Most cases required surgical removal of the injected vaccine to allow wound repair; three required extensive surgery and open drainage. Even with surgery recovery took as long as 9 months. Possible risk factors for self-inoculation and the resulting outcome are discussed. CONCLUSIONS: Gudair ovine paratuberculosis vaccine can cause prolonged granulomatous inflammation if inadvertently injected into human tissue. After.self-inoculation, early surgical debridement of the damaged tissue and drainage to remove the vaccine material are advised to avoid progression to extensive necrosis.

Chemical injuries: the Tasmanian Burns Unit experience.

BACKGROUND: Chemical burns account for relatively few admissions to a burns unit. These injuries, however, deserve separate consideration because of their ability to cause continuing tissue destruction, their potential to cause systemic toxicity and the value of early treatment with copious lavage. Widespread inexperience in the treatment of chemical burns highlights the potential for greater levels of general awareness and knowledge. METHODS: A review of 31 patients with chemical injuries admitted to the Tasmanian Burns Unit at the Royal Hobart Hospital (RHH) was carried out for the years 1989-1999. RESULTS: The majority of patients were men aged 20-49 years (mean age: 32 years). Fifty-one per cent of injuries occurred in a domestic and 38% in an industrial setting. The more common aetiological agents were cement (25%), sulphuric acid (16%) and hydrofluoric acid (16%). The upper and lower extremities were involved in all but four patients and the mean total body surface area affected was 3.4%. The mean length of hospital stay was 9 days with a range of 1-30 days. Management of injuries consisted of either surgical or conservative treatment. The former included debridement and split-thickness skin grafting or primary closure and the latter of topical treatment with 1% silver sulfadiazine cream and appropriate dressings. CONCLUSION: Widespread inexperience in the treatment of chemical injuries highlights the potential for greater levels of knowledge. This is particularly apparent in the early management of these injuries.

[Subcutaneous "wash-out" in extravasations]. / Technik der subkutanen Spülung bei hochtoxischen Paravasaten--Ein Kurzbeitrag.

Extravasations of chemotherapeutic drugs may lead to large soft-tissue losses in the hand and forearm and necessitating surgical excision with secondary flap coverage. Unfortunately, a delayed referral to a hand and plastic surgical unit with an already established soft-tissue defect is most common. Nevertheless, in our unit the method of choice is early emergency subcutaneous "wash-out", which facilitates dilution and reduction of concentration of the extravasation and therefore reliably avoids the development of soft-tissue defects. The aim of this paper is to present the surgical technique.