Acute surgical management of hand burns.

A hand represents 3% of the total body surface area. The hands are involved in close to 80% of all burns. The potential morbidity associated with hand burns can be substantial. Imagine a patient carrying a pan of flaming cooking oil to the doorway or someone lighting a room-sized pile of leaves and branches doused with gasoline. It is clear how the hands are at risk in these common scenarios. Not all burn injuries will require surgical intervention. Recognizing the need for surgery is paramount to achieving good functional outcomes for the burned hand. The gray area between second- and third-degree burns tests the skill and experience of every burn/hand surgeon. Skin anatomy and the size of injury dictate the surgical technique used to close the burn wound. In addition to meticulous surgical technique, preoperative and postoperative hand therapy for the burned hand is essential for a good functional outcome. Recognizing the burn depth is paramount to developing the appropriate treatment plan for any burn injury. This skill requires experience and practice. In this article, we present an approach to second- and third-degree hand burns.

Vascularized plantar myocutaneous free flap transfer for amputee stump preparation: a proof of concept cadaver study.

Lower extremity amputee stump ulceration, irritation, and pain have been a deterrent to consistent long-term or continuous use of lower extremity prosthetics. This study is the first in a series that hypothesizes that these complications can be minimized through the insetting of a vascularized plantar free flap (VPFF) on the amputee stump. Using three hip disarticulated cadaver specimens, a VPFF was designed, dissected, and implanted on one transfemoral and two transtibial stumps. Using accepted vascular anastomosis techniques, the posterior tibial artery was anastomosed to the distal femoral or popliteal artery with corresponding anastomoses for venous drainage. In addition, the possibility of a limited to partial sensate flap may be created with a neurorrhaphy of the associated nerves. This potentially sensate area would provide plantar skin that aids the existing local sensate flap used to close the defect. It is hypothesized that this procedure offers significant rehabilitative and long-term benefits to battlefield or other acute causes for lower extremity amputation. The procedure can be accomplished in battlefield surgical setting as an immediate or delayed inset for some but not all traumatic amputations. Salvaging a partial or complete VPFF from a traumatized foot will obviously be predicated on the degree of trauma to the donor tissue.

A regionalised strategy for improving motor vehicle-related highway driver deaths using a weighted averages method.

OBJECTIVE: The state of Florida has some of the most dangerous highways in the USA. In 2006, Florida averaged 1.65 fatalities per 100 million vehicle miles travelled (VMT) compared with the national average of 1.42. A study was undertaken to find a method of identifying counties that contributed to the most driver fatalities after a motor vehicle collision (MVC). By regionalising interventions unique to this subset of counties, the use of resources would have the greatest potential of improving statewide driver death. METHODS: The Florida Highway Safety Motor Vehicle database 2000-2006 was used to calculate driver VMT-weighted deaths by county. A total of 3,468,326 motor vehicle crashes were evaluated. Counties that had driver death rates higher than the state average were sorted by a weighted averages method. Multivariate regression was used to calculate the likelihood of death for various risk factors. RESULTS: VMT-weighted death rates identified 12 out of 67 counties that contributed up to 50% of overall driver fatalities. These counties were primarily clustered in central and south Florida. The strongest independent risk factors for driver death attributable to MVC in these high-risk counties were alcohol/drug use, rural roads, speed limit ≥45 mph, adverse weather conditions, divided highways, vehicle type, vehicle defects and roadway location. CONCLUSIONS: Using the weighted averages method, a small subset of counties contributing to the majority of statewide driver fatalities was identified. Regionalised interventions on specific risk factors in these counties may have the greatest impact on reducing driver-related MVC fatalities.

Mortality and management of 96 shark attacks and development of a shark bite severity scoring system.

Humans share a fascination and fear of sharks. We predict that most shark attacks are nonfatal but require skilled, timely medical intervention. The development of a shark bite severity scoring scale will assist communication and understanding of such an injury. We retrospectively reviewed records of the prospectively maintained International Shark Attack File (ISAF) at the University of Florida. The ISAF contains 4409 investigations, including 2979 documented attacks, 96 of which have complete medical records. We developed a Shark-Induced Trauma (SIT) Scale and calculated the level of injury for each attack. Medical records were reviewed for the 96 documented shark attack victims since 1921. Calculated levels of injury in the SIT Scale reveal 40 Level 1 injuries (41.7%), 16 Level 2 injuries (16.7%), 18 Level 3 injuries (18.8%), 14 Level 4 injuries (14.6%), and eight Level 5 injuries (8.3%). The overall mortality of shark attacks was 8.3 per cent. However, SIT Scale Level 1 injuries comprised the greatest percentage of cases at 41.7 per cent. Injury to major vascular structures increases mortality and necessitates immediate medical attention and definitive care by a surgeon. Shark bites deserve recognition with prompt resuscitation, washout, débridement, and follow up for prevention of infection and closure of more complex wounds.

All-terrain vehicle safety in Florida: is legislation really the answer?

Florida is among the nation's leaders in all-terrain vehicle (ATV)-related injuries and fatalities. We hypothesized that patients sustaining injuries while in compliance with ATV laws would demonstrate less severe injury patterns and improved outcomes when compared with noncompliant patients. We reviewed patients treated for ATV-related injuries over a 36-month period. We grouped patients according to conformity with Florida statutes and compared demographics, admission status, injuries sustained, and outcome measures. Three hundred seventy-seven patients were treated for ATV-related injuries. In 294 cases, sufficient data existed to assess compliance with Florida's statutes regarding ATV rider safety: safety helmet use for persons younger than age 16 years and prohibition of ATV operation on roadways. Forty-three per cent (n = 126) had violated one or both statutes; 57 per cent (n = 168) had violated neither. The group in violation was younger (15 vs 24 years, P < 0.001) and wore helmets less often (6 vs 34%, P < 0.001). Groups required admission at similar rates (62% violators vs 60% nonviolators, P = 0.770), showed similar injury patterns, and had comparable mortality rates (2% violators vs 5% nonviolators, P = 0.451). Current Florida laws are inadequate to prevent ATV-related injuries and their sequelae. This issue should be addressed through an increased focus on safety education for ATV operators.

Hand injuries in the state of Florida, are centers of excellence needed?

INTRODUCTION: Hand injuries are common and costly. The need for hand surgery specialists is undeniable. In the state of Florida, the availability of specialty services in hand surgery is limited. Florida ranks 4th in population and 32nd in hand surgeons per 100,000 state residents. Recent media reports highlight these limitations among hand surgeons and other specialists in the state. METHODS: To evaluate the need for hand surgery centers of excellence in the state, we performed a retrospective review of data collected from the Agency for Health Care Administration database of hospital inpatient admissions from 1997 to the second quarter of 2007. Demographic information, details of the injury, and outcome data were evaluated in patients with amputation injuries. Amputations of the thumb, fingers, and hand/wrist/forearm were counted and factors associated with these injuries were recorded. Place of occurrence and injuries caused by machinery were evaluated. A regression analysis was performed to evaluate trends in the number of amputations and replantation procedures. RESULTS: We identified 4,858 patients with amputations in this time period. There were approximately 462 amputations per year. The trend in finger amputations appeared to be increasing yearly, whereas the trend for replantation surgery was decreasing. Six percent of the hospitals recording admissions with the Agency for Health Care Administration performed 68% of the replantation surgeries in the state. We also noted an increasing proportion of patients being admitted and treated outside of their own county and region. CONCLUSION: With fewer replantation surgeries performed and patients traveling farther for treatment we conclude that there is a need for coordinated evaluation, triage and treatment of patients with hand injuries requiring specialized hand surgery services at centers of excellence in Florida.

Cardiac contractility during hemofiltration in an awake model of hyperdynamic endotoxemia.

BACKGROUND: To determine whether continuous veno-venous hemofiltration can ameliorate hemodynamic instability and left ventricular (LV) dysfunction by reducing circulating plasma mediators, the authors used the LV end-systolic elastance (Ees) as a contractility index, in an awake swine model simulating human hyperdynamic endotoxemia. METHODS: Nineteen instrumented pigs were divided into a control group (CTRL, n = 7), a hemofiltration (HF, n = 7) group, and an extracorporeal circuit (ECC, n = 5) only group. All animals received intravenous E. coli endotoxin (10 microg x kg x h) and resuscitation in a common regimen for 24 hours. Hemofiltration was started 30 minutes after initiation of endotoxemia and continued until the end of the experiment. RESULTS: : Ees was maintained at baseline levels in the HF group, whereas a progressive decrease of Ees was found in both the CTRL and the ECC groups. Cardiac output was significantly higher in the HF group than the CTRL group. There was no significant difference between the groups in plasma catecholamines. CONCLUSION: We conclude that hemofiltration prevented LV impairment.

Game-based mass casualty burn training.

An interactive, video game-based training module, Burn Center, was developed to simulate the real-life emergency events of a mass casualty disaster scenario, involving in 40 victims.The game contains two components - triage and resuscitation. The goal of the triage game is to correctly stabilize, sort, tag and transport burn victims during a mass casualty event at a busy theme park. After complete the triage component, the player will then take on the role of a burn care provider, balancing the clinical needs of multiple burn patients through a 36-hour resuscitation period, using familiar computer-simulated hospital devices. Once complete, players of Burn Center will come away with applicable skills and knowledge of burn care, for both field triage and initial resuscitation of the burn patients.

A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries.

Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.

Wound management in a juvenile tiger (Panthera tigris) with vacuum-assisted closure (V.A.C. Therapy).

A 6-wk-old tiger (Panthera tigris) was evaluated for severe skin lacerations from an adult tiger attack. A caudal superficial epigastric skin flap was surgically placed to cover a defect that could not be closed over the hind limb; however, the skin flap did not adhere well to the granulation tissue over a period of 1 mo. The granulation bed matured and deteriorated. A subatmospheric pressure technique (vacuum-assisted closure, V.A.C. Therapy, Kinetic Concepts Inc., San Antonio, Texas 78219, USA) was utilized, and flap adherence occurred after 4 wk. This technique should be considered when dealing with severe or chronic wounds in tractable animals.

The Pope Air Force Base aircraft crash and burn disaster.

This report describes the initial hospital and burn center management of a mass casualty incident resulting from an aircraft crash and fire. One hundred thirty soldiers were injured, including 10 immediate fatalities. Womack Army Medical Center at Fort Bragg, North Carolina, managed the casualties and began receiving patients 15 minutes after the crash. As a result of repetitive training that included at least two mass casualty drills each year, the triage area and emergency department were cleared of all patients within 2 hours. Fifty patients were transferred to burn centers, including 43 patients to the US Army Institute of Surgical Research. This constitutes the largest single mass casualty incident experienced in the 57-year history of the Institute. All patients of the US Army Institute of Surgical Research survived to hospital discharge, and 34 returned to duty 3 months after the crash. The scenario of an on-ground aircraft explosion and fire approximates what might be seen as a result of an aircraft hijacking, bombing, or intentional crash. Lessons learned from this incident have utility in the planning of future response to such disasters.

Pattern of dysphagia recovery after thermal burn injury.

Providing nutritional support after thermal burn injury is a critical element in achieving successful patient outcomes. The medical records of 28 patients admitted to an acute care burn unit and referred to speech pathology for a swallowing evaluation were reviewed for patterns of dysphagia care. Results revealed a strong positive linear relationship between percent body burns (r = .71), number of days with a tracheostomy (r = .85), number of days on the ventilator (r = .94) and days to oral feeding. These data can be used for comparison with other models of care, such as early identification and intervention for dysphagia by the speech pathologist during the acute phase of recovery.

Temporal patterns of gene expression in murine cutaneous burn wound healing.

The global changes in gene expression in injured murine skin were characterized following a second-degree scald burn. Dorsal skin was harvested from uninjured and from burned mice at 2 h and at 3 and 14 days following immersion in 65 degrees C water for 45 s. Gene expression was surveyed using an Affymetrix U74Av2 GeneChip, and patterns of gene expression were analyzed using hierarchical clustering and supervised analysis. Burn injury produced significant alterations in the expression of a number of genes, with the greatest changes seen 3 and 14 days after the scald burn. Using a supervised analysis with a false discovery rate of 1% or 5%, differences in the expression of 192 or 1,116 genes, respectively, discriminated among the unburned skin and the three time points after the burn injury. Gene expression was primarily a transient and time-dependent upregulation. The expression of only 24 of the 192 discriminating genes was downregulated after the burn injury. No gene exhibited a sustained increase in expression over the entire 14 days following the burn injury. Gene ontologies revealed an integrated upregulation of inflammatory and protease genes at acute time intervals, and a diminution of cytoskeletal and muscle contractile genes at 3 or 14 days after the injury. Following a second-degree scald burn, global patterns of gene expression in the burn wound change dramatically over several weeks in a time-dependent manner, and these changes can be categorized based on the biological relevance of the genes.

Indices of antioxidant status in rats subjected to wood smoke inhalation and/or thermal injury.

The present study investigated antioxidant status in lavage fluid, lung, liver, heart and kidney in a rat model to simulate an inhalation injury as might be encountered by firefighters and burn victims. Anesthetized rats received either a 20% total body surface area (TBSA) full thickness scald or a sham burn. After a 5 h recovery period, half of the animals in the burn or sham burn groups were exposed to cooled western bark (fir and pine) smoke for 16.25 min. The remaining rats in each group breathed room air. At 1, 12, 24, 48 and 96 h after exposure to the smoke, five rats from each of the four groups were euthanatized and lungs were lavaged by infusing three 5 ml aliquots of normal saline for evaluation of airway cellular content and lung wet to dry weight ratios to estimate lung water content. A second series of five rats/group per time point were euthanatized at the above times and lung, liver, kidney and heart were removed for evaluation of tissue antioxidant enzyme activities and for thiobarbituric acid reactive substances (TBARS) concentrations, as well as for lung histology. Smoke exposure resulted in average plasma carboxyhemoglobin (COHb) of 19+/-2% in the two smoke exposed groups and produced areas of erosion of the tracheal surface, resulting in loss of epithelium and exposed basement membrane. Lung water content was not significantly different among the four groups during the 96-h experimental period. Lung TBARS levels were 2-3-fold higher at 12 h in smoke exposed rats compared with controls. These levels peaked at 24 h and remained significantly elevated at 48 h compared to controls. TBARS were also elevated in liver, but not in heart or kidney in response to burn or combined injury. Minor effects on lung antioxidant enzyme activities were observed after smoke inhalation. These data suggest that smoke inhalation, independent of burn injury, induces an oxidant stress that persists for at least the first 48 h after smoke exposure.

Analysis of gene expression patterns in human postburn hypertrophic scars.

Hypertrophic scars cause cosmetic disfigurement and limited mobility in burn patients. To better understand the molecular pathophysiology of hypertrophic scar formation, microarray analyses were performed on normal skin and hypertrophic scars from four burn patients. Microarray analyses were determined in an effort to identify genes whose expression discriminated between normal skin and mature, hypertrophic scars. Surgical biopsies were obtained from two pediatric and two adult patients 6 to 15 months after burn injury. Total RNA was isolated from the samples and subjected to microarray analysis using the Affymetrix U95Av2 GeneChip. Results from this analysis revealed 31 probe sets representing genes that were consistently up-regulated at least two-fold in hypertrophic scar specimens from all four patients and four probe sets that were down-regulated. The significance analysis of microarrays algorithm also identified 35 probe sets whose increased expression resulted in the hierarchal clustering of the hypertrophic scar and normal tissue, seven of which were identical to the six genes identified by paired analyses. These six genes all displayed elevated levels of expression in the scar tissue. Proteins encoded by the genes identified included germline oligometric matrix protein, matrix metalloproteinase-16, collagen type 1alpha, pleiotrophin, and thrombospondin-4. Although the results presented here suggest that there may be unique patterns of gene expression in hypertrophic scars that may be important in the evaluation and treatment of hypertrophic scarring, the results must be confirmed with larger datasets.

Hospital-acquired infections and thermally injured patients: chlorhexidine gluconate baths work.

BACKGROUND: Thermally injured patients are at high risk for infections, including hospital acquired infections (HAIs). We modeled a twice-daily chlorhexidine gluconate (CHG) bath protocol aimed at decreasing HAIs. METHODS: Bathing with a 0.9% CHG solution in sterile water was provided twice daily as part of routine care. Institutional HAI prevention bundles were in place and did not change during the study. Baseline HAI rates were collected for 12 months before the quality study implementation. Centers for Disease Control and Prevention definitions for HAIs were used; our blinded Infection Control physician made each determination. This was an Institutional Review Board-exempt protocol. RESULTS: The study cohort included 203 patients before the quality trial and 277 patients after the quality trial. The median burn area was 25% of total body surface area. Baseline HAI rates were as follows: ventilator-associated pneumonia, 2.2 cases/1,000 ventilator-days; cathether-associated urinary tract infection, 2.7 cases/1,000 catheter-days; central line-associated bloodstream infection, 1.4 cases/1,000 device-days. With implementation of this protocol, the rates dropped to zero and have stayed at that level with the exception of 1 cathether-associated urinary tract infection. There were no untoward effects or observed delays in wound healing with this protocol. All of these changes were clinically significant, although not statistically significant; the study was not powered for statistical significance. CONCLUSIONS: Using this nurse-driven protocol, we decreased, in a sustainable manner, the HAI rate in our intensive care unit to zero. No integumentary difficulties or wound healing delays were related to this protocol.

Predicting resource utilization of elderly burn patients in the baby boomer era.

BACKGROUND: Census predictions for Florida suggest a 3-fold increase in the 65 and older population within 20 years. We predict resource utilization for burn patients in this age group. METHODS: Using the Florida Agency for Healthcare Administration admission dataset, we evaluated the effect of age on length of stay, hospital charges, and discharge disposition while adjusting for clinical and demographic factors. Using US Census Bureau data and burn incidence rates from this dataset, we estimated future resource use. RESULTS: Elderly patients were discharged to home less often and were discharged to short-term general hospitals, intermediate-care facilities, and skilled nursing facilities more often than the other age groups (P < .05). They also required home health care and intravenous medications significantly more often (P < .05). Their length of stay was longer, and total hospital charges were greater (P < .05) after adjusting for sex, race, Charleson comorbidity index, payer, total body surface area burned, and burn center treatment. CONCLUSIONS: Our data show an age-dependent increase in the use of posthospitalization resources, the length of stay, and the total charges for elderly burn patients.

Bacillus cereus necrotizing fasciitis in a patient with end-stage liver disease.

BACKGROUND: Bacillus cereus has been increasingly recognized as a virulent pathogen, particularly in immunocompromised patients. METHODS: Presented is a case report of a 24-year-old man with end-stage liver disease secondary to primary sclerosing cholangitis, who developed necrotizing fasciitis of the right lower leg due to B. cereus. The bacterium isolated from the patient was compared with environmental strains for quantity of secreted proteins as well as hemolytic and cytotoxic activities. RESULT: Despite above-the-knee amputation and aggressive antibiotic therapy, the patient expired on hospital day 13. The patient isolate demonstrated a protein secretion pattern and cytotoxicity similar to those of an environmental strain known to produce exotoxins. However, the isolate did produce a larger ratio of zone of hemolysis to colony size on blood agar plates compared with the environmental strain. CONCLUSION: To the best of our knowledge, this is the only report of B. cereus as the etiology of necrotizing fasciitis in a patient with end-stage liver disease. Because the infecting bacterium correlates with the environmental strain, the severity of the patient's disease is likely related to his immunocompromised state. Therefore, B. cereus should be considered a potential pathogen rather than a contaminant.

Recombinant thrombin: safety and immunogenicity in burn wound excision and grafting.

This study evaluated the safety, immunogenicity, and hemostatic effect of recombinant human Thrombin (rThrombin), in patients undergoing skin grafting for burns. This was a phase 2 multiple site, single-arm, open-label study in patients receiving partial- or full-thickness autologous grafts. rThrombin was applied using a spray applicator to newly excised wounds of 1 to 4% body surface area at 5 minutes intervals for up to 20 minutes, after point source bleeding was stopped. Adverse events, skin graft survival, and formation of anti-rThrombin antibodies were measured at baseline and Day 29. There were no deaths or study drug discontinuations. Adverse events occurred in 63 of 72 patients (88%), and were typical of sequelae of skin grafting. Hemostasis was achieved within 20 minutes after application of rThrombin in 65 of 71 patients (91.5%). Skin graft failure occurred in 4 patients (6%). At the day 29 evaluation, for those patients who returned, 88.9% had > or =90% graft survival. One patient (1 of 70, 1.4%) had specific, low titer antibodies to rThrombin at baseline, but no increase in titer posttreatment; a second patient (1 of 62, 1.6%), developed antibodies to rThrombin at day 29. None of the antibodies neutralized native human thrombin. In excised burn wounds, hemostasis at 20 minutes was achieved in 91.5% of patients and skin graft survival was excellent. There was a low rate of antibodies to rThrombin at baseline (1.4%) and a low rate of anti-rThrombin antibody formation at day 29 (1.6%). rThrombin was well tolerated when administered with a pump spray.