Burn resuscitation on the African continent.

A survey of members of the International Society of Burn Injuries (ISBI) and the American Burn Association (ABA) indicated that although there was difference in burn resuscitation protocols, they all fulfilled their functions. This study presents the findings of the same survey replicated in Africa, the only continent not included in the original survey. One hundred and eight responses were received. The mean annual number of admissions per unit was ninety-eight. Fluid resuscitation was usually initiated with total body surface area burns of either more than ten or more than fifteen percent. Twenty-six respondents made use of enteral resuscitation. The preferred resuscitation formula was the Parkland formula, and Ringer's Lactate was the favoured intravenous fluid. Despite satisfaction with the formula, many respondents believed that patients received volumes that differed from that predicted. Urine output was the principle guide to adequate resuscitation, with only twenty-one using the evolving clinical picture and thirty using invasive monitoring methods. Only fifty-one respondents replied to the question relating to the method of adjusting resuscitation. While colloids are not available in many parts of the African continent on account of cost, one might infer than African burn surgeons make better use of enteral resuscitation.

CD14-mediated alterations in transcription and splicing of endogenous retroviruses after injury.

Increase in systemic levels of lipopolysaccharide (LPS) contributes to the pathogenesis of distant organ injury after burn. Stress signals elicited from burn influence transcriptional activities of mouse endogenous retroviruses (MuERVs) in various distant organs. The involvement of LPS pathways in the burn-mediated regulation of MuERVs in the spleen was investigated in this study. Spleen harbors substantial numbers of tissue macrophages, a key responder to LPS stimulation. Spleen tissues collected from CD14 (LPS receptor) knockout (KO) and wild type (WT) mice after burn were subjected to RT-PCR analysis of MuERV expression. There was a substantial induction of 2 bands and a marked downregulation of a band in CD14 KO mice compared to WT mice after burn. Sequence analysis of these CD14- and burn-dependent bands identified 3 new alternatively spliced and 2 defective env transcripts of MuERVs as well as novel splicing signals. Chromosomal loci of putative MuERVs sharing the unique U3 sequences of these transcripts were mapped by surveying the entire genome of C57BL/6J mice. In addition, coding potentials, transcriptional regulatory elements, and adjacent cellular genes of these putative MuERVs were analyzed. The results from these studies suggest that injury-triggered LPS/CD14 signaling events play roles in the transcriptional regulation of certain MuERVs carrying unique U3 promoter sequences.

Current management of purpura fulminans: a multicenter study.

Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

Use of an improved Watusi collar to manage pediatric neck burn contractures.

Burns to the neck present a serious challenge to the pediatric burn team. Even when full neck range of motion is maintained, scarring may lead to banding and a loss of the neck's natural contour. Conventional thermoplastic neck conformers have been used to maintain neck position and provide pressure to maturing scars, but they are rigid and limit functional mobility. This is of particular concern in the pediatric population where limiting neck mobility can disrupt the development of sensory and motor patterns that are essential to normal developmental progression. The Multi-Ring Watusi collar is a flexible neck orthosis that allows mobility and provides circumferential pressure to the neck. We modified this collar to improve its comfort, cosmetic appearance and ease in donning/doffing. The improved Watusi collar is a flexible splint that supports neck position, provides circumferential pressure, and allows for functional neck mobility.

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century.

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

Inverted television and video games to maintain neck extension.

It has been the standard of care in our pediatric facility to keep patients on strict bedrest with the neck in hyperextension for 5 days after a neck contracture release or grafting. Multiple methods have been used to help maintain neck immobility after grafting. It has been challenging to maintain strict bedrest protocols, because of decreased compliance and boredom. To address this issue, we examined common sedentary diversional activities engaged in by children. We decided to use video games to facilitate the intrinsic motivation of play. The monitor of a video game activity was inverted and placed behind the head of the bed so that the child could maintain proper neck positioning. We found the activity to be beneficial in many aspects. It helped maintain neck positioning, decreased the demand for individual interventions, and provided opportunities for improving self-confidence.

Sodium azide burn: a case report.

Chemical burn injuries commonly occur at the workplace and can be caused by a variety of agents. Sodium azide is a volatile compound used in the industrial setting and it is also a constituent of car airbags. The known toxic effects of sodium azide include hypotension, bradycardia, and headaches. At the cellular level, it inhibits of ATP production by blocking the respiratory oxidation cascade. In the burn literature only one previous report documents a sodium azide hand burn caused by airbag malfunction. We report a case of massive exposure and resultant systemic toxicity from a sodium azide canister explosion.

Expression of insulin-like growth factor I by cultured skin substitutes does not replace the physiologic requirement for insulin in vitro.

Clinical efficacy of cultured skin substitutes may be increased if their carbohydrate metabolism is optimized by understanding whether endogenous insulin-like growth factor I can substitute for exogenous insulin. Cultured skin substitutes were prepared and incubated at the air-liquid interface for 4 wk in media containing 0.5 or 5 microg per ml insulin, 10 or 50 ng per ml insulin-like growth factor I, or 0 insulin and 0 insulin-like growth factor I (negative control). In situ hybridization showed that the epidermal and dermal cultured skin substitute components express insulin-like growth factor I mRNA throughout the 28 d interval. Immunohistochemistry confirmed the expression of insulin-like growth factor I protein by the human keratinocytes and fibroblasts in cultured skin substitutes. Insulin-like growth factor I at 10 or 30 ng per ml could partially replace insulin in a clonal assay of keratinocyte growth. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assays showed significantly higher values in cultured skin substitutes incubated with insulin at incubation days 14 and 28 compared to negative control or the 10 ng per ml insulin-like growth factor I condition. Cultured skin substitutes incubated in 50 ng per ml insulin-like growth factor I had MTT values similar to the insulin-treated cultured skin substitutes at day 14, but were significantly lower by day 28. Light microscopy agreed with MTT data showing that cultured skin substitutes grown with insulin media had multiple layers of nucleated keratinocytes and stratum corneum at days 14 and 28. The negative control and 10 ng per ml insulin-like growth factor I exhibited poor cultured skin substitute epidermal morphology throughout the experiment. In contrast, the cultured skin substitutes in 50 ng per ml insulin-like growth factor I were similar to the insulin-treated cultured skin substitutes at day 14, but by day 28 had deteriorated to resemble the negative control. Bromodeoxyuridine incorporation at day 28 was significantly higher for 5 microg per ml insulin cultured skin substitutes versus all other treatment groups. These data suggest that medium containing 5 microg per ml insulin supports greater physiologic stability in cultured skin substitutes over time, and that expression of insulin- like growth factor I by keratinocytes and fibroblasts in cultured skin substitutes is not sufficient to fully replace the requirement for exogenous insulin in vitro.

Parallel self-induction of TNF-alpha and apoptosis in the thymus of mice after burn injury.

BACKGROUND: Burn injury often causes multiple organ failure as well as skin damage. Several studies suggest that TNF-alpha plays an important role in postinjury immunosuppression by altering lymphoid tissues. We investigated the regulation of TNF-alpha expression and apoptosis in the spleen and thymus of mice after burn injury. MATERIALS AND METHODS: C57BLKS/J mice were subjected to 18% TBSA full-thickness burn and the spleen and thymus were harvested at various time points (3 h to 29 days). The expression of TNF-alpha mRNA and protein in tissue extracts was analyzed by RT-PCR and ELISA. Apoptosis was measured by flow cytometry using annexin V staining. RESULTS: Burn injury induced TNF-alpha mRNA expression in the thymus at Day 1 and it returned to the basal levels at Day 14 and thereafter. Similarly, TNF-alpha mRNA up-regulation peaked between Day 1 and Day 3 in the spleen. Induction of TNF-alpha protein peaked at Day 1 in the thymus, whereas, TNF-alpha protein was unchanged in the spleen after burn injury. There was a twofold increase in apoptotic cells at Day 1 in the thymus, which is consistent with mRNA and protein data. In contrast, burn injury did not change apoptotic events in the spleen. CONCLUSIONS: The parallel induction of TNF-alpha mRNA, TNF-alpha protein, and apoptosis suggests that TNF-alpha may contribute to immunosuppression after burn injury by inducing apoptosis in the thymus.

A multicenter clinical trial to evaluate the topical hemostatic efficacy of fibrin sealant in burn patients.

Current surgical management of deep partial-thickness and full-thickness burn wounds involves early excision and grafting. Blood loss during these procedures can be profound, thus prompting the use of topical hemostatic agents to control and minimize hemorrhage during grafting. The primary endpoint of this multicenter trial was to evaluate the efficacy of fibrin sealant as a topical hemostatic agent during skin grafting. The secondary endpoint was to obtain data to support the existing safety profile of a human fibrin sealant (FS) in participating patients as indicated by the type, severity, and frequency of any adverse events within the 24-hour postoperative period. A multicenter prospective, open label, Phase III multicenter, randomized, comparative clinical trial evaluated the use of fibrin sealant in burn patients undergoing skin graft procedures. Each patient served as his or her own control in this randomized, unblinded study of the effect on time to hemostasis in donor sites treated with the investigational FS product. At operation, 1 contiguous donor skin harvest site was bisected into 2 equal halves, 1 of which was then randomly selected and treated with fibrin sealant. At the end of the fibrin sealant application, the time to hemostasis in each of the donor site halves was identified by the operating surgeon and recorded by the research coordinator. The use of any other topical hemostatic agents was prohibited. A significant difference (P < .001) was demonstrated in the mean time to hemostasis between the fibrin sealant treated donor sites when compared painwise to the control sites. The significant difference was consistent across the 6 participating study centers. There were no adverse events associated with the use of fibrin sealant. The investigational FS product was shown to be efficacious, because it significantly decreases the time to hemostasis at the donor skin harvest site in patients undergoing skin grafting and was noted not to cause any adverse reactions.

Results of early excision and full-thickness grafting of deep palm burns in children.

The timing and method of treatment of deep palm and finger burns varies widely. Our protocol involves performing full-thickness skin grafts (FTSG) in nonhealing palm burns. We reviewed the functional and cosmetic results after FTSG to the palm. From August 1997 to April 1999, 11 patients (12 palms) underwent excision and FTSG within 2 weeks of injury. A panel of medical and nonmedical professionals evaluated follow-up pictures of the grafts at 1, 2 to 4, and beyond 4 months. Parameters used for evaluation were color match with the unburned skin (1 = no difference to 4 = large difference), graft thickness (1 = flat to 4 = markedly raised), overall appearance (1 = poor to 100 = excellent), and time to maturity. Hand function, as assessed by occupational therapy notes, was also recorded. All 12 grafted palms had a 100% take and healed with minimal scarring. Mean color match scores were 2.4 at 1 month, 1.8 at 2 to 4 months, and 1.6 beyond 4 months. On the graft thickness scale, grafts were given scores of 2.6, 2.2, and 1.9 during the same intervals. The overall appearance was 71 at 1 month, 81 at 2 to 4 months, and 85 beyond 4 months. All grafts except 1 were judged to be mature at 2 to 4 months follow-up. Full passive range of motion was attained in all grafted hands within the period of 2 to 4 months after operation. Early excision and FTSG of deep pediatric palm burns can be performed in the outpatient setting. The grafts have an acceptable color match, are minimally raised, and achieve excellent cosmetic result. The grafts mature within a few months after surgery to allow for rapid return to normal range of motion. FTSG should be considered as a first choice for deep palm burns.

Gelatinase activities in wounds of healing-impaired mice versus wounds of non-healing-impaired mice.

The gelatinases, matrix metalloproteinase-2 and -9 (MMP-2 and MMP-9), have been implicated in different aspects of wound repair. However, little is known about MMP-2 and MMP-9 activity in animal models of impaired wound healing. We sought to compare serial gelatinase activities for 25 days after full-thickness excisional wounds in genetically diabetic healing-impaired mice and their nondiabetic non-healing-impaired littermates. Wound samples were frozen, homogenized, clarified by centrifugation, and analyzed on zymography gels, and MMP bands were quantitated relative to a conditioned media standard from HT-1080 cells. Gelatinase activity in both diabetic mice and nondiabetic mice increased after the mice were wounded. However, levels of latent gelatinases peaked earlier in the diabetic wounds, and there was more active MMP-2 and MMP-9 in the wounds of the diabetic mice than in the wounds of the nondiabetic mice. Because the higher gelatinase activity in the wounds of the diabetic mice was similar to the higher levels of gelatinase reported in difficult-to-heal wounds such as ulcers and burns, this diabetic mouse model may be useful for studies of these proteinases and their inhibitors in impaired wound healing.

The effect of medical insurance coverage on the obtainment of pressure garments.

Pressure garments are used to alter the appearance of immature burn scars. These garments are costly, and delays in obtaining them are frequent. The purpose of the study was to determine the nature of the delays in the obtainment of pressure garments and to examine the role that the payer plays in these delays. The billing and medical records of all patients with burns measured for pressure garments between January 1, 1998, and August 1, 1999, were reviewed. The distribution of payers was as follows: workers' compensation, 37%; state-funded insurance, 32%; health maintenance organizations, 12%; private insurance, 16%; and other, 3%. Payment authorization time for pressure garments was 37 days for state payers and less than 10 days for all other groups. Patients with state-funded insurance waited an average of 67 days to receive their garments as opposed to a wait of 20 to 30 days for other payers. The percentage of billed charges paid was least for patients with state-funded and HMO insurance (58% and 51%, respectively). The interval to payment of charges was longer than 60 days for all groups. Marked delays in authorization exist for state-funded reimbursement of pressure garments. Reimbursement for patients with state- and HMO-funded insurance was lower than for other payers. These differences may have an adverse effect on outcome.

Torchiere-style halogen floor lamps: a need for fire safety awareness.

Torchiere-style halogen lamps pose a significant fire hazard. The 500-W halogen bulb in these lamps can generate temperatures as high as 1200 degrees F. Factors related to the design of the lamp also contribute to the fire risk. The Consumer Products Safety Commission has issued various warnings and recalls on these lamps because of a significant number of fire-related incidents and deaths. The impact of these recalls on a random sample of consumers was investigated. A survey of these participants revealed that 60% of lamp owners and nonowners were unaware of the recalls. The majority of respondents were also not aware of the risks of injury, the extreme bulb temperatures, or safety measures designed for these lamps. There is a need for increasing community awareness and education to reduce the fire hazards associated with this product.

Differential regulation of c-jun expression in liver and lung of mice after thermal injury.

In addition to skin injury, burns may also damage distant organs. Understanding the mechanisms of distant organ injury will substantially improve the survival of burn patients. Transcription factors are the major regulators of gene expression in response to most types of injury. C-Jun, which is a part of the activator protein-1 transcription factor complex, is one of the major immediate-early response genes, which is rapidly induced after injury. The expression of c-Jun in mouse liver and lung at different time points (3 h to 29 days) after thermal injury was examined by using Reverse Transcription-Polymerase Chain Reaction (RT-PCR), Western blot, and immunohistochemistry. Rapid induction of c-Jun mRNA and protein was observed in the liver 3 h after an 18% TBSA burn. C-Jun expression returned to basal levels within 3 days after injury. In contrast to the up-regulation observed in liver, lungs from the same mice expressed c-Jun constitutively throughout the same time points. The finding that thermal injury leads to up-regulation of c-Jun in liver but not lungs suggests that either the liver has a lower threshold for early response to injury or that different cellular events exist when each organ is stressed.

Delayed wound healing in immunodeficient TGF-beta 1 knockout mice.

Previous studies showed that full-thickness wounds in transforming growth factor-beta1-deficient mice initially heal normally. Unfortunately, transforming growth factor-beta1 deficiency leads to a multifocal inflammatory disease affecting most organs of the body, which ultimately interferes with later stages of wound healing in these mice. As this inflammatory disease is eliminated in transforming growth factor-beta1-deficient mice lacking T and B cells (Tgfb1-/- Scid-/- mice), we hypothesized that wound repair in the latter would proceed normally, even at later stages of healing. Unexpectedly, Tgfb1-/- Scid-/- mice demonstrate a major delay of approximately 1 wk in each of the major phases of wound healing: inflammation, proliferation, and maturation. Immuno- deficient Scid-/- mice that have the wild-type Tgfb1 allele do not experience this delay in wound healing. One interpretation of these findings is that lymphocytes and transforming growth factor-beta1 affect compensatory pathways in wound healing. An alternative interpretation is that the delayed expression of Tgfb2 and Tgfb3 that occurs in the absence of transforming growth factor-beta1 results in the delayed wound healing, suggesting that transforming growth factor-beta2 and/or transforming growth factor-beta3 play important parts in wound healing.

Management of acute burn injuries of the upper extremity in the pediatric population.

Burns of the upper extremity occur frequently in children. Because of differences in development and anatomy, patterns of burn injury are different in children compared to adults. Immediate goals after these injuries are to prevent compartment syndromes and minimize progressive damage. The second decision is whether the burn requires conservative care or grafting. If the injury heals within 2 weeks, then scarring is minimized. If the wound has not healed in that time period, then grafting should be considered. Grafting techniques that optimize function and cosmetic appearance are outlined.

Expression and localization of p53 and bcl-2 in healing wounds in diabetic and nondiabetic mice.

In a healing wound, inflammatory cells undergo apoptosis immediately beneath the leading edge of migrating epithelium. A potential mediator of this apoptosis pattern is p53, a protein with antiproliferative effects. Another protein, bcl-2, is antagonistic to p53 and prevents apoptosis. The purpose of this study was to determine the expression and location of p53 and bcl-2 mRNA and protein in healing wounds of normal and genetically diabetic mice. At various time points, full-thickness skin wounds from nondiabetic and diabetic mice were evaluated for p53 and bcl-2 by immunohistochemistry and in situ hybridization. Apoptosis patterns were also determined using the TUNEL method. Messenger RNA for p53 and bcl-2 were quantitated by competitive reverse transcriptase-polymerase chain reaction. Protein and mRNA for p53 were expressed in the leading edge of migrating epithelium, with apoptosis patterns closely following those of p53 production. p53 mRNA levels decreased soon after wounding, but after a few days, levels increased to greater than baseline. bcl-2 was localized to the wound epithelium, but relative amounts tended to oppose levels of p53, i.e, when p53 increased, bcl-2 decreased and vice versa. Wounds in diabetic animals showed a delayed onset of p53 mRNA expression but had persistently greater levels for longer periods of time. bcl-2 mRNA expression was further delayed in diabetic mice and did not develop to levels as high as p53. Production of both proteins was delayed, consistent with the mRNA expression. Our data show that immediately after wounding, bcl-2 increases and p53 decreases to allow for the cellular proliferation that is required for tissue repair. Over time, bcl-2 levels decrease while p53 levels increase to shut down the inflammatory process and down-regulate the proliferative response. Diabetic animals appear to lose the indirect relationship between p53 and bcl-2. This loss may contribute to the altered apoptosis patterns observed in diabetic healing.

Cost-effective use of helicopters for the transportation of patients with burn injuries.

We performed a retrospective review to analyze the use of helicopters for the transportation of patients with burn injuries to determine whether a more cost-effective approach could be developed without impairing the quality or delivery of health care. Charts were reviewed for all patients with burn injuries who were transported by helicopter to our hospitals during a 2-year period. Patients with inhalation injuries, with burn injuries received more than 24 hours before admission or more than 200 miles from our burn center, with more than 30% total body surface area (TBSA) burned, or with associated trauma injuries were excluded. Control patients with burn injuries who were transported by ambulance were identified and matched to the patients with burn injuries transported by helicopter for the percentage of TBSA burned, the percentage of third-degree burns, transport mileage, and age. The outcome was evaluated by comparison of length of stay, days on ventilator, and mortality rate. Comparisons were performed with Student t test. The transportation charge was determined for the patients transported by helicopter who we believed were eligible for transport by ambulance. Forty-seven of 85 patients transported by helicopter matched the inclusion criteria and had survived. There was no statistically significant difference between the percentage of TBSA burned, the percentage of third-degree burns, length of stay, days on ventilator, age, or transport mileage. There was, however, a significant difference in the time from the injury to admission to the hospital, as well as in the charge for transportation. Patients who had less than 30% TBSA thermal cutaneous injuries without evidence of inhalation injury, and who are less than 200 miles from a burn center may be safely transported by ambulance. Ambulance transportation may take additional time; however, stricter protocols for helicopter transportation of patients with burn injuries will result in potentially substantial savings without affecting outcomes for patients.

Expression of HSP70 in healing wounds of diabetic and nondiabetic mice.

BACKGROUND: Heat shock proteins (HSPs) stabilize intracellular processes of cells under stress. Little is known about the role of HSPs in wound healing, or whether their expression is altered by systemic disease. The focus of this study was to examine the local heat shock response to wounding in diabetic mice. METHODS: Congenitally diabetic and phenotypically normal mice underwent standardized full-thickness cutaneous wounding. Mice were sacrificed at sequential time points and the wound beds excised. Tissues underwent immunohistochemical (IHC) and RT-PCR analyses for inducible HSP70. RESULTS: HSP70 protein expression in the wound bed by IHC peaked at 24 h in the nondiabetic mice. Expression of HSP70 was delayed in the diabetic mice until Day 3, which correlates with the clinical delay in healing seen in this model. The protein was especially prominent in the epithelium and in inflammatory cells migrating into the granulation tissue matrix. RT-PCR demonstrated upregulation of HSP70 mRNA within 12 h after wounding, lasting until Day 3, and decreasing thereafter in both the nondiabetic and the diabetic animals. CONCLUSION: Cutaneous wounding produces a HSP response in inflammatory cells, and expression of inducible HSP70 is delayed in diabetic mice. This delay may be related to the impaired inflammatory response of diabetics, and may contribute to impaired wound healing. The wound may be a continuing source of the heat shock response in inflammatory cells after injury.