The prevalence of venous thromboembolism of the lower extremity among thermally injured patients determined by duplex sonography.

BACKGROUND: Morbidity and mortality from venous thromboembolism (VTE) remains a significant problem for hospitalized patients. Despite the ample prospective literature defining the prevalence of VTE in hospitalized patient populations, the prevalence of VTE in the thermally injured population remains largely unknown. METHODS: We prospectively studied 148 thermally injured patients with hospital stays of greater than 3 days with lower extremity duplex ultrasonograms obtained at admission and discharge. RESULTS: Nine patients experienced VTE (6.08%). Eight of the nine deep venous thromboses were proximal. One of the two pulmonary embolisms was fatal. Treatment risk factors that were associated with VTE were the presence of a central venous line (p = 0.020) and transfusion of more than 4 units of packed red blood cells (p = 0.023). These treatment factors were significantly related to each other (p < 0.0001), to body surface area burned, and to intervention. CONCLUSION: The prevalence of VTE in burn patients is similar to that of moderate- to high-risk general surgical patients for whom VTE prophylaxis is recommended. VTE prophylaxis of burn patients, especially those requiring central venous lines and more than 4 units of packed red blood cells, should be considered.

Trash and brush burning: an underappreciated mechanism of thermal injury in a rural community.

Open-fire injuries associated with burning trash or brush result in a significant number of burn admissions annually. Trash- and brush-burning injuries are more prevalent in rural environments where open burning is an acceptable practice of waste disposal. These injuries are not "unavoidable accidents" but follow a predictable injury pattern. Understanding this injury pattern is paramount to effective prevention. The purpose of this work is to describe the epidemiology of burn injuries associated with burning trash or brush. Charts were retrospectively reviewed for all trash and brush burning injuries from July 1989 to December 2000. One hundred ninety-four injuries were identified, accounting for one fifth of all flame admissions for the study period. Persons most at risk for these burn injuries were males between the ages of 25 to 45, followed by males ages 16 to 24. Accelerant use was identified in over 80% of these injuries. The median cost for admission was $9,363.00 US dollars. Cost was significantly related to age, percent body surface area burned, and operative intervention. Brush and trash burning can lead to costly injuries especially when accelerants are used. Additional research is needed to explore the cultural and social influences associated with these injuries to target effective prevention.

Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma.

BACKGROUND: The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. METHODS: Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. RESULTS: Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). CONCLUSION: Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

Predicting survival in an elderly burn patient population.

The purpose of this study was to analyze the outcome of elderly burn victims and to determine an instrument to predict survival in this population. Charts of three hundred and eight burn patients > or =60 yr of age who were admitted to a university-based hospital between the years of 1977-1996 were retrospectively analyzed. The mean age of the population was 71.5+/-8.6, with a male predominance (1.8 to 1, P < 0.001). The majority of the burns were secondary to flame injuries (210, 68.6%). The median body surface area (BSAB) was 13.0% with an in-hospital mortality rate of 30.2%. We demonstrated improved survival in patients aged 60-74 yr as compared to 1965-1971 national burn survival data. A similar trend could not be shown in the very old (> 75 yr of age). Only age and BSAB were related to death by multiple stepwise forward linear regression. The Baux score, which adds age and BSAB, was predictive of outcome in 87.0% of our population. In conclusion, this study reinforces the high mortality associated with burn injuries in the elderly and the superior ability of the Baux score (age + percent burn) in predicting outcome in this population.

Expression of thrombomodulin and consequences of thrombomodulin deficiency during healing of cutaneous wounds.

Thrombomodulin is a cell surface anticoagulant that is expressed by endothelial cells and epidermal keratinocytes. Using immunohistochemistry, we examined thrombomodulin expression during healing of partial-thickness wounds in human skin and full-thickness wounds in mouse skin. We also examined thrombomodulin expression and wound healing in heterozygous thrombomodulin-deficient mice, compound heterozygous mice that have <1% of normal thrombomodulin anticoagulant activity, and chimeric mice derived from homozygous thrombomodulin-deficient embryonic stem cells. In both human and murine wounds, thrombomodulin was absent in keratinocytes at the leading edge of the neoepidermis, but it was expressed strongly by stratifying keratinocytes within the neoepidermis. No differences in rate or extent of reepithelialization were observed between wild-type and thrombomodulin-deficient mice. In chimeric mice, both thrombomodulin-positive and thrombomodulin-negative keratinocytes were detected within the neoepidermis. Compared with wild-type mice, heterozygous and compound heterozygous thrombomodulin-deficient mice exhibited foci of increased collagen deposition in the wound matrix. These findings demonstrate that expression of thrombomodulin in keratinocytes is regulated during cutaneous wound healing. Severe deficiency of thrombomodulin anticoagulant activity does not appear to alter reepithelialization but may influence collagen production by fibroblasts in the wound matrix.

Our chemical burn experience: exposing the dangers of anhydrous ammonia.

Although chemical injuries account for only a small number of one burn unit's cases, the diversity, resulting complications, and sequelae of these burns pose special problems. We reviewed a 19-year period of the chemical burn experience of our burn unit. The population of patients with these types of burns consisted of young men (mean age: 29.8 years), the majority of whom were injured on the job. Unique to our series is the largest collection of injuries (30%) resulting from the common fertilizer anhydrous ammonia. Another population of concern, accounting for 14% of the injuries in our unit, is that of patients injured at home with routine household cleaners. Nearly one half of those patients injured at home incurred injuries that required grafting. The cornerstone of chemical burn prevention and treatment involves education regarding the caustic nature of chemicals, proper handling, adequate protection, and copious irrigation of the wound at the scene. From the analysis of our retrospective review, adequate education and treatment at the scene appear to be well implemented in the industrial and farming communities. The focus of our education efforts should be directed toward the public and emphasize the safe use of household chemicals. Finally our review illuminated the potential benefit of immediate excision and grafting for decreasing the length of stay, complications, and loss of productivity.

Fournier's gangrene with an unusual urologic etiology.

Fournier's gangrene is a necrotizing infection affecting the male genitalia and perineum, caused by synergistic aerobic and anaerobic organisms. We report on a previously undescribed upper urinary tract etiology for this life-threatening infection.

A retrospective study of the incidence and prevalence of thermal corneal injury in patients with burns.

The clinical course of thermal corneal injuries is not well described. A review of 1750 burn admissions to a regional burn center between 1979 through 1993 was done to determine the clinical course of thermal corneal injuries. Twenty-five out of 1750 burn admissions (1%) presented with a thermal corneal injury. Corneal injuries were identified with use of a fluorescein dye and a Wood's lamp. Ophthalmologic consultation was obtained for those identified. Data were analyzed with the Fisher's exact test and the unpaired two-tailed Student's t test. Patients with thermal corneal injury did not differ demographically from other patients with burn injury. Open-flame burns were the most common cause of injury. Improvement of corneal injury occurred in all survivors who had an intact globe on initial examination. Initial visual acuity was not a good predictor of outcome, and long-term complications were uncommon.

Treatment-resistant pain and distress during pediatric burn-dressing changes.

Recent research has suggested some efficacy for the use of hypnosis in the control of pain and distress in a pediatric population undergoing painful medical procedures. Here, we study a sample (N=23) of pediatric subjects undergoing burn-dressing changes and receiving either an imagery-based or control (social-support) treatment. Subjects' levels of distress were assessed with the Observational Scale of Behavioral Distress. Results indicated that distress behaviors in this population can be measured reliably using this scale. However, no support was found for the main hypothesis that imagery treatment would be superior to control treatment in the alleviation of distress, nor were these treatments effective in comparison to baseline conditions. We discuss the formidable problem that burn and dressing-change pain presents, as well as the reasons why this treatment attempt might have failed to have the predicted effects. We also discuss important developmental considerations regarding the adequate assessment of pain and distress.

A study of functional viability and metabolic degeneration of human skin stored at 4 degrees C.

We sought to ascertain whether an in vitro assay could be as reliable as an in vivo assay in determining the viability of human skin stored at 4 degrees C. Allografts from six human donors were stored in RPMI 1640 tissue culture medium at 4 degrees C. At fixed intervals during the storage period, all skin specimens were tested concurrently by two different viability assays: (1) transplantation onto surgically created defects on nude mice, and (2) intracellular enzyme activity with use of a 4-hour semiquantitative micromethod system activity (API ZYM; Biomerieux Vitek Inc., Hazelwood, Mo.). Human graft survival on the nude mice was 100% for the first 15 days of storage, and then declined to 50% on storage day 30. The API ZYM assay showed a comparable progressive decrease in enzyme activity over skin storage time. The API ZYM assay is a simple, rapid system that produces reproducible results and is cost-effective when compared to the biologic model.

Long-term neuropsychological sequelae of severe burns.

Eight patients who suffered severe burns and protracted periods of amnesia following those burns were evaluated for neuropsychological and neuropsychiatric problems between 6 months and 4 years following their accidents. All were found to have significant problems as evidenced in neuropsychological testing, activities of daily living, and reports from relatives. Findings on these burn patients with postburn amnesia were quite different from those of five burn patients who did not develop amnesia. Problems observed and reported in the burn-amnesia patients appeared to reflect clear neuropathological etiologies, which was not unexpected because their initial amnestic syndromes must also have been the result of significant central nervous system dysfunction. It is recommended that severe burn patients have neuropsychological, psychiatric, and neurological exams as part of routine postburn care.

Clinical trials of a biosynthetic temporary skin replacement, Dermagraft-Transitional Covering, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds.

Human cadaver allograft skin (HCAS) is widely used for covering excised burn wounds when limited available skin donor sites or the overall patient condition does not permit immediate grafting with autologous skin. However, recurring problems are associated with HCAS including limited supply, variable quality, ultimate immune rejection, and the potential for bacterial and viral disease transmission. These problems speak for the need for development of a dependable substitute for HCAS. We evaluated the ability of a biosynthetic analogue of human skin to temporarily close excised burn wounds in humans. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) is composed of human neonatal fibroblasts cultured on a synthetic dressing (Biobrane; Dow Hickam, Inc.) that consists of nylon mesh fabric covered with a thin layer of silicone rubber membrane, which provides an epidermal "barrier." The material is stored frozen and thawed immediately before use. DG-TC is semitransparent, thus facilitating continuous observation of the underlying wound surface. Burn wounds in 10 patients (mean age 33.5 years, mean burn size 39.9% total body surface area) were surgically excised. Two variants of the DG-TC skin analogs were tested: a material that was cryopreserved to maintain fibroblast viability (DG-TC Red) and a material that was frozen without efforts to maintain fibroblast viability (DG-TC Blue). A control site on each patient received cryopreserved HCAS. Each study site was approximately 1% total body surface area. When clinically indicated, patients were returned to the operating room where the skin replacements were removed, the wound bed was evaluated and prepared for grafting, and the wounds were closed with meshed split-thickness autograft skin. The results showed that adherence to the wound and subsequent autograft "take" were excellent with both DG-TC variants and were at least equivalent to HCAS. No evidence of immune rejection of DG-TC was seen, whereas in four patients evidence of epidermal sloughing/rejection was noted in the HCAS control sites, which limited persistence of those grafts on the wound. Further clinical trials with this skin analogue are in progress.

A multicenter clinical trial of a biosynthetic skin replacement, Dermagraft-TC, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds.

This multicenter study compared the use of a biosynthetic human skin substitute with frozen human cadaver allograft for the temporary closure of excised burn wounds. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) consists of a synthetic material onto which human neonatal fibroblasts are cultured. Burn wounds in 66 patients with a mean age of 36 years and a mean burn size of 44% total body surface area (28% total body surface area full-thickness) were surgically excised. Two comparable sites, each approximately 1% total body surface area in size, were randomized to receive either DG-TC or allograft. Both sites were then treated in the same manner. When clinically indicated (> 5 days after application) both skin replacements were removed, and the wound beds were evaluated and prepared for grafting. DG-TC was equivalent or superior to allograft with regard to autograft take at postautograft day 14. DG-TC was also easier to remove, had no epidermal slough, and resulted in less bleeding than did allograft while maintaining an adequate wound bed. Overall satisfaction was better with DG-TC.

Parent participation during burn debridement in relation to behavioral distress.

The data on the benefits of parent participation during pediatric medical procedures are mixed. Although a wealth of clinical experience and survey data strongly recommend parent participation in a child's medical care, the mere presence of a parent, particularly during medical procedures, may be insufficient to decrease behavioral distress. This study examined a sample of children aged 3 through 12 undergoing three successive burn dressing changes. For some sessions, parents were present, and for others, they were not. A valid and reliable measure of behavioral distress was taken, as was an informal measure of the level of parent participation. Results indicated no differences between mothers and fathers in the level or the nature of participation, little change in the level of participation across time, and higher levels of physical comforting than verbal comforting. Results also indicated higher levels of behavioral distress in subjects when parents were present versus when absent, which extends previous findings. Results are discussed in terms of the literature on parent and child preferences for parent involvement and parent coaching programs.

Cadaver skin allografts and transmission of human cytomegalovirus to burn patients.

BACKGROUND: The potential role of cadaver skin as a vehicle for CMV transmission to burn patients has never been clearly defined. We sought to determine if a cytomegalovirus (CMV)-positive cadaver allograft transmits CMV infections to CMV-seronegative burn patients. STUDY DESIGN: All patients in this study were CMV seronegative on admission. They received CMV-seronegative blood products, and cadaver allografts for temporary wound closure and management without regard to the donor's CMV serum status (positive or negative). RESULTS: Of 493 patients admitted from 1989 to 1993, 22 were CMV seronegative on admission and required cadaver allografts for their burn wounds. Five (22.7 percent) of 22 patients seroconverted during hospitalization: one of five had CMV pneumonia develop, two had CMV viruria develop, and three had persistent fever, abnormal liver enzymes, and diarrhea not ascribable to bacterial or other viral agents. CONCLUSIONS: Cytomegalovirus infections result from using CMV-seropositive cadaver allografts on seronegative burn patients.

Neurobehavioral sequelae of high voltage electrical injuries: comparison with traumatic brain injury.

Eighteen survivors of high voltage electrical injuries (HVEI) underwent neuropsychological evaluation in the acute, short-term or long-term epochs Deficits in verbal learning and delayed recall of verbal information were present across various epochs No other cognitive performances were in the impaired range for the HVEI group, although many individual patients also had compromised attention Depression, anxiety and irritability were widespread among HVEI patients, especially beyond the acute period Extreme irritability was accompanied by assaultive behavior in several patients The neurobehavioral effects of HVEI were very similar to those of a closely matched traumatic brain injury (TBI) control group in each epoch The only significant difference between the groups was less successful immediate visual retention by TBI patients in the long-term epoch.