Term Neonate Born With Right Upper Extremity Skin Necrosis at Birth: A Case Report.

Congenital skin and soft tissue necrosis is a rare condition associated with significant morbidity and mortality in neonates. The authors treated a neonate born with significant skin necrosis of the right forearm. The case report is followed by a literature review and discussion of previously published reports of neonatal skin necrosis. A term female neonate was admitted to our hospital at 24 h of age for skin necrosis of the right forearm with sloughing and edema below the right elbow and contractures of her fingers. Topical treatment with cleansing and antibiotic application was initiated. The LUNA florescent microangiography showed superficial perfusion defects in the arm and dorsum of the hand along with overt ischemia over the dorsal aspect of the forearm. She was treated with intravenous antibiotics following a sepsis evaluation. Subsequently, she developed hypotension treated with fluid boluses, dopamine, and stress dose steroids. Concerns of wound infection and sepsis led to debridement of the necrotic area within the first 24 h post-admission. Wet-to-dry dressing changes using Vashe wound solution were begun postoperatively.; followed by placement of Integra on postoperative day-of-life (DOL) 7; dressing takedown on DOL 12; and autografting of the right hand and forearm with disarticulation of the 4th distal interphalangeal joints and right 5th distal interphalangeal transection on DOL 24. Postoperative dressing care was continued during the remainder of the hospital stay, she remained stable without any further complications and was discharged home on DOL 34 with outpatient clinic follow-up.

The Effects of Rapid Rewarming on Tissue Salvage in Severe Frostbite Injury.

Frostbite is a high morbidity injury caused by soft tissue freezing, which can lead to digit necrosis requiring amputation. Rapid rewarming is a first-line treatment method that involves placing affected digits into a warm water bath. This study aims to assess the clinical practices for frostbite at facilities outside of dedicated burn centers, and any impact these practices have on tissue salvage. Retrospective chart review at a single burn center identified frostbite patients admitted directly or as transfers over a 7-year period. Records were reviewed to identify initial treatment strategies. If given, time to thrombolytics from admit was noted. Tissue salvage rates were calculated from radiologically derived tissue at-risk scores and final amputation scores. One-hundred patients were transferred from outside facilities, and 108 were direct admissions (N = 208). There was no significant difference in group demographics. Rapid rewarming was the initial treatment modality more commonly in direct admit patients (P = .016). The use of rapid rewarming did not correlate with tissue salvage (P = .112). Early use of thrombolytics had a positive impact on tissue salvage (P = .003). Thrombolytics were given 1.2 hours earlier in direct admit patients (P = .029), however there was no difference in tissue salvage rates between the groups (P = .127). Efforts should focus on larger scale study to further assess the effectiveness of rapid rewarming. Although rapid rewarming did not significantly impact tissue salvage in this study, we continue to recommend its use over less studied treatment methods, and continue to view it as an important bridge to burn center transfer and administration of thrombolytic therapy.

An Institutional Protocol for the Treatment of Severe Frostbite Injury-A 6-Year Retrospective Analysis.

The treatment of severe frostbite injury has undergone rapid development in the past 30 years with many different diagnostic and treatment options now available. However, there is currently no consensus on the best method for management of this disease process. At our institution, we have designed a protocol for severe frostbite injury that includes diagnosis, medical treatment, wound cares, therapy, and surgery. This study assess the efficacy of our treatment since its implementation six years ago. During this time, all patients with severe frostbite injury were included in prospective observational trial of the protocol. We found that this protocol results in significant tissue salvage with over 80.7% of previously ischemic tissue becoming viable and not requiring amputation. We also were able to improve our center's efficiency over the course of six years and now our current average time from rapid rewarming to delivery of thrombolytics is under six hours.

Severe Hypothermia and Frostbite Requiring ECMO and Four Limb Amputations.

Severe hypothermia and frostbite can result in significant morbidity and mortality. We present a case of a patient with severe hypothermia and frostbite due to cold exposure after a snowmobile crash. He presented in cardiac arrest with a core temperature of 19°C requiring prolonged cardiopulmonary resuscitation, active internal rewarming, venoarterial extracorporeal membrane oxygenation, and subsequently amputations of all four extremities. Although severe hypothermia and frostbite can be a fatal condition, the quick action of Emergency Medical Services, emergency physicians, trauma surgeons, cardiothoracic surgeons, intensivists, and the burn team contributed to a successful recovery for this patient including a good neurological outcome. This case highlights the importance of a strong interdisciplinary team in treating this condition.

Microangiography: An Alternative Tool for Assessing Severe Frostbite Injury.

Assessment of frostbite injury typically relies on computed tomography, angiography, or nuclear medicine studies to detect perfusion deficits prior to thrombolytic therapy. The aim of this study was to evaluate the potential of a novel imaging method, microangiography, in the assessment of severe frostbite injury. Patients with severe frostbite were included if they received a post-thrombolytic Technetium 99 (Tc99) bone scan, a Tc99 bone scan without thrombolytic therapy, and/or post-thrombolytic microangiography (MA) study. We included all patients from the years 2006 to 2018 with severe frostbite injury who had received appropriate imaging for diagnosis: Tc99 scan alone (N = 82), microangiography alone (N = 22), and both Tc99 and microangiography (N = 26). The majority of patients received thrombolytic therapy (76.2%), and the average time to thrombolytics was 6.9 hours. Tc99 scans showed strong correlation with amputation level (r = .836, P < .001), and microangiography showed a slightly stronger positive correlation with amputation level (r = .870, P < .001). In the subset who received both Tc99 scan and microangiography (N = 26), we observed significant differences in the mean scores of perfusion deficit (z = 3.20, P < .001). In this subset, a moderate correlation was found between level of perfusion deficit on Tc99 bone scan and amputation level (r = .525, P = .006). A very strong positive correlation was found between the microangiography studies and the amputation level (r = .890, P < .001). These results demonstrate that microangiography is a reliable alternative method of assessing severe frostbite injury and predicting amputation level.

Influence of Insurance Status on Hospital Length of Stay and Discharge Location in Burn Patients.

Insurance status affects many aspects of healthcare in America, from access to delivery to outcomes. Our goal in this study was to determine whether different subtypes of insurance status affected hospital lengths of stay (LOS) and/or the location to which patients were discharged. The National Burn Repository was used to examine a total of 119,509 burn patients. Patients with noncommercial insurance (NONCOM) have increased LOS and are more likely to be discharged to a nonhome location, compared with no insurance or other insurance subtypes. Patients with no insurance have similar injury characteristics and comorbidities as patients with NONCOM, but have a shorter LOS and are more likely to be discharged home rather than to a skilled nursing facility or rehabilitation facility.

Microangiography to Monitor Treatment Outcomes Following Severe Frostbite Injury to the Hands.

Frostbite injury causes direct damage to tissues following exposure to temperatures below their freezing point causing tissue death potentially leading to serious amputations. After rewarming, a variety of treatment options have been employed to avoid amputation. This case report details the use of indocyanine green fluorescence microangiography to monitor the clinical progression of perfusion following hyperbaric oxygen therapy (HBOT) for severe frostbite injury. We present a case report of a man with deep frostbite of the bilateral hands treated with thrombolytics and HBOT. After rewarming, the patient received thrombolytics shortly after arrival and then went on to be treated with HBOT on hospital day 5. Patient's healing progress was monitored using serial microangiography. Microangiography evaluation was performed on day 6 and then weekly to track treatment progress. A more uniform brightness appears in his left hand by completion of his therapies, consistent with normal perfusion. The dark ischemic areas in the right hand receded in digits 1 to 3 and appeared normalized in the fourth digit. The patient received a total of 20 HBO treatments. After completion of therapy, the patient went on to have a partial amputation of his first, second, and third fingers on his right hand. Our case report demonstrates serial microangiography to monitor a frostbite patient's progress during HBOT and provided additional information allowing us to plan duration of treatments. Our case report describes the role that microangiography may serve in monitoring patient progress following severe frostbite injury.

Early Mobilization in Lower Extremity Frostbite Injury: Preliminary Experience at a Single Burn Center.

Cold exposure that leads to frostbite puts patients at high risk for extremity amputations. Recent treatment advances, such as thrombolytic administration, have decreased amputation rates. However, little is known about patient outcomes with early mobilization of affected limbs. A retrospective review of 41 patients admitted for lower extremity frostbite was performed at an urban hospital burn unit. All patients received the institution's standard frostbite treatment protocol. The study group was allowed to bear weight within 72 hours, while the control group was immobilized beyond this time frame. No significant differences were found between groups when comparing total tissue loss, complications, or hospital length of stay. Previous treatment of frostbite at our institution involved strict avoidance of weight bearing to the affected extremity due to concern for repeat trauma and associated complications. Our findings show that patients who ambulated sooner had comparable outcomes to those immobilized for longer time periods. Larger studies would be useful to determine a standard time to mobilization in frostbite treatment protocols.

Time Matters in Severe Frostbite: Assessment of Limb/Digit Salvage on the Individual Patient Level.

Severe frostbite is associated with high levels of morbidity through loss of digits or limbs. The aim of this study was to examine the salvage rate following severe frostbite injury. Frostbite patients from 2006 to 2014 were identified in the prospectively maintained database at a single urban burn and trauma center. Patients with imaging demonstrating a lack of blood flow in limbs/digits were included in the analysis (N = 73). The Hennepin Frostbite Score was used to quantify frostbite injury and salvage. This score provides a single value to assess each individual patient's salvage rate. The majority of patients with perfusion deficits were male (80%) with an average age of 42 years (range 11-83 years). Patients requiring amputation tended to be older (P = .002), have more tissue impacted by frostbite (P < .001), and experienced a longer time from rewarming to thrombolytic therapy (P = .001). A majority of patients (62%) received thrombolytic treatment. The percentage of patients requiring amputation was lower and the salvage rate was higher in patients treated with thrombolytics; however, the differences failed to reach statistical significance (P = .092 and P = .061, respectively). The rate of salvage decreases as the time from rewarming to thrombolytic therapy increases. Regression analysis demonstrates an additional 26.8% salvage loss with each hour of delayed treatment (P = .006). When the amount of tissue at risk for amputation is included in the model, each hour delay in thrombolytic treatment results in a 28.1% decrease in salvage (P = .011). This study demonstrates a significant decrease in limb/digit salvage with each hour of delayed administration of thrombolytics in patients with severe frostbite.

Livedoid dermatitis and severe necrosis (Nicolau's syndrome) after intramuscular hydroxyzine injection.

Nicolau's syndrome, also called embolica cutis medicamentosa, is characterized by well- circumscribed livedoid dermatitis with aseptic necrosis after intramuscular injection. We report the case of a 45-year-old woman with severe necrosis of the thigh several days after a routine intramuscular injection of hydroxyzine who was transferred to and treated at our Regional Burn Center. Although there has been one case report and numerous voluntarily reported instances of intramuscular hydroxyzine-induced necrosis to the Food and Drug Administration Spontaneous Reporting System, this phenomenon is rare.

Duloxetine: a balanced and selective norepinephrine- and serotonin-reuptake inhibitor.

PURPOSE: The pharmacology, pharmacokinetics, efficacy, safety, drug interactions, dosage and administration, cost, and place in therapy of duloxetine for major depression, pain from diabetic peripheral neuropathy, and stress urinary incontinence are reviewed. SUMMARY: Duloxetine is a balanced selective serotonin and norepinephrine-reuptake inhibitor available in the United States for the treatment of major depressive disorder (MDD) and diabetic peripheral neuropathic pain (DPNP). Duloxetine has also been used for the treatment of stress urinary incontinence (SUI). Absorption of duloxetine begins two hours after oral administration, reaching a maximum plasma concentration in six hours. Half-life and volume of distribution are 12 hours and 1640 L, respectively. The recommended dosage of duloxetine is 40-80 mg daily, depending on the indication, preferably split into two doses per day. For the treatment of major depression, duloxetine has achieved remission rates similar to that of existing selective serotonin-reuptake inhibitors (SSRIs). For SUI and pain associated with diabetic peripheral neuropathy, duloxetine has not demonstrated equivalence or superiority to existing therapies. The adverse effects of duloxetine are similar to those of traditional SSRIs. Nausea is common and has been cited as the primary reason for discontinuation of duloxetine in trials. Increases in blood pressure have been mild, but caution should be used in patients with hypertension. Patients with a creatinine clearance of <30 mL/min and patients with hepatic impairment should avoid duloxetine. Duloxetine should not be recommended as first-line therapy for SUI or DPNP. For MDD, duloxetine may be a useful alternative for patients who do not benefit from or are unable to tolerate other antidepressant therapy. CONCLUSION: Duloxetine has been approved for the treatment of MDD and pain associated with diabetic peripheral neuropathy in adults.