Development of a colocutaneous fistula in a patient with a large surface area burn.

A 61 year old female sustained a large surface area burn, complicated by inhalation injury. One month before the incident, she had undergone a left hemicolectomy with colorectal anastomosis for diverticular disease. Due to the severity of her burns, multiple surgical debridement and skin grafting procedures were required, including a large fascial debridement of her flank and back. Her hospital course was complicated by recurrent episodes of pulmonary and systemic infection, as well as pre-existing malnutrition. Prior to her discharge to a rehabilitation center, stool began to drain from her left posterior flank. This complication represented a colonic fistula arising from the recent colon anastomosis. The fistula was managed nonoperatively and gradually closed. To our knowledge, this is the first report of a colocutaneous fistula spontaneously draining from the abdomen via the retroperitoneum in a burn victim, not related to direct thermal injury to the peritoneal cavity.

Cultured composite autografts as coverage for an extensive body surface area burn: case report and review of the technology.

Cultured epithelial autografts (CEA) have been used as an adjunct in the surgical management of extensive thermal burns. Unfortunately, the lack of a dermal matrix makes CEA susceptible to infection, shearing forces and limits their incorporation into the burn wound. A cultured composite autograft (CCA) has been developed in which autologous keratinocytes and fibroblasts are surgically harvested from the burn patient's normal skin. These components are proliferated and then combined to form an epidermal and dermal matrix, grown to confluence then applied. Standard wound coverage techniques as well as CCA technology were utilized for successful wound closure in a 12 yr-old female with an 81% third degree burn. After fascial excision and allograft coverage, autografts were placed on her posterior burns and then 7500 cm2 of CCA was placed onto her anterior thorax, abdomen and lower extremities. Sixty percent of the burn was covered with CCA resulting in a success rate of 40%. No evidence of infection was noted, even in areas where CCA failed, although in those areas random epithelialization appeared to occur which then seemed to facilitate autograft placement. Early debridement and allografting followed by conventional autografts and CCA placement may provide an effective skin coverage strategy in patients with extensive deep burns.

Recreational-outdoor burns: the impact and severity--a retrospective review of 107 patients.

INTRODUCTION: Campfires, bonfires and barbecues play a prominent role in outdoor activities and serve a variety of decorative and functional purposes. Given all of it's various forms, uses and benefits, the outdoor fire can turn dangerous in a matter of seconds: a stumble or fall (the child running that trips) leads to direct contact with the flames and subsequent burn injury. With it's everyday occurrence, we were surprised to find a paucity of information regarding this type of burn in the literature, including the NBIE analysis. METHODS: A retrospective review of 107 patients admitted to the Maricopa Medical Bum Center, from 1987 to 1996, was conducted. Each chart was analyzed for the patient demographics, mechanism of injury, percent total body surface area burned, operative versus non-operative treatment and overall outcome. RESULTS: An average burn injury involved 5.7% TBSA, with a wide range from 1 to 47%. The majority of our population involved either small children or intoxicated adults and a total of 50 patients required 92 operations. Severe morbidity, including 4 amputations and 2 mortalities, were seen. The average hospital stay was 14.3 days, ranging from 1 to 52 days. CONCLUSIONS: Recreational outdoor burns were extremely common injuries leading to loss of functional employment and prolonged physical therapy requirements. Small children and intoxicated adults comprised the majority of our study population. The impact and severity of such outdoor fires could be greatly affected by appropriate attention to prevention.

Rationale for 'early' percutaneous dilatational tracheostomy in patients with burn injuries.

Several investigators have cited the numerous complications that occur with conventional tracheostomies in patients with burn injuries. However, none of these studies included the technique of percutaneous dilatational tracheostomy, which has been shown to significantly decrease operative time, cost, perioperative, and long-term sequelae as compared to conventional tracheostomy. A retrospective analysis of 36 patients with burn injuries, from 1400 burn admissions, was conducted to compare conventional tracheostomy versus percutaneous dilatational tracheostomy. In this study, percutaneous dilatational tracheostomy resulted in significantly decreased operative times and cost compared to conventional tracheostomy. There were no major operative complications in either group, and alveolar-arterial oxygen gradients were improved in 71% of the patients with a tracheostomy. Percutaneous dilatational tracheostomy is an efficacious technique for airway management in patients with burn injuries. It can be safely performed at the bedside, at one fourth the cost of a conventional tracheostomy. Percutaneous dilatational tracheostomy may also benefit the patient with severe burns by decreasing alveolar-arterial oxygen gradients. Improved ventilatory mechanics might allow for a shorter duration of mechanical ventilation, thereby decreasing patient morbidity, hospital stay, and cost.

Laser Doppler evaluation of burned hands predicts need for surgical grafting.

Management of deep dermal hand burns represents a difficult clinical problem for the burn team because bedside estimation of burn depth is unreliable. Early identification of full-thickness injury and prolonged healing times might result in the decision to perform surgical excision of eschar and skin grafting of the wounds. Such a strategy may improve overall functional and cosmetic results of hand burn treatment. This report concerns a 2-year study of 31 patients with 43 burned hands using the LD6000 helium-neon laser Doppler flowmeter. After obtaining informed consent, burned areas of the hand were evaluated on days 1, 3, and 5 after burn. Results were reported as flow (mV), representing the quantity of moving erythrocytes multiplied by erythrocyte velocity in the capillary tissue. The reported volume in percentage of Doppler-shifted light represented only the quantity of moving erythrocytes. Median flow values in nongrafted hands were 150 mV; in those requiring skin grafts, median flow values were 89 mV. Flow values were significantly greater in nongrafted compared with grafted hand burns on days 1 and 5. Volume values were not associated with whether or not grafting was performed. Median volume values, however, did allow determination of whether the burns would spontaneously heal within 15 days (high group) or if a mean of 42 days would be required (low group). Functional and cosmetic outcomes were determined by retrospective chart review, which revealed comparable results regardless of grafting and regardless of short or prolonged healing times. Laser Doppler flowmetry may serve as a valuable adjunct to the prediction of the need for grafting and time to wound closure. Standardization of flowmetry data and techniques of evaluation are desirable. Spontaneous healing should be the goal in the majority of deep dermal hand burns.

Primary closure of fasciotomy incisions with a skin-stretching device in patients with burn and trauma.

Closure of fasciotomy wounds is often a clinical problem after successful management of compartment syndrome. Commonly, split-thickness skin grafts or regional composite grafts are used for fasciotomy closure. However, functional and cosmetic results would be improved if primary reapproximation of these wounds were more practical. The main obstacle that must be overcome is excessive tension on the wound edges. A recently developed skin-stretching device (Sure-Closure, Life Medical Sciences, Princeton, N.J.) allows large tissue defects to be closed with approximation of the wound edges. In this report we describe two patients in whom closure of the fasciotomy incisions was successfully accomplished with the skin-stretching device. These patients included an 11-month-old girl with a circumferential burn of the left arm, and a 42-year-old woman involved in a motor vehicle accident who sustained frostbite and crush injury to her left upper extremity without bone fractures. The skin-stretching device produced excellent functional and cosmetic wound closure results and eliminated the need for additional operative procedures.

Hyperdynamic resuscitation improves survival in patients with life-threatening burns.

Our clinical experience has led to the conclusion, shared by others, that standard vital signs produce inadequate data for the resuscitation of severe burns. We reviewed three groups of burn patients including an index group (N = 53) whose resuscitation was guided by means of a pulmonary artery catheter, a control group (N = 33) collected from the burn registry for the period just before the index group, and a current group (N = 30) resuscitated with hyperdynamic end points defined empirically from surviving patients as guidelines. The mortality rate and organ failures decreased over time; the mortality rate of the control group was 48%, the index group 32%, and the protocol group 10% (p = 0.003). We concluded that hyperdynamic resuscitation does improve survival and reduces the incidence of organ failure.

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.

Hemodynamic and oxygen transport monitoring in management of burns.

Burn resuscitation has been performed predominantly by means of the Parkland formula for the past 25 years. Normalization of heart rate, blood pressure, and production of 1 mL/kg/hr of urine were proposed as suitable guides to resuscitation. Recently, it has become apparent that the standard circulatory criteria of fluid replacement adequacy are too inaccurate to produce optimal hemodynamic end points. Our burn team has reported a 4-yr experience with use of the pulmonary artery catheter inserted on admission to the unit of severe burn injuries. This monitoring device allowed for additional fluid volume administration to enhance circulatory function with resulting production of maximal hemodynamic values. The ability to achieve hyperdynamic end points predicted survival in our series. Use of invasive monitoring to produce hyperdynamic circulatory end points has resulted in a significant decrease in overall mortality. Oxygen consumption (VO2) was important and there was a statistically significant difference in this variable which distinguished survivors from nonsurvivors. VO2 increased progressively in relation to burn size in survivors but stayed at a constant lower value in nonsurvivors. Elderly burn patients were resuscitated at lower end points than younger individuals because of volume intolerance. Inability to be aggressively resuscitated results in twice the mortality in burn-injured elderly patients. These experiences indicate that burn resuscitation as currently practiced with existing formulas produces inadequate circulatory responses, and both survival and organ function can be improved by maximizing circulatory end points.

The use of skin from a monozygotic twin combined with cultured epithelial autografts as coverage for a large surface area burn: a case report and review of the literature.

Definitive closure of a large burn may be a formidable task requiring a variety of techniques for success. This case report illustrates use of skin from a monozygotic twin to accomplish this goal. A 35-year-old woman ignited herself with gasoline after a domestic quarrel, which produced a burn involving 65% of her body surface area, predominantly full thickness in depth and associated with inhalation injury. After resuscitation, the patient underwent multiple burn excision procedures that used allograft coverage. Histocompatibility testing confirmed that use of her twin sister's skin was a viable strategy for burn wound closure, and ultimately, with use of this technique, the patient's anterior torso was covered. Her abdomen and anterior thighs were covered with cultured epithelial autografts, and her face and arms were autografted with the patient's donor sites. She was discharged on the one hundred sixth postburn day to a rehabilitation center. This is the fourteenth reported case of burn wound grafting with use of skin from an identical twin, and the first in which it was combined with cultured epithelial autografts. There were no adverse consequences of this procedure either for the patient or her donor twin.

Burn management in children.

Pediatric burn care consists of a coordinated program to provide acute physiological support during the shock phase, prompt wound closure, aggressive ancillary care, and appropriate postdischarge management. Adherence to predetermined burn care guidelines will produce the most optimal results in survival and return to function.

Survival in major burn injuries is predicted by early response to Swan-Ganz-guided resuscitation.

BACKGROUND: Two years ago the authors began to use Swan-Ganz catheters to generate more complex hemodynamic data as a better guide to resuscitation of burns. This study uses the information to identify differences between survivors and nonsurvivors. PATIENTS AND METHODS: Fifty-three consecutive patients with major burns were treated using Swan-Ganz-generated data. Additional information was collected, including demographics, intake and output, medications, and arterial blood gas (including calculated oxygen consumption). Statistical analysis incorporated adjustments for autocorrelation. RESULTS: The patients included 38 men and 15 women, averaged 43.7 years of age, and had a mean burn size of 40%. Thirteen patients suffered severe inhalation injury. Data collected hourly over 3 days were collapsed across 6-hour observation periods. Mean values, when plotted across time, discriminated the 37 survivors from the 16 nonsurvivors. Poor response to resuscitation as evidenced by increased use of colloid fluid and cardiotonic drugs plus failure to maximize oxygen consumption were associated with nonsurvival. CONCLUSIONS: Unsustained or inadequate response to hyperdynamic resuscitation of burns was associated with nonsurvival.

Pavement temperature and burns: streets of fire.

STUDY OBJECTIVE: To measure pavement temperatures over a 24-hour period to determine when patients are at risk for burns and to report cases of pavement burns with predisposing factors. DESIGN: Descriptive study of pavement temperatures and retrospective case series of 23 patients with pavement burns admitted to the Maricopa Medical Center during the years 1986 to 1992. PARTICIPANTS: Twenty-three patients with pavement burns serious enough for them to be admitted to the burn center. RESULTS: We measured the temperatures of asphalt, cement, and other outdoor materials hourly for one 24-hour period using a thermocouple thermometer. Asphalt pavement was hot enough to cause burns from 9 AM to 7 PM during the summer months. It was hot enough to cause a second-degree burn within 35 seconds from 10 AM to 5 PM. The group of burned patients could be divided into three categories: incapacitated, restrained, and sensory deficient. All burns involved less than 13% of the total body surface area. CONCLUSION: During summer days in the desert, pavement is often hot enough to cause burns and does so with regularity in the southwestern United States. No one should be allowed to remain in contact with hot pavement, even transiently.

A five-year experience with severe injuries in elderly patients.

Recent reports of injury in elderly patients document that aggressive care is justified. Our experience indicates that geriatric injury differs from that of other trauma patients. All patients entered into a large urban trauma center registry over a five-year period were analyzed. Variables reviewed included demographics, trauma indices, mechanism of injury, mean number of hospital days, and morbidity and mortality for patients under 60 years old and for geriatric patients defined as those aged 60 and above. There were 3,064 patients in the reviewed group, of whom 243 qualified for geriatric analysis. Blunt injuries in males were the most typical scenario. Failure to use safety belts and alcohol intoxication persist into the geriatric age group (83% and 13%, respectively). Trauma indices including Injury Severity Score (ISS) were slightly greater in the geriatric group (27 versus 23) as compared to younger patients; plus geriatric patients tolerated head injury less well (GCS in those who died 6.7 versus 4.6, respectively; p < 0.001). Mortality in the geriatric group was 31% while being 17.1% in the younger group (p < 0.005). Days in the hospital were 20 for the geriatric compared to 13 for the younger group (p < 0.025). Infections and chest complications were twice as common in the elderly and dysrhythmias were five times more frequent. Elderly patients constitute 8% of the trauma population and suffer a magnitude of injury at least comparable to the general population. Their mortality is approximately 50% above the population as a whole and morbidity twice as common, accounting for the prolonged hospital stay.

The use of expanded polytetrafluoroethylene gloves for care of upper-extremity burns.

The combination of a glove made of an expanded polytetrafluoroethylene membrane-based laminate and silver sulfadiazine cream was evaluated as a treatment for burned hands. Eight patients who had burns averaging 25% total body surface area and who had 11 extensive partial thickness hand burns (2% total body surface area) were treated with an average of 17 gloves over 9 days. The burn wounds healed with no unusual or unexpected outcomes. Nurses and therapists agreed that dressing changes were quick and easy and that the gloves provided greater range of motion and function in the hands. Patients also expressed a preference for this method of treatment.

Decreased growth hormone levels in the catabolic phase of severe injury.

BACKGROUND: Human growth hormone (hGH) is a potent anabolic agent, which has profound effects on protein, carbohydrate, and lipid metabolism. The role of this primarily anabolic hormone in the severe catabolic state of trauma is not known. METHODS: In a group of young, obese, and elderly patients with multiple traumas, plasma hGH levels were measured in the catabolic "flow" phase of injury, once before and then after 4 to 6 days of nutritional support sufficient to match their initial loss of calories and nitrogen. RESULTS: A decreased hGH level was noted in the hyperglycemic and hypercatabolic injured state, particularly in victims of trauma who were young and not obese, compared to respective volunteers. A significant (p = 0.025) inverse relationship was observed between age and plasma hGH levels in this group of patients who had experienced trauma. Nutritional therapy improved the protein and fat metabolism but could not reverse to the normal state. In young patients who had experienced trauma and who were not obese, the hGH levels were significantly improved because of dietary intake, whereas in elderly patients or patients who were obese no change was noted. CONCLUSION: These results are consistent with less lipid mobilization and inefficient utilization of fatty acids in the elderly patients or patients who were obese who had abundant fat sources to spare. Elevation of hGH level by exogenous administration may improve the nitrogen economy and lipid mobilization, particularly so in the elderly patients or patients who were overweight. Our study supports the view that provision of adequate nutrition with daily administration of human hGH in the first week after trauma would enhance the metabolic status of the patient, resulting in reduced morbidity and earlier discharge from the hospital.

Steroid use is associated with pneumonia in pediatric chest trauma.

A review of pediatric trauma focused on pediatric chest injuries was performed at a trauma center specializing in neurologic trauma. Eighty of 342 (23%) pediatric trauma patients admitted to the center had chest injuries. Age, gender, mechanism of injury, magnitude of injury, incidence of pulmonary infection, chest tube usage, endotracheal intubation, steroid or antibiotic usage, morbidity, and mortality data were reviewed. Sixteen of 78 children (20%) with chest injuries developed pulmonary infections and were compared with the noninfected group. Patients with pneumonia had a higher morbidity with significantly longer mean hospital stay (43.0 vs. 12.7 days; p = 0.001), duration of intubation (8.4 vs. 1.5 days; p = 0.001), and total days with chest tubes, (2.2 vs. 1.4 days; p = 0.02). Pneumonia was significantly associated with longer mean duration of steroid usage (6.4 vs. 0.8 days; p = 0.0001). Duration of steroid administration for the treatment of concomitant brain injury was a significant independent risk factor for the occurrence of pneumonia.

Glucose infusion improves endogenous protein synthesis efficiency in multiple trauma victims.

Metabolic costs of excessive nutritional support in stressed patients have been increasingly recognized. The decreased endogenous protein synthesis efficiency (PSE) following major injury has been attributed to the predominant need of amino acid precursors for gluconeogenesis. The present study tested the hypothesis that provision of glucose alone, not to exceed the resting energy expenditure (REE), for the first 4 to 5 days after trauma would be enough to restore PSE and stimulate the injured body to accept full nutrition. Eight severely injured, adult, hypermetabolic, and highly catabolic patients admitted to the Trauma Intensive Care Unit (TICU) served as our subjects. Integrated measurements of whole body fuel-substrate kinetics were obtained for energy metabolism (indirect calorimetry), protein kinetics (primed constant infusion of 15N-glycine), and glucose kinetics (labeled glucose infusions). Two studies were conducted on each same subject, one in the early flow phase of injury (48 to 60 hours after trauma) and a second after 4 to 5 days of hypertonic glucose (4.1 +/- 0.5 mg/kg/min; 80% REE calories) infusion with electrolytes, trace elements, and minerals. Significant (P less than .05) increases in PSE (14%, 65% +/- 2% to 74% +/- 2%), plasma growth hormone and insulin levels, and respiratory quotient (RQ) (31%, 0.74 +/- 0.03 to 0.97 +/- 0.04), and decreases in endogenous glucose appearance rate (55%, 3.1 +/- 0.5 to 1.4 +/- 0.1 mg/kg/min), and negative N balance (48%, 219 +/- 26 to 114 +/- 15 mgN/kg/d) were observed. The results suggest that hypertonic glucose infusion alone may be sufficient for physiological adaptation in the immediate posttrauma days. This therapy restores normal PSE, which should protect the labile protein pool.(ABSTRACT TRUNCATED AT 250 WORDS)