Incidence of Sinusitis in Burn Victims and Association With Inhalational Injury.

The purpose of this study is to determine the incidence of sinusitis in mechanically ventilated burn victims and to examine if the presence of inhalational injury increases the likelihood of developing sinusitis. The authors hypothesize that the incidence of sinusitis will be increased in burn victims who have concomitant inhalational injury. A retrospective chart analysis was performed on all patients who were admitted to the Nathan Speare Regional Burn Treatment Center over a 24-month time frame. Patients who were mechanically ventilated for greater than 24 hours were then selected, resulting in a total of 137 patients for analysis. Multiple variables including number of days on mechanical ventilation, presence of confirmed inhalational injury by bronchoscopy, and method of diagnosis were examined. Of 137 patients, a diagnosis of sinusitis was made in 32 patients (23%). In patients with sinusitis, 87.5% had inhalational injury confirmed with bronchoscopy, compared with only 33.3% of patients without sinusitis (P < .01). Rates of nasotracheal/nasogastric intubation, nasoenteric feeding, and length of mechanical ventilation before sinusitis diagnosis were not significantly different. Patients with sinusitis were found to have suffered inhalational injury at a significantly higher rate than those who did not develop sinusitis. This suggests that inhalational injury is a significant risk factor for developing sinusitis.

Lamotrigine-induced toxic epidermal necrolysis in three patients treated for bipolar disorder.

Exfoliative dermatitis, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), is a mild-to-life-threatening process that has been described after exposure to many antiepileptic drugs. The increased use of antiepileptic drugs for treatment of bipolar disorder and neurologic disorders has extended the risk of exfoliative disorder to this population of patients, and these patients and their health care providers may not be familiar with the risks involved with these drugs. We describe the cases of a 28-year-old woman with bipolar 1 disorder initially treated with lamotrigine, and two adolescent girls with bipolar 2 disorder treated with lamotrigine after poor responses to other drug regimens. In all three patients, rashes progressed to toxic epidermal necrolysis in spite of treatment with corticosteroids at their local hospitals; thus, they were transferred to our burn treatment center. Response to early corticosteroid treatment in suppressing progression of exfoliation was variable in these patients. Ultimately, two of the three required ventilatory support; their conditions improved within 8-32 days of treatment, and they were discharged from the hospital. Case reports of lamotrigine-induced exfoliative disorder in patients with bipolar disorder have been published. However, these three patients were admitted to our burn treatment center within a 12-month period. Our institution admits approximately 10-12 patients with TEN/year, and the increased use of lamotrigine for treatment of bipolar disorder is likely to result in more patients with TEN. Therefore, health care professionals need to be aware of the early signs and symptoms of exfoliative dermatotoxicity when treating patients with lamotrigine.

Evaluation of Aquacel Ag for Autogenous Skin Donor Sites.

An ongoing objective of burn research is to evaluate wound dressings and develop new treatments to expedite wound healing. This was a single-center, prospective, randomized, controlled study to evaluate the effectiveness of Aquacel Ag as a dressing for autogenous skin donor sites compared with Xeroform. We hypothesized that donor sites treated with Aquacel Ag would heal faster. Patients were considered for enrollment if they required skin grafting with two donor sites >100 cm at least 2 inches apart. Dressings were observed daily starting on post-op day #2 until discharge and then weekly in the outpatient burn clinic. Assessments evaluated pain, infection, and reapplication. Photographs were taken on post-op day #2, upon "90% re-epithelialization," and at post-op day #30-45. Scar assessments and blinded photographic reviews were completed to assess cosmetic healing. Twenty-nine patients completed the study. Re-epithelialization occurred faster with Xeroform (15.2 days vs. 17.6 days). Daily pain scores were higher with Xeroform (6.72 vs. 5.68) and Aquacel Ag needed to be replaced more often (1.72 times vs. 0.10 times). Three patients developed donor site infections with Aquacel Ag. Scar scores between the donor sites were not statistically significant. The blinded photo review concluded that Xeroform had a better cosmetic outcome (24 vs. 10%). Although patients complained of more pain with Xeroform, it demonstrated shorter healing times and better cosmetic outcomes. Aquacel Ag needed to be replaced more often and represented the only three donor site infections.

An open, prospective, randomized pilot investigation evaluating pain with the use of a soft silicone wound contact layer vs bridal veil and staples on split thickness skin grafts as a primary dressing.

An open, prospective, randomized, pilot investigation was implemented to evaluate the pain, cost-effectiveness, ease of use, tolerance, efficacy, and safety of a soft silicone wound contact layer (Mepitel One) vs Bridal Veil and staples used on split thickness skin grafts in the treatment of deep partial or full-thickness thermal burns. Individuals aged between 18 and 70 years with deep partial or full-thickness thermal burns (1-25% TBSA) were randomized into two groups and treated for 14 days or until greater than 95% graft take was achieved, whichever occurred first. Data were obtained and analyzed on pain experienced before, during, and after dressing removal. Secondary considerations included the overall cost (direct), graft take and healing, the ease of product use, overall experience of the dressing, and adverse events. A total of 43 subjects were recruited. There were no significant differences in burn area profiles within the groups. The pain level during dressing removal was significant between the groups (P = .0118) with the removal of Mepitel One being less painful. The staff costs were lower in the group of patients treated with Mepitel One (P = .0064) as reflected in the shorter time required for dressing removal (P = .0005), with Mepitel One taking on average less than a quarter of the time to remove. There was no significant difference in healing between the two groups, with 99.0% of the Mepitel One group and 93.1% of the Bridal Veil and staples group showing greater than 95% graft take at post-op day 7 (+/-1) (P = .2373). Clinicians reported that the soft silicone dressing was easier to use, more conformable, and demonstrated better ability to stay in place, compared with the Bridal Veil and staples regime. Both treatments were well tolerated, with no serious adverse events in either treatment group. Mepitel One was at least as effective in the treatment of patients as the standard care (Bridal Veil and staples). In addition, the group of patients treated with the soft silicone dressing demonstrated decreased pain and lower costs associated with treatment.

Burn center management of operating room fire injuries.

Approximately 100 operating room (OR) fires occur per year in the United States, with 15% resulting in serious injuries. Intraoperative cautery was frequently associated with OR fires before 1994; however, use of supplemental oxygen (O(2)), ethanol-based products, and disposable drapes have been more frequently associated with OR fires. Fires resulting from cosmetic and other small procedures involving use of nasal canula O(2) and electrocautery have been described in six published reports. We report five thermal injury cases admitted to our burn treatment center because of fires during surgical procedures over a 5-year period. Two patients undergoing supraorbital excision experienced 2.5 and 3% TBSA involvement burns; in a third patient surgical excision of a nasal polyp resulted in a 1% TBSA burn; in a fourth patient an excisional biopsy of a lymph node resulted in a 2.75% TBSA burn; and the last patient was burned during placement of a pacemaker, with resulting TBSA of 10.5%. Two of the five patients required intubation for inhalational injury. Two patients required tangential excision and grafting of their thermal injuries. All patients had received local or parenteral anesthesia with supplemental O(2)/nitrous oxide (N(2)O) for surgical procedure. There are a number of ignition sources in the OR, including electrocautery, lasers, and faulty OR equipment. The risk of OR fires increases with surgical procedures involving the face and neck, including tracheostomy and tracheobronchial surgery. The common use of O(2)/N(2)O mixtures or enriched O(2) for minimally complex surgical procedures and disposable drapes adds to the risk of an OR fire: the O(2)/N(2)O provides a fuel source, and the disposable drapes trap thedelivered gas. Electrocautery near an O(2)/N(2)O source resulted in the five thermal injuries and warrants careful reconsideration of technique for surgical procedures.

Amlodipine-induced toxic epidermal necrolysis.

The objective of this study is to report a case of amlodipine-induced dermatotoxicity following treatment for diabetic nephropathy. Although other members of the dihydropyridine calcium channel blockers have been reported to cause dermatotoxic reactions, this is the first report attributing this effect to amlodipine. A 71-year-old diabetic and hypertensive woman had been noted to have worsened renal dysfunction and hyperkalemia attributed to enalapril, thus a trial of amlodipine was begun. On day 12 of amlodipine therapy, the patient developed a pruritic maculopapular rash on her hands for which she sought medical attention. On day 16, she presented again to the emergency department now with hives and small blisters involving the trunk and arms with ∼25% TBSA involvement warranting transfer to a regional burn treatment center. The rash progressed after admission to 48.5% TBSA and included conjunctival sloughing. The patient's hospital course was uneventful, and she was discharged after 8 days. Drug-induced dermatotoxicity presenting as toxic epidermal necrolysis is often caused by antibiotics and antiepileptic medications; however, calcium channel blockers are an uncommon cause. The Naranjo assessment yielded a score of 5, and the SCORTEN was 4 with a predicted mortality of 58%. This report represents the first published case of amlodipine-induced toxic epidermal necrolysis.

Quality assurance assessment of the use of linezolid in the treatment of thermal injury patients at a community teaching hospital.

We sought to evaluate the adverse effect profile of linezolid among thermal injury patients requiring treatment for Enterococcus species or other Gram-positive infection warranting treatment with linezolid. Seventy-six inhalation injury and/or thermal injury patients experiencing 94 exposures to linezolid for 48 hours or longer (range, 2-83 days) were included. We evaluated leukocyte count and platelet count for the time period preceding, during, and after therapy with linezolid based on specified time periods of exposure for evaluation of specific adverse effects. Sixty-three of 76 (83%) patient admissions were complicated by inhalation injury. The average TBSA involvement was 34.4% (range, 0-98%). The onset of thrombocytopenia before linezolid therapy was noted in 21 of 57 patients (36.8%), which was attributable to fluid resuscitation and acute platelet consumption. After they were exposure to linezolid, 12 patients developed thrombocytopenia. Platelet counts recovered in 7 of these 12 patients with continued exposure to linezolid; however, thrombocytopenia persisted for more than 9 days after therapy in 9 patients, of whom 6 patients succumbed to sepsis. On average, thrombocytes increased by 102,000/mm3 during linezolid treatment. Leucopenia was rare in thermal injury patients, and persisting thrombocytopenia in this population was associated with sepsis and mortality. Continuing linezolid therapy after the onset of thrombocytopenia among survivors almost always resulted in recovery from thrombocytopenia.