Recipient wound bed characteristics affect scarring and skin graft contraction.

The use of autograft skin is essential in the treatment of full thickness burns and large cutaneous defects. Both autograft thickness and condition of the wound bed modulate aesthetic and functional outcomes. Thicker autografts contract less and maintain greater functionality as the scar matures. The presence of hypodermis can also positively affect the eventual appearance and functionality of the wound site by modulating contraction and alleviating inflammation and cellular stress responses. In this study, we characterize wound-site physical and cellular characteristics following split-thickness skin grafting onto hypodermis vs. onto fascia. Compared to autografts grafted onto fascia, identical thickness autografts grafted onto fat demonstrated reduced contraction, enhanced mobility and vascularity, and reduced topographical variability. Grafts onto fat also showed reduced levels of myofibroblasts and leukocytic infiltration. The status of the wound bed prior to engraftment is an important contributor of skin quality outcome. The presence of hypodermis is associated with improved functional and aesthetic qualities of split thickness skin grafts, which are correlated with reduced presence of myofibroblasts and leukocytic infiltration.

Emergency Decompressive Craniostomy "Burr Hole" Using an Intraosseous Vascular Access System in a Resource-Limited Setting: A Technical Report on a Cadaver.

This paper describes an alternative approach to emergency burr hole evacuation of epidural hematoma using the intraosseous (IO) vascular access system. The IO vascular access system is commonly available in the Emergency Department. We demonstrate that it can be used in rare situations where immediate neurosurgical intervention and the standard cranial drill and brace are not available for burr hole craniostomy.

Steroid-Induced Tumor Lysis Syndrome Accompanied by Diabetic Ketoacidosis and Acute Renal Failure in a Non-Hodgkin Lymphoma Patient.

We present a case of a 66-year-old male with a past history of newly diagnosed non-Hodgkin lymphoma, diabetes, and recent surgical splenectomy secondary to splenic infarct who presented to the Emergency Department (ED) with several nonspecific symptoms that were consistent with tumor lysis syndrome. This case report discusses the clinical presentation, diagnosis, and management of spontaneous tumor lysis syndrome.

Rare Presentation of Deep Vein Thrombosis and Submassive Pulmonary Emboli Due to Hypercoagulable State With Supratherapeutic Anticoagulation.

We present a case of an elderly male with multiple co-morbidities, including atrial fibrillation on warfarin and recently diagnosed left lower extremity deep vein thrombosis (DVT), who presented to the emergency department for dyspnea. He was found to be hypoxic and mildly hypotensive. He was diagnosed with submassive pulmonary emboli (PE) despite having a supratherapeutic international normalized ratio (INR). In this case report, the clinical presentation, diagnostic workup, and management of this patient are discussed.

Testicular Germ Cell Tumor Presenting to the Emergency Department.

The authors report on a case of a patient who presented to the emergency department (ED) and was ultimately diagnosed with stage IV testicular non-seminomatous germ cell tumor. The patient was cachectic with a tumor on the neck, abdomen, and scrotum. Germ cell tumors (GCTs) exhibit characteristic symptoms at different points in development. Appropriate treatment can cure most GCTs. While cancer may not be thought of as an ED diagnosis, it can often be the place where patients first present, even when advanced. Recognizing it is important for prompt treatment.

Acute Hypoxic Respiratory Failure and Septic Shock Secondary to Mycoplasma Pneumoniae Pneumonia Complicated by Heroin Overdose.

We present the case of a woman with a past medical history of intravenous drug use and tobacco abuse who was brought into the emergency department by emergency medical services after a heroin overdose. She was found to be in acute hypoxic respiratory failure and developed septic shock secondary to Mycoplasma pneumonia. In this case report, the presentation and management of fulminant Mycoplasma pneumonia are discussed, along with plain chest radiography findings.

Antecedent thermal injury worsens split-thickness skin graft quality: A clinically relevant porcine model of full-thickness burn, excision and grafting.

Current standard of care for full-thickness burn is excision followed by autologous split-thickness skin graft placement. Skin grafts are also frequently used to cover surgical wounds not amenable to linear closure. While all grafts have potential to contract, clinical observation suggests that antecedent thermal injury worsens contraction and impairs functional and aesthetic outcomes. This study evaluates the impact of antecedent full-thickness burn on split-thickness skin graft scar outcomes and the potential mediating factors. Full-thickness contact burns (100°C, 30s) were created on the backs of anesthetized female Yorkshire Pigs. After seven days, burn eschar was tangentially excised and covered with 12/1000th inch (300µm) split-thickness skin graft. For comparison, unburned wounds were created by sharp excision to fat before graft application. From 7 to 120days post-grafting, planimetric measurements, digital imaging and biopsies for histology, immunohistochemistry and gene expression were obtained. At 120days post-grafting, the Observer Scar Assessment Scale, colorimetry, contour analysis and optical graft height assessments were performed. Twenty-nine porcine wounds were analyzed. All measured metrics of clinical skin quality were significantly worse (p<0.05) in burn injured wounds. Histological analysis supported objective clinical findings with marked scar-like collagen proliferation within the dermis, increased vascular density, and prolonged and increased cellular infiltration. Observed differences in contracture also correlated with earlier and more prominent myofibroblast differentiation as demonstrated by α-SMA staining. Antecedent thermal injury worsens split-thickness skin graft quality, likely by multiple mechanisms including burn-related inflammation, microscopically inadequate excision, and dysregulation of tissue remodeling. A valid, reliable, clinically relevant model of full-thickness burn, excision and skin replacement therapy has been demonstrated. Future research to enhance quality of skin replacement therapies should be directed toward modulation of inflammation and assessments for complete excision.

Full-Thickness Thermal Injury Delays Wound Closure in a Murine Model.

Objective: The contemporary treatment of a full-thickness burn consists of early eschar excision followed by immediate closure of the open wound using autologous skin. However, most animal models study burn wound healing with the persistence of the burn eschar. Our goal is to characterize a murine model of burn eschar excision to study wound closure kinetics. Approach: C57BL/6 male mice were divided into three groups: contact burn, scald burn, or unburned control. Mice were burned at 80°C for 5, 10, or 20 s. After 2 days, the eschar was excised and wound closure was documented until postexcision day 13. Biopsies were examined for structural morphology and α-smooth muscle actin. In a subsequent interval-excision experiment (80°C scald for 10 s), the burn eschar was excised after 5 or 10 days postburn to determine the effect of a prolonged inflammatory focus. Results: Histology of both contact and scald burns revealed characteristics of a full-thickness injury marked by collagen coagulation and tissue necrosis. Excision at 2 days after a 20-s burn from either scald or contact showed significant delay in wound closure. Interval excision of the eschar, 5 or 10 days postburn, also showed significant delay in wound closure. Both interval-excision groups showed prolonged inflammation and increased myofibroblasts. Innovation and Conclusions: We have described the kinetics of wound closure in a murine model of a full-thickness burn excision. Both contact and scald full-thickness burn resulted in significantly delayed wound closure. In addition, prolonged interval-excision of the eschar appeared to increase and prolong inflammation.

Autologous Graft Thickness Affects Scar Contraction and Quality in a Porcine Excisional Wound Model.

BACKGROUND: Texture, color, and durability are important characteristics to consider for skin replacement in conspicuous and/or mobile regions of the body such as the face, neck, and hands. Although autograft thickness is a known determinant of skin quality, few studies have correlated the subjective and objective characters of skin graft healing with their associated morphologic and cellular profiles. Defining these relationships may help guide development and evaluation of future skin replacement strategies. METHODS: Six-centimeter-diameter full-thickness wounds were created on the back of female Yorkshire pigs and covered by autografts of variable thicknesses. Skin quality was assessed on day 120 using an observer scar assessment score and objective determinations for scar contraction, erythema, pigmentation, and surface irregularities. Histological, histochemical, and immunohistochemical assessments were performed. RESULTS: Thick grafts demonstrated lower observer scar assessment score (better quality) and decreased erythema, pigmentation, and surface irregularities. Histologically, thin grafts resulted in scar-like collagen proliferation while thick grafts preserves the dermal architecture. Increased vascularity and prolonged and increased cellular infiltration were observed among thin grafts. In addition, thin grafts contained predominately dense collagen fibers, whereas thick grafts had loosely arranged collagen. α-Smooth muscle actin staining for myofibroblasts was observed earlier and persisted longer among thinner grafts. CONCLUSIONS: Graft thickness is an important determinant of skin quality. High-quality skin replacements are associated with preserved collagen architecture, decreased neovascularization, and decreased inflammatory cellular infiltration. This model, using autologous skin as a metric of quality, may give a more informative analysis of emerging skin replacement strategies.