Alan R. Dimick

Clinical Evaluation of an Acellular Allograft Dermal Matrix in Full-Thickness Burns

A multicenter clinical study assessed the ability of an acellular allograft dermal matrix to function as a permanent dermal transplant in full-thickness and deep partial-thickness burns. The study consisted of a pilot phase (24 patients) to identify the optimum protocol and a study phase (43 patients) to evaluate graft performance. Each patient had both a test and a mirror-image or contiguous control site. At the test site, the dermal matrix was grafted to the excised wound base and a split-thickness autograft was simultaneously applied over it. The control site was grafted with a split-thickness autograft alone. Fourteen-day take rates of the dermal matrix were statistically equivalent to the control autografts. Histology of the dermal matrix showed fibroblast infiltration, neovascularization, and neoepithelialization without evidence of rejection. Wound assessment over time showed that thin split-thickness autografts plus allograft dermal matrix were equivalent to thicker split-thickness autografts.

The southern region burn disaster plan

A regional burn disaster plan for 24 burn centers located in 11 states comprising the Southern Region of the American Burn Association was developed using online and in-person collaboration between burn center directors during a 2-year period. The capabilities and preferences of burn centers in the Southern Region were queried. A website with disaster information, including a map of regional burn centers and spreadsheet of driving distances between centers, was developed. Standard terminology for burn center capabilities during disasters was defined as open, full, diverting, offloading, or returning. A simple, scalable, and flexible disaster plan was designed. Activation and escalation of the plan revolves around the requirements of the end user, the individual burn center director. A key provision is the designation of a central communications point colocated at a burn center with several experienced burn surgeons. In a burn disaster, the burn center director can make a single phone call to the communications center, where a senior burn surgeon remote from the disaster can contact other burn centers and emergency agencies to arrange assistance. Available options include diversion of new admissions to the next closest center, transfer of patients to other regional centers, or facilitation of activation of federal plans to bring burn care providers to the affected burn center. Cooperation between regional burn center directors has produced a simple and flexible regional disaster plan at minimal cost to institute or operate.

Delayed wound closure: indications and techniques.

Delayed wound closure should be used in wounds that are contaminated or contain devitalized tissue. The wound should be left open for three to four days for observation to determine if infection is present or if the tissues are devitalized. This management technique allows the physician to control infection and provide surgical debridement. Leaving the wound open provides the opportunity to inspect and evaluate the wound to determine if a problem is present. The wound then can be repaired with minimal risk. It is beneficial that the wound healing process is not delayed using this technique of wound closure.

Acute microwave injury to the hand

An acute microwave oven burn injury to the hand resulting in second- and third-degree burns to the left long finger is presented. Excision and coverage using a cross-finger flap resulted in full return of function. Because of the difficulty in evaluating the extent of tissue necrosis, we recommend hospitalization for most microwave injuries where obvious soft tissue damage has been sustained.

Emergency management of the acutely burned patient

Of the estimated two million thermal injuries which occur in the United States annually, approximately 5% will require hospital care. The acutely burned patient requires comprehensive management, beginning with classification based on a “Rule of Nines” estimate of the body area involved. Percentage of second and third degree burns is used as a criterion for determining the need to hospitalize a burn patient. Tetanus prophylaxis is recommended in all acute burn cases. The Brooke and Dallas formulas may be used as means of determining fluid therapy requirements. When eschar constriction causes circulatory problems, escharotomy should be performed. Tracheostomy may be considered only when other methods of respiratory care, including endotracheal intubation, are inapplicable. Analgesia administration is done intravenously during early post-burn treatment. Other aspects of burn patient management to be considered are wound care, inhalation injury, and deep-structure damage often resulting from electrical burns.