Arnold Luterman

Hypothermia in Trauma Victims: An Ominous Predictor of Survival

Hypothermia in trauma patients is generally considered an ominous sign, although the actual temperature at which hypothermia affects survival is ill defined. In this study, the impact of body core hypothermia on outcome in 71 adult trauma patients with Injury Severity Scores (ISS) greater than or equal to 25 was analyzed. Forty-two per cent of the patients had a core temperature (Tc) below 34 degrees C, 23% below 33 degrees C, and 13% below 32 degrees C. The mortality of hypothermia patients was consistently greater than those who remained warm, regardless of index core temperature. Mortality if Tc less than 34 degrees C = 40%, less than 33 degrees C = 69%, less than 32 degrees C = 100%, whereas mortality if Tc greater than or equal to 34 degrees C = 7%, and greater than or equal to 32 degrees C = 10%. Mortality and the incidence of hypothermia increased with higher ISS, massive fluid resuscitation, and the presence of shock. Within each subgroup (i.e., greater ISS, massive fluid administration, shock) the mortality of hypothermic patients was significantly higher than those who remained warm. No patient whose core temperature fell below 32 degrees C survived.

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.

Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment.

The safety and effectiveness of Integra Dermal Regeneration Template was evaluated in a postapproval study involving 216 burn injury patients who were treated at 13 burn care facilities in the United States. The mean total body surface area burned was 36.5% (range, 1-95%). Integra was applied to fresh, clean, surgically excised burn wounds. Within 2 to 3 weeks, the dermal layer regenerated, and a thin epidermal autograft was placed. The incidence of invasive infection at Integra-treated sites was 3.1% (95% confidence interval, 2.0-4.5%) and that of superficial infection 13.2% (95% confidence interval, 11.0-15.7%). Mean take rate of Integra was 76.2%; the median take rate was 95%. The mean take rate of epidermal autograft was 87.7%; the median take rate was 98%. This postapproval study further supports the conclusion that Integra is a safe and effective treatment modality in the hands of properly trained clinicians under conditions of routine clinical use at burn centers.

Laryngotracheal trauma: a protocol approach to a rare injury.

Laryngotracheal trauma is rare and complications are frequent. Twelve major series totalling 392 cases have been published over the past decade, with complication rates as high as 40%. We have treated over 30,000 trauma victims at our Level I Trauma Center over the past 5 years, of which 109 had neck injuries, but only 12 suffered cervical laryngotracheal trauma. The mechanism of injury was penetrating in eight and blunt trauma in four. The time to tracheostomy decannulation varied from 7 to 60 days. Airway patency was assured without stenosis or significant granulation tissue in 10 of the 12 patients. Three patients suffered permanent voice changes. Based on review of the 392 previously reported cases and a critical analysis of our 12 cases, a detailed management algorithm is proposed.

Randomized clinical study of Hydrofiber dressing with silver or silver sulfadiazine in the management of partial-thickness burns.

This prospective, randomized study compared protocols of care using either AQUACEL® Ag Hydrofiber® (ConvaTec, a Bristol-Myers Squibb company, Skillman, NJ) dressing with silver (n = 42) or silver sulfadiazine (n = 42) for up to 21 days in the management of partial-thickness burns covering 5% to 40% body surface area (BSA). AQUACEL® Ag dressing was associated with less pain and anxiety during dressing changes, less burning and stinging during wear, fewer dressing changes, less nursing time, and fewer procedural medications. Silver sulfadiazine was associated with greater flexibility and ease of movement. Adverse events, including infection, were comparable between treatment groups. The AQUACEL® Ag dressing protocol tended to have lower total treatment costs (

Infections in burn patients

1040 vs.

Severe itching in the patient with burns

1180) and a greater rate of re-epithelialization (73.8% vs 60.0%), resulting in cost-effectiveness per burn healed of

Maximum survival in pediatric trauma: the ideal system.

1,409.06 for AQUACEL® Ag dressing and

Pediatric maxillofacial trauma: Unique features in diagnosis and treatment†‡

1,967.95 for silver sulfadiazine. A protocol of care with AQUACEL® Ag provided clinical and economic benefits compared with silver sulfadiazine in patients with partial-thickness burns.

Efficacy and safety of a fibrin sealant for adherence of autologous skin grafts to burn wounds: Results of a phase 3 clinical study

Systemic sepsis resulting from invasive infection remains the leading cause of death among patients hospitalized with major thermal injury. Prevention of infection and death in burn patients requires a thorough knowledge of the multiple predisposing factors involved and expert application of appropriate diagnostic, supportive, and therapeutic modalities. The improved survival in this population is a result of all these factors, not any one. It is this principle and the adherence to a treatment program that encompasses all the modalities which are so essential in the care of burn patients if continuing progress is to be made in this field. This article describes the current management of infection and infection control in burn patients. The burn wound and pulmonary system remain the major foci for infection in this population. Less common types of infection include suppurative thrombophlebitis, suppurative chondritis, bacterial endocarditis, urinary tract sepsis, sinusitis, intra-abdominal sepsis, and infections of the eyes. Prophylaxis protocols involve proper control of the environment and an anticipation of bacterial colonization. A number of specific monitoring and treatment guidelines have evolved that have proved effective over the years in minimizing morbidity and mortality.