Charles F. T. Snelling

Heterotopic Bone Formation in the Patient with Burn Injuries: A Retrospective Assessment of Contributing Factors and Methods of Investigation

The incidence of heterotopic bone formation in seven of 25 patients with burn injuries who required endotracheal intubation and ventilation for smoke inhalation injury was believed to be unacceptably high. Factors in the affected patients distinguishing them from those unaffected were sought. Total protein levels were found to be higher in the affected group. This may correlate with the calciuretic response to protein loading reported previously. Of the affected patients, four demonstrated extreme agitation and resisted physiotherapy. Only one of the 18 nonaffected patients was equally agitated and resistant (p less than 0.05). The additional joint trauma sustained by the affected patients may contribute to the development of heterotopic bone. In bone scans in 18 consecutive patients deemed to be at risk, all showed increased radioactivity at multiple joints. Only seven patients developed heterotopic bone. Bone scans are not sufficiently specific to be used as a diagnostic tool in detecting heterotopic bone.

Comparison of donor-site healing under Xeroform and Jelonet dressings: unexpected findings.

&NA; Split‐thickness skin grafts remain central to the strategy of burn wound treatment. The dressing used to cover the donor wound site has a significant effect on healing parameters. The purpose of this study was to compare splitthickness skin graft donor site reepithelialization under Xeroform and Jelonet dressings. A dermatome was used to cut two consecutive strips of skin from 25 paired donor sites on the thigh, calf, or back of 19 participants. Standardization of the harvest method was achieved by using the same surgeon to harvest the compared skin graft strips, with attention to consistency of dermatome skinthickness setting, downward pressure, and angle of dermatome approach. A strip of Xeroform or Jelonet was applied to one of each pair of wounds. Epidermal and dermal thickness was measured from biopsy specimens cut at the midpoint of each split‐thickness graft strip. The day of final dressing separation was declared the day of complete donor reepithelialization (healing). The mean healing time for Xeroform and Jelonet was 10.4 ± 2.6 days (n = 25) and 10.6 ± 2.8 days (n = 25) (p = 0.76) at sites cut to a mean depth of 0.23 ± 0.08 mm and 0.23 ± 0.09 mm (p = 0.89), respectively. There was no correlation between graft thickness and healing time for sites dressed with Xeroform (r = 0.17) or Jelonet (r = 0.02). Donors sites reharvested 10 to 21 days after a prior harvest healed an average of 3.1 days earlier than virgin sites (8.4 ± 1.6 versus 11.5 ± 2.6 days, p < 0.001), although reharvested grafts were on average 0.05 mm thicker (p = 0.10). The mean thickness of reepithelialized donor‐site epidermis (0.13 ± 0.04 mm, n = 30) was found to be twice the thickness of virgin epidermis from the same sites (0.06 ± 0.02 mm, n = 38, p < 0.001). Thirty‐six grafts harvested with dermatomes set to cut 8/1000 inch (0.20 mm) deep ranged from 0.12 to 0.42 mm thick, with only eight of these grafts measuring within ± 10 percent of the desired thickness setting. Before donor dressing separation, Xeroform and Jelonet dressings were judged to be more comfortable by nine patients and one patient, respectively, whereas no difference was detected by six patients. The authors now use Xeroform as the preferred donor dressing. (Plast. Reconstr. Surg. 112: 430, 2003.)

Trends in hospital care of burns in Canada.

A review of burn admission patterns to Canadian hospitals from 1966 to 1991 from Statistics Canada data was prompted by a decrease to 125 burn patients admitted to Vancouver General Hospital in 1990 after a plateau at 180-195 per year for 6 years. The total number of fires from Fire Commissioners data and data from 20 of the 27 Canadian burn units was analyzed. Canadian burn admissions decreased from 57 per 100,000 in 1966 to 23 per 100,000 in 1989. The admission rate is three times greater for children 0-4 years of age but has decreased parallel with the total. The number of fires decreased from 370 to 270 per 100,000 in the last decade. In 1981, 1986, and 1989 15 Canadian units treated a constant 15% share of hospitalized burns, while nine units reported a constant 7% of burn patients who also required ventilation for associated smoke inhalation injury. These trends forecast a 2%-4% decrease in hospitalized burns per capita per year.

Comparison of silver sulfadiazine 1% with chlorhexidine digluconate 0.2% to silver sulfadiazine 1% alone in the prophylactic topical antibacterial treatment of burns.

Wound bacterial colonization in 118 patients treated with chlorhexidine digluconate 0.2% in silver sulfadiazine 1% applied daily to the burn wounds was compared to that of 135 comparable patients similarly treated with silver sulfadiazine 1%. With chlorhexidine digluconate 0.2% in silver sulfadiazine 1%, colonization by Staphylococcus aureus was less frequent (38%) than with silver sulfadiazine (54%, p = 0.016). No statistical difference was found for colonization by Enterococcus faecalis, Pseudomonas aeruginosa, or Enterobacter cloacae. Washing of the wounds of 65 patients with chlorhexidine gluconate 4% during daily dressing changes was associated with reduced wound colonization by S. aureus (35% versus 51%, p = 0.03) and P. aeruginosa (8% versus 16%, p = 0.08) when compared to the 188 washed with nonantibacterial soap. Chlorhexidine, whether added to the topical agent silver sulfadiazine (chlorhexidine digluconate 0.2%) or in the bath soap (chlorhexidine gluconate 4%), decreased colonization by S. aureus.

Histologic comparison of cultured epithelial autograft and meshed expanded split-thickness skin graft

Histologic appearance of cultured epithelial autograft (CEA) biopsies obtained up to 2100 days after application from patients with burn injuries differs from time-matched, meshed expanded autograft. The CEA interface with underlying bed remained flat for up to 3 years in three of four patients. CEA epidermal rete ridges, if formed subsequently, were fewer, thinner, and shorter, whereas expanded split-thickness skin grafts had well-defined rete ridges after 1 year. CEA basal layer remained separated from its bed up to 50 days after application, and late blister formation was seen on occasion for up to 3 years. The underlying bed was homogeneous up to 2 years; later some beds demonstrated differentiation with superficial, fine, filamentous collagen fibers and deeper, thick collagen fibers. Fine elastin filaments were initially identified in the superficial bed after 1 year in some specimens and in all after 3 years. Delay in rete ridge formation may explain poor adherence and poor stability.

Toxic epidermal necrolysis. Case report.

We present a case report of a patient with toxic epidermal necrolysis (TEN), associated with therapy with trimethoprin and sulfamethoxazole. Because of the similarity of TEN to an extensive partial-thickness burn, and the favorable response to the treatment used in burns, surgeons who treat burns should be familiar withe disease and take an active role in its management.

Major burns managed without blood or blood products.

Four major burns (two flame, one scald, one electrical) were managed without administration of blood or plasma. Serial changes in hemoglobin, and serum albumin and total protein measurements were compared with those of controlled patients matched in age and total body surface area burned who were treated by standard methods. Hemoglobin values were lower but within one standard deviation, although serum protein and albumin measurements fell more than one standard deviation below mean values observed in control patients at comparable times after burn injury. Important treatment principles that were instrumental to recovery include a high-calorie, high-protein diet, iron supplementation, use of pediatric blood sampling techniques, and monitoring for and prophylaxis against infection while allowing eschar to separate spontaneously rather than performing early debridement. Amputation of mummified electrically burned limbs at more proximal levels, including marginally viable muscle, is recommended to minimize infection and decrease blood loss associated with customary conservative serial debridements.

Comparison of 1% silver sulfadiazine with and without 1% chlorhexidine digluconate for topical antibacterial effect in the burnt infected rat.

The addition of 1% chlorhexidine digluconate to 1% silver sulfadiazine cream (CDSS) was compared with 1% silver sulfadiazine (SS) alone to assess the antibacterial effect of a once-daily application of the therapies on an experimental rat model with a 20% full-thickness burn wound seeded with 10(8) microorganisms originally isolated from infected wounds of burn patients. Separate series evaluated Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacter cloacae, and Streptococcus faecalis. The mean concentration of all four organisms recovered after one week from biopsy specimens of full-thickness eschar was less in the CDSS-treated animals compared with the SS-treated animals. Microbial invasion into subjacent muscle was less frequent in animals seeded with S faecalis, while the mean concentration of bacteria recovered from muscle of animals seeded with S aureus and E cloacae was less in animals treated with CDSS compared with those treated with SS (P less than 0.05). The addition of 1% chlorhexidine digluconate to 1% silver sulfadiazine increased the antibacterial effectiveness of the latter agent.

Burn units' share of Canada's total burn care.

The share of total hospital Canadian burn care provided by 17 of Canadas 27 present burn units increased marginally to 18.3% in 1991 from 17.0% in 1981 (p = 0.0506), and the mortality rate decreased from 5.6% in 1981 to 3.5% in 1991 (p < 0.05). In 10 units providing serial data, patients with burns undergoing ventilation therapy for a concomitant smoke inhalation injury increased from 6.3% (n = 58) of 1981 admissions to 11.1% (n = 73) of 1991 admissions (p < 0.05). In 1991 Canadas 27 burn units treated 32.4% of Canadas hospitalized patients with burns and provided 50.6% of hospital burn care days. Although the total number of patients with burns hospitalized in Canada decreased by 35% from 7923 in 1981 to 5161 in 1991 (32.6 to 18.9 per 100,000 population), with a proportional decrease in patients treated in burn units, the requirement for intensive care unit capability to treat patients undergoing ventilation therapy has remained the same or is greater and must be preserved as burn units shrink.

LOWER EXTREMITY BURNS AND UNNA PAST: CAN WE DECREASE HEALTH CARE COSTS WITHOUT COMPROMISING PATIENT CARE?

OBJECTIVE To compare an alternative treatment for lower extremity burns with the standard in-hospital treatment, in an attempt to shorten hospital stay. DESIGN A case-control series. SETTING A university-affiliated hospital. PATIENTS All patients with a burn isolated to a lower extremity were treated over an 8-month period with split-thickness skin grafting (STSG), Unna paste dressing, immediate mobilization and early discharge. This group was compared with matched controls from the preceding 8 years treated with STSG, occlusive burn gauze dressing, bed rest and hospitalization. MAIN OUTCOME MEASURES Duration of hospital stay and graft viability. RESULTS Thirteen patients with an average wound size of 131 cm2 were treated with Unna paste and had a graft viability of greater than 95% and a burn-scar rating equivalent to that of patients treated with the earlier regimen. The duration of hospital stay decreased from a mean of 12.9 days to 1.4 days, with no complications. This translated into a saving of