Edward J. Law

Diagnosis of burn depth using laser-induced indocyanine green fluorescence: a preliminary clinical trial

Clinical assessment of burn depth is frequently inaccurate. In order to effectively plan the treatment of burn wounds, an accurate diagnosis of burn depth is desirable. A new method for evaluating the depth of burns by imaging the blood flow through the burned tissue using fluorescence from intravenously injected indocyanine green (ICG) dye illuminated with a 785-nm, near-infrared diode laser array was evaluated. Nine patients and 15 individual burn sites were studied. Five sites were classified by the ICG study as superficial second degree, four were deep-dermal second degree, and six were third degree. Etiology of the injuries included flame, contact burns, and scalds. The date postburn of the study ranged from 1 to 11 days. In all cases, the relative fluorescence levels (e.g. superficial second-degree burns yielded relatively bright fluorescence, third-degree burns appeared much darker than surrounding normal skin) were found to correlate well with actual burn depth as determined by histologic examination of biopsies and intraoperative clinical assessment.

A laboratory method for selection of topical antimicrobial agents to treat infected burn wounds

Summary This report describes an in vitro method which predicts the antimicrobial effects of the drugs which are used for topical application in the treatment of infected burn wounds. Standard in vitro disc sensitivities are not available for this panel of drugs. The test incorporates an evaluation of the drug carriers, creams and ointments, which are not factors in standard disc or dilution sensitivity methods. Quantitative bacteriological data following treatment of infected burn wounds in children support the conclusion that the in vitro test correctly selects effective antimicrobial agents.

Evaluation of the circulation of reconstructive flaps using laser-induced fluorescence of indocyanine green.

A new method for evaluating the circulation in surgical flaps using laser-induced fluorescence of indocyanine green (ICG) images is reported. In clinical trials the authors found that ICG imaging demonstrated good circulation accurately in 16 of 21 flaps with no clinical manifestations of compromised circulation. In 3 patients in whom partial discoloration and cyanosis of the flaps were visible, the dye study indicated poor circulation in the identical areas. In 2 other patients in whom flaps appeared clinically satisfactory, the flaps were shown by ICG imaging to have greatly compromised circulation. In a patient in whom the flap was left in place, slough of almost the entire flap resulted. Another flap with questionable circulation was returned to its original location, where it healed. Thus, while it is a still a new approach and under continual evaluation, the use of ICG fluorescence shows promise as a valuable adjunct to current methods of flap evaluation.

Self-inflicted burns

Over a 3-year period 17 people were admitted for intentionally self-inflicted burns. The mean total body surface area burn was 29.5%, and 59% of the patients sustained an inhalation injury. Two patients died from their injuries (one male and one female). The method most often used (59%) was a flammable liquid ignited by a flame. Of those patients, 50% used gasoline. Fifty-nine percent of the patients were current substance abusers, with alcohol (80%) being the favored drug. Aside from substance abuse, psychiatric abnormalities were present in 53% of the patients. Schizophrenia/schizoaffective disorders was the primary psychiatric diagnosis (44%), with most patients having undergone previous psychiatric treatment. All had diagnosed disorders (using the Diagnostic and Statistical Manual III--Revised) including substance abuse and/or other psychiatric disorders. Actual stated suicidal intent was present in 41% of the cases, and another 41% were irrational attempts to escape from or control emotional pain.

Use of cultured epidermal autografts in the treatment of large burns

Mortality in patients with large areas of full skin thickness burns is, in part, due to complications developing during the period of prolonged delay required to obtain enough wound healing to permit skin grafting from limited donor sites. Cultured epithelial autograft (CEA) has become available as an alternative measure to the use of expanded skin autografts and regrafting. Small biopsies are taken and transported to the laboratories of BioSurface Technology where keratinocytes are grown to cover large areas during a 3-week period. The cultured keratinocytes are then available on petroleum jelly gauze which is applied to the patient. The gauze is used as a temporary dressing. To date, 37 patients have been biopsied. Grafts have been applied in 15. Graft take averaged 71.5 per cent at our institution. Two of the patients grafted with CEA died of sepsis. One patient had a 100 per cent loss of the CEA grafts. In 12 patients, the use of CEA probably contributed significantly to wound coverage and survival. Such grafts are more susceptible to mechanical loss than routine autograft, although long-term coverage after several years is considered to be satisfactory. The cost of the process is high.

A comparison of the effect of early insertion of standard latex and silver-impregnated latex foley catheters on urinary tract infections in burn patients.

A retrospective study was designed to compare the incidence of urinary tract infections during two different time periods in burn patients treated with two different types of Foley catheters. In time period 1, latex catheters present on admission were not changed. In time period 2, catheters were replaced on admission with silver alloy-impregnated catheters. In time period 1, the rate of symptomatic urinary tract infections was 7.2 per 1,000 catheter-days. In time period 2, the rate was 4.4 per 1,000 catheter-days. Results, compared using Fishers exact test, revealed a statistically significant P value of .029. The use of silver-impregnated catheters significantly lowered the rate of urinary tract infection at our burn center.

Experience with necrotizing fasciitis at a burn care center.

Necrotizing fasciitis is a soft tissue infection that causes necrosis of subcutaneous tissue and fascia but usually spares skin and muscle. Management of this condition consists of early diagnosis, broad-spectrum antibiotic coverage, aggressive surgical debridement, wound closure, and intensive supportive care. Mortality estimates reported in the literature have ranged from 20 to 75%. We report the cases of 12 patients treated at the Joseph M. Still Burn Center in Augusta, GA. Because aggressive surgical debridement combined with medical support is required for successful treatment, we recommend that treatment be administered at a burn care center. We performed a retrospective chart review of all patients admitted to our center with a diagnosis of necrotizing fascitis between May 1, 1995, and June 1, 2000. Patients were managed collaboratively by burn surgeons and critical care intensivists in consultation with other appropriate specialists. The mean time from initial diagnosis until transfer to the burn center was 14 days (range, 0–60 d). Complications included pneumonia, heart failure, metabolic abnormalities, anemia, and sepsis. Four (33%) of the 12 patients died, with the primary cause of death being multiorgan failure. Although our sample size is too small to reach statistical significance, the data suggest that early referral to a burn or wound care center improves patient outcome.

Experience with burns of the eyes and lids in a regional burn unit

During a 3-year period 1527 patients with burns were admitted to a regional burn unit in Augusta, Georgia. Two hundred thirty patients (15.06%) were referred for consultation by an ophthalmologist. Thirty-two patients had preexisting ophthalmic problems that were believed to warrant consultation. One hundred eighty-nine patients were seen because of facial burns. Of these, 143, or 9.36%, had burn injuries of the eyes or lids that required care. Lid involvement was encountered in 122 (7.98%) cases. In 78 cases lid involvement was bilateral (in the remainder, unilateral). In 61 cases thermal or chemical burns to the conjunctiva or lens were present. Skin grafts to the lids were required for acute care in 11 instances. Tarsorrhaphies were done in 11 instances. In one case the lids were essentially destroyed, and extensive reconstruction with flaps was needed. Late reconstruction with grafting of the lids was done in five cases. In three eyes (two patients) enucleation was eventually required. Ten patients without burns who had toxic epidermal necrolysis were also treated on the unit. Consultation with an ophthalmologist is believed to be important in patients with significant ocular or periocular injury. The importance of maintaining moisture to the globe is stressed.

Surgical treatment of elbow contractures in postburn children.

One-hundred and forty-six postburn elbow contractures in children were classified into four categories--simple band, complex band (crosses shoulder and/or wrist joint), diffuse scar, and limited scar--to assess the results of surgical treatment. The best results were seen in children less than 5 years of age and in children with less than 50 percent third-degree total body surface area burns. Types of release included skin grafts, local flaps (with or without graft), and deep releases. Generally, good to excellent results were seen regardless of technique of release, and in no case was the postoperative contracture worse than the preoperative contracture. Full extension was restored in 82 percent of contractures that were less than 50 degrees and in 50 percent of contractures greater than 50 degrees. Major complications were uncommon, with 4 of 171 elbows requiring reoperation because of skin-graft or flap loss. Repeat releases were of minimal functional benefit.

An approach to the management of toxic epidermal necrolysis in a burn centre

Toxic epidermal necrolysis syndrome, a life-threatening skin disorder, requires specialized nursing care to optimize survival. The similarity of the condition to partial skin thickness burns suggests that management on a burn unit is an effective means of therapy. A review of eight patients treated at our Burn Center emphasizes the need for aggressive team management of the condition.