Michael J. Feldman

Smoke inhalation injury in a pregnant patient: a literature review of the evidence and current best practices in the setting of a classic case.

For smoke inhalation injury of a pregnant woman, one must treat two patients and be aware of the potential effects of carbon monoxide (CO) and cyanide (CN) poisoning on both the mother and the fetus. In a pregnant woman, the size and age of the fetus and the degree of poisoning allow for tremendous variability in the toxicity of CO and CN and their respective treatment options. The authors will review a case of a 32-year-old woman who was at 37 weeks of gestation and admitted to the Evans-Haynes Burn Center after a house fire and received hydroxocobalamin (Cyanokit) for suspected CN poisoning. In addition, a review of the literature, current guidelines, and treatment options of inhalation injury during pregnancy will be discussed. The authors will focus only on the toxic components of smoke inhalation injury rather than the mechanical components from heat and particulate damage. Literature review clearly identifies that the treatment of pregnant women with inhalation injury remains a controversial subject. The use of hydroxocobalamin (Cyanokit) as a treatment modality for potential CN poisoning in a pregnant patient has not been reported in the literature. Animal studies have shown that combined CO and CN poisoning are more lethal than either one alone and at lower concentrations. Due to the synergistic effects of CO and CN, and because these two toxins concentrate at even higher levels in the fetus than the mother, the authors will clarify the urgent seriousness of prompt administration of hydroxocobalamin in a pregnant patient with suspected smoke inhalation injury. This case review details the treatment of a 32-year-old woman who was at 36 weeks of gestation on admission to the Evans-Haynes Burn Center. The authors will report her injuries and the course of treatment. Although burned and presenting with concomitant smoke inhalation injury, both the woman and her child fared well with no significant complications due to the smoke inhalation at 6 months of follow-up. Smoke inhaled from modern structural fires potentially contains both CN and CO gases. This makes the prompt recognition of this injury and selection of appropriate therapy an emergent priority. In October 2010, the Food and Drug Administration approved hydroxocobalamin for use in pregnant patients in the acute setting when CN toxicity is suspected. Because CO and CN have additive effects when both are present in the body, the prompt administration of hydroxocobalamin not only eliminates the effects of CN but also potentially attenuates its synergistic effects on CO. It is only through a better understanding of the details of smoke inhalation injury, the current treatment options, and the considerations regarding their use that new research and strong guidelines can be developed to better serve our patients.

Blast Injuries Caused by Vape Devices: 2 Case Reports

AbstractVaporizing devices have become a popular alternative to conventional nicotine products. They are thought to be safer as they produce aerosolized nicotine powered by a lithium ion battery. Many people have used these electronic devices as a tool to quit smoking; however, the batteries can be unstable and explode.We present 2 case reports where explosions of electronic vapor devices caused significant injuries. The first patient sustained a combustion injury to the maxilla resulting in bone and anterior maxillary tooth loss requiring reconstruction. The second patient had a severe blast injury to the hand which ultimately resulted in loss of a digit. Toxicology was consulted due to concerns for systemic absorption of metals in the soft tissue of the hand. Cobalt and manganese were initially elevated but decreased after surgical debridement. The patient did not have any systemic symptoms.Currently, there is no federal regulation of electronic cigarettes or vape devices in the United States. With the increasing use of these devices and no standard regulations, we anticipate more blast injuries occurring in the future. Medical providers will need to be able to be prepared to manage the devastating clinical injuries that ensue.

Vascular Issues in Thermal Injury

Thermal injury alone can be a devastating event with long-standing effects on wound healing. The presence of vascular disease severely complicates this already difficult clinical situation. Vascular disease, as manifested by arterial and venous insufficiency, is increasing in its prevalence and incidence. This chapter will focus on the known physiological changes in response to thermal injury in particular of the lower extremity arterial system. Initial evaluation and subsequent treatments for the patient with suspected vascular disease in the setting of thermal injury is detailed. The current state of the literature will be reviewed in regard to what is known about the alteration in vascular bed response to a thermal injury as well as the known complications of thermal injury in diabetic patients. A proposed algorithm will be detailed in terms of appropriate perfusion assessment and when a vascular consultant should be involved in the care of a thermally injured patient. Finally, a clinical case example with approach to this patient population will be detailed.

A Review of the First Seminar That Set the Stage for the Creation of the American Burn Association

As the first civilian burn center in the United States, the Evans-Haynes burn center shares a rich history with the American Burn Association. This is evidenced by a review of Dr. B.W. Haynes Jrs personal notes, which were shared with us by his daughter. Dr. Haynes states, in his own hand writing, that this 1959 burn seminar led to the formation of the American Burn Association. The manuscript contains a meticulous collection of discussions among leaders in the development of modern burn care. These discussions range from debates about burn resuscitation and the early use of antibiotics to the reconstruction of large burn defects and release of burn scars. We propose a detailed discussion of Dr. Hayness notes. In addition, we include a review of the participants in this event as well as some of their accomplishments. In conclusion, this article provides a rare insight into the history of burn management and highlights the many challenges that remain in modern burn care.

A Comparative Study of the ReCell® Device and Autologous Split-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries

Abstract Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.

A Model to Improve Detection of Nonaccidental Pediatric Burns

Context Pediatric burn patients warrant thorough evaluation because a sizeable proportion of pediatric burns are nonaccidental. Design A multidisciplinary method involving an internal child protection team (CPT) was developed and used to identify suspected nonaccidental pediatric burns in all pediatric burn patients 5 years of age or younger who were evaluated by the CPT and social workers at our institution over a 55-month period. Results We identified 343 cases for review that fit our age criteria, 6 of which we identified as cases of suspected abuse or neglect. On average, these patients were younger, suffered greater total body surface area burns (TBSA), and required a longer length of stay in the hospital than the total population. We have not had readmissions for repeat nonaccidental pediatric burn injuries in this group of patients since this model was implemented. Conclusions Our multidisciplinary method might provide a more consistent and reliable method for identifying cases of suspected abuse.

The Use of Vasopressors in Pedicled Flaps for Chest Wall Reconstruction

Introduction The effect of vasopressors on flaps remains controversial in the literature. Often, surgeons avoid vasopressors with the thought that vasoconstriction reduces flap perfusion resulting in flap loss. Methods A retrospective review was performed on patients who required chest wall reconstruction from 1998 to 2013. Patients were identified through the use of Current Procedural Terminology codes. The data collected included demographics, indications for surgery, prior debridement, preoperative albumin levels, and perioperative vasopressor use. Outcomes measures included flap survival, flap complications, reoperation rates, intensive care unit length of stay, and mortality. Results Of the 1220 patient records reviewed, 88 had chest reconstruction by a plastic surgeon. Twenty-one patient records were excluded due to incomplete data. One patient experienced complete flap loss; these data were excluded from statistical analysis. Fifty patients received perioperative vasopressors whereas 15 did not. There was no significant difference in flap survival or loss between groups who received perioperative vasopressors and those who did not receive vasopressors. Age, intensive care unit length of stay, flap complications, and reoperation rates were significantly higher in those with partial flap survival. Conclusions Perioperative vasopressor use does not adversely affect the outcome of pedicled flaps for chest wall reconstruction. Further research is warranted to review the effects of vasopressor dose and type on pedicled flaps.

Radiation Injuries and Vesicant Burns

Abstract Radiation injury can range in severity from solar exposure and minor intentional or accidental medical irradiation to the detonation of atomic bombs. The type and intensity of radiation determines the extent and damage, ranging from localized erythema to severe burns and acute radiation syndrome. The general principles of burn care apply to irradiated wounds with the understanding that these are more susceptible to infection, sepsis, and poor healing. Vesicant burns are blistering lesions of the skin caused by agents that are primarily used in chemical warfare. They principally affect the skin, but the eyes and respiratory and gastrointestinal tracts are frequently involved. The most commonly encountered clinical effects include erythema and blistering, cough and dyspnea, burning conjunctivitis, and nausea and vomiting. Treatment largely involves minimizing contact with the agents and supportive care.