Robert K. Finley

The effect of mechanical compression on chronic hand edema after burn injury: a preliminary report

Chronic hand edema after wound healing is a troublesome condition to treat in patients with burns. Stagnant edema can cause fibrosis, which impedes rehabilitation and may lead to deformity. Although favorable results have been reported with mechanical compression used in acute injuries, no literature was found on the effects of compression for the treatment of chronic hand-burn edema. Five male patients with nine chronically edematous burned hands were subject to mechanical compression at 55 mm Hg pressure. A single-cell unit was used for a 30-minute treatment at 4:1 treatment ratio. Goniometric and volumetric hand measurements were recorded both before and after treatment. Although patients expressed a subjective feeling of improvement, no statistical difference was found in finger joint range of motion nor in hand volume when comparing pretreatment and posttreatment measurements. Many different treatment protocols exist in the literature and are discussed.

The Use of Intestinal Antibiotics to Delay or Prevent Infections in Patients with Burns

Bacterial colonization and infection of wounds in seriously burned patients often comes from the patients indigenous bowel flora. A prospective randomized clinical trial that involved 30 patients with 20% or greater total body surface area burns was undertaken to evaluate the use of a standard antibiotic bowel preparation in the delay or prevention of bacterial colonization of the burn wound and sepsis. Certain enteric bacteria were seen less frequently in the treated group (Enterobacter organisms), but other bacteria appeared more often in the treated group (Proteus organisms and enterococci). The average time of colonization of the burn wounds was 6.1 days in the treated group and 6.7 days in the control group. Blood cultures were positive for enteric organisms earlier in the treatment group. Pseudomonads appeared earlier in the wound and blood cultures of the treated group than in the control group. The effect of antibiotic bowel suppression in patients with burns is varied and unpredictable. The bowel preparation may select certain organisms and lead to earlier colonization of the wounds. Overall outcome and survival was not improved by the use of an antibiotic bowel preparation in these patients.

Fluid retention and burn survival.

The relationship between retained fluid and survival has previously been reported from our burn unit. Two hundred thirty cc/kg lean body mass accurately delineated survivors from nonsurvivors. Our previous study did not account for fluid lost through the burn wound. This study was undertaken to evaluate fluid retention per square meter of body surface area which has been corrected for fluid loss from the burn wound using a formula suggested by Mason et al. Data collected from 95 adult patients with burns greater than or equal to 20% body surface area burn (mean age, 42.4 years; mean burn size, 37.7%), who were admitted to our burn unit between January 1978 and September 1985, were evaluated. All patients included in the study were adequately resuscitated and survived the initial 48 hours. A calculation of the total fluid retained during the first 48 hours postburn and estimation of fluid loss from the burn wound were made. A comparison was made between lean body retained fluid and surface area retained fluid. A positive correlation (r = 0.921; p less than 0.001) was demonstrated between these two methods of assessing fluid retention. Fluid retention determined by either method resulted in a higher correlation with survival than any single predictor (age, per cent body surface area burned) of burn survival. Surface area fluid is as accurate as lean body fluid in predicting survival. Additionally, we determined that for the first 48 hours postburn, 4,425 cc fluid retained per meter square body surface area accurately differentiated survivors from nonsurvivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Use in the Burn Unit: A Possible Role for Erythropoietin

Recently, several of our patients have raised questions concerning the safety of blood transfusions and especially the transmission of human immunodeficiency virus infection. We have noticed a growing reluctance of patients to receive blood transfusions. This prompted us to review the use of blood in our burn unit for 530 patients who were admitted from 1987 to 1989. Our traditional reasons for transfusion have been either an ongoing hemorrhage that leads to hypotension or a hematocrit of less than 30%. For these reasons 131 (24.7%) of the 530 patients reviewed required transfusions. The average number of units transfused in patients who received blood was 10 (range 1 to 69). Three hundred ninety-nine patients (75.3%) did not require transfusions. We undertook a prospective preliminary trial of recombinant erythropoietin in five patients who were admitted to our burn unit over a 2-month period to evaluate whether this agent could lessen the transfusion requirements. Because no definite value is given in the literature as to what level of hematocrit is most appropriate for transfusion, we chose a hematocrit of 20% as our new indication for transfusion. Inclusion into the trial required a total body surface area burn of over 10% that required at least one operation. Five patients met the inclusion criteria. Administration of erythropoietin was started on admission. According to our new criteria for transfusion none of the five patients receiving erythropoietin required the transfusion of blood or blood products. This study would suggest the need for both a prospective clinical trial of erythropoietin and further studies to better define the indications for transfusions in patients with burns.

A comparison of total body water analyses : Bioelectric impedance analysis versus the tritiated water method

Bioelectric impedance analysis (BIA) is used to measure the body composition and total body water of normal subjects. The purpose of this study was to determine if the hydration of patients with burns could be assessed by BIA. Assessments of total body water as determined by BIA and the tritiated water method were prospectively compared. The 2 analyses were performed 48 hours after admission for 5 patients with acute burns to determine the correlation of the 2 methods. The patients had a mean age of 36.4+/-14.7 years (range, 20-56 years), a mean burn size of 39.4%+/-15.9% of the body surface area (range, 23%-65%), and a mean full-thickness burn size of 27.7% of the body surface area. The total body water was measured on admission and again at 48 hours postburn. There is an excellent relationship between BIA and tritiated-water-method determinations of the total body water of patients with severe burns (r = 0.958). This correlation suggests that BIA provides an accurate measure of total body water, and so it is a reliable means of monitoring fluid resuscitation in patients with burns.

High-energy roller injuries to the upper extremity

Eleven cases of high-energy industrial roller injuries treated between 1980 and 1984 were retrospectively reviewed. The dominant extremity was affected in nine. Six patients sustained fractures and/or dislocations, and three of these patients required fasciotomies for clinical signs of impending compartment syndromes. All fracture/dislocations, with the exception of a scapula fracture, anterior dislocation of a thumb interphalangeal joint, and a fractured coronoid process of the ulna, required open reduction with internal fixation. Three patients required split-thickness skin grafting for extensive skin degloving. Two patients required immediate amputation. Late sequelae included prolonged edema, nutritional depletion, neuroma formation of the superficial branch of the radial nerve, late carpal tunnel syndrome, and partial brachial plexus palsy. Industrial roller injuries continue to be an occupational hazard associated with more severe crushing trauma than the low-energy wringer washer injuries first described by MacCollum (11). Attention must be paid to the treatment of crushed skin, muscle, and nerves, fracture stabilization, nutritional support, and occupational therapy. Concurrent monitoring for signs of a developing compartment syndrome and complications of rhabdomyolysis is essential.

Results of a Multicenter Outpatient Burn Study on the Safety and Efficacy of Dimac-ssd, a New Delivery System for Silver Sulfadiazine

Dimac with silver sulfadiazine (Dimac-SSD), a new silver sulfadiazine delivery system, was evaluated prospectively in a multicenter study for the treatment of outpatient burn injuries. The goal of this study was to evaluate the effect of Dimac-SSD on the microbiology of the burn wounds and to quantitate its clinical safety and efficacy. A total of 197 patients were evaluated. Eight (4%) of these patients did not complete the study. Six patients withdrew because of local discomfort caused by the Dimac-SSD and two patients were terminated because of technical problems. The mean +/- SD duration of treatment with Dimac-SSD was 12 +/- 8.5 days, during which time the mean number of dressing changes was 2.9 per patient. During treatment with Dimac-SSD, the burn wound bacterial flora remained stable and overgrowth with Pseudomonas species or Gram-negative bacilli did not occur. Only four (2%) patients developed clinical infections; thus the Dimac-SSD appeared to have good antimicrobial effectiveness. This dressing was not associated with any organ system or metabolic side-effects and patient discomfort during application and removal was minimal. Thus this new delivery system for silver sulfadiazine was associated with excellent wound healing, a low incidence of wound infections, reduced frequency for dressing changes, and excellent patient compliance.

Fluid retention during the first 48 hours as an indicator of burn survival.

The quantity of fluid retained during the first 48 hours of resuscitation has been suggested as an indicator of burn severity and mortality (13). In this study of 82 adult burned patients with more than 20% total body surface burns we found that the net fluid retention during the first 48 hours of resuscitation was a predictor of burn mortality and additionally 230 cc of retained fluid per kilogram of lean body mass in the initial 48 hours postburn was an excellent means for separating survivors from nonsurvivors. Fluid retention as an indicator of burn severity and mortality was compared to other methods of predicting burned patient mortality. Parameters evaluated included the per cent body surface area burned, per cent full thickness burn, presence or absence of inhalation injuries, sex, age, and ultimate outcome. The Abbreviated Burn Severity Index (ABSI) (14) was determined for each patient using these data. A comparison was made between fluid retention data, per cent body surface area burned, and the calculated Abbreviated Burn Severity Index and patient mortality. The power of each variable to predict mortality was evaluated by stepwise regression analysis. From this analysis net fluid retention during the first 48 hours of resuscitation was as accurate as the Abbreviated Burn Severity Index and was a better predictor of mortality than individual components of that Index.

Micrografts. II: Evaluation of 25:1, 50:1, and 100:1 expansion skin grafts in the porcine model.

This study was undertaken to evaluate 25:1, 50:1, and 100:1 expansions of micronized skin grafts in a porcine model. Two full-thickness skin excisions (graft and control) were performed on each of 30 immature pigs (20 pounds). The pigs were divided into three groups of 10 animals each: group A, 25 cm2; group B, 50 cm2; and group C, 100 cm2. One square centimeter of the excised skin was thinned to produce a thick split-thickness skin graft. Four 90-degree passes were made through a skin mesher with the smooth side of the plastic mesh carrier to produce uniform pieces of skin. These pieces were applied to one area on each pig. Both the graft and control sites were covered with film. The film was removed on postoperative day 7, and excision sites were photographed on postoperative days 7, 10, 14, and 21. Healing was evaluated with a 12 x 12 inch digitizing pad to estimate the percent area healed. Healing was compared via analysis of variance, with percent area healed used as the dependent variable and treatment (control or graft) and postoperative day and expansion size used as the independent variables. No difference was found on postoperative day 7. On postoperative day 10, 25:1 grafts healed better than the 50:1 grafts, which were healed more than the 100:1 grafts. No difference was seen between 25:1 and 50:1 grafts on postoperative day 14; however, they were healed better than the 100:1 expansion grafts. No difference was seen between the graft sites on postoperative day 21.(ABSTRACT TRUNCATED AT 250 WORDS)

Interpretation of Nutritional Parameters in Burn Patients

Data frequently used for a nutritional evaluation, eg, estimated calorie and protein needs, weight, triceps skinfold thickness, midarm-muscle circumference, serum albumin and transferrin levels, skin tests, total lymphocyte count, nitrogen balance, and creatinine height index determinations, are conceptualized herein. It is thought that many of these values lack appropriate validation in burn patients. With the accumulation of new data, many nutritional surveillance techniques will require modification and reinterpretation. Therefore, caution is essential when interpreting these data. In the meantime, currently available data are probably best construed by a team as an assemblage of findings that may classify a burn patient at risk of morbidity and mortality unless additional attention is given to meeting nutritional needs