Roberta Mann

Improved burn scar assessment with use of a new scar-rating scale.

The subjective assessment of scar appearance is a widely used method in the evaluation of burn outcomes and the efficacy of treatment methods. The purpose of this study is to design a numeric scar-rating scale with better interrater reliability than has previously been reported. The rating scale assesses scar surface, thickness, border height, and color differences between a scar and the adjacent normal skin. Eight raters were trained with use of a standardized set of photographs that provide examples of the scores to be assigned to each level of severity of each scar characteristic. The raters then rated 10 photographs of different scars, referring to the teaching set of pictures for comparison. The intraclass correlation (interrater reliability) was 0.94, 0.95, 0.90, and 0.85 for scar surface, border height, thickness, and color, respectively. This rating system has proved to be a useful tool for the evaluation of scar surface, thickness, border height, and color.

Is immediate decompression of high voltage electrical injuries to the upper extremity always necessary

OBJECTIVE To determine if immediate decompression is required for all high voltage injuries to the upper extremity. DESIGN Retrospective review. MATERIALS AND METHODS Charts reviewed of 62 patients who had upper extremity contact with >1,000 volts of electricity over a 10-year period. MAIN RESULTS One hundred upper extremities were treated. Twenty-two percent were decompressed within 24 hours because of progressive nerve dysfunction, clinical compartment syndrome, or failure of resuscitation. This group required a mean of 4.2 operations with an amputation rate of 45%, similar to other series. Thirty-five percent of burned extremities had their first operative procedure delayed until resuscitation was complete. This group required a mean of 2.1 operations with no amputations. Forty-three percent of extremities did not require operations to achieve healing. Overall results show a 10.0% amputation rate and mean hospital stay of 27 days. CONCLUSIONS We conclude that the need for amputation and multiple operations is determined by the injury itself and that immediate decompression is only required for the usual clinical signs of compartment syndrome. Selective decompression may actually preserve tissue and decrease the need for eventual amputation because fasciotomy can lead to soft tissue dessication by exposing viable tissue.

Facial mutilation after an assault with chemicals: 15 cases and literature review.

Facial mutilation after an assault with chemicals is rarely discussed in the literature even though it is a devastating injury that occurs worldwide and is not prohibited or punished by special laws. It is our purpose to describe the devastating outcome of facial mutilation after an assault with chemicals and to draw attention to this injury as a worldwide problem. We studied fifteen patients who sustained facial mutilation with chemicals. The common story was that the patients spouse was the perpetrator, that sulfuric acid was used, and that the deed occurred after marital or financial discord. All victims were disfigured severely and most became reclusive and rarely left their homes. Six patients (40%) had total bilateral blindness and one suffered partial loss of vision. Lower eyelid ectropion (14), microstomia (12), cervical flexion contracture (10), ear deformity (8), and nostril stenosis (6) were common. Few of the perpetrators were prosecuted. We reviewed the literature and found that the problem has been described all over the world, and that the outcome is similar to that which we described. The problem deserves worldwide recognition and attention.

A new tool to measure pressure under burn garments

This article introduces a new tool to measure the pressure that is under pressure garments. The Iscan (Tekscan, Inc.) system uses a patented ultra-thin (0.007 inch) sensor with multiple sensing locations that sample continuously at 100 times per second. It is noninvasive, convenient, and quick. The study had two parts. First, we established the validity and reliability of the device. Next, garment/scar interface pressures were measured on new garments with use of the Iscan system. Four garment types were studied, with 10 measurements made in each group: Isotoner gloves (Smith & Nephew Roylan, Inc.); custom-fit pressure gloves; Tubigrip forearm sleeves (Seton Health Care Group); and custom-fit pressure forearm sleeves. Mean garment/scar interface pressures were 18 +/- 2 mm Hg for the Isotoner glove, 34 +/- 5 mm Hg for the custom-fit pressure glove, 20 +/- 7 mm Hg for the Tubigrip sleeve, and 35 +/- 6 mm Hg for the custom-fit sleeve. We concluded that the Iscan system can be used to measure pressure under pressure garments accurately and reliably, and that custom-fit hand and forearm garments provide more pressure than Isotoner gloves or Tubigrip sleeves.

Comparison of pain control medication in three age groups of elderly patients

There are no published reports of burn pain management in the elderly population. To assess the range of requirement and use of opioids among elderly patients with burns of different age categories, a retrospective review of 89 consecutive admissions of patients over 55 years of age (January 1995 through July 1996) was conducted. Complete data were available on 44 patients with a burn mean total body surface area of 17.2%. Patient ages ranged from 55 to 92 years. Individuals were divided into three age categories: Group I (55 to 65) n = 20; Group II (66 to 75) n = 14; and Group III (76 to 92) n = 10. Use of commonly prescribed opioids for procedural pain and breakthrough pain were evaluated. We compared the opioid equivalents of medications prescribed versus the actual amount administered. Paired t tests comparing minimum amount of medication ordered with that given revealed Group I patients received significantly more procedural medication than the minimum prescribed (t = 3.88, p = 0.001), and that Group III patients were given significantly less as needed medication than the minimum prescribed (t = 2.58, p < 0.05).

Full-thickness grafting of acute eyelid burns should not be considered taboo.

Split-thickness skin grafts are commonly used for the treatment of acute eyelid burns; in fact, this is dogma for the upper lid. Ectropion, corneal exposure, and repeated grafting are common sequelae, almost the rule. It was hypothesized that for acute eyelid burns, the use of full-thickness skin grafts, which contract less than split-thickness skin grafts, would result in a lower incidence of ectropion with less corneal exposure and fewer recurrences. The records of all patients (n = 18) who underwent primary skin grafting of acutely burned eyelids (n = 50) between 1985 and 1995 were analyzed retrospectively. There were 10 patients who received full-thickness skin grafts (12 upper lids, 8 lower lids) and 8 patients who received split-thickness skin grafts (15 upper lids, 15 lower lids). Three of 10 patients (30 percent) who received full-thickness skin grafts and 7 of 8 patients (88 percent) who received split-thickness skin grafts developed ectropion and required reconstruction of the lids (p = 0.02). No articles were found substantiating the concept that only split-thickness grafts be used for acute eyelid burns. The treatment of acute eyelid burns with full-thickness rather than split-thickness skin grafts results in less ectropion and fewer reconstructive procedures. It should no longer be considered taboo and should be carried out whenever possible and appropriate.

Staged procedures for exsanguinating lower extremity trauma: an extension of a technique--case report.

Packing and temporary closure have been used in various clinical scenarios to control nonsurgical bleeders in the abdomen. We present a case where we have extended that technique and successfully utilized it in a patient with an exsanguinating lower extremity vascular injury.

Silipos neck wraps

Burns of the neck are a problem. Grafted anterior necks can result in disfiguring hypertrophic scar contractures and wrinkling of the graft. The development of contractures can be prevented by effective splinting as soon as possible after the burn and by following a continuous wearing schedule until scar maturation is complete. Traditional neck conformers do not allow free neck rotation and can lead to stiffness as a result of decreased mobility. We used Silipos neck wraps for 10 patients who had good range of motion in the neck and who required pressure only for flattening of grafts and wrinkle prevention. The neck wrap is user-friendly, low in cost, and easy to fabricate and custom-fit for individual patients.