Stephen M. Milner

The treatment of alkaline burns of the skin by neutralization.

Literature reports dating as far back as 1927 have lured clinicians into the belief that alkaline skin burns are best treated by water dilution and that neutralization attempts should be avoided. Although this belief has never been substantiated, neutralization of an alkaline burn of the skin with acid was thought to increase tissue damage secondary to the exothermic nature of acid-base reactions. The authors proposed that topical treatment of alkaline burns with a weak acid such as 5% acetic acid (i.e., household vinegar) would result in rapid tissue neutralization and reduction of injury in comparison to water irrigation alone. In a rat skin burn model, animals were exposed to an alkaline injury when filter paper (2 cm in diameter) saturated with 2N sodium hydroxide was placed over the volar aspect of the animal for a period of 1 minute. Treatment was initiated 1 minute after injury and included either neutralization with a 5% acetic acid solution (n = 8) or irrigation (n = 8) with water. Skin temperature and pH were monitored using subdermal needle probes until the pH of the skin returned to physiologic values. Punch-biopsy specimens were obtained from the wound edges 24 hours after injury to assess burn depth and leukocyte infiltration, and biopsies were repeated 10 days later to assess wound healing. The authors proposed that neutralization of an alkaline substance with household vinegar (i.e., 5% acetic acid solution) would result in rapid neutralization and thus reduce extent of tissue injury. Animals treated with acetic acid demonstrated a more rapid return to physiologic pH (14.69 +/- 4.06 minutes versus 31.62 +/- 2.83 minutes; p < 0.001), increased depth of dermal retention (0.412 +/- 0.136 mm versus 0.214 +/- 0.044 mm; p = 0.015), decreased leukocyte infiltrate (31.0 +/- 5.1 cells/high-power field versus 51.8 +/- 6.8 cells/high-power field; p < 0.001), and improved epithelial regeneration (4.0 +/- 0.6 cell layers versus 1.7 +/- 0.5 cell layers; p < 0.001) when compared with animals treated with water irrigation. No difference was detected in peak pH (10.35 +/- 0.28 pH versus 10.36 +/- 0.25 pH; p = 0.47) nor in rise of skin temperature (maximum temperature, 32.8 degrees C versus 32.9 degrees C; p = 0.33) between acetic acid-neutralized and water-irrigated burn wounds. The observed benefits of treating alkaline burns with 5% acetic acid in the rat model are significant and require clinical testing.

Psychological sequelae of failed scalp replantation.

Published reports of avulsed scalp replant attempts have been promising. Numerous case reports and published series have demonstrated a greater than 90 percent replantation success rate. However, there exists a paucity of articles on the management of patients following failed scalp replantation attempts. The authors recognize numerous stressors that affect these patients, including the inciting traumatic event, hospitalizations, multiple surgical interventions, postsurgical therapies, and disfigurement caused by non–hair-bearing scalp. Thus, as part of the medical management for scalp replant patients, one must address the psychological factors surrounding the medical management. Over the past 25 years, the authors have experienced four cases of scalp replant failures, each posing an opportunity to examine the postoperative course of these patients. Symptoms ranging from mild anxiety to depressive symptoms have been observed in all of these patients. In fact, patient symptoms often satisfied the criteria for major depressive disorder or posttraumatic stress disorder. The authors recognize the importance of informing patients and their families of the immediate and potential long-term complications following an unsuccessful scalp replant attempt. The authors advise that all patients be provided immediate psychiatric evaluation and, if necessary, counseling and medication therapy, regardless of scalp replantation outcome.

A Comparison of Two Different 2400 mOsm Solutions for Resuscitation of Major Burns

The reduction of burn edema is a common goal in the resuscitation of patients with thermal injury. Initial infusion of a 2400 mOsm hypertonic 7.5% NaCl 6% dextran (HSD) has been shown to reduce volume needs, but elevated serum sodium levels limit the dose that can be safely used. This study tested the hypothesis that a 2400 mOsm solution of NaCl, amino acids, glucose, and 6% dextran (Isosal-D) would reduce similar volume requirements while maintaining normal plasma sodium levels. Hemodynamics, plasma sodium, fluid balance, and tissue water content were measured after an initial baseline period and during resuscitation of a large scald injury in 21 anesthetized sheep. Resuscitation was begun 30 minutes after the scald with infusion of 10 ml/kg of either lactated Ringers (LR), Isosal-D, or HSD and was continued with LR to restore and maintain baseline oxygen delivery throughout the 8-hour period. Oxygen delivery, cardiac output, and mean arterial pressure were rapidly reestablished by all three solutions, although a persistent tachycardia was noted with Isosal-D. Net fluid requirements of both HSD (35 +/- 13 ml/kg) and Isosal-D (72 +/- 13 ml/kg) were significantly lower than in the LR group (203 +/- 39 ml/kg). Mean serum sodium increased 11 mEq with HSD to a peak after 4 hours of 152 +/- 5 mEq, whereas with LR sodium fell 7 mEq to 132 +/- 4. Isosal-treated animals had minimal change in serum sodium. HSD significantly decreased tissue water content in colon, liver, pancreas, and nonburned skin compared with LR, whereas Isosal-D reduced edema only in the colon. It is concluded that in this protocol Isosal-D was not as effective as HSD at reducing volume needs and edema and had unexpected chronotropic effects.

The use of a modified Dakin's solution (sodium hypochlorite) in the treatment of Vibrio vulnificus infection

We report the first clinical use of a modified Dakins solution (0.025% sodium hypochlorite [NaOCl]) to halt the progress of severe cutaneous Vibrio vulnificus infection in a critically ill patient. The regimen used arose from an initial in vitro study designed to examine the sensitivity of Vibrio species to topical antimicrobial agents. Twenty-eight wound isolates were tested against the following eight topical preparations: silver sulfadiazine (Silvadene), nitrofurazone, mupirocin ointment (Bactroban), polymyxin B/bacitracin, mafenide acetate (Sulfamylon), nystatin/Silvadene, nystatin/polymyxin B/bacitracin, and 0.025% NaOCl solution. The results showed that V vulnificus, along with the other 18 Vibrio species tested, was most sensitive to the modified NaOCl solution.