Terry A. Housinger

A prospective study of blood loss with excisional therapy in pediatric burn patients

Major blood loss occurs with excisional therapy of burns. To our knowledge no studies have quantitated blood loss in pediatric patients. This prospective study was performed to analyze blood loss in a pediatric burn population undergoing excision and grafting. Forty-four patients underwent 50 two-stage procedures. Blood loss was determined based on calculations of red cells administered in conjunction with estimates of total circulating red cell numbers. Results showed a mean value (+/- SEM) of 2.8% +/- 0.23% of circulating volume lost as a percentage of total body surface area (TBSA) excised, whereas 1.8% +/- 0.18% of circulating volume was lost as a percentage of TBSA grafted. Assessment of losses by age and depth of wound, patient age, and anatomic site showed no differences between these groups. Tourniquets lowered intraoperative losses but had no effect on overall losses. The value of knowing blood losses precisely is evaluated in terms of efficiency of ordering blood.

A prospective study of myocardial damage in electrical injuries.

A prospective study was undertaken to determine the incidence of possible myocardial damage following electrical injury. Sixteen patients with non-flash electrical injuries were assessed utilizing serial electrocardiograms (ECG), creatine kinase (CK) and MB creatinine kinase (MB-CK) determinations, technetium 99m stannous pyrophosphate scans, and 24-hour Holter monitors. Results showed that five patients (31%) had abnormal ECG, nine patients (56%) had elevations of the MB-CK isoenzyme, and one patient had a transiently abnormal Holter monitoring. No patient had an abnormal technetium pyrophosphate cardiac scan. Of the nine patients with elevated MB-CK levels, only two had abnormal ECG. None of the patients had clinical evidence of cardiac dysfunction. These results indicate a poor correlation of elevated MB-CK levels with ECG abnormalities, and demonstrate a relatively low incidence of myocardial damage in association with electrical injuries.

Conservative approach to the elderly patient with burns

A retrospective analysis of 55 elderly patients (more than 60 years of age) was undertaken to compare results of conservative management to standard operative treatment. Thirty-one percent of the patients died early from their injury. Twenty-three patients were treated without operation, with emphasis on careful outpatient wound care and physical therapy. The remaining 15 patients required excision and grafting of burn wounds or amputation. Conservatively managed patients had fewer complications, a shorter hospital stay, and functional results equal to the operative group. These results suggest that many elderly burn patients can be managed without operation with good outcome and lessened morbidity.

Management of Pediatrie Facial Burns

The acute management of pediatric facial burns is not uniform. Many surgeons prefer to wait until primary wound separation occurs before grafting. Concerns over early excision are accentuated in small pediatric patients. The possible benefits of early excision results have led to adoption of this technique at our facility. This study presents our recent experience with early excision and grafting. Sixty-six patients with a mean age of 6.2 years underwent early excision and grafting of facial burns. Patients underwent grafting a mean 12.7 days after burn. Procedures were done in two stages. All grafts were dressed open. There were no episodes of acute airway decompensation. No patient required regrafting. Patients wore pressure masks a mean of 15.5 months after grafting. Thirteen patients had releases (10 eyelids, three lips/commissures) in the first postoperative year. These results demonstrate that early excision and grafting of facial burns can be carried out safely in pediatric patients with burns. The benefits of early wound coverage can thus be applied to facial burns in this population of patients.

The use of Biobrane for coverage of the pediatric donor site.

Donor site dressings are highly diverse. The ultimate goal of any coverage is to minimize pain and healing time. Recently, synthetic laminates have become popular. Experience with Biobrane has mainly been with adult patients. This study examines the use of Biobrane in a pediatric population. One hundred eight consecutive applications of Biobrane in 95 patients (mean age 7.9 years) were reviewed. All applications were treated in identical fashion. Biobrane was left in place until healing occurred unless primary nonadherence occurred or fluid collections developed over a significant area, rendering the area nonadherent. Forty-three early removals of Biobrane were necessary at a mean of 3 1/2 days after application. The back and hip regions, with 43% and 80% early removal rates, respectively, were the areas where Biobrane was least successful in providing donor coverage until the site healed. The chest and thigh had successful full-term coverage in greater than 90% of cases. The principal basis for early removal was fluid accumulation, which reduced adherence. Early removal did not affect the healing time of the donor site. These results demonstrate a modest effectiveness of Biobrane as a donor site dressing on the back and hip regions in pediatric patients with burns. Selection of sites for which good success can be expected should be paramount in the decision to use this donor site material in this patient population.

Management of burns of the penis

Burns of the penis can be physically and psychologically devastating. This is particularly true in young pediatric patients who have to content with growth as well as with the trials of adolescence and the development of self-image. Little has been written on the grafting management of these injuries. This report reviews a management technique used with great success. Ten patients who sustained full-thickness penis burns were reviewed. The grafting technique consisted of excision and grafting with sheet grafts in a one- or two-stage setting. After grafting, the penis was placed in traction with a weighted Foley catheter. Grafts were left open or stented. No complications occurred from the traction apparatus, and graft take was uniformly excellent. Short-term results have been excellent, and no urethral problems have developed over a median 3-year follow-up. This technique appears to provide excellent means of supporting the penis to accomplish superb graft take in this hard-to-manage area.

Ordering of laboratory work in the management of pediatric burn patients: technical note.

A large number of laboratory tests are often ordered in the management of acutely burned patients. Administration of large volumes of fluid and frequent ventilator changes prompt many facilities to utilize ordering protocols. Forty-five consecutive acutely burned pediatric patients with burns measuring 25% or more of total body surface area (TBSA) sustained within 24 hours before admission were reviewed. Laboratory determinations were made at each shift and as indicated by changes in condition. Abnormal or critical values during the first 5 postinjury days were identified for electrolytes, renal function indices, complete blood counts (CBCs), glucose, and arterial blood gas (ABG) levels. Blood drawn for the laboratory tests was also measured. In the first 5 days postburn a total of 8303 laboratory determinations were made. Of these, 186 produced abnormal values. Four were critical values that were not expected from previous determinations. Of the four unexpected critical values obtained, two would have been picked up by our present standard noninvasive monitors. Six percent of estimated blood volume was used to perform laboratory tests. These results demonstrate that significant abnormal laboratory values are uncommon even in severely injured pediatric burn patients and that the ordering of these tests should be individualized based on patient examination and the use of noninvasive monitoring.