Because of their extensive wounds, burn patients are chronically exposed to inflammatory mediators. Thus, burn patients, by definition, already have "systemic inflammatory response syndrome." Current ...definitions for sepsis and infection have many criteria (fever, tachycardia, tachypnea, leukocytosis) that are routinely found in patients with extensive burns, making these current definitions less applicable to the burn population. Experts in burn care and research, all members of the American Burn Association, were asked to review the literature and prepare a potential definition on one topic related to sepsis or infection in burn patients. On January 20, 2007, the participants met in Tucson, Arizona to develop consensus for these definitions. After review of the definitions, a summary of the proceedings was prepared. The goal of the consensus conference was to develop and publish standardized definitions for sepsis and infection-related diagnoses in the burn population. Standardized definitions will improve the capability of performing more meaningful multicenter trials among burn centers.
Amputations are common after severe frostbite injuries, often mediated by postinjury arterial thrombosis. Since 1994, the authors have performed angiography to identify perfusion deficits in severely ...frostbitten digits and treated these lesions with intraarterial infusion of thrombolytic agents, usually combined with papaverine to reduce vasospasm. A retrospective review was performed of patients admitted to the regional burn center with frostbite injury from 1994 to 2007. Patients with severe frostbite, without contraindications to thrombolytic therapy, underwent diagnostic angiography of the affected extremities. Limbs with perfusion defects received intraarterial thrombolytic therapy according to protocol and the response was documented. Delayed amputation was performed for mummified digits. Angiogram results and amputation rates were tabulated. In this 14-year review, 114 patients were admitted for frostbite injuries. There was a male predominance (84%) and the mean age was 40.4 years. Of this group, 69 patients with severe frostbite underwent angiography; 66 were treated with intraarterial thrombolytic therapy. Four treated were excluded due to incomplete data. In the remaining 62 patients, angiography identified 472 digits with frostbite injury and impaired arterial perfusion. At the termination of thrombolytic infusion, a completion angiogram was performed. Partial or complete amputations were performed on only four of 198 digits (2.0%) with distal vascular blush, and in 71 of 75 digits (94.7%) with no improvement. Amputations occurred in 73 of 199 digits (36.7%) with partially restored flow. Overall complete digit salvage rate was 68.6%. Angiography after severe frostbite is a sensitive method to detect impaired arterial blood flow and permits catheter-directed treatment with thrombolytic agents. Improved perfusion after such treatment decreases late amputations following frostbite injury.
Cold injury Mohr, Wm J; Jenabzadeh, Kamrun; Ahrenholz, David H
Hand clinics,
11/2009, Letnik:
25, Številka:
4
Journal Article
Recenzirano
The pathophysiology of true frostbite reveals that the direct injury produced during the initial freeze process has a minor contribution to the global tissue damage. However, rapid rewarming to ...reverse the tissue crystallization has essentially been the lone frostbite intervention for almost half a century. The major pathologic process is the progressive microvascular thrombosis following reperfusion of the ischemic limb, with the cold-damaged endothelial cells playing a central role in the outcome of these frozen tissues. Newer interventions offer the opportunity to combat this process, and this article offers a scientific approach to frostbite injuries of the upper extremities.
Hidradenitis suppurativa (HS) is a chronic debilitating disease of apocrine gland-bearing skin characterized by recurrent abscesses with subsequent rupture, scarring, and draining sinus tracts, most ...frequently affecting the axillary, inguinal, and anogenital regions. Conservative and temporizing treatment methods have been used to treat mild to moderate disease, but wide local excision of affected tissue is necessary for advanced disease. This creates a large soft tissue defect for which there is no consensus for reconstruction. Recovery is hampered by disease recurrence, tissue necrosis, and reoperation. The authors have described in this case study an alternative surgical approach to treat severe HS. All surgical procedures were performed by dedicated burn surgeons at a regional burn center using a two-stage surgical approach. The first stage is a wide local excision of all affected axillary tissue with immediate placement of a bilayer dermal regeneration template to cover the defect. This is secured with a negative pressure wound therapy dressing. The second stage uses a thin split thickness skin graft to close the wound. Results of four patients are presented. There were no recurrences of HS. Two patients required reoperations to address granulation tissue overgrowth and small areas of autograft loss. One patient experienced skin substitute loss as a result of infection. Inadequate excision of HS is the leading cause of disease recurrence. Using a bilayer dermal regeneration template with subsequent skin graft, surgeons can be aggressive in their excision of HS, achieving satisfactory functional and cosmetic results and minimizing axillary recurrence.
In recent years, Burn Center has evolved to become a "wound intensive care unit" treating disease processes other than those due to thermal injury. Recent data have shown that more than 16% of ...admissions to Burn Centers are for nonburn injuries, particularly severe dermatologic diseases. The role of the Burn Center has been expanded to include treatment of patients with severe cutaneous manifestations of rheumatologic diseases. This approach has not been described before. All collagen vascular disease admissions to the Burn Center from 2005 to 2010 have been reviewed. There were 16 admissions where intensive wound management was a major component of the disease management. Disease processes included systemic lupus erythematosus, progressive systemic sclerosis, Raynaud's phenomenon, antiphospholipid syndrome, and dermatomyositis, among others. The authors describe five of these cases in detail. Comanagement of these patients by the Rheumatology and Burn services led to outstanding, successful outcomes. Collagen vascular diseases represent another area where the Burn Center may be the appropriate site for therapy.
Regional burn centers provide unique multidisciplinary care that has been associated with dramatically improved outcomes for burn victims. Patients with complex skin and soft tissue injuries are ...increasingly admitted to these centers for definitive care. This study was designed to assess current trends in burn center resource utilization. Members of the Multicenter Trials Group of American Burn Association were invited to participate in this retrospective review of all patients admitted to their respective regional burn centers during a 10-year period. Collected data included admission diagnosis, demographics, length of stay (LOS), hospital charges, and mortality. Five regional academic burn centers participated. They collectively admitted 18,246 patients during the study period, of whom 15,219 (83.4%) had a primary burn diagnosis and 3027 (16.6%) were patients with nonburn diagnoses. During this period, annual admissions for the five centers increased by 34.7%, ranging from 19 to 83% for individual centers. Simultaneously, mean burn size decreased from 12.3 to 8.8% TBSA. From 1998 to 2006, admissions for nonburn diagnoses increased by 244.9%, whereas burn admissions increased by 31.1%. Although mean LOS was reduced by >25%, total charges for all patients increased by 37.7% after adjustment for inflation. Nonburn patients had significantly higher mean age, longer LOS, greater mortality, and higher daily charges. This review of admissions to five academic burn centers reveals that these centers are treating more patients with smaller burns and an increasing number of complex nonburn conditions. Nonburn patients represent an older and more debilitated population that consumes disproportionately more resources than burn patients. These data show a dramatic shift in burn center resource utilization and the concurrent evolution of regional burn centers into centers for the care of complex wounds.
Nicolau's syndrome, also called embolica cutis medicamentosa, is characterized by well- circumscribed livedoid dermatitis with aseptic necrosis after intramuscular injection. We report the case of a ...45-year-old woman with severe necrosis of the thigh several days after a routine intramuscular injection of hydroxyzine who was transferred to and treated at our Regional Burn Center. Although there has been one case report and numerous voluntarily reported instances of intramuscular hydroxyzine-induced necrosis to the Food and Drug Administration Spontaneous Reporting System, this phenomenon is rare.
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