Prospective clinical study of Hydron, a synthetic dressing, in delivery of an antimicrobial drug to second-degree burns.

This clinical trial prospectively evaluates the potential beneficial effects of antimicrobial drug delivery from a synthetic dressing (Hydron-AgSD) formed on second-degree burn wounds. A paste composed of polyethylene glycol-400, poly 2-OH ethylmethacrylate, and silver sulfadiazine (AgSD 1%-3%) matured within one hour to form a solid dressing. In 27 patients, comparable areas of second-degree wounds on the same patient were selected at random for test and control (silver sulfadiazine 1% only) sites. The mean total time of the synthetic dressing application per patient was about nine days, and each dressing remained in place for nearly four days. During this interval the control sites required four dressings changes. In 17 tests for infections, the control areas were contaminated but no bacteria were detected under the synthetic dressing; in three tests, the controls had no bacteria, whereas the synthetic dressing did. Healing of burns was similar under both types of dressing. Benefits of Hydron treatment included increased patient comfort because of the reduced number of dressing changes and, in some cases, greater freedom from contaminating bacteria.

Biosynthetic skin substitute versus frozen human cadaver allograft for temporary coverage of excised burn wounds.

During the past 2 years a multicenter study was performed comparing Biobrane (Woodroof) and frozen cadaver allograft as temporary dressings on freshly excised full-thickness burns before the application of autograft. Each biologic dressing was evaluated with respect to the other on the same patient. Seventy-one patients were evaluated. The mean burn size was 35 +/- 20% with a mean full-thickness burn of 28 +/- 20%. Mean patient age was 34 +/- 21 years. Overall survival was 82%. The mean time of wound coverage was 10.2 +/- 6.7 days. There was no significant difference in the number of dressing changes, area changed, purulence, autograft take, and final results between allograft- and Biobrane-covered sites. There were no complications following use of either Biobrane or allograft. We conclude that Biobrane is as effective as frozen human cadaver allograft for the temporary coverage of freshly excised full-thickness burn wounds before autografting.

Ecthyma gangrenosum in a burned child.

The history of ecthyma gangrenosum has been presented, as well as its pathological diagnosis, prognosis and natural history. The history of forms of treatment has been outlined and the grave prognosis is emphasized. A case presentation introduces the experience at the Cincinnati Shriners Burns Institute. From a review of the literature and the experience at the Shriners Burns Institute, a suggestion for optimal treatment has been proposed. The particulars of this treatment include: early recognition, general nutritional and metabolic support, as well as high-dose aminoglycoside and semi-synthetic penicillin therapy, administered parentally and by sub-eschar clysis. Despite the grave prognosis, attention to these factors should result in optimal survival of patients with ecthyma gangrenosum.

An evaluation of Aquaphor Gauze dressing in burned children.

Aquaphor Gauze was evaluated as a dressing for skin graft donor sites, for partial thickness burn injuries and for split thickness skin grafts. Control dressings consisted of: fine mesh gauze for skin graft donor sites. silver sulphadiazine (Silvadene) on coarse mesh gauze for the partial thickness burns, and nitrofurazone cream (Furacin) on fine mesh gauze for the skin grafts. The Aquaphor Gauze was found to be inferior to the fine mesh gauze for donor site dressings. No statistically significant difference was identified between Aquaphor Gauze and controls for the treatment of partial thickness burns. As a dressing for skin grafts the Aquaphor Gauze was significantly superior to the control dressing as measured by graft take and reduced patient pain. We would recommend that Aquaphor Gauze be used as a dressing for skin grafts where the risk of infection is not excessive.

Failure of topical steroids and vitamin E to reduce postoperative scar formation following reconstructive surgery.

One hundred fifty-nine operative procedures for postburn contractures of interdigital webs (96), the axilla (46), or the neck (17) were prospectively randomized to be treated postoperatively for four months with a topical steroid (Aristocort A), topical vitamin E, or the base cream carrier for these drugs. The nature of the medication was blinded both to the patient and to the evaluator. Patients were followed for one year. Observations were made for range of motion, scar thickness, change in graft size, and ultimate cosmetic appearance. No beneficial effect of either vitamin E or topical steroid could be demonstrated. However, adverse reactions occurred in 16.4% of patients receiving active drug, compared to 5.9% treated only with base cream. Interestingly, the grafts initially contracted and subsequently grew to be a size larger (about 20%) than the original graft by one year. It is concluded that neither topical steroid nor topical vitamin E is effective in reducing scar formation after grafting procedures for reconstruction for postburn contractures.

Regeneration of full layer necrosis of the skull following high voltage electrical injury.

Scalp and skull necrosis often follow high voltage electrical injury to the head. Classically reconstruction of the scalp and skull is performed after sequestration of the necrotic bone. The relatively frequent complication of epidural infection, however, detracts from this approach. As an alternative we have attempted to induce regeneration of devitalized bone by covering it with a vascular tissue flap. A typical patient is described in this report with results which indicate that at least partial regeneration of the necrotic tissue can occur, thus one-stage management of such wounds is possible.

Surgical treatment of elbow contractures in postburn children.

One-hundred and forty-six postburn elbow contractures in children were classified into four categories--simple band, complex band (crosses shoulder and/or wrist joint), diffuse scar, and limited scar--to assess the results of surgical treatment. The best results were seen in children less than 5 years of age and in children with less than 50 percent third-degree total body surface area burns. Types of release included skin grafts, local flaps (with or without graft), and deep releases. Generally, good to excellent results were seen regardless of technique of release, and in no case was the postoperative contracture worse than the preoperative contracture. Full extension was restored in 82 percent of contractures that were less than 50 degrees and in 50 percent of contractures greater than 50 degrees. Major complications were uncommon, with 4 of 171 elbows requiring reoperation because of skin-graft or flap loss. Repeat releases were of minimal functional benefit.

Acute upper airway obstruction in the postburn period.

Upper airway obstruction in the severely burned patient is a well-known problem that is due to mucosal edema secondary to the effects of toxic substances and heat on the laryngeal and tracheal mucosa. Herein, we report a different cause of airway obstruction seen in the late postburn period during the induction of anesthesia for reconstructive procedures. This obstruction is due to the presence of severe burn-scar contractures of the neck that prevent successful endotracheal intubation. We have seen this occur 17 times in 13 patients. All of the patients were successfully treated by an emergency neck release, after which most of the patients could be intubated and the release then skin grafted. Surgeons operating on patients with scar contractures of the neck should be aware of this condition and its appropriate treatment.

Role of escharotomy and fasciotomy as a first aid measure in the early treatment of an electrically burned arm and wrist.

The saving of the hand and forearm of a patient with a deep circumferential electrical burn of the wrist and forearm following contact with 10 000 V AC demonstrates the important role played by escharotomy and fasciotomy in the early treatment of electrically injured extremities.

Early vascular grafting to prevent upper extremity necrosis after electrical burns. Commentary on indications for surgery.

Early vascular grafting is the only effective form of treatment for electrical burns of the wrist which are severe enough to impair blood flow to the hand. Failure to appreciate the significance of early changes in blood flow and to take prompt appropriate action may result in the irreversible loss of blood supply and subsequent amputation. This report analyses the problems encountered in six patients where the early signs of impaired blood flow were not appreciated and amputations were subsequently required.

Classification and management of burned thumb contractures in children.

Based on the position of the thumb metacarpal, 102 burned thumb contractures in children were classified into four categories: adduction, opposition, extension and flexion. The contractures were further classified as mild, moderate or severe, based on the amount of motion lost. All thumbs were surgically released. Coverage was obtained with local flaps or Z-plasties, skin grafts or a combination of local flaps and skin grafts. Factors influencing the results were as follows: Classification category: Extension contractures generally did poorly, whereas flexion contractures did well. Severity of contracture: The more severe the contracture, the worse the final results. Complexity of contracture: Contractures with a subluxated or dislocated joint did not do as well as those with undisturbed bony alignment. Type of surgical release: There was a trend towards better results when skin grafts (as opposed to local flaps) were used, especially in the treatment of moderate and severe contractures.

Candida parapsilosis fungemia in burn patients: report of three cases.

Three patients with Candida parapsilosis septicemia, secondary to large burns, are reported. All patients sustained large burns with inhalation injuries and were treated with various topical antibiotics. All had sepsis with various bacterial organisms and had received treatment with systemic antibiotics prior to the development of the Candida episode. Once a positive blood culture for Candida parapsilosis was obtained, treatment was carried out with amphotericin-B. Sensitivity data indicated that this was the appropriate systemic agent. All patients recovered uneventfully after a 10-day course of amphotericin-B therapy.

Reconstruction of the burned thumb by metacarpal lengthening.

Insufficient thumb length is a major functional handicap. A technique of metacarpal distraction lengthening of a burned thumb is described. To use this technique successfully, the surgeon must be prepared to replace scar tissue and release a thumb adduction contracture.

Intraoperative brachial plexus injuries during reconstruction of the burned axilla.

Since opening of the Shriners Burns Institute, Cincinnati Unit, 501 operations for release of burn scar-related contractures of the axilla have been carried out with skin grafting. Six of these cases, 1.2%, resulted in intraoperative stretch injuries to the brachial plexus. In two cases, isolated axillary nerve involvement was encountered. In four cases, additional diffuse injury to the brachial plexus was present. Intraoperative motion and postoperative splinting in a position of abduction were believed to be possible etiological agents. Prompt removal of the splint and institution of physical therapy were carried out. In all cases, there was full return of neurologic function. Indications for surgery were preoperative limitation of abduction at the shoulder due to scar in five cases; one operation was performed for cosmetically disfiguring webbing. Final range of motion, 1 year postoperatively, was normal in all cases. Time to full recovery varied from 2 to 9 months. The importance of preventing the problem by keeping intraoperative motion to a minimum and checking neurologic function promptly in the postoperative period is stressed.

The microclimate chamber: the effect of continuous topical administration of 96% oxygen and 75% relative humidity on the healing rate of experimental deep burns.

The healing rate of small experimental burns continuously treated topically with 96% O2 and 75% relative humidity was followed for 25 days. Serial image photographic magnifications (tenfold throughout) of the wounds enabled precise measurements of their size by means of a polar planimeter. Healing rate was expressed as decreased percentile of wound size on a given day compared to the initial area. The mean percentages of healing +/- SEM of the humidified O2 treated wounds on postburn days 6, 11, and 16 were 31.25 +/- 6.15, 82.09 +/- 3.52, and 98.29 +/- 1.46, respectively, and those for the control wounds were 7.08 +/- 2.20, 47.68 +/- 3.39, and 84.41 +/- 1.38, respectively. Analysis of variance revealed highly significant differences in the healing rate between O2-humidity-treated and control wounds (p less than 0.005). The results indicate that topical treatment with 96% O2 and 75% relative humidity improved healing of experimental burns in guinea pigs.

Failure of topical prostaglandin inhibitors to improve wound healing following deep partial-thickness burns.

The present study was designed to determine the efficacy of topical inhibitors of prostaglandins on wound healing. Two uniform deep partial-thickness burns were inflicted on mirror-image areas of guinea pig backs by an aluminum template heated to 75 degrees C and applied for 10 seconds. Indomethacin was tested extensively in a wide range of concentrations in groups of six or more animals each. The healing rates measured at 21 days postburn showed that topical indomethacin at each concentration tested was not effective for improving wound healing. In fact, the treated sites were consistently worse than the control sites. Moreover, the drug adversely affected the healing process proportional to the concentration and was associated with death, which was related to perforations of the GI tract. Also, the India ink filling in the dermal microcirculation was no better in the experimental wounds than in the controls. The evaluations for hair growth were definitely in favor of the controls. The other tested inhibitors, ibuprofen, flurbiprofen, tolmetin, zomepirac, piroxicam, and dipyridamole, also failed to show any benefit.

The microclimate chamber: morphological aspects of experimental deep burns treated topically with continuous humidified oxygen.

Scanning electron and transmission electron micrographs of tissue biopsies from experimental third-degree burns treated topically with 96% oxygen for twenty-five days, without modifying the environment of the whole animal, revealed a marked promotion of collagen maturation. The O2-treated wounds showed a high ratio of collagen-ground substance; assembling of distinct fibers to form bundles with individual fibers of 1,360 +/- 95 A in diameter and an organized orientation; a highly aggregated rough endoplasmic reticulum of the fibroblasts, consisting of large cisternae and abundant ribosomes. The control burn wounds exposed to ambient air exhibited a low ratio of collagen-ground substance; a loose, rough endoplasmic reticulum; fiber diameter of 700 +/- 70 A, with haphazard orientation of the fibers; and a poor tendency to form bundles. These findings suggest that topical treatment of experimental deep burns with 96% O2 promoted collagen maturation and organization as well as collagen synthesis.

Management of the acutely burned ear.

One hundred patients with burns of the ears were reviewed. Most had second-degree burns and did well. Loss of the external ear occurred in 15 patients, or 22 ears, due to the presence of very deep burn with full thickness injury. Chondritis developed in nine ears (5 per cent) with severe destruction of the ear in 8. Pseudomonas aeruginosa is an especially destructive organism to cartilage and was associated with all our cases of chondritis. Progression of deformity and development of infection can be minimized by avoidance of pressure, regular cleansing and application of topical antibiotics. Careful debridement and skin grafting of any third-degree burn areas are required and should be carried out as soon as possible.