Therapeutic and financial outcomes using a pulsating low-air-loss surface for patients surviving severe posterior burns.

Patients with posterior burns require extensive stays in the intensive care unit for recovery. The authors hypothesized that pulsating low-air-loss therapy would decrease the intensive care unit length of stay for burn patients, resulting in a potentially significant reduction in charges to payors. Eighty-one posterior burn patients enrolled in the primary study were randomly assigned to a pulsating low-air-loss surface (study group) or a nonpulsating low-air-loss surface (control group). The 54 survivors in this analysis (the secondary study) were well matched for age, pre-existing conditions, and total body surface area burned. Average intensive care unit length of stay was less for the study patients compared with the control patients--40 days versus 64 days (P < .05). Control patients used specialty surfaces for 49 days and study patients used them for 38 days. Based on a daily intensive care unit charge of $1,000 and the average daily specialty surface rental charge, the study patients averaged potential charges of under $44,000 in comparison to more than $67,000 for control patients. These data suggest that treatment of posterior burns with pulsating low-air-loss therapy may be of great clinical and financial benefit, decreasing the intensive care unit length of stay and potentially contributing to reduced charges to payors.

Burns due to aerosol can explosions.

This report describes one burn service's experience with burn injuries sustained by 18 patients over a 5-year period as a result of the explosion of pressurized aerosol cans. The burns were predominantly superficial flash burns and involved from 5 to 45 per cent of the body surface area. There were no deaths in the series. Heightened public awareness of the fire and explosive hazards of these cans, as well as a more prominent warning label on the can should aid in decreasing the incidence of these injuries.

Fatal toxic epidermal necrolysis related to lamotrigine administration.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are severe life-threatening dermatologic conditions. To date, eight cases of TEN and one of SJS related to lamotrigine administration have been reported in the literature. Most patients were also taking concomitant valproic acid. It was hypothesized that valproic acid may interfere with glucuronidation of lamotrigine, leading to increased serum lamotrigine levels, or perhaps alter the drug's metabolism, resulting in accumulation of a toxic intermediate metabolite. Ultimately, this may possibly predispose a patient to increased dermatologic reactions, including TEN. A 54-year-old man developed TEN 4 weeks after beginning lamotrigine for complex partial seizures related to a glioblastoma multiforme brain tumor. The patient had also been taking concomitant allopurinol and captopril for more than 4 years with no complications, and valproic acid 3 months before the cutaneous event. Despite aggressive intensive care management, the patient died 17 days from the onset of symptoms due to multiple organ failure. Administration of lamotrigine, especially in combination with valproic acid, may lead to the development of TEN.

Treatment of toxic epidermal necrolysis in a burn center.

The toxic epidermal necrolysis syndrome (TENS) is one of several clinically similar severe acute exfoliative skin disorders which have become of increasing interest to burn surgeons in recent years. Recognition of a clinical course similar to extensive second-degree burns has resulted in the development of treatment protocols which are best carried out in a burn unit by personnel experienced in critical care techniques, the management of major fluid and electrolyte derangements, the intensive nutritional support of critically ill patients, and the management of extensive cutaneous injuries with ready access to biologic wound dressings (homografts, xenografts). Current evidence suggests that TENS is a CD8 lymphocyte mediated reaction triggered by exposure to certain drugs in most instances. The target organs of the immune reaction are skin and mucus membranes. Treatment in burn units appears to have contributed significantly to the increasing survival of patients with this devastating and potentially lethal illness.

Experience with toxic epidermal necrolysis treated in a burn center.

Toxic epidermal necrolysis syndrome is one of several clinically similar, severe acute, exfoliative skin disorders that have become of increasing interest to burn surgeons in recent years. Recognition of a clinical course similar to extensive second-degree burns has resulted in the development of treatment protocols that are best carried out in a burn unit by personnel experienced in critical care techniques, the management of extensive cutaneous injuries, fluid and electrolyte derangements, and intensive nutritional support of critically ill patients. Current evidence suggests that in most instances toxic epidermal necrolysis syndrome is a CD8 lymphocyte-mediated reaction triggered by exposure to certain drugs. The target organs of the immune reaction are skin and mucous membranes. Appropriate management of the extensive skin wounds and the nutritional and critical care support afforded by treatment in burn units appears to have contributed significantly to the increasing survival of patients with this devastating and potentially lethal illness.

Application of American College of Surgeons' field triage guidelines by pre-hospital personnel.

BACKGROUND: The American College of Surgeons' Committee on Trauma (ACSCOT) has developed field triage guidelines intended to identify seriously injured patients. Unlike the 1990 version, the 1993 revision calls for on-line medical control assistance with the triage decision for patients whose only marker of severe injury is the mechanism of their injury. We prospectively examined the application of the 1990 ACSCOT field triage guidelines to evaluate Emergency Medical Service (EMS) utilization of these guidelines and the potential effects of the 1993 revision. STUDY DESIGN: Emergency Medical Service personnel identified all ACSCOT criteria applicable to patients delivered to the level 1 trauma center at the Medical University of South Carolina. Trauma registry data were used to compare actual injury severity with applicable indicators. Patients with an injury severity score greater than or equal to 16 were considered seriously injured. The South Carolina state trauma and EMS databases were queried to estimate systemwide overtriage and undertriage rates. RESULTS: Questionnaires were completed for 753 patients over 19 months of study. One hundred twenty-two patients had serious injuries. The estimated systemwide overtriage and undertriage rates were 2.7 and 20.3 percent, respectively. Physiologic criteria had a 64.8 percent sensitivity and a 41.8 percent positive predictive value (PPV). The addition of anatomic criteria increased sensitivity to 82.8 percent and decreased PPV to 26.9 percent. Adding mechanism of injury increased sensitivity to 95.1 percent but further reduced PPV to 18.2 percent. Review of EMS records suggests that the addition of on-line medical control for patients in whom only the mechanism of injury triage guidelines apply could improve PPV with little effect on sensitivity. CONCLUSIONS: The current ACSCOT field triage guidelines are appropriate when applied by field EMS personnel.

The diagnosis and management of primary hyperparathyroidism.

Primary hyperparathyroidism is being diagnosed with increasing frequency in recent years due to more widespread availability and reliability of the various appropriate diagnostic tests. Except in unusual circumstances patients with documented primary hyperparathyroidism are probably best served by early operation performed by an experienced parathyroid surgeon. Under such circumstances cure rate should approximate 95 percent, with less than a one percent incidence of recurrent laryngeal nerve injury or permanent hypoparathyroidism. The cure rate in the currently reported series of cases was 98 percent with no instances of recurrent laryngeal nerve injury or permanent hypoparathyroidism.

Application of field triage guidelines by pre-hospital personnel: is mechanism of injury a valid guideline for patient triage?

We prospectively investigated the appropriateness of Mechanism of Injury as an exclusive indicator for trauma center triage. For all patients transported to our level 1 trauma center, EMS personnel identified applicable American College of Surgeons' Committee on Trauma field triage guidelines. A total of 112 questionnaires were completed. Mechanism of injury was the only reason for trauma center transport in 29. Neither intubation nor emergent surgery was required in any of these patients, and all survived. Only two had an ISS > 15. The remaining 83 patients had an 11% mortality rate. Fourteen (16.9%) had ISS scores > 15. Defining an ISS of 16 or greater as severe injury, mechanism of injury alone had a positive predictive value of only 6.9%. Mechanism of injury may not, by itself, justify bypass of local hospitals in favor of trauma centers.

Ofloxacin versus cephalexin for treating skin and soft tissue infections.

Patients with acute localized skin or soft tissue infections were randomized to receive either ofloxacin (300 mg orally, b.i.d.) or cephalexin (500 mg orally, b.i.d.). Among 401 enrolled patients, 382 were evaluable for safety and 148 for microbiologic response. Microbiologic cure occurred in 93.4% of ofloxacin-treated patients and in 94.0% of those treated with cephalexin. Clinical cure or improvement, respectively, was found in 85.2% and 11.1% of patients treated with ofloxacin, and 83.6% and 14.9% of patients receiving cephalexin. Adverse effects (primarily associated with the gastrointestinal tract and central nervous system) were considered to be drug-related in 7.9% of those receiving ofloxacin and 4.8% of those receiving cephalexin. Thus, ofloxacin is as effective and well tolerated as cephalexin and a good alternate antibiotic for treating skin and skin structure infections caused by a variety of pathogens.

Ofloxacin versus cephalexin in the treatment of skin, skin structure, and soft-tissue infections in adults.

A multicenter study was conducted to compare the safety and efficacy of oral ofloxacin with that of cephalexin in microbiologic eradication of skin and skin-structure pathogens and the clinical treatment of skin and skin-structure infections. The subjects, 335 adult patients with acute localized infections of the skin, skin structure, or soft tissue, were randomly assigned to receive 400 mg of ofloxacin orally every 12 hours or 500 mg of cephalexin orally every six hours for 10 days. At admission, 398 aerobic pathogens were isolated, the most common being Staphylococcus aureus (160 isolates), Streptococcus pyogenes (49), coagulase-negative staphylococci (30), Staphylococcus epidermidis (25), and Pseudomonas aeruginosa (10). Of 317 isolates tested against ofloxacin, 96% were susceptible, and of 325 tested against cephalexin, 85% were susceptible (P less than 0.001). Microbiologic and clinical outcome were evaluated in 73 ofloxacin-treated patients and in 65 cephalexin-treated patients. The causative pathogens were eradicated in 95% of the ofloxacin group and in 92% of the cephalexin group. In the ofloxacin group, 75% were clinically cured and 23% improved, and in the cephalexin group, 74% and 23%, respectively. Drug-related adverse experiences were reported by 14% of the 161 ofloxacin-treated patients and by 11% of the 162 cephalexin-treated patients; gastrointestinal disturbances were reported by 8% and 7% and nervous system effects by 6% and 1%, respectively (P less than 0.05). It is concluded that both ofloxacin and cephalexin are safe and effective in the treatment of skin and soft-tissue infections.

Improving survival in the burned patient.

Improving survival of burned patients has been reported by the majority of burn units over the past decade. Although many sophisticated studies have attempted to delineate the major factors responsible for this improvement, no single factor has emerged as being clearly dominant. On the MUSC burn service, increased survival has been particularly apparent in patients with burns involving 50-90% of the BSA. Little improvement in survival has yet been noted in patients with burns involving more than 90% of the BSA. We are convinced that general improvements in topical antimicrobials, antibiotics, techniques of critical care, improved wound care techniques and, very importantly, maintenance of the patient's nutritional status are all critical factors in improving survival in the burned patient. Attributing the increased survival of burned patients to any one of these factors alone currently does not seem to be clearly supported by data reported in the literature nor by our own experience. It is to be hoped that as the quality of skin substitutes and techniques of culturing skin improve, inroads into the extremely high mortality of burns involving more than 90% of the BSA can be made. The MUSC burn service is currently investigating the place of aggressive early burn wound excision and grafting with cultured epithelial autografts in achieving this goal.

Resuscitative thoracotomy: the effect of field time on outcome.

In the past 5 years, 72 moribund patients have undergone resuscitative thoracotomy (RT) at the Medical University of South Carolina: 62 patients underwent the procedure before the adoption of a policy of mandatory rapid transport (scoop and run) for penetrating and unstable victims of trauma by our EMS system (Group I). Group II is comprised of ten patients who underwent RT following adoption of this policy. Resuscitation was successful in three patients in Group I (4.8%) and there were only two survivors (3.2%). In contrast, resuscitation was successful in two of ten patients in Group II (20%) and there was one survivor (10%). Nineteen patients in Group I (31%) were in traumatic full arrest on the scene, all of whom died. Twenty-five patients in Group I (40%) had a measureable pulse and/or blood pressure when EMS personnel arrived at the scene and subsequently "died" before their arrival at the trauma center. RT was also uniformly unsuccessful in this subgroup. Eighteen patients in Group I (29%) suffered cardiac arrest following their arrival at the hospital. Three of these patients (16.6%) were successfully resuscitated and two (11%) survived to leave the hospital. There were four traumatic full arrests in Group II (40%) and all four died. Only two patients in Group II (20%) lost their vital signs in transport and both died. Four patients in Group II (40%) suffered cardiac arrest after arrival at the hospital. Two of these patients (50%) were successfully resuscitated and one left the hospital (25%).(ABSTRACT TRUNCATED AT 250 WORDS)

Pharyngoesophageal diverticula.

We reviewed 17 cases of pharyngoesophageal diverticula treated at the Medical University of South Carolina during the period 1955 to 1979. Of these 17 patients, 13 had primary excision of the diverticulum, with no deaths, one recurrence, and two significant complications. One patient with a perforated diverticulum died after simple drainage. The average age of the patients was 68, with a range of 40 to 83 years. The indicence of concurrent serious disease was quite high. We conclude that primary diverticulectomy is the current treatment of choice and is the standard against which other surgical technics must be measured. The place of cricopharyngotomy deserves further evaluation.

Heat injuries among recreational runners.

With the increasing popularity of jogging and competitive running, more people are participating in races, particularly during the warm months. In the Southeastern United States, the combination of high temperatures and high relative humidity appears to be responsible for many heat-associated injuries. We studied the training, racing, and selected personal characteristics of heat-injured and age- and sex-matched uninjured recreational runners at four races. The major differences between the two groups were that injured runners had not been running as long, ran fewer miles per week, ran fewer miles per training run, and were more likely to be caught up in the excitement of the event.