Building a balanced scorecard for a burn center.

The Balanced Scorecard provides a model that can be adapted to the management of any burn center, burn service or burn program. This model enables an organization to translate its mission and vision into specific strategic objectives across the four perspective: (1) the financial perspective; (2) the customer service perspective; (3) the internal business perspective; and (4) the growth and learning perspective. Once the appropriate objectives are identified, the Balanced Scorecard guides the organization to develop reasonable performance measures and establishes targets, initiatives and alternatives to meet programmatic goals and pursue longer-term visionary improvements. We used the burn center at the University of Colorado Health Sciences Center to test whether the Balanced Scorecard methodology was appropriate for the core business plan of a healthcare strategic business unit (i.e. a burn center).

WEB2170, a specific platelet-activating factor antagonist, attenuates neutrophil priming by human serum after clinical burn injury: the 1991 Moyer Award.

Primed neutrophils may contribute to endothelial and end-organ damage after burn injury because of increased endothelial adherence and enhanced toxic oxygen metabolite generation in response to a "second insult" such as bacterial sepsis. The purposes of this study were to determine: (1) whether serum from patients with thermal injury causes priming of the neutrophil NADPH:O2 oxidoreductase, (2) whether time after burn (early vs late) influences neutrophil priming, and (3) whether priming could be attenuated by a specific platelet-activating factor antagonist, WEB2170. Normal human neutrophils were incubated with 10% sera that was obtained from healthy adult controls (normal human sera) and with 10% sera from patients with greater than 30% total body surface area burns, which was collected early (early postburn sera) (i.e., between 12 and 48 hours after burn) or late (late postburn sera) (5 to 15 days, after burn). Priming of the neutrophil oxidase was tested for by measurement of the generation of superoxide anion after a stimulus of 10(-6) mol/L formyl-methionine-leucine-phenylalanine (fMLP). In separate experiments, neutrophils were pretreated with WEB2170 before serum incubation and fMLP stimulation to block any priming that may be mediated by platelet-activating factor. All sera caused an increased rate of superoxide anion production in response to fMLP and thus "primed" the neutrophil NADPH:O2 oxidoreductase. Greater priming occurred after incubation with late postburn sera than with other sera. WEB2170 completely inhibited priming by normal human sera and early postburn sera and partially inhibited priming by late postburn sera.(ABSTRACT TRUNCATED AT 250 WORDS)

Healing characteristics of expanded autografts on wounds covered with homograft and Biobrane temporary wound dressing.

This study compared the healing characteristics of expanded autografts on wounds with interstices that were closed with cryopreserved cadaver homograft split-thickness skin and wounds with interstices that were closed with the synthetic skin substitute, Biobrane temporary wound dressing. Nine paired wounds in four patients with large burns were used in this study. When Biobrane temporary wound dressing adhered to a wound, epithelial migration did not proceed until it was removed. Although wounds covered with homograft immediately had the appearance of healed wounds, biopsy specimens showed evidence of a delay in epithelial migration. Although these results indicate impaired epithelial migration with the use of both materials, we concluded that homograft offered an advantage because the wounds that were covered with it remained closed during the entire reepithelialization process.

Preservation of devitalized calvarium following high-voltage electrical injury: case reports.

Three victims of electrical injury with necrosis of a portion of the skull had excision of overlying necrotic soft tissue soon after injury with immediate coverage of the devitalized bone with soft-tissue flaps. In two instances, the flap was from adjacent scalp; in the other a free myocutaneous flap was used. All wounds healed without sequestration of bone. Necrosis of the calvarium was substantiated by evidence of nonperfusion on a radionucleotide bone scan. In each instance, a followup bone scan showed evidence of regeneration of bone. This experience supports an earlier observation which suggested that devitalized but intact calvarium following electrical injury does not need to be removed and is the perfect in situ bone graft.

Hydrofluoric acid-induced hypocalcemia.

Among patients exposed to hydrofluoric acid the potentially lethal effect of calcium depletion induced by binding with fluoride ion has not been well reported. Three patients exposed to hydrofluoric acid had acute fluoride poisoning with serum calcium levels equal to or below 4.1 mgm/dl. Treatment included administration of large amounts of calcium, both intravenously and by subsechar injection, to replenish the biologically active calcium and to bind fluoride. This report describes successful treatment of two survivors, apparently the first two, of severe hypocalcemia caused by hydrofluoric acid.

The microstomia prevention appliance: 14 years of clinical experience.

Partial- or full-thickness perioral facial burns may lead to a contracture of the tissues surrounding the oral commissures that results in microstomia. The current investigators have used the microstomia prevention appliance (MPA) exclusively in the management of commissure burns at the University of Iowa Burn Center since 1972. To assess the effectiveness of the MPA, a retrospective chart review was conducted. The study population consisted of 85 patients admitted to the center between 1974 and 1986 who had incurred burns to the perioral region or to the lower two thirds of the face. The chart analysis of 83 patients revealed that, with diligent and persistent use of the MPA, only one patient required surgical repair for the development of microstomia. The MPA has proved effective in decreasing the need for reconstructive procedures and in preventing the occurrence of microstomia.

Near-total gastric bypass for morbid obesity.

Among 50 morbidly obese patients who underwent gastric bypass, the gastric pouch was made only large enough to permit an anastomosis with the jejunum. Eighteen months after operation, the mean weight loss was 55 kg, and the mean excess weight loss was 70%. One half of the patients had less than 22.7 kg of residual excess weight. The most frequent immediate postoperative complication involved the respiratory tract (ten patients). Staple line failure in three of ten patients who had pouch construction by a single application of staples and iron deficiency anemia in six patients were the most important late complications. Near-total gastric bypass in which the pouch is constructed with two applications of staples is an effective operation for weight control and should virtually eliminate the need for revision caused by staple line failure or for a pouch that is too large.

Calcium fractions in serum of patients with thermal burns.

Total calcium measurement is less useful clinically than assay of the physiologically active fractions, free and ionized calcium. The latter were measured in burned patients by ultrafiltration and by ion-selective electrode. Hypocalcemia was observed in these patients but it was generally limited to low total calcium. On average, free or ionized calcium were in the normal range. Total and free calcium were weakly correlated with severity of burn injury suggesting a loss of several forms of calcium in severe burn injury. An algorithm was derived to allow calculation of free calcium from total calcium and albumin. Interpatient variables are important, however, so that the algorithm should not be substituted for actual assay of free and ionized calcium.

Evaluation of the burn wound with perfusion fluorometry.

Determination of depth of burn injury using vital dyes has been unsatisfactory. The present study evaluated the ability of the fiberoptic perfusion fluorometer to assess the depth of burn in the early postburn period. Sixty-three burns were examined with the fluorometer after intravenous administration of sodium fluorescein. The fluorescein kinetics were monitored for 1 hour within the first 48 hours and again between the third and sixth days postburn. The rate of fluorescein uptake and burn wound fluorescence was determined and compared to that of normal unburned skin. Depth of burn was confirmed by biopsy and healing characteristics. Fluorometric analysis during both study periods consistently distinguished between partial-thickness and full-thickness burns. Partial-thickness burns uniformly exhibited fluorescence within 10 minutes; full-thickness burns showed nil fluorescence. None of the patients experienced a change in skin color or complications from the small dose of fluorescein given.

Survey of continuing education needs for nonemergency physicians in emergency medicine.

A questionnaire was mailed to every physician in Iowa (2,551) to determine their need for continued education in emergency medicine. There 884 usable responses (34.7%). Results revealed a low incidence of formal education in emergency medicine, particularly at the undergraduate and graduate levels, with a great incidence of continued education in the field. Approximately half of the responding physicians felt they treat an emergency patient at least once a week. The primary conclusion of the study is that continued education in basic emergency medical care is perceived as being necessary by physicians who are not specialists in emergency medicine, but, nevertheless, treat patients with medical emergencies. Physicians were most interested in education in basic life saving procedures, such as airway maintenance and cardiopulmonary resuscitation.

Single case study. Conjugal suicide pact.

Prior to entering into a suicide pact the married couple in this case study formed an intensely interdependent and socially isolated unit that illness threatened to dissolve. The depressed husband conveyed suicidal ideation to his wife in a manner suggestive of folie à deux.

Xenon-133 determination of muscle blood flow in electrical injury.

Xe-133 washout determination of muscle blood flow (MBF) was used to detect muscle ischemia in electrical injury of an experimental animal model and three patients. The control MBF of rabbit hindlimbs, which averaged 11.29 +/- 1.07 cc/min/100 gm, was significantly reduced by electrical injury, to 5.82 +/- 1.49 cc/min/100 gm (p less than 0.001). An electrical injury of 4,000 watt-seconds or greater was associated with uniform MBF less than 1.00 cc/min/100 gm and with histopathologic alterations of muscle necrosis. Thenar MBF less than 1.00 cc/min/100 gm in two patients was associated with muscle necrosis requiring distal arm amputation. The remaining patient with sequential muscle blood flows above this level had uneventful healing of hand electrical injuries. Xe-133 determination of MBF may be a useful objective technique to determine the extent of electrical injury in muscle.

Sequential circulatory changes in the circumferentially burned limb.

To assess the hemodynamic alterations in the circumferentially burned extremity, Doppler arterial examinations and Xenon-133 washout determinations of muscle blood flow (MBF) were obtained in 27 limbs. In this laboratory normal resting MBF was 2.82+/-0.86 cc/min/100 gm (mean +/- S.E.M., N=26) with no value less than 1.60 cc/min/100 gm. In 27 circumferentially burned limbs, the maximum decrement in MBF occurred by 36 hours following thermal injury. The lowest MBF value in the 11 extremities not requiring escharotomy was 1.50cc/min/100gm. Escharotomy was done in 16 extremities. Mean MBF immediately prior to escharotomy was 1.30+/-0.26cc/min/100gm and improved to 4.43+/-0.52cc/min/100gm following escharotomy (p less than 0.01). Correlation between MBF and Doppler examinations was present in 63% of all studies and in 88% of studies performed immediately before or after escharotomy. The diagnostic sensitivity of Doppler examination required audible recognition of abnormal velocity signals as well as absent velocity signals. Because the intial MBF determination or Doppler examination is not helpful in predicting which extremities will eventually require escharotomy, sequential studies should be done during the first 36-48 hours following thermal injury.

Algorithm for management of pulmonary complications in burn patients.

An algorithm for management of pulmonary complications in burn patients on the same basis as in patients with adult respiratory distress syndrome is outline. Pao2 of less than 60 torr (F(I)O2 0.21-0.4, PaCO2 over 40 torr, pH less than 7.35, respiratory rate over 40/min, and clinical evidence of compromised upper airway were the indications for initation of aggressive intensive respiratory care. This consisted of nasotracheal intubation, arterial cannulation, pulmonary artery catheterization, and establishment of mechanical ventilation. The algorithm further defines the subsequent management of these patients as far as need for continued mechanical ventilation, fluid and electrolyte balance, hemodynamic stability, and renal function.

Optimizing results of gastric bypass.

Gastric bypass is an extensive gastric exclusion operation used in patients who are more than twice their ideal weight. Most of the early postoperative deaths observed in 3% of 442 patients during the initial 9 years, could have been prevented by more attention to operative technique and early recognition and correction of leaks when they occurred. The best weight loss can be produced by adherence to three components of the operation: 1) Bypass of stomach and duodenum, 2) a small fundic segment and 3) a small (12 mm diameter) gastroenterostomy stoma. The average patient of 142 kg can expect to have a weight of around 107 kg at 1 year 103 kg at 5 years. Revision of a large stoma to a smaller (9 mm) diameter can induce further weight loss in some patients whose loss has been inadequate. The 1.8% incidence of stoma ulceration may be lowered with the present emphasis on a smaller fundic pouch, but could increase with longer observation. Presently stoma ulcers occur once in every 140 patient years at risk.