Epidemiology and Management of Pediatric Head and Neck Burns: An Institutional Review.

BACKGROUND: Pediatric head and neck burns (HNBs) require special attention due to the potential for long-term disfigurement, functional impairment, and psychosocial stigma. METHODS: We performed a retrospective review of patients <18 years old admitted to Grady Memorial Hospital with a diagnosis of HNB from 2009-2017. Demographic data, burn characteristics, management, and hospital course were analyzed. RESULTS: Of the 272 patients included, 65.4% were male with a mean age of 63.2 months. Burn mechanism was primarily secondary to scalding liquids (70.2%) or flames (23.9%). The average total body surface area involved was 10.3%, and 3.0% for the head/neck. Average length of stay was 5.2 days and overall mortality was 1.1%. Twenty-five patients (9.2%) required surgery in the acute setting, and 5 (1.8%) required secondary surgery for hypertrophic scarring or contracture. DISCUSSION: Pediatric HNBs occur most commonly in males <6 years old secondary to scalding liquids or open flames. Most patients can be managed nonoperatively without long-term sequelae.

"The Living Monument": The Desegregation of Grady Memorial Hospital and the Changing South.

Grady Memorial Hospital is a pillar of public medical and surgical care in the Southeast. The evolution of this institution, both in its physical structure as well as its approach to patient care, mirrors the cultural and social changes that have occurred in the American South. Grady Memorial Hospital opened its doors in 1892 built in the heart of Atlanta's black community. With its separate and unequal facilities and services for black and white patients, the concept of "the Gradies" was born. Virtually, every aspect of care at Grady continued to be segregated by race until the mid-20th century. In 1958, the opening of the "New Grady" further cemented this legacy of the separate "Gradies," with patients segregated by hospital wing. By the 1960s, civil rights activists brought change to Atlanta. The Atlanta Student Movement, with the support of Dr. Martin Luther King Jr., led protests outside of Grady, and a series of judicial and legislative rulings integrated medical boards and public hospitals. Eventually, the desegregation of Grady occurred with a quiet memo that belied years of struggle: on June 1, 1965, a memo from hospital superintendent Bill Pinkston read "All phases of the hospital are on a non-racial basis, effective today." The future of Grady is deeply rooted in its past, and Grady's mission is unchanged from its inception in 1892: "It will nurse the poor and rich alike and will be an asylum for black and white."

Management of Head and Neck Burns-A 15-Year Review.

PURPOSE: The purpose of this project was to characterize patients with isolated head and neck burns admitted to the Grady Memorial Hospital (GMH) Burn Center (Atlanta, GA). MATERIALS AND METHODS: This was a retrospective case series of patients admitted to the GMH Burn Center with the primary diagnosis of head and neck burns from 2000 through 2015. Demographic data (gender and age) were recorded. Burn details (etiology, mechanism, percentage of burned total body surface area, depth, and associated injuries) were summarized. Patient management and hospital course were documented. Data were collected using a standardized collection form. Descriptive statistics were computed. RESULTS: There were 5,938 patients admitted to the burn unit at the GMH Burn Center during the study period. Of these, 2,547 patients had head and neck burns and 205 patients met the inclusion criteria. Most (n = 136; 66%) were male, with a mean age of 40 years. The most common burn depth was superficial partial thickness. Flame burns were the most likely mechanism related to full-thickness injury. Approximately one fourth of patients had an associated injury, such as inhalation or ocular injury. Surgical interventions consisted of tangential excision and split-thickness skin grafting, contracture release, excision of hypertrophic scars, and rotational flaps. Mean length of hospital stay for isolated head and neck burns was 4.4 days. Overall mortality was 2%. CONCLUSION: The results of this study show that superficial partial-thickness head and neck burns are more likely to occur from accidental exposure to flames in men older than 55 years. Owing to an increase in risk and mortality of inhalation injury associated with head and neck burns, airway protection and respiratory management are critical considerations of head and neck burn management.

A rationale for significant cost savings in patients suffering home oxygen burns: despite many comorbid conditions, only modest care is necessary.

Increasingly, patients are being evaluated for burns related to home oxygen use. Although the majority of burns are minor, referral to a burn unit regardless of depth or size is still common. The care of this population was reviewed to determine the feasibility and potential saving if such patients could be managed by nonburn-trained surgeons. Prospectively collected data on 5103 consecutive patients admitted to an urban tertiary burn center between April 1997 and September 2010 was reviewed. Data collected included age, TBSA burned, comorbidities, mode of admission, distance transported, mode of transport, number requiring surgery, length of stay, and outcome. Of 5103 admissions, 64 were for home oxygen burns. Patients had a mean age of 62.5 years and five comorbidities. They suffered a mean 4% TBSA burn, and all were mostly superficial, of partial thickness, and healed without surgery. Patients had a mean length of stay of 2 days and required one follow-up visit. Twenty-seven percent were transferred from another facility after initial care, and 28% arrived intubated. Twenty-two percent were transported by helicopter, and 61% arrived intubated. Eighty percent of ventilated patients were extubated within 8 hours of admission, and all within 24 hours. Average distance by helicopter transport was 57 miles, and cost $12,500.00. Large savings could be realized if patients cared for by local physicians were educated in basic burn care. This would be more palatable with good communication between the community hospital and burn center, with consultation on an as-needed basis.

Overutilization of regional burn centers for pediatric patients--a healthcare system problem that should be corrected.

BACKGROUND: Minor burns represent .96% to 1.5% of emergency department visits, yet burn center referral is common. Analysis of the Grady Memorial Hospital Burn Center examined the feasibility and savings if pediatric burns were managed locally with as-needed consultation. METHODS: Prospective data on 219 consecutive admissions to Grady Memorial Hospital Burn Center between December 2008 and September 2010 were reviewed. National and international cohorts were compared. RESULTS: Sixty-six percent of patients were male, the mean age was 6.1 years, and 92% were insured. The most common mechanism of burning was liquid scalding (40%). Seventy percent had burns over <10% of the total body surface area, and 73% of all pediatric admissions healed without surgery. Thirty-six percent were discharged within 24 hours of admission. Forty-five percent of patients transferred from other facilities were discharged within 24 hours. Fifteen percent were transported by helicopter; of those, 37% were discharged within 24 hours. Helicopter transport cost $12,500 and averaged 45 miles. CONCLUSIONS: Pediatric burns require assessment, debridement, and dressing changes. Grafting is rarely necessary. Patients are transferred because of a lack of training, and patients suffer economic burden and treatment delay. Savings could be realized were patients treated locally with select burn center referral.

The demographics of modern burn care: should most burns be cared for by non-burn surgeons?

BACKGROUND: minor burns represent .96% to 1.5% of emergency department visits, yet burn center referral is common. Analysis of the Grady Memorial Hospital Burn Center was conducted to examine the feasibility and savings if burns were managed locally with consultation as needed. METHODS: data on 776 consecutive admissions to Grady Memorial Hospital Burn Center between November 2005 and July 2007 were prospectively reviewed. National and international cohorts were compared. RESULTS: patients' mean age was 31 years, 69.8% were male, and 87% were insured. Thirty-nine percent were transfers. Seventy-six percent of transfers (51% of air transfers) and 70% of all admissions were for ≤ 10% total body surface area burns. Helicopter transport cost $12,500 and averaged 48 miles. Eighty percent of burns were hot water (scald), grease, or flame burns, and 31% required skin grafting. CONCLUSIONS: most burns require assessment, debridement, and dressing changes. Grafting is rarely necessary. Patients are transferred because of a lack of training, and patients suffer economic burden and treatment delay. Savings could be realized were patients treated locally with select burn center referral. Video consultation and mentoring can help with triage and care of minor burns. Major burns require burn center referral. International practice reinforces these results.

Bilayer dermal matrix for the treatment of painful burn scars.

UNLABELLED:  Background. Outcomes following burn injury have improved considerably in recent years due to early excision and skin grafting. Despite a reduction in late burn complications, up to 70% of patients experience long-term pain at both the injured area and the skin-grafted scar. Current therapies do not ameliorate these symptoms for a majority of these patients. This report presents initial results of a new technique using a bilayer dermal substitute (Integra™, [Integra LifeSciences, Plainsboro, NJ]) for revision of painful scars. METHODS: This is a prospective cohort of six patients treated at Grady Memorial Hospital Burn Center (Atlanta, GA) from 2008 to 2009. Burn patients undergoing multi-modality pain therapy for chronic, painful burns were identified and consented for intervention. All patients underwent operative excision of the painful scar and placement of a bilayer dermal matrix (Integra). After 3 weeks the silicone mesh was removed, excessive granulation tissue was debrided, and a new split-thickness skin graft was placed on the wound. Prescription history and a patient questionnaire were used to collect data. RESULTS: All patients noticed improvement of symptoms post-operatively. Two patients (33%) experienced complete reduction of scar pain and three (50%) discontinued consumption of pain medications. At a mean follow up of 13 months, the average amount of narcotic-based pain medications decreased from 63.3 MED ([morphine equivalent per day], range: 30-135) before treatment to 7.5 MED (range: 0-20) postoperatively (P < 0.05). CONCLUSION: Scar excision, interval placement of a bilayer dermal matrix, and subsequent skin grafting is a new technique that can improve, and in some cases ameliorate, burn scar related pain. .

Early predictors of massive transfusion in patients sustaining torso gunshot wounds in a civilian level I trauma center.

BACKGROUND: Early prediction of the need for massive transfusion (MT) remains difficult. We hypothesized that MT protocol (MTP) utilization would improve by identifying markers for MT (>10 units packed red blood cell [PRBC] in 24 hours) in torso gunshot wounds (GSW) requiring early transfusion and operation. METHODS: Data from all MTPs were collected prospectively from February 1, 2007, to January 31, 2009. Demographic, transfusion, anatomic, and operative data were analyzed for MT predictors. RESULTS: Of the 216 MTP activations, 78 (36%) patients sustained torso GSW requiring early transfusion and operation. Five were moribund and died before receiving MT. Of 73 early survivors, 56 received MT (76%, mean 19 units PRBC) and 17 had early bleeding control (EBC), (24%, mean 5 units PRBC). Twelve transpelvic and 13 multicavitary wounds all received MT regardless of initial hemodynamic status (mean systolic blood pressure: 96 mm Hg; range, 50-169). Of 31 MT patients with low-risk trajectories (LRT), 18 (58%) had a systolic blood pressure <90 mm Hg compared with 3 of 17 (17%) in the EBC group (p < 0.01). In these same groups, a base deficit of <-10 was present in 27 of 31 (92%) MT patients versus 4 of 17 (23%) EBC patients (p < 0.01). The presence of both markers identified 97% of patients with LRT who requiring MT and their absence would have potentially eliminated 16 of 17 EBC patients from MTP activation. CONCLUSIONS: In patients requiring early operation and transfusion after torso GSW: (1) early initiation of MTP is reasonable for transpelvic and multicavitary trajectories regardless of initial hemodynamic status as multiple or difficult to control bleeding sources are likely and (2) early initiation of MTP in patients with LRT may be guided by a combination of hypotension and acidosis, indicating massive blood loss.

Outcome of ligation of the inferior vena cava in the modern era.

BACKGROUND: Ligation of the significantly injured infrarenal inferior vena cava (IVC) is an accepted practice in the setting of damage control surgery. This is a report of inpatient management, outcomes, and long-term follow-up in 25 patients after IVC ligation. METHODS: The records of patients with injuries to the IVC treated in an urban level I trauma center from 1995 to 2008 were reviewed. Demographics, injury severity, and outcome data were recorded. In addition, outpatient records were reviewed and telephone interviews were conducted to assess for the presence and severity of long-term sequelae. RESULTS: One hundred patients had IVC injuries, and 25 (25%) underwent ligation. Location of injury was infrarenal in 54 patients, suprarenal in 21, retrohepatic in 15, and suprahepatic in 10. Twenty-two of 54 (41%) injuries to the infrarenal IVC and 3 of 21 (14%) injuries to the suprarenal IVC were ligated. Patients who underwent ligation had a significantly higher Injury Severity Score (ISS) (22 vs 15, P < .001), a higher transfusion requirement (26 U vs 12 U, P < .001), a longer hospital length of stay (78 days vs 26 days, P = .02), a longer intensive care unit length of stay (24 days vs 9 days, P < .001), and a higher mortality (59% vs 21%, P < .001). Ten of 13 early survivors of infrarenal IVC ligation received early below knee fasciotomy. Three other patients with normal compartment pressures were treated expectantly without development of a compartment syndrome. The 1 survivor of suprarenal ligation had below knee fasciotomies and had normal renal function by 1 month post injury, despite an initial creatinine elevation from .7 mg/dL to 3.2 mg/dL. Ten (40%) patients with IVC ligation survived to hospital discharge (9 infrarenal, 1 suprarenal), and long-term follow-up data are available in 8 patients (7 infrarenal, 1 suprarenal). At an average of 42 months (11-117 months), no patient has significant lower extremity edema or dysfunction. CONCLUSIONS: (1) Ligation of the infrarenal IVC is an acceptable damage control technique, although it remains associated with a high mortality. Ligation of the suprarenal IVC may be done, if necessary, although few survivors of this technique exist. (2) Early fasciotomy is generally required, but occasional patients may be treated expectantly, based on measurements of compartment pressures. (3) Long-term sequelae in survivors of IVC ligation for trauma are rare.

Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center.

INTRODUCTION: Transfusion practices across the country are changing with aggressive use of plasma (fresh-frozen plasma [FFP]) and platelets during massive transfusion with current military recommendations to use component therapy at a 1:1:1 ratio of packed red blood cells to FFP to platelets. METHODS: A massive transfusion protocol (MTP) was designed to achieve a packed red blood cell:FFP:platelet ratio of 1:1:1 We prospectively gathered demographic, transfusion, and patient outcome data during the first year of the MTP and compared this with a similar cohort of injured patients (pre-MTP) receiving > or = 10 red blood cell (RBC) in the first 24 hours of hospitalization before instituting the MTP. RESULTS: One hundred sixteen MTP activations occurred. Twelve non-trauma patients and 31 who did not receive 10 RBC (15 deaths, 16 early bleeding controls) were excluded. Seventy-three MTP patients were compared with 84 patients with pre-MTP who had similar demographics and injury severity score (29 vs. 29, p = 0.99). MTP patients received an average of 23.7 RBC and 15.6 FFP transfusions compared with 22.8 RBC (p = 0.67) and 7.6 FFP (p < 0.001) transfusions in pre-MTP patients. Early crystalloid usage dropped from 9.4 L (pre-MTP) to 6.9 L (MTP) (p = 0.006). Overall patient mortality was markedly improved at 24 hours, from 36% in the pre-MTP group to 17% in the MTP group (p = 0.008) and at 30 days (34% mortality MTP group vs. 55% mortality in pre-MTP group, p = 0.04). Blunt trauma survival improvements were more marked and more sustained than victims of penetrating trauma. Early deaths from coagulopathic bleeding occurred in 4 of 13 patients in the MTP group vs. 21 of 31 patients in the pre-MTP group (p = 0.023). CONCLUSIONS: In the civilian setting, aggressive use of FFP and platelets drastically reduces 24-hour mortality and early coagulopathy in patients with trauma. Reduction in 30 day mortality was only seen after blunt trauma in this small subset.

Can secondary extremity compartment syndrome be diagnosed earlier?

BACKGROUND: In 2002, our institution published a 5-year retrospective review of 10 patients who developed secondary extremity compartment syndrome (SECS) with a mortality rate of 70%. Since then, we have aggressively screened for the development of SECS in high-risk patients. We postulate that awareness of SECS and vigilant monitoring for its development would result in earlier diagnosis and treatment and improved outcome. METHODS: Retrospective review of all patients at a level I trauma center developing SECS from 2002 to 2006. Data collected included demographics, mechanism of injury, injury complex, blood transfused prior to development of SECS, affected extremities, creatinine, creatine phosphokinase, management, and outcome. RESULTS: Seventeen of 11,468 trauma patients (.148%) developed SECS. Mean admission hematocrit was 31.7 +/- 8.9, mean admission base deficit was -13.3, mean worst base deficit was -17.8, and average Injury Severity Score was 36.3 +/- 16.6. Patients received 20.9 +/- 11.0 units of blood and 24.6 +/- 14 L of crystalloid prior to the development of SECS. Average time from admission to diagnosis of the SECS was 32.6 hours. Acute renal failure developed in 6 (35%) patients; 4 required dialysis, and 3 died. The number of affected extremities ranged from 1 to 4. Of the 46 affected extremities, 39 were salvaged and 7 required amputation. Mortality was 35.3%. CONCLUSIONS: SECS is an uncommon, but devastating complication in severely injured patients with hypotension undergoing massive transfusion, and developing systemic inflammatory response syndrome. Vigilance increases detection. While the overall mortality was reduced by half, patients requiring dialysis have a 75% mortality.

The accuracy of thoracic ultrasound for detection of pneumothorax is not sustained over time: a preliminary study.

BACKGROUND: Ultrasound has proven to be very accurate in the diagnosis of pneumothorax in the trauma suite. It is unknown whether this accuracy is maintained over time in patients with a thoracostomy (TT) in place. METHODS: Hospitalized patients with a TT placed to treat a traumatic pneumothorax underwent serial daily bedside surgeon-performed ultrasound by 1 of 2 experienced surgeon sonographers who were unaware of concomitant X-ray findings. Results were compared with daily chest X-ray films. Data collected included size and day of placement of the chest tube, as well as the results of the serial ultrasounds and the comparative X-ray films. RESULTS: Fourteen patients (78% men, mean age 33 years) sustained traumatic pneumothorax. The causes included stab wound (9), gunshot wound (3), and rib fracture (2). They underwent 126 (median 7) ultrasound evaluations and were followed between 4 and 26 (median 7) days after injury. Of these exams, 95 had a concomitant chest X-ray film within 1 hour of the ultrasound, thus 190 hemithoraces could be analyzed. Eighty-two ultrasounds were performed for hemithoraces that had no injury or TT in place and all 82 revealed normal pleural sliding. No pneumothoraces were noted on concomitant chest X-ray films (100% accuracy). One hundred eight ultrasounds were performed for hemithoraces that had a TT in place. For the first 24 hours, accuracy remained 100%. After 24 hours, however, sensitivity of ultrasound diagnosis of pneumothorax fell to 55%, specificity fell to 70%, positive predictive value to 43%, and negative predictive value to 79%. This led to an overall accuracy rate for ultrasound examination after 24 hours of 65%. CONCLUSIONS: Ultrasound evaluation for pneumothorax is very accurate for the first 24 hours after insertion of a TT, but the accuracy, especially the positive predictive value, is not sustained over time, possibly as a result of the formation of intrapleural adhesions.

The outcome of open pelvic fractures in the modern era.

BACKGROUND: Recent series have reported that the mortality rate of open pelvic fractures has decreased to < 10%. These injuries are often associated with intra-abdominal visceral damage, although few series have documented the prognostic significance of this injury complex. METHODS: A retrospective review in an urban level I trauma center of all patients who sustained open pelvic fracture between 1995 and 2004. RESULTS: Forty-four patients were identified as having sustained open pelvic fracture. Average Injury Severity Score was 30, with 77% of patients having a score > or = 16. Overall mortality was 45% (n = 20): 11 early deaths and 9 late deaths at an average of 17 days. Vertical shear injuries, although rare, were universally fatal. Other risk factors for overall mortality included revised trauma score, Injury Severity Score, transfusion requirement, Faringer zones I or II injury, Gustilo grade III soft tissue injury, need for therapeutic angiography, and presence of intra-abdominal injury, the latter of which conferred 89% mortality. Risk factors for late deaths also included pelvic sepsis, which occurred in 5 patients and was fatal in 3 (60%). CONCLUSIONS: The morbidity of open pelvic fractures remains high. Associated intra-abdominal injury or active arterial bleeding requiring therapeutic angiography is associated with a grim prognosis. There is a continuing need for new therapeutic approaches to this injury complex.

A review of upper extremity fasciotomies in a level I trauma center.

The purpose of this study was to review recent experience with upper extremity fasciotomy. This study is a retrospective review of injured patients undergoing fasciotomy in the upper extremity at an urban trauma center. Mechanisms of injury, indications for and timing of fasciotomy, role of compartment pressures, techniques of closure, amputation rate, and patient outcomes were collected. Over a 3-year period, 201 fasciotomies were performed in the extremities of 157 injured patients, including 37 in the upper extremities of 27 patients. The mechanisms of injury were penetrating trauma in 13 patients (10 GSW, three SW), blunt or crush in 9, and burns (4 electric, 1 flame) in 5. Vascular injuries and fractures were present in 15 (56%) and 9 (33%) patients, respectively. The decision to perform a fasciotomy was a clinical one in 21 patients (75%), and only 6 patients had compartment pressures measured (range, 40-87 mm Hg; mean, 52). Upper extremity fasciotomy was performed at a first operation in 24 patients, whereas only 3 patients had a delayed fasciotomy from 6 to 48 hours after injury. Two patients died on the first hospital day, and 5 others had an amputation of an upper extremity at a mean of 8 days (range 2 to 26) after injury; however, no amputation was due to the failure to perform a timely fasciotomy. In the remaining 20 patients, closure of the fasciotomy site was performed at a mean of 9 days (range, 2 to 22) after injury, most commonly by split thickness skin grafting. Hospital stay was a mean of 20 days (range, 7-35). We conclude that 1) upper extremity fasciotomy accounts for less than 20 per cent of all fasciotomies performed; 2) a clinical decision is the most common reason for performing upper extremity fasciotomy, and only 11 per cent of patients underwent a delayed fasciotomy in this review; 3) the need for upper extremity fasciotomy is associated with a length of stay longer than expected for overall injury severity.

Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same.

BACKGROUND: Damage control surgery (DCS) and treatment of abdominal compartment syndrome have had major impacts on care of the severely injured. The objective of this study was to see whether advances in critical care, DCS, and recognition of abdominal compartment syndrome have improved survival from penetrating abdominal injury (PAI). METHODS: The care of 250 consecutive patients requiring laparotomy for PAI (1997-2000) was reviewed retrospectively. Organ injury patterns, survival, and use of DCS and its impact on outcome were compared with a similar experience reported in 1988. RESULTS: Two hundred fifty patients had a positive laparotomy for PAI. Twenty-seven (10.8%) required abdominal packing and 45 (17.9%) did not have fascial closure. Seven (2.8%) required emergency department thoracotomy and 21 (8.4%) required operating room thoracotomy. Two hundred seventeen (86.8%) survived overall. Small bowel (47.2%), colon (36.4%), and liver (34.4%) were most often injured. Mortality was associated with the number of organs injured (odds ratio, 1.98; 95% confidence interval, 1.65-2.37; p < 0.001). Vascular injury was a risk factor for mortality (p < 0.001), as was need for DCS (p < 0.001), emergency department thoracotomy (p < 0.001), and operating room thoracotomy (p < 0.001). Seventy-nine percent of deaths occurred within 24 hours from refractory hemorrhagic shock. DCS was used in 17.9% (n = 45) versus 7.0% (n = 21) in 1988, with a higher survival rate (73.3% vs. 23.8%, p < 0.001). DCS was associated with significant morbidity including sepsis (42.4%, p < 0.001), intra-abdominal abscess (18.2%, p = 0.009), and gastrointestinal fistula (18.2%, p < 0.001). CONCLUSION: Penetrating abdominal organ injury patterns and survival from PAI have remained similar over the past decade. Death from refractory hemorrhagic shock in the first 24 hours remains the most common cause of mortality. DCS and the open abdomen are being used more frequently with improved survival but result in significant morbidity.

Factors affecting success of split-thickness skin grafts in the modern burn unit.

BACKGROUND: The use of early tangential excision or excision to fascia of burn wounds has led to the application of split-thickness skin grafts (STSGs) to a variety of graft beds, including dermis, granulation tissue, fat, and fascia. Because insufficient objective data are available on the effect of the graft bed on survival of an STSG, a 2-year review of success rates of STSGs on a variety of graft beds was completed. METHODS: The success rates of all 599 STSGs applied to dermis, granulation tissue, fat, and fascia in 233 consecutive burn patients (mean total body surface area [TBSA] burned, 14.5%) by one surgeon at a regional burn center over a 2-year period were reviewed. Data were analyzed to compare outcomes of STSGs on the graft beds listed and in low-risk versus high-risk groups of patients (TBSA burned < or = 35% and > 35%; age < or = 18 years and > 18 years; age < or = 55 years and > 55 years; and diabetes mellitus). One-way analysis of variance was used to compare results of STSGs on different graft beds, and tests were used to analyze differences in results of STSGs in low-risk versus high-risk groups (p < 0.05, significant). RESULTS: The mean success rate at 14 days for all 599 STSGs applied in the 233 patients was 90 +/- 22%. The success rate of STSG on the various surfaces ranged from 85% (fascia) to 93% (dermis; granulation), but the differences among the four graft beds were not significant. Total body surface area burned (> 35%), older age (> 55 years), and the presence of diabetes mellitus each had a significant impact on the percentage take of STSGs at 14 days after application. CONCLUSION: In the hands of an experienced burn surgeon, the recipient bed has no significant impact on the success rate of STSGs at 14 days postgrafting, except in those patients 18 years or younger, in which the mean STSG success rate was significantly greater on granulation tissue compared with fat. TBSA burned > 35%, age > 55 years, and the presence of diabetes mellitus continue to have an adverse impact on the success rate of STSGs at 14 days.

Three hundred consecutive emergent celiotomies in general surgery patients: influence of advanced diagnostic imaging techniques and procedures on diagnosis.

OBJECTIVES: To assess the utility of advanced tests performed before surgery on patients who needed emergent abdominal operations, and to assess the outcomes of these patients relative to their diagnoses. SUMMARY BACKGROUND DATA: Patients with a potential abdominal catastrophe may have various presentations, contributing to the difficulty of the decision about whether an operation is indicated. Advanced tests can be valuable, but the use of these adjuncts should be appropriate to the clinical status of the patient so that treatment is not delayed. The role of these tools in the evaluation of the patient who may need an emergent abdominal operation is less well defined. METHODS: Data were reviewed on adult patients undergoing emergent abdominal operations. Entrance criteria included patients who had an emergent abdominal operation, defined as one performed for presumed gastrointestinal perforation, infarction, or hemorrhage within 6 hours of admission or surgical consultation. Advanced tests were those that were time-consuming or invasive or required scheduling with other departments so that the risk/benefit ratio of these tests could be questioned. A useful test was one that provided information that contributed to a change in the patient's management. RESULTS: During a 5-year period, 300 consecutive adult patients (158 perforations, 66 hemorrhage, 53 ischemia/infarction, and 23 "other") underwent emergent nontrauma celiotomies. Overall, the death rate was 20%. Advanced preoperative tests were performed in 135 (45%) of the 300 patients, and 40 of these patients had delayed treatments. Preoperative localization of bleeding sites was accomplished in 77% of patients with upper gastrointestinal bleeding and 86% of patients with lower gastrointestinal bleeding. CONCLUSIONS: Most patients in need of emergent abdominal operations should not undergo advanced tests. The primary role of advanced tests in these patients is in the localization of a bleeding site. With the exception of patients who present with hemorrhage, advanced tests frequently cause a delay in treatment.