Escharotomies, fasciotomies and carpal tunnel release in burn patients--review of the literature and presentation of an algorithm for surgical decision making.

Escharotomies are usually performed in patients with circumferential third degree burns of the extremities or anterior trunk. Fasciotomies are recommended for patients who sustained high voltage (or associated crush) injuries, with entrance or exit wounds in one or more extremities. Carpal tunnel release is practiced routinely in some services for cases of electrical injury. We have reviewed the literature which provides relatively little information as to when should these procedures actually be performed and what would happen if they were not done. We present a series of patients treated at our institution when an algorithm was used for surgical decision making as to when (or not) to operate (perform an escharotomy, a fasciotomy or a carpal tunnel release), based on clinical signs and monitoring alternatives, using the oximeter and the Doppler flowmeter. 13 938 burn patients were treated at our institution during the year of 2005. Of these, 571, with an average of 22.3 % TBSA, were treated as inpatients. Of these, 58 (10.3 %) had circumferential or electrical burns of one or more extremities. Patients were monitored hourly from admission and decision to operate was based on clinical signs and in absent or below 90 % oximetry, regardless of Doppler flow signs. 68 % were males, 6 (11.3 %) patients had immediate escharotomies, while 4 (7.5 %) had immediate fasciotomies. 2 of these patients were operated regardless of positive Doppler sign but no oximetry. All patients recovered oximetry over 90 % immediately after the operations. 3 patients had negative Doppler sign but oximetry > 90 % and were not operated. 3 patients had carpal tunnel releases based on oximetry < 90 % and symptoms of compression of the median nerve. Patients who were not operated fared well with no signs or symptoms of impairment of circulation or nerve damage up to their 3 and 6 months reevaluations.

Learning curve of microvascular venous anastomosis: a never ending struggle?

In this study, a simple protocol based on the rat femoral venous anastomosis was established to provide a quantitative representation of the progress. The learning curve is based on the patency rate in each consecutive group of five anastomoses. Two groups of surgeons were observed. The inexperienced group encountered a tough time in the first 25 anastomoses. However, the progress was fast and is represented by the steep slope of the curve. A plateau was reached whereby the avearge patency rate matches that of the experienced group. As expected, there was no learning curve for the experienced group. Despite every effort to attempt to maintain a perfect 100% patency on this model, the best achievable patency was only 88%. The results and its implication are discussed.

Chemotactic mediator requirements in lung injury following skin burns in rats.

Partial-thickness skin burns have been shown to induce neutrophil-dependent microvascular injury both locally (skin) and systemically (lung). In the present study, interventional measures to block inflammatory chemoattractants were employed to define the pathophysiologic role of these mediators in the development of secondary lung injury following thermal injury of skin. Rats were treated with blocking antibodies to either C5a or to the alpha-chemokines, keratinocyte-derived cytokine (KC), or macrophage inflammatory protein-2 (MIP-2). To study the role of platelet activating factor, a receptor antagonist (PAF-Ra) was utilized. The development of lung vascular injury following thermal injury to skin was significantly attenuated by treatment with anti-C5a (84%), anti-KC (67%), and anti-MIP-2 (77%), but treatment with PAF-Ra had no protective effects. Protective interventions were paralleled by significant reductions in the tissue buildup of myeloperoxidase. When bronchoalveolar lavage fluids from thermally injured rats were evaluated, elevations in TNF;ZA and IL-1 were found and were determined to be C5a-dependent (but unaffected by treatment with PAF-Ra). These studies indicate that lung tissue injury after thermal skin burns is dependent on chemotactic mediators. The data also suggest that lung expression of TNFalpha and IL-1 after thermal injury of skin is C5a-dependent.

Role of chemotactic factors in neutrophil activation after thermal injury in rats.

Acute thermal trauma is well known to produce evidence of a "systemic inflammatory response" in vivo, as manifested by evidence of complement activation, appearance in plasma of a variety of inflammatory factors, and development of multi-organ injury. The current studies were focused on acute thermal injury of rat skin and factors responsible for accompanying activation of blood neutrophils. Acute thermal injury of rat skin resulted in a time-dependent loss of L-selectin and up-regulation of Mac-1 (CD11b/CD18) on blood neutrophils, with no changes in LFA-1 (CD11a/CD18). The loss of L-selectin was prevented by blockade of C5a but not by blockade of the alpha-chemokine, macrophage inflammatory protein-2 (MIP-2). C5a, the alpha chemokines, MIP-2 and keratinocyte-derived cytokine (KC), and platelet activating factor (PAF) contributed to up-regulation of blood neutrophil Mac-1. Blocking interventions against these mediators also blunted the degree of neutropenia developing after thermal trauma. These data suggest that activation of blood neutrophils after thermal trauma is related to the role of several chemotactic mediators. These studies may provide clues regarding factors responsible for development of the "systemic inflammatory response syndrome" after thermal injury in the experimental model employed.

Sun tanning-related burns--a 3-year experience.

A retrospective study has analyzed 562 sun-related burns out of 19,643 patients treated at our institution from 1 March 1988 to 28 February 1991. These patients were analysed according to sex, age, burn area, mode and length of treatment and outcome. Females, mainly adults, represented 60.8 per cent of all patients presenting burned due to sun bathing. There is a marked seasonal incidence, proportionally constant throughout these 3 years. The main causes of injury were sun only (36.7 per cent), sun plus fig leaf 'tea' tanning lotion (17.7 per cent) and lemon juice (17.7 per cent). Healing to normal skin appearance was achieved in 99.1 per cent, 0.7 per cent healed with scarring and one patient died due to massive sepsis. The effect of sunlight on skin and the process of 'sunburn' when using homemade plant-derived tanning lotions containing substances which can induce a photodermatitis reaction is also discussed.

Two years in burn care, an analysis of 12,423 cases.

This is a retrospective study analysing 12,423 patients treated at our institution from 1 July 1988 to 30 June 1990. Burn incidence and mode of treatment were classified according to age and sex, as well as causative agent, place of the accident, length of treatment and outcome. 96.6 per cent of the patients were surgically treated, about 41 per cent of the patients were under 14 years of age. The most frequent cause of injury was related to meal preparation, with more than two-thirds of the accidents occurring at home. Only large or complicated burns (1094-8.8 per cent) were admitted, with 49 deaths occurring during this period. We conclude that children and younger adults are at greater risk of being burned and preventative measures should be oriented towards the prevention of such accidents.

Estudo comparativo da eficácia de cinco medicamentos tópicos no tratamento de queimaduras / Efficacy of five topical agents in burn treatment: a comparative study

Os autores realizaram um estudo comparativo de cinco preparados para uso tópico no tratamento de queimaduras. Foram tratadas 125 (cento e vinte e cinco) pacientes, divididos aleatoriamente em cinco grupos de 25 (vinte e cinco) pacientes cada. Os medicamentos empregados foram o merbromino a 2(pôr cento), salicilato de sódio, sulfadiazinato de zinco e a combinaçäo de colagenase com clorafenicol. No grupo IV foi feita uma associaçäo do salicilato de sódio e sulfadiazinato de zinco. A análise estatística dos resultados mostrou näo haver diferença significativa entre os diversos grupos, quando se toma em consideraçäo o tempo necessário para a completa epitelizaçäo das lesÆes