Full-thickness burn of the foot: successful treatment with Apligraf. A case report.

Burn wounds, although uncommon in the foot, present a uniquely challenging opportunity to physicians. The keys to successful management include a proper and specific initial evaluation of the burning agent, the location, the TBSA affected, and the depth. Ultimately, proper recognition and meticulous wound care with skin grafting, when necessary, bring about the desired results. A case report of a patient with a third-degree burn over the dorsum of the left foot is presented. This case is unique in that Apligraf, a human skin equivalent, was used to gain coverage and eventual resolution of the wound. It is the authors' opinion that the use of Apligraf in this application is a viable alternative to traditional methods of skin harvesting and grafting. To the authors' knowledge, there have been no other cases reported of Apligraf use in burn wound coverage of the foot.

Pentoxifylline. Adjunctive therapy in the treatment of pedal frostbite.

Frostbite injury to the extremities has the potential for disastrous effects. Prompt recognition and treatment are paramount. The use of Pentoxifylline to minimize tissue damage in the treatment of frostbite is a viable addition to the traditional therapy of rewarming soaks, pain management, and vesicle débridement. The most well known action of Pentoxifylline is its ability to increase RBC flexibility, allowing easier vascularization. This explains its indication for PVD, arterial disease, and intermittent claudication. As is explained previously, however, Pentoxifylline has multiple actions that will enhance tissue survival. The dosage of Pentoxifylline in controlled release tablet form is one 400 mg tablet three times a day with meals. The duration of treatment should be from two to six weeks. As this drug has many actions and therefore possibilities, more research is warranted with regards to its use not only with frostbite, but with other pathological processes.

Nerve injury associated with plantarflexion-inversion ankle sprains.

This article presents some of the less frequently described nerve pathologies associated with severe plantarflexion-inversion ankle sprains. It outlines the likely mechanisms of nerve injury, the typical presentations, and treatment possibilities. An anatomic review of the lower extremity, with emphasis on the neurologic structures, is also included to assist in understanding the mechanism and location of the nerve injury.

Indomethacin pretreatment in continuous positive-pressure ventilation.

The purpose of the study was to investigate the possible involvement of prostaglandins (PG) and thromboxanes (TX) in the cardiovascular and pulmonary changes associated with the use of continuous positive-pressure ventilation (CPPV). Indomethacin (IND), an inhibitor of PG cyclo-oxygenase, was used to block the synthesis and release of PG and TX in the lung after alveolar stretch with CPPV. Groups of dogs received CPPV (buffer group) or CPPV + IND 5 mg/kh iv (CPPV + IND). Pulmonary edema or alveolar hemorrhage was evident in 5 of 6 buffer animals. This damage was also manifested by a 50% decrease in lung compliance. However, IND appeared to block development of lung tissue damage in 5 of 6 CPPV + IND dogs and compliance remained normal. A 52% lowering of cardiac index (CI) in the buffer group paralleled a 71% reduction of left ventricular dP/dt max (first derivative of left ventricular pressure). Peak transmural right heart filling pressure decreased only 15%. in contrast, the 38% decrement of CI in the CPPV + IND animals was coupled with a 98% reduction in filling pressure, but only a 25% decrease in dP/dt max. CPPV-induced changes may have been related, in part, to the release of cytotoxic negative inotrope(s) from damaged alveolar membranes because IND pretreatment blocked this damage.

Noninvasive evaluation of cardiovascular effects of preoperative sedation in children.

The cardiovascular effects of two premedication regimes used in paediatric anaesthesia were studied. Eleven patients received rectal methohexitone (22 mg - kg) and 11 patients received intramuscular Innovar (0.03 ml - kg). The effect of these drugs on ventricular function was evaluated by measuring the shortening of the left ventricular minor dimension by echocardiography. No significant changes in this dimension, blood pressure, heart rate or respiratory rate were demonstrated with either drug. Both rectal methohexitone and intramuscular Innovar were shown to have minimal cardiovascular effects when used as preoperative sedation in paediatric patients. Echocardiography proved to be a valuable technique for the noninvasive evaluation of drug effects on myocardial contractility in children.

Prophylactic antibiotics in the treatment of penetrating chest wounds. A prospective double-blind study.

Considerable controversy exists as to whether or not antibiotics should be administered "prophylactically" to patients with penetrating chest trauma. No prospective study of this problem has been reported. Therefore, 75 patients with isolated, penetrating chest injury were randomized prospectively in a double-blind study. Group A patients (38 patients) were given 300 mg. of clindamycin phosphate every 6 hours, beginning with admission and lasting until 1 day following chest tube removal or for 5 days, whichever was shorter. Group B patients (37 patients) were given a placebo on the same schedule. The patients' hospital course, fever, white blood count, culture data, and roentgenograms were recorded serially. Clindamycin-treated patients had a significantly lower incidence of radiographic pneumonia, less fever, and a lower incidence of positive pleural and wound cultures. They acquired empyema less frequently, required fewer operations, and had a shorter period of hospitalization. Antibiotics may be useful, therefore, as adjunctive therapy in the management of penetrating chest trauma.

Effects of methylprednisolone on coronary blood flow and myocardial metabolism during cardiopulmonary bypass.

Corticosteroids frequently are used during cardiopulmonary bypass (CPB) to enhance total body perfusion and myocardial preservation. The mechanisms by which steroids might provide protection to the myocardium have not been clearly defined, however. Therefore this study was performed to measure the effects of methylprednisolone (M-P) on coronary flow and distribution, and on myocardial metabolism and contractility. Twenty-three dogs underwent 1 hour of total CPB, 80 cc/kg/minute at normothermia with beating hearts. Alternate animals received M-P, 30 mg/kg. Myocardial blood flow (microspheres technique), myocardial tissue lactate and adenosine triphosphate, lactate extraction, coronary sinus flow (CSF), and coronary vascular resistance (CVR) were measured before, during, and 60 minutes after bypass. LV dp/dt and cardiac output (CO) were measured before and after bypass. Total coronary flow was significantly higher in the M-P group after 10 and 30 minutes of bypass (93 vs 56 ml/100 gm/minute, p less than 0.05, and 96 vs 71 ml/100 gm/minute, p less than 0.05). Right ventricular flow was higher in the M-P group at 10 and 30 minutes of bypass (98 vs 66 ml/100 gm/minute, p less than 0.05, and 90 vs 78 ml/100 gm/minute). Left ventricular flow was higher in the M-P group at 10 minutes of bypass (79 vs 52 ml/100 gm/minute, p less than 0.08). Septal flow also was higher in the treated group at 10 minutes of bypass (64 vs 49 ml/100 gm/minute) and at 30 minutes of bypass (92 vs 67 ml/100 gm/minute, p less than 0.05). CVR after 10 minutes of bypass was lower in the steroid group (88 mm Hg/ml/100 gm/minute vs 1.39 in the control group, p less than 0.03). It is concluded that M-P increases coronary blood flow and decreases CVR in the empty beating heart during normothermic CPB without altering myocardial metabolism or contractility.20

Effects of morphine and halothane anesthesia on coronary blood flow.

This study was undertaken to determine the relative effects of morphine and halothane anesthesia on coronary blood flow. Right heart bypass was instituted in 20 dogs by draining the vena cava blood into a cardiotomy reservoir and returning it to the main pulmonary artery. Coronary sinus drainage was measured by a right ventricular cannula. Group I (10 dogs) was sequentially given 0.5, 1, 1.5, 2.0, and 2.5% halothane. Group II (10 dogs) was given 1, 2, 3, 4, and 5 mg per kilogram of morphine intravenously. Arterial pressure, coronary sinus blood flow, cardiac output, arterial pH, PCO2, and PO2 were determined and repeated at each dose level of anesthesia and compared to the control values. Morphine significantly increased coronary flow at 3, 4, and 5 mg/kg without pressure adjustment and at 2 mg/kg after pressure adjustment. Coronary flow with halothane was unchanged from control values except for a decrease at 2.5%. Coronary flow was significantly greater with 3, 4, and 5 mg/kg of morphine than with 1.0 and 1.5% halothane.

Fatal air embolism following gunshot wound of the lung.

Air embolism following penetrating lung trauma has been reported infrequently and its existence is questioned. A death resulting from air embolism following a high-velocity gunshot wound is presented. Appropriate treatment and preventive measures are discussed.

Pulmonary sling. Case report and collective review.

The eighteenth survivor of correction of an anomalous left pulmonary artery arising from the right pulmonary artery is reported. This is the first case in which postoperative angiography demonstrated patency of the left pulmonary artery. The onset of symptoms in infancy, predominance of expiratory rather than inspiratory stridor, anterior indentation of the esophagus, and lethal progression of symptoms during the first year of life are peculiar to this anomaly. Operation through a left thoracotomy is advocated, with division of the proximal left pulmonary artery and implantation into the main pulmonary artery posterior to the phrenic nerve. Previously reported cases are collectively reviewed.