Cultured epidermal autograft and the treatment of the massive burn injury.

As a rule, adult and pediatric patients with thermal injuries that involve more than 90% total body surface area (TBSA) burn have poor prognoses. Even for patients who are 5 to 34 years old with a 70% TBSA burn, the mortality rate is 80%. Lack of autologous donor skin, which is essential for permanent wound closure, is the major problem. Recent advances in growth of cultured epidermal autograft (CEA) have allowed closure of full- and partial-thickness burns; in approximately 3 weeks, a 2 cm2 biopsy specimen will produce enough CEA to cover a pediatric patient. Since 1989, we have used this product on nine patients; the average age was 39, and the average TBSA burn was 70% (range, 44% to 93%). We report our approach to use of CEA in six of these patients, including topical applications of 1% silver sulfadiazine and excision of full- and deep partial-thickness wounds within 2 weeks of injury. Temporary closure was achieved with cadaver allograft. "Take" of the allograft forecasted take of CEA. The total operative time of CEA placement was decreased by a two-step technique that obviates repeating debridement: the technique consists of debriding and grafting with allograft, then removing it at the time of CEA placement. CEA take is best on early granulation tissue or freshly excised wounds. Early excision of burn eschar, temporary wound closure with cadaveric allograft and Biobrane (Winthrop Pharmaceuticals, Wound Care Div., Fountain Valley, Calif.), and permanent closure with CEA may improve survival rates among patients with massive burn wounds. CEA is a tremendous asset to the management of massive burn injuries.     

Personality characteristics and perceived health problems after burn injury

The relationship between personality traits and the perceived outcome of burn injury 1 to 18 years (mean, 9.2 years) after severe burn injury was evaluated in 166 individuals treated at the Uppsala Burn Unit. The perceived outcome was measured with the Burn Specific Health Scale-Brief (BSHS-B) and was related to personality traits evaluated by means of the Swedish universities Scales of Personality. After controlling for age at inquiry, time since injury, burn area, and sex, a stepwise logistic regression analysis revealed an association between the Swedish universities Scales of Personality domain Neuroticism and Bad outcome in all BSHS-B domains, both psychosocial and physical, and Insufficient outcome in the domains Work, Body image, Affect, and BSHS-B total score. The neurotic traits Somatic trait anxiety, Psychic trait anxiety, Stress susceptibility, Embitterment, and Mistrust each or in different combinations explained the observed relationships. The data suggest that personality is related to health status because it is perceived a long time after severe burn injury and that its effect is not confined only to psychological but also to physical aspects of life.     

Microalbuminuria in acute burn injury.

Microalbuminuria is a known finding in inflammatory states. We hypothesized that urinary albumin/creatinine ratio (ACR) would correlate with injury severity and resuscitation demands after acute burns. This pilot study evaluated 30 adults admitted within 12 hours of injury with burns > or =10% total body surface area burn injury (TBSA). The urinary ACR was calculated for each patient at 7 to 12 hours, 19 to 24 hours, and 43 to 48 hours following burn injury. Microalbuminuria was defined as a urinary ACR > or =20 mg/g. Study patients (23 males, 7 females) had a mean age of 42.9 + 14.0 years and a median TBSA burn injury of 18.8%. Inhalation injury was present in 10 of the study patients, and all patients with inhalation injury had microalbuminuria at the time of admission. One study patient died. Median time from burn injury to resuscitation was 30 hours, and the median fluid requirement was 4.2 ml/kg/%TBSA. Microalbuminuria was not uniformly present in burn-injured patients during the first 48 hours after injury. ACR values early in the hospital course correlated with higher lactate concentrations early after burn injury. However, ACR correlated with neither injury severity nor resuscitation demands after burn injury during any studied time range. Microalbuminuria does not have apparent clinical utility in burn-injured patients, and other markers of injury severity and resuscitation demands should be sought.     

163例老年人烧伤的特点与治疗

目的回顾总结163例老年烧伤发病特点及救治经验。方法从总的比率、性别比、季节、年龄特点、致伤地点、原因、部位、转归、创面处理、补液和抗生素应用等方面阐述老年烧伤的发病规律和治疗经验。结果男68例,女95例,其中146例家中致伤,年龄越大发病危险性越高,部位以下肢等暴露部位常见,对原有疾患要及时治疗并注重老年患者的护理,深Ⅱ°和Ⅲ°创面的患者,宜尽早手术。结论老年人致伤多在家中发生,要重视预防在家中烧、烫伤。     

Impact of oxandrolone treatment on acute outcomes after severe burn injury

Pharmacologic modulation of hypermetabolism clearly benefits children with major burns, however, its role in adult burns remains to be defined. Oxandrolone appears to be a promising anabolic agent although few outcome data are as yet available. We examined whether early oxandrolone treatment in severely burned adults was associated with improved outcomes during acute hospitalization. We evaluated for potential associations between oxandrolone treatment and outcomes in a large cohort of severely burned adults in the context of a multicenter observational study. Patients were dichotomized with respect to oxandrolone treatment, defined as administration within 7 days after admission, with duration of at least 7 days. Acute hospitalization outcomes were compared with univariate and multivariate analyses. One hundred seventeen patients were included in this analysis. Mean patient age was 42.6 years (range, 18-86); 77% were male, with an average TBSA of 44.1%. Baseline and injury characteristics were similar among treatment and nontreatment cohorts. Oxandrolone treatment (N = 59) did not impact length of stay but was associated with a lower mortality rate (P = .01) by univariate analysis. Oxandrolone treatment was independently associated with higher survival by adjusted analyses (P = .02). Examination of early oxandrolone treatment in this cohort of severely burned adults suggests that this therapy is safe and may be associated with improved survival. Further studies are necessary to define the exact mechanisms by which oxandrolone is beneficial during inpatient treatment.     

Laboratory monitoring of nutritional status in burn patients.

Most nutrition laboratory testing relies on serum concentrations of ingested nutrients, their coenzymes, proteins, or lipids. Alternatively, functional tests measure a specific physiological process or biochemical reaction. We compared these two approaches to nutritional assessment in intensive-care burn patients, in whom the serum concentrations of transthyretin (prealbumin), albumin, transferrin, carotene, retinol, ascorbic acid, copper, cholesterol, iron, and calcium were all below established reference ranges. In contrast, serum triglyceride concentrations were often above the reference range. Functional tests for thiamin, riboflavin, pyridoxine, and iron (by zinc protoporphyrin/heme ratio) in these patients all showed normal values. Dietary intake, weight trends, and nitrogen balances all indicated that these patients' estimated caloric and protein needs had been met. These findings suggest that static measurements of serum concentrations may be unreliable indicators of nutritional status in burn patients.     

Hypnotizability and trauma symptoms after burn injury.

This study investigated the association of trauma symptoms and hypnotizability in 43 hospitalized survivors of burn injury. Three to 17 days after the injury, participants rated the frequency of intrusive and avoidance symptoms and were interviewed with the posttraumatic stress disorder module of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-III-R. The Hypnotic Induction Profile was also administered at the postburn, hospital stage of recovery. Results indicated that when participants were divided into low, mid-range, and high hypnotizability categories, high hypnotizability was associated with more intrusive, avoidance, and arousal symptoms. Although causal relations cannot be assessed in this cross-sectional study, these results suggest that, as compared to the low and mid-range categories, high hypnotizables may experience a greater frequency of trauma symptoms after burn injury.     

Pharmacokinetics and pharmacodynamics of ranitidine after burn injury.

The pharmacokinetics and pharmacodynamics of ranitidine were studied in 10 hypermetabolic burned patients with normal creatinine clearance and compared with healthy volunteers. Ranitidine was administered as a single 50 mg intravenous bolus and multiple blood samples were obtained up to 10 hours after the dose for determination of plasma ranitidine concentrations. Gastric pH in burned patients was monitored by way of a nasogastric tube. Burned patients exhibited significantly higher (p less than 0.01) ranitidine clearance (mean +/- SD; 10.80 +/- 2.38 versus 7.53 +/- 1.71 ml/min/kg) and steady-state distribution volume (1.63 +/- 0.13 versus 1.16 +/- 0.33 L/kg). Within an hour of administration of drug the gastric pH was greater than or equal to 4.0 in all but one patient. This pH was maintained for at least 6 hours. In five patients the pH was greater than or equal to 4.0 throughout the 10-hour study. Thus, despite increased ranitidine clearance, the recommended dose of ranitidine maintained gastric pH greater than or equal to 4.0 throughout the normal dosing interval in the majority of patients. Dosage adjustment reported for many other drugs after burn injury may not be necessary for ranitidine.     

脑外伤后持续性植物状态的研究现状

持续性植物状态 ( Persistent Vegetative State, PVS) 是指一种持续觉醒而无意识状态 , 目前各国间对 PVS的诊断标准尚未达到统一 . PVS以脑外伤最为多见 , 其主要病理表现为弥漫性轴索损害、脑皮层弥漫性坏死及选择性丘脑坏死 . 正电子发射型计算机断层显像是目前检查 PVS最有意义的方法 . PVS目前没有确切有效的治疗方法 , 脑外伤后 PVS较其他原因的 PVS预后好 .     

A half-century of burn epidemiology and burn care in a rural state

The aim of this study is to quantify the changes in incidence, severity, and mortality in burn injuries in the state of Maine over the past 50 years from both prevention and treatment perspectives. The authors analyzed the data from multiple sources, including the U.S. Census, death certificates, hospital discharge abstracts, and institutional burn registries in Maine and Boston. The average annual number of burn-related deaths decreased from 53 in 1960-1964 to 14 in 2004-2008. The Maine age-adjusted rate of burn deaths was 8.6% above the national rate in 1960 and 1.4% below it in 2006. The annual number of burn patients admitted to Maine hospitals declined by 65% from 1978 to 2009. Since 1999, 12% of hospitalized patients in Maine were treated in an American Burn Association-certified burn center in Boston. Mortality for Maine burn patients, including those treated at Boston hospitals, is directly related to age and burn severity and similar to stratified mortality in the National Burn Repository. Incidence, severity, and mortality of burn injuries in Maine have decreased dramatically over the past 5 decades. Prevention programs, legislation, and a regionalized system of burn care have all likely contributed to bringing Maine's morbidity and mortality rate below the national average.     

Lifestyle adjustments in elderly patients after burn injury.

Although survival of older burn victims has improved significantly in recent years, controversy remains over the care that should be given to this group and the functional recovery of survivors. To assess the impact of burn injury on lifestyle in the elderly, we conducted a mail-in survey among surviving patients ages 45 years or older who were treated in our burn center from 1978 to the middle of 1987. The survey asked questions about living arrangements, personal care, family relations, social life, work status, and outlook on the future. Of 168 surveys mailed, 109 were completed and returned (64.9%). Responders consisted of 82 men and 27 women with a mean age of 57.8 years (range, 45 to 92 years). Ninety-seven percent of patients were able to return home after discharge, but 27% of the oldest patients (ages greater than 75 years) required permanent placement in extended care facilities. With increased age there was an increased tendency toward dependence and the need for assistance in daily living; half of the oldest patients required assistance in daily living. Even so, most of the patients in this survey remained independent and maintained a positive outlook on the future. These results appear to justify a policy of aggressive treatment for elderly burn victims.     

Influence of definition and location of hypotension on outcome following severe pediatric traumatic brain injury

OBJECTIVE: To examine the influence of definition and location (field, emergency department, or pediatric intensive care unit) of hypotension on outcome following severe pediatric traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: Harborview Medical Center (level I pediatric trauma center), Seattle, WA, over a 5-yr period between 1998 and 2003. PATIENTS: Ninety-three children <14 yrs of age with traumatic brain injury following injury, head Abbreviated Injury Score > or = 3, and pediatric intensive care unit admission Glasgow Coma Scale score <9 formed the analytic sample. Data sources included the Harborview Trauma Registry and hospital records. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The relationship between hypotension and outcome was examined comparing two definitions of hypotension: a) systolic blood pressure <5th percentile for age; and b) systolic blood pressure <90 mm Hg. Hospital discharge Glasgow Outcome Score <4 or disposition of either death or discharge to a skilled nursing facility was considered a poor outcome. Pediatric intensive care unit and hospital length of stay were also examined. Systolic blood pressure <5th percentile for age was more highly associated with poor hospital discharge Glasgow Outcome Score (p = .001), poor disposition (p = .02), pediatric intensive care unit length of stay (rate ratio 9.5; 95% confidence interval 6.7-12.3), and hospital length of stay (rate ratio 18.8; 95% confidence interval 14.0-23.5) than systolic blood pressure <90 mm Hg. Hypotension occurring in either the field or emergency department, but not in the pediatric intensive care unit, was associated with poor Glasgow Outcome Score (p = .008), poor disposition (p = .03), and hospital length of stay (rate ratio 18.7; 95% confidence interval 13.1-24.2). CONCLUSIONS: Early hypotension, defined as systolic blood pressure <5th percentile for age in the field and/or emergency department, was a better predictor of poor outcome than delayed hypotension or the use of systolic blood pressure <90 mm Hg.     

Growth hormone and cortisol secretion in patients with burn injury.

A prospective study of growth hormone, insulin-like growth factor (IGF-1), and cortisol secretion was undertaken in six adults with burn injury. Serum concentrations of growth hormone and IGF-1 were low in all patients during the first 2 weeks of hospitalization. The mean growth hormone level was 4.35 +/- 0.83 micrograms/L on day 1 and 1.70 +/- 0.50 micrograms/L on day 13. The mean serum concentration of IGF-1, which reflects overall growth hormone secretion, was 0.43 +/- 0.09 U/ml on day 1 and 0.61 +/- 0.11 U/ml on day 13; these values are distinctly low. After 3 to 4 weeks, IGF-1 concentrations increased to the mid-normal range, whereas growth hormone values did not change. Morning plasma cortisol concentrations were modestly elevated; however, urine free cortisol concentrations, which reflect total cortisol secretion, were elevated 2 to 28 times above normal values at the time of admission (mean, 443.5 +/- 323.7 nmol/L). Urinary free cortisol concentrations remained elevated after 2 weeks (mean, 230.5 +/- 94.5 nmol/L). Patients with burn injury have inappropriately low growth hormone secretion and IGF-1 production in spite of the stress of the injury and more than adequate nutritional therapy.     

Laryngeal and phonatory status after burn/inhalation injury: a long term follow-up study

Although persistent hoarseness has been recognized in patients who have sustained burn and/or smoke inhalation injuries, there is little documentation to support this observation. Furthermore, there is no quantification of either the pervasiveness of the problem or the severity of the dysphonia resulting. It was the intent of this study to examine the laryngeal condition and voice production of a group of patients who were long-term survivors of burns and inhalation injuries. Only 10 patients (8 male and 2 female) of a larger cohort were willing to return for this examination. They were ambulatory and did not require respiratory assistance, and it had been 16 to 25 years since their initial traumas. Videostrobolaryngoscopic examinations were performed and analyzed, measures of various acoustic and aerodynamic parameters were made, and severity of dysphonia was judged. Seven of the 10 subjects were rated by experienced listeners as having some degree of dysphonia. All subjects had some abnormality of the laryngeal mucosa. Stroboscopic examination was found to be helpful in identifying laryngeal abnormalities in at least half of the subjects. Early attention to these problems, many of which are treatable surgically or behaviorally or both could lead to an improved voice for the patient and for this reason an improved quality of life.     

Cutaneous heat loss shortly after burn injury in children.

1. Total heat loss and its components have been studied in cool (20 degrees C) and warm (30 degrees C) environments in 30 healthy children and 21 children who had been burned (10-17% body surface area) 0.5-29 h previously. 2. In healthy naked children at 20 degrees C, the partition of total heat loss was: radiation, 64%; convection, 32%; evaporation, 4%. On transfer to the warm, total heat loss was reduced by approximately 50%, with disproportionate reductions in the contributions from radiation and convection being offset, to some extent, by an increase in evaporative heat loss. 3. In patients during the first 5.5h after injury, the magnitude and pattern of heat loss at 20 degrees C and 30 degrees C were similar to those in control subjects and were unaffected by bandaging. 4. Ten to twenty-nine hours after injury, when the patients were bandaged and body temperature and heat content were significantly higher than in control subjects, radiant and convective heat losses were increased, but as evaporative heat loss tended to be reduced; total heat loss in the warm was unchanged. However, at this time at 20 degrees C, total heat loss was reduced compared with healthy children at the same ambient temperature. 5. The findings of unchanged or reduced total heat loss and reduced evaporative heat loss in injured patients are interpreted as inappropriate responses to an increased body temperature and heat content in children after burn injury.     

Indices of injury. Development and status

Each of the indices of injury provides a systematic method by which to collect and report data about the trauma victim. Since the 1960s, researchers and physicians have tried to develop predictive tools which are capable of evaluating the current status of the victim as well as determining morbidity and mortality. This article traces the development of indices of injury and provides their current status.     

Pediatric soup scald burn injury: etiology and prevention.

One of the leading causes of scald burn injury in children is from hot soup, particularly prepackaged instant soups. The purpose of this study was to determine the demographic, socioeconomic, and situational factors that contribute to the incidence of scald burns in children. A 20-item questionnaire was given to the caregiver of children who were treated for scald burn injury at a pediatric burn center from July 2006 to March 2007. Questions included demographics (child age, gender, siblings, ethnicity), socioeconomic status (income, education), factors contributing to the injury (type of soup, child supervision, type of container), and location of injury. The mean age of the 78 children sustaining burn injury and completing the survey was 4.8 +/- 0.6 years. The majority of patients were girls (51%), and the most frequently involved ethnic group was Hispanic (44%). Households had a mean of 3.0 +/- 0.3 children in residence, and an income of less than $29,000/year (59%). The highest educational level achieved was high school for 73% of the parents. Prepackaged soup (65%) with a narrow base heated directly in the original container (46%) using the microwave (51%) was implicated in the majority of burns. Soup scald burns, especially from prepackaged instant soups, appear to predominate in lower income families with multiple children. The majority of injuries occur when the caregiver heats the soup in the original container using the microwave. Prevention of these types of injuries will require a two-pronged approach: educating families with multiple children and changing the soup packaging.