Biomedical subjects

D G Greenhalgh

Publications and source records attributed to D G Greenhalgh.

71 records · Page 4Linked to original sources

PubMedDate not supplied

Inhalation injury severity scoring system: a quantitative method.

Inhalation injury, a major contributor to burn-related mortality, has been difficult to quantify. A scoring system paralleling current adult respiratory distress syndrome systems has the potential to distinguish survivors from nonsurvivors. The utility of the PaO2/FiO2 (P/F) ratio in predicting injury severity was first examined. In a review of 120 patients with inhalation injury, those with P/F ratios greater than or equal to 300 after resuscitation were more likely to survive than those with ratios less than 300. The P/F ratio had no value when obtained before resuscitation. Next, a scoring system was developed to assist in comparing the severity of injury in ventilator-dependent patients with burns. Measurements were recorded prospectively in four categories: chest x-ray evaluation, P/F ratio, peak inspiratory pressure, and bronchoscopy. When comparing survivors (20) versus nonsurvivors (6), significant differences were found early (day 0, day 1, and week 1) for P/F ratio and overall severity score. Differences were seen later (week 1 and week 2) for chest x-ray evaluation and peak inspiratory pressure values. Because of low numbers the value of bronchoscopy could not be evaluated. The role of an inhalation injury severity scoring system for predicting survival should be examined in larger prospective trials.

Adult↗

PubMedDate not supplied

Iron burns to the hand in the young pediatric patient: a problem in prevention.

Iron burns to the hand may result in both functional and cosmetic deformities in the young pediatric patient. To gain a better understanding of these injuries in terms of demographics, treatment, and outcome, and to address possible measures for prevention, the medical records of 82 pediatric patients suffering iron burns to the hand during the period 1987 to 1993 were reviewed. Iron burns to the hand occurred most commonly in male children less than 2 years of age. Most were minor partial-thickness burns that were treated in the outpatient setting with no adverse sequelae. Fifteen percent of patients, however, sustained full-thickness burns that required grafting. Ten percent of patients developed complications including hypertrophic scarring and scar contractures requiring surgical release. Socioeconomic factors and parental inexperience appeared to play a significant role, as most of these injuries occurred in low-income, single-parent, single-child households. Most injuries were unintentional, however, many were caused by carelessness or neglect. Abuse was suspected or proven in 7% of cases. Parents may be unaware of the consequences of leaving a child unattended in the presence of a hot iron. The incidence of these injuries could be reduced effectively by improved public awareness of the problem and education in prevention.

Burns↗

PubMedDate not supplied

The use of sheet autografts to cover extensive burns in patients.

We previously have reported on the enhanced cosmetic and functional outcome with the use of sheet autografts. The recent goal has been to cover larger surface areas with sheet grafts, or for patients with larger burns, covering the hands and face with sheet grafts, if possible. To evaluate the use of sheet grafts in burns of more than 30% total body surface area (TBSA), the percentage covered with sheet and meshed autograft was reviewed in 105 patients admitted between January 1, 1990, and August 30, 1994. Results were that 18 patients (17%), with a mean of 44.3% TBSA burns, had all of their full-thickness wounds (mean, 36.5% +/- 2.2%; range, 20% to 55.5%) covered with sheet grafts (Group 1). Seventeen patients (16%), with mean burn size of 64.3%, had their wounds (mean, 35.1% +/- 4.4%; range, 15% to 79%) covered solely with mesh graft (Group 2). The lower percentage covered by mesh alone was skewed by the high mortality rate (53%) in this group. Seventy patients, 58.4% +/- 19% (range, 30% to 92%) TBSA burn, had their full-thickness wounds covered with a combination of mesh and sheet graft (Group 3). In Group 3, the mean percentage of TBSA covered by sheet grafts was 15.0% +/- 1.4% (range, 1% to 42.5%) and that covered by meshed grafts was 39.4% +/- 2.6% (range, 4% to 93%). Three quarters (73%) of patients in this group had sheet grafts placed on the face, whereas 63% had them placed on the hands. Extremities and the trunk were more often grafted with mesh graft. Sheet grafts were the sole coverage in patients with burns up to 55.5%. With even larger burns, sheet grafts were used to cover the face and hands. Because of its superior cosmetic and functional outcome, sheet autografting should be considered for covering moderately sized burns. Sheet autografting should be considered for more important cosmetic and functional areas, such as the face and hands, for massive burns.

Adolescent↗

PubMedDate not supplied

Pediatric burn patients with respiratory failure: predictors of outcome with the use of extracorporeal life support.

Extracorporeal life support (ECLS) for pediatric burn patients is a viable option for respiratory failure that is unresponsive to maximal conventional therapy. No criteria have been identified that are predictive of the success of the use of ECLS for these patients. This article presents a retrospective review of the pediatric burn patients placed on ECLS at a single pediatric medical center. It was found that 12 patients (mean age, 30.3 months; range 6 to 69 months) were placed on ECLS because of profound pulmonary failure that was unresponsive to aggressive ventilatory support. The mean size of the burns of these patients was 50.2% of the total body surface area (average size of full-thickness burns, 41.8% total body surface area), with 6 patients having scald burns and 6 having flame burns. The overall survival was 67% (8 of 12). Nonsurvivors had greater positive end-expiratory pressure, mean airway pressure, peak inspiratory pressure, and oxygenation index before ECLS. It is felt that ECLS is a life-saving therapy for pediatric patients with thermal injury. Greater ventilator requirements before ECLS are associated with nonsurvival. Early institution of ECLS in pediatric burn patients with severe respiratory failure may prevent excessive barotrauma and thus discourage the onset of irreversible lung injury.

Burns↗

PubMedDate not supplied

Topical application of yeast extract accelerates the wound healing of diabetic mice.

Alcoholic extracts of yeast have been used as the active ingredient in medications under names such as "tissue or skin respiratory factor," Biodyne (Sperti Drug Co, Cincinnati, Ohio--now defunct), and live yeast cell derivative (LYCD). Beneficial clinical results from the use of LYCD have been reported for the treatment of burns, wounds, and hemorrhoids. The medicinal effects of LYCD have recently been localized to a protein fraction containing a mixture of several peptides. The effects of topical application of the peptide mixture on wounds were examined in diabetic mice, an animal model in which the healing process is disrupted and delayed. Full-thickness wounds were created on the backs of diabetic (DB) and nondiabetic (non-DB) mice. Half of the DB and non-DB mice were treated with 0.05 mL of LYCD after wounding and for 4 successive days. All other mice received vehicle. Wound areas were measured at Day 0 and at 2-day intervals. Mice were sacrificed at 3, 7, 10, 21, and 28 days postinjury. Differences in the extent and quality of healing appeared between DB mice receiving LYCD and DB mice receiving vehicle by day 10 (P < .0001). By 24 days postinjury, DB mice receiving LYCD had achieved 100% wound closure, whereas DB mice receiving vehicle had achieved only 31.4% wound closure. Histologic examination of wounds reflected improved wound healing in DB mice receiving LYCD as compared with those receiving vehicle. A topically applied yeast extract peptide mixture significantly attenuates wound closure and the degree of cellular reorganization of full-thickness excisional wounds of DB mice.

Administration, Topical↗

PubMedDate not supplied

Torchiere-style halogen floor lamps: a need for fire safety awareness.

Torchiere-style halogen lamps pose a significant fire hazard. The 500-W halogen bulb in these lamps can generate temperatures as high as 1200 degrees F. Factors related to the design of the lamp also contribute to the fire risk. The Consumer Products Safety Commission has issued various warnings and recalls on these lamps because of a significant number of fire-related incidents and deaths. The impact of these recalls on a random sample of consumers was investigated. A survey of these participants revealed that 60% of lamp owners and nonowners were unaware of the recalls. The majority of respondents were also not aware of the risks of injury, the extreme bulb temperatures, or safety measures designed for these lamps. There is a need for increasing community awareness and education to reduce the fire hazards associated with this product.

Burns↗

PubMedDate not supplied

Gelatinase activities in wounds of healing-impaired mice versus wounds of non-healing-impaired mice.

The gelatinases, matrix metalloproteinase-2 and -9 (MMP-2 and MMP-9), have been implicated in different aspects of wound repair. However, little is known about MMP-2 and MMP-9 activity in animal models of impaired wound healing. We sought to compare serial gelatinase activities for 25 days after full-thickness excisional wounds in genetically diabetic healing-impaired mice and their nondiabetic non-healing-impaired littermates. Wound samples were frozen, homogenized, clarified by centrifugation, and analyzed on zymography gels, and MMP bands were quantitated relative to a conditioned media standard from HT-1080 cells. Gelatinase activity in both diabetic mice and nondiabetic mice increased after the mice were wounded. However, levels of latent gelatinases peaked earlier in the diabetic wounds, and there was more active MMP-2 and MMP-9 in the wounds of the diabetic mice than in the wounds of the nondiabetic mice. Because the higher gelatinase activity in the wounds of the diabetic mice was similar to the higher levels of gelatinase reported in difficult-to-heal wounds such as ulcers and burns, this diabetic mouse model may be useful for studies of these proteinases and their inhibitors in impaired wound healing.

Animals↗

PubMedDate not supplied

The effect of medical insurance coverage on the obtainment of pressure garments.

Pressure garments are used to alter the appearance of immature burn scars. These garments are costly, and delays in obtaining them are frequent. The purpose of the study was to determine the nature of the delays in the obtainment of pressure garments and to examine the role that the payer plays in these delays. The billing and medical records of all patients with burns measured for pressure garments between January 1, 1998, and August 1, 1999, were reviewed. The distribution of payers was as follows: workers' compensation, 37%; state-funded insurance, 32%; health maintenance organizations, 12%; private insurance, 16%; and other, 3%. Payment authorization time for pressure garments was 37 days for state payers and less than 10 days for all other groups. Patients with state-funded insurance waited an average of 67 days to receive their garments as opposed to a wait of 20 to 30 days for other payers. The percentage of billed charges paid was least for patients with state-funded and HMO insurance (58% and 51%, respectively). The interval to payment of charges was longer than 60 days for all groups. Marked delays in authorization exist for state-funded reimbursement of pressure garments. Reimbursement for patients with state- and HMO-funded insurance was lower than for other payers. These differences may have an adverse effect on outcome.

Adult↗

PubMedDate not supplied

Cost-effective use of helicopters for the transportation of patients with burn injuries.

We performed a retrospective review to analyze the use of helicopters for the transportation of patients with burn injuries to determine whether a more cost-effective approach could be developed without impairing the quality or delivery of health care. Charts were reviewed for all patients with burn injuries who were transported by helicopter to our hospitals during a 2-year period. Patients with inhalation injuries, with burn injuries received more than 24 hours before admission or more than 200 miles from our burn center, with more than 30% total body surface area (TBSA) burned, or with associated trauma injuries were excluded. Control patients with burn injuries who were transported by ambulance were identified and matched to the patients with burn injuries transported by helicopter for the percentage of TBSA burned, the percentage of third-degree burns, transport mileage, and age. The outcome was evaluated by comparison of length of stay, days on ventilator, and mortality rate. Comparisons were performed with Student t test. The transportation charge was determined for the patients transported by helicopter who we believed were eligible for transport by ambulance. Forty-seven of 85 patients transported by helicopter matched the inclusion criteria and had survived. There was no statistically significant difference between the percentage of TBSA burned, the percentage of third-degree burns, length of stay, days on ventilator, age, or transport mileage. There was, however, a significant difference in the time from the injury to admission to the hospital, as well as in the charge for transportation. Patients who had less than 30% TBSA thermal cutaneous injuries without evidence of inhalation injury, and who are less than 200 miles from a burn center may be safely transported by ambulance. Ambulance transportation may take additional time; however, stricter protocols for helicopter transportation of patients with burn injuries will result in potentially substantial savings without affecting outcomes for patients.

Adolescent↗

PubMedDate not supplied

Results of early excision and full-thickness grafting of deep palm burns in children.

The timing and method of treatment of deep palm and finger burns varies widely. Our protocol involves performing full-thickness skin grafts (FTSG) in nonhealing palm burns. We reviewed the functional and cosmetic results after FTSG to the palm. From August 1997 to April 1999, 11 patients (12 palms) underwent excision and FTSG within 2 weeks of injury. A panel of medical and nonmedical professionals evaluated follow-up pictures of the grafts at 1, 2 to 4, and beyond 4 months. Parameters used for evaluation were color match with the unburned skin (1 = no difference to 4 = large difference), graft thickness (1 = flat to 4 = markedly raised), overall appearance (1 = poor to 100 = excellent), and time to maturity. Hand function, as assessed by occupational therapy notes, was also recorded. All 12 grafted palms had a 100% take and healed with minimal scarring. Mean color match scores were 2.4 at 1 month, 1.8 at 2 to 4 months, and 1.6 beyond 4 months. On the graft thickness scale, grafts were given scores of 2.6, 2.2, and 1.9 during the same intervals. The overall appearance was 71 at 1 month, 81 at 2 to 4 months, and 85 beyond 4 months. All grafts except 1 were judged to be mature at 2 to 4 months follow-up. Full passive range of motion was attained in all grafted hands within the period of 2 to 4 months after operation. Early excision and FTSG of deep pediatric palm burns can be performed in the outpatient setting. The grafts have an acceptable color match, are minimally raised, and achieve excellent cosmetic result. The grafts mature within a few months after surgery to allow for rapid return to normal range of motion. FTSG should be considered as a first choice for deep palm burns.

Burns↗

PubMedDate not supplied

A multicenter clinical trial to evaluate the topical hemostatic efficacy of fibrin sealant in burn patients.

Current surgical management of deep partial-thickness and full-thickness burn wounds involves early excision and grafting. Blood loss during these procedures can be profound, thus prompting the use of topical hemostatic agents to control and minimize hemorrhage during grafting. The primary endpoint of this multicenter trial was to evaluate the efficacy of fibrin sealant as a topical hemostatic agent during skin grafting. The secondary endpoint was to obtain data to support the existing safety profile of a human fibrin sealant (FS) in participating patients as indicated by the type, severity, and frequency of any adverse events within the 24-hour postoperative period. A multicenter prospective, open label, Phase III multicenter, randomized, comparative clinical trial evaluated the use of fibrin sealant in burn patients undergoing skin graft procedures. Each patient served as his or her own control in this randomized, unblinded study of the effect on time to hemostasis in donor sites treated with the investigational FS product. At operation, 1 contiguous donor skin harvest site was bisected into 2 equal halves, 1 of which was then randomly selected and treated with fibrin sealant. At the end of the fibrin sealant application, the time to hemostasis in each of the donor site halves was identified by the operating surgeon and recorded by the research coordinator. The use of any other topical hemostatic agents was prohibited. A significant difference (P < .001) was demonstrated in the mean time to hemostasis between the fibrin sealant treated donor sites when compared painwise to the control sites. The significant difference was consistent across the 6 participating study centers. There were no adverse events associated with the use of fibrin sealant. The investigational FS product was shown to be efficacious, because it significantly decreases the time to hemostasis at the donor skin harvest site in patients undergoing skin grafting and was noted not to cause any adverse reactions.

Administration, Topical↗

PubMedDate not supplied

Sodium azide burn: a case report.

Chemical burn injuries commonly occur at the workplace and can be caused by a variety of agents. Sodium azide is a volatile compound used in the industrial setting and it is also a constituent of car airbags. The known toxic effects of sodium azide include hypotension, bradycardia, and headaches. At the cellular level, it inhibits of ATP production by blocking the respiratory oxidation cascade. In the burn literature only one previous report documents a sodium azide hand burn caused by airbag malfunction. We report a case of massive exposure and resultant systemic toxicity from a sodium azide canister explosion.

Adult↗

PubMedDate not supplied

Inverted television and video games to maintain neck extension.

It has been the standard of care in our pediatric facility to keep patients on strict bedrest with the neck in hyperextension for 5 days after a neck contracture release or grafting. Multiple methods have been used to help maintain neck immobility after grafting. It has been challenging to maintain strict bedrest protocols, because of decreased compliance and boredom. To address this issue, we examined common sedentary diversional activities engaged in by children. We decided to use video games to facilitate the intrinsic motivation of play. The monitor of a video game activity was inverted and placed behind the head of the bed so that the child could maintain proper neck positioning. We found the activity to be beneficial in many aspects. It helped maintain neck positioning, decreased the demand for individual interventions, and provided opportunities for improving self-confidence.

Adolescent↗

PubMedDate not supplied

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century.

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

APACHE↗

PubMedDate not supplied

Use of an improved Watusi collar to manage pediatric neck burn contractures.

Burns to the neck present a serious challenge to the pediatric burn team. Even when full neck range of motion is maintained, scarring may lead to banding and a loss of the neck's natural contour. Conventional thermoplastic neck conformers have been used to maintain neck position and provide pressure to maturing scars, but they are rigid and limit functional mobility. This is of particular concern in the pediatric population where limiting neck mobility can disrupt the development of sensory and motor patterns that are essential to normal developmental progression. The Multi-Ring Watusi collar is a flexible neck orthosis that allows mobility and provides circumferential pressure to the neck. We modified this collar to improve its comfort, cosmetic appearance and ease in donning/doffing. The improved Watusi collar is a flexible splint that supports neck position, provides circumferential pressure, and allows for functional neck mobility.

Bandages↗

PubMedDate not supplied

Current management of purpura fulminans: a multicenter study.

Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

Adolescent↗

PubMedDate not supplied

Purpura fulminans: a disease best managed in a burn center.

Victims of purpura fulminans are overcome by a rapidly progressive and sometimes fatal course involving large amounts of tissue loss and multiple organ system failure. From 1986 to 1995, seven children ranging in age from 10 months to 19 years (mean, 6.2 years) were referred to the Shriners Burns Institute in Cincinnati with purpura fulminans. Neisseria meningitidis was identified as the precipitating pathogen in most of the patients. The mean TBSA full-thickness skin loss was 33%. Fourteen extremities were amputated in the seven patients, including three patients with amputations of all four extremities. Transfer to our institution occurred after a mean delay of 20 days, usually after the demarcation of viable tissue. In one patient, however, fasciotomies obviated multiple impending amputations. Monitoring for elevated compartment pressures, early fasciotomies, and expedient transfer to a burn center for a multidiciplinary approach to care should improve the outcome in patients with purpura fulminans.

Adolescent↗