Biomedical subjects
Publications and source records attributed to G F Purdue.
Early identification of soft tissue injury is a major problem in the patient with frostbite injury. A patient is presented with a method for early (less than 2 days) identification of nonviable tissue. This is a noninvasive method employing technetium 99m stannous pyrophosphate which was used to accurately predict the level of ultimate amputation.
Aneurysms of the high internal carotid artery, though rare, present a therapeutic problem. Presented herein is a case report and a method of primary repair.
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Cold injury remains a crippling problem. Although research is opening new avenues of accurate diagnosis and expeditious treatment, the gold standard against which these methods must be measured continues to be conservative treatment.
Considerable controversy exists as to whether a tracheostomy (TT) is ever indicated in burn patients. Eighty-eight tracheostomies were performed over a 48-month period. An inhalation injury was present in 59.6% of the patients, and 96% had preceding endotracheal intubation (ET). The mean duration of ET was 14 days. Seven percent, 17% and 58% of the TTs were performed within the 1st, 8th, and 14th postburn day, respectively. The indications for TT were: emergency airway access, 7%; complications secondary to ET, 8%; pulmonary sepsis, 75%; pulmonary failure, 10%. The mean duration of TT was 33 days (range: 1-209). Major complications associated with TT included: tracheomalacia, tracheostenosis, tracheoinnominate artery and tracheoesophageal fistulae, and posttracheostomy dysphagia. The decision to perform a TT or to continue with ET should not be predicated on an arbitrary number of days, but must be individualized and based on the clinical condition of the patient. The complications associated with a TT are related to previous ET and to the underlying pulmonary pathology necessitating ventilatory support.
A prospective study was performed to assess the indications for and complications of femoral vascular access in burn patients. In the study, 1655 femoral catheters (one-third arterial) were inserted in 232 patients; 136 of the catheters were inserted in 29 children (18 were younger than five years of age; the youngest was four months old). Insertion was "easy" in 83.9% of the insertions and "difficult" in 7.6%, with no difference noted between arterial and venous insertions. There were six significant complications: local abscess requiring drainage (2), arterial occlusion (3), and extravasation (1). No septic arthritis, deep infections, catheter erosions, venous thrombosis, embolisms, or late complications were noted. Venous and arterial access through the femoral vessels is an appropriate route for vascular access in burn patients when care is taken to minimize complications. This area is usually free of burn, provides ready access to central vessels, is technically easy, and has few complications.
Significant loss of shoulder range of motion (ROM) in the early stages of burn recovery is a common and frustrating complication of burn injury. Pain is a primary reason for decreased motion: it prevents the patient from cooperating in an aggressive therapy program that could minimize contracture formation. To combat loss of movement without inflicting severe pain, the performance of ROM exercises and gentle passive stretching while patients were anesthetized was used as a treatment. A total of 59 treatments were performed on 14 patients who had limited unilateral or bilateral shoulder motion. A significant gain in shoulder ROM was attained when this treatment was performed and resulted in an increase in shoulder ROM when the patient was alert after anesthesia compared with preanesthesia measurements.
Obesity is seldom recognized as a risk factor for the patient with burns. However, the overweight patient with burns presents major problems for the burn team, especially in the areas of wound care, pulmonary care, and general nursing care. One-hundred eighty adults (9.1% weighed more than 45 kg above ideal body weight or more than 100 kg in total weight. Mean weight was 110 kg, with 155 patients heavier than 100 kg. Mean age was 38 years with a mean burn size of 26% (11% full-thickness). The mortality rate was 21%, and respiratory and cardiovascular complications occurred in 33% of these patients. The obese patient presents problems disproportionate to burn size, burn location, and age. The obese patient's problems are related to weight. Care is often compromised by the physical constraints of a patient's size.
Secure positioning of orally or nasally placed endotracheal and gastric tubes is a necessity for the patient with burns. This article describes a technique for securing these tubes with a simple modification to avoid compression on the ear that may lead to subsequent necrosis and infection.
Many pediatric burns can be prevented. However, education must be presented in an informative and interesting manner to be effective. Is it possible to teach burn safety to elementary school children in four sessions? Sixty-six fourth-grade children were involved in age-appropriate activities, experiments, and discussion that were spaced evenly throughout the school year. Content was based on material furnished by the local fire department with added videos and exercises. By having children crawl blindfolded on their bellies through halls like GI Joe TV characters and by having them watch dry vapors swirl around their faces, boring burn lectures can be turned into challenging and entertaining games. In a game-type testing session, 40 of 49 questions were answered correctly the first time. A community teaching project for interested burn team members is easily planned and implemented. The enthusiastic response of the children and the satisfaction of preventing a possible burn injury promotes continued involvement.
Cardiac disease has many manifestations that may complicate burn care. A review of 2477 consecutive acute burn admissions was conducted to determine the types and incidence of cardiac complications in this patient population. Nearly one half of patients with a prior cardiac history manifested some form of cardiac dysfunction, most frequently arrhythmias. Eight percent had an in-hospital myocardial infarction. Only 6% of patients without a prior cardiac history manifested cardiac dysfunction. The in-hospital mortality rate after myocardial infarction for both groups was 3.5 to 4 times that of patients without burns. Except for patients with prosthetic valves, for whom anticoagulation and infection prophylaxis are required, burn care of the cardiac patient is expectant with selective use of invasive monitoring and therapy as determined by the patient's clinical course.
Review of admissions to a regional burn center showed that tap-water burns were an injury of pediatric, elderly, and neurologically impaired patients. A study was designed to measure general knowledge of tap-water injury and awareness of tap-water temperatures in homes. All those surveyed realized the potential for tap-water scald burns in their homes, and few believed that they could tolerate hot-only tap water at home for as long as 30 seconds. Respondents who had previous experience with tap-water burns had not lowered the settings of their water-heater thermostats. Economical but effective programs must be developed to encourage burn-reduction behaviors in high-risk groups.
One hundred fifty-nine consecutive patients with high-voltage burns were retrospectively reviewed to determine the ocular sequelae of these injuries. Five patients had ophthalmic changes (two had recurrent iritis, eight had cataracts, two had macular holes, and one had central retinal artery occlusion). All four patients with cataractous changes had characteristic anterior subcapsular opacifications, except for one patient who presented with a dense white opacified lens. All had bilateral lenticular changes in which the denser cataract developed earlier than the contact wound and ipsilateral to it. Central retinal artery occlusion has not been previously reported as a complication of electrical burns. Macular holes, formerly believed to be rare in these injuries, were found in two of the five patients. Ocular complications from electrical burn injuries are uncommon. Although a number of these ocular changes occur immediately after injury, many of the visually impairing changes develop days and even years after a severe electrical burn injury; thus, careful follow-up is mandated.
Acute adrenal insufficiency is an uncommon but devastating complication of severe burn injury. The diagnosis is rarely made antemortem. Acute, fatal, adrenal insufficiency developed in three patients among 807 critically ill patients with burns treated at this institution during the past 6 years. Thermal injuries elevate corticosteroid secretion for weeks after injury, severely stressing the adrenal glands. Overload of the hypothalamic-pituitary-adrenal axis is thought to make this system unusually vulnerable to acute infarction. Although the actual mechanism of adrenal hemorrhage is not clear, the combination of excessive adrenocorticotropic hormone stimulation and hemodynamic instability have been implicated in its evolution. Survival may be too short for characteristic Addisonian metabolic changes to develop. Acute adrenal insufficiency is a rare event that is historically associated with meningococcemia, although any life-threatening illness may precipitate this catastrophe. Therefore, when a sudden deterioration in the patient with thermal injuries is encountered, adrenal insufficiency must be considered.
Previous studies showing that propranolol upregulates beta-adrenergic receptors and protects against myocardial ischemia led us to hypothesize that preburn propranolol would protect against postburn cardiac dysfunction. Guinea pigs were treated with propranolol 3 mg/kg/day for 14 days, then deeply anesthetized and subjected to a 45% 3 degrees scald burn; eight guinea pigs treated with propranolol served as the control group (group 1). Burned guinea pigs were resuscitated with Ringer's lactate given as either 4 ml (group 2, N = 8), 6 ml (group 3, N = 10), or 8 ml (group 4, N = 6) per kg/% burn. Guinea pigs treated for 14 days with vehicle (water) were subjected to either sham burn (non-propranolol control, group 5, N = 10) or burn and treatment (group 6, N = 10) as described for group 2. Fluid resuscitation in non-propranolol-treated guinea pigs failed to overcome burn-induced cardiac deficits, as indicated by significantly lower left ventricular pressure, 86 +/- 2 versus 62 +/- 3 mm Hg; +dP/dt max, 1365 +/- 43 versus 1110 +/- 44 mm Hg/sec; -dP/dt max, 1184 +/- 31 versus 881 +/- 40 mm Hg/sec, p < 0.001. Burn-mediated cardiac defects occurred in all propranolol-treated guinea pigs regardless of the fluid volume given. Our data show that (1) propranolol did not protect against burn-induced cardiac dysfunction, and (2) chronic beta-adrenergic blockade increases postburn fluid requirements for maintenance of cardiodynamic stability and for survival.
Acute pseudo-obstruction of the colon (Ogilvie's syndrome) is a rare but potentially morbid complication of burn injury. Two thousand seven hundred three consecutive critically ill patients with burns were reviewed for findings consistent with pseudo-obstruction. Eight (0.29%) patients were identified. Mean age was 63.5 years, and mean burn size was 24.6% total body surface area. All patients were undergoing mechanical ventilation at the time of diagnosis. Six had a previous cardiac condition or complication, and five were on digoxin. Diagnosis was suspected in seven patients before colonoscopy or surgery. Six patients were treated with colonoscopy alone with one treatment failure. Two deaths occurred during hospitalization. Two late deaths were due to underlying cardiac conditions. The preferred treatment of Ogilvie's syndrome is nasogastric suction, colonic decompression, and close observation with surgery reserved for treatment failures or when diagnosis is in doubt. The incidence of Ogilvie's syndrome in patients with burns appears to be related to nonburn medical conditions, especially cardiopulmonary complications and age, rather than to the burn itself.
The objective of this study was to characterize the association between drug and alcohol intoxication at the time of injury and subsequent complications and mortality in hospitalized patients with burns. A computerized burn database was used to analyze data on 3047 consecutive adult (21 to 75 years) hospitalized patients with burns admitted between January 1982 and August 1994. Data for intoxicated (by history, blood alcohol content, or positive drug screen) and nonintoxicated patients were compared. The same analysis was also conducted on 429 consecutive adolescent patients with burns (ages 14 to 20 years) admitted during the same time period. The incidence of intoxication at the time of burn was 6.9%. No significant differences in age, sex, race, or burn size were noted. Intoxicated patients had a higher incidence of associated injuries. Skin graft loss, cellulitis, donor site conversion, hypotension, and pneumonia were more common in the intoxicated group. They also had more intensive care unit admissions, ventilator days, operations, transfusions, and total hospital days. Intoxicated patients had a lower mortality (7.1%) than patients in the control group (10.9%). Intoxication at the time of burn injury is an important predictor of complications in adult patients with burns.
This multicenter study compared the use of a biosynthetic human skin substitute with frozen human cadaver allograft for the temporary closure of excised burn wounds. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) consists of a synthetic material onto which human neonatal fibroblasts are cultured. Burn wounds in 66 patients with a mean age of 36 years and a mean burn size of 44% total body surface area (28% total body surface area full-thickness) were surgically excised. Two comparable sites, each approximately 1% total body surface area in size, were randomized to receive either DG-TC or allograft. Both sites were then treated in the same manner. When clinically indicated (> 5 days after application) both skin replacements were removed, and the wound beds were evaluated and prepared for grafting. DG-TC was equivalent or superior to allograft with regard to autograft take at postautograft day 14. DG-TC was also easier to remove, had no epidermal slough, and resulted in less bleeding than did allograft while maintaining an adequate wound bed. Overall satisfaction was better with DG-TC.