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Biomedical subjects

L H Engrav

Publications and source records attributed to L H Engrav.

At least 37 records · Page 2Linked to original sources
PubMed1990

Outcome and treatment of electrical injury with immediate median and ulnar nerve palsy at the wrist: a retrospective review and a survey of members of the American Burn Association.

Electrical injury to the upper extremity with immediate median and ulnar nerve palsy at the wrist is uncommon but devastating. When it does occur, the immediate clinical questions are (1) will the nerves recover, and (2) should the carpal tunnel and Guyon's canal be released? Our review of the literature did not answer these two questions. Therefore, we reviewed our experience with such patients and surveyed approximately 10% of the physician members of the American Burn Association. We reviewed approximately 80 patients with electrical injuries treated between January 1983 and September 1988, and found 5 patients (8 extremities) who did not require amputation and who manifested immediate palsy of the median and ulnar nerves at the wrist. The questionnaire was returned by 83% of those contacted. We concluded that such nerve palsies can recover to a significant degree and that a majority of surgeons would release the carpal tunnel and Guyon's canal, expecting improved recovery. Although it is still not proven whether decompression is beneficial, we will continue to decompress the carpal tunnel and Guyon's canal in such circumstances.

Adult↗
PubMed1990

Neurologic consequences of electrical burns.

Permanent neurologic damage following major electric injury is a dreaded and often discussed complication. The incidence, severity, and sequelae are not clear from the literature. Therefore we reviewed the charts of 90 consecutive patients admitted to the University of Washington Burn Center between 1980 and 1986 looking at neurologic consequences. Electric injuries accounted for 4% of 2,305 admissions. The mean age was 31 +/- 13 years, total body surface area involved (TBSA), 6 +/- 11%, and length of stay, 13 +/- 20 days. There were 82 males and eight females. There were four deaths, for a mortality rate of 4%. Fourteen patients had 18 amputations. Twenty-two patients sustained low-voltage injury; 50% had immediate neurologic symptoms which resolved in nine of 11 patients. Eleven patients (50%) were asymptomatic. Sixty-four patients sustained high-voltage injury and 33% were asymptomatic. Forty-three patients (67%) had immediate central and/or peripheral neurologic symptoms. Loss of consciousness accounted for the largest fraction of CNS sequelae in the high-voltage group (45%). Twenty-three patients (79%) recovered consciousness before arrival at the hospital. Six patients remained comatose, three died, and three awoke but had neurologic sequelae. Twenty-two patients in the high-voltage group had one or more acute peripheral neuropathies. Sixty-four per cent of these neuropathies resolved or improved. Five patients had transient initial paralysis, but there were no delayed spinal cord symptoms. Eleven patients developed one or more delayed peripheral neuropathies. Half of these delayed neuropathies resolved or improved.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1990

Upper abdominal wall defects: immediate or staged reconstruction?

One-stage reconstruction of the central and lower abdominal wall with vascularized tissue has been well described. A few cases of one-stage reconstruction of the upper abdomen also are reported. We attempted this procedure in six of seven patients who had large abdominal wall defects that reached the xiphoid process. In three patients, the intraabdominal parts of the procedures went well and the reconstructive goals were accomplished. In three other patients, prolonged and difficult intraabdominal operations resulted in considerable intestinal dilatation that compromised the reconstruction. We therefore recommend being prepared to abort a planned immediate abdominal wall reconstruction following a difficult intraabdominal operation. The abdomen should be temporarily closed with skin flaps, skin grafts, or absorbable mesh, and definitive reconstruction of the fascia should be done at a later operation.

Abdominal Muscles↗
PubMed1989

Topical growth factors and wound contraction in the rat: Part I. Literature review and definition of the rat model.

The isolation and production of growth factors and the observation that a platelet extract will promote wound healing in chronic wounds has led to an interest in the study of growth factors and wound healing. We wished to study the effect of platelet-derived growth factor on wound contraction. However, because studies of growth factors and wound contraction are quite recent, we could find only two models described in the literature and neither seemed ideal. Both used small wounds, which are difficult to measure, anesthetics with slow induction and recovery and which are difficult to titrate, and no dressings, which permits the animals to lick the wounds and possibly introduce other growth factors. We therefore reviewed wound contraction models used for other studies. In particular, we reviewed the animal used, anesthetic, wound size and shape, dressing methods, scab treatment, and measurement and comparison techniques. We then combined features of many of them into a model that solves the problems listed and permits the study of topically applied growth factors and wound contraction. The composite model to be described uses a large, circular wound on the rat, halothane anesthesia, and flexible, Tubigrip dressings.

Administration, Topical↗
PubMed1989

Topical growth factors and wound contraction in the rat: Part II. Platelet-derived growth factor and wound contraction in normal and steroid-impaired rats.

The wound contraction model described in Part I was used to study topically applied, recombinant platelet-derived growth factor (rPDGF-BB) and wound contraction in normal and steroid-impaired rats. Circular wounds 4 cm in size were made on the dorsum of the rats with halothane anesthesia. Five groups of 20 normal rats each were treated with the vehicle alone and four concentrations of rPDGF-BB (0.5, 1.0, 3.0, and 10.0 micrograms/ml). Four groups of 20 steroid-impaired rats each were treated with the vehicle alone and three concentrations of rPDGF-BB (0.5, 1.0, and 3.0 micrograms/ml). The wounds were dressed with 2 x 2 gauze, Adaptic, 4 x 4 gauze, and Tubigrip. The investigators were blinded to the treatments until the completion of the experiment, and the treatments were applied in random order. Dressings were changed every 2 to 3 days for 14 days and the wound areas were determined, expressed as a fraction of the original, and plotted versus time. The areas under the curves and the means of the fraction open each day were compared between groups using Student's t-test. The treatment with 3.0-micrograms/ml rPDGF-BB accelerated the rate of wound contraction in the steroid-impaired animals (p less than 0.05).

Administration, Topical↗
PubMed1989

The "sponge deformity" after tangential excision and grafting of burns.

Sequential excision and grafting of burns have resulted in several new problems. We have termed one of these the "sponge deformity," i.e., a grafted area where, in multiple small areas, the bed heals underneath the graft with or without slough of the overlying graft. If the graft sloughs, a pockmark forms. If the graft does not slough, an overlying bridge forms. In our experience, this deformity is very troublesome to patients because it is difficult to wash, catches on objects, bleeds, and looks quite unsightly. Between February of 1981 and June of 1986, we treated 16 patients with this deformity. All 16 patients were treated by simple excision of the bridges and pockmark edges with a curved iris scissors. In all patients, the wounds healed well and the resultant surfaces were considerably smoother. This retrospective review of the patients suggests that the deformity usually occurs around the periphery of the excised area where the excision was shallower and when thicker grafts are used. Perhaps the bed underneath the graft epithelializes from residual epithelial elements prior to vascularization of the autograft. If this is true, it might be possible to prevent the deformity by excising the wound deeper, by applying thinner grafts, or by applying allograft or xenograft, expecting that the area will heal promptly and not require autografting.

Adolescent↗
PubMed1988

A comparison of intramarginal and extramarginal excision of hypertrophic burn scars.

Hypertrophic scarring is common in burn patients. The treatment of such scarring is difficult, and recurrence of the hypertrophic changes after scar revision is not uncommon. It has been suggested that intramarginal excision diminishes the chances of recurrent hypertrophic scarring, but we could not find any papers in the literature actually comparing intramarginal and extramarginal excisions. We therefore reviewed our experience with intramarginal and extramarginal excision of hypertrophic scars. Between October 30, 1979, and March 26, 1986, we excised 50 hypertrophic scars in 23 burn patients. Thirty-one (62 percent) of the excisions were intramarginal and 19 (38 percent) were extramarginal. We compared the results and observed that the intramarginal excisions yielded better results than the extramarginal excisions.

Adolescent↗
PubMed1988

Ischemic injury to enteric free flaps: an experimental study in the dog.

Enteric free flaps have proven to be useful for reconstructing the cervical esophagus. Although jejunum is favored, the rationale for this is not at all clear. We have postulated that resistance to warm ischemia varies in different regions of the gut. An experiment was carried out in 10 mongrel dogs in which 10-cm segments of proximal, middle, and distal small bowel were isolated on single vascular pedicles. In each portion of the gut there were three segments: a control, a segment subjected to 60 minutes of warm ischemia, and a segment subjected to 120 minutes of warm ischemia. The following day each animal was reexplored, and the viability of bowel segments was assessed visually and with fluorescein. All control segments were viable at 24 hours. Twenty segments were subjected to 1 hour of warm ischemia, and all but two were viable. Nineteen gut segments were subjected to 2 hours of warm ischemia. Seven of eight proximal segments were viable, two of five midsegments were viable, and zero of six distal segments were viable. Survival in the distal portion compared to the proximal portion was significantly less (p less than 0.01). It appears from this study that isolated distal small bowel segments are less resistant to warm ischemia than proximal segments.

Adult↗
PubMed1987

Toxic epidermal necrolysis. A step forward in treatment.

Toxic epidermal necrolysis is an uncommon but severe form of epidermal sloughing with associated mucositis. Treated in a general hospital, it carries a high mortality (25% to 70%) and substantial long-term morbidity. If the patient is referred early to a burn center, where it can be treated with biologic dressings and intensive support care, the mortality can be reduced below 20% and there may be negligible long-term morbidity. We describe 19 patients so treated, with three deaths and no long-term complications.

Adolescent↗
PubMed1987

Clinical evaluation of laser Doppler blood flow measurements in free flaps.

Adequate assessment of blood flow in free flaps with early detection of circulatory failure is an unresolved clinical problem. In 23 patients undergoing microvascular free tissue transfers, laser doppler blood flow measurements and clinical observations were made hourly for the first two postoperative days. There was 1 flap failure in 6 instances in which it was clinically necessary to intervene, by reexploration or draining a hematoma, to ensure the survival of the flap. It was hypothesized that the laser doppler measurements would predict future clinical events. However, it was found that although these measurements did correlate with clinical observations, they did not predict them and were actually less accurate in indicating the need for clinical intervention or the final outcome of the free flap procedure.

Adult↗
PubMed1987

Impairment, time out of school, and time off from work after burns.

Objective measurement of impairment after burns is important to patients, physicians, lawyers, and insurance companies. Even so, we could not find any references in the English literature describing how to objectively rate the physical impairment of burn survivors. The American Medical Association (AMA) has published the book Guides to Evaluation of Permanent Impairment, which is commonly used by surgeons to rate injuries. We decided to use this document to rate the impairment of burn patients. We studied patients who were treated at the University of Washington Burn Center during the years 1981, 1982, and 1983; survived the injury; were hospitalized 5 or more days or were skin grafted; and were followed until their condition was fixed (usually 12 months). This group included 325 patients. The mean age was 28.2 years and the mean total body surface area burned (TBSA) was 11.6 percent. We measured whole-man impairment (WMI) as described by the Guides to the Evaluation of Permanent Impairment. The mean whole-man impairment was 7.7 percent. In addition, we recorded time off from work and out of school after burns. The average time off from work was 12.7 weeks, and the average time out of school was 8.5 weeks. We conclude that the AMA publication can be used to rate burn patients and that the whole-man impairment of burn survivors is quite low if amputation, loss of range of motion, and nerve damage can be prevented.

Absenteeism↗
PubMed1986

Excision of burns of the face.

Sequential excision of burns is now a common technique. Nevertheless, standard texts, when describing the treatment of facial burns, recommend allowing spontaneous separation of the eschar and then grafting on granulation tissue if healing does not occur. This method yielded disappointing results for us and the reconstructive procedures required were of great magnitude. Therefore, in January of 1979, we began primary excision and grafting of those face burns not essentially healed at 10 days. We have now treated 16 consecutive patients (approximately 5 percent of all face burns) in this manner who are at least 12 months postinjury. Three were lost to follow-up, leaving 13 for evaluation. This method yields better appearance and function than that obtained by allowing spontaneous healing over more than 3 weeks or grafting on granulation tissue and decreases the magnitude of subsequent reconstruction.

Burns↗
PubMed1986

Pediatric patients in a regional burn center.

Because scald burns are reported to be the leading cause of burn injuries to children, little is written about other etiologies of burn injury in the pediatric literature. To test the hypothesis that burns from other etiologies are more serious and require longer hospitalizations than scald burns, a retrospective chart review was undertaken. The charts of all patients less than 16 years of age who were admitted to Harborview Medical Center Burn Unit in the years 1979 to 1984 were reviewed. Four hundred sixty-four children were admitted to the regional burn center during that time. We found that children under four years of age are at greatest risk for being hospitalized for thermal injury, that the burn most commonly occurs inside the home between 6 PM and midnight, and that scalds are the most common etiology for thermal injuries in children (54%). However, 46% of the burns resulting in admission to our burn center were from etiologies other than scald injury. There was no significant correlation between etiology of the burns and length of hospital stay, rate of infection, or need for excision and grafting. Thermal injuries to children from any etiology are serious; pediatric health care providers should be aware that children may be burned in a variety of ways and should direct some of their well-child visit time to the topic of burn prevention in the home.

Accidents, Home↗
PubMed1984

Improved treatment of the Stevens-Johnson syndrome.

The Stevens-Johnson syndrome (SJS), a disease resulting in greater than 30% body surface area epidermal and mucosal desquamation, is reported to have a mortality of greater than 50%. Recommended treatment has included steroids, prophylactic antibiotics, nutritional support, and application of topical antibacterials. Since the lesions represent only epidermal loss without dermal necrosis, rapid reepithelialization should occur if the dermis is protected from desiccation with a biological dressing. Five nonburned patients with severe SJS were treated in the University of Washington burn center, Seattle, with urgent operative debridement of their wounds and application of porcine xenograft immediately after admission. Steroid administration was stopped. Antibiotics were used only for culture-proved infections. All patients completely re-epithelialized within a mean of 18 days. There was one death, a 9-year-old boy who was completely re-epithelialized when sudden fatal sepsis that originated from a ventriculovenous shunt placed when he was an infant developed. In this group of patients, rapid wound closure with xenograft and supportive care permitted rapid reepithelialization and decreased mortality and morbidity.

Adult↗
PubMed1984

Burn depth estimation--man or machine.

A Burn Depth Indicator, utilizing reflectance ratios of red, green, and infrared light, has been devised and clinically tested for 18 months at our Burn Center. Using the endpoint of wound healing in less than or more than 3 weeks, clinical assessment by two experienced surgeons of intermediate depth wounds was compared to readings from the BDI . In about one third of cases the surgeons were unwilling to commit themselves to a prediction. In the cases where the surgeons were willing to make a prediction, they were incorrect about 25% of the time. The BDI was significantly more accurate than the clinical assessment in those predicted not to heal by the surgeons and maintained an accuracy of 79% in the wounds where the surgeons would not make a prediction. The BDI is portable, noninvasive, and provides an immediate reading. It may have utility as a triage tool for emergency rooms or combat situations, and has utility at present in our Burn Center as a more accurate tool than our clinical judgment in predicting which wounds should be excised and grafted during the first few days after injury.

Burns↗
PubMed1983

Early excision and grafting vs. nonoperative treatment of burns of indeterminant depth: a randomized prospective study.

Compared to nonoperative treatment with silver sulfadiazine cream, early excision and grafting of 22 patients with indeterminant burns of less than 20% TBSA resulted in an average shorter hospitalization, lower cost, and less time away from work than 25 patients treated nonoperatively. While early excision and grafting resulted in increased use of blood products and operating room facilities, this did not result in increased patient morbidity. Long-term followup demonstrated no difference in need for reconstruction, incidence of blisters, incidence of loss of motion, or contour irregularities. Those patients treated nonoperatively required more late grafts for closure and demonstrated more hypertrophic scarring. Those treated by early excision demonstrated more mesh graft irregularity. We conclude that in otherwise healthy patients with dermal burns of indeterminant depth less than 20% total body surface area, early excision and grafting is the preferred form of treatment.

Adolescent↗
PubMed1982

Early surgical excision versus conventional therapy in patients with 20 to 40 percent burns. A comparative study.

Using the records of 72 patients treated at the University of Washington Burn Center, this study compared the results of early surgical excision (by 14 days postburn) and autografting to those of autografting after spontaneous separation and bedside debridement of burn eschar. Excised patients had shorter hospitalizations and lower rates of burn wound sepsis and serious burn wound contamination, and less use of potentially toxic antibiotics (p less than 0.05) than did the prognostically equivalent group treated before the introduction of early excision. Excised patients required more blood transfusions (p less than 0.05), but did not differ significantly from controls in rates of mortality or other inpatient complications, in the number of operations performed, or in the adjusted hospital costs. Evaluation of patients treated over the entire study period for more shallow burns indicated no concurrent change in other aspects of burn care which might account for the observed results. We conclude that early excision and grafting in young, otherwise healthy patients with 20 to 40 percent total body surface area burns that are likely to heal within 3 weeks is more effective than the more traditional management of slow wound separation and debridement.

Adolescent↗