Bacterial colonization and infection of wounds in seriously burned patients often comes from the patient's indigenous bowel flora. A prospective randomized clinical trial that involved 30 patients with 20% or greater total body surface area burns was undertaken to evaluate the use of a standard antibiotic bowel preparation in the delay or prevention of bacterial colonization of the burn wound and sepsis. Certain enteric bacteria were seen less frequently in the treated group (Enterobacter organisms), but other bacteria appeared more often in the treated group (Proteus organisms and enterococci). The average time of colonization of the burn wounds was 6.1 days in the treated group and 6.7 days in the control group. Blood cultures were positive for enteric organisms earlier in the treatment group. Pseudomonads appeared earlier in the wound and blood cultures of the treated group than in the control group. The effect of antibiotic bowel suppression in patients with burns is varied and unpredictable. The bowel preparation may select certain organisms and lead to earlier colonization of the wounds. Overall outcome and survival was not improved by the use of an antibiotic bowel preparation in these patients.

Adult↗

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The physiologic response of a patient with critical burns to continuous passive motion.

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Burns↗

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Burn size estimate reliability: a study.

A study was undertaken to assess any differences between physicians' and nurses' estimates of burn size from drawings of 10 hypothetical patients with burns. Patient drawings were sent to the 199 burn facilities that are listed in the American Burn Association's Burn Care Resources in North America 1989-1990. The mailings were randomized between physicians and nurses. In order to have an even distribution, the cover letter asked the individual who received the forms to fill them out himself or herself rather than to pass them on to someone else. Forty-one nurses and 16 doctors (29%) returned the completed forms. The length of experience in burn care for the nurses averaged 9.3 years (range, 2 to 20 years), and the length of experience in burn care for the physicians averaged 14.7 years (range, 1 to 30 years [p = 0.01]). There were significant differences in the estimate of mean burn size between the physicians and nurses for only the two smallest drawings; in these cases, size may have been hard to translate from the patient to the drawing. There were four smaller burn charts (less than 20% body surface area), and in two (50%) of these, there were significant differences in the estimation of the burn size. For the six larger burn charts (greater than 20% body surface area), there were no differences in the size estimates. With regression analysis, no trend was noted that correlated the size estimates with the length of experience in burn care for either the physicians or the nurses. Additionally, the participants were asked to indicate which method of estimating burn size was used in their units. Thirty-five percent use the Rule of Nines, 33% use the Lund & Browder chart, 5.3% use Berkow's method, 3% use other methods, and 1.75% use a combination of the Lund & Browder chart and the Rule of Nines. Twenty-one percent failed to indicate any preferred method. Estimates of burn sizes with the use of standardized burn forms were consistently the same whether estimates were made by physicians or nurses. Sixty-eight percent of the respondents used the Rule of Nines or the Lund & Browder chart to estimate burn size, but 21% of the respondents failed to answer the question about which method is used in their units. In conclusion, there appears to be little variance in estimation of burn size as made by experienced burn nurses and physicians, and use of these estimates in a centralized data bank should be reliable.

Burn Units↗

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Positioning screen.

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Burns↗

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A comparison of the Tanner and Bioplasty skin mesher systems for maximal skin graft expansion.

Maximizing wound coverage of patients with burns who have meshed autografts is a primary intervention for wound closure. This study compared the Tanner and Bioplasty skin graft meshing systems for optimal skin graft expansion. Twenty patients for skin grafting were randomly assigned to either a Tanner or Bioplasty skin mesher group. Skin expansion ratios used with the Tanner group were 1.5:1 and 3:1, while Bioplasty ratios included 2:1 and 4:1. The patients' thighs were used exclusively as donor sites, and all grafts were harvested by the same surgeon. Expanded skin ratios were compared as to the difference in percent of predicted expansion outcome compared with the actual areas of the measured skin grafts. Comparing the differences of actual skin expansion with expected expansion, statistically significant results were found. When meshed skin grafts are used for wound closure, a 12.9% to 58.6% greater than anticipated area of donor skin should be harvested based on the expansion ratio selected.

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The effect of mechanical compression on chronic hand edema after burn injury: a preliminary report.

Chronic hand edema after wound healing is a troublesome condition to treat in patients with burns. Stagnant edema can cause fibrosis, which impedes rehabilitation and may lead to deformity. Although favorable results have been reported with mechanical compression used in acute injuries, no literature was found on the effects of compression for the treatment of chronic hand-burn edema. Five male patients with nine chronically edematous burned hands were subject to mechanical compression at 55 mm Hg pressure. A single-cell unit was used for a 30-minute treatment at 4:1 treatment ratio. Goniometric and volumetric hand measurements were recorded both before and after treatment. Although patients expressed a subjective feeling of improvement, no statistical difference was found in finger joint range of motion nor in hand volume when comparing pretreatment and posttreatment measurements. Many different treatment protocols exist in the literature and are discussed.

Adult↗

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Blood use in the burn unit: a possible role for erythropoietin.

Recently, several of our patients have raised questions concerning the safety of blood transfusions and especially the transmission of human immunodeficiency virus infection. We have noticed a growing reluctance of patients to receive blood transfusions. This prompted us to review the use of blood in our burn unit for 530 patients who were admitted from 1987 to 1989. Our traditional reasons for transfusion have been either an ongoing hemorrhage that leads to hypotension or a hematocrit of less than 30%. For these reasons 131 (24.7%) of the 530 patients reviewed required transfusions. The average number of units transfused in patients who received blood was 10 (range 1 to 69). Three hundred ninety-nine patients (75.3%) did not require transfusions. We undertook a prospective preliminary trial of recombinant erythropoietin in five patients who were admitted to our burn unit over a 2-month period to evaluate whether this agent could lessen the transfusion requirements. Because no definite value is given in the literature as to what level of hematocrit is most appropriate for transfusion, we chose a hematocrit of 20% as our new indication for transfusion. Inclusion into the trial required a total body surface area burn of over 10% that required at least one operation. Five patients met the inclusion criteria. Administration of erythropoietin was started on admission. According to our new criteria for transfusion none of the five patients receiving erythropoietin required the transfusion of blood or blood products. This study would suggest the need for both a prospective clinical trial of erythropoietin and further studies to better define the indications for transfusions in patients with burns.

Adult↗

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Photographic measurement of volar forearm skin movement with wrist extension: the influence of elbow position.

An important function of skin is to allow joint range of motion to occur. An assumed clinical relationship exists between joint movement and skin pliability. The purpose of this research was to document skin movement of the forearm and wrist with photography, to quantify the amount of skin movement during wrist extension, and to investigate the influence of elbow positions on forearm skin movement. Twenty volunteers had markings placed on the skin of the volar forearm. Each subject performed the motion of wrist extension in two elbow test positions of flexion and extension. Photographs were taken of the skin markings at the beginning and end of wrist extension. A significant difference was found in the amount of forearm skin movement that occurred when the elbow was extended and flexed (p < 0.001). These results substantiate the use of multijoint range of motion during burn rehabilitation.

Adult↗

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The wide variety of designs for dorsal hand burn splints.

A search of the burn literature to find standard dimensions for fabrication of a typical splint to use with patients with a dorsal hand and finger burn is an elusive endeavor. The original impetus for such a search stemmed from a discussion with a student therapist on how to properly splint a burned hand. An ongoing interest was sustained when no one set of universal dimensions for a hand splint design was found to exist. In fact, the literature is replete with numerous individual recommendations on the dimensions to make such a hand splint. In general, dorsal hand burn splints can be classified either as position of function or antideformity splints. However, there is little agreement among authors about how to make these splints. The purpose of this investigation was to document the wide range and variable designs among splints for dorsal hand burns and present the findings for use as a resource guide when making decisions about their fabrication.

Burns↗

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The effect of extremity range of motion on vital signs of critically ill patients and patients with burns: a pilot study.

The purpose of this study was to evaluate the effects of range-of-motion exercise on vital signs of critically ill patients. The vital signs of 10 consecutive critically ill patients were evaluated during passive and active-assistive range-of-motion exercise. Vital signs monitored were heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure. The average length of an exercise session was 22.6 minutes. No clinically significant difference was found between pretreatment and treatment heart rate, systolic blood pressure, diastolic blood pressure, or mean arterial pressure. It appears from this study that passive and active-assistive range-of-motion exercise can be performed safely, without unnecessary physiologic stress, on critically ill patients.

Adult↗

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Micrografts. II: Evaluation of 25:1, 50:1, and 100:1 expansion skin grafts in the porcine model.

This study was undertaken to evaluate 25:1, 50:1, and 100:1 expansions of micronized skin grafts in a porcine model. Two full-thickness skin excisions (graft and control) were performed on each of 30 immature pigs (20 pounds). The pigs were divided into three groups of 10 animals each: group A, 25 cm2; group B, 50 cm2; and group C, 100 cm2. One square centimeter of the excised skin was thinned to produce a thick split-thickness skin graft. Four 90-degree passes were made through a skin mesher with the smooth side of the plastic mesh carrier to produce uniform pieces of skin. These pieces were applied to one area on each pig. Both the graft and control sites were covered with film. The film was removed on postoperative day 7, and excision sites were photographed on postoperative days 7, 10, 14, and 21. Healing was evaluated with a 12 x 12 inch digitizing pad to estimate the percent area healed. Healing was compared via analysis of variance, with percent area healed used as the dependent variable and treatment (control or graft) and postoperative day and expansion size used as the independent variables. No difference was found on postoperative day 7. On postoperative day 10, 25:1 grafts healed better than the 50:1 grafts, which were healed more than the 100:1 grafts. No difference was seen between 25:1 and 50:1 grafts on postoperative day 14; however, they were healed better than the 100:1 expansion grafts. No difference was seen between the graft sites on postoperative day 21.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of Variance↗

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Dynamic versus static splints: a prospective case for sustained stress.

Application of constant tension to elongate tissue has been shown to be beneficial. A dynamic splint was used to achieve tissue creep and full elbow extension. Use of a static splint on the contralateral elbow did not allow elbow extension. This case report demonstrates for this patient the superiority of a dynamic elbow extension splint over a static splint when used to correct progressive loss of elbow range of motion.

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