Extensive Thermal Injury Research Articles

Electrical Accidents

Electrical Accidents Abstract: When persons seek medical help after an electrical injury, physicians have to inquire on the type (AC/DC) and strength of current (>1000V is considered "high voltage") as well as the exact circumstances (loss of consciousness, falls) of the accident. In the advent of high-voltage accidents, loss of consciousness, arrhythmias, abnormal ECG or elevated troponin levels, in-hospital rhythm monitoring is warranted. In all other cases, the type of extra cardiac injury primarily directs the management. Superficial skin marks may disguise more extensive thermal injuries of inner organs.

Total Hip and Femoral Artery Replacement

A 67 year old man presented with acute right lower extremity ischaemia (Rutherford stage IIb) following total hip replacement. Digital subtraction angiography demonstrated occlusion of the femoral bifurcation (red arrow; A). During open surgery, an extensive thermal injury related to the prosthesis implantation was seen on the arterial wall and in the surrounding soft tissue; furthermore, a fistula (white arrow) was detected to the hip joint. The arterial bifurcation was replaced using autologous saphenous vein (B). The patient had an uncomplicated post-operative recovery and was discharged for rehabilitation with a patent vascular reconstruction.

391 Cutaneous Host Metabolomic Alterations after Burn Injury in a Murine Model

Metabolomics is the study of the biological pathways affected by the unique metabolites of an organism. This field has been extensively researched in many pathological processes such as cancer and blunt/penetrating trauma, but knowledge of the effects of thermal injury on the metabolome is comparatively limited. The aim of this study is to investigate the regulation of metabolites after an extensive thermal injury in a murine model to better understand the resulting tissue damage and identify potential therapeutic targets. Depilated mice were subjected to 30% total body surface area (TBSA) burn by submersion in 100⁰C water. Skin biopsies were taken on euthanasia at 2, 6 and 24 hours after injury (n=3 for all time points). An equal number of mice had sham procedures and biopsy collection for each time point. Samples were analyzed by ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF-MS). Multivariate analysis, the principal components analysis (PCA), was calculated using R and to validate metabolic changes. Two hours after burn injury, differential regulation between injured and sham animals was found in 4495 metabolites. Of these, 1733 metabolites achieved statistically significant difference (p<0.05). These metabolites have the greatest impact on the linoleic acid metabolism pathway. At hours 6 and 24, 1528 and 1924 metabolites respectively were differentially regulated with statistical significance. At hour 6, linoleic acid metabolism was again the most affected pathway. At hour 24, D-glutamine and D-arginine pathways were the most affected. Comparing all burned animals to all sham animals, 728 metabolites were differentially regulated. Pathways containing a significant number of these common elements include arachidonic acid, starch and sucrose metabolism. Thermal injury induces changes in the metabolome of mice that are evident in skin biopsies. The continual involvement of the arachidonic acid pathway highlights the inflammatory process that occurs in the 24 hours after burn injury. The common changes in starch and sucrose metabolic pathways reflects the hypermetabolism that results from burns. The dynamic process of burn injury response is revealed in the variability of differentially regulated metabolites at each time point. Further, the pathways most affected at hour 24 differ from those at the earlier time points, which are more closely associated with inflammation. Future research will determine the potential of using skin biopsies in human patients after thermal injury to investigate metabolomic changes. Early recognition of these alterations may help influence clinical interventions to promote appropriate inflammatory response and long-term healing.

Otologic considerations in a full face transplant recipient

Facial transplantation provides a functional and aesthetic solution to severe facial disfigurement previously unresolved by conventional reconstruction. Few facial allografts have been ear containing; hence, there is limited knowledge of the postoperative otologic considerations. We describe the case of a 44-year-old man who underwent transplantation of the total face, eyelids, ears, scalp, and skeletal subunits in 2015 after an extensive thermal injury. We detail the patient's transition from osseointegrated prosthetic ears to an ear-containing facial allograft, and describe the unique surgical approach and challenges encountered. Subsequent bilateral revision meatoplasties were performed, which provided relief from stenosis of the external auditory meatus. Laryngoscope, 129:2008-2011, 2019.

Extensive Hand Thermal and Blast Injury From Electronic Cigarette Explosion: A Case Report.

Background: As the use of electronic cigarettes rises, more reports of injuries related to device explosion are surfacing. Methods: Presented here is the case of a 35-year-old man sustaining extensive thermal and blast injuries to his hand when the device exploded while he was holding it. He required multiple surgeries involving groin flap coverage, tendon transfer, and nerve grafting to optimize his postinjury function. Results: While much of his hand function has been restored, he has continued deficits in range of motion and sensation as a result of the incident. Conclusions: With increasing numbers of such injuries, hand surgeons must be aware of the blast mechanism involved so as to avoid missing deep soft tissue injury or disruption of deep structures, as demonstrated in this case.

Aspergillus Orbital Gangrene Following Extensive Thermal Injury

Aspergillus Orbital Gangrene Following Extensive Thermal Injury

Increased serum NKG2D-ligands and downregulation of NKG2D in peripheral blood NK cells of patients with major burns.

Immune suppression following major thermal injury directly impacts the recovery potential. Limited data from past reports indicate that natural killer cells might be suppressed due to a putative soluble factor that has remained elusive up to date. Here we comparatively study cohorts of patients with Major and Non-Major Burns as well as healthy donors. MICB and ULBP1 are stress ligands of NKG2D that can be induced by heat stress. Remarkably, serum concentration levels of MICB and ULBP1 are increased by 3-fold and 20-fold, respectively, already within 24h post major thermal injury, and are maintained high for 28 days. In contrast, milder thermal injuries do not similarly enhance the serum levels of MICB and ULBP1. This kinetics coincides with a significant downregulation of NKG2D expression among peripheral blood NK cells. Downregulation of NKG2D by high concentration of soluble MICB occurs in cancer patients and during normal pregnancy due to over production by cancer cells or extravillous trophoblasts, respectively, as an active immune-evasion mechanism. In burn patients this seems an incidental outcome of extensive thermal injury, leading to reduced NKG2D expression. Enhanced susceptibility of these patients to opportunistic viral infections, particularly herpes viruses, could be explained by the reduced NKG2D expression. Further studies are warranted for translation into innovative diagnostic or therapeutic technologies.

501 Incidence and Risk Factors for Sedation-Associated Complications in Gastrointestinal Endoscopy — Initial Data From the German Prosed Registry a Prospective, Multicenter Study by Members of the Working Group of Leading Hospital Gastroenterologists (Algk) in Germany

501 Incidence and Risk Factors for Sedation-Associated Complications in Gastrointestinal Endoscopy — Initial Data From the German Prosed Registry a Prospective, Multicenter Study by Members of the Working Group of Leading Hospital Gastroenterologists (Algk) in Germany

Effect of Mixed Transplantation of Autologous and Allogeneic Microskin Grafts on Wound Healing in a Rat Model of Acute Skin Defect

The treatment of extensive thermal injuries with insufficient autologous skin remains a great challenge to burn surgeons. In this study, we investigated the influence of the ratio of autologous and allogeneic tissue in mixed microskin grafts on wound healing in order to develop an effective method for using limited donor skin to cover a large open wound. Four different mixtures were tested: autologous microskin at an area expansion ratio of 10∶1 with allogeneic microskin at an area expansion ratio of 10∶1 or 10∶3 and autologous microskin at an expansion ratio of 20∶1 with allogeneic microskin at an expansion ratio of 20∶3 or 20∶6. Wound healing, wound contraction, and integrin β1 expression were measured. Mixed microskin grafting facilitated wound healing substantially. The mixture of autologous microskin at an expansion ratio of 10∶1 with the same amount of allogeneic microskin achieved the most satisfactory wound healing among the 4 tested mixtures. Histological examination revealed the presence of obviously thickened epidermis and ectopic integrin β1 expression. Keratinocytes expressing integrin β1 were scattered in the suprabasal layer. Higher levels of integrin β1 expression were associated with faster wound healing, implying that ectopic expression of integrin β1 in keratinocytes may play a pivotal role in wound healing. In conclusion, this study proves that this new skin grafting technique may improve wound healing.

Spinal Diastematomyelia: A means of identification of charred remains

The purpose of medico legal autopsy examination is the positive identification of the deceased in addition to the determination of the cause of death in most jurisdictions and additionally the manner of death in many jurisdictions. Notwithstanding the established and recognised value of DNA analysis in human identification, in the case of significant and extensive thermal injury in victims of fire, DNA analysis may prove difficult. Fire fatality identification can be assisted by alternative methods in this situation, including correlation between ante mortem and post mortem radiological investigations, identification of rare medical disease and or dental record examinations, where available. We describe a case where identification of charred human remains from a car fire was securely determined by demonstration of the presence of a rare congenital abnormality of the spinal cord, Diastematomyelia.

Experience with the use of close-relative allograft for the management of extensive thermal injury in local national casualties during Operation Iraqi Freedom

The care of host nation burn victims in Iraq and Afghanistan has been a significant challenge to US military healthcare providers. To provide burn care in an austere environment is more challenging by limitations in resources such as inadequate medical supplies, infection control issues, and a lack of blood or tissue banking capabilities. Large full thickness burns pose a significant obstacle due to limitations in the casualties' available donor skin, which can be used to achieve wound coverage. In US burn centers, allograft stored in skin banks provides temporary coverage during donor site healing in the management of large total body surface area burns. This report is a study of two severely burned Iraqi children with inadequate donor site surface area to achieve wound coverage that were managed with close-relative allograft harvested from their fathers to achieve temporary wound closure. A brief literature review and future recommendations are included.

Fluconazole plasma concentration measurement by liquid chromatography for drug monitoring of burn patients

Fluconazole (2-(2,4-difluorophenyl)-1,3-bis(1H-1,2,4-triazol-1-yl)-2-propanol) is a triazole antifungal agent that has been available since 1990. Fluconazole is a broad-spectrum triazole antifungal agent that has emerged as a suitable alternative to amphotericin B in the treatment of a wide variety of superficial and systemic fungal infections.1 Triazole drugs act by inhibiting the enzyme 14-α-demethylase, which belongs to the microsomal CYP system; triazoles also act by blocking the biosynthesis of ergosterol, resulting in the accumulation of 14-α-methyl sterols and producing a fungistatic action. In general, fluconazole is well tolerated, with side effects including nausea, headache, skin rash, vomiting, abdominal pain, and diarrhea occurring during long-term therapy.2 Excellent bioavailability has been reported after oral dosing, and a linear pharmacokinetics has been demonstrated at a dose of 200–800 mg daily. The elimination half-life of fluconazole ranges from 27 to 37 hours, the apparent volume of distribution ranges from 0.5 to 0.7 L/kg, and approximately 80% of unchanged drug is excreted in the urine.3–6 Fluconazole is now used prophylactically in the management of various immune-compromised patient subsets1. High morbidity and mortality in patients with severe thermal injury were associated with fungal sepsis; thus, a study of the efficacy of this drug to prevent fungal sepsis in burn patients is necessary. It is well-known that patients with thermal injuries show many changes in the pharmacokinetics of several drugs, but data on the clinical efficacy of fluconazole related to its kinetics are very limited.7,8 Since changes in the pharmacokinetics of fluconazole are still unknown, it is imperative to investigate burn patients’ drug levels with a controlled clinical protocol. Analytical methods using microbiological, spectrophotometric, and chromatographic techniques have all been shown to determine fluconazole in biological samples. High-performance liquid chromatography (HPLC) is preferred due to its selectivity and the specificity of the assay. Methods for the determination of fluconazole in biological samples by HPLC-UV have been described previously.9–16 The objective of the present study was to develop a simple analytical method to determine fluconazole for plasma drug monitoring in patients with extensive thermal injury. An additional focus is its application to future pharmacokinetic studies. The method was validated as per FDA guidelines.17

Dendritic cell:CD4+ T cells interactions following injury.

A number of laboratory and clinical studies have shown that extensive thermal injury induces a state of immune suppression, and that predisposes the injured host to critical morbidity and mortality. The principal outcome of such immune suppression is an increased susceptibility of injured host to opportunistic pathogens causing high risk of death. Both clinical and laboratory studies have shown that immune suppression with burns is characterized by monocyte/macrophage hyperactivity and/or depressed adaptive cell-mediated immunity associated with T lymphocyte functional deficit, viz., decreased IL-2 production and proliferation. Our studies showed that CD4+T cell apoptosis in burn or sepsis rats, although higher than in sham rats, was less than 50% of that in rats with the combined burn-plus-sepsis injury. Also, the CD4+ T cell responsiveness, assessed by IL-2 production and proliferation, in the burn or sepsis animals, though significantly less than in the sham group, was less than that in the burn-plus-sepsis group. The differences in the T cell deficits after the individual burn or sepsis injuries and the combined injury condition seemed well correlated with differences in mortality in these injured animal groups. From these observations, it seemed reasonable to hypothesize that T cell incompetence with burn or sepsis alone was mostly reversible which allowed for an eventual restoration of T cell homeostasis and competence compatible with high animal survival. On the other hand, the exacerbation of animal mortality with burn-plus-sepsis seemed related to a sustained loss of immune-competence and a critical deletion of antigen triggered T cells. (Supported by NIH MBRS SCORE Grant No. 3 S06 GM008043-34S1 project#6, and NSF MRI DBI-0520869)

Setting Properties of Four Acrylic and Two Calcium-Phosphate Cements Used in Vertebroplasty

Experimental study conducted in the laboratory with six different bone cements. To isolate the thermal properties of conventional and emerging bone cements used in vertebroplasty and to characterize their setting behavior. The heat released during setting has been linked to the desirable effects of pain relief and tumor destruction and to the undesirable effect of thermal necrosis of surrounding tissue. However, there are currently no studies that disconnect the exothermic reaction of the cements from the media in which they occur. Before the combined thermal effect is examined, it is important to understand the setting properties of cements alone. Thirty independent experiments were conducted with four PMMA cements (Cranioplastic, Vertebroplastic, Palacos LV-40, Antibiotic Simplex) and two calcium-phosphate cements (chronOS Inject and Biopex) in accordance with ASTM standard F 451-99a. A thermocouple was placed in the center of the cement mass, and the temperature-versus-time measurements were recorded. The calcium-phosphate cements took over half an hour to reach their maximum temperature, which was only 3-4 degrees C higher than the ambient temperature. The temperature increase for the acrylic cements was between 16 and 23 degrees C, and it took about 15 minutes to reach the maximum temperature. The variation within the groups was also important. The exothermic reaction of calcium-phosphate cements appears to be insignificant. Although the acrylic cements release considerably greater heat in a much shorter time period, it does not appear that their temperature is sufficiently high to cause extensive thermal injury. However, variations within each group must be considered along with the intended use when deciding on the cement to be used.

ROLE OF PHENERGAN IN ABNORMAL SCARS AND KELOIDS

Hypertrophic scar and keloids have affected patients and frustrated physicians for centuries. Hypertrophic scar (HSc) and keloids are a major problem for patients who survive extensive thermal and traumatic skin injuries. HSc and other fibroproliferative disorders are associated with excessive accumulation of collagen and extracellular matrix proteins due to an imbalance between synthesis and degradation. The therapeutic management of hypertrophic scars and keloids include occlusive dressings, compression therapy, intralesional corticosteroid injections, cryosurgery, excision, radiation therapy, laser therapy, interferon therapy and other promising lesser known therapies directed at collagen synthesis. In this study we investigated the effect of phenergan (promethazine hydrochloride) as one of the most potent histamine antagonists on cell proliferation, DNA synthesis and collagen production in fibroblast isolated from human post burn hypertrophic scar, keloids and normal skin. The proliferation of normal skin fibroblast was slightly decreased but hypertrophic scar and keloids showed significant (p&lt;0.001) level of decrease after 72 hours of phenergan (750 μM) treatment. The results of DNA synthesis also significantly (p&lt;0.001) decreased in hypertrophic scar and keloid fibroblasts. Phenergan (1.5 mM) decreased the collagen synthesis upto 61% and 66% in HSc and keloids in comparison to normal skin fibroblast, which showed reduction of 38% after 72 hours. Improved understanding of such regulatory mechanisms may eventually be of therapeutic significance in the control of hypertrophic scar and keloids.

In the early stage of major burns, is there a correlation between survival, interleukin-6 levels and oxygen delivery and consumption?

The correlation between haemodynamic and oxymetric parameters, and circulating cytokines has been little studied for the early phase of extensive burns. The aim of this prospective study was to evaluate survival, looking at variations in cardiac index (CI), oxygen delivery (DO 2I) and consumption (VO 2I) indexed to the body surface area (BSA), and circulating interleukin-6 (IL6) levels in the acute stage of major burns. Over a 12-month period, all patients admitted within 6 h of extensive thermal injury with total burn surface area (TBSA) of over 60 per cent, necessitating standardized resuscitation and mechanical ventilation, were included. Routine intensive care monitoring, including pulmonary and femoral artery catheters, was set up. During the first 3 days post-injury haemodynamic and oxymetric profiles were recorded every 6 h. Circulating IL6 samples were taken within 6 h of admission, then daily (at 24, 48 and 72 h). A comparison of the results in survivors (S) and non-survivors (NS) at those previously determined times was made. Ten consecutive patients were studied. Six patients survived (Age = 33 + 10 years; TBSA = 76 ± 11 per cent) and four died (Age = 40 ± 14 years; TBSA = 77 ± 13 per cent). Similar initial hypovolemic profiles were found in both groups. From 24 h, a hyperdynamic status was observed which increased until 72 h. This hyperkinetic evolution was more marked in the survivors (CI: 4.6 ± 2.0 for NS and 6.9 ± 1.5 l min −1 m −2 for S; SVRI: 2125 ± 1288 for NS and 918 ± 232 dynes cm −5 m 2 for S at 72 h). DO 2I and VO 2I were always higher in the survivors. DO 2I and VO 2I and VO 2I increased from admission to 72 h in the survivors whereas a significant drop in DO 2I and VO 2I occured in the non-survivors at 48 h (DO 2I: 536 ± 222 for NS and 1228 ± 268 ml min −1 m −2 for S; VO 2I: 120 ± 50 for NS and 251 ± 56 ml min −1 m −2 for S ( P < 0.01)). Plasma IL6 revealed abnormal values with consistent peaks at 24–48 h in the survivors (respectively 17411 ± 24542 and 10746 ± 11802 pg ml −1) and only moderate peaks in the non-survivors (865 ± 652 and 912 ± 485 pg ml −1). Finally, CI, DO 2I, VO 2I, and circulating IL6 were always higher, and SVRI lower, in the survivors than in the non-survivors. The ability to increase DO 2 and to optimize VO 2 during the ‘turning point’ of 48 h seems to improve the prognosis of critically burned patients: the role of IL6 in this systemic inflammatory response is discussed.

Burns of the female genitalia and perineum

Burns of the female genitalia and perineum mostly occur in connection with more extensive thermal injuries to the trunk and lower extremities. Isolated burns to the vulva are very unusual because this area is anatomically well-protected. A few reports in the literature describe injuries due to bizarre accidents and now obsolete techniques. The management of these injuries, possible complications, prognosis and long-term results are discussed following a case report of a 28-year-old woman who sustained extensive deep dermal burns to her external and internal genitalia in a suicide attempt involving a firework.

Pathophysiology of the burn wound and pharmacological treatment. The Rudi Hermans Lecture, 1995

The body's reaction to thermal injury is much more than an initial, local inflammatory response. The burn wound is a continuous, severe threat against the rest of the body due to invasion of infectious agents, antigen challenge and repeated additional trauma caused by wound cleaning and excision. The inflammatory mediators which control blood supply and microvascular permeability in the wound have been extensively studied and are largely understood. Attempts to suppress the inflammatory reaction by different drugs have, however, been less successful. Extensive thermal injury and sepsis also results in immunosuppression. The defects causing immunosuppression are still very much under consideration. An understanding of these defects is essential for the development of therapies. The increasing interest in the control of the inflammatory reactions by cytokines may, in the near future, be of great importance.

Regulation of Collagen Synthesis and mRNA Expression in Normal and Hypertrophic Scar Fibroblasts in Vitro by Interferon-γ

Development of hypertrophic scarring (HTS) is a major problem for patients who survive extensive thermal injuries. HTS and other fibroproliferative disorders are associated with excessive accumulation of collagen and other extracellular matrix proteins. Recent in vitro and in vivo studies have demonstrated that proteins of the interferon family have an inhibitory effect on collagen production by fibroblasts in some fibroproliferative disorders. This study investigated the effects of interferon-γ (IFN-γ) on cell proliferation, collagen production, and expression of types I and III procollagen mRNA in human postburn HTS fibroblasts. Paired fibroblast cultures were established from explants of biopsies obtained from HTS and normal skin (matched for location and skin tension) in five patients recovering from thermal injuries. Thus, normal dermis from each patient was used as a paired control. Administration of IFN-γ (1000 U/ml) to proliferating fibroblast cultures for 5 days resulted in 51% reduction ( P < 0.05) in HTS cell proliferation. Using hydroxyproline as an index for collagen production, a 34% reduction ( P < 0.05) in collagen synthesis was observed in HTS fibroblast culture media after treatment with IFN-γ (1000 u/ml) for 48 hr. Northern blot analysis demonstrated 55 and 36% reductions ( P < 0.05 for each) in type I and type III procollagen mRNA levels, respectively, after treatment for 12 hr with IFN-γ (1000 u/ml). The effect of IFN-γ on each of these parameters was at least as pronounced in HTS fibroblasts as their normal controls. These results suggest that IFN-γ has a down-regulatory effect on cell proliferation and collagen production in fibroblasts from patients with HTS, a condition resulting from excess collagen synthesis and deposition within the extracellular matrix. Improved understanding of such regulatory mechanisms may eventually be of therapeutic significance in the control of HTS.

The role of alloplastic skeletal modification in the reconstruction of facial burns.

The external appearance of the face is largely dictated by its supporting facial skeleton. After an extensive thermal injury, the underlying facial skeleton may need to be either augmented or restored to maintain the functional and aesthetic appearance of the face. The factors that make a structural reconstruction difficult are poor vascularity and compliance of the scar tissue, extreme contractile forces of the scar, and unstable skin coverage. The use of an alloplast in the setting of facial burn scars may be one of the greatest challenges for an implant material. We reviewed our experience with the use of the Medpor porous polyethylene implant in facial burn reconstruction. This biomaterial has structural characteristics that allow for tissue ingrowth, yet it resists deformation by contractile forces. A total of 57 consecutive implants were placed in 24 patients with facial burns. Implants were used for the chin, the nose, the malar region, and as an ear framework. Patient follow-up ranged from 6 months to 3 years. Although 4 implants became exposed and 1 was thought to become infected, only 1 of the implants was removed. There were no other implant-related complications. We believe that skeletal modification is an important step for a successful facial burn reconstruction. Porous polyethylene offers a promising solution for the complex reconstructive problem of using an alloplast in the environment of a facial burn.