Required Skin Grafting Research Articles

Prospective Randomized Trial of Accelerated Re-epithelization of Skin Graft Donor Sites Using Extracorporeal Shock Wave Therapy

Extracorporeal shock wave therapy may enhance revascularization and repair of healing soft tissue. Between January 2006, and September 2007, 28 patients with acute traumatic wounds and burns requiring skin grafting were randomly assigned in a 1:1 fashion to receive standard topical therapy (nonadherent silicone mesh [Mepitel, Mölnlycke Health Care] and antiseptic gel [polyhexanide/octenidine]) to graft donor sites with (n = 13) or without (n = 15) defocused extracorporeal shock wave therapy (ESWT, 100 impulses/cm(2) at 0.1 mJ/mm(2)) applied once to the donor site, immediately after skin harvest. The randomization sequence was computer generated, and the patients were blinded to treatment allocation. The primary endpoint was time to complete donor site epithelialization and was determined by an independent blinded observer. Statistical tests indicated no unbalanced distribution of subject characteristics across the two study groups. Mean times to complete graft donor site epithelialization for patients who did and did not undergo ESWT were 13.9 +/- 2.0 days and 16.7 +/- 2.0 days, respectively (p = 0.0001). For centers that apply nonadherent gauze dressings and topical antiseptics to skin graft donor sites, application of a single defocused shock wave treatment immediately after skin graft harvest can significantly accelerate donor site epithelialization.

Burn Injury and Wound Healing in X-Linked Ichthyosis

X-linked ichthyosis is a skin condition of decreased keratin degradation and hyperkeratosis resulting from a deficiency of steroid sulfatase causing scaly skin. Burns in these patients may require skin grafting and harvesting from diseased donor sites. No descriptions of the outcomes of attempted grafting, donor site healing, and burn recovery in patients with X-linked ichthyosis exist. The authors describe split-thickness skin grafting in one patient with X-linked ichthyosis who sustained a burn with crush injury to his bilateral lower extremities. Although he developed cellulitis, there is no evidence that patients with ichthyosis have higher rates of infection. The patient exhibited rapid healing at postgrafting clinic visits with a much flatter texture than expected early after meshed skin grafting. This could be a benefit of the excess keratin state. Wound healing was not impaired by the ichthyosis. Concerns over skin harvest were alleviated by aggressive topical emollients, which did not negatively impact harvest of donor skin or primary burn site healing.

Cutaneous vascular and sudomotor responses in human skin grafts

Each year millions of individuals sustain burns. Within the US 40,000-70,000 individuals are hospitalized for burn-related injuries, some of which are quite severe, requiring skin grafting. The grafting procedure disrupts neural and vascular connections between the host site and the graft, both of which are necessary for that region of skin to contribute to temperature regulation. With the use of relatively modern techniques such as laser-Doppler flowmetry and intradermal microdialysis, a wealth of information has become available regarding the consequences of skin grafting on heat dissipation and heat conservation mechanisms. The prevailing data suggest that cutaneous vasodilator capacity to an indirect heat stress (i.e., heating the individual but not the evaluated graft area) and a local heating stimulus (i.e., directly heating the graft area) is impaired in grafted skin. These impairments persist for ≥4 yr following the grafting procedures and are perhaps permanent. The capacity for grafted skin to vasodilate to an endothelial-dependent vasodilator is likewise impaired, whereas its capacity to vasodilate to an endothelial-independent vasodilator is generally preserved. Sweating responsiveness is minimal to nonexistent in grafted skin to both a whole body heat stress and local administration of the primary neurotransmitter responsible for stimulating sweat glands (i.e., acetylcholine). Likewise, there is no evidence that this absence of sweat gland responsiveness improves as the graft matures. In contrast to the heating stimuli, cutaneous vasoconstrictor responses to both indirect whole body cooling (i.e., exposing the individual to a cold stress but not at the evaluated graft area) and direct local cooling (i.e., directly cooling the graft area) are preserved in grafted skin as early as 5-9 mo postgrafting. If uninjured skin does not compensate for impaired heat dissipation of grafted skin, individuals having skin grafts encompassing significant fractions of their body surface area will be at a greater risk for a hyperthermic-related injury. Conversely, the prevailing data suggest that such individuals will not be at a greater risk of hypothermia upon exposure to cold environmental conditions.

The demographics of modern burn care: should most burns be cared for by non-burn surgeons?

Background Minor burns represent .96% to 1.5% of emergency department visits, yet burn center referral is common. Analysis of the Grady Memorial Hospital Burn Center was conducted to examine the feasibility and savings if burns were managed locally with consultation as needed. Methods Data on 776 consecutive admissions to Grady Memorial Hospital Burn Center between November 2005 and July 2007 were prospectively reviewed. National and international cohorts were compared. Results Patients' mean age was 31 years, 69.8% were male, and 87% were insured. Thirty-nine percent were transfers. Seventy-six percent of transfers (51% of air transfers) and 70% of all admissions were for ≤10% total body surface area burns. Helicopter transport cost $12,500 and averaged 48 miles. Eighty percent of burns were hot water (scald), grease, or flame burns, and 31% required skin grafting. Conclusions Most burns require assessment, debridement, and dressing changes. Grafting is rarely necessary. Patients are transferred because of a lack of training, and patients suffer economic burden and treatment delay. Savings could be realized were patients treated locally with select burn center referral. Video consultation and mentoring can help with triage and care of minor burns. Major burns require burn center referral. International practice reinforces these results.

Frostbite complicating therapeutic surface cooling after heat stroke

Dear Editor, We report the case of an apparently healthy young woman found unconscious in a sauna suffering from heat stroke syndrome (GCS score 3/15; core temperature 41.9 C; BP 80/60, pulse 160/min). She was immediately treated with external surface cooling, initially using towels soaked with ice packs (*20 min) followed by cold wet blankets (*40 min), applied from the lower abdomen to the proximal half of the thighs. No accessory cooling method was used. She was also administered oxygen (FiO2 100%) and a perfusion of 1,000 ml NaCl at ambient temperature. Within just about 1 h, the patient’s core temperature was actively decreased from 41.9 C (tympanic, on-site) to 38 C (rectal, ER) with immediate effects on vital parameters. Nevertheless, the following day, the patient developed within the initial cooling zone progressive skin lesions, evolving from blisters to full-thickness skin and fat necrosis, which required skin grafting 43 days after the incident (Fig. 1a, b). The diagnosis was frostbite secondary to local cooling for heat stroke syndrome treatment. Heat stroke syndrome is defined as core temperature exceeding 40 C associated with a change in mental status ranging from inappropriate behaviour or impaired judgment to delirium, epilepsy or coma [1–3]. In 20–65% of the cases, an acute circulatory failure (shock) is associated [1–3] as observed in our patient. Treatment consists mainly of therapeutic cooling and cardiovascular

Treatment of Axillary Hidradenitis with Transposition Flaps

In our series, 15 patients underwent 21 procedures for wide resection of axillary hidradenitis with coverage by posteriorly based Limberg transposition flaps. Twenty flaps (95%) healed without axillary contracture. One failed flap required skin graft coverage. Transposition flap coverage in these patients was a reliable, single-stage reconstruction allowing prompt arm movement.

Management of an unfortunate triad after breast reconstruction: Pyoderma gangrenosum, full-thickness chest wall defect and Acinetobacter Baumannii Infection

If diagnosed late, post-surgical pyoderma gangrenosum (PSPG) is a rare, tricky and potentially life-threatening complication. Once diagnosed, immunosuppressive agents may provoke further complications. Well-intentioned extensive serial debridement may cause deep skin and soft-tissue defects, requiring skin grafting and possible flap surgery. The combination of necessary immunosuppressive treatment, protracted hospital stay and broad-spectrum systemic antimicrobial therapy may encourage serious acquired multidrug resistance (MDR). We report an unfortunate triad following breast reconstruction of PSPG, full-thickness chest wall defect and MDR with Acinetobacter baumannii infection. Interdisciplinary treatment using free flap surgery and negative-pressure wound therapy with instillation therapy (V.A.C.Instill(R) Wound Therapy) enabled survival and complete wound closure.

Beach and Campfire Burns: A Site of Pleasure and Tragedy

Seasonal use of campground bonfires and beach fire pits is a common practice. A sense of fellowship is derived from this experience. Unfortunately, many people are injured by these fires. It was the objective of this study to quantify and better identify those factors that lead to these injuries. A retrospective review of patients injured from a beach or campground, fire pits, or bonfires was conducted using data from a regional burn registry (1999-2007). Patients sustaining burns serious enough to merit admission were included in this study. Demographic information, circumstances surrounding the injury events, size and location of burn, operative procedures, length of stay, and outcomes were analyzed. There were 3083 patients admitted to the burn center of which 241 met criteria for inclusion in this study. Each year, between 12 and 39 patients were injured by this mechanism; 84% were men. Ages fell into two discrete groups; young age (2-9 years) and adults (18-64 years). Alcohol was a contributing factor in 60.6% of adult burns. The areas of burn, by location and rank order include upper extremities (35.3% of patients), thorax/abdomen/buttocks (32.8%), lower extremities (30.7%), and hands (29.5%). The mean TBSA was 6.1% (1-100%). Approximately 80.7% of the patients sustained combination partial- and full-thickness burns whereas, 4.2% were only partial and 5.1% only full-thickness burns; 36.6% of the patients required skin grafting. The mean length of stay was 8.6 days. There were four fatalities including one suicide. Burn injuries from recreational bonfires remain a problem in our community. Beaches were the most common location for these injuries. Universal safeguards to prevent burn injury should be implemented, including designated areas for fires, protective mechanical barriers to keep children and adults from inadvertently walking or falling into the fire pit. Disposal areas for hot coals from fires or charcoal grills must be furnished and usage strictly enforced. Consideration of the elimination of free-standing beach bonfires should be considered.

Management of large scalp and skull defects in a severe case of Adams-Oliver syndrome

Adams-Oliver syndrome is a rare congenital disorder that includes congenital scalp and skull defects, variable degrees of terminal transverse limb anomalies, and cardiac malformations. Cutis aplasia occurring in 75% of patients is a potentially life-threatening condition. Large skin defects that cannot be closed primarily present a management dilemma, and may require skin grafting or flaps, or a combination of both operative and conservative modalities. The authors' experience in management of huge scalp and bone defects with the Integra Dermal Regeneration Template and regular dressing changes showed good scalp repair and no serious complications attributed to this approach.

A global plan for burn prevention and care

Introduction Each year more than 300 000 people die from fire-related burn injuries. Millions more suffer from burn-related disabilities and disfigurements which have psychological, social and economic effects on both the survivors and their families. The burden of burn injury is one that falls predominantly on the world's poor: 95% of fire-related burn deaths occur in low- and middle-income countries (LMICs). Not only are burn deaths and injuries more common in people of lower socioeconomic status, but the survivors find their pre-injury poverty levels worsen after recovery. Differences in burn mortality rates vary across different age groups. For example, fire-related burns are the sixth leading cause of death among 5-14 year olds in LMICs. Survivors develop burn wound contractures and other physical impairments that limit function, lead to handicaps and reduce their chance of leading economically productive lives. Additionally these disfigurements often result in social stigma and restriction in their participation in society. Inequity of injury As noted by Mock et al. in an editorial in the Bulletin (1), injuries and violence cause disability and death to tens of millions of children across the globe each year. The burden is unfairly borne primarily by those in low- and middle-income countries where prevention programmes are uncommon and the quality of acute care is inconsistent. Burn injuries are dramatic examples of inequity. Even in a high-income country such as the United States of America (USA), burn injuries occur out of proportion among racial and ethnic minorities, as socioeconomic status--more than cultural or educational factors--accounts for most of the increased susceptibility of these children to burns. For example, the proportion of African-American infants requiring hospitalization at burn centres is double their proportion in the general population. (2,3) Most burn injuries lead to prolonged and expensive hospital stays. In addition to pain management and wound care, burn patients require attention to nutritional deficiencies, to the consequences of suppression of the immune system and to rehabilitation therapy. In the USA, the average hospital fees for care of a child (aged 5-16 years) with extensive third-degree burns requiring skin grafting was more than US$ 140 000. (2) Yet in spite of this lavish medical care, many burned children leave hospitals in the USA with permanent physical and psychological scars. Recovery not just skin-deep When confronted with the story of a burned child, the first picture that comes to mind is that of the agonizing open wounds, that eventually turn into undeniably obvious burn scars. But the thickened, non-compliant skin tells only part of the story. Much of the impact of burns is psychological. Studies of recovery from burn injury in the USA show clearly that the ability to adjust following injury is less dependent on the physical characteristics of the burn (such as burn size, burn depth or location) and more on the patient's pre-injury situation. Coping ski]Is, family and community support, and general psychological health have more impact on recovery from burns than the burn itself. (5) In the USA, this means that children from struggling family backgrounds are likely to have problems reassimilating into school and community. In low-income countries, the consequences are more serious, including isolation from or even abandonment by the family, social segregation, unemployment and extreme poverty. Although children from affluent families in low-income countries have a chance of recuperation, most children's situations deny them the opportunity to recover from even a small burn. At the time of burn injury, all patients--young and old--experience shock, horror, pain and anxiety. For children, the events that follow their injury may confuse them and lead them to believe (sometimes correctly) that their death is imminent. …

The effects of topical epinephrine on haemodynamics and markers of tissue perfusion in burned and non-burned patients requiring skin grafting

Objective To compare the systemic effects in burn and non-burn patients undergoing skin grafting with or without the use of topical epinephrine to control bleeding. Background The effects of topical epinephrine on haemodynamics and bleeding are principally documented with burn patients. No reports are available on the effects of topical epinephrine on non-burn patients especially on markers of tissue perfusion. Material and methods A prospective study where topical epinephrine was used on burn and non-burn patients and five patients served as controls without epinephrine usage. Catecholamine concentrations were measured and to estimate the systemic effects of epinephrine, serum lactate and pyruvate concentrations were analyzed and perioperative haemodynamic changes recorded. Results Compared to the baseline values, there was a significant increase in the heart rate, serum epinephrine and lactate concentrations and LP-ratios in the burn patients and an increase in the epinephrine concentrations in the non-burn patients at 1 and 2 h. Epinephrine and lactate concentrations and LP-ratios were also higher in the burn patients compared to the other groups. Altogether, there were no changes in the control group. Conclusion This study showed that the use of topical epinephrine has systemic effects on haemodynamics and serum epinephrine concentrations. Increased epinephrine concentrations in burn patients suggest increased absorption properties in these patients. The increased lactate concentrations and LP-ratios suggest tissue ischaemia, likely in skin.

The spectrum and outcome of burns at a regional hospital in South Africa

Introduction Burns remain a major cause of morbidity and mortality in Southern Africa. The more vulnerable of our population, namely the urban poor, children and epileptics, are most often affected. This audit documents our experience with burns in a busy regional hospital in Southern Africa. Patients and methods A prospective data base was maintained from September 2006 to February 2008 of all burn wound patients admitted in Edendale hospital. Standard demographic data, detailed description of the burn, surgical intervention, outcome and length of stay are recorded. The size and depth of the burn, as well as the initial fluid management are also recorded. Results A total of 450 patients were admitted. Two hundred and thirty-five were male. There were 203 burnt children with an average age of 3 years (range 6 months to 12 years). Average age for adults was 40 years (range 13–82 years). The average surface area burnt in children was 7.5% versus 23% in adults. Of those who died, the average surface area burnt was 54%. In adults the average burn depth was superficial in 30%, deep dermal in 20% and full thickness in 50%. The aetiology of the burn was flame 70%, hot water 25% and miscellaneous 5%. In children the breakdown of burn depth was superficial in 77%, deep dermal in 15% and full thickness in 8%. The aetiology was hot water 83%, fire 6%, electrical 6% and miscellaneous 5%. The last mentioned included hot oil or porridge (15), electrical (10), chemical (6), flash burns (8) and lightning (4). Fifty percent of adults were epileptic and had sustained their burn wound during a seizure. In this group, over 40% had previously sustained burns. Fifteen percent had a delayed presentation on an average of 11 days. Hospital stay averaged 68 days (3.5 days per percent burn: range 1–161 days). Two hundred and two (45%) patients required skin grafting. The average time from burn to graft was 51 days (range 12–138). There were 40 deaths (9%) with an average age of 50 years (range 6 months to 82 years) and an average total burn surface area of 50% (range 14–85%). Aetiology of the burn in the deaths was fire in 30, lightning 4 and hot water 6. Cause of death was burn wound sepsis in 38 and inadequate resuscitation in 2. Conclusion Young children and epileptics are particularly vulnerable to sustaining burns. Our hospital sees a large number of burns predominantly involving smaller surface areas. Patients with small burns have a prolonged hospital stay and delayed grafting due to a conservative surgical approach and lack of resources. Large burns are fatal in our hands.

PR16 A PROSPECTIVE BLINDED RANDOMIZED CONTROLLED TRIAL OF COMMERCIAL VACUUM DRESSINGS VERSUS NON‐MECHANICAL TOPICAL NEGATIVE PRESSURE DRESSING FOR DAY SURGERY LOWER LEG SPLIT THICKNESS SKIN GRAFTS

Purpose: To show that ambulatory non‐mechanical negative pressure dressing results in equivalent graft take and survival compared with commercially available mechanical vacuum dressings.Methodology: Twenty‐four patients, both males and female, between 18 and 95 years of age in the Australian population requiring skin grafting of the lower limb from July 2008 were randomized consecutively into commercial vacuum assisted ambulatory dressing group, KCI Freedom VAC, [VAC] and non‐mechanical topical negative pressure dressing group using 14 gauge drain [Belovac]. Patients were discharged on the same day of surgery and reviewed at 5 or 6 days post‐operatively. Both groups were treated equally in all other facets of care. The dressings remained intact until outpatient review. A photo of the graft was taken upon removal of the dressing. Graft take/survival was measured from these photographs by an experienced plastic surgeon blinded to treatment group.Results: Graft take was found to be equivalent in both groups. All twelve patients in the VAC group were judged to have >95% graft take at five/six days post‐op. In the Belovac group all twelve were judged to have >95% graft take at 5/6 days. The cost for VAC group was $AUD413.50/478.50 [5/6 days] compared to $AUD55.93 for the Belovac dressing group.Conclusion: We conclude that non‐mechanical topical negative pressure dressings are equally effective as commercially available VAC dressings in for the treatment of lower limb skin grafts. We recommend that non‐mechanical topical negative pressure dressing is an acceptable, cheap and safe alternative to commercially available dressings for day surgery patient.

Bioreactor Maintained Living Skin Matrix

Numerous reconstructive procedures result in wounds that require skin grafting. Often, the amount of tissue available from donor sites is limited. In vivo tissue expanders have been used clinically to generate larger sections of skin, and other methods exist to cover large wounds, but all have significant limitations. We investigated whether these difficulties could be overcome by increasing the surface area of skin in vitro while maintaining tissue viability. Human foreskin was incrementally expanded in a computer-controlled bioreactor system over 6 days to increase its surface dimensions under culture conditions. Morphological, ultrastructural, and mechanical properties of the foreskin were evaluated before and after expansion using histology, scanning electron microscopy, mercury porosimetry, and tensile testing. The surface area of the tissue was 110.7% +/- 12.2% greater, with maintenance of cell viability and proliferative potential. Histomorphological and ultrastructural analyses showed that dermal structural integrity was preserved. The pore diameter of the expanded skin was 64.49% +/- 32.8% greater. The mechanical properties were not adversely affected. These findings show that expansion of living skin matrices can be achieved using a computer-controlled bioreactor system. This technique provides an opportunity to generate large amounts of skin for reconstructive procedures.

Free-style local perforator flaps: concept and classification system

Defect reconstruction according to the free-style concept applied to perforator flaps allows flap harvesting in any anatomical region where an audible Doppler signal of a perforator is detected. We report the results of a study in which local perforator flaps were selected for reconstruction in different anatomical areas and were harvested using the free-style concept. During a 2-year period, defect coverage was carried out in 21 patients (n=21) in the following anatomical areas: cervical (n=3), sternal/parasternal (n=4), axillary (n=2), tibial (n=5), trochanteric (n=2) and sacral/gluteal (n=5). The mean age of patients (15 male and six female) was 57.8 years. Flap selection was based solely on preoperative Doppler mapping in areas adjacent to soft-tissue defects. The mean follow-up period was 1 year. All flaps survived, demonstrating postoperatively acceptable aesthetic results with good patient satisfaction. The donor sites were closed primarily in 17 patients; four patients required skin grafting. Two patients required surgical revision due to flap-margin dehiscence. There was no loss of function at donor sites. Increased flap mobility could be achieved through extended perforator dissection. One perforator-based flaps offered the widest arc of rotation serving as propeller flaps. If more than one perforator vessel was preserved, flap mobility was limited, but still allowed sufficient flap movement either as a rotation or advancement flap or as a combination of both. A classification is proposed according to the number of perforator vessels preserved and to the type of flap movement. The concept of free-style local perforator flaps represents a safe, versatile and reliable surgical procedure. It not only offers a greater freedom in flap selection but also provides good aesthetic results. The classification proposed might aid in the decision-making process involved in order to achieve adequate results with this procedure.

A Modification of the Chinese Island Flap Technique for Simple Incomplete Syndactyly Release

This paper presents a modification of the technique described by Yao et al. using a vascular island flap based on a dorsal digital vessel, which allows transfer of the web proximally and retains the integrity of the web skin. The technique was used in nine patients, aged from 1 to 15 years at operation, with nine incomplete simple syndactylies. The results were assessed at a mean of 36 (range 5-60) months after surgery. No vascular compromise or web creep was noted. This technique enables transfer of web skin proximally in cases of simple, incomplete syndactyly, avoids the presence of scars in the web space and does not require skin grafts.

Incidence of Compartment Syndrome of the Arm in a Large Series of Transradial Approach for Coronary Procedures

Despite the fact that transradial approach is widely used, literature on this devastating complication after transradial approach is scarce. Pubmed review from 1992 to 2007 includes only 5 isolated reports. In one small series with 250 patients, an incidence of 0.4% is suggested. We conducted a retrospective review of the transradial cases in Laval Hospital from 1994 to September 2007 (51,296 procedures) to know the incidence of compartment syndrome of the arm (CSA) and compare it with the literature. In our institution CSA occurred in 2 of the 51,296 transradial procedures (0.004%). Both of them were in female patients with low BSA (1.7 and 1.5 m(2)) who received either an excess of unfractioned heparin during the procedure or uncorrected low-molecular-weight heparin after the procedure. Both of them underwent fasciotomy of the forearm. Recovery was complete in one patient. The other patient required skin graft and developed a partial Volkmann contracture at follow-up. This low incidence is due to a high index of suspicion when swelling or pain in the arm used for the procedure is noted and to the immediate application of a specific protocol. This protocol initiated by the nursing personnel consists of inflation of a tensiometer cuff at the point of pain or swelling. Cuff is inflated during at least 15 minutes up to 10-15 mmHg below the systolic pressure to allow distal pulsatile flow to the hand or forearm (monitored with oxymetry/plethismography) so the bleeding stops and diffuses to decrease the pressure within the forearm. Usually, two periods of 15 min of inflation are required to control bleeding. Incidence of CSA is very low at our institution. A high suspicion with any complaint of pain and swelling in the arm and a proper management of anticoagulation especially in the postprocedure period with great emphasis in patients with low BSA or low creatinine clearance are the key points. Implantation of an immediate specific nursing protocol is required.

Foot Injuries Associated With All-Terrain Vehicle Use in Children and Adolescents

Children can suffer serious foot injuries while riding or driving an all-terrain vehicle (ATV). The purpose of this study was to describe this injury pattern. A search of the trauma registry of the Arkansas Children's Hospital for the years 1998 through 2006 was conducted to find cases of children admitted for treatment of foot injuries related to ATV use. The cases were deidentified and summarized. The study was reviewed and deemed to be exempt by the local institutional review board. Ten cases of foot injury were identified. The median age was 3 years. Eight had forefoot injuries, including 6 who had amputation of the great toe. All but one patient had multiple open foot fractures. Seven required skin grafting. Complications included infection, scar formation, disfigurement, and gait disturbance. The mean length of stay on initial hospitalization was 6 days, and the mean hospital charge was $12,890. Children, particularly young children, on an ATV can suffer serious foot injuries resulting in disfigurement and disability. The recommendation that young children not ride on ATVs is emphasized by these findings.

Facilitating Residual Wound Closure After Partial Graft Loss With Vacuum Assisted Closure Therapy

Third degree burns require skin grafting. In most instances, if the graft becomes infected, it requires debridement of the site and re-grafting. The purpose of this report is to illustrate the successful healing of a skin graft using negative pressure wound therapy with silver impregnated foam and soft silicone wound contact layer in a 4% total body surface area burn of a lower extremity skin graft infected with Pseudomonas aerugenosa without regrafting. A 27-year-old Hispanic male sustained a gasoline flame burn and presented 72 hours postincident with right lower extremity cellulitis. After intravenous antibiotics, the area was grafted with a partial thickness sheet graft. At 9 days postoperatively, the patient developed a wound infection, with an eventual 40% graft loss and was started on a course of antibiotics. With continued graft loss, on the 22nd postoperative day, negative pressure wound therapy V.A.C. (Vacuum Assisted Closure-KCI, San Antonio, TX) with silver impregnated foam and soft silicone wound contact layer (Mepitel, Molnlycke Health Care, Gothenburg, Sweden) were applied. The wound was completely re-epithelialized by 9 days. In combination with antibiotics, it was possible to treat a residual open wound and prevent the need for regrafting.

QuikClot Use in Trauma for Hemorrhage Control: Case Series of 103 Documented Uses

Local hemostatics have recently been introduced for field use to control external hemorrhage. The objective of this report is to describe the initial clinical experience with QuikClot, a zeolite that works by absorbing water and concentrating coagulation factors to stop bleeding in a series of patients. Documented cases using a self-reporting survey sheet submitted by the users and first-hand detailed interviews with the users when possible. There were 103 documented cases of QuikClot use: 69 by the US military in Iraq, 20 by civilian trauma surgeons and 14 by civilian first responders. There were 83 cases involving application to external wounds and 20 cases of intracorporeal use by military and civilian surgeons. All field applications by first responders were successful in controlling hemorrhage. The overall efficacy rate was 92% with eight cases of ineffectiveness noted by physicians in morbid patients with massive injuries when the QuikClot was used as a last resort. These reported failures were thought to be a result of the coagulopathic state of the patient from massive resuscitation or the inability to get the product directly to the source of hemorrhage. When the QuikClot was applied on responsive patients, the heat generated by the exothermic reaction caused mild to severe pain and discomfort. There were three cases of burns caused by the heat generated by the QuikClot application with one case requiring skin grafting. There was one major complication from intracorporeal use caused by scar formation from a foreign body reaction. QuikClot has been effectively used by a wide range of providers in the field and hospital to control hemorrhage.