1/43. Symptomatic tracheal stenosis in burns.tracheal stenosis in burns is rare and usually results from prolonged intubation or tracheostomy. inhalation injury itself has the potential risk of tracheal stenosis. We reviewed the records of 1878 burn patients during 1987 to 1995 and found seven with tracheal stenosis (0.37%) after an average of 4.4 years follow up. There were 4 males and 3 females with an average age of 27.3 years. The tracheal stenosis developed 1-22 months after burn (average 7 months). Five patients had their inhalation injury confirmed by bronchoscopic examination. The incidence of tracheal stenosis among inhalation injury patients was 5.49% (5/92). Six patients needed intubation in the initial stage either for respiratory distress or prophylaxis, with an average duration of 195.2 h. In addition to prolonged intubation, the presence of inhalation injury, repeated intubations and severe neck scar contractures are also contributors to tracheal stenosis in burns. We favor T-tube insertion as the first treatment choice; permanent tracheostomy was unsatisfactory in our study.- - - - - - - - - - ranking = 1keywords = dura (Clic here for more details about this article) |
2/43. Patient-controlled analgesia in burn patients: a critical review of the literature and case report.Although patient-controlled analgesia has been well documented as effective in various types of patients, it has not been adequately studied in burn patients. In this paper, the authors review the literature on PCA in burn patients and present two cases. Flaws in most published studies make it difficult to determine the efficacy of PCA in burn patients. Both the literature and experience indicate that many patients with acute burns are not suitable candidates for PCA. The cases illustrate the different methods patients may use to achieve adequate analgesia with PCA. Both patients and nurses face a steep learning curve in using PCA for management of procedural pain in burn care.- - - - - - - - - - ranking = 1keywords = dura (Clic here for more details about this article) |
3/43. Dural reconstruction of a class IV calvarial burn with decellularized human dermis.Calvarial burns involving the brain (Class IV) are reported to be rare. They represent a treatment challenge. Wound coverage can be accomplished with serial debridement of bone and grafting over granulating tissue, local flaps and free tissue transfer. The former techniques are often not feasible in the young infant. We present a successful case of a six-week-old female patient affected of full thickness burns involving the skull and brain. The bone, dura mater and superficial brain were debrided and the defect covered with AlloDerm and split thickness grafts. The area engrafted completely and no complications or CSF leak occurred. An acellular human allogeneic dermis (AlloDerm) can be successfully used to replace dura mater in burn patients.- - - - - - - - - - ranking = 2keywords = dura (Clic here for more details about this article) |
4/43. A complication of intraoperative facial nerve monitoring: facial skin burns.OBJECTIVE: To report on three cases of severe facial skin burns resulting from intraoperative facial nerve monitoring in patients undergoing parotidectomies. STUDY DESIGN: This study is a retrospective case review. SETTING: A tertiary referral center. patients: This study includes three patients who underwent parotidectomies with concurrent facial nerve monitoring. RESULTS: Facial skin burns were proven to result from a technical defect of the intraoperative facial nerve monitoring device. burns were sustained at electrode insertion sites and their extent was related to the duration of monitoring. The most probable explanation of these burns is electrolysis. CONCLUSIONS: Successful retracing of technical defaults with biomedical engineers at the device manufacturer have led to the upgrade of the facial nerve monitor apparatus. The benefits of facial nerve monitoring largely outweigh the fortuitous occurrence of skin burns reported in this study. Therefore, this complication should not represent a drawback to the use of facial nerve monitoring.- - - - - - - - - - ranking = 1keywords = dura (Clic here for more details about this article) |
5/43. pulse oximeter-associated toe injuries in a premature neonate: a case report.pulse oximetry is noninvasive and widely used in the intensive care unit and during surgery. Complications associated with the use of pulse oximetry have been reported, including burns, pressure erosion, skin necrosis and digital sensory loss. The causes of these complications may be due to the incompatibilities between the probes and the monitors used from different companies, pressure duration for too long on a single skin site or overheating induced by a short circuit of the probe cable. We report a 940-g premature infant who had severe pulse oximetry-associated injury to the oximetry site. This may have been due to the infant's susceptibility to injury resulting from his critical condition, including low cardiac output, poor peripheral circulation and poor heat dissemination. Our experience shows that, when pulse oximetry is used, especially in critically ill, premature infants, frequent checking of the sensor and the site where the sensor is applied is required to avoid burn injury or pressure erosion of the skin.- - - - - - - - - - ranking = 1keywords = dura (Clic here for more details about this article) |
6/43. Soft-tissue reconstruction of sole and heel defects with free tissue transfers.Reconstruction of the weight-bearing surface of the foot is a challenging problem for the reconstructive surgeon. Because local tissues are not usually available for reconstruction, distant tissue transfers are often necessary. The authors report 20 patients with sole and heel defects that were reconstructed with free flaps. Two patients had bilateral reconstruction. Three patients were younger than 10 years. Etiological causes were burn scar (N = 7), trauma (N = 7), chronic wound (N = 3), and tumor resection (N = 5). All defects were located at a weight-bearing area. Gracilis muscle (N = 11), neurosensorial radial forearm (N = 7), latissimus dorsi muscle (N = 2), rectus abdominis muscle (N = 1), and posterolateral thigh flaps (N = 1) were used for reconstruction. Muscle flaps were preferred for the deep and irregular defects or chronic, open infected wounds. All flaps survived except for one total and two partial complications of necrosis. recurrence of ulceration was observed in 1 patient with spinal cord trauma. The mean follow-up period was 33.7 months (range, 1-84 months). patients were evaluated by direct gait observation, footprints, pedograms, and the Semmes-Weinstein monofilament test. All patients returned to normal daily activity with individual gait patterns. Functional outcomes of both muscle and fasciocutaneous flaps were satisfactory. Presence of deep sensation, preservation of musculoskeletal integrity, and patient compliance are the main factors for durability of reconstruction.- - - - - - - - - - ranking = 1keywords = dura (Clic here for more details about this article) |
7/43. Is 20 years of immobilization, not sufficient to render metacarpophalangeal joints completely useless?--Correction of a 20-year old post-burn palmar contracture: a case report.This report presents a case of post-burn palmar contracture with flexion contracture of thumb of 20-year duration. The contracture was released and the raw area was covered with split thickness skin graft. Only one 'K' wire in soft tissue was needed to keep all the fingers straight and immobilized, suggestive of intermetacarpal ligamentous contracture. A static night splint was given to maintain the correction. Complete range of movement was achieved in a month with the combination of dynamic splinting and physiotherapy. It was interesting to note that even 20 years of contracted position did not render the metacarpophalangeal joints completely stiff and useless. Probable reasons are discussed.- - - - - - - - - - ranking = 1keywords = dura (Clic here for more details about this article) |
8/43. Tracheal-innominate artery fistula caused by the endotracheal tube tip: case report and investigation of a fatal complication of prolonged intubation.CASE REPORT: A patient with extensive burns was intubated with an 8.0 mm internal diameter endotracheal tube (ETT) equipped with a subglottic suction port (Mallinckrodt HiLo Evac). The ETT was secured to a left upper molar with wire sutures throughout the hospitalization course to ensure airway stability. On the 40th day of intubation, the patient exsanguinated and died from a tracheo-innominate artery fistula. Postmortem examination revealed a 1 cm lesion of the left anterior tracheal wall at the position of the ETT tip. The prolonged stationary position of the ETT was considered the primary factor responsible for the fistula. Yet tracheo-innominate artery fistula normally is associated with high cuff pressures rather than with the tube tip. The special ETT construction required for the subglottic suction feature was suspected to have increased tube rigidity and may have played a contributory role. methods: The rigidity of the Mallinckrodt HiLo Evac was measured with a mechanical model and compared to 5 other commercially-available ETTs. Rigidity was expressed as the force generated by the ETT tip when the tube curvature was altered by 5 cm and 10 cm of flexion from its resting position. RESULTS: The mean force exerted by the Mallinckrodt HiLo Evac was 10.1 /- 2.8 g at 5 cm of flexion and 17.7 /- 5.1 g at 10 cm of flexion. This was significantly greater than all other ETT brands tested (by one-way analysis of variance and Student-Newman-Kuels test, p < 0.05). CONCLUSION: This case of fatal tracheo-innominate artery fistula formation associated with an ETT tip was unusual because of the extended duration of endotracheal intubation and the complexity of the patient's airway management problems. Our data suggest that the higher rigidity of the HiLo Evac ETT may have contributed to fistula development at the tube tip. However, we do not believe that the higher rigidity of the HiLo Evac ETT necessarily poses any greater risk than other ETTs under normal circumstances, in which the tube tip is not fixed in a stationary position for an extended period.- - - - - - - - - - ranking = 1keywords = dura (Clic here for more details about this article) |
9/43. pharmacokinetics of morphine and its glucuronidated metabolites in burn injuries.OBJECTIVE: To investigate the effects of major thermal burn injury and continuous intravenous morphine infusion on the disposition of morphine and its glucuronidated metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) once a week for three weeks. CASE SUMMARIES: Five patients with major first-, second-, or third-degree burn injuries received long-term intravenous morphine infusion. The required dose varied greatly (from 4 to 39.5 mg/h). The steady-state concentrations of morphine, M3G, and M6G ranged from 20 to 452, 29 to 3436, and 20 to 1240 mumol/L, respectively. The systemic clearance (Cls) of morphine ranged from 14.8 to 40.3 mL/min/kg and did not change over time. The ratios of M6G and M3G to morphine were not affected by dose, even with the wide variation of intravenous dosage. morphine kinetics appeared to be first-order. Mean recovery of morphine, M3G, and M6G in urine was 1.7 /- 1.0%, 42.0 /- 16.8%, and 11.8 /- 3.2%, respectively, and renal clearance ranged from 8 to 64, 26 to 325, and 59 to 589 mL/min, respectively. Mean pain intensity ratings at rest remained low and stable (0.7 /- 0.9 on day 7, 0.4 /- 0.3 on day 14, 0 /- 0 on day 21). DISCUSSION: To our knowledge, this is the first published report describing morphine, M3G, and M6G disposition in patients with major thermal burn injury. The Cls of morphine is similar to that observed in other patient populations and healthy subjects, suggesting that the presence of major burn injuries or a continuous morphine infusion over a three-week period may not contribute significantly to the variability among individuals. In these cases, the renal clearance of morphine and its glucuronides was within the range of values reported for other populations of patients and healthy subjects. Recovery of morphine and its glucuronides in urine was also similar to that in healthy individuals. CONCLUSIONS: These cases suggest that the effects of major burn injuries and of long-term intravenous infusion of morphine did not seem to modify morphine, M3G, and M6G disposition. Among patients with burn injuries, the severity of burns of duration of administration are not a cause of nonlinear kinetic of morphine or of morphine resistance. The morphine infusion rate was substantially variable and not directly related to its clearance, suggesting that monitoring of morphine should be focused on the clinical response.- - - - - - - - - - ranking = 1keywords = dura (Clic here for more details about this article) |
10/43. Long-term duration of reduced serum complement level following burn injury.We report the case of a boy whose serum CH50 was below the detection limit following burn injury and skin transplantation. The APCH50 level was slightly decreased, although C3, C4, and the other complements were within the normal range. Cold activation was not detected in his plasma. His peripheral blood monocyte ratio slightly elevated to 19% and then decreased to 5.9%. In this case, burn injury caused the depletion of the complement, particularly in the alternative pathway, and resulted in the reduced CH50 level, although C3 did not show the typical pattern of alternative pathway depletion. In previously reported cases of burn injury, the CH50 level returned to the normal range within 2 weeks. In this patient the reduced level of CH50 continued for 4 months. We should consider burn injury one of the causes of complement deficiency even in cases with a duration of more than 1 month.- - - - - - - - - - ranking = 5keywords = dura (Clic here for more details about this article) |
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