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Nash M, Cartwright K, Nguyen R, Middleton P, Maitz P. Surgical release of the chest wall skin and fascia for sclerodermatous graft versus host disease causing restrictive lung disease: A case report. Int J Surg Case Rep 2024; 117:109455. [PMID: 38471219 PMCID: PMC10945244 DOI: 10.1016/j.ijscr.2024.109455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Graft versus host disease (GVHD) remains a significant source of morbidity and mortality in the setting of allogeneic stem cell transplantation. Skin involvement is reported to be as high as 70-95 % in this group with GVHD and the severity of the involvement varies widely. Surgical management of complications of severe cutaneous GVHD is uncommon and is rarely mentioned as a treatment option. CASE PRESENTATION We present a case of severe sclerodermatous skin changes restricting chest expansion and exercise tolerance to the point of limiting basic activities of daily life. A 54-year-old male presents with severe restrictive lung disease from sclerodermatous graft versus host disease (GVHD) after stem cell transplant for Chronic Myeloid Leukaemia (CML). He experienced limited symptomatic relief from maximal medical therapy and photochemotherapy, and subsequently underwent a skin release and split skin grafting of his chest and abdomen in an effort to improve exercise tolerance and quality of life. CLINICAL DISCUSSION Despite an initial improvement in functioning, the patient's spirometry and lung function continued to decline with time, possibly suggesting that he did not gain a sustained benefit from surgical release of his cutaneous GVHD. CONCLUSION While delineating between disease progression and surgical outcome is difficult in this case, the patient would argue that by delaying or reducing further decline in function, the surgical release procedures led to improved quality of life in subsequent years. However further research is required to establish a clear role for surgery in the treatment of refractory cutaneous GVHD.
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Affiliation(s)
- Mitchell Nash
- Burns Unit, Concord Repatriation General Hospital, Concord, NSW 2137, Australia.
| | - Kim Cartwright
- Department of Haematology, Wollongong Hospital, Wollongong, NSW 2500, Australia
| | - Rebecca Nguyen
- Department of Respiratory Medicine, Liverpool Hospital, Liverpool, NSW 2170, Australia; South West Sydney Clinical School, Faculty of Medicine, University of New South Wales, Liverpool, NSW 2170, Australia
| | - Peter Middleton
- Respiratory & Sleep Medicine, Westmead Clinical School, Westmead Hospital, Westmead, NSW 2145, Australia; Sydney University, Camperdown, NSW 2006, Australia
| | - Peter Maitz
- Burns Unit, Concord Repatriation General Hospital, Concord, NSW 2137, Australia; Sydney University, Camperdown, NSW 2006, Australia
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Lee H, Rahul F, Makled B, Parsey C, Norfleet J, De S. Cognitive Task Analysis of Escharotomy. Mil Med 2023; 188:255-261. [PMID: 37948234 DOI: 10.1093/milmed/usad104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/01/2023] [Accepted: 03/23/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION With the Army's emerging doctrine of prolonged field care, and with burns being a common injury among soldiers, non-expert providers must be trained to perform escharotomy when indicated. However, the existing physical simulators and training protocols are not sufficient for training non-experts for performing effective escharotomy. Hence, to provide guidance in developing realistic escharotomy simulators and effective training protocols suitable for prolonged field care, a cognitive task analysis (CTA) is needed. This work aims to obtain educative information from expert burn surgeons regarding escharotomy procedures via the CTA. MATERIALS AND METHODS The CTA was done by interviewing five subject matter experts with experience in performing escharotomy ranging from 20 to over 100 procedures and analyzing their responses. Interview questions were developed to obtain educative information from expert burn surgeons regarding the escharotomy procedure. A "gold standard protocol" was developed based on the CTA of each of the subject matter experts. RESULTS The CTA helped identify general themes, including objectives, conditions that mandate escharotomy, signs of successful escharotomy, precautions, challenges, decisions, and performance standards, and specific learning goals such as the use of equipment, vital signs, performing the procedure, and preoperative and postoperative care. A unique aspect of this CTA is that it identifies the background information and preparations that could be useful to the practitioners at various levels of expertise. CONCLUSIONS The CTA enabled us to compile a "gold standard protocol" for escharotomy that may serve as a guide for practitioners at various levels of expertise. This information will provide a framework for escharotomy training systems and simulators.
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Affiliation(s)
- Hanna Lee
- Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Fnu Rahul
- Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Basiel Makled
- United States Army Combat Capabilities Development Command-Soldier Center, Orlando, FL 32826, USA
| | - Conner Parsey
- United States Army Combat Capabilities Development Command-Soldier Center, Orlando, FL 32826, USA
| | - Jack Norfleet
- United States Army Combat Capabilities Development Command-Soldier Center, Orlando, FL 32826, USA
| | - Suvranu De
- Rensselaer Polytechnic Institute, Troy, NY 12180, USA
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Sabry M, Elsheikh AM, Darwish AMAALLAH, Mohamed AA, Mahmoud EM, Saeed AM. Management of electric burn injury by NPWT, meshed skin graft and distant posterior thigh flap. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Singer Y, Gabbe BJ, Cleland H, Holden D, Schnekenburger M, Tracy LM. The association between out of hours burn centre admission and in-hospital outcomes in patients with severe burns. Burns 2022:S0305-4179(22)00202-9. [PMID: 35995642 DOI: 10.1016/j.burns.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 08/03/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Patients with severe burns (≥20 % total body surface area [TBSA]) have specific and time sensitive needs on arrival to the burn centre. Burn care systems in Australia and New Zealand are organised differently during weekday business hours compared to overnight and weekends. The aims of this study were to compare the profile of adult patients with severe burns admitted during business hours with patients admitted out of hours and to quantify the association between time of admission and in-hospital outcomes in the Australian and New Zealand context. METHODS Data were extracted from the Burns Registry of Australia and New Zealand for adults (≥18 years) with severe burns admitted to Australian or New Zealand burn centres between July 2016 and June 2020. Differences in patient profiles, clinical management, and in-hospital outcomes were investigated. Univariable and multivariable logistic and linear regression models were used to quantify associations between time of admission and in-hospital outcomes of interest. RESULTS We found 623 patients eligible for inclusion. Most patients were admitted out of hours (69.2 %), their median age was 42 years, and most were male (78 %). The median size burn was 30 % TBSA and 32 % of patients had an inhalation injury. A greater proportion of patients admitted out of hours had alcohol and/or drugs involved with injury compared to patients admitted during business hours. No other differences between groups were observed. Patients in both groups had similar odds of dying in hospital (Odds Ratio [OR], 95 % Confidence Interval [95 %CI] 1.49 [0.64, 3.48]), developing acute kidney injury within 72 h (OR, 95 %CI 0.58 [0.32, 1.07]), or sepsis (OR, 95 %CI 1.04 [0.46, 2.35]). No association was found between time of admission and hospital (%, 95 %CI 1.00 [0.82, 1.23]) nor intensive care length of stay (%, 95 %CI 0.97 [0.73, 1.27]). DISCUSSION In this first Australian and/or New Zealand study to explore the association between time of admission and burn patient in-hospital outcomes, out of hours admission was not associated with patient outcomes of interest. CONCLUSION These findings support current models of care in Australian and New Zealand burn centres, however further investigation is required. Nonetheless, given most severe burns patients arrive out of hours to burn the centre, it is plausible that out of hours availability of senior burn clinicians will improve patient care and safety resilience within burn care systems.
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Affiliation(s)
- Yvonne Singer
- Victorian Adult Burn Service, The Alfred, Melbourne, Australia.
| | - Belinda J Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Heath Data Research UK, Swansea University Medical School, Swansea University, United Kingdom
| | - Heather Cleland
- Victorian Adult Burn Service, The Alfred, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Australia
| | - Dane Holden
- Victorian Adult Burn Service, The Alfred, Melbourne, Australia
| | | | - Lincoln M Tracy
- Department of Epidemiology and Preventive Medicine, Monash University, Australia
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Brammer J, Wolf G, Baliban SM, Allen JC, Choi M, Kambouris AR, Simon R, Fiskum G, Chao W, Lopez K, Miller C, Singh NJ, Cross AS. A Nonlethal Full-Thickness Flame Burn Produces a Seroma Beneath the Forming Eschar, Thereby Promoting Pseudomonas aeruginosa Sepsis in Mice. J Burn Care Res 2022; 43:792-801. [PMID: 34739051 PMCID: PMC9249144 DOI: 10.1093/jbcr/irab195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The World Health Organization estimates ~180,000 deaths occur annually from burn-related injuries. Many victims who survive the initial burn trauma succumb to bacterial infections that lead to sepsis during treatment. Although advancements in burn care continue to improve in high-income countries due to their burn centers and advanced research, low and middle-income countries continue to see high frequencies of burn injuries and burn-related deaths due to secondary infections. Bacterial-derived sepsis is the most life-threatening danger for people that survive burn injuries. Here we provide evidence for the first time that a subeschar seroma forms postburn even in the absence of infection in mice. The seroma fills with a volume estimated at 500 µL of fluid, 25% of the blood supply, free of red blood cells. The seroma fluid supports robust Pseudomonas aeruginosa (PA) growth and contains inflammatory cytokines and chemokines, which recruit immature neutrophils and monocytes to the seroma in the absence of endothelial breakdown. These immune cells fail to contain PA expansion and dissemination. This recruitment of monocytes and immature neutrophils may result in sequestering these critical immune cells away from other tissues during a pivotal time during bacterial dissemination, promoting PA-mediated sepsis.
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Affiliation(s)
- Jerod Brammer
- Center for Vaccine Development and Global Health, University of Maryland, School of Medicine, Baltimore, USA
- Department of Microbiology and Immunology, University of Maryland, School of Medicine, Baltimore, USA
| | - Gideon Wolf
- Department of Microbiology and Immunology, University of Maryland, School of Medicine, Baltimore, USA
| | - Scott M Baliban
- Center for Vaccine Development and Global Health, University of Maryland, School of Medicine, Baltimore, USA
| | - Jessica C Allen
- Center for Vaccine Development and Global Health, University of Maryland, School of Medicine, Baltimore, USA
- Department of Microbiology and Immunology, University of Maryland, School of Medicine, Baltimore, USA
| | - Myeongjin Choi
- Center for Vaccine Development and Global Health, University of Maryland, School of Medicine, Baltimore, USA
| | - Adrienne R Kambouris
- Center for Vaccine Development and Global Health, University of Maryland, School of Medicine, Baltimore, USA
- Department of Microbiology and Immunology, University of Maryland, School of Medicine, Baltimore, USA
| | - Raphael Simon
- Center for Vaccine Development and Global Health, University of Maryland, School of Medicine, Baltimore, USA
| | - Gary Fiskum
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, USA
| | - Wei Chao
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, USA
| | - Kerri Lopez
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, Baltimore, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Catriona Miller
- Enroute Care Division, Department of Aeromedical Research, USAF School of Aerospace Medicine, Wright Patterson AFB, Dayton, Ohio, USA
| | - Nevil J Singh
- Department of Microbiology and Immunology, University of Maryland, School of Medicine, Baltimore, USA
| | - Alan S Cross
- Center for Vaccine Development and Global Health, University of Maryland, School of Medicine, Baltimore, USA
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Gibson JAG, Gorse SH, Pallister I, Cubitt JJ. Surgical simulation training for escharotomy: a novel course, improving candidate’s confidence in a time critical procedure. Burns 2022; 49:783-787. [PMID: 35654704 DOI: 10.1016/j.burns.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Circumferential deep burns on the limb lead to a constrictive, tourniquet-like effect causing critical limb ischaemia. The treatment, escharotomy, is a time-critical procedure that sometimes is required before the patient arrives at a burn centre. At present, no practical method of teaching this procedure is incorporated into formal educational courses. METHODS The feasibility of a comprehensive education package to teach upper limb escharotomy was assessed in a group of plastic and general surgery trainees in Wales. Small group workshops focused on the clinical presentation of patients requiring escharotomy. Participants then executed this on a custom-made high-fidelity simulation upper limb model. The articulated limb has subcutaneous silicone fat which bulges upon decompression and a finger-tip which turns pink indicating satisfactory reperfusion. A before and after five-point Likert scale was used to evaluate changes in participants' self-assessed confidence in the surgical management of escharotomy. Statistical significance between scores was assessed using the Wilcoxon signed-rank test. RESULTS A total of 34 participants took part. Following completion of the course, general surgery trainees' confidence in executing the procedure increased from a median score of 1.00 "not confident at all" (IQR 1.00-2.00) to 4.00 "fairly confident" (IQR 4.00-5.00, p < 0.01). Plastic surgery trainees' confidence increased from a median score of was 3.00 "somewhat confident" (IQR 1.75-4.00) to 4.00 "fairly confident" (IQR 3.00-4.25, p < 0.01). DISCUSSION We developed a comprehensive simulator course that has been demonstrated to improve candidate's confidence in performing escharotomy. The next stage in the course development is to confirm the results in a larger cohort. By developing this simulator course we aim to improve emergency burn care education in the UK and globally.
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Affiliation(s)
- John A G Gibson
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea SA6 6NL, United Kingdom.
| | - Sarah Hemington Gorse
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea SA6 6NL, United Kingdom
| | - Ian Pallister
- Department of Trauma & Orthopaedic Surgery, Morriston Hospital, Swansea SA6 6NL, United Kingdom
| | - Jonathan J Cubitt
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea SA6 6NL, United Kingdom
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Butts CC, Holmes JH, Carter JE. Surgical Escharotomy and Decompressive Therapies in Burns. J Burn Care Res 2021; 41:263-269. [PMID: 31504609 DOI: 10.1093/jbcr/irz152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Early recognition of the need for escharotomy and other decompressive therapies is imperative for experienced burn providers, as to avoid reversible tissue ischemia and necrosis. With full-thickness burns, the eschar that develops is largely noncompliant. The predictable edema that develops during resuscitation of larger burns increases the likelihood ischemia-inducing pressure, as the underlying tissues swell within noncompliant skin, resulting in burn-induced compartment syndrome. Conventionally, this has been treated with decompressive therapies, such as escharotomy. The most recent surveys have identified that the United States and Canada both face a shortage of practicing burn surgeons. In the event of a burn disaster, many nonburn surgeons would need to provide burn care, including decompressive therapies. We reviewed the literature to provide accurate, accessible, and applicable recommendations regarding this practice following burn injury for both the practicing burn surgeon and those that would provide care in the burn disaster.
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Affiliation(s)
- C Caleb Butts
- Division of Acute Care Surgery, Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - James H Holmes
- Division of Acute Care Surgery, Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Jeffrey E Carter
- UMC Burn Center, University Medical Center, New Orleans, Los Angeles
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Barış Cartı E, Deniz Uçar A, Yıldırım M. Is carpal tunnel release safe in electrical burn decompressive therapy: Six-years experience. Turk J Surg 2021. [DOI: 10.47717/turkjsurg.2021.4379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective: Upper extremity electrical burn can create severe sequela and debilitation if not treated properly. Immediate decompression with fasci- otomy and carpal tunnel release seem to be the most promising choice of treatment. Neurologic functional loss can be avoided if median nerve is liberated.
Material and Methods: During 6-year time interval, 50 out of 1158 burn patients underwent upper extremity decompressive fasciotomy with carpal tunnel release. Their hand motor function based on nerve innervation and daily usage questionnaire were followed in 12-month intervals.
Results: Average score rose markedly after 18th month and reached nearly normal at the end of 66th month. Median, ulnar and radial nerve function tests were all positive, and no irreversible nerve function loss observed.
Conclusion: All compartments of the forearm should be explored and carpal tunnel release should be added into upper extremity decompressive fasciotomy after electrical burns.
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Dargan D, Kazzazi D, Limnatitou D, Cochrane E, Stubbington Y, Shokrollahi K, Ralston D. Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature. Ann Plast Surg 2021; 86:517-531. [PMID: 33675628 DOI: 10.1097/sap.0000000000002755] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns. RESULTS An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes. DISCUSSION The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers. CONCLUSIONS More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.
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Affiliation(s)
| | - Diana Kazzazi
- From the Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital
| | | | - Elliott Cochrane
- From the Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital
| | | | - Kayvan Shokrollahi
- Mersey Regional Burns Centre, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Merseyside, Prescot, United Kingdom
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Hughes A, Almeland SK, Leclerc T, Ogura T, Hayashi M, Mills JA, Norton I, Potokar T. Recommendations for burns care in mass casualty incidents: WHO Emergency Medical Teams Technical Working Group on Burns (WHO TWGB) 2017-2020. Burns 2021; 47:349-370. [PMID: 33041154 PMCID: PMC7955277 DOI: 10.1016/j.burns.2020.07.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/02/2020] [Indexed: 12/15/2022]
Abstract
Health and logistical needs in emergencies have been well recognised. The last 7 years has witnessed improved professionalisation and standardisation of care for disaster affected communities - led in part by the World Health Organisation Emergency Medical Team (EMT) initiative. Mass casualty incidents (MCIs) resulting in burn injuries present unique challenges. Burn management benefits from specialist skills, expert knowledge, and timely availability of specialist resources. With burn MCIs occurring globally, and wide variance in existing burn care capacity, the need to strengthen burn care capability is evident. Although some high-income countries have well-established disaster management plans, including burn specific plans, many do not - the majority of countries where burn mass casualty events occur are without such established plans. Developing globally relevant recommendations is a first step in addressing this deficit and increasing preparedness to deal with such disasters. Global burn experts were invited to a succession of Technical Working Group on burns (TWGB) meetings to: 1) review literature on burn care in MCIs; and 2) define and agree on recommendations for burn care in MCIs. The resulting 22 recommendations provide a framework to guide national and international specialist burn teams and health facilities to support delivery of safe care and improved outcomes to burn patients in MCIs.
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Affiliation(s)
- Amy Hughes
- Interburns, International Network for Training, Education and Research in Burns, Swansea, Wales, UK,Humanitarian and Conflict Response Institute (HCRI), University of Manchester, UK,Cambridge Hospital NHS Foundation Trust (Addenbrookes), Paediatric ICU Department, UK
| | - Stian Kreken Almeland
- Department of Plastic, Hand and Reconstructive Surgery, Norwegian National Burn Center, Haukeland University Hospital, Bergen, Norway,Faculty of Medicine, University of Bergen, Norway
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France,Val-de-Grâce Military Medical Academy, Paris, France
| | - Takayuki Ogura
- Japanese Society for Burn Injuries, The Disaster Network Committee
| | - Minoru Hayashi
- Japanese society for burn injuries, The Academic Committee
| | - Jody-Ann Mills
- Rehabilitation Programme, Department of NCD, World Health Organization, Geneva, Switzerland
| | - Ian Norton
- World Health Organization (2013-2019), Emergency Medical Team Initiative Lead, Geneva,Respond Global, Queensland, Australia,Co-Chair World Health Organization EMT Technical Working Group on Burns, Geneva
| | - Tom Potokar
- Interburns, International Network for Training, Education and Research in Burns, Swansea, Wales, UK,Centre for Global Burn Injury Policy and Research, Swansea University, Wales, UK,Co-Chair World Health Organization EMT Technical Working Group on Burns, Geneva,Corresponding author at: Co Chair WHO-EMT Technical Working Group on Burns; Centre for Global Burn Injury Policy & Research; Swansea University; Wales; UK.
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11
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Gong J, Singer Y, Cleland H, Wood F, Cameron P, Tracy LM, Gabbe BJ. Driving improved burns care and patient outcomes through clinical registry data: A review of quality indicators in the Burns Registry of Australia and New Zealand. Burns 2021; 47:14-24. [PMID: 32811694 DOI: 10.1016/j.burns.2020.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/19/2019] [Accepted: 01/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND In 2009, the Burns Registry of Australia and New Zealand (BRANZ) published a set of clinical quality indicators (QIs) to monitor performance, improve quality of care, and inform and change policy. With several years of data collected since the initial development of the indicators for burns, the BRANZ QI Working Party reviewed the clinical QIs for relevance and meaning, and considered new QIs that had not been collected previously. METHOD Using published literature and expert opinion, the QI Working Party, consisting of multidisciplinary burn clinicians, reviewed the QIs for burn care to be included as routine data items in the BRANZ. RESULTS In July 2016, the list of clinical QIs in the BRANZ was updated to 23 QIs/data items, covering structure, process, and outcome measures. Four QIs were removed as they were not found to be useful, nine QIs/data items were revised, and eight new QIs/data items were added as they were considered to be clinically useful. CONCLUSION This review outlines the changes made to the QIs collected by the BRANZ four years since their development and implementation. Ongoing refinement of the BRANZ QIs will ensure that high quality data is collected to drive improvements in clinical and patient outcomes.
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Affiliation(s)
- Jennifer Gong
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria, 3004, Australia
| | - Yvonne Singer
- Victorian Adult Burns Service, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Heather Cleland
- Victorian Adult Burns Service, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Fiona Wood
- State Adult Burn Unit, Fiona Stanley Hospital, 11 Warren Drive, Murdoch, Western Australia, 6150, Australia; Burn Injury Research Unit, University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria, 3004, Australia; Emergency and Trauma Centre, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Lincoln M Tracy
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria, 3004, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria, 3004, Australia; Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, Swansea, Wales, United Kingdom.
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Goffinet L, Dantzer E. Coverage of soft tissue defects in acute surgery for deep burns of the limbs. ANN CHIR PLAST ESTH 2020; 65:345-379. [PMID: 32928577 DOI: 10.1016/j.anplas.2020.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
Burns of the limbs affect 48.6% of burn patients. Injury mechanisms condition their depth and degree of extension. Injury of the hands and/or the joint areas entails considerable risk of retraction. Coverage is consequently doubly challenging, it is a matter not only of compensating for a soft tissue defects, but also of striving to prevent early (infectious) and late (amplitude limitation, pain, loss of function…) complications. Thoroughgoing assessment of the initial injury and associated lesions is conducive to rapid determination of a therapeutic strategy tailored to the relevant functional issues and subsequent rehabilitation. Following a summary of the epidemiological elements and the medical context of management, a review of existing treatments has been drawn up based on the data in the literature and current professional recommendations. Emergency procedures, the different types of excision and the possibilities of autologous covering and skin substitutes are reported. Last but not least, routinely validated indications are synthesized.
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Affiliation(s)
- L Goffinet
- Service de chirurgie infantile orthopédique/pediatric orthpedic surgery unit, hôpital d'enfant/children's hospital, université de Lorraine/university of Lorraine, CHRU de Nancy, 11, rue du Morvan, 54510 Vandœuvre-lès-Nancy, France.
| | - E Dantzer
- Centre des brûlés/burn treatment, hôpital d'instruction des armées Sainte-Anne/Sainte-Anne armed forces teaching hospital, boulevard Sainte-Anne, BP 20545, 83041 Toulon, France.
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Vrouwe SQ, Zuo KJ, Grotski CH, Tredget EE, Chew HF, Cartotto R. Orbital Compartment Syndrome Following Major Burn Resuscitation: A Case Series and Survey of Practice Patterns. J Burn Care Res 2020; 42:193-199. [PMID: 32818243 DOI: 10.1093/jbcr/iraa126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Orbital compartment syndrome (OCS) is a rare but devastating complication of over-resuscitation in burn patients that may lead to permanent visual loss. The purpose of this study was to 1) present a series of burn patients with OCS and 2) survey practice patterns of monitoring intra-ocular pressure (IOP) during burn resuscitation. Cases of OCS at two American Burn Association (ABA)-verified burn centers were retrospectively reviewed. Patients were included if they 1) required lateral canthotomy/cantholysis for elevated IOPs or 2) developed blindness on admission unrelated to any other ocular pathology. Data were collected on demographics, burn characteristics, fluid administration, ophthalmologic findings, and complications. An eight-item electronic survey was distributed by email through the ABA to all physician members. Twelve patients with OCS were identified, with a mean age of 47.8 ± 12.4 years and TBSA of 63.7 ± 18.6%. Mean fluid resuscitation at 24 hours was 4.9 ± 1.6 ml/kg/%TBSA or 0.29 ± 0.06 liter/kg. Eight patients underwent canthotomy/cantholysis for OCS, whereas four were later found to have visual loss. A total of 83 (14%) ABA physicians responded to the survey. IOP was routinely measured by 23% of respondents during acute burn resuscitation. OCS appears to have developed despite a relatively low 24-hour ml/kg/% burn resuscitation volume, but with a relatively higher cumulative (liter/kg) fluid volume. Their survey found that monitoring of IOP during burn resuscitation is not routinely performed by the majority of providers. Taken together, the present study suggests clinical guidelines to recognize this complication of over-resuscitation.
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Affiliation(s)
- Sebastian Q Vrouwe
- Division of Plastic and Reconstructive Surgery, University of Toronto, Ontario, Canada
| | - Kevin J Zuo
- Division of Plastic and Reconstructive Surgery, University of Toronto, Ontario, Canada
| | | | - Edward E Tredget
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Hall F Chew
- Department of Ophthalmology and Vision Sciences, Ontario, Canada
| | - Robert Cartotto
- Division of Plastic and Reconstructive Surgery, University of Toronto, Ontario, Canada.,Ross Tilley Burn Centre, University of Toronto, Ontario, Canada
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14
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Yoshino Y, Hashimoto A, Ikegami R, Irisawa R, Kanoh H, Sakurai E, Nakanishi T, Maekawa T, Tachibana T, Amano M, Hayashi M, Ishii T, Iwata Y, Kawakami T, Sarayama Y, Hasegawa M, Matsuo K, Ihn H, Omoto Y, Madokoro N, Isei T, Otsuka M, Kukino R, Shintani Y, Hirosaki K, Motegi S, Kawaguchi M, Asai J, Isogai Z, Kato H, Kono T, Tanioka M, Fujita H, Yatsushiro H, Sakai K, Asano Y, Ito T, Kadono T, Koga M, Tanizaki H, Fujimoto M, Yamasaki O, Doi N, Abe M, Inoue Y, Kaneko S, Kodera M, Tsujita J, Fujiwara H, Le Pavoux A. Wound, pressure ulcer and burn guidelines – 6: Guidelines for the management of burns, second edition. J Dermatol 2020; 47:1207-1235. [DOI: 10.1111/1346-8138.15335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 01/28/2023]
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15
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Mataro I, Lanza A, Di Franco S, Di Franco L, Sangiuolo M, Notaro M, d'Alessio R, Villani R. Releasing Burn-Induced Compartment Syndrome by Enzymatic Escharotomy-Debridement: A Case Study. J Burn Care Res 2020; 41:1097-1103. [PMID: 32232328 DOI: 10.1093/jbcr/iraa055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Burn-induced compartment syndrome represents a serious and acute condition in deep circumferential burns of the extremities which, if left untreated, can cause severe complications. The surgical escharotomy that releases the high subdermal pressure is the therapeutic treatment of choice for burn-induced compartment syndrome. Guidelines for escharotomy indications and timing include pressure greater than 30 mm Hg and 6 Ps (Pain, Pallor, Paresthesia, Paralysis, Pulseless, and Poikilothermia). Nevertheless, despite the need for an early as possible pressure release, escharotomy is often delayed when a capable surgeon is not available, or if the indication is not completely clear to justify potential risks associated with surgical escharotomy. Early treatment of circumferential burns of the extremities with a Bromelain-based enzymatic agent NexoBrid® may represent a less traumatic and invasive procedure to reduce intra-compartmental pressure, replacing surgical escharotomy. This case study of 23 patients describes the variation of compartmental pressure in patients with circumferential burns of the extremities treated with NexoBrid® enzymatic escharotomy-debridement. All the patients were treated with NexoBrid® within 2 to 22 hours post-injury in our Burn Intensive Care Center. The excessive pressure recorded before treatment returned to normal below 30 mm Hg and an approximately 60% reduction of the compartmental pressure was observed in most cases within 1 hour from NXB application. On NexoBrid® removal after 4 hours complete debridement-escharotomy of the burns was achieved. Enzymatic escharotomy-debridement appears to be a useful and safe method to reduce postburn compartmental pressure. Additional randomized, well-controlled powered studies are needed to further support these results.
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Affiliation(s)
- Ilaria Mataro
- Plastic and Reconstructive Surgery and Burn Unit, Hospital A. Cardarelli, Naples, Italy
| | - Anna Lanza
- Burn Intensive Care Unit, Hospital A. Cardarelli, Naples, Italy
| | - Sveva Di Franco
- Resident Doctor in Anesthesia, Critical Care and Pain Medicine, Naples, Italy
| | | | | | - Maria Notaro
- Burn Intensive Care Unit, Hospital A. Cardarelli, Naples, Italy
| | - Roberto d'Alessio
- Plastic and Reconstructive Surgery and Burn Unit, Hospital A. Cardarelli, Naples, Italy
| | - Romolo Villani
- Burn Intensive Care Unit, Hospital A. Cardarelli, Naples, Italy
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16
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Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T, Lefort H, Louvet N, Losser MR, Lucas C, Pantet O, Roquilly A, Rousseau AF, Soussi S, Wiramus S, Gayat E, Blet A. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med 2020; 39:253-267. [PMID: 32147581 DOI: 10.1016/j.accpm.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children. DESIGN A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion. RESULTS The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations. CONCLUSION Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, San Francisco, United States.
| | - Damien Barraud
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France
| | - Isabelle Constant
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | | | - Nicolas Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Mathieu Fontaine
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Laetitia Goffinet
- Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | | | - Mathieu Jeanne
- CHU Lille, Anaesthesia and Critical Care, Burn Centre, 59000 Lille, France; University of Lille, Inserm, CHU Lille, CIC 1403, 59000 Lille, France; University of Lille, EA 7365 - GRITA, 59000 Lille, France
| | - Jeanne Jonqueres
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Hugues Lefort
- Department of emergency medicine, Legouest Military Teaching Hospital, Metz, France
| | - Nicolas Louvet
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Marie-Reine Losser
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France; Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France; Inserm UMR 1116, Team 2, 54000 Nancy, France; University of Lorraine, 54000 Nancy, France
| | - Célia Lucas
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), BH 08-651, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Antoine Roquilly
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University of Nantes, Nantes, France
| | | | - Sabri Soussi
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Interdepartmental Division of Critical Care, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sandrine Wiramus
- Department of Anaesthesia and Intensive Care Medicine and Burn Centre, University Hospital of Marseille, La Timone Hospital, Marseille, France
| | - Etienne Gayat
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alice Blet
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France; Department of Research, University of Ottawa Heart Institute, Ottawa, ON, Canada
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18
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Fischer S, Kotsougiani D, Kneser U, Hirche C. Response to: Re: Feasibility and safety of enzymatic debridement for the prevention of operative escharotomy in circumferential deep burns of the distal upper extremity. Surgery 2019; 167:512-513. [PMID: 31378481 DOI: 10.1016/j.surg.2019.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Sebastian Fischer
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
| | - Dimitra Kotsougiani
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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19
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Feasibility and safety of enzymatic debridement for the prevention of operative escharotomy in circumferential deep burns of the distal upper extremity. Surgery 2019; 165:1100-1105. [DOI: 10.1016/j.surg.2018.11.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/16/2018] [Accepted: 11/20/2018] [Indexed: 11/23/2022]
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20
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Salmerón-González E, García-Vilariño E, García-Sánchez J, Sánchez-García A, Pérez-Del-Caz L, Valverde-Navarro AA. Retrospective study comparing escharotomy incidence in the treatment of deep circular burns affecting limbs with traditional treatment or enzymatic debridement. Surgery 2019; 166:953-954. [PMID: 31128850 DOI: 10.1016/j.surg.2019.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
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21
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Endo A, Shiraishi A, Otomo Y, Fushimi K, Murata K. Volume-outcome relationship on survival and cost benefits in severe burn injury: a retrospective analysis of a Japanese nationwide administrative database. J Intensive Care 2019; 7:7. [PMID: 30733868 PMCID: PMC6354429 DOI: 10.1186/s40560-019-0363-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background Although it has been reported that high hospital patient volume results in survival and cost benefits for several diseases, it is uncertain whether this association is applicable in burn care. Methods We conducted a retrospective observational study on severe burn patients, defined by a burn index ≥ 10, using 2010–2015 data from a Japanese national administrative claim database. A generalized additive mixed-effect model (GAMM) was used to evaluate the nonlinear associations between patient volume and the outcomes (in-hospital mortality, healthcare costs per admission, and hospital-free days at 90 days). Generalized linear mixed-effect regression models (GLMMs) in which patient volume was incorporated as a continuous or categorical variable (≤ 5 or > 5) were also performed. Patient severity was adjusted using the prognostic burn index (PBI) or the risk adjustment model developed in this study, simultaneously controlling for hospital-level clustering. Sensitivity analyses evaluating patients who were directly transported, those with PBI ≤ 120 and those excluding patients who died within 2 days of admission, were also performed. Results We analyzed 5250 eligible severe burn patients from 737 hospitals. The PBI and the developed risk adjustment model had good discriminative ability with areas under the receiver operating characteristic curves of 0.86 and 0.89, respectively. The GAMM plots showed that in-hospital mortality and healthcare costs increased according to the increase in patient volumes; then, they reached a plateau. Fewer hospital-free days were observed in the higher volume hospitals. The GLMM model showed that patient volume (incorporated as a continuous variable) was significantly associated with increased in-hospital mortality (adjusted odds ratio [95% confidence interval (CI)] = 1.14 [1.09–1.19]), high healthcare costs (adjusted difference [95% CI] = $4876 [4436–5316]), and few hospital-free days (adjusted difference [95% CI] = − 3.1 days [− 3.4 to − 2.8]). Similar trends were observed in the analyses in which patient volume was incorporated as a categorical variable. The results of sensitivity analyses showed comparable results. Conclusions Analysis of Japanese nationwide administrative database demonstrated that high burn patient volume was significantly associated with increased in-hospital mortality, high healthcare costs, and few hospital-free days. Further studies are needed to validate our results. Electronic supplementary material The online version of this article (10.1186/s40560-019-0363-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Akira Endo
- 1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Atsushi Shiraishi
- 1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan.,2Emergency and Trauma Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba Japan
| | - Yasuhiro Otomo
- 1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Kiyohide Fushimi
- 3Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Kiyoshi Murata
- 1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan.,The Shock Trauma and Emergency Medical Center, Matsudo City General Hospital, 933-1 Sendabori,, Matsudo, Chiba Japan
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22
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Abstract
Escharotomy incisions must be made in the inelastic skin eschar that is typical of circumferential third-degree burns. Later, the necrotic tissue must be debrided and substituted with a skin graft. Many reports on this topic have revealed that concepts and techniques vary widely. This study aims to present a critical review of the literature about escharotomy in burns and to highlight a different strategy to perform escharotomy in patients with burned extremities. We conducted a critical review in Pubmed/MEDLINE using the keywords "escharotomy" and "burns." In the present study, we included 22 articles published from 1955 to 2015 (60 years) that contain the aforementioned keywords. With respect to the extremities, most of the publications recommend that medial and lateral longitudinal incisions be performed and that care must be taken to avoid deep structures, particularly nerves. Moreover, the publications mention that escharotomy might result in thick, hypertrophic, retracting, and painful scars. We advocate that incisions performed only on the lateral and medial borders of the extremities are usually unnecessary, and that they contribute to the creation of misconceptions about burns. In addition, these incisions can somehow trigger complications that can be avoided by using the concept of escharotomy in multiple directions, as highlighted in this review.
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23
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Kuo LW, Yen CI, Fu CY, Pan CH, Hsu CP, Hsiao YC, Hsieh CH, Hsu YP. The role of preliminary hospitals in the management of a mass burn casualty disaster. Burns 2017; 44:800-806. [PMID: 29258727 DOI: 10.1016/j.burns.2017.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/19/2017] [Accepted: 11/30/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The Formosa Fun Coast explosion is an internationally-known event that occurred in Taiwan on June 27th, 2015. The blast involved 495 casualties in total, with 253 patients receiving 2nd degree or deeper burns on greater than 40% of the total body surface area (TBSA). Questions were raised regarding whether these victims were sent to the appropriate hospitals or not. Therefore, we analyzed the effect of the initial admission destination in this study. MATERIAL AND METHODS We retrospectively reviewed all of the victims from the explosion who were sent to the emergency department of Linkou and Keelung Chang Gung Memorial Hospitals. Patients were divided by direct admission and received via transfer. The basic demographics, the efficacy of the initial resuscitation and the clinical outcomes were analyzed. RESULTS In total, forty-six patients were included. Thirty-five of them were primarily admitted, and eleven of them were received via transfer. Between the two groups, there was no significant difference in the resuscitation outcome. The ratio of delaying intubation was similar (14.3% vs 27.3%, p=0.322). The rate of delayed-detected ischemic events was significantly increased in the referral group (0% vs 27.3%, p=0.001). However, there was no amputation event in either group. No difference in mortality was observed between groups (5.7% vs 9.1%, p=0.692). CONCLUSION Our preliminary findings suggest that local hospitals are capable of providing high-quality acute care to mass casualty burn victims. Our results suggest that patients with suspected limb ischemia should be rapidly transferred to a regional burn center to ensure optimal care. Systemic pre-planning such as employing telemedicine and personnel collaboration, should be considered by the administration to maximize the function of preliminary hospitals in burn care.
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Affiliation(s)
- Ling-Wei Kuo
- Chang Gung Memorial Hospital, Trauma and Critical Care Center, Linkou, Taoyuan, Taiwan
| | - Cheng-I Yen
- Chang Gung Memorial Hospital, Burn Center, Linkou, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Chang Gung Memorial Hospital, Trauma and Critical Care Center, Linkou, Taoyuan, Taiwan.
| | - Chun-Hao Pan
- Chang Gung Memorial Hospital, Department of Plastic & Reconstructive Surgery, Keelung, Taiwan
| | - Chih-Po Hsu
- Chang Gung Memorial Hospital, Trauma and Critical Care Center, Linkou, Taoyuan, Taiwan
| | - Yen-Chang Hsiao
- Chang Gung Memorial Hospital, Burn Center, Linkou, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Chang Gung Memorial Hospital, Trauma and Critical Care Center, Linkou, Taoyuan, Taiwan
| | - Yu-Pao Hsu
- Chang Gung Memorial Hospital, Trauma and Critical Care Center, Linkou, Taoyuan, Taiwan
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24
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Nicholson B, Dhindsa H. Helicopter Transport in Regionalized Burn Care: One Program's Perspective. Air Med J 2016; 35:355-359. [PMID: 27894559 DOI: 10.1016/j.amj.2016.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 09/14/2016] [Accepted: 10/10/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The decision to use helicopter EMS (HEMS) for the transport of burn patients is a complex decision. This analysis sought to evaluate burn patients flown to burn centers who met predetermined criteria for patients who likely benefit from HEMS care. METHODS A retrospective transport chart review of all burn transports covering the preceding nine and a half years was conducted to evaluate for HEMS appropriate criteria defined as patients requiring advanced airway management, ventilator support, facial burns, inhalation injury, circumferential burns, electrical or chemical burn, or major burns. All ages were included. RESULTS A total of 171 cases were identified. Thirty-one (18.1%) were pediatric. Facial burns constituted the most frequent criteria met with 112 (65.5%) patients identified. Sixty-nine (40.4%) had suspected inhalation injuries. Fifty-five (32.2%) patients were intubated. Forty (28.6%) adults and twelve (38.7%) children had major burns. CONCLUSION Of the 171 burn patient transported, twenty-one (12.3%) patients did not meet any HEMS criteria. Excluding those who did not meet any criteria, 98 (57.3%) patients were flown with non-major burns. Efforts are needed to determine the risks burn patients face if slower, non-critical care transport is utilized and which patients are appropriate for HEMS.
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Affiliation(s)
| | - Harinder Dhindsa
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
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25
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Abstract
Failed burn resuscitation can occur at various points. Early failed resuscitation will be largely caused by prehospital factors. During resuscitation, failure will present as a patient's nonresponse to adjunctive therapy. Late failure will occur in the setting of multiple organ dysfunction syndrome. Burn care providers must be vigilant during the resuscitation to identify a threatened resuscitation so that adjunctive therapies or rescue maneuvers can be used to convert to a successful resuscitation. However, when a patient's resuscitative course becomes unsalvageable, transition to comfort care should be taken to avoid prolongation of suffering.
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Affiliation(s)
- Elisha G Brownson
- Department of Surgery, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, WA 98104, USA
| | - Tam N Pham
- Department of Surgery, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, WA 98104, USA.
| | - Kevin K Chung
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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26
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Hardwicke J. The influence of outcomes on the provision and practice of burn care. Burns 2016; 42:307-15. [DOI: 10.1016/j.burns.2015.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/06/2015] [Indexed: 01/10/2023]
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Novel use of a flowable collagen-glycosaminoglycan matrix (Integra™ Flowable Wound Matrix) combined with percutaneous cannula scar tissue release in treatment of post-burn malfunction of the hand--A preliminary 6 month follow-up. Burns 2015; 42:e1-e7. [PMID: 26652220 DOI: 10.1016/j.burns.2015.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 08/12/2015] [Accepted: 10/07/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Long-term function following severe burns to the hand may be poor secondary to scar adhesions to the underlying tendons, webspaces, and joints. In this pilot study, we report the feasibility of applying a pasty dermal matrix combined with percutaneous cannula teno- and adhesiolysis. PATIENTS AND METHODS In this 6 month follow-up pilot study, we included eight hands in five patients with hand burns undergoing minimal-invasive, percutaneous cannula adhesiolysis and injection of INTEGRA™ Flowable Wound Matrix for a pilot study of this new concept. The flowable collagen-glycosaminoglycan wound matrix (FCGWM) was applied with a buttoned 2mm cannula to induce formation of a neo-gliding plane. Post treatment follow-up was performed to assess active range of motion (AROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, Vancouver Scar Scale (VSS) and quality of life Short-Form (SF)-36 questionnaire. RESULTS No complications were detected associated with the treatment of FCGWM injection. The mean improvement (AROM) at 6 months was 30.6° for digits 2-5. The improvement in the DASH score was a mean of 9 points out of 100. The VSS improved by a mean of 2 points out of 14. DISCUSSION The study demonstrates the feasibility and safety of percutaneous FCGWM for dermal augmentation after burn. Results from this pilot study show improvements in AROM for digits 2-5, functional scores from the patient's perspective (DASH) and scar quality (VSS). The flowable form of established INTEGRA™ wound matrix offers the advantage of minimal-invasive injection after scar release in the post-burned hand with a reduction in the risk of postsurgical re-scarring.
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28
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Toussaint J, Singer AJ. The evaluation and management of thermal injuries: 2014 update. Clin Exp Emerg Med 2014; 1:8-18. [PMID: 27752547 PMCID: PMC5052819 DOI: 10.15441/ceem.14.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 08/21/2014] [Accepted: 08/28/2014] [Indexed: 11/23/2022] Open
Abstract
Burns are among the most common injuries presenting to the emergency department. While burns, especially large ones, may be associated with significant morbidity and mortality, most are minor and can be managed by emergency practitioners and discharged home with close follow-up. In contrast, patients with large burns require aggressive management of their airway, breathing and circulation in order to reduce mortality and morbidity. While early endotracheal intubation of patients with actual or impending airway compromise and aggressive fluid resuscitation have been emphasized, it appears that the pendulum may have swung a bit too far towards the extreme. The current review will briefly cover the epidemiology, pathogenesis and diagnosis of burn injuries with greater emphasis on airway and fluid management. We will also discuss the local management of the burn wound, which is all that is required for most burn patients in the emergency department.
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Affiliation(s)
- Jimmy Toussaint
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
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29
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Abstract
For the physician or surgeon practicing outside the confines of a burn center, initial assessment and fluid resuscitation will encompass most of his or her exposure to patients with severe burns. The importance of this phase of care should not be underestimated. This article provides a review of how to perform initial resuscitation of patients with significant burns and/or inhalation injury, while arranging for transfer to a regional burn center.
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Affiliation(s)
- Leopoldo C Cancio
- Medical Corps, U.S. Army, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA, Fort Sam Houston, TX 78234-6315, USA.
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Strang SG, Van Lieshout EM, Breederveld RS, Van Waes OJ. A systematic review on intra-abdominal pressure in severely burned patients. Burns 2014; 40:9-16. [DOI: 10.1016/j.burns.2013.07.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/10/2013] [Accepted: 07/02/2013] [Indexed: 12/12/2022]
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Cancio LC, Lundy JB, Sheridan RL. Evolving changes in the management of burns and environmental injuries. Surg Clin North Am 2012; 92:959-86, ix. [PMID: 22850157 DOI: 10.1016/j.suc.2012.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Burns and environmental injuries are common as primary or secondary problems in survivors of natural disasters, terrorist incidents, and combat operations. In recent years, intensive military medical experience has resulted in substantial progress in treatment of these important problems. This article reviews practical applications of this new knowledge.
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Affiliation(s)
- Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX 78234-6315, USA
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Hoogewerf CJ, Hop MJ, Nieuwenhuis MK, Middelkoop E, Van Baar ME. Early excision and grafting for burns. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Cornelis J Hoogewerf
- Association of Dutch Burn Centres; Burn Centre, Maasstad Hospital; PO Box 9100 Rotterdam South-Holland Netherlands 3007 AC
| | - M. Jenda Hop
- Association of Dutch Burn Centres; Burn Centre, Maasstad Hospital; PO Box 9100 Rotterdam South-Holland Netherlands 3007 AC
| | - Marianne K Nieuwenhuis
- Association of Dutch Burn Centres; Burn Centre, Martini Hospital; PO Box 30033 Groningen Groningen Netherlands 9700 RM
| | - Esther Middelkoop
- Association of Dutch Burn Centres; Burn Centre, Red Cross Hospital; Red Cross Hospital PO Box 1074 Beverwijk North-Holland Netherlands 1940 EB
| | - Margriet E Van Baar
- Association of Dutch Burn Centres; Burn Centre, Maasstad Hospital; PO Box 9100 Rotterdam South-Holland Netherlands 3007 AC
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Seifman M, Ek EW, Menezes H, Rozen WM, Whitaker IS, Cleland HJ. Bushfire Disaster Burn Casualty Management. Ann Plast Surg 2011; 67:460-3. [DOI: 10.1097/sap.0b013e3182111021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lumenta DB, Vierhapper MF, Kamolz LP, Keck M, Frey M. Train surfing and other high voltage trauma: differences in injury-related mechanisms and operative outcomes after fasciotomy, amputation and soft-tissue coverage. Burns 2011; 37:1427-34. [PMID: 21852047 DOI: 10.1016/j.burns.2011.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 07/21/2011] [Accepted: 07/22/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND In the context of scarce reports on train surfers among high voltage electric injuries, we conducted a retrospective review between January 1994 and December 2008. METHODS After matching for inclusion criteria we reviewed patient records of 37 true high voltage injuries (12 train surfers [TS] and 25 other high voltage injuries [HV]). RESULTS TS were significantly younger (TS 15.8 years vs. HV 33.3 years, p<0.0001), and had a greater %TBSA (TS 49.7%TBSA vs. HV 21.5%TBSA, p=0.0003) without affecting the median length-of-stay (TS 52 days vs. HV 49 days) or number of operations (TS 4 vs. HV 3). TS had different injury patterns, with a higher percentage of affected extremities (TS 72.9% vs. HV 52.0%, p=0.0468) and associated injuries (TS 58% vs. HV 20%, n.s.) than HV. Both groups demonstrated comparable fasciotomy (TS 71.4% vs. HV 55.8%) and amputation rates (TS 17.1% vs. HV 15.4%). While TS required less flaps (TS 3/12 vs. HV 18/25; p=0.0153), soft-tissue reconstruction revealed an overall low incidence of complication rates (one partial pedicled flap loss and two total free flap losses). CONCLUSIONS Train surfers have proven to be a distinct group of patients among high-voltage injuries notably as a result of a younger age, a shorter electric contact duration and higher velocity-induced trauma. With a possibly declining trend of train surfing-related accidents in an aging society, it will be interesting to see if emerging economies will face comparable phenomena, for which prevention strategies remain key.
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Affiliation(s)
- David Benjamin Lumenta
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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McKee DM. Reconstructive options of burn injuries to the hand and upper extremity. J Hand Surg Am 2011; 36:922-5. [PMID: 21186087 DOI: 10.1016/j.jhsa.2010.10.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 10/19/2010] [Indexed: 02/02/2023]
Affiliation(s)
- Desirae M McKee
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX 79430-9436, USA.
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