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Biomedical subjects

D M Heimbach

Publications and source records attributed to D M Heimbach.

At least 109 records · Page 6Linked to original sources
PubMedDate not supplied

Laser Doppler flowmetry for the early detection of hypertrophic burn scars.

In this preliminary study it was hypothesized that patients with hypertrophic scars have increased microcirculatory perfusion in the areas of scarring. Sixteen former patients whose burn injuries involved less than 30% TBSA and who required autologous skin grafting were evaluated using laser Doppler flowmetry. Data grouped at three-week intervals showed higher flow values in patients with hypertrophic scarring than in those with non-hypertrophic scars. These initial data suggest that hypertrophic scars may be associated with increased microcirculatory blood flow. These values are elevated early and could possibly serve as an early indicator for the occurrence of hypertrophic scarring.

Adult↗
PubMedDate not supplied

Patient self-reports three months after sustaining a major burn.

As survival rates of patients with major burns increase, it is becoming more important to study the course and quality of their recovery. Few studies of the recovery of these patients exist that use a prospective design and standardized measures. This paper describes a preliminary study of the self-reported health of patients three months after sustaining a major burn. An initial analysis was conducted on selected data gathered from 29 patients as part of a more comprehensive, prospective study of burn rehabilitation outcome. Measurements analyzed included the Sickness Impact Profile (SIP), the Health-Specific Locus of Control Scale (HLC), and the total body surface area burned (TBSA). Findings showed that TBSA was related to the degree to which patients perceived they had control over their health, but few correlations were found between TBSA, and HLC scale, and the SIP scale. On the SIP, most patients reported few or no problems, but a significant minority reported major problems in one or more areas of their lives. The problems that were reported tended to cluster in the areas of vocation and emotional adjustment. These results suggest that patients with major burns should not be considered a homogeneous group with respect to rehabilitation outcome.

Adaptation, Psychological↗
PubMedDate not supplied

Partial excision of residual burn lesions.

Most burn victims have unattractive residual lesions, which may include hypertrophic donor sites, unsightly skin grafts, hypertrophic scars, and mature scars with altered pigmentation or texture. Some of these lesions can be treated by total excision in one or more stages or they can be reconstructed utilizing grafts, flaps, Z-plasties, or tissue expansion. But frequently these procedures are either not indicated or not elected by the patient. In such a situation, the only surgical option is partial excision, with the goal of making the lesion less conspicuous and more easily concealed by clothing. Whether or not such partial excisions are worthwhile is the obvious question. We could not find an answer in the literature and therefore decided to review our own experience. Between 6/30/81 and 3/12/86, 92 such procedures were performed and followed in 25 patients. Partial excision of hypertrophic donor sites, unsightly skin grafts, and hypertrophic scars did yield improved appearance in most patients. However, partial excision of mature scars, ie, areas of altered pigmentation or texture, did not have the same success. We continue to treat the first three types of lesions in this fashion but no longer include the latter.

Adolescent↗
PubMedDate not supplied

Molten metal burns to the lower extremity.

In this study of ten consecutive patients sustaining molten metal injuries to the lower extremity who were treated with excision and grafting, treatment with compression Unna paste boot was compared with that with conventional dressing. Hospital stay was decreased from 12.2 days in the conventional dressing group (five patients) to 6.4 days in the Unna group (five patients). Ambulation was initiated on postoperative day (POD) 2.2 in the Unna group, compared with POD 8.0 in the conventional dressing group. Return to work was on POD 44.8 in the Unna group versus POD 86.3 in the conventional dressing group. Treatment of molten metal injuries to the lower extremity with Unna paste compression dressing resulted in shorter hospital stay, earlier ambulation, and more rapid return to work.

Accidents, Occupational↗
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Effects of body surface thermal injury on apparent renal and cutaneous blood flow in goats.

The etiology of postburn circulatory impairment ("burn shock") is multifactorial and incompletely understood. However, systemic vasoconstriction is a consistent observation during this period and occurs in spite of aggressive fluid resuscitation therapy. We studied the degree and time course of systemic vasoconstriction in goats for 24 hours following burns of two sizes (20% and 35% TBSA), in which fluid resuscitation was performed according to a common clinical crystalloid regimen. Cardiac index and urine output (reflecting renal perfusion) fell dramatically at two hours after burn, but returned slowly to preburn levels by 24 hours. The degree of fall and rate of recovery were dependent on burn size. Dermal perfusion was assessed by laser Doppler flowmetry in both burned and unburned skin. Dermal perfusion was negligible in burned skin. Unburned skin blood flow fell with increasing burn size, progressively recovered to preburn levels after the small burn, but at 24 hours remained significantly depressed after the larger burn. The stimulus for this persistent skin vasoconstriction is unclear.

Animals↗
PubMedDate not supplied

Laser Doppler monitoring of microcirculatory changes in acute burn wounds.

Because burns are dynamic wounds that can change in apparent depth during the first 72 hours, we asked whether measuring changes in cutaneous blood flow might help predict the ultimate fate of burns that were not obviously shallow or deep. A laser Doppler flowmeter was used to study cutaneous perfusion for at least 72 hours in partial-thickness wounds on patients with burns of less than 15% TBSA and in experimental wounds of similar size on rats. Clinical wounds that healed without grafting consistently showed elevated perfusion levels which increased further within 72 hours, whereas wounds eventually requiring grafting experienced lower perfusion levels with no obvious pattern of increase. Differences between average flow levels for healing and nonhealing burns were statistically significant throughout the study period. Perfusion levels in experimental wounds were stratified according to burn severity, with shallower wounds showing a pattern of increase similar to the clinical wounds.

Adult↗
PubMedDate not supplied

Risk management in children with burn injuries.

The currently accepted "high risk/no risk" concept of assessing pediatric injuries inadequately describes the range of situations in which children are burned and the spectrum of appropriate interventions. All children are at risk for injury; the question is not when but how best to intervene. A retrospective chart analysis of 101 pediatric admissions in 1985 demonstrated that childhood burns and follow-up requirements varied, depending on circumstances of injury, presence and behavior of caregivers, and the ability of parents or caregivers to assume responsibility for the child's supervision, safety, and health needs. We must view childrens' risk for injury as dependent upon the supervisory capacity of their parents, and continue to identify and develop specific interventions appropriate to each level of understanding and responsibility. Adequate documentation of the circumstances of injury and parent behavior are the key factors in determining level of risk and appropriate management.

Adolescent↗
PubMedDate not supplied

Relating mental health and physical function at discharge to rehabilitation status at three months postburn.

Preinjury mental health is said to be a major predictive factor in the rehabilitation progress of burn patients. However, it is unclear which component of rehabilitation (emotional v physical) is predicted by this variable; furthermore, the predictive validity of preinjury mental health has not been compared with physical variables. The present study compared preinjury mental health, physical variables, and length of hospitalization in predicting the rehabilitation progress of 59 major burn patients at three-month follow-up. Preinjury mental health was assessed by the Rand Mental Health Form; physical status, by the Upper Extremity Index (standard measures of upper limb joint mobility); and hospital stay, by the number of days of acute hospitalization. These variables were assessed at the time of discharge. Three-month rehabilitation outcome was measured by the Sickness Impact Profile, a self-report inventory that evaluates patient outcome in 12 different areas. These areas were in turn placed in the categories of disability (ie, difficulties in functioning in activities of daily living; eating) handicap (ie, difficulties in functioning in general areas of living; employment) and mental health status. In predicting mental health status at three months, preinjury mental health was significantly correlated. In predicting physical disability, physical factors were found to be important. Conversely, physical status was not significantly related to mental health outcome, and preinjury mental health was not related to physical disability. The results indicate the importance of defining outcome when attempting to predict rehabilitation progress of burn patients.

Activities of Daily Living↗
PubMedDate not supplied

Use of 5% sulfamylon (mafenide) solution after excision and grafting of burns.

In previous reports, 5% sulfamylon solution has been utilized on unexcised burns and granulation tissue. We prospectively evaluated 67 burn patients to determine graft take and the incidence of side effects with use of sulfamylon solution dressings after excision and grafting. Of patients excised and grafted, the mean graft take for a total of 100 procedures was 86%. Rash occurred in 18% of patients and sulfamylon was discontinued with no sequelae. Twenty-five percent had at least one positive fungal wound culture, yet only 3% required treatment for candidemia. Those patients who developed a rash and fungal colonization had a significantly larger percent burn and were treated with sulfamylon for a longer period of time. Pain intensity was rated on a Visual Analog Scale with a mean score of 2.4; in no case was the pain considered severe enough by the patient to terminate treatment. Acidosis was present in 3% of patients but felt to be unrelated to the sulfamylon treatment. As an antimicrobial agent, 5% sulfamylon solution is a viable alternative for fresh autografts with excellent graft take and acceptable side effects.

Administration, Topical↗
PubMedDate not supplied

Effectiveness of nalbuphine for relief of burn debridement pain.

A prospective double-blind study was undertaken to compare the effectiveness of the agonist-antagonist nalbuphine hydrochloride with morphine sulfate in relieving pain from burn debridement. The study consisted of two groups in which each was given a preprocedure dose of the study medication followed by administration of incremental doses up to one half the initial dose as requested. After reviewing the literature, we set the ratio of nalbuphine hydrochloride/morphine sulfate at 2:1 mg, respectively. Safety and efficacy were determined by measurements of vital signs, sedation, adverse effects, and patient evaluation of pain intensity and relief with the use of both an adjective and a visual analogue scale. Analysis showed no significant differences in the variables measured. Therefore in relieving burn debridement pain, we found nalbuphine hydrochloride to be as effective as morphine sulfate. We also found that respiratory depression was not a problem in either group.

Adult↗
PubMedDate not supplied

Determinants of donor site infections in small burn grafts.

Studies indicate no advantage to the early use of systemic antibiotics in patients with burns, but the use of prophylactic antibiotics during excision is still being questioned. The records of 213 patients who required excision and who had less than 20% total body surface area burned were reviewed. We investigated risk factors associated with donor- and graft-site infections and whether or not perioperative antibiotics influenced the incidence of infections. Statistically significant increases in donor-site infections occurred when patients did not receive perioperative antibiotics, when the excision was large, and when the time between injury and excision was prolonged. Age, burn size, or type of dressing did not influence the development of infections. A risk of graft infections in those patients who were not receiving perioperative antibiotics existed, but it was not significant. The time between injury and excision and the actual size of the excision influence the development of donor-site infections. However, perioperative antibiotics seem to decrease the risk of these infections.

Adult↗
PubMedDate not supplied

The management of burns to the perineum and genitals.

A review of 1987 patients treated during the years 1981 to 1986 was conducted to answer the following questions about perineal burns: (1) Are Foley catheters necessary for all patients? (2) Is there any advantage to early excision of the perineal burn wound? (3) What are the complications of perineal wounds? One hundred three patients with perineal burns were identified; mean burn size was 36% of total body surface area. There were 29 deaths in this group but none were related to the perineal burns. Of the 74 survivors 36 (49%) needed Foley catheters. However, the catheters were in place for the period of resuscitation only. There were no urethral complications associated with catheterization. Only three patients required surgery: one had a urethral meatotomy and two had split-thickness skin grafts. In conclusion, we found no genitourinary complications associated with perineal burns. Almost all perineal and genital burns were managed without indwelling catheters. Early excision of the perineal burn wound is not necessary, and most of these wounds will heal satisfactorily without grafting.

Burns↗
PubMedDate not supplied

Treatment of postextubation stridor in a pediatric patient with burns: the role of heliox.

Stridor is a common problem in patients with burns after extubation, especially in children and in those with facial burns or airway injuries. The usual treatments for severe respiratory distress, such as reintubation and tracheotomy, carry substantial risks for patients. We report our successful treatment of severe postextubation stridor in a 7-year-old patient with burns with the administration of heliox in addition to more traditional therapies, review the literature about the use of heliox in postextubation stridor, and suggest cases in which its use may prevent the need for more hazardous interventions.

Burns↗
PubMedDate not supplied

Infection control in a burn center.

No consensus has been reached on the ideal isolation technique to prevent hospital-acquired infection in the patient with burns. This study reports four 2-month consecutive periods of microbial surveillance in a burn center intensive care unit. Phase I, the first period of surveillance, demonstrated a unit-acquired colonization rate of 63%, with the marker organisms appearing at 4 to 8 days. Direct observation of isolation technique showed a 51% error rate. A mandatory educational session reviewing the high colonization rates, observed breaks in isolation technique, and principles of infection control failed to decrease the colonization rates as measured in phase II. A simplified isolation technique was adopted, which led to a decrease in unit-acquired colonization, from 63% to 33% in phase III from phase I values (p = 0.0514); and to a significant delay in inception, from 7.8 to 21 days, in those colonized with Pseudomonas aeruginosa (p less than 0.05). The simplified isolation technique decreased isolation costs over a 6-month period from $53,000 to $30,000. To confirm the decrease colonization rates from phase I to phase III, a fourth 2-month surveillance period was undertaken 6 months later. Phase IV demonstrated similar results to those of phase III.

Burn Units↗
PubMedDate not supplied

A nonuser's questions about cultured epidermal autograft.

Clinical experience assumes major importance as the source of data on cultured epidermal autograft (CEA), since a large controlled study is probably not forthcoming. Among the general questions to be answered are: Which patients are candidates for grafting with CEA? Do selection criteria specify size of total body surface area burn or age? Is CEA more suitable for certain body areas than others? Does CEA close the wound as quickly, as well, and as safely as other available methods of coverage? Fresh or frozen allograft, the gold standard, is presumed to be safe, but the current concern about transmission of viral diseases raises doubts. Presumably, CEA would be safe. Other concerns are care of the wound and control of infection during the 3-week waiting period that is required for CEA. What is actual CEA "take" (i.e., areas that do not require regrafting)? What is the clinical experience with follow-up? Cost-effectiveness of CEA is a factor including hospital stay and hidden costs such as failure of temporary wound coverage. Whether CEA saves lives is probably unanswerable, but as a skin cover it may reduce incidence of burn wound sepsis. Perhaps in the future, a combination of cultured epidermal cells and a type of permanent dermis will produce a cover that is genuine skin. Today we have only materials that are parts of skin.

Burns↗
PubMedDate not supplied

Treatment of fourth-degree hand burns.

Fourth-degree hand burns are rare but devastating injuries. They cannot be grafted readily but often require flaps and amputation, and impairment is significant. We report our 10-year experience (1981 to 1990) with deep hand burns to characterize our treatment and outcome. A total of 25 patients (35 hands) were treated. Eight local flaps, nine distant flaps, and two free-tissue transfers were performed. Eleven hands were treated with K-wire immobilization and grafting. Thirty-three amputations were done. Postburn function was evaluated in 25 salvaged hands. Eleven hands had good outcomes, whereas seven had moderate sequelae and seven were severely affected. Patients who were treated with flap coverage of exposed tendons and joints had better functional outcomes than those treated with delayed closure with immobilization and grafting. The excellent outcomes in the flap coverage group justifies the added commitment of technical and therapeutic resources that this treatment requires.

Adult↗