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Biomedical subjects

David M Heimbach

Publications and source records attributed to David M Heimbach.

At least 19 recordsLinked to original sources
PubMed2006

An outcome analysis of patients transferred to a regional burn center: transfer status does not impact survival.

BACKGROUND: Optimal burn care is provided at specialized burn centers. Given the geographic location of these centers, many burn patients receive initial treatment at local emergency departments prior to transfer. The purpose of this study was to determine whether patients transferred from other facilities have worse outcomes than those admitted directly from the field. STUDY DESIGN: A retrospective cohort study was performed comparing the outcomes of patients admitted to our burn center directly from the field with patients requiring transfer from a preliminary care facility. The outcomes of interest were mortality, length of stay, length of stay/TBSA burned, number of operations and hospital charges. Poisson regression or Cox proportional hazards model was used to evaluate differences in outcomes after adjusting for potential confounders. RESULTS: From 2000 to 2003 a total of 1877 patients were admitted to our burn center and 953 (51%) were transferred from a preliminary care facility. No difference (p<0.05) was found in length of stay, number of operations, hospital charges and mortality between the two cohorts. CONCLUSIONS: This study demonstrates that patients transferred to a regional burn center from local hospitals have equivalent mortality, length of stay and hospital charges as those admitted directly from the field.

Adolescent↗
PubMed2006

Complex wound management utilizing an artificial dermal matrix.

The benefits of the Integra Dermal Regeneration Template in the management of extensive burn injuries have been well documented. Integra can reduce donor- and graft-site scarring and has been reported to be capable of vascularizing over small areas of exposed bone and tendon. Given these potential advantages, we have used Integra for a variety of other reconstruction applications. We performed a retrospective review of patients with complex wounds treated with Integra at our burn center. Integra was used in the management of a variety of wounds, including necrotizing fasciitis, extremity degloving injury, meningococcemia, Marjolin ulcer, postburn lip reconstruction, and fourth-degree burns with exposed bone or tendon. Engraftment rates of Integra and autograft were 98% +/- 4% and 97% +/- 4%, respectively. All areas of graft loss healed without need for regrafting. The benefits of Integra in the management of acute burn wounds can be extended to other traumatic and complex wounds.

Adolescent↗
PubMed2006

Correlation of clinical outcome of integra application with microbiologic and pathological biopsies.

BACKGROUND: Integra, a dermal replacement template consisting of bovine collagen, chondroitin-6-sulfate, and a silastic sheet is a postexcisional treatment for deep partial to full thickness burns where autograft is limited. This study correlates Integra histology and quantitative microbiology cultures with clinical outcomes after autografting. METHODS: Charts of 29 burn patients who underwent Integra treatment and neodermis biopsy at the time of ultra thin autografting were reviewed. We analyzed microbial contamination, inflammatory reaction, and autograft take. RESULTS: The mean burn size and age were 43% total body surface area and 39 years old, respectively. In quantitative neodermis cultures, 90% of samples had bacterial growth; nine samples (31%) had > 10(5) colony forming units per gram. The most common organism was Staphylococcus aureus (31%). Patients with quantitative bacterial counts >10(5) CFU/g received targeted systemic antibiotics. Integra take (83%) and autograft take (92%) were acceptable even in patients with high bacterial counts (78% Integra take; 86% autograft take). More than 50% of biopsies had dermal regeneration similar to normal dermis; foreign body reactions were unusual. Histologic evidence of inflammation, especially polymorphonuclear cells, was increased in biopsies with high bacterial counts. CONCLUSION: Integra and autograft take can be acceptable even with high bacterial counts if wounds are treated with appropriate targeted topical and systemic antibiotics in the presence of microbial contamination. Neodermis biopsies showed fibrous in-growth congruent with existing Integra fibers with minimal foreign body reaction. These data support Integra use as a safe and effective treatment modality in patients with major burns.

Administration, Topical↗
PubMed2006

Elevated orbital pressure: another untoward effect of massive resuscitation after burn injury.

BACKGROUND: Fluid resuscitation remains a fundamental component of early burn care management. However, recent studies suggest that excessive volumes of resuscitation are being administered. Overresuscitation results in negative sequelae including abdominal and extremity compartment syndromes. Elevated intraocular pressure (IOP) has been described as another potentially devastating effect of massive fluid resuscitation in trauma patients. The orbit, similar to the abdomen and extremity, is a compartment, limited to expansion from edema anteriorly by the eyelids and orbital septum, and posteriorly by the bony orbital walls. The purpose of this study was to review the incidence of elevated IOP in a series of patients with major burn injury. METHODS: We retrospectively reviewed the charts of 13 consecutive patients admitted to our burn center with burn sizes >25% total body surface area (TBSA). All patients underwent serial IOP measurements for the first 72 hours following admission. Medical records were reviewed for fluid resuscitation volume, IOP measurements, need for canthotomy, and results of canthotomy procedures. RESULTS: Five of 13 patients had IOP >30 mm Hg and required lateral canthotomy. Canthotomy immediately reduced IOP (p = 0.009). Patients who developed elevated IOP received a significantly larger fluid resuscitation (9.0 cc/kg/%TBSA versus 6.0 cc/kg/%TBSA, p = 0.02). Elevated IOP was significantly associated with delivery of larger fluid resuscitation volume (p = 0.027). CONCLUSIONS: Massive fluid resuscitation following burn injury can result in orbital compartment syndrome requiring lateral canthotomy. Early diagnosis and treatment of orbital compartment syndrome should be incorporated into the management of patients with major burn injury receiving large fluid resuscitation volume.

Adult↗
PubMed2006

The optimal time for early excision in major burn injury.

INTRODUCTION: Early excision and grafting (E&G) drastically changed burn care in America by reducing morbidity, mortality and hospital length of stay (LOS). The present study was intended to determine whether an optimal time window exists between resuscitation and wound sepsis for the first E&G in a patient with a large burn. MATERIAL AND METHOD: The authors conducted a retrospective study of patients admitted between January 1994 and December 2000 with > or = 40% TBSA burns and at least 1 E&G procedure. Patients were grouped according to the day of their first operation. Patients allowed to heal indeterminate burns prior to excision and grafting of deep partial or full thickness burns were grouped as > or = d7 and were excluded from the present study. The authors correlated the time of first excision with infection, mortality and LOS. RESULTS: Seventy-five patients were identified and 12 patients allowed to heal indeterminate burn prior to excision and grafting of deep partial or full thickness burns were excluded. Sixty-three remaining patients included 51 males and 12 females. Mean burn size was 49% of total body surface area (TBSA) (44% deep partial or full thickness) and the mean age was 36 years. There were 61 flame (2 combined with electrical injuries), 1 scald and 1 chemical burn. Twelve died (19%) and 52 patients developed 121 infections. Whereas there was no statistical difference in mortality for patients operated on different days (p > 0.2), 60% of patients operated within the first 48 hours after injury died; this was not significant due to a small patient number CONCLUSIONS: The present data suggest that patients who undergo early excision and grafting within seven days following a major burn > or = 40% TBSA have equivalent infection or mortality rates regardless of when the first operation occurs between post burn day(PBD) 2 and PBD 7 (p > 0.2).

Adult↗
PubMed2005

Patterns of grease burn injury: development of a classification system.

Grease burns occur commonly in the home during food preparation. It has been our observation that grease burns follow a particular pattern of injury. The purpose of this study was to review our institutional experience in the management of these burns to develop a classification scheme. We performed a retrospective review of patients admitted to our burn center with grease burns. Subjects were identified through our database and their charts were reviewed with particular attention to burn distribution, TBSA and need for grafting. We excluded workplace burns and children under the age of six. A total of 249 patients who fit the above criteria were admitted with grease burns to our burn center from 1993 to 2003. The sequence of events leading to burn and its distribution followed a consistent pattern. The majority of patients (86%) had an isolated upper extremity burn or upper extremity burn in combination with a face, trunk or lower extremity burn. Forty percent of patients required at least one excision and grafting procedure. Grease burns associated with cooking at home follow predictable patterns of injury. Based on these patterns we proposed a classification system for domestic grease burns.

Accidental Falls↗
PubMed2004

Is supra-Baxter resuscitation in burn patients a new phenomenon?

Baxter described the use of 4 cm3/kg/%TBSA as a guideline for fluid resuscitation after burns. However, recent studies have shown that, at the present time, patients generally receive greater than the "Baxter" formula. Pruitt has called this phenomenon "fluid creep," and it has the potential for significant consequences including abdominal and extremity compartment syndromes and severe pulmonary insults. The purpose of this paper is to determine if this supra-Baxter resuscitation is a new phenomenon. We performed a retrospective chart review with two cohorts of patients. Group 1 consisted of 11 patients admitted between 1975 and 1978 to our burn center. Group 2 consisted of 11 patients admitted to our burn center in 2000 who were matched for age, sex, and percent total body surface area burned. Group 1 received 3.6 +/- 1.1 cm3/kg/% TBSA of fluid in the first 24 h. Group 2 received 8.0 +/- 2.5 cm3/kg/% TBSA, which is 100% more than the Baxter formula. There was no difference in the median age, weight, or 24-h urine output between the two groups. Our data demonstrate that the "fluid creep" phenomenon is relatively new.

Adolescent↗
PubMed2004

"Opioid creep" is real and may be the cause of "fluid creep".

Recent studies have shown that burn patients receive larger volumes of fluids than predicted by the Baxter formula and the reason for this is unclear. One potential reason is that increased analgesics are used which could blunt the response to fluid resuscitation. The purpose of this study was to compare the administration of opioid agonists in patients treated at a single burn center in the 1970s and in the year 2000. We performed a retrospective chart review comparing two matched cohorts. Group I consisted of 11 patients admitted between 1975 and 1978. Group II consisted of 11 patients admitted in 2000 matched for age, sex and %TBSA. Patients in Group II received a significantly higher mean opioid equivalent than those in Group I (26.5 +/- 12.3 versus 3.9 +/- 2.2 in the first 24h, P < 0.001). In addition, in Group II, a larger variety and combination of opioid agonists were used. This review demonstrates a significant increase from the 1970s to 2000 in the type, dose prescribed and dose delivered of opioid agonists. Along with "fluid creep", we have also increased our use of opioid agonists or "opioid creep". Higher doses of opioid agonists may have hemodynamic consequences, which may contribute to the increased fluid volumes.

Adolescent↗
PubMed2003

What is the prevalence of hypertrophic scarring following burns?

Hypertrophic scarring after burns remains a major problem and is considered to be "common". Pressure garments are commonly used as treatment even though there is little sound data that they reduce the prevalence or magnitude of the scarring. In 1999 we began a study of the efficacy of pressure garments on forearm burns. After studying 30 patients, mainly white adults, we found no hypertrophic scar in either those treated with pressure or without. This prompted us to review the literature on the prevalence of hypertrophic scarring after burns and found only four articles with a relatively small number of patients and only three geographical locations. It became clear that the prevalence of hypertrophic scarring is really unknown. We then did a retrospective study of 110 burn survivors and counted all hypertrophic scars of all sizes and locations in all races and found the prevalence hypertrophic scarring to be 67% which conflicts with the published reports and our prospective study and suggests that further research is necessary. We concluded that a worldwide, prospective survey is necessary to establish the prevalence of hypertrophic scarring after burns. In this article we are calling for and offering to organize this survey.

Adolescent↗
PubMed2003

Clinical effects of inhibiting leukocyte adhesion with monoclonal antibody to intercellular adhesion molecule-1 (enlimomab) in the treatment of partial-thickness burn injury.

BACKGROUND: A randomized, prospective, multicenter, double-blind, placebo-controlled, phase II clinical trial was performed to determine whether inhibition of leukocyte adherence by administration of monoclonal antibody directed against intercellular adhesion molecule-1 would improve burn wound healing. METHODS: One hundred ten patients with burn injury ranging from 10% to 30% total body surface area were enrolled. Fifty-six patients received placebo (saline) and 54 patients received murine monoclonal antibody to the human intercellular adhesion molecule-1 (enlimomab). Treatment was initiated within 6 hours of injury. Patients had three distinct partial-thickness wound sites assessed. Laser Doppler flowmetry was used to stratify wounds on the day of injury. Wounds were assessed for healing status on day 21 postburn and categorized as healed, nonhealed, or grafted. RESULTS: Patients treated with enlimomab had a significantly increased percentage of wounds that healed spontaneously in less than 21 days overall and when stratified by burn wound laser Doppler blood flow readings for those wounds at greatest risk for nonhealing. CONCLUSION: These results support the concept that leukocyte adherence is involved in the pathogenesis of burn wound necrosis and suggest a therapeutic mechanism for modulating the inflammatory response after the burn injury that may improve wound healing.

Adult↗
PubMed2002

Early excision and grafting of face and neck burns in patients over 20 years.

Although excision and grafting of burns has become common and standard, many surgeons have been reluctant to excise and graft face burns. In fact, we could find photographic results at 1 year after grafting of only eight patients in the English literature. We began excision and grafting of face burns in 1979 and presented our first 16 patients in 1986 in this journal. With encouragement from Janzekovic and Jackson, we continued and have now used essentially the same procedure for more than 20 years in approximately 100 patients and, from this large series, are able to present outcomes. From January of 1979 to May of 1999, we performed excision and grafting on 91 patients with deep face burns. Data were recorded and 35-mm photographs were obtained throughout the 20-year period. We reviewed that database and the slide files of these patients. We found 45 patients with complete photographic sets including 1-year follow-up. Since, in our opinion, there is no useful, objective measure of appearance, we decided to simply publish all 45 sets of complete photographs, permitting the reader to subjectively form an opinion of the outcome of this procedure. The results are all shown as "full" face burns and two "partial" face burns. We continue to believe that early excision and grafting is indicated for face burns that will not heal within 3 weeks and that the procedure yields results that permit the burn victims to return to society and minimizes the time off work or out of school.

Burns↗
PubMedDate not supplied

Inpatient depression in persons with burns.

In this investigation the authors collected data regarding trait anxiety, well-being, and depression from 209 men and women who had been screened for prior psychiatric diagnosis and treated in an acute-care setting for burn injuries. Well-being was measured in reference to the month before the burn injury, whereas level of depression was self-rated by patients within 2 days of hospitalization, 5 days later, and 5 days after that. Ratings of depression were also obtained 1 month after hospital discharge. Results indicated that few patients rated their depression as severe at any point in time. Depression scores decreased significantly across the hospitalization period and were correlated with burn size, trait anxiety, and well-being. Depression ratings after discharge were significantly related to depression scores obtained at the end of the inpatient phase of the study. Although most patients did not report experiencing severe levels of depression, the stability of scores across time suggests the usefulness of early screening procedures. Catching such problems early may head off longer-term difficulties.

Adaptation, Psychological↗
PubMedDate not supplied

Comparison of patient satisfaction and self-reports of pain in adult burn-injured patients.

Procedural and background pain scores were assessed prospectively and compared with treatment goals and satisfaction scores in 84 adult (67 men and 17 women) burn-injured patients treated at a single, tertiary care medical center. We hypothesized that patient satisfaction with pain management plans would be highest among those patients who were experiencing the least pain and also among patients whose experiences most closely matched their treatment analgesic goals. Twice-weekly patient self-reports of worst and average procedural pain, background pain, treatment goals (the level of procedural pain and background pain patients reported that they would be satisfied as experiencing), and overall satisfaction with pain management plans were assessed using 10-point Graphic Rating Scales. Data concerning adjunctive treatments were also obtained. Opioid equivalents, representing pain medications administered, were compared. The majority of patients perceived that "no pain" during burn wound care was an unrealistic goal, a perception that was consistent throughout hospitalization. As hypothesized, average procedural pain levels demonstrated a negative association with patient satisfaction, indicating that patients with the highest levels of procedural pain also reported the lowest level of satisfaction. Opioid analgesic dosing was not significantly associated with ratings of procedural pain or treatment goals. Our findings support the hypothesis that patient satisfaction with pain management is highest in those who experience the least amount of burn care pain and do not support the hypothesis that satisfaction is highest in those whose pain experiences most closely match treatment analgesic goals.

Adolescent↗
PubMedDate not supplied

Pediatric pain control practices of North American Burn Centers.

This study investigated pediatric pain control practices in North American Burn Centers using a mail-in survey. Questions were asked regarding pain control practices, pain assessment methods, and perceived treatment efficacy for inpatients and outpatients in four age groups. Eighty-two centers responded with 111 surveys. Intravenous morphine was the most frequently used analgesic for wound care pain. The most common background pain medications were intravenous morphine, acetaminophen with codeine, and acetaminophen alone. The use of long-acting medications increased with increasing age. Additional areas reported in the text include nonpharmacologic and pharmacologic adjuvants, treatment of itching, pain assessment, outpatient pain management, and efficacy of pain control and assessment practices. There have been great advances in pediatric burn pain control and assessment in recent years, but room for improvement remains. This study provides a basis for evaluation and comparison among burn centers. It further highlights areas that may warrant additional study and intervention.

Adolescent↗
PubMedDate not supplied

Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment.

The safety and effectiveness of Integra Dermal Regeneration Template was evaluated in a postapproval study involving 216 burn injury patients who were treated at 13 burn care facilities in the United States. The mean total body surface area burned was 36.5% (range, 1-95%). Integra was applied to fresh, clean, surgically excised burn wounds. Within 2 to 3 weeks, the dermal layer regenerated, and a thin epidermal autograft was placed. The incidence of invasive infection at Integra-treated sites was 3.1% (95% confidence interval, 2.0-4.5%) and that of superficial infection 13.2% (95% confidence interval, 11.0-15.7%). Mean take rate of Integra was 76.2%; the median take rate was 95%. The mean take rate of epidermal autograft was 87.7%; the median take rate was 98%. This postapproval study further supports the conclusion that Integra is a safe and effective treatment modality in the hands of properly trained clinicians under conditions of routine clinical use at burn centers.

Adolescent↗
PubMedDate not supplied

Social support correlates with survival in patients with massive burn injury.

Large burn size, inhalation injury, age, and associated trauma increase the rate of mortality after burns. However, not all patients with large burns and significant risk factors die. In this study, we wanted to determine other presenting factors that might indicate a survival benefit for burn patients with large burns. We reviewed charts of 36 patients with burns > or =60% TBSA that were aggressively resuscitated at the University of Washington Burn Center from 1990 to 2000 to determine whether survivors of large burns exhibit presenting variables that predict survival. Patients who had comfort care measures initiated at admission were excluded from this analysis. Survivors (n = 16) and nonsurvivors (n = 20) had no significant differences in age, total burn size, inhalation injury, or need for escharotomy. Full-thickness burn size was significantly smaller for survivors (58%) than for nonsurvivors (73%; P = .02). Survivors (81%) were more likely than nonsurvivors to have social support (35%; P = .007). A full-thickness burn > or =80 % TBSA was the only variable uniformly associated with mortality, suggesting that patients who survive large burns have a partial-thickness component that heals without surgery. The difference in degree of social support was one unique distinction that may impact patient survival and is worth further investigation.

Adolescent↗