Abstract Introduction Our state has the second highest rate of drug overdose deaths in the country, with an epicenter located in our greater metropolitan area. Burn patients using drugs can fall victim to burns commonly related to drug use or risky behavior while intoxicated. As our institution is the safety net for this community, we aimed to analyze burn presentation and outcomes of burn patients with active drug use to help clinicians anticipate challenges related to drug usage and limited socioeconomic support. Methods Retrospective cohort analysis was performed of patients over the age of 18 years presenting to our institution from 2015 to 2020 with burn injuries. We considered drug use to include marijuana, intravenous drug use, cocaine, methamphetamines, opiates, and alcohol use disorder. We analyzed admission rate with logistic regression, controlling for differences in inhalation burns, related traumatic injury, and other confounding factors. Results We reviewed a total of 1339 burn patients with 30.19% reporting drug use. On presentation, burn patients using drugs had a greater percentage of full thickness burns (+0.56%, p< 0.02), TBSA (+1.84%, p< 0.03), burn related trauma (+8.53%, p< 0.01), and concomitant inhalation burns (+3.65%, p< 0.01). Flame burns were most common overall, with scald (-6.15%) and explosion burns (+2.61%) showing the greatest change in frequency for patients using drugs (p< 0.03). During their hospital course, a larger proportion of burn patients using drugs were admitted (+16.75%, p< 0.01), and drug use was associated with a 2.4 increased log odds of admission (p< 0.01, 95% CI: 1.7-3.4). LOS, surgical intervention, ICU days, and infection showed no significant difference between cohorts. Patients using drugs were less likely to follow-up (-7.39%, p< 0.01) after discharge. Conclusions Burn victims who use drugs do not experience clinically significant increase in burn severity, such as TBSA and depth, compared with non-drug users, but were more likely to have inhalation burns and associated traumatic injury. A larger proportion of burn patients using drugs were uninsured or on Medicaid, suggesting the presence of unmanaged chronic conditions that could better explain higher rates of admission after controlling for their burns. Drug use furthermore where more likely to be lost to follow-up, possibly attributed to decreased access to healthcare secondary to insurance status and limited financial resources. Therefore, we must carefully consider discharge disposition and barriers to care to minimize post burn complications. Applicability of Research to Practice We aim to help clinicians treat burn patients who use drugs by anticipating challenges related to their usage and limited socioeconomic support.
Abstract Introduction Exfoliative skin conditions such as Steven Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN) and other significant drug related reactions are complex medical conditions that provide a challenge to the burn surgeon, especially with regards to local wound care. Various modalities of wound care require frequent dressing changes; however, these changes put the patient through significant pain and potentially harmful experiences that could lead to worse skin exfoliation, scarring and pigmentation changes. As part of our burn unit, we have created a dressing utilizing silver impregnated nylon sheets that limits the amount of wound care performed and therefore the amount of potential exfoliative damage. Methods We have employed this means of dressing in all our Steven Johnson patients with significant open or blistered areas. We performed a retrospective analysis looking at our patients who were admitted with Steven Johnson Syndrome/toxic epidermal necrolysis or other exfoliative skin disorder over the last 7 years. We had 52 patients who ranged from having 2-100% of skin involved with significant blistering or exposed areas. The suit is made specific to the patient as each area is measured and the silver sheets are formed to the patient and secured in place. The silver sheets are saturated with sterile water and rewet with saline every four hours and changed every three days. Results By utilizing these silver-based dressings, we have limited the amount of dressing changes and concomitant pain for patients while also limiting skin infections to only 1 out of our 52 patients. For blisters on the face, a local antibiotic ointment was used; and once the skin lesions had healed, a moisturizing lotion was used. Conclusions Steven Johnson Syndrome and other exfoliative skin conditions require significant wound care. By minimizing dressing changes, one can lessen the pain to patients and by utilizing dressings that are infused with silver, one can also potentially decrease the risk for infection as was seen in our patient population.
Mineral oil injection represents a dated practice of rapid and inexpensive breast augmentation. After a latency period, surrounding tissue becomes inflamed and fibrotic. Breast paraffinoma is well-documented in women; however, only 3 cases of such masses in male patients exist in the literature.
Pyoderma gangrenosum (PG) is a rare disease characterized by ulcerative cutaneous lesions that can occur postoperatively and is often associated with autoimmune disorders. PG is diagnosed by excluding other conditions that can cause ulcerations, such as infections, which may also result in immunosuppressive treatment delays and suboptimal wound care. Operative debridement of wounds has traditionally been avoided in the acute setting secondary to pathergy. This article presents a case of extensive breast PG that was successfully treated with surgical debridement, porcine-derived extracellular matrix, and negative pressure wound therapy while on systemic immunosuppressive therapy.
Abstract Introduction Patients with diabetes typically account for 3 to 14% of burn patients. Diabetes augments the challenges presented to the body with a burn injury. Vascular injury, increased blood viscosity, and immune system dysfunction all put diabetic patients at a higher risk for developing an infection and poor wound healing. Also, the peripheral neuropathy associated with diabetes, dampening sensation, largely contributes to lower extremity burns during colder months when patients are using heating pads or warm compresses. There is conflicting evidence in the literature regarding predicted outcomes and hospital courses of diabetic burn patients. We analyzed how this prevalent comorbidity impacts health consequences among patients with burn injuries to strengthen treatment strategies and predict outcomes. Methods A retrospective cohort analysis was performed on all patients between 2015-2020 over the age of 18 years that presented to our emergency department for burns. The data was obtained from the electronic medical record and statistical analysis was conducted using SPSS version 28. Results Of the 1329 patients included, 14% were diabetic. 26% of diabetic patient burns experienced scald burns, while only 15% of nondiabetic burns were of that category (p< 0.01). Upper extremity burns were more common in non-diabetic patients (68%) compared to diabetic patients (50%) (p< 0.01). Nondiabetic patients presented statistically ≈1.5% lower area percentage of second-degree burns and ≈2.5% TBSA, compared to the diabetic population. We did not see any seasonal variations in burn incidents between the diabetic and non-diabetic populations. Having diabetes was not significantly correlated with having surgery, number of surgeries, surgical complications, infections, or being admitted to the ICU. Diabetes was a significant variable for increased length of stay (roughly 3 days longer when age, BMI, number of surgeries, total TBSA, and ICU days were held constant). Conclusions The glycemic state of burn patients is important because of the influence of hyperglycemia on circulation, immune cell migration and function, and tissue repair. Our data recognize an extended hospital stay for diabetic patients, but without increased surgical complications. Moreover, we did not see a difference in burn occurrence for diabetic patients in colder months, likely due to the lack of cold temperatures in this region. Rather, we typically expect lower extremity burns in diabetics resulting from walking outside barefoot. Understanding diabetes as a comorbidity is crucial for preparing a treatment plan, particularly in burn injuries that strain the body’s healing capacity. Applicability of Research to Practice Diabetes is a prevalent comorbidity that challenges the body's capability to heal. Understanding the impact diabetes has on burn outcomes can better prepare physicians to care for these patients.
Abstract Introduction Autologous skin cell suspensions (ASCS) minimize the donor site required for addressing partial and full thickness burns. ASCS is currently FDA approved for use in combination with meshed split thickness skin grafts (STSGs) for full-thickness thermal burns in pediatric and adult patients. Besides the initial clinical trials of ASCS and STSG use for burn wounds, there are minimal studies reporting outcomes of their use. Here, we present our experience using ASCS in the past six years. We hypothesized that ASCS and STSG would result in a low reoperation and infection rate. Methods Retrospective review of patients seen at an American Burn Association verified burn center between 2017 and 2023 identified 15 patients treated with ASCS overlying STSG. Data collected included patient demographics, burn characteristics, surface area of ASCS usage, and patient outcomes. The primary outcome of interest was the requirement for reoperation following ASCS use. Secondary outcomes included hospital length of stay (LOS), ICU LOS, infection, and the necessity for scar revision via surgery or laser treatment. Data was analyzed using descriptive statistics with categorical variables presented as frequencies and percentages and continuous variables reported as medians and ranges. Results The median age of patients treated with ASCS was 36 years (13-67 years). The median BMI was 27.4 (17.7-35.4) and median total body surface area (TBSA) affected by burn was 18% (5.75-69.5%). Six patients (40%) had full thickness in addition to partial thickness burns. Most burns, 11 (73%) were the result of flames, although there were three grease burns and one friction burn. The median time to ASCS application was 10 days (1-39 days) and the median number of ASCS application sites was 2 (1-6). Most ASCS sites were on the upper or lower extremities or the torso; however, two patients had ASCS applied to their feet while another patient had it applied to their genitalia. Median ASCS surface area was 2,464 cm2 (289-20,000 cm2). Median LOS was 23 days (8-125 days) and median ICU LOS was 3 days (0-94 days). Four patients (26.7%) required reoperation on sites of ASCS application with the median time to reoperation being 40.5 days (28-66 days). Three patients (20%) required scar contracture surgery and three (20%) received laser treatments. There were no cutaneous infections in our cohort. Conclusions ASCS was effectively used to treat both partial thickness and full thickness burns and burns due to flame, grease, and friction. There did not seem to be any relationship between the necessity for reoperation after ASCS and the burn depth, etiology, surface area, or location. Applicability of Research to Practice Clinicians can look to our study for potential outcomes when using ASCS with STSG in a variety of situations.
Split-thickness skin grafts (STSG) are the standard of care for large burn wound coverage but can be limited by the amount of donor site skin available. STSGs are inherently partial thickness and do not have the ability to replace full-thickness skin leading to potentially increased risk of graft failure, scarring, contraction, and donor site morbidity. We evaluated the ability of a Autologous Homologous Skin Construct (AHSC) generated from a small full-thickness skin harvest, to cover large, full-thickness burn defects across both lower extremities in a patient with limited skin donor sites. A 45-year-old female was found unconscious at a house fire with 75% total body surface area (TBSA) mixed deep partial/full thickness burns to her upper/lower extremities, anterior/posterior torso, and inhalation injury. She developed septic shock, acute respiratory distress syndrome (ARDS), and acute kidney injury while in the Intensive Care Unit, also requiring cardiac resuscitation. She did not have enough donor site skin for complete burn wound coverage; therefore, AHSC was used for her lower extremity burns. An ~7x2cm fusiform full-thickness skin sample, including fat, was taken from uninjured abdominal skin and was processed into AHSC at an FDA-registered facility following current good tissue practices and returned to the provider two days following harvest. Following wound bed preparation and adequate debridement, AHSC was deployed on her bilateral lower extremities (30% TBSA) and STSG autograft covered her upper extremities as well as anterior/posterior torso over a staged timeframe. Full epithelialization of her lower extremities was noted by 6 weeks and she was discharged from the hospital at 8 weeks post-application. At 6 months, the regenerated skin covering her lower extremities demonstrated some pigmentation, scattered secondary skin appendages and full healing, requiring only a single application, no return to the operating room for revision and only local wound care. AHSC created from a full thickness donor piece of abdominal skin successfully regenerated a diffuse, intact skin replacement over bilateral lower extremities with some re-pigmentation noted within 2 months of post application. We plan on another biopsy at the 6 month timeframe. AHSC provides an opportunity to potentially treat and cover large surface area burns in patients who do not have sufficient unburned donor site skin for STSG harvesting.
Hypergranulation is the abnormal accumulation of granulation tissue in a wound and is commonly seen in burns. It impairs wound healing and can predispose patients to infection. There is no gold standard treatment for hypergranulation tissue, but some options include surgical debridement, chemical cautery with silver nitrate, and topical steroids. Silver nitrate treatment is painful and can lead to scarring, so topical steroid use is on the rise. A retrospective review, between January 1, 2017 and August 30, 2021, at a tertiary burn center was performed to analyze outcomes of hypergranulation tissue after treatment with a topical 50/50 mixture of triamcinolone (Perrigo, Dublin, Ireland) and Polysporin (Johnson & Johnson, New Brunswick, NJ). One hundred and sixteen patients were treated with triamcinolone and Polysporin for hypergranulation tissue, although 24 did not meet inclusion criteria. Eighty-eight out of 92 patients were successfully treated until hypergranulation resolution, while 4/92(4.3%) required silver nitrate or surgery despite the topical cream to achieve resolution. In the 88 patients successfully treated until hypergranulation resolution, 99 areas of hypergranulation were treated. Forty-one of 99 (41.4%) hypergranulation areas resolved within 2 weeks. The average time to hypergranulation resolution was 27.5 ± 2.5 days. We found that a novel 50/50 mixture of triamcinolone and Polysporin topical ointment is an effective and safe treatment for hypergranulation tissue in burn wounds. Further prospective studies are needed to determine its efficacy and safety profile.
