Complex Limb Salvage with Placental-Based Allografts: A Pilot Study

Background: Commercially available human placental amnion/chorion tissue allografts have been successfully used as protective treatment barriers for wounds and diabetic ulcers. Burn and traumatic limb injuries with exposed bone or tendon generally require surgical flaps or amputations for healing. The purpose of this study was to determine if dehydrated human amnion/ chorion membrane allografts (dHACM) with decellularized human collagen matrix (dHCM) could be used to salvage injured human extremities. Methods and Materials: dHACM/dHCM was topically applied to the wounds after debridement. Negative Pressure Wound Therapy (NPWT) was concurrently initiated, primarily to bolster the tissue with moisture and contamination control. Approximately every seven days, wounds were re-evaluated for granulation tissue growth response. As needed, patients received dHACM/ dHCM and NPWT in the outpatient or home care settings after discharge. Results: Fifteen males and two females (26 extremities) were treated for fourteen burn and three Necrotizing Soft Tissue Infections (NSTI) injuries. Closure was observed in patients after two to five dHACM/dHCM applications. The dHACM/dHCM treatment was initiated: (median) 17-days after injury;NPWT for 17-days;autograft or primary closure after 21-days;discharge 25-days after the first application. Conclusion: Treatment with human placental-derived allografts provided a protective covering that enabled the healing cascade to generate granulation tissue formation in extremity wounds with exposed tendon and/or bone. In select limb salvage cases, dHACM/dHCM treatment may be a promising alternative to amputations, tissue rearrangements, free tissue flaps or other techniques for resolution of extremity wounds with bone and tendon exposure.

Trauma Activation and Substance Use in an Urban Trauma Center

Background: Alcohol and drug screens in trauma patients are endorsed by the American College of Surgeons Committee on Trauma. The objective was to determine the characteristics and frequency of alcohol and poly-drug combinations in patients triaged by Trauma Team Activation (TTA) codes. Methods: A retrospective study of a Level I hospital trauma registry was initiated with 14,972 patients of whom 7028 (47%) were Substance Users (SU). There were 10,369 TTA patients: 5396 (52%) were SU, and 4603 (31%) non-TTA patients, of whom 1632 (35.5%) were SU. Inclusion criteria were: age ≥14 years old, blood alcohol level and Urine Drug Screen (UDS) documentation, Injury Severity Score (ISS), TTA code, hospital charges and Length of Hospitalization (LOS). Statistical analyses were performed with one-way ANOVA, Maximum Likelihood chi squared, and Mann-Whitney U tests. Results: The median ISS was 5 for both groups. TTA patients were younger than non-TTA patients (median 33 years versus 41 years). Mortality was significantly higher for TTA (4.7%) than for non-TTA (0.7%) patients. From 2010-2013 to 2014-2018, all substance users had a significant decrease in alcohol only use (58.0% to 42.0%) with an increase in single drug (42.0% to 58.0%) and poly-drug use (36.9% to 63.1%), p < 0.0001. For all SU patients (TTA and non-TTA), the major single drugs used were opiates (19.9%), cannabinoids (THC) (15.2%), benzodiazepines (7.7%), amphetamines (6.6%), and cocaine (2.5%). The major poly-drugs were: opiates/THC (4.7%), opiates/benzodiazepines (4.6%), THC/amphetamines (3.1%), THC/benzodiazepines (2.2%). Conclusions: By trauma activation code designation, the TTA group had most of the positive alcohol and drug screens in this study. Since the change in mandated opioid prescription practices in 2014, this study showed increased poly-drug use (two to six-drug combinations) in urban trauma patients between 2014-2018. Opioids and cannabinoids continued to be the most frequently used drugs singly and in combinations.

Necrotizing Soft Tissue Infections of the Male and Female Breast: A Literature Review

Background: Within the spectrum of necrotizing soft tissue infections (NSTI), necrotizing fasciitis (NF) has been characterized by tissue and fascial necrosis with systemic toxicity. The objective was to determine and summarize the frequency and characteristics of breast NF and NSTI in the literature. Methods: Cases were obtained through PubMed, Google Scholar, Google, and from published article reference sections. One hundred twenty-three cases were gleaned from 96 articles that reported NF and NSTI of the breast (1924 through 2021). Results: NF was reported in 70 and NSTI in 53 cases (111 women and 12 men). Patients presented with swollen, painful breasts, erythema, bullae, crepitus, necrosis, gangrene, fever, tachycardia, and neutrophilia. Fifty-nine of 123 (48.4%) patients were septic on admission. The most frequent microorganisms were β hemolytic Group A Streptococcus, and Staphylococcus aureus. Treatment consisted of antibiotics, mastectomy and debridement with flaps, skin grafts or primary and secondary closure. Forty-four (63.0%) of the NF cases had chest wall involvement;of these, 18 (14.6%) involved the breast secondarily, P < 0.0001. There were twelve mortalities (9.8%): eleven (9.0%) with NF and one (0.8%) with NSTI, P = 0.007. Conclusions: Men and women with breast NF and NSTI presented with similar signs and symptoms and required the same emergent treatment as provided for NF and NSTI of the more common sites. As a time-sensitive disease, patients treated within 12 hours of admission had a better survival. Patients with NF were more likely to have sepsis on admission, a higher mortality, and fascial chest wall/muscle involvement than patients with NSTI.

Antithrombin in the treatment of burn trauma

Antithrombin(AT) is a natural anticoagulant with antiinflammatory properties that has demonstrated value in sepsis, disseminated intravascular coagulation and in burn and inhalation injury. With high doses, AT maydecrease blood loss during eschar excision, reducing blood transfusion requirements. There are no human randomized, placebo-controlled studies, which have tested the true benefit of this agent in these conditions. Two main forms of AT are either plasma-derived AT(ph AT) and recombinant AT(rh AT). Major ovine studies in burn and smoke inhalation injury have utilized rh AT. There have been no studies which have either translated the basic rh AT research in burn trauma, or determined the tolerance and pharmacokinetics of rh AT concentrate infusions in burn patients. Advantages of rh AT infusions are no risk of blood borne diseases and lower cost. However, the majority of human burn patient studies have been conducted utilizing ph AT. Recent Japanese clinical trials have started using ph AT in abdominal sepsis successfully. This review examines the properties of both ph AT and rh AT, and analyzes studies in which they have been utilized. We believe that it is time to embark on a randomized placebo-controlled multi-center trial to establish the role of AT in both civilian and military patients with burn trauma.

Hypochlorous Acid for Septic Abdominal Processes Using a Unique Negative Pressure Wound Therapy System:A Pilot Study

Background: Septic open abdomens occur in trauma, burn and surgery. Currently, multiple concentrations of hypochlorous acid solutions have effectively decreased the microbiotic burden in wounds. We hypothesized that Vashe?, a neutral hypochlorous acid solution (V-HOCL), would be safe as an intraperitoneal irrigation or washout disinfectant for septic open abdomens utilizing negative pressure wound therapy. Methods: This is a retrospective observational review of patients who required delayed abdominal closures after exploratory laparotomies. Group A (n = 8) had cyclical V-HOCL irrigation to their open abdomens combining AbtheraTM and V.A.C. Dressing System for negative pressure wound therapy with irrigation (NPWT-i) and Group B (n = 9) had intra-abdominal V-HOCL washouts. Results: Fifty percent of both groups had either septic or hemorrhagic shock on admission. Compared to Group B, Group A patients were older (median 50 vs 37 years), and had a median hospitalization of 28 vs 8 days, 4 times as many operations, more acute renal failure and co-morbidities. No statistically significant differences were detected be-tween the two treatment methods with the V-HOCL delivery and removal. Conclusion: There were no episodes of electrolyte imbalance, hypotension, hypertension, anaphylaxis, hemorrhage, visceral injury or systemic toxicity. V-HOCL with/without NPWT-i irrigation was a safe modality and tolerated well in this study.

“Streets of Fire”revisited:contact burns

Background:Pavement-street contact burns are rare.This study compared recent contact burns to those published in“Pavement temperature and burns:Streets of Fire”in 1995.The hypothesis was that there were a significantly increased number of pavement-street burns,as a result of increased ambient temperatures,and that motor vehicle crash(MVC)contact burns were less severe than pavements-street burns.Methods:This was a retrospective burn center registry study of naturally heated surface contact burns during May to September from 2016 to 2018.Statistical analyses were performed with one-way analysis of variance(ANOVA)and Maximum Likelihood chi-squared for age,percent of total burn surface area(%TBSA),treatment,hospitalization,comorbidities,hospital charges,mortality,ambient,and surface temperatures(pavement,asphalt,rocks).Results:In the 1995 study,median ambient temperatures were 106(range 100–113)°F compared to the 108(range 86–119)°F highest noon temperature in the current study.No ambient temperature differences were recorded on days with pavement burn admissions compared to days without these admissions.There were 225 pavement,27 MVC,15 road rash,and 103 other contact burns.The major injuries in the pavement group were due to being“down”(unknown reason),falls,and barefoot.Compared to the others,the pavement group was older,56+years,p<0.001,and had smaller burns but similar length of stay.Fifty percent of the 225 pavement group patients with full-thickness burns required skin grafts.There were 13(6%)fatalities in the pavement group vs 1(4%)in the MVC group,p=0.01.Fatalities were secondary to sepsis,shock,cardiac,respiratory,or kidney complications.Compared to survivors,the non-survivors had a significantly higher%TBSA(10%vs 4%),p=0.01,and lower Glasgow Coma Scores(10 vs 15),p=0.002.Conclusion:There was a median 2°F increase in ambient temperature since 1995.The increase in pavement burn admissions was multi-factorial:higher temperatures,population,and the number of older patients,with increased metropolis expansion,outreach,and urban heat indices.Pavement group was similar to the MVC group except for significantly older age and increased mortality.Morbidity associated with age contributed to increased mortality.