Background: Severely burned patients often suffer white blood cell and platelet drop following injury. Though coagulopathy after burn injury has been reported, the association between leukopenia or thrombopenia and mortality is still unknown. This study was performed to determine whether early drastic drops in white blood cells (WBCs) and platelets following injury can be prognostic markers in patients with major burns.
Methods: This is a retrospective cohort study at a single Burn Center in Japan.
Data comprising the patients’ characteristics and blood cell counts (red blood cells [RBCs], WBCs including neutrophils, monocytes, and lymphocytes, and platelets) over the first 30 days after burn injury were serially collected from patients suffering major burn injury (≥20 ％TBSA) from January 1, 2006, to December 31, 2015. To determine blood cell counts affecting the 60-day mortality, we used multivariable Cox proportional hazard analysis to assess associations between each blood cell count and the mortality, adjusting for age and %TBSA as covariates, and evaluated the predicted value of the hazard ratio (HR) of death.
Results: We enrolled 280 patients. Following burn injury, all blood cell counts were high on admission, and then decreased. RBCs diminished progressively and plateaued 2 weeks after injury. WBCs decreased suddenly 2 days after injury, then increased and stabilized. Platelets decreased more rapidly than WBCs to their nadir at 3 days, then continually increased. After covariate adjustment, low RBCs from day 1 (HR: 0.566, 95% C.I. 0.423, 0.759) to day 5 (HR: 0.524, 95% C.I. 0.175, 0.576) were predictors of mortality. Neutrophil count was not a risk factor, but day 3 lymphocyte count (HR: 0.131, 95% C.I. 0.026, 0.646) and day 10 monocyte count (HR: 0.044, 95% C.I. 0.005, 0.396) were risk factors. Low platelet counts from day 3 (HR: 0.545, 95% C.I. 0.300, 0.981) to day 30 following injury were always a predictor of mortality.
Conclusions: Early thrombopenia and lymphopenia were independent risk factors for 60-day mortality, and prolonged thrombopenia and monocytopenia were independent risk factors for mortality. These findings may shed light on the mechanisms of immune response following severe burns.
Split-thickness skin grafts (STSGs) are essential for burn wound broad skin deficiency. The post-harvest management of STSG donor sites is quite controversial. We prefer to use hydrogel wound dressings (Viewgel®) for the first several days. Although hydrogel wound dressing is quite painless, it is a bit too moist for resurfacing, thus a second wound dressing after removal is necessary. Hydrophilic gelling wound dressing (Aquacel® Ag) filled with saline is considered useful as a second dressing.
Covering saline-filled Aquacel® Ag with IV3000® is our new method, and painless dressing change is compatible with smooth re-epithelialization.
In a study of 8 STSG donor sites using our new method, the re-epithelialization time and infection was assessed. The re-epithelialization time was an average of 16.0 days and no infection was observed. During changing the dressing, children suffered no pain from Aquacel® Ag treatment.
This method causes less pain and shows no delay for resurfacing. Therefore, we consider this method useful for second donor site dressing.
We report the case of an 81-year-old female patient with flame burn of 45% of the total body-surface area (TBSA) and severe inhalation burns. First, we planed the affected area to provide treatment with cultured epithelial autograft
(CEA). Then, we started preparing the wound bed by removing the burned skin and covering the wound with an artificial dermis. Generally, preparing the wound bed requires two to four weeks, and infection in the wound area during wound bed preparation period is possible. Unfortunately, on post-operative Day 13, infection developed in the area where the artificial dermis was patched, and we performed re-debridement of the entire wound. In order to prepare a good enough wound bed to introduce CEA, we tried Thin INTEGRA® instead of the usual artificial dermis for shortening the wound bed preparation period. Although this was our first attempt, we obtained favorable results.
Electrical injuries can be divided into low-voltage and high-voltage ones, that is, below or above 1,000 V, respectively. Two cases of electrical injury caused by exposure to high-voltage alternating current are reported.
Case 1: A 15-year-old boy trespassed and climbed up the train inspection stand. He swung his right leg forward, near the overhead tension wire (20,000 V) , and sustained an electrical injury from his right toe into the right hand from grasping the safety bar, before falling to the ground. Compartment syndrome, which required incisional decompression, developed in the right forearm and lower leg. Following primary treatment, the antecubital contracture was released with a pedicled reverse-flow lateral arm flap（reverse-flow LAF）.
Case 2: A 78-year-old male in the transformer station during an occupational inspection accidentally came into contact with the tension wire（3,810 V）with his left elbow. A deep skin ulcer around the olecranon was covered with a radial collateral artery perforator（RCAP）-based propeller flap.
The island flap of the reverse-flow LAF revealed congestion from during the operation. The operative time using the RCAP-based propeller flap was shorter, used a continuous skin paddle, and congestive change was not found. Both cases achieved effective results and functional improvement.
For extensive burns, the usual methods of treatment reported are those such as the Hybrid method, which combines Cultured Epithelial Autograft（CEA）and an autologous stratified skin graft, and the sandwich method, where an artificial dermis is attached on top of the meshed autografts.
In this case, we used as an artificial dermal substitute, a collagen/gelatine scaffold with sustained release of basic Fibroblast Growth Factor（bFGF）for the sandwich method, and report the results in comparison with the Hybrid method.
The hybrid method was used for most sites, but the sandwich method was performed on the section where CEA was insufficient.
Engraftment was observed in both the sandwich method and the hybrid method, and epithelialization was completed at about the same time two weeks later.
This skin grafting method has almost the same engraftment rate and time required for epithelialization compared to the sites where the Hybrid method was performed, and it can handle a larger variety of situations and treat burns at a lower medical cost. It is therefore considered to be a valuable treatment of extensive burns.
We present the case of a 26-year-old man with urethral injury caused by severe frostbite.
He became lost while climbing a mountain in winter and suffered from frostbite. He was found three days after his disappearance and taken to a hospital. After intensive care, he was transported to our hospital for the treatment of frostbite. We found frostbite on the penis, both hands, both feet, and the left groin. Therefore, we performed debridement of necrotic tissue. During that procedure, the urethra was preserved. However, due to the urethral injury caused by progression of necrosis after the surgery, we needed to perform urethral reconstruction. We performed urethral reconstruction with oral mucosa grafting and covered the reconstructed urethra with a scrotal skin flap. The urethral catheter was removed on postoperative day 28, and the urethral lumen was observed with a urethral cystoscope to confirm that the oral mucosa was biopsied and that there was no urethral stricture. One and a half years have passed since the urethral reconstruction surgery, and the patient has maintained good urinary function and had fathered a baby after discharge from the hospital, confirming that erectile function and fertility have been preserved.
Urethral injury due to frostbite is considered to be very rare. The surgical selection was made according to the treatment of urethral injuries due to trauma. In this case, reconstruction with an oral mucosa graft was performed with good results. Urethral reconstruction was effective for urethral injuries caused by frostbite.