Journal of burn care & research : official publication of the American Burn Association
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Case Reports
The emerging role of tissue plasminogen activator in the management of severe frostbite.
This article presents a small case series demonstrating clinical success with thrombolytic agents for severe frostbite injury to the lower extremities. The authors report three patients with severe frostbite injuries to their distal lower extremities who were managed with urgent interventional radiology and intra-arterial tissue plasminogen activator infusion according to a prespecified protocol. ⋯ Although further studies are needed, results of this study support a new approach in the management of frostbite: from conservative management and observation to urgent interventional radiology and possible tissue plasminogen activator infusion. A protocol for the management of such injuries is presented.
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The objective of this article is to outline the elements of an international burn care outreach program in a resource-constrained country. The program has grown from a collaborative effort with Ukrainian physicians and healthcare officials. With this collaboration, a multipronged approach has been developed to address the gaps in burn care as discovered by years of interaction with the medical community in Ukraine. ⋯ Multiple clinical research projects related to burn prevention and improving perioperative care have been initiated, presented at national meetings, and submitted for publication in peer-reviewed journals. Our outreach program in Lviv, Ukraine, strives to improve overall burn care by a multilayered approach. These elements can serve as a possible template for additional international burn outreach plans as they can be customized for both large and small interventions.
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Opioids are the cornerstone of pain treatment in burn patients. Undertreatment of pain has been associated with psychological sequela. However, prescription opioids have been increasingly associated with adverse drug effects. ⋯ Continued opioid therapy is necessary as the patients transition to the out-patient setting. This study identified several areas that could be modified to align with safer opioid prescribing practices, including lowering daily amount of prescribed opioids, prescribing only short-acting opioids, and providing patient opioid education. Future studies should focus on the adverse effects of opioid use in burn patients.
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The use of high-dose vitamin C (hdVC, 66 mg/kg/hour × 18 hours) infusion is a useful adjunct to reducing fluid requirements during resuscitation of burn shock. Routine point-of-care glucose (POCG) analysis has been inaccurately high in observed patients undergoing hdVC. Inaccurate POCG could potentially lead to iatrogenic hypoglycemia if the fictitious hyperglycemia is treated with insulin. ⋯ POCG analysis during hdVC infusion is significantly higher than laboratory glucose measurements. Once the hdVC infusion is complete, POCG and laboratory glucose measurements are not statistically different. Treating erroneously high glucose based on POC testing is potentially dangerous and could lead to hypoglycemia and seizures.
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In order to further understand the role of the cholinergic anti-inflammatory pathway, the authors determined the effects of burn plasma from donor rats (DRs) on the microvascular circulation of healthy recipient rats and whether these could be altered by pretreatment with physostigmine (PT). DRs underwent thermal injury (100°C water, 12 seconds, 30% BSA) for positive controls. For negative controls DRs underwent sham burn (same procedure but water at 37°C). ⋯ After 120 minutes no significant changes in the systemic circulation (mean arterial pressure, heart rate, wall shear rate) were found between the groups. Burn plasma transfer results in significant increases in plasma extravasation and leukocyte-endothelial wall adherence, which are reversed by pretreatment with PT. These results suggest that the cholinergic anti-inflammatory pathway may play a role in the microcirculatory response to thermal injury.