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Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

The 12-member American Burn Association/Shriners Hospitals for Children Outcomes Task Force was charged with developing a health outcomes questionnaire for use in children 5 years of age and younger that was clinically based and valid. A 55-item form was tested using a cross-sectional design on the basis of a range of 184 infants and children between 0 and 5 years of age at 8 burn centers, nationally. A total of 131 subjects completed a follow-up health outcomes questionnaire 6 months after the baseline assessment. A comparison group of 285 normal nonburn children was also obtained. Internal consistency reliability of the scales ranged from 0.74 to 0.94. Tests of clinical validity were significant in the hypothesized direction for the majority of scales for length of hospital stay, duration since the burn, percent of body surface area burned, overall clinician assessment of severity of burn injury, and number of comorbidities. The criterion validity of the instrument was supported using the Child Developmental Inventories for Burn Children in early childhood and preschool stages of development comparing normal vs abnormal children. The instrument was sensitive to changes over time following a clinical course observed by physicians in practice. The Health Outcomes Burn Questionnaire for Infants and Children 5 years of age and younger is a clinically based reliable and valid assessment tool that is sensitive to change over time for assessing burn outcomes in this age group.

Burns to the neck present a serious challenge to the pediatric burn team. Even when full neck range of motion is maintained, scarring may lead to banding and a loss of the neck's natural contour. Conventional thermoplastic neck conformers have been used to maintain neck position and provide pressure to maturing scars, but they are rigid and limit functional mobility. This is of particular concern in the pediatric population where limiting neck mobility can disrupt the development of sensory and motor patterns that are essential to normal developmental progression. The Multi-Ring Watusi collar is a flexible neck orthosis that allows mobility and provides circumferential pressure to the neck. We modified this collar to improve its comfort, cosmetic appearance and ease in donning/doffing. The improved Watusi collar is a flexible splint that supports neck position, provides circumferential pressure, and allows for functional neck mobility.

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

It has been the standard of care in our pediatric facility to keep patients on strict bedrest with the neck in hyperextension for 5 days after a neck contracture release or grafting. Multiple methods have been used to help maintain neck immobility after grafting. It has been challenging to maintain strict bedrest protocols, because of decreased compliance and boredom. To address this issue, we examined common sedentary diversional activities engaged in by children. We decided to use video games to facilitate the intrinsic motivation of play. The monitor of a video game activity was inverted and placed behind the head of the bed so that the child could maintain proper neck positioning. We found the activity to be beneficial in many aspects. It helped maintain neck positioning, decreased the demand for individual interventions, and provided opportunities for improving self-confidence.

Chemical burn injuries commonly occur at the workplace and can be caused by a variety of agents. Sodium azide is a volatile compound used in the industrial setting and it is also a constituent of car airbags. The known toxic effects of sodium azide include hypotension, bradycardia, and headaches. At the cellular level, it inhibits of ATP production by blocking the respiratory oxidation cascade. In the burn literature only one previous report documents a sodium azide hand burn caused by airbag malfunction. We report a case of massive exposure and resultant systemic toxicity from a sodium azide canister explosion.

The timing and method of treatment of deep palm and finger burns varies widely. Our protocol involves performing full-thickness skin grafts (FTSG) in nonhealing palm burns. We reviewed the functional and cosmetic results after FTSG to the palm. From August 1997 to April 1999, 11 patients (12 palms) underwent excision and FTSG within 2 weeks of injury. A panel of medical and nonmedical professionals evaluated follow-up pictures of the grafts at 1, 2 to 4, and beyond 4 months. Parameters used for evaluation were color match with the unburned skin (1 = no difference to 4 = large difference), graft thickness (1 = flat to 4 = markedly raised), overall appearance (1 = poor to 100 = excellent), and time to maturity. Hand function, as assessed by occupational therapy notes, was also recorded. All 12 grafted palms had a 100% take and healed with minimal scarring. Mean color match scores were 2.4 at 1 month, 1.8 at 2 to 4 months, and 1.6 beyond 4 months. On the graft thickness scale, grafts were given scores of 2.6, 2.2, and 1.9 during the same intervals. The overall appearance was 71 at 1 month, 81 at 2 to 4 months, and 85 beyond 4 months. All grafts except 1 were judged to be mature at 2 to 4 months follow-up. Full passive range of motion was attained in all grafted hands within the period of 2 to 4 months after operation. Early excision and FTSG of deep pediatric palm burns can be performed in the outpatient setting. The grafts have an acceptable color match, are minimally raised, and achieve excellent cosmetic result. The grafts mature within a few months after surgery to allow for rapid return to normal range of motion. FTSG should be considered as a first choice for deep palm burns.

We performed a retrospective review to analyze the use of helicopters for the transportation of patients with burn injuries to determine whether a more cost-effective approach could be developed without impairing the quality or delivery of health care. Charts were reviewed for all patients with burn injuries who were transported by helicopter to our hospitals during a 2-year period. Patients with inhalation injuries, with burn injuries received more than 24 hours before admission or more than 200 miles from our burn center, with more than 30% total body surface area (TBSA) burned, or with associated trauma injuries were excluded. Control patients with burn injuries who were transported by ambulance were identified and matched to the patients with burn injuries transported by helicopter for the percentage of TBSA burned, the percentage of third-degree burns, transport mileage, and age. The outcome was evaluated by comparison of length of stay, days on ventilator, and mortality rate. Comparisons were performed with Student t test. The transportation charge was determined for the patients transported by helicopter who we believed were eligible for transport by ambulance. Forty-seven of 85 patients transported by helicopter matched the inclusion criteria and had survived. There was no statistically significant difference between the percentage of TBSA burned, the percentage of third-degree burns, length of stay, days on ventilator, age, or transport mileage. There was, however, a significant difference in the time from the injury to admission to the hospital, as well as in the charge for transportation. Patients who had less than 30% TBSA thermal cutaneous injuries without evidence of inhalation injury, and who are less than 200 miles from a burn center may be safely transported by ambulance. Ambulance transportation may take additional time; however, stricter protocols for helicopter transportation of patients with burn injuries will result in potentially substantial savings without affecting outcomes for patients.

Torchiere-style halogen lamps pose a significant fire hazard. The 500-W halogen bulb in these lamps can generate temperatures as high as 1200 degrees F. Factors related to the design of the lamp also contribute to the fire risk. The Consumer Products Safety Commission has issued various warnings and recalls on these lamps because of a significant number of fire-related incidents and deaths. The impact of these recalls on a random sample of consumers was investigated. A survey of these participants revealed that 60% of lamp owners and nonowners were unaware of the recalls. The majority of respondents were also not aware of the risks of injury, the extreme bulb temperatures, or safety measures designed for these lamps. There is a need for increasing community awareness and education to reduce the fire hazards associated with this product.

Pressure garments are used to alter the appearance of immature burn scars. These garments are costly, and delays in obtaining them are frequent. The purpose of the study was to determine the nature of the delays in the obtainment of pressure garments and to examine the role that the payer plays in these delays. The billing and medical records of all patients with burns measured for pressure garments between January 1, 1998, and August 1, 1999, were reviewed. The distribution of payers was as follows: workers' compensation, 37%; state-funded insurance, 32%; health maintenance organizations, 12%; private insurance, 16%; and other, 3%. Payment authorization time for pressure garments was 37 days for state payers and less than 10 days for all other groups. Patients with state-funded insurance waited an average of 67 days to receive their garments as opposed to a wait of 20 to 30 days for other payers. The percentage of billed charges paid was least for patients with state-funded and HMO insurance (58% and 51%, respectively). The interval to payment of charges was longer than 60 days for all groups. Marked delays in authorization exist for state-funded reimbursement of pressure garments. Reimbursement for patients with state- and HMO-funded insurance was lower than for other payers. These differences may have an adverse effect on outcome.