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Frequently burns of the hand occur as part of a major thermal injury, but appropriate treatment of the hands has high priority, because even small burns of the hand may result in severely limited function and compromised aesthetic appearance. The functional importance of the hand cannot be overemphasized, because the patient's ability to perform useful work after recovery or the ability to care for themselves is to a great degree determined by residual hand function. This article describes the management of burn injuries involving the hand, stressing the importance of appropriate initial treatment. A comprehensive review of hand reconstruction and rehabilitation, to optimize form and function, is provided., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: With the increasing success of organ transplantation, many traditional contraindications to organ procurement are being reconsidered. Burn disease has constituted a traditional contraindication to solid organ procurement because of concerns that such organs may have been compromised by ischemia secondary to burn shock and contaminated by bacteremia. With the current shortage of solid organs, the transplant community continues to look for ways to increase the number of organ donors, including the use of marginal donors., Methods: Between 1999 and 2009 we have successfully procured 14 organs from four burn patients, who had suffered concurrent anoxic brain injury. There were one male and three female patients with an average age of 43.3 years and a total burned body surface area of 32.5%. Organ transplantation was performed at an average of 4.75days after the injury. Eight kidneys, three livers, two hearts and one pancreas were procured and transplanted into 13 patients., Results: We were able to follow-up on the organ recipients for an average of 80.5 months. The 5-year survival of the donated organs following transplant was 78.6% and the 5-year organ recipient survival was 92.3%., Conclusions: Organ procurement after burns is not contraindicated and transplantation can be performed with good long-term results., (Copyright © 2017 Elsevier Ltd and ISBI. All rights reserved.)

Objective: The aim of the present study was to evaluate the efficacy of a newly developed cognitive-behavioral group training, specifically designed for burn patients., Method: In a multicenter-study data pre- and post treatment and at 6-month follow-up were obtained from participants of the group program (Intervention group, IG; n=86) and a control group who received treatment as usual (TAU; n=128). Outcome variables of psychological distress, resources and health-related quality of life of both groups were compared using linear mixed models., Results: Up to 6 months after group treatment, the IG reported a substantial decline of general symptom severity as well as posttraumatic stress, whereas the TAU group showed no significant change over time. Optimism increased in the IG after group treatment, but not in the TAU group. Regarding overall quality of life both groups showed a gradual improvement over the three assessment points., Conclusion: The newly developed burn-specific cognitive-behavioral group intervention had positive effects on psychological well-being and resources of burn participants. As a consequence, the group intervention has been implemented as inherent part of the regular burn treatment in two rehabilitation centers in Germany., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

The aim of this study was to identify the long-term quality of life after severe burn injury. In a prospective longitudinal design, N = 265 burn patients were examined 6, 12, 24, and 36 months after burn injury. A multilevel approach was used to measure stability and change in self-reported health status. Besides injury-related variables, self-report instruments included measures of quality of life, psychological distress, personality, and specific burn outcome measures. Fitting of unconditional growth models indicated that there was significant intra- and inter-individual variation in self-reported physical and mental health short form-12. Over the course of 3 years, participants reported on average a slight improvement of physical quality of life. Physical health was mainly predicted by mobility and level of burn severity. Variance in mental health status was mainly predicted by gender, mobility, neuroticism, level of depression and posttraumatic stress disorder (PTSD)-related avoidance. Thus mobility (i.e., simple abilities) seems a crucial variable for overall quality of life. An early identification and treatment of patients with high levels of depression and PTSD-related avoidance may contribute to better mental health.

Background: The treatment of burn wounds is still a challenge regarding the management of antiseptic wound conditioning. Especially, in the United States, silver-containing dressings, such as Acticoat and Aquacel are frequently used. Because silver-containing dressings have well-known drawbacks such as an antimicrobial lack against Pseudomonas aeruginosa, we sought to develop an alternative dressing method. In previous studies, we could demonstrate the excellent antiseptic properties of acetic acid against common burn unit germs, and in another study, the feasibility and suitability of a Suprathel-acetic acid matrix as an antiseptic dressing., Materials and Methods: This study was designed to test the in vitro antimicrobial effect of a Suprathel-acetic acid matrix versus Acticoat and Aquacel. To cover the typical bacterial spectrum of a burn unit, the following Gram-negative and Gram-positive bacteria strains were tested: Escherichia coli, extended-spectrum beta-lactamase-positive Klebsiella pneumoniae, P. aeruginosa, Acinetobacter baumannii, Enterococcus faecalis, and methicillin-resistant Staphylococcus aureus., Results: The tests showed an excellent bactericidal effect of the Suprathel-acetic acid matrix particularly with problematic Gram-negative bacteria such as Proteus vulgaris, P. aeruginosa, and Acinetobacter baumannii. The efficiency was superior to that of Acicoat and Aquacel., Conclusions: Our results support the notion, that the Suprathel-acetic acid matrix has an excellent bactericidal effect and therefore seems to be suitable as a local antiseptic agent in the treatment of burn wounds.

Bacterial colonization and infection are still the major causes of delayed healing and graft rejection following burns and they are furthermore the basis for second and third hit sepsis. Topical treatment is necessary to reduce the incidence of burn wound infection. Silver sulphadiazine (SD-Ag) is a frequently used microbicidal agent. However, this treatment causes adverse reactions and side-effects. Additionally, in recent years multiresistant bacteria, which have not been treated sufficiently, are on the rise. On the basis of experimental data and clinical application of a polylacticacid-acetic acid matrix, we performed this study to establish the effectiveness of the antiseptic therapy with the topical application of a polylacticacid-acetic acid matrix to provide an alternative method for burn treatment, using SD-Ag as a reference. Twenty patients with IIb° or III° burns from the Plastic Surgery and Burns Unit were treated within a matched pair comparative setting. One burned area was treated with SD-Ag, the other corresponding area with the polylacticacid-acetic acid matrix. All patients underwent a necrectomy 4-5 days after the trauma. The excised burned skin was sent to our microbiological laboratory to determine the different bacteria per gram in this tissue. Despite the number of 20 patients, statistical significance was not achieved, there were tendencies to a better antiseptic effectiveness of the polylacticacid-acetic acid matrix. These results suggest that the polylacticacid-acetic acid matrix should be studied in greater depth and could be used as a valid alternative for the topical treatment of burns, as it is equivalent or even more effective than SD-Ag., (© 2010 by the Wound Healing Society.)

Background: As the versatility and variability of free flaps have significantly increased during recent years, so have the indications for free tissue transplantation in burn reconstruction expanded., Methods: The authors report retrospectively the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience enabled the authors to establish reconstructive principles pertinent to the type of injury (burn versus high-voltage injuries) and the timing of reconstruction procedures., Results: In high-voltage injuries (n = 17), early free flap coverage with muscular flaps was the most frequently used type of reconstruction. The reconstruction site was predominately the forearm. In burn injuries, free flap coverage was performed during a later stage of the treatment course. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and dorsum of the hand underwent defect coverage in most circumstances. For reconstruction of complex or large defects (n = 6), combined "chimeric" flaps were used. Overall, the flap failure rate was 12 percent (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four of five flap failures occurred within 5 to 21 days after trauma, and all five flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction., Conclusions: The authors' data demonstrate that burn and high-voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if the authors' flap failures all occurred during the first 6 weeks, it should not be forgotten that this type of coverage is the only alternative to amputation in selected cases.

Emotional distress as well as psychosocial resources in 55 patients with burn injuries was assessed during acute and follow-up treatment. Results showed significantly greater values of emotional distress among patients when compared with norms of the general population. As well as higher levels of general psychopathology, particularly prevalent were anxiety, depression, and posttraumatic symptoms. However, patients also reported high levels of resources such as general optimism, self-efficacy, and perceived social support. Within the sample, no significant correlation between severity of emotional distress and severity of burn injury was found. By psychological assessments a subgroup of highly distressed patients was identified. These patients were highly emotionally distressed while having objective injury severity comparable with the other patients in the sample. Reactions to burn accidents vary individually. The results demonstrate the importance of routine screenings of psychological symptoms. An early identification of patients at-risk allows for tailored psychotherapeutic interventions and can thus help to improve quality of life and general well-being of burn patients on a long-term basis.

The purpose of this study was to observe the interactions between cardiac index (CI), stroke volume index (SVI), central venous pressure (CVP), intra-abdominal pressure (IAP) and total circulating blood volume index (TBVI) during resuscitation of major burns. Sixteen patients with an average TBSA of 46% (26-67%) and an average abbreviated burn severity index of 8.9 (7-11) were included into an intra-individual comparative prospective study over an 18-month period. The COLD Z-021 system (Pulsion Medical Systems, Munich, Germany) was used to obtain CI, SVI and TBVI. Two hundred and thirty-four to 278 intra-individually comparative measurements were performed for the analyses during the first 4 days after the burn injury. Correlations were shown for the interactions between CI and TBVI (r = 0.550; rs = 0.518), SVI and TBVI (r = 0.606; rs = 0.626) and for CVP versus IAP (r = 0.487; rs = 0.474). Poor or no correlations were demonstrated for the comparisons CI versus CVP (r = 0.401; rs = 0.352), CVP-PEEP versus IAP (r = 0.255; rs = 0.272). TBVI versus IAP (r = -0.120; rs = -0.169), TBVI versus CVP (r = 0.025; rs = -0.036), TBVI versus CVP-PEEP (r = -0.046; rs = -0.101), CI versus CVP-PEEP (r = 0.088; rs = 0.092) as well as for IAP versus CI (r = 0.050; rs = 0.034). An additional analysis demonstrated no correlation between TBVI and MAP (r = -0.095; rs = -0.136). Our data provide evidence that the CVP is influenced more by external pressures (IAP) than by the actual intravascular volume status of the patient. Thus, the CVP is not a suitable tool to guide fluid resuscitation during burns with shock. The TBVI may be an ideal value to guide resuscitation because the augmentation of TBVI during fluid resuscitation correlated well with improved cardiac output and stroke volume. Future randomised studies are required to demonstrate whether TBVI guided resuscitation of burns has an impact on outcome.

In a recent clinical trial we evaluated the safety and immunogenicity of a recombinant OprF-OprI vaccine consisting of the mature outer membrane protein I (OprI) and amino acids 190-342 of OprF of Pseudomonas aeruginosa in burn patients and compared the elicited antibodies with antibodies against tetanus as response to a simultaneous immunization given on the day of admission. Safety and immunogenicity of the vaccine had been tested before in healthy human volunteers as published in 1999. In this first clinical trial we immunized eight burn patients suffering from second or third degree burns involving between 35% and 55% of the body surface three times with 100 microg of the OprF-OprI vaccine. The vaccine was found to be very well tolerated. The patients did not show any serious side effects - and in particular no activation of the mediator cascade was observed. None of the subjects showed systemic P. aeruginosa infections during or after the treatment of their burns. The serological tests (ELISA) for detection of antibodies against P. aeruginosa and tetanus toxoid showed seroconversion for seven patients after inoculation. The data indicate that OprF-OprI can be a useful vaccine in the therapeutic management of burn injuries.

The purpose of this study was to compare the approximated values for intrathoracic blood volume (ITBV) and extravascular lung water (EVLW) obtained from a single indicator dilution to the exact data measured by double-indicator dilution. Eighteen patients with an average TBSA of 46.3% (range, 26 to 67%) and an average abbreviated burn severity index of 8.7 (range, 7 to 11) were included into a intraindividual comparative prospective study over a 20-month period. The COLD Z-021 system (Pulsion Medical Systems, Munich, Germany) was used to obtain both the exact measurements, as well as the estimated values for ITBV and EVLW. Two hundred ninety intraindividually comparative measurements were performed during the first 4 days after the burn injury. A good correlation between both techniques was shown for ITBVI (0.77; P <.01) for the overall measurements. However, the overall bias demonstrated a standard deviation higher than the mean value (-87.4 +/- 136 ml/m2), and precision for the estimated values for ITBVI was poor (-491 to 783 ml/m2). Additional analyses demonstrated a poor but significant correlation for low states of ITBV (r =.37; P <.01), but no significant correlations were found between the techniques for normal and high ITBV states. Thus, the approximated ITBV obtained from single thermodilution should not be used to guide volume therapy in major burn resuscitation. Furthermore, the EVLW is neither suitable for diagnostic use nor for therapeutic decisions because it is calculated on the basis of the poorly estimated values for ITBV in single thermodilution. Transcardiopulmonary single thermodilution is not suitable to assess intrathoracic blood volume and extravascular lung water in burn shock. However, the method is suitable to assess cardiac output and its derived parameters in burn resuscitation as shown in previous studies. It still must be proven whether the exactly measured ITBV obtained from transcardiopulmonary double-indicator dilution is superior to the commonly used parameters to guide major burn resuscitation.

The objective of this study was to validate a new method of transcardiopulmonary thermodilution for assessment of cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI) and additional parameters such as intrathoracic blood volume index and extravascular lung water index (EVLWI) by comparison with conventional pulmonary artery catheter values in a severely burned population. The pulmonary artery measurements were performed continuously with the Vigilance system, and the transcardiopulmonary thermodilution with the PiCCO(R) system. One hundred thirteen measurements with each system on up to six consecutive days were taken in 14 severely burned patients (average TBSA, 49.6%; average ABSI, 10.3), aged 21 to 61 years (mean, 42.2 years) and compared intraindividually. An excellent correlation between the two methods was shown for CI (r = 0.80) and its derived parameters SVI and SVRI in states of low to normal cardiac output. The correlation was poor for cardiac indices greater then 5.5 up to their maximum values (r = 0.46). No correlation between index of oxygenation (PaO2/FiO2) vs EVLW I was observed. There was no difference between survivors and nonsurvivors, and between patients with and without inhalation injury in EVLWI. The method of transcardiopulmonary thermodilution is suitable to assess SVI, CI and SVRI under the special pathophysiologic condition of a major burn for low to normal cardiac output states. It is less reliable when cardiac output is high. The lower cost and less invasive nature are the advantages of the system compared with use of the pulmonary artery catheter. The role of intrathoracic blood volume index and EVLWI in cardiopulmonary monitoring of severely burned patients remains to be further determined.

This article presents a retrospective analysis of a series of nine patients requiring reconstruction of exposed bone, tendons or joint capsules as a result of acute high-voltage injuries in a single burn centre. As an alternative to free tissue transfer, the dermal substitute Matriderm® was used in a one-stage procedure in combination with split-thickness skin grafts (STSG) for reconstruction. Nine patients, in the period between 2005 and 2009 with extensive high-voltage injuries to one or more extremities which required coverage of exposed functional structures as bone, tendons or joint capsule, were included. A total of 11 skin graftings and 2 local flaps were performed. Data including regrafting rate, complications, hospital stays, length of rehabilitation and time until return to work were collected. Eleven STSG in combination with Matriderm® were performed on nine patients (success rate 89%). One patient died. One patient needed a free-flap coverage as a secondary procedure. The median follow-up was 30 months (range 6-48 months). The clinical results of these nine treated patients concerning skin-quality and coverage of exposed tendons or joint capsule were very good. In high-voltage injuries free-flap failure occurs between 10% and 30% if performed within the first 4-6 weeks after trauma. The use of single-stage Matriderm® and skin grafting for immediate coverage described in this article is a reliable alternative to selected cases within this period. [ABSTRACT FROM AUTHOR]