practice

Operative management of acute pavement burns: a case series  Objective: Acute burns suffered from contact with environmentally heated roadways and walkways are a rare entity. The aim of this report is to assess the information gained from the treatment of a series of patients. l Method: A retrospective review of a consecutive series of cases, where operative treatment was necessary, that occurred during July 2010 in southern Arizona. l Results: Seven patients were included, with an average total body surface area burn of 10.2%. Direct fascial excision and tangential excision were carried out on three and four patients, respectively. Although tangential excision was carried out to normal endpoints, there was commonly a need for repetitive debridement. The total hospital costs were over $4,400,000 (£2,730,000). l Conclusion: Burns suffered from contact with roadways/walkways are often deeper than suggested by their appearance. Direct fascial excision minimises the number of debridement sessions. We hypothesise that the failure to offload pressure on these wounds may be a causative factor in their observed deepening. l Declaration of interest: The authors have no conflicts of interest. No funding was received for this work. l

burns; pavement burn; debridement; roadway burn; operative management

A

cute burns due to contact with a pavement heated by the environment are uncommon in the majority of burn units. As such, the optimal operative modality with which to treat these unique burn wounds has not been elucidated. Furthermore, the scarce published literature on these injuries is limited to the events leading to the injuries, without attention to the hospitalisation and impact on the health-care system. A study performed in southern Arizona showed that pavement temperatures could become hot enough to cause a second-degree burn in as little as 35 seconds when the ambient temperature reached 100°F.1 The previously described circumstances surrounding this type of burn have included motor vehicle accidents, seizure disorders, assault, police restraint, drug use, diabetic neuropathy, syncope and even child abuse.1-4 In addition, essentially any situation in which prolonged contact with heated pavement occurs can and will cause such injuries.

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Methods The authors performed a retrospective review of all patients admitted to the burn care unit with thermal injuries resulting from contact with environmentally heated pavements during the month of July 2010. The continuation of the patients’ care in subsequent months was included in this analysis. Data collected include patient demographics, inciting circumstances, duration of contact with the pavement, comorbidities, total body surface area

(TBSA) burned, initial documented depth of burn injury, location of burns, treatment modalities including mechanism of debridement and products used, admission and discharge dates, total hospital cost, pay source, disposition, and complications.

Results A total of seven patients were identified for analysis (Table 1). The average high temperature during this time period was 106.6°F (41.5oC).5 Out of the seven patients, five were intoxicated when they suffered their burns, two of whom had been in the same facility on multiple occasions for alcohol-related problems and one of the five was a self-described recovering alcoholic who had relapsed prior to suffering his fall and burn. There was one patient who suffered a syncopal episode and the final patient fell and was immobile due to a preexisting disability. The downtime of two patients was noted to be 15 minutes and 120 minutes (patients 3 and 1), while no such estimate was available for the remaining five patients. The average TBSA burned was 10.2% (range: 7–20%). The most common sites of injury were the posterior trunk (n=6) and lower extremities (n=5). Initially, two patients were treated with an enzymatic debriding agent (patients 1 and 4), without significant clinical impact. All patients required multiple trips to the operating room, with an average of three operative sessions per patient (range: 2–4). Excision down to fascia using electrocautery or tangential excision with Goulian blades was the primary debridement method for three patients each

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A.G. Silver, MD, Senior Resident; W.A. Zamboni, MD; Chairman of Surgery, Professor Division of Plastic Surgery; R.C. Baynosa, MD, FACS, Assistant Professor Division of Plastic Surgery; All at University of Nevada, School of Medicine, Department of Surgery, Division of Plastic. Email: asilver@medicine. nevada.edu

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practice Table 1. Patient characteristics Patient

Age/sex

Down time

Depth*

% TBSA effected

$/TBSA

ICU

Number of operations

Pay source

Discharged to

1

71/M

120 min

full

8

32,240

no

3

Private

Rehab

2

37/M

unknown

partial

10

27,143

no

3

CCSS

Home

3

77/F

15 min

mixed

7

23,054

no

2

Medicare

Rehab

4

57/M

unknown

partial

10

27,512

no

4

Private

Home

5

29/F

unknown

full

20

34,539

no

3

CCSS

Shelter

6

57/M

unknown

full

7

230,546

yes

3

Medicaid

Rehab

7

50/M

unknown

partial

10

113,607

yes

3

Medicaid

SNF

CCSS - a county supported social service insurance for the indigent population; SNF - skilled nursing facility; TBSA - total body surface area *Depth as clinically judged by an experienced burn surgeon

(patients 1, 5, and 7, and patients 2, 4 and 6, respectively). Hydrodebridement with Versajet (Smith & Nephew, London, England) was the primary debridement method for the remaining patient (patient 3). Regardless of the chosen operative modality, each debridement was taken down to a level of what appeared to be healthy tissue. Each patient that underwent partial-thickness tangential excision and the areas taken as partial-thickness by hydrodebridement required at least one re-excision of the wound bed prior to definitive skin grafting. Integra Dermal Regenerative Template (Interga Life Sciences, Plainsboro, NJ) was used on three patients. In two of these patients, while areas of adequate take did show improved contour irregularity, areas of template loss remained, which were able to be autografted. Porcine xenografts were used on the two patients, prior to definitive autografting, which proved effective in temporarily aiding the wounds.

b

564

Patient 1 A 71-year-old male suffered a syncopal episode while working outside of his house with a suspected down time of two hours. He was operatively debrided after an attempt at chemical debridement while correcting his coagulopathy. Chemical debridement was found to be ineffective. The wounds appeared to be of full-thickness, and direct excision to fascia was performed. Wound coverage was temporarily accomplished by the placement of a bilayered dermal regenerative template, which was complicated by haematoma formation that required bedside evacuation. The patient was discharged to a rehabilitation facility and subsequently developed a superficial wound infection and anaemia, leading to readmission. During his second hospital stay, his medical comorbidities were corrected as much as possible and his wounds were grafted with splitthickness autografts which achieved approximately

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a

Cases

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Fig 1. Patient 1 posterior leg and foot wound, on admission (a) and after debridement and placement of dermal regenerative template (b).

With regards to associated injuries, three patients suffered acute kidney injuries, while one suffered acute renal failure and required haemodialysis. Rhabdomyolysis, the breakdown of muscle tissue releasing damaged muscle cells into the blood, was diagnosed in three patients, as was heat stroke. Two patients were admitted to the intensive care unit (ICU) and found to have septic shock. Complications other than partial graft loss included a lower extremity deep venous thrombosis (DVT), urinary tract infections (UTI) (n=2), pneumothorax (n=1) and pneumonia (n=1). Two patients required admission to the ICU, and their average cost per TBSA was $172,076 (£107,280), while their average length of hospital stay was 173 days. For the five patients who did not require ICU admission, the average cost per %TBSA was $28,898 (£18,017), and the average length of stay was 45 days. Total hospital cost for all patients was in excess of $4,400,000 (£2,730,000).

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practice

Fig 2. Patient 2 Upper back wound. Initial appearance (a), after progression of burn depth (b) and post final debridement and autograft placement (c).

as. The patient was unable to abstain from consistent prone positioning and the wounds appeared to progress to a greater depth after initial debridement, and went on to require subsequent resection of all areas. Definitive closure with autografts was performed at the posterior arms on the second operative session, while wounds on the back and buttocks occurred on the third operative session. Fig 2c shows the patients back postoperatively.

Patient 3

a

A 77-year-old handicapped female fell while trying to assist her disabled son, with an approximate down time of 15 minutes. Wounds were initially debrided with a hydrodebridement system until healthy tissue was encountered. Areas debrided, full-thickness to subcutaneous tissue, did not require subsequent debridement, those left partial-thickness did require additional excision before grafting.

Patient 4 A 57-year-old former alcoholic male passed out on a walkway and landscaping gravel after binge drinking for an unknown down time. Although the wounds did not initially appear to be full-thickness, they required three sessions of tangential excisions b

References 1. Harrington, W.Z., Stroschein, B.L., Reedy, D., et al. Pavement temperature and burns: streets of fire. Ann Emerg Med Nov1995; 26: 5, 563–568. 2. Berens, J.J. Thermal contact burns from streets and highways. JAMA. Dec 1970; 214: 11, 2075–2077. 3. Rimmer, B.R., Curtis, B.R., Foster, K.N., et al. Thermal injury in patients with seizure disorders: An opportunity for prevention. J Burn Care Res 2007; 28: 2, 318–323. 4. Vardy, D.A., Khoury, M., Ben-Meir, P, Ben-Yakar Y, Shoenfeld Y. Full thickness skin burns caused by contact with the pavement. Burns 1989; 15, 2: 115–6. 5. National weather service forecast office. weather.http://www.wrh. noaa.gov/psr/climate/ monthlyData.php. (accessed October 2014)

Fig 3. Patient 5 leg wound, initial appearance (a), post-operative appearance (b). Posterior shoulder/arm wound initial appearance (c).

a c

80% take. The remainder of the open wound did not require further operative intervention. Fig 1a shows a pre-operative photo and Fig 1b post placement of dermal regenerative template.

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Patient 2 A 37-year-old male was riding a bicycle while intoxicated. He fell off the bicycle and passed out on a roadway for an unknown down time. Fig 2a shows the patient upon initial presentation and Fig 2b the progression of burn. Debridement was performed by tangential excision down to healthy appearing tissue and the application of porcine grafts was performed for temporary wound closure. This was owing to concern that the initial attempt at autograft placement fail as the patient had not been able to follow requests to offload the wounded areJ O U R N A L O F WO U N D C A R E V O L 2 3 , N O 1 1 , N O V E M B E R 2 0 1 4

b

c

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practice

A 29-year-old intoxicated female was involved in an altercation. She was knocked off her feet onto a roadway by a moving vehicle and passed out with an unknown down time. All extremities were involved. The initial appearance of the full thickness burns to the leg and posterior shoulder/arm can be seen in Fig 3a and 3c, respectively. The majority of her wounds appeared full thickness and were originally directly excised to fascia in two sessions, as one extremity was required for anaesthesia monitoring. Bilayered dermal regenerative templates were applied after direct excision (Fig 3b). The remainder of the burns that were originally determined to be of less depth were treated with tangential excision. Prior to grafting all areas treated with tangential excision required further debridement. Significant amounts of the grafts were lost as the patient was unable to tolerate pressure-offloading recommendations.

Patient 6 A 57-year-old homeless male known to suffer from alcoholism was found after an unknown down time on pavement. The patient was unresponsive in the emergency department and required intubation. He was admitted to an intensive care unit. Direct excision down to underlying fascia was performed at the first operative session. The patient was unstable and the operation was terminated without an attempt at definitive wound closure. Return to the operating room was delayed due to sepsis and poor overall medical condition. The patient also developed renal failure, required a tracheostomy for ventilatordependent respiratory failure, and had a chest tube Fig 4. Patient 6 Initial appearance of upper back wound

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Patient 7 A 50-year-old homeless male known to suffer from alcoholism was found after an unknown down time on the pavement. The patient was unresponsive in the emergency department and required intubation. He was admitted to the intensive care unit. The patient also suffered from acute hepatic necrosis and sepsis, which rendered him too unstable to be taken to the operating room for debridement early in his hospital course. Multiple bedside debridements were performed prior to direct excision down to fascia and including muscle in the operating theatre. These areas were subsequently minimally debrided during an additional operative session undertaken primarily for tracheostomy. The patient’s wounds were eventually grafted prior to discharge to a skilled nursing facility.

Discussion There is limited published literature on burns suffered through contact with environmentally heated pavement (including streets/roadways, highways, and walkways). Therefore, the optimal modality of treatment has not been established. Nevertheless, as in the management of all burns, the principles of excising non-viable tissue and subsequent wound closure are clearly applicable. The above cases show that the treatment of pavement burns is a costly endeavour. These injuries are often of substantial thickness, of which the full extent is not always appreciated on clinical examination and even during operative debridement. Although an objective measure of burn depth was not used in the care of this series of patients, experienced burn surgeons clinically judged the wounds as either full- or partial-thickness. For burns judged as partial-thickness, debridements were consistently taken down to a level of healthy appearing tissue, which was the primary surgical endpoint in those undergoing tangential excision by any method. Burns that were clinically deemed to be full-thickness were directly excised down to the underlying fascia at the initial operation. Even after such operative debridement, we often noticed a continued progression of the depth of injury. Given the retrospective nature of the study, we are unable to clearly elucidate the reason(s) for this further progression of wound depth which required subsequent debridement. We hypothesise that this might be explained in part by continued pressure on these wounds, as they are most often found in areas of dependency when recumbent. In addition to this case series’ retrospective nature, it is further limited by the small overall number of

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Patient 5

placed for a pneumothorax. His wounds did not require re-excision and were grafted after his medical condition improved and stabilised (Fig 4).

© 2014 MA Healthcare

with chemical debridement for several weeks prior to discharge. The patient was discharged home for social reasons. However, he continued to use chemical debridement on an outpatient basis for a threeweek period, after which a final operative session was required for final tangential excision and successful split-thickness autografting.

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practice cases. With only seven patients included in the analysis, it becomes difficult if not impossible to draw powerful conclusions. While there were several primary attending burn surgeons assigned to this series of patients, this one-month sample was specifically chosen because there was a consistent surgeon who assisted in the hospital care, operative management, and documentation of these patients’ medical records, which helped maintain uniformity of data collection and confirmation of intraoperative details. Undoubtedly, expanding the dates of the analysis would increase the power of the study; however, there would likely be a much higher degree of inference and speculation, as the author would no longer solely be using their own records and documentation. This study represents one of the largest series of cases in this subset of burn injuries, and serves as a

precursor to a prospective study to further evaluate this unique patient population. The data and lessons learned from a preliminary examination of a series of seven patients suggests that these patients might benefit from more aggressive debridement than other burn aetiologies. A prospective study in which there is an initial, objective measurement of the depth of these wounds may elucidate whether these injuries are truly full-thickness at presentation, or if the authors’ observation that these wounds have a prolonged period of progression is indeed accurate. Additionally, utilising specialised pressure-offloading beds in the care of these patients might test the hypothesis of pressure-induced deepening of these wounds, and further, provide an opportunity for quality improvement in the care of these unique injuries. n

Trends in Wound Care Volume V About the book

About the author

Trends in Wound Care Volume V

This highly reputable source of up-to-date monographs has becom e a standard text for those seeking to keep in touch with key areas of clinical and scientifi c research. This volume contain eclectic miscellany of chapters, s an each based upon published (and so, peer-reviewed) articles from the Journal of Wound Care. Where important new information has been published, chapters have been updated accordingly. Topics included in this volume are: wound survey/ audit, topical negative pressure, bacterial profiling and biofilms, wound pH, scar assessm ent, fibroblast senescence, the role of nitric oxide, and theorie s on wound contraction. This collection of chapters shows how field has progressed in recent this years, and helps busy clinicians keep appraised of important researc h.

Keith Cutting is Principal Lecture r inof Tissuemonographs This highly reputable source has Viability in the Faculty of Society Buckinghamshire New Univer and Health, sity. He has been involved in tissue viability for a number of years and worked in what has now become the Wound Healing Resear ch Unit in become a standard those seeking to keep lecturing on text Cardiff . Apart from in wound carefor management he has maintained clinical and research roles and has supported these activities via a number of publications. Keith is also Clinical Editor of Wound Journal and is a of membeclinical s-UK r of a number of wound touch with key areas and scientifi c research. healing societies. He is a Fellow of Higher Education and a Region of the Academy al Fellow of the Royal Society of Medicine, and he works closely with various international medica l device, pharm aceutic Edited by Keith asCutting, volumeal, biotech maintains nology and publishing companies an independent consultthis ant. the established standard. It offers something for those with a practical focus as well as science and theoretical debate. Topics covered include:

Trends in Wound Care Volume V Edited by Keith Cutting

• Wound survey and audit • Bacterial profiling and biofilms • Scar assessment

ISBN 1-85642-374-3

• Fibroblast senesence • The role of nitric oxide

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781856 423748

Edited by Keith Cutting

• Wound pH

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Trends in Wound care V.indd

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• Wound contraction theories 1

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Operative management of acute pavement burns: a case series.

Acute burns suffered from contact with environmentally heated roadways and walkways are a rare entity. The aim of this report is to assess the informa...
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