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Technique of split skin graft fixation using hypafix: a 15-year review
INTERNATIONAL ABSTRACTS
GENERAL CONSIDERATIONS Multiple Trauma in Pediatric Patients. J. Schalomon, S. v Bismarck, P.H. Schober, et al. Pediatr Surg Internat 19:417– 423, (August), 2003. Multiple trauma is still the leading cause of morbidity and mortality in children even though improved prehospital and hospital care decreased the mortality rate. The authors analyzed 70 consecutive children suffering from multiple trauma during a 7-year period and focused on cause and pattern of injury early and late follow-up, and quality of life. Inclusion criteria were age less than 16 years, 2 or more injured regions or organs and an ISS of greater than 16. Two patients with death on arrival were not included. The author’s management protocol includes indoor rehabilitation as soon as the resuscitation phase was terminated and fractures were stabilized. The program starts with early coma stimulation and ends with assistance at school. Fifty-eight patients were investigated 2 to 9 years after the trauma, including physical and special neurologic examination and a questionnaire asking for long-time consequences of the trauma. Measurement of outcome was categorized with Glasgow Outcome Scale (GOS) and Injury Impairment Scale (IIS). Sixty-eight percent had traffic accident, 19% sportsrelated accidents, 7% agricultural, and 6% domestic accidents. Transfer of the children was by helicopter (68%), ambulance (32%), or parents (3%). Sixty-two percent were intubated at the scene or emergency room. Prehospital fluid replacement took place in 94%. The average number of injuries was 5.1, mean ISS 24.6. Eighty-seven percent showed injuries to head and neck; 76% sustained extremity fractures; 62% thoracic trauma with rib fractures and lung contusions; 33% blunt abdominal trauma with hepatic, spleen, or renal injuries; 14% pelvic injuries; and 6% spine fractures. Sixty-three percent needed ventilation for 1 to 18 days, mainly for head or thoracic trauma. Thirty-four percent got blood transfusions. Mean stay at ICU was 8.8 days; mean duration of hospitalization was 26.3 days. One hundred thirty-five surgical interventions were performed in 55 patients, 60% of them during the first 24 hours, including craniotomy in 12 children, extremity fracture stabilization in 46 children, thoracic tube drainage in 10 children, and laparotomy in 9 patients, none requiring splenectomy. Forty-three of 44 late interventions (⬎4 weeks after trauma) concerned the extremities. Complications occurred in 13 patients, mainly infections and problems with fracture management, one MOF. At discharge, 36% showed cognitive or physical impairment, 20% of them severe disorders. GOS scoring found 64% grade 5 (capacity to resume normal), 29% grade 4 (independent but disabled), and 7% grade 3 (severe disabled from head trauma, peroneus paresis, and spinal trauma). At follow-up, only 11 children showed cognitive, physical, or combined impairment, 8 of them scored with GOS 4, 3 with GOS 3. Head trauma was the cause of impairment in 8 of the 11 children. Twenty-four children had scars, minor pain, weather sensitivity, or limb length discrepancy after fractures, but only 1 needed surgical intervention (shortening osteotomy). Eight children needed assistance at school up to 1 year, 4 passed 1 form, and 2 visited a school for special education. Eighty-six percent mentioned no change of well being and 14% described depressions. Parents reported changed behavior in 24%, and in 4 cases problems derived from blaming one parent for having caused the accident. Survival and long-term disabilities after severe multiple trauma depend on severity of head trauma. However, no child died in this series even though 10% had GCS of less than 6. Early rehabilitation after early fracture stabilization makes a reduction of impairments possible, and long-term rehabilitation reduces residual impairments. Social problems (school, family) can be minimized by early psychological intervention and later school assistance.—P. Schmittenbecher
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Cost Factors in Pediatric Trauma. D. Gurses, A. Sarioghu-Buke, M. Baskan, et al. Can J Surg 46:441– 445, (December), 2003. The authors in the Pediatric Emergency Unit of a university hospital in Turkey prospectively investigated cost factors in pediatric trauma and attempted to identify cost predictors. They reviewed the charts of and sent out questionnaires to 91 children (50 boys, 41 girls) less than 16 years (mean, 6 years) who were admitted consecutively with multiple trauma to their emergency unit October 1998 to September 1999. They obtained data on age, gender, date, mechanism of injury, site of injury, type of treatment, and length of hospital stay. They also studied physical findings, Pediatric Trauma Score (PTS), Revised Trauma Score (RES), and Pediatric Glasgow Trauma Score (GCS). Motor vehicle crashes (MVA) accounted for 45% of injuries, falls, 41%, and bicycle accidents, 14%. Sites of injury were head (74%), abdomen (57%), and extremity (37%). Seventeen patients (19%) required major and 27 (30%) minor surgical treatment, whereas 44 (48%) were treated conservatively. There were 3 deaths. Mean duration of hospital stay was 4 days. Mean total cost of care was US $376 ($20 to $1,995), reflecting the significantly lower health care cost in Turkey. There was no correlation between cost and age. The cost associated with MVA was higher than for other injuries. Forty-eight percent of patients were referred from another hospital, and here the cost of care was significantly higher. Total cost correlated directly with duration of hospital stay and distance of referring hospital but inversely with the PTS, RETS, and GCS.—Sigmund H. Ein
Technique of Split Skin Graft Fixation Using Hypafix: A 15-Year Review. R.B. Davey, A.L. Sparnon, and M. Lodge. Aust N Z J Surg 73:958 –962, (November), 2003. Effective take of a split skin graft (SSG) after a burn is promoted by a reduction in movement of the SSG in relation to the debrided wound bed. The authors retrospectively reviewed their clinical experience in 749 children with Hypafix or Fixomul dressing (Smith and Nephew, Melbourne, Victoria, Australia) in promoting satisfactory SSG take between 1986 and 2001. The dressing is an adhesive, semiporous polyester retention dressing. The Hypafix was cut into a variety of sizes, packaged, and steam sterilized at 134°C for 4 minutes. After application of the SSG to the debrided burn, a sheet of Hypafix was applied firmly to secure the graft. Any residual hematoma was then expressed by gentle pressure on the hypafix before applying a crepe bandage. Depending on the size of the area covered, additional fixation of the edges of the dressing may be achieved with staples. The authors observed a reduction in theater time, reduction in the numbers of dressing changes, and reduced bed occupancy, although none of these were quantified. The dressing was usually removed at 7 days after the application of either Cit-Sol (RCR International, Melbourne, Victoria, Australia) or peanut oil. The authors might then reapply a Hypafix dressing as part of their scar management program. Over the 15-year study period, there were 18 (2%) graft failures: 11 caused by infection, 5 inadequate debridement, 1 hematoma, and 1 early removal of the dressing. Comment: The authors do not comment on the difficulty of securing the dressing to a typically moist burn wound. In the authors’ experience, it is necessary for surrounding unburnt skin to be carefully dried for satisfactory adherence. Any vegetable oil may be used to dissolve the adhesive and ease removal of the dressing. Whereas the authors have suggested important advantages in terms of reduced theater time, nursing care, dressing changes, and improvements in scar management, no data were supplied to support these statements. Clearly, there have been many other improvements in general burn care over 15 years that would act as confounding factors.—A.J.A. Holland
GENERAL CONSIDERATIONS Multiple Trauma in Pediatric Patients. J. Schalomon, S. v Bismarck, P.H. Schober, et al. Pediatr Surg Internat 19:417– 423, (August), 2003. Multiple trauma is still the leading cause of morbidity and mortality in children even though improved prehospital and hospital care decreased the mortality rate. The authors analyzed 70 consecutive children suffering from multiple trauma during a 7-year period and focused on cause and pattern of injury early and late follow-up, and quality of life. Inclusion criteria were age less than 16 years, 2 or more injured regions or organs and an ISS of greater than 16. Two patients with death on arrival were not included. The author’s management protocol includes indoor rehabilitation as soon as the resuscitation phase was terminated and fractures were stabilized. The program starts with early coma stimulation and ends with assistance at school. Fifty-eight patients were investigated 2 to 9 years after the trauma, including physical and special neurologic examination and a questionnaire asking for long-time consequences of the trauma. Measurement of outcome was categorized with Glasgow Outcome Scale (GOS) and Injury Impairment Scale (IIS). Sixty-eight percent had traffic accident, 19% sportsrelated accidents, 7% agricultural, and 6% domestic accidents. Transfer of the children was by helicopter (68%), ambulance (32%), or parents (3%). Sixty-two percent were intubated at the scene or emergency room. Prehospital fluid replacement took place in 94%. The average number of injuries was 5.1, mean ISS 24.6. Eighty-seven percent showed injuries to head and neck; 76% sustained extremity fractures; 62% thoracic trauma with rib fractures and lung contusions; 33% blunt abdominal trauma with hepatic, spleen, or renal injuries; 14% pelvic injuries; and 6% spine fractures. Sixty-three percent needed ventilation for 1 to 18 days, mainly for head or thoracic trauma. Thirty-four percent got blood transfusions. Mean stay at ICU was 8.8 days; mean duration of hospitalization was 26.3 days. One hundred thirty-five surgical interventions were performed in 55 patients, 60% of them during the first 24 hours, including craniotomy in 12 children, extremity fracture stabilization in 46 children, thoracic tube drainage in 10 children, and laparotomy in 9 patients, none requiring splenectomy. Forty-three of 44 late interventions (⬎4 weeks after trauma) concerned the extremities. Complications occurred in 13 patients, mainly infections and problems with fracture management, one MOF. At discharge, 36% showed cognitive or physical impairment, 20% of them severe disorders. GOS scoring found 64% grade 5 (capacity to resume normal), 29% grade 4 (independent but disabled), and 7% grade 3 (severe disabled from head trauma, peroneus paresis, and spinal trauma). At follow-up, only 11 children showed cognitive, physical, or combined impairment, 8 of them scored with GOS 4, 3 with GOS 3. Head trauma was the cause of impairment in 8 of the 11 children. Twenty-four children had scars, minor pain, weather sensitivity, or limb length discrepancy after fractures, but only 1 needed surgical intervention (shortening osteotomy). Eight children needed assistance at school up to 1 year, 4 passed 1 form, and 2 visited a school for special education. Eighty-six percent mentioned no change of well being and 14% described depressions. Parents reported changed behavior in 24%, and in 4 cases problems derived from blaming one parent for having caused the accident. Survival and long-term disabilities after severe multiple trauma depend on severity of head trauma. However, no child died in this series even though 10% had GCS of less than 6. Early rehabilitation after early fracture stabilization makes a reduction of impairments possible, and long-term rehabilitation reduces residual impairments. Social problems (school, family) can be minimized by early psychological intervention and later school assistance.—P. Schmittenbecher
1149
Cost Factors in Pediatric Trauma. D. Gurses, A. Sarioghu-Buke, M. Baskan, et al. Can J Surg 46:441– 445, (December), 2003. The authors in the Pediatric Emergency Unit of a university hospital in Turkey prospectively investigated cost factors in pediatric trauma and attempted to identify cost predictors. They reviewed the charts of and sent out questionnaires to 91 children (50 boys, 41 girls) less than 16 years (mean, 6 years) who were admitted consecutively with multiple trauma to their emergency unit October 1998 to September 1999. They obtained data on age, gender, date, mechanism of injury, site of injury, type of treatment, and length of hospital stay. They also studied physical findings, Pediatric Trauma Score (PTS), Revised Trauma Score (RES), and Pediatric Glasgow Trauma Score (GCS). Motor vehicle crashes (MVA) accounted for 45% of injuries, falls, 41%, and bicycle accidents, 14%. Sites of injury were head (74%), abdomen (57%), and extremity (37%). Seventeen patients (19%) required major and 27 (30%) minor surgical treatment, whereas 44 (48%) were treated conservatively. There were 3 deaths. Mean duration of hospital stay was 4 days. Mean total cost of care was US $376 ($20 to $1,995), reflecting the significantly lower health care cost in Turkey. There was no correlation between cost and age. The cost associated with MVA was higher than for other injuries. Forty-eight percent of patients were referred from another hospital, and here the cost of care was significantly higher. Total cost correlated directly with duration of hospital stay and distance of referring hospital but inversely with the PTS, RETS, and GCS.—Sigmund H. Ein
Technique of Split Skin Graft Fixation Using Hypafix: A 15-Year Review. R.B. Davey, A.L. Sparnon, and M. Lodge. Aust N Z J Surg 73:958 –962, (November), 2003. Effective take of a split skin graft (SSG) after a burn is promoted by a reduction in movement of the SSG in relation to the debrided wound bed. The authors retrospectively reviewed their clinical experience in 749 children with Hypafix or Fixomul dressing (Smith and Nephew, Melbourne, Victoria, Australia) in promoting satisfactory SSG take between 1986 and 2001. The dressing is an adhesive, semiporous polyester retention dressing. The Hypafix was cut into a variety of sizes, packaged, and steam sterilized at 134°C for 4 minutes. After application of the SSG to the debrided burn, a sheet of Hypafix was applied firmly to secure the graft. Any residual hematoma was then expressed by gentle pressure on the hypafix before applying a crepe bandage. Depending on the size of the area covered, additional fixation of the edges of the dressing may be achieved with staples. The authors observed a reduction in theater time, reduction in the numbers of dressing changes, and reduced bed occupancy, although none of these were quantified. The dressing was usually removed at 7 days after the application of either Cit-Sol (RCR International, Melbourne, Victoria, Australia) or peanut oil. The authors might then reapply a Hypafix dressing as part of their scar management program. Over the 15-year study period, there were 18 (2%) graft failures: 11 caused by infection, 5 inadequate debridement, 1 hematoma, and 1 early removal of the dressing. Comment: The authors do not comment on the difficulty of securing the dressing to a typically moist burn wound. In the authors’ experience, it is necessary for surrounding unburnt skin to be carefully dried for satisfactory adherence. Any vegetable oil may be used to dissolve the adhesive and ease removal of the dressing. Whereas the authors have suggested important advantages in terms of reduced theater time, nursing care, dressing changes, and improvements in scar management, no data were supplied to support these statements. Clearly, there have been many other improvements in general burn care over 15 years that would act as confounding factors.—A.J.A. Holland