Search

This study aimed to investigate the feasibility of facilitating four sessions of art therapy intervention with a primary focus on implementation and acceptability. The exploratory aim was on assessing the effect of art therapy on self-reported outcomes on anxiety and mood among five individuals (aged 18+ years) hospitalized for burn injuries and to understand their perceptions of engagement with art therapy. A convergent mixed-methods small N design was adopted wherein both quantitative and qualitative data are gathered and then integrated, and an individual served as his/her own control when assessed before and after art therapy. Anxiety was assessed using Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety short-form of the emotional distress bank, and mood was assessed using the Positive and Negative Affect Schedule (PANAS). There was a statistically significant decrease in anxiety scores and negative mood scale. Positive mood scale scores tended to improve after art therapy though were not statistically significant. Thematic analysis of qualitative data indicates that art therapy improves 1) symptom management, 2) facilitates emotional expression and 3) insight, 4) brings out symbolic and metaphorical representations, and 5) allows tactile and sensory exploration of art media. This study demonstrated that art therapy can be successfully implemented with acute burn patients and can have promising psychosocial benefits. Further research in needed to determine the effectiveness of art therapy with more burn patients, in ways that is meaningful to the patients.

The purpose of this review is to discuss commonly used dressings for burn treatments, including short-acting topicals and long-acting silver dressings. Recent literature supports the use of long-acting silver dressings over traditional daily use topical treatments. Longer acting topical dressings result in less frequent dressing changes, less pain, and greater ease of use, but have similar results in wound healing and infection prevention. There are many topical agents on the market for use on burn wounds. Short-acting topicals can be divided into 3 generalized classes: antiseptics, antimicrobials, and enzymatic debridement agents. Longer acting applied dressings include silver-bonded nylon and fiber (Silverlon® Argentum, Clarendon Hills, IL); multilayer rayon, polyester silver-coated mesh polyethylene (Acticoat™ Smith & Nephew London, UK); silver sodium carboxymethylcellulose (Aquacel® Ag, ConvaTec, Greensboro, NC); silver-containing soft silicone foam (Mepilex® Ag; Molnlycke Health Care, Gothenburg); soft silicone silver (Mepitel Ag® Molnlycke Health Care, Gothenburg). Tradition and surgeon preference are major influences on frequency of use. While recent literature supports using long-acting silver-based dressings over short-acting topicals, more research, particularly randomized controlled trials, is needed to provide evidence-based recommendations regarding their use.

Background: To report the case of a burn patient with meningitis secondary to pseudomonal endophthalmitis that led to death. Case Presentation: An 18-year-old female who sustained flame bu...

Purpura fulminans (PF) and toxic epidermal necrolysis (TEN) are rare and life-threatening diseases. TEN is a notorious epidermolytic condition, most cases of which are drug induced. TEN is a more severe variant of epidermal necrolysis than Stevens-Johnson syndrome, as it affects a greater percentage of skin surface area. PF occurs in acute severe infections, deficiencies of protein C and S, and rarely, is idiopathic. PF is a thrombotic disorder of hemorrhagic cutaneous infarction and disseminated intravascular coagulation. While the two diseases are distinct in etiology, their clinical presentations can be strikingly similar. This report illustrates the clinical overlap between PF and TEN and reveals the potential for the diseases to coincide. The case of a patient with biopsy-proven TEN who developed PF was reviewed in detail. The topics of PF and TEN were searched using the MEDLINE database to investigate the relationship between the two diseases. Our case report raises diagnostic suspicion for PF in cases of TEN, particularly in patients with rapid clinical deterioration and failure of conventional management. In addition to the case presented from our institution, a similar case has been reported in which biopsy-proven PF clinically mimicked the epidermolytic condition Stevens-Johnson syndrome. These observations reflect that, although rare, conditions of epidermal necrolysis and PF may coincide more frequently than currently recognized.

Pyoderma gangrenosum (PG) is a rare immunological disorder with inexplicable white blood cell infiltration into the epidermis with necrosis and excruciating pain. Diagnosis is by exclusion which delays proper treatment. Surgical intervention often exacerbates wounds. Between 2004 and 2010, seven patients with PG were admitted to our burn treatment center (BTC). Multiple treatment modalities were used on these patients. An institutional review board-approved retrospective study investigated seven PG BTC admissions. Demographic information, symptom onset, time to diagnosis, admission or transfer, length of stay (LOS), use of corticosteroids, and prior surgery were collected. The average time to PG diagnosis was 18.7 days and the average wound surface area was 3.9%. The average patient age was 64.6 years (median 66 years) and there were five men and two women patients. The average symptom onset was 70.5 days prior to BTC admission. The BTC wound care lasted 24 days. Six of the seven patients had lower extremity lesions vs one with lesions involving the abdomen. Inflammatory bowel disease was noted in two patients, one with malignant melanoma, and another with psoriasis. Corticosteroids were begun 1.75 days after admission for six of the seven patients. Of the seven PG patients, five had excision and/or skin grafting with vacuum-assisted wound closure used in four. Six patients were discharged, but one patient succumbed early to sepsis. Skin grafting often speeds up chronic wound closure; however for PG this causes progression of lesions. Persistent non-healing wounds with pain disproportionate to size may be PG. Prompt diagnosis and BTC specialized care greatly improve outcomes for PG patients.

The purpose of this study is to determine the incidence of sinusitis in mechanically ventilated burn victims and to examine if the presence of inhalational injury increases the likelihood of developing sinusitis. The authors hypothesize that the incidence of sinusitis will be increased in burn victims who have concomitant inhalational injury. A retrospective chart analysis was performed on all patients who were admitted to the Nathan Speare Regional Burn Treatment Center over a 24-month time frame. Patients who were mechanically ventilated for greater than 24 hours were then selected, resulting in a total of 137 patients for analysis. Multiple variables including number of days on mechanical ventilation, presence of confirmed inhalational injury by bronchoscopy, and method of diagnosis were examined. Of 137 patients, a diagnosis of sinusitis was made in 32 patients (23%). In patients with sinusitis, 87.5% had inhalational injury confirmed with bronchoscopy, compared with only 33.3% of patients without sinusitis (P < .01). Rates of nasotracheal/nasogastric intubation, nasoenteric feeding, and length of mechanical ventilation before sinusitis diagnosis were not significantly different. Patients with sinusitis were found to have suffered inhalational injury at a significantly higher rate than those who did not develop sinusitis. This suggests that inhalational injury is a significant risk factor for developing sinusitis.

Isolation of Staphylococcus aureus with minimum inhibitory concentrations, 1 to 2 mg/L, suggests increasing vancomycin trough ranges, from 10 to 20 mg/L or even higher. Vancomycin troughs from 604 treatment courses from 560 patients with suspected or actual Gram-positive infection were analyzed with focus on potential toxicity/efficacy. Trough concentrations were required to be drawn within 15 to 45 minutes before the administration of at least the third vancomycin dose. Patients were retrospectively evaluated for their total daily dose and milligrams per kilograms per vancomycin dose. Data on the duration of vancomycin therapy, days to a normal temperature, and white blood cells were obtained. Data were stratified by trough concentration as5, 5 to 10, and10 mg/L to determine whether there was any relationship between response and trough concentration. Demographic data were obtained in 560 patients with 604 vancomycin treatment courses. For 361 patients with 379 separate treatment courses of vancomycin therapy no other nephrotoxic antimicrobial agent had been used. The greatest risk of vancomycin nephrotoxicity correlated with the duration of treatment. Using the log time to normal temperature, white blood cell count, heart rate, outcome from vancomycin therapy was assessed and no relationship could be demonstrated for the three vancomycin trough strata using analysis of variance (F2.62 for all parameters; p.05). These data indicate that vancomycin trough elevation may not guarantee treatment success and that there may be no real benefit from higher vancomycin trough concentrations in thermal injury patients with burns20% TBSA.

Acinetobacter baumannii represents a cunning pathogen with multiple resistance genes. The authors report their experience with the treatment of two multiple drug-resistant A. baumannii clones. At least one positive culture was noted in 359 patients and, 323 had sufficient data for analysis. Of these, 42 patients were colonized leaving 281 antibiotic-treated infected patients. The average age was 48.1 ± 20.6 years (mean ± standard deviation), total body burn surface area involvement (TBSA) was 30.8 ± 25%. Inhalation injury was confirmed by bronchoscopy in 238 of 323 (74%) patients. The day to the first A. baumannii culture was 7.9 ± 8.9 and 6.5 ± 8.8 days for the colonized and infected patients, respectively. Survival to discharge was 95.4% for colonized patients and 77.1% for infected patients. A total of 1425 sputum cultures, 123 catheter cultures from 40 patients, 1130 blood cultures from 176 patients, and 1925 wound cultures were obtained from the 318 infected patients (14 cultures per patient). Imipenem-cilastatin was first used in 162 patients, ampicillin-sulbactam in 40 patients, and cephalosporin in 41 patients. Imipenem-cilastatin was combined with ampicillin-sulbactam in 18 patients. Imipenem-cilastatin eradicated A. baumannii in 27%, caused persistence in 55%, and failure in 20%. Ampicillin-sulbactam eradicated A. baumannii in 17%, caused persistence in 51%, and failure in 34%. Imipenem-cilastatin combined with ampicillin-sulbactam eradicated 23% of the A. baumannii, with 54% persisting, and 23% failing therapy. Nonparametric analysis of three sets of 34 matched patients treated with imipenem-cilastatin, ampicillin-sulbactam, or a cephalosporin showed little difference in treatment outcomes. More rapid fever resolution and fewer positive cultures were noted in the imipenem-cilastatin treated group; however, length of stay was not different.

Development of metrics for burn care, including healing of skin wounds during the acute phase of treatment, is essential in an environment of decreasing resources and increasing interest in quality and accuracy of medical information. Advantages of consensus metrics include: tracking of trends in care; consistency of care; and correlation of treatment with medical outcomes. For cutaneous burn wounds, these advantages are confounded by factors that contribute to the heterogeneity of burn wounds, including but not limited to: TBSA of injury, depth of injury (partial or full thickness), cause, patient-dependent factors such as age, sex, and comorbidities, anatomic site, and time between injury and treatment. Similar factors contribute to complex injuries from trauma, depth, debridement or excision of devitalized tissue, dressing or grafting of the prepared wound bed, and assessment to determine wound closure. In the absence of confounding factors or comorbidities, wound closure is one of the key criteria for discharge from acute care whether in hospital, or ambulatory care. Not surprisingly, these metrics for wound healing have been used repeatedly in the assessment of developing therapies for wound care. In response, review by the FDA of novel therapies has led to Guidance for Industry: chronic cutaneous ulcer and burn wounds developing products for treatment. and allow for risk adjustment of individuals in the population, who otherwise may be outliers to the statistical mean of the entire population.

Approximately 100 operating room (OR) fires occur per year in the United States, with 15% resulting in serious injuries. Intraoperative cautery was frequently associated with OR fires before 1994; however, use of supplemental oxygen (O(2)), ethanol-based products, and disposable drapes have been more frequently associated with OR fires. Fires resulting from cosmetic and other small procedures involving use of nasal canula O(2) and electrocautery have been described in six published reports. We report five thermal injury cases admitted to our burn treatment center because of fires during surgical procedures over a 5-year period. Two patients undergoing supraorbital excision experienced 2.5 and 3% TBSA involvement burns; in a third patient surgical excision of a nasal polyp resulted in a 1% TBSA burn; in a fourth patient an excisional biopsy of a lymph node resulted in a 2.75% TBSA burn; and the last patient was burned during placement of a pacemaker, with resulting TBSA of 10.5%. Two of the five patients required intubation for inhalational injury. Two patients required tangential excision and grafting of their thermal injuries. All patients had received local or parenteral anesthesia with supplemental O(2)/nitrous oxide (N(2)O) for surgical procedure. There are a number of ignition sources in the OR, including electrocautery, lasers, and faulty OR equipment. The risk of OR fires increases with surgical procedures involving the face and neck, including tracheostomy and tracheobronchial surgery. The common use of O(2)/N(2)O mixtures or enriched O(2) for minimally complex surgical procedures and disposable drapes adds to the risk of an OR fire: the O(2)/N(2)O provides a fuel source, and the disposable drapes trap thedelivered gas. Electrocautery near an O(2)/N(2)O source resulted in the five thermal injuries and warrants careful reconsideration of technique for surgical procedures.

Emergence of resistance to vancomycin and the increasing incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) warrant careful initiation of antimicrobial agents after nasal swab polymerase chain recombination (PCR) MRSA positive screen. Current MRSA PCR nasal swab (PCR) screening does not distinguish non-hospital-acquired strains. A retrospective, institutional review board-approved study of collected PCR screenings among 826 burn center admissions over a 23-month period assessed culture results, antimicrobial agents chosen, and patient demographics. Seventy-seven of the 826 were known chronic carriers (n = 11); had MRSA on initial PCR (n = 48); or converted to positive PCR screen on later testing (n = 18). The 48 patients with initial positive PCR were decolonized with mupirocin. MRSA carriers were not decolonized. The 18 patients who became PCR positive were also not decolonized with 10 having positive cultures. The 48 initial PCR nasal swab positive patients represented 5.8% of admissions. Demographic data did not differ among chronic carriers, initial PCR positive patients, nor those converting to PCR positive. Length of stay was shorter for initial PCR positive decolonized patients (P << .05) and they had a 35% of decrease in MRSA infection. All 11 chronic carriers became infected with MRSA; however, five had non-hospital-acquired MRSA and two solely non-hospital-acquired MRSA. For the 48 PCR positive patients, 17 had isolated MRSA and one having exclusively non-hospital-acquired MRSA. Of the 39 patients with isolated MRSA, 20 (43%) non-hospital-acquired MRSA. Non-hospital-acquired MRSA was 43%, however PCR fails to distinguish hospital-acquired MRSA from community-acquired MRSA.

Exfoliative dermatitis, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), is a mild-to-life-threatening process that has been described after exposure to many antiepileptic drugs. The increased use of antiepileptic drugs for treatment of bipolar disorder and neurologic disorders has extended the risk of exfoliative disorder to this population of patients, and these patients and their health care providers may not be familiar with the risks involved with these drugs. We describe the cases of a 28-year-old woman with bipolar 1 disorder initially treated with lamotrigine, and two adolescent girls with bipolar 2 disorder treated with lamotrigine after poor responses to other drug regimens. In all three patients, rashes progressed to toxic epidermal necrolysis in spite of treatment with corticosteroids at their local hospitals; thus, they were transferred to our burn treatment center. Response to early corticosteroid treatment in suppressing progression of exfoliation was variable in these patients. Ultimately, two of the three required ventilatory support; their conditions improved within 8-32 days of treatment, and they were discharged from the hospital. Case reports of lamotrigine-induced exfoliative disorder in patients with bipolar disorder have been published. However, these three patients were admitted to our burn treatment center within a 12-month period. Our institution admits approximately 10-12 patients with TEN/year, and the increased use of lamotrigine for treatment of bipolar disorder is likely to result in more patients with TEN. Therefore, health care professionals need to be aware of the early signs and symptoms of exfoliative dermatotoxicity when treating patients with lamotrigine.

Results of previous studies suggest that β-adrenoreceptor activation may augment pain, and that β-adrenoreceptor antagonists may be effective in reducing pain, particularly in individuals not homozygous for the catechol-O-methyltransferase (COMT) high-activity haplotype.Consenting patients admitted for thermal burn injury at participating burn centers were genotyped; those who were not high-activity COMT homozygotes were randomized to propranolol 240 mg/d or placebo. Primary outcomes were study feasibility (consent rate, protocol completion rate) and pain scores on study days 5 to 19. Secondary outcomes assessed pain and posttraumatic stress disorder symptoms 6 weeks postinjury.Seventy-seven percent (61/79) of eligible patients were consented and genotyped, and 77% (47/61) were genotype eligible and randomized. Ninety-one percent (43/47) tolerated study drug and completed primary outcome assessments. In intention-to-treat and per-protocol analyses, patients randomized to propranolol had worse pain scores on study days 5 to 19.Genotype-specific pain medication interventions are feasible in hospitalized burn patients. Propranolol is unlikely to be a useful analgesic during the first few weeks after burn injury.

Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) are mild-to-life-threatening adverse reactions that have been described after exposure to fluoroquinolones. No published reports, however, exist of exfoliative disease after treatment with levofloxacin. A 78-year-old woman with many medical problems, including chronic obstructive pulmonary disease, was treated with parenteral levofloxacin for community-acquired pneumonia. She was discharged with oral levofloxacin to complete an additional 3 days of treatment as an outpatient. Two days after completing this regimen, the patient developed a rash with blistering. The rash progressed to TEN in 7 days, and she was transferred to a burn treatment center. She was treated with fluid resuscitation, wound dressing, and antibiotics. Her condition improved, and she was discharged after 22 days. To our knowledge, this case is the first published report of levofloxacin-induced TEN.

Trichosporon beigelii is a fungus once thought to cause only superficial infections, but recently has been increasingly identified as an opportunistic systemic pathogen in immunocompromised patients. There have been very limited reports of this organism in the burn patient population. We describe the first report of pharmacological management of invasive T. beigelii with a combination of amphotericin B and high dose fluconazole in a burn patient. Antifungal susceptibility testing of T. beigelii determined a change in minimum inhibitory concentrations (MICs) of amphotericin B and a consistent resistance pattern with the use of flucytosine. This paper will review our experience with T. beigelii fungus in a regional burn treatment center and review the literature on other experiences in the burn population.

Trimethoprim is well known to cause rashes; however, what is not commonly known is that it causes sudden and profound hyperkalemia in 10 to 20% of treated patients. The uniqueness of burn patients begs the question whether changes known to occur in these patients might also increase this trimethoprim effect. After institutional review board approval, a retrospective study evaluated 224 patients with thermal injury who had been treated with trimethoprim sulfamethoxazole (TMP-SMX), 24 of whom had underlying renal impairment (creatinine clearances50 ml/min) and were excluded, leaving 200 patients for analysis. Three definitions of drug-induced hyperkalemia were used: 1) a ≥ 1 mEq/L rise, 2) a0.8 mEq rise in potassium in24 hours warranting early discontinuation of TMP-SMX, and 3) "marked" hyperkalemia defined as serum potassium of ≥ 5.5 mEq/L within 48 hours. A potassium level before trimethoprim exposure (TxK) and after TxK were collected retrospectively. Demographic data were analyzed with Student's t-test and trimethoprim dose alone, demonstrating a significant difference. Analysis of 200 patients exposed to trimethoprim demonstrated an elevation of potassium (first definition) in 31 patients (15.5%), a rapid change in serum potassium in two patients (second definition), and marked hyperkalemia (5.5 mEq/L) in 13 patients (6.5%). Hyperkalemia never occurred in 166 of 200 patients (82%; before TxK, 3.9 ± 0.4; after TxK, 4.3 ± 0.5 mEq/L). Change in serum potassium among patients with hyperkalemia was 4.0 ± 0.5 mEq/L before TxK and 5.3 ± 0.7 mEq/L after TxK. Twelve published hyperkalemia risk factors were reviewed in these 200 patients and only history of hypertension and need for intubation was more common in those with hyperkalemia. A nearly 20% incidence of hyperkalemia and 6% serious hyperkalemia in burn patients is consistent with reports in patients without burn injury. These data also suggest that the metabolic and hormonal changes associated with burn injury do not increase further the genetically predisposed hyperkalemia resulting from exposure to trimethoprim. These data suggest patients treated with TMP-SMX should have routine serum potassium monitoring before discharge.

Background Nebulized antibiotics are used to locally treat colonizations of multi-resistant organisms. Prior systemic nephrotoxic antibiotic use with serum creatinine rises warranted an alternative therapy in 69 ventilator-dependent patients with persisting sputum cultures and need for ventilatory support. Materials and methods Following IRB approval, retrospective patient data were reviewed. Analysis included comparison of these 69 patients (71 treatments) to 142 Gram-negative infected burn patients matched for age and burn size. Results Mean pooled age and burn wound percent for the 71 triplicates ( n = 211 patients) were 55.6 ± 18.3 years and 27.4 ± 22.3% burns. Fifty-seven of 69 (83%) patients had inhalation injuries and 54 of 69 (78%) patients survived. Nebulizations averaged 6.8 ± 3.3 days (range 3–12 days). Serum creatinine rose in 2 patients receiving colistimethate nebulizations, known to cause nephrotoxicity following nebulization. Triplicate comparisons via ANOVA noted prolonged ventilatory support ( F = 13.39; p ≪ 0.05) and length of stay ( F = 6.11; p ≪ 0.5). Variance was attributed to the sicker nebulized patients. Twenty-four inhalation injury-only triplicates further confirmed that nebulized patient subgroup was more ill. Conclusion Short duration antibiotic nebulization may allow higher intra-tracheal antibiotic concentrations and may facilitate weaning from the ventilator by reducing bacterial bioburden.

Increasing evidence suggests that stress system activation after burn injury may contribute to burn-related pain. If this is the case, then genetic variations influencing the function of important stress system components, such as the enzyme catechol-O-methyltransferase (COMT), may predict pain severity after thermal burn injury. The authors evaluated the association between COMT genotype and pain intensity in 57 individuals hospitalized after thermal burn injury. Consenting participants at four burn centers were genotyped and completed daily 0 to 10 numeric rating scale pain assessments on 2 consecutive days including evaluation of waking, least, and worst pain. The association between COMT genotype and individual pain outcomes was calculated using a linear mixed model adjusting for sociodemographic and burn injury characteristics. Overall pain (combination of least, worst, and waking pain scores) was significantly higher in patients with a COMT pain vulnerable genotype (6.3 [0.4] vs 5.4 [0.4], P = .037). Individuals with a COMT pain vulnerable genotype also had significantly higher “least pain” scores (3.8 [0.5] vs 2.6 [0.4], P = .017) and significantly higher pain on awakening (6.8 [0.5] vs 5.3 [0.4], P = .004). Differences in worst pain according to genotype group were not significant. COMT pain vulnerable genotype was a stronger predictor of overall pain severity than burn size, burn depth, or time from admission to pain interview assessment. These findings suggest that genetic factors influencing stress system function may have an important influence on pain severity after burn injury. Further studies of genetic predictors of pain after burn injury are needed. (J Burn Care Res 2012;33:518–523)

Vancomycin-resistant Enterococcus faecium and faecalis (VRE) remains a major complication among critically ill patients. A 26-year-old patient with 65% total body surface area burns (TBSA) was infected with several E. faecium strains during his admission that were resistant to vancomycin. Because chloramphenicol was the standard treatment at this time, this drug was initiated until, the organism was identified as E. faecium and reported as susceptible to quinupristin-dalfopristin. Given these data, it was then decided to discontinue the chloramphenicol therapy. Quinupristin-dalfopristin therapy resulted in initial reduction of fever and white blood cell counts that continued over the next 5 days. However, on day 7 of quinupristin-dalfopristin therapy, a return of fever and elevation of the white blood cell count was noted and a repeated E. faecium blood culture demonstrated sudden resistance to quinupristin-dalfopristin (Bauer-Kirby zone size

We sought to evaluate the adverse effect profile of linezolid among thermal injury patients requiring treatment for Enterococcus species or other Gram-positive infection warranting treatment with linezolid. Seventy-six inhalation injury and/or thermal injury patients experiencing 94 exposures to linezolid for 48 hours or longer (range, 2-83 days) were included. We evaluated leukocyte count and platelet count for the time period preceding, during, and after therapy with linezolid based on specified time periods of exposure for evaluation of specific adverse effects. Sixty-three of 76 (83%) patient admissions were complicated by inhalation injury. The average TBSA involvement was 34.4% (range, 0-98%). The onset of thrombocytopenia before linezolid therapy was noted in 21 of 57 patients (36.8%), which was attributable to fluid resuscitation and acute platelet consumption. After they were exposure to linezolid, 12 patients developed thrombocytopenia. Platelet counts recovered in 7 of these 12 patients with continued exposure to linezolid; however, thrombocytopenia persisted for more than 9 days after therapy in 9 patients, of whom 6 patients succumbed to sepsis. On average, thrombocytes increased by 102,000/mm3 during linezolid treatment. Leucopenia was rare in thermal injury patients, and persisting thrombocytopenia in this population was associated with sepsis and mortality. Continuing linezolid therapy after the onset of thrombocytopenia among survivors almost always resulted in recovery from thrombocytopenia.

We present an interesting case of the first adult reported in the United States to suffer from thermal burns, adult respiratory distress syndrome (ARDS) and to be treated with extracorporeal membrane oxygenation (ECMO) who survived. Our patient is a 26 year old male who sustained thermal burns (12% TBSA) to his face and anterior trunk and broncoscopically demonstrable inhalation injury. He was transported to our regional burn center for burn wound care and ventilatory support. The patient was treated with silver sulfadiazine 1% to his wounds which healed per primam. Because of low oxygen saturation he required increasing FIO2. The following parameters: FIO2= 1, PEEP = 17, minute ventilation of 15.1 1, peak airway pressure of 45 and mean of 27, along with chest X-rays corroborated the severity of ARDS. The patient failed volume control ventilation. A trial of pressure ventilation was attempted but the patient only reached O2 saturation in the low 80s. At this point, the decision was made to transfer the patient to a hospital capable of ECMO treatment. The patient was subsequently treated with veno venous ECMO. Six weeks later the patient was discharged from the hospital off all ventilatory support.

A 48-year-old man with a history of ethanol abuse and bipolar disease fell asleep while smoking in an intoxicated state. The patient received a 30% total body surface area burn involving his face and upper torso that resulted in an inhalation injury. Several attempts at weaning from mechanical ventilation failed due to his extreme agitation, which was unresponsive to benzodiazepines, opiates, and antipsychotic agents. Propofol therapy was begun in combination with valproic acid, fluoxetine, and risperidone to assist in the treatment of his severe agitation associated with the bipolar disease, inhibiting ventilatory weaning. Repeated attempts to discontinue propofol were associated with withdrawal symptoms such as severe agitation, tremors, tachycardia, tachypnea, and hyperpyrexia. His symptoms resolved only after each time the propofol infusion was restarted. The patient received propofol for 95 days for management of his agitation before dying from refractory septic shock and multiple organ failure.

Streptococcal toxic shock syndrome (STSS) is caused by infection with a toxicogenic strain of Streptococcus pyogenes. Clinical manifestations may be those of a mild illness, characterized by malaise, fever, and muscle pain, to severe sepsis and multisystem organ failure. The syndrome may be associated with several invasive infections including necrotizing fasciitis. Treatment is primarily surgical debridement of infected tissue with supportive care, antibiotics, and hemodynamic monitoring. Intravenous immunoglobulin (IVIG) is reported to have beneficial effects in the management of STSS associated with necrotizing fasciitis. The agent was successful in conjunction with surgical excision and antibiotics in a patient with necrotizing fasciitis, toxic shock, and multisystem organ failure. On the basis of this experience and a thorough literature review, we concur that IVIG may be a useful adjunct in the treatment of STSS associated with necrotizing fasciitis.

Insight into the pathogenesis and etiology of experimental duodenal ulceration was sought by studying the modulation of this disease in rats by selective vagotomy, chemical sympathectomy, histamine depletion, histamine H-2 receptor antagonists (eg, metiamide, cimetidine), or endocrine ablations. Gastric secretion was examined in intact and pylorus-ligated animals. The formation of duodenal ulcers induced by the administration of propionitrile or cysteamine was abolished by vagotomy, decreased by sympathectomy, histamine depletion, histamine H-2 receptor antagonists, hypophysectomy, thyroidectomy, or adrenalectomy. Cimetidine and metiamide exerted a dose-dependent antiulcer effect, but metiamide enhanced the mortality of rats given propionitrile or cysteamine. The non-ulcerogen derivative of cysteamine, ethanolamine, did not increase mortality when given in combination with metiamide. The gastric hyperacidity elicited by cysteamine was reduced by metiamide or vagotomy, the latter being more effective in this respect. Thus, the chemically induced duodenal ulcer in rats resembles the human peptic ulcer disease in sensitivity to therapeutic modalities and may serve as an appropriate model to study the role of neural, hormonal, and other factors in the etiology and pathogenesis of this disorder.

Among patients exposed to hydrofluoric acid the potentially lethal effect of calcium depletion induced by binding with fluoride ion has not been well reported. Three patients exposed to hydrofluoric acid had acute fluoride poisoning with serum calcium levels equal to or below 4.1 mgm/dl. Treatment included administration of large amounts of calcium, both intravenously and by subsechar injection, to replenish the biologically active calcium and to bind fluoride. This report describes successful treatment of two survivors, apparently the first two, of severe hypocalcemia caused by hydrofluoric acid.