Introduction Exfoliative skin conditions such as Steven Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN) and other significant drug related reactions are complex medical conditions that provide a challenge to the burn surgeon, especially with regards to local wound care. Various modalities of wound care require frequent dressing changes; however, these changes put the patient through significant pain and potentially harmful experiences that could lead to worse skin exfoliation, scarring and pigmentation changes. As part of our burn unit, we have created a dressing utilizing silver impregnated nylon sheets that limits the amount of wound care performed and therefore the amount of potential exfoliative damage. Methods We have employed this means of dressing in all our Steven Johnson patients with significant open or blistered areas. We performed a retrospective analysis looking at our patients who were admitted with Steven Johnson Syndrome/toxic epidermal necrolysis or other exfoliative skin disorder over the last 7 years. We had 52 patients who ranged from having 2-100% of skin involved with significant blistering or exposed areas. The suit is made specific to the patient as each area is measured and the silver sheets are formed to the patient and secured in place. The silver sheets are saturated with sterile water and rewet with saline every four hours and changed every three days. Results By utilizing these silver-based dressings, we have limited the amount of dressing changes and concomitant pain for patients while also limiting skin infections to only 1 out of our 52 patients. For blisters on the face, a local antibiotic ointment was used; and once the skin lesions had healed, a moisturizing lotion was used. Conclusions Steven Johnson Syndrome and other exfoliative skin conditions require significant wound care. By minimizing dressing changes, one can lessen the pain to patients and by utilizing dressings that are infused with silver, one can also potentially decrease the risk for infection as was seen in our patient population.

Tracheocutaneous fistula (TCF) is a complication occurring after decannulation of a long-term tracheostomy and can lead to significant morbidity. We describe a case of a TCF in a burn patient treated without surgery. No previous cases have been described. A 65-year-old woman presented with symptomatic hypertrophic burn scar contractures of the anterior neck 6 months after undergoing excision and grafting of full-thickness burns to the neck and chest. She had a history of tracheostomy placement at the time of burn. Two months later, she was decannulated with no evidence of TCF. She subsequently underwent excision of hypertrophic burn scar contractures of the neck with placement of bilayer wound matrix followed by split-thickness skin grafting. Postoperatively she was noted to have a TCF with subgraft emphysema and difficulty in phonation and respiration. With local wound care, the TCF closed spontaneously and a new skin graft was placed uneventfully. At 18 months postoperatively, fistula closure was maintained with good functional and aesthetic outcome. Conservative management of an iatrogenic TCF in a burn patient may result in adequate soft-tissue coverage and allow for subsequent successful skin grafting. This method affords minimal morbidity to the patient and is a viable alternative to more elaborate flap reconstruction.

Introduction Prolonged opioid usage remains a concern in pain management in procedural care. Recent evidence also suggests that a considerable number of patients who were prescribed opioids struggle with transitioning to non-opioid pain medications. As a continuous effort to reduce opioid consumption following burn surgical procedures, our institution recently evaluated methadone administration for burn procedural care in patients with 20–30% total burn surface area (TBSA) requiring excision and grafting. Methods After IRB approval, we performed a retrospective chart review of patients who underwent excision and grafting procedure for 20–30% TBSA burn injuries between January 1, 2019 and June 30, 2020. The following data was evaluated: postoperative opioid consumption, postoperative pain intensity (rated as “No Pain” [NRS=0], “Minor Pain” [NRS 1 to 3], “Moderate Pain” [NRS 4 to 6], “Severe Pain” [NRS 7 to 10]), time to physical therapy and time to hospital discharge. Data was analyzed using chi square/Fisher exact test for categorical variables and t-test/Wilcoxon rank sum test for continuous variables. Results Our preliminary data included 12 patients who met inclusion criteria, of which two patients received methadone administration. Our patient sample consisted of average age of 43 years, 75% male, and 24% TBSA (92% were flame burns). Patients in both methadone and non-methadone groups had no significant differences in medical histories and TBSA (23% TBSA in methadone, 25% TBSA in non-methadone). There was no significant difference in reported preoperative pain intensity between the two groups, rating moderate to severe. Postoperative pain intensity remained the same, rating moderate to severe and controlled with fentanyl, oxycodone, morphine and non-opioid analgesics. While there was no difference in postoperative fentanyl, opioid and non-opioid analgesic consumptions between the two groups, morphine consumption was significantly lower in the methadone group compared to non-methadone group (2±2 mg vs 51±54 mg, respectively, p=0.02). There was no significant difference between average time from surgery to first physical therapy session and time to hospital discharge (about 21 days after surgery) between the two groups. Conclusions This evaluation shows a potential trend in reduction of inpatient postoperative opioid consumption with the conjunctive administration of methadone, although a bigger sample size is needed for further assessment.