Showing papers in "Journal of Burn Care & Research in 2011"

Resuscitation After Severe Burn Injury Using High-Dose Ascorbic Acid: A Retrospective Review

Abstract: Resuscitation of burn victims with high-dose ascorbic acid (vitamin C [VC]) was reported in Japan in the year 2000. Benefits of VC include reduction in fluid requirements, resulting in less tissue edema and body weight gain. In turn, these patients suffer less respiratory impairment and reduced requirement for mechanical ventilation. Despite these results, few burn centers resuscitate patients with VC in fear that it may increase the risk of renal failure. A retrospective review of 40 patients with greater than 20% TBSA between 2007 and 2009 was performed. Patients were divided into two groups: one received only lactated Ringer's (LR) solution and another received LR solution plus 66 mg/kg/hr VC. Both groups were resuscitated with the Parkland formula to maintain stable hemodynamics and adequate urine output (>0.5 ml/kg/hr). Patients with >10-hour delay in transfer to the burn center were excluded. Data collected included age, gender, weight, %TBSA, fluid administered in the first 24 hours, urine output in the first 24 hours, and Acute Physiology and Chronic Health Evaluation II score. PaO2 in millimeters mercury:%FIO2 ratio and positive end-expiratory pressure were measured at 12-hour intervals, and hematocrit was measured at 6-hour intervals. Comorbidities, mortality, pneumonia, fasciotomies, and renal failure were also noted. After 7 patients were excluded, 17 patients were included in the VC group and 16 in the LR group. VC and LR were matched for age (42 ± 16 years vs 50 ± 20 years, P = .2), burn size (45 ± 21%TBSA vs 39 ± 15%TBSA, P = .45), Acute Physiology and Chronic Health Evaluation II (17 ± 7 vs 18 ± 8, P = .8), and gender. Fluid requirements in the first 24 hours were 5.3 ± 1 ml/kg/%TBSA for VC and 7.1 ± 1 ml/kg/%TBSA for LR (P < .05). Urine output was 1.5 ± 0.4 ml/kg/hr for VC and 1 ± 0.5 ml/kg/hr for LR (P < .05). Vasopressors were needed in four VC patients and nine LR patients (P = .07). VC patients required vasopressors to maintain mean arterial pressure for a mean of 6 hours, but LR needed vasopressors for 11 hours (P = .2). No significant differences in PaO2 in millimeters mercury:%FIO2 ratio, positive end-expiratory pressure, frequency of pneumonia, renal failure, or inhalation injury were found. VC group had four mortalities, and LR group had three mortalities (P = 1). VC is associated with a decrease in fluid requirements and an increase in urine output during resuscitation after thermal injury. Although this study did not find a difference in outcomes with VC administration, it demonstrates that VC can be safely used without an increased risk of renal failure. The effects of VC should be further studied in a large-scale, prospective, randomized trial.

Changes in Cardiac Physiology After Severe Burn Injury

Abstract: Cardiac stress, mediated by increased catecholamines, is the hallmark of severe burn injury typified by marked tachycardia, increased myocardial oxygen consumption, and increased cardiac output (CO) It remains one of the main determinants of survival in large burns Currently, it is unknown for how long cardiac stress persists after a severe injury Therefore, the aim of this study was to determine the extent and duration of cardiac stress after a severe burn To determine persistence of cardiac alteration, the authors determined cardiac parameters of all surviving patients with burns ≥ 40% TBSA from 1998 to 2008 One hundred ninety-four patients were included in this study Heart rate, mean arterial pressure, CO, stroke volume, cardiac index, and ejection fractions were measured at regular intervals from admission up to 2 years after injury Rate pressure product was calculated as a correlate of myocardial oxygen consumption All values were compared with normal nonburned children to validate the findings Statistical analysis was performed using log transformed analysis of variance with Bonferroni correction and Student's t-test, where applicable Heart rate, CO, cardiac index, and rate pressure product remained significantly increased in burned children for up to 2 years when compared with normal ranges (P < 05), indicating vastly increased cardiac stress Ejection fraction was within normal limits for 2 years Cardiac stress persists for at least 2 years postburn, and the authors suggest that attenuation of these detrimental responses may improve long-term morbidity

Early enteral nutrition in burns: compliance with guidelines and associated outcomes in a multicenter study.

Abstract: Early nutritional support is an essential component of burn care to prevent ileus, stress ulceration, and the effects of hypermetabolism. The American Burn Association practice guidelines state that enteral feedings should be initiated as soon as practical. The authors sought to evaluate compliance with early enteral nutrition (EN) guidelines, associated complications, and hospitalization outcomes in a prospective multicenter observational study. They conducted a retrospective review of mechanically ventilated burn patients enrolled in the prospective observational multicenter study "Inflammation and the Host Response to Injury." Timing of initiation of tube feedings was recorded, with early EN defined as being started within 24 hours of admission. Univariate and multivariate analyses were performed to distinguish barriers to initiation of EN and the impact of early feeding on development of multiple organ dysfunction syndrome, infectious complications, days on mechanical ventilation, intensive care unit (ICU) length of stay, and survival. A total of 153 patients met study inclusion criteria. The cohort comprised 73% men, with a mean age of 41 ± 15 years and a mean %TBSA burn of 46 ± 18%. One hundred twenty-three patients (80%) began EN in the first 24 hours and 145 (95%) by 48 hours. Age, sex, inhalation injury, and full-thickness burn size were similar between those fed by 24 hours vs after 24 hours, except for higher mean Acute Physiology and Chronic Health Evaluation II scores (26 vs 23, P = .03) and smaller total burn size (44 vs 54% TBSA burn, P = .01) in those fed early. There was no significant difference in rates of hyperglycemia, abdominal compartment syndrome, or gastrointestinal bleeding between groups. Patients fed early had shorter ICU length of stay (adjusted hazard ratio 0.57, P = 0.03, 95% confidence interval 0.35-0.94) and reduced wound infection risk (adjusted odds ratio 0.28, P = 0.01, 95% confidence interval 0.10-0.76). The investigators have found early EN to be safe, with no increase in complications and a lower rate of wound infections and shorter ICU length of stay. Across institutions, there has been high compliance with early EN as part of the standard operating procedure in this prospective multicenter observational trial. The investigators advocate that initiation of EN by 24 hours be used as a formal recommendation in nutrition guidelines for severe burns, and that nutrition guidelines be actively disseminated to individual burn centers to permit a change in practice.

A 26-Year Population-Based Study of Burn Injury Hospital Admissions in Western Australia

Abstract: The aim of the study was to use state-wide health administrative data to assess the incidence, temporal trends, and external cause of burn injury-related hospital admissions and mortality in Western Australia from 1983 to 2008. Linked hospital morbidity and death data for all persons hospitalized with an index burn injury in Western Australia for the period 1983-2008 were identified. Annual age-specific incidence and age standardized rates were estimated. Poisson regression analyses were used to estimate temporal trends in hospital admissions and mortality. Zero-truncated negative binomial regression analysis was used to identify factors associated with hospital length of stay. From 1983 to 2008, there were 23,450 hospitalizations for an index burn injury. Hospital admission rates declined by an average annual rate of 2% (incidence rate ratio [IRR], 95% confidence interval [CI] = 0.983, 0.981-0.984), and burn-related mortality declined by an average annual rate of 2% (IRR, 95% CI = 0.98, 0.96-1.01). Aboriginal people while having significantly higher hospitalization rates than non-Aboriginal people experienced a greater 26-year decline in hospitalizations of 58% (IRR, 95% CI = 0.42, 0.37-0.48) compared with 32% (IRR, 95% CI = 0.68, 0.65-0.71) for non-Aboriginal people. Children younger than 5 years, 20- to 24-year-old men, and adults older than 65 years remain at high risk for burn injury, and males continue to be hospitalized twice as frequently as females. The results demonstrate declines in burn injury hospitalizations and mortality in both Aboriginal and non-Aboriginal populations. Continued research is required of the impacts of medical interventions and the burn pathway of identified high-risk populations.

An open, parallel, randomized, comparative, multicenter study to evaluate the cost-effectiveness, performance, tolerance, and safety of a silver-containing soft silicone foam dressing (intervention) vs silver sulfadiazine cream.

Abstract: An open, parallel, randomized, comparative, multicenter study was implemented to evaluate the cost-effectiveness, performance, tolerance, and safety of a silver-containing soft silicone foam dressing (Mepilex Ag) vs silver sulfadiazine cream (control) in the treatment of partial-thickness thermal burns. Individuals aged 5 years and older with partial-thickness thermal burns (2.5-20% BSA) were randomized into two groups and treated with the trial products for 21 days or until healed, whichever occurred first. Data were obtained and analyzed on cost (direct and indirect), healing rates, pain, comfort, ease of product use, and adverse events. A total of 101 subjects were recruited. There were no significant differences in burn area profiles within the groups. The cost of dressing-related analgesia was lower in the intervention group (P = .03) as was the cost of background analgesia (P = .07). The mean total cost of treatment was $309 vs $513 in the control (P < .001). The average cost-effectiveness per treatment regime was $381 lower in the intervention product, producing an incremental cost-effectiveness ratio of $1688 in favor of the soft silicone foam dressing. Mean healing rates were 71.7 vs 60.8% at final visit, and the number of dressing changes were 2.2 vs 12.4 in the treatment and control groups, respectively. Subjects reported significantly less pain at application (P = .02) and during wear (P = .048) of the Mepilex Ag dressing in the acute stages of wound healing. Clinicians reported the intervention dressing was significantly easier to use (P = .03) and flexible (P = .04). Both treatments were well tolerated; however, the total incidence of adverse events was higher in the control group. The silver-containing soft silicone foam dressing was as effective in the treatment of patients as the standard care (silver sulfadiazine). In addition, the group of patients treated with the soft silicone foam dressing demonstrated decreased pain and lower costs associated with treatment.

Building Resilience in Burns Nurses: A Descriptive Phenomenological Inquiry

Abstract: The purpose of this qualitative study was to explore the concept of building resilience as a strategy for responding to adversity experienced by burns nurses. Nurses who care for patients with severe burn injury are often exposed to patients' pain and disfigurement, encountering emotional exhaustion, distress, reduced self-esteem, and desensitization to pain. Resilience has been identified as an essential characteristic for nurses in their work environment. Resilience assists nurses to bounce back and to cope in the face of adversity, sustaining them through difficult and challenging working environments. Nonetheless, there remains limited information that addresses the concept of building resilience in burns nurses. In 2009, seven burns nurses were recruited from a severe burn injury unit in New South Wales, Australia. A qualitative phenomenological methodology was used to construct themes depicting nurses' experiences. Participants were selected through purposeful sampling, and data were collected through in-depth individual semistructured interviews using open-ended questions. Data were analyzed with Colaizzi's phenomenological method of data analysis. The concept of building resilience as a strategy for coping with adversity was identified and organized into six categories: toughening up, natural selection, emotional toughness, coping with the challenges, regrouping and recharging, and emotional detachment. The findings clearly demonstrate that it is vital for burns nurses to build resilience to endure the emotional trauma of nursing patients with severe burn injury. Knowledge about building resilience could be incorporated into nursing education for both undergraduate and experienced nurses. Building resilience within the domain of burns nursing has the potential to retain nurses within the profession, having implications for staff development, orientation, and retention.

Functional and Psychosocial Outcomes of Older Adults After Burn Injury: Results From a Multicenter Database of Severe Burn Injury

Abstract: A number of factors increase the susceptibility of older adults to burn injury. The majority of studies of older adults have focused on patient and injury factors related to mortality risk. However, little is known about the long-term functional and psychological outcomes of older adults after severe burn. The purpose of this study is to examine the long-term outcomes of older adults after burn injury. The authors performed an analysis of the outcomes of older adults (age 55 years or older) enrolled in a prospective study of burn injury outcomes. Change in living situation as well as distress, functional impairment, and quality of life were examined at discharge and at 6, 12, and 24 months after hospital discharge. Mixed effects modeling was performed to compare differences across age groups and time as well as to account for missing data. A total of 737 patients aged 55 years or older were enrolled and followed in the National Institute on Disability and Rehabilitation Research burn program. Patients in all age groups had significant deficits in Short Form-36, Functional Independence Measure, and Brief Symptom Inventory scores at time of discharge. Recovery of physical and psychosocial functioning was greatest from discharge to 6 months in patients aged 55 to 74 years and greatest at 1 year for patients aged 75 years or older. This study confirms that severe burn injury significantly impacts both functional outcome and psychosocial quality of life in older adults. However, the impact seems to be age related as are recovery trajectories. Rehabilitation programs lasting up to 1 year after injury could be of tremendous benefit in helping older adults achieve maximal potential recovery.

Enoxaparin and Antifactor Xa Levels in Acute Burn Patients

Abstract: Altered pharmacokinetics in critically ill patients have been shown to result in inadequate enoxaparin dosing for venous thromboembolism (VTE) prophylaxis. In the burn unit, routine monitoring of antifactor Xa levels was implemented to ensure adequate VTE prophylaxis. The purpose of this study was to examine the appropriateness of enoxaparin dosing for VTE prophylaxis in this specialized patient population. The authors reviewed patients with acute burn injury from June 1, 2009, to October 20, 2009, who had enoxaparin therapy monitored with antifactor Xa levels. Data collection occurred prospectively. Thirty-eight patients received enoxaparin subcutaneously for prophylaxis of VTE and had antifactor Xa levels measured. Thirty (79%) patients had initial antifactor Xa levels less than 0.2 U/ml. Enoxaparin dosages were subsequently increased as needed to achieve antifactor Xa levels of 0.2 to 0.4 U/ml. Eight of 38 patients never achieved goal antifactor Xa level before enoxaparin was discontinued. The median final dose required to achieve an antifactor Xa level within therapeutic range was 50 mg every 12 hours (range 30-70 mg). In linear regression, final enoxaparin dose correlated with TBSA. Two patients had clinically significant thromboembolic events. There were no documented episodes of significant hemorrhage, thrombocytopenia, or heparin-associated allergy. The low antifactor Xa levels observed in this study demonstrate that standard dosing of enoxaparin for VTE prophylaxis is inadequate for patients with acute burns. In these patients, both a higher initial enoxaparin dose and routine monitoring of antifactor Xa levels are recommended.

Evaluation of SCORTEN on a cohort of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis included in the RegiSCAR study.

Abstract: The purpose of this study was to evaluate the severity-of-illness score called SCORTEN with respect to its predictive ability and by using data obtained in the RegiSCAR study, the most comprehensive European registry of patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) For advanced comparisons, an auxiliary score (AS) was defined using data obtained in a previous study Three hundred sixty-nine patients with SJS/TEN were included in RegiSCAR between 2003 and 2005 The data needed for calculation of SCORTEN were available for 45% of patients The score revealed a moderate predictive ability with a slight underestimation of the total number of in-hospital deaths by 11%, an area under the receiver operating characteristic curve of 075, and a Brier score of 014 Problems could be seen by analyzing subgroups such as patients with TEN The AS was better calibrated but discriminated worse (area under the receiver operating characteristic curve: 072; Brier score: 014) With the help of a refined score derived from SCORTEN and AS, potential for a possible improvement could be demonstrated The authors were able to show that the predictive ability of SCORTEN is acceptable Although improvement might be possible, SCORTEN remains the tool of choice, whereas AS might be an alternative in retrospective settings with missing laboratory data

The changing pattern of pediatric burns.

Abstract: After scalds, flame burns have been considered the next most common mode of burn injury in childhood. Recent experience in the authors' unit suggested that contact burns were becoming more frequent. The authors sought to determine the contemporary frequency of different burn modalities in children presenting to a burns unit. A retrospective review of 3621 children treated in the burns unit, both ambulatory and inpatient, at the authors' institution between January 2003 and December 2007 was performed. Patients were identified using the Burns Unit database. Data collected included age, gender, burn etiology and site, TBSA, and whether operative surgery was required. Of the 3515 patients eligible for inclusion, scalds accounted for 55.9%, contact 30.5%, and flame 7.9% of all burns. Contact burns were shown to be consistently more frequent than flame burns for every year of the study (z = 17.30, P < .001). No seasonal variation was demonstrated amongst contact burns, reflecting the variety of mechanisms involved. The data suggest a change in the historical pattern of pediatric burns previously reported in the literature. These findings have implications for public health awareness and burns prevention campaigns.

Colloid normalizes resuscitation ratio in pediatric burns.

Abstract: Fluid resuscitation of burned children is challenging because of their small size and intolerance to over- or underresuscitation. Our American Burn Association-verified regional burn center has used colloid "rescue" as part of our pediatric resuscitation protocol. With Institutional Review Board approval, the authors reviewed children with ≥15% TBSA burns admitted from January 1, 2004, to May 1, 2009. Resuscitation was based on the Parkland formula, which was adjusted to maintain urine output. Patients requiring progressive increases in crystalloid were placed on a colloid protocol. Results were expressed as an hourly resuscitation ratio (I/O ratio) of fluid infusion (ml/kg/%TBSA/hr) to urine output (ml/kg/hr). We reviewed 53 patients; 29 completed resuscitation using crystalloid alone (lactated Ringer's solution [LR]), and 24 received colloid supplementation albumin (ALB). Groups were comparable in age, gender, weight, and time from injury to admission. ALB patients had more inhalation injuries and larger total and full-thickness burns. LR patients maintained a median I/O of 0.17 (range, 0.08-0.31), whereas ALB patients demonstrated escalating ratios until the institution of albumin produced a precipitous return of I/O comparable with that of the LR group. Hospital stay was lower for LR patients than ALB patients (0.59 vs 1.06 days/%TBSA, P = .033). Twelve patients required extremity or torso escharotomy, but this did not differ between groups. There were no decompressive laparotomies. The median resuscitation volume for ALB group was greater than LR group (9.7 vs 6.2 ml/kg/%TBSA, P = .004). Measuring hourly I/O is a helpful means of evaluating fluid demands during burn shock resuscitation. The addition of colloid restores normal I/O in pediatric patients.

Hospital length of stay--does 1% TBSA really equal 1 day?

Abstract: Length of stay (LOS) continues to be a standard variable when evaluating progress and outcomes in burn care. Common wisdom would dictate that this measure is linearly related to TBSA. Is this truly the case? A retrospective review of the National Burn Repository was conducted to evaluate factors that affect hospital LOS. The National Burn Repository data set was obtained from the American Burn Association. Data from the years 2002-2007 were extracted. Unique patients were identified by removing readmissions, outpatients, and patients not admitted. Patients whose "HOSPLOS" and/or "AREATOT" field was blank or 0 were excluded, as were nonthermally injured patients. Patients without an entry for age and dead patients were also excluded. This left a final data set of 52,712 patients for analysis. The data were then analyzed, with %TBSA burned as the independent variable. In patients who survived their entire LOS, the mean LOS increased linearly by decile. Females with a TBSA 60% and age older than 70 years. Anticipating hospital LOS is not a simple task. Using complex statistical analysis, a linear trend associated with %TBSA can be seen; however, other variables do contribute. Until the precise role of these variables can be elucidated, anticipating patient LOS to be 1 day for every %TBSA is still a useful exercise.

Curcumin reduces injury progression in a rat comb burn model.

Abstract: The oriental spice curcumin has anti-inflammatory and antioxidant effects. When given orally before injury, curcumin reduces burn progression in a rat comb burn model. The authors hypothesized that intravenous administration of curcumin after injury would reduce burn progression and that its effects are mediated through iron chelation. Two comb burns were created on the dorsum of Sprague-Dawley rats (weight, 300 g) using a brass comb with four rectangular prongs preheated in boiling water and applied for 30 seconds resulting in four rectangular 10 × 20 mm full-thickness burns separated by three 5 × 20 mm unburned interspaces (zone of ischemia). Animals were randomized to receive one of four doses of crude curcumin or one of six doses of purified curcumin intravenously 1 and 24 hours after injury. Another set of animals were randomized to deferoxamine or control vehicle. Wounds were observed at 7 days after injury for visual evidence of necrosis in the unburned interspaces. Full-thickness biopsies from the interspaces were evaluated with Hematoxylin and Eosin staining 7 days after injury for evidence of necrosis. The percentage of unburned interspaces undergoing necrosis at 1 week by purified curcumin doses was 0 μg/kg, 74%; 0.3 μg/kg, 58%; 1 μg/kg, 53%; 3 μg/kg, 37%; 10 μg/kg, 63%; 30 μg/kg, 53%; and 100 μg/kg, 26%. The differences among the groups were significant (P = .03). When compared with controls, the 1 and 3 μg/kg curcumin treatment groups had significantly less progression of interspaces to necrosis (P = .04 and .002) as did the 30 and 100 μg/kg treatment groups (P = .03 and <.001). Deferoxamine did not reduce burn progression. When administered intravenously 1 and 24 hours after injury, both crude and purified curcumin reduce the percentage of unburned interspaces that undergo necrosis in a rat hot comb burn model. The effects of purified curcumin appear to be bimodal, suggesting more than one mechanism of action. The effects of curcumin do not appear to be mediated by iron chelation.

Comparisons of the effects of biological membrane (amnion) and silver sulfadiazine in the management of burn wounds in children.

Abstract: This prospective study was conducted on 102 children with second-degree thermal burns to assess qualitative differences between topical silver sulfadiazine (SD) and oven-dried, radiation-sterilized human amnion as wound dressing. The patients were divided into silver SD and amniotic membrane (AM) group by random sampling technique. The variables compared 1) the number of days admitted in the hospital, 2) the number of dressing changes, 3) time needed for epithelialization, 4) comfort and pain of the patients during dressing, 5) comfort and pain of the patients between dressings, 6) activities during treatment, 7) acceptability of the modules by the patients or attending guardians, and 8) comfort of the doctor during application. Patients' ages ranging from 1 day to 12 years and admitted to inpatient burn unit within 72 hours of occurrence were included in this study. Fifty-one burned children enrolled in each group. The mean hospital stay is significantly lower in AM group (P < .01). The number of dressing changes in AM group was significantly low (P < .001). The mean time taken for epithelial coverage of superficial second-degree burns is significantly lower in AM than in SD group (P < .001) and also those of deep second-degree burns (P < .001). Application was painless in AM than SD group (P < .001). State of pain in-between application shows significant difference (P < .001). Application of AM was comfortable to the attending doctor (P < .001). Significant activity of the patients was observed during treatment (P < .01) with AM. AM was accepted by the patients or parents (P < .001). This study indicates that radiation-sterilized, oven-dried AM is a better treatment option because its use reduces hospital stay and the number of dressing changes. Epithelialization of the wound is quicker. The use of AM is painless and odorless. The procedure is easy and comfortable to the doctor, and it is well accepted. Most of the patients remain ambulatory during treatment.

Validation of a vertical progression porcine burn model.

Abstract: A major potential goal of burn therapy is to limit progression of partial- to full-thickness burns. To better test therapies, the authors developed and validated a vertical progression porcine burn model in which partial-thickness burns treated with an occlusive dressing convert to full-thickness burns that heal with scarring and wound contraction. Forty contact burns were created on the backs and flanks of two young swine using a 150 g aluminum bar preheated to 70°C, 80°C, or 90°C for 20 or 30 seconds. The necrotic epidermis was removed and the burns were covered with a polyurethane occlusive dressing. Burns were photographed at 1, 24, and 48 hours as well as at 7, 14, 21, and 28 days postinjury. Full-thickness biopsies were obtained at 1, 4, 24, and 48 hours as well as at 7 and 28 days. The primary outcomes were presence of deep contracted scars and wound area 28 days after injury. Secondary outcomes were depth of injury, reepithelialization, and depth of scars. Data were compared across burn conditions using analysis of variance and χ(2) tests. Eight replicate burns were created with the aluminum bar using the following temperature/contact-time combinations: 70/20, 70/30, 80/20, 80/30, and 90/20. The percentage of burns healing with contracted scars were 70/20, 0%; 70/30, 25%; 80/20, 50%; 80/30, 75%; and 90/20, 100% (P = .05). Wound areas at 28 days by injury conditions were 70/20, 8.1 cm(2); 70/30, 7.8 cm(2); 80/20, 6.6 cm(2); 80/30, 4.9 cm(2); and 90/20, 4.8 cm(2) (P = .007). Depth of injury judged by depth of endothelial damage for the 80/20 and 80/30 burns at 1 hour was 36% and 60% of the dermal thickness, respectively. The depth of injury to the endothelial cells 1 hour after injury was inversely correlated with the degree of scar area (Pearson's correlation r = -.71, P < .001). Exposure of porcine skin to an aluminum bar preheated to 80°C for 20 or 30 seconds results initially in a partial-thickness burn that when treated with an occlusive dressing progresses to a full-thickness injury and heals with significant scarring and wound contracture.

A new method for estimation of involved BSAs for obese and normal-weight patients with burn injury

Abstract: An accurate measurement of BSA involved in patients injured by burns is critical in determining initial fluid requirements, nutritional needs, and criteria for tertiary center admissions. The rule of nines and the Lund-Browder chart are commonly used to calculate the BSA involved. However, their accuracy in all patient populations, namely obese patients, remains to be proven. Detailed BSA measurements were obtained from 163 adult patients according to linear formulas defined previously for individual body segments. Patients were then grouped based on body mass index (BMI). The contribution of individual body segments to the TBSA was determined based on BMI, and the validity of existing measurement tools was examined. Significant errors were found when comparing all groups with the rule of nines, which overestimated the contribution of the head and arms to the TBSA while underestimating the trunk and legs for all BMI groups. A new rule is proposed to minimize error, assigning 5% of the TBSA to the head and 15% of the TBSA to the arms across all BMI groups, while alternating the contribution of the trunk/legs as follows: normal-weight 35/45%, obese 40/40%, and morbidly obese 45/35%. Current modalities used to determine BSA burned are subject to significant errors, which are magnified as BMI increases. This new method provides increased accuracy in estimating the BSA involved in patients with burn injury regardless of BMI.

Surgical burn wound infections and their clinical implications

Abstract: Typically, burn wound infections are classified by the organisms present in the wound within the first several days after injury or later by routine surveillance cultures. With universal acceptance of early excision and grafting, classification of burn wound colonization in unexcised burn wounds is less relevant, shifting clinical significance to open burn-related surgical wound infections (SWIs). To better characterize SWIs and their clinical relevance, the authors identified the pathogens responsible for SWIs, their impact on rates of regrafting, and the relationship between SWI and nosocomial infection (NI) pathogens. Epidemiologic and clinical data for 71 adult patients with ≥ 20% TBSA burn were collected. After excision and grafting, if a grafted site had clinical characteristics of infection, a wound culture swab was obtained and the organism identified. Surveillance cultures were not obtained. SWI pathogen, anatomic location, postburn day of occurrence, and need for regrafting were compiled. A positive culture obtained from an isolated anatomic location at any time point after excision and grafting of that location was considered a distinct infection. Pathogens responsible for NIs (urinary tract infections, pneumonia, bloodstream and catheter-related bloodstream infections, pseudomembranous colitis, and donor site infections) and their postburn day were identified. The profiles of SWI pathogens and NI pathogens were then compared. Of the 71 patients included, 2 withdrew, 6 had no excision or grafting performed, and 1 had incomplete data. Of the remaining 62 patients, 24 (39%) developed an SWI. In these 24 patients, 70 distinct infections were identified, of which 46% required regrafting. Candida species (24%), Pseudomonas aeruginosa (22%), Serratia marcescens (11%), and Staphylococcus aureus (11%) comprised the majority of pathogens. Development of an SWI with the need for regrafting increased overall length of stay, area of autograft, number of operative events, and was closely associated with the number of NIs. The %TBSA burn and depth of the burn were the main risk factors for SWI with need for regrafting. The SWI pathogen was identified as an NI pathogen 56% of the time, with no temporal correlation between shared SWI and NI pathogens. SWIs are commonly found in severely burned patients and are associated with regrafting. As a result, patients with SWIs are subjected to increased operative events, autograft placement, and increased length of hospitalization. In addition, the presence of an SWI may be a risk factor for development of NIs.

Local and systemic treatments for acute edema after burn injury: a systematic review of the literature

Abstract: Burn injury is a complex trauma that results in local and generalized edema. Edema fluid limits the exchange of vital nutrients in healing the burn wound and will compromise vulnerable tissues. Although the importance of edema control in tissue salvage is recognized, treatments targeted at edema control have not been critically reviewed. Thus, the objective was to assess the evidence for the effectiveness of local and systemic treatments for edema management immediately after burn injury. Searches for randomized controlled trials were conducted of online databases, research and thesis registers, and grey literature repositories. Handsearches included journals, bibliographies, and proceedings. Authors were contacted to clarify and submit extra study details. Eight studies were included. Management of acute major burn resuscitation including colloid increases lung edema (mean difference [MD], 0.04 ml/ml alv vol; 95% confidence interval [CI], 0.03-0.04; P < .00001) and mortality (risk ratio, 3.67; 95% CI, 1.16-11.58; P = .03). Continuous administration of vitamin C in acute burn resuscitation reduces local wound edema (MD, -3.50 ml/g; 95% CI, -4.63 to -2.37; P < .00001) and systemic fluid retention (MD, -8.60 kg; 95% CI, -13.47 to -3.73; P = .0005). Local acute hand burn edema is reduced (MD, -29.00 ml; 95% CI, -53.14 to -4.86; P = .02), and active hand motion increased (MD, 10.00°; 95% CI, 4.58-15.42; P = .0003), using electrical stimulation with usual physiotherapy. Each review outcome was based on a small single-facility study. Thus, future research in intervention for acute burn edema must focus on multicentre trials and validation of outcome measures in the burn population.

Select practices in management and rehabilitation of burns: a survey report.

Abstract: The purpose of this study is to document the organization and current practices in physical rehabilitation across burn centers. An online survey developed for the specific purposes of this study sought information regarding a) logistics of the burn center; b) inpatient and outpatient treatment of patients with burn injury; and c) specific protocols in the treatment of a few complications secondary to burn injuries. Of the 159 responses received, 115 were received from the United States, 20 from Australia, 16 from Canada, and 7 from New Zealand. The overall sample included responses from 76 physical therapists (PTs) and 78 occupational therapists. Seventy-three of those surveyed considered themselves primarily a burn therapist. Nurses (86%) were reported as primarily responsible for wound care of inpatients, followed by wound care technicians (24%). Ninety-seven percent of the therapists reported following their own treatment plans. The trunk and areas of head and neck were treated by both PTs and occupational therapists, whereas the lower extremities continue to be treated predominantly by PTs. Some common practices regarding treatment of a few complications secondary to burn injuries such as splinting to prevent contractures, treatment of exposed or ruptured extensor tendons, exposed Achilles tendons, heterotopic ossification, postoperative ambulation, conditioning, scar massage, and use of compression garments are described. Opportunities exist for 1) developing a common document for practice guidelines in physical rehabilitation of burns; and 2) conducting collaborative studies to evaluate treatment interventions and outcomes.

Hydrogen-rich saline protects against acute lung injury induced by extensive burn in rat model.

Abstract: Hydrogen has been reported to selectively quench detrimental reactive oxygen species, particularly hydroxyl radical, and to prevent myocardial or hepatic ischemia/reperfusion injury in multiple models. The aim of this study is to investigate whether hydrogen protects against severe burn-induced acute lung injury in rats. Rats were divided into four groups: sham plus normal saline, burn injury plus normal saline, burn injury plus hydrogen-rich saline, and burn injury plus edaravone. Animals were given full-thickness burn wounds (30% TBSA) using boiling water, except the sham group that was treated with room temperature water. The rats in hydrogen group received 5 ml/kg of hydrogen-rich saline, sham and burn controls obtained the same amount of saline, and the edaravone group was treated with 9 mg/kg of edaravone in saline. Lactated Ringer's solution was given at 6 hours postburn. The lungs were harvested 12 hours postburn for laboratory investigations. Severe burns with delayed resuscitation rapidly caused lung edema and impaired oxygenation in rats. These dysfunctions were ameliorated by administration of hydrogen-rich saline or edaravone. When compared with the burn injury plus normal saline group, hydrogen-rich saline or edaravone group significantly attenuated the pulmonary oxidative products, such as malondialdehyde, carbonyl, and 8-hydroxy-2'-deoxyguanosine. Furthermore, administration of hydrogen-rich saline or edaravone dramatically reduced the pulmonary levels of pulmonary inflammation mediators and myeloperoxidase. Intraperitoneal administration of hydrogen-rich saline improves pulmonary function by reducing oxidative stress and inflammatory response in severe burn-induced acute lung injury.

Management of ocular conditions in the burn unit: thermal and chemical burns and Stevens-Johnson syndrome/toxic epidermal necrolysis.

Abstract: Patients in burn intensive care units suffer from potentially life-threatening conditions including thermal or chemical burns and Stevens-Johnson syndrome/toxic epidermal necrolysis. There is often involvement of the ocular surface or adnexal structures which may be present at the time of hospital admission or may develop later in the hospital course. This article will describe the types of ocular burns, the mechanisms and manifestations of Stevens-Johnson syndrome/toxic epidermal necrolysis, the circumstances that may influence outcome, and acute and long-term treatment strategies, including new and evolving options.

Evaluation of the usefulness of two established pain assessment tools in a burn population.

Abstract: Evaluation of burn pain and its successful treatment has proven challenging for all staff who care for burn patients. As successful pain relief is important for full physical and psychological recovery, accurate assessment of burn pain is essential. The authors sought to prospectively evaluate two previously validated pain scales, the Critical Care Pain Observation Tool (CCPOT) and the Adult Nonverbal Scale (ANVS), in our burn population and compare them with patients' reports of pain. Both scales include nonverbal behaviors that are numerically scored and can be used in communicative as well as noncommunicative patients. Thirty-eight patients underwent 225 paired pain assessments. Assessments were compared with patients' self reports of pain using the numeric rating scale (NRS) and the visual analog scale (VAS). Performance of the scales was evaluated by psychometric analysis. Logistic regression was used to compare pain scores with patient demographics, burn demographics, and administered analgesia. Both CCPOT and ANVS were internally consistent and able to discriminate pain intensity. However, these scales had poor interrater reliability. Furthermore, they correlated poorly with patients' self-reports of pain per the NRS and VAS pain scale scores. By logistic regression, all the pain scales showed a decrease in patient pain corresponding to the length of time after the burn. Otherwise, pain was not related to any patient demographics or evaluator experience. The size of burn was the only burn-related variable significantly associated with the pain scores, and this was only for the scores obtained with the CCPOT scale. In addition, only CCPOT and ANVS scales correlated with administered analgesia during hospitalization. The authors conclude that CCPOT and ANVS do not accurately assess pain in burn patients. However, it seems that the staff may administer analgesia based on several nonverbal clues encompassed in these scales. Future studies should address nonverbal signs of pain in burn patients. These signs could then be used in pain scales to target burn patient pain more effectively.

TRPV channel expression in human skin and possible role in thermally induced cell death.

Abstract: Cell death via necrosis and apoptosis is a hallmark of deep dermal to full-thickness cutaneous burn injuries. Keratinocytes might act as thermosensory cells that transmit information regarding ambient temperature via heat-gated transient receptor potential vanilloid (TRPV) ion channels. The aim of this study was to investigate the distribution of TRPV1, 2, 3, and 4 in uninjured and thermally burned skin. The authors investigated warmth-evoked currents in keratinocytes and cell kinetics of thermally injured keratinocytes in culture with agonists and antagonists of TRPV channels. Specimens of uninjured normal skin and discarded tissue of thermally injured skin were stained for TRPV1, 2, 3, and 4. Cultured primary human keratinocytes were heated for 5 minutes at the following temperatures: 37°C (control), 42°C, and 60°C and thereafter cultured for 24 or 48 hours at 37°C. Thermally stressed cells were treated with TRPV antagonists capsazepine or ruthenium red, and cell viability capacity was determined. TRPV1, TRPV2, TRPV3, and TRPV4 immunoreactivity was differentially identified on basal and suprabasal keratinocytes of healthy human skin. Patch clamp analysis showed a functional response of human keratinocytes at temperatures >40°C. Cell death of keratinocytes after heating at 42°C was reduced by 15 and 5% with ruthenium red and by 20 and 30% by capsazepine at 24 and 48 hours, respectively. Cell death after treatment at 60°C was significantly reduced at 24 hours with capsazepine (22%) or ruthenium red (18%) but only minimally affected after 48 hours postinjury. Interaction with TRPV channels on keratinocytes may offer a new strategy to counteract cell death after thermal injury.

Inflammatory response in multiple organs in a mouse model of acute alcohol intoxication and burn injury.

Abstract: This study characterized the inflammatory response after burn injury and determined whether ethanol (EtOH) intoxication at the time of burn injury influences this response. To accomplish this, male mice were gavaged with EtOH (2.9 g/kg) 4 hours before 12 to 15% TBSA sham or burn injury. Mice were killed on day 1 after injury; blood, small intestine, lung, and liver were collected to measure interleukin (IL)-6, IL-10, IL-18, and Monocyte chemotactic protein-1 (MCP-1) levels. In addition, neutrophil infiltration, myeloperoxidase activity, and edema formation were also measured in the small intestine, lung, and liver. There was no difference in the inflammatory markers in the small intestine, lung, and liver in mice receiving either sham or burn injury alone except IL-6 that was increased in all four tissue compartments after burn injury alone. However, when compared with EtOH or burn injury alone, EtOH combined with burn injury resulted in a significant increase in cytokines, neutrophil infiltration, myeloperoxidase activity, and edema in the small intestine, liver, and lung tissue. Furthermore, a significant increase in IL-6 and MCP-1 was observed in circulation after EtOH intoxication and burn injury compared with either EtOH intoxication or burn injury alone; no other cytokines were detected in circulation. These findings suggest that acute EtOH intoxication exacerbates the inflammatory response after burn injury.

Employment Outcomes After Burn Injury: A Comparison of Those Burned at Work and Those Burned Outside of Work

Abstract: This study compares employment rates and barriers to return to work in subjects burned at work with those burned outside of work. Further, this study examines the influence of electrical etiology on return to work outcomes. The electronic records of burn survivors treated at a Regional Burn Center outpatient clinic from 2001 to 2007 were retrospectively reviewed. Inclusion criteria included employment at the time of burn injury and age of 18 years or older. Demographic and medical data were collected. Documentation of barriers to return to work was reviewed and classified into eight categories. Return to employment was grouped into four time intervals: 0 to 3, 3 to 6, 6 to 12, and greater than 12 months after injury. Logistic regression analysis was used to determine predictors of unemployment at greater than 1 year for subjects burned at work, outside of work, and those burned at work without electric injury. The authors identified 197 patients for inclusion in the study. Their age was 37 ± 0.8 years (mean ± SEM), and TBSA burned was 16 ± 1%. Fifty percent of subjects were burned at work. Electric etiology was seen only in those burned at work (n = 24). Forty-four percent (n = 43) of subjects injured at work remained unemployed at 1 year compared with 22% (n = 22) of subjects injured outside of work. The most frequent employment barriers included pain (72%), neurologic problems (62%), and psychiatric problems (53%) for those burned at work; and pain (63%), neurologic problems (59%), and impaired mobility (54%) for those burned outside of work. Significant predictors of unemployment at greater than 12 months included burn at work, pain, impaired mobility, other medical problems, and inpatient rehabilitation (P < .05). When the electrical injury subjects are removed from the analysis, significant predictors of unemployment at 12 months include burn at work, pain, inpatient rehabilitation, and length of stay (P < .05). Burn survivors experience multiple complex barriers in returning to work. Burn at work is a significant predictor of unemployment at 1 year even after controlling for electric etiology. Further study is required to better understand the influence of work setting on employment outcomes.

The relationship of early pain scores and posttraumatic stress disorder in burned soldiers.

Abstract: Early acute pain after injury has been linked to long-term patient outcomes, including the development of posttraumatic stress disorder (PTSD). Several studies have identified a negative correlation between early anesthetic/analgesic usage and subsequent development of PTSD. This retrospective study examined the relationship between early acute pain and severity of PTSD symptoms in soldiers with burn injuries. Of the soldiers injured in Overseas Contingency Operations who had pain scores recorded at admission to the Emergency Department, 113 had burn injuries. Of those transferred to the military burn center, 47 were screened for PTSD using the PTSD checklist-military (PCL-M) survey at least 1 month after injury. Soldiers with mild, moderate, and severe pain scores had similar Injury Severity Scores and TBSA burned (P = .339 and .570, respectively). However, there were significant differences in PCL-M scores between the mild and severe pain groups (P = .017). The pain levels positively correlated with the PCL-M score (rho = 0.41, P = .004) but not with injury severity markers (Injury Severity Score and TBSA). These data suggest that early acute pain may be related to increased PCL-M score and PTSD symptoms. The intensity of pain was not related to the injury severity, and these data also show no association between pain intensity and physiological measures, including blood pressure and heart rate. However, this is a small sample size, and many other factors likely influence PTSD development. Further study is necessary to explore the relationship between early acute pain and subsequent development of PTSD symptoms.

Comic Books Can Educate Children About Burn Safety in Developing Countries

Abstract: Burns in developing countries account for significant morbidity and many occur within the pediatric population. This study investigates whether a comic book can increase burn awareness in primary school age children, both domestically and abroad. Based on demographic data regarding pediatric burns in developing nations, a comic book was developed to educate primary school age children on key risk factors regarding burn safety, including teaching children to not touch active stoves, not to light fireworks without supervision, and to "stop, drop, and roll" after burn injury. Students, aged 5 to 7 years, in both West Virginia, United States (N = 74), and West Bengal, India (N = 39), answered a three-question survey regarding these issues both before and after reading the comic book. Groups were compared using Fisher's exact test and significance was defined as P < .05. Initially, students answered 67.8 and 66.9% of the questionnaire correctly overall in West Virginia and West Bengal, respectively. These scores improved to 81.6 and 99.1% (P < .01 for each group), respectively, after reading the comic as a class. Specifically, there were significant increases in both groups for the questions regarding avoiding hot stoves (P < .01) and fireworks (P < .01). The lesson required 30 minutes total per class. The teachers reported that students enjoyed reading the comic and were engaged during the sessions. This study demonstrates that a comic book has value in teaching children about burn awareness. Comic books may be a cost-effective method as an outreach tool for children.

Development of a combined radiation and burn injury model.

Abstract: Combined radiation and burn injuries are likely to occur after nuclear events, such as a meltdown accident at a nuclear energy plant or a nuclear attack. Little is known about the mechanisms by which combined injuries result in higher mortality than by either insult alone, and few animal models exist for combined radiation and burn injury. Herein, the authors developed a murine model of radiation and scald burn injury. Mice were given a single dose of 0, 2, 4, 5, 6, or 9 Gray (Gy) alone, followed by a 15% TBSA scald burn. All mice receiving <4 Gy of radiation with burn survived combined injury. Higher doses of radiation (5, 6, and 9 Gy) followed by scald injury had a dose-dependent increase in mortality (34, 67, and 100%, respectively). Five Gy was determined to be the ideal dose to use in conjunction with burn injury for this model. There was a decrease in circulating white blood cells in burn, irradiated, and combined injury (5 Gy and burn) mice by 48 hours postinjury compared with sham (49.7, 11.6, and 57.3%, respectively). Circulating interleukin-6 and tumor necrosis factor-α were increased in combined injury at 48 hours postinjury compared with all other treatment groups. Prolonged overproduction of proinflammatory cytokines could contribute to subsequent organ damage. Decreased leukocytes might exacerbate immune impairment and susceptibility to infections. Future studies will determine whether there are long lasting consequences of this early proinflammatory response and extended decrease in leukocytes.

Venous Thromboembolism in Thermally Injured Patients: Analysis of the National Burn Repository

Abstract: Currently, there is a paucity of information on the incidence of venous thromboembolism (VTE) in thermally injured patients. By using the National Burn Repository, the authors examined the incidence and risk factors for VTE after burn injury. The National Burn Repository was queried to identify adult burn patients treated between 1995 and 2007. Patients who died within 24 hours of admission, with length of stay less than 1 day, or who had nonthermal injuries were excluded. Bivariate statistics were generated to identify risk factors associated with VTE. Logistic regression was used to identify risk factors that were independently associated with VTE. The incidence of VTE in thermally injured patients was 0.6%. VTE incidence increased to 1.2% when patients required intensive care unit (ICU) admission or when patients had >10%TBSA burns. Patients with 40 to 59% TBSA burns were at highest risk for VTE (2.4%). TBSA burned, ICU days, and the number of operations were independently associated with increased VTE risk, when controlling for other risk factors. We created a predictive model for VTE, which included all variables that were known or could be derived at the time of admission. The combination of increased TBSA burned and need for ICU admission was strongly predictive (c-statistic = 0.82) of patients who developed VTE. At admission, the combination of increased TBSA burned and need for ICU admission predicts patients who develop VTE with high discrimination. Patients with these risk factors may benefit from early, aggressive VTE prophylaxis.

Emerging Gram-Negative Infections in Burn Wounds

Abstract: Gram-negative infection remains a major contributor to morbidity, mortality, and cost of care. In the absence of comparative multinational epidemiological studies specific to burn patients, we sought to review literature trends in emerging Gram-negative burn wound infections within the past 60 years. Mapping trends in these organisms, although in a minority compared with the six "ESKAPE" pathogens currently being targeted by the Infectious Diseases Society of North America, would identify pathogens of increasing concern to burn physicians in the near future and develop patient profiles that may predict susceptibility to infection. Aeromonas hydrophila infection was identified as the emerging pathogen of note, constituting 76% of the identified publications. A. hydrophila constituted 96% of Aeromonas spp. isolates (mortality 10.7%). The following patient profile indicated predisposition to Aeromonas infection: mean age (mean 33.7 years, range 17 ≤ R ≤ 80, SD = 15.6); TBSA (mean 41.1%, range 8% ≤ R ≤ 80%, SD = 15.2); full-thickness skin burns (mean 27.7%, range 3% ≤ R ≤ 60%, SD = 16.6); and a male predominance (81.3%). Other pathogens included Stenotrophomonas maltophilia Vibrio spp., Chryseobacterium spp., Alcaligenes xylosoxidans, and Cedecia lapigei. Arresting the thermal injury by untreated water was the common predisposing factor. These emerging infections clearly constitute a minority of Gram-negative bacterial infections in burn patients at present. However, these are the infections most likely to pose significant clinical challenge because of the high prevalence of multidrug resistance, rapid acquisition of multidrug resistance, high mortality, and ubiquity in the natural environment. This article therefore presents a rationale for understanding and recognizing the role of these emerging infections in burn patients.