What You Need to Know About: Assessment of Burns and Initial Management.

Major burns: Part 1. Epidemiology, pathophysiology and initial management

Major burns: part 2. Anaesthesia, intensive care and pain management

Introduction:The UK government introduced lockdown measures on 23 March 2020 due to the first wave of the COVID-19 pandemic. A restructuring of clinical services was necessary to accommodate mandatory changes while also maintaining the best possible standards for patient care. The present study explored the initial management, follow-up and patient-reported outcomes of burn injuries <15% total body surface area (TBSA) during the height of the COVID-19 lockdown at a tertiary burns centre.Methods:A retrospective review of all adult patients with burns <15% TBSA during the national lockdown (23 March 2020 to 10 May 2020) was undertaken at The Queen Elizabeth Hospital Birmingham (QEHB), UK. All referrals from non-QEHB telemedicine (external) or QEHB emergency (internal) departments were reviewed for management, length of hospital stay and pattern of follow-up (ward attender, self-care, community or outreach nurses). A telephone survey based on a structured questionnaire was conducted to establish patients’ satisfaction.Results:A total of 84 burn patients were included in the study. The mean age was 39 years (age range = 19–91 years) and the male:female ratio was 4:1. Patients were managed non-operatively (n = 69, 82%) or operatively (n = 15, 18%). Patients attended the ward attender acute burns clinic only once (n = 36, 61%). The telephone survey captured 70% (n = 59) of the study population and 57 patients (97% of respondents) were pleased with the ongoing care and burn healing.Conclusion:The integration of patient led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for small burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with the burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period.Lay SummaryThe lockdown measures due to the first wave of COVID-19 pandemic affected the way we manage all medical emergencies including burns. The initial management, follow-up and patient satisfaction for small burn injuries during lockdown has not been reported previously. The aim of this study is to examine the outcome in terms of small burn management, hospital stay, number of clinic reviews, healing and patient satisfaction during the lockdown period in a burn centre in the UK. This would look at the need for operations and whether patients stayed longer if they required an intervention. We reviewed adult patients with small burns during the national lockdown (23 March 2020 to 10 May 2020) at The Queen Elizabeth Hospital Birmingham (QEHB). All referrals from telemedicine, referral system (external) or QEHB (internal) were reviewed for management, length of hospital stay and pattern of follow-up. Patients were reviewed in the acute burns clinic and given advice for burn management and dressing for self-care. Follow-up was mostly via email (telemedicine) A telephone survey based on a structured questionnaire was conducted to find out patients’ satisfaction. Four times more men than women had small burns during the lockdown period. The average age was 39 years. The majority were managed conservatively with dressings (82%) and a small proportion required an operation (18%). Most patients attended the acute burns clinic only once (61%) for initial assessment and management. The telephone survey captured 70% of patient and 97% of respondents were pleased with the care and burn healing. The integration of patient-led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period.

Introduction Burn injuries pose a significant healthcare burden, with a substantial number of patients requiring hospital or emergency room treatment each year. Janzekovic generated renewed interest in early excision in 1970 when she reintroduced the concept of tangential excision of the necrotic tissue and immediate resurfacing with split-thickness skin grafts. Timely excision and grafting are now the standard surgical management of deep burns. However, existing studies lack comprehensive verification and fail to specify optimal operative periods for patients with third-degree burns. To address this gap, our objective was to determine the optimal skin graft operative days for burn surgery in patients suffering from third-degree burns. Methods In this retrospective analysis, we isolated a group of burn patients who met the criteria for surgical burn repair, including burns injuries greater than 20% total body surface area (18-64 years old) or greater than 15% total body surface area (65-89 years old). The patients were categorized based on the percentage of third-degree burns, and an area under the curve (AUC) analysis was performed to evaluate the correlation between earlier surgical intervention and survival outcomes (AUC&amp;gt;0.5 with a p&amp;lt; 0.05 were considered significant. Results A total of 163 patients fitting the criteria were included in the ten-year period 2012-2022. Our results demonstrated that earlier operative days were a significant predictor of mortality for patients with third-degree burn percentages within the ranges of 0.0-9.9% TBSA (n=58, AUC=0.5740, p=0.0002), 10-19.9% TBSA (n=38, AUC=0.5572, p=0.0043), and 30-39.9% TBSA (n=12, AUC=0.7272, p=0.0106). Interestingly, the operative day for patients with 20-29.9% TBSA burns did not significantly predict mortality (n=34, AUC=0.275, p=0.0112). Due to the limited number of patients with greater than 40% TBSA third-degree burns (n=21), further research with a larger sample size is required for accurate data analysis for that category. Conclusions In summary, our retrospective analysis highlights the crucial role of operative timing in treating third-degree burns. We found a significant association between earlier surgical intervention and better survival outcomes for patients with burns covering less than 40% TBSA. While further research is needed for patients with greater than 40% TBSA burns, our findings provide valuable insights into optimizing surgical timing to enhance patient care and reduce mortality in burn management. Applicability of Research to Practice Our research findings offer practical implications for healthcare practitioners. We emphasize the importance of timely surgical intervention for patients with third-degree burns covering less than 40% total body surface area (TBSA). Specifically, our study recommends performing skin graft surgery within three days of admission, when feasible for improved patient outcomes and reduced mortality rates in burn management.

Introduction:Estimation of total body surface area (TBSA) burnt and burn depth are among the most central parts of acute burn assessment/treatment as they determine the level and type of care needed. Traditional methods for determining burn extent on admission often lead to inaccurate estimations, especially in paediatric or overweight patients.Aim:To compare %TBSA at admission with validated %TBSA at discharge in different patient populations to investigate if significant over- or underestimation occurs.Method:This retrospective observational study is based on a patient registry of all the patients (n = 863) treated at the Uppsala University Hospital’s Burn Centre between 2010 and 2018. The patients were divided into subgroups based on age, gender, body mass index (BMI) and validated burn extent. The %TBSA estimated at admission was compared to the validated %TBSA in all groups separately.Results:As has been published before, we also found that the %TBSA in paediatric patients was more often overestimated as were the smaller injuries, whereas larger injuries were often underestimated. BMI did not clearly affect the estimations and there was no clear difference between the genders in estimated %TBSA.Conclusion:Inaccurate estimations of %TBSA are common, particularly for paediatric patients and small or large injuries. We recommend a careful accurate approach when calculating %TBSA in the paediatric population to avoid over- and under-resuscitation. Increased education and training are recommended to improve accurate estimation in the future.Lay SummaryThe correct estimation of both extent and depth of burn is very important. This assessment guides the lever of care needed, the necessary amount of fluid resuscitation, the predicted outcome and more. It has been proven notably difficult to correct assess, especially the extent of a burn. Despite different tools as the “Rule of Nine” (body area divided into multiples of 9% body surfaces), the “Rule of Palm” (Patient’s palm, fingers included, approximates 1% of body surfaces), the Lund & Browder chart (detailed, age-specific body areas) and different more technical solutions. Often inaccurate estimations are done which thus affect the treatment. This depth and extent estimation is usually performed when the patient is admitted. However, it is known that burns change appearance during the first few days of care. In our Burn Center we have also performed this estimation when the patient is discharged. At this point it is known the true extent and depth of the initial burn. In this retrospective observational study, we compared the burn extent estimated on admission with the one on discharge to investigate whether the initial assessment is accurate. This study highlights the issue of frequent inaccurate burn extent estimations, especially in subgroups as overweight patient or pediatric patients.

Introduction The percent total body surface area (TBSA) burned is a critical determinant of required level of care, initial management, and prognosis in burn patients. The current gold standard for TBSA estimation, the Lund-Browder (LB) chart, requires familiarity with its construction and is not necessarily feasible in the field. Recently, many mobile applications (apps) have been developed to calculate TBSA. However, few have been rigorously validated. In this study, we present a novel TBSA calculator app developed for first responders and validate its accuracy. Methods Infant, pediatric, and adult mannequins were fabricated with eight simulated burns (Figure 1). Thirteen first- and second-year medical students with no experience in burn care were tasked with calculating the TBSA of these burns using both LB and our app. Students then completed a questionnaire to assess their experience using both methods. A paired t-test was used to compare absolute mean differences in TBSA between student estimates using both methods and those of two expert burn surgeons using LB. Results The app performed significantly better than LB for three of the simulated burns with mean TBSA values better approximating expert values (Burn 2 p = 0.002, Burn 5 p = 0.039, and Burn 8 p = 0.006). For the remaining five simulated burns, there was no significant difference in performance between the two methods (Table 1). Students overwhelmingly reported the app was easier and faster to use (92%, n = 12), and universally preferred it over LB for the calculation of TBSA. Students cited the visual nature of the app interface and the lack of need for manual calculations as reasons for their preference. Conclusions The app offered an easier, faster, and more accurate alternative to LB for calculation of TBSA among inexperienced users. Future directions include replicating this study with first responders. Applicability of Research to Practice Our app may be a valid alternative to LB for TBSA calculation.

Myth: silver sulfadiazine is the best treatment for minor burns.

Early excision with autograft-allograft closure is standard in severe burn management. Cadaver skin is associated with risks such as antigenicity, infection, and limited availability and shelf life. Previous studies have shown that Integra is safe to use in burns of <20% total body surface area. However, the suitability of its use in large burns (>50% total body surface area), its effects on postburn hypermetabolism, and the long-term cosmetic and functional results have not yet been evaluated. Twenty children with an average burn size of 73 +/- 15% total body surface area (71 +/- 15% full-thickness burn) were randomized to be treated with either Integra or with autograft-allograft technique. Outcome measures such as length of hospital stay, mortality, incidence of infection and sepsis, acute phase protein levels, and muscle fractional synthetic rate were compared between and within groups during the acute stay (admission to discharge). Outcome measures such as resting energy expenditure, body composition data (measured by dual-energy radiograph absorptiometry), cardiac function indexes, and number of reconstructive procedures were compared during acute hospital stay and at long-term follow-up (up to 2 yrs postinjury). Scar evaluation was performed at long-term follow-up. There were no significant differences between Integra and controls in burn size (70 +/- 5% vs. 74 +/- 4% total body surface area), mortality (40% vs. 30%), and length of stay (41 +/- 4 vs. 39 +/- 4 days). In the short term, resting energy expenditure significantly decreased (p < .01), and serum levels of constitutive proteins significantly increased (p < .03) in the Integra group compared with controls. Long-term follow-up revealed a significant increase in bone mineral content and density (24 months postburn, p < .05), as well as improved scarring in terms of height, thickness, vascularity, and pigmentation (12 months and 18-24 months, p < .01) in the Integra group. Integra can be used for immediate wound coverage in children with severe burns without the associated risks of cadaver skin.

Introduction Published information on the relationship between patient characteristics such as total body surface area (TBSA) of burn on number of procedures and length of stay (LOS) is not widely available in the United States. Clinical expertise assumes a “rule of thumb” of 1 day stay per percentage TBSA, but deviations based on burn and patient characteristics is rarely explored. The American Burn Association NBR version 8.0 (2002–2011) was analyzed to understand the relationship between key patient and burn characteristics for surviving, severe (TBSA 10–60%) burn patients and number of procedures or LOS. Methods Outcomes include the number of procedures autograft, debridement, and excision procedures and LOS. Independent variables considered were TBSA, TBSA of partial-thickness and full-thickness (FT) burn, age (linear, squared and cubed to account for non-linearity), hospital-acquired infection (HAI), other infection, inhalation injury, female gender and diabetes status. Statistical regression models were developed to control for the independent variables and predict the number of procedures and LOS based on such characteristics. Results Among 21,175 surviving burn patients (TBSA 10–60%), the mean age was 33 years old, and the mean TBSA was 19.9%. Number of excision and autografting procedures increased with TBSA. All independent variables were retained in the LOS model. After adjusting for gender, age and comorbidities, predicted LOS for adults (18+) was 16.4, 29.5, 42.7 and 56.0 days for 10%, 20%, 30% and 40% TBSA respectively. Similarly, predicted LOS for pediatrics (age&amp;lt; 18) was 12.9, 26.0, 28.6 and 55.4 days for each TBSA group, respectively. Conclusions When considering all independent variables, the LOS per percent TBSA is estimated at approximately 1.12 days for adults and 1.01 for pediatrics. However, when considering patient (age, comorbidity status) and burn (burn depth, TBSA) characteristics, the observed LOS could vary by 66% more, as seen with detailed investigations into trends for patients with TBSA 20%. Using the predictive equations from this study, burn centers can generate tailored rule-of-thumb estimates for LOS/%TBSA that better reflect the influence of factors beyond burn center practice patterns. Applicability of Research to Practice

The estimated 32,600,000 fires that occur annually in the United States produce over 300,000 injuries and 7,500 deaths. Ten percent of hospitalized burn victims die as a direct result of the burn. Initial evaluation and management of the burn patient are critical. The history should include the burn source, time of injury, burn environment, and combustible products. The burn size is best estimated by the Lund and Browder chart, and the burn depth is determined by clinical criteria. Pulmonary involvement and circumferential thoracic or extremity burns require detection and aggressive treatment to maintain organ viability. Hospitalization is usually necessary for adults with burns larger than 10% of the total body surface area (TBSA) or children with burns larger than 5% of TBSA. Major burns, those of 25% or more of TBSA or of 10% or more of full thickness, should be considered for treatment at a burn center, as well as children or elderly victims with burns of greater than 10% TBSA. Lactated Ringer's solution, infused at 4 ml/kg/% TBSA, is generally advocated for initial fluid restoration. After the acute phase (48 hours), replacement of evaporative and hypermetabolic fluid loss is necessary. These losses may constitute 3 to 5 liters per day for a 40% to 70% TBSA burn. Blood transfusion is often required because of persistent loss of red blood cells (8% per day for about ten days). Many electrolyte abnormalities may occur in the first two weeks. Pulmonary injury commonly is lethal. Circumoral burns, oropharyngeal burns, and carbonaceous sputum are indicative of inhalation injury, but arterial blood gas determinations, fiberoptic bronchoscopy, and xenon lung scans are useful for confirming the diagnosis. Humidified oxygen, intubation, positive-pressure ventilation, and pulmonary toilet are the mainstays of therapy for inhalation injury. Wound care is initially directed at preservation of vital function by escharotomy, if restrictive eschar impairs ventilatory or circulatory function. Antibacterial agents may be applied to the burn, but invasive sepsis, defined as greater than 10(5) organisms per gram of tissue with invasion of subjacent viable tissue, requires systemic antibiotic therapy. Wound debridement is done by daily hydrotherapy, tangential excision, chemicals, primary excision, and grafting, tailoring the technique to the individual burn.(ABSTRACT TRUNCATED AT 400 WORDS)

1. Ramin Jamshidi, MD* 2. Thomas T. Sato, MD† 1. *The Pediatric Surgeons of Phoenix, Phoenix, AZ. 2. †Division of Pediatric Surgery, Children’s Specialty Group, Children’s Hospital of Wisconsin, and The Medical College of Wisconsin, Milwaukee, WI. Burns are a frequent cause of injury in children and adolescents. Clinicians should be familiar with initial assessment and management of burns and be capable of identifying burn injuries appropriate for referral to a regional burn center. After reading this article, readers should be able to: 1. List 3 types of burn injuries. 2. Describe the initial evaluation of a burned child in terms of burn depth, size, and associated injuries or medical conditions. 3. Describe appropriate burns for outpatient management. 4. Estimate initial fluid resuscitation requirements for the first 24 hours in children with large (>25% total body surface area) partial-thickness burns. 5. Describe 2 methods of dressing management for a 5% total body surface area partial-thickness burn. 6. Recognize indications for transfer of a burned child to a regional burn center. Death from fires and burn injuries is the third leading cause of fatal home injury and the third leading cause of unintentional death in children younger than 14 years in the United States. (1) In 2009, the Centers for Disease Control and Prevention estimated 437 deaths and 120,761 nonfatal burn injuries in children age 0 to 19 years. (2) Although hospitalization rates for children with burns appear to be decreasing in the past decade, annual cost estimates of approximately 10,000 inpatient hospitalizations for pediatric burn care exceeded $211 million in 2000. (3) Although it is difficult to estimate the global incidence rate, morbidity, and mortality of burn injuries, it is clear that burns are a major cause of injury in both developed and developing countries. (4) Burns are one of the most physiologically and psychologically stressful injuries that occur in children and adults. Given the …

Introduction Foot burns in patients with diabetes mellitus (DM) tend to be more severe with delayed presentation due to comorbid peripheral neuropathy (PN) and peripheral vascular disease (PVD). Impaired wound healing in diabetes further complicates management. Currently, there is no consensus on best management of diabetic foot burns. Our regional burn center has adopted a treatment algorithm that prioritizes non-operative local wound care instead of early excision and grafting. Here we characterize the diabetic foot burn patients treated at our institution to compare the outcomes of patients treated operatively and non-operatively. Methods A retrospective review of all patients with DM admitted to a large urban burn center between 1/1/2015 and 6/30/2023 was conducted. Adult (age &amp;gt;18) patients with burns involving the foot were included for analysis. Patients with inaccessible charts and patients with burns greater than 20% total body surface area (TBSA) were excluded. In addition to descriptive statistics, linear and multinomial regression analyses were performed. Results A total of 3,035 DM patients were identified, of which 197 (6.5%) were adults with burns involving the foot. After additional screening, 172 patients were included for analysis. The mean patient age was 56.3 years (standard deviation 11.6), and 134 (77.9%) were male. Admission hemoglobin A1C was &amp;gt;7% in 66.9% (n = 115) of patients. Common comorbidities included PN (44.2%), PVD (8.1%), and obesity (37.2%). The majority of burns were partial thickness (72.1%, n = 124) and affected 2.5% TBSA or less (75.6%, n = 130). The plantar foot was involved in 50% (n = 86) of cases. Only 12.8% (n = 22) of patients were managed operatively, including debridement (9.9%, n = 17), grafting (5.8%, n = 10), and amputation (4.1%, n = 7). While 5 patients (2.9%) were primarily amputated, 2 patients (9.1%) were secondarily amputated, defined as amputation after initial debridement and grafting. Surgical management was significantly associated with increased days to wound closure (standardized coefficient = 0.251, p = 0.002) and increased length of stay (standardized coefficient = 0.576, p &amp;lt; 0.001). Surgical management (OR 9.3, p = 0.02, CI = 1.34 - 64.39) and peripheral neuropathy (OR 6.9, p = 0.03, CI = 1.24 - 38.68) were independent predictors of wheelchair-dependency at discharge compared to normal ambulatory status. Conclusions Surgical management of foot burns in diabetic patients is associated with greater morbidity, including longer wound closure times, longer hospitalization, and decreased functional status at discharge. These findings suggest that local wound care of diabetic foot burns may yield better clinical outcomes than operative management. Applicability of Research to Practice This study can be considered when recommending treatment options for diabetic foot burn patients.

Introduction Caloric intake has been a vital component for burn wound healing and recovery. The hypothesis was that caloric requirements are based on injury severity &amp; post-burn week as predicated by indirect calorimetry (IC)/predictive equations. Methods This was a retrospective chart review of 115 burn patients (2012–2017). Caloric requirements were determined by the Curreri equation [which includes % total body surface area (TBSA)] and IC for a 5-week period provided mainly by enteral nutrition. Patients received supplements and total parenteral nutrition as needed. Results The mean±sd age was 43±18 years, 41±18 % TBSA, Body Mass Index of 28±7 kg/m2, and mortality of 26 (23%). The major mechanisms of injury were flame/flash/explosions. There were 59 (51%) of patients with &amp;lt; 40 % TBSA burns, [median Injury Severity Score (ISS) 9; Apache score 14], and 56 (49%) with ≥40 % TBSA (median ISS 25; Apache score 21), p &amp;lt; .0001. The Respiratory Quotient (RQ) had a median of 0.94 (range 0.79 to 1.02). The median number of surgeries for the &amp;lt; 40 % TBSA group was 5 versus 12 for the ≥40 % TBSA, p &amp;lt; .0001. The Injury Factor did not differ from weeks 1–5 (1.8 for &amp;lt; 40 % TBSA and 2.0 for the ≥ 40 % TBSA). The Curreri equation calculation for this study was a median 3640 (range 2161–5950) calories. The Curreri equation resulted in significantly increased caloric recommendations for the ≥ 40 %TBSA compared to the &amp;lt; 40 %TBSA patients, p &amp;lt; .0001. The &amp;lt; 40 %TBSA group had caloric requirements ranging between 1500- 2700 calories compared to the ≥ 40 %TBSA group, whose calories ranged between 2000–3700. The total daily caloric recommendations were also significantly increased in the ≥40 %TBSA compared to the &amp;lt; 40 %TBSA patients. The maximum levels of resting energy expenditure (REE) from IC, total daily calories recommended by the dietitian and average calories ranged between 3000–4500 in the &amp;lt; 40 %TBSA group and 3600–6700 in the ≥ 40 %TBSA group. The caloric recommendations increased for all patients from week 1 to week 3 and leveled off during weeks 4–5. Conclusions Patient caloric requirements were dependent not only on the severity of the burn injury but also the post-burn hospitalization during which surgeries, debridement/grafting, and infectious complications occurred. They increased until the third week post-burn and leveled off in the recovery period. The study caloric recommendations and requirements were consistent with the REE and Curreri equation assessments. Applicability of Research to Practice There is no constant number of calories for all patients. Caloric requirements are modified by the severity of Burn %TBSA and phases of resuscitation through recovery.

The convergence of artificial intelligence (AI) and biological engineering technology (BET) can potentially revolutionize public safety efforts. However, the responsible use of these technologies requires crucial considerations. This study employed an exploratory sequential mixed-method to examine the governance mechanisms apropos AI and BET in the context of crime prevention in the Philippines. It identifies several key components that contribute to establishing governance mechanisms, including multisectoral agencies, legislative initiatives, and regulatory frameworks. The study also identifies a 3-factor model for the governance convergence of AI and BET in public safety. These factors include empowerment and sufficiency, ethical considerations, and laws and regulations. The findings underscore the notable implications of integrating AI and BET into public safety efforts, such as improving surveillance systems, proactively preventing public health crises, and optimizing emergency response capabilities. However, ethical considerations and regulatory guidelines must be in place to address privacy concerns and mitigate potential risks associated with these technologies. The convergence of AI and BET also presents opportunities for sustainability. Nevertheless, concerns arise regarding its improper utilization. Based on the study's findings, policy recommendations are directed at ethical considerations, governance and regulation, and sustainability. These policy actions aim to address the opportunities and challenges associated with the convergence of AI and BET in public safety, ensuring responsible and beneficial use within the framework of Public Safety 4.0.

Introduction Severe thermal burns are a catastrophic injury. Those surviving the initial insult are subject to life-long disability, prolonged hospital admission, nutritional issues and poor wound healing. Oxandrolone has been shown to reduce hospital duration and promote lean body mass. Despite not being licenced for use in burns trauma within the United Kingdom (UK), services across the country utilise Oxandrolone in the management of severe burns. We aim to analyse the use of Oxandrolone in major burns across burns services within the UK. Methods We conducted a survey across all burn centres and units across the UK. Any burns service provider with experience in patient management of patients sustaining burns with a total body surface area >15% was included. All services were identified using the British Burns Association website. We conducted a survey of all centres and units and contacted them via telephone through the trust's switchboard. Responses were accepted from any healthcare staff familiar with the day-to-day in-patient care of patients on the ward. Services with no in-patient services were excluded. Results A total of 24 burns centres and services responded to our survey. Twelve of the respondents were in a burns unit and 12 were in a burns centre. Eight respondents were paediatric facilities, and the remaining 16 dealt with adult burns. In total, 16/24 (66.6%) services reported using Oxandrolone. Conversely, 8/24 (33.3%) burns services denied using Oxandrolone. 7/12 (58.3%) burns units use Oxandrolone in the management of burns. 5/12 (42.7%) burns units do not use Oxandrolone in severe burns. 9/12 (75%) of burns centres described using Oxandrolone, whilst the remaining 3/12 (25%) did not. Discussion Oxandrolone is used varyingly across burns services across the UK. Burns centres were more likely to use Oxandrolone compared to units. We also find that more paediatric services used Oxandrolone in comparison to adult services. Studies have shown that the benefit of Oxandrolone is not age-dependent. Further work is required to assess the impact of this medication on patients with severe burns and national guidance would help further improve burns management across the UK.