Acute Burn Injury Research Articles

The Incidence and Significance of Raised Troponin Levels in Acute Burns.

The place and significance of troponin testing in acute burn injuries has not yet been established. The aims of this study were to determine the incidence and pattern of troponin testing within a large population of acute burn injuries and subsequently to determine the resultant clinical significance of the troponin test results. A retrospective analysis of all patients with acute burn admissions (n = 1,621 patients) to a busy tertiary adult burns center between July 2009 and July 2015. More than a third of our patients had at least one troponin test performed. Men, the elderly, and those with larger burns were more likely to be tested. The majority tested had the laboratory test done within 24 hours of admission. A positive troponin test strongly correlated with increased risk of acute cardiac complication and death, as did burns greater than 15% total body surface area (%TBSA) and age. Acute burns of ≥15% TBSA are associated with elevated troponin levels. Troponins should be tested in those ≥50 years old, with significant burns, and/or premorbid cardiac disease; positive results investigated as they affect cardiac and survival outcomes.

Tissue repair in neonatal and pediatric surgery: analysis on infections in surgically implanted natural biomaterials.

Over the past 4 decades commercially available natural and synthetic biomaterials have been employed for various reconstructive procedures in the pediatric population. The aim of this study was to identify the types of commercially available natural biomaterials and their areas of application in the pediatric age group. Furthermore, to perform an analysis to identify areas of application and types of biomaterials those have increased susceptibility to infections in the pediatric population. The literature was reviewed from 1970-2015 using a Medline search and data concerning application of different natural biomaterials was collected. Specific search was performed regarding to infections associated with these biomaterials. The rate of major infection after implantation of the biomaterial in the group of 298 reviewed cases was 5%. Patients with acute burn wounds which were treated with biomaterials presented the group with higher infection rates of 5-33%. The demand for these biomaterials has exponentially increased due to the worldwide rise in interest in tissue engineering research. Even using the appropriate techniques of implantation and professional postoperative care biomaterial associated infections cannot be eliminated. However, the current rate of infections is not a limiting factor for using the biomaterials in pediatric surgery.

The effect of adipose derived stromal vascular fraction on stasis zone in an experimental burn model

BackgroundStasis zone is the surrounding area of the coagulation zone which is an important part determining the extent of the necrosis in burn patients. In our study we aim to salvage the stasis zone by injecting adipose derived stromal vascular fraction (ADSVF). MethodsThermal injury was applied on dorsum of Sprague–Dawley rats (n=20) by the “comb burn” model as described previously. When the burn injury was established on Sprague–Dawley rats (30min); rat dorsum was separated into 2 equal parts consisting of 4 burn zones (3 stasis zone) on each pair. ADSVF cells harvested from inguinal fat pads of Sprague–Dawley rats (n=5) were injected on the right side while same amount of phosphate buffered saline (PBS) injected on the left side of the same animal. One week later, average vital tissue on the statis zone was determined by macroscopy, angiography and microscopy. Vascular density, inflammatory cell density, gradient of fibrosis and epithelial thickness were determined via immunohistochemical assay. ResultsMacroscopic stasis zone tissue viability (32±3.28%, 57±4.28%) (p<0.01), average number of vessels (10.28±1.28, 19.43±1.72) (p<0.01), capillary count (15.67±1.97, 25.35±2.15) (p<0.01) vascular density (1.55±0.38, 2.14±0.45) (p<0.01) epithelial thickness (0.014±0.009mm, 0.024±0.0011mm) were higher on ADSVF side. Fibrosis gradient (1.87±0.51, 1.50±0.43) (p<0.01) and inflammatory cell density (1.33±0.40, 1.20±0.32) (p<0.01) were higher on the PBS side. ConclusionMacroscopic and microscopic findings determined that ADSVF has a statistically significant benefit for salvaging stasis zone on acute burn injuries.

Antioxidant and Trace Element Supplementation Reduce the Inflammatory Response in Critically Ill Burn Patients.

Oxidative stress after burn injury induces inflammatory and hypermetabolic responses associated with adverse outcomes. We propose that antioxidant and trace element supplementation may reduce oxidative stress and subsequently alleviate inflammation and hypermetabolism, thus improving clinical outcomes. We conducted a cohort study of adult patients with an acute burn injury admitted to our provincial burn center. Patients in the antioxidant group received an intravenous infusion of multivitamins and trace elements for the first 14 days after admission. The inflammatory profile was assessed at early time points, < 14 days postburn, and later time points, ≥ 15 days postburn, and included interleukin (IL)-1β, interferon-γ, IL-1 receptor antagonist, IL-6, granulocyte-macrophage colony-stimulating factor, and FMS-like tyrosine kinase 3 ligand. Hypermetabolism was assessed by resting energy expenditure. Clinical outcomes included mortality, morbidities, hospital length of stay, and infections including days to the last positive culture after injury. We studied 172 patients, mean age 49 ± 17 years and 33 ± 13% TBSA burned, with 91 controls and 81 patients in the antioxidant group. Patients in the antioxidant group had significantly lower levels of inflammatory markers at both early and late time points, P < .05. Antioxidant treatment was associated with decreased measure of hypermetabolism, P < .05. Morbidity and mortality were not significantly different between groups. Length of hospital stay was significantly shorter in the antioxidant group when adjusted for patient demographics and injury characteristics (risk ratio (RR), 0.78; 95% confidence interval (CI), 0.66-0.92). In the antioxidant group, while infections were not different, the last positive culture post-injury was documented at median 19 days (Interquartile range (IQR), 11-43 days) compared with controls at 35 days (IQR, 15-59 days), P = .012. Patients receiving antioxidant and trace element supplementation had reduced markers of burn stress-induced inflammation; they were also associated with a decreased hypermetabolic response, shorter length of stay, and improved bacterial clearance.

Surgical treatment and management of the severely burn patient: Review and update

Since one of the main challenges in treating acute burn injuries is preventing infection, early excising of the eschar and covering of the wound becomes critical. Non-viable tissue is removed by initial aggressive surgical debridement. Many surgical options for covering the wound bed have been described, although split-thickness skin grafts remain the standard for the rapid and permanent closure of full-thickness burns.Significant advances made in the past decades have greatly improved burns patient care, as such that major future improvements in survival rates seem to be more difficult. Research into stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients.

Fluids in Sepsis and Septic Shock (FISSH): protocol for a pilot randomised controlled trial

IntroductionObservational evidence suggests physiological benefits and lower mortality with lower chloride solutions; however, 0.9% saline remains the most widely used fluid worldwide. Given uncertainty regarding the association of lower chloride...

Early pathogenic colonisers of acute burn wounds: A retrospective review

BackgroundEarly excision of burns reduces the incidence of local and systemic infections caused by colonising microorganisms, and reduces mortality and length of hospital stay. Appropriate antibiotic prophylaxis can reduce the risk of postoperative wound infections and skin graft loss. Antibiotic selection should be based on likely pathogens. However, there are few studies that have investigated the early pathogenic colonisers of acute burn wounds. AimTo describe pathogenic microorganisms found in acute burns and to make further recommendations on the use of early perioperative prophylactic antibiotics. MethodsAll burns patients admitted at the tertiary adult burns centre in Victoria over a 2-year period, who had surface swabs or tissue samples obtained from wounds within 24h of injury were included in this retrospective cohort study. Pathogenic organisms were examined with respect to patient characteristics, burn characteristics, treatment provided and immediate exposure to environmental contaminants. ResultsNearly one third of burns patients had wounds colonised with pathogenic microorganisms. Gram-negative bacteria were isolated from 52% of these. Staphylococcus aureus was the most common isolate. Pseudomonas and Enterobacter species were the most common gram-negatives. The only independent risk factor associated with early colonisation with gram-negative bacteria was per cent TBSA burn. ConclusionIncreased colonisation of acute burn wounds with pathogenic gram-negative bacteria was associated with increased size of burn.

The Cost of Burn Transfers: A Retrospective Review of 7 Years of Admissions to a Regional Burn Center.

The transport of thermally injured patients can involve significant costs; however, not all thermally injured patients necessitate transfer to a burn center. The purpose of this study was to review transfers to an American Burn Association-verified regional burn center to determine whether the transfers were necessary and the cost associated with unnecessary transfers. A retrospective chart review identified 707 patients transferred to an American Burn Association-verified burn center with an acute burn injury during a 7-year period. For the purposes of this study, "unnecessary transfer" was defined as any patient admitted fewer than 7 days who did not undergo operative intervention. Transfer cost estimates were based on records from regional land paramedic and land and air medical transport services. In total, 27.3% of transfers were potentially "unnecessary transfers," with an associated cost of approximately $227,396.93 (18.9% of total transfer costs in study). Average unnecessary transfer cost varied by method of transport: land ambulance (n = 130) $285.72, helicopter (n = 27) $4,136.34, and airplane (n = 15) $4,908.67. The transfer of thermally injured patients is associated with significant cost. Unnecessary transfers represent an inefficient use of a limited resource in an already strained healthcare system. The findings of this study suggest that further initiatives should be explored to ensure the appropriate transfer of thermally injured patients.

Surgical treatment and management of the severely burn patient: Review and update

Since one of the main challenges in treating acute burn injuries is preventing infection, early excising of the eschar and covering of the wound becomes critical. Non-viable tissue is removed by initial aggressive surgical debridement. Many surgical options for covering the wound bed have been described, although split-thickness skin grafts remain the standard for the rapid and permanent closure of full-thickness burns.Significant advances made in the past decades have greatly improved burns patient care, as such that major future improvements in survival rates seem to be more difficult. Research into stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients.

(150) Development of a Murine Model of Acute Burn Injury and Chronic Pain

(150) Development of a Murine Model of Acute Burn Injury and Chronic Pain

Bivalent flagellin immunotherapy protects mice against Pseudomonas aeruginosa infections in both acute pneumonia and burn wound models

Pseudomonas aeruginosa infections are a serious challenge to therapy because of the complex pathogenesis and paucity of new effective antibiotics, thus renewing interest in antibody-based therapeutic strategies. Immunotherapy strategies typically target selected virulence factors that are expressed by the majority of clinical strains of P. aeruginosa, particularly because virulence factors mediate infection. Type a and b flagellins (flagellin a+b) of P. aeruginosa are acute virulence factors that play a major role in the establishment of infection. Here we evaluate the protective efficacy of antibodies raised against “flagellin a+b” in both acute pneumonia and burn models. A combination strategy using antibodies against “flagellin a+b” provided greater protection against cell invasion and enhanced opsono-phagocytosis and decreased motility of P. aeruginosa strains, compared to strategies using antibodies against a single flagellin. Antibodies against “flagellin a+b”-protected mice infected with P. aeruginosa strains significantly reduced bacterial dissemination from the site of infection to the liver and spleen. Passive immunization with antibodies against “flagellin a+b” led to an efficacious protection against P. aeruginosa infection in both acute pneumonia and burn models.

The hospital costs associated with acute paediatric burn injuries.

Ongoing rationing of healthcare threatens services that are well established, and cripples others that desperately require investment. Burn, for one, remains a neglected epidemic in South Africa (SA), despite the magnitude of the problem. To identify the prominent components contributing to the cost of hospital admission with paediatric burn injury. Determining the true costs of specialist services is important, so that resources can be allocated appropriately to achieve the greatest possible impact. A retrospective study was undertaken over 1 year to determine patient demographics and injury details of 987 patients admitted with burn injuries to Red Cross War Memorial Children's Hospital, Cape Town, SA. The in-hospital financial records of 80 randomly selected patients were examined. This was followed by a prospective study to determine the financial implications of four cost drivers, i.e. bed cost per day, costs of medications received, costs of dressings for wound care, and costs of surgical intervention. A random selection of 37 dressing changes (in 31 paediatric patients) and 19 surgical interventions was observed, during which all costs were recorded. As expected, severe flame burns are responsible for more prolonged hospital stays and usually require surgical intervention. Scald burns comprise the greatest proportion of burn injuries, and therefore account for a considerable part of the hospital's expenditure towards burn care. While community programmes aiming to prevent burn injuries are important, this study motivates for the implementation of accessible ambulatory services in low-income areas. This strategy would enable the burn unit to reduce its costs by limiting unnecessary admissions, and prioritising its resources for those with more severe burn injuries.

Cutaneous Imaging Technologies in Acute Burn and Chronic Wound Care.

Wound assessment relies on visual evaluation by physicians. Such assessment is largely subjective and presents the opportunity to explore the use of emergent technologies. Emergent and powerful noninvasive imaging technologies applicable to assess burn and chronic wounds are reviewed. The need to estimate wound depth is critical in both chronic wound and burn injury settings. Harmonic ultrasound technology is powerful to study wound depth. It addresses the limitations of optical imaging with limited depth of penetration. What if a wound appears epithelialized by visual inspection, which shows no discharge yet is covered by repaired skin that lacks barrier function? In this case although the wound is closed as defined by current standards, it remains functionally open, presenting the risk of infection and other postclosure complications. Thus, assessment of skin barrier function is valuable in the context of assessing wound closure. Options for the study of tissue vascularization are many. If noncontact and noninvasive criteria are of importance, laser speckle imaging is powerful. Fluorescence imaging is standard in several clinical settings and is likely to serve the wound clinics well as long as indocyanine green injection is not of concern. A major advantage of harmonic ultrasound imaging of wound depth is that the same system is capable of providing information on blood flow dynamics in arterial perforators. With many productive imaging platforms to choose from, wound care is about to be transformed by technology that would help assess wound severity.

Prevalence of methicillin-resistant &lt;i&gt;Staphylococcus aureus&lt;/i&gt; and extended spectrum β–lactamase producers among bacteria isolated from infected wounds in a tertiary hospital in Ibadan City

Wound colonization by microorganisms is most frequently polymicrobial and incidences of high level resistance among bacterial isolates from wounds have been reported. Methicillin-resistant Staphylococcus aureus (MRSA) and extendedspectrum beta-lactamase (ESBL) producing Gram-negative bacteria both constitute serious challenge to physician in their choice of antibiotic treatment of infections caused by these bacteria. This study determined the antibiotic susceptibility profiles and prevalence of MRSA and ESBL producers among wound bacterial isolates from a tertiary hospital in Ibadan City. Forty (40) clinical bacterial isolates from five wound sources were collected from the Microbiology unit of the University College Hospital (UCH), Ibadan and were authenticated with standard bacteriological techniques. Antibiotic susceptibility test was done by disc-diffusion method using 19 antibiotics belonging to 12 classes. MRSA strains were detected by their resistance to cefoxitin and/or oxacillin antibiotics. Presumptive ESBL production was by double-disc synergy test using 30 μg cefotaxime and ceftazidime around 20/10 μg amoxicillin-clavulanic acid discs. ESBL confirmation was by minimum inhibitory concentration (MIC) using agar-dilution method. The authenticated isolates include Proteus spp (47.5%), Staphylococcus aureus (27.5%), Pseudomonas aeruginosa (12.5%), Klebsiella spp (7.5%), Acinetobacter baumanii (2.5%) and E. coli (2.5%). Distribution of the isolates collected according to wound sources includes: acute soft tissue wounds (35%), leg ulcer (32.5%), surgical wounds (17.5%), burn wounds (12.5%) and diabetic foot ulcer (2.5%). Distributions according to patients’ gender are: male (65%), female (35%), and according to age-groups are: 0 – 19 years (22.5%), 20 – 39 years (35%), 40 – 59 years (32.5%) and ≥ 60 years (10%). All (100%) the isolates were multidrug resistant (MDR) being resistant to ≥ 3 classes of antibiotics. Percentages of isolates resistance to each of the antibiotic include: piperacillin, piperacillin tozobactam and amoxicillin-clavulanic acid were 100%, ceftazidime, cefuroxime, cefixime, aztreonam, sulphamethoxazole-trimethoprim, erythromycin, chloramphenicol and doxycyclin were > 70%, cefoxitin (62.5%), Nitrofurantion (52.5%), ciprofloxacin (45%), ofloxacin (35%), perfloxacin (37.5%), gentamicin (32.5%) and imipenem (2.5%). Of the 11 Staphylococcus aureus collected, 54.5% were detected to be MRSA strains while ESBL production was detected in 55.2% of the Gram negative isolates. This study revealed 100% MDR phenotype constituting high level of MRSA strains (54.5%) and ESBL producers (55.2%) among Gram-positive and Gram-negative bacterial wound isolates respectively. Hence, this calls for caution in the use of extended spectrum antibiotics in treating patients with infected wounds.

Acute burns of the hands - physiotherapy perspective.

Acute burns of the hands are complex and may impact on various aspects of a person's life. Physiotherapy rehabilitation and restoration of hand function is critical for the patient's independence and re-integration into society. This study aimed to explore the perceptions and experiences of physiotherapists in the management of patients with their hand burn injuries. Five focus groups consisting of physiotherapists and physiotherapy assistants working with burn injured patients from each of the five selected public hospitals in KwaZulu-Natal were recruited. An explorative qualitative approach was adopted. Physiotherapists emphasised that the acute management of the hand was trivialised due to a primary focus on the survival of the burn sufferer. Therapists identified several factors that determined the patients' level of participation and motivation in therapy one of which was the procedural pain experienced. The role of the therapists' within the rehabilitation framework was found to be critical to their recovery however there appeared to be a breakdown in the collaboration and communication among health care professionals to the detriment of effective intervention. A multidisciplinary team approach is the foundation in the management of acute burn injuries and during the trajectory of the trauma care continuum.

Effectiveness of medical hypnosis for pain reduction and faster wound healing in pediatric acute burn injury: study protocol for a randomized controlled trial.

BackgroundBurns and the associated wound care procedures can be extremely painful and anxiety-provoking for children. Burn injured children and adolescents are therefore at greater risk of experiencing a range of psychological reactions, in particular posttraumatic stress disorder, which can persist for months to years after the injury. Non-pharmacological intervention is critical for comprehensive pain and anxiety management and is used alongside pharmacological analgesia and anxiolysis. However, effective non-pharmacological pain and anxiety management during pediatric burn procedures is an area still needing improvement. Medical hypnosis has received support as a technique for effectively decreasing pain and anxiety levels in adults undergoing burn wound care and in children during a variety of painful medical procedures (e.g., bone marrow aspirations, lumbar punctures, voiding cystourethrograms, and post-surgical pain). Pain reduction during burn wound care procedures is linked with improved wound healing rates. To date, no randomized controlled trials have investigated the use of medical hypnosis in pediatric burn populations. Therefore this study aims to determine if medical hypnosis decreases pain, anxiety, and biological stress markers during wound care procedures; improves wound healing times; and decreases rates of traumatic stress reactions in pediatric burn patients.Methods/DesignThis is a single-center, superiority, parallel-group, prospective randomized controlled trial. Children (4 to 16 years, inclusive) with acute burn injuries presenting for their first dressing application or change are randomly assigned to either the (1) intervention group (medical hypnosis) or (2) control group (standard care). A minimum of 33 participants are recruited for each treatment group. Repeated measures of pain, anxiety, stress, and wound healing are taken at every dressing change until ≥95 % wound re-epithelialization. Further data collection assesses impact on posttraumatic stress symptomatology, speed of wound healing, and parent perception of how easy the dressing change is for their child.DiscussionStudy results will elucidate whether the disease process can be changed by using medical hypnosis with children to decrease pain, anxiety, and stress in the context of acute burn wounds.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12615000419561

English

English

Study on acute burn injury survivors and the associated issues

ObjectiveTo explore the phenomenon of surviving burn injury and its associated issues and concerns. MethodsA cross sectional survey approach was utilized to obtain data from one hundred burn survivors who were purposely selected. Descriptive statistics and content analysis were used to analyze data. ResultsFindings from the study indicate that burns from flames stood out as a major cause of burns. Physical discomfort/pain, anxiety, needing assistance in meeting self-care needs, financial and social limitations were identified as the major impact of the injury. Furthermore, participants perceived the existence of societal stigma. In addition, hope in God or a spiritual being as well as family support were the two key resources participants relied on to cope effectively. ConclusionsSurviving burn injury is associated with varied physical, social and psychological factors and survivors may need professional assistance to fully adjust after discharge.

Wnt3a suppresses Pseudomonas aeruginosa-induced inflammation and promotes bacterial killing in macrophages.

Pseudomonas aeruginosa (PA) is a common Gram-negative bacterium and can cause serious infections, including hospital-acquired pneumonia, suppurative bacterial keratitis and acute burn wound infection. The pathogenesis of PA infections is closely associated with excessive inflammatory responses and bacterial virulence factors. Wingless-type MMTV integration site family, member 3A (Wnt3a), an upstream mediator in the canonical Wnt signaling pathway, has been implicated as a regulator of inflammation. However, its role in PA-induced inflammation and bacterial clearance remains unknown. In the present study, the efficacy of Wnt3a conditioned media (Wnt3a-CM) was assessed using western blotting and immunofluorescence, which showed that β-catenin, a downstream molecule of Wnt3a, was upregulated and translocated to the nucleus following exposure to 50% Wnt3a-CM for 6 h. To explore the role of Wnt3a in PA-induced inflammation, the mRNA levels of pro-inflammatory cytokines and apoptosis in macrophages were measured using reverse transcription-quantitative polymerase chain reaction and flow cytometry, respectively. This indicated that Wnt3a suppressed inflammation by reducing the production of pro-inflammatory cytokines and by promoting apoptosis in macrophages. Furthermore, the mechanism of macrophage-mediated bacterial killing was investigated, and the results indicated that Wnt3a enhanced macrophage-mediated intracellular bacterial killing via the induction of the production of cathelicidin-related antimicrobial peptide and β-defensins 1. Taken together, the current study explored the role of Wnt3a in inflammation and bacterial invasion, which may provide an improved understanding of host resistance to PA infection.

Baux’s and Abbreviated Burn Severity Score for the Prediction of Mortality in Patients with Acute Burn Injury

jdjdBackground &amp; Objectives: Prediction of outcome for patients with major thermal injury is important to inform clinical decision making, alleviate individual suffering and improve hospital resource allocation. Early prediction of outcome (i.e., survival or mortality) may help triage effectively, and to implement medical and surgical interventions efficiently as soon as possible. Burn mortality has decreased markedly with the improvement in burn management in the past 100 years, and multiple burn mortality prediction models have been developed over these times in response to that decline. But these services are still not enough to reduce the burn related injuries in low income country like Nepal. So we did a study to observe the effectiveness of two different but very popular models (Baux and ABSI) in our context.Materials &amp; Methods: This was a prospective observational study where 92 cases of severe burn injury was selected and the results were compared with Baux and ABSI scoring system.Results: Total admission was 140 and mortality was 33. Out of these admission 92 cases of severe burn injury was selected for the study. Most (85.8 %) of were among the young group 16-40 years. It comprises 41.3 % in total. In total 63.7 % were female. Mortality with severe burn injury was 29.3%. No death had occurred below the Baux’s score 30 and there was more than 51% mortality above the score of 60. There was no mortality with ABSI scoring &lt; 3 and mortality was high in ABSI scoring &gt; 6.Conclusion: Baux and ABSI score systems are simple to calculate and ABSI is more accurate for prediction of acute burn injury.Journal of College of Medical Sciences-Nepal, Vol.11(4) 2015: 24-27