Baux Score Research Articles

19 Epidemiology of Acute Burn Admissions at a Referral Center in Nepal: A Comparison Between Direct Admissions and External Referrals

Abstract Introduction Nepal is a low-income country where burn injury is a leading cause of preventable deaths and disabilities. A major burn center was established in 2013 to care for patients with acute injuries and reconstruction needs from local and from distant communities. We aimed to characterize the epidemiology of admissions and patterns of referral to guide health system planning and efforts. Methods We described prospectively collected data from patients with acute burns from January 2016 to July 2019. Sociodemographic and injury data included age, sex, hospital of provenance or direct admission status, total burn surface area (TBSA), and presence of complications on admission (e.g., wound infection, sepsis). Outcomes included length of stay and mortality. Differences in proportions and medians were compared with Chi square and Wilcoxon Rank Sum tests, respectively. Results There were 1,813 patients admitted with acute burns over the study period. Median patient age was 26 years (IQR 12–45). More than half of patients were female (55%). Median TBSA was 15% (IQR 7–30%) with a median Baux score of 48 (IQR 27–75). Most patients were transferred from another facility (65% of admissions). Referrals came from over 300 facilities across the country. Referred patients had larger TBSA (median 16%, IQR 9–30%) compared to directly admitted patients (median 12%, IQR 5–30% (p=0.0001). Although median day post-burn day of presentation was 1 day for both groups, referrals had significant admission delays (IQR 0–7) compared to direct admissions (IQR 0–4, p=0.0001). An infection was present on admission in 5% of referrals compared to 2.4% of direct admissions (p=0.01). Median length of stay (among survivors) was longer for referrals (10 days, IQR 5–17) compared to 6 days (IQR 2–12) for direct admissions [p=0.001]). Mortality rate was relatively unchanged across the study period (23% in 2016, 21% in 2019, p=0.82). For patients with burn TBSA >40%, inpatient mortality decreased from 76% in 2016 to 51% in 2019 (p=0.05), however there were few instances of hospital discharges with a palliative intent. There was no difference in mortality rate for referrals compared to direct admissions (21 vs 22%, p=0.63]. Conclusions Despite significant delays in presentation and higher rates of infection on admission, mortality for referral patients was similar to directly admitted patients. Additionally, improvements in care quality have led to significant decreases in the mortality rate for large burns. These data suggest that regionalization of care in Nepal may successfully rescue and manage severe burns in a specialized center. Applicability of Research to Practice These data support regionalization of care for patients with burn injuries in Nepal. Further work to understand the epidemiology and care of patients who do not get referred is required to address system gaps.

96 Treatment of Donor Sites in Large TBSA Burn Injuries with an Autologous Skin Cell Suspension Supports Early Reharvesting

Abstract Introduction Treatment of large TBSA burn injuries is often limited by donor site availability and requires reharvesting to obtain definitive closure. Patients with severe injuries may have delayed closure compared to uncompromised patients that typically have their donor sites healed in 7–14 days. Autologous skin cell suspension (ASCS) can be prepared to treat burn wounds at the point-of-care. The safety and effectiveness have not yet been established for use in the treatment of donor sites. This study presents the use of ASCS for the treatment of donor sites in patients with life-threatening burn injuries that were enrolled in a prospective uncontrolled observational study (IDE 15945—NCT02992249). Methods ASCS was applied to the donor site after harvesting of STSGs. Clinical outcomes out to one year were evaluated including percentage of re-epithelialization, long-term cosmetic outcomes, and adverse events. Results Ninety-six subjects from 22 burn centers had their donor sites treated with ASCS as part of their treatment regimen. The average subject age was 30.1 and the average TBSA injury was 53.7 ±17.3%. The mean Baux score was 89.2 with 36% of subjects having a score greater than 100. Collectively, 528 donor sites were individually treated. In this compromised patient population 37.5% were ≥95% re-epithelialized by week 1 (n=435), and by week 2, 82.7% of the donor sites were ≥95% re-epithelialized (n=434), regardless of how many times they were harvested. Approximately 19% of the donor sites treated with ACSC were reharvested multiple times following initial healing (15% two times, 2.3% three times, and 7 donor sites were harvested 4 times) and retreated. Of donor sites harvested more than once, 39.3% (n=84), 81% (n=79), and 85.7% (n=77) of sites were ≥ 95% re-epithelialized by week 1, 2 and 4, respectively. One-year data was available for 427 donor sites and the majority had matched or mildly mismatched color, pigment, and texture. Adverse events included one site with a hematoma, one patient with donor sites that had fragile skin loss secondary to traumatic friction, one patient with active bleeding, two patients with anemia secondary to donor site bleeding, one patient with delayed closure due to mild infection of staph species. All AEs were unlikely or unrelated to the device. Conclusions ASCS has been successfully used to achieve closure of donor site wounds without significant safety risk in patients with extensive burn injuries. Applicability of Research to Practice Application of ASCS for donor site healing may be particularly relevant for patients with large burn injuries requiring subsequent reharvesting to achieve definitive closure.

1 The Impact of No Next of Kin Decision Makers on End-of-life Care

Abstract Introduction For critically ill burn patients without a next of kin (NOK), the medical team is tasked with becoming the surrogate decision maker. This poses difficult ethical and legal challenges for burn providers. Despite this frequent problem, there has been no investigation of how the presence of a NOK affects treatment in burn patients. This study is the first to evaluate this relationship. Methods A retrospective chart review was performed on a cohort of patients who died during the acute phase of their burn care from a single burn center from 2015 to 2019. Inclusion criteria were age ≥18 years and mortality within 4-weeks of admission. Exclusion criteria were death from dermatologic disease or trauma. Variables collected included age, gender, mechanism of injury, length of stay (LOS), total body surface area (TBSA), revised Baux score, and the presence of a NOK. Fisher’s Exact Test and Student’s t-test were used for analysis. Results In total, 67 patients met inclusion criteria. Of these patients, 14 (21%) did not have a NOK involved in medical decisions. Table 1 shows the means and odds ratio between the two groups. Patients without a NOK were younger (p < 0.05), more likely to be homeless (p < 0.01), had higher TBSA (p < 0.01), had shorter LOS (p < 0.01), and were 5 times less likely to receive comfort care (p < 0.05). Gender and ethnicity were not statistically significant. Conclusions Patients without a NOK present to participate in medical decisions are transitioned to comfort care less often despite having a higher burden of injury. This disparity in standard of care between the two groups demonstrates a need for a cultural shift in burn care to prevent suffering of these marginalized patients. Burn providers should be empowered to reduce suffering when no decision maker is present. Applicability of Research to Practice We report that the absence of a NOK has a significant impact leading to a decreased initiation of comfort care in critically ill burn patients. National protocols should be created to allow burn providers to act as a surrogate to prevent prolonged suffering.

Baux Score as a Predictor of Mortality at the CHBAH Adult Burns Unit

BackgroundThe Chris Hani Baragwanath Academic Hospital (CHBAH) Adult Burns Unit (ABU) often operates in excess of its capacity. Our aim was to investigate the risk factor profile of the ABU population and to apply the Baux score as a model for predicting mortality to assist with appropriate resource allocation. MethodsIn this retrospective study, the Baux score was calibrated to the mortality rates in ABU burn population and the effects of various variables on mortality were assessed with Mann-Whitney U-test, chi-square test, and regression analysis. ResultsThe relationship between the Baux score and mortality rate was characterized by this regression equation: y = −0.0002×3 + 0.0547×2 - 2.5815× + 32.649, which was used to tabulate expected mortalities per Baux score band. Univariable regression analysis revealed that Baux score, gender, suspected inhalation injury, mechanism, and intent each had statistically significant associations with mortality (P-values <0.05), whereas the multivariable model showed that only Baux score, gender, and suspected inhalation injury were statistically significant factors in predicting mortality. ConclusionsAn increase in the Baux score is the most predictive and statistically significant risk factor and is easy to calculate. Thus, expected mortality can be determined using the Baux score band versus mortality table created in this study to assist with prioritizing patients in a resource-limited environment.

Efficacy and Safety of High Vs Standard Daptomycin Doses Examined in Chinese Patients With Severe Burn Injuries by Pharmacokinetic Evaluation.

Previous studies and the concentration-dependent antibacterial actions of daptomycin suggested that a high dose would be needed for difficult-to-treat infections in burn patients. Here, we evaluated the effects of administration of low and high doses of daptomycin in patients with severe burn injuries. The study retrospectively analyzed 10 patients with severe burn injuries, using pharmacokinetic (PK) and pharmacodynamic (PD) evaluations of daptomycin doses given to combat serious infections. Daptomycin was administered as a single dose or by multiple doses intravenously at a standard dose of 6 mg/kg/d or a high dose of 12 mg/kg/d for 7 to 14 days. The serum concentrations of daptomycin from patients were analyzed by liquid chromatography–mass spectrometry/mass spectrometry (LC-MS/MS). Burn injury patients treated with high-dose daptomycin had a linear PK profile and a negative correlation between the AUC0–24 and Baux score (R2 = .953 and R2 = .801). The Cmax, AUC0–24, and t(h)½ increased significantly compared with patients given a standard dose. The efficacy of daptomycin against Staphylococcus aureus showed significantly higher rates of (AUC0–24)/MIC and Cmax/MIC after high-dose daptomycin compared with the standard dose, reflected in a significant correlation between a high dose and the Baux score (r = .976, P < .001). Positive S. aureus cultures from two of three high-dose and none of two daptomycin low-dose patients converted from positive to negative after therapy. No serious adverse events or discontinuation of the drug occurred during the treatment period. Daptomycin doses up to 12 mg/kg/d were well tolerated in Chinese patients with severe burn injuries, which were complicated by infections with S. aureus.

Value of joint prediction model based on the modified systemic inflammatory response syndrome score for predicting mortality risk of patients with large area burns at early stage after admission

Objective: To investigate the predictive value of the joint prediction model based on the modified systemic inflammatory response syndrome (SIRS) score (hereinafter referred to as the joint prediction model) for the mortality risk of patients with large area burns within 24 hours after admission. Methods: The clinical data of 158 patients [111 males, 47 females, aged 40 (28, 50) years] admitted to the Department of Burn Surgery of the First Affiliated Hospital of Naval Medical University from January 2005 to January 2018, conforming to the study criteria, were analyzed retrospectively by the method of case-control study. The age, gender, total burn area, full-thickness burn area, injury cause, with or without inhalation injury, severity of inhalation injury, and tracheotomy condition of patients were recorded, and the modified SIRS score and the modified Baux score of patients were calculated. According to the final outcome, all patients were divided into survival group (n=123) and death group (n=35). The clinical data of patients between two groups, except for modified Baux score, were compared by chi-square test or Mann-Whitney U test to screen the death-related factors of patients. The indexes with statistically significant difference between the two groups were included in the multivariate logistic regression analysis to screen the independent risk factors related to the death of patients, and the prediction model was constructed by combining the modified SIRS score. The receiver's operating characteristic curves of the modified SIRS score, the modified Baux score, and the joint prediction model of 158 patients were drawn to analyze their ability to predict death of patients. The area under curve (AUC) of the receiver's operating characteristic and the sensitivity and specificity of optimal threshold were calculated, and the quality of AUC of the three prediction indexes was compared with Jonckheere-Terpstra test. Results: (1) There were statistically significant differences between the two groups in the modified SIRS score, age, total burn area, full-thickness burn area, severity of inhalation injury, with or without inhalation injury, and tracheotomy condition of patients (Z=-4.356, -3.568, -5.291, -6.052, -4.720, χ(2)=12.967, 19.692, P<0.01). (2) The modified SIRS score, age, full-thickness burn area were the independent risk factors for the death of patients with large area burn (odds ratio=2.699, 1.069, 1.029, 95% confidence interval=1.447-5.033, 1.029-1.109, 1.005-1.054, P<0.05). (3) The AUC of modified SIRS score, the joint prediction model, and the modified Baux score for predicting death of 158 patients within 24 hours after admission were 0.730, 0.879, and 0.895 respectively (95% confidence interval=0.653-0.797, 0.818-0.926, 0.836-0.938, P<0.01). The sensitivities of the three optimal threshold values to death prediction were 54.3%, 91.4%, and 82.9% respectively, while the specificities were 81.3%, 76.4%, and 84.6% respectively. The AUC quality of the joint prediction model was similar to that of the modified Baux score (95% confidence interval=-0.057-0.088, P>0.05), and both of them were significantly better than that of the modified SIRS score (95% confidence interval=0.072-0.259, 0.023-0.276, P<0.05 or P<0.01). Conclusions: Both the joint prediction model and the modified Baux score are considered to be good to predict the death rate of patients with large area burns at early stage after admission. However, the joint prediction model has better clinical practice value due to its advantage of simple scoring and easier access to data acquisition.

Epidemiological and clinical characteristics and outcomes of inpatient burn injuries in older adults: Factors associated with mortality.

There is a lack of epidemiological research on defining the epidemiological profile of burn injuries in older adults in different regions of Turkey. This study was designed to document the prevalent epidemiological pattern of burn injuries and factors that affect mortality in older adults admitted for treatment to the inpatient unit of Adana City Training and Research Hospital (ACTRH). Demographic data, burn mechanism, presentation, percentage of total body surface area (TBSA) burn, abbreviated burn severity index (ABSI) and revised Baux scores, comorbidities, and treatment modalities burn patients aged 60 years and over admitted to our burn center January 1, 2016, and December 31, 2019, were evaluated retrospectively in this study. The medical records of 1754 inpatient burns over 4 years were retrospectively reviewed. A total of 104 (5.5%) hospitalized adult burn patients aged 60 years old or over and treated more than 24 h were included in the study. There were 38 males and 66 females with a male-to-female ratio of 1.00: 2.05 in survivors and 1.25: 1.00 in non-survivors. The mean age was 70.5±8.5 (60.0-92.0) for survivors and 72.7±8.4 (62.0-90.0) years for non-survivors. The mean (%) TBSA burned was 11.4±9.9% for survivors and 37.8±30.0% for non-survivors. Most of the burn injuries occurred at indoor locations (81%), caused by hot water scalds, representing more than one-third of all burns, especially in the kitchen and bathroom. Considering the age (p=0.329), the etiology (p=0.984) and place of burns (p=0.071), burned anatomical regions (p=0.817), and the surgical procedure (yes/no) (p=0.798), no statistical difference was observed between survivors and non-survivors. The more extended %TBSA burn, the inhalation injury, and deep burns were found to be significantly the most effective factors in mortality. Revised Baux (R Baux) and ABSI scores had a high value of predicting mortality.

Predictive value of quick SOFA and revised Baux scores in burn patients

Several scoring systems, such as the Baux score, help predict outcomes in burn patients. The quick Sequential Organ Failure Assessment (qSOFA) score (composed of a respiratory rate of 22/min or greater, systolic blood pressure of 100 mmHg or less, and altered mental status) is a new bedside index proposed to help identify patients with suspected infection at risk of complications. We hypothesized that qSOFA scores would be associated with in-hospital mortality, ICU admission, and length of stay (LOS) in patients with burns. We performed a retrospective review of all burn patients admitted between January 2010–March 2017 at an academic, suburban, hospital with a regional burn center. qSOFA scores were calculated as 1 point each for GCS<15, RR≥22, and SBP≤100. A qSOFA value of>2 was considered high risk. Revised Baux (rBaux) scores were calculated as age +%TBSA burned +17 (if inhalation injury). A rBaux score >140 was considered high risk. Univariate, multivariate and receiver operating characteristics analyses were performed to compare qSOFA and rBaux scores. There were 1039 burn admissions during the study period. Mean age was 30 ± 24 years, 66% were male. Mean TBSA was 10 ± 12%, mean injury severity score was 5 ± 8. Mean hospital LOS was 8 ± 24 days, 22 patients (2.1%) died. qSOFA scores were associated with mortality and ICU admission. Of all patients, 80 were high risk by qSOFA and 7 by Baux scores. ROC characteristics of qSOFA and Baux scores for predicting death were sensitivity 36% vs. 32%, specificity 94% vs. 100%, PPV 13% vs. 100%, and NPV 98% vs. 99% respectively. The AUC for qSOFA (0.68 [95% CI, 0.54–0.81]) was lower than for Baux (0.99 [95%CI, 0.99–1.00]). Youden’s index identified an optimal cutoff of 85 on the Baux score yielding sensitivity 100%, specificity 94%, PPV 27%, and NPV 100% for mortality. Our results indicate that while qSOFA scores were associated with outcomes, a rBaux score had greater predictive value. The optimal rBaux score for predicting all mortality and ICU admission was 85.

Coupled-plasma filtration and adsorption for severe burn patients with septic shock and acute kidney injury treated with renal replacement therapy

BackgroundCoupled-plasma filtration adsorption (CPFA) is a sorbent-based technology aimed at removing soluble mediators of septic shock. We present our experience on the use of CPFA in septic shock severe burn patients with acute kidney injury (AKI) needing renal replacement therapy (RRT) with the main goal to evaluate efficacy and safety of CPFA in this specific subset of septic shock patients. MethodsIn this observational study, we retrospectively reviewed the medical notes of all burn patients admitted to our adult Burn Center who received CPFA, as part of the septic shock treatment requiring RRT, between January 2001 and December 2017 (CPFA group).We compared CPFA group with all the burn patients admitted to our Center in the same period of time, with the same range of relevant clinical characteristics, who developed AKI and were treated with RRT, but not CPFA (control group). We collected demographic characteristics, burn size, Sequential Organ Assessment Failure (SOFA) score, microbiological data, and patient outcome, in terms of in-hospital mortality rate and the probability of survival calculated using the revised Baux score. We also collected data regarding CPFA safety (hemorrhagic episodes, catheter associated-complications, hypersensitivity reactions) and efficiency (number and duration of CPFA sessions, plasma treated amount, plasma processed dose). Results39 severe burn patients were treated with CPFA (CPFA group) (mean age 46.0 years, range 40.0–56.0 years; mean burn size 48.0% TBSA, range 35.0–60.0% TBSA), and 87 patients treated with RRT, but not CPFA, who had similar clinical characteristics (control group). Observed mortality rate was 51.3% in the CPFA group and 77.1% in the control group (p 0.004). Regarding factors affecting survival in the CPFA group, SOFA score on the 1st day of CPFA resulted significant (OR 2.016, 95% CI, 1.221–3.326; p < 0.004) in the multivariate analysis logistic model. ConclusionsCPFA treatment for burn patients with AKI-RRT and septic shock, sustained by bacterial strains non or poorly responsive to therapy, was associated with a lower mortality rate, compared to RRT alone. However, further research, such as large prospective studies, is required to clarify the role of CPFA in the treatment of burns with septic shock and AKI-RRT.

Predictors of mortality and validation of burn mortality prognostic scores in a Malaysian burns intensive care unit

BackgroundMajority burn mortality prognostic scores were developed and validated in western populations. The primary objective of this study was to evaluate and identify possible risk factors which may be used to predict burns mortality in a local Malaysian burns intensive care unit. The secondary objective was to validate the five well known burn prognostic scores (Baux score, Abbreviated Burn Severity Index (ABSI) score, Ryan score, Belgium Outcome Burn Injury (BOBI) score and revised Baux score) to predict burn mortality prediction.MethodsPatients that were treated at the Hospital Sultan Ismail’s Burns Intensive Care (BICU) unit for acute burn injuries between 1 January 2010 to 31 December 2017 were included. Risk factors to predict in-patient burn mortality were gender, age, mechanism of injury, total body surface area burn (TBSA), inhalational injury, mechanical ventilation, presence of tracheotomy, time from of burn injury to BICU admission and initial centre of first emergency treatment was administered. These variables were analysed using univariate and multivariate analysis for the outcomes of death. All patients were scored retrospectively using the five-burn mortality prognostic scores. Predictive ability for burn mortality was analysed using the area under receiver operating curve (AUROC).ResultsA total of 525 patients (372 males and 153 females) with mean age of 34.5 ± 14.6 years were included. There were 463 survivors and 62 deaths (11.8% mortality rate). The outcome of the primary objective showed that amongst the burn mortality risk factors that remained after multivariate analysis were older age (p = 0.004), wider TBSA burn (p < 0.001) and presence of mechanical ventilation (p < 0.001). Outcome of secondary objective showed good AUROC value for the prediction of burn death for all five burn prediction scores (Baux score; AUROC:0.9, ABSI score; AUROC:0.92, Ryan score; AUROC:0.87, BOBI score; AUROC:0.91 and revised Baux score; AUROC:0.94). The revised Baux score had the best AUROC value of 0.94 to predict burns mortality.ConclusionCurrent study evaluated and identified older age, total body surface area burns, and mechanical ventilation as significant predictors of burn mortality. In addition, the revised Baux score was the most accurate burn mortality risk score to predict mortality in a Malaysian burn’s population.

Patients’ survival rates and their correlated factors in the prehospital setting of a dust explosion incident

Background: Triage plays a critical role in mass casualty incidents by optimizing the use of medical resources. The Formosa Fun Coast (Baxian Water Park) dust explosion incident in 2015 revealed the lack of resources in the Taiwanese medical system to handle large-scale burn and scald casualties; however, this incident resulted in only 3% mortalities (15/499) by the end of 2015. Objective: This study aims to examine the key features and correlated factors of the prehospital setting in 15 mortalities. Materials and methods: This retrospective cohort study enrolled all patients from the Formosa Fun Coast incident (N = 499). The follow-up period was from 27 June to 31 December 2015. We first examined the correlation between patient survival and various variables and then tested the correlation between survival-correlated variables and the level of hospitals that provided treatment. Results: The survivor and nonsurvivor groups shared similar distributions of all study variables. Emergency medical technician performed the triage assessment, and the Baux score correlated with patient survival. This study further tested whether the hospital level correlated with the emergency medical technician–performed triage assessment or Baux score. A chi-square test revealed that the emergency medical technician–performed triage assessment and Baux score correlated with patient survival, thereby indirectly affirming the planning, training, and auditing of the Taiwanese emergency medical technician system. Conclusion: The lack of the effect of the hospital level on patient mortality indicated that mortality might be related to the severity of burn injury rather than the level of hospital chosen for initial treatment, besides being related to a satisfactory emergency medical technician–performed triage system.

Comparison between revised Baux score and abbreviated burn severity index as a predictor of mortality in burn patients at a tertiary care center in Yogyakarta, Indonesia

The outcome prediction of patients with extensive burns is essential in determining clinical decisions. Various burn mortality prediction models have been developed, and burn mortality had decreased markedly with the improvement in burn management. This study aimed to compare the effectiveness of revised Baux score (RBS) and abbreviated burn severity index (ABSI) in predicting mortality of burn injury patients. This was a retrospective cross-sectional method. The subjects of the study were 111 medical records of burn patients who were treated in the Burn Unit of a tertiary health care in Yogyakarta, Indonesia, from 2015 to 2016. There were 111 patients, of whom 81 were males and 30 females. The outcomes of burn injury patients were 97 survived, and 14 died. There were significant association between percentage of total body surface area burned, and inhalation injury with the ABSI score of ≥ 8. The patients with an ABSI score of ≥ 8 have a relatively higher risk by 4.1-fold to die compared with patients who scored < 8, but statistically did not reach a significant level. In contrast, the patients with an RBS score ≥ 60 have a relatively lower risk by 2.43-fold to die compared with the patients with a score of < 60, but statistically, the results did not reach a significant level. In conclusions, ABSI and RBS score systems are simple to calculate, and ABSI is more accurate for prediction of acute burn injury. Presence of inhalation injury and large TBSA were significant predictors of mortality. Level of evidence: Level III, risk/prognostic study

Nonmedical Factors Influencing Early Deaths in Burns: A Study of the National Burn Repository.

It is well-established that survival in burn injury is primarily dependent on three factors: age, percent total-body surface area burned (%TBSA), and inhalation injury. However, it is clear that in other (nonburn) conditions, nonmedical factors may influence mortality. Even in severe burns, patients undergoing resuscitation may survive for a period of time before succumbing to infection or other complications. In some cases, though, families in conjunction with caregivers may choose to withdraw care and not resuscitate patients with large burns. We wanted to investigate whether any nonmedical socioeconomic factors influenced the rate of early deaths in burn patients. The National Burn Repository (NBR) was used to identify patients that died in the first 72 hours after injury and those that survived more than 72 hours. Both univariate and multivariate regression analyses were used to examine factors including age, gender, race, comorbidities, burn size, inhalation injury, and insurance type, and determine their influence on deaths within 72 hours. A total of 133,889 burn patients were identified, 1362 of which died in the first 72 hours. As expected, the Baux score (age plus burn size), and inhalation injury predicted early deaths. Interestingly, on multivariate analysis, patients with Medicare (p = .002), self-pay patients (p < .001), and those covered by automobile policies (p = .045) were significantly more likely to die early than those with commercial insurance. Medicaid patients were more likely to die early, but not significantly (p = .188). Worker's compensation patients were more likely to survive the first 72 hours compared with patients with commercial insurance (p < .001). Men were more likely to survive the early period than women (p = .043). On analysis by race, only Hispanic patients significantly differed from white patients, and Hispanics were more likely to survive the first 72 hours (p = .028). Traditional medical factors are major factors in early burn deaths. However, these results show that nonmedical socioeconomic factors including race, gender, and especially insurance status influence early burn deaths as well.

P.081 Critical illness neuropathy and clinical correlates in severely burned patients

Background: Reported incidence of critical illness neuropathy (CIN) in burn patients is between 7-41%. Methods: Retrospective review including patients admitted to quaternary ICU for burn injuries between 2010-16. Variables include demographics, burn and neurologic characteristics, EMG reports, and measurements of illness severity. Patients with and without neuropathies were compared. Results: Of 147 patients admitted to ICU, thirteen had EMG studies and eight met CIN criteria. Five had electrophysiological CIN evidence, three had clinical diagnosis. Six EMGs focused on upper limb injuries only, insufficient to diagnose CIN. One patient was diagnosed with critical illness myopathy and nine had superimposed focal mononeuropathies or plexopathy. CIN patients had a mean of larger burns (TBSA 63% vs 21%), more operations (8 vs 2) and escharotomies performed (63% vs 12%), longer ICU admissions (23 vs 9 days), longer ventilation (28 vs 8 days), higher revised Baux score (101 vs 76) and initial APACHE II scores (21 vs 15) than those without. Conclusions: CIN was identified in 5.4% of burn patients admitted to ICU, lower than previously reported in literature, and associated with higher illness severity. CIN may be under recognized if not screened for. Unit examinations should include screening neurological measures and indicated EMGs to evaluate for CIN.

The Impact of Introducing a Physical Medicine and Rehabilitation Consultation Service to an Academic Burn Center.

Prior retrospective studies suggest that physical medicine and rehabilitation (PM&R) acute care consultation improves outcome and reduces acute care length of stay (ACLOS) in trauma patients. There have not been prospective studies to evaluate this impact in burn patients. This cohort study compared outcomes before and after the introduction of a PM&R consultation service to the acute burn program, and the inpatient rehabilitation program, at a large academic hospital. The primary outcome measures were length of stay (LOS) in acute care and during subsequent inpatient rehabilitation. For the acute care phase, there were 194 patients in the preconsultation group and 114 who received a consultation. There was no difference in age, Baux score, or LOS in these patients. For the rehabilitation phase, there were 109 patients in the prephysiatrist group and 104 who received PM&R care. The LOS was significantly shorter in the latter group (24 days vs 30 days, P = .002). Functional independence measure (FIM) change, unexpected readmission, and discharge destination were not significantly different. The addition of a burn physiatrist did not influence ACLOS. However, there was a significant reduction in inpatient rehabilitation LOS.

Does Acute Kidney Injury Condition Affect Revised BAUX Score in Predicting Mortality in Major Burn Patients?

Objective: This study aimed to assess the accuracy of the revised BAUX score for predicting mortality among the major burn patients with acute kidney injury (AKI) compared with non-AKI group. The epidemiologic information and risk factors of AKI in major burn patients were also the point of interest. Methods: This study was a retrospective cohort study. The medical records of 144 major burn patients admitted at the burns unit of Siriraj Hospital from 2010-2016 were reviewed and important data were retrieved. Results: Age, hypertension, diabetes mellitus, severity of the burn injuries, and inhalation injuries were the factors related to AKI in major burn patients. The mortality rate due to AKI in burn patients was high (44.4%). The accuracy of the revised BAUX score in predicting the mortality among the major burn patients from our series was only fair (66.7%). Conclusion: AKI affected on mortality of the major burn patients. Until the better predictor comes up, the revised BAUX score should be considered as a predictor of mortality in these patients.

216 Risk Stratification of Orbital Compartment Syndrome: A Comparison of Intra-Ocular Pressure and the Baux Score

Early fluid resuscitation is a mainstay in acute burn care. Aggressive fluid therapy in significant thermal burns can lead to third spacing of fluid into the orbit thus increasing the risk of orbital compartment syndrome. The Baux score is a simple tool often used in burn care to help predict mortality and thus indicate severity of the burn. This study aims to quantify the intra-ocular pressures (IOP) as it relates to the patient’s Baux score, in an effort to stratify the risk for orbital compartment syndrome. This study is a retrospective analysis of 70 patients with thermal burns at a level one burn center. The initial Baux score was noted for each patient as well as the highest measured IOP within the first 72 hour period. Linear regression was used to test for an association between peak intraocular pressure and the Baux score. Patients requiring orbital decompression were compared with those who did not, using the Fisher exact test. Eleven of 70 patients required emergent orbital decompression with a lateral canthotomy and cantholysis and had a higher Baux score than patients who did not receive the procedure (p = 0.03). The average IOP was 18.7 +/- 5mmHg but patients who underwent an orbital decompression all had IOP greater than 40. There was a positive relationship between the Baux score and IOP for Baux scores greater than 70; however, this was no longer statistically significant when adjusted for periocular burns. The risk of orbital compartment syndrome linearly increases with beaux scores greater than 70 and additionally in patients with periocular burns. As such, a high index of suspicion and early evaluation by an ophthalmologist is warranted in these patients to preserve vision. An elevated Beaux score can predict the necessity for ophthalmic intervention in patients at a high risk for vision loss secondary orbital compartment syndrome

506 A Burn Center’s Four Year Experience with a Cerium Nitrate &amp; Silver Sulfadiazine Burn Cream

Morbidity from burn wound infection & sepsis remains high, but can be improved by early excision & grafting. However, certain situations preclude early surgery. In these cases, topical agents allow for staged excision. The combination of cerium nitrate & silver sulfadiazine (Cerium) is an inexpensive burn cream with broad antibacterial activity. It also forms an eschar over the wound that may promote reepithelialization. Methemoglobinemia (MetHba), an oft-cited side effect, is rare, but the compound is infrequently used worldwide. This is a retrospective cohort study investigating the effects of Cerium at a regional burn center. After IRB approval, patients admitted between 7/1/2014 & 7/1/2018 were screened to determine if they received Cerium. Data including demographics, burn injury & management, laboratory values & cerium application were extracted. Primary endpoints were time to surgery of Cerium-treated burns, reepithlialization & incidence of MetHba & its treatment. Of the 142 patients meeting inclusion criteria, the mean age was 56.3 & the majority were black (46%) males (67%). The most common etiologies were flame (43%), contact (25%) & scald (18%). Smoking was prevalent (28.5%). Mean TBSA was 9.9% with mean adjusted Baux score of 67.9 & APACHE II score of 10.8. 64.3% were admitted to the ICU & 10.7% had inhalation injury. Time to Cerium application was 1.67 days with 15.5 total doses received. Total TBSA treated with Cerium was 6.1% (4.5% full thickness, 1.6% partial thickness). Time to any surgery was 2.6 days whereas the time to surgery for areas treated with Cerium was 4.8 days. 10.7% of patients had treated wounds smaller than presentation at time of surgery. The mean pre-Cerium methemoglobin (MetHb) value was 1.2, while checks 12-36 h & 48-72 h post first application were 1.2 & 1.4, respectively. 9.8% developed MetHba levels >2.5%. All patients except 1 were asymptomatic. The symptomatic patient became hypoxic with MetHb of 9.4%, required reintubation, & was treated with Methylene Blue. At our center, Cerium is a well-tolerated medication with a minimal side-effect profile. Only one patient (0.7%) developed clinically significant MetHba requiring intervention. Reintubation in this patient was multifactorial as he had been extubated the same day & required frequent suctioning for copious, thick secretions, in addition to MetHba. Previous reports have described patients tolerating MetHb levels up to 31.8% without intubation. It can successfully be used to temporize burn wound excision & grafting, with our data supporting reepithelialization. Future work will study Cerium prospectively. Cerium cream is a topical dressing with few side effects which allows delayed burn excision & may improve tissue salvage.

498 Healing of Donor Sites with an Autologous Skin Cell Suspension for Large TBSA Burn Injuries: A Prospective Evaluation

Current treatment for burn injuries is the use of split-thickness skin grafts (STSG), however this treatment is often limited by donor site availability and requires reharvesting of donor sites to obtain definitive closure. In uncompromised patients it can take 7-14 days to heal, and for patients with severe injuries, this time can be delayed. The RECELL® System is a point-of-care device that allows for the preparation and application of non-cultured, autologous skin cells; however the safety and effectiveness has not been established for use in the treatment of donor sites. This study presents the use of autologous skin cell suspension (ASCS), prepared using the RECELL® System for the treatment of donor sites in patients enrolled in a prospective uncontrolled observational study (IDE 15945—NCT02992249) with life-threatening burn injuries. Following harvesting of STSGs, ASCS was applied to the donor site. Clinical outcomes were evaluated up to one year including percentage of re-epithelialization, long-term cosmetic outcomes, and adverse events. Seventy-three patients from 15 burn centers had their donor sites treated with ASCS as part of their treatment regimen. The average subject age was 29 and the average TBSA injury was 54.1 ±16.5%. The mean Baux score was 84.3 with 32% of subjects having a score greater than 100. Collectively, 430 donor sites were individually treated. In this compromised patient population 45.5% were ≥95% re-epithelialized by week 1 (n=345), and by week 2, 91% of the donor sites were ≥95% re-epithelialized (n=277), regardless of times harvested. Approximately 20% of the donor sites treated with ACSC were reharvested multiple times following initial healing (3.5% three times, and two donor sites were harvested four times) and retreated. Of donor sites harvested more than once, 51.6% (n=62), 84.6% (n=66), and 96.4% (n=55) of sites were ≥ 95% re-epithelialized by week 1, 2 and 4, respectively. One-year data was available for 300 donor sites and the majority had matched or mildly mismatched color, pigment, and texture. Adverse events included one site with a hematoma and one patient with donor sites that had fragile skin loss secondary to traumatic friction. There were no other instances of infection or delayed healing. ASCS has been successfully used to achieve closure of donor site wounds without infection or delayed healing in patients with extensive burn injuries. Application of ASCS for donor site healing may be particularly applicable for patients requiring subsequent reharvesting to achieve definitive closure.

Timely access to care for patients with critical burns in India: a prehospital prospective observational study

BackgroundLow/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care...