Body Surface Area Burn Research Articles

102 Wildfire Burns: Implications for Burn Care

Abstract Introduction Climate change, the encroachment of populations into wilderness, and carelessness have combined to increase the incidence of wildfire injuries. With the increased incidence has come an increase in the number of burn injuries. Prolonged extrication, delays in resuscitation, and the extreme fire and toxic air environment in a wildfire has the potential to cause more severe burn injury. The purpose of this study is to examine the demographics and outcomes of wildfire injuries and compare those outcomes to non-wildfire injuries. Methods Charts of patients admitted to a regional burn center during a massive wildfire in 2018 were reviewed for demographic, treatment, and outcome. We then obtained age, gender, and burn size matched controls from within 2 years of the incident, analyzed the same measures, and compared treatment and outcomes between the two groups. Results A total of 20 patients, 10 wildfire (WF) burns and 10 non-wildfire (NWF) burns, were included in the study. Age (59.6±7.8 WF vs. 59.4±7.4 years), total body surface area burn (TBSA) (14.9±4.7 WF vs. 17.2±0.9 NWF) and inhalation injury incidence (2 WF and 2 NWF) were similar between groups. Days on mechanical ventilation (24.3±19.4 WF vs. 9.4±9.8 NWF), length of stay (49.9±21.8 WF vs. 28.2±11.7 days) and ICU length of stay (43.0±25.6 WF vs 24.4±11.2 NWF) were higher in the WF group. WF patients required twice the number of operations. Mortality was similar in both groups (1 death/group). Conclusions Wildfire burn injuries, when compared to age, inhalation injury, and burn size matched controls, require more ventilatory support and have more operations. As a result, they have longer lengths of stay and have a prolonged ICU course. Burn centers should be prepared for the increased resource utilization that accompanies wildfire injuries. Applicability of Research to Practice All burn centers must be prepared for the possibility of wildfires and the increased resource utilzation that accompanies mass casualty events.

793 Development and Validation of a Burn Center Discharge Readiness Checklist to Identify Patients at High Risk of 30 Day Readmission

Abstract Introduction With increased focus amongst hospital systems regarding the quality of care provided, there has been augmented awareness on minimizing unplanned 30 day hospital readmission rates. As part of our burn center’s internal quality improvement process, a discharge readiness checklist was developed to identify patients at high risk for readmission. Methods A 20 item checklist of potential risk factors was developed, and was then cross referenced to all patients readmitted within 30 days of discharge over a one year period (September 2018-August 2019). Retrospective chart review was used to determine how many checklist factors were positive for each patient. The primary outcome was determining the main risk factors leading to a high risk for readmission. Results During this time period, there were 683 admission to our burn center. A total of 13 patients led to a sum of 14 readmissions (2.0%). The age range of patients was between 37 and 84 years old, with a median and average age of approximately 59 years. The distribution of patients included 7 with burn injuries (50%), 6 with soft tissue infections (42.9%) and 1 with frostbite (7.1%). Traditional LACE (Length of stay, Acuity, Co-morbidities, ED visits) score calculation would have identified only 1 of 14 readmissions in the high risk category. Average LACE score was 8.1 for all patients. Of the 20 item checklist, the risk factors most commonly associated with readmission were lack of family support (12/14, 85.7%), surgery performed during index hospitalization (11/14, 78.6%), significant co-morbidities (11/14, 78.6%), location of injuries in difficult to access anatomical regions (8/14, 57.1%), poor nutritional status (6/14. 42.8%) and length of stay greater than 1 day per percent of total body surface area burn involvement (5/7, 71.4%). The average number of identifiable risk factors was 5.38 per patient (ranging from 2 to 9 risk factors per patient). Conclusions Traditional risk assessment scores (i.e. LACE) do not capture patients at high risk for readmission in a burn center. Development of an alternative checklist may help to identify these patients prior to discharge, with the potential to allocate additional resources to ultimately decrease 30 day readmission rates. Applicability of Research to Practice Decreased 30 day readmission rates would lead to overall cost savings and improved patient outcomes.

553 Work-related Burn Injuries Among Burn Patients in a Tertiary Care Burn Facility, 2013 – 2018

Abstract Introduction The characteristics of work-related (WR) burn injuries compared to non-work-related (non-WR) burns are not well defined in the literature. In an effort to determine the potential impact of commonly accepted prevention efforts, we compared WR and non-WR burn injuries in our facility for the last five years. Methods All patients admitted to the burn center between January 1st, 2013 and December 31st, 2018, of working age were included. Demographics, burn characteristics, and patient outcomes were evaluated using Student’s t-test and chi-squared test where appropriate, significance was accepted at p< 0.05. Results 3,545 patients were included in this study. WR patients were 22% of all patients in this cohort. The majority of patients in both cohorts were white males in their twenties. Compared to non-WR patients, WR patients had fewer comorbidities with 30% smaller total body surface area burns, and shorter lengths of stay (see table). WR patients were more likely to suffer chemical (14.5% vs 2.3%) and electrical burns (11.9% vs 1.2%) compared to non-WR patients, respectively. 67% percent of WR burn fatalities were from electrical injuries, while flame was the leading cause of death in non-WR patients. Conclusions WR burn injured patients are young males with fewer co-morbid conditions. Etiologies of injuries are vastly different between non-lethal and lethal WR and non-WR injuries. Classic burn prevention strategies that target flame burn injuries and fatalities will have little impact on WR burn injuries. Applicability of Research to Practice This study highlights the importance of focusing prevention campaigns to industry as well as schools and homes.

Influence of Inhalation Injury on Incidence, Clinical Profile and Recovery Pattern of Dysphagia Following Burn Injury.

Inhalation injury is predictive of dysphagia post burns; however, the nature of dysphagia associated with inhalation burns is not well understood. This study describes the clinical profile and recovery pattern of swallowing following inhalation burn injury. All patients admitted 2008–2017 with confirmed inhalation burns on laryngoscopy and managed by speech-language pathology (SLP) were included. Initial dysphagia presentation and dysphagia recovery pattern were documented using the FOIS. Co-presence of dysphonia was determined clinically and rated present/absent. Persistent laryngeal/pharyngeal injury at 6 months was documented using laryngoscopy. Data were compared to published data from a large adult burn cohort. All patients with confirmed inhalation burns during the study period received SLP input, enabling review of 38 patients (68% male; m = 40.8 years). Percent Total Body Surface Area burn ranged 1–90%, 100% had head and neck burns, 97% required mechanical ventilation (mean 9.4 days), 18% required tracheostomy and 100% had dysphonia. Comparing to non-inhalation burn patients, the inhalation cohort had significantly (p < 0.01) higher dysphagia incidence (89.47% vs 5.6%); more with severe dysphagia at presentation (78.9% vs 1.7%); increased duration to initiate oral intake (m = 24.69 vs 0.089 days); longer duration of enteral feeding (m = 45.03 vs 1.96 days); and longer duration to resolution of dysphagia (m = 29.79 vs 1.67 days). Persistent laryngeal pathology was present in 47.37% at 6 months. This study shows dysphagia incidence in burn patients with inhalation injury is 16 times greater than for those without inhalation injury. Laryngeal pathology due to inhalation injury increases dysphagia severity and duration to dysphagia recovery.

Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision.

Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs. 4:1 packed red blood cell to fresh frozen plasma transfusion strategy during massive burn excision. Children with >20% total body surface area burns were randomized to a 1:1 or 4:1 packed red blood cell/fresh frozen plasma transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, pediatric risk of mortality (PRISM) scores, pediatric logistic organ dysfunction scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n = 34). Mean age, PRISM scores, estimated blood loss (600 ml (400-1175 ml) vs. 600 ml (300-1150 ml), P = 0.68), ventilator days (5 vs. 9, P = 0.47), and length of stay (57 vs. 60 days, P = 0.24) had no difference. No differences in frequency of blood stream infection (20 vs. 18, P = 0.46) or pneumonia events (68 vs. 116, P = 0.08) were noted. On multivariate analysis, only total body surface area burn size, inhalation injury, and PRISM scores (P < 0.05) were significantly associated with infections.

The Optimal Treatment for Partial Thickness Burns: A Cost-Utility Analysis of Skin Allograft vs. Topical Silver Dressings.

Partial thickness burns not undergoing surgical excision are treated with topical silver products including silver sulfadiazine (SSD) and Mepilex Ag. Skin allograft is a more costly alternative that acts as definitive wound coverage until autogenous epithelialization. Economic constraints and the movement toward value-based care demand cost and outcome justification prior to adopting more costly products. A cost-utility analysis was performed comparing skin allograft to SSD and Mepilex Ag using decision tree analysis. The base case modeled a superficial partial thickness 20% total body surface area burn. Utilities were derived from expert opinion on the basis of personal experience. Costs were derived from 2019 Medicare payments. Quality adjusted life years were calculated using rollback method assuming standard life expectancies in the United States. Probabilistic sensitivity analysis was performed to asses model robustness. The incremental costs of skin allograft to Mepilex Ag and SSD were $907.71 and $1257.86, respectively. The incremental quality adjusted life year (QALY) gains from allograft over Mepilex Ag and SSD were 0.011 and 0.016. This yielded an incremental cost-utility ratio for allograft vs. Mepilex Ag of $84,189.29/QALY compared with an incremental cost-utility ratio of $79,684.63/QALY for allograft vs. SSD. Assuming willingness-to-pay thresholds of $100,000/QALY, probabilistic sensitivity analysis demonstrated that allograft was cost effective to Mepilex Ag in 62.1% of scenarios, and cost effective to SSD in 64.9% of simulations. Skin allograft showed greater QALYs compared with topical silver dressings at a higher cost. Depending on willingness-to-pay thresholds, skin allograft may be a considered a cost-effective treatment of partial-thickness burns.

Management of Critically Injured Burn Patients During an Open Ocean Parachute Rescue Mission.

Best practices and training for prolonged field care (PFC) are evolving. The New York Pararescue Team has used part task training, cadaver labs, clinical rotations, and a complicated sim lab to prepare for PFC missions including critical care. This report details an Atlantic Ocean nighttime parachute insertion to provide advanced burn care to two sailors with 50% and 60% body surface area burns. Medical mission planning included pack-out of ventilators, video laryngoscopes, medications, and 50 L of lactated Ringer's (LR). Over the course of 37 hours, the patients required high-volume resuscitation, analgesia, wound care, escharotomies, advanced airway and ventilator management, continuous sedation, telemedicine consultation, and complicated patient movement during evacuation. A debrief survey was obtained from the Operators highlighting recommendation for more clinical rotations and labs, missionspecific pack-outs, and tactical adjustments. This historic mission represents the most sophisticated PFC ever performed by PJs and serves to validate and share our approach to PFC.

The association between vitamin D levels and burn factors in different burn types.

BackgroundPatients with burns present with different clinical features depending on the types of burn injury and burn patients with lower levels of vitamin D have worse prognoses and more complications. The study aims to investigate the association between vitamin D levels and burn factors according to each burn type in relation to early intensive rehabilitation therapy initiated for inpatients with burns.MethodsIn this retrospective study, we enrolled 757 of 1716 inpatients who underwent rehabilitative therapy between May 2013 and April 2017. Burn types were divided into flame burn, electrical burn and other burns, including scalding, contact and chemical burns. Age, burned body surface area (BSA), wound healing time (WHT), length of hospital stay (LOS) and body mass index were analysed between vitamin D deficient and non-deficient patient groups using Student’s t-tests, or Mann-Whitney U test and among three burn types using one-way analysis of variance (ANOVA) or Kruskal-Wallis one-way ANOVA. The relationship between vitamin D levels and burn factors was evaluated using Pearson's or Spearman's correlation coefficient tests, and multiple linear regression analysis in different burn groups.ResultsIn total, 88.9% patients were vitamin D deficient, and these patients had a larger burned BSA (p = 0.015) and longer WHT and LOS (all p < 0.001) than non-deficient patients. Burned BSA, WHT and vitamin D levels showed significant differences in their mean values according to three burn types (all p < 0.001). WHT was a communal factor significantly associated with vitamin D levels in all three burn types (p < 0.05). The WHT cut-off points to predict vitamin D deficiency were 55 days for flame burn (p < 0.001) and 62.5 days for electrical burn (p = 0.001).ConclusionsWHT across all three burn types was a common factor associated with vitamin D levels for inpatients with burns who had undergone rehabilitative therapy. Electrical burn patients with vitamin D deficiency, even those with a low burned BSA percentage, showed prolonged wound healing over a two-month post-burn period. Independent of burned BSA, nutritional intervention concerning vitamin D in relation to burn wound healing should be considered to guide early initiation of intensive rehabilitation therapy.

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.

Metal chelation reduces skin epithelial inflammation and rescues epithelial cells from toxicity due to thermal injury in a rat model.

BackgroundOne of the most pervasive complications of burn injury is wound progression, characterized by continuous tissue destruction in untreated wounds, which leads to wound infection, inflammation, oxidative stress and excessive scar formation. We determined whether additional tissue destruction could be attenuated with Livionex formulation (LF) lotion, which contains a metal-chelating agent and reduces inflammation in burn wounds.MethodsWe subjected male Sprague Dawley rats to a 2% total body surface area (TBSA) burn using a brass comb model and topically applied LF lotion (containing ethylenediaminetetraacetic acid and methyl sulfonyl methane) to the affected area every 8 hours over 3 days. Inflammatory cytokine levels, cell apoptosis and wound healing were compared in LF lotion-treated and untreated rats. Statistical analysis was performed using a one-way analysis of variance in conjunction with Tukey’s post-hoc test.ResultsSerum inflammatory cytokines were not detectable after 3 days, suggesting that small burn wounds induce only an immediate, localized inflammatory response. Microscopy revealed that LF lotion improved burn site pathology. Deoxynucleotidyl transferase biotin-d-UTP nick-end labeling staining showed reduced cell death in the LF-treated samples. LF lotion prevented the spread of tissue damage, as seen by increased amounts of Ki-67-positive nuclei in the adjacent epidermis and hair follicles. Tumor necrosis factor-alpha, interleukin-6 and inducible nitric oxide synthase levels in LF-treated skin sections from burned rats were comparable to the levels observed in unburned control sections, indicating that LF lotion reduces inflammation in and around the burn site.ConclusionsThese results establish LF lotion as a therapeutic agent for reducing inflammatory stress, cell death and tissue destruction when applied immediately after a burn injury. Further studies of LF lotion on large TBSA burns will determine its efficacy as an emergency treatment for reducing long-term morbidity and scarring.

Surgical Management Evolution Between 2 Massive Burn Cases at 17-Year Interval: Contribution of Cell Therapies in Improving the Surgical Care

We report the cases of 2 patients admitted to our hospital at a 17-year interval, both with 90% total body surface area (TBSA) burns. These two young patients were in good health before their accident, but major differences in time of intensive care and hospitalization were observed: 162 versus 76 days in intensive care unit and 18 versus 9.5 months for hospitalization, respectively. We have analyzed the different parameters side-by-side during their medical care and we have identified that the overall improved outcomes are mainly due to a better adapted fluid reanimation in combination with the evolution of the surgical management to encompass allogenic cellular therapy (Biological Bandages). Indeed, autologous cell therapy using keratinocytes has been used for over 30 years in our hospital with the same technical specifications; however, we have integrated the Biological Bandages and routinely used them for burn patients to replace cadaver skin since the past 15 years. Thus, patient 1 versus patient 2 had, respectively, 83% versus 80% TBSA for autologous cells, and 0% versus 189% for allogenic cells. Notably, it was possible that patient 2 was able to recover ∼6% TBSA with the use of Biological Bandages, by stimulating intermediate burn zones toward a spontaneous healing without requiring further skin grafting (on abdomen and thighs). The body zones where Biological Bandages were not applied, such as the buttocks, progressed to deeper-stage burns. Despite inherent differences to patients at their admission and the complexity of severe burn care, the results of these two case reports suggest that integration of innovative allogenic cell therapies in the surgical care of burn patients could have major implications in the final outcome.

Prevalence and associated predictors for patients developing chronic neuropathic pain following burns.

BackgroundChronic pain, unrelated to the burn itself, can manifest as a long-term complication in patients sustaining burn injuries. The purpose of this study was to determine the prevalence of chronic neuropathic pain (CNP) and compare burn characteristics between patients who developed CNP and patients without CNP who were treated at a burn center.MethodsA single-center, retrospective analysis of 1880 patients admitted to the adult burn center was performed from 1 January 2014 to 1 January 2019. Patients included were over the age of 15 years, sustained a burn injury and were admitted to the burn center. CNP was diagnosed clinically following burn injury. Patients were excluded from the definition of CNP if their pain was due to an underlying illness or medication. Comparisons between patients admitted to the burn center with no pain and patients admitted to the burn center who developed CNP were performed.ResultsOne hundred and thirteen of the 1880 burn patients developed CNP as a direct result of burn injury over 5 years with a prevalence of 6.01%. Patients who developed CNP were a significantly older median age (54 years vs. 46 years, p = 0.002), abused alcohol (29% vs. 8%, p < 0.001),abused substances (31% vs. 9%, p < 0.001), were current daily smokers (73% vs. 33%, p < 0.001), suffered more full-thickness burns (58% vs. 43%, p < 0.001), greater median percent of total body surface area (%TBSA) burns (6 vs. 3.5, p < 0.001), were more often intubated on mechanical ventilation (33% vs. 14%, p < 0.001), greater median number of surgeries (2 vs. 0, p < 0.001) and longer median hospital length of stay (LOS) (10 days vs. 3 days, p < 0.001), compared to those who did not develop CNP, respectively. Median patient follow-up was 27 months.ConclusionsThe prevalence of CNP over 5 years was 6.01% in the burn center. Older ages, alcohol abuse, substance abuse, current daily smoking, greater percent of total body surface area (%TBSA) burns, third degree burns, being intubated on mechanical ventilation, having more surgeries and longer hospital LOS were associated with developing CNP following burn injury, compared to patients who did not develop CNP following burn injury.

Evaluation of EpiProtect® microbial cellulose burns dressings in young children.

Introduction:EpiProtect® is a biosynthetic cellulose dressing indicated for the treatment of superficial burns and the dressing of deep burns. Prior to this study the youngest reported patient treated with EpiProtect® was aged 13 years.Method:Data were collected prospectively for patients aged < 5 years, presenting to the Children’s Burns Unit with ⩾ 2% total body surface area (TBSA) burns sustained by any mechanism.Results:Thirty children were treated (median age = 17 months, age range = 1–61 months). Thirty-six burn depths were documented: superficial partial thickness (SPT) in 53% (n=19); mid-partial thickness (MPT) in 33% (n=12); deep partial thickness (DPT) in 11% (n=4); and full thickness (FT) in 3% (n=1). Median burn size was 4.5% TBSA (range = 2%–12%). EpiProtect® was applied under general anaesthesia in all cases. The median length of stay (LOS) was two days (range = 0–6 days). EpiProtect® was tolerated well and provided effective analgesia for subsequent dressing changes. Median healing time was 13 days (SPT burns), 14 days (MPT) and 24 days (DPT burns). Three patients required split skin grafting. Hypertrophic scarring arose in one patient.Discussion:This case series represents the youngest published patient group to have been treated with EpiProtect®. Authors conclude that EpiProtect® provides a safe, reliable and well-tolerated dressing option for all burn depths in young children. Importantly, EpiProtect® is culturally neutral and may be used in situations which, for cultural reasons, may preclude the use of animal-derived products. Further studies are warranted to evaluate pain scores, burn depth, size and LOS correlation, and comparative analysis between dressing types.Lay SummaryBurn injuries in the paediatric population are common and often require multiple dressing changes. Dressing changes can be painful and distressing to both children and their care givers. This article describes the experience of using a synthetically derived burns dressing, called EpiProtect®, in children aged ⩽ 5 years. Thirty patients were recruited with varying depths of scald burns and all underwent application of EpiProtect® dressing. The results suggested that EpiProtect® was a user-friendly dressing that can be used to treat partial-thickness burns and to dress full-thickness (FT) burns. It was well-tolerated and provided effective analgesia at the time of dressing changes. There was no incidence of increased burn wound infection rates and all wounds healed. In addition, as EpiProtect® is a synthetic product, it has the benefit of being culturally neutral, which is advantageous in a culturally diverse population. Further studies are warranted to evaluate the effectiveness of this dressing and to compare it to similar dressings that are available.

The Use of Dehydrated Human Amniotic Membrane Versus Amniotic/Chorionic Membrane Allografts to Treat Partial Thickness Facial Burns.

Facial burns have significant physical and psychologic effects on patients. Human dehydrated amniotic membrane represents novel technology, yet its outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the benefits of amniotic membrane (DHAM) to amniotic/chorionic membrane (DHACM) skin substitutes to treat partial thickness facial burns. Retrospective review of data collected from our institutional burn registry from 2012 to 2016. Demographic characteristics including age, total body surface area (TBSA) burn and injury severity scores were collected and outcome measures were compared between the 2 groups. Paired sample t-test and Chi-squared were used with significance defined as P < 0.05. A total of 77 adult patients with partial thickness facial burns who received DHAM and DHACM skin substitutes were included in the analysis. The mean age for the DHAM group was 39.8 compared to 41.4 for the DHACM. Mean TBSA was similar, with 10.9% in the DHAM group compared to 8.3% in the DHACM. Patients receiving DHAM had higher requirement for skin substitute surgical reapplications as compared to the DHACM group (23.7% versus 5.1%, P ≤ 0.05). Remaining morbidities remained low and not significantly different between patients receiving DHAM and DHACM substitutes (P > 0.05). The DHAM and DHACM skin substitutes are valid and safe alternatives in the treatment of adult partial thickness facial burns.

"Home" Alone.

"Home" Alone Andrea Hope Rubin and Monica L. Gerrek This narrative is a collaboration between Andrea Rubin, burn survivor, and Monica Gerrek, burn unit ethicist. Monica begins by describing Andrea's injuries and hospitalization. Monica On October 11, 2014, Andrea Hope Rubin was in a freak car accident. Though she was rescued from the burning car, she suffered a 58% total body surface area burn with third degree burns to her chest, arms, back, legs, head, and face. Andrea was left without a nose or ears, barely any lips or eyelids, and she lost partial vision in her right eye. She also suffered fourth degree burns on her lower right arm, which was quickly amputated just below the elbow. Andrea's scalp was so badly burned that her hair will never grow back and, to this day, she continues to seek treatment for the wounds on her head. Andrea spent approximately 12 weeks in the burn intensive care unit. She was intubated and sedated for about half of that time. After being discharged from the burn unit, she spent roughly eight weeks in a rehabilitation unit, which was located in the hospital. Because of this set up, Andrea was easily able to receive continuing treatment from the burn team and other providers. During this time, she was told repeatedly that she would be going to acute rehab for eight weeks upon discharge. Though Andrea was not looking forward to this, she was committed to ensuring the best possible recovery for herself and doing the necessary work to achieve independence. Needless to say, Andrea was elated when she was told she was too advanced with respect to occupational therapy to go to acute rehab and would be going home instead. No one had expected Andrea to recover so quickly. She had received a lot of praise during her time in inpatient rehab because of her diligence and dedication to regaining her physical abilities. Andrea knew she had worked hard and was proud of herself for being an overachiever. After hearing the news, Andrea quickly started making phone calls to family and friends to share her excitement with them. Her elation over her new discharge plans quickly turned to tremendous fear, however, when her family and friends panicked at the news. Andrea Everyone who asked about my going home asked about "acute care." I had to convince them that I was going home home, and I couldn't believe no one was happy that I was coming home five months after my accident. I was just so happy to go home that I figured surely insurance or someone will care for me. I didn't think beyond it. I was just so excited to get out of the institutionalized environment. Then I saw everyone around me panic and they started [End Page 210] talking about putting me in a nursing home and I didn't know who was going to pay for that. I got frightened. Monica Conversations with family and friends made Andrea realize that she couldn't actually take care of herself. She could barely feed herself or brush her teeth, let alone cook, shower, dress, or drive herself to the numerous doctors' appointments she would have upon discharge. When Andrea expressed her concerns to her providers and asked them to reconsider, they told her that it wasn't up to them—that according to her insurance company she was not eligible for acute rehab given she had met the standards for discharge to home. Andrea was incredulous. She couldn't believe anyone expected her to go home and manage activities of daily living or instrumental activities of daily living on her own. Andrea There was nothing that bridged the gap for care—from hospital to home. My family was so freaked out. What are we going to do with her? Who's going to do what and where and when and how? My family was so stressed out . . . I need rides, I need to get places, there was constant care. The exit strategy was non-existent. Monica In addition, Andrea didn't have a home to go home to. Prior to the accident, she had been living with a...

The effect of a hydrolyzed collagen-based supplement on wound healing in patients with burn: A randomized double-blind pilot clinical trial

IntroductionBurn is among the most severe forms of critical illness, associated with extensive and prolonged physical, metabolic and mental disorders. The aim of this study was to assess the effect of an oral, low-cost, and accessible collagen-based supplement on wound healing in patients with burn. MethodsIn this randomized double-blind controlled pilot clinical trial, 31 men, 18–60years, with 20–30% total body surface area burn were studied. Patients were randomly assigned to receive either a collagen-based supplement (1000kcal) or an isocaloric placebo, for 4 weeks. Serum pre-albumin, rate of wound healing, length of hospital stay, and anthropometries were assessed at baseline, and the end of week 2 and 4. ResultsSerum pre-albumin was significantly higher at week 2 (29.7±13.6 vs. 17.8±7.5mg/dL, P=0.006) and week 4 (35.1±7.6 vs. 28.3±8.2mg/dL, P=0.023) in collagen than control group. Changes in pre-albumin concentration were also significantly higher in collagen group at week 2 (13.9±9.8 vs. −1.9±10.3mg/dL, P<0.001) and week 4 (19.2±7.5 vs. 8.5±10.1mg/dL, P=0.002). The Hazard ratio of wound healing was 3.7 times in collagen compared to control group (95% CI: 1.434–9.519, P=0.007). Hospital stay was clinically, but not statistically, lower in collagen than control group (9.4±4.6 vs. 13.5±7 days, P=0.063). There were no significant differences in weight, body mass index, dietary energy and protein intakes between the two groups. ConclusionThe findings showed that a hydrolyzed collagen-based supplement could significantly improve wound healing and circulating pre-albumin, and clinically reduce hospital stay in patients with 20–30% burn.

Clinical characteristics and risk factors for severe burns complicated by early acute kidney injury.

Early acute kidney injury (AKI) is a frequent fatal complication of severely burned patients. Although significant progress has been made in fluid resuscitation, intensive care, and renal replacement therapy (RRT) technology in recent years, the incidence and mortality rate in severely burned patients with AKI remains considerable. This study aims to provide theoretical evidence for prevention and treatment by investigating the clinical characteristics and risk factors influencing the incidence and severity of early AKI in severely burned patients. This 3-year retrospective, single-center study was conducted in critically ill burned patients admitted to the Burn ICU at Guangzhou Red Cross Hospital of Jinan University. Patients whose age is older than 18 years with ≥30% burned total body surface area (TBSA) were enrolled in this study. Those patients who arrived at our burn ICU>72h after injury or died within 48h from arrival were excluded. Data of 128 patients were studied in the final. Demographic and injury details were recorded. KDIGO criteria were used to assess the incidence and severity of early AKI. Factors influencing early AKI were determined using univariate and multiple logistic regression analysis. Between January 2016 and December 2018, Data from 128 critically ill burned patients were available for analysis. The median age was 44.9±16.8 years; 68.8% of the patients were male. The median TBSA% was 60 (IQR, 41.3-80%). According to the KDIGO criteria, 36 patients (28.3%) developed early AKI, as follows: stage 1 AKI, 69.4% (25/36); stage 2 AKI, 13.9% (5/36); and stage 3 AKI, 16.7% (6/36). The incidence of early AKI was associated with TBSA%, full-thickness TBSA%, abbreviated burn severity index on admission (ABSI), inhalation injury, mechanical ventilation, cardiovascular complications, and rhabdomyolysis. Multiple logistic regression analysis indicate that TBSA% (OR=0.224, p=0.007), full-thickness TBSA% (OR=0.254, p=0.014), ABSI (OR=18.326, p=0.009), and rhabdomyolysis (OR=24.036, p=0.000) were independent risk factors for the occurrence of early AKI. Significant factors influencing the severity of early AKI included full-thickness body surface area burns, electrical burns, and rhabdomyolysis. Full-thickness TBSA% (OR=1.437, p=0.041) and rhabdomyolysis (OR=5.401, p=0.035) are associated with mortality. The risk of death due to the occurrence of AKI was 5.407 in the Cox model adjusted for TBSA%, full-thickness body surface area burns, ABSI and rhabdomyolysis. Three patients died, all of whom had stage 3 AKI, accounting for 8.3% (3/36) of AKI patients. The death rate of stage 3 AKI who did and did not receive early RRT was 33.3% and 66.7%, respectively. Rhabdomyolysis is an independent risk factor for early AKI and closely related to the severity of early AKI in critically ill burned patients. Although with a high incidence of early AKI in severely burned patients, most of them are mild. Early adequate fluid resuscitation, timely and effective escharotomy, reducing the incidence and severity of rhabdomyolysis, most of them can achieve a relatively good prognosis.

Silver serum levels in burned patients treated with silver sulfadiazine and its toxicity on inflammatory cells.

Silver sulfadiazine (SSD) has been widely used in burned patients for the prevention of local infections. To be biologically active and exert antimicrobial properties, silver needs to be present in the form of silver ions (Ag1+) that bind to negatively charged proteins, namely, the RNA and DNA in microorganisms. However, previous published studies conducted with SSD in the 1990s reported a high level of silver absorption through damaged skin and noted the potential cytotoxicity of Ag1+ to human cells. SSD toxicity, however, had been described in cell cultures using arbitrary silver concentrations. In the present study, we determined the serum silver levels in burned patients treated with SSD and, taking into account the molar Ag1+ concentrations found in these patients, we evaluated the Ag1+ toxicity effects on inflammatory cells (ROS and cytokine production) in vitro. Twenty patients with an average burned body surface area of 27.68% were included in this study. Patients' Ag1+ serum levels reached up to 558 times those of the unexposed controls. Ag1+ was then added to inflammatory cells in vitro at levels up to 2000 times the level of the control, and there was no effect on the viability of the cells nor on the rate of apoptosis. We observed a decrease in reactive oxygen species production by mononuclear (MN) and polymorphonuclear (PMN) cells, as well as a substantial decrease in cytokines IL-1β, IL-6, IL-8, IL-10, and TNF-α production by leukocytes (MN and PNM). These findings suggest that Ag1+ may contribute to negative outcomes after burns, decreasing the primary defense mechanism (respiratory burst) and altering cytokine production.

Epidemiology and outcome analysis of facial burns: A retrospective multicentre study 2011–2015

BackgroundThe head and neck regions are frequent sites of burns, but few studies have analysed and reported the epidemiology of facial burns. As the face is the centre of one’s identity and persona, facial injuries often result in physical and psychological morbidity. The aim of this article is to describe the epidemiology and outcome of facial burns in China and to suggest future preventive strategies. MethodsThis retrospective analysis included all patients with facial burns in a database at eight institutions from 2011–2015. The data collected included sex, age, month distribution, aetiology, location, presence of inhalation injury, total burn surface area, burn surface area with full-thickness and outcome including Post-traumatic stress disorder Checklist-Civilian Version scores and mortality. SPSS 19.0 software was used to analyse the data. ResultsA total of 1126 patients were included; 65.63% (739) had facial burns, of which 546 (73.88%) were male patients and 193 (26.12%) were female patients. Predictors of facial burns were being of male sex, working-related place, flame burns, total body surface area, and full-thickness burns. In addition, total body surface area and full-thickness burns increased the risk of poor prognosis for post-traumatic stress disorder and mortality. ConclusionsFacial burns benefit not only the healing of wound, but also the prevention of their incidence and PTSD symptom. This study may contribute to the elaboration of strategies to prevent facial burns and the establishment of a nationwide burn database in China.

Diagnostic blood loss from phlebotomy and hospital acquired anemia in patients with severe burns.

The study was performed to estimate the diagnostic blood loss (DBL) volume during hospitalization and investigate its relationship with the development of moderate to severe hospital acquired anemia (HAA) and increased number of red blood cell (RBC) transfusion following extensive burns. This was a retrospective study of adult burned patients with total body surface area (TBSA) burn larger than 40%, who were admitted to burn center of Changhai hospital between January 2005 and December 2017. We included a final number of 157 patients in the present study. Moderate to severe HAA within the fourth week postburn was developed in 46 of 121 patients who stayed over 28-day hospitalization. Patients with moderate to severe HAA had both significantly higher total DBL volume [245 (IQR: 183.75, 325.25) mL vs 168 (119, 163) mL ; P = 0.001] and DBL volume per day [10.22 (IQR: 8.57, 12.38) mL vs 6.63 (5.22, 10.42) mL/day; P = 0.005]. Logistic regression analysis revealed that both DBL volume per day and TBSA burn were independent risk factors for the development of moderate to severe HAA. Severely burned patients appear to be prone to develop HAA during hospitalization. The DBL volume contribute to the occurrence of moderate to severe HAA, which might be a modifiable target for preventing HAA.