Burn Depth Assessment Research Articles

VACUETTE® for burn depth assessment – A simple and novel alternative use for a ubiquitous phlebotomy device

The depth of any burn wound is an important determinant of its management and outcome. It also governs the outcome of wound healing and scarring making initial depth assessment extremely vital. Various methods both invasive and non-invasive have been described in literature for burn depth estimation.We describe a useful adjunct to clinical burn depth assessment, a VACUETTE® venous blood sampling device. This single cheap, ubiquitous and sterile device usually used for phlebotomy allows subjective assessment of the most useful parameters in the assessment of burn wounds, including, capillary refill, evaluation of sensation to blunt and sharp stimuli including pain.

Early Depth Assessment of Local Burns by Dermoscopy

This article has been retracted. See Notice of Retraction. To investigate the effectiveness of early depth assessment of local burns, the depth of which is difficult to assess with the naked eye, by dermoscopy. The morphological findings of burn wounds were prospectively evaluated by dermoscopy and videomicroscopy. Prior to dermoscopic and videomicroscopic measurement, clinical assessment was performed. All patients received conservative treatment for 21 days after injury. A burns unit at a primary care hospital. Thirty-two patients with 41 intermediate-depth local burn wounds were included. Inclusion criteria were time to presentation greater than 24 hours after injury and total burn size greater than 1% and less than 10% of the total body surface area. Primary healing within 21 days (superficial partial thickness) and failure of primary healing within 21 days (deep partial thickness). The accuracy, sensitivity, and specificity of the assessment according to the algorithm proposed in this study were evaluated by dermoscopy, and the accuracy of the dermoscopic measurements was compared with videomicroscopic measurements and clinical assessments. The results of dermoscopic measurements according to the proposed algorithm showed an accuracy of 93%, sensitivity of 86%, and specificity of 100%. The dermoscopic measurements were significantly more accurate compared with clinical assessment (P=.01). Dermoscopy is a noninvasive, portable, relatively inexpensive, and effective approach for assessment of the burn wound healing potential. It is more accurate if compared with clinical observation in burn depth assessment. It has a broader utility and is equally or more accurate compared with the more expensive videomicroscopy.

FluxEXPLORER: a new high‐speed laser Doppler imaging system for the assessment of burn injuries

Deep burn assessment made by clinical evaluation has an accuracy varying between 60% and 80% and will determine if a burn injury will need tangential excision and skin grafting or if it will be able to heal spontaneously. Laser Doppler Imaging (LDI) techniques allow an improved burn depth assessment but their use is limited by the time-consuming image acquisition which may take up to 6 min per image. To evaluate the effectiveness and reliability of a newly developed full-field LDI technology, 15 consecutive patients presenting with intermediate depth burns were assessed both clinically and by FluxExplorer LDI technology. Comparison between the two methods of assessment was carried out. Image acquisition was done within 6 s. FluxEXPLORER LDI technology achieved a significantly improved accuracy of burn depth assessment compared to the clinical judgement performed by board certified plastic and reconstructive surgeons (P < 0.05, 93% of correctly assessed burns injuries vs. 80% for clinical assessment). Technological improvements of LDI technology leading to a decreased image acquisition time and reliable burn depth assessment allow the routine use of such devices in the acute setting of burn care without interfering with the patient's treatment. Rapid and reliable LDI technology may assist clinicians in burn depth assessment and may limit the morbidity of burn patients through a minimization of the area of surgical debridement. Future technological improvements allowing the miniaturization of the device will further ease its clinical application.

Early depth assessment of local burns by videomicroscopy: A novel proposed classification

PurposeVideomicroscopy is very useful for burn depth assessment in an early phase; however, there is no practical classification that includes complicated anatomic, pathologic, and morphologic findings of burn wounds.The aim of this study was to propose a novel classification to assess burn depth in its early phase easily and reliably by videomicroscopy. MethodsForty-four patients with 56 intermediate-depth burn wounds were included. Burn depth was divided into each grade according to our proposed classification, which is composed of five categories based on dermal capillary integrity patterns. The intrarater and interrater reliabilities of the assessment by the second and third authors were evaluated by Cohen's unweighted κ-value. ResultsThe results of the measurements according to the proposed classification showed an accuracy of 92.9%, sensitivity of 81.8%, and specificity of 100.0%.The intrarater reliability of the second and third authors showed substantial agreement (κ=0.719 and 0.729, respectively). The interrater reliability of the sum of each observer's variable also showed substantial agreement (κ=0.636). ConclusionThis pattern analysis system is easy to use even for inexperienced personnel, and is reliable with high accuracy and specificity. Intrarater and interrater statistics also support its reliability and reproducibility.

The Use of Laser Doppler Imaging as a Predictor of Burn Depth and Hypertrophic Scar Postburn Injury

Hypertrophic scarring (HTS) is a fibroproliferative disorder that commonly develops after severe burn injuries. Overexpression of transforming growth factor-β (TGF-β) by an increased number of fibrocytes has been associated with increased extracellular matrix molecule expression leading to HTS. The most widely accepted adjuvant to clinical assessment of burn depth is laser Doppler imaging (LDI) and may predict injury to the dermis that corresponds to cellular and molecular changes associated with HTS. A prospective, blinded, control trial was performed comparing LDI and clinical assessment for the decision to operate. Immunohistochemistry and real-time reverse transcription polymerase chain reaction was performed to determine whether there is a correlation between histological assessment of burn depth and LDI, and the presence of fibrocytes was detected using confocal microscopy. The positive predictive value for a burn requiring a graft was calculated to be >90%. Immunohistochemistry on biopsy samples revealed an increased expression of TGF-β, connective tissue growth factor, heat shock protein 47, and collagen type I in deep burn wounds compared to superficial burns. Using the fibrocyte-specific markers procollagen type I and lymphocyte-specific protein-1, there was an increased number of fibrocytes in deep burn areas compared to superficial burn. In deep burn injuries, increased infiltration of fibrocytes occurs leading to an overexpression of TGF-β1 and connective tissue growth factor. More importantly, LDI was >90% accurate at predicting the need for excision and grafting. The accuracy of the decision to debride deep dermal burns to avoid HTS using both clinical parameters and LDI was supported by histological and biochemical measurements.

Burn size estimation in children: Still a problem

Accurate determination of burn size and depth forms an integral part of the initial assessment of any burn injury. Errors might lead to inaccurate fluid resuscitation and inappropriate transfer of patients to specialized burns units (BUs). Although recent data suggest some improvement in the estimation of burn injury in adults, this has not been shown in children. A retrospective review of children with burn injuries referred to the BU of our institution was performed. Data were collected from all patients presenting to the BU during the calendar year 2009. The total body surface area burned (TBSA-B) estimated by the referring centre was compared with the actual TBSA determined measured on arrival at the BU. Of the 71 paediatric patients referred during the study period, 10 did not have any TBSA-B estimation documented by the referring hospital. Inaccurate estimation of burn area was noted in 48 out of 61 patients (79%). Burn size was more likely to be overestimated than underestimated by a ratio of 2.2 to 1, especially in burns >10% TBSA-B (P= 0.002). Inaccurate estimation of burn size remains a problem in children. The persistent miscalculation of burn size might be a result of the various methods employed in assessing burn area, the inclusion of simple erythema and inadequate training or exposure of first responders. Accurate assessment of TBSA-B and burn depth in children remains elusive and would appear to require additional training and education.

Medical management of paediatric burn injuries: Best practice

Burns commonly occur in children and their first aid remains inadequate despite burn prevention programmes. While scald injuries predominate, contact and flame burns remain common. Although typically less severe injuries overall than those in adults, hypertrophic scarring complicating both the burn wound and even donor sites occur more frequently in children. The heterogeneous nature of burn wounds, coupled with the difficulties associated with the early clinical assessment of burn depth, has stimulated the application of novel technologies to predict burn wound outcome. This review explores current best practice in the management of paediatric burns, with a focus on prevention, optimal first aid, resuscitation, burn wound prediction and wound management strategies.

Early depth assessment of local burns by videomicroscopy: 24 h after injury is a critical time point

Purpose Videomicroscopy has simple and prompt operability, and useful in the burn depth assessment in its early phase. A burn wound is, however, a dynamic environment in the first few days and the critical time to assess a burn wound by videomicroscopy has not been investigated. The aim of this study is to investigate the critical time point to assess the burn depth by videomicroscopy. Methods Forty one patients with 44 intermediate depth burns admitted within 7 days after injury were included. Accuracies were assessed by comparison with clinical outcome: healing within 21 days after injury or not with conservative treatment. We prospectively evaluated and compared the accuracy of the videomicroscopy measurements with the clinical assessments. All findings were serialized in order of time after injury and divided into three groups, and we compared the appreciation of burn depth by videomicroscopy findings among groups. Results The videomicroscopy measurements is significantly accurate compared with clinical assessments ( p = 0.001). The accuracy of videomicroscopy measurements was significantly lower in the post-injury <24 h group compared with post-injury ≥24 h group ( p = 0.004). Conclusion Videomicroscopy is effective tool in assessment of early burn depth and the critical time point to assess the burn depth by videomicroscopy is 24 h after injury.

Man or Machine? The Clinimetric Properties of Laser Doppler Imaging in Burn Depth Assessment

Burns of an indeterminate depth present a challenge to burns surgeons and nurses on a daily basis in terms of healing and subsequent management, be it by a surgical or a more conservative approach. Laser Doppler imaging has become an important diagnostic modality in assisting the clinical decision-making process, being used widely in burns units throughout the United Kingdom and the rest of the world. Clinimetrics focuses on the methodology of measuring various biological parameters, and this article aims to describe laser Doppler imaging in this context by appraising the current body of evidence that illustrate its various properties. The authors conclude that indeterminate burn depth assessment should be a clinical judgment assisted by information provided by this device.

Revisiting protocols for burn injury management

The aim of the study was to reassess surgical protocols developed and introduced in 2005; to examine the changes that have been made and to understand why they have been necessary or felt to be an improvement on the original; and to introduce a new protocol to assist with burn depth assessment. A discussion of how the protocols were developed and the environment in which they are used is undertaken. Four years of experience using the protocols has been accrued. An examination of alterations is performed. The protocols have allowed a single-handed practitioner to deal successfully with a large caseload and enabled a greater understanding of time and resource management. The original development of the protocols was worthwhile but their continued evolution by frequent audit and evaluation of innovations in burn care is mandatory.

A review of burn care at an emerging centralised burns unit

Background. The aim of the study was to investigate the demographics, aetiological factors, anatomical lesions, biological features, management protocol and outcomes of patients admitted with major burn injuries to the Nelson Mandela Academic Hospital (NMAH), which is one of only three tertiary hospitals in the Eastern Cape and is in the process of establishing a designated burns unit. Methods. All burns patients admitted to the burns ward from January 2006 to July 2008 were included in the study. All were treated using multidisciplinary team care, a high index of suspicion for inhalation injuries, followed by prompt treatment, accurate burn extent and depth assessment, fluid therapy, patient-controlled analgesia, strict aseptic wound care, and early enteral feeding. Data collected included gender, age, residential address, cause and extent and depth of burns, serum albumin, whether any skin graft was done, hospital stay, complications and mortality. Results. The sample comprised 66 patients; 59 were children <14 years old, and 38 were <4 years. There were 34 males and 32 females; scalds and flame injuries accounted for 68% and 17% of cases respectively. The majority (85%) sustained burns ranging from 11% to 40% total body surface area (TBSA). The body areas injured were the left upper limb (60%), chest (58%), abdomen (49%) and right upper limb (48%). All sustained major burns, and skin grafts were performed on 39%. Complications included respiratory distress syndrome, fluid and electrolyte imbalances, protein energy malnutrition, infection and contracture deformities. The mean hospital stay was 3.7 days/%TBSA burn, and the overall mortality rate was 17%. Conclusion. Mortality was unacceptably high. The strain of aggressive management to reduce mortality and morbidity would be alleviated by measures such as community health education, raised socio-economic status, and safety legislation. Establishing a well-staffed and well-equipped burn unit would greatly improve patient care.

Critical Review of Burn Depth Assessment Techniques: Part II. Review of Laser Doppler Technology

The judgment of which wounds are expected to heal within 21 days is one of the most difficult and important tasks of the burn surgeon. The quoted accuracy of 64 to 76% by senior burn surgeons underscores the importance of an adjunct technology to help make this determination. A plethora of techniques have been developed in the last 70 years. Laser Doppler imaging (LDI) is one of the most recent and widely studied of these techniques. The technology provides an estimate of perfusion through the burn wound, the assumption being that a lower perfusion correlates with a deeper wound and, therefore, a longer time to heal. Although some reports suggest accuracy between 96 and 100% and that it does this 2 days ahead of clinical judgment, others have questioned its applicability to clinical practice. This article, the second of a two-part series, has two objectives: 1) a review of the Doppler principle and how the LDI uses it to estimate perfusion; and 2) a critical assessment of the burn literature on the LDI. Part I provides a historical perspective of the different technologies used through the last 70 years to assist in the determination of burn depth. Laser Doppler has brought technology closer to provide a reliable adjuvant to the clinical prediction of healing, yet, caution is warranted. A clear understanding of the limitations of LDI is needed to put the current research in perspective to find the right clinical application for LDI.

Critical Review of Burn Depth Assessment Techniques: Part I. Historical Review

The assessment of burn depth, and as such, the estimation of whether a burn wound is expected to heal on its own within 21 days, is one of the most important roles of the burn surgeon. A false-positive assessment and the patient faces needless surgery, a false-negative one and the patient faces increased length of stay, risks contracture, and hypertrophic scar formation. Although many clinical signs can aid in this determination, accurate assessment of burn depth is possible only 64 to 76% of the time, even for experienced burn surgeons. Through the years, a variety of tools have become available, all attempting to improve clinical accuracy. Part 1 of this two-part article reviews the literature supporting the different adjuvants to clinical decision making is, providing a historical perspective that serves as a framework for part 2, a critical assessment of laser Doppler imaging.

Pharmacologic Modification to Resuscitation Fluid After Thermal Injury—Is Drotrecogin Alfa the Answer to Arrest Burn Depth Progression?

The addition of drotrecogin alfa (DA), an anti-inflammatory useful in septic shock, to standard burn shock resuscitation fluids will protect burned, injured skin from further injury. Anesthetized animals were subjected to a standardized burn pattern by applying a branding iron to 10 different locations on the back of the rat for 1 seconds to 14 seconds, creating a range of burn depths and severities. Animal burn shock and resuscitation model. Thirty-one male adult Sprague-Dawley rats. Control animals were resuscitated with lactated Ringer's solution (LRS) at 2 mL/kg/percent total body surface area/24 h; experimental animals received LRS plus DA 24 microg/kg/h (LRS + DA). Perfusion to each burned area was assessed using a laser Doppler imaging technology. Punch biopsies at each burned area were stained with hematoxylin and eosin and assessed for burn depth and for inflammation using previously reported measures. Samples from 14 animals were stained for terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling and caspase-3 (apoptosis markers). Increasing branding iron contact times worsened perfusion, burn depth, and apoptotic ratios. There was no correlation between inflammatory markers and burn contact time. The addition of DA leads to worse perfusion, deeper burns, worse inflammation, and decreased apoptotic ratios. Laser Doppler imaging is a useful technology to assess burn depth. The addition of DA to traditional resuscitation fluids for burn shock is deleterious to the injured, burned skin. Modifying the traditional burn shock resuscitation fluids, although intellectually attractive, needs to be rigorously studied.

Current burn wound management

Burn injury is common, but can have severe consequences for the individual patient. Assessment of burn depth, and the different ways of treating burns are topics which are often shrouded in mystery. Burn surgery is seen by some as a ’dark art’. This article attempts to shed some light on these topics.

Evaluation of a new high-speed laser-doppler camera for early burn depth assessment

Evaluation of a new high-speed laser-doppler camera for early burn depth assessment

Relationship between healing time and mean perfusion units of laser Doppler imaging (LDI) in pediatric burns

Background Laser Doppler imaging (LDI) is a noninvasive technique used to assess burn depth. However, there have been no studies regarding the use of LDI in predicting burn healing time. Objectives The aims of this study are to evaluate the relationship between healing time and the amount of perfusion seen on LDI and to determine a cut-off value for LDI that predicts if a burn will heal within 14 days. Study design Consecutive patients younger than 15 years old with partial-thickness burns were recruited from May to November 2006 for this prospective observational study. The mean number of perfusion units (PU) as determined by LDI (Periscan PIM 3 system) was obtained within 2–3 days following injury. Healing time was estimated clinically by two physicians and marked by the observation of reepithelization. The mean PU was compared between the early (healed with 14 days) and late healing groups (healed later than 14 days). The usefulness of the mean PU in predicting healing time within 14 days was estimated by receiver operating characteristic curve analysis. Results A total of 103 patients with 181 partial-thickness burn wounds were enrolled in this study. The mean PU from LDI was higher in the early healing group compared to the late healing group (380.2 ± 157.8 vs. 185.8 ± 115.8, p < 0.001). When using 250 PUs as a cut-off value to predict early healing, the sensitivity and specificity were 80.6% and 76.9%, respectively. The area under the ROC curve was 0.844 ( p < 0.001, 95% CI = 0.780–0.908). Conclusions This study suggests the mean PU as determined by LDI can be used as a valuable tool in predicting the healing time of burn wounds.

Successful assessment and management of burn injuries

Burn injuries are common and vary in severity. Early management is essential to reduce patient mortality and morbidity. Immediate care involves accurate assessment of burn depth and appropriate fluid management. This article offers an overview of the assessment and nursing care involved in ensuring successful management of patients with burn injuries.

Accuracy of early burn depth assessment by laser Doppler imaging on different days post burn

Background Accurate diagnosis of burn depth is essential in selecting the most appropriate treatment. Early assessment of burn depth by clinical means only has been shown to be inaccurate, resulting in unnecessary operations or delay of grafting procedures. Laser Doppler imaging (LDI) was reported as an objective technique to determine the depth of a burn wound, but the accuracy on very early days post burn has never been investigated yet. Methods In 40 patients with intermediate depth burns, we prospectively evaluated and compared the accuracy of the LDI measurements with the clinical assessments on days 0, 1, 3, 5, 8. Clinical evaluation of the depth of the burn was performed by two observers blinded to the LDI images. Accuracies were assessed by comparison with outcome: healing times longer than 21 days were considered to be equivalent to a biopsy finding of a deep dermal wound. Obviously superficial and full thickness wounds were excluded. LDI flux level was used for LDI prediction of outcome: less than 220 PU to predict non-healing at day 21. Results The accuracies of burn depth assessments on the day of burn and post burn days 0, 1, 3, 5 and 8 using LDI were 54%, 79.5%, 95%, 97% and 100% compared with clinical assessment accuracies of 40.6%, 61.5%, 52.5%, 71.4% and 100%, respectively. LDI accuracy was significantly higher than clinical accuracy on day 3 ( p < 0.001) and day 5 ( p = 0.005). Burn depth conversion was also considered. This is the first study to quantify the advantage of LDI scanning over clinical assessments during these important early after burn days.

Outpatient Management of Pediatric Burns

The leading etiologies of pediatric burns are scald, thermal, and electrical injuries. The initial management of burns involves assessment of burn depth and total body surface area (TBSA) affected, a history, and physical examination. Calculation of percent of TBSA affected is an important determinant of the necessity for hospitalization versus outpatient management. Only second- and third-degree burns are included in the calculation. The criteria for outpatient management vary based on the center experience and resources. One such set of criteria in an experienced burn center includes burn affecting less than 15% TBSA, therefore not requiring fluid resuscitation; the ability to take in oral fluids, excluding serious perioral burns; no airway involvement or aspiration of hot liquid; no abuse; and dependable family able to transport the patient for clinic appointments. Once the child is ready to reenter school, the physician must discuss with the family and school staff any needs and expectations for the child, including wound care. Social reintegration can be difficult. Educating the teachers and staff of the child's appearance may help prepare the students.