Burn Size Assessment Research Articles

Medico-legal evaluation of burn trauma injuries. Epidemiological features and predictors of mortality and other adverse outcomes

Introduction: Burn trauma is a devastating, life-threatening public health issue responsible for significant morbidity and mortality. Developing countries suffer more from the medical, psychological, and economic consequences of burns. The current study aimed to investigate the medicolegal aspects of burn trauma by identifying the epidemiological factors and injury characteristics associated with increased risk of mortality, intentional infliction, and different types of complications. Methods: A prospective cross-sectional study was conducted enrolling the burn trauma patients admitted to Burn Unit, Tanta University Hospital, Egypt over one year. Results: The current study was conducted among 138 burn trauma patients with a case fatality rate of 13.8 %. Of them, 5.8 % were victims of intentional burns, 44.9 % were complicated, and the length of hospital stay ranged between one day and 52 days. Patients aged less than 10 years constituted about 33.3 %. The burn trauma was the highest in June, May and March. Intentionally exposed patients, patients with third-degree burns affecting the head, neck and trunk and those with burns involving a total body surface area (TBSA) of more than 33 % were at high mortality risk. Intentional burns were induced mainly by flame (100 %) and characterized by high severity (TBSA = 85 % and 87.5 % third-degree burns). Intentional burns involved mainly the trunk (p = 0.002) and external genitalia (p = 0.022). The involved TBSA and the highest burn degree were significant predictors of mortality with an excellent area under curves of 0.956 and 0.870, respectively and (p < 0.001). The TBSA of more than 17 % and the burn degrees above the second were significant predictors of in hospital complications (p < 0.001). Daytime intentional burns, burns involving the upper extremities and face, deep and widely distributed burns, and infected wounds were associated with a significant need for surgical treatments. The median length of hospital stay was ten days, primarily attributed to the in hospital complications (p = 0.02). Conclusion: A high degree of vigilance and accurate assessment of burn size, depth and distribution with meticulous interpretation of the mechanism of infliction are central not only for treatment interventions but from the medicolegal point of view.

Technical and Medical Aspects of Burn Size Assessment and Documentation.

In burn medicine, the percentage of the burned body surface area (TBSA-B) to the total body surface area (TBSA) is a crucial parameter to ensure adequate treatment and therapy. Inaccurate estimations of the burn extent can lead to wrong medical decisions resulting in considerable consequences for patients. These include, for instance, over-resuscitation, complications due to fluid aggregation from burn edema, or non-optimal distribution of patients. Due to the frequent inaccurate TBSA-B estimation in practice, objective methods allowing for precise assessments are required. Over time, various methods have been established whose development has been influenced by contemporary technical standards. This article provides an overview of the history of burn size estimation and describes existing methods with a critical view of their benefits and limitations. Traditional methods that are still of great practical relevance were developed from the middle of the 20th century. These include the “Lund Browder Chart”, the “Rule of Nines”, and the “Rule of Palms”. These methods have in common that they assume specific values for different body parts’ surface as a proportion of the TBSA. Due to the missing consideration of differences regarding sex, age, weight, height, and body shape, these methods have practical limitations. Due to intensive medical research, it has been possible to develop three-dimensional computer-based systems that consider patients’ body characteristics and allow a very realistic burn size assessment. To ensure high-quality burn treatment, comprehensive documentation of the treatment process, and wound healing is essential. Although traditional paper-based documentation is still used in practice, it no longer meets modern requirements. Instead, adequate documentation is ensured by electronic documentation systems. An illustrative software already being used worldwide is “BurnCase 3D”. It allows for an accurate burn size assessment and a complete medical documentation.

The effect of a known object in a static image of a burn to improve the burn size estimation

IntroductionCurrently information regarding burn size from referring departments to burn centres varies in accuracy. Inaccurate assessment of burn size can lead to over or under treatment. Photographs of injuries may improve accuracy of assessment. We aimed to assess the accuracy of measuring burn size on a static image by including a standard object in the image. MethodsSimulated burn areas were drawn on different body parts of the model. Using an iPhone® model 5 s with an 8 megapixel camera we took photos of the marked area, and repeated them with the palm, a standard bank card and a penny in the picture. First the Du Bois formula, was used to calculate body surface area. Members of the Burns team were asked to view the photos (n = 30) and estimate the percentage of the simulated burn. ResultsWe found an overall overestimation of burn size. Small areas of the forearm were better estimated and within 1.1% of the calculated surface area, however we found no improvement when using a standard object in these images. The back areas were most overestimated ranging from 0.9%–8.9% despite all being the same sized area. ConclusionsStatic images tend to overestimate burn size despite the use of a standard object in the image.

Advances in emergency care for burn disorders: Treatment strategies and outcomes

Background: Effective management of burn injuries is crucial for optimizing patient outcomes, yet challenges remain in prehospital care and accurate assessment. This article reviews the advancements in emergency burn care, focusing on the prehospital management by Helicopter Emergency Medical Services (HEMS) in Switzerland and the implications for North American practices. Aim: To explore and compare burn care strategies, particularly in prehospital and initial hospital settings, and to evaluate updates in fluid resuscitation protocols and burn size estimation techniques. Methods: The study incorporates a decade-long review of HEMS data from Switzerland and examines North American practices, including referral criteria and transport strategies. Analysis of recent studies on air transport overtriage and updated fluid resuscitation formulas, such as the Parkland and Modified Brooke formulas, is also included. Results: Findings indicate a high degree of consistency in burn size assessment in Switzerland, contrasting with varying results in North America where overtriage and inaccuracies in burn size estimation are prevalent. Fluid resuscitation protocols have been refined to address these issues, with updated ABLS guidelines reflecting advancements in technology and evidence-based practices. Conclusion: Enhanced prehospital care and accurate burn size estimation are critical for effective burn management.

Development and evaluation of a novel smart device-based application for burn assessment and management

We have developed a novel software application that provides a simple and interactive Lund–Browder diagram for automatic calculation of total body surface area (TBSA) burned, fluid formula recommendations, and serial wound photography on a smart device platform. The software was developed for the iPad (Apple, Cupertino, CA) smart device platforms. Ten burns ranging from 5 to 95% TBSA were computer generated on a patient care simulator using Adobe Photoshop CS6 (Adobe, San Jose, CA). Burn clinicians calculated the TBSA first using a paper-based Lund–Browder diagram. Following a one-week “washout period”, the same clinicians calculated TBSA using the smart device application. Simulated burns were presented in a random fashion and clinicians were timed. Percent TBSA burned calculated by Peregrine vs. the paper-based Lund–Browder were similar (29.53 [25.57] vs. 28.99 [25.01], p=0.22, n=7). On average, Peregrine allowed users to calculate burn size significantly faster than the paper form (58.18 [31.46] vs. 90.22 [60.60]s, p<0.001, n=7). The smart device application also provided 5 megapixel photography capabilities, and acute burn resuscitation fluid calculator. We developed an innovative smart device application that enables accurate and rapid burn size assessment to be cost-effective and widely accessible.

Accuracy of burn size estimation in patients transferred to adult Burn Units in Sydney, Australia: An audit of 698 patients

BackgroundThe purpose of this study was to compare burn size estimation between referring centres and Burn Units in adult patients transferred to Burn Units in Sydney, Australia. MethodsA review of all adults transferred to Burn Units in Sydney, Australia between January 2009 and August 2013 was performed. The TBSA estimated by the referring institution was compared with the TBSA measured at the Burns Unit. ResultsThere were 698 adults transferred to a Burns Unit. Equivalent TBSA estimation between the referring hospital and Burns Unit occurred in 30% of patients. Overestimation occurred at a ratio exceeding 3:1 with respect to underestimation, with the difference between the referring institutions and Burns Unit estimation being statistically significant (P<0.001). Significant overestimation occurs in the early transfer of burn-injured patients as well as in patients transferred more than 48h after the burn (P<0.005). Underestimation occurs with less frequency but rises with increasing time after the burn (P<0.005) and with increasing TBSA. Throughout the temporal spectrum of transferred patients, severe burns (≥20% TBSA) were found to have more satisfactory burn size estimations compared with less severe injuries (<20% TBSA; P<0.005). ConclusionsThere are significant inaccuracies in burn size assessment by referring centres. The systemic tendency for overestimation occurs throughout the entire TBSA spectrum, and persists with increasing time after the burn. Underestimation occurs less frequently but rises with increasing time after the burn and with increasing TBSA. Severe burns (≥20% TBSA) are more accurately estimated by the referring hospital. The inaccuracies in burn size assessment have the potential to result in suboptimal treatment and inappropriate referral to specialised Burn Units.

Photographic assessment of burn size and depth: reliability and validity

The aim of this study was to examine the reliability and validity of using photographs of burns to assess both burn size and depth. Fifty randomly selected photographs taken on day 0-1 post burn were assessed by seven burn experts and eight referring physicians. Inter-rater reliability in both groups (experts vs. referrers) was calculated. The validity of burn size assessment was calculated using live assessment as the gold standard, and of burn depth using clinical assessment in combination with laser Doppler imaging as the gold standard. The validity of the photographically-assessed indication for surgery was calculated using laser Doppler imaging and actual treatment as the gold standard. Finally, agreement in referral indication was calculated. Using photographs, burn size could be assessed reliably and validly by experts (ICCs of 0.83 and 0.87), but not by referrers (ICCs of 0.68 and 0.78). Photographic assessment of burn depth was neither reliable nor valid, with ICCs respectively of 0.38 and 0.28 for experts and 0.24 and 0.13 for referrers. The indication for surgery could also not be assessed validly. Agreement between assessors regarding referral indication was low. Burn size, but not burn depth, can be assessed reliably and validly by experts using photographs of the burn wound. We recommend exploring other forms of telemedicine, like live interactive video, to investigate whether this leads to an improved burn depth assessment where clinical assessment is not possible. There were no external sources of funding for this study. The authors have no conflicts of interest to declare with regard to the manuscript or its content.

Accuracy of Burn Size Estimation in Adults and Children: Are Emergency Departments Doing Any Better?

When presented with a burn injury, the role of emergency departments includes treatment of life threatening injuries, burn size estimation and instigation of fluid resuscitation. The accurate assessment of burn size is one of the most important facets of acute burn care as it determines whether transfer to a regional burns centre is necessary and the volume of intravenous fluid required. Failure to estimate burn size correctly has potentially life threatening consequences including hypovolaemic shock, pneumonia, extremity compartment syndrome, pulmonary oedema and electrolyte imbalance.

Accuracy of burn size assessment prior to arrival in Dutch Burn centres and its consequences in children: A nationwide evaluation

BackgroundTotal body surface area (TBSA) burned, expressed as percentage is one of the most important aspects of the initial care of a burn victim. It determines whether transfer to a burn centre is necessary as well as the need for, and amount of, intravenous fluid resuscitation. Numerous studies, however, have highlighted inaccuracies in TBSA assessment. Therefore, the differences in burn size estimates between referrers and burn centre's in children and its consequences in terms of transfer and intravenous fluid resuscitation were investigated. MethodsThis study involved two time periods from January 2002 until March 2004 and January 2007 until August 2008. All referred children admitted to a Dutch Burn centre within 24h post burn were eligible. Data were obtained from patient records retrospectively and in part prospectively. ResultsA total of 323 and 299 children were included in periods 1 and 2, respectively. Referring physicians overestimated burn size with a factor two (mean difference: 6% TBSA±5.5). About one in five children was referred to a burn centre without fulfilling the criteria for referral with regard to burn size (assessed by burn specialists) special localisation or inhalation trauma. Proportions of children receiving intravenous fluid resuscitation regardless of indication increased from 33% to 49% (p<0.01). The received volumes tended to be higher than necessary. ConclusionsReferring physicians overestimate burn size in children admitted to Dutch burn centres. This has little negative consequences, however, in terms of unindicated transfers to a burn centre or unnecessary fluid resuscitation.

Increased fluid resuscitation can lead to adverse outcomes in major-burn injured patients, but low mortality is achievable

Background Excessive fluid resuscitation of large burn injuries has been associated with adverse outcomes. We reviewed our experience in patients with major-burn injury to assess the relationship between fluid, clinical outcome and cause of variance from expected resuscitation volumes as defined by the Parkland formula. Methods Eighty patients with new burns ≥15% total body surface area (TBSA) admitted to the intensive care unit within 48 h of injury were included. Results Mean fluid volume was 6.0 ± 2.3 mL/kg/% TBSA at 24 h. Bolus fluids for hypotension and oliguria explained 39% of excess variance from Parkland estimates and inaccurate burn size and weight assessment explained 9% of variance. Higher fluid volume was associated with pneumonia (adjusted odds ratio [AOR] = 2.0; 95% confidence interval [CI] 1.2–3.4) and extremity compartment syndrome (AOR = 7.9; 95% CI 2.4–26). Colloid use during the first 24 h reduced the risk of extremity compartment syndrome (AOR = 0.06; 95% CI 0.007–0.49) and renal failure (AOR = 0.11; 95% CI 0.014–0.82). In-hospital mortality was low (10%) and not associated with >125% Parkland resuscitation ( P = 0.39). Conclusions Although fluid resuscitation in excess of the Parkland formula was associated with several adverse events, mortality was low. A multi-centre trial is needed to more specifically define the indications and volumes needed for burns fluid resuscitation and revise traditional formulae emphasising patient outcome. Improved training in burn size assessment is needed.

Early in‐hospital management of burn injuries in Australia

The accurate initial assessment and management of burn injuries influences subsequent clinical outcome. The purpose of the present study was to evaluate, over a 12-year period (1989-2001), changes in the practices of referring hospitals in terms of early management of patients with burn injuries prior to transfer to a burns unit. The details of all consecutive patients over two separate 12-month periods between June 1989 to May 1990 and between April 2000 and March 2001 who were transferred to the Burns Unit, Concord Repatriation General Hospital, Sydney, were prospectively recorded and retrospectively reviewed. In particular, the referral procedure, the accuracy of the referring hospital's assessment of burn size and initial fluid resuscitation were compared between the two time frames. There were 51 patients in the initial 12-month period and 57 patients in the latter 12-month period. Regarding the transfer of the latter group of patients, the referring hospital liaised directly by telephone with the Burns Unit registrar or consultant significantly more often (77%vs 45%, respectively, P < 0.05). Similar proportions of patients in the two time periods received correct initial assessment of burn size (39% in the 1989-1990 group vs 42% in the 2000-2001 group, P = 0.76). The latter group of patients was significantly more likely to receive the correct choice of fluid for initial resuscitation at the referring hospital (98%vs 61%, respectively, P < 0.05). Over this 12-year period, there has been marked improvement in referral practices and appropriate initial fluid resuscitation for patients with burn injuries. Referring hospitals' assessment of burn size has not improved. Possible reasons for the observed changes include: increased postgraduate education programmes by the Royal Australasian College of Surgeons and the Australian and New Zealand Burns association; the formalization of emergency medicine training programmes by the Australasian College of Emergency Medicine and increasing awareness within the medical community of the presence of dedicated burns units.