TBSA Burn Research Articles

Maximizing Micrograft Take in Extensive Back Burns.

Extensive burns involving the back pose unique challenges. Offloading in the prone position is not possible with concomitant deep facial and neck burns. We describe our experience in maximizing graft take in a patient who had extensive back burns with concomitant anterior body burns. The two main goals in graft fixation for extensive back wounds are mechanical stabilization of micrografts to reduce shearing and prevention of water logging from exudates or bleeding to optimize contact with wound bed. Guided by the stages of wound healing, graft take, and burn care, we describe three stages of postoperative negative pressure wound therapy (NPWT) in a patient with 54% TBSA burns treated with micrografting. After complete excision of the deep dermal burns of the entire back, the wounds were covered with micrograft-allograft composites. In phase I, days 1 to 3, conventional topical negative pressure dressing with a thin sponge was applied and a leak-proof seal was achieved with gel sealant and high tack adhesive drapes. In phase II, days 4 to 5, foam dressings with topical negative pressure were applied, but with a less stringent seal, supported by wall suction. In phase III, the selective removal of allografts was initiated to facilitate expansion of micrografts. Negative pressure was continued for another 2 weeks at the most dependent site to prevent wound maceration from exudates. Micrograft take was optimized with the patient in the supine/semirecumbent position. The back wounds healed completely between 60 and 70 days without repeat micrografting. Since prone positioning was not possible in this patient, clearance of exudates and maintenance of micrograft contact with the wound bed using this technique proved successful.

725 Paediatric Resuscitation Burns Maintenance Fluid Selection - a Retrospective Review of Cases and Adherence to NICE, LSEBN and EMSB Guidelines

Abstract Aim Appropriate fluid management in major burn injuries is directly related to burn survival rates. Despite this fact, there are still controversies regarding the choice of replacement fluid given during the resuscitation and maintenance stages in the acute management of burns. The aims of this study are to compare current paediatric maintenance fluid prescriptions against current guidelines, and to assess whether there is of any adverse effects (i.e., electrolyte disturbance). Method Details of all paediatric burn's patients (aged 18 years or under) who were admitted to the paediatric burns ward during an 18-month-period were screened. Only those coded as having sustained 10% TBSA burns or greater were included in data analysis. Data was then sourced using Cerner electronic patient record software. Results A total of 17 patients were identified, all sustaining scald injuries with between 10% and 22% TBSA burns. Every patient was given 0.45% NaCl with 5% dextrose as maintenance fluid. All IV maintenance supplementation was ceased after 24hrs. Only 53% of patients had pre- and post-fluid bloods taken. Average drop in sodium amongst these patients was 2mmol, with largest drop (5mmol) in the patient with the largest burns % TBSA. Conclusions We found zero compliance with current NICE guidelines, which suggests an isotonic crystalloid (such as 0.9% NaCl with 5% dextrose) for maintenance, therefore guidance in line with this should be considered. Larger burns TBSA or prolonged IV fluids may amplify electrolyte imbalances. The importance of consistent electrolyte monitoring amongst this patient cohort is key and should be encouraged.

A National Analysis of Discharge Disposition in Older Adults with Burns-Estimating the Likelihood of Independence at Discharge.

Whereas older age predicts higher burn mortality, the impact of age on discharge disposition is less well defined in older adults with burns. This investigation assesses the relationship between older age and discharge disposition after burns in a nationally representative sample. We queried the 2007 to 2015 National Trauma Data Bank for non-fatal burn hospitalizations in older adults. Pre-defined age categories were 55 to 64 years (working-age comparison group), 65 to 74 years (young-old), 75 to 84 years (middle-old), and 85+ years (old-old). Covariables included inhalation injury, comorbidities, burn total body surface area, injury mechanism, and race/ethnicity. Discharge to non-independent living (nursing home, rehabilitation, and other facilities) was the primary outcome. Logistic regression assessed the association between older age and discharge to non-independent living. There were 25,840 non-fatal burn hospitalizations in older adults during the study period. Working-age encounters comprised 53% of admissions, young-old accounted for 28%, middle-old comprised 15% and old-old comprised 4%. Discharge to non-independent living increased with burn TBSA and older age in survivors. Starting in young-old, the majority (65 %) of patients with burns ≥20% TBSA were discharged to non-independent living. Adjusted odd ratios for discharge to non-independent living were 2.0 for young-old, 3.3 for middle-old, and 5.6 for old-old patients, when compared with working-age patients (all P < .001). Older age strongly predicts non-independent discharge after acute burn hospitalization. Matrix analysis of discharge disposition indicates a stepwise rise in discharge to non-independent living with higher age and TBSA, providing a realistic discharge framework for treatment decisions and expectations about achieving independent living after burn hospitalization.

The longitudinal development of posttraumatic growth among U.S. adult burn injury survivors.

Posttraumatic growth is the phenomenon of positive change resulting from coping with challenging or traumatic events. This study examines posttraumatic growth (PTG) in adult burn injury survivors via growth trajectories and correlates across time. Three-hundred forty-eight burn injury survivors aged 19-86 years old completed a self-report measure of posttraumatic growth at 6, 12, and 24 months. An unconditional and conditional growth curve model with predictors were fitted to the posttraumatic growth data. Predictors included psychosocial variables (satisfaction with life, stigma, body image, anxiety, depression, and pain), demographic variables (age, education, sex), and burn injury variables (days hospitalized, cause of injury, TBSA burn, and admittance to rehab). On average participants experienced midlevel posttraumatic growth scores and experienced little change across time. Participants' sex, age, educational attainment, burn severity level, satisfaction with life pre-burn injury, and perceived stigma were each significantly associated with initial posttraumatic growth scores. Burn survivors vary in their degree of posttraumatic growth, with growth largely stable by 6 months postinjury. Targeted intervention to facilitate growth, and thus physical health and mental health, should be completed prior to 6 months postinjury. Burn-related stigma may be a modifiable factor that can enhance posttraumatic growth. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Role of Early Enteral Glutamine Supplementation in Reducing Infectious Morbidity in Burn Patients: A Case-Control Study

Severe burn injury is more challenging to sustain life than a preburn status. The situation changes drastically in terms of energy demands/ expenditure and the great degree of susceptibility to infections due to the loss of amino acids. Glutamine stimulates the immune system and prevents catabolism. The bacterial translocation from the gut can be decreased by glutamine supplementation, thereby suppressing the inflammatory response. In acute burn injury, plasma and muscle glutamine depletion is observed to contribute to muscle wasting, weight loss, and infection. Patients with 20%–50% TBSA burns presenting within 24 hours of injury to the emergency department or outpatient department were included in the study. The patients were divided into two groups randomly. In group 1 (Cases), all patients were given enteral glutamine supplementation at the dose of 0.5 mg/kg/day either orally or through a nasogastric tube started within 24 hours of injury. Group 2 (Control) had all the patients in whom enteral glutamine supplementation was not given. In both groups, blood analysis for total leucocyte count (TLC) and total serum proteins (TSP) was done upon admission. On Day 4, followed by analysis every fourth day, after that, till healing occurred or the patient was taken up for grafting. Blood and wound swab cultures were done on the third day of admission, then the first week, followed by weekly cultures for 4 weeks or till healing occurred or the patient was taken up for grafting. A total of 123 patients were studied. There was a decreasing trend in the mean values of the TLC and an increasing trend in TSP in both groups. The difference became statistically significant from Day 20 onwards. The pattern of wound cultures was found to be statistically significant in Week 3 and Week 4, whereas the difference in blood culture positivity among the groups was statistically significant in Week 3. We noted, in our study, that the glutamine supplementation to the early enteral nutrition increased the TSP levels and decreased the TLC, wound, and blood culture positivity rates in the study group. Glutamine supplementation can contribute to improved immunity and reduce burn wound sepsis and bacteremia. All these combined can lead to decreased morbidity, improved wound healing, and better outcomes with lesser costs.

Impacts of Financial Assistance on Quality of Life Among People Living With Burn Injury: Matched Cohort Analysis of the National Institute on Disability, Independent Living and Rehabilitation Research Burn Model System Database.

Disparities in socioeconomic status and minority status affect the risk of burn injury and the severity of that injury, thus affecting the subsequent cost of care. We aimed to characterize the demographic details surrounding receipt of financial assistance due to burn injury and its relationship with health-related quality of life scores. Participants ≥18 from Burn Model System National Longitudinal Database (BMS) with complete demographic data were included (n = 4330). Nonresponders to financial assistance questions were analyzed separately. The remaining sample (n = 1255) was divided into participants who received financial assistance because of burn injury, those who received no financial assistance, and those who received financial assistance before injury and as a result of injury. A demographic and injury-characteristic comparison was conducted. Health-related quality of life metrics (Satisfaction with Life, Short Form-12/Veterans RAND 12-Item Health Survey, Community Integration Questionnaire Social Component, and the Post-Traumatic Growth Inventory) were analyzed preinjury, then 6-months, 1-year, and 2-years postinjury. A matched cohort analysis compared these scores. When compared to their no financial assistance counterparts, participants receiving financial assistance due to burns were more likely to be minorities (19% vs 14%), have more severe injuries (%TBSA burn 21% vs 10%), and receive workers' compensation (24% vs 9%). They also had lower health-related quality of life scores on all metrics except the post-traumatic growth inventory. Financial assistance may aid in combating disparities in posttraumatic growth scores for participants at the greatest risk of financial toxicity but does not improve other health-related quality of life metrics.

Enzymatic debridement: past, present, and future

Introduction Early surgical debridement of the deep second and third-degree burns is still the standard of care (SOC) to prepare the wound bed for skin grafting. However, this technique has some drawbacks that explain the growing interest in enzymatic debridement as an alternative. In this article, we provide a historic overview as well as the current state-of-the-art and future prospective of this type of non-surgical debridement. Materials and methods A narrative review of the available literature was conducted using a systematic search. Results A total of 32 articles were included. The only enzyme mixture still used nowadays for burn eschar removal is bromelain-based. There is increasing evidence that this type of enzymatic debridement is a powerful tool to selectively remove the eschar in deep burns, thereby reducing the need for autologous skin grafting compared to surgical SOC. Moreover, off-label use of enzymatic debridement with NexoBrid® (facial, pediatric, and >15%TBSA burns) has proven to be effective and safe. Conclusion There is increasing evidence that bedside administered NexoBrid®, preferably under regional anesthesia, is a powerful tool for selective burn eschar removal. However, the clinical wound bed evaluation post-NexoBrid® procedure in relation to the optimal treatment decision—conservative treatment vs. surgery—is not yet completely elucidated. More high-quality prospective clinical trials are necessary to compare enzymatic debridement of objectively confirmed deep burns with the current standard treatment and assess the effectiveness of the eschar removal, the need for surgery, the healing time of such wounds, and the long-term scar quality.

Performance of BEAMS Risk of Death Score for Mortality Prediction in Australian and New Zealand Burns Patients.

The BEAMS (Burns Evaluation and Mortality Study) risk of death score was developed in 2013 as a mortality prediction tool for burns patients admitted to an ICU (intensive care unit) in Australia and New Zealand. While it previously performed well, identifying high-risk groups and allowing benchmarking, over time such scores may lose calibration or be superseded by improved scoring systems. Our aim was to assess the performance of the BEAMS score in a modern cohort of burns patient. Data were sourced from the Burns Registry of Australia and New Zealand (BRANZ) and the Australia New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) databases. Data were linked using probabilistic methodology. BEAMS risk of death scores was calculated for all adult patients. Between 2009 and 2019, there were 2075 patients admitted to an Australian or New Zealand ICU with a burn-related injury. Advanced age, female gender, higher %TBSA burns, and inhalation injury were all associated with increased rate of mortality (P < .05). Overall hospital mortality was 9.4% (n = 195). The predicted risk of death from BEAMS was 8.7% and the score had an area under the receiver operating characteristic curve of 0.934. We found the BEAMS risk of death score continues to have excellent performance in a modern cohort of adult critically ill burns patients. It remains a valid tool for mortality prediction among adult burns patients admitted to ICU across Australia and New Zealand.

Evaluation of Kinesiophobia in Survivors of Major Burn Injury.

Kinesiophobia, the fear of movement and reinjury, has not been described in burn injury survivors. Physical activity is a key component of burn rehabilitation programs. Yet, not all burn survivors exercise at the recommended level. This is an exploratory study examining the association of the demographics and injury characteristics of burn survivors with a fear of movement. The subjective fear of movement was measured using the Tampa Scale for Kinesiophobia (TSK). The TSK score was compared between several demographics and injury characteristics by performing the independent sample t-test. Sixty-six percent of subjects in our study (n = 35), reported high levels of kinesiophobia (score 37 or above). The mean scores of the TSK were greater in males (40.7), non-white (43.0), Hispanic/Latino (41.1), age greater than 50 years (42.3), and TBSA burn of >15% compared to females (36.9), white (38.5), non-Hispanic/Latino (39.3), age 50 years or less (38.1), and TBSA 15% or less (39.4), respectively. However, with the exception of time postinjury, none of the mean differences were statistically significant. Subjects who had sustained a burn injury more than 12 months ago showed higher levels of kinesiophobia than the subjects who were injured within 12 months with a mean difference of 7.35 (P = .01). Thus, this study highlights the importance of 1) continued, long-term follow-up for burn survivors, and 2) appropriate educational and treatment interventions to address any underlying existing, new, or emerging medical issues that may contribute to the fear or avoidance of movement.

A five-year prospective study of the Aetiology, Pattern of Presentation, and Management of patients with burns in Ekiti State University Teaching Hospital

Background: Burns constitute a significant public health problem worldwide, with most reported mortalities occurring in low and medium-income countries (LMICs). Therefore, this study aimed to generate epidemiological data on the aetiologies, patterns of presentations, and outcomes of burn injuries in Ado Ekiti, the capital of Ekiti State. Methodology: This was a five-year prospective study of all patients with burns managed at Ekiti State University Teaching Hospital. The required information was entered into a hospital-based burn data collection form from admission to discharge. The data generated were exported to IBM SPSS version 23 for analysis. Results: A total of 160 patients were included in this study. The median age was 10.5 years (IQR 2 – 33). Half of the patients were aged <10 years old. About 66.9% of the injuries occurred indoors, with the kitchen being the most common injury site (49.4%). Scald was the most common aetiology, and most injuries occurred in the morning. While 71.9% had first aid at the injury site, the first aid agents used were potentially harmful in most cases. The injuries were predominantly partial-thickness with a mean TBSA burn of 14% and a median ABSI of 4 (IQR 3 – 5). The lower limbs were the most frequently affected body regions, with an overall mortality rate of 5%. Conclusion: Scalds are the most common aetiology of burns in Ado Ekiti, with most injuries occurring in the kitchen. The populace needs to be adequately educated on the suitable materials to provide first aid to burn victims

603 Timing of autologous spray cell suspension: better early than late

IntroductionAutologous spray cell suspension is associated with multiple beneficial outcomes, however, the optimal timing of use has not been determined. We examined the timing of spay cell application, and hypothesize that early (< 72 hr) use is associated with faster definitive wound coverage, impacting multiple clinical outcomes compared to late ( >72 hr) use of spray cells.MethodsA retrospective review of 28 patients with spray cell application from March 2020 -- May 2021 was conducted. Pediatric patients < 16 yrs (n=1) as well as deaths (n=2--including 1 withdrawal) were excluded, leaving 25 patients. Those that received spray cells early (< 72 hrs, n=14) were compared to late ( >72 hrs, n=11). Time to index operation, time to spray cell application, rate of complete wound coverage, number of OR trips required for wound closure, wound infection rates, LOS / %TBSA, and overall hospital LOS were examined.ResultsThere was no difference in demographics or % TBSA burn (21.4% vs. 23/5%), between early and late spray cell groups. The early group had a significantly faster time to index operation (1.2 dys vs. 2.5 dys P= .05), and faster time to spray cell application (1.6 dys vs. 18.1 dys P=.036) (Table 1). The early group had a greater wound coverage rate at index operation —64.2% complete coverage vs. 18.1% in the late group (p< .03). The total number of OR trips needed for wound coverage was less in the early group (1.5 trips / pt) vs. the late (7.0 trips / pt) P=0.03. The early group had less wound infections, a shorter LOS / % TBSA burn ( 0.83 dys vs. 1.85 dys P=0.005), and shorter overall LOS (16.5 dys vs. 46.9 dys P=0.03).ConclusionsAutologous spray cell use has multiple beneficial outcomes, however, the optimal timing of application has not been determined. We report that early (< 72 hr) application of spray cells is associated with greater rate of complete wound coverage at index operation, decreased total number of operations needed for wound coverage, less wound infections, shorter LOS / %TBSA, and shorter overall LOS. This is likely related to earlier definitive wound coverage and closure, which is afforded by the large expansion ratio of spray cells.

86 Outcomes for 43 Hand Burns Treated with 2:1 Meshed and Epidermal Autografts with Abundant Donors

IntroductionOur group has previously reported our experience in treating hand burns with 2:1 meshed autografting and simultaneous application of autologous skin cell suspension (ASCS) even when donor sites are abundant. Here, we sought to expand on this experience. We hypothesized that the use of 2:1 meshed autografting and ASCS (MA/ASCS) would provide comparable outcomes to hand burns treated with sheet graft.MethodsA retrospective review was conducted of all subjects operated on for deep 2nd and 3rd degree hand burns at our ABA-verified burn center from April, 2018 to May, 2021. Exclusion criterion was a burn of >20% TBSA. The cohorts were those subjects treated with MA/ASCS versus those treated with split thickness sheet, pie-crust, or 1:1 meshed autograft alone (STAG). Outcomes included proportion returning to work (RTW), length of time for RTW, and time to wound closure. Mann-Whitney U test was used for comparisons of continuous variables, and Fishers Exact test for categorical variables. Values are reported as median and interquartile range.ResultsSixty-eight subjects fit the study criteria (MA/ASCS n=43, STAG n=25). The MA/ASCS group was significantly older than the STAG cohort (45.5 yrs [32, 59.25] vs 35 [28, 45], p=0.013) with larger %TBSA burns overall (11.5% [7, 16.25] vs 2% [1, 3], p < 0.0001), and larger hand burns (186 cm2 [124.75, 330.5] vs 104 cm2 [56, 164], p=0.001). Comparable results were seen between MA/ASCS and STAG, respectively, for time to wound closure (8 days [7, 13] vs 8 [6, 14], p=0.48), proportion RTW (51% vs 64%, p=0.33), and days for RTW among those returning (38 [29.25, 62.75] vs 34.5 [20.75, 57], p=0.471). Fractional ablations were performed in 14% of the MA/ASCS group and 12% of the STAG group.ConclusionsDespite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure and return to work as subjects treated with 1:1, pie-crust, or sheet STAG.

525 Dysphagia in Thermal Injury: The Impact of Inhalation Injury on Incidence and Recovery

IntroductionDysphagia is known to be a prevalent condition in the burn population. Dysphagia can lead to adverse events such as aspiration pneumonia, dehydration, and malnutrition. However, there is little data on the incidence and duration of dysphagia specifically in the inhalation injury subset of burn patients. The aim of this study is to determine the incidence and factors that contribute to dysphagia in the inhalation injury burn population as compared to the cutaneous burn population.MethodsA retrospective study was conducted of patients admitted to a burn center from January 2016 - January 2021 and intubated for >48 hours. Patients who died during hospitalization or transferred hospitals were excluded. Dysphagia duration was analyzed based on days free from the ventilator. Two groups were compared: 1) non-inhalational injury vs inhalational injury patients and 2) Grade 1 vs Grade ≥2 inhalational injury patients. Statistical analysis included student’s t-test, chi-square test, and Kruskal-Wallis test. Bayesian generalized linear models were created to measure the independent association of inhalational injuries with the outcomes.ResultsDuring the study period, 142 patients were admitted, of whom 49 patients had inhalation injury (35%). Inhalational injury patients had a lower %TBSA burn than non-inhalational injury patients (mean 18% ± 21% vs 31% ± 15%, p< 0.001). There were no significant differences in age, sex, tracheostomy placement, ventilator days, or hospital length of stay between the two groups. The inhalational injury group had a higher rate of dysphagia at the first Speech Language Pathologist (SLP) instrumental assessment (88% versus 51%, p< 0.001) and at discharge (55% versus 28%, p=0.001). After controlling for %TBSA, inhalational injury was independently associated with an increased odds of dysphagia at first SLP instrumental assessment (OR 13.0, 95% CrI 4.7-43.4, posterior probability ≥99%) and at discharge (OR 3.2, 95% CrI 1.5-6.9, posterior probability ≥99%). Additionally, inhalational injury patients had a longer period of dysphagia post-extubation with an average of 9.5 vs 7.1 days to any diet (p< 0.006) and average of 12.6 vs 7 days to a regular texture diet (p < 0.001). Grade 1 inhalational injuries had no difference in duration of dysphagia or dysphagia at discharge compared to Grade ≥2 inhalational injury patients.ConclusionsInhalational injury was independently associated with dysphagia upon initial SLP instrumental assessment and at discharge. Patients with an inhalational injury also had a longer dysphagia resolution time. The severity of the inhalation injury did not impact dysphagia incidence.

714 Safety and Efficacy of Enteral Nutrition During Burn Surgery: A Retrospective Chart Review

IntroductionBurn injuries are life-threatening conditions consisting of elevated oxidative stress, severe inflammation, and an increased hypermetabolic and catabolic state. It is recommended to start enteral nutrition (EN) early in the burn injured patients. These patients undergo many operations, and with stopping of EN the intermittent caloric deficit multiplies. This leads to increased risk of negative outcomes. We sought to analyze the efficacy of continuing EN feedings during burn surgeries to maximize caloric intake while also evaluating for adverse outcomes such as pneumonia.MethodsA retrospective chart review of intraoperative feeding and pneumonia rates in pediatric and adult burn patients admitted during 2011-2017 to a regional burn center was conducted. Inclusion criteria included patients with secured airway via endotracheal tube or tracheostomy, mechanical ventilation for at least four days, and those who received EN during operations. The 2017 National Burn Repository (NBR) was used as the control population with mechanical ventilation ≥4 days and a yes/no pneumonia diagnosis. Our assumption was that these patients likely did not receive intraoperative EN as this is not standard protocol at this time.Results67 patients from our center and 779 NBR patients met inclusion criterion. EN were provided in 49-79% of total operations in the study group. The study group had a longer length of stay (LOS: 62 ± 34.4 vs 41 Days ± 31.7; p< 0.0001), Ventilator days (39 ± 28.9 vs 23 ± 43.9; p< 0.0001) and total body surface area burn percentage (TBSA: 36 ± 21 vs 31 ± 23 p-0.029).The relationship between pneumonia, inhalation injury, COPD, diabetes, and current smoking status was examined in the case population. The odds of a patient with inhalation injury developing pneumonia was 2.83 times greater than a patient without an inhalation injury. There was a higher pneumonia rate in the study group compared to control population (56.7% vs 18.9%; p< 0.0001). However based on a multinomial logistics regression analysis, there was no statistically significant association between intraoperative feeding and pneumonia in the study group (p-0.597).ConclusionsWe found a significant difference in the occurrence of pneumonia in our patient group compared to the NBR population, but our patients had higher LOS, ventilator days and TBSA burns. This suggest that our study group may have had higher acuity increasing risk of pneumonia. Our pneumonia rates do correspond with the rates reported from other comparable populations of burn patients. Despite this we did not find and association suggesting intraoperative feedings as the cause.

5 Admission Frailty Is Associated with Acute Respiratory Failure and Mortality in Burn Patients &amp;gt; 50

IntroductionPre-injury frailty has been shown to predict mortality of older burn patients. Herein, we assessed the utility of the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS) to predict burn-specific outcomes. We hypothesize that frail patients are at greater risk for complications such as graft loss, acute respiratory failure, and acute kidney injury and will require increased healthcare support at discharge.MethodsThis is a retrospective cohort study. Patients 50 years and older admitted to our Institution for burn injuries between July 2009 and June 2019 were included. Patients with inhalation injury only, no data on total burn surface area, or for whom medical history was incomplete were excluded. Demographics; comorbidities; pre-injury functional status; admission, injury, and hospitalization information; complications (graft loss, acute respiratory failure, and acute kidney disease (AKI)); mortality, and discharge disposition were collected. Patients were scored on the CSHA-CFS based on pre-admission health and functional status. The frail and non-frail groups were compared. Multivariate analyses were performed to assess the association between admission frailty and outcomes. P < 0.05 was considered significant.ResultsWe included 851 patients, 697 were not frail and 154 were frail. Frail patients were significantly older (66.1 ± 10.8 vs. 63.5 ± 10.9, p = 0.002), more likely Caucasian (98.1% vs. 91%, p = 0.027) and to have suffered flame burn injuries (68.8% vs. 59.8%, p < 0.001). Frail patients had a lower %TBSA (4.4 ± 8.1% vs. 10.1 ± 13.1, p < 0.001) but were more likely to stay longer in hospital relative to %TBSA (3.6 ± 6.7 vs. 1.9 ± 3.1, p < 0.001). Frail patients were less likely to have had skin graft procedures (27.3% vs. 57.4, p < 0.001). On multivariate analysis, controlling for age, sex, race, mechanism of injury, %TBSA, 2nd degree and 3rd degree burn surface, inhalation injury, frailty was associated with acute respiratory failure (OR = 2.599 [1.460-4.628], p = 0.001). Frailty was also associated with mortality (OR = 6.915 [2.455-19.980]; p < 0.001) when controlling for the same variables as well as acute respiratory failure and AKI. Frailty was also associated with discharge to home with healthcare services (OR = 2.678 [1.491-4.809], p = 0.001), to SNF, rehabilitation, or long-term acute care facilities (OR = 3.572 [1.933-6.602], p < 0.001), and to hospice (OR = 5.759 [1.519-21.827], p = 0.010) when compared to home without healthcare services.ConclusionsFrailty is associated with increased risk of acute respiratory failure, mortality, and requiring increased healthcare support post-discharge. Our data suggest frailty as a tool to predict morbidity and mortality as well as for goals of care discussions for the burn patient.

767 Medical Decision Making in the Burn Unit: A Qualitative Study

IntroductionIn 1973, Dax Cowart was severely burned as a result of a car explosion. He spent the next 46 years advocating for patients’ rights to decline treatment as he felt his repeated wishes to do so and be allowed to die were ignored by his burn providers. Due in large part to his advocacy, many strongly believe that burn providers are problematically paternalistic and force unwanted treatment upon capacitated, autonomous patients (e.g., Hurst et al 2014). Unfortunately, there are only a few attempts to provide the perspectives of other severely burned patients (e.g., Brewster et al 2006 and Gerrek 2018). The purpose of this qualitative study was in part to gain further understanding of the views of severely burned patients regarding medical decision making during the acute phase of their injury.MethodsBuilding on Brewster et al. and Gerrek, our team created a semi-structured interview questionnaire. We followed standard IRB research study protocols and then identified adult individuals with 2nd and 3rd degree thermal injury minimum 30% TBSA burns for recruitment. Though 20 patients met the criteria, we completed 5 (26%) interviews (3 females, 2 males).ResultsAll interviewees discussed ways in which they struggled to make informed autonomous decisions for weeks or even months post-injury and felt dependent on the burn team to lead them through treatment decisions. “[I]t's all new to me … obviously I've never been burnt like this before. I will assume it's similar for most of the people … when you wake up and find out how badly you were burned, and maybe you try to move and you figure out how bad you're hurting, you don't really make the decisions for yourself. I kinda put myself in their hands … I figured that's my best shot, to listen to them and let them do what they need to do. Really, I didn't want to make any decisions. I just listened to them and put my trust in them that they were doing the best they could for me”. (P2)None of the interviewees, not even those who underwent amputation, felt the team acted in an inappropriately paternalistic manner. In fact, as a whole, they believed the team only did procedures that were absolutely necessary for their survival and wellbeing. “I believe that they made all the right decisions surgery wise and everything.” (P5)ConclusionsThis study supports the limited but important work of the perspectives of severely burned patients’ regarding, among other things, how medical decisions were made during the acute phases of their injury. It shows that patients trusted their providers to make and encourage life-saving, wellbeing enhancing decisions during the early stages of treatment when patients are not sure they are capacitated and autonomous. Furthermore, the positive feelings patients had about those decisions did not change over time.

500 Return To Work After A Burn Injury: Even The Small Burns Need Attention

IntroductionAn important part of burn recovery and reintegration involves the return to meaningful employment. Studies have determined that the workman’s compensation burn patient faces multiple barriers to return to work (RTW). Factors that increase time to RTW include increased TBSA burns, full thickness depth and grafting, burns to the hands and feet, and increased age. We hypothesize that patients with grafted burns, hand and feet burns, or psychological disorders following injury take longer to return to work.MethodsA retrospective analysis was performed of burn patients seen in the outpatient burn clinic with work related injuries equal to or less than 5% TBSA, from 11/1/2016 to 5/31/2021. In addition to demographic data, also collected were locations of burns, dates of RTW, and positive PTSD and depression symptoms on screening.Medians with interquartile ranges are reported due to nonnormal distribution, Wilcoxon Mann Whitney tests were performed using StataCorp. burn patients seen in the outpatient burn clinic with work related injuries.ResultsOf 118 patients, more injuries occurred in males (89%) than females with a median age of 36.5 years (IQR 26-49). The median TBSA was 1% (IQR .025-1.5) and the median time to return to work was 34 days (IQR 16-75). The 21 patients that were grafted took significantly longer to return to work (median 107.5 days; IQR 60-199.5) compared to 97 patients that were not grafted (median 28 days; IQR 13-59; p=0.0000]. Presence of a hand/foot burn trended towards increased time to RTW but was not significant, median 37 days (IQR 19-81) vs 26 days (IQR 14-61; p =.0306).Patients with PTSD and depression (n=16) also took longer to return to work (Median 66; IQR 33-89.5) compared to patients (n=90) that showed no symptoms on screening (median 30.5; IQR 14-72; p=0.032).ConclusionsThe increased RTW for grafted, hand and foot burns is supported in the current research, however the addition of PTSD and depression and its interplay with RTW has not yet been fully vetted in determining return to work readiness. Within our population, positive screens for these psychological stressors profoundly affected their ability to return to employment. This study continues to validate the need for early screening and intervention in our population and the need to intervene as early as possible with psychological support services.

514 The Outcomes of Tracheostomy on Burn Inhalation injuries

IntroductionTracheostomy has been proposed for patients with expected prolonged intubation and it has been shown to be beneficial for trauma patients with severe brain injury; however, the benefit of performing tracheostomy on burn inhalation injuries has not been extensively investigated. Our study aims to determine the outcomes of performing tracheostomy on patients with burn inhalation injuries requiring mechanical ventilation.MethodsRetrospective review of our institutional burn registry from 2011 to 2019. We compared the outcomes of all burn patients that met our inclusion criteria which included: adequate data recording of inhalation injury within the registry, ventilator support for at least 24 hours, and a TBSA burn injury of < 15%. We stratified the patients into two groups: tracheostomy (group 1) versus no tracheostomy (group 2). Outcome measures included: in-hospital mortality rate, hospital length of stay, ICU length of stay, ventilator days, and ventilator associated pneumonia (VAP). Chi-squared and t-test analyses were used with significance defined as p< 0.05.ResultsA total of 33 burn patients met our inclusion criteria. Group 1 consisted of 10 patients and group 2 consisted of 23 patients. There was no statistically significant difference between the two groups in terms of %TBSA (p =0.24, t-test). There was a significantly higher ICU length of stay at 23.8 days in group 1 compared to 3.16 days in group 2 (p=0.0001, χ2). There was a significantly higher hospital length of stay at 28.4 days in group 1 compared to 5.26 days in group 2 (p=0.0001, χ2). Ventilator days was also significantly higher in group 1 with 20.8 days compared to 2.5 days in group 2. There was no statistically significant difference between the two groups in terms of mortality, however, the incidence of VAP was significantly higher in group 1 than in group 2, with six cases compared to zero cases, respectively(p=0.0001, χ2).ConclusionsThe ideal timing and implementation of tracheostomy with inhalational injury has yet to be determined. In our study, tracheostomy was associated with much longer lengths of stay and pneumonia. The impact of the underlying lung injury, versus the tracheostomy itself on these observations, is unclear. The challenge of characterizing the severity of an inhalation injury based on early visual inspection remains.

44 Endothelial Monolayers Treated with Burn Patient Plasma Exhibit Differential Gene Expression Linked to Cytoskeletal Rearrangement

IntroductionBurn shock is one of the most serious and complex complications suffered by patients following thermal injury. Endothelial dysfunction may play a role in the pathogenesis of burn shock. However, the mechanisms underlying the contribution to pathophysiology are still largely unknown. Previous studies have shown a connection between the rearrangement of cytoskeletal elements leading to increased vascular permeability. The aim of this study was to examine the differential expression of genes involved in cytoskeletal arrangement in endothelial cell monolayers treated with plasma from burn patients.MethodsHuman umbilical vein endothelial cells (HUVECs) were seeded into transwell plates to form confluent monolayers. Plasma was collected from burn patients 4 hours post-admission. HUVEC cells were exposed to 10% multi-donor pooled healthy human plasma (HHP) or burn patient plasma. Monolayers were subsequently incubated with FIT-C Dextran (40,000 kD) for 2 hours. Monolayer permeability was measured with indices calculated by normalizing values to blank wells (transwell inserts) and HHP-treated monolayer FIT-C diffusion. RNA was isolated from these same cells that had increased monolayer permeability and PCR analysis was carried out using an 84 gene array of human cytoskeletal regulators (Qiagen). A Ct value of 35 was used to indicate expression and a fold change of 1.5 to indicate differential expression in the control vs. injured groups.ResultsFour burn patient plasma samples were utilized to create injuries. Patients were mostly male (75%) with a mean age of 50±20 years and mean %TBSA burn of 37±34%. Differential gene expression in burn vs. HHP was compared. Ten genes showed significant upregulation (ARHGDIB, AURKA, AURKB, CCNB2, CIT, IQGAP2, VASP, SSH2, MYLK and DIAPH1). Four genes showed significant downregulation in (FSCN2, ARHGAP6, CYFIP2, CCNA1). Monolayer permeability indices showed statistically significant increases when compared to controls ranging from 3-13.33% (p < .05).ConclusionsThe interplay of burn shock and endothelial dysfunction remains a complex process of which much is unknown. However, RNA analyses of burn patient plasma reveals involvement of multiple cytoskeletal regulators. Furthermore, all these samples show a concurrent increase in permeability indices when compared to controls, further strengthening the association between cytoskeletal rearrangement and endotheliopathy. Future research to better understand the specifics of these pathways could help aid in the development of more targeted treatments of endotheliopathy and burn shock. Cytoskeletal rearrangement may be an interesting target for future work to understand this mechanistic interplay.

703 Evaluation of a Stress Ulcer Prophylaxis Protocol in an Burn Intensive Care Unit

IntroductionPatients suffering from large burn injuries have an increased risk of gastrointestinal mucosal damage from stress ulcers. Proton pump inhibitors (PPIs) and histamine H2-receptor antagonists (H2RAs) are routinely used for stress ulcer prophylaxis in burn patients, however there are few comparative trials evaluating the efficacy of these therapies in the burn population. Our burn center uses a stress ulcer prophylaxis protocol that incorporates both classes in a step-wise manner. The objective of this study was to evaluate the protocol by comparing the incidence of uncontrolled gastric pH, positive gastric occult blood, and gastrointestinal bleed (GIB) while on famotidine or pantoprazole prophylaxis.MethodsThis was a single-center retrospective observational study conducted at an academic medical center and was approved by the hospital’s Institutional Review Board. Patients were included if they were at least 18 years of age, admitted to the burn intensive care unit (BICU) from June 2017 to August 2020 with burns involving at least 1% TBSA, and had at least one documented gastric pH and/or occult blood test while receiving famotidine or pantoprazole. The primary endpoint was a composite of gastric pH less than 5, a positive occult blood test, or occurrence of GIB.ResultsIn total, 107 patients with a mean age of 55 yo were included in the study. The median TBSA burn was 16% and length of stay was 23 days. Seventy seven (72%) patients received famotidine and 93 (87%) of patients received pantoprazole. The incidence of the primary endpoint in all patients receiving famotidine and pantoprazole were 69 (90%) and 86 (92%), respectively (p = 0.513). During famotidine prophylaxis, 256 (43%) gastric pH tests were less than 5 and 397 (47%) gastric occult blood tests were positive, with no reports of GI bleeding. During pantoprazole prophylaxis, 751 (33%) gastric pH tests were less than 5 and 1220 (47%) gastric occult blood tests were positive, and 4 (4%) were diagnosed with a GI bleed. A total of 91 (85%) patients had deviations from the protocol, which included 42 (46%) patients who did not receive the recommended dose or agent, 27 (30%) patients who were not initiated on the recommended initial agent, and 22 (24%) patients who did not receive a recommended increase in dose or switch agents when recommended.ConclusionsIn the setting of burn injuries of at least 1% TBSA, no difference was detected in uncontrolled gastric pH, positive occult blood tests, or GIB when using famotidine or pantoprazole in our stress ulcer prophylaxis protocol. The overall incidence of gastric pH less than 5 and positive gastric occult blood was high for both agents, while the incidence of GIB was low in both groups.