Extensive Burns Research Articles

A prospective before-after self-control study of the scenario simulation teaching of junior nurses in a burns department on the fluid resuscitation care of massive burn patients during shock stage

Objective: To explore the effects of scenario simulation teaching of junior nurses in a burns department on the fluid resuscitation care of massive burn patients during shock stage. Methods: From March 2018 to July 2019, 25 junior nurses fixed in the Department of Burn of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine met the inclusion criteria and were recruited in this prospective before-after self-control study, including 21 females and 4 males, aged 23 to 26 years. They had a work experience of 1.0 (1.0, 2.0) years in the Department of Burn. Three teaching scenarios were made according to the three major problems in the fluid resuscitation nursing of extensive burn patients during shock stage. The teaching plans were written based on the theoretical framework of Jeffrie's nursing simulation teaching. The high feasibility and practicability of the teaching plans was verified through expert consultation and evaluation by junior nurses. According to the three scenarios in the teaching plan, the junior nurses were performed with scenario simulation teaching, with 2 hours for each scenario, 6 hours in total. In one month before and after the teaching (hereinafter referred to as before and after teaching), the comprehensive ability of junior nurses was evaluated by the teachers using the self-designed junior nurse comprehensive ability evaluation scale, and their behaviors were evaluated by themselves with Performance Self-rating Scale for Nursing Students on High Simulation Training. Data were statistically analyzed with paired sample t test. Results: After teaching, the scores on communication skills, patient admissions, condition assessments, fluid resuscitation, emergency treatment, drug management, nursing skills, instrument use, teamwork, and humanitarian care and total score in the comprehensive ability evaluation of junior nurses as evaluated by teachers were significantly higher than those before teaching (t=-8.060, -11.421, -17.232, -24.800, -4.670, -11.916, -12.131, -11.606, -14.632, -13.325, -25.068, P<0.01), with 4 items including fluid resuscitation, condition assessment, nursing skills, and equipment operation having higher scores. After teaching, the nurses' self-rating scores on communication, division of labor and cooperation, clinical decision-making, professional knowledge and skills, and professional development and critical thinking and total score were (4.6±0.4), (4.8±0.3), (4.6±0.3), (4.6±0.4), (4.6±0.4), and (23.2±1.5) points respectively, which were significantly higher than the corresponding scores of (4.1±0.7), (4.2±0.7), (3.9±0.5), (3.7±0.6), (3.9±0.5), and (18.8±2.6) points before teaching (t=-3.361, -5.721, -6.987, -7.923, -7.922, -7.367, P<0.01). Conclusions: With solving the practical problems in nursing works of fluid resuscitation care of massive burn patients during shock stage as entry point, scenario simulation teaching aims to train the clinical practice ability and adaptability of junior nurses, thereby improving junior nurses' comprehensive ability of clinical practice in the fluid resuscitation care of massive burn patients during shock stage, enhancing their self-confidence and critical thinking ability.

Aspartate transaminase/alanine transaminase (De Ritis ratio) predicts survival in major burn patients

BackgroundAlthough treatment of burn patients has significantly improved in recent decades, major burns remain fatal. Therefore, the evaluation of the death risk of the patients with extensive burns is very important. The ratio between the serum levels of aspartate transaminase and alanine transaminase (De Ritis ratio) was an independent predictor of poor outcomes in patients with acute ischemic stroke, cardiac surgery, non-metastatic renal cell carcinoma, and upper urinary tract urothelial carcinoma. Our aim was to determine whether the ratio between the serum levels of AST and ALT (De Ritis ratio) was useful to assess prognosis in extensively burned patients. MethodsWe conducted a single-center cohort study at the Burns Department of Changhai Hospital. This retrospective observational analysis was performed based on the clinical data of major burn patients admitted between May 1, 2005 and April 30, 2018. Univariate and multivariate logistic regression analyses were performed on variables such as age, sex, total body surface area (TBSA), De Ritis ratio, and serum albumin level, which may affect mortality in major burn patients. We assessed their diagnostic value and found the cut-off value by receiver operative characteristic (ROC) curve analysis. We used the Kaplan–Meier curve to display the impact of the De Ritis ratio and serum albumin level on survival in burn patients. ResultsA total of 351 patients with extensive burns were included in the study. The cohort predominantly consisted of males (74.64%), and most of the patients (78.35%) had been burned by a flame. Age, TBSA, inhalation, and the De Ritis ratio were found to be independent risk factors for the 30-days mortality of major burn patients, while age, TBSA, inhalation, and the De Ritis ratio were independent risk factors for 90-day mortality. Further, the De Ritis ratio was a better mortality predictor than serum albumin in severely burned patients, whose area under ROC for 30-day and 90-day mortality was 0.771 (95% confidence intervals [CI], 0.708–0.835) and 0.750 (95% CI, 0.683, 0.818). ConclusionsThe De Ritis ratio was useful as a prognostic indicator for major burn patients, which can be conveniently obtained through blood examination. Regardless of whether the prediction was for 30-day or 90-day mortality, the accuracy remained high. Moreover, compared to serum albumin level, the De Ritis ratio was superior in assessing the prognosis of extensively burned patients.

Enzymatic debridement in critically injured burn patients — Our experience in the intensive care setting and during burn resuscitation

BackgroundMuch of the recent literature on bromelain based enzymatic debridement of burn injury has focused on its use in smaller burn injury and specialist areas such as the hands or genitals (Krieger et al., 2012; Schulz et al., 2017a,b,c,d). This is despite the original papers describing its use in larger burn injury (Rosenberg et al., 2004, 2014).The current EMA license for Nexobrid™ advises that it should not be used for burn injuries of more than 15% TBSA and should be used with caution in patients with pulmonary burn trauma and suspected pulmonary burn trauma. The original safety and efficacy trial of NexoBrid™ limited its use to 15% TBSA aliquots with concern regarding the effect of bromelain on coagulation. In a European consensus paper of experienced burns clinicians, now on its second iteration, 100% of respondents agreed that “up to 30% BSA can be treated by enzymatic debridement based on individual decision” (Hirche et al., 2017). Hofmaenner et al.’s recent study on the safety of enzymatic debridement in extensive burns larger than 15% provides some further evidence that “bromelain based enzymatic debridement can be carried out safely in large-area burns” (Hofmaenner et al., 2020) but the literature is scant in these larger debridement areas.In our centre we have been using enzymatic debridement for resuscitation level burn injury since 2016. We have gained significant learning in this time; this article aims to describe our current protocol for enzymatic debridement in this patient population and highlight specific learning points that might aid other centres in using enzymatic debridement for larger burn injury. MethodWe performed a search of the IBID database to identify all adult patients who satisfied the inclusion criteria of resuscitation level burn injury (defined as total burn surface area (TBSA) ≥15% in patients aged >16 years), or level 3 admission following burn injury and who underwent Enzymatic Debridement. A case note review was completed, and details comprising patient demographics, TBSA, mechanism of burn, presence of inhalation injury, sequencing of debridement, length of ICU and hospital stay, blood product utilisation and the need for autografting were recorded. No ethical approval has been sought for this retrospective review. ResultsWe identified 29 patients satisfying the inclusion criteria (Table 1). Between June 2016 and June 2020 the average total burn size of patients who had at least some of their burn treated by enzymatic debridement increased from 21.4% in 2016/17 to 34.7% in 2019/20. In these patients the actual area treated by enzymatic debridement also increased from 11.9% TBSA to 20.3% TBSA. 19 patients (66%) had enzymatic debridement performed within 24 h of injury, a further 2 patients (7%) within 48 h after injury. Patients were more likely to have enzymatic debridement commenced in the first 24 h after injury if they had circumferential limb injury (39% vs 9%) or were planned for enzyme only debridement (78% vs 28%). Those who were planned for combination enzyme and surgical debridement were more likely to have enzymatic debridement commenced after the first 48 h (75%). We have performed enzymatic debridement overnight on one occasion, for a patient who presented with circumferential limb injury and was determined to undergo urgent debridement. ConclusionMuch of the literature has described the use of enzymatic debridement in smaller burns, and specialist areas. However, it is our opinion that the advantages of enzymatic debridement appear to be greater in larger burns with a facility for whole burn excision on the day of admission in the ICU cubicle. We have demonstrated significantly reduced blood loss, improved dermal preservation, reduced need for autografting, and a reduction in the number of trips to theatre. We would advocate that both the team and the patient need to be as prepared as they would be for a traditional surgical excision. The early part of our learning curve for enzymatic debridement in resuscitation level injuries was steep, and we were able to build on experience from managing smaller injuries. We recommend any team wishing to using enzymatic debridement gain experience in the same way and develop robust local pathways prior to attempting use in larger burn injuries.

Wound healing and dermal regeneration in severe burn patients treated with NovoSorb® Biodegradable Temporising Matrix: A prospective clinical study

IntroductionFor extensive burns, autologous donor skin may be insufficient for early debridement and grafting in a single stage. A novel, synthetic polyurethane dermal template (NovoSorb® Biodegradable Temporising Matrix, BTM) was developed to address this need. The aim of this study was to evaluate use of BTM for primary dermal repair after deep burn injury. MethodsA multicentre, prospective, clinical study was conducted from September 2015 to May 2018. The primary endpoint was % split skin graft take over applied BTM at 7–10 days after grafting. Secondary endpoints included % BTM take, incidence of infection and adverse events, and scar quality to 12 months after BTM application. ResultsThirty patients were treated with BTM and delayed split skin grafting. The % graft take had a mean of 81.9% and % BTM take had a mean of 88.6%, demonstrating effective integration of BTM. When managed appropriately, it was possible for BTM to integrate successfully despite findings suggestive of infection. Scar quality improved over time. DiscussionThese results provide additional clinical evidence on the safety and performance of BTM as an effective dermal substitute in the treatment of patients with deep burn injuries.

QS5: Cryopreserved Adipose for Hypodermal Augmentation After Full-thickness Burns

Purpose:Burn and blast injuries to the face and extremities are highly morbid injuries affecting quality of life, ability to work, and psychosocial well-being. Without exception, extensive burn injuries require surgical debridement, with standard of care reconstruction involving autologous skin grafting to restore cutaneous integrity. This treatment modality is limited in extensive burns or in highly visible areas by lack of donor site and/or soft tissue deficits resulting in significant disfigurement. Hypodermal restoration via autologous adipose transplantation provides padding for the overlying skin, helps restore native features, and enhances contour and texture. However, this technique is limited by graft retention and often requires multiple rounds of grafting and consequently, multiple rounds of surgery, each with separate anesthesia, to achieve adequate results. The goal of this study was to demonstrate the therapeutic validity and efficacy of utilizing cryopreserved adipose to avoid multiple liposuction events when serial skin and fat grafting procedures are performed to restore epidermal, dermal, and hypodermal integrity after full-thickness burn.Methods:Adipose was collected from female Yorkshire swine and processed day-of-collection for immediate cryopreservation. This adipose was preserved for 3 months prior to initiation of the next stage of the experiment. After three-month elapse, female Yorkshire swine received 16, 4x4 cm full-thickness burns using an electric brand. After 48 hours, eschar was removed down to fascia. Skin grafts were collected as split-thickness skin grafts. The pigs were maintained for 8 weeks from time of engraftment and interval serum, photography, ultrasound, and biopsies were collected. At 8 weeks post-engraftment animals were sacrificed and all wounds were collected for histology and proteomic evaluation.Results:Split thickness skin graft take was greater than 95% in all injuries. Adipose grafts from Group B, were noted to remain present and incorporated into the granulation tissue in absence of skin graft with viability confirmed on biopsy. Initial increase in granulation layer thickness was noted in presence of fat graft with Group B vs. Group A. On serial ultrasound assessment, penetrating adipose grafts from Group D were noted to be present without gross resorption at all time points. Cryopreserved adipose remained viable throughout the duration of the experiment with histologic evidence of incorporation at 8 weeks post-operative.Conclusion:Burn and blast injuries predominantly affect military personnel and first responders for whom improvement in protective equipment has decreased mortality without resolving the risk of morbidity to the face or extremities. Hypodermal augmentation with lipografting as part of a strategy of autologous skin grafting addresses contour deficits and skin quality, however is limited by the need for multiple liposuction and grafting procedures, requiring multiple trips to the operating room with increased surgical and anesthetic risk and high economic burden. Here we demonstrate cryopreservation of adipose as an avenue to alleviate that burn.

Glycerolised Skin Allografts for Extensive Burns in Low- and Middle-income Countries.

Introduction:There has been a significant improvement in the outcome of treatment of large surface area burns in developed countries. A major contributory factor is an early excision and skin grafting of burn wounds. The initial coverage of large surface area deep burn wounds requires the use of temporary skin substitutes such as allografts due to limited skin autografts. Cadaveric skin allografts are the commonest source of skin allografts in use; however, there may be religious, cultural, cost, or other factors mitigating its availability and routine use in low- and middle-income countries (LMICs). Human skin allografts may be used fresh or stored in tissue banks to ensure its ready availability. The purpose of this review is to promote glycerolised skin allografts as a means of skin preservation in low-resource countries above other modalities cryopreservation due to its cost advantages and relative ease of operation.Materials and Methods:A literature search for articles related to human skin allograft use in burn care, skin banks, and glycerolised skin allografts in LMICs was done using PubMed, EMBASE, and Web of Science databases. The key words used were ‘allograft’ and ‘burn’ with a filter in the search for human studies. The relevant references in the articles obtained were also searched for and included in the reviewResults:Sixty-three journal articles were reviewed for contents in line with the objectives of this study.Conclusion:Glycerolised skin graft is a viable option for coverage of extensive burns in LMICs.

Adipose tissue versus stem cell-derived small extracellular vesicles to enhance the healing of acute burns.

Aim: Proper healing of extensive burns remainsa healthcare challenge. In the present study, we proposed a distinct therapeutic application of adipose tissue and small extracellular vesicles isolated from human menstrual blood-derived mesenchymal stem cells (MenSC) small extracellular vesicles (sEVs) to enhance the repair of third-degree burn injury. Materials & methods: Mouse model of third-degree burn was used. Adipose tissue in the form of nano-fat (NF)and MenSC-sEVs wasinjected subcutaneously at the site of injuries. Results: NF and sEVs were capable of enhancing wound closure and increasing neoangiogenesis. NF was also effective in accelerating the formation of granulation tissue and boosting the thickness of the new epithelial layer. Conclusion: This study demonstrates the effectiveness of NF and MenSC-sEVs as promising therapeutic approaches to facilitate the repair of skin burns.

Use of negative pressure wound therapy as a bolster over skin grafts in patients with severe burn injuries at a tertiary care burn centre in India

BackgroundManagement of deep burn requires aggressive debridement of non-viable burnt tissue and closure with skin grafts or flaps but challenge is to manage wound exudates and patient discomfort and to avoid shear force and pain cause by frequent dressing changes. This observational case series assessed outcomes of negative pressure wound therapy (NPWT) use as a bolster in pilot surgery (primary surgery) over skin grafts in patients with severe burns in a burn center in Indore, India in term of wound healing, pain, caregivers and nurses workload. MethodsPatients with extensive burns (≥30% total body surface area [TBSA]) were admitted to the burn unit between January and December 2020. Acute burn victims (burns present <24 h from burn injury) and patients over the age of 18 were included in this study. All patients received primary standard burn care including debridement of non-viable tissue, wound closure with homograft or autografts, and application of NPWT as a bolster in first sitting (Pilot surgery). NPWT dressings were changed every three to four days. Skin graft healing was monitored during dressing changes. Patient reported pain was recorded using the 10-point Likert pain scale. ResultsThirteen patients with an average TBSA of 42.6% (range 30–63%) underwent treatment. A total of 8 patients suffered from flame burns, 4 from electrical burns, and 1 from scald burns. The average length of hospital stay was 18.1 ± 6.2 days with wound closure in 9.1 ± 4.3 days. An average of 3.5 ± 1.3 dressing changes occurred. All patients were discharged without requiring re-grafting. No complications were observed, except small non-healing burn wounds in four patients that required further standard wound care to reach complete re-epithelisation. The overall patient reported pain was 3.4 ± 1.2. ConclusionsUse of NPWT as a bolster in patients with severe burns resulted in decreased wound healing time, pain score, workload of nursing staff and caregivers and early rehabilitation of survivor.

Features of autophagy in the cytoplasm of endotheliocytes of blood capillaries in severe burn septicotoxemia

Burn injury and its consequences are an important medical and social problem, given the high mortality and disability rates. The leading cause of death in patients with extensive and deep burns is burn septicotoxemia.Material and methods. The material was the heart muscle of the anterior, posterior and lateral walls of the left ventricle of those who died from burn disease during septicotoxemia. The control group included cases of male mortality as a result of “acute coronary death”. The study of the ultrastructure of endotheliocytes of blood capillaries of the myocardium has been carried out.Results and discussion. Ultrastructural analysis of endotheliocytes of blood capillaries of the myocardium showed that in burn septicotoxemia, intracellular degradation processes are observed in the form of swelling of the cytoplasm and organelles, a decrease in the concentration of vesicular structures, as well as activation of autophagy due to the appearance of autophagosomes and autolysosomes in the cytoplasm. Activation of autophagy should be considered as a naturally developing compensatory reaction aimed at preserving the cellular pool of endotheliocytes of the blood capillaries of the myocardium in response to the alterative effect caused by burn septicotoxemia.Conclusion. The obtained data can serve as a justification for the manifestation of left ventricular contractile insufficiency, which is a consequence of endothelial dysfunction and microcirculatory disorders in the myocardium in burn septicotoxemia.

The features оf immunopathogenesis of sepsis and immunodiagnostics in severely burned patients

Intention. To study the possibility of predicting early burn sepsis based on the content of proinflammatory cytokines in the peripheral blood of patients with extensive burns.Methodology. The study included 60 patients (of them 37 men) aged 21 to 58 years (mean age 46.8 ± 9.3 years) with extensive skin burns (Degree III burns by ICD 10 from 20 to 60 %, average 34.1 %, of the body surface). Depending on the skin area affected and the course of burn disease, the patients were divided into three groups, each of 20 patients: group 1 - the course of burn disease without early sepsis, burn area from 21 to 40 % of the body surface; group 2 - the course of burn disease without early sepsis, burn area from 41 to 60 % of the body surface; group 3 - the early burn sepsis, burn area of 20 to 60 % of the body surface. To achieve the goal of the study, all the patients underwent sequential peripheral blood sampling 24 and 72 hours after a burn injury. The levels of IL-1β, IL-6, IL-10, and TNFa were analyzed in the obtained samples. Data were processed using Microsoft Office Excel 2007 and IBM SPSS 20.0 by methods of descriptive and non-parameter statisticsResults and Discussion. The analyzed indicators statistically significantly correlated with the severity of burn injury and the likelihood of burn sepsis. Decreased concentrations of IL-1β, IL-6 and TNFα within Days 1-3 after getting a burn suggest a relatively favorable course of burn disease. No significant positive dynamics of these laboratory parameters may indicate a high probability of developing early burn sepsis.Conclusion. Concentrations of IL-1β, IL-6 and, especially, TNFα in the peripheral blood make it possible to predict early burn sepsis.

The Effects of Topical Vitamin C on Burn Wound Healing

Background and Aim: Topical supplements and vitamins have often been used to accelerate the healing of burn wounds. This study investigated the effects of topical application of vitamin C solution on burn wounds. Methods &amp; Materials: This research was performed on 30 patients with extensive second-degree burns on one or two organs with similar burns. The study subjects were randomly divided into the intervention and control groups. The intervention group received topical application of vitamin C solution in addition to silver sulfadiazine ointment in the burn area; however, only silver sulfadiazine ointment was applied in the burn area in the control group. The wounds were examined and scored on days 1, 3, 7, and 14 using the Bates-Jensen Wound Assessment Tool. The collected data were analyzed in SPSS using repeated-measures Analysis of Variance (ANOVA). Ethical Considerations: This study was approved by the ethics committee of sabzevar university medical sciences. (Code: IR.MEDSAB.REC.1394.60). Results Eighteen of the 30 examined patients were male and 12 were female. Their Mean±SD age and body mass index were 43.03±11.90 years and 27.82±4.08 kg/m2, respectively. Conclusion: The repeated-measures ANOVA data indicated that the study groups were significantly different concerning the final mean scores given to the wounds (P=0.047). In other words, the research groups significantly differed in wound healing; thus, topical application of vitamin C significantly improved wound healing in the study participants.

NETosis in the pathogenesis of acute lung injury following cutaneous chemical burns.

Despite the high morbidity and mortality among patients with extensive cutaneous burns in the intensive care unit due to the development of acute respiratory distress syndrome, effective therapeutics remain to be determined. This is primarily because the mechanisms leading to acute lung injury (ALI) in these patients remain unknown. We test the hypothesis that cutaneous chemical burns promote lung injury due to systemic activation of neutrophils, in particular, toxicity mediated by the deployment of neutrophil extracellular traps (NETs). We also demonstrate the potential benefit of a peptidyl arginine deiminase 4 (PAD4) inhibitor to prevent NETosis and to preserve microvascular endothelial barrier function, thus reducing the severity of ALI in mice. Our data demonstrated that phenylarsine oxide (PAO) treatment of neutrophils caused increased intracellular Ca2+-associated PAD4 activity. A dermal chemical burn by lewisite or PAO resulted in PAD4 activation, NETosis, and ALI. NETs disrupted the barrier function of endothelial cells in human lung microvascular endothelial cell spheroids. Citrullinated histone 3 alone caused ALI in mice. Pharmacologic or genetic abrogation of PAD4 inhibited lung injury following cutaneous chemical burns. Cutaneous burns by lewisite and PAO caused ALI by PAD4-mediated NETosis. PAD4 inhibitors may have potential as countermeasures to suppress detrimental lung injury after chemical burns.

Retrospective Evaluation Of The Accuracy Of Five Different Severity Scores To Predict The Mortality In Burns Patients.

Patients with great clinical impairment, due to extensive burns, need to be admitted to intensive care units, in these treatment sites, indices are used to classify the severity of patients. The aim of the study was to compare the accuracy of the FLAMES score in relation to the Acute Physiologic and Chronic Health Evaluation II (APACHE II), the Simplified Acute Physiologic Score II (SAPS II), the Logistic Organ Dysfunction System (LODS) and the Abbreviated Burn Severity Index (ABSI) applied to the severe burn patient facing mortality in an ICU of a reference center for burns in Brazil. A retrospective study conducted in ICU comparing the accuracy the APACHE II, SAPS II, LODS, ABSI and FLAMES instruments were applied to all the selected medical records. To evaluate the accuracy of the SIs, the Receiver Operating Characteristic curve was calculated and the area under the curve (AUC). Among the 574 patients included in the study, male individuals (70.13%), with an average age of 44.01 ± 28.64 prevailed and the majority of the burns were caused by accidents (76.53%). The outcome accounted for 35.29% of deaths. It was observed that the FLAMES and ABSI presented the two largest areas under the ROC curves and the highest sensitivities (96% and 89%, respectively). The APACHE II, SAPS II and LODS presented sensitivities equal to or greater than 80%. It has been demonstrated that indices specifically developed for burn patients, specifically the FLAMES and ABSI indices, presented better accuracies and prediction performances.

Adolescents with and without head and neck burns: comparison of long-term outcomes in the burn model system national database

IntroductionFacial burns account for persistent differences in psychosocial functioning in adult burn survivors. Although adolescent burn survivors experience myriad chronic sequelae, little is known about the effect of facial injuries. This study examines differences in long-term outcomes with and without head and neck involvement. MethodsData collected for 392 burn survivors between 14–17.9 years of age from the Burn Model System National Database (2006–2015) were analyzed. Comparisons were made between two groups based on presence of a head and neck burn (H&N) using the following patient reported outcome measures: Satisfaction with Appearance Scale, Satisfaction with Life Scale, Community Integration Questionnaire, and Short Form-12 Health Survey at 6, 12, and 24 months after injury. Regression analyses were used to assess association between outcome measures and H&N group at 12-months. ResultsThe H&N group had more extensive burns, had longer hospital stays, were more likely to be burned by fire/flame and were more likely to be Hispanic compared to the non-H&N group. Regression analysis found that H&N burn status was associated with worse SWAP scores. No significant associations were found between H&N burn status and other outcome measures. ConclusionsAdolescents with H&N burn status showed significantly worse satisfaction with appearance at 12-months after injury. Future research should examine interventions to help improve body image and coping for adolescent burn survivors with head and neck burns.

Innovative adaptation of the “spare tissues concept” applied for olecranon coverage of a severe burn patient: A case report

The management of bone exposure in patients with extensive burns could be a challenge due to the lack of healthy tissue. In such cases, it could be interesting to use any still healthy tissue initially destined for amputation and use it to cover up another site. We present the case of a sever burn patient for whom we used the only healthy palmar hand skin to cover an olecranon exposure. A 38-year-old man has been admitted in burn victim unit with extensive deep burns on 60% of the total body surface. An exposure of the left olecranon was appeared occurring on a burned area, with absence of healthy local tissues available for coverage. Concomitantly a trans-radial amputation was indicated because of severe digits burns leading to an impossibility to preserve the function of the hand. A palmar skin area was healthy leading to harvested this palmar skin flap pedicled on ulnar vessels. Early post-operative healing was satisfactory and no vascular suffering of the flap has been observed with a total healing at three weeks. In any patient the spare tissues concept should be keep in mind when amputation is indicated simultaneously with a problematic of loss of substance coverage to a proximity area. In this case of severe burn patient, we used a palmar skin flap pedicled on the ulnar vessels to cover an olecranon exposure.

612 Non-burn Injuries in the Emergency Department as Indicators for Future Burn Abuse

Abstract Introduction Thermal burns are a common form of child abuse. They account for up to 20% of all abuse cases reported and are a significant cause of morbidity and mortality. It is imperative that healthcare professionals maintain a high degree of vigilance recognizing signs of abuse, however subtle they may be. This is necessary to protect these vulnerable patients and prevent further injury. Our study seeks to identify predictors of future abuse in patients presenting to the emergency department. This might allow us to identify at risk patients and employ earlier interventions to prevent future harm. Methods A retrospective data review was conducted on all pediatric patients admitted to our burn center between 2008–2018 who were also suspected victims of abuse. Data collected included patient demographics, length of stay, size of the burn, type, degree and location of burn, number of previous emergency room visits, and patterns of injury during previous emergency room visits. Abuse was suspected and investigated if the history was inconsistent with the injury or if it changed, if there was an unreasonable delay in seeking medical care. or if the patient was discharged to an alternative caregiver. Data was analyzed with SPSS Statistics version 10. Results Out of the 5915 total burn admissions between 2008–2018, abuse was suspected and investigated in 297 cases and confirmed in 131 of those suspected. Patients admitted for suspicious burn injuries had an average of 1.82 (SD=3.15, Min=0, Max=25) previous ED visits. Of these patients, 93.6% had medical insurance, 80.5% had a primary care physician, and 72.7% were up to date with their immunizations. The majority presented with 2nd degree burns (86.5%) and the most common mechanism of injury was scald (60.1%). Pediatric patients with confirmed abusive burn injuries had longer hospital length of stay (9.23 days vs. 3.90 days, p&amp;lt; 0.001), and had greater total body surfaced area burned (9.24% vs 4.71%, p=0.001). Significant indicators of abuse included burn injuries to the bilateral lower extremities (thigh and legs) (p&amp;lt; 0.001), bilateral feet (p=0.030), buttocks (p=0.047), and genitalia (p=0.018), as well as signs of abusive non-burn injuries during previous emergency room visits (p=0.005). Conclusions Non-accidental burns should be highly suspected in children presenting with injuries to the bilateral lower extremities, bilateral feet, buttocks, or genitalia, or those with a history of previous non-burn injuries suspicious of abuse. Furthermore, patients with non-accidental burn injuries had more extensive burns and longer lengths of stay in the hospital.

549 Lessons Learned from Two Survivors of Greater Than 90% Total Body Surface Area Full Thickness Burn Injuries Using a Dermal Biodegradable Substitute and Autologous Skin Cell Suspension: A Case Series

Abstract Introduction Advances in burn injury knowledge, critical care, and pharmacological developments have increased survival rates among extensive burn patients. Survival now dependents not just on skin coverage, but effective control of SIRS response, metabolic derangement, fluid loss and sepsis. Novel synthetic dermal substitutes create robustness, thickness, and pliability of the skin in addition to an improved aesthetic appearance while; point-of-care autologous skin cell harvesting enhances treatment by amplifying small split-thickness skin samples to produce an autologous skin cell suspension (ASCS) to cover a larger burn area. This study reports on two survivors with greater than 90% total body surface area full-thickness burns utilizing a combined treatment of a dermal substitute along with ASCS and traditional burn management strategies. Methods Chart review of two patients with &amp;gt;90% burns and inhalation injury after being trapped in a burning vehicle following a traffic collision occurred. Most of the burns in both patients were “leathery” and consistent with full thickness, sparing only the plantar and dorsal aspect of the feet and bilateral small areas of the hip in Patient 1. Patient 2 had fourth-degree burns in some areas of the chest and flank with only the bilateral groin regions and feet spared. The patients were treated with a multi-step process which included using allograft, dermal substitute, and ASCS with split-thickness skin grafts (STSG) in place of cultured epidermal autograft to achieve coverage of &amp;gt;90% burns with high meshed ratio. Results The dermal substitute was limited to deep burns that penetrated down to fat, muscle, and/or joints. Fluid loss was well controlled by the dermal substitute during initial resuscitation. Post reconstruction, areas covered with the dermal substitute and grafted with autogenous STSG with ASCS exhibited less hypertrophy and contracture bands. The elbow and knee joints showed minimal restriction with passive motion and good skin compliance, but contractures persisted in areas where 4th degree tendon and fascia thermal injury occurred. Areas that showed signs of infection were trimmed or unroofed and allowed to drain while maintaining the remainder of the dermal substitute. Conclusions The use of dermal substitutes and ASCS allowed the care team to achieve SIRS control, improved fluid management, enhanced skin coverage, and reduced hospitalization stay. The process experienced in these cases shows promise for future patients with extensive burns. Both patients were able to survive and show improvement during rehabilitation.

135 Vital, Porcine Skin Xenotransplants Provide Safe and Efficacious Temporary Wound Closure of Severe Burns in a First-in-Human Phase I Clinical Trial

Abstract Introduction Temporary wound closure with human allograft skin is considered the gold standard after early excision of a large burn injury. Limitations of allograft include availability, cost, and safety; thus, an alternative that provides the same quality with enhanced safety would be a valuable surgical adjunct to the clinical options currently available to treat severe and extensive full thickness burn wounds. A live cell skin xenotransplant from a clinical grade porcine donor is one candidate. Advantages of this alternative include retention of 70% or more of the innate metabolic activity following cryopreservation, vascularly favorable dermal thickness, and genetic modifications that eliminate hyperacute graft rejection. Combined, these result in pliability, strength, survivability, and function that far exceed those of conventional xenografts and mirror those of human allograft. Methods Split-thickness skin xenotransplants containing vital dermal and epidermal cells were aseptically procured from alpha-galactosyltransferase knockout porcine donors from a closed, Designated Pathogen Free, colony. They were then processed to achieve both sterility and cellular viability and cryopreserved for long term storage. In 2018, the FDA authorized a first-in-human Phase I clinical trial to evaluate the safety and tolerability of a genetically modified skin xenotransplant to treat severe and extensive burn wounds. A two cohort, open-label, dose-escalation study evaluated 6 consenting patients with severe burns requiring allograft. Each received surgical grafting with a skin xenotransplant and human allograft skin in a side-by-side, in-situ comparison. Results The skin xenotransplant was well tolerated by all patients, resulting in zero adverse events or safety issues, and without zoonotic disease transmission. In all cases, the skin xenotransplant appeared indistinguishable from the human allograft comparator and at the time of autografting, both were vascularized and fully adherent. These findings build upon the series of preclinical studies reported by these authors and presented at the ABA in 2019. Conclusions These highly promising patient outcomes demonstrate a potential treatment for complicated burns, especially when human allograft skin is unavailable. Further study of the efficacy of the porcine skin xenotransplants is warranted. As such, a multi-center, Phase II efficacy trial is planned for 2021.

133 Oxidative Stress Can Be Significantly Influenced and Reduced by Polylactide-based Membrane Dressings

Abstract Introduction Oxidative stress is part of the physiological response to local thermal injuries and has systemic effects in more extensive burns, vascular hyperpermeability, burn edema, cellular damage, and functions of the heart, lung, liver, kidneys, muscles, and other organs. Free NO and OH radicals affect mitochondrial function, and lower energy delivery to other organelles releases thermal energy, leading to hypermetabolism. Antioxidant therapies have attempted to reduce the consequences of oxidative stress with limited effects; however, the effect of external dressings is unclear. This study aimed to investigate the positive effects of polylactide-based membranes (PLM) on oxidative stress and clinical outcomes in burns. Methods Herein, a prospective study assessed the correlation between oxidative stress and the severity of injuries by measuring serum malonaldehyde (MDA) and glutathione levels and the total oxidant and antioxidant capacities (TOC and TAC) among children with electrical injuries. Furthermore, a prospective randomized study evaluated the TOC and TAC, MDA, glutathione, IL-6, TNF-α, and TGF-β levels, and the ratio of telomerase positive staining in epidermal cells along the particle thickness of burns in children, when comparing polylactide dressings to Hydrofiber Ag(HFAg), autografts, and controls. Results Coherence between measured oxidative stress and injury severity was apparent herein. Application of PLMs significantly reduced oxidative stress in partial-thickness burns compared to HFAg. PLMs decreased the TOC (4,91 VS. 16,78 µmol/L, day 7) and increased the TAC (14,47 VS. 4,34 µmol/L, day 7). The healing duration was lesser than that of HFAg (13 VS. 21 d). Proinflammatory IL-6 levels were significantly lower in the PLM group and TNF-α values were significantly reduced from days 7 to 14. The anti-inflammatory levels of TGF-β was significantly elevated (days 3–21) in the PLM Group. Telomerase levels and the cell count were higher in healed skin in the PLM group. Conclusions Oxidative stress depends on injury severity and is potentially influenced by dressings. PLM mediates the regulation of oxidative stress, as evident from the TOC and TAC, and pro- and anti-inflammatory cytokines including IL-6, TNF-α, and TGF-β by PLMs might positively influence the healing duration and skin quality in burns. These results could show that oxidative stress can be significantly influenced and reduced by PLM dressings.

644 Use of Plantar Foot Plate Splints and High-Profile Leg Net Devices for Prevention of Plantarflexion Contracture following Placement of Cultured Epidermal Autograft to Lower Extremities

Abstract Introduction Burn Therapists strive to prevent burn scar contracture through positioning strategies beginning in the acute phase of burn injury. This task is even more challenging when paired with posterior offloading and joint immobilization required for the viability of cultured epidermal autograft (CEA). High profile leg net devices are the standard for posterior offloading after application of CEA circumferentially to lower extremities but can result in poor positioning of the ankle. Custom foot plate splints were designed and fabricated to preserve ankle dorsiflexion during the initial stages of CEA healing. Methods The high-profile leg net devices were assembled using 3/4 inch PVC piping and PVC fittings (45 degrees, 90 degrees, and tees) with double layered elastic tubular netting to allow proper wound ventilation while supporting the lower extremity with the patient in supine. The plantar foot plates were custom molded to the patient’s foot using thermoplastic material and lined with medium density temper foam for pressure relief. The foot plate was attached to the frame using Velcro and straps. Instructions with photographs were posted in the patient’s room for nursing staff to reference. Netting was exchanged daily and frames were disinfected using standard techniques. Results Goniometric measures were taken for ankle dorsiflexion were taken on day of CEA application with lower extremities positioned on high profile nets (in alignment with cutaneous functional unit modified position): -6 degrees right ankle, -2 degrees left ankle. Repeat measures were taken after one week period of bilateral lower extremity immobilization per CEA protocol: -1 degree right ankle, 2 degrees left ankle. One month follow-up at the discontinuance of leg net devices showed bilateral ankle dorsiflexion preserved with 3-degree right ankle dorsiflexion and 5 degrees on the left. Conclusions The use of custom foot plates on high profile leg net devices appears to improve ankle dorsiflexion range of motion while maintaining adequate posterior offloading required for CEA precautions for a burn survivor with extensive lower extremity burn wounds.