Full-thickness Burn Research Articles

59 Predictors and Impact of Pneumonia on Adverse Outcomes in Inhalation Injury Patients

Abstract Introduction Next to age and burn size, the presence of inhalation injury (II) is the third mortality prognostic factor for burn injury. II can lead to pulmonary complications such as pneumonia, acute respiratory distress syndrome (ARDS), and acute lung injury (ALI), all of which have been hypothesized to increase mortality in II. Herein, we aimed to identify variables associated with the risk of developing pneumonia and to determine the impact of pneumonia on selected outcomes. Methods De-identified data from the Prospective Inhalation study (ISIS) were used. II was confirmed by fiberoptic bronchoscopy. Baseline demographics, injury data, burn size, laboratory data, radiographic results, treatment, and hospital course were recorded. Ventilator use, complications, including pneumonia, ARDS, ALI, and death, were tracked daily for seven days and then weekly until discharge. Univariate and multivariate analysis were performed. Variables included in multivariate analysis had a p value of 0.1 or less. A p value of < 0.05 was considered significant. Results Of the 108 ISIS study group, 106 had complete data and were included in the analysis. Median age was 48.5 y, 59.4% of the subjects were male, 76.4% White and 9.4% Black. Regarding complications, 46.2% of the subjects developed pneumonia, 11.3% ARDS, 9.4% ALI, and 17% died. On univariate analysis, subjects who developed pneumonia were more likely to be white (87.8% vs. 66.7%, p = 0.006), to present with higher total burn surface area (24.70 [8.00-49.50] vs. 2.85 [0.00-25.38], p = 0.002), and full thickness burn (55.1% vs. 31.6%, p = 0.018). On multivariate analysis, being white (p = 0.033) and receiving colloids in the first 24 h of admission (OR = 3.582 [1.157-11.087], p = 0.027) were associated with increased risk of pneumonia while higher level of MMP-9 in the plasma (OR = 0.999 [0.998-1], p = 0.041) lowered the risk. Admission radiographs, FB score, clinical examination findings, and other demographic factors were not related to developing pneumonia. Pneumonia was independently associated with increased risk of developing ARDS (OR = 8.496 [1.322-54.61], p = 0.024) but not with ALI or mortality. Pneumonia was also associated with a longer hospital length of stay (B = 15.2 [2.4-28], p = 0.020) and higher number of days on a ventilator (B = 15.6 [8.2-23], p < 0.001). Conclusions Pneumonia is associated with increased LOS and ventilator days but not mortality. Those who received colloids were 3.5 times more likely to develop pneumonia. The relationship between colloid and pneumonia requires more research, however, the search for other intervenable clinical variables to prevent pneumonia remains elusive. Applicability of Research to Practice As colloids may affect the glycocalyx and contribute to inflammation, their role in developing pneumonia needs to be elucidated.

74 Secondary Immunohistochemical Analysis of Viable Cells as Determined by Hematoxylin and Eosin Staining

Abstract Introduction Accurate clinical differentiation of deep partial-thickness (DPT) and full-thickness (FT) wounds is essential in justifying appropriate treatments for heterogeneous burns. Only recently has non-invasive burn depth imaging been ground-truthed with tissue punch biopsies; an endeavor that will no doubt improve AI imaging algorithms in the near future. Prior literature supports unique apoptotic and necrotic properties of DPT and FT wounds, suggesting a use for not only standard stains (H&E), but apoptotic marker staining in assisting clinical diagnosis of burn depth, progression and/or conversion. Methods The aim of this study was to evaluate the presence of apoptotic cells in DPT and FT samples previously diagnosed by a burn biopsy algorithm (BBA-V2) for burn depth and severity by expert review of H&E-stained slides. Eight paired biopsies were collected from DPT and FT wounds in four patients within 72 hours of thermal injury and were immunofluorescently labeled for apoptosis markers by detection of deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) and cleaved caspase-3 (CC-3) staining. Fluorescence intensity in dermal appendages within images was used to quantify signal at 40x magnification for CC-3. % positive TUNEL cells were graded by an investigator blinded to the burn severity. A higher grade indicated higher % positivity. TUNEL grading was evaluated by Chi square test. CC-3 intensity was evaluated by Student’s t-test. Results Across all four patients, FT burns had higher levels of CC-3 in dermal appendages compared to DPT burns (Cy3:DAPI ratios: 1.53 ± 0.28 vs. 0.75 ± 0.13; p=0.1074). Within each patient, all FT biopsy sites had significantly higher levels of CC-3 versus DPT biopsy sites (p< 0.05)(Table). DPT burns had a greater proportion of patients with increasing grades of TUNEL positive cells (DPT: Grade 1: 16%, Grade 2: 36%, Grade 3: 48%; FT: Grade 1: 42.3%, Grade 2: 23.1%, Grade 3: 34.6%, p=0.1178). Conclusions CC-3 and TUNEL levels within dermal appendages align with burn depth classification by H&E staining, wherein appendages graded as necrotic had higher levels of CC-3 and lower levels of TUNEL. Therefore, CC-3 and TUNEL are potential secondary histological markers for burn depth. Further analysis of isolated, individual dermal appendages is underway to identify what additional information this secondary marker may add to the diagnosis of burn depth. Applicability of Research to Practice For the first time there is access to a large tissue repository of biopsies from burn wounds. Although staining from these samples has been used to build diagnosis algorithms with success, much more can be learned from the cellular pathophysiology when secondary analyses are performed. These assays may help us understand the processes of burn conversion.

555 Pain Management During Bromelain-Based Enzymatic Debridement in a U.S. Adult Burn Center

Abstract Introduction Outside the United States, bromelain-based enzymatic debridement (BBED) has become an effective tool for removal of burn eschar. BBED can be performed at bedside and allows for complete eschar removal with maximal dermal preservation and markedly reduced blood loss. It may also decrease the need for autografting or the amount of autograft required. A primary concern with BBED is that it is a painful procedure requiring appropriate analgesia. Experience with BBED in the U.S. has been gained through a multicenter phase 3 clinical trial (DETECT) and an expanded access treatment protocol (NEXT). In this retrospective study, we describe our experience using BBED, with particular focus on pain management. Methods A retrospective review was conducted on 29 adult burn patients enrolled in the DETECT or NEXT trials who underwent BBED of acute deep partial- and full-thickness thermal burn wounds at a major burn center between November 2016 and July 2022. Patient demographics and procedural characteristics, including pain management strategies and Numerical Pain Rating Scale (NPRS) scores before, during, and after debridement, were analyzed and described. Results Twenty-nine patients with an average age of 41.2 years (SD=17.8, range 18-72) and an average TBSA of 6.3% (SD=5.6, range 1-24.5) underwent a total of 29 BBED. For pain control during debridement, 6 patients required conscious sedation (CS), 7 a regional block (RB), 5 a local block (LB), and 9 only IV and oral (IVPO) medications. Two patients were intubated and sedated prior to the procedure. No patient required additional BBED treatment and all patients achieved >95% eschar removal. The average NPRS pain score 24 hours before treatment, during treatment, and 24 hours after treatment was 4.0, 4.6, & 4.4, respectively (P=0.65). Sixteen patients (55%) healed without the need for autografting. The average number of days from debridement to wound closure for all patients was 34.9 days (SD=11.9) and for patients who underwent autografting was 40.1 days (SD=12.3). Conclusions With appropriate analgesia, it is possible to perform BBED of acute deep partial- and full-thickness thermal burns without significant changes in patient-reported pain scores. Prior to debridement, it is critical to establish procedure logistics and reasonable patient expectations. Applicability of Research to Practice The authors review their experience controlling pain associated with BBED.

52 Open-Label, Expanded-Access Study of a Bioengineered Allogeneic Cellularized Construct in Adults With Deep Partial-Thickness Burns

Abstract Introduction An FDA-approved bioengineered allogeneic cellularized construct (BACC) provides burn surgeons with an alternative treatment for deep partial-thickness (DPT) burns and may reduce the need for autografting. A phase 3b, open-label, single-arm, multicenter, expanded-access study (NCT04123548) evaluated safety and clinical outcomes of BACC treatment in adults with DPT thermal burns containing intact dermal elements. Methods Patients aged ≥18 years with 3% to < 50% total body surface area of partial-thickness ± full-thickness thermal burns were enrolled. A single application of up to 1:1 meshed BACC was applied to ≤3 burn areas on the torso or extremities (≤2000 cm2 area of BACC). Patients were followed for 24 weeks. The primary endpoint was count and percentage of patients with treatment-emergent adverse events (TEAEs). Additional endpoints were patients and treatment sites with confirmed wound closure (complete re-epithelialization without drainage for 2 consecutive visits ≥2 weeks apart) of the BACC treatment site without autografting by Week 12; durable wound closure by Week 24; time to wound closure without autografting (determined by Kaplan-Meier estimate); scar evaluation using the Patient and Observer Scar Assessment Scale (POSAS); and patients with wound infection-related events. The sample was not designed or sized to determine efficacy. Results Overall, 52 patients were enrolled. Pruritus was the most frequently reported TEAE (n=22 [42.3%]). There were 2 (3.8%) BACC-related TEAEs; both were pruritus and mild in severity. There were 20 serious AEs in 10 (19.2%) patients; none were related to BACC. No patients discontinued the study due to TEAEs. There were 4 (7.7%) deaths (aspiration, myocardial infarction, self-injury, and Gram-negative rod sepsis); none were related to BACC. Wound infection-related events occurred in 5 (9.6%) patients. Overall, 46 (88.5%) patients and 87 (90.6%) BACC-treated wounds did not require autografting. Half of patients achieved wound closure by Week 5. At Weeks 12 and 24, observer and patient total POSAS scores (mean ± SD) were 18.7 ± 8.08 and 18.8 ± 9.84, and 24.5 ± 11.0 and 20.2 ± 12.5, respectively. Wound closure of the BACC treatment site without autografting Conclusions There were no unexpected wound or BACC-related events. The safety of BACC supported its prescribing information. Patients treated with BACC achieved durable wound closure without autografting and thus showed expected clinical benefit in this population. The use of BACC in DPT burns in this study was donor-site sparing. Applicability of Research to Practice Treatment with BACC may offer a promising alternative to autografting for DPT burns.

287 Assessment of the National Burn Repository’s Ability to Examine Obesity and Determine Burn Related Outcomes

Abstract Introduction Despite obesity being a national epidemic there is a paucity of literature examining the effect of obesity in burn-injured patients. Controversy exists on whether obesity provides a protective benefit dubbed the “Obesity Paradox”. Previous literature examining the role of the National Burn Repository (NBR) in obesity-related research identified a lack of nutrition-related fields as a limitation of the dataset. The aim of this work was to provide an interval assessment of the NBR dataset and determine if an effect of obesity on burn-related outcomes and care can be elucidated. Methods A retrospective review of patient data contained within the NBR dataset from 2016-2018 was conducted. The data dictionary was queried for patients with “obesity” listed as a comorbidity. Information on patient weight was available, but no data on height, body mass index, or other nutrition-related fields were found. The primary outcome measure was mortality. Secondary outcomes included hospital length of stay (LOS), ICU LOS and total hospital costs. Patients were stratified by total body surface area burn (TBSA) to examine the effect of obesity on mortality under different injury severities. Mann-Whitney Tests were used to compare obese and non-obese patients. Multiple logistic regression (MLG) was used to compare effects of several common independent variables (age, gender, inhalation injury (IHI), percent full thickness burn (%FT), TBSA and obesity) on mortality, ICU LOS >7days, hospital LOS >10 days and total hospital costs >$200,000. Results Of 41,031 patients included in the analysis, 3,845 (9.37%) were identified as obese. Overall, obese patients had a higher mean TBSA (8.68 ± 13.19% vs. 7.83 ± 12.39%, p=0.01), but not a higher %FT (7.86 ± 14.09% vs. 7.60 ± 14.25%, p=0.85) or occurrence of inhalation injury (8.92 vs. 8.86%, p=0.90). Obese patients had significantly longer hospital LOS (11.93 ± 18.92 days vs. 10.13 ± 18.73 days, p< 0.001), ICU LOS (10.03 ± 18.96 days vs. 9.44 ± 17.68 days, p< 0.001) and total hospital costs ($364,385 vs $211,513, p< 0.001). MLG found obesity to an independent predictor of ICU LOS >7 days, hospital LOS >10 days and total hospital costs >$200,000 (p=0.036, p=0.039 and p=0.046, respectively). MLG also identified age, TBSA and %FT as independent predictors of mortality in the < 20% TBSA group. Age, TBSA, %FT and IHI were independent predictors of mortality in the 20-40% and >40% TBSA groups. Obesity was not an independent predictor of mortality in any group. Conclusions This study showed obesity was not found to be a predictor of mortality for any burn size but did influence extended ICU LOS, hospital LOS and total hospital costs. Standardizing the data dictionary and adding obesity-related fields may greatly strengthen the role of the NBR in obesity-related burn research. Applicability of Research to Practice Utilizing the NBR and understanding its limitations can help to improve this database and better understand the obese burn patient population.

706 Epidemiology, Therapeutic Complexity and Prognostic Challenges of Burns to the Perineum, Buttocks and Genitals

Abstract Introduction Burns that involve the perineum, buttocks and genitals (PBG) have been associated independently with more challenging therapeutic needs and worse clinical outcomes in case series and smaller patient collectives, while large scale epidemiology of this injury is lacking. We studied a cohort of 1024 patients admitted to our burn center to assess clinical outcomes based on the presence of PBG burns. Methods Medical records were screened for patients who did or did not sustain PBG burns and patients stratified accordingly (PBG vs. control (CTR)). Demographic baseline data, burn etiology, presence of inhalation injury (IHT), presence of full thickness burns (FT), number of operations (NOR), mortality, length of ICU treatment (LOS ICU) and hospitalization (LOS) were assessed to compare clinical characteristics and outcomes between the groups. Multivariate regression analyses adjusting for TBSA, sex and age were conducted for key clinical outcomes. Results Between 2014 and 2022, 1024 patients were included in the analysis (PBG: n=227; CTR: n=797). PBG burns were older (median (IQR) 54 (38) vs. 44, (31) years, p< 0.0001), more frequently female (35% vs. 23%, p=0.002) presented with larger TBSA burns overall (27 (37) vs. 10 (13) %, p< 0.0001) and sustained FT burns more frequently (69% vs. 26% p< 0.0001). Scald burns were more frequently the cause of PBG burns (45% vs. 15%, p< 0.0001), PBG patients needed twice as many surgical procedures (2 (4) vs. 1 (1), p< 0.0001) as CTR. PBG patients remained longer in the ICU per per cent TBSA (0.9 (1.1) vs. 0.5 (0.8) days/%TBSA, p< 0.001). Mortality was higher in patients with PBG burns (33.1% vs. 7.8%, p< 0.0001). Multivariate logistic regression yielded significant effects of PBG burns on LOS ICU, LOS and NOR. Conclusions Burns to the perineum, buttocks and genitals are associated with more challenging baseline characteristics upon admission and substantially worse clinical outcomes than burns not involving PBG. Applicability of Research to Practice Expectable therapeutic challenges regarding prolonged intensive care, more frequent surgeries and increased risk for mortality should be taken into account and planned for when admitting patients with PBG burns.

300 Intraoperative Thresholds for Transfusion During Burn Surgery

Abstract Introduction Burn injury is associated with significant morbidity. Deep partial thickness or full thickness burns require surgical excision and skin grafting. This process results in significant blood loss and frequently requires blood transfusions. There is scarcity in published literature addressing intraoperative blood transfusion requirements. The relationship between blood product volume and patient characteristics has not been clearly defined. The enhanced ability to predict blood transfusion requirements would allow for improved allocation of blood products and safer overall operations. Methods This is a retrospective review conducted at a large academic burn center. Inclusion criteria are adult patients admitted between December 2019 and August 2020 with burns requiring surgical excision. Prisoners, children, and non-operative burns were excluded. Operative cases requiring blood product administration were compared to cases that did not require transfusion. Two-tailed student’s t-tests were conducted with p < 0.05 considered significant. Results There were 103 total patients who underwent a total of 217 operations. Forty-eight percent (n=104) of cases required blood transfusion. As detailed in the table, the transfusion group had significantly increased percent total body surface area (TBSA) burn, along with longer hospital and ICU lengths of stay (LOS). Operatively, this group underwent more tissue excision (approximately 15% TBSA compared to 5%) with longer case lengths, coupled with higher estimated blood loss and a lower preoperative hemoglobin. Interestingly, the median time for the initiation of packed red blood cell transfusion was six minutes after incision. Conclusions The average estimated blood loss in cases resulting in transfusion was 907±462mL (with a median of 800mL) compared to 467±398mL estimated blood loss in the non-transfused group. Expected blood loss along with parameters such as planned area of excision (which was approximately three times greater in transfused patients) and severity of burn injury can guide the surgeon in anticipating perioperative administration of blood products. Future directions include stratification of blood volume administration by %TBSA, operative time, LOS, and percent excision. Applicability of Research to Practice The ability to predict blood product requirements preoperatively coupled with the incorporation of perioperative parameters can assist in the judicious and appropriate use of blood products during burn operations.

771 Enzymatic Burn Wound Debridement: The Learning Curve

Abstract Introduction The European Medicines Agency (MEA) approved the use of a proteolytic enzymatic debriding agent enriched in bromelain in 2012. It has become a widely used non-surgical treatment alternative for the debridement of deep partial thickness to full thickness thermal burns. We will present our early experience with this product candidly. We will outline our sequential learning. Moreover, we will describe the pitfalls and lessons learned as well as demonstrate the evolution of our current practice guidelines. Methods This is a retrospective analysis of all patients treated with a bromelain based enzymatic debridement agent at a regional burn unit. 17 patients with a mean age of 44.53 years were treated with enzymatic debridement between April 2017 and April 2022. This period includes an 18 month pause where we did not use the product. We reviewed analgesia requirements, efficacy of debridement using the product, wound care post debridement (including the use of skin substitutes), skin grafting post application and overall outcomes. Results 17 patients were treated during this period. Nine patients had burns involving less than 5% TBSA, three patients had burns between 5 and 15% TBSA and five had burns greater than 15% TBSA. Of the 17 patients, 10 had the enzymatic debridement agent applied on the ward and seven had it applied in theatre. For the application of the product three patients had general anaesthesia, two had a combination of general and regional anaesthesia (e.g. spinal, axillary block), three had regional analgesia alone, seven received oral analgesia and ward based sedation and two received oral analgesia and ward based Methoxyflurane. 10 patients required skin grafting. One patient was treated with allograft post enzymatic debridement. One patient had their post enzymatic debridement wounds covered with Xenograft. The remainder had their post debridement wounds treated with dressings. There were three cases where the proteolytic agent failed to debride the burns. In the skin grafted group, 1 patient had complete graft loss. We will provide a narrative description and outline how each case contributed to the development of our current treatment algorithm. Conclusions We now believe that enzymatic debridement does have a real place within the armamentarium of burn wound excision with dermal preservation. Undoubtedly, there is a learning curve associated with its use. This must be considered by any service intending to adopt its use. Applicability of Research to Practice We support the use of bromelain enriched proteolytic enzymatic debriding agent in appropriate cases. With experience, it is likely to be useful in the management of many patients who sustain deep partial thickness to full thickness burns.

780 Injury to Intervention: Is There Another Opportunity to Improve Burn Care?

Abstract Introduction The treatment of burn-injured patients requires early intervention to prevent adverse events such as local or systemic infection, increased mortality, or exacerbation of other homeostatic processes. Early intervention also reduces delays in treatment, return to work, and the related costs of hospitalization, wound care, and pain control. The purpose of this study was to evaluate potential delays in treatment and the associated costs compared to those seen with more accurate diagnosis and treatment on admission. Methods A prospective, IRB-approved study was undertaken with nine burn centers in nine states and three ABA burn regions. Data points included times of injury, admission, and surgery. Inclusion criteria included: life expectancy > 6 months, thermal burn mechanism (flame, scald, or contact), and minimum burn wound size for adult or pediatric patients of 0.5% TBSA. Data was collected by onsite research staff and confirmed during periodic monitoring visits. Avoidable inpatient days (AID) was defined as the time of admission to the time of surgery, and avoidable treatment delays (ATD) as the time of injury to the time of surgery. The average daily bed costs were defined as $7,554 from recent real-world published data. Results One hundred thirty-eight (138) patients in this study were admitted and treated with surgical intervention for full thickness burn injuries from 2017 to 2022. The total AID was 506 (median 3 days, range 0-9, mean 4, 25%tile 3, 75% 4). The total ATD was 733 days for 138 patients (median 5 days, range 0-9, mean 5, 25%tile 4, 75%tile 6). The median AID cost savings were calculated at $22,662 per patient had surgery been indicated and performed within 24 hours of admission. The median ATD cost savings were $30,216 per patient had surgery been indicated and conducted within 24 hours of injury or evaluation at an emergency room or burn center. The total savings for 138 patients whose surgery had been determined necessary and performed within 24 hours of the burn would have been $4,169,808 as opposed to having surgery indicated and completed within 24 hours of admission, $2,084,904. Conclusions If early diagnosis of burn injuries requiring surgery could be obtained within 24 hours of injury or admission, facilities and patients would benefit from reduced treatment delays and inpatient care costs. Our study was limited to patients undergoing surgery and those with non-healing wounds. An additional benefit could also be found in patients with healing wounds; if a confident diagnosis could be made earlier, such patients could be discharged rather than spending excess time as inpatients. Further studies are in progress with larger populations and more burn centers to better determine benefits for these patients. Applicability of Research to Practice We must understand the economic impact of our clinical decisions to pursue research initiatives that are clinically significant to our patients and financially viable to the institutions that support burn care.

768 Intraoperative Use of Intravenous Methadone and Post-Operative Opioid Requirements in Adult Burn Patients

Abstract Introduction Post-operative pain management can be a significant challenge in patients undergoing burn excision. Standard pharmacologic pain management strategies include both opioid and non-opioid medications. Given the national overuse of opioids and the associated negative repercussions, it is prudent that we find ways manage pain with fewer or no opioids. We hypothesize that intraoperative administration of intravenous methadone will reduce the total morphine milligram equivalents (MME) used in the 36 hours following surgery. Methods This is a retrospective single-center cohort study of adult burn patients who underwent a first excision of full thickness burn between January 2019 through January 2021. The exposure group received intraoperative methadone while the control group did not. The primary outcome was total MME utilized in the 36 hours following surgery. Secondary outcomes included average pain score and post-anesthesia care unit (PACU) total MME utilized. Chi squared tests were used for statistical analysis of categorical variables and unpaired t-tests were used for continuous variables. Results The control group contained 35 subjects and the methadone group contained 19 subjects who did not differ in baseline characteristics. The average burned total body surface area (TBSA) was 9% in the control group and 18% in the methadone group (t(53)=-3.9, p < 0.01). Intraoperative narcotic requirements did differ between groups due to intravenous methadone utilization in the intervention group (t(53)=-15, p < 0.01). In the early post-operative period, the methadone group received 155 MME while the control group received 137 MME (t(53)=-0.36, p = 0.72). While in the PACU, patients in the methadone group received 5 MME while the control group received 12 MME (t(53)=1.60, p=0.12). Patient pain scores did not differ significantly between the groups (t(53)=-0.15, p=0.88). Conclusions Intraoperative utilization of methadone for burn surgery did not affect post-operative opioid usage in the first 36 hours or post-operative pain scores in a statistically significant manner. We acknowledge the data set is not large enough to power the study to detect a significant difference; additional data collection is ongoing to include several hundred subjects. Confounding variables such as different multimodal pain regimen techniques, % TBSA, extent of surgical excision, and history of opioid tolerance may exist within this data set. Further analysis is warranted to adequately power this study and account for potential confounding variables. Applicability of Research to Practice Intraoperative use of intravenous methadone may reduce use of opioid medications in the early post-operative period.

75 Tranexamic Acid Reduces Burn Wound Conversion and Lung Inflammation in a Murine Comb Burn Model

Abstract Introduction Burn wound conversion is a process where superficial partial thickness burns convert into deep partial and even full thickness burn injuries. Unfortunately, the pathophysiology of this phenomenon is poorly understood. A therapeutic intervention that may prevent secondary progression and cell death in burn-injured tissue is desirable. Recent work by our group has established that tranexamic acid (TXA) has significant anti-inflammatory properties in addition to its well-known anti-fibrinolytic effects. This study investigates tranexamic acid as a novel therapeutic treatment to mitigate burn wound conversion and reduce systemic inflammation. Methods Sprague-Dawley rats were subjected to a hot comb burn contact injury using a 150-g brass comb preheated to 100°C, to create four rectangular burns, separated by three unburned interspaces. A subset of animals underwent the comb burn injury with an adjacent 30% TBSA contact injury using solid brass rods. The interspaces represent the ischemic zones simulating the zone of stasis. The treatment group received IP injection of TXA (100mg/kg) immediately after injury and once daily until sacrifice. Sham animals underwent an identical procedure, with application of a room temperature comb. Animals were sacrificed at 6hrs and 7-day time points post-injury. Photo images were obtained of the comb burn injury. Full-thickness biopsies from the ischemic zones and lung tissue were assessed with established histological and immunohistochemical (IHC) techniques. Results At 7-days post injury, the percentage of ischemic zones with necrosis was significantly reduced in the treatment group when compared with untreated burn controls by photographic image analysis. When compared with controls, the treatment groups had significantly less progression of ischemic zones to necrosis when assessed by standard microscopy. These findings were consistent in both the comb burn only and comb burn + 30%TBSA injury models. The TXA treatment group demonstrated significantly more expression of the regeneration marker (CTHRC-1) and a trend toward increased expression of the Ki-67 proliferation marker when compared to untreated burn group. At 6 hours post-injury, TXA significantly decreased infiltration of neutrophils in the lungs for the 30%TBSA burn injury model. Furthermore, systemic levels of mitochondrial DNA, IL-1α and TNFα were significantly lower in TXA treated animals when compared to untreated burn controls. Conclusions Animals treated with tranexamic acid demonstrated reduced burn wound conversion and decreased burn-induced SIRS response. Lung inflammation was also significantly reduced by administration of TXA after injury. Applicability of Research to Practice Tranexamic acid and agents with similar mechanisms of action may provide a treatment to reduce burn wound conversion. This therapy could be easily incorporated into standard acute burn care practices.

578 Impact of Acellular Fish Skin on Wound Healing in a Standardized Pre-Clinical Model

Abstract Introduction Acellular fish skin has proven to be effective in acute and chronic wound healing. Multiple human studies have to date demonstrated that products from acellular skin grafts accelerate wound healing and are efficacious, safe and cost-effective. Here we wanted to investigate the effects of acellular fish skin on wound healing in a pig model. Methods The primary aim of this study was to investigate the effects of acellular fish skin on wound healing progression in a full thickness skin defect pig model. The superiority of fish skin was tested in a standardized pig model and compared to normal wound healing (without acellular fish skin grafts) (n=6). The experiments were carried out in male landrace pigs with a mean weight of 28.8 +/- 2.8 kg at the start of the study. The experiment lasted for 21 days. Wound documentation, thermography, photo-documentation and wound perfusion were carried out 5, 9, 14 and 21 days post wounding. Results Clinical evaluation of the wounds showed that there were no major differences between the different dressings on day 5 post wounding. On the next evaluation days ( day 9, 14 and 21 post wounding) the acellular fish skin showed rapid epithelialization with minimal wound contraction, when compared to untreated control wounds, which showed significant signs of contraction (i.e. star-like wound appearance). Wound area measurements clearly showed that wound size upon treatment with the acellular fish skin and the untreated control rapidly and significantly decreased through contraction of untreated controls. However, wound perfusion seemed to be affected by the treatment with acellular fish skin. Thermography at day 9 and 14 showed higher surface temperature in treated wounds (d9 and d14; p = 0.0005), followed by a trend towards increased oxygenation and perfusion, analyzed by laser speckle and hyperspectral imaging. Conclusions Acellular fish skin seems to provide fast wound healing and counteract wound contraction. Untreated wounds showed a slight trend of faster healing, but showed significant signs of wound contraction which points towards wound healing by contraction but not by epithelialization. This contraction was not observed in wounds treated with acellular fish skin. Applicability of Research to Practice Standardized preclinical models give valuable insights to the mechanisms of wound healing. Porcine in vivo models are of special interest as the porcine skin is highly similar to human skin with regard to anatomical and physiological structures. Therefore, data generated in such models, as described here, show a high rate of translatability to the human situation.

561 Three-Year Follow Up Treatment For Major Full-Thickness Burns Using Dermal Biodegradable Substitute and Autologous-Skin-Cell-Suspension

Abstract Introduction Novel techniques and technologies have shown increased survival in large TBSA burns, however, challenges with meaningful quality of life and functional outcome pose a concern. Dermal substitute and skin cell suspensions provide an area of ongoing investigation to reduce morbidity from scars, loss of functionality from contractures, and need for further procedures. This study is a follow up on the use of a dermal substitute along with autologous skin cell suspension (ASCS) with long term physical and mental outcomes as assessed with the Burn Specific Health Scale in two survivors of greater than 90% TBSA full-thickness burns. Methods We report on two 18-year-old patients treated with the use of allograft, dermal substitute, and ASCS with split-thickness skin grafts (STSG) to achieve coverage of >90% burns. Patient 1 initially had full-thickness “leathery” burns, sparing only the plantar and dorsal aspect of the feet and patient 2 had fourth-degree burns in most areas with only the groin and feet spared. The patients’ clinic visits were reviewed and both patients agreed to participate in the Brief Burn Specific Health Scale (BSHS-B) questionnaire three-years post discharge. The survey responses of each patient were separated into their respective BSHS-B health domains and a raw Health-related quality of life (HRQOL) score was calculated for each domain. Results Patient survey responses were categorized into their respective domains: interpersonal relationships, simple abilities, affect, body image, sexuality, hand function, treatment regimens, heat sensitivity, and work. We observed in both patients that the hand function and heat sensitivity domains of the patient’s BSHS-B were the lowest scoring in their survey responses, while the interpersonal relationships and simple abilities were the highest scoring. 15 months post discharge the patients’ bilateral upper extremities had 130° of flexion, 80° of supination, and 80° of pronation with no instability of the elbow. Both patients were continuing to work with physical therapy and were able to ambulate in their own home. Conclusions Appropriate psychosocial management in addition to aggressive targeted surgical management and regular post-discharge clinical follow-ups were noted to have contributed to the improved post-operative outcomes in this patient with extensive burns. The findings reported in this follow-up case series demonstrate the promise of utilizing a dermal substitute and ASCS with STSG in acute surgical management of patients with extensive burns. This follow-up study demonstrates the importance of aggressive physical rehabilitation and psychosocial management in these patients’ post-operative course of recovery. Applicability of Research to Practice The findings reported in this follow-up case series suggest the importance of dermal substitute and ASCS is the enhanced positive psychosocial domains and adequate cosmetic appearance along with enhanced physical healing.

109 Effects of Fat-Rich Nutrients in the Pancreas of an Experimental Burn Model

Abstract Introduction Oversupply of nutrients overstimulates beta cells in standard conditions, and severe burn injuries increase the metabolic needs. In this study, we investigated the effects of fat-rich nutrients on the endocrine pancreas during the acute phase of severe burns. Methods Twenty-one Wistar albino rats were randomly divided into 3 groups. Two groups were fed with standard commercial rat chow (1 with sham procedure and 1 with burn procedure), and the third group (also with burn procedure) was fed a fat-rich diet (60% kcal fat). The burn procedure involved a 25% total body surface area fullthickness burn. Blood samples were taken at 36 hours and 7 days after burn injury or sham procedure. On postburn day 7, skin biopsies were taken and a pancreatectomy was performed. Pancreatic tissues were examined under light microscopy; islets size and cellularity were calculated and investigated immunohistochemically. Results Plasma glucose, C-Peptide, and insulin levels were similar in all the study groups 36 hours and 7 days after burn induction or sham procedure. There was a significant increase in the number of cells per one islet in the burn group given a fat-rich diet compared with the other groups (P = .05). Caspase-3 was strongly expressed in both groups with burn injuries. Conclusions Overconsumption of certain fats can lead to a compensatory response by beta cells that eventually can progress to beta-cell dysfunction during the acute phase of burns. Severe burns induce pancreatic islet cell hyperplasia. Providing excessive fat nutrients during the acute postburn period attenuates this response. Despite the morphophysiological changes observed in the pancreas, all animals in our study achieved similar glycemic homeostasis. Applicability of Research to Practice The delivery of nutritional support is a vital element of burn care, and the main goal is simply to avoid nutritional complications. Lipotoxicity contributes to multisystem organ failure and worse clinical outcomes in obese patients and mice with pancreatitis. Neutralization of IL-1β produces beneficial effects on postburn glycemic control and improves survival. apoptosis in the pancreas of patients with severe burns may be linked to a series of events that can induce Caspase-1 activation and IL-1β release, and these pathways may be influenced by the nutritional status, especially in the early postburn phase. Effective nutritional assessment and management can optimize wound healing and decrease complications and mortality.

579 Histopathological Changes in the Endocrine Pancreas of Rats During the Acute Period of Burns

Abstract Introduction Severe burn victims experience a systemic inflammatory response and a hypermetabolic response. Presence of hyperglycemia, even with concurrent hyperinsulinism, is indicative of insufficient insulin secretion from beta cells to overcome the glycemia. However, the underlying molecular mechanisms of beta-cell failure in patients with acquired insulin resistance after burn trauma are not clearly understood. Our aim in this study was to describe the histopathological changes in the pancreatic islets secondary to severe burns in an experimental animal model. Methods Fourteen Wistar albino rats were randomly divided into 2 groups: the sham group and the burn group. A full-thickness burn model was designed to induce a burn of 25% total body surface area. Seven days after burn induction and sham procedure, pancreatectomy was performed. Pancreatic tissues were examined under light microscopy, and islet size and cellularity were calculated. Results The histopathologic examination was unremarkable, but the mean number of islets per pancreatic tissue was lower in the burn group than in the sham group. We observed a significant difference in the mean number of cells per one islet between the 2 groups, with the cell count higher in the burn group (P < .05). Conclusions During the acute phase of burn injury in rats, we observed a decrease in the number of pancreatic islets with remarkable hypercellularity. Further studies are needed to determine the histological and cellular basis of these changes. Applicability of Research to Practice Major burn injury causes severe alterations in beta-cell mass, which increases and decreases both function and mass to maintain the glycemic level within a very narrow physiological range. Patients with acute and prolonged hyperglycemia can have complications leading to impaired wound healing, increased skin graft loss, increased muscle protein catabolism, increased incidence of infections, and mortality. Therefore, a detailed understanding of the pancreatic changes under different preexisting conditions and therapeutic interventions in the context of a major burn trauma might guide treatment options.

559 Verticalization Therapy for ICU-Level Burn Patient: A Case Study

Abstract Introduction The entire interdisciplinary team can be faced with many challenges when treating a bariatric, critically ill patient with significant burn injuries. Some studies suggest that the care of these patients increases staff workload and leads to the need for increased assistance for proper turning, positioning, and completion of wound care. When caring for these types of patients, patient and staff safety should be considered, as well as what will ensure the best patient outcomes. Our rehab team initiated the use of verticalization therapy with a patient on the burn unit with 28% TBSA full-thickness burns to back, chest, BUEs and a BMI of 45.8 in order to promote improved healing, cognitive status, and pulmonary function. While verticalization therapy is described for use in patients with pulmonary issues or invasive cardiac support devices, this was the first time this therapy was used in our busy ABA-verified burn center. Methods Once deemed appropriate for participation with PT/OT, a collaborative protocol with nursing, therapy, and burn provider team was developed. The patient was transitioned into a specialized bed allowing for verticalization up to 90 degrees. The patient was incrementally verticalized by 10 degrees at a time while monitoring vitals, assessing patient safety and pain response. Ultimately, the patient reached 40 degrees vertical and maintained this position for up to 2 hours. This intervention was utilized by both rehab specialists and nursing staff and was taught to nursing staff to be performed daily until patient was able to actively participate and tolerate edge of bed or out of bed activity. Results Use of the verticalization positioning was used to promote weight bearing activity, improve pulmonary function, improve cognitive status through upright positioning, and for pressure relief of graft areas specifically for offloading pressure to back wounds and grafts. The bed was used for 1 month. During this time, the patient successfully liberated from mechanical ventilation and shock state and mobilized with therapy assistance. The patient demonstrated improved strength, active participation with therapies, and decreased agitation as the month progressed. Autograft split-thickness skin grafts with autologous cell suspension epithelial autografts to the patient’s posterior torso healed well and were fully closed by the time of discharge to inpatient rehabilitation. Conclusions Use of verticalization beds can be implemented in the care of patients with burn injuries safely and successfully. Further research regarding skin healing related to use of the bed and verticalization therapy in burn injured patients should be conducted. Applicability of Research to Practice This intervention can be used for patients of all sizes and can be implemented as soon as hospital day one, if the patient is medically appropriate

Integra® Dermal Regeneration Template: From Design to Clinical Use.

Integra® Dermal Regeneration Template (IDRT, Integra LifeSciences, Princeton, NJ, USA) is a bilayer membrane developed, by Yannas and Burke in the 1980s, to fulfill the unmet need of surgeons having a readily available off-the-shelf dermal regeneration method. IDRT is composed of a sheet of porous cross-linked type I collagen and glycosaminoglycans, with a semi-permeable silicone sheet cover. IDRT is bio-engineered, from adult bovine Achilles tendons and chondroitin-6-sulfate derived from shark cartilage, in a multi-step process involving cross-linking using glutaraldehyde. By design, the composition, porosity, and biodegradation rate of IDRT guides the mechanism of wound repair towards a regenerative pathway. Its mechanism of action involves four distinct phases: imbibition, fibroblast migration, neovascularization, and remodeling/maturation. Originally developed for the post-excisional treatment of deep-partial to full-thickness burns where autograft is limited, over the years its use has expanded to reconstructive surgery.

Who Gets Burned in Brazil?

Burns are preventable injuries that still represent a relevant public health issue. The identification of risk factors might contribute to the development of specific preventive strategies. Data of patients admitted at the Hospital due to acute burn injuries from May 2017 to December 2019, was extracted manually from medical records. The population was analyzed descriptively, and differences between groups were tested using the appropriate statistical test. The study population consisted of 370 patients with burns admitted to the Hospital burn unit during the study period. The majority of the patients were males (257/370, 70%), median age was 33 (IQR:18-43), median TBSA% was 13 (IQR 6.35-21.5 and range 0-87.5%), and 54% of patients had full-thickness burns (n = 179). Children younger than 13 years old represented 17% of the study population (n = 63), 60% of them were boys (n = 38), and scalds was the predominant mechanism of burn injury (n = 45). No children died, however 10% of adults did (n = 31). Self-inflicted burns were observed in 16 adults (5%), of whom 6 (38%) died during admission, however self-inflicted burns were not observed in children. Psychiatric disorders and substance misuse were frequent in this subgroup. White adults male from urban areas who had not completed primary school degree were the major risk group for burns. Smoking and alcohol misuse were the most frequent comorbidities. Accidental domestic flame burns were the predominant injuries in the adult population and scalds in the pediatric.

A Hand-Held, Single-Sided NMR Sensor for Full-Thickness Skin Detection

To rapidly assess burn depth, a hand-held, single-sided NMR sensor was designed for full-thickness skin detection. The sensor is composed of a single-sided magnet, a radio frequency coil, a matching circuit, and an aluminum shell. The permanent magnet array was optimized using the sparrow search algorithm with low vertical gradient strength and each layer obtaining maximal uniformity in field of view. The actual measured magnetic field of the single-sided magnet is perfect match with the simulation results. Experimental results of depth–transverse relaxation time(T <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">2</sub> ) map prove that this sensor has high sensitivity to distinguish deep dermal and full thickness burns and superficial partial-thickness burns.

Lessons Learned from a Multiple Casualty Blast Incident

Introduction:On February 24, 2021, a large explosion and fire occurred in an industrial estate in Singapore. Eight casualties with major burns were conveyed to the emergency department (ED) at Singapore General Hospital, the designated regional Burns Centre. This article details the events and recommendations arising from this multiple casualty incident.Method:An After-Action Review (AAR) was conducted to examine the prehospital notification process, casualty triage &amp; tagging, medical management, manpower and resource allocation, and command-and-control structure.Results:All eight casualties were conveyed by the national Emergency Medical Services (EMS) and arrived within a 46-minute window. The first three suffered 90% full-thickness burns and inhalational injuries and were intubated. The remaining five suffered between 37% to 64% burns, with three requiring intubations as well.Four major areas were identified for improvement:Firstly, there was scant information from EMS regarding total casualty count. There was also inadequate knowledge of mass burns triage protocols in the ED. Thus, resources were heavily utilized for the first three casualties - all of whom were later deemed unsalvageable, given palliative care and demised.Secondly, casualty identities were initially unknown. They were tagged with similar-looking ten-digit serial numbers, resulting in a near-miss event involving mislabelled blood tubes.Thirdly, there was unfamiliarity with the incident response plan for a multiple casualty incident of this scale. This contributed to lack of situational oversight and inconsistent leadership direction from various stakeholders with resulting conflicting instructions.Fourthly, routine trauma computed tomography pan-scans for all casualties caused delayed reporting by Radiology and created a bottleneck in casualty disposition.A multi-disciplinary workgroup comprising Emergency, Trauma, Burns and Intensive Care departments outlined several recommendations based on the AAR findings. Drills were strongly recommended to resume following a hiatus due to COVID-19.Conclusion:AARs help provide invaluable insights. Response plans should be refined together with relevant stakeholders.