Greater Total Body Surface Area Research Articles

573 The Impact of Burn Injuries on Indigenous Populations

Abstract Introduction Racial and ethnic minorities experience disparities in prevention and treatment of burn injury. However, research on burn injuries in Indigenous populations is limited. This review summarizes literature on burn injuries in Indigenous populations that require consideration due to systemic racism, intergenerational trauma, and health disparities to inform new research. Methods A search was conducted in CINAHL, Ovid MEDLINE, PSYCinfo, and SocINDEX. for “burn OR scars OR scald OR deformity OR disfigurement” and “Aboriginal OR Indigenous OR First Nation OR American Indian OR Maori OR Native OR Torres Strait Islander OR Amerindian OR Inuit OR Metis OR Pacific Islander”. Search criteria were set by the authors with librarian assistance. Inclusion 1) peer-reviewed studies of burns in Indigenous persons 2) in English. Exclusion 1) no data specific to Indigenous burns 2) not peer-reviewed 3) not in full text 4) protocol publications. Selection was performed by a member of the research team and reviewed by the co-authors. Results The search identified 1,091 studies with 51 for review. Fifteen were excluded. Three were editorials or letters. Five were not full text. One was a protocol only, and one did not reference Indigenous persons. Two reported accident rates in Indigenous populations but not burns data. Two excluded articles did not report burns data in the Indigenous population. One was excluded as the conclusions were not supported by the data. Included publications were published between 1987 and 2021 with 24 between 2011 - 2021. Indigenous populations have a rate of burn injury up to two times of the general population in the US, Canada, New Zealand, and Australia. Indigenous people suffered more injuries from flame and inhalation. Burns in Indigenous people are of greater total body surface area and deeper. Indigenous persons had longer lengths of stay, more complications, and need for additional surgeries. The Indigenous population in the US is associated with more hypertrophic scarring. Indigenous patients in Australia struggle with a lack of culturally safe communication and support for aftercare. Conclusions Current literature is limited specific to burns in Indigenous populations. Racial disparities exist in burn injury incidence and outcomes for Indigenous persons. Indigenous populations suffer burn injuries, have more complications, and longer lengths of stay in hospital. Current care practices lack cultural safety considerations. Applicability of Research to Practice Qualitative research in this area will help providers better understand the experiences of Indigenous burn patients to develop more culturally competent care. We are currently developing a study using qualitative hermeneutic methodology to learn about the experiences of Indigenous burn survivors’ injuries, recovery, and social reintegration.

Effect of Burns over Speech: In Context to Dying Declaration

The dying declaration remains important evidence in trials of burned victims in India. However, its evidentiary value is often negated because facial involvement or larger body area involved due to burns may make victims incapable of speaking properly. Hence, this study aimed to study the effect of burn on speech in relation to parameters like age, gender, and total body surface area affected (TBSA). The study included eighty patients having burn injuries over the head, neck, face, and upper chest. They were evaluated longitudinally from the time of infliction of burns at six hourly intervals, at 6 hours, 12 hours, 18 hours, and 24 hours. The speech was assessed using a scale having components of orientation, content, coherence, and articulation. The speech was well preserved in maximally affected age groups (21-40 years); speech was found to be preserved in varying involvement of body surface area. While considering gender and speech, it is observed that speech is relatively unaffected in females; in fact, females can tolerate burns better than males and have well-preserved speech. The above findings were constant at all-time intervals, i.e., at 6 hours, 12 hours, 18 hours, and 24 hours. Overall, the study disproves the notion that burn victims having facial involvement and greater total body surface area (TBSA) involvement cannot give a valid dying declaration.

1207. Epidemiology and Timing of Infectious Complications from Battlefield-Related Burn Injuries

Abstract Background Thermal injury alters the host response, making burn patients more susceptible to infections. In fact, infections represent the most frequent complication and cause of mortality in burn patients. We describe the epidemiology, clinical characteristics, timing, and outcomes of infections among wounded military personnel with burns. Methods Data were collected through the Trauma Infectious Disease Outcomes Study, an observational study of US service members injured in Iraq and Afghanistan (6/09-12/14). Patients who sustained ≥1 burn injury and were admitted to the Burn Center at Brooke Army Medical Center were included in the analysis. Infections were defined using standardized criteria. For patients with multiple infections, only the initial infection was assessed. Results Among 144 burn patients, 99% were males and 62% had combat-related burns with a median total body surface area (TBSA) of 6% (IQR 3-14%) thermally injured. Infections were diagnosed in 26 (18%) patients with pneumonia being the predominant initial syndrome (N=16, 62%), followed by skin and soft-tissue infections (N=6, 23%), bloodstream infections (N=3, 12%), and intra-abdominal infections (N=1, 4%). Median number of days to each of these initial infecting syndromes were 4 (IQR 3-5), 7 (IQR 4-12), 7 (IQR 6-7), and 17 (IQR 17-17) days, respectively. Patients with infections were more severely injured with greater TBSA (median 31 vs 5) and Baux scores (median 59 vs 29), and were more likely to have combat trauma, inhalation injury, require mechanical ventilation, and have longer time to definitive grafting (Table 1). Microbiology of initial infections varied with 35% of patients having polymicrobial infections (Table 2). Gram-negative organisms were recovered from 20 (77%) patients, of whom 20% had a multidrug-resistant Gram-negative. Gram-positive organisms and fungi were identified in 42% and 8% of patients, respectively. Conclusion Improved understanding of risk factors and the timing of infections in this unique population is critical for effective management. Patients with infections were more severely injured, had higher rates of inhalational injury, and longer days to definitive grafting. Initial infections were more commonly pneumonia. Disclosures David R. Tribble, DrPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.

CLASSIC IL-6 SIGNALING IS ASSOCIATED WITH POOR OUTCOMES IN BURN PATIENTS.

Background: Interleukin (IL)-6 is a multifunctional cytokine with both a proinflammatory and anti-inflammatory role. In many studies, IL-6 increases rapidly after burn injury and is associated with poor outcomes. However, there are two aspects to IL-6; it can signal via its soluble IL-6 receptor (sIL-6R), which is referred to as trans-signaling and is regarded as the proinflammatory pathway. The role of sIL-6R postburn injury has yet to be explored in its entirety. We hypothesized that patients with a lower ratio of IL-6 to sIL-6R would have worse outcomes. Methods: Patients admitted to our burn center within 7 days of injury were included in this study. Patients were divided into two groups based on IL-6 and sIL-6R levels measured within the first 7 days postburn injury. Patients were in the high ratio group if their IL-6/sIL-6R ratio was ≥0.185. Clinical outcomes included organ biomarkers, morbidities, and hospital length of stay. Groups were compared using Student's t test, Mann-Whitney U , and Fisher's exact test as appropriate; a P value of <0.05 was considered statistically significant. Results: We studied 86 patients with a median age of 50 years (36-66 years) and a median total body surface area burn of 18% (10-31). There were 40 patients categorized with a low IL-6/sIL-6R ratio and 46 patients with a high IL-6/sIL-6R ratio. Patients in the high IL-6/sIL-6R ratio group had a significantly greater total body surface area burn ( P < 0.001) and a significantly greater proportion of patients with inhalation injury ( P = 0.001). Levels of IL-6 were significantly higher in patients with a high IL-6/sIL-6R ratio ( P < 0.0001). However, levels of sIL-6R were not significantly different among the low and high groups ( P = 0.965). Mortality was significantly greater in the high IL-6/sIL-6R ratio group (3% vs. 26%; P = 0.002). Conclusions: Interestingly, patients with a higher ratio of IL-6/sIL-6R had significantly greater mortality. Using sIL-6R as a marker for the proinflammatory immune response, we expected patients with a lower IL-6/sIL-6R ratio to have poor outcomes, typically associated with a hyperinflammatory or exaggerated immune response. However, the absolute value of sIL-6R did not differ. This suggests that classical signaling of IL-6 via its membrane-bound receptor, with an anti-inflammatory function, is important.

Burns in Israel: Etiologic, Demographic, and Clinical trends-A 9-Year Updated Comprehensive Study, 2004-2010 versus 2011-2019.

Based on the Israeli National Trauma Registry (INTR) data, this study reports etiological, demographic, and clinical trends and includes all admissions to burn and trauma centers across Israel from 2011 to 2019 and compares these with 2004 to 2010 rates. From 2011 to 2019, 5,710 patients were admitted to burn centers across Israel. Children aged 0 to 1 years (25.9%), non-Jews (40.7%), and males (67.2%) remain the main groups of the burn casualties. Most of the casualties sustained 1 to 9% total body surface area (TBSA) burns with various depths. Scalds were less fatal than fire/flame-related casualties (<1 vs. 11.5%). Fewer surgical procedures were conducted for burns under 9% TBSA compared with greater TBSA. The percentage of TBSA and burn depth were found to be the most significant predictor of mortality among all age groups (>200 times increased risk with full-thickness burns >30% TBSA burn) and correlated with prolonged length of stay (>7 days).

598 Burns Management at A UK Major Trauma Centre During The COVID-19 Lockdown

AimThe COVID-19 pandemic forced huge changes in healthcare delivery in the UK within a matter of weeks. We report our experience of managing burns presenting to a UK Major Trauma Centre during the COVID-19 lockdown period.MethodRetrospective patient data was collected on aetiology, severity and management of burns during the first six weeks of the government-enforced lockdown. Data was compared with patients presenting with burns during the same period in 2019 (control) and statistical analysis was performed.ResultsFifteen patients were treated during the COVID-19 lockdown and fourteen in the control group. Adults treated during the COVID-19 lockdown had a greater total body surface area (TBSA) (9% vs. 2.9%, p 0.035) and were more likely to suffer full thickness burns (40% vs. 0%). In the COVID-19 group all patients that did not require resuscitation, seven of whom met criteria for referral to burns services, were managed locally by the plastic surgery department with good outcomes.ConclusionsDespite the increase in severity of adult burns seen during the COVID-19 lockdown period, local plastic surgery units have been able to adapt their practice and successfully manage more complex burns. This adaptability will be key as we move through the pandemic.

607 Characteristics of Pediatric Burn Patients with Child Protective Services Involvement at an Academic Children’s Hospital

Abstract Introduction Pediatric burns are typically accidental, but burns caused by caregiver abuse/neglect represent a significant proportion of patients. Literature on risk factors most associated with these injuries include younger age, male, African American, and larger burns. This study examined child and burn injury factors that were associated with Child Protective Services (CPS) involvement at an urban, academic children’s hospital. Methods At this institution, decision to report a burn patient to CPS is determined by a multi-disciplinary medical team. Criteria for referral is multifactorial and may include burn patterns consistent with forced immersion, a reported mechanism that does not match the burn pattern or the patient’s developmental capabilities, concern for lack of supervision, or a delay in seeking medical care. Data from inpatient admissions over a 3-year period (July 2016 – June 2019) were extracted from hospital charts, and analyses (chi-square, t-tests) examined age, sex, total body surface area (TBSA), burn severity, length of stay, insurance type, race/ethnicity, and whether a CPS report was made (i.e., yes/no). Records for the outcome and disposition of the CPS case, such as whether the CPS investigation confirmed the abuse/neglect allegations, were not readily available as the law requires confidentiality. Results 389 children were admitted for burn treatment. 80% had partial-thickness burns; 33% White, 43% Black, 62% male; 10% had CPS involvement. 72% had Medicaid/other government insurance, 23% had private/commercial, 4% were uncovered, and 1% insurance status unknown. Medicaid/government insurance was overrepresented among burns compared to other inpatients at the hospital (72% vs 51%). Consistent with previous findings, CPS reports involved children who were younger (2.8 vs 4.8 years), had greater TBSA (8.4% vs 4.9%), and had longer admissions (7.5 vs 3.0 days). Children with Medicaid/governmental or no insurance were more likely to have CPS reports than commercial/private insurance (97% vs 3%). Importantly, contrary to prior findings, child sex, child ethnicity, and burn thickness were not significantly different between children with and without CPS reports. Conclusions Younger children with bigger burns and longer admissions were most associated with CPS involvement. Historical findings on risk factors of male sex, African American ethnicity, and greater burn thickness were not replicated. Prior literature may not be generalizable to many settings; the current study provides an important update. Further research is needed to examine outcomes of CPS involvement and long-term patient health outcomes. Findings are limited to only urban, inpatient pediatric burns.

Prevalence and associated factors of post-traumatic stress disorder in burned patients and their family members

BackgroundPost-traumatic stress disorder (PTSD) is common among burn patients and their family members. The objective of this study was to document the prevalence of PTSD and explore the sociodemographic and burn-specific associated factors of PTSD among Chinese burn survivors and their family members. MethodsA total of 131 adult patients with unintentional burns and 194 family members of burn patients were recruited from two burn units. All participants completed a general information form and the PTSD Checklist for the DSM-5 (PCL-5). ResultsFifty-five (42.0%) burn victims and ninety-nine (51.0%) family members of burn victims met the criteria for PTSD; the average score of the sample was 31.21 ± 21.56 and 33.16 ± 19.30. Logistic regression analysis revealed that middle age (45–55 years), poor economic status, greater total body surface area (TBSA) and longer time since the burn incident positively predicted the PTSD of patients and that female family members had a higher risk of PTSD. ConclusionsBurn patients and their family members are susceptible to PTSD. Suitable and long-term psychological intervention programmes should be executed for burn patients and their family members.

Anti-human Leukocyte Antigen Immune Sensitization Effects of Cryopreserved Allograft and Blood Transfusion.

Vascularized composite allotransplantation (VCA) is the most advanced reconstructive technique available to patients who suffer devastating burns to the limbs or face. However, VCA requires donor-recipient matching. Burn patients have been reported to experience sensitization, or the development of anti-human leukocyte antigen antibodies, during resuscitation and wound coverage, potentially precluding them from future VCA. This study sought to investigate the contributions of both blood and allograft to sensitization in burn patients. Four groups were compared: burn patients who received blood products and allograft (group 1), burn patients who received blood products only (group 2), trauma patients who received blood products only (group 3), and healthy volunteer controls (group 4). The average calculated panel-reactive antibody (indicating sensitization) was higher in group 1 compared to group 4 (P = .035). Additionally, the incidence of severe sensitization was higher in group 1 relative to the other groups (P = .049). When comparing groups of patients who had no sensitization, mild sensitization, moderate sensitization, and severe sensitization, there were no significant differences in age, sex, blood products received, total body surface area burned, or allograft used between groups, though severely sensitized patients tended to have greater total body surface area involvement and received more units of packed red blood cells and allograft (P = .079, P = .196, and P = .072, respectively). We therefore conclude that while burn patients who received allograft and blood demonstrated a higher incidence of anti-human leukocyte antigen sensitization relative to healthy controls, this difference cannot solely be attributed to either allograft use or transfusion.

518 Relationship of Microbiome, Antimicrobial Resistance, and Wound Closure in &amp;gt;90% Burn Patients

Abstract Introduction Patients with 90% or greater total body surface area (TBSA) burns of face many unique challenges, including prolonged open wounds and antibiotic use. Furthermore, increased antibiotic use can be associated with increased antibiotic resistance. Despite the commonality, the relationship between prolonged wound closure (months) combined with prolonged duration of antibiotic use (months) has not been fully explored. The specific aim of this study was to examine the evolution of burned patients’ microbiome over time in association with wound healing and antibiotic use. Methods We conducted a retrospective review of all patients admitted to our ABA-verified burn center from 2010-present with 90% TBSA or greater burns who survived to discharge. Demographic data, length of stay, percentage monthly wound closure (including donor sites), microbial culture data of bacteria, yeast, fungus, and mold (YFM), antibiotic susceptibilities, and systemic antimicrobial agents administered were recorded. Statistical analysis was performed using Pearson correlation coefficient. Results Two patients met inclusion criteria. Patient A (PtA), a 36 year old (yo) female with 95% TBSA burns and Patient B (PtB), a 45 yo male with 90% TBSA burns. Patients spent a combined 766 days (PtA 425, PtB 341) as inpatients. 347 separate positive cultures were analyzed, 180 of which were bacterial. 15 distinct species of bacteria were cultured (8 PtA, 9 PtB), along with 4 subtypes of Pseudomonas aeruginosa, and 9 distinct YFM (6 PtA, 6 PtB). Increasing antibiotic resistance was found in 57% (PtA) and 71% (PtB) of bacterial species. Pseudomonas was the most commonly isolated organism in 65% (n=118) of cultures. The relationships between percent wound closure, daily antibiotic use, and Pseudomonas antibiotic resistance are shown in the Graph below. There was a strong correlation between wound closure of &amp;gt;50% with decreased amount of antibiotics used per day (PtA 0.83, PtB 0.86) and decreasing % of Pseudomonas antibiotic resistance (PtA 0.66, PtB 0.8). Conclusions Antibiotic resistance increases over time and efforts should be taken to decrease number of antibiotics administered. As wound closure passes a certain threshold, the number of antibiotics needed decreases, and Pseudomonas antibiotic resistance appears to decrease as well. Applicability of Research to Practice Recognition of different environmental pressures for bacteria may point to changes in microbial resistance patterns and thus clinical management.

714 IL-6 and Soluble IL-6 Receptor – Two Sides of the Same Coin

Abstract Introduction Interleukin (IL)-6 is a multifunctional cytokine that has both a pro- and anti-inflammatory role. In many studies, IL-6 has been shown to increase rapidly after burn injury and is associated with poor outcomes. IL-6 can signal via its soluble IL-6 Receptor (sIL-6R) and is referred to as trans-signaling, which is regarded as the pro-inflammatory pathway. The role of sIL-6R post-burn injury has not yet been explored. We hypothesized that patients with a lower ratio of IL-6 to sIL-6R would have worse outcomes. Methods Patients admitted to our burn centre within 7 days of injury were included in this study. Patients were divided into two groups based on IL-6 and sIL-6R levels measured within the first 30 days post-burn injury. Patients were in the high ratio group if their IL-6:sIL-6R ratio was ≥ 0.185. Clinical outcomes included organ biomarkers, morbidities, and hospital length of stay. Groups were compared using Student’s t-test, Mann-Whitney U, and Fisher’s exact test as appropriate; a P value of &amp;lt; 0.05 was considered statistically significant. Results We studied 104 patients, mean age 51 ± 18 years and 24 ± 17% total body surface area (TBSA) burn. There were 49 patients categorized with a low IL-6:sIL-6R ratio and 55 patients with a high IL-6:sIL-6R ratio. Patients in the high IL-6:sIL-6R ratio group had a significantly greater TBSA burn and a significantly greater proportion of patients with inhalation injury (p&amp;lt; 0.05). Levels of sIL-6R were not significantly different among the low and high group (770 ± 264 pg/mL vs. 798 ± 268 pg/mL respectively; p=0.601). However, levels of IL-6 were significantly higher in patients with a high IL-6:sIL-6R ratio (37 IQR 19–97 pg/mL vs. 567 IQR 273–916 pg/mL; p&amp;lt; 0.0001). Mortality was significantly greater in the high IL-6:sIL-6R ratio group (2% vs. 27%; p&amp;lt; 0.001). Conclusions Interestingly, patients with a higher ratio of IL-6:sIL-6R had significantly greater mortality. Using sIL-6R as a marker for the proinflammatory immune response, we expected patients with a lower IL-6:sIL-6R ratio to have poor outcomes which are typically associated with a hyperinflammatory or exaggerated immune response. However, the absolute value of sIL-6R did not differ. This suggests that classic signaling of IL-6 via its membrane bound receptor, with an anti-inflammatory function, is an important factor. Applicability of Research to Practice The opposing pro- and anti-inflammatory function of IL-6 through trans- and classic signaling is contingent on the ratios expressed. The demonstrated increase in classic signaling highlights the importance of measuring both IL-6 and sIL-6R in future studies. Additionally, it lays the foundation for potential precision medicine approaches to selectively block specific signaling pathways.

Clearance of Indocyanine Green in Severe Pediatric Burns.

Clearance of indocyanine green dye (ICGc) reflects sinusoidal perfusion and hepatocyte cell membrane function. Thus, ICGc is a reflection of the functional reserve of intact hepatocytes. The purpose of this study was to identify predictors of ICGc in severely burned children during the acute hospitalization and at the time of discharge from the intensive care unit (ICU). A secondary aim was to determine the relationship between liver size and patient ICGc. Twenty-six children (0.8-17 years old) with 35% or greater total body surface area burned (%TBSA-B) were included. Assessment of ICGc (in milliliters per minute per meter squared) was done during the acute hospitalization (median: 6 days after admission, median: 14 days postburn) and at the time of discharge from the ICU (median: 19 days after admission, median: 27 days postburn). Age, TBSA-B, % third-degree burns, inhalation injury, preexisting chronic malnutrition, hematocrit, liver dysfunction, and time from burn injury were incorporated in multiple linear regressions as predictive variables of ICGc. Only variables with p < 0.05 were retained in the final models. Time from injury and age were the strongest predictors of ICGc during the acute admission but not at the time of discharge from the ICU. Time from injury was negatively associated with ICGc, whereas age was positively associated. At the time of discharge from the ICU, ICGc was increased in proportion to the %TBSA-B, whereas inhalation injury and preexisting chronic malnutrition were associated with lower ICGc. There was no correlation between change-to-predicted liver length and ICGc. The intrinsic ability of the liver to extract ICG from plasma was lower in younger burned patients during the acute admission and in those with preexisting chronic malnutrition and inhalation injury at the time of discharge from the ICU. Prognostic/Epidemiologic, level III.

A Model to Improve Detection of Nonaccidental Pediatric Burns.

Pediatric burn patients warrant thorough evaluation because a sizeable proportion of pediatric burns are nonaccidental. A multidisciplinary method involving an internal child protection team (CPT) was developed and used to identify suspected nonaccidental pediatric burns in all pediatric burn patients 5 years of age or younger who were evaluated by the CPT and social workers at our institution over a 55-month period. We identified 343 cases for review that fit our age criteria, 6 of which we identified as cases of suspected abuse or neglect. On average, these patients were younger, suffered greater total body surface area burns (TBSA), and required a longer length of stay in the hospital than the total population. We have not had readmissions for repeat nonaccidental pediatric burn injuries in this group of patients since this model was implemented. Our multidisciplinary method might provide a more consistent and reliable method for identifying cases of suspected abuse.

Spinal Deformities in Pediatric Burn Patients

IntroductionExtensive third-degree burns in pediatric patients can be associated with the development of spinal deformities. MethodsForty pediatric burn patients with scoliosis and one with kyphosis were identified based on a retrospective review of patient records at the Shriners Hospital for Children in Galveston, Texas. ResultsAverage age at time of burn was 7 years 4 months. Average age at follow-up was 11 years 10 months. Twenty-one patients had a thoracolumbar curve, with an average of 20 degrees. Sixteen patients had a thoracic curve, with an average of 16 degrees. Three patients had a lumbar curve, with an average of 9 degrees. Five patients had scoliosis greater than 40 degrees. The kyphosis was 90 degrees. All patients had contractile burn scar on the trunk on the concavity of the curve. DiscussionMild scoliosis curves are common following third-degree burns in the pediatric population, but extensive burns at a young age can cause severe curves. Risk factors include burn scar traversing the entire length of the trunk, young age, greater total body surface area burn, and greater percentage of third-degree burn. Soft tissue procedures and bracing may be used to treat flexible curves. Posterior stabilization may be needed for more severe curves.

Predictors of muscle protein synthesis after severe pediatric burns.

Following a major burn, skeletal muscle protein synthesis rate increases but is often insufficient to compensate for massively elevated muscle protein breakdown rates. Given the long-term nature of the pathophysiologic response to burn injury, we hypothesized that muscle protein synthesis rate would be chronically elevated in severely burned children. The objectives of this study were to characterize muscle protein synthesis rate of burned children over a period of 24 months after injury and to identify predictors that influence this response. A total of 87 children with 40% or greater total body surface area (TBSA) burned were included. Patients participated in stable isotope infusion studies at 1, 2, and approximately 4 weeks after burn and at 6, 12, and 24 months after injury to determine skeletal muscle protein fractional synthesis rate. Generalized estimating equations with log link normal distribution were applied to account for clustering of patients and control for patient characteristics. Patients (8 ± 6 years) had large (62, 51-72% TBSA) and deep (47% ± 21% TBSA third degree) burns. Muscle protein fractional synthesis rate was elevated throughout the first 12 months after burn compared with established values from healthy young adults. Muscle protein fractional synthesis rate was lower in boys, in children older than 3 years, and when burns were greater than 80% TBSA. Muscle protein synthesis is elevated for at least 1 year after injury, suggesting that greater muscle protein turnover is a component of the long-term pathophysiologic response to burn trauma. Muscle protein synthesis is highly affected by sex, age, and burn size in severely burned children. These findings may explain the divergence in net protein balance and lean body mass in different populations of burn patients. Prognostic study, level III.

Total body surface area overestimation at referring institutions in children transferred to a burn center.

Total body surface area (TBSA) burned is a powerful descriptor of burn severity and influences the volume of resuscitation required in burn patients. The incidence and severity of TBSA overestimation by referring institutions (RIs) in children transferred to a burn center (BC) are unclear. The association between TBSA overestimation and overresuscitation is unknown as is that between TBSA overestimation and outcome. The trauma registry at a BC was queried over 7.25 years for children presenting with burns. TBSA estimate at RIs and BC, total fluid volume given before arrival at a BC, demographic variables, and clinical variables were reviewed. Nearly 20 per cent of children arrived from RIs without TBSA estimation. Nearly 50 per cent were overestimated by 5 per cent or greater TBSA and burn sizes were overestimated by up to 44 per cent TBSA. Average TBSA measured at BC was 9.5 ± 8.3 per cent compared with 15.5 ± 11.8 per cent as measured at RIs (P < 0.0001). Burns between 10 and 19.9 per cent TBSA were overestimated most often and by the greatest amounts. There was a statistically significant relationship between overestimation of TBSA by 5 per cent or greater and overresuscitation by 10 mL/kg or greater (P = 0.02). No patient demographic or clinical factors were associated with TBSA overestimation. Education efforts aimed at emergency department physicians regarding the importance of always calculating TBSA as well as the mechanics of TBSA estimation and calculating resuscitation volume are needed. Further studies should evaluate the association of TBSA overestimation by RIs with adverse outcomes and complications in the burned child.

Strong ion difference and gap predict outcomes after adult burn injury

The strong ion difference (SID) (apparent [SIDa] and effective [SIDe]) and strong ion gap (SIG) provide a comprehensive method of evaluating acid-base status in critically ill patients. The SID is the difference between strong cations and strong anions in plasma, while the SIG demonstrates the presence of unmeasured ions. This approach accounts for changes in a patient's protein status, which is particularly important in those with burn injuries. We hypothesized that the SIDa, SIDe, and SIG during the first 72 hours after admission would be predictive of mortality in burn patients. This study is a retrospective review of adults with 20% or greater total body surface area burns admitted during a 7-year period to a regional burn center. SIDa, SIDe, and SIG were calculated at admission and for the first 3 days. These results were then compared with Acute Physiology and Chronic Health Evaluation II (APACHE II) and sepsis-related organ failure assessment (SOFA) scores. A total of 113 patients met the criteria and had full data sets, with mean ± SEM age of 45.4 ± 1.4 years and total body surface area burn of 41.4% ± 1.6%. Mortality was 27.4%. At admission, APACHE II remained most predictive of mortality (p = 0.006). However, admission SIG (SIDa - SIDe) was also predictive of mortality on multivariate analysis (odds ratio, 1.11). Day 1 SIDa (Na+ + K+ + Ca2+ + Mg2+ - Cl-) and SIDe ([1,000 × 2.46 × 10(-11) × PaCO2/10(-pH)] + [[albumin] × (0.123 × pH - 0.631)] + [[PO4] × (0.309) × pH - 0.469)]) were also associated with mortality (odds ratio, 1.16 and 1.13 respectively), and SIDe with length of stay and ventilator days (p < 0.05). The SID and SIG are predictive of mortality, hospital length of stay, and ventilator days in adult burn patients. They also elucidate complex acid-base disorders. Prognostic study, level II.

Clinical application and viability of cryopreserved cadaveric skin allografts in severe burn: A retrospective analysis

IntroductionCadaveric cutaneous allografts are used in burns surgery both as a temporary bio-dressing and occasionally as definitive management of partial thickness burns. Nonetheless, limitations in the understanding of the biology of these grafts have meant that their role in burns surgery continues to be controversial. MethodsA review of all patients suffering 20% or greater total body surface area (TBSA) burns over an eight year period that received cadaveric allografts were identified. To investigate whether tissue viability plays a role in engraftment success, five samples of cryopreserved cadaveric cutaneous allograft processed at the Donor Tissue Bank of Victoria (DTBV) were submitted to our laboratory for viability analysis using two methods of Trypan Blue Exclusion and tetrazolium salt (MTT) assays. ResultsDuring the study period, 36 patients received cadaveric allograft at our institution. The average total burn surface area (TBSA) for this group of patients was 40% and all patients received cadaveric skin as a temporizing measure prior to definitive grafting. Cadaveric allograft was used in complicated cases such as wound contamination, where synthetic dressings had failed. Viability tests showed fewer than 30% viability in processed allografts when compared to fresh skin following the thawing process. However, the skin structure in the frozen allografts was histologically well preserved. ConclusionCryopreserved cutaneous cadaveric allograft has a positive and definite role as an adjunct to conventional dressing and grafting where available, particularly in patients with large TBSA burns. The low viability of cryopreserved specimens processed at DTBV suggests that cell viability in cadaveric allograft may not be essential for its clinical function as a wound dressing or even as permanent dermal substitute.

High-carbohydrate, high-protein, low-fat versus low-carbohydrate, high-protein, high-fat enteral feeds for burns

Severe burn injuries increase patients' metabolic needs. Aggressive high-protein enteral feeding is used in the post-burn period to improve recovery and healing. To examine the evidence for improved clinical outcomes in burn patients treated with high-carbohydrate, high-protein, low-fat enteral feeds (high-carbohydrate enteral feeds) compared with those treated with low-carbohydrate, high-protein, high-fat enteral enteral feeds (high-fat enteral feeds). We searched the Cochrane Injuries Group Specialised Register (searched 28 Nov 2011), Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4), MEDLINE (Ovid) 1950 to Nov (Week 3) 2011, EMBASE (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Nov 2011), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to Nov 2011), PubMed (Searched 28 Nov 2011). Online trials registers and conference proceedings were also searched to April 2010. We included all randomized controlled trials (RCTs) comparing high-carbohydrate enteral feeds to high-fat enteral feeds for treatment of patients with 10% or greater total body surface area (TBSA) burns in the immediate post-burn period, with data for at least one of the pre-specified outcomes. Two authors collected and analysed the following data: mortality, incidence of pneumonia and days on ventilator. Meta-analysis could only be performed for the outcomes mortality and incidence of pneumonia. A random-effects model was used for all comparisons. Two RCTs, reporting results from 93 patients, were included in this review. Patients given a high-carbohydrate feeding formula had an odds ratio (OR) of 0.12 (95% confidence interval (CI) 0.04 to 0.39) for developing pneumonia compared to patients given a high-fat enteral formula (P value = 0.0004). Patients given a high-carbohydrate formula had an OR of 0.36 (95% CI 0.11 to 1.15) for risk of death compared to patients given a high-fat enteral formula; this difference did not reach statistical significance (P value = 0.08). Risk of bias in these studies was assessed as high and moderate. The available evidence suggests that use of high-carbohydrate, high-protein, low-fat enteral feeds in patients with at least 10% TBSA burns might reduce the incidence of pneumonia compared with use of a low-carbohydrate, high-protein, high-fat diet. The available evidence is inconclusive regarding the effect of either enteral feeding regimen on mortality. Note that the available evidence is limited to two small studies judged to be of moderate risk of bias. Further research is needed in this area before strong conclusions can be drawn.

Profile of acute thermal burn admissions to the intensive care unit of a tertiary burn care center in India

Aim: To analyze the profile of acute thermal burn patients admitted to intensive care unit of a tertiary burn care center in India. Materials and Methods: Acute thermal burn patients admitted to the burn intensive care unit during June, August and December 2011 representative of summer, monsoon and winter season were included in this study. Observations: Overall 416 patients were admitted during this period. A total of 162 patients fulfilled the study criteria. Females outnumbered male victims. Patients in the age group of 20-40 years were most affected. Burns in females involve greater total body surface area (TBSA). Liquefied petroleum gas stoves, kerosene oil stoves and kerosene oil lamps are the most common causes of burns reporting to our center. Average distance travelled by patients to reach this hospital was 69.4 kilometers. Ten percent of the female thermal burn victims were pregnant and 3% were lactating. Discussion: An education program is needed to make the population aware of various etiological factors causing burns and their prevention. Safer means and practices should be adopted in kitchen. Local health care facility should play a major and proactive role in managing burns. Burn care needs to be decentralized for better management.