Inhalation Injury Research Articles

120 Venous Thromboembolism Prophylaxis in Burn Patients

Abstract Introduction Venous thromboembolism (VTE) is extensively studied in trauma patients, but burn patients require special consideration due to their unique pathophysiology and management strategies. Currently, there are no specific prophylaxis recommendations to help mitigate VTE in burn patients. Methods The US National Trauma Data Bank (NTDB) was analyzed to identify patients with burn encounters from 2017-2021 using ICD-10 event codes. Our primary outcome measure was incidence of VTE, which included deep venous thrombosis and pulmonary embolism. Secondary outcome measures included need for blood transfusion and need to return to the operating room due to hemorrhage from skin/soft tissues/extremities. Multivariable regressions were conducted to evaluate the relationship between various VTE prophylaxis types and timing of VTE prophylaxis and VTE incidence while controlling for age, sex, %TBSA and inhalation injury. Results A total of 326,614 patients with burn injuries were identified in the NTDB during the study period, of whom 5,604 (1.7%) had a VTE event during their hospital admission. The majority of patients did not receive VTE prophylaxis (54.1%). Of those that did, the most commonly used VTE prophylaxis was LMWH (37.9%), followed by unfractionated heparin (4.1%). When controlling for age, sex, inhalation injury, and %TBSA, unfractionated heparin and LMWH were significantly associated with an increased risk of VTE (heparin: OR=1.8 95% CI 1.3-2.5, p < .001; LMWH: OR=1.5 95% CI 1.2-1.8, p < .001). Longer time to VTE prophylaxis was significantly associated with increased odds of VTE when controlling for the same covariates (OR=1.04 95% CI 1.03=1.07, p < .001). Neither VTE prophylaxis type nor timing of VTE prophylaxis administration was significantly associated with an increased need for blood transfusion. Heparin was the only VTE prophylaxis type significantly associated with increased odds of returning to the OR for a bleeding-related complication (p < .001). Conclusions A majority of burn patients in the NTDB did not receive VTE chemoprophylaxis, and counterintuitively, patients who received VTE chemoprophylaxis had higher rates of VTE than patients who did not, despite controlling for known VTE risk factors. In patients who did get chemoprophylaxis, unfractionated heparin is associated with a higher rate of VTE and surgical bleeding complications when compared with LMWH. Delayed initiation of VTE prophylaxis correlates with a higher likelihood of VTE occurrence. These findings underscore the importance of better studying and developing specialized VTE prevention guidelines for burn patients to enhance their care and outcomes. Applicability of Research to Practice Prompt initiation of VTE prophylaxis is essential to reduce the risk of VTE among burn patients, highlighting the importance of timely interventions. Developing specialized VTE prevention guidelines for this population can enhance their care and outcomes.

506 Methamphetamine Intoxication and Inpatient Outcomes for Burn Patients

Abstract Introduction Methamphetamine intoxication frequently complicates inpatient burn admissions. While single-institution studies describe adverse outcomes during resuscitation, less is known about the associated inpatient complications and perioperative management in users. This analysis aims to identify these trends on a national level. Methods The US National Trauma Data Bank was queried to identify burn patients between 2017-2021. Methamphetamine intoxication was identified on admission and compared to those who screen negative. Primary outcomes included death, stroke, and myocardial infarction (MI). Secondary outcomes included organ failure, timing of surgery, admission vitals, length of stay (LOS), and days in the intensive care unit (ICU). Multivariable regressions modeled the effects on outcomes adjusting for available covariates including demographics, total body surface area (TBSA) burned, and inhalation injury. Bonferroni adjustments were applied. Results 326,614 burn encounters were identified, and 5,380 (1.7%) had positive methamphetamine drug screens upon admission. Users were significantly older (35.2 versus 31.9 years, p < .001), had a greater percentage of males (85.3 vs. 82.0, p < .001), were more likely to have inhalation injury and overall had larger %TBSA burns (16% vs. 13%, (p < .001). Users had significantly higher but clinically insignificant ED systolic blood pressures (132.1 vs. 129.9, p < .001). There was no significant difference between the two groups regarding pulse rate >120 (1.7% vs. 1.6%, p=.611). Users were not more likely to die, sustain an MI, or stroke during admission. In contrast, users were significantly more likely to have alcohol withdrawal (0.8% vs. 0.5%, p=.019), drug withdrawal (0.3% vs. 0.2%, p=.003), a pulmonary embolism (PE) (0.9% vs. 0.7%, p=.039), and delirium (1.2% vs. 0.4%, p=.003). Users had longer times to surgery adjusting for burn severity and demographics (1.6 vs. 1.4 days, p=.033). There were no significant differences in the average number of wound coverage procedures (1.50 vs. 1.45, p=.947). Users had significantly longer hospitalization (8.7 vs. 6.2 days, p < .001); however, there was no significant difference between days in the ICU (6.7 vs. 6.4 days, p=.072). Conclusions While not associated with mortality, methamphetamine intoxication was associated with an increased risk of many complications including PE, drug withdrawal, and delirium. Methamphetamine use was associated with delays in surgery and hospitalization. Applicability of Research to Practice Recognize the increased risk of complications and the need for tailored perioperative care for methamphetamine users. Additionally, burn centers may consider how to avoid delaying care for users and support interventions for withdrawal.

7 Alcohol Use Acuity and Burn Mortality: A Ten-Year Retrospective Analysis

Abstract Introduction The high incidence of alcohol consumption nationally is linked to increased susceptibility for burn injuries in both cases of acute intoxication as well as chronic misuse. While detection of elevated blood ETOH levels on admission intuitively does not always reflect a patient’s history of use, it does introduce bias and can influence clinical decision-making. Understanding these inherent biases at play, our institution through a retrospective analysis, sought to investigate the differing effects a positive blood alcohol level and true chronic alcohol use disorder had on overall mortality within our burn center. Methods We conducted a retrospective analysis utilizing data from the Institutional Burn Center Registry, which was linked to clinical and administrative records. Our study included all adult patients admitted to the Burn Center between January 1, 2012, and December 31, 2022. We collected and analyzed various parameters, including patient demographics, length of hospital stay (LOS), comorbid conditions, and mortality outcomes. Using logistic regression modeling we evaluated the association between burn mortality and ETOH. Results Over the ten-year study period, a total of 9,955 adult patients were admitted to our burn center. 6,943 tested negative and 541 patients tested positive for blood ETOH on admission. The remaining 2,471 had no test. 567 were determined to have a diagnosis of alcohol use disorder. A positive for ETOH did not have significant impact on mortality (p=0.76) while history of chronic ETOH use had a nearly three-fold increase in odds of mortality (OR 2.58, CI 1.52-4.24, p=0.000) when accounting for factors present in traditional predictive models such as burn size, age, and inhalational injury. Conclusions Chronic alcoholism has a greater association with mortality than acute alcohol intoxication at our institution. Further, clinicians should exercise caution when presuming alcohol use disorder solely based on a positive test. This highlights the necessity of accurate medical history taking when estimating and counseling patients on mortality risk. Applicability of Research to Practice This emphasizes the pressing need for research into the effects of multiple comorbidities and social determinants on mortality among burn patients. The insights gained have practical implications for refining clinical approaches and optimizing care strategies for this vulnerable patient population.

13 Thromboelastographic Coagulation Assessment in Burn Patients Receiving Plasma Inclusive Resuscitation

Abstract Introduction As resuscitative strategies in burn patients are re-evaluated, a consensus has not been reached on the role for colloids, as lactated ringers remain the fluid of choice with variable use of colloids. Colloids, such as fresh frozen plasma (FFP), may be effective at maintaining oncotic pressure, resupplying coagulation factors, mitigating coagulopathy, and treating the endothelium. This work aims to characterize the coagulation profile of burn patients treated with plasma inclusive resuscitation (PIR) using rapid thromboelastography (rTEG) by comparing it to burn patients primarily resuscitated with crystalloids alone. Methods Patients admitted to a regional burn center who had greater than 20% total body surface area (TBSA) burns that received PIR were included in the study. Patients admitted with burn injuries and resuscitated primarily with lactated ringers were included in the comparison group. Demographic data and blood samples were collected at 4 time points: baseline, before FFP, immediately following the initial unit of FFP, and following the completion of consecutive units of FFP. Samples collected from patients that received LR only were approximated to the FFP group time points. Coagulation parameters were measured using rTEG in blood samples. Descriptive analysis was used to compare demographic and burn injury characteristics at admission. A mixed effects model was used to compare the two groups through the observation period overall and at each time point. Results There were 35 patients in the FFP group and 15 patients in the comparison group. The groups were primarily male (74.3% vs 73.3%), and there was no difference in demographics, TBSA (34.0% (27.0-48.5) vs 33.0% (26.5-46.5, p=0.82)), Baux score, inhalation injury, and mortality rate (28.6% vs 26.7%, p=0.99). Major coagulation markers of rTEG (k, α-angle, MA, and ly30) were not different between these groups and were within normal ranges. The R time in the crystalloid group was greater than the normal range at all 4 time points. There were significant differences in R time at pre-FFP (30.0(25.0-32.5) secs vs 48.0 (36.0-54.0) secs, p< 0.001) and after all units (27.5(20.9-33.8) secs vs 48.0(48.0-54.0) secs, p< 0.0001) when compared to the FFP group where R time was in the normal range. Conclusions Plasma inclusive burn resuscitation did not result in hypercoagulability or changes in lysis when compared to patients primarily resuscitated with crystalloids. The elevated R time in the crystalloid group, which was not seen in the FFP group, may be due to the lack of replenishment in coagulation factors that FFP would provide. Further understanding of PIR’s role in the inflammatory response is needed to evaluate its impact during resuscitation. Applicability of Research to Practice Plasma inclusive resuscitation may be another tool to treat the multifactorial nature of burn shock and burn induced coagulopathy.

101 The Burden of Burns: An Analysis of Public Health Measures

Abstract Introduction Accurate analysis of injuries and illnesses is paramount when allocating resources for education, prevention, recovery, and research. Inconsistencies in public health reports and increased lobbying/marketing by medical nonprofits has obscured the perception of burn injury (BI) leading to inequities in healthcare access and funding of reconstruction and research. A primary example of these developments is the frequently referenced and inaccurate BI statistics. Our study aims to compare national references reporting the incidence of BI and the related sequela in the U.S. Methods The American Burn Association Burn (ABA) Injury Summary Report (BISR), ABA Fact Sheet, Centers for Disease Control and Prevention (CDC) Web-based Injury Statistics Query and Reporting (WISQARS) database, the CDC National Center for Health Statistics’ National Hospital Ambulatory Medical Care Survey (NHAMCS), and the commercially available claims databases were queried for 2020 burn admissions and emergency department (ED) visits. Non-U.S. reports, claims, or analyses were excluded from our review. The costs of BI were reported in U.S. dollars where available. Claims analyses were conducted using ICD-10 BI codes coupled with burn DRG for admission, and CPT for surgical intervention from a commercially available database incorporating managed care, Medicare, and Medicaid payors. Results The ABA Fact Sheet reported 486,000 BI annually. The 2021 ABA BISR data represented burn admissions at approximately 100 burn centers (BC) excluding non-BC, ED, and BC not participating in BCQP. CDC’s WISQARS database reported 3,529 burn-related deaths resulting in 45,135 years of potential years of life lost, 287,926 non-fatal BI from fire/flame and contact with 76.1% of patients treated in ED only and total costs of $42.4B. Mechanisms such as scald, chemical, electrical, radiation, and inhalation injury were not included. The CDC NHAMCS reported 359,000 BI presenting to ED (23% increase from CDC WISQARS). Our analysis from claims databases demonstrated over 698,555 BI as the primary code likely underreporting self-pay/uninsured, military facilities, and endowment or community-based hospitals not submitting claims data. Conclusions Our study demonstrates a large variability in the incidence of BI. Given the increased population noted in the U.S. 2020 census, the true number of BI is likely closer to the claims database suggesting a substantial misunderstanding in the burden of burns. We additionally noted no ICD-10 codes to characterize the sequela of BI limiting our assessment of post-acute burn care challenges. Future efforts to improve CDC reporting policies and new ICD-10 codes capturing BI sequela are essential to improve advocacy and understanding of our patients and their healthcare needs. Applicability of Research to Practice This abstract will help clinicians, patients, and investigators better advocate for population health research in burn injury.

599 To Titrate or Not to Titrate, That Is the Burning Question: Enoxaparin and VTE Prophylaxis

Abstract Introduction Patients who sustain burn injury undergo metabolic and physiologic changes that place them at elevated risk of developing venous thromboembolism (VTE). Although the benefit and safety of enoxaparin titration for prevention of VTE in trauma patients is well established, there is a lack of evidence regarding its applicability for burn injured patients. In this study, we sought to determine the safety and applicability of enoxaparin titration for burn injured patients admitted for treatment of their injury. Methods We performed a single center retrospective study of burn injured patients admitted to our American Burn Association verified burn center from June 2022 to June 2023. In May 2022, our burn center adopted the American Association for Surgeons in Trauma (AAST) protocol for enoxaparin dosing. This includes twice daily administration of enoxaparin, followed by measurement of anti-Xa levels prior to administration of the fourth or fifth dose. We previously administered a standard dose of 30mg twice daily. Anti-Xa levels were used to guide enoxaparin dose adjustments to remain within prophylactic range. Patients hospitalized for under 48 hours, with glomerular filtration rate less than 30, and with repeated refusal of enoxaparin were excluded. Results Eighty seven patients met our inclusion criteria. Fifty six patients started at 40mg twice daily dosing; the remainder started at 30mg twice daily dosing. Of these patients, forty two (48%) required dose adjustments by anti-Xa levels. Of those who required dose adjustment, thirty three (78%) required an increase. There was no significant difference in BMI (p=0.25) or inhalation injury (p=0.62) between patients who did and did not require enoxaparin titration. Patients who required titration had a non-significant trend toward larger percent total body surface area affected (p=0.08). There was also a significantly greater change in dosing for patients who required an increase in dose adjustment as opposed to those who required a decrease in dose adjustment (p < 0.0001). Finally, there was no difference in post-operative bleeding between patients who did and did not require dose titration (p=0.57). Conclusions Our results demonstrate that an individual approach to VTE prevention through enoxaparin titration is necessary in order to maintain appropriate prophylactic doses in burn injured patients. Furthermore, adoption of the AAST guidelines is safe and does not result in an increase in post-operative bleeding events. Applicability of Research to Practice This work highlights the safety and benefit of enoxaparin titration in burn injured patients to prevent VTE.

114 Burn Specific VTE Prophylaxis: Higher Enoxaparin Dose and Anti-Xa Adjustments Is Safe and Potentially Beneficial

Abstract Introduction Burn and trauma patients are at high risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolus (PE). VTE prophylaxis guidelines for trauma patients recommends a higher standard dose of enoxaparin and anti-Xa level adjustments in select patients; however, no guidelines specific to burn patients exist. We hypothesize that higher standard doses of enoxaparin and anti-Xa level adjustments will be safe and effective at reducing VTE complications in burn patients. Methods This retrospective review included patients admitted to a regional burn center six months prior to and after the initiation of a VTE prophylaxis quality improvement protocol. The protocol doubled the standard dose of enoxaparin, 40 mg daily to 40 mg twice a day, for all burn patients who were > 50 kg and had creatinine clearance > 60mg/dl. Peak anti-Xa level monitoring was indicated if a high-risk factor (TBSA ≥20%, inhalation injury, burn shock, BMI ≥40) was present. Patients on therapeutic anticoagulation or anti-platelet therapy, had a history of chronic kidney disease, decompensated cirrhosis, coagulation disorder, heparin induced thrombocytopenia (HIT), or were admitted for polytrauma were excluded. Efficacy was evaluated by rates of VTE within 31 days of discharge. Safety was evaluated by bleeding complications, including estimated blood loss (EBL), number of transfusions and gastrointestinal (GI) bleeding events. Differences between groups were compared using a two-sample t-test or Wilcoxon rank-sum test. A p-value of < 0.05 signified statistical significance. Results The pre-protocol group included 217 patients and the post-protocol group included 207 patients. There were no significant differences in age (45 vs 44 years), BMI (27 vs 26.4 kg/m2), TBSA (5.9 vs 5.3%), IHI (4.6 vs 7%), number of procedures (3 vs 3), mortality (4.1 vs 3%), or ICU length of stay (1.9 vs 1.6 days) between groups. No significant difference in EBL (50 vs 25 cc), number of transfusions (3.3 vs 2.4 units), or GI bleeding events (1 vs 1) was noted between groups, and no patient developed thrombocytopenia or HIT. There were 5 patients (2.3%) with a VTE within 31 days of discharge in the pre-protocol group compared to 1 patient (0.4%) in the post-protocol group (p=0.19). There was not enough power to determine statistically significant VTE prevention. Conclusions A lack of VTE prophylaxis recommendations for burn patients leads to variability in protocols among burn centers. These protocols are infrequently studied. This protocol, which doubled the standard dose of enoxaparin and adjusted based on anti-Xa levels for high-risk patients, was safe. Efficacy and applicability to other centers needs further elucidation. Applicability of Research to Practice Enoxaparin 40mg twice a day with anti-Xa level adjustments is safe and a promising strategy to reduce the rates of VTE in the burn population without increasing bleeding complications.

39 Deep Learning and Mechanical Ventilation Period Based Inhalational Injury Score

39 Deep Learning and Mechanical Ventilation Period Based Inhalational Injury Score

570 Adult Self-Inflicted Burn Demographics in West Texas

Abstract Introduction Self-inflicted burns (SIB) are a subset of burns defined based on self-injury, sometimes also referred to as self-immolation. The United States generally reports SIB in the context of psychiatric ailment. However, due to the difference in geographic locations, the West Texas burn coverage has never been checked for SIB patients. We hypothesize that patients with SIB have higher rates of psychiatric disorders and are generally older men. Methods We obtained a list of all patients admitted to the burn intensive care unit (BICU) with a Second/Third-degree burn. After, we verified the inclusion of patients meeting the study criteria from July 01, 2011, to July 01, 2021, ages between 18 and 89, and a completed Lund-Browder Chart. Data was collected from a mix of manual chart review from electronic health records and electronic data retrieval. Patients were split into two groups, SIB and non-intentional burns (NIB). Bivariate analysis was conducted using Mann Whitney U test and either Fisher’s exact test or Chi-square test when independent variables were categorical. Results The initial data set (n=2,875) decreased due to missing burn documentation, burn intensive care unit admission, and incomplete records and was split into two groups: SIB (n=49) and NIB (n=1,243). The average age and percentage of male patients compared between NIB and SIB were not significant (p=0.32, p=0.39). However, TBSA, frequency of inhalation injury, burn symmetry, suicidal ideation, history of drug abuse, history of self-harm, history of mental illness, past mental health hospitalization, and mortality were all significantly higher in the SIB group (p< 0.001). There was also a statistically significant higher frequency of psychological disorders in the SIB group for depression, acute schizophrenia, borderline personality disorder, bipolar disorder (p>0.001), anxiety disorders (p=0.02), post-traumatic stress disorder (p=0.006), atypical psychosis, drug-induced psychosis, and delirium (p=0.04). Conclusions The demographics of the West Texas SIB population are comparable to that of the United States, predominantly older male patients. Similarly, many psychiatric disorders occur at a higher frequency in SIB patients than NIB: depression, acute schizophrenia, borderline personality disorder, anxiety disorder, post—traumatic stress disorder, bipolar disorder, atypical psychosis, drug-induced psychosis, and delirium. Applicability of Research to Practice While SIB patients make a small portion of the total burn population, there burns are often associated with worse outcomes – mortality, larger burns, and length of stay. The severity of their injuries begs the need for further analysis and hopefully prevention of SIB. Addressing psychiatric facilities and preventing these incidents from occurring may offer preventative methods.

Challenges of PICC placement via the popliteal vein under ultrasound guidance in a patient with severe burns: A case report.

Peripherally inserted central catheters are widely used in patients with extensive burns, with the guidelines recommending insertion through unburned skin. This case report describes a patient who was burned over 88% of their surface area and suffered severe inhalation injury. For him, the popliteal vein was the only vein on unburned skin available for catheter catheterization. Based on evidence, we successfully placed a peripherally inserted central catheter through the popliteal vein under ultrasound while the patient was in the prone position and avoided associated complications.

Inhalation Injury.

Inhalation injury is a critical component of thermal injury that can significantly increase mortality in burn survivors. This poses significant challenges to managing these patients and profoundly impacts patient outcomes. This comprehensive literature review delves into the epidemiology, pathophysiology, diagnosis, classification, management, and outcomes of inhalation injury with burns.

Effect of glycemic variability on infectious outcomes in critically Ill burn patients

After acute burn injury, patients experience a hypermetabolic state often complicated by a stress-induced hyperglycemia. Recent research points towards glycemic variability as a contributing factor in adverse outcomes in critically ill patients. In burn patients, greater glycemic variability has been associated with increased rates of mortality and sepsis. However, no studies to date have examined the impact of glycemic variability on rates of infection in this population or determined which measure may be most useful. Infection, and subsequent sepsis, remains the leading contributor to morbidity and mortality after burn injury. The primary objective of this study is to evaluate the relationship between different measures of glycemic variability and infectious complications in burn patients. This retrospective study included patients admitted to a single American Burn Association-verified burn center between January 1, 2020 and December 31, 2020 with burn or inhalation injury. The primary outcome was a composite of autograft loss, mortality, and proven infection. Secondary outcomes included hospital length of stay and a further analysis of the proven infection component of the composite primary outcome. In addition to mean glucose, several different measures of glycemic variability were used for comparison, including standard deviation, coefficient of variation, mean amplitude of glycemic excursions, and J-index. Outcomes were analyzed using multiple logistic regression analysis while controlling for revised Baux score. A quantile analysis was performed to do determine the optimal mean threshold. Three hundred and ninety-two patients were admitted and screened for inclusion during the study period. Most patients were excluded due to a LOS less than 72 h. 112 patients were included in the study. Of the 112 patients, 22.3% experienced an infectious complication (25 patients with 28 complications). Mean glucose (OR 1.024; 95% CI 1.004–1.045) and J-index (OR 1.044; 95% CI 1.003–1.087) were associated with occurrence of infectious complications. Regarding target mean glucose threshold, a daily mean glucose above 150 mg/dL showed the strongest association with infectious complications (OR 3.634; 95% CI 1.008–13.101). Mean glucose, standard of deviation, and J-index were all independently associated with proven infection.

Hydroxocobalamin is not associated with methemoglobinemia in patients with inhalation injury and suspected cyanide toxicity and a proposed algorithm for hydroxocobalamin administration

BackgroundCyanide poisoning poses a significant threat to burn patients exposed to smoke in residential or workplace fires, leading to central nervous system dysfunction, hemodynamic instability, cardiovascular collapse, and death. Prompt administration of an effective antidote is critical. Hydroxocobalamin, a form of vitamin B12, is the gold standard treatment for cyanide toxicity, by binding to cyanide molecules and converting them into non-toxic cyanocobalamin that is eliminated by the kidneys. This mechanism is distinct from previous cyanide antidotes, which induce the formation of methemoglobin to bind to cyanide. Recent case studies have reported elevated methemoglobin levels after hydroxocobalamin administration, raising concerns regarding its safety. The current study investigates smoke inhalation patients treated with hydroxocobalamin at a single institution Burn Unit in hopes of enhancing our understanding of the complexities surrounding cyanide antidote therapy. MethodsAfter Institutional Board Approval, a retrospective cohort study was conducted. Our sample comprised burn patients with inhalation injury admitted to a single institution from 2013 to 2023 and treated with hydroxocobalamin for suspected cyanide toxicity. We also analyzed a matched control cohort of similar patients with inhalation injury not treated with hydroxocobalamin. We analyzed changes and peaks in methemoglobin levels, lactate levels, blood urea nitrogen (BUN) and creatinine, ventilator days, % total body surface area (TBSA), various types of medications and dressings, and mortality. Statistical analyses included t-tests, chi-square, linear and logistic regressions, and correlation analysis. ResultsIn the study, 36 patients with suspected inhalation injury were treated with hydroxocobalamin at the Los Angeles General (LAG) Burn Unit from 2013 to 2023, who were matched to 32 control patients with inhalation injury who were not treated with hydroxocobalamin. Demographic and baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in methemoglobin levels. The study also revealed no significant disparities in initial lactate levels, mortality, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups. When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that hydroxocobalamin administration was not significantly associated with changes in methemoglobin or mortality. Increased %TBSA, however, was linked to elevated lactate levels. ConclusionsOur investigation sought to assess the potential risks associated with hydroxocobalamin administration in burn patients with concomitant inhalation injury. Contrary to our initial hypothesis, we found no statistically significant differences in methemoglobinemia, lactate levels, mortality, or kidney function. The influence of other factors, such as methemoglobinemia-inducing drugs or hydroxocobalamin's interference with co-oximetry, adds complexity. Although elevated methemoglobin levels were observed in some cases, their clinical significance was limited. However, this study's limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of hydroxocobalamin administration on burn patients' outcomes.

Acute Burn Care.

After studying this article and viewing the videos, the participant should be able to: 1. Describe the current epidemiology of burn injuries. 2. Understand burn pathophysiology and perform a wound assessment. 3. Summarize the initial emergency management of a burn patient. 4. Calculate the anticipated fluid resuscitation requirements for a burn injury, and diagnose the complications of overresuscitation. 5. Describe the diagnosis and management of inhalation injury. 6. List the goals of wound care for superficial and deep burns, and describe the closed dressing technique. 7. Perform excision of a burn wound. 8. Compare various wound closure techniques using autografts and skin substitutes. Plastic surgeons are essential members of the multidisciplinary burn team. Burn injuries remain common, and plastic surgeons have an opportunity to develop and innovate the field of acute burn care in light of workforce shortages. Burn pathophysiology is complex and dynamic, which informs the challenges encountered during the perioperative phase. Accurate burn wound assessment remains difficult, with implications for diagnosis and management. A systematic approach is required when stabilizing a major burn and/or inhalation injury with newly updated fluid resuscitation and triage guidelines. Wound care continues to evolve, with an emphasis on a closed dressing technique. For deeper burns, new surgical techniques are emerging for surgical débridement, along with improvements to traditional methods of tangential excision. Following excision, a number of established and novel techniques are available to close the wound with either autografts or skin substitutes.

Analysis of epidemiological characteristics and risk factors of catheter-associated urinary tract infections in patients with perineal and/or hip burns

Objective: To explore the epidemiological characteristics and risk factors of catheter-associated urinary tract infections in patients with perineal and/or hip burns. Methods: This study was a retrospective case series study. From January 2018 to December 2022, 260 patients with perineal and/or hip burns and urinary catheters indwelling who met the inclusion criteria were admitted to the Department of Burns and Wound Repair of the Second Affiliated Hospital of Zhejiang University School of Medicine, including 192 males and 68 females, aged 20-93 years. The total incidence of catheter-associated urinary tract infections in patients with perineal and/or hip burns, the detection of pathogenic bacteria, and the resistance of major Gram-negative and Gram-positive bacteria to commonly used antimicrobial drugs in clinic were recorded. According to whether catheter-associated urinary tract infection occurred or not, the patients were divided into infection group (43 cases) and non-infection group (217 cases). The basic conditions including gender, age, total burn area, depth of perineal burn, depth of hip burn, and burn site on admission, complications of diabetes mellitus, inhalation injury, and hypoproteinaemia, invasive operations including tracheotomy and non-perineal/hip debridement/skin transplantation surgery, duration of catheter retention, number of urethral catheterization, and bladder irrigation of patients between the two groups were compared, and the independent risk factors influencing the occurrence of catheter-associated urinary tract infections in patients with perineal and/or hip burns were screened. Results: The total incidence of catheter-associated urinary tract infections in patients with perineal and/or hip burns in this study was 16.5% (43/260). The pathogens detected were predominantly Gram-negative, followed by fungi; the main Gram-negative bacterium was Klebsiella pneumoniae, and the main Gram-positive bacterium was Enterococcus faecalis. The resistance rates of Klebsiella pneumoniae to amoxicillin/clavulanic acid, amitraz, amikacin, ciprofloxacin, ceftriaxone, and levofloxacin were higher than 70.0%, the resistance rates of Klebsiella pneumoniae to cefoxitin, cefoperazone/sulbactam, cefepime, meropenem, imipenem, and piperacillin/tazobactam ranged from 56.3% to 68.8%, and the resistance rates of Klebsiella pneumoniae to ceftazidime and tigecycline were lower than 50.0%. The resistance rates of Enterococcus faecalis to ciprofloxacin and penicillin were both 85.7%, the resistance rates of Enterococcus faecalis to erythromycin, clindamycin, moxifloxacin, and tetracycline ranged from 14.3% to 57.1%, and the resistance rates of Enterococcus faecalis to linezolid, tigecycline, and vancomycin were all 0. The differences were statistically significant between the two groups in terms of gender, status of complication of hypoproteinaemia, depth of perineal burn, status of non-perineal/hip debridement/skin transplantation surgery, status of bladder irrigation, number of urethral catheterization, and duration of catheter retention of patients (with χ2 values of 7.80, 4.85, 10.68, 9.11, and 16.48, respectively, and Z values of -4.88 and -5.42, respectively, P<0.05). There were no statistically significant differences in the age, total burn area, complications of diabetes mellitus and inhalation injury, burn site, depth of hip burns, and status of tracheotomy of patients between the two groups (P>0.05). Multifactorial logistic regression analysis showed that gender, deep partial-thickness perineal burns, non-perineal/hip debridement/skin transplantation surgery, bladder irrigation, and duration of catheter retention were the independent risk factors for catheter-associated urinary tract infections in patients with perineal and/or hip burns (with odds ratios of 2.86, 2.63, 2.79, 2.34, and 1.04, respectively, with 95% confidence intervals of 1.21-6.73, 1.03-6.71, 1.03-7.59, 1.05-5.22, and 1.02-1.06, respectively, P<0.05). Conclusions: The incidence of catheter-associated urinary tract infections is high in patients with perineal and/or hip burns, with Klebsiella pneumoniae as the predominant pathogenic bacteria having a high resistance rate to commonly used antimicrobial drugs in clinic. Gender, deep partial-thickness perineal burns, non-perineal/hip debridement/skin transplantation surgery, bladder irrigation, and duration of catheter retention are the independent risk factors for catheter-associated urinary tract infections in patients with perineal and/or hip burns.

Multicenter retrospect analysis of early clinical features and analysis of risk factors on prognosis of elderly patients with severe burns

Objective: To investigate the early clinical characteristics of elderly patients with severe burns and the risk factors on prognosis. Methods: This study was a retrospective case series study. Clinical data of 124 elderly patients with severe burns who met the inclusion criteria and were admitted to the 12 hospitals from January 2015 to December 2020 were collected, including 4 patients from the Fourth People's Hospital of Dalian, 5 patients from Fujian Medical University Union Hospital, 22 patients from Guangzhou Red Cross Hospital of Jinan University, 5 patients from Heilongjiang Provincial Hospital, 27 patients from the First Affiliated Hospital of Naval Medical University, 9 patients from the First Affiliated Hospital of Nanchang University, 10 patients from Affiliated Hospital of Nantong University, 9 patients from Tongren Hospital of Wuhan University & Wuhan Third Hospital, 12 patients from the 924th Hospital of PLA, 6 patients from Zhangjiagang First People's Hospital, 4 patients from Taizhou Hospital of Zhejiang Province, and 11 patients from Zhengzhou First People's Hospital. The patients' overall clinical characteristics, such as gender, age, body mass index, total burn area, full-thickness burn area, inhalation injury, causative factors, whether combined with underlying medical diseases, and admission time after injury were recorded. According to the survival outcome within 28 days after injury, the patients were divided into survival group (89 cases) and death group (35 cases). The following data of patients were compared between the two groups, including the basic data and injuries (the same as the overall clinical characteristics ahead); the coagulation indexes within the first 24 hours of injury such as prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time, D-dimer, fibrinogen degradation product (FDP), international normalized ratio (INR), and fibrinogen; the blood routine indexes within the first 24 hours of injury such as white blood cell count, platelet count, neutrophil-to-lymphocyte ratio, monocyte count, red blood cell count, hemoglobin, and hematocrit; the organ function indexes within the first 24 hours of injury such as direct bilirubin, total bilirubin, urea, serum creatinine, aspartate aminotransferase, alanine aminotransferase, total protein, albumin, globulin, blood glucose, triglyceride, total cholesterol, alkaline phosphatase, creatine kinase, electrolyte indexes (potassium, sodium, chlorine, calcium, magnesium, and phosphorus in blood), uric acid, myoglobin, and brain natriuretic peptide; the infection and blood gas indexes within the first 24 hours of injury such as procalcitonin, C-reactive protein, pH value, oxygenation index, base excess, and lactate; treatment such as whether conducted with mechanical ventilation, whether conducted with continuous renal replacement therapy, whether conducted with anticoagulation therapy, whether applied with vasoactive drugs, and fluid resuscitation. The analysis was conducted to screen the independent risk factors for the mortality within 28 days after injury in elderly patients with severe burns. Results: Among 124 patients, there were 82 males and 42 females, aged 60-97 years, with body mass index of 23.44 (21.09, 25.95) kg/m2, total burn area of 54.00% (42.00%, 75.00%) total body surface area (TBSA), and full-thickness burn area of 25.00% (10.00%, 40.00%) TBSA. The patients were mainly combined with moderate to severe inhalation injury and caused by flame burns. There were 43 cases with underlying medical diseases. The majority of patients were admitted to the hospital within 8 hours after injury. There were statistically significant differences between patients in the 2 groups in terms of age, total burn area, full-thickness burn area, and inhalation injury, and PT, APTT, D-dimer, FDP, INR, white blood cell count, platelet count, urea, serum creatinine, blood glucose, blood sodium, uric acid, myoglobin, and urine volume within the first 24 hours of injury (with Z values of 2.37, 5.49, 5.26, 5.97, 2.18, 1.95, 2.68, 2.68, 2.51, 2.82, 2.14, 3.40, 5.31, 3.41, 2.35, 3.81, 2.16, and -3.82, respectively, P<0.05); there were statistically significant differences between two groups of patients in whether conducted with mechanical ventilation and whether applied with vasoactive drugs (with χ2 values of 9.44 and 28.50, respectively, P<0.05). Age, total burn area, full-thickness burn area, serum creatinine within the first 24 hours of injury, and APTT within the first 24 hours of injury were the independent risk factors for the mortality within 28 days after injury in elderly patients with severe burns (with odds ratios of 1.17, 1.10, 1.10, 1.09, and 1.27, 95% confidence intervals of 1.03-1.40, 1.04-1.21, 1.05-1.19, 1.05-1.17, and 1.07-1.69, respectively, P<0.05). Conclusions: The elderly patients with severe burns had the injuries mainly from flame burns, often accompanied by moderate to severe inhalation injury and enhanced inflammatory response, elevated blood glucose levels, activated fibrinolysis, and impaired organ function in the early stage, which are associated with their prognosis. Age, total burn area, full-thickness burn area, and serum creatinine and APTT within the first 24 hours of injury are the independent risk factors for death within 28 days after injury in this population.

Diagnostic and Prognostic Value of Thrombocytopenia in Severe Burn Injuries.

Burn injuries are the most severe type of trauma, with complex biological consequences associated with high rates of morbidity and mortality. Prompt recognition and management of burn-related complications are imperative for improving the vital and functional prognosis of the patient. Changes in biological parameters can be essential determinants in the prognosis of the burned patient. Thrombocytopenia in critically ill patients is linked to an elevated risk of mortality. We sought to investigate the significance of thrombocytopenia in severely burned patients while considering the limited available data in the literature. A two-year retrospective study was conducted on 90 patients with severe burns admitted to our Burn Centre. Demographic data, burn lesion characteristics, and daily total blood counts, including platelet assessment, complications, and mortality, were recorded and analyzed. Patients with extensive burns in our study had a poor prognosis based on their Abbreviated Burn Severity Index score (ABSI), age, percentage of total body surface area (TBSA) burned, presence of third-degree burns, and inhalation injuries. Regardless of the moment, patients with thrombocytopenia in our study died significantly more frequently. Compared with the survivors, the platelet count was significantly lower at any given time in the non-survivors group. Significant statistical associations between thrombocytopenia and ABSI score, burn surface area, presence of third-degree burns, and inhalation injuries were identified at different timeframes post-burn injury. Sepsis was encountered in one-third of the patients. Thrombocytopenia was more frequent in patients with sepsis who did not survive compared to survivors and did not normalize until the time of death. Thrombocytopenia represents an early indicator of severe complications and outcome predictor in severely burned patients. It is correlated with recognized negative prognostic factors and also with sepsis occurrence. Future research efforts should focus on refining early detection parameters and interventions to improve the prognosis of burn patients.

Efficacy of hydrosurgical eschar excision following MEEK microskin grafting in patients with massive burns: A retrospective study of a single center

IntroductionOne of the most common traumatic injuries, burn injuries lead to at least 180,000 deaths each year worldwide. Massive burns result in severe tissue loss and increase the rate of infection. Eschar excision with skin grafting is the gold standard of treatments for massive burns. Retaining dermis tissue is the key to ensuring the survival of skin grafts and rapidly closing exposed tissues. Traditional eschar excision with Humby or Weck knife controls the depth of excision until the dermis, but ensuring the accuracy of excision is challenging. Hydrosurgery minimizes damage to uninjured tissues during the removal of necrotic tissues. A foot pedal is used to adjust debridement depth for precise debridement. To figure out the clinical advantages and risks of using hydrosurgery in treating massive burns, this study has been conducted. MethodForty-two patients with massive burns and total body surface area (TBSA) of > 30% were treated at the First Affiliated Hospital of Anhui Medical University from May 2020 to January 2023. They underwent hydrosurgical eschar excision with MEEK microskin graft (n = 23) or tangential excision with MEEK microskin graft (n = 19). ResultNo statistically significant differences (p > 0.05) in the following demographics were found between the two groups: age, weight, TBSA, deep-partial-thickness burn, gender, inhalation injury, shock, excision area, and MEEK ratio. By contrast, statistically significant differences in per unit area of operation time, per unit area of operation spending, hospitalization cost, hospitalization duration, wound-healing time, skin graft survival, and scar quality were found between hydrosurgical excision group with MEEK microskin graft and conventional excision group with MEEK microskin graft. ConclusionThe hydrosurgical excision system showed better clinical effects for patients with massive burns.

Revisiting the Pathophysiology of Acute Respiratory Distress Syndrome in Burn with Inhalation Injury: A Comprehensive Review

Acute respiratory distress syndrome (ARDS) is a common complication in severe burn patients, arising from inflammatory responses following burns or inhalation injuries. This literature review explores the mechanisms and diagnostic approaches for ARDS in burn patients. Methods involved searching open-access journals using specific keywords on PubMed, Google Scholar, and Elsevier. The review highlights the involvement of various immune cells and cytokines in ARDS pathophysiology, with diagnostic tools including clinical signs, imaging, and bronchoscopy. Therapeutic strategies focus on ventilation and pharmacological interventions targeting inflammation. Further research is needed to better understand ARDS in burn patients, particularly regarding inflammatory markers and pharmacological treatments.

Pediatric Polytrauma Fire Victim Simulation.

Pediatric trauma has long been one of the primary contributors to pediatric mortality. There are multiple cases in the literature involving cyanide (CN) toxicity, carbon monoxide (CO) toxicity, and smoke inhalation with thermal injury, but none in combination with mechanical trauma. In this 45-minute simulation case, emergency medicine residents and fellows were asked to manage a pediatric patient with multiple life-threatening traumatic and metabolic concerns after being extracted from a van accident with a resulting fire. Providers were expected to identify and manage the patient's airway, burns, hemoperitoneum, and CO and CN toxicities. Forty learners participated in this simulation, the majority of whom had little prior clinical experience managing the concepts highlighted in it. All agreed or strongly agreed that the case was relevant to their work. After participation, learner confidence in the ability to manage each of the learning objectives was high. One hundred percent of learners felt confident or very confident in managing CO toxicity and completing primary and secondary surveys, while 97% were similarly confident in identifying smoke inhalation injury, preparing for a difficult airway, and managing CN toxicity. This case was a well-received teaching tool for the management of pediatric trauma and metabolic derangements related to fire injuries. While this specific case represents a rare clinical experience, it is within the scope of expected knowledge for emergency medicine providers and offers the opportunity to practice managing multisystem trauma.