Inhalation Injury Research Articles

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.

58 Achieving < 2cc/kg/%TBSA - A Restrictive Adjusted Ideal Body Weight Resuscitation Formula with Fresh Frozen Plasma

Abstract Introduction Fresh frozen plasma (FFP) is used as an adjunct in burn resuscitation as it decreases endothelial cell permeability by restoring the glycocalyx. The authors have previously demonstrated a reduction in fluid administration using adjusted ideal body weight (AIBW) index to adjust for avascular adipose tissue with an FFP rescue. Since publication, the authors have further restricted the fluid administered in this protocol and hypothesize that this iteration results in further reductions without an increase in clinically significant acute kidney injury (AKI) and need for dialysis. Methods A retrospective review of burn patients with 2nd/3rd degree burns of 20% TBSA admitted between 6/20-5/22 at a single academic burn center was performed. Demographics and injury characteristics were tracked along with ventilator free days, volume/type of fluids administered during resuscitation, UOP, max creatinine (Cr) in the 1st 72 hrs post injury, AKI requiring HD, length of stay (LOS), LOS O/E ratio (using NBR data), and death. Data was reported in medians + IQR. Subjects were resuscitated with 2mL/kg/%TBSA LR using an AIBW formula with FFP. AIBW index = ideal body weight + 0.3 [actual body weight – ideal body weight]. Those with 30-50% TBSA burns received 1 U FFP on admission; those with >50% TBSA had 2 U FFP. Starting hourly rate was calculated with 2 cc/AIBW in kg/%TBSA as a default, while 3 cc was used if mostly 3rd degree injury + inhalation. Nursing driven titration was done by 10-20% per hr based on deviation from target UOP of 30cc/hr. For very obese or small patients, the UOP goal was reset to 0.5cc/AIBW/hr by MD. If oliguric for 2 hrs, patients received 1-2 units of FFP as rescue therapy. Results Twenty-three patients were included in the study, and 10 received FFP during resuscitation. Burn size was 33% TBSA (IQR:27,38), and 3rd degree burn was 8% (IQR:3,15). Three subjects had inhalation injury, and 2 were resuscitated with 3cc/kg /%TBSA. Median fluid volume given over 24 hrs was 1.653 (IQR:1.022,2.358) cc/kg/%TBSA (including FFP). UOP was 0.67 cc/kg/hr (IQR:0.397,1.064). Ventilator free days was 29 (IQR: 24,30). One received a tracheostomy; 3 had escharotomies. Three (13%) patients had elevated Cr < 72 hours post injury (max creatinine- 1.7 mg/dL). LOS was 32 days (IQR:19,46) or 1.105 days/%TBSA. Median expected LOS was 88.5 days or 2.6 days/%TBSA based on NBR data. LOS O/E ratio was 0.42. Two patients died (9%). Conclusions Despite the single-arm, retrospective nature, this study suggests that patients who were treated with a restrictive AIBW formula plus FFP received less total fluid than the previously published iteration of the formula (1.63 vs 3.3cc/kg/%TBSA), and far less than the traditional Parkland formula. Even with reduced fluids, no one had a clinically significant AKI. Preliminary data suggests this protocol is safe and effective, but additional prospective study is necessary. Applicability of Research to Practice Treat burn shock and prevent over resuscitation

61 Effect of Pre-Existing Hypertension on Cardiovascular Support and Mortality Among Major Burn Patients

Abstract Introduction Hypertension (HTN) is the most common comorbidity seen in patients who sustain a major burn. HTN causes increased responsiveness of the autonomic nervous system to stressful stimuli, activation of RAAS, arterial and myocardial hypertrophy, and impaired vasodilation. Changes to these pathways are also seen in response to major burns. Given this common pathophysiology, patients with pre-existing HTN may demonstrate different mortality risk after major burn than those without HTN. The objective of this study is to compare the risk of in-hospital mortality among adult patients with and without pre-existing HTN admitted to the intensive care unit (ICU) with a major burn. In addition, we sought to determine the association of pre-existing HTN with the need for vasoactive agents, fluid resuscitation and urine output in the first 48-hours of ICU admission Methods Single-centre, historical cohort study using data from a Burn Registry, Intensive Care Database, and medical chart review. Variables of interest were demographic and injury characteristics, use of vasoactive agents, 12-, 24-, and 48-hour fluid requirements and urine output, and in-hospital mortality. We included adult (≥18 years) patients presenting with ≥20% total body surface area (TBSA) burns who were admitted to the ICU from January 2010 to August 2021. Pre-existing HTN was defined by pharmacy records showing the patient had filled a prescription for an anti-HTN medication within the 12-months prior to their burn. We compared variables of interest by HTN exposure and conducted univariate analysis to assess mortality risk Results 199 patients met inclusion criteria. Of these, 145 records were complete. The mean (standard deviation, SD) age was 47 (7) years and TBSA was 37 (16) percent. Most patients were males (83.5%) who sustained a flame burn (87.6%) without an inhalation injury (28.5%). Pharmacy records revealed that 28 patients (19.3%) had pre-existing HTN. Mean (SD) 24-hour fluid requirements were 7.1 (5.6) L and 5.2 (3.2) L for HTN and non-HTN patients, respectively (p=0.17). Mean (SD) 24-hour urine output was 1024 (747) mL and 1314 (780) mL for HTN and non-HTN patients, respectively (p=0.12). Sixty-one percent of HTN patients required vasoactive agents in the first 24-hours compared to 46.2% of non-HTN patients (p=0.18). Pre-existing HTN was associated with a 5-fold increase in in-hospital mortality (OR 5.5, CI 2.2-14.0) Conclusions Preliminary results suggest differences in fluid requirements, urine output and mortality risk between HTN and non-HTN patients with major burns. An external registry has been queried to identify pharmacy records for the 54 patients with missing data Applicability of Research to Practice Identifying differences in mortality risk and need for cardiovascular support among burn patients with HTN changes our approach to counselling and caring for these patients

503 The Accuracy of the Revised Baux Score in Predicting Burn Mortality: A Systematic Review

Abstract Introduction Osler et al. revised the Baux score in 2010 to include inhalation injury, attempting to improve upon the original 1961 model given the significant advances in modern burn care. Other predictive models of burn mortality have similarly been developed using use an assortment of other variables, however there is no consensus on the preferred formula to use. This systematic review aims to investigate the accuracy of the revised Baux (rBaux) score in comparison to other models when determining mortality risk in patients with burn injuries. Methods A systematic review was performed by two independent reviewers using electronic databases (PubMed, EMBASE, Scopus) from March 1, 2010 to May 22, 2022. The majority of studies were classified as “high” quality and no studies were excluded due to risk of bias. Articles were included if they were published in English and assessed risk of mortality from burns using the rBaux model and an alternative model. The PRISMA statement was followed, and all the PROBAST quality appraisal checklist was used during data extraction. Results The search identified 79 non-duplicate citations, of which 33 underwent full-text review, and 21 met inclusion criteria. They assessed the predictive ability of the rBaux score in comparison to the original Baux score, Belgian Outcome for Burn Injury, Abbreviated Burn Severity Index, APACHE II, Sequential Organ Failure Assessment score, Boston Group/Ryan scores, the FLAMES model, the Prognostic Burn Index, and several other equations that have not been externally validated. The accuracy of mortality prediction (area under ROC curves) for the rBaux score ranged from 0.68 to 0.99 and 14 studies found a value greater than 0.90. These ROC values were found to be lowest in the two studies with subgroupings for age, demonstrating an ROC of 0.01 in children, and 0.68 and 0.92 in the elderly. Eleven studies described sensitivity, specificity, or both, with sensitivity ranging from 12% to 96%, and specificity ranging from 80% to 100%. Conclusions The rBaux score offers a relatively easy method to rapidly assess the mortality risk from burn injury in a broad range of patient populations based on age, percent total body surface area burned, and presence/absence of an inhalation injury. This tool remains valid despite the exclusion of patient comorbidities and other injury-related factors. However, this study also identified the rBaux’s ability to predict mortality risk was limited when applied to patients at the extremes of age, highlighting an important area for future research. At present, given its relative simplicity and generalizability, the rBaux score remains a useful clinical tool for predicting mortality. Applicability of Research to Practice The rBaux score remains a simple yet powerful predictor of mortality in burn patients, which can be applied at the bedside on initial presentation across diverse patient populations.

285 Determinants of Mortality Amongst Adult Burn Patients Admitted to a Regional Burn Center: Twenty-year Review

Abstract Introduction Established determinants of morbidity and mortality in burn patients include age and total burn surface area (TBSA), followed by inhalation injuries. We investigated determinants of mortality in burn patients admitted to our unit over the last two decades. The goal of this study was to determine the trends associated with burn mortality. Methods The burn registry was reviewed for the data of 5,401 burn patients admitted to our burn unit from 2002 to 2021. Patient demographics, payer source, burn characteristics, TBSA, injury circumstances, length of stay, ventilator and ICU days, comorbidities, complications, and surgery/procedures data were obtained for all patients. Chart reviews were completed for patients who died to investigate trends in mortality. The chi-square test, Wilcoxon two sample Test, Cochran-Armitage trend test, and Jonckheere-Terptra test will be used to evaluate the difference in risk factors of patients who survived and those who died. Two-sided p values less than 0.05 were considered statistically significant. Results A total of 4093 adult burn patients were hospitalized from 2002 to 2021, of which 155 died. Data showed a significant mortality risk for patients of older age with increased TBSA, higher number of ventilator days, higher ICU Days, and a higher number of complications and smoke inhalation. Male patients had a significantly higher mortality rate. Burn injury by flash-flame represented a higher mortality risk. Accidental burn injury unrelated to employment was significantly more common in all patient populations. The relationship between the number of comorbidities and mortality risk was not clear. There wasn’t a significant difference in the mortality risk based on ethnicity (p=0.1218). Mortality rates did not change significantly over the 20 years (p=0.2027). Conclusions Age, %TBSA, and presence of inhalation injury continue to be major determinants of mortality. Higher incidence of longer stay and ICU/ventilator days, complications, and surgical procedures are associated with burn patients who don’t survive but these may be related to previous parameters. Overall mortality trends have not changed. Applicability of Research to Practice The results of this study can be used to increase accuracy in the triage of burn patients at higher risk of complications and death, to offer patients precise prognostics and better outcomes in terms of morbidity and mortality.

537 Epidemiology of Elderly Burn Injuries – A Five Decade Single Center Retrospective Review

Abstract Introduction Age has long been known to be an independent risk factor for worse outcomes in burn patients. In comparison to younger patients, geriatric patients have higher morbidity and mortality. As the median age of the US population has increased, we have seen a greater proportion of elderly burn patients at our burn unit over the last five decades. Methods Retrospective chart review was performed for all burn patients admitted to our burn unit between 2000 and 2019. Demographics and outcomes data was collected for geriatric patients (age 65 and older). This was compared to historic data available for our burn unit between 1972 to 2000. Results Between 2000 to 2019, our burn unit admitted a total of 5881 burn patients of all ages. There were 652 (11%) geriatric patients admitted. The proportion of geriatric patients admitted statistically significantly increased over that period. Meanwhile, length of stay and mortality statistically significantly decreased in the 2000-2019 time period compared to the previous period. The main mechanism of burn injury was flame exposure. Compared to data on geriatric burn patients from 1972 to 2000, mortality has decreased substantially. In the 1970s mortality was 77% compared to 21% in the past decade. The mortality rate increased significantly with age, TBSA and inhalation injury over both time periods. Conclusions Though lagging behind younger age groups, overall survival and outcomes are improving in elderly burn patient due to advances in critical care and surgical burn management. Acknowledging the unique characteristics of this group of patients, such as impaired healing and multiple comorbidities, allows for improved outcomes. Applicability of Research to Practice Burn centers should notice and prepare for an increasing trend in elderly burn patient admission.

113 Impact of State Labor and Industry Benefits on Quality-Adjusted Life-Years Among Working Burn-Injured Adults

Abstract Introduction State labor and industry benefits (L&I) include workers’ compensation, wage replacement, vocational rehabilitation (VcR), workplace accommodations, job retraining, and labor protections. These vital services are not available to working adults injured outside their workplaces. We aimed to examine the impact of L&I on quality-adjusted life-years (QALY) lost among working adults with burn injury. Methods Burn Model System National Database was queried for adult participants who self-identified as worker, volunteer, or caretaker and who answered the Veterans RAND 12-Item Health Survey (VR-12) at discharge (pre-injury recall) and 6-, 12- and 24-month post-injury. Participants were stratified into those with and without L&I and compared using independent samples t-test and Chi-squared test. Primary outcome, QALYs lost, was calculated by transforming VR-12 responses to SF-6D (SF-12) utility values. Mixed effects linear regression modeling was used to assess the impact of L&I on utility values over a 2-year period post-injury. Models were adjusted for age, sex, race, substance use, chronic medical conditions, burn size, hand injury, inhalation injury, and number of surgeries. Results 495 participants were analyzed (90 with L&I, 405 without L&I). Males accounted for 87% of L&I beneficiaries and 72% of those without L&I (p=0.001). No significant difference was seen in the other covariates. Mean utility values were 0.73 for L&I beneficiaries and 0.73 for those without L&I (p=0.99) pre-injury and were significantly lower for both groups at each timepoint post-injury (Figure 1). Greater utility value loss was seen in those with L&I compared to those without L&I at 6-month (p< =0.07), 12-month (p=0.02), and 24-month (p=0.03). During the 2 years post-injury, L&I beneficiaries lost 0.26 QALY and those without L&I lost 0.18 QALY (p=0.03). Conclusions All working adults experienced a drop in utility values post-injury. Those who received L&I benefits lost more QALYs than their non-L&I peers. These findings are consistent with investigations among working adults with non-burn upper extremity and back injuries, suggesting there is opportunity to improve the delivery of L&I benefits and VcR for all injured workers. Applicability of Research to Practice Current L&I benefits and VcR services for working adults with burn injury may not meet their needs. To actualize the benefits of VcR service delivery, the intensity of interventions should be more tailored to person-specific needs, risks of complicated return-to-work and recovery journeys.

712 Added Effect, Injuries, And Complications Of Blast Injuries Among Burn Patients On Resuscitation And Outcomes

Abstract Introduction Major burn injuries present as complex cases due to the hemodynamic and cardiodynamic changes that occur following the injury which can lead to the development of sepsis, multiple organ failure, and death[1]. Complexity of these cases increase furthermore with the inclusion of explosion induced injuries. Concussive explosive forces can be particularly devastating for air containing organs like the lung, bowel and middle ear [8]. In explosion-related cases, “the mortality correlated significantly with higher burned total body surface area (TBSA), higher abbreviated burn severity index (ABSI) score, accompanying inhalation injuries, and lung contusions” [2]. Cardiac blast traumas may occasionally result directly from blast energy but are more often presented as indirect coronary emboli [4]. Explosive energies have been observed to induce bradycardia, hypotension, and apnea [5]. Although more common in underwater blasts, small bowel perforations can result directly from an explosion or indirectly up to 2 weeks following the explosion [4]. A longer ICU length of stay is also associated with patients suffering from an explosion event [7]. Methods Through a hypothesis-driven retrospective study, we isolated a group of 68 burn patients, ages 18-85, from 2010-2017 that fit our criteria. Inclusion to the test group required the presence of an injury related to an explosion that resulted in a TBSA% greater than 10%. We then collected data and compared that to the outcomes of patients who had burn injuries not caused by an explosion. The control group had statistically similar age, TBSA percentage, and comorbidities. We compared major outcomes such as length of stay, length of time on a ventilator, and mortality rates. Results When controlled for age, TBSA %, presence of inhalation injuries and comorbidities, the explosion group had significantly higher mortality rates (p< 0.001). The length of stay and length of intubation were not significantly different for the explosion group. The incidence of sepsis in the explosion group was nearly significant with a p-value of 0.051. Conclusions After analyzing the data, we conclude that patients experiencing an explosion experience higher mortality rates than burn patients of similar age, TBSA%, and comorbidities. The shockwave present in explosion cases likely causes additional injuries to patients that decrease survivability. There was indication that sepsis or infection events may be more likely in patients experiencing an explosion, but results nearly missed the standard of significance. Due to the relatively small sample size of 68 patients, some of the data might be limited in its generalizability. A larger study could provide more insight into the outcomes of patients experiencing explosions. Applicability of Research to Practice The effect of explosions on mortality provides an opportunity for quality improvement research and development of improved methods for treating explosion involved burn injuries.

92 Effect of Blood Transfusion on Outcomes After Major Burns

Abstract Introduction Severely burnt patients frequently receive blood transfusions to treat anemia, increase blood volume and improve wound healing. However, transfusion is not a safe prescription as it is associated with infections and immunosuppression. Aim Understand blood transfusion practices and assess patient transfusion-related outcomes. Methods A single-center retrospective review of 113 ICU patients with >20% TBSA burns from Jan 2014 to June 2022 was performed. Data collected: Age, type of burns, prior use of blood thinners, # of burn operations, hematocrit level pre and post-last transfusion, # of infections, AKI, ARDS during hospitalization, and hospital and ICU length of stay (LOS) Statistical analysis For univariate analysis comparing groups below to the above median of transfusions per hospital stay, a Fisher test was used to compare proportions, and either a t-test or a Wilcoxon test was used to compare continuous features. Cox proportional hazards model and logistic regression were used to analyze the survival and ARDS in multivariate analysis. Results Demographics Out of 113 patients: •94 survived admission •54 had a concurrent inhalational injury •21 developed ARDs •38 developed AKI •95 received at least 1 blood product Median Data: •Age: 43 years •TBSA: 34% •Hospital LOS: 37 days •ICU LOS: 18 days Mean Data: PRBC transfusion/patient: 12 PRBC per 1% TBSA burnt: 0.36 Univariate analysis comparing the median # of transfusions per hospital LOS. Patients who had more transfusions were mostly men, had higher TBSA burns, less inhalational injury, longer ICU and hospital stays, and more burn surgeries. They also had higher hemoglobin levels before their first transfusion and more infections. There was no difference in terms of mortality, AKI, or ARDS. Having anemia (defined here as hemoglobin < 8g/dL) before burn injury did not affect survival. After controlling for the revised Baux score and hemoglobin before initial transfusion, more transfusions per hospital day were associated with decreased survival and increased infections. There was no association between ARDS in multivariate analysis and increased transfusions. Conclusions The number of transfusions per hospital day was associated with decreased survival, although not meeting statistical significance (likely due to the small sample size). Hemoglobin < 8 g/dL before burns was not associated with decreased survival in multivariate analysis. On exploratory analysis, more transfusions per hospital day were significantly associated with increased infection, offering a possible reason for the negative survival association. Applicability of Research to Practice Understanding blood transfusion practices and outcomes improve the utilization of blood in severely burnt patients.

88 Does Weight Matter? A Secondary Analysis from ABRUPT

Abstract Introduction Burn shock resuscitation fluids should be titrated to achieve a urine output (UOP) of 0.5 to 1 mL/kg/hr. It is unknown whether this UOP goal should be indexed to actual body weight (ABW) or predicted body weight (PBW). The purpose of this study was to evaluate differences related to ABW and PBW-indexed UOP using data from ABRUPT. Methods We queried the database from ABRUPT, which was a multicenter prospective observational study of acute fluid resuscitation practices involving 379 adults treated at 21 burn centers between 4/2017 and 6/2020. Values are presented as the mean ± SD or median (IQR) as appropriate. Results There were 379 subjects (age 46 ± 15.9 yrs, %TBSA burn 31.6 (18), 12.7% with inhalation injury). ABW (N=379) was 90 ± 24.8 kg and PBW (N=375) was 69.5 ± 10.4 kg. ABW exceeded PBW in 84% of subjects. In the 1st 24 h post burn, UOP was 0.87 (0.51) mL/kg ABW/h compared to 1.1 (0.6) mL/kg PBW/h (Figure). Total UOP in the 1st 24 h did not differ between body mass index (BMI) categories. Neither ABW UOP nor PBW UOP was predictive of the decision to initiate 5% albumin (OR and 95% CIs 0.914 [0.754, 1.109] and 0.882 [0.687, 1.133], respectively). We compared subjects with a mean hourly UOP < 0.5 mL/kg/h based on ABW but still > 0.5 mL/kg/h based on PBW (N=61) with subjects whose mean hourly UOP remained > 0.5 mL/kg/h based on ABW (N=283). Subjects whose UOP was < 0.5 mL/kg ABW/h but > 0.5 mL/kg PBW/h were significantly older than subjects whose UOP was > 0.5 mL/kg ABW/h (51.2 [15.6] Vs 44.4 [15.4] yrs, p=0.002), but otherwise we found no significant differences within the 1st 24 hours between these two groups in heart rate, blood pressure, peak lactate, creatinine, total fluids administered, or SOFA score. There were no significant differences in SOFA at 48 and 96 hours, ventilation days, need for dialysis in the 1st 96 hours, or survival. Conclusions ABW in a large majority of the ABRUPT population was greater than PBW. Consequently UOP was numerically lower when indexed to ABW than when indexed to PBW. Patients whose UOP was < 0.5 mL/kg ABW /h but > 0.5 mL/kg PBW/h did not appear to have any worse outcomes than those whose UOP remained > 0.5 mL/kg ABW/h. Applicability of Research to Practice This study generates a hypothesis and a question as to whether titration based on PBW UOP rather than ABW might result in more aggressive titration and administration of less resuscitation fluid, since PBW-indexed UOP ‘looks’ higher. While this can only be answered in a randomized comparison between the two approaches, our study did not identify any adverse outcomes in patients who had a UOP < 0.5 mL/kg ABW/h but > 0.5 mL/kg PBW/h, which might indicate that titration to > 0.5 mL/kg PBW is feasible.

305 Increasing Nursing Burn Care Knowledge Through a Podcast Platform

Abstract Introduction Various educational methods and platforms have been developed to teach burn care such as Advanced Burn Life Support, Fundamentals of Burn Care, e-platforms, and supplementary lectures. However, there are nuances to each burn centers’ practices that general knowledge courses do not address. This study investigates the usefulness of using a burn unit podcast as a platform to provide educational delivery of clinical explanations aimed at improving nursing staff knowledge and understanding of clinical burn care. Methods A seven-episode podcast curriculum was developed at our ABA verified burn center focusing on seven core topic areas: burn evaluation; burn resuscitation; inhalation injury; wound care/pain management; psychology/nutrition; exfoliative/electrical injuries; frostbite. Each podcast ranged from 14-35 minutes led by burn attending moderators. Baseline data was obtained via an 18 question pre-test completed by participants prior to gaining access to the podcast. A post-test was administered after listening to episodes, comprised of different matched questions. Participant feedback survey was also given. A matched pair analysis of pre and post test results was performed utilizing paired t-test to measure significance. Results Over the course of two years, 18 nurses (RN) with varying levels of experience participated in the study. Overall post podcast test score averages significantly improved from 0.77 pre to 0.90 post (P< 0.01). Specific knowledge areas of burn evaluation (0.76 pre, 0.93 post), resuscitation (0.38 pre, 0.88 post), and frostbite (0.69 pre to 0.97 post), were all significantly improved post podcast (p< 0.01). Wound care/pain management (0.88 pre, 0.9 post), psychology/nutrition (0.85 pre, 0.88 post) were not significantly improved. Exfoliative/electrical injuries demonstrated non-significant decrease in scores (0.94 pre, 0.83 post). 93% of RNs strongly agreed that the podcast speaker(s) were knowledgeable and engaged. 86.66% of RNs agreed that the interactive teaching strategy enhanced learning. Additional feedback noted that the podcast was, “entertaining,” “a fun way to learn,” and “a great way to introduce new information.” Conclusions Unit specific podcast can improve burn knowledge while engaging the adult learner. Analysis of results can help educators focus on areas that need further attention and emphasis. Nursing feedback revealed that a flexible method of electronic content delivery engaged and entertained the learner while increasing the effectiveness of knowledge attained. Applicability of Research to Practice Any burn center focused on education for adult learners as an adjunct to traditional means of learning.

562 Therapy Resources for Management of Large TBSA Burns: A Case Study

Abstract Introduction Therapy studies involving large percent TBSA burns ( >50% TBSA) are not well described. Studies show the highest predictor of preventing burn scar contracture is the amount of burn rehabilitation time received per cutaneous functional units involved, but what does “more therapy time” mean for larger burns in terms of therapy resources for burn centers? Methods A case study was completed on a 20-year-old male admitted after sustaining 85% TBSA full thickness flame burns to his face, neck, arms, legs, and trunk, along with an inhalation injury. He was admitted to the inpatient burn ICU for 113 days, undergoing 16 surgeries to achieve skin coverage prior to discharge to acute rehab. Therapy was initiated < 24 hours after admission to the Burn ICU. Direct therapy contact minutes were tracked during all session and divided into therapy treatment domains. (resource). If co-treating occurred, a single unit of time was used for the time of the session to avoid doubling the units provided. Results Therapy occurred on 106/113 days of admission, receiving 238 therapy sessions (113 PT, 125 OT). He received 21,027 minutes of direct therapy, averaging 196.5 min/rehab days. The highest number of therapy minutes were spent on ROM (9,032 min). Other domains of care included Mobilization (3,171 min), Positioning (2,298 min), Orthotic management (1,326 min), etc. (Table 1). Despite focus on ROM and positioning, he discharged with 7 moderate (left wrist extension, bilateral hip abduction, bilateral ankle dorsiflexion, left neck rotation, and left forearm supination) and 4 severe contractures (right wrist extension, bilateral hip extension, neck extension). He was able to transfer with moderate assistance and walk 150 ft with a platform walker at discharge. Conclusions Therapy interventions in the literature are often described in isolated “domains” of practice, however guidelines on a global approach to management of those with catastrophic injuries does not exist. Prioritization between domains with limited therapy resources when facing patients with extensive deficits is challenging. A dedicated burn therapy staff with availability to secure additional resources was required to ensure optimal outcomes in the management of this patient Applicability of Research to Practice This case study demonstrates the comprehensive burden of care and need for additional therapy resources in the management large TBSA burns.

770 Outcome Results of the Prospective CEA Registry

Abstract Introduction Cultured epidermal autograft (CEA) is a permanent skin replacement indicated for use in adult and pediatric patients with deep dermal or full thickness burns comprising a total body surface area (TBSA) ≥ 30%. CEA may be used in conjunction with split-thickness autografts or alone, in patients for whom split-thickness autografts may not be an option due to the severity and extent of their burns. CEA was approved for use in adults in the United States in 2007 as a Humanitarian Use Device (HUD) under a Humanitarian Device Exemption (HDE) and was approved for pediatric use in 2016. Methods The objective of the CEA Registry is to allow prospective collection and analysis of demographic, treatment, and outcome data for the real-world use of CEA. Prior to initiation of the Registry, a central Institutional Review Board reviewed and approved written procedures and informed consent from each participating burn center. As of the date of this analysis, 5 centers were enrolling patients in the Registry. The data are collected and stored in a 21 Code of Federal Regulations (CFR) Part 11 and Health Insurance Portability and Accountability Act (HIPAA) compliant environment. First patient enrollment in the Registry was 13 June 2019 and data cutoff for this analysis was 28 July 2022. Results Sixtyeight patients (50 adults and 18 children) had completed data in the registry, up through hospital discharge, for this analysis. Except for age and revised Baux score, demographics and burn characteristics were similar between the adult and pediatric populations. The majority of patients were male in both the adult (76%) and pediatric (67%) groups, with burn caused by flame the most common etiology (86% and 78%, respectively). The total body surface area (TBSA) of burn was 58% in adults and 56% in pediatric patients (range 30% to 96%), and almost half had inhalation injury in each group. Approximately 74% of adults and 67% of pediatric patients had TBSA ≥50%. Median age in the adult group was 42 years, and in the pediatric group was 15 years. Since age is a component of the calculation of Baux score, pediatric patients had lower mean revised Baux scores (75) compared to adults (107.5). Overall, 59 of the 68 patients (87%) survived until hospital discharge. The mean % graft take (engraftment) in both adult (81%) and pediatric (84%) groups is notable when compared to mean final graft take in 453 Epiceltreated patients reported in the HDE database (67% in adults and 70% in pediatric). By age group, adults had 84% survival rate and pediatric patients had 94% survival. Conclusions Outcomes from this prospective collection of data in severely burned patients treated with CEA demonstrate favorable engraftment and survival rates and are in general agreement with recent literature. Applicability of Research to Practice Reported outcomes from the CEA Registry can be used as a benchmark by centers using CEA for treatment of burns.

60 A Retrospective Review of High-Frequency Percussive Ventilation in Inhalation Injury

Abstract Introduction Inhalation injury (II) is a major contributor to mortality in burn patients. These patients often require mechanical ventilation, but there is no clear consensus on optimal ventilatory strategy for this population. Previous studies in patients with acute respiratory distress syndrome (ARDS) demonstrated that high frequency percussive ventilation (HFPV) improved oxygenation and mobilization of airway secretions. However, HFPV in the context of II remains poorly studied. We hypothesized that for these patients, use of HFPV in addition to conventional mechanical ventilation (CMV) would reduce complications and decrease mortality compared to patients treated with CMV only. Methods We conducted a retrospective chart review of 200 patients admitted to a burn center from February 2008 - January 2019 with burns and/or II and ventilated either with CMV alone or with CMV + HFPV. Patients who were under the age of 18 or who received mechanical ventilation for less one day were excluded. Information including patient demographics and comorbidities, percent total body surface area burned, ventilation method, length of stay, complications, and outcomes were collected. Two-sample comparisons were performed by using score test for proportions and Wilcoxon rank sum test for continuous variables with significance defined as p< 0.05. Results Of 200 patients studied, 84 received CMV + HFPV and 116 received CMV alone. There was no difference in mortality between groups (CMV+HFPV 39.3% vs CMV 31.0%; p=0.23). There was also similar incidence of pneumonia (CMV+HFPV 53.6% vs CMV alone 63.8%; p=0.15), pneumothorax, ARDS, and sepsis. Patients on CMV + HFPV had a greater incidence of acute kidney injury (CMV+HFPV 60.7% versus CMV alone 43.1%; p=0.014) and reduced development of wound complications (CMV+HFPV 7.1% versus CMV alone 16.4%; p=0.05). In surviving patients (n=131), length of hospital stay was not significantly different between groups. Conclusions These single-center results do not support the use of CMV + HFPV rather than CMV alone in patients with II. Further research in this area, including larger multi-center studies, is warranted. Applicability of Research to Practice This is a hypothesis-generating study that adds to the currently limited understanding of best practice for managing patients with II.

718 Estimation of Total Body Surface Area Burns in a Bilateral Above-Knee Amputee Patient

Abstract Introduction The burn injury extension estimate is necessary for the initial IV fluid resuscitation planning, however, current Wallace rule of nines, Lund & Browder charts as well as smartphone applications are based anatomical models with full body integrity. The purpose of this paper is to accurately estimate the TBSA burned in a bilateral asymmetric above-knee amputee patient. Methods An amputation is defined as major amputation when the level is at or proximal ankle or wrist. We present a case example of an 80-year-old patient with a past medical history of long-standing type 2 diabetes mellitus with inadequate metabolic control, left above-knee amputation seven years ago, as well as a contralateral asymmetric above-knee amputation seven months before hospital admission. The patient was brought to the emergency department one hour after suffering burn injuries by fire at his shelter. Upon his arrival inhalational injury was ruled out, and at physical examination second and third-degree burns were noted circumferentially on both above-knee stumps, genitalia, right flank, lower abdomen and back, right hands and forearm, as well as left hand digits (Figure 1A-B). Initial TBSA burned was estimated using the E-burn application yielding a 27% extension; however, this percentage would correspond to patient with full integrity of both lower limbs (Figure 2A) Results This is the first major amputee burned patient of 285 cases admitted for in-hospital treatment at our institution from March 2020 to October 2022. After performing an online search on MEDLINE/Pubmed (keywords: TBSA, estimation, amputated) we found only one published paper in 2020 which presented a Correction Factor (CF) formula for a hypothetical burn patient with bilateral and symmetric fore-quarter amputation. We estimated the amputated surface area (13.7%) with e-burn, to calculate the major amputee CF published in 2020 and test it on a clinical setting. By means of the following formula (Figure 1C): CF = 100 / (100 - % of amputated body part) CF = 100 / (100 – 13.7) CF = 100 / (86.3) = 1.15 Finally, the initial TBSA burnt was multiplied by the CF to adjust it accordingly to major amputations of the patient, as follows: Originally estimated TBSA burnt (27%) x CF (1.15) = 31.05 % (Figure 2B-C) Conclusions This case report serves as an example of the clinical application of the Correction Factor for major amputees burn patients which can be easily estimated with the aid of smartphone applications such as e-burn in mismatched bilateral amputations. Applicability of Research to Practice To our knowledge this is the first clinical application of the major amputee CF, which its simplified estimation by means of E-burn could be of use for burn centers with higher volume.

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.

773 Inhalation Injury Severity Score on Admission Predicts Overall Survival in Burn ICU Patients

Abstract Introduction Inhalation injury (II) is identified in about one-third of burn patients and is associated with increased morbidity and mortality. There are multiple scoring systems to grade II; however, no study has compared ability of these scoring systems to predict outcomes of interest such as overall survival. We hypothesized that II grades from each scoring system assessed would correlate strongly and that higher scores (representing higher grade II) would be associated with worse overall survival (OS). Methods This was a prospective, observational study that included intubated burn patients who underwent fiberoptic bronchoscopy within 24 hours of admission. II was graded using three scoring systems: Abbreviated Injury Score (AIS), Inhalation Injury Severity Score (I-ISS), and Mucosal Score (MS). All scoring systems use a Likert-type scale (AIS: 0-4; I-ISS and MS: 0-3) with more severe IIs given higher scores. Agreement between scoring systems was assessed with Krippendorff’s Alpha (KA) >0.80 indicating high reliability. Multivariable analyses were used to determine variables independently associated with OS. Significance was set at p< 0.05. Results 99 patients were included in the analysis. Median percent total body surface area burned and Injury Severity Score (ISS) were 19.5% (interquartile range [IQR] 9-39%) and 25 (13-34), respectively. At admission, median AIS, I-ISS, and MS scores were 2 (1-3) for all scoring systems. Patients who died had higher overall injury burden than those who survived (Table 1). Additionally, patients who died had similar median admission AIS and MS scores, but higher I-ISS scores than those who survived (Table 1). There was strong correlation between the grade of II at admission using the three scoring systems (KA=0.85). On regression analysis, the only II scoring system independently associated with overall survival was I-ISS (score 3 compared to scores 1-2: OR 13.16, 95% CI 1.65-105.07; p=0.02). Conclusions Grade of II on admission correlated well between scoring systems, but only I-ISS on admission was independently associated with OS. Progression of injury after initial assessment may contribute to the poor correlation between admission score and overall survival for IIs graded with AIS and MS. Repeated assessment and re-grading II after initial resuscitation may more accurately identify patients at increased risk for mortality. Applicability of Research to Practice Grading II is common practice in Burn ICUs. This study demonstrates good reliability between the three most common II scoring systems utilized and that I-ISS on admission can be used to predict risk of mortality, which is useful prognostic information for both burn care providers as well as patients and their families.

37 The Epidemiology of Burn Injury in A Large Southern Geographic Area

Abstract Introduction Given the resource-intense nature of treatment for burn injuries and the knowledge of at-risk populations, a public health approach to reducing individual and societal burden is indicated. To accomplish this, it is critical to understand the regional distribution of these injuries and the risk factors influencing one’s susceptibility to being burned. We hypothesize that there are common sociodemographic trends in burn injuries in a large southern geographic area. Methods Data was retrospectively reviewed for all burn patients admitted between 08/2013 and 12/2021 at a major burn center in a large southern geographic area. Sociodemographic data, burn characteristics and outcomes were analyzed. Patients with isolated inhalation injuries were excluded. One-way ANOVA was used for continuous variables with a P-value < 0.05. Binary logistic regression was used to evaluate independent risk factors for mortality. GIS software mapped injury locations alongside census data to augment statistics with visuospatial analysis. Results 1753 patients were included with an annual incidence rate of 36 per 100,000 person-years. Most were male (68%), Caucasian (60%) and non-Hispanic (67%). The most common etiology was cooking-related (14%), with scald and flame burns collectively making up 80%. Flame burns were significantly larger when compared to scald, electrical and chemical mechanisms (p< 0.05). Those between 19 and 45 years old were the largest age group (40%) with significantly larger burns compared to those 0-18 and 46-64 (p< 0.05), but not those > 65. Non-Hispanic patients had significantly larger burns than their Hispanic counterparts (p< 0.05) but no difference in mortality (p=.306). Patients utilizing Medicare/Medicaid were over three times more likely to die compared to those with commercial insurance. Conclusions In this cohort, male patients are injured at higher rates, however, they do not have more severe burns. The larger burns are distributed in a bimodal fashion between those 19-45 and those > 65, with hispanic ethnicity protective against larger burn injuries. This suggests separate mechanisms mediating larger burns in these two groups, and warrants further investigation. Insurance type, a surrogate for socioeconomic status (SES), is not associated with TBSA or LOS, however it does confer an increase in mortality in those with Medicare/Medicaid. GIS mapping verifies neighborhoods concentrated in more urban areas with lower median household incomes have higher injury rates. This highlights populations worth targeting for injury prevention, namely those between 19 and 45 of lower SES, particularly in the setting of cooking and food preparation. Applicability of Research to Practice Understanding regional trends in burn injury can target prevention efforts and identify at risk populations where further resources might be best allocated to ease the burden of burn injury.

782 The Effect of Medical Comorbidites on Mortality in Burn Patients

Abstract Introduction Age, percent total burn surface area (TBSA) burn, and presence of inhalation injury have been well accepted as prognostic factors associated with burn injury. However, there may be additional comorbidities that affect mortality to consider. Recently published data include comorbidities specifically in the elderly population or focus on a specific comorbidity. As such, this analysis sought to identify comorbidities with a more comprehensive approach while focusing on the adult population. Methods The National Inpatient Sample was queried for all patients with age 18-65 years with ICD-9 codes for total body surface area (TBSA) burn ≥ 20% and non-elective admissions. Years included were 2013- third quarter of 2015. Age, race, comorbidities and mortality were recorded. Cases with missing data for mortality were excluded. Statistical analysis was done with Chi-Square testing. Mortality was then used to perform a binary logistic regression using these variables. Results There were 5545 weighted cases. The median age was 41.0 years (IQR 29-52 years). Mortality was 14.7%. The presence of AIDS, chronic blood loss anemia, chronic pulmonary disease, congestive heart failure, peptic ulcer disease (excluding bleeding), peripheral vascular disease, renal failure, rheumatoid arthritis/collagen vascular disease, and solid tumor without metastasis were not found to be statistically significant. The significant variables were then entered into a binary regression model on mortality. For the regression analysis, age, gender and race were also included. Age and race were statistically significant (p < 0.001 for both), while gender was not (p=0.072). While significant on univariate analysis, alcohol abuse (p=0.059), diabetes with chronic complications (p=0.244), metastatic cancer (p=0.999), psychoses (p=0.053) and valvular disease (p=0.998) were no longer significant on multivariate analysis. The results of the significant comorbidities are listed in the table. In those who died, there were increased odds of having coagulopathy, uncomplicated diabetes, liver disease, paralysis, pulmonary circulation disorders and obesity. Conclusions Identification of these significant comorbidities potentially highlights the need for updated models to assist clinicians in determining risk of mortality in burn patients. Theses comorbidities also point to the importance of resources for primary care physicians to optimize these patient populations and potentially minimize the risk of complications should patients become injured. Applicability of Research to Practice

779 Utilization of Palliative Care in Patients Succumbing to Primary Burn Injury

Abstract Introduction Burn injury is associated with significant morbidity and mortality. Access to palliative care (PC) is variable, and many patients who die after burns do not receive specialized PC consultation. We conducted a retrospective nation-wide study of patients admitted with a primary diagnosis of burn injury who died prior to hospital discharge to identify factors associated with receiving palliative care. Methods Data from the HCUP National Inpatient Sample (2016-2019) were queried to identify inpatient deaths among adults ≥18 admitted with a primary ICD-10 burn diagnosis. Differences in demographic and clinical characteristics were assessed between patients who did and did not receive PC using chi-square tests and multivariable Poisson regression on data weighted to represent the national population. Baux scores were calculated by adding age and percentage of body burnt based upon ICD-10 code categorizations; a revised Baux score was calculated for inhalation injury. Results Of 98,845 patients admitted to inpatient care from 2016 to 2019 with a primary burn diagnosis, 3250 (3.3%) died prior to discharge. 1390 (42.8%) of patients who died had a PC encounter. Patients who did not receive PC were younger (mean 58.7 vs. 63.9, p=0.0002), had lower Baux scores (mean 104.6 vs. 112.4, p=0.002) and a longer length of stay (LOS) (mean 19.3 vs. 13.3, p=0.008). Controlling for age, sex, Baux score and LOS, White patients had a 35% greater likelihood of receiving PC than Black patients (incidence rate ratio, IRR 1.35, 0.95 CI (1.02,1.79)). All else held constant, patients aged 70-79 had the greatest likelihood (68%, IRR 1.68, 0.95 CI (1.31,2.15)) of receiving PC versus patients < 60 years old. Urban teaching hospitals had the highest percentage of burn patients (92.7% vs. 5.2% non-teaching vs. 2.1% rural) and the highest rate of providing PC (43% vs. 30% non-teaching vs. 20% rural, p=0.446) to patients that died. Insurance type (Medicare, Medicaid, Private, and other) did not correlate with receiving PC (p=0.054). The number of diagnoses, procedures and gender did not differ between deceased patients who did and did not receive PC. Conclusions More than half of burn patients who died prior to discharge did not receive a palliative care consultation. Unsurprisingly, older patients were more likely to receive PC. Patients who did not receive PC were more likely to have been younger, Black, have had lower Baux scores or to have been treated in non-urban non-teaching hospitals. The high Baux score of the younger patients (104.6) is associated with significant risk of death; this population might benefit from PC consultation. The discrepancy between White and Black patients in the delivery of PC services is striking. Further study is necessary to identify not only those burn patients most likely to benefit from PC but also the barriers to receiving palliative care in burn injury. Applicability of Research to Practice Demonstrates the inconsistency of palliative care use in the burn population