Burn Injury Mortality Research Articles

The measured effect magnitude of co-morbidities on burn injury mortality

IntroductionThe ability to better prognosticate burn injury outcome is challenging and historically, most center use the Baux or revised Baux score to help prognosticate burn outcome, however, the weighted contribution of comorbidity on burn mortality has traditionally not been accounted for nor adequately studied. We therefore sought to determine the effect of comorbidities, using the Charlson comorbidity index (CCI) on burn mortality. MethodsThe purpose of this study was to determine the effect of comorbidities on burn injury mortality as determined by the LA50 (lethal TBSA burn at which 50% of the cohort will succumb from the burn injury) in a retrospective analysis of patients admitted to a regional burn center from 2002 to 2012. Independent variables analyzed included basic demographics, burn mechanism, presence of inhalation injury, TBSA (total body surface area), length of hospital stay, and pre-existing comorbidities. Bivariate analysis was performed and logistic regression modeling using significant variables was utilized to estimate odds of death. Results7640 patients were included in this study. Overall survival rate was 96%. 40% of our burn cohort had at least one comorbidity. There was a linear increase in the likelihood of death with an increase in CCI. The logistic regression model for mortality outcomes identified four statistically significant variables: age, TBSA, inhalational injury and the presence of comorbidities (OR=1.59 for each 1 point increase in CCI; 95% CI 1.44–1.77). The unadjusted LA50 was 53% for the entire cohort. Partial adjustment multivariate regression controlling for burn mechanism and inhalation injury only, produced a slight reduction in LA50 for the 0–18 and 19–64 age categories to 76% and 48% TBSA, respectively, but a significant decrease occurred in the ≥65 years age group with a reduced LA50 to 20% TBSA (p<0.001). After full adjustment for all significant covariates, including comorbidities, the independent magnitude of effect of comorbidities on the LA50 was evident in the <65 cohort. The full adjustment showed a LA50 decreased to 61% and 43% TBSA, respectively in the 0–18 and >18–65 age groups respectively (p<0.001), however, in the >65 years age cohort there was no change in the LA50. ConclusionPreexisting comorbidities have a significant effect on burn injury mortality in all age groups, particularly the younger burn population. The measured effect of comorbidities in the >65 yr age cohort was mitigated by the co-linearity between age and comorbidities. The inclusion of CCI is imperative so as to better prognosticate burn outcome and help guide expectations and resource utilization, particularly in the younger burn cohort.

The measured effect magnitude of co-morbidities on burn injury mortality

The measured effect magnitude of co-morbidities on burn injury mortality

Initial Assessment and Management of Thermal Burn Injuries in Children

1. Ramin Jamshidi, MD* 2. Thomas T. Sato, MD† 1. *The Pediatric Surgeons of Phoenix, Phoenix, AZ. 2. †Division of Pediatric Surgery, Children’s Specialty Group, Children’s Hospital of Wisconsin, and The Medical College of Wisconsin, Milwaukee, WI. Burns are a frequent cause of injury in children and adolescents. Clinicians should be familiar with initial assessment and management of burns and be capable of identifying burn injuries appropriate for referral to a regional burn center. After reading this article, readers should be able to: 1. List 3 types of burn injuries. 2. Describe the initial evaluation of a burned child in terms of burn depth, size, and associated injuries or medical conditions. 3. Describe appropriate burns for outpatient management. 4. Estimate initial fluid resuscitation requirements for the first 24 hours in children with large (>25% total body surface area) partial-thickness burns. 5. Describe 2 methods of dressing management for a 5% total body surface area partial-thickness burn. 6. Recognize indications for transfer of a burned child to a regional burn center. Death from fires and burn injuries is the third leading cause of fatal home injury and the third leading cause of unintentional death in children younger than 14 years in the United States. (1) In 2009, the Centers for Disease Control and Prevention estimated 437 deaths and 120,761 nonfatal burn injuries in children age 0 to 19 years. (2) Although hospitalization rates for children with burns appear to be decreasing in the past decade, annual cost estimates of approximately 10,000 inpatient hospitalizations for pediatric burn care exceeded $211 million in 2000. (3) Although it is difficult to estimate the global incidence rate, morbidity, and mortality of burn injuries, it is clear that burns are a major cause of injury in both developed and developing countries. (4) Burns are one of the most physiologically and psychologically stressful injuries that occur in children and adults. Given the …

Norepinephrine Inhibits Macrophage Migration by Decreasing CCR2 Expression

Increased incidences of infectious and septic complications during post-burn courses represent the main contributor to burn injury mortality. Sustained increases in catecholamine levels, especially norepinephrine (NE), contribute to immune disturbances in severely burned patients. The precise mechanisms underlying NE-mediated immunoregulation are not fully understood. Here we hypothesize that persistently elevated NE levels are associated with immunodysfunctions. We examined the effects of NE on the phenotype and functions of bone marrow-derived macrophages (BMMs). Whole mouse bone marrow cells were treated in vitro with 40 ng/mL of M-CSF and with 1 x 10-6 M or 1 x 10-8 M of NE or without NE for 7 days; cells were collected and stained with antibodies for CD11b, F4/80, MHC II and the inflammatory CC chemokine receptor 2 (CCR2). We found 1 x 10-6 M of NE inhibited MHC II and CCR2 expression on CD11b+/F4/80+ BMM cells. It also inhibited BMM proliferation by inhibiting CSF-1R expression. On the contrary, 1 x 10-8 M of NE slightly increased both MHC II and CCR2 expression on CD11b+/F4/80+ BMM cells but inhibited CD11b+/F4/80+ BMM proliferation. MCP-1 based migration assay showed that the migration of 1 x 10-6 M of NE-treated BMM toward MCP-1 was significantly decreased compared to BMM without NE treatment. Both 1 x 10-8 M and 1 x 10-6 M of NE enhanced TNF-α production and phagocytosis of FITC-Dextran. Intracellular staining of transcriptional factor MafB showed that 1 x 10-6 M of NE treatment enhanced its expression, whereas 1 x 10-8 M of NE decreased expression. Stimulation with LPS in the last 24-hours of BMM culture further decreased CCR2 and MHC II expression of these BMM, suggesting the synergistic effect of LPS and NE on macrophage. Our results demonstrate that NE regulates macrophage differentiation, proliferation and function, and may play a critical role in the dysfunctional immune response post-burn.

A Half-Century of Burn Epidemiology and Burn Care in a Rural State

The aim of this study is to quantify the changes in incidence, severity, and mortality in burn injuries in the state of Maine over the past 50 years from both prevention and treatment perspectives. The authors analyzed the data from multiple sources, including the U.S. Census, death certificates, hospital discharge abstracts, and institutional burn registries in Maine and Boston. The average annual number of burn-related deaths decreased from 53 in 1960-1964 to 14 in 2004-2008. The Maine age-adjusted rate of burn deaths was 8.6% above the national rate in 1960 and 1.4% below it in 2006. The annual number of burn patients admitted to Maine hospitals declined by 65% from 1978 to 2009. Since 1999, 12% of hospitalized patients in Maine were treated in an American Burn Association-certified burn center in Boston. Mortality for Maine burn patients, including those treated at Boston hospitals, is directly related to age and burn severity and similar to stratified mortality in the National Burn Repository. Incidence, severity, and mortality of burn injuries in Maine have decreased dramatically over the past 5 decades. Prevention programs, legislation, and a regionalized system of burn care have all likely contributed to bringing Maine's morbidity and mortality rate below the national average.

Incidence and mortality of burn injuries in Sulaymaniyah, Iraq

BackgroundLittle is known about burns in Iraq. This study was undertaken to investigate epidemiology of burn injuries in Sulaymaniyah province with 1.7 million people.MethodsA prospective study from November 2007 to...

Inhalation burn injury in children

With advances in burn care, many children are surviving severe burn injuries. Inhalation injury remains a predictor of morbidity and mortality in burn injury. Inhalation of smoke and toxic gases leads to pulmonary complications, including airway obstruction from bronchial casts, pulmonary edema, decreased pulmonary compliance, and ventilation-perfusion mismatch, as well as systemic toxicity from carbon monoxide poisoning and cyanide toxicity. The diagnosis of inhalation injury is suggested by the history and physical exam and can be confirmed by bronchoscopy. Management consists of supportive measures, pulmonary toilet, treatment of pulmonary infection and ventilatory support as needed. This review details the pathophysiology, diagnosis, and management options for inhalation injury.

Burn injuries in Enugu, Nigeria

Background: Burn injury has been observed as a world wide problem.. The knowledge of the epidemiology is important for planning of management and preventive programmes and every community is encouraged to study the epidemiology of burns since this important problem varies from community to community. Method: This is a retrospective review of all our burn patients who presented with acute burn injuries between January 1993 and December 1997. Admission registers and patients' folders were the sources of information. The information obtained include age, sex, place of injury, month of injury, cause of injury, management and outcome. Results: A total of 285 patients with acute burn injuries were studied. Males were 180 [63.2%] while females were 101 [35.4%]. Flame was the single most common cause of burn injury [147 or 49.1%] while electrical burns was less frequent [4 or 1.4%]. Majority of burn injuries occurred in the months of December and January. The mortality rate was 23.2%. Conclusion: The incidence and mortality of burn injury has remained high in this environment. We suggest a well targeted prevention campaign program to reduce this high incidence and high mortality in this environment. Keywords: burn injuries, epidemiology, flame mortality, December/ January Nigerian Journal of Surgical Research Vol. 7(3&4) 2005: 271-273

The vulnerabilities of age: burns in children and older adults

Both children and older adults are thought to sustain burns serious enough to warrant hospitalization disproportionately more often than other age groups, but the incidence, injury characteristics, and outcome have not been precisely defined. Patients hospitalized with a burn diagnosis were identified from hospital discharge data from California, Florida, New Jersey, and New York for the 5-year period 2000-2004. In those states, 60,024 residents were hospitalized with a diagnosis of burn and/or inhalation injury according to the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Using population data from the United States Census 2000, we found that the average annual incidence of hospitalization with a burn diagnosis in these 4 states was 155 per million (per M) (95% confidence interval,153-158). There were 13,453 children under 15 years of age: incidence, 163 per M (range, 157-169). Of these 9508 (70%) were under 5 years of age: incidence, 363 per M (range, 347-379). In contrast, there were 10,686 patients 65 years of age or older: incidence, 214 per M (range, 205-224), of whom 2091 were at least 85 years old: incidence, 347 per M (range, 314-380). The incidence of hospitalization with a burn diagnosis for patients 15 to 64 years of age was 141 per M (range, 138-145). Compared with children younger than 15 years, patients aged 65 years and older more often had flame burns (odds ratio [OR], 2.12), burns of 20% or more of body surface area (OR, 2.41), inhalation injury (OR, 2.88), respiratory failure (OR, 4.48), and death (OR, 16.53), all P < .0001. Older individuals are the most vulnerable to the morbidity and mortality of burn injury. Prevention strategies targeted to those older than 65 years should be developed.

Mortality in Burn Injury Related to Medical Comorbidities

Mortality in Burn Injury Related to Medical Comorbidities

Increased Risk of Mortality in Burn Injuries Among Children Under Four Years Old: Evidence from the American Burn Association National Burn Repository

Several studies have found that age less then 48 months is a risk factor for mortality subsequent to thermal injury, whereas other studies have found no difference compared to older children. All of these studies were conducted with relatively small samples from single burn centers. The objective of this study was to assess the risk of mortality associated with age less than 48 months in a large, representative sample of children from the ABA National Burn Repository database. Data was obtained from 13,815 children under the age of 16 (213 deaths, 1.5%) admitted with thermal injuries to over 40 burn centers in the United States from 1992 to 2002. The sample was 64.2% male with a mean age of 4.9 years (range 0–15.9), and a mean TBSA of 11.3% (range 0–100). Unadjusted mortality odds ratios were calculated for children under the age of 48 months as compared to children ages...

Burn Injury Exacerbates Hemodynamic and Metabolic Responses in Rats with Polymicrobial Sepsis

The most common and life-threatening complication of severe burn injury is infection, which often results in multiple organ failure (MOF). However, the mechanism of development of MOF after burn injury associated with infection is not fully understood. Our previous studies showed that when polymorphonuclear neutrophils (PMNs) are depleted, burn injury-induced increase in microvascular permeability to albumin is markedly attenuated. Thus, we hypothesized that the combination of burn injury and polymicrobial infection exacerbates PMN activation, increases intestinal microvascular permeability to albumin, and alters hemodynamics and metabolism more than burn injury or infection alone. Sprague-Dawley rats (250-275 g) were divided into four groups. In the burn group, rats were subjected to a 30% TBSA burn injury. In the cecal-ligation puncture (CLP) group, CLP was performed using a 22-gauge needle with one puncture. In burn+CLP group, rats were subjected to CLP immediately after burn procedure. In sham group, rats were subjected to sham procedures. Transient polymicrobial bacteremia and persistent polymicrobial bacteremia were induced in the CLP group and burn+CLP group, respectively. Microvascular permeability, myeloperoxidase, and PMN production of elastase and reactive oxygen species increased in the burn group and CLP group and further increased in the burn+CLP group. Hemodunamic and metabolic alterations on day 1 and 3 after injury correlated with those alterations. Although there was only a low mortality in the burn group and CLP group, there was a high mortality in burn+CLP group (79%). The mechanism of MOF that leads to high mortality in burn injury complicated by infection may involve uncontrolled microvascular damage mediated by PMN activation.

Burns and smoke inhalation

The mortality of burn injury has decreased over the past 20 years thanks to effective resuscitation and early surgical intervention. Burn severity is classified according to depth of tissue injury, total body surface area affected and the presence or absence of an inhalation injury. These data are used to calculate the patient’s fluid resuscitation requirements. Acute treatment of the burn patient aims to limit extension of the tissue injury and prevent end-organ damage. Following the acute phase treatment of the burn patient, intensive care priorities include nutritional support of the hypercatabolic patient, pain control and early recognition and treatment of sepsis. The patient also requires multiple surgical interventions to debride, graft and dress the burn wounds. Inhalation injury is associated with an increased mortality in burn patients. Diagnosis relies on a combination of clinical suspicion coupled with bronchoscopic evidence of injury to the bronchial tree. Inhalation injury is subdivided into direct thermal injury to the airway, usually seen above the glottis, and chemical tracheobronchitis below the airway, resulting from inhalation of the incomplete products of combustion. Inhalation injury can be complicated by carbon monoxide and cyanide poisoning.

A retrospective analysis of 19,157 burns patients: 18-year experience from Hallym Burn Center in Seoul, Korea

This is a retrospective, epidemiological study of 19,157 acute burn patients admitted to the Hallym Burn Centre, Hangang Sacred Heart Hospital, Seoul, Korea, during the period 1986–2003. The study was conducted to identify characteristics of burn patients that could lead to development of preventive programs to reduce both the frequency and mortality of burn injury. The majority of patients admitted had relatively minor burns, which were treated conservatively. Males predominated in all age groups with a summer peak seasonal variation. Typical burn in the children <5 years of age was a scald injury, occurring at home, affecting upper limbs and resulting in a relatively short hospital stay. Electrical burns due to steel chopsticks and steam burns due to electric rice cookers were also found in this age group. Adult burns, affecting upper and lower limbs, were caused by flames, hot liquids or electricity. Burns were sustained at the workplace and outdoors. Flame accidents in males were the leading cause of death with overall mortality of 8.2%. 13.9% of admissions needed intensive care and average length of hospital stay was 32.6 days. The annual number of patients undergoing burn related surgery has continuously increased reflecting a more aggressive surgical management. Our ongoing efforts are to promote prevention program and look for changes in the incidence of burn injury based on these epidemiologic features. Further study for implications of changes in management protocols and policies on treatment outcomes would improve the provision of appropriate care for the patients.

Notfallmanagement bei der Prim�rversorgung kindlicher Verbrennungen

In den vergangenen Jahren konnte die Mortalitat schwerstbrandverletzter Kinder durch eine Verbesserung des intensivmedizinischen Managements erheblich reduziert werden. Gleichzeitig wurde durch die Optimierung der lokalen Wundbehandlung und der chirurgischen Transplantationstechnik das kosmetische und funktionelle Outcome deutlich verbessert. Der Erfolg der Behandlung brandverletzter Kinder hangt aber nicht zuletzt auch von der richtigen Primarversorgung ab. Diesbezuglich werteten wir 80 brandverletzte Intensivpatienten unserer Klinik der vergangenen vier Jahre aus. Die haufigsten Fehlerquellen bei der Erstversorgung von brandverletzten Kindern liegen in der Unterkuhlung durch fehlerhafte Wundversorgung und zu lange Wundkuhlung, fehlende Analgosedierung bis hin zu fehlerhaftem Infusionsregime durch Fehleinschatzung der verbrannten Korperoberflache. Glucklicherweise enden diese Fehlbehandlungen nur selten letal und konnen durch eine enge Zusammenarbeit zwischen dem Intensiv-Padiater und Kinderchirurgen korrigiert werden. Dennoch veranlassen gerade Einzelfalle von Missmanagement ein Uberdenken der bisherigen Vorgehensweise, um eine Qualitatsverbesserung bei der Erstversorgung von kindlichen Verbrennungen zu erreichen. Daher hat der Arbeitskreis “Das schwerbrandverletzte Kind” die Therapieempfehlungen fur die notarztliche Primarversorgung von Brandverletzten mit speziellen Empfehlungen fur die Versorgung von Kindern erganzt.

Pathophysiology of acute lung injury in combined burn and smoke inhalation injury.

In the U.S.A., more than 1 million burn injuries occur every year. Although the survival from burn injury has increased in recent years with the development of effective fluid resuscitation management and early surgical excision of burned tissue, the mortality of burn injury is still high. In these fire victims, progressive pulmonary failure and cardiovascular dysfunction are important determinants of morbidity and mortality. The morbidity and mortality increases when burn injury is associated with smoke inhalation. In the present review, we will describe the pathophysiological aspects of acute lung injury induced by combined burn and smoke inhalation and examine various therapeutic approaches.

Application of extracorporeal membrane oxygenation in adult burn patients.

Adult respiratory distress syndrome (ARDS) has been the major cause of mortality in burn injury. The authors reported the experience of using extracorporeal membrane oxygenation (ECMO) to treat adult burn patient with ARDS. Three patients with burn or electric injury, around 48.9% of body surface area over second-degree burns, developed ARDS after resuscitation. All had positive blood culture and depended on a ventilator more than 5 days before ECMO. Venovenous (VV) ECMO was started at the beginning of severe respiratory failure with an oxygen index of 61.6 +/- 15.5 cm H2O/mm Hg (> or =40 cm H2O/mm Hg), partial arterial oxygen tension to inspired oxygen fraction (Pa(O2)/Fi(O2)) of 46.1 +/- 7.0 mm Hg (< or =200 mm Hg), positive end expiratory pressure (PEEP) of 15.7 +/- 1.6 cm H2O (> or =10 cm H2O), alveolar-arterial difference in oxygen concentration (A-a D(O2)) of 618.9 +/- 19.3 mm Hg (> or =300 mm Hg), and lung compliance of 17.3 +/- 4.6 ml/cm H2O (< or =30 ml/cm H2O). The VV type had to be converted to the newly designed veno-venoarterial (V-VA) ECMO due to the myocardial dysfunction. Two of three patients survived. The duration of ECMO was 160.2 +/- 51.1 h. Two patients received debridement of escar during ECMO support and desmopressin infusion, and no increased bleeding or coagulopathy was found. The respiratory parameters were significantly improved after ECMO, especially in the survivors. ECMO is also suitable for ARDS in adult burn injury.

The establishment of a burns unit in a developing country – a collaborative venture in Malawi

In September 1993, the recently completed 32-bedded Burns Unit in the Queen Elizabeth Central Hospital, Blantyre, Malawi, was officially opened. This represented the culmination of 3 years’ planning and construction; this paper presents our experience in developing this type of project, and an analysis of the early results of treatment in the unit. The widespread neglect of this common injury in developing countries is highlighted and the importance of input from specialists in this field working in collaboration with local medical and nursing staff is emphasised. The potential for making a significant impact in reducing the morbidity and mortality in burn injuries is highlighted.

Inhalation injury in children: nursing care.

Inhalation injury is a leading cause of morbidity and mortality in burn injury in all age groups. The injury may occur alone or in combination with surface bums or other trauma. Exposure to fire conditions produces violent response in the respiratory system. This paper focuses on the incidence and pathophysiology of inhalation injury in children. The nursing care at the scene, in the emergency department, and in the intensive care unit are presented in depth. The ICU aspect is discussed in the form of a nursing standard. Long-term complications are also considered.The nursing care of these children is complex. It can be viewed as both a science and an art.

Mortality of Burn Injuries in Jordan

Mortality of Burn Injuries in Jordan