Pediatric Burn Center Research Articles

Pediatric Burn Care for Burn Injury: Outcomes by Timing of Referral Using a U.S. Single-Center Retrospective Cohort, 2005-2019.

Burn centers offer specialized care to pediatric patients with burn injuries. However, data about outcome in relation to timing of transfer are limited. We examined these timings and outcomes among burn-injured pediatric patients. Single-center, retrospective cohort study of U.S. national and international practice. Shriners ESO Trauma Burn Registry, 2005-2019. Patients 0-17 years old admitted to a pediatric burn center with 10-80% total body surface area (TBSA) burn between 2005 and 2019. None. The cohort of 761 patients was subcategorized according to timing of referral: early presentation (EP) (0-7 d), delayed presentation (DP) (8-60 d), and very delayed presentation (VDP) (> 60 d). Primary outcomes included hospital length of stay (LOS), ICU LOS, percent TBSA (%TBSA)/LOS ratio, mortality, and disposition. Dichotomous outcomes were analyzed using logistic regression and continuous outcomes were compared using median regression, both utilizing multivariable analysis adjusting for a priori confounders and presented as adjusted coefficients (ACs) with 95% CI. Delayed referral (DP and VDP) was associated with higher %TBSA burn and with fewer referrals from high-income countries. Compared with EP, VDP was associated with higher LOS/%TBSA (AC, 0.2 [0.01-0.4]). On univariate analysis, in comparison with EP, DP and VDP were associated with higher ICU (DP 16 [6-29]; VDP 8 [0-18]) and hospital LOS (DP 34 [21-55]; VDP 32 [18-58]). Overall, ten of 761 patients died (1.3%), and we found no association between timing of referral and mortality. Also, in 751 survivors, 635 patients (84.6%) were discharged home without home health, and we found no association with timing of referral on multivariable analysis. In this report, we have reviewed our single-center, international burn-injured pediatric cohort, operating in the United States (2005-2019). We find that referral with VDP as opposed to EP was associated with increased LOS/%TBSA.

Utility of the Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) in Pediatric Stevens-Johnson Syndrome Patients.

The Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) is a system that predicts in-hospital mortality for Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN). The system is widely utilized in adults but not pediatrics. We aim to determine the accuracy of the SCORTEN in pediatrics. A retrospective review of pediatric patients admitted to a verified pediatric burn center with SJS/TEN from 2008 to 2022 was performed. Twenty-four patients were analyzed. Ten patients had 0-1 SCORTEN risk factor, thirteen had 2 risk factors, and one had three risk factors. There was no relationship between initial BUN, bicarbonate, glucose, or initial heart rate on the length of intensive care unit (ICU) stay or ventilator days. Hospital length of stay and feeding tube days were positively related (p<0.001) along with length of stay and maximum total body surface areas (TBSA) (p<0.05 Hospital length of stay, ICU length of stay, and ventilator days were not statistically significant between those having 0-1 and 2 risk factors. This study suggests that the SCORTEN system is not useful for pediatrics and a different scoring system is needed, as SCORTEN overestimates mortality and does not have a relationship to outcome measures.

547 ADHD and Burn Injuries: The Hidden Readmission Risk in Pediatric Patients

Abstract Introduction Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with the hallmark characteristics of poor impulse control, inattention, hyperactivity, and other cognitive dysfunction; as a consequence, children with ADHD are at an increased risk of burn injury. We hypothesized that pediatric burn patients with ADHD have a higher rate of unplanned readmission compared to patients without a diagnosis of ADHD. Methods We analyzed the Nationwide Readmission Database (01/2018 - 10/2018) to compare 60-days readmission rates in children (&amp;lt; 18 yo) with and without a diagnosis of ADHD who were treated for burn injuries on their index admission. Weighted multiple logistic regression was performed to obtain population estimates of odds ratios (OR), adjusting for patients’ demographics, burn severity and location, comorbidities, socioeconomic status, other psychiatric illnesses, and burn treatment on index admission. Results Our cohort included 1,879 children with burn injury. Of these, 79 (4.2%) had a diagnosis of ADHD. ADHD patients were more likely to be male (86.1% vs 59.8%, p=0.0002 ) and older (11.6 ± 3.7 vs 5.4 ± 5.3 years, p=0.0001). Children with ADHD were more likely to have other psychiatric diagnoses (26.6% vs 3.8%), specifically obsessive compulsive disorder (2.5% vs 0%, p=0.004), and other developmental disorders (15.2% vs 1.6%, p=0.0002). Patients with ADHD were more likely to be readmitted within 60 days of their index admission (15.2% vs. 4.8%, p=0.002). On weighted multiple regression analysis, ADHD had a higher adjusted odds ratio of readmission (OR: 2.66, 95%CI: 1.13-6.29). Conclusions Children with ADHD have a higher adjusted risk of readmission following thermal injury. This is potentially due to higher barriers to compliance with wound care, physical therapy, and scar management. Targeted discharge planning for patients with ADHD, including scheduled short-term follow-up appointments, home nursing assistance, and post-discharge phone calls, may potentially lower readmission risks in this vulnerable population. Applicability of Research to Practice Pediatric patients with ADHD are at higher than average risk for unplanned readmission within 60 days of discharge. Pediatric burn centers have the opportunity to adjust their post-discharge practice with these high-risk patients to decrease this risk. Interventions could include: more frequent clinic follow-up, longer duration with outpatient therapy, and additional coaching for caretakers on how to improve patient compliance.

Critical Care of the Pediatric Burn Patient.

Life-saving pediatric burn care is often initiated in hospitals that are not designated as a pediatric burn center. Therefore, familiarity with critical care of pediatric burn patients is crucial for physicians working in all healthcare settings equipped to care for children. Management of airway, mechanical ventilation, preservation of ideal circulatory status, and establishment of vascular access in pediatric burn patients requires many unique considerations. This article aims to summarize important principles of critical care of children with significant burn injuries for review by physicians and surgeons working in hospitals designated as a pediatric burn center and those that stabilize these patients prior to referral.

Initial Pediatric Burn Management: A Practical Guide.

Children have an imperative to explore their environment to grow and develop, which puts them at risk for sustaining burn injury. Burn injury remains the third leading cause of injury-related death worldwide. Plastic surgeons, as experts in the evaluation and management of cutaneous injuries, are frequently called upon to evaluate and treat children with burn injuries. This article focuses on the unique physiologic aspects of children and how they impact initial evaluation and management of burn injury. Children are not "little adults," and they have different airway, circulatory, and cutaneous systems. Understanding the signs of potential child abuse is important to avoid further child harm. Finally, recognition of the criteria for referral to a pediatric burn center is important to optimize both short- and long-term outcomes for patients and families.

Management of Outpatient Pediatric Burns at a Pediatric Burn Center.

Burn injuries are a serious emergency. Most burn injuries in children can be treated as outpatients. The aim of this study was to present the clinical and epidemiologic characteristics of pediatric burn injuries treated in our outpatient burn clinic. This study included pediatric patients treated in an outpatient burn clinic over an 8-year period. The demographic and clinical characteristics of the patients were retrospectively analyzed. The patients were divided into 4 groups according to their age groups, and the differences between the groups were investigated. Statistical analysis was performed using IBM SPSS Statistics, Version 25.0. P < .05 was accepted as statistically significant. Of the total 5167 patients, 2811 (54.4%) were male. Scald burns were the most common cause of burns (81.4%). Contact burns accounted for 12.2% of all burns. There were no differences between sexes for any variable. The highest incidence was seen in children in the 2- to 5-year-old age group (28.3%). There were differences between age groups in terms of sex, burn area, burn visit, burn type, burn location, need for wound dressing under anesthesia, and need for grafting. Among the patients, 4.9% were hospitalized due to the need for wound dressing under anesthesia. However, most of the patients (95.1%) were treated as outpatients. In conclusion, the majority of pediatric burn patients can be treated as outpatients. This allows pediatric patients to complete treatment in a psychologically comfortable environment and has low complication rates. Outpatient treatment should become the standard for children who are suitable for outpatient follow-up and who have home support.

Age and Sex Differences of Virtual Reality Pain Alleviation Therapeutic During Pediatric Burn Care: A Randomized Clinical Trial.

Virtual reality (VR) effectively alleviates pain for pediatric patients during many medical procedures, such as venipuncture and burn care. In our previously published randomized clinical trial among 90 pediatric burn patients, participants in the active VR group had significantly lower scores for overall pain compared with participants in the standard care control and for worst pain compared with participants in the passive VR and control group. However, whether VR differs by a patient's age or sex remains unresolved. Thus, we reanalyzed our data by comparing the active and passive VR participants to evaluate how age and sex affect VR pain alleviation during dressing care for pediatric burns. In total, 90 patients aged 6-17 years (inclusive) with burn injuries were recruited from an outpatient burn clinic of an American Burn Association-verified pediatric burn center. Before randomization, VR helpfulness and need expectations were assessed on a visual analog scale (0-100). Participants were randomly assigned to active VR, passive VR, or control for one dressing change. Immediately following the dressing change, active and passive VR participants self-reported pain and the time spent thinking about pain and rated the VR features on the degree of realism, pleasure/fun, and perceived engagement level. Path analyses assessed how these VR features were interrelated and how they affected self-reported pain by age and sex. Patients aged 6-9 years reported higher mean expectations of VR helpfulness and need (mean = 73.6 and 94.5, respectively) than 10-12-year-olds (mean = 55.7 and 84.2, respectively) and 13-17-year-olds (mean = 68.6 and 77.4, respectively). The path analysis indicated VR engagement and fun were significantly correlated (p-value < 0.05). VR engagement significantly negatively impacted overall pain scores (coefficient = -0.45, -0.41; p-value < 0.05) and significantly positively impacted time thinking of pain (coefficient = 0.38, 0.32; p-value < 0.05). Younger patients had the highest expectations of VR helpfulness and need. VR game realism, fun, and engagement features were not statistically different between age groups and sexes. VR engagement and thinking of pain during burn dressing significantly positively affected self-reported pain (p-value < 0.05), suggesting an analgesic mechanism beyond distraction alone. Younger patients benefited more from VR than older patients.

Features of virtual reality impact effectiveness of VR pain alleviation therapeutics in pediatric burn patients: A randomized clinical trial.

Key features of virtual reality (VR) that impact the effectiveness of pain reduction remain unknown. We hypothesized that specific features of the VR experience significantly impact VR's effectiveness in reducing pain during pediatric burn dressing care. Our randomized controlled trial included children 6 to 17 years (inclusive) who were treated in the outpatient clinic of an American Burn Association-verified pediatric burn center. Participants were randomly assigned (1:1:1) to active VR (playing the VR), passive VR (immersed in the same VR environment without interactions), or standard-of-care. On a scale from 0 to 100, participants rated overall pain (primary outcome) and features of the VR experience (game realism, fun, and engagement). Path analysis assessed the interrelationships among these VR key features and their impact on self-reported pain scores. From December 2016 to January 2019, a total of 412 patients were screened for eligibility, and 90 were randomly assigned (31 in the active VR group, 30 in the passive VR group, and 29 in the standard-of-care group). The current study only included those in the VR groups. The difference in median scores of VR features was not statistically significant between the active (realism, 77.5 [IQR: 50-100]; fun, 100 [IQR: 81-100]; engagement, 90 [IQR: 70-100]) and passive (realism, 72 [IQR: 29-99]; fun, 93.5 [IQR: 68-100]; engagement, 95 [IQR: 50-100]) VR distraction types. VR engagement had a significant direct (-0.39) and total (-0.44) effect on self-reported pain score (p<0.05). Key VR features significantly impact its effectiveness in pain reduction. The path model suggested an analgesic mechanism beyond distraction. Differences in VR feature scores partly explain active VR's more significant analgesic effect than passive VR. Trial Registration: ClinicalTrials.gov Identifier: NCT04544631.

Telehealth experience during COVID-19 at an American burn Association (ABA) verified adult and pediatric burn center

IntroductionThe COVID-19 pandemic resulted in unprecedented changes to healthcare services. Non-emergent, out-patient care was either discontinued, greatly reduced, or switched to telehealth during the first wave of the pandemic. Here, we describe an American Burn Association (ABA) verified Burn Center’s experience with telehealth services during and after the COVID-19 emergency. Material and methodsIn this retrospective study, all patients who underwent out-patient care at a large academic hospital’s ABA Burn Center between March 2018 and March 2023 were identified from the electronic medical record system. Descriptive analysis was carried out to delineate trends in outpatient in-person and telehealth services during the COVID-19 pandemic. The travel distance saved from the introduction of telehealth was determined. ResultsDuring the study period, 3471 patients underwent a total of 7444 out-patient visits for burn care. There were no telehealth visits prior to the onset of the COVID-19 pandemic. In the first year of the COVID-19 pandemic, 14.9% of all out-patient visits were conducted with telehealth. This decreased to 8.3% and 6.8% of all out-patient care in the second and third years of the pandemic, respectively. The average round trip travel distance saved was 123 miles (2.8–––2312 miles). No complications were reported specific to receiving telehealth care. ConclusionsTelehealth is a feasible option for out-patient burn care in selected patients and reduces travel for patients. Further studies are needed to assess patient and clinician satisfaction, clinical outcomes, and the economic impact of telehealth utilization to help guide appropriateness of use.

Characterizing Delirium and Associated Risk Factors Using the Cornell Assessment of Pediatric Delirium Score in Pediatric Burn Patients.

Delirium is a syndrome of acute brain dysfunction with disturbance in consciousness and cognition that is increasingly recognized in critically ill pediatric patients. The Cornell Assessment of Pediatric Delirium (CAPD) tool is used to detect delirium in children of all ages and developmental stages in various hospital settings. To date, the incidence of delirium in the pediatric burn population has been poorly defined. In order to describe the incidence as well as risk factors for delirium in this patient population, we retrospectively reviewed patients <18 years of age admitted to our American Burn Association-verified pediatric burn center from March 2018 to May 2021 who underwent delirium screening using the CAPD tool. Patient demographics, burn characteristics, hospitalization details, and date of first positive delirium screening were collected, and χ2, Fisher's exact test, univariate, and multivariate analyses were performed. Delirium was identified in 42 (10.8%) of 389 patients meeting inclusion criteria. Patients screening positive for delirium were older (4 years [IQR: 2, 11] vs 2 years [IQR: 1, 6], P < .0005) and had larger TBSA burns (21.63% [IQR: 9, 42] vs 3.5% [IQR: 1.75, 6], P < .0001) than delirium-negative patients. Delirium-positive patients required a longer duration of mechanical ventilation (OR 4.23; 95% CI [1.16-15.39], P = .0289) and had higher TBSA burns (OR 1.12; 95% CI [1.06-1.17], P < .0001). Delirium-positive patients had 1.6 day longer length-of-stay adjusted for TBSA burned (95% CI [0.81-2.41], P < .0001). Compared to delirium-negative patients, delirium-positive patients had a 5.4-day longer PICU admission (95% CI [2.93-10.3]; P < .0001). Screening pediatric burn patients with risk factors known to be associated with delirium by using the CAPD score could improve delirium prevention and allow for early intervention.

Access to Certified Burn Centers in the United States: The Geospatial and Transport Cost of Transfer.

Specialized burn centers are critical to minimizing burn-associated morbidity and mortality. However, American Burn Association-verified burn centers are unequally distributed across the United States, and fewer centers are available for pediatric patients relative to adults. The economic burden of transporting patients to these centers contributes significantly to the high cost of burn care. This study quantifies inequitable burn care access in the contiguous United States due to age group and location as a function of physical proximity to a verified burn center and transportation cost. County-level distances to the nearest verified adult or pediatric burn center were determined and mapped. Distance calculations for each population were combined with transport cost data (2022 CMS Ambulance Fee Schedules) to estimate transportation costs for each population (adult vs pediatric, urban vs rural). Pediatric patients reside 30.5 miles further than adults from the nearest center, significantly increasing transportation costs. Ground and air transport costs also increased for rural versus urban patients. Notably, rural patients face almost double the cost of air transport. While physical proximity to burn care appears to differ only modestly across age and region, this marginal increase in distance is associated with significant economic impact. This study highlights physical and economic barriers to burn care access faced by rural and pediatric patients and underscores the critical need to improve equity in burn care access. Future studies should expand on this report's findings to more fully characterize the additional costs associated with inequitable burn care access.

As time goes by – Overlooking 40 years of inpatient burn treatment at a national pediatric burn center in Switzerland

BackgroundDespite extensive prevention programs, burns remain a frequent cause of injury in Switzerland with a known age peak in children. Pediatric burns may cause substantial morbidity, a psyochological burden and therapy related high economic costs. To improve preventive measures, precise knowledge of etiology and treatment of pediatric burns in Switzerland as well as their temporal evolution is indispensable. MethodsThe present retrospective analysis included pediatric burn patients admitted for acute treatment to the Pediatric Burn Center of the University Children`s Hospital Zurich over the last four decades. Sociodemographic, injury related, and treatment related data were extracted from medical records. Linear regression analysis was applied to determine temporal changes during the past four decades and chi-square and t-tests were applied wherever applicable. ResultsA total of 3425 acute burn patients were included in the study between 1977 and 2020, corresponding to a mean of 89 patients/year. Mean age was 3.60 ± 4.12 years, three quarters of all patients were preschool children (0–5 years) and mean total body surface area (TBSA) burned was 8.01% ± 9.57%, however only around one fifth had severe burns (>10% TBSA). Scald burns (65.31%) and flame burns (32.99%) were most commonly seen. Linear regression analysis showed the total number of thermal injuries treated at our center to have increased significantly as of 2004 (p < 0.001). Separate analysis showed the same for small and medium (<10% TBSA) burns (p < 0.001), whereas the number of severe burns did not increase significantly. Length of stay (LOS) was highly associated with %TBSA burned. The percentage of female patients amongst all patients increased over time (p = 0.012). LOS per TBSA burned decreased significantly (p < 0.001). ConclusionThe present data show pediatric burns to remain a major health burden in Switzerland, especially small and medium burns in preschool children. Prevention programs should focus on this age population as well as on scald and flame burns as most common etiologies. The observed decrease in length of stay suggests a major improvement in overall quality of care in pediatric burns and supports centralization of care.

39 Certified Burn Center Access in the United States: The Geospatial and Transport Cost of Transfer

Abstract Introduction Specialized burn centers are critical in minimizing burn-associated morbidity and mortality. However, American Burn Association (ABA)-verified burn centers are unequally distributed across the US, and fewer verified centers are available for pediatric patients relative to adults. The economic burden of transport to verified centers represents a significant proportion of the already high cost of burn-associated care. The present study aims to quantify inequitable burn care access in the contiguous US due to age group and locality as a function of physical proximity and transportation cost. Methods County-level distances (n=3,106) to the nearest ABA-verified adult or pediatric burn center were determined and mapped. Distances were then analyzed separately for rural (n = 1440) and urban (n = 1666) counties for both adult and pediatric burn centers. Distance calculations for each population were combined with transport cost data (2022 CMS Ambulance fee Schedules) to determine the average cost of transport for each patient population (adult vs. pediatric, urban vs. rural). Results 59 Adult and 43 Pediatric ABA-verified centers were identified from the ABA burn center directory. Pediatric patients reside 30.57 miles (p &amp;lt; 0.001) further than adults from the nearest center, accounting for a 10.5% - 15.9% transport cost increase. Transport costs increased dramatically between urban and rural counties, with rural patients facing a cost increase of 32.7% and 80.88% for ground and air transportation, respectively. Conclusions Physical proximity to burn care may appear to differ only modestly across age and region. However, the seemingly marginal increase in distance significantly impacts the cost of patient transport. The present study highlights both physical and economic barriers to burn care access faced by rural and pediatric patients. Increasing ABA burn center certification in targeted areas across the US may decrease the disparities in access to burn care faced by these groups. Applicability of Research to Practice Identify areas that may benefit from expansion of certified burn-care access and additional provider education.

772 Bismuth Tribromophenate Gauze is Superior to Silver Sulfadiazine Cream for Mixed-depth Scald Burns in Children

Abstract Introduction Silver sulfadiazine 1% cream was historically the mainstay initial treatment for burn wounds at our pediatric burn center. Over the last several years, we transitioned to using closed dressings of 3% bismuth tribromophenate petrolatum gauze in the initial care of partial thickness burns with the goal of reducing the pain experienced with daily wound cleaning necessitated when using silver sulfadiazine. The gauze adheres to the wound, allows exudate to drain through, and acts as a scaffold for re-epithelialization after which it falls off without traumatizing the healed burn. The purpose of this study is to compare our burn patient outcomes with the initial use of bismuth tribromophenate gauze to those in patients treated with silver sulfadiazine cream. Methods A retrospective chart review was conducted of our patients aged 5 years and younger presenting with mixed-depth scald injuries within two time frames: 1) years 2004-2008, during which silver sulfadiazine 1% cream was the standard initial choice for wound care at our institution, and 2) years 2015-2018, when 3% bismuth tribromophenate petrolatum gauze had become standard. Data collected included demographics, burn total body surface area (TBSA), length of hospital stay, need for excision or grafting, time to grafting, and graft size. Results Three hundred forty-seven patients were included, 200 of whom were treated with silver sulfadiazine cream and 147 treated with only bismuth tribromophenate gauze. Burn TBSA and rates of skin grafting were similar between the two groups; however, the mean area of the skin graft was significantly smaller (p = 0.027) among the patients in the bismuth tribromophenate group (147 cm2) compared to those in the silver sulfadiazine group (336 cm2). On the other hand, the time from injury to skin grafting was significantly longer in the bismuth tribromophenate group (24 days vs. 9.9 days, p = 0.002), with a larger proportion of these patients returning for elective grafting in the outpatient setting. Conclusions The percentage of patients who required skin grafting in both groups was similar; however, initial treatment with a closed dressing of 3% bismuth tribromophenate petrolatum gauze promotes healing in the zone of stasis, resulting in smaller skin grafts and hence smaller donor sites. The mechanical forces of daily wound cleaning when using silver sulfadiazine cream likely harm those areas at risk, leading to the need for larger skin grafts for coverage. Although time to grafting was longer when using gauze, these patients were in closed dressings with fewer painful changes. Applicability of Research to Practice Bismuth tribromophenate petrolatum gauze remains on a wound bed for up to three weeks, whereas silver sulfadiazine cream must be changed regularly resulting in constant disruption of the healing tissue. Fewer dressing changes combined with later skin grafting could allow burn wounds to demarcate and heal more effectively, benefiting both graft and donor sites.

66 Key Features of Virtual Reality Impact Effectiveness of Pain Reduction in Pediatric Burn Patients

Abstract Introduction Virtual reality (VR) is a safe and effective pain management during burn dressing. However, key features of VR that impact the effectiveness of pain reduction remains unknown. Methods Our randomized clinical trial included 90 children aged 6 to 17 years who were treated in the outpatient clinic of an American Burn Association–verified pediatric burn center. Active VR participants (n=31) played a VR game while passive VR participants (n=30) were immersed in the same VR environment without interactions. VR groups were also compared with a standard care group (n=29). The primary outcome was self-reported overall pain and worst pain during burn dressing using a visual analog scale (VAS; range, 0-100). Participants in the active and passive VR groups reported 3 key features of the VR game (engaging, fun, realistic) and all participants (VR and standard care group) reported how much time he/she thought about pain during the burn dressing. Key features of the VR game and time thinking about pain were reported using a scale ranging from 0 (not at all) to 100 (very much). A composite score was created by ranking scores of the 3 key features of the VR game and then summarizing them into one final composite score. Our study hypothesis was that the key features of the VR game significantly impact the effectiveness of VR in reducing pain during burn dressing care. Results Nonparametric Spearman correlation analysis indicated the active VR group reported statistically significant higher average scores for all 3 key features of VR (engaging: 78.9, 95% confidence interval (CI)=68.5-89.3; fun: 85.7, 95%CI=76.6-94.7; realistic: 73.1, 95% CI=62.3-83.8) in comparison with the passive VR group (engaging: 72.7, 95% CI=59.9-85.5; fun: 77.3, 95%CI=65.6-89.0; realistic: 59.1, 95% CI=44.7-73.5) (all p-value &amp;lt; 0.01). The composite VR score was also significantly correlated with how much time the participant thought about pain during the burn dressing (coefficient= -0.344, p=0.007). The final multivariate logistic regression model of reporting moderate-to-severe pain found that key features of the VR game were statistically significant factors for overall pain and worst pain after adjusting for age, race/ethnicity, healing degree, pain medication use within 6 hours, and anxiety score (p&amp;lt; 0.01). Conclusions This study provides evidence that key features of VR significantly impact its effectiveness in pain management among pediatric burn patients. Applicability of Research to Practice Active VR game is more effective and should be used for pediatric pain management.

302 A Classification System and Surgical Algorithm for Pediatric Postburn Ear Deformities

Abstract Introduction The outward projection of the external ear makes this anatomically complex appendage susceptible to trauma. Notably, up to 40-60% of facial burns involve the ear, frequently impacting function and aesthetics. Significant postburn sensory deficits and changes to the ear’s intricate architecture can markedly impair physical health, psychosocial functioning, and quality of life. Scar tissue and contracture, traumatized cartilage, and compromised blood supply and surrounding soft tissues all influence the reconstructive plan. The authors describe a new classification system and surgical algorithm for pediatric postburn ear deformities informed by both their extensive operative experience on the traumatized ear and a retrospective study of different reconstructive techniques for more severe burn injuries to the pediatric ear. Methods To develop the classification system and surgical algorithm, three senior surgeons with over 85 years of combined experience reconstructing ears carried out an iterative joint review of their relevant clinical cases and insights, including their personal approach to assessing postburn ear trauma and developing an operative plan. Particular attention was focused on how the type and extent of soft tissue injury affects available reconstructive options. To inform classification of the most complex ear burn cases, a retrospective review was conducted on patients aged 0 to 21 years who underwent cartilage framework reconstruction between January 2004 to January 2021 at a specialized pediatric burn center. Medical records were screened and 54 patients (61 ears) who met study criteria were identified and patient demographics, procedural characteristics, and outcomes were analyzed. Results For postburn ear deformities (Table 1) involving total or near-total preservation of the ear’s anatomical structural elements (Type I and Type II deformities, respectively), scar release, local tissue rearrangement, and/or skin grafting are typically sufficient for optimal reconstruction. For cartilage defects involving less than or more than two-thirds of the helix (Type III and Type IV deformities, respectively), a partial to complete ear scaffold can be successfully reconstructed using a composite graft, conchal transposition flap, costal cartilage graft, or porous polyethylene implant. Conclusions The proposed classification system and surgical algorithm (not shown) for postburn ear deformities facilitate a tailored approach that addresses reconstructive course duration, anticipated aesthetic results, complication potential, and patient goals and expectations. Applicability of Research to Practice The authors provide a new classification system to pediatric postburn ear deformities that, along with a proposed surgical algorithm, can help guide planning for reconstruction.

546 Winning the Race Against Pathogens: A Regional Burn Center Experience with a Cleansing Protocol

Abstract Introduction The skin is the first immune defense mechanism, and it functions as a barrier against various microorganisms. Burn injury will compromise this important barrier. Infections are the primary factor contributing to burn mortality, resulting in &amp;gt;50% of deaths in burn patients. In 2020, our Adult and Pediatric Burn Center instituted a pure Hypochlorous Acid (pHA) antimicrobial protocol to enhance skin barrier function. Methods We conducted a retrospective analysis on the effect of the introduction of the pHA protocol on the number of reportable infections in our Burn Center. The period of observation in this report is 2017-2021. Beginning in 2020, adults and children received topical wound care and bathing with our pHA protocol. No dilution of the product was used. The product was placed into a sterile basin and the patient was cleaned head to toe, including the genitalia and the wounds. Since invasive procedures such as placement of central venous catheters or urinary collection catheters may be a conduit of infection, the present report includes data regarding the number of patients experiencing clostridium difficile, central line-associated blood stream infection and catheter-associated urinary tract infections. Results From 2017-2021, our Burn Center admitted 2,223 patients. We computed a percent change in infections from before (2017-2019) to after (2021) the pHA protocol was implemented. We used 2021 because this was the first full year after the pHA protocol was introduced. We subtracted the total number of infections in 2021 from the average number of infections per year in 2017-2019 and divided by the average number of infections per year in 2017-2019. We found a 55% decrease in infections after the pHA protocol was introduced. There was no evidence of toxicity in adult or pediatric patients associated with care during introduction of the pHA protocol, including skin graft sites. Conclusions This analysis indicates a notable decrease in infections. The pHA procedure shows no evidence of viral, fungal or bacterial pathogens causing significant issues with the studied patient group. This analysis does not determine whether the decrease in infections is clinically or statistically significant. Applicability of Research to Practice Reducing infections in burn patients which can be life saving.

68 Using the Cornell Assessment of Pediatric Delirium Score to Identify Delirium in Pediatric Burn Patients

Abstract Introduction Delirium rates in pediatric critical care range from 18-40% and its development is associated with baseline cognitive dysfunction, primary diagnosis, and mechanical ventilation. The Cornell Assessment of Pediatric Delirium (CAPD) is a tool used to detect delirium in children of all ages, but has not been validated in burn patients. Our study aimed to use CAPD score to determine the frequency of delirium in pediatric burn patients and assess the association of delirium with burn demographics. Methods We conducted a retrospective review of patients aged 2.5 weeks to 18 years who were admitted to our ABA-verified pediatric burn center from 2018-2021 and who underwent delirium screening with the CAPD tool (CAPD ≥9 indicates a diagnosis of delirium). Injury mechanism, patient demographics, hospitalization details, and CAPD score were collected and χ2, Fisher’s exact test, and univariate analyses performed. Results 389 patients with documented CAPD scores were included in our cohort, with median age of 2 years at the time of burn injury. Delirium was identified in 42 (10.8%) patients. Delirious patients were generally older compared to non-delirious patients (4 years (IQR 2, 11) vs 2 years (IQR 1, 6), P &amp;lt; 0.0005) and had higher TBSA burned (21.63% (IQR 9, 42) vs 3.5% (IQR 1.75, 6), P &amp;lt; 0.0001). Odds of developing delirium with increasing age was 1.08 (95% CI: 1.02-1.15, P = 0.0068) and 1.16 (95% CI: 1.11-1.20, P = &amp;lt; 0.0001) for each percent increase in TBSA burned. Delirium diagnosis did not vary significantly with gender or race/ethnicity. Though it did not reach statistical significance, percent probability of developing delirium was highest among fire burns (26.53% (95% CI: 17.79-35.27)), and lowest among chemical burns (1.49% (95%CI: 0-4.40), P &amp;gt; 0.05). Patients who underwent 6 or more Anesthesia Events (AE) were 74.43 times more likely to develop delirium than patients who underwent 0 AEs (P &amp;lt; 0.001). Compared to non-delirious patients, patients with delirium were 81.02 times more likely to have an ICU admission (95% CI: 38.79-169.22, P &amp;lt; 0.0001) and 11.37 times more likely to have a longer hospital admission (95% CI: 7.74-16.72, P &amp;lt; 0.0001). Conclusions Screening with the CAPD tool identified delirium in pediatric burn patients with known risk factors for delirium including higher TBSA burned, greater number of AEs, and longer ICU course or hospital admission. Delirium increased with age in our study group. There are few validated tools for measuring delirium in pediatric burn patients, and further studies are needed determine whether CAPD accurately captures delirium in younger burn patients. Applicability of Research to Practice Knowing associations between clinical burn characteristics and delirium can help predict which patients are at highest risk. Early identification of these patients can enable extra precautions to prevent delirium and to treat it early if it develops.

715 Ocular Complications of Facial Burns in the Pediatric Population

Abstract Introduction Pediatric burns commonly involve the face and periocular areas, with a risk of impairing vision. The aim of this study is to characterize ocular injuries in burn patients and identify the patients at most risk of ocular complications. Methods This study is a retrospective review within a single academic, urban pediatric burn center. All burn patients under 18 years of age admitted from January 2010 to December 2020 with periorbital or ocular involvement were included. Variables analyzed included patient demographics, burn characteristics, presence of ophthalmology consultation, ocular exam findings, follow up time period, and early and late ocular complications. Results In the study period, 2,781 patients were admitted to our burn center, 300 of whom had facial burns involving the eyes and/or eyelids. Etiologies of burn injuries were as follows: 112 (37.5%) scald, 80 (26.8%) flame, 35 (11.7%) contact, 31 (10.4%) chemical, 28 (9.4%) grease, and 13 (4.3%) friction. Overall, 70.9% of patients with ocular burns received an ophthalmology consult. Of these patients, 61.5% had periorbital swelling and 39.8% had corneal injuries. Of the 207 patients who were followed as inpatients by ophthalmology, only 61 (29.5%) presented for a follow-up visit, as recommended, 6 of which had serious ocular sequelae including ectropion, entropion, symblepharon, and corneal decompensation, and 4 of whom had a firework-related injury. Conclusions While burns involving the ocular surface and eyelid margins are infrequent overall, they can lead to long-term sequelae. Ophthalmology consultation is critical, particularly in the setting of chemical and firework-related injury. As ocular and periocular burns can cause immediate as well as delayed sequelae, ophthalmologic evaluation is a key component of assessment. Applicability of Research to Practice This paper characterizes ocular injuries in pediatric patients with facial burn injuries and identifies patients most at risk for ocular complications. We believe this will be valuable for many burn researchers and clinicians in order to better identify patients who could benefit from ophthalmologic evaluation and those at risk for both immediate as well as delayed sequelae from periocular burns.

Protocol for a feasibility, acceptability and safety study of the PICO device (negative pressure wound therapy) in acute paediatric burns

IntroductionNegative pressure wound therapy (NPWT) in acute burn care may decrease the time to re-epithelialisation by more than 20%. Despite this, the perceived burden of use; including therapeutic, physical and...