Cases Of Severe Burns Research Articles

Impact of Microsurgical Reconstruction Timing on the Risk of Free Flap Loss in Acute Burns: Systematic Review and Meta-Analysis.

Free tissue transfer is usually considered as a last resort in severe burn cases, when skin substitutes and local flaps are not viable options. Prior studies have demonstrated a free flap loss rate ranging from 0% to 44%. The aim of this study is to identify the ideal timing to perform free flap reconstruction in acute burn-related injuries to minimize free flap loss. A systematic review and meta-analysis was performed and reported according to PRISMA guidelines. PubMed, Embase, Web of Science, and Cochrane Library databases were queried. The review protocol was registered on PROSPERO database (CRD42023404478). Three time intervals from day of injury were identified: (1) 0-4 days, (2) 5-21 days, and (3) 22 days-6 weeks. The primary outcome was total free flap loss. A total of 17 articles met inclusion criteria. The analysis included 275 free flaps performed in 260 patients (88% men, 12% women) affected by acute burn injuries. The pooled prevalence of free flap failure in the three time intervals (0-4 days, 5-21 days, and 22 days-6 weeks) were 7.32% [95% confidence interval (CI): 2.38%-20.37%], 16.55% (95% CI: 11.35%-23.51%), and 6.74% (95% CI: 3.06%-14.20%), respectively. Free flap reconstruction carries a high risk of failure in patients with acute burn. However, timing of the reconstruction appears to influence surgical outcomes. Free flap reconstruction performed between 5 and 21 days from burn injury had a trend toward higher flap loss rates and should be discouraged.

Thermal Injuries in Children: A Literature-Based Overview

Burns are a significant cause of morbidity and mortality in children. While the majority of pediatric burns are not life-threatening, they can have a significant impact on a child's physical and psychological health. They pose a major social and financial burden, particularly in developing countries. The management of pediatric patients with thermal injuries requires a complex and multifaceted approach.
 Pediatric burns constitute approximately 40-50% of all reported cases of severe burns. The most common etiologies of pediatric burns include scalds, contact burns, flames, and chemicals. From 80% to 90% of burns occurred at home and were accidental. Despite advancements in treatment, severe burns can lead to life-threatening complications, such as sepsis, multisystem organ failure, and hypermetabolic response or even death.
 This article aims to provide a literature-based overview of pediatric burn trauma, outlining its unique characteristics, etiology, epidemiology, classification, and initial management.

Hematological Trends in Severe Burn Patients: A Comprehensive Study for Prognosis and Clinical Insights.

Severe burn injuries pose diagnostic challenges, contributing to increased fatality rates with delayed diagnoses. This study aims to identify early risk factors and understand their impact on clinical outcomes by examining hematological dynamics in severe burn cases. The focus includes age-related patterns, total body surface area (TBSA) affected by burns, hospital stay duration, and changes in hematological markers during burn injuries. An analytical cross-sectional study at the burn care center involved 135 participants hospitalized between January 2018 and December 2021. Demographic data and hematological markers were recorded, and statistical analysis was performed using IBM SPSS 25.0. Nonsurvivors exhibited a greater mean TBSA, shorter hospital stay, and an enhanced early immune response indicated by white blood cell count on the first day. Hematological markers, including hemoglobin, red cell count (RCC), and platelet count, showed dynamic patterns over the study period. Marginal variations in platelet counts and intriguing patterns in RCC suggested potential consequences like disseminated intravascular coagulation. The study provides crucial insights into hematological responses to severe burn injuries. Early identification of risk factors, particularly age-related patterns and immune responses, informs clinicians about predicting outcomes and guiding therapeutic interventions. Despite limitations, this work underscores the need for further multicenter research to comprehensively understand the complex relationships between burn injuries, hematological responses, and clinical outcomes.

Psychiatric Risk Factors and Burn Severity in Self-immolation.

Self-immolation, a form of self-harm involving setting oneself on fire, is associated with high mortality, morbidity, and healthcare burden. This study aimed to characterize potential clinical correlates and predisposing factors for self-immolation based on burn severity using TBSA percentage scoring. Additional objectives included identifying motivational elements, associated risk factors, and clinical characteristics to optimize patient care and reduce future self-immolation incidents. A retrospective review of admissions to the Arizona Burn Center from July 2015 to August 2022 identified 103 self-immolation patients for the study. Burn severity was categorized as mild to moderate (TBSA < 20%) or severe (TBSA ≥ 20%) based on TBSA. This study population had a mortality rate of 21%. Positive urine drug screens were found in 44% of subjects, and 63% having chronic substance use, with methamphetamine (37%) and alcohol (30%), being the most prevalent. Underlying psychiatric illnesses were present in 83% of patients. Suicidal intent strongly predicted severe burns (P < .001) among the 68 severe burn cases identified. In conclusion, this study emphasizes that the presence of suicidal intent among self-immolation patients significantly correlates with burn severity. These findings highlight the importance of involving psychiatric services early in patient care to improve outcomes and reduce the recurrence of self-immolation acts.

Comparison of the safetyand efficacyfor different regimens of pharmaco-prophylaxis among severely burned patients: a randomized controlled trial.

Venous thromboembolism (VTE) is a common complication in critically ill patients, including severe burn cases. Burn patients respond differently to medications due to pharmacokinetic changes. This study aims to assess the feasibility and safety of different VTE pharmaco-prophylaxis in patients admitted to the ICU with severe burns. A pilot, open-label randomized controlled trial was conducted on ICU patients with severe burns (BSA ≥ 20%). By using block randomization, patients were allocated to receive high-dose enoxaparin 30mg q12hours (E30q12), standard-dose enoxaparin 40mg q24hours (E40q24), or unfractionated heparin (UFH) 5000 Units q8hours.In this study, the primary outcomes assessed were the recruitment and consent rates, as well as bleeding or hematoma at both the donor and graft site. Additionally, secondary measures were evaluated to provide further insights. Twenty adult patients out of 114 screened were enrolled and received E30q12 (40%), E40q24 (30%), and UFH (30%). The recruitment rate was one patient per month with a 100% consent rate. Donor site bleeding occurred in one patient (16.7%) in the UFH group. On the other hand, graft site bleeding was only reported in one patient (12.5%) who received E30q12. Major bleeding happened in two patients, one in E30q12 and one in the UFH group. Five patients (25.0%) had minor bleeding;two patients (25.0%) received E30q12, two patients E40q24, and onepatient UFH. RBC transfusion was needed in four patients, two on E30q12 and two on UFH. Only one patient had VTE, while four patients died in the hospital. The study observed a low recruitment rate but a high consent rate. Furthermore, there were no major safety concerns identified with any of the three pharmacologic prophylaxis regimens that were evaluated. NCT05237726.

Is CRP-Albumin Ratio an Indicator for Wound Infection in Children Exposed to Severe Burns? A Retrospective Cohort Study

Background. In the early stages of severe burn cases, an increase in serum C-reactive protein (CRP) level and a decrease in serum albumin level can be observed. Objective. This study aimed to investigate whether the CRP/albumin ratio at the time of hospital admission in children exposed to severe burns would be an indicator for bacterial growth at the wound site. Method. A total of 137 pediatric patients who were treated in our hospital’s burn center due to third-degree burns of 30% or more of their body between January 2019 and October 2023 were included in the study. Results. The mean age was 3.69 ± 4.16 years. CRP/albumin ratio was found to be an independent risk factor for culture positivity (odds ratio: 1.162; P = .01). Conclusion. High CRP/albumin ratio in children with severe burns may provide important information about the development of wound colonization or infection, most likely due to prolonged hospital stay.

CASE REPORT: “Boston type I keratoprosthesis with buccal mucosal overlay in severe chemical burn” ‘Barcelona CP’

Objective To describe a case of severe chemical burn treated with a novel Boston type I keratoprosthesis (B1-KPro) technique. Methods We present the case of a 25-year-old woman with poor light perception in both eyes who had bilateral chemical burn with caustic soda 3 months earlier. She underwent several amniotic membrane implants and subconjunctival triamcinolone injections without significant improvement. We decided to perform a two-stage surgery on the right eye (RE). Reconstruction of the ocular surface was first performed using a buccal mucosa allograft. Nine months later the second surgical stage was performed, which consisted of partial lifting of the buccal mucosa, B1-KPro implantation covered with the buccal mucosa overlay and exposing the optics of the keratoprosthesis. Results Two days following surgery the uncorrected visual acuity (UCVA) was +0.2 logMAR. Best-corrected visual acuity (BCVA) at one month was 0,0 logMAR, remaining stable after one year and eleven months of follow-up. Conclusions Boston type 1 keratoprosthesis covered with buccal mucosa (B1-KPro with mucosa overlay technique) could be considered an alternative in severe ocular chemical burn with marked shortening of the fornix, as an alternative to osteo-odonto-keratoprosthesis (OOKP) or tibial bone keratoprosthesis or when the Boston type II keratoprosthesis is not available. It allows restoration of the anatomy and condition of the ocular surface using autologous tissue, with better aesthetics than OOKP and material easily available as it has the CE marking.

Association of race and ethnicity with pediatric burn outcomes: A population study of the Kids’ Inpatient Database

BackgroundWhile most studies on burn outcomes have focused on adults, it is unclear if the same socioeconomic and environmental inequalities affect paediatric patients. This study aims to investigate the impact of race and ethnicity on outcomes in paediatric burn patients. MethodsThe Kids' Inpatient Database is released by Agency for Healthcare Research and Quality, and is the largest publicly available database for the United States inpatient paediatric population. All paediatric burned patients in 2016 and 2019 were identified. Race and/or ethnicity was the primary exposure variable, and the primary outcome was a composite of several in-hospital morbidities. Secondary outcomes included death, non-routine disposition, and length of stay. Fine-Gray competing risks regression and multivariable logistic regression were used to analyze length of stay and all other outcomes, respectively. Analysis also isolated subgroups related to socioeconomic status and case severity. ResultsWe included12,582 pediatric burn patients in this study. No difference was found in composite morbidity between White patients and those of other race or ethnicity groups. Hispanic ethnicity was associated with longer lengths of stay and increased odds of routine (i.e. home) discharge. Black patients had increased length of stay compared to White patients only in severe burn cases. ConclusionsOur study implies that race- or ethnicity-associated mechanisms driving outcome disparities in adults does not necessarily apply in paediatric burn patients.

Оказание медицинской помощи пациентам с острой глазной патологией в условиях пандемии

Purpose. Comparative assessment of frequency and structure of patients who underwent inpatient treatment for acute eye pathology before and during the coronavirus infection (COVID-19) pandemic. Material and methods. A quantitative analysis was carried out in 826 patients treated for various acute eye pathologies in the Khabarovsk branch of the S. Fyodorov Eye Microsurgery Federal State Institution (the Branch) for the time periods: from May 2018 to February 2020 (the first) and from March 2020 to the end of December 2021 (the second). An assessment of frequency and nosological forms of diseases was carried out, examples of most severe cases of diseases and injuries were given.Results. For the first period, 318 patients were treated, for the second period - 508 patients. In the second period, there was significant increase in number of patients with acute eye pathology by 1.6 times. In both periods, patients with inflammatory lesions of tuveal tract prevailed: before the pandemic - 179 eyes, during the pandemic - 243 eyes. Also in the second period, 29 cases of severe burns of the cornea - II and III degrees were registered. Conclusion. All patients who applied to the Branch during study periods and needed emergency ophthalmic care were provided in timely manner and in full. The COVID-19 pandemic has made significant adjustments to work of the entire Branch, including work of Complex Rehabilitation Treatment Department in form of increase in number of patients with acute eye pathology by 1.6 times.

Predictive value of perioperative peripheral blood cells counts for bacteremia and 90-day mortality in severe burn patients

ObjectiveBurn bacteremia is related to immune barrier damage, but whether the level of circulating immune cells predicts outcomes in severe burns is still not clear. This study aimed to explore the predictive value of perioperative blood cells of the first surgery after burn for bacteremia and 90-day death. MethodsData from severe burn patients treated at the First Affiliated Hospital of Sun Yat-sen University from 2011 to 2020 were retrospectively analyzed. Data on monocytes (M), lymphocytes (L), white blood cell-to-platelet ratio (WPR), neutrophil-to-lymphocyte ratio (NLR) in peripheral blood and changes in temperature (T-37) were collected at one day before(X0), the first day after (X1) and the third day after (X3) the primary surgery.Univariate and multivariate logistic regression were used to identify the independent risk factors of bacteremia and death within 90 days, which were used to establish the risk prediction models (xbac and x90d-m) in severely burned patients. Severe burn cases from two other burn centers were selected to verify the prediction models. ResultsWe analyzed 169 severe burn cases in the training dataset, with a 90-day mortality of 21.3% (36/169); 56 (33.1%) patients experienced burn bacteremia. Higher M0, WPR0, NLR0, NLR3, T3–37, ∆M (M0-M3) and lower M3, L3 were associated with higher risk of bacteremia (P < 0.05). Multivariate regression analysis showed that SOFA0, WPR0, M3, and T3–37 were independently associated with bacteremia. The prediction model for bacteremia Xbac = 0.1809 × SOFA0 + 6.532 × WPR0–1.171 × M3 + 0.6987 × T3–37- 2.297. TBSAB, SOFA0, and ∆M (M0-M3) were independently correlated with 90-day mortality. The risk prediction model X90d-m= 0.055 × TBSAB + 0.301 ×SOFA0 + 1.508 × ∆M - 7.196. External validation suggested that the specificity, sensitivity and AUC of the prediction model Xbac was 90.7%, 62.5% and 0.797, respectively; of the prediction model X90d-m was 69.2%, 90.0% and 0.873, respectively. ConclusionPeripheral M3, WPR0 and ∆M (M0-M3) during the primary surgery has reasonable predictive ability for bacteremia and 90-day mortality in severe burn patients, which could inform clinical antimicrobial judgment and prognostication.

An unusual case of severe electric burn of the skull: A rare incident

An unusual case of severe electric burn of the skull: A rare incident

Invasive Aspergillus outbreak in inhalation injury: a case presentation and literature review

BackgroundInvasive pulmonary aspergillosis often occurs in patients with poor immune function, who abuse steroids or broad-spectrum antibiotics, or who use intravenous drugs. Among the Aspergillus genus of pulmonary infection, Aspergillus fumigatus is the most important pathogen, followed by Aspergillus flavus, Aspergillus niger, and Aspergillus terreus. Inhalation injury complicated by Aspergillus infection has atypical clinical manifestations. Diagnosis is difficult, and it is easy to make mistakes in treatment. Moreover, there are few cases of burn inhalation injury complicated with pulmonary Aspergillus.Case presentationWe report a case of severe burns combined with severe inhalation injury, early pulmonary aspergillosis, and severe respiratory failure due to treatment discontinuation. Through analyzing the processes of diagnosis and treatment in the present case and performing a literature review, we explore feasible diagnosis and treatment plans.ConclusionsEarly application of a variety of diagnostic measures can be used to identify Aspergillus infection, and targeted anti-infection treatment is likely to reverse a severe adverse prognosis.

The Future of Burn Care From a Complexity Science Perspective.

Health care is undergoing a profound technological and digital transformation and has become increasingly complex. It is important for burns professionals and researchers to adapt to these developments which may require new ways of thinking and subsequent new strategies. As Einstein has put it: "We must learn to see the world anew." The relatively new scientific discipline "Complexity science" can give more direction to this and is the metaphorical open door that should not go unnoticed in view of the burn care of the future. Complexity science studies "why the whole is more than the sum of the parts." It studies how multiple separate components interact with each other and their environment and how these interactions lead to "behavior of the system." Biological systems are always part of smaller and larger systems and exhibit the behavior of adaptivity, hence the name complex adaptive systems. From the perspective of complexity science, a severe burn injury is an extreme disruption of the "human body system." But this disruption also applies to the systems at the organ and cellular levels. All these systems follow the principles of complex systems. Awareness of the scaling process at multilevel helps to understand and manage the complex situation when dealing with severe burn cases. This paper aims to create awareness of the concept of complexity and to demonstrate the value and possibilities of complexity science methods and tools for the future of burn care through examples from preclinical, clinical, and organizational perspectives in burn care.

Experience of successful treatment and recovery of a patient with severe high voltage electric burns complicated with unilateral electric cataract

Electrical burns are a special type of burn in which a certain amount of current passes through the human body and causes different degrees of tissue injury, organ dysfunction, or sudden death. Compared with other burn patients, the amputation rate of electric burns is higher and often leads to various complications. In this study, a case of severe electric burn complicated with unilateral electric cataract was reported, which recovered well after 173 days of operation and symptomatic support.

Management of A Case of Severe Electrical Burn, With Multiple Vital Organ Injuries

Management of A Case of Severe Electrical Burn, With Multiple Vital Organ Injuries

Mucormycosis - A catastrophic mycotic lesion

Mucormycosis (phycomycosis, zygomycosis) is an severe opportunistic infection 2 caused by a saprophytic fungus found in soil, bread molds, decaying fruits and vegetables. This disease is commonly found in immunodeficiency patients like diabetes, tuberculosis, renal failure, leukemia, Cirrhosis and in severe burn cases. The fungal spores enter paranasal sinuses through inhalation and infection spreads to orbital and intracranial structures via blood vessels or by direct invasion. These organisms invade the arteries leading to thrombosisand subsequently cause necrosis of hard and soft tissues. We report a rare case of mucormycosisinvolving extensive area of palate in a 48-year old male patient with a medical history of diabetes andliver cirrhosis and met with accident a month back. Histopathological examination of H&amp;E stainedsections revealed fungal hyphae in a connective tissue stroma. Non-septate branching hyphae were better appreciated through Gomori methenamine staining. Early diagnosis andtimely treatment can reduce the mortality and morbidity of this fatal condition.

Risk factors and the associated limit values for abnormal elevation of extravascular lung water in severely burned adults

BackgroundIncreased extravascular lung water (EVLW) correlates with pulmonary morbidity and mortality in critical illness. The extravascular lung water index (EVLWI), which reflects the degree of EVLW in an individual, increases in the fluid reabsorption stage rather than the initial resuscitation stage in severe burn cases. While many factors contribute to EVLWI variation, the risk factors contributing to its abnormal elevation in severe burns remain unclear. The aim of this study was to identify the risk factors and associated limit values for abnormal elevation of EVLWI during the fluid reabsorption stage in a cohort of severely burned adults. MethodThis prospective, single-center study included only adults with burn sizes≥50% of the total body surface area (TBSA) who were admitted within 24h after burn. Demographic data were collected, and transpulmonary thermodilution (TPTD) measurements and blood biochemistry tests were performed upon admission and up to day (PBD) 9. Risk factors for abnormal EVLWI were analyzed by logistic regression. Receiver operating characteristic (ROC) curves were constructed to determine the optimal cut-offs for each risk factor. ResultsSeventy-two patients were ultimately enrolled, with a mean age of 40.3 years and mean burn size of 69.4% TBSA. EVLWI began to abnormally increase (>7ml/kg) on day 3 and up to PBD 9, indicating that a supranormal EVLWI developed in the fluid reabsorption stage. Several relevant factors were considered, including patient age, burn size, intrathoracic blood volume index (ITBVI), pulmonary vascular permeability index (PVPI), cardiac index (CI), systemic vascular resistance index (SVRI), serum albumin, time of first excision and grafting, and number of operations and daily fluid administration. Among these factors, we found that only burn size and ITBVI were significantly correlated with EVLWI variation and were further identified as the independent risk factors for EVLWI abnormality. ROC analysis showed that the limits for predicting a supranormal EVLWI during the fluid reabsorption stage were 65.5% TBSA for burn size and 845ml/m2 for ITBVI. Patients with burn sizes or ITBVIs higher than the limit showed significantly longer mechanical ventilation time and substantially higher occurrences of acute respiratory distress syndrome (ARDS) and pneumonia within two weeks after burn. ConclusionsBurn size and ITBVI are the independent risk factors for EVLWI abnormality during the fluid reabsorption stage in severely burned adults. The limit values for predicting a supranormal EVLWI in those patients are 65.5% TBSA for burn size and 845ml/m2 for ITBVI.

Patient and injury characteristics associated with in-hospital mortality among adult acute burns patients. The case of a burns center in the Western Cape, South Africa

Background Specialized burns centers should manage the most severe burn cases. They often cater for large geographical areas and in low-income settings must deal with patient volumes far larger than their capacity. In such context, understanding the most significant determinants of in-unit mortality and knowing how to best predict it is instrumental to priority settings. The objective of this study is two-fold: firstly to identify patient and wound characteristics that best predict in-hospital outcome, and secondly, to assess whether prediction mortality scores, such as the Burn Abbreviated Severity Index (ABSI), established in high-income settings, are suitable in other settings where resources are limited. Methods The study is set in the burns center at Tygerberg Hospital in the Western Cape Province of South Africa, the only burns center catering for adult patients. All patients there during two consecutive years 2015-2016 (n = 452) were identified of which palliative care patients (n = 7) were excluded. A case report form was then used to systematically collect data on the characteristics of the patient (sex, age, comorbidity and referral status), injury (mechanism, intent, body part, inhalation, burn depth and size), the treatment received and, if applicable, on in-hospital mortality (prior to discharge from the center). Associations between in-hospital mortality and individual patient and injury characteristics were measured using simple logistic regression, and expressed as odds ratios (OR). A stepwise multivariate logistic regression model was then used and odds ratios adjusted for all other variables were obtained. For all variables, the reference category was defined as the one with the smallest mortality rate. The sensitivity and specificity of the determined all cases aggregated using a cut-off point of 8 (equivalent to a mortality rate of 50%). Results Almost half (47.6%) of the patients had a TBSA > 20%, and almost as many (42.0%), full thickness burns. The overall mortality rate was 19.8%. In-hospital mortality was associated with age (OR = 1.03 per year increase), being a female (OR = 2.25 (1.58–3.97 compared to male) and having an inhalation burn (OR = 5.27 (3.14–8.84) compared to those with no inhalation burn). Patients with flame burns had 16.9 higher odds of dying compared to those with scaldings and deep/full thickness burns patients, 8.9 higher odds than those with superficial/partial burns. There was a graded association between burn surface and the odds of dying. Five variables remained associated with in-hospital mortality after adjusting for all others in a multivariate regression model: age, sex, inhalation, burn size and depth. The mean of the ABSI-scores was 6 but there is a steep increase in mortality rates between the two consecutive scores of 7 and 8 (12.1% and 39.5% respectively). The score's sensitivity was 68%, and its specificity 92%. It is of note that all 14 patients with scores higher than 11 died, whereas the published scores predict a chance of survival smaller than 10%. Conclusion At the center, the mortality rate was high, with age, sex, inhalation, mechanism of injury, depth and size all being individually associated with in-hospital mortality. Our adjusted model retained age, sex, inhalation, burn size and depth as predictors of in-hospital mortality. These 5 variables are the same as the ones used in ABSI, confirming both the potential to use that score and their importance in mortality predictions. The mixed results regarding the ABSI score suggest it would perform better to foresee in-unit mortality of severe burns rather than less severe ones at the center. Whether lowering down the cut-off value from 8 to 6 as an option remains to be determined.

A rare case of severe third degree friction burns and large Morel-Lavallee lesion of the abdominal wall

BackgroundMorel-Lavallee lesions (MLLs) are rare internal degloving injuries typically caused by blunt traumatic injuries and most commonly occur around the hips and in association with pelvic or acetabular fractures. MLL is often overlooked in the setting of poly-trauma; therefore, clinicians must maintain a high degree of suspicion and be familiar with the management of such injuries, especially in obese poly-trauma patients.Case presentationWe present a 30-year-old female pedestrian struck by a motor vehicle who sustained multiple long bone fractures, a mesenteric hematoma, and full-thickness abdominal skin friction burn which masked a significant underlying abdominal MLL. The internal degloving caused significant devascularization of the overlying soft tissue and skin which required surgical drainage of hematoma, abdominal wall reconstruction with tangential excision, allografting, negative pressure wound therapy, and ultimately autografting.ConclusionMLL is a rare, often overlooked, internal degloving injury. Surgeons must maintain a high index of suspicion when dealing with third degree friction burns as they may mask underlying injuries such as MLL, and a delay in diagnosis can lead to increased morbidity.

Adolescents “Dabbing” With Marijuana: A Novel Mechanism for Smoking Highly Concentrated Tetrahydrocannabinol

Back to table of contents Previous article Next article CommentaryNo AccessAdolescents “Dabbing” With Marijuana: A Novel Mechanism for Smoking Highly Concentrated TetrahydrocannabinolKatrina Furey, M.D.Katrina FureySearch for more papers by this author, M.D.Published Online:26 Apr 2017https://doi.org/10.1176/appi.ajp-rj.2016.110604AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The legalization of marijuana and decriminalization of its possession across America has likely contributed to the public’s view of marijuana as a relatively safe drug (1, 2). Marijuana is still the most widely abused drug among adolescents (1). Yet, public health campaigns depicting the harms associated with adolescent marijuana use, such as increased rates of psychosis in teenagers with a predisposition for schizophrenia and a dose-dependent increase in rates of suicide attempts, have not kept pace with legalization (1). Although epidemiologic data are sparse and inconsistent, there is evidence that the rates of youth marijuana abuse increase postlegalization (1, 3). Given peer pressure and access to drugs in this population, novel mechanisms for ingestion, like dabbing, may be used earlier and more frequently by adolescents.Dabbing is a mode of marijuana ingestion in which individuals inhale a highly concentrated form of tetrahydrocannabinol (THC) from vaporized butane hash oil (colloquially called dabs, earwax, budder, shatter) created via butane extraction (3). Dabs contain THC concentrations up to 23%–80%, compared to the 3%–6% seen in traditionally smoked cannabis (2, 4, 5). Up to 40% of the THC can be inhaled, based on controlled experiments (4). Recreational users can synthesize dabs at home through a process known as blasting, with directions easily found via Internet search (2, 3).Dabbing brings up several safety concerns, primarily dangers inherent to blasting, potential contamination of homemade dabs, and an increased risk of addiction and psychosis associated with the highly concentrated THC vapors (2, 4, 5). The safety of at-home blasting has been compared to that of home methamphetamine labs due to butane’s highly flammable and volatile nature (3). Blasting has resulted in several documented cases of fires, explosions, and severe burns (3).Advocates of dabbing argue that this preparation of THC eliminates dangerous bacteria, mold, fungi, and other toxic compounds found in traditionally smoked cannabis (3). However, a recent study examining 57 dab concentrates available for consumption in the California medical cannabis market found that 80% were contaminated by considerable amounts of residual solvent, most commonly isopentane, and less frequently pesticides, like paclobutrazol and bifenthrin (4).In 2014, Loflin and Earleywine (2) reported that 357 surveyed dab users, ranging from 18–71 years of age, preferred dabbing over smoking traditional cannabis due to the potency of dabs. The high was described by users as “stronger” and “qualitatively different.” However, the authors also found that dabbing was associated with statistically significant increases in subjective withdrawal and tolerance symptoms, suggesting that dabbing could have a greater addictive potential than traditional smoking (2, 3).Because of this growing trend, increasing numbers of patients will likely present to emergency room settings with acute marijuana wax intoxication. At least one case of butane hash oil-induced psychosis that did not respond to an antipsychotic has been reported in the literature (5). It is unclear whether dabbing-induced psychosis is transient or could lead to chronic psychotic illness in vulnerable patients. Because dabs can be easily made at home following online tutorials and most adults would not recognize these small, waxy resins as marijuana, adolescents may be at particularly high risk of experimenting with dabbing and subsequently experiencing its negative consequences.Dr. Furey is a second-year resident in the Department of Psychiatry, Yale-New Haven Hospital, New Haven, Conn.