Significant Burn Injury Research Articles

Upper eyelid reconstruction due to scar contracture following major burn injury: A case series

Background: Upper eyelid contracture is a regular occurrence after severe facial burns. Numerous problems, such as corneal ulcers and exposure keratitis, may result from it. It is difficult for plastic surgeons to operate in this situation to preserve worst-case scenarios and enhance palpebral function. Methods: In this piece, we showcase two instances: (1) Eight months after suffering a chemical burn injury, a 26-year-old male was diagnosed with bilateral superior palpebral contracture with iris prolapse. Both eyes' visual acuity was 6/6 - 1/¥. A 75-year-old female patient was identified as having a corneal ulcer and a contracture on her left upper eyelid. Both eyes' visual acuity was 20/6 - 1/¥. In order to restore the top eyelid in both patients, we undertook a contracture release and a full-thickness skin graft. Results: Evaluation five days after surgery revealed no evidence of graft lysis and that the graft had taken nicely. On the patient graft from the second, we discovered shifting, although new epithelization will take place. Both of the patients had good eyelid looks following restoration. Conclusion: Plastic surgeons should be aware of the seriousness of significant burn injuries to the face. Patients must receive appropriate instruction on the significance of avoiding consequences from eyelid contractures. In this instance, creating the top eyelid via a skin graft and contracture release technique made sense. We acknowledge that one of the limitations of our study is the brief observational period of the patient's conditions.

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.

Post-Traumatic Growth Among Patients Suffering From Burn: A Cross-Sectional Study

Background: Burn and wounds are one of the most serious hospital cases in all healthcare settings, both social and psychological support are needed to overcome all depressive and anxious feelings afterward the burns' incidence. This study aims to assess and evaluate all posttraumatic growth experiences from healthcare professionals after burns and wounds on selected patients with various degrees of burns. Methods: It was a cross-sectional descriptive design. The present study utilized regression analysis as a statistical tool to examine the variables linked to posttraumatic growth in a sample of 191 individuals who had undergone significant burn injuries. Results: The study revealed that those undergoing therapy for mild depression exhibited a modest degree of depressive symptoms and a diminished feeling of positive self-perception compared to those in the acute phase. Therefore, a statistically significant difference in the averages was noticed between the two groups. An important correlation was found between depressive symptoms and social support, which had a significant impact on posttraumatic growth during the recovery phase. Conclusions: The present study revealed that social support exerted a noteworthy influence in promoting posttraumatic growth among individuals belonging to the acute phase group.

Pattern, Cause of Childhood Burn injuries and their Management Outcome At Jimma Medical Center, Jimma Zone, Oromia Region, Southwest Ethiopia.

Burn injuries are prevalent worldwide, especially in developing countries; and there are significant pediatric burn injuries in Ethiopia. This study was performed to analyze the pattern, cause, and management outcome of burn injuries in Jimma Medical Center. A hospital‑based retrospective cross‑sectional study was conducted at Jimma university medical center burn unit. Data were collected through chart review of pediatric patients aged 0 to 14 years who were admitted to the burn unit with a burn injury. A total of 92 hospitalized children were studied from Jan 1, 2020 to Dec 31, 2021 GC. Data were analyzed using SPSS version 25. The statistical significance was determined using odds ratio (OR) with a 95% confidence interval (CI) and the corresponding P-value of less than 0.05. The majority of the patients were males (52.2%). Scald burn was the most common cause of burn in 57(62.0%). The TBSA of majority of the patients (52.2%) was found to be between 11% and 20%. After adjusting for possible confounders in the multivariate analysis, preexisting illness and time of presentation to care were found to have a statistically significant association with the outcome of burn at discharge (P= 0.007) (P= 0.021) respectively. The most common cause of burn in our setup was scald burn; upper extremities were also the most affected site. According to our study, the factors associated with the outcome of burn injury were preexisting illness and late presentation to health facilities.

96 A Quality Improvement Study of Routine Mattress Exchange to Reduce Microbial Recontamination

Abstract Introduction It is industry standard for a patient to maintain a single mattress throughout admission, which may be problematic with burn injuries. Significant burn injuries are high exudate wounds which provide challenging care, including frequent dressing changes and environmental contamination. As part of an infection prevention process improvement (PI) including routine air mattress (AM) exchanges throughout admission, the purpose of this study was to examine microbial contamination of mattresses before and after utilization. Methods This single center, retrospective study was conducted in an ABA-verified burn center. Routine AM exchanges began in November 8, 2020, including logging serial numbers of incoming/outgoing AM and periodic environmental cultures. Pre- and post-occupation AM environmental cultures (EC) (outside and inside the top cover and baffles) were compared with patient culture data. All patients were admitted to the Burn Center. Results During the 91 weeks, a total of 635 AM were exchanged. A total of 34 AM were cultured with 20 (59%) being post- and 14 being the pre-occupation. For the pre-occupation AM cultures, all 14 outer and inner surfaces cultured sterile. Regarding post-occupation AM, 80% had a positive EC of the outside surface, while 58% had positive environmental culture from inside the sealed AM. The median time of AM utilization prior to culturing was 6 (6, 7) days. All microbes isolated from post-occupation AM matched culture data from each patient’s hospital course. There were a total of 42 microbes isolated from environmental swabs taken from the outside cover with the most common: S.epidermidis 38%, S.aureus 14%, and P.aeruginosa 12%. A total of 40 microbes were isolated from inside the sealed AM with the most common: S.epidermidis 25%, Acinetobacter spp. 13%, Enterobacter spp. 10%, and Pseudomonas spp. 10%. There were 5 different EC taken from inside the sealed AM resulting in fungal growth. The 34 EC were taken from AM of 9 patients during the 91 week period. The median age was 48 (22, 66) years with 42 (21.25, 44) %TBSA burned. The median weight was 92 (76, 98) kg with body mass index of 27.47 (23.72, 37.11) kg/m2. Two of the 9 patients were below 20 % TBSA burned (9 and 19.5%) while the remaining 7 patients had greater that 20% TBSA burns. There was an inverse signals between size of burn and amount of wound closure and contamination. Conclusions AM are not impervious to the heavy exudate of patients with large burn injuries. Over time, the mattress becomes contaminated with microorganisms specific to the patient. This study justifies the infection prevention practice of routine mattress exchanges during admission for patients with large, open burn wounds. We do not send patients back from the operatory theater or hydrotherapy with reused dressing. Given these findings mattresses should be no different. Applicability of Research to Practice First study to analyze infectious mitigation potential of routine AM exchanges in burn patients.

559 Verticalization Therapy for ICU-Level Burn Patient: A Case Study

Abstract Introduction The entire interdisciplinary team can be faced with many challenges when treating a bariatric, critically ill patient with significant burn injuries. Some studies suggest that the care of these patients increases staff workload and leads to the need for increased assistance for proper turning, positioning, and completion of wound care. When caring for these types of patients, patient and staff safety should be considered, as well as what will ensure the best patient outcomes. Our rehab team initiated the use of verticalization therapy with a patient on the burn unit with 28% TBSA full-thickness burns to back, chest, BUEs and a BMI of 45.8 in order to promote improved healing, cognitive status, and pulmonary function. While verticalization therapy is described for use in patients with pulmonary issues or invasive cardiac support devices, this was the first time this therapy was used in our busy ABA-verified burn center. Methods Once deemed appropriate for participation with PT/OT, a collaborative protocol with nursing, therapy, and burn provider team was developed. The patient was transitioned into a specialized bed allowing for verticalization up to 90 degrees. The patient was incrementally verticalized by 10 degrees at a time while monitoring vitals, assessing patient safety and pain response. Ultimately, the patient reached 40 degrees vertical and maintained this position for up to 2 hours. This intervention was utilized by both rehab specialists and nursing staff and was taught to nursing staff to be performed daily until patient was able to actively participate and tolerate edge of bed or out of bed activity. Results Use of the verticalization positioning was used to promote weight bearing activity, improve pulmonary function, improve cognitive status through upright positioning, and for pressure relief of graft areas specifically for offloading pressure to back wounds and grafts. The bed was used for 1 month. During this time, the patient successfully liberated from mechanical ventilation and shock state and mobilized with therapy assistance. The patient demonstrated improved strength, active participation with therapies, and decreased agitation as the month progressed. Autograft split-thickness skin grafts with autologous cell suspension epithelial autografts to the patient’s posterior torso healed well and were fully closed by the time of discharge to inpatient rehabilitation. Conclusions Use of verticalization beds can be implemented in the care of patients with burn injuries safely and successfully. Further research regarding skin healing related to use of the bed and verticalization therapy in burn injured patients should be conducted. Applicability of Research to Practice This intervention can be used for patients of all sizes and can be implemented as soon as hospital day one, if the patient is medically appropriate

527 Practical Use of Biomarkers During Nutritional Support of Pediatric Burn Patients

IntroductionCurrent guidelines for evaluating nutritional risk in acutely ill patients incorporate the assessment of inflammation and disease burden. Inclusion of laboratory measures such as C-reactive protein (CRP) in screening criteria used to identify nutritional risk has gained credibility. Other biomarkers influenced by inflammation include visceral proteins albumin (ALB) and pre-albumin (PAB). While visceral proteins are not valid indicators of nutritional status, they may be indicators of nutritional risk, which could potentially lead to poor clinical outcome. The purpose of this study is to evaluate if PAB, ALB, CRP, are useful markers for predicting clinical outcomes in children with severe burn injury.MethodsAs part of our quality assurance program, we collect data on all nutrition support interventions, monitoring and outcome in children admitted to our hospital with significant burn injuries. This analysis describes data collected from 2006-2019 in children who had a burn injury and received nutritional support for five days or greater. Data elements collected include general demographics, weekly measures PAB, CRP, ALB; length of stay (LOS), number of intensive care unit (ICU) days, days to wound closure, and days on nutrition support. Biomarkers PAB, ALB, CRP and burn size (as an indicator of disease burden) were entered into a multiple regression model using a stepwise procedure for each dependent outcome variables (LOS, ICU LOS, Days to Wound Closure, and Days on Nutrition Support).ResultsA total of 182 patients, 7.0 ± 5.0 years of age with 41.1 ±16.9 % total body surface area (TBSA) burns were included in the analysis. TBSA, mean CRP and mean PAB were significant predictors of hospital LOS (R=0.60; p < 0.001); TBSA and PAB were significant predicters of ICU LOS (R=0.67; p< 0.000), days to wound healing (R= 0.37; p < 0.000) and days on nutrition support (R=0.60; p< 0.000). Albumin was not a significant predictor for any of the clinical outcome measures.ConclusionsOur findings indicate that monitoring PAB and CRP is useful for identifying risk of poor outcome. Mean PAB was inversely associated with LOS, ICU LOS, days to wound healing, and days on nutritional support even when controlling for CRP and burn size.

The Development of Acute Kidney Injury in Burn Patients Undergoing Computed Tomography With Intravenous Contrast

AbstractAcute kidney injury (AKI) is a major complication of significant burn injuries and a significant cause of patient morbidity and mortality. Patients that sustain traumatic burn injuries may require computed tomography (CT) imaging as part of their initial trauma management. This multicenter retrospective chart review of patients admitted to two level I trauma centers with ≥10% TBSA burns between 2014 and 2017 aims to determine if patients with greater than 10% TBSA burns that received CT imaging with intravenous contrast were more likely to develop acute kidney injury during their admission. A total of 439 patients were included in the study. The average age was 45.3 years and average TBSA was 23.2%. Sixty-seven of the 439 patients underwent CT scans with IV contrast on admission. The rate of AKI between patients who did or did not receive CT scans was not statistically significant (9.1 vs 6.0%, P = 0.40). Patients who developed an AKI had higher TBSA (45.6 vs 21.1%, P &amp;lt; .01), amount of fluids per TBSA given within the first 24 hours (457.4 vs 321.6, P &amp;lt; .01), and mortality (71.1 vs 6.2%, P &amp;lt; .01) than those who did not develop an AKI. There was no significant difference in the development of acute kidney injury in burn patients who received CT scans with IV contrast on admission. Although there is a risk of contrast induced nephropathy, the risk is not increased in burn patients and this should not prevent a thorough evaluation to rule out additional life-threatening injuries in the burn trauma patient.

Temperature management of adult burn patients in intensive care: findings from aretrospective cohort study in atertiary centre in the United Kingdom.

Patients with major burn injury are prone to hypothermia, potentially resulting in an increase in mortality and length of hospital stay. Our study comprehensively evaluates the practicalities of physiological thermoregulation and temperature control in the largest cohort of critically ill adult burn patients to date. This retrospective study of routinely collected patient data from the Intensive Care Unit (ICU) of the West Midlands Burn Centre was conducted over athree-year period (2016-2019). Data were analysed to assess temperature control against local and International Society for Burn Injury (ISBI) standards. Thirty-one patients with significant burn injuries, requiring active critical care treatment for more than 48 hours were included (total body surface area [TBSA] mean = 42.7%, SD = 18.1%; revised Baux score [rBaux] = 99, SD = 25). The majority were male (77.29%) with an average age of 44 years (17-77 years). The patients were cared for in the ICU for atotal of 15 119 hours. Hypothermia, defined as core temperature below 36.0°C, was recorded for 251 hours (2% of total stay). Only 27 patients (87%) had their temperature ≥ 36°C for more than 95% of their admission. Non-survivors were more prone to hypothermia during their stay in ICU. There was an association between rBaux score and post-opera-tive temperature, with a0.12°C decrease per 10 points increase in rBaux score (P = 0.04). We have observed ahigh variability of temperature control between individual patients, especially in non-survivors, and have demonstrated an association between high rBaux score and poor temperature control, specifically during the postoperative period.

598 Temperature profiles of sunlight-exposed surfaces in a desert climate: Determining the risks for pavement burns.

Abstract Introduction In the desert climates of the United States, plentiful sunlight and high summer temperatures cause significant burn injuries from hot pavement and other surfaces. Although it is well known that surfaces reach temperatures sufficient to cause full-thickness burns, the peak temperature, time of day, and highest risk materials is not well described. This work measured continuous temperature measurements of six materials in a desert climate over a five-month period. Methods Six different solid materials common in an urban environment were utilized for measurement. Asphalt, brick, concrete, sand, porous rock, and galvanized metal were equipped with thermocouples attached to a data acquisition module. All solid materials except metal were placed in a 2’x2’x3.5” form, and identical samples were placed in both shade and direct sunlight. Ambient temperature was recorded, and sunlight intensity was measured using a pyranometer. Measurement time interval was set at three minutes. A computational fluid dynamics (CFD) model was created using Star CCM+ to validate the data. Contour plots of temperature, solar irradiance, and time of day were created using MiniTab for all surfaces tested. Results 75,000 temperature measurements were obtained from March through August 2020. Maximum recorded temperatures for sunlight-exposed samples of porous rock was 170 F, asphalt 166 F, brick 152 F, concrete 144 F, metal 144 F, and sand 143 F. Peak temperatures were recorded on August 6, 2020 at 2:10 pm, when ambient temperature was 120 F and sunlight intensity 940 W/m2 (Table). Temperatures ranged from 36 F - 56 F higher than identical materials in the shade at the same time. The highest daily temperatures were achieved between 2:00 pm to 4:00 pm due to maximum solar irradiance. Contour plots of surface temperature as function of solar irradiation and time of day were created for all surfaces tested. Nearly identical results obtained from the CFD models to the experimentally collected data, which validated the experimental data. Conclusions Surfaces exposed to direct, continuous sunlight in a desert climate achieve temperatures from 143 F to 170 F in the early afternoon and are high enough to cause significant injury with sufficient exposure. Porous rock reached the highest temperature, followed closely by asphalt. This information is useful to inform the public of the dangers of exposed surfaces in a desert climate.

601 Burn Injuries Associated with At-home Hair Braiding

Abstract Introduction Hair braiding that incorporates synthetic extensions has increased in popularity across all age groups. During the styling process, the ends of the braid are commonly dipped in hot water. As a result of this practice, an increasing number of patients have presented to our Burn Center after containers of recently boiled water are accidentally tipped over and spilled onto patients. Here, we report on patient demographics, outcomes, and our experience managing this injury pattern. Methods A retrospective chart review was performed of all patients who sustained burn injuries associated with at-home hair braiding presenting to an ABA-verified Burn Center between January 1, 2006 and July 31, 2020. Data on patient demographics, injury characteristics, wound management and, burn outcomes was collected. Results A total of 41 patients presented over the study period with burn injuries related to at-home hair braiding. The frequency of this type of burn increased over time, with 54% of injuries occurring in the last three years (2018–2020). The mean patient age was 7.5 years (range 0.7 – 32 years). Demographically, the vast majority of patients were under 18 years of age (90%), female (95%), and African American (98%). Seventy-three percent of injuries occurred at the patient’s home and 88% of incidents involved another person in the hair braiding process. The mean total body surface area of burn was 5% (range 1–20%). The most commonly involved areas were the back (54%), thigh/leg (37%), neck (24%), shoulder (24%), and arm/forearm (22%). Ninety percent were entirely partial thickness injuries with 10% of patients suffering some degree of full thickness injury. Ninety percent of patients required inpatient admission, and 36% of patients required at least one operative procedure. For those managed as inpatients, the average length of stay was 5.4 days (range 1–30 days). Three patients were reported to experience complications with one developing respiratory failure and two with delayed wound healing. Conclusions Hair braiding, with the use of scalding water to seal and set the ends of braids, can lead to significant accidental burn injuries. At our institution, these injuries occur predominantly in young African-American females. These burns can result in acute hospitalization and the need for surgical intervention. This is the largest series of this injury type to date with trends towards increasing frequency in the most recent time period.

69 Defining Numerical Cutoff Values for Mild, Moderate, and Severe Pain in Adult Burn Survivors

Abstract Introduction Pain is a common and often debilitating sequelae of a significant burn injury. Clinicians and researchers need clinically valid, reliable pain measures to guide treatment decisions and to provide evidence for study protocol development. Pain rating scores that represent mild, moderate, and severe pain in the burn survivor population have not been established. The aim of this study was to determine the numerical pain intensity rating scores that best represent mild, moderate, and severe pain in adult burn survivors. Methods Average pain intensity visual analog scale (VAS; 0–10) and customized PROMIS pain interference short form was administered to adult burn survivors (age ≥18) treated at a regional burn center at hospital discharge and at 6, 12, and 24-months postburn. To identify the optimal VAS scores for mild, moderate, and severe pain we computed F values and Bayesian Information Criterion (BIC) statistics associated with multiple ANOVA comparisons for mean pain interference scores by various VAS pain intensity cut points. Six possible cut points (CP) were compared: CP 3,6; CP 3,7; CP 4,6; CP 4,7; CP 2,5; and CP 3,5. For example, CP 3,6 refers to pain categorized as mild (0–3), moderate (4–6), and severe (7–10). Optimal cutoffs were those with the highest ANOVA F statistics. Models with similar F statistics were compared using changes in BIC. Results 178 participants (85% white, 65% male, mean age of 46 years) with pain intensity and interference scores at one or more timepoints comprised the study sample. The optimal classification for mild, moderate, and severe pain at baseline and 12-months was CP 2,5. Although CP 3,6 had the highest F value at 6-months, there was not strong evidence to support CP 3,6 over CP 2,5 (BIC difference: 2.9); similarly, CP 3,7 had the highest value at 24-months, but the BIC difference over CP 2,5 was minimal (2.2). Conclusions We recommend that visual analog pain intensity scores for adult burn survivors be categorized as mild (0–2), moderate (3–5), and severe (6–10). These findings advance our understanding regarding the meaning of pain intensity ratings following a burn injury and provide an objective definition for clinical management, quality improvement, and pain research.

Model to Predict Probability of Significant Skin Burn Injury From a Directed-Energy Source.

Millimeter wave directed energy in the frequency regime of 94-95 GHz has potential for use in numerous military applications including crowd control and area denial. Although proven to be very safe, millimeter wave energy has the potential, because of accidental over exposure, to produce significant injuries. Currently, the Dynamic Thermal Model (DTM), developed by Beason and colleagues, is used to calculate the temperature profile in skin undergoing (millimeter wave) heating, using an all-or-nothing threshold of injury. Risk of significant injury (RSI) is determined by product of the probability of an injury outcome on a region of the body times the probability of that the injury will occur. Thus, a threshold injury determination may over predict burn probability and fail safety requirements. This work augments the DTM, replacing the current threshold value of injury with a probabilistic risk of injury to better quantify the risk of significant injury. In this study, continuous probabilistic dose-response models using logistic regression analysis have been developed to account for mild second-degree, deep second-degree, and third-degree burn injuries based on a historic experimental burn dataset. Statistical analysis methods such as Hosmer-Lemeshow statistics, McFadden's pseudo R2 and receiver operator characteristic were used to validate the models against an independent experimental burn dataset. Comparison of logistic models fit using damage coefficients from the literature showed that Mehta and Wong provided the best fits historic burn data, which was corroborated by the McFadden pseudo R2 statistic for mild second-degree, deep second-degree, and third-degree severity. The dose-response models developed in this study are shown to be an excellent predictor of burn injury for each severity. The DTM was repackaged with the probabilistic burn models to more accurately determine the risk of significant burn injury.

"Living Well" After Burn Injury: Using Case Reports to Illustrate Significant Contributions From the Burn Model System Research Program.

The Burn Model System (BMS) program of research has been funded since 1993 by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The overarching aim of this program is to improve outcomes and quality of life for people with burns in the areas of health and function, employment, and community living and participation. This review reports on BMS contributions that have affected the lives of individuals with a significant burn injury using case reports to associate BMS contributions with recovery. In January 2020, current BMS grantee researchers assessed peer-reviewed BMS publications from 1994 to 2020. Using case report methodology, contributions were linked to three individuals treated at one of the four Burn Model System institutions. With over 25 years of NIDILRR funding, unique BMS contributions to patient recovery were identified and categorized into one of several domains: treatment, assessment measures, sequelae, peer support, employment, and long-term functional outcomes. A second review for significant results of BMS research that add to the understanding of burn injury, pathophysiology, and recovery research was identified and categorized as injury recovery research. The case study participants featured in this review identified select NIDILRR research contributions as having direct, personal benefit to their recovery. The knowledge generation and clinical innovation that this research program has contributed to our collective understanding of recovery after burn injury is considerable. Using case study methodology with three adult burn survivors, we highlight the impact and individual significance of program findings and reinforce the recognition that the value of any clinical research must have relevance to the lives of the study population.

Opportunities for Palliative Care in Patients with Burn Injury—A Systematic Review (GP718)

•Identify, compare and discuss shared fundamental components of quality palliative care and quality burn care.•Describe process of designing and executing a systematic review of palliative care interventions for burn patients and analyze results.•Assess implications of our results for further research opportunities at the intersection of palliative medicine and burn care. Patients with significant burn injuries likely have palliative care needs. We performed a systematic review of existing evidence concerning the palliative care needs of burn patients. Through November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using search terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles were required to involve burn injured patients who were treated with an intervention targeting at least one of the eight domains of quality palliative care. For each article meeting criteria, two members of the team independently extracted data. Results from the identified studies were presented in a tabular summary and summarized in a qualitative synthesis. Meta analysis was not possible due to varied content and data. Our searches yielded 7,532 unique records which led to 238 manuscripts for full review and 88 studies which met inclusion criteria. Seventy-five studies addressed the domain “Physical Aspects of Care” and merit a separate systematic review; 13 studies were included in our final review. Four of the 7 domains—rocesses of care, psychologic symptoms, social aspects, and end-of-life—were addressed by studies, but three domains—spiritual, cultural, or ethics—were unaddressed. Included studies highlight potential benefits in patient quality-of-life from peri-discharge self-care education programs, peer support and group therapy. End-of-life decision making protocols initiated in patients with severe injuries were associated with increased utilization of comfort-focused treatments. Most existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Future research opportunities include: intervention generation and testing for under-researched domains and standardizing language and outcomes across palliative care interventions.

633 ‘Living Well’ After Burn Injury: Using Case Report Mapping to Illustrate Life Changing Contributions from the Burn Model System Research Program

Abstract Introduction The Burn Model System (BMS) program of research has been funded since 1994. The overarching aim of this program is to improve outcomes and quality of life for people with disabilities in the areas of: 1) health and function, 2) employment, and 3) community living and participation. This review reports BMS contributions that have positively impacted lives of individuals with a significant burn injury using case report mapping to relate contributions to the recovery of a burn survivor. Methods Peer-reviewed publications derived from BMS data were reviewed in July 2019 for significant contributions as identified by current grantees. Results With 25 years of funding, many unique contributions (see Table) with direct benefit to patient recovery were identified and categorized into one of the following areas: Treatment, Assessment measures, Sequelae, Peer support, Employment, and Long-term functional outcomes. A second review for significant results of BMS research that add to the understanding of burn injury, pathophysiology and recovery research were identified and categorized as Injury and recovery research. Conclusions The knowledge generation and clinical innovation that this program has contributed to our collective understanding of recovery after burn injury is considerable. Using a case study story board, impact of these findings will be illustrated. Applicability of Research to Practice Past contributions help inform future research, particularly in the arena of rehabilitation research.

75 Burn Survivors Can Exercise for 30 Min, Even in the Heat, Without a Risk of Excessive Hyperthermia

Abstract Introduction Excision of burned skin and subsequent grafting removes sweat glands and thereby impairs thermoregulation. Consequently, rehabilitation and associated exercise may be accompanied by a greater risk of hyperthermia, depending on exercise duration, intensity and environmental temperature. Current physical activity guidelines recommend adults perform at least 150 min of moderate-intensity exercise per week, which is often divided into 30-min daily sessions. This project tested the hypothesis that burn survivors could exercise for 30 min without excessive elevations in core body temperature, regardless of the total body surface area (%TBSA) burned or environmental temperature. Methods Ten subjects cycled for 60 min at 1) a moderate intensity (97±8 watts) in a thermoneutral environment (24°C, MOD_NEU), 2) a moderate intensity (100±17 watts) in a hot environment (39°C, MOD_HOT), and 3) a low intensity (65±10 watts) in a hot environment (39°C, LOW_HOT). Burn injuries were simulated by covering 0%, 20%, 40%, or 60% of the individual’s TBSA with an absorbent material that prevented sweat evaporation. Changes in gastrointestinal temperature (ΔTcore) were analyzed at 15-min increments throughout exercise. Results For the MOD_NEU trial, there were no differences in ΔTcore between the %TBSA coverage bouts at any time point during exercise. For the MOD_HOT trial, there were no differences in ΔTcore at 15 and 30 min of exercise regardless of the %TBSA coverage, while ΔTcore was appreciably elevated (P&amp;lt; 0.05) at 45 and 60 min of exercise for 20%+ TBSA bouts. For the MILD_HOT trial, there were no differences in ΔTcore at any time point between %TBSA bouts, with the sole exception of 60% simulated burn having a slightly greater ΔTcore (0.3±0.34°C; P&amp;lt; 0.05) at 60 min of exercise relative to the 0% TBSA bout. Conclusions These data indicate that individuals with up to 60% of their TBSA burned could exercise at a moderate intensity for 30 min, even in hot environmental conditions, without excessive elevations in body core temperature. Applicability of Research to Practice Individuals with significant burn injuries can benefit from exercise, without the risk of excessive hyperthermia, for up to 30 min in the heat or at least 60 min in an air conditioned space. Funding: DOD W81XWH-15-1-0647

Opportunities for Palliative Care in Patients With Burn Injury—A Systematic Review

ContextPatients with significant burn injuries likely have palliative care needs. ObjectivesWe performed a systematic review of existing evidence concerning the palliative care needs of burn patients. MethodsThrough November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles involved burn-injured patients treated with an intervention targeting at least one of the eight domains. ResultsOur searches yielded 7532 unique records, which led to 238 articles for full review and 88 studies that met inclusion criteria. Seventy-five studies addressed the domain physical aspects of care and merit a separate systematic review; 13 studies were included in our final review. Four of the seven domains—processes of care, psychologic symptoms, social aspects, and end of life—were addressed by studies but three domains—spiritual, cultural, or ethics—were unaddressed. Included studies highlight potential benefits from peridischarge self-care education programs, peer support, and group therapy in improving quality of life. In patients with severe injuries, end-of-life decision-making protocols were associated with increased utilization of comfort-focused treatments. ConclusionMost existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Opportunities exist for further research of palliative care in burn populations with emphasis on addressing interventions for all domains and better standardizing the language and outcomes for the palliative care interventions.

87 The Development of Acute Kidney Injury in Burn Patients Undergoing Computed Tomography with Intravenous Contrast

Acute kidney injury (AKI) is a major complication of significant burn injuries and may be a significant cause of patient morbidity and mortality. Contrast-induced nephropathy is one of the common causes of acute renal failure in hospitalized patients. Patients that sustain both burn injuries and blunt traumatic injuries may require computed tomography (CT) imaging as part of their initial management. The purpose of this investigation was to determine if patients with greater than 10% TBSA burns that received CT imaging with IV contrast were more likely to develop AKI during their admission. This is a multicenter retrospective chart review of patients admitted to two level I trauma centers with ≥10% TBSA burns between 2014–2017. Patients were excluded if they were admitted for less than 48 hours or died within 48 hours of admission. The electronic medical record was used to extract patient data such as demographics, TBSA, length of stay, baseline and peak creatinine, if a CT scan with IV contrast was done and amount of fluid given over the initial 24 and 48 hours. A total of 443 patients were included in the study. The average age was 45 years. The average TBSA was 23.1%, ranging from 10%-92%. Sixty-eight of the 443 patients underwent CT scans with IV contrast on admission. The rate of AKI in the total population was 8.8%. The rate of AKI between patients who did or did not receive CT scans was not statistically significant (7.4 vs 9.1%). There was no significant difference in the amount of fluids per TBSA given within the first 24 hours between those who developed an AKI and those who did not (460.9 vs 366.7). Patients who received a CT scan had a higher TBSA (29.3 vs 22.0%, p<.01). Patients who developed an AKI had a significantly higher TBSA than those who did not (44.3 vs 21%, p<.0001). Overall mortality was 11.7%. Patients who developed an AKI had a significantly higher mortality than those patients that did not (70.3% vs 6.2%, p<.0001). There was no significant difference in the development of acute kidney injury in burn patients who received CT scans with IV contrast on admission. Although the patients that received IV contrast had a higher TBSA, there was no difference in the amount of IV fluids given in the first 24 hours. The extent of the burn remains a significant risk factor for the development of AKI. Development of AKI in the burn patient is associated with increased mortality. While there is a risk of contrast induced nephropathy, the risk is not increased in burn patients and this should not prevent a thorough evaluation to rule out additional life threatening injuries in the burn trauma patient. Concern for contrast induced nephropathy should not prevent adequate trauma imaging in the burn patient.

Acute abdominal compartment syndrome in a severely burned patient: Lack of colloid fluid availability in acute resuscitation may play a role

We report on a case in which a 27-year-old male patient sustained a significant burn injury requiring admission to the intensive care unit, with respiratory support and close haemodynamic monitoring. Owing to a lack of colloid resuscitation fluids, crystalloid fluids were used exclusively. The volume of fluid required to maintain an adequate urine output also resulted in fluid sequestration in other body compartments, eventually resulting in abdominal compartment syndrome. We believe this life-threatening complication could have been avoided had colloids been available