Significant Burn Injury Research Articles

Virtual reality analgesia for burn joint flexibility: A randomized controlled trial.

We conducted a randomized controlled study to determine the effects of virtual reality (VR) distraction on pain and range of motion (ROM) in patients hospitalized for burn care during active physical therapy exercises. Thirty-nine participants aged 15 to 66 (M = 36) years with significant burn injuries (mean burn size = 14% TBSA) participated. Under therapist supervision, using a within-subjects design, participants performed unassisted active ROM exercises both with and without VR distraction in a randomized order. Therapists provided participants with instructions but did not physically assist with stretches. Maximum active ROM was measured using a goniometer. A 0-100 Graphic Rating Scale (GRS) was used to assess the cognitive, affective, and sensory components of pain. A GRS rating of the amount of "fun" during stretching served as a measure of positive experience. Participants reported lower mean GRS ratings during VR, relative to No VR, for worst pain, pain unpleasantness, and time spent thinking about pain. They also reported having a more positive experience during VR than during No VR. However, patients did not show greater ROM during VR. Immersive VR reduced pain during ROM exercises that were under the control of the patient. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Intentional self-inflicted and peer-inflicted aerosol skin injuries called 'frosties': Cohort series and systematic literature review.

'Frosties' are deliberate cold skin burns caused by an aerosol device. The aim of this article was to examine our own cohort, and those previously published, to identify the key features of patients presenting with frosties and inform appropriate early clinical interventions. We compared cases in our dataset that occurred between 1 January 2013 and 30 June 2017 with those reported in the literature, focusing on seven domains: sex, age at injury, days to presentation, first aid, depth of injury and outcome. The median patient age was 13 years; 70.5% were female. Adequate first aid was not reported in any patient. Where recorded, the median time to presentation to a health service was six days. Where severity of injury was recorded, 13 of 37 cases (35.1%) were full thickness, and 10 patients received a split thickness skin graft. Two subgroups were identified: cluster injuries and psychological distress. Cluster injuries occur as the result of a mutual 'test of courage'. Solo injuries may point to underlying psychological distress. Frosties frequently result in significant burn injuries and often require skin grafting. The severity of frosties is underappreciated and, as a consequence, treatment, through first aid or presentation to a health service, is delayed or absent. General practitioners should be familiar with the appearance of frosties in order to identify them in unrelated consultations.

Intentional self-inflicted and peer-inflicted aerosol skin injuries called ‘frosties’: Cohort series and systematic literature review

'Frosties' are deliberate cold skin burns caused by an aerosol device. The aim of this article was to examine our own cohort, and those previously published, to identify the key features of patients presenting with frosties and inform appropriate early clinical interventions.We compared cases in our dataset that occurred between 1 January 2013 and 30 June 2017 with those reported in the literature, focusing on seven domains: sex, age at injury, days to presentation, first aid, depth of injury and outcome.The median patient age was 13 years; 70.5% were female. Adequate first aid was not reported in any patient. Where recorded, the median time to presentation to a health service was six days. Where severity of injury was recorded, 13 of 37 cases (35.1%) were full thickness, and 10 patients received a split thickness skin graft. Two subgroups were identified: cluster injuries and psychological distress.Cluster injuries occur as the result of a mutual 'test of courage'. Solo injuries may point to underlying psychological distress. Frosties frequently result in significant burn injuries and often require skin grafting. The severity of frosties is underappreciated and, as a consequence, treatment, through first aid or presentation to a health service, is delayed or absent. General practitioners should be familiar with the appearance of frosties in order to identify them in unrelated consultations.

Cardiac Sequelae of Severe Burn Injury

Research Article| March 01 2018 Cardiac Sequelae of Severe Burn Injury AAP Grand Rounds (2018) 39 (3): 34. https://doi.org/10.1542/gr.39-3-34 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Cardiac Sequelae of Severe Burn Injury. AAP Grand Rounds March 2018; 39 (3): 34. https://doi.org/10.1542/gr.39-3-34 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: burns, cardiac complications Source: Hundeshagen G, Herndon DN, Clayton RP, et al. Long-term effect of critical illness after severe paediatric burn injury on cardiac function in adolescent survivors: an observational study. Lancet Child Adolesc Health 2017; 1: 293– 301; doi. https://doi.org/10.1016/S2352-4642(17)30122-0Google Scholar Investigators from multiple institutions conducted a prospective observational study to assess the long-term cardiac sequelae of adolescent survivors of severe pediatric burn injury. Participants were eligible if they had a history of severe burn affecting at least 30% of the total body surface area at least 5 years before the study period, were treated acutely for the burn at the study institution, and were receiving follow-up care at the study institution. A convenience sample of healthy controls was also enrolled as age-matched controls. All study participants had demographic and medical information collected at enrollment, and all underwent transthoracic echocardiography to measure ejection fraction, diastolic function, ventricular compliance, and myocardial fibrosis. Exercise testing was also performed to assess peak oxygen consumption (VO2). Symptoms of heart failure were assessed among burn participants using the New York Heart Association (NYHA) classification (class I: no symptoms or limitation, class II: mild symptoms, class III: marked limitation in activity due to symptoms, and class IV: severe limitations). Investigators compared the cardiac characteristics among burn participants and healthy controls. Data on 40 burn participants and 25 healthy controls were included in analysis. Compared to healthy controls, burn participants had significantly lower ejection fractions (52% vs 61%, P=.004), worse diastolic function, and more myocardial fibrosis. Burn participants also had significantly lower absolute VO2 during exercise testing compared to healthy controls. Overall, most burn participants were classified as NYHA class I (65%), with 33% class II, 3% class III, and none as class IV. The investigators conclude that adolescent survivors of severe burns have long-term reductions in ejection fraction, diastolic function, and exercise tolerance. Dr Spar has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Significant burn injuries can lead to systemic responses affecting every organ system, including the heart and circulatory system. Acutely, cardiac stress secondary to increased catecholamine response is marked by tachycardia, increased myocardial oxygen consumption, and increased cardiac output. There are also elevated levels of catecholamines and stress hormones that persist for many years.1 Though the short-term activation of the stress response is important for survival, the prolonged duration leads to deleterious effects on metabolism, immune function, and cardiovascular function.2 Duke et al3 performed a population-based longitudinal study reviewing children with burn injuries and found that children with burns had 1.3 times as many admissions and 2.3 times the number of days in hospital for circulatory diseases. In a separate population-based longitudinal study, the same authors demonstrated that burn patients had increased hospital admission rates, prolonged length of hospital stay, and increased long-term mortality related to circulatory system diseases.1 The results of... You do not currently have access to this content.

Experience with a synthetic bilayer Biodegradable Temporising Matrix in significant burn injury

The NovoSorb™ Biodegradable Temporising Matrix (BTM) has been developed and evaluated over the past 12years, with publications documenting each step. The final step in our evaluation was a pilot human study of the efficacy of BTM in significant (20–50% TBSA full-thickness) burns. Following immediate (or very early) burn excision, BTM implantation was followed by its monitored integration. The timing of delamination and definitive grafting over the integrated polyurethane foam matrix was determined by the subject’s physiological status and the availability of split-skin autograft donor site but was typically around four weeks after the burn debridement. Donor site shortage forced serial grafting in some, which required the BTM to remain laminated for up to 7weeks without ill effect (spontaneous delamination, granulation tissue formation and wound contraction). The five subjects survived. Of 122% TBSA covered by BTM over the 5 subjects, <7% TBSA was removed for failure to adhere/integrate. Issues such as haematoma required removal and replacement of 9% TBSA with fresh BTM, with complete subsequent integration. The scar results at 12months using POSAS and MAPS scar scales were very good, both subjectively and objectively, considering the size and depth of the initial injuries. The culmination of this work has been the introduction of this novel material into our clinical practice.

Current Concepts in the Medical Management of the Pediatric Burn Patient

Management of the pediatric burn patient involves a careful, multi-faceted approach in order to meet treatment goals. Due to advances in surgical and medical care, mortality and morbidities can be minimized. This chapter seeks to address current advances which allow practitioners to provide excellent systemic care. Judicious fluid management of children with severe burn injury can improve the respiratory outcome measures of these children. A multi-modal approach to pain and sedation can improve the neurologic status of severely burned children. Children with significant burn injury can have the most favorable outcomes when the principles of skillful critical care are applied. Systemic critical care based on the best evidence available not only improves survival rates but also improves quality of life for these delicate patients.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care.

OBJECTIVE: Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation. DESIGN: BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles. SETTING: Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients. PARTICIPANTS: Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units. RESULTS: Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified. CONCLUSIONS: Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand. Language: en

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care.

Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation. BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles. Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients. Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units. Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified. Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.

Measuring the impact of a burns school reintegration programme on the time taken to return to school: A multi-disciplinary team intervention for children returning to school after a significant burn injury

IntroductionReturning to school can be a major step for burn-injured children, their family, and staff and pupils at the receiving school. Previous literature has recognised the difficulties children may face after a significant injury and factors that may influence a successful reintegration. AimA regional paediatric burns service recognised that some patients were experiencing difficulties in returning to school. A baseline audit confirmed this and suggested factors that hindered or facilitated this process, initiating the development of a school reintegration programme (SRP). Since the programme's development in 2009, it has been audited annually. The aim of this paper was to evaluate the impact of the SRP by presenting data from the 2009 to 2011 audits. MethodFor the baseline audit, the burn care team gathered information from clinical records (age, gender, total body surface area burned (TBSA), skin grafting and length of stay) and telephone interviews with parents and teachers of the school returners. For the re-audits, the same information was gathered from clinical records and feedback questionnaires. ResultsSince its introduction, the mean length of time from discharge to return to school has dropped annually for those that opted into the programme, when compared to the baseline by 62.3% (53 days to 20 days). Thematic analysis highlights positive responses to the programme from all involved. Increased awareness and feeling supported were amongst the main themes to emerge. ConclusionsReturning to school after a significant burn injury can be challenging for all involved, but we hypothesise that outreach interventions in schools by burns services can have a positive impact on the time it takes children to successfully reintegrate.

The Blue Man

Muriatic acid (hydrochloric acid), a common cleaning and resurfacing agent for concrete pools, can cause significant burn injuries. When coating a pool with chlorinated rubber-based paint, the pool surface is initially cleansed using 31.45% muriatic acid. Here we report a 50-year-old Hispanic male pool worker who, during the process of a pool resurfacing, experienced significant contact exposure to a combination of muriatic acid and blue chlorinated rubber-based paint. Confounding the clinical situation was the inability to efficiently remove the chemical secondary to the rubber-based nature of the paint. Additionally, vigorous attempts were made to remove the rubber paint using a variety of agents, including bacitracin, chlorhexidine soap, GOOP adhesive, and Johnson's baby oil. Resultant injuries were devastating fourth-degree burns requiring an immediate operative excision and amputation. Despite aggressive operative intervention and resuscitation, he continued to have severe metabolic derangements and ultimately succumbed to his injuries. We present our attempts at debridement and the system in place to manage patients with complex chemical burns.

Burn Injuries Resulting from Hot Water Bottle Use: A Retrospective Review of Cases Presenting to a Regional Burns Unit in the United Kingdom

Introduction. Hot water bottles are commonly used to relieve pain and for warmth during the colder months of the year. However, they pose a risk of serious burn injuries. The aim of this study is to retrospectively review all burn injuries caused by hot water bottles presenting to our regional burns unit. Methods. Patients with burns injuries resulting from hot water bottle use were identified from our burns database between the periods of January 2004 and March 2013 and their cases notes reviewed retrospectively. Results. Identified cases involved 39 children (aged 17 years or younger) and 46 adults (aged 18 years or older). The majority of burns were scald injuries. The mean %TBSA was 3.07% (SD ± 3.40). Seven patients (8.24%) required debridement and skin grafting while 3 (3.60%) required debridement and application of Biobrane. One patient (1.18%) required local flap reconstruction. Spontaneous rupture accounted for 48.20% of injuries while accidental spilling and contact accounted for 33% and 18.80% of injuries, respectively. The mean time to heal was 28.87 days (SD ± 21.60). Conclusions. This study highlights the typical distribution of hot water bottle burns and the high rate of spontaneous rupture of hot water bottles, which have the potential for significant burn injuries.

A Novel Approach to Soft-Tissue Repair

Postburn sequelae or excisional defect reconstruction after significant burn injury or resection of giant hairy nevus continues to be a significant challenge for the reconstructive surgeon. Unfortunately, the quality and quantity of available tissue for the repair of extensive defects is often limited. The techniques of tissue expansion have been used for many years to expand normal skin adjacent to the defect for the reconstruction of even wider defects in various parts of the body with its numerous advantages.Nine patients in whom reoverexpanded neighboring skin flaps were used to improve the capacity of wider soft-tissue defect coverage for postburn scar revision or excisional defect of giant hairy nevus in the various parts of the body is reported here.

Time to Rehabilitation in the Burn Population

A preliminary investigation of the burn rehabilitation population found a large variability of zero onset day frequency between facilities. Onset days is defined as the time from injury to inpatient rehabilitation admission; this variable has not been investigated in burn patients previously. This study explored if this finding was a facility-based phenomena or characteristic of burn inpatient rehabilitation patients. This study was a secondary analysis of Uniform Data System for Medical Rehabilitation (UDSmr) data from 2002 to 2007 examining inpatient rehabilitation characteristics among patients with burn injuries. Exclusion criteria were age less than 18 years and discharge against medical advice. Comparisons of demographic, medical and functional data were made between facilities with a high frequency of zero onset days versus facilities with a low frequency of zero onset days. A total of 4738 patients from 455 inpatient rehabilitation facilities were included. Twenty-three percent of the population exhibited zero onset days (n = 1103). Sixteen facilities contained zero onset patients; two facilities accounted for 97% of the zero onset subgroup. Facilities with a high frequency of zero onset day patients demonstrated significant differences in demographic, medical, and functional variables compared to the remainder of the study population. There were significantly more zero onset day admissions among burn patients (23%) than other diagnostic groups (0.5- 3.6%) in the Uniform Data System for Medical Rehabilitation database, but the majority (97%) came from two inpatient rehabilitation facilities. It is unexpected for patients with significant burn injury to be admitted to a rehabilitation facility on the day of injury. Future studies investigating burn rehabilitation outcomes using the Uniform Data System for Medical Rehabilitation database should exclude facilities with a high percentage of zero onset days, which are not representative of the burn inpatient rehabilitation population.

Treating Burn-Associated Joint Contracture

The prevention and treatment of scar contracture is critical after significant burn injuries to avoid functional impairment. However, descriptions of specific contracture treatment interventions and outcomes are limited. Our objective is to provide detailed information and range of motion outcomes regarding the use of an intensive stretching protocol for burn-associated contracture. As part of a quality improvement measure, all patients admitted to inpatient rehabilitation with burn injury were treated with at least 1 hour of daily stretching by experienced therapists and were tracked with standardized range of motion measurements. Eighty-eight joint contractures were treated across nine patients for up to 4 weeks. The average weekly improvement in range of motion was 8.2 degrees (95% confidence interval [CI], 6.5-9.9). The largest gains were seen in the first week of treatment with an average improvement of 11.2 degrees (95% CI, 8.7-13.6). Eighteen digit contractures were treated across four patients. The average weekly improvement in flexion was 7.2 mm (95% CI, 5.2-9.1) again with larger gains in the first week of treatment-12.8 mm (95% CI, 10.3-15.4). Thumb opposition improved across five patients in the first week with an average improvement of 1.4 on the opposition scale (95% CI, 0.4-2.5). Intensive stretching by experienced therapists yielded significant improvements in joint range of motion for patients with burn-associated joint contracture. Defining specific burn contracture interventions remains a key goal in advancing burn rehabilitation in the future.

A Tragic Miscommunication: Ethical Decision Making in Burns Care

Patients with extensive burns injuries are often given a poor prognosis. Those who survive after an initial early resuscitation phase often require extensive operative and critical care input, a prolonged hospital stay, and associated significant complications. The overwhelmingly high volume of patients already using the resource-stricken burns care service places extreme pressure on clinicians in respect of decisions they make about who should and should not be resuscitated. In this paper, we present the case of a young woman who sustained significant burn injuries, and discuss the ethical dilemmas encountered during the subsequent management of her care.

Ethics in burns surgery: when is enough, enough?

Patients with extensive burns injuries are often given a poor prognosis. Those who survive after an initial early resuscitation phase often require extensive operative and critical care input, a prolonged hospital stay, and associated significant complications. The overwhelmingly high volume of patients already using the resource-stricken burns care service places extreme pressure on clinicians in respect of decisions they make about who should and should not be resuscitated. In this paper, we present the case of a young woman who sustained significant burn injuries, and discuss the ethical dilemmas encountered during the subsequent management of her care.

Management of extensive cutaneous necrosis due to meningococcal septicaemia purpura fulminans with topical negative pressure (TNP) suits

Extensive cutaneous necrosis due to purpura fulminans presents many of the same treatment challenges as a significant burn injury. The areas of tissue loss are large, require complex and repeated dressings and create a significant reconstructive challenge. These patients are therefore often treated by burns multi-disciplinary teams (Ariivalo et al., Burns 24:272–274, 1). Topical negative pressure (TNP) therapy has a recognised role in the management of complex wounds, but its use is normally restricted to moderates sized defects. This paper describes a method of TNP dressing application to large purpura fulminans wound areas, including the buttocks and perineum, by fashioning ATNP suits. A photographically illustrated series is presented to demonstrate a TNP suit application in four consecutive paediatric cases of severe purpura fulminans, and they are representative of our practise. These cases illustrate how TNP suits provide a robust movement resistant dressing which removes exudate from the wound, splinting and reducing the wound area, promoting a graftable bed and facilitating graft take in these difficult to manage patients.

Severe cast burn after bunionectomy in a patient who received peripheral nerve blocks for postoperative analgesia

Although regional anesthesia offers advantages for intraoperative and postoperative pain relief, it is not possible without complications. A case of a significant burn injury after splint placement is described after a peripheral nerve block was performed for postoperative pain management. It is our hope that this case alerts physicians and others involved in the management of postoperative patients to the challenges of managing a blocked extremity after thermal cast placement and offers solutions that can be standardized.

A 6-year review of paediatric burns in the West of Ireland

Burn injury can be one of the most serious and devastating forms of trauma. In the UK, approximately 250,000 people experience burn injuries each year resulting in 16,100 hospital admissions. Of these, just almost 50% are children under the age of 16 years. The aims of this retrospective study were to define the regional incidence of significant paediatric burn injuries requiring hospital admission, as well as aetiological and demographical factors influencing this incidence. Additionally, the level of pre-hospital first aid provided, surgical procedures performed as well as morbidity and mortality resulting from these burns was identified. Case notes of 101 patients between the ages of 1 month and 16 years, admitted from January 1995 to December 2000, were reviewed retrospectively. The results, in general, were consistent with other similar studies. There were, however, certain notable differences: 35.6% burns were sustained from hot baths/showers, a higher percentage when compared to series from other European and Scandinavian countries. The level of parental and public awareness for simple first aid measures was alarmingly low, so that over half of the patients did not have any first aid help before they arrived in the hospital. More than 90% of paediatric burns are preventable. This study therefore brings up the need for devising and implementing an effective and consistent preventive strategy, including improved public health and safety education campaigns, which still appear to be receiving insufficient emphasis in Ireland.

A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child

careful selection of the appropriate mode of feeding and monitoring the success of the feeding strategy. The use of specific nutrients, which possess a drug-like effect on the immune or inflammatory state during critical illness, continues to be an exciting area of investigation. The lack of systematic research and clinical trials on various aspects of nutrition support in the PICU is striking and makes it challenging to compile evidence based practice guidelines. There is an urgent need to conduct well-designed, multicenter trials in this area of clinical practice. The extrapolation of data from adult critical care literature is not desirable and many of the interventions proposed in adults will have to undergo systematic examination and careful study in critically ill children prior to their application in this population. In the following sections, we will discuss some of the key aspects of nutrition support therapy in the PICU; examine the literature and provide best practice guidelines based on evidence from PICU patients, where available. While some PICU popu lations include neonates, A.S.P.E.N. Clinical Guidelines for neonates will be published as a separate series.