Suspected Inhalation Injury Research Articles

Severity of Inhalation Injury and Risk of Nosocomial Pneumonia: A Retrospective Cohort Study

BackgroundThe impact of inhalation injury on risk of nosocomial pneumonia, an important complication in burn patients, is not well established. Research QuestionIs more severe inhalation injury associated with increased risk of nosocomial pneumonia? Study Design and MethodsWe performed a retrospective cohort study of patients with suspected inhalation injury admitted to a regional burn center from 2011 to 2022 who underwent diagnostic bronchoscopy within 48 hours of admission. We estimated the association of high-grade inhalation injury (abbreviated injury score [AIS] 3-4) versus low-grade inhalation injury (AIS 1-2) with nosocomial pneumonia (NP) adjusted for age, burn size, and comorbid obstructive lung disease. Death and hospital discharge were considered competing risks. ResultsOf the 245 patients analyzed, 51 (21%) had high-grade injury, 180 (73%) had low-grade injury, and 14 (6%) had no inhalation injury. Among the 236 patients hospitalized for >48 hours, NP occurred in 24/50 (48%) patients in the high-grade group, 54/172 (31%) in the low-grade group, and 2/14 (14%) in the no inhalation injury group. High-grade (vs low-grade) inhalation injury was associated with higher hazard of NP in both the proportional cause-specific hazard model (CSHR 2.04; 95% CI, 1.26-3.30; p=0.004) and Fine-Gray subdistribution hazards model (SHR for NP, 2.24; 95% CI, 1.38-3.64; p=0.001). InterpretationAmong patients with inhalation injury, more severe injury was associated with higher hazard of NP in competing risk analysis. Additional research is needed to investigate mechanisms that may explain the relationship between inhalation injury and NP and to identify more effective prevention strategies.

704 Hydroxocobalamin Is Not Associated with Methemoglobinemia in Patients with Inhalation Injury and Suspected Cyanide Toxicity

Abstract Introduction Cyanide poisoning is a serious threat to burn patients, especially those exposed to smoke from fires, often leading to cyanide toxicity and cardiovascular collapse. Cyanokit, a widely used hydroxocobalamin product able to convert cyanide molecules into safe compounds, is known for its potential to avoid methemoglobinemia, a side effect of other treatments. Concerns about cyanokit's safety, especially in burn patients, have arisen due to recent cases with elevated methemoglobin levels. This study investigates methemoglobin levels in burn patients treated with Cyanokit, aiming to enhance our understanding of cyanide antidote therapy complexities, ultimately leading to safer treatment strategies. Methods A retrospective study was conducted of burn patients admitted to a single institution from 2013-2023 with inhalation injury treated with cyanokit for suspected cyanide toxicity. We also analyzed a control cohort of similar patients with inhalation injury not treated with cyanokit. We analyzed changes and peaks in methemoglobin, lactate levels, kidney function tests, ventilator days, % total body surface area (TBSA), medications and dressings, and mortality. Results In the study, 36 patients with suspected inhalation injury were treated with cyanokit, compared to 32 patients with inhalation injury who weren't treated with cyanokit. Baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in methemoglobin levels, initial lactate levels, mortality, Baux score, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups (Table 1). When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that cyanokit administration was not significantly associated with changes in methemoglobin or mortality. Conclusions Contrary to our initial hypothesis, our study did not find significant harm or benefit of cyanokit in burn patients during the acute phase. Methemoglobin, lactate levels, mortality, and kidney function remained largely unchanged. This study's limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of cyanokit administration on burn patients' outcomes. Applicability of Research to Practice Given the high stakes involved in treating cyanide poisoning promptly, our study holds significance for refining treatment strategies and enhancing patient safety. This insight is vital for medical practitioners making critical decisions in managing cyanide poisoning in burn patients, while also underlining the need for further research to fully understand the broader impact of cyanokit administration in this context.

Hydroxocobalamin is not associated with methemoglobinemia in patients with inhalation injury and suspected cyanide toxicity and a proposed algorithm for hydroxocobalamin administration

BackgroundCyanide poisoning poses a significant threat to burn patients exposed to smoke in residential or workplace fires, leading to central nervous system dysfunction, hemodynamic instability, cardiovascular collapse, and death. Prompt administration of an effective antidote is critical. Hydroxocobalamin, a form of vitamin B12, is the gold standard treatment for cyanide toxicity, by binding to cyanide molecules and converting them into non-toxic cyanocobalamin that is eliminated by the kidneys. This mechanism is distinct from previous cyanide antidotes, which induce the formation of methemoglobin to bind to cyanide. Recent case studies have reported elevated methemoglobin levels after hydroxocobalamin administration, raising concerns regarding its safety. The current study investigates smoke inhalation patients treated with hydroxocobalamin at a single institution Burn Unit in hopes of enhancing our understanding of the complexities surrounding cyanide antidote therapy. MethodsAfter Institutional Board Approval, a retrospective cohort study was conducted. Our sample comprised burn patients with inhalation injury admitted to a single institution from 2013 to 2023 and treated with hydroxocobalamin for suspected cyanide toxicity. We also analyzed a matched control cohort of similar patients with inhalation injury not treated with hydroxocobalamin. We analyzed changes and peaks in methemoglobin levels, lactate levels, blood urea nitrogen (BUN) and creatinine, ventilator days, % total body surface area (TBSA), various types of medications and dressings, and mortality. Statistical analyses included t-tests, chi-square, linear and logistic regressions, and correlation analysis. ResultsIn the study, 36 patients with suspected inhalation injury were treated with hydroxocobalamin at the Los Angeles General (LAG) Burn Unit from 2013 to 2023, who were matched to 32 control patients with inhalation injury who were not treated with hydroxocobalamin. Demographic and baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in methemoglobin levels. The study also revealed no significant disparities in initial lactate levels, mortality, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups. When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that hydroxocobalamin administration was not significantly associated with changes in methemoglobin or mortality. Increased %TBSA, however, was linked to elevated lactate levels. ConclusionsOur investigation sought to assess the potential risks associated with hydroxocobalamin administration in burn patients with concomitant inhalation injury. Contrary to our initial hypothesis, we found no statistically significant differences in methemoglobinemia, lactate levels, mortality, or kidney function. The influence of other factors, such as methemoglobinemia-inducing drugs or hydroxocobalamin's interference with co-oximetry, adds complexity. Although elevated methemoglobin levels were observed in some cases, their clinical significance was limited. However, this study's limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of hydroxocobalamin administration on burn patients' outcomes.

Machine learning approach for predicting inhalation injury in patients with burns

BackgroundThe coronavirus disease pandemic has had a tangible impact on bronchoscopy for burn inpatients due to isolation and triage measures. We utilised the machine-learning approach to identify risk factors for predicting mild and severe inhalation injury and whether patients with burns experienced inhalation injury. We also examined the ability of two dichotomous models to predict clinical outcomes including mortality, pneumonia, and duration of hospitalisation. MethodsA retrospective 14-year single-centre dataset of 341 intubated patients with burns with suspected inhalation injury was established. The medical data on day one of admission and bronchoscopy-diagnosed inhalation injury grade were compiled using a gradient boosting-based machine-learning algorithm to create two prediction models: model 1, mild vs. severe inhalation injury; and model 2, no inhalation injury vs. inhalation injury. ResultsThe area under the curve (AUC) for model 1 was 0·883, indicating excellent discrimination. The AUC for model 2 was 0·862, indicating acceptable discrimination. In model 1, the incidence of pneumonia (P < 0·001) and mortality rate (P < 0·001), but not duration of hospitalisation (P = 0·1052), were significantly higher in patients with severe inhalation injury. In model 2, the incidence of pneumonia (P < 0·001), mortality (P < 0·001), and duration of hospitalisation (P = 0·021) were significantly higher in patients with inhalation injury. ConclusionsWe developed the first machine-learning tool for differentiating between mild and severe inhalation injury, and the absence/presence of inhalation injury in patients with burns, which is helpful when bronchoscopy is not available immediately. The dichotomous classification predicted by both models was associated with the clinical outcomes.

Maternal and Fetal Outcome in Second and Third Trimesters of Pregnancy with Burn

Introduction: Burns in pregnancy is common in Bangladesh. Burns are a major, global public health problem, resulting in an estimated 195,000 deaths annually. The majority of burns occur in low-and middle-income countries, with almost half occurring in the World Health Organization (WHO) South-East Asia Region. Objective: To assess the maternal and fetal outcome in second and third trimesters of pregnancy with burn. Methods: This is a retrospective study was conducted in Burn and plastic surgery unit Dhaka Medical College Hospital, Dhaka, Bangladesh from March to May 2022. Total 28 patients admitted were included. The data was collected on the basis of age, percentage of burn over the body surface, gestational age, maternal and foetal outcome. All admitted patients having burn with live pregnancy was included in the study and epidermal burn and burn with other severe co-morbidities were excluded from the study group. All patients were informed about the study. Then those patients willing to take part in the study were included. Results: Total 28 patients (3.1% of female burn patient of childbearing age), having burn with Pregnancy were included in this study fulfilling the inclusion and exclusion criteria. Among 28 patients, 10 (35.7%) patients were in age group 15-20 years followed by 11 (39.3%) in age group 21-25 years, 5 (17.8%) in age group 26-30 and 1 (3.6%) patient each was in age group 31-35 years and 41-45 years group. Age range was 16-45years. 96.4% burn Accidental and 3.6% burn Suicidal. Among 28 patients, 16 (57.1%) were survived after treatment and 12 (42.9%) patients died. The causes of death were septicemia and MODS in maximum cases. Fetal outcome shows, 16(57.1%) fetus were survived. Of them 8 pregnancy continued till discharge, 8 babies were delivered during treatment period (6 by normal vaginal delivery, 2 by caesarian section). 12 (42.9%) fetal death occurred. Among them 5 fetus died with maternal death, 1 intrauterine death follower by normal delivery and 1 still birth occurred. Conclusion: Most burns with pregnancy are in the 16-30 years age group and accident was the major cause of injury. Inhalation injury, burn related complications like burn shock, septicemia and infection are major factors responsible for maternal and fetal mortality. Early hospitalization, prompt and aggressive fluid management, proper management of suspected inhalation injury and early identification and management.

Suspected Inhalation Injury and other Factors related to Mortality in Hospitalized Burn Patients in Peru

Inhalation Injury is a risk factor for mortality in burn patients; the diagnosis is suspected by clinical history and findings. Aims: Determine if suspected inhalation injury is a risk factor for mortality in burn patients and if there are other risk factors. Retrospective cohort study that included 156 medical records in the HNAL between 2015-2016. Dependent variable was mortality and independent variables included suspected inhalation injury, sex, age, depth and extent of burn and place of origin. Relative risks were estimated. The HNAL “Thermic Registry” was used for data recollection.Descriptive analyzes performed with median and interquartile ranges and relative and absolute frequencies for categorical variables. Fisher, Chi square and U Mann Whitney tests were used in bivariate analysis. Poisson Regression was used in multivariate analysis. Overall mortality of 9%. 46% of patients had suspected inhalation injury. Percentage of deceased patients was higher in those exposed to suspected inhalation injury (16.7% vs. 2.38%), place of origin outside Lima (16.7% vs. 5.56%), third-degree burn (13.3% vs. 1.72%) and median extent of burn (56.3 vs. 10). Suspected inhalation injury [RR: 6.24 (IC95% 1.48-26.3) (p:0.013)], third degree burn [RR 6.86 (IC95% 1.17-40.2) (p:0.033)], burn extension greater than 11% [RR 6.12 (IC95% 1.77-21.1) (p:0.004)] and place of origin outside Lima [RR 3.69 (IC95% 1.54-8.86) (p:0.003)] were significant in multivariate analysis. Suspected inhalation injury, third degree burn, extension greater than 11% and place of origin outside Lima are risk factors for mortality in burn patients.

The utility of arterial blood gas parameters and chest radiography in predicting appropriate intubations in burn patients with suspected inhalation injury—A retrospective cohort study

BackgroundThis study evaluates the utility of arterial blood gas (ABG) parameters and chest radiography in predicting intubation need in patients with burn injuries with suspected inhalation injury. MethodsPatients with suspected inhalation injury admitted to a single centre, Burn Intensive Care Unit, between April 4th 2016 and July 5th 2019, were included. Admission ABG parameters and chest radiograph opacification were compared with whether the patient received an appropriate intubation: defined as intubation for a duration of over 48 h. Area under the receiver operator characteristic curve was calculated (AUROC). ResultsEighty-nine patients were included. The majority (84%; n = 75) were intubated, of which 81% (n = 61) received appropriate intubations. pH had an AUROC of 0.88 and a pH of <7.30 had an 80% sensitivity and specificity for detecting appropriate intubation. P/F ratio had an AUROC of 0.81 and a P/F ratio of <40 had a 70% sensitivity and specificity for appropriate intubation. Chest radiograph opacification had poor utility in this regard (AUROC = 0.69). Adding pH and P/F ratio to the ABA criteria improved their sensitivity in detecting appropriate intubations (sensitivity: ABA + pH + P/F = 0.97 vs ABA = 0.86; p = 0.013), without altering their specificity. ConclusionsIn patients suspected inhalation injury, pH and P/F ratio were good predictors for appropriate intubations. Incorporating the parameters into the ABA criteria improved their clinical utility.

Analysis of risk factors of mortality for pediatric burned patients with inhalation injury and comparison of different treatment protocols.

We present our approach of pediatric burned patients with the suspicion of inhalation injury. This retrospective study was conducted on children with the suspicion of inhalation injury admitted to our burn center from December 2009 to December 2019. We collected data on patient demographics, total burn surface area (TBSA), presence of inhalation injury, level of carboxyhemoglobin, grade of inhalation injury, duration of mechanical ventilation, reintubation rate, total length of hospital stay, and the mortality rate. We also reviewed the required treatment of patients with inhalation injury. A total of sixty pediatric burn patients were suspected inhalation injury were included in this retrospective study. 40 pa-tients included in the study were male. Age average of the patients was 87.7 months. Total burned surface area average was 32%. 46 of these patients had inhalation injury. Patients with larger cutaneous burn and needed early intubation have a higher risk of inhalation injury. There was no significant relation between inhalation injury grades and mortality and treatment protocols. Higher levels of car-boxyhemoglobin and larger TBSA are the risk factors for mortality at univariate analysis. Pediatric patient with inhalation injury whose TBSA is higher than 47.5% has a 5 times higher risk of mortality at multivariate analysis. This study demonstrated that TBSA is the risk factor that independently affects the mortality in pediatric patients with inhalation injury. Among the patients with higher than 47.5% burn surface area, the mortality rate rises 5 times.

Soluble suppression of tumorigenicity-2 predicts pneumonia in patients with inhalation injury: Results of a pilot study

IntroductionSeveral mechanisms play a role in the development of pneumonia after inhalation injury. Our aim was to analyze whether higher concentrations of inflammatory markers or of biomarkers of epithelial injury are associated with a higher incidence of pneumonia in patients with inhalation injury. Material and methodsSecondary analysis of a single-center prospective observational cohort pilot study, performed over a two-year period (2015–2017) at the Burns Unit of the Plastic and Reconstructive Surgery Department of Vall d’Hebron University Hospital. All patients aged 18 with suspected inhalation injury undergoing admission to the Burns Unit were included. Plasma biomarkers of the lung epithelium (RAGE and SP-D), inflammation markers (IL6, IL8), and IL33, as well as soluble suppression of tumorigenicity-2 (sST2) levels, were measured within the first 24 h of admission. ResultsTwenty-four patients with inhalation injury were included. Eight (33.3%) developed pneumonia after a median of 7 (4–8) days of hospital stay. Patients with pneumonia presented higher plasma concentrations of sST2 (2853 [2356–3351] ng/mL vs 1352 [865–1839] ng/mL; p < 0.001), IL33 (1.95 [1.31–2.59] pg/mL vs 1.26 [1.07–1.45] pg/mL; p = 0.002) and IL8 (325.7 [221.6–430.0] pg/mL vs 174.1 [95.2–253.0] pg/mL; p = 0.017) on day 1 of inclusion. Plasma sST2 concentration in the first 24 h demonstrated excellent diagnostic accuracy for predicting the occurrence of pneumonia in patients with smoke inhalation (AUROC 0.929 [95%CI 0.818–1.000]). A cutoff point of ≥2825 ng/mL for sST2 had a sensitivity of 75% and a specificity of 100%. The risk ratio of pneumonia in patients with sST2 ≥ 2825 ng/mL was 7.14 ([95% CI 1.56–32.61]; p = 0.016). ConclusionsPlasma sST2 in the first 24 h of admission predicts the occurrence of pneumonia in patients with inhalation injury.

Harvesting human skin allografts for burn care in a developing country

The usage of fresh and glycerolized preserved human skin allograft in burn care is a challenge in a developing countries despites it’s benefits in improving morbidity and mortalities in burn patients. We present two case reports to demonstrates it’s usage. In our first case report, the skin harvested allograft was from a consented patient who was undergoing abdominoplasty. It was harvested as a full thickness skin graft from the panniculus. The harvested skin allograft underwent process of glycerolisation and was stored in 85% glycerol in a fridge at 4°C. The skin allografts were used on the donor site of a patient with 51 percent burns undergoing burn wound excision and skin grafting. The skin was secured with sutures and adherence of the skin allograft on the donor site was noted on the wound review on the third day. Evidence of rejection of some parts of the skin allograft (sloughing off of the skin) was noted by the 7th day post-surgery. The second case report, a two-year-old girl who presented with 37% total burn surface area predominantly deep dermal flame burn injury with suspected inhalation injury. She had tangential wound excision and split thickness skin grafting with both autograft and living donor allograft (donor was the mother). The donor was screened for human immunodeficiency virus (HIV) I and II, hepatitis B surface antigen (HBsAg) and hepatitis C virus (HCV). The autografts were meshed 6:1. Allografts were previously harvested from the thigh of the mother on the same day using a power dermatome and meshed 3:1. By the 12th day, there was a 60% loss of the allograft on the left thigh while there was 5% graft loss for the autograft. On the right thigh, there was a 50% graft loss for the allograft while there was a 2% graft loss for the autograft. Human Skin allograft can be used as an option for wound coverage in patients who have sustained burns.

The Predictive Applicability of Liberal vs Restrictive Intubation Criteria in Adult Patients With Suspected Inhalation Injury-A Retrospective Cohort Study.

This study compares the ability of liberal vs restrictive intubation criteria to detect prolonged intubation and inhalation injury in burn patients with suspected inhalation injury. Emerging evidence suggests that using liberal criteria may lead to unnecessary intubation in some patients. A single-center retrospective cohort study was conducted in adult patients with suspected inhalation injury admitted to intensive care at Queen Elizabeth Hospital, Birmingham between April 2016 and July 2019. Liberal intubation criteria, as reflected in local guidelines, were compared to restrictive intubation criteria, as outlined in the American Burn Association guidelines. The number of patients displaying positive characteristics from either guideline was compared to the number of patients who had prolonged intubation (more than 48 hours) and inhalation injury. In detecting a need for prolonged intubation (n = 85), the liberal criteria had greater sensitivity (liberal = 0.98 [0.94-1.00] vs restrictive = 0.84 [0.75-0.93]; P = .013). However, the restrictive criteria had greater specificity (restrictive = 0.96 [0.89-1.00] vs liberal = 0.48 [0.29-0.67]; P < .001). In detecting inhalation injury (n = 72), the restrictive criteria were equally sensitive (restrictive = 0.94 [0.87-1.00] vs liberal = 0.98 [0.84-1.00]; P = .48) and had greater specificity (restrictive = 0.86 [0.72-1.00] vs liberal = 0.04 [0.00-0.13]; P < .001). In patients who met liberal but not restrictive criteria, 65% were extubated within 48 hours and 90% did not have inhalation injury. Liberal intubation criteria were more sensitive at detecting a need for prolonged intubation, while restrictive criteria were more specific. Most patients intubated based on liberal criteria alone were extubated within 48 hours. Restrictive criteria were highly sensitive and specific at detecting inhalation injury.

Baux Score as a Predictor of Mortality at the CHBAH Adult Burns Unit

BackgroundThe Chris Hani Baragwanath Academic Hospital (CHBAH) Adult Burns Unit (ABU) often operates in excess of its capacity. Our aim was to investigate the risk factor profile of the ABU population and to apply the Baux score as a model for predicting mortality to assist with appropriate resource allocation. MethodsIn this retrospective study, the Baux score was calibrated to the mortality rates in ABU burn population and the effects of various variables on mortality were assessed with Mann-Whitney U-test, chi-square test, and regression analysis. ResultsThe relationship between the Baux score and mortality rate was characterized by this regression equation: y = −0.0002×3 + 0.0547×2 - 2.5815× + 32.649, which was used to tabulate expected mortalities per Baux score band. Univariable regression analysis revealed that Baux score, gender, suspected inhalation injury, mechanism, and intent each had statistically significant associations with mortality (P-values <0.05), whereas the multivariable model showed that only Baux score, gender, and suspected inhalation injury were statistically significant factors in predicting mortality. ConclusionsAn increase in the Baux score is the most predictive and statistically significant risk factor and is easy to calculate. Thus, expected mortality can be determined using the Baux score band versus mortality table created in this study to assist with prioritizing patients in a resource-limited environment.

Epidemiological study of burn patients admitted in tertiary care hospital in India and associated risk factors: A retrospective observational review

Introduction: Burn injuries constitute a major part of traumatic injuries and most commonly are accidental. They have devastating mental and functional sequelae apart from increased chances of mortality. Knowledge about the prognosis of various burn injuries and the risk factors leading to complications helps treat them. This study was undertaken to document the epidemiological data of burn patients admitted in Pt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, from January 2019 to December 2019. Materials and Methods: Demographic details including age, sex, cause and nature of injury, associated comorbidities, depth and percentage of body area involved, involvement of the face and suspected inhalation injury, survival, period of survival, and mortality rate were recorded. For the pediatric population, weight for age was taken as an indicator for nutrition. Patients who left against medical advice were excluded from the study. P Results: Burn injuries were most common in the age group of 21–60 years. Males were more commonly injured. Thermal injuries were most common (91%), followed by electric burns. Accidental burns were 88%, in 9% alleged history of suicide, and in rest, homicide was suspected. Out of 104 pediatric patients, 50% were undernourished. The mortality among undernourished patients had the odd's ratio of 8.5. The survival rate was 81% overall. It was noted that burns more than 40% total body surface area (TBSA) involvement had mortality of 56.25% and 9.44% in Conclusion: Pediatric age group, inhalation injury, undernutrition, and thromboembolism are factors which contribute to increased mortality, apart from large TBSA involvement. Initial 10 days need careful monitoring to decrease mortality and initiate early treatment. Limitation: This study has been conducted in a tertiary care hospital. Only referred cases needing hospital care were included in this study. Hence, the data represent only a part of demographic data sustaining burn injuries.

Impact of diagnostic bronchoscopy in burned adults with suspected inhalation injury

IntroductionInhalation injury is a common complication of thermal trauma. Fiberoptic bronchoscopy (FOB) is regarded as current standard practice in diagnosing and grading inhalation injury. Nonetheless, its predictive value in terms of therapeutic decision-making and clinical outcome is controversial. MethodsAdult burn patients with inhalation injury (InI) were selected from the National Burn Repository of the American Burn Association. Subjects were propensity score pair-matched based on injury severity and grouped based on whether or not FOB had been performed (FOB, CTR, respectively). Mortality, incidence of pneumonia, length of hospitalization, length of ICU stay and dependency on mechanical ventilation were compared between the two groups. Results3014 patients were matched in two groups with a mean TBSA of 22.4%. There was no significant difference in carboxyhemoglobin fraction at admission. Patients, who underwent FOB on admission had a significantly increased incidence of pneumonia (p < 0.001), mortality (p < 0.05), length of hospitalization (p = 0.002), ICU stay (p < 0.001) and duration of mechanical ventilation (p = 0.006). In a subgroup analysis of patients with TBSA of at least 20%, incidence of pneumonia was significantly higher in the FOB group (p < 0.001) and longer mechanical ventilation was required (p = 0.036). DiscussionDiagnosis and grading of InI through FOB is the current standard, although its predictive value regarding key outcome parameters and therapeutic decision-making, remains unclear. The potential procedural risk of FOB itself should be considered. This study demonstrates correlations of FOB with major clinical outcomes in both a general collective of burned adults as well as severely burned adults. Although these findings must be interpreted with caution, they may induce further research into potential harm of FOB and critical review of routine diagnostic FOB in suspected inhalation injury in thermally injured patients.

Securing airway in a burn patient with inhalation injury – A narrow escape

Inhaltion injury is one of the major determinants of the outcome, morbidity and mortality in burn patients. Early intervention to secure the airway in a suspected inhalation injury proves vital in the management and outcome of such patients. Failure to identify such cases will push the attending physicians into a vortex and the patients will succumb to the injury. High degree of suspicion and the ability to identify airway burns is a must for all physicians involved in the management of burn patients. Here we present a case of inhalation injury where airway management was delayed by a few hours due to technical and logistic issues, where in we had a very hard time securing the airway.

Selective Digestive Decontamination Attenuates Organ Dysfunction in Critically Ill Burn Patients.

To evaluate whether selective decontamination of the digestive tract (SDD) attenuates organ dysfunction in critically ill burn patients. The effect of SDD on the development and progression of organ dysfunction, as an important determinant of mortality in burned patients, is still unknown. We asked whether organ dysfunction is mitigated by treatment with SDD. Patients with burns >20% of total body surface or suspected inhalation injury from a randomized placebo-controlled trial were analyzed to determine the relationship between treatment received (placebo or SDD) and the severity of organ dysfunction as measured by the area under the curve of the Sequential Organ Failure Assessment (SOFA) score (and its individual components) from day 1 to day 7 of admission. One hundred seven patients (53 in the SDD group and 54 in the placebo group) were included. Survival was significantly higher in SDD-treated patients (48 of 53, 90.6%) than in placebo-treated patients (39 of 54, 72.2%, P = 0.013). Total (P < 0.01) and respiratory (P < 0.01), cardiovascular (P = 0.04) and hematological (not reaching statistical significance, P = 0.07) organ dysfunction was associated with mortality after adjusting for predicted mortality. In multivariate logistic regression, SDD treatment was independently associated with total (P < 0.01), respiratory (P = 0.02), and hematological (P < 0.01) dysfunction over the first week postinjury. The beneficial effect of SDD on mortality in critically ill burned patients is accompanied by a reduction in the degree of organ dysfunction. SDD seems to be a valuable therapeutic strategy to prevent organ dysfunction and, more specifically, respiratory and hematological dysfunction in severely ill burn patients.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland

IntroductionInitial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines. Material and methodsA specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered. Results17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance. ConclusionWhile many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.

Management of the Patient with Thermal Injuries

Optimal care of the burn patient requires not only specialized equipment but also, more importantly, a team of dedicated surgeons, nurses, therapists, nutritionists, pharmacists, social workers, psychologists, and operating room staff. Burn care was one of the first specialties to adopt a multidisciplinary approach, and over the past 30 years, burn centers have decreased burn mortality by coordinating prehospital patient management, resuscitation methods, and surgical and critical care of patients with major burns. This review covers where to treat burn patients, fluid management, airway management, temperature regulation, airway control, nutrition, anemia, pain management, deep vein thrombosis prophylaxis, and putting it all together: an algorithmic approach to early care of the burn-injured patient. Figures show that the size of a burn can be estimated by means of the Rule of Nines, which assigns percentages of total body surface to the head, the extremities, and the front and back of the torso, the approach to the burn patient in the first 24 hours, and the approach to the burn patient during the second to fifth days after burn injury. Tables list American Burn Association criteria for burn injuries that warrant referral to a burn unit, criteria for outpatient management of burn patients, acute physiologic changes during burn resuscitation, acute biochemical and hematologic changes during burn resuscitation, measures of pulmonary function, mechanisms of pulmonary dysfunction and indications for mechanical ventilation, clinical manifestations of carbon monoxide poisoning, half-life of carbon monoxide–hemoglobin bonds with inhalation therapy, increased acute kidney injury in patients treated with hydroxocobalamin for suspected inhalation injury, clinical findings associated with specific inhaled products of combustion, bronchoscopic criteria used to grade inhalation injury, and formulas for estimating caloric needs in burn patients. This review contains 3 highly rendered figures, 12 tables, and 134 references

Management of the Patient with Thermal Injuries

Optimal care of the burn patient requires not only specialized equipment but also, more importantly, a team of dedicated surgeons, nurses, therapists, nutritionists, pharmacists, social workers, psychologists, and operating room staff. Burn care was one of the first specialties to adopt a multidisciplinary approach, and over the past 30 years, burn centers have decreased burn mortality by coordinating prehospital patient management, resuscitation methods, and surgical and critical care of patients with major burns. This review covers where to treat burn patients, fluid management, airway management, temperature regulation, airway control, nutrition, anemia, pain management, deep vein thrombosis prophylaxis, and putting it all together: an algorithmic approach to early care of the burn-injured patient. Figures show that the size of a burn can be estimated by means of the Rule of Nines, which assigns percentages of total body surface to the head, the extremities, and the front and back of the torso, the approach to the burn patient in the first 24 hours, and the approach to the burn patient during the second to fifth days after burn injury. Tables list American Burn Association criteria for burn injuries that warrant referral to a burn unit, criteria for outpatient management of burn patients, acute physiologic changes during burn resuscitation, acute biochemical and hematologic changes during burn resuscitation, measures of pulmonary function, mechanisms of pulmonary dysfunction and indications for mechanical ventilation, clinical manifestations of carbon monoxide poisoning, half-life of carbon monoxide–hemoglobin bonds with inhalation therapy, increased acute kidney injury in patients treated with hydroxocobalamin for suspected inhalation injury, clinical findings associated with specific inhaled products of combustion, bronchoscopic criteria used to grade inhalation injury, and formulas for estimating caloric needs in burn patients. This review contains 3 highly rendered figures, 12 tables, and 134 references

Initial evaluation and management of the critical burn patient

The major improvement in burn therapy is likely to focus on the early management of hemodynamic and respiratory failures in combination with an aggressive and early surgical excision and skin grafting for full-thickness burns.Immediate burn care by first care providers is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to cease the burning process as well as prevent future complications and secondary injuries for burn shock. Identifying burn patients appropriate for immediate or subacute transfer is an important step in reducing morbidity and mortality. Delays in transport to Burn Unit should be minimized.The emergency management follows the principles of the Advanced Trauma Life Support Guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure and environment control.All patients with suspected inhalation injury must be removed from the enclosure as soon as possible, and immediately administer high-flow oxygen. Any patient with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, and history of being in a fire in an enclosed space should be strongly considered for early intubation. Fibroscopy may also be useful if airway damage is suspected and to assess known lung damage.Secondary evaluation following admission to the Burn Unit of a burned patient suffering a severe thermal injury includes continuation of respiratory support and management and treatment of inhalation injury, fluid resuscitation and cardiovascular stabilization, pain control and management of burn wound.