TBSA Burn Injury Research Articles

772 Analysis of Therapeutic Time and Functional Outcomes After a 92% TBSA Burn Injury

772 Analysis of Therapeutic Time and Functional Outcomes After a 92% TBSA Burn Injury

A heterogenous population of extracellular vesicles mobilize to the alveoli postinjury.

Acute lung injury and subsequent resolution following severe injury are coordinated by a complex lung microenvironment that includes extracellular vesicles (EVs). We hypothesized that there is a heterogenous population of EVs recruited to the alveoli postinjury and that we could identify specific immune-relevant mediators expressed on bronchoalveolar lavage (BAL) EVs as candidate biomarkers of injury and injury resolution. Mice underwent 30% TBSA burn injury and BAL fluid was collected 4 hours postinjury and compared with sham. Extracellular vesicles were purified and single vesicle flow cytometry (vFC) was performed using fluorescent antibodies to quantify the expression of specific cell surface markers on individual EVs. Next, we evaluated human BAL specimens from injured patients to establish translational relevance of the mouse vFC analysis. Human BAL was collected from intubated patients following trauma or burn injury, EVs were purified, then subjected to vFC analysis. A diverse population of EVs were mobilized to the alveoli after burn injury in mice. Quantitative BAL vFC identified significant increases in macrophage-derived CD44+ EVs (preinjury, 10.8% vs. postinjury, 13%; p < 0.05) and decreases in IL-6 receptor alpha (CD126) EVs (preinjury, 19.3% vs. postinjury, 9.3%, p < 0.05). Bronchoalveolar lavage from injured patients also contained a heterogeneous population of EVs derived from myeloid cells, endothelium, and epithelium sources, with CD44+ EVs being highly detected. Injury causes mobilization of a heterogeneous population of EVs to the alveoli in both animal models and injured patients. Defining EV release after injury will be critical in identifying diagnostic and therapeutic targets to limit postinjury acute lung injury.

75 Tranexamic Acid Reduces Burn Wound Conversion and Lung Inflammation in a Murine Comb Burn Model

Abstract Introduction Burn wound conversion is a process where superficial partial thickness burns convert into deep partial and even full thickness burn injuries. Unfortunately, the pathophysiology of this phenomenon is poorly understood. A therapeutic intervention that may prevent secondary progression and cell death in burn-injured tissue is desirable. Recent work by our group has established that tranexamic acid (TXA) has significant anti-inflammatory properties in addition to its well-known anti-fibrinolytic effects. This study investigates tranexamic acid as a novel therapeutic treatment to mitigate burn wound conversion and reduce systemic inflammation. Methods Sprague-Dawley rats were subjected to a hot comb burn contact injury using a 150-g brass comb preheated to 100°C, to create four rectangular burns, separated by three unburned interspaces. A subset of animals underwent the comb burn injury with an adjacent 30% TBSA contact injury using solid brass rods. The interspaces represent the ischemic zones simulating the zone of stasis. The treatment group received IP injection of TXA (100mg/kg) immediately after injury and once daily until sacrifice. Sham animals underwent an identical procedure, with application of a room temperature comb. Animals were sacrificed at 6hrs and 7-day time points post-injury. Photo images were obtained of the comb burn injury. Full-thickness biopsies from the ischemic zones and lung tissue were assessed with established histological and immunohistochemical (IHC) techniques. Results At 7-days post injury, the percentage of ischemic zones with necrosis was significantly reduced in the treatment group when compared with untreated burn controls by photographic image analysis. When compared with controls, the treatment groups had significantly less progression of ischemic zones to necrosis when assessed by standard microscopy. These findings were consistent in both the comb burn only and comb burn + 30%TBSA injury models. The TXA treatment group demonstrated significantly more expression of the regeneration marker (CTHRC-1) and a trend toward increased expression of the Ki-67 proliferation marker when compared to untreated burn group. At 6 hours post-injury, TXA significantly decreased infiltration of neutrophils in the lungs for the 30%TBSA burn injury model. Furthermore, systemic levels of mitochondrial DNA, IL-1α and TNFα were significantly lower in TXA treated animals when compared to untreated burn controls. Conclusions Animals treated with tranexamic acid demonstrated reduced burn wound conversion and decreased burn-induced SIRS response. Lung inflammation was also significantly reduced by administration of TXA after injury. Applicability of Research to Practice Tranexamic acid and agents with similar mechanisms of action may provide a treatment to reduce burn wound conversion. This therapy could be easily incorporated into standard acute burn care practices.

514 The Outcomes of Tracheostomy on Burn Inhalation injuries

IntroductionTracheostomy has been proposed for patients with expected prolonged intubation and it has been shown to be beneficial for trauma patients with severe brain injury; however, the benefit of performing tracheostomy on burn inhalation injuries has not been extensively investigated. Our study aims to determine the outcomes of performing tracheostomy on patients with burn inhalation injuries requiring mechanical ventilation.MethodsRetrospective review of our institutional burn registry from 2011 to 2019. We compared the outcomes of all burn patients that met our inclusion criteria which included: adequate data recording of inhalation injury within the registry, ventilator support for at least 24 hours, and a TBSA burn injury of < 15%. We stratified the patients into two groups: tracheostomy (group 1) versus no tracheostomy (group 2). Outcome measures included: in-hospital mortality rate, hospital length of stay, ICU length of stay, ventilator days, and ventilator associated pneumonia (VAP). Chi-squared and t-test analyses were used with significance defined as p< 0.05.ResultsA total of 33 burn patients met our inclusion criteria. Group 1 consisted of 10 patients and group 2 consisted of 23 patients. There was no statistically significant difference between the two groups in terms of %TBSA (p =0.24, t-test). There was a significantly higher ICU length of stay at 23.8 days in group 1 compared to 3.16 days in group 2 (p=0.0001, χ2). There was a significantly higher hospital length of stay at 28.4 days in group 1 compared to 5.26 days in group 2 (p=0.0001, χ2). Ventilator days was also significantly higher in group 1 with 20.8 days compared to 2.5 days in group 2. There was no statistically significant difference between the two groups in terms of mortality, however, the incidence of VAP was significantly higher in group 1 than in group 2, with six cases compared to zero cases, respectively(p=0.0001, χ2).ConclusionsThe ideal timing and implementation of tracheostomy with inhalational injury has yet to be determined. In our study, tracheostomy was associated with much longer lengths of stay and pneumonia. The impact of the underlying lung injury, versus the tracheostomy itself on these observations, is unclear. The challenge of characterizing the severity of an inhalation injury based on early visual inspection remains.

The impact of simultaneous inoculation of Pseudomonas aeruginosa, Staphylococcus aureus, and Candida albicans on rodent burn wounds

Burn wound infection often involves a diverse combination of bacterial and fungal pathogens. In this study, we characterize the mixed species burn wound infection by inoculating the burn surface with 1 × 103/4/5 CFU of Pseudomonas aeruginosa, Staphylococcus aureus, and Candida albicans in a 1:1:1 ratio. Using the revised Walker–Mason scald burn rat model, 168 male Sprague-Dawley rats (350–450 g) subject to ∼10% TBSA burn injury, with or without inoculation, were evaluated for 11 days after burn. In the wound, P. aeruginosa and S. aureus formed robust biofilms as determined by the bacterial tissue load, ∼1 × 109 CFU/g, and expression of key biofilm genes. Interestingly, within 3 days C. albicans achieved tissue loads of ∼1 × 106 CFU/g, but its numbers were significantly reduced beyond the limit of detection in the burn wound by day 7 in partial-thickness injuries and by day 11 in full-thickness injuries. The pathogenic biofilms contributed to burn depth progression, increased release of HMGB-1 into circulation from injured tissue, and significantly elevated the numbers of circulating innate immune cells (Neutrophils, Monocytes, and Basophils). This robust model of multi-species burn wound infection will serve as the basis for the development of new antimicrobials for combating biofilm-based wound infections.

The effect of neighborhood Area Deprivation Index on residential burn injury severity

IntroductionResidential fires account for the majority of burn-related injuries and fatalities. Established risk factors for burn injury include male gender, racial minority, children and elderly individuals, poverty, and substandard housing characteristics. In North Carolina, the rate of residential fire injuries and deaths is higher than the national average. Therefore, we sought to describe residential fire hospitalizations at a large regional burn center and describe the neighborhoods in which they live. We hypothesized that patients living in areas with higher Area Deprivation Index (ADI) are more likely to have major residential burns. MethodsWe conducted a retrospective analysis of burn admissions from January 2002 to December 2015. We dichotomized patients into two cohorts: residential and non-residential burns and performed a bivariate analysis. Multivariate Poisson regression models were utilized to determine if ADI was associated with inhalation injury and ≥20% total body surface area burn. ResultsOf the 10,506 patients presented during the study period. Of these, 10,016 (95.3%) patients resided in North Carolina, and 7894 (78.8%) had a residential burn. Of the overall cohort, 6.0% (n=458) of patients had ≥20% TBSA burns and 6.4% (n=506) had inhalation injury. The majority of patients were in the highest (most disadvantaged) ADI quartile (n=3050, 39.5%), and only 6.8% of patients (n=525) were in the lowest (least disadvantaged) ADI quartile. In the Poisson multivariate regressions to determine if the ADI was associated with severe burns, patients in the highest ADI quartile had an increased relative risk of ≥20% TBSA burn (RR 1.31, 95% CI 1.02–1.68) and inhalation injury (RR 1.39, 95% CI 1.09–1.76) when compared to patients in the second-lowest ADI quartile when controlled for pertinent covariates. ConclusionResidential structure fires represent the major source of burns and fatalities. People who reside in the highest ADI quartile are more like to present with higher burn injury severity in terms of burn size and the presence of inhalation injury. The use of the ADI to target neighborhoods for burn prevention is imperative.

39 Nurses Can Resuscitate

Abstract Introduction Fluid resuscitation in the first 48 hours post burn is crucial in the management of burn shock. Hourly titration of fluids is needed to avoid complications of over or under resuscitation which can increase morbidity and mortality. Historically these titrations have been driven by the burn physician; we hypothesized that given protocols with specific resuscitation parameters the burn nurse can accurately resuscitate the burn patient without complications. Methods This quality improvement project at our ABA verified adult Burn Center tracked performance of a nurse-driven protocol for all inpatients with burns who underwent formal fluid resuscitation. Education regarding the nursing-driven protocol was provided to 90 surgical intensive care nurses. Badge buddies with both the Parkland formula and the Modified Albumin formula were made for the staff. Burn order sets were updated to reflect burn resuscitation guidelines with fluid adjustment parameters. A 48-hour data resuscitation data collection tool was developed by the burn physicians and nurses and all resuscitations were reviewed in real-time and in burn leadership meeting to identify opportunities for improvement. Follow up and education reinforcement was done in real time by the clinical nurse specialist following each burn resuscitation. Results Over a one-year period, 23 patients’ resuscitations were tracked and reviewed by the burn quality team. One patient was excluded because of early transition to comfort care. After the initial three tracked resuscitations, the data collection tool was evaluated and modifications made to more effectively capture relevant findings. Mean age of patients was 45.1 (18–82) with a mean TBSA burn injury of 32.5 (15–42.5) In the first 24 hours patients (n=22) received a mean volume of 3.47 ml/kg/%TBSA (0.66 – 8.39) with a mean urine output of 0.95 mL/kg/hr (0.30 – 2.16 ml/kg/hr). For patients who remained on resuscitation during the second 24 hours (n = 16), they received a mean volume of 2.68ml/kg/%TBSA (0.56- 8.44) and had a mean urine output of 1.31 mL/kg/hr (0 .30–2.16). There were no complications related to fluid administration. Appropriate hourly fluid adjustments were made in 21 of the 22 patients. The one patient who did not have fluids titrated appropriately was attributed to resident physician education because the resident failed to provide the burn order set that includes the fluid resuscitation protocol. Conclusions Using a multidisciplinary approach and preparatory and real time education processes, burn nurses can successfully guide burn resuscitation. Providing education and follow up in real time can improve the process. Applicability of Research to Practice The use of nurse-driven protocols can improve outcomes for burn patients.

Exercise Core Temperature Response with a Simulated Burn Injury: Effect of Body Size.

Using a simulated burn injury model to mimic the detrimental effect of a 40% TBSA injury on whole-body evaporative heat dissipation, core temperature response to exercise in physiologically uncompensable conditions between morphologically disparate groups were examined at (i) an absolute Hprod (W), and (ii) a mass-specific Hprod (W·kg). Healthy, young, nonburned individuals of small (SM, n = 11) or large (LG, n = 11) body size cycled for 60 min at 500 W or 5.3 W·kg of Hprod in 39°C and 20% relative humidity conditions. A 40% burn injury was simulated by affixing a highly absorbent, vapor-impermeable material across the torso (20% TBSA), arms (10% TBSA), and legs (10% TBSA) to impede evaporative heat loss in those regions. Although the elevation in core temperature was greater in SM compared with LG at an Hprod of 500 W (SM, 1.69°C ± 0.26°C; LG, 1.05°C ± 0.26°C; P < 0.01), elevations in core temperature were not different at an Hprod of 5.3 W·kg between groups (SM, 0.99°C ± 0.32°C; LG, 1.05°C ± 0.26°C; P = 0.66). These data suggest that among individuals with a 40% TBSA burn injury, a smaller body size leads to exacerbated elevations in core temperature during physical activities eliciting the same absolute Hprod (non-weight-bearing tasks) but not activities eliciting the same mass-specific Hprod (weight-bearing tasks).

Clinical and Socioeconomic Differences in Methamphetamine-Positive Burn Patients.

Previous research on burn patients who test positive for methamphetamines (meth) has yielded mixed results regarding whether meth-positive status leads to worse outcomes and longer hospitalizations. We hypothesized that meth-positive patients at our regional burn center would have worse outcomes. We reviewed burn admissions from January 2014 to December 2017 and compared total patients versus meth-positive, and matched meth-negative versus meth-positive for total BSA burn, length of stay (LOS), intensive care unit (ICU) days, days on ventilator, discharge status (lived/died), number of operating room (OR) visits, number of procedures, socioeconomic status, comorbidities, and discharge disposition. Of 1363 total patients, 264 (19.4%) were meth-positive on toxicology screen. We matched 193 meth-positive patients with meth-negative controls based on TBSA burn, age, and inhalation injury. In the total population comparison, meth-positive patients had larger burns (15.6% vs 12.2%; P = .004), longer LOS (17.8 vs 14.3 days; P = .041), and fewer operations/TBSA (0.12 vs 0.2; P = .04), and lower socioeconomic status. Meth-positive patients were less likely to be discharged to a skilled nursing facility, and more likely to leave against medical advice. In the matched patients, we found no significant differences in LOS or OR visits/TBSA burn. Meth-positive patients have lower socioeconomic status, larger burns, and longer LOS compared to the total burn population. Methamphetamine use, by itself, does not appear to change outcomes. Methamphetamine use leads to larger burns in a population with fewer resources than the general population.

Identification of substance use disorders in burn patients using simple diagnostic screening tools (AUDIT/DAST-10)

Introduction and objectivesSubstance use is disproportionately high in burn patients and associated with adverse outcomes. Screening methods for substance use disorders may help predict or avoid adverse outcomes.The University of Utah Burn Center records self-reported Alcohol Use Disorders Identification Tests (AUDIT) and Drug Abuse Screening Tests (DAST-10) for all adult burn admissions. This study assessed for association between AUDIT/DAST-10 scores and burn patient outcomes. MethodsA retrospective chart review of adult burn patients admitted to the University of Utah from 05/01/2014–06/30/2017. Patient demographics, injury data, and substance use data were collected and analyzed. Results322 patients underwent AUDIT/DAST-10 screening (n = 322). 56 (17.4%) had positive AUDIT screens (score ≥ 8). 15/50 with alcohol use at time of injury (TOI) had negative AUDIT screens. Median AUDIT score with TOI alcohol use was 12, without TOI alcohol use was 1. 30/55 patients offered alcohol counseling accepted.14 patients (4.3%) had positive DAST-10 screens (score ≥3). 9/25 with drug use at TOI had negative DAST-10 screens. No patients without TOI drug use had DAST-10 scores >2. 9/11 patients offered drug counseling accepted.Mean standardized length of stay (LOS) per TBSA burn injury was 1.7 days for positive AUDIT, 1.6 days for negative AUDIT. Median standardized LOS was 1.4 days for positive DAST-10, 1.7 days for negative DAST-10. ConclusionsAUDIT and DAST-10 screens can identify burn patients with problematic substance use, allowing early intervention. Positive screening scores do not independently predict longer hospital stays, increased wound severity, or treatment noncompliance.

78 Intravenous Resuscitation Attenuates Gut Microbiome and Intestinal Changes after 40% TBSA Burn Injury in Swine

78 Intravenous Resuscitation Attenuates Gut Microbiome and Intestinal Changes after 40% TBSA Burn Injury in Swine

31 Implementation of Provincial Adult Burn Clinical Practice Guidelines and their Impact on Patient Outcomes

In 2011, our institution implemented province clinical practice guidelines were implemented in 2011 to standardize acute burn management and resuscitation practices to optimize consistency in patient care prior to transport to a designated burn center. A retrospective review was performed to evaluate the impact of these guidelines on burn patient care since their implementation. A review of patients admitted at our burn center between 2011–2016 after the implementation of the 2011 provincial burn guidelines was performed evaluating TBSA estimation, resuscitation records and clinical outcomes. Study inclusion required patients greater than 18 years old with a TBSA burn injury larger than 15%. Patients were categorized into groups based on treatment adherence to the 2011 guidelines and if they were treated initially peripherally or directly at our quaternary burn center. Results were compared previous burn outcome data obtained prior to guideline implementation. A total of ninety-five patients met the study inclusion criteria. In the first 24 hours after acute burn injury, the patients that were initially managed peripherally and then transferred, received an average of 5.8cc/kg/%TBSA of fluids when there was no evidence of guideline adherence. If the guidelines were implemented only after transferred to our center, patients received an average of 5.0cc/kg/%TBSA. For burns patients where guidelines were utilized both peripherally and after transfer, an average 4.0cc/kg/%TBSA was used for resuscitation. Complications such as respiratory failure (17% vs. 11%), abdominal compartment syndrome (4% vs. 0%) and acute kidney injury (50% vs. 33%) more frequently developed when the guidelines were implemented only after transfer to our burn center. The implementation of new clinical practice guidelines to aid in fluid resuscitation following major burns has decreased IV fluid administration for patients initially assessed in peripheral low volume centers. Early guideline implementation may decrease burn associated systemic morbidities. This research reinforces the importance of standardizing treatment practices to improve burn patient care and discusses the obstacles associated with disseminating specialized clinical skills and knowledge.

Fetal bovine dermis as an alternative to allograft in large burn injuries

IntroductionDermal substitutes can be an essential treatment option for patients with very large burn injuries. We reviewed and compared our experience with a fetal bovine dermis dermal substitute versus allograft for adult burn patients with large burn injuries. MethodsAfter obtaining regulatory approval from our local institutional review board, we performed a 1 year retrospective review of adult burn patients with a TBSA of 50% or greater who underwent grafting with either fetal bovine dermis or allograft. We collected data that included age, TBSA, length of stay, number of operations,% area grafted with either allograft or fetal bovine dermis, and time between allograft or fetal bovine dermis grafting to autografting. All mean values are mean ± standard deviation, and all median values are median (interquartile range) ResultsOverall for this review 15 patients met entry criteria. The mean age was 36 ± 9 years and mean TBSA was 71 ± 15%. Mean area grafted with either allograft (ALLO) or fetal bovine dermis (FBD) was 20 ± 8%. Mean time from grafting with ALLO or FB was 30 ± 12 days. There was no difference in median age between the ALLO group (30 (26–31)) and FBD group (35 (32–46) and there was no difference in median TBSA between the ALLO group (68(60–75)%) and FBD group (69(59–88)%). The median area grafted with allograft was 20(20–30)% which was not significantly different than the median area grafted with FBD (16.5(11–26)%). Additionally, there was no difference between the time from grafting with ALLO to autologous skin grafting (26(22–36) days) and the time from grafting with FBD to autologous skin grafting (25.5(21–32) days). ConclusionsFetal bovine dermis is an acceptable alternative to allograft in patients with a large TBSA burn-injury. Further studies are needed to determine if infectious and functional outcomes are improved with fetal bovine dermis.

410 Effects of the Combination of Daily Insulin plus Resistance Exercise During the Unloading and Reloading Phases Following Burn and Disuse in Rats on Body Mass, Food Intake and Fat Mass

Treatment and recovery of patients with severe traumatic injuries is impacted by an increase in metabolism. After burn injury, the ability to resume normal activities is compromised due to inactivity associated with bed rest as well as the catabolic response. Following discharge, a major goal is the ability to execute a long-term recovery plan. Previously we found daily exercise combined with SQ insulin improved body mass loss during the unloading period. The purpose of this study was to determine immediately following burn and disuse injury how a combination of daily resistance exercise and daily insulin injections during the unloading phase followed by daily resistance exercise during the reloading phase affects body and fat mass and food intake. Male, Sprague-Dawley rats were used. Injury was induced by a 40% TBSA burn injury and hindlimb unloaded immediately following injury. Rats were weight-matched into either saline vehicle (VEH; N=12) or insulin (INS; 5U/kg; N=12) for 14 days with daily resistance exercise. Daily resistance exercise was completed prior and following injury by adding weight to the tail during repetitive ladder climbing (5 climbs, 2X/days). Following removal from unloading at 14 days, rats were re-distributed within the original VEH or INS to exercise (EX; N=6) or no exercise (NEX; N=6) for 14 days. Body mass and food intake was collected daily throughout the study. Fat mass was collected at the end of the study. No differences in body mass were observed between any groups at the time of injury or day 14. Daily insulin showed a decrease in mean food intake over the last 5 days of the unloading phase with no differences in body mass. During the reloading phase, a steady increase in body mass was shown in all groups, however, INS, irrespective of exercise had a greater body mass increase. In addition, mean food intake was significantly increased in the INS + EX group during the reloading phase. Fat mass was not different between any of the groups. During the unloading phase, daily exercise with insulin elicited a decrease in food intake, however, the decrease in food intake did not result in differences between treatment groups in either body mass or fat mass, possibly showing additional mechanisms are causing overall metabolic changes. Possible metabolic changes during the reloading phase, indicate improvements may be occuring following removal from disuse. Different underlying factors seem to be influencing the acute metabolic changes offering possible opportunities for combinations of early interventions resulting in positive long-term outcomes. An exercise program may improve metabolic health following discharge.

Reducing Postburn Injury Anemia in a Jehovah’s Witness Patient

Anemia is a complication of severe burn injury. Burn patients who refuse blood transfusions, such as Jehovah's Witnesses, present difficult challenges, and treatment paradigms need to be altered to reduce blood loss and increase red cell restoration. In this report the authors present a case of a 36-year-old Jehovah's Witness who suffered a 35% TBSA burn injury. In addition to standard burn injury treatment, the authors attempted to reduce blood loss with a combination of intraoperative (tranexamic acid) and perioperative (erythropoietin, intravenous iron) strategies.

Strong ion gap is associated with mortality in pediatric burn injuries.

Severe burn injury produces significant tissue damage, resulting in metabolic acidosis. Current methods of acid-base evaluation are based on dependent variables that may not be accurate after burn injury. The strong ion method of acid-base evaluation is based on independent variables and may accurately predict outcomes in severely burn-injured patients. The authors hypothesize that an increased strong ion gap present on admission will be associated with mortality in severely burn-injured pediatric patients. A retrospective chart review was performed of burn-injured pediatric patients with a TBSA 20% or greater. Data collected included age, TBSA burn injury, mechanism of injury, survival, ventilator days, hospital length of stay, intensive care unit length of stay, and admission laboratory values. Apparent and effective strong ion difference (SIDa, SIDe) were calculated. The strong ion gap (SIG) was determined as the difference between SIDa and SIDe. A total of 48 patients were included in the study. Mean age (years) and TBSA were 7.9 ± 0.8 years and 56.8 ± 2.6%. Eleven patients (23%) died. Mean TBSA for survivors (54.2 ± 2.9%) did not significantly differ from that of nonsurvivors (65.7 ± 5.34%). Ten patients suffered inhalation injury, which was associated with an odds ratio of 10.1* for mortality. Mean SIDa was 44.2 ± 3.2 for the entire study population. Survivors had a significantly lower SIDa (36.6 ± 0.5) than nonsurvivors (59.7 ± 13*). Mean SIDe for all patients was (25 ± 0.7) and did not differ significantly between survivors (24.7 ± 0.7) and nonsurvivors (25.8 ± 2). SIG for nonsurvivors (33.91 ± 14*) was significantly higher than for survivors (14.9 ± 0.3). Controlling for both TBSA and inhalation injury, death was associated with both an increased SIDa (B = 19.3*) and SIG (B = 17.3*). SIG is increased in severely burn-injured pediatric patients, indicating the presence of metabolic acidosis. Furthermore, an increased SIG is significantly associated with mortality. (*P <.05.).

Herpes Simplex Activation Prolongs Recovery From Severe Burn Injury and Increases Bacterial Infection Risk

Recovery from severe burn injury is complicated by infections that are result of immune suppression created by massive inflammatory states. One indication of immune suppression may be activation of viruses like herpes simplex virus (HSV), which may negatively impact recovery. A 5-year retrospective review was performed of adult patients with ≥30% TBSA burn injury. TBSA burn injury, length of hospital stay, ventilator days, mortality, and cultures were reviewed. Twenty-one patients had cutaneous HSV activation (HSV+) and 50 did not (HSV-). Age (44.2 vs 39.8 years) and TBSA burn injury (45.9 vs 45.5%) did not differ between the groups. Length of hospital stay (60.9 vs 39.8 days, P < .05) and ventilator days (34.9 vs 22.2 days, P < .05) were greater in HSV+ patients. HSV activation increased hospital stay (odds ratio [OR] 1.6, confidence interval [CI] 1.08-2.39, P < .05) and mechanical ventilation (OR 1.02, CI 1.00-1.05, P < .05). HSV activation increased the risk of developing positive Acinetobacter baumannii pulmonary cultures (OR 6.4, CI 1.8-22.3, P < .05) and methicillin-resistant Staphylococcus aureus wound cultures (OR 3.3, CI 1.2-9.6, P < .05). HSV activation also increased the risk of developing any positive A. baumannii cultures (OR 9.1, CI 1.9-44, P < .05). HSV activation during severe burn injury is associated with increased length of mechanical ventilation and hospital stay. In addition, these patients have an increased risk of infections from opportunistic bacteria.

Takotsubo Cardiomyopathy Caused by Severe Burn Injury

The purpose of this report is to describe the clinical course of a 12% TBSA burn injury with takotsubo cardiomyopathy and to discuss this lesser known diagnosis. The authors performed a case study with retrospective chart review and conducted a literature search. Takotsubo cardiomyopathy is characterized by severe left ventricular dysfunction that is incited by severe psychological or physical stress. The patient's treatment course was complicated by the underlying cardiomyopathy requiring intubation, volume expansion, and vasoactive medications. After treatment for her burn injuries, her cardiac myopathy resolved, and she was discharged home. Takotsubo cardiomyopathy may be precipitated by burn injury. Treatment is supportive, but it should be instituted quickly to avoid complications.

A Comparison of Dexmedetomidine and Midazolam for Sedation in Severe Pediatric Burn Injury

Dexmedetomidine (DEX) is an α-adrenergic agonist that has been used for sedation during invasive procedures and endotracheal intubation. In pediatric burn injury, DEX has been shown to be safe as a long-term sedative in the intensive care unit (ICU). However, comparison of DEX with traditional sedatives, such as midazolam, for sedation in pediatric burn injury has not been performed. The purpose of this study was to compare DEX with midazolam in terms of sedation, efficacy, and side effects in children with burn injury. A retrospective review of all children with a TBSA burn injury ≥20% admitted from December 2008 to September 2010 was performed. Children who received a continuous DEX infusion were compared with children receiving a continuous midazolam infusion. Data collected included: age, TBSA burn, ventilator days, ICU days, hypotensive episodes, bradycardic episodes, and Richmond Agitation Score (RAS). A total of 21 patients who received DEX infusions were compared with 21 age-matched and burn size-matched patients who received midazolam infusions. Of the 21 DEX patients, nine also received midazolam infusions, eight prior to DEX and one after. These patients did not receive DEX and midazolam simultaneously. There was no difference in age (6.9 vs 6.4 years), TBSA (45.5 vs 49.2%), ICU days (45.3 vs 55.4), and ventilator days (38.5 vs 45.5) between the DEX and midazolam patients, respectively. The mean duration of infusion was 22.5 ± 24.9 days for DEX and 20.1 ± 24.8 days for midazolam. DEX patients had a mean RAS of -0.91 ± 0.8. Midazolam patients were more sedated with a mean RAS of -1.33 ± 0.7. Only one episode of bradycardia was noted in the DEX group. The DEX group had fewer hypotensive episodes (mean arterial pressure <60 mm Hg) while on infusion compared with the midazolam group (15.8 vs 29.7 episodes). Thus, it can be surmised that DEX is a safe and effective sedative for pediatric burn patients. Compared to midazolam, DEX may provide more effective sedation and less sedation-related hypotension.

Inflammatory Response in Multiple Organs in a Mouse Model of Acute Alcohol Intoxication and Burn Injury

This study characterized the inflammatory response after burn injury and determined whether ethanol (EtOH) intoxication at the time of burn injury influences this response. To accomplish this, male mice were gavaged with EtOH (2.9 g/kg) 4 hours before 12 to 15% TBSA sham or burn injury. Mice were killed on day 1 after injury; blood, small intestine, lung, and liver were collected to measure interleukin (IL)-6, IL-10, IL-18, and Monocyte chemotactic protein-1 (MCP-1) levels. In addition, neutrophil infiltration, myeloperoxidase activity, and edema formation were also measured in the small intestine, lung, and liver. There was no difference in the inflammatory markers in the small intestine, lung, and liver in mice receiving either sham or burn injury alone except IL-6 that was increased in all four tissue compartments after burn injury alone. However, when compared with EtOH or burn injury alone, EtOH combined with burn injury resulted in a significant increase in cytokines, neutrophil infiltration, myeloperoxidase activity, and edema in the small intestine, liver, and lung tissue. Furthermore, a significant increase in IL-6 and MCP-1 was observed in circulation after EtOH intoxication and burn injury compared with either EtOH intoxication or burn injury alone; no other cytokines were detected in circulation. These findings suggest that acute EtOH intoxication exacerbates the inflammatory response after burn injury.