Pre-hospital emergency burn management in Shanghai: Analysis of 1868 burn patients

Background

There are few studies reporting the level of pre-hospital emergency management of burn patients and related influencing factors in China. This study is a summary of our investigation on emergency education and people's awareness about pre-hospital emergency management of burn patients in Shanghai, China, and analyses key factors influencing pre-hospital emergency management of burn patients.

Methods

The survey was conducted by questionnaire in burn patients who sought initial clinical visits at the Burn Center of Changhai Hospital (Shanghai, China) between November 2009 and December 2010, including demographic data, burn conditions, pre-hospital emergency management and education about emergency burn management. Data were statistically treated by SPSS software.

Results

Altogether 1868 effective questionnaire forms were collected; 33.9% of these burn patients received cooling treatment before admission and 32.2% of them used ‘folk remedies’ or antibiotics to treat the wound surface. Only 12.2% of these burn patients had received education about the knowledge of emergency management, mainly through public media (38.2%), relatives and friends (24.6%), Internet (15.8%), workplace (11.4%) and schools (10.1%). The result of logistic regression analysis showed that emergency education, especially via Internet and workplace, played an important role in pre-hospital emergency management, and that different channels of emergency education affected different age groups of people: network and unit education mainly affected young adults, while relatives and friends mainly affected elderly people. In addition, educational level was an important factor favourably affecting ‘cooling therapy’.

Conclusions

The level of emergency burn management and related education is relatively low in China at present, and it is therefore necessary to intensify education about pre-hospital emergency management to raise the level of emergency burn management. At the same time, more attention should be paid to age- and population-specific education. Finally, universal emergency education should be included in the national basic education as a long-term strategy.     

成批烧伤病人的救治体会

目的探讨保证成批烧伤病人救治顺利进行的方法和措施。方法从成批烧伤的现场、休克期处理，以及抢救工作的组织领导、伤员的转送时机、事故的预防几个方面，总结了１９７０年至今２２批４０３例成批烧伤的救治经验和体会。结果２２批４０３例病人中治愈３８２例，治愈率９４．７９％。结论只要组织、措施和治疗方法得当，成批烧伤病人的救治，可以取得满意的效果     

成批烧伤病人的救治体会

目的 探讨保证成批烧伤病人救治顺利进行的方法和措施。方法 从成批烧伤的现场、休克期处理,以及抢救工作的组织领导、伤员的转送时机、事故的预防几个方面,总结了１９７０年至今２２批４０３例成批烧伤的救治经验和体会。结果 ２２批４０３例病人中治愈３８２例,治愈率９４．７９％。结论 只要组织、措施和治疗方法得当,成批病人的救治,可以取得满意的效果。     

Early in-hospital management of burn injuries in Australia

Background: The accurate initial assessment and management of burn injuries influences subsequent clinical outcome. The purpose of the present study was to evaluate, over a 12‐year period (1989?2001), changes in the practices of referring hospitals in terms of early management of patients with burn injuries prior to transfer to a burns unit. Methods: The details of all consecutive patients over two separate 12‐month periods between June 1989 to May 1990 and between April 2000 and March 2001 who were transferred to the Burns Unit, Concord Repatriation General Hospital, Sydney, were prospectively recorded and retrospectively reviewed. In particular, the referral procedure, the accuracy of the referring hospital's assessment of burn size and initial fluid resuscitation were compared between the two time frames. Results: There were 51 patients in the initial 12‐month period and 57 patients in the latter 12‐month period. Regarding the transfer of the latter group of patients, the referring hospital liaised directly by telephone with the Burns Unit registrar or consultant significantly more often (77%vs 45%, respectively, P < 0.05). Similar proportions of patients in the two time periods received correct initial assessment of burn size (39% in the 1989?1990 group vs 42% in the 2000?2001 group, P = 0.76). The latter group of patients was significantly more likely to receive the correct choice of fluid for initial resuscitation at the referring hospital (98%vs 61%, respectively, P < 0.05). Conclusions: Over this 12‐year period, there has been marked improvement in referral practices and appropriate initial fluid resuscitation for patients with burn injuries. Referring hospitals’ assessment of burn size has not improved. Possible reasons for the observed changes include: increased postgraduate education programmes by the Royal Australasian College of Surgeons and the Australian and New Zealand Burns association; the formalization of emergency medicine training programmes by the Australasian College of Emergency Medicine and increasing awareness within the medical community of the presence of dedicated burns units.     

Adult burn injuries in an Emergency Department in Central Anatolia,Turkey: a 5-year analysis

PURPOSE: Burn injuries require a multidisciplinary approach. Emergency Departments can play vital roles in the treatment of burns. The purpose of this study is to investigate the epidemiological and clinical characteristics of the adult burn patients admitted to our Emergency Department and to determine the frequency of the patients who were treated on an outpatient basis and discharged from the Emergency Department. PROCEDURE: A retrospective review of 314 adult burn patients who presented to the Emergency Medicine Department of Erciyes University Hospital from January 1996 to December 2000. FINDINGS: Sixty-four percent of the patients were male. Mean age was 32.9+/-14.7. Ninety-nine patients (32%) had moderate to major burns. The highest numbers of patients were in the 21-30 age group. Flame burns comprised the majority of presentations and admissions (48 and 69%, respectively). Thirteen patients had associated injuries (4%). Eighty-seven patients (28%) were hospitalized, 21 of these died. Death occurred mostly from respiratory failure and sepsis. Domestic accidents were the leading mechanism (63%). CONCLUSION: Burns were mostly due to accidents arising from carelessness, ignorance, hazardous traditions and improperly manufactured products. These can be prevented through mass education programs countrywide. Because almost all burn patients present to Emergency Departments first and not all hospitals can employ burn specialists, the patients with minor burns can be treated on an outpatient basis and the treatment of severe burns can be effectively initiated by emergency physicians.     

Demographic characteristics and prognostic indicators of childhood burn in a developing country

Children constitute a significant proportion of burn victims in most studies from the developing countries. While there has been a progressive improvement in the outcome from childhood burn in many developed nations, the morbidity and mortality remains high in many low and middle income countries. The aim of our study is to evaluate the demographic characteristics and prognostic indicators of childhood burn in a major referral teaching hospital in a developing country. A review of the records of 638 patients with acute burns managed over a 10-year period from January 2001 to December 2010 at the University College Hospital, Ibadan Nigeria was done. The clinical and epidemiological data were retrieved from computerized data base using the ISBI proforma. Information obtained includes Biodata, Etiology, location, TBSA, presence of Inhalation injury and the treatment outcome. Data of patients aged 16 years and below were analyzed using the SPSS version 16. The main outcome measure was the patient's survival. 289 children representing 45.3% of the total number of burn patients were managed over the period. The M:F ratio was 1.1:1. The median age of the cohort was 4.0 years while the median TBSA was 21.0%. Non-intentional causes were responsible for 89.6% cases. Most of the injuries (88.6%) occurred at home. Eighty-three patients had inhalation injury out of which 57 (68.7%) deaths were recorded. The overall mortality rate in the cohort was 39.5% with an LA50 of burn size of 45%. The TBSA was also found to be a determinant of outcome.Majority of childhood burns are from preventable causes with attendant dismal mortality figures. Effective burn prevention strategies and improved quality of care remain pivotal in reducing childhood burn morbidity and mortality in the developing countries.     

The domestic washing machine: a common cause of electrical burn

The dependence of the domestic washing machine on electricity makes it a potential source of an electric shock that can therefore lead to a burn. The aim of this report is to present a typical case of a washing machine burn and analyse their frequency and circumstances. Using a database, patients who had sustained a burn from a washing machine in a 2.8 year period were identified and the case notes obtained for review. Washing machine burns accounted for 12% of all electrical burns and 22% of all electrical domestic burns. All patients were males who had been attempting to repair a faulty machine. Six of the ten patients required surgical treatment. Despite numerous safety features, washing machines are a common cause of electrical burn, and methods of prevention of such injury need to be addressed.     

Obese patients in a burn care unit: A major challenge

ObjectiveObesity is an important predictor of mortality and morbidity during a hospital stay. There is very little data concerning the impact of the BMI on clinical outcomes in obese burn patients.The purpose of this study is to document the general epidemiological aspects of thermal injuries in an obese population and draw attention to topics relating to the management, rehabilitation and prognosis of burns in this emerging subpopulation of patients.MethodsAll patients >16 years of age admitted to the burn unit between January 2008 and December 2012 and fulfilling the burn center referral criteria were enrolled in the study. SPSS version 20 (SPSS GmbH Software, Illinois, USA) was employed for data analysis.ResultsEleven extreme obese patients (men:women, 6:5) had a mean BMI of 38 kg/m². Their incidence in our study was 5.5%. The mean length of stay was 41.5 days, almost twice that of the non-obese. The presence of co-morbidities such as diabetes, hypertension, cardiac disease, or pulmonary disease, the problematic wound healing and the burn wound infection were significantly higher in the obese patients than in the non-obese. The mortality of obese burned patients was 36.4%.ConclusionsThese facts indicate admission of these patients to a burn care unit for the best possible treatment although they might not always fulfill criteria for admission to burn intensive care unit. Burn centers must be also prepared in terms of special nursing equipment for obese patients.     

Peripheral neuropathy in burn patients

Neuropathy in burn patients is frequently overlooked. This study aimed at looking for neuropathies among burn patients. It included 55 burn patients, whether symptomatic or asymptomatic, with variable depths of burn at different stages. Their ages ranged from 8 to 55 years with a mean age of 23.6 ± 11.1 years. All patients were submitted to clinical examination, electromyographic and motor conduction velocities of burned and unburned limbs. Serum electrolyte, blood urea and creatinine were measured for all patients. Sixteen patients (29 per cent) had peripheral neuropathy. Only six had symptoms and signs of peripheral neuropathy. The most frequently diagnosed neuropathy in this study was mononeuritis multiplex in nine patients (56 per cent), then generalized distal axonal neuropathy in five patients (31 per cent) and entrapment neuropathy in two patients (13 per cent). In patients with mononcuritis, 29 nerves were affected, 24 nerves related to the site of the burn and five nerves were away from the site of the burn. All the entrapment neuropathy developed after wound healing. Age above 20 years, electric burns, burns involving full thickness of the skin and a surface area of more than 20 per cent were associated with a significantly higher prevalence of neuropathy. Other parameters were not found to be significant in the development of neuropathy.     

Effect of growth hormone therapy in burn patients on conservative treatment

Evaluation of growth hormone therapy in burns is limited and none is reported from developing countries where burns still carry high mortality. We analysed serial observations on the clinical and biochemical profiles in 13 patients with second and third degree burns who received recombinant human growth hormone (rhGH) (0.5 IU/kg body wt) for 2 weeks in addition to standard conservative treatment and in 9 patients who were managed with standard conservative treatment only. The two groups of patients had burns, comparable in extent and severity. Additional rhGH treatment resulted in improved wound healing (p<0.001), delayed separation of eschars (p<0.01), increase in haemoglobin (p<0.05), serum albumin (p<0.01), calcium (p<0.05), phosphorus (p<0.001), glomerular filtration rate (p<0.05) and 7 fold elevation in IGF-1. Also, a reduction in weight loss (p<0.01), nitrogen production rate (p<0.05), catabolic index (p<0.01), duration of sepsis (p<0.01) and hospital stay by 40% (p<0.01) was noted with rhGH therapy. Transient hypercalcemia (3 patients), albuminuria (2 patients) and elevated blood glucose (one patient) were noted in the rhGH treated group not necessitating any specific therapy. Mortality in rhGH treatment group was 8.3% compared to 44.5% in the “no rhGH” treatment group. These observations suggest significant benefits of short term rhGH treatment in burn patients on conservative management.     

Mass casualty incidents with multiple burn victims: Rationale for a Swiss burn plan

Introduction

Mass casualty incidents involving victims with severe burns pose difficult and unique problems for both rescue teams and hospitals. This paper presents an analysis of the published reports with the aim of proposing a rational model for burn rescue and hospital referral for Switzerland.

Methods

Literature review including systematic searches of PubMed/Medline, reference textbooks and journals as well as landmark articles.

Results

Since hospitals have limited surge capacities in the event of burn disasters, a special approach to both prehospital and hospital management of these victims is required. Specialized rescue and care can be adequately met and at all levels of needs by deploying mobile burn teams to the scene. These burn teams can bring needed skills and enhance the efficiency of the classical disaster response teams. Burn teams assist with both primary and secondary triage, contribute to initial patient management and offer advice to non-specialized designated hospitals that provide acute care for burn patients with Total Burn Surface Area (TBSA) <20–30%. The main components required for successful deployments of mobile burn teams include socio-economic feasibility, streamlined logistical implementation as well as partnership coordination with other agencies including subsidiary military resources.

Conclusions

Disaster preparedness plans involving burn specialists dispatched from a referral burn center can upgrade and significantly improve prehospital rescue outcome, initial resuscitation care and help prevent an overload to hospital surge capacities in case of multiple burn victims. This is the rationale behind the ongoing development and implementation of the Swiss burn plan.     

重大事故中成批黄磷烧伤患者的救治

目的 总结成批黄磷爆炸致烧伤的特点及救治经过,为今后应急抢救积累经验. 方法 收集整理与本次特大黄磷烧伤事故相关的资料,分析总结成批黄磷烧伤患者的伤情特点及处置经过. 结果 本次事故共造成81人受伤,其中男72人、女9人,年龄5～42岁[(24±13)岁],烧伤面积0.4%～70.0%[(9±11)%],Ⅲ/Ⅳ度烧伤面积为0.4%～60.0%TBSA[(7±10)%TBSA].大部分患者伴有磷中毒表现;27例肝功能异常占33.3%,15例肾功能异常占18.5%;42例电解质紊乱占51.9%.烧伤面积＞10%且≤20%TBSA的8例患者中,有6例伴心肌酶谱升高;6例出现贫血,其中3例为进行性贫血;1例于伤后48 h出现窒息;1例发生消化道应激性溃疡.72例患者于伤后4 d内行切削痂植皮手术.部分患者遗留瘢痕及手部功能障碍,3例患者部分截指.无一例患者死亡. 结论 黄磷爆炸易导致周围人员头、手等暴露部位深度烧伤,并造成严重的中毒和内脏损伤.立即组织足够的专业医疗力量对成批患者进行急救,尽早清除创面坏死组织、促进毒素排泄等,是抢救成功的关键.     

头面部和双手电弧烧伤患者不同治疗阶段心理反应差异的研究

目的:对头面部及双手电弧烧伤住院患者在伤后不同治疗阶段进行心理问卷调查,了解患者焦虑和抑郁的发生状况.方法:对20例成人头面部及双手电弧烧伤住院患者于入院初(伤后24 h内),扩创术前(伤后第5天)、恢复期(伤后2周～1个月)3个不同治疗阶段,采用Zung氏焦虑和抑郁评定量表进行心理问卷调查,统计分析存在焦虑、抑郁状态的存在情况.结果:20例患者在入院初(伤后24 h内)、扩创术前(伤后第5天)及恢复期(伤后2周～1个月)3个治疗阶段均存在焦虑或(和)抑郁倾向;患者在入院初(伤后24 h内)的焦虑和抑郁状况最明显,焦虑和抑郁评分(37.60±7.06和36.90±8.48)均明显高于扩创术前(33.45±6.15±和34.70±8.24)和恢复期(28.75±5.63和29.30±5.69),差异均有显著性(P均＜0.05).结论:头面部及双手电弧烧伤住院患者伤后24 h内焦虑抑郁状态相对于其他诊疗阶段重,建议采取相应的心理护理干预措施.     

Sex differences in the skin microbiome of burn scars

Sex differences are observed in various spectrums of skin diseases, and there are differences in wound healing rate. Herein, sex differences were identified for the newly healed skin microbiome of burn patients. Fifty-two skin samples (26 normal skin, 26 burn scars) were collected from 26 burn patients (12 male, 14 female) and microbiota analysis was performed. The correlation between skin microbiota and biomechanical properties of burn scars was also investigated. There were no significant differences in clinical characteristics between male and female patients. Considering the biomechanical properties of burn scars and normal skin around it performed before sample collection, the mean erythema level of men's normal skin was significantly higher than that of women, whereas the mean levels of melanin, transepidermal water loss and skin hydration showed no significant sex differences. The erythrocyte sedimentation rate was significantly higher in females than that in males. Alpha diversity showed no significant differences between normal skin and burn scars in the male group. However, the scar was significantly higher than that of normal skin in the female group. Microbial network analysis revealed that the male group had more complex microbial network than the female group. Additionally, in the male group, the edge density and clustering coefficient were higher in burn scars when compared to normal skin, than the female group. There were sex differences in the results of microbiome of normal skin and burn scars. Some of the altered microbiota have been correlated with the biomechanical properties of burn scars. In conclusion, sex difference in the burn scar microbiome was confirmed. These results suggest that burn treatment strategies should vary with sex.     

Medical management after indoor fires: a review

Fires involving mass burn casualties require extreme efforts and flexibility from the regular health care system. The café fire in Volendam, which occurred shortly after midnight on the first of January 2001, resulted in the worst indoor mass burns incident in Dutch history. During the extensive medical evaluation of this disaster, it became obvious that information on similar incidents is relatively scarce in the literature. This article systematically reviews the existing information in the medical literature on indoor fires and provides findings and knowledge used in the evaluation of the medical management after indoor fires and for future mass burn casualty preparedness, mitigation and response. METHODS: A literature review was undertaken for burn disasters with characteristics similar to the indoor Volendam fire disaster. In all fires, the following aspects were investigated: characteristics of the fire; the initial emergency response; triage and on-site treatment; primary and secondary distribution; hospital admission; severity of the sustained injuries and mortality. RESULTS: A total of nine similar indoor fires were selected. The number of people involved was reported in seven fires (range 137-6000). All reports provided the mortality rate (range 1.4% to over 50%). Data regarding the emergency response could be collected in half of the studies. On-scene triage was performed in five fires. The number of hospitals participating in the primary distribution ranged from 1 to 19. Except for the Volendam fire, all patients were primarily distributed to general hospitals. CONCLUSION: Characteristics of indoor fires, which are relevant for disaster preparedness, mitigation and response are not frequently reported in medical literature. The current articles on indoor fires, mainly report on numbers of casualties and the mortality. Limited data are available to provide insight in the characteristics of management and medical treatment and to come up with suggestions for improvement of future burn incidents management. The evaluation of disasters should be based on uniform methods and structured reports and effective record keeping is essential to achieve this.     

Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion

PurposeTo provide an insight into the challenges faced by the closest hospital to the Formosa Fun Coast Dust Explosion (FFCDE) disaster scene, and to examine how the hospital staff adapted to cope with the mass burn casualty (MBC) in their overcrowded emergency department (ED) after the disaster.Material and methodsThe critical incident technique was used for the investigation. Data was gathered through in-depth individual interviews with 15 key participants in this event. The interview data was combined with the medical records of the FFCDE patients and admission logs to build a detailed timeline of ED workload. Process tracing analysis was used to evaluate how the ED and other units adapted to deal with actual and potential bottlenecks created by the patient surge.ResultsFifty-eight burn patients were treated and registered in approximately six hours while the ED managed 43 non-FFCDE patients. Forty-four patients with average total body surface area burn 51.3% were admitted. Twenty burn patients were intubated. The overwhelming demand created shortages primarily of clinicians, ED space, stretchers, ICU beds, and critical medical materials for burn care. Adaptive activities for the initial resuscitation are identified and synthesized into three typical adaptation patterns. These adaptations were never previously adopted in ED normal practices for daily surge nor in periodical exercises. The analysis revealed adaptation stemmed from the dynamic re-planning and coordination across roles and units and the anticipation of bottlenecks ahead.ConclusionIn the hospital closest to the FFCDE disaster scene, it caused an overwhelming demand in an already crowded, beyond-nominal-capacity ED. This study describes how the hospital mobilized and reconfigured response capacity to cope with overload, uncertainty, and time pressure. These findings support improving disaster planning and preparedness for all healthcare entities through organizational support for adaptation and routine practice coping with unexpected scenarios.     

烧伤瘢痕癌12例临床治疗分析

目的：探讨烧伤瘢痕癌的临床特点与防治方法.方法：回顾性分析12例烧伤瘢痕癌患者的临床资料.结果：12例烧伤瘢痕癌10例为鳞状细胞癌,2例为基底细胞癌.其中溃疡型9例,菜花型3例.手术植皮或皮瓣均成活.12例患者分别于术后3个月～12年获得随访,2例术后3～6个月复发,1例行二次手术植皮,另1例放弃治疗,5月后死亡,其余10例局部无复发,目前仍健在.结论：病理检查结果结合临床表现是确定诊断与治疗方案的重要依据,手术是烧伤瘢痕癌的首选治疗方法,烧伤瘢痕癌是可以预防的.     

A review of emergency department fluid resuscitation of burn patients transferred to a regional,verified burn center

The purpose of this study was to examine the adequacy of burn patient fluid resuscitation in relationship to the American Burn Association formula before arrival at a regional burn center. Further substratification of the data was undertaken to compare total burn surface area and fluid volume resuscitation as evaluated from the primary hospital's emergency department staff vs. the burn intensive care unit staff. The charts of all patients admitted to the burn center during 1 year were reviewed retrospectively. Data were compiled to calculate the time of injury, time of arrival in the referring emergency room, time in transit to the burn unit, and time of arrival in the burn unit. The total number of patients evaluated in the study was 41. Patients who were not referred from outside hospitals or who had incomplete charts were excluded. The average time from initial burn to transfer to the burn intensive care unit was 6.26 hours (range, 0.5-96 hours). The average total body surface area (TBSA) evaluated by the referring emergency department staff was 23.9% (range, 5-70%) compared with the burn intensive care unit staff evaluation average of 17.8% (range, 2-55%). Using the referring emergency department staff TBSA percentage, evaluation of the data revealed that only 23% of patients fell within the accepted range using the American Burn Association formula. Furthermore, 30% of patients were overresuscitated whereas 47% were underresuscitated. Of the overresuscitated patients, 1 patient was critically overresuscitated. In the group of underresuscitated patients, five were critically underresuscitated. Thirty-three percent of the patients' TBSA had a more than 50% discrepancy between the burn unit and the emergency department calculations. The authors conclude that better educating providers referring patients to regional burn centers can make a marked improvement in the overall care of burn patients. More important, early communication with the referring burn staff has been encouraged. Early communication permits review of estimated TBSA burn evaluations and permits cooperative calculations and optimal delivery of early fluid resuscitation. Burn center practitioners can improve care of patients before arrival by appropriately guiding the referring physician.     

Factors affecting fluid requirement on the first day after severe burn trauma

BACKGROUND: Parkland formula (PF) is the most often used schema for calculating intravenous resuscitation fluid requirement in burn patients. Some studies have reported that PF underestimates the fluid requirement in 45-63% of patients. The aim of this retrospective study was to analyse factors influencing first-day intravenous fluid replacement set for a targeted urinary output in severely burnt patients. METHODS: Data of 47 patients with burn injury affecting equal or more than 15% of body surface area were retrieved from the archived files. The local intensive care protocol rendered the infusion rate of lactated Ringer's solution to achieve a urinary output of 0.5-1.0 mL/kg per hour in the first 24 h after burn trauma. RESULTS: First-day i.v. infusion volume was significantly higher than PF preferred. In the first 24 h the hourly volume of intravenous fluid resuscitation per bodyweight per burnt surface area showed significant negative correlation to the burnt body surface area and body mass index, (r = -0.553, P < 0.001; r = -0.570, P < 0.001, respectively) no correlation was found to bodyweight, height or patient age. Patients having deep-burn injury required higher intravenous fluid resuscitation rate than patients having superficial injury only (P < 0.01). CONCLUSION: Our data suggest that fluid requirement is higher than predicted by PF if the extent of burn or body mass index is low and less if the extent of burn or body mass index is high. The presence of deep burn increases fluid requirement.