Neighborhood risk: Socioeconomic status and hospital admission for pediatric burn patients

BackgroundBurn injury continues to cause significant morbidity and mortality in the US pediatric population. Many studies using inpatient samples have found a relationship between low socioeconomic status (SES) and burn injury. The purpose of our study was to evaluate the association between SES and the likelihood of admission for Emergency Department (ED) visits for pediatric burn injury.Study designA retrospective database review of pediatric ED visits for burn injury from a statewide hospital system, from January 1, 2005 to December 31, 2014. SES was assigned using an eight factor Neighborhood Risk Index (NRI) created from census block group data, with a higher score indicative of lower SES. The outcome measure was ED visits admitted to inpatient care.ResultsWe analyzed a sample of 1845 pediatric ED visits for burn injuries. Most visits were discharged from the ED (88.4%) while 10.5% were admitted to inpatient care and 1.0% were transferred to another hospital. In a multivariable logistic regression model, patients from high risk areas (>75th percentile NRI) had 1.58 higher odds of inpatient admission compared to patients from low risk areas (<75th percentile NRI; 95% CI: 1.08–2.30), after adjusting for age, gender, ethnicity, distance to the hospital, and previous ED visit for burn injury in the past 30 days. In addition, for every 1-mile increase in distance, a child’s likelihood of admission increased by 6% (95% CI: 4–9%).ConclusionsChildren with a burn injury from the highest risk socioeconomic areas in Rhode Island had a higher likelihood of inpatient admission. Further research is needed to determine what factors associated with socioeconomic status impact this finding.     

凝血酶烧伤膏治疗血液病鼻衄的临床观察

目的 为探讨血液病鼻衄的理想处理方法。方法 对２３例治疗组患者采用浸有凝血酶２０００Ｉｕ／ｍｌ的明胶海绵局部敷贴出血点,３～４日后用烧伤膏创面换药;３４例对照组采用凡士林纱条填塞止血。结果 治疗组有效率８６．９％,显效率６９．７％;对照组分别是５８．５％和３５．３％。两种方法有显著性差异（Ｐ〈０．０１）。结论 用凝血酶敷贴出血点及创面烧伤膏换药是治疗血液病鼻衄一种安全、有效的方法。     

颅通定对烧伤早期大鼠心室肌细胞的保护作用

目的：探讨中药颅通定对烧伤早期心室肌细胞保护作用物机理。方法：应用Ｃａ＾２＋荧光控针及ＥＰＣ－９光电联合检测系统测定烧伤早期大鼠心室肌细胞胞浆Ｃａ＾２＋浓度变化及颅通定对其影响。结果：烧伤对照组心室肌细胞于伤后１小时胞浆Ｃａ＾２＋浓度明显升高,６小时达高峰,１２小时后渐恢复。正常对照组及颅通定治疗组（浓度：３００μｍｏｌ／Ｌ）心室肌细胞胞浆Ｃａ＾２＋浓度未见明显升高。结论：颅通定可显著抑制烧伤早期大鼠心室肌细胞内Ｃａ＾２＋超载。     

Percutaneous endoscopic gastrostomy in burn patients

Background: Prolonged enteral feedings are required occasionally in seriously burned individuals. We have employed percutaneous endoscopic gastrostomy (PEG) in selected patients who require particularly prolonged access, thus prompting this review. Methods: The PEG procedure was performed under general anesthesia in combination with another surgical procedure using a variety of commercially available needle and guidewire kits in 14 patients. Results: These 14 patients had an average age of 55.2 ± 6.6 years and a burn involving 38 ± 8% of the body surface. Eleven of these patients had suffered an inhalation injury. The tubes were placed an average of 57 ± 10.5 days after injury through unburned and unharvested skin in four patients (28%), healed donor sites in five patients (35%), healed burn in one patient (1%), and grafted burn in four patients (28%). One patient, whose catheter was placed through a grafted fascial excision, developed moderate local wound erosion. Tubes were known to have been left in place as long as 155 days. However, most were removed in rehabilitation hospitals, and we were unable to determine how long most were left in place. We are unaware of any problems with the tubes occurring after discharge from the acute care setting. Conclusions: In selected patients, PEG can provide more comfortable access for prolonged enteral feedings than nasogastric tubes and can be placed with minimal morbidity. Received: 29 March 1998/Accepted: 1 August 1998     

Extracellular fluid and its proteins: dehydration, shock, and recovery

This review highlights characteristics of extracellular fluid (ECF) that are often overlooked. ECF has, in addition to plasma and interstitial fluid (ISF) surrounding cells, a third large compartment, the ISF of skin and connective tissue. This acts as a reservoir that gives up ECF to plasma volume (PV) in order to sustain circulation in the event of either shock or dehydration. While Starling forces drive filtration, ECF is returned to PV more by lymph and less by Starling forces than previously appreciated. Lymph return to PV is dependent on physical activity and muscle contraction to overcome gravity. Regional change in metabolic rate alters the need for oxygen and nutrients that is met by a regional increase in capillary blood flow. Blood flow is controlled by vasoactive compounds released in response to a drop in PO₂; these relax capillary smooth muscle to increase blood flow and delivery of oxygen and nutrients. Plasma proteins, including albumin, are filtered into the interstitium through larger pores than those filtering ECF. The rate of protein filtration is set by size and charge of these larger endothelial pores and by size and charge of proteins. Charge of these pores, hence albumin permeability, is regulated by many of the same vasoactive compounds that control capillary flow. As a consequence, in response to gravitational stress and other forms of shock that reduce effective circulation, albumin as well as ECF is rapidly shifted from plasma and sequestered in ISF. When this has occurred, as in burn shock, restoration is better effected by generous expansion of ECF with Ringer’s solution alone, rather than with Ringer’s solution supplemented with human serum albumin or other colloid. Restoring both PV and ISF volume restores lymph circulation and returns sequestered albumin to PV. Received: 12 November 1998 / Revised: 30 March 1999 / Accepted: 2 April 1999     

Progression of burn wound depth by systemical application of a vasoconstrictor: an experimental study with a new rabbit model

The final depth of a necrosis resulting from burn trauma is determined within 3 days. The zone of stasis has the potential for complete regeneration or there may be ischemic influences that lead to necrosis. In our model, we examined the dermal influence of vasoconstrictors with reference to the development of burn necrosis. On the backs of New Zealand white rabbits (4.0–4.5 kg) standardized lesions were made with a heated aluminum stamp at 80°C, 14 s in duration.

The lesions were intradermal, whereby the border zone of the coagulated tissue was found in the middle two quarters of the dermis in 100% of untreated animals after 72 h. For dermal vasoconstriction epinephrine in a dose of 0.5 μg/kg/min was used.

There were two groups of seven animals each. One group received epinephrine and the dosage was dependent on the clinical state of the animal. Several cycles were administered within a 3-day period. The reduction of skin perfusion was documented by Laser–Doppler-flowmetry. After 3 days, the skin with the lesions was excised and using a hematoxylin dye, a histological examination followed. The parameter used to determine the efficacy was the thickness of the uncoagulated part of the excised dermis.

Over a period of 48 h, an average of 2.3 epinephrine cycles of average of 88 min per animal in duration resulted in an average reduction of skin diffusion of 41%. The uncoagulated part of the dermis in the epinephrine group was 28.6% average; in the control group, this was 43.5%. The statistical analysis revealed significant differences with a p-value of 0.0312 (significant, when value is less than 0.05). The test results indicate that temporary reduction of skin perfusion through external administration of vasocontrictors may lead to progression of burn necrosis in our animal model.

Clinically, this result indicates that for patients with burn injuries and systemic inflammatory response syndrome who have insufficient volume therapy, the administration of vasocontrictors may produce similar results in the injured area.     

Skin expansion in burn patients: problems, rules and indications

Skin expansion in burn patients can be a useful method for secondary skin resurfacing, scar revision or facial remodelling. However, complications and problems occur more often in these patients than in any other. In this paper the incidence of complication in the first and second stages of expansion will be presented. Several rules will then be stated and we will clarify the indications for skin expansion in the treatment of hypertrophic scars, contractures, and post-burn destructions.Lecture given at the first State of the art course on burn reconstruction — Milano, May 1994     

Modell eines computergestützten qualitätssicherungssystems in der verbrennungsintensivtherapie

Zusammenfassung Ausgehend von Überlegungen für ein angemessenes Qualitätssicherungssystem im intensiv-medizinischen Bereich werden die Voraussetzungen für ein ganzheitliches Qualitätsmanagementsystem im Krankenhaus entworfen. Die Grundlage für ein dynamisches Qualitätssicherungssystem ist auf der dokumentatorischen Ebene eine umfassende Datenbasis, die auf einer zeitlich und datentechnisch unbegrenzten Patientenakte basiert. Die notwendige Hard- und Softwarestruktur wird durch die konsequente Anwendung einer Client-Server-Architektur gewährleistet. Die ständige Überprüfung der bestehenden Qualitätsziele in einem ökonomischen Regelkreis benötigt ein System mit flexiblen Abfragemechanismen. Dieser informatorische Datenzugriff auf jeder Hierarchieebene der Krankenhausstruktur wird durch das Konzept des Data-Warehouse ermöglicht, das als Datenbanksystem mit subjektorientierten, integrierten, zeitvariablen und beständigen Informationen konzipiert ist.

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A computer-assisted quality-assurance model for burn intensive care applications

The prerequisites for an integrated quality management system for hospitals were developed as a result of considerations regarding the necessity of an appropriate quality-assurance system for the intensive care sector. The basis for a dynamic quality-assurance system on the documentational level is a comprehensive data base containing patient files unlimited in terms of time and data technology. The necessary hardware and software structure will be provided by consistent application of a client-server architecture. Permanent surveillance of existing quality objectives within the scope of an economic close-loop system requires a system with flexible query mechanisms. Informational data access from all hierarchical level within the hospital organization is facilitated by the data warehouse concept, a data base system with subject-oriented, integrated, time-variable, and persistent data.

     

休克期削痂加复合植皮治疗大面积深度烧伤

目的　探讨休克期削痂加复合植皮治疗大面积深度烧伤的可行性。方法　对 15例烧伤面积(70 5± 19 2 ) %、深Ⅱ～Ⅲ度面积平均 (5 0 1± 2 0 5 ) %的患者采用休克期削痂加复合植皮 ,第一次手术时间是伤后 2 4～ 4 8h ,一次削痂面积约 (30 6± 9 3) % ,以神态、尿量、心率和中心静脉压 (centrevainpressure,CVP)为主要监护指标。结果　术中术后各监护指标在正常范围。治疗组病例全部治愈出院 ,与条件相似 16例休克期后削痂植皮患者对比 ,创面愈合天数缩短 12d左右。结论　休克期削痂加复合植皮治疗大面积深度烧伤是可行的。     

电刺激迷走神经对严重烫伤大鼠的治疗作用

目的:观察电刺激迷走神经对严重烫伤大鼠平均动脉压(MAP)、心率、存活时间及存活率的影响。方法:取24只健康成年SD雄性大鼠(200-240 g),30%TBSAⅢ度烫伤,随机分为假伤组(Sham组)、烫伤组(Scald组)、迷走神经切断组(VGX组)、迷走神经电刺激组(STM组)。各组大鼠右颈总动脉置管后通过压力传导系统与心电监护仪相连,以连续监测MAP和心率变化,并记录生存状况。结果:STM组血压、心率下降趋势平缓,各时间点血压和心率明显高于Scald组和VGX组,生存时间延长,存活率高。结论:电刺激迷走神经对严重烫伤大鼠具有治疗作用。