Critical care management of patients with severe burns and inhalational injury

Anaesthetists and critical care physicians involved in emergency care provision must be equipped with the adequate knowledge and skills to accurately assess and manage patients with severe burns. This summary aims to review the key principles in managing patients with severe burns including airway management, fluid resuscitation, sedation, burn care, analgesia and nutrition.     

Management of burn injury

Burns are a major cause of morbidity and mortality worldwide. Vulnerable people such as children, the frail and elderly, and the socially deprived are at particular risk. Most burns are caused by thermal injury to the skin, but electrical and chemical burns can be very severe. Fortunately, most burns are minor and superficial and can be managed by primary health care professionals. However, major and severe burns require in-hospital management from a team of surgeons and other specialists. Life-threatening conditions such as smoke inhalation airway damage and severe fluid loss should be addressed during the initial resuscitation. Prevention of further thermal damage by cooling is important along with prevention of secondary infection of burn injuries. A wide variety of dressings is available for the management of burns and expert nursing care is vital. Surgical intervention may be urgently required for fasciotomy or escharotomy in cases of compartment syndrome or circumferential burns, respectively. Debridement, skin grafting and reconstructive procedures will be required over the medium or long term for patients with severe or complex burns and should be planned with appropriate multidisciplinary expertize. The functional and psychological impact of major burn injury should not be underestimated.     

Surgical management of acute severe burns

Surgical management of patients presenting severe burns begins from hospital admission. In association with intensive care, it preserves and improves patients' vital prognosis. Secondarily, excision and grafting surgery is used in second deep and third degree burns.     

The respiratory insult in burns injury

Inhalation injury may result from numerous noxious triggers and in association with other injuries, the most common being cutaneous burns. While patients with severe burns often require transfer to a regional unit for specialist management, this is not the case for those with inhalation injury associated with minor burns or occurring in isolation. These latter patients may require management in a general intensive care unit and yet they present some unique challenges to the clinician that may otherwise go unnoticed. The aim of this review is to provide an overview of the pathophysiology, presentation and management of patients with inhalation injury by way of a guide to those who manage such patients on an infrequent basis.     

Verbrennungen im Kindesalter

In Germany, burns are the third most frequent cause of serious accidents in children, most of them happening in the second to fourth years of life. Improved understanding of the illness caused by burns in childhood and improvements in intensive medicine have led to a definite reduction in mortality among children with severe burns. Primary care includes removing the children from the danger area and otherwise follows the recommendations of emergency care. The proportion of the body surface area that is burnt is estimated by means of the rule of nines after Wallace or the hand area rule, while the Lund and Browder method gives more exact values. The most precise estimate is obtained by using modern EDP-supported programs. To decide whether referral to a special unit/burn injuries centre the child’s age, whether or not inhalation injury is present and the mechanism of the accident must all be considered. Apart from fluid substitution, depending on the degree of burns surgical treatment may be indicated. This is so in the case of burns more severe than grade 2a. The treatment of severe burns in children requires an interdisciplinary team consisting of plastic surgeons with a special training in treating burns and/or paediatric surgeons, anaesthetists, psychiatrists and/or psychologists, specially trained care staff, physiotherapists, occupational therapists and social workers.     

Quality of life of adult patients with severe burns

Background

Burns are one of the most significant health problems throughout the world, leading to prolonged hospitalisation and hence increased expense for the patients, their families and society. Today, the prognosis of patients with burns is dependent, apart from adequate treatment, upon the health-care system and health-care professionals, regarding not only survival, but also lifelong quality of life. This study aims to assess quality of life of adult patients with severe burns.

Patients and methods

This study was conducted on 100 adult patients with severe burns in the burn outpatient clinic (male and female) at Mansoura University Hospital. Parameters of burn and Burn Specific Health Scale (BSHS-B) were used to assess quality of life following burns.

Results

The study revealed that burns has negative impact on most dimensions of the quality of life of patients with burns.

Conclusions

The quality of life for people who have sustained a burns should be recognised and valued by the burn team in all phases of burn care.     

Can systemic inflammatory response syndrome score at admission predict clinical outcome in patients with severe burns?

IntroductionThe use of SIRS score as a predictor of outcomes in patients with severe burns has not been fully evaluated. Here, we aimed to test that whether admission SIRS score, combining with other predictors, could be used in predicting outcomes in patients with severe burns. Additionally, we compared the prognostic accuracy of admission SIRS score with other score systems and newly developed models.MethodsWe performed a retrospective study of adult patients with ≥40% total body surface area burns admitted to a burn center from 2005 to 2017. The primary outcome was in-hospital mortality, and the secondary outcomes were hospital and intensive care unit length of stay. SIRS score, rBaux score, ABSI and newly developed models were compared using area under the receiver operating characteristic curve analysis.ResultsOut of the total 144 patients, 128 (88.9%) met SIRS criteria on admission; with a predominant SIRS scores of 3. Patients with admission SIRS were more likely to have larger burns and have higher rBaux and ABSI scores when compared with non-SIRS patients. With the each increment of admission SIRS score, total and full-thickness burn areas, proportion of inhalation injury, tracheostomy and mortality increased significantly. However, SIRS score at admission was not increasingly predictive of deleterious outcomes when analyzed by multivariable regression analysis. Although the combination of SIRS score, age, and burn-specific variables showed better or equal prognostication of outcomes than that of other score systems, the contribution of the variable SIRS score was negligible.ConclusionsThe model with the variables age, percentage full-thickness burns, and inhalation injury provided excellent prediction of poor outcomes in patients with severe burns, while SIRS score has limited use for prognostic determinations.     

Monitoring of the burn patient

Technologic advances have made routine use of some form of monitoring mandatory in modern burn care. Nevertheless, not all patients require all forms of monitoring. Patients with minimal burns require only minimal monitoring (vital signs, 24-hour urine output, biochemical and hematologic profile). Larger burns, associated injuries, or underlying disease necessitate more aggressive monitoring and may justify invasive monitoring with its attendant risks of infection. Very large burns, severe cardiac dysfunction, and inhalation injury mandate vigorous invasive monitoring including pulmonary artery catheters.     

Recent advances in the management of severely burned patients]

With recent advances in the systemic care of burns, patients with burns covering 80% of their body surface can frequently survive. The percentage of total body surface area burn for an expected 50% mortality rate has improved to 98% for children and 72% for adults in one burn center in the USA. From the results of 11 burn units in Tokyo, the mortality rate of burn patients with a prognostic burn index of 90-100 was 51.4%. The improvement is attributable to advances in the understanding of the pathophysiology of severe burns as a systemic inflammatory response syndrome. Improved cardiopulmonary management of extensive burns and respiratory tract burns has also played a part in reducing the mortality rate. Individualized fluid resuscitation programs based on hemodynamic monitoring have reduced the incidence of burn shock and acute renal failure. Early eschar excision and wound closure by immediate grafting have further reduced the mortality rate from extensive full-thickness burns. The use of bilayer artificial skin has improved the survival and cosmetic results of early eschar excision in patients with massive full-thickness burns. Cultured autologous epidermal sheets hold promise if used on an appropriate dermal bed.     

Bone metabolism in pediatric burned patients: A review

Severe burns in children can lead to growth delays, bone loss, and wasting of lean body mass and muscle with subsequent long-term effects such as osteoporosis. The following review examines 11 randomized, placebo-controlled, prospective clinical trials in pediatric burns between 1995 and 2017. These studies included approximately 250 burned children, and they were conducted to evaluate the impact of severe burn on markers of bone formation and bone metabolism. Some trials also analyzed current therapy regimens such as pamidronate and vitamin D. The clinical utility of these outlined biomarkers is uncertain with regard to acute burn care, as the current literature remains unclear. This review thus serves to address the impact of severe burn on markers of bone formation and bone metabolism in pediatric patients but will not focus on the clinical utility of the markers. The aim of this review is to summarize the findings of the trials to guide the future care of burned patients to maximize bone recovery.     

The association between out of hours burn centre admission and in-hospital outcomes in patients with severe burns

IntroductionPatients with severe burns (≥20 % total body surface area [TBSA]) have specific and time sensitive needs on arrival to the burn centre. Burn care systems in Australia and New Zealand are organised differently during weekday business hours compared to overnight and weekends. The aims of this study were to compare the profile of adult patients with severe burns admitted during business hours with patients admitted out of hours and to quantify the association between time of admission and in-hospital outcomes in the Australian and New Zealand context.MethodsData were extracted from the Burns Registry of Australia and New Zealand for adults (≥18 years) with severe burns admitted to Australian or New Zealand burn centres between July 2016 and June 2020. Differences in patient profiles, clinical management, and in-hospital outcomes were investigated. Univariable and multivariable logistic and linear regression models were used to quantify associations between time of admission and in-hospital outcomes of interest.ResultsWe found 623 patients eligible for inclusion. Most patients were admitted out of hours (69.2 %), their median age was 42 years, and most were male (78 %). The median size burn was 30 % TBSA and 32 % of patients had an inhalation injury. A greater proportion of patients admitted out of hours had alcohol and/or drugs involved with injury compared to patients admitted during business hours. No other differences between groups were observed. Patients in both groups had similar odds of dying in hospital (Odds Ratio [OR], 95 % Confidence Interval [95 %CI] 1.49 [0.64, 3.48]), developing acute kidney injury within 72 h (OR, 95 %CI 0.58 [0.32, 1.07]), or sepsis (OR, 95 %CI 1.04 [0.46, 2.35]). No association was found between time of admission and hospital (%, 95 %CI 1.00 [0.82, 1.23]) nor intensive care length of stay (%, 95 %CI 0.97 [0.73, 1.27]).DiscussionIn this first Australian and/or New Zealand study to explore the association between time of admission and burn patient in-hospital outcomes, out of hours admission was not associated with patient outcomes of interest.ConclusionThese findings support current models of care in Australian and New Zealand burn centres, however further investigation is required. Nonetheless, given most severe burns patients arrive out of hours to burn the centre, it is plausible that out of hours availability of senior burn clinicians will improve patient care and safety resilience within burn care systems.     

Toxic epidermal necrolysis: 10 years experience of a burns centre in Hong Kong

Toxic epidermal necrolysis syndrome is characterized by extensive skin rash with blisters and exfoliation similar to that of major burns. Current evidence suggests that toxic epidermal necrolysis syndrome is most likely due to cell-mediated immune response triggered by certain drugs. Recognition of the clinical situation which is similar to major burn has resulted in general agreement that these patients are best treated in a burns unit, where critical support and meticulous wound care can be carried out by experienced personnel. This represents a major step forward in the management of this condition. The 10 year experience of managing seven patients with severe toxic epidermal necrolysis in a tertiary burns centre in Hong Kong is presented and the controversies over classification and management of the disease are also discussed.     

外科脓毒症免疫功能障碍的监测与调理策略

脓毒症是一种严重的感染并发症,通常是由微生物感染、严重烧（创）伤及外科大手术对机体应激打击等引发,并伴有全身炎症反应综合征和MODS,从而导致在ICU中的高发病率及病死率.长期以来,由于临床医师对于外科打击后机体免疫功能障碍的确切机制及其在脓毒症中的作用认识不足,临床上缺乏切实有效的免疫功能监测手段和调理措施.近年来随着对脓毒症发病本质的逐步了解,临床医师已认识到脓毒症发病机制非常复杂,除感染与炎症过程外,机体免疫功能障碍参与了脓毒症的病理生理过程,且发挥关键作用.因此,对烧（创）伤、外科大手术后脓毒症机体免疫状况的合理监测,寻求新的有效防治途径,对于严重脓毒症的早期识别、诊断和干预,降低重症患者病死率及提高患者生命质量具有重大意义.     

The cost of inpatient burn management in Nepal

IntroductionThe management of burns is costly and complex with inpatient burns accounting for a high proportion of the costs associated with burn care. We conducted a study to estimate the cost of inpatient burn management in Nepal. Our objectives were to identify the resource and cost components of the inpatient burn care pathways and to estimate direct and overhead costs in two specialist burn units in tertiary hospitals in Nepal.MethodsWe conducted fieldwork at two tertiary hospitals to identify the cost of burns management in a specialist setting. Data were collected through semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs) with burn experts; unit cost data was collected from hospital finance departments, laboratories and pharmacies. The study focused on acute inpatient burn cases admitted to specialist burn centres within a hospital-setting.ResultsExperts divided inpatient burn care pathways into three categories: superficial partial-thickness burns (SPT), mixed depth partial-thickness burns (MDPT) and full thickness burns (FT). These pathways were confirmed in the FGDs. A ‘typical’ burns patient was identified for each pathway. Total resource use and total direct costs along with overhead costs were estimated for acute inpatient burn patients. The average per patient pathway costs were estimated at NRs 102,194 (US$ 896.4), NRs 196,666 (US$ 1725), NRs 481,951 (US$ 4,227.6) for SPT, MDPT and FT patients respectively. The largest cost contributors were surgery, dressings and bed charges respectively.ConclusionThis study is a first step towards a comprehensive estimate of the costs of severe burns in Nepal.     

Phenol burns

This case report describes the treatment of three men who suffered severe phenol burns while working in a chemical manufacturing plant. Emergency room care is described, and treatment received in the burn unit at the Santa Clara Valley Medical Center is evaluated. The toxic action of phenol, and its effects on the human system, are explained. Based on the experience with these three patients, specific precautions are outlined for those who are in contact with phenol, and a method of treating phenol burns is presented, including a discussion of the most effective solvents.     

Impact of COVID-19 pandemic on the care of severe burns in Japan: Repeated survey of specialized burn care facilities

BackgroundThe spread of coronavirus disease 2019 (COVID-19), which began in 2020, has had a major impact on healthcare systems. The spread of COVID-19 has been reported to have affected the readiness to treat patients with burns worldwide. However, the existing reports have evaluated burn care status within a limited time period during the pandemic, and no report clarifies the change in the impact of infection status on burn care from the beginning of the pandemic to the present.MethodsJapanese Society for Burn Injuries–accredited burn care facilities were surveyed using questionnaires on April 9–23, 2020; June 23–July 6, 2020; July 9–21, 2021; and January 21–31, 2022. Differences between groups were evaluated using Friedman’s test or Bonferroni’s multiple comparison test, as appropriate.ResultsFrom the 103 facilities included in the study, we received 85, 55, 56, and 58 responses in the first, second, third, and fourth surveys, respectively. We could continuously observe 34 facilities. The rate of acceptance of patients with severe burns improved significantly over time (P < 0.05). However, in the second and third surveys, there was an increase in the number of respondents who did not accept patients with burns irrespective of COVID-19 status.ConclusionsThe number of facilities treating patients with burns who have COVID-19 is increasing; however, COVID-19 care may negatively impact routine burn care. It is necessary to continuously examine medical resource allocation through methods such as information sharing by academic societies.     

Health related quality of life 5–7 years after minor and severe burn injuries: a multicentre cross-sectional study

IntroductionBurn injury can affect health-related quality of life (HRQL). Knowledge concerning long-term HRQL in burn patients is limited. Therefore our aim was to evaluate long-term HRQL and to study predictors of impaired long-term HRQL.MethodsAll adults with a length of stay (LOS) of ≥1 day (2011–2012) were invited. Also, adults with severe burns, i.e., >20% total body surface area (TBSA) burned or TBSA full thickness>5% (2010–2013) were invited. Participants completed the EuroQol(EQ)-5 D-5L + C and visual analogue scale (EQ-VAS) 5–7 years after burns.ResultsThis study included 256 patients (mean %TBSA 10%); 187 patients with minor burns and 69 patients with severe burns. Mean EQ-5D summary was 0.90 and EQ-VAS 83.2 in the minor burn patients, and 0.79 and 78.1 in the severe burn patients. Some problems in at least one dimension were experienced by 81% of patients with severe burns and 45% of those with minor burns. However, a minority reported severe or extreme problems; 15% of those with severe burns and 6% of those with minor burns. Patients with severe burns reported significantly more problems, except for anxiety/depression. In both patient groups most problems were reported on pain/discomfort. Length of hospital stay, gender and age were associated with lower long-term HRQL (EQ-VAS) in multivariate analyses, whereas only length of stay was associated with a lower summary score.ConclusionsThe majority of patients experienced some problems with HRQL 5–7 years post burn. This emphasizes that burns can have a negative impact on an individual’s HRQL, particularly in more severely burned patients, that persists for years. The HRQL dimensions most frequently affected include pain/discomfort and anxiety/depression. Patients with a prolonged hospital stay, females and older patients are at higher risk of poor HRQL in the long-term.     

Flüssigkeits-, Schmerz-, und chirurgische Therapie des Verbrennungstraumas in den ersten Stunden nach Klinikaufnahme

Extensive and deep burns are one of the most severe forms of trauma. The mortality has clearly decreased over the last decades so that even patients with burns to 70% of the body surface have a 50% chance of survival. Optimized early treatment of burn patients begins at the site of the accident. The first hours after admission to the burn center are highly important for the outcome of burn patients. Infusion therapy, pain treatment and early surgical therapy are crucial. Additionally care must be taken to protect the patient from hypothermia. Burn patients with combined injuries must be recognized and an earliest possible clinical diagnosis is essential and must be followed by definitive interdisciplinary surgical treatment.