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.     

No influence of burn size on ventilator-associated pneumonia in burn patients with inhalation injury

Objective

Burn size and inhalation injury are important predictors of mortality following burn. The important factors for predicting ventilator-associated pneumonia (VAP) following burn remain unclear. The aim of our study was to investigate the effect of burn size on VAP in burn patients with inhalation injury.

Methods

We retrospectively studied 52 burn patients with inhalation injury requiring mechanical ventilation admitted to the Department of Acute Medicine, Kawasaki Medical School Hospital, Okayama, Japan, between June 2007 and October 2010.

Results

The overall mortality for all patients was 15%. Twenty-six patients (50%) developed VAP. Patients with VAP required longer ICU stay and mechanical ventilation than those without VAP. There was no difference in age, gender, mortality, and TBSA between burn patients with inhalation injury with and Without VAP. VAP rate had no difference with increasing TBSA in burn patients with inhalation injury.

Conclusions

Our data indicated that burn size had no relationship with the development of VAP in burn patients with inhalation injury.     

Negative pressure dressing assisted healing in pediatric burn patients

Background/Purpose

Pediatric burn patients traditionally require multiple dressing changes and significant amounts of narcotics. Negative pressure dressings (NPDs) have emerged as an effective wound therapy that may represent an alternative primary dressing for these patients.

Methods

This is a single institution, retrospective study of pediatric burn patients treated with NPDs over a defined 2 year period. Twenty-two patients were identified and their charts reviewed for age, sex, mode of injury, location of injury, degree of burn, length of stay, length of dressing required, number of dressing changes, and narcotic use between dressing changes.

Results

The average patient was 3.5 years old (range of 8 months to 10 years old) with partial thickness burns involving 8.5% (range 3–18%) body surface area. The average treatment regimen was 3.5 dressing changes more than 6.6 days, with a mean hospital stay of 9.6 days. The average child received 9.4 total doses of delivered narcotics during their inpatient care.

Discussion

The use of NPD in pediatric burn patients does require sedation and narcotics which limits its usefulness in the general pediatric burn population. Yet, they adhere well and stay in place even on active children, they capture and quantify fluid losses, they only require changes every 2–4 days and promote the adherence of split thickness skin grafts making them useful in various clinical situations.

Conclusions

NPDs are a viable option for both partial and full thickness burns in pediatric patients that do not require transfer to a burn unit. NPDs may be advantageous in highly active children, those with extensive fluid losses, those that require sedation for dressing changes and those that will require grafting.     

Burn care in relation to burn epidemiology in Italy

Aim

Burn centres are ‘hubs’ of referral for large areas and should be organised in a network optimised for the needs of their area. Burn centres’ organisation and activity in Italy are analysed with reference to burn epidemiology in the country.

Methods

A questionnaire was submitted to Italian burn centres concerning organisation, activity and epidemiology of burns treated in 2008.

Results

A total of 2067 patients were admitted to a burn centre in 2008; 50% of burns were due to flames (21% alcohol); and 25% of patients were <14 years old. Overall mortality was 5.3%. 144 beds in 15 burn centres were available (seven reserved for children; bed/inhabitants ratio, 1/414,.023). However, distribution is not uniform in the country. Bed rotation was 14.4 patients/bed, and hospital stay varied from 11.7 days for <20% total body surface area (TBSA) burns to >120 days for burns >70%. About half (57%) of patients admitted had less than 20%TBSA burns, 32% had 20-50% TBSA burns, 7% from 50% to 70% and 4% over 70% TBSA. A national network coordinating burn centre activity is lacking.

Conclusions

Italy seems to have less availability of beds for burn care than other countries, and distribution and organisation of the network may be improved. The high prevalence of child burns should be noticed and this makes prevention campaigns advisable.     

A study of energy-related injuries from hospital admissions among children and adults in South Africa

Introduction

Burn and ingestion injuries are common in developing countries because of poor access to safe energy sources, crowded living conditions, and insufficient knowledge of potential risks. The purpose of this study is to understand the scope of burn and ingestion injuries due to various energy source usages in South Africa.

Methods

Patients at 16 regional hospitals throughout South Africa presenting with an energy-related injury between 2006 and 2012 were interviewed to obtain demographics and injury characteristics.

Results

A total of 12,443 patients were included in this study. Children aged 1–2 years predominantly experienced burn and ingestion injuries (21%). Liquid burns (30%) were more common than flame burns (14%). Chi-squared tests show that age was significantly related to degree of burn, type of burn, and severity of burn (p < 0.001). Non-intentional injuries (45%) were more frequent than self-inflicted or assault injuries. Temporal and seasonal injury trends reflect usage patterns. Burn injuries result in longer hospital length of stay than ingestion injuries.

Conclusion

Non-intentional liquid burns and ingestions to infants and babies were most common in this study, with many injuries also occurring among young adults. It is advised that interventions targeting low-income communities be conducted to increase awareness of burn and ingestion injuries.     

The application of glycerol-preserved skin allograft in the treatment of burn injuries: An analysis based on indications

Introduction

Glycerol-preserved skin allograft (GPA) plays a crucial role in the management of burns. Its indications include wound-bed preparation, definitive dressing and sandwich grafting technique.

Objective

We analysed the experience of using GPA and its efficacy in burn treatment in our burn centre.

Methods

All burns managed with GPA in our burn centre from October 2001 to May 2008 were analysed.

Results

Mean total body surface area (TBSA) of 43 consecutive cases was 28.7%. GPA adhered to the wound for an average of 8.4 days before rejection. The length of hospital stay of the survivors was 42.5 days. The autograft take after wound-bed preparation with GPA was 88.4%. For sandwich grafting technique, the autograft take was 74.4%. When GPA was applied for partial-thickness burn as definitive dressing, all patients achieved complete healing within an average of 19 days without further surgical intervention. Despite colonisation of burn wounds after application of skin allograft, the outcomes of autograft take and wound healing were not significantly different.

Conclusion

The selective and strategic use of the GPA in major burn patients ensures optimal benefits in the management of burns. It is versatile in various categories of burn wounds with minimal morbidity.     

Epidemiological analysis of burn patients in East Bulgaria

Objective

The purpose of the study was to identify the basic epidemiological characteristics of burn patients in East Bulgaria, as well as to analyze trends in burns in the region over the last decade.

Methods

Retrospective data of burn patients treated at Military Hospital-Varna, in the period January 2002–December 2011, was reviewed and statistically interpreted in terms of patients and burn demographics; etiology; place of incidents; hospital stay and mortality. Trends were observed for the entire period and comparative analyses of patients’ data were made between two periods: first – 2002–2006 and second 2007–2011.

Results

A total of 2627 burn patients, median age 41 years (IQR 9–61) were admitted to our burn unit. For the entire period the most affected age groups were ≤4 years (21.6%) and ≥65 years (21.1%). Hospitalized patients increased in the second period (n = 1701) compared to the first one (n = 926), while the size of total burn surface area decreased (first period – 9.8% vs. second period – 10.6%). Scald (51%) and flame (23.8%) were the most frequent aetiological agents for both periods. Work related burns reduced in the second period (9.4% vs. 4.9%), while home burns (90.6 vs. 95.1%) increased. Hospital stay declined from 17days (2002–2006) to 7days (2007–2011), whereas mortality rate slightly increased (first period – 2.3% vs. second period – 3.6%).

Conclusion

Burns remain a significant health problem in Bulgaria. The future preventive actions should take into account the observed changes in burn demographics and target the most vulnerable groups.     

Mortality and treatment cost estimates for 1075 consecutive patients treated by a regional adult burn service over a five year period: The Liverpool experience

Objective

To assess the clinical outcomes and treatment costs of a regional adult burn service in northwest England.

Methods

We retrospectively reviewed data on a five year cohort of 1075 patients treated by the Mersey Regional Burn Service between 2006 and 2010 to obtain age-stratified mortality estimates based on the lethal area 50 (LA50) measure. Treatment cost estimates were made for a one year cohort of 262 patients treated between April 2011 and April 2012.

Results

44 (4.1%) of the five year cohort died; 36 had suffered flame burns. Our LA50 was 71.08 for the 15–44 age group, 56.64 for the 45–64 age group, and 28.82 for the 65 and over age group. Mean treatment costs associated with patients allocated to different burn-specific healthcare resource groups ranged from £2527.77 to £31,870.95. Detailed cost estimates for three patients ranged from £12,553.23 to £66,029.33.

Conclusion

The LA50 estimates for the Mersey Regional Burn Service compare favourably with previous reports in the literature. Our treatment costs were substantially lower compared to those reported previously in the United Kingdom. This study demonstrates that high quality and cost effective care can be delivered by a service that treats relatively few major burns (>70% TBSA).     

Differential expression of the immunoinflammatory response in trauma patients: burn vs. non-burn

Rationale

Cytokines are central mediators of the immune-inflammatory response to injury and subsequent multiple organ dysfunction syndrome (MODS). Although previous studies evaluated cytokine levels after trauma, differences between patients with burn and non-burn trauma have not been assessed systematically.

Methods

A prospective database of trauma patients admitted between May 2004 and September 2007 to the burn or surgical intensive care units within 24 h of injury with an anticipated stay of at least 72 h was analyzed. Sequential clinical and laboratory parameters were collected in the first week, including multiplex analysis data for plasma levels of inflammatory cytokines (IL-6, and IL-8). Patients with known pre-injury coagulopathy were excluded. A Marshall score of 10 or greater was defined as MODS.

Results

A total of 179 patients were enrolled (67 burn and 112 non-burn). Plasma IL-6 and IL-8 levels were markedly elevated in both burn and non-burn patients compared to healthy volunteers. Burn subjects had higher levels of IL-6 and IL-8 than the non-burn on days 1 through 7 after injury. Subjects with burns and at least 30% total body surface area were older and had a lower injury severity score, a higher prevalence of MODS, and correspondingly higher mortality. Multivariate analysis of injury type, MODS, and time did not demonstrate an influence of MODS.

Conclusions

Burns were associated with a greater and more sustained immune-inflammatory response than non-burn trauma as evidenced by elevated plasma IL-6 and IL-8 levels during the first week. There was no association between MODS and plasma cytokine levels.     

Assessment of mortality prediction models in a Ghanaian burn population

Purpose

Over 40 new or modified outcome prediction models have been developed for severe burns; with age, total burned surface area (TBSA) and inhalation area as major determinants of mortality. The objective of this study was to assess their applicability in a developing country.

Procedures

Data were collected retrospectively of a consecutive series of 261 patients (2009–2011) admitted to a Burns Intensive Care. Five outcome prediction models based on admission criteria were evaluated: Bull grid, Abbreviated Burn Severity Index – ABSI, Ryan-model, Belgian Outcome in Burn Injury – BOBI and revised Baux. Discriminative power and goodness-of-fit were assessed by receiver operating characteristic analyses (area under the curve – AUC) and Hosmer–Lemeshow tests.

Findings

Median age was 10.5 years (IQR: 2.5–27 years), median TBSA 21% (IQR: 11–34%); 55.2% were male, 28 patients died (10.7%). Only 2 patients were intubated (0.8%). The AUC were between 77 and 86%. The ABSI model showed the best calibration (28.7 expected deaths). Ryan, BOBI and rBaux significantly underestimated mortality, whereas Bull showed an overestimation.

Conclusion

This study on a young group of burn patients showed moderate to good discriminative power using all five prediction models. The expected number of deaths tended to be underestimated in the three most recent prediction models.     

Noncontact electrosurgical grounding – A useful and safe tool in the initial surgical management of thermal injuries

Background

Electrosurgical instruments – one of the useful and most-used instruments within the surgeon's armamentarium – are potentially dangerous by causing unanticipated direct burns; fire occurring as a result of electrosurgical instruments and electromagnetic interference with a pacemaker, defibrillator, or cardiac monitoring device.

Methods

The Mega 2000 Patient Return Electrode System produced by Megadyne Medical Products is a noncontact electrode designed to provide adequate electrical return to facilitate function of electrocautery devices. We used this noncontact device in 67 patients (28 women, 39 men) with large burns during their stay in our burn unit and in 11 of these patients (4 women, 7 men) for escharotomies during admission in our burn care.

Results

The device functioned well in all cases, no additional cutaneous burns on the patients’ body were noticed.

Conclusion

This paper is a review of our experience with this noncontact electrosurgical grounding in burn surgery highlighting its advantages comparing with the conventional electrosurgical instruments.     

Exhaust system burn injuries in children

Background/Purpose

The authors had noted a number of children who had sustained burn injuries from the exhaust systems of recreational vehicles and wished to document the incidence of pediatric burn injury sustained from the exhaust systems of a wide scope of motorized vehicles.

Methods

The authors conducted a 10-year retrospective chart review including all children admitted to our institution with burn injuries from contact with vehicular exhaust systems.

Results

Twenty-three children were included. There were 18 boys, with a median patient age of 7 years. Most children (7 of 23) were injured from the exhaust systems of all-terrain vehicles. The average burn size (5%) was small, but almost two thirds of the burn injuries were full thickness. Of the 23 children, 21 required operative intervention for their burns, with 2 children requiring multiple surgical interventions. The average length of hospital stay was 11 days, and all children, except one who went to a rehabilitation facility, were discharged to home.

Conclusions

Pediatric health care providers should be aware that exhaust system contact burns in children are not rare events and they do tend to be significant. Surgical consultation should be requested early in the management of these particular burn injuries in children.     

Influencing factors of the quality of life in Chinese burn patients: Investigation with adapted Chinese version of the BSHS-B

Objective

The study aims to evaluate the quality of life (QOL) in burn patients in China and find out principal influencing factors, so as to provide evidence for interventions.

Methods

A total of 271 burn patients in three major burn units in China were asked to fill in the adapted Chinese version (ACV) of the Burn Specific Health Scale-Brief (ACV BSHS-B) in order to seek out the principal influencing factors in combination with a self-designed demographic and disease condition questionnaire. Multivariable linear regression was used to analyse the principal influencing factors.

Results

The findings showed that there were seven principal influencing factors for the overall ACV BSHS-B score. They were: percent total body surface area (TBSA) burned (with the standardised regression coefficient being −0.594), burn area of lower limber (0.241), itch level (−0.227), pain level (−0.220), gender (0.217), mechanical ventilation (0.216) and hand deformity (−0.141).

Conclusion

QOL decreased in burn patients to different degrees depending on the intensity of burns. With a better understanding of influencing factors of burn patients’ QOL, the medical and nursing staff can take specific countermeasures to help patients gain a higher QOL.     

The epidemiology of patients with burn injuries admitted to Norwegian hospitals in 2007

Objectives

To study the incidence and outcome of burns in Norway in 2007, and to establish estimates for effective length of stay, mortality and economical costs.

Methods

Data from the Norwegian Patient Registry on all patients discharged from all somatic hospitals in Norway in 2007 with main or subsidiary diagnosis of burn injury (ICD-10: T20–31) were collected.

Results

Seven hundred and twenty-six patients (65.0% male) with acute burns were admitted to Norwegian hospitals in 2007, requiring 8157 in-hospital days and resulting in a mean length of hospitalization per burn case of 11.3 days (S.D. 15.2). The mean age of the patients was 26.9 years (S.D. 25.5), and the mortality was 2.1%. For children below 5 years of age the incidence of burns admitted to hospital was 82.5/100,000/year. The annual total cost for in-hospital burn care exceeded €10.5 million (€2,200,000/million inhabitants)

Conclusion

Compared to similar data from Norway (1992) the rate of admission for burns in 2007 (15.5/100,000/year) appeared as high as in 1992, whereas the mean length of stay was reduced by 26%. Children under the age of 5 had a seven times higher incidence compared the rest of the population.     

Epidemiology of burns in the United Arab Emirates: Lessons for prevention

Purpose

To study mechanism, risk factors and outcome of hospitalized burns so as to give recommendations for prevention.

Methods

Burn patients admitted to Al Ain hospital for more than 24 h or who died after arrival were studied over 4 years. Demographics, burn type, location and time of injury, total body burned surface area (TBSA), body region, hospital and ICU stay and outcome were analyzed.

Results

203 patients were studied, 69% were males and 25% were children under 5 years old. The most common location for burn was home. Women were burned more at home (p < 0.0001). 28% of patients were injured at work with more men (p < 0.0001) and non-UAE nationals (p < 0.01). Scalds from water, tea were the major hazard at home, while majority of burns at work were from gas and flame. Burns caused by gas and flame had larger TBSA and longer ICU stay. Six (3%) patients died and nine (4%) were transferred to the specialized burn center.

Conclusions

Safety education for caregivers and close supervision of young children is important to reduce pediatric burns. Occupational safety education of young men could prevent burns caused by gas and flame.     

Photographic assessment of burn wounds: A simple strategy in a resource-poor setting

Objective

To validate the use of photographic burn wound assessment in evaluation of burn size and wound characteristics.

Methods

Feasibility study of agreement between methods of measurement of burn size and characteristics, in patients admitted to the burn unit at Kamuzu Central Hospital (KCH), Malawi, over two months in 2011. Burn wounds were photographed and assessed clinically, concurrently, by an experienced clinician. Photographs reviewed by two blinded burn clinicians after 4–6 weeks. Correlation between clinical assessment and photographic evaluation was calculated using kappa score and Pearson's correlation coefficient.

Results

Thirty-nine patients were included in evaluation of TBSA, and fifty wounds assessed for their characteristics. Pearson's correlation coefficient for agreement of TBSA between clinical exam and photograph review by expert#1, and #2, was 0.96, 0.93 (p < 0.001), respectively. Pearson's correlation coefficients comparing expert#1 and #2 to the gold standard were: proportion of full-thickness burn (0.88 and 0.81, p < 0.001), and epithelialized superficial burn (0.89 and 0.55, p < 0.001). Kappa scores were significant for wound evolution (expert#1 0.57, expert#2 0.64, p < 0.001), and prognosis (expert#1 0.80, expert#2 0.80, p < 0.001).

Conclusions

Burn assessment with digital photography is a valid and affordable alternative to direct clinical exam, alleviating access issues to burn care in developing countries.     

Accuracy of early burn depth assessment by laser Doppler imaging on different days post burn

Background

Accurate diagnosis of burn depth is essential in selecting the most appropriate treatment. Early assessment of burn depth by clinical means only has been shown to be inaccurate, resulting in unnecessary operations or delay of grafting procedures. Laser Doppler imaging (LDI) was reported as an objective technique to determine the depth of a burn wound, but the accuracy on very early days post burn has never been investigated yet.

Methods

In 40 patients with intermediate depth burns, we prospectively evaluated and compared the accuracy of the LDI measurements with the clinical assessments on days 0, 1, 3, 5, 8. Clinical evaluation of the depth of the burn was performed by two observers blinded to the LDI images. Accuracies were assessed by comparison with outcome: healing times longer than 21 days were considered to be equivalent to a biopsy finding of a deep dermal wound. Obviously superficial and full thickness wounds were excluded. LDI flux level was used for LDI prediction of outcome: less than 220 PU to predict non-healing at day 21.

Results

The accuracies of burn depth assessments on the day of burn and post burn days 0, 1, 3, 5 and 8 using LDI were 54%, 79.5%, 95%, 97% and 100% compared with clinical assessment accuracies of 40.6%, 61.5%, 52.5%, 71.4% and 100%, respectively. LDI accuracy was significantly higher than clinical accuracy on day 3 (p < 0.001) and day 5 (p = 0.005). Burn depth conversion was also considered. This is the first study to quantify the advantage of LDI scanning over clinical assessments during these important early after burn days.     

Burns at KCMC: Epidemiology,presentation, management and treatment outcome

Background

About 90% of the global burden of burns occurs in the low and middle income countries. In Africa it is estimated that between 17,000 and 30,000 children under five die each year due to burns. In Tanzania there are no specialized burn centers. Burn patients are often managed in the general surgical wards in most hospitals. Kilimanjaro Christian Medical Centre is one of the four tertiary referral hospitals in Tanzania.

Rationale

This study aimed to review the epidemiology presentation management and outcome of burn patients in this challenging environment.

Patients and methods

A cross-sectional prospective study involving 41 patients was undertaken from October 2011 to April 2012.

Results

65.9% were males. The largest age group was below 5 years (36.6%). 19.5% were epileptic. More than half of the burns were due to open flame. 80.5% had second degree burns. 56.1% had a BSA of 15% or less and 56.1% had an APACHE score of 10 or less. It was found that 73.2% of burns occurred at home. The commonest prehospital first aid applied was honey. Only 41.5% arrived in hospital within the first 24 h after burn. Among the 14.6% who had skin grafting, none had early excision of burn wound. 53.7% developed wound sepsis while 24.4% developed contractures. The mortality rate was 26.8%.

Conclusion

Children under five are the worst affected by burns. Most patients had second degree burn wounds. Inappropriate management of the burn wound started just after injury and continued even in hospital. Mortality and complication rates are high.     

Rehabilitation of burn patients: An underestimated socio-economic burden

Purpose

Patients with burns utilise intensive medical care and rehabilitation. Deep dermal burns lead to scar contractures. Virtually no published data exists on costs for treatment of acute burns in comparison to burn sequelae. Our purpose was to collect financial data on burn therapy to estimate the socio-economic burden of thermal injuries.

Methods

German-DRG for in-patient treatment of burns was collected from our burn center. DRG-related T95.- coding served as a search tool for burn associated sequelae. To include rehabilitation costs, data from the largest health care insurance and a workmen compensation fund were acquired.

Findings

Acute burn treatment comprised 92% of costs for intensive care with approximately 4.600 EUR per percent total burned surface area (TBSA). Expenses for non-intensive care patients were significantly lower than for burn sequelae. Rehabilitation expenses were 4.4-fold higher than costs for acute burns including 59% for manual therapy and 37% for auxiliary material.

Conclusions

TBSA multiplied by factor 4600 could serve for cost calculation of severely burned patients. Approximately 0.3 billion EUR in total or 270.000 EUR per patient/year were spent on burn sequelae. Early admission to specialized burn centers is advocated with state-of-the-art treatment to minimize burn sequelae and health care expenses.