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.     

Improving burn care and preventing burns by establishing a burn database in Ukraine

Background

Burns are a challenge for trauma care and a contribution to the surgical burden. The former Soviet republic of Ukraine has a foundation for burn care; however data concerning burns in Ukraine has historically been scant. The objective of this paper was to compare a new burn database to identify problems and implement improvements in burn care and prevention in this country.

Methods

Retrospective analyses of demographic and clinical data of burn patients including Tukey's post hoc test, analysis of variance, and chi square analyses, and Fisher's exact test were used. Data were compared to the American Burn Association (ABA) burn repository.

Results

This study included 1752 thermally injured patients treated in 20 hospitals including Specialized Burn Unit in Municipal Hospital #8 Lviv, Lviv province in Ukraine. Scald burns were the primary etiology of burns injuries (70%) and burns were more common among children less than five years of age (34%). Length of stay, mechanical ventilation use, infection rates, and morbidity increased with greater burn size. Mortality was significantly related to burn size, inhalation injury, age, and length of stay. Wound infections were associated with burn size and older age. Compared to ABA data, Ukrainian patients had double the length of stay and a higher rate of wound infections (16% vs. 2.4%).

Conclusion

We created one of the first burn databases from a region of the former Soviet Union in an effort to bring attention to burn injury and improve burn care.     

Trauma capacity in the central plateau department of Haiti

Background

Surgical burden is a large and neglected global health problem in low- and middle-income countries. With the increasing trauma burden, the goal of this study was to evaluate the trauma capacity of hospitals in the central plateau of Haiti.

Materials and methods

The World Health Organization Emergency and Essential Surgical Care survey was adapted with a focus on trauma capacity. Interviewers along with translators administered the survey to key hospital staff.

Results

Seven hospitals in the region were surveyed. Of the hospitals surveyed, 3/7 had functioning surgical facilities. None of the hospitals had trauma registries. 71% of the hospitals had no formal trauma guidelines. 2/7 hospitals had a general surgeon available 100% of the time. All surgical facilities had oxygen cylinders available 100% of the time, but three of the primary level hospitals only had it available 51%–90% of the time. Intubation equipment was available at 57% of the facilities. Ventilators were only available in the operating room. Only the largest hospital had a computed tomography scanner. Other hospitals (66%) had a functioning x-ray machine 76%–90% of the time. Hospitals (57%) had an ultrasound machine. The most common reasons for referral were lack of appropriate facilities and supplies at the primary level care centers or lack of trained personnel at higher-level facilities.

Conclusions

Trauma capacity in the central plateau of Haiti is limited. There is a great need for more personnel, trauma training at all staff levels, emergency care guidelines, trauma registries, and imaging equipment and training, specifically in ultrasonography. To accomplish this, coordination is needed between the Haitian government and local and international nongovernmental organizations.     

Adherence to National Burn Care Review referral criteria in a paediatric Emergency Department

Introduction

The National Burn Care Review (NBCR) gives guidance on the recognition of potentially complex burns requiring assessment and management in a burn unit. This guidance provides a referral framework for those initiating assessment and management of burns. The effect of close adherence to NBCR guidance on workload is at present unknown.

Objectives

To audit referral patterns of burns in our paediatric Emergency Department (ED) in comparison to NBCR referral criteria. To identify the type of injuries not referred despite meeting criteria, and their outcomes, to assess whether these patients come to any harm short-term. To estimate the effect that closer adherence would have on workload and how our unit proposes to work with the ED to improve its distribution and our patients care.

Methods

A retrospective case-note audit of patients presenting to a paediatric ED with a triage diagnosis of “burn/scald” over a 6-month period between 1st April and 29th September 2008.

Results

190 patients presented with burns during this period, of which 126 (66%) had potentially complex burns. Of these, 93 (74%) were not referred to the burns unit i.e. were “under-referred”. In this group burns to specialized areas in patients under 5 years of age were particularly prevalent. 78 (84%) were reviewed in the ED and received no specialist input. Seven patients suffered minor complications. Only three of these patients (3.2%) required subsequent referral to the burns unit for opinion. None required any further specialist intervention.

Conclusion

Strict adherence to NBCR referral criteria could result in a significant increase in workload for regional burn units with as yet unquantifiable benefit in patient outcomes. Many minor injuries appear to be safely managed in the ED with little adverse outcome. Even small improvements in practice could result in a considerable workload increase for a burns unit. Further prospective research is required, particularly looking at longer-term outcomes. We are hoping to improve educational and clinical links between our EDs and burn unit to improve patient care and distribution of clinical workload. Further national guidance maybe necessary.     

Examining disaster planning models for large scale burn incidents—A theoretical plane crash into a high rise building

Background

The escalation of global terrorist attacks has resulted in a rise of traumatic injuries. Planning for mass casualty incidents (MCIs) is critical to decrease the morbidity and mortality that ensues after large-scale terrorist attacks. This study provides criteria for the management of burn victims following large-scale disasters.

Methods

Mass casualty outcomes from three disasters involving commercial aircraft crashes were analyzed. The three events included the El-Al cargo Aircraft crash near the Amsterdam Schiphol Airport in 1992, the World Trade Center attacks in New York and the attack against the Pentagon in Washington, DC on 9/11/01.

Results

Using the data obtained from these events, the severity of injuries in patients were determined. The result is a general template that may be customized with locally or regionally specific data, in order to evaluate the preparedness of a specific burn alignment for such a scenario.

Conclusion

Recommendations based on the analysis of previous MCI's were put forth. Based on the needs recognized during these past events, suggestions were made to enhance the preparedness of burn units, hospitals and national agencies as well as municipal authorities.     

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.     

Epidemiology and outcome of burns in Esteqlal Hospital of Kabul,Afghanistan

Introduction

Burns are a major public health issue in Afghanistan, at least in terms of morbidity and long term disability. Little data exists to document the extent of the problem. This study reports the epidemiology and outcome of burns seen in Esteqlal Hospital of Kabul, a regional referral and teaching hospital run jointly by the Afghan Ministry of Public Health and the Italian Cooperation. It furthermore aims to investigate the underlying conditions which lead to this dramatically widespread event in order to develop effective burn prevention programmes.

Methods

A total of 532 patients admitted for burns between March 1, 2007 and June 30, 2008 in Esteqlal Hospital were studied retrospectively through the review of medical records.

Results

Male to female ratio was 0.7:1 and the median age at presentation was 19 years. The mean total body surface area (TBSA) burned was 36.5%. Overall mortality rate was 28% with a prevalence of death among females (68%). The most common cause of burn was flame (46.2%), followed by gas cylinder explosion (36.4%). Self-immolation was reported in 21 patients, 76% of whom resulted in death.

Conclusion

A large number of burn injuries occur in domestic settings and are preventable. Strategies might include implementation of educational programs through mass communications and development of policies for the commerce of unadulterated petroleum products. Other goals such as disability prevention and mortality reduction might be achieved building burns centres and training healthcare professionals working at the peripheral level.     

The International Assessment of Capacity for Trauma (INTACT): an index for trauma capacity in low-income countries

Background

Injury remains a leading cause of death worldwide with a disproportionate impact in the developing world. Capabilities for trauma care remain limited in these settings. We propose the implementation of the International Assessment of Capacity for Trauma (INTACT) index to provide a standardized way of assessing a health care facility's capacity to provide adequate trauma care.

Materials and methods

A retrospective review of the trauma capacity of 10 government hospitals (district, secondary, regional, maternity, and tertiary facilities) in Sierra Leone was performed using data collected during on-site visits in August 2011. The index incorporates 40 key elements, including resuscitation, laparotomy, chest tube insertion, fracture repair, and burn management capabilities. The INTACT index was calculated on a scale of 0–10 and compared with a previously published index of surgical capacity, the personnel, infrastructure, equipment, and supplies (PIPES) index.

Results

Connaught Hospital, the only tertiary referral center, had the highest index (9.0), consistent with it being the best equipped and staffed of the country. The three district hospitals assessed had the lowest scores from 3.5 to 4.3. INTACT and PIPES scores were correlated overall (r = 0.88). The proportionate difference compared with the PIPES survey was 30% for the maternity hospital and 1% for the tertiary center, suggesting that the INTACT index may be specific for trauma. Deficiencies are especially prominent in personnel, imaging, fracture repair, and burn management.

Conclusions

The INTACT index is a simple tool designed to specifically assess trauma capacity from initial resuscitation to definitive care. Shortcomings in trauma capacity remain prominent and the INTACT index could be used to assess trauma care deficiencies in developing countries.     

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.     

Organ donation from burn-injured patients—a national perspective

Background

There is a discrepancy between publically available data from the United Network for Organ Sharing (UNOS) database and perception of the incidence of mortally burn-injured patients serving as organ donors. In the last 5 y, a single burn center referred several patients who went on to successfully donate multiple organs. However, UNOS data indicate very few referrals of patients with burn injuries nationwide. This discrepancy in UNOS-reported occurrences versus institutional experience prompted this work.

Methods

UNOS data from 1988–2012 was examined for causes of death related to thermal injury, electrical injury, inhalation injury, or carbon monoxide poisoning. The National Burn Repository was examined for burn center death rates and patient characteristics of those with reported nonsurvivable burn injuries. Finally, a national survey queried the clinical experiences and educated opinions of burn center directors, transplant surgeons, and organ procurement organization (OPO) representatives regarding organ donation in the burn-injured population.

Results

Between 42% and 52% of those surveyed responded. Survey data indicate that at least 61 patients with burn-related injuries have served as organ donors in the past 5 y alone, versus 23 identified in 24 y of UNOS data. Survey data also indicate that inhalation injuries were the most common burn-related injuries seen before successful organ procurement. Kidneys were the most commonly donated organs, but all major organs and tissues were represented in the experiences of surgeon and organ procurement organization respondents. Up to 10% surgeon respondents believe that patients with burn injuries should not be referred for possible organ donation.

Conclusions

There are more organs donated by patients with mortal burn injuries than currently available UNOS data would suggest. Survey data suggest that these patients should be able to contribute successfully to the supply of organs needed by those on transplant waiting lists, but remain inconsistently recognized as such a resource. Knowledge about long-term organ and tissue viability from burn-injured patients is lacking, and should be the focus of future research.     

Long term health-related quality of life after burns is strongly dependent on pre-existing disease and psychosocial issues and less due to the burn itself

Background

Health-related quality of life (HRQoL) is reduced after a burn, and is affected by coexisting conditions. The aims of the investigation were to examine and describe effects of coexisting disease on HRQoL, and to quantify the proportion of burned people whose HRQoL was below that of a reference group matched for age, gender, and coexisting conditions.

Method

A nationwide study covering 9 years and examined HRQoL 12 and 24 months after the burn with the SF-36 questionnaire. The reference group was from the referral area of one of the hospitals.

Results

The HRQoL of the burned patients was below that of the reference group mainly in the mental dimensions, and only single patients were affected in the physical dimensions. The factor that significantly affected most HRQoL dimensions (n = 6) after the burn was unemployment, whereas only smaller effects could be attributed directly to the burn.

Conclusion

Poor HRQoL was recorded for only a small number of patients, and the decline were mostly in the mental dimensions when compared with a group adjusted for age, gender, and coexisting conditions. Factors other than the burn itself, such as mainly unemployment and pre-existing disease, were most important for the long term HRQoL experience in these patients.     

Epidemiology of operative burns at Kijabe Hospital from 2006 to 2010: Pilot study of a web-based tool for creation of the Kenya Burn Repository

Introduction

In order to implement effective burn prevention strategies, the WHO has called for improved data collection to better characterize burn injuries in low and middle income countries (LMIC). This study was designed to gather information on burn injury in Kenya and to test a model for such data collection.

Methods

The study was designed as a retrospective case series study utilizing an electronic data collection tool to assess the scope of burn injuries requiring operation at Kijabe Hospital from January 2006 to May 2010. Data were entered into a web-based tool to test its utility as the potential Kenya Burn Repository (KBR).

Results

174 patients were included. The median age was 10 years. There was a male predominance (59% vs. 41%). Findings included that timing of presentation was associated with burn etiology (p = 0.009). Length of stay (LOS) was associated with burn etiology (p < 0.001). Etiology differed depending on the age group, with scald being most prominent in children (p = 0.002).

Conclusions

Burn injuries in Kenya show similarities with other LMIC in etiology and pediatric predominance. Late presentation for care and prolonged LOS are areas for further investigation. The web-based database is an effective tool for data collection and international collaboration.     

Banking and use of glycerol preserved full-thickness skin allograft harvested from body contouring procedures

Introduction

The use of glycerol preserved skin allograft (GPA) became a main stay in burn treatment. However, harvesting of cadaveric skin is not yet legalized in many countries including Egypt.

Objectives

To estimate the feasibility of using skin harvested from body contouring procedures as a source of GPA and its clinical efficacy.

Patients and methods

Skin harvested from body contouring procedures done in Al-Azhar university hospitals was preserved by glycerolization and used in management of burn and complicated wounds.

Results

In the period between February 2012 and February 2013 skin was harvested from 24 abdomenoplasty cases, 6 bilateral breast reduction cases, and 1 case of thigh lift done in Al-Azhar university hospitals. This yielded about 22,000 cm² of skin preserved by glycerolization. This GPA was used in 15 excised burn wounds, in 9 cases of chronic burn wounds, and in 6 complicated wounds. Partial graft loss occurred in 3 cases and total graft loss occurred in 1 case.

Conclusion

The glycerolized full-thickness skin harvested from body contouring procedures is clinically effective in burn and wound management. In the presence of regional coordination, it can serve as an abundant source for skin banking in where cadaveric skin use is not legalized.     

Detection of microalbuminuria: A simple test for prognosis in severe burns

Purpose

To evaluate the effectiveness of microalbuminuria monitoring in the management of patients with severe burns.

Methods

Consecutive patients admitted to the burn unit with total body surface area burn between 20% and 50% were examined for microalbuminuria during the hospitalisation. The findings were correlated to different clinical variables usually encountered in this patient category.

Results

Microalbuminuria was found in patients with inhalation injuries (100%), systemic inflammatory response syndrome (SIRS, 88.4%), burn sepsis (95.1%) and postoperatively (94.9%).

Conclusion

Microalbuminuria is the only simple, non-invasive, bedside, immediate and cost-effective test to indicate for occurrence of SIRS, if the other variables were stabilised. It can be measured with every urine void or more often when a urinary catheter is inserted. This will affect our management of patients with severe burns.     

Incidence and treatment of burns: A twenty-year experience from a single center in Germany

Objective

To analyze trends in incidence and treatment of thermal injuries over the last two decades.

Methods

We retrospectively reviewed our local single center database of patients with thermal injuries admitted to the burn intensive care unit (BICU) of the Cologne-Merheim Medical Center (University Hospital of Witten/Herdecke). The cohort was divided into two groups according to the decade of admission and the epidemiology and clinical course of the patient sample admitted during the period 1991–2000 (n = 911) was compared to that of 2001–2010 (n = 695).

Results

The following variables were significantly different in the bivariate analysis: mean age (39.8 years vs. 44.0 years), burn size of total body surface area (23.2% vs. 18.0%) and size of 3rd degree burns (9.6% vs. 14.9%). The incidence of inhalation injury was significantly lower in the last decade (33.3% vs. 13.7%) and was associated with a shorter duration of mechanical ventilation (10.8 days vs. 8.5 days). The ABSI-score as an indicator of burn severity declined in the second period (6.3 vs. 6.0) contributing partially to the decline of BICU length of stay (19.1 days vs. 18.8 days) and to the mortality rate decrease (18.6% vs. 15.0%).

Conclusion

The severity of burn injuries during the last two decades declined, probably reflecting the success of prevention campaigns. Concerning mortality, the chance of dying for a given severity of injury has decreased.     

Determinants of burn first aid knowledge: Cross-sectional study

Introduction

This study investigated demographic factors, experience of burn/care and first aid course attendance as factors influencing burn first aid knowledge.

Methods

A cross-sectional study was undertaken using convenience sampling of members of sporting and recreation clubs. The main outcome measure was the proportion of correct responses to multiple-choice questions relating to four burn scenarios: (1) scald, (2) contact burn, (3) ignited clothing, and (4) chemical burn.

Results

A total of 2602 responses were obtained. Large gaps (30–50% incorrect answers) were identified in burn first aid knowledge across all scenarios. 15% more individuals gave correct answers if they had attended a first aid course compared to those who had not (p < 0.0001); this proportion increased if the course was undertaken within the previous five years (p < 0.0001) or contained a burns-specific component (p < 0.0001). Males and younger (≤25 years) and older (≥65 years) age-groups had relatively lower levels of burn first aid knowledge. Gender and age were significant predictors of first aid course attendance, with males and younger (≤25 years) and older (≥65 years) age-groups less likely to have attended a first aid course.

Conclusion

In this sample, first aid training undertaken within the last 5 years with a specific burns component was associated with enhanced burn first aid knowledge.     

Development and restructuring of a burn centre in an emerging nation, based on the example of Kyrgyzstan

Aim

To implement and review a four-tier plan to develop a burn centre in an emerging nation (Kyrgyzstan).

Method

From 2001, the developing burn centre in Bishkek was supported with numerous material donations and, once a year, teams from Germany operatively treated numerous burn victims on site. Training and further education for our Kyrgyzstani colleagues were based on ‘helping them to help themselves’, with additional consultations on conceptual hygienic and structural improvements.

Results

Material donations were delivered personally by the project teams. Education and training were also limited due to physician emigration. However, in the seven trips made by the team from Germany, numerous operations were performed and there was fundamental progress in the areas of bandaging protocols, hygienic concepts and structural improvements.

Conclusion

An exact plan patiently tailored to the local situation and culture must be followed, to provide cost-effective support.     

Inhalation injury in southwest China—The evolution of care

Aim

This study aims to review the changes in management of inhalation injury and the associated reduction in mortality over the past 2 decades.

Methods

The records of burn patients with inhalation injury hospitalised in our institute from 1986 to 2005 were retrospectively analysed. The incidence of inhalation injury and the associated mortality were analysed. Meanwhile, the relationship of inhalation injury with age, total burn area, tracheostomy intubation and mechanical ventilation were studied.

Results

The incidence of inhalation injury was 8.01% in the total 10 608 hospitalised burn patients during the 20 years surveyed. Inhalation injury was always associated with large-sized burn and was more common in adults. The incidence of tracheostomy and mechanical ventilation increased from 39.46 and 30.28% in the period from 1986 to 1995 to 70.12 and 39.74% from 1996 to 2005, respectively. The overall mortality of inhalation-injured burn patients was 15.88% compared with 0.82% of the non-inhalation group. The mortality of the burn patients with inhalation injury dropped from 25.29% during the first 10 years to 11.71% during the second decade (p < 0.01). Mortality secondary to inhalation injury as the lead cause decreased from 14.56 to 6.29% (p < 0.01).

Conclusion

The care of inhalation injury has made significant progress over the past 2 decades. The early diagnosis of inhalation injury, early airway control and pulmonary function assistance with mechanical ventilation contribute to the reduction of mortality.     

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.     

A burn center paradigm to fulfill deferred consent public disclosure and community consultation requirements for emergency care research

Introduction

To fulfill Food and Drug Administration and Department of Health and Human Services emergency care research informed consent requirements, our burn center planned and executed a deferred consent strategy gaining Institutional Review Board (IRB) approval to proceed with the clinical study. These federal regulations dictate public disclosure and community consultation unique to acute care research.

Objective

Our regional burn center developed and implemented a deferred consent public notification and community consultation paradigm appropriate for a burn study.

Methods

Published accounts of deferred consent strategies focus on acute care resuscitation practices. We adapted those strategies to design and conduct a comprehensive public notification/community consultation plan to satisfy deferred consent requirements for burn center research.

Results

To implement a robust media campaign we engaged the hospital's public relations department, distributed media materials, recruited hospital staff for speaking engagements, enlisted community volunteers, and developed initiatives to inform “hard-to-reach” populations. The hospital's IRB determined we fulfilled our obligation to notify the defined community.

Conclusion

Our communication strategy should provide a paradigm other burn centers may appropriate and adapt when planning and executing a deferred consent initiative.