Early tracheostomy improves outcomes in severely injured children and adolescents

Background

Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes.

Methods

Injured children undergoing tracheostomy over a 10-year period (2002–2012) were reviewed. Early tracheostomy was defined as post-injury day ≤ 7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p < 0.05 with 95% confidence intervals.

Results

During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were < 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p = 0.003), ICU days (p = 0.003), hospital days (p = 0.046), and tracheal complications (p = 0.03) compared to late tracheostomy. There was no difference in pneumonia (p = 0.48) between early and late tracheostomy.

Conclusion

Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child.

Summary

Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7.     

Tracheostomy in craniectomised survivors after traumatic brain injury: A cross-sectional analytical study

Background

Decompressive craniectomy (DC) is a life-saving measure for traumatic brain injury (TBI). However, survivors may remain in a vegetative or minimally conscious state and require tracheostomy to facilitate airway management. In this cross-sectional analytical study, we investigated the predictors for tracheostomy requirement and influence of tracheostomy timing on outcomes in craniectomised survivors after TBI.

Methods

We enrolled 160 patients undergoing DC and surviving >7 days after TBI in this 3-year retrospective study. The patients were subdivided into 2 groups based on whether tracheostomy was (N = 38) or was not (N = 122) performed. We identified intergroup differences in early clinical parameters. Multivariable logistic regression was used to adjust for independent predictors of the need for tracheostomy. Early tracheostomy was defined as the performance of the procedure within the first 10 days after DC. Intensive care unit (ICU) stay, hospital stay, mortality, and Glasgow outcome scale (GOS) were analysed according to the timing of the tracheostomy procedure.

Results

After TBI, 24% of craniectomised survivors required tracheostomy. In the multivariate logistic regression mode, the significant factors related to the need for tracheostomy were age (odds ratio = 1.041; p = 0.002), the Glasgow coma score (GCS) at admission (odds ratio = 0.733; p = 0.005), and normal status of basal cisterns (odds ratio = 0.000; p = 0.008). The ICU stay was shorter for patients with early tracheostomy than for those undergoing late tracheostomy (p = 0.004). The timing of tracheostomy had no influence on the hospital stay, mortality, or GOS.

Conclusion

Age and admission GCS were independent predictors of the need for tracheostomy in craniectomised survivors after TBI. If tracheostomy is necessary, an earlier procedure may assist in patient care.     

Validation of predictive factors of dysphagia risk following thermal burns: A prospective cohort study

Purpose

The objective of this study was to prospectively evaluate the validity and reliability of a risk factor model developed for use in predicting dysphagia risk within the first 24 h after injury/hospitalisation in patients with thermal burns.Method(s): Three hundred and fifty six patients with thermal burns, with or without inhalation injury, who were consecutively admitted to and received management at a quaternary state-wide burn center over a 12 month period, were included. Patients were reviewed for dysphagia risk by nursing staff using an established set of predictive factors. If risk factors for dysphagia were present, referral to speech-language pathology was initiated to investigate swallow function.Result(s): Of the 356 admissions, 83 patients were identified as meeting one or more risk criteria for dysphagia after burn.Of these, 24.9% (n = 30; 8.42% of the total cohort) presented with dysphagia. Using these criteria, sensitivity and specificity for detection of dysphagia risk were high (100% and 83.74%, respectively). The criteria over identify patients who may be at risk of dysphagia and who require dysphagia assessment (positive predictive value = 36.14%). However, as a set of predictors of dysphagia risk when thermal burn is the only complaint, a negative result reassures that a patient does not have dysphagia (negative predictive value = 100%).

Conclusion

Overall, the risk factor model provided a valid measure for predicting dysphagia risk. Incorporating these criteria into a dysphagia screening assessment can ensure an evidence-based pathway for early detection and timely referral to speech-language pathology for patients at risk of dysphagia after thermal burns.     

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.     

Malnutrition among pediatric burn patients: A consequence of delayed admissions

Early definitive burn treatment is assumed to improve prognosis, in part because open wounds rapidly stimulate muscle catabolism and systemic inflammation. This study describes the incidence and management of injury associated malnutrition among pediatric burn patients transferred for definitive care 21–166 days following burn injury. Medical records of patients admitted to our hospital between January 2003 and January 2009, at least 3 weeks after burn injury, were retrospectively reviewed. Only children with an initial total body surface area (TBSA) burn of ≥20% were included in this study (n = 36). Patients were classified as acutely well nourished or malnourished by the medical team. All patients were admitted with chronic open wounds (31 ± 16% TBSA). Sixty-one percent (n = 22) of patients were diagnosed with malnutrition. These patients had a significantly longer delay to transfer (26–166 days) than well nourished patients who transferred at 21–138 days (p < 0.05). Average protein (2.8 ± 0.18 g/kg), and kilocalorie (1.6 ± 0.1% basal metabolic rate) provision did not differ between groups. Incidence of infection was not different between well nourished and malnourished patients. Malnutrition occurs frequently among pediatric burn patients with delayed admissions. Adequate surgical care, infection control, and nutrition are required for wound healing.     

Tissue expansion for correction of scars due to burn and other causes: A retrospective comparative study of various complications

Background

Tissue expansion is associated with a relatively high complication rate. The aim of this study was to quantify the complication risk of burn scar patients who underwent tissue expansion in comparison to patients with other indications such as skin tumors. Furthermore it was attempted to compare the complication rates in children and adults.

Methods

A retrospective analysis was performed on 148 expanders implanted in 73 patients during the years 1994–2011. Two patient cohorts (burn scar cohort n = 31 and other indication cohort n = 42) were identified and analyzed.

Results

27 male and 46 female patients with a median age of 21 years were included. No statistically significant difference for complication risk between the burn and other indication cohorts could be found (p = 0.1412). Statistical analyses revealed a higher complication rate (52%) in the lower limb compared to all other anatomic sites (29%) (p = 0.1746). In addition, statistical analyses revealed a significantly higher total complication rate in children younger than 10 years (p = 0.0043). Moreover a greater TBSA was accompanied by a higher complication rate (p = 0.0258).

Conclusion

This set of data suggests that the burn scar patient is at no greater risk to suffer complications from tissue expansion. Other factors like age, TBSA and anatomical site have far more influence on the expander complication rate than the initial indication for tissue expansion.     

Evaluation of the spontaneous breathing trial in burn intensive care patients

Background

The extubation failure rate in our burn patients is 30%.

Objective

To evaluate the influence of the 30 min spontaneous breathing trial on extubation outcome in burn patients.

Methods

A prospective, observational study in a burn intensive care unit. All adult patients requiring mechanical ventilation for >24 h and meeting the inclusion criteria underwent a 30 min spontaneous breathing trial (SBT). Extubation was undertaken after a successful SBT.

Results

Of 49 planned extubations, 9 failed (18%), much lower than the 30% extubation failure rate identified prior to the implementation of the SBT. The duration of ventilation was significantly shorter (p = 0.04) in the patients who passed a SBT and those who failed extubation were significantly older (p = 0.003). The logistic regression analysis identified that age independently predicted extubation outcome. Patients who failed extubation, after a successful SBT, had a significantly longer duration of ventilation (p = 0.0001) and ITU length of stay (p = 0.001).

Conclusions

The incidence of extubation failure was much lower and the duration of ventilation significantly shorter in patients who were extubated after a successful SBT. These findings support the use of the SBT in burn patients. Age independently predicts extubation outcome in burn patients who have passed a SBT.     

Goitre and difficulty of tracheal intubation

Objectives

To assess the difficulty in both laryngoscopy and tracheal intubation related to goitre and to identify factors predictive of difficult intubation due to this condition.

Study design

Prospective observational.

Methods

We used the Intubation Difficulty Scale (IDS) in 80 consecutive patients with large goitre (defined by the inability to palpate the cricoid cartilage, the presence of endothoracic goitre, tracheal deviation of more than 1 cm or tracheal stenosis on the chest x-ray) and 77 control patients.

Results

Cormack grades 3–4 were more frequent at initial laryngoscopy in patients with goitre (23/80 vs. 9/77; p < 0.05), but the difference was no longer significant after application of an external laryngeal pressure (8/80 vs. 5/77). IDS scores (median [25th–75th percentiles]) were higher in the goitre group (1 [0 – 4]) than in the control group (0 [0 – 1]; p = 0.001), corresponding to an increase in slightly difficult intubation (IDS 1–5: 36/80 vs. 15/77; p < 0.05). However, incidence of moderate to major difficulty in intubation (IDS > 5: 8/80 vs. 7/77) as well as time to completion of intubation were similar in both groups. Tracheal stenosis (≥ 30%) and reduced mouth opening (< 4.4 cm) were the only significant predictors of increased difficulty in intubation in patients with a goitre.

Conclusion

Large goitres are usually associated with slight difficulty in intubation only. Increased difficulty should be expected when severe tracheal stenosis is present on chest x-ray, especially when associated with a reduced mouth opening.     

Influence of race and neighborhood on the risk for and outcomes of burns in the elderly in North Carolina

Risk factors for mortality and length of hospital stay in elderly burn patients are well established, but the influence of race and socioeconomic status has not been evaluated. This study evaluates the effect of neighborhood level socioeconomic indicators on burns risk, and determines whether race and neighborhood influence burn injury outcomes in the elderly.Data from the North Carolina Jaycee Burn Center was linked to United States Census Bureau block group socioeconomic data. The odds of death and increased length of hospital stay for European-Americans and Minorities were determined using logistic regression. Rates of burn were determined using Poisson regression, and multilevel modeling was used to evaluate the influence of neighborhood on outcomes.No significant differences in mortality were observed between European-American and Minority patients in individual (Minority OR 0.71; p = 0.3200) and multilevel (0.72; p = 0.4020) models. Minorities had significantly higher odds of increased length of hospital stay in individual (2.05; p = 0.0020) and multilevel (2.55; 0.037) models. High proportions of rural households (RR = 1.39; p = 0.0010) and poverty (1.26; p < 0.0001) were significantly associated with increased risk of burn. Additional investigation using larger databases will allow further elucidation of the contextual effects of socioeconomic status on burn in the elderly.     

Acute burn induced coagulopathy

Background

Acute traumatic coagulopathy is well described in the trauma population. Major burns are characterised by a similar endothelial injury and cellular hypoperfusion. These features could be a driver for an acute burn induced coagulopathy (ABIC).

Methods

Patients admitted to a regional burn centre over a 71 months period with a total body surface area burn of 30% or more were identified. The metavision electronic patient database was scrutinised for a predetermined list of demographics, interventions and admission investigations to identify any clinically significant ABIC.

Results

On admission 39.3% of the 117 patients analysed met our criteria for a coagulopathy. Of the patients with a coagulopathy, 71.7% had an elevated Prothrombin Time (PT), 2.2% had an elevated Activated Partial Thromboplastin time (APPT) and 26.1% had an elevation of both. Patients with a coagulopathy received a similar volume of fluid (p = 0.08). There was a statistically significant correlation between the PT and the abbreviated burn severity index (p = 0.0013, r = 0.292) and serum lactate (p = 0.0013, r = 0.292). ABIC was an independent predictor of 28 day mortality, OR 3.42(1.11–10.56).

Conclusion

In patients with major thermal injuries a clinically significant ABIC exists. Early diagnosis and treatment of ABIC should be considered particularly in those undergoing total burn wound excision.     

Clinical outcomes of isolated lower extremity or foot burns in diabetic versus non-diabetic patients: A 10-year retrospective analysis

Introduction

The incidence of diabetes mellitus (DM) in the United States is expected to increase from 8 per 1000 in 2008 to 15 per 1000 by 2050 [20]. As a result, DM patients will constitute a large proportion of Burn Center admissions, with burns typically due to contact burn or scalding. Peripheral vascular disease (PVD) and peripheral neuropathy (PN) are far more common in DM patients, particularly in those with poorly controlled disease, and are often associated with worse outcomes than non-diabetic (nDM) burn patients. This study sought to analyze whether the outcome of isolated leg and foot burns among DM and nDM individuals differed significantly.

Materials and methods

Retrospective data on 207 consecutive patients (>18 years old) admitted to a Burn Center with isolated leg or foot burns between 1999 and 2009 was collected and analyzed for this study. Age, gender, ethnicity, total body surface area (TBSA), degree of burn, etiology, hospital and burn intensive care unit (ICU), length of stay (LOS), and status at discharge were reviewed. Patients were grouped as diabetic (DM) or non-diabetic (nDM). Differences were analyzed using either the Student's t-test or Chi-square.

Results

43 DM and 164 nDM patients with isolated lower extremity or foot burns were treated during the study period (1999–2009). The mean age of DM and nDM patients was 54.6 and 43.7 years, respectively (p < 0.001). The most common burn etiology was scalding, flame, or contact burn. Percentage of total body surface area (TBSA) burn in DM patients averaged ± standard deviation 1.8 ± 1.3% compared to 1.8 ± 1.6% in nDM (p < 0.9). Among DM patients, 86% (N = 37) of patients suffered third degree burns and 14% (N = 6) of patients had second degree burns compared to 76% (N = 125) of patients and 24% (N = 39) of patients among nDM patients, respectively (p < 0.16). The DM group had significantly higher burn ICU admission rates, 16.3% of patients versus 8.5% of patients (p < 0.001), total length of hospital stay (mean ± standard deviation), 14.1 ± 10 versus 9.8 ± 9.3 days (p < 0.01) and renal failure, 4.7% of patients versus 0.6% of patients (p < 0.05) compared to the nDM group. 93% of DM patients were discharged to home without further medical attention while 4.7% of patients underwent further treatment. In comparison, 85.4% of the nDM patients were discharged home with no further treatment while 8.5% of patients received home care (p < 0.01).

Conclusion

DM patients who suffer isolated burns to the feet or lower extremities have poorer clinical outcomes and more complicated and protracted hospital courses when compared to nDM patients with similar burns. Although diabetics in the current study did not experience larger or more severe burns than nDM patients, they were nearly twice as likely to be admitted to the ICU, spent an average of four days longer in the hospital, and had a higher likelihood of developing renal failure compared to nDM patients.     

Vancomycin pharmacokinetics in patients with severe burn injuries

Vancomycin is used in patients with severe burns and methicillin-resistant Staphylococcus aureus (MRSA) infection. This study investigated vancomycin pharmacokinetics in people with burns in comparison to people without burns and examined the factors contributing to pharmacokinetic variability. This was a retrospective, case-control study of hospitalised burns patients compared with a control patient cohort administered vancomycin without burn injury. Vancomycin pharmacokinetic parameters were determined using therapeutic drug monitoring data and a population pharmacokinetic modelling approach employing a two-compartment pharmacokinetic model. The impact of patient characteristics on vancomycin clearance was explored. Vancomycin clearance was significantly higher (p < 0.001) in burns patients (5.9 ± 3.1 L/h, n = 37) when compared to control patients (3.4 ± 1.8 L/h, n = 33), as was estimated creatinine clearance, which was correlated to drug clearance in burns patients (r² = 0.64). There was no significant change in volume of distribution between patient groups. The majority of patients received a dosing regimen of 1 g twice daily, resulting in significantly (p = 0.004) lower serum trough concentrations in patients with burns (median, 6.4 mg/L; range, 0.2–22.3 mg/L) than control (median, 9.2 mg/L; range, 4.0–29.8 mg/L). Higher clearance and lower serum vancomycin concentrations in people with severe burn may increase the risk of suboptimal bactericidal action and the development of resistance highlighting the need for dosage individualisation.     

Periprosthetic Joint Infection with Negative Culture Results: Clinical Characteristics and Treatment Outcome

Negative culture result is frequently encountered in periprosthetic joint infection, but its clinical feature has not been well studied. In this study, clinical characteristics and treatment outcome were compared in two patient groups: (1) 40 periprosthetic joint infections with negative culture results (culture-negative group) and (2) 135 patients with positive culture results (culture-positive group). In comparison of two groups, the culture-negative group showed significantly higher incidence of prior antibiotic use (p = 0.005), higher incidence of prior resection surgery (p < 0.001) and lower ESR (p = 0.02) than the culture-positive group. The success rate of infection control was higher in the culture-negative group (p = 0.006), which suggests that culture negativity may not necessarily be a negative prognostic factor for periprosthetic joint infection.     

The severe burns patient with tracheostomy: Implications for management of dysphagia,dysphonia and laryngotracheal pathology

Introduction

Insertion of a tracheostomy for a severe burn patient is not uncommon. The method of decannulation, effects of the tracheostomy on voice and swallowing and subsequent complications have not been described in the literature specifically for this population. The aim of this study was to investigate the risk of dysphagia, dysphonia and laryngotracheal pathology in severe burn patients with tracheostomy and following decannulation.

Method

A retrospective chart review was conducted for severe burn patients admitted from January 2000 to December 2007 that received tracheostomy as part of their treatment.

Results

Two hundred and thirty patients were admitted during the study period, 26 of whom underwent tracheostomy. Significant positive correlations were identified between tracheostomy duration and %TBSA burn, days to commence oral intake and days to commence pre-morbid oral diet. Several dysphagic features were identified within the oral and pharyngeal phases of swallowing and dysphonia was frequently demonstrated on perceptual voice assessment with the tracheostomy in situ and following decannulation. Laryngotracheal pathology was diagnosed in 12 of the 26 patients (46.2%) whilst the tracheostomy was in place; 2 with laryngeal granulation tissue, 2 with tracheal granulation tissue, 2 with supraglottic oedema and erythema and 6 with reduced vocal mobility.

Conclusion

Severe burn patients that have prolonged tracheostomy are likely to have a larger size burn, take longer to commence oral intake and achieve pre-morbid oral diet. These patients are also at risk for dysphagia, dysphonia and laryngotracheal pathology.     

Biological markers of stress in pediatric acute burn injury

Background

Burns and their associated wound care procedures evoke significant stress and anxiety, particularly for children. Little is known about the body's physiological stress reactions throughout the stages of re-epithelialization following an acute burn injury. Previously, serum and urinary cortisol have been used to measure stress in burn patients, however these measures are not suitable for a pediatric burn outpatient setting.

Aim

To assess the sensitivity of salivary cortisol and sAA in detecting stress during acute burn wound care procedures and to investigate the body's physiological stress reactions throughout burn re-epithelialization.

Methods

Seventy-seven participants aged four to thirteen years who presented with an acute burn injury to the burn center at the Royal Children's Hospital, Brisbane, Australia, were recruited between August 2011 and August 2012.

Results

Both biomarkers were responsive to the stress of burn wound care procedures. sAA levels were on average 50.2 U/ml higher (p < 0.001) at 10 min post-dressing removal compared to baseline levels. Salivary cortisol levels showed a blunted effect with average levels at ten minutes post dressing removal decreasing by 0.54 nmol/L (p < 0.001) compared to baseline levels. sAA levels were associated with pain (p = 0.021), no medication (p = 0.047) and Child Trauma Screening Questionnaire scores at three months post re-epithelialization (p = 0.008). Similarly, salivary cortisol was associated with no medication (p < 0.001), pain scores (p = 0.045) and total body surface area of the burn (p = 0.010).

Conclusion

Factors which support the use of sAA over salivary cortisol to assess stress during morning acute burn wound care procedures include; sensitivity, morning clinic times relative to cortisol's diurnal peaks, and relative cost.     

Grip strength dynamometry: Reliability and validity for adults with upper limb burns

Background

Upper limb (UL) burns can result in significant loss of strength and physical function. The aim of this study was to establish the reliability and validity of grip strength dynamometry (GSD) for measuring burn-affected UL strength over time.

Methods

A retrospective sample of adult participants (n = 89) with UL burns was obtained from Royal Perth Hospital. Data were compiled from assessments conducted at discharge, one, three, six and 12 months afer burn. Within-session reliability and validity was examined through multivariable analyses.

Results

GSD demonstrated within-session reliability for all investigated timepoints (ICC's ≥ 0.87, p < 0.0005.) Criterion validity was confirmed with GSD and QuickDASH being significantly associated in both right (b = 0.17, p = 0.002) and left (b = 0.14, p = 0.002) hands. Construct validity was demonstrated through significant association of GSD values with location of burn (p < 0.35); time after burn (p < 0.012); surgical intervention (p = 0.003) and burn size (p < 0.05).

Conclusion

This study demonstrates that grip strength dynamometry is a reliable and valid outcome measure for measuring burn-affected UL strength from one month to one year after burn.     

The use of theraputic plasma exchange (TPE) in the setting of refractory burn shock

Introduction

This study examines the physiologic effects of theraputic plasma exchange (TPE) in the setting of refractory burn shock and attempts to identify variables that correlate with the eventual need for TPE.

Methods

A retrospective analysis was conducted of 40 patients over 24 months with >20% TBSA burns who experienced complicated resuscitations. TPE was utilized in 21 patients when the patients’ total resuscitation volumes exceeded 1.2 times the amount predicted by the modified Baxter formula (3 cm³ LR/kg/%TBSA). Nineteen matched, contemporaneous patients served as controls. Demographic, injury severity, and acute clinical variables were abstracted for comparison between the two groups. Additionally, the TPE group was analyzed for blood lactate levels, mean arterial pressure (MAP) and urine output (UOP) before and after TPE. Univariate and multivariate statistical analyses were used for comparisons, where appropriate.

Results

In response to TPE, MAP increased by 24% (p < 0.0001), UOP increased by >400% (p =  < 0.0001), IVF rates were reduced by 25% (p = 0.01), and lactate levels decreased by almost 50% (p = 0.0006). On univariate analysis, admission lactate (p = 0.0006) and %TBSA (p = 0.01) were found to be significantly increased in the TPE group compared to controls, while there was no difference in age, gender, weight, admission HCT, incidence of acute renal failure, or mortality between the groups. However, on multivariate logistic regression analysis, only elevated admission lactate was independently associated with the eventual need for TPE (OR 2.23, 95% CI = 1.30–3.84, p = 0.004).

Conclusions

This is the largest study to date examining TPE as an adjunct in burn resuscitation and suggests that TPE may be effective as a salvage intervention for refractory burn shock. Physiologic parameters clearly improved after the use of TPE without any detected adverse consequences. Also, admission lactate may be a useful indicator to determine who will fail standard burn resuscitation and require TPE.     

Outpatient burn data: An untapped resource

Introduction

The National Burn Repository (NBR) currently only contains inpatient data from participating United States burn centres. However, the majority of the patients treated in burn centres are managed as outpatients. Unfortunately, this significant demographic is not represented in the NBR annual report. The purpose of this study is to compare the difference in aetiology and demographics between inpatient and outpatient burn patients. In addition, the workload demands for data entry of inpatient and outpatient records in the burn registry will be compared.

Methods

Outpatient and inpatient burn data at an American Burn Association-Verified Burn Center were prospectively collected during fiscal year 2008. Data collected included age, burn size and aetiology of burn. Aetiology was also stratified by age group. Inpatient data were compared with outpatient data with Fisher's exact test. The amount of time taken to enter inpatients’ and outpatients’ data parameters in the TRACS v5.0 database was also recorded.

Results

Data were collected for 241 inpatients and for 543 outpatients during fiscal year 2008. No significant differences in gender or race were found between the two groups. When comparing demographics, outpatients tended to be younger (26 ± 19 years vs. 32 ± 22 years, p = 0.01) with a smaller burn size (2.5 ± 7% vs. 6.8 ± 12%, p < 0.001) and a lower frequency of full-thickness burns (17% vs. 41%, p < 0.001).Of the patients managed as an outpatient, a total 29.7% were eventually admitted to the hospital. Just over half of those (16.7%) initially managed in the outpatient setting were admitted for a planned surgical procedure. The other 13% were admitted for pain control and wound-care issues.Injury was more likely to be caused by flame in inpatients (p < 0.001). Scald injuries were more common in the outpatient setting (34% vs. 27%), but this difference did not reach statistical significance (p = 0.079). Outpatients were more likely to be injured with a contact burn (p < 0.0001). Outpatient injury was more likely to be work-related than inpatient injury (p = 0.0497), but less likely to be related to recreational activity (p = 0.006) or arson/abuse/assault (p = 0.0158). An experienced TRACSv5.0 user required 11 ± 0.6 min to enter an inpatient record and 6 ± 0.6 min to enter an outpatient record in the system (p = 0.002).

Conclusions

Inpatient injury is more likely to be caused by flame, whereas outpatient injury is more likely to be caused by scald and contact burns. Work-related burn is more likely to be treated in the outpatient setting. Outpatient burn data also take less time to enter. Since significant differences in aetiology exist, outpatient data should be reported separately from inpatient data in order to understand the full spectrum of burn aetiology. The NBR and other registries should be modified to track outpatient burn data and outcomes.     

Evaluation of arterial waveform derived variables for an assessment of volume resuscitation in mechanically ventilated burn patients

Objective

The purpose of this study was to assess the usefulness of stroke volume variations to monitor the early fluid resuscitation in mechanically ventilated burn ICU patients.

Methods and results

Data of 29 burn patients (APACHE II – 9.8 ± 3.6, SAPS II – 29 ± 5, TBSA – 39.5 ± 14) were prospectively included in this observational study. Hemodynamic parameters were determined using arterial pressure wave analysis for up to 36 h after burn. Statistically significant changes in cardiac index (CI), systemic vascular resistance index (SVRI), stroke volume variation (SVV) were recorded during the observation period. There were significant correlations between CI and SVV (r = −0.454, p = 0.03), SVV and SVRI (r = 0.482, p = 0.02) at 16 h postburn; CI and SVV (r = −0.513, p = 0.012), SVV and SVRI (r = 0.480, p = 0.02) at 24 h postburn, CI and SVV at 36 h postburn (r = −0.478, p = 0.021). Significant changes in CI (1.9 ± 1 vs. 3.4 ± 0.9), p = 0.02 and in SVV (24.9 ± 3 vs. 14.6 ± 2, p = 0.01) were observed in patients with low cardiac output state after administration of 10 ml/kg of Ringer lactate.

Conclusion

Our results suggest that measurement of stroke volume variations by arterial pulse contour analysis is valuable in monitoring volume administration and in predicting volume responsiveness during the early postburn period.     

Mental disorders among acute burn patients

Objective

To investigate mental disorders among acute hospitalized burn patients.

Method

Consecutive acute adult burn patients (n = 107) admitted to Helsinki Burn Centre were interviewed by an experienced psychiatrist with the Structured Clinical Interview for DSM-IV-TR for Axis I and II mental disorders assessed in three time frames (lifetime, the month prior to burn, and in acute care). Information on clinical features, psychiatric symptoms, personality traits, and burn severity (total body surface area, TBSA) was gathered.

Results

The mean TBSA was 9%. Most (61%) acute burn patients had at least one lifetime Axis I or II mental disorder. Prevalences of lifetime substance-related disorders (47%), psychotic disorders (10%), and Axis II personality disorders (23%) were high. The overall prevalence of Axis I mental disorders increased significantly (Q = 6.40, df = 1, p = 0.011) from the month prior to burn (40%) to acute care (48%). The prevalence of delirium for this period was significantly higher (0.9% vs. 13%; Q = 13.00, df = 1, p < 0.001) in acute care.

Conclusions

Mental disorders, particularly substance use disorders, psychotic disorders, and personality disorders are common among acute burn patients before injury. These disorders may predispose to burns. Burn itself may also predispose to mental disorders, particularly delirium.