Improved survival following thermal injury in adult patients treated at a regional burn center.

Since January 1999, changes in the management of acute burn patients at a regional adult burn center included no hydrotherapy, blood sparing surgical techniques, a restrictive blood transfusion strategy, newer protective modes of mechanical ventilation, aggressive surgical wound excision, temporary wound closure with allograft skin, employment of advanced critical care trained nurses, and an increased number of dedicated full-time fellowship-trained burn surgeons. The purpose of this study was to determine the composite effect of these modifications on burn patients' survival. A retrospective hospital chart review was conducted among adult burn patients admitted during a 10-year period (1996-2005). Patients were stratified in two time periods: PAST (1996-1998) and RECENT (1999-2005). RECENT patients were selected by matching age, gender, total body surface area burn, full thickness burn, and presence of inhalation injury with PAST patients. All values are mean +/- SD. Student's t-test and chi2 analysis were performed accordingly with a P < .05 considered significant. Of 1569 acute burn patients admitted between 1996 and 2005, 96 (6%) were excluded because they received comfort measures only. Of the remaining 1473 patients, 684 patients (PAST = 342, RECENT = 342) were selected by the matching criteria. More RECENT patients required mechanical ventilation (25% vs 17%, P = .011), with a trend toward more prolonged duration (9 vs 11.5 days, P = .175), more escharotomies (9.6% vs 5.6%, P = .036), more operations (1.1 vs 0.8, P = .003), and more temporary allograft skin (10% vs 2%, P < .001) than did PAST patients. RECENT patients had lower mortality than did PAST patients (2.3% vs 5.6%, P = .048), specifically patients aged 60 or older (5.4% vs 25.5%, P = .004), patients with TBSA lower than 20% (1% vs 3.9%, P = .031), patients on mechanical ventilation (9.3% vs 27.6%, P = .006), and patients who had surgery (2.6% vs 7.3%, P = .032). The significant decrease in burn patient's mortality was likely due to the composite effects of improvements in clinical care between the two time periods.     

Fournier's gangrene: management at a regional burn center.

Fournier's gangrene (FG) describes necrotizing infections of the perineum in both sexes. Controversies in treatment of FG include the roles of orchiectomy, urinary and/or fecal diversion, and hyperbaric oxygen (HBO). Because burn centers often treat these patients, we reviewed our experience with FG during a 14-year period. With Institutional Review Board approval, we reviewed our TRACS/ABA database for patients treated for FG during 1992 to 2005. Data was recorded on demographics, preexisting medical conditions, treatment, and outcomes. Thirty patients (20 men) were identified. Mean age was 54.3 +/- 14.1 years. Predisposing conditions included diabetes in 16 patients (53%), and morbid obesity and immunosuppression in 6 each. Twenty-two patients were transferred from outside hospitals, 12 after initial surgery. Sixteen patients presented with shock (blood pressure <90/60 mm Hg). Patients underwent a mean of 4.1 surgical procedures. Ten infections penetrated the deep fascia of the perineum or abdominal wall. Suprapubic cystostomy was performed in three patients, colostomy in seven, orchiectomy in one. HBO was not used. Hospitalization averaged 25.3 +/- 15.6 days. Mean charges ($1000) were $131.5 +/- 108.3. Definitive wound closure was obtained before discharge with suture repair and/or skin grafting in 18 of 25 survivors (72%). Five patients died (17%). In logistic regression analysis, the presence of shock on admission and female gender (mortality 40%) were significantly associated with mortality. FG remains a devastating infection, which occurs primarily in compromised patients. In this series, aggressive burn center care produced outcomes equivalent to those published in other series with or without use of HBO. Colostomy and urinary diversion can be used very selectively in these patients; orchiectomy is rarely required.     

Purpura fulminans: a case series managed at a regional burn center.

Purpura fulminans (PF) is a protein C deficiency disease process with a high case fatality rate; however, overall incidence of the disease remains relatively very low. The similarity between skin necrosis secondary to PF and full-thickness skin burns provides the rationale for treating PF case in a burn center. In this case series we reviewed our experiences in managing PF and their associated favorable outcomes. Retrospective chart review of five PF cases managed between September 2004 and August 2006 at our Burn Center with 100% survival. Management of cases following the standard care of the Burn Center for a full-thickness burn included antibiotics, fluid resuscitation, surgical debridement with skin grafting, and activated protein C (Drotrecogin alfa) replacement. Two patients required amputations of extremities and all had surgical debridement. One required hemodialysis and two needed both hemodialysis and positive-pressure mechanical ventilator. No patient experienced any bleeding complications during or after surgery while receiving activated protein C. Early diagnosis and treatment at a burn center may reduce mortality and morbidity and loss of extremities in PF cases.     

Experience with necrotizing fasciitis at a burn care center

Necrotizing fasciitis is a soft tissue infection that causes necrosis of subcutaneous tissue and fascia but usually spares skin and muscle. Management of this condition consists of early diagnosis, broad-spectrum antibiotic coverage, aggressive surgical debridement, wound closure, and intensive supportive care. Mortality estimates reported in the literature have ranged from 20 to 75%. We report the cases of 12 patients treated at the Joseph M. Still Burn Center in Augusta, GA. Because aggressive surgical debridement combined with medical support is required for successful treatment, we recommend that treatment be administered at a burn care center. We performed a retrospective chart review of all patients admitted to our center with a diagnosis of necrotizing fascitis between May 1, 1995, and June 1, 2000. Patients were managed collaboratively by burn surgeons and critical care intensivists in consultation with other appropriate specialists. The mean time from initial diagnosis until transfer to the burn center was 14 days (range, 0-60 d). Complications included pneumonia, heart failure, metabolic abnormalities, anemia, and sepsis. Four (33%) of the 12 patients died, with the primary cause of death being multiorgan failure. Although our sample size is too small to reach statistical significance, the data suggest that early referral to a burn or wound care center improves patient outcome.     

烧伤科护士的职业危害分析与防护对策

为减少或消除烧伤科护士职业危害,通过对烧伤科护士最常面临的生物、化学、物理、运动功能、心理社会等方面的职业危害进行分类,分析原因并制订防护措施,包括提高烧伤科护士的自身防护意识和职业技能,优化护理工作流程,实施科学管理,降低护士体能消耗和心理压力,以减少烧伤科护士职业危害。     

Epidemiology of 1974 burn patients at a major burn center in beijing: a nine-year study

To date, little epidemiological data are available on burns in China. This study describes the characteristics of burn patients admitted to a major burn center in Beijing to show trends in admission and outcomes in burned patients to share information about the current state of care for burned patients in our burn center. A retrospective study on 1974 burn patients admitted to Jishuitan Hospital in Beijing was conducted during the 9-year period from 2000 to 2008, and data were collected on age, gender, TBSA, etiology, length of hospital stay, mortality, and inhalation injury. The male:female ratio of the burn population was 2.41:1 and did not differ significantly over the study period (P > .05). The mean age of admission was 36 ± 16.3 years, and most patients were 30 to 39 years old (24.0%) or 20 to 29 years old (23.8%). The mean TBSA of burn was 14.7 ± 3.4%, ranging from 1 to 100%, and the mean size/age did not change significantly over the course of the study (P > .05). The incidence in burn injury decreased over the study period (P < .05). The most common cause of burn was flame (67.9%) followed by electrical (16.1%) and scald (9.5%). The mean length of hospital stay was 33.2 ± 3.5 days, extending from 1 to 413 days, and it did not differ significantly over the study period (P > .05). The mortality and inhalation injury rate were 2.8 and 6.9%, respectively. Annual mortality rate did not differ significantly over the study period (P > .05). This retrospective review of the specific epidemiological features of burn patients will provide important information for the development of proper control programs to reduce the incidence of burns and burn-related deaths.     

ISBT Code 128 implementation at a regional blood center

BACKGROUND: Application specifications for ISBT 128 bar code symbology and the International Council for Commonality in Blood Bank Automation (ICCBBA) were created in 1994. By June 2000, the FDA considered ISBT 128 a standard for uniform labeling of blood and blood components. Our blood center initiated a change process for ISBT 128 implementation and "went live" in 2003. STUDY DESIGN AND METHODS: The intention to adopt ISBT 128 symbology with hospitals was actively communicated in October 2001. A Codabar-ISBT label cross-reference book was developed, FDA approval for the fullface label format in April 2002 was requested, and FDA approval was received in March 2003. In December 2002, donor identification labels and number sets were ordered, and an integration test plan was subsequently developed with departmental process flowcharts for each of the nine affected departments. Each step was tested, the labeling changes were approved in May 2003, training was completed in June 2003, and ISBT bar code symbology was implemented on July 1, 2003. A written survey was sent to hospital transfusion services in April 2004. RESULTS: Implementation went smoothly except for an unanticipated high rate of "no-reads" on some analyzers in the testing lab. The hospitals spent an average of 18 hours preparing for changes, 14 hours on validation, 4 hours on documentation and procedure development, and 8 hours on training. CONCLUSION: ISBT bar code symbology was successfully implemented. Hospital transfusion services made some adjustments and, overall, readily accepted the new bar code symbology.     

The burn nursing shortage: a burn center survey

The Membership Advisory Committee of the American Burn Association sponsored a survey of burn units in North America to review the issue of nursing staffing, to which 124 of 133 (93%) of the burn centers identified responded. Sixty-two percent had experienced a nursing shortage, and the 77 of 124 units with current vacancies had an average of 4.6 positions open. Licensed practical nurses, aides, and nonlicensed caregivers provide direct patient care in 83% of the units. Ten of 124 units had identified adverse patient outcomes because of staff shortages in their quality assurance programs. Areas identified by two surveys that require further development are nursing acuity systems applicable to burn units and burn nursing educational programs.     

SCORTEN accurately predicts mortality among toxic epidermal necrolysis patients treated in a burn center

SCORTEN is a scoring system used to predict mortality in toxic epidermal necrolysis (TEN) patients. The accuracy of SCORTEN among TEN patients treated in burn centers has not been established. The purpose of this study was to assess the discriminative power and calibration of SCORTEN among TEN patients treated at an adult regional burn center. Retrospective analysis of a consecutive series of TEN patients was used to compare actual mortality with that predicted by SCORTEN. A standardized mortality ratio was obtained to compare the actual number of deaths to the predicted number based on SCORTEN. Discrimination was measured using the area under the receiver operator characteristic curve, and model fit (calibration) was measured using the Hosmer-Lemeshow goodness-of-fit statistic. A total of 61 adult patients were analyzed. The actual overall mortality rate of 29.5% was not significantly different than the mortality rate of 25.2% predicted by SCORTEN (standardized mortality ratio, 1.17; 95% confidence intervals, 0.695-1.853; P = .08). The area under the receiver operator characteristic curve was 0.82 and the Hosmer-Lemeshow statistic was 1.381 (P = .710). SCORTEN is an accurate scoring system for estimation of mortality among TEN patients treated in a burn center setting.     

Infection control in a burn center

No consensus has been reached on the ideal isolation technique to prevent hospital-acquired infection in the patient with burns. This study reports four 2-month consecutive periods of microbial surveillance in a burn center intensive care unit. Phase I, the first period of surveillance, demonstrated a unit-acquired colonization rate of 63%, with the marker organisms appearing at 4 to 8 days. Direct observation of isolation technique showed a 51% error rate. A mandatory educational session reviewing the high colonization rates, observed breaks in isolation technique, and principles of infection control failed to decrease the colonization rates as measured in phase II. A simplified isolation technique was adopted, which led to a decrease in unit-acquired colonization, from 63% to 33% in phase III from phase I values (p = 0.0514); and to a significant delay in inception, from 7.8 to 21 days, in those colonized with Pseudomonas aeruginosa (p less than 0.05). The simplified isolation technique decreased isolation costs over a 6-month period from $53,000 to $30,000. To confirm the decrease colonization rates from phase I to phase III, a fourth 2-month surveillance period was undertaken 6 months later. Phase IV demonstrated similar results to those of phase III.     

Dodgeball-related injuries treated at emergency departments

BackgroundThere is little published information on injuries from playing dodgeball. This investigation described dodgeball-related injuries among children and adults managed at emergency departments (EDs).MethodsCases were dodgeball-related injuries reported to the National Electronic Injury Surveillance System (NEISS) during 2001–2018. Cases were divided into patients age 0–19 years (children) and patients age 20 years or greater (adults).ResultsA total of 5533 dodgeball-related injuries were identified, resulting in a national estimate of 185,382 injuries. Children accounted for 167,766 (90.5%) and adults for 17,617 (9.5%) of the injuries. For both age groups, the number of injuries increased during 2001–2006 then fluctuated but did not demonstrate any clear trend during 2007–2018. The highest proportion of children were treated on Friday (21.8%) while the highest proportion of adults were treated on Saturday (20.2%). While 57.8% of child injuries occurred at school, 46.7% of adult injuries occurred at a sports or recreational facility. The more common reported types of injuries among children and adults, respectively, were sprain or strain (30.7% vs 38.5%), fracture (24.7% vs 23.9%), contusion or abrasion (16.3% vs 7.5%), and dislocation (3.0% vs 11.7%). The most frequently affected body parts among children and adults, respectively, were the upper extremity (50.4% vs 46.3%), head and neck (22.8% vs 15.4%), and lower extremity (21.4% vs 31.5%).ConclusionThe majority of dodgeball-related injuries occurred among children. Children and adults tended to differ with respect to when and where the injuries occurred as well as the type of injury.     

Electrical burn injuries

This article examines electrical burn injuries, how they occur and the nature of the injuries caused when people come into contact with electrical currents. The aetiology of tissue damage is discussed along with the pathophysiology of such encounters. The management of patients presenting with such injuries is explored including the vital role of the nurse in stabilizing and reassuring the patient. Careful handling of patients is needed in order to minimize further damage and this is discussed along with the resuscitation measures required and fluid replacement protocols. Pain management requires careful consideration as does the nursing care the patient receives. These are explored along with the support required by the family at such a time. The importance of communication is also stressed. Conclusions are drawn along with preventative measures to help avoid electrical burn injuries occurring.     

Occupation-related burn injuries

Unlike household burn injuries, the characteristics of burn injuries in the workplace have not been well described. In an effort to understand the causes and effects of occupation-related burn injuries and to aid in prevention, we sought to describe work-related burn injuries by frequency, burn type, age of the patients, body parts burned, and occupation of the patients. This was a statewide, cross-sectional study of all burns that occurred in the workplace during 1994. Data on fatal injuries were obtained from the National Census of Fatal Occupational Injuries. Survey data from the North Carolina Department of Labor were used for nonfatal injuries. Burns caused 34 deaths (15.3%) and 1720 injuries in the workplace in 1994. Of the nonfatal injuries, 1363 (79.2%) were caused by exposure to caustic substances or hot objects or substances. The head and upper extremities were the most frequently injured body parts (936 injuries; 57.6%). The average age of those burned was 30.7 years; most of the patients ranged from 25 to 35 years old. High-risk occupations included vehicle and equipment cleaners, food service personnel, and millwrights (11.3%, 5.3%, and 5.2% of burn injuries, respectively). Unlike the flame burns that occur in homes, exposure to caustics and hot objects and substances caused the majority of on-the-job burn injuries. Protective gear for the head and upper extremities may prevent a significant number of burns. Education and prevention programs may best be directed at workers with high-risk occupations and workers in the 25- to 35-year age range.