Burns caused by automobile radiators: a continuing problem.

In spite of the fact that injury warning labels have been placed on radiator caps for the last 15 years, automobile radiator scald burns continue to be a burn prevention problem. The temperature of radiator fluid may be as high as 100 degrees F to 250 degrees F in a properly functioning car and higher in an overheated vehicle. From 1974 to 1990, 100 patients with burns that were caused by automobile radiators have been admitted to the Parkland Memorial Hospital Burn Unit (1.5% of acute admissions). Eighty-two percent of the injuries occurred in the summer months, and 93% of the patients were male. Mean age was 31 +/- 17 years (range, 8 months to 79 years), and mean burn size was 11.3% total body surface area (TBSA) (range, 1% to 32%) with a mean full-thickness burn size of 0.6% TBSA. Length of stay was 7 +/- 7.4 days (range, 1 to 38 days). Burns to the face, neck, and trunk necessitated most admissions. Although there were no deaths, five patients required intensive care for airway monitoring; mean length of stay was 6 days. One patient required endotracheal intubation for a total of 11 days. Ten patients required one or more skin grafting procedures, and three patients required burn resuscitation. Four patients sustained minor ocular injuries. A subgroup of patients demands special review: 10 children younger than 10 years of age (mean age, 4.1 years) of which 70% were boys. Mean burn size was 15.5% TBSA; mean full-thickness burn size was 2.4% (four times larger than the mean burn size for the adult population).(ABSTRACT TRUNCATED AT 250 WORDS)     

Social support correlates with survival in patients with massive burn injury

Large burn size, inhalation injury, age, and associated trauma increase the rate of mortality after burns. However, not all patients with large burns and significant risk factors die. In this study, we wanted to determine other presenting factors that might indicate a survival benefit for burn patients with large burns. We reviewed charts of 36 patients with burns > or =60% TBSA that were aggressively resuscitated at the University of Washington Burn Center from 1990 to 2000 to determine whether survivors of large burns exhibit presenting variables that predict survival. Patients who had comfort care measures initiated at admission were excluded from this analysis. Survivors (n = 16) and nonsurvivors (n = 20) had no significant differences in age, total burn size, inhalation injury, or need for escharotomy. Full-thickness burn size was significantly smaller for survivors (58%) than for nonsurvivors (73%; P = .02). Survivors (81%) were more likely than nonsurvivors to have social support (35%; P = .007). A full-thickness burn > or =80 % TBSA was the only variable uniformly associated with mortality, suggesting that patients who survive large burns have a partial-thickness component that heals without surgery. The difference in degree of social support was one unique distinction that may impact patient survival and is worth further investigation.     

Firefighter burn injuries: predictable patterns influenced by turnout gear

Approximately 100 firefighters suffer fatal injuries annually and tens of thousands receive nonfatal injuries. Many of these injuries require medical attention and restricted activity but may be preventable. This study was designed to elucidate etiology, circumstances, and patterns of firefighter burn injury so that further prevention strategies can be designed. In particular, modification of protective equipment, or turnout gear, is one potential strategy to prevent burn injury. An Institutional Review Board-approved retrospective review was conducted with records of firefighters treated for burn injury from 2005 to 2009. Data collected included age, gender, TBSA, burn depth, anatomic location, total hospital days per patient, etiology, and circumstances of injury. Circumstances of injury were stratified into the following categories: removal/dislodging of equipment, failure of equipment to protect, training errors, and when excessive external temperatures caused patient sweat to boil under the gear. Over the 4-year period, 20 firefighters were treated for burn injury. Mean age was 38.9 ± 8.9 years and 19 of 20 patients were male. Mean burn size was 1.1 ± 2.7% TBSA. Eighteen patients suffered second-degree burns, while two patients suffered first-degree burns. Mean length of hospitalization was 2.45 days. Scald burns were responsible for injury to 13 firefighters (65%). Flame burns caused injury to four patients (20%). Only three patients received contact burns (15%). The face was the site most commonly burned, representing 29% of injuries. The hand/wrist and ears were the next largest groups, with 23 and 16% of the injuries, respectively. Other areas burned included the neck (10%), arm (6.5%), leg (6.5%), knees (3%), shoulders (3%), and head (3%). Finally, the circumstance of injury was evaluated for each patient. Misuse and noncontiguous areas of protective equipment accounted for 14 of the 20 injuries (70%). These burns were caused when hot steam/liquid entered the gear via gaps in the sleeve or face mask. Three patients (15%) received injury due to removal/dislodging of their safety equipment, two patients (10%) suffered their injuries during training exercises when they were not wearing their safety equipment, and the final patient (5%) received burns due to sweat evaporation. Firefighter burn injuries occur to predictable anatomic sites with common injury patterns. Modification and optimization of gear to eliminate gaps that allow steam/hot liquid entry may decrease burn injury. Improving education regarding the use of protective equipment may also be beneficial.     

Blood transfusion in burns: what do we do?

Over 11 million units of blood are transfused yearly in the United States. Although blood transfusion is common in burns, data are lacking on appropriate transfusion thresholds. The purpose of the study was to identify current burn center physician blood transfusion practices. A 30-question survey of blood transfusion practices was developed and sent to burn center directors. The survey assessed demographics, burn experience, and blood transfusion thresholds. Physicians were asked to list factors affecting their blood transfusion thresholds and then to give their blood transfusion threshold for patients based on age and percent burn. The final section presents three case scenarios with alterations in one physiological parameter to assess the effect on transfusion thresholds. A total of 55 of the 180 surveys (31%) were returned. Mean number of burn beds was 15.7 +/- 1.4, with 264 +/- 25 burn admissions per year. The respondents had been in burn care for 15.9 +/- 1.4 years. Their mean hemoglobin transfusion threshold was 8.12 +/- 1.7 g/dl. The most frequent reasons for transfusion were ongoing blood loss (22%), anemia (20%), hypoxia (13%), and cardiac disease (12%). Inhalation injury influenced the decision to transfuse blood in 34%. The hemoglobin level below which respondents would transfuse blood increased with increasing TBSA burn, history of cardiac disease, acute respiratory distress syndrome, and age. Blood transfusion thresholds in burns vary based on burn percentage, age, and presence of cardiac disease. To date, no standard of care exists for blood transfusions in burns. Future prospective studies are needed to determine the appropriate use of blood in burns.     

Review of a fluid resuscitation protocol: "fluid creep" is not due to nursing error

Recent reviews of burn resuscitation have included the suggestion that "fluid creep" may be influenced by practitioner error. Our center uses a nursing-driven resuscitation protocol that permits titration of fluid based on hourly urine output, including the addition of colloid when patients fail to respond appropriately. The purpose of this study was to examine protocol compliance. We reviewed 140 patients (26 children) with burns of ≥20% TBSA who received protocol-directed resuscitation from 2005 to 2010. We compared each patient's actual hourly fluid infusion with that predicted by the protocol. Sixty-seven patients (48%) completed resuscitation using crystalloid alone, whereas 73 patients required colloid supplementation. Groups did not differ in age, gender, weight, or time from injury to admission. Patients requiring colloid had larger median total burns (33.0 vs 23.5% TBSA) and full-thickness burns (15.5 vs 4.5% TBSA) and more inhalation injuries (60.3 vs 28.4%; P < .001) than those who resuscitated with crystalloid alone. Because we included basic maintenance fluids in their regimen, patients had median predicted requirements of 5.4 ml/kg/%TBSA. Crystalloid-only patients required fluid volumes close to Parkland predictions (4.7 ml/kg/%TBSA), whereas patients who received colloid required more fluid than the predicted volume (7.5 ml/kg/%TBSA). However, the hourly difference between the predicted and received fluids was a median of only 1.0% (interquartile range: -6.1 to 11.1%) and did not differ between groups. Pediatric patients had greater calculated differences than adults. Crystalloid patients exhibited higher urine outputs than colloid patients until colloid was started, suggesting that early over-resuscitation did not contribute to fluid creep. Adherence to our protocol for burn shock resuscitation was excellent overall. Fluid creep exhibited by more seriously injured patients was not due to nurses' failure to follow the protocol. This review has illuminated some opportunities for practice improvement, possibly using a computerized decision support system.     

The methamphetamine burn patient

Early aggressive fluid resuscitation has significantly decreased the morbidity and mortality associated with volume losses from large burns. Although most patients are adequately resuscitated using the Parkland formula, we noted increased fluid requirements for shock resuscitation in patients involved in methamphetamine laboratory explosions. Because predominant users are young healthy individuals in their 20s and 30s, we had not anticipated burn shock resuscitation failures in this patient group. We reviewed our experience with burn patients with documented methamphetamine use to determine whether this patient group presents new dilemmas to the burn surgeon. A 2-year retrospective study of 30 patients (15 methamphetamine users, 15 controls) revealed that the methamphetamine burn patient requires two to three times the standard Parkland formula resuscitation. In this study, methamphetamine burns larger than 40% TBSA had a 100% mortality.     

The role of the psychiatrist in the team treatment of the adult patient with burns.

Improved survival rates for patients with major burn injuries and the consistent finding of significant long-term psychologic disability among survivors of burn trauma call for a redefinition of the role of the psychiatric consultant in the care of patients with burns. In addition to the traditional functions of diagnosis and treatment of discrete psychiatric disorders in patients with burns, this expanded role includes assisting the patient's normal process of psychologic adaptation after injury, assessing and managing burn pain, and facilitating communication among all members of the burn team. The functions of the psychiatrist are most effectively carried out when the psychiatrist is able to participate on a regular basis in the care of every patient as a member of the burn team.     

The assessment and management of burns

Each year many people seek medical advice or hospital treatment for burn or scald injuries. There is limited data on the number of burns patients seen in primary care, however a recent national survey suggested that there are 250,000 presentations of burn injuries to primary care teams in the UK per year (National Burn Care Review, 2001). This article discusses the nursing management of burns in the community, outlining the initial assessment of the burns patient in terms of trauma management, and focusing primarily on those patients with non-complex burns. A full patient assessment incorporates the patient's general condition, the type, cause, depth and extent of the burn and the effects on the individual patient. Good patient management is an essential element of care and the focus of this is the management of pain, prevention of infection, provision of evidence based wound care and onward referrals as appropriate. However not all patients can be managed solely in the community and the nurse needs to know when to refer and to whom to refer. The article outlines the recommendations from the National Burn Care Review in terms of patient referral.     

A qualitative analysis of family member needs and concerns in the population of patients with burns

The importance of family support to ameliorate the recovery of a patient with burns has been documented in the literature. However, there is a dearth of research that identifies family members' needs and concerns during the hospitalization of patients with burns. Study aims were as follows: (1) identify support needs and concerns of family members of adult and pediatric patients currently in a burn center and (2) explore the relationship between family needs and the patient's severity of injury. An observational design was used that incorporated semistructured interviews with family members 1 to 3 days after the burn. A convenience sample of family members of burn center patients (n = 97) was recruited over 9 months. Content analysis was used to establish themes from interview data. Interrater reliability on coding of thematic units from 15% of the interviews was 86%; discrepancies were corrected to 100%. The average family member was 42.3 years old, female, white, and at least a high school graduate. Family members' concerns included general patient concerns, physical concerns about the patient, satisfaction of personal needs, and psychologic concerns about the patient. Major sources of support were family and friends, burn center staff, and spirituality. Family members of pediatric patients identified pain and skin graft surgery as priority worries. Satisfaction of personal needs, financial support, and information needs were greater among family members of intensive care unit patients in comparison with step-down patients. These findings underscore the importance of communication and reassurance between the burn team and the family members. Alterations to the support provided to families can be made on the basis of study subjects' responses.     

Cardiac disease and the patient with burns

Cardiac disease has many manifestations that may complicate burn care. A review of 2477 consecutive acute burn admissions was conducted to determine the types and incidence of cardiac complications in this patient population. Nearly one half of patients with a prior cardiac history manifested some form of cardiac dysfunction, most frequently arrhythmias. Eight percent had an in-hospital myocardial infarction. Only 6% of patients without a prior cardiac history manifested cardiac dysfunction. The in-hospital mortality rate after myocardial infarction for both groups was 3.5 to 4 times that of patients without burns. Except for patients with prosthetic valves, for whom anticoagulation and infection prophylaxis are required, burn care of the cardiac patient is expectant with selective use of invasive monitoring and therapy as determined by the patient's clinical course.     

Acute respiratory failure that complicates the resuscitation of pediatric patients with scald injuries.

Respiratory failure that requires endotracheal intubation is an uncommon but potentially fatal complication of scald burns in children. Because scalds are rarely associated with a direct pulmonary injury, the pathophysiology of respiratory failure is unclear. A possible mechanism may be upper airway edema, diminished pulmonary compliance secondary to fluid resuscitation, or both. To identify an at-risk population for intubation after a scald injury, the hospital courses of 174 consecutive patients under the age of 14 years who were admitted after a scald injury to a single burn center during a 6-year period were examined. Seven of these patients (4%) required endotracheal intubation. No patient older than 2.8 years or who had a scald injury that covered less than 19% of the total body surface area required intubation. Patients who required intubation were younger (mean age, 1.4 vs. 2.8 years, P<.001), had a larger mean burn size (29.9% vs. 12.3% total body surface area, P<.001), and required more fluid resuscitation (7.66 vs. 4.07 cc/kg per percentage of total body surface area burned, P<.001) than patients who did not require intubation. Examination of the adequacy of resuscitation revealed that the intubated patients had an average hourly urine output of 0.84 cc/kg during the first 24 hours, suggesting that resuscitation was not excessive. Multivariate analysis demonstrated that both larger burn size (P = .041) and younger age (P = .049) were independent predictors of the need for intubation. Young patients with large body surface area burns that required large volumes of resuscitation comprise an at-risk group for respiratory failure after a scald injury. Increased vigilance is merited during the resuscitation of these patients.     

Hydrofluoric acid burns: a 15-year experience

Hydrofluoric acid (HF) is a strong inorganic acid commonly used in many domestic and industrial settings. It is one of the most common chemical burns encountered in a burn center and frequently engenders controversy in its management. We report our 15 year experience with management of HF burns. We reviewed our experience from 1990 to 2005 for patients admitted with HF burns. Primary treatment was with calcium gluconate gel. Arterial infusion of calcium and fingernail removal were reserved for unrelenting symptoms. There were 7944 acute burn admissions to our center during this study period, 204 of which were chemical burns. HF burns comprised 17% of these chemical burn admissions (35 patients). All were men, with a mean burn size of 2.1 +/- 1.5% (range, 1-6%) and hospital stay of 1.6 +/- 0.7 days (range, 0-3 days). The most common seasonal time of injury was in the summer. Twelve patients (34%) were admitted to the intensive care unit for a total of 14 intensive care unit days, primarily for arterial infusions. Ventilator support was not required in any patient. No electrolyte abnormalities occurred. All burns were either partial thickness or small full thickness with no operative intervention required and no deaths. The upper extremity was most commonly involved (29 patients, 83%). The most common cause was air conditioner cleaner (8 patients, 23%). HF is a common cause of chemical burns. Although hospital admission is usually required for vigorous treatment and pain control, burn size is usually small and does not cause electrolyte abnormalities, significant morbidity, or death.     

Noncontact electrosurgical grounding is useful in burn surgery

Grounding patients with large burns to facilitate the use of electrocautery devices during surgery is commonly difficult because of the paucity of available grounding sites. The Mega 2000 Patient Return Electrode System (Megadyne Medical Products, Draper, UT) is an electrode designed to provide electrical return to facilitate function of electrocautery devices without direct patient contact. It accomplishes this by having a very large surface area (720 square inches) in the form of a reusable pad placed on the operating table that is covered by an impermeable drape and clean sheet beneath the patient. We used this noncontact device in 25 operations of 17 children with large burns and limited availability of traditional grounding sites. The patients had an average age of 8.8 + 4.6 years (range, 14 months-14 years), average burn size of 55 + 33% of the body surface (range, 10-95%), and average weight of 33.0 + 17.9 kg (range, 9-75 kg). Operations included 22 excision and grafting operations, an axillary release, a neck release, and bilateral groin releases. The device functioned well in all cases. There were no cutaneous burns observed. No additional traditional devices required placement. We found the device useful in burn surgery in those cases where there is a paucity of traditional grounding sites available.     

Hospital costs associated with pediatric burn injury.

Modern burn care is a resource intensive endeavor requiring specialized equipment, personnel, and facilities in order to provide optimum care. The costs associated with burn injury to both patients and society as a whole can be multifaceted and large. The purpose of this study was to evaluate the association between hospital costs, patient characteristics, and injury factors in a cohort of pediatric patients admitted to a regional burn center. We performed a review of the hospital charges accrued by pediatric patients (age <16 years) admitted to our burn center from 1994 to 2004 and explored the relationship between baseline patient, injury and hospital course characteristics and total costs. Hospital charges were converted to 2005 dollar costs using an inflation index and a cost to charge ratio. Univariate and multivariate regressions were performed to identify the factors most significantly associated with cost. In addition, we performed a subset cost analysis for patients with burns more than 20% TBSA. A total of 1443 pediatric patients (age <16) were admitted to our burn center during the study period. The overall mean hospital cost in 2005 dollars was dollars 9026 (SD = dollars 25,483; median = dollars 2138). Area of full thickness burn was the only patient or injury factor significantly associated with greater hospital costs (P < .05) on multivariate analysis. No single anatomic area was associated with increased hospital costs when adjusted for total overall burn size. Injury severity was the most significant factor impacting index hospitalization costs following pediatric burn injury. Further studies defining the long-term societal costs impact of burn injury are needed as are studies that evaluate the impact of burn injury on quality of life.     

The burn unit experience at Grady Memorial Hospital: 844 cases.

Between February 20, 1987 and July 13, 1990, 844 patients were admitted to the Grady Memorial Hospital Burn Unit. Mean age was 25.5 years, mean burn size 16.5% total body surface area, mean survivor hospital length of stay 15.9 days, and an overall survival 90.5%. Seventy-three percent were male. One half of the burns were less than 10% total body surface area. Almost half (48.5%) of the patients had flame burns, which accounted for 88.8% of the 80 deaths. The peak burn incidence occurred in infants and children as a result of scalds. If those with toxic epidermal necrolysis (n = 5), those without skin injury (n = 13), and those who were allowed to die (n = 16) are excluded, survival was 92.2%. Survival in 62 patients with inhalation injury (55.23%) was significantly less than that in 474 patients without inhalation injury (98.10%) (p less than 0.0001). The three variables--age, burn size, and inhalation injury--each influenced survival significantly but appeared to be dependent on each other; all three tended to increase or decrease together. Logistic regression equations to predict survival were developed.     

Emergency nursing care of the burned patient.

The emergency nursing care of patients with major burns presents one of nursing's greatest challenges. Priority is given to lifesaving measures. After a quick overall assessment, a careful estimate of fluid and electrolyte loss is made. An issue in burn care is whether colloids should be given in the immediate postburn period. Large amounts of fluid are always given, and balanced salt solutions are being used increasingly without colloid. The patient's response to fluid therapy can be monitored by central venous pressure readings, vital signs, and hourly measurements of urinary output. Psychologic and physiologic stress intensify the problems and should be kept to a minimum. Only after other aspects of care have been attended is attention directed to care of the burn wound.     

Thermal injury in the elderly. The limited need for nursing home care

Although it appears that survival has been increased and hospital stays have been decreased in elderly patients with burn injuries, limited information is available on the functional status of these patients at the time of discharge from the hospital. Because this information is necessary to assess more fully the success or failure of current modes of therapy, we have reviewed the records of 99 surviving patients with burn injuries over the age of 55 years. These patients had a mean age 71.8 years and a mean +/- SD burn size of 8.9% +/- 8.6%, with 36 patients having burns over greater than 10% of body surface area and 14 patients having burns over greater than 20%. The mean hospital stay of these patients was 16.9 days, and 75% of the patients required surgery to heal the burn wounds. Since just five (5%) of the 99 patients required nursing home placement at discharge, it appears that the majority of elderly patients with burn injuries recover sufficiently from the injuries to resume their preinjury life-style.     

The effects of burn severity and institutional differences on the costs of care

Burn care treatment is among the costliest yet least studied forms of care. This paper presents estimates of the magnitude and components of burn care costs. It analyzes the extent to which burn care cost is determined by severity of burns or by characteristics of the institution in which the patient is treated, based on patient-specific data from eight hospitals representing different levels of technical sophistication in the delivery of burn care. Costs of care are higher in specialized facilities. Many patients with small burns are treated in specialized facilities, at much higher costs than patients treated in general care facilities. Among specialized facilities, patient severity accounts for a portion of the variance in costs, but significant cost differences remain after adjusting for severity. These results suggest that cost-control efforts should concentrate on specifying criteria for admission to specialized burn facilities, regional coordination of facilities and institutions, and improved facilities design and management.     

1701例烧伤患者的流行病学现况分析

[目的]分析一组烧伤患者的发生特点,为制定烧伤干预策略提供科学依据.[方法]统计在湘雅医院烧伤重建外科住院的烧伤患者1 701例,对其年龄、性别、地域来源、烧伤原因、发生季节、烧伤部位、烧伤面积、严重程度、住院天数及治愈情况等进行分析.[结果]①患者年龄:儿童784例(46.1%),其中0～3岁婴幼儿411例(52.4%);25～60岁的患者688例(40.4%),0~7岁儿童患者比例显著高于其他年龄组( P <0.01);②性别:男性1175人(69.1%),女性:526人(30.9%);儿童中男∶女=2.4∶1,男性明显多于女性( P <0.01);③烧伤原因:热力烧伤1444例(84.9%),不同年龄段烧伤原因不同( P <0.01);农村与城市的烧伤原因构成比尚无明显差别;④发生季节:春夏秋冬无明显差别,春季最高,秋季最低;⑤地域来源:来自农村者930例(54.7%),城市771例(45.3%);⑥烧伤部位:全身多部位烧伤(3处以上)者1010例(59.5%),头面颈烧伤215例(12.6%),下肢烧伤182例(10.7%)和手烧伤118例(6.9%);⑦烧伤面积:烧伤面积＞30%TBSA者448例(26.3%),不同烧伤原因所致烧伤面积不全相同( P <0.05);⑧严重程度:严重烧伤患者653例(38.4%),其中特重烧伤395例(23.2%),以热液烫伤和火焰烧伤患者重度烧伤居多( P <0.01);⑨病死率1.5%;⑩住院时间:＞14 d者921例(54.1%),其中≥1个月者360例(15%),≥2个月者105例(6.2%).[结论]儿童烧伤的发生率高,以热力烧伤为主,男性患者明显多于女性,可预防性强,应在不同季节和地域加强烧伤的三级预防工作;本院烧伤患者危重症比例大,应进一步提高护士和其他医务人员对危急重症烧伤患者的救治和烧伤康复的能力.