Enzymatic debridement of burn wound with collagenase in children with partial-thickness burns

Seventy-eight pediatric burn patients treated by enzymatic debridement with collagenase clostridiopeptidase A (CCA), were compared to 41 patients those burn wounds were excised surgically. Patients whose burn wounds were initially assessed as partial-thickness at admission were enrolled in the study. Total removal of eschar was achieved in 49 of 78 (62.8%) patients by CCA only (group D). In 29 patients (37.2%), therapy with CCA was ceased because of the development of burn wound infection or a manifest need for grafting of the wound, therefore, these patients underwent tangential wound excision (group DS). The records of 41 patients, treated by early tangential excision, having similar burn wounds by extent and depth with groups D and DS were used as controls (group S).

There was no significant difference between the time to achieve a clean wound bed in groups D, DS and S (mean 7.8, 8, and 7 days, respectively, P>0.05). In group D, none of the patients required blood transfusion, except one. Patients in group DS were found to have fewer excisions (mean 1.1) when compared to those in group S (mean 1.5, P<0.05). The shortest hospital stay was found in group D (12.5 days, P<0.01). In conclusion, the use of CCA, provided a short hospital stay, reduced the overall need for surgery and blood transfusions in patients with partial-thickness burns. Thus, CCA should be considered as an initial treatment of choice for removal of eschar in children, having a partial-thickness burn wound without infection.     

Characteristics of 1494 pediatric burn patients in Shanghai

To analyze the epidemiological characteristics of pediatric burn patients in Shanghai and to determine the targets for a pediatric burn prevention program, a retrospective review of all medical records of acute pediatric burn patients (age相似文献   

Epidemiological characteristics of burn injuries in Iraq: A burn hospital-based study

This study was conducted to determine the epidemiological and clinical characteristics of burn injuries, estimate the case fatality rate for burn patients, and determine the main determinants of the associated death among burn patients who were admitted to Baghdad Burn Hospital, Medical City Teaching Hospitals, Baghdad, Iraq during 2015. This study involved a retrospective review of medical records of all burn patients who were admitted to Baghdad Burn Hospital in 2015. Data were collected using a special form and included information on demographic characteristics and burn characteristics and outcomes. A total of 676 patients with burn were included in this study, who constituted 75% of admitted patients. The remaining was admitted for treatment of old scars. About one third of patients (37.0%) aged 21–30 years, 67.1% were males, 34.8% were military personnel, and 60.7% of the patients had primary school education. About 71.6% of patients were burned by flame and 23.4% were burned by hot fluid. Half of patients had a second degree burns. Almost half of patients had 11–20% of their body surface area affected. About 13% of patients died, mainly due to multiple organs failure (53.3%), septicemia (44.4%), and shock (2.2%). In conclusion, young adults and children, males, and low educated patients represent the majority of admitted burn cases in Iraq. Flame and scalds were the most important causes of burn. More than one tenth of patients died mostly due to septicemia and multi-organ failure.     

Pruritus in patients with small burn injuries

OBJECTIVE: To document incidence of pruritus and the presence of predisposing factors after small burns and their (subjective) impact on daily life. METHODS: Retrospective study interviewing all patients treated in an outpatient burn clinic during 2004. Patients were contacted by phone and questioned on aspects of the burn and the presence, intensity and impact of pruritus. Predisposing factors for pruritus were analysed by multivariate logistic regression analysis. RESULTS: Eighty-five percent of the 318 outpatients consented to the interview. Median total burned surface area (TBSA) was 2% (interquartile range of 1-4%). Thirty-five percent of patients recalled moderate pruritus, 14% severe pruritus. Impact on daily life was reported in 42% of patients suffering from moderate pruritus and 92% of patients suffering from severe pruritus. A multi variant logistic regression model based on baseline parameters (TBSA, age and anatomical region burned) only predicted 16.8% of experienced pruritus. CONCLUSION: Recovery from small burns is associated with a high incidence of pruritus, which has substantial impact on daily life. It is difficult to identify patients at risk at the time of injury, as baseline demographic and injury related parameters only play a minor role. Future studies are needed to assess the effect of prevention and treatment and to define predictors for the incidence of pruritis.     

Increasing ambulatory treatment of pediatric minor burns—The emerging paradigm for burn care in children

Introduction

Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm.

Variation in acute fluid resuscitation among pediatric burn centers

BackgroundAccurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates.MethodsFive pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received.ResultsDifferences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers’ resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35 ml/kg/% TBSA, p < 0.001), (4.90 versus 6.35 ml/kg/TBSA, p = 0.002) and (3.38 versus 6.35 ml/kg/TBSA, p < 0.0001).ConclusionsThis variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.     

Assessment of a quality improvement intervention to improve the consistency of total body surface area burn estimates between referring facilities and a pediatric burn center

BackgroundBurns are a significant source of pediatric morbidity and frequently result in transfer of care to a pediatric burn center. Data suggest that referring facilities often overestimate the total body surface area (%TBSA) of burns in comparison to the subsequent assessment at the pediatric burn center. Such discrepancies may trigger inappropriately aggressive interventions with potential for patient harm. Our baseline assessment of data from 106 patients transferred to our pediatric burn center over a one-year period showed that 59/106 (56%) patients had a %TBSA recorded at the time of transfer and 18/59 (31%) had clinically significant differences (>5% difference) in estimates between the referring facility and the pediatric burn center.MethodsInformed by this clinical audit and a root cause analysis, we implemented practices to enhance consistency of clinical assessments between referring facilities and our pediatric burn center. These practices included the use of a common clinical assessment instrument (a standardized Lund and Browder form) that was integrated into the interfacility transfer process as well as educational outreach at referring facilities for providers who treat children with burns, prioritizing facilities with the highest number of discrepancies.ResultsFollow up data was reviewed 16–23 months after initiating the intervention. Cumulatively, we found significant improvement in the proportion of patients with %TBSA recorded (94% vs 56%, p < 0.001) that achieved our goal to exceed 90% and a reduction in clinically significant discrepancies that exceeded our goal of 15% (10% vs 31%, p = 0.002).ConclusionsReferring facilities often overestimate the %TBSA in comparison to the subsequent assessment at the pediatric burn center. The consistency of the %TBSA estimates can be improved by interventions that utilize the sharing of a common clinical assessment instrument and standardization of the transfer intake process.     

Epidemiology of paediatric burn injuries in Hamadan,Iran

Burn injuries are prevalent worldwide, especially in developing countries; and they are significant paediatric injuries in Iran. This study was performed to analyse the epidemiology and aetiology of paediatric burns in Hamadan province in the west part of Iran from March 2004 to March 2007. The incidence rate of child hospitalisation for burns was 33.4 per 100 000 person-years. The median age was 3 years with 69% of the patients under 4 years. The male-to-female ratio of incidence rate for all age groups was 1.52. Scald was the leading cause in almost all age groups and caused 266 (71.7%) burns. Correlation analysis showed that younger children are more vulnerable to scald injury. The mean body surface area (BSA) of burns was 16.36 (SD = 11.42) in all cases. Flame was more fatal than other causes of burns. The total fatality rate in this study was 3.5%. Epidemiological findings reveal that scald, age, gender and residence in rural area are the major issues that should be discussed in considering childhood burns. Prevention efforts should focus on the reduction of scald injuries during food preparation or hot liquid spillage. These efforts should target rural infants, toddlers and boys.     

Overutilization of regional burn centers for pediatric patients--a healthcare system problem that should be corrected

Background

Minor burns represent .96% to 1.5% of emergency department visits, yet burn center referral is common. Analysis of the Grady Memorial Hospital Burn Center examined the feasibility and savings if pediatric burns were managed locally with as-needed consultation.

Methods

Prospective data on 219 consecutive admissions to Grady Memorial Hospital Burn Center between December 2008 and September 2010 were reviewed. National and international cohorts were compared.

Results

Sixty-six percent of patients were male, the mean age was 6.1 years, and 92% were insured. The most common mechanism of burning was liquid scalding (40%). Seventy percent had burns over <10% of the total body surface area, and 73% of all pediatric admissions healed without surgery. Thirty-six percent were discharged within 24 hours of admission. Forty-five percent of patients transferred from other facilities were discharged within 24 hours. Fifteen percent were transported by helicopter; of those, 37% were discharged within 24 hours. Helicopter transport cost $12,500 and averaged 45 miles.

Conclusions

Pediatric burns require assessment, debridement, and dressing changes. Grafting is rarely necessary. Patients are transferred because of a lack of training, and patients suffer economic burden and treatment delay. Savings could be realized were patients treated locally with select burn center referral.     

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.     

Demographic characteristics and prognostic indicators of childhood burn in a developing country

Children constitute a significant proportion of burn victims in most studies from the developing countries. While there has been a progressive improvement in the outcome from childhood burn in many developed nations, the morbidity and mortality remains high in many low and middle income countries. The aim of our study is to evaluate the demographic characteristics and prognostic indicators of childhood burn in a major referral teaching hospital in a developing country. A review of the records of 638 patients with acute burns managed over a 10-year period from January 2001 to December 2010 at the University College Hospital, Ibadan Nigeria was done. The clinical and epidemiological data were retrieved from computerized data base using the ISBI proforma. Information obtained includes Biodata, Etiology, location, TBSA, presence of Inhalation injury and the treatment outcome. Data of patients aged 16 years and below were analyzed using the SPSS version 16. The main outcome measure was the patient's survival. 289 children representing 45.3% of the total number of burn patients were managed over the period. The M:F ratio was 1.1:1. The median age of the cohort was 4.0 years while the median TBSA was 21.0%. Non-intentional causes were responsible for 89.6% cases. Most of the injuries (88.6%) occurred at home. Eighty-three patients had inhalation injury out of which 57 (68.7%) deaths were recorded. The overall mortality rate in the cohort was 39.5% with an LA50 of burn size of 45%. The TBSA was also found to be a determinant of outcome.Majority of childhood burns are from preventable causes with attendant dismal mortality figures. Effective burn prevention strategies and improved quality of care remain pivotal in reducing childhood burn morbidity and mortality in the developing countries.     

Paediatric burn injuries in Sub Saharan Africa--an overview

Paediatric burn injuries in Sub Saharan Africa are common and often lead to devastating consequences. Unfortunately relevant and accurate data regarding these injuries is sketchy and incomplete. This paper reviews the available information on the epidemiology of paediatric burns in Africa, associated health problems and contributing environmental factors responsible for these burns. The current status of burn care, the lack of infrastructure, and traditional methods of treatment, further contribute to the unsatisfactory status of overall burn management, prevention, and rehabilitation of burn survivors. A strategy for improving burn care in Africa has been formulated. The management of childhood burns will only be successful if educational, social, fiscal and infrastructure standards are improved. Traditional beliefs and methods cannot be discarded as they play an important role in the management of these children. It is furthermore essential that local and central government organisations support these initiatives. Clearly, the children of Africa deserve better burn care.     

Negative pressure dressing assisted healing in pediatric burn patients

Background/Purpose

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

Methods

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

Results

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

Discussion

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

Conclusions

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

Race,area deprivation index,and access to surgical burn care in a pediatric population in North Carolina

BackgroundBurns represent a leading cause of morbidity and mortality for children. This study explores the intersecting effects of social deprivation and race in pediatric burn patients.MethodsWe performed a retrospective review of all pediatric patients (<18 years old) admitted to a tertiary burn center in North Carolina from 2009 to 2019. We used bivariate analysis to compare patients based on reported race, comparing African Americans (AA) to all others. Modified Poisson regression was used to model the probability of undergoing autologous skin grafting based on AA race.ResultsOf 4227 children admitted, AA children were disproportionally represented, comprising 33.7% of patients versus a state population of 22.3%. AA patients had larger %TBSA with a median of 3% (IQR 1–6) compared to 2% (IQR 1–5, p < 0.001) and longer median length of stay at 5.8 days (SD 13.6) versus 4.9 days (SD 13.8). AA patients were more likely to have autologous skin grafting compared to other races, with an adjusted RR of 1.49 (95% CI 1.22–1.83) when controlling for Area Deprivation Index (ADI) national rank, age, %TBSA, and burn type.ConclusionsAA children were disproportionately represented and had larger burns, even when controlling for ADI. They had longer hospital stays and were more likely to have autologous skin grafting, even accounting for burn size and type. The intersection between social deprivation and race creates a unique risk for AA patients. Further investigation into this phenomenon and factors underlying surgical intervention selection are indicated to inform best treatment practices and future preventative strategies.     

Use of gauze-based negative pressure wound therapy in a pediatric burn patient

Negative pressure wound therapy (NPWT) is described as it is used in the treatment of an infant burn victim. This case highlights the ability and techniques used to maintain an airtight dressing seal in the perirectal region. Use of this dressing type post–skin grafting allowed for 100% graft adhesion and no bacterial contamination despite close proximity to the rectum. Favorable experience and outcome with this patient are strong indicators that NPWT should be considered as a viable treatment in pediatric populations and that situations where body contour or fluids may make NPWT difficult to administer should not be a deterrent to therapy.     

Mucormycosis following burn injuries: A systematic review

IntroductionMucormycosis is an opportunistic fungal infection with a high mortality rate. Though typically associated with diabetes and other conditions that affect innate immune function, infections can also be precipitated by conditions such as trauma and burns. Burn patients are particularly susceptible to fungal infections due to the immune dysfunction that often accompany their wounds. Indeed case series have described mucormycosis to occur in patients with burn injuries, however the factors contributing to mortality have not been well described. Thus, the purpose of our review was to identify factors contributing to morbidity and mortality in burn patients with Mucormycosis.MethodsA systematic review of the literature of mucormycosis infection in burn injury patients was performed on Pubmed and Google Scholar using the keywords: Mucor, Mucorales, Mucormycosis, Mucormycotina, Zygomycosis and burn or thermal injury. Clinical trials, observational studies, case reports, and case reviews were included if they provided information regarding mortality in adult and pediatric burn patients diagnosed with mucormycosis, review articles, non-English articles, and articles without patient information were excluded. No time limit was placed on our review. Individual patient data was stratified based on mortality. Statistical analysis was performed to investigate the relationship between patient risk factors and mortality, and the Oxford Level of Evidence was used to evaluate study quality.Results46 articles were included in our final review, encompassing 114 patients. On average, survivors had a total body surface area (TBSA)% of 46 (SD 19.8) while non-survivors had a TBSA of 65% (SD 16.4), and this difference was significant (p < .001). Patients with disseminated mucormycosis experienced an 80% mortality rate compared to 36% mortality rate in patients with localized disease (p < .001). We found no statistically significant difference in mean age (p > .05), diabetes (p > .05), mean delay in diagnosis (p > .05), time to antifungal therapy (p > .05), or type of therapy used (p > .05) between survivors and non-survivors. Our review was limited by the lack of prospective, controlled trials; thus, our review primarily consists of case reports.ConclusionDisseminated infections and higher TBSA both increased the risk of mortality in burn patients with mucormycosis, while diabetes did not increase mortality risk. The severity of the initial injury and infection locations must be taken into consideration to inform patient prognosis.     

Perioperative use of cuffed endotracheal tubes is advantageous in young pediatric burn patients

Uncuffed endotracheal tubes traditionally have been preferred over cuffed endotracheal tubes in young pediatric patients. However, recent evidence in elective pediatric surgical populations suggests otherwise. Because young pediatric burn patients can pose unique airway and ventilation challenges, we reviewed adverse events associated with the perioperative use of cuffed and uncuffed endotracheal tubes. We retrospectively reviewed 327 cases of operating room endotracheal intubation for general anesthesia in burned children 0–10 years of age over a 10-year period. Clinical airway outcomes were compared using multivariable logistic regression, controlling for relevant patient and injury characteristics. Compared to those receiving cuffed tubes, children receiving uncuffed tubes were significantly more likely to demonstrate clinically significant loss of tidal volume (odds ratio 10.62, 95% confidence interval 2.2–50.5) and require immediate reintubation to change tube size/type (odds ratio 5.54, 95% confidence interval 2.1–13.6). No significant differences were noted for rates of post-extubation stridor. Our data suggest that operating room use of uncuffed endotracheal tubes in such patients is associated with increased rates of tidal volume loss and reintubation. Due to the frequent challenge of airway management in this population, strategies should emphasize cuffed endotracheal tube use that is associated with lower rates of airway manipulation.     

Inter-facility transfers for burn patients with concomitant traumatic injuries

Burn patients with concomitant traumatic injuries suffer increased morbidity and mortality. Complex care coordination is necessary for these patients, and the prevalence of resulting inter-facility transfers has not yet been quantified by literature. This study examined the outcomes for traumatically injured burn patients to identify the occurrence of trauma system transfers in this group. The National Trauma Data Bank was reviewed from the years 2007–2016 for 6,565,577 patients with traumatic, burn, and concomitant burn & traumatic injuries. There were 5068 patients with both traumatic and burn injuries, 145,890 patients with burn injuries, and 6,414,619 patients with traumatic injuries. Trauma/burn patients were more often admitted to the ICU from the ED at a rate of 35.5% compared to 27.1% for burn and 19.4% for trauma (P < 0.001). For disposition when discharged from the hospital, trauma/burn patients required more inter-facility transfers at a rate of 2.5% compared to 1.7% for burn and 1.3% for trauma (P < 0.001). For level I trauma centers, 5.5% of trauma/burn, 7.1% of burn, and 0.5% of trauma patients required inter-facility transfers. For level II trauma centers, 29.1% of trauma/burn, 47.0% of burn, and 2.8% of trauma patients required inter-facility transfers. Among level I and level II trauma centers, patients with only burns and burn patients with concomitant traumatic injuries required more inter-facility transfers, and level II trauma centers required more inter-facility transfers for all patients. Quantifying these findings is the first step toward improving triage decisions and allocation of health care resources while expediting appropriate care.     

Trauma mechanisms and injury patterns in pediatric burn patients

The objective of this study was to evaluate the frequency, severity, exact patterns and mechanisms of burn injuries in children.The patient records of children with acute burns admitted to the University Children‘s Hospital of Zurich were retrospectively reviewed over an 11 year period.The age group with the highest risk, were children under the age of five (69%). Boys were overrepresented in all age groups, but the gender imbalance increased with age.Infants and toddlers were mainly injured by scalds and contact burns. Conversely, almost three quarters of injuries over the age of 9 were caused by flame. The majority of scald injuries was a result of pulling down hot liquids. The typical distribution of this accident scenario involved mainly the face, trunk and arms.More than half of all flame injuries occurred due to fire accelerants. 55% of children were passively involved while other children throwing flammable substances into a fire. Most of these injuries involved the face and arms.This study shows that burn etiology is age dependent. Additionally, our results demonstrate the diversity of burn accidents and their resulting injuries. These findings may help better specify target groups and subjects for prevention.