Quality of life of adult patients with severe burns

Background

Burns are one of the most significant health problems throughout the world, leading to prolonged hospitalisation and hence increased expense for the patients, their families and society. Today, the prognosis of patients with burns is dependent, apart from adequate treatment, upon the health-care system and health-care professionals, regarding not only survival, but also lifelong quality of life. This study aims to assess quality of life of adult patients with severe burns.

Patients and methods

This study was conducted on 100 adult patients with severe burns in the burn outpatient clinic (male and female) at Mansoura University Hospital. Parameters of burn and Burn Specific Health Scale (BSHS-B) were used to assess quality of life following burns.

Results

The study revealed that burns has negative impact on most dimensions of the quality of life of patients with burns.

Conclusions

The quality of life for people who have sustained a burns should be recognised and valued by the burn team in all phases of burn care.     

Burns to the head and neck: Epidemiology and predictors of surgery

Background

The face is a frequent site of burn, but prevalence rates vary and reports are often limited to one healthcare setting. We examined the incidence of facial burns in the Netherlands in Emergency Departments (ED), hospitals and burn centres. Additionally, we identified which patient, injury and burn-related characteristics were predictors of facial burns, facial surgery and facial reconstruction in burn centres.

Methods

A retrospective, observational study was conducted including data from the Dutch Injury Surveillance System, the National Hospital Discharge Register and burn centres in a 5-year period (2003–2007).

Results

Facial burn incidences per 100,000 were 15.1 for ED visits, 1.3 for hospital admissions and 1.4 for burn centre admissions. A total of 2691 patients were admitted to Dutch burn centres; 47.5% (n = 1277) had facial burns of which 20.5% received primary facial surgery and 5.3% received facial reconstruction in follow-up. Predictors of facial burns and facial surgery were identified. Predictors of facial reconstructive surgery were burns to the neck (ventral), fire/flame burns and number of facial surgeries in the acute phase of the burn.

Conclusions

One in five patients with facial burns admitted to a Dutch burn centre received primary facial surgery and 1 in 20 received facial reconstructive surgery within a follow-up of minimum 2 years.     

Improved hair restoration method for burns

Background

Extracted partial longitudinal follicular units can be used as complete follicular units to regenerate completely differentiated hair growth. The partial follicular units that remained in the dermis in the donor area can survive and produce hairs. This technique enables us to multiply hair follicles in vivo, while preserving the donor area and therefore is suitable in persons, who have a relative small donor area compared to the recipient area, as in scalp burns.

Objectives

With this study, we try to determine if partial longitudinal follicular unit transplantation (PL-FUT) can be used for facial and/or scalp burns.

Materials and methods

Four burn victims (age 22-39 years, mean 27.75 years) were treated in the face (eyebrows, and beard) and/or on the scalp with PL-FUT. The grafts were harvested with hollow wave-tipped needles with an inner diameter of 0.6 mm from the occipital area of the scalp. The suitable longitudinal partial follicular units were impregnated with a preservative medium, and implanted into the recipient area. Hair growth in the donor area as well as the recipient area was observed before treatment, and at intervals of 1 week, 3 months and 1 year after the treatment.

Results

After evaluation of the donor area, sometimes a few little white spots were visible, but almost all hair follicles in the donor site re-produce hairs after 2 years. All treated patients had satisfactory or very satisfactory cosmetic results in the treated area.

Conclusions

Longitudinal partial follicular unit transplantation (LP-FUT) may represent the first reliable patient-friendly method to generate two hair follicles from one hair follicle with consistent results and preservation of the donor area. Therefore, this method is very suitable for people with facial and/or scalp burns.     

Burn care in relation to burn epidemiology in Italy

Aim

Burn centres are ‘hubs’ of referral for large areas and should be organised in a network optimised for the needs of their area. Burn centres’ organisation and activity in Italy are analysed with reference to burn epidemiology in the country.

Methods

A questionnaire was submitted to Italian burn centres concerning organisation, activity and epidemiology of burns treated in 2008.

Results

A total of 2067 patients were admitted to a burn centre in 2008; 50% of burns were due to flames (21% alcohol); and 25% of patients were <14 years old. Overall mortality was 5.3%. 144 beds in 15 burn centres were available (seven reserved for children; bed/inhabitants ratio, 1/414,.023). However, distribution is not uniform in the country. Bed rotation was 14.4 patients/bed, and hospital stay varied from 11.7 days for <20% total body surface area (TBSA) burns to >120 days for burns >70%. About half (57%) of patients admitted had less than 20%TBSA burns, 32% had 20-50% TBSA burns, 7% from 50% to 70% and 4% over 70% TBSA. A national network coordinating burn centre activity is lacking.

Conclusions

Italy seems to have less availability of beds for burn care than other countries, and distribution and organisation of the network may be improved. The high prevalence of child burns should be noticed and this makes prevention campaigns advisable.     

Pediatric facial burns: Is facial transplantation the new reconstructive psychosurgery?

INTRODUCTION:

Current pediatric burn care has resulted in survival being the expectation for most children. Composite tissue allotransplantation in the form of face or hand transplantation may present opportunities for reconstructive surgery of patients with burns. The present paper addresses the question “Could facial transplantation be of therapeutic benefit in the treatment of pediatric burns associated with facial disfigurement?”

METHODS:

Therapeutic benefit of facial transplantation was defined in terms of psychiatric adjustment and quality of life (QOL). To ascertain therapeutic benefit, studies of pediatric burn injury and associated psychiatric adjustment and QOL in children, adolescents and adults with pediatric burns, were reviewed.

RESULTS:

Pediatric burn injury is associated with anxiety disorders, including post-traumatic stress disorder and depressive disorders. Many patients with pediatric burns do not routinely access psychiatric care for these disorders, including those for psychiatric assessment of suicidal risk. A range of QOL outcomes were reported; four were predominantly satisfactory and one was predominantly unsatisfactory.

DISCUSSION:

Facial transplantation may reduce the risk of depressive and anxiety disorders other than post-traumatic stress disorder. Facial transplantation promises to be the new reconstructive psychosurgery, because it may be a surgical intervention with the potential to reduce the psychiatric suffering associated with pediatric burns. Furthermore, patients with pediatric burns may experience the stigma of disfigurement and psychiatric conditions. The potential for improved appearance with facial transplantation may reduce this ‘dual stigmata’. Studies combining surgical and psychiatric research are warranted.     

Exhaust system burn injuries in children

Background/Purpose

The authors had noted a number of children who had sustained burn injuries from the exhaust systems of recreational vehicles and wished to document the incidence of pediatric burn injury sustained from the exhaust systems of a wide scope of motorized vehicles.

Methods

The authors conducted a 10-year retrospective chart review including all children admitted to our institution with burn injuries from contact with vehicular exhaust systems.

Results

Twenty-three children were included. There were 18 boys, with a median patient age of 7 years. Most children (7 of 23) were injured from the exhaust systems of all-terrain vehicles. The average burn size (5%) was small, but almost two thirds of the burn injuries were full thickness. Of the 23 children, 21 required operative intervention for their burns, with 2 children requiring multiple surgical interventions. The average length of hospital stay was 11 days, and all children, except one who went to a rehabilitation facility, were discharged to home.

Conclusions

Pediatric health care providers should be aware that exhaust system contact burns in children are not rare events and they do tend to be significant. Surgical consultation should be requested early in the management of these particular burn injuries in children.     

Electricity and fishing - a dangerous mix

Background

The advent of fishing rods made of carbon fiber and graphite rods has greatly increased the risks of electrical injuries associated with fishing. The braided fishing lines and metal hooks put the fishermen at risk for electrical injuries.

Purpose

We review our burn center's experience with electrical injuries related to fishing activities during the last four years.

Patients and method

We retrospectively collected data on patients with electrical burns related to fishing activities between January 2006, when our burns unit was established, and December 2009. Eight patients with electrical burns were admitted during this period of time, five who sustained the injury while fishing, due to contact of the fishing rod with overhead high-voltage cables and three who were injured during illegal fishing, using electricity to stun the fish.

Results

The total burn surface area ranged from 0.5% to 70%. Three of the patients sustained fourth degree burns, while the rest had second and third degree burns. One patient underwent scapulohumeral disarticulation and an above-knee amputation. Two patients had fingers and toes amputated. Latissimus dorsi and anterolateral thigh flaps were used to cover the defects in two cases. Local flaps were employed in other two cases to cover the tissue defects. Two patients died.

Conclusion

Fishing-related burns and illegal fishing can lead to serious injuries and death.     

Comparable results of epidemiology of children with burns among different decades in a burn unit in JinZhou, China

Objective

The aim of this study was to compare the epidemiological results of children with burns among different decades from 1970 to 2008.

Methods

The clinical data of all children with burns younger than 14 years admitted between 1970 and 2008 were compared among different decades using Statistical Package for Social Sciences (SPSS).

Results

Of all patients with burns, children accounted for 28.6%, despite differences in different decades (18.7-31%). In all children with burns, greater than 80% were accounted by children with mild and moderate burns, and by scalds, in which greater than 80% was caused by hot water. The proportion of scald gradually increased from 60% in the 1970s to 88% in 21st century. The increase in the number in the infant group was the direct cause for the decline of the average age of children injured over time. The case fatality rate in all children with burns was 0.7%, despite significant differences in different decades.

Conclusion

Current prevention strategies should be aimed at the ‘susceptible group’, namely infants, scald injuries and hot water scald, in particular, according to the epidemiologic characteristics of this study. Prevention methods from government, mass media and schools to the family is a tremendous need for the further development of prevention of paediatric burns in the future.     

Health-Related Quality of Life Before and After a Solid Organ Transplantation (Kidney, Liver, and Lung) of Four Catalonia Hospitals

Introduction and Aims

It has been described that patients who receive a transplant display a better Health Related Quality of Life (HRQoL). Our objective was to describe the HRQoL before and after a solid organ transplantation, comparing results among various transplantations.

Methods

This HRQoL study using the SF-36 was implemented before as well as at 3 and 12 months posttransplantation. Posttransplantation were compared with pretransplantation scores as well as with the general population.

Results

One hundred sixty-two renal, 159 liver, and 58 lung candidates were included before transplantation, among whom there were 126 renal, 108 liver, and 22 lung recipients. The median age of all transplant recipients was 53 years with 68% men. The various transplant types began with different HRQoL: lung showed the worst, followed by the liver, and then renal. The scores of the SF-36 before and 3 months posttransplantation showed significant improvements, except for “Pair.” At 12 versus 3 months, mental health was somewhat better for renal, and almost all dimensions showed significant improvement for liver and lung patients. All subjects showed clear improvements after transplantation.

Conclusion

All patients showed clear improvements after transplantation when mental health was compared with the general population, particularly lung transplant recipients who expressed the greatest improvement. However, they still showed deficits in physical health.     

Psychiatric and psychosocial predictors of medical outcome after liver transplantation: a prospective, single-center study

Objective

Recognizing the potential impact of psychiatric and psychosocial factors on liver transplant patient outcomes is essential to apply special follow-up for more vulnerable patients. The aim of this article was to investigate the psychiatric and psychosocial factors predicted medical outcomes of liver transplanted patients.

Methods

We studied 150 consecutive transplant candidates, attending our outpatient transplantation clinic, including 84 who had been grafted 11 of whom died and 3 retransplanted.

Results

We observed that active coping was an important predictor of length of stay after liver transplantation. Neuroticism and social support were important predictors of mortality after liver transplantation.

Conclusion

It may be useful to identify patients with low scores for active coping and for social support and high scores for neuroticism to design special modes of follow-up to improve their medical outcomes.     

Transcranial magnetic stimulation can diagnose electrical burn-induced myelopathy

Introduction

We conducted motor- and sensory-evoked potential analyses and investigated their diagnostic value in differentiating between electrical burns without evidence of neurologic injury and those with clinical evidence of myelopathy.

Methods

We studied high-voltage electrical burn injury patients with lower extremity weakness and evidence of myelopathy and those without any evidence of neurological complications. Motor-evoked potentials (MEPs), somatosensory-evoked potentials (SEPs), and MRI studies of the spinal cord, as well as transcranial magnetic stimulations, were performed. The central motor conduction time (CMCT) was also calculated.

Results

The upper limb MEP and upper and lower limb SEP variables did not statistically differ between the 2 groups. The CMCT and total motor conduction time recorded in the lower limb were delayed in the burn myelopathy group. MRI revealed no abnormal signal changes in myelopathy patients.

Conclusion

Our study demonstrates that MEP is useful in identifying myelopathy in patients who have sustained high-voltage electrical burns.     

Early excision and skin grafting versus delayed skin grafting in deep hand burns (a randomised clinical controlled trial)

Introduction

Early excision and grafting (E&G) of burn wounds has been reported to decrease hospital stay, hospital costs and septic complications, and some purport reduced mortality while decreasing hospital costs.In today's practice, all burn wounds unlikely to achieve spontaneous closure within 3 weeks are excised and grafted. Early studies did not demonstrate dramatic differences in cosmetic or functional results. This is particularly true with burns of the face, hands and feet. In this study, early excision and skin grafting was compared with delayed skin grafting in deep hand burns.

Materials and methods

From September 2006 to February 2008, 50 patients with hand burns and average burn size less than 30% total body surface area (TBSA) deep second- and third-degree were randomly divided into early E&G group (group I) and delayed grafting group (group II).Gradual and careful limb and digit range of motion was started on about 10th-14th postoperative day. We used a questionnaire based on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire to evaluate final functional outcome. Further, hypertrophic scar formation, contracture and deformities were followed and managed accordingly.

Results

The most common site of involvement was the metacarpophalangeal (MCP) joint with frequency of 39% and 40% in groups I and II, respectively. There were no statistically significant differences between both groups regarding deformity severity, scar formation, sensation, major activities and overall satisfaction.

Discussion

In treating burns of the hand, the primary goal should always be to restore the functionality of the hand. Although early surgery shortens the healing time and lessens the hospital stay, our results did not show any significant difference between these two methods regarding the function, scar formation, daily activity limitation and overall satisfaction.     

Avoiding calvarial defects in a Harrison's class IV thermally injured skull

Introduction

Harrison's class IV calvarial burns with greater than 75% exposure present a special problem in flame injury. This problem is compounded in small children and or those with a large total body surface area burn, thus limiting the possibility of local flaps and free tissue transfers for coverage and leaving only wound care and skin grafts as options for closure. The literature suggests trephination with a high speed drill until viable bone is reached, then autografting the subsequent granulation tissue. In the most severe cases when the calvarium is deeply thermally injured and drilling down to the level of the Dura does not yield any sign of viability; should the surgeon proceed with removal of the clearly compromised calvarium down to Dura or leave it in place?

Methods

At a pediatric burn center, we reviewed all Harrison's class IV flame burns to the head with more than 75% exposure of the calvarium for a 2.5-year period. Five cases fit our inclusion criteria.

Results

All five patients had drilling of the calvarium to debride dead bone. Three of the children had drilling that reached viable bone and were treated with a combination of early grafting and allowing granulation tissue to form then grafting. Two of the patients had extreme flame burns to the head with large areas having no clinical evidence of viability down to the Dura. The photographic record and CT reconstructions of these two cases are presented. The figures show the progression of healing of the calvarium in each child. A persistent calvarial defect only in the area of complete removal of calvarium to Dura is seen in each child's record. The remaining areas demonstrate progressive wound closure with remodeling of the skull in long term follow-up.

Conclusion

In deep massive calvarial burns to the head it is difficult to achieve wound closure. Trepanation with subsequent grafting and expectant management while awaiting granulation tissue bed is the current recommended treatment for this clinical problem. The aggressiveness of surgical debridement of dead bone is largely based on clinical appearance of the tissue. In the cases presented here, complete removal of clinically non-viable burned calvarium resulted in calvarial defects that were avoided when some deep calvarium was left in place despite its poor clinical appearance. The clinical challenge of closing calvarial defects in the reconstructive phase of care should not be underestimated. Therefore, avoidance of a defect if possible by allowing some bone to remain during trephination is recommended.     

Relationships between the Quality of Life Questionnaire (QLQ) and the SF-36 among young adults burned as children

Objective

To examine the relationship between two measures that can be used to examine quality life among pediatric burn survivors.

Design

Prospective, correlational study.

Setting

Acute and rehabilitation pediatric burn care facility.

Participants

Eighty young adult survivors of pediatric burns, who were 18–28 years of age, with burns of 30% or greater, and were at least 2 years after burn.

Interventions

Not applicable.

Main outcome measures

The SF-36 and the Quality of Life Questionnaire (QLQ) were used to assess participant's self-reported general health and long-term adjustment.

Results

Significant correlations (p ≤ 0.001) were found between the total quality of life score of the QLQ and the mental component scale of the SF-36. However, no significant correlations were found between the total quality of life score of the QLQ and the SF-36 physical component scale.

Conclusions

Approximately 100,000 children are treated for burns annually, with a high percentage surviving, creating a challenge for health care professionals who need to prepare burn survivors with their psychosocial and physical well-being as adults. This study found that the SF-36 and QLQ are measuring somewhat different aspects of psychosocial and physical adjustment. It is recommended that both tools could be useful to the burn practitioner in assessing quality of life.     

A silver-impregnated antimicrobial dressing reduces hospital costs for pediatric burn patients

Purpose

Since using a novel silver-impregnated antimicrobial dressing (Aquacel Ag, ConvaTec, Princeton, NJ) in our pediatric patients with partial-thickness burns, hospital LOS has been significantly reduced. Here we investigated whether there was concomitant cost-effectiveness of this approach.

Methods

We retrospectively reviewed Burn Registry Data from a large Children's Hospital Burn Unit from January 2005 through August 2005 for inpatients with partial-thickness burns treated with Aquacel Ag. A comparison group was composed of patients from the same period the previous year treated with silver sulfadiazine cream (SSD, Par Pharmaceuticals, Woodcliff, NJ) and matched for age and %TBSA burned. Patients with inhalation injury or full-thickness burns were excluded. Intent-to-treat analysis was limited to patients with less than 22% TBSA burn. Direct costs and total charges were compared statistically after log transformation due to the skewedness of the data.

Results

Total charges and direct costs were significantly lower for Aquacel Ag-treated patients (n = 38) than for SSD-treated patients (n = 39) (P = .004 and P < .001, respectively). In addition, Aquacel Ag-treated patients had a shorter LOS than SSD-treated patients.

Discussion

These data strongly support our findings that the application of Aquacel Ag reduces hospital LOS which results in a significant cost savings in the care of pediatric patients with partial-thickness burns.     

Evaluation of long term health-related quality of life in extensive burns: a 12-year experience in a burn center

Objectives

We sought to evaluate the long term health-related quality of life (HRQOL) in patients survived severely extensive burn and identify their clinical predicting factors correlated with HRQOL.

Methods

A cross-sectional study was conducted in 20 patients survived more than 2 years with extensive burn involving ≥70% total body surface area (TBSA) between 1997 and 2009 in a burn center in Shanghai. Short Form-36 Medical Outcomes Survey (SF-36), Brief Version of Burn Specific Health Scale (BSHS-B) and Michigan Hand Outcome Questionnaire (MHQ) were used for the present evaluation. SF-36 scores were compared with a healthy Chinese population, and linear correlation analysis was performed to screen the clinical relating factors predicting physical and mental component summary (PCS and MCS) scores from SF-36.

Results

HRQOL scores from SF-36 were significantly lower in the domains of physical functioning, role limitations due to physical problems, pain, social functioning and role limitations due to emotional problems compared with population norms. Multiple linear regression analysis demonstrated that only return to work (RTW) predicted improved PCS. While age at injury, facial burns, skin grafting and length of hospital stay were correlated with MCS. Work, body image and heat sensitivity obtained the lowest BSHS-B scores in all 9 domains. Improvements of HRQOL could still be seen in BSHS-B scores in domains of simple abilities, hand function, work and affect even after a quite long interval between burns and testing. Hand function of extensive burn patients obtained relatively poor MHQ scores, especially in those without RTW.

Conclusions

Patients with extensive burns have a poorer quality of life compared with that of general population. Relatively poor physical and psychological problems still exist even after a long period. Meanwhile, a trend of gradual improvements was noted. This information will aid clinicians in decision-making of comprehensive systematic regimens for long term rehabilitation and psychosocial treatment.     

A prospective study of burns trauma in children in the University of Calabar Teaching Hospital, Calabar, south-south Nigeria

Background

Burns are among the most devastating injuries seen in the emergency units. The epidemiology varies from one part of the world to another. This communication is a 3-year report of burns in children in an attempt to provide information on the current epidemiology of burns in this centre.

Method

Children admitted into the University of Calabar Teaching Hospital, Calabar with burns were prospectively studied from February 2005 and January 2008.

Results

There were 56 patients (28 males and 28 females). The ages ranged from 9 days and 14 years (mean 3.5 years) and 19 (73.1%) were preschool children. There were 39 (69.6%) who sustained scald injuries while 17 (30.4%) suffered flame injuries. Twenty-six (46.4%) patients sustained burns with total burn surface area above 10%.

Conclusion

Education of the public on burns prevention based on the factors highlighted, establishment of burns support groups dedicated to publicity on prevention and provision of financial aid would sustain strategies when adopted.     

Thermal injury within the first 4 months of life

Aim

To determine the incidence, magnitude of injury, fluid management, role of surgery and outcome in newborns and infants under 4 months of age admitted to a Burns Unit.

Method

Retrospective analysis of patient records.

Results

86 patients under the age of 4 months were admitted over a 37 year period (0.34% of admissions). Their injuries were caused by hot water in 45 and fire in 38, primitive heating devices in 2 and non-accidental paraffin burn in 1. Twenty-eight sustained superficial partial thickness burns, 12 deep partial thickness and 46 full thickness injuries. The total body surface area ranged from 1 to 55% with an average of 11.5%. Bacterial contamination of the burn wounds was present on admission in 52.3% and consisted of both gram positive and gram negative organisms. The resuscitation formula of 3.5 ml/kg/% burn on the first day and 1.5 ml/kg/% burn on the second day plus maintenance fluid at 30-120 ml/kg/day was not always adequate in maintaining haemodynamic stability. Three surgical methods were employed in 59 patients (69%). These included early tangential excision in 25, excision with or without allograft and delayed grafting in 27, and conventional therapy with eventual grafting in 7 patients. Releasing escharotomies were required in 9 children. Nineteen children required amputations. Three craniectomies, 2 tracheostomies and 1 colostomy were additional procedures. The mortality was 9.3%. Three causes of death were identified: magnitude of injury, sepsis and inhalation injury.

Conclusion

Neonates and infants are very vulnerable and preventable environmental factors are often implicated. Fire and hot water are the most common causes resulting in significant physical trauma. Resuscitation especially during the first few days of life can be problematic. Wound infection and sepsis are common and surgery should be individualised. Long-term outcome is very satisfactory for those with small burns however those with larger burns may remain permanently disfigured.     

Early depth assessment of local burns by videomicroscopy: 24 h after injury is a critical time point

Purpose

Videomicroscopy has simple and prompt operability, and useful in the burn depth assessment in its early phase. A burn wound is, however, a dynamic environment in the first few days and the critical time to assess a burn wound by videomicroscopy has not been investigated. The aim of this study is to investigate the critical time point to assess the burn depth by videomicroscopy.

Methods

Forty one patients with 44 intermediate depth burns admitted within 7 days after injury were included. Accuracies were assessed by comparison with clinical outcome: healing within 21 days after injury or not with conservative treatment. We prospectively evaluated and compared the accuracy of the videomicroscopy measurements with the clinical assessments. All findings were serialized in order of time after injury and divided into three groups, and we compared the appreciation of burn depth by videomicroscopy findings among groups.

Results

The videomicroscopy measurements is significantly accurate compared with clinical assessments (p = 0.001). The accuracy of videomicroscopy measurements was significantly lower in the post-injury <24 h group compared with post-injury ≥24 h group (p = 0.004).

Conclusion

Videomicroscopy is effective tool in assessment of early burn depth and the critical time point to assess the burn depth by videomicroscopy is 24 h after injury.     

Optimization of burn referrals

Introduction

Correct estimation of the severity of burns is important to obtain the right treatment of the patient and to avoid over- and undertriage. In this study we aimed to assess how often the guidelines for referral of burn injured patients are met at the national burn centre (NBC), Denmark.

Methods

We included burn patients referred to the NBC in a three-months period. Patient records were systematically analyzed and compared with the national guidelines for referral of burn injured patients.

Results

A total of 97 burn injured patients were transferred for treatment at the NBC and the most common reason for referral was partial thickness burn exceeding 3% estimated area of burn (55% of the patients) while facial burns (32%) and inhalational injury (25%) were other common reasons. We found that 29 (30%) of the referrals were considered potentially unnecessary according to the guidelines. The overtriage was highest among patients suffering of burns due to scalding and these were mostly children below 2 years of age.

Conclusion

An overtriage of referred burn injured patient was found and 30% of the referred patients were treated as outpatients. A telemedicine solution may be useful in the evaluation of burn injured patients before transfer.