A retrospective analysis of 1083 Turkish patients with serious burns. Part 2: burn care, survival and mortality

Epidemiological investigations of burn patient series help practitioners to identify factors that affect patient survival. Our aim was to contribute to the body of knowledge in this area by determining how survival related to certain variables in burn cases. The records of 1083 burn patients who were hospitalised between August 1988 and the end of 1997 were retrospectively reviewed. Of this total, 363 (33.5%) died of burn complications, namely, multi-organ injury due to sepsis (47.1% of deaths), renal failure (44.6%), respiratory injury (5.8%) and gastrointestinal bleeding (2.5%). Mortality was higher in children/students, females, retired persons. Extent and depth of burn were important predictors of patient survival. Flame not only was the commonest burn cause but also carried the highest mortality risk. Most of the 1083 patients were referred to our hospital within 3 days of the injury. Deaths commonly occurred within 7 days. The mortality rate for patients who received medical therapy only was higher than that in the group that underwent both medical and surgical treatment (48.4 versus 10.0%, respectively). The study results highlighted various factors that are related to patient survival. These should be considered in the provision of optimal burn care. Training and experience are important elements in burn care and educational meetings should be held regularly for the staff of the burn unit.     

Bacteriological monitoring after burn injury

The most frequent and serious complication after burn injury is infection. Bacteriological monitoring of patients after burn injury is part of complex care. The algorithm of bacteriological checkups is set. Burned areas are microbiologically monitored by semi quantitative imprint method. Colonization is proportional to the length of patient's hospital stay. Resistance of the bacteria to antibiotics is usually higher in burn units than in other departments. That is why it is important to consider antibiotic treatment and strictly observe sensitivity by obtaining bacteriological results and current epidemiological situation. Burned patients are in danger of infection from the burned areas, respiratory tract, urinary tract and central venous catheters. Attending doctor should daily be in contact with the bacteriological laboratory.     

Burns

The treatment of burn wounds is subject to a defined management which can be divided into preclinical treatment, emergency room management, and the clinical phase. A decisive factor for the care of a burn patient is correct assessment of the extent of the burn injury. At the location of the accident, vital functions, i.v. catheters, fluid management, the decision for intubation, and sufficient pain control are crucial. The admission of patients to the emergency room should be subject to a standardized protocol, which is quickly and effectively performed by an interdisciplinary team. Emergency room management consists of a mechanical cleaning and subsequent accurate assessment of the extent of the burn injury, monitoring of vital functions, diagnosis and treatment of an inhalation injury as well as associated injuries, and the appropriate care of the burn wounds.     

Verbrennungen

The treatment of burn wounds is subject to a defined management which can be divided into preclinical treatment, emergency room management, and the clinical phase. A decisive factor for the care of a burn patient is correct assessment of the extent of the burn injury. At the location of the accident, vital functions, i.v. catheters, fluid management, the decision for intubation, and sufficient pain control are crucial. The admission of patients to the emergency room should be subject to a standardized protocol, which is quickly and effectively performed by an interdisciplinary team. Emergency room management consists of a mechanical cleaning and subsequent accurate assessment of the extent of the burn injury, monitoring of vital functions, diagnosis and treatment of an inhalation injury as well as associated injuries, and the appropriate care of the burn wounds.     

Burn prevention mechanisms and outcomes: pitfalls, failures and successes

Burns are responsible for significant mortality and morbidity worldwide and are among the most devastating of all injuries, with outcomes spanning the spectrum from physical impairments and disabilities to emotional and mental consequences. Management of burns and their sequelae even in well-equipped, modern burn units of advanced affluent societies remains demanding and extremely costly. Undoubtedly, in most low and middle income countries (LMICs) with limited resources and inaccessibility to sophisticated skills and technologies, the same standard of care is obviously not possible. Unfortunately, over 90% of fatal fire-related burns occur in developing or LMICs with South-East Asia alone accounting for over half of these fire-related deaths. If burn prevention is an essential part of any integrated burn management protocol anywhere, focusing on burn prevention in LMICs rather than treatment cannot be over-emphasized where it remains the major and probably the only available way of reducing the current state of morbidity and mortality. Like other injury mechanisms, the prevention of burns requires adequate knowledge of the epidemiological characteristics and associated risk factors, it is hence important to define clearly, the social, cultural and economic factors, which contribute to burn causation. While much has been accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs) such as the United States due to sustained research on the epidemiology and risk factors, the same cannot be said for many LMICs. Many health authorities, agencies, corporations and even medical personnel in LMICs consider injury prevention to have a much lower priority than disease prevention for understandable reasons. Consequently, burns prevention programmes fail to receive the government funding that they deserve. Prevention programmes need to be executed with patience, persistence, and precision, targeting high-risk groups. Depending on the population of the country, burns prevention could be a national programme. This can ensure sufficient funds are available and lead to proper coordination of district, regional, and tertiary care centres. It could also provide for compulsory reporting of all burn admissions to a central registry, and these data could be used to evaluate strategies and prevention programmes that should be directed at behavioural and environmental changes which can be easily adopted into lifestyle. Particularly in LMICs, the emphasis in burn prevention should be by advocating change from harmful cultural practices. This needs to be done with care and sensitivity. The present review is a summary of what has already been accomplished in terms of burn prevention highlighting some of the successes but above all the numerous pitfalls and failures. Recognizing these failures is the first step towards development of more effective burn prevention strategies particularly in LMICs in which burn injury remains endemic and associated with a high mortality rate. Burn prevention is not easy, but easy or not, we have no options; burns must be prevented.     

Inhalationstrauma, Kohlenmonoxid- und Cyanidintoxikation

Approximately 20-30% of patients with burn injuries also experience inhalation injury, which in addition to age and the extent of thermal body surface damage, is one of the main factors for increased mortality following burn injuries. The term inhalation damage does not describe a uniform set of symptoms and therefore a variety of mechanisms can be responsible for the damage to the respiratory tract. In addition to thermal and/or chemical damage of the lungs by inhalation of smoke and gases liberated by burning, there is also often a systemic inhalation intoxication by carbon monoxide (CO) and/or cyanide (CN). The diagnosis of inhalation injury is a clinical suspicion based on the accident mechanism and the clinical symptoms. At the scene self-protective measures must be taken. The indications for administration of oxygen should be generously applied and intubation and ventilation should be considered early on. Patients should be admitted to an experienced centre for the severely burned.     

How to study the aetiology of burn injury: the epidemiological approach

Effective prevention of burn injury should be based on sound aetiological knowledge. This article deals with epidemiological methods to study the incidence of burn injury as a function of its risk factors. Central methodological issues are comparability of baseline prognosis, comparability of measurements (of effects in cohort studies and of risk factors in case-control studies), and comparability of external circumstances. These principles are clarified with a number of fictitious examples of risk factors for burn injury. It is explained that in preventive trials comparability may be achieved by randomization, blinding and placebo intervention. The main tools in non-experimental studies are deliberate selection and multivariate analysis. Special attention is given to the definition of the source population and to reducing measurement incomparability in case-control studies. Some well-designed case-control studies following these principles might bring effective prevention of burn injury some steps nearer.     

Burn injuries in primary care in the Netherlands: Risk factors and trends

BackgroundResearch to date has mainly focused on burn injuries treated in secondary care. This study aims to provide knowledge on the epidemiology of burn injuries in primary care, to give directions for burn prevention.MethodsData were derived from routine electronic health records of general practices and their out-of-hours service organisations in the Netherlands that participated in the Nivel Primary Care Database 2010–2015. We studied risk factors and trends.ResultsThe average burn injury prevalence rate was 4.40 (95% CI 4.27–4.53) per 1000 person-years in daytime general practice care and 1.47 (95% CI 1.46–1.49) per 1000 inhabitants in out-of-hours care. Children of 0?4 years old, especially boys, and young adult women had a higher risk. Burn injury risk was higher during the summer months and around New Year’s Eve. Living in low socioeconomic and strongly urbanised neighbourhoods was associated with a higher risk of burn injury than living in other neighbourhoods.ConclusionDutch general practitioners have a large share in burn care and therefore can play a significant role in burn prevention. Prevention may be most effective in the summer and around New Year’s Eve, and specific attention seems to be warranted for low socioeconomic groups and strongly urbanised neighbourhoods.     

Specific aspects of the treatment of patients with multiple mechanical and burn injuries

Fewer than 5 percent of all burn patients sustain other traumatic injuries before, during, or immediately after their accident. Multiple traumas associated with a burn injury create special problems during the care of the thermally injured patients. Conversely, the burn injury often complicates the diagnosis and treatment of the trauma. The combination of mechanical and burn injuries can be divided into two types: a) any associated fracture located outside the burned area, or b) fractured bones within the burned area. This situation represents a critical factor which must be taken into account during treatment procedures. The following options should be considered: in fractures outside the burned area, there would be no difference in standard, skeletal treatment procedures. For the treatment of fractures in burned areas (mostly on the extremities), the optimal procedure is osteosynthesis within 48 hours of the burn trauma, when the burn wound is nearly sterile (without significant bacterial colonisation). We prefer two-team surgery. Firstly, a trauma surgeon performs osteosynthesis and, after that, burn surgeons treat the burns. The optimal approach in full-thickness burns would be necrectomy and autografting. This is, however, not always possible, because of the overall condition of the patient who has been continuously resuscitated during the shock period. All individual factors must be considered during the decision-making process.     

危重烧伤患者早期护理工作量影响因素分析

目的 寻找危重烧伤患者伤后早期护理工作量的影响因素,为危重烧伤病房护理人力配备提供借鉴.方法 统计136例危重烧伤患者伤后5 d的护理工作量,对其影响因素行逐步回归分析.结果 危重烧伤患者第1天护理工作量显著高于其后4 d(均P＜0.01);烧伤指数和头面烧伤是危重烧伤患者伤后早期护理工作量最重要的影响因素(均P＜0.01).结论 危重烧伤患者入院5 d内以第1天护理工作量最大,其后逐步递减;危重烧伤患者中烧伤指数高、头面烧伤者护理工作量大;护理管理者在配备护理人力时应予充分考虑.     

Prognostic scoring systems in burns: a review

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve.The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.     

Management of burn injury

Burns are a major cause of morbidity and mortality worldwide. Vulnerable people such as children, the frail and elderly, and the socially deprived are at particular risk. Most burns are caused by thermal injury to the skin, but electrical and chemical burns can be very severe. Fortunately, most burns are minor and superficial and can be managed by primary health care professionals. However, major and severe burns require in-hospital management from a team of surgeons and other specialists. Life-threatening conditions such as smoke inhalation airway damage and severe fluid loss should be addressed during the initial resuscitation. Prevention of further thermal damage by cooling is important along with prevention of secondary infection of burn injuries. A wide variety of dressings is available for the management of burns and expert nursing care is vital. Surgical intervention may be urgently required for fasciotomy or escharotomy in cases of compartment syndrome or circumferential burns, respectively. Debridement, skin grafting and reconstructive procedures will be required over the medium or long term for patients with severe or complex burns and should be planned with appropriate multidisciplinary expertize. The functional and psychological impact of major burn injury should not be underestimated.     

The scourge of burn contractures: Who will bell the cat?

IntroductionMajority of burn injuries occur in developing world. There have been many advances in burn care management. But this advance comes at a price of ever increasing burn sequel of scarring. Burn scar contractures, in spite of being preventable, continue to be a common reality in our world. This paper aims to evaluate the lacunae in burn care leading to formation of contractures, to evaluate common sites of contractures, practice of advising splintage and anti-deformity positioning.ProcedureThis retrospective observational study was conducted over a period of six years (January 2010–December 2015) at a tertiary Burn unit in Mumbai (India). The records of burn contracture patients were scrutinized to obtain the data regarding patient’s socio-demographic profile, details of burn injury, splinting and exercises advised and details of surgeries required. Data was tabulated and analysed.ResultsThere was a significantly lower prevalence of advice regarding splinting, mobilization exercises and pressure garments. The prevalence of early surgery was also found to be low.ConclusionsAttempt has been made to identify the factors affecting the prevalence of burn scar contractures. Authors recommend that efforts be made for improving the knowledge of the treating doctors. Also, efforts should be made to increase awareness of burn prevention and emergent management.     

Factors influencing the implementation of best practice in burn care in Western Australia

Aims and objectivesThe study aimed to determine the factors which influence clinician behaviour and adherence to best practice when clinicians provide the initial care for paediatric burn patients admitted to a burns unit.BackgroundOptimal initial care of burn patients influences morbidity and mortality. Non-burn specialist clinician adherence to best practice is influenced by previously unexplored factors.DesignGeneral inductive qualitative methods were used to explore factors which influenced clinicians providing acute pre-admission burn care for children in Western Australia.MethodsInterviews of nineteen clinicians using standardised open-ended questions based on the Gilbert Behaviour Engineering Model were used to collect data.ResultsThe main influencing factors identified were the telehealth service which supported practice, whilst IT issues provided challenges to clinicians.ConclusionTelehealth services support clinicians when providing burn care, however IT issues are an major barrier to both best practice and accessing the telehealth service and should be optimised to support clinical careImpact statementWhat does this paper contribute to the wider global community? It provides burn clinicians with an insight into the factors which facilitate optimal care for patients prior to transfer to burn units, as well as the barriers faced by non-burn specialist clinicians when patients initially present for care. Models of care which acknowledge these factors can help facilitate optimal patient care.     

Economic burden of burn injuries in the Netherlands: A 3 months follow-up study

IntroductionBurn care has rapidly improved in the past decades. However, healthcare innovations can be expensive, demanding careful choices on their implementation. Obtaining knowledge on the extent of the costs of burn injuries is an essential first step for economic evaluations within burn care. The objective of this study was to determine the economic burden of patients with burns admitted to a burn centre and to identify important cost categories until 3 months post-burn.Patients and methodsA prospective cohort study was conducted in the burn centre of Maasstad Hospital Rotterdam, the Netherlands, including all patients with acute burn related injuries from August 2011 until July 2012. Total costs were calculated from a societal perspective, until 3 months post injury. Subgroup analyses were performed to examine whether the mean total costs per patient differed by age, aetiology or percentage total body surface area (TBSA) burned.ResultsIn our population, with a mean burn size of 8%, mean total costs were €26,540 per patient varying from €742 to €235,557. Most important cost categories were burn centre days (62%), surgical interventions (5%) and work absence (20%). Flame burns were significantly more costly than other types of burns, adult patients were significantly more costly than children and adolescents and a higher percentage TBSA burned also corresponded to significantly higher costs.Discussion and conclusionMean total costs of burn care in the first 3 months post injury were estimated at €26,540 and depended on age, aetiology and TBSA. Mean total costs in our population probably apply to other high-income countries as well, although we should realise that patients with burn injuries are diverse and represent a broad range of total costs. To reduce costs of burn care, future intervention studies should focus on a timely wound healing, reducing length of stay and enabling an early return to work.     

Hospital-based,acute care within 30 days following discharge for acute burn injury

BackgroundWhile the acute management of burn injury has received substantial attention, patients may undergo additional hospital based, acute care following initial management. We conducted this study to quantify and describe patients’ full hospital based, acute care needs within 30 days following an acute burn injury.MethodsUsing Florida, Nebraska, and New York state inpatient and emergency department databases, we identified adult patients discharged for an acute burn injury from January 1, 2010-November 30, 2014. The primary outcome was the frequency of hospital based, acute care (ED visit or hospital admission) within 30 days of initial discharge. Multivariable logistic regression modeling was used to identify patient factors associated with more frequent hospital based, acute care in the overall population.ResultsThe final sample included 126,685 patients who sustained an acute burn injury and were initially managed through the ED (88.3%) or by hospital admission (11.7%). Overall, 16.5% of patients experienced at least one hospital based, acute care encounter within 30 days of discharge of their initial encounter. Most commonly, these were ED visits not undergoing hospital admission for wound care, ongoing burn care, or infectious complications. Patient-level factors associated with more frequent encounters included a history of opioid misuse or abuse (Adjusted Odds Ratio = 2.23, [95% Confidence Interval 2.01−2.47]), chronic obstructive pulmonary disease (AOR = 1.25, [1.12–1.38]), diabetes mellitus (AOR = 1.13, [1.04–1.23]), and mental health diagnoses (AOR = 1.22, [1.11–1.34]).ConclusionsHospital based, acute care encounters are common after initial burn management. Further efforts are needed to improve the transition to outpatient care.     

Pediatric burn contractures in low- and lower middle-income countries: A systematic review of causes and factors affecting outcome

In low- and lower middle-income countries (LMICs), timely access to primary care following thermal injury is challenging. Children with deep burns often fail to receive specialized burn care until months or years post-injury, thus suffering impairments from hypertrophic scarring or joint and soft tissue contractures. We aimed to examine the correlation between limited access to care following burn injury and long-term disability in children in LMICs and to identify specific factors affecting the occurrence of late burn complications. A systematic literature search was conducted to retrieve articles on pediatric burns in LMICs using Medline, Embase, the Cochrane Library, LILACS, Global Health, African Index Medicus, and others. Articles were assessed by two reviewers and reported in accordance with PRISMA guidelines. Of 2896 articles initially identified, 103 underwent full-text review and 14 met inclusion criteria. A total of 991 children who developed long-term burn sequelae were included. Time from injury to consultation ranged from a few months to 17 years. Factors associated with late complications included total body surface area burned, burn depth, low socio-economic status, limited infrastructure, perceived inability to pay, lack of awareness of surgical treatment, low level of maternal education, and time elapsed between burn injury and reconstructive surgery.     

Factors affecting fluid requirement on the first day after severe burn trauma

BACKGROUND: Parkland formula (PF) is the most often used schema for calculating intravenous resuscitation fluid requirement in burn patients. Some studies have reported that PF underestimates the fluid requirement in 45-63% of patients. The aim of this retrospective study was to analyse factors influencing first-day intravenous fluid replacement set for a targeted urinary output in severely burnt patients. METHODS: Data of 47 patients with burn injury affecting equal or more than 15% of body surface area were retrieved from the archived files. The local intensive care protocol rendered the infusion rate of lactated Ringer's solution to achieve a urinary output of 0.5-1.0 mL/kg per hour in the first 24 h after burn trauma. RESULTS: First-day i.v. infusion volume was significantly higher than PF preferred. In the first 24 h the hourly volume of intravenous fluid resuscitation per bodyweight per burnt surface area showed significant negative correlation to the burnt body surface area and body mass index, (r = -0.553, P < 0.001; r = -0.570, P < 0.001, respectively) no correlation was found to bodyweight, height or patient age. Patients having deep-burn injury required higher intravenous fluid resuscitation rate than patients having superficial injury only (P < 0.01). CONCLUSION: Our data suggest that fluid requirement is higher than predicted by PF if the extent of burn or body mass index is low and less if the extent of burn or body mass index is high. The presence of deep burn increases fluid requirement.     

The incidence of toxic shock syndrome due to nosocomial methicillin-resistant Staphylococcus aureus infection in burn patients: A four-year retrospective cohort study

Among adult and pediatric patients, concern is growing in regard to toxic shock syndrome (TSS) resulting from methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infection. We investigated the incidence and characteristics of this form of TSS in patients with burn injury who were admitted to our burn care units from January 2008 to December 2011. Of the 244 patients with nosocomial MRSA infection admitted during the study period, TSS occurred in 20 (8.2%) patients whose average age was 42.9 years, average total burn surface area (TBSA) was 31.7%, and average day of TSS appearance was 9.5 days after injury. There were no particular characteristics associated with age, TBSA or day of TSS appearance in these patients. All but 1 patient recovered from TSS within an average of 9.4 days. The incidence of TSS due to nosocomial MRSA infection in these burn patients was higher than expected. TSS due to nosocomial MRSA infection should be considered in burn care.