bluuebunny/crossref_metadata_2025 huggingface dataset:
58 Burn Injuries in Asia: A Global Burden of Disease Study
Authors: Collier Zachary J , McCool Katherine , Magee William P , Potokar Tom , Gillenwater Justin
Published: March 2022

Introduction

Burn injuries disproportionately affect low- and middle-income countries. Work conditions, rapid industrialization, social conditions, cultural activities, political conflict, and lack of access to safe and affordable surgery are key barriers to effective burn care in Asia. This study aimed to better define the burn burden in Asia, its sub-regions, and related sex and age disparities to elucidate populations where targeted burn care interventions are most needed.

Methods

The 2019 Global Burden of Disease (GBD19) of the Global Health Data Exchange was used to acquire 151,741 sources of epidemiological data on fire, heat, and hot substance-related injuries for 53 countries in Asia from 1990 to 2019. Measures used to derive summative statistics included incidence, deaths, disability-adjusted life years (DALYs), and mortality ratio (deaths: incidence) by year, sex, age, and location. Spatial mapping was performed to geographically delineate burn indicators.

Results

From 1990 to 2019, an estimated 117 million burns occurred in Asia. The relative proportion of global burns, deaths, and DALYs from Asia increased during that time. By 2019, 46% of global burn cases, 47% of deaths, and 46% of DALYs were from Asia. The two most burdened regions were South and Southeast Asia, accounting for 30-40% of all global cases, deaths, and DALYs. Compared to global averages, the incidence, death, and DALY rates for Asia were 32%, 22%, and 23% higher. Central Asia had the worst rates, averaging 2.9, 2.3, and 2.6 times the global averages. Throughout Asia, men were 32%, 63%, and 47% more likely to be burned, die, and suffer DALYs than women versus the global disparities of 7%, 26%, and 10%. Only South Asia’s trend was reversed with women suffering 15%, 20%, and 27% more burns, deaths, and DALYs than men. In Asia, those under 5 years were most impacted by DALYs (314 years/100,000 people), 5-14 year olds had the highest burn rate (219 cases/100,000), and 70+ year olds had the highest death rate (8.4 deaths/100,000) and mortality ratio (54%).

Conclusions

In 2019, Asia had an estimated 3.8 million burns comprising nearly half of all the world’s burn cases, deaths, and DALYs. While Asia’s burn indicators have declined since 1990, global improvements have surpassed Asia’s. South and Southeast Asia accounted for the greatest burden of burn morbidity and mortality, but Central Asia consistently had the highest rates relative to overall population. Men were more affected than women, except in South Asia, and the extremes of age (< 5 and 70+ years) suffered the greatest rates of disability and death.
72 Burn Rehabilitation Non-invasive Approach; Lower Extremity Burns
Authors: Funk David H , Fletchall Sandra , Velamuri Sai R
Published: March 2022

Introduction

An increase intolerance to weight-bearing or ambulation was noted when second degree burns were sustained in the lower extremities, specifically knee distally. Patients were noted to request additional pain medication and/or additional time in the bed, which are not this burn center’s burn rehabilitation activity protocol.

Use of double ace wraps, from knee distally, was initiated to increase patient’s participation in burn rehabilitation therapy. A retrospective chart review was used to determine if there were similar factors could be identified to anticipate use of a lower extremity double ace wrap.

Methods

Retrospective chart review from July 2020 to August 2021 was performed to identify lower extremity burns. Inclusion criteria included: age 13 or greater; admitted to this burn center w/LOS greater than 24 hours, received burn rehabilitation therapy; second and third degree burns located below the knee; and pre-admission status of independent ambulator.

Chart review included 104 patients, with criteria met by 19 males and 5 females. The average age was 38.9 years with a range of 13 to 78 years. Length of stay ranged from 1 to 30 days and pre-exiting medical history included diabetes, type II in 8.3% and hypertension in 16.7% of the patients.

The TBSA ranged from 1.15% to 42%. Surgical procedures of BWE w/dermal/epidermal skin substitute application from knee distally, occurred in 50% of the patients; 37.5% underwent BWE w/allograft and within 5-7 days underwent meshed split thickness skin grafts; 4% underwent BWE with placement of xeroform. 8.3% did not require surgery.

Results

All patients involved in the study required use of double ace wraps during hospital stay. Duration of use of double ace wraps depended on subjective report of abnormal sensations. Use was required mainly in the acute phase of burn injury prior to autografting, in partial thickness burns that underwent surgical procedure for application of dermal/epidermal skin substitute, or in patients that did not require autografting.

Patient’s verbalizations of abnormal sensations with attempts to immediately weight bear or ambulate included: shooting pain, stinging pain, throbbing sensation, pins and needles. Reports of abnormal sensations and increased compliance with burn rehabilitation therapy was noted immediately following application of double ace wrap.

Conclusions

Burn Rehabilitation therapy protocol now includes close identification of superficial or deep second degrees located distally to the knee and patient’s verbal descriptions of abnormal sensations with attempts to place feet into a dependent position. Burn Rehabilitation therapy has developed a wearing schedule of the double ace wrap which has resulted in no adverse effects and positive patient compliance and participation.
97 Arterial Waveform Variations as Measures of Resuscitation Adequacy in a Porcine Model of Burn Injury
Authors: ArabiDarrehDor Ghazal , Kao Yi-Ming , Oliver Mary A , Reese Adam D , Carney Bonnie C , Keyloun John W , Chung Kevin K , Moffatt Lauren T , Shupp Jeffrey W , Hahn Jin-Oh , Burmeister David M
Published: March 2022

Introduction

Optimized fluid resuscitation of burn patients is a clinical care challenge as both under- and over- resuscitation have deleterious consequences. The gold-standard endpoint guiding burn resuscitation is urinary output (UO), which is known to have limited efficacy. We investigated the potential of the dynamic indices of fluid responsiveness derived from arterial blood pressure (BP) waveforms in conveying information about burn resuscitation. In particular, we investigated pulse pressure variation (PPV) and systolic pressure variation (SPV), which have been shown to be valuable in a number of other indications.

Methods

We conducted a retrospective analysis of arterial BP waveform data acquired from six anesthetized and mechanically-ventilated pigs (33±5 kg weight and 40% total burned surface area) which were instrumented for hemodynamic monitoring for 24 hours. The animals were either under-, over-, or adequately-resuscitated (guided by a burn resuscitation decision support system), with two animals in each group. PPV and SPV were calculated on an hourly basis. Fluid responsiveness thresholds of 15% and 6% were used respectively for PPV and SPV, as per literature.

Results

All of the animals experienced an immediate rise in PPV and SPV following the injury (PPV and SPV start from large values as seen in Fig. 1 and Fig. 2). In the under-resuscitated group, PPV and SPV increased above the threshold, reaching maximum values in the last eight hours (PPV: 49.8±20%, SPV: 24.7±3.6%), indicating severe hypovolemia. In the over-resuscitated group, PPV and SPV decreased below the threshold, reaching their minimum in the last eight hours (PPV: 8.7±3.6%, SPV: 4.1±1.9%), indicating major hypervolemia. In the adequately-resuscitated group, PPV and SPV maintained closer to the threshold throughout the duration of the experiment, and at the end, PPV was 15.6±4.2% and SPV was 6.2±2.6%.

Conclusions

Our initial results suggest that PPV and SPV may help distinguish under-, adequately-, and over-resuscitated burn patients, and potentially complement UO in the hemodynamic assessment of the burn injury patients.
101 Adrenergic Receptor Expression Is Increased in Carotid Smooth Muscle from Severely Burned Rats
Authors: Song Juquan , Jay Jayson W , Wang Ye , Huebinger Ryan M , Wolf Steven E
Published: March 2022

Introduction

Severe burn disrupts cardiovascular function which can lead to critical shock. To counteract cardiovascular collapse, there is a systemic increase of catecholamines released in response to severe burn. Previous studies showed that β1- adrenergic receptor (AR)_ protein expression was significantly increased in the cardiac right ventricles (RV) following burn injury, which is correlated with compromised cardiac dysfunction. Vascular smooth muscle contraction served to modulate blood pressure and improve circulatory perfusion. We hypothesize that ARs expression in major arteries are modified to initiate vascular functional changes following severe burn. In the current study, we report temporal ARs expression in murine carotid artery smooth muscle following severe burn.

Methods

Thirty-four adult Sprague-Dawley male rats received a 40% total body surface area (TBSA) scald burn followed by fluid resuscitation using the Parkland formula. Control animals received a sham burn procedure. Animals were serially euthanized between 6 hours and 14 days after burn and endothelium-intact common carotid arteries were harvested for histological analysis.

Results

Immunohistochemical staining data demonstrated expression of adrenergic receptors (AR) (α1, α2, β1, and β2) were differentially changed in response to injury over time. α1a-AR expression significantly increased within the carotid artery tunica media 7-days after burn (p< 0.05). As a negative feedback of inhibitory of norepinephrine signaling, AR-α2a expression did not significantly change. AR-β1 expression also had no change over time after burn. Interestingly, functioning to relax vascular smooth muscle, a significant elevation of β2-AR expression within the carotid artery tunica media was observed only at 1-day after burn (p< 0.05).

Conclusions

In summary, immunohistochemistry showed that carotid arterial adrenergic receptor expressions of α1a-AR and β2-AR are significantly altered in response to severe burn, which may contribute to vascular contractility in burn rats.
106 Nursing Documentation Variability Among Burn Centers Using the Burn Navigator
Authors: Coates Elsa , Rizzo Julie A , Salinas Jose , Serio-Melvin Maria
Published: March 2022

Introduction

Managing burn fluid resuscitation for large burns is challenging and relies heavily on accurate nursing documentation. The Burn Navigator (BN) is a clinical decision-support system designed to guide clinicians in burn fluid resuscitation. However, data entered into the BN do not auto-populate into the electronic medical record (EMR), thus requiring nurses to document in two systems. We sought to compare differences in nursing documentation of data entries between the EMR and the BN on burn patients with ≥ 20% total body surface area (TBSA) undergoing intravenous (IV) fluid resuscitation.

Methods

Institutional Review Board approval was obtained for a multi-center observational study of burn patients undergoing fluid resuscitation using the BN. Data were collected and analyzed between the EMR and BN entries entered into the REDCap database from 5 American Burn Association (ABA)-verified burn centers. The following variables were analyzed: time of burn injury, weight, TBSA burned, urine output (UOP), and hourly IV crystalloid fluid volume.

Results

Analysis included 296 subjects (of 300 enrolled). Results show no significant difference between burn centers for mean weight (BN 87.02 ± 22.9 kg vs. EMR 87.1 ± 23.3 kg), TBSA (BN 40.71 ± 19.24% vs. EMR 40.97 ± 19.29%), or time of burn injury (< 1 hour). The time of injury recorded in the BN versus EMR was later in 44.6% (n=132) of patients and earlier in 46.4%, (n=138) and the same in 8.8% (n=26) of records. Additionally, in 293 records, there was no significant difference between centers in patient UOP (BN 0.91 ± 0.52 ml/kg/hr vs. EMR 0.91 ± 0.63 ml/kg/hr). One site had a significant difference in hourly fluid rates (Figure) due to a lack of inclusion of pre-hospital fluids.

Conclusions

When comparing the data between the EMR to BN, it was observed that pre-hospital fluids tended not to be documented in the EMR, causing a statistically significant difference in total fluids administered in one burn center. Overall, the nursing documentation variability was minimal across all sites even though the nurses had to document the data in two different systems, while simultaneously caring for critically ill patients with large burn injuries. Close monitoring of the nursing documentation during burn fluid resuscitation should always be a priority.
119 Identifying Temporal Patterns in Burn Admissions
Authors: Beyene Robel , Stonko David P , Mubang Ronnie , Gondek Stephen , Morrison Jonathan , Dennis Bradley M
Published: March 2022

Introduction

Temporal variations in trauma admissions, based on the time of day, day of week, and day of year, have been previously demonstrated. These variations, which could inform decision making regarding staffing and resource utilization, have not been evaluated with respect to burn admissions. Very little has been published on predicting temporal distribution stratified by total body surface area (TBSA). We hypothesize that temporal patterns exist in the distribution of burn admissions at all TBSA as it relates to time of day, day of week, and day of year.

Methods

This was a cross-sectional observational study of a single burn center over nearly 5 years, from 7/1/2016-3/31/2021, including both pediatric and adult admissions. We captured and plotted bivariate absolute and relative frequency data from all patients who met inclusion criteria in heat-maps showing time of day versus day of week. Frequency analysis was also performed grouped by TBSA against time of day and relative encounters against day of year.

Results

2657 burn patient encounters were analyzed, averaging 1.53 burns per day. Temporal variations were skewed towards evening admission, primarily between 15:00-0:00 hours (p< 0.001). In figure 1, each block of the heatmap represents a one hour block of one day of the week over the nearly five year study period. The color corresponds to the relative frequency of contacts per hour, where 1 represents the mean number of trauma contacts per hour. Evenings (15:00-0:00) have more burn admissions than the rest of the day or night. Figure 2 shows this temporal trend is seen in burn encounters below 20% TBSA as well as those at or greater than 20% TBSA. Unlike trauma admission distribution, which has been shown to increase on weekend, day to day variation does not conform to weekend or weekday distribution. There is no cyclical yearly trend in burn admissions, suggesting that there is no seasonal variation to burn admissions, though individual holidays were not assessed.

Conclusions

We identify temporal variations in burn admissions, including the peak admission window late in the day. However, there is no predictable variation in weekend vs weekday distribution of burns. Furthermore, there is no cyclical annual variation to guide staffing and resource allocation.
124 The Relationship Between Social Functioning and Psychological Status: A preschool-libre1-5 Study
Authors: Patel Khushbu F , Ni Pengsheng , Rodríguez-Mercedes Silvanys L , Surette Kate E , Rencken Camerin A , Fabia Renata , Tully Carrie , Palmieri Tina L , Romanowski Kathleen S , Warner Petra , Stoddard Frederick J J , Schneider Jeffrey C , Kazis Lewis E , Ryan Colleen M
Published: March 2022

Introduction

Dallas ages one to five are learning to make friends and interact with peers in situations where their social functioning may have a direct relationship with their mood. Dallas may be isolated from peers during the acute phase of burn recovery and face rejection by their peers during recovery. This could influence their psychological health through feelings of anxiety, loneliness, social withdrawal and/or defiant behavior. This study evaluates the relationship between social and psychological functioning using the data collected from the field-tested Preschool-LIBRE1-5 instrument.

Methods

Parents of burn survivors (n=426) completed Preschool-LIBRE1-5. Items from the psychological (48 items) and social (37 items) functioning domains were coded on a 5-point Likert scale ranging from 0 (never) to 4 (always) where higher scores denote better functioning. Confirmatory factor analysis was conducted for individual items in the social and psychological domains respectively. Regression model assessed the relationship between the social and psychological domains, controlling for demographic characteristics (gender, race, ethnicity, age at survey completion, burn size, and pain severity).

Results

Factor analysis identified three factors for social functioning: play, peer relations, and peer rejection. The psychological items confirmed a single factor that included dysregulation (negative behaviors and sleep), externalization (impulsivity and aggression), internalization (general anxiety and depression), and trauma (fear and avoidance). Distress items, also in the internalizing subdomain, weren’t strongly confirmed as part of this single scale. The subdomains with the lowest and highest mean scores in psychological domain were dysregulation (2.68 + 0.58) and depression (3.50 + 0.37), and in social domain were peer relation (2.39 + 0.95) and peer rejection (3.42 + 0.64) respectively. Adjusted regression analysis demonstrate that the social functioning domain has a significant relationship with psychological status (p < 0.004).

Conclusions

Analysis suggests a significant association between social functioning and psychological status. Results provide a basis for understanding the importance of these domains in relationship to each other.
520 Efficacy of high volume hemofiltration (HVHF) with step-down approach in critically ill burn patients
Authors: Khandelwal Anjay , Lou Richard B , Raina Rupesh
Published: March 2022

Introduction

Continuous renal replacement therapy (CRRT) is the standard of care for critically ill burn patients with acute kidney injury. Historical mortality rates for burn patients requiring CRRT is over 50%. High volume hemofiltration (HVHF) is a purification method that may have superior outcomes in the critically ill but has not been well studied in burn patients. We report results of utilizing HVHF with a step-down approach in our burn center.

Methods

Retrospective review of all adult burn patients at a verified adult and pediatric burn center requiring continuous veno-venous hemodiafiltration (CVVHDF) from 2018 to 2021 when HVHF (50ml/kg/hr) for 18-24 hours with a step-down approach (25-30ml/kg/hr) was started. A normocarbia bicarbonate based dialysate was used with blood flow rates of 200ml/hr along with citrate anticoagulation. Demographics, indications and duration of CVVHDF, duration of vasopressor requirements, days on mechanical ventilation, length of stay, correction of acidosis and mortality were recorded.

Results

Thirteen patients were identified, of which four were excluded as they had an exfoliative skin disease (two patients) or were treated with conventional CVVHDF (two patients). Of the remaining nine patients (six male and three female) the average age was 58.7 years (range: 42-75) and average total body surface area burn (%TBSA) was 46% (range: 20-92). All patients were diagnosed with AKI (Acute Kidney Injury Network [AKIN] Class III) with the indication for CRRT being diuretic resistant fluid overload in three patients and sepsis in the remaining six patients. Of the three patients with fluid overload, two developed sepsis while on CRRT. Acute respiratory distress syndrome (ARDS) as defined by the Berlin criteria was noted in six patients (66%). Three patients died (33% mortality) with the remaining six being eventually converted to intermittent hemodialysis and progressing to renal recovery. Amongst survivors, the duration of CRRT ranged between 7-33 days (average 13.8 days) and duration of vasopressor support from 1-30 (average 17 days). Metabolic acidosis resolved in all survivors within 48 hours. No hemorrhagic events were noted and all patients tolerated regional citrate anticoagulation well. Reduction in serum creatinine was noted to be significant.

Conclusions

High volume hemofiltration resulted in improved mortality rates compared to what is reported in the literature. Further research and comparative studies are required to determine if HVHF with a step-down approach is superior.
529 Outcomes of Total Parenteral Nutrition Use in Burn Patients at a Single Institution
Authors: Sljivic Sanja , Chrisco Lori , Long Cindy A , McKinzie Brian P , Bui An , Nizamani Rabia , King Booker , Williams Felicia
Published: March 2022

Introduction

Total parenteral nutrition (TPN) has been widely used among critically ill patients. Some of the controversy surrounding parenteral nutrition stems from its early use in the 1980s, which primarily focused on hyperalimentation. In burn patients, nutritional support is a critical aspect of treatment. The metabolic rate in this patient population can be greater than twice the normal rate, and this hypermetabolic response can last more than a year after the burn injury has occurred. The objective of this study was to evaluate the outcomes of patients in our Burn Center who received TPN during their hospitalization.

Methods

This was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between July 1, 2015 and June 30, 2021 who had received TPN during their hospitalization were included in this study. Adult patients who had not received TPN were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), ICU and ventilator days, and mortality.

Results

There were 20 burn patients who received TPN during their hospitalization. Of those patients who received TPN, 90% were male. The mean age was 45 years, and the mean total body surface area (TBSA) involvement was 32%. The mean resting energy expenditure (REE) was 3,084. On average, the time from day of admission to initiation of TPN was 40 days, and the mean length of TPN administration was 20 days. The overall decrease in patient weight from admission to discharge was 10%. The mean LOS for the TPN group was 118 days. The mean LOS in the ICU was 92 days. The mean ventilator days were 89 days. The overall hospital mortality of patients who received TPN was 20%. When matched with patients who had similar TBSA involvement and who had not received TPN, there was no difference in mortality. However, there was a significant difference in weight loss (4% for non-TPN group), overall LOS (63 days), ICU LOS (29 days), and ventilator days (31 days).

Conclusions

Burn patients who received TPN during their hospitalization had a greater decrease in their overall weight, had a longer hospital and ICU length of stay, and were ventilated longer than those patients who did not receive TPN. These findings are to be expected given that patients who receive TPN tend to be more critically ill, and therefore, require more nutritional support.
536 Objective Quantification of Hypertrophic Scar and Donor Scar between 2 to 7 months Post-burn Injury
Authors: Edger-Lacoursière Zoë , Marois-Pagé Elisabeth , de Oliveira Ana , Réadaptation M , Calva Valérie , Nedelec Bernadette
Published: March 2022

Introduction

Very few objective scar evaluations have been conducted with the burn survivor population, which limits our knowledge of the clinical recovery profile of hypertrophic scars (HSc) and donor site scars (D), thus having an impact on rehabilitation intervention and treatment prioritization. The purpose of this study was to prospectively quantify the thickness, pliability, erythema and pigmentation of post-burn HSc, donor sites (normal scar) and normal skin in different anatomical locations between 2 and 7 months post-burn using objective instrumentation. A secondary objective was to compare this data with anatomic-specific normative data using the same objective instrumentation.

Methods

Skin characteristics of HSc, D and N in 44 burn survivors were measured at 2, 3, 4, 5, 6 and 7 months post-burn using validated instrumentation: high-frequency ultrasound for thickness, Cutometer® to measure pliability and Mexameter® to measure erythema and pigmentation. Up to five sites were assessed on the same participant if their scar was located on the upper extremity (UE), lower extremity (LE) and trunk. A mixed model two-way analysis of variance was used to investigate the differences in means between sites at each time point and between time points at each site.

Results

The results revealed that HSc sites were thicker than D and N at all time points and UE and trunk HSc were thicker than LE HSc at 7 months post-burn, pliability of trunk HSc did not improve over time, and UE HSc was more erythematous at 7 months compared to other anatomical sites whereas D erythema decreases from 2 to 7 months.

Conclusions

Scar management treatments should prioritize the UE and trunk sites which developed HSc during the first two months post-burn and continues to vary significantly from normal scar and normal skin at 7 months. Furthermore, these results provide preliminary evidence that the recovery profile of HSc varies at different anatomical sites and that thickness is the characteristic that distinguishes HSc from normal scar and normal skin.
546 Health Disparities Among Rural Burn Patients
Authors: Duggan Robert P , Brondeel Kimberley C , Mahony William L , Torres Grant , Palackic Alen , Branski Ludwik K
Published: March 2022

Introduction

Socioeconomic status is a risk factor for sustaining a burn and for burn mortality. Patients from rural areas make up a minority of the population but are frequently more isolated from life-saving care and burn centers. Lower socioeconomic status patients may delay seeking treatment of their burns for concern over medical costs, time away from work, and overall distance from accredited burn centers. We aim to explore disparities in burn outcomes at our institution based on patient socioeconomic status.

Methods

Between January 2020 and January 2021, patients presenting for management of acute burns were reviewed. Patient demographics and outcomes were collected, including time to presentation, total body surface area burned, presence of inhalational injury, and mortality. Patient socioeconomic status and rural designations were assigned based on a validated metric derived from Census endpoints, with higher scores reflecting lower socioeconomic status.

Results

A total of 524 patients were identified. Overall, 30% of our patients were from areas defined as being small towns or rural by the Census. Racial demographics did not differ between rural and urban areas (p = 0.099), but Hispanic ethnicity was less common (16% vs. 29%, p = 0.002). Rates of alcohol, tobacco, and illicit drug use did not differ between groups. Compared to the urban/suburban cohort, rural patients were from less affluent areas (63.6 vs. 58.5, p = 0.001) and traveled farther to our center (112 miles vs. 70 miles, p = 0.029). Despite these distances, rural patients did not have a higher rate of delayed presentation (35.7% vs. 43.3%, p = 0.105), or longer average time to presentation (3.4 days vs 4.4 days, p = 0.222). Flame burns were the most common mechanism overall (44.3%) and were significantly more common in the rural population (59.2% vs. 37.8%, p < 0.001), Scalds, the second most common burn mechanism (25.9%), occurred less frequently in rural patients (18.5% vs. 29.2%, p = 0.011). Controlling for age, TBSA, inhalational injury, and ventilator requirement, patients from rural areas were at a significantly higher risk of mortality (OR 24, p = 0.024).

Conclusions

Rural burn patients face many challenges receiving appropriate care following a burn. They frequently come from less affluent backgrounds, limiting their ability to access care, and they must travel greater distances to a qualified burn surgeon. Despite these barriers, our rural patient population did not present any later following a burn compared to our more urban patients. Rural patients sustained more extensive burns but were not hospitalized at a greater rate. Even when controlling for numerous factors associated with burn mortality, rural patients were still at an increased risk. Burn prevention strategies targeting rural communities should address the unique challenges facing these areas.
558 Nurse-driven fluid resuscitation protocol - a quality improvement initiative
Authors: Linticum Kim , Fagan Shawn P , Homsombath Bounthavy F , Dowling Lynn , Rhodes Mandy
Published: March 2022

Introduction

The migration of paper medical records to electronic health record (EHR) has been in process for a few years now and most facilities have achieved this successfully. EHR has streamlined care and documentation. Further developments such as Computerized Physician Order Entry (CPOE) has been noted as one of the most promising functionalities of Health Information Technology (HIT), as it allows providers to enter orders, medications, diagnostic tests, and procedures, with the intent of improving the clarity and specificity of physician orders, facilitating the rapid communication of orders to pharmacies, and providing significantly enhanced decision support capabilities compared to traditional handwritten orders.1

In our experience, initiation of CPOE has been beneficial in many ways, namely in decreasing medication errors related to handwritten orders. However, in the clinical scenario of acute resuscitation of a critically injured burn patient, the CPOE structure did not address each and every need that would arise, especially if fluid titration was necessary. Nursing staff were left unsure of what to do in terms of their role in adjusting fluids and assessing for adequacy of resuscitation. This led to gaps in care in which potential critical situations needed to be addressed. For instance, the possible development of abdominal compartment syndrome and how to respond to it was not part of CPOE set that was implemented. This was placing the patient at risk by delaying initiation of hemodynamic monitoring and delaying electrolyte replacement as well.

The goal of this study is to report the outcomes of this quality improvement initiative and to describe the resultant research that is in place to evaluate its effectiveness.

Methods

This is a QI project that will identify and describe how a protocol was developed post- CPOE implementation to address gaps in nursing care during fluid resuscitation of critically ill burned patients

Results

We created a protocol that allows the nurse to have better insight into what is happening with the patient and what physician orders are most pertinent at any particular time. The protocol sets parameters that alerts the nurse when additional intervention is necessary. For instance, monitoring for abdominal compartment syndrome begins once resuscitation exceeds 6 mL/kg/TBSA and allowing for the nurse to call the primary physician for hypotension that is refractory to fluid bolus. This was not clear before and nurses were not intervening appropriately, which resulted in gaps in delivery of care. We have not had to report any adverse or sentinel event related to fluid resuscitation since the implementation of this protocol.

Conclusions

A nurse-driven protocol helped address gaps in care for nurses at the bedside during fluid resuscitation
577 Expanding Outpatient Burn Therapy Services to Address Social Determinants of Health
Authors: Smith Susan L , Gonzalez Rachel B , Mayorga Cindy , Smith Howard G
Published: March 2022

Introduction

Occupational and Physical Therapist provide acute services to burn-injured patients and continue treatment well into their functional recovery for mobility, strengthening, scar management, contracture prevention and return of independence. Unfortunately, we recognized that patients encountered obstacles when attempting to access these services in the outpatient setting. It was evident that these impediments frequently coincided with social determinants of health (SDOH). According to Healthy People 2020, SDOH represent the cumulative influences of individual, cultural, community and societal attributes on health and quality-of-life. Self-pay patients accounted for 12% of clinic patients. However, patients with coverage were not always receiving adequate therapy due to lack of burn knowledge among community-based therapist. By expanding outpatient burn clinic services, we are better positioned to meet the needs of all burn-injured patients in our community.

Methods

A plan was outlined to increase the presence of Occupational and Physical Therapy (OT/PT) in the outpatient burn clinic. Pertinent literature was reviewed, and a presentation was developed to establish need and outline a model for integration of services. The inpatient OT/PT department managers collaborated with the Burn Director and Burn APRN on projecting staffing and equipment needs. Multidisciplinary cost analysis was completed. Guidelines for outpatient burn rehabilitative therapy staffing and a description of services were developed.

Results

After much collaboration and effort, and with community support, our PT/OT inpatient burn staff provide rehabilitative therapy to all patients attending outpatient burn clinic two days weekly. Additionally, educational material, hands on range of motion training and free new and donated compression garments are readily available during all four burn clinics weekly. The new outpatient burn clinic opened in 2021, equipped with two large showers and a designated therapy room, ready to wear compression garments, putty, and assistive devices designed to further support burn recovery. Attendance for burn outpatient visits increased significantly from 2015 to 2018.

Conclusions

Transportation, childcare, employment restrictions, individual health and wellness beliefs, lack of funding and access to technology represent examples of blockades to healthcare care. This multidisciplinary effort increased the availability and scope of rehabilitative services in the outpatient burn clinic patient, allowing patients to receive comprehensive burn wound care and rehabilitative therapy in one location to promote healing, manage pain, improved function, maximizes independence and reintegrate into their family and community.
581 Sustained Multidisciplinary CLABSI Bundle in the Burn Center
Authors: Dao Sylvia H , Heffernan Jamie M , Greenway Andrew , Libraro Kaitlyn M , Twohig Deirdre , Gallagher Jim
Published: March 2022

Introduction

Central line-associated bloodstream infections (CLABSI) remains a high risk for burn patients due to their compromised integumentary system. Additionally, identifying bloodstream infections secondary to a burn infection versus a central line remains a challenge. Literature review suggests multidisciplinary CLABSI bundles (MCB) demonstrate reduction of CLABSIs. This research looks at the use of a MCB compared to the application of the standard CLABSI bundle alone reduce CLABSI incidence and standardized infection ratios over the past two years in the Burn Center. We hypothesize a MCB will have sustained CLABSI SIR and incidence reduction over time.

Methods

Infection Prevention & Control CLABSI data collection on all burn patients pre-intervention (2017-2018) and post-intervention (2019-2020) were performed as a quality improvement project; IRB was not obtained. In addition to the CLABSI Bundle (optimal site, aseptic insertion, aseptic maintenance, timely removal, & education), MCB was also implemented in Qtr. 1, 2019. MCB includes necessity of line discussion during daily and multidisciplinary rounds, strategic blood culture collection upon admission/transfers for patients with existing central line, improved nursing and provider documentation of burn infection per CDC definitions, integration of CLABSI reviews in tiered Burn Quality Improvement Program, and universal zero CLABSI goal setting for RNs. Two-sample t-test will be used to compare results pre-intervention (2017-18) & post-intervention (2019-20). CLABSI incidence and standardized Infection ratio will be illustrated per year.

Results

The post-intervention CLABSI SIR data (M= 0.08, SD=0.11) significantly improved when compared to the pre-intervention CLABSI SIR data (M= 0.77, SD= 0.169), t(2)=4.72, p=0.02. The post-intervention CLABSI incidence data (M=0.5, SD=0.70) significantly improved when compared to the pre-intervention CLABSI incidence data (M=4.5, SD= 0.70), t(2)= 5.65, p= 0.01

Conclusions

The combination of the CLABSI bundle with the MCB demonstrated favorable CLABSI SIR and incidence reduction, as literature suggests. Implementing multimodal, multidisciplinary interventions must be a priority for sustained CLABSI reduction. Considerations for future studies should measure length of catheter days, incidence of positive blood cultures on admission/transfers for patients with existing central lines, and incidence of burn infection rates with positive blood culture and an existing central line.
597 Reconstruction of Lop Ear Deformities After Severe Burn Injury in Pediatric Patients: An 11-year Experience
Authors: Ehrlichman Richard J , Sadeq Farzin , Driscoll Daniel N
Published: March 2022

Introduction

The ear is one of the most highly visible structures on the face. One or both ears are frequently involved in panfacial burns. Because they are bilateral structures, asymmetries are clearly visible. Reconstruction of burned ear deformity often requires replacement or modification of skin and/or cartilage. Even these are successfully replaced, scar contractile forces can cause deformation of the ear. One of these deformities is lop or cup ear, in which the helical rim is either folded over, wrinkled or tight. We describe the necessity of applying otoplasty techniques to address this problem.

Methods

A retrospective chart review analysis was performed to assess demographic variables, procedural indications and procedural outcomes in pediatric patients treated at our hospital for complex ear reconstruction for ear deformities after her surgery. Inclusion criteria were pediatric patients aged 0 to 21 years admitted to Shriners Hospital for Children-Boston from January 1, 2010 to January 1, 2021 for burn injury, who subsequently required follow-up complex ear reconstruction for ear deformities after burn injury. Of these patients, those with lop ear deformities who required construction were examined. Using the Trauma Registry of the American College of Surgeons (TRACS) and Shriners Hospital for Children Information Source (SHCIS) databases, we identified 12 eligible patients. Surgical procedure data was obtained from the SHCIS electronic medical records. Surgical photographs were obtained with patient informed consent. Those patients who required Medpor or cartilage frame reconstructions were excluded.

Results

12 patients required an otoplasty-type procedure to obtain desired results or symmetry with the contralateral ear. This technique involved a posterior incision in the auriculomastoidmastoid sulcus, are you a year and cartilage modification with sutures to to re-create the antihelical fold an superior crus as well as conchal setback sutures.

Conclusions

Because ears are bilateral structures, symmetry is extremely poor. Because of multiple contractile forces on the external ear from secondary healing or contraction of skin grafts, the ear is often displaced anteriorly and the upper portions become folded. Treatment requires reconstruction of the natural folds of the ear and shortening of the helical rim to mastoid distance. this requires an otoplasty approach with a posterior incision,, exposure of the cartilaginous framework and modification of the cartilage with incisions and sutures. This technique however requires adequate soft tissue coverage of the ear.
605 Revision Surgery Following Severe Frostbite Compared to Similar Hand and Foot Burns
Authors: Coward Alexandra , Nygaard Rachel M , Endorf Frederick W
Published: March 2022

Introduction

Severe frostbite is associated with high levels of morbidity through loss of digits or limbs. The current practice is to salvage as much of the limb/digit as possible with the use of thrombolytic and adjuvant therapies. Sequalae from amputation can include severe nerve pain and poor wound healing requiring revision surgery. The aim of this study was to examine the rate of revision surgery after primary amputation and compare this to revision surgery in isolated hand/foot burns.

Methods

Frostbite and burn patients from 2006 to 2019 were identified in the prospectively maintained database at a single urban burn and trauma center. Patients with primary amputations related to isolated hand/foot burns or frostbite were included in the study. Descriptive statistics included Student’s T-test and Fisher’s Exact test.

Results

A total of 63 patients, 54 frostbite injuries and 9 isolated hand or foot burns, met inclusion criteria for the study. The rate of revision surgery was similar following frostbite and burn injury (24% vs 33%, P=0.681). There were no significant differences in age, gender, or LOS on the primary hospitalization. Neither the impacted limb nor the presence of infection or cellulitis on primary amputation were associated with future need for revision surgery. Of the 16 patients requiring revision surgery, 5 (31%) required additional debridement alone, 6 (38%) required re-amputation alone, and 5 required both. A total of 6 patients (38%) had cellulitis or infection at the time of revision surgery. Time from primary surgery to revision ranged from 4 days to 3 years.

Conclusions

Planned, delayed primary amputation is a mainstay of frostbite management. To our knowledge, this is the first assessment of revision surgery in the setting of severe frostbite injury. Our observed rate of revision surgery following frostbite injury did not differ significantly from revision surgery in the setting of isolated hand or foot burns. This study brings up important questions of timing and surgical planning in these complex patients that will require a multicenter collaborative study.
613 Evaluation of Non-Euphoric Phytocannabinoid Elixir 14 (NEPE-14) Application in Deep Partial-Thickness Burn Wounds
Authors: Larson David A , Carlsson Anders H , Nuutila Kristo , Christy Sean E , Jockheck-Clark Angela R , Christy Robert J
Published: March 2022

Introduction

Combat-related burn wounds can be caused by exposure to a wide variety of agents including heat, electricity, radiation, chemicals, and friction. Early intervention can decrease injury severity by preventing excess inflammation and improve long term healing outcomes. In recent years, numerous studies have demonstrated that cannabinoids can trigger anti-inflammatory responses and promote wound closure. This study investigates whether a proprietary, non-euphoric, topical cannabinoid formulation (NEPE-14) facilitates burn wound healing when compared with Silverlon®, the military standard of care for burns incurred while in the field.

Methods

Forty-eight deep-partial thickness burns were created on the dorsum of four anesthetized swine (Sus scrofa domestica) using a thermocoupled burn device at 100°C. One hour following burn, biopsies from each site were collected and either NEPE-14, NEPE-14 Vehicle Control, Silverlon®, or dry gauze was placed on the wound. Wounds were assessed on post-burn days (PBD) 3, 7 and 14. Assessments consisted of digital photographs, Laser-Speckle imagery (blood perfusion), FLIR imagery, MolecuLight® imagery and biopsies for histology and immunohistochemistry.

Results

By PBD 14, no significant differences in re-epithelialization or contraction were observed between any of the tested treatment groups. Silverlon® had the highest percent re-epithelialization with 42%, and the Vehicle control has the lowest percent re-epithelialization with 28 %. Both NEPE-14 and dry gauze performed intermediately with 29% and 34% re-epithelialization, respectively. On PBD 14, the wounds of the NEPE-14 treated wounds contracted 8%, the vehicle control 7%, Silverlon® treated wounds 10%, and gauze treated wounds showed 9% contraction compared with the original wound area. Blood perfusion at PBD 14 indicated that NEPE-14 treated wounds had the lowest amount of observed blood flow and the gauze treated wounds contained the highest amount of observed blood flow. However, no statistically significant differences were observed.

Conclusions

No statistically significant results were seen between treatment groups for contraction, re-epithelialization, or blood perfusion. Although not significant, blood perfusion results indicate that NEPE-14 treatment had the lowest amount of blood flow, which can be seen as an indicator of healthy underlying tissue and a wound re-epithelializing. At PBD 14, all treatment groups had slightly contracted after increasing in wound area on PBD 3 and 7, which is a pattern seen in similar burn injury studies. We are currently awaiting histological analysis to strengthen our re-epithelialization results and evaluate burn wound progression.
714 Safety and Efficacy of Enteral Nutrition During Burn Surgery: A Retrospective Chart Review
Authors: Toepfer Danielle M , Mangano Lacey , Eshraghi Niknam
Published: March 2022

Introduction

Burn injuries are life-threatening conditions consisting of elevated oxidative stress, severe inflammation, and an increased hypermetabolic and catabolic state. It is recommended to start enteral nutrition (EN) early in the burn injured patients. These patients undergo many operations, and with stopping of EN the intermittent caloric deficit multiplies. This leads to increased risk of negative outcomes. We sought to analyze the efficacy of continuing EN feedings during burn surgeries to maximize caloric intake while also evaluating for adverse outcomes such as pneumonia.

Methods

A retrospective chart review of intraoperative feeding and pneumonia rates in pediatric and adult burn patients admitted during 2011-2017 to a regional burn center was conducted. Inclusion criteria included patients with secured airway via endotracheal tube or tracheostomy, mechanical ventilation for at least four days, and those who received EN during operations. The 2017 National Burn Repository (NBR) was used as the control population with mechanical ventilation ≥4 days and a yes/no pneumonia diagnosis. Our assumption was that these patients likely did not receive intraoperative EN as this is not standard protocol at this time.

Results

67 patients from our center and 779 NBR patients met inclusion criterion. EN were provided in 49-79% of total operations in the study group. The study group had a longer length of stay (LOS: 62 ± 34.4 vs 41 Days ± 31.7; p< 0.0001), Ventilator days (39 ± 28.9 vs 23 ± 43.9; p< 0.0001) and total body surface area burn percentage (TBSA: 36 ± 21 vs 31 ± 23 p-0.029).

The relationship between pneumonia, inhalation injury, COPD, diabetes, and current smoking status was examined in the case population. The odds of a patient with inhalation injury developing pneumonia was 2.83 times greater than a patient without an inhalation injury. There was a higher pneumonia rate in the study group compared to control population (56.7% vs 18.9%; p< 0.0001). However based on a multinomial logistics regression analysis, there was no statistically significant association between intraoperative feeding and pneumonia in the study group (p-0.597).

Conclusions

We found a significant difference in the occurrence of pneumonia in our patient group compared to the NBR population, but our patients had higher LOS, ventilator days and TBSA burns. This suggest that our study group may have had higher acuity increasing risk of pneumonia. Our pneumonia rates do correspond with the rates reported from other comparable populations of burn patients. Despite this we did not find and association suggesting intraoperative feedings as the cause.