bluuebunny/crossref_metadata_2025 huggingface dataset:
24 A Retrospective Review of Vitamin D Levels and Dosing in Burn Center Patients
Authors: Calder Sara , Quan Asia N , Osborn Suzanne C , Richey Karen J , Bay Curt , Foster Kevin N
Published: April 2021

Introduction

The potential consequences of vitamin D insufficiency/deficiency (I/D), include increases in ICU length of stay, organ dysfunction, infectious complications, and mortality. Burn patients, in particular, may be at increased risk of vitamin D I/D due to bleeding, systemic inflammatory response syndrome, increased utilization of vitamin D by injured tissues, compromised vascular integrity, fluid shifts, and leakage of vitamin D binding protein (VDBP) and albumin. The purpose of this study is to determine the incidence of vitamin D I/D and evaluate the institutional vitamin D dosing regimen.

Methods

A retrospective chart review was performed of all adult patients from January 1, 2018 through December 31, 2019 who received cholecalciferol and had at least one vitamin D hydroxy level during their hospitalization. Vitamin D level was drawn on admission, then weekly thereafter. Patients found to be I/D were initiated on high dose vitamin D supplementation and then adjusted based on the weekly levels. The therapeutic goal for vitamin D supplementation was set at 50 ng/ml.

Results

Three hundred and sixteen patients met criteria for review. Of those patients, 293 patients (93%) were vitamin D I/D. The magnitude of vitamin D deficiency was strongly positively correlated with %TBSA burn size (p< 0.001). Mean time to reach therapeutic vitamin D levels following initiation of supplementation was 19 days with an average weekly dose of 142,877 international units cholecalciferol. Many patients were discharged prior to reaching therapeutic levels. Time to reach therapeutic levels was also positively correlated with increasing burn size (p< 0.05).

Conclusions

Vitamin D I/D is present is over 90% of burn patients and the degree of I/D was profound. Additionally, vitamin D I/D was not easily corrected, taking almost 3 weeks to reach therapeutic levels using an aggressive supplementation regimen. Further studies documenting the clinical consequences of vitamin D I/D and development of evidence-based supplementation dosing regimens are warranted.
28 Timing of Enteral Nutrition Initiation in Severely Burned Patients
Authors: Curtis Nicolle M , Shields Beth A , Williams Alicia M , Vega Saul J , Cancio Leopoldo C
Published: April 2021

Introduction

Early initiation of enteral nutrition (EN) for severely burned patients (pts) has been found to be associated with decreased catabolism, decreased wound infections, lower sepsis rates, shorter intensive care unit (ICU) days and hospital days, and improved mortality. The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends initiating EN within 4–6 hrs of injury for critically ill adult burn pts; however, they also recommend waiting for hemodynamic stability to be achieved before starting EN in all critically ill pts. The objectives of this performance improvement project (PIP) were to evaluate the timing of EN initiation and reasons for delays in initiating EN in our critically ill burn pts.

Methods

We performed a retrospective evaluation on pts admitted to our ICU in 2019 with at least 20% TBSA burns. Exclusion criteria were death within 72 hrs of admission, oral nutrition, and admission over 1 calendar day after injury. This PIP was approved by our regulatory compliance division. We clinically defined hemodynamic stability as lactate levels less than 3 mmol/L with vasopressor requirements of less than 10 mcg/min norepinephrine. Demographic data were collected along with timing of EN and reasons for delays in EN initiation.

Results

EN was initiated 28 ± 17 hrs after admission for the 19 included pts with the following characteristics: 44 ± 16 years old, 38 ± 16% TBSA burn, all required mechanical ventilation on admission. These pts had 16 ± 10 mechanical ventilator days and 42% mortality. The shortest time to EN initiation was 9 hrs after admission. EN was delayed for initial hemodynamic instability for 10 ± 17 hrs after admission. Other delays in EN initiation after initially achieving hemodynamic stability included time to feeding tube placement (1 ± 2 hrs) and x-ray confirmation (4 ± 9 hrs), and time to EN orders (8 ± 10 hrs). EN was initiated 6 ± 6 hrs after the preceding events occurred. Some of the delays in placement of EN orders and for EN initiation after the above criteria were met included procedures (2 ± 2 hrs), becoming hemodynamically unstable again (5 ± 7 hrs), and placement of a small bore, post-pyloric feeding tube when an orogastric or nasogastric feeding tube was already available for use (2 ± 4 hrs). We were not able to retrospectively identify reasons for delays during 5 ± 6 hrs per patient.

Conclusions

As a result of this PIP, we found EN was not initiated in any of our critically ill burn pts within the timeline recommended by ASPEN/SCCM. The primary reasons for delays included hemodynamic instability, feeding tube placement and confirmation, adding a post-pyloric feeding tube, and procedures.
41 Enhancing Burn Medical Care During a Disaster Using a Novel Augmented-Reality Application
Authors: Veazey Sena , SerioMelvin Maria , Luellen David E , Samosorn Angela , Helms Alexandria , McGlasson Allison , Fenrich Craig , Colston Patricia , Salinas Jose
Published: April 2021

Introduction

In disaster or mass casualty situations, access to remote burn care experts, communication, or resources may be limited. Furthermore, burn injuries are complex and require substantial training and knowledge beyond basic clinical care. Development and use of decision support (DS) technologies may provide a solution for addressing this need. Devices capable of delivering burn management recommendations can enhance the provider’s ability to make decisions and perform interventions in complex care settings. When coupled with merging augmented reality (AR) technologies these tools may provide additional capabilities to enhance medical decision-making, visualization, and workflow when managing burns. For this project, we developed a novel AR-based application with enhanced integrated clinical practice guidelines (CPGs) to manage large burn injuries for use in different environments, such as disasters.

Methods

We identified an AR system that met our requirements to include portability, infrared camera, gesture and voice control, hands-free control, head-mounted display, and customized application development abilities. Our goal was to adapt burn CPGs to make use of AR concepts as part of an AR-enabled burn clinical decision support system supporting four sub-applications to assist users with specific interventional tasks relevant to burn care. We integrated relevant CPGs and a media library with photos and videos as additional references.

Results

We successfully developed a clinical decision support tool that integrates burn CPGs with enhanced capabilities utilizing AR technology. The main interface allows input of patient demographics and injuries with step-by-step guidelines that follow typical burn management care and workflow. There are four sub-applications to assist with these tasks, which include: 1) semi-automated burn wound mapping to calculate total body surface area; 2) hourly burn fluid titration and recommendations for resuscitation; 3) medication calculator for accurate dosing in preparation for procedures and 4) escharotomy instructor with holographic overlays.

Conclusions

We developed a novel AR-based clinical decision support tool for management of burn injuries. Development included adaptation of CPGs into a format to guide the user through burn management using AR concepts. The application will be tested in a prospective research study to determine the effectiveness, timeliness, and performance of subjects using this AR-software compared to standard of care. We fully expect that the tool will reduce cognitive workload and errors, ensuring safety and proper adherence to guidelines.
53 Frailty is Not Only a Phenomenon of Elderly Burn Patients
Authors: Romanowski Kathleen S , Grigsby Melissa J , Sen Soman , Palmieri Tina L , Greenhalgh David G
Published: April 2021

Introduction

Recent evidence indicates that increased frailty is associated with increased mortality in patients with burn injuries over the age of 50 years old. This work found that 35.7% of burn patients over 65 years old were frail at the time of their burn admission while 19.2% of burn patients 50 to 64 years old were frail. While frailty is associated with increased age the two are separate entities suggesting that frailty may be present in much younger patients who present with burn injuries. We hypothesize that frailty exists in all age groups of patients presenting with burn injury and the prevalence increases with age.

Methods

Following IRB approval, a 5-year (2014–2019) retrospective chart review was conducted of all burn patients admitted to the burn center. Data collected includes age, gender, and burn size (% TBSA). Frailty was determined using the Modified Frailty Index 11 (MFI 11) from co-morbidities included in the burn registry. Patients were considered frail if they have an MFI ³ 2 and pre-frail for an MFI³1 and < 2. Patients were assessed by decades for age. Statistical analysis included descriptive statistics, chi-square, and t-tests.

Results

A total of 2173 patients (mean age 46.1±17.3 years, 1584 males (72.8%), mean % TBSA 12.5±16.3%) were analyzed. All age groups included patients who were pre-frail (Table 1). In the under 20-year-old group, 8.5% were pre-frail. This increases with each age group to the 71-80-year-old group in which 41.7% of patients are pre-frail. The over 80-year-old group had slightly fewer pre-frail patients (35.9%). There were no frail patients in the under 20-year-old group. In the 21–30 there were 3 patients (0.7%) that had an MFI of 2 or more placing them in the frail group. Frailty was significantly different across the age groups (p< 0.001). As patients age, the proportion of female patients increases (from 17.6% to 37.5%. p< 0.0001). Frailty was also associated with gender with women having a higher percentage of frailty (p=0.0006). With respect to burn size, age category was not associated with burn size (p=0.12), but frail patients had smaller burns than non-frail or pre-frail patients (9.5% vs. 13.3% vs. 12.2%, p=0.0002).

Conclusions

Pre-frail patients were identified in all age groups. Frailty was present in all age groups except for those who are under 20 years of age. Frailty was associated with female sex and smaller burns. By not specifically looking for frailty in all burn patients admitted to the hospital we are potentially missing frail patients who may benefit from interventions to improve their outcomes.
64 Temperature Sensitivity Is Associated with Lower Satisfaction with Life After Burns
Authors: Oh Jamie , Seek Carolina , Sibbett Stephen H , Carrougher Gretchen J , Ryan Colleen M , Friedstat Jonathan S , Kowalske Karen J , Gibran Nicole S , Stewart Barclay T
Published: April 2021

Introduction

Temperature sensitivity is a common problem after burn injury. However, the impact of temperature sensitivity on health-related quality of life (QoL) is unknown. We aimed to describe characteristics associated with temperature sensitivity and determine its association with patient reported QoL. We hypothesized that temperature sensitivity negatively impacts both mental and physical health.

Methods

We reviewed a multicenter burn database for participants who had been asked about hot or cold temperature sensitivity 6, 12 and 24 months after injury. Outcomes of interest included the Satisfaction with Life Scale (SWLS) score and Veterans RAND 12 (VR-12) physical (PCS) & mental health summary (MCS) scores. Chi square and Kruskal-Wallis tests determined differences in patient and injury characteristics. Generalized linear regression models included burn size (%TBSA), graft size (%TBSA), location of burn, pruritis intensity, amputation status, study site, and review of systems questions at each follow-up visit as covariates to determine the impact of temperature sensitivity on QoL.

Results

The cohort was comprised of 637 participants. Prevalence of temperature sensitivity at each follow-up period ranged from 48%-54%. Those who experienced temperature sensitivity had larger burns, required more grafting, and had higher intensity of pruritus at discharge. Temperature sensitivity was associated with lower SWLS scores and lower VR-12 PCS and MCS at each follow-up period. After controlling for confounding variables, temperature sensitivity remained a significant independent predictor of lower SWLS scores (OR -3.2, 95% CI -5.4, -1.1) and VR-12 MCS (OR -4.4, 95% CI -7.4, -1.4) at 6 months follow-up.

Conclusions

Temperature sensitivity is a highly prevalent symptom after burn injury and an independent predictor of worse satisfaction with life and worse mental health recovery.
75 Geographic Location-Allocation Modeling to Optimize National Burn Care Delivery and Disaster Planning
Authors: Li Kevin , Mehta Kajal , Wright Ada , Lee Joohee , Pham Tam N , Nakarmi Kiran K , Stewart Barclay T
Published: April 2021

Introduction

The study country has a disproportionally high burn incidence rate compared to other low- and middle-income countries. Preventable death and disability are common due to poor population-level spatial access to organized burn care, including no organized system of ground or aeromedical transport. Currently, severe burns are referred to a single facility nationwide, often with suboptimal stabilization and/or significant care delay. Therefore, we aimed to identify existing candidate hospitals that would optimize population-level access to acute burn care if burn stabilization capabilities were strengthened in each hospital.

Methods

The 175 general hospitals that referred patients to the single national burn referral center between 2016–2020 were designated as candidate hospitals. Demand points for location-allocation modelling were derived from a 2020 estimated population density grid for the country (total population 30,184,338). Road network and national speed limit data were extracted from publicly available geodata to inform travel distance and time. Six models were developed (Models A-F) using cost-distance and network analyses to identify the 3 vs 5 candidate hospitals that would optimize population-level spatial access if their initial burn stabilization capabilities were strengthened. Three travel time thresholds (≤2, 6, and 12 hours) were used for both sets of models.

Results

Currently, 6,151,298 people (20.3% of the national population) have access to organized burn care within 2 hours of travel, 11,240,957 (37.2%) within 6 hours and 21,925,928 (72.6%) within 12 hours [Table 1]. If acute burn stabilization capabilities were strengthened, Models A-C of 3 chosen hospitals would increase population-level burn care access to 45.2%, 89.4%, and 99.8% of the national population at ≤2, 6, and 12 travel-hours, respectively. Models D-F demonstrated that 5 chosen hospitals would increase population-level burn care access to 53.4%, 95.0%, and 99.9% of national the population at ≤2, 6, and 12 travel-hours, respectively.

Conclusions

This exercise demonstrates two sets of models for increasing population-level access to acute burn stabilization in the study country. If acute burn stabilization capabilities were strengthened in the identified hospitals, approximately 90% of the national population would have access to burn care within 6 travel-hours in both the 3 and 5 hospital scenarios. Although the models with 5 strengthened hospitals reduce mean travel time, the percent of population with improved travel time access is only marginally higher. Strategic, organized efforts to increase burn stabilization capabilities might reduce the rates of preventable burn-related death and disability country-wide by reducing delays.
84 Pediatric Scald Burns: Using Geographic Information Systems to Identify High Risk Communities
Authors: Lee Jeanne , Higginson Sara , Strait Eli , Santorelli Jarrett E , Smith Alan , Costantini Todd , Doucet Jay , Godat Laura N
Published: April 2021

Introduction

Identifying modifiable risk factors for pediatric scald burn injury prevention efforts is an important function for burn registries. Geographic information systems (GIS) analysis can provide additional census tract data about patient home and injury location. We hypothesize that (GIS) analysis of burn registry data using census tract data could identify geographic areas and additional risk factors for pediatric scald burn injury prevention efforts.

Methods

The burn registry of a U.S. regional burn center was used retrospectively to identify burn admissions, ages 0–17, within the county from 1/1/2018 to 7/31/2020. Data collected included demographics, vitals, burn type and body surface area burned (BSA%), hospital charges, length of stay, complications, and mortality. GIS geocoding of patient home addresses with census tract data including poverty level, languages spoken at home and highest educational level was performed. Burn incident hot spot analysis to identify statistically significant burn incident clusters was done using the Getis Ord Gi* statistic.

Results

There were 1057 burn initial admissions during the study period, 152 (14.3%) patients were children 17 and younger with scald injury who were county residents. The average age was 4.0 ± 4.0 years, and 59.9% were male. Mean scald injury BSA was 4.9% ± 5.7, 14/152 admissions (9.2%) had a burn ≥10% BSA. There were no in-hospital deaths. 120/728 county census tracts were identified as high risk with higher rates of child scald injury admissions than the countywide mean of 1.27 cases/1000 children. Regression analysis of high-risk census tracts were more likely to have increased poverty levels (O.R. 3.30, 95% C.I.: 1.1–9.7, p< 0.031) and lower educational attainment (O.R. 1.10, 95% C.I.: 1.0–1.18, p< 0.047). Non-white race, unemployment level, living with grandparents and speaking Spanish at home were non-significant risk factors. GIS analysis identified geographic hot spots for child scald injury admissions (p< 0.001).

Conclusions

GIS analysis of county burn registry data identified census tracts with increased poverty and lower educational attainment levels to have an increased risk of pediatric scald injury admission. Burn prevention efforts should be focused on these high-risk areas.
101 Homeless Status, Distance from Clinic, and Substance Dependence Associated with Low Follow-Up Rates for Burn-Injured Survey Respondents
Authors: Solomon Eve A , Phelan Elizabeth , Tumbaga Lilia G , Karashchuk Irina P , Greenhalgh David G , Sen Soman , Palmieri Tina L , Romanowski Kathleen S
Published: April 2021

Introduction

Over 25% of burn-injured patients at our institution never attended a follow-up appointment. A quality-improvement discharge survey (QIS) identified potential barriers to follow-up as distance from the clinic, transportation, and time off work. This study compares follow-up rates before and after the QIS was administered and correlates them with patients’ self-identified barriers.

Methods

Following IRB approval, a retrospective chart review was conducted using electronic medical records of adult burn-center admits who responded to the QIS and were discharged between September 2019 and July 2020. Controls were burn-center admits discharged from 2016–2018, prior to the survey period. Exclusions included patients with non-burn injuries, and those who died in the hospital were transferred to another hospital, did not require follow-up, or followed up elsewhere. Data analysis was conducted using chi-square, t-test, and logistic regression models.

Results

The post-survey group includes 272 patients (mean age 47 ± 16.8, 201 males (73.6%), mean burn size (TBSA) of 9.3% ± 9.6%). The pre-survey control group includes 878 patients (mean age 45.1 ± 16.8 years, 646 males (73.6%), mean burn size (TBSA) 10.16 ± 11.7%). Compared to the pre-survey group, post-survey patients had a lower frequency of missed appointments (MA) (47.3% post vs. 56% pre), but worse overall follow-up rates (63.7% post vs. 74.5% pre). Per multivariate analysis, different factors were associated with follow-up and MA in the two groups (Table 1). Rates of follow-up and MA were not significantly different before and after the onset of the Covid-19 pandemic.

Conclusions

Patients who were surveyed to identify barriers to follow-up had fewer missed appointments but worse overall follow-up rates. Patients fail to follow up due to homelessness, substance dependence, and distance to the hospital. These findings are consistent with patients’ self-identified barriers to follow-up in a QI survey.
117 Feasibility and Scar Outcome with a Single-use Adhesive Silicone in Pediatric Burn Survivors
Authors: Parry Ingrid , Sen Soman , Palmieri Tina L , Greenhalgh David G , Romanowski Kathleen S
Published: April 2021

Introduction

Silicone sheets are commonly used for prevention and treatment of burn scars and silicone-based products have recently been recommended as the gold standard non-invasive treatment choice. One problem with silicone gel sheets application is that the sheets lose their adhesive qualities making them difficult to affix to the patient and costly to replace when lost. A new ultra-thin, clear and adhesive silicone gel sheet layered on a semi-permeable polyester backing was trialed at our burn center. The silicone is designed to be a one-time application, worn during all activities until it naturally falls off, thus eliminating the need for daily removal and cleaning. The purpose of this study was to evaluate the feasibility and effectiveness of the single-use adhesive silicone sheets with pediatric burn survivors.

Methods

Medical records of pediatric burn survivors who used the adherent silicone sheets between September 2019 and July 2020 were retrospectively reviewed. Information regarding details of silicone use and scar outcome scores were extracted from the records. Data were analyzed using paired Student t-tests and Wilcoxon Signed Rank to compare scars before and after using the silicone.

Results

The silicone was applied to 22 body areas of 9 patients. The average age of the patients was 7.4 (±8.5) years and TBSA 53 ±17%. The time from injury or grafting to when the silicone was applied was 200.5 (±13.4) days. The silicone was worn without interruption for an average of 12.8 days. Total Patient Observer Scar Assessment Scale (POSAS) scores for both the patient and observer evaluations significantly improved after use with the single-use adherent silicone (↓13.83 patient p=.005, ↓5.4 observer p=.01). Evaluating individual scar parameters showed 4/7 patient reported and observed areas of the POSAS evaluation improved significantly with adherent silicone use (Figure 1). Only one patient reported a complication of itch at day 5 and the silicone was removed.

Conclusions

The single-use adhesive silicone investigated in this study appears to adequately adhere to patients over multiple days, thus overcoming common barriers to silicone use of the products falling off, getting lost and needing to be replaced. Use of such a product could improve ease and continuity with scar management. In addition, for this small cohort of patients, scar improvement was noted with silicone use. The results of this study indicate that larger prospective studies evaluating the silicone efficacy may be beneficial.
122 In Patients with Lower Extremity Burns and Osteomyelitis, Diabetes Mellitus Increases Amputation Rate
Authors: Iles Kathleen A , Chrisco Lori , Heisler Stephen , King Booker , Williams Felicia N , Nizamani Rabia
Published: April 2021

Introduction

Diabetes mellitus (DM) is a critical comorbidity with burn injury due to the disrupted healing process. Previous reports have confirmed the increased rate of osteomyelitis (OM) and subsequent amputation in this cohort, however this has yet to be studied in comparison to non-diabetic patients. In this retrospective analysis, we investigate OM and amputation in both the diabetic and non-diabetic lower extremity burn populations to determine the impact of DM on these outcomes.

Methods

The burn registry was used to identify all patients admitted to our tertiary burn center from January 1, 2014 to December 31, 2018. Only patients with lower extremity burns (foot and/or ankle) were included. Patients with burns to additional body areas were excluded. Amputations were categorized by time from injury. Statistical analysis was performed using Student’s t test, chi-squared test, and Fischer’s exact test.

Results

Of the 315 patients identified, 103 had a known diagnosis of DM and 212 did not. Scald injury was the most common mechanism and average TBSA was similar. Differences were observed in average length of stay (LOS) and admission cost, with diabetics demonstrating both a higher LOS (13.7 days vs 9.2 days, p-value= 0.0016) and cost ($72,883 vs $50,500, p-value= 0.0058) (Table 1).

In total, 17 patients were found to have radiologically confirmed OM within three months of the burn injury. Fifteen of these patients had a history of DM and two had no history of DM (p-value= < 0.001) (Table 2). The DM OM patients were found to have a higher blood glucose level on admission (219 mg/dL vs 110 mg/dL, p-value= 0.0452). No significant difference was seen in Hgb A1c in diabetics with or without OM (9.26% vs 8.81%, p= 0.2743). Notably, when non-diabetics were diagnosed with OM, significant differences were observed in both LOS and cost in comparison to their counterparts without OM (36 days vs 9 days; p= 0.0003; $226,289 vs $48,818, p=0.0001). Of the 11 patients who required an amputation, 10 (90.9%) of these patients had comorbid DM.

Conclusions

DM patients with lower extremity burns are more likely to develop OM than their non-diabetic counterparts. When radiologically confirmed OM is present, DM patients have an increased rate of amputation. OM incurs significant healthcare utilization and cost in both the diabetic and non-diabetic populations.
135 Vital, Porcine Skin Xenotransplants Provide Safe and Efficacious Temporary Wound Closure of Severe Burns in a First-in-Human Phase I Clinical Trial
Authors: Chang Elizabeth J , Goverman Jeremy
Published: April 2021

Introduction

Temporary wound closure with human allograft skin is considered the gold standard after early excision of a large burn injury. Limitations of allograft include availability, cost, and safety; thus, an alternative that provides the same quality with enhanced safety would be a valuable surgical adjunct to the clinical options currently available to treat severe and extensive full thickness burn wounds.

A live cell skin xenotransplant from a clinical grade porcine donor is one candidate. Advantages of this alternative include retention of 70% or more of the innate metabolic activity following cryopreservation, vascularly favorable dermal thickness, and genetic modifications that eliminate hyperacute graft rejection. Combined, these result in pliability, strength, survivability, and function that far exceed those of conventional xenografts and mirror those of human allograft.

Methods

Split-thickness skin xenotransplants containing vital dermal and epidermal cells were aseptically procured from alpha-galactosyltransferase knockout porcine donors from a closed, Designated Pathogen Free, colony. They were then processed to achieve both sterility and cellular viability and cryopreserved for long term storage.

In 2018, the FDA authorized a first-in-human Phase I clinical trial to evaluate the safety and tolerability of a genetically modified skin xenotransplant to treat severe and extensive burn wounds. A two cohort, open-label, dose-escalation study evaluated 6 consenting patients with severe burns requiring allograft. Each received surgical grafting with a skin xenotransplant and human allograft skin in a side-by-side, in-situ comparison.

Results

The skin xenotransplant was well tolerated by all patients, resulting in zero adverse events or safety issues, and without zoonotic disease transmission. In all cases, the skin xenotransplant appeared indistinguishable from the human allograft comparator and at the time of autografting, both were vascularized and fully adherent. These findings build upon the series of preclinical studies reported by these authors and presented at the ABA in 2019.

Conclusions

These highly promising patient outcomes demonstrate a potential treatment for complicated burns, especially when human allograft skin is unavailable. Further study of the efficacy of the porcine skin xenotransplants is warranted. As such, a multi-center, Phase II efficacy trial is planned for 2021.
532 Intravenous Supplementation of Micronutrients in Patients with Severe Burns
Authors: Arnold Olivia M , Shields Beth A , Kieffer Adam J , Cole Renee E , Vega Saul J , Aden James K , Williams Alicia M , Cancio Leopoldo C
Published: April 2021

Introduction

Pneumonia is a prominent cause of morbidity and mortality in burn patients. The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends supplementing with intravenous copper, selenium, and zinc, as a randomized controlled trials on burn patients in Switzerland showed decreased pneumonia rates. The purpose of this performance improvement project was to determine whether the intravenous supplementation of copper, selenium, and zinc had an association with the incidence of pneumonia in patients with total body surface area (TBSA) burns over 20% in order to determine if this practice should be re-initiated.

Methods

Based on available randomized controlled trial evidence, we began the clinical practice of providing intravenous trace elements to our patients with burns over 20% TBSA who were admitted to the burn intensive care unit and who had a central line. This clinical practice ended after 2 years when there was a national shortage of these intravenous trace elements. We performed a retrospective evaluation on patients admitted for initial burn care to our intensive care unit who received an intravenous solution containing 4 mg copper, 500 mcg selenium, and 40 mg zinc daily for a goal duration of 14 days in patients with 20–40% TBSA burns and 21 days in patients with over 40% TBSA burns. Patients who survived less than two days were excluded. In order to compare the incidence of pneumonia within the first 30 hospital days in patients who received intravenous trace element supplementation to those who did not, we matched patients based on age, burn size, and gender. Matched subjects were admitted either before or after the time period of intravenous trace element supplementation and these subjects received oral zinc supplementation. Descriptive statistics and Chi-Square were performed using JMP. Significance was set at p< 0.05.

Results

Pneumonia within the first 30 hospital days occurred in 63% of the 52 included patients with the following characteristics: 71% male, 52 ± 18 years old, 43 ± 15% TBSA burn, 29 ± 25 mechanical ventilator days, and 44% mortality. A significant difference in the incidence of pneumonia during the first 30 hospital days was not found between groups (intravenous trace element group: 70%; comparison group: 56%, p=0.28).

Conclusions

Supplementation of intravenous copper, selenium, and zinc was not significantly associated with incidence of pneumonia in our severely burned patients, contrary to previous research findings.
539 If Seeing Was Believing - A Retrospective Analysis of Potential Reduced Treatment Delays with a Novel Burn Wound Assessment Device.
Authors: Huson Henry B , Phelan Herbert , G’Sell David , Smith Sydney , Carter Jeffrey E
Published: April 2021

Introduction

Burn care (BC) remains a highly specialized and resource intensive specialty with only 2% of hospitals featuring a burn center and less than 1% of graduating general surgery and plastic surgery residents pursing a burn fellowship each year. Access to specialized care is further complicated by burn wound assessment (BWA) which is commonly performed visually without adjunctive devices. To help clinicians make more accurate assessments and potentially reduce delays in transfer or treatment, a new non-invasive imaging device for BWA is being developed using visible and non-visible wavelengths of light with machine learning algorithms. Our goal was to assess the potential reduced treatment delay (RTD) and associated financial savings by implementing such a device using our burn center’s historical data.

Methods

The study was an IRB-approved, retrospective review of admissions from 07/01/2018 through 06/30/2019. Inclusion criteria: thermal, chemical, contact, or electrical mechanism of injury, >15 years of age requiring excision, and length of stay >72 hours. Inclusion data included: presence/absence of concomitant trauma, day of surgery, day of admission, day of electronic order entry for case request, and length of stay per percent total body surface area (LOS%TBSA). RTD was defined starting >48 hours after injury daily until electronic order entry for surgical case request. Reduced costs were calculated per day from prior studies ranging $3,000 to $5,100/day.

Results

A total of 109 patients were included. 29 patients had case requests placed within 48 hours of admission. Of the remaining 80 patients, a potential of 398 days would have been saved had a novel BWA adjunctive imaging devices aided surgeon to requests earlier surgical intervention. Overall savings from reduced length of stay range from $1,194,000 to $2,029,800 dollars.

Conclusions

Our study demonstrates that should a BWA technology with accuracy 48 hours after injury be developed, even burn centers with 24-hour access to operating rooms can reduce treatment delays. The study does not look at additional cost savings offered by reduced emergent transfers or admissions which offer additional intrigue and promise.
543 Escharotomy Incisions in the Burn Foot and Toe with Compartment Syndrome
Authors: Lifferth Greg S , Roth Bryan J , Lardizabal Marisse , Kowal-Vern Areta , Foster Kevin N , Matthews Marc R
Published: April 2021

Introduction

Patients with burn injuries are at risk for lower extremity compartment syndrome, especially if the injury is circumferential. The hypothesis was that two dorsal escharotomy incisions to release foot and toe compartment syndrome would be most efficacious in the prevention of lower extremity amputations.

Methods

This was a retrospective chart review of foot compartment syndrome in burn patients between January 2001 and May 2019.

Results

The study consisted of 59 feet from 32 patients who had been admitted to the Burn Center for thermal injury. The patient age was a mean±sd of 29±30 years, and 41±29 as the % total body surface area (%TBSA); there were 19 males and 13 females. All patients had received fluid resuscitation on admission. Twenty-one (66%) of the patients did not require amputations after undergoing a median of two incisions (range 1–5); 6 of 59 (11%) required fasciotomies. Compared to medial or dorsal or multiple echarotomies, the majority of patients who underwent two dorsal foot escharotomies did not require amputations, p = .0001. Significantly more patients were alive with no amputation 15 (50%) compared to 4 (13%) (dead with amputations), p = .02. Survivors were significantly younger than the non-survivors (median 20 and range1-69) compared to the non-survivors (48, 12–59), p =.04. The survivors also had significantly less severe %TBSA median 22 (range 2–75) versus 83 (35–95) %TBSA, p < .0002. Dorsal/Lateral incisions had the highest number of amputations.

Conclusions

Foot dorsal compartment release is the most effective site for escharotomies in the treatment of burn-induced compartment syndrome. It does not require more than two incisions at the skin/fat level and over the second and fourth metatarsal bones on the dorsal part of the foot to decrease the lower extremity amputation rate in the majority of cases.
547 Face Escharotomy in an Acute Deep Facial Burn
Authors: Ozkan Burak , Uysal Cagri A , Ertas Nilgun Markal , Haberal Mehmet
Published: April 2021

Introduction

Escharotomy is the relaxation of the eschar through longitudinal or horizontal incisions in order to protect the region’s deep perfusion. The pressure that it will create in the peripheral areas such as hard eschar limb, trunk, and neck causes the circulatory disorder in the limb and the risk of limb loss, inadequate thoracic expansion in the thorax and vital perfusion and oxygenation problems in the neck. It is one of the most basic rules of burn surgery to perform the determined escharotomy incisions very quickly and without hesitation to prevent complications. In this report, a case of facial subunit principles based escharotomy is presented.

Methods

42-year-old man felt into hot sand while working in an iron and steel factory. Patient was transferred to our burn unit for corresponding 35% of the total body surface burns on the face, neck and upper extremities. The patient was consulted to plastic surgery after the initiation of fluid replacement therapy, insertion of a chest tube for hemothorax, and tracheostomy. The patient had massive edema in the face and neck (Figure 1). There was no capillary fill in the facial skin. Doppler ultrasound examination showed bilateral weak facial artery, temporal superficial artery, supraorbital and trochlear artery flow.

Results

A decision was made to perform escharotomy to relieve arterial traces at 10th hour of the injury. Bilateral nasolabial, infraorbital rim, superior glabellar, temporal incisions were performed from eschar to subcutaneous fat layer in accordance with aesthetic subunits (Figure 2). Relief of the base perfusion during escharotomy was observed and bleeding was observed at the base of the incision. Doppler examination was repeated after escharotomy. The facial edema rapidly regressed. Deepitelization and reepithelization was observed in the areas with hair roots within 10 days and the patient was operated on the 15th day of hospitalization for debridement and skin grafting. Eschars were debrided and covered with split thickness skin grafts according to aesthetic subunit principles. Post-operative image of the patient seen (Figure 3).

Conclusions

Face is not an area in which eschar formation commonly seen because of its robust vascular supply and protection reflex of the patients. Although descriptive drawings and guides for facial escharotomy has not been published yet, relaxation of axial arteries in terms of compression due to eschar formation may be needed. In this report, a case of facial subunit principles based escharotomy is presented and acceptable results were achieved.
568 Ethical Challenges in the Pregnant Burn Patient
Authors: Khandelwal Anjay , Gerrek Monica L
Published: April 2021

Introduction

Classically, ethics in pregnancy have revolved around abortion. However, there are numerous issues that require attention including the fetus as a patient, the mother’s autonomy and medical treatment of the pregnant patient amongst others. These are further complicated when the pregnant patient has sustained a traumatic or burn injury. Although there are numerous case reports of managing the pregnant burn patient, there is a paucity of literature that focuses on the ethical challenges in the pregnant patient.

Methods

We report the case of an 18-year-old engaged female who sustained 60% total body surface area full-thickness burns. She was found to be 6 weeks pregnant with a viable fetus on ultrasound. The pregnancy was not planned, but desired. During the early portion of the hospitalization, she was found to lack capacity for both complex medical decision making and assigning of a surrogate decision maker. Furthermore, her mother only intermittently had custody of the patient when she was a minor, complicating whether she would be the best surrogate decision maker. Medical treatments that would significantly decrease morbidity and mortality would have had a negative impact on the viability of the fetus. Morning sickness compromised the nutrition care of the patient. Ethical issues that arose included capacity for complex medical decision making, the mother’s autonomy, surrogate decision making and whether a surrogate decision maker can make decisions regarding the fetus, the fetus as a patient, and medical interventions of the pregnant patient. Later on in the hospitalization, the patient was refusing many aspects of her care, raising the issue of paternalism in the burn center.

Results

The patient was later deemed to have capacity for assigning a surrogate decision maker, but not for complex medical decision making. She assigned her fiancée as the surrogate decision maker, although he initially refused. Medical treatments that would significantly decrease morbidly and mortality were instituted even though some were “contraindicated” in pregnancy. A gastrostomy tube was placed through burnt tissue for direct enteral access even though the patient was alert, oriented, and could tolerate oral intake in order to enhance her nutritional status. The burn center adopted a practice of “benevolent parentalism” as a means to overcome the patient’s resistance of medical care and treatments.

Conclusions

Pregnancy in the burn patient represents a deeply ethically challenging situation which have not been discussed in previous case reports. Ethical guidelines for the management of the pregnant burn patient should be established. Guidelines for surrogate decision making must be followed. In addition, the concept of “benevolent parentalism” must be elucidated and should replace the notion that burn centers are paternalistic.
571 Palliative Care Utilization in Burn Patients
Authors: Geffre Marcus , Endorf Frederick W , Nygaard Rachel M
Published: April 2021

Introduction

The morbidity and mortality of the severely burned patient can be affected by multiple variables. Many of these variables are also associated with an increased likelihood of withdrawal of care. Palliative care services can aid families in difficult decision making during this time and improve the process of transition to comfort cares. Despite this, palliative care services may be underutilized. The aim of our study is to assess factors associated with palliative care consultation in the setting of severe burns.

Methods

We analyzed 191 patients with a burn TBSA of ≥30% at our institution from 2007 to 2019. Univariate and multivariate analysis was performed to identify factors associated with consultation to palliative care.

Results

17 of the 191 (8.9%) patients received a palliative care consultation. The average time to consultation was 10.3 days. On univariate analysis, age, inhalation injury, multiple comorbid conditions, and code status were associated with consultation to palliative care. Independent predictors of palliative care consult included inhalation injury, non-white race, code status, and ventilator days.

Conclusions

Palliative care consultation appears to be seldomly requested at our facility. The presence of an inhalation injury and comorbidities increase the likelihood of consultation. These factors correspond to the same factors that increase likelihood of transition to comfort care. Consult to palliative care on patients with these factors can help improve patient and family care.
592 Medwatch: A Public Service Media Outlet Promoting Burn Prevention and Survivor Awareness
Authors: Henry Shana M , Kopari Nicole M
Published: April 2021

Introduction

The American Burn Association estimates 486,000 burn injuries occur each year. Inability to receive specialized treatment from a verified burn center can negatively impact long term outcomes and survival rates for burn survivors. The burn team has a multidisciplinary approach to meeting the physical and emotional needs of burn patients and their families. Ongoing education and outreach programs are key elements in preventing fire tragedies. We identified an opportunity to incorporate burn and fire prevention education as well as burn survivor testimonies into a pre-existing media platform.

Methods

We identified burn injury trends, at an American Burn Associated Verified Burn Center, via the burn registry and determined the most common etiologies of injuries treated at our center. We utilized an established relationship with burn prevention community partners, our hospitals communication department, and local news station. Our aftercare and burn prevention coordinator partnered with these established relationships to produce 10-minute television segments on burn and fire safety topics. The interactive television sessions were aired during the local news. Within each segment, viewers were provided with safety tips, preventative strategies, and/or burn survivor testimony.

Results

30 news segments over the past 3 years have been produced reaching an average of 58,000 people per year spanning 7 local counties. This health and wellness tool has provided education regarding pet fire safety, scald/contact burn prevention, outdoor/BBQ burn/fire prevention, car fire safety, honey oil explosion education, and holiday burn prevention. We have also had segments focusing on smoke alarm awareness/education and home/fire escape planning to make our communities safer. We have been able to promote our successful aftercare programs by highlighting our support groups, burn survivor activities, and grateful patient stories sharing burn survivor testimony.

Conclusions

We identified burn prevention topics as well as grateful patients to spread awareness of burns within our community. We partnered with the hospital communications department and local news stations to produce directed educational television segments. These segments were designed to educate the community as well as highlight our successful multidisciplinary approach to managing burn patients. This media platform is one component of our burn centers ongoing burn prevention and outreach program.