bluuebunny/crossref_metadata_2025 huggingface dataset:
17 The Impact of Modifiable Comorbid Conditions on Long-term Patient Reported Outcomes in Burn Survivors
Authors: Sheckter Clifford C , Li Kevin , Carrougher Gretchen J , Pham Tam N , Gibran Nicole S , Stewart Barclay T
Published: March 2020

Introduction

Pre-existing comorbidities in burn survivors increase the risk of death and negatively impact quality of life. Investigations to date have only evaluated comorbidities as cumulative indices, which prevents identification of specific conditions for risk reduction after injury. Therefore, we aimed to evaluate the differential effects of specific conditions on patient reported outcomes.

Methods

A prospectively maintained trauma registry was merged with a longitudinal burn database using unique patient identifiers for burn survivors from 2007–2018. Admission comorbidities included: chronic liver disease, diabetes, hypertension, chronic pulmonary disease, chronic gastrointestinal disease, malignancy, cerebrovascular accident, congestive heart failure, bleeding disorder, coagulopathy, congenital condition, psychiatric illness, major depressive disorder, smoking status, alcohol use disorder, substance use disorder, trauma history, and steroid use. Demographic and burn related variables included age, gender, race, surface area burned, and number of operations during admission. Health related quality of life was assessed using the Short Form-12/Veterans RAND 12(SF/VR-12©) health survey component scores at 6, 12, & 24 months post injury. SF/VR-12 outcomes were evaluated with generalized linear models.

Results

The dataset included 493 adult participants of which 354 were male (71.8%). Median burn size was 14% TBSA (IQR 5%, 28%), and mean age was 45.0±16.3 years. 343 participants (69.6%) had ≥1 comorbidity, with a mean of 1.32±1.30 comorbidities/participant. SF/VR-12 mental component scores at 6 and 12 months post injury were negatively associated with history of psychiatric illness (p< 0.001, p=0.013); there were no significant predictors at 24 month follow up. SF/VR-12 physical component scores were negatively associated with smoking (p=0.019), diabetes (p=0.001), alcohol use disorder (p=0.001), and history of CVA (p=0.005) at 6 month follow up. 12 month SF/VR-12 physical component scores were negatively associated with trauma history (p=0.001), diabetes (p=0.042), and CHF (p=0.016). 24-month SF/VR-12 physical component scores were negatively associated with psychiatric illness (p=0.003).

Conclusions

Smoking, alcohol use disorder, and diabetes were associated with lower physical component scores 6-months after injury; diabetes persisted a negative covariate at 12 months. Psychiatric illness was negatively associated with mental component scores at 6 and 12 months after injury. Burn survivors may benefit from integrated diabetes management and mental health treatment during their rehabilitation.

Applicability of Research to Practice

Specific comorbid conditions differentially affect quality of life in burn survivors. Targeting management of specific conditions during recovery may improve quality of life.
54 Validation of Infrared Thermography for Prediction of 21-day Burn Wound Healing
Authors: Peterson Michael P , Firpo Matthew A , Fleming Irma D , Vachet Clement , Huston Zachary T , Graham Emily M , Lewis Giavonni
Published: March 2020

Introduction

Although trained specialists easily identify most full and superficial partial thickness burn injuries, deep partial-thickness injuries present a true challenge to the clinician. Various imaging modalities to assess perfusion and determine healing potential include skin biopsy with histology, laser doppler imaging, active dynamic and static infrared thermography, vital dyes, indocyanine green video angiography and others. Prior studies indicate, with small clinical and animal studies, forward looking infrared is a valid tool to assess healing potential and 21-day healing within the first 48 hrs after presentation. The aim of our study is to determine if an absolute increase or decrease in temperature (°C) measurements across a burn wound in a large clinical cohort correlates with 21-day healing after 48 hrs from time of injury.

Methods

After informed photo consent was obtained, thermographic images were captured at presentation, 24hrs, and 48hrs from patients admitted to our center between October 2018 and August 2019. Thermographic images were reviewed and temp measurements obtained using a linear vector through the wound. Next we determined if patients healed within 21 days. Data collected includes demographic data, burn characteristics, injury site (based on Lund Browder segmentation) and wound temp (average, minimum, maximum). Data was analyzed using Wilcoxon rank sum test with continuity correction.

Results

We reviewed images for 159 burn sites from 29 patients, the largest image set to be reviewed to date. The cases were 84% male, the mean and range was 33.1 years (1.7 – 70) for age and 25% (2 – 54.5) for TBSA. We found an average temp difference between 24 hrs – 48 hrs (p-value= 0.007) was significant, and no significant difference in average temp change when evaluating admit – 24 hrs (p-value=0.053) and admit – 48 hrs (p-value=0.316), consistent with predictions of prior studies. Average temp from admit – 24 hrs decreased by 0.86°C in healed (n=48) vs non-healed (n=91); increased on average by 1.25°C in healed (n=39) vs non-healed (n=74) from 24 hrs – 48 hrs; and showed a modest decrease by 0.3°C in healed (n=50) vs non-healed (n=82) when comparing admit 48 hr temp.

Conclusions

These data demonstrate that burn wound temperature difference between 24 and 48 hours after admittance as measured by infrared thermography correlates with clinical outcomes and 21 day healing.

Applicability of Research to Practice

Infrared thermography is a validated tool to assess burn depth after 48 hrs. In the future, this modality may impact triage in the military, rural, accidental and non-accidental disasters.
56 Reduced Length of Stay with Autologous Skin Cell Suspension Reduces Burn Injuries
Authors: Carter Jeffrey E , Platt Blake , Tuggle Charles T
Published: March 2020

Introduction

Burn injuries remain a surgical challenge with few recent innovations. Grafting with split-thickness skin grafts (STSGs) has been the standard of care for decades. Although shown to have mortality benefits, STSGs are associated with significant morbidity in the form of pain and additional open wounds. For years, surgeons have looked for ways to decrease this associated morbidity. To that end, autologous skin cell suspension (ASCS) is a recently FDA-approved point of care regenerative medicine technology that reduces donor skin requirements without compromising clinical outcomes. Our study evaluated the cost and length of stay comparing STSG alone versus ASCS.

Methods

We obtained IRB-approval for single institution, retrospective chart review of patients age >14 years admitted with burn injuries from March 2018 – September 2018. Primary outcome was length of stay/%TBSA for patients undergoing STSG alone as compared to patients undergoing ASCS. The 2016 American Burn Association National Burn Repository (NBR) was used to benchmark LOS/%TBSA. Age, percentage burn injury (TBSA), LOS, mortality, and number of surgeries were reviewed. Student’s t-test was used to assess statistical significance of intragroup analysis.

Results

36 patients were treated with ASCS in combination with meshed autografts for full-thickness acute burn injuries. 37 patients were treated with STSGs at our center. Mean age and %TBSA was 45.2 years and 6.6% for the STSG group and 46.0 years and 18.6% for the ASCS group. The LOS/%TBSA for the STSG was 1.72 versus 1.19 for the ASCS patients (p-value=0.02). The NBR predicts a LOS/%TBSA of 3.38 and 3.42 for the STSG and ASCS groups. Patients in the STSG group and ASCS group had statistically similar surgeries and mortalities.

Conclusions

Burn injured patients treated with ASCS had a decreased LOS/%TBSA when compared to both the STSGs and NBR predictions. ASCS is a novel technology allowing for point-of-care treatment that may decrease LOS for burn injured patients and should be considered as an adjunct to traditional techniques for burn patients.

Applicability of Research to Practice

Reduced length of stay compared to traditional burn care.
75 Burn Survivors Can Exercise for 30 Min, Even in the Heat, Without a Risk of Excessive Hyperthermia
Authors: Crandall Craig G , Cramer Matthew N , Huang Mu , Moralez Gilberto , Belval Luke , Watso Joseph C , Fischer Mads
Published: March 2020

Introduction

Excision of burned skin and subsequent grafting removes sweat glands and thereby impairs thermoregulation. Consequently, rehabilitation and associated exercise may be accompanied by a greater risk of hyperthermia, depending on exercise duration, intensity and environmental temperature. Current physical activity guidelines recommend adults perform at least 150 min of moderate-intensity exercise per week, which is often divided into 30-min daily sessions. This project tested the hypothesis that burn survivors could exercise for 30 min without excessive elevations in core body temperature, regardless of the total body surface area (%TBSA) burned or environmental temperature.

Methods

Ten subjects cycled for 60 min at 1) a moderate intensity (97±8 watts) in a thermoneutral environment (24°C, MOD_NEU), 2) a moderate intensity (100±17 watts) in a hot environment (39°C, MOD_HOT), and 3) a low intensity (65±10 watts) in a hot environment (39°C, LOW_HOT). Burn injuries were simulated by covering 0%, 20%, 40%, or 60% of the individual’s TBSA with an absorbent material that prevented sweat evaporation. Changes in gastrointestinal temperature (ΔTcore) were analyzed at 15-min increments throughout exercise.

Results

For the MOD_NEU trial, there were no differences in ΔTcore between the %TBSA coverage bouts at any time point during exercise. For the MOD_HOT trial, there were no differences in ΔTcore at 15 and 30 min of exercise regardless of the %TBSA coverage, while ΔTcore was appreciably elevated (P< 0.05) at 45 and 60 min of exercise for 20%+ TBSA bouts. For the MILD_HOT trial, there were no differences in ΔTcore at any time point between %TBSA bouts, with the sole exception of 60% simulated burn having a slightly greater ΔTcore (0.3±0.34°C; P< 0.05) at 60 min of exercise relative to the 0% TBSA bout.

Conclusions

These data indicate that individuals with up to 60% of their TBSA burned could exercise at a moderate intensity for 30 min, even in hot environmental conditions, without excessive elevations in body core temperature.

Applicability of Research to Practice

Individuals with significant burn injuries can benefit from exercise, without the risk of excessive hyperthermia, for up to 30 min in the heat or at least 60 min in an air conditioned space. Funding: DOD W81XWH-15-1-0647
92 Improved Burn Healing Classification via Artificial Intelligence
Authors: Baxter Ronald D , Carter Jeffrey E , Craig Christopher K , Williams Jeffrey W , Holmes James H
Published: March 2020

Introduction

Current methods of assessment for burn severity and healing potential are insufficient but this determination remains critical in providing optimal burn care. A novel device using multispectral imaging and artificial intelligence (AI) has shown prior success aiding in this process. Promising initial results of this proof-of-concept case series have been presented previously, invoking much interest from the burn care community. These results reflect the final results of this study and provide support for continued investigation with this device for the treatment of burn wounds.

Methods

Subjects with thermal burns were enrolled within 72 hours of injury. The goal was to enroll at least 12 burn wounds from each category of severity: 1°; superficial 2°; deep 2°; and 3°. Upon enrollment burns were imaged with the study device serially for up to 7 days post-burn. The true healing potential of each imaged burn area was determined using either healing assessment at 21 days post-burn or multiple punch biopsies of the burn wound taken at time of excision and grafting. This ground truth was used to train the AI algorithm to automatically identify the margins of non-healing burn tissue within device images. Accuracy of the study device to identify and differentiate healing and non-healing burn tissue within the captured wound area was computed.

Results

Data from 38 subjects with 58 total burns and 393 wound images were obtained during this study. Following completion of training, AI predictions achieved 90.7% sensitivity with 87.5% specificity in predicting non-healing burn tissue using cross-validation. Results improved throughout the study as more wound images were used in AI training (Figure 1).

Conclusions

The AI algorithm trained on 58 burn wounds (38 subjects) had an area under the curve of 0.955 and has continued to improve with the addition of more burn wounds. Expansion of this study has been initiated at multiple burn centers to continue collecting data for AI algorithm training.

Applicability of Research to Practice

These results demonstrate feasibility of utilizing AI-assisted diagnosis in burn wounds and possible application in the management of burn patients.
106 Heads or Tails? Scalp versus Non-scalp Donor Sites for Split-thickness Skin Grafting of Burns: A Systematic Review and Retrospective Review
Authors: Rokui Sorush , Pawliuk Colleen , Bone Jeffrey , Papp Anthony , Hynes Sally
Published: March 2020

Introduction

The scalp is an appealing donor site for split-thickness skin grafting (STSG) of burns due to its concealment upon hair regrowth and healing potential; however, it is often reserved for massive burns with limited donor sites. This study aims to understand scalp donor site (SDS) outcomes and complications to elucidate viability of the SDS as a first-line option for coverage of burns.

Methods

A systematic review across five databases was conducted. Original research reporting cohort outcomes of STSG coverage of burns using the SDS was included. Donor site healing time, graft thickness, graft take, and complications were analyzed. Thereafter, a retrospective chart review of patients who had SDS-STSGs for burns from 2010–2018 was done. Outcomes and complications were compared to non-SDS-STSGs (NSDS-STSGs) in criteria-matched controls.

Results

Systematic Review: 1489 articles were reviewed. 15 cohort studies met inclusion criteria, yielding 1761 patients who has SDS-STSG (mean age=17 yrs, mean TBSA=37%). Alopecia and folliculitis occurred in 5% and 3% of patients, respectively; folliculitis was associated with certain hair types. Other complications (eg. hypertrophic scarring, hair transfer) were seen in less than 1.5% of patients. Rapid donor site healing times (mean=8 days) and capacity for re-harvest (mean=2 harvests/patient) were noted.

Retrospective Review: 30 patients underwent grafting with SDS-STSGs, 23 of whom also received NSDS-STSGs and were thus self-controls; criteria-matched controls were found for the remaining 7. Graft thickness and graft take did not differ between SDS and NSDS groups, while donor site healing time was faster for SDSs vs NSDSs (9 vs 11 days, p=0.02).

SDS complications included: alopecia (n=2), delayed healing (3), and folliculitis (1). NSDS complications included: delayed healing (n=1), dyspigmentation (2), and hypertrophic scarring (3). These complications could not be attributed to age, ethnicity, graft thickness, number of graft harvests, comorbidity burden, TBSA, or inhalational injury status.

Conclusions

The scalp donor site may represent a viable first-line option for split-thickness skin grafting of burns. Our cohort suggests that scalp donor sites pose comparable risks to non-scalp donor sites. Further studies elucidating the role of hair type in SDS-STSG complications are required to optimize outcomes with patient-specific donor site selection.

Applicability of Research to Practice

In select patients, the scalp may be considered as a first-line donor site for split-thickness skin grafting of burns, with potentially faster donor site healing time and comparable risks to non-scalp donor sites. Some scalp-specific complications may be linked to differences in hair type.
123 Burn Patients’ Pain Experiences and Perceptions at a Regional Burn Center
Authors: Duchin Emma R , Moore Megan , Carrougher Gretchen J , Min Emily K , Gordon Debra B , Stewart Barclay T , Sabel Jody , Jo-Nes Anne , Pham Tam N
Published: March 2020

Introduction

Burns are often painful injuries, associated with a long recovery. Little is known about patients’ pain experience or understanding of burn pain. Patients may also not be receiving sufficient pain education to optimize their pain experience. The aim of this project was to obtain patients’ perspectives to inform future burn pain education efforts at a regional burn center.

Methods

We conducted mixed-methods interviews in inpatient and outpatient units. Participants were >=14 years with acute burn injury, who received at least two wound care episodes, and were able to cognitively participate. Provider stakeholders designed the interview using a modified Delphi technique. Survey questions focused on patients’ pain experiences, understanding and desire to gain knowledge of burn pain and management. Descriptive quantitative analysis was performed on categorical data. Recorded interview segments were transcribed for content analysis using an online, HIPAA-compliant software.

Results

We interviewed 21 adult burn patients. Participants reported variable pain and pain management effectiveness, with inpatients reporting more severe pain than outpatients. Only 11% of inpatients reported having received enough pain information, compared to 50% of outpatients. Participants expressed, in decreasing order of importance, a need for more information on burn-related pain, medications and alternative treatments, analgesic weaning, and addiction risk. In-person education ranked as the most desirable education method, followed by pamphlets and video education. Qualitative content analysis yielded 3 major themes: patient’s pain experience, range of expectations, and clinical information/services desired. Mental and physical effects were key parts of participants’ pain experiences, with many participants reporting mental anguish in addition to pain. Most participants’ pain expectations were matched by their experience, while some individuals described higher pain levels than they anticipated. Positive experiences with the burn care team primarily revolved around provided education and information on pain, whereas negative experiences concentrated on wound care events. Participants desired more information on sleep and pain medications, realistic expectations of recovery timelines, and available mental health services.

Conclusions

Burn patients report variable pain experiences and a strong desire to receive additional pain education. This project informs key strategies to educate burn patients on pain. A high-level of interest in pain, pharmacologic and alternative therapies, weaning and addiction risks indicates a need for newer targeted education materials.

Applicability of Research to Practice

Burn patients’ perspectives help inform strategies and content creation for education materials that burn centers can provide.
523 Silkworm Silk as an Alternative to Two Common Epidermal Substitutes for the Treatment of Acute Superficial Burns
Authors: Schiefer Jennifer L , Fuchs Paul
Published: March 2020

Introduction

During the treatment of superficial burn injuries patients are often confronted with painful dressing changes. Therefore we usually treat these wounds with materials that can stay on the wound and slowly peel off during re-epithelialization. Since 2013 we started using pure silk as cost efficient alternative for the treatment of these wounds. Therefore we wanted to compare it directly with the other dressings.

Methods

In a prospective intra-individual design we evaluated the wound healing of 50 patients with superficial burn injuries. Hereof 30 patients received both silk and Nylon mesh with collagen and 20 further patients received silk and a synthetic epidermal substitute for the treatment of their burn injuries. Following a standardized case report form, we monitored pain, active bleeding, exudation, dressing change and inflammation. Furthermore we evaluated scar quality objectively with the Cutometer, Mexameter and Tewameter as well as subjectively with the patient and observer scar scale (POSAS) and the Vancouver scar scale (VSS).

Results

During wound healing no significant differences could be found regarding wound closure, inflammation and acute bleeding. Pain levels fell fast during after dressing application and during wound healing. Long-term results in functional and aesthetic outcome were similar. High satisfaction rates were reported for all dressings, with different individual preferences.

Conclusions

All three dressings provided a safe and effective healing environment, with low complication rates in regard to infection and exudation. Additionally, no significant differences regarding scarring could be found with an overall pleasing aesthetic outcome.

Applicability of Research to Practice

Silkworm silk is now the standard of care in our clinic for superficial burns.
564 Use of the Pediatric Quality of Life Measure in the Burn Camps Population
Authors: Mikolaj Kerry , Boulter Trudy , Jackson Brad , Schuetz Tim
Published: March 2020

Introduction

The Pediatric Quality of Life Inventory (PedsQL) is a tool used to measure health-related quality of life in children and adolescents. The PedsQL measures physical, emotional, social, and academic function. Our burn camp program provides comprehensive programming in a supportive, challenging environment to enhance care of a child with a burn injury. Our camp addresses: isolation, social skill development, body image, negative beliefs, risk-taking, and academic challenges. The lessons learned at camp are unique and build lifelong success. The PedsQL will provide data on changes that are being made with our campers over time. We hypothesize positive changes in PedsQL scores with the addition of burn camp.

Methods

The PedsQL consists of forms for children ages 2–4, 5–7, 8–12, and 13–18. Pediatric self-report is measured in children and adolescents ages 5–18. There is a separate parent proxy-report of the child’s health-related quality of life for ages 2–18. Before camp begins, parents are mailed the parent report to fill out and are due back prior to the first day of camp. Campers fill out the form on the first day of camp. Data is entered into an excel spreadsheet. Follow up parent and child/adolescent surveys are then sent out 3 months post camp. Three month follow up data is entered and compared to original scores. Three scores are generated from the data including total score, psychosocial score, and physical health score. A higher score indicates a better Health-Related Quality of Life.

Results

We trialed the use of the PedsQL in our adolescent burn camp, consisting of 23 campers ages 13–18. We received 8 (34%) follow up surveys. The results of these scores are trending in a positive direction. We used the PedsQL for our burn camp program consisting of 77 campers ages 8–18. We will obtain 3 month follow up data by Dec 2019 and will assess the data and report the changes.

Conclusions

The PedsQL is a tool that can help our camp program track changes/progress in our campers in the areas listed above. We have seen positive changes in our small sample size and predict we will see positive changes with our larger camp population in the next few months.

Applicability of Research to Practice

Using outcome measures for medical specialty camps is necessary and currently lacking in the literature. The PedsQL tool is used in healthy, acute and chronic health conditions, making it applicable for burn camp programs. The PedsQL has established norms for the healthy population for benchmarking purposes and community health comparisons. This tool will help our burn camp program assess the psychosocial, physical and academic growth of our campers.
593 Ambient Room Temperature in a Burn Intensive Care Unit - A Quality Improvement Project
Authors: Rogers Alan D , Cartotto Robert , Ho George
Published: March 2020

Introduction

In patients with burns > 20% TBSA, hypermetabolism, evaporative water loss, infection risk and discomfort are all amplified by exposure to cold ambient temperatures. Post-operative patient hypothermia is also detrimental. It is essential to not only maintain a warm patient room temperature, but also to be able to rapidly increase room temperature in the burn ICU. The purpose of this study was to measure typical patient room temperatures in a burn ICU at an adult regional ABA-verified burn center, and to evaluate our ability to intervene and raise room temperature.

Methods

The ambient temperatures of nine patient rooms were recorded from 14 June to 14 August, 2019. Temperature was measured every minute by a wall-mounted smart sensor placed at standardized positions away from windows or electronic equipment. All devices were tested prior to use, with temperature and humidity accurate and standardized to < 0.2oC and 2% respectively at 18-25oC. Data was transmitted to a mobile smartphone.

On 15 August 2019 all room temperatures were manually adjusted to ‘maximum’. This was identified as a sound change initiative, and replicated a potential medical order to increase the ambient temperature should a hypothermic patient be imminently returning from the operating room or resuscitation area after admission.

Results

Over the baseline observation period (Figure 1) the mean ± SD room temperature was 23.3 ± 1oC. Temperatures deviated below a mean of 22oC during 166 hours per room (11.5%, range 3–362).

Following the intervention on 15 August (Figure 2), ambient temperature increased minimally in 6/9 rooms and only by 2–3°C in two rooms (mean rise of 1.03oC; range -0.88oC to 3.26oC).

Conclusions

The burn ICU rooms are relatively cold and our ability to raise ambient temperature quickly is limited. Further QI change ideas include: 1) a facility engineering assessment 2) set alarms on the smart sensors to alert staff when room temperature falls below a designated threshold.

Applicability of Research to Practice

This project has identified an important future QI initiative to maintain warm ambient patient room temperatures in the burn ICU.
608 The Impact of a Nurse Morbidity and Mortality Meeting
Authors: Figel Ginny , Jelnicky Liz M
Published: March 2020

Introduction

Physicians have long held Morbidity and Mortality (M&M) conferences to discuss complications and deaths. The format for these conferences is to lay out the case, discuss the care performed, and generate discussion on areas of opportunity. Physician M&M usually focuses on teaching and the presenter may not be the caregiver. There is not much literature on the use of this teaching methodology in nursing. Due to the strong culture of safety on the unit, it was determined that creating a Nurse M&M could prove beneficial for discussion of complications, deaths, errors, and good catches as they related to nursing care.

Methods

Nurse M&M is held monthly for one hour. All personnel involved in the cases are informed ahead of time what will be discussed. They are given the opportunity to present the individual case or give personal testimony as to the situation from their point of view. Each case is presented in the same format. The initial slides cover background, history of present illness, and the origin of the report. Next is the pertinent review from the electronic medical record and discussions had with those involved in the case. The floor is then open for discussion. If there was a variation in practice, the policy that relates to the error is reviewed. Topics for Nurse M&M are gathered through many venues. The hospital uses an online reporting system for electronic submission of adverse events, variations in care, and good catches. The entire multidisciplinary team have all individually reported something they wanted discussed at Nurse M&M. If clarification is needed on a case, the question is directed to the appropriate decision maker and followed up on.

Results

Nurse M&M is the most highly attended, non-mandatory, meeting held on the unit. The nursing staff was surveyed to determine their perceptions on how the addition of Nurse M&M had effected them. The results were overwhelmingly positive. All nurses surveyed rated the statement, “I feel that Nurse M&M has had a positive outcome on the unit’s collective practice”, as agree or strongly agree. Over time, the notes taken have evolved from just the discussion to action items created off the case. The staff have will now self-report events before they are entered into the online system.

Conclusions

The nursing staff are highly engaged Nurse M&M. The staff are open to discussing errors in a way that fosters educational growth and critical thinking development. If the case being discussed is because of a personal error, more often than not, the person responsible will discuss why they made the decision they did and facilitate the discussion as to what could have been done differently. The nurses’ commitment to being present, engaged, and open minded are strong signs of the healthy work environment present on the unit.

Applicability of Research to Practice

The format of a nursing M&M conference is applicable to all units. Patient safety and nurse engagement are the top factors effected by Nurse M&M.
625 Death Due to Fractal Wood Burning: An Emerging Public Health Problem
Authors: Campbell Harold , Nizamani Rabia , Jones Samuel W , Cairns Bruce , Williams Felicia N
Published: March 2020

Introduction

The art of pyrography, creating designs in wood with a thermal heat source, dates back to prehistory. Risks include cutaneous burns and airway injury. Fractal woodburning is a niche method of pyrography utilizing a high-voltage electrical source to burn branched designs – Lichtenberg patterns – into the surface of wood. While this technique has grown in popularity, the associated risks are not well described.

Methods

We describe a patient who presented to our burn center after sustaining high-voltage electrical burns from a homemade high-voltage device constructed for fractal woodburning. We also evaluated publicly reported cases of death or injury due to this technique.

Results

An otherwise healthy 17-year-old male was admitted to our burn center with injuries sustained while making fractal wood art. The patient improvised a high-voltage transformer from a discarded microwave, generating 2000 volts from household current. While using this device to burn Lichtenberg patterns in wood, he contacted the electrodes and sustained full-thickness electrical burns to the neck, chest, and bilateral upper extremities. Bilateral upper extremity fasciotomies were required on admission. Multiple subsequent operative procedures culminated with autografting to the majority of the wounds and ongoing complex reconstruction of the left thumb.

In evaluating online news reports, we found 21 unique individuals with death or injury attributed to fractal woodburning. Four sustained substantial injuries, while 17 reportedly died. The first reported incident occurred in July 2016 and the most recent report was from July 2019. Ages ranged from 17 years old to the 60s. Eighteen individuals were younger than 50 years old. All of the mortalities and 3 of the 4 injuries occurred in males. Of the survivors, 3 sustained significant upper extremity injuries and 2 suffered cardiac arrest at the time of injury. The devices used in 4 incidents were microwave transformers and generated 2000 volts. Device characteristics were not identified in the remainder of cases.

Conclusions

Fractal woodburning is associated with devastating high-voltage electrical injuries and death. Prevention efforts should be focused on the potential risks of this art form.

Applicability of Research to Practice

News reports likely underestimate the actual incidence of injury and death due to fractal woodburning, however, even this limited data suggests an emerging public health problem requiring further study and public education.
661 Dietitian Order-writing in a Burn Intensive Care Unit
Authors: Graves Caran
Published: March 2020

Introduction

Recent changes in Center for Medicare & Medicaid Services guidelines recommend that Registered Dietitians (RD) write nutrition-related orders for hospitalized patients. The goal is to improve patient care and assist other clinical providers. Permitted orders may include diets, enteral nutrition and monitoring along with referrals per hospital policies. RD order-writing started in our intensive care units (ICU) the past year. This study reviewed the type and number of orders written by the RD.

Methods

The ICU RD prospectively (January 17, 2019 – August 31, 2019) tallied RD orders including: diet and supplement changes, enteral nutrition, calorimetry, nitrogen balance and intake orders (calorie count). Orders that could have been completed by the RD but were completed by a doctor or physician assistant (PA) were also noted. Data was analyzed using descriptive statistics and results reported as percent of patient days and type of order completed.

Results

Results were collected on a total of 1775 patient day. The majority (1519 = 85.5%) did not require changes in nutritional intervention or monitoring (see Table). Of the 446 nutrition related orders written, the RD completed 347 (77.8%) with 99 (22.2%) completed by the PA. Changes to enteral nutrition, calorie counts and nutrition-related tests (calorimetry and nitrogen balance) the most common. The majority of changes occurred during team rounds.

Conclusions

Most patients did not require changes in diets, nutrition support or nutritional assessment parameters. The most common changes were stopping/starting calorie counts and adjusting enteral nutrition or nutritional monitoring. RD order-writing decreased the number of orders the MD or PA completed.

Applicability of Research to Practice

Order-writing protocols can assist the burn medical team with workflow and allow for more timely nutritional interventions when needed.
663 Effect of Admission Vitamin D Levels on Outcomes in Pediatric Burn Patients
Authors: Pape Kate , Galet Colette
Published: March 2020

Introduction

The effect of vitamin D levels on clinical outcomes has been studied in critically ill non-burn patients and adult burn patients. Low vitamin D levels predicted sepsis and were associated with in-hospital mortality in critically ill non-burn patients. Vitamin D deficiency and insufficiency in adult burn patients correlated with higher rates of complications and longer ICU and hospital length of stay (LOS). Vitamin D levels in pediatric patients have been studied during the post-burn period, showing that low vitamin D levels post-burn may play a role in post-burn osteopenia. However, the effects of admission vitamin D levels on outcomes have not been evaluated in the pediatric burn population.

Methods

This is a retrospective study of pediatric burn patients admitted to an American Burn Association verified burn center over a 3-year period. Patients were included if they were under the age of 18 years and had a vitamin D level measured within 7 days of admission. Vitamin D deficiency was defined as vitamin D level less than 12 ng/mL; insufficiency as vitamin D level 12–20 ng/mL; sufficiency greater than 20 ng/mL. Basic demographics were collected. Outcome data collected included infection, graft loss, renal failure requiring renal replacement therapy, LOS, number of days requiring the ventilator, and need for vasopressors. Univariate and multivariate analyses were performed using SPSS 25.0. P < 0.05 was considered significant.

Results

A total of 249 pediatric patients were admitted during the study period. Of those, 38 patients had vitamin D levels measured within the first 7 days of admission and were included in the study. No patients were vitamin D deficient, and 7 (18%) patients were vitamin D insufficient. No significant differences were observed between patients who were vitamin D sufficient or insufficient with regards to sex, race, or mechanism of burn injury. Patients who were vitamin D insufficient had a longer LOS (15 days vs. 3.34 days; p = 0.023), a larger total body surface area burn size (16.75% vs. 7.23%; p = 0.027), and required more surgeries (1.14 vs. 0.06; p = 0.037). After adjustment for age and gender, higher vitamin D levels were associated with an increased chance of not having surgery (OR = 1.29, 95%CI[1.06–1.58]; p = 0.013).

Conclusions

Despite its retrospective nature and small sample size, our study suggests that pediatric patients who present with vitamin D insufficiency may be at risk for increased LOS and need for surgery.

Applicability of Research to Practice

Larger studies are warranted to identify outcomes affected by low vitamin D levels on admission as well as socioeconomic factors, such poverty level and food insecurity, that may affect vitamin D levels on admission.
704 Lessons Learned from a Mass Disaster: Successful Institutional Planning and Preparedness
Authors: Singhal Maneesh
Published: March 2020

Introduction

This abstract discusses the experience of a Burn disaster at the largest thermal power plant of the country, which was successfully managed at our center. The experience gained will hopefully help in the planning and management of similar disaster scenes in resource-constrained developing countries.

Methods

In a National thermal power plant, there was an explosion in the 500-megawatt unit. Hot fuel gases and steam escaped affecting close to 100 people working around the area. Twenty-six people succumbed to death and six victims who sustained burn injuries were referred to our trauma center where they were received about twenty-six hours after the injury. Despite having no infrastructure supporting the treatment of acute burns, proper planning and coordinated effort by all sectors and persons concerned were immediately initiated and ultimately all patients were discharged in a healthy state with no incidence of mortality or significant morbidity from the burns.

Results

All the six patients were males ranging from 25 to 45 years age and sustained 20% to 45% deep thermal burns over their bodies. All patients were initially evaluated in the emergency where triage was conducted, and four patients out of six were found to have symptoms of respiratory burns and carbon monoxide poisoning. One high dependency unit (HDU) was immediately converted to a burn ICU(Intensive care unit), and all these patients were nursed in isolation. Two patients had severe airway burns and had to be intubated and ventilated. These patients also required hyperbaric oxygen therapy to revert the carbon monoxide poisoning. Out of the six patients, two patients underwent tangential burn wound excision of both upper limbs and skin allograft placement procured from Skin bank. The other four patients underwent debridement, and allograft application subsequently.

all the patients recovered from the burn injuries and were discharged with advice to continue rehabilitation at the regional center. This was one of a kind effort where a trauma center was converted to a full-fledged burn ICU to provide the best possible burn care to the victims. A team of 20 people consisting of Plastic Surgeons, Intensivists, Physiotherapists, Nutritionists, Infection Control Nurses, Wound Care Nurses, Hyperbaric oxygen therapist, and other support staff contributed immensely for management of these patients.

Conclusions

planned cooperation and prepared coordination between the team of doctors and other support staff are the key in the successful management of a disaster.

Applicability of Research to Practice

In the event of a mass disaster a level 1 trauma center was immediately converted to a facility equipped to handle burns. This experience gained may be useful in the future in the planning and management of similar disaster scenes in developing countries with limited resources.
713 Delayed Spinal Cord Injury from Electrical Burns: Case Reports
Authors: AlQasas Taeq , Wibbenmeyer Lucy , Galet Colette , Bertellotti Robert , Granchi Thomas , Mashruwala Neil
Published: March 2020

Introduction

Spinal cord injury has been described in only 2–5% of electrical injuries. Its presentation is often delayed for several days to weeks after the initial injury. Recovery is also variable. Prompted by two recent patients, we sought to review our center’s electrical injury experience.

Methods

Data from all electrical injury patients admitted to our burn center from 12/2002 to 7/2019 were retrieved from the burn registry. Abstracted variables included demographics; admission, injury and treatment data; hospital length of stay (LOS); complications, including infection, graft loss and neurologic injury information if any; and mortality. The medical records of the two spinal cord injury patients were reviewed for hospital course and follow up. Pertinent imaging and neurology consultation were noted. Descriptive statistics were obtained using SPSS.

Results

A total of 168 patients with electrical injuries were identified. The cohort were Caucasians (89.3%) and males (92.3%) with a mean age of 35.6 ± 15.5 years. Almost 90% sustained cutaneous burns with an average burn size of 6.1 ± 11.4%. The mean LOS was 6.3 ± 10.7 days. Less than 20% required mechanical ventilation for 5.6 ± 9.5 days. Seventeen patients were found to have new neurological findings on or after admission; 11 had intracerebral injuries, 3 had peripheral nerve injuries, and 1 had new onset seizures, while 2 developed spinal cord injuries. Complete resolution occurred in 6 of the 14 surviving patients. The two spinal cord injury cases are presented.

Case 1

A 60-year-old male presented with a 40% TBSA after contacting a power line. His burns involved his chest wall and paraspinal muscles of the lower back. On hospital day 6, we noted weakness in his lower extremities which progressed to flaccid paralysis. He had an abnormal magnetic resonance imaging (MRI) and was diagnosed with thoracic myelopathy. He elected to have comfort measures only and died.

Case 2

A 58-year-old male sustained a high voltage injury from an electrical source arcing to a pole he was carrying. He underwent CPR for 2 minutes. On day 2, he started to have progressive weakness of his lower extremities that progressed to flaccid paralysis of his lower extremities. He underwent bilateral below knee amputation. Electromyography and imaging were normal. He is walking with assistance.

Conclusions

Neurological complications after electrical injuries are rare and vary in presentation and outcomes. Complete flaccid paralysis of the lower extremities late after electrical injury is rare and associated with variable degrees of recovery. Of the 17 patients with neurologic problems after electrical injury, nearly half resolved on follow up.

Applicability of Research to Practice

This suggests that electrical injury patients with neurologic signs and symptoms should be closely evaluated and followed.
734 A Comparison of Burn Depth Assessment Between Clinical Diagnosis and Laser Doppler Imaging
Authors: Mitchell Suzanne , Bhavsar Dhaval , Reynolds Jessica , Jones Jessica , Pena Julia M
Published: March 2020

Introduction

Accurate burn assessment is crucial to prescribing appropriate treatment and is dependent upon the experience of the provider and the timing of diagnosis relative to the burn injury evaluation. Differentiating between a deep partial thickness and full thickness burn may not be easily discernible. To augment the clinical diagnosis of burn depth, a laser doppler image measures the microvascular blood flow of injured tissue to predict burn wound healing. The aim of this study is to evaluate the clinical assessment of burn wounds by experienced burn providers compared to the laser doppler image assessment in predicting which burn wounds should heal spontaneously in 3 weeks.

Methods

A retrospective chart review from 2012–2016, included 54 subjects. The clinical assessment included a description of burn variables relevant to the determination of spontaneous burn wound healing (burn depth, total body surface area, mechanism of injury, anatomical location, clinical burn depth diagnosis, and laser doppler image). A chi-square analysis compared the clinical diagnosis and the laser doppler assessment of burn wound depth, as well as the correlation between clinical diagnosis versus laser doppler image in predicting spontaneous burn wound healing.

Results

Comparing partial thickness burn injuries, there were 38 clinically diagnosed partial thickness injuries (by experienced burn providers) and 38 partial thickness burn injures diagnosed via LDI. Deep partial thickness burn injuries were diagnosed clinically in 9 subjects, compared to 10 via LDI. Full thickness burn injuries were diagnosed clinically in 7 subjects and 6 via LDI. A chi-square test was performed to examine the relationship between clinical diagnosis of burn depth and laser doppler image. The relation between these variables was significant,X2= 26.884, p< .000. Comparing clinically diagnosed burn depth to LDI, each approach (clinical or LDI) diagnosed 42 subjects with partial thickness or deep partial thickness burn injuries and all healed spontaneously. Two of the clinically diagnosed full thickness burn injuries required skin grafting. Six patients were lost to follow-up (X2= 17.745, p < .001).

Conclusions

This study confirms there is no difference between an experienced burn provider’s clinical diagnosis of burn wound depth and prognosis for spontaneous healing compared to a laser doppler image prognosis of burn wound healing.

Applicability of Research to Practice

In an era of advanced technologies, expert clinical bedside assessment is the standard of care.