bluuebunny/crossref_metadata_2025 huggingface dataset:
543 Challenges in Burn Nurse and Therapy Staffing During and After a Category 4 Hurricane
Authors: Peterson Abbey , Compton Desiree , Nakamura Dana Y , Landry Jeremy , Keating Aimee , Kopari Nicole M , Carter Jeffrey E , Phelan Herb A
Published: March 2022

Introduction

Burn nurse/therapy staffing has been stretched for months by the pandemic. Along the Gulf Coast, Hurricane Ida recently taxed these resources further as regional burn centers saw a weeks-long surge in serious burn injuries in the setting of prolonged power and water outages. We reviewed the execution of a plan for the provision of burn nurse/therapist staffing at an ABA-verified adult burn center that experienced a direct hit by a Category 4 storm.

Methods

Hospital leadership planned to activate Code Gray on 8/29/21 at which time the hospital would be placed on lockdown with no one allowed in or out until Code Gray was lifted.

Our burn leadership subsequently designed a plan to have ten burn nurses and one Occupational Therapist (TEAM A) in house from the inception of Code Gray at 7am on 8/29 thru 7am on 9/1. If Code Gray conditions persisted, nine dedicated burn nurses (TEAM B) were to relieve TEAM A. TEAM B was planned to remain in-house until 7am on 9/4. If Code Gray conditions continued, the plan was to be reassessed at that time. The same burn therapist was planned to remain in-house throughout. Physician coverage was to be provided by the in-house trauma team during Code Gray. No housing or bedding was provided for in-house personnel, and the hospital generator system ostensibly had a 30-day fuel supply.

Results

TEAM A day/night staffing was 6/4 with the off crew sleeping in conference rooms and clinic spaces. An unexpected event occurred when a mission-critical tower for the city’s grid toppled into a river resulting in delays for restoration of the grid, and city-wide boil-water and burn-ban policies. As generators came into widespread use, our pre-storm census of 9 increased to a mean of 12.7 + 1.4. Due to this increase, on the morning of 9/1 six TEAM A nurses elected to stay and be absorbed into Team B with day/night staffing of 6/6.

The rapid influx in number and complexity of burn patients made it clear a burn surgeon presence was needed during Code Gray. One burn attending was able to make it to the hospital at 7am on 8/30 and worked until being relieved at 7am on 9/5. An informal triage strategy was enacted in which only burns of >10% TBSA would be considered for admission. OR availability went down to 2 + 1 at the inception of Code Gray and 3 + 1 on 9/6. Eleven cases were done during this time with a mean TBSA of 20.2 + 10.7%.

Hospital generators were found to consume fuel at a rate almost twice predicted. Due to prioritization, the hospital went back on city power on 9/2. Code Gray was lifted at 7am on 9/4 and normal operations resumed at 7am on 9/11.

Conclusions

The successful provision of care required a willingness for nurses and one therapist to remain in the hospital for six consecutive days and for hospital administration to approve the overtime.
545 “After The Fire: Legacy of A College Dormitory Fire Twenty Years Later"
Authors: Conlon Kathe M , Marano Michael A , Lee Robin A
Published: March 2022

Introduction

In January 2000 fire erupted at a local college. Panicked students, many who failed to attend school-sponsored fire drills or simply ignored alarms, found themselves scrambling to escape. Seven students were admitted to a burn center (BC) for critical burns, with 54 initially staged in the Medical Center Emergency Department. While this dormitory fire took place more than twenty years ago, its legacy is still being felt today.

Methods

History shows that, with any tragedy, there are lessons to be learned to lessen the impact on property destruction, injury or death. Looking at the legacy of this fire, four key areas of improvement emerged: disaster preparedness, media relations, legislation and fire prevention.

Results

Changes to disaster preparedness include an expanded, more comprehensive response plan, revised triage and transfer protocols, BC staffing protocols, creation of a regional group of BCs, which eventually morphed into a Disaster Consortium, and a medical command center for regional disaster response. A series of articles resulted in a Pulitzer Prize-finalist book, documenting the journey of two of the survivors, with award-winning photographs displayed at a national museum. Redesigned fire safety programs emphasizing escape plans and the dangers of false alarms now targets high school and college students, an often overlooked group, and clinical education programs have expanded to include nursing’s role in disasters, reinforced with a functional exercise. Two survivors are motivational speakers, continuing to share their personal story on campuses across the United States. New legislation mandated sprinkler installation in dormitories nationwide, and a non-profit foundation was formed to improve burn care. The anniversary of this fire is commemorated annually on campus to serve as a powerful reminder for new generations of students.

Conclusions

Despite this dormitory fire being ranked as the deadliest in state history, all these years later the legacy of this landmark event remains one of triumph and resilience, as its impact is still evident today. These lessons serve as the foundation for improved disaster response, locally, regionally and nationally.
559 Nursing Management of Multiple Concurrent Pediatric Patients with Cultured Epidermal Autografts
Authors: Grauer Christine M , Yelvington Miranda L
Published: March 2022

Introduction

For patients with large areas of full-thickness burns and limited autologous donor sites, cultured epidermal autografts (CEAs) can provide life-saving coverage. Nursing care of a patient with CEAs can be challenging due to the fragility of these grafts and compounded by the critical status of the patient. Care of a single patient with CEAs can prove challenging, but in cases in which multiple patients receive CEAs concurrently, these challenges are amplified.

Methods

Three pediatric patients with large burn injuries were admitted on a single day to a large academic hospital with a Burn Center (Table 1).

Nursing care of these children with concurrent CEA placement required an all-hands-on-deck approach and collaboration between the Burn Center (BC) and the Pediatric Intensive Care Unit (PICU) with regards to staffing, care, and positioning. Consistent primary RNs from both the BC and PICU staffed patients and volunteered to work additional shifts during a period of high census. To meet patient needs, the multi-disciplinary care team developed a schedule for CEA exposure, wound care, and therapy interventions.

Results

To meet the needs of these patients under the current staffing pattern, a team schedule was developed (Table 2).

Table 2. Care Schedule

0300-0400 Night shift staff removed anterior and extremity dressings with patients in supine.

0800-0900 Therapy staff arrived early during the day shift to perform therapy interventions with anterior CEAs exposed. Multi-disciplinary teams applied anterior and extremity dressings, positioned patients prone, and removed dressings from posterior CEA sites.

1700-1800 After approximately six to eight hours of CEA exposure, teams reapplied dressings and positioned patients supine.

Conclusions

Staff followed this schedule for these patients until their CEAs were determined to be integrated. Planning and collaboration among all members of the treatment team are integral to the successful care of pediatric patients with CEAs. A schedule for wound care, turning, and CEA exposure can improve staff communication, ease hand-offs, and ensure optimal quality of care for multiple patients with these large burn injuries.
562 Influence of the COVID-19 Pandemic on Emergency Room Visits for Burn Injury
Authors: Gotewal Sunny , Chokshi Shivan N , Song Juquan , El Ayadi Amina , Golovko George , Wolf Steven E
Published: March 2022

Introduction

The COVID-19 pandemic was a devastating occurrence that left millions in critical condition in emergency rooms (ER) across the country. While hospitalizations due to COVID-19 increased exponentially in the last year, several reports have indicated declines in ER use due to common non-COVID related problems. There is currently a dearth of literature examining the effect of the COVID-19 pandemic on emergency room use for acute burn injuries. Thus, we performed a retrospective database analysis using the TriNetX database to quantify the effects of COVID-19 on United States ER visits for acute burn injuries. We hypothesize that ER visits due to burn injury decreased, especially in patients with severe burn injuries- defined as burned total burn surface area (TBSA) >20%.

Methods

Patients who visited the ER from 2010-2020 due to burn injury were identified using ICD-10 codes. We then stratified these patients by age (< 18 and ≥18), severe ( >20% TBSA) vs. non-severe (< 20% TBSA) burn injury, and by change over time in 1-year intervals from 2010 to 2020. Extracted data was analyzed using chi-square with p< .05 considered significant.

Results

We identified a total of 24,620,393 ER visits from 2010-2020. Of these, 142,007 (0.58%) were due to burn injury. A large majority of burn-related ER visits were for non-severe burns (n=134,120, 94.4%). ER visits for acute burn injury decreased by 21.6% during 2020 when compared to years prior. Stratification by age group revealed that pediatric patients (< 18) had more significant decreases in ER Visits than adult patients (≥18). Pediatric patients visited the ER 71.6% less than adults during 2020. When stratified by burn severity, patients with severe burns ( >20% TBSA) and patients with non-severe burns (< 20% TBSA) had similar decreases in ER usage during 2020 when compared to years prior (21.7% and 24.6%, respectively). Further age analysis revealed that both pediatric patients with severe burns and pediatric patients with non-severe burns visited the ER less than their adult counterparts (71.4% and 60.9%, respectively). All of the above differences were statistically significant (p< .05).

Conclusions

During the COVID-19 pandemic in 2020, there was a sharp decrease in ER usage by patients with severe and non-severe burn injuries. This decrease was particularly salient in pediatric populations across all TBSA data points measured.
564 The Impact of COVID-19 on the Provision of Pediatric Burn Care
Authors: Chakera Hawwa , Zuccaro Jennifer , Kelly Charis , Fish Joel
Published: March 2022

Introduction

The WHO declared the outbreak of COVID-19 a pandemic in the spring of 2020 which led to widespread restrictions on daily life activities as people were instructed to isolate at home. Given that 75 – 85% of pediatric burns occur in the home, it is likely that these measures had an impact on pediatric burn care. Thus, the aim of this study was to investigate the impact of the COVID-19 pandemic on the provision of pediatric burn care at an American Burn Association-verified pediatric burn center.

Methods

Data was retrospectively extracted from all new burn patients aged 0-18 years during a pre-pandemic period (April 2019 – August 2019) and a pandemic period (April 2020 – August 2020). Continuous data was examined using 2 tailed t-tests (p < 0.05), while non-continuous data was examined using Pearson chi-squared tests (p < 0.05). These analyses were used to analyze burn demographics and examine changes in the delivery of acute and follow-up burn care before and during the pandemic.

Results

During the pre-pandemic period, 213 new burns were identified, compared to 172 new burns during the pandemic period. No clinically significant changes were observed in patient age at presentation (p = 0.54), total body surface area of burn (p = 0.85), and time to presentation following the injury (p = 0.24). Interestingly, a significant increase in friction burns (p = 0.023) was observed, which mainly consisted of treadmill burns. During the pandemic, burn operating room utilization remained high and represented approximately 25% of the hospital's total surgical capacity. In addition, there were no significant changes to inpatient and outpatient encounters (p = 0.56 and p = 1.00) between the two periods thereby highlighting the need for these essential services during the pandemic.

Conclusions

Burn-related service needs remained consistent across the pre-pandemic and pandemic cohorts as demonstrated by the number of new burns as well as the continued provision of burn care. Overall, no clinically significant changes to patient demographics, aside from the increase in friction burns, were observed. Furthermore, the ability to provide all aspects of pediatric burn care at this tertiary pediatric hospital remained consistent across the pre-pandemic and pandemic cohorts. Although this study presents data from the first five months on the pandemic, further analysis of the entire year will be carried out in order to identify additional trends.
565 Impact of Municipal Ordinances on Firework-Related Injuries
Authors: Mefford Austin T , Duggan Robert P , Kirk Katie , Palackic Alen , Branski Ludwik K
Published: March 2022

Introduction

There is significant heterogeneity in firework-related legislation across the country, with some states outright banning sales, possession, and use. Others restrict the dates and types of fireworks that can be purchased. Municipalities often adopt firework ordinances that apply within their city limits, pushing the sale and use into unincorporated areas or permitting easy access to illegal fireworks for transport into city limits. We seek to understand how effective firework ordinances are at preventing firework injuries. We hypothesize lax municipal ordinances will have a limited effect on firework-related injuries.

Methods

Two time periods where the commercial sale of fireworks is legal were identified, and we reviewed patients presenting during those windows for the acute management of firework-related burns. This corresponds to June 24 – July 11 and December 20 – January 8. Patient demographics and burn outcomes were collected. Socioeconomic status was determined using a standardized scale (0-100) that incorporates Census data, with higher scores reflecting more disadvantaged communities. Legality was determined by a review of municipal ordinances and patient residence.

Results

Thirty-five patients were identified between December 2016 and January 2021. More injuries occurred around July 4th compared to New Year’s (54% vs. 46%). The cohort was predominantly men (77%) with an average age of 29 years. Patients most commonly came from suburban areas (34.3%), compared to rural (25.7%), urban (20%), or small towns (17.1%). Alcohol use at the time of injury was reported in 14% of cases. Explosive fireworks (e.g., mortar shells) (63%) were more common than sparklers. Hands were the most frequently injured area (83%), but no amputations, traumatic or surgical, occurred. Eye injuries occurred in 17.1% of patients, but no long-term damage to vision was sustained. Eight patients (23.9%) required inpatient management, and six (17.1%) required operative management. Split thickness skin grafting and local tissue rearrangement were the extent of the operations performed. One patient required neurosurgical intervention after a mortar shell detonated adjacent to their cranium, representing the lone fatality in the cohort. There was no significant difference in the number of legal (18) and illegal (17) firework injuries. Socioeconomic status was not different between legal and illicit groups (46 vs. 54, p = 0.101).

Conclusions

A substantial number of patients sustained firework-related injuries in municipalities where fireworks are banned, giving the impression that current ordinances are ineffective. Public health officials and legislatures may consider the more widespread implementation of regulations or increased penalties to combat firework-related injuries.
572 Burn injury from smoking electronic cigarettes while on supplemental oxygen
Authors: Kahn Steven A , Hollowed Kathleen , Ozhathil Deepak
Published: March 2022

Introduction

Burn injuries from exploding electronic cigarettes have been well documented in the medical literature and lay press, as have injuries from smoking conventional cigarettes while on supplemental oxygen. However, there is a paucity of literature regarding injuries from smoking electronic cigarettes while on supplemental oxygen. Empirically, it might seem safe to use e-cigarettes while on oxygen, but it can result in explosion. The electronic cigarette coil can heat up to 350°C and serve as a source of ignition. The purpose of this study is to describe and characterize this relatively novel and uncommon mechanism of injury.

Methods

This study was a descriptive review of 2013-2016 National Burn Repository (NBR) Data. Injury description fields were queried for “oxygen”, “O2”, “electronic cigarettes”, and various abbreviations and misspellings. Demographics, burn size, length of stay, expected length of stay using 1.1 days per %TBSA, and LOS index were reported. In addition, a Google search for lay press articles using the terms “smoking,” “’oxygen,” and “electronic (or e) cigarettes was performed, and these cases were tabulated.

Results

Of approximately 60,000 NBR entries, only 8 records of injury while smoking e-cigs on oxygen were found. Patients were predominantly male (63%) with a mean age of 63±9 years old, burn size of 3.4%±4 TBSA and LOS of 5.8±7 days. Inpatient stay averaged 1.65 days per %TBSA, which was 150% of expected LOS for the cohort. Two patients sustained third degree burns of 0.5% and 11%TBSA. Three patients were intubated, and had a mean of 3.33 ventilator days. Most injuries occurred at home (88%), while one occurred in a hospital. All 8 patients had Medicare and none of them suffered mortality. A google search revealed three distinct lay press articles regarding this topic.

Conclusions

Although an uncommon mechanism of injury, smoking electronic cigarettes on supplemental oxygen can result in injury and a significant hospital stay. Limitations in abstraction from the database and/or reporting might have resulted in an under capture of the true number of injuries. Circumstances resulting in this phenomenon warrant further investigation, as it is unclear if it occurs from malfunction or a hot coil alone. Patients who are prescribed home O2 should be warned about this potential danger.
584 Where Are They Now? - A Single-Center Survey of Burn Surgery Fellow Graduates
Authors: Prophete Justine , Lodin Daud , Gallagher Jim , Houng Abraham
Published: March 2022

Introduction

Burn surgery encompasses different surgical disciplines such as general surgery, trauma, surgical critical care and plastic surgery. Those who apply to burn fellowship also have various interests. This study’s purpose was to discern the various career paths of burn fellowship graduates. It also investigated the frequency of specific chosen specialties and workplace settings. The results of the study could be used to modify current clinical burn fellowship curriculum.

Methods

A survey was created using an internet tool and emailed to graduates of the clinical burn fellowship program from an American Burn Association verified burn center. The survey was sent to graduates of the last 10 years (2010-2020). The questions inquired about surgical field of work, board certification, additional training experience, work setting, and time since fellowship graduation. The participants’ responses were recorded anonymously to account for biases. The quantitative data was then collected for each question, and the data was calculated into percentages.

Results

Of the possible 17 fellows who graduated in the past ten years, 11 responded to our survey (64.7%). The most common surgical field pursued after the fellowship was plastic surgery with 5 graduates (45.5%). The following three fields all had 2 graduates each: burn surgery (burn/trauma), general surgery and wound care (18.2%). Almost all of the participants had completed additional training: 6 in plastic surgery (54.5%), and 4 in surgical critical care (36.4%). The work settings were primarily academic institutions (45.5%), followed by office-based practices (35.4%), ambulatory surgery centers (9.1%), and community hospitals (9.1%). Of the participants, 4 are board-certified in their chosen field, and 5 are board-eligible. Only 3 graduates are affiliated with a burn center.

Conclusions

The results of the study indicate the interests and career choices of previous burn fellows. This information can be used to modify burn fellowship curriculums to the needs and future career paths of the fellows. Traditional clinical burn fellowship programs emphasize burn critical care and acute burn surgery. Since some of the graduates are interested in plastic surgery, burn reconstruction could be added to the current curriculum. Plastic surgery faculty members could also serve as mentors to the fellows.
585 Focused Wound Care Handoff Improves Burn Center Physician-Nursing Communication and Wound Care Education
Authors: Rostami Sohayla , Kawaji Qingwen , Martinez Stephanie L , Lagziel Tomer , Orosco Rowena , Flores Carolina J , Hultman Charles S , Caffrey Julie
Published: March 2022

Introduction

Burn patients often require changing wound care routines dependent on wound characteristic and operative interventions. Unfortunately, order discrepancies on electronic medical systems, poor communication between providers, nursing, and wound care technicians leads to incorrect wound care treatment. By creating a daily dedicated wound care discussion involving integral components of the wound care team (provider, charge nurse, and wound care technicians), we hope to improve communication amongst team members and provide wound care education at all levels.

Methods

The study was carried out at a single-center burn unit. A pre-intervention, de-identified survey was distributed to the nursing staff to determine familiarity with wound care as well as assessment of communication regarding wound care in the burn unit. A planned intervention was then initiated for a period of four weeks. Daily, timed dedicated wound care rounds were carried out. The wound plan was then reflected on a personalized diagram for each patient, on electronic medical records and updated on resident/fellow notes. Nursing staff satisfaction and assessment of communication was completed again using a post-intervention, de-identified survey.

Results

Initial data from our planned four-week intervention showed that on average, we round on 7.9 patients on burn wound unit, 4 patients on intermediate care unit (IMC), and 2.9 patients on intensive care unit daily. During wound care handoff, we discussed 12.5 patients daily with an average time of 51 seconds per patient. When wound care routines are added to morning rounds, we spend 50 seconds per each burn wound unit patient, 120.5 seconds per each IMC patient and 735 seconds per each ICU patient. There was a total of 19 surveys collected prior to intervention. Four of the 19 surveys were filled by burn wound floor nurses and 15 were filled by ICU nurses. On average, nursing reported their wound care proficiency to be 4 out of 5 (5 being the highest score). Majority reported spending about 1-3 hours per shift on wound care (58%). Most nurses review wound care routine on nursing handoff (66%), resident/fellow notes (22%) and electronic medical record orders (11%). Mid-intervention satisfaction survey showed that most nurses felt that communication was improved, discrepancies between staff members were minimized, and that 100% of nurses wanted this intervention to be continued.

Conclusions

Adverse wound care events can happen despite nursing self-reported high level of wound care proficiency. To ensure accurate plan of care, wound care routine needs to be communicated at multiple levels: during rounds, in daily progress notes, and on electronic medical record orders.
586 Graft Loss: 5-year Review of a Single Burn Center’s Experience with an Institutional Grading Scale
Authors: Nosanov Lauren B , Travis Taryn E , Tejiram Shawn , Brantley Melissa , McLawhorn Melissa M , Moffatt Lauren T , Shupp Jeffrey W , Johnson Laura S
Published: March 2022

Introduction

Despite increasing attention on provisioning quality burn care, there continues to be no consensus definition of burn “graft loss”, nor a uniformly adopted scale to grade severity. The American Burn Association Burn Quality Improvement Project metric is a binary code identifying only "failure to achieve >95% autograft take." We introduced an institutional graft loss scale in 2014 for quality improvement and reported initial results and interrater reliability. With additional data now available for analysis, a secondary review was undertaken.

Methods

All patients with graft loss were identified on departmental Morbidity and Mortality (M&M) reports between 7/2016-7/2021. Graft loss grades were assigned during clinical care per institutional scale (Table 1). Non-burn acute surgical wounds that underwent skin grafting were included, but chronic non-healing wounds were excluded. Data abstracted included demographics, medical history, injury details, surgical procedures, graft loss, and lengths of stay. In situations where the graft loss grade recorded on M&M documentation was discordant with the grade documented in the medical record, the grade assigned at the later point in time was used for analysis.

Results

Graft loss was noted in 260 instances for 200 patients. Mean age was 51.4(±7.5y)years. The majority were male (60.7%) and African American (48.0%). Smoking (26.0%) and diabetes (37.5%) were prevalent. Overall mortality was 4% (8/200). Graft loss percentages by grade are 28% (grade I), 28% (grade II), 13% (grade III), and 22% (grade IV). An additional 9% were deemed either unknown or due to a technical error. Overall reporting of graft loss grades improved over time as surgeons became more familiar with the scale. Reported percentages of Grades I and II graft loss also increased over time, indicating better compliance with the overall goals of this quality improvement project.

Conclusions

A graft loss grading scale can be applied to track split thickness autografting outcomes among a diverse group of surgeons. Regular reporting of low grade graft loss needs to be done to understand the complete distribution of graft loss after surgical intervention, including documentation of allograft and other skin substitute loss. Improved reporting in the medical record can optimize data collection for quality assessment purposes.
596 Implementation of a Burn Laser Program at a Children’s Hospital
Authors: Kopari Nicole M , Lindsey Kristen , Phelan Herb A , Carter Jeffrey E
Published: March 2022

Introduction

Carbon dioxide ablative fractional laser (CO2-AFL) therapy has become standard of care for adult burn hypertrophic scars (HTS). This therapy option has not been widely adopted in pediatric burn care and no established guidelines for treatment protocols have been published. We sought to modify our American Burn Associated Adult Verified Burn Centers laser protocol at our Children’s Hospital with hopes to provide optimal care to our pediatric burn population. We present our protocol and early experience of CO2-AFL therapy for pediatric burn HTS.

Methods

We conducted a retrospective chart review of pediatric burn patients undergoing CO2-AFL treatment of HTS during the study period of Jan 2021-Oct 2021. Pediatric burn patients were offered laser treatment if their scars were symptomatic with patient complaints of HTS, pruritis, neuropathic pain, and scar contractures. 37 pediatric patients ≤13 years of age were included in our review.

Results

We treated 13 pediatric patients for a total of 40 laser sessions with each patient averaging 3 sessions. Of the 13 patients that were treated with laser, 62% (8 of the 13 patients) had split-thickness skin grafting with 38% (3 of the 8 patients) of those having a staged grafting procedure with dermal substitute. 15% (2 of the 13 patients) healed primarily and 15% (2 of the 13 patients) required excision and closure. Only 1 patient treated with ASCS alone required laser therapy. Our protocol requires patients to receive pre-operative Tylenol, Benadryl, Pepcid, and Oxycodone. The patients then received MAC anesthesia with Toradol, Dexamethasone, Ketamine or Propofol, and Zofran. Patients with extensive HTS on the face or neck were intubated for the procedures. Oxycodone and/or Dilaudid were provided if needed in the post-operative phase. All patients were discharged with Tylenol or Motrin and Triamcinolone 0.1% ointment to be applied daily for 48 hours and then 3-4x/day until the follow-up clinic appointment at one week. Patients were able to resume normal activities the day following the procedure.

Conclusions

Patients and their parents have reported improvements in pigment, pliability, thickness, and pruritis following laser treatments. We created a protocol that allows on average 8 pediatric patients per day to receive laser treatment without it over burdening the pre-operative and post-operative recovery room nursing staff. We are currently tracking outliers of patients requiring increased post-operative analgesia and/or greater than 1 hour in the recovery phase. With the implementation of a laser protocol, we have successfully introduced laser therapy as a viable option for our pediatric burn survivors.
598 Reconstruction of Trochanteric Pressure Ulcers with Pedicled Vastus Lateralis-Anterolateral Thigh Flap
Authors: Ozkan Burak , Uysal Cagri A , Aydogan Cem , Haberal Mehmet
Published: March 2022

Introduction

Trochanteric region is one of the most frequent site for pressure ulcer development. High-voltage electric injuries with neurovascular damage is an important reason of paraplegia. These patients have prolonged hospitalization period and develop cachexia by time. Grade 3-4 sores with thoracanter major of femur exposition generally need flap reconstruction. Musculocutaneous flaps are preferred to cover exposed bone and fill the dead space. Although loco regional flaps such as tensor fasia lata, gluteus Maximus muscle flap have been used for thoracanteric ulcers, these flaps have mandatory muscles for ambulation in the following rehabilitation period. Another disadvantage of these flaps are the possible donor site problems due to pressure loading. Thus, we aimed to used vastus lateralis- anterolateral thigh(VL-ALT) flap for decreasing donor-site morbidity and tension.

Methods

Between 2019 and 2021 we have operated 6 trochanteric pressure ulcers in 5 patients. All patients had history of electric injury related paraplegia. The mean age of the patients was 33 (24-50) The defect size were ranging between 5x4cm and 10x12 cm. Flap size were planned according to exact size of the defect. VL muscle were harvested according to the size of dead space. The donor site was closed primarily in 3 patients. Split thickness skin graft were needed in 2 patients. Patients were hospitalized in lateral decubitus or supine position during follow –up.

Results

Mean follow up time was 10 months (6-18). All flaps were survived. Hematoma development were seen in 1 patient in the donor site which were treated with bedside debridement. No recurrence was seen during follow-up period. No restriction or morbidity were encountered during ambulation.

Conclusions

VL-ALT musculocutaneous flap provides the required tissue for dead space filling and defect closing simultaneously. The advantages of this flap are; lower donor site morbidity, perfect match in terms of skin quality and bulk, protecting the major muscles such as gluteus maximus and tensor fascia lata. The technique needs knowledge of quadratus femoris anatomy which has a short learning curve.
602 Foot burns in diabetic patients: A single center experience
Authors: Choi Katherine J , Gillenwater Justin , Pham Christopher H , Sheckter Clifford C , Collier Zachary J , Dang Justin , Huang Samantha , Yenikomshian Haig A , Garner Warren L
Published: March 2022

Introduction

The most significant sequelae of foot burns in diabetic patients is a non-healing wound that results in a diabetic foot ulcer, which has been a predictor for need for amputation and mortality. Even minor amputations in patients with diabetes have a significant mortality rate. Our systemic review found that when 60% of a diabetic patient cohort with foot burns was managed by skin grafting, 29% subsequently required amputations, which is concerning. The practice at our regional burn center has been to manage patients with foot burns and diabetes non-operatively with daily dressing changes, and we believe that this may result in better functional outcomes, ambulatory status, and lower amputation rates.

Methods

A retrospective review of patients with diabetes and foot burns admitted to an ABA verified regional burn center was conducted. The primary outcome was amputation. Secondary outcomes were ambulatory status, wound closure, and infection. Rank sum and fisher exact tests were performed to compare patient demographics, comorbidities, uncontrolled DM (A1c >9%), and burn characteristics between patients who were treated surgically and those who received daily wound care only. These associations were subsequently evaluated with odds ratios (OR) and 95% confidence intervals (CI). A multivariable logistic regression was performed to evaluate for possible differentiating factors that resulted in maintaining ambulatory status at completion of burn care. Statistical significance was defined as p< .05.

Results

Of 75 patients identified, median TBSA burned was 2% (IQR 2), and 61% (n=46) had full thickness burns. Mean A1c at admission was 9% (SD 2). In terms of management, 9% (n=7) were treated with debridement and/or skin grafting, and 9% (n=7) later required lower extremity amputations. Infection during first admission developed in 8% (n=6). At completion of burn care, 73% had normal or same ambulatory status, and older patients were less likely to maintain ambulatory status (p=.009, OR=0.92, 95% CI=0.86-0.98). Median time to wound closure was 95 (IQR 130) days, and 12% (n=9) of wounds never fully closed. Burn depth (second vs third degree), burn location (plantar burn vs other areas), uncontrolled DM, and surgical treatment did not result in a statistically significant difference in maintaining ambulatory status at completion of burn care.

Conclusions

Diabetic patients with foot burns are best managed non-operatively with daily dressing changes, and should be allowed to heal secondarily. This may result in a longer time to close the wounds, but the amputation rates were much lower when compared to surgical management. However, 5% of our cohort developed diabetic foot ulcers at completion of burn care, which is a complex disease process that carries a dire prognosis.
604 From admission to discharge: a total friction burn review from a single institution
Authors: Estrada Munoz Oscar I , Sabour Andrew F , Carroll Joseph T , Flores Carmen E , Fraser Douglas R , Chestovich Paul J , Saquib Syed F
Published: March 2022

Introduction

Most friction burns are adequately managed in an outpatient setting. However, many require hospital admission, operative excision, and extended care especially those that present at trauma or burn centers. There is a wide variance in friction burn management. Our goal is to review the etiology, management, and outcomes of such burns warranting hospitalization.

Methods

We conducted a retrospective review of all friction burns admitted to a single, American Burn Association verified burn center from January 1, 2016 to December 31, 2020. Individual chart analysis was performed using data from the hospital’s burn registry. Statistical analysis was performed using Chi-square and Wilcoxon rank-sum test with p< 0.05 being significant.

Results

Eighty-two patients met the inclusion criteria. Mean age was 35.4 years (95% CI 31.6-39.2). The overall mean Total Body Surface Area (TBSA) was 9.0 % (95% CI 7.5-10.6), and mean TBSA of 3rd degree burns was 1.1 % (95% CI 0.6-1.7). The most common mechanism of injury was motorcycle collision (45, 55%), followed by pedestrian struck by automobile (13, 16%). Fifty-four individuals (65%) had a concomitant injury. The most common topical agent used was silver sulfadiazine (52%), followed by bacitracin (21%). Sixteen patients (20%) required ICU level of care. Twenty-eight (34%) patients required surgery for their friction burns and 15 (18%) ultimately required a split-thickness skin graft. The mean number of operations was 2.4 (95% CI 1.6-3.1).

Overall, the operative group was younger (29.9 vs 38.3 years, p=0.026), more likely to have a concomitant traumatic brain injury (25% vs 7%, p=0.027) and had a longer hospital length of stay (17.5 vs 3.9 days, p< 0.001). Both groups had a similar overall TBSA (8.5% vs 10.0%, p=0.35), but the operative group had larger surface area comprised of 3rd degree burns (3.05% vs 0.2%, p< 0.001). Eighty-one patients survived with the sole death due to massive hemoptysis.

Conclusions

Friction burns resulting in hospital admission are associated with high-energy traumatic mechanisms and concomitant injuries. Patients who need operative intervention of their burns typically require multiple procedures often culminating in a split-thickness skin graft.
606 Novel application of a surgeon-operated clysis delivery system in burn surgery
Authors: Morzycki Alexander , Wong Joshua N
Published: March 2022

Introduction

Tangential excision of burns is associated with significant bleeding. Sub-eschar insufflation of epinephrine-containing clysis has shown to decrease blood loss and associated complications. Administration of adrenaline-containing infiltrates are also beneficial in the harvest of split thickness skin grafts. Clysis is typically delivered with the assistance of a perfusionist-operated system. This method, however, is associated with significant cost and dependent on personnel availability. This study evaluated the use of a novel surgeon-operated fluid management system in the delivery of clysis in burn surgery.

Methods

Our initial experience with a novel fluid management system is presented. Prospective collection of infiltration data, including average temperature, pressure, and volume of clysis was performed. Patient and burn factors were evaluated and complications collected. Finally, a cost-effectiveness analysis was conducted.

Results

Thirty-seven consecutive cases comprising 22 adult patients (15/22, 68% male), with a mean age of 49 years (+/- 19) were reviewed. The mean % total body surface area of all patients was 39 (+/- 21.7). The mean temperature, pressure and volume of administered clysis was 32.2 degrees Celsius (+/- 4.4), 265.04 mmHg (+/-56.17), and 5805.8 mL (+/- 4844.4), respectively. The mean dose of epinephrine administered was 14.5mg (+/- 12.1). The mean temperature variability was 1.1 °C (+/- 1.2). Total mean packed red blood cells (PRBC) transfused was 507.6 mL (+/- 624.4). There were no recorded complications. We identified a cost savings of $20,766 CAD over the cases examined.

Conclusions

We present the novel application of a fluid management system in burn surgery. This technique provides rapid and safe infiltration of warmed clysis. We are able to maintain intra-operative euthermia despite a large volume of administered clysis and significant intraoperative vulnerability to hypothermia. In addition, this technique may be transfusion-sparing. The introduction of this method of clysis administration was associated with significant cost-savings.
608 Utilization of Phase-Based Guidelines For Patient Care After Application of Cultured Epithelial Autograft
Authors: Ewanowski Kathleen M , Bramble Caitlin , Anyan Walter R , Fleming Irma D , Hopkins Ronda , Morris Stephen E , Thompson Callie M , Lewis Giavonni M
Published: March 2022

Introduction

Cultured epithelial autografts (CEA) have been clinically utilized since 1981 & can be a lifesaving procedure in patients with extensive full thickness burns. CEA is more susceptible to bacterial contamination & complete graft loss than traditional split-thickness autografts, yet no standard of practice exists for the postoperative care of these grafts to minimize infection & maximize graft take.

Prior to 2019, care of CEA patients at our institution was not standardized & instead varied upon the attending surgeon’s practice. With the input of interdisciplinary team members, CEA patient care was standardized via phase-based guidelines (PBGs), leading to improved team communication & improved patient outcomes.

Methods

PBGs were created via interdisciplinary collaboration among surgeons, APCs, nursing staff, PT/OT, & psychosocial providers. Team members agreed upon 3 facets of patient care: Wound Care/Airing Out, Restrictions/Visitors, & Burn Therapy (Figure 1). As wounds progressed postoperatively, patient phases were advanced, liberalizing them from rigorous infection-prevention techniques to strict unit standards for non-CEA burn patients.

In 2019, the utilization of patient-specific CEA care plans ceased in favor of standardized PBGs. A retrospective chart review was conducted on all patients from 2018-2021 who received CEA & survived their injuries. Some patients underwent a single CEA application while others underwent multiple operations. CEA graft take was assessed on all wounds from each surgery.

Results

CEA was rarely used at our institution. Beginning in 2018, seven patients received CEA & survived their injuries, ranging in age from 4-59 yrs (mean 24) & %TBSA from 38-80 (mean 53) (Table 1). Implementation of PBGs correlated with subjective improvement in team communication & increased mean percentages of CEA graft take from < 35% to >75%.

Conclusions

PBGs have standardized care for our CEA patients, eliminated communication errors among team members, & increased CEA graft take. Further research is needed to determine efficacy in decreasing infection, antibiotic use, hospital stay length, & mortality in these patients.
614 Laser-treatment of Hypertrophic Scar Induces Change to Epidermal Histoarchitecture Correlating to Improved Epidermal Barrier Function
Authors: Jimenez Lesle M , Oliver Mary A , Keyloun John W , Travis Taryn E , Shupp Jeffrey W , Moffatt Lauren T , Carney Bonnie C
Published: March 2022

Introduction

Mechanisms and timing of hypertrophic scar (HTS) improvement with laser therapy are incompletely understood. Epidermal keratinocytes influence HTS through paracrine signaling, yet they are understudied compared to fibroblasts. It was hypothesized that fractional ablative CO2 laser scar revision (FLSR) would change the fibrotic histoarchitecture of the epidermis in HTS.

Methods

Duroc pigs (n=4 FLSR and n=4 controls) were injured and allowed to form HTS. HTS and normal skin (NS) were assessed weekly by non-invasive skin probes measuring trans-epidermal water loss (TEWL) and biopsy collection. There were 4 weekly FLSR treatments. Early laser treatment began on day 49, and late began on day 77. Punch biopsies from NS and HTS were processed and stained with H&E. Image J was used to obtain epidermal thickness and rete ridge ratios (RRR). Gene and protein expression of involucrin (IVL) was examined through qRT-PCR and immunofluorescent (IF) staining.

Results

After treatment, peeling sheets of stratum corneum were apparent which were not present in the controls. TEWL was increased in HTS vs. NS at day 49 indicating decreased barrier function (42.2±8.0 vs. 22.0±4.62g/m2h, p=0.05). In the early group, TEWL was significantly decreased at week 4 to 16.4±3.5 g/m2h (p< 0.05). The late group was not significantly altered from NS at the pre-laser timepoint (day 77=12.1±1.99 g/m2h). Hence, there was no decrease in TEWL post-FLSR. After 4 sessions, epidermal thickness was significantly increased in treated scars in both FLSR groups (early:pre=85.6±6.8 vs. week 4=115.2±12.0 µm, p< 0.01) and (late:pre=75.2±6.6 vs. week 4=125.7±12.0 µm p< 0.001, n=8 scars,). There was no increase in controls. Late intervention significantly increased RRR (pre=1.3±0.1 vs. week 4=1.9±0.1, n=8 scars, p< 0.05), and early treatment trended towards increase (pre=1.17±0.05 vs. week 4=1.4 + 0.1). There was no increase in controls. There was increased IVL gene expression in HTS vs. NS that decreased after FLSR. Eight scars had up-regulated gene expression of IVL vs. NS levels pre-treatment (FC >1.5) compared to 4 scars at week 4. This was confirmed by IF where IVL staining decreased at week 4.

Conclusions

Changes in epidermal HTS histoarchitecture and expression levels of epidermal differentiation markers were induced by FLSR. The timing of laser intervention contributed to differences in TEWL, epidermal thickness, and RRR.
615 Evaluation of Topical Off-The-Shelf Therapies to Improve Burn Wound Healing During Prolonged Field Care
Authors: Varon David E , Nuutila Kristo , Cooper Laura E , Chapa Javier , Valdera Franklin , Christy Sean E , Christy Robert J , Chan Rodney K , Carlsson Anders H
Published: March 2022

Introduction

Burns are common injuries in the battlefield. Given austere environments, prolonged field care (PFC) is often necessary. Delays in surgical debridement create a risk of infection and deranged healing for burn patients. As such, this study attempts to identify the best commercially available off-the-shelf (OTS) dressings with field-deployable potential.

Methods

Deep-partial thickness burns (1" diameter) were created on the dorsum of 3 anesthetized pigs utilizing a thermocoupled burn device at 100°C for 15s. Non-surgical debridement was done 1-h post-burn creation and either an OTS dressing or standard-of-care (SOC) treatment (Silver Sulfadiazine) was applied to the wound in order to simulate a PFC environment. OTS dressings were randomized and included irradiated sterile human skin allograft (ISHSA), alloplastic absorbable skin substitute (AASS), and synthetic polyurethane dermal matrix (SPDM). Wounds were serially assessed on post-burn days 3, 7, 14, 21, and 28. Assessments were conducted using a combination of photographs, histology, and quantitative bacteriology. Endpoints included burn wound progression, re-epithelialization, wound contraction, scar elevation index (SEI), and colony forming units (CFU).

Results

No statistically significant differences in burn wound progression were seen on days 3 and 7 for the ISHSA or SPDM and the SOC. The differences between the AASS and the SOC were statistically significant on both days (p≤0.05). Day 21 re-epithelialization results for the ISHSA, AASS, SPDM and SOC treated wounds were 30%, 85%, 95%, and 78% re-epithelialized, respectively. The difference between the AASS and the SOC was statistically significant (p≤0.05). Results showed that by day 28, wound contraction for the ISHSA, AASS, SPDM and SOC treated wounds were 65%, 80%, 82%, and 78%, respectively. No statistically significant differences in wound contraction were seen for any of the OTS dressings and the SOC. SEI showed no statistically significant difference in scar hypertrophy between the OTS dressings and the SOC on day 28. CFU results showed no statistically significant differences between the OTS dressings and the SOC on days 3 and 7.

Conclusions

Three OTS dressings were compared to the SOC for use in the PFC setting. Generally, all the dressings performed well when compared to the SOC in terms of burn wound progression, re-epithelialization, wound contraction, SEI, and CFU. Although significant differences in burn progression and re-epithelialization for burns treated with AASS were seen. In the future, we hope to continue to discover and test various OTS dressings to determine their appropriateness for use in the PFC setting.