The impact of acquired coagulation factor XIII deficiency in traumatic bleeding and wound healing.

Factor XIII (FXIII) is a protein involved in blood clot stabilisation which also plays an important role in processes including trauma, wound healing, tissue repair, pregnancy, and even bone metabolism. Following surgery, low FXIII levels have been observed in patients with peri-operative blood loss and FXIII administration in those patients was associated with reduced blood transfusions. Furthermore, in patients with low FXIII levels, FXIII supplementation reduced the incidence of post-operative complications including disturbed wound healing. Increasing awareness of potentially low FXIII levels in specific patient populations could help identify patients with acquired FXIII deficiency; although opinions and protocols vary, a cut-off for FXIII activity of ~ 60-70% may be appropriate to diagnose acquired FXIII deficiency and guide supplementation. This narrative review discusses altered FXIII levels in trauma, surgery and wound healing, diagnostic approaches to detect FXIII deficiency and clinical guidance for the treatment of acquired FXIII deficiency.

Ventilation practices in burn patients-an international prospective observational cohort study.

BACKGROUND: It is unknown whether lung-protective ventilation is applied in burn patients and whether they benefit from it. This study aimed to determine ventilation practices in burn intensive care units (ICUs) and investigate the association between lung-protective ventilation and the number of ventilator-free days and alive at day 28 (VFD-28). METHODS: This is an international prospective observational cohort study including adult burn patients requiring mechanical ventilation. Low tidal volume (V T) was defined as V T ≤ 8 mL/kg predicted body weight (PBW). Levels of positive end-expiratory pressure (PEEP) and maximum airway pressures were collected. The association between V T and VFD-28 was analyzed using a competing risk model. Ventilation settings were presented for all patients, focusing on the first day of ventilation. We also compared ventilation settings between patients with and without inhalation trauma. RESULTS: A total of 160 patients from 28 ICUs in 16 countries were included. Low V T was used in 74% of patients, median V T size was 7.3 [interquartile range (IQR) 6.2-8.3] mL/kg PBW and did not differ between patients with and without inhalation trauma (p = 0.58). Median VFD-28 was 17 (IQR 0-26), without a difference between ventilation with low or high V T (p = 0.98). All patients were ventilated with PEEP levels ≥5 cmH2O; 80% of patients had maximum airway pressures <30 cmH2O. CONCLUSION: In this international cohort study we found that lung-protective ventilation is used in the majority of burn patients, irrespective of the presence of inhalation trauma. Use of low V T was not associated with a reduction in VFD-28. TRIAL REGISTRATION: Clinicaltrials.gov NCT02312869. Date of registration: 9 December 2014.

Point-of-care measured serum cholinesterase activity predicts patient outcome following severe burns.

Risk stratification is of utmost importance in burn therapy. However, suitable bedside biomarkers to evaluate the emerging inflammatory response following burn injuries are missing. Serum cholinesterase (butyrylcholinesterase, BChE) has been shown to be a clinically relevant biomarker in acute inflammatory diseases including burns. In this observational cohort study BChE activity was measured by using point-of-care testing (POCT), a novel method in acute burn care. POCT measurements were performed at emergency room admission (ERA) of 35 patients and repeated 12, 24 and 48 h later. All patients or their legal designees gave informed consent. Patients with burn injuries showed sustained BChE activity reduction following hospital admission. BChE activity correlated negatively with burn injury severity, organ failure severity and intensive care unit resource requirements. BChE activity measured at ERA and 12 h later identified survivors and predicted 28-day patient outcome with noninferior efficacy compared to the abbreviated burn severity index (ABSI) scoring. Finally, POCT-measured BChE activity might complement ABSI scoring and possibly improve early risk stratification in acute burn care therapy.

International Multi-Center Analysis of In-hospital Morbidity and Mortality of Low-Voltage Electrical Injuries.

Background : Patients with high- and low-voltage electrical injuries differ in their clinical presentation from minor symptoms to life-threatening conditions. For an adequate diagnosis and treatment strategy a multidisciplinary team is often needed, due to the heterogeneity of the clinical presentation. To minimize costs and medical resources, especially for patients with mild symptoms presenting after low-voltage electrical injuries, risk stratification for the development of further complications is needed. Methods : During 2012-2019 two independent patient cohorts admitted with electrical injuries in two maximum care university hospitals in Germany and Austria were investigated to quantify risk factors for prolonged treatment, the need of surgery and death in low-voltage injuries. High-voltage injuries were used as reference in the analysis of the low-voltage electrical injury. Results : We analyzed 239 admitted patients with low-voltage (75%; 276 ± 118 V), high-voltage (17%; 12.385 ± 28.896 V) or unclear voltage (8%). Overall mortality was 2% (N = 5) associated only with high-voltage injuries. Patients with low-voltage injuries presented with electrocution entry marks (63%), various neurological symptoms (31%), burn injuries (at least second degree) (23%), pain (27%), and cardiac symptoms (9%) including self-limiting thoracic pain and dysrhythmia without any therapeutic need. Seventy three percentage of patients with low-voltage injury were discharged within 24 h. The remaining patients stayed in the hospital (11 ± 10 days) for treatment of entry marks and burns, with an overall need for surgery of 12% in all low-voltage injuries. Conclusions : The only identified risk factors for prolonged hospital stay in patients with low-voltage electrical injuries were the treatment of burns and electric marks. In this multi-center analysis of hospitalized patients, low-voltage electrical injuries were not associated with cardiac arrhythmia or mortality. Therefore, we suggest that asymptomatic patients, without preexisting conditions, with low-voltage injury can be discharged after an initial check-up without prolonged monitoring.

[Improvement in burn wound care: summary of the AWMF guideline for the treatment of thermal injuries in adults]. / Optimierung der chirurgischen Behandlung Brandverletzter: Auszüge aus der fachübergreifenden S2k-Leitlinie "Behandlung thermischer Verletzungen des Erwachsenen".

INTRODUCTION: More than half a million patients suffer from minor burns in Germany per year. In 2018, almost 2000 patients needed intensive care for their burn injuries. Despite high standards of burn care, mortality remains high. Burn injuries may lead to long-term sequelae. In order to provide up-to-date burn care, guidelines are available online with public access. METHODS AND RESULTS: This overview presents a summary of the German AWMF guideline for the treatment of thermal injuries in adults (https://www.awmf.org/leitlinien/detail/ll/044-001.html). Experts of eleven different medical organisations and specialties have contributed to this S2k guideline with their expertise. The focus of the article is on acute burn wound assessment, the indication for specialised care in burn centres, the management of the burn wound at the trauma scene and in hospitals as well as scar management and rehabilitation. CONCLUSION: This overview reports on the consensus-based treatment of acute burn wounds in adults in Germany. The article is intended to guide doctors and professional caretakers to perform state-of-the-art burn care. The current guideline aims to improve burn outcome.

Are burn centers in German-speaking countries prepared to respond to a burn disaster? Survey-based study.

Burn disasters present a challenge not only to burn centers but the entire healthcare system. Most burn centers worldwide are unprepared to deal with a burn disaster as it is an uncommon event. We investigated the status of burn center preparedness in German-speaking countries to respond to a burn disaster. Self-administered survey questionnaires were sent to the directors of burn centers; the questions of survey used before in a similar way in Belgium were translated into German language. Of the 46 questioned burn centers, 32 (78%) responded, including all of the German adult burn centers. A clear difference in the preparation status of the burn centers in the three countries was observed due to geopolitical factors such as decentralized healthcare systems. However, the healthcare system is generally well-prepared concerning command, transfer, and capacity to provide sustained supplies to handle a massive influx of patients. Nevertheless, there are some gaps in the areas of planning and preparation, funding for disaster activities, and regular training of staff for burn disasters. We call for a unified burn disaster plan and increased cooperation between burn centers and civil defense regarding communication and training. We strongly recommend the implementation of a special disaster fund and telemedicine in disaster management to circumvent shortages in burn staff.

Safety, Pharmacodynamics, and Efficacy of High- Versus Low-Dose Ascorbic Acid in Severely Burned Adults.

In sepsis and burns, ascorbic acid (AA) is hypothesized advantageous during volume resuscitation. There is uncertainty regarding its safety and dosing. This study evaluated high dose AA (HDAA: 66 mg/kg/h for 24 hours) versus low dose AA (LDAA: 3.5 g/days) administration during the first 24 hours in severely burned adults. We conducted a retrospective study comparing fluid administration before and after switching from low dose to HDAA in severely burned adults. A total of 38 adults with burns >20% TBSA, who received either HDAA or LDAA were included in this retrospective study. AA serum concentrations were quantified at 0, 24, and 72 hours postburn. HDAA impact on hemodynamics, acid-base homeostasis, acute kidney injury, vasopressor use, resuscitation fluid requirement, urinary output, and the incidence of adverse effects was evaluated; secondary clinical outcomes were analyzed. AA plasma levels were 10-fold elevated in the LDAA and 150-fold elevated in the HDAA group at 24 hours and decreased in both groups afterwards. HDAA was not associated with a significantly increased risk of any complications. A significant reduction in colloid fluid requirements was noted (LDAA: 947 ± 1722 ml/24 hours vs HDAA: 278 ± 667 ml/24 hours, P = 0.029). Other hemodynamic and resuscitation measures, as well as secondary clinical outcomes were comparable between groups. HDAA was associated with higher AA levels and lower volumes of colloids in adults with severe burns. The rate of adverse events was not significantly higher in patients treated with HDAA. Future studies should consider prolonged administration of AA.

Early hypothermia as risk factor in severely burned patients: A retrospective outcome study.

INTRODUCTION: Burn trauma-related hypothermia is a frequent observation but risk factors and impact on patient related outcome are ambiguously reported. It is expected that hypothermia is associated with increased mortality and reduced overall outcome in severely burned patients, but available evidence is limited. METHODS: This retrospective single-center-study reviewed preclinical service protocols and medical records of patients sustaining a burn with a total body surface area (TBSA) ≥15% from 2008 to 2012. General patient and burn specific characteristics, outcome parameters as well as body temperature at admission measured via urine catheter or nasal temperature probe were recorded and statistically analyzed comparing normothermic (≥36 °C), mild hypothermic (<36 °C) and severely hypothermic (<34.5 °C) patients. Chi-square test was performed to demonstrate impact of hypothermia on primary outcome parameters and to reveal risk factors for developing hypothermia. To assess independent influences on mortality, a multivariate logistic regression analysis was performed. RESULTS: Out of 300 patients matching inclusion criteria, a sufficient record of temperature was found in 144 patients (48%). Out of 141 eligible patients with an average burn extent (SD) of 33.38% (24.5%) TBSA, 31.9% (n = 45) suffered from severe hypothermia (<34.5 °C) and 28.4% (n = 40) showed mild hypothermia. Total burn extent, presence of full thickness burns, presence of inhalation injury, preclinical mechanical ventilation and administration of sedative drugs were risk factors for developing hypothermia. Patients' age, total burn extent and presence of full thickness burns could be identified as independent factor for mortality. Although a trend towards an independent positive influence of normothermia at admission on mortality was seen, it was not statistically significant. CONCLUSION: Incidental hypothermia of burned patients is associated with an increased mortality and needs to be addressed by emergency health care providers and immediately at the burn center. Especially patients with extensive burns, full-thickness burns, inhalation injury or patients undergoing preclinical intubation are at risk for hypothermia and benefit from any measures for temperature preserving.

Impact of diagnostic bronchoscopy in burned adults with suspected inhalation injury.

INTRODUCTION: Inhalation injury is a common complication of thermal trauma. Fiberoptic bronchoscopy (FOB) is regarded as current standard practice in diagnosing and grading inhalation injury. Nonetheless, its predictive value in terms of therapeutic decision-making and clinical outcome is controversial. METHODS: Adult burn patients with inhalation injury (InI) were selected from the National Burn Repository of the American Burn Association. Subjects were propensity score pair-matched based on injury severity and grouped based on whether or not FOB had been performed (FOB, CTR, respectively). Mortality, incidence of pneumonia, length of hospitalization, length of ICU stay and dependency on mechanical ventilation were compared between the two groups. RESULTS: 3014 patients were matched in two groups with a mean TBSA of 22.4%. There was no significant difference in carboxyhemoglobin fraction at admission. Patients, who underwent FOB on admission had a significantly increased incidence of pneumonia (p < 0.001), mortality (p < 0.05), length of hospitalization (p = 0.002), ICU stay (p < 0.001) and duration of mechanical ventilation (p = 0.006). In a subgroup analysis of patients with TBSA of at least 20%, incidence of pneumonia was significantly higher in the FOB group (p < 0.001) and longer mechanical ventilation was required (p = 0.036). DISCUSSION: Diagnosis and grading of InI through FOB is the current standard, although its predictive value regarding key outcome parameters and therapeutic decision-making, remains unclear. The potential procedural risk of FOB itself should be considered. This study demonstrates correlations of FOB with major clinical outcomes in both a general collective of burned adults as well as severely burned adults. Although these findings must be interpreted with caution, they may induce further research into potential harm of FOB and critical review of routine diagnostic FOB in suspected inhalation injury in thermally injured patients.

Feasibility and safety of enzymatic debridement for the prevention of operative escharotomy in circumferential deep burns of the distal upper extremity.

BACKGROUND: Burn-induced compartment syndrome is a severe sequela after circumferential burns of the extremities and is avoidable by immediate release of the underlying pressure under the eschar. Although the current gold standard is operative escharotomy, this procedure carries considerable morbidity. Our study evaluates the safety and effectiveness of immediate enzymatic debridement to prevent the need for operative escharotomy because of burn-induced compartment syndrome in selected patients. PATIENTS AND METHODS: From 2015 to 2017, all patients suffering from deep circumferential burns of the upper extremities requiring operative escharotomy were potential candidates for the treatment algorithm evaluated by this study. Exclusion criteria involved burn trauma > 12 hours, clinically established burn-induced compartment syndrome, intolerance to the enzymatic debriding agent, dry burns requiring presoaking, as well as blast and electrical injuries requiring fasciotomy or carpal tunnel release. All patients with the inclusion criteria received enzymatic debridement with Nexobrid immediately after admission to our burn center. Enzymatic debridement was applied according to the manufacturer's recommendations. After enzymatic debridement, extremities were revisited every 2 hours for 24 hours to determine the need for conversion to conventional operative escharotomy. The indication for and time to skin grafting was reviewed, and functional outcomes assessed during follow-up examination. RESULTS: Included in this sturdy were 13 patients with 20 burned upper extremities. Enzymatic debridement provided a sufficient eschar removal in all patients. Conversion to conventional operative escharotomy was thus not necessary in any patient. Secondary skin grafting was required in 9 patients. Functional outcomes were favorable 11.9 months after burn trauma. CONCLUSION: If the specific contraindications are respected, enzymatic debridement is safe and effective for the prevention of burn-induced compartment syndrome after deep circumferential burns at the upper extremity, and thus making operative escharotomy unnecessary.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland.

INTRODUCTION: Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines. MATERIAL AND METHODS: A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered. RESULTS: 17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance. CONCLUSION: While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.

Enzymatic debridement for the treatment of severely burned upper extremities - early single center experiences.

BACKGROUND: Severe burns of hands and arms are complex and challenging injuries. The Standard of care (SOC) - necrosectomy with skin grafting - is often associated with poor functional or aesthetic outcome. Enzymatic debridement (ED) is considered one promising alternative but, until recently, results proved to be highly variable. METHODS: Between 04/2014 and 04/2015, 16 patients with deep partial- to full-thickness burns of the upper extremities underwent enzymatic debridement (ED) in our Burn Center and were evaluated for extent of additional surgery, wound healing, pain management and functional parameters. RESULTS: Following ED, no further surgical intervention was required in 53.8 % of the study population. In patients who required surgical treatment, the the skin-grafted area could be reduced by 37.0 % when compared to initial assessment. Time from injury to ED was 24.4 h and patients were able to start physical therapy after 2.0 days but suffered from prolonged wound closure (28.0 days). Regionally administered anesthesia proved to be superior to pain medication alone as pain levels and consumed morphine-equivalent were lower. Post-demission follow-up showed good functional results and pain levels with low scores in two self-report questionnaires (DASH, PRWE-G) but 3 patients reported increased susceptibility to shear stress. Based on these early experiences, we developed a 3-step algorithm for consecutive patients allowing appropriate and individualized treatment selection. CONCLUSIONS: We see a potential benefit for ED in the treatment of severely burned hands and forearms but further investigations and proper prospective, randomized controlled trials are needed to statistically support any outlined assumptions.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version.

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the "Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care". Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade "A" (strong recommendation), Grade "B" (recommendation) and Grade "0" (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

[Practice report: Structured training to improve quality of care in emergency medical service. On-scene supervision: A new approach to emergency medical service training in Wiesbaden and Rheingau-Taunus-Kreis?]. / Bericht aus der Praxis: Strukturierte Fortbildung zur Verbesserung der Versorgungsqualität im Rettungsdienst. Einsatz-Supervision als neuer Ansatz im Bereich der Rettungsdienst-Fortbildung in Wiesbaden und im Rheingau-Taunus-Kreis?

In recent years, the emergency medical services in Wiesbaden and the Rheingau-Taunus district made great efforts to standardise structures. Since there are only few established procedures in the annual examinations for paramedics, there is reason to assume that treatment procedures for patients have not been standardised either. Materials and equipment are not handled uniformly, and employee satisfaction has significantly decreased over the last few years. To solve these problems, all paramedics undergo standardised and structured trainings. These training courses make use of the internationally accepted PHTLS (Pre-Hospital Trauma Life Support) and AMLS (Advanced Life Support Medial) programmes. In addition, practising skills and handling the equipment as well as on-scene supervision is to be established in practical training sessions.