Executive summary: Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Telemedicine evaluation of acute burns is accurate and cost-effective.

BACKGROUND: As the number of US burn centers has declined, access to burn care is increasingly limited. Inexperience in burn wound assessment by referring physicians often results in overtriage or undertriage. In an effort to improve access to burn care in our region, we instituted a program of telemedicine evaluation of acute burns. METHODS: We created a telemedicine network linking our burn center to three hospitals located 298 to 350 air miles away. Participants agreed to perform telemedicine consultation for acutely burned patients admitted to their emergency departments. We compared consults and referrals from these facilities during the period July 2005 to August 2007 (TELE) to those during a 2-year period before instituting telemedicine (PRE-TELE). RESULTS: During the TELE period, 80 patients were referred, of whom 70 were seen acutely by telemedicine, compared with 28 PRE-TELE referrals. The groups did not differ in age or burn size. Only 31 patients seen by telemedicine received emergency air transport (44.3%), compared with 100% of PRE-TELE patients (p < 0.05). Nine other TELE patients were transported by family; 30 other patients were treated locally. Ten remaining patients were transported without telemedicine evaluation. TELE patients transported by air had somewhat larger burn sizes (9.0% vs. 6.5% total body surface area; p = NS) and longer length of stay (13.0 days vs. 8.0 days; p = NS) than PRE-TELE patients. Burn size estimates by burn center physicians made either by telemedicine or direct inspection correlated closely but both differed significantly from those of referring physicians. Providers and patients expressed a high level of satisfaction with the telemedicine experience. CONCLUSIONS: Acute evaluation of burn patients can be performed accurately by telemedicine. This can reduce undertriage or overtriage for air transport, improve resource utilization, and both enhance and extend burn center expertise to many rural communities at low cost.

Prevention and management of infections associated with burns in the combat casualty.

Burns complicate 5% to 10% of combat associated injuries with infections being the leading cause of mortality. Given the long term complications and rehabilitation needs after initial recovery from the acute burns, these patients are often cared for in dedicated burn units such as the Department of Defense referral burn center at the United States Army Institute of Surgical Research in San Antonio, TX. This review highlights the evidence-based recommendations using military and civilian data to provide the most comprehensive, up-to-date management strategies for burned casualties. Areas of emphasis include antimicrobial prophylaxis, debridement of devitalized tissue, topical antimicrobial therapy, and optimal time to wound coverage.

Guidelines for the prevention of infection after combat-related injuries.

Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.

Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy.

HYPOTHESIS: Thrombolytic therapy will decrease the incidence of amputation when administered within 24 hours of exposure. DESIGN: Single institution retrospective review of clinical outcomes and resource use. SETTING: Burn unit of a tertiary academic referral center. PATIENTS: From 2001 to 2006, patients with severe frostbite admitted within 48 hours of injury underwent digital angiography and treatment with intra-arterial tissue plasminogen activator (tPA) if abnormal perfusion was demonstrated. These patients were compared with those treated from 1995 to 2006 who did not receive tPA. INTERVENTIONS: Tissue plasminogen activator vs traditional management of frostbite injury. MAIN OUTCOME MEASURES: Number and type of surgery were recorded, along with amputations of digits (fingers or toes) and more proximal (ray, transmetatarsal, or below-knee) amputations. Resource utilization including length of stay, total costs, cost per involved digit, and cost per saved digit were analyzed. RESULTS: Thirty-two patients with digital involvement (hands, 19%; feet, 62%; both, 19%) were identified. Seven patients received tPA, 6 within 24 hours of injury. The incidence of digital amputation in patients who did not receive tPA was 41%. In those patients who received tPA within 24 hours of injury, the incidence of amputation was reduced to 10% (P<.05). CONCLUSIONS: Tissue plasminogen activator improved tissue perfusion and reduced amputations when administered within 24 hours of injury. This modality represents the first clinically significant advancement in the treatment of frostbite in more than 25 years.

Burn patient characteristics and outcomes following resuscitation with albumin.

BACKGROUND: Use of colloids in acute burn resuscitation may reduce fluid requirements, but effect on mortality is unknown. We hypothesized that patients who received albumin would have similar mortality to patients who did not receive albumin. METHODS: We performed a case-controlled study of inpatients who sustained burns of > or =20% total body surface area (TBSA). Patients who received albumin during resuscitation because of increased fluid requirements (ALB) were compared to a cohort of patients matched for age and TBSA who did not receive albumin (CON). RESULTS: Patients with inhalation injury were significantly more likely to receive albumin (OR 4.89, 95% CI 2.58-9.30). ALB patients had significantly higher mean initial lactate (3.64 versus 2.29, p=0.01), longer mean time to resuscitation (52.8 h versus 36.3 h; p=0.001), and higher resuscitation volume (9.4 mL/kg/%TBSA versus 6.4 mL/kg/%TBSA for CON). Mortality was not significantly different between the two groups (OR 1.90, 95% CI 0.85-4.22). Albumin was protective in a multivariate model of mortality (OR 0.27, 95% CI 0.07-0.97). CONCLUSIONS: Despite more severe systemic dysfunction, burn patients who received albumin did not suffer increased mortality. A novel finding is the decreased likelihood of mortality associated with the administration of albumin during burn resuscitation.

Telemedicine for acute burn treatment: the time has come.

This brief paper sets out the arguments for the routine use of telemedicine in the evaluation of burns. Two cases are reported from the author's practice that show the need for it.

Fluid Creep and Over-resuscitation.

Fluid creep is the term applied to a burn resuscitation, which requires more fluid than predicted by standard formulas. Fluid creep is common today and is linked to several serious edema-related complications. Increased fluid requirements may accompany the appropriate resuscitation of massive injuries but dangerous fluid creep is also caused by overly permissive fluid infusion and the lack of colloid supplementation. Several strategies for recognizing and treating fluid creep are presented.

Gender influences on burn outcomes in the elderly.

BACKGROUND: Women, aged 65 and older, now comprise a larger number of injuries requiring hospitalization than do young men. The purpose of this study was to evaluate gender differences in outcome and disposition of elderly (>65 years) burn patients. METHODS: We compared demographic, etiologic, and outcome differences between male and female patients 65 years of age and older admitted for acute burn treatment during a five-year period. RESULTS: Elderly patients comprised 8.5% of burn admissions. Women, who accounted for 33% of burns occurring in this group, tended to have smaller (12.0% versus 17.2% total body surface area (TBSA); p = 0.20) and less severe (3.6% versus 9.7% 3rd TBSA; p < 0.05) injuries, but mortality did not differ from men. Although not significant, elderly women, who were less likely to be married, tended to stay in the hospital longer and were significantly less likely to be discharged home than men (41.7% versus 66.7%; p < 0.05). CONCLUSIONS: Elderly burn patients, particularly women, utilize more resources than younger patients. Further research on the social and economic resources available to the elderly burn population, particularly women, is warranted in order to provide cost effective quality care during acute hospitalization and upon discharge.

Defining the ratio of outcomes to resources for triage of burn patients in mass casualties.

Management of a mass casualty involving burn patients that overwhelms local resources will likely require a triage process in which limited resources are devoted to the patients with the highest likelihood of survival. No objective criteria exist which define how patients could be categorized in such a situation. A table that classifies patients according to their anticipated survival from burn injury, and the resources required to achieve that survival, is presented here. The limitations and restrictions of applying such a guideline are discussed in detail.

Transition from grant funding to a self-supporting burn telemedicine program in the western United States.

BACKGROUND: Many Americans have limited access to specialty burn care, and telemedicine has been proposed as a means to address this disparity. However, many telemedicine programs have been founded on grant support and then fail once the grant support expires. Our objective was to demonstrate that a burn telemedicine program can be financially viable. METHODS: This retrospective review from 2005 to 2014 evaluated burn telemedicine visits and financial reimbursement during and after a Technology Opportunities Program grant to a regional burn center. RESULTS: In 2005, we had 12 telemedicine visits, which increased to 458 in 2014. In terms of how this compares to in-person clinic visits, we saw a consistent increase in telemedicine visits as a percentage of total clinic visits from .26% in 2005 to 14% in 2014. Median telemedicine reimbursement has been equivalent to in-person visits. CONCLUSIONS: Specialty telemedicine programs can successfully transition from grant-funded enterprises to self-sustaining. The availability of telemedicine services allows access to specialty expertise in a large and sparsely populated region without imposing an undue financial burden.

Systemic Candida infection in burn patients: a case-control study of management patterns and outcomes.

BACKGROUND: Burn patients are ideal hosts for opportunistic infections. Candida infection in burn patients has a reported mortality ranging from 14% to 90%. This retrospective case-control study compares management patterns and outcomes of burn patients who develop systemic Candida with those who do not. METHODS: Inpatients at our burn center with two or more positive culture sites for Candida from January 1, 1995, through December 31, 2000 and who sustained burn injury of >/=10% total body surface area (TBSA) were identified. A cohort of patients without Candida was matched for age and size of burn injury using our institution's TRACS/ABA trade mark registry. Management variables included days to burn wound coverage; use of artificial dermis; number of antibiotic days; treatment with imipenem, vancomycin, or aminoglycosides; need for abdominal surgery; and receipt of tracheostomy. Outcome measures were hospital length of stay (LOS) and mortality. RESULTS: Candida patients (n = 44) had a mean age of 39.8 years, and sustained an average burn size of 47.2% TBSA with 28.6% full-thickness injury. Controls (n = 44) had a mean age of 39.8 years, and sustained an average burn size of 46.0% TBSA with 26.6% full-thickness injury. Patients with multiple Candida sites required 36 days to achieve burn wound coverage with autograft versus 21 days for the control group (P = 0.004). Candida patients were significantly more likely to be managed with artificial dermis than were controls (Odds Ratio = 9.56, 95% Confidence Interval = 1.64-181.53). Patients with Candida infection averaged 72 days of treatment with systemic antibiotics, whereas the controls averaged only 36 days of antibiotic treatment (P = 0.001). Further, patients with multiple sites of Candida were more likely to have received imipenem, vancomycin, or an aminoglycoside (Odds Ratio = 11.99, 95% Confidence Interval = 3.10-79.71). Mean LOS was 62 days for patients with Candida and 30 days for the controls (P < 0.001). The mortality rate in patients with Candida was 23%, which did not differ significantly from the 27% mortality rate of the controls. CONCLUSION: Early wound coverage with autograft clearly decreases the likelihood of systemic Candida infection in burn patients. Patients who received artificial dermis as a component of their wound management strategy more often developed systemic Candida infection in this series. Burn patients who require prolonged courses of antibiotics or treatment with broad-spectrum antibiotics should be carefully monitored for the development of Candida. Survival of burn patients who develop systemic Candida infection is no different from survival in comparable burn patients who do not acquire Candida. Future research should address optimal management of Candida infection in burn patients.

Early tracheostomy does not improve outcome in burn patients.

Early tracheostomy (ET) has been claimed to reduce ventilator support or intensive care unit or hospital length of stay in intensive care unit patients. This study was performed to assess the potential benefits of ET in burn patients. From October 1996 to July 2001, we evaluated all intubated and acutely burned adults using a formula to predict the probability of prolonged ventilator dependence. We randomized each patient with a probability of prolonged ventilator dependence more than 0.5 to ET, performed on the next operative day, or to conventional therapy (CON), which consisted of continued endotracheal intubation as needed, with tracheostomy (TRACH) performed on postburn day (PBD) 14 if necessary. During this period, 44 patients were randomized, 23 to CON and 21 to ET. Groups did not differ in age, total burn size, or inhalation injury, although ET patients had larger full-thickness burns. ET patients underwent TRACH at a mean of PBD 4 vs PBD 14.8 for CON patients (P <.01). ET patients had a significant improvement in PaO2 /FiO2 ratios within 24 hours following TRACH (139 +/- 15 vs 190 +/- 12; P <.01). There were no differences in ventilator support, length of stay, incidence of pneumonia, or survival. However, six CON patients (26%) were successfully extubated by PBD 14 compared with one ET patient (P <.01). Although tracheostomy offers some advantages in terms of patient comfort and security, routine performance of ET in burn patients does not improve outcomes, nor does it result in earlier extubation. This may be partly caused by the comfort and convenience of tracheostomy.

Self-reported quality of life after electrical and thermal injury.

Electrical injury patients (EI) often require more procedures and longer hospital stays than their thermal injury counterparts. We hypothesized that postinjury quality of life might be better in thermal injury patients (TIs) than in EI. Each EI recorded in our institution's TRACS trade mark /ABA registry between 1995 and 2000 was matched with a TI for age and TBSA involvement. We compared SF-36 scores of EI and TIs to evaluate quality of life. Age and TBSA injury were similar between groups. SF-36 results demonstrated no significant differences in self-reported quality of life indices. Return to full-time employment did not differ significantly between groups. EI and TIs do not differ significantly in quality of life after their burn injuries. Self-evaluated function for EI and TIs is comparable. Quality of life in both EI and TIs are above population means on many dimensions.

Home treadmill friction injuries: a five-year review.

Treadmills are popular home fitness machines in American homes. Young children are at risk for friction injuries if they contact moving treadmills. The purpose of this study was to determine the impact of treatment of treadmill friction injuries in children. A review of 1,211 pediatric patients younger than 6 years treated at the Intermountain Burn Center between July 1997 and June 2002 was conducted. Forty-eight of these cases (4%) were treadmill friction injuries. The mean TBSA of these burns was 0.5%. The volar surface of the hand was the most common site of injury. Twenty-two (46%) of the 48 identified patients had full-thickness injuries that were treated surgically. Medical costs associated with treadmill friction injuries averaged US 2,385 dollars. The number of treadmill friction accidents resulting in friction injuries to children less than 6 years of age deserves serious attention and increased public awareness.

Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment.

The safety and effectiveness of Integra Dermal Regeneration Template was evaluated in a postapproval study involving 216 burn injury patients who were treated at 13 burn care facilities in the United States. The mean total body surface area burned was 36.5% (range, 1-95%). Integra was applied to fresh, clean, surgically excised burn wounds. Within 2 to 3 weeks, the dermal layer regenerated, and a thin epidermal autograft was placed. The incidence of invasive infection at Integra-treated sites was 3.1% (95% confidence interval, 2.0-4.5%) and that of superficial infection 13.2% (95% confidence interval, 11.0-15.7%). Mean take rate of Integra was 76.2%; the median take rate was 95%. The mean take rate of epidermal autograft was 87.7%; the median take rate was 98%. This postapproval study further supports the conclusion that Integra is a safe and effective treatment modality in the hands of properly trained clinicians under conditions of routine clinical use at burn centers.

Redefining the outcomes to resources ratio for burn patient triage in a mass casualty.

Recent disasters highlight the need for predisaster planning, including the need for accurate triage. Data-driven triage tables, such as that generated from the 2002 National Burn Repository, are vital to optimize resource use during a disaster. The study purpose was to generate a burn resource disaster triage table based on current burn-treatment outcomes. Data from the NBR after the year 2000 were audited. Records that missed age, burn size, or survival status were excluded from analysis. Duplicate records, readmissions, transfers, and nonburn injuries were eliminated. Resource use was divided into expectant (predicted mortality >90%), low (mortality 50-90%), medium (mortality 10-50%), high (mortality <10%, admission 14-21 days), very high (mortality <10%, admission <14 days), and outpatient. Tables were created for all patient admissions and with/without inhalation injury. Of the 286,293 records, 210,683 were from the year 2000 or later. Expectant status for those aged >70 years began at 50% burn; a 20- to 29-year-old never reached expectant status. Inhalation injury lowered the expectant category to a burn size of 40% in >70-year-olds, and at >90% in 20- to 29-year-olds. The 0- to 1.9-year old group without inhalation injury never reached expectant status; with inhalation injury, expectant status was reached at >80% burn. Changes in the triage tables suggest that burn care has changed in the past 10 years. Inhalation injury significantly alters triage in a burn disaster. Use of these updated tables for triage in a disaster may improve our ability to allocate resources.