Same day/next day discharge of burn patients treated with skin grafts.

In the past, many patients were admitted for a minimum of 72 h for split-thickness skin grafting (STSG). Several factors have caused us to discharge burn patients on the same day or within 24 h following STSG. We have reviewed outcomes of such patients to determine whether early discharge has an adverse effect on graft outcome and to determine patient acceptance of this new procedure. We retrospectively reviewed charts of patients consecutively treated at our hospital. Two hundred patients were identified. All patients were found to have successful grafts. From our results, we can conclude that patient discharge in less than 24 h following STSG does not predispose patients to poor graft take or other adverse outcomes.

Preinjury behavioral and emotional problems among pediatric burn patients.

Standardized behavior rating scales have been used in the routine care of children during medical visits because they provide an objective, norm-based index for the child's behavioral functioning. The purpose of this study was to examine behavior problems among children (aged 2.5-18 years) with burn injuries using the Behavioral Assessment System for Children, a multi-informant system of standardized rating scales that assesses clinical and adaptive behavior areas. Parents and youth (ages 8-18) completed the Behavioral Assessment System for Children with reference to the pediatric patient's behavioral functioning before hospital admission for a burn injury. In total, data were collected on 94 children. Results suggested that a substantial portion of the sample endorsed significantly elevated levels of behavioral difficulties across a broad range of problem behaviors. On the basis of parent report, preschoolers exhibited concerns related to hyperactivity, anxiety, aggression, and attention problems, whereas school-aged children were reported to have these same concerns as well as depression and conduct problems. Twenty percent of our adolescent sample (ages 12-18 years) were described to be experiencing even more internalizing and externalizing behavior problems relative to the two groups of their younger counterparts. Boys were found to contribute to the cause of their burn injury significantly more often than girls. The strengths, limitations, and clinical implications of our findings are discussed.

Influences of different resuscitation regimens on acute early weight gain in extensively burned patients.

Dissatisfaction with the massive weight gain that commonly followed crystalloid resuscitation of extensively burned patients dictated the need for a study to determine if acute weight gain could be minimized with an alternative form of resuscitation. Three groups of ten patients each with statistically similar age and burn size (mean BSA 46 per cent) were resuscitated with lactated Ringer's solution (LR), hypertonic saline solution (HPT), or fresh frozen plasma (FFP). The volume of infused fluid and the patient weight gain were measured over the first 48 h of treatment. The mean urine output of the three groups was comparable (P greater than 0.05). The volume of infused resuscitation fluid to maintain urine output was a mean of 4.8 ml/kg/per cent BSA in the LR group, 3.16 in the HPT group and 2.68 in the FFP group. The difference in infusion rate between the FFP group and the LR group was statistically significant (P less than 0.01). All patients gained weight with resuscitation. The median percentage weight gain at the end of the first day of treatment was 10.69 per cent in the LR group, 7.88 per cent in the HPT group and 2.38 per cent in the FFP group. Weight gain at the end of the second day of treatment was 13.9 per cent in the LR group, 11.99 per cent in the HPT group, and 4.37 per cent in the FFP group. The differences between FFP, HPT and LR groups were statistically significant (P less than 0.01). In our study the use of fresh frozen plasma for resuscitation of extensively burned patients has been associated with minimal weight gain and minimal oedema. We believe that fresh frozen plasma resuscitation is an attractive alternative to crystalloid infusion and that further comparative studies should be performed.

Ophthalmological complications as a manifestation of burn injury.

Facial burns are a frequent component of the presentation of victims who have sustained thermal trauma, reportedly occurring in 20 per cent of burn patients. Even apparently 'f2p4r' facial injuries might well be associated with significant ocular trauma. A retrospective review of 865 patients admitted to our burn centre showed 22 per cent (192) with facial burns. Ocular involvement, defined as globe or eyelid pathology, was present in 15 per cent (127) of these patients. The aetiology and spectrum of ocular injuries is reviewed with lid burns and subsequent lid contractures, accounting for over 50 per cent of ocular complications. Serious ocular pathology necessitating enucleation occurred in only two patients. The difficulties encountered in performing a complete ophthalmological examination in the presence of facial burns are presented in conjunction with a recommended therapeutic plan.

Helicopter transportation of burn patients.

Analysis of 437 consecutive acute burn patients transported to our burn center revealed 339 transported by ground and 98 by helicopter. There were 18 air transport patients from within a 25-mile-radius, and 80 flown further than 25 miles. Mean age was the same in all groups (P>0.05). Percent total body surface area (TBSA) burned was 8.26% in ground transport patients, significantly less than the 20.35% (within 25 miles) and 21.40% (greater than 25 miles) seen in helicopter transports (P<0.0001). Three percent of ground transport patients and 28% of helicopter patients had inhalation injury (P<0.0001). There was no difference in incidence of inhalation injury among helicopter groups (28 vs. 29%, P=0.8). In patients with coexistent inhalation injury, the mean TBSA burned was significantly larger when compared with the TBSA of burns without inhalation injury (P<0.001). Air transported groups contained patients whose status was not critical based upon lack of inhalation injury and small burn size, and who could have been transported by ground. Non clinical factors such as insurance status, desire to keep ground ambulances in their community, and competing helicopter services reluctant to refuse to transport a patient appears to be factors in choosing air ambulance transportation. Regional single helicopter services and regional cooperative ground ambulance services should reduce use of helicopter transport of burn patients when it is not clinically indicated.

Parental correlates of unintentional burn injuries in infancy and early childhood.

The main purpose of this paper is to review parental factors associated with unintentional burns in early childhood. The problem and characteristics of early childhood burns are discussed. Child injury prevention strategies and models are presented. Parental correlates of pediatric injuries in general and specific to burns are reviewed. In conclusion, the authors recommend greater examination of parental variables potentially amenable to treatment, such as psychological functioning, and improved methodology including the use of prospective analyses, multiple methods and informants, and comparison groups. These efforts should enable greater understanding of parental factors related and causal to early childhood burns and, in turn, guide prevention initiatives.

Effect of diagnosis and treatment of sinusitis in critically ill burn victims.

The purpose of this study was to assess the incidence of diagnosed sinusitis and the effect of diagnosis and treatment on the outcome in critically ill burn victims. Chart analysis of 84 consecutive burn victims requiring mechanical ventilation for greater than 7 days was performed. Sinusitis was diagnosed in 13/84 patients (15%). There was no difference in age or total body surface area burned, or the incidence of inhalation injury, ARDS, pneumonia and sepsis (P>0.05). Co-morbid disease was similar in both the groups. The number of ventilator-dependent days and hospital length of stay were higher in the sinusitis group (P<0.05). The hospital mortality in those diagnosed and treated for sinusitis was 23% (3/13) as opposed to 48% (34/71) in those not diagnosed with sinusitis (P<0.05). Increased number of ventilator-dependent days and longer hospital stay are associated with the diagnosis of sinusitis. Our findings suggest an improved survival in those diagnosed and treated for sinusitis.

Analysis of deep vein thrombosis in burn patients.

OBJECTIVE: Deep vein thrombosis (DVT) represents a major cause of morbidity in surgical patients. Controversial reports exist on the incidence of DVT in burn patients. We report our experience over a 10-year period. METHODS: Patients admitted to our Burn Unit over the period 1991-2001 and diagnosed with DVT were identified. Their records were retrospectively reviewed for demographic factors, extent and severity of burn injury and outcome. RESULTS: A total of 4102 patients were admitted to the WPH Burn unit during the study period. All patients received routine subcutaneous heparin prophylaxis. Ten patients were diagnosed with DVT (0.25%). Compared to our total burn population, these patients were older (mean age 47 +/- 22.7 years versus 35 +/- 22 years P = 0.14) and had more extensive burns (mean total body surface area (TBSA) 34.7 +/- 25.3% versus 12 +/- 15.7% P = 0.02). Two patients developed non-fatal pulmonary embolism (PE). There were three deaths, none due to thromboembolic disease. There were no complications from the routine administration of subcutaneous heparin. CONCLUSION: The incidence of DVT in our study is much less than the incidence reported in other critically ill patients and less than that of most reports on burn patients. In our experience, routine heparin prophylaxis is effective for the prevention of DVT in burn patients.

Acute septic cholecystitis in patients with burn injuries.

Acute cholecystitis continues to be a life-threatening complication in patients after trauma. In an 18-month period we have recognized and treated five patients with burn injuries who had acute cholecystitis. They ranged in age from 13 to 40 years. Four of the five patients had positive blood cultures and all five patients had positive bile cultures. The diagnosis was made on the basis of unexplained sepsis and an abnormal sonogram or hepatobiliary scan. Four patients underwent cholecystectomy and one patient underwent a cholecystostomy. Four patients survived and were discharged from the hospital. All five patients were receiving nutritional support. Factors such as prolonged fasting, dehydration, narcotic administration, and sepsis have been suggested as contributing factors in the development of acute cholecystitis. Acute cholecystitis is a serious complication in such patients and must be considered and treated promptly. Serial ultrasound studies have been helpful in managing patients suspected of having acute septic cholecystitis.

Multidisciplinary approach to working with burn victims of child abuse.

Successful outcomes in abuse cases are dependent upon close coordination of professional hospital staff with referring agencies including child protective services and the legal and judicial systems. A four-year retrospective study of 369 pediatric burn patients admitted to our Burn/Trauma Center was completed to: (1) assess demographic factors of patients and families that differentiate cases of child abuse from cases of children burned as a result of accidental injury, and (2) determine the impact of a multidisciplinary team approach to working with abused children and their families during the course of hospitalization. When medical evaluation reveals the possibility of child abuse, a social work assessment, including a developmental history of the child and psychosocial assessment of the family, is crucial. In addition, physicians must be well versed in the gathering of evidence for potential utilization by the legal system. This includes the obtainment of photographs and detailed documentation of the burn injury. A plan of evaluation and the effective coordination of services during hospitalization and following discharge have proven essential to meeting the best interests of the child.

Bad advice; bad burn: a new problem in burn prevention.

Deep partial-thickness burns had been inflicted on the perineal area of an infant who was recently treated in our Burn Center. The burns were a result of advice to the patient's mother by a pediatrician. The doctor told her to use a hair dryer to prevent diaper rash. We surveyed pediatricians, well-baby clinics, and pediatric nurse practitioners in our area and found that approximately half of them advised the use of hair dryers to treat or prevent diaper rash. We tested four widely available hand-held hair dryers to determine potential for inflicting burn injury. All of the dryers are capable of delivering air heated to at least 53 degrees C after 2 minutes of use. We believe that warnings against the use of hair dryers for perineal hygiene should be included in burn prevention programs.

Burned children: a socioeconomic profile for focused prevention programs.

A review of 197 consecutive admissions of children 16 years of age and under to the Western Pennsylvania Hospital Burn/Trauma Center during a 28-month period (January 1984-April 1986) found that the majority of these children came from economically disadvantaged homes and that scalding was the most frequent mechanism of injury. Black children, poor children, and children of single parents were disproportionally represented in the study population compared with a similar-aged population in the hospital's referral area. By identifying a specific group of children who are at highest risk of being burned, and by determining the burn injuries these children are most likely to sustain, the study makes it possible to realistically tailor burn prevention programs to meet the specific social and economic characteristics of the group at highest risk.

Effect of aggressive surgical treatment in older patients with burns.

A group of 103 patients with burns, 65 years old and older, was compared with a similar group treated a decade ago. The survival rate of the early group was 37%, and the survival rate of the currently treated group is 52%. The length of stay in the hospital of surviving patients dropped from 42 to 22 days. Ten years ago 62% of surviving patients with burns in our series were operated on. In the more recently treated group with improved survival and decreased lengths of stay, 90% of the patients had one or more operations. We believe that early excision of eschar and early wound closure are associated with increased survival and decreased length of stay for older patients with burns.

Experience with patients with burns who refuse blood transfusion for religious reasons.

Patients with extensive full-thickness burns who refuse blood transfusion present a challenge to the burn team. We have recently treated four such patients, and we achieved a successful outcome in three. Staged excision and skin graft operations with minimal blood loss were performed. Two patients were treated with erythropoietin. Patient autonomy should be accepted by the burn team, but opportunity should exist for reassessment of treatment plans.

Discharge videotaping: a means of augmenting occupational and physical therapy.

Regional burn centers commonly receive patients from medical facilities that are geographically distant. Logistic problems that may hamper follow-up care in the burn center can lead to a decrease in function as a result of contractures and hypertrophic scar formation. Inexperience on the part of therapists at community facilities serves to intensify this problem. Discharge videotaping, with respect to physical and occupational therapy programs, is a means of documenting range of motion at the time of discharge and providing visual documentation of the therapy program to be followed on an outpatient basis. The video tapes are forwarded to the outlying community hospital's therapy department in order to accomplish these goals.

Survey of treatment modalities for the prevention of hypertrophic facial scars.

The application of pressure to facial burns as a means of preventing or treating hypertrophic scar formation constitutes a major clinical challenge. Success depends on the experience of the therapist, choice of the pressure treatment, proper measurement technique, and adequate duration of therapy. A mail survey of therapists involved in the use of the various pressure modalities reveals a common trend with respect to the type of device used and the duration of therapy. The majority of therapists report that no one treatment produces uniformly excellent results.

Inhalation injury: a decade without progress.

Despite major advances in the management of patients with critical burn injuries, inhalation injury continues to be a major determinant of death resulting from burn injuries. Two cohort groups of victims with burn and inhalation injuries, separated by a decade, were retrospectively reviewed in an effort to determine the impact of newer treatment modalities. Patients were categorized as being at "high" or "low" risk on the basis of primary and secondary diagnostic criteria. Despite a statistically significant decrease in the percent of total body surface injury, no change in mortality rate was noted between the two groups. The advent of sophisticated diagnostic and management techniques does not appear to have decreased the mortality rate associated with inhalation injury.

An assessment of burn prevention knowledge in a high burn-risk environment: restaurants.

Our facility has seen an increase in the number of cases of children burned in restaurants. Fieldwork has revealed many unsafe serving practices in restaurants in our tristate area. The current research targets what appears to be an underexamined burn-risk environment, restaurants, to examine server knowledge about burn prevention and burn care with customers. Participants included 71 local restaurant servers and 53 servers from various restaurants who were recruited from undergraduate courses. All participants completed a brief demographic form as well as a Burn Knowledge Questionnaire. It was found that server knowledge was low (ie, less than 50% accuracy). Yet, most servers reported that they felt customer burn safety was important enough to change the way that they serve. Additionally, it was found that length of time employed as a server was a significant predictor of servers' burn knowledge (ie, more years serving associated with higher knowledge). Finally, individual items were examined to identify potential targets for developing prevention programs.

Assessing the relationship between locus of control and social competence in pediatric burn survivors attending summer cAMP.

Previous research suggests that children with burn injuries often exhibit psychological and social difficulties. The areas of functioning that are affected most often include level of anxiety, social competence, and self-esteem. Those children having an internal locus of control (LOC) have been shown to react more positively to physical disorders and to have better psychological responding in nonburn populations. The purpose of this study was to determine whether there is a relationship between LOC and social competence in pediatric burn survivors. Participants were children aged 8 to 18 years who had been treated for a burn injury and attended a 1-week summer camp for pediatric burn survivors. Results indicated that the type of LOC was not a predictor of the overall level of social competence, as reported on three different measures of social competence. However, LOC significantly accounted for variability in the child's cooperation level, according to parent report. Other results are discussed, as well as implications for future research and clinical work in this area.

Sildimac: a new delivery system for silver sulfadiazine in the treatment of full-thickness burn injuries.

Wound care is painful for the patient with a burn injury and tedious for the burn unit staff but necessary to remove exudates and debris and to limit infections. In an effort to circumvent daily dressing changes while ensuring optimal wound protection, Sildimac (Marion Laboratories, Kansas City, Mo.), a new drug delivery system for silver sulfadiazine, was developed. When silver sulfadiazine, a topical antimicrobial commonly used for the treatment of burns, is incorporated into the delivery system, the drug is released in a sustained fashion. We report here the results of a multicenter evaluation of the safety and efficiency of Sildimac for treatment of full-thickness burn wounds. Sildimac, when left in place for up to 4 days, appears to be as effective as twice-daily wound cleansing and application of Silvadene cream 1% (Marion Laboratories, Kansas City, Mo.) for the treatment of full-thickness burns.