Initial Pediatric Burn Management: A Practical Guide.

Children have an imperative to explore their environment to grow and develop, which puts them at risk for sustaining burn injury. Burn injury remains the third leading cause of injury-related death worldwide. Plastic surgeons, as experts in the evaluation and management of cutaneous injuries, are frequently called upon to evaluate and treat children with burn injuries. This article focuses on the unique physiologic aspects of children and how they impact initial evaluation and management of burn injury. Children are not "little adults," and they have different airway, circulatory, and cutaneous systems. Understanding the signs of potential child abuse is important to avoid further child harm. Finally, recognition of the criteria for referral to a pediatric burn center is important to optimize both short- and long-term outcomes for patients and families.

Plasma-derived Extracellular Vesicles (EVs) as Biomarkers of Sepsis in Burn Patients via Label-free Raman Spectroscopy.

Sepsis following burn trauma is a global complication with high mortality, with ~60% of burn patient deaths resulting from infectious complications. Sepsis diagnosis is complicated by confounding clinical manifestations of the burn injury, and current biomarkers markers lack the sensitivity and specificity required for prompt treatment. Circulating extracellular vesicles (EVs) from patient liquid biopsy as biomarkers of sepsis due to their release by pathogens from bacterial biofilms and roles in subsequent immune response. This study applies Raman spectroscopy to patient plasma derived EVs for rapid, sensitive, and specific detection of sepsis in burn patients, achieving 97.5% sensitivity and 90.0% specificity. Furthermore, spectral differences between septic and non-septic burn patient EVs could be traced to specific glycoconjugates of bacterial strains associated with sepsis morbidity. This work illustrates the potential application of EVs as biomarkers in clinical burn trauma care, and establishes Raman analysis as a fast, label-free method to specifically identify features of bacterial EVs relevant to infection amongst the host background.

Management of Heat-Related Illness and Injury in the ICU: A Concise Definitive Review.

OBJECTIVES: The increasing frequency of extreme heat events has led to a growing number of heat-related injuries and illnesses in ICUs. The objective of this review was to summarize and critically appraise evidence for the management of heat-related illnesses and injuries for critical care multiprofessionals. DATA SOURCES: Ovid Medline, Embase, Cochrane Clinical Trials Register, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov databases were searched from inception through August 2023 for studies reporting on heat-related injury and illness in the setting of the ICU. STUDY SELECTION: English-language systematic reviews, narrative reviews, meta-analyses, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed. DATA EXTRACTION: Data regarding study methodology, patient population, management strategy, and clinical outcomes were qualitatively assessed. DATA SYNTHESIS: Several risk factors and prognostic indicators for patients diagnosed with heat-related illness and injury have been identified and reported in the literature. Effective management of these patients has included various cooling methods and fluid replenishment. Drug therapy is not effective. Multiple organ dysfunction, neurologic injury, and disseminated intravascular coagulation are common complications of heat stroke and must be managed accordingly. Burn injury from contact with hot surfaces or pavement can occur, requiring careful evaluation and possible excision and grafting in severe cases. CONCLUSIONS: The prevalence of heat-related illness and injury is increasing, and rapid initiation of appropriate therapies is necessary to optimize outcomes. Additional research is needed to identify effective methods and strategies to achieve rapid cooling, the role of immunomodulators and anticoagulant medications, the use of biomarkers to identify organ failure, and the role of artificial intelligence and precision medicine.

Acute care for burn patients: fluids, surgery, and what else?

PURPOSE OF REVIEW: Recently published initiatives spanning the burn care spectrum have substantially changed the standard of care in burn care. The purpose of this article is to describe new impactful concepts in burn first aid, triage, resuscitation, and treatment as well as their impact on future research. RECENT FINDINGS: First aid after burn injury traditionally consists of extinguishing the burn and applying dressings. Recent evidence suggests that applying 20 min of cool tap water to the burn wound in the first 3 h postburn mitigates burn injury extent. National burn center transfer criteria have been updated, impacting patient initial transfer and management. The adverse effects of hydroxocobalamin, a commonly used antidote for cyanide toxicity, have been delineated. Initial burn resuscitation recommendations for both volume and potentially fluid type are being reexamined. The emergence of innovative skin substitutes may improve burn survival by providing a physiologically stabilizing intermediate dressing. Finally, formal clinical practice guidelines for early mobility in the ICU after burn injury have been defined. SUMMARY: These changes in burn care, triage, resuscitation, and treatment have challenged traditional burn care standards, created new standards, and are the basis for future prospective randomized trials.

Examining Obesity and Its Association With Burn Injury: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation Study.

INTRODUCTION: Literature examining the connection between obesity and burn injuries is limited. This study is a secondary analysis of a multicenter trial data set to investigate the association between burn outcomes and obesity following severe burn injury. MATERIALS AND METHODS: Body mass index (BMI) was used to stratify patients as normal weight (NW; BMI 18.5-25), all obese (AO; any BMI>30), obese I (OI; BMI 30-34.9), obese II (OII; BMI 35-39.9), or obese III (OIII; BMI>40). The primary outcome examined was mortality. Secondary outcomes included hospital length of stay (LOS), number of transfusions, injury scores, infection occurrences, number of operations, ventilator days, intensive care unit LOS, and days to wound healing. RESULTS: Of 335 patients included for study, 130 were obese. Median total body surface area (TBSA) was 31%, 77 patients (23%) had inhalation injury and 41 patients died. Inhalation injury was higher in OIII than NW (42.1% versus 20%, P = 0.03). Blood stream infections (BSI) were higher in OI versus NW (0.72 versus 0.33, P = 0.03). Total operations, ventilator days, days to wound healing, multiorgan dysfunction score, Acute Physiology and Chronic Health Evaluationscore, hospital LOS, and intensive care unit LOS were not significantly affected by BMI classification. Mortality was not significantly different between obesity groups. Kaplan-Meier survival curves did not significantly differ between the groups (χ2 = 0.025, P = 0.87). Multiple logistic regression identified age, TBSA, and full thickness burn as significant independent predictors (P < 0.05) of mortality; however, BMI classification itself was not predictive of mortality. CONCLUSIONS: No significant association between obesity and mortality was seen after burn injury. Age, TBSA, and percent full- thickness burn were independent predictors of mortality after burn injury, while BMI classification was not.

The Role of the US Trauma Centers in Older Adult Fall Prevention: A National Survey.

INTRODUCTION: Approximately 27.5% of adults 65 and older fall each year, over 3 million are treated in an emergency department, and 32 000 die. The American College of Surgeons and its Committee on Trauma (ACSCOT) have urged trauma centers (TCs) to screen for fall risk, but information on the role of TC in this opportunity for prevention is largely unknown. METHODS: A 29-item survey was developed by an ACSCOT Injury Prevention and Control Committee, Older Adult Falls workgroup, and emailed to 1000 trauma directors of the National Trauma Data Bank using Qualtrics. US TCs were surveyed regarding fall prevention, screening, intervention, and hospital discharge practices. Data collected and analyzed included respondent's role, location, population density, state designation or American College of Surgeons (ACS) level, if teaching facility, and patient population. RESULTS: Of the 266 (27%) respondents, 71% of TCs include fall prevention as part of their mission, but only 16% of TCs use fall risk screening tools. There was no significant difference between geographic location or ACS level. The number of prevention resources (F = 31.58, P < .0001) followed by the presence of a formal screening tool (F = 21.47, P < .0001) best predicted the presence of a fall prevention program. CONCLUSION: Older adult falls remain a major injury risk and injury prevention opportunity. The majority of TCs surveyed include prevention of older adult falls as part of their mission, but few incorporate the components of a fall prevention program. Development of best practices and requiring TCs to screen and offer interventions may prevent falls.

Understanding Factors in Burn Patient Follow-up.

Follow-up rates are concerningly low among burn-injured patients. This study investigates the factors associated with low follow-up rates and missed appointments. We hypothesize that patients who are homeless, use illicit substances, and have psychiatric comorbidities will have lower rates of follow-up and more missed appointments. Data from a discharge-planning survey of 281 burn-injured patients discharged from September 2019 to July 2020 were analyzed and matched with patients' electronic medical records for a retrospective chart review. Data collected included general demographics, burn characteristics, hospitalization details, follow-up visits, missed appointments, homeless status, substance use, major psychiatric illness, and survey responses. Data analysis used chi-square, Fisher's exact test, Student's t-test, Wilcoxon rank sum test, and multivariate regression analysis. Overall, 37% of patients had no follow-up in clinic and 46% had one or more missed appointment. On multivariate regression analysis, homeless patients were more likely to never follow-up, odds ratio (OR) = 0.23 (95% confidence interval [CI] = 0.11-0.49), as were patients who anticipated experiencing transportation difficulties, OR = 0.28 (95% CI = 0.15-0.50). Homeless patients were more likely to have missed appointments, OR = 0.23 (95% CI = 0.1-0.54). On univariate analysis, patients with one or more documented major psychiatric illness had lower follow-up rates, with 50.62% having no follow-up (P < .01). Among patients who responded to the survey that they were current drug users, 52% had no follow-up as compared to 28% of patients who responded that they did not use drugs (P < .01).

Suicide by self-inflicted burns - A persistent psychiatric problem.

Self-inflicted burns are a relatively uncommon but profound attempt at suicide. Twenty years ago, we first reviewed our experience with self-inflicted burns. With this current study, we sought to determine whether there had been any change in the incidence or outcomes of self-inflicted burns. All burn patients admitted between January 1, 2012, and December 31, 2021, with self-inflicted burns were compared with all other admissions. The frequency of self-inflicted burns and confounding risk factors of patients with self-inflicted burns remained unchanged. A large proportion (87.4 %) of the patients had psychiatric disease. They also had larger burns and higher mortality than accidental burns. Unexpectedly, logistic regression analysis that controlled for age, total percent total body surface area (TBSA) burn, sex, and inhalation injury revealed that those patients with self-inflicted burns had 72 % lower odds of dying than the general population. In conclusion, there has been no improvement in the incidence of self-inflicted burns. They result in very severe injuries, but when age, burn size, gender, and inhalation injury are controlled for, they have at least as good a chance for survival as the general burn population.

Emerging Therapies for Full-Thickness Skin Regeneration.

The classical treatment of extensive full-thickness skin loss due to trauma or burns has been the split-thickness skin graft. While split-thickness skin grafts close the wound, they leave patients with visible scars, dry skin, pruritis, pain, pigmentation alterations, and changes in sensation. The optimal replacement for full-thickness skin loss is replacement with intact full-thickness skin. New technologies combined with advances in the understanding of the mechanisms behind wound healing have led to the development of techniques and products that may eventually recapitulate the functions, appearance, and physical properties of normal skin. Autologous homologous skin constructs, minimal functional skin units, and composite bioengineered skin with dermal substitutes all represent potential avenues for full-thickness composite skin development and application in extensive wounds. This article summarizes the progress, state, and future of full-thickness skin regeneration in burn and massive wound patients.

Modified Frailty Index is an Independent Predictor of Death in the Burn Population: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation (TRIBE) Study.

Frailty can increase the risk of dying after suffering a severe injury. The Modified Frailty Index (MFI) was developed by the American College of Surgeons National Surgical Quality Improvement Program to determine the impact of frailty on outcomes. Our aim was to correlate frailty with survival following a burn injury using the 11-item and 5-item MFI. We performed a secondary analysis of the Transfusion Requirement in Burn Care Evaluation (TRIBE) study. Data including, age, gender, medical history, extent and severity of burn injury, inhalation injury and discharge disposition was collected from the TRIBE database. The 11-item MFI (MFI-11) and 5-item MFI (MFI-5) scores were calculated for all patients in the TRIBE database. The TRIBE database included 347 patients. The mean age of subjects was 43 ± 17 years. Mean total body surface area burn (TBSA) was 38 ± 18%, and 23% had inhalation injury. Multivariate logistic regression analysis determined that both MFI-5 (OR 1.86; 95% CI: 1.11-3.11; P-value .02) and MFI-11 (OR 1.83; 95% CI: 1.18-2.8; P-value .007) were independent predictors for mortality. Additionally, MFI-11 scores that are >1 were independently associated with a markedly increased risk of dying after a burn injury (OR 2.91; 95% CI: 1.1-7.7; P-value .03). The MFI can be used to identify vulnerable burn injured patients who are at high risk of dying.

Pharmacogenetic Gene-Drug Associations in Pediatric Burn and Surgery Patients.

Management of critically ill patients requires simultaneous administration of many medications. Treatment for patient comorbidities may lead to drug-drug interactions which decrease drug efficacy or increase adverse reactions. Current practices rely on a one-size-fits-all dosing approach. Pharmacogenetic testing is generally reserved for addressing problems rather than used proactively to optimize care. We hypothesized that burn and surgery patients will have one or more genetic variants in drug metabolizing pathways used by one or more medications administered during the patient's hospitalization. The aim of this study was to determine the frequency of variants with abnormal function in the primary drug pathways and identify which medications may be impacted. Genetic (19 whole exome and 11 whole genome) and medication data from 30 pediatric burn and surgery patients were analyzed to identify pharmacogene-drug associations. Nineteen patients were identified with predicted altered function in one or more of the following genes: CYP2C9, CYP2C19, CYP2D6, and CYP3A4. The majority had decreased function, except for several patients with CYP2C19 rapid or ultrarapid variants. Some drugs administered during hospitalization that rely on these pathways include hydrocodone, oxycodone, methadone, ibuprofen, ketorolac, celecoxib, diazepam, famotidine, diphenhydramine, and glycopyrrolate. Approximately one-third of the patients tested had functionally impactful genotypes in each of the primary drug metabolizing pathways. This study suggests that genetic variants may in part explain the vast variability in drug efficacy and suggests that future pharmacogenetics research may optimize dosing regimens.

Development of the School-Aged Life Impact Burn Recovery Evaluation (SA-LIBRE5-12) Profile: A Conceptual Framework.

Pediatric burn injuries can alter the trajectory of the survivor's entire life. Patient-centered outcome measures are helpful to assess unique physical and psychosocial needs and long-term recovery. This study aimed to develop a conceptual framework to measure pediatric burn outcomes in survivors aged 5 to 12 years as a part of the School-Aged Life Impact Burn Recovery Evaluation Computer Adaptive Test (SA-LIBRE5-12 CAT) development. This study conducted a systematic literature review guided by the WHO International Classification of Functioning-Child and Youth and domains in the American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire5-18. Interviews with eight parents and seven clinicians were conducted to identify important domains in child recovery. One clinician focus group with four clinicians was completed to identify gaps in the preliminary framework, and semiweekly expert consensus meetings were conducted with three experts to solidify the framework. Qualitative data were analyzed by grounded theory methodology. Three major thematic outcome domains emerged: 1) Physical Functioning: fine motor and upper extremity, gross motor and lower extremity, pain, skin symptoms, sleep and fatigue, and physical resilience; 2) Psychological Functioning: cognitive, behavioral, emotional, resilience, and body image; and 3) Family and Social Functioning: family relationships, and parental satisfaction, school, peer relations, and community participation. The framework will be used to develop item banks for a CAT-based assessment of school-aged children's health and developmental outcomes, which will be designed for clinical and research use to optimize interventions, personalize care, and improve long-term health outcomes for burned children.

Face Burns: A 4-Year Experience.

Burns on the face pose unique management challenges because they are in a place that is constantly visible, so scars are hard to hide. The goal of this study was to review our experience of adult patients who had face burns. We performed a retrospective review of adult patients (≥18 years old) who were admitted to a regional burn center from July 2015 to June 2019 with face burns. Sex, age, ethnicity, burn etiology, burn size, and discharge status were collected from electronic medical records of the patients who met study criteria. Descriptive statistics, Student's t-tests, and chi-square tests were performed in Stata/SE 16.1. Significance was defined as a P-value < .05. In 4 years, 595/1705 patients (~35% of admissions) were admitted with face burns. The mean age was 44.9 ± 17.0 (mean ± SD) years, with the majority being men (475, 80%). The mean burn size was 19.8 ± 20.9% TBSA with 10.1 ± 19.8% TBSA being third degree. The mean head burn size for any face burn was 2.8 ± 1.8% TBSA. The majority of burns were due to flames (478, 80%) and of those 122 (21%) were from accelerant use and 43 (7%) resulted from propane or butane use. Scalds caused 53 (9%), electric 25 (4%), hot tar 5 (1%), and chemical 5 (1%). Overall, 208 (35%) patients had grafting of some portion of their body, but only 31 patients (5.2%) had face grafting. The mean age of those with face grafting compared with patients who did not need grafting was 45.9 ± 13.8 and 44.9 ± 17.2 years, respectively. Patients who needed grafting had a mean third-degree burn size of 31.7 ± 25.4% TBSA and a mean head (including face) burn size of 4.7 ± 2.0% TBSA, whereas patients who did not need grafting had a mean third-degree burn size of 8.9 ± 18.7% TBSA and a mean head burn size of 2.7 ± 1.8% head TBSA. Patients requiring face grafts had longer lengths of stay, intensive unit stays, ventilator days, and mortality than those whose face burns healed spontaneously. Overall, head burns in adults were common within the 4-year time span we studied, but only a small fraction (5%) had face grafts. The patients who needed grafting for their head burns had significantly larger total body and face burns and had a 2.4-fold higher mortality rate compared to patients who did not need grafting. Most face burns were caused by flame, especially the use of accelerants or flammable gases. Prevention efforts should focus on avoiding the use of accelerants and being careful with flammable gases.

Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015-2019.

Electronic cigarettes are advertised as safer alternatives to traditional cigarettes yet cause serious injury. U.S. burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal injuries related to their use. A multicenter retrospective chart review of American Burn Association burn registry data from five large burn centers was performed from January 2015 to July 2019 to identify patients with electronic cigarette-related injuries. A total of 127 patients were identified. Most sustained less than 10% total body surface area burns (mean 3.8%). Sixty-six percent sustained second-degree burns. Most patients (78%) were injured while using their device. Eighteen percent of patients reported spontaneous device combustion. Two patients were injured while changing their device battery, and two were injured modifying their device. Three percent were injured by secondhand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (3.93%). Flame burns were the most common (70%) type of thermal injury; however, most patients sustained a combination-type injury secondary to multiple burn mechanisms. The most injured body region was the extremities. Silver sulfadiazine was the most common agent used in the initial management of thermal injuries. Sixty-three percent of patients did not require surgery. Of the 36% requiring surgery, 43.4% required skin grafting. Multiple surgeries were uncommon. Our data recognize electronic cigarette use as a public health problem with the potential to cause thermal injury and secondary trauma. Most patients are treated on an inpatient basis although most patients treated on an outpatient basis have good outcomes.

Wildfire Burn Patients: A Unique Population.

In the past ten years wildfires have burned an average of 6.8 million acres per year and this is expected to increase with climate change. Wildfire burn patient outcomes have not been previously well characterized. Wildfire burn patients from the Tubbs or Camp wildfires and non-wildfire burn matched controls were identified from the burn center database and outcomes were compared. The primary outcome was mortality. Secondary outcomes included length of stay (LOS), intensive care unit (ICU) LOS, readmission and development of wound infections. Time of presentation and operating room use after wildfires was evaluated. Sixteen wildfire burn patients were identified and matched with 32 controls. Wildfire burn patients trended towards higher mortality (19% wildfire vs. 9% non-wildfire, p=0.386), longer LOS (18 days wildfire vs. 15 days non-wildfire, p=0.406), longer ICU LOS (17 days wildfire vs. 11 days non-wildfire, p=0.991), increased readmission (19% wildfire vs. 3% non-wildfire, p=0.080) and higher rates of wound infection (31% wildfire vs. 19% non-wildfire, p=0.468). The majority of wildfire patients (88%) presented within 24 hours of the wildfire reaching a residential area. Operating room time within the first week was 13 hours 44 minutes for the Tubbs Fire and 19 hours 1 minute for the Camp Fire. Patients who sustain burns in wildfires are potentially at increased risk of mortality, prolonged LOS, wound infection and readmission.

Follow-up After Burn Injury Is Disturbingly Low and Linked With Social Factors.

For medical and social reasons, it is important that burn patients attend follow-up appointments (FUAs). Our goal was to examine the factors leading to missed FUAs in burn patients. A retrospective chart review was conducted of adult patients admitted to the burn center from 2016 to 2018. Data collected included burn characteristics, social history, and zip code. Data analysis was conducted using chi-square, Wilcoxon Rank-Sum tests, and multivariate regression models. A total of 878 patients were analyzed, with 224 (25.5%) failing to attend any FUAs and 492 (56.0%) missing at least one appointment (MA). Patients who did not attend any FUAs had smaller burns (4.5 [8]% vs 6.5 [11]% median [inter quartile range]), traveled farther (70.2 [111.8] vs 52.5 [76.7] miles), and were more likely to be homeless (22.8% vs 6.9%) and have drug dependence (47.3% vs 27.2%). Patients who had at least one MA were younger (42 [26] vs 46 [28] years) and more likely to be homeless (17.5% vs 2.6%) and have drug dependence (42.5% vs 19.4%). On multivariate analysis, factors associated with never attending an FUA were distance from hospital (odds ratio [OR] 1.004), burn size (OR 0.96), and homelessness (OR 0.33). Factors associated with missing at least one FUA: age (OR 0.99), drug dependence (OR 0.46), homelessness (OR 0.22), and Emergency Department visits (OR 0.56). A high percentage of patients fail to make any appointment following their injury and/or have at least one MA. Both FUAs and MAs are influenced by social determinants of health.

Measuring the impact of burn injury on the parent-reported health outcomes of children 1-to-5 years: Item pool development for the Preschool1-5 Life Impact Burn Recovery Evaluation (LIBRE) Profile.

Modern, reliable, and valid outcome measures are essential to understanding the health needs of young children with burn injuries. Burn-specific and age-appropriate legacy assessment tools exist for this population but are hindered by the limitations of existing paper-based instruments. The purpose of this study was to develop item pools comprised of questions appropriate for children aged 1-5 with burn injuries. Item development was based on a framework provided by previous work to develop the Preschool Life Impact Burn Recovery Evaluation (LIBRE) Conceptual Model. The Preschool LIBRE Conceptual Model work established four sub-domains of functioning for children with burns aged 1-5. Item development involved a systematic literature review, a qualitative item review process with clinical experts, and parent cognitive interviews. Four item pools were established: (1) communication and language development; (2) physical functioning; (3) psychological functioning and (4) social functioning for preschool-aged children with burn injuries. We selected and refined candidate items, recall periods, survey instructions, and response option choices through clinical and parental feedback during the qualitative review and cognitive interview processes. Item pools are currently being field-tested as part of the process to calibrate and validate the Preschool1-5 LIBRE Computer Adaptive Test (CAT) Profile.