Intravenous Ketamine as an Adjunct to Procedural Sedation During Burn Wound Care and Dressing Changes.

Little has been published regarding intravenous (IV) ketamine for burn wound care in adult patients. Ketamine may serve as a safe alternative to provide conscious sedation and limit opioid administration to patients. The purpose of this study was to characterize IV ketamine use during burn wound care and establish its potential role as a safe adjunct to opioid and benzodiazepine medications. This is a retrospective review of adult patients admitted to a regional burn center who received IV ketamine for burn wound care. Patient demographics, medications, and ketamine-related adverse effects including hypertension and dysphoric reactions were recorded. Cardiopulmonary complications were also tracked. Thirty-six patients met inclusion criteria; fifty total cases were performed. The median patient age was 37 (interquartile range [IQR]: 28-55] years with a median burn size of 9.5 (IQR: 4.0-52) %TBSA. The median ketamine dose administered was 1.2 (IQR: 0.8-2.1) mg/kg. IV midazolam was administered in almost all cases (98%) at a median dose of 3.0 (IQR: 2.0-5.0) mg. Opioids were administered in 13 of 50 cases (26%) at a median morphine equivalent dose of 10 (IQR: 5.0-18) mg. In 46 cases (92%), patients denied unpleasant recall of medication. Dysphoric reactions were observed in three cases (6%). Ketamine-induced hypertension occurred in three cases (6%) and all immediately responded to IV labetalol. There were no cardiopulmonary complications. These findings suggest that IV ketamine provides a safe analgesia and sedative option for burn wound care. Given these findings, IV ketamine for burn wound care warrants further study.

A survey of the use of propranolol in burn centers: Who, what, when, why.

INTRODUCTION: Many burn centers utilize propranolol in both adult and pediatric burn patients to attenuate the hypermetabolic response related to thermal injury despite the relative paucity of data in adults compared to children. The purpose of this study was to identify practice patterns related to propranolol, for which groups it is being used, length of use, and the intended benefit. METHODS: A 17 question survey regarding the use of propranolol was distributed to burn centers listed in the ABA website with a link to provide anonymous responses. RESULTS: A 31% response rate was achieved. Results demonstrated 60.5% use propranolol while 39.5% do not. Use in both adult and pediatric patients was reported in 82% of centers. The majority of centers (60.8%) initiate propranolol in patients with >20% TBSA burns. The drug is continued while inpatient for most adults (43%) with only 10% continuing treatment up to 6 months vs. rates of 17.6% long term outpatient use in pediatric patients. Drug dosing ranged from 10 to 40mg in adults and 0.1mg/kg to 5mg/kg in pediatric patients dosed twice daily to four times daily with 25% and 40% titrating the dose to a reduced heart rate respectively. Propranolol was felt to improve outcomes in 56% of responses while 39% were "unsure". CONCLUSION: The majority of centers use propranolol for both adult and pediatric patients despise the lack of randomized studies in adult populations. A wide variation of practice patterns highlights the need for further study in regard to patient outcomes, duration of therapy, and dosing to drive consensus guidelines.

The Fire Challenge: A Case Report and Analysis of Self-Inflicted Flame Injury Posted on Social Media.

With the advent of social media platforms such as Facebook and YouTube, online dissemination of exhibitionist videos has gained popularity. One recent disturbing trend is the "fire challenge" wherein a participant douses his or herself in a household accelerant such as isopropyl alcohol or acetone, sets him or herself ablaze, and attempts to extinguish the flames before serious burns are incurred. As expected, participants in the "fire challenge" often accidentally suffer serious burns. A 17-year-old white male was recently treated at our burn center after participating in the "fire challenge." He suffered 15% TBSA full and partial thickness burns requiring split thickness skin grafting to his abdomen. He reported lighting himself on fire because he had seen this stunt performed on the internet. A search for "fire challenge" and similar terms was conducted on YouTube (www.youtube.com). Gender and ethnicity of each participant were documented. Burn size, burn depth, and age of video participant were estimated by two attending burn surgeons evaluating YouTube videos. Results were reported with descriptive statistics. The search yielded thousands of hits, mostly home videos, compilations of stunts, and commentaries. After omitting duplicate and irrelevant videos, 50 videos were selected for the study. Of these, 13 videos included postburn footage demonstrating burn wounds of various location, size, and severity. Of these burns, the median TBSA burned was 4 ± 2.7% with a maximum size of 10%. Superficial and partial thickness burns were sustained on the torso (10/13, 77%), face (4/13, 31%), and extremities (2/13, 15%). Full thickness burns were seen in 2/13 videos. Some burn wounds were obscured by dressings. Of the 50 videos reviewed, 45/50 participants (90%) were male and 32/50 (64%) were African American with 29/50 participants (58%) estimated to be under age 20. The "fire challenge" is a popular social media phenomenon, but it can result in severe injury as seen with the patient at our institution. The lure of a challenge and potential for a shocking video to "go viral" might entice people to mimic this risky behavior. This study shows a disturbing trend, but undoubtedly only reflects a small portion of actual participants. A disproportionate number of videos featured young African American males, making this a target population for education and prevention efforts. Our patient's TBSA exceeded the maximum found on YouTube, suggesting that less severe burns may be posted online while larger burns are not, diminishing perceived risk and encouraging this behavior.

Do fentanyl and morphine influence body temperature after severe burn injury?

Fentanyl lacks the antiinflammatory properties of morphine. Morphine attenuates the inflammatory response through differential stimulation of µ-receptor subtypes. Patients who receive morphine during coronary artery bypass graft have been shown to experience less postoperative fever than those who receive fentanyl. Patients who receive continuous fentanyl infusions in increased room temperatures after thermal injury may be at increased risk to experience higher body temperature than those who receive morphine. The records of 28 patients with >20%TBSA burn in 30 intensive care unit rooms (13 received fentanyl and 15 received morphine or hydromorphone) and 12 trauma patients who received fentanyl in 22°C intensive care unit rooms were reviewed. Mean maximum core temperature and percentage of temperature recordings > 39°C in the first 48 hours of admission were compared between burn patients who received fentanyl, those who did not, and with trauma patients. Burn patients exposed to fentanyl experienced significantly higher temperatures (40.1 ± 0.9°C) compared with those given morphine (38.7 ± 0.8°C) and compared with trauma patients (37.5 ± 2.4°C), P < .01 and P < .001, respectively. Burn patients on fentanyl had temperatures > 39°C for a higher percentage of time (33 ± 27%) than those without fentanyl (7.2 ± 13%) and trauma patients (1 ± 2.8%), P < .01 and P < .001, respectively. No differences in other medications administered, acute physiology and chronic health evaluation II scores, or the number of infections that could account for temperature disparities between groups existed. Burn patients who receive fentanyl in 30°C rooms experience higher body temperatures and are febrile for a higher percentage of time than those receiving morphine only. Morphine has well-established antiinflammatory properties and likely attenuates the postburn inflammatory response more than fentanyl, resulting in lower body temperatures. This phenomenon needs to be further investigated in additional studies.

Resuscitation after severe burn injury using high-dose ascorbic acid: a retrospective review.

Resuscitation of burn victims with high-dose ascorbic acid (vitamin C [VC]) was reported in Japan in the year 2000. Benefits of VC include reduction in fluid requirements, resulting in less tissue edema and body weight gain. In turn, these patients suffer less respiratory impairment and reduced requirement for mechanical ventilation. Despite these results, few burn centers resuscitate patients with VC in fear that it may increase the risk of renal failure. A retrospective review of 40 patients with greater than 20% TBSA between 2007 and 2009 was performed. Patients were divided into two groups: one received only lactated Ringer's (LR) solution and another received LR solution plus 66 mg/kg/hr VC. Both groups were resuscitated with the Parkland formula to maintain stable hemodynamics and adequate urine output (>0.5 ml/kg/hr). Patients with >10-hour delay in transfer to the burn center were excluded. Data collected included age, gender, weight, %TBSA, fluid administered in the first 24 hours, urine output in the first 24 hours, and Acute Physiology and Chronic Health Evaluation II score. PaO2 in millimeters mercury:%FIO2 ratio and positive end-expiratory pressure were measured at 12-hour intervals, and hematocrit was measured at 6-hour intervals. Comorbidities, mortality, pneumonia, fasciotomies, and renal failure were also noted. After 7 patients were excluded, 17 patients were included in the VC group and 16 in the LR group. VC and LR were matched for age (42 ± 16 years vs 50 ± 20 years, P = .2), burn size (45 ± 21%TBSA vs 39 ± 15%TBSA, P = .45), Acute Physiology and Chronic Health Evaluation II (17 ± 7 vs 18 ± 8, P = .8), and gender. Fluid requirements in the first 24 hours were 5.3 ± 1 ml/kg/%TBSA for VC and 7.1 ± 1 ml/kg/%TBSA for LR (P < .05). Urine output was 1.5 ± 0.4 ml/kg/hr for VC and 1 ± 0.5 ml/kg/hr for LR (P < .05). Vasopressors were needed in four VC patients and nine LR patients (P = .07). VC patients required vasopressors to maintain mean arterial pressure for a mean of 6 hours, but LR needed vasopressors for 11 hours (P = .2). No significant differences in PaO2 in millimeters mercury:%FIO2 ratio, positive end-expiratory pressure, frequency of pneumonia, renal failure, or inhalation injury were found. VC group had four mortalities, and LR group had three mortalities (P = 1). VC is associated with a decrease in fluid requirements and an increase in urine output during resuscitation after thermal injury. Although this study did not find a difference in outcomes with VC administration, it demonstrates that VC can be safely used without an increased risk of renal failure. The effects of VC should be further studied in a large-scale, prospective, randomized trial.

The burn surgeon: an endangered species. Can exposure in medical school increase interest in burn surgery?

The nation is faced with a shortage of subspecialty physicians, including burn surgeons. Exposure to a specialty in medical school has been shown to influence students' career choices. The authors postulate that exposure to burn surgery increases their interest in the field. Students from a medical school with an American Burn Association-verified burn center and from a school without a burn center were anonymously surveyed and asked to report their interest and knowledge regarding burn surgery using a 5-point Likert scale. They were asked about their current year in school, gender, overall interest in surgery, and any prior exposure to burn surgery (eg, preceptorship or rotation). Students were asked whether exposure to burn surgery or to a strong mentor might increase their interest in the field. Finally, they were asked to pick the most important factor in a list of deterrents to pursuing a career in burn surgery. Predictors of interest in burn surgery were determined with regression analyses. A total of 380 of 662 students responded to the survey (57.4%). Significant predictors of interest in burn surgery were an interest in surgery (P < .001, odds ratio [OR] = 56.3), prior exposure to burn surgery (P = .02, OR = 5.7), and year in school (P = .006, OR = 1.7). First- and second-year students were more likely to report interest in burn surgery (P < .001). Gender and medical school attended were not significant predictors. Prior exposure to burn surgery became a stronger predictor in subgroup analysis of the fourth-year students (P < .001, OR = 24.5). The majority of students reported that exposure to burn surgery (76%) and a strong mentor (87%) would make them more likely to consider burn surgery as a career. "Not interested in surgery" was the most important deterrent to pursuing a career in burn surgery, which was selected by 33% of students. However, 25% of students chose "I don't know anything about burn surgery" as the most important deterrent. Factors specific to burn surgery were less frequently selected (eg, wound care and hot operating room). The majority of students reported ignorance of the field of burns: 64% disagreed that they understood what a burn surgeon does on a daily basis, and 74% agreed they did not know enough about the field to consider it as a career. Exposure to burn surgery in the form of a clinical rotation fosters medical student interest. However, the majority of medical students lack knowledge about the field of burn surgery. Many consider this a deterrent to selecting it as a career. More exposure during medical school and strong mentorship may influence more students to become burn surgeons. Mentorship and recruiting efforts should be focused on students with a general interest in surgery.

Use of acellular dermal replacement in reconstruction of nonhealing lower extremity wounds.

Dermal templates are well established in the treatment of burn wounds and acute nonburn wounds. However, the literature regarding their use for reconstruction of chronic, nonhealing wounds is limited. This study describes a series of patients with chronic wounds reconstructed with a commercially available bilayer, acellular dermal replacement (ADR) containing a collagen-glycosaminoglycan dermal template and a silicone outer layer. A retrospective review was performed of 10 patients treated for chronic wounds with ADR and negative pressure dressing followed by split-thickness skin graft between July 2006 and January 2009. Data collected included age, gender, comorbidities, medications, wound type or location, wound size, the number of applications of ADR, the amount of ADR applied (in square centimeter), the amount of time between ADR placement and grafting, complications, need for reoperation, and percentage of graft take after 5 and 14 days. The mean age of study subjects was 44 years. All patients in the study had comorbidities that interfere with wound healing and were treated for lower extremity wounds (four to legs, five to ankles, and one to foot). The wounds had a variety of causative factors including venostasis ulcers (6, 60%), trauma in diabetic patients (2, 20%), brown recluse bite (1, 10%), and a wound caused from purpura fulminans (1, 10%). The average wound size and amount of ADR applied was 162±182 cm². Each patient required only one application of ADR. The average time between ADR placement and skin grafting was 36.5 days. The mean percentage of graft take at 5 days was 89.55%, 14 days was 90%, and 21 days was 87.3%. Only two patients required regrafting, and one of these grafts was lost because of patient noncompliance. ADR can be used successfully in the treatment of chronic wounds. ADR provides direct wound coverage and can conform to a variety of anatomical sites. This study demonstrates that the use of ADR in treating chronic wounds results in high rates of skin graft take. Favorable results were obtained despite the majority of patients having comorbidities that would normally interfere with wound healing.

Purulent skin and soft tissue infection: antibiotic selection in the community.

INTRODUCTION: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) requently causes skin and soft tissue infections (SSTIs). Referring primary care physicians often prescribe inactive antibiotics when referring SSTIs caused by MRSA for incision and debridement. METHODS: Demographics and culture results (organism and sensitivity) were collected for patients treated for SSTI between 2007-2009. Antibiotic regimens started by referring PCPs were noted. Prevalence of MRSA and antibiotic resistance profiles were tabulated. Isolates resistant to the drug initially prescribed were also noted. RESULTS: Of 187 patients, 40.1% grew MRSA. All MRSA was sensitive to doxycycline and trimethoprim-sulfamethoxazole, whereas 88% were sensitive to clindamycin and 79% to levofloxacin. 48% of patients received an antibiotic inadequate for their isolate before referral. CONCLUSIONS: CA-MRSA is extremely common. Patients are often prescribed antibiotics inadequate for MRSA. Doxycycline or trimethoprim-sulfamethoxazole with incision/drainage should be used as initial therapy for SSTI when MRSA is suspected.