Technical Tips: The Role of the Charge Neurodiagnostic Technologist.

The purpose of this strategic staffing study was to retrospectively evaluate the impact of the charge neurodiagnostic technologist (NDT) within a 24/7 pediatric NAEC Level IV, ABRET LAB-LTM accredited epilepsy monitoring unit (EMU) during a 4-month pilot. The association between a high-reliability organization (HRO), Lean thinking, and organizational strategic goals were utilized as guiding principles. This paper reviews the operational need to further develop frontline neurodiagnostic leadership roles within Ann & Robert H. Lurie Children's Hospital of Chicago along with the design and implementation, training, and competencies required.

Psychiatric Risk Factors and Burn Severity in Self-Immolation.

Self-immolation, a form of self-harm involving setting oneself on fire, is associated with high mortality, morbidity, and healthcare burden. This study aimed to characterize potential clinical correlates and predisposing factors for self-immolation based on burn severity using Total Body Surface Area (TBSA) percentage scoring. Additional objectives included identifying motivational elements, associated risk factors, and clinical characteristics to optimize patient care and reduce future self-immolation incidents. A retrospective review of admissions to the Arizona Burn Center from July 2015 to August 2022 identified 103 self-immolation patients for the study. Burn severity was categorized as mild to moderate (TBSA < 20%) or severe (TBSA ≥ 20%) based on TBSA. This study population had a mortality rate of 21%. Positive urine drug screens were found in 44% of subjects, and 63% having chronic substance use, with methamphetamine (37%) and alcohol (30%) being the most prevalent. Underlying psychiatric illnesses were present in 83% of patients. Suicidal intent strongly predicted severe burns (p < 0.001) among the 68 severe burn cases identified. In conclusion, this study emphasizes that the presence of suicidal intent among self-immolation patients significantly correlates with burn severity. These findings highlight the importance of involving psychiatric services early in patient care to improve outcomes and reduce the recurrence of self-immolation acts.

Predictors and Impact of Pneumonia on Adverse Outcomes in Inhalation Injury Patients.

Inhalation injury (II) is the third mortality prognostic factor for burn injury following age and burn size. II can lead to pulmonary complications such as pneumonia and acute respiratory distress syndrome (ARDS); all of which have been hypothesized to increase morbidity and mortality in II. Herein, we aimed to identify variables associated with the risk of developing pneumonia and to determine the impact of pneumonia on selected II outcomes. De-identified data from the Prospective Inhalation Study titled Inhalation Injury Scoring System to Predict Inhalation Injury Severity (ISIS) were used. II was confirmed by fiberoptic bronchoscopy. Demographics, injury, and hospital course information were recorded. P < .05 was considered significant. One hundred subjects were included. On univariate analysis, pneumonia was associated with burn severity, race, and receipt of colloid during the first 24 hours. Patients who developed pneumonia spent more time on a ventilator, had longer hospitalizations (LOS) and were more likely to need a tracheostomy. On multivariate analysis, total number of ventilator days was associated with pneumonia (Odd ratio (OR) = 1.122 [1.048-1.200], P = .001). Both pneumonia and receipt of colloid were predictive of increased ventilator days (OR = 2.545 [1.363-4.753], P < .001 and OR = 2.809 [1.548-5.098], P < .001, respectively). Pneumonia was not an independent predictor of LOS, ARDS, or mortality. Pneumonia remains a high-risk complication associated with two times more ventilator days in II. Future research should focus on prevention of pneumonia and the relationship between colloid fluids and pneumonia and early ventilator liberation in II patients.

Using Hospital Incident Command Systems to Respond to the Pediatric Mental and Behavioral Health Crisis of the COVID-19 Pandemic.

ABSTRACT: Hospital incident command systems (HICS) were implemented to expand mental and behavioral healthcare (MBHC) services during the COVID-19 pandemic. Data on patient census, nurse vacancies, staff injuries, and staff perceptions were analyzed to quantify issues and track progress toward HICS goals. Data, environment of care, staffing, staff support, staff education, and communication resources were developed. After HICS implementation, 84% of nurses reported confidence in providing care to youth with acute MBHC needs. Nurse leaders should consider HICS for addressing other crises.

Development and Application of Multidimensional Lipid Libraries to Investigate Lipidomic Dysregulation Related to Smoke Inhalation Injury Severity.

The implication of lipid dysregulation in diseases, toxic exposure outcomes, and inflammation has brought great interest to lipidomic studies. However, lipids have proven to be analytically challenging due to their highly isomeric nature and vast concentration ranges in biological matrices. Therefore, multidimensional techniques such as those integrating liquid chromatography, ion mobility spectrometry, collision-induced dissociation, and mass spectrometry (LC-IMS-CID-MS) have been implemented to separate lipid isomers as well as provide structural information and increased identification confidence. These data sets are however extremely large and complex, resulting in challenges for data processing and annotation. Here, we have overcome these challenges by developing sample-specific multidimensional lipid libraries using the freely available software Skyline. Specifically, the human plasma library developed for this work contains over 500 unique lipids and is combined with adapted Skyline functions such as indexed retention time (iRT) for retention time prediction and IMS drift time filtering for enhanced selectivity. For comparison with other studies, this database was used to annotate LC-IMS-CID-MS data from a NIST SRM 1950 extract. The same workflow was then utilized to assess plasma and bronchoalveolar lavage fluid (BALF) samples from patients with varying degrees of smoke inhalation injury to identify lipid-based patient prognostic and diagnostic markers.

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.

Severe Acute Respiratory Syndrome Coronavirus 2 Point Prevalence Among Asymptomatic Hospitalized Children and Subsequent Healthcare Worker Evaluation.

Asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) carriage among hospitalized children and risk of transmission to healthcare workers (HCWs) was evaluated by point prevalence survey. We estimated 1-2% prevalence of SARS-CoV-2 among children without coronavirus disease 2019 symptoms. There was no secondary transmission among HCWs exposed to these patients.

"Streets of Fire" revisited: contact burns.

BACKGROUND: Pavement-street contact burns are rare. This study compared recent contact burns to those published in "Pavement temperature and burns: Streets of Fire" in 1995. The hypothesis was that there were a significantly increased number of pavement-street burns, as a result of increased ambient temperatures, and that motor vehicle crash (MVC) contact burns were less severe than pavements-street burns. METHODS: This was a retrospective burn center registry study of naturally heated surface contact burns during May to September from 2016 to 2018. Statistical analyses were performed with one-way analysis of variance (ANOVA) and Maximum Likelihood chi-squared for age, percent of total burn surface area (% TBSA), treatment, hospitalization, comorbidities, hospital charges, mortality, ambient, and surface temperatures (pavement, asphalt, rocks). RESULTS: In the 1995 study, median ambient temperatures were 106 (range 100-113) °F compared to the 108 (range 86-119) °F highest noon temperature in the current study. No ambient temperature differences were recorded on days with pavement burn admissions compared to days without these admissions. There were 225 pavement, 27 MVC, 15 road rash, and 103 other contact burns. The major injuries in the pavement group were due to being "down" (unknown reason), falls, and barefoot. Compared to the others, the pavement group was older, 56+ years, p < 0.001, and had smaller burns but similar length of stay. Fifty percent of the 225 pavement group patients with full-thickness burns required skin grafts. There were 13 (6%) fatalities in the pavement group vs 1 (4%) in the MVC group, p = 0.01. Fatalities were secondary to sepsis, shock, cardiac, respiratory, or kidney complications. Compared to survivors, the non-survivors had a significantly higher % TBSA (10% vs 4%), p = 0.01, and lower Glasgow Coma Scores (10 vs 15), p = 0.002. CONCLUSION: There was a median 2 °F increase in ambient temperature since 1995. The increase in pavement burn admissions was multi-factorial: higher temperatures, population, and the number of older patients, with increased metropolis expansion, outreach, and urban heat indices. Pavement group was similar to the MVC group except for significantly older age and increased mortality. Morbidity associated with age contributed to increased mortality.

A multicenter study of preventable contact burns from glass fronted gas fireplaces.

Glass fronted gas fireplaces (GFGFs) have exterior surfaces that can reach extremely high temperatures. Burn injuries from contact with the glass front can be severe with long-term sequelae. The Consumer Product Safety Commission reported that these injuries are uncommon, whereas single-center studies indicate a much higher frequency. The purpose of this multi-institutional study was to determine the magnitude and severity of GFGF injuries in North America. Seventeen burn centers elected to participate in this retrospective chart review. Chart review identified 402 children ≤10 years of age who sustained contact burns from contact with GFGF, who were seen or admitted to the study hospitals from January 2006 to December 2010. Demographic, burn, treatment, and financial data were collected. The mean age of the study group was 16.8 ± 13.3 months. The majority suffered burns to their hands (396, 98.5%), with burns to the face being the second, much less common site (14, 3.5%). Two hundred and sixty-nine required rehabilitation therapy (66.9%). The number of GFGF injuries reported was 20 times greater than the approximately 30 injuries estimated by the Consumer Product Safety Commission's 10-year review. For the affected children, these injuries are painful, often costly and occasionally can lead to long-term sequelae. Given that less than a quarter of burn centers contributed data, the injury numbers reported herein support a need for broader safety guidelines for gas fireplaces in order to have a significant impact on future injuries.

Measuring the burden of pediatric burn injury for parents and caregivers: informed burn center staff can help to lighten the load.

This study sought to identify which commonly experienced burn-related issues parents/caregivers of burn-injured youth deemed most stressful, difficult, and disruptive during their child's initial acute burn care hospitalization, and following the child's discharge. Parents completed an 11-item survey, asking them to rate the difficulty of items regarding their child's burn injury. The scale was created by burn doctors, nurses, and psychologists with an average of 10.5 (SD ± 4.8) years of experience. Items selected were among common parental problems reported in the burn literature. Respondents included 69 parents/caregivers of previously hospitalized, burn-injured youth. The majority were mothers, n = 51 (74%), and n = 34 (49%) were Caucasian. The most represented age group was 37 to 45 years, n = 31 (45%). Children were on average, 6.04 years out from their initial injury. All parents reported their child's pain as the most difficult part of the injury, n = 69 (100%). The second most common issue was the child's first hospital stay. The other two items found to be "very hard" or "pretty hard" were the time spent away from their other children, and feelings of hopelessness in being unable to fix everything for their child. In this study, key parental problems occurred during the child's initial hospitalization. Burn staff cannot alleviate all problems, however, staff education regarding distressing problems faced by parents, as well as possible solutions, can be made available.

Results of a prospective randomized controlled trial of early ambulation for patients with lower extremity autografts.

It is common practice to keep those patients with lower extremity autografts immobile until post-operative day (POD) 5. There is however inherent risks associated with even short periods of immobility. As of now there are no randomized controlled trials looking at early ambulation of patients with lower extremity autografts in the burn community.The objective of this study was to show that patients who begin ambulation within 24 hours of lower extremity autografting will have no increased risk of graft failure than those patients who remain immobile until POD 5. Thirty-one subjects who received autografts to the lower extremity were randomized after surgery into either the early ambulation group (EAG;17 subjects) or the standard treatment group (STG;14 subjects). Those subjects randomized to the EAG began ambulating with physical therapy on POD 1. Subjects in the STG maintained bed rest until POD 5. There was no difference in the number of patients with graft loss in either the EAG or STG on POD 5, and during any of the follow-up visits. No subjects required regrafting. There was a significant difference in the mean minutes of ambulation, with the EAG ambulating longer than the STG (EAG 23.4 minutes [SD 12.03], STG 14.1 [SD 9.00], P=.0235) on POD 5. Burn patients with lower extremity autografts can safely ambulate on POD 1 without fear of graft failure compared with those patients that remain on bed rest for 5 days.

The blue man: burn from muriatic acid combined with chlorinated paint in an adult pool construction worker.

Muriatic acid (hydrochloric acid), a common cleaning and resurfacing agent for concrete pools, can cause significant burn injuries. When coating a pool with chlorinated rubber-based paint, the pool surface is initially cleansed using 31.45% muriatic acid. Here we report a 50-year-old Hispanic male pool worker who, during the process of a pool resurfacing, experienced significant contact exposure to a combination of muriatic acid and blue chlorinated rubber-based paint. Confounding the clinical situation was the inability to efficiently remove the chemical secondary to the rubber-based nature of the paint. Additionally, vigorous attempts were made to remove the rubber paint using a variety of agents, including bacitracin, chlorhexidine soap, GOOP adhesive, and Johnson's baby oil. Resultant injuries were devastating fourth-degree burns requiring an immediate operative excision and amputation. Despite aggressive operative intervention and resuscitation, he continued to have severe metabolic derangements and ultimately succumbed to his injuries. We present our attempts at debridement and the system in place to manage patients with complex chemical burns.

Tracheobronchial protease inhibitors, body surface area burns, and mortality in smoke inhalation.

The objective of this study was to assess tracheobronchial protease inhibitor concentrations longitudinally and determine whether initial concentrations predict subsequent lung injury and mortality in intubated burn victims. Tracheobronchial suction fluid was collected every 2 hours for 36 hours. Alpha-1-antitrypsin (AAT), secretory leukocyte peptidase inhibitor (SLPI), alpha-2-macroglobulin (A2M), and cell and differential counts were assayed. Partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FIO2) and peak airway pressure (PAP) were recorded for 72 hours. Standard statistics were used to evaluate cross-sectional relationships; random coefficient (mixed) models were used to evaluate temporal trends in marker concentrations and relation to clinical outcomes. Among 29 patients, 24 (83%) developed hypoxemia (PaO2/FIO2 <200); six died within 2 weeks. When adjusted for gender, age, %TBSA burn, and positive end-expiratory pressure setting, A2M (P = .007) and neutrophils (P = .032) increased linearly during 36 hours, and SLPI decreased (P = .038). Initial SLPI concentration was a negative predictor of maximum PAP (P = .009). None of the markers predicted longitudinal change in PaO2/FIO2. Mean levels of AAT and A2M in initial samples were significantly lower in patients with >35% TBSA burn (P = .010 and .033, respectively), when compared with patients with less severe burns. However, patients with increased A2M in combination with >35% TBSA burn had a 6-fold (95% CI: 1.8-20) increased relative risk of death. Tracheobronchial AAT and A2M levels were significantly lower in patients with more severe burns and increased over time. Initial SLPI levels predicted subsequent PAP. Increased early A2M in combination with extensive burn predicted early mortality.

Tracheobronchial markers of lung injury in smoke inhalation victims.

Although smoke inhalation injury victims frequently develop severe hypoxemia and are at increased risk of acute respiratory distress syndrome (ARDS), no early prognostic tests are currently available. The objectives were to determine early longitudinal changes in tracheobronchial fluid inflammatory markers and assess the value of initial concentrations as predictors of subsequent lung injury. Partial pressure of arterial oxygen (Pao2) and the fraction of inspired oxygen (Fio2) were recorded approximately every 6 hours from intubated smoke inhalation victims admitted to a regional burn center. Tracheobronchial suction fluid was collected every 2 hours and assayed for interleukins (IL-1beta, -8, and -10), tumor necrosis factor-alpha, transforming growth factor-beta1, soluble Fas ligand (sFasL), and complement factor 5a. Temporal trends in marker concentrations during 36 hours and the relations between initial concentrations and lowest Pao2/Fio2 or ARDS within 72 hours were assessed using random coefficients modeling and cross-sectional analysis. In 21 subjects with tracheobronchial samples collected within 6.5 hours of intubation, 14 (66.7%) developed acute hypoxemia (Pao2/Fio2 < or =200) within 72 hours of exposure and nine (42.9%) developed ARDS, as defined by the American-European consensus conference on ARDS. IL-8 increased sharply in the first 6.5 hours postexposure (P < .001), and IL-1beta in the first 6.1 hours (P < .001). No significant temporal trends in IL-10, tumor necrosis factor-alpha, transforming growth factor-beta1, sFasL, or complement factor 5a were found. Only initial IL-8 was associated with increased Pao2/Fio2 (P = .013) and with a minimum Pao2/Fio2 >200 (P = .042) during 72 hours. In smoke inhalation victims, tracheobronchial IL-1beta and IL-8 increase rapidly and high initial IL-8 may predict improved oxygenation.

Clinical evaluation of a flexible fecal incontinence management system.

BACKGROUND: Management of fecal incontinence is a priority in acute and critical care to reduce risk of perineal dermatitis and transmission of nosocomial infections. OBJECTIVE: To evaluate the safety of the Flexi-Seal Fecal Management System in hospitalized patients with diarrhea and incontinence. METHODS: A prospective, single-arm clinical study with 42 patients from 7 hospitals in the United States was performed. The fecal management system could be used for up to 29 days. The first 11 patients (all from critical care) underwent endoscopic proctoscopy at baseline; 8 of these had endoscopy again after treatment. The remaining 31 patients (from critical or acute care) did not have endoscopy. RESULTS: Rectal mucosa was healthy after use of the device in all patients who had baseline and follow-up endoscopy. Physicians and nurses reported that the system was easy to insert, remove, and dispose of; its use improved management of fecal incontinence; and it was practical, caregiver- and patient-friendly, time-efficient, and efficacious. Skin condition improved or was maintained in more than 92% of patients. Patients' reports of discomfort, pain, burning, or irritation were uncommon. Adverse events were reported for 11 patients (26%). Death (considered unrelated to study treatment) occurred in 5 patients, 2 patients had generalized skin breakdown, and 1 patient had gastrointestinal bleeding after 4 days of treatment. CONCLUSIONS: The fecal management system can be used safely in hospitalized patients with diarrhea and fecal incontinence. Additional well-designed, controlled clinical trials may help to measure clinical and economic outcomes associated with the device.