Bronchoalveolar lavage and plasma Antithrombin and cytokines in inhalation and burn injury: a pilot study.

Systemic inflammatory response syndrome (SIRS) is initiated during the acute phase of thermal injury. The objective was to determine the SIRS impact on cytokine and Antithrombin (AT) levels in smoke inhalation and burn injury. This observational pilot study compared plasma and bronchoalveolar lavage fluid (BAL) cytokine and AT levels in the first six days post smoke inhalation and burn injury. Twenty-five patients, 14 with inhalation + burn injury > 10% total body surface area (TBSA) and 11 with inhalation injury and ≤ 10% TBSA participated. Human Th1/Th2 cytometric bead array kit from BD Biosciences Pharmingen determined cytokine levels; AT levels with Sigma Diagnostics and spectrophotometry. Results indicated no significant age difference between the two groups (42.1 ± 7.2) versus 49.6 ± 6.4 years. On admission, the inhalation group had 5.4 ± 3.9% TBSA compared to 35.0 ± 22.2% TBSA in the inhalation + burn group, P < 0.001. Comparing groups, AT plasma levels were significantly decreased (P = 0.025) and IL-2 levels significantly increased (P = 0.025) in the inhalation + burn group compared to the inhalation group; there was no significant difference in BAL AT or cytokine levels. Combined group plasma AT levels (65.41 ± 4.44%) were significantly increased compared to BAL AT levels (1.06 ± 0.71%), P < 0.001. In contrast, BAL TNF-α levels (35.61 ± 16.01 pg/ml) were significantly increased in relation to the plasma levels (4.68 ± 1.27 pg/ml), P = 0.02. On days 1-2, AT plasma levels were significantly decreased in the inhalation + burn group (41.01 ± 5.24%) compared to the inhalation group (81.02 ± 10.99%), P = 0.002. IL-6 plasma levels were higher in the inhalation + burn group compared to the inhalation group on admission, but both levels decreased by days 3-6. IL-6 BAL levels were elevated in both groups on days 1-2 and decreased by days 3-6. In the first six days of resuscitation, all plasma cytokines were increased in the two groups compared to controls. AT plasma and BAL levels were significantly reduced in both groups, contributing to the coagulopathy. Increased BAL TNF-α and IL-6 levels may have contributed to the pulmonary perturbations during the initial SIRS response in both groups.

Burn prevention in Zambia: a work in progress.

The aim of this study was to assess both burn prevention knowledge and the effectiveness of educational intervention in alleviating the current knowledge deficit in Zambian youth. In one rural Zambian district, a burn prevention program was implemented in June 2011. Children at two elementary schools completed a 10-question survey that aimed to assess knowledge regarding burn injuries. After completing the survey, children received a burn and fire safety presentation and a burn prevention coloring book. Children were reassessed in May 2012 using the same survey to determine program efficacy and knowledge retention. Burn knowledge assessments were also completed for children at other schools who did not receive the burn prevention program in 2011. Logistic regression analysis was used for statistical adjustment for confounding variables. Between June 2011 and May 2012, 2747 children from six schools were assessed for their burn knowledge, with 312 of them resurveyed after educational intervention since initial survey. Reassessed children performed significantly better on three questions after controlling for confounders. They did better on five questions but their performance on these failed to achieve statistical significance. Children performed significantly worse on one concept about first aid treatment of a burn. A majority of the children demonstrated knowledge deficit in three concepts, even after educational intervention. There is a large variation in first burn knowledge survey performance of children from different schools, with inconsistency between concepts. With half the questions, knowledge deficit did not improve with advancement in school grade. Low- and moderate-income countries (LMICs) face the largest burns burden. With the lack of adequate burn care facing LMICs, burn injury prevention is of particular importance in those countries. This study shows that burn educational intervention could be effective in reducing burn knowledge deficit; however, the residual deficit posteducation could still be large and potentially contributing to heightened burn injury incidence. Customized and integrated educational programs may be proposed regarding the epidemiological profile of burn knowledge deficit from various schools. This study represents one of the few reports on the effectiveness of a burn prevention program in an LMIC. Future epidemiological data will be needed from nearby healthcare facilities to determine whether this program decreased burn morbidity and mortality at the hospital level.

Burn prevention in Zambia: a targeted epidemiological approach.

The aim of this study is to assess primary burn prevention knowledge in a rural Zambian population that is disproportionately burdened by burn injuries. A 10-question survey was completed by youths, and a 15-question survey was completed by adults. The survey was available in both English and Nyanja. The surveys were designed to test their knowledge in common causes, first aid, and emergency measures regarding burn injuries. Logistic regression analysis was used to explore relationships between burn knowledge, age, school, and socioeconomic variables. A burn prevention coloring book, based on previous local epidemiological data, was also distributed to 800 school age youths. Five hundred fifty youths and 39 adults completed the survey. The most significant results show knowledge deficits in common causes of burns, first aid treatment of a burn injury, and what to do in the event of clothing catching fire. Younger children were more likely to do worse than older children. The adults performed better than the youths, but still lack fundamental burn prevention and treatment knowledge. Primary burn prevention data from the youths and adults surveyed demonstrate a clear need for burn prevention and treatment education in this population. In a country where effective and sustainable burn care is lacking, burn prevention may be a better investment to reduce burn injury than large investments in healthcare resources.

Trends in 393 necrotizing acute soft tissue infection patients 2000-2008.

OBJECTIVE: To determine the outcomes effect of changing trends in patients with necrotizing acute soft tissue infections (NASTI) 2000-2008. METHODS: A single institution retrospective chart review of all patients treated for NASTI. RESULTS: There were 393 patients with mean age 50 years, diabetes 53%, % body surface area excised 3.5. Wounds were located on: extremity 57%, perineum 40%, trunk 26%. Wound cultures %: polymicrobial=62, Staphylococci=48, Streptococci=31. Patients developing complications %: Pulmonary=23, renal insufficiency/failure=27. During the study period, overall mortality rate remained unchanged: 30/393=7.6% (5.5% for patients first admitted by burn/trauma/acute care surgery vs. 29% for all other services, p=0.003). Significant annual increases were found in number of patients, p=0.03, male sex, p=0.000, transfer from outside hospital, p<0.001, BMI p=0.003, ventilator requirement >24h, p=0.0005, APACHE II p=0.002, and number of patients developing any complication, p=0.04. Statistically significant decreases annually were found in: days of antibiotic use, p=0.008, number of operations required for excision, p=0.02, development of non-wound infections, p=0.002, and length of stay in days (LOS), p=0.03. CONCLUSIONS: This is the largest cohort of NASTI patients from a single institution to date, demonstrating significantly shorter LOS and decreased non-wound infection rates in the face of increasing BMI and APACHE II scores. The increasing number of patients and BMI suggests a causal relationship between NASTI and obesity. Initial care by surgeons experienced in caring for these patients provides mortality rates well below the national average.

Burn injuries in eastern Zambia: impact of multidisciplinary teaching teams.

The American Burn Association/Children's Burn Foundation (ABA/CBF) sponsors teams who offer burn education to healthcare providers in Zambia, a sub-Saharan country. The goals of this study are 1) to acquire burn-patient demographics for the Eastern Province, Zambia and 2) to assess the early impact of the ABA/CBF-sponsored burn teams. This is a retrospective chart review of burn patients admitted in one mission hospital in Katete, Zambia, July 2002 to June 2009. July 2002 to December 2006 = data before ABA/CBF burn teams and January 2007 to June 2009 = burn care data during/after burn outreach. There were 510 burn patients hospitalized, male:female ratio 1.2:1. Average age = 15.6 years, with 44% younger than 5 years. Average TBSA burned = 11% and mean fatal TBSA = 25%. Average hospital length of stay = 16.9 days survivors and 11.6 days nonsurvivors. Most common mechanisms of burn injuries: flame (52%) and scald (41%). Ninety-two patients (18%) died and 23 (4.5%) left against medical advice. There were 191 (37.4%) patients who underwent 410 surgical procedures (range 1-13/patient). There were 138 (33.7%) sloughectomies, 118 (28.7%) skin grafts, 39 (9.5%) amputations, and 115 (28.1%) other procedures. Changes noted in the 2007 to 2009 time period: more patients had burn diagrams (48.6 vs 27.6%, P < .001), received analgesics (91 vs 84%, P = .05), resuscitation fluid (56 vs 49%, P = not significant [NS]), topical antimicrobials (40 vs 37%, P = NS), underwent skin grafting (35.5 vs 25.1%, P = NS), and underwent any operative intervention (40.6 vs 35.2%, P = NS), compared with patients treated between 2002 and 2006. This study represents the largest, most comprehensive burn data set for a sub-Saharan region in Africa. There has been a statistically significant improvement in documentation of burn size as well as administration of analgesics, validating the efficacy of the ABA/CBF-sponsored burn teams. Continued contact with burn teams may lead to increased use of resuscitation fluids, topical antimicrobials, and more patients undergoing operative intervention, translating into improved burn patient outcomes.

Long-term outcomes of patients with necrotizing fasciitis.

CONTEXT: Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. OBJECTIVE: To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. DESIGN: Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. SETTINGS: A university-based Burn and Trauma Center. PATIENTS: A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. INTERVENTION: None. MAIN OUTCOME MEASURES: Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last driver's license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalen's additive hazard model. RESULTS: Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1-86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0-15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25-13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. CONCLUSIONS: Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.

The effect of burn center and burn center volume on the mortality of burned adults--an analysis of the data in the National Burn Repository.

Regional variations of care, and improved outcomes with larger volumes, have been well described in the medical and surgical literature for a variety of conditions including heart surgery, vascular surgery, and orthopedic surgery. Burn care has not been recently subjected to such an analysis. The National Burn Repository (NBR) contains de-identified patient and burn center data to allow this analysis. The NBR was queried for adult burn patients admitted for an acute thermal burn injury. A multivariable regression analysis to identify risk of death was performed incorporating patient characteristics, de-identified burn center, and burn center volume. Patient characteristics such as age, size of burn, mechanism of burn, inhalation injury, race, and sex determine mortality. There is also a statistically significant difference in death rates when individual, de-identified centers are compared. This difference in care persists even when accounting for burn center volume. Analysis of registries like the NBR, insurance claims databases, and statewide hospital discharge databases may help identify opportunities to improve burn care. According to this analysis of data available in the NBR, burn mortality depends not only on patient characteristics but also where the patient is treated. Mortality does not linearly improve with burn center volume and plateaus with increasing burn center size. The optimal burn center size is a complicated and contentious question. Future discussions about burn center size and density should incorporate not only mortality but also the region's ability to absorb surges in volume, and the optimal "staffing" ratios for the multidisciplinary aspects of burn care.

Critical care of the burn patient: the first 48 hours.

OBJECTIVE: The goal of this concise review is to provide an overview of some of the most important resuscitation and monitoring issues and approaches that are unique to burn patients compared with the general intensive care unit population. STUDY SELECTION: Consensus conference findings, clinical trials, and expert medical opinion regarding care of the critically burned patient were gathered and reviewed. Studies focusing on burn shock, resuscitation goals, monitoring tools, and current recommendations for initial burn care were examined. CONCLUSIONS: The critically burned patient differs from other critically ill patients in many ways, the most important being the necessity of a team approach to patient care. The burn patient is best cared for in a dedicated burn center where resuscitation and monitoring concentrate on the pathophysiology of burns, inhalation injury, and edema formation. Early operative intervention and wound closure, metabolic interventions, early enteral nutrition, and intensive glucose control have led to continued improvements in outcome. Prevention of complications such as hypothermia and compartment syndromes is part of burn critical care. The myriad areas where standards and guidelines are currently determined only by expert opinion will become driven by level 1 data only by continued research into the critical care of the burn patient.

The efficacy of hair and urine toxicology screening on the detection of child abuse by burning.

Abuse by burning is estimated to occur in 1 to 25% of children admitted with burn injuries annually. Hair and urine toxicology for illicit drug exposure may provide additional confirmatory evidence for abuse. To determine the impact of hair and urine toxicology on the identification of child abuse, we performed a retrospective chart review of all pediatric patients admitted to our burn unit. The medical records of 263 children aged 0 to 16 years of age who were admitted to our burn unit from January 2002 to December 2007 were reviewed. Sixty-five children had suspected abuse. Of those with suspected abuse, 33 were confirmed by the Department of Health and Human Services and comprised the study group. Each of the 33 cases was randomly matched to three pediatric (0-16 years of age) control patients (99). The average annual incidence of abuse in pediatric burn patients was 13.7+/-8.4% of total annual pediatric admissions (range, 0-25.6%). Age younger than 5 years, hot tap water cause, bilateral, and posterior location of injury were significantly associated with nonaccidental burn injury on multivariate analysis. Thirteen (39.4%) abused children had positive ancillary tests. These included four (16%) skeletal surveys positive for fractures and 10 (45%) hair samples positive for drugs of abuse (one patient had a fracture and a positive hair screen). In three (9.1%) patients who were not initially suspected of abuse but later confirmed, positive hair test for illicit drugs was the only indicator of abuse. Nonaccidental injury can be difficult to confirm. Although inconsistent injury history and burn injury pattern remain central to the diagnosis of abuse by burning, hair and urine toxicology offers a further means to facilitate confirmation of abuse.

Transfusions in burn patients with/without comorbidities.

Medical comorbidities such as renal, cardiac, and cerebrovascular disease are known risk factors for mortality in burn patients. Patients with large burns often require blood transfusions during excision and skin grafting. The purpose of this study was to determine if there was a difference in the transfusion requirements of burn patients with/without comorbidities. This was a retrospective review of burn patient data between March 1999 and May 2004. There were 1,615 admissions to the burn unit; comorbidity data was available on 1,490 patients. Of these, 383/1,490 (26%) had comorbid conditions upon admission: 85/383 (22%) were transfused; 52/85 (61%) also underwent skin grafting. Most patients (298/383) with comorbidities were not transfused; however, 108/298 (36%) were grafted. Transfused patients with comorbidities had a mean +/- SD age of 53 +/- 18 years old, a 19% +/- 22% TBSA burn, and a length of stay of 29 +/- 26 days compared with patients with comorbidities who did not require transfusion and were 48 +/- 19 years old, had 8 +/- 13% TBSA, and a length of stay of 8 +/- 8 days. Of patients with comorbidities, 31/54 (57%) were transfused in the <10% TBSA group and 26/44 (59%) in the 10 to 19% TBSA group. There was a 5-fold increase in mortality among the transfused patients with comorbidities compared with the nontransfused group. Patients with comorbidities were more likely to be transfused in the <20% TBSA patient group. The odds of receiving a transfusion were highest in patients with cardiac diseases, stroke, and other central nervous system and psychiatric disorders. Co-occurring conditions that increased the odds of receiving a transfusion were procedures and inhalation with burn injury.

Demographics of pediatric burns in Vellore, India.

The American Burn Association, Children's Burn Foundation, and Christian Medical College in Vellore, India have partnered together to improve pediatric burn care in Southern India. We report the demographics and outcomes of burns in this center, and create a benchmark to measure the effect of the partnership. A comparison to the National Burn Repository is made to allow for generalization and assessment to other burn centers, and to control for known confounders such as burn size, age, and mechanism. Charts from the pediatric burn center in Vellore, India were retrospectively reviewed and compared with data in the American Burn Association National Burn Registry (NBR) for patients younger than 16 years. One hundred nineteen pediatric patients with burns were admitted from January 2004 through April 2007. Average age was 3.8 years; average total body surface area burn was 24%: 64% scald, 30% flame, 6% electric. Annual death rate was 10%, with average fatal total body surface area burn was 40%. Average lengths of stay for survivors was 15 days. Delay of presentation was common (45% of all patients). Thirty-five of 119 patients received operations (29%). Flame burn patients were older (6.1 years vs 2.6 years), larger (30 vs 21%), had a higher fatality rate (19.4 vs 7.7%), and more of them were female (55 vs 47%) compared with scald burn patients. Electric burn patients were oldest (8.3 years) and all male. When compared with data in the NBR, average burn size was larger in Vellore (24 vs 9%). The mortality rate was higher in Vellore (10.1 vs 0.5%). The average mortal burn size in Vellore was smaller (40 vs 51%). Electric burns were more common in Vellore (6.0 vs 1.6%). Contact burns were almost nonexistent in Vellore (0.9 vs 13.1%). The differences in pediatric burn care from developing health care systems to burn centers in the US are manifold. Nonpresentation of smaller cases, and incomplete data in the NBR explain many of the differences. However, burns at this center in Vellore, India were larger, and occurred to younger patients than burns that reported in the NBR. Individualized assessment of care systems are needed when implementing development plans.

The partnership of the American Burn Association, Children's Burn Foundation, and the Pediatric Burn Team in Vellore, India - a progress report.

Foreign medical service trips, though worthy, raise questions about efficacy, durability, and cultural sensitivity. A structured intervention by a multidisciplinary team can lead to sustained and integrated changes in the delivery of burn care. The American Burn Association, Children's Burn Foundation, and other donors have sponsored four interventions with the Pediatric Burn Center at Christian Medical Center in Vellore, India. Using qualitative research methods, we report our interventions and changes in burn care in Vellore. Using a multifaceted intervention over 2 years, there are skilled and practiced changes in burn care in Vellore, India. These changes involved changes in medical care, nursing care, wound care, operative timing, patient activity, and rehabilitation. Protocols and student and staff education tools have been developed and implemented. Major changes in burn care were observed by the visiting burn team. These skills are practiced and routinely used. The Vellore burn team reports an improvement in nursing satisfaction, patient tolerance, cleanliness, decreased antibiotic use, earlier excision and grafting, and more efficient care. Educational partnerships to improve burn care can induce durable changes, regardless of local language, culture, resources, technology, and skill.

Emergence of the USA300 strain of methicillin-resistant Staphylococcus aureus in a burn-trauma unit.

Community-associated methicillin-resistant Staphylococcus aureus (MRSA), particularly USA300, is a major pathogen in the outpatient setting. We suspected that USA300 had been introduced into our burn-trauma unit (BTU) when three burn patients presented with numerous simultaneous abscesses. We did molecular typing on 206 MRSA isolates from all patients on the BTU who had MRSA isolated from either nares cultures or clinical specimens obtained between April 11, 2002 and October 24, 2006. We reviewed medical records for all patients who had USA300 and for 75 control patients. Twenty-five of 206 (12.1%) patients who were colonized (n = 3) or infected (n = 22) with MRSA had USA300. Thirteen patients had abscesses drained surgically and eight had necrotizing fasciitis excised. Seven patients had burns (mean burn size 11.8 +/- 3.4%), of who four (66.7%) acquired numerous simultaneous (3-33) abscesses. Fourteen patients acquired USA300 outside of the BTU, and three acquired this strain on the BTU. Cases were more likely to have been hospitalized or to have had an operation in the 6 months before they were hospitalized than were controls (P = .001 for both). To our knowledge, this is the first study to describe numerous simultaneous MRSA abscesses in burn patients. The MRSA strain USA300 may be introduced onto burn units from the community by patients admitted with skin and soft tissue infections, especially abscesses and necrotizing fasciitis. Burn patients may be at risk for numerous abscesses with USA300, because they have open wounds and their immune systems may be compromised.

Defining intra-abdominal hypertension and abdominal compartment syndrome in acute thermal injury: a multicenter survey.

The definitions of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are not uniform despite the increasing awareness of IAH/ACS in burn patients. A short survey including definitions, resuscitation protocols, and monitoring practices was sent to every physician listed in the American Burn Association Directory. Thirty-two of 123 (26%) surveys were returned; 22 (69%) were from verified burn centers. Survey respondents said that bladder pressure indicating IAH is 19.6 mm Hg (range 12-30) and ACS is 25.9 mm Hg (range 15-40). Fifteen percentage of those responding do not include clinical sequellae in their definition of ACS. Bladder pressure is not routinely measured by 22 (69%) burn physicians, and staff at 17 centers (53%) wait until the abdomen is tense to measure abdominal pressure. Tense abdomen, along with elevated peak inspiratory pressures (PIP), is used in most centers (94%) to determine IAH/ACS, followed by oliguria (88%), and difficulty ventilating (78%). Resuscitation formulae used are primarily the Parkland/modified Parkland in 24 (75%) burn centers. Criteria for abdominal decompression is based on bladder pressures alone in 25 centers (78%); 16/32 (50%) use PIP, and 10/32 (31%) staff use other criteria including organ dysfunction or increased lactate. Eleven physicians (34%) advocate percutaneous decompression before decompressive laparotomy. Although most United States burn physicians define ACS as >or=25 mm Hg along with physiologic compromise, bladder pressure is routinely measured by only 31% of burn physicians. Most burn staff do not differentiate between IAH and ACS. Consensus definitions of IAH/ACS are necessary for burn care practitioners to compare research studies and discuss outcomes. Concise definitions will promote understanding of the pathophysiological processes involved and allow us to develop data-driven patient care protocols.

Methamphetamine-related burns in the cornbelt.

Methamphetamine (MA) is a highly addictive drug that is easily manufactured from everyday household products and chemicals found at local farm stores. The proliferation of small MA labs has led to a dramatic increase in patients sustaining thermal injury while making and/or using MA. We hypothesized that these patients have larger injuries with longer hospital stays, and larger, nonreimbursed hospital bills compared with burn patients not manufacturing or using MA. In a retrospective case-control study, all burn patients >or=16 years of age admitted to our burn center from January 2002 to December 2005 were stratified into two groups based on urine MA status. Of the 660 burn patients >or=16 years of age admitted during this 4 year period, urine drug screens were obtained at admission on 410 patients (62%); 10% of urine drug screens were MA (+). MA (+) patients have larger burns compared with MA (-) patients (9.3 vs 8.6% body surface area burns), have higher rates of inhalation injuries (20.4 vs 9.3%, P = .015), and more nonthermal trauma (13.0 vs 3.1%, P = .001). When compared with MA (-) patients, MA (+) patients require longer hospital stays (median 9.5 vs 7.0 days, P = .036), accrue greater hospital bills per day (dollars 4292 vs dollars 2797, P = .01), and lack medical insurance (66.7 vs 17.7%, P < .0001). The epidemic of MA use and its manufacture mandates that burn centers monitor patients for MA use and develop and institute protocols to ensure proper care of this increasingly costly population.