Review of machine learning for optical imaging of burn wound severity assessment.

Significance: Over the past decade, machine learning (ML) algorithms have rapidly become much more widespread for numerous biomedical applications, including the diagnosis and categorization of disease and injury. Aim: Here, we seek to characterize the recent growth of ML techniques that use imaging data to classify burn wound severity and report on the accuracies of different approaches. Approach: To this end, we present a comprehensive literature review of preclinical and clinical studies using ML techniques to classify the severity of burn wounds. Results: The majority of these reports used digital color photographs as input data to the classification algorithms, but recently there has been an increasing prevalence of the use of ML approaches using input data from more advanced optical imaging modalities (e.g., multispectral and hyperspectral imaging, optical coherence tomography), in addition to multimodal techniques. The classification accuracy of the different methods is reported; it typically ranges from ∼70% to 90% relative to the current gold standard of clinical judgment. Conclusions: The field would benefit from systematic analysis of the effects of different input data modalities, training/testing sets, and ML classifiers on the reported accuracy. Despite this current limitation, ML-based algorithms show significant promise for assisting in objectively classifying burn wound severity.

Surviving Sepsis After Burn Campaign.

INTRODUCTION: The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS: The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS: The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION: Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Unnecessary Early Gastrostomy for Trauma Patients.

While early gastrostomy tube placement (GTP) may decrease hospital length of stay and facilitate disposition, GTP may be unnecessary as some patients regain the ability to eat earlier than expected. No guidelines currently exist regarding optimal GTP timing or minimum duration of need indicating appropriateness of GTP. This retrospective (9/2017-12/2019) single center study evaluated the incidence of adequate (>75%) oral caloric intake (ACI) after GTP during index hospitalization and associated characteristics before discharge. Bivariate analyses were performed to compare patients achieving ACI and patients not achieving ACI at discharge. By discharge, 10 (12.5%) patients achieved ACI and 6 (7.5%) had their GT removed prior to discharge suggesting many patients undergo unnecessary GTP. Also, 6 (7.5%) patients suffered GTP-related complications. Future multicenter studies are needed to corroborate these findings and establish GTP guidelines for trauma patients to avoid unnecessary GT procedures and associated morbidities.

No Difference in Mortality and Outcomes After Addition of a Nearby Pediatric Trauma Center.

OBJECTIVES: Previous studies demonstrate that higher volume pediatric trauma centers (PTCs) offer improved outcomes. This study evaluated pediatric trauma volume and outcomes at an existing level I (L-I) adult and level II (L-II) PTC after the addition of a new children's hospital L-II PTC within a 2-mile radius, hypothesizing no difference in mortality and complications. METHODS: A retrospective review of patients aged 14 years or younger presenting to a single adult L-I and L-II PTC was performed. Patients from 2015-2016 (PRE) were compared with patients from 2018-2019 (POST) for mortality and complications using bivariate analyses. RESULTS: Compared with the PRE cohort, there were less patients in the POST cohort (277 vs 373). Patients in the POST cohort had higher rates of insurance coverage (91.3% vs 78.8%, P < 0.001), self-transportation (7.2% vs 2.7%, P < 0.01), and hospital admission (72.6% and 46.1%, P < 0.001). There was no difference in all complications and mortality (all P > 0.05) between the 2 cohorts. CONCLUSIONS: After opening a second L-II PTC within a 2-mile radius, there was an increase in the rate of admissions and self-transportation to the preexisting L-II PTC. Despite a nearly 26% decrease in pediatric trauma volume, there was no difference in length of stay, hospital complications, or mortality.

The Effects of the COVID-19 Pandemic on Burn Clinic.

The COVID-19 pandemic has led to anxiety and fears for the general public. It is unclear how the behavior of people with acute burns and the services available to them has changed during the pandemic. The aim of our observational study was to evaluate our clinic's experience with patients presenting with burns during the first 10 months of the COVID-19 pandemic and determine if delays in presentation and healthcare delivery exist within our burn population. Patients referred to our clinic from March 1, 2020 to December 15, 2020 were reviewed for time of presentation after injury. We defined a true delay in presentation of >5 days from date of injury to date of referral for patients who were not inpatients at our facility or received initial care elsewhere prior to referral. Of the 246 patients who were referred to our clinic, during this time period, 199 patients (80.89%) attended their appointments. Our in-person clinic volume from referrals increased in July 2020 with a sharp decrease in August 2020. Our total clinic volume decreased in 2020 from 2019 by about 14%. Referrals to our clinic decreased in 2020 from 2019 by about 34%. Video telehealth visits did not account for the decrease in visits. There was low incidence of delays in presentation to our clinic during the pandemic. Additional investigation is necessary to see if the incidence of burn injury decreased. Despite the pandemic, our clinic remained ready and open to serve the burn population.

Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury.

OBJECTIVES: Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level. METHODS: The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis. RESULTS: The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001). CONCLUSIONS: In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.

No Difference in Morbidity or Mortality Between Octogenarians and Other Geriatric Burn Trauma Patients.

BACKGROUND: Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate than younger adults. With the population of the US aging, the number of elderly burn and trauma patients is expected to increase. A past study using the National Burn Repository revealed a linear increase in mortality for those >65 years old. We hypothesized that octogenarians with burn and trauma injuries would have a higher rate of in-hospital complications and mortality, than patients aged 65-79 years old. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for burn trauma patients. To detect mortality risk a multivariable logistic regression model was used. RESULTS: From 282 patients, there were 73 (25.9%) octogenarians and 209 (74.1%) aged 65-79 years old. The two cohorts had similar median injury severity scores (16 vs. 15 in octogenarians, P = .81), total body surface area burned (P = .30), and comorbidities apart from an increased smoking (12.9% vs. 4.1%, P = .04) and decreased hypertension (52.2% vs. 65.8%, P = .04) in the younger cohort. Octogenarians had similar complications, including acute respiratory distress syndrome, pulmonary embolism, deep vein thrombosis (P > .05), and mortality (15.1% vs. 10.5%, P = .30), compared to the younger cohort. Octogenarians were not associated with an increased mortality risk (odds ratio 1.51, confidence interval 0.24-9.56, P = .67). DISCUSSION: Among burn trauma patients ≥65 years, age should not be a sole predictor for mortality risk. Continued research is necessary in order to determine more accurate approaches to prognosticate mortality in geriatric burn trauma patients, such as the validation and refinement of a burn-trauma-related frailty index.

Comparison of surgical fixation and non-operative management in patients with traumatic sternum fracture.

PURPOSE: The incidence of sternal fractures in blunt trauma patients lies between 3 and 7%. The role, timing and indications for surgical management are not well delineated and remain controversial for patients undergoing surgical stabilization of sternum fracture (SSSF). We sought to identify the national rate of SSSF in patients with a sternum fracture hypothesizing patients undergoing SSSF will have a decreased rate of mortality and complications. METHODS: The Trauma Quality Improvement Program (2015-2016) was queried for patients with sternum fracture. Propensity scores were calculated to match patients undergoing SSSF to patients managed non-operatively in a 1:2 ratio using demographic data. RESULTS: From 9460 patients with a sternum fracture, 114 (1.2%) underwent SSSF. After propensity-matching, 112 SSSF patients were compared to 224 patients undergoing non-operative management (NOM). There were no differences in matched characteristics (all p > 0.05). Compared to patients undergoing NOM, patients undergoing SSSF had an increased median length of stay (LOS) (16 vs. 7 days, p < 0.001), ICU LOS (9.5 vs. 5.5 days, p = 0.016) and ventilator days (8 vs. 5, p = 0.035). The SSSF group had a similar rate of ARDS (2.7% vs. 2.2%, p = 0.80), pneumonia (1.8% vs. 0.9%, p = 0.48) and unplanned intubation (8.9% vs. 5.8%, p = 0.29) but a lower mortality rate (2.7% vs. 11.2%, p = 0.008). CONCLUSION: Just over 1% of patients with sternum fracture underwent SSSF in a national analysis. Patients undergoing SSSF had an increased LOS and similar rate of all measured pulmonary complications, however a lower mortality rate compared to patients managed non-operatively.

Class-Modeling of Septic Shock With Hyperdimensional Computing.

Sepsis arises when a patient's immune system has an extreme reaction to an infection. This is followed by septic shock if damage to organ tissue is so extensive that it causes a total systemic failure. Early detection of septic shock among septic patients could save critical time for preparation and prevention treatment. Due to the high variance in symptoms and patient state before shock, it is challenging to create a protocol that would be effective across patients. However, since septic shock is an acute change in patient state, modeling patient stability could be more effective in detecting a condition that departs from it. In this paper we present a one-class classification approach to septic shock using hyperdimensional computing. We built various models that consider different contexts and can be adapted according to a target priority. Among septic patients, the models can detect septic shock accurately with 90% sensitivity and overall accuracy of 60% of the cases up to three hours before the onset of septic shock, with the ability to adjust predictions according to incoming data. Additionally, the models can be easily adapted to prioritize sensitivity (increase true positives) or specificity (decrease false positives).

Detecting COVID-19 Related Pneumonia On CT Scans Using Hyperdimensional Computing.

Pneumonia is a common complication associated with COVID-19 infections. Unlike common versions of pneumonia that spread quickly through large lung regions, COVID-19 related pneumonia starts in small localized pockets before spreading over the course of several days. This makes the infection more resilient and with a high probability of developing acute respiratory distress syndrome. Because of the peculiar spread pattern, the use of pulmonary computerized tomography (CT) scans was key in identifying COVID-19 infections. Identifying uncommon pulmonary diseases could be a strong line of defense in early detection of new respiratory infection-causing viruses. In this paper we describe a classification algorithm based on hyperdimensional computing for the detection of COVID-19 pneumonia in CT scans. We test our algorithm using three different datasets. The highest reported accuracy is 95.2% with an F1 score of 0.90, and all three models had a precision of 1 (0 false positives).

Vices-paradox in trauma: Positive alcohol and drug screens associated with decreased mortality.

BACKGROUND: Improved survival in trauma patients with acute alcohol intoxication has been previously reported. The effect of illegal and controlled substances on mortality is less clear. We hypothesized that alcohol, illegal and controlled substances are each independently associated with lower odds of mortality in adult trauma patients. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for patients screening positive for alcohol, illegal or controlled substances on admission. A multivariate logistic regression analysis was used to determine odds of mortality. A similar analysis was used after stratification by injury severity scale (ISS). RESULTS: From 1,299,705 adult patients, 660,135 were screened for substance use. Of these patients, 497,872 were male, 227,995 (34.5 %) screened positive for alcohol, 155,437 (23.5 %) for illegal substances and 90,259 (13.7 %) for controlled substances. Mortality rate was 6.2 % with alcohol, 5.1 % with illegal substances, and 5.7 % with controlled substances compared to 8.0 % with no substance use (p < 0.001). After controlling for covariates, all groups had lower odds of mortality: alcohol (OR = 0.88, CI = 0.84-0.92, p < 0.001), illegal substances (OR = 0.83, CI = 0.77-0.90, p < 0.001), controlled substances (OR = 0.72, CI = 0.67-0.79, p < 0.001). When stratified by ISS, alcohol and illegal substances continued to be associated with decreased mortality until ISS 50. Controlled substances were associated with decreased mortality when ISS > 16. CONCLUSION: Patients positive for alcohol, illegal or controlled substances have 12 %, 17 %, and 28 % decreased odds of mortality, respectively. This paradoxical association should be confirmed with future clinical studies and merits basic science research to identify biochemical or physiological components conferring a protective effect on survival in trauma patients.

A phase 3, open-label, controlled, randomized, multicenter trial evaluating the efficacy and safety of StrataGraft® construct in patients with deep partial-thickness thermal burns.

OBJECTIVE: This phase 3 study evaluated StrataGraft construct as a donor-site sparing alternative to autograft in patients with deep partial-thickness (DPT) burns. METHODS: Patients aged ≥18 years with 3-49% total body surface area (TBSA) thermal burns were enrolled. In each patient, 2 DPT areas (≤2000cm2 total) of comparable depth after excision were randomized to either cryopreserved StrataGraft or autograft. Coprimary endpoints were: the difference in percent area of StrataGraft treatment site and autograft treatment site autografted at Month 3 (M3), and the proportion of patients achieving durable wound closure of the StrataGraft site without autograft at M3. Safety assessments were performed in all patients. Efficacy and safety follow-up continued to 1 year. RESULTS: Seventy-one patients were enrolled. By M3, there was a 96% reduction in mean percent area of StrataGraft treatment sites that required autografting, compared with autograft treatment sites (4.3% vs 102.1%, respectively; P<.0001). StrataGraft treatment resulted in durable wound closure at M3 without autografting in 92% (95% CI: 85.6, 98.8; n/n 59/64) of patients for whom data were available. The most common StrataGraft-related adverse event was pruritus (15%). CONCLUSIONS: Both coprimary endpoints were achieved. StrataGraft may offer a new treatment for DPT burns to reduce the need for autografting. CLINICAL TRIAL IDENTIFIER: NCT03005106.

Characterization of Macrophage and Cytokine Interactions with Biomaterials Used in Negative-Pressure Wound Therapy.

Macrophages are innate immune cells that help wounds heal. Here, we study the potential immunomodulatory effects of negative-pressure wound therapy (NPWT) materials on the macrophage inflammatory response. We compared the effects of two materials, Granufoam™ (GF) and Veraflo Cleanse™ (VC), on macrophage function in vitro. We find that both materials cause reduced expression of inflammatory genes, such as TNF and IL1B, in human macrophages stimulated with bacterial lipopolysaccharide (LPS) and interferon-gamma (IFNγ). Relative to adherent glass control surfaces, VC discourages macrophage adhesion and spreading, and may potentially sequester LPS/IFNγ and cytokines that the cells produce. GF, on the other hand, was less suppressive of inflammation, supported macrophage adhesion and spreading better than VC, and sequestered lesser quantities of LPS/IFNγ in comparison to VC. The control dressing material cotton gauze (CT) was also immunosuppressive, capable of TNF-α retention and LPS/IFNγ sequestration. Our findings suggest that NPWT material interactions with cells, as well as soluble factors including cytokines and LPS, can modulate the immune response, independent of vacuum application. We have also established methodological strategies for studying NPWT materials and reveal the potential utility of cell-based in vitro studies for elucidating biological effects of NPWT materials.

Octogenarians with blunt splenic injury: not all geriatrics are the same.

Geriatric trauma patients (GTP) (age ≥ 65 years) with blunt splenic injury (BSI) have up to a 6% failure rate of non-operative management (NOM). GTPs failing NOM have a similar mortality rate compared to GTPs managed successfully with NOM. However, it is unclear if this remains true in octogenarians (aged 80-89 years). We hypothesized that the failure rate for NOM in octogenarians would be similar to their younger geriatric cohort, patients aged 65-79 years; however risk of mortality in octogenarians who fail NOM would be higher than that of octogenarians managed successfully with NOM. The Trauma Quality Improvement Program (2010-2016) was queried for patients with BSI. Those undergoing splenectomy within 6 h were excluded to select for patients undergoing NOM. Patients aged 65-79 years (young GTPs) were compared to octogenarians. A multivariable logistic regression model was used to determine the risk for failed NOM and mortality. From 43,041 BSI patients undergoing NOM, 3660 (8.5%) were aged 65-79 years and 1236 (2.9%) were octogenarians. Both groups had a similar median Injury Severity Score (ISS) (p = 0.10) and failure rate of NOM (6.6% young GTPs vs. 6.8% octogenarians p = 0.82). From those failing NOM, octogenarians had similar units of blood products transfused (p > 0.05) and a higher mortality rate (40.5% vs. 18.2%, p < 0.001), compared to young GTPs. Independent risk factors for failing NOM in octogenarians included ≥ 1 unit of packed red blood cells (PRBC) (p = 0.039) within 24 h of admission. Octogenarians who failed NOM had a higher mortality rate compared to octogenarians managed successfully with NOM (40.5% vs 23.6% p = 0.001), which persisted in a multivariable logistic regression analysis (OR 2.25, CI 1.37-3.70, p < 0.001). Late failure of NOM ≥ 24 h (vs. early failure) was not associated with increased risk of mortality (p = 0.88), but ≥ 1 unit of PRBC transfused had higher risk (OR 1.88, CI 1.20-2.95, p = 0.006). Compared to young GTPs with BSI, octogenarians have a similar rate of failed NOM. Octogenarians with BSI who fail NOM have over a twofold higher risk of mortality compared to those managed successfully with NOM. PRBC transfusion increases risk for mortality. Therefore, clinicians should consider failure of NOM earlier in the octogenarian population to mitigate the risk of increased mortality.

Intracranial pressure monitors associated with increased venous thromboembolism in severe traumatic brain injury.

BACKGROUND: Utilization of intracranial pressure monitors (ICPMs) has not been consistently shown to improve mortality in patients with severe traumatic brain injury (TBI). A single-center analysis concluded that venous thromboembolism (VTE) chemoprophylaxis (CP) posed no significant bleeding risk in patients following ICPM implementation; however, there is still debate about the optimal use and timing of CP in patients with ICPMs for fear of worsening intracranial hemorrhage. We hypothesized that ICPM use is associated with increased time to VTE CP and thus increased VTE in patients with severe TBI. METHODS: A retrospective analysis of the Trauma Quality Improvement Program (2010-2016) was performed to compare severe TBI patients with and without ICPMs. A multivariable logistic regression analysis was completed. RESULTS: From 35,673 patients with severe TBI, 12,487 (35%) had an ICPM. Those with ICPMs had a higher rate of VTE CP (64.3% vs. 49.4%, p < 0.001) but a longer median time to CP initiation (5 vs. 4 days, p < 0.001) as well as a longer hospital length of stay (LOS) (18 vs. 9 days, p < 0.001) compared to those without ICPMs. After adjusting for covariates, ICPM use was found to be associated with a higher risk of VTE (9.2% vs 4.3%, OR = 1.75, CI = 1.42-2.15, p < 0.001). CONCLUSIONS: Compared to patients without ICPMs, those with ICPMs had a longer delay to initiation of CP leading to an increase in VTE. In addition, there was a nearly two-fold higher associated risk for VTE in patients with ICPMs even when controlling for known VTE risk factors. Improved adherence to initiation of CP in the setting of ICPMs may help decrease the associated risk of VTE with ICPMs.

Adult Bicycle Collisions: Impact of Helmet Use on Head and Cervical Spine Injury.

BACKGROUND: No states currently require adult bicycle riders to wear helmets. Opponents of a universal helmet law argue that helmets may cause a greater torque on the neck during collisions, potentially increasing the risk of cervical spine fracture (CSF). This assumption has not been supported by data for motorcyclists. Therefore, we sought to evaluate the risk of CSF and cervical spinal cord injury (CSCI) in helmeted bicyclists (HBs) versus nonhelmeted bicyclists (NHBs) involved in collisions. We hypothesize that in adult HBs, there is an increased incidence of CSF and injury but lower rates of severe head injury and mortality than in NHBs. MATERIALS AND METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for adult bicyclists involved in collisions, comparing HBs with NHBs. A multivariable logistic regression model was used for analysis. RESULTS: Of 25,047 bicyclists, 14,234 (56.8%) were NHBs. NHBs were more often black (13.3% versus 2.3%, P < 0.001) and screened positive for alcohol on admission (25.7% versus 4.6%, P < 0.001). NHBs had lower rates of CSF (17.7% versus 23.7%, P < 0.001) and CSCI (1.1% versus 1.9%, P < 0.001) but higher rates of mortality (4.9% versus 2.2%, P < 0.001) and a higher risk for severe head injury (odds ratio [OR]: 2.26, 2.13-2.40, P < 0.001). After adjusting for covariates, NHBs had a higher risk of mortality (OR: 2.38, 2.00-2.84, P < 0.001) but lower risk of CSF (OR: 0.66 0.62-0.71, P < 0.001) and CSCI (OR: 0.53, 0.42-0.68, P < 0.001). CONCLUSIONS: HBs involved in collisions have a higher risk of CSF and CSCI; however, NHBs have a higher risk of severe head injury and mortality. Consideration for a universal helmet law among bicyclists and ongoing research regarding helmet development is needed.

Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis.

BACKGROUND: Trauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients. METHODS: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity. RESULTS: 93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p<0.001) with no difference in mortality (1.1% vs 1.1%, p=1.00), intensive care unit (ICU) LOS (3 vs 3 days, p=0.55), or complications including decubitus ulcer (0% vs 1.1%, p=0.32), deep vein thrombosis (0% vs 0.5%, p=0.48), extremity compartment syndrome (1.1% vs 0%, p=0.16), and urinary tract infection (1.1% vs 1.1%, p=1.00). CONCLUSION: Pediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.

American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps.

The ABA pain guidelines were developed 14 years ago and have not been revised despite evolution in the practice of burn care. A sub-committee of the American Burn Association's Committee on the Organization and Delivery of Burn Care was created to revise the adult pain guidelines. A MEDLINE search of English-language publications from 1968 to 2018 was conducted using the keywords "burn pain," "treatment," and "assessment." Selected references were also used from the greater pain literature. Studies were graded by two members of the committee using Oxford Centre for Evidence-based Medicine-Levels of Evidence. We then met as a group to determine expert consensus on a variety of topics related to treating pain in burn patients. Finally, we assessed gaps in the current knowledge and determined research questions that would aid in providing better recommendations for optimal pain management of the burn patient. The literature search produced 189 papers, 95 were found to be relevant to the assessment and treatment of burn pain. From the greater pain literature 151 references were included, totaling 246 papers being analyzed. Following this literature review, a meeting to establish expert consensus was held and 20 guidelines established in the areas of pain assessment, opioid medications, nonopioid medications, regional anesthesia, and nonpharmacologic treatments. There is increasing research on pain management modalities, but available studies are inadequate to create a true standard of care. We call for more burn specific research into modalities for burn pain control as well as research on multimodal pain control.