Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients.

INTRODUCTION: Relative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival. METHODS: Retrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05. RESULTS: In 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89). CONCLUSIONS: This is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival.

Identifying Abuse and Neglect in Hospitalized Children With Burn Injuries.

BACKGROUND: The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries. METHODS: The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome. RESULTS: There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned >20% (odds ratio (OR) 2.79, P < 0.001) and burn of the lower limbs (OR 1.37, P < 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P < 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001). CONCLUSIONS: This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.

Vascular Reconstruction Is Not Warranted in Most Civilian Traumatic Shank Vascular Injuries.

BACKGROUND: Operative management of traumatic shank vascular injuries (SVI) evolved significantly in the past few decades, thereby leading to a dramatic decrease in amputation rates. However, there is still controversy regarding the minimum number of patent shank arteries sufficient for limb salvage. METHODS: Between January 2006 and September 2011, 191 adult trauma patients presented to an urban level I trauma center in Miami, Florida, with traumatic lower extremity vascular injuries. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: A total of 48 (25.1%) patients were identified comprising 66 traumatic shank arterial injuries. Mean age was 38.2 ± 13.4 years, and the majority of patients were men (40 patients, 83.3%) presenting with blunt injuries (35 patients, 72.9%). Ligation was performed in 38 injured arteries (57.6%) and no vascular intervention was required in 20% of the patients. Vascular reconstruction was performed in only 6 patients (9.1%): 4 (6.1%) with concurrent popliteal trauma, 1 (1.5%) isolated anterior tibial, and 1 (1.5%) 3-vessel injury. Autogenous venous interposition conduit and polytetrafluoroethylene grafting were performed in 5 (7.6%) and 1 (1.5%) patient, respectively. All amputations (8 patients, 16.7%) occurred in blunt trauma patients presenting with unsalvageable limbs. The overall mortality rate in this series was 2.1%. CONCLUSIONS: Civilian shank arterial injuries are associated with acceptable rates of limb loss. Patients with a single-vessel patent inflow did not require vascular reconstruction in this series. Arterial reconstruction may no longer be determinant for successful management of isolated and double arterial SVI, whereas it is yet essential in the presence of 3-vessel or concurrent above-the-knee vascular injuries. Further investigation including larger number of patients is still warranted to define the role of conservative management in these complex injuries.

Hypercoagulability and venous thromboembolism in burn patients.

To our knowledge, this is the first comprehensive review on the subject of venous thromboembolism (VTE) and hypercoagulability in burn patients. Specific changes in coagulability are reviewed using data from thromboelastography and other techniques. Disseminated intravascular coagulation in burn patients is discussed. The incidence and risk factors associated with VTE in burn patients are then examined, followed by the use of low-molecular-weight heparin thromboprophylaxis and monitoring techniques using antifactor Xa levels. The need for large, prospective trials in burn patients is highlighted, especially in the areas of VTE incidence and safe, effective thromboprophylaxis.

Does obesity affect outcomes of adult burn patients?

BACKGROUND: Obesity negatively affects outcomes after trauma and surgery; results after burns are more limited and controversial. The purpose of this study was to determine the effect of obesity on clinical and economic outcomes after thermal injury. METHODS: The National Inpatient Sample was queried for adults from 2005-2009 with International Classification of Diseases-9 codes for burn injury. Demographics and clinical outcomes of obese and nonobese cohorts were compared. Univariate and multivariate analysis using logistic regression models were performed. Data are expressed as median (interquartile range) or mean ± standard deviation and compared at P < 0.05. RESULTS: In 14,602 patients, 3.3% were obese (body mass index ≥30 kg/m(2)). The rate of obesity increased significantly by year (P < 0.001). Univariate analysis revealed significant differences between obese and nonobese patients in incidence of wound infection (7.2% versus 5.0%), urinary tract infection (7.2% versus 4.6%), deep vein thrombosis in total body surface area (TBSA) ≥10% (3.1% versus 1.1%), pulmonary embolism in TBSA ≥10% (2.3% versus 0.6%), length of stay [6 d (8) versus 5 d (9)], and hospital costs ($10,122.12 [$18,074.72] versus $7892.07 [$17,191.96]) (all P < 0.05). Death occurred less frequently in the obese group (1.9% versus 4%, P = 0.021). Significant predictors of grouped adverse events (urinary tract infection, wound infection, deep vein thrombosis, and pulmonary embolism) on multivariate analysis include obesity, TBSA ≥20%, age, and black race (all P ≤ 0.05). CONCLUSIONS: Obesity is an independent predictor of adverse events after burn injury; however, obesity is associated with decreased mortality. Our findings highlight the potential clinical and economic impact of the obesity epidemic on burn patients nationwide.

Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center.

Introduction: Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes. Methods: This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts. Results: 4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities. Conclusion: Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center. Level of evidence: Level IV, retrospective study.

Mental Health Support Is an Unmet Need for Long-Term Burn Survivors: A Web-Based Survey.

A National Trauma Research Action Plan identified the involvement of burn survivors as critical informants to determine the direction of research. This study employed a web-based survey to identify care gaps in a sample of burn survivors. We surveyed burn survivors from around the United States through social media and email contact with the Phoenix Society for Burn Survivors. We elicited demographic info, burn history, and unmet needs. Statistical analysis was performed to test our hypothesis that lack of access to mental health support/professionals would be identified as an unmet need in long-term burn survivors. Of 178 survey respondents, most were at least ten years removed from the date of their burn injury (n=94, 53%). Compared to those less than 3 years from their burn injury, individuals greater than 10 years were at least 5 times more likely to note lack of access to mental health support [11-20 years OR 8.7, p< 0.001; >20 years OR5.7, p=0.001]. 60% of Spanish speakers reported lack of support group access was among their greatest unmet needs, compared to 37% of English speakers (p=0.184). This study highlights the need for ongoing access to mental health resources in burn survivors. Our findings emphasize that burn injury is not just an acute ailment, but a complex condition that evolves into a chronic disease. Additional studies should focus on the experiences of Spanish-speaking burn survivors, given small sample size leading to a likely clinically significant but not statistically different lack of access to support groups.

Eighteen years of experience with Acinetobacter baumannii in a tertiary care hospital.

OBJECTIVE: To characterize the descriptive and molecular epidemiology of Acinetobacter baumannii in our hospital. DESIGN: Longitudinal analysis of electronic microbiology laboratory records and isolates. SETTING: A 1,500 bed public teaching hospital in the Miami area. PATIENTS: Consecutive patients with A. baumannii from January 1994 to December 2011. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: : Data on all A. baumannii isolates were clustered at the patient level, and the first isolate per single patient was determined. Yearly trends were analyzed based on carbapenem susceptibilities and originating units for all first isolates and first blood isolates per unique patient. Additionally, carbapenem nonsusceptible isolates frozen in the microbiology laboratory since 1998 were retrieved and evaluated using polymerase chain reaction and randomly amplified polymorphic DNA techniques. A total of 9,334 A. baumannii isolates were detected, of which 4,484 isolates (48%) were identified as first positive isolates per unique patient. Most of the burden of disease was located in the ICUs (odds ratio, 2.64 [95% CI, 2.17-3.22]; p < 0.0001) and in the adult wards (odds ratio, 3.867 [95% CI, 2.71-5.52]; p < 0.0001). Respiratory specimens constituted the most frequent source (49%; odds ratio, 1.619 [95% CI, 1.391-1.884]; p < 0.0001). Of the 4,484 first isolates, 846 isolates (18.9%) were carbapenem nonsusceptible and 3,638 isolates (81.1%) were carbapenem susceptible. Over the years, the number of carbapenem nonsusceptible isolates increased, whereas the number of carbapenem susceptible decreased (p < 0.0001). The trauma ICU had the highest burden of carbapenem nonsusceptible first isolates (205 of 846; 24.2%). Seven clones were discovered among 144 carbapenem nonsusceptible isolates; one of these clones was found from 1999 to 2005. OXA-23 and OXA-40 were identified in 96 and 13 isolates, respectively. One isolate harbored a novel CTX-M-115 enzyme. CONCLUSIONS: This constitutes the largest experience with A. baumannii reported to date from a single center. Half of all isolates were respiratory specimens and were from adult ICUs, especially trauma. Even though this was a polyclonal process, a single clone was identified in the hospital through a 6-year span.

Aerosolization of Acinetobacter baumannii in a trauma ICU*.

OBJECTIVE: To establish the presence of air contamination with Acinetobacter baumannii in the trauma ICU. DESIGN: Point prevalence microbiological surveillances. SETTINGS: A 1,500-bed public teaching hospital in the Miami metro area. PATIENTS: Trauma ICU patients. MEASUREMENTS: Pulsed field electrophoresis was performed on environmental and clinical isolates to determine the association of any isolates from the air with clinical isolates. MAIN RESULTS: Out of 53 patient areas cultured, 12 (22.6%) had their air positive for A. baumannii. The presence of an A. baumannii-positive patient (underneath the plate) was associated with positive air cultures for A. baumannii (11 of 21 [52.4%] vs 0 of 25 [0%]; p < 0.0001). However, we were not able to find differences in air contamination based on the presence of A. baumannii in respiratory secretions versus absence (p = 1.0). Air and clinical isolates were found to be clonally related. CONCLUSIONS: Aerosolization of A. baumannii in the ICUs is a concern, and its role in the transmission of this organism among patients should be further clarified.

Statistical Power of Randomized Controlled Trials in Trauma Surgery.

BACKGROUND: Our purpose was to conduct a bibliometric study investigating the prevalence of underpowered randomized controlled trials (RCTs) in trauma surgery. STUDY DESIGN: A medical librarian conducted a search of RCTs in trauma published from 2000 to 2021. Data extracted included study type, sample size calculation, and power analyses. Post hoc calculations were performed using a power of 80% and an alpha level of 0.05. A CONSORT checklist was then tabulated from each study as well as a fragility index for studies with statistical significance. RESULTS: In total 187 RCTs from multiple continents and 60 journals were examined. A total of 133 (71%) were found to have "positive" findings consistent with their hypothesis. When evaluating their methods, 51.3% of articles did not report how they calculated their intended sample size. Of those that did, 25 (27%) did not meet their target enrollment. When examining post hoc power, 46%, 57%, and 65% were adequately powered to detect small, medium, and large effect sizes, respectively. Only 11% of RCTs had complete adherence with CONSORT reporting guidelines and the average CONSORT score was 19 out of 25. For positive superiority trials with binary outcomes, the fragility index median (interquartile range) was 2 (2 to 8). CONCLUSIONS: A concerningly large proportion of recently published RCTs in trauma surgery do not report a priori sample size calculations, do not meet enrollment targets, and are not adequately powered to detect even large effect sizes. There exists opportunity for improvement of trauma surgery study design, conduct, and reporting.

Improved survival for severely injured patients receiving massive transfusion at US teaching hospitals: A nationwide analysis.

BACKGROUND: Previous studies have shown improved survival for patients treated at American College of Surgeons (ACS)-verified level I trauma centers compared with level II, level III, and undesignated centers. This mortality difference is more pronounced in severely injured patients. However, a survival benefit for severely injured trauma patients has not been established at teaching institutions compared with nonteaching centers. Because massive transfusion (MT) is associated with high mortality, we hypothesize that patients receiving MT have lower mortality at teaching hospitals than at nonteaching hospitals. METHODS: All adult ACS Trauma Quality Improvement Program-eligible patients who underwent MT, defined as >10 U of packed red blood cells in the first 4 hours after arrival, in the 2019 ACS Trauma Quality Programs participant use file were eligible. Patients with severe head injury (head Abbreviated Injury Scale score, ≥3), prehospital cardiac arrest, and interhospital transfers were excluded. Logistic regression models were used to assess the effects of trauma center hospital teaching status on the adjusted odds of 3-hour, 6-hour, and 24-hour mortality. RESULTS: A total of 1,849 patients received MT (81% male; median Injury Severity Score, 26 [18-35]), 72% were admitted to level I trauma centers, and 28% were admitted to level II centers. Overall hospital mortality was 41%; 17% of patients died in 3 hours, 25% in 6 hours, and 33% in 24 hours. Teaching hospitals were associated with decreased 3-hour (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.27-0.75), 6-hour (OR, 0.37; 95% CI, 0.24-0.56), 24-hour (OR, 0.50; 95% CI, 0.34-0.75), and overall mortality (OR, 0.66; 95% CI, 0.44-0.98), compared with nonteaching hospitals, controlling for sex, age, heart rate, injury severity, injury mechanism, and trauma center verification level. CONCLUSION: Severely injured patients requiring MT experience significantly lower mortality at teaching hospitals compared with nonteaching hospitals, independently of trauma center verification level. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Illuminating the Use of Trauma Whole-Body CT Scan During the Global Contrast Shortage.

BACKGROUND: Use of whole-body CT scan (WBCT) is widespread in the evaluation of traumatically injured patients and may be associated with improved survival. WBCT protocols include the use of IV contrast unless there is a contraindication. This study tests the hypothesis that using plain WBCT scan during the global contrast shortage would result in greater need for repeat contrast-enhanced CT, but would not impact mortality, missed injuries, or rates of acute kidney injury (AKI). STUDY DESIGN: All trauma encounters at an academic level-I trauma center between March 1, 2022 and June 24, 2022, excluding burns and prehospital cardiac arrests, were reviewed. Imaging practices and outcomes before and during contrast shortage (beginning May 3, 2022) were compared. RESULTS: The study population included 1,109 consecutive patients (72% male), with 890 (80%) blunt and 219 (20%) penetrating traumas. Overall, 53% of patients underwent WBCT and contrast was administered to 73%. The overall rate of AKI was 6% and the rate of renal replacement therapy (RRT) was 1%. Contrast usage in WBCT was 99% before and 40% during the shortage (p < 0.001). There was no difference in the rate of repeat CT scans, missed injuries, AKI, RRT, or mortality. CONCLUSIONS: Trauma imaging practices at our center changed during the global contrast shortage; the use of contrast decreased despite the frequency of trauma WBCT scans remaining the same. The rates of AKI and RRT did not change, suggesting that WBCT with contrast is insufficient to cause AKI. The missed injury rate was equivalent. Our data suggest similar outcomes can be achieved with selective IV contrast use during WBCT.

Examining the Definition of Ventilator-Associated Pneumonia in the Trauma Setting: A Single-Center Analysis.

Background: Ventilator associated pneumonia (VAP) is defined by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) using laboratory findings, pathophysiologic signs/symptoms, and imaging criteria. However, many critically ill trauma patients meet the non-specific laboratory and sign/symptom thresholds for VAP, so the TQIP designation of VAP depends heavily upon imaging evidence. We hypothesized that physician opinions widely vary regarding chest radiograph findings significant for VAP. Patients and Methods: The TQIP Spring 2021 Benchmark Report (BR) was used to identify 14 patients with VAP at an academic Level 1 Trauma Center. Critically ill trauma patients (n = 7) who spent at least four days intubated and met TQIP's laboratory and sign/symptom thresholds for VAP but did not appear as VAPs on the BR comprised the control group. For each deidentified patient, four successive chest radiographic images were compiled and arranged chronologically. Cases and controls were randomly arranged in digital format. Blinded physicians (n = 27) were asked to identify patients with VAP based solely on imaging evidence. Results: Radiographic evidence of VAP was highly subjective (Krippendorff α = 0.134). Among physicians of the same job description, inter-rater reliability remained low (α = 0.137 for trauma attending physicians; α = 0.141 for trauma fellows; α = 0.271 for radiologists). When majority judgment was compared to the TQIP BR, there was disagreement between the two tests (Cohen κ = -0.071; sensitivity, 64.3%; specificity, 28.6%). Conclusions: Current definitions of VAP rely on subjective imaging interpretation and ignore the reality that there are numerous explanations for opacities on CXR. The inconsistency of physicians' imaging interpretation and protean physiologic findings for VAP in trauma patients should preclude the current definition of VAP from being used as a quality improvement metric in TQIP.

Burn excision within 48 hours portends better outcomes than standard management: A nationwide analysis.

BACKGROUND: Previous studies have debated the optimal time to perform excision and grafting of second- and third-degree burns. The current consensus is that excision should be performed before the sixth hospital day. We hypothesize that patients who undergo excision within 48 hours have better outcomes. METHODS: The American College of Surgeons Trauma Quality Programs data set was used to identify all patients with at least 10% total body surface area second- and third-degree burns from years 2017 to 2019. Patients with other serious injuries (any Abbreviated Injury Scale, >3), severe inhalational injury, prehospital cardiac arrest, and interhospital transfers were excluded. International Classification of Diseases, Tenth Revision , procedure codes were used to ascertain time of first excision. Patients who underwent first excision within 48 hours of admission (early excision) were compared with those who underwent surgery 48 to 120 hours from admission (standard therapy). Propensity score matching was performed to control for age and total body surface area burned. RESULTS: A total of 2,270 patients (72% male) were included in the analysis. The median age was 37 (23-55) years. Early excision was associated with shorter hospital length of stay (LOS), and intensive care unit LOS. Complications including deep venous thrombosis, pulmonary embolism, ventilator-associated pneumonia, and catheter-associated urinary tract infection were significantly lower with early excision. There was no significant difference in mortality. CONCLUSION: Performance of excision within 48 hours is associated with shorter hospital LOS and fewer complications than standard therapy. We recommend taking patients for operative debridement and temporary or, when feasible, permanent coverage within 48 hours. Prospective trials should be performed to verify the advantages of this treatment strategy. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The effect of mesenchymal stem cells improves the healing of burn wounds: a phase 1 dose-escalation clinical trial.

Background: Stem cell therapy holds promise to improve healing and stimulate tissue regeneration after burn injury. Preclinical evidence has supported this; however, clinical studies are lacking. We examined the application of bone marrow-derived mesenchymal stem cells (BM-MSC) to deep second-degree burn injuries using a two-dose escalation protocol. Methods: Ten individuals aged 18 years or older with deep second-degree burn wounds were enrolled. The first five patients were administered 2.5 × 10³ BM-MSC/cm2 to their wounds. After safety of the initial dose level was assessed, a second group of five patients was treated with a higher concentration of 5 × 10³ allogeneic BM-MSC/cm2. Safety was assessed clinically and by evaluating cytokine levels in mixed recipient lymphocyte/donor BM-MSC reactions (INFγ, IL-10 and TNFα). At each visit, we performed wound measurements and assessed wounds using a Patient and Observer Scar Assessment Scale (POSAS). Results: All patients responded well to treatment, with 100% closure of wounds and minimal clinical evidence of fibrosis. No adverse reactions or evidence of rejection were observed for both dose levels. Patients receiving the first dose concentration had a wound closure rate of 3.64 cm2/day. Patients receiving the second dose concentration demonstrated a wound closure rate of 10.47 cm2/day. The difference in healing rates between the two groups was not found to be statistically significant (P = 0.17). Conclusion: BM-MSC appear beneficial in optimising wound healing in patients with deep second-degree burn wounds. Adverse outcomes were not observed when administering multiple doses of allogeneic BM-MSC. Lay Summary: Thermal injuries are a significant source of morbidity and mortality, constituting 5%-20% of all injuries and 4% of all deaths. Despite overall improvements in the management of acutely burned patients, morbidities associated with deeper burn injuries remain commonplace. Burn patients are too often left with significant tissue loss, scarring and contractions leading to physical loss of function and long-lasting psychological and emotional impacts.In previous studies, we have demonstrated the safety and efficacy of administering bone marrow-derived mesenchymal stem cells (BM-MSC) to chronic wounds with substantial improvement in healing and evidence of tissue regeneration. In this report, we have examined the application of BM-MSC to deep second-degree burn injuries in patients.The aim of the present phase I/II clinical trial was to examine the safety and efficacy of administering allogeneic BM-MSC to deep second-degree burns. We utilised two different dose levels at concentrations 2.5 × 103 and 5 × 103 cells/cm2. Patients with deep second-degree burn wounds up to 20% of the total body surface area were eligible for treatment. Allogeneic BM-MSC were applied to burn wounds topically or by injection under transparent film dressing <7 days after injury. Patients were followed for at least six months after treatment.Using two dose levels allowed us to gain preliminary information as to whether different amounts of BM-MSC administered to burn wounds will result in significant differences in safety/ clinical response. Once the safety and dose-response analysis were completed, we evaluated the efficacy of allogeneic stem cell therapy in the treatment of deep second-degree burn wounds.In this study, we examined the role of allogeneic BM-MSC treatment in patients with deep second-degree burn injuries, in a dose-dependent manner. No significant related adverse events were reported. Safety was evaluated both clinically and by laboratory-based methods. Efficacy was assessed clinically through evidence of re-pigmentation, hair follicle restoration and regenerative change. While these findings are encouraging, more studies will be needed to better establish the benefit of BM-MSC in the treatment of burn injuries.

The Key to Combat Readiness Is a Strong Military-Civilian Partnership.

INTRODUCTION: In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents <0.5% of military hospital admissions and not all team members have daily clinical responsibilities. Military surgeon clinical experience has been described, but no data exist for other members of the FRST. We test the hypothesis that the clinical experience of non-physician FRST members varies between active duty (AD) and Army reservists (AR). METHODS: Over a 3-year period, all FRSTs were surveyed at one civilian center. RESULTS: Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P < .001). These differences persisted across all specialties, including perioperative nurses, certified registered nurse anesthetists, operating room (OR) techs, critical-care nurses, emergency room (ER) nurses, licensed practical nurse (LPN), and combat medics. CONCLUSIONS: This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.

Continuous-infusion oxacillin for the treatment of burn wound cellulitis.

BACKGROUND: Burn cellulitis is an infection of the unburned skin at the margin of a burn wound or graft donor site, typically caused by group A beta-hemolytic streptococci and Staphylococcus aureus. beta-Lactam antibiotics exhibit time-dependent killing and, because of their narrow spectrum, minimize bacterial resistance. We therefore use continuous-infusion oxacillin in the treatment of burn cellulitis. METHODS: Patients at a regional burn center who were treated for burn cellulitis from January 2003 to December 2005 were included. Charts were reviewed for all pertinent data regarding the antibiotic treatment methods and outcomes. Successful treatment was defined as resolution of physical findings, fever, and leukocytosis and intravenous antibiotic cessation. RESULTS: Thirty-seven patients were treated for burn cellulitis, 26 (70%) of whom were treated initially with continuous-infusion oxacillin. Other initial antibiotics were chosen because of concomitant infections, penicillin allergy, or development of cellulitis during treatment with a beta-lactam antibiotic. Oxacillin treatment was successful in 19 patients (73%). Success required an average of 5.16 days, with 1.53 days required for fever resolution and 0.89 days for resolution of leukocytosis. Seven patients who did not respond rapidly were switched to intravenous vancomycin an average of 2.4 days after starting oxacillin, leading to a 100% success rate. There were no deaths, and only one suspected case of allergic reaction to oxacillin. In eleven patients treated with other antibiotics, the success rate was 75%. Success with these drugs required a longer treatment course of 6.45 days. Leukocytosis resolved significantly more slowly at 4.45 days (p = 0.02), and fever resolution was also slower at 3.18 days. CONCLUSIONS: Continuous-infusion oxacillin was successful in the treatment of 73% of patients, a success rate that might have been higher with clinical patience, and leukocytosis resolved faster than with other antibiotics. Failure of continuous-infusion oxacillin can be managed without clinical consequence by conversion to intravenous vancomycin.

Electrical Burns During Fruit Harvesting.

Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.

Nonoperative management of pediatric burn injuries.

There are an estimated 1.2 million burn injuries per year in the United States, one third of which occur in children. Most of these injuries will be treated nonoperatively, frequently in an outpatient setting. This article aims to provide the practitioner with a understanding of the pathophysiology of burn injuries, a guide to the initial assessment of the patient, and management recommendations for nonoperative treatment of the burned pediatric patient.

Critical care and monitoring of the pediatric burn patient.

Burn injuries continue to be a significant cause of pediatric morbidity in the United States, with approximately 20,000 admissions per year to centers specializing in the treatment of burn injuries. In this article, we aim to provide the practitioner with a guideline to the unique challenges, advances and current expectations, and treatment in this patient population.