American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res. 2008;29:257-266. [PMID: 18182930 DOI: 10.1097/BCR.0b013e31815f3876]

Cardiovascular Responsiveness to Vasopressin and α1-Adrenergic Receptor Agonists After Burn Injury

The effects of burn injury on cardiovascular responsiveness to vasoactive agents are not well understood. The aims of this study were to determine whether burn injury alters cardiovascular reactivity to vasoactive drugs in vivo and intrinsic function of isolated mesenteric resistance arteries. Anesthetized Sprague-Dawley rats were subjected to sham procedure or 30% TBSA dorsal scald burn, followed by crystalloid resuscitation (Parkland Formula). At 24, 72, 96, and 168 hours post burn, rats were reanesthetized, and the mean arterial blood pressure (MAP) responses to various doses of the α1-adrenergic receptor agonist phenylephrine and arginine vasopressin were tested. Mesenteric arteries were harvested from uninjured animals and at 24 and 168 hours post burn. The responsiveness of arteries to phenylephrine and arginine vasopressin was tested by pressure myography. Dose response curves were generated and EC50 concentrations, Hill slopes, and maximal effects were compared. The potency of phenylephrine to increase MAP was reduced 2-fold 24 hours post burn (P < .05 vs sham) and gradually normalized at later time points. The reactivity of isolated arteries to phenylephrine was not significantly altered after burns. The potency of arginine vasopressin to increase MAP and to constrict isolated arteries was increased 2- to 3-fold at 24 hours post burn (P < .05) and normalized at later time points. Our findings suggest that burn injury differentially regulates vasopressor and blood pressure effects of α-adrenergic and vasopressin receptor agonists. Intrinsic vasopressin receptor reactivity of resistance arteries is sensitized early after burns. These findings will help to optimize resuscitation strategies and vasopressor use in difficult to resuscitate burn patients.

Burn State of the Science: Fluid Resuscitation

Recognition of fluid creep has driven a large amount of the scientific investigation in the area of acute fluid resuscitation for burn patients. The role of colloids in ameliorating fluid creep is controversial, despite the fact that a fluid-sparing effect of colloids has been recognized for some time. All but one of the available prospective studies using colloids are more than a decade old, and a modern randomized controlled trial (RCT) comparing crystalloids to colloids is long overdue. While urinary output continues to be the main endpoint for fluid titration, there has been a moderate amount of interest in the use of transpulmonary thermodilution to guide fluid resuscitation. The available studies have found that transpulmonary thermodilution has had an inconsistent effect on limiting fluid resuscitation volumes and improving clinical outcomes. Computerized Decision Support Systems show great promise in optimizing fluid titration and reducing fluid resuscitation volumes, and an RCT comparing Computerized Decision Support Systems with conventional titration approaches will be the important next step. Use of high-dose vitamin C (ascorbic acid) has become a popular approach to limit fluid resuscitation volumes and edema formation, but it has been investigated in only two clinical studies: one a pseudo-randomized prospective study and the other a retrospective study. Improvements in clinical outcome have not been convincingly demonstrated, and concerns persist surrounding the possibility of induction of an osmotic diuresis, leading to intravascular volume depletion. An RCT is urgently required to evaluate high-dose vitamin C as an adjunct to crystalloid resuscitation compared with the use of crystalloids alone.

The Care of Thermally Injured Patients in Operational, Austere, and Mass Casualty Situations

Burn injury affects a half million people in the United States annually. The severe thermal injury can have long-term debilitating effects. The management of burn patients in austere and operational environments is more complex. Mass casualty incidents can result in a large number of patients with multiple traumatic injuries, which often include burn injury. Appropriate triage of casualties is essential. Severely burned patients should be evacuated to a burn center if possible. Airway management and fluid resuscitation of burn patients present unique challenges. Supplies, resources, and expertise to maintain a definitive airway may not be readily available. Airway adjuncts can be helpful but judicious use of resources is warranted in the austere setting. Traditional resuscitation of severe thermal injury is not practical in the austere environment. Oral resuscitation and in rare cases rectal hydration may be utilized until the patient can be transported to a medical facility. Much has been learned about the management of burn and polytraumatized patients after mass casualty incidents such as the September 11, 2001 terror attacks and the Pope Air Force Base disaster. A well-coordinated emergency preparedness plan is essential. The care of burn patients in austere, operational, and mass casualty situations can tax resources and manpower. The care of these patients will require creativity and ingenuity. Burn patients can be difficult to manage under normal circumstances but the care of these patients under the above situations complicates the management severalfold.

Advances in keratinocyte delivery in burn wound care

This review gives an updated overview on keratinocyte transplantation in burn wounds concentrating on application methods and future therapeutic cell delivery options with a special interest in hydrogels and spray devices for cell delivery. To achieve faster re-epithelialisation of burn wounds, the original autologous keratinocyte culture and transplantation technique was introduced over 3 decades ago. Application types of keratinocytes transplantation have improved from cell sheets to single-cell solutions delivered with a spray system. However, further enhancement of cell culture, cell viability and function in vivo, cell carrier and cell delivery systems remain themes of interest. Hydrogels such as chitosan, alginate, fibrin and collagen are frequently used in burn wound care and have advantageous characteristics as cell carriers. Future approaches of keratinocyte transplantation involve spray devices, but optimisation of application technique and carrier type is necessary.

A Rat Burn Injury Model for Studying Changes in Microvascular Permeability

The management of burn patients is an extremely complex and clinically challenging for patient care. Aside from the increasing reports of burn injury and morbidity and mortality directly related to it, the pathobiology of burn trauma is not clearly understood. The rat model of burn trauma described here is currently used in research laboratories to study various aspects of burn injury, including vascular dysfunctions. This model demonstrates the infliction of thermal injury in Sprague-Dawley rats using a well-established boiled water approach. We have utilized intravital microscopy to examine the microvascular hyperpermeability, the excessive leakage of proteins and fluids from the intravascular space to the extravascular space in mesenteric postcapillary venules using this model. An increase in microvascular permeability is a strong indicator of microvascular dysfunctions leading to tissue edema in burn trauma.

Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage

OBJECTIVES

We sought to evaluate the efficacy, efficiency, and physiologic consequences of automated, endpoint-directed resuscitation systems and compare them to formula-based bolus resuscitation.

DESIGN

Experimental human hemorrhage and resuscitation.

SETTING

Clinical research laboratory.

SUBJECTS

Healthy volunteers.

INTERVENTIONS

Subjects (n = 7) were subjected to hemorrhage and underwent a randomized fluid resuscitation scheme on separate visits 1) formula-based bolus resuscitation; 2) semiautonomous (decision assist) fluid administration; and 3) fully autonomous (closed loop) resuscitation. Hemodynamic variables, volume shifts, fluid balance, and cardiac function were monitored during hemorrhage and resuscitation. Treatment modalities were compared based on resuscitation efficacy and efficiency.

MEASUREMENTS AND MAIN RESULTS

All approaches achieved target blood pressure by 60 minutes. Following hemorrhage, the total amount of infused fluid (bolus resuscitation: 30 mL/kg, decision assist: 5.6 ± 3 mL/kg, closed loop: 4.2 ± 2 mL/kg; p < 0.001), plasma volume, extravascular volume (bolus resuscitation: 17 ± 4 mL/kg, decision assist: 3 ± 1 mL/kg, closed loop: -0.3 ± 0.3 mL/kg; p < 0.001), body weight, and urinary output remained stable under decision assist and closed loop and were significantly increased under bolus resuscitation. Mean arterial pressure initially decreased further under bolus resuscitation (-10 mm Hg; p < 0.001) and was lower under bolus resuscitation than closed loop at 20 minutes (bolus resuscitation: 57 ± 2 mm Hg, closed loop: 69 ± 4 mm Hg; p = 0.036). Colloid osmotic pressure (bolus resuscitation: 19.3 ± 2 mm Hg, decision assist, closed loop: 24 ± 0.4 mm Hg; p < 0.05) and hemoglobin concentration were significantly decreased after bolus fluid administration.

CONCLUSIONS

We define efficacy of decision-assist and closed-loop resuscitation in human hemorrhage. In comparison with formula-based bolus resuscitation, both semiautonomous and autonomous approaches were more efficient in goal-directed resuscitation of hemorrhage. They provide favorable conditions for the avoidance of over-resuscitation and its adverse clinical sequelae. Decision-assist and closed-loop resuscitation algorithms are promising technological solutions for constrained environments and areas of limited resources.

Presenting hypertension, burn injury, and mortality in combat casualties

INTRODUCTION

The effect of presenting hypertension is poorly studied in combat casualties. We hypothesized that elevated mean arterial pressure (MAP) on presentation to combat hospitals would be associated with poor outcomes.

METHODS

Data was obtained from the Department of Defense Trauma Registry and the Armed Forces Medical Examiner System. Variables analyzed included presenting vital signs to Role II-III military theater hospital, demographic variables, injury severity score (ISS), location and mechanism of injury, presence of traumatic brain injury (TBI), acute kidney injury (AKI), and mortality. Patients were stratified by decile of MAP and logistic regression analysis was employed to adjust for confounders.

RESULTS

A total of 4072 subjects injured from February 2002 to February 2011 were identified. Compared to patients in the middle deciles of presenting MAP, patients in the highest and lowest MAP deciles were the only groups that demonstrated a higher mortality on univariate analysis (OR 2.06, 95% CI 1.16-2.31 and OR 2.86, 95% CI 1.76-4.67, respectively), and this relationship persisted after adjustment for ISS, HR, temperature, presence of burn injury, TBI, and AKI. Burn injury was associated with mortality in the full multivariate analysis. However, further analysis limited to patients without burn injury did not demonstrate an association between high MAP and mortality (OR 0.84, 95% CI 0.36-1.99; p=0.70). Conversely, when limited to patients with burn injury, high MAP was associated with mortality (OR 3.78, 95% CI 1.74-8.20; p=0.001).

CONCLUSION

The relationship between mortality and presenting MAP appears to be U-shaped, demonstrating increased mortality in the lowest and highest deciles. However, mortality in the highest MAP decile appears to be limited to casualties with associated burn injury, even after adjustment for TBI, AKI, and ISS, which takes into account the severity of the burn injury. Physicians should recognize that burn patients presenting with an elevated MAP are at an increased risk for poor outcomes.

LEVEL OF EVIDENCE

III.

Determinants and time to blood transfusion among thermal burn patients admitted to Mulago Hospital

Background

Blood transfusion, a practice under re-evaluation in general, remains common among thermal burn patients due to the hematological alterations associated with burns that manifest as anemia. Today advocacy is for restrictive blood transfusion taking into account individual patient characteristics. We went out to identify the parameters that may determine transfusion requirement and the time to blood transfusion for thermal burn patients in Mulago Hospital in order to build statistics and a basis to standardize future practice and Hospital protocol.

Methods

112 patients with thermal burns were enrolled into a prospective cohort study conducted in the Surgical Unit of the Accidents and Emergency Department and Burns Unit of Mulago Hospital. Relevant data on pre-injury, injury and post-injury factors was collected including relevant laboratory investigations and treatment modalities like surgical intervention. Patients were clinically followed up for a maximum period of 28 days and we identified those that were transfused.

Results

22.3% of patients were transfused. The median time to transfusion was 17 days from time of injury and varied with different patient characteristics. The median pre-transfusion hemoglobin (Hb) level was 8.2 g/dL. Transfusion was significantly related to; admission to the intensive care unit (p = 0.001), a body mass index (BMI) <2 kg/m² (p = 0.021), % total burn surface area (TBSA) >20 (p = 0.049), pre-existing illness (p = 0.046), and white blood cell (WBC) count <4000 or >12,000/μL (p = 0.05).

Conclusion

Pre-existing illnesses, a low BMI, TBSA of >20%, admission to the intensive care unit and abnormalities in the WBC count are useful predictors of blood transfusion among thermal burns patients admitted to Mulago Hospital. The precise time to transfusion from time of burns injury cannot be generalized. With close monitoring of each individual patient lies the appropriateness and timeliness of their management.

The impact of patient weight on burn resuscitation

BACKGROUND

Optimal fluid resuscitation of burn patients with burns greater than 20% total body surface area is critical to prevent burn shock during the initial 24 hours to 48 hours postburn. Currently, most resuscitation formulas incorporate the patient's weight when estimating 24-hour fluid requirements. The objective of this study was to determine the impact of weight on fluid resuscitation requirements and outcomes during the initial 24 hours after admission.

METHODS

We performed a retrospective review of patients admitted to our burn intensive care unit from December 2007 to April 2013, resuscitated with a computerized decision support system. We classified patients into body mass index (BMI) categories of underweight (BMI: <18.5), normal (BMI: 18.5-24.9), overweight (BMI: 25.0-29.9), or obese (BMI: >30.0). We also calculated the percent difference from ideal body weight (IBW) and compared 24-hour fluid volumes received.

RESULTS

Patients with missing weight and/or height values were excluded from the study, resulting in a final cohort of 161 patients for analysis. Mean total body surface area was 42 ± 20% with a full thickness burn of 18 ± 23%. Mean age, weight, and height were 47 ± 19 years, 83 ± 19 kg, and 68 ± 4 inches, respectively. IBW for this cohort was 68 ± 11 kg with a BMI of 28 ± 6. Univariate analysis showed significant differences in 24-hour resuscitation volumes (mL/kg) between normal and obese patients (p < 0.05). Further analysis revealed that increasing percent difference from IBW was associated with lower fluid volumes. Although obesity was not associated with inhalation injury or renal replacement therapy, it was correlated to an increased risk for mortality (p < 0.05).

CONCLUSION

This analysis showed that increasing weight was associated with lower fluid resuscitation volume requirements and a higher mortality rate, despite the low incidence of inhalation injury and renal replacement therapy in our obese patients. The use of actual body weight to drive resuscitation volumes may result in overresuscitation of obese patients, depending on the resuscitation formula. Further studies are needed to better explain the relationship between mortality and obesity in burn patients.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Future Therapies in Burn Resuscitation

Since the 1940s, the resuscitation of burn patients has evolved with dramatic improvements in mortality. The most significant achievement remains the creation and adoption of formulae to calculate estimated fluid requirements to guide resuscitation. Modalities to attenuate the hypermetabolic phase of injury include pharmacologic agents, early enteral nutrition, and the aggressive approach of early excision of large injuries. Recent investigations into the genomic response to severe burns and the application of computer-based decision support tools will likely guide future resuscitation, with the goal of further reducing mortality and morbidity, and improving functional and quality of life outcomes.

Monitoring End Points of Burn Resuscitation

This article discusses commonly used methods of monitoring and determining the end points of resuscitation. Each end point of resuscitation is examined as it relates to use in critically ill burn patients. Published medical literature, clinical trials, consensus trials, and expert opinion regarding end points of resuscitation were gathered and reviewed. Specific goals were a detailed examination of each method in the critical care population and how this methodology can be used in the burn patient. Although burn resuscitation is monitored and administered using the methodology as seen in medical/surgical intensive care settings, special consideration for excessive edema formation, metabolic derangements, and frequent operative interventions must be considered.

Colloids in Acute Burn Resuscitation

Colloids have been used in varying capacities throughout the history of formula-based burn resuscitation. There is sound experimental evidence that demonstrates colloids' ability to improve intravascular colloid osmotic pressure, expand intravascular volume, reduce resuscitation requirements, and limit edema in unburned tissue following a major burn. Fresh frozen plasma appears to be a useful and effective immediate burn resuscitation fluid but its benefits must be weighed against its costs, and risks of viral transmission and acute lung injury. Albumin, in contrast, is less expensive and safer and has demonstrated ability to reduce resuscitation requirements and possibly limit edema-related morbidity.

Important Developments in Burn Care

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the epidemiology of severe burn injury in the context of socioeconomic status, gender, age, and burn cause. 2. Describe challenges with burn depth evaluation and novel methods of adjunctive assessment. 3. Summarize the survival and functional outcomes of severe burn injury. 4. State strategies of fluid resuscitation, endpoints to guide fluid titration, and sequelae of overresuscitation. 5. Recognize preventative measures of sepsis. 6. Explain intraoperative strategies to improve patient outcomes, including hemostasis, restrictive transfusion, temperature regulation, skin substitutes, and Meek skin grafting. 7. Translate updates in the pathophysiology of hypertrophic scarring into novel methods of clinical management. 8. Discuss the potential role of free tissue transfer in primary and secondary burn reconstruction.

SUMMARY

Management of burn-injured patients is a challenging and unique field for plastic surgeons. Significant advances over the past decade have occurred in resuscitation, burn wound management, sepsis, and reconstruction that have improved outcomes and quality of life after thermal injury. However, as patients with larger burns are resuscitated, an increased risk of nosocomial infections, sepsis, compartment syndromes, and venous thromboembolic phenomena have required adjustments in care to maintain quality of life after injury. This article outlines a number of recent developments in burn care that illustrate the evolution of the field to assist plastic surgeons involved in burn care.

Predicting the proportion of full-thickness involvement for any given burn size based on burn resuscitation volumes

INTRODUCTION

The depth of burn has been an important factor often overlooked when estimating the total resuscitation fluid needed for early burn care. The goal of this study was to determine the degree to which full-thickness (FT) involvement affected overall 24-hour burn resuscitation volumes.

METHODS

We performed a retrospective review of patients admitted to our burn intensive care unit from December 2007 to April 2013, with significant burns that required resuscitation using our computerized decision support system for burn fluid resuscitation. We defined the degree of FT involvement as FT Index (FTI; percentage of FT injury/percentage of total body surface area (TBSA) burned [%FT / %TBSA]) and compared variables on actual 24-hour fluid resuscitation volumes overall as well as for any given burn size.

RESULTS

A total of 203 patients admitted to our burn center during the study period were included in the analysis. Mean age and weight were 47 ± 19 years and 87 ± 18 kg, respectively. Mean %TBSA was 41 ± 20 with a mean %FT of 18 ± 24. As %TBSA, %FT, and FTI increased, so did actual 24-hour fluid resuscitation volumes (mL/kg). However, increase in FTI did not result in increased volume indexed to burn size (mL/kg per %TBSA). This was true even when patients with inhalation injury were excluded. Further investigation revealed that as %TBSA increased, %FT increased nonlinearly (quadratic polynomial) (R = 0.994).

CONCLUSION

Total burn size and FT burn size were both highly correlated with increased 24-hour fluid resuscitation volumes. However, FTI did not correlate with a corresponding increase in resuscitation volumes for any given burn size, even when patients with inhalation injury were excluded. Thus, there are insufficient data to presume that those who receive more volume at any given burn size are likely to be mostly full thickness or vice versa. This was influenced by a relatively low sample size at each 10%TBSA increment and larger burn sizes disproportionately having more FT burns. A more robust sample size may elucidate this relationship better.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Acute Fluid Management of Large Burns: Pathophysiology, Monitoring, and Resuscitation

This article reviews the pathophysiology of large burn injury and the extreme fluid shifts that occur in the hours and days after this event. The authors focus on acute fluid management, monitoring of hemodynamic status, and end points of resuscitation. Understanding the need and causes for fluid resuscitation after burn injury helps the clinician develop an effective plan to balance the competing goals of normalized tissue perfusion and limited tissue edema. Thoughtful, individualized treatment is the best answer and the most effective compromise.

Patient Safety in Burn Care: Application of Evidence-based Medicine to Improve Outcomes

This article reviews 5 areas in burn care that increasingly use evidence-based medicine to optimize quality and safety: resuscitation protocols, transfusion practices, vascular access, venous thromboembolic prophylaxis, and rational use of antibiotics.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Can leukocyte antisedimentation rate (LAR) predict septic complications and critical care survival early in polytrauma and burn victims?

BACKGROUND

In polytrauma and burn injury Systemic Inflammatory Response Syndrome (SIRS) develops. SIRS is presented in many hospitalized patients, including those who never develop infection or sepsis. Both in SIRS and sepsis the leukocyte activation occurs. In acute phase reaction leukocytes' upward flotation i.e. leukocyte antisedimentation rate (LAR) can indicate infectious origin.

OBJECTIVE

To evaluate the predictive power of LAR, serum C-reactive protein (CRP) and procalcitonin (PCT) levels regarding mortality risk and development of septic complications.

METHODS

In a prospective, observational study, 36 patients were followed for 5 days (T1-T5) after admission to a critical care unit immediately with severe polytrauma or burn injury. Eleven patients developed septic complications, their LAR, CRP and PCT levels were analyzed before and after 3 days of sepsis was declared.

RESULTS

Ten patients died due to septic complications. In survivors LAR at T1 (p < 0.001) and T2 (p < 0.001) as well as CRP at T1 (p < 0.05) were significantly higher compared to controls and non survivors. In septic patients LAR (p < 0.05) and CRP (p < 0.05) showed a significant drop one day before sepsis was declared. PCT levels failed to predict this.

CONCLUSIONS

Drop in LAR and CRP levels may be warning signs regarding the onset of septic complications after severe polytrauma and burn injury.

Antithrombin use and 28-day in-hospital mortality among severe-burn patients: an observational nationwide study

BACKGROUND

Previous studies have suggested that antithrombin may be beneficial for treating coagulopathy in patients with severe burns. However, robust evidence for this idea is lacking. We examined the hypothesis that antithrombin may be effective in treating patients with severe burns.

METHODS

We performed propensity score-matched analyses of the nationwide administrative Japanese Diagnosis Procedure Combination inpatient database. We identified patients with severe burns (burn index ≥ 10) who were recorded in the database from 1 July 2010 to 31 March 2013. We compared patients who were administered antithrombin within 2 days of admission (antithrombin group) and those who were not administered antithrombin (control group). The main outcomes were 28-day mortality and ventilator-free days (VFDs).

RESULTS

Eligible patients (n = 3223) from 618 hospitals were categorized into either an antithrombin group (n = 152) or control group (n = 3071). Propensity score matching created a matched cohort of 103 pairs with and without antithrombin. Twenty-eight-day mortality was lower in the antithrombin group compared with the control group in propensity-matched analysis (control vs. antithrombin, 47.6 vs. 33.0%; difference, 14.6%; 95% confidence interval [CI] 1.2-28.0). Cox regression analysis showed a significant difference in 28-day in-hospital mortality between the control and antithrombin propensity-matched groups (hazard ratio 0.58; 95% CI 0.37-0.90). There were significantly more VFDs in the antithrombin compared with the control group in propensity score-matched analysis (control vs. antithrombin, 12.6 vs. 16.4 days; difference -3.7; 95% CI -7.2 to -0.12).

CONCLUSIONS

This nationwide database study demonstrated that antithrombin use may improve 28-day survival and increase VFDs in patients with severe burns. Further prospective studies are required to confirm these results.

Management of Critical Burn Injuries: Recent Developments

Background

Burn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve vital organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage problems related to thermal injury, including lightning and electrical injuries.

Methods

A selected review is provided of key management concepts as well as of recent reports published by the American Burn Association.

Results

The burn-injured patient is easily and frequently over resuscitated, with ensuing complications that include delayed wound healing and respiratory compromise. A feedback protocol designed to limit the occurrence of excessive resuscitation has been proposed, but no new “gold standard” for resuscitation has replaced the venerated Parkland formula. While new medical therapies have been proposed for patients sustaining inhalation injury, a paradigm-shifting standard of medical therapy has not emerged. Renal failure as a specific contributor to adverse outcome in burns has been reinforced by recent data. Of special problems addressed in burn centers, electrical injuries pose multisystem physiologic challenges and do not fit typical scoring systems.

Conclusion

Recent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury has been generally adopted, but new standards for description of burn-related infections have been presented. The value of the burn center in care of the problems of electrical exposure, both manmade and natural, is demonstrated in recent reports.

Exam 4 Questions

A 73-year-old male with a history of hypertension and hyperlipidemia is currently in the stroke unit after suffering a right middle cerebral artery infarct. His symptoms started 2 h prior to arrival at the hospital, and tPA was administered. The patient is plegic on the left side and with mild dysarthria, but is otherwise neurologically intact. His labwork is within normal limits. Which of the following describes the optimal deep venous thrombosis (DVT) prophylaxis regimen for this patient?A.

Wait 6 h post tPA, then administer unfractionated heparin (UFH) along with intermittent pneumatic compression (IPC)

B.

Wait 24 h post tPA, then administer UFH along with IPC

C.

Wait 6 h post tPA, then administer low molecular weight heparin (LMWH) along with IPC

D.

Wait 24 h post tPA, then administer LMWH along with IPC

E.

IPC only for the first 72 h, then LMWH or UFH after obtaining follow-up imaging

All of the following causes of acute encephalitis have the matching characteristic radiological features except:A.

Autoimmune limbic encephalitis: T2/FLAIR hyperintensity in the mesial temporal lobes

B.

Cytomegalovirus: T2/FLAIR hyperintensity in the subependymal white matter

C.

JC virus: T2/FLAIR hyperintensity in the parieto-occipital lobes and corpus callosum

D.

Herpes simplex virus type 1: restricted diffusion in frontal/temporal lobes and insular cortex

E.

Varicella zoster: T2/FLAIR hyperintensity in the brainstem

Which of the following categorizations is most accurate regarding acute respiratory distress syndrome (ARDS) in the setting of subarachnoid hemorrhage (SAH)?A.

Non-neurogenic, non-cardiogenic

B.

Neurogenic, non-cardiogenic

C.

Neurogenic, cardiogenic

D.

Non-neurogenic, cardiogenic

E.

None of the above accurately reflect ARDS in SAH

A 52-year-old female is admitted to the ICU with a Hunt-Hess 1, modified Fisher 2 subarachnoid hemorrhage. Her past medical history is significant for hypertension, diabetes mellitus, and chronic renal insufficiency. She undergoes craniotomy for surgical clipping of an anterior cerebral artery aneurysm, and does not experience any additional complications. Two weeks later, she begins complaining of left calf pain, and a lower extremity sonogram demonstrated a proximal deep venous thrombosis (DVT). The patient weighs 60 kg. Her laboratory values are as follows: sodium 142 mEq/L, potassium 3.4 mEq/L, carbon dioxide 18 mEq/L, blood urea nitrogen (BUN) 70 mg/dL, and serum creatinine 2.5 mg/dL. What would be the optimal treatment for this patient’s proximal DVT?A.

Unfractionated heparin infusion for at least 5 days concomitantly with warfarin therapy

B.

Low molecular weight heparin 60 mg twice a day for at least 5 days concomitantly with warfarin therapy

C.

Fondaparinux 7.5 mg daily for 5 days followed by warfarin therapy

D.

Apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily

E.

Rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily

All of the following are currently implicated in uremic encephalopathy except:A.

Derangements in cerebral metabolism

B.

Alterations in the blood-brain barrier

C.

Accumulation of circulating toxins

D.

Imbalance of endogenous neurotransmitters

E.

Recurrent lobar hemorrhages

A 70-year-old female is hospitalized with a recent ischemic infarct. As part of stroke core measures, you obtain a hemoglobin A1c of 10.0. What is an approximate estimation of this patient’s average blood glucose level over the last several months?A.

70 mg/dL

B.

100 mg/dL

C.

130 mg/dL

D.

190 mg/dL

E.

240 mg/dL

A 28-year-old female with no known past medical history is in the ICU in status epilepticus, with anti-N-methyl D-aspartate (NMDA) receptor antibodies isolated in the cerebrospinal fluid. Which of the following is most likely to identify the root cause of her illness?A.

Transvaginal ultrasound

B.

Contrast-enhanced CT of the chest

C.

Contrast-enhanced CT of the brain

D.

Virtual colonography

E.

Thorough examination of the skin, particularly in sun-exposed areas

A 17-year-old male with no significant past medical history collapses during a high school football game, and goes into cardiac arrest. He did not have any complaints earlier in the day. The patient is brought to a nearby hospital, where is he resuscitated, intubated, and transferred to the ICU for further management. The patient is currently undergoing therapeutic hypothermia, and a work-up is underway to determine the cause of his sudden collapse. Which of the following is the most likely diagnosis?A.

Rupture of a previously undiagnosed cerebral aneurysm

B.

Hypertrophic cardiomyopathy

C.

Commotio cordis

D.

Severe hyponatremia and cerebral edema

E.

Brugada syndrome

A 31-year-old female at 38 weeks gestation is currently hospitalized for the treatment of preeclampsia. Due to her medical condition, her obstetrician is currently considering induced labor. At which point will this patient no longer be at risk for developing frank seizure activity as a result of her condition?A.

48 h postpartum

B.

1 week after delivery

C.

2 weeks after delivery

D.

4 weeks after delivery

E.

6 weeks after delivery

A 38-year-old male with no prior medical history presents to the emergency department with fever and severe headaches for several days. A CT scan of the brain is unremarkable, and the results of a lumbar puncture are pending. What is the most appropriate empiric antimicrobial regimen at this time?A.

Cefazolin and vancomycin

B.

Ceftriaxone and vancomycin

C.

Ceftriaxone, vancomycin and ampicillin

D.

Piperacillin/tazobactam and vancomycin

E.

Meropenem and vancomycin

The majority of intramedullary spinal cord neoplasms are:A.

Astrocytomas

B.

Meningiomas

C.

Metastatic lesions

D.

Ependymomas

E.

Hemangioblastomas

Which of the following derived parameter formulas is correct?A.

Cardiac index = cardiac output x body surface area

B.

Stroke volume = cardiac output/heart rate

C.

Systemic vascular resistance = 80 × (mean arterial pressure/cardiac output)

D.

Pulmonary vascular resistance = 80 × (mean pulmonary artery pressure/cardiac output)

E.

All of the above are correct

A 23-year-old female marathon runner is currently in the ICU after suffering from heat stroke following an outdoor run on a particularly hot summer day. She was initially delirious in the emergency department, but progressed to coma and respiratory failure requiring mechanical ventilation. Her oral temperature is 42.1 °C. Which of the following would be most effective in reducing this patient’s severe hyperthermia?A.

Regularly scheduled alternating acetaminophen and ibuprofen

B.

Spraying room temperature water on the patient, followed by fanning

C.

Ice water immersion

D.

Dantrolene sodium, 2.5 mg/kg

E.

Application of ice packs to the groin and axilla

Hyperinsulinemia-euglycemia (HIE) therapy may be useful for toxicity related to which of the following?A.

Tricyclic antidepressants

B.

Calcium channel blockers

C.

Aspirin

D.

Digoxin

E.

Lithium

A 71-year-old female with a history of alcohol abuse is currently intubated in the ICU following a catastrophic spontaneous left basal ganglia hemorrhage with resultant herniation. You have just declared her brain dead. The patient’s family agrees to make her an organ donor, and the organ donation coordinator requests you initiate levothyroxine therapy. Which of the following benefits would be expected with this treatment?A.

Increase the number of solid organs available for transplant

B.

Eliminate the need for hepatic biopsy prior to liver transplant

C.

Eliminate the need for cardiac catheterization prior to heart transplant

D.

Eliminate the need for bronchoscopy prior to lung transplant

E.

Reduce the need for supplementation of sodium, potassium, calcium, and magnesium

Which of the following is not an element of the Full Outline of Unresponsiveness (FOUR) score?A.

Eye opening

B.

Respiratory function

C.

Brainstem reflexes

D.

Motor response

E.

Verbal response

A 23-year-old female is currently in the ICU with status asthmaticus. She was initially on noninvasive positive pressure ventilation, with an arterial blood gas (ABG) as follows: pH 7.13, pCO₂ 60 mmHg, PaO₂ is 61 mmHg, HCO₃ 24 mmol/L, and oxygen saturation of 90%. She is given continuous inhaled albuterol, intravenous steroids, and magnesium sulfate. She subsequently becomes more lethargic and is intubated, with settings as follows: volume assist-control, rate of 12 breaths/min, tidal volume of 500 cc, PEEP of 5 cm H₂O, and FiO₂ of 50%. Peak airway pressure is 50 cm H₂O and plateau pressure is 15 cm H₂O. A stat portable chest x-ray shows hyperinflation with no pneumothorax. A repeat ABG after 30 min of invasive ventilation shows the following: pH of 7.24, pCO₂ 49 mmHg, PaO₂ 71 mmHg, HCO₃ is 25 mmol/L. Which of the following should be performed next?A.

Increase rate to 16

B.

Increase tidal volume to 600 cc

C.

Initiate bicarbonate infusion

D.

Switch to pressure assist-control

E.

Maintain current settings

Which of the following mechanisms is implicated in super-refractory status epilepticus?A.

Influx of proinflammatory molecules

B.

Upregulation of NMDA receptors

C.

Upregulation of molecular transport molecules

D.

Downregulation of GABA receptors

E.

All of the above

A 85-year-old male with a history nephrolithiasis, mild dementia, and alcohol abuse presented to the emergency department after a fall from standing, and was found to a right holohemispheric subdural hematoma. His clot was evacuated successfully, in spite of his oozing diathesis in the operating room (INR on arrival was 1.4 with a platelet count of 88 × 10³/μL). His serum transaminases are twice the normal value, and he has had refractory chronic hyponatremia. He has had three convulsions during this week of hospitalization, in spite of levetiracetam therapy at 1.5 g twice a day. Over the past 24 h, he has had a marked increase in agitation. He has also just had a 5-s run of non-sustained ventricular tachycardia, and his systolic blood pressure is now 85 mmHg. You are considering discontinuing his levetiracetam and starting a new agent. Which of the following would be the best choice in this scenario?A.

Carbamazepine

B.

Phenytoin

C.

Valproate

D.

Lacosamide

E.

Topiramate

A 65-year-old male with a history of COPD on rescue albuterol and ipratropium is diagnosed with myasthenia gravis, and started on an acetylcholinesterase inhibitor. He returns several days later complaining of increased salivation and worsening bronchial secretions in the absence of fevers, purulent sputum, or increasing dyspnea. These symptoms are not relieved by use of his albuterol. On exam, he has slightly decreased air movement throughout both lung fields without any clear wheezing, no focal rales, and a normal inspiratory to expiratory ratio. Which treatment option is most likely to be beneficial?A.

Increase frequency of short-acting ß₂ agonist use

B.

Add a standing long-acting inhaled ß₂ agonist

C.

Add glycopyrrolate as needed

D.

Add inhaled corticosteroids

E.

Add oral systemic corticosteroids

Regarding states of impaired consciousness, which of the following statements regarding arousal and awareness is correct?A.

Coma: intact arousal, but impaired awareness

B.

Minimally conscious state: impaired arousal and impaired awareness

C.

Persistent vegetative state: intact arousal, but impaired awareness

D.

Locked-in state: intact arousal, but impaired awareness

E.

All of the above are correct

A 62-year-old female is currently in the ICU following craniotomy for clipping of a cerebral aneurysm. Postoperatively, she is noted to have an oxygen saturation of 92% on 50% non-rebreather face mask, and her respiratory rate is 32 breaths/min. She denies chest pain. Her blood pressure is 96/72 mmHg and heart rate is 120 beats/min. Nimodipine has been held according to blood pressure parameters. A portable chest x-ray shows hazy opacities bilaterally, and bedside echocardiogram shows decreased left ventricular systolic function with apical, septal, lateral, anterior, anteroseptal and inferolateral wall akinesis, along with apical ballooning. Which of the following should be performed next?A.

Intubate the patient and begin mechanical ventilation

B.

Call urgent cardiology consult for cardiac catheterization

C.

Start noninvasive positive airway pressure ventilation

D.

Administer broad spectrum antibiotics

E.

Administer albuterol and systemic corticosteroids

Which of the following is the most common etiology of acute spinal cord ischemia and infarction?A.

Atherosclerotic disease

B.

Rupture of an abdominal aortic aneurysm

C.

Degenerative spine disease

D.

Cardioembolic events

E.

Systemic hypotension in the setting of other disease processes

A 62-year-old female with a history of coronary artery disease has just been admitted to the ICU with a left-sided spontaneous basal ganglia hemorrhage. The patient takes 325 mg of aspirin daily at home, and you are considering platelet transfusion. Which of the following has been demonstrated regarding platelet transfusion in this setting?A.

Improved chances of survival to hospital discharge

B.

Decreased hospital length-of-stay

C.

Improved chances of survival at 3 months

D.

Improved modified Rankin scale at 3 months

E.

None of the above

Which of the following therapies has been shown to decrease the incidence of delayed cerebral ischemia (DCI) in the setting of subarachnoid hemorrhage (SAH)?A.

Atorvastatin

B.

Magnesium

C.

Methylprednisolone

D.

Nicardipine

E.

None of the above

A 70-year-old male with a history of diabetes, hypertension, and cigarette smoking (one pack per day for the last 40 years) is currently in the ICU with a COPD exacerbation. This is his third exacerbation this year, and was discharged from the hospital only 3 weeks prior. On your examination, he is alert, his breathing is labored, and he has rales at the right lung base. His vital signs are as follows: blood pressure 90/60 mmHg, heart rate 120 beats per minute, respirations 28 per minute, and temperature 38.3 °C. His oxygen saturation on 50% face mask is 93%, and his most recent PCO₂ is 55 mmHg. Labs are notable for the following: white blood cell count 14.4 × 10⁹/L with 90% neutrophils, blood urea nitrogen (BUN) 30 mg/dL, serum creatinine 1.2 mg/dL, and glucose 240 mg/dL. Ketones are negative. He is currently on noninvasive positive pressure ventilation at 10/5 cm H₂O and 50% FiO₂, and broad spectrum antibiotics have been administered. An hour later, the nurse pages you because his heart rate is now 140 beats per minute and irregular, blood pressure is 85 systolic, oxygen saturation is 85%, and he is minimally responsive. You now hear bilateral rales, most prominently in the right lung base, and scattered wheezes. Which of the following should be performed next?A.

Increase inspiratory pressure to 15 and FiO₂ to 100%

B.

Start a continuous diltiazem infusion and give intravenous furosemide

C.

Start a continuous phenylephrine infusion targeting a mean arterial pressure (MAP) > 65

D.

Give 125 mg of solumedrol and administer albuterol via nebulizer

E.

Intubate the patient and initiate mechanical ventilation

A 57-year-old male with a history of epilepsy is currently in the stroke unit following a large right middle cerebral artery infarction. A nasogastric tube has been inserted, and 24 h continuous enteral feeds have been initiated. The patient is currently on 100 mg of phenytoin every 8 h for seizure prophylaxis. Which of the following measures should be taken to prevent the patient from developing subtherapeutic phenytoin levels?A.

Change to 18 h tube feeds, and only administer phenytoin at night

B.

Change to 18 h tube feeds, and only administer phenytoin twice daily

C.

Switch from standard to hydrolyzed tube feeds

D.

Switch from standard to glycemic control tube feeds

E.

Hold tube feeds for 2 h before and after phenytoin administration

A 37-year-old female presents to the emergency department with approximately 2 weeks of progressively worsening clumsiness and drastic mood swings. Her past medical history is significant only for Crohn’s disease, for which she takes both natalizumab and infliximab. A contrast-enhanced CT scan of her head is performed, revealing hypodense, non-enhancing lesions in the cortical white matter of the frontal and parietal lobes. Despite treatment, the patient expires 1 month later. Which of the following is true regarding the most likely diagnosis?A.

The diagnosis may be confirmed via CSF analysis

B.

The pathologic process spares oligodendrocytes

C.

It is a prion-based disease

D.

The condition is universally fatal despite treatment

E.

All of the above

A 58-year-old female presents to the emergency department with dry cough, fever and rapidly progressive dyspnea over 1 week. She has a history of rheumatoid arthritis (RA) and is maintained on weekly methotrexate and daily prednisone (which was increased to 30 mg starting 1 month ago for an acute flare). She takes no other medications. Her vital signs are as follows: blood pressure 100/70 mmHg, heart rate 110 beats/min, respiratory rate 20 breaths/min, and temperature 38.0 °C. In the ED she develops progressive hypoxemia with oxygen saturation 92% on 100% nonrebreather, and is increasingly diaphoretic. She is emergently intubated, and a chest x-ray post intubation shows extensive bilateral lung opacities. Which of the following should be administered at this time?A.

Ceftriaxone and azithromycin

B.

Vancomycin and piperacillin-tazobactam

C.

Vancomycin, cefepime, and fluconzole

D.

Ceftriaxone, levofloxacin, and trimethoprim-sulfamethoxazole

E.

Tigecycline only

A 45-year-old woman undergoes uncomplicated transsphenoidal resection of a pituitary macroadenoma. She appears well hydrated and is not complaining of excessive thirst. Post-operatively, she is noted to have increased urine output. Serum sodium is 137 mEq/L, and serum osmolarity is 275 mOsm/kg. What is the most likely cause of her polyuria?A.

Syndrome of inappropriate antidiuretic hormone

B.

Diabetes insipidus

C.

Cerebral salt wasting

D.

Fluid mobilization

E.

All of the above are equally likely

A 36-year-old female with a recent lumbar puncture to rule out subarachnoid hemorrhage is now complaining of a severe headache unlike anything she has experienced previously. She reports her headache is worse when standing, and better upon lying flat. She is otherwise neurologically intact. All of the following medications may be beneficial in this scenario except:A.

Acetaminophen

B.

Ibuprofen

C.

Caffeine

D.

Aminophylline

E.

Methylprednisolone

Which of the following is the most common overall cause of acute myocardial infarction?A.

Coronary dissection

B.

Plaque rupture

C.

Imbalance between oxygen demand and supply across a fixed obstruction

D.

Coronary vasospasm

E.

Ischemia related to hypotension and decreased perfusion

A 78-year-old male is in the ICU recovering from sepsis and pneumonia. He was just recently extubated after 2 days of mechanical ventilation and sedation with a fentanyl infusion. Over the ensuing days, he develops worsening abdominal distention, poor bowel sounds, and no stool output. CT scan reveals significant colonic distention, but no mass or obstruction. Records demonstrate a normal routine colonoscopy performed 6 weeks ago. You have appropriately hydrated the patient, corrected any electrolyte abnormalities, placed a rectal tube, withheld all opiates, and given intravenous erythromycin, but to no avail. Abdominal x-rays continue to demonstrate marked cecal dilatation greater than 12 cm in diameter. What is the next best appropriate therapy for this patient?A.

Neostigmine

B.

Naloxone

C.

Metoclopromide

D.

Surgical consultation for hemicolectomy

E.

Endoscopic percutaneous cecostomy tube placement

Which of the following is the most common cerebral vascular malformation in the general population?A.

AV malformation

B.

Dural AV fistula

C.

Developmental venous anomaly

D.

Cavernous malformation

E.

Vein of Galen malformation

A 49-year-old female with a history of acute lymphoblastic leukemia and recent subcutaneous cerebrospinal fluid (CSF) reservoir placement presents to the emergency department with fever, chills, and increased confusion for the past 3 days. Her CSF reservoir was last accessed 1 week ago. A thorough work-up reveals no other obvious infectious source, and there is concern for CSF reservoir-associated meningitis. Which of the following is the most likely causative organism?A.

Coagulase-negative staphylococci

B.

Propionobacterium acnes

C.

Methicillin-resistant Staphylococcus aureus

D.

Klebsiella pneumoniae

E.

Neisseria meningitidis

A 47-year-old woman presents to the emergency department with headache, nausea, and vomiting. Non-contrast head CT is performed, revealing subarachnoid blood in the right Sylvian fissure, and conventional angiography reveals the presents of a large right-sided MCA aneurysm. The patient undergoes successful surgical clipping of her aneurysm, and is being observed in the ICU. On admission, the patient’s serum sodium was 142 mEq/L and the hematocrit was 37%; by the seventh post-operative day, the serum sodium is 127 mEq/L and the hematocrit is 44%. Bedside ultrasonography demonstrates an IVC diameter of approximately 0.9 cm. Which of the following interventions would be least reasonable at this time?A.

Fludrocortisone, 0.2 mg twice a day

B.

2% hypertonic saline, infused peripherally

C.

3% hypertonic saline, infused centrally

D.

Sodium chloride oral tablets

E.

1500 mL daily fluid restriction

Which of the following is true regarding central (non-infectious) fever?A.

Less common in subarachnoid hemorrhage

B.

More common versus infectious fever

C.

Earlier onset versus infectious fever

D.

Easier to confirm versus infectious fever

E.

All of the above

Flaccid paralysis is most commonly associated with which of the following forms of encephalitis?A.

West Nile

B.

Varicella zoster

C.

Rabies

D.

Herpes simplex

E.

Epstein-Barr

Which of the following would not be considered appropriate therapy for heparin-induced thrombocytopenia (HIT)?A.

Discontinuation of heparin products alone

B.

Danaparoid

C.

Fondaparinux

D.

Argatroban

E.

All of the above are acceptable treatment options

A 45-year-old male with severe blunt traumatic brain injury (TBI) from a motor vehicle collision suffered a ventricular fibrillation cardiac arrest at the time of injury with return of spontaneous circulation (ROSC) in the field after endotracheal intubation and one dose of epinephrine. On arrival to the emergency department, no regional wall motion abnormalities were noted on surface echocardiography and no ST segment changes were seen on the presenting EKG. Head CT revealed cerebral contusions but no extra-axial mass lesions. The patient is now in the ICU and found to be comatose without sedation. Mild therapeutic hypothermia to 33° is being considered in the management of this post-arrest patient. Which of the following statements is true?A.

Mild therapeutic hypothermia is contraindicated due to the risk of induced epilepsy

B.

Mild therapeutic hypothermia is contraindicated with any intracranial pathology on CT imaging

C.

Mild therapeutic hypothermia does not induce a clinically significant coagulopathy

D.

Patients who have sustained ROSC after an arrest associated with TBI do not benefit from therapeutic hypothermia

E.

Endovascular cooling is superior to surface cooling in young patients with ROSC

A 35-year-old male is in the intensive care unit following resection of a large right-sided meningioma. He is currently intubated and sedated on a continuous fentanyl infusion. The nurse calls you to the bedside due to concerns over “unusual ventilator waveforms”. Upon arrival, you note the following (see Image 1). What is the best way to describe this phenomenon?A.

Reverse triggering

B.

Double triggering

C.

Breath stacking

D.

Missed triggering

E.

None of the above; normal ventilator waveforms are present

Fluid resuscitation management in patients with burns: update

Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns? To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.

Protocolized Resuscitation of Burn Patients

Fluid resuscitation of burn patients is commonly initiated using modified Brooke or Parkland formula. The fluid infusion rate is titrated up or down hourly to maintain adequate urine output and other endpoints. Over-resuscitation leads to morbid complications. Adherence to paper-based protocols, flow sheets, and clinical practice guidelines is associated with decreased fluid resuscitation volumes and complications. Computerized tools assist providers. Although completely autonomous closed-loop control of resuscitation has been demonstrated in animal models of burn shock, the major advantages of open-loop and decision-support systems are identifying trends, enhancing situational awareness, and encouraging burn team communication.

Fluid Creep and Over-resuscitation

Fluid creep is the term applied to a burn resuscitation, which requires more fluid than predicted by standard formulas. Fluid creep is common today and is linked to several serious edema-related complications. Increased fluid requirements may accompany the appropriate resuscitation of massive injuries but dangerous fluid creep is also caused by overly permissive fluid infusion and the lack of colloid supplementation. Several strategies for recognizing and treating fluid creep are presented.

The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation

Burn trauma in the current age of medical care still portends a 3% to 8% mortality. Of patients who die from their burn injuries, 58% of deaths occur in the first 72 hours after injury, indicating death from the initial burn shock is still a major cause of burn mortality. Significant thermal injury incites an inflammatory response, which distinguishes burns from other trauma. This article focuses on the current understanding of the pathophysiology of burn shock, the inflammatory response, and the direction of research and targeted therapies to improve resuscitation, morbidity, and mortality.

Burns During Pregnancy: Implications for Maternal-Perinatal Providers and Guidelines for Practice

IMPORTANCE

When a major burn is suffered during pregnancy, the obstetric provider is challenged to respond on an evidence basis because personal experience usually is lacking. Currently, there is a paucity of publications to inform the obstetrician, guide practice, and impact early critical decision making.

OBJECTIVE

The aims of this study were to summarize the available information on early management of burns during pregnancy and to identify components of best practices for optimal outcome.

EVIDENCE ACQUISITION

The PubMed database was searched for relevant titles and abstracts involving pregnant patients suffering from second-/third-degree burns. Among these studies, the bibliographies were investigated for further relevant literature. A total of 114 studies were identified during the initial search, and only studies published in English and French were included for a total of 42. Variable data were available for 1141 patients, with complete data for 139 cases. Mediation and regression analysis were used for available data. Insufficient data were available to undertake a systematic review.

RESULTS

Total body surface area of burns (TBSAB) was positively associated with maternal death, and the odds of maternal mortality increase by 1.08 per percentage increase of TBSAB (P < 0.001). Fetal survival depends on maternal survival (P ≤ 0.001). Maternal survival declines incrementally when TBSAB exceeds 55%, and inhalation injury further exacerbates maternal-perinatal risk.

CONCLUSIONS

Emergent assessment of the pregnant burn victimincludes determination of gestational age, extent of TBSAB, presence of inhalation injury, and continuous fetal monitoring. If gestational age is 24 weeks or longer and TBSAB exceeds 55%, urgent cesarean delivery appears desirable for the mother and baby.

RELEVANCE

A specific analysis of maternal-perinatal outcome based on TBSAB and gestational age is relevant to obstetric and emergency providers who provide care to pregnant burn patients.

Evaluation of the "Early" Use of Albumin in Children with Extensive Burns: A Randomized Controlled Trial

OBJECTIVE

To compare early versus delayed albumin resuscitation in children with burns in terms of clinical outcome and response.

DESIGN

Randomized controlled trial.

SETTING

Burn center at a tertiary care teaching hospital.

PATIENTS

Forty-six children aged 1-12 years with burns greater than 15-45% total body surface area admitted within 12 hours of burn injury.

INTERVENTIONS

Fluid resuscitation was based on the Parkland formula (3 mL/kg/% total body surface area), adjusted according to urine output. Patients received 5% albumin solution between 8 and 12 hours post burn in the intervention group (n = 23) and 24 hours post burn in the control group (n = 23). Both groups were assessed for reduction in crystalloid fluid infusion during resuscitation, development of fluid creep, and length of hospital stay.

MEASUREMENTS AND MAIN RESULTS

There was no difference between groups regarding age, weight, sex, % total body surface area, cause of burn, or severity scores. The median crystalloid fluid volume required during the first 3 days post burn was lower in the intervention than in the control group (2.04 vs 3.05 mL/kg/% total body surface area; p = 0.025 on day 1; 1.2 vs 1.71 mL/kg/% total body surface area; p = 0.002 on day 2; and 0.82 vs 1.3 mL/kg/% total body surface area; p = 0.002 on day 3). The median urine output showed no difference between intervention and control groups (2.1 vs 2.0 mL/kg/hr; p = 0.152 on day 1; 2.58 vs 2.54 mL/kg/hr; p = 0.482 on day 2; and 2.9 vs 3.0 mL/kg/hr; p = 0.093 on day 3). Fluid creep was observed in 13 controls (56.5%) and in one patient (4.3%) in the intervention group. The median length of hospital stay was 18 days (range, 15-21 d) for controls and 14 days (range, 10-17 d) in the intervention group (p = 0.004).

CONCLUSIONS

Early albumin infusion in children with burns greater than 15-45% total body surface area reduced the need for crystalloid fluid infusion during resuscitation. Significantly fewer cases of fluid creep and shorter hospital stay were also observed in this group of patients.

Coagulopathy and its management in patients with severe burns

Severe burn injury is associated with systemic coagulopathy. The changes in coagulation described in patients with severe burns resemble those found patients with sepsis or major trauma. Coagulopathy in patients with severe burns is characterized by procoagulant changes, and impaired fibrinolytic and natural anticoagulation systems. Both the timing of onset and the severity of hemostatic derangements are related to the severity of the burn. The exact pathophysiology and time course of coagulopathy are uncertain, but, at least in part, result from hemodilution and hypothermia. As the occurrence of coagulopathy in patients with severe burns is associated with increased comorbidity and mortality, coagulopathy could be seen as a potential therapeutic target. Clear guidelines for the treatment of coagulopathy in patients with severe burns are lacking, but supportive measures and targeted treatments have been proposed. Supportive measures are aimed at avoiding preventable triggers such as tissue hypoperfusion caused by shock, or hemodilution and hypothermia following the usually aggressive fluid resuscitation in these patients. Suggested targeted treatments that could benefit patients with severe burns include systemic treatment with anticoagulants, but sufficient randomized controlled trial evidence is lacking.

Pyruvate in oral rehydration salt improves hemodynamics, vasopermeability and survival after burns in dogs

BACKGROUND

To investigate whether pyruvate-enriched oral rehydration solution (Pyr-ORS), compared with citrate-enriched ORS (Cit-ORS), improves hemodynamics and organ function by alleviating vasopermeability and plasma volume loss during intra-gastric fluid rehydration in dogs with severe burn.

METHODS

Forty dogs subjected to severe burn were randomly divided into four groups (n=10): two oral rehydrated groups with Pyr-ORS and Cit-ORS (group PR and group CR), respectively, according to the Parkland formula during the first 24h after burns. Other two groups were the intravenous (IV) resuscitation (group VR) with lactated Ringer's solution with the same dosage and no fluid rehydration (group NR). During the next 24h, all groups received the same IV infusion. The hemodynamics, plasma volume, vasopermeability and water contents and function of various organs were determined. Plasma levels of vascular endothelial growth factor (VEGF) and platelet activating factor (PAF) were detected by ELISA.

RESULTS

Hemodynamics parameters were significantly improved in group PR superior to group CR after burns. Levels of VEGF and PAF were significantly lower in group PR than in group CR. Organ function parameters were also greatly preserved in group PR, relative to groups CR and NR. Lactic acidosis was fully corrected and survival increased in group PR (50.0%), compared to group CR (20.0%).

CONCLUSION

Pyr-ORS was more effective than Cit-ORS in improving hemodynamics, visceral blood perfusion and organ function by alleviating vasopermeability-induced visceral edema and plasma volume loss in dogs with severe burn.

The wound/burn guidelines - 6: Guidelines for the management of burns

Burns are a common type of skin injury encountered at all levels of medical facilities from private clinics to core hospitals. Minor burns heal by topical treatment alone, but moderate to severe burns require systemic management, and skin grafting is often necessary also for topical treatment. Inappropriate initial treatment or delay of initial treatment may exert adverse effects on the subsequent treatment and course. Therefore, accurate evaluation of the severity and initiation of appropriate treatment are necessary. The Guidelines for the Management of Burn Injuries were issued in March 2009 from the Japanese Society for Burn Injuries as guidelines concerning burns, but they were focused on the treatment for extensive and severe burns in the acute period. Therefore, we prepared guidelines intended to support the appropriate diagnosis and initial treatment for patients with burns that are commonly encountered including minor as well as moderate and severe cases. Because of this intention of the present guidelines, there is no recommendation of individual surgical procedures.

First resuscitation of critical burn patients: progresses and problems

Currently, the aim of the resuscitation of burn patients is to maintain end-organ perfusion with fluid intake as minimal as possible. To avoid excess intake, we can improve the estimation using computer methods. Parkland and Brooke are the commonly used formulas, and recently, a new, an easy formula is been used, i.e. the 'Rule of TEN'. Fluid resuscitation should be titrated to maintain the urine output of approximately 30-35 mL/h for an average-sized adult. The most commonly used fluids are crystalloid, but the phenomenon of creep flow has renewed interest in albumin. In severely burn patients, monitoring with transpulmonary thermodilution together with lactate, ScvO2 and intraabdominal pressures is a good option. Nurse-driven protocols or computer-based resuscitation algorithms reduce the dependence on clinical decision making and decrease fluid resuscitation intake. High-dose vitamin C, propranolol, the avoidance of excessive use of morphine and mechanical ventilation are other useful resources.

Update in the management of critically ill burned patients

The management of critically ill burn patients is challenging. These patients have to be managed in specialized centers, where the expertise of physicians and nursing personnel guarantees the best treatment. Mortality of burn patients has improved over the past decades due to a better understanding of burn shock pathophysiology, optimal surgical management, infection control and nutritional support. Indeed, a more aggressive resuscitation, early excision and grafting, the judicious use of topical antibiotics, and the provision of an adequate calorie and protein intake are key to attain best survival results. General advances in critical care have also to be implemented, including protective ventilation, glycemic control, selective decontamination of the digestive tract, and implementation of sedation protocols.

Clinical efficacy of nasogastrically administered rhubarb for gastrointestinal dysfunction after burn shock

AIM: To evaluate the therapeutic effects of rhubarb on gastrointestinal dysfunction after burn shock.

METHODS: This was a prospective, randomized, controlled study. Eighty-three patients with gastrointestinal dysfunction after burn shock were randomly divided into either an observation group (42 cases) or a control group (41 cases). The effective rate, duration of gastrointestinal dysfunction, days required for achieving negative occult blood (OB) test, oxygenation index (PaO₂/FiO₂), alanine transaminase (ALT), aspartate aminotransferase (AST), immunoglobulin (Ig) A, IgG, and IgM were compared for the two groups.

RESULTS: The effective rate for the observation group was significantly higher than that for the control group (88.10% vs 48.78%, P < 0.05). The duration of gastrointestinal dysfunction and days required for achieving negative OB test were significantly lower in the observation group than in the control group (1.16 d ± 0.56 d vs 3.48 d ± 0.77 d, 3.894 d ± 0.857 d vs 4.617 d ± 1.112 d, P < 0.05). The levels of PaO₂/FiO₂, serum creatinine (SCr), blood urea nitrogen (BUN), ALT, AST, and IgM for the observation group were better after intervention than before intervention (P < 0.05). The levels of SCr, BUN, and IgM for the control group were better after intervention than before intervention (P < 0.05). The levels of PaO₂/FiO₂, SCr, BUN, ALT, and AST after intervention were better in the observation group than in the control group (P < 0.05).

CONCLUSION: Treatment with rhubarb shortens the duration of gastrointestinal dysfunction and the days required for achieving negative OB test in patients with gastrointestinal dysfunction after burn shock, suggesting that rhubarb can protect the gastric mucosa and enhance gastrointestinal tract motility.

Key Controversies in Colloid and Crystalloid Fluid Utilization

Nearly 2 centuries have passed since the use of intravenous fluid became a foundational component of clinical practice. Despite a steady stream of published investigations on the topic, questions surrounding the choice, dose, timing, targets, and cost-effectiveness of various fluid options remain insufficiently answered. In recent years, 2 of the most debated topics reference the role of albumin in acute care and the safety of normal saline. Although albumin has a place in therapy for specific patient populations, its high cost relative to other fluids makes it a less desirable option for hospitals and health systems with escalating formulary scrutiny. Pharmacists bear responsibility for reconciling this disparity and supporting the rational use of albumin in acute care through a careful evaluation of recently published literature. In parallel, it has become clear that crystalloids should no longer be considered a homogenous class of fluids. The past reliance on normal saline has been questioned due to recent findings of renal dysfunction attributable to the solution's supraphysiologic chloride concentration. These safety concerns with 0.9% sodium chloride may result in a practice shift toward more routine use of "balanced crystalloids," such as lactated Ringer's or Plasma-Lyte, that mimic the composition of extracellular fluid. The purpose of this review is to summarize the evidence regarding these 2 important fluid controversies that are likely to affect hospital pharmacists in the coming decades - the evidence-based use of human albumin and the rising role of balanced salt solutions in clinical practice.

Update on Severe Burn Management for the Intensivist

Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.

Burn wound healing and treatment: review and advancements

Burns are a prevalent and burdensome critical care problem. The priorities of specialized facilities focus on stabilizing the patient, preventing infection, and optimizing functional recovery. Research on burns has generated sustained interest over the past few decades, and several important advancements have resulted in more effective patient stabilization and decreased mortality, especially among young patients and those with burns of intermediate extent. However, for the intensivist, challenges often exist that complicate patient support and stabilization. Furthermore, burn wounds are complex and can present unique difficulties that require late intervention or life-long rehabilitation. In addition to improvements in patient stabilization and care, research in burn wound care has yielded advancements that will continue to improve functional recovery. This article reviews recent advancements in the care of burn patients with a focus on the pathophysiology and treatment of burn wounds.

Modeling Fluid Resuscitation by Formulating Infusion Rate and Urine Output in Severe Thermal Burn Adult Patients: A Retrospective Cohort Study

Acute burn injuries are among the most devastating forms of trauma and lead to significant morbidity and mortality. Appropriate fluid resuscitation after severe burn, specifically during the first 48 hours following injury, is considered as the single most important therapeutic intervention in burn treatment. Although many formulas have been developed to estimate the required fluid amount in severe burn patients, many lines of evidence showed that patients still receive far more fluid than formulas recommend. Overresuscitation, which is known as “fluid creep,” has emerged as one of the most important problems during the initial period of burn care. If fluid titration can be personalized and automated during the resuscitation phase, more efficient burn care and outcome will be anticipated. In the present study, a dynamic urine output based infusion rate prediction model was developed and validated during the initial 48 hours in severe thermal burn adult patients. The experimental results demonstrated that the developed dynamic fluid resuscitation model might significantly reduce the total fluid volume by accurately predicting hourly urine output and has the potential to aid fluid administration in severe burn patients.

Acute and perioperative care of the burn-injured patient

Care of burn-injured patients requires knowledge of the pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Massive airway and/or lung edema can occur rapidly and unpredictably after burn and/or inhalation injury. Hemodynamics in the early phase of severe burn injury is characterized by a reduction in cardiac output and increased systemic and pulmonary vascular resistance. Approximately 2 to 5 days after major burn injury, a hyperdynamic and hypermetabolic state develops. Electrical burns result in morbidity much higher than expected based on burn size alone. Formulae for fluid resuscitation should serve only as guideline; fluids should be titrated to physiologic endpoints. Burn injury is associated basal and procedural pain requiring higher than normal opioid and sedative doses. Operating room concerns for the burn-injured patient include airway abnormalities, impaired lung function, vascular access, deceptively large and rapid blood loss, hypothermia, and altered pharmacology.

Development and validation of an in vitro pharmacokinetic/pharmacodynamic model to test the antibacterial efficacy of antibiotic polymer conjugates

This study describes the use of a novel, two-compartment, static dialysis bag model to study the release, diffusion, and antibacterial activity of a novel, bioresponsive dextrin-colistin polymer conjugate against multidrug resistant (MDR) wild-type Acinetobacter baumannii. In this model, colistin sulfate, at its MIC, produced a rapid and extensive drop in viable bacterial counts (<2 log10 CFU/ml at 4 h); however, a marked recovery was observed thereafter, with regrowth equivalent to that of control by 48 h. In contrast, dextrin-colistin conjugate, at its MIC, suppressed bacterial growth for up to 48 h, with 3 log10 CFU/ml lower bacterial counts after 48 h than those of controls. Doubling the concentration of dextrin-colistin conjugate (to 2× MIC) led to an initial bacterial killing of 3 log10 CFU/ml at 8 h, with a similar regrowth profile to 1× MIC treatment thereafter. The addition of colistin sulfate (1× MIC) to dextrin-colistin conjugate (1× MIC) resulted in undetectable bacterial counts after 4 h, followed by suppressed bacterial growth (3.5 log10 CFU/ml lower than that of control at 48 h). Incubation of dextrin-colistin conjugates with infected wound exudate from a series of burn patients (n = 6) revealed an increasing concentration of unmasked colistin in the outer compartment (OC) over time (up to 86.3% of the initial dose at 48 h), confirming that colistin would be liberated from the conjugate by endogenous α-amylase within the wound environment. These studies confirm the utility of this model system to simulate the pharmacokinetics of colistin formation in humans administered dextrin-colistin conjugates and further supports the development of antibiotic polymer conjugates in the treatment of MDR infections.

The evaluation and management of thermal injuries: 2014 update

Burns are among the most common injuries presenting to the emergency department. While burns, especially large ones, may be associated with significant morbidity and mortality, most are minor and can be managed by emergency practitioners and discharged home with close follow-up. In contrast, patients with large burns require aggressive management of their airway, breathing and circulation in order to reduce mortality and morbidity. While early endotracheal intubation of patients with actual or impending airway compromise and aggressive fluid resuscitation have been emphasized, it appears that the pendulum may have swung a bit too far towards the extreme. The current review will briefly cover the epidemiology, pathogenesis and diagnosis of burn injuries with greater emphasis on airway and fluid management. We will also discuss the local management of the burn wound, which is all that is required for most burn patients in the emergency department.