The determination of total burn surface area: How much difference?

Burn related globe and adnexal trauma at trauma centres

INTRODUCTION

Prompt management of burn-related globe trauma can prevent long term complications. Delays in diagnosis may occur when globe trauma is associated with life-threatening injuries. We aimed to improve the understanding of the epidemiology, acute assessment and management of burns-related globe and adnexal trauma admitted to two trauma centres in Sydney, Australia.

METHOD

Admitted patients with burns-related globe and/or adnexal trauma were retrospectively reviewed at Royal North Shore Hospital (RNSH) and Royal Prince Alfred Hospital (RPAH) between January 2015 and December 2019. The International Classification of Disease, Tenth Revision codes was used to search and identify patients. Medical records were reviewed to extract data on demographics, injuries, ocular examination and ophthalmology involvement.

RESULTS

Over the 5-years, 101 patients with globe and/or adnexal burns-related trauma were admitted to RNSH or RPAH. Median age was 37years. Most patients were male (76%) and were injured while at home or work (74%). Patients with chemical exposure were more likely to have globe trauma (100% vs 72%, p < 0.001) and severe globe trauma (54% vs 32%, p = 0.028). On initial review by emergency staff, 14 patients were not referred to ophthalmology, of these there were 2 patients where the diagnosis was delayed.

CONCLUSION

Globe trauma is common in patients with chemical exposure. Thorough ocular assessment within the acute setting is vital to diagnose globe trauma. We investigated hospitals with specialised burn staff, further research is required to understand the management of globe trauma in hospitals without such resources.

SYNOPSIS

Chemicals in household-products can cause severe globe trauma. Globe trauma can occur alongside large burns leading to delay in its diagnosis and management. Ophthalmology can assist in the early diagnosis and management of globe trauma.

Accreditation of the handheld 3-dimensional scanner and conventional photo images for area measurement

Accurate assessment of wound areas is crucial in making therapeutic decisions, as the prognosis and changes in the size of the wound over time play a significant role. An ideal assessment method should possess qualities such as speed, affordability, accuracy, user-friendliness for both patients and healthcare professionals, and suitability for daily clinical practice. This study aims to introduce a handheld 3-dimensional (3D) scanner and evaluate its accuracy in measuring wound areas. Engineers from the Industrial Technology Research Institute in Taiwan developed a handheld 3D scanner with the intention of extending its application to the medical field. A project was conducted to validate the accuracy of this 3D scanner. We utilized a smartphone (Asus ZenFone 2 with a 13-million-pixel rear camera), a digital single-lens reflex digital camera (Nikon, D5000, Tokyo, Japan), and the 3D scanner to repeatedly measure square papers of known size that were affixed to the curved surface of life-size facial mask or medical teaching breast models. The "Image J" software was employed for 2-dimensional image measurements, while the "3D Edit" software was used to assess the "area of interest" on 3D objects. By using square papers with predetermined dimensions, the measurement-associated error rate (ER) could be calculated for each image. Three repeated measurements were performed using the "Image J" software for each square paper. The ERs of the 3D scan images were all below 3%, with an average ER of 1.64% in this study. The close-up mode of the smartphone exhibited the highest ER. It was observed that as the area increased, the ER also increased in the digital single-lens reflex camera group. The extension distortion effect caused by the wide-angle lens on the smartphone may increase the ER. However, the definition of a healthy skin edge may vary, and different algorithms for calculating the measurement area are employed in various 3D measurement software. Therefore, further validation of their accuracy for medical purposes is necessary. Effective communication with software engineers and discussions on meeting clinical requirements are crucial steps in enhancing the functionality of the 3D scanner.

An Introduction to Burn Care: The Sequel

GENERAL PURPOSE

To review burn care, with an emphasis on burn-specific issues and treatment.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Select the appropriate treatment guidelines for patients who have burn injuries.2. Identify common complications of major burns.3. Choose the recommended pharmacologic approaches to burn care.

Evaluation and Optimization of the Wallace Rule of Nines for the Estimation of Total Body Surface Area in Obese and Nonobese Populations

BACKGROUND

Currently, the Wallace Rule of Nines is the most widely used method to measure total body surface area (TBSA) in burned patients due to its practicality and speed in its application; however, it often provides inaccurate estimations in obese patients, affecting the fluid resuscitation process.

OBJECTIVE

In this study, we aimed to modify and optimize the Rule of Nines' values for its application in these patients.

METHODS

We compared the estimations of the TBSA established by the Wallace Rule of Nines against the measurements of the three-dimensional (3D) software Skanect - Meshmixer 3.5Ⓡ in participants without different obesity grades. Based on our results, we generate an optimized guideline for the evaluation of TBSA in normal body mass index (BMI) and obese patients.

RESULTS

In our study, 32 participants were recruited with a mean age of 28.5 ± 3.3 years. In the general population, we observed a poor correlation between the Wallace Rule of Nines and the 3D method measures in all body regions (e.g., Anterior Trunk: 18.0 vs. 16.61 ± 2.11, p = 0.0008) except the anterior arm. Interestingly, these differences narrowed in the Trunk and Leg regions as the participants' BMI increased (e.g., Anterior Trunk in Obesity Grade II patients: 18.0 vs. 18.66 ± 1.69, p = 0.3089).

CONCLUSIONS

We found important differences in TBSA determination using the 3D Skanect-MeshmixerⓇ software compared with the Wallace Rule of Nines. Therefore, we generated a modified and optimized Wallace Rule of Nines estimations based on BMI. Future studies are needed to assess the safety and efficacy of this optimized table.

Use of Isokinetic Dynamometry To Assess Muscle Function In Burned Patients Is A Reliable Tool To Assist Progressive Resistance Exercise Prescription

Isokinetic dynamometry is used during exercise testing and rehabilitation to obtain a quantitative strength measurement on which progressive strength training programs can be based. This study assesses the test-retest reliability of isokinetic leg function in the knee flexors and extensors at 150°/s in children and young adults with severe burns to be used for rehabilitation exercise program prescription. In 39 severely burned patients (49 ± 14% total body surface area burn [TBSA], mean ± SD; 34 ± 21% TBSA 3rd degree; 14 ± 5 years, 153.3 ± 16.5 cm height; 53.8 ± 17.9 kg) knee flexion/extension isokinetic dynamometry at 150°/s was performed on each patient's dominant leg in two sessions. The patient was acquainted with the test and performed 1 set of 10 repetitions at 150°/s. A second session of 1 set of 10 repetitions at 150°/ was performed within 24 h of the first. Muscle function outcomes were knee flexion/extension peak torque, average peak torque, and average power. One-sample paired t tests were performed for all muscle function outcomes; intraclass correlation coefficients and r2 values with session two as a function of session one were calculated. Sessions did not differ significantly in knee extension or flexion for any muscle function outcome or the hamstrings to quadriceps ratio. All intraclass correlation coefficients were >0.89 and r2 > 0.79. Test-retest isokinetic dynamometry functional measurements in the knee flexors and extensors at 150°/s are reliable in the burn population and may aid resistance rehabilitation program prescriptions.

Agreement of clinical assessment of burn size and burn depth between referring hospitals and burn centres: A systematic review

BACKGROUND

The quality of burn care is highly dependent on the initial assessment and care. The aim of this systematic review was to investigate the agreement of clinical assessment of burn depth and %TBSA between the referring units and the receiving burn centres.

METHODS

Included articles had to meet criteria defined in a PICO (patients, interventions, comparisons, outcomes). Relevant databases were searched using a predetermined search string (November 6th 2021). Data were extracted in a standardised fashion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for test accuracy was used to assess the certainty of evidence. The QUADAS-2 tool was used to assess the risk of bias of individual studies as 'high', 'low' or 'unclear'.

RESULTS

A total of 412 abstracts were retrieved and of these 28 studies with a total of 6461 patients were included, all reporting %TBSA and one burn depth. All studies were cross-sectional and most of them comprising retrospectively enrolled consecutive cohort. All studies showed a low agreement between %TBSA calculations made at referring units and at burn centres. Most studies directly comparing estimations of %TBSA at referring institutions and burn centers showed a proportion of overestimations of 50% or higher. The study of burn depth showed that 55% were equal to the estimates from the burn centre. Most studies had severe study limitations and the risk of imprecision was high. The overall certainty of evidence for accuracy of clinical estimations in referring centres is low (GRADE ⊕⊕ОО) for %TBSA and very low (GRADE ⊕ООО) for burn depth and resuscitation.

CONCLUSION

Overestimation of %TBSA at referring hospitals occurs very frequently. The overall certainty of evidence for accuracy of clinical estimations in referring centres is low for burn size and very low for burn depth. The findings suggest that the burn community has a significant challenge in educating and communicating better with our colleagues at referring institutions and that high-quality studies are needed.

Mid-Term Follow-Up Study of Children Undergoing Autologous Skin Transplantation for Burns

Deep partial and full-thickness burns require surgical treatment with autologous skin grafts after necrectomy, which is the generally accepted way to achieve permanent wound coverage. This study sought to examine the grafted and donor areas of children who underwent autologous skin transplantation, using two assessment scales to determine the severity of the scarring and the cosmetic outcome during long-term follow-up. At the Surgical Unit of the Department of Paediatrics of the University of Pécs, between 1 January 2015 and 31 December 2019, children who had been admitted consecutively and received autologous skin transplantation were analyzed. Twenty patients met the inclusion criteria in this retrospective cohort study. The authors assessed the results using the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale (VSS). There was a significant difference in how parents and examiners perceived the children’s scars. In the evaluation of the observer scale, the most critical variables for the area of skin grafted were relief and thickness. Besides color, relief was the worst clinical characteristic on the patient scale. However, when medical professionals evaluated the donor site, significantly better results were obtained compared to the transplanted area (average observer scale score: 1.4 and 2.35, p = 0.001; VSS: 0.85 vs. 2.60, p < 0.001), yet it was similar to the graft site in the parents’ opinion (Patient Scale: 2.95 and 4.45, p = 0.181).

Pediatric First-Degree Burn Management With Honey and 1% Silver Sulfadiazine (Ag-SD): Comparison and Contrast

Background The cardinal area of managing fire wounds is guided by adequately evaluating the burn-induced lesion's profundity and size. Superficial second-degree burns are often treated through daily reinstating with fresh sterile bandaging with appropriate topical antimicrobials to allow rapid spontaneous epithelialization. Around the world, a wide variety of substances are used to treat these wounds, from honey to synthetic biological dressings. Objective This study intended to determine honey's therapeutic potential compared with 1% silver sulfadiazine (Ag-SD) in arsenal-caused contusion medicament fulfillment. Methods A total of 70 cases were evaluated in this research work after fulfilling the required selection criteria during the study period of January 2014 to December 2014 and January 2017 to December 2017. Purposive selection criteria were adopted in the study to select research patients. The patients in Group-1 (n = 35) relied on honey as medication, while patients in Group-2 (n = 35) relied on 1% Ag-SD. Results In Group-1, exudation (68.4%) and sloughing (82.9%) were substantially reduced by Days 3 and 5 of therapeutic intervention, respectively. However, in Group-2, a reduction of exudation (17.1%) and sloughing (22.9%) occurred after Days 3 and 5 of treatment, respectively. Completion of the epithelialization process was observed among Group-1 and Group-2 cases. It was detected after Days 7 and 10 of treatment at 36.3% and 77% (Group-1) and 27% and 67% (Group-2), respectively. Around 3 ml of 1% honey was required per body surface area per dressing in Group-1. On the other hand, in Group-2, 2 gm Ag-SD was needed per body surface area per dressing. Conclusion Patients treated with honey found better clinical outcomes in managing superficial partial-thickness burns.

Deep Learning-Assisted Burn Wound Diagnosis: Diagnostic Model Development Study

BACKGROUND

Accurate assessment of the percentage total body surface area (%TBSA) of burn wounds is crucial in the management of burn patients. The resuscitation fluid and nutritional needs of burn patients, their need for intensive unit care, and probability of mortality are all directly related to %TBSA. It is difficult to estimate a burn area of irregular shape by inspection. Many articles have reported discrepancies in estimating %TBSA by different doctors.

OBJECTIVE

We propose a method, based on deep learning, for burn wound detection, segmentation, and calculation of %TBSA on a pixel-to-pixel basis.

METHODS

A 2-step procedure was used to convert burn wound diagnosis into %TBSA. In the first step, images of burn wounds were collected from medical records and labeled by burn surgeons, and the data set was then input into 2 deep learning architectures, U-Net and Mask R-CNN, each configured with 2 different backbones, to segment the burn wounds. In the second step, we collected and labeled images of hands to create another data set, which was also input into U-Net and Mask R-CNN to segment the hands. The %TBSA of burn wounds was then calculated by comparing the pixels of mask areas on images of the burn wound and hand of the same patient according to the rule of hand, which states that one's hand accounts for 0.8% of TBSA.

RESULTS

A total of 2591 images of burn wounds were collected and labeled to form the burn wound data set. The data set was randomly split into training, validation, and testing sets in a ratio of 8:1:1. Four hundred images of volar hands were collected and labeled to form the hand data set, which was also split into 3 sets using the same method. For the images of burn wounds, Mask R-CNN with ResNet101 had the best segmentation result with a Dice coefficient (DC) of 0.9496, while U-Net with ResNet101 had a DC of 0.8545. For the hand images, U-Net and Mask R-CNN had similar performance with DC values of 0.9920 and 0.9910, respectively. Lastly, we conducted a test diagnosis in a burn patient. Mask R-CNN with ResNet101 had on average less deviation (0.115% TBSA) from the ground truth than burn surgeons.

CONCLUSIONS

This is one of the first studies to diagnose all depths of burn wounds and convert the segmentation results into %TBSA using different deep learning models. We aimed to assist medical staff in estimating burn size more accurately, thereby helping to provide precise care to burn victims.

Prise en charge des brûlures en préhospitalier et aux urgences

Une brûlure est une lésion de la peau ou d’un autre tissu organique principalement causée par la chaleur ou les rayonnements, la radioactivité, l’électricité, la friction ou le contact avec des produits chimiques. Les plus fréquentes, les brûlures thermiques (dues à la chaleur), surviennent lorsque certaines cellules ou toutes les cellules de la peau ou d’autres tissus sont détruites par des liquides bouillants, des solides chauds (brûlures de contact), ou des flammes. En France, l’incidence des brûlures prises en charge à l’hôpital est environ de 13 pour 100 000 habitants. La prise en charge en urgence du brûlé grave par lésion thermique est bien décrite, une recommandation de pratique professionnelle a été publiée en 2019 par la Société française d’anesthésie et de réanimation, en association avec la Société francophone de brûlologie, la Société française de médecine d’urgence et l’Association des anesthésistes-réanimateurs pédiatriques d’expression française. Pourtant, l’urgentiste va être confronté à de nombreuses brûlures de gravité et de nature différentes. Nous faisons ici une mise au point sur les données connues en termes d’épidémiologie, de manifestations cliniques et des différentes thérapeutiques qui peuvent être proposées dans la prise en charge des brûlures. Nous faisons aussi le point sur les localisations à risque particulier que l’urgentiste doit connaître, ainsi que sur les intoxications qui peuvent être associées aux brûlures. Nous détaillons aussi certains contaminants qui sont à connaître.

A 1%TBSA chart reduces math errors while retaining acceptable first-estimate accuracy

Life-threatening and treatment-altering errors occur in estimates of the percentage of total body surface area burned (%TBSA burned) with unacceptable frequency. In response, numerous attempts have been made to improve the charts commonly used for %TBSA-burned estimation. Recent research shows that the largest errors in %TBSA-burned estimates probably come from sources other than inaccurate values in the charts. Here, we develop a taxonomy of the possible sources of error and their impact on %TBSA-burned estimates. Also, we observe that different caregivers have different estimation needs: First-responders require a rapid estimate with sufficient accuracy to enable them to begin care and determine patient transport options, while burn surgeons ordering skin grafts desire accuracy to the square centimeter, and can afford considerable time to attain that accuracy. These competing needs suggest that a one-tool-fits-all-caregivers approach is suboptimal. We therefore present a validated, simplified burn chart that minimizes one of the largest sources of random errors in %TBSA-burned estimates—simple calculation errors—while also being quick and requiring little training. NCHart-1 also enables simple consensus estimates, as well as separation of estimation subtasks across caregivers, leading to several potential improvements in mass casualty situations. Our results demonstrate that NCHart-1 possesses the accuracy necessary for first responders, while reliably producing results in less than 2 minutes. Of 76 healthcare professionals surveyed, a large majority indicated a preference for NCHart-1 over their previous methods for ease of both use and training. For clinical or commercial use of NCHart-1, please contact: tech.commercialization@nationwidechildrens.org

Clinical significance of serum matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 in the first phase of burn trauma evolution

No prospective study has specifically examined the serum levels of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) in the early shock phase of burn-injured patients. Thus, we aimed to detect early changes, activity dynamics, and the predictive value of MMP-9, TIMP-1, and the MMP-9/TIMP-1 ratio to better understand the early repair mechanisms for the development of future therapies for patients with thermal burns. Twenty-five patients with a total body surface area (TBSA) affected by burn <25%, and 30 healthy subjects were enrolled in the study. Serum levels of MMP-9 and TIMP-1 were determined by the ELISA method. Our results showed that MMP-9 concentrations increased immediately after injury and remained on a plateau. In contrast, TIMP-1 showed an upward trend throughout the 7-day study period, and the time course of the MMP-9/TIMP-1 ratio followed the inverse dynamics of TIMP-1. Analysis of the areas under the receiver operating characteristic (ROC) curves (AUC) showed that patients with burn wounds tended to have a MMP-9 value higher than 421.5 ng/ml (AUC=0.979), TIMP-1 value higher than 231.6 ng/ml (AUC=0.908), and MMP-9/TIMP-1 ratio higher than 2.31 (AUC=0.959) (P<0.001). Our findings suggest that although the variations in the two biomarkers were different regarding the time of the initial insult, their ratio is a specific and sensitive indicator of burn evolutivity in patients with a TBSA affected by a burn <25%.

Evaluating Discrepancies in Percent Total Body Surface Area Burn Assessments Between Prehospital Providers and Burn Center Physicians

Burns are routinely assessed at the scene of the incident by prehospital or emergency medical services providers. The initial management of burns is based on the calculation of the extent of the injury, reported as percent total body surface area. This study evaluates discrepancies in estimation of total body surface area (TBSA) between prehospital providers and burn team physicians over a 3-year period at an academic, university medical center serving as the regional burn center. A total of 120 adult and 27 pediatric patients (less than age 16 years) were included, with 95 (65%) male, 67 (45.6%) Caucasian, 62, median age 35 years (Interquartile Range 27). The most common etiology of burns was hot liquid, 39 (26.5%). Median [IQR] and mean (SD) estimated TBSA (%) were 4[1, 10] and 8.6 (12.8) for prehospital providers, and 2 [1, 6] and 5.9 (9.9) for burn team physicians. Bland-Altman plots evaluating 2nd and 3rd degree burns separately and combined demonstrated that, as burns involved more surface area, agreement decreased between emergency medical service providers and burn physicians. Agreement between pre-hospital providers and burn physicians decreased as total body surface areas of burns increased. This finding reaffirms the need for more standardized education and training for all medical personnel.

A systematic review of machine learning and automation in burn wound evaluation: A promising but developing frontier

BACKGROUND

Visual evaluation is the most common method of evaluating burn wounds. Its subjective nature can lead to inaccurate diagnoses and inappropriate burn center referrals. Machine learning may provide an objective solution. The objective of this study is to summarize the literature on ML in burn wound evaluation.

METHODS

A systematic review of articles published between January 2000 and January 2021 was performed using PubMed and MEDLINE (OVID). Articles reporting on ML or automation to evaluate burn wounds were included. Keywords included burns, machine/deep learning, artificial intelligence, burn classification technology, and mobile applications. Data were extracted on study design, method of data acquisition, machine learning techniques, and machine learning accuracy.

RESULTS

Thirty articles were included. Nine studies used machine learning and automation to estimate percent total body surface area (%TBSA) burned, 4 calculated fluid estimations, 19 estimated burn depth, 5 estimated need for surgery, and 2 evaluated scarring. Models calculating %TBSA burned demonstrated accuracies comparable to or better than paper methods. Burn depth classification models achieved accuracies of >83%.

CONCLUSION

Machine learning provides an objective adjunct that may improve diagnostic accuracy in evaluating burn wound severity. Existing models remain in the early stages with future studies needed to assess their clinical feasibility.

Predictive Modeling for Personalized Three-Dimensional Burn Injury Assessments

For patients with major burn injuries, an accurate burn size estimation is essential to plan appropriate treatment and minimize medical and surgical complications. However, current clinical methods for burn size estimation lack accuracy and reliability. To overcome these limitations, this paper proposes a 3D-based approach-with personalized 3D models from a limited set of anthropometric measurements-to accurately assess the percent TBSA affected by burns. First, a reliability and feasibility study of the anthropometric measuring process was performed to identify clinically relevant measurements. Second, a large representative stratified random sample was generated to output several anthropometric features required for predictive modeling. Machine-learning algorithms assessed the importance and the subsets of anthropometric measurements for predicting the BSA according to specific patient morphological features. Then, the accuracy of both the morphology and BSA of 3D models built from a limited set of measurements was evaluated using error metrics and maximum distances 3D color maps. Results highlighted the height and circumferences of the bust, neck, hips, and waist as the best predictors for BSA. 3D models built from three to four anthropometric measurements showed good accuracy and were geometrically close to gold standard 3D scans. Outcomes of this study aim to decrease medical and surgical complications by decreasing errors in percent TBSA assessments and, therefore, improving patient outcomes by personalizing care.

Technical and Medical Aspects of Burn Size Assessment and Documentation

In burn medicine, the percentage of the burned body surface area (TBSA-B) to the total body surface area (TBSA) is a crucial parameter to ensure adequate treatment and therapy. Inaccurate estimations of the burn extent can lead to wrong medical decisions resulting in considerable consequences for patients. These include, for instance, over-resuscitation, complications due to fluid aggregation from burn edema, or non-optimal distribution of patients. Due to the frequent inaccurate TBSA-B estimation in practice, objective methods allowing for precise assessments are required. Over time, various methods have been established whose development has been influenced by contemporary technical standards. This article provides an overview of the history of burn size estimation and describes existing methods with a critical view of their benefits and limitations. Traditional methods that are still of great practical relevance were developed from the middle of the 20th century. These include the "Lund Browder Chart", the "Rule of Nines", and the "Rule of Palms". These methods have in common that they assume specific values for different body parts' surface as a proportion of the TBSA. Due to the missing consideration of differences regarding sex, age, weight, height, and body shape, these methods have practical limitations. Due to intensive medical research, it has been possible to develop three-dimensional computer-based systems that consider patients' body characteristics and allow a very realistic burn size assessment. To ensure high-quality burn treatment, comprehensive documentation of the treatment process, and wound healing is essential. Although traditional paper-based documentation is still used in practice, it no longer meets modern requirements. Instead, adequate documentation is ensured by electronic documentation systems. An illustrative software already being used worldwide is "BurnCase 3D". It allows for an accurate burn size assessment and a complete medical documentation.

Does the estimation of burn extent at admission differ from the assessment at discharge?

INTRODUCTION

Estimation of total body surface area (TBSA) burnt and burn depth are among the most central parts of acute burn assessment/treatment as they determine the level and type of care needed. Traditional methods for determining burn extent on admission often lead to inaccurate estimations, especially in paediatric or overweight patients.

AIM

To compare %TBSA at admission with validated %TBSA at discharge in different patient populations to investigate if significant over- or underestimation occurs.

METHOD

This retrospective observational study is based on a patient registry of all the patients (n = 863) treated at the Uppsala University Hospital's Burn Centre between 2010 and 2018. The patients were divided into subgroups based on age, gender, body mass index (BMI) and validated burn extent. The %TBSA estimated at admission was compared to the validated %TBSA in all groups separately.

RESULTS

As has been published before, we also found that the %TBSA in paediatric patients was more often overestimated as were the smaller injuries, whereas larger injuries were often underestimated. BMI did not clearly affect the estimations and there was no clear difference between the genders in estimated %TBSA.

CONCLUSION

Inaccurate estimations of %TBSA are common, particularly for paediatric patients and small or large injuries. We recommend a careful accurate approach when calculating %TBSA in the paediatric population to avoid over- and under-resuscitation. Increased education and training are recommended to improve accurate estimation in the future.

LAY SUMMARY

The correct estimation of both extent and depth of burn is very important. This assessment guides the lever of care needed, the necessary amount of fluid resuscitation, the predicted outcome and more. It has been proven notably difficult to correct assess, especially the extent of a burn. Despite different tools as the "Rule of Nine" (body area divided into multiples of 9% body surfaces), the "Rule of Palm" (Patient's palm, fingers included, approximates 1% of body surfaces), the Lund & Browder chart (detailed, age-specific body areas) and different more technical solutions. Often inaccurate estimations are done which thus affect the treatment. This depth and extent estimation is usually performed when the patient is admitted. However, it is known that burns change appearance during the first few days of care. In our Burn Center we have also performed this estimation when the patient is discharged. At this point it is known the true extent and depth of the initial burn. In this retrospective observational study, we compared the burn extent estimated on admission with the one on discharge to investigate whether the initial assessment is accurate. This study highlights the issue of frequent inaccurate burn extent estimations, especially in subgroups as overweight patient or pediatric patients.

The initial validation of a novel outcome measure in severe burns- the Persistent Organ Dysfunction +Death: Results from a multicenter evaluation

INTRODUCTION

A need exists to improve the efficiency of clinical trials in burn care. The objective of this study was to validate "Persistent Organ Dysfunction" plus death as endpoint in burn patients and to demonstrate its statistical efficiency.

METHODS

This secondary outcome analysis of a dataset from a prospective international multicenter RCT (RE-ENERGIZE) included patients with burned total body surface area >20% and a 6-month follow-up. Persistent organ dysfunction was defined as persistence of organ dysfunction with life-supportiing technologies and ICU care.

RESULTS

In the 539 included patients, the prevalence of 0p p+ pdeath was 40% at day 14 and of 27% at day 28. At both timepoints, survivors with POD (vs. survivors without POD) had a higher mortality rate, longer ICU- and hospital-stays, and a reduced quality of life. POD + death as an endpoint could result in reduced sample size requirements for clinical trials. Detecting a 25% relative risk reduction in 28-day mortality would require a sample size of 4492 patients, whereas 1236 patients would be required were 28-day POD + death used.

CONCLUSIONS

POD + death represents a promising composite outcome measure that may reduce the sample size requirements of clinical trials in severe burns patients. Further validation in larger clinical trials is warranted.

STUDY TYPE

Prospective cohort study, level of evidence: II.

Convolution neural network for effective burn region segmentation of color images

BACKGROUND

Burn injuries are one of the most severe forms of wounds and trauma across the globe. Automated burn diagnosis methods are needed to provide timely treatment to the concerned patients. Artificial intelligence is playing a vital role in developing automated tools and techniques for medical problems. However, the use of advanced AI techniques for color images based burn region segmentation is not much explored.

METHOD

In this work, we explore the use of deep learning for the challenging problem of burn region segmentation. We prepared a pixel-wise labelled new burn images dataset for segmentation and investigated the efficacy of existing state-of-the-art color images based semantic image segmentation techniques. Lately, we proposed a new convolution neural network (CNN) that uses atrous convolution for encoding rich contextual information and utilizes pre-trained model ResNet-101 for better extraction of low-level and middle-level layer features.

RESULTS

The proposed approach achieves the state-of-the-art performance on the prepared burn image dataset with 77.6% of Mathews correlation coefficient (MCC) and 93.4% of accuracy. The improvement of 11.6/5.8/6.9/1.2% is observed in precision, Dice similarity coefficient, Jaccard index and specificity, in comparison to the second best performance.

CONCLUSION

In this work, we propose a CNN based novel method for performing burn-region segmentation in color images and evaluate it using newly prepared Burn Images dataset. The experimental results illustrate its effectiveness in comparison to existing approaches. Further, the proposed pixel-level segmentation method could be useful in estimating the burn surface area and burn severity in an accurate and time efficient manner.

Estimates of Total Burned Surface Area by Emergency Department Clinicians and Burn Specialists

Introduction

Correctly assessing burn size is extremely important since it is directly associated with a patient’s subsequent management. Further, an accurate assessment of the total body surface area (TBSA) involved is crucial to decide if specialty care in a burn unit is necessary, whereby overestimation has the potential to lead to unnecessary patient transfers and undesirable burdens on the healthcare system and inconvenience to patients. The goal of this study was to identify whether burn injury estimates of TBSA percentage correlate between emergency department (ED) clinician and burn specialists.

Methods

This was a retrospective study conducted between February 1, 2018 and July 31, 2019 of patients with a burn injury who were evaluated by both an ED clinician and a burn specialist during the same ED visit. Charts were reviewed to identify the documentation of TBSA by pre-hospital personnel, ED nursing staff, ED mid-level providers (MLP), ED attending physicians, burn consultant MLPs, and burn consultant attending physicians.

Results

During the study period, 189 subjects with both an ED and burn consultant. The median age was 11 years [interquartile range (IQR) 1-49], and 103 (54%) were males. More than half of the subjects (n=106, 56%) were under the age of 18. There was a statistically significant correlation between estimates of TBSA between ED and burn consultants overall (p<0.0001). Furthermore, there was a statistically significant correlation between ED and burn MLPs (p<0.0001) as well as ED and burn attending physicians (p<0.0001). When adjusted for MLP and attending sex, there was still a correlation among all groups (p<0.0001).

Conclusions

In this study, there was a statistically significant correlation between estimates of TBSA between ED and burn consultants

Early clinical management of severe burn patients using telemedicine: a pilot study protocol

Background

Emergency physicians are responsible for assessing the severity of a patient's burns, which determines whether the patient needs to be transferred to a burn center. Such a proper assessment represents a daunting task because severe burn injuries are rare. Inaccurate estimates often result in unjustified and costly transfers and unneeded fluid resuscitation and assisted ventilation procedures. Telemedicine offers a solution to these challenges. The present pilot study aims to investigate the feasibility, acceptability, and potential value of a large telemedicine initiative at the University of Montreal Health Center's burn center and its network of referring hospitals.

Methods

A three-stage study protocol is proposed to achieve this objective. First, a proof of concept phase will assess the technical feasibility of telemedicine at one referring hospital with a high volume of patient transfers. Second, the organizational and human feasibility of the project will be evaluated in four referring medical centers. All teleconsultation sessions will be analyzed using the WHO's telemedicine implementation model. The third phase will consist of evaluating the potential impacts of telemedicine in a subset of 10 referring hospitals. The quality of communications between referring physicians and specialists will be assessed using semi-structured interviews. A pre-test/post-test with a comparison group design will be used to assess the effects of telemedicine on patient transfers, ventilation procedures, patient complications, mortality, length of ICU stay, and additional surgical procedures. The economic viability of telemedicine will be assessed using a cost-minimization approach.

Discussion

The telemedicine initiative is expected to yield positive and significant outcomes that are relevant to a wide range of medical centers that already use or are considering using a similar technology. The contribution of this pilot study lies in its ability to reveal technological, organizational, and human barriers and provide a preliminary assessment of the clinical and economic value of a large-scale telemedicine initiative in the context of burn medicine.

Changing the Way We Think About Burn Size Estimation

Burn size estimation is a crucial component of acute burn management that guides referral to burn centers, fluid resuscitation parameters, hospital resource distribution, and mortality-based interventions. Referring providers often misestimate the total BSA (TBSA) of burn injury, which contributes to unnecessary healthcare costs, misappropriation of limited resources, and delay in provision of appropriate patient care. A systematic literature review of articles available on PubMed, Scopus, Google Scholar, OvidSP Medline, and Web of Science was performed. All articles were evaluated in a standardized fashion by a panel of reviewers to assess applicability to the research question. Twenty-six relevant articles identified pervasive TBSA miscalculations ranging from 5% to 339% regardless of provider level with < 20% TBSA burns being disproportionately overestimated. This resulted in up to 77% of burns being inappropriately transferred to burn centers from referring hospitals. Improper use of TBSA estimation tools (palm, hand, Rule of 9s) without considering patient body mass index, race, age, and sex standards contributes to TBSA misestimation. Few studies with limited sample sizes argue that TBSA misestimations significantly affect fluid resuscitation volume, although the findings suggest that small burns (<20% TBSA) are over-estimated and over-resuscitated-the opposite of larger burns. TBSA misestimation is associated with an increased incidence of inappropriate transfers to burn centers and the associated costs. The data remains lacking, however, and larger studies are required to further elucidate the clinical impact of such errors. A systematic approach with telemedicine-facilitated computer-based burn assessments is required.

A Critical Update of the Assessment and Acute Management of Patients with Severe Burns

Significance: Burns are debilitating, life threatening, and difficult to assess and manage. Recent advances in assessment and management have occurred since a comprehensive review of the care of patients with severe burns was last published, which may influence research and clinical practice. Recent Advances: Recent advances have occurred in the understanding of burn pathophysiology, which has led to the identification of potential biomarkers of burn severity, such as protein C. There is new evidence about the potential superiority of natural colloids over crystalloids during fluid resuscitation, and new evidence about components of initial and perioperative management, including an improved understanding of pain following burns. Critical Issues: The limitations of the clinical examination highlight the need for imaging and biomarkers to assist in estimations of burn severity. Fluid resuscitation reduces mortality, although there is conjecture over the ideal method. The subsequent perioperative period is associated with significant morbidity and the evidence for preventing and treating pain, infection, and fluid overload while maximizing wound healing potential is described. Future Directions: Promising developments are ongoing in imaging technology, histopathology, biomarkers, and wound healing adjuncts such as hyperbaric oxygen therapy, topical negative pressure therapy, stem cell treatments, and skin substitutes. The greatest benefit from further research on management of patients with burns would most likely be derived from the elucidation of optimal fluid resuscitation protocols, pain management protocols, and surgical techniques from randomized controlled trials.

Lund and Browder chart-modified versus original: a comparative study

Background

The Lund and Browder (LB) chart is currently the most accurate and widely used chart to calculate total body surface area affected by a burn injury. However, it is not easy to use charts to calculate burn percentages because of the difficulty in performing mathematical calculations with the percentages attributed to various body regions that are only partially burned. It is also cumbersome to have to perform mental calculations, especially in emergency situations.

Methods

We compared results from the LB chart with a modified Lund and Browder (MLB) chart using 10 assessors on five different burn wounds each drawn on both charts.

Results

Variability of results was significantly reduced using the MLB chart compared to the LB chart.

Conclusions

Assessments performed using the MLB chart are less variable than those using the LB chart. Using this chart will help burn care providers rapidly, accurately, and reliably estimate burn extent.

Changes in total body surface area and the distribution of skin surfaces in relation to body mass index

BACKGROUND

A correct estimation of total burn surface area is important since it is used for determining fluid resuscitation volumes, nutritional estimates and hospital admission criteria. Wallace's rule of nines is the most commonly used methods for this purpose. However, fat distribution is non-uniform and the total body surface area changes with obesity. The aim of this study was to determine if the rule of nines applies to all body mass index groups.

METHODS

A total of 217 individuals were included in the study. The patients were divided into 4 groups according to their BMI (18.5-25kg/m² (60 persons)), 25-29.9kg/m² (61 individuals)), 30-34.9kg/m² (55 persons)), >35kg/m² (41 persons)). Each patient underwent a complete duel-energy X-ray absorptiometry body scan to determine the surface area (cm²) of the various regions of the body.

RESULTS

We found no statistically significant variations between the Wallace body percentage distributions and our results in the men for all BMI ranges (head p=0.331, arms p=0.861, legs p=0.282, trunk p=0.696). In contrast, among women we found a statistically significant change in body surface area percentage distribution between the BMI groups and specific body regions (head p=0.000, legs p=0.000 and trunk p=0.001).

CONCLUSION

The Wallace rule of nines is a quick and acceptable method for estimating the total burn surface area percentage in men of all BMI ranges. However, for women, a more accurate method of burn area estimation is required as proposed by our BMI adjusted charts.

Mobilization practices for patients with burn injury in critical care

PURPOSE

Patients with burn usually undergo prolonged hospitalization due partially to the treatment of wounds and scars. Although the benefits of early mobilization are well-known in critical care patients, there are a lack of studies reporting mobilization practices and functional status for patients with burn.

MATERIALS

Clinical and physiotherapy data were daily collected, including ICU mobility scale (IMS) and reported barriers to mobilization therapy during a one-year period. At hospital discharge, the 6-min walking test (6MWT), Medical Research Council scale (MRCS) and handgrip strength test were applied to evaluate the patients' functionality.

RESULTS

Of the 74 patients admitted, 66% were placed on mechanical ventilation (MV). Mobilization therapy was administered in 67.2% of physiotherapy sessions, with passive mobilization being the most prevalent (53.2%) followed by active in-bed exercises (13.6%). Reported barriers for mobilization included hemodynamic instability followed by limited time for assistance. At hospital discharge, the 6MWD was 270(136) meters. A positive correlation was found between handgrip evaluation and 6MWD and a negative correlation with hospital length of stay.

CONCLUSIONS

Mobilization therapy of patients with burns in the ICU was characterized by a low mobility level during MV with a low functional status at hospital discharge.

Characterization of the Blister Fluid Proteome for Pediatric Burn Classification

Blister fluid (BF) is a novel and viable research matrix for burn injury study, which can reflect both systemic and local microenvironmental responses. The protein abundance in BF from different burn severities were initially observed using a 2D SDS-PAGE approach. Subsequently, a quantitative data independent acquisition (DIA) method, SWATH, was employed to characterize the proteome of pediatric burn blister fluid. More than 600 proteins were quantitatively profiled in 87 BF samples from different pediatric burn patients. These data were correlated with clinically assessed burn depth and time until complete wound re-epithelialization through several different statistical analyses. Several proteins from these analyses exhibited significant abundance change between different burn depth or re-epithelialization groups, and can be considered as potential biomarker candidates. Further gene ontology (GO) enrichment analysis of the significant proteins revealed the most significant burn related biological processes (BP) that are altered with burn depth, including homeostasis and oxygen transport. However, for wounds with re-epithelialization times more or less than 21 days, the significant GO annotations were related to enzyme activity. This quantitative proteomics investigation of burn BF may enable objective classification of burn wound severity and assist with clinical decision-making. Data are available via ProteomeXchange with identifier PXD011102.

The Estimation of Survival and Associated Factors in Self-Immolation Attempters in Ilam Province of Iran (2011-2015)

BACKGROUND

Self-immolation is the most common method of suicide in Ilam province.

AIM

This study aimed to estimate the survival rate in self-immolation attempters in Ilam and identify the associated factors.

METHODS

A descriptive-analytic study was conducted based on data collected at Taleghani Hospital in Ilam, Iran. All persons passed away due to self-immolation or those hospitalised in the centre of the self-burned patients located in Ilam during 2011 to 2015 were assessed. Survival rate was calculated based on Kaplan-Meier. To compare the survival rate between groups, Univariate Log Rank and for multivariate analysis, the Cox test of STATA12 software was used.

RESULTS

During 2011 to 2015, 236 persons including 168 females and 69 males committed self-immolation. The mean and median of survival time in attempters were 32.2 ± 4.7 and 3 ± 0.33 days, respectively. In Univariate Log-Rank test, the following variables including age, sex, burn degree, Total Body Surface Area (TBSA), and burns in neck and head and lower limbs had a significantly meaningful relation with survival, while in multivariate Cox Regression test only two variables including Total Body Surface Area and age remained in the model.

CONCLUSION

The mean and median survival rate in self-attempters are very low. Quickly hospitalisation without waste of time should be considered. Providing prompt treatments and compensating dehydration in early hours especially within the first 24 hours of self-immolation are very vital. Younger persons and those with lower burn surface have more chance for longer survival and recuperation.

Teleburn: Designing A Telemedicine Application to Improve Burn Treatment

Background

Due to the increasing rate of the burn injuries and a limited number of specialized treatment centers, providing medical advice and medical care at the point of need is necessary. The aim of the present study was to design and implement a teleburn system to enhance the quality of care for the burn patients.

Methods

This study was completed in 2016. In order to design the system, information needs assessment was conducted by using a questionnaire. The participants of this phase were five specialists, five general practitioners, and 12 nurses. The setting of the study was the burn department of a public hospital and a burn center. The prototype of the system was designed based on the findings derived from the first phase, and the usability of the system was evaluated later.

Results

The teleburn system was a web-based system with different sections for GPs/nurses and specialists. In total, 28 burn consultations were made successfully by using the system. The findings of the usability testing showed that most of the participants evaluated the system at a good level. The mean score for the specialists, general practitioners and nurses was 8.4±0.46, 7.7±0.39, and 7.5±0.51, respectively.

Conclusion

Although it was the first time in the country that the teleburn system was designed and introduced to the clinicians, they seemed to be satisfied with using the system. This system could help general practitioners and nurses to receive specialist's advice on a timely manner to improve the treatment of the burn patients. However, more research should be conducted to determine the effectiveness of using this technology in the real work environment.

Challenges of Burn Mass Casualty Incidents in the Prehospital Setting: Lessons From the Formosa Fun Coast Park Color Party

Objective: A burn mass casualty incident (BMCI) involving 499 patients occurred at a "color party" in Taiwan in June 27, 2015. We implemented a study to identify critical challenges regarding the prehospital emergency care in BMCIs. Methods: A 3-stage, mixed methods study was conducted in 2016. First, a statistical analysis of prehospital management using the data retrieved from the Emergency Medical Management System of the Ministry of Health and Welfare, Taiwan was performed. This was followed by a face-to-face, open-ended interview with the emergency medical technicians and the staff of the emergency operations center who responded to the incident; and the transcription of the interview data into constructed themes. Results: Our study indicated that the signs of inhalation injury needed to be incorporated in the field triage protocol for BMCIs; the collaborative utilization of regional emergency medical services may improve the surge capacity in the field; and an "island-hopping" strategy for patient transportation may allow the healthcare systems to manage the surge of burn patients more efficiently. Conclusions: Current field triage protocols may be insufficient for burn patients and should be further investigated. The practices in field triage, transport capacity, and transfer strategy can be considered as a part of an efficient prehospital emergency response to BMCIs.

Emergency Care of Pediatric Burns

Although the overall incidence of and mortality rate associated with burn injury have decreased in recent decades, burns remain a significant source of morbidity and mortality in children. Children with major burns require emergent resuscitation. Resuscitation is similar to that for adults, including pain control, airway management, and administration of intravenous fluid. However, in pediatrics, fluid resuscitation is needed for burns greater than or equal to 15% of total body surface area (TBSA) compared with burns greater than or equal to 20% TBSA for adults. Unique to pediatrics is the additional assessment for non-accidental injury and accurate calculation of the percentage of total burned surface area (TBSA) in children with changing body proportions are crucial to determine resuscitation parameters, prognosis, and disposition.

The validation study on a three-dimensional burn estimation smart-phone application: accurate, free and fast?

Background

Accurate total body surface area burned (TBSAB) estimation is a crucial aspect of early burn management. It helps guide resuscitation and is essential in the calculation of fluid requirements. Conventional methods of estimation can often lead to large discrepancies in burn percentage estimation. We aim to compare a new method of TBSAB estimation using a three-dimensional smart-phone application named 3D Burn Resuscitation (3D Burn) against conventional methods of estimation—Rule of Palm, Rule of Nines and the Lund and Browder chart.

Methods

Three volunteer subjects were moulaged with simulated burn injuries of 25%, 30% and 35% total body surface area (TBSA), respectively. Various healthcare workers were invited to use both the 3D Burn application as well as the conventional methods stated above to estimate the volunteer subjects’ burn percentages.

Results

Collective relative estimations across the groups showed that when used, the Rule of Palm, Rule of Nines and the Lund and Browder chart all over-estimated burns area by an average of 10.6%, 19.7%, and 8.3% TBSA, respectively, while the 3D Burn application under-estimated burns by an average of 1.9%. There was a statistically significant difference between the 3D Burn application estimations versus all three other modalities (p < 0.05). Time of using the application was found to be significantly longer than traditional methods of estimation.

Conclusions

The 3D Burn application, although slower, allowed more accurate TBSAB measurements when compared to conventional methods. The validation study has shown that the 3D Burn application is useful in improving the accuracy of TBSAB measurement. Further studies are warranted, and there are plans to repeat the above study in a different centre overseas as part of a multi-centre study, with a view of progressing to a prospective study that compares the accuracy of the 3D Burn application against conventional methods on actual burn patients.

Accuracy of Currently Used Paper Burn Diagram vs a Three-Dimensional Computerized Model

Burn units have historically used paper diagrams to estimate percent burn; however, unintentional errors can occur. The use of a computer program that incorporates wound mapping from photographs onto a three-dimensional (3D) human diagram could decrease subjectivity in preparing burn diagrams and subsequent calculations of TBSA burned. Analyses were done on 19 burned patients who had an estimated TBSA burned of ≥20%. The patients were admitted to Shriners Hospitals for Children or the University of Texas Medical Branch in Galveston, Texas, from July 2012 to September 2013 for treatment. Digital photographs were collected before the patient's first surgery. Using BurnCase 3D (RISC Software GmbH, Hagenberg, Austria), a burn mapping software, the user traced partial- and full-thickness burns from photographs. The program then superimposed tracings onto a 3D model and calculated percent burned. The results were compared with the Lund and Browder diagrams completed after the first operation. A two-tailed t-test was used to calculate statistical differences. For partial-thickness burns, burn sizes calculated using Lund and Browder diagrams were significantly larger than those calculated using BurnCase 3D (15% difference, P < .01). The opposite was found for full-thickness burns, with burn sizes being smaller when calculated using Lund and Browder diagrams (11% difference, P < .05). In conclusion, substantial differences exist in percent burn estimations derived from BurnCase 3D and paper diagrams. In our studied cohort, paper diagrams were associated with overestimation of partial-thickness burn size and underestimation of full-thickness burn size. Additional studies comparing BurnCase 3D with other commonly used methods are warranted.

Does Overestimation of Burn Size in Children Requiring Fluid Resuscitation Cause Any Harm?

Overestimation of burn size especially in children is common. It is unclear if this may cause harm. This study was designed to assess the accuracy of burn size estimation by referring non-burn clinicians and investigate whether inaccurate estimates caused any harm. Three and a half years retrospective review of pediatric resuscitation burns (ie, ≥10% TBSA) referred to a tertiary burns center from other hospitals was performed. This included basic demographics, data from referring emergency departments (initial TBSA estimations and fluid volumes prescribed), and data on arrival to the burn center (actual burn TBSA sustained, fluid volumes given prior to arrival, and actual fluid volumes required). Clinical parameters at 8 and 24 hr after injury were also examined. Forty-six patients were identified. Mean age was 3.9 years and weight 18 kg. Mean time to arrival from initial burn injury to our tertiary center was 5 hr. Thirty-two children (70%) had their burns overestimated, seven (15%) underestimated, and another seven (15%) were correctly estimated. After accurate calculations of the burn size and the required resuscitation fluids on arrival to the burns center, only five children of the entire cohort of 46 patients (11%) had received more fluids than required. These five children were in the overestimated burn size group. Only three children received the appropriate amount of fluid prior to arrival to the burns center. There were no mortalities or significant clinical adverse events in any of the children. Overestimation led to overprescription of fluid volumes, but this did not translate into over-resuscitation, and in most cases was in fact associated with inadequate fluid administration. Although 70% of the children in our cohort had the burn size overestimated, only 11% had actually received more fluids than required before arrival. None of these children went on to have any significant complications as a result of overestimation. Training and education is essential for clinicians in emergency departments. However, estimation of size in pediatric burns, in particular scalds, is challenging and the importance of early transfer to a specialist service cannot be overemphasized.

Three-dimensional imaging is a novel and reliable technique to measure total body surface area

OBJECTIVE

The aim of this study was to explore the diverse clinimetric aspects of three-dimensional imaging measurements of TBSA in clinical practice compared with the methods currently used in clinical practice (i.e., the rule of nines and palm method) to measure TBSA in clinical practice.

METHOD

To assess reliability, two independent researchers measured the TBSAs of 48 burn patients using Artec MHT™ Scanner and software. Subsequently, a resident and burn specialist estimated the TBSA of the same wounds using the rule of nines and palm method.

RESULTS

Three-dimensional imaging showed excellent inter-observer reliability, with an intra-class correlation coefficient (ICC) of 0.99, standard error of measurement (SEM) of 0.054, and limits of agreement (LoA) of ±0.15×the mean TBSA (between the measurements of two researchers). The inter-observer reliability of the methods used in current clinical practice was less reliable, with an ICC of 0.91, SEM of 0.300 and LoA of ±0.78×the mean TBSA. The inter-observer reliability was least reliable between three-dimensional imaging and the residents compared with the burn specialists for the estimated TBSA, with an ICC of 0.68, SEM of 0.69 and LoA of ±1.49×the mean TBSA.

CONCLUSION

The inter-observer reliability of three-dimensional imaging was superior compared with the rule of nines and palm method.

Comparison of two-dimensional methods versus three-dimensional scanning systems in the assessment of total body surface area estimation in burn patients

BACKGROUND

Accurate measurement of percent total body surface area (%TBSA) burn is crucial in the management of burn patients for calculating the estimated fluid resuscitation, determining the need to transfer to a specialized burn unit and probability of mortality. %TBSA can be estimated using many methods, all of which are relatively inaccurate. Three-dimensional (3D) systems have been developed to improve %TBSA calculation and consequently optimize clinical decision-making. The objective of this study was to compare the accuracy of percent total burn surface area calculation by conventional methods against novel 3D methods.

METHODS

This prospective cohort study included all acute burn patients admitted in 2016 who consented to participate. The staff burn surgeon determined the %TBSA using conventional methods. In parallel, a researcher determined 3D %TBSA using the BurnCase 3D program (RISC Software GmbH, Hagenberg, Austria). Demographic data and injury characteristics were also collected. Wilcoxon Signed Rank test was used to determine differences between each measure of %TBSA, with assessment of the influence of body mass index (BMI) and gender on accuracy.

RESULTS

Thirty-five patients were included in the study (6 female and 29 male). Average age was 47.5 years, with a median BMI of 26.6kg/m². %TBSA determined by BurnCase 3D program was statistically significantly different from conventional %TBSA assessment (p=0.007), with the %TBSA measured using Burn Case 3D being lower than the %TBSA determined using conventional means (Lund and Browder Diagram) by 1.3% (inter-quartile range -0.6% to 5.6%). BMI and gender did not have an impact on the estimation of the %TBSA.

CONCLUSION

The BurnCase 3D program underestimated %TBSA by 1.3%, as compared to conventional methods. Although statistically significant, this difference is not clinically significant as it has minimal impact on fluid resuscitation and on the decision to transfer a patient to a burn unit. 3D %TBSA evaluation systems are valid tools to estimate %TBSA, and should therefore be considered to improve %TBSA estimation at centers with no available experienced burn staff surgeon. Their use may ultimately prevent inappropriate transfers and allow for improved management of patients with acute burns.

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.

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.

Chemical and Common Burns in Children

Burns are a common cause of preventable morbidity and mortality in children. Thermal and chemical burns are the most common types of burns. Their clinical appearance can be similar and the treatment is largely similar. Thermal burns in children occur primarily after exposure to a hot surface or liquid, or contact with fire. Burns are typically classified based on the depth and total body surface area, and the severity and onset of the burn can also depend on the temperature and duration of contact. Chemical burns are caused by chemicals-most commonly acids and alkalis-that can damage the skin on contact. In children, the most common cause of chemical burns is from household products such as toilet bowl cleaners, drain cleaners, detergents, and bleaches. Mild chemical burns generally cause redness and pain and can look similar to other common rashes or skin infections, whereas severe chemical burns are more extreme and may cause redness, blistering, skin peeling, and swelling.

systematized review of telemedicine applications in treating burn patients

Background: Telemedicine has been used in different fields of medicine in the past 20 years. The main advantages of this technology include saving costs, improving quality of care, and increasing access to specialists. This study aimed to review telemedicine applications in treating burn patients. Methods: In this systematized review study, related papers were searched using various databases, including PubMed, Scopus, and Science Direct. The time frame was between January 2000 and March 2016; finally, 32 papers were included in the study. Results: The findings revealed that telemedicine was used in burn care in three different ways: Remote patient follow-up, teleconsultation, and patient assessment. Conclusion: It seems that telemedicine can be easily applied in treating burn patients even when there is a limited financial resource. The use of this technology can help reduce possible errors in categorizing burn patients and decrease patients' transportation and treatment costs.

A computer-based method for precise detection and calculation of affected skin areas

BACKGROUND

The aim of this study was to describe and validate a method to obtain reproducible and comparable results concerning extension of a specific skin area, unaffected by individual differences in body surface area.

METHODS

A phantom simulating the human torso was equipped with three irregular areas representing the increasing extension of an affected skin area over time. A large sheet of flexible calques paper was placed at the phantom, and five clinicians copied the three irregular shapes two times, resulting in 60 copies. Subsequently, a digital photograph was taken of the calques papers with a clinical ruler placed at the margin. The images were postprocessed and measured in the program 'ImageJ' by two observers. An exact area measurement of the three irregular shapes was performed for comparison.

RESULTS

We found an interobserver variation of 0·36% when comparing the measurements of all three areas. Comparing observer measurements with the exact areas size, we found an underestimate of 2·52%. We observed a tendency that the discrepancy in measurement increases when the measured area decreases.

CONCLUSION

We find this method accurate, reproducible and easy to use. The presented method can be of help when documenting psoriasis and other dermatologic conditions as well as when exploring the effects of new types and variations of ultrasound-guided peripheral nerve blocks - especially in study volunteers.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland

INTRODUCTION

Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines.

MATERIAL AND METHODS

A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered.

RESULTS

17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance.

CONCLUSION

While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.