Optimization of burn referrals

Virtual burn care - Friend or foe? A systematic review

INTRODUCTION

Evidence on the impact of virtual care for patients with burn injuries is variable. This review aims to evaluate its use in remote assessment, rounding, and follow-up through outcomes of efficacy, usability, costs, satisfaction, clinical outcomes, impacts on triage and other benefits/drawbacks.

METHODS

A PRISMA-compliant qualitative systematic review (PROSPERO CRD42021267787) was conducted in four databases and the grey literature for primary research published between 01/01/2010 and 12/31/2020. Study quality was appraised using three established tools. Evidence was graded by the Oxford classification.

RESULTS

The search provided 481 studies, of which 37 were included. Most studies (n = 30, 81%) were Oxford Level 4 (low-level descriptive/observational) designs and had low appraised risk-of-bias (n = 20, 54%). Most applications were for the acute phase (n = 26, 70%). High patient compliance, enhanced specialist access, and new educational/networking opportunities were beneficial. Concerns pertained to IT/connection, virtual communication barriers, privacy/data-security and logistical/language considerations. Low-to-moderate-level (Oxford Grade C) evidence supported virtual burn care's cost-effectiveness, ability to improve patient assessment and triage, and efficiency/effectiveness for remote routine follow-up.

CONCLUSION

We find growing evidence that virtual burn care has a place in acute-phase specialist assistance and routine outpatient follow-up. Low-to-moderate-level evidence supports its effectiveness, cost-effectiveness, usability, satisfactoriness, and capacity to improve triage.

A comparative study of outcomes of burns across multiple levels of care

BACKGROUND

Burn injuries are a significant contributor to the burden of diseases. The management of burns at specialised burn centres has been shown to improve survival. However, in low- and middle-income countries (LMICs) major burns are managed at non-specialised burn centres due to resource constraints. There is insufficient data on survival from treatment at non-specialised burn centres in LMICs. This study aimed to compare the outcomes of burns treatment between a specialised burn centre and five non-specialised centres.

METHODS

A prospective cohort study was conducted on patients aged 18 years or above from January 1, 2021 to September 30, 2021. Participants were selected from the admission register at the emergency department. All burns irrespective of the mechanism of injury or %TBSA were included. Data were entered into REDCap. Statistical analysis of outcomes such as positive blood culture, length of hospital stay (LOHS) and 90-day mortality between specialised burn versus non-specialised centres was performed. Furthermore, an analysis of risk factors for mortality was performed and survival data computed.

RESULTS

Of the 488 study participants, 36% were admitted to a specialised burn centre compared to 64% admitted to non-specialised centres. The demographic characteristics were similar between centres. Patients at the specialised burn centre compared to non-specialised centres had a significantly higher inhalation injury of 30.9% vs 7.7% (p < 0.001), > 10%TBSA at 83.4% vs 45.7% (p < 0.001), > 20%TBSA at 46.9% vs 16.6% (p < 0.001), and a median (IQR) ABSI score of 6 (5-7) vs 5 (4-6) (p < 0.0001). Furthermore, patients from specialised burn vs non-specialised centres had a longer median (IQR) time from injury to first burn excision at 7 (4-11) vs 5 (2-10) days, higher rate of burn sepsis 69% vs 35%, increased LOHS 17 (11-27) vs 12 (6-22) days, and 90-day mortality rates at 19.4% vs 6.4%. After adjusting for cofounding variables, survival data showed no difference between specialised burn and non-specialised centres (HR 1.8 95% CI 1.0-3.2, p = 0.05).

CONCLUSION

Although it appears that the survival of burn patients managed at non-specialised centres in a middle-income country is comparable to those managed at specialised burn centres, there is uncounted bias in our survival data. Hence, a change in practice is not advocated. However, due to resource constraint specialised burn centres in addition to managing major burns should provide training and support to the non-specialised centres.

Clinical decision-support for acute burn referral and triage at specialized centres - Contribution from routine and digital health tools

BACKGROUND

Specialized care is crucial for severe burn injuries whereas minor burns should be handled at point-of-care. Misdiagnosis is common which leads to overburdening the system and to a lack of treatment for others due to resources shortage.

OBJECTIVES

The overarching aim was to evaluate four decision-support tools for diagnosis, referral, and triage of acute burns injuries in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

METHODS

Study I retrospectively assessed adherence to referral criteria of 1165 patients admitted to the paediatric burns centre of the Western Cape of South Africa. Study II assessed mortality prediction of 372 patients admitted to the adults burns centre by evaluating an existing score (ABSI), and by using logistic regression. In study III, an online survey was used to assess the diagnostic accuracy of burn experts' image-based estimations using their smartphone or tablet. In study IV, two deep-learning algorithms were developed using 1105 acute burn images in order to identify the burn, and to classify burn depth.

RESULTS

Adherence to referral criteria was of 93.4%, and the age and severity criteria were associated with patient care. In adults, the ABSI score was a good predictor of mortality which affected a fifth of the patients and which was associated with gender, burn size and referral status. Experts were able to diagnose burn size, and burn depth using handheld devices. Finally, both a wound identifier and a depth classifier algorithm could be developed with relatively high accuracy.

CONCLUSIONS

Altogether the findings inform on the use of four tools along the care trajectory of patients with acute burns by assisting with the diagnosis, referral and triage from point-of-care to burns centres. This will assist with reducing inequities by improving access to the most appropriate care for patients.

Adherence of Burn Outpatient Clinic Referrals to ABA Criteria in a Tertiary Centre: Creating Unnecessary Referrals?

Initial assessment and triage of burns are guided by the American Burn Association criteria for referral to a burn center. These criteria are sensitive but not specific and can potentially lead to over-triage and “unnecessary” clinic visits. We are a Level 1 trauma center with burn subspecialty care, and due to the COVID-19 pandemic, referrals to our multidisciplinary outpatient burn clinic required triaging for virtual care appointments. In order to improve the triage process, we retrospectively reviewed our outpatient burn clinic referrals over a 2-year period, 2018 to 2019, for adherence to American Burn Association criteria. We collected data pertaining to patient and burn characteristics, as well as treatment outcome, to characterize referrals not requiring an in-person appointment. Of the 244 patients referred, 73% met the referral criteria, with 45% of these patients being healed at the first visit and 14.6% requiring surgical management. Mean time from injury to first visit was 9.7 days (mode 6), and the average number of visits was 2. Overall, mean burn size was 2%, with the majority of injuries being partial thickness (71%), located in the hand or extremity (77%). There was a fairly equal distribution of contact (36%), flame (21%), and scald (26%) burns. This study highlights the nonspecific nature of the American Burn Association referral criteria. We found that pediatric and hand burns in particular were over-triaged and lead to “unnecessary” appointments. This information is useful to help adjust referral criteria and to guide triaging of appointments with the evolution of telehealth and virtual care.

Adherence to the emergency management of severe burns referral criteria in burn patients admitted to a hospital with or without a specialized burn center

BACKGROUND

The primary aim was to determine to what extent referral and admission of burn patients to a hospital with or without a burn center was in line with the EMSB referral criteria.

METHODS

This was a retrospective, multicenter cohort study. Burn patients admitted from 2014 to 2018 to a hospital in the Southwest Netherland trauma region and Network Emergency Care Brabant were included in this study. Outcome measures were the adherence to the EMSB referral criteria.

RESULTS

A total of 1790 patients were included, of whom 951 patients were primarily presented to a non-burn center. Of these patients, 666 (70.0%) were managed according to the referral criteria; 263 (27.7%) were appropriately not referred, 403 (42.4%) were appropriately referred. Twenty (2.1%) were overtransferred, and 265 (27.9%) undertransferred. In 1213 patients treated at a burn center 1119 (92.3%) met the referral criteria. Adherence was lowest for electrical (N = 4; 14.3%) and chemical burns (N = 16; 42.1%), and was highest in 'children ≥5% total body surface area (TBSA) burned' (N = 109; 83.2%).

CONCLUSION

The overall adherence to the referral criteria of patients presented to a non-burn center was fairly high. However, approximately 25% was not transferred to a burn center while meeting the criteria. Most improvement for individual criteria can be achieved in patients with electrical and chemical burns.

The effect of a known object in a static image of a burn to improve the burn size estimation

INTRODUCTION

Currently information regarding burn size from referring departments to burn centres varies in accuracy. Inaccurate assessment of burn size can lead to over or under treatment. Photographs of injuries may improve accuracy of assessment. We aimed to assess the accuracy of measuring burn size on a static image by including a standard object in the image.

METHODS

Simulated burn areas were drawn on different body parts of the model. Using an iPhone® model 5 s with an 8 megapixel camera we took photos of the marked area, and repeated them with the palm, a standard bank card and a penny in the picture. First the Du Bois formula, was used to calculate body surface area. Members of the Burns team were asked to view the photos (n = 30) and estimate the percentage of the simulated burn.

RESULTS

We found an overall overestimation of burn size. Small areas of the forearm were better estimated and within 1.1% of the calculated surface area, however we found no improvement when using a standard object in these images. The back areas were most overestimated ranging from 0.9%-8.9% despite all being the same sized area.

CONCLUSIONS

Static images tend to overestimate burn size despite the use of a standard object in the image.

Digital Otoscopy Videos Versus Composite Images: A Reader Study to Compare the Accuracy of ENT Physicians

OBJECTIVES/HYPOTHESIS

With the increasing emphasis on developing effective telemedicine approaches in Otolaryngology, this study explored whether a single composite image stitched from a digital otoscopy video provides acceptable diagnostic information to make an accurate diagnosis, as compared with that provided by the full video.

STUDY DESIGN

Diagnostic survey analysis.

METHODS

Five Ear, Nose, and Throat (ENT) physicians reviewed the same set of 78 digital otoscope eardrum videos from four eardrum conditions: normal, effusion, retraction, and tympanosclerosis, along with the composite images generated by a SelectStitch method that selectively uses video frames with computer-assisted selection, as well as a Stitch method that incorporates all the video frames. Participants provided a diagnosis for each item along with a rating of diagnostic confidence. Diagnostic accuracy for each pathology of SelectStitch was compared with accuracy when reviewing the entire video clip and when reviewing the Stitch image.

RESULTS

There were no significant differences in diagnostic accuracy for physicians reviewing SelectStitch images and full video clips, but both provided better diagnostic accuracy than Stitch images. The inter-reader agreement was moderate.

CONCLUSIONS

Equal to using full video clips, composite images of eardrums generated by SelectStitch provided sufficient information for ENTs to make the correct diagnoses for most pathologies. These findings suggest that use of a composite eardrum image may be sufficient for telemedicine approaches to ear diagnosis, eliminating the need for storage and transmission of large video files, along with future applications for improved documentation in electronic medical record systems, patient/family counseling, and clinical training.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1668-E1676, 2021.

Triage and Transfer to a Regional Burn Center—Impact of a Mobile Phone App

Telemedicine technology can be used to facilitate consultations from nonburn-trained referring providers. However, there is a paucity of evidence indicating these technologies influence transfer decisions and follow-up care. In 2016, our regional burn center implemented a mobile phone app, which allows a referring provider to send photos of the wound along with basic demographic and clinical data to the burn specialist. A retrospective review was performed on consults to our regional burn center from a Level I trauma center approximately 70 miles away with a shared electronic medical record. Patients were considered to be “down-triaged” if they could be managed locally or if the transfer could occur via personal vehicle instead of ground or air ambulance transport. During the 2-year study period, 126 consultations were made for thermal injuries. Eighty-seven patients (69%) were referred using the Burn App. Overall, 49 patients (39%) were transferred. When the subset of intermediate size (1–10% TBSA) burns were considered (n = 48), the Burn App allowed for successful “down-triage” of 12 patients (33%) referred through the app. No patient referred without the app could be “down-triaged” (P = .02). Although 57 patients (44%) were recommended for outpatient follow-up, only 42% followed up. A mobile app can be used to successfully triage patients with intermediate size burn injuries to a lower acuity of follow-up and transfer mode. However, only a minority of patients triaged to outpatient management actually follow up with a regional burn center. Telemedicine efforts should focus on improving not only initial triage, but also aftercare.

Emergency Care of the Burn Patient Before the Burn Center: A Systematic Review and Meta-analysis

Good burn care starts with correct management of the burn patient before transfer to a burn center. The purpose of this study was to perform a systematic review of the medical literature describing preburn center care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this review. Studies were included if they were published from a burn center and they measured or evaluated any aspect of preburn center care of adult or pediatric acute burn patients referred to that burn center. A comprehensive search of MEDLINE, EMBASE, and Cochrane databases was performed from their inception to May 28, 2018. Outcomes of interest included errors in burn size estimation, airway management, fluid resuscitation, dressings and wound care, use of systemic antibiotics, core temperature monitoring and preservation, and analgesia provision. Meta-analysis of the discrepancy between preburn center and burn center burn size estimation was conducted. From 3768 initially identified titles, 37 studies were included in this systematic review. Burn size estimation was frequently inaccurate. The ratio of overestimation to underestimation in burn size ranged between 2.2:1 and 19:1. The pooled mean absolute error in % total body surface area burn was 6.28 (95% CI: 4.72, 7.85). The average relative percent error in burn size estimation by referring providers ranged between 75% and 3500%. Unnecessary endotracheal intubation was performed in 28% to 53% of transfers. Over-estimation and over-delivery of fluid resuscitation volumes was prevalent, but other problems pertaining to resuscitation included administration of the wrong fluid and failure to titrate fluids. Wounds were not consistently covered with simple dry dressings or sheets. Core temperature was not consistently monitored or preserved. Analgesics were often not given or were of insufficient dose. Many elements of preburn center care need improvement. These findings should be used to form the foundation of future initiatives between burn professionals and emergency providers to improve care of the burn patient before transfer to a burn center.

Updating the Burn Center Referral Criteria: Results From the 2018 eDelphi Consensus Study

Existing burn center referral criteria were developed several years ago, and subsequent innovations in burn care have occurred. Coupled with frequent errors in the estimation of extent of burn injury and depth by referring providers, patients are both over and under-triaged when the existing criteria are used to support patient care decisions. In the absence of compelling clinical trial data on appropriate burn patient triage, we convened a multidisciplinary panel of experts to execute an iterative eDelphi consensus process to facilitate a revision. The eDelphi process panel consisted of n = 61 burn stakeholders and experts and progressed through four rounds before reaching consensus on key clinical domains. The major findings are that 1) burn center consultation is strongly recommended for all patients with deep partial-thickness or deeper burns ≥ 10% TBSA burned, for full-thickness burns ≥ 5% TBSA burned, for children and older adults with specific dressing and medical needs, and for special burn circumstances including electrical, chemical, and radiation injuries; 2) smaller burns are ideally followed in burn center outpatient settings as soon as possible after injury, preferably without delays of a week or more; 3) frostbite, Stevens-Johnson syndrome/TENS, and necrotizing soft-tissue infection patients benefit from burn center treatment; and 4) telemedicine and technological solutions are of likely benefit in achieving this standard. Unlike the original criteria, the revised consensus-based guidelines create a framework promoting communication so that triage and treatment are specifically tailored to individual patient characteristics, injury severity, geography, and the capabilities of referring institutions.

Teleconsultation Using Mobile Phones for Diagnosis and Acute Care of Burn Injuries Among Emergency Physicians: Mixed-Methods Study

Background

The referral process in acute care remains challenging in many areas including burn care. Mobile phone apps designed explicitly for medical referrals and consultations could streamline the referral process by using structured templates and integrating features specific to different specialties. However, as these apps are competing with commercial chat services, usability becomes a crucial factor for successful uptake.

Objective

The aim of this study was to assess the usability of a mobile phone app for remote consultations and referrals of burn injuries.

Methods

A total of 24 emergency doctors and 4 burns consultants were recruited for the study. A mixed-methods approach was used including a usability questionnaire and a think-aloud interview. Think-aloud sessions were video-recorded, and content analysis was undertaken with predefined codes relating to the following 3 themes: ease of use, usefulness of content, and technology-induced errors.

Results

The users perceived the app to be easy to use and useful, but some problems were identified. Issues relating to usability were associated with navigation, such as scrolling and zooming. Users also had problems in understanding the meaning of some icons and terminologies. Sometimes, some users felt limited by predefined options, and they wanted to be able to freely express their clinical findings.

Conclusions

We found that users faced problems mainly with navigation when the app did not work in the same way as the other apps that were frequently used. Our study also resonates with previous findings that when using standardized templates, the systems should also allow the user to express their clinical findings in their own words.

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.

The role of preliminary hospitals in the management of a mass burn casualty disaster

PURPOSE

The Formosa Fun Coast explosion is an internationally-known event that occurred in Taiwan on June 27th, 2015. The blast involved 495 casualties in total, with 253 patients receiving 2nd degree or deeper burns on greater than 40% of the total body surface area (TBSA). Questions were raised regarding whether these victims were sent to the appropriate hospitals or not. Therefore, we analyzed the effect of the initial admission destination in this study.

MATERIAL AND METHODS

We retrospectively reviewed all of the victims from the explosion who were sent to the emergency department of Linkou and Keelung Chang Gung Memorial Hospitals. Patients were divided by direct admission and received via transfer. The basic demographics, the efficacy of the initial resuscitation and the clinical outcomes were analyzed.

RESULTS

In total, forty-six patients were included. Thirty-five of them were primarily admitted, and eleven of them were received via transfer. Between the two groups, there was no significant difference in the resuscitation outcome. The ratio of delaying intubation was similar (14.3% vs 27.3%, p=0.322). The rate of delayed-detected ischemic events was significantly increased in the referral group (0% vs 27.3%, p=0.001). However, there was no amputation event in either group. No difference in mortality was observed between groups (5.7% vs 9.1%, p=0.692).

CONCLUSION

Our preliminary findings suggest that local hospitals are capable of providing high-quality acute care to mass casualty burn victims. Our results suggest that patients with suspected limb ischemia should be rapidly transferred to a regional burn center to ensure optimal care. Systemic pre-planning such as employing telemedicine and personnel collaboration, should be considered by the administration to maximize the function of preliminary hospitals in burn care.

Adherence to Referral Criteria at Admission and Patient Management at a Specialized Burns Centre: The Case of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa

Referral guidelines for burn care are meant to assist in decision-making as regards patient transfer and admissions to specialized units. Little is known, however, concerning how closely they are followed and whether they are linked to patient care. This is the object of the current study, focused on the paediatric burns centre of the Red Cross War Memorial Children’s Hospital in Cape Town, South Africa. All patients admitted to the centre during the winters of 2011–2015 (n = 1165) were included. The patient files were scrutinized to clarify whether the referral criteria in place were identified (seven in total) and to compile data on patient and injury characteristics. A case was defined as adherent to the criteria when at least one criterion was fulfilled and adherence was expressed as a percentage with 95% confidence intervals, for all years aggregated as well as by year and by patient or injury characteristics. The association between adherence to any individual criterion and hospital care (surgery or longer length of stay) was measured using logistic regressions. The overall adherence was 93.4% (100% among children under 2 years of age and 86% among the others) and it did not vary remarkably over time. The two criteria of “injury sustained at a specific anatomical site” (85.2%) and “young age” (51.9%) were those most often identified. Children aged 2 years or older were more likely to undergo surgery or to stay longer than those of young age (although a referral criterion) and so were those with higher injury severity (a referral criterion). In this specialized paediatric burns centre, children are admitted mainly according to the guidelines. However, given the high prevalence of paediatric burns in the region and the limited resources at the burns centre, adherence to the guidelines need to be further studied at all healthcare levels in the province.

Assessing guidelines for burn referrals in a resource-constrained setting: Demographic and clinical factors associated with inter-facility transfer

AIM

The aim was to assess demographic and clinical factors associated with inter-facility referrals for patients with burns in a resource-constrained setting.

METHODS

This was a cross-sectional case review of patients presenting with a burn at the trauma unit at the Red Cross War Memorial Children's Hospital (RXH) in Cape Town, South Africa.

RESULTS

Six hundred and eleven-(71%) children were referred to the burns or the intensive care unit and 253 children were treated and discharged from the trauma unit. Of those admitted as inpatients 94% fulfilled at least one of the criteria for referral and 80% of those treated and discharged fulfilled the criteria for referral.

CONCLUSIONS

Almost three out of four children evaluated at the trauma unit were referred to the burns unit for further management. However, a large number of patients were treated and discharged from the trauma unit despite being eligible for referral.

Urban Telemedicine: The Applicability of Teleburns in the Rehabilitative Phase

Telemedicine has been successfully used in many areas of medicine, including triage and evaluation of the acute burn patient. The utility of telemedicine during the rehabilitative phase of burn care has yet to be evaluated; therefore, we expanded our telemedicine program to link our burn center with a rehabilitation facility. The goal of this project was to demonstrate cost-effective improvements in the transition and quality of care. A retrospective review was performed on all patients enrolled in our telemedicine/rehabilitation program between March 2013 and March 2014. Data collected included total number of encounters, visits, type of visit, physician time, and readmissions. Transportation costs were based on local ambulance rates between the two facilities. The impact of telemedicine was evaluated with respect to the time saved for the physician, burn center, and burn clinic, as well as rehabilitative days saved. A patient satisfaction survey was also administered. A total of 29 patients participated in 73 virtual visits through the telemedicine project. Virtual visits included new consults, preoperative evaluations, and postoperative follow-ups. A total of 146 ambulance transports were averted during the study period, totaling $101,110. Virtual visits saved 6.8 outpatient burn clinic days, or 73 clinic appointments of 30-min duration. The ability to perform more outpatient surgery resulted in 80 inpatient bed days saved at the burn hospital. The rehabilitation hospital saved an average of 2 to 3 patient days secondary to unnecessary travel. Satisfaction surveys demonstrated patient satisfaction with the encounters, primarily related to time saved. The decrease in travel time for the patient from the rehabilitation hospital to outpatient burn clinic improved adherence to the rehabilitation care plan and resulted in increased throughput at the rehabilitation facility. Videoconferencing between a burn center and rehabilitation hospital streamlined patient care and reduced health care costs, while maintaining quality of care and patient satisfaction. This program has improved inpatient burn rehabilitation by maximizing time spent in therapy and avoiding unnecessary patient travel to offsite appointments.

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 noninvasive computational method for fluid resuscitation monitoring in pediatric burns: a preliminary report

The fluid resuscitation needs of children with small area burns are difficult to predict. The authors hypothesized that a novel computational algorithm called the compensatory reserve index (CRI), calculated from the photoplethysmogram waveform, would correlate with percent total body surface area (%TBSA) and fluid administration in children presenting with ≤20% TBSA burns. The authors recorded photoplethysmogram waveforms from burn-injured children that were later processed by the CRI algorithm. A CRI of 1 represents supine normovolemia; a CRI of 0 represents the point at which a subject is predicted to experience hemodynamic decompensation. CRI values from the first 10 minutes of monitoring were compared to clinical data. Waveform data were available for 27 children with small to moderate sized burns (4-20 %TBSA). The average age was 6.3 ± 1.1 years, the average %TBSA was 10.4 ± 0.8%, and the average CRI was 0.36 ± 0.03. CRI inversely correlated with the %TBSA (P < .001). Twenty children were transferred with an average reported %TBSA of 16.5 ± 1.4%, which was significantly higher than the actual %TBSA (P < .001). CRI correlated better with actual %TBSA compared to reported %TBSA (P = .02). CRI correlated with the amount of fluid resuscitation given at the time of CRI measurement (P = .02) and was inversely related to total fluids given per 24 hours for children with adequate urine output (>0.5 ml/kg/hr) (P < .001). The CRI is decreased in children with small to moderate size burns, and correlates with %TBSA and fluid administration. This suggests that the CRI may be useful for fluid resuscitation guidance, warranting further study.

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.