The Revised Baux Score as a Predictor of Burn Mortality: A Systematic Review and Meta-Analysis

Major burns in adults: a practice review

There are approximately 180 000 deaths per year from thermal burn injury worldwide. Most burn injuries can be treated in local hospitals but 6.5% require specialist burn care. The initial ED assessment, resuscitation and critical care of the severely burned patient present significant challenges and require a multidisciplinary approach. The management of these patients in the resuscitation room impacts on the effectiveness of continuing care in the intensive care unit. The scope of the present practice review is the immediate management of the adult patient with severe burns, including inhalation injury and burn shock. The article uses an illustrative case to highlight recent developments including advanced airway management and the contemporary approach to assessment of fluid requirements and the type and volume of fluid resuscitation. There is discussion on new options for pain relief in the ED and the principles governing the early stages of burn intensive care. It does not discuss minor injuries, mass casualty events, chemical or radiation injuries, exfoliative or necrotising conditions or frost bite.

Models predicting mortality risk of patients with burns to ≥ 50% of the total body surface

BACKGROUND

Several models predicting mortality risk of burn patients have been proposed. However, models that consider all such patients may not well predict the mortality of patients with extensive burns.

METHOD

This retrospective multicentre study recruited patients with extensive burns (≥ 50% of the total body surface area [TBSA]) treated in three hospitals of Eastern China from 1 January 2016 to 30 June 2022. The performances of six predictive models were assessed by drawing receiver operating characteristic (ROC) and calibration curves. Potential predictors were sought via "least absolute shrinkage and selection operator" regression. Multivariate logistic regression was employed to construct a predictive model for patients with burns to ≥ 50% of the TBSA. A nomogram was prepared and the performance thereof assessed by reference to the ROC, calibration, and decision curves.

RESULT

A total of 465 eligible patients with burns to ≥ 50% TBSA were included, of whom 139 (29.9%) died. The FLAMES model exhibited the largest area under the ROC curve (AUC) (0.875), followed by the models of Zhou et al. (0.853) and the ABSI model (0.802). The calibration curve of the Zhou et al. model fitted well; those of the other models significantly overestimated the mortality risk. The new nomogram includes four variables: age, the %TBSA burned, the area of full-thickness burns, and blood lactate. The AUCs (training set 0.889; internal validation set 0.934; external validation set 0.890) and calibration curves showed that the nomogram exhibited an excellent discriminative capacity and that the predictions were very accurate.

CONCLUSION

For patients with burns to ≥ 50％of the TBSA, the Zhou et al. and FLAMES models demonstrate relatively high predictive ability for mortality. The new nomogram is sensitive, specific, and accurate, and will aid rapid clinical decision-making.

The systemic inflammation indexes after admission predict in-hospital mortality in patients with extensive burns

PURPOSE

To explore the clinical value of various complete blood count (CBC)-derived inflammation indicators to predict in-hospital mortality in patients with extensive burns.

METHODS

Systemic inflammation indexes, including lymphocyte-platelet ratio (LPR), neutrophil-lymphocyte ratio (NLR), neutrophil-monocyte ratio (NMR), monocyte-lymphocyte ratio (MLR), neutrophil-to-lymphocyte * platelet (NLPR), systemic inflammation index (SII), and systemic inflammation response index (SIRI) on days 1, 3, and 7 after admission were calculated in 135 patients with extensive burns.

RESULTS

We included 135 patients with extensive burns, including 97 survivors and 38 non-survivors. After adjusting for confounders, only the LPR on day 1, NLPR on days 3 and 7 were significantly associated with survival (OR= 1.237, 1.097, 1.104; 95 % CI: 1.055-1.451, 1.002-1.202, 1.005-1.212; respectively) in the analysis of multivariate logistic regression. The optimum cutoff values of the LPR on day 1 and NLPR on day 3 were 6.37 and 8.06, and the area under the curves (AUC) were 0.695 and 0.794, respectively. The AUC of NLPR on day 7 had the highest value, 0.814, and the optimum cut-off value was 3.84. The efficacy of LPR on day 1, NLPR on days 3 and 7 combined with the burn prognostic score index in predicting the prognosis of patients was higher than that of the burn index alone, and the three composite inflammatory indexes combined with PBI had the highest efficacy in predicting the prognosis (AUC = 0.994). Kaplan-Meier survival analysis showed poor prognosis in patients with higher LPR on day 1 and higher NLPR on days 3 and 7 (log-rank χ2 =9.623,31.564, 20.771, respectively; P < 0.01).

CONCLUSIONS

LPR on day 1 and NLPR on days 3 and 7 after admission are reliable predictors of prognosis in patients with severe extensive burns. The combination of the burn prognostic score index, LPR on day 1, and NLPR on days 3 and 7 was superior to the burn indexes alone in predicting a patient's prognosis.

A comparative study of the predictive value of four models for death in patients with severe burns

OBJECTIVE

To assess the prognostic value of the Ryan score, Belgian Outcome of Burn Injury (BOBI) score,revised Baux (rBaux) score, and a new model (a Logit(P)-based scoring method created in 2020) for predicting mortality risk in patients with extremely severe burns and to conduct a comparative analysis.

METHODS

A retrospective analysis was conducted on 599 burn patients who met the inclusion criteria and were admitted to the burn unit of the First Affiliated Hospital of Nanchang University from 2017 to 2022. Relevant information was collected, and receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) were plotted for each of the four models in assessing mortality in these burn patients using both age-stratified and unstratified forms. The ROC curve section was further compared with the area under the curve (AUC), optimal cutoff value, as well as its sensitivity and specificity. Additionally, the quality of the AUC was assessed using the Delong test.

RESULT

Among the patients who met the inclusion criteria, 532 were in the survival group and 67 in the death group. Irrespective of age stratification, the novel model exhibited superior performance with an AUC of 0.868 (95% CI: 0.838-0.894) among all four models predicting mortality risk in included patients, and also demonstrated better AUC quality than other models; the calibration curves showed that the accuracy of all four models was good; the DCA curves showed that the clinical utility of the novel model and rBuax score were better. In the comparison of four scoring models across different age groups, the new model demonstrated the largest AUC in both 0-19 years (0.954, 95% CI 0.914-0.979) and 20-59 years groups (0.838, 95% CI 0.793-0.877), while rBuax score exhibited the highest AUC in ≥ 60 years group (0.708, 95% CI of 0.602-0.800). The calibration curves showed that the four models exhibited greater accuracy within the age range of 20-59 years, while the DCA curves indicated that both the novel model and rBuax score scale displayed better prediction in both the 20-59 and ≥ 60 years groups.

CONCLUSIONS

All four models demonstrate accurate and effective prognostication for patients with severe burns. Both the novel model and rBaux score exhibit enhanced prediction utility. In terms of the model itself alone, the new model is not simpler than, for example, the rBaux score, and whether it can be applied clinicallyinvolves further study.

Letter to the Editor: The Revised Baux Score as a Predictor of Burn Mortality: A Systematic Review and Meta-analysis

Introduction

The odds of being struck by lightning are one in a million, however lightning strike accounts for 24,000 annual fatalities worldwide (Jensen et al, 2023). Due to its rarity, guidelines for the management of burns acquired by lightning strike are scarce. Current standard of treatment is to treat burns acquired as one would treat electrical burns (Stander & Wallace, 2011). We present a case series of three patients that were struck by lightning and contrast their outcomes to patients with electrical burns. We attempt to provide general recommendations for lightning burns.

Methods

We conducted retrospective chart review of patients presenting between 2015- 2022 for electrical and lightning burns. SPSS V28 was used for statistical analysis. Lightning burn patients were matched to electric burn patients by age, gender, Total Burn Surface Area (TBSA), and comorbidities. Descriptive statistical analysis was conducted between the three groups due to discrepancies in sample size.

Results

We report three lightning burn cases: 2 adult males with 1-1.5% TBSA second-degree burns and 1 pediatric case with 4% TBSA. The pediatric case had a more complex hospital course: longer stay (15 vs 4-5 days), ICU stay (13 vs 2 days), and required ventilation but no surgery.

In adults aged 19-29, electrical burns patients had longer hospital stays (6.38 vs 5.00 days), similar ICU stays (2.25 vs 2 days), and lower initial CPK (1624.29 vs 3506.00) than lightning burn patients. In those 50+ with TBSA < 5% and hypertension, electrical burns patients had longer stays (6.75 vs 4 days), longer ICU stays (3.25 vs 2.00 days), and lower initial CPK levels (435.5 vs 648.00). CPK normalization took longer for electric burns (29.5 vs 6 hours). In younger patients, lightning burns had lower initial myoglobin (569.30 vs 759.01) but faster normalization (8.5 vs 15.92 hours), while in older patients, myoglobin trends favored lightning burns (6 vs 3.25 hours). Pediatric patients with TBSA < 5% had shorter stays (3.83 vs 15.00 days), ICU stays (0.83 vs 13 days), lower initial CPK (508.25 vs 17393.00), lower myoglobin (91.50 vs 10000.00), and quicker CPK normalization (10.00 vs 14.00) in electric burns compared to lightning burns.

Conclusions

Electric burns and lightning burns present similarly in adults. Although initial CPK levels are elevated in lightning burn patients, time taken for CPK to trend down was less than electric burn patients. More research is needed on lightning burn management in a pediatric population.

Applicability of Research to Practice

Lightning burns can be managed similarly to electric burns. Providers ought to expect an increased length of stay in patients who sustain electric burns as well as an extended recovery time for muscular injury.