CHILDREN UNDER 4 YEARS ARE AT GREATER RISK OF MORTALITY FOLLOWING ACUTE BURN INJURY

Serum Plasminogen Activator Inhibitor-1, α 1-Acid Glycoprotein, C-Reactive Protein, and Platelet Factor 4 Levels-Promising Molecules That Can Complete the "Puzzle" of the Biochemical Milieu in Severe Burns: Preliminary Results of a Cohort Prospective Study

Background: Burns represent a serious health problem, associated with multiple-organ failure, prolonged hospitalization, septic complications, and increased rate of mortality. The main aim of our study was to evaluate the levels of various circulating molecules in children with severe burns (more than 25% TBSA), in three different moments: 48 h, day 10, and day 21 post-burn. Materials and Methods: This study included 32 children with burns produced by flame, hot liquid, and electric arc and 21 controls. Serum plasminogen activator inhibitor-1 (PAI-1), α 1-acid glycoprotein (AGP), C-reactive protein (CRP), and platelet factor 4 (PF4) were detected using the Multiplex technique. Several parameters, such as fibrinogen, leucocyte count, thrombocyte count, triiodothyronine, thyroxine, and thyroid-stimulating hormone were also determined for each patient during hospitalization. Results: Significant statistical differences were obtained for CRP, AGP, and PF4 compared to the control group, in different moments of measurements. Negative correlations between CRP, AGP, and PF4 serum levels and burned body surface, and also the hospitalization period, were observed. Discussions: CRP levels increased in the first 10 days after burn trauma and then decreased after day 21. Serum PAI-1 levels were higher immediately after the burn and started decreasing only after day 10 post-burn. AGP had elevated levels 48 h after the burn, then decreased at 7-10 days afterwards, and once again increased levels after 21 days. PF4 serum levels increased after day 10 since the burning event. Conclusions: Serum CRP, AGP, PAI-1, and PF4 seem to be promising molecules in monitoring patients with a burn within the first 21 days.

Palliative Care and Burn Care: Empirically Derived Referral Criteria

Burns frequently require complex interdisciplinary care. Specialist palliative care (PC) minimizes suffering, aids in decision making, and provides family support in addition to end-of-life care. Specialist PC is a limited resource, best conserved by identifying persons most likely to benefit from a PC referral. Little guidance is available for clinicians on whether and when to refer to PC. This study's purpose was to identify referral criteria using a mixed-methods approach. Data were examined for between-group differences using Fisher's exact, chi-square, or Wilcoxon Rank Sum tests. Qualitative thematic analysis was used to analyze PC provider notes to describe interventions provided. These data formed initial referral criteria, which were reviewed by an expert panel. Significant between-group differences included dying in the burn center; whether multiple patients were transported to the burn center from one event; and ventilator days. Four themes emerged from qualitative analysis. These included managing physical aspects of care; clarifying goals of care; managing end-of-life care; and managing patient/family psychosocial distress. Expert panel input clarified referral criteria language and supplemented the proposed criteria. We present empirically derived referral criteria to guide burn providers in referring persons for specialist PC. Subsequent testing is required to determine their efficacy in improving patient/family outcomes.

Lower Risk of Burn Injury in Children and Adolescents with Autism Spectrum Disorder: A Nationwide Population-Based Study

Little research has examined burn injury in the pediatric population with autism spectrum disorder (ASD). We used data from Taiwan's National Health Insurance Research Database to identify 15,844 participants aged <18 years with ASD and 130,860 participants without ASD. Our results revealed that the hazard ratios differed across three age ranges. The ASD group had a lower risk of burn injury than the non-ASD group when they were less than 6 years of age, a higher risk from 6 years to 12 years of age, and no difference when they were older than 12 years of age. More research is required to study the characteristics and causes of burn injury in the pediatric population with ASD.

Burn Registries State of Affairs: A Scoping review

Registry science allows for the interpretation of disease-specific patient data from secondary databases. It can be utilized to understand disease and injury, answer research questions, and engender benchmarking of quality-of-care indicators. Numerous burn registries exist globally, however, their contributions to burn care have not been summarized. The objective of this study is to characterize the available literature on burn registries. The authors conducted a scoping review, having registered the protocol a priori. A thorough search of the English literature, including grey literature, was carried out. Publications of all study designs were eligible for inclusion provided they utilized, analyzed, and/or critiqued data from a burn registry. Three hundred twenty studies were included, encompassing 16 existing burn registries. The most frequently used registries for peer-reviewed publications were the American Burn Association Burn Registry, Burn Model System National Database, and the Burns Registry of Australia and New Zealand. The main limitations of existing registries are the inclusion of patients admitted to burn centers only, deficient capture of outpatient and long-term outcome data, lack of data standardization across registries, and the paucity of studies on burn prevention and quality improvement methodology. Registries are an invaluable source of information for research, delivery of care planning, and benchmarking of processes and outcomes. Efforts should be made to stimulate other jurisdictions to build burn registries and for existing registries to be improved through data linkage with administrative databases, and by standardizing one international minimum dataset, in order to maximize the potential of registry science in burn care.

An Exploration of Emergency Department Visits for Home Unintentional Injuries Among Children With Autism Spectrum Disorder for Evidence to Modify Injury Prevention Guidelines

OBJECTIVES

Current childhood injury prevention guidance is anchored by a child's age. For example, children are considered at high risk for falls at ages 4 years and less, and guidance for prevention focuses on these ages. However, these guidelines may not be adequate for children with autism spectrum disorders (ASD).

METHODS

This retrospective chart review examined injury characteristics for children with ASD receiving treatment in a pediatric emergency department between 2014 and 2016. Bivariate statistics determined injury demographic correlates. Chart narratives were also coded using traditional content analysis to determine the mechanism that caused the home injury.

RESULTS

The sample (27 cases) was mostly male (89%), Black (48%), with a mean age of 7.8 (SD, 4.9) years. The most common mechanism was a fall (44%), followed by self-injurious behavior (33%), and then burns (22%). All cases identified at least 1 mechanism contributing to the injury, in 2 cases, 2 items were mentioned. Of the 29 items identified, most involved a house feature that was not stairs (24%); some included stairs, furniture, or a combination of foreign object and grill (21%); and few identified food/beverage/liquid (11%).

CONCLUSIONS

Analyses suggest that unintentional home injury prevention for children with ASD may require prevention guidance extended through older ages.

Characteristics of Burn-Injured Children in 117 U.S. PICUs (2009-2017): A Retrospective Virtual Pediatric Systems Database Study

OBJECTIVES

To describe characteristics and outcomes of children with burn injury treated in U.S. PICUs.

DESIGN

Retrospective study of admissions in the Virtual Pediatric Systems, LLC, database from 2009 to 2017.

SETTING

One hundred and seventeen PICUs in the United States.

PATIENTS

Patients less than 18 years old admitted with an active diagnosis of burn at admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,056 patients were included. They were predominantly male (62.6%) and less than 6 years old (66.7%). Cutaneous burns were recorded in 92.1% of patients, mouth/pharynx burns in 5.8%, inhalation injury in 5.1%, and larynx/trachea/lung burns in 4.5%. Among those with an etiology recorded (n = 861), scald was most common (38.6%), particularly in children less than 2 years old (67.8%). Fire/flame burns were most common (46.6%) in children greater than or equal to 2 years. Multiple organ failure was present in 26.2% of patients. Most patients (89%) were at facilities without American Burn Association pediatric verification. PICU mortality occurred in 4.5% of patients. On multivariable analysis using Pediatric Index of Mortality 2, greater than or equal to 30% total body surface area burned was significantly associated with mortality (odds ratio, 5.40; 95% CI, 2.16-13.51; p = 0.0003). When Pediatric Risk of Mortality III was used, greater than or equal to 30% total body surface area burned (odds ratio, 5.45; 95% CI, 1.95-15.26; p = 0.001) and inhalation injury (odds ratio, 5.39; 95% CI, 1.58-18.42; p = 0.007) were significantly associated with mortality. Among 366 survivors (18.6%) with Pediatric Cerebral Performance Category or Pediatric Overall Performance Category data, 190 (51.9%) had a greater than or equal to 1 point increase in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category disability category and 80 (21.9%) had a new designation of moderate or severe disability, or persistent vegetative state.

CONCLUSIONS

Burn-injured patients in U.S. PICUs have a substantial burden of organ failure, morbidity, and mortality. Coordination among specialized facilities may be particularly important in this population, especially for those with higher % total body surface area burned or inhalation injury.

Use of Fresh Scalp Allografts From Living Relatives for Extensive Deep Burns in Children: A Clinical Study Over 7 Years

Conventionally, pediatric patients with major burns need frozen cadaveric allografts to save their lives. However, these allografts are insufficient in many burn units because of cultural and local governmental laws in China. This paper reported 22 pediatric patients with major burns who received fresh scalp allografts from their parents, siblings, or relatives from January 2011 to December 2017. These 22 pediatric patients sustained deep partial-thickness to full-thickness burns involving 40% total body surface area (TBSA) on average. Wounds were covered with fresh scalp allografts alone or with postage stamp autografts and fresh scalp allografts post excision. Data were collected from medical files of the treated patients, including sex, age, etiology of burn injury, abbreviated burn severity index (ABSI), and TBSA. Postoperative variables included early survival rate of skin grafts, mean time to rejection, length of hospital stay (LHS), healing time of donor sites, and follow-up complications of donors. The 1-year survival rate of the 22 pediatric patients included into the study was 100%. The early survival rate of the scalp allografts was similar to the autografts. The mean time to rejection was 15.5 ± 3.60 days. The average LHS was 58 days. All donor sites healed within 7.6 days on average, without scar formation, alopecia areata, or folliculitis. Following up data of the donors revealed a full psychological sense of accomplishment and no regrets of donating the scalp to save the burned children. Therefore, the use of fresh scalp allografts is a feasible alternative to save pediatric patients with major burns when frozen allografts are unavailable.

Weaning of Children With Burn Injury by Noninvasive Ventilation: A Clinical Experience

The aim of this study was to report the respiratory management of a cohort of infants admitted to a Pediatric Intensive Care Unit (PICU) over a 7-year period due to severe burn injury and the potential benefits of noninvasive ventilation (NIV). A retrospective review of all pediatric patients admitted to PICU between 2009 and 2016 was conducted. From 2009 to 2016, 118 infants and children with burn injury were admitted to our institution (median age 16 months [IQR = 12.2-20]); 51.7% of them had face burns, 37.3% underwent tracheal intubation, and 30.5% had a PICU stay greater than 7 days. Ventilated patients had a longer PICU stay (13 days [IQR = 8-26] vs 4.5 days [IQR = 2-13]). Both ventilation requirement and TBSA% correlated with PICU stay (r = .955, p < .0001 and r = .335, p = .002, respectively), while ventilation was best related in those >1 week (r = .964, p < .0001 for ventilation, and r = -.079, p = .680, for TBSA%). NIV was introduced in 10 patients, with the aim of shorten the invasive ventilation requirement. As evidenced in our work, mechanical ventilation is frequently needed in burned children admitted to PICU and it is one of the main factors influencing PICU length of stay. No difference was found in terms of PICU length of stay and invasive mechanical ventilation time between children who underwent NIV and children who did not, despite children who underwent NIV had a larger burn surface. NIV can possibly shorten the total invasive ventilation time and related complications.

Our Inner-city Children Inflicted With Burns: A Retrospective Analysis of Pediatric Burn Admissions at Harlem Hospital, NY

Pediatric burns in the urban environment present special problems. Communities in the inner-city may be unique with hardships due to various socioeconomic factors. Few, if any, papers have specifically sought to analyze pediatric burns in the inner-city, and there has been no report to date reviewing Harlem New York City, one of the most challenged areas in the nation. The aim of this study is to understand the prehospital circumstances and socioeconomic factors of affected patients, hospital care, and management of pediatric patients admitted with burns in Harlem. A retrospective review was performed of all the patients aged 0 to 18 years old admitted to the burn care unit from January 2006 to May 2017. Data collected included age, gender, ethnicity, burn mechanism, total burn surface area, first aid and management, socioeconomic factors including parental supervision, single or binary parenting, caregiver financial and employment status, New York City Administration for Children's Services (ACS) child protective services reporting for child abuse or neglect. Analysis was done using Microsoft Excel 2016 and SPSS statistics v23. A total of 177 pediatric burn patient admissions were included. The majority of the patients were toddlers (1-5 years of age). The most common type was scald burns. The average TBSA burnt was approximately 9%. Nearly all the injuries occurred at home with more being during winter months. Strikingly, the majority of patients, over 75%, did not receive appropriate first aid measures. Moreover, socioeconomic issues were significant with 60% of patients having single parents, approximately 35% with lack of supervision and neglect or abuse reported in 25% of these cases. Unemployment rate of the caregiver was high, with 50% unemployed or in between jobs. In 73% of the patients, their parents were receiving some form of social aid for childcare and sustenance of family needs. Pediatric burns are a major public health issue. An understanding of community variations with these injuries is essential taking into account socioeconomic challenges that these children face. Our inner-city hospital pediatric burn admissions have substantial caregiver and socioeconomic challenges in excess of traditionally reported in the literature. Most injuries occurred at home and the majority lacked proper prehospital first aid care. This analysis is informative, providing professionals and caregivers topics of consideration regarding safe practices at home, appropriate first aid measures, prevalent socioeconomic issues in our community in Harlem. There is a need to address socioeconomic factors which may potentially prevent pediatric burn admissions in these inner-city communities.

Variations in access to specialty care for children with severe burns

BACKGROUND

Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access.

METHODS

Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not.

RESULTS

Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692).

CONCLUSION

The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.

The seasonal and monthly distribution of body limbs affected by burns in paediatric patients in southeast Turkey

Studies on the frequency of burned limbs according to season and months are limited. The burning of some body limbs, especially in some months, shows that the causes of burns are different, and knowing the reasons is important for providing preventive measures. The aims of this study were to determine the distribution rate of child burns by months and seasons and to contribute to preventive measures by determining the distribution of the burning of body limbs by months. We retrospectively evaluated 419 paediatric patients (0-17 years of age) who were hospitalised in the burn unit between 1 May 2017 and 1 November 2018. The demographic characteristics of the patients were recorded according to age, gender, months, and seasons of the patients admitted; cause of burns; degree of burns; total body surface area; and burning regions. The distribution of burns by months was established as being mainly in May to October. As for the distribution of the patients according to the seasons, it was found that it was most common in summer, 122 (29.1%), and in the autumn season as well, it was 122 (29.1%). While body burns increased in the summer-autumn seasons (P < .023), genital area burns were the lowest in winter and were the highest in summer and autumn seasons. Genital site burns increased statistically in September, October, and November (P < .010). Burn traumas are observed to be more frequent in some seasons and months. The environments where individuals live, forms of life, forms of warming, areas of interest, and sociocultural and economic levels are the causes of this variability.

Clearance of Indocyanine Green in Severe Pediatric Burns

BACKGROUND

Clearance of indocyanine green dye (ICGc) reflects sinusoidal perfusion and hepatocyte cell membrane function. Thus, ICGc is a reflection of the functional reserve of intact hepatocytes. The purpose of this study was to identify predictors of ICGc in severely burned children during the acute hospitalization and at the time of discharge from the intensive care unit (ICU). A secondary aim was to determine the relationship between liver size and patient ICGc.

METHODS

Twenty-six children (0.8-17 years old) with 35% or greater total body surface area burned (%TBSA-B) were included. Assessment of ICGc (in milliliters per minute per meter squared) was done during the acute hospitalization (median: 6 days after admission, median: 14 days postburn) and at the time of discharge from the ICU (median: 19 days after admission, median: 27 days postburn). Age, TBSA-B, % third-degree burns, inhalation injury, preexisting chronic malnutrition, hematocrit, liver dysfunction, and time from burn injury were incorporated in multiple linear regressions as predictive variables of ICGc. Only variables with p < 0.05 were retained in the final models.

RESULTS

Time from injury and age were the strongest predictors of ICGc during the acute admission but not at the time of discharge from the ICU. Time from injury was negatively associated with ICGc, whereas age was positively associated. At the time of discharge from the ICU, ICGc was increased in proportion to the %TBSA-B, whereas inhalation injury and preexisting chronic malnutrition were associated with lower ICGc. There was no correlation between change-to-predicted liver length and ICGc.

CONCLUSIONS

The intrinsic ability of the liver to extract ICG from plasma was lower in younger burned patients during the acute admission and in those with preexisting chronic malnutrition and inhalation injury at the time of discharge from the ICU.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, level III.

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.

Pediatric inhalation injury

Smoke inhalation injury can cause severe physiologic perturbations. In pediatric patients, these perturbations cause profound changes in cardiac and pulmonary physiology. In this review, we examine the pathology, early management options, ventilator strategy, and long-term outcomes in pediatric patients who have suffered a smoke inhalation injury.

The Effect of Burn Center Volume on Mortality in a Pediatric Population: An Analysis of the National Burn Repository

The effect of burn center volume on mortality has been demonstrated in adults. The authors sought to evaluate whether such a relationship existed in burned children. The National Burn Repository, a voluntary registry sponsored by the American Burn Association, was queried for all data points on patients aged 18 years or less and treated from 2002 to 2011. Facilities were divided into quartiles based on average annual burn volume. Demographics and clinical characteristics were compared across groups, and univariate and multivariate logistic regressions were performed to evaluate relationships between facility volume, patient characteristics, and mortality. The authors analyzed 38,234 patients admitted to 88 unique facilities. Children under age 4 years or with larger burns were more likely to be managed at high-volume and very high-volume centers (57.12 and 53.41%, respectively). Overall mortality was low (0.85%). Comparing mortality across quartiles demonstrated improved unadjusted mortality rates at the low- and high-volume centers compared with the medium-volume and very high-volume centers although univariate logistic regression did not find a significant relationship. However, multivariate analysis identified burn center volume as a significant predictor of decreased mortality after controlling for patient characteristics including age, mechanism of injury, burn size, and presence of inhalation injury. Mortality among pediatric burn patients is low and was primarily related to patient and injury characteristics, such as burn size, inhalation injury, and burn cause. Average annual admission rate had a significant but small effect on mortality when injury characteristics were considered.

The Parkland Burn Center experience with 297 cases of child abuse from 1974 to 2010

INTRODUCTION

Pediatric burns due to abuse are unfortunately relatively common, accounting for 5.8-8.8% of all cases of abuse annually. Our goal was to evaluate our 36-year experience in the evaluation and management of the victims of abuse in the North Texas area.

METHODS

A prospectively maintained database containing records on all admissions from 1974 through 2010 was queried for all patients aged less than 18 years. Patients admitted for management of a non-burn injury were excluded from the analysis.

RESULTS

Of 5,553 pediatric burn admissions, 297 (5.3%) were due to abuse. Children with non-accidental injuries tended to be younger (2.1 vs. 5.0 years, p<0.0001) and male (66.0 vs. 56.5%, p=0.0008). Scald was the most common mechanism of injury overall (44.8%), and was also the predominant cause of inflicted burns (89.6 vs. 42.3%, p<0.0001). Multivariate logistic regression identified age, gender, presence of a scald, contact, or chemical burn, and injury to the hands, bilateral feet, buttocks, back, and perineum to be significant predictors of abuse. Victims of abuse were also found to have worse outcomes, including mortality (5.4 vs. 2.3%, p=0.0005). After adjusting for age, mechanism of injury, and burn size, abuse remained a significant predictor of mortality (OR 3.3, 95% CI 1.5-7.2) CONCLUSIONS: Clinicians should approach all burn injuries in young children with a high index of suspicion, but in particular those with scalds, or injuries to the buttocks, perineum, or bilateral feet should provoke suspicion. Burns due to abuse are associated with worse outcomes, including length of stay and mortality.

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.

Long term mortality in burned children

Studies about risk factors for mortality in burn children are scarce and are even less in the follow up of this population across time. Usually, after complete event attendance, children are not follow-up as risk patients, burn injury affects all facets of life. Integration of professionals from different disciplines has enabled burn centers to develop collaborative methods of assessing the quality of care delivered to patients with burns. In this editorial we comment the paper of Duke et al. The authors highlight the importance of maintaining a long-term monitoring of children who suffered burns. The importance of this original study is to promote the reconsideration of clinical guides of long-term follow-up of burn patients.

Do standard burn mortality formulae work on a population of severely burned children and adults?

Accurate prediction of mortality following burns is useful as an audit tool, and for providing treatment plan and resource allocation criteria. Common burn formulae (Ryan Score, Abbreviated Burn Severity Index (ABSI), classic and revised Baux) have not been compared with the standard Acute Physiology and Chronic Health Evaluation II (APACHEII) or re-validated in a severely (≥20% total burn surface area) burned population. Furthermore, the revised Baux (R-Baux) has been externally validated thoroughly only once and the pediatric Baux (P-Baux) has yet to be. Using 522 severely burned patients, we show that burn formulae (ABSI, Baux, revised Baux) outperform APACHEII among adults (AUROC increase p<0.001 adults; p>0.5 children). The Ryan Score performs well especially among the most at-risk populations (estimated mortality [90% CI] original versus current study: 33% [26-41%] versus 30.18% [24.25-36.86%] for Ryan Score 2; 87% [78-93%] versus 66.48% [51.31-78.87%] for Ryan Score 3). The R-Baux shows accurate discrimination (AUROC 0.908 [0.869-0.947]) and is well-calibrated. However, the ABSI and P-Baux, although showing high measures of discrimination (AUROC 0.826 [0.737-0.916] and 0.848 [0.758-0.938]) in children), exceedingly overestimates mortality, indicating poor calibration. We highlight challenges in designing and employing scores that are applicable to a wide range of populations.

Post-burn hepatic insulin resistance is associated with endoplasmic reticulum (ER) stress

Insulin resistance with its associated hyperglycemias represents one significant contributor to mortality in burned patients. A variety of cellular stress-signaling pathways are activated as a consequence of burn. A key player in the cellular stress response is the endoplasmic reticulum (ER). Here, we investigated a possible role for ER-stress pathways in the progression of insulin function dysregulation postburn. Rats received a 60% total body surface area thermal injury, and a laparotomy was performed at 24, 72, and 192 h postburn. Liver was harvested before and 1 min after insulin injection (1 IU/kg) into the portal vein, and expression patterns of various proteins known to be involved in insulin and ER-stress signaling were determined by Western blotting. mRNA expression of glucose-6-phosphatase and glucokinase were determined by reverse-transcriptase-polymerase chain reaction and fasting serum glucose and insulin levels by standard enzymatic and enzyme-linked immunosorbent assay techniques, respectively. Insulin resistance indicated by increased glucose and insulin levels occurred starting 24 h postburn. Burn injury resulted in activation of ER stress pathways, reflected by significantly increased accumulation of phospho-PKR-like ER-kinase and phosphorylated inositol requiring enzyme 1, leading to an elevation of phospho-c-Jun N-terminal kinase and serine phosphorylation of insulin receptor substrate (IRS) 1 postburn. Insulin administration caused a significant increase in tyrosine phosphorylation of IRS-1, leading to activation of the phosphatidylinositol 3 kinase/Akt pathway in normal liver. Postburn tyrosine phosphorylation of IRS-1 was significantly impaired, associated with an inactivation of signaling molecules acting downstream of IRS-1, leading to significantly elevated transcription of glucose-6-phosphatase and significantly decreased mRNA expression of glucokinase. Activation of ER-stress signaling cascades may explain metabolic abnormalities involving insulin action after burn.

Epidemiology and profile of pediatric burns in a large referral center

BACKGROUND

Burns are a preventable cause of pediatric injury with over 100 000 annual hospitalizations. The authors hypothesize that analysis of injury patterns can generate age-specific and injury-specific prevention strategies to reduce these injuries.

METHODS

Data from the burn registry were collected over a 9-year period. Cross-tabulations were employed to examine associations. An analysis of variance model was used to examine differences in injury pattern.

RESULTS

Burns in children less than 1 year accounted for 16% of all admissions. The most common mechanism of injury was scalds (48.4%). Electrical and chemical burns occurred more often in older children. Suspected abuse (N = 142) accounted for 6.7% of all admissions. House fire injuries (N = 94) had a higher mean total burn surface area (18.2%). Smoke detectors were present in two thirds of the cases.

CONCLUSIONS

These predictors can form the basis for targeted public health initiatives with a potential reduction in the number of burn injuries.

Clinical and demographic features of pediatric burns in the eastern provinces of Turkey

Background

The aim of this study is to perform a retrospective analysis of the causes of burns observed in children in the eastern provinces of Turkey.

Method

In this study, patients were studied retrospectively with regard to their age, sex, cause of burns, seasonal variations, social and economic factors, length of hospital stay, burned body surface area, medical history, site of injury, and mortality.

Results

A total of 125 patients undergoing inpatient treatment were male, (53.2%) and 110 were female (46.8%). The most common causes of burns in patients treated on an inpatient basis were scald burns (65.5%) and tandir burns (15.7%). The mean total body surface area of all the patients was 12.17+9.86%. When the patients were grouped according to tandir, cauldron, and others burn causes, a significant difference was seen between the in burn percentages caused by tandir and cauldron burns and other causes (p < 0.001). Higher burn percentages were seen for cauldron burns than for tandir burns (p < 0.05). The average length of hospital stay was 17.67+13.64 days. When the patients were grouped according to burn causes (tandir, cauldron, and others), a significant difference was determined between the hospitalization periods of patients with tandir burns and other burn causes (p = 0.001) The most commonly proliferating microorganism in burned areas was Pseudomonas aeruginosa (20.4%). Of the 235 patients, 61 were treated in operating rooms. During the 24-month period of the study, 2 of the 235 patients died (0.85%).

Conclusion

Pediatric burns in the eastern part of Turkey are different from those in other parts of Turkey, as well as in other countries. Due to the lifestyle of the region, tandir and cauldron burns, which cause extensive burn areas and high morbidity, are frequently seen in children. Therefore, precautions and educational programs related to the use of tandirs and cauldrons are needed in this region.

Variations in U.S. pediatric burn injury hospitalizations using the national burn repository data

An understanding of population-specific variation in pediatric burn injuries is essential to the development of effective prevention strategies. The purpose of this study was to examine the etiology of pediatric burn injury considering age and race categories using the National Burn Repository. The authors reviewed the records of all pediatric patients (age <18 years) in the American Burn Association's National Burn Registry injured between 1995 and 2007. The authors compared patient and injury characteristics across race, age, etiology, and payor status. A total of 46,582 patients were included in this study. The etiology of burn injury varied by both age and race. Populations of color were younger, constituting 53.8% of patients younger than 5 years, whereas 53.9% of the total study population identified as Caucasian. Scald etiology was disproportionately less common in patients identifying as Caucasian (39.9 vs 61.4%, P < .001), and scald was a common etiology in older children identifying as African American, Asian, and Hispanic. Inhalation injuries were also higher in patients identifying as Native American (5.4%), Hispanic (4.2%), and African American (3.7%). Pediatric burn injury etiology varies with age and race. These data should encourage careful consideration of race, age, and other differences in formulating the most effective, population-specific prevention and outreach strategies.

Risk factors for the development of pneumonia in older adults with burn injury

Older adults with burns are at risk for worse outcomes because of factors related to age, comorbidities, and response to treatment. Although the impact of pneumonia has been previously described in burn patients, less is known in the older adult population. In this study, we used the National Burn Repository to characterize patient and injury factors associated with pneumonia development in older adults with burns. We examined the records of all patients in the National Burn Repository aged 55 years and older from 1995 to 2007. To better characterize the effects of age on outcomes, patients were stratified into three categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Pneumonia was identified by listed complications and ICD-9 codes. Comorbidities were classified by Charlson Comorbidity Index Score. Unadjusted and multivariate regression analyses were performed to distinguish the impact of age, comorbidities, and injury factors on pneumonia development and mortality. A total of 23,794 patient records met inclusion criteria during the study period, and 2,052 (8.6%) had pneumonia. Patients who developed pneumonia were more likely to be men (65 vs 56%, P < .001), have higher TBSA (21 vs 13%, P < .001), have sustained inhalation injury (21 vs 7%, P < .001), and have comorbid condition (34 vs 13%, P < .001). On multivariate analysis, factors significantly associated with pneumonia development were male sex, percent TBSA, inhalation injury, and presence of comorbidity. Specifically, chronic lung and heart disease had adjusted odds ratio (OR) of 2.70 and 3.48, respectively, for development of pneumonia (P < .001). By logistic regression, adjusted OR for pneumonia were 0.89 (95% CI 0.74-1.06, P = .18) in the 65 to 74 years age group and 1.26 (95% CI 1.07-1.48, P = .005) in the oldest group compared with the 55 to 64 years age group. Pneumonia during hospitalization was associated with an adjusted OR of 1.91 for death (95% CI 1.61-2.27, P < .001) after controlling for the factors of age, sex, comorbidity, TBSA, and inhalation injury. Injury factors and the presence of comorbidities consistently predicted the development of pneumonia in this large national patient sample. Higher age category also predicted higher pneumonia risk, although this association was only significant in the highest age group. This study, thus, highlights the importance of comorbidities over chronological age in pneumonia development in older adults with burn injuries.

Simplified estimates of the probability of death after burn injuries: extending and updating the baux score

BACKGROUND

: Generations of clinicians have used the Baux score, defined as the sum of age in years and percent body burn, to predict percent mortality after trauma, but advances in burn care have rendered the predictions of this score too pessimistic. Additionally, this score does not include the effects of inhalation injury.

METHODS

: We revised the Baux score to include inhalation injury and recalibrated its predictions using a single-term logistic regression model developed using data on 39,888 burned patients provided by the national burn repository. We compared this revised Baux score to a more complex logistic regression model derived from the same data set and predictors.

RESULTS

: A preliminary logistic regression model showed that age and percent burn contribute almost equally to mortality and further that the presence of inhalation injury added the equivalent of 17 years (or 17% burn). These observations suggested a revised Baux Score:Age + Percent Burn + 17 * (Inhalation Injury, 1 = yes, 0 = no)A logistic model based on the Revised Baux Score performed well, but a more complex model obtained using modern statistical model building tools had better discrimination and calibration.

CONCLUSIONS

: Our proposed revised Baux score is simple enough for mental calculation, and its inverse logit transformation (provided with a calculator or nomogram) can provide precise predictions of mortality. Better predictions can be obtained using our more complex statistical model. Burn surgeons and nurses accustomed to using the original Baux score may welcome an updated version.

Pediatric burn injuries treated in US emergency departments between 1990 and 2006

OBJECTIVE

The goal was to examine comprehensively the patterns and trends of burn-related injuries in children, adolescents, and young adults treated in US emergency departments between 1990 and 2006.

METHODS

Through use of the National Electronic Injury Surveillance System database, cases of nonfatal burn-related injuries were selected by using diagnosis codes for burns (scalds, thermal, chemical, radiation, electrical, and not specified). Sample weights were used to calculate national estimates. US Census Bureau data were used to calculate injury rates per 10000 individuals <or=20 years of age. Computation of relative risks with 95% confidence intervals was performed.

RESULTS

An estimated 2054563 patients <or=20 years of age were treated in US emergency departments for burn-related injuries, with an average of 120856 cases per year. Boys constituted 58.6% of case subjects. Children <6 years of age sustained the majority of injuries (57.7%), and more than one half of all injuries (59.5%) resulted from thermal burns. The body parts injured most frequently were the hand/finger (36.0%), followed by the head/face (21.1%). Of the 1542913 cases for which locale was recorded, 91.7% occurred at home. The rate of burn-related injuries per 10000 children decreased 31% over the 17-year time period.

CONCLUSIONS

Burn-related injuries are a serious problem for individuals <or=20 years of age and are potentially preventable. Children <6 years of age consistently sustained a disproportionately large number of injuries during the study period. Increased efforts are needed to improve burn-prevention strategies that target households with young children.

Pediatric fluid resuscitation after thermal injury

Fluid resuscitation after thermal injury in a child or infant can pose a set of unique and significant challenges. Many approaches to fluid resuscitation of children after burns exist, and most are nonevidence based. This review will highlight the important concepts involved in pediatric fluid resuscitation from thermal injury.

Paediatric ICU burns in Finland 1994-2004

INTRODUCTION

The paediatric burn population requiring intensive care in Finland has never been examined before. The aim of this study was firstly to determine the aetiology, incidence and prognosis of paediatric burns requiring intensive care in Finland and secondly to compare the possible differences between the two national burn centres.

METHODS

All burn patients' charts were retrospectively reviewed in two national burn centres from an 11-year-period. Patients whose ICU stay was more than 48h, were included.

RESULTS

Forty-five children who were hospitalized in the two burn centres during the study period met the inclusion criteria. They represent 2.4% (45/1898) of all burns victims hospitalized in these burn centres during that time giving an incidence of 0.1/100,000 per year in Finland. The median age was 5 years, every third patient was 0-2 years old and 75.6% were male. Most burns were scalds (42.2%), which caused all burns (100%) in age group 0-2 years. Flame burns were most frequent (83%) in the age group 6-10 years. In the 11-16 years old patients, high voltage/electric burns caused 50% of all burns and flame the other 50%. The overall median TBSA in all burns was 26%. The median (range) hospital stay was 12 days (2-193) (0.88 days/% burned) and the median (range) ICU days was 7 (2-64) (0.29 days/%). Intubation and respirator therapy was needed in 31 (46%) patients. There were no patients who needed haemofiltration or haemodialysis and no mortality. Only six patients (13%) were treated conservatively and 39 (87%) surgically. Dressing changes under general anaesthesia were preferred in Helsinki (37 times) and especially in the paediatric hospital (32 times) compared to Kuopio (7 times). Allografts were used only in Helsinki in 4 patients whereas artificial skin was used only in Kuopio in 15 patients. The overall cost of care was very similar in both centres being 1292-1425 euros per hospital day.

CONCLUSIONS

There were some small differences between the two burn centres in treatment policies. Most patients were male and most common aetiology was scald. The prognosis of these patients was excellent with no mortality.