The Impact of Combined Trauma and Burns on Patient Mortality

Characteristics and clinical outcomes of patients with combined burns and trauma in Japan: Analysis of a nationwide trauma registry database

INTRODUCTION

Patients with combined burns and trauma are often seen in the United States. The combination of trauma with burns increases mortality. In contrast, the characteristics and outcomes of these cases remain unknown in Japan. This study investigated the characteristics and outcomes of trauma associated with burns in Japan.

METHODS

This multicenter retrospective cohort study was conducted by utilizing data from the Japan Trauma Data Bank for the period between 2004 and 2017. We evaluated the characteristics of burn patients (n = 5783) divided into two groups: burns only (n = 5537) and combined burns and trauma (n = 246). Clinical characteristics, including patient background, severity of trauma, injury mechanism, total body surface area affected, injury location, treatments, and clinical outcomes, were examined.

RESULTS

Most patients in both the groups were injured by flames. The number proportion of patients with 40-89% of the total body surface area affected was 1069/5537 (19.3%) in the burn-only group and 23/246 (9.3%) in the combined burn and trauma group. The in-hospital mortality was 1006/5537 (18.2%) in the burn-only group and 17/246 (6.9%) in the combined burn and trauma group.

CONCLUSIONS

We demonstrated the characteristics of Japanese patients with burns only compared with those with combined burns and trauma. Flames were the main cause of burns, and in-hospital mortality was lower in the combined burn and trauma group associated with a smaller burn area.

Inter-facility transfers for burn patients with concomitant traumatic injuries

Burn patients with concomitant traumatic injuries suffer increased morbidity and mortality. Complex care coordination is necessary for these patients, and the prevalence of resulting inter-facility transfers has not yet been quantified by literature. This study examined the outcomes for traumatically injured burn patients to identify the occurrence of trauma system transfers in this group. The National Trauma Data Bank was reviewed from the years 2007-2016 for 6,565,577 patients with traumatic, burn, and concomitant burn & traumatic injuries. There were 5068 patients with both traumatic and burn injuries, 145,890 patients with burn injuries, and 6,414,619 patients with traumatic injuries. Trauma/burn patients were more often admitted to the ICU from the ED at a rate of 35.5% compared to 27.1% for burn and 19.4% for trauma (P < 0.001). For disposition when discharged from the hospital, trauma/burn patients required more inter-facility transfers at a rate of 2.5% compared to 1.7% for burn and 1.3% for trauma (P < 0.001). For level I trauma centers, 5.5% of trauma/burn, 7.1% of burn, and 0.5% of trauma patients required inter-facility transfers. For level II trauma centers, 29.1% of trauma/burn, 47.0% of burn, and 2.8% of trauma patients required inter-facility transfers. Among level I and level II trauma centers, patients with only burns and burn patients with concomitant traumatic injuries required more inter-facility transfers, and level II trauma centers required more inter-facility transfers for all patients. Quantifying these findings is the first step toward improving triage decisions and allocation of health care resources while expediting appropriate care.

The Impact of Flame Burn Injuries on Patients Who Sustain Mild Injuries From Motor Vehicle Crashes

BACKGROUND

The purpose of this study was to determine the differences in patient outcomes between motor vehicle crash (MVC) victims with an ISS < 15 and those with a similar ISS and a flame burn injury.

METHODS

Data for patients involved in a MVC with a GCS ≥12 and an ISS < 15 with and without flame burn injury were reviewed from the American College of Surgeons National Trauma Data Bank between 2007 and 2017. International Classification of Diseases-9 and -10 revisions and External Injury Codes were used to identify patients who were divided into MVC only (Group 1) and MVC with additional flame burn injury (Group 2). In-hospital mortality was the primary outcome whereas secondary outcomes included ICU admission, ICU length of stay (LOS), hospital LOS, sepsis, deep vein thrombosis, acute respiratory distress syndrome, and pneumonia. Simple linear regression was used in the form of odds ratios to investigate risk factors for mortality and secondary outcomes.

RESULTS

The mean LOS and ICU LOS were longer in Group 2 (5.9 vs 4.0 days, p-value <0.001, and 1.2 vs 0.6 days, p-value <0.001, respectively), with more patients being admitted to the ICU as well (22.9% vs 17.3%, p-value <0.001). Also, there were significantly higher rates of pneumonia (0.8% vs 0.5%, p-value 0.0014), deep vein thrombosis (0.6% vs 0.4%, p-value 0.028), and acute respiratory distress syndrome (0.5% vs 0.3%, p-value 0.004) in Group 2. Patients in Group 1 were older and more likely had hypertension, congestive heart failure, and COPD. There was no significant difference in mortality between Groups by odds ratios (OR 0.85, p-value 0.743) or raw percentages (0.3% vs 0.3%, p-value = 0.874).

CONCLUSION

MVC victims with mild injuries who also sustain a burn injury are more likely to require admission to the ICU regardless of their comorbidities and more likely to develop respiratory complications, especially pneumonia and an increase in ICU and hospital LOS.

Thermo-mechanical combination injuries - A rare but life-threatening entity

Thermo-mechanical-combination-injuries (TMCI) are feared for their demanding preclinical and clinical management and bear the risk of high mortality compared to the single injury of a severe burn or multiple traumata. There remains a significant lack of standardized algorithms for diagnostics, and therapy of this rare entity. The aim of the present study was to profile TMCI aiming at standardized procedures. In this study, TMCI were extracted from our burn database of a level 1 burn and trauma centre. From 2004 to 2017, all patients with TMCI were retrospectively analyzed. Further inclusion criteria were multiple trauma accompanied by burn with ≥10% TBSA. Patient and injury characteristics including ISS and outcome parameter were analyzed. A total of 45 patients matched the selective inclusion criteria of TMCI comprising of 4% of all burn injuries during the period. Average age was 38 years (range: 14-86), with a mean TBSA of 43% (range: 10-97%). The mean recorded temperature at admission was 34.8°C (range: 29.6 - 37.1) with 2215 ml volume (range: 500 - 8000) administered preclinically in total. The mean ISS was 16. The overall mortality rate was 22%. TMCI are rare and life-threatening events which require highly qualified management in combined level 1 trauma and burn centres to adress both burn and trauma treatment. The multiple injury pattern is diverse, complicating standardized management in view of burn care specific measures, as normothermia and restrictive volume management. The present study reveals further profiles and underlines the need for addressing TMCI in ABLS®; ATLS® and PHTLS® programs.

Characteristics of burn casualties treated at role 2 in Afghanistan

BACKGROUND

Role 2 medical treatment facilities (MTFs) are frequently located in austere settings and have limited resources. A dedicated assessment of burn casualties treated at this level of care has not been performed. Therefore, the objective of this study was to characterize burn casualties presenting to role 2 MTFs in Afghanistan, along with the procedures they required, complications, and mortality to begin understanding the resources consumed by their care.

METHODS

We identified burn casualties from the Department of Defense Trauma Registry (DODTR). The inclusion criteria were (1) experienced burn injuries in Afghanistan between October 2005 and April 2018 and (2) had documentation of treatment at role 2 in the DODTR. We excluded casualties with only first-degree burns, not otherwise specified burns, or only corneal burns. Casualty demographics, injury characteristics, procedures, and outcomes were reported.

RESULTS

We identified 453 burn casualties with a median (interquartile range) Injury Severity Score of 10 (4-22) and percent total body surface area burned of 11 (5-30). There were 123 casualties (27.2%) with inhalation injury, and the casualties experienced 3,343 additional traumatic injuries and needed 2,530 procedures. Casualties with documentation of resuscitation information received a median (interquartile range) of 1.9 (0.7-3.7) L of crystalloid fluids. Complications were documented in 53 casualties (11.7%). Final mortality was reported in 36 casualties (8.0%), and mortality at role 2 MTFs was reported in 7 casualties (1.5%).

CONCLUSION

Burn casualties had many injuries and needed many procedures, including those related to airway management, resuscitation, and wound care. Given the urgency of these procedures, ensuring that there is enough equipment and supplies will be important in the future. Although infrequent, some casualties experienced complications. Factors that may influence resuscitation include injury severity, concomitant traumatic injuries, and available supplies. Obtaining more contextual information on the patient care environment will be useful going forward.

LEVEL OF EVIDENCE

Epidemiological, level III.

[Reconstruction in polytraumatized burn patients]

BACKGROUND

Polytraumatized burn patients represent a rare patient collective and necessitate an individualized treatment concept due to the particular combination of injuries.

OBJECTIVE

Against the background of this special injury pattern, especially with deep burns overlying the fracture zone, the question of a specific and interdisciplinary treatment algorithm arises.

MATERIAL AND METHODS

This article is based on a PubMed database search and experiences of a trauma center for severely injured burn patients at a university hospital, with presentation of the special therapeutic requirements and goals exemplified by a case report.

RESULTS

The evaluation of the literature search and own treatment results comes to the conclusion that the rate and extent of amputations and infections can be reduced by an early and interdisciplinary involvement of the plastic surgeon by early combined fracture stabilization, excision of necrotic tissue and immediate skin grafting. Furthermore, plastic reconstructive procedures enable a functional and esthetic reconstruction with optimized prosthesis fitting.

CONCLUSION

Polytraumatized severely burned patients necessitate an interdisciplinary treatment approach, whereby preservation of length, functionality and esthetic appearance of the affected extremities and concurrent avoidance of bone and soft tissue infections have utmost priority.

Laboratory Markers in the Management of Pediatric Polytrauma: Current Role and Areas of Future Research

Severe trauma is the most common cause of mortality in children and is associated with a high socioeconomic burden. The most frequently injured organs in children are the head and thorax, followed by the extremities and by abdominal injuries. The efficient and early assessment and management of these injuries is essential to improve patients' outcome. Physical examination as well as imaging techniques like ultrasound, X-ray and computer tomography are crucial for a valid early diagnosis. Furthermore, laboratory analyses constitute additional helpful tools for the detection and monitoring of pediatric injuries. Specific inflammatory markers correlate with post-traumatic complications, including the development of multiple organ failure. Other laboratory parameters, including lactate concentration, coagulation parameters and markers of organ injury, represent further clinical tools to identify trauma-induced disorders. In this review, we outline and evaluate specific biomarkers for inflammation, acid-base balance, blood coagulation and organ damage following pediatric polytrauma. The early use of relevant laboratory markers may assist decision making on imaging tools, thus contributing to minimize radiation-induced long-term consequences, while improving the outcome of children with multiple trauma.

Results From an Evidenced-Based Curriculum Design With Innovative Simulators to Prepare Providers in Caring for Those With Burn Injuries

Burn care and medical education have undergone dramatic changes. Trauma has over seven courses covering fundamentals, whereas burns has one. Our goal was to develop a course to meet the needs of healthcare professionals requiring more advanced burn management training. A survey was distributed to burn physicians, nurses, therapists, administrators, and survivors, to assess the perceived proficiency of those managing adult and pediatric patients. Procedure simulators were developed, and a course was designed and delivered. An after-course survey of participants captured how this course filled identified knowledge gaps. A total of 188 initial surveys were sent to individuals involved in burn care. A diverse pool of 109 individuals participated (58% response rate). Survey results by providers demonstrated the lowest self-rated proficiency scores at managing large pediatric burns and frostbite. Nonphysicians reported low proficiency in developing wound treatment algorithms, performing escharotomies, and aftercare/reintegration. Following rigorous curriculum development, the course was conducted, and after-course surveys noted students' improved understanding of managing burn injuries, ability to troubleshoot, confidence to manage patients, and their recommending the course to a peer. Providing quality care beyond the initial assessment and stabilization of a burn-injured patient requires additional skills and knowledge. Providers that are uncomfortable or challenged in providing this care may benefit from additional training. Initial data show that a course, such as this one, provides the education necessary to fill the most commonly reported gaps in knowledge and skills. Further work is being invested to develop disaster management skills, assessment components, and further determine course validity.

No Difference in Mortality Between Level I and II Trauma Centers for Combined Burn and Trauma

BACKGROUND

Trauma patients with burn injuries have higher morbidity and mortality rates compared with patients who solely experience burn or trauma injuries. There is a paucity of data regarding burn-trauma (BT) patient outcomes at level I (LI) trauma centers compared with level II (LII) centers. We hypothesized that BT patients at LI trauma centers have lower mortality rates than those at LII trauma centers.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients aged ≥18 y who had BT injuries. Patients treated at an LI were compared with those at an LII center with a primary outcome of in-hospital mortality. Secondary outcomes included hospital length of stay (LOS) and intensive care unit (ICU) LOS. A multivariable logistic regression analysis was used to identify factors associated with all-cause mortality.

RESULTS

From 1971 BT patients, 1540 (78%) were treated at an LI trauma center, and 431 (22%) at an LII center. Compared with LII centers, LI BT patients had a longer median LOS (10 versus 7 d; P < 0.001) and ICU LOS (5 versus 4 d; P < 0.001). Both LI and LII centers had similar mortality rates (8.5% versus 7.0%; P = 0.300). On multivariable analysis, receiving care at an LI trauma center was not associated with decreased mortality (odds ratio 0.79, 95% confidence interval 0.42-1.48; P = 0.456).

CONCLUSIONS

We report that LI trauma center BT patients had an increased hospital and ICU LOS compared with those at LII centers. However, there was no significant difference in mortality between patients cared for at LI and LII trauma centers in risk-adjusted models.

Patients With Combined Thermal and Intraabdominal Injuries: More Salvageable Than Not

This study aims to better characterize the course and outcome of the uncommon subset of trauma patients with combined thermal and intraabdominal organ injuries. The National Trauma Data Bank was queried for burn patients with intraabdominal injury treated in all U.S. trauma centers from July 1, 2011 to June 30, 2015. General demographics, Glasgow coma scale (GCS), shock index (SI), Abbreviated Injury Scale (AIS) for burn, Injury Severity Score (ISS), blood transfusions, and abdominal surgery were evaluated. During the 5-year study period, there were 334 burn patients with intraabdominal injury, 39 (13.2%) of which received abdominal surgery. Burn patients who underwent operations had more severe injuries reflected by higher SI, AIS, ISS, blood transfusion, and worse outcomes including higher mortality, longer hospital and ICU length of stay, and more ventilator days compared to patients who did not undergo an operation. Nonsurvivors also exhibited more severe injuries, and a higher proportion received abdominal operation compared to survivors. Multivariate logistic regression analysis revealed that GCS on arrival, SI, AIS, ISS, blood transfusion, and abdominal operation to be independent risk factors for mortality. Propensity score matching to control covariables (mean age, systolic blood pressure on arrival, GCS on arrival, SI, ISS, time to operation, blood transfusion, and comorbidities) showed that of trauma patients who received abdominal operation, those with concomitant burn injury exhibited a higher rate of complications but no significant difference in mortality compared to those without burns, suggesting that patients with concomitant burns are not less salvageable than nonburned trauma patients.

Mortality following combined burn and traumatic brain injuries: An analysis of the national trauma data bank of the American College of Surgeons

BACKGROUND

Severe burn and traumatic brain injuries (TBI) lead to significant mortality, and combined burn-TBI injuries may predispose towards even worse outcomes. The purpose of this study was to investigate the mortality of patients with burn, burn with non-TBI trauma, and combined burn/TBI to determine if combined injury portends a worse outcome.

METHODS

We obtained the National Trauma Data Bank from 2007 to 2012, identifying 32,334 patients with burn related injuries, dividing this cohort into three injury types: BURN ONLY, BURN with TRAUMA/NO TBI, and BURN with TBI. For each patient, demographic data was obtained, including age, gender, presence of trauma, TBI, or inhalation injury, burn total body surface area (TBSA), Glasgow Coma Scale, Injury Severity Score, and mortality. Multivariable logistic regression was performed.

RESULTS

Age, gender, and TBSA were similar across the three injury groups, but the incidence of inhalation injury was doubled in the BURN with TRAUMA/NO TBI (15.4 %) and BURN with TBI (15.3 %) groups when compared to the BURN ONLY (7.2 %) group. Mortality differed across injury categories after adjusting for age, TBSA, and inhalation injury. Increased mortality was seen in BURN with TRAUMA/NO TBI versus BURN ONLY (OR = 1.27 [1.06, 1.53]) and was higher when comparing BURN with TBI versus BURN ONLY (OR = 4.22 [2.85, 6.18]). BURN with TBI also had higher mortality when compared to BURN with TRAUMA/NO TBI (OR = 3.33 [2.30, 4.82]). The logs odds of mortality also increased with increasing age, TBSA and presence of inhalation injury.

DISCUSSION

This analysis of the NTDB suggests that mortality following burn-related injuries may be higher when burn injury is combined with TBI when compared to burns with other trauma, even after correcting for age, TBSA, and inhalation injury. Further clinical and laboratory research is needed to validate these findings and better understand how to optimize combined TBI and burn injury treatment.

Collocated burn and fracture injuries in major trauma: a 10 year experience

INTRODUCTION

Collocated burn and fracture injuries, defined as a burn overlying the site of a fracture, represent a serious subset of major burns and trauma. The literature pertaining to these rare injuries is inconclusive. Recent studies cast doubt on the safety of operative fixation in this population. No study to date has examined outcomes of collocated burn and fracture injuries compared with control. The aim of this study was to compare characteristics, injury patterns and complication rates in major burns and fracture patients with a collocated injury to those without.

METHODS

A retrospective chart review of all consecutive patients with dermal burns and major fractures were undertaken between January 2005 and December 2015 at a tertiary referral trauma hospital. Outcomes assessed included demographics, injury characteristics and complications, including infection. Orthopaedic infection was defined as orthopaedic surgical site infection or osteomyelitis.

RESULTS

Of the 40 patients identified, 21 subjects sustained collocated injuries. Patients with collocated injuries demonstrated a trend towards higher injury severity, higher percentage of total body surface area affected, longer length of stay and greater overall and orthopaedic complication rate. Significant predictors of orthopaedic infection were related to injury severity rather than collocation or operative management.

CONCLUSION

There are differences in the characteristics and complication rates between collocated and non-collocated burn and fracture injuries. Collocated injuries tend to result from greater energy mechanisms, undergo longer inpatient stays and demonstrate increased morbidity. Injury severity appears to be the most important factor in determining postoperative orthopaedic infection. These characteristics must be considered when managing these rare but significant injuries.

Incidence of combined burns and major trauma in England and Wales

Introduction

Within the United Kingdom’s major trauma networks, limited consideration is given to the management of concomitant burns and trauma injuries, prominently highlighted in the arrangement of specialist services for major trauma and burns care. The majority of the literature regarding this topic, based almost exclusively on North American studies, predicts between 5 and 7% of all patients admitted to burns centres will suffer from concomitant (non-thermal) trauma injuries, in addition to their burn injuries. The aim of this study is to understand the epidemiology and outcomes for patients sustaining burns and trauma injuries in England and Wales.

Methods

A retrospective review of patients sustaining concomitant burns and trauma injuries was made over a 71-month period from January 2010 to November 2016, using the national trauma registry for England and Wales, the Trauma Audit and Research Network database, identifying all patients with injury codes for burns and trauma (AIS >3). Data collected comprised patient demographic information, burn injury percentages, details of trauma injuries, details of hospital stay, and patient outcome. Comparison of information was made against the total burns and total trauma cohort to form a base standard for burns and trauma injuries, respectively.

Results

Over the period analysed, 188 patients were found to have concomitant burns and trauma injuries. The patients were stratified according to age and the percentage of total body surface area burned. Hospital length of stay for concomitant burns and trauma patients was found to be higher than that of patients with isolated burns injuries. Mortality rates, although low overall, were found to be relatively higher for patients with concomitant burns and trauma injuries.

Conclusions

This study demonstrated the rarity of this combination of injury pattern, in particular the occurrence of severe burns in the presence of major trauma, in UK. Improvements in burns care and trauma care hopefully contributes to the higher level of survival in concomitantly injured patients against data from previous literature. However, the synergistic effect of burns and trauma injuries appears to impact on the course of such patients, although larger scale analysis is required to determine the true prognostic factors.

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 impact of non-thermal injuries in combined burn trauma: A retrospective analysis over the past 35 years

INTRODUCTION

Combined burn trauma is rather uncommon and frequently difficult to manage. Historically combined burn trauma contributed to high mortality rates in severely injured patients. The purpose of this study was to determine the incidence, mechanisms and impact of non-thermal injuries in patients with severe burns.

METHODS

The charts of 2536 patients admitted to the Burn Center of the University Hospital Zurich between 1977 and 2013 were reviewed and retrospectively analyzed. Patients with additional injuries were identified and analyzed statistically.

RESULTS

Over 35 years from 1977 to 2013 a total of 100 burn patients (3.9%) with additional trauma were identified. Motor vehicle crash was the most common mechanism of injury (44%) from 1977 to 1995, compared to electrical injury (33%) from 1996 to 2013. Skeletal trauma including spinal and pelvic injury was the most common form (71%). Additional thoracic or abdominal trauma represented the highest risk factor for in-hospital mortality (adjusted RR 2.2, 95% CI 0.6-7.6). However, after 1995 the presence of any form of additional injury did not have a significant impact on in-hospital mortality (unadjusted RR 0.97, 95% CI 0.5-1.7, p = 0.914).

CONCLUSIONS

Concomitant trauma did not reveal a significant impact on in-hospital mortality in our burn center recently. Retrospectively, trauma mechanisms shifted from motor vehicle crashes to electrical injuries in our population. Safety measures for motor vehicles and adequate emergency room algorithms seem to have contributed to a reduction of severity of injury and mortality.

Rising mortality in patients with combined burn and trauma

Combined trauma in the burn patient has been previously shown to have higher mortality. With improved critical care and multidisciplinary approach, we hypothesized the risk of mortality in combined burn and trauma has decreased. A retrospective analysis of trauma, burn and combined burn-trauma patients in the National Trauma Data Bank was performed comparing years 2007-2015 to years 1994-2002. The impact of burn injuries on mortality in patients with minor trauma has decreased (OR 2.45, CI 2.26-2.66, p<0.001 compared to OR 4.04, CI 4.51-4.66, p<0.001) in years 2007-2015 while the impact of burn injuries on mortality in patients with severe trauma has increased (OR 1.37, CI 1.29-1.47, p<0.001 compared to OR 1.26, CI 1.05-1.51, p<0.001). When controlling for known risk factors of mortality in burn and trauma, the contribution of the severity of trauma on mortality in combined burn-trauma patients with total body surface area ≥20% is negligible. In contrast, an increase in percentage of total body surface area burned is associated with a step-wise increase in mortality for all combined burn-trauma patients. However, the largest impact is seen in patients with minor trauma. This population represents a unique overlap of patients where future collaborative research can help identify best practices and improve outcomes.

The utility of microalbuminuria measurements in pediatric burn injuries in critical care

PURPOSE

Microalbuminuria, as measured by urinary albumin-creatinine ratios (ACRs), has been shown to be a marker of systemic inflammation and an indicator of the potential severity of trauma and critical illness. Severe pediatric burns represent the best model in which to investigate the clinical utility of microalbuminuria. This study aims to ascertain whether ACR measurements have any role in predicting the severity or the intensive care requirements in the critically unwell pediatric burn population.

MATERIALS AND METHODS

A retrospective observational study was undertaken within a regional burn center with a dedicated 8-bed burn intensive care unit (ICU). This looked at 8 years of consecutive pediatric burns requiring intensive care support-a total of 63 patients after exclusions. Daily urinary ACR measurements were acquired from all patients.

RESULTS

All patients had greater than or equal to 1 ACR measurement out with the reference range, and only 8% (5/63) presented to the ICU with a normal ACR. The median day for the peak ACR measurement was day 4. The relative lack of mortalities (3/63) precluded adequate correlations between ACR and outcomes. Peak and mean ACR values correlate well with length of ICU stay, and the peak ACR also correlates with total length of hospital stay and severity of burn injury as measured by total body surface area burnt and number of organ systems requiring support. No significant differences were found when the patients were stratified by age. The peak ACR measurement was found to be independently predictive of the length of the ICU stay. As such, we have created a predictive model to prove that an ACR that remains less than 12 mg/mmol is predicative of an ICU stay of less than or equal to 7 days.

CONCLUSIONS

The clinical utilities of ACR measurements are demonstrated by their correlation with the severity of injury, length of ICU stay, and requirements for multiple organ support. Albumin-creatinine ratios raised over certain thresholds highlight to the clinician the need for closer observation and the potential deterioration of patients.

Rat an experimental model for burns: a systematic review

PURPOSE

To revise and systematize scientific knowledge of the experimental model for cutaneous burns in rats.

METHODS

A bibliographical review from 2008 up to January 2011 in PubMed, EMBASE and LILACS was undertaken. Were used the keywords: animal models, burns and rats. 221 studies were identified, and 116 were selected.

RESULTS

It was found that: 54/86 (62.7%) had third degree burns; 55/73 (75.3%) studied the back; 45/78 (57.6%) used heated water and 27/78 (35.9%) incandescent instruments; 39/78 (50%) studied systemic effects; 22/71 (31%) used ketamine associated with xylazine; 61/64 (95.3%) performed depilation with appropriate equipment; 36/72 (50%) used microscopy; more than 50% did not describe analgesia or antibiotics during the postoperative period; in 42/116 (36.2%) postoperative fluid therapy was performed; and the time interval after the burn, up to the beginning of the results analysis varied from 7s up to four weeks. Legislation issues on burn experiments are discussed.

CONCLUSION

The hot water was the main method to induce burns those of third degree on the back, with anesthesia using ketamine and xylazine, after depilation. These were evaluated microscopically, without using analgesia or an antibiotic during the postoperative period. The studies were not very reproducible.

Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact?

BACKGROUND

Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted.

STUDY DESIGN

A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data.

RESULTS

Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data.

CONCLUSIONS

There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.

The Alfred pre-hospital fluid formula for major burns

BACKGROUND

The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg)×%TBSA burnt=mls in the first 2 h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration.

METHODS

A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period.

RESULTS

There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22-0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04-0.26) mL/kg/%TBSA administered in the prior period (p=0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24 h, the volume of fluid administered in patients when The Alfred formula was used was 4.9±1.6 mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8±2.2 mL/%TBSA/kg (p=0.802).

DISCUSSION

The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current 'gold standard'.

Microalbuminuria in acute burn injury

Microalbuminuria is a known finding in inflammatory states. We hypothesized that urinary albumin/creatinine ratio (ACR) would correlate with injury severity and resuscitation demands after acute burns. This pilot study evaluated 30 adults admitted within 12 hours of injury with burns > or =10% total body surface area burn injury (TBSA). The urinary ACR was calculated for each patient at 7 to 12 hours, 19 to 24 hours, and 43 to 48 hours following burn injury. Microalbuminuria was defined as a urinary ACR > or =20 mg/g. Study patients (23 males, 7 females) had a mean age of 42.9 + 14.0 years and a median TBSA burn injury of 18.8%. Inhalation injury was present in 10 of the study patients, and all patients with inhalation injury had microalbuminuria at the time of admission. One study patient died. Median time from burn injury to resuscitation was 30 hours, and the median fluid requirement was 4.2 ml/kg/%TBSA. Microalbuminuria was not uniformly present in burn-injured patients during the first 48 hours after injury. ACR values early in the hospital course correlated with higher lactate concentrations early after burn injury. However, ACR correlated with neither injury severity nor resuscitation demands after burn injury during any studied time range. Microalbuminuria does not have apparent clinical utility in burn-injured patients, and other markers of injury severity and resuscitation demands should be sought.

Improving the ability to predict mortality among burn patients

BACKGROUND

Early efforts to predict death following severe burns focused on age and burn size; more recent work incorporated inhalation injury and pneumonia. Gender, co-morbid illness, and co-existent trauma have been implicated in burn mortality but have rarely been incorporated into predictive models.

METHODS

The National Burn Repository (NBR) and the National Trauma Data Bank (NTDB) provided data on 68,661 (54,219 and 14,442, respectively) burn patients that was used to develop and validate, respectively, a predictive model of burn mortality. Logistic regression was used to model the odds of mortality with respect to age, gender, % body surface area burned (BSAB), co-existent trauma, inhalation injury, pneumonia, and co-morbid illness. Performance of the predictive model was assessed using a deviance statistic, receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow (HL) statistic.

RESULTS

The predictive model that demonstrated optimal performance included the variables age, percent total BSAB, inhalation injury, co-existent trauma, and pneumonia. The area under the ROC curve for this model was 0.94 and the HL statistic was 16.0. The inclusion of additional variables, i.e., gender, co-morbid illness, did not improve the performance of the model despite reduction in the model deviance. When the predictive model was applied to the validation data source, the area under the ROC curve was 0.87 and the HL statistic was 10.0, indicating good discrimination and calibration.

CONCLUSION

The results of this study suggest that a comprehensive predictive model of burn mortality incorporating certain variables not previously considered in other models provides superior predictive ability.

Burn patient characteristics and outcomes following resuscitation with albumin

BACKGROUND

Use of colloids in acute burn resuscitation may reduce fluid requirements, but effect on mortality is unknown. We hypothesized that patients who received albumin would have similar mortality to patients who did not receive albumin.

METHODS

We performed a case-controlled study of inpatients who sustained burns of > or =20% total body surface area (TBSA). Patients who received albumin during resuscitation because of increased fluid requirements (ALB) were compared to a cohort of patients matched for age and TBSA who did not receive albumin (CON).

RESULTS

Patients with inhalation injury were significantly more likely to receive albumin (OR 4.89, 95% CI 2.58-9.30). ALB patients had significantly higher mean initial lactate (3.64 versus 2.29, p=0.01), longer mean time to resuscitation (52.8 h versus 36.3 h; p=0.001), and higher resuscitation volume (9.4 mL/kg/%TBSA versus 6.4 mL/kg/%TBSA for CON). Mortality was not significantly different between the two groups (OR 1.90, 95% CI 0.85-4.22). Albumin was protective in a multivariate model of mortality (OR 0.27, 95% CI 0.07-0.97).

CONCLUSIONS

Despite more severe systemic dysfunction, burn patients who received albumin did not suffer increased mortality. A novel finding is the decreased likelihood of mortality associated with the administration of albumin during burn resuscitation.

Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom

OBJECTIVE

To assess outcome differences between locally burned civilians and military personnel burned in a distant combat zone treated in the same facility.

SUMMARY BACKGROUND DATA

The United States Army Institute of Surgical Research (USAISR) Burn Center serves as a referral center for civilians and is the sole center for significant burns in military personnel. We made the hypothesis that outcomes for military personnel burned in the current conflict in Iraq and Afghanistan would be poorer because of delays to definitive treatment, other associated injury, and distance of evacuation.

METHODS

We reviewed the civilian and military records of patients treated at the USAISR from the outset of hostilities in Iraq in April 2003 to May 2005. Demographics, injury data, mortality, and clinical outcomes were compared.

RESULTS

: We cared for 751 patients during this time period, 273 of whom were military (36%). Military injuries occurred in a younger population (41 +/- 19 vs. 26 +/- 7 years for civilian and military respectively, P < 0.0001) with a longer time from injury to burn center arrival (1 +/- 5 days vs. 6 +/- 5, P < 0.0001), a higher Injury Severity Score (ISS 5 +/- 8 vs. 9 +/- 11, P < 0.0001), and a higher incidence of inhalation injury (8% vs. 13%, P = 0.024). Total burn size did not differ. Mortality was 7.1% in the civilian and 3.8% in the military group (P = 0.076). When civilians outside the age range of the military cohort were excluded, civilian mortality was 5.0%, which did not differ from the military group (P = 0.57). Total body surface area (TBSA) burned, age > or =40 years, presence of inhalation injury, and ventilator days were found to be important predictors of mortality by stepwise regression, and were used in a final predictive model with the area under receiver operator characteristic curve of 0.97 for both populations considered together. No significant effect of either group was identified during development.

CONCLUSIONS

Mortality does not differ between civilians evacuated locally and military personnel injured in distant austere environments treated at the same center.

Comparison of combat and non-combat burns from ongoing U.S. military operations

BACKGROUND

Military burns result from either combat or non-combat causes. We compared these etiologies from patients involved in ongoing conflicts to evaluate their impact and provide prevention recommendations.

METHODS

All military patients with significant burns treated at the United States Army Institute of Surgical Research from April 2003 to May 2005 were reviewed. Injuries were categorized as having resulted from combat or non-combat causes. Demographics, burn severity and pattern, mortality, and early outcomes were compared.

RESULTS

There were 273 burn patients seen with 63% injured in combat. A high early rate of non-combat injuries was noted. Feedback on non-combat burn prevention was provided to the combat theater, and the incidence of non-combat burns decreased. Mean age and time from injury to admission did not differ. The majority of combat injuries resulted from explosive device detonation. Waste burning, ammunition handling, and gasoline caused most non-combat injuries. Combat casualties had more associated and inhalation injuries and greater full-thickness burn size; total body surface area burned was equivalent. The hands and the face were the most frequently burned body areas. Mortality was 5% in combat and 2% in non-combat patients. The majority of survivors in both groups returned to military duty.

CONCLUSIONS

The disparity in full-thickness burn size and incidence of inhalation and associated injuries resulted from differing mechanisms of injury, with explosions and penetrating trauma more common in combat wounds. Despite the severity of combat burns, mortality was low and outcomes generally good. Non-combat burns are preventable and have decreased in incidence.