Regional and National Review of Factors Associated With Burn Wound Cellulitis:

Does the heat source affect the risk of wound infection in children with scalds?

INTRODUCTION

Scalds are the leading cause of burns in children younger than 5 years of age with most being related to food preparation and consumption. Hot substances causing scalds have different degrees of viscosity varying from low (liquid substances, such as water), to high (semi-solids or solids, such as oils or grease). It is still underknown whether heat substances with different viscosities are associated with varying risks of developing burn wound infections (BWI). The aim of this study was to investigate the association between heat sources of different viscosities and development of BWI within the first week after injury in children with scalds.

METHOD

Children 5 years and younger of age admitted at the Linköping Burn Center for new scalds between 2015 and 2020 were included. Data source for the study population was the Burn Unit Database. BWI was defined as fulfilment of at least two ABA criteria at the time of systemic antibiotic therapy (AB) initiation between day 2-7 following scald. Medical record review was undertaken to identify the heat source causing the scald, BWI criteria, and the use of AB. Legal guardians were contacted in cases in which information was missing. Logistic regression was used to analyse the association between heat source and development of BWI.

RESULT

The study population consisted of 271 children, median age was 1.5 years, 61 % were boys, median burn size was 3.5 % of the total body surface area (TBSA), 10 (4 %) had a full thickness burn. BWI were identified in 69 (26 %) of the children. Most scalds were caused by contact with hot liquids (n=184), followed by semisolids (n=52) and solids (n=35). The logistic regression model showed that the size of the burn (TBSA) was associated with BWI, while type of heating agent was not.

CONCLUSION

Our results indicate that the viscosity of the heat source does not affect the risk of wound infection in children with scalds; only the size of the area burned was an independent factor for BWI.

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.

The Impact of Race/Ethnicity on the Outcomes of Burn Patients: A Systematic Review of the Literature

Racial and ethnic disparities are endemic to the United States and are only beginning to attract the attention of researchers. With an increasingly diverse population, focused and tailored medicine to provide more equitable care is needed. For surgical trauma populations, this topic is a small but expanding field and still rarely mentioned in burn medicine. Disparities in prevention, treatment, and recovery outcomes between different racial and ethnic minorities who are burned are rarely discussed. The purpose of this study is to determine the current status of identified disparities of care in the burn population literature and areas of future research. A systematic review was conducted of literature utilizing PubMed for articles published between 2000 and 2020. Searches were used to identify articles that crossed the burn term (burn patient OR burn recovery OR burn survivor OR burn care) and a race/ethnicity and insurance status-related term (race/ethnicity OR African-American OR Black OR Asian OR Hispanic OR Latino OR Native American OR Indigenous OR Mixed race OR 2 or more races OR socioeconomic status OR insurance status). Inclusion criteria were English studies in the United States that discussed disparities in burn injury outcomes or risk factors associated with race/ethnicity. One thousand one hundred and sixty-nine papers were populated, 55 were reviewed, and 36 articles met inclusion criteria. Most studies showed minorities had poorer inpatient and outpatient outcomes. While this is a concerning trend, there is a paucity of literature in this field and more research is needed to create culturally tailored medical care and address the needs of disadvantaged burn survivors.

Chronic Neuropathic Pain Following Hand Burns: Etiology, Treatment, and Long-Term Outcomes

PURPOSE

Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment.

METHODS

Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP.

RESULTS

Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up.

CONCLUSIONS

Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Burn Wound Colonization, Infection, and Sepsis

Background: Infection is a major cause of morbidity and mortality among burn patients, and it is important to understand the progression of wound colonization to wound infection to systemic sepsis. Methods: After a review of the literature we describe the clinical characteristics of burn wound colonization, infection, and sepsis, and conclude with best practices to decrease these complications. Results: Burn wounds are initially sterile after the thermal insult but become colonized by gram-positive organisms and subsequently by gram-negative organisms. Some populations are especially susceptible to initial or subsequent colonization by drug-resistant organisms. An increase in fungal colonization has been observed because of the widespread use of topical antibiotic agents. Male gender, older age, lower extremity burn, scald burn, full-thickness burn, delay in treatment, and pre-existing diabetes place patients at increased risk of infection. These infections range from cellulitis that requires systemic antibiotic agents, to invasive burn wound infection that requires prompt treatment with antibiotic agents and excision. Fungal wound infections pose a special challenge and cause substantial morbidity. Infection that leads to systemic sepsis is difficult to define in burn patients because of the body's compensatory hypermetabolic response to the burn injury. Potential sources of sepsis include wound infections and common nosocomial infections. The American Burn Association Sepsis criteria, defined in 2007, has demonstrated poor specificity for identifying sepsis and septic shock. The best approach to decrease wound infections is prevention. Practices that have been beneficial include isolation rooms, handwashing, appropriate wound care, early excision and grafting, antibiotic stewardship, and nutritional support. Conclusions: A burn patient remains at a substantial risk of wound infection despite advances in care. A burn care provider must understand the natural progression of colonization to infection to sepsis, and the multidisciplinary approach to wound care to limit the morbidity and mortality from these infectious.