Acute assessment and management of burn injuries

Burns are ubiquitous injuries in modern society, with virtually all adults having sustained a burn at some point in their lives. The skin is the largest organ of the body, basically functioning to protect self from non-self. Burn injury to the skin is painful, resource-intensive, and often associated with scarring, contracture formation, and long-term disability. Larger burns are associated with morbidity and mortality disproportionate to their initial appearance. Electrical and chemical burns are less common injuries but are often associated with significant morbidity.

Ophthalmic Manifestations of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis and Relation to SCORTEN

PURPOSE

To evaluate the severity of ocular involvement of patients with Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap, and to investigate the relationship of the SCORTEN (a severity-of-illness score for SJS and TEN based on a minimal set of well-defined variables calculated within 24 hours of admission) with eye disease in this patient population.

DESIGN

Retrospective observational case series.

METHODS

Charts of all patients admitted to the Parkland Memorial Hospital Burn Center with a preliminary diagnosis of SJS, SJS/TEN overlap, or TEN between 1998 and 2008 were reviewed. Patients were included for study if they met clinical criteria, had positive diagnostic skin biopsy, and had dermatologic and ophthalmologic consultations. Eighty-two patients with a diagnosis of SJS, SJS/TEN overlap, or TEN met inclusion criteria. Ocular manifestations were classified as mild, moderate, or severe. Admission data were used to calculate the SCORTEN. Main outcome measure was the severity of ocular involvement with respect to diagnosis and SCORTEN.

RESULTS

Overall, 84% of patients had ocular involvement (71% SJS, 90% TEN, 100% SJS/TEN overlap). There was no difference in the severity of acute ocular complications among groups. While the SCORTEN value did correlate well with mortality rate (correlation coefficient 0.97, P = .005), there was no correlation between the SCORTEN value and severity of eye involvement in the acute setting. There was also no association of any individual diagnosis of SJS/overlap/TEN with the severity of eye involvement, although eye findings are more common in TEN (P = .03).

CONCLUSIONS

Ocular damage in the acute setting was more frequent in patients with epidermal detachment >10% of the total body surface area. The SCORTEN value did not correlate with the severity of eye involvement in the acute setting.

The diagnosis and management of electrical injuries

Electrical injuries to the extremity can result in significant local tissue damage and systemic problems. An understanding of the pathophysiology of electrical injuries is critical to the medical and surgical management of patients who sustain these injuries.

Sustained impairments in cutaneous vasodilation and sweating in grafted skin following long-term recovery

We previously identified impaired cutaneous vasodilation and sweating in grafted skin 5 to 9 months postsurgery. The aim of this investigation was to test the hypothesis that cutaneous vasodilation, but not sweating, is restored as the graft heals. Skin blood flow and sweat rate were assessed from grafted skin and adjacent noninjured skin in three groups of subjects: 5 to 9 months postsurgery (n=13), 2 to 3 years postsurgery (n=13), and 4 to 8 years postsurgery (n=13) during three separate protocols: 1) whole-body heating and cooling, 2) local administration of vasoactive drugs, and 3) local heating and cooling. Cutaneous vasodilation and sweating during whole-body heating were significantly lower (P<.001) in grafted skin when compared with noninjured skin across all groups and demonstrated no improvements with recovery time postsurgery. Maximal endothelial-dependent (acetylcholine) and endothelial-independent (sodium nitroprusside) cutaneous vasodilation remained attenuated (P<.001) in grafted skin up to 4 to 8 years postsurgery, indicating postsynaptic impairments. In grafted skin, cutaneous vasoconstriction during whole-body and local cooling was preserved, whereas vasodilation to local heating was impaired, regardless of the duration postsurgery. Split-thickness skin grafts have impaired cutaneous vasodilation and sweating up to 4 to 8 years postsurgery, thereby limiting the capability of this skin's contribution to thermoregulation during a heats stress. In contrast, grafted skin has preserved vasoconstrictor capacity.

Cutaneous vasoconstriction during whole-body and local cooling in grafted skin five to nine months postsurgery

The aim of this investigation was to test the hypothesis that skin grafting (5-9 months after surgery) impairs sympathetically mediated cutaneous vasoconstrictor responsiveness. Skin blood flow (laser-Doppler flowmetry) was assessed in grafted skin and adjacent healthy control skin in fourteen subjects (seven male, seven female) during indirect whole-body cooling (ie, cooling the entire body, except the area where skin blood flow was assessed), as well as local cooling (ie, only cooling the area where skin blood flow was assessed). Whole-body cooling was performed by perfusing 5 degrees C water through a water perfusion suit for 3 minutes. Local cooling was performed on a separate visit using a custom Peltier cooling device, which decreased local skin temperature from 39 degrees C to 19 in 5 degrees C decrements in 15-minute stages. Cutaneous vascular conductance (CVC) was calculated from the ratio of skin blood flow to mean arterial pressure. Indirect whole-body cooling decreased CVC from baseline (DeltaCVC) similarly (P = 0.17) between grafted skin (DeltaCVC = -0.23 +/- 0.04 au/mm Hg) and adjacent healthy skin (DeltaCVC = -0.16 +/- 0.02 au/mm Hg). Likewise, decreasing local skin temperature from 39 to 19 degrees C resulted in similar decreases (P = .82) in CVC between grafted skin (DeltaCVC = -1.11 +/- 0.18 au/mm Hg) and adjacent healthy skin (DeltaCVC = -1.06 +/- 0.18 au/mm Hg). Appropriate cutaneous vasoconstriction in grafted skin to both indirect whole-body and local cooling indicates re-innervation of the cutaneous vasoconstrictor system at the graft site. These data suggest that persons with significant skin grafting may have a normal capacity to regulate body temperature during cold exposure by cutaneous vasoconstriction.

Impaired cutaneous vasodilation and sweating in grafted skin during whole-body heating

The aim of this investigation was to identify the consequences of skin grafting on cutaneous vasodilation and sweating in split-thickness grafted skin during indirect whole-body heating 5 to 9 months after surgery. In addition, thermoregulatory function was examined at donor skin sites on a separate day. Skin blood flow and sweat rate (SR) were assessed from both grafted (n = 14) or donor skin (n = 11) and compared with the respective adjacent control skin during indirect whole-body heating. Cutaneous vascular conductance (CVC) was calculated from the ratio of skin blood flow (arbitrary units; au) to mean arterial pressure. Whole-body heating significantly increased internal temperature (37.0 +/- 0.1 degrees C to 37.8 +/- 0.1 degrees C; P < .05). Cutaneous vasodilation (ie, the increase in CVC from baseline, deltaCVC) during whole-body heating was significantly attenuated in grafted skin (deltaCVC = 0.14 +/- 0.15 au/mm Hg) compared with adjacent control skin (deltaCVC = 0.84 +/- 0.11 au/mm Hg; P < .05). Increases in sweat rate (deltaSR) were also significantly lower in grafted skin (deltaSR = 0.08 +/- 0.08 mg/cm2/min) compared with adjacent control skin (deltaSR = 1.16 +/- 0.20 mg/ cm2/min; P < .05). Cutaneous vasodilation and sweating during heating were not significantly different between donor sites (deltaCVC = 0.71 +/- 0.19 au/mm Hg; deltaSR = 1.04 +/- 0.15 mg/cm2/min) and adjacent control skin (deltaCVC = 0.50 +/- 0.10 au/mm Hg; deltaSR = 0.83 +/- 0.17 mg/cm2/min). Greatly attenuated or absence of cutaneous vasodilation and sweating suggests impairment of thermoregulatory function in grafted skin, thereby, diminishing the contribution of this skin to overall temperature control during a heat stress.

Use of high-frequency percussive ventilation in inhalation injuries

Inhalation injury causes significant morbidity and mortality, accounting for nearly 80% of non-fire-related deaths and affecting nearly 25% of all patients hospitalized with thermal injury. High-frequency percussive ventilation (HFPV) has been reported to decrease both the incidence of pulmonary barotrauma and pneumonia in inhalation injury. It has evolved into a ventilatory modality promoted to rapidly remove airway secretions and improve survival of patients with smoke inhalation injury. From 1997 to 2005, a total of 92 patients with inhalation injury were treated with HFPV. This group was compared with 130 patients treated with conventional mechanical ventilation between 1997 and 2005. The diagnosis of inhalation injury was made on admission, based on the following clinical criteria: injury in a closed space, carbonaceous sputum, and/or positive bronchoscopy (presence of carbonaceous deposits, erythema or ulceration). Both modes of ventilation were begun within 24 hours of injury. Both groups were similar with respect to demographics and injury severity. The mean number of ventilator days, days in the intensive care unit, length of stay, and incidence of pneumonia did not differ significantly between groups. Twenty-six of 92 (28%) patients treated with HFPV, and 56 of 130 with conventional mechanical ventilation (43%) died. There was a significant decrease in both overall morbidity and mortality in the subset of patients with < or = 40% TBSA treated with HFPV. Future randomized, controlled trials are needed to determine the precise role of HFPV in the treatment of inhalation injuries.

Skin grafting impairs postsynaptic cutaneous vasodilator and sweating responses

This study tested the hypothesis that postsynaptic cutaneous vascular responses to endothelial-dependent and -independent vasodilators, as well as sweat gland function, are impaired in split-thickness grafted skin 5 to 9 months after surgery. Intradermal microdialysis membranes were placed in grafted and adjacent control skin, thereby allowing local delivery of the endothelial-dependent vasodilator, acetylcholine (ACh; 1 x 10(-7) to 1 x 10(-1) M at 10-fold increments) and the endothelial-independent nitric oxide donor, sodium nitroprusside (SNP; 5 x 10(-8) to 5 x 10(-2) M at 10-fold increments). Skin blood flow and sweat rate were simultaneously assessed over the semipermeable portion of the membrane. Cutaneous vascular conductance (CVC) was calculated from the ratio of laser Doppler-derived skin blood flow to mean arterial blood pressure. deltaCVC responses from baseline to these drugs were modeled via nonlinear regression curve fitting to identify the dose of ACh and SNP causing 50% of the maximal vasodilator response (EC50). A rightward shift in the CVC dose response curve for ACh was observed in grafted (EC50 = -2.61 +/- 0.44 log M) compared to adjacent control skin (EC50 = -3.34 +/- 0.46 log M; P = .003), whereas the mean EC50 for SNP was similar between grafted (EC50 = -4.21 +/- 0.94 log M) and adjacent control skin (EC50 = -3.87 +/- 0.65 log M; P = 0.332). Only minimal sweating to exogenous ACh was observed in grafted skin whereas normal sweating was observed in control skin. Increased EC50 and decreased maximal CVC responses to the exogenous administration of ACh suggest impairment of endothelial-dependent cutaneous vasodilator responses in grafted skin 5 to 9 months after surgery. Greatly attenuated sweating responses to ACh suggests either abnormal or an absence of functional sweat glands in the grafted skin.

Abdominal Compartment Syndrome in the Severely Burned Patient

Scant data exist regarding patient outcome after treatment of abdominal compartment syndrome (ACS) with decompressive laparotomy. This work reviews the outcome of 25 burn patients at a single institution who underwent decompressive laparotomy for treatment of ACS in the periresuscitation period. A computerized burn registry and directed chart review were used for data collection and analysis in this retrospective review. From September 1996, 25 patients underwent decompressive laparotomy after developing ACS. Mean burn size was 65 +/- 19% TBSA. Mean age was 28 +/- 19 years. Twenty-two (88%) died. Myo/ hemoglobinuria was present at admission in eight patients, one of whom survived. Fourteen patients had inhalation injury, of whom two survived. Before decompressive laparotomy, mean bladder pressure and peak inspiratory pressure were 57 +/- 4.2 mm Hg and 41 +/- 2.2 mm Hg, respectively. Mean urine output improved from 28 ml/hr to 90 ml/hr after decompressive laparotomy. The mean Ivy score was 443 +/- 34.95 ml/kg. Development of ACS in burn patients is associated with a high mortality. With development of IAH, therapeutic maneuvers such as sedation and paralysis, escharotomies, or changes in fluid management can be performed in hopes of altering the evolution of intra-abdominal hypertension to ACS. In patients with >40% TBSA burns, bladder pressures should initially be measured every 6 hours. When the Ivy score reaches 200 ml/kg, measure bladder pressures hourly. Decompressive laparotomies should be performed in all patients with ACS if less-invasive maneuvers fail.

CD14-159 C allele is associated with increased risk of mortality after burn injury

Although comprehension of postburn pathophysiology has grown in recent years, we are still unable to accurately identify burn patients who are at an increased risk of infectious complications and death. This unexplained variation is likely influenced by heritable factors; the genetic predisposition for death from infection has been estimated as greater than that for cardiovascular disease or cancer. Identify genetic variants associated with increased mortality after burn injury. A total of 233 patients with burns of 15% of total body surface area or greater or smoke inhalation injury who survived more than 48 h after admission and were without significant nonburn-related trauma (injury severity score > or = 16), traumatic or anoxic brain injury, or spinal cord injury. We examined the influence of genotype at five candidate loci (interleukin [IL]-1beta, IL-6, tumor necrosis factor-alpha, toll-like receptor 4, CD14) on mortality risk after burn injury. DNA was isolated from residual blood from laboratory draws and candidate genotypes were determined by real-time polymerase chain reaction using TaqMan probes. Clinical data were prospectively collected into a local, curated database. Allelic associations were analyzed by multivariate logistic regression. After adjustment for age, full-thickness burn size, inhalation injury, ethnicity, and sex, carriage of the CD14-159 C allele imparted at least a 1.3-fold increased risk for death after burn injury, relative to TT homozygotes (adjusted odds ratio, 2.9; 95% confidence interval, 1.3-6.8; P = 0.01). This association was stronger (adjusted odds ratio, 3.3; 95% confidence interval, 1.3-8.4; P = 0.01) when the analysis was conducted only on deaths accompanied by severe sepsis. In addition, a gene dosage effect for increased mortality was apparent for carriage of the CD14-159 C allele (P = 0.006). The gene dosage effect remained when white, Hispanic, or African American patients were analyzed independently, although statistical significance was not achieved in the subgroup analysis. None of the other single nucleotide polymorphisms examined were significantly associated with mortality. These data provide strong evidence that a CD14 promoter allele that is known to impart lower baseline and induced CD14 transcription also affects mortality risk after burn injury. A potential (although untested) mechanism for our observation is that reduced signaling through CD14/toll-like receptor 4 in response to challenge by gram-negative bacteria after burns results in a blunted innate immune response and subsequent increased likelihood for systemic infection and death.

Searching for alleles associated with complicated outcomes after burn injury

Sepsis is a serious and growing health problem among patients admitted to intensive care units. When accompanied by organ failure, sepsis carries a 30-50% case-fatality rate. Although our understanding of burn pathophysiology has grown in recent years, we are still unable to identify accurately patients who are at increased risk for infectious complications and death. Genetic predisposition is likely to explain a portion of this variation. Understanding which genes and allelic variants contribute to disease risk would increase our ability to predict who is at increased risk and intervene accordingly, as well as identify molecular targets for novel and individualized therapies. Several obstacles exist to identification of which specific alleles and loci contribute to patient risk, including achievement of sufficient statistical power, population admixture and epistatic interaction among multiple genes and environmental factors. Although increasing sample size will resolve most, if not all, of these issues, slow patient accrual often makes this solution impractical for a single institution within a reasonable timeframe. This situation is complicated by the fact that traditional analysis methods perform poorly in the face of data sparseness. Identification of risk factors for severe sepsis and death after burn injury will likely require collaborative patient enrollment as well as development of advanced analytical methodologies. While overcoming these obstacles may prove difficult, the effort is warranted, as the ultimate benefit to patients is considerable.

Innate immunity SNPs are associated with risk for severe sepsis after burn injury

OBJECTIVE

To analyze allelic association with clinical outcome in a cohort of burn patients.

PATIENTS

Two hundred twenty-eight individuals with burns > or =15% total body surface area without significant non-burn related trauma who survived >48 hours post-admission were enrolled. One hundred fifty-nine of these patients were analyzed previously.

METHODS

Candidate polymorphisms within interleukin-1 beta (IL-1beta), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-alpha), cellular differentiation marker 14 (CD14) and toll-like receptor 4 (TLR4) were evaluated by logistic regression analysis for association with increased risk for severe sepsis (sepsis plus organ dysfunction or shock).

RESULTS

After adjustment for age, burn size, ethnicity, gender and inhalation injury, alleles at TNF-alpha (308G, p=0.013), TLR4 (+896G, p=0.027), IL-6 (174C, p=0.040) and CD14 (159C, p=0.047) were significantly associated with an increased risk for severe sepsis.

CONCLUSIONS

Carriage of variant alleles at immune response genes were associated with increased risk for severe sepsis after burn injury.

National Burn Repository 2005: a ten-year review

In the early 1990s, the American Burn Association (ABA) started its first burn registry development initiatives. The impetus for the registry development software originated from several directions, including the following: (1) the recognition that national registries were widespread and of proven benefit; (2) growing demands from accrediting institutions, payers, and patient advocacy groups for objective and verifiable data regarding patient costs, treatments, and outcomes; and (3) the shift toward "evidence-based" medicine and the ongoing analysis of treatment effectiveness. The ABA has issued three calls for burn registry data for its National Burn Repository (NBR): 1994, 2002, and 2005. In 1994, 28 burn centers contributed data for more than 6,400 patients treated from 1991 to 1993. The ABA announced its second call for data in 2001 and distributed the published results of more than 54,000 acute burn admissions treated from 1974 to 2002 at the Association's 2002 Annual Meeting. The third ABA call for data was issued in the Fall of 2005. The results are detailed in this report, which provides a summary of more than a quarter million acute burn admissions from 1995 to 2005, representing 70 hospitals from 30 states plus the District of Columbia. Statistics are presented in chart and table format to illustrate such key factors as patient age, burn size group, types of injuries, mortality rates, and average hospital charges by etiology and length of hospital stay. The data presented herein should help stimulate quality improvement programs in burn care, as burn centers compare their performance with the national data and as research is expanded using the NBR. The NBR will be published annually and, with continued refinements to the registry software, should become of increasing importance to clinicians, payers, researchers, and the public.

Heterotopic ossification revisited: a 21-year surgical experience

Heterotopic ossification (HO) is an infrequently encountered complication of a burn. A retrospective review was undertaken to evaluate our treatment and results. Forty-two patients were identified with HO during 21 yrs. Mean age was 38 yrs. Mean total body surface area and third-degree burn were 55% and 37%, respectively. The elbow was the most frequent site (>90%), and 44% were bilateral. The next most common sites were shoulder, hip, knee, and forearm. Greater than 90% of patients had ventilator support and intensive care unit length of stay 58 and 79 days, respectively. HO was first suspected by decreased range of motion, painful and/or swollen joint, or a nerve deficit. Conventional radiographs were used to confirm the clinical diagnosis. The majority of burns overlying joints with HO were associated with prolonged wound closure because of depth, wound infection, or graft loss. Mean day of diagnosis was 71 days (range, 21-134). Excision of HO was undertaken only when range of motion compromised activities of daily living. Surgery successfully improved range of motion in all cases. The mean elbow arc of motion before and after surgery was 52 degrees and 119 degrees (range, 30-180 degrees), respectively. Seventy percent of elbows were ankylosed. A continuous passive motion device was instituted immediately postoperatively. Local postoperative complications included hematoma, wound dehiscence, infection, and nerve deficit. Maintaining range of motion was difficult for 75% of patients. Symptomatic recurrence of HO occurred in four elbows and one forearm. Because the cause(s) are unknown, prevention is impossible; once diagnosed, medical treatment is problematic and spontaneous resolution is infrequent. Surgery continues to be the recommended treatment when activities of daily living or life style are affected.

Self-Esteem Measurement Before and After Summer Burn Camp in Pediatric Burn Patients

Pediatric burn injury results in significant mortality and morbidity, from which some children will experience prolonged psychological and social difficulty. As early as 1967, it was noted that participation in a group was important in the resolution of problems caused by severe disability and stressful experiences. Since 1982, there have been summer burn camps for children and adolescent burn survivors. The primary focus of camp is to have "fun" at the various daily activities. The principal goal, however, is psychosocial readjustment. Fifty-three burn survivors attended the 1-week duration annual summer camp. Campers were invited to complete a Rosenberg Self-Esteem Scale on the first day of summer burn camp and shortly after the camp ended. Younger children were assisted with the survey tool by their parents. Of the 53 campers, 45 completed both pre- and postcamp surveys. The age of the campers ranged from 6 to 18 years (mean, 12.8 years). Burn size ranged from 1% to 90% TBSA (mean, 30.4% TBSA). The interval from date of injury to camp attendance was 2 months to 15.5 years. Nine campers had never attended burn camp before this year. Twenty- nine percent of the campers had an increase in self-esteem score. Fifty-eight percent had no change, and 13% demonstrated a decrease. The burn camp experience though an enriching summer activity, did not necessarily increase self-esteem in the majority of campers as measured by the survey tool employed.

Detecting genetic predisposition for complicated clinical outcomes after burn injury

Sepsis, septic shock and organ failure are common among patients with moderate to severe burns. The inability of demographic and clinical factors to identify patients at high risk for such complications suggests that genetic variation may influence clinical outcome. Moreover, the genetic predisposition to death from infection has been estimated to be greater than for cardiovascular disease or cancer . While it is widely accepted that genetic factors influence many complex disease processes, controversy has emerged regarding the most appropriate methods for detection and even the validity of many published allelic associations . This article will review the few studies of genetic predisposition that have been conducted in the setting of burn injury, then discuss some of the obstacles and potential approaches for the discovery of additional allelic associations.

Acute cholecystitis in burn patients

Acute cholecystitis is a complication in critical illnesses, including burns. The purpose of this report is to review one institution's experience with this complication during a 21-year time period. A computerized burn registry was used for data collection and analysis in this retrospective review. Twenty patients developed cholecystitis from a total burn admission population of 10,762 in this 21-year period (0.18%). Mean patient age was 43.5 years, and their mean burn size was 37.4% with a mean full-thickness burn size of 23% TBSA. Mean patient length of stay was 77.4 days. Sixteen of these patients were intubated and mechanically ventilated for a mean of 56 days. Total parental nutrition was required in 12 patients. The use of total parental nutrition steadily decreased over the length of the study, and early enteral tube feed use has become the norm. All but two patients were in the Burn Intensive Care Unit at the time of diagnosis. Men outnumbered women by three to one. Nine patients with positive sonograms were successfully managed without surgical intervention. Two of these patients also had positive hydroxy iminodiacetic acid scans. Surgically managed patients were treated with both open and laparoscopic cholecystectomy as well as cholecystostomy tube placement. Mortality was 25%. Acute cholecystitis remains a serious although relatively rare complication in burn patients. Patients often have an unreliable physical examination, several possible causes of fever, and abnormal laboratory results. A high index of suspicion and sound clinical judgment is required to manage this rare-but-challenging problem.

A case report of phaeohyphomycosis caused by Cladophialophora bantiana treated in a burn unit

Black molds are a heterogeneous group of fungi that are distributed widely in the environment and that occasionally cause human infection. The spectrum of disease includes mycetomas, chromoblastomycosis, sinusitis, and superficial, cutaneous, subcutaneous, and systemic phaeohyphomycosis. Cladophialophora bantiana, an agent of phaeohyphomycosis, causes rare infections mainly of the central nervous system. Extracerebral involvement is uncommon, and only a few cases have been reported. We present the case of a 32-year-old immunosuppressed female who developed a cutaneous phaeohyphomycosis from C. bantiana. The patient was treated in a burn unit with wound care, surgical excision, grafting, and itraconazole. Patients with complex fungal infections represent yet another population with specialized needs that are adequately met in a verified burn center.

Electrical injuries: a 20-year review

Electrical injuries continue to present problems with devastating complications and long-term socioeconomic impact. The purpose of this study is to review one institution's experience with electrical injuries. From 1982 to 2002, there were 700 electric injury admissions. A computerized burn registry was used for data collection and analysis. Of these injuries, 263 were high voltage (> or =1000 V), 143 were low voltage (<1000 V), 277 were electric arc flash burns, and 17 were lightning injuries. Mortality was highest in the lightning strikes (17.6%) compared with the high voltage (5.3%) and low voltage (2.8%) injuries, and mortality was least in electric arc injuries without passage of current through the patient (1.1%). Complications were most common in the high-voltage group. Mean length of stay was longest in this group (18.9 +/- 1.4 days), and the patients in this group also required the most operations (3 +/- 0.2). Work-related activity was responsible for the majority of these high-voltage injuries, with the most common occupations being linemen and electricians. These patients tended to be younger men in the prime of their working lives. Electrical injuries continue to make up an important subgroup of patients admitted to burn centers. High-voltage injuries in particular have far reaching social and economic impact largely because of the patient population at greatest risk, that is, younger men at the height of their earning potential. Injury prevention, although appropriate, remains difficult in this group because of occupation-related risk.

TLR4 and TNF-alpha polymorphisms are associated with an increased risk for severe sepsis following burn injury

CONTEXT

Sepsis, organ failure, and shock remain common among patients with moderate to severe burn injuries. The inability of clinical factors to identify at-risk patients suggests that genetic variation may influence the risk for serious infection and the outcome from severe injury.

OBJECTIVE

Resolution of genetic variants associated with severe sepsis following burn injury.

PATIENTS

A total of 159 patients with burns > or =20% of their total body surface area or any smoke inhalation injury without significant non-burn related trauma (injury severity score (ISS)> or =16), traumatic or anoxic brain injury, or spinal cord injury and who survived more than 48 h post-admission.

METHODS

Candidate single nucleotide polymorphisms (SNPs) within bacterial recognition (TLR4 +896, CD14 -159) and inflammatory response (TNF-alpha -308, IL-1beta -31, IL-6 -174) loci were evaluated for association with increased risk for severe sepsis (sepsis plus organ dysfunction or septic shock) and mortality.

RESULTS

After adjustment for age, full-thickness burn size, ethnicity, and gender, carriage of the TLR4 +896 G-allele imparted at least a 1.8-fold increased risk of developing severe sepsis following a burn injury, relative to AA homozygotes (adjusted odds ratio (aOR) 6.4; 95% confidence interval (CI) 1.8 to 23.2). Carriage of the TNF-alpha -308 A-allele imparted a similarly increased risk, relative to GG homozygotes (aOR = 4.5; 95% CI 1.7 to 12.0). None of the SNPs examined were significantly associated with mortality.

CONCLUSIONS

The TLR4 +896 and TNF-alpha -308 polymorphisms were significantly associated with an increased risk for severe sepsis following burn trauma.

Sentinel Lymph Node Biopsy Identifies Occult Nodal Metastases in Patients with Marjolinʼs Ulcer

Since Marjolin's description, the management of burn scar carcinoma has remained controversial. A multitude of options and recommendations exist for the management of both primary lesions and regional nodal metastasis. This work reviews six cases of Marjolin's ulcer staged using sentinel lymph node biopsy. All primary lesions were confirmed to be squamous cell carcinoma and occurred a median of 29.5 years after burn. No patient had clinically detectable lymphadenopathy. In all cases, preoperative lymphoscintigraphy successfully identified a single draining regional nodal basin. Subsequent intraoperative lymphatic mapping/sentinel lymph node (SLN) biopsy was successful in five of six cases (83%). A successful intraoperative lymphatic mapping/SLN biopsy was defined as the identification of blue (uptake of isosulfan blue dye) or "hot" (uptake of radiolabeled sulfur colloid as measured with a handheld gamma counter) node(s) and subsequent excision. Four of five SLN biopsies identified previously occult nodal metastasis. SLN biopsy represents a minimally invasive and accurate staging procedure for Marjolin's ulcer.

The risk factors and time course of sepsis and organ dysfunction after burn trauma

BACKGROUND

Sepsis and organ dysfunction are common and likely contribute to death after burn trauma. We sought to define relationships between sepsis, severe multiple organ dysfunction (MOD), and death after burn trauma.

METHODS

Adults with > or = 20% total body surface area burns were prospectively enrolled. Information regarding infection, severity of sepsis, and organ failure was collected daily. Risk factors (e.g., age, burn size, shock) were analyzed for their association with severe MOD, complicated sepsis, and death. We characterized the temporal relationship between organ failure and sepsis.

RESULTS

Of 175 patients, 27% developed severe MOD, 17% developed complicated sepsis, and 22% died. Full-thickness burn size, age, and inhalation injury were associated with MOD, sepsis, and death. Infection preceded MOD in 83% of patients with both. A base deficit of > or = 6 mEq/L at 24 hours after injury was associated with death.

CONCLUSION

When it occurs, severe MOD is usually preceded by infection. In addition, an elevated base deficit at 24 hours and septic shock are the most important factors associated with and possibly contributing to death after burn trauma.

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

Differential activation of coronary and pulmonary endothelial cells by thermal injury

Remote organ dysfunction during resuscitation of severe thermal injury is characterized by early, transient pulmonary insufficiency and cardiac contractile dysfunction. Thermal injury is typified by profound systemic alterations of endothelial immunological, vasoactive, and barrier functions. The unique location of this ubiquitous, fragile monolayer makes it vulnerable to circulating serum factors created at remote cutaneous wounds. We examined endothelial "activation" in 2 distinct cell types, human coronary and pulmonary endothelial cells (EC), after severe thermal injury. By using human serum isolated at specific times after thermal injury ("early" [2 h post-burn] or "late" [26 h post-burn]), the endothelial release of vasoactive mediators, ICAM-1 expression, and monolayer permeability were assessed in vitro. Early burn serum enhanced coronary EC vasoconstrictor (ET-1) release and ICAM expression, inhibited vasodilator (PGI2) release, but had no effect on permeability. Conversely, under similar conditions, pulmonary EC PGI2 release and permeability were enhanced, ET-1 release was diminished, but ICAM was unaffected. Late burn serum enhanced vasodilator (NO) release and permeability to albumin in both coronary and pulmonary EC, whereas ET-1 release was inhibited. Under these conditions, only pulmonary ICAM expression was significantly enhanced. These data suggest that human endothelium isolated from divergent vascular beds are activated by burn injury in a unique manner for time post-burn and vascular site of cell origin.

Objective estimates of the incidence and consequences of multiple organ dysfunction and sepsis after burn trauma

BACKGROUND

Organ dysfunction and sepsis are frequent after major burn trauma, represent quantifiable consequences of the systemic response to injury, and may be important end points by which to measure treatment effectiveness. However, standard and widely applied methods for their measurement have not been applied to burn trauma victims. Therefore, the purpose of this study was to quantify these complications after burn trauma.

METHODS

Patients with > or = 20% total body surface area burns admitted to a single center were prospectively enrolled. Standard sepsis criteria and multiple organ dysfunction (MOD) scores for the pulmonary, renal, cardiovascular, hepatic, and hematologic systems were determined. The incidence and risk factors for severe MOD (cumulative MOD score > or = 6) and severe sepsis were determined. The relationships between these complications and mortality and resource utilization were examined by univariate and multivariate analyses.

RESULTS

A total of 85 patients were enrolled over 1 year. Severe MOD developed in 24 (28%) and severe sepsis or septic shock developed in 12 (14%). Both were associated with increasing age and burn size and were more likely to occur in men. Most patients who developed severe MOD or severe sepsis survived (71% and 67%, respectively), and both were associated with longer intensive care unit stays and duration of mechanical ventilation.

CONCLUSION

According to simple and objective scoring systems, severe MOD and severe sepsis/septic shock are both related to burn size, age, and male sex. Both are related to intensive care unit length of stay and duration of mechanical ventilation.

An evaluation of risk factors for mortality after burn trauma and the identification of gender-dependent differences in outcomes

BACKGROUND

The primary objective of this study was to determine an objective method for estimating the risk of mortality after burn trauma, and secondarily, to evaluate the relationship between gender and mortality, in the setting of a quantifiable inflammatory stimulus. Previously reported estimates of mortality risk after burn trauma may no longer be applicable, given the overall reduction in case-fatality rates after burn trauma. We expect that future advances in burn trauma research will require careful and ongoing quantification of mortality risk factors to measure the importance of newly identified factors and to determine the impact of new therapies. Conflicting clinical reports regarding the impact of gender on survival after sepsis and critical illness may in part, be from different study designs, patient samples, or failure to adequately control for additional factors contributing to the development ofsepsis and mortality.

STUDY DESIGN

Data from the prospectively maintained burn registry for patients admitted to the Parkland Memorial Hospital burn unit between January 1, 1989 and December 31, 1998 were analyzed. Logistic regression was used to generate estimates of the probability of death in half of the study sample, and this model was validated on the second half of the sample. Risk factors evaluated for their relationship with mortality were: age, inhalation injury, burn size, body mass (weight), preexisting medical conditions, nonburn injuries, and gender.

RESULTS

Of 4,927 patients, 5.3% died. The best model for estimating mortality included the percent of total body surface area burned; the percent of full-thickness burn size; the presence of an inhalation injury; age categories of: < 30 years, 30 to 59 years, > or = 60 years; and gender. The risk of death was approximately two-fold higher in women aged 30 to 59 years compared with men of the same age.

CONCLUSIONS

We have provided a detailed method for estimating the risk of mortality after burn trauma, based on a large, contemporary cohort of patients. These estimates were validated on a second sample and proved to predict mortality accurately. We have identified an increased mortality risk in women of 30 to 59 years of age.

Cardiovascular effect of 7.5% sodium chloride-dextran infusion after thermal injury

HYPOTHESIS

Clinical study can help determine the safety and cardiovascular and systemic effects of an early infusion of 7.5% sodium chloride in 6% dextran-70 (hypertonic saline-dextran-70 [HSD]) given as an adjuvant to a standard resuscitation with lactated Ringer (RL) solution following severe thermal injury.

DESIGN

Prospective clinical study.

SETTING

Intensive care unit of tertiary referral burn care center.

PATIENTS

Eighteen patients with thermal injury over more than 35% of the total body surface area (TBSA) (range, 36%-71%) were studied.

INTERVENTIONS

Eight patients (mean +/- SEM, 48.2% +/- 2% TBSA) received a 4-mL/kg HSD infusion approximately 3.5 hours (range, 1.5-5.0 hours) after thermal injury in addition to routine RL resuscitation. Ten patients (46.0% +/- 6% TBSA) received RL resuscitation alone.

MAIN OUTCOME MEASURES

Pulmonary artery catheters were employed to monitor cardiac function, while hemodynamic, metabolic, and biochemical measurements were taken for 24 hours.

RESULTS

Serum troponin I levels, while detectable in all patients, were significantly lower after HSD compared with RL alone (mean +/- SEM, 0.45 +/- 0.32 vs 1.35 +/- 0.35 microg/L at 8 hours, 0.88 +/- 0.55 vs 2.21 +/- 0.35 microg/L at 12 hours). While cardiac output increased proportionately between 4 and 24 hours in both groups (from 5.79 +/- 0.8 to 9.45 +/- 1.1 L/min [mean +/- SEM] for HSD vs from 5.4 +/- 0.4 to 9.46 +/- 1.22 L/min for RL), filling pressure (central venous pressure and pulmonary capillary wedge pressure) remained low for 12 hours after HSD infusion (P = .048). Total fluid requirements at 8 hours (2.76 +/- 0.7 mL/kg per each 1% TBSA burned [mean +/- SEM] for HSD vs 2.67 +/- 0.24 mL/kg per each 1% TBSA burned for RL) and 24 hours (6.11 +/- 4.4 vs 6.76 +/- 0.75 mL/kg per each 1% TBSA burned) were similar. Blood pressure remained unchanged, and serum sodium levels did not exceed 150 +/- 2 mmol/L (mean +/- SD) in either group.

CONCLUSIONS

The absence of deleterious hemodynamic or metabolic side effects following HSD infusion in patients with major thermal injury confirms the safety of this resuscitation strategy. Postburn cardiac dysfunction was demonstrated in all burn patients through the use of cardiospecific serum markers and pulmonary artery catheter monitoring. Early administration of HSD after a severe thermal injury may reduce burn-related cardiac dysfunction, but it had no effect on the volume of resuscitation or serum biochemistry values.

Thermal injury alters endothelial vasoconstrictor and vasodilator response to endotoxin

BACKGROUND

The unique location of the endothelium makes it vulnerable to injury from circulating factors created at remote wounds. In this study, we examined the effect of a sequential burn and lipopolysaccharide (LPS) challenge on endothelial function in vitro.

METHODS

Human umbilical vein endothelial cells treated with 20% human serum isolated from burn patients (>40% total burn surface area) at 2 and 24 hours postinjury. Cultures were subsequently treated with Escherichia coli LPS:0111:B4 (0.10-100ng/mL). Endothelin-1 (ET-1), 6-ketoPGF1a, and NO2/NO3 were detected by using specific enzyme immunoassays.

RESULTS

Burn serum did not alter endothelial ET-1, PGI2, or NO secretion compared with Control serum. LPS significantly enhanced 6-ketoPGF1a (54,242+/-14,466 pg/10(6) cells) and NO2/ NO3 (723+/-210 microM) secretion, but not ET-1 compared with Control serum alone (3,878+/-963 and 219+/-110). Burn serum pretreatment significantly enhanced the ET-1 response to LPS (303+/-36 pg/10(6) cells vs. 193+/-47). The 6-ketoPGF1a (16,509+/-3,785) and NO2/NO3 (354+/-98) responses to Burn/LPS were significantly diminished compared with Control/LPS. Although this level of 6-ketoPGF1a was elevated compared with Control alone (7,518+/-2,299), NO2/NO3 was unchanged (significance at p < 0.05).

CONCLUSION

Thermal injury may prime remote endothelium and alter the response to a septic focus with an enhanced vasoconstrictor (ET-1) and diminished vasodilator (PGI2/NO) response, a situation that may contribute to postburn distal organ injury.

Traumatic wound care

The scope and importance of traumatic wound care, assessment, debridement, pre and postoperative management, and subsequent skin care during the course of treatment cannot be over-emphasized, and indeed, are the most important considerations for functional and cosmetic outcome. Care begins in the emergent phase and continues through acute and convalescent phases. Efforts are directed at methods and techniques which prevent infection, facilitate wound healing, promote comfort, and at the same time, maintain optimal function and minimize deformities.

Evaluation of troponin-I as an indicator of cardiac dysfunction after thermal injury

BACKGROUND

Biochemical serum markers commonly used to assess human cardiac injury (creatinine phosphokinase, creatine phosphokinase-MB) have been shown to have diminished specificity for detection of cardiac injury in the setting of burn-related soft-tissue and skeletal muscle injury. Laboratory studies have demonstrated that severe cutaneous thermal injury is associated with cardiac contractile dysfunction and a corresponding elevation in serum cardiac troponin-I (cTn-I) in several species.

METHODS

Twenty-three patients admitted to a tertiary care burn referral center were evaluated. Patients were monitored with pulmonary artery catheters, and creatinine phosphokinase, creatine phosphokinase-MB, and cTn-I levels were determined for 24 hours. Using a database, 6,722 burn patients were reviewed to determine the incidence of preexisting cardiac disease and postburn cardiac complications.

RESULTS

All patients had persistent sinus tachycardia (>115 beats per minute) without obvious electrical anomalies. All patients centrally monitored with a pulmonary artery catheter (n=20) maintained a cardiac index of greater than 3.0 L x min(-1) x m(-2) x cTn-I was present (>0.3 ng/mL) within 3.0 hours and elevated (>0.55 ng/mL) at 24 hours for all burns of more than 18% total body surface area. Historically, although only 5% of all admissions manifest acute postburn cardiac complications, 94% of these patients presented with preexisting heart disease.

CONCLUSION

Severe thermal injury was associated with a mild elevation in serum troponin-I; however, this did not correlate with overt cardiac morbidity or mortality. Postburn elevation of cTn-I suggested that a subtle degree of cardiac injury was present after a severe thermal injury despite hyperdynamic cardiac function during resuscitation.

Tracheostomy in the young pediatric burn patient

OBJECTIVE

To evaluate the incidence of complications in comparison with the benefits of tracheostomy in young pediatric burn patients (newborn to 3 years old).

DESIGN

Retrospective survey.

SETTING

Tertiary care burn center.

PATIENTS

A total of 1549 consecutive pediatric burn patients, of whom 180 were intubated.

INTERVENTIONS

Tracheostomy was performed in 76 children.

MAIN OUTCOME MEASURES

Duration of mechanical ventilation, mortality, respiratory complications, airway complications, and condition of the airway at discharge from the hospital.

RESULTS

Seventy-six patients required tracheostomy. Their mean burn size was 34% total body surface area and mean length of stay in the hospital was 56 days. There were no perioperative complications. Eight patients (10%) could not be decannulated because of airway obstruction. Five of these outgrew their obstruction, 2 required surgery, and 1 continues to be evaluated for laryngeal reconstruction.

CONCLUSION

Pediatric tracheostomy can be performed safely with no perioperative complications and acceptable chronic morbidity.

Toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a poorly understood and devastating condition. It is usually diagnosed in a primary care setting. Treatment of severe cases by burn care personnel is usually by referral. In this review, we report excessive mortality rates associated with prolonged use of systemic steroid therapy and delayed referral (more than 1 week from diagnosis). Forty-four consecutive patients admitted to a regional burn center with the diagnosis of TEN over a 14-year period, (0.7% of all admissions) were included. Precipitating factors were identified in 30 cases. Twenty-one patients had known prehospital allergy conditions directly related to the inciting agent. The mean age of this population was 44.9 years, and the mean total body surface area (TBSA) injury was 52.4%. Eighty-four and one-half percent of all patients with TEN were admitted to the ICU. Twenty-four patients required ventilator support. Overall mortality rate was 36%. Nonsurviving patients had a mean age of 61.6 years, compared to 35.3 years for survivors. Nonsurvivors had a mean TBSA of 64.4%, survivors had a mean TBSA of 44%. TEN, although a nonthermal injury, is best managed by personnel experienced in the care of severe thermal injuries. Despite the availability of this expertise, delayed transfer of severe presentations continues to contribute to exceptionally high morbidity and mortality rates.

A multicenter clinical trial of a biosynthetic skin replacement, Dermagraft-TC, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds

This multicenter study compared the use of a biosynthetic human skin substitute with frozen human cadaver allograft for the temporary closure of excised burn wounds. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) consists of a synthetic material onto which human neonatal fibroblasts are cultured. Burn wounds in 66 patients with a mean age of 36 years and a mean burn size of 44% total body surface area (28% total body surface area full-thickness) were surgically excised. Two comparable sites, each approximately 1% total body surface area in size, were randomized to receive either DG-TC or allograft. Both sites were then treated in the same manner. When clinically indicated (> 5 days after application) both skin replacements were removed, and the wound beds were evaluated and prepared for grafting. DG-TC was equivalent or superior to allograft with regard to autograft take at postautograft day 14. DG-TC was also easier to remove, had no epidermal slough, and resulted in less bleeding than did allograft while maintaining an adequate wound bed. Overall satisfaction was better with DG-TC.

Alcohol, drug intoxication, or both at the time of burn injury as a predictor of complications and mortality in hospitalized patients with burns

The objective of this study was to characterize the association between drug and alcohol intoxication at the time of injury and subsequent complications and mortality in hospitalized patients with burns. A computerized burn database was used to analyze data on 3047 consecutive adult (21 to 75 years) hospitalized patients with burns admitted between January 1982 and August 1994. Data for intoxicated (by history, blood alcohol content, or positive drug screen) and nonintoxicated patients were compared. The same analysis was also conducted on 429 consecutive adolescent patients with burns (ages 14 to 20 years) admitted during the same time period. The incidence of intoxication at the time of burn was 6.9%. No significant differences in age, sex, race, or burn size were noted. Intoxicated patients had a higher incidence of associated injuries. Skin graft loss, cellulitis, donor site conversion, hypotension, and pneumonia were more common in the intoxicated group. They also had more intensive care unit admissions, ventilator days, operations, transfusions, and total hospital days. Intoxicated patients had a lower mortality (7.1%) than patients in the control group (10.9%). Intoxication at the time of burn injury is an important predictor of complications in adult patients with burns.

Pediatric grease burn injury

OBJECTIVES

To evaluate the incidence and severity of grease and oil burns in children and to discuss prevention.

DESIGN

All pediatric patients admitted with hot grease burns were compared with the general pediatric burn population.

SETTING

All admissions to a regional burn center during a 20-year period were reviewed using a computerized database.

PATIENTS

Eight thousand three hundred sixteen patients with acute burn injuries were admitted. Children less than 15 years old accounted for 31.9% of this population (2651 patients). Two hundred fifteen children had burns caused by hot grease or oil.

INTERVENTIONS

Sixty-nine patients (32%) in the pediatric grease burn group were admitted to the intensive care unit. Thirteen patients (6%) required intubation, and six (46%) eventually required tracheostomy. Sixty-three patients (29.3%) required operative procedures for wound care.

MAIN OUTCOME MEASURES

Grease burn patients had a significantly higher incidence of full-thickness burns, wound infection, and burns involving the face, neck, chest, and arms but lower mortality compared with the general pediatric burn population. Fifty percent of grease burns were caused by home deep fryers.

RESULTS

There was no difference between the groups regarding age, sex, or ethnic distribution, size of injury, length of hospitalization, number of intensive care unit admissions, pulmonary infections, operative procedures, or mechanical ventilator requirements.

CONCLUSIONS

Grease burns often result in long-lasting, disfiguring, and debilitating injuries. Home deep fryers are frequently involved in these injuries. Careful use of these appliances is mandatory. Increased public awareness is vital to this effort.

High-voltage electric injury: assessment of muscle viability with MR imaging and Tc-99m pyrophosphate scintigraphy

PURPOSE

To evaluate use of magnetic resonance (MR) imaging and technetium-99m pyrophosphate (PYP) scintigraphy in preoperative assessment of muscle viability after high-voltage electric injury.

MATERIALS AND METHODS

Twelve injured limbs were studied. Immediate, equilibrium, and delayed Tc-99m PYP scintigrams and gadolinium-enhanced and unenhanced MR images were obtained. Imaging results were compared with clinical findings.

RESULTS

Scintigraphy demonstrated nonperfusion in four limbs that were subsequently amputated, but MR imaging had poor sensitivity in nonperfused regions owing to lack of edema. Tc-99m PYP uptake increased at transition zones between normal and nonperfused regions. MR imaging allowed further characterization of these zones by demonstrating edema as enhancing (perfused) or nonenhancing (nonperfused). In all nonamputated limbs, edema showed enhancement.

CONCLUSION

In high-voltage electric injury, gadolinium-enhanced MR imaging appears able to demonstrate zones of potential viability within radionuclide-avid tissue but has poor perfusion sensitivity when used alone.

Acute pseudo-obstruction in critically ill patients with burns

Acute pseudo-obstruction of the colon (Ogilvie's syndrome) is a rare but potentially morbid complication of burn injury. Two thousand seven hundred three consecutive critically ill patients with burns were reviewed for findings consistent with pseudo-obstruction. Eight (0.29%) patients were identified. Mean age was 63.5 years, and mean burn size was 24.6% total body surface area. All patients were undergoing mechanical ventilation at the time of diagnosis. Six had a previous cardiac condition or complication, and five were on digoxin. Diagnosis was suspected in seven patients before colonoscopy or surgery. Six patients were treated with colonoscopy alone with one treatment failure. Two deaths occurred during hospitalization. Two late deaths were due to underlying cardiac conditions. The preferred treatment of Ogilvie's syndrome is nasogastric suction, colonic decompression, and close observation with surgery reserved for treatment failures or when diagnosis is in doubt. The incidence of Ogilvie's syndrome in patients with burns appears to be related to nonburn medical conditions, especially cardiopulmonary complications and age, rather than to the burn itself.

A double-blinded prospective evaluation of recombinant human erythropoietin in acutely burned patients

OBJECTIVE

To evaluate the effects of recombinant human erythropoietin (r-HuEPO) in attempting to prevent anemia in acutely burned patients.

DESIGN

Prospective double-blind randomized study of 40 patients.

METHODS

Patients with burns from 25% to 65% total body surface were enrolled. r-HuEPO or a placebo was begun within 72 hours of admission. Cell blood count, reticulocyte counts, transfusion requirements, and blood loss were measured. Comparison was carried out by the unpaired t test.

MAIN RESULTS

There was no statistically significant difference in hemoglobin, hematocrit, reticulocyte count, ferritin, serum iron, total iron blinding capacity, or transfusion requirements. In patients with burns from 25% to 35%, the reticulocyte counts were statistically significantly higher.

CONCLUSION

In our work the administration of r-HuEPO in acutely burned patients did not prevent the development of postburn anemia or decrease transfusion requirements. Increased erythropoiesis in smaller burns (25% to 35%) was observed and may indicate a reason for further study.

Effects of propranolol administration on cardiac responses to burn injury

Previous studies showing that propranolol upregulates beta-adrenergic receptors and protects against myocardial ischemia led us to hypothesize that preburn propranolol would protect against postburn cardiac dysfunction. Guinea pigs were treated with propranolol 3 mg/kg/day for 14 days, then deeply anesthetized and subjected to a 45% 3 degrees scald burn; eight guinea pigs treated with propranolol served as the control group (group 1). Burned guinea pigs were resuscitated with Ringer's lactate given as either 4 ml (group 2, N = 8), 6 ml (group 3, N = 10), or 8 ml (group 4, N = 6) per kg/% burn. Guinea pigs treated for 14 days with vehicle (water) were subjected to either sham burn (non-propranolol control, group 5, N = 10) or burn and treatment (group 6, N = 10) as described for group 2. Fluid resuscitation in non-propranolol-treated guinea pigs failed to overcome burn-induced cardiac deficits, as indicated by significantly lower left ventricular pressure, 86 +/- 2 versus 62 +/- 3 mm Hg; +dP/dt max, 1365 +/- 43 versus 1110 +/- 44 mm Hg/sec; -dP/dt max, 1184 +/- 31 versus 881 +/- 40 mm Hg/sec, p < 0.001. Burn-mediated cardiac defects occurred in all propranolol-treated guinea pigs regardless of the fluid volume given. Our data show that (1) propranolol did not protect against burn-induced cardiac dysfunction, and (2) chronic beta-adrenergic blockade increases postburn fluid requirements for maintenance of cardiodynamic stability and for survival.

Acute adrenal insufficiency in the patient with burns

Acute adrenal insufficiency is an uncommon but devastating complication of severe burn injury. The diagnosis is rarely made antemortem. Acute, fatal, adrenal insufficiency developed in three patients among 807 critically ill patients with burns treated at this institution during the past 6 years. Thermal injuries elevate corticosteroid secretion for weeks after injury, severely stressing the adrenal glands. Overload of the hypothalamic-pituitary-adrenal axis is thought to make this system unusually vulnerable to acute infarction. Although the actual mechanism of adrenal hemorrhage is not clear, the combination of excessive adrenocorticotropic hormone stimulation and hemodynamic instability have been implicated in its evolution. Survival may be too short for characteristic Addisonian metabolic changes to develop. Acute adrenal insufficiency is a rare event that is historically associated with meningococcemia, although any life-threatening illness may precipitate this catastrophe. Therefore, when a sudden deterioration in the patient with thermal injuries is encountered, adrenal insufficiency must be considered.