Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT).

OBJECTIVES: ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial. SUMMARY BACKGROUND DATA: No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation. METHODS: Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols. RESULTS: Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone. CONCLUSIONS: Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.

Cross-Sectional Assessment of Burn Center and Nonburn Center Patient Care: A Multi-Database Comparison.

The practice of burn care is complex and continues to be a rapidly evolving field. To assess how differences in management affect hospital stay characteristics and outcomes, the authors sought to compare outcomes data from two sources, such as burn center and nonburn center data. The National Burn Repository (NBR, version 8) and the 2014 Nationwide Readmission Database (NRD) were compared based on ICD-9 948-series burn-related diagnosis codes, generating a total of 83,068 and 14,131 burn patients from the NBR and NRD, respectively. Patients were stratified by burn size and compared based on demographic factors and hospital stay characteristics. t-Test and chi-squared statistics were performed with SAS, version 9.4. Burn patient populations from the NBR and NRD databases, when stratified by patient demographic factors, were found to have similar sex distributions, 68% and 64% male, respectively. The average age was significantly higher in the NRD data at 39.5 ± 23.6 compared with 30.9 ± 22.3 years. Hospital stay characteristics, including length of stay and mortality, were not found to differ significantly. Differences were identified in the number of trips to the OR, which was significantly greater in the NBR population as well as the total cost of care, which was significantly less in the NBR population at $92k compared with $125k. This study has shown through the interpretation of multiple databases that not only do demographics differ between burn and nonburn center populations, but also do management strategies, particularly in operative intervention and cost.

Clinical outcomes after burns in elderly patients over 70 years: A 17-year retrospective analysis.

INTRODUCTION: In the United Stated population >70years is likely to double by the year 2050. Elderly population (>70years) are most vulnerable to burns and outcomes following such injuries in this special group is poorly studied. This study aimed to look at outcomes following burns in patients >70years over a period of 17 years. MATERIALS AND METHODS: Data on 6512 patients admitted to a Level I Burn Center between 1995 and 2011 was analyzed. Age, gender, ethnicity, TBSA, burn etiology, hospital and burn intensive care unit (ICU) length of stay (LOS) and status at discharge were abstracted. Three broad categories were created based on presence or absence of smoke inhalation, No smoke inhalation (Group A), smoke inhalation only (Group B) and smoke inhalation with burn injury (Group C). Differences were analyzed using the student's t-test for continuous variables and Chi-Square test for categorical variables. RESULTS: The study group was comprised of 564 patients, 72.3% in group A, 4.8% in group B and 22.9% in group C formed the study population. The mean age of the patients studied was 80.4±6.7, with female patients being more common (58%). The number of Caucasians (72.9%) was highest in group C compared to other racial groups (p=0.047). Majority of patients in the group B (59.3%) were admitted directly compared to other two groups (group A=24.0%, group B=34.9%, p<0.001). Overall percent total body surface area (% TBSA) and % TBSA third degree burns were higher in group C, whereas % TBSA second degree burns were common in group B (p<0.05). The number ICU admissions, the mean length of ICU stay, mean duration of ventilator support and mean length of hospitalization were all highest in group C patients (p<0.001). The number of discharges to home without home health aide were higher in group A, whereas the number of discharges to nursing home/rehabilitation/extended care facility were higher in group B (p<0.001). The in-hospital mortality (58.1%, p<0.001) and overall burn related mortality (62.8%, p<0.001) were highest in group C. There was no significant difference between the groups for the number of patients converted to hospice care (p=0.21). On multivariate analysis ICU admission (Odds Ratio [OR]=3.7, 95% Confidence Interval [95% CI]=2.1-6.5), ventilator support (OR=7.1, 95% CI=4.1-12.0), and %TBSA >10% (OR=3.1, 95% CI=1.9-5.0) significantly increased mortality. In terms of complications, group C had a significantly higher incidence of pneumonia (18.6%, p<0.001), respiratory failure (17.1%, p=0.001), and sepsis (7.8%, p=0.003). CONCLUSIONS: Patients >70 years constitute small (8.6%) but significant number among burn patients. The overall ICU admissions, number of days on ventilator, ICU stay, in-hospital mortality and overall mortality is higher in this group of population even for low % TBSA burns. Presence of smoke inhalation increases mortality.

The Use of Fetal Bovine Dermal Scaffold (PriMatrix) in the Management of Full-Thickness Hand Burns.

OBJECTIVE: Management of full-thickness burn wounds represents a challenge when reconstructive options are not applicable. Fetal bovine dermal matrix is a bioactive collagen scaffold that assimilates into wounds and stimulates vascularization and dermal regeneration. METHODS: We present the use of fetal bovine dermal scaffold PriMatrix in the treatment of a patient who sustained scald-immersion full-thickness burns of her bilateral hands that failed conventional wound therapy. RESULTS: A 71-year-old woman with advanced Parkinson's disease sustained self-induced 5% mixed second- and third-degree scald-immersion burns of her bilateral hands and fingers. The patient underwent extensive debridement that resulted in partially avascular wounds measuring 66 cm(2) and 72 cm(2) with exposed extensor tendons and no evidence of bleeding. Meshed homograft was applied, but her hands remained partly avascular. PriMatrix fetal bovine dermal scaffold was applied to provide tissue remodeling over the bones, which allowed successful skin grafting and complete wound healing. CONCLUSIONS: Our experience shows fetal bovine dermal scaffold to be an effective method in management of complicated burn wounds in selected cases. Further studies need to be implemented to confer this conclusion.

Clinical outcomes of isolated lower extremity or foot burns in diabetic versus non-diabetic patients: a 10-year retrospective analysis.

INTRODUCTION: The incidence of diabetes mellitus (DM) in the United States is expected to increase from 8 per 1000 in 2008 to 15 per 1000 by 2050 [20]. As a result, DM patients will constitute a large proportion of Burn Center admissions, with burns typically due to contact burn or scalding. Peripheral vascular disease (PVD) and peripheral neuropathy (PN) are far more common in DM patients, particularly in those with poorly controlled disease, and are often associated with worse outcomes than non-diabetic (nDM) burn patients. This study sought to analyze whether the outcome of isolated leg and foot burns among DM and nDM individuals differed significantly. MATERIALS AND METHODS: Retrospective data on 207 consecutive patients (>18 years old) admitted to a Burn Center with isolated leg or foot burns between 1999 and 2009 was collected and analyzed for this study. Age, gender, ethnicity, total body surface area (TBSA), degree of burn, etiology, hospital and burn intensive care unit (ICU), length of stay (LOS), and status at discharge were reviewed. Patients were grouped as diabetic (DM) or non-diabetic (nDM). Differences were analyzed using either the Student's t-test or Chi-square. RESULTS: 43 DM and 164 nDM patients with isolated lower extremity or foot burns were treated during the study period (1999-2009). The mean age of DM and nDM patients was 54.6 and 43.7 years, respectively (p<0.001). The most common burn etiology was scalding, flame, or contact burn. Percentage of total body surface area (TBSA) burn in DM patients averaged±standard deviation 1.8±1.3% compared to 1.8±1.6% in nDM (p<0.9). Among DM patients, 86% (N=37) of patients suffered third degree burns and 14% (N=6) of patients had second degree burns compared to 76% (N=125) of patients and 24% (N=39) of patients among nDM patients, respectively (p<0.16). The DM group had significantly higher burn ICU admission rates, 16.3% of patients versus 8.5% of patients (p<0.001), total length of hospital stay (mean±standard deviation), 14.1±10 versus 9.8±9.3 days (p<0.01) and renal failure, 4.7% of patients versus 0.6% of patients (p<0.05) compared to the nDM group. 93% of DM patients were discharged to home without further medical attention while 4.7% of patients underwent further treatment. In comparison, 85.4% of the nDM patients were discharged home with no further treatment while 8.5% of patients received home care (p<0.01). CONCLUSION: DM patients who suffer isolated burns to the feet or lower extremities have poorer clinical outcomes and more complicated and protracted hospital courses when compared to nDM patients with similar burns. Although diabetics in the current study did not experience larger or more severe burns than nDM patients, they were nearly twice as likely to be admitted to the ICU, spent an average of four days longer in the hospital, and had a higher likelihood of developing renal failure compared to nDM patients.

Clinical outcome analysis of male and female genital burn injuries: a 15-year experience at a level-1 burn center.

OBJECTIVES: The American Burn Association classifies a burn to the genitalia as a major injury. Isolated burns to the penis, scrotum or vulva are rare as a result of protection provided by the thighs and abdomen. Thus, burned genitalia represent an ominous sign of a more extensive total body surface area burn. METHODS: A retrospective analysis of consecutive patients admitted to a Level-1 Burn Unit with a burn involving the genitalia from January 1995 to December 2009 comprised the study population. RESULTS: A total of 393 patients of 5878 patients (6.7%) admitted to the Burn Unit suffered a burn involving the genitalia, including 253 males (64.4%) and 140 females (35.6%). The median total body surface area was 12% (range 1-100%), the most common cause of genital burn was scald (n = 246, 62.9%) and median length of stay was 9 days (range 1-472 days). A total of 269 patients (68.4%) were discharged to home from the hospital, and in-hospital mortality was 20.9%. CONCLUSIONS: The typical profile for those sustaining a genital burn include younger patients (≤30 years-of-age), sustaining a median total body surface area burn of 12% from a scald injury, with extensive genitalia involvement. Length of stay for genital burns is usually extended and, as a result of concomitant injuries, is associated with a 20% in-hospital death rate.

Pediatric genital burns: a 15-year retrospective analysis of outcomes at a level 1 burn center.

BACKGROUND/PURPOSE: Burns involving the genitalia and perineum are commonly seen in the context of extensive total body surface area (TBSA) burns and rarely as isolated injuries because of protection provided by the thighs and the abdomen. Genital burns usually result in extended hospital stays and are accompanied by severe morbidity and increased mortality. METHODS: A retrospective analysis of consecutive pediatric (<18 years) patients with burns involving the genitalia admitted to the Saint Barnabas Medical Center Level 1 Burn Unit from January 1, 1995, to December 31, 2009, was performed. RESULTS: One hundred sixty pediatric patients (8.3%) had a genital burn, including 105 patients younger than 5 years (65.6%) and 55 patients between 5 and 18 years (34.4%). Overall mean TBSA was 13.8% ± 16.8%, mean TBSA (genitalia) was 0.84% ± 0.25%, mean length of stay (LOS) was 11.9 ± 11.9 days, and mean burn intensive care unit LOS was 4.9 ± 9.7 days. CONCLUSIONS: In patients younger than 5 years, a TBSA burn more than 10% with extensive genitalia involvement is almost always the result of a scald injury. Younger patients (<5 years) are more often the victims of abuse, and prolonged LOS is the norm (>2 weeks). Patients 5 years or older are more often male and usually have a TBSA burn more than 15%.