Lightning burns.

We present the case of a lightning-strike victim. This case illustrates the importance of in-field care, appropriate referral to a burn center, and the tendency of lightning burns to progress to full-thickness injury.

Intravenous immune globulin therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis complicated by hemolysis leading to pigment nephropathy and hemodialysis.

BACKGROUND: Intravenous immune globulin (IVIG) is generally thought to be of relatively low risk for adverse events and some experts consider this to be the best treatment for Stevens-Johnson syndrome/toxic epidermal necrolysis. OBJECTIVE: We evaluated the underlying cause of anemia and renal failure in 2 consecutive patients being treated with IVIG for Stevens-Johnson syndrome/toxic epidermal necrolysis. METHODS: This is a retrospective chart review. RESULTS: We present 2 patients with Stevens-Johnson syndrome/toxic epidermal necrolysis and severe hemolysis requiring blood transfusion who subsequently developed pigment nephropathy necessitating hemodialysis after treatment with IVIG. Both patients had antibodies to their ABO blood type detected in the eluate from their red blood cell membrane. LIMITATIONS: This is a retrospective review with only 2 cases. CONCLUSIONS: We propose that IVIG-associated hemolysis is an adverse reaction that may not be as rare as once thought, presenting as a mild decrease in hemoglobin and hematocrit. Antibodies to blood type A and B are given as part of pooled immune globulin and are considered to be the cause of hemolysis. More severe anemia requiring transfusion is less common, and the breakdown products produced by hemolysis can lead to pigment nephropathy and renal failure. We present methods by which this severe complication can be anticipated and managed more effectively.

Process improvement in trauma: compliance with recommended imaging evaluation in the diagnosis of high-grade renal injuries.

BACKGROUND: Appropriate imaging in renal trauma can avoid delayed recognition of collecting system injuries, allowing for prompt intervention and less morbidity. Current recommendations include obtaining abdominal and pelvic computed tomographic scans with intravenous contrast, followed by excretory images for high-grade injury or perinephric fluid. The purpose of this study was to evaluate compliance with this recommendation among adult Level I trauma centers in Utah. METHODS: A retrospective review was performed on all renal trauma patients evaluated at adult Level I trauma centers in Utah from January 2005 to January 2011. For all American Association for Surgery of Trauma grade 3 to 5 renal injuries, injury characteristics and outcomes were reviewed. We defined compliance as obtaining delayed images for grade 3 injuries with perinephric fluid or any grade 4 to 5 injuries. Descriptive statistics and univariate comparisons were calculated using statistical software. RESULTS: A total of 147 patients were identified with injuries of grade 3 or higher, but only 126 had available images for review at the time of the study. Of the 102 patients with a perinephric fluid collection or grade 4 to 5 injuries, delayed images were obtained in 74 (73%). In these patients, 14 (19%) had a collecting system injury. In the 28 patients without delayed images, 7 (25%) were later identified to have a collecting system injury. Of the 21 collecting system injuries, 7 (33%) had a delay in diagnosis because of lack of excretory images obtained on initial evaluation. CONCLUSION: Our findings support obtaining excretory images in patients with grade 4 to 5 injuries or those with a perinephric fluid collection. Poor compliance led to delayed diagnosis, with several patients requiring intervention for persistent urinary leak. We have implemented trauma imaging guidelines within Utah Level I trauma hospitals, which seek to minimize these diagnostic problems. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.

Process improvement in trauma: traumatic bladder injuries and compliance with recommended imaging evaluation.

BACKGROUND: We hypothesized that our compliance was low with recommended imaging for evaluation of traumatic bladder injury, which includes either a computed tomographic (CT) cystogram or plain cystogram. We sought to determine if poor compliance impacted diagnosis, management, and outcome of patients with bladder injury. METHODS: Patients with bladder injury were identified from all Level 1 hospital trauma registries in Utah from 1996 to 2010. Details including presentation, management, and outcome of bladder injury were described using descriptive statistics and bivariate and logistic regression analysis. RESULTS: A total of 124 patients were identified from the trauma registries with bladder injury and adequate records for review. The mean age was 35 years. Blunt trauma occurred in 110 patients (88%). Mean Injury Severity Score was 26.3. The leading concomitant injury was pelvic fracture in 98 patients (79%). Bladder injury was extraperitoneal in 75 patients (60%), intraperitoneal in 39 (31%), and both or undetermined in 10 (8%). A higher risk of death was seen in intraperitoneal with or without concomitant extraperitoneal injury compared with extraperitoneal injury only (odds ratio, 12.4; 95% confidence interval, 2.37-99.2). Management was operative in 68 (55%) patients (95% intraperitoneal, 31% extraperitoneal). Of the 124 injuries, 100 were detected with imaging: standard CT scan in 70 (56%) and cystogram or CT cystogram in 30 (24%). The remaining injuries were discovered operatively or were undocumented (n = 24, 19%). Initial imaging missed or incorrectly diagnosed bladder injury in 13 (13%) patients (nine from standard CT scan and four from CT or plain cystogram). In five cases diagnosed by standard CT scan, extraperitoneal injuries were misdiagnosed as intraperitoneal and operatively explored. CONCLUSION: There was poor compliance with imaging recommendations for evaluation of suspected bladder injury by either CT cystogram or plain cystogram at Level 1 trauma centers in Utah. We have implemented a genitourinary trauma imaging algorithm designed to minimize errors in bladder injury diagnosis. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Telemedicine evaluation of acute burns is accurate and cost-effective.

BACKGROUND: As the number of US burn centers has declined, access to burn care is increasingly limited. Inexperience in burn wound assessment by referring physicians often results in overtriage or undertriage. In an effort to improve access to burn care in our region, we instituted a program of telemedicine evaluation of acute burns. METHODS: We created a telemedicine network linking our burn center to three hospitals located 298 to 350 air miles away. Participants agreed to perform telemedicine consultation for acutely burned patients admitted to their emergency departments. We compared consults and referrals from these facilities during the period July 2005 to August 2007 (TELE) to those during a 2-year period before instituting telemedicine (PRE-TELE). RESULTS: During the TELE period, 80 patients were referred, of whom 70 were seen acutely by telemedicine, compared with 28 PRE-TELE referrals. The groups did not differ in age or burn size. Only 31 patients seen by telemedicine received emergency air transport (44.3%), compared with 100% of PRE-TELE patients (p < 0.05). Nine other TELE patients were transported by family; 30 other patients were treated locally. Ten remaining patients were transported without telemedicine evaluation. TELE patients transported by air had somewhat larger burn sizes (9.0% vs. 6.5% total body surface area; p = NS) and longer length of stay (13.0 days vs. 8.0 days; p = NS) than PRE-TELE patients. Burn size estimates by burn center physicians made either by telemedicine or direct inspection correlated closely but both differed significantly from those of referring physicians. Providers and patients expressed a high level of satisfaction with the telemedicine experience. CONCLUSIONS: Acute evaluation of burn patients can be performed accurately by telemedicine. This can reduce undertriage or overtriage for air transport, improve resource utilization, and both enhance and extend burn center expertise to many rural communities at low cost.

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.

Safety and efficacy of an intensive insulin protocol in a burn-trauma intensive care unit.

Aggressive glycemic management in critically ill patients with acute burn injury or life-threatening soft-tissue infections has not been thoroughly evaluated. An intensive insulin protocol with target glucose values of less than 120 mg/dl was implemented in October 2005 in our regional Burn-Trauma intensive care unit. We reviewed our initial experience with this protocol to evaluate the safety and efficacy of aggressive glycemic control in these patient groups. Patients were placed on the intensive insulin protocol based upon the need for glycemic management during their hospitalization for burn or soft-tissue disease. Patient information prospectively collected while on protocol included all measured blood glucose values, total daily insulin use, and incidence of hypoglycemic episodes, defined as serum glucose <60 mg/dl. Thirty patients (17 burns, 13 soft-tissue infections) were placed on the intensive insulin protocol during the first 16 months of use. The mean daily blood glucose level for burn patients was 115.9 mg/dl and for soft-tissue disease patients was 119.5 mg/dl. There was a 5% incidence of hypoglycemic episodes per protocol day. All hypoglycemic episodes were treated by holding the insulin infusion, and no episode had known adverse effects. Hyperglycemia in critically ill patients with burns and extensive soft-tissue disease can be effectively managed with an insulin protocol that targets blood glucose values of less than 120 mg/dl with minimal incidence of hypoglycemia. A multicenter prospective randomized trial would provide the ideal forum for evaluating clinical outcome benefits of using an intensive insulin protocol.

Use of inhaled heparin/N-acetylcystine in inhalation injury: does it help?

Inhaled heparin/N-acetylcystine (AHA) has been reported to decrease mortality in children with inhalation injury. The use of AHA therapy in adult burn patients with inhalation injury has not been evaluated. We hypothesized that patients who received AHA therapy in the management of inhalation injury would have better pulmonary mechanics and better clinical outcomes than patients who did not. This study is a retrospective chart review of pulmonary mechanics and clinical outcomes in all inpatients identified in the institutional ABA/TRACS database as having sustained inhalation injury from 1999 to 2005. Patients were not assigned to a treatment group. One hundred and fifty patients with inhalation injury were identified. Sixty-two patients were treated with AHA during the first 72 hours of admission. Treatment occurred mostly in patients admitted after 2002, with only 18 patients receiving AHA from 1999 through 2002. Treated and untreated patients did not differ in age or TBSA burn injury, nor did any studied clinical outcome differ between treated and untreated groups. In addition, there was no difference in pulmonary findings at 1 week after injury between treated and untreated patients. Although best Pao2 was higher in treated patients during the first 72 hours, this was not a durable finding, and the best Pao2/Fio2 ratio was unaffected by treatment. Importantly, the use of AHA in adults with inhalation injury did not affect clinical outcomes. A prospective, randomized trial would be of benefit to delineate the clinical benefits of AHA treatment for inhalation injury.

Fournier's gangrene: management at a regional burn center.

Fournier's gangrene (FG) describes necrotizing infections of the perineum in both sexes. Controversies in treatment of FG include the roles of orchiectomy, urinary and/or fecal diversion, and hyperbaric oxygen (HBO). Because burn centers often treat these patients, we reviewed our experience with FG during a 14-year period. With Institutional Review Board approval, we reviewed our TRACS/ABA database for patients treated for FG during 1992 to 2005. Data was recorded on demographics, preexisting medical conditions, treatment, and outcomes. Thirty patients (20 men) were identified. Mean age was 54.3 +/- 14.1 years. Predisposing conditions included diabetes in 16 patients (53%), and morbid obesity and immunosuppression in 6 each. Twenty-two patients were transferred from outside hospitals, 12 after initial surgery. Sixteen patients presented with shock (blood pressure <90/60 mm Hg). Patients underwent a mean of 4.1 surgical procedures. Ten infections penetrated the deep fascia of the perineum or abdominal wall. Suprapubic cystostomy was performed in three patients, colostomy in seven, orchiectomy in one. HBO was not used. Hospitalization averaged 25.3 +/- 15.6 days. Mean charges ($1000) were $131.5 +/- 108.3. Definitive wound closure was obtained before discharge with suture repair and/or skin grafting in 18 of 25 survivors (72%). Five patients died (17%). In logistic regression analysis, the presence of shock on admission and female gender (mortality 40%) were significantly associated with mortality. FG remains a devastating infection, which occurs primarily in compromised patients. In this series, aggressive burn center care produced outcomes equivalent to those published in other series with or without use of HBO. Colostomy and urinary diversion can be used very selectively in these patients; orchiectomy is rarely required.

Learner satisfaction with Web-based learning as an adjunct to clinical experience in burn surgery.

Web-based learning provides an effective adjunct to clinical experience in medical education. However, few efforts have assessed learner satisfaction with web-based medical education experiences. American Burn Association and Advanced Burn Life Support (ABLS)-Now is a self-directed web-based curriculum designed to teach clinicians how to assess and stabilize patients with serious burns during the critical hours after injury. The purpose of this study is to evaluate time spent by learners taking the course, to demonstrate successful completion of an exam by these clinicians after the course, and to describe learner satisfaction with ABLS-Now. This preliminary descriptive study analyzed exam scores and voluntary course evaluations of medical students and interns to assess effectiveness of and satisfaction with the web-based ABLS-Now curriculum. Eighteen students and interns completed the web-based ABLS-Now curriculum and follow-up survey. The mean exam score was 88%. Learner scores strongly correlated with time spent completing the course (r2 = .66, P = .01). Learner satisfaction was very high. Learners expressed an interest in using similar web-based tools to learn about other topics in surgery. For novice clinicians, ABLS-Now seems to be an effective way to provide basic burn care education at a time when other educational opportunities have been reduced by work hour restrictions. Learners found the modules easy to use, relevant, and interesting. They indicated an interest in future use of web-based learning to supplement clinical experiences. Web-based learning represents an effective and well-received addition to clinical education in surgery for residents and medical students.

Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy.

HYPOTHESIS: Thrombolytic therapy will decrease the incidence of amputation when administered within 24 hours of exposure. DESIGN: Single institution retrospective review of clinical outcomes and resource use. SETTING: Burn unit of a tertiary academic referral center. PATIENTS: From 2001 to 2006, patients with severe frostbite admitted within 48 hours of injury underwent digital angiography and treatment with intra-arterial tissue plasminogen activator (tPA) if abnormal perfusion was demonstrated. These patients were compared with those treated from 1995 to 2006 who did not receive tPA. INTERVENTIONS: Tissue plasminogen activator vs traditional management of frostbite injury. MAIN OUTCOME MEASURES: Number and type of surgery were recorded, along with amputations of digits (fingers or toes) and more proximal (ray, transmetatarsal, or below-knee) amputations. Resource utilization including length of stay, total costs, cost per involved digit, and cost per saved digit were analyzed. RESULTS: Thirty-two patients with digital involvement (hands, 19%; feet, 62%; both, 19%) were identified. Seven patients received tPA, 6 within 24 hours of injury. The incidence of digital amputation in patients who did not receive tPA was 41%. In those patients who received tPA within 24 hours of injury, the incidence of amputation was reduced to 10% (P<.05). CONCLUSIONS: Tissue plasminogen activator improved tissue perfusion and reduced amputations when administered within 24 hours of injury. This modality represents the first clinically significant advancement in the treatment of frostbite in more than 25 years.

The relationship of serum lactate and base deficit in burn patients to mortality.

Serum lactate and base deficit in trauma patients have been shown to correlate with mortality. This study examines the relationship of these parameters to mortality among burn patients. We evaluated patients with >or=20% TBSA burn injury who had a serum lactate or base deficit recorded during the initial 48 hours of admission over a 5-year period. The primary study outcome was mortality. The mean (+/-SD) age of study patients (N = 128) was 35.2 +/- 21.1 years, the mean burn size was 41.7 +/- 17.9% TBSA, and the mortality rate was 17.1%. Mean serum lactate values of patients who died were significantly higher than those of survivors at admission and at 12, 18, and 24 hours after admission. The highest serum lactate value in the first 48 hours after admission was higher for nonsurvivors than survivors. Mean base deficit at admission and 6 hours after admission was significantly lower in patients who died than in survivors; in addition, the worst base deficit during the first 48 hours of care was significantly lower in patients who died than in those who survived. Early serum lactate and base deficit values are often worse for burn patients who die than for survivors. Elevation of serum lactate values during the first 48 hours after a burn is an independent risk factor for death, but no threshold value for serum lactate is demonstrable. Resuscitation should not be withheld from burn patients on the basis of any lactate or base deficit value.

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.

Effect of blood transfusion on outcome after major burn injury: a multicenter study.

OBJECTIVE: To delineate blood transfusion practices and outcomes in patients with major burn injury. CONTEXT: Patients with major burn injury frequently require multiple blood transfusions; however, the effect of blood transfusion after major burn injury has had limited study. DESIGN: Multicenter retrospective cohort analysis. SETTING: Regional burn centers throughout the United States and Canada. PATIENT POPULATION: Patients admitted to a participating burn center from January 1 through December 31, 2002, with acute burn injuries of >or=20% total body surface area. OUTCOMES MEASURED: Outcome measurements included mortality, number of infections, length of stay, units of blood transfused in and out of the operating room, number of operations, and anticoagulant use. RESULTS: A total of 21 burn centers contributed data on 666 patients; 79% of patients survived and received a mean of 14 units of packed red blood cells during their hospitalization. Mortality was related to patient age, total body surface area burn, inhalation injury, number of units of blood transfused outside the operating room, and total number of transfusions. The number of infections per patient increased with each unit of blood transfused (odds ratio, 1.13; p<.001). Patients on anticoagulation during hospitalization received more blood than patients not on anticoagulation (16.3+/-1.5 vs. 12.3+/-1.5, p<.001). CONCLUSIONS: The number of transfusions received was associated with mortality and infectious episodes in patients with major burns even after factoring for indices of burn severity. The utilization of blood products in the treatment of major burn injury should be reserved for patients with a demonstrated physiologic need.

Gender influences on burn outcomes in the elderly.

BACKGROUND: Women, aged 65 and older, now comprise a larger number of injuries requiring hospitalization than do young men. The purpose of this study was to evaluate gender differences in outcome and disposition of elderly (>65 years) burn patients. METHODS: We compared demographic, etiologic, and outcome differences between male and female patients 65 years of age and older admitted for acute burn treatment during a five-year period. RESULTS: Elderly patients comprised 8.5% of burn admissions. Women, who accounted for 33% of burns occurring in this group, tended to have smaller (12.0% versus 17.2% total body surface area (TBSA); p = 0.20) and less severe (3.6% versus 9.7% 3rd TBSA; p < 0.05) injuries, but mortality did not differ from men. Although not significant, elderly women, who were less likely to be married, tended to stay in the hospital longer and were significantly less likely to be discharged home than men (41.7% versus 66.7%; p < 0.05). CONCLUSIONS: Elderly burn patients, particularly women, utilize more resources than younger patients. Further research on the social and economic resources available to the elderly burn population, particularly women, is warranted in order to provide cost effective quality care during acute hospitalization and upon discharge.

Home treadmill friction injuries: a five-year review.

Treadmills are popular home fitness machines in American homes. Young children are at risk for friction injuries if they contact moving treadmills. The purpose of this study was to determine the impact of treatment of treadmill friction injuries in children. A review of 1,211 pediatric patients younger than 6 years treated at the Intermountain Burn Center between July 1997 and June 2002 was conducted. Forty-eight of these cases (4%) were treadmill friction injuries. The mean TBSA of these burns was 0.5%. The volar surface of the hand was the most common site of injury. Twenty-two (46%) of the 48 identified patients had full-thickness injuries that were treated surgically. Medical costs associated with treadmill friction injuries averaged US 2,385 dollars. The number of treadmill friction accidents resulting in friction injuries to children less than 6 years of age deserves serious attention and increased public awareness.

Regional air transport of burn patients: a case for telemedicine?

BACKGROUND: Air transport of burn patients is plagued by frequent "overtriage." We examined the use of air transport and the feasibility of using alternative methods such as telemedicine to assist in evaluation and treatment of burn patients within our region. METHODS: We reviewed all burn patients transported by air during 2000 to 2001. Each patient was classified as being most appropriate for air, ground, or family transport. In addition, a decision was made regarding whether telemedicine evaluation of the patient before transport could have significantly altered initial treatment decisions. RESULTS: Two hundred twenty-five acutely burned patients were transferred from referring hospitals in nine states, at a mean distance of 246 air miles. Mean burn size calculated by burn center physicians was 19.7% total body surface area, whereas referring physicians' mean estimate was 29% total body surface area. In 92 cases, over- or underestimation of burn size by referring physicians of as much as 560% or decisions regarding performance of endotracheal intubation suggested that telemedicine evaluation before transport might have significantly altered transport decisions or care. Air transport charges exceeded hospital charges in 21 cases. CONCLUSION: Frequent discrepancies in burn assessment contribute to overuse of air transport. The ability to evaluate burn patients by telemedicine may have the potential to assist decisions regarding transfer, avoid errors in initial care, and reduce costs. We are currently attempting to develop and test such a system.

Self-reported quality of life after electrical and thermal injury.

Electrical injury patients (EI) often require more procedures and longer hospital stays than their thermal injury counterparts. We hypothesized that postinjury quality of life might be better in thermal injury patients (TIs) than in EI. Each EI recorded in our institution's TRACS trade mark /ABA registry between 1995 and 2000 was matched with a TI for age and TBSA involvement. We compared SF-36 scores of EI and TIs to evaluate quality of life. Age and TBSA injury were similar between groups. SF-36 results demonstrated no significant differences in self-reported quality of life indices. Return to full-time employment did not differ significantly between groups. EI and TIs do not differ significantly in quality of life after their burn injuries. Self-evaluated function for EI and TIs is comparable. Quality of life in both EI and TIs are above population means on many dimensions.

Sustained bone mineral density changes after burn injury.

BACKGROUND: Body-composition changes have been observed after burn injury. In particular, several studies have shown that bone mineral density (BMD) in burn patients is decreased when compared to the normal population. Little is known about the frequency, severity, or duration of these changes. The purpose of this study was to describe body-composition changes over time after burn injury. MATERIALS AND METHODS: Twenty-nine burn patients participated in this study. Portable dual-energy X-ray absorptiometry (pDEXA) measuring forearm BMD, fat, and lean mass was obtained as soon as possible after admission and repeated bi-weekly until discharge and, when possible, for 2 years post-injury. The scan showing the greatest change in BMD, fat, or lean mass was compared to the baseline scan for each individual. RESULTS: Although lean and fat mass did not change significantly after injury, BMD decreased significantly. The greatest change in BMD did not occur during the acute burn hospitalization, but rather 131 days after burn injury. Changes in post-burn BMD inversely correlated with % total body surface area (TBSA) and % 3rd-degree TBSA. The magnitude of change was similar between adults and children. CONCLUSIONS: These results confirm earlier studies, suggesting that BMD can be negatively altered post-injury, with the greatest changes occurring after patients are discharged from the hospital. Although the clinical significance of these changes is not known, this study supports the need for long-term musculoskeletal assessments in burn patients and for further research to elucidate the mechanisms of burn-induced body-composition changes.

Early tracheostomy does not improve outcome in burn patients.

Early tracheostomy (ET) has been claimed to reduce ventilator support or intensive care unit or hospital length of stay in intensive care unit patients. This study was performed to assess the potential benefits of ET in burn patients. From October 1996 to July 2001, we evaluated all intubated and acutely burned adults using a formula to predict the probability of prolonged ventilator dependence. We randomized each patient with a probability of prolonged ventilator dependence more than 0.5 to ET, performed on the next operative day, or to conventional therapy (CON), which consisted of continued endotracheal intubation as needed, with tracheostomy (TRACH) performed on postburn day (PBD) 14 if necessary. During this period, 44 patients were randomized, 23 to CON and 21 to ET. Groups did not differ in age, total burn size, or inhalation injury, although ET patients had larger full-thickness burns. ET patients underwent TRACH at a mean of PBD 4 vs PBD 14.8 for CON patients (P <.01). ET patients had a significant improvement in PaO2 /FiO2 ratios within 24 hours following TRACH (139 +/- 15 vs 190 +/- 12; P <.01). There were no differences in ventilator support, length of stay, incidence of pneumonia, or survival. However, six CON patients (26%) were successfully extubated by PBD 14 compared with one ET patient (P <.01). Although tracheostomy offers some advantages in terms of patient comfort and security, routine performance of ET in burn patients does not improve outcomes, nor does it result in earlier extubation. This may be partly caused by the comfort and convenience of tracheostomy.