Variation in documented inhalation injury rates following burn injury in Australia and New Zealand.

INTRODUCTION: The negative impact of inhalation injuries on in-hospital outcomes for burn patients is well known, but the burns community is yet to form a consensus on diagnostic criteria and clinical definitions. The diagnosis of inhalation injuries is consequently highly subjective. This study aimed to assess the variation in the rate of documented inhalation injury for adult patients in Australian and New Zealand burn units. METHODS: Data for sequential admissions collected from eight adult burn centres across Australia and New Zealand between July 2009 and June 2016 were extracted from the Burns Registry of Australia and New Zealand (BRANZ). Inhalation injury was classified in two ways: (i) a field in the BRANZ data dictionary, and (ii) through a series of International Classification of Disease 10th Revision Australian Modification (ICD-10-AM) codes. Variation in inhalation injury prevalence was assessed using descriptive statistics, funnel plots, logistic regression, and predicted probabilities. RESULTS: There were 11,206 admissions to BRANZ sites over the study period. Inhalation injury prevalence was the highest at Site D (13.1% for the BRANZ field and 11.8% for the ICD-10-AM codes), but there was significant variation between the contributing sites and the inhalation injury classification methods. CONCLUSION: There is significant variation in the prevalence of documented inhalation injury among Australian and New Zealand burns units. The variation in the prevalence of documented inhalation injury across Australian and New Zealand sites reinforces the need for a consensus definition in the diagnosis of these injuries. Further work is required to improve data quality and reconcile the differences between clinical and ICD-10-AM coding prevalence before changes in clinical practice can be recommended from these data.

Reliability of the primary triage process after the Volendam fire disaster.

In a major incident, correct triage is crucial to emergency treatment and transportation priority. The aim of this study was to evaluate the triage process pursued at the site of the fire disaster in Volendam, the Netherlands on January 1, 2001. On-site (OS) and Emergency Department (ED) data regarding total body surface area burned (TBSA) and inhalation injury (INH) were compared with the final (FIN) assessment of these two parameters after hospital admission. Finally, the effect of OS intubation and the time of arrival at a hospital were evaluated. There were 245 injured. Mean age was 17.3 years. Final median TBSA was 12%; 96 patients (39%) had inhalation injury. Agreement between TBSA-OS (n = 46) and TBSA-FIN was poor (Pearson's correlations coefficient [PCC] = 0.77; R(2) = 0.60). TBSA-ED (n = 78) was more accurate (PCC = 0.96; R(2) = 0.93). INH-OS (n = 79, sensitivity 100%, specificity 24%) and INH-ED (n = 198, sensitivity 99%, specificity 36%) were sensitive but not specific. Eight patients were intubated on-site. No differences in outcome were found between this group and the patients who were intubated in the hospital. There was no difference in time of arrival at a hospital (p = 0.55). TBSA was not estimated reliably in a non-clinical environment. The diagnosis of inhalation injury was adequate but resulted in over-triage on-site and at the ED. Triage did not lead to transport priorities for the severely wounded. In a major burn accident, a field triage protocol for rapid evaluation of burn injuries may be useful. Detailed assessment of injuries of burn casualties is practical only in a specialized clinical setting.

Fiber-optic bronchoscopic classification of inhalation injury: prediction of acute lung injury.

BACKGROUND: Fiber-optic bronchoscopy is widely used for the early diagnosis of inhalation injury. However, there is no current bronchoscopic classification of inhalation injury for the prediction of acute lung injury (ALI). Our goal was to devise such a classification. METHODS: Between February 1993 and January 2002, 167 patients with highly suspicious inhalation injuries were collected. All patients received fiber-optic bronchoscopy within 24 h after their accident. In total, 108 patients were diagnosed as positive under direct inspection. The patients were divided into three groups (G(1), G(2), and G(3)) according to the depth of mucosal damage. Six patients were found to be positive by biopsy and were assigned to group Gb. Of these 114 positive cases, 27 developed ALI. Meanwhile, 53 patients were diagnosed as negative; these patients were assigned to group G(0). RESULTS: After analysis, the following results were noted: G(0) (n = 53), two ALI (3.8%); G(1) (n = 49), two ALI (4%); G(2) (n = 46), 15 ALI (33%); G(3)(n = 13),10 ALI (77%); Gb (n = 6), no ALI. We discovered that the deeper the mucosal injuries, the higher the rate of ALI. There were no deaths related to the procedure. CONCLUSIONS: Fiber-optic bronchoscopy is a safe and effective method for the early diagnosis of inhalation injuries. Also, it is a good predictor of ALL. We hope that in the near future, this classification will serve as a treatment guideline for the early prevention of ALI. The more severe the damage, the more alert clinicians need to be to improve the patient's chances for survival.

[Bronchoscopic methods in complex diagnosis and treatment of burned patients with inhalation injuries]. / Bronkhoskopicheskie metody v kompleksnoi diagnostike i lechenii obozhzhennykh s ingaliatsionnymi porazheniiami.

Chromobronchoscopy was first used in treatment of 37 burned patients with inhalation injuries for better visual manifestation of the injuries of the tracheobronchial tree mucosa. The trachea and bronchi mucosa was irrigated with a viral stain--0.25% aqueous solution of methylene blue. The intensity of staining the mucosa in light blue colour showed the true limits and depth of the injury. Resulting from the clinico-endoscopic examinations supplemented with findings of chromobronchoscopy, cytological and bacteriological analyses, a working classification of inhalation injuries in burned people was developed which allowed the adequate methods of local treatment during fiber bronchoscopy to be worked out taking into account the degree of thermochemical injuries of the respiratory pathways. It resulted in 19.7% lower lethality of burned patients.

Major burns in Cape Town: a modified burns score for patient triage.

Major burns equal to, or greater than, 30 per cent total body surface area (TBSA) constitute 23 per cent of the admissions to the adult burns unit in Cape Town. A retrospective review over a 28-month period identified 87 cases of major burns. This paper summarizes the epidemiology and mortality amongst this patient group over this period. Demand for treatment can exceed bed availability in the unit. The difficult issue, this raises, of patient triage in relation to the relatively limited resources is addressed and a simple modified burns score proposed for this unit. The effect this score would have in optimizing the use of our resources is demonstrated.

[Initial management of severely burned patients from the anesthesiologic viewpoint]. / Die Erstversorgung des schwerbrandverletzten Patienten aus anästhesiologischer Sicht.

The first priority in the management of a burn patient, as in any patient with major trauma, is to ensure adequate vital functions. In case of inhalation trauma and burns of the face and neck, early intubation always has to be considered. While various concepts of treatment of the fluid management are still being discussed, treatment according to the Parkland schema is widely used. A favourable influence of drugs on the course of disease is still doubtful. Stabilisation of the cardiocirculation and pulmonal parameters is of extreme importance. Extensive complete monitoring is necessary. The anaesthesist has to plan in advance and according to the severity of the injury.

Classification and specificity of cement burns.

In this report cement burns are divided into abrasion, heat and explosive type according to the cause or to the environment in which the injury occurred. This classification reflects the obvious differences in the cause, damage factors, specificity of wounds and clinical manifestation of the various types of cement burns.

Inhalation injury by paraffin flames (an African experience).

The paraffin flames predominate over all the aethiological agents of inhalation injury in South Africa. During the period of 16 months (from April 1992 to July 1993) we admitted 104 patients with inhalation injury by paraffin flames and we classified this type of injury into four main categories: a) patients with definite smoke inhalation injury but showing no respiratory insufficiency within the first 24 hours post burn, b) patients with developing respiratory insufficiency within the first 24 hours post burn, c) patients presenting intense symptoms on arrival, d) patients dying on arrival or very soon after. Tracheostomy was done if it was not possible to extubate within a period of 6 days after the injury. Bronchoscopy as well as chest X-ray examination, blood gases analysis, histological and cytological findings of sputum were performed in all patients. Authors evaluate also first experience with Bivona Fome Cuf Silicone Tracheostomy Tube.

Classification of inhalation injuries.

A new system of classification of inhalation injuries called APB classification is proposed. The classification is based on the anatomical level of the injury (A), degree of pathological changes of the respiratory tract mucosa (P), extent and severity of associated cutaneous burns (B). The authors assume the classification would be of help in the analysis of severity, prognosis and treatment methods of inhalation injuries particularly in larger groups of burn patients.

New concepts of pulmonary burn injury.

Based on our experience with two large groups of fire victims injured in a semiclosed environment, the clinical course of the survivors, and the pathologic examination of those who died, a modified classification of pulmonary burns into thermal burns and chemical burns is suggested. The results of our study indicate a close relationship between carbon monoxide poisoning and chemical intoxication in patients injured in a relatively closed environment. The clinical course and prognosis of patients suffering from a thermal pulmonary burn are different from that of a chemical pulmonary burn.

Inhalation injury caused by the products of combustion.

Inhalation injury results from a type of chemical burn (tracheobronchitis) of the respiratory tract. When this injury occurs in patients with serious cutaneous burns the mortality is exceedingly high- 48% to 86%. The injury can be divided into three types according to the level at which the damage occurs; upper airway, major airway and terminal airway. The early signs and symptoms may be complicated by carbon monoxide poisoning. The patient's condition usually follows a staged progression that is proportional to the extent and severity of the tracheobronchitis. Indirect laryngoscopy, bronchoscopy, scintiscanning of the lung with xenon 133 and serial analysis of arterial blood gases are useful diagnostic techniques. Treatment must be expeditious, and it depends on the severity of the injury. The prophylactic use of antibiotics and steroids is contraindicated.