The association between burn and trauma severity and in-hospital complications.

OBJECTIVE: The aim of this study was to analyze the association between in-hospital complications and burn and trauma severity, inhalation injury, length of intensive care unit and hospital stay, and mortality in burned patients. METHOD: This observational and retrospective study included 68 burn patients hospitalized in a university hospital located in São Paulo, Brazil. The severity of the burn injury and trauma were measured by means of Abbreviated Injury Scale and the Injury Severity Score, respectively. Thecomplications were considered as a dependent variable. The statistical analysis for continuous variables was performed using the Student's t or the Mann-Whitney test and for categorical variables the Chi-square test, Fisher's Exact or Verisimilitude Ratio test, considering a significance level of 5%. RESULTS: The majority (60.3%) of patients had complications, and among them, those with infections were the most frequent (70.7%). Burned patients with complications had higher burn injury severity, were hospitalized for longer and their mortality was higher. Cardiovascular complications were associated with severe burns and mortality; infectious ones with a larger length of hospitalization. CONCLUSION: Complications are frequent in patients with severe burns and inhalation injuries, increasing length of hospital stay and mortality. Burn studies measuring severity of thermal and inhalation injuries and other associated traumas allow to expand the analysis of burned patients.

Points & Pearls: Emergency department management of smoke inhalation injury in adults

Smoke inhalation injury portends increased morbidity and mortality in fire-exposed patients. Upper airway thermal burns, inflammation from lower airway irritants, and systemic effects of carbon monoxide and cyanide can contribute to injury. A standardized diagnostic protocol for inhalation injury is lacking, and management remains mostly supportive. Clinicians should maintain a high index of suspicion for concomitant traumatic injuries. Diagnosis is mostly clinical, aided by bronchoscopy and other supplementary tests. Treatment includes airway and respiratory support, lung protective ventilation, 100% oxygen or hyperbaric oxygen therapy for carbon monoxide poisoning, and hydroxocobalamin for cyanide toxicity. Due to its progressive nature, many patients with smoke inhalation injury warrant close monitoring for development of airway compromise. [Points & Pearls is a digest of Emergency Medicine Practice.].

Severe burn injury, burn shock, and smoke inhalation injury in small animals. Part 1: burn classification and pathophysiology.

OBJECTIVE: To review the literature related to severe burn injury (SBI), burn shock, and smoke inhalation injury in domestic animals. Current animal- and human-based research and literature were evaluated to provide an overview of thermal burn classification and the pathophysiology of burn shock and smoke inhalation injury. ETIOLOGY: Severe burn injury, burn shock, and smoke inhalation injury may be encountered as a result of thermal injury, radiation injury, chemical injury, or electrical injury. DIAGNOSIS: Burns can be subdivided based on the amount of total body surface area (TBSA) involved and the depth of the burn. Local burn injuries involve <20% of the TBSA whereas SBI involves >20-30% of the TBSA. The modern burn classification system classifies burns by increasing depth: superficial, superficial partial-thickness, deep partial-thickness, and full-thickness. SUMMARY: Local burn injury rarely leads to systemic illness whereas SBI leads to significant metabolic derangements that require immediate and intensive management. SBI results in a unique derangement of cardiovascular dysfunction known as "burn shock." The physiologic changes that occur with SBI can be divided into 2 distinct phases; the resuscitation phase and the hyperdynamic hypermetabolic phase. The resuscitation phase occurs immediately following SBI and lasts for approximately 24-72 hours. This period of hemodynamic instability is characterized by the release of inflammatory mediators, increased vascular permeability, reduced cardiac output, and edema formation. The hyperdynamic hypermetabolic phase begins approximately 3-5 days after injury. This phase is characterized by hyperdynamic circulation and an increased metabolic rate that can persist up to 24 months post burn injury in people.

Inhalation injury, pulmonary perturbations, and fluid resuscitation.

Inhalation injury (INHI) associated with thermal injury has been shown to increase the rate of mortality. Several investigators have shown that patients with inhalation and burn injuries will require increased fluid volumes during acute resuscitation when compared with patients with burn injury alone. Other groups have examined the use of lung compliance and airway resistance as predictors of outcome in patients with INHI. We hypothesized that increased fluid requirements would more closely correlate with perturbations in pulmonary performance than with mere presence or absence of INHI or the degree of injury by bronchoscopic criteria. We performed a retrospective chart review during a period of 3 years. We identified 80 patients with suspected INHI that required intubation, mechanical ventilation, and fiber optic bronchoscopy in the first 24 hours of their admission. Variables collected included age, sex, weight and %TBSA burned, as well as blood alcohol level, the presence of head and neck burns and escharotomies, and admission carbon monoxide levels. Patients were classified into five groups according to a grading system of INHI (0, 1, 2, 3, and 4), derived from findings at initial bronchoscopy and based on AIS criteria. The following pulmonary parameters were noted at regular intervals: mode of ventilation, tidal volume, peak inspiratory pressures, mean airway pressures, and compliance. The P:F ratio also was recorded at regular intervals. Total fluid volume infused was noted at 0-, 24-, and 48-hour intervals, and was calculated as ml/kg/%TBSA. Outcomes were measured by in-hospital survival, ventilator days, intensive care unit days, and total length of stay. Patients were well matched for %TBSA among the different bronchoscopic grades of INHI, and those with grades 2, 3, and 4 injuries had a significantly worse survival than those with grades 0 or 1 (P = .03). However, grades 2, 3, and 4 did not have increased acute fluid requirements when compared with grades 1 and 2 injuries. Initial pulmonary compliance likewise did not correlate with acute fluid requirements. However, those patients with a P:F ratio less than 350 at presentation had a statistically significant increase in ml/kg/%TBSA compared with those with P:F >350 (P = .03). They did not have more ventilator days or a statistically worse survival. Fiber optic bronchoscopy is useful in the diagnosis of INHI, and overall survival is worse in those patients with worse grades of injury by bronchoscopic criteria. However, the P:F ratio may be a more accurate predictor of increased fluid requirements during the acute resuscitation.

Body habitus as a predictor of burn risk in children: do fat boys still get burned?

Previous research at this institute has demonstrated that heavy-for-age boys are more burn prone than their normal sized counterparts. As this study is now 26 years old, we reexamined the anthropomorphic indices of 372 children admitted to one burn center between January 1991 and July 1997 to determine if this trend was still evident. Male children were over-represented in the < or =5th and >95th percentiles for both height (p < 0.001, p < 0.05) and weight (p < 0.01, p < 0.001). Female children were over-represented in the < or =5th and > 95th percentiles for height (p < 0.01, p < 0.05). Twenty-eight percent of boys at or below the 5th percentile for weight were burned as a result of known or suspected intentional injury, compared to 5.9% of the entire pediatric burn population. (p < 0.0004). 'Fat boys' continue to be over-represented in the pediatric burn population. Additionally, in the more recent time period, boys at or below the 5th percentile for height or weight and girls= < 5th percentile or >95th percentile for height are also over-represented. The increased frequency of burn injury in small-for-age children may reflect an increased risk of burn injury secondary to neglect or nonaccidental trauma.

Is there still a place for comfort care in severe burns.

Successive improvements in burn care have steadily increased the survivability of many major burn injuries, however for some patients with the most severe injuries comfort care rather than active resuscitation has been seen as the correct course of action. A survey of UK burn unit directors by postal questionnaire sought details of current practice regarding comfort care, the factors involved in the decision making process and their response to eight hypothetical case histories. An 84% response to the survey showed that units would, on average, actively resuscitate thirty-seven patients a year and administer comfort care three times per year. Opinion was often divided regarding the decision to resuscitate in the cases presented.

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.