A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries.

Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.

Burn Care of the Elderly.

As part of the State of Science Meeting, care in elderly was one of the foci. This "white paper" deriving from this meeting indicates advances in the field of burn injuries in the elderly but more importantly areas that are in need of novel insights and investigations. The group created specific segments of a patient's course pre- and postinjury to selectively identify specifics we need to improve on. Tasks were created that were assigned to volunteers of the group and are given in detail in this article. The overarching aim is to initiate substantial momentum among the members of the American Burn Association to improve the outcomes in the elderly burn patients.

Epidemiology of burns throughout the World. Part II: intentional burns in adults.

A significant number of burns and deaths from fire are intentionally wrought. Rates of intentional burns are unevenly distributed throughout the world; India has a particularly high rate in young women whereas in Europe rates are higher in men in mid-life. Data from hospitalized burn patients worldwide reveal incidence rates for assault by fire and scalds ranging from 3% to 10%. The average proportion of the body surface area burned in an assault by fire or scalds is approximately 20%. In different parts of the world, attempted burning of others or oneself can be attributed to different motives. Circumstances under which assaults occur fall largely into the categories of interpersonal conflict, including spousal abuse, elder abuse, or interactions over contentious business transactions. Contributing social factors to assaults by burning include drug and alcohol abuse, non-constructive use of leisure time, non-participation in religious and community activities, unstable relationships, and extramarital affairs. Although the incidence of self-mutilation and suicide attempts by burning are relatively low, deliberate self-harm carries a significant risk of death, with an overall mortality rate of 65% worldwide. In those who resort to self-immolation, circumstantial themes reflect domestic discord, family dysfunction, and the social ramifications of unemployment. Preventing injurious burn-related violence requires a multifaceted approach, including legislation and enforcement, education, and advocacy. Better standardized assessment tools are needed to screen for risks of abuse and for psychiatric disorders in perpetrators.

Epidemiology of burns throughout the world. Part I: Distribution and risk factors.

Globally in 2004, the incidence of burns severe enough to require medical attention was nearly 11 million people and ranked fourth in all injuries, higher than the combined incidence of tuberculosis and HIV infections. Fortunately, although burns and fires account for over 300,000 deaths each year throughout the world, the vast majority of burns are not fatal. Nonetheless, fire-related burns are also among the leading causes of disability-adjusted life years (DALYs) lost in low- and middle-income countries (LMIC). Morbidity and mortality due to fire and flames has declined worldwide in the past decades. However, 90% of burn deaths occur in LMIC, where prevention programs are uncommon and the quality of acute care is inconsistent. Even in high-income countries, burns occur disproportionately to racial and ethnic minorities such that socioeconomic status--more than cultural or educational factors--account for most of the increased burn susceptibility. Risk factors for burns include those related to socioeconomic status, race and ethnicity, age, and gender, as well as those factors pertaining to region of residence, intent of injury, and comorbidity. Both the epidemiology and risk factors of burns injuries worldwide are reviewed in this paper.

Structure fires, smoke production, and smoke alarms.

Smoke inhalation injury causes severe morbidity and death. In the United States, the majority of fatalities from fire and burns occur because of inhalation of smoke. Medical treatment is only supportive; there is no known antidote to the damaging effects of smoke toxicants on pulmonary tissue. Without question, minimization of the morbidity and mortality that are caused by smoke inhalation is best accomplished by prevention of the injury. Effective prevention programs depend on a thorough and detailed understanding of the mechanism of damage caused by smoke, as well as of the available options for efficacious prevention. This summary presents details of smoke production from structure fires, the effects of smoke on physiology, and the devices currently in use to prevent damage and death from smoke.

Reimbursement for out-of-state burn patients is not always lower than that for in-state patients at regional burn centers.

Because burn care in the United States is regionalized, burn patients are often transported across state lines to receive their burn treatment. The authors hypothesized that there are differences between in-state and out-of-state reimbursement for burn care. This project was conducted by the American Burn Association (ABA) Government Affairs Committee through the ABA Multicenter Trials Group. Participation was open to any member of the ABA. This retrospective observational study was approved by the institutional review boards of each participating institution. Subjects were identified using registry of each site, selecting patients hospitalized for burn injuries during FY2004-FY2006 of the hospitals. Once identified by the registry, the ID numbers were used to collect billing and reimbursement data from the financial offices. Data were sorted by age (adult and pediatric), location (in state and out of state), and payor source (Medicare, Medicaid, commercial, workers compensation, and self-pay). The rate of reimbursement was calculated based on charges and recoveries. Comparisons on data of each center were performed using Student's t-test with type I error <1%. Six facilities contributed data. A total of 4850 burn patients were reviewed, of whom 3941 were in-state burn patients and 909 were out-of-state burn patients. When the results from all six states were analyzed together, reimbursement for adults from Medicaid and Medicare was higher for in-state patients than for out-of-state patients. However, when analyzed by state, Medicare reimbursement between in-state and out-of-state patients did not differ significantly. In one state (Kansas), in-state Medicaid reimbursement was higher, but in two others (Arizona and Pennsylvania), in-state Medicaid reimbursement was lower than that for out-of-state reimbursement. Reimbursement for the care of children did not differ significantly based on state of residence. From these data, we conclude that there are indeed variations between in-state and out-of-state reimbursement, but those variations differ regionally. Indeed, in some cases, out-of-state reimbursement exceeds in-state reimbursement. Careful examination of these data is necessary before recommending policy change, although consideration should be given to a national policy that guarantees uniformity of reimbursement across all payors for burn patients regardless of their state of residence.

Assessing elder mistreatment: instrument development and implications for adult protective services.

Assessment of elder mistreatment is hindered by a myriad of factors, including inconsistent definitions, divergent and untested theories of causation, and limited research attention to the problem. In addition to these difficulties, professionals encounter complex situations requiring considerable clinical assessment skills and decision-making capacity. Adult Protective Services (APS) workers, as well as mandated reporters such as healthcare providers and social workers, need an assessment tool that can reliably and accurately assess for elder mistreatment. Based on a structured review of screening and assessment instruments, this article discusses the psychometric properties of 15 instruments and the relevance to APS. Implications of the findings for future research, practice, and policy are discussed.

Association between socioeconomic status and burn injury severity.

BACKGROUND: It has been previously established that the incidence of burn is higher in lower socioeconomic (SES) groups. What is not clear, however, is whether or not the severity of burn is also higher in lower SES groups. The purpose of this study is to establish a relationship between household-level socioeconomic status (SES) and severity-based incidence of burn. METHODS: A burn injury database was generated from the National Injury Database (2001-2003) with a 1-year follow-up period containing information about the date and time of burn injury, the International Classification of Disease 10th Edition-based (ICD-10) diagnostic codes, gender, age, residence, and type of insurance. In addition, we calculated the severity of each burn using the Excess Mortality Ratio-adjusted Injury Severity Score (EMR-ISS), which is similar to the New Injury Severity Score. Socioeconomic status was measured on the basis of quintiles of premiums for National Health Insurance, which was decided on a household-level either by monthly salary (Employee Insurance, EI) or by owned property (Self-Employed Insurance, SEI). Medical Aid (MA) population was regarded as a reference. After calculation of 5 year-gender specific standardized incidence rates (SIRs) of burn by SES groups, the association of SES and severity of burn was evaluated using a multivariate logistic regression model and the Cox-proportional hazard regression analysis. RESULTS: A total of 870,411 burn cases were examined. The standardized incident rates (SIRs) of mild(1

Low-tidal-volume ventilation as a strategy to reduce ventilator-associated injury in ALI and ARDS.

One of the most hotly debated aspect of inhalation injury is the "best" method of mechanical ventilation. Mechanical ventilation protocols differ between both physicians and burn centers, and multiple different strategies for mechanical ventilation are currently being used to support the burn patient with inhalation injury. These strategies range from applying recent advances in acute respiratory distress syndrome to conventional mechanical ventilation to the use of alternative modes of ventilation such as the volumetric diffusive respirator. The articles in this section describe recent changes in philosophy with respect to mechanical ventilation, the various modes of ventilation being used to support the patient with inhalation injury, and the rationale behind each strategy.

Burns and injuries from non-electric-appliance fires in low- and middle-income countries Part II. A strategy for intervention using the Haddon Matrix.

A large proportion of burns in developing countries are related to the nature of domestic appliances used for cooking, heating, and lighting. Our overview of the problem elucidated the need for better surveillance with epidemiologic studies, which will more accurately assess the true incidence in vulnerable populations. This paper will create a framework for envisaging new approaches to the problem and begin to evaluate the strengths and weaknesses of proposed interventions. We used the Haddon Matrix to accumulate proposed interventions that encompass a pre-event, event, and post-event timeline. We propose an initial strategic outline plan for interventions based on values that are suited to the problem and the setting, are culturally appropriate, and can be employed in a reasonable period of time for a sustained period to ensure success. Recommended action steps include promoting the use of alternative energy sources, encouraging an integrated approach to finding interdisciplinary solutions, devising a better system of kerosene containerization, re-engineering appliance designs, legislating for enforcement of health and safety standards, taking a holistic approach through government inter-departmental collaboration, formally discouraging corruption, encouraging ventilation of cooking or living areas, implementing building codes, educating consumers, and training caregivers and health and emergency workers.

Burns and fires from non-electric domestic appliances in low and middle income countries Part I. The scope of the problem.

Severe burn is a major public health issue in developing nations. Although burn and smoke inhalation in 2002 were documented as being responsible for over 322,000 deaths worldwide, this figure is most likely a gross underestimate. The burden of suffering from fire is exceedingly distributed among the poor. A large proportion of burns are related to the nature of domestic appliances that are used for cooking, heating, lighting or all three. We undertook a retrospective review of the literature as well as analyzing our institutional and regional experiences with injuries caused by non-electric domestic appliances. The incidence of injuries is largely associated with the use of stoves and lamps; and from kerosene or petroleum as well as butane, liquid petroleum gas and alcohol. Associated problems include appliance design and construction, fuel combustion and instability, and mechanical inefficiency. Ignorance of safe usage techniques is also contributory. Industry and government regulations and standards are either nonexistent or not adequately enforced. Solving this substantial problem will depend on improved surveillance by means of formal epidemiologic studies, and the contributions and collaboration of international governmental and nongovernmental organizations.

The contemporary management of electrical injuries: resuscitation, reconstruction, rehabilitation.

PURPOSE: Due to advances in resuscitation of patients with electrical injuries, new challenges in reconstruction and rehabilitation have emerged. This study is a comprehensive institutional review of a prospectively gathered database of patients with electrical injuries, from initial resuscitation through final impairment ratings. METHODS: A trauma registry was used to identify patients with electrical injuries. Procedures needed, their timing, final impairment ratings, and return to work were recorded. RESULTS: From 2000 through 2005, we managed 115 patients with electrical injuries. Mean follow-up was 352 days. The average patient age was 34.9 years. Eighty-five (73.9%) of these injuries were work-related. There were 2 mortalities (1.7%). Although average burn size was only 8%, patients suffered many complications acutely and chronically. Numerous surgical interventions were required during the resuscitative (within 48 hours), an early reconstructive and resurfacing (within 30 days), and a late reconstructive and rehabilitative phase. Mean final impairment rating was 11%. Average time to return to work was 101 days. CONCLUSIONS: Electrical injuries can produce significant morbidity despite relatively small burn sizes. Patients require early operative procedures for prevention of further injury. Timely reconstructive surgery may improve final function and return to productivity. Finally, continued reconstruction may ensure improved late outcomes. The plastic surgeon is essential to patients with electrical injuries through all phases of their care.

A collaborative systems approach to rural burn care.

A collaborative systems approach was created between the regional verified burn center (BC) and the rural verified Level 1 trauma center (TC) to treat minor burns. This study assesses the feasibility of providing outpatient burn care at the TC. A retrospective review was performed from January 2000 to June 2005 of burn patients seen at the TC. Seven trauma/critical care surgeons and a dedicated burn nurse staffed the clinic twice a week. Burn surgeons from the BC provided consultation via email and telephone links and served as the regional resource. In the TC clinic, 314 injuries occurred in 311 patients. 196 patients were male with an average age of 34.5 +/- 1.1 years. The mean burn TBSA was 2.9 +/- 0.2%. Fourteen patients (4%) required skin grafts. Patients averaged 3.5 +/- 0.1 clinic visits over a mean follow-up period of 42.9 +/- 7.4 days from initial injury. There were 1252 scheduled appointments during the study period. Silver sulfadiazine or triple antibiotic ointment was applied in the majority of the cases. Thirty-one patients (9.9%) were documented to have complications, most of which were local wound infections. Long-term sequelae (scarring, chronic pain, and contractures) occurred in 13.4% of patients. Clinical success in outpatient burn care can be achieved at a non burn center with dedicated personnel. The successful collaboration between the BC and TC can unload some minor burn care from the burn center, while providing good clinical care to the local rural population.

The Southern Region burn disaster plan.

A regional burn disaster plan for 24 burn centers located in 11 states comprising the Southern Region of the American Burn Association was developed using online and in-person collaboration between burn center directors during a 2-year period. The capabilities and preferences of burn centers in the Southern Region were queried. A website with disaster information, including a map of regional burn centers and spreadsheet of driving distances between centers, was developed. Standard terminology for burn center capabilities during disasters was defined as open, full, diverting, offloading, or returning. A simple, scalable, and flexible disaster plan was designed. Activation and escalation of the plan revolves around the requirements of the end user, the individual burn center director. A key provision is the designation of a central communications point colocated at a burn center with several experienced burn surgeons. In a burn disaster, the burn center director can make a single phone call to the communications center, where a senior burn surgeon remote from the disaster can contact other burn centers and emergency agencies to arrange assistance. Available options include diversion of new admissions to the next closest center, transfer of patients to other regional centers, or facilitation of activation of federal plans to bring burn care providers to the affected burn center. Cooperation between regional burn center directors has produced a simple and flexible regional disaster plan at minimal cost to institute or operate.

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.

Chest wall necrosis and death secondary to hydrochloric acid infusion for metabolic alkalosis.

Central line complications are common, and extravasation injuries related to infusion of caustic substances have been previously described. Although hydrochloric acid has been used for many years to treat metabolic alkalosis, there have been no reported fatal complications. We report the case of a 53-year-old female who received a fatal chemical burn due to extravasation from a subclavian central venous catheter of hydrochloric acid infused to correct severe metabolic alkalosis. This case illustrates the hazards of the infusion of caustic substances through central lines and underscores the importance of constant vigilance regarding line positioning and changes to the surrounding tissues when infusing these substances.

Managing a combined burn trauma disaster in the post-9/11 world: lessons learned from the 2003 West Pharmaceutical plant explosion.

At 1:37 pm on January 29, 2003, an explosion occurred at the West Pharmaceutical chemical plant in Kinston, North Carolina. The explosion killed three people at the scene and resulted in more than 30 admissions to area hospitals. The disaster resulted in 10 critically ill burn patients, who were all intubated with inhalation injuries, many with combined burn and trauma injuries. All 10 critically injured patients were admitted to a tertiary care facility 100 miles away with both a Level I trauma center and a verified burn center. Ultimately, 7 of 10 patients survived (a mortality rate of 30%), and none were transferred to another trauma or burn center. This article analyzes the unique challenges that combined burn and trauma patients present during a disaster, critically examines the response to this disaster, describes lessons learned, and presents recommendations that may improve the response to such disasters in the future.