Burn Casualty Care in the Deployed Setting.

Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting.

Postdischarge Cause-of-Death Analysis of Combat-Related Burn Patients.

Combat operations in Iraq and Afghanistan have resulted in up to 8.8% of combat-related casualties suffering burns. From World War I through Desert Storm, burns have been associated with approximately 4% of the combat-related deaths. Experiencing a blast injury and exposure to killing and death while deployed has been shown to increase suicide risk. Although several studies of military populations have investigated risk factors for death among burn patients during the acute phase, no studies have reported mortality rates, cause-of-death, or the prevalence of suicide after hospital discharge. This study examined the case fatality rate, causes of death, and the prevalence of suicide among 830 combat burn patients discharged from the sole burn center in the U.S. Department of Defense, between March 7, 2003 and March 6, 2013. Cause-of-death was determined through the Armed Forces Medical Examiner's Office and the Office of the Secretary of Defense's National Death Index. A total of 11 deaths occurred among the 830 burn survivors, for an overall case fatality rate of 1.3%. Of the 11 who died, five deaths were related to accidental poisoning by exposure to drugs; three were related to operations of war (two after returning to the war zone), and the remaining three died from other accidental causes (one explosion and two vehicle crashes). There was no indication of suicide or suspicion of suicide as a cause-of-death for the former patients included in this study, suggesting that combat burn injury did not appear to increase the risk of death by suicide in our study population. Further research is needed to understand the factors that contribute to the apparent resilience of combat burn survivors.

Inability to determine tissue health is main indication of allograft use in intermediate extent burns.

INTRODUCTION: Cutaneous allograft is commonly used in the early coverage of excised burns when autograft is unavailable. However, allograft is also applied in intermediate-extent burns (25-50%), during cases in which it is possible to autograft. In this population, there is a paucity of data on the indications for allograft use. This study explores the indications for allograft usage in moderate size burns. METHODS: Under an IRB-approved protocol, patients admitted to our burn unit between March 2003 and December 2010 were identified through a review of the burn registry. Data on allograft use, total burn surface area, operation performed, operative intent, number of operations, intensive care unit length of stay, and overall length of stay were collected and analyzed. Data are presented as means±standard deviations, except where noted. RESULTS: In the study period, 146 patients received allograft during their acute hospitalization. Twenty-five percent of allograft recipients sustained intermediate-extent burns. Patients with intermediate-extent burns received allograft later in their hospitalization than those with large-extent (50-75% TBSA) burns (6.8 days vs. 3.4 days, p=0.01). Allografted patients with intermediate-extent burns underwent more operations (10.8 vs. 6.1, p=0.002) and had longer hospitalizations (78.3 days vs. 40.9 days, p<0.001) than non-allografted patients, when controlled for TBSA. Clinical rationale for placement of allograft in this population included autograft failure, uncertain depth of excision, lack of autograft donor site, and wound complexity. When uncertain depth of excision was the indication, allograft was universally applied onto the face. In half of allografted intermediate-extent burn patients the inability to identify a viable recipient bed was the ultimate reason for allograft use. CONCLUSIONS: Unlike large body surface area burns, allograft skin use in intermediate-extent injury occurs later in the hospitalization and is driven by the inability to determine wound bed suitability for autograft application. Allograft application can be utilized to test recipient site viability in cases of autograft failure or uncertain depth of excision.

Elevations in inflammatory cytokines are associated with poor outcomes in mechanically ventilated burn patients.

BACKGROUND: The treatment of burn patients who undergo mechanical ventilation is complicated by many factors; patient outcomes and mortality could potentially be improved with predictive biomarkers. Severe burn provokes a systemic inflammatory response characterized by the release of a host of cytokines. Recent studies evaluated the prognostic value of temporal changes in cytokine levels in several patient populations, but few have compared differences in the cytokine profiles of survivors and nonsurvivors following severe burn. We previously compared high-frequency percussive ventilation and low-tidal-volume ventilation and found no difference in mortality or cytokine levels between the two treatments. Since it is unknown whether cytokine levels are predictive of mortality in these patients, we performed a post hoc analysis comparing cytokine levels in survivors and nonsurvivors. METHODS: We evaluated plasma levels of several cytokines (interleukin 1ß [IL-1ß], IL-6, IL-8, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor α) for their prognostic biomarker potential related to mortality at 0, 3, and 7 days in survivors and nonsurvivors of burns. RESULTS: While the majority of values for IL-1ß, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor α fell below the limit of quantification, univariate analysis demonstrated higher plasma levels of IL-6 and IL-8 in nonsurvivors on Day 7. Logistic regression revealed that elevated plasma IL-8 was independently associated with an increased likelihood of the composite end point of death or ventilator-associated pneumonia with odds ratios of 7.9, 26, and 7.3 on Days 0, 3, and 7, respectively. CONCLUSION: Early increases in plasma IL-8 are associated with a multifold increase in death or ventilator-associated pneumonia in mechanically ventilated burn patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level IV.

Operative utilization following severe combat-related burns.

The goal of burn surgical therapy is to minimize mortality and to return survivors to their preinjury state. Prompt removal of the burn eschar, early durable coverage, and late corrections of functional deformities are the basic surgical principles. The operative burden, while presumed to be substantial and significant, is neither well described nor quantified. The burn registry at the U.S. Institute of Surgical Research Burn Center was queried from March 2003 to August 2011 for all active duty burn admissions; active duty subjects were chosen to eliminate subject follow-up as a significant variable. Subject demographics including age, sex, branch of service, injury type, injury severity score, transfusion, allograft use, length of stay, mechanism of injury, and survival were tabulated as were their percentage TBSA, specific body region involvement, and nature and dates of operations performed. Univariate analysis and multiple logistic regressions were performed to determine independent factors which predict early and late operative burden. In the 8-year study period, 864 active duty patients were admitted to the burn center. Among them, 569 (66%) were operative in nature. The operations that were performed during acute hospitalization were 62%, while the remaining 38% were performed following discharge. A linear relationship exists between TBSA and the number of acute operations with an average of one acute operation required per 5% TBSA. No direct relationships however were found between TBSA and the number of reconstructive operations. Based on multiple logistic regression, battle vs nonbattle (odds ratio [OR], 0.559; 95% confidence interval [CI], 0.298-1.050; P = .0706), injury severity score (OR, 1.021; 95% CI, 1.003-1.039; P = .0222), intensive care unit length of stay (OR, 1.076; 95% CI, 1.053-1.099; P ≤ .0001), allograft use (OR, 2.610; 95% CI, 1.472-4.628; P = .0010), and TBSA of the trunk (OR, 0.982; 95% CI, 0.965-1.000; P = .0439) (but not overall TBSA) were associated with a high acute operative burden. Battle vs nonbattle (OR, 0.546; 95% CI, 0.360-0.829; P = .0045), and TBSA of the upper extremities (OR, 1.008; 95% CI, 1.002-1.013; P = .0042) were noted to be significant variables in predicting late reconstruction operations. The operative burden of burn, not previously well characterized, consists of operations performed during as well as after the initial hospitalization. While injury severity and truncal involvement are significant determinants of acute surgical therapy, the presence of upper extremity burns is a significant determinant of reconstruction following discharge.

Are visceral proteins valid markers for nutritional status in the burn intensive care unit?

The aim of this study was to determine whether visceral protein levels increase under positive nitrogen balance during times of decrease in acute-phase reactant levels in patients with burn injury. This was a post hoc analysis of a prospective, interventional study approved by the local institutional review board. A total of 10 subjects between the ages of 18 and 72 with ≥ 20% total body surface area burn were enrolled over a 14-month period. Data were collected for five subjects (average age of 28 ± 8 years and total body surface area burn of 69 ± 15%) who met the inclusion criteria. Changes in visceral protein levels were examined along with nitrogen balance and acute-phase reactants when the subjects were on enteral nutrition, and the proteins were not examined during times of acute kidney injury. Descriptive statistics were performed, and linear regression was used to analyze the association of visceral proteins and nitrogen balance during times that acute-phase reactant levels were decreasing. The subjects received an average of 3044 ± 1613 kcal/day (39 ± 20 kcal/kg), meeting 72% of caloric goals and achieving positive nitrogen balance during 68% of the 40 weekly measurements, with 174 ± 85 g of protein intake per day (2.2 ± 1.1 g/kg). There was a weak relationship between nitrogen balance and changes in visceral protein levels during times that the acute-phase reactant levels were decreasing (P > .05). Visceral proteins were found to be poor markers of nutritional status. This study is unique because the subjects were able to achieve positive nitrogen balance despite severe burns.

Mucormycosis attributed mortality: a seven-year review of surgical and medical management.

INTRODUCTION: Historically, mucormycosis infections have been associated with high mortality. The purpose of this study was to determine the incidence, associated mortality, and management strategies of mucormycosis in a major burn center. METHODS: A retrospective review was performed via obtaining all patients with mucormycosis admitted from January 2003 to November 2009 at our adult burn center was performed obtaining demographic data relevant to fungal burn wound infection or colonization. RESULTS: The incidence of mucormycosis at our facility was 4.9 per 1000 admissions; specifically, 11 military casualties and one civilian were diagnosed with mucormycosis. The median percentage Total Body Surface Area (TBSA) burned, 11 patients, or open wound, one patient, was 60 (IQR, 54.1-80.0), and the incidence of documented inhalation injury was 66.7% (8 of 12). Ten patients had surgical amputations. A median of eight days (IQR, 3.5-74.5) elapsed from diagnosis of mucormycosis until death in the 11 patients who expired. The overall mortality was 92%; however, autopsy attributed mucormycosis mortality was 54.5% (6 of 11) with all six patients having invasive mucormycosis. CONCLUSION: Aggressive surgical intervention should be undertaken for invasive mucormycosis; additionally, implementation of standardized protocols for patients with large soft tissue injuries may mitigate mucormycosis superimposition.

Acute respiratory distress syndrome in wartime military burns: application of the Berlin criteria.

BACKGROUND: Acute respiratory distress syndrome (ARDS) prevalence and related outcomes in burned military casualties from Iraq and Afghanistan have not been described previously. The objective of this article was to report ARDS prevalence and its associated in-hospital mortality in military burn patients. METHODS: Demographic and physiologic data were collected retrospectively on mechanically ventilated military casualties admitted to our burn intensive care unit from January 2003 to December 2011. Patients with ARDS were identified in accordance with the new Berlin definition of ARDS. Subjects were categorized as having mild, moderate, or severe ARDS. Multivariate logistic regression identified independent risk factors for developing moderate-to-severe ARDS. The main outcome measure was the prevalence of ARDS in a cohort of patients burned as a result of recent combat operations. RESULTS: A total of 876 burned military casualties presented during the study period, of whom 291 (33.2%) required mechanical ventilation. Prevalence of ARDS in this cohort was 32.6%, with a crude overall mortality of 16.5%. Mortality increased significantly with ARDS severity: mild (11.1%), moderate (36.1%), and severe (43.8%) compared with no ARDS (8.7%) (p < 0.001). Predictors for the development of moderate or severe ARDS were inhalation injury (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.01-3.54; p = 0.046), Injury Severity Score (ISS) (OR, 1.04; 95% CI, 1.01-1.07; p = 0.0021), pneumonia (OR, 198; 95% CI, 1.07-3.66; p = 0.03), and transfusion of fresh frozen plasma (OR, 1.32; 95% CI, 1.01-1.72; p = 0.04). Size of burn was associated with moderate or severe ARDS by univariate analysis but was not an independent predictor of ARDS by multivariate logistic regression (p > 0.05). Age, size of burn, and moderate or severe ARDS were independent predictors of mortality. CONCLUSION: In this cohort of military casualties with thermal injuries, nearly a third required mechanical ventilation; of those, nearly one third developed ARDS, and nearly one third of patients with ARDS did not survive. Moderate and severe ARDS increased the odds of death by more than fourfold and ninefold, respectively. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Citation classics in the burn literature during the past 55 years.

The objective of this study was to identify the 100 most cited, peer-reviewed burn-related articles over the past half century. Burn care presents ongoing challenges to both U.S. civilian and military healthcare personnel. Improvements in burn survival and quality of life are the result of advances in burn research. The Web of Science (including Science Citation Index) was searched for the most cited articles related to burn care, published from 1955 to the present. The most cited article was "Permanent coverage of large burn wounds with autologous cultured human epithelium," by G.G. Gallico et al, New England Journal of Medicine, 1984 (711 citations). Between the 1970s and the 1990s, there was a near doubling of the number of highly cited publications with each subsequent decade. A total of 85% of the articles were on the topics of pathophysiology (37%), wounds, tissue, or dressings (31%), or organ failure/sepsis (17%). B.A. Pruitt Jr. (2320 citations), D.N. Herndon (1972 citations), and A.D. Mason Jr. (1435 citations) were the most cited authors. This study identified some of the most important contributions to burn research and the areas of greatest scientific interest to the specialty during the past five decades, and highlights key research that has contributed to the evolution of modern burn care.

Evaluation of an oxygen-diffusion dressing for accelerated healing of donor-site wounds.

Accelerating the healing process and reducing pain during healing are beneficial for the following reasons: faster return to work, lower risk of wound infection, improved quality of life, and possibly reduced need for analgesia. This clinical study assessed the effectiveness of a new oxygen-diffusion dressing (OxyBand; Oxyband Technologies, St. Louis, MO) compared with standard Xeroform gauze dressings (Convidien, Mansfield, MA), in the care of skin-graft donor sites in burn patients. Time to healing was the primary endpoint, and pain scores and cosmetic outcome were also assessed. This was a prospective, randomized, controlled study of burn patients undergoing harvesting of two donor sites. Patients were followed at predetermined time points for 30 to 45 days to determine the time to reepithelialization, cosmetic appearance, and pain. Subjects were adult burn patients with less than 30% TBSA burns admitted to the burn center, who required excision and grafting. Twenty patients were enrolled, of whom 17 completed the study. Average age was 35 years. Average burn size was 9.2% TBSA. Patients underwent harvesting of split-thickness skin grafts with one donor wound dressed with OxyBand and the other dressed in Xeroform gauze. Wounds were inspected and photographed on postoperative days 4 and 8, and then every 2 days until the donor wounds were healed. Pain scores at each site were also collected at these visits (rated by patients on a scale from 0 to 10). Mean time to wound healing for OxyBand was 9.3 ± 1.7 days; for Xeroform, 12.4 ± 2.7 days (P < .001). Pain scores were lower (P < .01) at the OxyBand site compared with the Xeroform site at all time points during postoperative days 4 to 12. There was no difference in the cosmetic outcome of the wounds at 30 to 45 days postoperatively. This study revealed a decrease in the time to healing and in pain at donor sites dressed with an oxygen-diffusion dressing.

Silver-coated nylon dressing plus active DC microcurrent for healing of autogenous skin donor sites.

INTRODUCTION: Burn wounds are a significant cause of morbidity and mortality, and improved outcomes are demonstrated with early closure of both primary burn wounds and skin donor sites. Thus, technology that decreases the healing time of burns and donor sites would be potentially lifesaving. We present the results of a single-center, prospective, double-blinded, randomized controlled trial to evaluate the efficacy of silver-coated dressing with active microcurrent in comparison to silver-coated dressing with sham microcurrent on wound-closure time for autogenous skin donor sites. METHODS: Four hundred five patients were screened for treatment of their donor sites using a silver-coated nylon dressing with either sham or active microcurrent stimulation. Thirty patients were enrolled in the study and then randomized. Of these, 5 patients were removed from analysis due to protocol deviations. Differences in time-to-closure were analyzed using Kaplan-Meier analysis and the proportional hazard regression model. Subjective verbal pain rating scores (0-10; 0, no pain; 10, worst pain) were also recorded. All devices were blinded and programmed at an outside facility, so that every patient had either an active or sham device. The study was unblinded only after the final patient's donor site had healed. All patients achieved donor-site healing before postoperative day 20. The 14 patients in the active microcurrent group [mean, 10.8 (2.9) days; range, 7-15 days] experienced no difference in time to wound healing as compared to the remaining patients in the sham microcurrent group [mean, 11.1 (2.0) days; range, 8-14 days; P = 0.75]. There were no differences in pain from one group compared to the other. None of the donor sites exhibited clinical signs of infection. CONCLUSIONS: In a sample size of 25 burn patients, the addition of direct microcurrent to silver-nylon dressings did not decrease time to wound closure of skin donor sites, and it did not show a difference in reported pain levels.

Complications of male circumcision treated at a military hospital in Afghanistan.

Circumcision of male infants and children is a common ritual in Afghanistan. As in many other developing countries, there are few safeguards relating to the procedure, particularly in rural areas. Performance of ritual circumcision may result in complications requiring treatment beyond the capabilities of the practitioner performing the initial procedure. It is not uncommon for local nationals to seek care at deployed military medical facilities for a wide variety of problems, and complications related to attempted circumcision are no exception. We describe 2 such cases recently presented to a US Army combat support hospital in rural Afghanistan for surgical treatment of the unintended consequences of male circumcision. We offer a review of the most common complications associated with circumcision and treatment options for each. It is valuable for the surgeon operating at the military medical hospital in remote areas of the world to be familiar with the management of the most common complications of circumcision.

Anaphylactoid reaction during first hemofiltrationwith a PUREMA polysulfone membrane.

Adverse reactions during hemodialysis are extremely common and include a wide range of clinical presentations from mild to life threatening. We present a case of a 34 year old woman in the Burn Intensive Care Unit, who developed acute kidney injury requiring renal replacement therapy. She was placed on continuous veno-venous hemofiltration with the NxStage machine which uses a synthetic PUREMA polyethersulfone filter sterilized by gamma radiation. Within two minutes of initiating hemofiltration, the patient complained of pruritus as well as dyspnea and became flushed and agitated. She subsequently developed hypotension ultimately resulting in cardiopulmonary arrest. Cardiopulmonary resuscitation was initiated and the patient was given epinephrine with return of spontaneous circulation. The following day, the patient was rechallenged with a PUREMA filter, and had a similar reaction with flushing, dyspnea, pruritus and hypotension requiring treatment to be discontinued. The patient was transitioned to the Prismaflex filter, another synthetic membrane, which she tolerated well and continued to utilize through the remainder of her hospital course without complication. Her clinical presentation was consistent with an anaphylactoid reaction, though a tryptase level was not obtained and a radioallergosorbent test performed with membrane material was negative. This case shows the difficulty of identifying the cause of hypersensitivity reactions involving synthetic membranes not sterilized by ethylene oxide, a commonly use sterilizing agent known to cause hypersensitivity reactions. This rare, but potentially fatal reaction has not previously been reported with a PUREMA filter and this case should raise awareness of hypersensitivity reactions with this widely used method of renal replacement therapy.

High risk but not always lethal: the effect of cirrhosis on thermally injured adults.

The aim of this article was to determine the effect of cirrhosis on mortality in thermally injured adult patients. We conducted a retrospective review of patients admitted to our burn center during 2003 to 2010. Eight hundred eight patients were included in this study, of whom 24 had the diagnosis of cirrhosis established from electronic medical records and/or autopsy reports. The mortality rate for the cirrhotic patients was 50%, and for the noncirrhotic patients it was 14.8%. On logistic regression, age (odds ratio [OR], 1.08; confidence interval [CI], 1.06-1.10), TBSA (OR, 1.08; CI, 1.06-1.10), inhalation injury (OR, 3.17, CI, 1.61-6.25), and cirrhosis (OR, 8.78; CI, 2.97-25.98) had independent effects on mortality. Of the 24 cirrhotic patients in this study, the admission Model for End-Stage Liver Disease score for the patients who survived hospitalization was 12.1 ± 4.0, and for the patients who died it was 13.8 ± 6.0 (P = .4). When comparing patients with 10 to 50% TBSA burn, the mortality rate for cirrhotic patients was 83.3% (10/12), and for the noncirrhotic patients it was only 12.7% (50/394), P < .0001. Adults with cirrhosis are rarely able to survive burn injuries > 10% TBSA. Although we did not detect a significant association between admission Model for End-Stage Liver Disease score and death, the presence of cirrhosis is a high premorbid contributor and, therefore, new strategies are needed to improve outcomes.

Characterization of skin allograft use in thermal injury.

This study provides objective data on the practice of allograft usage in severely burned patients. Furthermore, gaps in our knowledge are identified, and areas for further research are delineated. Using an institutional review board-approved protocol, active duty military patients injured while deployed in support of overseas contingency operations and treated at our burn center between March 2003 and December 2010 were identified. Their electronic medical records were reviewed for allograft use, TBSA burned, injury severity score, anatomic distribution of burns, operative burden, length of stay, transfusions, and outcome. Among 844 patients, 112 (13.3%) received allograft and 732 (86.7%) did not. The amount of allograft used per patient varied and was not normally distributed (median, 23.5; interquartile range, 69.5). Patients received allograft skin an average of 12.75 times during their admission. Allografted patients sustained severe burns (µ, 53.8% TBSA); most were transfused (71.2%) and grafted frequently, averaging every 7.45 days. Most commonly, allograft was placed on the extremities (66.5%) followed by the trunk (44.2%); however, the vast majority of allografted patients also had concomitant burns of the head (91.1%) and hands (87.5%). All-cause mortality among the allografted patients was 19.1%. In conclusion, allograft is commonly used in the surgical treatment of severe burns. Although there are no anatomic limitations to allograft placement, there are distinct patterns of use. Given the role of allograft in the acute management of large burns, there is need for further investigation of its effect on mortality, morbidity, and antigenicity.

Comparison of traditional burn wound mapping with a computerized program.

Accurate burn estimation affects the use of burn resuscitation formulas and treatment strategies, and thus can affect patient outcomes. The objective of this process-improvement project was to compare the accuracy of a computer-based burn mapping program, WoundFlow (WF), with the widely used hand-mapped Lund-Browder (LB) diagram. Manikins with various burn representations (from 1% to more than 60% TBSA) were used for comparison of the WF system and LB diagrams. Burns were depicted on the manikins using red vinyl adhesive. Healthcare providers responsible for mapping of burn patients were asked to perform burn mapping of the manikins. Providers were randomized to either an LB or a WF group. Differences in the total map area between groups were analyzed. Also, direct measurements of the burn representations were taken and compared with LB and WF results. The results of 100 samples, compared using Bland-Altman analysis, showed no difference between the two methods. WF was as accurate as LB mapping for all burn surface areas. WF may be additionally beneficial in that it can track daily progress until complete wound closure, and can automatically calculate burn size, thus decreasing the chances of mathematical errors.