Pavement Burns Treated at a Desert Burn Center: Analysis of Mechanisms and Outcomes

2020 ◽  
Vol 41 (5) ◽  
pp. 951-955
Author(s):  
Matthew Eisenberg ◽  
Paul Chestovich ◽  
Syed F Saquib
Keyword(s):  
Radiant Energy ◽  
Retrospective Chart Review ◽  
Skin Grafting ◽  
Common Mechanism ◽  
Burn Patients ◽  
Ambient Temperatures ◽  
Burn Center ◽  
Public Health Initiative ◽  
Increased Risk ◽  
Split Thickness Skin Grafting

Abstract Burns from contact with hot pavement are a common mechanism treated at burn centers located in desert climates. Previous work has shown increased risk of pavement burns as ambient temperatures rise above 95 degrees. In direct sunlight, pavement absorbs radiant energy causing the temperature to rise high enough to cause second-degree burns in seconds. The goal of this study is to review the mechanisms and outcomes of patients suffering pavement burns and to compare patients who presented with hyperthermia to their normothermia counterparts. A retrospective chart review was performed on pavement burns at an ABA-verified Burn Center for 5 years from 2014 to 2018. A total of 195 patients were identified. It was found that 50.5% of admitted pavement burn patients required burn excision and 35.9% required split-thickness skin grafting. The leading causes of pavement burn admissions were found down by EMS and walking on pavement at 21.6% each, followed by mechanical falls at 15.1%. We found that patients with recorded hyperthermia had statistically significant increase in 30-day hospital mortality, intensive care unit days, surgical procedures, and %TBSA. Data provided from this study can be used for a public health initiative to help patients who may be at risk of acquiring pavement burns. The data may also be helpful for clinicians gaining information about the management, mechanism, and outcomes of pavement burn patients.

740 Mechanisms, Outcomes and Management of Pavement Burns

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S201-S202
Author(s):  
Matthew T Eisenberg ◽  
Paul J Chestovich ◽  
Syed F Saquib
Keyword(s):  
At Risk ◽  
Average Length ◽  
Radiant Energy ◽  
Retrospective Chart Review ◽  
Skin Grafting ◽  
Operative Management ◽  
Body Region ◽  
Burn Patients ◽  
Increased Risk ◽  
Split Thickness Skin Grafting

Abstract Introduction Burns from contact with hot pavement are commonly seen at burn centers located in desert climates. Previous work has shown increased risk of pavement burns as ambient temperatures rise above 95 degrees. In direct sunlight pavement absorbs radiant energy causing it to rise to temperatures high enough to cause second degree burns in under 35 seconds. This study aims to review the experience of treating pavement burns in a desert climate. Methods A retrospective chart review was performed on pavement burns at an ABA-verified Burn Center for 5 years from 2014–2018. The data collected included %TBSA, surface area per body region, cause, operative management, comorbidities, complications, incident location and cause of death. Patients were separated by cause into groups which included found down, walked on pavement, heat/dehydration, mechanical fall, syncope, seizure, trauma, substance/psych and unknown. Results A total of 185 patients admitted for pavement burns were identified in the study period. The average length of stay for survivors was 16.7 days. Of the survivors, 23% spent time in the ICU with an average stay of 11.4 days. The average TBSA was 5.5% (IQR 2–7.5%) with a maximum of 25%. TBSA breakdown by body region is shown in figure 1. It was found that 50.5% of admitted pavement burn patients required burn excision and 35.9% required split thickness skin grafting. The leading causes of pavement burn admissions were being found down by EMS and walking on pavement at 21.6% each, followed by mechanical falls at 15.1% (See figure 2). Of the 185 patients admitted 17.8% were under the influence of alcohol or drugs. Comorbidities were common; 32.4% had hypertension, 21.6% had diabetes, 13.5% had neuropathy, 2.2% had coronary artery disease, 5.4% had chronic kidney disease. Of the patients that walked on pavement to receive their burns, 50% also had peripheral neuropathy. Rhabdomyolysis developed in 5.4%, and hospital 30-day mortality was 4.9%. Conclusions Pavement burns are a common burn mechanism in hot and sunny climates, but may be seen in other locations during periods of high heat. Patients at risk are those with medical comorbidities and who come in contact with hot pavement for long time periods. Applicability of Research to Practice Data provided from this study can be used for a public health initiative to help patients who may be at risk of acquiring pavement burns. The data may also be helpful for clinicians gaining information about the management, cause and outcomes of pavement burn patients.

667 A Retrospective Review of Vitamin D Levels and Dosing in Burn Center Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S178-S179
Author(s):  
Sara Calder ◽  
Asia N Quan ◽  
Suzanne Osborn ◽  
Virginia Nisbet ◽  
Karen J Richey ◽  
...  
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Total Body Surface Area ◽  
Retrospective Chart Review ◽  
Vitamin D Supplementation ◽  
High Dose ◽  
Burn Patients ◽  
Burn Center ◽  
Increased Risk ◽  
Vitamin D Levels

Abstract Introduction The potential consequences of vitamin D insufficiency/deficiency (I/D) in critically ill patients include: increased ICU length of stay, organ dysfunction, infectious complications, and mortality. Burn patients, in particular, may be at increased risk of vitamin D I/D due to bleeding, systemic inflammatory response syndrome, increased utilization of vitamin D by injured tissues, compromised vascular integrity, fluid shifts, and leakage of vitamin D binding protein (VDBP) and albumin. The purpose of this study is to determine the incidence of vitamin D I/D and evaluate the institutional vitamin D dosing regimen. Methods A retrospective chart review was performed on all adult patients from January 1, 2018 through December 31, 2019 who received cholecalciferol and had at least one 25-hydroxy vitamin D level during their hospitalization. Vitamin D level was drawn on admission, then weekly thereafter. Patients found to be I/D were initiated on high dose vitamin D supplementation and then adjusted based on the weekly levels. The therapeutic goal for vitamin D supplementation was set at 50 ng/ml. Results Three hundred and sixteen patients met criteria for review. Of those patients, 293 patients (93%) were vitamin D I/D. The magnitude of vitamin D deficiency was strongly negatively correlated with increasing % total body surface area (TBSA) burn size (p< 0.001). Mean time to reach therapeutic vitamin D levels following initiation of supplementation was 19 days, requiring an average of 116,125 units cholecalciferol weekly. Time to reach therapeutic levels was also positively correlated with increasing burn size (p< 0.05). Many patients, however, were discharged prior to reaching therapeutic levels. Conclusions Vitamin D I/D is present in over 90% of burn center patients and the degree of I/D was profound. Additionally, vitamin D I/D was not easily corrected, taking almost 3 weeks to reach therapeutic levels using an aggressive supplementation regimen. Further studies documenting the consequences of vitamin D I/D and development of evidence-based supplementation dosing regimens are warranted. Applicability of Research to Practice This study documents common and severe vitamin D deficiency in burn patients, and difficulty in correcting this deficiency.

610 Small Pediatric Burns Can Be Safely Managed on an Outpatient Basis

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S148-S149
Author(s):  
Andrea C Grote ◽  
Alexandra M Lacey ◽  
Warren L Garner ◽  
Justin Gillenwater ◽  
Ellen Maniago ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Retrospective Chart Review ◽  
Outpatient Setting ◽  
Outpatient Basis ◽  
Close Monitoring ◽  
Burn Center ◽  
Increased Risk ◽  
Significant Difference ◽  
Pediatric Burns ◽  
Inpatient Management

Abstract Introduction American Burn Association guidelines recommend that all pediatric burns be transferred to a burn center if their presenting hospital lacks the necessary personnel or equipment for their care. Our institution often treats small (< 10% TBSA) burns in pediatric patients as outpatients with a non-daily dressing. The aim of this study was to determine if small pediatric burns could be managed in an outpatient manner and risk factors for failure. Methods A retrospective chart review was conducted from July 2016 to July 2019 at a single ABA-verified burn center. All patients under the age of 18 who presented for evaluation were included. Post burn day, age, sex, TBSA, burn etiology, body area burned, burn dressing type, outpatient versus inpatient management, reason(s) for admission, and any operative intervention were collected. Results In total, 742 patients were included in our cohort (Table 1). The most common burn etiologies were scald (68%), contact (20%), and flame (5%). From initial presentation, 101 patients (14%), mean TBSA 9%, were admitted to the burn unit and 641 patients (86%), mean TBSA 3%, were treated outpatient. Of those, 613 (96%) were treated entirely outpatient and 28 (4%) were admitted at a later date. There were no significant differences in age (p=0.6) nor gender distribution between those who were successfully treated outpatient and those who failed. There was a significant difference (p < 0.001) in TBSA between the patients who were treated successfully as outpatients (3±2%) versus those who failed outpatient care (4±3%). The primary reason for admission of these patients was nutrition optimization (61%). Conclusions The vast majority of small pediatric burns can be treated as an outpatient with a non-daily dressing with good results. Over 80% of pediatric patients seen in our clinic were successfully managed in this manner. As suspected, when the burns are larger in size (>4% TBSA) there is a potential increased risk for admission especially with regards to poor PO intake, so this requires close monitoring and family education. Applicability of Research to Practice Pediatric patients with small burns can be safely managed in an outpatient setting with a non-daily dressing. Those who fail will most likely fail from poor PO intake at home.

711 A Retrospective Review of Enoxaparin Dosing Practices in Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S187-S187
Author(s):  
Asia N Quan ◽  
Aisha Aden ◽  
Claudia Islas ◽  
Karen J Richey ◽  
Kevin N Foster
Keyword(s):  
Current Practice ◽  
Retrospective Chart Review ◽  
Medication Administration ◽  
Inhalation Injury ◽  
Low Flow ◽  
Common Mechanism ◽  
Burn Patients ◽  
Dosing Regimen ◽  
Actual Weight ◽  
Starting Dose

Abstract Introduction Enoxaparin, a low molecular weight heparin, has been proven to safely and effectively prevent venous thromboembolism (VTE) in acutely ill patients. Burn patients may be particularly vulnerable to the occurrence of a VTE due to prolonged immobility, frequent operating room procedures, and low flow states. Treatment of acute VTE is associated with a direct medical cost of $12000-$15000 and subsequent complications increase costs to $18000 to $23000 per case. Current institutional protocol for initiation of enoxaparin an all burn adult patients is 40 mg administered subcutaneously every 12 hours. Anti-Xa levels are used to monitor anticoagulation prophylaxis, with 0.3–0.5 U/mL recognized as the prophylactic range. Doses are subsequently modified in 10 mg increments to achieve goal prophylaxis anti-Xa levles. The purpose of this study was to evaluate current practice (CP) and assess if the implementation of a published enoxaparin dosing algorithm could minimize delay in achieving anticoagulation prophylaxis. Methods A retrospective chart review was performed of 94 adult burn patients. The doses and time required to reach goal prophylaxis anti-Xa levels using current practice (CP) were compared to the predicted algorithm dose (AD). The number of dose adjustments and the number of days needed for adjustments for CP were documented. Charges related for laboratory determinations and medication administration were calculated. Results Of the 94 patients reviewed, the average age was 47 years, the majority were male (74%), mean actual weight 92 kilograms and mean TBSA 15.7%. The most common mechanism of injury was flash/flame (63%) with 18% suffering an inhalation injury. On average, using CP, it took 9.3 days to get to goal prophylaxis anti-Xa levels, with a mean of 2.86 anti-Xa lab tests needed and an average prophylactic dose of 55.5 mg. A total of 360 labs draws were performed and 74% were timed correctly. The CP average starting dose was lower than the AD 40 mg versus 45 mg (p < .0001). If the algorithm had been used the number of dosing adjustments would have been 25% less. The algorithm overestimated the starting dose in only 2.1% of the population. The average charges until goal was met for enoxaparin were $2,933 and $787 for anti-Xa levels. Conclusions This study demonstrates increased clinical efficacy and cost-effectiveness for an algorithm driven enoxaparin dosing regimen for burn patients. Prospective study with larger patient numbers is warranted. Applicability of Research to Practice Increased efficacy combined with decreased cost for an new enoxaparin dosing regimen.

scholarly journals A Short History of Skin Grafting in Burns: From the Gold Standard of Autologous Skin Grafting to the Possibilities of Allogeneic Skin Grafting with Immunomodulatory Approaches

Medicina ◽  
2021 ◽  
Vol 57 (3) ◽  
pp. 225
Author(s):  
Frederik Schlottmann ◽  
Vesna Bucan ◽  
Peter M. Vogt ◽  
Nicco Krezdorn
Keyword(s):  
Skin Grafting ◽  
Burn Patients ◽  
Skin Substitutes ◽  
Therapeutic Approaches ◽  
The Past ◽  
Thickness Skin ◽  
Split Thickness Skin Grafting ◽  
Burn Surgery ◽  
History Of ◽  
Transplant Immunology

Due to groundbreaking and pioneering developments in the last century, significant improvements in the care of burn patients have been achieved. In addition to the still valid therapeutic standard of autologous split-thickness skin grafting, various commercially available skin substitutes are currently available. Significant progress in the field of tissue engineering has led to the development of promising therapeutic approaches. However, scientific advances in the field of allografting and transplant immunology are of great importance. The achievement of various milestones over the past decades has provided thought-provoking impulses in the field of skin allotransplantation. Thus, biologically viable skin allotransplantation is still not a part of the clinical routine. The purpose of this article is to review the achievements in burn surgery with regards to skin allotransplantation in recent years.

587 DVT Screening in Lower Extremity Burns

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S135-S136
Author(s):  
Cameron J Gibson ◽  
Aakanksha Gupta ◽  
Abraham Houng
Keyword(s):  
Lower Extremity ◽  
Burn Injury ◽  
Compliance Rate ◽  
Delayed Presentation ◽  
Burn Patients ◽  
Central Lines ◽  
Burn Center ◽  
Increased Risk ◽  
Burn Unit ◽  
Screening Protocol

Abstract Introduction Burn patients are at in increased risk for developing deep vein thromboses (DVT), with rates as high as 6%. Known risk factors include large burn size, use of central lines, increasing age, male, active smoker or alcoholic, increased blood transfusions and surgeries. No study to date has looked specifically at burn location as a possible risk factor. We hypothesized that lower extremity burns with delayed presentation to our burn center are at in increased risk for DVT formation. Methods A DVT screening protocol was developed and implemented for all burn patients admitted to our burn unit starting in May 2017. Patients who presented with lower extremity burns >48 hours from their injury time underwent screening ultrasounds at admission to evaluate for DVT in the affected extremity. Data was collected from May 2017 through December 2018 for all lower extremity patients. Screened patients were identified by reviewing the burn registry for patients admitted >2 days from their injury date and then reviewing the electronic medical record for screening US. DVT rates were compared between screened patients and the overall rate for all admissions during the study period. Results There were 1041 patients admitted to the burn unit during the study period, including 445 lower extremity burns with 118 admitted >48 hours after their burn injury. The overall compliance rate with the screening protocol was 41.5% (49/118). There were a total of 4 DVT’s diagnosed among all admitted patients during the study period (1 lower extremity, 3 upper extremity), giving an overall rate of 0.5% for our unit. No DVT’s were identified in the delayed presentation group (p=0.46). Conclusions Our overall DVT rate was much lower than quoted rates in the literature. Patients with lower extremity burns and delayed presentation to a burn center do not appear to be at increased risk for DVT. Compliance with our screening protocol was relatively poor, which may be due to short hospital stays and unavailability of ultrasound on weekends for non-urgent studies. Applicability of Research to Practice Patients with lower extremity burns should receive routine DVT prophylaxis (chemical and mechanical) similar to other burn patients.

722 An Experience with a Biodegradable Temporizing Matrix in a Metropolitan Burn Center

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S192-S192
Author(s):  
Rachelle J Lodescar ◽  
Cameron J Gibson ◽  
James Gallagher
Keyword(s):  
Wound Closure ◽  
Retrospective Chart Review ◽  
Skin Grafting ◽  
Burn Center ◽  
Life Saving ◽  
Complex Wound ◽  
Critical Patients ◽  
Grafting From ◽  
Wound Bed Preparation ◽  
Complex Wounds

Abstract Introduction In a large adult and pediatric metropolitan burn center, we are faced with a variety of challenging burn and complex wound cases that require surgical intervention. With the introduction of a new biodegradable temporizing matrix (BTM) in the US in 2017, we have introduced into our surgical routine a new option for wound coverage in these complex cases. This new biodegradable temporizing matrix has allowed us to provide dermal support and temporary wound closure in critical patients undergoing life-saving clinical support while awaiting skin graft closure. We share our experience using BTM in managing complex wounds in a series of patients over the past year. Methods A retrospective chart review of six patients who were admitted to our burn center, underwent BTM placement and subsequent skin grafting from February 2018 – August 2019 was performed. We analyzed mechanism and type of injury, indication for BTM placement, post burn day (PBD) placement of BTM and PBD to skin grafting and objective patient outcome. Results Conclusions: The availability of a biodegradable temporizing, polyurethane-based material in our burn center has positively added to our repertoire as surgeons an additional method for temporary wound closure as a dermal template. What we have learned is that we can improve wound bed preparation for ultimate skin grafting, particularly in critically ill patients with complex wounds and comorbidities. Applicability of Research to Practice Directly applicable to research.

scholarly journals Perioperative Multimodal Analgesia Reduces Opioid Use Following Skin Grafting in Nonintubated Burn Patients

2020 ◽  
Vol 41 (6) ◽  
pp. 1202-1206
Author(s):  
Richard Lennertz ◽  
Haley Zimmerman ◽  
Timothy McCormick ◽  
Scott Hetzel ◽  
Lee Faucher ◽  
...  
Keyword(s):  
Rating Scale ◽  
Oral Morphine ◽  
Retrospective Chart Review ◽  
Skin Grafting ◽  
Multimodal Analgesia ◽  
Numeric Rating Scale ◽  
Burn Patients ◽  
Opioid Use ◽  
Perioperative Analgesia ◽  
University Of Wisconsin

Abstract Hundreds of patients are treated for burn injuries each year at University of Wisconsin School of Medicine and Public Health. Pain management is particularly challenging during dressing changes and following skin grafting procedures. We performed a retrospective chart review from January 2011 through June 2018 to evaluate the effect of nonopioid analgesic medications on opioid use in nonintubated patients. Our primary outcome was the change in opioid use following the procedure. We found that most patients (69%) report severe pain (Numeric Rating Scale ≥7) immediately after autologous skin grafting. On average, patients required an additional 52 mg of oral morphine equivalents (ME) in the 24 h after the procedure compared with the 24 h before. The use of perioperative nonopioid analgesia varied between patients (acetaminophen 29%, gabapentin 29%, ketamine 35%, and all three 8%). Patients who received either gabapentin or a combination of acetaminophen, gabapentin, and ketamine had a smaller increase in their opioid use than patients who did not receive the medications (−25 ME, 95% confidence interval [−46, −4]; P = .018 and −47 ME, [−81, −11]; P = .010, respectively). These results support using a combination of acetaminophen, gabapentin, and ketamine for perioperative analgesia in burn patients undergoing autologous skin grafting.

24 A Retrospective Review of Vitamin D Levels and Dosing in Burn Center Patients

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S21-S21
Author(s):  
Sara Calder ◽  
Asia N Quan ◽  
Suzanne C Osborn ◽  
Karen J Richey ◽  
Curt Bay ◽  
...  
Keyword(s):  
Vitamin D ◽  
Retrospective Chart Review ◽  
Vitamin D Insufficiency ◽  
Infectious Complications ◽  
Vitamin D Supplementation ◽  
High Dose ◽  
Weekly Dose ◽  
Burn Patients ◽  
Increased Risk ◽  
Vitamin D Levels

Abstract Introduction The potential consequences of vitamin D insufficiency/deficiency (I/D), include increases in ICU length of stay, organ dysfunction, infectious complications, and mortality. Burn patients, in particular, may be at increased risk of vitamin D I/D due to bleeding, systemic inflammatory response syndrome, increased utilization of vitamin D by injured tissues, compromised vascular integrity, fluid shifts, and leakage of vitamin D binding protein (VDBP) and albumin. The purpose of this study is to determine the incidence of vitamin D I/D and evaluate the institutional vitamin D dosing regimen. Methods A retrospective chart review was performed of all adult patients from January 1, 2018 through December 31, 2019 who received cholecalciferol and had at least one vitamin D hydroxy level during their hospitalization. Vitamin D level was drawn on admission, then weekly thereafter. Patients found to be I/D were initiated on high dose vitamin D supplementation and then adjusted based on the weekly levels. The therapeutic goal for vitamin D supplementation was set at 50 ng/ml. Results Three hundred and sixteen patients met criteria for review. Of those patients, 293 patients (93%) were vitamin D I/D. The magnitude of vitamin D deficiency was strongly positively correlated with %TBSA burn size (p< 0.001). Mean time to reach therapeutic vitamin D levels following initiation of supplementation was 19 days with an average weekly dose of 142,877 international units cholecalciferol. Many patients were discharged prior to reaching therapeutic levels. Time to reach therapeutic levels was also positively correlated with increasing burn size (p< 0.05). Conclusions Vitamin D I/D is present is over 90% of burn patients and the degree of I/D was profound. Additionally, vitamin D I/D was not easily corrected, taking almost 3 weeks to reach therapeutic levels using an aggressive supplementation regimen. Further studies documenting the clinical consequences of vitamin D I/D and development of evidence-based supplementation dosing regimens are warranted.

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