Timing of Flap Surgery in Acute Burn Patients Does Not Affect Complications

2020 ◽  
Vol 41 (5) ◽  
pp. 967-970
Author(s):  
David Perrault ◽  
Danielle Rochlin ◽  
Christopher Pham ◽  
Arash Momeni ◽  
Yvonne Karanas ◽  
...  
Keyword(s):  
Independent Predictor ◽  
Multivariable Analysis ◽  
Total Body Surface Area ◽  
Free Flaps ◽  
Stepwise Logistic Regression ◽  
Electrical Injury ◽  
Burn Patients ◽  
Burn Wound ◽  
Burn Care ◽  
Flap Coverage

Abstract Pedicled and free flaps are occasionally necessary to reconstruct complex wounds in acute burn patients. Flap coverage has classically been delayed for concern of progressive tissue necrosis and flap failure. We aim to investigate flap complications in primary burn care leveraging national U.S. data. Acute burn patients with known % total body surface area(TBSA) were extracted from the Nationwide/National Inpatient Sample from 2002 to 2014 based on the International Classification of Disease (ICD) codes, ninth edition. Variables included age, sex, race, Elixhauser index, %TBSA, mechanism, inhalation injury, and location of burn. Flap complication was defined by ICD-9 procedure code 86.75, return to the operating room for flap revision. Multivariable analysis evaluated predictors of flap compromise using stepwise logistic regression with backward elimination. The weighted sample included 306,924 encounters of which 526 received a flap (0.17%). About 7.8% of flap encounters sustained electric injury compared to 2.7% of non-flap encounters (odds ratio [OR] 3.76, 95% confidence interval [CI] 1.95–7.24, P < .001). The mean hospital day of the flap procedure was 10.1 (SD 10.7) days. Flap complications occurred in 6.4% of cases. The timing of flap coverage was not associated with complications. The only independent predictor of flap complication was electrical injury (OR 40.49, 95% CI 2.98–550.64, P = .005). Electrical injury was an independent predictor of flap complications compared to other mechanisms. Flap timing was not associated with return to surgery for complications. This suggests that the use of flaps is safe in acute burn care to achieve burn wound closure with an understanding that electrical injuries may warrant particular consideration to avoid failure.

105 The Impact of Flap Timing and Mechanism of Injury on Flap Complications in Acute Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S69-S70
Author(s):  
Clifford C Sheckter ◽  
David Perrault ◽  
Danielle H Rochlin ◽  
Christopher H Pham ◽  
Yvonne L Karanas
Keyword(s):  
Independent Predictor ◽  
Multivariable Analysis ◽  
Inhalation Injury ◽  
Electrical Injury ◽  
Burn Patients ◽  
Burn Care ◽  
Flap Coverage ◽  
Comorbidity Index ◽  
The Mean ◽  
The Impact

Abstract Introduction Burn wounds are often amenable to excision and grafting, but pedicled and free flaps are sometimes necessary to achieve closure of complex wounds. Flap coverage of exposed bone, tendons and cartilage has classicaly been delayed in acute burn patients due to concern of progressive tissue necrosis, microvascular thrombosis and percieved high failure rates. More recently, a number of reports have demonstrated that the use of flaps is safe earlier in acute burn care. We aim to elucidate the role of flaps in primary burn woud coverage leveraging national US data. Methods Acute burn patients with known % total body surface area were extracted from the Nationwide/National Inpatient Sample from 2002–2014 based on International Classification of Disease (ICD) Codes 9th edition. Flap procedures were identified based on ICD-9 procedure codes. Flap and non-flapped patients were compared using multivariable analysis. Variables included age, gender, race, Elixhauser comorbidity index, %TBSA, burn mechanism, inhalation injury, and location of burn. Flap complication was defined by ICD-9 procedure code 8675, return to OR for revision of flap. Multivariable analysis evaluated predictors of flap compromise based on stepwise logistic regression with backwards elimination. Results The weighted sample included 306,924 encounters of which 526 received a flap (0.17%). The mean age of encounters receiving a flap was 45.0 (SD 21.2) years versus 35.5 (SD 24.2) years in the non flap group (p=0.023). 7.8% of patients who received a flap suffered electric injury compared to 2.7% of non-free flap encounters (OR 3.76, 95% CI 1.95–7.24, p< 0.001). Patients who underwent flap wound coverage were more likely to have a lower extremity burn; 55.3% of encounters versus 43.1% in non- flap patients (OR 2.26, 95% CI 1.05–2.15, p=0.024). There were no significant differences in gender, race, Elixhauser comorbidity index, %TBSA, or inhalation injury. The mean hospital day of the flap procedure was 10.1 (SD 10.7) days. Flap complications occurred in 6.4% of flap encounters. The only independent predictor of flap complication was electrical injury (OR 40.49, 95% OR 2.98–550.64, p=0.005). The time to flap coverage and location were not associated with complications. Conclusions Electrical injury was an independent predictor of flap complications compared to other mechanisms. Flap timing was not associated with return to surgery for complications. This suggests that the use of flaps is safe in acute burn care to achieve burn wound closure with an understanding that electrical injuries may deserve particular consideration to avoid failure. Applicability of Research to Practice Inform surgeon decision making when deciding candidacy for flap surgery in acute burn patients.

674 Machine Learning and Automation in Burn Care: A Systematic Review

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S193-S193
Author(s):  
Samantha Huang ◽  
Justin Dang ◽  
Clifford C Sheckter ◽  
Haig A Yenikomshian ◽  
Justin Gillenwater
Keyword(s):  
Machine Learning ◽  
Systematic Review ◽  
Total Body Surface Area ◽  
Burn Wound ◽  
Burn Care ◽  
Surgeon Experience ◽  
Automated Software ◽  
Burn Depth ◽  
Automated Methods ◽  
Equal Weighting

Abstract Introduction Current methods of burn evaluation and treatment are subjective and dependent on surgeon experience, with high rates of inter-rater variability leading to inaccurate diagnoses and treatment. Machine learning (ML) and automated methods are being used to develop more objective and accurate methods for burn diagnosis and triage. Defined as a subfield of artificial intelligence that applies algorithms capable of knowledge acquisition, machine learning draws patterns from data, which it can then apply to clinically relevant tasks. This technology has the potential to improve burn management by quantitating diagnoses, improving diagnostic accuracy, and increasing access to burn care. The aim of this systematic review is to summarize the literature regarding machine learning and automated methods for burn wound evaluation and treatment. Methods A systematic review of articles available on PubMed and MEDLINE (OVID) was performed. Keywords used in the search process included burns, machine learning, deep learning, burn classification technology, and mobile applications. Reviews, case reports, and opinion papers were excluded. Data were extracted on study design, study objectives, study models, devices used to capture data, machine learning, or automated software used, expertise level and number of evaluators, and ML accuracy of burn wound evaluation. Results The search identified 592 unique titles. After screening, 35 relevant articles were identified for systematic review. Nine studies used machine learning and automated software to estimate percent total body surface area (%TBSA) burned, 4 calculated fluid requirements, 18 estimated burn depth, 5 estimated need for surgery, 6 predicted mortality, and 2 evaluated scarring in burn patients. Devices used to estimate %TBSA burned showed an accuracy comparable to or better than traditional methods. Burn depth estimation sensitivities resulted in unweighted means >81%, which increased to >83% with equal weighting applied. Mortality prediction sensitivity had an unweighted mean of 96.75%, which increased to 99.35% with equal weighting. Conclusions Machine learning and automated technology are promising tools that provide objective and accurate measures of evaluating burn wounds. Existing methods address the key steps in burn care management; however, existing data reporting on their robustness remain in the early stages. Further resources should be dedicated to leveraging this technology to improve outcomes in burn care.

559 Benzocaine-Lidocaine-Tetracaine (BLT) Cream Adverse Effects in Burn Patients: A Case Report and Literature Review

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S129-S129
Author(s):  
Todd A Walroth ◽  
Michelle E Brown ◽  
Katelyn Gordon ◽  
Moises Martinez ◽  
Cortni Grooms ◽  
...  
Keyword(s):  
Literature Review ◽  
Adverse Effects ◽  
Surface Area ◽  
Total Body Surface Area ◽  
Neurological Deficits ◽  
Published Data ◽  
Burn Patients ◽  
Burn Wound ◽  
Lidocaine Concentration ◽  
Topical Lidocaine

Abstract Introduction Historically, BLT cream has been used at our burn center in laser procedures and tattoo removal with 6–8% lidocaine to improve tolerance of outpatient procedures. Recently, the laser BLT formulation (8%) has been trialed as an opioid-sparing alternative for managing pain during inpatient microneedling procedures. When utilizing this formulation for microneedling, the high percentage of lidocaine absorption may correlate with adverse central nervous system (CNS) effects. Methods A literature evaluation and retrospective chart review of burn patients receiving BLT cream for inpatient microneedling was performed. Results From January to June 2020, two elderly females (77 and 78 years old) received several doses of BLT cream during inpatient microneedling procedures with no documented adverse events attributed to the medication. A 68 year old male with a total body surface area (TBSA) of 8% reported dizziness shortly after he received BLT cream. Vitals were normal, but the patient was unable to focus his eyes or communicate clearly. Neurological exam revealed sluggish, pinpoint pupils. Patient remained disoriented with gargling and tongue thrusting though vitals remained stable. At this time, the remainder of the BLT cream was removed from the wound and his mentation returned to baseline within 90 minutes. No residual neurologic deficits occurred. No other potential causes were identified. Literature review revealed topical lidocaine can be absorbed systemically and cause CNS depression, confusion, and disorientation. Based on limited published data in healthy patients, it is recommended to use no more than 5% of topical lidocaine in large quantities, especially over raw surfaces or blistered areas. The amount of lidocaine systemically absorbed is linked to both the duration of application and the surface area over which it is applied. Using study data from lidocaine/prilocaine 2.5% cream and lidocaine patches, we explored a safer BLT formulation for burn patients as published data do not exist for this group. Conclusions Based on our review, we determined 2% to be the maximum lidocaine concentration to apply to a burn wound, 5% TBSA as the maximum surface area involved, and total exposure time limited to 30 minutes or less to reduce incidence of adverse effects. Specifically, formulations with a higher lidocaine concentration applied to a burn wound have the potential to result in untoward neurological deficits.

524 Effectiveness of Burns Wound Cleansing by Comparison of Prewash and Post Wash Swab Reports

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
M A Sayed ◽  
S Jabeen ◽  
A Soueid
Keyword(s):  
Bacterial Load ◽  
Total Body Surface Area ◽  
Wound Management ◽  
Burn Patients ◽  
Burn Wound ◽  
Staph Aureus ◽  
Sex Type ◽  
Total Body ◽  
Burns Unit ◽  
Type Of Injury

Abstract Aim The main aim and objective were to optimise wound healing through infection prevention. This clinical audit aimed to investigate the effectiveness of burn wound cleansing in decreasing bacterial load by comparing pre-wash and post-wash swab results against local burn wound management and aseptic non touch technique (ANTT) guidelines. Method The audit was conducted retrospectively on children admitted to Burns Unit during August 2019, excluding resuscitation burn patients. Pre- and post-wash swabs taken on admission were included and the results obtained from Chameleon database. Data were collected on excel spread sheets including demographic variables such as age, sex, type of injury, percentage total body surface area (TBSA) and mechanism of injury. Data were analysed and results compiled. Results Fifty patients were admitted over a month period; amongst those 60% were male and 40% female of ages ranging from 5 months to 14 years. Scald (50%) was found to be the most common mode of injury followed by contact burn (36%) involving 0.30 to 9% TBSA. Among 50 patients, 30 (60%) showed no growth in pre-wash and 36 (72%) in post-wash swabs. However, 6% post-wash swabs that were initially negative later showed bacillus cereus, staph aureus, Enterobacter, and Acinetobacter. Similarly, another 4% post-wash swabs developed new microorganisms as compared to pre-wash swabs. Conclusions The most common bacteria colonising both pre- and post-wash swabs was staph aureus. Overall, cleansing had reduced the bacterial load significantly around 82% very effective. It is imperative to stick to local guidelines to reduce morbidity and mortality in burn patients.

Management of burns in the ICU

2016 ◽  
Author(s):  
Shahriar Shahrokhi ◽  
Marc G. Jeschke
Keyword(s):  
Total Body Surface Area ◽  
The Elderly ◽  
Similar Data ◽  
Burn Patients ◽  
Burn Care ◽  
Future Developments ◽  
Appropriate Treatment ◽  
Total Body ◽  
Critical Components ◽  
Current Standards

Outcomes of burn patients have significantly improved over the last two decades. A recent study in The Lancet showed that a burn size of over 60% total body surface area (TBSA) burned is now recognized as being associated with high risks; a decade ago similar risks resulted from a 40% TBSA burned. Similar data have been obtained in severely-burned adults and the elderly. This chapter discusses current standards, recent evidence, and future developments in burn care to improve outcomes of these patients. Critical components in the management of patients with burns are early adequate resuscitation, recognition and management of airway burns and appropriate treatment of the different stages of burn care—prehospital, early, and late management.

1 The Impact of No Next of Kin Decision Makers on End-of-life Care

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S4-S5
Author(s):  
Ryan K Ota ◽  
Maxwell B Johnson ◽  
Trevor A Pickering ◽  
Warren L Garner ◽  
Justin Gillenwater ◽  
...  
Keyword(s):  
Critically Ill ◽  
Decision Maker ◽  
Total Body Surface Area ◽  
Burn Patients ◽  
Inclusion Criteria ◽  
Next Of Kin ◽  
Medical Decisions ◽  
Comfort Care ◽  
Burn Care ◽  
The Impact

Abstract Introduction For critically ill burn patients without a next of kin (NOK), the medical team is tasked with becoming the surrogate decision maker. This poses difficult ethical and legal challenges for burn providers. Despite this frequent problem, there has been no investigation of how the presence of a NOK affects treatment in burn patients. This study is the first to evaluate this relationship. Methods A retrospective chart review was performed on a cohort of patients who died during the acute phase of their burn care from a single burn center from 2015 to 2019. Inclusion criteria were age ≥18 years and mortality within 4-weeks of admission. Exclusion criteria were death from dermatologic disease or trauma. Variables collected included age, gender, mechanism of injury, length of stay (LOS), total body surface area (TBSA), revised Baux score, and the presence of a NOK. Fisher’s Exact Test and Student’s t-test were used for analysis. Results In total, 67 patients met inclusion criteria. Of these patients, 14 (21%) did not have a NOK involved in medical decisions. Table 1 shows the means and odds ratio between the two groups. Patients without a NOK were younger (p < 0.05), more likely to be homeless (p < 0.01), had higher TBSA (p < 0.01), had shorter LOS (p < 0.01), and were 5 times less likely to receive comfort care (p < 0.05). Gender and ethnicity were not statistically significant. Conclusions Patients without a NOK present to participate in medical decisions are transitioned to comfort care less often despite having a higher burden of injury. This disparity in standard of care between the two groups demonstrates a need for a cultural shift in burn care to prevent suffering of these marginalized patients. Burn providers should be empowered to reduce suffering when no decision maker is present. Applicability of Research to Practice We report that the absence of a NOK has a significant impact leading to a decreased initiation of comfort care in critically ill burn patients. National protocols should be created to allow burn providers to act as a surrogate to prevent prolonged suffering.

scholarly journals Surgical Management Evolution Between 2 Massive Burn Cases at 17-Year Interval: Contribution of Cell Therapies in Improving the Surgical Care

2020 ◽  
Vol 29 ◽  
pp. 096368972097364
Author(s):  
Sandra Monnier ◽  
Philippe Abdel-Sayed ◽  
Anthony de Buys Roessingh ◽  
Nathalie Hirt-Burri ◽  
Michèle Chemali ◽  
...  
Keyword(s):  
Intensive Care ◽  
Surgical Management ◽  
Total Body Surface Area ◽  
Young Patients ◽  
Surgical Care ◽  
The Body ◽  
Burn Patients ◽  
Cell Therapies ◽  
Burn Care ◽  
Technical Specifications

We report the cases of 2 patients admitted to our hospital at a 17-year interval, both with 90% total body surface area (TBSA) burns. These two young patients were in good health before their accident, but major differences in time of intensive care and hospitalization were observed: 162 versus 76 days in intensive care unit and 18 versus 9.5 months for hospitalization, respectively. We have analyzed the different parameters side-by-side during their medical care and we have identified that the overall improved outcomes are mainly due to a better adapted fluid reanimation in combination with the evolution of the surgical management to encompass allogenic cellular therapy (Biological Bandages). Indeed, autologous cell therapy using keratinocytes has been used for over 30 years in our hospital with the same technical specifications; however, we have integrated the Biological Bandages and routinely used them for burn patients to replace cadaver skin since the past 15 years. Thus, patient 1 versus patient 2 had, respectively, 83% versus 80% TBSA for autologous cells, and 0% versus 189% for allogenic cells. Notably, it was possible that patient 2 was able to recover ∼6% TBSA with the use of Biological Bandages, by stimulating intermediate burn zones toward a spontaneous healing without requiring further skin grafting (on abdomen and thighs). The body zones where Biological Bandages were not applied, such as the buttocks, progressed to deeper-stage burns. Despite inherent differences to patients at their admission and the complexity of severe burn care, the results of these two case reports suggest that integration of innovative allogenic cell therapies in the surgical care of burn patients could have major implications in the final outcome.

656 Autologous Skin Cell Suspension is Associated with Decreased Hospital Length of Stay and Limited Surgical Interventions

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S194-S194
Author(s):  
Nicole M Kopari ◽  
Yazen Qumsiyeh
Keyword(s):  
Length Of Stay ◽  
Cell Suspension ◽  
Average Length ◽  
Total Body Surface Area ◽  
Hospital Length ◽  
Care Quality ◽  
Hospital Length Of Stay ◽  
Burn Patients ◽  
Burn Care ◽  
Skin Cell

Abstract Introduction Hospital length of stay is a measure of burn care quality and resource allocation. Traditionally, the average length of stay (LOS) for patients with burns is estimated at 1 day/% total body surface area (TBSA) although the 2016 American Burn Association National Burn Repository predicts closer to 3 days/%TBSA. Recent literature has shown that application of autologous skin cell suspension (ASCS) is associated with decreased hospital LOS and therefore is considered economically advantageous. Our study evaluated the LOS as it related to TBSA as well as the number of operations in patients treated with ASCS. Methods This is a single institution, retrospective review of burn patients at an American Burn Associated verified burn center admitted from August 2019 - August 2020 who underwent epidermal autografting. Patients were treated for partial thickness and full thickness burns either with epidermal grafting alone or in combination with widely meshed skin grafting. Demographics included age and sex of patient. The TBSA, LOS, number of operations, and re-admission rates were also collected. Results A total of 52 patients were included in the review. 73% were male with an average age of 42 years (range 15 months to 88 years. The patients were stratified into 4 different categories based on their burn TBSA: 0-10% (n=25), 11-20% (n=16), 21-30% (n=5), and >30% (n=6). The average number of operations increased with %TBSA (0-10%=1, 11-20%=1, 21-30%=2, >30%=4). The average LOS overall was 0.9 days/%TBSA (0-10%=1.0, 11-20%=0.7, 21-30%=0.9, >30%=0.8). Only one patient required re-admission after the first dressing takedown and underwent a second application of ASCS with subsequent healing. No patients required reconstructive surgery. Conclusions Burn patients treated with ASCS continue to demonstrate a decreased LOS/%TBSA and an overall decrease in the number of operations. The most significant impact may be noted as burn size increases.

scholarly journals The Effect of Transfer on Outcomes in Burns

2021 ◽  
Author(s):  
Nathan E Bodily ◽  
Elizabeth H Bruenderman ◽  
Neal Bhutiani ◽  
Selena The ◽  
Jessica E Schucht ◽  
...  
Keyword(s):  
Total Body Surface Area ◽  
Infectious Complications ◽  
Burn Injuries ◽  
Burn Patients ◽  
Burn Care ◽  
Burn Center ◽  
Field Versus ◽  
High Acuity ◽  
Total Body ◽  
Inhalation Burn

Abstract Patients with burn injuries are often initially transported to centers without burn capabilities, requiring subsequent transfer to a higher level of care. This study aimed to evaluate the effect of this treatment delay on outcomes. Adult burn patients meeting American Burn Association (ABA) criteria for transfer at a single burn center were retrospectively identified. A total of 122 patients were evenly divided into two cohorts – those directly admitted to a burn center from the field, versus those transferred to a burn center from an outlying facility. There was no difference between the transfer and direct admit cohorts with respect to age, percent total body surface area burned, concomitant injury, or intubation prior to admission. Transfer patients experienced a longer median time from injury to burn center admission (1 vs. 8 hours, p &lt, 0.01). Directly admitted patients were more likely to have inhalation burn (18 vs. 4, p &lt, 0.01), require intubation after admission (10 vs. 2, p = 0.03), require an emergent procedure (18 vs. 5, p &lt, 0.01), and develop infectious complications (14 vs. 5, p = 0.04). There was no difference in ventilator days, number of operations, length of stay, or mortality. The results suggest that significantly injured, high acuity burn patients were more likely to be immediately identified and taken directly to a burn center. Patients who otherwise met ABA criteria for transfer were not affected by short delays in transfer to definitive burn care.

Deep Learning Assisted Burn Wound Diagnosis (Preprint)

2020 ◽  
Author(s):  
Che Wei Chang ◽  
Feipei Lai ◽  
Mesakh Christian ◽  
Yu Chun Chen ◽  
Ching Hsu ◽  
...  
Keyword(s):  
Deep Learning ◽  
Total Body Surface Area ◽  
Ground Truth ◽  
Burn Patients ◽  
Burn Wound ◽  
Burn Wounds ◽  
Burn Victims ◽  
Step Procedure ◽  
Resuscitation Fluid ◽  
Total Body

BACKGROUND Accurate assessment of the percentage of total body surface area (%TBSA) of burn wounds is crucial in the management of burn patients. The resuscitation fluid and nutritional needs of burn patients, their need for intensive unit care, and probability of mortality are all directly related to %TBSA. It is difficult to estimate a burn area of irregular shape by inspection. Many articles have reported discrepancy in estimating %TBSA by different doctors. OBJECTIVE We propose a method, based on deep learning, for burn wound detection, segmentation and calculation of % TBSA on a pixel-to-pixel basis. METHODS A two-step procedure was used to convert burn wound diagnosis into %TBSA. In the first step, images of burn wounds were collected and labeled by burn surgeons and the dataset was then input into two deep learning architectures, U-Net and Mask R-CNN, each configured with two different backbones, to segment the burn wounds. In the second step, we collected and labeled images of hands to create another dataset, which was also input into U-Net and Mask R-CNN to segment the hands. The percentage of TBSA of the burn wounds was then calculated by comparing the pixels of mask areas on the images of the burn wound and hand of the same patient according to the rule of hand, which says that one’s hand accounts for 0.8% of TBSA. RESULTS A total of 2591 images of burn wounds were collected and labeled to form the burn-wound dataset. The dataset was randomly split into a ratio of 8:1:1 to form the training, validation, and testing sets. Four hundred images of volar hands were collected and labeled to form the hand dataset, which was also split into three sets using the same method. For the images of burn wounds, Mask R-CNN with ResNet101 had the best segmentation result with a Dice coefficient (DC) of 0.9496, while U-Net with ResNet101 had a DC of 0.8545. For the hand images, U-Net and Mask R-CNN had similar performance with a DC of 0.9920 and 0.9910, respectively. Lastly, we conducted a test diagnosis in a burn patient. Mask R-CNN with ResNet-101 had on average less deviation (0.115% TBSA) from the ground truth than burn surgeons. CONCLUSIONS This is one of the first studies to diagnose all depths of burn wounds and convert the segmentation results into %TBSA using different deep learning models. We aimed to assist medical staff in estimating burn size more accurately and thereby helping to provide precise care to burn victims.

Sign in / Sign up

Export Citation Format

Share Document