Avery B. Nathens

An Analysis of the Long-Distance Transport of Burn Patients to a Regional Burn Center

The concentration of specialized burn care to relatively few centers within relatively large geographic regions requires an organized system of patient triage, referral, and transport. The purpose of this study was to identify systematic errors in either the initial evaluation or care of burn patients requiring transport more than 90 miles to a single regional burn center. Therefore, we undertook a descriptive analysis of patients transported more than 90 miles to a single regional burn center from 2000 to 2003. The outcomes of interest were duration of transport, errors in burn size estimation, errors in fluid management, appropriateness of intubation, and complications during transport. During the years 2000 to 2003, there were 1877 admissions to the burn center; 949 (51%) were transferred from an outside facility. Of these 949, 424 (45%) were transferred more than 90 miles from a referring facility to our burn center. The average transport time from injury to our burn center was 7.2 hours (range, 1.6–48). There were no patient deaths during transport, and the most common complications were loss of or inability to secure intravenous access and inability to secure an airway. Burn size estimates differed significantly (P < .001) between referring providers and burn center physicians. This study confirms that patients can be transported safely and efficiently over long distances to a regional burn center. Given the current geographic distribution of burn centers and concerns about declining numbers of burn surgeons, organized systems of patient triage and transport may become increasingly important.

Shock and Resuscitation

In 1872, Gross referred to shock as the “manifestation of the rude unhinging of the machinery of life.”1 We now know that shock, at its most fundamental level, represents the clinical syndrome arising as a result of inadequate tissue perfusion. The discrepancy between substrate delivery and the cellular substrate requirement leads to cellular metabolic dysfunction. Inadequate oxygen delivery is implicated as the principal defect in shock states. The clinical manifestations of shock are caused by end-organ dysfunction secondary to impaired perfusion and the body’s sympathetic and neuroendocrine response to an insufficient cellular supply/demand ratio for oxygen.

Perioperative Fluids and Electrolytes

Surgical patients undergo acute alterations in the volume and composition of fluids in the intracellular and extracellular spaces. To a great extent, these changes occur as a result of the patient’s underlying disease. For example, hemorrhage or bowel obstruction may acutely change the volume of fluid in the intravascular or extracellular compartments. However, these alterations are not limited to patients requiring urgent operative intervention, as even elective surgery may result in dramatic fluid shifts in the absence of significant blood loss. In addition to changes in fluid volume, surgical patients may develop potentially dangerous fluctuations in concentrations and total body content of important electrolytes. Precise perioperative management of fluids and electrolytes is thus required to minimize perioperative morbidity and mortality.

Mediator-Directed Therapy in Pancreatitis and Trauma

Both acute pancreatitis and severe trauma induce a systemic sterile inflammatory process which leads to a high incidence of remote organ dysfunction and death. Several attributes of these two entities make them ideal for evaluation of the effects of mediator-directed therapy. The rationale and evidence for mediator-directed therapy in pancreatitis and trauma are reviewed. In pancreatitis, organ dysfunction and death are best prevented using strategies designed to limit the inflammatory response, particularly IL-1a and IL-10. By contrast, the sequelae of a post-traumatic systemic inflammatory response are best mitigated using strategies designed to limit neutrophil adhesion.