Bruce Philp

The Baux score is dead. Long live the Baux score: A 27-year retrospective cohort study of mortality at a regional burns service

Background: To assess trends in mortality after burn injuries treated in a regional specialist burns service between 1982 and 2008. Methods: Patient and burn-specific information and mortality were collated from written admission ledgers and the hospital coding department for 11,109 patients. The data set was divided into age cohorts (0–14, 15–44, 45–64, and >65 years) and time cohorts (1982–1991, 1992–2000, and 2000–2008). Lethal area 50 (LA50) was calculated by logistic regression and probit analysis. Mortality was related to the Baux score (age + total % burned surface area) by logistic regression. Results: In the time period 2000 to 2008, the LA50 values with approximate 95% confidence intervals (CIs) were 100% (CI, 85.5–100%) in the 0 to 14 cohort (LA10, 78.3%; CI, 64.1–92.5%), 76.4% (CI, 69.1–83.8%) in the 15 to 44 cohort, 58.6% (CI, 50.8–66.5%) in the 45 to 64 cohort, and 30.8% (CI, 24.7–36.9%) in the >65 cohort. The point of futility (the Baux Score at which predicted mortality is 100%) was 160 and the Baux50 (the Baux score at which predicted mortality is 50%) was 109.6 (CI, 105.9–113.4) in the 2000 to 2008 cohort. Conclusions: Mortality is markedly improved over earlier data from this study and other historical series and compares favorably with outcomes published from the US National Burn Repository. The Baux Score continues to provide an indication of the risk of mortality. Survival after major burn injury is increasingly common, and decisions by nonspecialist about initial triage, management, and futility of care should be made after consultation with a specialist burn service.

Prognostic scoring systems in burns: A review

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve. The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.

The use of the Cortrak Enteral Access System™ for post-pyloric (PP) feeding tube placement in a Burns Intensive Care Unit

INTRODUCTION 50% of critically ill patients fail to reach caloric targets with NG feeding. PP feeding may enhance caloric intake. PP feeding can be continued throughout theatre in patients with a secure airway. Blind PP tube placement is difficult. CEAS has been developed to assist tube placement and eliminate check X-rays of tube position. METHOD All BITU patients with CEAS PP feeding tube placement were identified. Notes and X-rays were reviewed. Tube position, calorie deficit and time off feed were recorded. RESULTS 44 tubes were placed in 21 patients using CEAS. 84% were PP, 16% NG. Position correlated to X-ray findings in 86%. In 16% position was NG on CEAS but was PP on X-ray. 10 patients required both CXR and AXR to confirm position, the remainder required CXR only. Time off feed varied from 0-24 h (mean 7.4 h). Calorie deficit ranged from 0-2465 kCal (mean 858 kCal). Average wait for X-ray was 3.4h. If X-ray wait was eliminated calorie deficit would be reduced by 45% to 393 kCal. CONCLUSION The Cortrak system is safe and effective on BITU. It reduces calorie deficit, reduces X-ray exposure and is cost effective. We recommend its use on BITU.

Body Mass Index (BMI) and mortality in patients with severe burns: is there a "tilt point" at which obesity influences outcome?

BACKGROUND Obesity is a serious health hazard. Despite advances in burn care severely obese patients with large burns have higher mortality compared with normal-weight patients. The Body Mass Index is the universal measure to define and classify obesity. This study aims to evaluate the effect of Body Mass Index (BMI) on mortality of severe burn patients. METHODS A retrospective study of 95 patients treated over 2-year period in a dedicated burn ITU. Mortality was studied in relation to BMI as well as demographic, burn characteristics well as length of hospital stay. Logistic regression model and non-parametric comparison tests were used for analysis. RESULTS Mean age was 42 ± 22 years (mean ± SD), Total Burn Surface area (TBSA) 33 ± 16%, BMI 29 ± 7.5 (kg/m²) and hospital stay was 37 ± 33 days. Incidence of inhalation injury was 29% and over all mortality was 19%. By logistic regression age, TBSA and inhalation injury were separately associated with mortality. Patients with BMI ≥ 35 (kg/m²) had significantly higher mortality compared with patients with BMI < 25 (kg/m²) [p=0.037 (Fishers exact test)]. CONCLUSIONS Body Mass Index ≥ 35 (kg/m²) is a tilt point, which is associated with a higher than predicted mortality following burns when compared to burned patients with a normal BMI.

Spectrophotometric Intracutaneous Analysis : A Novel Imaging Technique in the Assessment of Acute Burn Depth

The noncontact spectrophotometric intracutaneous analysis scope (SIAscope) is a novel portable imaging device that rapidly produces images of the blood and melanin content of large areas of skin. The estimation of burn depth is often difficult in the clinical setting, and this pilot study was conducted to assess the potential for the SIAscope in aiding burn assessment. Nine patients with a variety of burn injuries had images taken of their acute burns within 48 hours of injury, both with a noncontact SIAscope and a laser Doppler perfusion imaging system (LDPI). Results showed that superficial partial thickness burns had increased hemoglobin and loss of melanin on SIAgraphs, whereas deep partial thickness burns had more pronounced hemoglobin concentrations and apparent melanin increases, helping to differentiate these 2 burn types. The SIAscope, a relatively inexpensive, portable device, has the potential to be a highly useful clinical adjunct in the bedside estimation of acute burn depth.

Comfort care in burns: The Burn Modified Liverpool Care Pathway (BM-LCP)

INTRODUCTION Despite advances in burn care some injuries remain non survivable. Good end of life care for these patients is arguably as important as life prolonging care. The Liverpool Care Pathway is a useful tool for providing good quality end of life care. It has previously been modified for the acute setting. We modified it further specifically for use in burn care in 2007 and would like to share our experience of using it. METHODS A retrospective case series of deaths occurring between 01/01/08 and 31/12/09 is presented and adherence to the Burn Modified Liverpool Care Pathway (BM-LCP) is assessed. RESULTS There were 22 deaths over the study period with a mean TBSA of 55%. Mean Acute Burn Severity Index score (ABSI) 12.5. A decision of futility was made in 14 cases, 11 of these were started on the BM-LCP. 7 were started on the pathway at the time of admission. Mean time from decision to start the pathway to death 11 h (range 3-48). There were no variances from the pathway. CONCLUSION The BM-LCP appears to be an appropriate tool for assisting in end of life care in burns and when used appears to improve end of life care. We recommend its use and would encourage others to implement its use.

Survival of a 75% burn in a patient with longstanding Addison’s disease

This is the first reported case of survival of a significant burn in a patient with established Addisons disease. The systemic stress response to thermal injury is well recognised, there is a marked hypermetabolic response with prolonged periods of catabolism. In particular, the elevation of plasma cortisol levels is crucial for this response to severe systemic stress. Cortisol elevation is maintained for the duration of burn wound healing, is proportional to the burned body surface area and the normal circadian rhythm of endogenous cortisol is lost. Acute adrenal insufficiency has been described in patients suffering major burn injuries with generally poor outcomes. We discuss the management and complications of adrenal replacement therapy in a severe burn setting, as illustrated by this case report.

The Belgian severity prediction model compared to other scoring systems in a burn intensive care population

We read with interest the paper by Brusselaers et al. [1] which was itself the validation of work done by the Belgian Outcome in Burn Injury Study Group [2]. The development of a reliable and user-friendly tool for the prediction of burn mortality will prove useful for audit, research and at the bedside. We have compared three different scoring systems; The Abbreviated Burn Severity Index [3] that proposed by Ryan [4] and this one. When applied to a cohort of 105 consecutive burns intensive care patients from a 2-year period, the Belgian model proved most accurate.

Burns ITU admissions: length of stay in specific levels of care for adult and paediatric patients.

Prediction of total length of stay (LOS) for burns patients based on the total burn surface area (TBSA) is well accepted. Total LOS is a poor measure of resource consumption. Our aim was to determine the LOS in specific levels of care to better inform resource allocation. We performed a retrospective review of LOS in intensive treatment unit (ITU), burns high dependency unit (HDU) and burns low dependency unit (LDU) for all patients requiring ITU admission in a regional burns service from 2003 to 2011. During this period, our unit has admitted 1312 paediatric and 1445 adult patients to our Burns ITU. In both groups, ITU comprised 20% of the total LOS (mean 0.23±0.02 [adult] and 0.22±0.02 [paediatric] days per %burn). In adults, 33% of LOS was in HDU (0.52±0.06 days per %burn) and 48% (0.68±0.06 days per %burn) in LDU, while in children, 15% of LOS was in HDU (0.19±0.03 days per %burn) and 65% in LDU (0.70±0.06 days per %burn). When considering Burns ITU admissions, resource allocation ought to be planned according to expected LOS in specific levels of care rather than total LOS. The largest proportion of stay is in low dependency, likely due to social issues.

Use of biobrane® to dress split-thickness skin graft adjacent to skin graft donor sites or partial-thickness burns.

Biobrane® (Smith & Nephew Wound Management, Hull, United Kingdom) is a flexible biosynthetic wound dressing that has been widely used to dress partial-thickness burns and donor sites of split-thickness skin grafts (SSG).1–3 We reported 11 cases from March 2008 to March 2012 in which Biobrane was used to dress SSG, where the grafted areas were adjacent to donor sites or partial-thickness burns. Biobrane was used to dress SSG and their adjacent donor sites in five cases. In the other six described cases, we used Biobrane in mixed-depth burns. After tangential excision and skin grafting the deep burns, Biobrane was used to dress the SSG and adjacent superficial partial-thickness burns. Nine of the 11 cases were children. Biobrane was used to cover SSG over scalp, forehead, arms, legs, dorsum of foot, and abdomen. It was fixed with staples. An outer absorbent dressing was applied for 2 days, then Biobrane was left exposed (Figure 1). After removal of staples, Biobrane came off the sheet grafts on day 5 and it peeled off the meshed grafts, superficial burnt areas, and donor sites on days 10 to 14. In all reported cases, SSG fully took without complications, and patients were comfortable. Biobrane applied over SSG on flat and convex body surfaces promoted adherence of the SSG to the wound, prevented shearing, and allowed fluid drainage. Its transparency allowed regular checking without disrupting the graft, and at the same time facilitated healing of the adjacent donor sites or partial-thickness burns. In all cases, Biobrane was our first choice to dress the partial-thickness burns or SSG donor sites. By using the same dressing to cover the adjacent SSG, we negated the extra theater time needed when using different dressings; therefore, this method is cost-effective.