C. Gillon Ward

Transfers from emergency room to burn center: errors in burn size estimate.

Errors in estimation of burn size are commonplace in community hospital emergency rooms. In 24 of 132 transfers to a burn center the extent of injury was overestimated at the transferring emergency room by 100% or more. This incorrect burn size estimation seems related to reliance on guesswork or use of the Rule of Nines. The incidence of error is greater in smaller burns.

A Prospective, Randomized Trial of Acticoat Versus Silver Sulfadiazine in the Treatment of Partial-Thickness Burns: Which Method Is Less Painful?

Despite recent improvements in analgesia, pain control during dressing changes continues to be a major challenge in patients with burns. We investigated two different dressing modalities to compare how much pain the patient experienced during and after the dressing change. Patients with partial-thickness burns that required only topical wound care were assigned randomly to treatment with Acticoat (Smith and Nephew USA, Largo, FL) or silver sulfadiazine (AgSD). The outcome variable was pain during wound care, which was measured using visual analog pain scores. The mean visual analog pain scores for the wounds treated with Acticoat or AgSD wounds were 3.2 and 7.9, respectively (P < .0001; paired Students t-test). In 41 of the 47 paired pain score observations, the pain in the wound treated with AgSD was perceived as greater than in the wound treated with Acticoat. Burn wound care with Acticoat is less painful than burn wound care with AgSD in patients with selected partial-thickness burns.

The value of isokinetic exercise and testing in burn rehabilitation and determination of back-to-work status.

Determination of work capability may require assessment of function at speeds consistent with the patients workday requirements. Standard isotonic physical therapy techniques do not adequately test strength, power, and endurance. Isokinetic training and testing improve both outcome and assessment.

Continuous-infusion oxacillin for the treatment of burn wound cellulitis.

BACKGROUND Burn cellulitis is an infection of the unburned skin at the margin of a burn wound or graft donor site, typically caused by group A beta-hemolytic streptococci and Staphylococcus aureus. beta-Lactam antibiotics exhibit time-dependent killing and, because of their narrow spectrum, minimize bacterial resistance. We therefore use continuous-infusion oxacillin in the treatment of burn cellulitis. METHODS Patients at a regional burn center who were treated for burn cellulitis from January 2003 to December 2005 were included. Charts were reviewed for all pertinent data regarding the antibiotic treatment methods and outcomes. Successful treatment was defined as resolution of physical findings, fever, and leukocytosis and intravenous antibiotic cessation. RESULTS Thirty-seven patients were treated for burn cellulitis, 26 (70%) of whom were treated initially with continuous-infusion oxacillin. Other initial antibiotics were chosen because of concomitant infections, penicillin allergy, or development of cellulitis during treatment with a beta-lactam antibiotic. Oxacillin treatment was successful in 19 patients (73%). Success required an average of 5.16 days, with 1.53 days required for fever resolution and 0.89 days for resolution of leukocytosis. Seven patients who did not respond rapidly were switched to intravenous vancomycin an average of 2.4 days after starting oxacillin, leading to a 100% success rate. There were no deaths, and only one suspected case of allergic reaction to oxacillin. In eleven patients treated with other antibiotics, the success rate was 75%. Success with these drugs required a longer treatment course of 6.45 days. Leukocytosis resolved significantly more slowly at 4.45 days (p = 0.02), and fever resolution was also slower at 3.18 days. CONCLUSIONS Continuous-infusion oxacillin was successful in the treatment of 73% of patients, a success rate that might have been higher with clinical patience, and leukocytosis resolved faster than with other antibiotics. Failure of continuous-infusion oxacillin can be managed without clinical consequence by conversion to intravenous vancomycin.

Securing endotracheal tubes in patients with facial burns or trauma.

Securing an endotracheal tube on patients with facial burns or trauma can pose difficulties. A nasotracheal support splint, made of materials commonly used by occupational therapists, can facilitate safe anchoring of a nasotracheal tube.

The bactericidal power of the blood and plasma of patients with burns.

Patients with burns are unusually susceptible to bacterial infections, but so far there is no satisfactory explanation for this lack of resistance. Since resistance to infection involves many different mechanisms, examination of individual components of the immune system may not sufficiently explain the underlying reasons for increased susceptibility. The use of whole blood for antibacterial tests has the advantage that all the immune systems present in that fluid compartment can take part in the bactericidal effect. Tests with Klebsiella pneumoniae and Staphylococcus aureus showed no evidence that the bactericidal power of the blood and plasma of patients with burns was less than that of normal control plasma. This suggests that the solution to the problem of increased susceptibility to infection in patients with burns does not lie with the blood but must be looked for elsewhere.

The effect of iron on mixed infection of Bacteroides fragilis and Escherichia coli in mice

Survival of an infected animal is improved in a mixed infection when Bacteroides fragilis is the bacterial species acting as a microbial antagonist against Escherichia coli. The protective effect afforded an animal by B. fragilis against E. coli is altered when ferric ammonium citrate is added to the injected mixed culture. In mice an E. coli concentration of 10(9) produced zero survival; the concentration 10(8) produced 40% survival; the concentration 10(7) and less produced 100% survival. Bacteroides fragilis concentrations of 10(8) and less did not kill the 15- to 20-g mouse within 5 days. Mice were given ip injections of the constant amount of 10(8) E. coli and serially diluted amounts of B. fragilis beginning with 10(8) organisms/ml. There was 40% survival in the 10(8) E. coli controls and 96% survival in the animals receiving 10(8) E. coli plus B. fragilis. The addition of ferric ammonium citrate to 10(8) E. coli plus B. fragilis reduced animal survival from 96 to 63%.

Invited Critique: Changing Pattern of Adult Burn Referrals to A Regional Burn Center

How much is too much? If the work load becomes twice what it was before, what are the consequences? It depends on what the work is. Peeling two potatoes instead of one ought not to be overwhelming. Raising twins, as opposed to one child, can be overwhelming—just ask a mother. Using that crude analogy, consider the consequences of doubling your patient load while transforming from a local facility to a regional referral center. That is what happened to Pinderfields General Hospital, Wakefield, U.K., as described in the article Changing Pattern of Adult Burn Referrals to a Regional Burn Center, in this month’s issue. Looking at the total number of patients admitted in a year might make members of burn teams, which routinely admit 350 patients a year, laugh. But think a moment. I admit to putting on a coat when the temperature goes down to 60°F in the summer, when the temperature usually runs around 92° to 93°F, but this is no different than the temperature going from 65° to 35°F. It is all relative. Comparing patient demographics, length of stay, size of injury, and number of admitted patients documents the change and improvement of burn care at a facility that evolved into a regional referral burn center following a policy change in burn care by the national government. The burn center evaluated three 12-month periods separated by 10-year intervals: 1981, 1991, and 2001. The national policy was established in 2000. Before the policy change, Pinderfields experienced an increase in the number of patients admitted between 1981 and 1991. The size of injury and the number of days in the hospital also increased. This is consistent with changing patterns of care in all burn centers. Intensive care units were evolving and there was little concern, at least in the United States, about lengths of stay. The major emphasis was on technology and new methods of care. Between 1991 and 2001, however, it was recognized that with proper outpatient care and support, patients could be discharged earlier than previously thought possible. Wound care, therapy, psychological support, social services, and 24-hour stays for outpatient operations drastically reduced in-hospital stays, and the final results in care were no different. The statistical differences for Pinderfields were greatest in the number of patients treated, a greater number of injuries less than 20% TBSA, decreased hospital stay, and reduced mortality. But more important, their review shows that a small program that is suddenly thrust into a position of being a designated referral center of expertise can respond and rise to the occasion.