David H. Ahrenholz

American Burn Association consensus conference to define sepsis and infection in burns.

Because of their extensive wounds, burn patients are chronically exposed to inflammatory mediators. Thus, burn patients, by definition, already have “systemic inflammatory response syndrome.” Current definitions for sepsis and infection have many criteria (fever, tachycardia, tachypnea, leukocytosis) that are routinely found in patients with extensive burns, making these current definitions less applicable to the burn population. Experts in burn care and research, all members of the American Burn Association, were asked to review the literature and prepare a potential definition on one topic related to sepsis or infection in burn patients. On January 20, 2007, the participants met in Tucson, Arizona to develop consensus for these definitions. After review of the definitions, a summary of the proceedings was prepared. The goal of the consensus conference was to develop and publish standardized definitions for sepsis and infection-related diagnoses in the burn population. Standardized definitions will improve the capability of performing more meaningful multicenter trials among burn centers.

Burns from hot oil and grease: a public health hazard

We examined the incidence, etiology, and morbidity of burns due to hot oil and grease. Over a 10-year period from 1976 to 1985, of 1818 patients hospitalized for burns, 85 (4.7%) injuries were due to hot grease or oil. The mean age was 20 years; 34% of patients were less than 8 years old. The mean total body surface areas of second- and third-degree burns was 11.5% (range 0.5% to 40%), and the average length of hospital stay was 19.6 days. Fifty-eight percent of patients required split-thickness skin grafting (n = 49), three required intubation, and one required tracheostomy. Seventy-eight percent of oil burns occurred in the home. The most common circumstances consisted of children who grabbed the handle or electric cord of a frying pan and pulled the hot oil down onto themselves. (Nineteen of the 29 children were less than 8 years old (66%).) Burns due to cooking oil and grease are associated with considerable morbidity. The high boiling point, high viscosity, and potential combustibility of oil increase the potential soft-tissue damage when compared with typical scald injuries from hot water. The dangers of children pulling on the appliance, the dangers of transporting hot oil, the importance of supervision while children are cooking, and the importance of knowledge of the management of grease fires is stressed. Public education is needed to underline the potential seriousness of these burns.

Serum zinc response in thermal injury.

Zinc is an essential trace element required for RNA and DNA synthesis and the function of over 200 zinc metalloenzymes. After surgery or trauma, the serum zinc concentration usually decreases. The magnitude and duration of this hypozincemia after thermal injury are unclear, as are mechanisms for this hypozincemia. In this study we evaluated, over the duration of their hospital course, serum zinc concentrations in 23 thermal injury patients. The initial mean serum zinc concentration was significantly depressed (42 +/- micrograms/dl; normal 66-110 micrograms/dl). By the second week of hospitalization, serum zinc concentrations gradually increased into the normal range in the majority of patients. Mechanisms for this hypozincemia were evaluated. Decreases in the serum zinc concentration did not correlate with increased urinary zinc excretion; thus increased urinary zinc excretion was an unlikely mechanism for the observed hypozincemia. Values for albumin, the major zinc binding protein in serum, generally were inversely correlated with the serum zinc concentration. Thus, hypoalbuminemia could not explain the decreased serum zinc concentration. Certain cytokines such as interleukin-1 are known to cause a decrease in the serum zinc concentration as part of the acute phase response. Therefore, we measured serum C reactive protein concentrations as an indicator of the acute phase response. Thermally injured patients initially had markedly elevated C-reactive protein levels which gradually decreased during hospitalization. We suggest that the initial hypozincemia observed in thermally injured patients may be a reflection of interleukin-1 mediated acute phase response. Whether one should vigorously attempt to correct this initial marked hypozincemia requires further investigation.

The evolution of resource utilization in regional burn centers.

Regional burn centers provide unique multidisciplinary care that has been associated with dramatically improved outcomes for burn victims. Patients with complex skin and soft tissue injuries are increasingly admitted to these centers for definitive care. This study was designed to assess current trends in burn center resource utilization. Members of the Multicenter Trials Group of American Burn Association were invited to participate in this retrospective review of all patients admitted to their respective regional burn centers during a 10-year period. Collected data included admission diagnosis, demographics, length of stay (LOS), hospital charges, and mortality. Five regional academic burn centers participated. They collectively admitted 18,246 patients during the study period, of whom 15,219 (83.4%) had a primary burn diagnosis and 3027 (16.6%) were patients with nonburn diagnoses. During this period, annual admissions for the five centers increased by 34.7%, ranging from 19 to 83% for individual centers. Simultaneously, mean burn size decreased from 12.3 to 8.8% TBSA. From 1998 to 2006, admissions for nonburn diagnoses increased by 244.9%, whereas burn admissions increased by 31.1%. Although mean LOS was reduced by >25%, total charges for all patients increased by 37.7% after adjustment for inflation. Nonburn patients had significantly higher mean age, longer LOS, greater mortality, and higher daily charges. This review of admissions to five academic burn centers reveals that these centers are treating more patients with smaller burns and an increasing number of complex nonburn conditions. Nonburn patients represent an older and more debilitated population that consumes disproportionately more resources than burn patients. These data show a dramatic shift in burn center resource utilization and the concurrent evolution of regional burn centers into centers for the care of complex wounds.

Pulmonary failure in geriatric patients with burns: the need for a diagnosis-related group modifier.

One hundred eleven patients with burns who were age 60 years or older were treated from January 1984 through December 1992. Twenty-nine patients had pulmonary failure defined as 7 or more days of ventilatory support from the day of burn. The mortality rate for these patients was 41%; only four were discharged to home. The mortality rate for patients without pulmonary failure was 11%. Billing information was analyzed for 102 of the 111 patients. Charges for patients without pulmonary failure were two to three times greater than reimbursement. Charges for patients with pulmonary failure were 4 to 14 times greater than reimbursement. Reimbursement for elderly patients with burns is inadequate. Altering the Diagnosis-Related Group (DRG) definition of extensive burn to reflect the severity of injury in the geriatric population is one step toward reimbursement reform. Patients who require 7 or more days of ventilatory support after burn injury should be reimbursed under a separate DRG category or should have a DRG modifier.

Paraquat poisoning in a burn patient

Paraquat is a bipyridyl compound widely used as a contact herbicide. Since its introduction in 1962, hundreds of deaths have occurred, usually after suicidal or accidental ingestion. Death after dermal absorption of paraquat is uncommon, but has occurred after either contact with undiluted paraquat, disruption of skin integrity, or prolonged exposure. It is the purpose of this case report to describe a patient who had fatal dermal paraquat absorption after a crop-dusting accident in which he sustained 37% TBSA burns. After 9.5 hours of cutaneous exposure, a paraquat level of 0.169 mg/ml was obtained at 20 hours, the standard lethal dose at 16 hours being 0.16 mg/ml. In light of the apparently irreversible pathophysiology of paraquat poisoning with plasma levels as low as 3 mg/L, prevention and early intervention are the best treatments. Our patient may have survived an otherwise routine thermal injury had his wounds been aggressively irrigated in the field.

Scalping Injuries: New Technique for Stabilization of Flaps to the Skull

Extensive scalping injuries offer a unique challenge for tissue coverage because of the wide expanse of bone and lack of deep soft tissue or significant perforating vessels. For smaller injuries, pedicle flaps offer ideal coverage. Larger defects can be covered by omental flaps. Coverage with a free muscle flap followed by split-thickness skin grafting offers optimal long-term coverage. Two new techniques are introduced. The wire-button technique offers stabilization, and the halo frame provides good support and protection for a new free-flap graft and may increase the success rate of flaps in patients with scalping injuries.

Halo immobilization in the treatment of burns to the head, face, and neck.

The care of burns to the head, face, and neck remains a challenge to the clinician. From 1978 to 1986, halo traction was used as an immobilizing device and as a protective frame for 31 patients with burns to the head (n = 8), face (n = 24), and neck (n = 28). The patients ranged in age from 8 months to 80 years (mean = 16 years) and had second- and third-degree burns covering a total body surface area of 8% to 75% (mean = 28%). The halo was used for an average of eight days (range one to 19 days) and served to immobilize and protect areas of fresh skin grafts, as well as to elevate and protect scalp donor sites (n = 10). Traction was initially used in patients who were confused and uncooperative, and in patients whose burns involved the neck to provide extension for prophylaxis against contractures. Treatment side effects included intermittent headache and backache, the latter occurring especially in the patients subjected to hyperextension. Eight patients (26%) complained of discomfort, which was reduced with adequate analgesia, sedation, and emotional support. The halo had to be removed from one patient after one day because of a loose pin, and in another patient after eight days because of the development of cellulitis at a pin site. Halo immobilization was used successfully to minimize graft loss in 30 of 31 patients.

Primary closure of wounds in burned tissue: Experimental and clinical study

Penetrating wounds in burn tissue may become infected, therefore primary closure of such wounds has only been recommended for lacerations of the face. To determine if wounds in burned areas can be closed primarily if seen early, we created partial- or full-thickness thermal burns in guinea pigs (n = 54) and made incisions through the burned tissue. One side was closed primarily at variable time intervals postburn. Infectious complications were determined by observation and the quantitative bacterial smear technique. All wounds closed primarily at 24 hours or longer postburn became infected. Wounds closed primarily at 4 hours postburn had fewer infectious complications than wounds left open (p less than 0.05). We also reviewed our experience with 23 multiply injured burn patients over an 11-year period who had peritoneal lavage or exploratory laparotomy. There were no wound infections in 12 patients with incisions closed primarily in unburned areas or in 11 patients with wounds through burned tissue. We conclude that lacerations or surgical incisions in burned tissues seen early (less than 12 hrs) postburn should be treated as wounds in unburned patients. Wounds in burned tissue seen late (greater than 24 hrs) postburn should be considered contaminated.