Derek E. Bell

Firefighter Burn Injuries: Predictable Patterns Influenced by Turnout Gear

Approximately 100 firefighters suffer fatal injuries annually and tens of thousands receive nonfatal injuries. Many of these injuries require medical attention and restricted activity but may be preventable. This study was designed to elucidate etiology, circumstances, and patterns of firefighter burn injury so that further prevention strategies can be designed. In particular, modification of protective equipment, or turnout gear, is one potential strategy to prevent burn injury. An Institutional Review Board-approved retrospective review was conducted with records of firefighters treated for burn injury from 2005 to 2009. Data collected included age, gender, TBSA, burn depth, anatomic location, total hospital days per patient, etiology, and circumstances of injury. Circumstances of injury were stratified into the following categories: removal/dislodging of equipment, failure of equipment to protect, training errors, and when excessive external temperatures caused patient sweat to boil under the gear. Over the 4-year period, 20 firefighters were treated for burn injury. Mean age was 38.9 ± 8.9 years and 19 of 20 patients were male. Mean burn size was 1.1 ± 2.7% TBSA. Eighteen patients suffered second-degree burns, while two patients suffered first-degree burns. Mean length of hospitalization was 2.45 days. Scald burns were responsible for injury to 13 firefighters (65%). Flame burns caused injury to four patients (20%). Only three patients received contact burns (15%). The face was the site most commonly burned, representing 29% of injuries. The hand/wrist and ears were the next largest groups, with 23 and 16% of the injuries, respectively. Other areas burned included the neck (10%), arm (6.5%), leg (6.5%), knees (3%), shoulders (3%), and head (3%). Finally, the circumstance of injury was evaluated for each patient. Misuse and noncontiguous areas of protective equipment accounted for 14 of the 20 injuries (70%). These burns were caused when hot steam/liquid entered the gear via gaps in the sleeve or face mask. Three patients (15%) received injury due to removal/dislodging of their safety equipment, two patients (10%) suffered their injuries during training exercises when they were not wearing their safety equipment, and the final patient (5%) received burns due to sweat evaporation. Firefighter burn injuries occur to predictable anatomic sites with common injury patterns. Modification and optimization of gear to eliminate gaps that allow steam/hot liquid entry may decrease burn injury. Improving education regarding the use of protective equipment may also be beneficial.

Vacuum-Assisted Closure Device as a Split-Thickness Skin Graft Bolster in the Burn Population

The vacuum-assisted closure device (VAC) is associated with improved wound healing outcomes. Its use as a bolster device to secure a split-thickness skin graft has been previously demonstrated; however, there is little published evidence demonstrating its benefits specifically in the burn population. With use of the VAC becoming more commonplace, its effect on skin graft take and overall time to healing in burn patients deserves further investigation. Retrospective review of burn registry database at a high-volume level I trauma center and regional burn center during a 16-month period was performed. Patients who had a third-degree burn injury requiring a split-thickness skin graft and who received a VAC bolster were included. Data points included age, sex, burn mechanism, burn location, grafted area in square centimeters, need for repeat grafting, percent graft take, and time to complete reepithelialization. Sixty-seven patients were included in the study with a total of 88 skin graft sites secured with a VAC. Age ranged from <1 year to 84 years (average 41 years). The average grafted area was 367 ± 545 cm2. The three most common were the leg, thigh, and arm (28, 15, and 12%, respectively). Average percent graft take was 99.5 ± 1.5%. Notably, no patients returned to the operating room for repeat grafting. The average time to complete reepithelialization was 16 ± 7 days. The VAC is a highly reliable and reproducible method to bolster a split-thickness skin graft in the burn population. The observed rate of zero returns to the operating room for repeat grafting was especially encouraging. Its ability to conform to contours of the body and cover large surface areas makes it especially useful in securing a graft. This method of bolstering results in decreased repeat grafting and minimal graft loss, thus decreasing morbidity compared with conventional bolster dressings.

Prevention of Hypophosphatemia After Burn Injury With a Protocol for Continuous, Preemptive Repletion

Severe burn injury has been shown to result in hypophosphatemia. Hypophosphatemia can cause cardiac, hematologic, immunologic, and neuromuscular dysfunction. This study compares serum phosphate levels and outcomes in patients who were administered a continuous, preemptive phosphate repletion protocol vs those who only received phosphate supplementation after they developed hypophosphatemia. Records of patients with greater than 19% TBSA burn admitted to the intensive care unit from 2006 to 2010 were reviewed. Patients were divided into two groups: historical controls who received responsive repletion when serum phosphate levels were less than 2.5 mg/dl (2006–2008) and the experimental group that received 30 mmol intravenous every 6 hours starting at approximately 24 hours after injury as long as serum phosphate levels were less than 4 mg/dl (2008–2010). Patients with chronic kidney disease or acute kidney injury were excluded. Data collected included age, weight, burn size, age, all serum phosphate levels, and total amount of phosphate administered. Differences in groups were compared with Mann–Whitney U test and Fisher’s exact test. A total of 30 patients were included in the study, 20 in the responsive repletion group and 10 in the continuous repletion group. No significant difference was detected in age, sex, burn size, or full thickness burn size between groups. The continuous group had a statistically lower percentage of hypophosphatemic lab values compared with the responsive group, 13 ± 14% vs 45 ± 21% (P < .0001). No difference was found in percent of observations reflecting hyperphosphatemia (median of 2% in each group, P = .7). Four patients in the continuous group suffered cardiac and/or infectious complications compared with 16 in the responsive group (P = .04). Continuous, pre-emptive repletion of phosphate prevents hypophosphatemia after severe burn injury when compared with responsive repletion in historical controls. The protocol resulted in less hypophosphatemia without increasing the risk of hyperphosphatemia. This study also suggests that continuous repletion may result in fewer complications, but this needs to be confirmed in larger, prospective studies.

A rare case of a superior lumbar hernia secondary to penetrating injury

Lumbar hernias are rare occurrences, with only 300 cases reported in the literature. We present a unique case of a superior lumbar hernia secondary to penetrating trauma to the right flank. We performed a herniorrhaphy using porcine mesh, and provided additional support by mobilizing the external oblique and latissimus dorsi into the defect. At follow up three months after repair, the patient was asymptomatic and exam revealed an intact lumbar abdominal wall with normal contour. Although literature displays a consensus on the need for lumbar hernia repair, specific repair techniques must be tailored to defect etiology, size, location, and contents.

Jewelry ring-associated electrothermal burn injuries: a nine-patient case series

Ring-associated burns are infrequent, comprising only a small fraction of burn consults and admissions. However, because of the location of these burns and the propensity for circumferential wounds, small burn size may belie the severity of resultant injuries. Herein, the authors present their experience with this potentially severe type of burn. Records from a regional burn center were retrospectively analyzed during a 36-month period. All patients who sustained ring burns were included. Data points included demographics, burn location, need for surgical intervention, grafted area, hospital days (length of stay), percent graft take, complications, and time to re-epithelialization. Nine patients sustained ring-associated burns during the study period, accounting for 1.4% of all patients with burns seen during the same period. Average age was 41 years (range: 29–52 years). Seven (77%) ring-associated burns involved contact with a battery. All injuries were circumferential. Average burn TBSA was 0.07%. Two patients (22%) had third-degree injuries, both of which received split-thickness skin grafts. Grafted area was 4 and 5 cm2, respectively. Average length of stay was 2.8 days. Mean graft take was 99.5 ± 1.5%. Average time to complete re-epithelialization was 12 days. One patient suffered temporary disability. No patients suffered from compartment syndrome. Ring-associated burns are an uncommon source of injury in the burn population. Despite small burn TBSA, these patients are more likely to require split-thickness skin grafts and suffer dysfunction compared with similarly-sized burns in other body regions. Expedient treatment and coordination with occupational therapy should be undertaken to achieve optimal outcomes.

Epidemiology and Outcomes of Auricular Burn Injuries

Auricular burns represent a unique type of injury. The acute management and clinical course of these injuries can be different from other facial burns. There is a paucity of literature pertaining to the epidemiology and acute management of auricular burns. Most studies focus on deformity reconstruction. The aim of this study was to characterize the epidemiology, treatment, and outcomes of auricular burns. Data from all patients presenting to a regional burn center in a 4-year period were reviewed and those with auricular burns were identified. Demographic data, burn mechanism, insurance status, method of treatment, need for skin grafting, percentage graft-take, time to reepithelialization and incidence of deformity were reviewed. During the study period, 593 facial burns were evaluated and 132 (22%) sustained burns to the auricle. The most common mechanisms of injury were flame (65.1%) and scalding (22.5%). Auricular burns were mostly second degree (88%), involved both ears in 44%, and involved only the ventral aspect of the ear in 57%. The majority of patients healed well with conservative management; none suffered from chondritis. Of the 89 patients followed to healing, 1 patient (1.1%) received full-thickness skin grafts to the auricle, resulting in excellent graft-take. All other patients were managed nonoperatively, and none suffered from ear deformities. Auricular burns occur with surprising frequency in patients presenting to burn centers. Careful acute management of these injuries can eliminate development of chondritis and minimize the rate of deformity and need for reconstruction. The majority of wounds heal with conservative management, but time to reepithelialization can be prolonged.

Use of a home vacuum-assisted closure device in the burn population is both cost-effective and efficacious

INTRODUCTION The vacuum assisted closure device (VAC) improves wound-healing when utilized as a bolster to secure split thickness skin grafts (STSG). Patients typically remain hospitalized for VAC therapy; however, home VACs (hVAC) are now available. Limited studies examine burns treated with hVAC as a STSG bolster. METHOD A retrospective study of records from an ABA verified regional burn center was conducted over 23 months. Patients included STSGs for burn. Data points included demographics, burn mechanism and location, graft characteristics, hospital length of stay (LOS), and time to heal. RESULTS AND DISCUSSION Fifty patients were included, with average age of 39 years (range <1-83years). Average burn TBSA was 1.27±1.42 (range 0.05-8.18). Grafted area average was 102.9±128.1cm2. The most commonly treated areas were the leg/foot, thigh, and torso (53%, 16%, and 16%, respectively). Average LOS was 1.1±1.2 days. Mean graft-take was 99.2±2.8% with one patient undergoing repeat STSG. Average post-operative time to heal was 16±6 days. A 5-day inpatient stay with a VAC costs an average of

Outpatient burn data: An untapped resource

34,635, compared to

512 Delusional Parasitosis: An Unusual yet Dangerous Diagnosis in Self-Inflicted Burn Injury

9134 for an hVAC over the same period. CONCLUSIONS The hVAC is a cost-effective STSG bolster in the burn population for appropriate candidates. Excellent graft-take and low morbidity rates imply that this is an efficacious alternative for STSG bolster.