Duncan Nickerson

SCORTEN accurately predicts mortality among toxic epidermal necrolysis patients treated in a burn center.

SCORTEN is a scoring system used to predict mortality in toxic epidermal necrolysis (TEN) patients. The accuracy of SCORTEN among TEN patients treated in burn centers has not been established. The purpose of this study was to assess the discriminative power and calibration of SCORTEN among TEN patients treated at an adult regional burn center. Retrospective analysis of a consecutive series of TEN patients was used to compare actual mortality with that predicted by SCORTEN. A standardized mortality ratio was obtained to compare the actual number of deaths to the predicted number based on SCORTEN. Discrimination was measured using the area under the receiver operator characteristic curve, and model fit (calibration) was measured using the Hosmer-Lemeshow goodness-of-fit statistic. A total of 61 adult patients were analyzed. The actual overall mortality rate of 29.5% was not significantly different than the mortality rate of 25.2% predicted by SCORTEN (standardized mortality ratio, 1.17; 95% confidence intervals, 0.695–1.853; P = .08). The area under the receiver operator characteristic curve was 0.82 and the Hosmer-Lemeshow statistic was 1.381 (P = .710). SCORTEN is an accurate scoring system for estimation of mortality among TEN patients treated in a burn center setting.

Survey on current hydrotherapy use among North American burn centers.

The authors have reviewed hydrotherapy practices in North American burn centers and described the epidemiology of hydrotherapy-associated nosocomial infections. A web-based survey was distributed to the directors of all burn care facilities listed by the American Burn Association. Questions addressed aspects of practice, including the method, additives, disposable liners, decontamination practices, nosocomial pathogens, and perceptions regarding the “ideal” method of hydrotherapy. The response rate was 44%, 59 of 142 centers, or 827 of 1900 beds. Hydrotherapy is regularly used by 83% of centers. Among these centers, 10% use exclusively immersion hydrotherapy (IH), 54% use exclusively shower cart hydrotherapy (SCH), and 35% use a combination of IH and SCH. Disposable liners are used at 80% of centers. Tap water alone is used by 51% of centers, 27% add detergent, 16% chlorhexidine, and 7% povidone-iodine. The majority of centers (57%) do not routinely culture their hydrotherapy equipment, 20% culture weekly, 7% monthly, and 17% less than once per month. Directors believe that Pseudomonas aeruginosa, methicillin-sensitive Staphylococcus aureus, and methicillin-resistant S. aureus are the most common nosocomial pathogens, followed by Acinetobacter species and Candida albicans. The relative frequency of occurrence of the first three pathogens did not vary with regard to the hydrotherapy method used. Given the opportunity to redesign, 45% of burn unit directors would implement SCH only, 42% a combination of SCH and IH, 2% exclusively IH, and 11% no hydrotherapy or bedside irrigation only. The prevalence of hydrotherapy use at North American burn centers has decreased since 1990 (83% vs 95%), yet continues to be used at the majority of centers. The use of IH has also declined (55% vs 81%). The trend away from the exclusive use of IH will likely continue, because more centers incorporate showering methods.

Use of cyanide antidotes in burn patients with suspected inhalation injuries in North America: A cross-sectional survey

This study aimed to assess the use of cyanide antidotes and the determine the opinion on empiric administration of hydroxocobalamin in North American burn patients with suspected smoke inhalation injuries. An online cross-sectional survey was sent to directors of 90 major burn centers in North America, which were listed on the American Burn Association Web site. A multiple-choice format was used to determine the percentage of patients tested for cyanide poisoning on admission, the current administration of a cyanide antidote based solely on clinical suspicion of poisoning, and the antidote used. To ascertain views on immediate administration of hydroxocobalamin before confirmation of cyanide poisoning an option was included to expand the response in written format. Twenty-nine of 90 burn directors (32%) completed the survey. For the population of interest, the majority of burn centers (59%) do not test for cyanide poisoning on admission and do not administer an antidote based solely on clinical suspicion of cyanide poisoning (58%). The most commonly available antidote is hydroxocobalamin (50%), followed by the cyanide antidote kit (29%). The opinion regarding instant administration of hydroxocobalamin when inhalation injury is suspected is mixed: 31% support its empiric use, 17% do not, and the remaining 52% have varying degrees of confidence in its utility. In North America, most patients burnt in closed-space fires with inhalation injuries are neither tested for cyanide poisoning in a timely manner nor empirically treated with a cyanide antidote. Although studies have shown the safety and efficacy of empiric and immediate administration of hydroxocobalamin, most centers are not willing to do so.

Treating pain on skin graft donor sites: Review and clinical recommendations

ABSTRACT Split-thickness skin grafting is the most common reconstructive procedure in managing burn injuries. Harvesting split-thickness skin creates a new partial thickness wound referred to as the donor site. Pain at the donor site is reported to be one of the most distressing symptoms during the early postoperative period. Here, we (a) identify strategies for managing donor site pain, (b) assess the quality of individual studies, and (c) formulate evidence-based recommendations based on the amount and consistency of evidence. Our analysis revealed five distinct approaches to minimize donor site pain. These include: continuous subcutaneous local anesthetic infusion (three studies), subcutaneous anesthetic injection (five studies), topical agents (six studies), nonpharmacological interventions (three studies), and wound dressings (18 studies). Available randomized control trials typically evaluated pain on standardized scales (i.e. Visual Analog Scale, Numerical Rating Scale), and compared the experimental group with standard care. Recommended treatments include: (a) subcutaneous anesthetic injection of adrenaline-lidocaine; (b) ice application; (c) topical agents, such as lidocaine and bupivacaine; and (d) hydrocolloid- and polyurethane-based wound dressings accompanied with fibrin sealant. Methodologically sound randomized control trials examining the efficacy of modified tumescent solution, ropivacaine, plasma therapy, noncontact ultrasound, and morphine gels are lacking and should be a priority for future research.

Trends in postcoronary artery bypass graft sternal wound dehiscence in a provincial population.

BACKGROUND It appears that the medical profile of patients undergoing coronary artery bypass graft (CABG) surgery has changed. The impact of this demographic shift on CABG outcomes, such as sternal wound dehiscence, is unclear. OBJECTIVES To quantify the incidence and trends of sternal wound dehiscence, quantify the demographic shift of those undergoing CABG and identify patient factors predictive of disease. METHODS A prospective analysis was performed on a historical cohort of consecutive patients who underwent CABG (without valve replacement) in Alberta between April 1, 2002 and November 30, 2009. The incidence and trends of sternal wound dehiscence were determined. In addition, the trend of the mean Charlson index score and European System for Cardiac Operative Risk Evaluation (EuroSCORE) (capturing patient comorbidities) was analyzed. Univariable analysis and multivariable models were performed to determine factors predictive of wound dehiscence. RESULTS A total of 5815 patients underwent CABG during the study period. The incidence proportion of sternal wound dehiscence in Alberta was 1.86% and the incidence rate was 1.98 cases per 100 person-years. Although both the EuroSCORE and Charlson scores significantly increased over the study period, the incidence of sternal wound dehiscence did not change significantly. Factors predictive of sternal wound dehiscence were diabetes (OR 2.97 [95% CI 1.73 to 5.10]), obesity (OR 1.55 [95% CI 1.05 to 2.27]) and female sex (OR 1.90 [95% CI 1.26 to 2.87]). CONCLUSIONS The incidence proportion of sternal wound dehiscence in Alberta was comparable with the incidence previously published in the literature. While patients undergoing CABG had worsening medical profiles, the incidence of sternal wound dehiscence did not appear to be increasing significantly.

A Review of Perforator Flaps for Burn Scar Contractures of Joints

Objective: Perforator flaps are one possible surgical treatment for burn scar contractures; however, a review of evidence on this topic is lacking. Methods: MEDLINE was searched for articles related to perforator flaps for burn contractures. Following title and abstract screen, full texts were searched to identify articles describing perforator flaps for burn scar joint contractures. Data were extracted and summarized descriptively. Only articles that contained ≥10 patients with burn scar contracture were considered. Results: Two hundred forty-eight articles were identified, of which 17 met criteria for review. Of these, 16 were low-quality case series, while 1 was an open randomized controlled trial. In total, perforator flaps were performed on 339 patients (age range: 3-75 years), with the most common contracture locations being cervical (n = 218) and knee (n = 41). Nine of the 17 articles described a rehabilitation strategy. In general, functional outcomes were excellent, with the majority of patients experiencing return of normal joint range of motion and no recontracture. Compared to full-thickness skin grafts, perforator flaps showed greater improvements in joint range of motion. Cosmetically, perforator flaps were shown to have good color match with surrounding tissue, good contour around anatomical landmarks, and improved overall patient appearance. The most common complications were marginal flap necrosis (n = 26 patients) and venous congestion (n = 17 patients). Conclusions: Preliminary evidence from low-quality case series and 1 high-quality trial suggests perforator flaps may be successful for resurfacing released burn scar contractures; however, there is a need for additional trials comparing perforator flaps to other approaches.

Burns from illegal cannabis oil manufacturing: a case series

BACKGROUND The increasing consideration of cannabis legalization in Canada and the United States has motivated physicians to assess its prospective impact on the health care system. Health care providers in the burns community are concerned about injuries sustained as a result of the illegal manufacturing of cannabis oil because it involves highly flammable reagents. METHODS We report a retrospective case series of patients with cannabis oil burns (identified by evidence of combustion during cannabis oil manufacturing) treated from April 2012 to March 2014 at the Foothills Medical Centre in Calgary, Alberta, Canada. We compare the characteristics of these patients with those of patients admitted over the same period with any burns. RESULTS We found that 12 (out of 161 patients) admitted over the review period sustained burns from cannabis oil manufacturing. Compared with patients in the total burn group, patients with cannabis oil burns were younger (75% and 48% were younger than 41 years in the group with cannabis oil burns and the total burn group, respectively), were more likely to be male (83% in the group with cannabis oil burns v. 74% in the total burn group) and sustained burns over a larger percentage of their total body surface area (24% v. 9%). Patients with cannabis oil burns also required extensive surgical management (skin grafting in 75% of cases) and spent a substantial amount of time (mean 32 d) in the burn unit. INTERPRETATION Burns from illegal cannabis oil manufacturing are large, require extensive management and involve younger patients than burns in general. Given that the frequency of cannabis oil burns may increase in Canada after legalization, Canadian burn centres are encouraged to monitor and report on cases with this injury mechanism.

Burn clinical trials: A systematic review of registration and publications

BACKGROUND Randomized controlled clinical trials (CTs) are gold standard tools for assessing interventions. Although burn CTs have improved care, their status, publication frequency, and publication quality are not known. OBJECTIVES (1) Characterize burn CTs by analyzing location, completion status, temporal trend, and funding sources. (2) Assess quality of trial reporting. DATA SOURCES CT records were obtained from ClinicalTrials.gov and WHOs CT Registry (searched May 2017). Publications were obtained from PubMed, Google Scholar, OVID MEDLINE, and ClinicalTrials.gov (searched June 2017). PUBLICATION APPRAISAL 23-item rubric adapted from CONSORT and ICH E3 guidelines. RESULTS 738 burn CTs were identified globally, of which majority were publically-funded (77%), ongoing (52%), and assessed behavioral, pharmacological, device-based, dietary-based, and biological/procedural interventions. Amongst the ended trials, 69 (28%) published their findings. Significantly fewer industry-funded trials published findings (14% vs 33% publically-funded). Quality of reporting was suboptimal, and most underreported categories were trial phase, severity, and sample size estimation. LIMITATIONS Incomplete, outdated, and non-registered CTs which are difficult to track. CONCLUSIONS Burn trials are proliferating in number, location, and interventions assessed. Only a small proportion are published and quality of reporting is suboptimal. IMPLICATIONS OF KEY FINDINGS Burn researchers should aim to register and report on all clinical trials regardless of outcome. Superior a priori design can reduce precocious termination and mandatory reporting of data fields can improve quality of reporting. Systematic review registration number: CRD42017068549.

Mesenteric ischemia, intra-abdominal hypertension, and the abdominal compartment syndrome.

In the Winter 2015 issue of Plastic Surgery, Sun et al (1), in their report “Ischemic bowel as a late sequela of abdominal compartment syndrome secondary to severe burn injury”, reported a case of a presumably ischemic complication likely attributable to multiple episodes of the secondary and recurrent abdominal compartment syndrome (ACS) in a young child. This report and the author’s discussion is an important and timely addition to the admittedly sparse literature concerning mesenteric ischemia, intra-abdominal hypertension (IAH) and ACS, particularly in the burn population, raising many points that warrant further consideration and potentially directing future research efforts. As the authors explain, it has long been assumed that mesenteric ischemia is a critical concern with pathologically raised intraabdominal pressure, one that facilitates bacterial translocation and exacerbates the biomediator burden driving multisystem organ failure (2). In animals, even low levels of IAH have been shown to greatly diminish mucosal perfusion, disrupt the gut mucosa, alter the protein expression of tight junctions, increase the mucosal permeability and to drive endotoxin systematically (3-5). This appears to be a compelling argument, except that it remains to be proven in humans. The best data remains the experience of Ivatury et al (6), who found that after severe penetrating abdominal trauma, the majority of those with severe grade III IAH (>25 mmHg), had acidotic gut mucosal pHi (7.10±0.2) even without exhibiting the classic signs of overt ACS. In those selected for decompression, the pHi subsequently improved and none developed ACS. Two patients who had no sustained response in pHi and IAH after abdominal decompression progressed to manifest ACS and multiple organ dysfunction syndrome, and subsequently died. Overall, multiple organ dysfunction syndrome points and death were greater in those with IAH than those without. In the case presented by Sun et al (1), it is noteworthy that the sequelae of the likely ischemic small bowel injury became apparent long after the presumed ischemic injury. This may have related to subclinical mucosal injury that healed with scar and no full-thickness perforation. Mohan et al (7) described that, in a porcine model in which postoperative IAH was induced and then relieved, there was small bowel but not large bowel necrosis. Clearly, however, more study is required to understand the full implications for therapy. As the authors also point out, however, although the gut is assumed to be central to IAH/ACS, better human data simply are not available. Many authors share this view and, as such, the terms ‘acute bowel injury’ and ‘acute intestinal distress syndrome’ have been coined (8). The delayed appreciation of these gut-related events may relate to the dramatic clinical events of the overt ACS, with respiratory, cardiovascular and renal failure being obvious and dominating the clinical picture. These overt cases, however, are becoming significantly fewer in contemporary trauma/critical care, attributed largely to radical changes in resuscitation strategies that emphasize restricted crystalloid balanced blood and plasma-based strategies (9,10). This remarkable success in nearly eradicating the ACS has prompted the former World Society of the Abdominal Compartment Syndrome to rebrand as the World Society of the Abdominal Compartment, emphasizing a new emphasis on trying to understand the more complicated role of IAH in critical illness/injury, and to focus on the study and care of the entire abdominal compartment rather than a single syndrome. Thus, any data and discussion of the more subtle aspects of IAH, such as its role in gut disorders, are greatly encouraged. Regardless of the name of the professional society, or institution, there remains tremendous work still to be done in understanding IAH/ ACS in both burns and the pediatric patient. In this particular case report, the child underwent standard resuscitation with crystalloid fluid. There is suggestive nonrandomized evidence that hypertonic fluids may reduce the risk for secondary ACS with lower fluid load in burn shock patients (11). However, more study is needed because large-volume crystalloid resuscitation remains the most common approach to fluid resuscitation of burn shock. Judiciousness is essential, because modern burn resuscitation frequently grossly exceeds volumes predicted by the Parkland formula (12,13), and other formulas. Thus, it may not be surprising that it remains accepted – if not expected – that nearly all patients with large burns (>60% to 70% body surface area), especially with smoke inhalation, will develop severe IAH/ACS (12,14,15). Given this expected risk, we believe it is mandatory, not elective, to measure IAP in all severe burns, regardless of the physical examination of the abdomen, because clinical examination has proven inaccurate (16,17). Another important point to emphasize is that the patient in question was clearly a young child, in whom the standard ranges for IAH/ ACS based on adult populations are not applicable. The recent guidelines from the Abdominal Compartment Society state that ACS in children is defined as a sustained elevation in IAP >10 mmHg associated with new or worsening organ dysfunction that can be attributed to elevated IAP (18). Thus, this child’s ACS was of longer duration and severity than may have been appreciated. It is unstated whether IAPs were measured to document resolution of the first episode of secondary ACS, although there was clear resolution and return to normal IAP after the use of percutaneous drainage for the two subsequent episodes of recurrent ACS. If medical IAH/ACS management techniques fail to resolve IAH/ACS, it is absolutely recommended to proceed to percutaneous drainage therapies because this may often be quite effective (15,18). The abdominal compliance will typically be a steep part of the pressure/volume curve such that small reductions in volume yield marked improvements in pressure (19). However, vigilance must be maintained such that after successful treatment of IAH, satisfactory levels of IAP are maintained at all times in the management of the critically ill/injured, which simply means measuring IAP levels in patients at risk (20). Another admonition, however, is that we would suggest that bedside ultrasound can greatly increase the safety and effectiveness of percutaneous drainage and we would assume all clinicians caring for the critically ill should be familiar with these techniques. It will never be known whether the eventual stricture causing the small bowel obstruction was related to a potential injury at blind paracentesis, a criticism that can now be completely mitigated by using real-time ultrasound guidance (21). editorial

Burn Progression Secondary to Cardioversion

Severe burns result in a profound hypermetabolic response. Catecholaminergic surges secondary to the burn injury itself, particularly if superimposed on premorbid cardiac disease, can result in cardiac arrhythmias. If unstable, these cardiac rhythm disturbances necessitate immediate cardioversion to regain normal sinus rhythm. Because of the high impedance at the skin-paddle interface, superficial cutaneous burns have been known to develop secondary to cardioversion. The authors describe a novel case of the subsequent local progression of a previously sustained superficial flame burn to full-thickness burn injury after cardioversion.