Harvey Slater

Influences of different resuscitation regimens on acute early weight gain in extensively burned patients

Dissatisfaction with the massive weight gain that commonly followed crystalloid resuscitation of extensively burned patients dictated the need for a study to determine if acute weight gain could be minimized with an alternative form of resuscitation. Three groups of ten patients each with statistically similar age and burn size (mean BSA 46 per cent) were resuscitated with lactated Ringers solution (LR), hypertonic saline solution (HPT), or fresh frozen plasma (FFP). The volume of infused fluid and the patient weight gain were measured over the first 48 h of treatment. The mean urine output of the three groups was comparable (P greater than 0.05). The volume of infused resuscitation fluid to maintain urine output was a mean of 4.8 ml/kg/per cent BSA in the LR group, 3.16 in the HPT group and 2.68 in the FFP group. The difference in infusion rate between the FFP group and the LR group was statistically significant (P less than 0.01). All patients gained weight with resuscitation. The median percentage weight gain at the end of the first day of treatment was 10.69 per cent in the LR group, 7.88 per cent in the HPT group and 2.38 per cent in the FFP group. Weight gain at the end of the second day of treatment was 13.9 per cent in the LR group, 11.99 per cent in the HPT group, and 4.37 per cent in the FFP group. The differences between FFP, HPT and LR groups were statistically significant (P less than 0.01). In our study the use of fresh frozen plasma for resuscitation of extensively burned patients has been associated with minimal weight gain and minimal oedema. We believe that fresh frozen plasma resuscitation is an attractive alternative to crystalloid infusion and that further comparative studies should be performed.

Antibiotic Prophylaxis in Patients Undergoing Burn Wound Excision

Eleclive excision of burn wound eschar is frequently associated with transient bacteremias that may predispose to episodes of surgically induced sepsis. The need for parenteral administration of prophylactic antibiotics, often used in nonseptic burn patients undergoing early elective burn wound excision, was therefore evaluated. Sixty patients with 4% to 90% total body surface area (TBSA) burn undergoing elective burn wound excision [full- thickness eschareetomies and deep partial-thickness tangential excisions] were stratified on the basis of percent TBSB and divided into treated and untreated groups. Blood cultures were obtained preoperatively, intraoperatively, and postoperatively for temperature elevations greater than 38.5C. A positive intraoperative blood culture associated with a subsequent postoperative septic course was not identified in any patient with a burn of less than 60% TBSA, during either the initial or subsequent surgical procedures. These data show that antibiotic prophylaxis for early elective wound excision in nonseptic burn patients with less than 60% TBSB may be an unnecessary expense.

Helicopter transportation of burn patients

Analysis of 437 consecutive acute burn patients transported to our burn center revealed 339 transported by ground and 98 by helicopter. There were 18 air transport patients from within a 25-mile-radius, and 80 flown further than 25 miles. Mean age was the same in all groups (P>0.05). Percent total body surface area (TBSA) burned was 8.26% in ground transport patients, significantly less than the 20.35% (within 25 miles) and 21.40% (greater than 25 miles) seen in helicopter transports (P<0.0001). Three percent of ground transport patients and 28% of helicopter patients had inhalation injury (P<0.0001). There was no difference in incidence of inhalation injury among helicopter groups (28 vs. 29%, P=0.8). In patients with coexistent inhalation injury, the mean TBSA burned was significantly larger when compared with the TBSA of burns without inhalation injury (P<0.001). Air transported groups contained patients whose status was not critical based upon lack of inhalation injury and small burn size, and who could have been transported by ground. Non clinical factors such as insurance status, desire to keep ground ambulances in their community, and competing helicopter services reluctant to refuse to transport a patient appears to be factors in choosing air ambulance transportation. Regional single helicopter services and regional cooperative ground ambulance services should reduce use of helicopter transport of burn patients when it is not clinically indicated.

Parental correlates of unintentional burn injuries in infancy and early childhood.

The main purpose of this paper is to review parental factors associated with unintentional burns in early childhood. The problem and characteristics of early childhood burns are discussed. Child injury prevention strategies and models are presented. Parental correlates of pediatric injuries in general and specific to burns are reviewed. In conclusion, the authors recommend greater examination of parental variables potentially amenable to treatment, such as psychological functioning, and improved methodology including the use of prospective analyses, multiple methods and informants, and comparison groups. These efforts should enable greater understanding of parental factors related and causal to early childhood burns and, in turn, guide prevention initiatives.

Inhalation injury with burns: A lethal combination

Inhalation injury is known to add significant morbidity and mortality to patients with burns. Estimating the severity of inhalation injury is difficult, as signs of respiratory failure may occur hours or even days after the injury. We have reviewed 86 consecutive patients who were admitted to our Burn/Trauma Center with burns and evidence suggestive of smoke inhalation. Of these patients, 88% required endotracheal intubation. There was a 62% mortality. Admission chest x-rays studies, PAO2, and auscultation of the patients lungs were normal in 90% of the study group. These factors could not be used to predict respiratory failure or death. Patients with as little as 15% total body surface burns with mild smoke inhalation are at significant risk of respiratory failure and the need for ventilatory support.

Burns in Older Patients

An increasing percentage of the burn victims admitted to the Western Pennsylvania Hospital and Burn Care Center are aged 65 or older. Among 108 such elderly patients admitted during the past six years, 68 died and 40 survived—a mortality rate of 63 percent. Those who died of burns (average age 76.4) had burns over 44.8 percent of the mean body surface, whereas the survivors (average age 73.5) had burns over a smaller area (16.7 percent). Survival also was related to the presence of significant heart and lung disease which antedated the thermal injury. Treatment of the burns was in keeping with standard recommendations for intravenous fluid resuscitation, wound care, and skin grafting. Cimetadine and antacids proved effective in the prevention of significant gastrointestinal bleeding. Ninety percent of the survivors returned to their homes after treatment. Although the mortality for elderly burn patients remains high, the favorable results in rehabilitation of the survivors are encouraging. Increased attention should be paid to safety programs for the elderly and those who care for them, to prevent such serious accidental injuries.

Assessing the relationship between locus of control and social competence in pediatric burn survivors attending summer cAMP.

Previous research suggests that children with burn injuries often exhibit psychological and social difficulties. The areas of functioning that are affected most often include level of anxiety, social competence, and self-esteem. Those children having an internal locus of control (LOC) have been shown to react more positively to physical disorders and to have better psychological responding in nonburn populations. The purpose of this study was to determine whether there is a relationship between LOC and social competence in pediatric burn survivors. Participants were children aged 8 to 18 years who had been treated for a burn injury and attended a 1-week summer camp for pediatric burn survivors. Results indicated that the type of LOC was not a predictor of the overall level of social competence, as reported on three different measures of social competence. However, LOC significantly accounted for variability in the childs cooperation level, according to parent report. Other results are discussed, as well as implications for future research and clinical work in this area.