James C. Jeng

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.

The Advanced Health and Disaster Aid Network: A Light-Weight Wireless Medical System for Triage

Advances in semiconductor technology have resulted in the creation of miniature medical embedded systems that can wirelessly monitor the vital signs of patients. These lightweight medical systems can aid providers in large disasters who become overwhelmed with the large number of patients, limited resources, and insufficient information. In a mass casualty incident, small embedded medical systems facilitate patient care, resource allocation, and real-time communication in the advanced health and disaster aid network (AID-N). We present the design of electronic triage tags on lightweight, embedded systems with limited memory and computational power. These electronic triage tags use noninvasive, biomedical sensors (pulse oximeter, electrocardiogram, and blood pressure cuff) to continuously monitor the vital signs of a patient and deliver pertinent information to first responders. This electronic triage system facilitates the seamless collection and dissemination of data from the incident site to key members of the distributed emergency response community. The real-time collection of data through a mesh network in a mass casualty drill was shown to approximately triple the number of times patients that were triaged compared with the traditional paper triage system.

Wireless Medical Sensor Networks in Emergency Response: Implementation and Pilot Results

This project demonstrates the feasibility of using cost- effective, flexible, and scalable sensor networks to address critical bottlenecks of the emergency response process. For years, emergency medical service providers conducted patient care by manually measuring vital signs, documenting assessments on paper, and communicating over handheld radios. When disasters occurred, the large numbers of casualties quickly and easily overwhelmed the responders. Collaboration with EMS and hospitals in the Baltimore Washington Metropolitan region prompted us to develop miTag (medical information tag), a cost- effective wireless sensor platform that automatically track patients throughout each step of the disaster response process, from disaster scenes, to ambulances, to hospitals. The miTag is a highly extensible platform that supports a variety of sensor add-ons - GPS, pulse oximetry, blood pressure, temperature, ECG - and relays data over a self-organizing wireless mesh network Scalability is the distinguishing characteristic of miTag: its wireless network scales across a wide range of network densities, from sparse hospital network deployments to very densely populated mass casualty sites. The miTag system is out-of-the-box operational and includes the following key technologies: 1) cost-effective sensor hardware, 2) self-organizing wireless network and 3) scalable server software that analyzes sensor data and delivers real-time updates to handheld devices and web portals. The system has evolved through multiple iterations of development and pilot deployments to become an effective patient monitoring solution. A pilot conducted with the Department of Homeland Security indicates miTags can increase the patient care capacity of responders in the field A pilot at Washington Hospital showed miTags are capable of reliably transmitting data inside radio-interference-rich critical care settings.

Effects of oxandrolone on outcome measures in the severely burned: a multicenter prospective randomized double-blind trial.

Severe burns induce pathophysiologic problems, among them catabolism of lean mass, leading to protracted hospitalization and prolonged recovery. Oxandrolone is an anabolic agent shown to decrease lean mass catabolism and improve wound healing in the severely burned patients. We enrolled 81 adult subjects with burns 20% to 60% TBSA in a multicenter trial testing the effects of oxandrolone on length of hospital stay. Subjects were randomized between oxandrolone 10 mg every 12 hours or placebo. The study was stopped halfway through projected enrollment because of a significant difference between groups found on planned interim analysis. We found that length of stay was shorter in the oxandrolone group (31.6 ± 3.1 days) than placebo (43.3 ± 5.3 days; P < .05). This difference strengthened when deaths were excluded and hospital stay was indexed to burn size (1.24 ± 0.15 days/% TBSA burned vs 0.87 ± 0.05 days/% TBSA burned, P < .05). We conclude that treatment using oxandrolone should be considered for use in the severely burned while hepatic transaminases are monitored.

National Burn Repository 2005: a ten-year review.

In the early 1990s, the American Burn Association (ABA) started its first burn registry development initiatives. The impetus for the registry development software originated from several directions, including the following: (1) the recognition that national registries were widespread and of proven benefit; (2) growing demands from accrediting institutions, payers, and patient advocacy groups for objective and verifiable data regarding patient costs, treatments, and outcomes; and (3) the shift toward “evidence-based” medicine and the ongoing analysis of treatment effectiveness. The ABA has issued three calls for burn registry data for its National Burn Repository (NBR): 1994, 2002, and 2005. In 1994, 28 burn centers contributed data for more than 6,400 patients treated from 1991 to 1993. The ABA announced its second call for data in 2001 and distributed the published results of more than 54,000 acute burn admissions treated from 1974 to 2002 at the Association’s 2002 Annual Meeting. The third ABA call for data was issued in the Fall of 2005. The results are detailed in this report, which provides a summary of more than a quarter million acute burn admissions from 1995 to 2005, representing 70 hospitals from 30 states plus the District of Columbia. Statistics are presented in chart and table format to illustrate such key factors as patient age, burn size group, types of injuries, mortality rates, and average hospital charges by etiology and length of hospital stay. The data presented herein should help stimulate quality improvement programs in burn care, as burn centers compare their performance with the national data and as research is expanded using the NBR. The NBR will be published annually and, with continued refinements to the registry software, should become of increasing importance to clinicians, payers, researchers, and the public.

Serum lactate, not base deficit, rapidly predicts survival after major burns

BACKGROUND Clinical studies document correlation of serum lactate and base deficit with mortality in trauma and sepsis. No study of the prognostic value of these two serum markers has been reported in burn injury. METHODS Resuscitation data from 49 patients admitted to the adult Burn ICU were analyzed. Lactate and base deficit were analyzed upon admission and every 2h during the initial 48 h after admission. Resuscitation was managed per standard routine, blinded to these data, guided by the Parkland formula. Initial statistical analysis with Coxs regression model was used to determine the relationship between survival, resuscitation parameters, and demographics. Then, a logistic regression was used to determine if any of these variables were quickly predictive (initial values) of the risk of death. RESULTS Two variables were predictive of mortality by the Cox regression model: (1) serum lactate value and (2) patient age. Furthermore, analysis by logistic regression revealed that the initial serum lactate value was separately predictive of mortality. CONCLUSION In this study, serum lactate but not base deficit, was a predictor of mortality following major burns. Moreover, initial serum lactate values were also predictive of mortality separately.

National burn repository 2006: A ten-year review

This article presents findings from the National Burn Repository (NBR) 2006 Annual Report. Data reported herein cover a 10-year period from January 1, 1996, through June 30, 2006. This year’s report includes the first comparative presentations of data over time to show what appear to be trends in the dataset. The purpose of this report is to share information about the current state of care for burned patients in the United States. Some of the implications include epidemiology, burn-prevention efforts, research, education, acute care and quality improvement in burn programs, resource allocation, and reimbursement issues.

Seven years' experience with integra as a reconstructive tool

The bilayered dermal substitute Integra (Integra Life Sciences Corp., Plainsboro, NJ) was developed and has been widely used as primary coverage for excised acute burns. Our take has been slightly different, finding it most useful in the management of complex soft-tissue loss and threatened extremities as the result of tendon, joint, or bone exposure. Often tasked to fill significant volume loss, we have become adept at stacked multiple-layer applications. Creative use of this material has resulted in unexpected successes with distal limb salvage; the technique takes its place beside adjacent tissue transfer, composite flaps, and vascular pedicle flaps in our burn reconstructive practice. A prospective registry (44 patients) has been kept during the past 7 years that catalogs wounds with complex soft-tissue loss treated with Integra grafts. Many of these patients were at risk of extremity loss because of exposed tendons, joints, or bone. Integra was applied after 1:1 meshing. With profound soft-tissue defects, multiple layers of Integra were serially applied 1 to 2 weeks apart for reconstitution of soft-tissue contours. Local Integra graft infections were managed by silicone unroofing followed by topical sulfamylon liquid dressings. Wounds addressed included fourth-degree burns, necrotizing fasciitis, pit-viper envenomations, and total abdominal wall avulsion in one patient after being run over by a bus. Patients generally were free of pain from their wounds during the maturation phase of the Integra neodermis. Restoration of tissue contour was significantly better when using multiple layers for deep defects. Second and third layers of Integra were successfully applied after an abbreviated first graft maturation period of 7 days. Epithelial autografts on multilayer Integra applications frequently “ghosted”; they would auto-digest to dispersed cells followed subsequently by the reappearance of a confluent epithelial layer. Final grafted skin morphology over palmar and plantar surfaces assumed the type and fingerprint pattern of the original tissues. Infections were readily visible. Early recognition kept them to easily treated circumscribed areas, which did not jeopardize the entire wound. Lengths of stay were long (range, 2–246 days) but not significantly greater than with traditional techniques. The specific reconstructive use of Integra permitted unexpected salvage of several threatened extremities by protecting exposed tendons, bones and joints. Long-term histologic examination revealed unexpected persistence of Integra collagen. Large volume loss wounds benefited from the ability to fill voids with multilayered applications.

Critical Review of Burn Depth Assessment Techniques: Part I. Historical Review

The assessment of burn depth, and as such, the estimation of whether a burn wound is expected to heal on its own within 21 days, is one of the most important roles of the burn surgeon. A false-positive assessment and the patient faces needless surgery, a false-negative one and the patient faces increased length of stay, risks contracture, and hypertrophic scar formation. Although many clinical signs can aid in this determination, accurate assessment of burn depth is possible only 64 to 76% of the time, even for experienced burn surgeons. Through the years, a variety of tools have become available, all attempting to improve clinical accuracy. Part 1 of this two-part article reviews the literature supporting the different adjuvants to clinical decision making is, providing a historical perspective that serves as a framework for part 2, a critical assessment of laser Doppler imaging.

Critical Review of Burn Depth Assessment Techniques: Part II. Review of Laser Doppler Technology

The judgment of which wounds are expected to heal within 21 days is one of the most difficult and important tasks of the burn surgeon. The quoted accuracy of 64 to 76% by senior burn surgeons underscores the importance of an adjunct technology to help make this determination. A plethora of techniques have been developed in the last 70 years. Laser Doppler imaging (LDI) is one of the most recent and widely studied of these techniques. The technology provides an estimate of perfusion through the burn wound, the assumption being that a lower perfusion correlates with a deeper wound and, therefore, a longer time to heal. Although some reports suggest accuracy between 96 and 100% and that it does this 2 days ahead of clinical judgment, others have questioned its applicability to clinical practice. This article, the second of a two-part series, has two objectives: 1) a review of the Doppler principle and how the LDI uses it to estimate perfusion; and 2) a critical assessment of the burn literature on the LDI. Part I provides a historical perspective of the different technologies used through the last 70 years to assist in the determination of burn depth. Laser Doppler has brought technology closer to provide a reliable adjuvant to the clinical prediction of healing, yet, caution is warranted. A clear understanding of the limitations of LDI is needed to put the current research in perspective to find the right clinical application for LDI.