Peter Dziewulski

Prognostic scoring systems in burns: A review

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve. The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.

Pruritus in burns: review article.

Pruritus represents a common and distressing feature of burn wounds. Over the last decades, significant advances in neuroanatomical and neurophysiological knowledge have resulted in the elucidation of the mediators and pathways involved in the transmission of pruritic impulses. A plethora of therapeutic approaches have been evaluated mostly in small-scale studies involving burns patients targeting both the peripheral and the central components of the neurologic pathway. Antihistamines, doxepin, massage therapy, and transcutaneous electrical nerve stimulation are effective strategies to combat pruritus in burns patients. Recent studies have provided preliminary evidence regarding the effectiveness of gabapentin and ondansetron. The area of burns pruritus is under-researched and large-scale studies are required to reinforce the armamentarium of specialists with evidence-based regimens for the treatment of this highly distressing symptom.

Comparative evaluation of antipruritic protocols in acute burns. The emerging value of gabapentin in the treatment of burns pruritus.

Pruritus is a distressing symptom in burns rehabilitation and its treatment represents a challenge for the multidisciplinary burns team. We conducted a comparative study of two different therapeutic approaches in hospitalized burns patients using a combination of pharmacological agents. The observed symptomatic response to gabapentin as monotherapy as well as in combination therapy with two antihistamines was higher than chlorpheniramine alone and in combination with another two antihistamines (t = 3.70, df = 89, P < .001 for monotherapy and &khgr;2 = 12.2, df = 1, P = .001 for polytherapy). Patients with higher initial itch scores needed a combination of pharmacologic agents for effective symptomatic relief. A linear regression model showed that the likelihood of failure of monotherapy was marginally associated with decreasing patient age (P = .013) and increasing TBSA (P = .021, sum of square = 1.986, df = 2, P = .04). A combined approach using centrally and peripherally acting agents is most effective in the treatment of acute burns pruritus.

Severe gastrointestinal haemorrhage and ischaemic necrosis of the small bowel in a child with 70% full-thickness burns : a case report

Splanchnic ischaemia is an important problem in patients with large burns. This reports the case of an 11-year-old boy with 70% full-thickness TBSA burns who sustained multiple episodes of severe gastrointestinal haemorrhage due to both extensive ischaemic enterocolitis and severe gastric ulceration which required surgical intervention on several occasions. Causative mechanisms of splanchnic ischaemia in this patient including increased mesenteric vascular resistance, abdominal compartment syndrome and enteric feeding, are considered.

The use of the Cortrak Enteral Access System™ for post-pyloric (PP) feeding tube placement in a Burns Intensive Care Unit

INTRODUCTION 50% of critically ill patients fail to reach caloric targets with NG feeding. PP feeding may enhance caloric intake. PP feeding can be continued throughout theatre in patients with a secure airway. Blind PP tube placement is difficult. CEAS has been developed to assist tube placement and eliminate check X-rays of tube position. METHOD All BITU patients with CEAS PP feeding tube placement were identified. Notes and X-rays were reviewed. Tube position, calorie deficit and time off feed were recorded. RESULTS 44 tubes were placed in 21 patients using CEAS. 84% were PP, 16% NG. Position correlated to X-ray findings in 86%. In 16% position was NG on CEAS but was PP on X-ray. 10 patients required both CXR and AXR to confirm position, the remainder required CXR only. Time off feed varied from 0-24 h (mean 7.4 h). Calorie deficit ranged from 0-2465 kCal (mean 858 kCal). Average wait for X-ray was 3.4h. If X-ray wait was eliminated calorie deficit would be reduced by 45% to 393 kCal. CONCLUSION The Cortrak system is safe and effective on BITU. It reduces calorie deficit, reduces X-ray exposure and is cost effective. We recommend its use on BITU.

Use of colistin in treating multi-resistant Gram-negative organisms in a specialised burns unit

Patients with burns are at an increased risk of infection which can affect their outcome-duration of hospital stay, intensive care requirements, organ support, inotrope requirements, renal replacement therapy, ventilatory requirements and overall mortality. Our study aimed to evaluate the use of colistin in our burns intensive care unit (ICU) in treating multi-resistant Gram-negative infections. This was a retrospective study carried out in a regional referral centre for burns and plastics, Chelmsford, UK. We looked at data from patients admitted to our intensive care over a two-year period from November 2003 to November 2005. All patients who received colistin were included in the study. Admission data included demographic data and burn data, other relevant medical history, and blood results. We also recorded: length of ICU stay, ultimate outcome, total dose of colistin, repeated doses, and mode of drug delivery, organ support, organisms grown and their resistance. Response to colistin was judged by improvement in clinical status, decrease in white blood cell count (WCC) and inflammatory markers and no growth on cultures. The data were subjected to non-parametric Wilcoxon Signed Rank Test using SPSS version 14. Twenty-nine patients were included in the study all of whom received colistin in one form or the other. The average total dose of colistin was 69 million units (range 1-268). Of these, 17 patients survived (58.6%) and 12 died (41.4%). Twenty patients improved (69%) and 9 did not improve (31%) after administration of colistin. We also compared creatinine levels on admission and post colistin. We used non-parametric Wilcoxon Signed Rank test which showed no difference in the two groups (p=0.38). We found colistin to be safe and effective in treating multi-resistant Gram-negative infections in burns patients and we did not see any statistically significant impairment of renal function.

Body Mass Index (BMI) and mortality in patients with severe burns: is there a "tilt point" at which obesity influences outcome?

BACKGROUND Obesity is a serious health hazard. Despite advances in burn care severely obese patients with large burns have higher mortality compared with normal-weight patients. The Body Mass Index is the universal measure to define and classify obesity. This study aims to evaluate the effect of Body Mass Index (BMI) on mortality of severe burn patients. METHODS A retrospective study of 95 patients treated over 2-year period in a dedicated burn ITU. Mortality was studied in relation to BMI as well as demographic, burn characteristics well as length of hospital stay. Logistic regression model and non-parametric comparison tests were used for analysis. RESULTS Mean age was 42 ± 22 years (mean ± SD), Total Burn Surface area (TBSA) 33 ± 16%, BMI 29 ± 7.5 (kg/m²) and hospital stay was 37 ± 33 days. Incidence of inhalation injury was 29% and over all mortality was 19%. By logistic regression age, TBSA and inhalation injury were separately associated with mortality. Patients with BMI ≥ 35 (kg/m²) had significantly higher mortality compared with patients with BMI < 25 (kg/m²) [p=0.037 (Fishers exact test)]. CONCLUSIONS Body Mass Index ≥ 35 (kg/m²) is a tilt point, which is associated with a higher than predicted mortality following burns when compared to burned patients with a normal BMI.

Comfort care in burns: The Burn Modified Liverpool Care Pathway (BM-LCP)

INTRODUCTION Despite advances in burn care some injuries remain non survivable. Good end of life care for these patients is arguably as important as life prolonging care. The Liverpool Care Pathway is a useful tool for providing good quality end of life care. It has previously been modified for the acute setting. We modified it further specifically for use in burn care in 2007 and would like to share our experience of using it. METHODS A retrospective case series of deaths occurring between 01/01/08 and 31/12/09 is presented and adherence to the Burn Modified Liverpool Care Pathway (BM-LCP) is assessed. RESULTS There were 22 deaths over the study period with a mean TBSA of 55%. Mean Acute Burn Severity Index score (ABSI) 12.5. A decision of futility was made in 14 cases, 11 of these were started on the BM-LCP. 7 were started on the pathway at the time of admission. Mean time from decision to start the pathway to death 11 h (range 3-48). There were no variances from the pathway. CONCLUSION The BM-LCP appears to be an appropriate tool for assisting in end of life care in burns and when used appears to improve end of life care. We recommend its use and would encourage others to implement its use.

Survival of a 75% burn in a patient with longstanding Addison’s disease

This is the first reported case of survival of a significant burn in a patient with established Addisons disease. The systemic stress response to thermal injury is well recognised, there is a marked hypermetabolic response with prolonged periods of catabolism. In particular, the elevation of plasma cortisol levels is crucial for this response to severe systemic stress. Cortisol elevation is maintained for the duration of burn wound healing, is proportional to the burned body surface area and the normal circadian rhythm of endogenous cortisol is lost. Acute adrenal insufficiency has been described in patients suffering major burn injuries with generally poor outcomes. We discuss the management and complications of adrenal replacement therapy in a severe burn setting, as illustrated by this case report.

Burn injury to a reconstructed breast via a hot water bottle

Breast reconstruction following mastectomy for breast cancer has become an almost routine procedure within the United Kingdom. A number of autologous tissue flaps have been described including the latissimus dorsi (LD), transverse rectus abdominis myocutaneous (TRAM) and DIEP flap. The DIEP has now become the flap of choice for breast reconstruction as it does not involve harvest of rectus muscle hence maintaining abdominal strength and reducing the risk of abdominal herniation. It is also less painful postoperatively and has a shorter recovery phase. However, flap elevation usually results in transection of nerves responsible for cutaneous sensation and thermoregulatory function which may increase the risk of accidental thermal damage. A fit and well 76 year old lady who had a failed immediate implant reconstruction of her right breast underwent a delayed DIEP reconstruction approximately 12 months post-mastectomy. Three months post-procedure she used a hot water bottle wrapped up in a towel to relieve back pain. Unfortunately, she fell asleep with the bottle, waking up later on to find it on her chest. There were no immediate indications of a burn injury, however later on in the day she noted increased redness and blistering over the surface of the flap. This was initially managed conservatively by her GP. However, as the wound failed to heal and in fact appeared to expand, she was referred to our unit 3 weeks later. She had a clearly defined well circumscribed adherent layer of eschar over the flap (Figure 1). The patient had suffered a full thickness burn to her DIEP flap with the resulting wound measuring approximately 6 7 cm in size. The burn was debrided and a split skin graft applied soon after presentation. The graft took well and the wound healed completely within 2 weeks (Figure 2). This is the first report of a burn injury to a DIEP flap from a hot water bottle. The potential for hot water bottles to