Steven A. Kahn

Resuscitation After Severe Burn Injury Using High-Dose Ascorbic Acid: A Retrospective Review

Resuscitation of burn victims with high-dose ascorbic acid (vitamin C [VC]) was reported in Japan in the year 2000. Benefits of VC include reduction in fluid requirements, resulting in less tissue edema and body weight gain. In turn, these patients suffer less respiratory impairment and reduced requirement for mechanical ventilation. Despite these results, few burn centers resuscitate patients with VC in fear that it may increase the risk of renal failure. A retrospective review of 40 patients with greater than 20% TBSA between 2007 and 2009 was performed. Patients were divided into two groups: one received only lactated Ringers (LR) solution and another received LR solution plus 66 mg/kg/hr VC. Both groups were resuscitated with the Parkland formula to maintain stable hemodynamics and adequate urine output (>0.5 ml/kg/hr). Patients with >10-hour delay in transfer to the burn center were excluded. Data collected included age, gender, weight, %TBSA, fluid administered in the first 24 hours, urine output in the first 24 hours, and Acute Physiology and Chronic Health Evaluation II score. PaO2 in millimeters mercury:%FIO2 ratio and positive end-expiratory pressure were measured at 12-hour intervals, and hematocrit was measured at 6-hour intervals. Comorbidities, mortality, pneumonia, fasciotomies, and renal failure were also noted. After 7 patients were excluded, 17 patients were included in the VC group and 16 in the LR group. VC and LR were matched for age (42 ± 16 years vs 50 ± 20 years, P = .2), burn size (45 ± 21%TBSA vs 39 ± 15%TBSA, P = .45), Acute Physiology and Chronic Health Evaluation II (17 ± 7 vs 18 ± 8, P = .8), and gender. Fluid requirements in the first 24 hours were 5.3 ± 1 ml/kg/%TBSA for VC and 7.1 ± 1 ml/kg/%TBSA for LR (P < .05). Urine output was 1.5 ± 0.4 ml/kg/hr for VC and 1 ± 0.5 ml/kg/hr for LR (P < .05). Vasopressors were needed in four VC patients and nine LR patients (P = .07). VC patients required vasopressors to maintain mean arterial pressure for a mean of 6 hours, but LR needed vasopressors for 11 hours (P = .2). No significant differences in PaO2 in millimeters mercury:%FIO2 ratio, positive end-expiratory pressure, frequency of pneumonia, renal failure, or inhalation injury were found. VC group had four mortalities, and LR group had three mortalities (P = 1). VC is associated with a decrease in fluid requirements and an increase in urine output during resuscitation after thermal injury. Although this study did not find a difference in outcomes with VC administration, it demonstrates that VC can be safely used without an increased risk of renal failure. The effects of VC should be further studied in a large-scale, prospective, randomized trial.

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.

Use of acellular dermal replacement in reconstruction of nonhealing lower extremity wounds.

Dermal templates are well established in the treatment of burn wounds and acute nonburn wounds. However, the literature regarding their use for reconstruction of chronic, nonhealing wounds is limited. This study describes a series of patients with chronic wounds reconstructed with a commercially available bilayer, acellular dermal replacement (ADR) containing a collagen-glycosaminoglycan dermal template and a silicone outer layer. A retrospective review was performed of 10 patients treated for chronic wounds with ADR and negative pressure dressing followed by split-thickness skin graft between July 2006 and January 2009. Data collected included age, gender, comorbidities, medications, wound type or location, wound size, the number of applications of ADR, the amount of ADR applied (in square centimeter), the amount of time between ADR placement and grafting, complications, need for reoperation, and percentage of graft take after 5 and 14 days. The mean age of study subjects was 44 years. All patients in the study had comorbidities that interfere with wound healing and were treated for lower extremity wounds (four to legs, five to ankles, and one to foot). The wounds had a variety of causative factors including venostasis ulcers (6, 60%), trauma in diabetic patients (2, 20%), brown recluse bite (1, 10%), and a wound caused from purpura fulminans (1, 10%). The average wound size and amount of ADR applied was 162±182 cm2. Each patient required only one application of ADR. The average time between ADR placement and skin grafting was 36.5 days. The mean percentage of graft take at 5 days was 89.55%, 14 days was 90%, and 21 days was 87.3%. Only two patients required regrafting, and one of these grafts was lost because of patient noncompliance. ADR can be used successfully in the treatment of chronic wounds. ADR provides direct wound coverage and can conform to a variety of anatomical sites. This study demonstrates that the use of ADR in treating chronic wounds results in high rates of skin graft take. Favorable results were obtained despite the majority of patients having comorbidities that would normally interfere with wound healing.

Burn Resuscitation Index: A Simple Method For Calculating Fluid Resuscitation in the Burn Patient

The Parkland formula is the standard for calculating the initial intravenous fluid rate for resuscutation after thermal injury. However, it is cumbersome when used by those with modest burn training. We propose an easier method to calculate fluid requirements that can be initiated by first-line providers. Burn size is estimated by using the Burn Size Score (BSS), which is then crossreferenced with the patients weight on a preprinted Burn Resuscitation Index (BRI), based on the Parkland formula, to determine initial hourly fluid rate. Seventy-two residents and faculty in the Departments of Surgery and Emergency Medicine were surveyed. Participants were shown a diagram of a burn patient and asked to calculate the initial fluid rate using the Parkland formula from memory. The study was repeated with a different diagram, and the participants were asked to calculate the initial fluid rate using the BRI (a preprinted card with written instruction pertaining to its use). Statistical analysis was performed with the McNemar test. Using the Parkland formula, 33% of surgeons and 17% of emergency medicine physicians were able to calculate the initial fluid rate. Using the BRI, 56% of surgeons and 77% of emergency medicine physicians were able to calculate the fluid rate correctly (P < .01 and P < .001, respectively). Fifty-four percent of physicians surveyed believed that the BRI was easier to use. The accuracy of determining initial fluid rate was low using the Parkland formula and “rule of nines” from memory. Accuracy increased when the BRI was used. The BRI serves as a visual aid and provides some instruction, allowing the user to calculate fluid resuscitation with greater accuracy than with rote memorization of a formula. The BRI might be a useful tool for providers with minimal burn training. However, further investigation is warranted.

Fictitious hyperglycemia: point-of-care glucose measurement is inaccurate during high-dose vitamin C infusion for burn shock resuscitation.

The use of high-dose vitamin C (hdVC, 66 mg/kg/hour × 18 hours) infusion is a useful adjunct to reducing fluid requirements during resuscitation of burn shock. Routine point-of-care glucose (POCG) analysis has been inaccurately high in observed patients undergoing hdVC. Inaccurate POCG could potentially lead to iatrogenic hypoglycemia if the fictitious hyperglycemia is treated with insulin. This study is a retrospective analysis of plasma glucose measurements from a central laboratory (LG) compared with POCG during and 24 hours after hdVC infusion. Records of adult patients receiving hdVC infusions during burn resuscitation over 1 year were reviewed. Charts selected for analysis included those with glucose measurements using POCG and LG that were taken simultaneously, during hdVC infusion, and 24 hours after completion. All specimens were drawn from arterial lines. POCG was measured with Accu-Chek Inform (Roche, Indianapolis, IN) and LG was measured by Siemens Dimension Vista 500 (Siemens, Deerfield, IL) using biochromic analysis. Nonparametric statistical analysis was performed using Wilcoxon’s matched pairs test and Spearman correlation with significance at P < .05. Of 18 adult patients undergoing burn resuscitation with hdVC infusion, 5 were chosen for analysis (%TBSA 40 ± 15; age 51 ± 18). All data were pooled with 11 comparisons both during and after hdVC. The mean POCG (225 ± 71) was significantly higher than mean LG (138 ± 41) on hdVC (P = .002). There was no difference between POCG (138 ± 30) and LG (128 ± 23) after hdVC was finished (P = .09). There was a negative correlation between POCG and LG on hdVC (−0.64, P = .04) and a positive correlation off hdVC (0.89, P = .0005). POCG analysis during hdVC infusion is significantly higher than laboratory glucose measurements. Once the hdVC infusion is complete, POCG and laboratory glucose measurements are not statistically different. Treating erroneously high glucose based on POC testing is potentially dangerous and could lead to hypoglycemia and seizures.

Impact of a graduated driver's license law on crashes involving young drivers in New York State

BACKGROUND Motor vehicle crashes constitute the greatest risk of injury for young adults. Graduated driver licensing (GDL) laws have been used to reduce the number of injuries and deaths in the young driver population. The New York State GDL law increased supervision of young driver and limited both time-of-day driven and number of passengers. This review examines the impact of a GDL enacted in New York in September 2003. METHODS A retrospective review of New York State administrative databases from 2001 to 2009 was performed. During this period, a state-wide GDL requirement was implemented. Database review included all reported crashes to the New York State Department of Motor Vehicles by cause and driver age as well as motor fuel tax receipts by the New York State Comptroller’s Office. Motor fuel tax receipts and consumption information were used as a proxy for overall miles driven. RESULTS Before 2003, drivers younger than 18 years were involved in 90 fatal crashes and 10,406 personal-injury (PI) crashes, constituting 4.49% and 3.38% of all fatal and PI crashes in New York State, respectively. By 2009, the number of fatal and PI crashes involving drivers who are younger than 18 years decreased to 44 (2.87%) and 5,246 (2.24%), respectively. Of note, the number of crashes experienced by the age group 18 years to 20 years during this period also declined, from 192 (9.59% of all fatal crashes) and 25,407 (8.24% of all PI crashes) to 135 (8.81%) and 18,114 (7.73%), respectively. Overall numbers of crashes reported remained relatively stable, between 549,000 in 2001 and 520,000 in 2009. Motor fuel use during this period also declined, but to a lesser degree (

Line of duty firefighter fatalities: an evolving trend over time.

552 million to

Surgeon-Performed Hemodynamic Transesophageal Echocardiography in the Burn Intensive Care Unit.

516 million or 6.6%). CONCLUSION The use of a GDL law in New York State has shown a large decrease in the number of fatalities and PI crashes involving young drivers. The delay in full driver privileges from the GDL did not result in an increase in fatal or PI crashes in the next older age group. LEVEL OF EVIDENCE Epidemiologic study, level III.

Firefighter safety: rampant unsafe practices as documented in mainstream media

Between 1990 and 2012, 2775 firefighters were killed in the line of duty. Myocardial infarction (MI) was responsible for approximately 40% of these mortalities, followed by mechanical trauma, asphyxiation, and burns. Protective gear, safety awareness, medical care, and the age of the workforce have evolved since 1990, possibly affecting the nature of mortality during this 22-year time period. The purpose of this study is to determine whether the causes of firefighter mortality have changed over time to allow a targeted focus in prevention efforts. The U.S. Fire Administration fatality database was queried for all-cause on-duty mortality between 1990 to 2000 and 2002 to 2012. The year 2001 was excluded due to inability to eliminate the 347 deaths that occurred on September 11. Data collected included age range at the time of fatality (exact age not included in report), type of duty (on-scene fire, responding, training, and returning), incident type (structure fire, motor vehicle crash, etc), and nature of fatality (MI, trauma, asphyxiation, cerebrovascular accident [CVA], and burns). Data were compared between the two time periods with a &khgr;2 test. Between 1990 and 2000, 1140 firefighters sustained a fatal injury while on duty, and 1174 were killed during 2002 to 2012. MI has increased from 43% to 46.5% of deaths (P = .012) between the 2 decades. CVA has increased from 1.6% to 3.7% of deaths (P = .002). Asphyxiation has decreased from 12.1% to 7.9% (P = .003) and burns have decreased from 7.7% to 3.9% (P = .0004). Electrocution is down from 1.8% to 0.5% (P = .004). Death from trauma was unchanged (27.8 to 29.6%, P = .12). The percentage of fatalities of firefighters over age 40 years has increased from 52% to 65% (P = .0001). Fatality by sex was constant at 3% female. Fatalities during training have increased from 7.3% to 11.2% of deaths (P = .00001). The nature of firefighter mortality has evolved over time. In the current decade, line-of-duty mortality is more likely to occur during training. Mortality from burns, asphyxiation, and electrocution has decreased; but death from MI and CVA has increased, particularly in older firefighters. Outreach and education should be targeted toward vehicle safety, welfare during training, and cardiovascular disease prevention in the firefighter population.

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

The use of transesophageal echocardiography (TEE) for resuscitation after burn injury has been reported in small case studies. Conventional TEE is invasive and often requires a subspecialist with a high level of training. The authors report a series of surgeon-performed hemodynamic TEE with an indwelling, less bulky, user-friendly probe. Records of patients treated in a regional burn center who underwent hemodynamic TEE between October 1, 2012 and May 30, 2014 were reviewed. The clinical course of each patient was recorded. All bedside interpretations were retrospectively reviewed for accuracy by a cardiac anesthesiologist. Eleven patients were included in the study. Median age was 68.5 years (interquartile range, 49.5–79.5). Median burn size was 37% TBSA (interquartile range: 16.3–53%). Seven patients were male, and four suffered inhalation injury. The operator’s interpretation matched that of the echocardiography technician and cardiac anesthesiologist in all instances. No complications occurred from probe placement. Four patients underwent hemodynamic TEE to determine volume status during resuscitation. Changes in volume status on echocardiography preceded the eventual changes in urine output and vital signs for one patient. Hemodynamic TEE diagnosed cardiogenic shock and was used to titrate inotropes and vasopressors in seven elderly patients. Hemodynamic TEE is a useful adjunct to manage the burn patient who deviates off the expected course, especially if there is a question of cardiac function or volume status. It is less invasive and can be accurately performed by surgical intensivists when transthoracic echo windows are limited. The role of echocardiography in optimizing routine burn resuscitations needs to be further studied.