Analysis of life expectancy and living status of elderly patients surviving a burn injury

Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes

BACKGROUND

Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management.

OBJECTIVE

Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries.

METHODS

We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center.

RESULTS

A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia.

CONCLUSIONS

Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

The prognostic nutritional index on postoperative day one is associated with one-year mortality after burn surgery in elderly patients

BACKGROUND

Burn injury in elderly patients can result in poor outcomes. Prognostic nutritional index (PNI) can predict the perioperative nutritional status and postoperative outcomes. We aim to evaluate the risk factors, including PNI, for one-year mortality after burn surgery in elderly patients.

METHODS

Burn patients aged ≥65 years were retrospectively included. PNI was calculated using the following equation: 10 × serum albumin level (g/dL) + 0.005 × total lymphocyte count (per mm³). Cox regression, receiver operating characteristic curve and Kaplan-Meier survival analyses were performed to evaluate the risk factors for postoperative one-year mortality.

RESULTS

Postoperative one-year mortality occurred in 71 (37.6%) of the 189 elderly burn patients. Risk factors for one-year mortality were PNI on postoperative day one (hazard ratio (HR) = 0.872; 95% CI = 0.812-0.936; p < 0.001), Sequential Organ Failure Assessment score (HR = 1.112; 95% CI = 1.005-1.230; p = 0.040), American Society of Anesthesiologists physical status (HR = 2.064; 95% CI = 1.211-3.517; p = 0.008), total body surface area burned (HR = 1.017; 95% CI = 1.003-1.032; p = 0.015) and preoperative serum creatinine level (HR = 1.386; 95% CI = 1.058-1.816; p = 0.018). The area under the curve of PNI for predicting one-year mortality after burn surgery was 0.774 (optimal cut-off value = 25.5). Patients with PNI ≤25.5 had a significantly lower one-year survival rate than those with PNI >25.5 (32.1% vs 75.9%, p < 0.001).

CONCLUSIONS

PNI on postoperative day one was associated with postoperative one-year mortality in elderly burn patients. The postoperative one-year survival rate was lower in patients with PNI ≤25.5 than in those with PNI >25.5. These findings indicate the importance of identifying elderly burn patients with low PNI, thereby reducing the mortality after burn surgery.

Early Enteral Nutrition in Geriatric Burn Patients: Is There a Benefit?

Nutrition is a critical component of acute burn care and wound healing. There is no consensus over the appropriate timing of initiating enteral nutrition in geriatric burn patients. This study aimed to assess the impact of early enteral nutrition on outcomes in this patient population. We performed a 1-year (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program and included all older adult (age ≥65 years) isolated thermal burn patients who were admitted for more than 24 hr and received enteral nutrition. Patients were stratified into two groups based on the timing of initiation of feeding: early (≤24 hr) vs late (>24 hr). Multivariate logistic regression was performed to control for potential confounding factors. Outcome measures were hospital and intensive care unit lengths of stay, in-hospital complications, and mortality. A total of 1,004,440 trauma patients were analyzed, of which 324 patients were included (early: 90 vs late: 234). The mean age was 73.9 years and mean TBSA burnt was 31%. Patients in the early enteral nutrition group had significantly lower rates of in-hospital complications and mortality (15.6% vs 26.1%; P = 0.044), and a shorter hospital length of stay (17 [11,23] days vs 20 [14,24] days; P = 0.042) and intensive care unit length of stay (13 [8,15] days vs 17 [9,21] days; P = 0.042). In our regression model of geriatric burn patients, early enteral nutrition was associated with improved outcomes. The cumulative benefits observed may warrant incorporating early enteral nutrition as part of intensive care protocols.

Clothing Flammability and Burn Injuries: Public Opinion Concerning an Overlooked, Preventable Public Health Problem

The objective of this study was to describe knowledge of clothing flammability risk, public support for clothing flammability warning labels, and stronger regulation to reduce the risk. As part of a national survey of homeowners about residential sprinkler systems, the authors included questions about clothing flammability. The authors used an online web panel to sample homeowners and descriptive methods to analyze the resulting data. The sample included 2333 homeowners. Knowledge of clothing flammability and government oversight of clothing flammability risk was low. Homeowners were evenly split about the effectiveness of current standards; however, when presented with clothing-related burn injury and death data, a majority (53%) supported stricter standards. Most homeowners (64%) supported warning labels and indicated that such labels would either have no effect on their purchasing decisions (64%) or be an incentive (24%) to purchase an item. Owners of sprinkler-equipped homes were more likely to support these interventions than owners of homes without sprinkler systems. Public knowledge about clothing flammability risks is low. Most homeowners supported clothing labels to inform consumers of this risk and increased government intervention to reduce the risk.

Burn treatment in the elderly

The population of elderly patients is expected to rise continuously over the next decades due to global demographic changes. The elderly seem to be most vulnerable to burns and their management remains undoubtedly a challenge. A clear age margin for elderly patients is not yet defined, but most studies adhere to the inclusion of patients 65 years and above, but the general condition and social situation must be taken into account. The understanding of the physiological basis of aging and its related pathophysiological changes has only marginally influenced treatment and decision making in elderly burn patients. When looking at treatment regimens currently applied in elderly burn patients, the discussion of standards in intensive care as well as surgical strategies is ongoing. However, trends towards a moderate, non-aggressive resuscitation approach and careful inclusion of key parameters like physiological age, pre-burn functional status and premorbid conditions, seem to be useful guidelines for interdisciplinary treatment decisions. Once ordered for surgical treatment, the amount of body surface area operated in one session should be adapted to the general status of the patient. Even if older burn victims have a reported higher mortality rate than younger patients, improved therapeutic options have contributed to a reduced mortality rate even in the elderly over the last decades. As a result of improved outcome, more attention has to be given to a comprehensive rehabilitation program. This review will give an overview of the current literature and will draw attention to specific topics related to this important subpopulation of burn patients.

Trauma and falls in the elderly

The number of people living longer and staying active continues to rise, resulting in an increase in the incidence of trauma-related vis-its by older persons to emergency departments. The elderly sustain a disproportionate share of fractures and serious injury, and represent a unique subset of patients with special needs and considerations. This article reviews the current literature on the management of elderly patients with trauma, including the physiologic changes of aging relevant to the management of trauma, injury patterns unique to geriatric victims of trauma, and aspects particular to resuscitation and general management of geriatric trauma victims. We include a discussion of the evaluation and management of falls in the elderly, including assessment of fall risk.

Functional outcome after burns: a review

We conducted a Medline search (1966-11/2003) on empirical studies into the consequences of burns. The International Classification of Functioning, disabilities and health (ICF) was used to classify dimensions of functional outcome. We included 50 studies, reporting a wide spectrum of ICF-dimensions. The current state of knowledge on the functional outcome after burns was hard to summarise, due to the wide variety in study designs and outcome assessment methods. Some indications on the major functional problems after burns were gained. Problems in mental function were described in subgroups of patients, both in children/adolescents and adults. Restrictions in range of motion were observed in about one-fifth of burn patients, even 5 years after injury. Problems with appearance were reported often (up to 43%), even in patients with minor burns (14%). Problems with work were reported in 21-50% of the adult patients, with permanent incapacity for work in 1-5%. None of the publications gave sufficient information to fully estimate the functional consequences of burns. We recommend the development of a standard core set for measurement and reporting of functional outcome after burns.

A three decade analysis of factors affecting burn mortality in the elderly

This study's objective was to identify variables that affect the mortality of elderly burn patients and to assess their changes over time. A retrospective review was conducted on all patients 75 or older (n=201) admitted to a university-based burn center between 1972 and 2000. Variables examined were age, sex, TBSA, ABSI, inhalation injury, timing from burn to operative intervention, the number of surgical procedures, the number of pre-morbid conditions, and mortality. There were 95 fatalities. TBSA strongly correlated with mortality (p<0.0001). Adjusting for TBSA and inhalation injury, mortality significantly decreased (p=0.04, odds ratio=0.58). Mortality significantly increased with inhalation injury (p<0.01). Fatality risk increased by 400% with inhalation injury. Absence of inhalation injury was not significant with respect to mortality in the 1970s, however there was a significant decrease (p=0.02) in mortality without an inhalation injury in the 1980s and 1990s. ABSI was strongly predictive of mortality (p<0.0001). On average there was a 200% increase in mortality per unit increase of ABSI. The elderly are 58% less likely to die from burns now as compared to the 1970s. Although mortality rose with increasing TBSA equally in each decade, the absolute risk of mortality decreased over time. This data suggests major strides have been made in burn care, however similar success has not been achieved with inhalation injuries.

Effectiveness of a Burn Prevention Campaign for Older Adults

Older adults are involved in one fifth of burn injury admissions in the Province of Ontario Canada. Most burn injuries in this population occur at home while cooking, bathing, or smoking. The purpose of this study was to evaluate the effectiveness of an educational campaign to improve burn prevention knowledge in older adults of a major metropolitan city. Changes in participants' burn prevention knowledge were determined using standardized precampaign and postcampaign (4-6 weeks) surveys. Of 209 older adult participants, 126 (60.3%) completed the precampaign and postcampaign surveys. There was a significant increase (P <.05) in burn prevention knowledge postintervention. Age, education level, and living conditions did not influence the change in burn prevention knowledge. This burn prevention campaign for older adults was effective in improving burn prevention knowledge, but it remains unclear as to whether this will ultimately result in a change in burn prevention behavior.

A survey of risk factors for burns in the elderly and prevention strategies

Elderly burn patients suffer from greater morbidity and mortality than younger patients with similar burn extents. The purpose of this study was to identify risk factors for burn injuries in the elderly to develop an effective preventive program. A cross-sectional survey was conducted among 20 elderly (> or =65 years of age) burn survivors on the circumstances surrounding their burn injury and on burn prevention. A control group of 20 nonburned elderly completed a similar survey only on burn prevention. The majority of burned subjects believed that their injury was preventable (85%). The home was the commonest location for burn injury (70%), and scalds (50%) and flame burns (25%) were the most common etiologies. Most subjects felt that a burn prevention program would be useful (95%) and television, news, and posters were the preferred sources of prevention information. Compared with the burn group, the control group had more risk factors for burn injury. However, the control group also took more active preventive measures. Burn prevention campaigns for elderly should focus on reducing flame and scald burns that occur in the home, preferably using television, news, and poster media.

The continuing risk of domestic hot water scalds to the elderly

Elderly people are particularly at risk of accidents in the home and with an ageing population, they constitute a large proportion of scald victims. We have seen several elderly patients every year in our own unit who had sustained domestic hot water burns. We decided to ascertain the temperature of water in the private homes of elderly people and in residential care homes in our community. Twenty-five private homes and 14 residential care homes were visited and peak water temperatures were measured in the kitchens and bathrooms. Only one private home and one residential home had water below 45 degrees C. It is recommended that water should be delivered at less than 43 degrees C. We conclude that water is dangerously hot. However, if water is stored at a temperature of less than 60 degrees C there is a risk of infection with Legionella pneumophila. Existing regulations governing the use of 'fail safe' thermostatic mixing devices must be enforced and extended to cover domestic hot water systems.

Quality of life of the Spanish burn patient

This is a study of the quality of life as performed on a sample of 115 Spanish patients treated for burns in the Burn Care Unit of the Alicante General Hospital. Through the application of the sole existing scale for measuring quality of life specific to burn patients, the following percentages of alterations were obtained: 9.7% in physical domains; 14.2% in body image; 27.4% in psychological domains; and 22.5% for the complete scale. Results similar to those published by the original authors of the scale have been encountered by us and we are now able to confirm that the questionnaire "adapted and validated" in Spanish is equally capable of measuring changes in quality of life of the group studied herein.

Evidence-based management of patients with burns

A review of the evidence for the management of burn wounds

Objective estimates of the probability of death from burn injuries

BACKGROUND

Over the past 20 years, there has been remarkable improvement in the chances of survival of patients treated in burn centers. A simple, accurate system for objectively estimating the probability of death would be useful in counseling patients and making medical decisions.

METHODS

We conducted a retrospective review of all 1665 patients with acute burn injuries admitted from 1990 to 1994 to Massachusetts General Hospital and the Shriners Burns Institute in Boston. Using logistic-regression analysis, we developed probability estimates for the prediction of mortality based on a minimal set of well-defined variables. The resulting mortality formula was used to determine whether changes in mortality have occurred since 1984, and it was tested prospectively on all 530 patients with acute burn injuries admitted in 1995 or 1996.

RESULTS

Of the 1665 patients (mean [+/-SD] age, 21+/-20 years; mean burn size, 14+/-20 percent of body-surface area), 1598 (96 percent) lived to discharge. The mean length of stay was 21+/-29 days. Three risk factors for death were identified: age greater than 60 years, more than 40 percent of body-surface area burned, and inhalation injury. The mortality formula we developed predicts 0.3 percent, 3 percent, 33 percent, or approximately 90 percent mortality, depending on whether zero, one, two, or three risk factors are present. The results of the prospective test of the formula were similar. A large increase in the proportion of patients who chose not to be resuscitated complicated comparisons of mortality over time.

CONCLUSIONS

The probability of mortality after burns is low and can be predicted soon after injury on the basis of simple, objective clinical criteria.

Disaster triage: START, then SAVE--a new method of dynamic triage for victims of a catastrophic earthquake

Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of time, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49-72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage. The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of "Simple Triage and Rapid Treatment" (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, "Secondary Assessment of Victim Endpoint" (SAVE). The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology. Pre-existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources-both personnel and equipment-and would be triaged to an "expectant area." Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a "treatment" area. The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR-SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster.

Burns in octogenarians

With the aim of identifying patterns of burn injury, remediable risk factors, and policies in the overall surgical and medical management a retrospective review of 111 octogenarian burn victims admitted between 1983 and 1993 is presented. The mean age was 84 years, with the mean percentage body surface area burned (%BSAB) being 9.6 per cent (range 0.5-65 per cent). Contrary to expectations, the annual incidence appears to be declining, the possible reasons for which are discussed. Surgery was required in 69 patients; in 11 this was performed within 1 week of injury. When compared to the more traditional delayed surgical approach, early surgery conveyed no benefits in either mortality (early group, 18 per cent; delayed group, 13 per cent) or length of hospital stay (early group survivors, 38 days; delayed group survivors, 42 days). Medical and social problems were very common and led to an often difficult and frequently prolonged rehabilitation, with the mean length of hospital stay for all patients being 29 days. The mortality of the whole group was 26 per cent, the patients on average faring better than their predicted mortalities as derived using either the Baux index, the Bull table or the Abbreviated Burn Severity Score.

Burns in the elderly in the south east of Scotland: review of 176 patients treated in the Bangour Burns Unit (1982-91) and burn inpatients in the region (1975-91)

One hundred and seventy-six patients aged 65 years and above, treated in Bangour Burns Unit during a 10-year period between 1982 and 1991 were studied in detail. Annual number of burn cases treated as inpatients in the South East of Scotland, within or outwith the Bangour burns unit, and all deaths due to burns, during the period from 1975 to 1991, among the estimated population were analysed to assess the trend in incidence and rates of burns in elderly persons in the community.

Management of trauma in the elderly patient

Injuries among the elderly are a common occurrence and, as the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly sustain the same injuries that younger people do; however, because of a variety of age-related processes, the elderly suffer more severe consequences from these injuries. Epidemiologic factors and physiologic processes are used to explain the "susceptibility" of the elderly population to traumatic injuries. Recommendations for initial resuscitation and management of specific injuries are presented along with general principles of injury prevention and rehabilitation. The socioeconomic cost of trauma in the elderly is discussed in terms of physical disabilities and financial burdens.

The elderly burn patient

During a 16-year period, 547 patients who were older than 64 years of age with a mean total body surface area (TBSA) (third-degree burns) of 25% were treated. Etiologies were flame/flash in 81% of patients, scald in 11%, solids in 7%, and electrical/chemical in 1%. Seventeen percent of patients had significant causal factors. An inhalation injury was present in 13% of patients, and the mortality in these patients was 100%. Burn excision was performed 239 times in 165 patients. The majority of excisions were for full-thickness burns. Excision did not improve overall survival in patients with third-degree burns of 0% to 10%, but the length of stay (LOS) in excised and nonexcised survivors was improved (9 versus 21 days, respectively). The LOS and survival were not significantly different in patients with burns between 11% and 20%. Postburn complications occurred in 28% of patients. Overall mortality was 50% (mean age: 77 years; TBSA: 40%). There were no survivors with over 47% TBSA burns. The leading cause of death was pulmonary sepsis. Most surviving patients returned to a satisfactory lifestyle after discharge.

Reduction of the mortality rate in aged burn patients

The management of elderly burn patients is time consuming for both nursing staff and physicians, and therapy remains often challenging and controversial. In a retrospective study, we analysed the outcome of two periods with different treatment modalities. An increased number of nurses, a change in the local burn wound treatment, better documentation of wound status and general conditions, and last, but not least, of nutritional aid, enabled us to reduce the mortality rate in patients over 65 years of age.

Geriatric injury: an analysis of prehospital demographics, mechanisms, and patterns

STUDY OBJECTIVE

To evaluate emergency medical services (EMS) system use, injury mechanisms, and prehospital assessments among elderly victims of trauma.

DESIGN

We analyzed all prehospital data for injuries among patients 70 years old or older for whom 911 EMS dispatch was requested in a medium-sized metropolitan area during a 12-month period.

RESULTS

A total of 1,154 cases occurred (women, 65.1%), which represented 30.3% of all 911 dispatches involving elderly patients. Injury mechanisms were fall (60.7%), motor vehicle accident (MVA; 21.5%), fight (2.4%), accidental poisoning (2.3%), and choking (2.1%). Persons in their 90s had a lower frequency of MVAs (3.4%) than did younger patients (23.0%) (P less than .005). The most frequent injuries determined by prehospital assessment were head or face (25.1%), upper extremity (17.2%), hip (14.5%), lower extremity (13.8%), back (9.8%), and chest or abdomen (5.0%). The frequency of serious neurologic injuries was less for falls or MVAs than for other mechanisms (P less than .005). Suspected hip (P less than .001) and pelvic (P less than .005) injuries occurred more frequently during falls than during other mechanisms of injury, whereas back injuries occurred most frequently in MVAs (P less than .001). Seventy-one fall victims (10.1%) had suspected medical causes of their fall. Twelve patients (1.0%) were in cardiac arrest.

CONCLUSION

We report injury patterns and mechanisms among elderly victims of trauma presenting to an EMS system. A knowledge of these patterns will be useful to emergency physicians and EMS administrators.