Steroids in the Treatment of Smoke Inhalation Injury:

Burn Care in Low-Resource and Austere Settings

More than 95% of the 11 million burns that occur annually happen in low-resource settings, and 70% of those occur among children. Although some low- and middle-income countries have well-organized emergency care systems, many have not prioritized care for the injured and experience unsatisfactory outcomes after burn injury. This chapter outlines key considerations for burn care in low-resource settings.

Systemic and Local Management of Burn Wounds

Management of severe burn injury (SBI) requires prompt, complex, and aggressive care. Despite major advances in the management of SBI-including patient-targeted resuscitation, management of inhalation injuries, specific nutritional support, enhanced wound therapy, and infection control-the consequences of SBI often result in complex, multiorgan metabolic changes. Consensus guidelines and clinical evidence regarding specific management of small animal burn patients are lacking. This article aims to review updated therapeutic consideration for the systemic and local management of SBI that are proven effective to optimize outcomes in human burn patients and may translate to small animal patients.

Risk Factors for In-Hospital Mortality in Smoke Inhalation-Associated Acute Lung Injury: Data From 68 United States Hospitals

BACKGROUND

Mortality after smoke inhalation-associated acute lung injury (SI-ALI) remains substantial. Age and burn surface area are risk factors of mortality, whereas the impact of patient- and center-level variables and treatments on survival are unknown.

METHODS

We performed a retrospective cohort study of burn and non-burn centers at 68 US academic medical centers between 2011 and 2014. Adult inpatients with SI-ALI were identified using an algorithm based on a billing code for respiratory conditions from smoke inhalation who were mechanically ventilated by hospital day 4, with either a length-of-stay ≥ 5 days or death within 4 days of hospitalization. Predictors of in-hospital mortality were identified using logistic regression. The primary outcome was the odds ratio for in-hospital mortality.

RESULTS

A total of 769 patients (52.9 ± 18.1 years) with SI-ALI were analyzed. In-hospital mortality was 26% in the SI-ALI cohort and 50% in patients with ≥ 20% surface burns. In addition to age > 60 years (OR 5.1, 95% CI 2.53-10.26) and ≥ 20% burns (OR 8.7, 95% CI 4.55-16.75), additional risk factors of in-hospital mortality included initial vasopressor use (OR 5.0, 95% CI 3.16-7.91), higher diagnostic-related group-based risk-of-mortality assignment and lower hospital bed capacity (OR 2.3, 95% CI 1.23-4.15). Initial empiric antibiotics (OR 0.93, 95% CI 0.58-1.49) did not impact survival. These new risk factors improved mortality prediction by 9.9% (P < .001).

CONCLUSIONS

In addition to older age and major surface burns, mortality in SI-ALI is predicted by initial vasopressor use, higher diagnostic-related group-based risk-of-mortality assignment, and care at centers with < 500 beds, but not by initial antibiotic therapy.

Early single-shot intravenous steroids do not affect pulmonary complications and mortality in burned or scalded patients

BACKGROUND AND OBJECTIVES

Inhalation injury, especially in combination with cutaneous burns, is the major cause of morbidity and mortality in patients admitted to burn care centers. Either with or without the presence of a cutaneous burn, inhalation injury contributes to high risk for developing severe pulmonary complications. Steroids may reduce a prolonged and destructive inflammatory response to toxic or allergic substances. The objective of this study was to evaluate the effect of early single-shot intravenous steroids on pulmonary complications and mortality in burned or scalded patients with or without inhalation injury.

METHODS

Retrospective analysis of a prospective single center database of patients registered between 1989 and 2011 who were admitted to the intensive care unit of our burn care center after burn or scald injury. Uni-variate statistical analysis was performed comparing two groups (steroid treated vs. non steroid treated patients) with regard to clinical outcome. Main parameters were sepsis, mortality and pulmonary complications such as pneumonia, ALI and ARDS. Multi-variate analysis was used by logistic regression with mortality and pulmonary complications as the dependent variables to identify independent risk factors after burn or scald injuries.

RESULTS

A total of 1637 patients with complete data were included in the present analysis. 199 (12.2%) received single-shot intravenous steroids during the prehospital phase of care. In 133 (66.8%) of these patients, inhalation injury was diagnosed via bronchoscopy. Steroid treated patients had sustained a significantly higher severity of burn than non-steroid treated patients (Abbreviated Burn Severity Index 7.1±3 vs. 6.0±2.9; p<0.001). In a multivariate analysis using a logistic regression model early intravenous steroid treatment had no significant effect on pulmonary complications and mortality.

CONCLUSIONS

In our single center cohort of burned and scalded patients single-shot intravenous steroids during the pre-hospital phase of care was not associated with pulmonary complications or mortality.

Update on the critical care management of severe burns

Care of the severely injured patient with burn requires correct diagnosis, appropriately tailored resuscitation, and definitive surgical management to reduce morbidity and mortality. Currently, mortality rates related to severe burn injuries continue to steadily decline due to the standardization of a multidisciplinary approach instituted at tertiary health care centers. Prompt and accurate diagnoses of burn wounds utilizing Lund-Browder diagrams allow for appropriate operative and nonoperative management. Coupled with diagnostic improvements, advances in resuscitation strategies involving rates, volumes, and fluid types have yielded demonstrable benefits related to all aspects of burn care. More recently, identification of comorbid conditions such as inhalation injury and malnutrition have produced appropriate protocols that aid the healing process in severely injured patients with burn. As more patients survive larger burn injuries, the early diagnosis and successful treatment of secondary and tertiary complications are becoming commonplace. While advances in this area are exciting, much work to elucidate immune pathways, diagnostic tests, and effective treatment regimens still remain. This review will provide an update on the critical care management of severe burns, touching on accurate diagnosis, resuscitation, and acute management of this difficult patient population.

[Inhalation injury--epidemiology, diagnosis and therapy]

OBJECTIVE

Inhalation injury is a vitally threatening medical syndrome, which might appear in patients with or without burn injuries. Thus, knowledge about development, diagnosis and treatment of inhalation injury should be available for each physician working in an intensive care unit.

METHODS

This review starts with the causal and formal pathogenesis of inhalation injuries. Furthermore, diagnosis and treatment in the critical care setting are presented, followed by the discussion of possible complications. Specific intoxications such as carbon monoxide are due to their importance separately discussed.

CONCLUSIONS

Inhalation injury present with an attributable excess mortality and thus worsen the prognosis of burned patients. New insights into the pathogenesis of inhalation injury, however, have led to improved therapeutic possibilities with improved outcome. Necessary prerequisites are a timely diagnosis and restrictive volume management, especially in patients with extensive burns. Prospective studies are needed to be able to answer the many emerging questions.