Inhalation Injury in the Burned Patient

An Unusual Pediatric Case of an Insidious Thermal Airway Injury Without Initial Signs of Facial or Intraoral Scalding

Thermal airway injuries, usually accompanied by facial burns, require emergency management. We encountered a pediatric case of a late airway-scalding injury without any initial signs of scalding on the face or inside the oral cavity. A 16-month-old boy was accidentally exposed to boiling water from overhead and developed tachypnea and dyspnea at 8 h after the injury. When he visited our hospital at 12 h after the injury, there were no scalding-related findings on his face or inside his oral cavity; however, severe laryngeal edema was observed, which required emergency intubation. Thermal airway injuries can occur later, even if there is no evidence of facial or oral scalding immediately after the injury. Airway injuries should be considered when a patient has been exposed to hot water from overhead.

Frequency, complications, and mortality of inhalation injury in burn patients: A systematic review and meta-analysis protocol

INTRODUCTION

Burns are tissue traumas caused by energy transfer and occur with a variable inflammatory response. The consequences of burns represent a public health problem worldwide. Inhalation injury (II) is a severity factor when associated with burn, leading to a worse prognosis. Its treatment is complex and often involves invasive mechanical ventilation (IMV). The primary purpose of this study will be to assess the evidence regarding the frequency and mortality of II in burn patients. The secondary purposes will be to assess the evidence regarding the association between IIs and respiratory complications (pneumonia, airway obstruction, acute respiratory failure, acute respiratory distress syndrome), need for IMV and complications in other organ systems, and highlight factors associated with IIs in burn patients and prognostic factors associated with acute respiratory failure, need for IMV and mortality of II in burn patients.

METHODS

This is a systematic literature review and meta-analysis, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). PubMed/MEDLINE, Embase, LILACS/VHL, Scopus, Web of Science, and CINAHL databases will be consulted without language restrictions and publication date. Studies presenting incomplete data and patients under 19 years of age will be excluded. Data will be synthesized through continuous (mean and standard deviation) and dichotomous (relative risk) variables and the total number of participants. The means, sample sizes, standard deviations from the mean, and relative risks will be entered into the Review Manager web analysis software (The Cochrane Collaboration).

DISCUSSION

Despite the extensive experience managing IIs in burn patients, they still represent an important cause of morbidity and mortality. Diagnosis and accurate measurement of its damage are complex, and therapies are essentially based on supportive measures. Considering the challenge, their impact, and their potential severity, IIs represent a promising area for research, needing further studies to understand and contribute to its better evolution. The protocol of this review is registered on the International prospective register of systematic reviews platform of the Center for Revisions and Disclosure of the University of York, United Kingdom (https://www.crd.york.ac.uk/prospero), under number RD42022343944.

Carbon monoxide poisoning: A problem uniquely suited to a medicinal inorganic chemistry solution

Carbon monoxide poisoning is one of the most common forms of poisoning in the world. Although the primary mode of treatment, oxygen therapy, is highly effective in many cases, there are instances in which it is inadequate or inappropriate. Whereas oxygen therapy relies on high levels of a low-affinity ligand (O2) to displace a high-affinity ligand (CO) from metalloproteins, an antidote strategy relies on introducing a molecule with a higher affinity for CO than native proteins (Kantidote,CO > Kprotein,CO). Based on the fundamental chemistry of CO, such an antidote is most likely required to be an inorganic compound featuring an electron-rich transition metal. A review is provided of the protein-, supramolecular complex-, and small molecule-based CO poisoning antidote platforms that are currently under investigation.

Effect of Cough Machine Assistance and Care Bundle Combined Therapy on Burned Patients With Moderate To Severe Inhalation Injury

To investigate the effectiveness of cough machine assistance combined with care bundle on mental resilience and self-efficacy on burned patients with moderate to severe inhalation injury. Totally 98 burned patients with moderate to severe inhalation injury from April 2021 to April 2022 were enrolled in this retrospective analysis. They were divided into the control group (n = 49, conventional therapy) and combined-therapy group (n = 49, cough machine assistance and care bundles). The mental resilience, posttraumatic growth, and self-efficacy were conducted. The arterial blood gas analysis indicators and incidence of pulmonary infection were also evaluated. The length of hospital stay in combined-therapy group was significantly less than that of control group. There was no difference of pulmonary infections between two groups before treatment. However, the incidence of pulmonary infection in the combined-therapy group was significantly lower. After the therapy, the combined-therapy group showed significantly higher partial pressure of oxygen, and lower levels of oxyhemoglobin saturation and partial pressure of carbon dioxide compared with the control group. The evaluation with the mental resilience, posttraumatic growth, and self-efficacy after the therapy, indicated that the patients in the combined-therapy group had significantly higher scores of optimism, strength, tenacity, relating to others, new possibilities, personal strength, appreciation of life and spiritual change, and self-efficacy. The combined therapy with cough machine assistance and care bundles can effectively improve the mental resilience and self-efficacy level of burned patients with moderate to severe inhalation injury, showing potential for possible clinical applications.

The risks of sedation and pain control during burn resuscitation: Increased opioids lead to over-resuscitation and hypotension

INTRODUCTION

Pain management and sedation are necessary in severely burned persons. Balancing pain control, obtundation, and hemodynamic suppression can be challenging. We hypothesized that increased sedation during burn resuscitation is associated with increased intravenous fluid administration and hemodynamic instability.

METHODS

A retrospective review of a single burn center was performed from 2014 to 2019 for all admissions to the burn unit with > 20% total body surface area (TBSA) burns. Within 48 h of admission, we compared total amounts of sedation/pain medications (morphine milligram equivalents (MME), propofol, dexmedetomidine, benzodiazepines) with total resuscitation volumes and frequency of hypotensive episodes. Resuscitation volumes and frequency of hypotension were modeled with multivariable linear regression adjusting for burn severity and weight.

RESULTS

208 patients were included with median age of 43 years (IQR 29-55) and median %TBSA of 31 (IQR 25-44). Median 48-hour resuscitation milliliters per weight per %TBSA were 3.3 (IQR 2.28-4.92). Pain/sedative medications included a combination of opioids in 99%, benzodiazepines in 73%, propofol in 31%, and dexmedetomidine in 11% of patients. MMEs were associated with greater resuscitation volumes (95% CI: 0.15-0.54, p = 0.01) as well as number of hypotensive events (95% CI: 1.57-2.7, p < 0.001). No associations were noted with other sedative medications when comparing the number of hypotensive events and resuscitation volumes.

CONCLUSIONS

Increased opioid administration has physiological consequences and should be carefully monitored during resuscitation as higher volume administrations lead to worse outcomes. Opioids and sedating medications should be titrated to the least amount needed to achieve reasonable comfort and sedation.

Diagnostic value of procalcitonin and red blood cell distribution width at admission on the prognosis of patients with severe burns: A retrospective analysis

The plasma procalcitonin (PCT) concentration and red blood cell distribution (RDW) value after severe burns can be used as prognostic indicators, but at present, it is difficult to give consideration to sensitivity and specificity in diagnosing the prognosis of severe burns with a single indicator. This study analysed the diagnostic value of plasma PCT concentration and RDW value at admission on the prognosis of severe burn patients to improve its sensitivity and specificity. A total of 205 patients with severe burns who were treated in the First Affiliated Hospital of Anhui Medical University from November 2017 to November 2022 were retrospectively analysed. The optimal cut-off values of plasma PCT concentration and RDW were analysed and counted through the subject curve (ROC curve). According to the cut-off value, patients were divided into high PCT group and low PCT group, high RDW group and low RDW group. The independent risk factors of severe burns were analysed by single-factor and multiple-factor COX regression. Kaplan-Meier survival was used to analyse the mortality of high PCT group and low PCT group, high RDW group and low RDW group. The area under the curve of plasma PCT concentration and RDW value at admission was 0.761 (95% CI, 0.662-0.860, P < .001), 0.687 (95% CI, 0.554-0.820, P = .003) respectively, and the optimal cut-off values of serum PCT concentration and RDW were 2.775 ng/mL and 14.55% respectively. Cox regression analysis found that age, TBSA, and RDW were independent risk factors for mortality within 90 days after severe burns. Kaplan-Meier survival analysis showed that there was a significant difference in the 90-day mortality rate of severe burns between the PCT ≥ 2.775 ng/mL group and the PCT < 2.775 ng/mL group (log-rank: 24.162; P < .001), with the mortality rate of 36.84% versus 5.49%, respectively. The 90-day mortality rate of severe burns was significantly different between the RDW ≥ 14.55% group and the RDW < 14.55% group (log-rank: 14.404; P < .001), with the mortality rate of 44% versus 12.2% respectively. The plasma PCT concentration and RDW value at admission are both of diagnostic value for the 90-day mortality of severe burns, but the plasma PCT concentration has higher sensitivity and the RDW value has higher specificity. Age, TBSA, and RDW were independent risk factors for severe burns, and then plasma PCT concentration was not independent risk factors.

Facteurs associés à une issue défavorable chez les brûlés hospitalisés

BACKGROUND

In 2015, Médecins Sans Frontières opened the Arche Kigobe Trauma Centre in Bujumbura, Burundi, to treat victims of violence, and in 2016 extended the admission criteria to burns, without a specialised unit to treat these.

OBJECTIVE

To study the factors associated with an unfavourable outcome (death, referrals and discharges against medical advice) in burn patients hospitalised at this centre.

METHOD

This is a retrospective descriptive and analytical study of hospitalised burn patients.

RESULTS

From 2016 to 2020, 477 patients were hospitalised at the Centre for burns, of whom 301 (63%) were less than 5 years old, 169 (35%) were female, and 48 (10%) had an unfavourable outcome. Anaemia (OR 11, 95% CI 2.7-48), infection (OR 11, 95% CI 5.7-22), and smoke inhalation (OR 28, 95% CI 7-111) were among the main factors associated with an unfavourable outcome.

CONCLUSION

To minimise adverse outcomes related to inhalation and infection in burn patients, a septic isolation circuit, training, a bacteriology service and continuous positive airway pressure could be implemented even in resource-limited settings.

Increased Incidence of Suspected Smoke Inhalation During the Coronavirus Disease 2019 Pandemic: A National Database Study

The COVID-19 pandemic has forced many Americans to adapt their daily routines. In 2020, there was a significant increase in house fires according to the National Fire Prevention Association (NFPA). The objective of this study was to characterize the changes in suspected smoke inhalations (SSIs) during the first year of the pandemic in the National Emergency Medical Services Information System (NEMSIS). The NEMSIS database was queried for all EMS transports captured between 2017 and 2020. Differences in the incidences of SSIs and fire dispatches in 2020 were estimated using Poisson regression models. There was a 13.4% increase in the incidence of fire dispatches and a 15% increase in SSIs transported in 2020 compared to the previous 3 years. The incidence rate ratio of both fire dispatches (1.271; 95% CI: 1.254-1.288; P < .001) and SSI (1.152; 95% CI: 1.070-1.241; P < .001) was significantly elevated in 2020. The increases in fire dispatches and SSIs observed in the NEMSIS database are in concordance with other literature indicating the increase in fire incidence and morbidity observed during the pandemic. These results should inform fire prevention outreach efforts and resource allocation in burn centers in the event of future pandemic.

First-day computed tomography: does it has a role in the assessment of patients with inhalation lung injury?

Background

Inhalation lung injury occurs in almost one-third of all serious burns and is responsible for a considerable proportion of burn patient fatalities each year. History of closed space fire or unconsciousness at the accident site, occurrence of pharyngeal or facial burns, hoarseness, and wheezing, and laboratory tests that include blood gas abnormalities or Carboxyhemoglobin levels in blood ˃ 10% are used to diagnose inhalation lung injury. It is also characterized by radiological findings of alveolar or interstitial edema, atelectasis, and/or consolidations, as well as the presence of erythema with laryngeal or tracheal edema in the bronchoscope.

Objectives

To study the diagnostic and prognostic efficacy of radiologist score and bronchial wall thickening as radiological CT findings in inhalation lung injury.

Methods

This prospective case–control study included 48 patients with inhalation lung injury (ILI) as a case group and 10 patients without ILI were selected as the control group, all recruited from the burn and plastic department. Within the first 12 h of suspected ILI, a fiberoptic bronchoscope was done to confirm the diagnosis. An initial chest X-ray was done followed by computed tomography through which the radiologist score (RADS) together with bronchial wall thickening (BWT) was done.

Results

Duration of ventilation was higher in cases than in controls (8.50 ± 3.94 vs 3.25 ± 0.50). The hospital duration was higher in cases than in controls (13.6 ± 4.68 vs9.50 ± 4.52). The BWT was 2.12 ± 0.66 (mean ± SD) in the ILI group while the control group was 1.32 ± 0.48 (mean ± SD). Correlating between baseline PaO2 and RADS score and BWT, it was found that there was a highly significant negative correlation between PaO2 and RADS score and BWT among inhalation lung injury patients (P value 0.001). The sensitivity of BWT in the detection of the need for mechanical ventilation was 83% at a cut-off point of 1.65. Its specificity was 78% and accuracy 75%.

Conclusion

CT done within 24 h of burn patients has a good role in the diagnosis and management of ILI from the burn.

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BACKGROUND

A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.

METHODS

The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.

RECOMMENDATIONS

The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.

Protective Effect of Nebulized Heparin in the Animal Models of Smoke Inhalation Injury: A Meta-analysis and Systematic Review of Experimental Studies

The pathophysiological mechanism of abnormal coagulation can result from smoke inhalation injury (SII). Heparin nebulization is a common treatment for lung disorders. This study aimed to use meta-analysis in animal models to examine the effectiveness of atomized heparin on SII. For our online searches, we used the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Chinese National Knowledge Infrastructure, Chinese BioMedical Literature Database, and Wanfang Database up to January 2022. Data for SII were retrieved and compared to control animals. The studies' findings were determined by combining standardized mean difference (SMD) analysis with 95% confidence intervals (CIs). The findings showed that as compared to the control group, the heparin-treated group had a lower death rate (relative risk 0.42; 95% CI 0.22, 0.80; p < .05). The meta-analysis demonstrated favorable changes in lung physiology, including PaO2/FiO2 (SMD 1.04; 95% CI 0.65, 1.44; p < .001), lung wet-to-dry weight ratio (SMD -1.83; 95% CI -2.47, -1.18; p < .001), and pulmonary shunt Qs/Qt (SMD -0.69; 95% CI -1.29, -0.08; p < .05) after heparin nebulization for lung injury. The present data indicated that pulmonary artery mean pressure in the heparin therapy group was significantly lowered after 24 and 48 hours of therapy, suggesting that the cardiovascular system could recover following heparin treatment. As a result, heparin nebulization appeared to be more effective against SII and improved cardiopulmonary function compared to the control group. Graphical Abstract.

Outcomes of COPD Patients with Flame Burn and Inhalation Injuries at a Single Institution

The presence of any comorbid condition may lead to worse outcomes after burn injury. Chronic obstructive pulmonary disease (COPD) is a condition with significant morbidity and mortality. In 2018, about 16 million adults in the United States reported a diagnosis of COPD based on data from the American Lung Association. The objective of this study was to explore the outcomes of patients with COPD admitted to our Burn Center with flame burns and/or inhalation injury. Patients were identified using our Institutional Burn Center registry and linked to the clinical and administrative data. All adult flame-injured and/or inhalation injury-only patients admitted to our burn center between July 1, 2011 and June 30, 2020 were included. Demographics, length of stay, burn, and patient characteristics and outcomes, including mortality, were evaluated. Four thousand three hundred ninety-seven patients were included in the study. Patients were divided into two populations, those with COPD (n = 515) and those without a diagnosis of COPD (n = 3882). Patients with COPD were older, more likely to be white and male, and had smaller sized burns, p < .001. Patients with COPD were more likely to be smokers and have comorbid conditions. There was no statistically significant difference between the incidence of inhalation injury, lengths of stay, or number of ventilator days. Burn size and inhalation injury increased mortality risk regardless of COPD severity, as did age among those not on home oxygen. More studies are needed to determine the genomic or proteomic changes in patients with COPD that lead to worse outcomes after flame injury, and/or inhalation injury alone.

Clinical characteristics and predictors of burn complicated with smoke inhalation injury: A retrospective analysis

Fire smoke enters the human lungs through the respiratory tract. The damage to the respiratory tract and lung tissue is known as smoke inhalation injury (SII). Fire smoke can irritate airway epithelium cells, weaken endothelial cell adhesion and lyse alveolar type II epithelia cells, leading to emphysema, decreased lung function, pneumonia and risk of acute lung injury/acute respiratory distress syndrome (ARDS). The purpose of the present study was to analyze the clinical characteristics of patients with SII and the risk factors affecting their prognosis. A total of 103 patients with SII admitted between January 2016 to December 2021 to the Burns Unit of the Characteristic Medical Center of Chinese People's Armed Police Force and 983 Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army were selected for the present study. The demographics and clinical features between different severities of SII were analyzed. Univariate/multivariate logistic regression was used to analyze the potential predictors for severity, ARDS and mortality of patients with SII. Receiver operating characteristic (ROC) curves were used to screen independent risk factors and identify their prediction accuracy. It was concluded that total body surface area (TBSA), III burn area (of total %TBSA), cases of respiratory infections, ARDS morbidity, mortality, acute physiology and chronic health evaluation II, lung injury prediction score, lactic acid, white blood cells (WBC), alanine transaminase, blood urea nitrogen, serum creatinine and uric acid were indicators that were raised with increasing severity of SII. However red blood cells, hemoglobin, platelet count, total protein, albumin, and albumin/globulin were decreased with the increasing severity of SII (P<0.05). WBC >20.91 (10⁹/l) was a reliable indicator for severe SII. Lactic acid >9.60 (mmol/l) demonstrated a high degree of accuracy in predicting ARDS development in patients with SII. Hemoglobin <83.00 (g/l) showed a high degree of accuracy in predicting mortality. In summary, the highlighted assessment parameters could be used to contribute to devising improved treatment plans to preempt worsening conditions (such as shock, ARDS, multiple organ dysfunction syndrome and death).

Factors Associated With Mechanical Ventilation Duration in Pediatric Burn Patients in a Regional Burn Center in the United States

OBJECTIVES

Among burned children who arrive at a burn center and require invasive mechanical ventilation (IMV), some may have prolonged IMV needs. This has implications for patient-centered outcomes as well as triage and resource allocation decisions. Our objective was to identify factors associated with the duration of mechanical ventilation in pediatric patients with acute burn injury in this setting.

DESIGN

Single-center, retrospective cohort study.

SETTING

Registry data from a regional, pediatric burn center in the United States.

PATIENTS

Children less than or equal to 18 years old admitted with acute burn injury who received IMV between January 2005 and December 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Ventilator days were defined as any full or partial day having received IMV via an endotracheal tube or tracheostomy, not inclusive of time spent ventilated for procedures. Of 5,766 admissions for acute burn care, 4.3% ( n = 249) required IMV with a median duration of 10 days. A multivariable model for freedom from mechanical ventilation showed that the presence of inhalational injury (subhazard ratio [sHR], 0.62; 95% CI, 0.46-0.85) and burns to the head and neck region (sHR, 0.94; 95% CI, 0.90-0.98) were associated with increased risk of remaining mechanically ventilated at any time point. Older (sHR, 1.03; 95% CI, 1.01-1.04) and male children (sHR, 1.39; 95% CI, 1.05-1.84) were more likely to discontinue mechanical ventilation. A majority of children (94.8%) survived to hospital discharge.

CONCLUSIONS

The presence of inhalational injury and burns to the head and neck region were associated with a longer duration of mechanical ventilation. Older age and male gender were associated with a shorter duration of mechanical ventilation. These factors should help clinicians better estimate a burned child's expected trajectory and resource-intensive needs upon arrival to a burn center.

Outcomes of Patients with Burns Associated with Home Oxygen Therapy: An Institutional Retrospective Review

Home oxygen therapy (HOT) burns carry high morbidity and mortality. Many patients are active smokers, which is the most frequent cause of oxygen ignition. We conducted a retrospective review at our institution to characterize demographics and outcomes in this patient population. An IRB-approved single-institution retrospective review was conducted for home oxygen therapy burn patients between July 2016 and January 2021. Demographic and clinical outcome data were compared between groups. We identified 100 patients with oxygen therapy burns. Mean age was 66.6 years with a male to female ratio of 1.3:1 and median burn surface area of 1%. In these patients, 97% were on oxygen for COPD and smoking caused 83% of burns. Thirteen were discharged from the emergency department, 35 observed for less than 24 hours, and 52 admitted. For admitted patients, 69.2% were admitted to the ICU, 37% required intubation, and 11.5% required debridement and grafting. Inhalational injury was found in 26.9% of patients, 3.9% underwent tracheostomy, and 17.3% experienced hospital complications. In-hospital mortality was 9.6% and 7.7% were discharged to hospice. 13.5% required readmission within 30 days. Admitted patients had significantly higher rates of admission to the ICU, intubation, and inhalational injury compared to those that were not admitted (p &lt; .01). Most HOT-related burns are caused by smoking and can result in significant morbidity and mortality. Efforts to educate and encourage smoking cessation with more judicious HOT allocation would assist in preventing these unnecessary highly morbid injuries.

Periodontal damage after thermal inhalation injury - The impact of high temperature inhalation injury on long term periodontal health

PURPOSE

Thermal inhalation injury is a common, life-threatening problem in burned patients. Whether or not this single event of damage to the oral integrity causes long term health problems is yet to be examined.

MATERIAL AND METHODS

All consecutive burn patients between 2014 and 2017 of Marienhospital Stuttgart (MHS), Germany, with at least 10% of burned skin surface were included and compared. The Periodontal Screening Index as well as Vitamin D levels were examined. Vitamin D has been suspected to contribute to the genesis of periodontitis. Risk factors and subjective oral life quality were prompted.

RESULTS

We included a total of 32 patients, 15 of which had an inhalation injury in their medical history. Risk factors were examined via Renatus' questionnaire. While risk factors were equally distributed in both groups we saw a remarkable difference in periodontal integrity, with the Periodontal Screening Index (PSI) per sextant differing drastically (with inhalation injury: 2.40, without inhalation injury: 1.10, p < 0.001). Patients with an inhalation injury had a mean of 5.2 out of 6 possible sextants with a pathologic PSI (with the median being 6/6), while patients without an inhalation injury had a mean of 1.83 out of 6 (median: 1/6), p < 0.001. The oral health impact profile showed a difference as well, albeit without statistical significance (with inhalation injury: median = 11, without: median = 3.5, p = 0.414). A correlation between Serum Vitamin D levels and periodontal integrity could not be seen in this group.

CONCLUSION

Inhalation injury is a possible cause for periodontitis and hence impacts the quality of life of burned patients.

Prediction of Mortality in Acute Thermal Burn Patients Using the Abbreviated Burn Severity Index Score: A Single-Center Experience

Background

Burn injuries are highly variable and dynamic. The outcome of patients is influenced by various factors and requires prompt therapeutic interventions, including fluid resuscitation, for a favorable result. Although having varying shortcomings, many scoring indexes are developed and validated in Western countries to predict mortality in a burn patient. The Abbreviated Burn Severity Index (ABSI) estimates survival expectancy in a burn patient via various negative prognostic factors. This study describes the pattern of burn injuries to validate the ABSI as an outcome predictor in burnt patients.

Methodology

From January to December 2018, 100 patients participated in this observational research conducted in the Department of Surgery at Mahatma Gandhi Hospital’s Burn Ward, a part of Dr. Sampurnanand Medical College, Jodhpur. Risk factors for death from a burn were patients’ age and gender, the depth of the burn, the inhalation burn, and the total burned body surface area (TBSA). The area under the receiver operating curve (AUROC) was used to determine how well it could predict burn deaths.

Results

This study included 100 patients (69 men and 31 women, with a ratio of 2.22:1). In total, 73 patients survived, and 27 died (a mortality rate of 27%). The fatality rate increased with increased burn surface area, reaching 100% in patients with >80% burns (p < 0.0001). Additionally, those with an ABSI of >11 expressed 100% mortality rate (p < 0.0001).

Conclusions

In this study, older age, high burned surface area, concomitant inhalational burns, full-thickness burns, and a higher ABSI were found to be significant predictors of mortality.

Care of the Critically Injured Burn Patient

Care of the critically injured burn patient presents unique challenges to the intensivist. Certified burn centers are rare and geographically sparse, necessitating that much of the initial management of patients with severe burn injuries must happen in the pre-burn center setting.1 Severe burn injuries often lead to a wide range of complications that extend beyond the loss of skin integrity and require specialized care. As such, medical intensivists are often called upon to stabilize these critically injured patients. This focused review outlines the clinical care of these medically complex patients, including airway management, post-burn complications, volume resuscitation, nutrition, and end-of-life care.

A Rationale for Safe Ventilation with Inhalation Injury: An Editorial Review

Lung injury from smoke inhalation manifests as airway and parenchymal damage, at times leading to the acute respiratory distress syndrome. From the beginning of this millennium, the approach to mechanical ventilation in the patient with ARDS was based on reduction of tidal volume to 6 milliliters/kilogram of ideal body weight, maintaining a ceiling of plateau pressure, and titration of driving pressure (plateau pressure minus PEEP). Beyond these broad constraints, there is little specification for the mechanics of ventilator settings, consideration of the metabolic impact of the disease process on the patient, or interaction of patient disease and ventilator settings. Various studies suggest that inhomogeneity of lung injury, which increases the risk of regional lung trauma from mechanical ventilation, may be found in the patient with smoke inhalation. We now appreciate that energy transfer principles may affect optimal ventilator management and come into play in damaged heterogenous lungs. Mechanical ventilation in the patient with inhalation injury should consider various factors. Self-injurious respiratory demand by the patient can be reduced using analgesia and sedation. Dynamic factors beginning with rate management can reduce the incidence of potentially damaging ventilation. Moreover, preclinical study is underway to examine the flow of gas based on the ventilator mode selected, which may also be a factor triggering regional lung injury.

The expression profile of lung long non-coding RNAs and mRNAs in a mouse model of smoke inhalation injury

To study the potential expression of lung long non-coding RNAs (lncRNAs) and mRNAs during smoke inhalation injury (SII), using a SII mouse model that we created in our previous work. Microarray was used to investigate the lncRNAs and mRNAs profiles. A bioinformatics analysis was performed. Changes in the top 10 down-regulated and 10 up-regulated lncRNAs were validated using Quantitative Reverse Transcription-PCR (RT-qPCR). The acute lung injury (ALI) mouse model was successfully induced by smoke inhalation, as confirmed by the aberrantly modified cell numbers of red blood cells and neutrophils counts, increased levels of TNF-α, IL-1β, Bax, caspase-7, caspase-3, and decreased Bcl-2 content in lung tissues. When compared to the control mice, 577 lncRNAs and 517 mRNAs were found to be aberrantly expressed in the SII mice. According to the Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses, the altered mRNAs were enriched in acute-phase response, oxidoreductase activity, oxidation-reduction process, glutathione metabolism, the wnt signaling pathway, and ferroptosis. A lncRNA-related competitive endogenous RNA (ceRNA) network, including 383 lncRNAs, 318 MicroRNAs (miRNAs), and 421 mRNAs specific to SII, was established. The changes in NONMMUT026843.2, NONMMUT065071.2, ENSMUST00000235858.1, NONMMUT131395.1, NONMMUT122516.1, NONMMUT057916.2, and NONMMUT013388.2 in the lung matched the microarray results. Our findings help to provide a more comprehensive understanding of the pathogenesis of SII as well as new insights into potential therapeutic targets.

Development and Application of Multidimensional Lipid Libraries to Investigate Lipidomic Dysregulation Related to Smoke Inhalation Injury Severity

The implication of lipid dysregulation in diseases, toxic exposure outcomes, and inflammation has brought great interest to lipidomic studies. However, lipids have proven to be analytically challenging due to their highly isomeric nature and vast concentration ranges in biological matrices. Therefore, multidimensional techniques such as those integrating liquid chromatography, ion mobility spectrometry, collision-induced dissociation, and mass spectrometry (LC-IMS-CID-MS) have been implemented to separate lipid isomers as well as provide structural information and increased identification confidence. These data sets are however extremely large and complex, resulting in challenges for data processing and annotation. Here, we have overcome these challenges by developing sample-specific multidimensional lipid libraries using the freely available software Skyline. Specifically, the human plasma library developed for this work contains over 500 unique lipids and is combined with adapted Skyline functions such as indexed retention time (iRT) for retention time prediction and IMS drift time filtering for enhanced selectivity. For comparison with other studies, this database was used to annotate LC-IMS-CID-MS data from a NIST SRM 1950 extract. The same workflow was then utilized to assess plasma and bronchoalveolar lavage fluid (BALF) samples from patients with varying degrees of smoke inhalation injury to identify lipid-based patient prognostic and diagnostic markers.

Early tracheostomy and active exercise programmes in adult intensive care patients with severe burns

BACKGROUND

Tracheostomy is a strategy often employed in patients requiring prolonged intubation in ICU settings. Evidence suggests that earlier tracheostomy and early active exercise are associated with better patient centered outcomes. Severe burn patients often require prolonged ventilatory support due to their critical condition, complex sedation management and multiple operating room visits. It is still unclear the optimal timing for tracheostomy in this population.

METHODS

We conducted a service evaluation where we compared Early Tracheostomy (≤10 days) with Late Tracheostomy (>10 days) in 41 severely burned patients that required prolonged respiratory support.

RESULTS

Early Tracheostomy cohort was associated with fewer days of mechanical ventilation (16 vs 33, p = 0.001), shorter hospital length of stay (65 vs 88 days, p = 0.018), earlier first day of active exercise (day 8 vs day 25, p < 0.0001) and higher Functional Assessment for Burns scores upon discharge (32 vs 28, p = 0.016).

CONCLUSION

Early tracheostomy in patients with severe burns is associated with earlier active exercise, fewer days of ventilation, shorter length of hospital stay and better physical functional independence upon discharge from hospital.

Different Depths May Not Determine the Fluid Resuscitation Volume in Early-stage Management of Severe Burns: a Model-Comparison Retrospective Analysis of Fluid Volume Determining Factors

BACKGROUND

Large-volume fluid resuscitation remains irreplaceable in the early-stage management of severe burns. We aimed to explore the relationship between fluid volume and other indicators.

METHOD

Data of severe burn patients with successful resuscitation in the early stage was collected. Correlation and linear regression analyses were performed. Multiple linear regression models, related goodness-of-fit assessment (adjusted R-square and Akaike Information Criterion), scatter plots and paired t-test for two models, and a likelihood ratio test were performed.

RESULTS

96 patients were included. The median of total burn area (TBA) was 70%TBSA, with full thickness burn area (FTBA)/TBA of 0.4, a resuscitation volume of 1.93 mL/kg/%TBSA. Among volume-correlated indicators, two linear regression models were established (Model 1: TBA × weight and tracheotomy; and Model 2: FTBA × weight, partial thickness burn area (PTBA) × weight, and tracheotomy). For these models, close values of Akaike Information Criterion, adjusted R-squares, outliers of the prediction range, and the result of paired t-test, all suggest similarity between two models estimations, while the likelihood ratio test for coefficients of FTBA × weight and PTBA × weight showed a statistical difference.

CONCLUSION

inhalational injury and decompression surgery only correlated with volume, while Tracheotomy, TBA × weight, FTBA × weight, and PTBA × weight correlated with and were accepted in linear models of volume. Although FTBA and PTBA differed statistically, there may be no need to distinguish them when estimating the resuscitation volume requirements in this patient set. Further study about different depths fluid should be conducted.

Inhalation Injury is Associated with Endotheliopathy and Abnormal Fibrinolytic Phenotypes in Burn Patients: A Cohort Study

Burn injury is associated with endothelial dysfunction and coagulopathy and concomitant inhalation injury increases morbidity and mortality. The aim of this work is to identify associations between inhalation injury (IHI), coagulation homeostasis, vascular endothelium, and clinical outcomes in burn patients. One-hundred and twelve patients presenting to a regional burn center were included in this retrospective cohort study. Whole blood was collected at set intervals from admission through 24 hours and underwent viscoelastic assay with rapid TEG (rTEG). Syndecan-1 (SDC-1) on admission was quantified by ELISA. Patients were grouped by the presence (n=28) or absence (n=84) of concomitant IHI and rTEG parameters, fibrinolytic phenotypes, SDC-1, and clinical outcomes were compared. Of the 112 thermally injured patients, 28 (25%) had IHI. Most patients were male (68.8%) with a median age of 40 (IQR, 29-57) years. Patients with IHI had higher overall mortality (42.68% vs. 8.3%; p<0.0001). rTEG LY30 was lower in patients with IHI at hours 4 and 12 (p<0.05). There was a pattern of increased abnormal fibrinolytic phenotypes among IHI patients. There was a greater proportion of IHI patients with endotheliopathy (SDC-1 > 34 ng/mL) (64.7% vs. 26.4%; p=0.008). There was a pattern of increased mortality among patients with inhalation injury and endotheliopathy (0% vs. 72.7%; p=0.004). Significant differences between patients with and without IHI were found in measures assessing fibrinolytic potential and endotheliopathy. Mortality was associated with abnormal fibrinolysis, endotheliopathy, and inhalation injury. However, the extent to which IHI associated dysfunction is independent of TBSA burn size remains to be elucidated.

Pediatric tracheal trauma

Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.

Does High-Frequency Chest Wall Oscillation Have an Impact on Improving Pulmonary Function in Patients With Smoke Inhalation Injury?

Smoke inhalation results in bronchospasm of the trachea, increasing secretion of mucus, casts formation, and improvement of blood flow of the airway. High frequency chest wall oscillation is a common modality used for clearing mucus secretion in patients suffering from hypersecretion of thick mucus and used also to help cough clearance. This study aimed to detect the effect of high frequency chest wall oscillation in improving pulmonary function in burn patients suffering from smoke inhalation. Sixty smoke inhalation injury patients were randomly distributed into two groups of equal size. Group A: received high frequency chest wall oscillation and conventional chest physical therapy (breathing exercises, early ambulation, and cough training) thrice per week for 8 weeks. Group B: received traditional chest physical therapy (breathing exercises, early ambulation, and cough training) thrice per week for 8 weeks. Pulmonary function test (forced vital capacity, forced expiratory volume in the first second and peak expiratory flow rate) was measured at enrollment and after 8 weeks by using spirometer. Pulmonary function increased significantly posttreatment when compared with that pretreatment in groups A and B (P > .001). Also, they increased significantly in group A compared with that of group B posttreatment (P > .05). High-frequency chest wall oscillation have an impact on improving pulmonary function and should be handled to be a part of the pulmonary rehabilitation plan for smoke inhalation injury patients.

A surfactant polymer wound dressing protects human keratinocytes from inducible necroptosis

Chronic wounds show necroptosis from which keratinocytes must be protected to enable appropriate wound re-epithelialization and closure. Poloxamers, a class of synthetic triblock copolymers, are known to be effective against plasma membrane damage (PMD). The purpose of this study is to evaluate the efficacy of a specific poloxamer, surfactant polymer dressing (SPD), which is currently used clinically as wound care dressing, against PMD in keratinocytes. Triton X-100 (TX100) at sub-lytic concentrations caused PMD as demonstrated by the efflux of calcein and by the influx of propidium iodide and FM1-43. TX100, an inducer of necroptosis, led to mitochondrial fragmentation, depletion of nuclear HMGB1, and activation of signaling complex associated with necroptosis (i.e., activation of RIP3 and phosphorylation of MLKL). All responses following exposure of human keratinocytes to TX100 were attenuated by pre- or co-treatment with SPD (100 mg/ml). The activation and translocation of phospho-MLKL to the plasma membrane, taken together with depletion of nuclear HMGB1, characterized the observed cell death as necroptosis. Thus, our findings show that TX100-induced plasma membrane damage and death by necroptosis were both attenuated by SPD, allowing keratinocyte survival. The significance of such protective effects of SPD on keratinocytes in wound re-epithelialization and closure warrant further studies.

Advances in airway management and mechanical ventilation in inhalation injury

PURPOSE OF REVIEW

Airway management, mechanical ventilation, and treatment of systemic poisoning in burn patients with inhalation injury remains challenging. This review summarizes new concepts as well as open questions.

RECENT FINDINGS

Several life-threatening complications, such as airway patency impairment and respiratory insufficiency, can arise in burn patients and require adequate and timely airway management. However, unnecessary endotracheal intubation should be avoided. Direct visual inspection via nasolaryngoscopy can guide appropriate airway management decisions. In cases of lower airway injury, bronchoscopy is recommended to remove casts and estimate the extent of the injury in intubated patients. Several mechanical ventilation strategies have been studied. An interesting modality might be high-frequency percussive ventilation. However, to date, there is no sound evidence that patients with inhalation injury should be ventilated with modes other than those applied to non-burn patients. In all burn patients exposed to enclosed fire, carbon monoxide as well as cyanide poisoning should be suspected. Carbon monoxide poisoning should be treated with an inspiratory oxygen fraction of 100%, whereas cyanide poisoning should be treated with hydroxocobalamin.

SUMMARY

Burn patients need specialized care that requires specific knowledge about airway management, mechanical ventilation, and carbon monoxide and cyanide poisoning.

Bronchoalveolar lavage and plasma Antithrombin and cytokines in inhalation and burn injury: a pilot study

Systemic inflammatory response syndrome (SIRS) is initiated during the acute phase of thermal injury. The objective was to determine the SIRS impact on cytokine and Antithrombin (AT) levels in smoke inhalation and burn injury. This observational pilot study compared plasma and bronchoalveolar lavage fluid (BAL) cytokine and AT levels in the first six days post smoke inhalation and burn injury. Twenty-five patients, 14 with inhalation + burn injury > 10% total body surface area (TBSA) and 11 with inhalation injury and ≤ 10% TBSA participated. Human Th1/Th2 cytometric bead array kit from BD Biosciences Pharmingen determined cytokine levels; AT levels with Sigma Diagnostics and spectrophotometry. Results indicated no significant age difference between the two groups (42.1 ± 7.2) versus 49.6 ± 6.4 years. On admission, the inhalation group had 5.4 ± 3.9% TBSA compared to 35.0 ± 22.2% TBSA in the inhalation + burn group, P < 0.001. Comparing groups, AT plasma levels were significantly decreased (P = 0.025) and IL-2 levels significantly increased (P = 0.025) in the inhalation + burn group compared to the inhalation group; there was no significant difference in BAL AT or cytokine levels. Combined group plasma AT levels (65.41 ± 4.44%) were significantly increased compared to BAL AT levels (1.06 ± 0.71%), P < 0.001. In contrast, BAL TNF-α levels (35.61 ± 16.01 pg/ml) were significantly increased in relation to the plasma levels (4.68 ± 1.27 pg/ml), P = 0.02. On days 1-2, AT plasma levels were significantly decreased in the inhalation + burn group (41.01 ± 5.24%) compared to the inhalation group (81.02 ± 10.99%), P = 0.002. IL-6 plasma levels were higher in the inhalation + burn group compared to the inhalation group on admission, but both levels decreased by days 3-6. IL-6 BAL levels were elevated in both groups on days 1-2 and decreased by days 3-6. In the first six days of resuscitation, all plasma cytokines were increased in the two groups compared to controls. AT plasma and BAL levels were significantly reduced in both groups, contributing to the coagulopathy. Increased BAL TNF-α and IL-6 levels may have contributed to the pulmonary perturbations during the initial SIRS response in both groups.

The short-term rinsing of airways by N-acetylcysteine helps expectoration: The mechanism of sodium and chloride transport

N-acetyl-L-cysteine (NAC) mucolytic and antioxidant role is well known, but the effect on epithelial ion transport has not been yet described. The aim of the study was to evaluate the short-term and prolonged influence of NAC on ion transport in the epithelium. The experiment was performed on 108 fragments of rabbit tracheae. Fragments were divided into four groups: inhibited sodium (I) and chloride (II) transport, NAC with inhibited sodium (III) and NAC with inhibited chloride (IV) transport. The changes in electrophysiological parameters were measured in stationary conditions and during mechanical-chemical stimulation after immediate (15 s) and prolonged (60 min) N-acetylcysteine administration on the tissue. Each 15-second stimulation caused repeatable changes in the electric potential of the tissue. In trachea fragments with blocked chloride ion transport, significantly lower (P <0.0001) values of electric potential following prolonged NAC effect were observed when compared to short-term NAC-stimulation. The values of resistance were constant during experiments, which reflects the vitality of the tissue. Short-term NAC administration influences sodium ion transport, which is not observed in a prolonged stimulation. The use of the NAC solution to rinse the airways is of great clinical importance due to the short and intense contact with the epithelium.

An Analysis of Factors Associated with Burn Injury Outcomes in Low- and Middle-Income Countries

BACKGROUND

Burn injuries are a major cause of morbidity and mortality within low- and middle-income countries (LMICs). The World Health Organization developed the Global Burn Registry to centralize data collection for the guidance of burn prevention programs. This study analyzed the epidemiologic and hospital-specific factors associated with burn injury outcomes in LMICs and high-income countries (HICs).

METHODS

A retrospective review was performed using the Global Burn Registry over 3 y. Patients were stratified by income region. Bivariate analyses and stepwise regressions were performed to evaluate patient and hospital demographics and variables associated with injury patterns and outcomes. Outcomes of interest included mortality and length of stay.

RESULTS

Over the study period, data were collected on 1995 patients from 10 LMICs (20 hospitals) and four HICs (four hospitals). Significantly higher mortality was seen in LMICs compared with HICs (17% versus 9%; P < 0.001). There was no significant difference between income regions for injury patterns (P = 0.062) or total body surface area of the burn injury (P = 0.077). Of the LMIC hospitals in this data set, 11% did not have reliable access to an operating theater.

CONCLUSIONS

HICs had a lower overall mortality even with higher rates of concurrent injuries, as well as longer length of stay. LMIC hospitals had fewer resources available, which could explain increased mortality, given similar total body surface area. This study highlights how investing in health care infrastructure could lead to improved outcomes for patients in low-resource settings.

Intubation in burns patients: a 5-year review of the Manchester regional burns centre experience

Despite criteria to guide intubation from the American Burn Association (ABA), concerns remain regarding over-intubation of burns patients. The purpose of this study was to review appropriateness of intubation at a UK regional burns centre over a 5-year period. A 5-year retrospective review of adult patients admitted to the Manchester Burns Centre who underwent intubation at or prior to admission was performed. Intubations for non-burn indications or burns >40%TBSA were excluded. Patient demographic and burn characteristics data were extracted from medical records. Indications for intubation were compared to ABA and Denver criteria. 47 patients were identified, of which 40 met inclusion criteria for analysis. 72.5% and 95% of these patients met ABA or Denver criteria respectively. 30.8% of patients were extubated within 48 h. 50% patients extubated within 48 h had ≤1 indication for intubation or negative laryngoscopy. Complications related to intubation and ventilation were noted in 37.5% of patients, with ventilation associated pneumonia (VAP) being the most common occurring in 27.5%. 95% of patients fulfilled recognised criteria for intubation. However, 30% were extubated within 48 h, suggesting potentially avoidable intubation. This study suggests current intubation criteria may over-estimate risk of airway compromise and supports results from non-UK studies that a proportion of patients may be suitable for close observation rather than early intubation.

Obstructive Tracheal Necrosis in a Dog Secondary to Smoke Inhalation Injury-Case Report

A 4-year-old Siberian Husky mix was referred to the emergency service of the University of California Davis Veterinary Medical Teaching Hospital after being found unconscious in a housefire. Upon arrival, the dog was conscious and panting with normal breathing effort. The dog was initially treated with oxygen therapy to minimize the risk of carbon monoxide toxicosis. Progressive agitation with paroxysmal episodes of increased respiratory effort and increased upper airway sounds were noted ~48 h after presentation. Hypoxemia was then documented. Clinical signs continued to progress despite supportive measures, and five days after initial presentation mechanical ventilation was deemed indicated. Following anesthetic induction, endotracheal intubation was performed. Capnography and peak inspiratory pressures recorded on the mechanical ventilator were consistent with airway obstruction. Diffuse intraluminal tracheal obstruction with grossly necrotic tracheal tissue was confirmed using fiber optic tracheoscopy. The patient was humanely euthanized due to grave prognosis. At necropsy, the tracheal lumen was obstructed by sloughed, necrotic tracheal mucosa. This is the first report describing a severe delayed intrathoracic large airway complication secondary to smoke inhalation in a dog.

The Predictive Applicability of Liberal vs Restrictive Intubation Criteria in Adult Patients With Suspected Inhalation Injury-A Retrospective Cohort Study

This study compares the ability of liberal vs restrictive intubation criteria to detect prolonged intubation and inhalation injury in burn patients with suspected inhalation injury. Emerging evidence suggests that using liberal criteria may lead to unnecessary intubation in some patients. A single-center retrospective cohort study was conducted in adult patients with suspected inhalation injury admitted to intensive care at Queen Elizabeth Hospital, Birmingham between April 2016 and July 2019. Liberal intubation criteria, as reflected in local guidelines, were compared to restrictive intubation criteria, as outlined in the American Burn Association guidelines. The number of patients displaying positive characteristics from either guideline was compared to the number of patients who had prolonged intubation (more than 48 hours) and inhalation injury. In detecting a need for prolonged intubation (n = 85), the liberal criteria had greater sensitivity (liberal = 0.98 [0.94-1.00] vs restrictive = 0.84 [0.75-0.93]; P = .013). However, the restrictive criteria had greater specificity (restrictive = 0.96 [0.89-1.00] vs liberal = 0.48 [0.29-0.67]; P < .001). In detecting inhalation injury (n = 72), the restrictive criteria were equally sensitive (restrictive = 0.94 [0.87-1.00] vs liberal = 0.98 [0.84-1.00]; P = .48) and had greater specificity (restrictive = 0.86 [0.72-1.00] vs liberal = 0.04 [0.00-0.13]; P < .001). In patients who met liberal but not restrictive criteria, 65% were extubated within 48 hours and 90% did not have inhalation injury. Liberal intubation criteria were more sensitive at detecting a need for prolonged intubation, while restrictive criteria were more specific. Most patients intubated based on liberal criteria alone were extubated within 48 hours. Restrictive criteria were highly sensitive and specific at detecting inhalation injury.

Nebulized heparin for inhalation injury in burn patients: a systematic review and meta-analysis

Background

Smoke inhalation injury increases overall burn mortality. Locally applied heparin attenuates lung injury in burn animal models of smoke inhalation. It is uncertain whether local treatment of heparin is benefit for burn patients with inhalation trauma. We systematically reviewed published clinical trial data to evaluate the effectiveness of nebulized heparin in treating burn patients with inhalation injury.

Methods

A systematic search was undertaken in PubMed, the Cochrane Library, Embase, Web of Science, the Chinese Journals Full-text Database, the China Biomedical Literature Database and the Wanfang Database to obtain clinical controlled trails evaluating nebulized heparin in the treatment of burn patients with inhalation injury. Patient and clinical characteristics, interventions and physiological and clinical outcomes were recorded. Cochrane Risk of Bias Evaluation Tool and the Newcastle–Ottawa Scale were used to evaluate data quality. Potential publication bias was assessed by Egger’s test. A sensitivity analysis was conducted to assess the stability of the results. The meta-analysis was conducted in R 3.5.1 software.

Results

Nine trials were eligible for the systematic review and meta-analysis. Nebulized heparin can reduce lung injury and improve lung function in burn patients with inhalation injury without abnormal coagulation or bleeding, but the findings are still controversial. Mortality in the heparin-treated group was lower than that of the traditional treatment group (relative risk (RR) 0.75). The duration of mechanical ventilation (DOMV) was shorter in the heparin-treated group compared to the traditional treatment group (standardized mean difference (SMD) −0.78). Length of hospital stay was significantly shorter than that in the traditional treatment group (SMD −0.42), but incidence rates of pneumonia and unplanned reintubation were not significantly different in the study groups (RRs 0.97 and 0.88, respectively). No statistically significant publication biases were detected for the above clinical endpoints (p > 0.05).

Conclusions

Based on conventional aerosol therapy, heparin nebulization can further reduce lung injury, improve lung function, shorten DOMV and length of hospital stay, and reduce mortality, although it does not reduce the incidence of pneumonia and/or the unplanned reintubation rate.

Initial management of severe burn injury

PURPOSE OF REVIEW

Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management. This review critically discusses current practices and recently published data regarding the evaluation and management of severe burn injury.

RECENT FINDINGS

Burn patients have long, complex ICU stays with accompanying multiorgan dysfunction. Recent advances in burn intensive care have focused on acute respiratory distress syndrome from inhalation injury, acute kidney injury (AKI), and transfusion, resulting in new strategies for organ failure, including renal replacement therapy and extracorporeal life support.

SUMMARY

Initial evaluation and treatment of acute severe burn injury remains an ongoing area of study. This manuscript reviews current practices and considerations in the acute management of the severely burn injured patient.

The Effects of Pre-Burn Center Intubation on Rates of Pneumonia, Early Extubation, and Death: A Systematic Review

Airway burns cause delayed collapse of airways due to airway edema. Transferring clinicians are trained to intubate at the first suspicion of airway collapse, which can lead to vague reasons for intubation such as "airway protection." Intubation, however, is not without risks, such as pneumonia and death. The objective of this research review is to compare pre-burn center intubations with those performed at burn centers and compare rates of pneumonia, mortality, and time to extubation. A systematic review of articles from MEDLINE and CINAHL Plus was performed to identify eligible trials and observational studies that compared pre-burn center intubations with those performed at burn centers between the years 2014 and 2018. Four studies met eligibility requirements. There were mixed results on the correlation of pre-burn center intubation with pneumonia and death; however, pre-burn center patients were more likely to have earlier extubation times, which points to potentially unnecessary intubations. Clinicians should be aware of the increased mortality and morbidity associated with intubation. Providers should use objective evidence-based tools such as the ABA (American Burn Association) and Denver criteria to determine the need for intubation to avoid unnecessary intubations and their potential complications.

Risk factors for acute respiratory distress syndrome in severe burns: prospective cohort study

INTRODUCTION

Age and inhalation injury are important risk factors for acute respiratory distress syndrome (ARDS) in the burned patient; however, the impact of interventions such as mechanical ventilation, fluid balance (FB), and packed red blood cell transfusion remains unclear. The purpose of this study was to determine the incidence of moderate and severe ARDS and its risk factors among burn-related demographic variables and clinical interventions in mechanically ventilated burn patients. Risk factors for death within 28 days were also evaluated.

METHOD

A prospective longitudinal study was carried out over a period of 30 months between July 2015 and December 2017. Patients older than 18 years, with a burn injury and under mechanical ventilation were included. The outcomes of interest were diagnosis of ARDS up to seven days after admission and death within 28 days. The proportional Cox regression risk model was used to obtain the hazard ratio for each independent variable.

RESULTS

The cases of 61 patients were analyzed. Thirty-seven (60.66%) of the patients developed ARDS. The groups of patients with or without ARDS did not present differences regarding age, sex, burned body surface, or prognostic scores. Factors independently related to the occurrence of ARDS were age (hazard ratio [HR] = 1.04; 95% confidence interval [CI] 1.02-1.06; P < 0.001), inhalation injury (HR = 2.50; 95% CI 1.25-5.02; P = 0.01), and static compliance (HR = 0.97; 95% CI 0.94-0.99; P = 0.03). Tidal volume, driving pressure, acute renal injury, and FB between days 1 and 7 were similar in both groups. Accumulated FBs of 48, 72, 96, and 168 hours were also similar. Mortality at 28 days was 40.98% (25 patients). ARDS (HR = 3.63, 95% CI 1.36 to 9.68; P = 0.01) and burned body surface area (HR = 1.03, 95% CI 1.02 to 1.05; P < 0.001) were associated with death in 28 days.

CONCLUSION

ARDS was a frequent complication and a risk factor for death in patients under mechanical ventilation, with large burned areas. Age and inhalation injury were independent factors for ARDS. Current tidal volume, driving pressure, red blood cell transfusion, acute renal injury, and FB were not predictors of ARDS.