Treatment before transfer: the patient with burns

Temporal trends in burn size estimation and the impact of the NSW Trauma App on estimation accuracy

BACKGROUND

Several studies demonstrated that burn size calculations by referring clinicians are poor. The purpose of this study was to determine if inaccuracies in burn size estimation have improved with time within the same population, and whether widespread roll-out of a smartphone-based TBSA calculator (in the form of the NSW Trauma App) had an impact on accuracy.

METHODS

A review of all burn-injured adult patients transferred to Burn Units from August 2015, following the roll out of the NSW Trauma App, to January 2021 was performed. The TBSA determined by the referring centre was compared with the TBSA calculated by the Burn Unit. This was compared to historical data from the same population between January 2009 and August 2013.

RESULTS

There were 767 adult burn-injured patients transferred to a Burn Unit between 2015 and 2021. The median overall TBSA was 7%. There were 290 patients (37.9%) who had equivalent TBSA calculations by the referring hospital and the Burn Unit. This was a significant improvement compared to the preceding time period (P < 0.005). Overestimation by the referring hospital occurred in 364 cases (47.5%), which was significantly reduced compared to 2009 - 2013 (P < 0.001). Unlike the earlier time period where changes in estimation accuracy were seen in relation to increasing time after the burn injury, burn size estimation accuracy remained relatively consistent in the contemporary time period with no significant change observed (P = 0.86).

CONCLUSIONS

This cumulative, longitudinal study of nearly 1500 adult burn-injured patients over 13 years demonstrates improvements in burn size estimation by referring clinicians over time. It is the largest cohort of patients analysed with respect to burn size estimation and is the first to demonstrate improvements in accuracy of TBSA in association with a smartphone-based app. Adopting this simple strategy into burn retrieval systems will augment early assessment of these injuries and improve outcomes.

Burn related injuries: a nationwide analysis of adult inter-facility transfers over a six-year period in the United States

Background

US emergency department (ED) visits for burns and factors associated with inter-facility transfer are unknown and described in this manuscript.

Methods

We conducted a retrospective analysis of burn-related injuries from 2009–2014 using the Nationwide Emergency Department Sample (NEDS), the largest sample of all-payer datasets. We included all ED visits by adults with a burn related ICD-9 code and used a weighted multivariable logistic regression model to predict transfer adjusting for covariates.

Results

Between 2009–2014, 3,047,701 (0.4%) ED visits were for burn related injuries. A total of 108,583 (3.6%) burn visits resulted in inter-facility transfers occurred during the study period, representing approximately 18,097 inter-facility transfers per year. Burns with greater than 10% total body surface area (TBSA) resulted in a 10-fold increase in the probability of transfer, compared to burn visits with less than 10% TBSA burns. In the multivariable model, male sex (adjusted odds ratio [aOR] 2.4, 95% CI 2.3–2.6) was associated with increased odds of transfer. Older adults were more likely to be transferred compared to all other age groups. Odds of transfer were increased for Medicare and self-pay patients (vs. private pay) but there was a significant interaction of sex and payer and the effect of insurance varied by sex.

Conclusions

In a national sample of ED visits, burn visits were more than twice as likely to have an inter-facility transfer compared to the general ED patient population. Substantial sex differences exist in U.S. EDs that impact the location of care for patients with burn injuries and warrants further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00705-6.

Agreement of clinical assessment of burn size and burn depth between referring hospitals and burn centres: A systematic review

BACKGROUND

The quality of burn care is highly dependent on the initial assessment and care. The aim of this systematic review was to investigate the agreement of clinical assessment of burn depth and %TBSA between the referring units and the receiving burn centres.

METHODS

Included articles had to meet criteria defined in a PICO (patients, interventions, comparisons, outcomes). Relevant databases were searched using a predetermined search string (November 6th 2021). Data were extracted in a standardised fashion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for test accuracy was used to assess the certainty of evidence. The QUADAS-2 tool was used to assess the risk of bias of individual studies as 'high', 'low' or 'unclear'.

RESULTS

A total of 412 abstracts were retrieved and of these 28 studies with a total of 6461 patients were included, all reporting %TBSA and one burn depth. All studies were cross-sectional and most of them comprising retrospectively enrolled consecutive cohort. All studies showed a low agreement between %TBSA calculations made at referring units and at burn centres. Most studies directly comparing estimations of %TBSA at referring institutions and burn centers showed a proportion of overestimations of 50% or higher. The study of burn depth showed that 55% were equal to the estimates from the burn centre. Most studies had severe study limitations and the risk of imprecision was high. The overall certainty of evidence for accuracy of clinical estimations in referring centres is low (GRADE ⊕⊕ОО) for %TBSA and very low (GRADE ⊕ООО) for burn depth and resuscitation.

CONCLUSION

Overestimation of %TBSA at referring hospitals occurs very frequently. The overall certainty of evidence for accuracy of clinical estimations in referring centres is low for burn size and very low for burn depth. The findings suggest that the burn community has a significant challenge in educating and communicating better with our colleagues at referring institutions and that high-quality studies are needed.

Inappropriate Transfer of Burn Patients: A 5-Year Retrospective at a Single Center

OBJECTIVE

Burn injuries have an annual incidence exceeding 40,000. The Burn Center Referral Criteria published by the American Burn Association (ABA) serve to guide health centers in determining appropriateness of patient transfer to a specialized center. With inappropriate transfer rates reaching up to 77%, reliance on the ABA criteria is critical as the decision to transfer a patient can impose significant costs to both the patient and healthcare system. The aim of this study is to evaluate the appropriateness of all burn patient transfers to a single burn center over a 5-year period and assess the potential role of telemedicine to optimize the assessment and care of this patient population.

METHODS

A 5-year retrospective review was conducted to all burn patients transferred or consulted for transfer to our burn center between January 2013 and January 2017. After application of inclusion and exclusion criteria, 767 cases were analyzed, with 612 ultimately being transferred. Outcome measures included basic clinical and demographic information, as well as logistical burn and transfer data such as percent total body surface area and transfer distance. After data collection, 5-year descriptive trends were analyzed, and the ABA criteria were applied to each patient case to evaluate appropriateness of transfer. Patients transferred despite not meeting at least one of the ABA criteria were classified as inappropriately transferred.

RESULTS

A total of 25 patients (3.2%) were found to be inappropriate transfers. Statistical analysis compared appropriately transferred patients (n = 587) with those inappropriately transferred. Overall, inappropriately transferred patients were more likely to have superficial partial thickness burns (76% vs 46%, P = 0.05), were less likely to need surgery (4% vs 22%, P < 0.05), and had a higher incidence of upper extremity burns (32% vs 4%, P < 0.01).

CONCLUSIONS

Our study increases awareness of the most commonly seen presentation of inappropriately transferred burn patients over a 5-year period at our center. Given the advent of telemedicine, the ability of institutions to pinpoint a subset of patients most vulnerable to inappropriate transfer will allow for a streamlining of resources that will serve to benefit both patients and the health system.

Emergency Care of the Burn Patient Before the Burn Center: A Systematic Review and Meta-analysis

Good burn care starts with correct management of the burn patient before transfer to a burn center. The purpose of this study was to perform a systematic review of the medical literature describing preburn center care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this review. Studies were included if they were published from a burn center and they measured or evaluated any aspect of preburn center care of adult or pediatric acute burn patients referred to that burn center. A comprehensive search of MEDLINE, EMBASE, and Cochrane databases was performed from their inception to May 28, 2018. Outcomes of interest included errors in burn size estimation, airway management, fluid resuscitation, dressings and wound care, use of systemic antibiotics, core temperature monitoring and preservation, and analgesia provision. Meta-analysis of the discrepancy between preburn center and burn center burn size estimation was conducted. From 3768 initially identified titles, 37 studies were included in this systematic review. Burn size estimation was frequently inaccurate. The ratio of overestimation to underestimation in burn size ranged between 2.2:1 and 19:1. The pooled mean absolute error in % total body surface area burn was 6.28 (95% CI: 4.72, 7.85). The average relative percent error in burn size estimation by referring providers ranged between 75% and 3500%. Unnecessary endotracheal intubation was performed in 28% to 53% of transfers. Over-estimation and over-delivery of fluid resuscitation volumes was prevalent, but other problems pertaining to resuscitation included administration of the wrong fluid and failure to titrate fluids. Wounds were not consistently covered with simple dry dressings or sheets. Core temperature was not consistently monitored or preserved. Analgesics were often not given or were of insufficient dose. Many elements of preburn center care need improvement. These findings should be used to form the foundation of future initiatives between burn professionals and emergency providers to improve care of the burn patient before transfer to a burn center.

Comparative Analysis of the Host Response in a Rat Model of Deep-Partial and Full-Thickness Burn Wounds With Pseudomonas aeruginosa Infection

Burn wound injury affects soldiers and civilians alike, often resulting in a dynamic, but un-orchestrated, host response that can lead to infection, scarring, and potentially death. To mitigate these factors, it is important to have a clinically relevant model of burn wound infection that can be utilized for advancing burn wound treatments. Our previous reports have demonstrated the ability of Pseudomonas aeruginosa to generate a biofilm infection within a modified Walker-Mason rat burn model of deep-partial (DPT) and full-thickness (FT) burn wounds (10% total body surface area) in male Sprague-Dawley rats (350–450 g). Here, we further define this model with respect to the host response when challenged with P. aeruginosa infection between the two burn types. Following burn injury and immediate surface exposure to P. aeruginosa, inflammation at the local and systemic levels were monitored for an 11 days period. Compared to burn-only groups, infection with P. aeruginosa further promoted local inflammation in both DPT and FT burn wounds, which was evident by enhanced cellular influx (including neutrophils and monocytes), increased levels of several pro-inflammatory cytokines (IL-1β, IL-6, GRO/KC, andMIP-1α), and reduced IL-10. Systemically, only minor changes were seen in circulating white blood cells and cytokines; however, increases in high mobility group box-1 (HMGB-1) and hyaluronan, as well as decreases in fibronectin were noted particularly in FT burns. Compared to the burn-only group, P. aeruginosa infection resulted in sustained and/or higher levels of HMGB-1 and hyaluronan. Combined with our previous work that defined the burn depth and development of P. aeruginosa biofilms within the wound, this study further establishes this model by defining the host response to the burn and biofilm-infection. Furthermore, this characterization shows several similarities to what is clinically seen and establishes this model for future use in the development and testing of novel therapeutics for burn wound treatment at home and on the battlefield.

Education in burns: Lessons from the past and objectives for the future

Burns are devastating to the individual and society, representing a huge biomedical burden. Improved education in burns has however ignited a revolution in high-income countries-burn mortality is reducing. Education in burns is far-reaching. For the purpose of this concise review, we focus on four categories: education of both (1) emergency and (2) specialist physicians, and the general population, both at a (3) societal and (4) individual level. Tragically, the global burns picture is bleak with burns representing a neglected but solvable health crisis. Ninety-five percent of burns occur in low-income countries, causing enormous suffering, death and disability. Here, we examine the literature detailing burn education with a focus on past lessons, current trends and future objectives. We have identified key educational objectives to revolutionise burn care on a global perspective. Now is the time to build on promising educational strides to reduce the global burns burden.

Time from accident to admission to a burn intensive care unit: how long does it actually take? A 25-year retrospective data analysis from a german burn center

Severe burn injuries often require specialized treatment at a burn center. It is known that prompt admission to an intensive care unit is essential for achieving good outcome. Nevertheless, very little is known about the duration of time before a patient is admitted to a specialized center after a burn injury in Germany, and whether the situation has improved over time. We retrospectively analyzed time from burn injury to admission to the burn intensive care unit in the Cologne-Merheim Medical Center - one of Germany's specialized burn centers - over the last 25 years. Moreover, we analyzed the data based on differences according to time of injury and day of the week, as well as severity of the burn injury. There was no weekend effect with regard to transfer time; instead transfer time was particularly short on a Monday or on Sundays. Furthermore, patients with severe burn injuries of 40-89% total body surface area (TBSA) showed the least differences in transfer time. Interestingly, the youngest and the oldest patients arrived at the burn intensive care unit (BICU) the fastest. This study should help elucidate published knowledge regarding transfer time from the scene of the accident to admission to a BICU in Germany.

Prehospital Care of Burn Patients and Trajectories on Survival

We sought to identify factors associated with the prognosis and survival of burn patients by analyzing data related to the prehospital treatment of burn patients transferred directly to the burn unit from the accident site. We also aimed to assess the role of prehospital physicians and paramedics providing care to major burn patients. This study included adult burn patients with severe burns treated between 2006 and 2010. Prehospital patient records and clinical data collected during treatment were analyzed, and the Injury Severity Scale (ISS) was calculated. Patients were grouped into two cohorts based on the presence or absence of a physician during the prehospital phase. Data were analyzed with reference to survival by multivariable regression model. Specific inclusion criteria resulted in a sample of 67 patients. The groups were comparable with regard to age, gender, and injury etiology. Patients treated by prehospital physicians (group 1, n = 49) were more severely injured than patients treated by paramedics (group 2, n = 18) in terms of total burn surface area (%TBSA) (32% vs. 17%, p = 0.033), ISS (25 vs. 8, p < 0.000), and inhalation injuries (51% vs. 16%, p = 0.013), and presented with a higher pulse rate, lower systolic blood pressure, and lower median pH. Age, gender, %TBSA, and ISS were significantly associated with survival in both groups. Survival at 30 days was associated with age, gender, the amount of intravenous fluids (in liters) received during the first 24 hours, and the final %TBSA. Variables found to be independently associated by multivariable regression model with 30 day mortality were age, female gender, and final TBSA. We identified prehospital prognostic factors affecting patient outcomes. Based on the results from this study, our current EMS system is capable of identifying seriously injured burn patients who may benefit from physician attendance at the injury scene.

The efficacy of hydrogel dressings as a first aid measure for burn wound management in the pre-hospital setting: a systematic review of the literature

The aim of this systematic review was to determine the supporting evidence for the clinical use of hydrogel dressings as a first aid measure for burn wound management in the pre-hospital setting. Two authors searched three databases (Ovid Medline, Ovid Embase and The Cochrane Library) for relevant English language articles published through September 2014. Reference lists, conference proceedings and non-indexed academic journals were manually searched. A separate search was conducted using the Internet search engine Google to source additional studies from burns advisory agencies, first aid bodies, military institutions, manufacturer and paramedic websites. Two authors independently assessed study eligibility and relevance of non-traditional data forms for inclusion. Studies were independently assessed and included if Hydrogel-based burn dressings (HBD) were examined in first aid practices in the pre-hospital setting. A total of 129 studies were considered for inclusion, of which no pre-hospital studies were identified. The review highlights that current use of HBD in the pre-hospital setting appears to be driven by sources of information that do not reflect the paramedic environment. We recommend researchers in the pre-hospital settings undertake clinical trials in this field. More so, the review supports the need for expert consensus to identify key demographic, clinical and injury outcomes for clinicians and researchers undertaking further research into the use of dressings as a first aid measure.

Prehospital pain management in children with traumatic injuries

Damage that arises as a result of injuries is one of the most common causes of children presenting to hospital emergency departments.

OBJECTIVES

The aim of the study was to assess the implementation of recommendations for prehospital pain management in injured children provided by various health care centers.

METHODS

A total of 7146 children aged 0 to 18 years because of injury were admitted to the Department of Paediatric Emergency Medicine in the Maria Konopnicka Memorial University Teaching Hospital No. 4 in Lodz within the period of 12 months. From this group, 1493 children received prehospital emergency care from various health care centers.

RESULTS

Health care centers provided prehospital aid to 21% of all children with injuries. Boys (60.3%) and children older than 5 years (80%) predominated among pediatric trauma cases. Prehospital emergency aid was most frequently administered to children by emergency medical services personnel (42.7%) and a primary health care physician (28.1%). Injuries of head (42.1%), neck (1.1%), chest (1.7%), abdomen (2.5%), upper (32.2%), and lower (19.9%) limbs as well as burns (5.3%) were diagnosed in pediatric patients. Indications for prehospital analgesia were found in 489 of 1493 patients (32.7%). Analgesia was administered to 159 children (32%), pain medication was not given to 223 children (46%), and in 107 cases (22%), there was a lack of information on that subject.

CONCLUSIONS

Despite the training of medical staff, provision of analgesia for children with burns and traumatic injuries of the osteoarticular system is inadequate.

Curbing inflammation in burn patients

Patients who suffer from severe burns develop metabolic imbalances and systemic inflammatory response syndrome (SIRS) which can result in multiple organ failure and death. Research aimed at reducing the inflammatory process has yielded new insight into burn injury therapies. In this review, we discuss strategies used to curb inflammation in burn injuries and note that further studies with high quality evidence are necessary.

[Burn trauma. Part 1: pathophysiology, preclinical care and emergency room management]

Severe burn injuries are rare and represent less than 1% of all medical emergencies. At the scene of the accident self-protection is important. The progress of thermal injury should be stopped, while cold water therapy is usually not indicated as the resulting hypothermia severely reduces the prognosis. A thorough body check reveals the burn size, depth and presence of co-injuries. Volume depletion is the main pathophysiological reason for burn shock. Early infusion therapy is of prognostic significance. Sufficient analgesia has to be established. Intubation is not generally indicated even with extensive burns, whereas early intubation can be life-saving in the case of circular thoracic burns, face burns and inhalation trauma. Local or systemic administration of corticosteroids is not indicated. Transfer to a specialized burn unit depends on burn size and depth. Emergency room management includes stabilization of vital functions, evaluation of co-injuries and initiation of the specific surgical and intensive care therapy.

The Bradford Burn Study: the epidemiology of burns presenting to an inner city emergency department

OBJECTIVE

The Bradford Burn Study prospectively reviewed all burn attendances at a single emergency department in the UK over a 1 year period. The study reviewed the epidemiology, demographics and outcomes of all patients entered into the study.

DESIGN AND SETTING

A 12 month prospective study of burn injuries attending an inner city emergency department serving a population of 1 million people.

RESULTS

460 patients were enrolled into the study. Average patient age was 22.7 years, male: female ratio was 1:1.4, and children <10 years of age accounted for 36% of the case mix. Asian patients accounted for 41% of all attendances; 85% of the cases in the study were accidental in nature, with scalds accounting for 52% of the injuries. Final outcomes were as follows: 54% of patients were reviewed by the emergency department physicians and only one of these patients ultimately needed skin grafting; 19% had follow-up by their primary care physicians; 12% were reviewed by plastic surgeons, and 5% were admitted; of those patients admitted, 16% needed surgery; only 12 patients (3%) were admitted to specialised burn units.

CONCLUSIONS

Emergency departments manage patients with burns well, and referrals to plastic surgery departments are appropriate. The majority of burns can be prevented by addressing educational issues and vulnerable sections of the population.

Burn injuries

PURPOSE OF REVIEW

To summarize new advances and research findings that relate to the treatment of burn victims.

RECENT FINDINGS

Recent advances in burn resuscitation and critical care reflect a better understanding of the acute phase pathophysiology of severe burns. Aggressive management of the unstable burn airway is always the most important clinical priority. Emphasis has been placed on the early identification of inhalation injury and its impact on fluid resuscitation, as well as on a protective lung strategy to reduce the development of pulmonary edema, acute lung injury and pneumonia, and to reduce the risk of barotrauma. New blood markers, such as serum cholinesterase and inflammatory cytokines, have been introduced to assist in the prognosis of morbidity and mortality, beyond the traditional vital signs. At this time, however, these are available only for research purposes. Finally, early burn wound excision and coverage with new biodegradable materials results in less pain and more rapid healing for the patient.

SUMMARY

The combination of innovative approaches and a dedicated burn team is expected to continue to improve survival in the next few years even in the most severe cases.

The use of a cardiac output monitor to guide the initial fluid resuscitation in a patient with burns

A case of initial resuscitation of a patient with severe burns is described. Such patients can have hypotension and reduced organ perfusion for a number of reasons, and can remain in the emergency department for many hours while awaiting transfer to specialist centres. The case provides a comparison between resuscitation using traditional burns formulae and a relatively new and simple-to-use cardiac output (CO) monitor--the Vigileo monitor (Edwards Lifesciences, Irvine, California, USA). The case demonstrates that relying on fluid regimes alone can lead to insufficient resuscitation. We suggest that using technologies such as those mentioned in this article, which have the potential to be used in the emergency department, could improve the initial resuscitation of patients with burns.

The café fire on New Year's Eve in Volendam, the Netherlands: description of events

AIM OF STUDY

The café fire at Volendam occurred shortly after midnight on the first of January 2001 and resulted in one of the worst mass burn incidents in recent Dutch history. The aim of this study was to provide insight into medical and organisational requirements of a major burns incident.

METHODS

Shortly after the fire, two university hospitals and a burn center in the region of the accident developed a plan for evaluation of medical care given during and after this major burn incident. A multidisciplinary research group investigated the management of victims at the scene, in the emergency departments (ED) and during admission in the hospitals. All 245 casualties were included in this study.

RESULTS

A brief severe fire occurred in a crowded cafe with around 350 young visitors on a small embankment of a relatively isolated town, resulting in a unusually high number of severely injured burn victims. Four died immediately. The ensuing rescue effort was hampered by poor access and chaotic circumstances. At the scene of the incident, mobile medical teams ensured orderly transport and treatment priority for the injured. There were 245 victims with a median total body surface area burned of 12%. Inhalation injury was present in 96 patients. A total of 182 victims were admitted, with 112 to intensive care. Ten patients died in the hospital. Seventy-eight patients were secondarily transported, many to specialised centers in the Netherlands and abroad. In total, 36 hospitals in three countries participated.

CONCLUSION

An incident with high numbers of burn victims poses a challenge to any health care system. The difficult circumstances at the site demonstrated the need for robust organisational structures. The primary and secondary distribution of patients required coordination, general hospitals were able to provide initial medical care to these major burn casualties.

Consensus on the prehospital approach to burns patient management

Burns patients form a large group of trauma patients cared for by first aiders, ambulance staff, nurses, and doctors before reaching specialist care in hospital. Guidance for these important carers is often poor or confused and this engenders anxiety and detracts from optimal patient care. This paper outlines nine key steps in the initial management of burn patients in the prehospital environment based on current available evidence and a consensus of specialists from all disciplines caring for burns patients. The basis of care should be that simple things should always be performed well.

Consensus on the pre-hospital approach to burns patient management

Burns patients form a large group of trauma patients cared for by first-aiders, ambulance staff, nurses and doctors before reaching specialist care in hospital. Guidance for these important carers is often poor or confused and this engenders anxiety and detracts from optimal patient care. This paper outlines nine key steps in the initial management of burn patients in the pre-hospital environment based on current available evidence and a consensus of specialists all disciplines caring for burns patients. The basis of care should be that simple things should always be performed well.

Consensus on the pre-hospital approach to burns patient management

Burns patients form a large group of trauma patients cared for by first aiders, ambulance staff, nurses and doctors before reaching specialist care in hospital. Guidance for these important carers is often poor or confused and this engenders anxiety and detracts from optimal patient care. This paper outlines nine key steps in the initial management of burn patients in the pre-hospital environment based on current available evidence and a consensus of specialists from all disciplines caring for burns patients. The basis of care should be that simple things should always be performed well.

Consensus on the prehospital approach to burns patient management

Burns patients form a large group of trauma patients cared for by rst-aiders, ambulance staff, nurses and doctors before reaching specialist care in hospital. Guidance for these important carers is often poor or confused and this engenders anxiety and detracts from optimal patient care. This paper outlines nine key steps in the initial management of burn patients in the prehospital environment based on current available evidence and a consensus of specialists of all disciplines caring for burns patients. The basis of care should be that simple things should always be performed well.