Journal of Burn Care & Research最新文献

Negative pressure wound therapy (NPWT) is a form of wound coverage that involves negative pressure and a semi-occlusive membrane to manage wound closure. In burn care, NPWT are currently utilized as temporary dressings for large wounds, skin-grafted burn wounds, and as a dressing on dermal substitutes. Little is known regarding optimal roles and indications of NPWT in burn care. This systematic review better characterizes the role of NPWT in burn care and provides updated recommendations. A systematic review of PubMed and Cochrane databases was performed utilizing PRISMA guidelines. All peer-reviewed publications published any time through September 17, 2021 were included. Inclusion criteria consisted of studies containing a control group without NPWT, an intervention group with NPWT, and studies involving the use of NPTW in burn care. A total of 15 studies were analyzed, with a Risk of Bias (ROB) analysis performed to rate the quality of included studies. We find NPWT is superior to conventional dressings as a modality for skin grafting coverage, dressing on dermal substitutes, dressing on donor site wounds, and dressing on moderate to large burns. Outcomes such as length of hospitalization, length of wound healing, and rates of infections were improved in those treated with NPWT compared to conventional dressings. In conclusion, several clear benefits to utilizing NPWT have been defined for several modalities in burn care. However, further research with more robust controlled clinical trials is necessary to better quantify the role of NPWT in burn care and to better define parameters to optimize wound healing.

Treatment of a burn wound often depends on the vertical depth of injury, which is commonly determined by visual assessment. Burn progression is the concept that in the early post-burn period, a partial thickness burn may progress to a deeper burn requiring surgery. Therefore, the initial appearance of the wound may not be indicative of the eventual extent of injury. Several preclinical studies attribute burn wound progression to events such as vasoconstriction, inflammation, programmed cell death, free radical damage, and microvascular occlusion. Due to the concern for translatability of animal models for burn wounds, human studies are essential to understand burn progression in patients. Unfortunately, only a few small human studies exploring mechanisms including apoptosis, ischemia, and infection exist. Inherent to determining burn progression is burn depth determination and healing potential, an area of research that has many ongoing investigations without a clear standard method to replace visual evaluation. Treatments to prevent burn progression in humans, including use of negative pressure wound therapy and application of cooling dressings, have been studied with small sample sizes. Here, we aim to summarize the current data on human burn progression. Additionally, we discuss novel methods that could be used in future research to define early burn wound progression. Future work in human tissue should focus on the assessment and timeline of progression, explore the reversibility and prevention of injury progression and use animal models in parallel as complementary tools for hypothesis-driven research based on findings in humans.

Unplanned extubation rates in burn patients were previously reported at 27% (3 cases per 100 ventilator days). As facial burns pose a unique challenge to tube securement, patients in our unit have surgically placed bite blocks to secure the endotracheal tube at the provider's discretion. Herein, we assessed unplanned extubation rates at our burn center. We performed a retrospective cohort study including burn patients who required mechanical ventilation from 7/01/2015 to 6/30/2023. Demographics, comorbidities, injuries, and hospital course information were collected and compared between patients who had an unplanned extubation and those who did not. Binary logistic regression analyses were performed to identify factors associated with unplanned extubation and ventilator-associated pneumonia (VAP) complication. P < 0.05 was considered significant. Of 360 patients, 17 (4.7%) had unplanned extubations, representing 0.7 cases per 100 ventilator days. There were no significant differences in demographics, comorbidities, or burn injury characteristics between groups. Patients with unplanned extubation were more likely to have an inhalation injury (70.6% vs. 42.6%, p=0.001), paCO2 ≥50 (70.6% vs. 39.1%, p=0.031), more ventilator days (6 [2-15] vs. 2 [1-4] days, p<0.001), and more hospital days (14 [8.5-25.5] vs. 8 [2-20], p=0.020). VAP rate tended to be higher in the unplanned extubation group (17.6% vs. 5.5%, p=0.077. On multivariate analysis, inhalation injury was associated with increased risk of unplanned extubation (Odds ratio (OR) = 4.68 [1.59-13.81], p=0.005). No patients with bite blocks had an unplanned extubation. Further study on the utility of advanced securement devices is recommended.

Wildland firefighting is a niche specialization in the fire service - inherently dangerous with unique risks. Over the past decade, fatalities amongst all firefighters have decreased; however, wildland firefighter fatalities have increased. This subject has only been described in the grey literature, and a paucity of medical literature exists. The United States Fire Administration's online fatality database was queried for on duty mortality between 1990 and 2022. The year 2001 was excluded due to the 340 deaths that occurred on September 11th. Data collected included demographics, incident characteristics, and nature of fatality and was compared between the decades using a Fisher's exact test. From 1990-2000 to the decade of 2013-2022, there has been a significant increase in wildland fatalities, from 2% to 10% of total fatalities (p < 0.00001). Despite the recent wave of 2023 wildfires across North America, the average annual number of wildfires has decreased 23% (from 79,829 to 61,377) between 1990-2000 and 2013-2022. Burn related fatalities have increased over time, from 9% of fatalities to 27% (p < 0.01), while trauma related injuries decreased significantly between the second and third decade (p <0.01). MI accounted for 16% of total fatalities, with no significant change over time. Although wildfires have become less common over the past decade, there was a 5-fold increase in wildland firefighter fatalities with burn related fatalities also increasing. Further investigation, including analysis of 2023 data, is required to augment development of health and safety measures for these heroes.

The standard modality for diagnosis of smoke inhalational injury in burn patients is bronchoscopy with or without bronchoalveolar lavage (BAL). However, the risks associated with these procedures are poorly described in established literature. We sought to investigate the association between diagnostic BAL at admission and the development of pneumonia in burn patients. This retrospective analysis of intubated burn patients studied those who underwent bronchoscopy on admission, comparing patients who received BAL to those who did not. Demographics and baseline characteristics were analyzed using chi-squared or Student's t-test. Unadjusted and multivariable logistic regression studies assessed the effect of admission BAL on the development of pneumonia. Out of the 196 patients who underwent bronchoscopy, 98 met our criteria for analysis. The BAL group was more likely to be male and have a higher grade of abbreviated injury score. Patients who received BAL were more likely to develop pneumonia during the admission in both unadjusted and multivariable logistic regression models. These patients also had a longer hospital length of stay, greater number of ventilator days, and were more likely to undergo second bronchoscopy. These findings associate admission BAL with increased risk of pneumonia during the index hospitalization, suggesting a judicious use of BAL during admission bronchoscopy in burn patients.

Assessment and management of burns require nuanced, timely interventions in high-stake settings, creating challenges for trainees. Simulation-based education has become increasingly popular in surgical and nonsurgical subspecialties to supplement training without compromising patient safety. This study aimed to systematically review the literature on existing burn management-related simulations. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing burn-specific surgical and nonsurgical simulation models were included. The model type, study description, simulated skills, assessment methods, fidelity, cost, and outcomes were collected. Of 3472 articles, 31 met the inclusion criteria. The majority of simulations were high-fidelity (n = 17, 54.8%). Most were immersive (n = 17, 54.8%) and used synthetic benchtop models (n = 13, 41.9%), whereas none were augmented reality (AR)/virtual reality (VR). Simulations of acute and early surgical intervention techniques (n = 16, 51.6%) and burn wound assessments (n = 15, 48.4%) were the most common, whereas burn reconstruction was the least common (n = 3, 9.7%). Technical skills were taught more often (n = 29, 93.5%) than nontechnical skills (n = 15, 48.4%). Subjective assessments (n = 18, 58.1%) were used more often than objective assessments (n = 23, 74.2%). Of the studies that reported costs, 91.7% (n = 11) reported low costs. This review identified the need to expand burn simulator options, especially for burn reconstruction, and highlighted the paucity of animal, cadavers, and AR/VR models. Developing validated, accessible burn simulations to supplement training may improve education, patient safety, and outcomes.

The percent total body surface area (TBSA) burned is a critical determinant of the required level of care, initial management, and prognosis in patients with burns. The current gold standard for estimating this measurement, the Lund-Browder (LB) chart, requires familiarity with its construction and may not be practical for use by first responders in the field. In this study, we present a novel burn surface area calculator mobile application developed for first responders and validate its accuracy. Infant, pediatric, and adult manikins were fabricated with 8 simulated burns of varying sizes and distributions. In total, 42 preclinical medical students and firefighters were tasked with estimating the TBSA of each burn using both the FireSync EMS app and LB chart. Univariate analysis and mixed-effects linear regression modeling were performed to compare the accuracy of both methods in relation to user experience, manikin size, and burn size. FireSync EMS significantly reduced overestimation bias (0.11%, SD 2.33 vs 0.91%, SD 4.12, P = .002), particularly for burns on child-size manikins (P < .001) and burns involving <10% (P = .005) and >20% (P = .030) TBSA. Multivariable modeling revealed that the LB chart was an independent determinant of the magnitude of estimation error, with a 1.19 times multiplicative effect relative to FireSync EMS (P < .001). The participants overwhelmingly found FireSync EMS easier, more intuitive, faster, and preferable (P < .001 for all). FireSync EMS may be an easier, faster, and more accurate alternative to the LB chart for estimation of the TBSA burned.

While occupation began as the central concept of occupational therapy at the dawn of the profession, the use of occupation throughout the therapy process, including assessment, has wavered in recent decades. Occupation is defined as meaningful and purposeful activities that individuals do to occupy their time and attention. The use of occupation-based assessments is vital to establishing care with an occupational focus. The purpose of this article is to review the outcome assessment tools commonly used in the burn literature to evaluate hand function and critique the presence of occupation in each assessment using the Occupation-Based Practice Assessment. Knowledge of the occupational nature of assessments is important to the delivery of an occupational therapy evaluation comprised of a battery of assessments inclusive of discrete measures of movement as well as performance-based tools to represent the person from an occupational perspective. Many outcome measures used in upper extremity burn rehabilitation are discrete in nature and do not measure occupations of clients. The Suitcase Packing Activity may be a viable addition to an assessment battery to address this essential need.

Vitamin D deficiency appears to be more prevalent than previously considered in the adult critically ill population, specifically burn-injured patients. No definitive regimen has been shown to restore vitamin D (25(OH)D) levels more effectively to therapeutic levels in the burn-injured population. The purpose of this study was to investigate the effects of either ergocalciferol (D2, 50 000 IU weekly) or cholecalciferol (D3, 6000 IU daily) in adults with burns ≥10% TBSA. This retrospective, observational study (2020-2022) included patients with vitamin D insufficiency (<30 ng/mL) who received replacement and monitoring with weekly vitamin D levels. Patients on dialysis or those with a hospital length of stay less than 2 weeks were excluded. Forty-five patients treated with ergocalciferol and 99 patients with cholecalciferol were included in the study. Patients treated with cholecalciferol were more likely to achieve 25(OH)D levels greater than 30 ng/mL compared to ergocalciferol over a 42-day period (HR 23.56, [95% CI, 12.57-44.16], P < .0001). A higher proportion of patients in the cholecalciferol group achieved vitamin D greater than 20 ng/mL (HR 6.37, [95% CI, 4.20-9.66], P < .0001). The adjusted hazard ratios (D3 vs D2) for achieving 25(OH)D levels > 30 ng/mL and > 20 ng/mL were and 23.94 (95% CI 5.09-427.6, P = .0019) and 7.32 (95% CI, 3.83-15.52, P < .0001) respectively, after controlling for TBSA and initial 25(OH)D. Cholecalciferol appears to be a more effective agent than ergocalciferol for correcting vitamin D deficiency and insufficiency in patients with burn injuries.