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The routine use of high-dose opioids for analgesia in patients with acute burns and soft-tissue injuries often leads to the development of opioid-induced constipation. The opioid antagonist methylnaltrexone (MLTX) reverses narcotic-related ileus without affecting systemic pain treatment. The authors' burn center developed a bowel protocol that included administration of MLTX for relief of opioid-induced constipation after other methods failed. The authors performed a retrospective review of patients with acute burns or necrotizing soft-tissue infections, who had been given subcutaneous MLTX to induce laxation. All patients who received MLTX were included and all administrations of the drug were included in the analysis. The primary outcome examined was time to laxation from drug administration. Forty-eight patients received MLTX a total of 112 times. Six patients were admitted with soft-tissue injuries and the rest suffered burns with an average TBSA of 17%. The median patient age was 41 years and the majority (75%) were men. Administration of a single dose of MLTX resulted in laxation within 4 hours in 38% of cases, and within 24 hours in 68%. Patients given MLTX received an average of 174 mg morphine equivalents daily for pain control. MLTX was given after an average of 52 hours since the last bowel movement. As this experience has evolved, it has been incorporated into an organized bowel protocol, which includes MLTX administration after other laxatives have failed. MLTX is an effective laxation agent in patients with burn and soft-tissue injuries, who have failed conventional agents.

Extensive patient handling in burn care provides ample opportunities for staff injury. The objective of this retrospective study was to evaluate frequency of work-related back injury pre- and postinstallation of overhead lifting systems (OLS) in a burn intensive care unit. After receiving institutional review board approval, the Workers Compensation Fund of Utah released deidentified back injury claims filed from the authors' burn center between January 1, 2001 and December 31, 2012. Number of back injuries, cost to workers' compensation, and missed workdays were examined. Three distinct time periods were analyzed based on the timing of installation of OLS in the burn center. Forty-five workers were injured in the burn unit; most were female (76%) nurses (73%), with the majority having lower-back injury (71%). Thirty claims (67%) involved staff with a previous back injury. Median age was 32 years (interquartile range, 22-40) and median term of employment at the burn center before injury was 3.7 years (interquartile range, 1.6-7.7). During the intervention period, rate of staff injuries, number of missed workdays, and total number of paid claims decreased significantly. In the period since installation, only one claim has been filed, which is the lowest number of claims that any individual intensive care unit has reported in the facility. The burn unit installed five OLS at a cost of $7000 per unit. This retrospective review indicated that the installation of OLS on the burn unit was an effective tool for reducing staff injury and associated costs. Back injury was essentially eliminated when five OLS were installed.

Fournier's gangrene (FG) describes necrotizing infections of the perineum in both sexes. Controversies in treatment of FG include the roles of orchiectomy, urinary and/or fecal diversion, and hyperbaric oxygen (HBO). Because burn centers often treat these patients, we reviewed our experience with FG during a 14-year period. With Institutional Review Board approval, we reviewed our TRACS/ABA database for patients treated for FG during 1992 to 2005. Data was recorded on demographics, preexisting medical conditions, treatment, and outcomes. Thirty patients (20 men) were identified. Mean age was 54.3 +/- 14.1 years. Predisposing conditions included diabetes in 16 patients (53%), and morbid obesity and immunosuppression in 6 each. Twenty-two patients were transferred from outside hospitals, 12 after initial surgery. Sixteen patients presented with shock (blood pressure90/60 mm Hg). Patients underwent a mean of 4.1 surgical procedures. Ten infections penetrated the deep fascia of the perineum or abdominal wall. Suprapubic cystostomy was performed in three patients, colostomy in seven, orchiectomy in one. HBO was not used. Hospitalization averaged 25.3 +/- 15.6 days. Mean charges ($1000) were $131.5 +/- 108.3. Definitive wound closure was obtained before discharge with suture repair and/or skin grafting in 18 of 25 survivors (72%). Five patients died (17%). In logistic regression analysis, the presence of shock on admission and female gender (mortality 40%) were significantly associated with mortality. FG remains a devastating infection, which occurs primarily in compromised patients. In this series, aggressive burn center care produced outcomes equivalent to those published in other series with or without use of HBO. Colostomy and urinary diversion can be used very selectively in these patients; orchiectomy is rarely required.

Microalbuminuria is a known finding in inflammatory states. We hypothesized that urinary albumin/creatinine ratio (ACR) would correlate with injury severity and resuscitation demands after acute burns. This pilot study evaluated 30 adults admitted within 12 hours of injury with burnsor =10% total body surface area burn injury (TBSA). The urinary ACR was calculated for each patient at 7 to 12 hours, 19 to 24 hours, and 43 to 48 hours following burn injury. Microalbuminuria was defined as a urinary ACRor =20 mg/g. Study patients (23 males, 7 females) had a mean age of 42.9 + 14.0 years and a median TBSA burn injury of 18.8%. Inhalation injury was present in 10 of the study patients, and all patients with inhalation injury had microalbuminuria at the time of admission. One study patient died. Median time from burn injury to resuscitation was 30 hours, and the median fluid requirement was 4.2 ml/kg/%TBSA. Microalbuminuria was not uniformly present in burn-injured patients during the first 48 hours after injury. ACR values early in the hospital course correlated with higher lactate concentrations early after burn injury. However, ACR correlated with neither injury severity nor resuscitation demands after burn injury during any studied time range. Microalbuminuria does not have apparent clinical utility in burn-injured patients, and other markers of injury severity and resuscitation demands should be sought.

Serum lactate and base deficit in trauma patients have been shown to correlate with mortality. This study examines the relationship of these parameters to mortality among burn patients. We evaluated patients with >or=20% TBSA burn injury who had a serum lactate or base deficit recorded during the initial 48 hours of admission over a 5-year period. The primary study outcome was mortality. The mean (+/-SD) age of study patients (N = 128) was 35.2 +/- 21.1 years, the mean burn size was 41.7 +/- 17.9% TBSA, and the mortality rate was 17.1%. Mean serum lactate values of patients who died were significantly higher than those of survivors at admission and at 12, 18, and 24 hours after admission. The highest serum lactate value in the first 48 hours after admission was higher for nonsurvivors than survivors. Mean base deficit at admission and 6 hours after admission was significantly lower in patients who died than in survivors; in addition, the worst base deficit during the first 48 hours of care was significantly lower in patients who died than in those who survived. Early serum lactate and base deficit values are often worse for burn patients who die than for survivors. Elevation of serum lactate values during the first 48 hours after a burn is an independent risk factor for death, but no threshold value for serum lactate is demonstrable. Resuscitation should not be withheld from burn patients on the basis of any lactate or base deficit value.

We present the case of a lightning-strike victim. This case illustrates the importance of in-field care, appropriate referral to a burn center, and the tendency of lightning burns to progress to full-thickness injury.