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Background: Accurate estimation of a burned area is crucial to decisions about fluid resuscitation, surgical options, nutritional support, and prognosis. Widely used clinical methods to estimate a burn area are two-dimensional. They do not consider age, sex, body mass, physical deformities, or other relevant factors. Computer-aided methods have improved the accuracy of estimating burned areas by including data analysis and reducing subjective differences. Three-dimensional (3D) scanning allows us to determine body dimensions rapidly and reproducibly. We describe an individualized, cost-efficient, portable 3D scanning system, BurnCalc, that can create an individual 3D model and then calculate body surface area (BSA) and the burn area accurately and quickly., Methods: The BurnCalc system was validated by verifying the accuracy and stability of BSA calculation. We measured 10 regular objects in experiment 1, using Student's t-test and the intraclass correlation coefficient (ICC) in the analysis. In experiment 2, artificial paper patches of known dimensions were attached to various parts of the body of 40 volunteers. Their sizes were then calculated using BurnCalc. The BurnCalc data were compared to actually measured values to verify accuracy and stability. Total BSAs of these 40 volunteers were also calculated by BurnCalc and compared to those derived from an accepted formula. In experiment 3, four experts using Chinese Rule-of-Nines or Rule-of-Palms methods calculated the percentages of the total BSA in 17 volunteers. Student's t-test and ICC, respectively, were used to compare the results obtained with the BurnCalc technique., Results: Statistically, in experiment 1, p = 0.834 and ICC = 0.999, demonstrating that there was no difference between the BurnCalc and real measurements. Also, the hypothesis of null difference among measures (experiment 2) was true because p > 0.05 and ICC = 0.999, indicating that calculations of the total BSA and the burn area were more accurate using the BurnCalc technology. The reliability of the BurnCalc program was 99.9%. In experiment 3, only the BurnCalc method exhibited values of p > 0.05 (p = 0.774) and ICC = 0.999., Conclusions: BurnCalc technology produced stable, accurate readings, suggesting that BurnCalc could be regarded as a new standard clinical method.

Objective: To investigate the analgesic and sedative effects of inhaling a mixture of nitrous oxide and oxygen on burn patient during and after dressing change., Methods: A total of 240 burn patients hospitalized in the Institute of Burn Research of Changhai Hospital Affiliated to the Second Military Medical University, Department of Burns of the First People's Hospital in Zhengzhou, and Department of Burns and Plastic Surgery of General Hospital of Ningxia Medical University from October 2011 to September 2012 were enrolled in our study, and they were all in accordance with the inclusion criteria. The 240 patients were divided into control group (n = 60, treated with inhalation of oxygen during dressing change) and treatment group (n = 180, treated with inhalation of a mixture of 65% nitrous oxide and oxygen during dressing change) according to the computer-generated list of random number. The other treatments in control group and treatment group were the same. Before, during, and after dressing change, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), oxygen saturation (SO2), and adverse effects were observed. The degree of pain and anxiety felt by the patients were respectively evaluated with the visual analogue scale (VAS) and Chinese version of the burn specific pain anxiety scale (C-BSPAS) at the same time points as above. Data were processed with analysis of covariance, chi-square test, analysis of variance, and rank sum test., Results: There were no significant differences between control group and treatment group in the levels of HR, SBP, DBP, and SO2 before dressing change (with F values respectively 0.76, 0.06, 1.11, 0.70, P values all above 0.05). Compared with those of control group, the levels of HR, SBP, DBP, and SO2 in treatment group were significantly ameliorated during dressing change (with F values respectively 81.78, 146.36, 226.44, 205.62, P values all below 0.01). After dressing change, the levels of DBP in the two groups were close (F = 0.31, P > 0.05), but the levels of HR, SBP, and SO2 showed statistical differences (with F values respectively 7.02, 8.69, 12.23, P < 0.05 or P < 0.01). Before dressing change, the VAS scores were approximate between control group and treatment group (Z = 0.21, P > 0.05). Compared with those in control group (9.4 ± 0.7, 1.7 ± 2.5), the VAS scores were significantly lowered in treatment group during and after dressing change (1.6 ± 1.3, 0.7 ± 1.1, with Z values respectively 11.84, 3.35, P values all below 0.01). There was no significant difference in C-BSPAS score between control group and treatment group before dressing change (Z = 0.62, P > 0.05). Compared with those in control group (75 ± 13, 73 ± 12), the C-BSPAS scores in treatment group were decreased during and after dressing change (9 ± 15, 9 ± 14, with Z values respectively 11.91, 12.28, P values all below 0.01). There were no obvious adverse effects in two groups before, during, and after dressing change., Conclusions: A mixture of nitrous oxide and oxygen seems to have obvious analgesic and sedative effects on burn patients during dressing change, and it can be widely used.

Burn surgery belongs to disaster medicine. Burn is a common trauma that occurs in social activities of human beings in all ages, either in the time of peace or war. During the development of human medicine in modern times, the summary of experience in treating massive burn casualties due to severe fire accidents has effectively promoted the renovation of treating technology and theory of burns and the development of burn surgery. The results of treatment of burn injury in casualties occurred in the fire of Cocoanut Grove night club in Boston in 1942, and the high-rise apartment house fire in Shanghai in 2010 were summarized and analyzed in this article, emphasizing the correlating issues of inhalation injury.

Background: More and more Chinese drink hot water from water dispensers while many children were scalded due to this change. The present study aimed to propose a feasible strategy for prevention., Methods: A retrospective study was conducted for all water dispensers related pediatric burns admitted to Changhai Hospital from January 2005 to December 2009., Results: The number of new cases and incidences of pediatric burns due to hot water from water dispensers was significantly increasing year after year. In the total 238 involved cases, 175 cases happened on males and 78.9% were at the age of 1 - 4 years. The burn areas were mainly located in upper extremities. All water dispensers in the surveyed families had no isolate protection devices and 85.2% of their locations were easy for children to reach. Nearly half of the children were in the same room with their guardians when injured. Total 196 burned children were playing the taps of water dispensers before injured, unfortunately, 80.6% of them have not been stopped until burned., Conclusion: As the kind of burns is quite serious and with bad outcome, some recommendations should be followed, such as buying water dispensers with protection devices, keeping children from touching them and so on.

Background: Unplanned extubation is associated with adverse outcomes in intensive care unit. The massive burn patient differs from other critically ill patients in many ways. However, little is known about the unplanned decannulation (UD) in Burn Intensive Care Unit. This paper describes the special features of the circumstances and outcome of UD of tracheotomy tube in massive burn patients., Methods: A case series study was performed between January 1999 and December 2008 and UD of tracheotomy tube was analyzed retrospectively. A total of 21 patients with 29 UD events were identified. Demographic data, diagnosis, intervention, UD events and outcome of UD patients were collected. Differences in proportions were compared using the chi-square (χ(2)) or Fisher's exact test., Results: Patients with UD were often burned with head and neck (67%) and combined with inhalation injury (62%). The majority of them (76%) were transferred patients, occurred early (55%) and were accidental UD (79%). UD events tended to happen in day shift (90%) and to be associated with the medical procedure that was performing by caregivers at besides (79%). Loose of the stabilizing rope, medical procedure and tracheotomy malposition were the main causes of UD. Early UD and reintubation failure were associated with patients' death., Conclusions: UD happened to massive burn patients can lead to patient death. Careful management of respiratory tract was essential for massive burn patients.

Background: Glucocorticoid (GC) insensitivity/GC resistance is an important etiological and prognostic factor in multiple diseases and pathophysiological processes such as scald, shock and asthma. The function of GC was mediated by glucocorticoid receptor (GR). Scald not only decreased the expression of GR but also reduced the affinity of GR, which played an important role in GC resistance in scalded rats. Whereas the molecular mechanism responsible for the decrease of GR affinity resulted from scald remains unclear. Recent studies showed that the changes of heat shock proteins (hsp) especially hsp90 and hsp70 of GR heterocomplex were associated with GR low affinity in vitro., Methods: The affinity of GR in hepatic cytosols and in the cytosols of SMMC-7721 cells were determined by radioligand binding assay and scatchard plot. GR heterocomplex in cytosols were captured by coimmunoprecipation and the levels of hsp90 and hsp70 of GR complex were detected by quantitative Western blotting., Results: Similar with that of hepatic cytosol of scalded rats, a remarkable decrease of GR affinity was also found in the cytosol of heat stressed SMMC-7721 cells. The level of hsp70 of GR complex in hepatic cytosol of scalded rats (30% total body surface area immersion scald) and in cytosol of heat stressed human hepatocarcinoma cell line SMMC-7721 were both increased by 1.5 fold, whereas no change of hsp90 in GR heterocomplex was found. According to the correlation analysis, there may be a positive relationship between increased hsp70 of GR complex and decreased GR affinity in the cytosols., Conclusions: The primary results indicated that the level of hsp70 of GR heterocomplex was increased in the hepatic cytosol of scalded rats and the cytosol of heat stressed SMMC-7721 cells. The increase of hsp70 of GR complex might be associated with the decrease of GR affinity.

Unlabelled: The 105 patients admitted to our Burn Institute from 1st January 1996 to 31st December 2007, with ship fire-related burns were studied retrospectively. The mean age was 30.2+/-12.6 years with a range of 1-58. One hundred and three patients (98.1%) were men and 2 (1.9%) women. The mean total burn surface area (TBSA) was 46.5%, mostly deep burns. The most common areas of burn were the head, neck and upper limb. Summer months July, August, June and September were times of highest incidence. Fifty-seven (54.3%) patients had inhalation injury, 42 received tracheotomy, and 38 received mechanical ventilation. The treatment was complex, difficult, long, and costly. The interval between burn and start of resuscitation ranged from 2.1 to 67 h with a mean of (5.9+/-4.4)h. Forty-two patients (40%) started intravenous fluid resuscitation 6h after burn. Twenty-four patients (23%) received insufficient fluid resuscitation developed hypotension and severe shock at admission. Ninety-two (87.6%) patients required operations including tracheotomy, debridement and grafting, per patient was 5.2. The mean length of hospital stay was 44.2 days. Pulmonary edema was the most common complication during the early post-burn period (within 7 days), and sepsis during the later period (>7 days). Nine patients died of MODS or sepsis, giving a mortality rate of 8.57%., Conclusion: Caution and preventive measures are needed for persons in ships for fire-related burns., ((c) 2009. Published by Elsevier Ltd.)

Objective: To identify treatment-related factors associated with mortality in massively burned adult patients., Methods: This retrospective cohort study examined survival outcomes at a burn unit of 54 beds and 10 burn ICU beds, totaling 900 admissions per year. The cases of 102 adult patients, admitted consecutively from January 1993 to October 2007, with massive burns (burn area>70% of the total body surface area, TBSA) were studied. Relevant variables were recorded from the initial injury and throughout the hospital course. Survival analysis, based on univariate and stepwise multivariate Cox proportional hazards regression, was performed to determine which variables predicted mortality., Results: The overall mortality rate was 30.4%. Burn size, severe inhalation injury, full-thickness burns, serum creatinine levels, inotropic support, platelet counts<20,000 per mm3, sepsis and ventilator dependency were significantly associated with mortality as determined by univariate analysis. Only sepsis, ventilator dependency and platelet counts were significant independent predictors of mortality as determined by multivariate analysis., Conclusions: Sepsis, ventilator dependence (indicating severe respiratory complications), and low platelet counts (indicating thrombocytopenia) are associated with increased mortality risk in adult patients with massive burns. Methods should be sought to ameliorate these complications during treatment in burn-care units., (Copyright (c) 2009 Elsevier Ltd and ISBI. All rights reserved.)

Objective: To summarize the clinical experience in repair of deep burn and traumatic wounds with combined transplantation of different types of pedicled skin flaps in lower extremities., Methods: Two hundred and thirty-six patients with 271 deep wounds in lower extremities after burn or trauma were repaired with muscular skin flaps, local fascial flaps and island flaps with vascular pedicle (more than 20 types) in our department from Jan. 1998 to Sept. 2008., Results: Complete necrosis of skin flaps occurred in 1 case, congestion and necrosis over the edge of skin flaps occurred in 3 cases, which were healed after grafting, and other skin flaps survived well with soft texture. Skin flaps were too bulky in 26 cases, among them 17 cases were thinned, and the appearance of other skin flaps were satisfactory. In 68 patients with functional region injury were recovered to certain extent without contracture., Conclusions: Skin flaps with pedicles, multiple transplantations if necessary, can repair deep wounds satisfactorily in lower extremities after deep burn or trauma injury.

Background: Ever since the introduction of invasive hemodynamic monitoring to major burn care, its utility remains controversial. Besides complications, invasive monitoring as a guideline for burn shock resuscitation is often associated with significant excessive fluid burden. This study was to summarize the clinical experiences of noninvasive esophageal echo-Doppler (ED) monitoring in burn shock resuscitation and discuss the significance of hemodynamic variables in assessment of fluid therapeutic goal., Methods: Twenty-one burn patients with an average total body surface area of 78.86% +/- 7.75% (62-92%) was enrolled in this retrospective study. Fluid therapy was guided according to Chinese general formula and adjusted with urinary output 1 mL/kg/hr as resuscitation goal. Hemodynamic parameters using ED was obtained, including cardiac output (CO), stroke volume (SV), myocardial contractility parameter--maximum acceleration at onset of systole (Acc), afterload parameter--total systemic vascular resistance (TSVR), preload parameter SV/Acc., Results: All patients were clinically diagnosed with a relatively stable condition during early shock stage. There existed inherent and dynamic tendency of hemodynamics during burn shock resuscitation with low CO, Acc, SV/Acc, and high TSVR at first followed by a continuous trend of increase in CO, Acc and SV/Acc and decrease in TSVR. Significant correlations could be seen between CO and Acc, CO and TSVR, CO and SV/Acc. The Standardized Regression Coefficients of Acc, TSVR, and SV/Acc with CO as dependent variable were 0.343, -0.670, and 0.053, respectively demonstrating that myocardial contractility and angiotasis played more important role than blood volume did in hemodynamic variation., Conclusions: Hemodynamic variables cannot routinely substitute traditional variables as the burn shock resuscitation goal. Because of its noninvasiveness, ability to real-timely provide complete profile of hemodynamics, ED monitoring is a good adjunctive method for clinical judgment.

Objective: To investigate the validity of transesophageal echo-Doppler technique for hemodynamic monitoring of patients with extensive burns during shock stage to provide guidance for fluid resuscitation., Methods: Mongrel dogs were inflicted with 50% TBSA full-thickness burns. Cardiac output (CO) were determined by Swan-Ganz catheter, and other hemodynamic indices by transesophageal echo-Doppler device, including aortic blood flow (ABF), stroke volume (SVa), left ventricle ejection time (LVET), peak velocity (PV), max acceleration (max ACC), total systemic vascular resistance (TSVR) were collected before and after burns. Hemodynamic indices of ten patients with extensive burns were collected by transesophageal echo-Doppler device with in 24 hours after the injury., Results: Both CO and ABF showed continuous decrease after burns, and there was positive correlation between them (r = 0.90, P < 0.01). The myocardiac contractibility (ACC, PV) and the preload of the left ventricle (LVET) were also decreased continuously after bums,but the postburn afterload (TSVR) were obviously increased. For the patients with conventional therapy, the hemodynamic state of low cardiac output and high peripheral resistance during early period was converted to high cardiac output and low peripheral resistance 24 hours after injury., Conclusion: Transesophageal echo-Doppler technique is useful in monitoring hemodynamic in patients with extensive burn, and it is non-invasive, real-time, synchronized and rapid, and it can provide complete profile of hemodynamic data.

Objective: To investigate the role of c-Jun NH (2)-terminal kinase (JNk) in insulin resistance after burn and its mechanism., Methods: Twenty-four Sprague-Dawley rats were randomized to control, burn and burn + anisomycin groups. The rats in control group received sham burn trauma, and burn and burn + anisomycin groups received 30% total body surface area (TBSA) full thickness burn injury. Anisomycin (5 mg/kg) together with 250 microl dimethyl sulfoxide (DMSO) was injected to the rats in anisomycin group intravenously, and only 250 microl DMSO in the other two groups. Euglycemic-hyperinsulinemic glucose clamps was performed 2 hours after the injection. The changes of phospho-serine 307, phospho-tyrosine of insulin receptor substrate (IRS)-1 and phospho-JNK in muscle tissues were determined and compared using immunoprecipitation and Western blot analysis or immunohistochemistry in the three groups., Results: The infusing rates of total 10% glucose (mg x kg(-1) x min(-1)) in control, burn and burn + anisomycin group were 12.3 +/- 0.4, 6.6 +/- 0.3, 6.5 +/- 0.4, respectively. The level of IRS-1 Serine 307 phosphorylation and phospho-JNK in muscle increased significantly, while insulin-induced tyrosine phosphorylation of IRS-1 decreased markedly after burn., Conclusions: The activation of JNK elevates the level of IRS-1 phospho-serine 307 and might play a role in insulin resistance after burn in rats.

Objective: To investigate the role and mechanism of c-Jun N-terminal kinase (JNk) inhibitor (SP600125) in amelioration of insulin resistance after scald., Methods: Twenty-four Sprague-Dawley rats were randomized into sham (the process of scald was mimicked by water at room temperature) , scald, scald and SP600125 groups. The rats were inflicted with 30% TBSA full-thickness scald in the latter two groups. Euglycemic-hyperinsulinemic glucose clamp experiment was carried out 4 days after scald. SP600125 was administered to the rats in scald and SP600125 2 hrs before Euglycemic-hyperinsulinemic glucose clamp was performed. Changes in the phospho-Serine307 and phospho-tyrosine of IRS-1 activity, as well as expression of phospho-JNK in muscles were determined., Results: Euglycemic-Hyperinsulinemic Glucose Clamps experiment showed that the infusion rate of 100 g/L glucose in sham, scald, scald and SP600125 groups were (12. 33 +/-0. 42) , (6. 61 +/-0. 27) , (11. 11 +/-0. 68) mgx kg(-1) x min(-1) , respectively ( P <0.01). The level of IRS-1 Serine307 phosphorylation and JNK activity in muscles were significantly increased, while insulin-induced tyrosine phosphorylation of IRS-1 decreased markedly after scald. Compared with scald group, the level of IRS-1 Serine307 phosphorylation and JNK activity in scald and SP600125 group were decreased but tyrosine phosphorylation was elevated., Conclusion: SP600125 can partially ameliorate insulin resistance after scald by inhibition of JNK activation, and decrease the level of IRS-1 phospho-serine307.

Objective: To investigate the role of p38 mitogen-activated protein kinase (MAPK) signal transduction pathway in the production of the proinflammatory factors such as tumor necrosis factor (TNF-alpha) and interleukin 1beta (IL-1beta) in lungs and in the pulmonary endothelial cell injury in severely scalded rats., Methods: Forty eight adult healthy SD rats were randomly divided into three groups with 16 rats in each group, i.e. sham, burn and burn with SB203580 treatment groups. The changes in the TNF-alpha and IL-1beta contents in serum and bronchoalveolar lavage fluid (BALF), the von Willebrand factor (vWF) contents in plasma and pulmonary microvessels and pulmonary activating protein (AP-1) activity were determined at 24 postburn hours (PBH)., Results: Compared with those in sham group, the TNF-alpha and IL-1beta contents in serum and BALF and the vWF content in plasma (194.2% +/- 28.3% vs 93.2% +/- 14.3%) at 24 PBH in burn group increased significantly (P < 0.01), whereas vWF content in pulmonary microvessel decreased obviously (1.1 +/- 0.3 vs 3.3 +/- 0.4, P < 0.01). In addition, the pulmonary AP-1 activity also increased at 24 PBH. Nevertheless, all the above indices improved obviously in burn with SB203580 (inhibitor of p38 MAPK signal transduction pathway) treatment group when compared with those in burn group., Conclusion: AP-1 might mediate the production of proinflammatory factors, such as TNF-alpha and IL-1beta in lungs leading to pulmonary vascular endothelial injury, after being activated by activated p38 MAPK.

Objective: To evaluate the safety and long-term effect of recombinant human epithelial growth factor (rhEGF) on deep partial-thickness burn wounds., Methods: Thirty-seven burn patients were enrolled in this study and were observed by randomized, double-blinded and placebo-controlled protocol. An area of deep partial-thickness burn wounds from each patient was divided into control (C) and treatment (T) portions. The wound in C was treated with normal saline while that in T with rhEGF. The patients were followed-up for 1 and 4 years after wound healing. The healed wounds were evaluated by modified Vancouver scar scale in terms of scar index (SI)., Results: 1 year after wound healing, it was found that the SI in T group (7.19 +/- 1.67) was obviously lower than that in C group (8.92 +/- 1.78, P < 0.01). The SI in T group (6.12 +/- 1.54) was still evidently lower than that in C group (8.09 +/- 1.81, P < 0.01) four years after wound healing. There were no signs of development of tumor or cancer in all the tested burn wound areas., Conclusion: External application of rhEGF might be beneficial to the healing quality of deep partial-thickness burn wound with less scar formation and better long-term effects, and it is safe.

Objective: To study whether nimodipine, a dihydropyridine-type calcium channel blocker, can inhibit the production of interleukin-1beta(IL-1beta), interleukin-6(IL-6) by Kupffer cells(KC) and down-regulate its level of plasma after severe burn injury., Methods: KC of normal rats were isolated with portal vein catheter, intrahepatic digestion and density gradient centrifugation. Intracellular calcium concentration ([Ca2+]i) in individual KC after stimulated with postburn serum was assessed fluorometrically with microspectrofluorimeter. Level of IL-1beta and IL-6 in the supernatant of KC cultured with postburn serum were detected by enzyme-linked immunosorbent assay(ELISA). SD rats underwent 30% total body surface area(TBSA) full thickness burn 6 hours later, KCs was isolated and their mRNA were extracted. Level of IL-1beta mRNA and IL-6 mRNA were detected by ribonuclease protection assay(RPA). Levels of plasma IL-1beta and IL-6 were also detected. Role of nimodipine on above-mentioned effects were observed., Results: Compared with that of control group, levels of [Ca2+]i of KCs and IL-1beta and IL-6 supernatant in burn group increased significantly(all P<0.01). At present of 1 micromol/L nimodipine, however, the [Ca2+]i, IL-1beta, IL-6 values decreased significantly(all P<0.01). The level of plasma cytokines and KC mRNA in burn group also increased significantly. After intravenously injection with nimodipine (40 microg x kg(-1) x h(-1)), the numerical values decreased significantly(all P<0.01)., Conclusion: Kupffer cells of rats are activated to secret IL-1beta and IL-6 after severe burn injury and this process is realized through calcium ion signal transduction channel. Nimodipine can inhibit IL-1beta and IL-6 production of KC by preventing its mRNA transcription, down-regulating its level of plasma.