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Summary Introduction E-cigarettes have become the main alternative to traditional cigarettes. An increasing number of explosive accidents with e-cigarettes have been described over the past years. Through our experience of sixteen consecutive cases, we wanted to acquire a better understanding of the origins and to specify the principles of management for these particular new burns. Methods A retrospective study was conducted to review all cases of burns related to e-cigarettes referred to our burn center from April 2014 through May 2019. Several key data were collected in relation to the patients, the circumstances and characteristics of the burns, their treatment and follow-up. Results In the past five years, sixteen patients were burned by e-cigarette explosions. They were all males with an average age of 41 years. They all had second or third degree burn injuries. The average burned area was 5% TBSA. The areas that were burned were the hands, buttocks, thorax, thighs and genital areas, and were always related to clothes pocket location. Eight patients described an increase in pain after cooling, suggesting significant contamination of the burn by lithium-ion deposits. Six required surgical management with excision and split-thickness skin graft. The others healed spontaneously in several weeks. Conclusions Burns by e-cigarette lithium batteries explosion have a double mechanism (thermal and chemical). Carrying cigarettes in a pocket close to the body is a significant risk factor to which the male population is particularly exposed. Early debridement is recommended when possible while initial cooling does not seem helpful and is sometimes painful.

Introduction: Chemical burns are comparably rare but often result in full-thickness skin defects with frequent involvement of underlying structures. Hands are the most commonly affected injury site and impaired functional outcome is common. We present a case of an unusual chemical burn to the dorsum of the hand of a child secondary to application of a topical anti-wart treatment containing formic acid. Case report: An 11-year-old girl was referred to our outpatient department with a full-thickness injury resulting from a chemical burn having used a topical formic acid solution in the treatment of common warts. On examination, a 20-mm circular full-thickness defect was noted to the dorsum of the hand. The extensor tendons were not involved and there were no signs of infection. She required surgical debridement and local flap coverage. The postoperative recovery was unremarkable. Conclusion: Through a comprehensive literature review, four common topical solutions used in anti-wart treatment were identified to be associated with burns. Together with our case, this highlights the importance of careful patient education in the usage of common topical over-the-counter treatments., Lay Abstract Viral warts to the skins are common and are expected to heal by themselves with time. However, they can be associated with stigma and discomfort, leading many people to seek treatment for their removal. There are many different types of treatment options, the most common being to freeze them (cryotherapy) or using a solution that is painted on to the wart. Recently, there has been a rise in the number of different types of solutions that are used in the treatment of warts, including formic acid. Here we describe a case of an 11-year-old girl who used a formic acid-based solution to treat a wart on her hand. This resulted in a deep chemical burn that required surgery under local anaesthetic. She did not have any immediate complications from her surgery. On reviewing the literature, we identified two other acid-based solutions, salicylic acid and monochloroacetic acid, and a third chemical called other glutaraldehyde, that are commonly found in anti-wart treatments and have been described to cause chemical burns. These anti-wart treatments are widely available over the counter and we would like to highlight the importance of proper patient education when used to minimise the risk of chemical burns.

BackgroundSevere burn injuries create large skin defects that render the host susceptible to bacterial infections. Burn wound infection often causes systemic sepsis and severe septicemia, resulting in an increase in the mortality of patients with severe burn injuries. Therefore, appropriate wound care is important to prevent infection and improve patient outcomes. However, it is difficult to heal a third-degree burn injury. The aim of this study was to investigate whether hyperdry human amniotic membrane (HD-AM) could promote early granulation tissue formation after full-thickness skin excision in third-degree burn injury sites in mice.MethodsAfter the development of HD-AM and creation of a third-degree burn injury model, the HD-AM was either placed or not placed on the wound area in the HD-AM group or HD-AM group, respectively. The groups were prepared for evaluation on postoperative days 1, 4 and 7. Azan staining was used for granulation tissue evaluation, and estimation of CD163, transforming growth factor beta-1 (TGF-β1), vascular endothelial growth factor (VEGF), CD31, alpha-smooth muscle actin (α-SMA) and Iba1 expression was performed by immunohistochemical staining. Quantitative reverse-transcription polymerase chain reaction (PCR) was used to investigate gene expression of growth factors, cell migration chemokines and angiogenic and inflammatory markers.ResultsThe HD-AM group showed significant early and qualitatively good growth of granulation tissue on the full-thickness skin excision site. HD-AM promoted early-phase inflammatory cell infiltration, fibroblast migration and angiogenesis in the granulation tissue. Additionally, the early infiltration of cells of the immune system was observed.ConclusionsHD-AM may be useful as a new wound dressing material for full-thickness skin excision sites after third-degree burn injuries, and may be a new therapeutic technique for improving the survival rate of patients with severe burn injuries.

Made available in DSpace on 2021-06-25T12:32:17Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-01-01 Background: Thermal injury is one of the most common type of skin damage found in clinical care, which results in a chronic wound. The treatment of chronic wounds should be specific, because it has a greater vulnerability of the organism to the external agents input. So, the treatment can be performed with covers to keep the lesion clean and free of contamination and also promote healing. Considering the amount of products available for the treatment, as well as the scarcity of studies in the literature proving the effectiveness of hydrocolloid in dogs, the aim of this case report was to describe a third degree bum wound in the sternal region of a dog treated with this material. Case: A 2-year-old non-castraded German Spitz dog, was attended in a private veterinary clinic located in Ribeirao Preto city, Sao Paulo state. The animal was submitted to general anesthesia for microneedling session to treat alopecia X, and after the procedure, it showed a burn focus due to the resting time on the thermal mattress, affecting the entire sternal region. The choice treatment was a surgical debridement followed by second intention healing. The superficial crust of the wound was removed and the debridement of almost all the tissue that was not fit for healing was continued, resulting in a wide wound, with healthy tissue and only a small portion of devitalized musculature. On the same day, the daily dressing phase with crystal sugar was started, in order to promote the debridement of the remaining devitalized tissue and enable the appearance of granulation tissue, together with the asepsis provided by the chiorhexidine ointment (0.7 g/100mL). After five days, the wound presented with ascending granulation, with no signs of contamination and minimal residue of devitalized tissue. Then, the treatment with the hydrocolloid plate was chosen, which was cut and molded to the wound to allow the debridement with crystal sugar to continue in the devitalized muscle region. At this stage of treatment, the wound region where crystal sugar was used was cleaned and given a new dressing to be changed the next day, while the rest of the wound that had the hydrocolloid plate remained unmanaged for an average of five days, in order to improve animal welfare. After six days of dressing, the wound showed significant contraction, however the growth of the granulation tissue was exuberant. Four days after the first dressing change, the contraction of the wound proceeded at an accelerated rate, as well as the proliferation of granulation tissue, and on the 15th day of treatment with the hydrocolloid plaque, the wound was already quite reduced, with the maintenance of the tissue with healthy granulation, without contamination and with signs of good evolution. On the 27th day, the wound was practically healed, leaving a small central portion of the lesion. The scar tissue that involved the bum contributed to its retraction and accelerated the reepithelialization process. Finally, after 42 days, when the treatment fmished, it was possible to notice hair growth and poor visibility of scar tissue. Discussion: The application of this type of dressing in the micro-needling bum injury suggested a better healing due the increase of keratinocyte proliferation and cell proliferation, since when used in the inflammation process, it accelerated the cleaning of purulent and necrotic tissues, stimulating the repair of clean wounds leading to good results and greater patient comfort. This study demonstrated that good healing could be achieved in alternative treatment using hydrocolloid dressing. In this method, healing proved to be more effective than conventional treatment, considering wound resolution and wound healing time. Univ Estadual Paulista Julio de Mesquita Filho Un, Dept Clin & Cirurgia Vet, Fac Ciencias Agr & Vet FCAV, Campus Jaboticabal, Jaboticabal, SP, Brazil Curso Med Vet Anhanguera Educ, Leme, SP, Brazil Inst Ciencias Agr UFVJM, Campus Unai, Unai, MG, Brazil Univ Estadual Paulista Julio de Mesquita Filho Un, Dept Clin & Cirurgia Vet, Fac Ciencias Agr & Vet FCAV, Campus Jaboticabal, Jaboticabal, SP, Brazil

Many people have irreversible defects and to be death due to burn wounds every year. The current study was conducted to assess the effects of eucalyptus essence (EE) and its mixture with licorice in burn wound healing in rats. One hundred fifty rats were divided to five equal groups. Twenty-four hours after induction of third-degree burn wound, inoculation of 108 colony-forming units of Pseudomonas aeruginosa (PA 103) into the burnt area was performed in form of subcutaneous. Group 1 was given no treatment, and group 2 received gel base. Group 3 (positive control) was treated with silver sulfadiazine (SSD). Groups 4 and 5 used EE 1% and its mixture with licorice gel 10%, respectively. After 3, 7, 14, 21, and 28 days, the animals were euthanized and the wound healing parameters were evaluated through macroscopic and microscopic examinations. Microscopically, the rats treated with EE and mixture gel showed better wound healing than SSD (P

Introduction: Burns are one of the most common household and industrial injuries. There are evidences which demonstrate the therapeutic properties of honey and Aloe vera. We evaluated the topical influences of this material and nano zinc combination on healing the wounds caused by third-degree burns. Materials and methods: 32 balb/c mice divided into a control group (without treatment), group 1 (treated with Aloe vera and nano zinc), group 2 (treated with Aloe vera, honey and nanoz inc) and group 3 (treated with honey and nano zinc). The third-degree burn was created on the back of balb/c mice with general anesthesia observing sterile conditions. Local treatment of burn was conducted once a week during 6 weeks and after the end of treatment, were anesthetized by ether and then killed. After fixation, the practical steps of general histology technique were performed on it. The samples stained with hematoxylin–eosin and they observed with a microscope. Results: We found full tightening of the burn wound and less scar in the group treated with nano zinc and honey compared to control group and other groups. In histological studies, a significant increase was found in the overall thickness of the skin, keratinocyte layer, the epidermis and hypodermis, number and diameter of the hair follicles in a third group versus other groups. Conclusion: The results showed the organic honey and nano zinc combination accelerate the healing process of burn wound in male balb/c mice. While adding Aloe vera to this composition doesn't have an effect on wound healing.

Introduction Pediatric burn resuscitation has improved dramatically over the years with improved survival and outcomes. Recent studies have shown the amount of fluid given (ml/kg/%TBSA) has direct correlation to the outcomes. Over resuscitation (fluid creep) results in multiple systemic and wound complications. We hypothesize the addition of maintenance IV fluid with Parkland resuscitation fluid in younger pediatric burns (< 30kg) may not be needed to achieve adequate end points of resuscitation. Methods We performed a retrospective chart analysis of our pediatric burn patients at our institution by categorizing younger patients (< 30kg) into two groups: The maintenance IV fluid (MF) group and the resuscitation fluid (RF) only group. We identified 18 patients that met the criteria with 9 patients in each group. All of the patients in both groups were under 30kg, age range 2-8yrs, and TBSA: 16–50 %. We included 3 patients under 20% TBSA that were resuscitated due to full thickness burns and smoke inhalation injury. We analyzed their hourly and 24-hour fluid administration including all oral intake and tube feeds as well as their hourly vitals, urine output, and laboratory values during the resuscitation. Results We found that the RF group received 1.311+/- 1.295 cc/kg cc less fluid compared to the MF group without any hypoglycemic events or deleterious hemodynamic effects. The patients who had good oral intake or received tube feeds during resuscitation resulted in significantly less resuscitation volume than the estimated resuscitation volume in both groups. Conclusions We conclude that resuscitation can be safely done in pediatric burn patients under 30 kg without adding routine maintenance IV fluid. Early oral and enteral feeding is very critical in all burn patients. The volume that was administered enterally should also be considered in hourly fluid titration rates to reduce the resuscitation fluids given thereby preventing fluid creep and ensuing deleterious complications.

Background and objective The use of pulsed dye laser (PDL) and fractional CO2 (FX CO2 ) laser therapy to treat and/or prevent scarring following burn injury is becoming more widespread with a number of studies reporting reduction in scar erythema and pruritus following treatment with lasers. While the majority of studies report positive outcomes following PDL or FX CO2 therapy, a number of studies have reported no benefit or worsening of the scar following treatment. The objective of this study was to directly compare the efficacy of PDL, FX CO2 , and PDL + FX CO2 laser therapy in reducing scarring post burn injury and autografting in a standardized animal model. Materials and methods Eight female red Duroc pigs (FRDP) received 4 standardized, 1 in. x 1 in. third degree burns that were excised and autografted. Wound sites were treated with PDL, FX CO2 , or both at 4, 8, and 12 weeks post grafting. Grafts receiving no laser therapy served as controls. Scar appearance, morphology, size, and erythema were assessed and punch biopsies collected at weeks 4, 8, 12, and 16. At week 16, additional tissue was collected for biomechanical analyses and markers for inflammatory cytokines, extracellular matrix (ECM) proteins, re-epithelialization, pigmentation, and angiogenesis were quantified at all time points using qRT-PCR. Results Treatment with PDL, FX CO2 , or PDL + FX CO2 resulted in significantly less contraction versus skin graft only controls with no statistically significant difference among laser therapy groups. Scars treated with both PDL and FX CO2 were visually more erythematous than other groups with a significant increase in redness between two and three standard deviations above normal skin redness. Scars treated with FX CO2 were visually smoother and contained significantly fewer wrinkles. In addition, hyperpigmentation was significantly reduced in scars treated with FX CO2 . Conclusions The use of fractional carbon dioxide or pulsed dye laser therapy within 1 month of autografting significantly reduced scar contraction versus control, though no statistically significant difference was detected between laser modalities or use of both modalities. Overall, FX CO2 therapy appears to be modestly more effective at reducing erythema, and improving scar texture and biomechanics. The current data adds to prior studies supporting the role of laser therapy in the treatment of burn scars and indicates more study is needed to optimize delivery protocols for maximum efficacy. Lasers Surg. Med. 50:78-87, 2018. © 2017 Wiley Periodicals, Inc.

BACKGROUND Our research purpose was to compare the curative efficacy of different skin grafting methods for treating third-degree burn wounds. MATERIAL AND METHODS A total of 105 patients with third-degree burns were involved in this study. The burn wounds of these patients were treated using three different methods: Meek skin grafting, Stamp skin grafting, and Microskin grafting. Patients treated with different methods were placed in different groups. The skin graft survival rate, skin graft fusion time, wound healing time, total time of surgery, and 1% total body surface area (TBSA) treatment costs in each group were evaluated during and after the grafting procedures. After the operations, patients were followed up for 3 to 18 months in order to evaluate the postoperative outcomes. RESULTS The skin graft survival rate was significantly higher in the Meek group compared to the rates in the Stamp and Microskin groups (both P

With the legalization of marijuana in four states, and decriminalization in many others, marijuana is becoming easier to obtain. The authors have experienced an increase in burn injuries related to the production of butane hash oil (BHO; a concentrated tetrahydrocannabinol product produced by the distillation of marijuana plant products with pressurized butane). This article updates our experience and highlights the increasing public health problem associated with these burns. Charts of patients who presented to the burn center with suspicion of BHO-related injuries between January 2007 and December 2014 were examined. Data collected included demographics, injury characteristics, treatment utilized, and outcomes. Charts of 101 patients were identified as having BHO-related burn injury. The mean age of these patients was 30.5 ± 10.6 years (mean ± standard deviation, range: 2-55 years) and 93.1% were male. Patients sustained a mean of 26.8 ± 24.1% TBSA burn with 14.3 ± 25.1% third degree burns. Three patients died as the result of their injuries. Patients required a mean of 12 ± 48.4 ventilator days, and 27.1 ± 59.4 days in the hospital. The number of patients presenting with these burns increased over the past 7 years. BHO burns occur most commonly in February (12 patients), on Wednesday (19 patients), and between 18:00 and 06:00 (58 patients). There has been a sharp increase in the number of patients presenting with burn-associated BHO production in the region over the past 7 years. The authors as burn care providers need to increase public awareness of this issue and aid in the development of legislation to help prevent these burns before it becomes a public health crisis.

Background: Several studies have shown that the application of amniotic membrane as a biological dressing in the management of burns is accompanied by rapid re-epithelialisation. In this follow-up study, we aimed to evaluate the possible role of amniotic membrane as an adjunct to split thickness skin grafting on reducing itching and severity of hypertrophic scar formation. Materials and Methods: From October 2013 to January 2015, in a prospective follow-up study, 54 patients (108 limbs) with second and third degree burns, covering 4%–15% of total body surface area (TBSA), were included in the study. All patients needed split-thickness skin grafts for burn-wound coverage. Selected patients had symmetric burns on two (upper or lower) extremities. Then, in every patient, the extremities were randomly divided into two groups: In one limb, the skin graft was traditionally fixed with skin staples (control group) and in the other limb, the skin graft was covered with an amniotic membrane (amnion group). Therefore, in every patient, the graft was covered with an amniotic membrane in one extremity and fixed with skin staples in the other extremity. Finally, after 6 months, the degree of itching and hypertrophic scar formation was compared between the two groups. Results: The study group was composed of 108 limbs in 54 patients (27 males and 27 females) with a mean age of 23.54 ± 4.9 years and burn 9.03 ± 2.69% TBSA. The patients were divided into two groups: 54 limbs in amnion group and 54 limbs in control group. In 59.25% of the cases, patient had less itching in the extremity covered with amniotic membrane. Furthermore, in 64.81% of the cases, patients had less hypertrophic scar formation in the extremity covered with amniotic membrane. These differences were statistically significant (P < 0.001). Conclusions: Amniotic membrane used as an adjunct in split thickness skin grafting is a novel modality which significantly reduces scar formation and itching that can be greatly distressing to burn patients. However, still more prospective well designed studies are needed to prove it.

Introduction Chronic pain, unrelated to the burn itself, can manifest as a long-term complication in patients sustaining burn injuries. The purpose of this study was to determine the prevalence and compare burn characteristics between burn patients who developed chronic neuropathic pain (CNP) and burn patients without CNP treated at a Burn Center. Methods A single-center, retrospective analysis of 1880 patients admitted to the adult Burn Center was performed from January 1, 2014 through January 1, 2019. Patients included were over the age of fifteen years, sustained a burn injury and were admitted to the Burn Unit. CNP was diagnosed clinically following burn injury. Patients were excluded from the definition of CNP if their pain was due to an underlying medical illness or medication. Comparisons between patients admitted to the Burn Unit with no pain and patients admitted to the Burn Unit who developed CNP were performed. Results One hundred thirteen (n=113) of the 1880 burn patients developed CNP as a direct result of burn injury over five years with a prevalence of 6%. Patients who developed CNP were a significantly older median age [54 vs. 46, p=0.002], abused alcohol [29% vs. 8.5%, p< 0.001], abused substances [31% vs. 9%, p< 0.001], were current everyday smokers [73% vs. 34%, p< 0.001], suffered more full-thickness burns [58% vs. 43%, p< 0.001], greater median %TBSA burns [6 vs. 3.5, p< 0.001], were more often intubated on mechanical ventilation [33% vs. 14%, p< 0.001], greater median number of surgeries [2 vs. 0, p< 0.001] and longer median hospital length of stay (LOS) [10 vs. 3 days, p< 0.001], compared to those who did not develop CNP, respectively. Median patient follow-up was 27 months. Conclusions The prevalence of CNP over five years was 6% in the Burn Center. Older ages, alcohol abuse, substance abuse, current everyday smoking, greater %TBSA burns, third degree burns, being intubated on mechanical ventilation, having more surgeries and longer hospital LOS were associated with developing CNP following burn injury. Applicability of Research to Practice The largest study to date assessing the prevalence of chronic nerve pain following burns. Identified new independent predictors for chronic neuropathic pain following burn injury, not previously assessed in the literature.

Introduction As extracorporeal membrane oxygenation (ECMO) becomes more popular, there is increasing evidence supporting the safety and feasibility of early physical and occupational therapy (PT, OT) and mobility with patients on ECMO. However, there is limited evidence to support mobilizing burn ECMO patients. This case discusses safety and feasibility and explains how to successfully mobilize a burn patient on ECMO. Methods The patient is a 56-year old male admitted after sustaining 16% total body surface area partial and full thickness burns to his face, neck, forearms, and hands following an explosion at work. He sustained an inhalational injury and was intubated upon admission. Progression of his inhalation injury led to respiratory failure despite maximal ventilatory support. To maintain appropriate oxygenation, he underwent placement of left femoral-left internal jugular veno-venous ECMO (VV-ECMO). The patient received PT and OT throughout his stay in the Burn ICU. After starting ECMO, the patient resumed therapy with a sitting restriction to < 45 degrees of left hip flexion. The critical care, burn, OT, PT, and cardiothoracic surgery teams discussed factors impacting his ability to participate in therapy, e.g., managing sedation to maximize wakefulness and titrating medications due to hypertension. Modifications to therapy treatments were made based on medical changes and the patient’s ability to participate. The patient was seen daily for mobilization by a PT, OT, nurse, and ECMO specialist team. Clinicians had extensive training and experience working with patients with acute mechanical circulatory support. Safety considerations were followed during all therapy sessions, including careful monitoring of ECMO flows, vitals signs, and securement of medical devices. Results While on ECMO for 11 days, the patient was engaged in daily therapy consisting of active exercise, bed mobility, transfers and standing balance activities. ECMO flows were maintained and no adverse events occurred during mobilization. From the first session on ECMO to day of discharge, the patient exhibited a 14-point increase in his Boston University Activity Measure for Post-Acute Care functional outcome score and progressed to ambulating 300 feet. Conclusions Burn patients on VV-ECMO with femoral cannulation can safely and effectively engage in therapy and early mobilization, which yield positive functional outcomes. A well-coordinated inter-disciplinary team and highly skilled staff is essential to provide safe and effective intervention. Applicability of Research to Practice Early mobilization of burn patients on ECMO is feasible and can ameliorate the effects of immobility. Burn therapists are an integral part of the inter-disciplinary team and should be trained to be skilled at providing care for patients on mechanical circulatory support.

Introduction Burn morbidity and mortality increases with advancing age. Frailty is characterized by reduced homeostatic reserves and is associated with an increased biological age compared to chronological age. Our primary aim was to determine whether frailty as assessed on admission would be predictive of outcomes in the burn population. Methods We conducted a single institution 7-month retrospective chart review of all admitted acute burn patients ages 45 and older. Patient and injury characteristics were collected and compared using standard statistical analysis. Frailty scores were assessed upon admission using the FRAIL Scale. Results Eighty-five patients met inclusion criteria and were able to complete the FRAIL assessment. Patient and injury characteristics are listed in Table 1. . Mean burn size was 6.7%TBSA (95%CI 4.9–8.4%). 34 patients (40%) were classified as robust (FRAIL score 0), 26(30.6%) as pre-frail (FRAIL score 1–2) and 25(29.4) as frail (FRAIL score 3–5). When comparing the robust, pre-frail, and frail cohorts, there was no difference between potentially confounding variables including %TBSA, presence of inhalation injury, presence of full thickness burns, intubation status on admission, presence of infection on admission, mechanism of injury, or delayed presentation status. There was no difference between the robust cohort compared to the pre-frail/frail cohort in overall mortality (p=.971), Patients in the pre-frail/frail cohort received more palliative care consultations (p=.096) and had a longer length of stay (3.3d vs 7.55d p = .002), while prefrail patients had a similar LOS to frail patients (7.46 vs 7.64d p =.938). Patients in the pre-frail/frail cohort were also more likely to be discharged to a higher level of care than they were admitted from(p=.032) with prefrail patients experience an escalation in level of care more frequently than frail patients. The distribution by age by half-decade ranges is in Figure 1. By age 55–59, the majority of patients were prefrail or frail. Conclusions We demonstrated that frailty as assessed by the FRAIL score was predictive of increased length of stay and an escalation in post discharge care. In addition, patients characterized as pre-frail experience outcomes similar to frail patients and should be managed as such. Given the prevalence of frailty and prefrailty in the younger group of patients, we advocate for routine frailty screening beginning at age 55. Applicability of Research to Practice Frailty scores upon admission may allow for a more complete assessment of a patient’s functional status and can help guide discussions of expected outcomes.

Introduction Burn injury is the fourth most common form of trauma worldwide, requiring unique management considerations and a collaborative approach to treatment. Thermal injuries sustained during pregnancy add considerably to case complexity. Overall, there is a low incidence of burns in gravid women living in developed countries, making management guidelines in this patient population scarce. Despite few data, it is recognized that early intervention and inter-disciplinary treatment are critical to optimize maternal and fetal outcomes. Thus, interventions including fluid resuscitation, excision and grafting, routine debridement and dressing changes, antibiotic administration, and early mobilization are the cornerstones of management. Effective pain management is crucial in allowing patients to tolerate these often-painful procedures, engage in rehabilitation, and to prevent pain-related morbidity. Methods The patient is a 34-year-old G5P3013 in her third trimester of pregnancy, who sustained partial and full thickness burns to 18% of total body surface area in a grease fire. She was brought to the ED approximately 2 hours post-injury by EMS. During her hospital stay, Acute Pain Management Service (APMS) was consulted for a comprehensive pain management plan. APMS recommendations included IV acetaminophen, hydromorphone PCA, gabapentin, and ketamine infusion with a reduced dose bolus for procedural analgesia. Risks and benefits of these medications were explained to patient and her family by the APMS, Maternal-Fetal Medicine, and the Burn team, stressing the importance of tolerating routine burn care to decrease morbidity. Although human data are limited, it was explained that low doses (as outlined in our regimen) present little fetal risk in animal models. Results The patient was discharged at hospital day 11 and seen for burn follow-up after 2 weeks post-discharge (35 weeks gestation) with returning color, no evidence of hypertrophy, and overall excellent wound healing. Patient reported no pain, and her pain regimen was discontinued. Patient demonstrated significant improvement in her injuries, and had a normal spontaneous vaginal delivery of a live born male 7 weeks post discharge, with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. Additionally, the patient brought her infant to the office visit and conveyed that the child was consistently reaching pediatric milestones. Conclusions Ketamine may be considered as an adjunct for procedural and background analgesia during the third trimester, as part of a multi-modal strategy in a short-term, monitored setting after a thorough and complete analysis of risks and benefits and careful patient selection. Applicability of Research to Practice Procedural pain management in a third-trimester burn patient.

Introduction The hand and upper extremity is one of the most common sites for burn injury. The total body surface area (TBSA) of the hand is small but the resultant impairment can limit a patient’s ability to return to functional independence. Split thickness skin grafting (STSG) has long been supported in the literature as the main means of treatment following full thickness burn injury. Surgical placement of STSG is often followed by a period of immobilization to the grafted area for graft adherence. The length of time which the grafted area is immobilized has evolved over time as surgical methods have improved. There is no set standard to balance the length of time necessary to prevent complications while maintaining functional mobility. A literature review revealed several studies and a meta-analysis examining the optimal timing for immobilization and bedrest following STSG to the lower extremities. Additional studies have examined guidelines for range of motion protocols and splinting as well as reconstructive procedures for improved function following burn injury. There are currently no studies examining the optimal timing for immobility following the placement of STSG and the implications this can have on functional independence. The proposed study details the results of one burn center’s standard of treatment following STSG to the upper extremity. Methods Following obtaining approval from the IRB, deidentified data was retrospectively collected from the electronic medical record from January 1, 2014-January 1, 2019 for all inpatients ages 18 and up who underwent split thickness skin grafting to the upper extremity. Results Data collected from 2014–2018 revealed a decreasing trend in the days of immobilization following STSG from an average of 4 days to 2 days to the resumption of range of motion (ROM). Additional trends include a decrease in the utilization of splinting as a prophylactic treatment for contractures with a shift towards interventional splinting. Access to home health care services upon hospital discharge also showed a decline from 2014–2018. Conclusions The decrease in days of immobilization following STSG combined with the shift from prophylactic to interventional splinting put more emphasis on increasing patient autonomy for functional independence. This trend coincides with a significant decrease in the utilization of home health services upon hospital discharge in the same time period. Applicability of Research to Practice The findings of this retrospective study provide evidence supporting that decreasing the length of immobilization following STSG to 2 days did not result in an increase in post-operative complications. There was also not a significant decrease in functional independence found with a change in splinting practices from prophylactic to interventional.

Introduction The four main prognostic models used to determine risk of burn mortality are the revised Baux (rBaux), Belgian Outcome in Burn Injury (BOBI), Abbreviated Burn Severity Index (ABSI), and quick Sequential Organ Failure Assessment (qSOFA). These models fail to factor in medical comorbidities. The ASA PS (American Society of Anesthesiologists Physical Status) is a simple scale incorporating severity of traumatic injury with comorbidities, which strongly predicts mortality in surgical patients. The purpose of this study is to determine whether the ASA PS is an adequate adjunct to measure burn severity. Methods All adults admitted to an ABA verified burn center from January 2016 to April 2019 with TBSA ≥10% who underwent surgery were reviewed. Demographics (age, gender, TBSA, race, ASA PS), vital signs (GCS, blood pressure, respiratory rate), and outcome variables (length of stay [LOS], mechanical ventilation [MV] days, and complications) were evaluated. rBaux, BOBI, ABSI, and qSOFA scores were calculated. The primary outcome was in-hospital mortality. After descriptive statistical analysis, mortality associations of the models were assessed by determining odds ratios. Firth’s logistic regression and area under the receiver operator curves determined the predictive utility of the prognostic scores. Results Of the 183 patients who fit inclusion criteria, median age was 44 years (30–57), and the majority (70%) were male. Median TBSA was 20%, 65% (n=118) had full thickness burns, 14% (n=25) had inhalation injury, and mortality was 9% (n=17). rBaux score was the best predictor of mortality (AUC=.84), ICU LOS (R2=.04), and MV days (R2=.06). For every 10-point increase in rBaux score, there was a 1.7 times increase in mortality (OR=1.7, CI 1.4–2.3, p< .00). The predicted ICU LOS increases from 2.8 to 31.4 days for the lowest and highest rBaux score quartiles. Compared to rBaux scores of 30–53, patients with scores of 54–70 had 4 times more MV days (CI 1.5–11, p< .00). The ASA PS was slightly inferior to rBaux in predicting mortality (AUC=.72), although not statistically significant (p=0.1). As ASA PS score went from I/II to III, III to IV, and IV to V/VI; mortality increased by 2.8 (OR=2.8, CI 1.5–5.5, p< .00). Conclusions rBaux is the best predictor of mortality, ICU LOS, and MV days although ASA PS also predicts mortality. Future studies should determine the combined predictive ability of ASA PS and rBaux. Applicability of Research to Practice rBaux and ASA PS scores can be used to determine risk of mortality in burn patients.

Introduction Gasoline burns represent a significant source of preventable morbidity each year. Often used inappropriately as an accelerant, gasoline is substantially more volatile than other commonly used accelerants due to its low flash point and vapor pressure. We sought to review the clinical outcomes for patients presenting with burns caused by gasoline accelerated flame. Methods An IRB exempt retrospective study of consecutive patients presenting from 2010–2017 to a single ABA verified institution was performed. Exclusion criteria included ultraviolet burns, allergic reactions and Stevens-Johnson Syndrome. Collected patient demographics included age and gender. The primary clinical endpoint was percent total body surface area (%TBSA) burned, delineated into second or third degree burn. Secondary endpoints included length of stay (LOS), days admitted to the intensive care unit (ICU), and mortality. Kruskal-Wallis Test and Wilcoxon Rank Sum Test were used for statistical comparison between the etiologies of burns. Fisher’s Exact test was used for comparison of mortality rates using a Bonferroni correction accounting for nine pairwise comparisons. Results A total of 5,994 patients were included; 256 with burns from gasoline fueled flame and 5,738 from other etiologies including flame with other accelerants, flame, scald, contact, electrical, chemical, friction, radiation, and frostbite. Gasoline burns resulted in a higher %TBSA of second degree burns (x̅=4.37%: 95% CI 3.62–5.12; p < 0.001; Table 1) and higher overall %TBSA (x̅=4.94%: 95% CI 3.99–5.88; p < 0.001; Table 2) than burns of all other etiologies except radiation burns where no statistically significant difference was found. Gasoline burns had a lower percent mortality (0.39%) than flame burns (4.98%; p< 0.05) and showed no statistically significant difference in mortality rate compared to other etiologies of burns. Comparison of second degree measures of LOS and number of ICU days yielded mixed results and lacked statistical significance. Conclusions Patients with burns caused by gasoline accelerated flame sustain a higher %TBSA of second degree burns and overall %TBSA than all other etiologies of burns except radiation burns. Applicability of Research to Practice Our results highlight the extent of burns caused by gasoline accelerated flame and underscore the importance of public education to reduce the inappropriate use of gasoline as an accelerant with the ultimate goal of reducing the significant morbidity associated with these burns.

Introduction Road rash is a unique burn injury due to imbedded foreign debris and deeply seeded bacteria. Literature on this injury fails to address its unique mechanism and ways to reduce scarring and infection. Given the paucity of data, a retrospective review was performed at a single level 1 trauma center to study friction burn characteristics and outcomes from these injuries Methods We performed a systematic literature search with PubMed, Scopus, and OvidSP Medline databases using the following keywords: friction burn, traumatic tattoo, and road rash. Subsequently, we analyzed all patients treated by our ABA verified burn center for friction related injuries from January 1, 2015 to September 15, 2019 and evaluated demographics, interventions, and outcomes. Results Twenty-four pertinent articles were identified. Seven articles were included after full-text analysis. Analysis of 225 patients from these studies identified an average age of 23±7 years with 66% male. Most occurred from motor accidents (74%) with industrial (11%) and blast (10%) mechanisms accounting for the majority of the remaining cases. None of the studies recorded TBSA, but 49% were full thickness and 36% had associated injuries. Most patients (58%) required surgery. At our institution, 44 patients met inclusion criteria and the majority were young (25±18 years), men (75%), involved in motor accidents (75%), and low TBSA burns (6.3±5.6%). Over half (57%) had full thickness burns and 72% required surgery. Length of stay was 12±11 days. Of the 27% of patients with traumatic tattooing on admission, 92% successfully had all foreign debris removed by discharge. Eight (18%) patients had wound infections. Importantly, 75% of patients with wound infections had delayed evaluation by a burn practitioner; elucidating a strong and significant correlation (p< 10–5, Cramer’s V 0.84). Conclusions While road rash injuries are often small TBSA, the majority tend to be full thickness, often involve underlying critical structures and frequently require operative intervention. Significantly, patients who developed wound infections were often not evaluated by a burn provider. Applicability of Research to Practice The unique trauma of road rash causes a high degree of superficial and deep tissue injury with high risk for contamination, infection, and scarring such that rapid debridement is critical for optimal care. Burn surgeons should be consulted early as these patients have a high risk of wound infection when not consulted by wound experts.

Introduction Hypertrophic scars are seen in 70% of individuals after a burn. Survival from acute burns have psychosocial and functional challenges. Hypertrophic scars contain disorganized whorls of collagen, an increase in occluded blood vessels resulting in raised discoloration, inflamed dermis/epidermis and painful sequelae. Management of such scars have been limited to invasive and non-invasive management. One innovative technology is a non-invasive high-intensity laser operating at 1275 nm and 74 Watts, optimizing increased depth of penetration into the tissue utilizing photomechanical effects to biostimulate tissue to heal and regenerate. We present a series of 10 patients. Methods 10 patients were enrolled with hypertrophic scarring secondary to deep partial or full thickness burns. Hypertrophic areas were identified and numerical pain scale, Vancouver Scar Scale and the World Health Organization Quality of Life score were recorded. The non-contact, high-intensity laser was passed over the hypertrophic scars, continuously moving the laser over the entirety of the scar. Each area of hypertrophic scar tissue was lasered for progressively longer sessions, reaching a therapeutic time of 10 min in each section. Results Patients were utilizing previously known non-invasive therapies for scar reduction, such as, compression garments, scar treatment ointments, as well as steroid injection and non-medical therapies such as acupuncture. In our series, 90% of the patients reported decrease in scar pain, inflammation, pigmentation and improved pliability by the second treatment. Decreased scar height was identified by the eighth session, where conventional protocols could require months to years before any changes were observed. Changes in the scars were even identified after the normal time period identified for maximal improvement using conventional burn therapies. In a survey presented to patient, even pain was improved, identified with reduction in narcotic/NSAID use in patients undergoing the therapies. Conclusions Non-invasive high-intensity laser therapies are useful adjuncts for reduction of hypertrophic burn scars. Our case series presents a treatment option in patients that have functional, physical and cosmetic challenges. We anticipate broader applications for hypertrophic burn scar reduction utilizing adjunctive non-invasive laser therapy, reducing the need for invasive scar revision and limiting psychosocial strain. Applicability of Research to Practice In this case series, non-invasive high-intensity laser therapy provided timely decrease in hypertrophic scar characteristics in an outpatient setting. Thus, leading to decrease in invasive operative therapy and overall improvement in quality of life. Further studies are needed to elucidate other benefits and utility of the laser and possible evaluation of keloid scars.

Skin-derived precursors (SKPs) are remnants of the embryonic neural crest stem cells that reside in the dermis until adulthood. Although they possess a wide range of differentiation potentials, their differentiation into keratinocyte-like cells and their roles in skin wound healing are obscure. The present study aimed to investigate the differentiation of SKPs into keratinocyte-like cells and evaluate their role in healing of third degree burn wounds. To this aim, SKPs were differentiated into keratinocyte-like cells on tissue culture plate and collagen-chitosan scaffold prepared by freeze-drying. Their differentiation capability was detected by real-time RT-PCR and immunofluorescence. Thereafter, they were cultured on scaffold and implanted in a rat model of burn wound. Histopathological and immunohistochemical analyses were employed to examine the reconstituted skin. The research findings revealed that SKPs were able to differentiate along the epidermal lineage and this ability can be enhanced on a suitable scaffold. Additionally, the results indicated that SKPs apparently promoted wound healing process and accelerate its transition from proliferating stage to maturational phase, especially if they were differentiated into keratinocyte-like cells. Regarding the results, it is concluded that SKPs are able to differentiate into keratinocyte-like cells, particularly when they are cultured on collagen-chitosan scaffold. Moreover, they can regenerate epidermal and dermal layers including thick collagen bundles, possibly through differentiation into keratinocyte-like cells.

A hydrofluoric acid (HFA) burn is a severe condition with the characteristics of acute onset, rapid progression, and high complication and mortality rates. Emergency and systemic treatments are especially important for major HFA burns. The author presents the case of a 46-year-old man burned by the spillage of HFA at a high concentration (45–50%). He suffered burns over 30% of his total body area (5% deep partial-thickness burns and 25% third-degree burns). Debridement, tangential excision, and electrolyte therapy were quickly performed for urgent treatment. Symptomatic treatment was sustained to address severe complications and recurrent injury. For successful management, the patient was stabilized, and he exhibited complete wound repair after 3 months. The author summarizes severe cases of HFA burns to emphasize the difficulty of treatment. The existing approved therapies and complications are discussed, and the significance of electrolyte disorders, especially hypocalcemia, is highlighted. The pathophysiology of HFA burns and recommendations for the treatment of HFA burns at different sites are presented to provide a relatively complete treatment guideline focused on electrolyte disorders.

Few studies are reported on immunomodulatory potential of non-mulberry (Antheraea mylitta) silk fibroin (SF) combined with polyurethane (PU) in diabetic wound healing. In this study, PU/SF (Antheraea mylitta) scaffolds were fabricated by blending and immobilization techniques. Effective SF dosage was determined and incorporated according to minimum inhibitory concentrations against wound associated bacterial strains while fabricating scaffold. Dermal fibroblast NIH3T3 cells were seeded on epidermal growth factor (EGF) treated and untreated PU/SF scaffolds, fabricated by blending and immobilization techniques. Fibroblast seeded PU/SF scaffolds were investigated for anti-inflammatory response in wound recovering potential comparing with Acticoat™ in third degree burn of streptozotocin induced diabetic rats. At 16th, 24th days, promising healing was achieved with faster granulation, enhanced collagenization, patterned re-epithelialization by EGF treated cellular immobilized PU/SF in normal, hyperglycemic burn. Biomarkers of different healing stages, CD31 (haemostasis), Ki67 (proliferative), alpha-sma, COL III (maturation) were examined. Since hyperglycemic burn is characterized by inflated pro-inflammatory cytokines, serum, tissue IL-6,8,10 were recorded, which revealed timely restoration of inflated IL-6,8 and protection against IL-10 elevation by cellular immobilized PU/SF compared to Acticoat™ (p ≤ 0.05), control (p ≤ 0.01). E-cadherin (gap junction protein), MMP 9 response suggested anti-inflammatory role of PU/SF on accelerated healing of thermal injury as potent dermal substitute.

As burn treatment rapidly evolves, early closure, skin repair, functional recovery and cosmetic improvement become major goals in this field.

On‐site, prehospital care is vital for minimizing the severity of injuries caused by acute burns, especially those of the second and third degrees. Burn wounds typically have irregular shapes and depths and cover a large total body area. Due to the severity and complexity of burn wounds, traditional sheet‐like wound dressings are not always suitable. Alternatively, sprayable wound dressings can be used for convenient, quick, and large‐scale dressing changes. They can also prevent infection and secondary trauma depending on their reagent content. Sprayable wound dressings function as a therapeutic barrier that provides moisturization and pain relief, absorbs extrudates, protects against bacterial infections, and acts as a delivery system for small molecules and drugs. This review discusses the recent developments in sprayable hydrogel‐based wound dressings for high‐degree burns. An introduction to burn wound classifications, the ideal burn dressing designs and characteristics, and the current availability of commercial spray‐on burn dressings are presented. To achieve the optimal healing capacities using sprayable wound dressings, researchers are currently focusing on modifying the solution viscosities, propellant systems, and pump nozzle designs for spray formulations. Finally, the use of hydrogel‐based dressings to replace skin graft surgeries for tissue regeneration is discussed.

Introduction Advances in burn injury knowledge, critical care, and pharmacological developments have increased survival rates among extensive burn patients. Survival now dependents not just on skin coverage, but effective control of SIRS response, metabolic derangement, fluid loss and sepsis. Novel synthetic dermal substitutes create robustness, thickness, and pliability of the skin in addition to an improved aesthetic appearance while; point-of-care autologous skin cell harvesting enhances treatment by amplifying small split-thickness skin samples to produce an autologous skin cell suspension (ASCS) to cover a larger burn area. This study reports on two survivors with greater than 90% total body surface area full-thickness burns utilizing a combined treatment of a dermal substitute along with ASCS and traditional burn management strategies. Methods Chart review of two patients with >90% burns and inhalation injury after being trapped in a burning vehicle following a traffic collision occurred. Most of the burns in both patients were “leathery” and consistent with full thickness, sparing only the plantar and dorsal aspect of the feet and bilateral small areas of the hip in Patient 1. Patient 2 had fourth-degree burns in some areas of the chest and flank with only the bilateral groin regions and feet spared. The patients were treated with a multi-step process which included using allograft, dermal substitute, and ASCS with split-thickness skin grafts (STSG) in place of cultured epidermal autograft to achieve coverage of >90% burns with high meshed ratio. Results The dermal substitute was limited to deep burns that penetrated down to fat, muscle, and/or joints. Fluid loss was well controlled by the dermal substitute during initial resuscitation. Post reconstruction, areas covered with the dermal substitute and grafted with autogenous STSG with ASCS exhibited less hypertrophy and contracture bands. The elbow and knee joints showed minimal restriction with passive motion and good skin compliance, but contractures persisted in areas where 4th degree tendon and fascia thermal injury occurred. Areas that showed signs of infection were trimmed or unroofed and allowed to drain while maintaining the remainder of the dermal substitute. Conclusions The use of dermal substitutes and ASCS allowed the care team to achieve SIRS control, improved fluid management, enhanced skin coverage, and reduced hospitalization stay. The process experienced in these cases shows promise for future patients with extensive burns. Both patients were able to survive and show improvement during rehabilitation.

Introduction Full-thickness thermal burns may require staged procedures with temporary coverage to ensure the wound bed is optimized for autografting. A potential dermal substitute for thermal injury is fish skin grafts. These are made in Iceland from freeze dried, sterilized, decellularized skin of North Atlantic cod (Gadus morhua). The gentle processing of the fish skin removes the risk of viral disease transmission to humans and retains its naturally occurring Omega3 fatty acids which are known for their pain and inflammation modulating effects. Fish skin graft has a shelf life of 3 years at room temperature, whereas cadaver skin, the current standard of care at many institutions, has to be cryopreserved, is donor derived, and contains only trace amounts of Omega3. While fish skin graft has been cleared by the FDA as a medical device for use in acute, surgical, chronic wounds, and partial thickness burns, it has not yet been indicated for use in full-thickness burns. The purpose of this clinical trial is to assess the safety and efficacy of decellularized, freeze dried fish skin as an alternative to cadaveric skin (standard of care) for temporary coverage in the setting of a full-thickness burn requiring staged grafting. Methods Patients with full thickness burns to their extremities and/or chest were randomized to have two adjacent areas (70–140 cm2 each) covered with either fish skin or cadaver skin for one week following excision. Patients then received a split thickness skin graft (STSG). Healing was observed by blinded assessors for each area weekly for three weeks, with a scarring assessment completed at 3 months post STSG. Background pain was measured by a visual analogue scale (VAS) for pain and wounds were photographed at each time point. Results Five patients are included in this initial analysis and all completed the 3-month post STSG follow up. TBSA ranged from 8–37%. The fish skin treated area was assessed to be 90% healed at the same timeframe or earlier than cadaver treated areas in all subjects. There was a trend towards a reduction in pain in the fish skin covered areas. One patient was unable to give a pain score due to heavy sedation. Adverse events were reported in all five patients, but none were associated with the use of the investigational product. Graft failures were observed in two cadaver skin covered areas and one partial failure in a fish skin covered area. Conclusions Results from this trial so far indicate that the fish skin is safe and non-inferior to cadaver skin as an early coverage for full thickness burns. Enrollment in this study is still ongoing, and patients will be followed up for 12 months.

Introduction Burn injuries contribute a considerable burden of disease in variable-resource settings, often resulting in mortality. Despite contributing a substantial burden, outcomes from burn injuries in rural Africa are rarely described. The objective of this study was to examine factors associated with mortality from burn injury in rural Africa. Methods A retrospective chart review was conducted for all patients with burn injury from January 1, 2014 to December 31, 2017 at a 300-bed faith-based, teaching hospital in eastern Africa. Bivariate analysis was used to compare patients who survived the hospital stay with those who did not. Using total body surface area (TBSA), the LD50 (Lethal Dose 50, burn size with a lethality of 50% of patients), and the modified-Baux score were calculated. Due to small sample size, lasso inference techniques for logistic regression were utilized to avoid overfitting a model and to determine relevant risk factors for mortality, by evaluating burn severity, age, sex, location of residence, payer status, time from injury to arrival, distance from hospital, presence of full thickness burns, inhalational injury, and referral status. Results A total 171 burn injury patients were reviewed for this study; two were excluded due to missing data. Among 169 patients, 14.8% (n=25) experienced mortality prior to hospital discharge. Fifty patients suffered an adverse event (29.6%) including: 17 wound infections, 10 urinary tract infections, 10 with sepsis, and 25 with respiratory complications. The LD50 for TBSA was 42%. The LD50 for the modified-Baux score was 81. Non-survivors had higher average TBSA (31.0±5.0% vs 11.5±0.8%; p< 0.01), more inhalational injury (44% vs 2.8%, p< 0.01), full-thickness burns (56.5% vs 23.9%, p< 0.01), and complications (88% vs 19.4%, p< 0.01). Odds of mortality increased 1.06 times for every percent increase in TBSA burn (95%CI: 1.02, 1.11; p< 0.01) and 13.9 times with inhalational injury (95%CI: 3.4, 56.4; p < 0.01). Conclusions Mortality from burn injury represents a substantial portion of patients at a hospital in rural Africa. Factors of larger TBSA and inhalational injury represent the greatest risk.

Introduction Bilayer dermal substitutes, composed of bovine collagen cross-linked with glycosaminoglycan and silicone, have become increasingly integrated into the algorithm for management of complex burns. In complex hand burns, dermal substitutes improve functional and aesthetic outcomes while also allowing early excision in high percentage TBSA burns. We detail the outcomes of 17 patients with 25 cases of complex hand burns managed at our center using a staged procedure of cadaveric allografting followed by dermal substitute placement and early definitive STSG. Methods Between Jan 2018 and Aug 2019, all patients who sustained deep partial/full thickness burns to their hands managed with dermal substitution were identified. Patients less than 18 yo, with additional non-burn trauma to the hands, and with initial operative management at another center prior to transfer were excluded. A retrospective chart review was used to collect data regarding time to operative excision, placement of allografts and substitutes, definitive STSG, and functional outcome. Results 17 patients from 18 and 89 yo presented with 25 deep partial/full thickness hand burns. TBSA varied from 0.75 to 78% (mean 17.7%). On average, patients underwent first excision 5.3 (2–16) days after initial burn or 4.2 days after presentation. Our protocol often uses allografting prior to placement of the dermal substitute, therefore, 22 of 25 burned hands received cadaver allografts at initial excision. Dermal substitute was placed an average of 9.2 days later. 3 of 25 burns had immediate application of dermal substitute at first excision. Following substitute, non-meshed, split-thickness autografts were placed on 18 hands. 5 of the burns did not require STSG and two hands were not further evaluated due to loss of patient follow-up. Of the 25 cases, all had near complete incorporation of the substitute without need for revision. In follow-up, patients who did not require STSG have shown no major limitations in ROM/scarring. Of those who underwent STSG, 6 hands underwent contracture release, with 2 of these progressing to amputation. One hand required repeat autografting due to graft loss. All remaining 18 hands healed well with near complete graft take and minimal scarring or functional limitation. Conclusions Dermal substitutes assist in the closure of complex deep hand burns. Cadaveric allografting prior to placement of the substitute ensures an appropriately excised wound base, allowing for near complete integration without need for reapplication. Autografting following dermal substitution placement may be initiated earlier than previously pursued and occasionally allows for healing without STSG.

Burn scars remain a serious physical and psychological problem for the affected people. Clinical studies as well as basic scientific research have shown that medical needling can significantly increase the quality of burn scars with comparatively low risk and stress for the patient with regards to skin elasticity, moisture, erythema and transepidermal water loss. However, medical needling has no influence on repigmentation of large hypopigmented scars.The goal of this study is to evaluate whether two established methods – needling (for improvement of scar quality) and non-cultured autologous skin cell suspension (for repigmentation) – can be successfully combined.Twenty subjects with mean age of 33 years (6–60 years) with scars from deep second and third degree burns have been treated. The average treated surface area was 94cm2 (15–250cm2) and was focused on prominent areas such as the face, neck, chest and arm.Percutaneous collagen induction or “medical needling” was performed using a roller covered with 3mm long needles. The roller is vertically, horizontally and diagonally rolled over the scar, inducing microtrauma. Then, non-cultured autologous skin cell suspension (NCASCS) was produced and applied using the ReNovaCell Autologous Cell Harvesting Device (Avita Medical), according to the manufacturer's instructions.The patients were followed 12 months postoperatively. Pigmentation changes were measured objectively, as well as with patient and observer ratings. Patient satisfaction/preference was also obtained.Taken together, the pigmentation ratings and objective measures indicate individual improvement in 17 of the study participants. The melanin increases seen 12 months after NCASCS treatment are statistically significant.Medical needling in combination with NCASCS shows promise for repigmentation of burn cars.

PURPOSE: To evaluate the effects of low intensity ultrasound on the healing process of third degree burn wounds in experimentally induced diabetic Wistar rats. METHODS: One hundred rats were divided into: control group; non-diabetic treated group; diabetic control group; diabetic treated group. The therapy was performed with a 3MHz ultrasound application, pulsed emission at 100Hz frequency, modulated at 20% with a dosage of 0.5W/cm2 during three minutes throughout 30 days. The surgical debridement of the wound was performed once at day 2. The wounds were morphometrically, macroscopically and microscopically evaluated at 3, 7, 14, 21 and 30 days. RESULTS: The wound contraction and collagen quantification were higher in all treated groups. Macroscopically, necrosis was higher in the diabetic control group. Granulation tissue was higher in treated groups during the proliferative and remodeling phase. Microscopically, there were greater mononuclear inflammatory infiltration, angiogenesis and fibroblast quantification in treated groups during the proliferative and remodeling phases. CONCLUSIONS: therapeutic ultrasound is beneficial in the inflammatory and proliferative phases of the healing process because it controlled the necrotic tissue, increased the granulation tissue and wound contraction. However in the remodeling phase it is not beneficial because of the continued angiogenesis and a mononuclear inflammatory infiltration.

Unfortunately burns are a common occurrence, leading to scarring or death. Platelet-rich plasma (PRP) contains many growth factors that can accelerate wound healing. We analyzed the use of PRP in deep second-degree (dSD), deep second-degree associated with diabetes mellitus (dSDD), and third-degree (TD) burns in rats. Sixty syngeneic rats divided into three groups (dSD, dSDD, and TD) were burned, half receiving topical PRP and half being used as control; 10 additional rats per group were used for PRP preparation. On day 21, the animals were sacrificed and skin biopsies were collected. dSD and dSDD wounds treated with PRP showed faster wound closure, reduction in CD31-, CD68-, CD163-, MPO-, and in TGF-β-positive cells, and an increase in MMP2-positive cells. The neo-epidermis was thinner in the control of both the dSD and dSDD groups and granulation tissue was less reduced in the control of both the dSDD and TD groups. These results indicate that PRP can accelerate the healing process in dSD and dSDD, but not in TD burns.

OBJECTIVES: To review hospitalised burn patients from 2004 to 2010 admitted to Israeli burn units and compare these result with data from 1997 to 2003. METHODS: Retrospectively, data was collected from the Israeli Trauma Registry (ITR) encompassing all burn admissions to Israeli burn units from 2004-2010 and compared to 1997-2003. RESULTS: Of the 5269 burn patients admitted from 2004 to 2010, 39.8% were non-Jewish. Infants under two years were the prominent age group (24.1%). Second to third degree burns 1-9% TBSA/first degree burns were 71%, second to third degree burns 10-19% TBSA were 16% and those 20%>TBSA consisted of 13%. Only 2.7% involved an inhalation injury. The average length of stay was 11.67 days and mortality rate 3.72%. All data was compared to the previous year's 1997-2003 and trends were identified. CONCLUSIONS: Within Israel, high risk populations remain infants under two years of age, males and those from non-Jewish populations. National prevention strategies and campaigns are warranted to inform and educated parents of young children and those at risk of burns. Of note, advances in burn care and procedures might have contributed to a decrease in the length of hospital stay (LOS). Language: en

Objectives The catabolic phase following burn injuries increases caloric imbalance and results in substantial weight loss because of hypermetabolism; energy expenditures as high as twice the normal limit have been documented during the first 3 weeks. Furthermore, the wound size and healing duration seem to be related to the length of stay in the intensive care unit, which results in the loss of muscle mass, the so-called sarcopenia; weakness; and physical frailty. Possible therapeutic strategies include exercises, use of anabolic steroids, or replacement with human growth hormone (hGH). To determine the clinical effects of hGH on sarcopenia after burn injuries, we compared patients who received subcutaneous hGH injections during rehabilitation with control patients who received placebo treatment. Methods A total of 33 patients with third degree burn injuries covering a total body surface area of > 20% were randomly divided into a test group (n = 18), which received 2-mg injections of sustained release hGH (SR-hGH) weekly for 3 months during rehabilitation, and a control group (n = 15), which followed the same rehabilitation protocol with placebo injections. Muscular strength, cardiopulmonary function, body composition, and body weight were measured at baseline and 1 and 3 months after SR-hGH or placebo administration. Results The mean age of patients was 37.67 ± 7.64 years in the SR-hGH group and 37.22 ± 8.19 years in the control group, while the interval between injury and SR-hGH or placebo injection was 123.7 ± 53.6 and 126.6 ± 43.5 days, respectively. The oxygen consumption at the lactate threshold, maximum oxygen consumption, lean body mass, knee extensor peak torque, and insulin-like growth factor 1 (IGF-1) and adiponectin levels were significantly higher in the SR-hGH group than in the control group at 3 months. There were no differences in the body weight, systolic and diastolic blood pressure (BP), bone mineral content, percentage body fat, and burn scar characteristics between groups. Conclusion Our results suggest that SR-hGH treatment during the rehabilitation of adult burn survivors positively affects physical fitness levels, muscle power, and metabolic processes, although further confirmation through research of metabolic pathways in burn survivors is required.

Burns are injuries caused by direct or indirect contact to chemical, physical, or biological agents. Low-level laser therapy (LLLT) is a promising treatment since it is low-cost, non-invasive, and induces cell proliferation. This study aimed to investigate the effects of LLLT (660 nm) at two different fluences (12.5 J/cm(2) and 25 J/cm(2) ) per point of application on third-degree burns in rats. Thirty rats (Wistar) divided into GC, GL12.5, and GL25 were used in the study, and submitted to burn injury through a soldering iron at 150°C, pressed on their back for 10 s. LLLT was applied immediately, and 2, 4, 6, and 8 days after wound induction. Histological analysis revealed a decreased inflammatory infiltrate in the group treated with 25 J/cm(2) , and intense inflammatory infiltrate in the control group and in the group treated with 12.5 J/cm(2) . The immunostaining of COX-2 was more intense in the control groups and in the group treated with 12.5 J/cm(2) than in the group treated with 25 J/cm(2) . Conversely, VEGF immunomarking was more expressive in the group treated with 25 J/cm(2) than it was in the other two groups. Therefore, our findings suggest that the use of 25 J/cm(2) and 1 J of energy was more effective in stimulating the cellular processes involved in tissue repair on third-degree burns in rats by reducing the inflammatory phase, and stimulating angiogenesis, thus restoring the local microcirculation which is essential for cell migration.

Context: Early surgical debridement in burns has its disadvantages like extensive blood loss and long anaesthesia time and risks. Enzymatic wound debridement as an alternative to surgical debridement has been assessed for its effectiveness, safety and patient compliance. Aims: To assess the effectiveness and safety of papaya pulp as an enzymatic wound debriding agent in burns. Setting and Design: The study was conducted including 50 patients with second degree and third degree burns, age ranging from 15 to 60 years from January 2004 to December 2004 at the Burns Centre, Department of Plastic, Reconstructive and Burns Surgery, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India. Materials and Methods: A prospective study including 50 patients with second degree and third degree burns, age ranging from 15 to 60 years was carried out from January 2004 to December 2004 at the Burns Centre, Department of Plastic, Reconstructive and Burns Surgery, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India. There were 38 female and 12 male patients in the study group. Areas of burns ranging from 10% to 60% TBSA were included in the study. Daily dressings were done using autoclaved unripe papaya pulp smeared on potato peel dressing. The progress was assessed daily and application stopped when adequate debridement has been achieved or a maximum of 1 week. Statistical Analysis Used: None. Results: All 50 patients included initially completed the study. There were 38 females and 12 males. Papaya pulp was found to be a very effective debriding agent in all cases. Deep dermal wounds cleared up in 5 to 6 days and eschar in full thickness burns became loose by this period so that it needed minimal surgical debridement. The granulation tissue found following debridement with papaya pulp was pink and healthy. In patients who had to be taken up for grafting, a mild scraping was sufficient before placement of a graft. This has helped on reducing blood transfusions and has considerably reduced anaesthesia time. Conclusions: The use of papaya pulp results in 1. Early and complete non-invasive debridement, 2. Healthy granulation tissue, 3. Decreased blood loss and hence decreased number of blood transfusions in cases which have to be grafted, as excision is avoided. 4. Less operating time and hence less anaesthesia time.

Introduction This study was to establish a method for wound repair in patients with extensive deep burns using fresh allogeneic scalp combined with autologous micrograft. Methods Two patients with burn injuries involving 90% (3rd degree, 70%) and 97% (3rd degree, 85%) total body surface area (TBSA) respectively were treated with fresh scalp allografts donated by 32 males aged (31.5 ± 8.2) years or autologous micrografting. The bilateral limbs with third-degree burns were selected as treatment and control groups. Wounds in the treatment group were treated with fresh allogeneic scalp and autologous micrograft, while wound in the control group received MEEK grafting. Preoperatively, the surgical area on the extremities was calculated to estimate the necessary amount of allogeneic scalp and MEEK grafts. Fresh scalps (0.30 - 0.35 mm) were harvested from each donor to prepare a larger piece of skin allograft. Autologous micrografts were transported onto the epidermis of the skin allograft. The treatment and control group received grafting according to our protocol. The donors received follow-up visits after 3 months to see if there is alopecia and scar hypertrophy. The wound coverage rate was observed in both treatment and control groups on postoperative weeks 2, 3, 4 and 5. Results The donor sites in all allogeneic skin donors healed within 10 days postoperatively. The scalp recovered well without any alopecia or scar hypertrophy during the follow-up visits. The wound coverage rate of the treatment group was approximate to or higher than that of the control group. Conclusions Considering that allogeneic skin is scarce and expensive and the patient’s relatives are willing to help save the patient’s life by donating the scalp, this method may be a feasible clinical treatment option. Applicability of Research to Practice This study is a clinical study which is highly applicable in practice.

Introduction Prior studies comparing scalds and contact burns rarely address the affect of burn etiology on burn depth. However, it is commonly believed that scalds tend to heal faster than similarly sized contact and flame burns. As a result, expectant therapy is often preferred after scald injuries. We compared the percentages of full-thickness burns based on burn etiology controlling for burn size, location and patient age. We hypothesized that the percentage of full thickness burns would be lower after scalds compared with contact and flame burns. Methods We performed a retrospective chart review of a prospectively collected burn registry of all patients admitted to a regional burn center between 2000–2010. Data collection included patient and burn characteristics including age, gender, body location, and burn etiology. We compared the percentages of full thickness burns among scald, contact and flame burns using Chi-square tests. Stepwise logistic regression was used to adjust for age, location, and burn size. Results There were 1038 patients in the study with either scald (n=537, 52%), fire/flame (n=434, 42%) or contact (n=67, 6%) burn. Mean (SD) age was 29 (25); 75% were male. Mean (SD) total body surface area (TBSA) was 11 (13)%. Mean (SD) length of stay was 10 (18) days. The percentages of full thickness burns by etiology were scalds 13.1%, fire/flame 34%, and contact burns 45% (P< 0.001). Patients with scalds were younger (22+/-24) than patients with contacts (32+/-28) and fire/flame (38+/-22) burns. Multivariate analysis for predicting full thickness burns found that compared with contact burns, scalds were less likely full thickness (OR 0.23, 95%CI 0.11–0.48) while fire/flame burns were as likely to be full thickness (OR 0.54, 95%CI 0.26–1.15). TBSA and age were also associated with full thickness burns (OR 1.06, 95%CI 1.04–1.09 and OR 1.015, 95%CI 1.007–1.024, respectively). Burns on the head and neck were less likely to be full thickness (OR 0.30, 95%CI, 0.11–0.82). Conclusions Scald burns are significantly less likely to be full thickness than contact or fire/flame burns. Applicability of Research to Practice Based on these results, expectant therapy may be more appropriate for scalds than contact or fire/flame burns.

Introduction Early excision and grafting (E&G) remains a mainstay in the treatment of burns. Procedures to remove necrotic tissue from severe burn wounds continue to be challenging and may affect rates of successful grafting. The use of laser speckle imaging (LSI) may help detect necrotic tissue remaining but requires human interpretation. Additional decision-making support is needed, especially in prolonged field care settings. The purpose of this study was to evaluate whether graft success or failure can be predicted from LSI using machine learning (ML) and deep learning (DL) techniques in a porcine burn model of various burn depths. Methods Anesthetized Yorkshire pigs (n=12) were burned with a 5x5 cm square brass block (0.4 kg/cm2) @ 100°C to produce partial, deep partial, or full thickness burns (PT, DPT, FT) at 10 square sections on the back of each pig. Debridement was randomized from 1 (0.030”) to 4 (0.120”) passes performed using a dermatome, and then meshed split thickness skin grafts taken from 4 caudal donor sites were applied to wounds. Post-debridement was denoted as Day 0. Graft success/failure (>70% graft take) was determined at Day 7. Laser speckle images were captured at Days 0, 3, 7, 10, and 14. ML and DL were used to develop models in order to predict graft failure and burn/debridement depth. Model performance was measured using loss, accuracy, and confusion matrices. Results Of 120 sections corresponding to 12 pigs, 7.5% (9/120) were not burned, 41.7% (50/120) were PT, 25.8% (31/120) were DPT, and 25.0% (30/120) were FT burns. Graft failure was 19.2% (23/120), with a 50.0% (10/20) rate for DPT burns involving 1- or 2-pass debridement. Both ML and DL used 600 images for algorithm development; 540 images, for training; and 60 images, for testing. DL was superior over ML in test accuracy (93.3% vs 75.0%, p< 0.05). A three-stage architecture plus image resizing was employed in DL to predict graft failure and burn/debridement depth. A best convolutional neural network for graft failure prediction was obtained, yielding a minimum cross entropy loss of 11.7% and accuracies of 96.5% (training), 93.3% (testing 1), 100.0% (testing 2), and 96.2% (overall). Promising results were also obtained for predicting burn/debridement depth: 97.6% (training), 93.3% (testing). Conclusions This study showed that graft success or failure can be predicted from LSI and DL in a porcine burn model of various debridement depths. Use of this technology may provide a potential approach for accurately assessing early E&G in severely burned patients and may aid providers during prolonged field care scenarios. Applicability of Research to Practice Use of LSI in conjunction with DL may provide a potential approach for accurately assessing early E&G in severely burned patients and may aid providers during prolonged field care scenarios.

Introduction Accurate burn assessment is crucial to prescribing appropriate treatment and is dependent upon the experience of the provider and the timing of diagnosis relative to the burn injury evaluation. Differentiating between a deep partial thickness and full thickness burn may not be easily discernible. To augment the clinical diagnosis of burn depth, a laser doppler image measures the microvascular blood flow of injured tissue to predict burn wound healing. The aim of this study is to evaluate the clinical assessment of burn wounds by experienced burn providers compared to the laser doppler image assessment in predicting which burn wounds should heal spontaneously in 3 weeks. Methods A retrospective chart review from 2012–2016, included 54 subjects. The clinical assessment included a description of burn variables relevant to the determination of spontaneous burn wound healing (burn depth, total body surface area, mechanism of injury, anatomical location, clinical burn depth diagnosis, and laser doppler image). A chi-square analysis compared the clinical diagnosis and the laser doppler assessment of burn wound depth, as well as the correlation between clinical diagnosis versus laser doppler image in predicting spontaneous burn wound healing. Results Comparing partial thickness burn injuries, there were 38 clinically diagnosed partial thickness injuries (by experienced burn providers) and 38 partial thickness burn injures diagnosed via LDI. Deep partial thickness burn injuries were diagnosed clinically in 9 subjects, compared to 10 via LDI. Full thickness burn injuries were diagnosed clinically in 7 subjects and 6 via LDI. A chi-square test was performed to examine the relationship between clinical diagnosis of burn depth and laser doppler image. The relation between these variables was significant,X2= 26.884, p< .000. Comparing clinically diagnosed burn depth to LDI, each approach (clinical or LDI) diagnosed 42 subjects with partial thickness or deep partial thickness burn injuries and all healed spontaneously. Two of the clinically diagnosed full thickness burn injuries required skin grafting. Six patients were lost to follow-up (X2= 17.745, p < .001). Conclusions This study confirms there is no difference between an experienced burn provider’s clinical diagnosis of burn wound depth and prognosis for spontaneous healing compared to a laser doppler image prognosis of burn wound healing. Applicability of Research to Practice In an era of advanced technologies, expert clinical bedside assessment is the standard of care.

Introduction Deep Full thickness burns require tangential excision of the burned tissues down to viable tissue. This often leaves exposed muscle, tendon and bone. Coverage of these areas is vital to limb salvage. Multiple modalities are necessary with these type of patients, such as, dermal matrix graft, split thickness skin graft, sprayed autologous cell suspension (ACS) and wound vacuum therapy(VAC). A dermal matrix provides a scaffold for tissue and vascular en growth that is suitable for accepting a skin graft and also provides a layer between the muscle, tendon, bone and the skin graft which improves movement and produces a more pliable graft. Biodegradable temporizing matrix(BTM), produced by PolyNovo Ltd, was used to cover the muscle, bone and tendon. This product has a silicone backing which can be delaminated once it has matured with tissue and vascular en growth for auto grafting. A combination of a wide meshed skin graft at 3:1 ratio and a sprayed ACS allows for faster healing and less donor site usage which decreases the overall wound burden. Methods A 73 y/o male with total body surface area burn of 24 % suffered deep full thickness burns to the bilateral lower legs. He underwent multiple debridements with management of the right leg with irrigating wound vacuum therapy. The deeper right leg had a wound base with that consisted of muscle from the thigh down onto the foot with exposed tendons and anterior tibial bone. The open wounds to the right leg were grafted with BTM for dermal substitute coverage. Once the BTM was mature it was delaminated, and the wound surface was covered with a 3:1 ratio split thickness skin graft (STSG) and sprayed on autologous cell suspension. This resulted in using less donor skin than a 1.5 or 2:1 meshed graft STSG which decreased his wound burden. Donor sites were also sprayed with ACS. Results We had nearly 100% take of the STSG and sprayed autologous suspension epidermal graft. There was a small area over the patella tendon where the BTM did not incorporate. This is though to be because of lack of immobilization of his knee and a pseudomonal infection. Donor sites healed faster and there were minimal open areas to the graft POD 11 excluding the patella area. Conclusions BTM can be used to provide a suitable dermal substitute in complex wounds when muscle, tendon and/or bone are exposed. Immobilization of the joints is necessary to allow the tissue en growth into the dermal matrix. Wide meshed graft with sprayed ACS can be used with good results with wound vacuum therapy. Decreased wound burden and time to heal open wounds of the graft and donor sites. Applicability of Research to Practice Use of a dermal matrix, wide mesh split thickness graft and sprayed epidermal ACS with wound vacuum therapy is a good option for limb salvage when vital structures are exposed.

Introduction Many burn centers use a restrictive blood transfusion strategy based on randomized controlled trials in burn patients (e.g. Transfusion Requirements in Burn Care Evaluation -TRIBE) and non-burn populations (e.g. Transfusion Requirements in Critical Care – TRICC), which have demonstrated no increased morbidity or mortality between restrictive and liberal transfusion approaches. The purpose of this study was to evaluate the adherence to a restrictive hemoglobin transfusion trigger strategy of 7 g/dL. Methods Retrospective study of all patients admitted to an adult regional ABA-verified burn centre between 15/11/ 2015 and 15/6/2018 who received at least one unit of blood (RBC). We use a restrictive transfusion strategy that administers RBC for a hemoglobin (HGb) < 7 gm/dL, one unit at a time, with a pre and post HGb level for each RBC transfusion, unless the patient is actively bleeding and/or hemodynamically unstable. RBC transfusions in the operating room do not follow this policy and were not studied. Values are presented as mean ± SD or median (IQR) as appropriate. Results We studied 66 patients (30% female) with age 53.2 ± 18.3 years, % TBSA burn 22 (11–41), % TBSA full thickness burn 6.5 (0.5 -21.8), and with 41% having inhalation injury. Overall, there were 691 RBC transfusions (TXns). A pre-TXn HGb was obtained 95% of the time and was 6.8 (6.5–7) gm/dL. TXn for a HGb > 7 gm/dL occurred in 35%. A post TXn HGb was obtained for 92% of these TXns with a HGb of 7.6 (7.2–8) gm/dL. RBC TXns during nighttime (1700 to 0800, n=449) were given for a HGb trigger of 6.8 (6.4–6.9) and were not compliant with our restrictive strategy 22% of the time. Daytime transfusions (0800 to 1700, n=207) were given for a significantly higher HGb [7 (6.7–7.1), p< 0.001] with significantly more non-compliance with the restrictive strategy (50%, p< 0.001). We also compared TXns before and after the TRIBE publication. Pre-TRIBE TXns (n=484) were given for significantly lower HGb than 172 post TRIBE TXns [6.8 (6.4–7) vs 6.9 (6.6–7.1) gm/dL respectively, p=0.001] and at significantly lower rate of non-compliance with the 7 gm/dL threshold than post TRIBE transfusions (28.1% vs 37.8%, respectively, p=0.02). Conclusions While a pre-TXn HGb level was available for 95% of blood transfusions, approximately one-third were given for a HGb > 7 gm/dL. Transfusion during nighttime (being predominantly ordered by housestaff physicians) were administered at a significantly lower HGb trigger and with significantly better compliance with the restrictive strategy than daytime transfusions. Paradoxically, compliance with the restrictive strategy was worse following the TRIBE publication. Applicability of Research to Practice These results identify important areas for improvement in adherence to our restrictive transfusion strategy.

Introduction Hair highlighting treatment has become popular at salons across the country. The ubiquity of this beauty treatment gives many people the impression that it is safe. The process of changing hair color differs between hair salons and hair stylists. We describe the cases of two teenage patients who received third degree burns from hair highlighting treatments. Differences in highlighting technique and treatment modality will be compared and contrasted. Methods As part of a quality assurance project looking at variation in scalp burn treatment and outcome, two patients were identified who experienced scalp burn injury due to hair highlighting. Patient 1 received a hot foil hair lighting application. After 5 minutes, the patient experienced tingling in the scalp and removed heat lamp and foils from hair. The first two weeks of treatment were administered by her primary care provider before the patient admitted to our burn facility, where topical collagenase was initiated. Forty two days after initial injury the patient underwent first surgery for debridement, followed by subsequent excision and grafting of scalp. Patient returned for tissue expansion nine months later. Patient 2 received a hair highlighting treatment of bleach and water. Patient 2 complained of burning and immediately her hair was washed out by the hairdresser. The patient was seen two weeks later in our clinic, and treated conservatively with mineral oil and antibacterial topical application. Patient was offered tissue expansion surgery but declined. Results Table 1. compares injury type, treatment and outcome in these two patients. Both injuries required significant time to heal, ranging between 56–70 days. Although similar injuries, mode of treatment differed at this same institution. Both patients made decisions based on school activities and fear or surgery, which prolonged time of conservative treatment. Patient 1 received psychological support and anti-anxiety medication prior to all treatments. After tissue expansion Patient 1 no longer required medication and had no sign of alopecia. Patient 2 has area of alopecia 2x2 cm. Neither patient requires further follow up, however Patient 2 could return for tissue expansion if desired. Conclusions Hair highlighting is a risk for serious scalp burn injury. Conservative treatment (often per patient preference) is associated with prolonged days to healing. Surgical intervention which includes subsequent tissue expansion, combined with psychological support and anxiety management results in good outcome. Applicability of Research to Practice Results from this analysis will be used to develop treatment protocols and staff education on scalp burn injury.

Introduction Autograft is considered the standard of care for severe burns; however, data on the economic outcomes in the pediatric population are sparse. This study assessed the healthcare resource utilization (HCRU) and costs of care among pediatric patients undergoing autografting for thermal burns. Methods The HealthCore Integrated Research Database was used to identify patients < 18 years old with thermal burns receiving the first inpatient autograft between 1/1/2011 and 6/30/2016. The first admission date was assigned as the index date; 12-month pre- and 24-month post-index-date continuous enrollment were required. Patient demographics, clinical characteristics, HCRU, and total costs were assessed. Results Of 65 identified patients, mean age was 7.2 years (standard deviation, SD=5.19), 46.2% were < 6 years old, and 69.2% were male. The majority of burn sites were in upper limbs (64.6%) and lower limbs (52.3%), followed by trunk (41.5%) and eye, face, head, and neck (24.6%). Over 80.0% of patients had third or deep third degree burns; 60% had total body surface area (TBSA) < 10% of any degree burn, and only a few patients (≤ 10) had TBSA ≥ 30%. The mean total all-cause cost in the one-year pre-index period was $14,359 (SD=$27,393), and $9,274 (SD=$25,694) of that cost were burn-related. The average length of stay of the index hospitalization was 10.9 days (SD=10.72), with mean total cost of $94,652 (SD=$162,176). The first-year post-index mean total cost was $111,536 (SD=$174,616) and 93.5% (including index hospitalization) were burn-related. On average, the index hospitalization accounted for 84.9% of the first-year costs. The second-year mean total cost was $10,734 (SD=$40,185), with 5.9% burn-related. Very few (≤ 10) patients had a burn-related hospitalization in the first year after discharge from the index hospitalization, and none had any burn-related inpatient stay in the second year. Conclusions The first-year economic burden after burn injury in this pediatric population was substantial, driven by the initial hospitalization for those undergoing autografting. Burn-related HCRU and cost reduced considerably in the second year post-index. Applicability of Research to Practice This study provided insights on the economic burden of pediatric patients with thermal burns who underwent inpatient autografting. Although autograft is part of the standard of care for severe burns, healthy skin availability and morbidity associated with skin harvest for autograft are major concerns among this vulnerable population. Innovations in burn care are warranted to ensure improved clinical and economic outcomes among patients with thermal burns.