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Objectives: Studies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20-59% TBSA) burn using a restrictive or a liberal blood transfusion strategy., Methods: Patients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin <7 g/dL) or liberal (transfuse hemoglobin <10 g/dL) strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes., Results: Three hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 ± 47.63 vs. 77.16 ± 55.0, p < 0.03 massive; 11.0 ± 16.70 vs. 16.78 ± 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20-59%) group (p > 0.05)., Conclusions: A restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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

Objectives: Major trials examining storage age of blood transfused to critically ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused., Design: A secondary analysis of the multicenter randomized Transfusion Requirement in Burn Care Evaluation study which compared restrictive and liberal transfusion strategies., Setting: Eighteen tertiary-care burn centers., Patients: Transfusion Requirement in Burn Care Evaluation evaluated 345 adults with burns greater than or equal to 20% of the body surface area. We included only the 303 patients that received blood transfusions., Interventions: The storage ages of all transfused red cell units were collected during Transfusion Requirement in Burn Care Evaluation. A priori measures of storage age were the the mean storage age of all transfused blood and the proportion of all transfused blood considered very old (stored ≥ 35 d)., Measurements and Main Results: The primary outcome was the severity of multiple organ dysfunction. Secondary outcomes included time to wound healing, the duration of mechanical ventilation, and in-hospital mortality. There were 6,786 red cell transfusions with a mean (± SD) storage age of 25.6 ± 10.2 days. Participants received a mean of 23.4 ± 31.2 blood transfusions (range, 1-219) and a mean of 5.3 ± 10.7 units of very old blood. Neither mean storage age nor proportion of very old blood had any influence on multiple organ dysfunction severity, time to wound healing, or mortality. Duration of ventilation was significantly predicted by both mean blood storage age and the proportion of very old blood, but this was of questionable clinical relevance given extreme variability in duration of ventilation (adjusted r ≤ 0.01)., Conclusions: Despite massive blood transfusion, including very old blood, the duration of red cell storage did not influence outcome in burn patients. Provision of the oldest blood first by Blood Banks is rational, even for massive transfusion.

The authors report on the use of combination intravenous and inhaled colistin therapy in 2 patients with major burns admitted to an American Burn Association-verified burn center during a multidrug-resistant (MDR) Acinetobacter baumannii outbreak. Both patients had documented, culture-proven MDR Acinetobacter ventilator-associated pneumonia and bacteremia leading to sepsis. Both patients were successfully extubated and subsequently discharged from hospital. In this article, the authors provide the timeline of events and treatments that were used in these 2 cases. Combination intravenous and inhaled colistin therapy may be a valuable tool against MDR Acinetobacter infections.

Introduction: Published experience describing the use of Biobrane ® for wound management in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS-TEN) is limited to case reports and case series involving ten or fewer patients. We have used Biobrane ® in the care of SJS-TEN since 2000, and the purpose of this study was to review our experience with the application of Biobrane ® for wound coverage in SJS-TEN., Methods: A retrospective review of all cases of SJS-TEN admitted to an adult regional ABA-verified burn center between January 1, 2000 and June 1, 2015 was conducted. Biobrane ® application was performed at burn center admission. Values are presented as the median (IQR), or mean±SD where appropriate., Results: We identified 42 eligible subjects with SJS-TEN. Biobrane ® was applied in 24 subjects. Biobrane ® -treated subjects had an age of 51.4±21.7years, with a %TBSA epidermal detachment of 39.5 (30-46), 63% were female and the admission SCORTEN was 3 (2-4, range 1-5). Biobrane ® was applied at burn center (BC) admission in 18/24 subjects (82%), and between post admission days 1-4 in four subjects. Biobrane ® was applied to 35 (22-40) % of the TBSA (range 7-90) involving all anatomic areas including the head and neck. There were no complications, infections, premature removals, or Biobrane ® -associated sepsis in 24/25 applications (96%). In one subject a sheet of the TBSS was removed due to sub-Biobrane ® fluid collection, but with negative microbiological cultures. Time to healing was 13 (12-16) days, and burn center length of stay was 34 (15.3-62.3) days. Subjects treated with dressings only (n=18) had a significantly smaller %TBSA epidermal detachment [10 (5-22), p<0.001], and were predominantly diagnosed with SJS (50%) or SJS-TEN overlap (33%). Time to healing among dressing-only subjects was not significantly different [12 (10-14.5) days] than among the Biobrane ® -treated subjects, (p=0.127)., Conclusion: Biobrane ® was applied to SJS-TEN subjects with more extensive epidermal detachment, had no significant complications, and generally facilitated epidermal healing in under 2 weeks from application., (Copyright © 2017 Elsevier Ltd and ISBI. All rights reserved.)

While topical antimicrobial agents are indicated for most if not all burn wounds, the choice of a topical agent must consider many factors such as the wound depth, anticipated time to healing, need for surgical intervention, and the known cytotoxicity of the agent. Especially relevant to the pediatric burn patient are the antimicrobial agent's properties related to causing pain or irritation and the required frequency of application and dressings. This article will discuss the general principles surrounding the use of topical antimicrobials on burn wounds and will review the most common agents currently in use.

Objective: Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality., Background: Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown., Methods: This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7-8 g/dL) or liberal (hemoglobin 10-11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes., Results: Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 ± 32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 ± 44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, χ test)., Conclusions: A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).

The objective of this study was to review the incidence of skin allograft discard and bacterial contamination due to donor bioburden at the Ontario Professional Firefighters Skin Bank over a 14-year period. We sought to determine whether modifications to our prerecovery donor preparation process have been effective in reducing skin bioburden and identify other potential risk factors of allograft contamination. A retrospective review of all skin donors (n = 259) processed from 2002 to 2015 was performed. Multivariate logistic regression was used to determine whether donor-related factors and procurement-related factors were significantly associated with microbial contamination predisinfection and discard secondary to contamination. Eighty-one donor recoveries were discarded (81/259; 31%) or 694 grafts (694/2636; 26%), with bacterial contamination being the most common reason for discard (29/81; 36%) followed by positive viral serology (21/81; 26%) primarily for hepatitis B core antibodies. Bacterial contamination predisinfection was detected in 46% of donors (49% of grafts). Analysis of risk factors showed that only donor preparation using a 70% alcohol spray significantly reduced odds of both bacterial contamination predisinfection (P < .0001) and discard secondary to bacterial contamination (P = .0233). Our results suggest that selective screening of donors to reduce risk of microbial contamination is unlikely to alter the rate of allograft contamination. However, use of a 70% alcohol spray during donor preparation may minimize bacterial contamination and subsequent bacterial-related discards. Given that detailed guidelines for donor preparation do not exist, use of an alcohol spray may be of value for tissue banks experiencing allograft loss due to bacterial contamination.

The classic determinants of mortality from severe burn injury are age, size of injury, delays of resuscitation, and the presence of inhalation injury. Of the major determinants of mortality, inhalation injury remains one of the most challenging injuries for burn care providers. Patients with inhalation injury are at increased risk for pneumonia (the leading cause of death) and multisystem organ failure. There is no consensus among leading burn care centers in the management of inhalation injury. This article outlines the current treatment algorithms and the evidence of their efficacy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Stevens-Johnson syndrome and toxic epidermal necrolysis are rare, life-threatening, cutaneous drug reactions. Medications are the most common cause, although an infection may be responsible. A link between genetics and certain medications has been established. Clinical diagnosis should be confirmed with biopsy. When the area of epidermal detachment approaches 30%, burn center care is advisable. An ophthalmologist should be consulted to optimize ocular care. Pharmacologic interruption has been sought but there is little consensus on the most appropriate agent and no high-quality studies have been conducted to demonstrate if any of these agents lead to improved survival., (Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.)

Recognition of fluid creep has driven a large amount of the scientific investigation in the area of acute fluid resuscitation for burn patients. The role of colloids in ameliorating fluid creep is controversial, despite the fact that a fluid-sparing effect of colloids has been recognized for some time. All but one of the available prospective studies using colloids are more than a decade old, and a modern randomized controlled trial (RCT) comparing crystalloids to colloids is long overdue. While urinary output continues to be the main endpoint for fluid titration, there has been a moderate amount of interest in the use of transpulmonary thermodilution to guide fluid resuscitation. The available studies have found that transpulmonary thermodilution has had an inconsistent effect on limiting fluid resuscitation volumes and improving clinical outcomes. Computerized Decision Support Systems show great promise in optimizing fluid titration and reducing fluid resuscitation volumes, and an RCT comparing Computerized Decision Support Systems with conventional titration approaches will be the important next step. Use of high-dose vitamin C (ascorbic acid) has become a popular approach to limit fluid resuscitation volumes and edema formation, but it has been investigated in only two clinical studies: one a pseudo-randomized prospective study and the other a retrospective study. Improvements in clinical outcome have not been convincingly demonstrated, and concerns persist surrounding the possibility of induction of an osmotic diuresis, leading to intravascular volume depletion. An RCT is urgently required to evaluate high-dose vitamin C as an adjunct to crystalloid resuscitation compared with the use of crystalloids alone.

Prominent scars and contractures may form along the seams between adjacent skin grafts. Seams may be constructed either by approximating the graft edges (AP), or by slightly overlapping the graft edges (OV), but it is not known if one technique creates a less conspicuous seam scar. The purpose of this study was to compare seam scars between seams constructed using the AP and OV techniques. This was a prospective within-patient and within-seam controlled study in adult burn patients treated at an American Burn Association-verified burn center. At skin graft application and seam construction, study seams were divided in half. One half of the seam was made by approximating the graft edges (AP group), while the other half was made by overlapping graft edges (OV group), before identical staple or suture fixation of each half. The AP or OV technique was randomly assigned to the medial or lateral ends of transversely oriented seams or to the proximal and distal ends of longitudinally oriented seams. At 3, 6, and 12 months post surgery, a blinded rater compared the two halves of each study seam scar using the Vancouver Scar Score (VSS). Subjects were also blinded and rated each half of their study seam using a 0 (poor) to 10 (excellent) visual analogue scale. Values are shown as the median (Q1-Q3). There were 44 study seams among 19 subjects (age 51 [36-70] years, with % TBSA burn 10 [7-18], % BSA full-thickness burn 8 [6-15]). Study seams were constructed at 10 (4-15) days post burn. Study seam length was 14.5 (10.3-18.0) cm, with 25% transversely oriented and 75% longitudinally oriented, and with 35/44 seams (80%) between meshed grafts and 9/44 (20%) between sheet grafts. There were no significant differences in any of the individual domain VSS scores (height, pliability, vascularity, and pigmentation) or total VSS score between AP and OV seams at 3, 6, and 12 months. At 12 months, among the 30 study seams that were visible to the subjects, the visual analogue scale score for the AP seams was 9 (8.5-10), which did not differ significantly from the OV seams (9.5 [8.45-10], P = .821). Overlapping or approximating adjacent skin grafts at the time of seam construction does not appear to affect final seam scar quality.

Background: The Berlin definition of Acute Respiratory Distress Syndrome (ARDS) has been applied to military burns resulting from combat-related trauma, but has not been widely studied among civilian burns. This study's purpose was to use the Berlin definition to determine the incidence of ARDS, and its associated respiratory morbidity, and mortality among civilian burn patients., Methods: Retrospective study of burn patients mechanically ventilated for ≥48h at an American Burn Association-verified burn center. The Berlin criteria identified patients with mild, moderate, and severe ARDS. Logistic regression was used to identify variables predictive of moderate to severe ARDS, and mortality. The outcome measures of interest were duration of mechanical ventilation and in-hospital mortality. Values are shown as the median (Q1-Q3)., Results: We included 162 subjects [24% female, age 48 (35-60), % total body surface area (TBSA) burn 28 (19-40), % body surface area (BSA) full thickness (FT) burn 13 (0-30), and 62% with inhalation injury]. The incidence of ARDS was 43%. Patients with ARDS had larger %TBSA burns [30.5 (23.1-47.0) vs. 24.8 (17.1-35), p=0.007], larger FT burns [20.5(5.4-35.5) vs. 7 (0-22.1), p=0.001], but had no significant difference in the incidence of inhalation injury (p=0.216), compared to those without ARDS. The % FT burn predicted the development of moderate to severe ARDS [OR 1.034, 95%CI (1.013-1.055), p=0.001]. ARDS developed in the 1st week after burn in 86% of cases. Worsening severity of ARDS was associated with increased days of mechanical ventilation in survivors (p=0.001), a reduction in ventilator-free days/1st 30 days in all subjects (p=0.004), and a strong indication of increased mortality (0% in mild ARDS vs. 50% in severe ARDS, unadjusted p=0.02). Neither moderate ARDS nor severe ARDS were significant predictors of death., Conclusions: ARDS is common among mechanically ventilated civilian burn patients, and develops early after burn. The extent of full thickness burn predicted development of moderate to severe ARDS. Increasing severity of ARDS based upon the Berlin definition was associated with a significantly greater duration of mechanical ventilation and a trend toward higher mortality., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Colloids have been used in varying capacities throughout the history of formula-based burn resuscitation. There is sound experimental evidence that demonstrates colloids' ability to improve intravascular colloid osmotic pressure, expand intravascular volume, reduce resuscitation requirements, and limit edema in unburned tissue following a major burn. Fresh frozen plasma appears to be a useful and effective immediate burn resuscitation fluid but its benefits must be weighed against its costs, and risks of viral transmission and acute lung injury. Albumin, in contrast, is less expensive and safer and has demonstrated ability to reduce resuscitation requirements and possibly limit edema-related morbidity., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The χ, Fisher's exact, and Cochran-Mantel-Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association-supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.

Rationale: The impact of hospital length of stay (LOS) on the distribution and susceptibility of Gram negative bacteria (GNB) causing infection in burn patients remains unexplored. Knowledge of causative pathogens is important in guiding empiric antibiotic therapy., Objectives: To characterize the distribution of GNB causing infection and to identify changes in susceptibility with LOS in a tertiary care burn center., Methods: A retrospective review of all admissions to the Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre with clinical cultures yielding GNB (duplicates excluded) between March 12, 2010 to July 17, 2013 was completed. Positive cultures were categorized into 5 clinically relevant time periods (in days) based on specimen collection date relative to the patient's date of admission: 0-7, 7-14, 14-21, 21-28, >28. Chi-square for proportions was used to compare the time periods., Results: The proportion of patients with clinical cultures for P. aeruginosa increased with hospital LOS (0-7 days: 8% vs. >28 days: 55%; p<0.05). Conversely, clinical cultures for H. influenzae occurred primarily within the first 7 days of hospitalization (0-7 days: 36% vs. >28 days: 0.7%; p<0.05). Enterobacteriaceae isolation was highest between 7 and 14 days of hospitalization (7-14 days: 62% vs. >28 days: 38%; p<0.05). Antibiotic resistance was directly proportional to hospital LOS (% patients with multidrug resistant GNB increased from 6% [LOS 0-7 days] to 44% [LOS>28 days]; p<0.05)., Conclusions: This study provides objective data documenting changes in species and resistance patterns of GNB causing infection in patients admitted to a burn center as a function of hospital LOS; which may support delaying the use of broad spectrum antibiotics (e.g. carbapenems and beta-lactam/beta-lactamase inhibitors) in clinically stable patients., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

Although fiber-optic bronchoscopy is essential in the diagnosis of smoke inhalation injury (INH), controversy still exists over whether or not the visualized severity of the mucosal injury predicts clinically meaningful outcomes. The purpose of this study was to assess whether the grade of mucosal INH severity was associated with various outcomes among adult burn patients. We conducted a retrospective review of all patients requiring greater than or equal to 48 hours of mechanical ventilation who were admitted between January 1, 2007 and June 1, 2014 to an adult regional American Burn Association-verified burn center. Bronchoscopy was performed on all subjects at burn center admission and grading of severity was documented using the grades 0 to 4 abbreviated injury score (AIS). Subjects with grade 1 or 2 injury formed the low-grade INH group, whereas those with grade 3 or 4 injury formed the high-grade INH group. Values are shown as the median (first to third quartiles). A P value less than .05 was considered significant. The study population consisted of 160 subjects (age, 48 [35-60] years; %TBSA burn, 28 [19-39.9]; % full thickness burn, 12.8 [0-30]; and 61% with INH). There were no significant differences in age, %TBSA burn, or % full thickness burn between subjects with different individual INH severity grades. Oxygenation on the day of injury worsened significantly as the severity of INH increased, but otherwise there were no significant differences in 24 and 48-hour fluid requirements, duration of ventilation, ventilator free days, incidence of acute respiratory distress syndrome, or mortality between subjects with different individual grades of INH severity. Subjects with high-grade INH showed statistically insignificant trends toward larger 48-hour fluid volumes (P = .07), poorer oxygenation over the first 3 post burn days (P = .055), longer duration of ventilation (P = .08), and fewer ventilator free days (P = .047) than low-grade INH. High-grade and low-grade INH subjects did not differ significantly in the incidence of acute respiratory distress syndrome or mortality. The individual grades of the 0 to 4 AIS INH severity grading scale were not particularly robust in the prediction of various outcomes among a population of adult burn patients. However, clinically relevant trends toward worsened oxygenation over postburn days 0 to 3, longer duration of mechanical ventilation, and reduced ventilator-free days in association with more severe INH were identified when subjects were broadly stratified into low-grade (grades 1and 2) INH and high-grade (grades 3 and 4) INH. This suggests that there may clinically meaningful differences between patients with less and more severe INH, and that further refinement of the grades 0 to 4 AIS INH severity should be subjected to additional investigation.

Enteral nutrition (EN) is commonly interrupted in burn patients for many reasons, which leads to discrepancies between prescribed and actual EN delivery. The magnitude and origin of these discrepancies have never been well documented among burn patients. The purpose of this study was to examine differences between prescribed and actual EN delivery and to identify the specific causes of EN interruption and to quantify these. Retrospective review of patients treated between June 6, 2009 and June 6, 2012 at an adult regional American Burn Association-verified burn center who had ≥10% TBSA burns and who were prescribed EN for at least 24 hours. On postburn days (PBD) 0 to 14 the daily volume of EN prescribed by the dietitian was compared with the actual volume received by the patient. The cause and duration of interruptions to EN delivery were recorded. A total of 90 subjects, [mean (± SD) age 47 ± 18 years, 32% female, median %TBSA burn size 28, median %TBSA full-thickness burn size 11, and a 54% incidence of inhalation injury], were studied. EN was initiated at a median of 9.5 hours after burn center admission. Received calories were significantly less than prescribed calories on every study day. The median daily caloric deficit ranged between 172 and 930 kcal. The median percent of prescribed calories received each day ranged from 19% on PBD 0 to 91% on PBD 14. The mean (± SD) total duration of EN interruption was 8.9 ± 3.0 hours per day. Gradually increasing the feed rate to reach the prescribed EN goal rate ("ramping-in") was the most common cause of a discrepancy between prescribed and actual EN delivery, accounting for 35% of total discrepancy time. Interruptions for surgery accounted for 24% of total discrepancy time. Other causes of discrepancies were physician- or nurse-directed interruptions (16% of time), planned extubation (7%), feed intolerance (11%), tube malfunction (2%), bedside procedures (2%), and dressing changes (3%).Enterally fed burn patients received significantly less nutrition than prescribed. Some of the causes for discrepancies between prescribed and received EN are unavoidable, but many are not, suggesting the need for careful review and possible alteration of existing EN practices.

This article describes a practical, clinically based approach to classification of postburn deformities. Burn scar contractures are of either the broad diffuse type or linear band-like type. The former generally respond well to release and insertion of a skin graft or substitute, whereas the latter are generally repaired using a simple or modified Z-plasty or a transpositional flap technique. The pulsed dye laser is a promising technique used to reduce scar thickness and redness. Postburn deformities of the face, upper and lower extremities, and trunk are discussed, in addition to novel techniques for vascularized composite allotransplantation of the face., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Blood banks now store blood up to 42 days. With increasing duration of storage, units of red blood cells (RBCs) develop a storage lesion characterized by alterations in oxygen transport capability and heightened proinflammatory properties. However, there is considerable controversy as to whether the storage lesion affects outcomes in transfused patients and burn patients, which has not been studied. The purpose was to identify whether any relationship exists between the storage age of transfused blood and outcome in severely burned adults. This is a retrospective review of adults, with burns 20% or more TBSA, treated at an adult regional ABA-verified burn center, who received at least one RBC transfusion. Subjects were stratified a priori based on the mean age of all RBC units transfused during the first 30 days postburn, to either a Fresh Group (mean storage age ≤28 days), or an Old Group (mean storage age >28 days). The Fresh Group (N = 89) did not differ significantly from the Old Group (N = 38) in baseline characteristics. The median (range) mean blood storage age was 22.2 (10.3-28) days in the Fresh Group and 31.5 (28.3-41) days in the Old Group, (P < .001). The Fresh Group had a significantly higher median daily transfusion rate when alive and in hospital, during the first 30 days postburn, than the Old Group (0.5 [range 0.03-5.5] units/day vs 0.35 [0.03-2.7] units/day; P = .04). There were no significant differences between the groups in mean daily sequential organ failure assessment (SOFA) score, peak SOFA score, delta SOFA score (peak-admission SOFA), time to wound healing, length of stay, and 30-day mortality or in-hospital mortality. Linear regression revealed no significant effect of the mean age of transfused blood on mean daily SOFA score/first 30 days postburn. The Fresh Group had a significantly longer median duration of mechanical ventilation (29 [range 1-195] vs 17 [range 1-80] days, P = .03) and had significantly more sepsis episodes. Transfusion of RBCs with a mean storage age of more than 28 days was not associated with any worsened outcome compared with transfusion of blood with a mean storage age of less than 28 days, among this cohort of adult burn patients. These findings do not suggest the need to preferentially transfuse fresher blood to burn patients, but randomized prospective studies of this question are needed.

This review article examines the use of human albumin (HA) in burn treatment. Generally, there are two scenarios where HA may be administered: acutely as a volume expander during burn shock resuscitation and chronically following resuscitation to correct hypoalbuminemia. Although colloids were the cornerstone of the earliest burn resuscitation formulas, HA was in fact rarely used. More recently however, with the recognition of fluid creep, HA usage during resuscitation has increased. Animal studies demonstrate that during acute fluid resuscitation, administration of colloids, including albumin (ALB), have no ability to arrest the formation of burn wound edema, but they do reduce edema formation in the nonburn soft tissues and help preserve intravascular volume and reduce resuscitation fluid requirements with no apparent increase in extravascular water accumulation in the lung. Human studies suggest that immediate use of ALB during acute resuscitation achieves adequate resuscitation using a lower total overall volume requirement, transiently provides better maintenance of intravascular volume and cardiac output, produces less overall edema gain than crystalloid resuscitation alone but may be associated with increased extravascular lung water accumulation during the first postburn week. However, many questions remain unanswered, and modern, large-scale prospective studies are desperately needed. Maintenance of normal serum ALB levels through continuous supplementation of HA following burn resuscitation is even less well understood. Although this approach makes physiologic sense, the limited amount of available data from human burn studies reveal that chronic ALB supplementation is expensive and may not result in any major clinical benefits. Again, modernized prospective studies are greatly needed in this area.

High-frequency oscillatory ventilation (HFOV) is a mainstay in the ventilatory management of severe acute respiratory distress syndrome in our burn center. Many patients require burn surgery while on HFOV, potentially necessitating the use of HFOV during general anesthesia in the operating room. The purpose of this study was to describe the technique of providing and maintaining intraoperative HFOV. This is a retrospective analysis of the hospital and anesthesia records of all adult burn patients who went to the operating room on HFOV at our regional burn center between October 22, 1999, and April 30, 2009. There were 57 procedures performed on 36 patients who were receiving HFOV for severe acute respiratory distress syndrome available for analysis (age 45 ± 16 years, %TBSA burn 43 ± 14, % full-thickness burn 32 ± 19, and 69% with inhalation injury). Intraoperative HFOV settings were mean airway pressure 33 ± 4 cm H₂O, frequency 5 ± 1 Hz, and FiO₂ 0.7 ± 0.2. There were no significant changes in oxygenation as measured by the PaO₂/FiO₂ ratio and the oxygenation index, but there was a transient but significant increase in PaCO₂ intraoperatively. Existing continuous infusions of midazolam, opioids, and neuromuscular blockers were continued during surgery and were augmented by a variety of parenteral agents, including propofol, fentanyl, and ketamine during surgery. Prone positioning was required in 16 of 57 procedures. Subanalysis of the prone cases showed no significant changes in the PaO₂/FiO₂ ratio or oxygenation index but again showed a significant but temporary increase in intraoperative PaCO₂. HFOV was aborted for conventional mechanical ventilation in three cases due to respiratory deterioration (2 cases) and hemodynamic instability (1 case). There were no intraoperative deaths. In-hospital mortality was 33%. Intraoperative HFOV was feasible and safe in the overwhelming majority of cases, and aside from an inconsequential period of intraoperative hypercapnia, this was not associated with any hemodynamic instability or compromise in oxygenation.

Increased capillary permeability and reduced plasma colloid osmotic pressure following burn injury result in hypovolemia and development of edema in the burn and nonburn tissues. Replenishment of the intravascular deficit with crystalloid fluid has been the mainstay of resuscitation for the better part of four decades. A progressive but as yet unexplained trend toward provision of resuscitation volumes well in excess of those predicted by the Parkland formula, associated with numerous edema-related complications, has been repeatedly observed recently. Correction of this phenomenon, called fluid creep, will likely revolve around several strategies, which may include tighter control of titration, re-emergence of colloids and hypertonic salt solutions, and possibly the use of adjunctive markers of resuscitation other than urinary output.

Background: Exogenous arginine vasopressin (VP) has been increasingly used in the hemodynamic management of critically ill patients with septic shock, but its use in septic burn patients has not been systematically examined., Purpose: To review our experience with the use of VP in septic burn patients., Methods: Retrospective review of all patients who received VP at a tertiary care adult regional burn centre. Only patients who strictly met the American College of Chest Physicians/Society of Critical Care Medicine Consensus Criteria for sepsis at the time of VP initiation were analysed., Results: There were 30 septic burn patients treated on 43 distinct occasions with VP. This group had a mean (+/-S.D.) age of 49+/-19 years, a mean % TBSA burn of 41+/-15% and a 37% incidence of inhalation injury. A significant increase in mean arterial pressure (MAP), a significant decrease in heart rate (HR), and a trend towards increased urine output (UO) occurred following initiation of VP. When VP was added to an existing infusion of norepinephrine (NE), there was a significant NE sparing effect. VP was implicated in the death of one patient who developed diffuse upper gastrointestinal necrosis while on VP. Other complications in patients treated with VP included peripheral ischemia (2), skin graft failure (1) and donor site conversion (1). In all complications, VP had been administered in combination with prolonged NE infusions (mean of 10 microg/min over a mean of 177 h)., Conclusion: VP is a useful adjunctive pressor that spares NE requirements in septic burn patients, but its use is not without risks, particularly when VP is combined with sustained moderate to high infusions of NE.

Cytokines play a role in the immunopathological and molecular mechanisms of sulfonamide-induced hypersensitivity reactions (HSRs). The objective of this study was to analyze the reliability and correlation between the clinical symptoms observed in affected patients (n = 86) because of a sulfonamide-induced HSR and their lymphocyte toxicity assay (LTA) values. Another goal was to determine the cytokine secretion in the patient's sera and their expression in the peripheral blood mononuclear cells (PBMCs) and to explore whether a correlation exists among positive LTA score, cytokine levels, and HSR occurrence. The final goal is to determine whether these measures could be used to predict the likelihood of a patient to experience an HSR during sulfonamide treatment. Such a predictive ability would be valuable to the clinician to know whether the patient would tolerate sulfonamides or whether an alternative antibiotic should be prescribed. The LTA showed a good correlation with the clinical involvement of patients with hypersensitivity syndromes. In addition, the pro-inflammatory cytokines presented significant differences in patients that had rash, fever, and organ involvement than in control patients or any of the other patient groups. Expression of tumor necrosis factor alpha (TNF-alpha) is significantly higher in patients presenting rash, fever, and organ involvement versus all other groups. It is concluded that a positive LTA is a predictor for sulfonamide-induced true HSR. In addition, T-helper cell 1 cytokines [TNF-alpha, interleukins (ILs) 1 and 2] as well as the chemokine regulated upon activation, normal T-cell expressed and secreted (RANTES) control the pathogenesis of sulfonamide-induced HSR and may be used in early diagnosis of the syndrome.

Transfusion-related acute lung injury (TRALI) has not been systematically described in patients with burn injury, and the characterization of TRALI in patients with pre-existing acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) also is lacking. Our aim was to identify TRALI in burn patients and to attempt to characterize transfusion (TXN)-related pulmonary deterioration in burn patients with pre-existing ALI or ARDS. We undertook a retrospective review of mechanically ventilated and transfused burn patients at an adult regional burn center between January 1, 2003, and January 5, 2005. A blinded intensivist independently rated pre- and post-TXN chest radiographs (CXRs). There were 25 patients (age 51 +/- 19 years, %TBSA burns 30 +/- 19, full thickness %BSA 17 +/- 19, with a 24% incidence of smoke inhalation) who received 124 TXNs. New ALI developed within 6 hours after four TXNs. In one TXN, there were no other precipitating causes (eg, infection, inhalation injury), suggesting possible TRALI (incidence 0.8%). Existing ALI or ARDS was present before 63 (51%) of the TXNs. Definite worsening of the CXR and deterioration in the PaO2/FiO2 ratio (18% +/- 4%) within 6 hours of TXN occurred after six transfusions. In two of the TXNs, there were no other precipitating causes, suggesting possible TXN-related pulmonary deterioration (incidence 3.2%). Vigilance must be maintained for TRALI in burn patients. For patients with existing ALI or ARDS, we suggest that worsening of the CXR and reduction in the PaO2/FiO2 ratio by 20% or more within 6 hours of transfusion should be investigated for possible TRALI with appropriate donor investigations.

Determining burn patients' need for inpatient rehabilitation at discharge is difficult and an objective clinical indicator might aid in this decision. The functional independence measure (FIM) is a validated outcome measure that predicts the need for rehabilitation services. This study evaluated the utility of the FIM score for discharge planning in burn patients. A retrospective chart review and FIM score determination was performed on all major burn patients discharged from a regional adult burn centre between July 1, 1999 and June 30, 2000. From 164 adult burn patients discharged, 37 met the American Burn Association criteria for major burns. One patient had insufficient data. Therefore, 36 patients were studied (mean age 47.3 +/- 17.4 years, and mean body area burned 27.4 +/- 12.9%). All 17 patients with FIM scores greater than 110 were discharged home, and patients with FIM score of 110 or lower were discharged to another institution (rehabilitation hospital n = 14, other acute care hospital n = 4, or a nursing home n = 1) p < 0.0001. A discharge FIM score of 110 or lower was strongly associated with the need for inpatient rehabilitation, while a FIM score greater than 110 indicates the patient is independent enough to manage at home. Further prospective studies will be necessary to validate these findings.

Deep partial- and full-thickness burns to the hands are common and the source of significant potential morbidity for the patient. This article emphasizes that when these burns are managed by an experienced team of burn surgeons, rehabilitation therapists, and nurses, using a standardized protocol, good long-term functional outcomes may be reliably obtained in most cases. The details of the author's standardized protocol, as well as late outcomes achieved using this approach, are discussed.

Despite improved survival after burn center treatment for patients with toxic epidermal necrolysis (TEN), little is known about the overall long-term outcomes in these patients. In this work we sought to analyze late outcomes in survivors of TEN who were treated in our burn center. Subjects completed a questionnaire that included the RAND 36-Item Health Survey (SF-36) and the Dermatology Life Quality Index. Subjects were examined, when possible, and completed the Functional Independence Measure. Scores on the SF-36 were compared with age- and sex-matched National normative data. All results are presented as the mean +/- SD. Of 35 adults admitted with TEN between January 1, 1995, and January 6, 2003, 10 have died in hospital, 4 have died since discharge, and 8 have been lost to follow-up, leaving a study population of 13 subjects (age 45 +/- 18 years with initial %TBSA involvement 65 +/- 29). Follow-up occurred at 38 +/- 27 months after discharge. The most common ophthalmic problems were chronic photosensitivity (54%) and dry eyes (31%). The Dermatology Life Quality Index (maximum-worst score = 30) was 9 +/- 10. SF-36 scores were significantly lower than in the age- and sex-matched normal population across all domains except mental health. The Functional Independence Measure score (maximum-best score = 126) was 123 +/- 4. Survivors of TEN demonstrate a high level of independent function in activities of daily living, but numerous complications of TEN significantly impair their overall quality of life, emphasizing the need for long-term follow-up.

Older adults are involved in one fifth of burn injury admissions in the Province of Ontario Canada. Most burn injuries in this population occur at home while cooking, bathing, or smoking. The purpose of this study was to evaluate the effectiveness of an educational campaign to improve burn prevention knowledge in older adults of a major metropolitan city. Changes in participants' burn prevention knowledge were determined using standardized precampaign and postcampaign (4-6 weeks) surveys. Of 209 older adult participants, 126 (60.3%) completed the precampaign and postcampaign surveys. There was a significant increase (P <.05) in burn prevention knowledge postintervention. Age, education level, and living conditions did not influence the change in burn prevention knowledge. This burn prevention campaign for older adults was effective in improving burn prevention knowledge, but it remains unclear as to whether this will ultimately result in a change in burn prevention behavior.

Background: High frequency oscillatory ventilation (HFOV) improves gas exchange while providing lung protective effects during the ventilation of patients with the acute respiratory distress syndrome (ARDS). The purpose of this study was to review our experience with HFOV in adult burn patients with oxygenation failure secondary to ARDS., Methods: Retrospective cohort review of all burn patients treated with HFOV at a regional adult burn center., Results: All values are reported as the mean +/- standard deviation (S.D.). HFOV was used on 28 occasions in 25 patients (age 44 +/- 16 years, %TBSA burns 40 +/- 15, and a 28% incidence of inhalation injury) who had severe oxygenation failure from ARDS (PaO2/FiO2 ratio 98 +/- 26, and oxygenation index (OI) (FiO2 x 100 x mean airway pressure/PaO2) 27 +/- 10) following 4.8 +/- 4.4 days of conventional mechanical ventilation (CMV). After switching from CMV to HFOV, there were significant improvements in the PaO(2)/FiO2 ratio within 1h and in the oxygenation index within 24 h. The duration of HFOV was 6.1 +/- 5.8 days. HFOV was continued during 26 surgeries for 14 patients where a mean of 18 +/- 9% TBSA burns were excised and closed. The only complications related to HFOV were three episodes of severe hypercapnia. In-hospital mortality was 32%., Conclusions: HFOV was safe, and was highly effective in correcting oxygenation failure associated with ARDS in burn patients, and can be successfully used as an intra-operative ventilation modality for burn patients.

Intravenous Immunoglobulin (IVIG) has been proposed as a beneficial therapy for toxic epidermal necrolysis (TEN). However, this has been based on a limited amount of Class 5 evidence. To compare outcomes in TEN patients treated in our burn unit since 1999, when we began to use IVIG (IG group), with TEN patients treated between 1995 and 1999 who did not receive IVIG (control group). Retrospective cohort review of the records of all TEN patients admitted between April 5, 1995 and December 4, 2002. There were 16 patients in the IG group (age 53 +/- 21 years, with initial rash involving 65 +/- 29% TBSA) and 16 patients in the control group (age 52 +/- 20 years, with initial rash involving 65 +/- 27% TBSA). The IG group received 0.7 +/- 0.2 g/kg/day of IVIG for 4 +/- 1 days. There were no significant differences between the groups with respect to the length of stay, duration of mechanical ventilation, severity of systemic inflammatory response syndrome and multiple organ dysfunction syndrome, or the incidence of sepsis. Significant progression of the wound occurred in 13% of the IG patients and in 27% of control patients, whereas no wound progression was observed in 47% of the IG patients and in 18% of the control patients (P =.299). The time to healing did not differ between IG and control groups (11.2 +/- 3.6 vs 11.4 +/- 2.6 days, respectively). There was no significant difference in the mortality rate between the IG group (25%) and the control group (38%). There were no complications from IVIG aside from one case of hyponatremia from the hypotonic IVIG solution. Although there may have been a trend towards less severe wound progression in patients who received IVIG, this was not associated with any substantial improvement in outcome in our TEN patients. A prospective randomized study with a larger sample size is needed to confirm our findings.

Introduction: Toxic epidermal necrolysis (TEN) is a life-threatening adverse drug reaction (ADR) that is primarily the result of drug exposure (incidence 0.4-1.3 per million person-years). Life-threatening ADRs such as TEN should be reported to ADR monitoring programmes, which collect reports for suspected ADRs and alert the public and medical practitioners to new drug hazards. In Canada, reports are made to the Canadian Adverse Drug Reaction Monitoring Program (CADRMP)., Objective: To examine the extent of under-reporting for TEN in Canada., Design: A retrospective case series design was used to collect all TEN cases for the period January 1995 to December 2000., Methods: The CADRMP and 22 burn centres across Canada were contacted for all TEN patients treated during the specified time period. PATIENT GROUPS STUDIED: The study population consisted of patients admitted to burn treatment sites across Canada, patient cases reported to the CADRMP and patient cases recorded by the Canadian Institute for Health Information (CIHI) hospital discharge summaries as the International Classification of Diseases Version 9 Clinical Modification (ICD-9-CM) code 695.1., Results: Twenty-five TEN cases (six fatal) were reported to CADRMP from January 1995 to December 2000. During this period, 14 (63.6%) burn treatment sites reported admission of 250 TEN cases. Hospital discharge summaries using the ICD-9-CM code 695.1 indicated that 4349 cases were admitted to hospital during this time period and it was estimated that 15.5% (n = 674) of these cases were TEN. Using the burn facility data as the denominator, 10% (25 of 250) of TEN cases were reported to CADRMP. Using CIHI data as a denominator, only 4% (25 of 674) of TEN cases were reported to CADRMP., Conclusions: There is serious under-reporting of TEN. Lack of reporting of life-threatening ADRs can compromise population safety. There is a need to increase awareness of ADR reporting programmes.

Although subcutaneous and topical epinephrine are widely used for hemostasis during burn surgery, the acute systemic cardiovascular effects of the epinephrine are neither well documented nor completely understood. The purpose of this work was to prospectively study the acute cardiovascular responses to epinephrine (epi) administered subcutaneously and topically during burn surgery. Consecutive patients who received subcutaneous and topical epi during burn surgery were monitored prior to the administration of epi, at 2-minute intervals during subcutaneous epi infiltration, and then after epi infiltration (during which time, topical epi was applied). This period of monitoring lasted up to 20 minutes and was referred to as an epinephrine event (EE). A total of 100 EEs from 38 operations in 24 patients (mean +/- SD: age 43 +/- 16 years, mean % TBSA burn 23 +/- 17%) were studied. The mean dose of subcutaneous epi was 30 +/- 30 microg/kg. Although all patients received topical epi, it was impossible to document the topical dose. There was no significant increase in heart rate from baseline, and no arrhythmias occurred. Mean arterial pressure (MAP) did acutely increase significantly by 17.0 +/- 14.1% from baseline (P =.009) and increased more than 10% from baseline in 64/100 EEs. However, the increase in MAP was independent of the dose of epi (r =.053). The increase in MAP was not clinically significant, did not require intervention, and did not appear to be related to the type of wound that received epi (donor site vs burn wound), or the depth of anesthesia, analgesia, or sedation. On the basis of these findings, the use of subcutaneous and topical epi appears to be safe and produces minimal acute cardiovascular effects.

It is not known whether objective measurements of burn scar quality reflect, or even bear any relationship to, the patient's opinion of their scar. The purpose of this study was to determine whether any correlation exists between the rehabilitation therapist's rating of the scar using the Vancouver Scar Scale (VSS) and the patient's subjective opinion of their scar. A total of 37 scars in 20 adult patients (mean age, 34 +/- 13 years; 30% female; mean %TBSA burn, 16 +/- 11%) were evaluated at 3.1 +/- 1.9 months after injury (early assessment). Patients were asked to rate their own scar (question 1) and to rate how they perceive other people view the scar (question 2). A visual analog scale (VAS) was used to score the answers to both questions. A burn occupational therapist who was blinded to the VAS scores performed a VSS rating of the scar. These evaluations were repeated 1.5 years after injury (late assessment). At the early assessment, there was no correlation between the VSS score and VAS scores for question 1 (r =.291) or question 2 (r =.371). At the late assessment, there was significant improvement in the VSS score and the VAS score for question 2. Also, a significant correlation developed between the VSS score and the VAS score for question 1 (r =.646, P =.003) but not between the VSS score and VAS score for question 2 (r =.099). The VSS measurement of the scar bears no relationship to the patient's opinion of their scar early after a burn injury. As the scar improves over time, the patient's opinion of their scar appears to improve and shows better correlation with the VSS rating. Conversely, the patient's impression of what others think of the scar continues to bear no relationship to the VSS rating, suggesting that scar acceptance by the patient is incomplete despite objective improvement in the quality of the scar. Although the VSS was never intended to measure a patient's opinion of their scar, these preliminary findings emphasize the necessity of including a patient-centered subjective component to routine scar monitoring and assessment.

An excessive base deficit (BD) and elevated serum lactate are increasingly recognized as important markers of a malperfusion state during the resuscitation of thermally injured patients. In a previous retrospective study, we found that patients with a BD less than -6 mmol/l during fluid resuscitation developed more severe systemic inflammatory response syndrome (SIRS), more frequent acute respiratory distress syndrome (ARDS), and more severe multiple organ dysfunction syndrome (MODS). The object of this study was to reexamine prospectively the relationship between the BD during fluid resuscitation and the subsequent development of SIRS, ARDS, and MODS by undertaking a prospective observational study of a cohort of consecutive burn patients. Analysis was completed on 38 patients with a mean age of 39 +/- 17 years and a mean %TBSA burn of 36 +/- 15%. The mean BD in the first 24 hours was less than -6 mmol/l in five patients (BD24 < -6 group), and was greater than -6 mmol/L in 33 patients (BD24 > -6 group). Patients in both groups were resuscitated to nearly identical endpoints of urinary output (1.2 ml/kg/hr in the BD24 < -6 group vs 1.3 ml/kg/hr in the BD24 > -6 group). Patients in the BD24 < -6 group had a trend toward a greater number of SIRS signs on the first postburn day, had a significantly higher incidence of ARDS (P =.02), and had significantly more severe MODS (P <.001) than patients in the BD24 > -6 group. The results concur with those of our previous retrospective study. Despite resuscitation to an acceptable urinary output, some burn patients develop a more extreme BD and go on to experience more severe organ dysfunction than do patients who do not generate a BD. The effect of specific correction of the BD during fluid resuscitation is not known at this time.

Elderly burn patients suffer from greater morbidity and mortality than younger patients with similar burn extents. The purpose of this study was to identify risk factors for burn injuries in the elderly to develop an effective preventive program. A cross-sectional survey was conducted among 20 elderly (> or =65 years of age) burn survivors on the circumstances surrounding their burn injury and on burn prevention. A control group of 20 nonburned elderly completed a similar survey only on burn prevention. The majority of burned subjects believed that their injury was preventable (85%). The home was the commonest location for burn injury (70%), and scalds (50%) and flame burns (25%) were the most common etiologies. Most subjects felt that a burn prevention program would be useful (95%) and television, news, and posters were the preferred sources of prevention information. Compared with the burn group, the control group had more risk factors for burn injury. However, the control group also took more active preventive measures. Burn prevention campaigns for elderly should focus on reducing flame and scald burns that occur in the home, preferably using television, news, and poster media.

The relevance of an elevated base deficit (BD) during the fluid resuscitation of a thermally injured patient is not completely understood. After nonthermal trauma, early elevation of the BD represents insufficient cellular perfusion and is ultimately associated with a higher incidence of organ dysfunction and death. However, this relationship has not been completely examined after burn injuries. The purpose of this study was to determine if elevation of the BD during burn resuscitation was associated with potential consequences of malperfusion, such as systemic inflammatory response syndrome, acute respiratory distress syndrome, and multiple organ dysfunction. The records of 72 patients with burn injuries (mean age, 46 +/- 17 years; mean total body surface area burned, 44% +/- 18%) who required fluid resuscitation on admission to an adult regional burn center were analyzed. Patients with a mean BD of less than -6 mmol/L during the first 24 hours were compared with patients with a mean BD of more than -6 mmol/L. Despite adequate resuscitation with good maintenance of urinary output, the patients in the group with a mean BD of less than -6 mmol/L had more florid systemic inflammatory response syndrome (P = .004), had more prevalent acute respiratory distress syndrome (P = .012), and experienced more severe multiple organ dysfunction (P < .001) compared with patients in the group with a mean BD of more than -6 mmol/L. The results suggest that abnormal elevation of the BD after burn injuries represents a malperfusion state, which may not be recognized if only "traditional" parameters, such as UO, are followed. Furthermore, this state appears to be related to the onset of more severe systemic inflammation and organ dysfunction.

Herpes simplex virus (HSV) infection in the burn patient is thought to occur relatively frequently. Most commonly, children with significant burns, particularly involving the head and neck, are affected. Burn related immunosuppression is thought to allow reactivation of latent HSV in most cases, although primary HSV infection has been recognized. Clinical manifestations vary from asymptomatic viral shedding, to prolonged fever with eruption of vesicles, to rare cases of systemic visceral dissemination. Healing partial thickness wounds and donor sites are most prone to infection. Laboratory confirmation of HSV infection relies on direct demonstration of the virus and/or observation of a rise in antibody titer. Treatment of an established HSV infection includes use of IV Acyclovir, meticulous wound care, and efforts to prevent nosocomial spread. The vast majority of cases resolve without sequelae unless complicated by systemic, multiorgan HSV infection.

Background: There has been a progressive reduction in the extent of resection of primary cutaneous melanoma. Although overall survival appears to have been unaffected by this trend, the effect of narrow resection on local recurrence is not entirely clear., Objective: To examine the relationship between narrow resection margins and local recurrence of primary cutaneous melanoma., Methods: Primary melanoma, 104 cases, treated by surgical resection were reviewed retrospectively., Results: "Thin" (< 1 mm) melanomas (31 cases) were resected with a mean margin of 0.87 cm; "intermediate" (1-4 mm) melanomas (37 cases) were resected with a mean margin of 1.26 cm; and 14 "thick" (> 4 mm) melanomas were resected with a mean margin of 1.25 cm. Local recurrence rates were 6.5%, 16.2%, and 42.9%, respectively. In the "intermediate" group, two local recurrences occurred in melanomas < 2 mm thick despite use of margins of 1.7 cm and 2.4 cm., Conclusions: The results to not support the use of excessively narrow resection margins around primary cutaneous melanoma. Additionally, we question the true safety of currently accepted 1 to 2 cm margins for 1 to 2 mm thick melanomas.

Objectives: To report a burn unit's experience with chemical burns and to discuss the fundamental principles in managing chemical burns., Design: A chart review., Setting: A burn centre at a major university-affiliated hospital., Patients: Twenty-four patients with chemical burns, representing 2.6% of all burn admissions over an 8-year period at the Ross Tilley Regional Adult Burn Centre. Seventy-five percent of the burn injuries were work-related accidents. Chemicals involved included hydrofluoric acid, sulfuric acid, black liquor, various lyes, potassium permanganate and phenol., Results: Fourteen patients required excision and skin grafting. Complications were frequent and included ocular chemical contacts, wound infections, tendon exposures, toe amputation and systemic reactions from absorption of chemical. One patient died from a chemical scald burn to 98% of the body surface area., Conclusions: The key principles in the management of chemical burns include removal of the chemical, copious irrigation, limited use of antidotes, correct estimation of the extent of injury, identification of systemic toxicity, treatment of ocular contacts and management of chemical inhalation injury. Individualized treatment is emphasized.

The rectus femoris myocutaneous flap has proved to be an effective means of closing particularly difficult wounds in 2 patients. One patients had a massive defect in the lower abdomen, pubic, and right groin area after the radical resection of a recurrent pleomorphic liposarcoma of the spermatic cord. The second patient presented with a huge, right greater trochanteric wound measuring 15 cm in diameter. Both patients progressed to relatively uneventful primary healing.

Human bite injuries of the hand may become complicated and therefore demand an organized approach to management. Thirty-two patients with human bites to the hand, admitted to Toronto's Wellesley Hospital between 1981 and 1985, were analyzed. The history and etiology, delay before presentation, microbiology results versus time from injury, and treatment regimens were reviewed. Streptococci appeared to be early pathogens and staphylococci later pathogens. However, a prospective study with serial aerobic, anaerobic, and 10% CO(2) cultures is needed to confirm these findings. Lack of organization in management was the most notable finding. Inpatient therapy with intravenous antibiotics usually is required. Treatment should revolve around the mnemonic 'ODD BITES': open treatment; debridement; drugs (antibiotics); bloodwork (leukocyte count); irrigation; tetanus prophylaxis; exploration (including X-rays); and swab (for culture and sensitivity).

The authors present an unusual and bizarre missile type of maxillofacial injury in a 7-year-old girl, who was struck in the middle of her face by an iron hook. The area between her forehead and upper lip was obliterated, making a clinical and radiologic diagnosis impossible. The authors review the current diagnostic methods used in maxillofacial trauma, including standard and computed tomography, to emphasize the importance of a correct preoperative diagnosis in the management of maxillofacial injuries.