Search

We sought to characterize if prehospital transfer origin from the scene of injury (SCENE) or from a referral emergency department (REF) alters the survival benefit attributable to prehospital plasma resuscitation in patients at risk of hemorrhagic shock.We performed a secondary analysis of data from a recently completed prehospital plasma clinical trial. All of the enrolled patients from either the SCENE or REF groups were included. The demographics, injury characteristics, shock severity and resuscitation needs were compared. The primary outcome was a 30-day mortality. Kaplan-Meier analysis and Cox-hazard regression were used to characterize the independent survival benefits of prehospital plasma for transport origin groups.Of the 501 enrolled patients, the REF group patients (n = 111) accounted for 22% with the remaining (n = 390) originating from the scene. The SCENE group patients had higher injury severity and were more likely intubated prehospital. The REF group patients had longer prehospital times and received greater prehospital crystalloid and blood products. Kaplan-Meier analysis revealed a significant 30-day survival benefit associated with prehospital plasma in the SCENE group (P.01) with no difference found in the REF group patients (P = .36). The Cox-regression verified after controlling for relevant confounders that prehospital plasma was independently associated with a 30-day survival in the SCENE group patients (hazard ratio 0.59; 95% confidence interval 0.39-0.89; P = .01) with no significant relationship found in the REF group patients (hazard ratio 1.03, 95% confidence interval 0.4-3.0).Important differences across the SCENE and REF cohorts exist that are essential to understand when planning prehospital studies. Prehospital plasma is associated with a survival benefit primarily in SCENE group patients. The results are exploratory but suggest transfer origin may be an important determinant of prehospital plasma benefit.

Background Prehospital plasma transfusion in trauma reduces mortality. However, the underlying mechanism remains unclear. Reduction in shock severity may play a role. Lactate correlates with physiologic shock severity and mortality after injury. Our objective was to determine if prehospital plasma reduces lactate and if this contributes to the mortality benefit of plasma. Methods Patients in the Prehospital Air Medical Plasma trial in the upper quartile of injury severity (Injury Severity Score, >30) were included to capture severe shock. Trial patients were randomized to prehospital plasma or standard care resuscitation (crystalloid ± packed red blood cells). Regression determined the associations between admission lactate, 30-day mortality, and plasma while adjusting for demographics, prehospital crystalloid, time, mechanism, and injury characteristics. Causal mediation analysis determined what proportion of the effect of plasma on mortality is mediated by lactate reduction. Results A total of 125 patients were included. The plasma group had a lower adjusted admission lactate than standard of care group (coefficient, -1.64; 95% confidence interval [CI], -2.96 to -0.31; p = 0.02). Plasma was associated with lower odds of 30-day mortality (odds ratio [OR], 0.27; 95% CI, 0.08-0.90; p = 0.03). When adding lactate to this model, the effect of plasma on 30-day mortality was no longer significant (OR, 0.36; 95% CI, 0.07-1.88; p = 0.23), while lactate was associated with mortality (OR, 1.74 per 1 mmol/L increase; 95% CI, 1.10-2.73; p = 0.01). Causal mediation demonstrated 35.1% of the total effect of plasma on 30-day mortality was mediated by the reduction in lactate among plasma patients. Conclusion Prehospital plasma is associated with reduced 30-day mortality and lactate in severely injured patients. More than one third of the effect of plasma on mortality is mediated by a reduction in lactate. Thus, reducing the severity of hemorrhagic shock appears to be one mechanism of prehospital plasma benefit. Further study should elucidate other mechanisms and if a dose response exists. Level of evidence Therapeutic, level II.

BACKGROUND Prehospital plasma improves survival for severely injured trauma patients transported by air ambulance. We sought to characterize the unexpected survivors, patients who survived despite having high predicted mortality after traumatic injury. METHODS The Prehospital Air Medical Plasma trial randomized severely injured patients (n = 501) to receive either standard care (crystalloid) or two units of prehospital plasma followed by standard care fluid resuscitation. We built a generalized linear model to estimate patient mortality. Area under the receiver operating characteristic curve was used to evaluate model performance. We defined unexpected survivors as patients who had a predicted mortality greater than 50% and survived to 30 days. We characterized patient demographics, clinical features, and outcomes of the unexpected survivors. Observed to expected (O/E) ratios and Z-statistics were calculated using model-estimated mortality for each cohort. RESULTS Our model predicted mortality better than Injury Severity Score or Revised Trauma Score parameters and identified 36 unexpected survivors. Compared with expected survivors, unexpected survivors were younger (33 years [24, 52 years] vs. 47 years [32, 59 years], p = 0.013), were more severely injured (Injury Severity Score 34 [22, 50] vs. 18 [10, 27], p < 0.001), had worse organ dysfunction and hospital resource outcomes (multiple organ failure, intensive care unit, hospital length of stay, and ventilator days), and were more likely to receive prehospital plasma (67 vs. 46%, p = 0.031). Nonsurvivors with high predicted mortality were more likely to receive standard care resuscitation (p < 0.001). Unexpected survivors who received prehospital plasma had a lower observed to expected mortality than those that received standard care resuscitation (O/E 0.56 [0.33-0.84] vs. 1.0 [0.73-1.32]). The number of prehospital plasma survivors (24) exceeded the number of predicted survivors (n = 10) estimated by our model (p < 0.001). CONCLUSION Prehospital plasma is associated with an increase in the number of unexpected survivors following severe traumatic injury. Prehospital interventions may improve the probability of survival for injured patients with high predicted mortality based on early injury characteristics, vital signs, and resuscitation measures. LEVEL OF EVIDENCE Therapeutic Level III.

Background A recent analysis derived from the Prehospital Air Medical Plasma trial data set demonstrated no significant independent plasma survival benefit in those who required massive transfusion (≥10 units of red cells in 24 hours). The definition of massive transfusion has evolved over time to minimize bias and predict those at highest risk of death. We sought to characterize the definition of massive transfusion, their associated mortality risks and the survival benefit associated with prehospital plasma. Methods A secondary analysis was performed using data from a recent prehospital plasma trial. Patients transferred directly from the scene were characterized. We defined historic massive transfusion using ≥10 units red cells in 24 hours and critical administration threshold (CAT) as ≥3 units per hour in the first hour (CAT1hr) or in any of the first 4 hours (CAT4hr) from arrival. The primary outcome was 30-day mortality. Kaplan-Meier analysis and Cox hazard regression were used to characterize the survival benefit of prehospital plasma. Results There were a total of 390 enrolled patients who were transferred from the scene and represent the study cohort. Overall, 126 patients were positive for the CAT1hr metric, 183 patients were positive for the CAT4hr metric and 84 patients were positive for historic massive transfusion metric. The overall study mortality rate for those patients who met each transfusion definition was 13.1%, 17.4% and 10.0%, respectively. The CAT4hr metric had the lowest potential for survival bias. Kaplan-Meier survival analysis demonstrated a prehospital plasma survival benefit in the patients who were CAT4hr positive. Conclusion The current analysis demonstrates the superior utility of the CAT4hr definition with optimization of survival bias while conserving mortality risk prediction. This transfusion definition was associated with a prehospital plasma survival benefit and may be the most appropriate definition of massive transfusion for pragmatic studies which focus on hemorrhagic shock. Level of evidence Epidemiologic, Level II.

Severe burn leads to substantial skeletal muscle wasting that is associated with adverse outcomes and protracted recovery. The purpose of our study was to investigate muscle tissue homeostasis in response to severe burn. Muscle biopsies from the right m. lateralis were obtained from 10 adult burn patients at the time of their first operation. Patients were grouped by burn size (total body surface area of

Importance Prehospital plasma transfusion is lifesaving for trauma patients in hemorrhagic shock but is not commonly used owing to cost and feasibility concerns. Objective To evaluate the cost-effectiveness of prehospital thawed plasma transfusion in trauma patients with hemorrhagic shock during air medical transport. Design, setting, and participants A decision tree and Markov model were created to compare standard care and prehospital thawed plasma transfusion using published and unpublished patient-level data from the Prehospital Plasma in Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock (PAMPer) trial conducted from May 2014 to October 2017, health care and trauma-specific databases, and the published literature. Prehospital transfusion, short-term inpatient care, and lifetime health care costs and quality of life outcomes were included. One-way, 2-way, and Monte Carlo probabilistic sensitivity analyses were performed across clinically plausible ranges. Data were analyzed in December 2019. Main outcomes and measures Relative costs and health-related quality of life were evaluated by an incremental cost-effectiveness ratio at a standard willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). Results The trial included 501 patients in the modified intention-to-treat cohort. Median (interquartile range) age for patients in the thawed plasma and standard care cohorts were 44 (31-59) and 46 (28-60) years, respectively. Overall, 364 patients (72.7%) were male. Thawed plasma transfusion was cost-effective with an incremental cost-effectiveness ratio of $50 467.44 per QALY compared with standard care. The preference for thawed plasma was robust across all 1- and 2-way sensitivity analyses. When considering only patients injured by a blunt mechanism, the incremental cost-effectiveness ratio decreased to $37 735.19 per QALY. Thawed plasma was preferred in 8140 of 10 000 iterations (81.4%) on probabilistic sensitivity analysis. A detailed analysis of incremental costs between strategies revealed most were attributable to the in-hospital and postdischarge lifetime care of critically ill patients surviving severe trauma. Conclusions and relevance In this study, prehospital thawed plasma transfusion during air medical transport for trauma patients in hemorrhagic shock was lifesaving and cost-effective compared with standard care and should become commonplace.

Introduction Burn depth assessment (BDA) is an essential component of the physical exam used in the treatment and triage of burn injured patients. And while many specialties incorporate labs and imaging to determine diagnoses, burn professionals must rely on a physical exam that is accurate in only 70-80% of cases. Our goal was to assess the accuracy of a new imaging technology called Multispectral imaging (MSI) combined with a machine learning algorithm to aid in rapid BDA. We present the results of the first multi-center study using this technology in adult burn injuries. Methods In a multi-center IRB-approved study, an MSI device was used to image subjects >18 years of age with thermal burn injuries. The imaging device captured a set of images measuring the reflectance of visible and near-IR light. Subjects were enrolled and imaged within 72 hours of injury with serial imaging as permitted. The images were used to develop a type of machine learning algorithm called a convolutional neural network (CNN) that could identify the regions of non-healing burn within an image. Non-healing burn areas were determined by a panel of three burn surgeons using two standards: a) images confirming 21-day spontaneous healing; or b) pathology reports detailing histologic changes from multiple punch biopsies taken prior to burn excision. From this data, an ensemble of eight separate CNN algorithms was used to automatically identify non-healing burn tissue. Training and test accuracies of the ensemble CNN were calculated using cross-validation at the level of the subject. Results One hundred (100) adults were enrolled and imaged. The population had a mean age 45.6 ± 16.7; mean TBSA 13.0 ± 9.3; and was 31% female. From these adults, 210 burn regions were serially imaged. The estimated performance result from the ensemble CNN for identification of non-healing burn regions was AUC of 0.96. Based on the ROC curve, an ideal threshold showed an accuracy of 92.0%, sensitivity 91.9%, and specificity 92.0%. Conclusions Our study demonstrates a non-invasive technology that rapidly determines an accurate DBA relative to traditional bedside exam. More accurate burn wound assessment could lead to avoiding unnecessary surgeries or delays in treatment and dramatic cost savings. Use of such a device in a disaster has additional value to better align a patient’s burn care needs and available resources.

Introduction Natural disasters are commonly associated with mass destruction and severe injuries. On August 29th, 2021 a category 4 hurricane made landfall before mandatory evacuations were ordered in a major metropolitan community. The powerful storm challenged disaster management teams and first responders as communities struggled to recover. Our study analyzes the demographics of those injured and the injury patterns treated at our state’s only verified burn/trauma center and the adjacent children’s hospital in the aftermath of the hurricane. Methods A retrospective chart review was performed on patients seeking emergent care following the hurricane. Demographic data was abstracted from the medical records along with injury pattern including age, gender, mechanism of injury, total body surface area (TBSA), surgical interventions, and length of stay. In addition, brief surveys of fire chiefs from the two most impacted regions were performed to assess prehospital challenges. Results 41 patients (76% male) presented to our ER with a median age of 44 (7 patients < 12 years of age). 85% of injuries occurred at home while 15% occurred at work. Of the 78% requiring admission, 66% underwent excision and autograft with a mean TBSA of 17% (range 1-80%). Power outages resulted in increased gas generator usage across the region. Most of the burn injuries following the storm were due to generator and cooking accidents (56%). Each fire chief reported up to 91 calls/day due to suspected carbon monoxide poisoning for the two weeks following the storm. A single event resulted in 8 inhalation injuries treated in our ER with one burn ICU admission. The mean hospital length of stay was 1.11 days/%TBSA for those undergoing surgery. Conclusions Hurricanes are more common today with many coastal cities as risk for similar natural disasters. Despite our generator safety media outreach efforts prior to the storm, this remains an opportunity for improved injury prevention. Many patients suffered delays in discharge as their homes/nursing facilities suffered structural damages and were without power and water. Disaster planning should account for limited disposition options during severe storms. Our study is the first to describe burn-related injuries from a category 4 storm and our communities’ response.

Introduction Burn nurse/therapy staffing has been stretched for months by the pandemic. Along the Gulf Coast, Hurricane Ida recently taxed these resources further as regional burn centers saw a weeks-long surge in serious burn injuries in the setting of prolonged power and water outages. We reviewed the execution of a plan for the provision of burn nurse/therapist staffing at an ABA-verified adult burn center that experienced a direct hit by a Category 4 storm. Methods Hospital leadership planned to activate Code Gray on 8/29/21 at which time the hospital would be placed on lockdown with no one allowed in or out until Code Gray was lifted. Our burn leadership subsequently designed a plan to have ten burn nurses and one Occupational Therapist (TEAM A) in house from the inception of Code Gray at 7am on 8/29 thru 7am on 9/1. If Code Gray conditions persisted, nine dedicated burn nurses (TEAM B) were to relieve TEAM A. TEAM B was planned to remain in-house until 7am on 9/4. If Code Gray conditions continued, the plan was to be reassessed at that time. The same burn therapist was planned to remain in-house throughout. Physician coverage was to be provided by the in-house trauma team during Code Gray. No housing or bedding was provided for in-house personnel, and the hospital generator system ostensibly had a 30-day fuel supply. Results TEAM A day/night staffing was 6/4 with the off crew sleeping in conference rooms and clinic spaces. An unexpected event occurred when a mission-critical tower for the city’s grid toppled into a river resulting in delays for restoration of the grid, and city-wide boil-water and burn-ban policies. As generators came into widespread use, our pre-storm census of 9 increased to a mean of 12.7 + 1.4. Due to this increase, on the morning of 9/1 six TEAM A nurses elected to stay and be absorbed into Team B with day/night staffing of 6/6. The rapid influx in number and complexity of burn patients made it clear a burn surgeon presence was needed during Code Gray. One burn attending was able to make it to the hospital at 7am on 8/30 and worked until being relieved at 7am on 9/5. An informal triage strategy was enacted in which only burns of >10% TBSA would be considered for admission. OR availability went down to 2 + 1 at the inception of Code Gray and 3 + 1 on 9/6. Eleven cases were done during this time with a mean TBSA of 20.2 + 10.7%. Hospital generators were found to consume fuel at a rate almost twice predicted. Due to prioritization, the hospital went back on city power on 9/2. Code Gray was lifted at 7am on 9/4 and normal operations resumed at 7am on 9/11. Conclusions The successful provision of care required a willingness for nurses and one therapist to remain in the hospital for six consecutive days and for hospital administration to approve the overtime.

Introduction Our group previously reported a theoretical burn biopsy algorithm (BBA-V1) for the categorization of burn wound depth based on histologic analysis, and informed it with the largest series of burn wound biopsies in the literature. That iteration of the BBA resulted in clinical misclassification rates consistent with past literature. Since our last report of that process, we have refined the algorithm with new criteria and a larger repository of burn wound biopsies. Here, we sought to promulgate this newer, simpler version of the BBA (BBA-V2). Methods This was an IRB-approved, prospective, multicenter study. Patients with burn wounds assessed by burn experts as requiring excision and autograft underwent 4mm biopsies procured every 25cm2. Serial still photos were obtained at enrollment and at excision intraoperatively. Using H&E with whole slide scanning, a board-certified dermatopathologist assessed each burn biopsy. The criteria used for categorization of burn wound depth in BBA-V1 were: 1) proportion of necrotic adnexal structures, and 2) presence/absence of each of epidermis, papillary dermis, and reticular dermis. The criteria used for BBA-V2 were: 1) magnitude of reticular dermal degeneration, 2) proportion of necrotic adnexal structures, and 3) magnitude of vessel thrombosis. Biopsy pathology results were correlated with still photos by 3 burn experts for consensus of final burn depth diagnosis. Superficial partial thickness (SPT) wounds were considered to be burn wounds likely to have healed without surgery, while deep partial thickness (DPT) and full thickness (FT) were considered unlikely to heal by 21 days. Results The development of BBA V-1 was previously informed by 66 subjects with 117 wounds and 816 biopsies, and resulted in wound categorizations as follows: SPT (20%), DPT (43%), and FT (37%). Therefore, according to BBA-V1, 20% of burn wounds were incorrectly judged as needing excision and grafting by the clinical team. The overall cohort was enlarged to 162 subjects with 294 wounds and 1142 biopsies. The most recent 838 burn wound biopsies were then re-reviewed and re-categorized according to the new BBA-V2 criteria and algorithm. Under BBA-V2, 3% of all burn wound biopsies were categorized as superficial partial thickness, 69% were categorized as deep partial thickness, and 29% were categorized as full thickness. Conclusions Our study demonstrates that by adding dermal degeneration severity and vessel thrombosis to our previous criterion of adnexal structure necrosis, BBA-V2 had a much higher rate of concordance with visual clinical assessment for burn wounds clinically judged as needing surgical excision. This study serves as the largest analysis of burn biopsies by modern day burn experts.

Introduction Over 10,000 cases of autologous skin cell suspension have been performed around the world for the treatment of burn and soft tissue injuries. A key component of the procedure is the harvest of skin biopsies which are exposed to enzymatic degradation. In some regions, epidermal graft harvest has been attempted manually without enzymatic degradation. Our study goal was to examine the histologic changes of the skin biopsies in manual versus enzymatic degradation. Methods Our study was an IRB-approved, prospective controlled analysis of residual skin harvested from 10 patients undergoing hernia repair. Two specimens from each patient were procured intraoperatively with each measuring 2x3cm. Each specimen produced two 4mm punch biopsies from three regions (control, mechanical, and enzymatic) for a total of 12 specimens per patient. Enzymatic specimens were prepared using the Avita Medical ReCell® system per manufacture instructions for use. Mechanical specimens were prepared using an abrasive pad until epidermis was macroscopically removed. Histologic analysis was performed with hematoxylin and eosin stain and whole slide scanning. Two or more investigators reviewed each biopsy concurrently with consensus agreement on the remaining epidermis and evidence of degraded reticular dermis. Descriptive statistics were used to assess the variances in the three groups. Results The mean residual epidermis was 9% in the enzymatic group, 35% in the mechanical, and 98% in the control. Epidermal harvest was higher in the enzymatic group relative to the mechanical group (two tailed t-test = 0.0008). Reticular dermis was degraded in 10% of the mechanical specimens and none of the enzymatic specimens. Conclusions Epidermal harvest was more consistent in the enzymatic group with less trauma to the dermis. Our study suggest that mechanical harvest requires larger donor sites given the decreased epidermal harvest. Further research is needed to determine impact of cell isolation technique on autograft cell suspension viability and distribution of cell types harvested.

Introduction Burn injury is the third most common cause of childhood injury resulting in death. The CDC recognizing the South as having the highest rate of pediatric burn deaths in the U.S. Unfortunately, 10% of all child abuse cases involve burn injuries and 20% of all pediatric burn admissions are due to nonaccidental trauma. Our study demonstrated that aftercare was a major challenge in starting a pediatric burn center. We analyzed the rate of lost to follow-up in burn-injured children following surgery and our steps to address this need in our community through key partnerships within our state. Methods Our study is a single center review of pediatric burn-injured children undergoing surgery from 01/01/2021 through 09/30/2021. Lost to follow-up was defined as three or more consecutive months without clinic or telemedicine visits despite three of more documented communication attempts by attending surgeons and/or clinic staff. Children requiring child protective services (CPS) for suspected nonaccidental trauma were compared to those where nonaccidental trauma was not suspected. All children sustained burn injuries of sufficient severity to require excision and autograft with follow-up in the outpatient clinic. Families were provided with an after-visit summary reviewing the clinic appointment, transportation and meal assistance, and they received a call prior to clinic to remind them of the scheduled appointment. Results A total of 35 children required surgery with outpatient follow-up per protocol. 23% of the patients required CPS investigations. We reviewed 151 subsequent clinic visits and the associated cancellations, rescheduled appointments, and no-show visits. Children under the care of CPS had a higher rate of being lost to follow-up (50%) compared to other children (17%). Parents undergoing CPS investigation were 4x less likely to provide cancellation notice. Children placed in foster care had no cancellations, reschedules appointments, or missed visits despite a higher number of clinic visits overall. Conclusions Children suffering nonaccidental injuries represent an exceptionally vulnerable portion of our population. Burn injuries often are a public and personal reminder of severe trauma. CPS works to find a balance in securing a safe home while attempting to maintain a family unit. Our work demonstrated an unacceptably high rate of loss to follow-up for children requiring surgical intervention after injury especially in those with concerns for nonaccidental etiologies. As a result, our burn surgeons led an initiative with statewide burn directors and our state’s emergency response network to engage the state’s CPS department. Our goal was to raise awareness and increase education for CPS social workers and foster families on burn injury and aftercare needs.

Introduction Our group has previously reported our experience in treating hand burns with 2:1 meshed autografting and simultaneous application of autologous skin cell suspension (ASCS) even when donor sites are abundant. Here, we sought to expand on this experience. We hypothesized that the use of 2:1 meshed autografting and ASCS (MA/ASCS) would provide comparable outcomes to hand burns treated with sheet graft. Methods A retrospective review was conducted of all subjects operated on for deep 2nd and 3rd degree hand burns at our ABA-verified burn center from April, 2018 to May, 2021. Exclusion criterion was a burn of >20% TBSA. The cohorts were those subjects treated with MA/ASCS versus those treated with split thickness sheet, pie-crust, or 1:1 meshed autograft alone (STAG). Outcomes included proportion returning to work (RTW), length of time for RTW, and time to wound closure. Mann-Whitney U test was used for comparisons of continuous variables, and Fishers Exact test for categorical variables. Values are reported as median and interquartile range. Results Sixty-eight subjects fit the study criteria (MA/ASCS n=43, STAG n=25). The MA/ASCS group was significantly older than the STAG cohort (45.5 yrs [32, 59.25] vs 35 [28, 45], p=0.013) with larger %TBSA burns overall (11.5% [7, 16.25] vs 2% [1, 3], p < 0.0001), and larger hand burns (186 cm2 [124.75, 330.5] vs 104 cm2 [56, 164], p=0.001). Comparable results were seen between MA/ASCS and STAG, respectively, for time to wound closure (8 days [7, 13] vs 8 [6, 14], p=0.48), proportion RTW (51% vs 64%, p=0.33), and days for RTW among those returning (38 [29.25, 62.75] vs 34.5 [20.75, 57], p=0.471). Fractional ablations were performed in 14% of the MA/ASCS group and 12% of the STAG group. Conclusions Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure and return to work as subjects treated with 1:1, pie-crust, or sheet STAG.

Burn experts are only 77% accurate when subjectively assessing burn depth, leaving almost a quarter of patients to undergo unnecessary surgery or conversely suffer a delay in treatment. To aid clinicians in burn depth assessment (BDA), new technologies are being studied with machine learning algorithms calibrated to histologic standards. Our group has iteratively created a theoretical burn biopsy algorithm (BBA) based on histologic analysis, and subsequently informed it with the largest burn wound biopsy repository in the literature. Here, we sought to report that process. This was an IRB-approved, prospective, multicenter study. A BBA was created a priori and refined in an iterative manner. Patients with burn wounds assessed by burn experts as requiring excision and autograft underwent 4 mm biopsies procured every 25 cm2. Serial still photos were obtained at enrollment and at excision intraoperatively. Burn biopsies were histologically assessed for presence/absence of epidermis, papillary dermis, reticular dermis, and proportion of necrotic adnexal structures by a dermatopathologist using H&E with whole slide scanning. First degree and superficial second degree were considered to be burn wounds likely to have healed without surgery, while deep second- and third-degree burns were considered unlikely to heal by 21 days. Biopsy pathology results were correlated with still photos by five burn experts for consensus of final burn depth diagnosis. Sixty-six subjects were enrolled with 117 wounds and 816 biopsies. The BBA was used to categorize subjects’ wounds into four categories: 7% of burns were categorized as first degree, 13% as superficial second degree, 43% as deep second degree, and 37% as third degree. Therefore, 20% of burn wounds were incorrectly judged as needing excision and grafting by the clinical team as per the BBA. As H&E is unable to assess the viability of papillary and reticular dermis, with time our team came to appreciate the greater importance of adnexal structure necrosis over dermal appearance in assessing healing potential. Our study demonstrates that a BBA with objective histologic criteria can be used to categorize BDA with clinical misclassification rates consistent with past literature. This study serves as the largest analysis of burn biopsies by modern day burn experts and the first to define histologic parameters for BDA.

In order to address the confounder of TBSA on burn outcomes, we sought to analyze our experience with the use of autologous skin cell suspensions (ASCS) in a cohort of subjects with hand burns whose TBSA totaled 20% or less. We hypothesized that the use of ASCS in conjunction with 2:1 meshed autograft for the treatment of hand burn injuries would provide comparable outcomes to hand burns treated with sheet or minimally meshed autograft alone. A retrospective review was conducted for all deep partial and full-thickness hand burns treated with split-thickness autograft (STAG) at our urban verified burn center between April 2018 and September 2020. The exclusion criterion was a TBSA greater than 20%. The cohorts were those subjects treated with ASCS in combination with STAG (ASCS(+)) vs those treated with STAG alone (ASCS(−)). All ASCS(+) subjects were treated with 2:1 meshed STAG and ASCS overspray while all ASCS(−) subjects had 1:1, piecrust, or unmeshed sheet graft alone. Outcomes measured included demographics, time to wound closure, proportion returning to work (RTW), and length of time to RTW. Mann–Whitney U test was used for comparisons of continuous variables and Fisher’s exact test for categorical variables. Values are reported as medians and 25th and 75th interquartile ranges. Fifty-one subjects fit the study criteria (ASCS(+) n = 31, ASCS(−) n = 20). The ASCS(+) group was significantly older than the ASCS(−) cohort (44 [32–54] vs 32 years [27.5–37], P = .009) with larger %TBSA burns (15% [9.5–17] vs 2% [1–4], P < .0001) and larger size hand burns (190 [120–349.5] vs 126 cm2 [73.5–182], P = .015). Comparable results were seen between ASCS(+) and ASCS(−), respectively, for time to wound closure (9 [7–13] vs 11.5 days [6.75–14], P = .63), proportion RTW (61% vs 70%, P = .56), and days for RTW among those returning (35 [28.5–57] vs 33 [20.25–59], P = .52). The ASCS(+) group had two graft infections with no reoperations, while ASCS(−) had one infection with one reoperation. No subjects in either group had a dermal substitute placed. Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure, proportion of RTW, and time to return to work as subjects treated with 1:1 or piecrust meshed STAG. Our group plans to follow this work with scar assessments for a more granular picture of pliability and reconstructive needs.

Ambulatory surgery centers (ASCs) are frequently utilized; however some ambulatory procedures may be performed in hospital outpatient departments (HOPs). Our aim was to compare operating room efficiency between our ASC and HOP.We reviewed outpatient general surgery procedures performed at our ASC and HOP. Total case time was divided into five components: ancillary time, procedure time, exit time, turnover time, and nonoperative time.Overall, 220 procedures were included (114 ASC, 106 HOP). Expressed in minutes, the mean turnover time (29.8 ± 9.6 vs. 24.5 ± 12.7; p 0.01), ancillary time (32.2 ± 7.0 vs. 22.2 ± 4.5; p 0.01), procedure time (77.4 ± 44.9 vs. 56.2 ± 23.0 p 0.01), exit time (11.8 ± 4.4 vs. 8.5 ± 4.3; p 0.01), and nonoperative time (62.9 ± 21.9 vs. 48.7 ± 15.0; p 0.01) were longer at the HOP than at the ASC.ASC outpatient procedures are more efficient than those performed at our HOP. A system evaluation of our HOP operating room efficiency is necessary.

Background Recent randomized clinical trial evidence demonstrated a survival benefit with the use of prehospital plasma in patients at risk of hemorrhagic shock. We sought to characterize the survival benefit associated with prehospital plasma relative to the blood transfusion volume over the initial 24 hours. We hypothesized that the beneficial effects of prehospital plasma would be most robust in those with higher severity of hemorrhage. Methods We performed a prespecified secondary analysis using data derived from a prospective randomized prehospital plasma trial. Blood component transfusion volumes were recorded over the initial 24 hours. Massive transfusion (MT) was defined a priori as receiving ≥10 units of red cells in 24 hours. We characterized the 30-day survival benefit of prehospital plasma and the need for MT and overall 24-hour red cell transfusion volume utilizing Kaplan-Meier survival analysis and Cox proportional hazard regression. Results There were 501 patients included in this analysis with 230 randomized to prehospital plasma with 104 patients requiring MT. Mortality in patients who received MT were higher compared with those that did not (MT vs. NO-MT, 42% vs. 26%, p = 0.001). Kaplan-Meier survival curves demonstrated early separation in the NO-MT subgroup (log rank p = 0.008) with no survival benefit found in the MT group (log rank p = 0.949). Cox regression analysis verified these findings. When 24-hour red cell transfusion was divided into quartiles, there was a significant independent association with 30-day survival in patients who received 4 to 7 units (hazard ratio, 0.33, 95% confidence interval, 0.14-0.80, p = 0.013). Conclusion The survival benefits of prehospital plasma was demonstrated only in patients with red cell requirements below the transfusion level of MT. Patients who received 4 to 7 units of red cells demonstrated the most robust independent survival benefit attributable to prehospital plasma transfusion. Prehospital plasma may be most beneficial in those patients with moderate transfusion requirements and mortality risk. Level of evidence Therapeutic, Level I.

The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a 30-day survival benefit among hypotensive trauma patients treated with prehospital plasma during air medical transport. We characterized resources, costs and feasibility of air medical prehospital plasma program implementation.We performed a secondary analysis using data derived from the recent PAMPer trial. Intervention patients received thawed plasma (5-day shelf life). Unused plasma units were recycled back to blood bank affiliates, when possible. Distribution method and capability of recycling varied across sites. We determined the status of plasma units deployed, utilized, wasted, and returned. We inventoried thawed plasma use and annualized costs for distribution and recovery.The PAMPer trial screened 7,275 patients and 5,103 plasma units were deployed across 22 air medical bases during a 42-month period. Only 368 (7.2%) units of this total thawed plasma pool were provided to plasma randomized PAMPer patients. Of the total plasma pool, 3,716 (72.8%) units of plasma were returned to the blood bank with the potential for transfusion prior to expiration and 1,019 (20.0%) thawed plasma units were deemed wasted for this analysis. The estimated average annual cost of implementation of a thawed plasma program per air medical base at an average courier distance would be between US $24,343 and US $30,077, depending on the ability to recycle plasma and distance of courier delivery required.A prehospital plasma program utilizing thawed plasma is resource intensive. Plasma waste can be minimized depending on trauma center and blood bank specific logistics. Implementation of a thawed plasma program can occur with financial cost. Products with a longer shelf life, such as liquid plasma or freeze-dried plasma, may provide a more cost-effective prehospital product relative to thawed plasma.Therapeutic, level III.

Their group previously demonstrated high-patient satisfaction for the treatment of hypertrophic burn scar (HBS) with the erbium: yttrium aluminum garnet (Er:YAG) laser, but this and other literature supporting the practice suffer from a common weakness of a reliance on subjective assessments by patients or providers. Herein, they sought to prospectively study the effects of Er:YAG fractional ablation on HBS using noninvasive, objective technologies to measure outcomes. Patients with HBS had identical regions of scar designated for treatment by the Er:YAG laser (TREAT) or to be left untreated (CONTROL). They prospectively collected scar measurements of TREAT and CONTROL regions preoperatively, 3 weeks, and 3 months after Er:YAG treatment. Scar measurements included viscoelastometry, transepidermal water loss, optical coherent tomography, and high-frequency ultrasound. Outcomes were measured for the aggregate difference between the TREAT group vs the CONTROL group, as well as within each group in isolation. Seventeen patients were seen preoperatively, followed by n = 15 at 3 weeks and n = 11 at 3 months. A mixed-model repeated measures analysis showed no significant effect of fractional ablation when comparing the overall TREAT group measurements with those of the CONTROL group. However, when considered as within-group measurements, TREAT scars showed significant improvement in viscoelastic deformity (P = .03), elastic deformity (P = .004), skin roughness (P = .05), and wrinkle depth (P = .04) after fractional ablation, whereas CONTROL scars showed no such within-group changes. HBS treated by the Er:YAG laser showed objective improvements, whereas no such changes were seen within the untreated scars over the same time frame.

OBJECTIVE The aim of this study was to determine whether prehospital blood products reduce 30-day mortality in patients at risk for hemorrhagic shock compared with crystalloid only resuscitation. SUMMARY OF BACKGROUND DATA Hemorrhage is the primary cause of preventable death after injury. Large volume crystalloid resuscitation can be deleterious. The benefits of prehospital packed red blood cells (PRBCs), plasma, or transfusion of both products among trauma patients is unknown compared with crystalloid. METHODS Secondary analysis of the multicenter PAMPer trial was performed on hypotensive injured patients from the scene. The trial randomized 27 helicopter bases to prehospital plasma or standard resuscitation. Standard resuscitation at the sites was equally divided between crystalloid and crystalloid + PRBC. This led to 4 prehospital resuscitation groups: crystalloid only; PRBC; plasma; and PRBC+plasma. Cox regression determined the association between resuscitation groups and risk-adjusted 30-day mortality. The dose effect of resuscitation fluids was also explored. RESULTS Four hundred seven patients were included. PRBC+plasma had the greatest benefit [hazard ratio (HR) 0.38; 95% confidence interval (95% CI) 0.26-0.55, P < 0.001], followed by plasma (HR 0.57; 95% CI 0.36-0.91, P = 0.017) and PRBC (HR 0.68; 95% CI 0.49-0.95, P = 0.025) versus crystalloid only. Mortality was lower per-unit of PRBC (HR 0.69; 95% CI 0.52-0.92, p = 0.009) and plasma (HR 0.68; 95% CI 0.54-0.88, P = 0.003). Crystalloid volume was associated with increased mortality among patients receiving blood products (HR 1.65; 95% CI 1.17-2.32, P = 0.004). CONCLUSION Patients receiving prehospital PRBC+plasma had the greatest mortality benefit. Crystalloid only had the worst survival. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably PRBC+plasma. Prehospital whole blood may be ideal in this population.

Previously, our group developed the Parkland grading scale for cholecystitis (PGS) to stratify gallbladder (GB) disease severity that can be determined immediately when performing laparoscopic cholecystectomy (LC). In prior studies, PGS demonstrated excellent interrater reliability and was internally validated as an accurate measure of LC outcomes. Here, we compare PGS against a more complex cholecystitis severity score developed by the national trauma society, American Association for the Surgery of Trauma (AAST), which requires clinical, operative, imaging, and pathologic inputs, as a predictor of LC outcomes.Eleven acute care surgeons prospectively graded 179 GBs using PGS and filled out a postoperative questionnaire regarding the difficulty of the surgery. Three independent raters retrospectively graded these GBs using PGS from images stored in the electronic medical record. Three additional surgeons then assigned separate AAST scores to each GB. The intraclass correlation coefficient statistic assessed rater reliability for both PGS and AAST. The PGS score and the median AAST score became predictors in separate linear, logistic, and negative binomial regression models to estimate perioperative outcomes.The average intraclass correlation coefficient of PGS and AAST was 0.8647 and 0.8341, respectively. Parkland grading scale for cholecystitis was found to be a superior predictor of increasing operative difficulty (R, 0.566 vs. 0.202), case length (R, 0.217 vs. 0.037), open conversion rates (area under the curve, 0.904 vs. 0.757), and complication rates (area under the curve, 0.7039 vs. 0.6474) defined as retained stone, small-bowel obstruction, wound infection, or postoperative biliary leak. Parkland grading scale for cholecystitis performed similar to AAST in predicting partial cholecystectomy, readmission, bile leak rates, and length of stay.Both PGS and AAST are accurate predictors of LC outcomes. Parkland grading scale for cholecystitis was found to be a superior predictor of subjective operative difficulty, case length, open conversion rates, and complication rates. Parkland grading scale for cholecystitis has the advantage of being a simpler, operative-based scale which can be scored at a single point in time.Single institution, retrospective review, level IV.

Delays to the operating room (OR) or discharge (DC) lead to longer lengths of stay and increased costs. Surprisingly, little work has been done to quantify the number and cost of delays for inpatients to the OR, and to DC to outpatient status. They reviewed their burn admissions to determine how often a patient experiences delays in healthcare delivery. Data for all burn admissions were prospectively collected from 2014 to 2016. A quality improvement filter was created to define acceptable parameters for patient throughput. Every hospital day was labeled as 1) No delay, 2) Operation, 3) Delay to the OR, or 4) Delay to DC. They had 1633 admissions: 432 ICU admissions (26%) and 1201 floor admissions (74%). Six hundred fifteen patients (37.7%) received an operation. Patients with delays included 331 with OR delays (20.3%) and 503 with DC delays (30.8%). Average delay days included (Mean ± SD): OR delay days = 4.7 ± 6.2 and DC delay days = 4.1 ± 4.4. Total number of hospital days was 13,009, divided into 1616 OR delay days (12%) and 2096 DC delay days (16%). Significant OR delays were due to patient unstable for OR (n = 387 [24%]), OR space availability (n = 662 [41%]), indeterminate wound depth (n = 437 [27%]), and donor site availability (n = 83 [5%]). Significant DC delays were due to medical goals not reached (n = 388 [19%]), pain control and wound care (n = 694 [33%]), PT/OT clearance (n = 168 [8.0%]), and DC placement delays (n = 754 [36%]). Costs for OR and DC delays ranged between US$1,000,000 and US$5,000,000. Costs of increasing OR capacity and/or additional social work ancillary staff can be justified through millions of dollars of savings annually.

BackgroundPrehospital plasma administration during air medical transport reduces the endotheliopathy of trauma, circulating pro-inflammatory cytokines, and 30-day mortality among traumatically injured patients at risk of hemorrhagic shock. No clinical data currently exists evaluating the age of thawed plasma and its association with clinical outcomes and biomarker expression post-injury.MethodsWe performed a secondary analysis from the prehospital plasma administration randomized controlled trial, PAMPer. We dichotomized the age of thawed plasma creating three groups: standard-care, YOUNG (day 0–1) plasma, and OLD (day 2–5) plasma. We generated HRs and 95% CIs for mortality. Among all patients randomized to plasma, we compared predicted biomarker values at hospital admission (T0) and 24 hours later (T24) controlling for key difference between groups with a multivariable linear regression. Analyses were repeated in a severely injured subgroup.ResultsTwo hundred and seventy-one patients were randomized to standard-care and 230 to plasma (40% YOUNG, 60% OLD). There were no clinically or statistically significant differences in demographics, injury, admission vital signs, or laboratory values including thromboelastography between YOUNG and OLD. Compared with standard-care, YOUNG (HR 0.66 (95% CI 0.41 to 1.07), p=0.09) and OLD (HR 0.64 (95% CI 0.42 to 0.96), p=0.03) plasma demonstrated reduced 30-day mortality. Among those randomized to plasma, plasma age did not affect mortality (HR 1.04 (95% CI 0.60 to 1.82), p=0.90) and/or adjusted serum markers by plasma age at T0 or T24 (p>0.05). However, among the severely injured subgroup, OLD plasma was significantly associated with increased adjusted inflammatory and decreased adjusted endothelial biomarkers at T0.DiscussionAge of thawed plasma does not result in clinical outcome or biomarker expression differences in the overall PAMPer study cohort. There were biomarker expression differences in those patients with severe injury. Definitive investigation is needed to determine if the age of thawed plasma is associated with biomarker expression and outcome differences following traumatic injury.Level of evidenceII.

Introduction Management of pediatric burn injuries resulting in optimal aesthetic remains a significant challenge in burn care. Wound care and acute surgical intervention coupled with reconstructive interventions is an essential component of burn care. Incorporation of new technologies in burn care has challenged historic paradigms. Our goal was to evaluate the use of autologous skin cell suspension (ASCS) for the treatment of partial-thickness pediatric burn injuries. Methods A retrospective chart review from a single pediatric institution over a 10-month period was performed on patients undergoing treatment with ASCS. Patients with full-thickness injuries treated with autografting were excluded. Demographics and data collection included total burn surface area (TBSA), location of burn, mechanism of burn, time to ASCS application, time to >90% re-epithelization, hospital length of stay, ASCS failure requiring repeat operation, and reconstructive procedures or laser interventions. Results 26 pediatric patients ≤13 years of age charts were reviewed. 14 patients received ASCS and met inclusion criteria. 8 faces were included in our study along with 11 upper extremity burns, 5 lower extremity burns, and 8 torso burns or some combination of the above. The most common etiology was scald injury from hot water followed by noodle soup burns and grease burns. Other etiologies included road rash, flame burn, and a steam burn. ASCS was applied 2 days (range 1-4) after injuries and patients only required 1 operation. The average length of hospital stay was 4 days (range 1-10) and the average TBSA was 10% (range 4-17). The average time to >90% re-epithelization was 7 days with one outlier with healing at day 24. This is the only patient in the ASCS group that required laser interventions. No patients required repeat procedures, subsequent autografting, or reconstructive procedures. Conclusions Pediatric patients with partial-thickness burns benefitted from the ASCS by having limited donor sites, short hospitalizations compared to %TBSA, improved time to >90% re-epithelization, and no repeat surgical interventions. The fast-healing time and good cosmetic outcome decreases the need for compression garments and subsequent laser interventions. Key factors include patient selection and appropriate wound preparation.

Introduction Estimation of burn depth, and hence severity, is critical for burn management. Burn depth estimates vary widely, and these inaccuracies can be compounded in pediatric burns. A reliable, objective, non-invasive device for the accurate assessment of burn depth is needed. A non-invasive imaging technology, using multispectral imaging (MSI) combined with a machine learning algorithm (MLA), is being developed as a tool for burn depth assessment. The results of the initial multi-center study using this artificial intelligence (AI) technology in pediatric burns are presented. Methods The MSI device was used to image subjects < 18y of age with thermal burns < 50% TBSA. It captured a set of images measuring the reflectance of visible and near-IR light, within a 23x23 cm field-of-view. Images were collected from up to 2 separate burned regions within 72 hours of injury that were then serially imaged for up to 7d post-injury. Burns that the investigator believed would heal spontaneously (superficial or superficial partial-thickness) were managed per institutional standard of care (SOC) and assessed at 21d post-injury for complete healing. Burns that the investigator felt would not heal by 21d post-injury (deep partial-thickness or full-thickness) were excised and grafted per institutional SOC, with multiple biopsies being taken prior to excision. Regions of non-healing burn within every MSI image were identified by a panel of 3 burn surgeons. To accurately identify these non-healing regions, the panel of surgeons was given access to 1 of 2 clinical reference standards: a) the 21-day healing assessments for burns allowed to heal spontaneously; or b) pathology reports detailing histologic analyses from the biopsies. This information was then used to develop a type of MLA called a convolutional neural network (CNN) that could automatically identify the regions of non-healing burn within an image. From these data, an ensemble of 8 separate CNN algorithms was used to automatically identify non-healing burn tissue. Training and test accuracies of the ensemble CNN were calculated using cross-validation at the level of the subject. Results Twenty-four (24) pediatric burn patients were enrolled, with 26 burned areas being serially imaged. The age range of the subjects was 7 months - 17y, with a mean age of 5.7y. Subjects had a mean burn size of 8.0 ± 4.2% TBSA, and 70% of the subjects were male. The AI performance results showed an accuracy of 88.2 ± 3.7%, sensitivity of 80.0 ± 14.6%, specificity of 88.0% ± 3.7%, and an area under the curve (AUC) of 0.92. Conclusions Our study demonstrates an improvement in the accuracy of burn depth assessment over the traditional exam, which could lead to improved burn care.

Introduction Carbon dioxide ablative fractional laser (CO2-AFL) therapy has become standard of care for adult burn hypertrophic scars (HTS). This therapy option has not been widely adopted in pediatric burn care and no established guidelines for treatment protocols have been published. We sought to modify our American Burn Associated Adult Verified Burn Centers laser protocol at our Children’s Hospital with hopes to provide optimal care to our pediatric burn population. We present our protocol and early experience of CO2-AFL therapy for pediatric burn HTS. Methods We conducted a retrospective chart review of pediatric burn patients undergoing CO2-AFL treatment of HTS during the study period of Jan 2021-Oct 2021. Pediatric burn patients were offered laser treatment if their scars were symptomatic with patient complaints of HTS, pruritis, neuropathic pain, and scar contractures. 37 pediatric patients ≤13 years of age were included in our review. Results We treated 13 pediatric patients for a total of 40 laser sessions with each patient averaging 3 sessions. Of the 13 patients that were treated with laser, 62% (8 of the 13 patients) had split-thickness skin grafting with 38% (3 of the 8 patients) of those having a staged grafting procedure with dermal substitute. 15% (2 of the 13 patients) healed primarily and 15% (2 of the 13 patients) required excision and closure. Only 1 patient treated with ASCS alone required laser therapy. Our protocol requires patients to receive pre-operative Tylenol, Benadryl, Pepcid, and Oxycodone. The patients then received MAC anesthesia with Toradol, Dexamethasone, Ketamine or Propofol, and Zofran. Patients with extensive HTS on the face or neck were intubated for the procedures. Oxycodone and/or Dilaudid were provided if needed in the post-operative phase. All patients were discharged with Tylenol or Motrin and Triamcinolone 0.1% ointment to be applied daily for 48 hours and then 3-4x/day until the follow-up clinic appointment at one week. Patients were able to resume normal activities the day following the procedure. Conclusions Patients and their parents have reported improvements in pigment, pliability, thickness, and pruritis following laser treatments. We created a protocol that allows on average 8 pediatric patients per day to receive laser treatment without it over burdening the pre-operative and post-operative recovery room nursing staff. We are currently tracking outliers of patients requiring increased post-operative analgesia and/or greater than 1 hour in the recovery phase. With the implementation of a laser protocol, we have successfully introduced laser therapy as a viable option for our pediatric burn survivors.

BACKGROUND: Prehospital plasma improves survival in severely injured patients transported by air ambulance. We hypothesized that prehospital plasma would be associated with a reduction in immune imbalance and endothelial damage. METHODS: We sampled blood from 405 trauma patients enrolled in the Prehospital Air Medical Plasma (PAMPer) trial upon hospital admission (0 hours) and 24 hours post admission across 6 U.S. sites. We assayed samples for 21 inflammatory mediators and 7 markers associated with endothelial function and damage. We performed hierarchical clustering analysis (HCA) of these biomarkers of the immune response and endothelial injury. Regression analysis was used to control for differences across study and to assess any association with prehospital plasma resuscitation. RESULTS: HCA distinguished two patient clusters with different injury patterns and outcomes. Patients in cluster A had greater injury severity and incidence of blunt trauma, traumatic brain injury, and mortality. Cluster A patients that received prehospital plasma showed improved 30-day survival. Prehospital plasma did not improve survival in cluster B patients. In an adjusted analysis of the most seriously injured patients, prehospital plasma was associated with an increase in adiponectin, IL-1β, IL-17A, IL-23, and IL-17E upon admission, and a reduction in syndecan-1, TM, VEGF, IL-6, IP-10, MCP-1, and TNF-α, and an increase in IL-33, IL-21, IL-23, and IL-17E 24 hours later. CONCLUSION: Prehospital plasma may ameliorate immune dysfunction and the endotheliopathy of trauma. These effects of plasma may contribute to improved survival in injured patients. TRIAL REGISTRATION: NCT01818427. FUNDING: Department of Defense; National Institutes of Health, U.S. Army.

The last generation has seen Ethiopia, a low income country with a population of 100 million people, undergo a marked increase in urbanization and development. The effects of these demographic changes on the epidemiology of burn risk and thermal injury in Ethiopia are unknown. This gap constitutes a major barrier to the creation of effective burn prevention programs.Yekatit 12 Hospital in Addis Ababa is the only burn unit in Ethiopia. In this cross sectional retrospective study, we identified and reviewed all admissions due to burn injury at that facility between 1/1/2016 and 12/31/2016. We then compared them to a previously published burn cohort treated at the same facility between 7/1/2001 and 9/31/2002. Chi square was used to compare proportions between the two samples. Continuous covariates are reported as descriptive data due to missing variance data in the 2001-02 publication.There were a total of 121 subjects in the 2001-02 sample and 176 subjects in the 2016 sample. The 2016 sample was found to have a significantly larger proportion of males (57%) as compared to the 2001-02 sample (36%) (p=0.0003) and a significantly higher proportion of electrical injuries (27%) than the previous cohort (5%) (p0.0001). No significant differences were seen in mortality rates between the 2016 and 2001-02 cohorts (8% vs 12%, respectively, p=0.29) or in the regions of origin (44% outside Addis Ababa vs 54%, p=0.09) For the 2016 sample, the highest surviving Baux score was 76 while the mean Baux score for survivors was 29.6±20.11.As Ethiopia has become more industrialized over the last 15 years, the demographic pattern of burn injury has changed accordingly as electrical injuries have increased five-fold with males now constituting a majority of burn cases.

Acute kidney injury (AKI) is a common and morbid complication in patients with severe burn. The reported incidence of AKI and mortality in this population varies widely due to inconsistent and changing definitions. They aimed to examine the incidence, severity, and hospital mortality of patients with AKI after burn using consensus criteria. This is a retrospective cohort study of adults with thermal injury admitted to the Parkland burn intensive care unit (ICU) from 2008 to 2015. One thousand forty adult patients with burn were admitted to the burn ICU. AKI was defined by KDIGO serum creatinine criteria. Primary outcome includes hospital death and secondary outcome includes length of mechanical ventilation, ICU, and hospital stay. All available serum creatinine measurements were used to determine the occurrence of AKI during the hospitalization. All relevant clinical data were collected. The median total body surface area (TBSA) of burn was 16% (IQR: 6%–29%). AKI occurred in 601 patients (58%; AKI stage 1, 60%; stage 2, 19.8%; stage 3, 10.5%; and stage 3 requiring renal replacement therapy [3-RRT], 9.7%). Patients with AKI had larger TBSA burn (median 20.5% vs 11.0%; P < .001) and more mechanical ventilation and hospitalization days than patients without AKI. The hospital death rate was higher in those with AKI vs those without AKI (19.7% vs 3.9%; P < .001) and increased by each AKI severity stage (P trend < .001). AKI severity was independently associated with hospital mortality in the small burn group (for TBSA ≤ 10%: stage 1 adjusted OR 9.3; 95% CI, 2.6–33.0; stage 2–3 OR, 35.0; 95% CI, 9.0–136.8; stage 3-RRT OR, 30.7; 95% CI, 4.2–226.4) and medium burn group (TBSA 10%–40%: stage 2–3 OR, 6.5; 95% CI, 1.9–22.1; stage 3-RRT OR, 35.1; 95% CI, 8.2–150.3). AKI was not independently associated with hospital death in the large burn group (TBSA > 40%). Urine output data were unavailable. AKI occurs frequently in patients after burn. Presence of and increasing severity of AKI are associated with increased hospital mortality. AKI appears to be independently and strongly associated with mortality in patients with TBSA ≤ 40%. Further investigation to develop risk-stratification tools tailoring this susceptible population is direly needed.

Background After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduc...

Introduction The relationship between psychiatric conditions and burn injury is complex, as disorders in thought or mood can both predispose to as well as result from thermal injury. We sought to describe our center’s experience with implementation of a psychological distress screening program in the run-up to and during the COVID-19 pandemic. Methods We undertook an analysis of de-identified data as part of a quality improvement review focusing on the results of psychological screening of our outpatient burn population. In the spring of 2019, our verified burn center implemented an outpatient screening program consisting of a registered nurse administering three validated test to screen for Post-Traumatic Stress Disorder screen, depression and anxiety, and problematic alcohol consumption to all patients at the time of physically checking in for their first burn clinic appointment. All outpatients triggering a positive screen are subsequently referred to the burn unit PsyD while a negative screen results in monthly repeat screenings until discharge from the burn clinic or a positive screen, whichever comes first. We analyzed data from the last twelve months of normal outpatient workflow. Loess regression was used to analyze the monthly proportions of patients screening positive. Results During the peak of COVID-19 in our region, clinic staff were reduced, and screening procedures suspended for the months of March and April 2020. Therefore, the study period consisted of 01 July 2019 to 31 August 2020. A median of 36.5 screens were conducted per month [interquartile range 27.75, 44.75]. Of these screens, 26.5% were positive, with 94.2% successfully referred to the burn unit’s postdoctoral fellow. The Loess regression showed the proportion of patients screening positive for psychological stressors from July 2019 until a peak in November 2019. A downtrend was then noted in the proportion screening positive from December 2019 to date (Figure). Conclusions Psychological stressors are prevalent in burn outpatients. We attribute the decrease in positive responses beginning in December 2019 to a combination of a decrease in the frequency of repeat administrations of the screening test in patients after screening positive, and a reluctance of anxious patients to present to the burn clinic for fear of COVID exposure while at the facility.

Introduction Antibiotic stewardship is widely recognized as being a necessary component of modern hospital care but remains difficult to put into practice particularly on burn services where the risk of infection is known to be higher than the general hospital population. Our burn service instituted a protocol for sepsis screening triggers and antibiotic usage, becoming the only unit in our hospital to do so. In-house quality metrics have shown this protocol to be successful in reducing utilization. Methods With the opening of our burn unit in April 2018, a burn sepsis screening protocol was put in place (see accompanying image). Briefly, the first level of screening consists of threshold hemodynamic and physiologic parameters. If these are met the pathway leads to drawing of basic laboratory tests plus lactate and procalcitonin. Group A findings consist of either Serum Lactic Acid >2.2mmol/Lor Procalcitonin >0.69ng/ml, and Group B findings consist of: Platelets < 100,000/mmorGlucose >150 mg/dL or New Insulin Requirement. If one finding from each of groups A and B are present, antibiotics are started, and a source work up is initiated. De-identified aggregate data on antibiotic usage are routinely tracked as a quality metric by our hospital’s Infection Control Committee. The results from calendar year 2019 are presented here for all antibiotics, vancomycin usage, and beta-lactam usage. One-way Analysis of Variance with Tukey’s post-hoc testing was used to analyze the differences in intravenous antibiotic usage rates between the Burn Intensive Care Unit (BICU), the Trauma ICU (TICU), and the remainder of the hospital. Results The BICU used significantly fewer IV antibiotics than the TICU across all examined parameters and fewer than the remainder of the hospital for all antibiotics and vancomycin usage. Data is presented as antibiotic days/1000 patient days. Conclusions Initiation of a formal protocol for sepsis screening and IV antibiotic initiation significantly lowers antibiotic utilization. Future work will focus on this protocol’s impact on clinical outcomes.

Acute kidney injury (AKI) is a common and morbid complication after severe burn, with an incidence and mortality as high as 30% and 80%, respectively. AKI is a broad clinical condition with many etiologies, which makes definition and diagnosis challenging. The most recent Kidney Disease: Improving Global Outcomes (KDIGO) consensus guidelines defined stage and severity of AKI based on changes of serum creatinine and urine output (UOP) across time. Burn-related kidney injury is typically classified as early (0-3days after injury) or late (4-14days after injury). Early burn AKI is typically due to hypovolemia, poor renal perfusion, direct cardiac suppression from TNF-alpha, and precipitation of denatured proteins, while late AKI is often due to sepsis, multi-organ failure, and nephrotoxic drugs. Diagnosis can be difficult as UOP and biochemical markers can be relatively normal even with significant renal injury. A sensitive and specific biomarker for the early diagnosis of AKI is sorely needed, and multiple potential biomarkers are being investigated. For treatment, the reversal of the underlying cause is the first intervention. The advent of renal replacement therapy has significantly improved the mortality of burn patients with AKI and should be initiated early if injury progresses despite initial maneuvers. Unfortunately, no beneficial pharmacologic agents have been identified, despite multiple investigations. Of burn patients who survive AKI, the vast majority do not receive long-term hemodialysis and they are generally thought to have a good renal prognosis although this view is shifting. Preliminary data in the burn population suggest that AKI may confer an increased risk of end-stage renal disease and long-term all-cause mortality, but further research is needed.

The nine-center Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium has validated the Geriatric Trauma Outcome Score (GTOS) as a prognosis calculator for injured elders. We compared GTOS' performance to that of the Trauma Injury Severity Score (TRISS) in a multicenter sample.Three Prognostic Assessment of Life and Limitations After Trauma in the Elderly centers not submitting subjects to the GTOS validation study identified subjects aged 65 years to 102 years admitted from 2000 to 2013. GTOS was specified using the formula [GTOS = age + (Injury Severity Score [ISS] × 2.5) + 22 (if transfused packed red cells (PRC) at 24 hours)]. TRISS uses the Revised Trauma Score (RTS), dichotomizes age (55 years = 0 and ≥55 years = 1), and was specified using the updated 1995 beta coefficients. TRISS Penetrating was specified as [TRISSP = -2.5355 + (0.9934 × RTS) + (-0.0651 × ISS) + (-1.1360 × Age)]. TRISS Blunt was specified as [TRISSB = -0.4499 + (0.8085 × RTS Total) + (-0.0835 × ISS) + (-1.7430 × Age)]. Each then became the sole predictor in a separate logistic regression model to estimate probability of mortality. Model performances were evaluated using misclassification rate, Brier score, and area under the curve.Demographics (mean + SD) of subjects with complete data (N = 10,894) were age, 78.3 years ± 8.1 years; ISS, 10.9 ± 8.4; RTS = 7.5 ± 1.1; mortality = 6.9%; blunt mechanism = 98.6%; 3.1 % of subjects received PRCs. The penetrating trauma subsample (n = 150) had a higher mortality rate of 20.0%. The misclassification rates for the models were GTOS, 0.065; TRISSB, 0.051; and TRISSP, 0.120. Brier scores were GTOS, 0.052; TRISSB, 0.041; and TRISSP, 0.084. The area under the curves were GTOS, 0.844; TRISSB, 0.889; and TRISSP, 0.897.GTOS and TRISS function similarly and accurately in predicting probability of death for injured elders. GTOS has the advantages of a single formula, fewer variables, and no reliance on data collected in the emergency room or by other observers.Prognostic, level II.

Background Frailty syndrome (FS) is a well-established predictor of outcomes in geriatric patients. The aim of this study was to quantify the prevalence of FS in geriatric trauma patients and to determine its association with trauma readmissions, repeat falls, and mortality at 6 months. Methods we performed a 2-year (2012-2013) prospective cohort analysis of all consecutive geriatric (age, ≥ 65 years) trauma patients. FS was assessed using a Trauma-Specific Frailty Index (TSFI). Patients were stratified into: nonfrail, TSFI ≤ 0.12; prefrail, TSFI = 0.1 to 0.27; and frail, TSFI > 0.27. Patient follow-up occurred at 6 months to assess outcomes. Regression analysis was performed to assess independent associations between TSFI and outcomes. Results Three hundred fifty patients were enrolled. Frail patients were more likely to develop in-hospital complications (nonfrail, 12%; prefrail, 17.4%; and frail, 33.4%; p = 0.02) and an adverse discharge disposition compared with nonfrail and prefrail (nonfrail, 8%; prefrail,18%; and frail, 47%; p = 0.001). Six-month follow-up was recorded in 80% of the patients. Compared with nonfrail patients, frail patients were more likely to have had a trauma-related readmission (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-3.6) and/or repeated falls (OR, 1.6; 95%CI, 1.1-2.5) over the 6-month period. Overall 6-month mortality was 2.8% (n = 10), and frail elderly patients were more likely to have died (OR, 1.1; 95% CI, 1.04-4.7) compared with nonfrail patients. Conclusion Over a third of geriatric trauma patients had FS. TSFI provides a practical and accurate assessment tool for identifying elderly trauma patients who are at increased risk of both short-term and long-term outcomes. Early focused intervention in frail geriatric patients is warranted to improve long-term outcomes. Level of evidence Prognostic study, level II.

Introduction Traditionally lactated ringers (LR) has been utilized for the resuscitation of thermally injured patients. Both the Parkland and Brooke formula’s include the addition of albumin as part of their ongoing resuscitation after the initial 24 hours. Over the last five years, the addition of albumin to current protocols has been reported to decrease fluid creep. Our institution has adopted these practices and here we present our findings during the adoption phase of rescue albumin during resuscitation. Methods A prospectively collected burn registry was queried for patients greater than 18 years, between July 2017 and December 2018, who sustained a thermal injury and required a formal resuscitation. Patients were included in the rescue albumin group if the treating team administered 25% albumin for a sustained urine output less than 0.5ml/kg over 2–3 hours. Our primary outcome was a total volume of resuscitation ml LR/%TBSA/kg. Our secondary outcomes were the change in resuscitation rate and the change in urine output three hours before and three hours after the administration of albumin normalized to %TBSA/kgs. Finally, we compared clinical outcomes of ICU days and length of stay (LOS) between the rescue albumin and no rescue albumin group. Results A total of 92 patients with thermal injuries were included: median age was 40 (IQR 31–57), 73% were male, and 30 patients received rescue albumin. The TBSA was increased in those who received rescue albumin (47% vs 38% p=0.02). Despite a higher TBSA in the albumin group the total LR given during resuscitation normalized to TBSA and KG was not significantly different (ml LR/%TBSA/kg: 3.66 vs. 4.31, p=0.149). Similarly, the total urine output (UOP) and the adjusted UOP showed no significant difference, total UOP 1,781 ml no albumin vs 1,483ml rescue albumin (p=0.149) and UOP/kg 21.7ml no albumin vs 18.9 ml rescue albumin (p=0.341). But our secondary outcomes did demonstrate there was a decrease in the LR rate by -0.06 ml/%TBSA/kg/hr (SD 0.13) and an increase in the UOP by 1.61 ml/kg/hr (SD 3.25), see Figure 1. Conclusions Rescue albumin administration decreases the amount of fluid administered during resuscitation, and increases end organ function as evidenced by increase UOP. This was observed in patients who sustained larger burns and were failing traditional increases in resuscitation LR. These findings are the basis for a modification to our current protocol and a prospective study of the clinical outcomes. Applicability of Research to Practice We believe these findings support the limited use of albumin in patients who fail a conventional LR based resuscitation.

INTRODUCTION Recent evidence demonstrated that prehospital plasma in patients at risk of hemorrhagic shock was safe for ground transport and resulted in a 28-day survival benefit for air medical transport patients. Whether any beneficial effect of prehospital plasma varies across injury mechanism remains unknown. METHODS We performed a secondary analysis using a harmonized data set derived from two recent prehospital plasma randomized trials. Identical inclusion/exclusion criteria and primary/secondary outcomes were used for the trials. Prehospital time, arrival shock parameters, and 24-hour transfusion requirements were compared across plasma and control groups stratified by mechanism of injury. Stratified survival analysis and Cox hazard regression were performed to determine the independent survival benefits of plasma across blunt and penetrating injury. RESULTS Blunt patients had higher injury severity, were older, and had a lower Glasgow Coma Scale. Arrival indices of shock and coagulation parameters were similar across blunt and penetrating injury. The percentage of patients with a prehospital time less than 20 minutes was significantly higher for penetrating patients relative to blunt injured patients (28.0% vs. 11.6%, p < 0.01). Stratified Kaplan-Meier curves demonstrated a significant separation for blunt injured patients (n = 465, p = 0.01) with no separation demonstrated for penetrating injured patients (n = 161, p = 0.60) Stratified Cox hazard regression verified, after controlling for all important confounders, that prehospital plasma was associated with a 32% lower independent hazard for 28-day mortality in blunt injured patients (hazard ratio, 0.68; 95% confidence interval, 0.47-0.96; p = 0.03) with no independent survival benefit found in penetrating patients (hazard ratio, 1.16; 95% confidence interval, 0.4-3.1; p = 0.78). CONCLUSION A survival benefit associated with prehospital plasma at 24 hours and 28 days exists primarily in blunt injured patients with no benefit shown in penetrating trauma patients. No detrimental effects attributable to plasma are demonstrated in penetrating injury. These results have important relevance to military and civilian trauma systems. LEVEL OF EVIDENCE Therapeutic, I.

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33–3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined.

Background While the prevalence of HIV infection in the population is 0.5%, it is higher among trauma patients as are rates of unknown seropositivity. Routine HIV screening for all trauma evaluations was implemented at our urban level I center in 2009. We aimed to evaluate use and results of the program in our trauma population. Methods This was a retrospective analysis of all trauma evaluations between July 2015 and February 2018. After passage of legislation rescinding the requirement for consent to perform HIV testing, our trauma service instituted an order set which automatically tested for HIV unless the ordering physician opted out. Patients found to be infected with HIV were to be counseled and referred to specialty care. Results Of 6175 consecutive trauma evaluations during the study period, 449 (7.3%) patients had been screened within the prior year and were excluded. Of the remaining cohort, 2024 (35.3%) patients were screened with 27 (1.3%) testing positive. Among those testing positive for infection, 100% were male, 77% white, 63% non-Hispanic, and 70% lacked insurance. Twenty-five (92.6%) patients received counseling and 19 were referred to specialty care. Age, gender, race, ethnicity, Injury Severity Score, trauma activation level, and payor type were not significant predictors for positive HIV screen on logistic regression analysis. Conclusions Despite a significantly higher rate of HIV in the trauma population, only a third of patients are screened. Such high infection rates justify the existence of this screening program but steps must be taken to increase screening rate. Level of Evidence Level 3.

Objectives Quality improvement in geriatric trauma depends on timely identification of frailty, yet little is known about providers' knowledge and beliefs about frailty assessment. This study sought to understand trauma providers' understanding, beliefs, and practices for frailty assessment. Methods We developed a 20-question survey using the Health Belief Model of health behavior and surveyed physicians, advanced practice providers, and trainees on the trauma services at a single institution that does not use formal frailty screening of all injured seniors. Results were analyzed via mixed methods. Results One hundred fifty-one providers completed the survey (response rate 92%). Respondents commonly included calendar age as an integral factor in their determinations of frailty but also included a variety of other factors, highlighting limited definitional consensus. Respondents perceived frailty as important to older adult patient outcomes, but assessment techniques were varied because only 24/151 respondents (16%) were familiar with current formal frailty assessment tools. Perceived barriers to performing a formal frailty screening on all injured older adults included the burdensome nature of assessment tools, insufficient training, and lack of time. When prompted for solutions, 20% of respondents recommended automation of the screening process by trained, dedicated team members. Conclusions Providers seem to recognize the impact that a diagnosis of frailty has on outcomes, but most lack a working knowledge of how to assess for frailty syndrome. Some providers recommended screening by designated, formally trained personnel who could notify decision makers of a positive screen result.

Background: The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties’ attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty’s ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so. Methods: A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine. Results: Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions. Conclusions: Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.

Despite increasing evidence that assessing frailty facilitates medical decision-making, a quick and clinically simple frailty assessment tool is not available for trauma settings.This study examined accuracy and acceptability of a novel wearable technology (upper-extremity frailty [UEF]) to objectively assess frailty status in older adults (65 years or older) admitted to the hospital due to traumatic ground-level falls. Frailty was measured using a validated modified Rockwood questionnaire, the Trauma-Specific Frailty Index (TSFI), as the gold standard. Participants performed a 20-second trial of rapid elbow flexion with the dominant elbow in a supine posture while wearing the UEF system.We recruited 101 eligible older adults (age 79 ± 9 years). Parameters of the UEF indicative of slowness, weakness, and exhaustion during elbow flexion were independent predictors of the TSFI score, while adjusted for age, sex, and body mass index. A high agreement (r = 0.72, p 0.0001) was observed between TSFI score and the UEF model; sensitivity and specificity for predicting the frailty status were 78% and 82%, respectively. Of recruited participants, 57% were not able to walk at the time of measurements, suggesting a limitation for walking-based frailty assessments. Significant correlations were observed between UEF parameters and number of falls within a previous year, with highest correlation observed for elbow flexion slowness (r = -0.41).The results suggest that a simple test of 20-second elbow flexion may be practical and sensitive to identify frailty among hospitalized older adults. The UEF test is independent of walking assessments, reflects several frailty markers, and it is practical for bed-bound patients.