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The presence of any comorbid condition may lead to worse outcomes after burn injury. Chronic obstructive pulmonary disease (COPD) is a condition with significant morbidity and mortality. In 2018, about 16 million adults in the United States reported a diagnosis of COPD based on data from the American Lung Association. The objective of this study was to explore the outcomes of patients with COPD admitted to our Burn Center with flame burns and/or inhalation injury. Patients were identified using our Institutional Burn Center registry and linked to the clinical and administrative data. All adult flame-injured and/or inhalation injury-only patients admitted to our burn center between July 1, 2011 and June 30, 2020 were included. Demographics, length of stay, burn, and patient characteristics and outcomes, including mortality, were evaluated. Four thousand three hundred ninety-seven patients were included in the study. Patients were divided into two populations, those with COPD (n = 515) and those without a diagnosis of COPD (n = 3882). Patients with COPD were older, more likely to be white and male, and had smaller sized burns, p < .001. Patients with COPD were more likely to be smokers and have comorbid conditions. There was no statistically significant difference between the incidence of inhalation injury, lengths of stay, or number of ventilator days. Burn size and inhalation injury increased mortality risk regardless of COPD severity, as did age among those not on home oxygen. More studies are needed to determine the genomic or proteomic changes in patients with COPD that lead to worse outcomes after flame injury, and/or inhalation injury alone.

Acute alcohol intoxication in burn patients has been associated with increased mortality, renal dysfunction, and difficulty with adequate fluid resuscitation. It is less clear how chronic alcohol use, regardless of intoxication status on admission, impacts patient outcomes. In this study, we examine varying levels of alcohol use in burn patients and its impact on both short- and long-term outcomes.

The use of alcohol and illicit substances has been associated with impaired judgment and health, but the effect on inpatient outcomes after burn injury remains unsettled. Our objective was to evaluate the effect of alcohol and illicit substance use on our inpatient burn outcomes. Adult patients admitted with burn injury—including inhalation injury only—between January 1, 2014 and June 30, 2019 were eligible for inclusion. Alcohol use and illicit drug use were identified on admission. Outcomes of interest included requiring mechanical ventilation, admission to the intensive care unit, length of stay, and inpatient mortality. Multivariable linear and logistic regression models were used to estimate the effects of use on inpatient outcomes. A total of 3476 patients were included in our analyses; 8% (n = 284) tested positive for alcohol, 10% (n = 364) tested positive for cocaine, and 27% (n = 930) tested positive for marijuana and at admission. Two hundred and eighty adults (18% of all positive patients) tested positive for at least two substances. Patients who tested positive for alcohol had longer lengths of stay and were more likely to be admitted to the intensive care unit. Patients who tested positive for cocaine had longer overall and intensive care unit lengths of stay. No differences in inpatient outcomes were seen among patients who tested positive for marijuana. Neither alcohol nor illicit substance use appears to affect inpatient mortality after burns. Alcohol and cocaine use significantly increased overall length of stay. Marijuana use had no impact on inpatient outcomes.

Burn injured patients are at high risk of thromboembolic complications. Morbid obesity further increases this risk. Our objective was to evaluate the efficacy of enoxaparin dosed 40 mg twice daily in achieving prophylactic plasma anti-Xa levels in obese burn patients. A retrospective chart review from November 2018 until September 2019 identified patients who were either ≥100 kg or had a body mass index ≥30 kg/m2 and initiated on enoxaparin 40 mg twice daily for venous thromboembolism prophylaxis. Patients were ≥18 yr of age and received ≥3 sequential doses of enoxaparin with appropriately timed peak plasma anti-Xa levels to monitor efficacy. One hundred forty-eight patients were screened with 43 patients included for analysis. Forty-two percent of the patients did not reach target peak plasma anti-Xa levels (0.2–0.5 IU/ml) on enoxaparin 40 mg twice daily. Patients who did not meet prophylactic target levels were more likely to be male (P < 0.05) and have an increased mean body weight (129 ± 24 kg vs 110 ± 16 kg, P < 0.05). Thirteen out of 18 patients received dosage adjustments with subsequent anti-Xa levels available for follow-up assessment, of which an additional six patients required further dosage adjustment to meet prophylactic goals. Current utilization of a fixed 40 mg twice daily regimen of enoxaparin for venous thromboembolism (VTE) is inadequate to meet target prophylactic peak plasma anti-Xa levels in the obese burn patient population. Dose adjusting enoxaparin to target anti-Xa levels to reduce VTE rates in obese burn patients should be further evaluated.

Introduction Patients with complicated wound care, rashes, desquamating skin disorders and necrotizing soft tissue infections are often transferred to burn centers due to the multi-disciplinary expertise in wound care despite the pathophysiology of burn injury being different. Our objective was to critically evaluate outcomes of patients admitted to our institution with skin disorders to patients with burn injury. Methods Patients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All adult patients admitted between January 1, 2012 and June 30, 2022 were eligible for inclusion. Demographics, length of stay (LOS), and mortality were evaluated. Bivariate logistic regression and inverse probability of treatment weighting (IPTW) was performed, and significance was accepted as p< 0.05. Results We included 9,821 patients in the study, of whom 805 (8.2%) were admitted with skin disorders. These patients were more likely to be older, Black, of female sex, have longer ICU stays, be on mechanical ventilation, and have complications, p< 0.001. Unadjusted estimates show that patients with skin disorders had 3.84 higher odds of mortality compared to patients admitted for burn injury. However, after adjusting for age, involved body surface area, sex, race, intensive care unit days, mechanical ventilation, inhalation injury, and complications using IPTW, patients with skin disorders twice higher odds of mortality. Conclusions Patients with skin disorders have increased morbidity and mortality compared to burn injured patients even when controlling for age, involved body surface area, sex, race, intensive care unit days, mechanical ventilation, inhalation injury, and complications when admitted to our burn unit. Further study is warranted to investigate and mitigate these outcome disparities in this patient population. Applicability of Research to Practice This study may demonstrate that all skin conditions are not the same, and may warrant different specialties to improve and optimize outcomes.

Paraquat dichloride is a widely used, highly toxic chemical herbicide and a significant cause of fatal poisonings. Toxicity is thought to be secondary to generation of reactive oxygen species. Hours after exposure, patients may experience signs and symptoms ranging from nausea to multisystem organ failure. To mitigate complications and death, immunosuppression with cyclophosphamide and corticosteroid-based therapies has shown to be an effective option in limited studies. Our objective is to report our center’s experience treating patients that had been exposed to paraquat over a 2-day period. Patients were identified using our Institutional Burn Center registry and linked to the clinical and administrative data. Demographics, length of stay (LOS), costs, and mortality were evaluated. There were nine patients admitted from the exposure. All were male. All survived. Eight were undocumented migrant farmers. The average age was 36 years (25–59 years). The average LOS was 3.3 days (2–5 days). Seventy-eight percent had cutaneous injury, but only one required debridement and placement of a skin substitute. Thirty-three percent complained of continued shortness of breath after discharge. Average total hospital cost was $28,131 ($9,500–$51,000). Paraquat is a highly toxic herbicide and exposure can be fatal if not treated promptly. Immediate decontamination and repeated pulse therapy with cyclophosphamide and methylprednisolone may be life-saving.

The addition of trauma to burn injuries may result in higher morbidity and mortality. The purpose of this study was to evaluate the outcomes of pediatric patients with a combination of burn and trauma injuries, and included all pediatric Burn only, Trauma only, and combined Burn-Trauma patients admitted between 2011 and 2020. Mean length of stay, ICU length of stay, and ventilator days were highest for the Burn-Trauma group. The odds of mortality were almost 13 times higher for the Burn-Trauma group when compared to the Burn only group ( P = .1299). After using inverse probability of treatment weighting, the odds of mortality were almost 10 times higher for the Burn-Trauma group in comparison to the Burn only group ( P < .0066). Thus, the addition of trauma to burn injuries was associated with increased odds of mortality, as well as longer ICU and overall hospital length of stay in this patient population.

The Rockwood Clinical Frailty Scale is a validated rapid assessment of frailty phenotype and predictor of mortality in the geriatric population. Using data from a large tertiary care burn center, we assessed the association between admission frailty in an elderly burn population and inpatient outcomes. This was a retrospective analysis of burn patients ≥65 years from 2015 to 2019. Patients were assigned to frailty subgroups based on comprehensive medical, social work, and therapy assessments. Cox proportional hazards regression was used to estimate associations between admission frailty and 30-day inpatient mortality. Our study included 644 patients (low frailty: 262, moderate frailty: 345, and high frailty: 37). Frailty was associated with higher median TBSA and age at admission. The 30-day cumulative incidence of mortality was 2.3%, 7.0%, and 24.3% among the low, moderate, and high frailty strata, respectively. After adjustment for age, TBSA, and inhalation injury, high frailty was associated with increased 30-day mortality, compared to low (hazard ratio 5.73; 95% confidence interval 1.86, 17.62). Moderate frailty also appeared to increase 30-day mortality, although estimates were imprecise (hazard ratio 2.19; 95% confidence interval 0.87–5.50). High frailty was associated with increased morbidity and healthcare utilization, including need for intensive care stay (68% vs 37% and 21%, P < .001) and rehab or care facility at discharge (41% vs 25% and 6%, P < .001), compared to moderate and low frailty subgroups. Our findings emphasize the need to consider preinjury physiological state and the increased risk of death and morbidity in the elderly burn population.

Introduction Burns are a major cause of accidental injury and death in the United States. Based on reports from the Centers for Disease Control and Prevention (CDC), approximately 1.1 million burn injuries require medical care each year. Even though 96.7% of individuals treated at burn centers will survive, many of the more extensive injuries require multiple surgical procedures, extensive pain control regimens, and prolonged intubation and hospitalization. We aim to establish a set of guidelines addressing the pre-, intra- and post-operative care of our burn patients. Methods Over the years, there has been a profound interest in developing and implementing an Enhanced Recovery after Surgery (ERAS) protocol, such as those already in place across a range of surgical subspecialties. Since its initial development in 1997 by Henrik Kehlet for colorectal surgery, ERAS has evolved into a multidisciplinary approach involving surgeons, anesthesiologists, pharmacists, nutritionists, and nursing staff. It is an evidence-based multimodal protocol focused on lowering recovery time and post-operative complications while also addressing the entire patient journey from admission to discharge. An ERAS protocol for Burn Surgery has yet to be created and will need to focus on some of the major challenges involved in the care of burn patients including fluid management, pain control, nutritional status, potential prolonged ventilation, and long-term rehabilitation. Results This set of guidelines will address the pre-operative care of our burn patients (e.g., acetaminophen and pregabalin/gabapentin on-call to the operating room), as well as the intra- and post-operative care (e.g., periodic lactate levels, operating room temperature at 85 degrees Fahrenheit, continued ketamine infusion for burns > 30% TBSA). These guidelines will be further evaluated in a clinical setting via a feasibility study to determine whether they would improve the overall outcome of our burn patients. Conclusions An ERAS protocol in Burn Surgery needs to address the challenges and complexities of treating burn patients, and should be aimed at the pre-, intra-, and post-operative care of this patient population.

Introduction Burn injuries are a significant cause of morbidity and mortality worldwide. Pre-existing conditions may further complicate a patient’s outcome and delay wound healing. Human immunodeficiency virus (HIV) remains an ongoing problem globally and contributes to the morbidity of patients with burn injuries. According to the Centers for Disease Control and Prevention (CDC), the prevalence of individuals with HIV in the United States was 1.2 million in 2018. Burn patients and those with desquamating skin disorders are already in an immunocompromised state, and thus, the effect of HIV on the healing and recovery process can be significant. The objective of this study was to evaluate the prevalence and outcomes of HIV-positive patients admitted to our Burn Center. Methods This was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between July 1, 2010 and June 30, 2020 who were HIV-positive were included in this study. All adult patients who were HIV-negative and admitted during the same period were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), cost of hospitalization, and mortality. Results There were 32 HIV-positive burn patients and 16 HIV-positive patients with desquamating skin disorders (e.g., Stevens-Johnson syndrome/Toxic Epidermal Necrolysis). For the burn group, the mean age was 46.9 years +/- 10.6 years, and the mean total body surface area (TBSA) involvement was 3.2% +/- 4.2%. The mean LOS among HIV-positive burn patients was 9.13 days +/- 17.73 days, and the mean cost of hospitalization was $54,613. For the desquamating skin disorders group, the mean age was 47.1 years +/- 13.9 years, and the mean TBSA was 16.2% +/- 29.0%. The mean LOS was 17.25 days +/- 25.26 days, and the mean cost of hospitalization was $138,358. In terms of overall hospital mortality, there were no deaths among HIV-positive burn patients; however, the mortality was 25% among HIV-positive patients with desquamating skin disorders (n = 4). When both groups were compared to HIV-negative patients, overall hospital mortality remained higher among HIV-positive patients with desquamating skin disorders. Conclusions Management of HIV-positive burn patients presents a unique challenge for clinicians due to the immunocompromised state of this patient population. The challenge may even be more pronounced in HIV-positive patients with desquamating skin disorders as demonstrated in this study.

Introduction Burn Intensive Care Units (BICU)s traditionally have changed central lines over a wire (COWs) as a method to reduce infection. To date, there is not a standard timeline for this process and every center has their own timeline for this process. We aimed to create a standardized process for this practice to then have a baseline for future study. Methods The Change-Over-Wire (COW) process was evaluated with the BICU Infection Control Nurse and Performance Improvement Manager. A protocol was developed that includes step-by-step detail that was modified until it was deemed practical and acceptable to all involved parties as the best practice for maintaining the most sterility as possible. The protocol was provided to the Central Line team, the ICU Advisory Board, and the UNC CLABSI committee for review Results While the hospital as a whole does not standardly endorse routine COWs, the protocol was reviewed and accepted as best practice by both the ICU Advisory Board and the UNC CLABSI committee. Additionally, the BICU had an 80% reduction in CLABSI’s from FY 2017 to 2020 with implementation of this protocol (p value = 0091). Conclusions Having a standardized method for COWs both allows for best practice and a starting point for study. Endorsement by both hospital committees allows this practice to be the published standard by which future studies can be measured.

Introduction Total parenteral nutrition (TPN) has been widely used among critically ill patients. Some of the controversy surrounding parenteral nutrition stems from its early use in the 1980s, which primarily focused on hyperalimentation. In burn patients, nutritional support is a critical aspect of treatment. The metabolic rate in this patient population can be greater than twice the normal rate, and this hypermetabolic response can last more than a year after the burn injury has occurred. The objective of this study was to evaluate the outcomes of patients in our Burn Center who received TPN during their hospitalization. Methods This was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between July 1, 2015 and June 30, 2021 who had received TPN during their hospitalization were included in this study. Adult patients who had not received TPN were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), ICU and ventilator days, and mortality. Results There were 20 burn patients who received TPN during their hospitalization. Of those patients who received TPN, 90% were male. The mean age was 45 years, and the mean total body surface area (TBSA) involvement was 32%. The mean resting energy expenditure (REE) was 3,084. On average, the time from day of admission to initiation of TPN was 40 days, and the mean length of TPN administration was 20 days. The overall decrease in patient weight from admission to discharge was 10%. The mean LOS for the TPN group was 118 days. The mean LOS in the ICU was 92 days. The mean ventilator days were 89 days. The overall hospital mortality of patients who received TPN was 20%. When matched with patients who had similar TBSA involvement and who had not received TPN, there was no difference in mortality. However, there was a significant difference in weight loss (4% for non-TPN group), overall LOS (63 days), ICU LOS (29 days), and ventilator days (31 days). Conclusions Burn patients who received TPN during their hospitalization had a greater decrease in their overall weight, had a longer hospital and ICU length of stay, and were ventilated longer than those patients who did not receive TPN. These findings are to be expected given that patients who receive TPN tend to be more critically ill, and therefore, require more nutritional support.

Introduction In times of crisis, medical institutions must utilize contingency plans to ensure the highest quality of patient care. When these plans are overwhelmed, crisis standards of care may be adopted, resulting in modifications in resource allocation. The current coronavirus pandemic has created tremendous strains on hospitals throughout the world, with periodic shortages in equipment, PPE, ICU beds, and personnel. These pressures have been great enough at times to result in several states implementing crisis standards of care to allow hospitals to triage patients and "do the most good possible for the largest number of people with limited resources". However, these guidelines may not account for the unique needs of burn patients, whose care is often resource intensive. We examined state-based crisis standards of care guidelines in the United States to ascertain the degree to which triage of burn patients was addressed. Methods Internet search engines were used to locate state-specific actionable “crisis standards of care” or “scarce resource allocation” policies available before October 1, 2021. Once identified, these guidelines were further examined to determine whether explicit information was provided to direct the triage of burn patients. Results Of the 50 states and the District of Columbia, only 35 states (70%) were confirmed to have official crisis standards of care policies that could be implemented by healthcare institutions during the current pandemic. Additionally, guidelines from non-government entities were identified for 4 states (Florida Bioethics Network, Ohio Hospital Association, Missouri Hospital Association, and West Virginia Hospital Association). Of the 39 plans available, only 13 (26%) provided specific information regarding triage of burn patients during implementation of crisis standards of care. Conclusions Crisis standards of care are heterogenous throughout the United States and have varying levels of specificity. The majority of states and the District of Columbia do not provide clear, actionable guidance on the triage of burn patients.

Introduction Burn injuries are a leading cause of morbidity and mortality among patients worldwide. Many survivors continue to suffer from psychiatric sequalae long after their physical injuries have healed. This may even be more pronounced in groups who have a history of mental health disorders prior to admission. Common pre-injury mental health problems may include substance abuse disorders, as well as affective, psychotic, and personality disorders. The aim of this study was to explore the outcomes of patients with previously diagnosed mental health disorders who were admitted to our Burn Center. Methods This was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between January 1, 2014 and June 30, 2021 who had a previous history of mental health disorders were included in this study. All adult patients who did not have any previous history of mental health disorders were also included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), cost of hospitalization, and mortality. A p-value of < 0.05 was considered statistically significant for all analyses. Results There were 7,976 patients included in this study, with 32% of these patients having a previous diagnosis of mental health disorders. The mean age was 43.5 years, and the mean total body surface area (TBSA) involvement was 5.9%. Both the groups with a history of mental health disorders and those without were predominantly male (63.8% versus 68.0%). Most patients were flame-injured in both groups (44.5% versus 40.9%). The mean LOS for those with mental health disorder history was 14.5 days compared to 8.3 days for those without (p < 0.00001). The overall cost of hospitalization was $133,967 for those with mental health disorder history and $65,993 for those without (p < 0.00001). The overall hospital mortality for those with mental health disorder history was 2.3% and 3.4% for those without (p = 0.007). Conclusions Although there was no increase in mortality among patients with pre-existing mental health disorders, we did find that there was an increase in the hospital length of stay, as well as the overall cost of hospitalization. These findings do indicate that individuals with pre-existing mental health disorders do not necessarily have worse outcomes in terms of mortality; however, they may need access to care for longer periods of time, which may contribute to increased medical costs.

BACKGROUND: Among burn patients, research is conflicted, but may suggest that females are at increased risk of mortality, despite the opposite being true in non-burn trauma. Our objective was to determine if sex-based differences in burn mortality exist, and assess whether patient demographics, co-morbid conditions, and injury characteristics explain said differences. METHODS: Adult patients admitted with burn injury-including inhalation injury only-between 2004 and 2013 were included. Inverse-probability of treatment weights (IPTW) and inverse-probability of censor weights (IPCW) were calculated using admit year, patient demographics, co-morbid conditions, and injury characteristics to adjust for potential confounding and informative censoring. Standardized Kaplan-Meier survival curves, weighted by both IPTW and IPCW, were used to estimate the 30-day and 60day risk of inpatient mortality across sex. RESULTS: Females were older (median age 44 vs. 41 years old, p

In this retrospective analysis, we investigated the rate of radiologically confirmed osteomyelitis, extremity amputation, and healthcare utilization in both the diabetic and nondiabetic lower extremity burn populations to determine the impact of diabetes mellitus on these outcomes. The burn registry was used to identify all patients admitted to our tertiary burn center from 2014 to 2018. Only patients with lower extremity burns (foot and/or ankle) were included. Statistical analysis was performed using Student’s t-test, chi-squared test, and Fisher’s exact test. Of the 315 patients identified, 103 had a known diagnosis of diabetes mellitus, and 212 did not. Seventeen patients were found to have osteomyelitis within three months of the burn injury. Fifteen of these patients had a history of diabetes. Notably, when nondiabetics were diagnosed with osteomyelitis, significant differences were observed in both length of stay and cost in comparison to their counterparts without osteomyelitis (36 vs 9 days; P = .0003; $226,289 vs $48,818, P = .0001). Eleven patients required an amputation and 10 (90.9%) of these patients had comorbid diabetes and documented diabetic neuropathy. Compared to nondiabetics, the diabetic cohort demonstrated both a higher average length of stay (13.7 vs 9.2 days, P-value = .0016) and hospitalization cost ($72,883 vs $50,500, P-value = .0058). Our findings highlight that diabetic patients with lower extremity burns are more likely to develop osteomyelitis than their nondiabetic counterparts and when osteomyelitis is present, diabetic patients have an increased amputation rate. Further study is required to develop protocols to treat this population, with the specific goal of minimizing patient morbidity and optimizing healthcare utilization.

The features of work-related burn (WRB) injuries are not well defined in the literature and they vary depending on geographical location. We wanted to describe these characteristics among patients treated in the UNC Burn Center to evaluate the potential impact of commonly accepted prevention efforts. Adults of working age, admitted between January 1, 2013, and December 31, 2018, were identified using our Burn Center Registry. Demographic data, characteristics of injury, course of treatment, and patients’ outcomes were described. Differences between work-related and non-work-related injuries were evaluated using the Chi-square test and Student t-test where appropriate. Three thousand five hundred and forty-five patients were included. WRB cases constituted 18% of the study population, and this proportion remained relatively stable during the study timeframe. Young white males were the majority of this group. When compared with non-WRB patients, they were characterized by fewer co-morbidities, decreased TBSA burns, decreased risk of inhalation injury, shorter time of intensive care treatment, shorter lengths of hospital stay, and lower treatment cost. In contrast to non-WRB, among which flame injuries were the main reason for admission, work-related patients most often suffered scald burns. They also had a dramatically increased proportion of chemical and electrical burns, making the latter the most common cause of death in that group. WRB are characterized by a characteristic patient profile, burn etiologies, and outcomes. Learning specific patterns at this group may contribute to optimize work safety regulations and medical interventions.

In patients with diabetes mellitus (DM), amputation rates exceed 30% when lower extremity osteomyelitis is present. We sought to determine the rate of osteomyelitis and any subsequent amputation in our patients with DM and lower extremity burns. We performed a single-site, retrospective review at our burn center using the institutional burn center registry, linked to clinical and administrative data. Adults (≥18 years old) with DM admitted from January 1, 2014 to December 31, 2018 for isolated lower extremity burns were eligible for inclusion. We evaluated demographics, burn characteristics, comorbidities, presence of radiologically confirmed osteomyelitis, length of stay (LOS), inpatient hospitalization costs, and amputation rate at 3 months and 12 months after injury. We identified 103 patients with DM and isolated lower extremity burns. Of these, 88 patients did not have osteomyelitis, while 15 patients had radiologically confirmed osteomyelitis within 3 months of the burn injury. Compared to patients without osteomyelitis, patients with osteomyelitis had significantly increased LOS (average LOS 22.7 days vs 12.1 days, P = .0042), inpatient hospitalization costs (average $135,345 vs $62,237, P = .0008), amputation rate within 3 months (66.7% vs 5.70%, P < .00001), and amputation rate within 12 months (66.7% vs 9.1%, P < .0001). The two groups were otherwise similar in demographics, burn injury characteristics, access to healthcare, and preexisting comorbidities. Patients with DM and lower extremity burns incurred increased LOS, higher inpatient hospitalization costs, and increased amputation rates if radiologically confirmed osteomyelitis was present within 3 months of the burn injury.

Alcohol and illicit drug use are common among burn-injured patients. Urine toxicology and alcohol screens are a part of our admission order sets and automatically ordered for all adult patients. Our objective was to determine the impact of bias in screening compliance and compare those results to patients who test positive. All adult patients admitted between January 1(st), 2014 and December 31(st), 2018 were eligible for inclusion. Multivariable logistic regression was used to identify potential predictors for compliance in obtaining samples for screens, and patient characteristics associated with testing positive. Four thousand nine hundred ninety-eight patients were included in the study. The biggest predictors for compliance in obtaining samples for screens were inhalation injury, intensive care unit stay, length of stay, burn size, and current smoking status. No differences in compliance with screens were seen across age, race, or ethnicity. Current smokers and patients with a history of major psychiatric illness were more likely to test positive for alcohol and illicit drugs. Non-Hispanic Black patients were more likely to test positive for illicit drugs. Male sex and pre-existing psychiatric conditions were significant predictors for compliance for alcohol screens, and, positive tests. Implicit bias based on age, race, or ethnicity played no predictive role in compliance for either screen, however, non-Hispanic Blacks were more likely to test positive for illicit drugs. More studies are needed to understand the effect of selection bias related to sample collection, and the significance of positive test results.

The art of pyrography, burning designs in wood, dates back to prehistory. Risks of traditional techniques included cutaneous burns and airway injury. Fractal wood burning is a niche technique using a high-voltage electrical source to burn branched designs into wood. While this technique has grown in popularity, the associated risks are not well understood. We describe a patient who presented to our burn center after sustaining high-voltage electrical injuries while making fractal wood art using an improvised a high-voltage transformer. During the wood-burning process, he contacted the electrodes and suffered full-thickness electrical burns to the neck, chest, and bilateral upper extremities. Bilateral upper extremity fasciotomies were performed on admission. Multiple subsequent operations culminated with autografting to most of the wounds and complex reconstruction of the left thumb. In evaluating online news reports, we found 25 unique individuals with death or injury attributed to fractal wood burning from July 2016 to January 2020. Five sustained substantial injuries, while 20 reportedly died. Ages ranged from 17 years old to the 60s. One death and one injury occurred in females, with the remainder of reports involving males. Of the survivors, four sustained significant upper extremity electrical injuries and three suffered cardiac arrest at the time of injury. Fractal wood burning is associated with devastating high-voltage electrical injuries and death. Prevention efforts should be focused on education about the potential for death and permanently disabling injuries from this art form.

Introduction The global pandemic caused by severe acute respiratory syndrome coronavirus-2 (COVID-19) has exhausted resources and devastated at-risk populations. Our objective was to determine if COVID-positive patients have worse outcomes compared to COVID-negative patients after burn injury or desquamating skin disorders. Methods Patients were identified using our institutional Burn Center registry and linked to the clinical and administrative data. All patients admitted between March 1, 2020 and August 31, 2021 were eligible for inclusion. Demographics, length of stay (LOS), co-morbid conditions, and mortality were evaluated. Statistical analysis was performed with Students’ t-test, chi-squared, and Fischer’s exact test. Results A total of 1,994 patients were admitted during this period, and of those patients, 1,467 were adults. Twenty-three adults were COVID-positive. There were no significant differences in age, LOS, total body surface area (TBSA) involvement, hospital costs, sex, race or ethnicities of patients. There were no significant differences in percentage of patients presenting for burn or desquamating skin disorders. COVID-positive adult patients had a significantly higher mortality after injury than COVID-negative adults, p=0.003. There were no differences in COVID-positive pediatric patients admitted to our burn center. Conclusions A positive COVID test is associated with worse outcomes in patients admitted for burn injury or skin-sloughing disorders. Further study is warranted to investigate and mitigate what aspect of their care could be adjusted to improve outcomes.

Introduction A history of malignancy is associated with worse outcomes in cardiac disease and trauma. Our objective was to determine if a past medical history of cancer portends increased morbidity or mortality in burns or skin-sloughing disorders. Methods Patients were identified using our institutional Burn Center registry and linked to the clinical and administrative data. All patients admitted between January 1, 2014 and June 30, 2021 were eligible for inclusion. Demographics, length of stay (LOS), co-morbid conditions, and mortality were evaluated. Statistical analysis was performed with Students’ t-test, chi-squared, and Fischer’s exact test. Results A total of 8,018 patients were admitted during this period, and of those patients, 436 had a history of cancer (5%). Patients with a history of cancer were older (56 years versus 44 years), p< 0.0001. They had a significantly longer LOS. They had larger burns and higher hospital costs. They were more likely to be female and more likely to have a skin-sloughing disorder. Patients with a history of cancer also had higher mortality rates. Conclusions A history of cancer is associated with worse outcomes in patients admitted for burn injury or skin-sloughing disorders. Further study is warranted to investigate and mitigate what aspect of their care could be adjusted to improve outcomes.

Introduction In August of 2020, our institution transitioned from porcine xenograft to a polylactic acid skin substitute for the management of pediatric partial thickness burns. This change in treatment was due to the discontinuation of porcine xenograft by the primary supplier to the United States. We sought to make a length of stay (LOS), postoperative pain score, postoperative dressing change, and cost analysis of the polylactic acid skin substitute as compared to porcine xenograft for the treatment of pediatric burns. Methods Patients were identified using an institutional Burn Center registry and linked to clinical and administrative data. All pediatric patients admitted between January 1st, 2019 and March 31st, 2021 who sustained partial thickness burns were eligible for inclusion. LOS, burn etiology, total burn surface area (TBSA), postoperative pain scores, postoperative dressing changes, complications, infections, and hospital cost were evaluated. Results A total of 259 patients were identified, 47 of whom received the polylactic acid skin substitute and 212 of whom received xenograft. Average age for polylactic acid skin substitute patients was 5.4 years with 51.1% male, average age for xenograft patients was 4.6 years with 58.5% male. Average LOS for polylactic acid skin substitute patients was 3.4 days and 3.2 days for xenograft patients (p = 0.45). Etiology of burns was 83.0% scald and 10.6% flame for polylactic acid skin substitute patients and 80.2% scald and 9.40% flame for xenograft patients (p = 0.66 and p = 0.71, respectively). Polylactic acid skin substitute patients had an average TBSA of 5.3% and xenograft patients an average TBSA of 4.3% (p = 0.11). Postoperative pain scores on postoperative day (POD) 1 were 1.1 for polylactic acid skin substitute and 1.2 for xenograft (p = 0.13). Average number of inpatient postoperative dressing changes was equivalent between the polylactic acid skin substitute and xenograft (p = 0.62), while average day of first postoperative dressing change was POD 10.9 for the polylactic acid skin substitute and POD 9.9 for xenograft (p = 0.15). Neither group had postoperative infections, though xenograft had a complication rate of 1% with 2 patients while the polylactic acid skin substitute had 0%. Polylactic acid skin substitute patients had an average hospital cost of $28,415 and xenograft patients an average of $27,935 (p = 0.80). Conclusions A polylactic acid skin substitute is equivalent to porcine xenograft in LOS, postoperative pain, postoperative dressing changes, and cost in the setting of similar age, burn etiology, and %TBSA. More analysis with wound healing indices and safety profiles could determine the clinically superior choice.

Introduction Obesity is a global epidemic that continues to worsen. In 2016, more than 1.9 billion adults were considered overweight worldwide and over 650 million were obese. It is well-known that excess adipose tissue may alter inflammatory and immune mediator regulations, which can lead to challenges in managing resuscitation efforts, respiratory support, and thromboprophylaxis of burn patients. The objective of this study was to evaluate the outcomes of burn patients with obesity at our institution. Methods This was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between July 1, 2013 and June 30, 2021 who were classified as obese (i.e., body mass index > 30.0) were included in this study. All adult patients who were classified as underweight, normal weight, or overweight were also included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), cost of hospitalization, and mortality. Results There were 7,626 patients included in this study, with the largest percentage of patients included in the obese category (38.4%). Among the obese population, most of the patients (53.2%) were classified under ‘Obesity Class I’ (i.e., body mass index 30.0 – 34.9). The majority of patients in each category were male, except in the ‘Obesity Class III’ category (i.e., body mass index > 40.0) where 54.8% of the population were female. The mean age of the entire study sample was 44.9 years +/- 17.5 years, while the mean total body surface area (TBSA) involvement was 5.1% +/- 10.0%. The mean LOS of the entire study population was 10.3 days +/- 22.6 days, with patients in the ‘Obesity Class III’ category having the longest LOS with 14.0 days +/- 36.5 days. The cost of hospitalization was lowest in the overweight group with $82,661, while the highest cost was in the ‘Obesity Class III’ group with $130,683. The overall hospital mortality for the entire study population was 3.0% with the highest mortality noted in the ‘Obesity Class III’ group (4.7%). Conclusions Obesity affects all aspects of a burn patient’s care throughout their hospitalization. In our study, obesity was associated with longer LOS, cost of hospitalization, and mortality; therefore, it is imperative to understand the negative effects that obesity can have on burn patients, not just in terms of their acute management, but also their continued care after hospitalization.

Introduction Chronic obstructive pulmonary disease (COPD) is a condition with significant morbidity and mortality. In 2018, about 16 million adults in the United States reported a diagnosis of COPD based on data from the American Lung Association. Home oxygen is often used in more severe cases of COPD, and despite warnings against smoking while using home oxygen, many patients continue to sustain burn injuries. An existing diagnosis of COPD can further complicate management of a burn patient, especially if there is concomitant inhalation injury present. The objective of this study was to explore the outcomes of COPD patients admitted to our Burn Center. Methods This was a single-site, retrospective review using our institutional Burn Center registry. All adult patients with flame burns (18 years or older) admitted to our Burn Center between July 1, 2011 and June 30, 2020 who had a history of COPD with and without home oxygen use were included in this study. All adult patients with flame burns, who did not have a history of COPD, were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), ICU and ventilator days, and mortality. Results There were a total of 4,397 patients with flame burns included in this study, and 515 of those patients were identified to have an existing diagnosis of COPD. The mean age of the COPD group was 45.1 years +/- 13.0 years, and the patient population was predominantly male (60.4%). The mean total body surface area (TBSA) involvement was 5.12% +/- 10.38%. Inhalation injury was present in 10.1% of patients with COPD and in 7.8% of those without COPD. The mean LOS for the COPD group was 11.9 days +/- 19.4 days and 13.4 days +/- 31.0 days for the non-COPD group. The mean ICU LOS for the COPD group was 11.2 days +/- 19.9 days and 18.0 days +/- 37.0 days for the non-COPD group. The mean number of ventilator days was 16.5 days +/- 35.4 days for the COPD group and 26.3 days +/- 42.0 days for the non-COPD group. The overall hospital mortality was 10.3% for the COPD group and 4.3% for the non-COPD group. Conclusions This study demonstrates that the overall hospital mortality was highest in the COPD group. Although hospital and ICU length of stay, as well as the number of ventilator days were higher in the non-COPD group, it remains clear that an existing diagnosis of COPD can negatively impact the outcomes of burn patients.

Introduction The purpose of the Affordable Care Act was to make affordable health insurance available to more people, to cover adults with fewer resources, and to facilitate delivering health care in a cost-effective way. Burn care is both financially and medically intense, expensive, and prolonged. We aimed to compare outcomes of patients treated at a tertiary care center with no insurance, those considered under-insured (Medicare/Medicaid), and those with private/commercial insurance. Methods Patients were identified using our institutional Burn Center registry and linked to the clinical and administrative data. All adult patients admitted to the Burn Center between January 1, 2011 and December 31, 2020 were eligible for inclusion. Demographics, length of stay (LOS), co-morbid conditions and mortality were evaluated. Statistical analysis was performed with Students’ t-test and chi-squared. Results A total of 9,306 patients were admitted during the study period. Forty-one percent of patients had private/commercial insurance. Thirty-four percent were under-insured, while 25% of patients had no insurance. Total body surface area (TBSA) of the burn was significantly higher for the under-insured, p< 0.05. Mortality was significantly higher for the under-insured, p< 0.05. The average LOS for the under-insured was 14.7 days, which was significantly longer than that for the insured (9.2 days) and for those without insurance (7.4 days), p< 0.05. Conclusions There are outcome disparities secondary to insurance coverage in burns. Under-insured patients had poorer outcomes than those with private/commercial insurance and those without insurance.

Introduction The Rockwood Clinical Frailty Scale is a validated rapid assessment of frailty phenotype, predictor of mortality and other clinical outcomes in the geriatric population, even when applied retrospectively. Using data from a large tertiary care burn center, we assessed the association between admission frailty in an elderly burn population and outcomes. Methods Retrospective analysis of burn patients > 65 years, admitted to a tertiary care referral burn center from 2015–2019 (n= 652). Patients were assigned to Rockwood frailty subgroups, low (1–3), moderate (4–6), or high (7–9), based on comprehensive medical, social work, physical and occupational therapy assessments. Patients who did not have complete assessments to allow for appropriate frailty scoring were excluded. Hospital-associated infections (HAIs) were identified through the institutional epidemiology database and healthcare utilization data were extracted from burn registry and medical records. Cox proportional hazards regression was used to estimate associations between admission frailty and 30-day inpatient mortality. Results Our study included 644 patients (low: 262, moderate: 345, and high: 37 frailty subgroups). Frailty was associated with higher percent TBSA (median TBSA: low 2.0%; moderate 3.0%; high 3.0%; p=0.01) and older age at admission (p=0.0004). The 30-day cumulative incidence of mortality was 2.3%, 7.0%, and 24.3% among the low, moderate, and high frailty strata, respectively. After adjustment for age, TBSA and inhalation, high frailty was associated with increased 30-day mortality (HR 5.73; 95% CI 1.86, 17.62). Moderate frailty appeared to increase 30-day mortality, although estimates were imprecise (HR 2.19; 95% CI 0.87–5.50). Morbidity and healthcare utilization results are reported in Table 1. Higher frailty was associated with any ICU stay during the hospitalization, need for mechanical ventilation, and higher median hospital cost/day. HAIs were infrequent in all frailty subgroups. The proportion of patients discharged to hospice, rehab, long and short-term care facilities was highest in the high frailty subgroup. Those in the moderate and low subgroups were more likely to be discharged home or home with services. Conclusions High admission frailty is associated with an increased 30-day mortality regardless of age group. Higher frailty correlates with increased morbidity and healthcare utilization.

Introduction Diabetes mellitus (DM) is a critical comorbidity with burn injury due to the disrupted healing process. Previous reports have confirmed the increased rate of osteomyelitis (OM) and subsequent amputation in this cohort, however this has yet to be studied in comparison to non-diabetic patients. In this retrospective analysis, we investigate OM and amputation in both the diabetic and non-diabetic lower extremity burn populations to determine the impact of DM on these outcomes. Methods The burn registry was used to identify all patients admitted to our tertiary burn center from January 1, 2014 to December 31, 2018. Only patients with lower extremity burns (foot and/or ankle) were included. Patients with burns to additional body areas were excluded. Amputations were categorized by time from injury. Statistical analysis was performed using Student’s t test, chi-squared test, and Fischer’s exact test. Results Of the 315 patients identified, 103 had a known diagnosis of DM and 212 did not. Scald injury was the most common mechanism and average TBSA was similar. Differences were observed in average length of stay (LOS) and admission cost, with diabetics demonstrating both a higher LOS (13.7 days vs 9.2 days, p-value= 0.0016) and cost ($72,883 vs $50,500, p-value= 0.0058) (Table 1). In total, 17 patients were found to have radiologically confirmed OM within three months of the burn injury. Fifteen of these patients had a history of DM and two had no history of DM (p-value= < 0.001) (Table 2). The DM OM patients were found to have a higher blood glucose level on admission (219 mg/dL vs 110 mg/dL, p-value= 0.0452). No significant difference was seen in Hgb A1c in diabetics with or without OM (9.26% vs 8.81%, p= 0.2743). Notably, when non-diabetics were diagnosed with OM, significant differences were observed in both LOS and cost in comparison to their counterparts without OM (36 days vs 9 days; p= 0.0003; $226,289 vs $48,818, p=0.0001). Of the 11 patients who required an amputation, 10 (90.9%) of these patients had comorbid DM. Conclusions DM patients with lower extremity burns are more likely to develop OM than their non-diabetic counterparts. When radiologically confirmed OM is present, DM patients have an increased rate of amputation. OM incurs significant healthcare utilization and cost in both the diabetic and non-diabetic populations.

Introduction Our state’s Strengthen Opioid Misuse Prevention (“STOP”) Act was enacted on January 1 st 2018 to reduce prescription opioid misuse. We sought to evaluate the impact of opioid-limiting legislation on readmission rates among burn patients to our tertiary care burn center related to uncontrolled pain. Methods Patients were identified using an institutional Burn Center registry and linked to clinical and administrative data. All patients admitted between July 1 st, 2014 to June 20 th, 2019 were eligible for inclusion. Injury mechanism categories and reasons for readmissions were evaluated. Statistical analysis was carried out using chi-squared test and significance was accepted as p< 0.05. Results Of the 7872 total admissions, 160 (2%) were readmissions. Mean number of readmissions for every year was 32. There was an increase in number of readmissions in 2018 observed but it was not statistically significant (2014 n=12, 2015 n=35, 2016 n=21, 2017 n=33, 2018 n=40, 2019 n=19). The reasons for readmission included wound progression, graft failure, infection, and pain. There was an increase in readmissions for infection, wound progression and graft failure after January 2018, p< 0.05. The percentage of patients readmitted for pain increased between 2014 to 2019 but it was not statistically significant. Conclusions The primary reasons for readmissions to our burn center were pain, infection, graft failure, and progression of disease. Despite the opioid-limiting law there was not an increase in readmissions related to pain. Applicability of Research to Practice This study demonstrates that our current discharge planning strategies are managing pain expectations for patients. Our focus should be shifted towards improving infection control and wound care.

Introduction In patients with type 2 diabetes (DM2), amputation rates exceed 30% when lower extremity osteomyelitis is present. We sought to determine the rate of osteomyelitis and any subsequent amputation in our patients with DM2 and lower extremity burns. Methods We performed a single site, retrospective review at our burn center using the institutional Burn Center registry with links to clinical and administrative data. Adults (≥18 years old) with DM2 admitted from January 1, 2014 to December 31, 2018 for isolated lower extremity burns were eligible for inclusion. We evaluated demographics, burn characteristics, comorbidities, admission laboratory values, presence of radiologically-confirmed osteomyelitis, length of stay (LOS), inpatient hospitalization costs, and amputation rate at 3 months and 12 months after injury. Statistical analysis was performed with Students’ t-test, chi-squared, and Fischer’s exact test. Results For 103 patients identified with DM2 and isolated lower extremity burns, the average age was 54 years old. The majority of patients were male (78.6%) and white (55.3%). The average total body surface area (TBSA) of burn was 1.8% and 53.4% were scald burns. Thirty percent of patients had a history of heart disease and 22% were current smokers. The average hemoglobin A1c was 9.19 and average creatinine was 2.01. Overall rates of any amputation were 14.6% at 3 months and 18.4% at 12 months. Fifteen patients (14.6%) had radiologically-confirmed osteomyelitis within 90 days of the burn injury. Compared to patients without osteomyelitis, this subset of patients had significantly increased LOS (average LOS 22.7 days vs 12.1 days, p=0.0041), inpatient hospitalization costs (average $135,345 vs $62,237, p=0.0008), amputation rate within 3 months (66.7% vs 5.70%, p< 0.00001), and amputation rate within 12 months (66.7% vs 10.2%, p< 0.0001). There were no significant differences in other characteristics between patients with osteomyelitis and those without. Conclusions Patients with DM2 and lower extremity burns incurred increased LOS, higher inpatient hospitalization costs, and increased amputation rates if radiologically-confirmed osteomyelitis was present. Applicability of Research to Practice Osteomyelitis in diabetic patients with lower extremity burns may predict need for amputation within one year of burn injury. Further study could aid in development of protocols for early identification and aggressive treatment of osteomyelitis in burn patients, which may improve LOS, cost, and amputation rates.

Introduction In recent years, burn centers are managing more patients with exfoliative skin disorders including Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), and SJS/TEN overlap. While it is well known that burn patients have higher rates of co-morbid psychiatric disorders than the general population, the incidence of pre-existing psychiatric disorders among patients who develop SJS, SJS/TEN overlap, and TEN is unknown. This study aimed to characterize a cohort of patients with pre-existing psychiatric disorders admitted to a tertiary burn center for treatment of SJS, SJS/TEN overlap, and TEN with specific focus on those who received the offending agent for a psychiatric indication. Methods A retrospective descriptive case series using an institutional burn center registry was performed. All patients admitted to a single verified burn center between January 1, 2009 and December 31, 2018 with biopsy-proven SJS, SJS/TEN overlap, or TEN and the presence of a co-morbid psychiatric disorder were identified. Demographic, hospital, and clinical information were extracted from the burn registry and verified through review of the electronic medical record. Results Among 168 patients with biopsy-proven SJS, SJS/TEN overlap, or TEN, 18% (30/168) had a pre-existing psychiatric disorder, with the offending agent being prescribed for a psychiatric indication in 30% (10/30) of patients. Lamotrigine was the offending agent in 80% of cases and prescribed 100% of the time for a psychiatric indication. Of those who received lamotrigine, patients were 100% female, 63% black, and had an average age of 38 years. The mean length of stay was 24 days and 88% received a psychiatric consultation. While 75% of patients were started on lamotrigine for a diagnosis of bipolar disorder, none of these patients met criteria for bipolar disorder. Conclusions Pre-existing psychiatric comorbidity is less common among patients that develop SJS, SJS/TEN overlap, and TEN than in burn-injured patients. For patients with pre-existing psychiatric disorders who develop these potentially fatal skin diseases from an offending agent that was prescribed for a psychiatric indication, early involvement of psychiatry colleagues is recommended to ensure proper psychiatric diagnosis and management moving forward. Applicability of Research to Practice This study highlights the importance of accurate assessment for and diagnosis of bipolar disorder prior to determining treatment approach. For the burn surgeon treating these patients, early involvement of psychiatric consultants is recommended and extremely important.

Introduction Stenotrophomonas maltophilia (SM) is a non-fermenting, gram-negative bacterium that is a challenge to treat in immunocompromised hosts. It is difficult to eradicate due to its natural resistance to multiple antibiotics and omni-presence. Our objective was to evaluate the clinical characteristics of burn patients diagnosed with SM infection in our Burn Unit. Methods A single-site, retrospective review using an institutional Burn Center registry and infection control data. All patients diagnosed with SM infection within our Burn Unit between June 1, 2012 and June 1, 2019 were included in this retrospective review. Demographics, burn characteristics, length of stay and mortality were evaluated. Patients were then compared to all admitted patients who were ventilated for greater than 4 days during the same time period. Significance was accepted at p< 0.05. Results Forty-seven patients were diagnosed with SM infection between 2012 to 2019. Among these patients 64% were male and 36% were female. Mean patient age was 51 years old +/- 16 years. The most common reason for admission was flame burns (64%), followed by Stevens Johnson/Toxic Epidermal Necrolysis (SJS/TEN) (17%). The average total body surface area (TBSA) involved was 29% +/- 18%. Mean time from admission to a positive SM culture was 34.5 days. One-hundred percent of the patients were intubated. Positive cultures for SM were obtained from bronchial alveolar lavage in 96% of positive cultures for SM. Mean length of stay in this group was 108 days +/- 86 days, ranging from 5 to 362 days. The mortality rate for patients diagnosed with a SM infection was 40%, compared to 27% in all patients admitted during this time who were ventilated for greater than 4 days. Conclusions SM is a highly virulent bacteria associated with increased morbidity and mortality in patients admitted to our burn unit. The patients with positive cultures were older, male, flame injured, mechanically ventilated, had large TBSA involvement, and had prolonged hospital courses. Applicability of Research to Practice This study demonstrates the virulence of SM in a high-volume burn center. Cultures positive for SM require aggressive source control and burn centers need to be hypervigilant in controlling environmental factors to mitigate risk.

Introduction Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a rare, severe mucocutaneous eruption caused by medications and resulting in diffuse epidermal detachment. Patients are often referred to burn units for specialized care. This study assesses trends in precipitating medications over 10 years at our Burn Center. Methods We performed a single-site, retrospective review at our burn center using the institutional burn registry and patient charts. Patients admitted from January 1, 2009 to December 31, 2018 identified as having SJS/TEN were eligible for inclusion. Demographics, comorbidities, diagnosis, treatment, inciting agents, and severity-of-illness score for TEN (SCORTEN) were evaluated. Statistical analysis was performed using the Mann Whitney U test using SAS version 9.4 (SAS Inc., Cary, NC). Results Biopsy-proven SJS, SJS/TEN overlap, or TEN was confirmed in 168 patients. Of these, 103 had a single identified offending drug. Of these patients, 36% had been exposed to sulfamethoxazole-trimethoprim (SMX-TMP), 11% to allopurinol, and 10% to lamotrigine. Trends in culprit drug by year are shown in Figure 1. The majority of SMX-TMP and penicillin cases occurred early in the period of study; lamotrigine and pembrolizumab cases occurred more recently. Patients exposed to allopurinol presented with higher SCORTENs than patients exposed to SMX-TMP, 2.9 vs 1.9, respectively (p< 0.035). Conclusions SMX-TMP once accounted for a large portion of SJS and TEN cases at our center. In recent years, lamotrigine has become a more common offending drug, prescribed in our cohort for psychiatric indications. Also notable, in the past year we have treated three patients with TEN due to immunotherapy (pembrolizumab) for metastatic or unresectable cancer. Paralleling the increasing use of immunotherapy has been a rise of immune-related adverse events, including severe skin toxicities. Further study is warranted to determine what can be done to prevent SJS/TEN from occurring in patients treated with these drugs. Applicability of Research to Practice Understanding emerging trends in causative agents of SJS/TEN will allow the burn community to focus education efforts for providers who prescribe these medications frequently. The psychiatric and oncology communities may benefit from increased awareness of the risk of SJS/TEN in patients receiving lamotrigine and immunotherapy, respectively.

Supply and demand dictate resource allocation in large academic institutions. Classic teaching is that burns is a seasonal specialty with winter being the “busiest” time of year. Resident allocation during the winter and summer months, however, is traditionally low due to the holidays and travel peaks. Our objective was to evaluate our acuity—defined as patient complexity—based on seasons, in order to petition for appropriate mid-level provider allocation. We performed a retrospective review of all admissions to an accredited, large academic burn center. All patients admitted between January 1, 2009 and December 31, 2018 were eligible for inclusion. Demographics, length of stay, injury characteristics, and mortality were evaluated. Thirteen thousand four hundred fifty-eight patients were admitted during this study period. Most patients were admitted during the summer. Patients admitted to the intensive care unit were more likely to be admitted in the winter, although this was not statistically significant. Winter admissions had the longest lengths of stay, and the highest incidence of inhalation injury. Female and elderly patients were more likely admitted during the winter. There was a significant difference in mortality between summer and winter seasons. Acuity is seasonal in our large academic burn center and resource allocation should align with the needs of the patients. This data may help large centers petition their institutions for more consistent experienced mid-level providers, specifically during critical seasons.

Introduction Paraquat dichloride is a widely used, highly toxic chemical herbicide and a leading cause of fatal poisonings. Toxicity is thought to be related to lipid peroxidation. Hours after exposure, patients may experience signs and symptoms ranging from nausea to multi-system organ failure. To prevent pulmonary complications and death, it is recommended to give patients repeated pulse therapy with cyclophosphamide and methylprednisolone administered over a 72-hour period. Our objective is to report our center’s experience treating patients who had been exposed to paraquat over a two-day period. Methods Patients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. Demographics, length of stay, costs and mortality were evaluated. Results There were nine patients admitted from the exposure. All were male. All survived. Eight were undocumented migrant farmer workers. The average age was 36 years (range 25–59 years). The average length of stay was 3.3 days (range 2–5 days). Fifty-six percent had cutaneous injury, but only one required debridement and placement of a skin substitute. Thirty-three percent complained of continued shortness of breath after discharge. Average total hospital cost was $28,131 ($9,500–51,000). Conclusions Paraquat is a highly toxic herbicide and exposure can be fatal if not treated promptly. Immediate decontamination and repeated pulse therapy with cyclophosphamide and methylprednisolone may be lifesaving.

Introduction The shelter-in-place mandate to mitigate the effects from the 2019 severe acute respiratory syndrome coronavirus 2 was associated with an increase in admissions of school-aged children to our burn center but a decrease in adult admissions. It was unclear how many admissions were from suspected abuse. Our objective was to determine the social impact of the shelter-in-place mandate on the number of burn admissions secondary to suspected abuse during the COVID pandemic compared to previous years. Methods Patients were identified using Institutional Burn Center registry and linked to the clinical and administrative data. All patients admitted from January 1, 2016 to July 31, 2020 with suspected abuse were eligible for inclusion. Demographics, patient and burn characteristics were evaluated. Statistical analysis was performed with Students’ t-test, and chi-squared test. Results There were 7177 patients included in the study. Prior to 2020, each year the percentage of cases with suspected abuse decreased compared to previous years (19% decrease in 2017, 23% decrease in 2018, 30% decrease in 2019). Compared 2019, the number of patients admitted with suspected abuse during the COVID pandemic increased 257%, p=0.00046. There were no significant differences in race, ethnicity, sex, burn mechanism, or burn size in those admitted with abuse-related injuries. The average age of patients with abuse-related injuries in 2020 was 13 years old, compared to an average age of 28 years old for the period from 2016–2019 (p< 0.003). Conclusions There is a significant increase in number of patients admitted for suspected abuse. Shelter-in-place mandate limited viral transmission of COVID-19 but led to unfathomable increases in abuse cases at our institution.

Introduction Stevens-Johnson syndrome (SJS) and Toxic epidermal necrolysis (TEN) are a spectrum of rare, life-threatening drug reactions characterized by diffuse skin detachment and mucositis. Our objective was to describe and analyze mortality trends at our institution for patients with biopsy-proven SJS and TEN over the last decade. Methods Patients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted with biopsy proven SJS, SJS/TEN overlap, and TEN between January 1, 2009 and December 31, 2018 were eligible for inclusion. Demographics, length of stay (LOS), co-morbid conditions and mortality were evaluated. Statistical analysis was performed with Students’ t-test, chi-squared, and Fischer’s exact test. Results One hundred sixty-eight patients had biopsy-proven SJS, SJS/TEN overlap, or TEN. The average age was 48 years. Sixty-one percent of patients were female. The average length of stay was 30 days. Fifty-six percent of patients were Black. Twenty-seven percent of patients died. Increased mortality risk was significantly associated with female gender, age, underrepresented minorities, Human Immunodeficiency Virus, and chronic obstructive pulmonary disease. The presence or absence of malignancy or chronic kidney disease was not evaluated. Conclusions Biopsy proven SJS, SJS/TEN overlap, and TEN are associated with increased mortality for females, underrepresented minority populations, and patients with comorbidities. Black patients represent 28% of our state’s population, but 56% of patients with biopsy proven SJS, SJS/TEN overlap, and TEN at our institution. Further study is warranted to investigate and mitigate these outcome disparities in these patient populations. Applicability of Research to Practice This study highlights the importance of acknowledging that these at-risk patient populations must be protected with higher vigilance during evaluation, assessment of the offending agent, and resuscitation.

Introduction Female gender is associated with poorer outcomes in burns, not necessarily related to co-morbid conditions. Our objective was to analyze the effect of gender in biopsy proven Stevens-Johnson syndrome (SJS) and Toxic epidermal necrolysis (TEN) spectrum disorders at our institution. Methods Patients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted with biopsy proven SJS, SJS/TEN overlap, and TEN between January 1, 2009 and December 31, 2018 were eligible for inclusion. Demographics, length of stay, and mortality were evaluated. Statistical analysis was performed with Students’ t-test, chi-squared, and Fischer’s exact test. Results One hundred and sixty-eight patients had biopsy proven SJS, SJS/TEN overlap, or TEN. Sixty-one percent of patients were female. The average age of female patients was 51 years while the average age of male patients was 44 years, p< 0.05. Fifty-sex percent of female patients were black. All American Indian patients were female. Female patients had significantly longer lengths of stay, 34 days versus 22 days, p< 0.05. Female patients had an average SCORTEN (a severity of illness score of TEN) compared to male patients. Thirty-three percent of female patients died compared to 18% of male patients, p< 0.05. Two out of three American Indian patients in this cohort died. Conclusions Female gender is associated with increased mortality in burn patients, as well as in our cohort of patients with SJS/TEN. Females represent 51% of our state’s population, but 61% of patients with biopsy proven SJS, SJS/TEN overlap, and TEN at our institution. Compared to male patients, female patients presented with more severe disease (higher SCORTEN at presentation). Genomic, and proteomic studies looking at sex-based differences may be helpful in elucidating the origin of these differences. Applicability of Research to Practice This study demonstrates sex-based differences related to skin desquamating disorders, and these outcomes, coupled with known disparities in burns, may indicate a need for hypervigilance in inpatient management for women, and a re-evaluation of prognostic scoring tools to include a variable for gender.

Introduction Burn injured patients are at high risk of thromboembolic complications. Morbid obesity further increases risk for thromboembolic complications. Recent evidence supports the use of anti-Xa guided enoxaparin dosing for the prevention of venous thromboembolism (VTE) in high risk populations. Our objective was to evaluate the efficacy of enoxaparin 40mg twice daily in achieving prophylactic plasma anti-Xa levels in obese burn patients. Methods A retrospective chart review of an ABA-verified burn center from November 2018 until September 2019 identified patients who were either ≥100 kilograms (kg) or had a body mass index (BMI) ≥ 30 kg/m2 and were initiated on enoxaparin 40 mg twice daily for VTE prophylaxis. Patients were included if they were at least 18 years of age and received at least three sequential doses of enoxaparin with appropriately timed peak plasma anti-Xa levels to monitor efficacy. Patient demographics were analyzed, as well as body weight, BMI, and total body surface area (TBSA) burn. Statistical analysis was performed with student’s t-test for continuous data and Fischer’s exact test for categorical data. Results During the study period, 148 patients were screened with 44 patients included for analysis. Forty-one percent of the patients evaluated did not reach target peak plasma anti-Xa levels (0.2–0.5 IU/mL) on enoxaparin 40 mg twice daily. Patients who did not meet prophylactic target levels were more likely to be male (p< 0.05) and have an increased body weight (129 +/- 24 kg versus 112 +/- 17 kg, p< 0.05). Eleven out of 18 patients received dosage adjustments with subsequent anti-Xa levels available for follow-up assessment, of which an additional four patients required further dosage adjustment to meet goal peak plasma levels. Conclusions Current utilization of a fixed 40 mg twice daily regimen of enoxaparin for VTE prophylaxis is inadequate to meet target prophylactic peak plasma anti-Xa levels in the obese burn patient population. Dose adjusting enoxaparin to target peak plasma anti-Xa levels to reduce VTE rates in obese burn patients should be further evaluated. Applicability of Research to Practice This study demonstrates the need for more accurate dosing and evaluation of our dosing practices for VTE prevention. It also demonstrates the importance of having a Burn dedicated pharmacist in facilitating appropriate care.

Introduction The art of pyrography, creating designs in wood with a thermal heat source, dates back to prehistory. Risks include cutaneous burns and airway injury. Fractal woodburning is a niche method of pyrography utilizing a high-voltage electrical source to burn branched designs – Lichtenberg patterns – into the surface of wood. While this technique has grown in popularity, the associated risks are not well described. Methods We describe a patient who presented to our burn center after sustaining high-voltage electrical burns from a homemade high-voltage device constructed for fractal woodburning. We also evaluated publicly reported cases of death or injury due to this technique. Results An otherwise healthy 17-year-old male was admitted to our burn center with injuries sustained while making fractal wood art. The patient improvised a high-voltage transformer from a discarded microwave, generating 2000 volts from household current. While using this device to burn Lichtenberg patterns in wood, he contacted the electrodes and sustained full-thickness electrical burns to the neck, chest, and bilateral upper extremities. Bilateral upper extremity fasciotomies were required on admission. Multiple subsequent operative procedures culminated with autografting to the majority of the wounds and ongoing complex reconstruction of the left thumb. In evaluating online news reports, we found 21 unique individuals with death or injury attributed to fractal woodburning. Four sustained substantial injuries, while 17 reportedly died. The first reported incident occurred in July 2016 and the most recent report was from July 2019. Ages ranged from 17 years old to the 60s. Eighteen individuals were younger than 50 years old. All of the mortalities and 3 of the 4 injuries occurred in males. Of the survivors, 3 sustained significant upper extremity injuries and 2 suffered cardiac arrest at the time of injury. The devices used in 4 incidents were microwave transformers and generated 2000 volts. Device characteristics were not identified in the remainder of cases. Conclusions Fractal woodburning is associated with devastating high-voltage electrical injuries and death. Prevention efforts should be focused on the potential risks of this art form. Applicability of Research to Practice News reports likely underestimate the actual incidence of injury and death due to fractal woodburning, however, even this limited data suggests an emerging public health problem requiring further study and public education.