American Burn Association

To the Editor: On Saint Patrick’s Day, 2019, the sky was torn asunder and the Earth beneath me shook violently. A mentor that my whole generation of burn and trauma surgeons called their own had left this Earthly plain. I first really got to know Dr. Pruitt during my American Burn Association Traveling Fellowship, decades ago. In a quest to understand the basis of burn resuscitation, that fellowship was graced by private audiences with William Monafo, Charles Baxter, and Basil Pruitt. The origins of hypertonic resuscitation (Monafo), the Parkland (Baxter) Formula, and the Brooke Formula (Dr. Pruitt’s World-Famous Burn Unit) were thus explained to me in original detail. All burn surgeons aged 45–65 have a deep catalogue of “Colonel Pruitt stories.” My favorite is when “Basil” related to me how, every year, he “bit his tongue” whenever examining for the American Board of Surgery, as the examinee knee-jerk quoted the Parkland Formula when resuscitating a severe burn injury!

Burn patients exhibit comorbidities that influence outcomes. This study examines whether existing comorbidity measures capture comorbidities in the burn inpatient rehabilitation population. Data were obtained from the Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury. International Classification of Diseases, 9th Revision, codes were used to assess three comorbidity measures (Charlson Comorbidity Index, Elixhauser Comorbidity Index, Centers for Medicare and Medicaid Services Comorbidity Tiers). The number of subjects and unique comorbidity codes (>1% of frequency) captured by each comorbidity measure was calculated. The study included 5347 patients with a median total body surface area burn decile of 20%-29%, mean age of 51.6 yrs, and mean number of comorbidities of 7.6. There were 2809 unique International Classification of Diseases, 9th Revision, comorbidity codes. The Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Centers for Medicare and Medicaid Services Comorbidity Tiers did not capture 67%, 27%, and 58% of the subjects, respectively. There were 107 unique comorbidities that occurred with a frequency of greater than 1%. Of these, 67% were not captured in all three comorbidity measures. Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the burn rehabilitation population. Future work is needed to assess the need for comorbidity indexes specific to the inpatient rehabilitation setting.

Journal Article Synopsis of the 2013 Annual Report of the National Burn Repository Get access Palmer Q. Bessey, MD, FACS, MS, Palmer Q. Bessey, MD, FACS, MS *Weill Medical College of Cornell University, New York, New York ***Address correspondence to Palmer Q. Bessey, MD, FACS, MS, Burn Division, Department of Surgery, Weill Medical College of Cornell University, 525 East 68th Street, Box 137, New York, New York 10021. Search for other works by this author on: Oxford Academic Google Scholar Bart D. Phillips, PhD, Bart D. Phillips, PhD †E-B Research, Minneapolis, Minnesota Search for other works by this author on: Oxford Academic Google Scholar Christopher W. Lentz, MD, FACS, FCCM, Christopher W. Lentz, MD, FACS, FCCM ‡Paul Silverstein Burn Center, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma Search for other works by this author on: Oxford Academic Google Scholar Linda S. Edelman, RN, PhD, Linda S. Edelman, RN, PhD §University of Utah College of Nursing, Salt Lake City, Pennsylvania Search for other works by this author on: Oxford Academic Google Scholar Iris Faraklas, RN, BSN, Iris Faraklas, RN, BSN ‖University of Utah Burn Center, Department of Surgery, Salt Lake City, Pennsylvania Search for other works by this author on: Oxford Academic Google Scholar Margaret A. Finocchiaro, BA, Margaret A. Finocchiaro, BA ¶The Nathan Speare Regional Burn Treatment Center, Crozer Chester Medical Center, Upland, Pennsylvania Search for other works by this author on: Oxford Academic Google Scholar Nathan A. Kemalyan, MD, FACS, Nathan A. Kemalyan, MD, FACS #Oregon Burn Center, Surgical & Burn Specialists, Portland Search for other works by this author on: Oxford Academic Google Scholar Matthew B. Klein, MD, MS, FACS, Matthew B. Klein, MD, MS, FACS **Santa Clara Valley Medical Center, San Jose, California Search for other works by this author on: Oxford Academic Google Scholar Sidney F. Miller, MD, FACS, Sidney F. Miller, MD, FACS ††The Ohio State University Wexner Medical Center, Columbus Search for other works by this author on: Oxford Academic Google Scholar Michael J. Mosier, MD, FACS, Michael J. Mosier, MD, FACS ‡‡Loyola University Medical Center, Maywood, Illinois Search for other works by this author on: Oxford Academic Google Scholar ... Show more Bruce M. Potenza, MD, FACS, Bruce M. Potenza, MD, FACS §§University of California San Diego Regional Burn Center, San Diego Search for other works by this author on: Oxford Academic Google Scholar Cynthia L. Reigart, RN, BSN, Cynthia L. Reigart, RN, BSN ¶The Nathan Speare Regional Burn Treatment Center, Crozer Chester Medical Center, Upland, Pennsylvania Search for other works by this author on: Oxford Academic Google Scholar Susan M. Browning, MPH, Susan M. Browning, MPH ‖‖American Burn Association, Chicago, Illinois Search for other works by this author on: Oxford Academic Google Scholar Maureen T. Kiley, BBA, Maureen T. Kiley, BBA ‖‖American Burn Association, Chicago, Illinois Search for other works by this author on: Oxford Academic Google Scholar John A. Krichbaum, JD John A. Krichbaum, JD ‖‖American Burn Association, Chicago, Illinois Search for other works by this author on: Oxford Academic Google Scholar Journal of Burn Care & Research, Volume 35, Issue suppl_2, May-June 2014, Pages S218–S234, https://doi.org/10.1097/BCR.0000000000000080 Published: 01 May 2014

Background Septicemia is associated with high mortality. Inadequate antimicrobial therapy leads to poor outcomes. Pathogen detection aids in clinical decision making by directing appropriate treatment. Sampling volume and in vivo microbial blood concentration affect analytical sensitivity and represent a significant design challenge for future point-of-care pathogen detection technologies. Methods We applied the Poisson distribution to identify the probability of collecting no pathogens from a given sampling volume and bloodstream pathogen concentration for existing blood culture and whole-blood polymerase chain reaction (PCR) pathogen detection technologies. The concept of “effective target pathogen concentration” is introduced to account for the unique detection of both cell-free and intracellular DNA by PCR methods. Results The probability for a 10-mL blood culture or a 1.5-mL PCR specimen not collecting pathogens was 4.54 × 10−5 and 0.22, respectively, when pathogen bloodstream concentrations were at 1 colony-forming unit/mL. The probability of collecting no pathogens decreased as pathogen bloodstream concentrations increased. Accounting cell-free target pathogen DNA, the PCR sampling probability substantially improved and exceeded blood culture performance. Conclusions The probability of not isolating pathogens from a PCR or blood culture specimen was highly dependent on sampling volume and pathogen concentration. Cell-free pathogen DNA enhances PCR performance despite smaller sampling volumes. The impact of sampling volume and target pathogen concentrations should be considered when developing point-of-care pathogen detection solutions that may be constrained to smaller sampling volumes. Further in vitro studies are warranted to validate this theory during dynamic sepsis conditions.

November 24, 2007, marked the 20th anniversary of the first Southern Region Burn Conference. Ever since it was first established to provide an educational forum for burn care providers on a regional level, the annual conference has been an energetic and productive meeting for all members of the extended burn team. One reason the meeting is so successful is that each of the 23 burn centers in the region is encouraged to submit oral presentations and posters that detail their research projects or their experiences in the clinical care of burn patients. As a result of this practice, each burn center serves as an integral part of the meeting program, and team members from each center come to the meeting to support their team's presenters. Abstract presentations at the conference are informal and interactive and give presenters a chance to “practice” delivering their presentation to a small, friendly group. Many of the presentations then go on to be refined and presented at the American Burn Association meeting. The informal nature of the regional conference provides an atmosphere that is conducive to networking and the exchange of practical ideas.

In the early 1990s, the American Burn Association (ABA) started its first burn registry development initiatives. The impetus for the registry development software originated from several directions, including the following: (1) the recognition that national registries were widespread and of proven benefit; (2) growing demands from accrediting institutions, payers, and patient advocacy groups for objective and verifiable data regarding patient costs, treatments, and outcomes; and (3) the shift toward "evidence-based" medicine and the ongoing analysis of treatment effectiveness. The ABA has issued three calls for burn registry data for its National Burn Repository (NBR): 1994, 2002, and 2005. In 1994, 28 burn centers contributed data for more than 6,400 patients treated from 1991 to 1993. The ABA announced its second call for data in 2001 and distributed the published results of more than 54,000 acute burn admissions treated from 1974 to 2002 at the Association's 2002 Annual Meeting. The third ABA call for data was issued in the Fall of 2005. The results are detailed in this report, which provides a summary of more than a quarter million acute burn admissions from 1995 to 2005, representing 70 hospitals from 30 states plus the District of Columbia. Statistics are presented in chart and table format to illustrate such key factors as patient age, burn size group, types of injuries, mortality rates, and average hospital charges by etiology and length of hospital stay. The data presented herein should help stimulate quality improvement programs in burn care, as burn centers compare their performance with the national data and as research is expanded using the NBR. The NBR will be published annually and, with continued refinements to the registry software, should become of increasing importance to clinicians, payers, researchers, and the public.

This editorial explains how well received and how important it has been to provide education regarding current burn care in a regional burn conference. In addition, the networking between burn team members from neighboring burn centers has been exceptional. The informal nature of the conference facilitates this camaraderie. The conference has been well received by the burn team members in the region as well in many other regions. In 1985, the American Burn Association (ABA) established 10 regions in the United States, using the same regions the American College of Surgeons Committee on Trauma have for their regional organization. Region IV (the southeastern region) comprises eight states: North and South Carolina, Georgia, Kentucky, Tennessee, Mississippi, Alabama, and Florida. At the time that Region IV was established by the ABA, there were 22 burn units in the region; however, currently there are 17 burn units. The initial charge from the ABA to all 10 regions was to develop disaster plans specific to that region. A regional director was appointed in each region to be the official representative of the ABA and was charged with the responsibility of facilitating the development of the regional disaster plan.

Toxic epidermal necrolysis syndrome is an uncommon, acute, life-threatening, medication-induced disorder with a reported mortality rate of 20 to 60 percent. Different variables have been identified as risk factors. The extent to which these variables, when combined, affect the mortality and outcome in toxic epidermal necrolysis syndrome patients has not yet been reliably defined. Because of the high mortality rate, the logistic analysis of studied variables was performed to see whether a prognostic algorithm could be developed to aid the management of these patients. Thus, a retrospective review of 56 consecutive toxic epidermal necrolysis syndrome patients treated over a period of 13 years was undertaken in the authors' burn center. The demographics included age, sex, race, and total body surface area involved. The other variables studied were comorbidities, sepsis, steroid administration, and the interval between onset of rash and burn center admission. Data were subjected to Fisher's exact test and logistic analysis. Thirty-six patients (64.3 percent) were alive and 20 (35.7 percent) died. Univariate analysis indicated that the male/female ratio was 12:24 for survivors and 9:11 for nonsurvivors (p = 0.4). The white/nonwhite ratio was 80 percent for survivors and 54 percent for nonsurvivors (p = 0.58). The median age was 48.4 +/- 22.8 years (survivors, 41.7 +/- 22.0; nonsurvivors, 60.5 +/- 19.5; p = 0.002). Total body surface area involvement for survivors was 56.9 +/- 32 and 77.7 +/- 21 for nonsurvivors (p = 0.005). The presence of one or more comorbidities between the two groups differed (53 percent survivors and 90 percent nonsurvivors, p = 0.007), indicating eight times higher odds of dying in their presence. The average time between the onset of symptoms and admission to the burn unit was 5.25 +/- 3.4 days for survivors and 7.15 +/- 4.5 days for nonsurvivors (p = 0.08). The presence of sepsis (19.4 percent survivors, 95 percent nonsurvivors, p < 0.001) decreased odds for survival by a factor of 79. Steroids given as a single dose or multiple doses before the patient's transfer to the burn unit were not significantly associated with death (44 percent survivors, 65 percent nonsurvivors, p = 0.14). A multivariate logistic regression model yielded odds ratios of 1.11 (95 percent confidence interval, 1.03 to 1.19) for age in years, 304 (95 percent confidence interval, 8.83 to 10,400) for the presence of sepsis, and 1.03 (95 percent confidence interval, 0.99 to 1.08) for body surface area in percent. All those entering the burn unit with sepsis died. Equivalently, no survivors had sepsis before admission to the burn unit, whereas 55 percent of nonsurvivors had sepsis before admission and 40 percent developed sepsis after admission. When investigating the effect of age and sepsis, no patients over age 60 ever having sepsis survived, whereas all those who were under 60 and without sepsis survived. Likewise, all patients whose age was over 60 and whose total body surface area involved was over 60 percent died. The main factors contributing to the mortality from toxic epidermal necrolysis syndrome, when considering covariates separately, are the presence of sepsis at any time (odds ratio, 79), the presence of comorbidities (odds ratio, 8.05), age, and total body surface area, whereas multivariate models suggested age (odds ratio per year of additional age, 1.11), total body surface area (odds ratio per additional percent of body surface area, 1.03), and the presence of sepsis (odds ratio, 304). By using the actual coefficients in the logistic model, the log odds that the patient will die as the result of his or her condition can be summarized in the following formula: -11.5 + (10 percent of the patient's age + 3 percent of total body surface area + 5.75 if sepsis is present). The awareness of the importance of these covariates, and their early recognition as risk factors, should offer a focused approach to the patients' management and improve their outcome.

To document the incidence of barotrauma, pneumonia, and respiratory death associated with a mechanical ventilation protocol based on permissive hypercapnia in pediatric burn patients. Retrospective review. Patients were managed using a mechanical ventilation protocol based on permissive hypercapnia, tolerating moderate (pH > 7.20) respiratory acidosis to keep inflating pressures below 40 cm H2O. Over a 2.5-year interval, 54 burned children (11% of 495 acute admissions) with an average age of 6.5 years (range 5 weeks to 17 years), average burn size of 44% (range 0 to 98%), and median burn size of 46% required mechanical ventilatory support for an average of 12.5 days (range 1 to 56 days). Inhalation injury was diagnosed in 34 (63%) of the children and 72% percent were admitted within 24 hours of injury. Overt barotrauma occurred in 5.6% of the patients, pneumonia in 32%, and respiratory death in 0%. A conventional ventilation protocol based on permissive hypercapnia is associated with acceptable rates of barotrauma and pneumonia. The low incidence of respiratory death associated with this strategy suggests that it also minimizes ventilator-induced lung injury.