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PubMed1981

Prophylactic intubation and continuous positive airway pressure in the management of inhalation injury in burn victims.

Burn mortality statistics are influenced by age and degree of total surface body burn. The addition of an inhalation injury to a cutaneous burn results in a significant increase in mortality rate. Nine hundred fourteen patients with acute thermal injury were screened for positive history of burn in a closed space, facial or oropharyngeal burn, singed nasal vibrisae, carbonacious sputum, and clinical signs of upper airway involvement. On admission, 84 patients (9.2%) had more than one of the previously mentioned factors. They were prophylactically intubated and placed on optimum level of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV). The mortality rate among patients without inhalation injury was 7.1%, while 54.7% of patients with inhalation injury died. Comparison of burn patients with inhalation injury to those without pulmonary involvement at the same age group and with the same percentage of burn showed significantly higher mortality rate in patients with inhalation injury. The main cause of death in the first 72 h postburn (stage 1) in patients without inhalation injury was peripheral shock (10.1%) and in patients with inhalation injury was peripheral shock (15.2%) and cardiac failure (10.8%). No pulmonary related death occurred in this stage. In 3-10 days postburn period (stage 2), burn wound sepsis (10.1%) and cardiac failure (11.8%) were the major causes of death in patients with inhalation injury. In patients with inhalation injury, pulmonary sepsis (26%) was the major cause of death in this stage. Major causes of death after 10 days postburn (stage 3) in patients without inhalation injury were pulmonary sepsis (20%) and burn wound sepsis (22%). In patients with inhalation injury, burn wound sepsis (21.7%) was the main cause of death. These data suggest that prophylactic intubation and CPAP therapy in burn patients with suspected inhalation injury prevent pulmonary related death in early stage of burn. Irrespective of presence of inhalation injury, sepsis originating from the wound or respiratory tract is the main cause of death in the late stage of burn.

Adolescent↗
PubMed2004

Ten year experience of burn, trauma, and combined burn/trauma injuries comparing outcomes.

BACKGROUND: Percent total body surface area (TBSA) burn, inhalation injury (INH), and age all have been shown to be independent predictors of mortality in burn victims. Little is known regarding patients sustaining combined thermal and mechanical injuries in relation to either injury sustained in isolation or with regard to these variables. This descriptive study profiles the 10-year experience of a single American Burn Association/American College of Surgeons verified Level I trauma and burn center and the treatment of this patient population. METHODS: A retrospective review of all burn and trauma patients admitted between 1990 and 2000. Patients were divided into three groups; Burn only (B), Trauma only (T), and combined Burn/Trauma (B/T). Groups were compared with respect to age, TBSA burn, length of stay (LOS), Injury Severity Score (ISS), INH and mortality. These groups were then compared with B, T and B/T patients from the National Burn Repository (NBR) and National Trauma Data Bank (NTDB). Student's t test and chi tests were performed, as well as multiple logistic regression to identify independent predictors of mortality. p <0.05 was considered significant. RESULTS: Through our trauma registry, 24,093 patients were identified (T=22,284, B=1717 and B/T=92). When comparing B and T, there was no difference in age, LOS, ISS, or mortality to those patients in the NBR or NTDB. B/T patients showed significantly increased percentage with INH (B/T=44.5% versus 11%), increased LOS (B/T=18 days versus 13.7 B and 5.3 T) and increased mortality (B/T=28.3% versus 9.8% B and 4.3% T). B/T were also significantly older (B/T=40.1 years versus 31.0 B and 35.1 T). When these variables are compared with the NBR and the NTDB benchmarks, mortality (28.3% versus 11.6% NBR and 7.0% NTDB) and ISS (23 versus 11.7 NTDB) were significantly higher with no difference in age (40.1 versus 33.4 NTDB, 35.9 NBR), LOS (18 days versus 23.3 NBR) or TBSA (20.8% versus 19.5% NBR). Multiple logistic regression comparing TBSA, age, ISS and INH of survivors versus non-survivors identified only ISS as an independent predictor of mortality. CONCLUSION: B combined with T presents a rare injury pattern that has a synergistic effect on mortality. Physicians and caregivers should be aware of a 2-3 fold increase in the incidence of INH in this population, and increased mortality despite similar TBSA burned when compared with patients with B as the sole mechanism; ISS appears to be an independent predictor of mortality in this combined injury pattern.

Adolescent↗
PubMed1991

Inhalation injuries and burns in the inner city.

Burns in the urban environment present special problems. Although there generally is ready access to appropriate care and short transport times, burn injury remains a serious concern. Inhalation injuries, electrical and chemical burns, and burns as a result of abuse or assault are common problems.

Burn Units↗
PubMed1989

Current concepts of inhalation injury in burn victims.

Twenty patients with bronchoscopic diagnosis of inhalation injury were reviewed. The history of a burn in a closed space was present in 90% of the patients in our study and evidence of orofacial burns in 100%. In four of these patients serum concentrations of human placental alkaline phosphatate (hPLAP) were determined. This protein can be detected in serum with hPLAP specific monoclonal antibody and increased serum levels of hPLAP are found when there is damage of pneumocyt I cells.

Adolescent↗
PubMed2006

Elevated cytokine levels in peritoneal fluid from burned patients with intra-abdominal hypertension and abdominal compartment syndrome.

BACKGROUND: Burn patients with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) undergo vigorous resuscitation and accumulate peritoneal fluid (PF) that is a plasma ultra-filtrate. This study compared antithrombin (AT) and cytokine levels in burn patient plasma and peritoneal fluid (PF). METHODS: Twenty-nine patients were studied: 22 developed IAH and 9 progressed to ACS. Burn + inhalation injury was present in 22 patients; 5 had burn only and 2 had inhalation only. Sixteen patients died: of these, 9 survived less than 48 h due to the severity of their injuries. Flow cytometry utilized the Cytometric Bead Array kit for Human Th1/Th2 cytokines. AT levels were determined by the Accucolor method spectrophotometrically. RESULTS: All cytokine levels were significantly elevated in burn plasma and PF compared to normal plasma, p < 0.001. AT plasma levels were decreased compared to normal. AT and cytokines were present in peritoneal fluid of burn patients with IAH and ACS. Patients who died had decreased plasma levels of AT and increased IFN-gamma, IL-10, IL-6, IL-4, IL-2 peritoneal fluid levels compared to survivors. CONCLUSIONS: Peritoneal fluid may be a reservoir for cytokines during initial resuscitation and contributes to homeostatic perturbations in burn patients.

Abdomen↗
PubMed2003

[Fluid management and cause of death during shock period in patients with severe burns or burns complicated by inhalation injury].

OBJECTIVE: To explore fluid management and cause of death during shock period in severe burns or burns with inhalation injury. METHODS: One hundred and twelve patients with severe burns or burn complicated by inhalation injury admitted to our hospital from 1991 to 2000 were analyzed. The fluid management and death conditions during shock period were discussed. RESULTS: The fluid volume for resuscitation could be described as follows: the total fluid volume was 2.2 ml/(%TBSA.kg) including colloid fluid 0.5 ml/(%TBSA.kg), crystalloid fluid 1 ml/(%TBSA.kg)and water 0.7 ml/(%TBSA.kg) during first 24 hours. The total fluid volume was 1.8 ml/(%TBSA.kg) including colloid fluid 0.4 ml/(%TBSA.kg), crystalloid fluid 0.7 ml/(%TBSA.kg) and water 0.7 ml/(%TBSA.kg) during second 24 hours. There were no difference in fluid management between burns and burns with inhalation injury. Seven patients died due to respiratory failure during shock period. CONCLUSIONS: Many fluid formula can provide guidance for resuscitation and it is very important that early fluid therapy should accord with concrete clinical conditions of patients in order to pass smoothly through shock period. Early fluid management is not different between burns and burns with inhalation injury.

Adolescent↗
PubMed1990

The role of inhalation injury in burn trauma. A Canadian experience.

From 1977 to 1987, 1705 thermally injured patients were admitted to the Firefighters' Burn Center at the University of Alberta Hospitals. Thirteen hundred forty-four were male (78.8%) and 361 were female (21.2%), with a mean total burn surface area (TBSA) of 15.1 (SEM +/- 0.4%) and a range of 1% to 99% TBSA. Sixteen hundred thirty-five patients survived to be discharged from hospital, with an overall survival rate of 95.9%. One hundred twenty-four burn patients (7.3%) suffered concomitant inhalation injury diagnosed by bronchoscopy. Patients with inhalation injury suffered from larger TBSA (39.7% +/- 2.8% versus 12.2% +/- 0.3%; p less than 0.01) than those without inhalation injury. Inhalation injury increased the number of deaths from burn injury (34.7% versus 1.7%; p less than 0.01) independent of age and TBSA. Inhalation injury was associated with a threefold prolongation of hospital stay (23.7 +/- 0.7 versus 74.4 +/- 6.2 days; p less than 0.01) and was independent of age and TBSA. Multifactorial probit analysis was performed for both inhalation- and noninhalation-injured burned patients to allow TBSA and age adjusted rates of mortality for the burn population presented. The maximum detrimental effects of inhalation injury in burn patient outcome occurred when it coexisted with moderate (15% to 29% TBSA) to large (30% to 69% TBSA) thermal injuries. These data demonstrate that inhalation injury is an important comorbid factor in burn injury that increases the number of deaths substantially. Most importantly such injuries also independently prolong the duration of hospitalization in a highly unpredictable fashion as compared to patients with cutaneous burns only. As such our data illustrate the extreme importance of inhalation injury as a comorbid factor following thermal injury and reveal the present limitations for accurate quantification of the magnitude of respiratory tract injury accompanying thermal trauma.

Adolescent↗
PubMedDate not supplied

Burn septicaemia in Kuwait: associated demographic and clinical factors.

OBJECTIVE: To study the demographic and clinical factors associated with burn septicaemia patients in Kuwait. MATERIALS AND METHODS: All burn in-patients, who developed septicaemia at the Burns Unit, Al-Babtain Centre for Burns and Plastic Surgery, Kuwait, during a 9-year period (June 1992 to May 2001) were included in the study. The data were recorded for age, sex, nationality, cause and percentage of burns, inhalation injury, resuscitation, number of episodes, septicaemia on post-burn day, the microorganisms responsible in each episode, treatment and outcome for statistical analysis. Using SPSS (PC version 11.0) software, a probability level of p < 0.05 was considered significant. RESULTS: Of the 2,082 patients treated in the Burns Unit, 166 [8%; 99 (60%) males and 67 (40%) females] with a mean age of 26 years (range 1-70) had septicaemia. Significantly higher (p < 0.001) cases were recorded among Kuwaiti children (< or =14 years) and non-Kuwaitis (25-59 years) than other corresponding age groups. The total body surface area burned ranged from 2 to 95% (mean 42%) and the main cause of burn was flame (77.1%). Inhalation injury was diagnosed in 39 (23.5%) patients. A total of 253 septicaemic episodes occurred in all patients. The majority, 123 (74.1%), had a single episode and the remaining 43 (25.6%) had multiple (2-10) episodes. One hundred and fifty-five (61.3%) episodes were due to gram-positive organisms, mainly methicillin-resistant Staphylococcus aureus, and 32 (12.7%) were polymicrobial. One hundred and twenty-four (74.7%) patients had wound excision and skin grafting procedures and their survival was significantly higher (OR = 4.3; 95% CI: 1.98-9.31) than non-surgically treated patients. Thirty-nine (23.5%) patients died mainly due to multi-organ failure. CONCLUSION: The findings indicate that the patients with extensive flame burns were prone to developing septicaemia due mainly to gram-positive bacteria. The surgical excision of eschar and wound covering improved the outcome of the patients while prophylactic antibiotic treatment had no role in the incidence and outcome of the burn patients.

Adolescent↗
PubMed2002

Fire and flame related events with multiple occupational injury fatalities in the United States, 1980-1995.

The National Traumatic Occupational Fatalities surveillance system recorded 1587 fire and flame related occupational fatalities among the civilian workforce in the United States between 1980 and 1995. Of these fatalities, 433 resulted from 127 incidents that involved two or more victims. For purposes of this study, these victims were categorized into one of three cause-of-death classifications: burns, inhalation or other traumatic injury. The classification 'Burns' accounted for 232 or just over one-half of the fatalities and an additional 172 cases were coded as inhalation. Other traumatic injury was named as the cause of death for another 23 fatalities or five percent of the multiple victims. The cause of death for the remaining six fatalities could not be determined from the death certificates. This study revealed the similarities and disparities of the demographic and employment characteristics associated with these three cause-of-death classifications.

Accidents, Occupational↗
PubMed2005

Prognostic significance of erythroblasts in burns.

Changes in hematopoiesis that occur in humans after a burn injury may have important effects on morbidity and mortality. In patients with a variety of severe diseases, the presence of erythroblasts in peripheral blood is known to be indicative of a poor prognosis. However, the prognostic significance of erythroblasts in peripheral blood of burn patients has not yet been estimated. This study included 464 consecutive burn patients, of whom 81 did not survive their injuries (17.5 percent). Together with erythroblasts in blood, data on age, sex, total burn surface area, third-degree burn, inhalation trauma, white blood cell count, C-reactive protein, and hemoglobin were studied. The mortality rate of patients with erythroblasts in peripheral blood (n = 53) amounted to 56.6 percent (n = 30; total burn surface area, 39 percent), which is significantly higher (p < 0.001) than the mortality rate of patients without erythroblasts (12.4 percent, n = 51; total burn surface area, 18.69 percent). None of the 10 patients with more than 1000 erythroblasts x 10/liter survived. The detection of erythroblasts in the peripheral blood of burn patients is highly predictive of death, with the odds ratio after adjustment for the other known prognostic factors being 8.3 (95 percent confidence interval, 4.5 to 15.3). Erythroblasts were detected for the first time on average 10 +/- 4 days (median, 6 days) after admission and 13 +/- 6 days (median, 7 days) before death. Detection of erythroblasts in burn patients is of high prognostic power with regard to in-hospital mortality, providing physicians with a strong prognostic method with which to identify seriously threatened patients. It seems attractive to think about an incorporation of erythroblasts into further refinements of burn scores.

Adult↗
PubMed1987

Extravascular lung water changes following smoke inhalation and massive burn injury.

During a 3-year period (1984 through 1987), 40 patients with smoke inhalation, cutaneous burns, or a combination of both injuries were studied. Injuries were assigned to the three categories on the basis of bronchoscopic findings and clinical history. Eleven patients had simultaneously sustained a common smoke-inhalation injury without burns while trapped in a burning ship; twelve patients had massive cutaneous burns over 50% of the total body surface area (TBSA); and seventeen patients had cutaneous burns over more than 30% of the TBSA and inhalation injury. Colloid oncotic pressure was maintained with salt-poor albumin infusion. Central venous pressure, arterial saturation, inspired oxygen, arterial pressure, and urine output were continuously monitored. Extravascular lung water (EVLW) and cardiac output were measured by the double indicator (thermal dye dilution) technique. EVLW remained normal throughout the study period in the group of patients with burns alone. In the first 24 hours after injury, EVLW increased in both groups with smoke injury and remained elevated for more than 48 hours after injury in patients with smoke injury only. The group with both smoke-inhalation and burn injuries showed an early increase in EVLW, which returned to normal by 28 hours after injury and which remained normal until 5 days after injury. The EVLW level then increased again until the end of the study period. In this study, lung edema formation is attributed to the toxic effect of smoke inhalation.

Adolescent↗
PubMedDate not supplied

Long-term management of extensive tracheal stenosis due to formic acid chemical burn.

We report on a 26-year-old woman who during early infancy (6 months) suffered from a chemical burn of the skin and upper airways due to spill of formic acid powder. Twenty years after the initial injury, she presented with dyspnea and stridor due to severe tracheal stenosis. Several interventional bronchoscopic manipulations were initiated: incision of the stenotic lesion with Nd:YAG laser and dilatation with a valvuloplasty balloon which enabled silicone stent placement which was subsequently kept in place for 3 years. Complications during the 4th year after stenting led to the successful replacement of this stent by two autoexpandable metallic stents covering the total length of the trachea from the subglottic area to the carina. In post-burn inhalation injuries, a complex inflammatory process may be active for many years after the initial insult. These injuries respond to prolonged tracheal stenting and a conservative approach is recommended.

Adult↗
PubMed2003

Mortality rates among 5321 patients with burns admitted to a burn unit in China: 1980-1998.

A retrospective study was conducted on 5321 burn patients hospitalized in a burn center in Jinzhou, China during the period 1980-1998. Of the 5321 patients, 57.8% were between 15 and 44 years old and 3.4% were > or =60 years old. Ninety-six percent had burns covering less than half of body surface area and 31.7% had only full thickness skin burn. The number of patients in the 1990s was three times that of the 1980s. Overall mortality rate was 0.86%. LA(50) for total body burn area (TBSA) and only full thickness skin burn (FTSB) was 94 and 87%, respectively. The high survival rate, may relate primarily to the low percentages of older patients and of patients with severe burns. Inhalation injuries, infection and MOD are the main causes of deaths in our patients and would be key targets to improve clinical care and in future study.

Adolescent↗
PubMed1994

The admission chest radiograph after acute inhalation injury and burns.

The admission chest radiographs of 29 patients admitted with acute inhalation injury and burns, who required ventilatory support, were analysed for signs of inhalation injury. Four were excluded because of a history of chronic bronchitis or cardiac failure. 13 had radiological signs of inhalation injury, which included oedema of a nodular, consolidatory and interstitial pattern, and linear opacities due to atelectasis. 12 chest radiographs were normal. Inhalation injury in burns cases often requires clinical, bronchoscopic and blood gas assessment. Although changes were noted on 13/25 chest radiographs, the admission chest radiograph is an insensitive indicator of airway and parenchymal lung damage following acute inhalation injury and burns. We draw attention to the fact that significant lung damage may be present even with a normal initial chest radiograph.

Adolescent↗
PubMed1998

Bronchoscopy and laryngoscopy findings as indications for tracheotomy in the burned child.

OBJECTIVE: To determine possible indications for tracheotomy in the burned child based on bronchoscopic and laryngoscopic findings. DESIGN AND SETTING: A retrospective case study of all patients admitted to a tertiary children's burn center. PARTICIPANTS: All children admitted with burn inhalation injury between 1990 and 1995 (n = 211). INTERVENTION: All patients underwent laryngoscopy and bronchoscopy and 19 underwent tracheotomy, with 5 tracheotomy tubes placed emergently. MAIN OUTCOME MEASURES: Observations during laryngoscopy and bronchoscopy included erythema, edema, carbonaceous material, ulcerations, and bronchial mucous casts. The supraglottis, glottis, and subglottis were analyzed separately, when possible. Any sepsis resulting from tracheotomy was determined. Complications, such as glottic webs, subglottic stenosis, and tracheomalacia, were noted. RESULTS: Indications for tracheotomy included 6 for airway obstruction, 6 for prolonged intubation, 6 for pulmonary cleansing, and 1 for endotracheal tube complications (subglottic stenosis). When examined by bronchoscopy and laryngoscopy, 17 of 19 children had significant airway edema, 10 had carbonaceous material in the airway, and 3 had ulcerations in the airway. CONCLUSIONS: Tracheotomy is indicated in the burned child when significant airway edema is present. Failure to place a tracheotomy tube in these cases leads to a high incidence of immediate tracheotomies (26%). There was no evidence of clinically significant infection attributable to tracheotomy. The number of airway complications due to tracheotomy was no higher than from endotracheal intubation.

Airway Obstruction↗
PubMed2002

Septicaemia after burn injury: a comparative study.

Seventy-nine (8.4%) patients during June 1992-May 1996 (Group-1) and 68 (7.2%) patients from June 1996 to May 2000 (Group-2) who developed septicaemia at the burns unit of Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, were retrospectively studied and compared. The mean age of 26 years, male predominance, flame burns as main aetiology and mean burn percentage of >or=40% was observed in both the groups. Both groups revealed extensive flame burn, inhalation injury, intubation and difficult resuscitation as the risk factors. The proportion of satisfactory resuscitation increased significantly (P<0.001) in Group-2. The septicaemia commonly occurred within 2 weeks postburn but the number of episodes during 5 days postburn was less in Group-2. The surface wound was found to be the likely source of entry of the organisms into the blood stream in both the groups. The gram positive organisms were dominant aetiologic factor in both groups but an increase frequency of Acnetobacter was found in Group-2. The proportion of MRSE and Pseudomonas septicaemia was significantly higher (P<0.01) in the Group-1. The rate of survivors, in both the groups was higher among operated patients but it was significantly higher (P<0.001) in the Group-1. A mortality rate 20.6% in Group-2 decreased against Group-1, which can be attributed to better resuscitation, nutritional care, early detection of septicaemia, appropriate antibiotics and early wound excision and skin grafting. MOF was the cause of death of 60.9% in Group-1 and 85.7% in Group-2. There was no role of prophylactic antibiotic in burn patients in the incidence of septicaemia and mortality.

Acinetobacter Infections↗
PubMed2004

Pathophysiology of acute lung injury in combined burn and smoke inhalation injury.

In the U.S.A., more than 1 million burn injuries occur every year. Although the survival from burn injury has increased in recent years with the development of effective fluid resuscitation management and early surgical excision of burned tissue, the mortality of burn injury is still high. In these fire victims, progressive pulmonary failure and cardiovascular dysfunction are important determinants of morbidity and mortality. The morbidity and mortality increases when burn injury is associated with smoke inhalation. In the present review, we will describe the pathophysiological aspects of acute lung injury induced by combined burn and smoke inhalation and examine various therapeutic approaches.

Acute Disease↗