August 2020 - Burn Trauma

August 2020
EAST Monthly Literature Review

"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee

This issue was prepared by EAST Burn Surgery Committee Members Caleb Butts, MD and Mack Drake, DO, FACS.

Thank you to Haemonetics for supporting the EAST Monthly Literature Review.

In This Issue: Burn Trauma

Scroll down to see summaries of these articles

Article 1 reviewed by Caleb Butts, MD
Pictures Do Influence the Decision to Transfer: Outcomes of a Telemedicine Program Serving an Eight-State Rural Population. Garber RN, Garcia E, Goodwin CW, Deeter LA. J Burn Care Res.  2020 May 2; 41(3): 690-694. 

Article 2 reviewed by Caleb Butts, MD
Releasing Burn Induced Compartment Syndrome (Bics) by Enzymatic Escharotomy-Debridement: A Case Series.  Mataro I, Lanza A, Di Franco S, Di Franco L, Sangiuolo M, Notaro M, d’Alessio R, Villani R.  J Burn Care Res.  2020 Mar 31; iraa055.

Article 3 reviewed by Mack Drake, DO, FACS
Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns. Freno D, Sahawneh J, Harrison S, et al. Burns. 2018;44(3):539-543.

Article 4 reviewed by Mack Drake, DO, FACS
Patients With Combined Thermal and Intraabdominal Injuries: More Salvageable Than Not. Chang J, Hejna E, Fu CY, et al. J Burn Care Res. 2020;41(4):835-840.

Article 1
Pictures Do Influence the Decision to Transfer: Outcomes of a Telemedicine Program Serving an Eight-State Rural Population. Garber RN, Garcia E, Goodwin CW, Deeter LA. J Burn Care Res.  2020 May 2; 41(3): 690-694.

One of the more difficult decisions faced when on-call is resource allocation.  In addition to caring for the individual patient, trauma surgeons must provide care to the traumatically injured across a region.  Accepting an inappropriate transfer now may deny a more severely injured patient care at the trauma center later.  The American Burn Association criteria for evaluation at a burn center are fairly broad, and the presence of one of these criteria may or may not necessitate immediate transfer (as opposed to outpatient referral and management).  Additionally, burn care is not a required part of surgical training, much less training for emergency medicine physicians or other physicians and advanced practice providers who staff emergency departments.  Further there are a very limited number of burn centers, and they are widely distributed, so the nearest burn center may be many hours away.  Transport to a burn center is also unique to each referring institution, and unwarranted transports are costly both in terms of economic impact, as well as opportunity cost, as many locations may have limited access to transport.  Based on these myriad of factors, even marginal improvements of appropriate triage can have a large impact on our improving trauma systems.
This study seeks to answer one aspect of this question—can HIPAA-compliant photographs impact our decision-making process when deciding to accept a burned patient in transfer?  This study was a prospective single-institution case series where the institution implemented HIPAA-compliant image-sharing from their referral centers as part of their initial consultation.  The burn physicians took the referral call from the referring institution and made a preliminary determination plan of care (outpatient vs. transfer).  Next, the images were sent and reviewed by the burn provider, who was able to review them with referring provider and make a final plan of care determination.  When the plan of care changed after review of the images, the results were recorded as an up-triage or down-triage.
Over a 20 month period, 155 patients were enrolled in this study.  Thirty-eight patients (24.5%) had a change in their plan of care as a result of the image review.  Of these 38 patients, 23 were down-triage to outpatient management, while 15 up-triaged for a transfer.  This results in a net of 8 fewer patients transferred.  The authors also evaluated for any association between types of referring providers (physician vs. APP) with changes in management, and found no difference.  The study did not include outcome data, such as ultimate admission status, time to healing, patient satisfaction, or referring provider satisfaction.
In summary, this paper shows one institution’s attempt at improving triage of burned patients.  The major limitation is a lack of outcomes data.  While the paper shows that the images changed the burn physician’s management plan, it does not show that review of images led to more accurate triage (i.e. whether patients that were managed outpatient required subsequent admission or patients that were transferred were able to be discharged within 24h).  Future studies should evaluate for improved triage in terms of outcomes beyond the initial decision to transfer, as improved triage allows for better care to be delivered across a trauma system.

Article 2
Releasing Burn Induced Compartment Syndrome (Bics) by Enzymatic Escharotomy-Debridement: A Case Series.  Mataro I, Lanza A, Di Franco S, Di Franco L, Sangiuolo M, Notaro M, d’Alessio R, Villani R.  J Burn Care Res.  2020 Mar 31; iraa055.

Circumferential burns are a very common cause for transfer to burn centers.  The risk of burn-induced compartment syndrome (BICS) is a very serious concern, as timely diagnosis and treatment is imperative.  The longstanding treatment of choice has been surgical escharotomy.  While this is a straightforward procedure in well-trained hands, surgical escharotomy is associated with early and delayed complications, including bleeding, pain, inadequate decompression, and damage to underlying structures.  Burn surgery is not a core part of surgical training nationally and access to burn surgeons may be limited in some parts of the country.  Bromelain-based enzymatic debridement, under the trade name of Nexobrid (NXB) has shown promise through early escharectomy in burned patients outside the US.  Some studies have shown decreased rates of escharotomies in patients treated with NXB as a secondary outcome. In the study presented, the authors treated patients at high risk of BICS with NXB to evaluate for the need for surgical escharotomy.
This is a prospective case series over a 12 months period of admitted patients with deep circumferential hand burns and total TBSA<30%.  Patients with clinical symptoms of BICS, impaired perfusion (SaO2 < 95%), or pulse extremity were excluded and underwent immediate surgical escharotomy.  Within 24 hours of injury, the patients’ wounds were cleaned with antiseptic agent, a compartment pressure measuring needle was placed, and NXB was applied under conscious sedation.  Compartment pressures were recorded prior to NXB application and at 1, 2, and 4 hours after NXB application.  If the pressure monitors showed increased pressure despite 2h of treatment, the dressings were removed and rescue surgical escharotomy was performed.
In total, 23 patients with 41 burned hands were evaluated.  The patients underwent NXB treatment at an average of 10.8h post-injury (range 2-22h).  The average compartment pressure was 33.6 mm Hg (range 28-42) prior to therapy, with a reduction to an average of 26.0 mm Hg (range 17-37) at 1h, 17.3 mm Hg (13-26) at 2h, and 13.6 mm Hg (11-16) at 4h.  None of the patients necessitated rescue surgical escharotomy.  Further, no adverse reactions or complications were noted (i.e. allergic reaction, signs or symptoms of bleeding).

The authors in this paper do an excellent job of describing their use of NXB and demonstrating its effectiveness of decreasing compartment pressures in hand burns.  With its approval in Europe, bromelain-based enzymatic debridement may play a larger role in treatment of burns in the United States in the coming years.  This study does a good job of using a quantitative means to measure patients at risk of BICS, and measuring its change through therapy.  This decrease in compartment pressures is consistent with the decrease found in surgical escharotomy.  The widespread use of NXB may decrease the need for surgical escharotomies; however, future studies should evaluate the role NXB in preventing the needs for escharotomies in burns beyond those of the hand.

Article 3
Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns. Freno D, Sahawneh J, Harrison S, et al. Burns. 2018;44(3):539-543.

Upper airway injury carries high morbidity and mortality when not addressed expeditiously in patients with facial burns. Aside from the classic signs of smoke inhalation and supraglottic injury the need for early intubation is not well characterized in the literature. Nasolaryngoscopy has been employed at some centers to assess for need for definitive airway securement early in the course of a patient prior to onset of edema. This information may be particularly useful when long transport to the nearest burn center is required. Concern must also be had surrounding complications associated with emergent endotracheal intubation and unnecessary intubation. The stated objective of this study was to determine if nasolaryngoscopy provides additional information in making the decision to electively intubate patients with facial burns.
This study was a retrospective single-institution review examining awake patients who received fiberoptic nasolaryngoscopy for evaluation of upper airway burn injury at a regional burn center over a two-year period. Patients intubated prior to arrival or who were intubated for reasons other than burn injury were excluded. Patients were separated into symptomatic and asymptomatic groups for analysis.  These groups were then subdivided based on results of nasolaryngoscopy followed by further analysis. Findings on fiberoptic examination associated with airway injury included: erythema, edema, and presence of carbonaceous debris.
210 patients met inclusion criteria. 69 patients were admitted to the floor and 141 to an ICU. Demographic collection yielded an average age of 41 which was predominantly (81%) male. Mean length of stay was 4 days. Median TBSA was 5%.  22 patients (10%) were classified as symptomatic for airway injury prior to fiberoptic nasolaryngoscopy. Looking at both subgroups, 73 patients (35%) had findings consistent with airway injury on nasolaryngoscopy (defined by erythema > edema > carbonaceous debris) regardless of symptoms on presentation of which 10 patients (5%) required intubation. Of 188 patients who were initially asymptomatic 58 (31%) of those had evidence of airway injury on nasolaryngoscopy. Of the subgroup of patients who were asymptomatic but had fiberoptic evidence of airway injury only 2 (3%) patients required intubation and both of those patients were extubated after two days.
In summary, this retrospective review of patients at a single center suggests a high false positive rate (97%) for fiberoptic nasolaryngoscopy in asymptomatic patients who trigger concern for thermal burns to the upper airways. In symptomatic patients who underwent nasolaryngoscopy, less than half of that subgroup required intubation (47%). These findings may be impacted by the subjectivity of airway injury severity assessment and documentation amongst providers. Though unnecessary intubation may be avoided with the presence of a negative nasolaryngoscopy, the absence of injury does not necessarily negate the need for endotracheal intubation. This underscores that in patients at risk for upper airway thermal injury fiberoptic nasolaryngoscopy is not the lone factor driving need for endotracheal intubation. Patients who are asymptomatic do not appear to benefit from fiberoptic nasolaryngoscopy. For moderately/mildly symptomatic patients fiberoptic nasolaryngoscopy may help influence the decision to endotracheally intubate or not prior to definitive care. 

Article 4
Patients With Combined Thermal and Intraabdominal Injuries: More Salvageable Than Not. Chang J, Hejna E, Fu CY, et al. J Burn Care Res. 2020;41(4):835-840.

Though combined thermal burn and traumatic injuries are more common in wartime combat scenarios than civilian, they carry a significantly morbidity and mortality when encountered. Explosions, motor vehicle collisions, electrical injuries, and domestic abuse are common etiologies. Intra-abdominal traumatic injury combined with thermal injury is cited as having a 4% to 24% prevalence in the literature but is poorly studied. This study group sought to better characterize risk factors, management, and outcomes of patients who sustain intra-abdominal traumatic injury combined with thermal burn injury.
A retrospective cohort review of the National Trauma Databank (NTDB) was performed from 2011 to 2015. Patients sustaining thermal burns as well as traumatic injuries were included. Total body surface area of burns is not included in NTDB data therefore External AIS was used as a surrogate. Demographic characteristics, acute complications, and outcomes were examined. 334 patients with combined thermal and intra-abdominal trauma met inclusion criteria of which 39 patients underwent abdominal surgical procedures. The abdominal surgical procedure vs non-operative groups had no significant differences in age nor gender. Patients undergoing abdominal surgical procedures were more severely injured, more likely to require blood transfusion (53.8% vs 4.4%, P<0.001), more likely to suffer complications (69.2% vs 26.8%, P<0.001), had higher hospital LOS, ICU LOS, more ventilator days, and exhibited higher rates of mortality (33% vs 5.8%, P< 0.001). With relatively similar demographics amongst survivors and non-survivors, 33.3% of non-survivors received blood transfusion compared to 7.9% of survivors (P<0.001) and 43.3% of non-survivors received abdominal surgical procedure compared to 8.6% of survivors (P<0.001). To evaluate independent risk factors for mortality in these thermally burned and traumatically injured patients, multivariate logistic regression was performed. Of examined variables only shock index (SI), AIS for burn, ISS, need for abdominal surgical procedure, and blood transfusion were associated with increased mortality. To evaluate the direct effect of thermal burn injury on examined variables a propensity matched group of non-burned trauma patients who underwent abdominal surgery for trauma during the same time period from the NTDB was analyzed. No mortality difference was seen as result of thermal burn injury itself but complications in the burn + abdominal trauma group were significantly higher (69.2%) versus those without burns (38.5%) (P=0.012). Noted complications included severe sepsis, deep surgical site infection, acute kidney injury, acute lung injury, and other unspecified complications. 

This review of patients from the NTDB addresses the stigmata of increased morbidity and mortality with combined burn injury and abdominal trauma in addition to highlighting some of the complexities in their management. Overall, patients who had thermal burns and required abdominal surgical procedure for associated traumatic injury arrived more ill (higher SI, AIS for burn, and ISS) and had worse outcomes measured by blood transfusion requirement, mortality, complications, ventilator days, and length of stay when compared to patients who did not require surgical intervention for abdominal trauma. Though no survival benefit was found with higher initial blood pressure reading, higher shock index was associated with mortality. GCS, SI, AIS for burn, ISS, abdominal surgical procedure, and blood transfusions were independent risk factors for mortality in thermally burned and abdominal traumatically injured patients. In the propensity score matched group from the NTDB of patients with abdominal trauma requiring operation without burn injury, burn injury was associated with increased risk of complications but not risk of mortality. Therefore, this leads the authors to conclude that patients with abdominal trauma and concomitant burn injury are not more likely to die because of the thermal injury itself but are more likely to require expectant management of complications thus subsequently requiring specialized multidisciplinary care.

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 This Literature Review is being brought to you by the EAST Manuscript and Literature Review Committee. Have a suggestion for a review or an additional comment on articles reviewed? Please email litreview@east.orgPrevious issues available on the EAST website.