Evaluating Discrepancies in Percent Total Body Surface Area Burn Assessments Between Prehospital Providers and Burn Center Physicians. Tran DP, Arnold DH, Thompson CM, Richmond NJ, Gondek S, Kidd RS. J Burn Care Res. 2022 Jan 5;43(1):225-231.
Adequate and accurate prehospital evaluation and assessment is extremely important in patients with traumatic injuries. This is especially important in burns, as burn resuscitation should be started quickly and is largely dependent on the depth and size of burn, as measured by percent burned of total body surface area (TBSA). These are particularly challenging, as burn injuries may not commonly be encountered by some prehospital providers to allow for consistently accurate and reliable assessments. This study evaluated the degree of discrepancy in burn size assessment between burn physicians at an American Burn Association (ABA) verified regional burn center and the prehospital providers of their local 911 EMS system. A retrospective chart review over a 3-year period identified 1,340 patients that were evaluated in the ED by the burn team, with 147 (11%) being transferred from the scene by the local 911 EMS providers. Median burn size as estimated by prehospital providers was 8.6% (median 4%), while median burn size as measured by the burn physicians was 5.9% (median 2%). In addition, prehospital providers estimated 9% of patients to be larger than 20% TBSA, while burn physicians were 5%. In addition, as TBSA got larger (>10% TBSA), the degree of discrepancy increased as well.
This study highlights the challenges of appropriate assessment and triage of burn patients. First, burns are less common that most other types of trauma but require a specialized knowledge base. Advanced Trauma Life Support (ATLS) training is accessible to many EMS agencies due to regionality of trauma centers, Advanced Burn Life Support (ABLS) may not be as readily accessible, as burn centers are much fewer in number and may not be able to provide this training. ABLS provides didactic, as well as hands-on experience in assessing burn patients, and is available in an online feature as well. Increased promotion and use of this course may help to improve prehospital providers’ abilities with assessment of these cases. In addition, traditional tools to assess burn depth in the field has largely been through the use of the Rule of Nines or the palmar method. Recently, newer mobile applications, such as the Burn Area app, have become available that allow for more reliable measurements based on three dimensional assessments based on sex and body habitus. Finally, these discrepancies exist between burn providers and the EMS system that they most commonly interact with—it would be reasonable to suspect that this group is actually a high outlier in terms of reliability. It would be reasonable to suspect that providers in referring hospitals see burn patients less often and would be prone to overestimate burn size. Telemedicine remains an underutilized strategy to mitigate unnecessary transfers.
Inpatient and Postdischarge Outcomes Following Inhalation Injury Among Critically Injured Burn Patients. Witt CE, Stewart BT, Rivara FP, Mandell SP, Gibran NS, Pham TN, Arbabi S. J Burn Care Res. 2021 Nov 24;42(6):1168-1175.
Burn patients with inhalation injury are at a statistically higher risk of death than those without, even controlling for the size of the burn itself, as patients with inhalation injury tend to have larger burns as well. In addition, studies have shown increased rate of pneumonia and longer lengths of stay in the intensive care unit and hospital, but there have been little studies to evaluate these patients through the post-discharge period. This retrospective study examined all burn patients admitted to the intensive care unit of an ABA verified regional burn center over a six year period. Patients who did not have cutaneous burns or were admitted more than 48 hours after their injury were excluded. In all, 830 patients were evaluated for in-hospital outcomes. Two hundred one (24%) had inhalation injury. Using multivariable regression, burn patients with inhalation injury had adjusted risk ratios of 2.3 for mortality, 1.8 for pneumonia, and 2.3 for requiring tracheostomy. When analyzing patients who underwent bronchoscopy and grading of inhalation injury with those without inhalation, those with inhalation injury had similar risk ratios. Of note, higher grades of inhalation injury on bronchoscopy were not predictive of inpatient mortality. When examining cumulative mortality (which includes both in-hospital and post-discharge deaths through the end of the study period), they were only able to evaluate 602 patients, with 144 (24%) having inhalation injury. Cumulative mortality was 35% for those with inhalation, while those without had a mortality rate of 20%, for a risk ratio of 1.8. Post-discharge mortality, readmissions, readmission for pulmonary diagnosis, or readmission requiring mechanical ventilation were not statistically significant between the two.
This study highlights two main points regarding inhalation injury. The first is that inhalation injury is a significant risk factor for both pulmonary morbidities and mortality in burn patients and should be taken into account when treating burn patients. Use of the modified Baux score (age + TBSA + 17 when inhalation present) is a useful tool to estimate mortality and identify futility. Secondly, bronchoscopic findings of inhalation may be of low yield, as they offer little in the way of prognostic value in differentiating severity of inhalation. For example, in this study, those with grade 1 inhalation injury (the most minor) on bronchoscopy had a higher mortality rate than those with grade 2 and nearly the same as those with grade 3 or 4 (the most severe).
Evaluating the Efficacy, Safety, and Tolerance of Silver Sulfadiazine Dressings Once Daily Versus Twice Daily in the Treatment of Burn Wounds. Lagziel T, Asif M, Born L, Quiroga LH, Duraes E, Slavin B, Shetty P, Caffrey J, Hultman CS. J Burn Care Res. 2021 Nov 24;42(6):1136-1139.
The goal of topical antimicrobials in the treatment of burn wounds remains to promote and facilitate healing of the wound while minimizing complications. The ideal topical antimicrobial has yet to be discovered. Topical silver sulfadiazine (SSD) is an effective topical antimicrobial agent widely used in the treatment of burn wounds. It is often the initial modality of topical therapy for burn patients both prior to and after reaching a definitive care facility. Variability in its frequency of SSD application exists throughout burn care avenues even though the medication’s FDA approval cites twice-daily application. This group out of the Johns Hopkins Burn Center underwent a practice algorithm change in 2019 in shifting from twice-daily wound care and dressing changes to once-daily wound care and dressing changes throughout their burn center. By changing from twice-daily to a once-daily application of antimicrobial therapy and performance of wound care for inpatient burn patients, one would in theory decrease cost to the facility as well as decrease pain to the patient and burden on nursing and providers while maintaining safety, morbidity, mortality. This study sought to evaluate whether a once-daily or twice-daily application of the topical SSD antimicrobial impacted burn wound healing outcomes. To determine these outcomes, they performed a noninferiority analysis which indicated that 75 patient sample size would sufficiently allow statistical endpoints to be reached. Primary outcomes examined included wound infection, average pain scores, average daily narcotic requirements, and length-of-stay. 75 pre-change patients and 75 post-change patients were randomly selected for analysis across all adult inpatients at the center and no demographic discrepancies between the two groups were noted. Mean %TBSA was 11.81% pre-change and 9.49% post-change. Need for surgical intervention in both groups was 50%. Rates of pre-and post-change wound infection were equal at 5.33%. Hospital complications (VAP, CAUTI, CLABSI, HAPI) were significantly higher in the pre-change group (10.67% vs 6.67%, P = 0.04). Average usage of SSD per day was significantly higher in the pre-change group (320g/day vs 202g/day; P=0.015). Non-significantly lower pain levels were examined between the groups but significant reduction in narcotic usage was noted in the once-daily dressing change group (6.81 vs 6.38; P=0.04). Average LOS was also higher in the pre-change group (11.97 days vs 10.31 days; P=0.018).
This study serves as early evidence that outcomes were non-inferior with a practice change to once-daily application of SSD. This practice seemed sufficient to maintain positive outcomes while limiting complications and even (non-wound related) reduced hospital complications, reducing costs, and decreasing narcotic usage required for wound care and dressing changes at a regional burn center. One would surmise that this practice would also decrease strain on nurse and provider staffing, however this was not specifically addressed by the study’s data. With these initial promising results additional investigation on a larger scale with multiple centers participating is necessary prior to broad application in the burn injured population.
Impact of Opioid-Minimizing Pain Protocols After Burn Injury. Donthula D, Conner CR, Truong VTT, Green C, Jiang C, Wandling MW, Komak S, Huzar TF, Adams SD, Freet DJ, Wainwright DJ, Wade CE, Kao LS, Harvin JA. J Burn Care Res. 2021 Nov 24;42(6):1146-1151.
While historically relying heavily on narcotic analgesia the optimal management of burn injured patients includes a multi-modal approach. There continues to be variability across the burn care spectrum in the ideal combination of opioids and opioid-sparing pathways in the patient population. Reduced opioid exposure while inpatient may translate to less opioid dependence and therefore abuse after clinical encounters. The group at the University of Texas Health Science Center at Houston’s Burn Center sought to examine the impact of application of an opioid-minimizing pain protocol with protocolized sedation for complex dressing changes. This protocol existed at the institution’s trauma center with initial published result of 31% in reduction of inpatient opioid exposure. The existing protocol was adapted and applied to the burn center. A retrospective cohort study was performed with identification of pre-and post-implementation cohorts of patients throughout the study period. The burn registry and the electronic medical record were used for analysis. Primary outcome was total morphine milligram equivalents (MMEs) with secondary outcomes of MMEs/day, pain domain specific MMEs, and pain scores. Significantly more patients were analyzed in the pre-group versus the post-group (n=495 vs n=174) but demographics and burn characteristics (including surgical requirement) were similar between the groups. The authors note that prior to implementation of this protocol there was wide variation throughout the burn center with treatment using opioid and nonopioid medications. This protocol necessitated utilization of scheduled acetaminophen, gabapentin, and naproxen with as-needed oxycodone in addition to sub dissociative ketamine infusions, scheduled opioids, dronabinol, hydroxyzine, and amitriptyline. Large/complex dressing changes were treated with a procedural pain protocol which included ketamine, propofol, and dexmedetomidine for minimal to moderate sedation. Results indicated that more moderate sedation was administered post-implementation, as one would predict. Significant reduction in opioid exposure in the post-group as measured by total MMEs (230 vs 110; P=0.001) and MMEs/day (52 vs 33; P=-.001) in addition to reduction in background, breakthrough, and procedural MMEs use was noted. There were no significant differences in NRS, BPAS, or average normalized pain scores between the groups. Post-implementation group had lower risk of being prescribed opioids at discharge. No differences in discharge disposition or mortality were observed. ICU length of stay and ventilator days were unchanged but there was reduction in hospital length of stay in the post-group (RR 0.61, 95% CrI).
While differences in the study groups existed and variability was significant in treatment algorithms between the groups this preliminary data implies that implementation of a standardized and heavily opioid-sparing protocol led to significant inpatient opioid exposure reduction and reduced opioid prescribing at discharge without significantly changed inpatient pain scores. Shorter length of stay was an unanticipated finding that may be related to confounding factors across protocol implementation. This may have affected the primary outcome of opioid use but MMEs/day and MMEs across three specific and unique domains were also found to be clinically and statistically significantly lower, indicating that the protocol may have been directly responsible for reduced opioid exposure. This study supports an aggressive multi-modal opioid-sparing approach to the care of acute burn patients to decrease narcotic exposure while inpatient, decrease narcotic prescribing on discharge, and optimize pain control while positively impacting outcomes.