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The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries.The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome.There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned20% (odds ratio (OR) 2.79, P 0.001) and burn of the lower limbs (OR 1.37, P 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001).This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.

Introduction In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents Methods Over a 3-year period, all FRSTs were surveyed at one civilian center. Results Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P Conclusions This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.

A significant proportion of readmissions occurs at a different hospital than the index admission, and is thus missed by current quality metrics. No study has examined all-hospital adult 30-day readmission rates, including different hospitals, following burn injury across the United States. The purpose of this study was to evaluate nationwide readmission rates, potential risk factors, and ultimately the burden of burn injury readmission, including readmission to a different hospital. The 2010-2014 Nationwide Readmissions Database was queried for patients admitted for burn. Multivariate logistic regression identified risk factors and associated cost for 30-day readmission at index and different hospitals. There were 94,759 patients admitted during the study period, with 7.4% (n = 7000) readmitted and of those, 29.2% (n = 2047) readmitted to a different hospital. The most common reason for readmission was infection (29.4% [n = 1990]). Risk factors for unplanned 30-day readmission to any hospital included burn of lower limbs (odds ratio [OR] 1.29, [1.21-1.37], P < .01), third degree burns (OR 1.31, [1.22-1.41], P < .01), Charlson Comorbidity Index ≥2 (OR 1.48, [1.37-1.60], P < .01), depression (OR 1.30, [1.19-1.41], P < .01), and psychoses (OR 1.53, [1.40-1.67], P < .01). Risk factors unique to readmission to a different hospital included: length of stay greater than 7 days (OR 2.07, [1.78-2.40], P < 0.01), and initial admission to a metropolitan teaching hospital (OR 1.50, [1.26-1.78], P < .01). Previously unreported, one in three burn readmissions nationally occur at a different hospital, have unique risk factors, and are costlier. Current hospital benchmarking underestimates readmission by failing to capture this unique subpopulation.

Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.

Whole body vibration (WBV) has been shown to improve strength in extremities with healed burn wounds. We hypothesize that WBV reduces pain during rehabilitation compared to standard therapy alone. Patients with ≥1% TBSA burn to one or more extremities from October 2014 to December 2015 were randomized to vibration (VIBE) or control. Each burned extremity was tested separately within the assigned group. Patients underwent one to three therapy sessions (S1, S2, S3) consisting of five upper and/or lower extremity exercises with or without WBV. Pain was assessed pre-, mid-, and postsession on a scale of 1 to 10. Mean pain scores at S1 to S3 were compared between groups with paired samples t-tests. An independent t-test was used to compare differences in pain scores between groups. Continuous variables were compared using a t-test or Mann-Whitney U test, and categorical variables were compared using a χ or Fisher's exact test, as appropriate. Forty-eight randomized test extremities (VIBE = 26, control = 22) were analyzed from a total of 31 subjects. There were no significant differences between groups in age, gender, overall TBSA, TBSA in the test extremity, pain medication use before therapy session, or skin grafting before therapy session. At S1, S2, and S3, there was a statistically significant decrease in mid- and postsession pain compared to presession pain in VIBE vs controls. Exposure to WBV decreased pain during and after physical therapy. This modality may be applicable to a variety of soft tissue injuries and warrants additional investigation.

Florida considers the International Classification Injury Severity Score (ICISS) from hospital discharges within a geographic region in the apportionment of trauma centers (TCs). Patients with an ICISS0.85 are considered to require triage to a TC, yet many are triaged to an emergency department (ED). We assess outcomes of those with an ICISS0.85 by the actual triage decision of emergency medical services (EMS). From October 2011 to October 2013, 39,021 consecutive admissions with injury ICD-9 codes were analyzed. ICISS was calculated from the product of the survival risk ratios for a patient's three worst injuries. Outcomes were compared between patients with ICISS0.85 either triaged to the ED or its separate, neighboring, free-standing TC at a large urban hospital. A total of 32,191 (83%) patients were triaged to the ED by EMS and 6,827 (17%) were triaged to the TC. Of these, 2544 had an ICISS0.85, with 2145 (84%) being triaged to the TC and 399 (16%) to the ED. In these patients, those taken to the TC more often required admission, and those taken to the ED had better outcomes. When the confounders influencing triage to an ED or a TC are eliminated, those triaged by EMS to the ED rather than the TC had better overall outcomes. EMS providers better identified patients at risk for mortality than did the retrospective application of ICISS. ICISS0.85 does not identify the absolute need for TC as EMS providers were able to appropriately triage a large portion of this population to the ED.

We aimed to determine the association between environmental exposure to carbapenem-resistant Acinetobacter baumannii and the subsequent risk of acquiring this organism. Patients exposed to a contaminated hospital environment had 2.77 times the risk of acquiring carbapenem-resistant A. baumannii than did unexposed patients (relative risk, 2.77 [95% confidence interval, 1.50–5.13]; P = .002).

Only one previous case report has described scald burns secondary to hair braiding in pediatric patients. The present case study is the largest to date of scald burns as a result of hair braiding in children and adults. Charts of all 1609 female patients seen at a single burn center from 2008 to 2014 were retrospectively reviewed to identify patients with scald burns attributed to hair braiding. Demographics, injury severity, injury patterns, and complications were analyzed. Twenty-six patients (1.6%) had scald burns secondary to hair braiding with median TBSA 3%. Eighty-five percent of patients were pediatric with median age 8 years. Injury patterns were as follows: back (62%), shoulder (31%), chest (15%), buttocks (15%), abdomen (12%), arms (12%), neck (12%), and legs (4%). No patients required operative intervention. Three patients were admitted to the hospital. Two patients required time off from school for 6 and 10 days post burn for recovery. Complications included functional limitations (n = 2), hypertrophic scarring (n = 1), cellulitis requiring antibiotics (n = 1), and anxiety requiring medical/psychological therapy (n = 2). This peculiar mechanism of injury not only carries inherent morbidity that includes the risks of functional limitations, infection, and psychological repercussions but also increases usage of resources through hospital admissions and multiple clinic visits. Further work in the form of targeted outreach programs is necessary to educate the community regarding this preventable mechanism of injury.

BACKGROUND Hypercoagulability is a homeostatic response to trauma, but relatively little information is available about coagulation changes after burn injury. Therefore, we tested the hypothesis that burn patients are hypercoagulable at admission and/or during recovery. METHODS A prospective observational trial was conducted at an American Burn Association verified Burn Center. Thromboelastography (TEG) was performed on blood drawn from indwelling catheters upon admission and weekly for those who remained hospitalized. Routine and special coagulation tests were performed on stored samples. Data are expressed as median (interquartile range). RESULTS Twenty-four patients (88% male) were enrolled, with a median age of 49 (20) years and a median total body surface area burn of 29% (23%); 21 experienced thermal burns (4 inhalational injuries), and 3 had electrical burns. There were no significant differences in TEG or coagulation assays between patients with thermal versus electrical burn injury, but there were significant differences between men versus women and between those with or without inhalational injury. Sixteen patients had repeat samples 1 week after intensive care unit admission. The repeat TEG was more hypercoagulable (all p < 0.05). Fibrinogen and natural anticoagulation proteins (protein C, protein S, and antithrombin III) were also increased (all p < 0.05). Two patients (8%) developed venous thromboembolism (VTE); TEG reaction time, fibrinogen, and partial thromboplastin time were decreased (all p < 0.05) at admission compared with those with no VTE. All changes occurred despite pharmacologic thromboprophylaxis. There was no significant correlation between TEG and total body surface area or between TEG and fluid balance. CONCLUSION In general, burn patients have normal coagulation parameters at admission but become hypercoagulable during recovery. However, those who are hypercoagulable at admission may have an increased risk of VTE. Additional monitoring and/or thromboprophylaxis may be indicated. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

Maintaining burn patients' body temperature during surgery is a significant challenge. Although increasing the ambient operating room (OR) temperature and other passive rewarming methods help, such measures have limited effectiveness and prove taxing on OR personnel. Initial studies indicate that an intravascular warming catheter may improve and sustain burn patient body temperatures. The authors hypothesize that the warming catheter is similarly effective at maintaining normothermia despite a lower OR temperature than in a cohort of matched control burn patients. This is a retrospective case-control study involving patients with major burns treated between January 2006 and June 2011. Cases received an intravascular warming catheter, whereas controls receive traditional temperature conserving interventions. As the catheters maintained body temperature, the room temperature was gradually lowered to normal. Twenty-three patients were involved in 31 cases using the catheter, compared with 39 controls in 62 surgeries. The mean temperature deviation for each catheter group was -0.76 ± 1°C and -0.80 ± 0.9°C for the control group. Given 20-minute intervals throughout the operations, the mean patient temperature for cases and controls never deviated by more than 1°C. OR staff satisfaction has improved with decreased room temperatures. An intravenous warming catheter reliably maintained patient core body temperature during surgery. To date, this is the largest cohort study of such a catheter among burn patients. This system may be more effective than current warming techniques, with the potential to decrease the total number of procedures and the time to complete wound closure.

The American Burn Association recommends that patients with toxic epidermal necrolysis-Stevens Johnson syndrome (TEN-SJS) or burn inhalation injuries would benefit from admission or transfer to a burn center (BC). This study examines to what extent those criteria are observed within a regional burn network. Hospital discharge data from 2000 to 2010 was obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Disease-9th revision discharge diagnoses for TEN-SJS or burn inhalation injury and their triage destination were compared using burn triage referral criteria to determine whether the patients were triaged differently from American Burn Association recommendations. Two hundred ninety-nine TEN-SJS and 131 inhalation injuries were admitted to all South Florida hospitals. Only 25 (8.4%) of TEN-SJS and 27 (21%) of inhalation injuries were admitted to the BC. BC patients had greater length of stay (TEN-SJS 22 vs 10 days; inhalation 13 vs 7) and were more likely to be funded by charity or be self-paid (TEN-SJS 24 vs 9.5%, P = .025; inhalation 44 vs 14%, P < .001), but less likely to hold some form of private or government insurance (TEN-SJS 72 vs 88%, P = .02; inhalation 48 vs 81%, P = .006). TEN-SJS BC patients were more frequently discharged home for self-care (76 vs 50%, P = .006). Non-BC patients were more often discharged to other healthcare facilities (28 vs 0% TEN-SJS, 20 vs 7.4% inhalation). Inappropriate triage may occur in more than 3 out of 4 of the TEN-SJS and inhalation injury patients within our burn network. Unfamiliarity with triage criteria, patient insurance status, and overcoding may play a role. Further studies should fully characterize the problem and implement education or incentives to encourage more appropriate triage.

Advances in burn care have decreased mortality in the past 20 years, but affecting elderly mortality rates (>65 years) remain challenging. This study evaluates the impact of home caregiver support on elderly burn patients' mortality. The authors retrospectively reviewed patients aged 65 and older admitted to their burn center from July 1995 to October 2004. Patient demographics, Injury Severity Score, TBSA, and patients' primary caregiver were collected. The outcomes were mortality, disposition, and length of stay and these were evaluated using univariate and subsequently multivariate regression. Significance was calculated at P ≤ .05. A total of 112 patients were included in the analysis. The mean age was 76±8. Male patients constituted 47%, whereas 53% were female patients, and mean TBSA was 21±16%. Thirty patients' primary caregiver was a spouse, for 38 it was a child, and 44 had no caregiver. Fifty-eight patients survived (51.7%), and 54 patients died (48.3%). Only 21% of the survivors had a child as their primary caregiver; however, 48% of the nonsurvivors had a child as the primary caregiver (P ≤ 0.05). On multivariate analysis, age, TBSA, and child as primary caregiver were all independent predictors of mortality. Having a child as a caregiver provided the largest impact, with an odds ratio of 4.4 (95% confidence interval, 1.2-15.62; P = .02).

INTRODUCTION: The elderly are the fastest growing population segment, and particularly susceptible to burns. Predicting outcomes for these patients remains difficult. Our objective was to identify early predictors of mortality in elderly burn patients. METHODS: Our Burn Center's prospective database was reviewed for burn patients 60+ treated in the past 10 years. Predictor variables were identified by correlative analysis and subsequently entered into a multivariate logistic regression analysis examining survival to discharge. RESULTS: 203 patients of 1343 (15%) were eligible for analysis. The average age was 72±10 (range 60-102) and the average total body surface area (TBSA) burned was 23±18% (range 1-95). Age, TBSA, base deficit, pO(2), respiratory rate, Glasgow Coma Score (GCS), and Revised Trauma Score (RTS, based on systolic blood pressure, respiratory rate, and GCS) all correlated with mortality (p≤0.05). Using multiple logistic regression analysis, a model with age, TBSA and RTS was calculated, demonstrating: In this model, β(0) is a constant that equals -8.32. CONCLUSIONS: Predicting outcomes in elderly burn patients is difficult. A model using age, TBSA, and RTS can, immediately upon patient arrival, help identify patients with decreased chances of survival, further guiding end-of-life decisions. Language: en

Burn cellulitis is an infection of the unburned skin at the margin of a burn wound or graft donor site, typically caused by group A beta-hemolytic streptococci and Staphylococcus aureus. beta-Lactam antibiotics exhibit time-dependent killing and, because of their narrow spectrum, minimize bacterial resistance. We therefore use continuous-infusion oxacillin in the treatment of burn cellulitis.Patients at a regional burn center who were treated for burn cellulitis from January 2003 to December 2005 were included. Charts were reviewed for all pertinent data regarding the antibiotic treatment methods and outcomes. Successful treatment was defined as resolution of physical findings, fever, and leukocytosis and intravenous antibiotic cessation.Thirty-seven patients were treated for burn cellulitis, 26 (70%) of whom were treated initially with continuous-infusion oxacillin. Other initial antibiotics were chosen because of concomitant infections, penicillin allergy, or development of cellulitis during treatment with a beta-lactam antibiotic. Oxacillin treatment was successful in 19 patients (73%). Success required an average of 5.16 days, with 1.53 days required for fever resolution and 0.89 days for resolution of leukocytosis. Seven patients who did not respond rapidly were switched to intravenous vancomycin an average of 2.4 days after starting oxacillin, leading to a 100% success rate. There were no deaths, and only one suspected case of allergic reaction to oxacillin. In eleven patients treated with other antibiotics, the success rate was 75%. Success with these drugs required a longer treatment course of 6.45 days. Leukocytosis resolved significantly more slowly at 4.45 days (p = 0.02), and fever resolution was also slower at 3.18 days.Continuous-infusion oxacillin was successful in the treatment of 73% of patients, a success rate that might have been higher with clinical patience, and leukocytosis resolved faster than with other antibiotics. Failure of continuous-infusion oxacillin can be managed without clinical consequence by conversion to intravenous vancomycin.

Gastrostomy tubes are used for primary and supplemental feeding and gastric decompression. The purpose of the study was to compare the complication rate of gastrostomy tube placement by either endoscopic or fluoroscopic technique. Between 1996 and 2004, the surgical and radiological services at a Level I trauma hospital placed gastrostomy tubes in 378 patients (endoscopy=268, fluoroscopy=110). The percutaneous gastrostomy group comprised 71% of the cohort with a mean age of 51+/-21 (range: 1-93 years of age), and the percutaneous radiographic gastrostomy group comprised the remaining cohort (29%) with a mean age of 57+/-19 (range: 17-95 years of age). Fifty-eight percent of the percutaneous gastrostomy group were female (n=155) and 42% were male (n=113), whereas the gender distribution for the percutaneous radiographic gastrostomy group was 33% female (n=36) and 67% male (n=74). There was an overall complication rate of 36% (22% and 70% for the endoscopic and fluoroscopic methods, respectively). The most frequent complication in both types of techniques was tube dislodgement (endoscopic=32% [19/268]; fluoroscopic=27% [21/110]). There were very few serious complications. Women had a higher rate of postprocedure complications than did men, at 35% versus 27%. We conclude that gastrostomy tube placement by either endoscopic or fluoroscopic methods results in a number of complications, though most of them are minor. Patients must therefore be informed that this is not a complication-free procedure.

Oxandrolone has been shown to improve lean muscle mass in patients with burns. Hepatic dysfunction is a known side effect of treatment with oxandrolone. The purpose of this study was to examine the incidence of hepatic dysfunction in our series of burn patients receiving oxandrolone. Fourteen patients who received oxandrolone (5 mg, n = 8; 10 mg, n = 6) were identified from our prospectively collected burn database. The records of 61 control patients also were reviewed. Demographics such as age, comorbidities, and burn size were recorded. The incidence of hepatic dysfunction was determined by the presence of abnormal liver function tests. The study and control groups were similar in age and burn size. Two of the eight (25%) oxandrolone patients receiving 5 mg and four of the six (67%) oxandrolone patients receiving 10 mg had evidence of hepatic dysfunction. Twenty six of the 61 (43%) control patients had evidence of hepatic dysfunction (P = NS). There appears no significant increased incidence of hepatic dysfunction in burn patients who received oxandrolone compared to those who did not.

The objective of this study was to determine the incidence of drug resistance among isolates of Acinetobacter baumannii from our Burn Intensive Care Unit (BICU), the rate of clinical cure, and the mortality rate. We undertook a retrospective review of all cases of infection from the BICU between January 2004 and November 2005. The group consisted of 24 men (80%) and 6 women with a mean age of 43 years (range, 17-76 years, +/-14.5 years). Mean TBSA burned was 43% (range, 9-75%, +/-19%). Mean BICU length of stay was 49 days (range, 5-118 days, +/-30 days). Patients developed their first infection after a mean of 16 days (5-73 days, +/-14 days). The initial site of infection was bronchoalveolar lavage in 21 (70%), blood in 6 (20%), central venous catheter tip in 2 (7%), and urine in 1 (3%). The isolates displayed resistance to imipenem in 87% of cases. No organism displayed resistance to colistin (polymixin E). Patients were treated with colistin in 20 cases (67%), with amikacin in 8 cases (27%), and with imipenem in 2 cases (7%). A total of 10 patients (33%) died, 1 from gastrointestinal bleeding and 9 from active infection, giving an infection related mortality of 30%. In 21 cases (70%), a cure was achieved with a mean duration of treatment of 16 days (range, 4-30 days, +/-7 days). The majority of A. baumannii isolates were multidrug resistant; however, no isolate displayed resistance to colistin. Cure rate was 70% and infection-related mortality reached 30%. More investigation is warranted to improve prevention and to assess new therapeutic agents.

Background Operative management of traumatic shank vascular injuries (SVI) evolved significantly in the past few decades, thereby leading to a dramatic decrease in amputation rates. However, there is still controversy regarding the minimum number of patent shank arteries sufficient for limb salvage. Methods Between January 2006 and September 2011, 191 adult trauma patients presented to an urban level I trauma center in Miami, Florida, with traumatic lower extremity vascular injuries. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. Results A total of 48 (25.1%) patients were identified comprising 66 traumatic shank arterial injuries. Mean age was 38.2 ± 13.4 years, and the majority of patients were men (40 patients, 83.3%) presenting with blunt injuries (35 patients, 72.9%). Ligation was performed in 38 injured arteries (57.6%) and no vascular intervention was required in 20% of the patients. Vascular reconstruction was performed in only 6 patients (9.1%): 4 (6.1%) with concurrent popliteal trauma, 1 (1.5%) isolated anterior tibial, and 1 (1.5%) 3-vessel injury. Autogenous venous interposition conduit and polytetrafluoroethylene grafting were performed in 5 (7.6%) and 1 (1.5%) patient, respectively. All amputations (8 patients, 16.7%) occurred in blunt trauma patients presenting with unsalvageable limbs. The overall mortality rate in this series was 2.1%. Conclusions Civilian shank arterial injuries are associated with acceptable rates of limb loss. Patients with a single-vessel patent inflow did not require vascular reconstruction in this series. Arterial reconstruction may no longer be determinant for successful management of isolated and double arterial SVI, whereas it is yet essential in the presence of 3-vessel or concurrent above-the-knee vascular injuries. Further investigation including larger number of patients is still warranted to define the role of conservative management in these complex injuries.

Objective The objective of this study was to review the outcome of nonoperative treatment for penetrating internal jugular vein (IJ) injuries in a continuous series of prospectively identified, hemodynamically stable patients. Methods All penetrating neck injuries assessed from February 1, 2004, to August 31, 2004, were prospectively identified. Patients without an indication for urgent neck exploration underwent diagnostic assessment with multislice helical computed tomographic angiography with or without vascular ultrasonography. All IJ injuries with no other indication for surgical exploration were treated nonoperatively. All patients were discharged home and followed up for a minimum of 1 week to document outcomes. Results From 51 neck injuries penetrating the platysma, 7 required urgent neck exploration, during which 2 IJ injuries were ligated. Forty-four patients underwent multislice helical computed tomographic angiography. Eight IJ injuries (two gunshot wounds and six stab wounds) with no other indication for neck exploration were identified and managed nonoperatively. One external wound was in zone 1, five were in zone 2, one was in zone 3, and one traversed all three zones. The average length of stay was 4.5 days. At follow-up, ranging from 1 week to 5 months, all patients were asymptomatic, and no patient required delayed operation for IJ injury. Conclusions In hemodynamically stable patients with no other indication for exploration, the nonoperative management of penetrating jugular vein injuries should be considered as a safe alternative.

Despite recent improvements in analgesia, pain control during dressing changes continues to be a major challenge in patients with burns. We investigated two different dressing modalities to compare how much pain the patient experienced during and after the dressing change. Patients with partial-thickness burns that required only topical wound care were assigned randomly to treatment with Acticoat (Smith and Nephew USA, Largo, FL) or silver sulfadiazine (AgSD). The outcome variable was pain during wound care, which was measured using visual analog pain scores. The mean visual analog pain scores for the wounds treated with Acticoat or AgSD wounds were 3.2 and 7.9, respectively (P < .0001; paired Student's t-test). In 41 of the 47 paired pain score observations, the pain in the wound treated with AgSD was perceived as greater than in the wound treated with Acticoat. Burn wound care with Acticoat is less painful than burn wound care with AgSD in patients with selected partial-thickness burns.

Objective The purpose of this study was to determine the optimal time interval for identifying a pneumothorax (PTX) on chest radiograph (CXR) after placing a chest tube on water seal. Methods One hundred nineteen chest tubes were placed on water seal according to a prospective, observational study protocol. After water seal, both an early (3.1 +/- 2.1 hours) and a late (17.6 +/- 8.0 hours) CXR was obtained. Results Thirty-one patients had a PTX on follow-up CXRs. There were 22 early and 9 late PTXs identified. Three patients in the early group had a clinically significant PTX or an increase in the size of PTX on follow-up CXR. None of the patients in the late group had a clinically significant PTX (any worsening of their PTX) or required further intervention. Conclusion A normal chest radiograph obtained 3 hours after placing a chest tube on water seal effectively excludes development of a clinically significant pneumothorax.

Femoral vessel injuries are a familiar injury treated in busy urban trauma centers. The majority of peripheral vascular injuries to the lower extremity occur most commonly to the femoral vessels. The increasing incidence of civilian violence provides an opportunity to perform a comprehensive review and management of these injuries.

Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. Mean age was 37.4 ± 18.0 years (range 16–66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9–50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition.

There continues to be debate about the routine use of deep vein thrombosis (DVT) prophylaxis in burn patients. The concern is that routine prophylaxis may lead to adverse events. The debate hinges on the incidence of DVT and its relation to the risk-benefit ratio. This study seeks to estimate the true rate of DVT in burn patients, and to evaluate possible risk factors to its development. The Nationwide Inpatient Sample was queried for all patients with age ≥18 years with ICD-9 codes for burn injuries. Demographic data, comorbidities, burn data, length of stay, total charges, procedures, presence of central venous catheter, and mortality were recorded. Patients were classified based on the presence of DVT. Student's t-test, χ test, and logistic regression were performed. 36,638 burn patients were identified. DVT rate was 0.8%. Patients with DVT were older, had longer hospitalizations, more procedures, and higher charges. On logistic regression, black race, TBSA ≥20%, history of previous venous thrombotic events, blood transfusion, and mechanical ventilation were the significant factors associated with DVT. Patients with DVT were almost twice as likely to die during the admission (P = .011). This is the largest series to date examining the risk factors for DVT in burn patients. DVT developed in approximately 0.8% of burn patients. Black race, TBSA ≥20%, blood transfusions, and mechanical ventilation were associated with approximately 2-fold odds of developing DVT. Identification of these additional risk factors may allow targeted patient prophylaxis. Additionally, patients with DVT incurred higher total charges and longer hospitalization.

The American Burn Association publishes a list of defined criteria for patients who require admission or transfer to a burn center. This study examines the extent to which those criteria are observed within a regional burn network. Hospital discharge data for 2008 were obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Diseases, 9th revision discharge diagnoses for burns were reviewed, and their triage destination was compared with the burn triage referral criteria to determine whether patients were inappropriately triaged. Descriptive statistics were used to analyze the data. Four hundred ninety-eight burn admissions were documented to non-burn center center hospitals, 269 (54%) of which were deemed inappropriate by burn triage referral criteria. Burn center patients had greater length of stay when compared with non-burn center patients (14 vs 7 days), but a greater percentage were discharged home for self-care (88 vs 57%). Thirty-three percent of the inappropriate admissions were in a neighboring county, whereas 27% were in the same county where the burn center is located. Inappropriate burn patient triage may be occurring to more than half of the burn patients within our regional burn network despite better functional outcomes at the burn center. This may be because of a lack of knowledge regarding triage criteria, patient insurance status, or other factors. Further studies are necessary to fully characterize the problem and implement education or incentives to encourage appropriate burn patient triage.

Background: The incidence of occult pneumothorax (OPTX) has dramatically increased since the widespread use of computed tomography (CT) scanning. The OPTX is defined as a pneumothorax not identified on plain chest X-ray but detected by CT scan. The overall reported incidence is about 5% to 8% of all trauma patients. We conducted a 5-year review of our OPTX incidence and asked if an objective score could be developed to better quantify the OPTX. This in turn may guide the practitioner with the decision to observe these patients. Methods: This is a retrospective review of all trauma patients in a Level I university trauma center during a 5-year period. The patients were identified by a query of all pneumothoraces in our trauma registry. Those X-ray results were then reviewed to identify those who had OPTX. After developing an OPTX score on a small number, we retrospectively scored 50 of the OPTXs by taking the largest perpendicular distance in millimeters from the chest wall of the largest air pocket. We then added 10 or 20 to this if the OPTX was either anterior/posterior or lateral, respectively. Results: A total of 21,193 trauma patients were evaluated and 1,295 patients with pneumothoraces (6.1%) were identified. Of the 1,295 patients with pneumothoraces, 379 (29.5%) OPTXs were identified. The overall incidence of OPTX was 1.8%: 95.7% occurred after blunt trauma, 222 (59%) of the OPTX patients had chest tubes and of the remaining 157 without chest tubes, 27 (17%) were on positive pressure ventilation. Of the 50 studies selected for scoring, the average score was 28.5. The average score for those with chest tubes was 34. The average score for those without chest tubes was 21. The positive predictive value for need of chest tube if the score was >30 was 78% and the negative predictive value if the score was

The purpose of this study was to review our experience with a mass casualty incident resulting from a boiler room steam explosion aboard a cruise ship. Experience with major, moderate, and minor burns, steam inhalation, mass casualty response systems, and psychological sequelae will be discussed. Fifteen cruise ship employees were brought to the burn center after a boiler room explosion on a cruise ship. Eleven were triaged to the trauma resuscitation area and four to the surgical emergency room. Seven patients were intubated for respiratory distress or airway protection. Six patients had >80 per cent burns with steam inhalation, and all of these died. One of the 6 patients had 99 per cent burns with steam inhalation and died after withdrawal of support within the first several hours. All patients with major burns required escharotomy on arrival to trauma resuscitation. One patient died in the operating room, despite decompression by laparotomy for abdominal compartment syndrome and pericardiotomy via thoracotomy for cardiac tamponade. Four patients required crystalloid, 20,000 mls/m2–27,000 ml/m2 body surface area (BSA) in the first 48 hours to maintain blood pressure and urine output. Three of these four patients subsequently developed abdominal compartment syndrome and died in the first few days. The fourth patient of this group died after 26 days due to sepsis. Five patients had 13–20 per cent burns and four patients had less than 10 per cent burns. Two of the patients with 20 per cent burns developed edema of the vocal cords with mild hoarseness. They improved and recovered without intubation. The facility was prepared for the mass casualty event, having just completed a mass casualty drill several days earlier. Twenty-six beds were made available in 50 minutes for anticipated casualties. Fifteen physicians reported immediately to the trauma resuscitation area to assist in initial stabilization. The event occurred at shift change; thus, adequate support personnel were instantaneously to hand. Our mass casualty preparation proved useful in managing this event. Most of the patients who survived showed signs of post-traumatic stress syndrome, which was diagnosed and treated by the burn center psychology team. Despite our efforts at treating large burns (>80%) with steam inhalation, mortality was 100 per cent. Fluid requirements far exceeded those predicted by the Parkland (Baxter) formula. Abdominal compartment syndrome proved to be a significant complication of this fluid resuscitation. A coordinated effort by the facility and preparation for mass casualty events are needed to respond to such events.

Background We recently reported that a new dressing, the Modified Rapid Deployment Hemostat (MRDH) controlled bleeding in hypothermic coagulopathic swine after traumatic liver avulsion. The purpose of this study was to evaluate the MRDH in coagulopathic trauma patients undergoing abbreviated laparotomy. Methods A prospective, observational clinical trial of the MRDH dressing was performed at our Level One Trauma Center in patients with high-grade visceral injuries with coagulopathy who failed conventional therapy and required packing. Attending surgeons graded the injury and the adequacy of hemostasis following application of the dressing. Patients were followed until discharge or death. Results Ten patients were enrolled: nine severe hepatic injuries, and one major abdominal vascular injury. All patients were hypothermic, acidotic, and clinically coagulopathic. Intraoperative hemostasis was immediately obtained after MRDH placement in all cases except one. There was one death. Conclusion The Modified Rapid Deployment Hemostat terminates bleeding from severe visceral injuries in coagulopathic patients undergoing abbreviated laparotomy.

Background The purpose of this study was to determine the appropriate time interval between the removal of a chest tube and the chest radiograph (CXR). We hypothesized that a CXR obtained 1 hour after chest tube removal would exclude the presence of a recurrent pneumothorax. Methods Of 214 trauma intensive care unit patients with a chest tube during a 1-year period, 75 met entry criteria and underwent chest tube removal according to an institutional review board-approved prospective study protocol. Patients were undergoing positive-pressure ventilation, with an existing solitary chest tube, and had less than 150 mL of drainage on water seal over the previous day. After chest tube removal, serial CXRs were obtained at approximately 1, 10, and 36 hours. Demographic, chest tube, and ventilator data were collected. Results None of the patients experienced hemodynamic or respiratory deterioration after chest tube removal. There were nine pneumothoraces (12%). All pneumothoraces were present on the initial CXR after chest tube removal. Two patients (3%) required intervention for pneumothorax. Of the remaining seven small pneumothoraces, three resolved and four were unchanged on the third CXR. Conclusion A CXR obtained within 1 to 3 hours after chest tube removal effectively identifies pneumothorax in mechanically ventilated patients.

Introduction Ureteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management. Literature review Eighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%. Conclusion The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.