Determinants of Mortality in Pediatric Patients with Greater than 70% Full-thickness Total Body Surface Area Thermal Injury Treated by Early Total Excision and Grafting
David N. HerndonDENNIS GOREMELVIN COLEManu H. DesaiHugo A. LinaresSally AbstonThomas C. RutanTIM VAN OSTENROBERT B. BARROW
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Abstract:
Recent advancements in burn care have improved the survival rates of victims with severe burn injuries. The total mortality rate in a series of 1,057 pediatric patients admitted to Shriners Burns Institute Galveston Unit between 1982 and 1986 was 2.7%. The burn size resulting in a 50% death rate was 95% of the total body surface area (TBSA). In this study 19 survivors and 13 nonsurvivors with greater than 70% full-thickness TBSA burn injuries were compared. All survivors were adequately resuscitated upon arrival 11 % sustained an inhalation injury. Forty-six per cent of the nonsurvivors sustained an inhalation injury; 31% were not initially adequately resuscitated. The presence of preadmission shock and inhalation injury were early determinants of mortality with secondary renal, pulmonary, or cardiovascular collapse being the later predictors of mortality in these massively burned pediatric patients.Keywords:
Body surface area
Skin grafting
Intention. To study the possibility of predicting early burn sepsis based on the content of proinflammatory cytokines in the peripheral blood of patients with extensive burns. Methodology. The study included 60 patients (of them 37 men) aged 21 to 58 years (mean age 46.8 ± 9.3 years) with extensive skin burns (Degree III burns by ICD 10 from 20 to 60 %, average 34.1 %, of the body surface). Depending on the skin area affected and the course of burn disease, the patients were divided into three groups, each of 20 patients: group 1 - the course of burn disease without early sepsis, burn area from 21 to 40 % of the body surface; group 2 - the course of burn disease without early sepsis, burn area from 41 to 60 % of the body surface; group 3 - the early burn sepsis, burn area of 20 to 60 % of the body surface. To achieve the goal of the study, all the patients underwent sequential peripheral blood sampling 24 and 72 hours after a burn injury. The levels of IL-1β, IL-6, IL-10, and TNFa were analyzed in the obtained samples. Data were processed using Microsoft Office Excel 2007 and IBM SPSS 20.0 by methods of descriptive and non-parameter statistics Results and Discussion. The analyzed indicators statistically significantly correlated with the severity of burn injury and the likelihood of burn sepsis. Decreased concentrations of IL-1β, IL-6 and TNFα within Days 1-3 after getting a burn suggest a relatively favorable course of burn disease. No significant positive dynamics of these laboratory parameters may indicate a high probability of developing early burn sepsis. Conclusion. Concentrations of IL-1β, IL-6 and, especially, TNFα in the peripheral blood make it possible to predict early burn sepsis.
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Proinflammatory cytokine
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Goal: To determine whether burn size in severely burned patients (more than 25% of body surface area covered with second and third degree burns) influences the level of serum albumin during the first 48 hours after burn injury. Material and method: This was a retrospective study of forty-seven patients with severe burns ranging from 25% to 90% of total body surface area consecutively admitted to intensive care unit of the Emergency Hospital of Bucharest from January 2006 to December 2012. We studied the relationship between burned surface area and the lowest serum albumin level during the first 48 hours after injury. Results: There was a negative linear correlation between the burned surface area and serum albumin level during the first 48 hours post injury. We find a mathematic relationship to express this correlation and to calculate the expected level of serum albumin for a specific burned body surface area. Conclusions: There is a negative correlation between burned surface area and serum albumin level; we proposed a linear polynomial fit in order to describe this correlation. Based on this relationship between those two parameters we suggest administration of intravenous albumin in the first 24 hours post injury, during the initial phase of fluid resuscitation when we would expect low levels of plasma albumin.
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Accurate assessments of the surface areas of burn injuries are important for the prognosis and initial fluid resuscitation of burn victims. The area of the surface of the hand is often used to estimate the area of a burn. In our previous study, the volar hand surface area is equal to 0.75% of body surface area in Taiwanese adult. But none discusses about variations in individual body weight. In this study, we used two-dimensional projection to estimate hand surface areas of Taiwanese adults in variant of body mass index. The areas of the volar hand, including that of the thumb and fingers, in healthy, overweight and obese Taiwanese were 0.82%, 0.74%, and 0.70% of body surface area, respectively. We conclude that the ratio between hand and body surface area of Taiwanese adults differ from that of individual body weight and suggest an adjustment of the ratio for use with overweight and obese people.
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BACKGROUND: The US Army’s Standards of Medical Fitness indicate that a burn injury spanning ≥40% of total body surface area (BSA) “does not meet the standard.” While whole-body sweat production and thus evaporation are diminished in burn survivors with extensive skin grafts, the impact of a 40% BSA burn injury on core temperature regulation during exercise is likely dependent on body size, as larger individuals will have a greater absolute skin area that can still participate in heat loss despite the same percentage BSA burn injury. PURPOSE: Using a simulated burn injury model, we tested the hypothesis that the detrimental effect of a 40% BSA “burn injury” would be exacerbated in individuals of smaller versus larger body size during exercise due to a lower absolute (i.e., in m2) skin area available for heat loss. METHODS: On separate occasions, healthy non-burned individuals of small (SM: n=8, 62.4 ± 5.8 kg, 1.69 ± 0.11 m2) or large (LG: n=8, 99.1 ± 8.4 kg, 2.25 ± 0.09 m2) body size cycled to elicit ~500 W of metabolic heat production for 1 h in a 39°C and 20% relative humidity environment with and without (0%) a simulated burn injury of 40% BSA. Burn injuries were simulated by affixing a highly absorbent, vapor-impermeable material to the torso (20% BSA), arms (10% BSA), and legs (10% BSA) to prevent sweat evaporation. Core temperature was measured in the gastrointestinal tract (Tgi). RESULTS: Greater increases in Tgi were observed in SM at 0% (SM: 1.09 ± 0.33°C; LG: 0.64 ± 0.22°C; P=0.03) and 40% (SM: 1.65 ± 0.32°C; LG: 1.14 ± 0.23°C; P=0.01). However, the exacerbated rise in Tgi from 0% to 40% was not different between groups (SM: 0.57 ± 0.28°C; LG: 0.49 ± 0.24°C; P=0.60). CONCLUSIONS: Preliminary data suggest that the exacerbated rise in core temperature with a simulated burn is not dependent on body size. Nevertheless, SM subjects with a simulated burn exercising at the same rate of metabolic heat production experienced the highest absolute Tgi and would therefore be at the greatest risk for a heat-related injury. Funding support: Department of Defense - US Army, W81XWH-15-1-0647.
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Burn injury in man is characterized by increased body temperature proportional to burn wound size and may represent fever and/or hyperthermia. A nonseptic animal model used to study this phenomena has not been described. To test the hypothesis that large burn injuries in rats would produce increased body temperature, the rectal, skin, and body temperatures were sequentially measured and were calculated for rats in the control group and rats with burn injuries covering 26% to 63% of the body surface area [< or = 35%, 36% to 45%, and > or = 46% body surface area]. The group with burns covering > or = 46% of the body surface area had significantly higher rectal temperatures than did at least one other group on postburn days 7, 9, 11, 13, 18, and 20. On postburn days 7 and 11 this increase was significantly higher than that of all burn and control groups. Animals did not demonstrate any overt evidence of wound infection. These data do not establish a cause for increased body temperature after burn injury but suggest that a reproducible animal model may be possible for the study of the cause of increased body temperature after burn injury.
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Estimation of the surface area involved is vital to evaluation and treatment of burns. Common teaching suggests the palm approximates 1% of the total body surface area (TBSA). However, early century literature suggests the palmar surface of the entire hand approximates 1% of the TBSA. We sought to determine whether the palm or the entire palmar surface of the hand approximates 1% TBSA in children.A prospective, convenience sample.Using height, weight, and standard nomograms, body surface area was determined. A photocopy of the hand was used to determine the surface area of the palm and the entire palmar surface of the hand.In 91 children, the mean percent of the TBSA represented by the entire palmar surface was 0.94% (95% confidence interval (C.I.) 0.93-0.97), and the mean percent of the TBSA represented by the palm was 0.52% (95% C.I. 0.51-0.53).The entire palmar surface of a child's hand more closely approximates 1% TBSA, while the palm approximate 0.5% TBSA.
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