Analysis of Factors Contributing to the Occurrence of Systemic Toxicity in Patients with Hydrofluoric Acid Skin Exposure Injury: An Individual Participant Data Meta-Analysis of 125 Clinical Cases from 1979 to 2020
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Abstract The purpose of this study is to analyze the factors contributing to the occurrence of systemic toxicity in patients injured after skin exposure to hydrofluoric acid (HFA) and to present guidelines for active treatment intervention based on this analysis. Data were acquired from EMBASE, PubMed, and Cochrane library for individual participant data (IPD) meta-analysis. Key searching terms included calcium gluconate (CAG), hydrofluoric acid, and case. This research consisted of case studies published between 1979 and 2020. Systemic toxicity was set as the main outcome. Data sets from 50 case studies (N = 125 participants) were analyzed. Multivariate binary logistic regression analyses of IPD found significant association effect of the total body surface area (TBSA) burned, indicating systemic toxicity [Regression coefficient estimate, 0.82; SE, 0.41; Odds ratio, 2.28; [95% confidence interval, 1.03–5.06], and p = 0.0424]. The optimal cutoff point (sensitivity; specificity) of the receiver operating characteristic curve of the total body surface area (TBSA) burned for contributing occurrence of systemic toxicity was 2.38(0.875; 0.959). IPD meta-analysis indicates that existing evidence supports the positive proportional association of the TBSA burned for systemic toxicity. If the TBSA burned (%) in patients exposed to hydrofluoric acid is greater than 2.38, early aggressive treatment intervention, including decontamination and various CAG application, should be recommended as the guideline.Keywords:
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To compare early versus delayed albumin resuscitation in children with burns in terms of clinical outcome and response.Randomized controlled trial.Burn center at a tertiary care teaching hospital.Forty-six children aged 1-12 years with burns greater than 15-45% total body surface area admitted within 12 hours of burn injury.Fluid resuscitation was based on the Parkland formula (3 mL/kg/% total body surface area), adjusted according to urine output. Patients received 5% albumin solution between 8 and 12 hours post burn in the intervention group (n = 23) and 24 hours post burn in the control group (n = 23). Both groups were assessed for reduction in crystalloid fluid infusion during resuscitation, development of fluid creep, and length of hospital stay.There was no difference between groups regarding age, weight, sex, % total body surface area, cause of burn, or severity scores. The median crystalloid fluid volume required during the first 3 days post burn was lower in the intervention than in the control group (2.04 vs 3.05 mL/kg/% total body surface area; p = 0.025 on day 1; 1.2 vs 1.71 mL/kg/% total body surface area; p = 0.002 on day 2; and 0.82 vs 1.3 mL/kg/% total body surface area; p = 0.002 on day 3). The median urine output showed no difference between intervention and control groups (2.1 vs 2.0 mL/kg/hr; p = 0.152 on day 1; 2.58 vs 2.54 mL/kg/hr; p = 0.482 on day 2; and 2.9 vs 3.0 mL/kg/hr; p = 0.093 on day 3). Fluid creep was observed in 13 controls (56.5%) and in one patient (4.3%) in the intervention group. The median length of hospital stay was 18 days (range, 15-21 d) for controls and 14 days (range, 10-17 d) in the intervention group (p = 0.004).Early albumin infusion in children with burns greater than 15-45% total body surface area reduced the need for crystalloid fluid infusion during resuscitation. Significantly fewer cases of fluid creep and shorter hospital stay were also observed in this group of patients.
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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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Obesity causes changes in the total body surface area as well as the distribution of skin surfaces. In burn management, three methods are commonly used to determine the surface area burned: the patient's palm, the rule of nines, and the Lund-Browder chart. These methods rely on the distribution of skin surface, although none of these methods consider differences in body mass. This study investigates the relationship between body surfaces and body mass in the assessment of burn size to determine the validity of the conventional methods when applied to obese individuals.The current literature was reviewed using relevant electronic databases. The initial search yielded 247 results. Relevant articles were then reviewed. A total of seven publications fulfilled the inclusion criteria.The palmar surface area ranged between 0.59%-1.22%, depending on BMI, gender, and ethnicity, compared to 1% according to conventional methods. The palmar surface area of obese individuals approximated 0.7% of the total body surface area in Caucasians. The surface areas comprised 5%-7.5% of the total body surface area for each arm, 15%-20% for each leg, and 40%-52% for the trunk in obese or morbidly obese individuals, compared to 9%, 18%, and 36%, respectively, for normal-weight adults.The commonly used methods for assessment of burns should be used with caution when applied to obese burn patients, and the clinical parameters observed even more systematically.
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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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