Through the establishment of Common Data Elements (CDEs), existing trauma databases could be leveraged to maximize research on trauma outcomes. CDEs promote data sharing, standardization, and uniform collection which facilitate meta-analysis and comparisons of studies, however there are no CDEs for trauma databases. The purpose of this study is to assess the extent of common data collection among six acute and longitudinal trauma databases. The data dictionaries of six trauma databases were examined to determine the extent of common data collection. Databases included three acute care databases (American Burn Association’s Burn Quality Improvement Program/National Burn Repository (BQIP/NBR), American College of Surgeons National Surgical Quality Improvement Program (NSQIP), and American College of Surgeons National Trauma Data Standard (NTDS)) and three longitudinal trauma databases (Burn Model System (BMS), Traumatic Brain Injury Model System (TBIMS), and Spinal Cord Injury Model System (SCIMS) National Databases). Data elements and data values were compared across the six databases. Qualitative and quantitative variations in the data were identified to highlight meaningful differences between datasets. Of the thirty data elements examined, 10 (33%) were present in all six databases. Another 8 (27%) elements were present in five of the six databases. Of the 30 examined data elements, the number of elements present in each database ranged from 16 (53%) to 26 (86%). There were inconsistencies in the data values across the databases. Seven of the ten data elements present in all six databases exhibited differences in the coding of the data elements (e.g. sex in BQIP/NBR is coded male or female, while sex in SCIMS is coded male, female, or other/transgender). This study demonstrates inconsistencies in the documentation of data elements in six common trauma databases. These discrepancies are a barrier to database harmonization and to maximizing the use of these databases through linking, pooling, and comparing data. A collaborative effort is required to develop a standardized set of elements for trauma research.

Electrical injury is a devastating and hard to treat clinical lesion. Fully understanding the pathophysiology of electrical trauma is still a challenge for clinicians and scientists. Further elucidating the natural history of this form of tissue injury could be helpful in improving limb salvage and offering stage-appropriate therapy. Multi-spectral imaging technique is a non-invasive technology that can be used to determine optical properties of tissues in and adjacent to injury. Images at different wavelengths can provide essential information related to the pathophysiological condition of the tissue. To promote the applicability of this technique in medical diagnosis, we built a complete experimental model of electrical injury. In this model, electrical injuries were created by a reliable high-tension shock system at preset voltage or current. A thermal camera recorded the change of skin temperature during the electrical shock. Then, a high-resolution spectral imaging system based on structured illumination was used to capture images for post analysis to extrapolate optical properties of the tissue. To test accuracy, this imaging system was calibrated by using a set of epoxy phantoms with known optical properties. In this paper, the results of experiments conducted on rats and discussions on the systemic changes in tissue optical properties before and after electrical shock are presented.

Introduction: Laser Doppler imaging produces a colour-coded image of dermal blood flow, which can be used to quantify the inflammatory response in a burn. The original colour palette had arbitrary boundaries, which inexperienced clinicians found difficult to interpret. The aim of this study was to define clinically useful boundaries that would assist in the prediction of burn healing potential.Method: We conducted a prospective, multi-centre study of burns in adults and children. LDI scans were performed between 48 h and 5 days after injury. The burns were assessed clinically and photographed on day of scan, day 14 and day 21 post-injury. Areas healed at day 14, healed between day 14 and 21 and unhealed at day 21 were identified on the LDI scan. The flow values for the pixels in these regions were analysed to calculate boundaries between the three healing categories.Results: We recruited 137 patients (ages 1-88 years, 65% male); 392 LDI scans contained 433 different burn sites; 109 regions of interest were studied. Analysis allowed us to define ranges for the three healing categories: HP14 colour coded red, >600PU; HP14-21, yellow, 260-140PU; HP>21, blue, <200PU; separated by two overlap regions pink, 440-600PU and green, 200-260PU. Blue was subdivided to show the very high association between LDI < 140PU and non-healing at day 21.Conclusion: We have devised a new colour palette for LDI burn imaging based on healing times of a series of burns. Validation of this palette is described separately, in Part 2. (C) 2010 Elsevier Ltd and ISBI. All rights reserved.

A thorough understanding of the factors which increase mortality following thermal injury is crucial for optimized patient and wound treatment. Traditionally, women between the ages 30-59 have been thought to fare worse than their male counterparts. Similarly, it has been generally accepted that mortality depends on the %TBSA involved, attributing an equal impact to second and third degree injuries. Finally, it has been thought that mortality follows a bimodal distribution with regards to age, with peaks in the very young and after 60 years, with a nadir in between. We reviewed five year retrospective data from 46 burn centers to put these traditional teachings to the test. We hypothesized that third-degree injury has a profound effect on mortality, regardless of the extent of second-degree, and that mortality increases progressively as a function of age, as opposed to having a bimodal distribution.

Education of first responders and referring medical professionals is considered vital to high-quality burn care. Prior to 1999, the community education program at this burn center was staffed by ICU nurses who volunteered their time. As the program became more popular in the mid-1990s, the requests for lectures exceeded the capacity of a volunteer program. A request to hospital administration for a full-time education coordinator proved to be a difficult “sell” in the climate of budget cut-backs and declining reimbursement. A business-oriented proposal, ultimately accepted, promised an increase in admissions and an improved payer mix, with an annual review of data to demonstrate the cost/benefit advantage. Historical admission and payer mix data were analyzed for annual averages and trends for the five years prior to creation of the education coordinator position and compared to data collected since the initiation of the formal program. During the period studied, additional data were obtained to characterize activity by referral sources, patient home zip codes, and charitable donations to the burn center.

Review of the various modalities put forth to determine burn wound depth suggests that laser Doppler imaging (LDI) is highly accurate and may be the best practical way of determining burn wound depth. We investigated the use of laser Doppler imaging to assess burn depth to confirm its reliability and to produce a standard palette that would facilitate the prediction of burn wound healing times. We conducted a prospective, international multicenter study of LDI for the determination of burn depth in adults and children. They were scanned and photographed two to five days after injury. All clinical decisions were based on standard clinical evaluation of the burn wound. Patients deemed to require surgery had biopsies performed of the deeper areas before excision to confirm depth. Those that did not require surgery were followed until their wounds healed. The patients' wounds were clinically assessed and photographed on day 14 and 21...

LDI has been shown to be a highly accurate and probably the most practical modality to determine burn wound depth but some newcomers have reported difficulties with the precise image interpretation. We investigated the accuracy and the clinical usefulness of LDI in the prediction of burn wound healing times. A prospective, multicenter clinical trial was conducted, with adults and children (181 patients, 532 scans). For each wound, an LDI image (MoorLDI) was obtained between 2 - 5 days post burn; each wound was photographed at this time and 14 and 21 days post burn (unless treated surgically). The images were later reviewed to compare wound outcome with LDI prediction of healing. Factors which confounded LDI prediction were identified and, taking these factors into account, images were scored for accuracy of prediction and clinical usefulness by 6 clinicians: for accuracy, grade 1= mostly misleading, grade 5= completely accurate; for use,...

Objective:To delineate blood transfusion practices and outcomes in patients with major burn injury. Context:Patients with major burn injury frequently require multiple blood transfusions; however, the effect of blood transfusion after major burn injury has had limited study. Design:Multicenter retrospective cohort analysis. Setting:Regional burn centers throughout the United States and Canada. Patient Population:Patients admitted to a participating burn center from January 1 through December 31, 2002, with acute burn injuries of ≥20% total body surface area. Outcomes Measured:Outcome measurements included mortality, number of infections, length of stay, units of blood transfused in and out of the operating room, number of operations, and anticoagulant use. Results:A total of 21 burn centers contributed data on 666 patients; 79% of patients survived and received a mean of 14 units of packed red blood cells during their hospitalization. Mortality was related to patient age, total body surface area burn, inhalation injury, number of units of blood transfused outside the operating room, and total number of transfusions. The number of infections per patient increased with each unit of blood transfused (odds ratio, 1.13; p < .001). Patients on anticoagulation during hospitalization received more blood than patients not on anticoagulation (16.3 ± 1.5 vs. 12.3 ± 1.5, p < .001). Conclusions:The number of transfusions received was associated with mortality and infectious episodes in patients with major burns even after factoring for indices of burn severity. The utilization of blood products in the treatment of major burn injury should be reserved for patients with a demonstrated physiologic need.

Burn depth progresses long after the thermal insult have stopped, thus causing secondary injury. We describe a mature, well-tested, mammalian model that captures user-selectable severity of partial thickness burns, and provides the ability to observe natural history of burn depth progression in real-time with laser Doppler imaging (LDI). Technical details of this model were worked out and matured in a pilot group of 15 rats. Subsequently, 156 rats (Sprague-Dawley, avg. wt = 460g) spanning three experiments represent our cumulative body of experience. Reproducibility was optimized by: 1) thermally massive (500gm) branding irons (100°C-boiling water, 2x2cm contact surface). 2) Consistent contact pressure by gravity only (contact time: 1–14 sec.). 3) Employing a metronome for precision contact timing. H&E stains gave histologic proof of burn depth. LDI at intervals as frequent as 5 minutes over a 5 hr period documented burn depth progression in real-time. These same techniques were scaled up for proof-of-concept YAG laser-burn excision of a range of partial thickness injuries (80 kg, porcine, single animal).

On September 11, 2001, an airplane flown by terrorists crashed into the Pentagon, causing a mass casualty incident with 189 deaths and 106 persons treated for injuries in local hospitals. Nine burn victims and one victim with an inhalation injury only were transported to the burn center hospital. The Burn Center at Washington Hospital Center admitted and treated the acute burn patients while continuing its mission as the regional burn center for the Washington DC region. Eight of the nine burn patients survived. Lessons learned include 1) A large-volume burn center hospital can absorb nine acute burns and maintain burn center and hospital operations, but the decision to keep or transfer burn patients must be tempered with the reality that several large burns can double or triple the work load for 2 to 3 months. 2) Transfer decisions should have high priority and be timely to ensure optimum care for the patients without need for movement of medical personnel from one burn center to another. 3) The reserve capacity of burn beds in the United States is limited, and the burn centers and the American Burn Association must continue to seek recognition and support from Congress and the federal agencies for optimal preparedness.

Real-time metabolic monitoring of varied vascular beds provides the raw data necessary to conduct ultraprecise burn shock resuscitation based on second-by-second assessment of regional tissue perfusion. It also illustrates shortcomings of current clinical practices. Arterial base deficit was continuously monitored during 11 clinical resuscitations of patients suffering burn shock using a Paratrend monitor. Separately, in a 30% TBSA rat burn model (N = 70), three Paratrend monitors simultaneously recorded arterial blood gas and tissue pCO2 of the burn wound and colonic mucosa during resuscitation at 0, 2, 4, 6, and 8 ml/kg/%TBSA. Paratrend data were analyzed in conjunction with previously reported laser Doppler images of actual burn wound capillary perfusion. With current clinical therapy, continuous monitoring of arterial base deficit revealed repetitive cycles of resolution/worsening/resolution during burn shock resuscitation. In the rat model, tissue pCO2 in both burn wounds and splanchnic circulation differed depending on the rate of fluid resuscitation (P <.01 between sham and 0 ml/kg/%TBSA and between 2 ml/kg/%TBSA and 4 ml/kg/%TBSA). Burn wound pCO2 values correlated well with laser Doppler determination of actual capillary perfusion (rho = -.48, P <.01). The following conclusions were reached: 1). Gratuitous and repetitive ischemia-reperfusion-ischemia cycles plague current clinical therapy as demonstrated by numerous "false starts" in the resolution of arterial base deficit; 2). in a rat model, real-time monitoring of burn wound and splanchnic pCO2 demonstrate a dose-response relationship with rate of fluid administration; and 3). burn wound and splanchnic pCO2 are highly correlated with direct measurement of burn wound capillary perfusion by laser Doppler imager. Either technique can serve as a resuscitation endpoint for real-time feedback-controlled ultraprecise resuscitation.

Journal Article Real-Time Metabolic Monitors, Ischemia-Reperfusion, Titration Endpoints, and Ultra-Precise Burn Resuscitation Get access T. D. Light, MD, T. D. Light, MD 1Washington Hospital Center, Washington, DC2MedStar Research Institute, Washington, DC3Uniformed Services University of the Health Sciences, Bethesda, MD Search for other works by this author on: Oxford Academic Google Scholar J. C. Jeng, MD, FACS, J. C. Jeng, MD, FACS 1Washington Hospital Center, Washington, DC2MedStar Research Institute, Washington, DC3Uniformed Services University of the Health Sciences, Bethesda, MD Search for other works by this author on: Oxford Academic Google Scholar A. K. Jain, MS, A. K. Jain, MS 1Washington Hospital Center, Washington, DC2MedStar Research Institute, Washington, DC3Uniformed Services University of the Health Sciences, Bethesda, MD Search for other works by this author on: Oxford Academic Google Scholar D. E. Kim, MD, D. E. Kim, MD 1Washington Hospital Center, Washington, DC2MedStar Research Institute, Washington, DC3Uniformed Services University of the Health Sciences, Bethesda, MD Search for other works by this author on: Oxford Academic Google Scholar T. M. Phillips, MD, T. M. Phillips, MD 1Washington Hospital Center, Washington, DC2MedStar Research Institute, Washington, DC3Uniformed Services University of the Health Sciences, Bethesda, MD Search for other works by this author on: Oxford Academic Google Scholar A. G. Rizzo, MD, FACS, A. G. Rizzo, MD, FACS 1Washington Hospital Center, Washington, DC2MedStar Research Institute, Washington, DC3Uniformed Services University of the Health Sciences, Bethesda, MD Search for other works by this author on: Oxford Academic Google Scholar M. H. Jordan, MD, FACS M. H. Jordan, MD, FACS 1Washington Hospital Center, Washington, DC2MedStar Research Institute, Washington, DC3Uniformed Services University of the Health Sciences, Bethesda, MD Search for other works by this author on: Oxford Academic Google Scholar The Journal of Burn Care & Rehabilitation, Volume 24, Issue suppl_2, March-April 2003, Page S61, https://doi.org/10.1097/00004630-200303002-00037 Published: 01 March 2003

Burn rehabilitation therapists rely on nursing staff to follow through with the positioning and splinting programs. To communicate more effectively, a communication tool that consisted of digital photos and written instructions was created. Microsoft Word and Nikon View software were used to design the communication tool. The purpose of the study was to assess the perceived effectiveness of a communication tool between burn therapists and burn nurses for splinting and positioning. Thirty-two surveys were distributed to burn nursing staff to assess their perception of the communication tool (digital photographs with written instructions) compared with previous methods of instructions (without digital photographs). Seventy-three percent of nurses felt the communication tool with verbal instructions were the best methods of communicating splinting and positioning needs. All respondents felt that the rehabilitation staff should continue to use the communication tool.

INTRODUCTION:Clinicians' judgment as to which burns require excision and grafting remains one aspect of burn care without objective measurements. This study presents a prospective, blinded trial to assess decision to operate by laser Doppler imaging (numerical criteria) versus the clinical judgment of an experienced burn surgeon.METHODS:A number of 23 patients were enrolled in this prospective trial and 41 representative wounds of indeterminate depth were selected for observation. Daily determination of need to operate (burn depth) was made by a single burn surgeon. Laser Doppler imager (LDI) scans of the same wounds were simultaneously obtained, and not revealed to the clinician. Data analysis compared quickness of decision to operate by LDI to the clinician's judgment. Concurrence of decisions by either method was compared.RESULTS:A total of 23 patients and 41 wounds were analyzed. LDI and the surgeon agreed in determination of wound depth 56% of the time (23/41, P=0.031). Biopsy confirmation was obtained for 21 wounds. The surgeon's determination of burn depth was accurate in 71.4% of wounds biopsied (15/21). When the LDI scan median flux indicated need for excision, it was 100% accurate (7/7). When both the surgeon and the LDI were correct in assessing wound depth, LDI would have saved median number of 2 days (minimum=0, maximum=4).CONCLUSION:LDI allowed for earlier, objective determination of need to operate. Concurrence with clinical judgment in this blinded study was excellent. LDI should be seen as an effective aid to clinical judgment when contemplating excision of burns with indeterminate depth.

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, nonburn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and nonburn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and nonburn centers. Early transport to a burn unit is warranted to improve patient outcome.

Background: Clinical studies document correlation of serum lactate and base deficit with mortality in trauma and sepsis. No study of the prognostic value of these two serum markers has been reported in burn injury. Methods: Resuscitation data from 49 patients admitted to the adult Burn ICU were analyzed. Lactate and base deficit were analyzed upon admission and every 2 h during the initial 48 h after admission. Resuscitation was managed per standard routine, blinded to these data, guided by the Parkland formula. Initial statistical analysis with Cox's regression model was used to determine the relationship between survival, resuscitation parameters, and demographics. Then, a logistic regression was used to determine if any of these variables were quickly predictive (initial values) of the risk of death. Results: Two variables were predictive of mortality by the Cox regression model: (1) serum lactate value and (2) patient age. Furthermore, analysis by logistic regression revealed that the initial serum lactate value was separately predictive of mortality. Conclusion: In this study, serum lactate but not base deficit, was a predictor of mortality following major burns. Moreover, initial serum lactate values were also predictive of mortality separately.