RESUMEN
Severe burn injury has been shown to result in hypophosphatemia. Hypophosphatemia can cause cardiac, hematologic, immunologic, and neuromuscular dysfunction. This study compares serum phosphate levels and outcomes in patients who were administered a continuous, preemptive phosphate repletion protocol vs those who only received phosphate supplementation after they developed hypophosphatemia. Records of patients with greater than 19% TBSA burn admitted to the intensive care unit from 2006 to 2010 were reviewed. Patients were divided into two groups: historical controls who received responsive repletion when serum phosphate levels were less than 2.5 mg/dl (2006-2008) and the experimental group that received 30 mmol intravenous every 6 hours starting at approximately 24 hours after injury as long as serum phosphate levels were less than 4 mg/dl (2008-2010). Patients with chronic kidney disease or acute kidney injury were excluded. Data collected included age, weight, burn size, age, all serum phosphate levels, and total amount of phosphate administered. Differences in groups were compared with Mann-Whitney U test and Fisher's exact test. A total of 30 patients were included in the study, 20 in the responsive repletion group and 10 in the continuous repletion group. No significant difference was detected in age, sex, burn size, or full thickness burn size between groups. The continuous group had a statistically lower percentage of hypophosphatemic lab values compared with the responsive group, 13 ± 14% vs 45 ± 21% (P < .0001). No difference was found in percent of observations reflecting hyperphosphatemia (median of 2% in each group, P = .7). Four patients in the continuous group suffered cardiac and/or infectious complications compared with 16 in the responsive group (P = .04). Continuous, pre-emptive repletion of phosphate prevents hypophosphatemia after severe burn injury when compared with responsive repletion in historical controls. The protocol resulted in less hypophosphatemia without increasing the risk of hyperphosphatemia. This study also suggests that continuous repletion may result in fewer complications, but this needs to be confirmed in larger, prospective studies.
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Quemaduras/complicaciones , Quemaduras/tratamiento farmacológico , Hipofosfatemia/tratamiento farmacológico , Hipofosfatemia/prevención & control , Fosfatos/administración & dosificación , Estudios de Casos y Controles , Protocolos Clínicos , Enfermedad Crítica , Femenino , Humanos , Hipofosfatemia/etiología , Infusiones Intravenosas , MasculinoRESUMEN
The use of high-dose vitamin C (hdVC, 66 mg/kg/hour × 18 hours) infusion is a useful adjunct to reducing fluid requirements during resuscitation of burn shock. Routine point-of-care glucose (POCG) analysis has been inaccurately high in observed patients undergoing hdVC. Inaccurate POCG could potentially lead to iatrogenic hypoglycemia if the fictitious hyperglycemia is treated with insulin. This study is a retrospective analysis of plasma glucose measurements from a central laboratory (LG) compared with POCG during and 24 hours after hdVC infusion. Records of adult patients receiving hdVC infusions during burn resuscitation over 1 year were reviewed. Charts selected for analysis included those with glucose measurements using POCG and LG that were taken simultaneously, during hdVC infusion, and 24 hours after completion. All specimens were drawn from arterial lines. POCG was measured with Accu-Chek Inform (Roche, Indianapolis, IN) and LG was measured by Siemens Dimension Vista 500 (Siemens, Deerfield, IL) using biochromic analysis. Nonparametric statistical analysis was performed using Wilcoxon's matched pairs test and Spearman correlation with significance at P < .05. Of 18 adult patients undergoing burn resuscitation with hdVC infusion, 5 were chosen for analysis (%TBSA 40 ± 15; age 51 ± 18). All data were pooled with 11 comparisons both during and after hdVC. The mean POCG (225 ± 71) was significantly higher than mean LG (138 ± 41) on hdVC (P = .002). There was no difference between POCG (138 ± 30) and LG (128 ± 23) after hdVC was finished (P = .09). There was a negative correlation between POCG and LG on hdVC (-0.64, P = .04) and a positive correlation off hdVC (0.89, P = .0005). POCG analysis during hdVC infusion is significantly higher than laboratory glucose measurements. Once the hdVC infusion is complete, POCG and laboratory glucose measurements are not statistically different. Treating erroneously high glucose based on POC testing is potentially dangerous and could lead to hypoglycemia and seizures.
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Ácido Ascórbico/administración & dosificación , Glucemia/análisis , Quemaduras/tratamiento farmacológico , Errores Diagnósticos/prevención & control , Hiperglucemia/inducido químicamente , Sistemas de Atención de Punto/normas , Choque Traumático/tratamiento farmacológico , Adulto , Anciano , Análisis Químico de la Sangre/métodos , Quemaduras/sangre , Quemaduras/complicaciones , Enfermedad Crítica , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Hiperglucemia/sangre , Hiperglucemia/diagnóstico , Hipoglucemia/diagnóstico , Hipoglucemia/prevención & control , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Choque Traumático/etiología , Equilibrio Hidroelectrolítico/efectos de los fármacos , Adulto JovenAsunto(s)
Quemaduras/epidemiología , Quemaduras/terapia , Sistema de Registros , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Atención Ambulatoria/organización & administración , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Distribución por Sexo , Índices de Gravedad del Trauma , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: The National Burn Repository (NBR) currently only contains inpatient data from participating United States burn centres. However, the majority of the patients treated in burn centres are managed as outpatients. Unfortunately, this significant demographic is not represented in the NBR annual report. The purpose of this study is to compare the difference in aetiology and demographics between inpatient and outpatient burn patients. In addition, the workload demands for data entry of inpatient and outpatient records in the burn registry will be compared. METHODS: Outpatient and inpatient burn data at an American Burn Association-Verified Burn Center were prospectively collected during fiscal year 2008. Data collected included age, burn size and aetiology of burn. Aetiology was also stratified by age group. Inpatient data were compared with outpatient data with Fisher's exact test. The amount of time taken to enter inpatients' and outpatients' data parameters in the TRACS v5.0 database was also recorded. RESULTS: Data were collected for 241 inpatients and for 543 outpatients during fiscal year 2008. No significant differences in gender or race were found between the two groups. When comparing demographics, outpatients tended to be younger (26±19 years vs. 32±22 years, p=0.01) with a smaller burn size (2.5±7% vs. 6.8±12%, p<0.001) and a lower frequency of full-thickness burns (17% vs. 41%, p<0.001). Of the patients managed as an outpatient, a total 29.7% were eventually admitted to the hospital. Just over half of those (16.7%) initially managed in the outpatient setting were admitted for a planned surgical procedure. The other 13% were admitted for pain control and wound-care issues. Injury was more likely to be caused by flame in inpatients (p<0.001). Scald injuries were more common in the outpatient setting (34% vs. 27%), but this difference did not reach statistical significance (p=0.079). Outpatients were more likely to be injured with a contact burn (p<0.0001). Outpatient injury was more likely to be work-related than inpatient injury (p=0.0497), but less likely to be related to recreational activity (p=0.006) or arson/abuse/assault (p=0.0158). An experienced TRACS v5.0 user required 11±0.6 min to enter an inpatient record and 6±0.6 min to enter an outpatient record in the system (p=0.002). CONCLUSIONS: Inpatient injury is more likely to be caused by flame, whereas outpatient injury is more likely to be caused by scald and contact burns. Work-related burn is more likely to be treated in the outpatient setting. Outpatient burn data also take less time to enter. Since significant differences in aetiology exist, outpatient data should be reported separately from inpatient data in order to understand the full spectrum of burn aetiology. The NBR and other registries should be modified to track outpatient burn data and outcomes.
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Unidades de Quemados/estadística & datos numéricos , Quemaduras/epidemiología , Hospitalización/estadística & datos numéricos , Servicio Ambulatorio en Hospital/estadística & datos numéricos , Vigilancia de la Población/métodos , Adolescente , Adulto , Distribución por Edad , Quemaduras/etiología , Niño , Preescolar , Recolección de Datos/estadística & datos numéricos , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Factores Sexuales , Estados Unidos , Adulto JovenAsunto(s)
Amish , Quemaduras/tratamiento farmacológico , Terapias Complementarias/ética , Medicina Tradicional , Preparaciones de Plantas/uso terapéutico , Negativa del Paciente al Tratamiento/ética , Adulto , Resultado Fatal , Humanos , Consentimiento Informado/ética , Masculino , Medicina Tradicional/métodos , Religión y MedicinaAsunto(s)
Trastornos Relacionados con Cocaína/complicaciones , Cocaína/efectos adversos , Levamisol/efectos adversos , Osteonecrosis/inducido químicamente , Traumatismos de los Tejidos Blandos/inducido químicamente , Vasculitis Leucocitoclástica Cutánea/inducido químicamente , Vasculitis Leucocitoclástica Cutánea/cirugía , Humanos , MasculinoRESUMEN
Approximately 100 firefighters suffer fatal injuries annually and tens of thousands receive nonfatal injuries. Many of these injuries require medical attention and restricted activity but may be preventable. This study was designed to elucidate etiology, circumstances, and patterns of firefighter burn injury so that further prevention strategies can be designed. In particular, modification of protective equipment, or turnout gear, is one potential strategy to prevent burn injury. An Institutional Review Board-approved retrospective review was conducted with records of firefighters treated for burn injury from 2005 to 2009. Data collected included age, gender, TBSA, burn depth, anatomic location, total hospital days per patient, etiology, and circumstances of injury. Circumstances of injury were stratified into the following categories: removal/dislodging of equipment, failure of equipment to protect, training errors, and when excessive external temperatures caused patient sweat to boil under the gear. Over the 4-year period, 20 firefighters were treated for burn injury. Mean age was 38.9 ± 8.9 years and 19 of 20 patients were male. Mean burn size was 1.1 ± 2.7% TBSA. Eighteen patients suffered second-degree burns, while two patients suffered first-degree burns. Mean length of hospitalization was 2.45 days. Scald burns were responsible for injury to 13 firefighters (65%). Flame burns caused injury to four patients (20%). Only three patients received contact burns (15%). The face was the site most commonly burned, representing 29% of injuries. The hand/wrist and ears were the next largest groups, with 23 and 16% of the injuries, respectively. Other areas burned included the neck (10%), arm (6.5%), leg (6.5%), knees (3%), shoulders (3%), and head (3%). Finally, the circumstance of injury was evaluated for each patient. Misuse and noncontiguous areas of protective equipment accounted for 14 of the 20 injuries (70%). These burns were caused when hot steam/liquid entered the gear via gaps in the sleeve or face mask. Three patients (15%) received injury due to removal/dislodging of their safety equipment, two patients (10%) suffered their injuries during training exercises when they were not wearing their safety equipment, and the final patient (5%) received burns due to sweat evaporation. Firefighter burn injuries occur to predictable anatomic sites with common injury patterns. Modification and optimization of gear to eliminate gaps that allow steam/hot liquid entry may decrease burn injury. Improving education regarding the use of protective equipment may also be beneficial.
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Quemaduras/epidemiología , Quemaduras/prevención & control , Bomberos/estadística & datos numéricos , Equipos de Seguridad , Adulto , Distribución por Edad , Unidades de Quemados , Quemaduras/terapia , Estudios de Cohortes , Femenino , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Salud Laboral , Valor Predictivo de las Pruebas , Prevención Primaria/métodos , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Distribución por Sexo , Tasa de SupervivenciaRESUMEN
BACKGROUND: Previous studies of recombinant human thrombin (rThrombin) enrolled adult and adolescent patients. This phase 4, open-label, single-group study was conducted in pediatric patients undergoing synchronous burn wound excision and skin grafting to provide information regarding the safety and immunogenicity of rThrombin (primary and secondary endpoints) in this population. METHODS: Topical rThrombin was applied as a hemostatic aid during a surgical procedure (day 1). Adverse events and clinical laboratory abnormalities were recorded during the study. Immunogenicity samples were collected on days 1 and 29 (study end). Study results were summarized with descriptive statistics. RESULTS: Thirty patients enrolled and 28 completed the study. Mean age was 6.9 years (range, 0.9-17.8 years); 40.0% of patients were girls. Flame and scald were the most common burn types (33.3% each, n = 10/30). Mean graft size was 3.6% total body surface area. Procedural pain (50.0% patients), pruritus (43.3%), and anemia (30.0%) were the most commonly reported adverse events. All adverse events and clinical laboratory abnormalities were considered unrelated to treatment. No patients developed anti-rThrombin product antibodies at day 29. CONCLUSIONS: In pediatric patients undergoing burn wound excision and skin grafting, rThrombin was well tolerated and did not lead to the formation of anti-rThrombin product antibodies.
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Pérdida de Sangre Quirúrgica/prevención & control , Quemaduras/cirugía , Hemostáticos/uso terapéutico , Isoanticuerpos/sangre , Proteínas Recombinantes/uso terapéutico , Trombina/uso terapéutico , Administración Tópica , Adolescente , Anemia/epidemiología , Niño , Preescolar , Terapia Combinada , Quimioterapia Combinada , Ensayo de Inmunoadsorción Enzimática , Epinefrina/uso terapéutico , Femenino , Técnicas Hemostáticas , Hemostáticos/efectos adversos , Hemostáticos/inmunología , Humanos , Lactante , Isoanticuerpos/biosíntesis , Masculino , Dolor/epidemiología , Complicaciones Posoperatorias/epidemiología , Hemorragia Posoperatoria/prevención & control , Prurito/epidemiología , Proteínas Recombinantes/efectos adversos , Proteínas Recombinantes/inmunología , Trasplante de Piel , Trombina/efectos adversos , Trombina/inmunologíaRESUMEN
Fentanyl lacks the antiinflammatory properties of morphine. Morphine attenuates the inflammatory response through differential stimulation of µ-receptor subtypes. Patients who receive morphine during coronary artery bypass graft have been shown to experience less postoperative fever than those who receive fentanyl. Patients who receive continuous fentanyl infusions in increased room temperatures after thermal injury may be at increased risk to experience higher body temperature than those who receive morphine. The records of 28 patients with >20%TBSA burn in 30 intensive care unit rooms (13 received fentanyl and 15 received morphine or hydromorphone) and 12 trauma patients who received fentanyl in 22°C intensive care unit rooms were reviewed. Mean maximum core temperature and percentage of temperature recordings > 39°C in the first 48 hours of admission were compared between burn patients who received fentanyl, those who did not, and with trauma patients. Burn patients exposed to fentanyl experienced significantly higher temperatures (40.1 ± 0.9°C) compared with those given morphine (38.7 ± 0.8°C) and compared with trauma patients (37.5 ± 2.4°C), P < .01 and P < .001, respectively. Burn patients on fentanyl had temperatures > 39°C for a higher percentage of time (33 ± 27%) than those without fentanyl (7.2 ± 13%) and trauma patients (1 ± 2.8%), P < .01 and P < .001, respectively. No differences in other medications administered, acute physiology and chronic health evaluation II scores, or the number of infections that could account for temperature disparities between groups existed. Burn patients who receive fentanyl in 30°C rooms experience higher body temperatures and are febrile for a higher percentage of time than those receiving morphine only. Morphine has well-established antiinflammatory properties and likely attenuates the postburn inflammatory response more than fentanyl, resulting in lower body temperatures. This phenomenon needs to be further investigated in additional studies.
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Analgésicos Opioides/efectos adversos , Temperatura Corporal/efectos de los fármacos , Quemaduras/complicaciones , Fentanilo/efectos adversos , Morfina/efectos adversos , Narcóticos/efectos adversos , APACHE , Adulto , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/farmacología , Antiinflamatorios , Unidades de Quemados/estadística & datos numéricos , Quemaduras/rehabilitación , Quemaduras/terapia , Cuidados Críticos , Femenino , Fentanilo/administración & dosificación , Fentanilo/farmacología , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Morfina/administración & dosificación , Morfina/farmacología , Narcóticos/administración & dosificación , Narcóticos/farmacología , Medición de Riesgo , Estadísticas no ParamétricasRESUMEN
Resuscitation of burn victims with high-dose ascorbic acid (vitamin C [VC]) was reported in Japan in the year 2000. Benefits of VC include reduction in fluid requirements, resulting in less tissue edema and body weight gain. In turn, these patients suffer less respiratory impairment and reduced requirement for mechanical ventilation. Despite these results, few burn centers resuscitate patients with VC in fear that it may increase the risk of renal failure. A retrospective review of 40 patients with greater than 20% TBSA between 2007 and 2009 was performed. Patients were divided into two groups: one received only lactated Ringer's (LR) solution and another received LR solution plus 66 mg/kg/hr VC. Both groups were resuscitated with the Parkland formula to maintain stable hemodynamics and adequate urine output (>0.5 ml/kg/hr). Patients with >10-hour delay in transfer to the burn center were excluded. Data collected included age, gender, weight, %TBSA, fluid administered in the first 24 hours, urine output in the first 24 hours, and Acute Physiology and Chronic Health Evaluation II score. PaO2 in millimeters mercury:%FIO2 ratio and positive end-expiratory pressure were measured at 12-hour intervals, and hematocrit was measured at 6-hour intervals. Comorbidities, mortality, pneumonia, fasciotomies, and renal failure were also noted. After 7 patients were excluded, 17 patients were included in the VC group and 16 in the LR group. VC and LR were matched for age (42 ± 16 years vs 50 ± 20 years, P = .2), burn size (45 ± 21%TBSA vs 39 ± 15%TBSA, P = .45), Acute Physiology and Chronic Health Evaluation II (17 ± 7 vs 18 ± 8, P = .8), and gender. Fluid requirements in the first 24 hours were 5.3 ± 1 ml/kg/%TBSA for VC and 7.1 ± 1 ml/kg/%TBSA for LR (P < .05). Urine output was 1.5 ± 0.4 ml/kg/hr for VC and 1 ± 0.5 ml/kg/hr for LR (P < .05). Vasopressors were needed in four VC patients and nine LR patients (P = .07). VC patients required vasopressors to maintain mean arterial pressure for a mean of 6 hours, but LR needed vasopressors for 11 hours (P = .2). No significant differences in PaO2 in millimeters mercury:%FIO2 ratio, positive end-expiratory pressure, frequency of pneumonia, renal failure, or inhalation injury were found. VC group had four mortalities, and LR group had three mortalities (P = 1). VC is associated with a decrease in fluid requirements and an increase in urine output during resuscitation after thermal injury. Although this study did not find a difference in outcomes with VC administration, it demonstrates that VC can be safely used without an increased risk of renal failure. The effects of VC should be further studied in a large-scale, prospective, randomized trial.
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Antioxidantes/uso terapéutico , Ácido Ascórbico/uso terapéutico , Quemaduras/terapia , Resucitación/métodos , APACHE , Adulto , Antioxidantes/administración & dosificación , Ácido Ascórbico/administración & dosificación , Comorbilidad , Femenino , Hemodinámica , Humanos , Soluciones Isotónicas/uso terapéutico , Masculino , Persona de Mediana Edad , Respiración con Presión Positiva , Estudios Retrospectivos , Lactato de Ringer , Estadísticas no Paramétricas , Resultado del Tratamiento , MicciónRESUMEN
The nation is faced with a shortage of subspecialty physicians, including burn surgeons. Exposure to a specialty in medical school has been shown to influence students' career choices. The authors postulate that exposure to burn surgery increases their interest in the field. Students from a medical school with an American Burn Association-verified burn center and from a school without a burn center were anonymously surveyed and asked to report their interest and knowledge regarding burn surgery using a 5-point Likert scale. They were asked about their current year in school, gender, overall interest in surgery, and any prior exposure to burn surgery (eg, preceptorship or rotation). Students were asked whether exposure to burn surgery or to a strong mentor might increase their interest in the field. Finally, they were asked to pick the most important factor in a list of deterrents to pursuing a career in burn surgery. Predictors of interest in burn surgery were determined with regression analyses. A total of 380 of 662 students responded to the survey (57.4%). Significant predictors of interest in burn surgery were an interest in surgery (P < .001, odds ratio [OR] = 56.3), prior exposure to burn surgery (P = .02, OR = 5.7), and year in school (P = .006, OR = 1.7). First- and second-year students were more likely to report interest in burn surgery (P < .001). Gender and medical school attended were not significant predictors. Prior exposure to burn surgery became a stronger predictor in subgroup analysis of the fourth-year students (P < .001, OR = 24.5). The majority of students reported that exposure to burn surgery (76%) and a strong mentor (87%) would make them more likely to consider burn surgery as a career. "Not interested in surgery" was the most important deterrent to pursuing a career in burn surgery, which was selected by 33% of students. However, 25% of students chose "I don't know anything about burn surgery" as the most important deterrent. Factors specific to burn surgery were less frequently selected (eg, wound care and hot operating room). The majority of students reported ignorance of the field of burns: 64% disagreed that they understood what a burn surgeon does on a daily basis, and 74% agreed they did not know enough about the field to consider it as a career. Exposure to burn surgery in the form of a clinical rotation fosters medical student interest. However, the majority of medical students lack knowledge about the field of burn surgery. Many consider this a deterrent to selecting it as a career. More exposure during medical school and strong mentorship may influence more students to become burn surgeons. Mentorship and recruiting efforts should be focused on students with a general interest in surgery.
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Quemaduras/cirugía , Selección de Profesión , Médicos/provisión & distribución , Estudiantes de Medicina/psicología , Adulto , Femenino , Humanos , Modelos Logísticos , Masculino , Análisis de Regresión , Encuestas y Cuestionarios , Estados UnidosRESUMEN
Dermal templates are well established in the treatment of burn wounds and acute nonburn wounds. However, the literature regarding their use for reconstruction of chronic, nonhealing wounds is limited. This study describes a series of patients with chronic wounds reconstructed with a commercially available bilayer, acellular dermal replacement (ADR) containing a collagen-glycosaminoglycan dermal template and a silicone outer layer. A retrospective review was performed of 10 patients treated for chronic wounds with ADR and negative pressure dressing followed by split-thickness skin graft between July 2006 and January 2009. Data collected included age, gender, comorbidities, medications, wound type or location, wound size, the number of applications of ADR, the amount of ADR applied (in square centimeter), the amount of time between ADR placement and grafting, complications, need for reoperation, and percentage of graft take after 5 and 14 days. The mean age of study subjects was 44 years. All patients in the study had comorbidities that interfere with wound healing and were treated for lower extremity wounds (four to legs, five to ankles, and one to foot). The wounds had a variety of causative factors including venostasis ulcers (6, 60%), trauma in diabetic patients (2, 20%), brown recluse bite (1, 10%), and a wound caused from purpura fulminans (1, 10%). The average wound size and amount of ADR applied was 162±182 cm². Each patient required only one application of ADR. The average time between ADR placement and skin grafting was 36.5 days. The mean percentage of graft take at 5 days was 89.55%, 14 days was 90%, and 21 days was 87.3%. Only two patients required regrafting, and one of these grafts was lost because of patient noncompliance. ADR can be used successfully in the treatment of chronic wounds. ADR provides direct wound coverage and can conform to a variety of anatomical sites. This study demonstrates that the use of ADR in treating chronic wounds results in high rates of skin graft take. Favorable results were obtained despite the majority of patients having comorbidities that would normally interfere with wound healing.
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Quemaduras/cirugía , Sulfatos de Condroitina , Colágeno , Traumatismos de la Pierna/cirugía , Extremidad Inferior/cirugía , Adolescente , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
The Parkland formula is the standard for calculating the initial intravenous fluid rate for resuscutation after thermal injury. However, it is cumbersome when used by those with modest burn training. We propose an easier method to calculate fluid requirements that can be initiated by first-line providers. Burn size is estimated by using the Burn Size Score (BSS), which is then crossreferenced with the patient's weight on a preprinted Burn Resuscitation Index (BRI), based on the Parkland formula, to determine initial hourly fluid rate. Seventy-two residents and faculty in the Departments of Surgery and Emergency Medicine were surveyed. Participants were shown a diagram of a burn patient and asked to calculate the initial fluid rate using the Parkland formula from memory. The study was repeated with a different diagram, and the participants were asked to calculate the initial fluid rate using the BRI (a preprinted card with written instruction pertaining to its use). Statistical analysis was performed with the McNemar test. Using the Parkland formula, 33% of surgeons and 17% of emergency medicine physicians were able to calculate the initial fluid rate. Using the BRI, 56% of surgeons and 77% of emergency medicine physicians were able to calculate the fluid rate correctly (P < .01 and P < .001, respectively). Fifty-four percent of physicians surveyed believed that the BRI was easier to use. The accuracy of determining initial fluid rate was low using the Parkland formula and "rule of nines" from memory. Accuracy increased when the BRI was used. The BRI serves as a visual aid and provides some instruction, allowing the user to calculate fluid resuscitation with greater accuracy than with rote memorization of a formula. The BRI might be a useful tool for providers with minimal burn training. However, further investigation is warranted.
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Algoritmos , Quemaduras/terapia , Fluidoterapia/métodos , Resucitación/métodos , Superficie Corporal , Peso Corporal , Quemaduras/patología , Humanos , Puntaje de Gravedad del Traumatismo , Soluciones Isotónicas/administración & dosificaciónRESUMEN
INTRODUCTION: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) requently causes skin and soft tissue infections (SSTIs). Referring primary care physicians often prescribe inactive antibiotics when referring SSTIs caused by MRSA for incision and debridement. METHODS: Demographics and culture results (organism and sensitivity) were collected for patients treated for SSTI between 2007-2009. Antibiotic regimens started by referring PCPs were noted. Prevalence of MRSA and antibiotic resistance profiles were tabulated. Isolates resistant to the drug initially prescribed were also noted. RESULTS: Of 187 patients, 40.1% grew MRSA. All MRSA was sensitive to doxycycline and trimethoprim-sulfamethoxazole, whereas 88% were sensitive to clindamycin and 79% to levofloxacin. 48% of patients received an antibiotic inadequate for their isolate before referral. CONCLUSIONS: CA-MRSA is extremely common. Patients are often prescribed antibiotics inadequate for MRSA. Doxycycline or trimethoprim-sulfamethoxazole with incision/drainage should be used as initial therapy for SSTI when MRSA is suspected.
RESUMEN
Contact burns from clothing irons are a common injury seen in children. These injuries occur when an unattended iron is within reach of toddlers in its upright position. In a previous study, the authors have shown that the surface of an iron takes 90 minutes to cool below the epidermal injury threshold of 49 degrees C. The authors have constructed an "iron shoe" to shield the iron surface from young hands during cooling. The device is intended to set the cooling iron in its down position providing additional protection. The device will insulate the iron surface to avoid the fire hazard when positioned in this manner. A silicone polymer was used to create an "iron shoe." This polymer is stable at temperatures up to 370 degrees C. The device included sidewalls to shield the edges from contact. Thermal analysis of the device was conducted using an inexpensive and expensive iron. Thermocouples were placed on the iron surface and below the iron shoe. The irons were heated to its maximum temperature, placed in the shoe and then unplugged. Temperature cooling curves were obtained from the thermocouples. The experiment was repeated by measuring the temperature difference between the iron edge and the shoe sidewalls. The surface of both expensive and inexpensive irons reached a maximum of 205 degrees C. The temperature below the iron shoe reached a maximum of 49 degrees C (inexpensive) and 60 degrees C (expensive). The iron edge temperature reached a maximum of 188 degrees C (inexpensive) and 154 degrees C (expensive). The shoe sidewall temperature achieved a maximum of 52 degrees C (inexpensive) and 49 degrees C (expensive). Both expensive and inexpensive irons reach temperatures over 200 degrees C. The silicone "iron shoe" effectively shielded the surface and edge of both irons and approached the epidermal injury threshold of 49 degrees C. The temperature beneath the expensive iron did exceed 49 degrees C, but because the intention of the device is to place the iron in the down position, the surface will be out of reach from children. This device prototype offers a solution to protect toddler's hands from contact with cooling irons. Further design modifications will be tested to reduce the cost of the device without impairing its effectiveness.
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Accidentes Domésticos/prevención & control , Quemaduras/prevención & control , Artículos Domésticos , Equipos de Seguridad , Diseño de Equipo , Seguridad de Equipos , HumanosAsunto(s)
Quemaduras/epidemiología , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Quemaduras/terapia , Niño , Preescolar , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Sistema de Registros , Distribución por Sexo , Tasa de Supervivencia , Factores de Tiempo , Índices de Gravedad del Trauma , Estados Unidos/epidemiologíaAsunto(s)
Quemaduras/epidemiología , Sistema de Registros , Adolescente , Adulto , Anciano , Quemaduras/mortalidad , Quemaduras/prevención & control , Niño , Preescolar , Femenino , Costos de la Atención en Salud , Humanos , Lactante , Recién Nacido , Tiempo de Internación , Masculino , Persona de Mediana Edad , Factores de Riesgo , Sobrevida , Estados Unidos/epidemiologíaRESUMEN
In the early 1990s, the American Burn Association (ABA) started its first burn registry development initiatives. The impetus for the registry development software originated from several directions, including the following: (1) the recognition that national registries were widespread and of proven benefit; (2) growing demands from accrediting institutions, payers, and patient advocacy groups for objective and verifiable data regarding patient costs, treatments, and outcomes; and (3) the shift toward "evidence-based" medicine and the ongoing analysis of treatment effectiveness. The ABA has issued three calls for burn registry data for its National Burn Repository (NBR): 1994, 2002, and 2005. In 1994, 28 burn centers contributed data for more than 6,400 patients treated from 1991 to 1993. The ABA announced its second call for data in 2001 and distributed the published results of more than 54,000 acute burn admissions treated from 1974 to 2002 at the Association's 2002 Annual Meeting. The third ABA call for data was issued in the Fall of 2005. The results are detailed in this report, which provides a summary of more than a quarter million acute burn admissions from 1995 to 2005, representing 70 hospitals from 30 states plus the District of Columbia. Statistics are presented in chart and table format to illustrate such key factors as patient age, burn size group, types of injuries, mortality rates, and average hospital charges by etiology and length of hospital stay. The data presented herein should help stimulate quality improvement programs in burn care, as burn centers compare their performance with the national data and as research is expanded using the NBR. The NBR will be published annually and, with continued refinements to the registry software, should become of increasing importance to clinicians, payers, researchers, and the public.