European Burn Journal

The CARe Burn Scales are a portfolio of burn-specific PROMs for people affected by burns, including a Child Form (for children < 8 years (parent-proxy)), a Young Person Form (for young people aged 8–17 years), an Adult Form, and a Parent Form (for parents/carers of children aged 0–17 years). This study aimed to determine the responsiveness and minimal important difference (MID) values of the three scales developed for use in paediatric burn services and research. Participants were recruited by 15 UK Burn Services. Participants completed the appropriate CARe Burn Scale and a set of appropriate comparison validated measures, at three time points: 4 weeks (T1), 3 months (T2) and 6 months (T3) post-burn injury. Spearman’s correlation analysis and effect sizes based on Cohen’s d thresholds were reported and MID values were calculated. At baseline, 250 participants completed the Child Form, 69 completed the Young Person Form, and 320 completed the Parent Form. A total of 85–92% of participants were retained at follow up. The tested CARe Burn Scales were all responsive to change over time. MID values were created for all subscales and ranged from 2 to 11 for the Child Form, 3 to 14 for the Young Person Form and 3 to 10 for the Parent Form. The CARe Burn Scales for children, young people and parents are responsive to change over time. The scales are freely available for clinical and research use. Full article

It is well-understood that wound care poses a significant burden on the healthcare system and patient well-being. As such, it is imperative to develop efficient methods that facilitate tissue repair. Our group previously developed a nutritional gel scaffold, proven to accelerate wound repair. Due to its gel-like properties, this scaffold requires a time-consuming reconstitution, and is optimized for cavernous wounds. This pilot study examined the feasibility of a powdered form of this scaffold to accelerate healing of full-thickness wounds, thus broadening the range of applications, while providing a practical product. Splinted full-thickness wounds were generated on the backs of 6 mice, and treated with either powder, the original gel scaffold, or no treatment. Feasibility and efficacy of the powder was assessed through comparison of clinical wound measurements and histological assessments. There was a significant effect of treatment on rate of epithelialization [H(3) = 8.346, p = 0.0024] and on days to epithelial closure [H(3) = 8.482, p = 0.0061]. Post hoc analysis revealed that while requiring no reconstitution and simple to apply, the powder was sufficient to accelerate epithelialization compared to untreated wounds (p < 0.05). Furthermore, our results suggest that application of this powder did not alter certain processes associated with healing progress, such as epidermal thickness and collagen deposition. As such, this powder may provide a novel alternative to our previously developed gel scaffold by accelerating epithelialization, while providing a practical product. Future studies necessitate further evaluation of healing measures with a larger sample size. Full article

The protein C (PC) system has proven to be a crucial cascade in systemic inflammatory and coagulopathic disorders such as severe sepsis and, more recently, in severe burns. We aimed to conflate our recent systemic findings with further investigations in the local tissue effects of a severe burn injury on the expression of PC and its main receptor endothelial protein C receptor (EPCR). Of the 86 patients enrolled in our recent study, 34 consented to biopsies of both normal and burn edge tissue. These were examined histologically and immunostained for PC, EPCR, and CD68. The burn samples expressed lower PC (p = 0.0027) and higher EPCR (p = 0.0253) than the normal samples in a histological severity-dependent manner. There was also a negative association between PC expression and CD68 positive macrophage infiltration (τ_b = −0.214, p = 0.020), which was expectedly higher in burn edge samples (p < 0.0005). Interestingly, while there were no correlations between tissue and plasma PC or EPCR, local PC expression was also prognostic of our previously established outcome of a patient requiring increased medical support (OR 0.217 (95%CI 0.052 to 0.901), p = 0.035). The results suggest that local PC cascade changes from a burn injury may be a separate process to the systemic effects and that the local levels may provide useful information in addition to the diagnostic and prognostic abilities we previously found in the circulating PC system. Full article

Stress disorders are common after burn injuries and universal screening is recommended. This study describes current screening practices and provider beliefs regarding screening for stress disorders in patients with burns in the US. This was a 31-question survey distributed to the American Burn Association. Sixty-two percent of 121 respondents indicated their institution formally screened for ASD and/or PTSD. The most common reason for not screening was a lack of mental healthcare providers (46%), lack of funding (26%) and lack of time (20%). The timing of screening, the person administering the screening, and the method of screening varied for both pediatric and adult patients. Most respondents (87%) believed screening should be a standard of care, but only 32% were comfortable screening pediatric patients and 62% were comfortable screening adults. While screening for ASD and PTSD is recommended for patients with burns, our study indicates that screening is not a current standard of care. Lack of mental healthcare providers, funding, and time are contributing factors. Among those institutions that screen, a uniform screening practice does not exist. Full article

Background: chronic wounds are complex to manage and require an objective assessment for diagnosis and prognosis purposes. Therefore, this article aims to provide an overview of available noninvasive imaging techniques for chronic wound healing described in the literature. Methods: a systematic literature review using electronic databases was performed with appropriate “Mesh” terms. The primary outcome was the validity and reliability of the instrument, whilst the secondary outcome was its feasibility, such as speed of assessment, ease of use and cost of the tool. All studies underwent quality assessment of diagnostic accuracy studies (QUADAS) to ensure the quality of the data. Results: 44 articles were identified evaluating six wound assessment modalities. Most studies (n = 9) reported on a two-dimensional device with a mean error ranging from 1.9–5.1% and an inter/intra rater correlation over 0.9 with a high ICC (>95%). The average QUADAS score was 13, with the lowest being 9 and the highest being 14. Conclusion: this review collectively evaluates objective, reliable, quantitative, and innovative tools to assess wound healing objectively. The most superior wound measuring device was two dimensional. However, hyperspectral imaging had strong potential but required further development in its technology and future clinic validation studies. Full article

The effect of poorly treated pain is well documented in the literature. To offer support for the development of geriatric-specific pain management protocols, this review sought to scope the literature to identify what has been accomplished in geriatric burn pain management and offer suggestions. Arksey and O’Malley’s scoping review methodology was employed with extensive database and grey literature searches. A narrative synthesis was employed to analyse the evidence. The PRISMA extension guidelines for scoping reviews were followed in reporting this review. Sixteen evidence types comprising eleven reviews, two retrospective studies, two book chapters, and one practice guideline were retained in the review. The two retrospective studies emerged from the United States. The review findings suggest that though a plethora of generic pain assessment tools exist, they are yet to be validated in the older adult burn population. Pain management strategies involved the use of pharmacological agents (mainly opioids), but no outcome regarding pain relief was reported. Key issues identified include cautious use of opioids, oversedation concerns, and varied complexities associated with pain management. Though the literature remains largely unexplored, the complexities associated with geriatric burn pain management suggest a need for a multidisciplinary approach. More prospective studies are also needed to evaluate both pharmacological and non-pharmacological interventions in the geriatric burn population. Full article

Invasive fungal wound infection (FWI) after burn injury, while uncommon, is associated with significant morbidity and mortality. There are numerous risk factors for FWI, including large burn size and incomplete excision of burn wounds. FWI can be challenging to diagnose. Close attention to changes in the physical examination and, in particular, to the appearance of burn wounds leads the burn team to be suspicious of FWI. Once FWI is suspected, histopathological evaluation of an incisional biopsy provides definitive diagnosis, while tissue culture enables identification of the causative organism to the species level and facilitates targeted antifungal therapy. Management of FWI focuses largely on aggressive surgical intervention, in addition to adjunctive systemic and topical antifungals and nonpharmacologic therapies. Treatment of FWI involves a multifaceted approach, which requires expertise from the entire multidisciplinary burn team. Full article

Treatment of patients with severe burn injuries is complex, relying on attentive fluid resuscitation, successful management of concomitant injuries, prompt wound assessment and closure, early rehabilitation, and compassionate psychosocial care. The goal of fluid resuscitation is to maintain organ perfusion at the lowest possible physiologic cost. This requires careful, hourly titration of the infusion rate to meet individual patient needs, and no more; the risks of over-resuscitation, such as compartment syndromes, are numerous and life-threatening. Recognizing runaway resuscitations and understanding how to employ adjuncts to crystalloid resuscitation are paramount to preventing morbidity and mortality. This article provides an update on fluid resuscitation techniques in burn patients, to include choosing the initial fluid infusion rate, using alternate endpoints of resuscitation, and responding to the difficult resuscitation. Full article

Burn patients are a unique population when considering strategies for ventilatory support. Frequent surgical operations, inhalation injury, pneumonia, and long durations of mechanical ventilation add to the challenging physiology of severe burn injury. We aim to provide a practical and evidence-based review of mechanical ventilation strategies for the critically ill burn patient that is tailored to the bedside clinician. Full article

Burn injuries can be life-threatening, thus standardized procedures are essential to ensure the best medical care is provided after injury. Therefore, burn care guidelines were created throughout the world. There are many similarities within the different burn guidelines, especially in basic burn care procedures. Taking a closer look, it becomes clear that there are also a lot of disparities within the guidelines. In this review the guidelines of the German Society of Burn Treatment (DGV), British Burn Association (BBA), European Burns Association (EBA), American Burn Association (ABA), Australian and New Zealand Burn Association (ANZBA), and the International Society for Burn Injuries (ISBI) are compared. The DGV-guidelines focus on pre-hospital treatment measures, intensive care treatment and acute wound therapy, whereas the BBA puts emphasis on infrastructure and staff qualification. The EBA created guidelines for medical practitioners and non-medical staff to standardize burn care in European countries with special focus on clear treatment recommendations and best infrastructural facilities. The ABA underlines the need for best qualified medical staff and ABLS- (Advanced Burn Life Support) standards. The ANZBA focuses on best treatment options including novel wound healing biotechnologies and post-burn return-to-function rehabilitation. In contrast to all other guidelines, the ISBI does not only deal with burn care in developed countries but also in resource-limited settings. Special focus lies on the discussion of ethical issues and cost-effectiveness. In this review, advantages and disadvantages of each guideline are discussed. These findings are supposed to help improving burn care procedures worldwide. Full article

Every year, thousands of soldiers and civilians succumb to burn wound trauma with highly unfavorable outcomes. We previously established a modified Walker-Mason rat scald model exhibiting a P. aeruginosa infection. Here we characterize deep partial- (DPT) and full-thickness (FT) burn wounds inoculated with Staphylococcus aureus. Male Sprague-Dawley rats (350–450 g) inflicted with 10% total body surface area burn inoculated with S. aureus (10^3–5 CFU/wound) were monitored over an 11-day period. S. aureus rapidly dominated the wound bed, with bacterial loads reaching at least 1 × 10⁹ CFU/g tissue in all wounds. Within 3 days, S. aureus biofilm formation occurred based on genetic transcripts and Giemsa staining of the tissue. S. aureus infection resulted in a slightly faster recruitment of neutrophils in FT wounds, which was related to necrotic neutrophils. The extent of the inflammatory response in S. aureus infected burn wounds correlated with elevated G-CSF, GM-CSF, GRO/KC and/or TNF-α levels, but a majority of pro- and anti-inflammatory cytokines (IL-1β, IL-6, IFN-γ, IL-10, and IL-13) were found to be suppressed, compared to burn-only controls. S. aureus infection resulted in dynamic changes in DAMPs, including elevated HMGB-1 and reduced levels of circulating hyaluronan within FT wounds. S. aureus also reduced complement C3 at all time points in DPT and FT wounds. These changes in DAMPs are believed to be correlated with burn severity and S. aureus specific bioburden. Collectively, this model showcases the evasiveness of S. aureus through dampening the immune response to flourish in the burn wound. Full article

Very few objective scar evaluations have been conducted with burn survivors, which limits our knowledge of the clinical recovery profile of hypertrophic scars (HSc) and donor site scars (D). The purpose of this study was to prospectively quantify the skin characteristics of post-burn HSc in different anatomical locations (D) and normal skin (N) using objective instrumentation. The skin characteristics of HSc, D, and N in 44 burn survivors were measured at 2, 3, 4, 5, 6, and 7 months post-burn using validated instrumentation: a high-frequency ultrasound (for thickness), Cutometer^® (for pliability), and Mexameter^® (for erythema and pigmentation). Up to five sites were assessed on the same participant, if their scar was located on the upper extremity (UE), lower extremity (LE), and trunk. A mixed model two-way analysis of variance was used to investigate the differences in means between sites at each time point and between time points at each site. The results revealed that the HSc sites were thicker than the D and N at all time points; the UE and trunk HSc were thicker than the LE HSc at 7 months post-burn; the pliability of the trunk HSc did not improve over time; and the UE HSc was more erythematous at 7 months, compared to other anatomical sites, whereas the D erythema decreased from 2 to 7 months. As clinicians have prioritized UE treatments due to their functional importance, this study provides objective measurements to further support this practice and encourages clinicians to also prioritize trunk HSc treatments after burn injuries. Full article

Over 95% of fire-related burns occur in low- and middle-income countries (LMICs), an important and frequently overlooked global health disparity, yet research is limited from LMICs on how survivors and their caregivers recover and successfully return to their pre-burn lives. This study examines the lived experiences of burn patients and caregivers, the most challenging aspects of their recoveries, and factors that have assisted in recovery. This qualitative study was conducted in KwaZulu-Natal, South Africa at a 900-bed district hospital. Participants (n = 35) included burn patients (n = 13) and caregivers (n = 22) after discharge. In-depth interviews addressed the recovery process after a burn injury. Data were coded using NVivo 12. Analysis revealed three major thematic categories. Coded data were triangulated to analyze caregiver and patient perspectives jointly. The participants’ lived experiences fell into three main categories: (1) psychological impacts of the burn, (2) enduring the transition into daily life, and (3) reflections on difficulties survivors face in returning for aftercare. The most notable discussions regarded stigma, difficulty accepting self-image, loss of relationships, returning to work, and barriers in receiving long-term aftercare at the hospital outpatient clinic. Patients and caregivers face significant adversities integrating into society. This study highlights areas in which burn survivors may benefit from assistance to inform future interventions and international health policy. Full article

The aim of this study was to describe the timing of venous thromboembolism diagnosis in patients with severe burns and determine the relationship between venous thromboembolism prophylaxis and venous thromboembolism development in a large trauma hospital. A retrospective cohort study over 10 years from 2009 to 2019 was conducted. Records of 226 patients with >20% total body surface area burns were surveyed, and 20 patients with symptoms suggestive of venous thromboembolism had a diagnosis of VTE confirmed on imaging. Enoxaparin was the most common primary thromboprophylaxis (85%, n = 192), followed by heparin (13.71%, n = 31) and sequential compression devices (0.88%, n = 2). Compared with patients who did not develop a venous thromboembolism, patients who developed a venous thromboembolism had a mean difference in time from admission to thromboprophylaxis prescription of 1.72 days (95% CI = −1.50 to 4.92, p > 0.05) and 10.51 days in those who developed a pulmonary embolus (mean difference = 10.51, 95% CI = 3.73 to 17.32, p = 0.0006). A threshold of 4 days was identified by which 96% of patients who never developed venous thromboembolism during admission were prescribed prophylaxis, compared with 32% of those who developed a pulmonary embolus. No bleeding or adverse events were recorded. Timely prescription of thromboprophylaxis in patients with severe burns is critical in reducing venous thromboembolism incidence. Avoidance of delay post injury is especially critical in preventing venous thromboembolism development. Guidelines on thromboprophylaxis must be considered on an individualised patient basis, considering likely surgical requirements and obesity. Full article

Burns are one of the most serious global public health challenges, and Nepal is no exception. This study aims to present national and local-level data regarding burn injuries within Nepal. Similarly, this study shows how the trained rural first responders respond to burn injuries at the community level, with an example from the Dhading district of Nepal. Police and Emergency Medical Services (EMS) records were used to describe the national and community-level burn injury patterns. The most common cause of burns was found to be household fire, mainly from cooking. The burn cases are distributed across all ages; however, young age group comprises a notable proportion. Victims who were injured but were still able to move primarily accessed emergency health services by walking to the closest facility. Mainly, burn victims received a dressing and cold sponging service at the primary health center. This study described the Emergency Medical Services (EMS) in detail and identified that appropriate training to the community people to respond the burns injuries minimizes the severity of the cases. Lessons learned from this project can be utilized to implement emergency burn injury management for the public and local responders in other rural areas at minimum costs. We recommend establishing burn care instruction in all rural/remote villages and health care centers in Nepal. Full article

Keloid scars are difficult to manage and remain a therapeutic challenge. Corticosteroid therapy alone or ionising radiation (radiotherapy) alone or combined with surgery are first-line treatments, but the scientific justification for these treatments is unclear. The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) is to assess the effects of intralesional corticosteroid injection in treating keloids or preventing their recurrence after surgical removal. Searches for RCTs were conducted through the MEDLINE, EMBASE, EBSCO and Cochrane databases from January 1974 to September 2017. Two authors independently reviewed study eligibility, extracted data, analysed the results, and assessed methodological quality. Sixteen RCTs that included more than 814 patients were scrutinised. The quality of evidence for most outcomes was moderate to high. In 10 RCTs, corticosteroid intralesional injections were compared with 5-fluorouracil, etanercept, cryosurgery, botulinum toxin, topical corticosteroid under a silicone dressing, and radiotherapy. Corticosteroid intralesional injections were more effective than radiotherapy (RR 3.3, 95% CI: 1.4–8.1) but equipotent with the other interventions. In conjunction with keloid excision, corticosteroid treatment was compared with radiotherapy, interferon α-2b and verapamil. In two RCTs, there were fewer keloid recurrences (RR 0.43, 95% CI: 0.21–0.89) demonstrated with adjuvant radiotherapy than with corticosteroid injections. More high-quality, large-scale RCTs are required to establish the effectiveness of corticosteroids and other therapies in keloid management. Full article

The aim of this study was to provide insight into the admission rate, treatment, and healthcare costs of patients with fireworks-related burns admitted to a Dutch burn center in the past 10 years. We hypothesized that, like the nationwide number of injuries, the number of patients admitted to a burn center with fireworks-related burn injuries would have decreased during the study period. In this retrospective multicenter cohort study, all patients with fireworks-related burns admitted to a Dutch burn center between 2009 and 2019 were eligible. Patients were identified from a national database and data were obtained regarding admission details, patient and injury characteristics, treatment, and healthcare costs. A total of 133 patients were included. On average, 12 patients were admitted per year. No increase or decrease was observed during the study period. The median total body surface area burned was 1% (P₂₅–P₇₅ 0.5–2.5) and 75% of the burns were of partial thickness. Thirteen (10%) patients were admitted to the ICU and 66 (50%) underwent surgical treatment. The mean total healthcare costs across all 133 patients were estimated at €9040 (95% CI €5830 to €12,260) per patient. In contrast to the hypothesis, no increase or decrease was observed in burn center admissions over the past 10 years. Most burns were of small size, but nevertheless, all patients were admitted to a burn center and half of them underwent surgical treatment. Full article

Second-degree burns result in the loss of the epidermal barrier and could lead to delayed complications during the healing process. Currently, therapeutic options to treat severe burns are limited. Thus, this work aims to evaluate the effect of NaHS, a hydrogen sulfide (H₂S) donor, in poloxamer hydrogel in topical application and the potentiating effect of injected encapsulated adipose-derived stem cells (ASCs) compared to monolayer ASCs using our previous second-degree burn model on human skin explants. Indeed, our model allows testing treatments in conditions similar to a clinical application. The observed benefits of NaHS may include an antioxidant role, which might be beneficial in the case of burns. Concerning ASCs, their interest in wound healing is more than well documented. In order to evaluate the efficiency of our treatments, we analyzed the kinetics of wound closure, keratinocyte proliferation, and dermal remodeling. The effect of NaHS led to a delay in re-epithelialization, with a decrease in the number of proliferating cells and a decrease in the synthesis of procollagen III. On the contrary, intradermal injection of ASCs, encapsulated or not, improves wound healing by accelerating re-epithelialization and collagen I synthesis; however, only encapsulated ASCs accelerate keratinocyte migration and increase the rate of procollagen III and collagen III. In conclusion, NaHS treatment did not improve burn healing. However, the injection of ASCs stimulated wound healing, which is encouraging for their therapeutical use in burn treatment. Full article

Background: Burn patients are susceptible to healthcare-associated infections. Contaminated surfaces play a role in microbial transmission. This study aimed to quantify the degree of contamination of burns theatre fomites during routine clinical use. Methods: The Patslide Patient Transfer Board (PAT slide) and operating table were investigated using two methods—bacterial swabs to culture viable organisms and adenosine triphosphate (ATP) swabs to measure biological material. Both items were sampled four times a day: before the first case, immediately after a case, immediately before the next case after cleaning and after the terminal clean. Results: Among 82 bacterial samples, four organisms were isolated, including Staphylococcus aureus, Enterobacter cloacae (E. cloacae) x2 and Pseudomonas aeruginosa (P. aeruginosa), all from the PAT slide. The E. cloacae persisted after cleaning. In 9/82 swabs, the ATP count was >10 relative light units (RLU). In all cases where an organism was identified, the ATP count was >10 RLU. Hence the sensitivity and specificity of ATP > 10 RLU in detecting an organism were 100% and 94% respectively. Conclusions: Within burns theatres, there are instances of bacterial contamination on surfaces that persist despite cleaning. ATP luminometers as a point-of-care device may have a role in determining the cleanliness of surfaces, potentially minimizing onwards-bacterial transmission. Full article