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Acute Burns - Introduction and Assessment

Acute Burns - Introduction and Assessment

Acute Burns - Introduction and Assessment

ABSTRACT

Burns are cutaneous injuries caused by various agents or mechanisms, including thermal (further subdivided into liquid, solid and gaseous agents), electric, chemical, and other rarer tissue insults such as radiation. The physiologic effects of burns are manifested by tissue damage and subsequent cell death. Annually in the United States, over half a million patients will present to emergency department with burns, and 10% of those require hospitalization. 

This topic provides an evidence-based review and framework for assessment of acute burns, including epidemiology, risk factors, etiology, pathophysiology, first aid, primary and secondary assessment, transfer criteria, burns classification, documentation and ICD-10 coding.

First Aid: The first responder should remove the subject from all potential burning sources including heat/flame, live electrical sources, and chemicals, with careful consideration of his/her own personal safety. See other steps recommended by Clinical Guidelines in this section.

Initial Care: The initial assessment of patients with acute burns must be expedited using a systematic protocol of care such as the Advanced Burn Life Support (ABLS) and Emergency Management of Severe Burns (EMSB). This systematic approach involves the assessment of the patient, resulting in a plan for subsequent management and transfer to a specialized burn center if necessary. See details on primary and secondary assessment, and assessment of inhalation injury in this section. 

Classification: Burn injuries are frequently classified according to the depth of tissue destruction and extent of the injury measured in body surface area percentage. See classification systems in this section.

Burn center referral criteria: See guidelines for referral to specialized burn units, as recommended by the American Burns Association 

Documentation: Ensure treatment documentation meets medical necessity criteria. See recommendations for documentation in this section

Treatment: See topic "Acute Burns - Treatment".

ICD-10 Coding:  See section 'ICD-10 Coding'

INTRODUCTION

Overview

This topic provides a review and framework for assessment of acute burns, including epidemiology, risk factors, etiology, pathophysiology, first aid, primary and secondary assessment, transfer criteria, burns classification, documentation and ICD-10 coding. For clinical guidelines and quality measures, see "Acute Burns - Overview". For management of acute burns see "Acute Burns - Treatment".

Background

  • Definition: Burns are cutaneous injuries caused by various agents or mechanisms, including thermal (further subdivided into liquid, solid and gaseous agents), electric, chemical, and other rarer tissue insults such as radiation. The physiologic effects of burns are manifested by tissue damage and subsequent cell death.
  • Relevance: Annually in the United States, over half a million patients will present to emergency department with burns, and 10% of those require hospitalization.[1]

Epidemiology

Prevalence and incidence data below were extracted from the American Burns Association National Burn Repository reports of 2015 and 2017 [1][2]:

Prevalence

  • By age:
    • Pediatric (ages 1-15 years): 23.5%
    • Adult (ages 20 to 59 years): 55%
    • Geriatric (age 60 years or older): 15%
  • By gender:
    • Male: 68%
    • Female: 32%
  • By ethnicity:
    • Caucasian: 59%
    • African-American: 20%
    • Hispanic: 14%
    • Other: 7%

Incidence

  • In the U.S. in 2016, there were 486,000 documented burn injuries (includes individuals that presented for and received medical treatment).

Mortality

  • Survival Rate: 96.8%, on average.[1][2] Rates differ depending on burn depth and extent. More than 67% of the reported total burn sizes were less than 10% total body surface area and these cases had a mortality rate of 0.6%.[1]
  • The mortality rate from severe burn injuries is much lower than it was in the 1960s due to advances in surgical management and the advent of intensive care. Apart from the establishment of specialized burns centers, the survival rate after severe burns improved between 1970 and 1980. The evolution of knowledge about burns has heavily evolved in all aspects of care, including the initial response at the accident site, diversity of the response to trauma, clinical and surgical management, understanding of the risk factors for complications and sequelae, as well as prevention including educational measures and campaigns aimed toward high risk populations.[3]

Etiology

  • By reported cause upon admission to healthcare facility:
    • Fire/Flame: 3%
    • Scald: 34%
    • Contact: 9%
    • Electrical: 4%
      • Sources can be either of low voltage, such as contact with a home electrical outlet, or of high voltage, which is most common in the workplace.[4] 
    • Chemical: 3%
      • Chemical agents include caustic acids (lab chemicals such as hydrochloric acid, battery acid), caustic bases (bleach, drain cleaner), and even fertilizer.[4] 
    • Other: 7%
  • By place of occurrence:
    • Home: 73%
    • Occupational: 8%
    • Street/Highway: 5%
    • Recreational/Sport: 5%
    • Other: 9% 
  • A large proportion of accidents leading to burn injuries occur at home, with children being victims in nearly half of all cases [1][2]; in this population, a common burn mechanism is direct contact with hot liquids (scald); abuse or neglect should be investigated. The geriatric population also has a high risk for liquid thermal burns due to their lessened ability to react coupled with other common physical manifestations of aging, such as diminished visual acuity. In adults, burns occur mostly at home or place of work.[1][2]

Pathophysiology

Thermal injury

  • Tissue trauma from burn injury results in local and systemic inflammatory responses. The local response depends on the intensity of the heat or level of causticity of the agent in contact with the tissues, making the depth of the burn directly proportional to the duration of contact between the agent and the tissues, as well as the amount of heat released by the agent.
  • Local inflammatory response was first described by Jackson in 1947 as being comprised of three zones (Figure 1)[5]: 
    • The zone of coagulation occurs at the point of the greatest thermal injury, which is generally at the most central area; this site has undergone irreversible damage due to the denaturation of tissue proteins.
    • The zone of stasis surrounds the central zone and is characterized by diminished tissue perfusion; the process of volume resuscitation post burn injury is to increase perfusion in this area and prevent progression of the damage.
    • The zone of hyperemia is the most peripheral zone, and represents an area of reactivity characterized by increased tissue perfusion. The chance of tissue recovery in the first 24 hours is likely, except in cases of prolonged hypoperfusion or severe sepsis. “Conversion” of burns, as it is commonly referred to, or apparent progression of injury to deeper tissue levels, can occur over this time period.

Figure 1. Pathophysiology of burns - Jackson's zones

  • Systemic inflammatory response occurs when the burn injury exceeds 20% of the TBSA (total body surface area). The release of pro-inflammatory cytokines and other inflammatory mediators in the anatomical site of the burn injury leads to hypovolemic and distributive shock, or “burn shock”, which is characterized by increased capillary permeability and systemic vascular resistance, small vessel hydrostatic pressure, third spacing, decreased cardiac output, and hypovolemia. Edema forms rapidly in the interstitial space during the first eight hours after initial injury, and continues to develop, though at a slower rate, for at least 18 hours.
    • Fluid resuscitation with crystalloids is required to reverse the evolution of shock. Volume required for resuscitation can be estimated by the calculated TBSA and the weight of the patient. The rate of fluid infusion must be titrated every hour, with adjustments based on the adequacy of the physiological response including the presence of adequate diuresis and normal arterial blood pressure. See "Fluid Resuscitation" section in "Acute Burns - Treatment" for available calculation methods.

    Electrical injury

      • The pathophysiology of electrical burn depends on the voltage, current flow, and tissue resistance. Electrical burns can damage tissue by the local generation of heat and the direct action of the passage of the current itself through the tissue. Heat leads to coagulative cell necrosis and the electrical current causes cell membrane disruption leading to tissue loss and death.[6]
      • Fatal complications include severe acute renal failure secondary to massive rhabdomyolysis and myoglobinuria, sepsis and disseminated intravascular coagulation.[6]

      Chemical injury

      • The severity and clinical appearance of chemical burns are directly correlated with the amount, concentration of the agent, viscosity, location and duration of contact and penetrability. The pathophysiology of a chemical injury varies according to the type of chemical, which can be acid or alkaline, and organic or inorganic [7]
        • Acids denature cellular proteins leading to coagulative necrosis. On the skin, substances with a pH of less than 2 cause coagulative necrosis upon contact with the skin; which  often results in an eschar that prevents further penetration of the acid.[7][8][9]
        • Alkaline substances denature proteins and causes saponification of lipids (present in the cell membrane); the combined effect allows alkaline substances to cause liquefactive necrosis and penetrate into the submucosa and muscularis, which often results in more severe injuries than those caused by acids.[9]
        • Organic substances differ from inorganic chemicals by the presence of carbon. Organic agents typically dissolve the lipid membrane of cells which disrupt physiological processes.
        • Inorganic solutions cause injury by denaturation of physiological proteins. Inorganic solutions form salts and directly bind to skin.[8]
      • In addition, as chemical reactions are exothermic, thermal burns often occur simultaneously.

      Systemic effects

      • Almost every organ system is affected by severe burns, causing inflammation, hypermetabolism, muscle wasting, insulin resistance and metabolic changes known to remain for several years following injury.[10][11]
      • Two distinct physiological phases have been identified after severe burns: emergent or 'ebb' phase, and 'flow' or hypermetabolic phase.[10][11]
        • Emergent or 'ebb' phase: the first phase, which peaks at 12 hours after burn injury, can last up to 72 hours and is marked by decreased tissue perfusion, decreased metabolism and edema. 
          • Primary goals during this phase involves restoring and preserving tissue perfusion to avoid ischemia from hypovolemic and cellular shock, and restoring or preserving normothermia.[10][11]
            • Adequate resuscitation is essential during this phase. Refer to section "Fluid Resuscitation" section in "Acute Burns - Treatment". 
            • Hypothermia may occur in people with severe burns and can lead to serious complications such as shock, multisystem organ failure, and death.[11] For people with more than 10% of the body surface burned, the core body temperature may reset up to 2oC above normal temperature readings.[11] That is, if their core body temperature is within the normal range of equal to or less than 36.5oC, they may be experiencing hypothermia and is therefore at risk of further harm and associated complications.[11] Risk factors for hypothermia include younger or older age, female gender, larger percentage of the body burned.[11] Targeted temperature management with adjuncts such as application of warming devices and prewarmed intravenous fluids in the early stages of hospital admission and during surgery is essential to survival.[11]
        • 'Flow' or hypermetabolic phase: the second phase phase, which starts approximately 3 days after the burn injury and lasts more than a year, is characterized by a decrease in vascular permeability, increased heart rate, and decreased peripheral vascular resistance resulting in an increase in cardiac output and increased metabolic phase.[10][11]

      ASSESSMENT

      First Aid 

      First aid starts with the first responder at the site of the accident and ends when Initial Care starts at a healthcare facility.[12] First aid steps recommended by the International Society for Burn Injuries (ISBI), are outlined below [12]

      • The first responder should remove the subject from all potential burning sources including heat/flame, live electrical sources, and chemicals, paying attention to his/her own personal safety. 
        • Removing the subject from the source of the flame is more important than putting out the fire.
        • If the person's clothes are on fire let the person lie down or sit down then pour water liberally, as wet clothes will not catch fire.
      • For heat/flame injuries, cool down the burn wound with clean cold running water for 15-20 minutes. After cooling the site of injury, the patient should be kept warm. 
      • For chemical burns, identify the agent. Ensure personal and bystanders' safety and remove and dispose of all contaminated clothing. Irrigate area with running clean water for up to 45 minutes. If possible, call poison control (while awaiting first responders) to determine if there is an antidote or or action that can be performed to reverse to diminish the chemical reaction causing the burn.
      • For electrical burns, ensure personal and bystanders' safety and separate the victim from the source using non-conductive material. Begin cardiopulmonary resuscitation if needed, and cool the burns
      • Transfer the victim to the nearest medical or burn facility. During transport:
        • Elevate limbs during transportation to limit edema
        • If suspicion of inhalation injury, position individual between lying and sitting (e.g., with the head of bed at 45 degrees)
        • If trained personnel available, initiate primary assessment (ABCDE) as described below

      Initial Care

      The initial assessment of burn patients must be expedited using a systematic protocol of care such as the Advanced Burn Life Support (ABLS) and Emergency Management of Severe Burns (EMSB).[3] This systematic approach involves the primary and secondary assessment of the patient, resulting in a plan for subsequent management and transfer to a specialized burn center if necessary.[13]

      Primary assessment

      The initial assessment of a patient with acute burn follows the sequence below:

      • Airway
      • Breathing and Respiration
      • Circulation
      • Disability (Neurologic status)
      • Exposure/environmental control: remove all the patient’s clothes completely but prevent hypothermia
      Airway
      • Protecting the airway in the patient with severe burns should be prioritized, and clinicians should always have a high index of suspicion for associated inhalation injury. Early endotracheal intubation is often indicated in patients with symptoms of inhalation injury or signs of burns on the face, in the nares, oral cavity, or oropharynx.[14] See section ‘Assessment of inhalation injury’ below.
      Breathing and respiration
      • After ensuring airway patency, auscultate lung fields to assess the adequacy of the patient’s ventilation and oxygenation. Early recognition of circumferential full thickness injury in the thoracic or cervical region is imperative for the timely performance of escharotomy to prevent respiratory compromise.[15]
      Circulation
      • Cardiac monitoring, continuous pulse oximetry, and measurement of arterial blood pressure must be performed for patients with major burns (see definition of 'major burn' in section 'Classification of Acute Burn Injuries - By severity' below ) in order to monitor the circulatory status of the patient. Volume resuscitation with crystalloids must be commenced based on the weight of the patient and the extent of burns, using a validated tool for calculation. [15] See  "Fluid Resuscitation" section in "Acute Burns - Treatment" 
      Disability (Neurologic status)
      • If there is a possibility of concomitant trauma, hypoxia related or unrelated to inhalation injury, drug use, or a preexisting neurological condition, neurological status should be assessed, and appropriate specialties consulted including orthopedics and neurology.[15]
      Exposure
      • The patient’s clothes must be removed completely, including accessories such as watches, rings, necklaces, including anything that may cause a tourniquet effect or prevent complete assessment. This process must occur in a warm environment in order to avoid hypothermia and associated sequelae.[15]
      Burn Total Body Surface Area Calculation (TBSA)
      • During the initial examination, Total Body Surface Area percentage (TBSA %) and depth of the burns will be estimated in order to best guide overall care, including accurate fluid resuscitation.[15] The extent of the burns may be calculated with:
        • Lund-Browder tables:  is the most accurate method for estimating TBSA for both adults and children and can be particularly useful in children since there is a great difference in proportions between the head and the lower limbs.
        • The rule of nines: the body is divided into anatomical regions, and each area receives a value that is equal to nine or a multiple thereof.
        • Patient’s palm: In cases where only one part of the body is burned, the rule of the patient’s palm may be used; the palm of the hand, including the fingers, corresponds to about 1% of the TBSA.[3]
      • When calculating TBSA, clinicians should exclude areas with superficial (first degree) burns.[16] See section ‘Classification of Burn Injuries’ below.
      • Patients with partial thickness burn injury that exceeds 20% of the TBSA experience “burn shock”, as described above, which requires carefully calculated volume resuscitation.[3][15] Fluid overload is as physiologically compromising to the patient as inadequate fluid resuscitation. Fluid overload can result in compartment syndrome in the extremities and abdomen as well as acute respiratory distress, whereas, inadequate fluid resuscitation may further prolong states of shock, cause the zone of coagulation to extend, and potentially lead to organ failure [14][15]. See "Fluid Resuscitation" section in "Acute Burns - Treatment" 
      Figure 2. Calculating the Total Body Surface Area with the "Rule of Nines" and "Lund-Browder" tables

      Assessment of inhalation injury

      • In spite of the great advances that have been made in the management of burns in recent decades, patients with concomitant inhalation injury continue to suffer increased morbidity and mortality. For this reason, efforts at developing new therapeutic approaches for improving outcomes in these patients are crucial. 
      • The diagnosis of inhalation injury is made based on [3]:
        • History of :
          • Exposure to fumes in an enclosed space with incomplete combustion of materials
          • Decreased level of consciousness during the physical examination
          • Presence of soot in the buccal or nasal cavity
          • Presence of burns of the face
        • Signs of :
          • Hoarseness, carbon eschars, wheezing, and dyspnea
        • Bronchoscopy: A systematic review concluded that bronchoscopy is a useful tool for identifying inhalation injury (moderate certainty evidence, level B) [17]
        • Chest X-rays or measured normal oxygenation do not exclude inhalation injury.
      • The three main classes of inhalation injury are: supraglottic, infraglottic and systemic.
        • The main physiologic presentation following infraglottic inhalation injury is increase in bronchial blood flow; the mucosa becomes hyperemic, edematous, produces copious mucous secretions, and transudation of plasma occurs in the airways, which alters the motility of local cilia.[18]
        • Currently, there is no consensus on the diagnosis or grading of inhalation injury. Approaches differ by geographic location, from conservative management to advanced therapies based on nebulization with various pharmacologic agents.
        • Treatment options for these three subtypes differ based on the patient presentation and symptoms.
      • Systemic effects of inhalation injury may occur [14][19][20]:
        • Indirectly by hypoxia or hypercapnia, which result from pulmonary function deficits and the systemic effects of pro-inflammatory cytokines 
        • Directly by toxicity from metabolic byproducts such as carbon monoxide and cyanide. Both of these agents with may cause nonspecific clinical symptoms, including circulatory collapse. Carbon monoxide and cyanide poisoning must be treated with oxygen and hydroxocobalamin respectively. See protocol for treatment of carbon monoxide poisoning with hyperbaric oxygen therapy in topic "Acute Carbon Monoxide Poisoning".

        Secondary Assessment

          • During this phase, assess the need of an indwelling urinary catheter, nasogastric tube, and other monitoring devices or lines.
          • Collect urine drug screens and serum specimens to assess for ingestion of or exposure to other substances that may have contributed to injury or changes in neurological status.
          • Tetanus immunization status must be investigated and if there is no definitive record of current vaccination, or if the vaccination is outdated, the patient must be immunized as soon as possible.[3]
          • This systematic process simplifies identification of the major contributors to mortality from extensive burns in the first 24 hours, without waste of time or resources.[3]

          Classification of acute burn injuries

          Burn injuries are frequently classified according to the depth and extent of the injury:

          By depth

          The preferred terminology referring to the depth of burns that used the word “degree” has been changed to “thickness”. The latter, more descriptive system, is recommended, although both terms continue to be used.[16] Table 1 below describes the types of burns by depth of injury:

          Table 1. Classification of burn injuries by depth

          DepthDescriptionInjury characteristics
          Healing process

          Superficial (first degree)

          Involves only the epidermis, without forming blisters

          Common causes include UV light, minor thermal burns

          There may be desquamation of the epidermis

        • Local pain and erythema that resolves within 4 to 6 days, with complete resolution in 10 days
        • No scar formation
        • Superficial partial thickness (superficial second degree)


          Affects the epidermis and upper layers of papillary dermis, may present with bullae

          Red, moist and painful base, often with erythematous, weeping bullae

        • Repair occurs within 7 to 14 days
        • Generally no scarring, but pigment changes possible
        • Deep partial thickness (deep second degree)

          Affects the epidermis and most of the dermis, including the reticular dermis

          White, dry base, less painful than superficial partial thickness

        • Repair can take 21 days or more depending on concomitant injuries and patient condition at time of injury
        • Typically causes some scarring and potentially contractures

        • Full thickness (third degree)

          Affects the entire skin structure

          Tight, leathery appearance, painless

          Presence of plaques that vary in color from white to black



        • No repair, no re-epithelialization
        • Requires excision and skin grafting
        • May require escharotomy depending on site
        • By extent (total body surface area)

          See calculation of TBSA in section ‘Burn Total Body Surface Area Calculation (TBSA)’ above. Table 2 illustrates a classification system based on TBSA. [21]

          Table 2. Classification of burn injuries by total body surface area

          ClassificationTotal body surface area (TBSA)
          Grafted Area

          Small

          Less than or equal to 10%

          Less than 4%

          Medium

          Greater than 10% and less than or equal to 25%

          Between 4 and 10%

          Large

          Greater than 25%

          Greater than 10%

          By severity

          Burns can be classified by severity according to the Table 3 below, based on data from The American Burns Association and The American College of Surgeons. [22][23]

          Table 3. Burns classification by severity.[22][23] Regardless of severity classification, patients that meet at least one of the referral criterion established by The American Burns Association (in general, moderate or major burns) should be referred to a burn center (see ‘Burn center referral criteria'). Many moderate burns may ultimately be treated at hospitals with experience in burn care, as determined by the burn center that would potentially manage the patient.

          MinorModerateMajor/ Severe
          • Partial-thickness burns <10% TBSA in patients 10 to 50 years old
          • Partial-thickness burns <5% TBSA in patients under 10 or over 50 years old
          • Full-thickness burns <2 % TBSA in any patient without other injury

          Also:

          • Does not meet any of the burn center referral criteria as defined by the American Burn Association
          • Isolated injury
          • Does not affect feet, face, hands, perineum or major joints
          • Is not circumferential
          • Partial thickness burns with 10–20% TBSA in adults
          • Partial thickness burns between 5-10% TBSA in children or those over age 50
          • 2–5% full thickness burn
          • Low voltage burn, suspected inhalation injury, circumferential burn
          • Concomitant medical problem predisposing to infection (e.g., diabetes, sickle cell disease)
          • Partial thickness burns greater than 20% TBSA in adults
          • Partial thickness burns greater than 10% TBSA in children or those over age 50
          • >5% full thickness burn
          • High voltage burn,
          • Chemical burn,
          • Any clinically significant burn to the eyes, ears, genitalia, or major joints,
          • Clinically significant associated injuries (e.g., fracture, other major trauma)

          Burn center referral criteria

          After assessment is complete, and if at least one criterion proposed by the American Burns Association (ABA) is met, patients are triaged and transferred to a burn unit. Criteria for transfer are listed below [24]:

          • Partial thickness burns greater than 10% TBSA.
          • Full thickness burns in any age group
          • Burn injury including the face, eyes, perineum, hands, feet and joints
          • Electrical burns
          • Chemical burns
          • Inhalation injury or circumferential burn injury of the chest or limbs
          • Associated illnesses that could complicate management, prolong recovery, or affect mortality.
          • Associated multi-system trauma,
          • Burned children in hospitals without qualified personnel or equipment for the care of children.
          • Burn injury in patients who will require special social, emotional, or rehabilitative intervention, or patients with attempted self-harm

          Infection Assessment

          Acute burn injuries are initially sterile, however within 24-48 hours normal bacterial flora from the surrounding non-injured skin spreads into the injured area, increasing risk for infection. In addition, patients with severe burns admitted to acute care facilities are at risk for hospital-acquired infection.

          • For patients with severe burn injuries (TBSA > 20%), the American Burn Association recommends constant monitoring for local and systemic signs of infection.[25]
            • The standard diagnostic criteria for infection and sepsis do not apply to burn patients.[25] Patients with severe burns are in a state of chronic systemic inflammatory stimulation, with a baseline temperature elevated to about 38.5°C. Tachycardia and tachypnea persist for months in patients with extensive burns. White blood cell count is abnormally elevated, making leukocytosis a poor indicator of sepsis. Locally, erythema, pain and exudate are constantly observed in non-infected burn injuries. As a result, patient and wounds need constant surveillance, so that subtle systemic or local changes that may signal infection can be detected.[25]
          • Definitions according to the American Burn Association Consensus on infection in burns [25]:
            • Wound infection: Presence of bacteria alone is not considered infection. A burn wound is considered infected if bacteria is present in the wound and wound eschar at high concentrations (>10^5 bacteria/g tissue), and there is no invasive infection.
            • Invasive infection: Infection is invasive if there is “presence of pathogens in a burn wound at concentrations sufficient in conjunction with depth, surface area involved and age of patient to cause suppurative separation of eschar or graft loss, invasion of adjacent unburned tissue or cause the systemic response of sepsis syndrome", culture shows >10^5 bacteria/g tissue, there is invasion or destruction of unburned skin/tissue. Invasive infection may occur with or without sepsis, but many burn wound invasive infections, however, are life threatening and need urgent treatment (usually wound excision). 
          • Diagnosis of wound infection: practically, diagnosis of wound infection is made when clinical signs of infection are observed and an organism is isolated from the wound organism.[25][26] Criteria by the American Burn Association are listed below [25]:
            • Objective criteria: 
              • Quantitative biopsy (can be used to confirm but is not reliable. It may help with identifying the organism) 
              • Quantitative swab (poor test but may help with identifying organism)
              • Tissue histology
            • Subjective criteria: 
              • Changes in pain, erythema, exudate, color of the wound bed
                • Yellow/green exudate may not be indicative of infection, as colonizing Pseudomonas aeruginosa produces exudate with this characteristics. Purple-black and “punched-out” areas of the wound suggests invasive Pseudomonas, which is a surgical emergency. 
                • Small papules of purulence may indicate Candida infection.
                • Gray-brown plaques that can be scooped out of the wound suggests Aspergillus.
                • Punched out lesions in the wound may indicate herpes simplex.
              • Unexpected change in the appearance or depth of the wound 
              • Systemic changes 
              • Premature separation of burn eschar (if eschar has not been surgically excised)
          • For management, see section 'Infection Management' in topic "Acute Burns - Treatment".

          Documentation

          Clinicians should ensure appropriate documentation of all encounters is in place, to support medical necessity. Important information to be included are listed below: 

          History and Physical Exam

          • Age of the patient
          • Burn mechanism and etiology of injury
          • Burn depth and extent
          • Time elapsed since injury, any first aid administered on site and during transport, mode of transport 
          • Primary and secondary assessment, presence of inhalation injury
          • Presence of infection, co-morbidities
          • Late effects/sequelae of burn injury
          • Any criterion that would require patient to be referred to a specialized burn center (see section 'Burn center referral criteria')
          • Work up, imaging, laboratory, and other diagnostic testing ordered

          Impression

          State mechanism of injury, agent, TBSA%, burn depth, if inhalation injury, presence of infection, co-morbid conditions

          Plan

          Depends on the severity of the acute burn, and should include: 

          • Disposition: should the patient be referred or treated at a designated burn center? If not, where is the place of service? 
          • Systemic treatment provided/ to be provided:
            • initial stabilization
            • pain control
              •  Medicare Quality Payment Program, Quality Measure: "Pain Assessment and Follow-Up"
            • coagulopathy management
            • thromboprophylaxis
            • antibiotics
            • nutrition
              •  Medicare Quality Payment Program, Quality Measure:
                • "Process Measure: Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers" 
                • "Patient Reported Nutritional Assessment and Intervention Plan in Patients with Wounds and Ulcers"
                • "Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up"
            • physical therapy
            • disposition plans
          • Local interventions:
            • escharotomy
            • excision with or without xenograft or autograft
            • debridement
            • cleansing
            • topical therapy
            • dressings

          See topic "Acute Burns - Treatment" 

          CODING

          ICD-10 

          See all Burn Injuries ICD-10 codes in the Appendix - ICD-10 Coding

          Identify [27]

          • Burn type: 
            • Thermal burn: due to a heat source (e.g., fire, hot appliance, electricity, and radiation - excludes sunburns)
            • Corrosion burn: due to chemicals. This code requires identification of the chemical substance, which is the first listed diagnosis. The chemical substance is found in the Table of Drugs and Chemicals. These codes identify the substance and the external cause or intent, so an external cause of injury code is not required. Assign codes for the place of occurrence, activity and external cause status.
          • Burn depth:
            • First degree (superficial): erythema
            • Second degree (superficial or deep partial thickness): blistering
            • Third degree (full thickness)
          • Burn extent: 
            • Total body surface area (TBSA%) burned
            • Total body surface area (TBSA%) burned with third degree burns
          • Agent: 
            • Corrosive (T code - see Table of Drugs and Chemicals)
              • Acids 
              • Alkalines 
              • Caustics
              • Chemicals 
            • Thermal (except sunburn) (X-code - see Alphabetic Index to External Causes )
              • Electricity
              • Flame
              • Heat (gas, liquid, or object)
              • Radiation
              • Steam

          Note: Burns of the eye and internal organs are classified by site but not by degree.

          Coding Guidelines for burns, related conditions, and complications of burns are as follows:

          • Code first: 
            • For multiple external burns, first list the code that reflects the highest degree of burn 
            • For cases in which the site of the burn is not specified, or if there is a need for additional information on the extent of the burns, first list codes from category T31 Burns classified according to the extent of body involved, or T32 Corrosions classified according to the extent of body surface involved
          • For each burn site, assign separate codes 
          • For burns of the same anatomic site:
            • If different degrees of burn are present in the same anatomic site, assign only the highest degree recorded in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-)
          • It is not recommended to use codes for 'unspecified sites' as these are extremely vague (codes from category T30)
          • Classifying burns and corrosions by extent of body surface area involved (codes from category T31 and T32)
            • Check TBSA% recorded with Lund-Browder tables, Rule of nines, or Palm Rule (see section 'Classification of Acute Burn Injuries')
            • Codes from category T31 should be used whenever possible to:
              • Provide data for evaluating burn mortality, such as that needed by burn units
              • When there is mention of a third-degree burn involving 20% or more of body surface
          • Non-healing burns: code as acute burns with 7th character extension 'A'. Necrosis of burned skin is coded as a non-healing burn
          • Infected burns: use additional code for the infection
          • Late effects/ sequelae of burns: use a burn or corrosion code with the 7th character 'S'. Both a code for a current burn or corrosion code and a code for sequela may be assigned on the same record

          APPENDIX

          ICD-10 Coding

          • T20-T25 
             Burns and corrosions of external body surface, specified by site
            • T20 
               Burn and corrosion of head, face, and neck
            • T21 
               Burn and corrosion of trunk
            • T22 
               Burn and corrosion of shoulder and upper limb, except wrist and hand
            • T23 
               Burn and corrosion of wrist and hand
            • T24 
               Burn and corrosion of lower limb, except ankle and foot
            • T25 
               Burn and corrosion of ankle and foot
          • T26-T28 
             Burns and corrosions confined to eye and internal organs
            • T26 
               Burn and corrosion confined to eye and adnexa
            • T27 
               Burn and corrosion of respiratory tract
            • T28 
               Burn and corrosion of other internal organs
          • T30-T32 
             Burns and corrosions of multiple and unspecified body regions
            • T30 
               Burn and corrosion, body region unspecified
            • T31 
               Burns classified according to extent of body surface involved
            • T32 
               Corrosions classified according to extent of body surface involved

          DRG

          • DRG 927 EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT
          • DRG 933 EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT
          • DRG 928 FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC
          • DRG 929 FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC
          • DRG 934 FULL THICKNESS BURN WITHOUT SKIN GRFT OR INHALATION INJURY
          • DRG 935 NON-EXTENSIVE BURNS

          See principal or secondary diagnosis for each DRG in the ICD-10-CM/PCS MS-DRG v38.1 Definitions Manual

          REVISION UPDATES

          DateDescription
          6/3/19Added section on Infection Assessment

          CURATED ARTICLES

          A systematic review of foam dressings for partial thickness burns., 2019 Jun
          Journal: The American Journal of Emergency Medicine

          BACKGROUND: Partial thickness burns are the most common form of thermal burns. Traditionally, dressing for these burns is simple gauze with silver sulfadiazine (SSD) changed on a daily basis. Foam dressings have been proposed to offer the advantage of requiring less frequent dressing change and better absorption of exudates.

          OBJECTIVE: To compare the impact of silver-containing foam dressing to traditional SSD with gauze dressing on wound healing of partial thickness burns.

          METHODS: We performed a systematic literature search using PubMed, EMBASE, CINAHL, Web of Science, Cochrane Library database and Google Scholar for trials comparing traditional SSD dressings to that of silver-containing foam dressing on wound healing in partial thickness burns < 25% of the body surface area. We excluded studies that enrolled burns involving head, face, and genitals; burns older than or equal to 36 h, non-thermal burns, and immunocompromised patients. Quality of trials was assessed using the GRADE criteria. The main outcome, complete wound healing, is reported as percentages of wound with complete epithelialization after the follow up period. Relative risks of complete healing are also reported with respective 95% CI. Time to healing and pain score before, during, and after dressing change at each follow up visit are compared between the groups (means with standard deviation or medians with quartiles).

          RESULTS: We identified a total of 877 references, of which three randomized controlled trials (2 combined pediatric and adult trials and 1 adult trial) with a total of 346 patients met our inclusion criteria. All three trials compared silver-containing foam dressing to SSD and gauze on partial thickness burns. Moderate quality evidence indicated no significant difference in wound re-epithelialization between the groups across all three trials as confidence intervals for the relative risks all crossed 1. Although pain scores favored foam dressing at the first dressing change (7 days), there was no significant difference between the groups at the end of the treatment period at 28 days. Time to wound healing was also similar across the three trials with no statistical difference. Infection rates favored the foam-dressing group, but data were inconsistent.

          CONCLUSION: Moderate quality evidence indicates that there is no significant difference in wound healing between silver-containing foam dressing and SSD dressing. However, foam has the added benefit of reduced pain during the early treatment phase and potentially decreased infection rates.

          Copyright © 2019. Published by Elsevier Inc.

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          Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: European consensus guidelines update., 2020 Jun
          Journal: Burns

          INTRODUCTION: Bromelain-based Enzymatic Debridement has been introduced as an additional concept to the burn surgeon's armamentarium and is best indicated for mid-to deep dermal burns with mixed patterns. Increasing evidence has been published focusing on special regions and settings as well as on limitations of Enzymatic Debridement to improve patient care. To better guide Enzymatic Debridement in view of the increasing experience, there is a need to update the formerly published consensus guidelines with user-orientated recommendations, which were last produced in 2017.

          METHODS: A multi-professional expert panel of plastic surgeons and burn care specialists from twelve European centers was convened, to assist in developing current recommendations for best practices with use of Enzymatic Debridement. Consensus statements were based on peer-reviewed publications and clinical relevance, and topics for re-evaluation and refinement were derived from the formerly published European guidelines. For consensus agreement, the methodology employed was an agreement algorithm based on a modification of the Willy and Stellar method. For this study on Enzymatic Debridement, consensus was considered when there was at least 80 % agreement to each statement.

          RESULTS: The updated consensus guidelines from 2019 refer to the clinical experience and practice patterns of 1232 summarized patient cases treated by the panelists with ED in Europe (2017: 500 cases), reflecting the impact of the published recommendations. Forty-three statements were formulated, addressing the following topics: indications, pain management and anesthesia, large surface treatment, timing of application for various indications, preparation and application, post-interventional wound management, skin grafting, outcome, scar and revision management, cost-effectiveness, patient´s perspective, logistic aspects and training strategies. The degree of consensus was remarkably high, with consensus in 42 out of 43 statements (97.7%). A classification with regard to timing of application for Enzymatic Debridement was introduced, discriminating immediate/very early (≤12 h), early (12-72 h) or delayed (>72 h) treatment. All further recommendations are addressed in the publication.

          CONCLUSIONS: The updated guidelines in this publication represent further refinement of the recommended indication, application and post-interventional management for the use of ED. The published statements contain detailed, user-orientated recommendations aiming to align current and future users and prevent pitfalls, e.g. for the successful implementation of ED in further countries like the USA. The significance of this work is reflected by the magnitude of patient experience behind it, larger than the total number of patients treated in all published ED clinical trials.

          Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.

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          The use of hydrogen peroxide in the treatment of burn wound infection: a systematic review, and survey of current clinical practice in the United Kingdom., 2020 Apr 15
          Journal: International journal of burns and trauma

          BACKGROUND: Current treatment of burn wound infection (BWI) is with antibiotics and/or wound cleaning/superficial debridement. The overuse of antibiotics has contributed to antibiotic resistance. One possible solution is the use of hydrogen peroxide (H2O2). The aim of this study is to investigate the current use of H2O2 in the treatment of BWI through a comprehensive review of published evidence and a survey of current clinical practice.

          METHODS: A systematic review was performed on the clinical use of H2O2 in the treatment of BWI using four major search engines from inception to 1st July 2018. English-written full-text publications of any study design were included and data extraction was conducted in duplicate. An 11-question survey on the use of H2O2 in the treatment of BWI was sent to all burn services in the United Kingdom (UK).

          RESULTS: The systematic review generated 1,168 papers, with only one fulfilling inclusion criteria. This was a randomised control trial (RCT) which demonstrated that soaking grafts with 2% H2O2 prior to grafting improved graft take rate in infected burn wounds compared with grafts treated with saline prior to grafting, concluding that H2O2 can be recommended in the treatment of BWI intraoperatively. A 72.7% (16 burns services) response rate was achieved to the survey. Of these, 75% of burn services (n = 12) do not currently use H2O2 in clinical practice. Of the 25% (n = 4) which do use H2O2, no service had a protocol for its use. The most common reasons for not using H2O2 were a lack of published evidence and fear of side-effects.

          CONCLUSION: Only 1 paper suggests H2O2 to be effective in BWI treatment and there is no national consistency or protocol for the use of H2O2 in the treatment of BWI in the UK. More large-scale research is required to determine whether H2O2 may offer a solution to the need to use antibiotics to treat BWI.

          IJBT Copyright © 2020.

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          Local Treatment of Burns with Cell-Based Therapies Tested in Clinical Studies., 2021 Jan 21
          Journal: Journal of clinical medicine

          Effective wound management is an important determinant of the survival and prognosis of patients with severe burns. Thus, novel techniques for timely and full closure of full-thickness burn wounds are urgently needed. The purpose of this review is to present the current state of knowledge on the local treatment of burn wounds (distinguishing radiation injury from other types of burns) with the application of cellular therapies conducted in clinical studies. PubMed search engine and ClinicalTrials.gov were used to analyze the available data. The analysis covered 49 articles, assessing the use of keratinocytes (30), keratinocytes and fibroblasts (6), fibroblasts (2), bone marrow-derived cells (8), and adipose tissue cells (3). Studies on the cell-based products that are commercially available (Epicel®, Keraheal™, ReCell®, JACE, Biobrane®) were also included, with the majority of reports found on autologous and allogeneic keratinocytes. Promising data demonstrate the effectiveness of various cell-based therapies; however, there are still scientific and technical issues that need to be solved before cell therapies become standard of care. Further evidence is required to demonstrate the clinical efficacy and safety of cell-based therapies in burns. In particular, comparative studies with long-term follow-up are critical.

          View on PubMed View on Source
          Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature., 2021 May 01
          Journal: Annals of Plastic Surgery

          INTRODUCTION: Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years.

          METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns.

          RESULTS: An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes.

          DISCUSSION: The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers.

          CONCLUSIONS: More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

          Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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          Use of infrared thermography for assessment of burn depth and healing potential: A systematic review., 2021 Jun 12
          Journal: Journal of Burn Care & Research

          INTRODUCTION: Burn wound depth assessments are an important component of determining patient prognosis and making appropriate management decisions. Clinical appraisal of the burn wound by an experienced burn surgeon is standard of care but has limitations. IR thermography is a technology in burn care that can provide a non-invasive, quantitative method of evaluating burn wound depth. IR thermography utilizes a specialized camera that can capture the infrared emissivity of the skin, and the resulting images can be analyzed to determine burn depth and healing potential of a burn wound. Though IR thermography has great potential for burn wound assessment, its use for this has not been well documented. Thus, we have conducted a systematic review of the current use of IR thermography to assess burn depth and healing potential.

          METHODS: A systematic review and meta-analysis of the literature was performed on PubMed and Google Scholar between June 2020-December 2020 using the following keywords: FLIR, FLIR ONE, thermography, forward looking infrared, thermal imaging + burn*, burn wound assessment, burn depth, burn wound depth, burn depth assessment, healing potential, burn healing potential. A meta-analysis was performed on the mean sensitivity and specificity of the ability of IR thermography for predicting healing potential. Inclusion criteria were articles investigating the use of IR thermography for burn wound assessments in adults and pediatric patients. Reviews and non-English articles were excluded.

          RESULTS: A total of 19 articles were included in the final review. Statistically significant correlations were found between IR thermography and laser doppler imaging (LDI) in 4/4 clinical studies. A case report of a single patient found that IR thermography was more accurate than LDI for assessing burn depth. Five articles investigated the ability of IR thermography to predict healing time, with four reporting statistically significant results. Temperature differences between burnt and unburnt skin were found in 2/2 articles. IR thermography was compared to clinical assessment in five articles, with varying results regarding accuracy of clinical assessment compared to thermography. Mean sensitivity and specificity of the ability of IR thermography to determine healing potential < 15 days was 44.5 and 98.8 respectively. Mean sensitivity and specificity of the ability of FLIR to determine healing potential < 21 days was 51.2 and 77.9 respectively.

          CONCLUSION: IR thermography is an accurate, simple, and cost-effective method of burn wound assessment. FLIR has been demonstrated to have significant correlations with other methods of assessing burns such as LDI and can be utilized to accurately assess burn depth and healing potential.

          © The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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          Effects and Safety of Different Silver Preparation in Burns Treatment: A Bayesian Network Meta-analysis., 2021 Apr 28
          Journal: The International Journal of Lower Extremity Wounds

          Silver formulation has been used for external use of burn wounds for several decades, mainly including silver sulfadiazine (SSD), nanosilver dressing (NSD), and silver ion dressing (SID). At present, there is no simultaneous comparison of the effects of silver formulation on burn wounds. The databases were retrieved in an orderly manner from the dates of their establishment to May 2020, including PubMed, the Cochrane Library, Web of Science, and Clinical Trials. Then a network meta-analysis was conducted using R and RevMan 5.1 software. A total of 13 randomized controlled trials (RCTs) involving 945 patients with burns were included. A pairwise meta-analysis of the results was presented: the wound healing time in the SID or NSD treatment group was less than that in the SSD group; and in relieving the pain there was a statistical difference between the SSD, SID, or NSD groups. Network meta-analysis of the results was presented: the wound healing time and relieving the pain in the SID or NSD treatment group were less than that in the SSD group, but there was no statistical difference between the SID and NSD groups. The possibility of NSD in the wound healing time being the best treatment was 75.2%, followed by SID (36.6%), and finally SSD (1.1%); and the possibility of NSD being the best relieving the pain was 83.5%; followed by SID (60.0%), and finally SSD (16.3%). According to the evidence, treatment for burns with NSD can improve the wound healing time and relieve the pain of wounds.

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          Fibroblast growth factor in the treatment of burns: A systematic review., 2021 Apr 14
          Journal: Burns

          INTRODUCTION: A burn is a trauma that breaks the skin barrier, causing local and systemic responses. Treatment is complex, multiprofessional and expensive. In addition to surgical treatment, topical dressings can be used to keep the wound moist, reduce the risk of infection and stimulate healing. Clinical studies show that topical use of fibroblast growth factors may accelerate healing. An assessment of the quality of the available evidence and its strength of recommendation is necessary.

          OBJECTIVE: This study aimed to evaluate the effectiveness and safety of topical use of fibroblast growth factor, compared to other topical treatments or placebo, in the healing of burns, to determine the strength of recommendation.

          METHOD: Based on a defined search strategy, randomized and quasi-randomized clinical trials, available in electronic databases, were gathered. These compare the topical use of FGF versus other topical or non-treatment. The primary outcome was healing and as adverse effects: pain, infection and mortality. The systematic review protocol was registered on the PROSPERO platform (CRD42018089556), developed in accordance with the "Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015" and within the "SWiM guideline 2019". GRADEpro was used for the critical analysis of the methodology of the studies.

          RESULTS: Four clinical trials were found, in which FGF reduced the healing time and improved the appearance of the scar. Two trials were determined to be of low strength, while two others have a moderate recommendation strength.

          CONCLUSION: This review gathered available evidence, between low and moderate recommendation strength for the use of FGF as a topical dressing. Further rigorous trials are needed to improve the strength of recommendation for topical use of FGF for burns.

          Copyright © 2021 Elsevier Ltd and ISBI. All rights reserved.

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          A systematic review and meta-analysis of randomized trials evaluating the efficacy of autologous skin cell suspensions for re-epithelialization of acute partial thickness burn injuries and split-thickness skin graft donor sites., 2021 Sep
          Journal: Burns

          BACKGROUND: This systematic review evaluated the efficacy of autologous skin cell suspensions (ASCS) on the re-epithelialization of partial thickness burn injuries and skin graft donor site wounds.

          METHODS: Four databases (EMBASE, Google Scholar, MEDLINE, Web of Science), grey literature and select journal hand-searching identified studies from 1975 - 2020. Randomized trials evaluating partial thickness burn management with non-cultured ASCS compared to any other intervention were included. Time to re-epithelialization (TTRE) was the primary outcome. Three independent researchers completed screening, data extraction and certainty of evidence assessment using Cochrane Risk of Bias Tool and Grading of Recommendations Assessment, Development and Evaluation.

          RESULTS: Five trials (n = 347) reported on adults (2 trials) and children (1 trial) with burn wounds, and adults with donor site wounds (2 trials). The effect of ASCS compared to control on TTRE in adult burn wounds was not estimable. TTRE was shorter in pediatric burn wounds (SMD -1.75 [95% CI: -3.45 to -0.05]) and adult donor site wounds (SMD-5.71 [95% CI: -10.61 to-0.81]) treated with ASCS. The certainty of evidence was very low.

          CONCLUSION: Compared to standard care, ACSC may reduce pediatric partial thickness burn wound and adult split-thickness skin graft donor site TTRE.

          REGISTRATION: PROSPERO CRD42019133171.

          Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.

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          Efficacy of stem cell therapy for burn wounds: a systematic review and meta-analysis of preclinical studies., 2020 Jul 29
          Journal: Stem Cell Research & Therapy

          BACKGROUND: Burns remain a serious public health problem with high morbidity and mortality rates worldwide. Although there are various treatment options available, there is no consensus on the best treatment for severe burns as of yet. Stem cell therapy has a bright prospect in many preclinical studies of burn wounds. The systematic review was performed for these preclinical studies to assess the efficacy and possible mechanisms of stem cells in treating burn wounds.

          METHODS: Twenty-two studies with 595 animals were identified by searching PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception to 13 May 2020. In addition, a manual search of references of studies was performed to obtain potential studies. No language or time restrictions were enforced. RevMan 5.3 was used for all data analysis.

          RESULTS: The overall meta-analysis showed that stem cell therapy significantly improved burn healing rate (SMD 3.06, 95% CI 1.98 to 4.14), irrespective of transplant type, burn area, and treatment method in the control group. Subgroup analyses indicated that hair follicle stem cells seemed to exert more beneficial effects on animals with burn wounds (SMD 7.53, 95% CI 3.11 to 11.95) compared with other stem cells. Furthermore, stem cell therapy seemed to exert more beneficial effects on burn wounds with second-degree (SMD 7.53, 95% CI 3.11 to 11.95) compared with third-degree (SMD 2.65, 95% CI 1.31 to 4.00).

          CONCLUSIONS: Meta-analysis showed that stem cell therapy exerts a healing function for burn wounds, mainly through angiogenesis and anti-inflammatory actions. These findings also demonstrate the need for considering variations in future clinical studies using stem cells to treat a burn wound in order to maximize the effectiveness. In general, stem cells can potentially become a novel therapy candidate for burn wounds.

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          Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States., 2019 May 07
          Journal: Advances in therapy

          INTRODUCTION: When introducing a new intervention into burn care, it is important to consider both clinical and economic impacts, as the financial burden of burns in the USA is significant. This study utilizes a health economic modeling approach to estimate cost-effectiveness and burn center budget-impact for the use of the RECELL® Autologous Cell Harvesting Device to prepare autologous skin cell suspension (ASCS) compared to standard of care (SOC) split-thickness skin graft (STSG) for the treatment of severe burn injuries requiring surgical intervention for definitive closure.

          METHODS: A hospital-perspective model using sequential decision trees depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, definitive closure) and predicts the relative differences between use of ASCS compared to SOC. Clinical inputs and ASCS impact on length of stay (LOS) were derived from clinical trials and real-world use data, American Burn Association National Burn Repository database analyses, and burn surgeon interviews. Hospital resource use and unit costs were derived from three US burn centers. A budget impact calculation leverages Monte Carlo simulation to estimate the overall impact to a burn center.

          RESULTS: ASCS treatment is cost-saving or cost-neutral (<  2% difference) and results in lower LOS compared to SOC across expected patient profiles and scenarios. In aggregate, ASCS treatment saves a burn center 14-17.3% annually. Results are sensitive to, but remain robust across, changing assumptions for relative impact of ASCS use on LOS, procedure time, and number of procedures.

          CONCLUSIONS: Use of ASCS compared to SOC reduces hospital costs and LOS of severe burns in the USA.

          FUNDING: AVITA Medical.

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          Use of WoundReference is subject to the Subscription and License Agreement. ​
          NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

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          Topic 1057 Version 1.0

          RELATED TOPICS

          Evidence-based, always current review on management of acute burns.

          Acute Burn Injury overview: evidence-based clinical guidelines, quality measures and resources