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https://t.me/med1917
Chapter7
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Predicting mortality and
end oflife care
Predicting mortality 54
Principles of end of life care in burns 56
Further reading 58
References 58
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CHAPTER7 Predicting mortality & end oflife care
Predicting mortality
Predicting mortality in burns patients is a complex and dicult process. It
can be obvious from the outset; however, it is sometimes determined by
the response to treatment. The decision should only be made after a multidisciplinary discussion.
Prognostic scoring systems
• Aim to predict outcome using predictive pre- morbid and injury factors
• Limited use in clinical setting, not a replacement for clinical judgement
• Not an absolute predictor of good/ poor outcome
• Good for discussions with family regarding prognosis as helpful to give
gures
• Perfect scoring system has not yet been determined
• Excellent for triggering internal practice review if variance noted
• Burn- specic and general scoring systems available
Burn- specic scoring systems
Baux score– 1961
• Mortality=age + %TBSA burn
• Later modied taking into account burn depth to the prognostic burn
index (PBI)
• PBI=TBSA full thickness + ½ (TBSA partial thickness) + age
Abbreviated Burn Severity Index (ABSI)– 1982
• Uses ve variables (gender, age, inhalational injury, TBSA, presence of
Full Thickness burn)
• Power of each variable assigned a numerical value which varies
according to severity
• The sum of these values is used to predict mortality
Ryan Score– 1998
2
• Risk factors for mortality include TBSA >40%, age >60, and
inhalational injury
• Scoring system based on presence of any of these three factors
• 0=0.3%, 1=3%, 2=33%, all three factors=90% chance of mortality
Cape Town Modied Burn Score– 1998
• Created to improve upon the Baux score
• Inhalation injury graded as mild=1, moderate=2, severe=3
• Modied burn score=age + %TBSA + (20 × inhalational score)
Belgian Outcome inBurn Injury (BOBI) Score– 2009
• Most recent scoring system, aimed to increase the predictive value of
the Ryan score
• Subdivides patients according to age, TBSA, and presence of
inhalational injury
• Sum of scores gives a prediction of mortality
General non- burn scoring systems
• Acute Physiology and Chronic Health Evaluation (APACHE) score
• Sepsis Related Organ Failure Assessment (SOFA)
• Simplied Acute Physiology Score (SAPS)
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PREDICTING MORTALITY
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CHAPTER7 Predicting mortality & end oflife care
Principles of end of life care in burns
• Despite improvements in burn care and ITU, the ultimate outcome for
some is still death
• Department of Health and general Medical Council guidance aimed at
standardizing end of life care
• Multidisciplinary decision needed at point of futility, and should involve
the family
Burns Modied Liverpool Care Pathway (BM- LCP)
The BM- LCP is divided into three sections. An overview of the pathway is
seen in Fig. 7.1.
Section 1:Initial assessment
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• Physical symptom relief, eg. nausea and pain
• Spiritual care, eg. religious beliefs
• Patient/ family communication
• Rationalization of unnecessary interventions
• Dressing needs, eg. odour control and comfort
• Medications are given IV due to unpredictability of the subcutaneous
route in burns
Section 2:Ongoing care
• Recording of observations
• Four- hourly basis to reduce interruptions between patient and family
• Comfort goals recorded as achieved (A)or variance (V)
• If V then adjustments in care made to achieve comfort
After death care
• Contact coroner
• Contact family doctor/ GP
• Minimize family distress
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Continue care
Re evaluate
goals every
48 hours
Yes
PRINCIPLES OF END OF LIFE CARE IN BURNS
Decision of futility
made by MDT
Yes
Conduct initial assessment
section 1, goals 1–11
Pain free? Not troubled by secretions?
Not agitated? Not Nausea or vomiting?
Not Breathless? Wound care adequate?
Mouth care? Medication given as planned?
Pressure care? Psychological support?
Wound care? Family support?
GP contact? Coroner contact?
Religious needs
addressed?
Paperwork completed? Valuables and
4 hourly assessment
12 hourly assessment
Care after death
Family discussion?
belongings?
Review decision
and discuss
with MDT
No
Adjust care
Record
adjustment
No
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Fig.7.1 An overview of the BM- LCP.
Reprinted from Hemington- Gorse SJ, et al. Comfort care in burns: The Bur n Modied Liverpool
Care Pathway (BM- LCP). Burns 2011:37(6):981– 85, Copyright © 2011 Elsevier Ltd and ISBI, with
permission from Elsevier.
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CHAPTER7 Predicting mortality & end oflife care
Further reading
Sheppard NN, Hemington- Gorse S, Shelley B, Dziewulski P. Prognostic scoring systems in burns:a
review. Burns 2011;37:1288– 95.
Hemington- Gorse SJ, Clover AJP, Macdonald C, etal. Comfort care in burns: the burn modied
Liverpool Care Pathway (BM- LCP). Burns 2011;37:981– 85.
References
1. Baux. Contribution a l’etude du traitement local des brulures thermiques etendues. These
Paris; 1961.
2. Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burnseverity index. Annals of Emergency
Medicine 1982;11:260– 2.
3. Ryan CM, Schoenfeld DA, Thorpe WP, etal. Objective estimates of the probability of death from
burn injuries. New England Journal of Medicine 1998;338:362– 6.
4. Godwin, Wood. Major burns in Cape Town: a modied burns score for patient triage. Burns
1998;24:58– 63.
5. Belgian Outcome in Burn Injury Study Group. Development and validation of a model for predic-
tion of mortalit y in patients with acute burn injury. British Journal of Surgery 2009;96111– 7.
6. Knaus WA, Zimmerman JE, Wagner DP, etal. APACHE– acute physiolog y and chronic health
evaluation:a physiologically based classication system. Critical Care Medicine 1981;9:591– 7.
7. Vincent JL, Moreno R, Takala J, Willatts S, et al. The SOFA (Sepsis- related Organ Failure
Assessment) score to describe organ dysfunction/ failure. On behalf of the Working Group on
Sepsis- Related Problems of the European Society of Intensive Care
8. Le Gall JR, Lemeshow S, Saulnier F. A new Simplied Acute Physiology Score (SAPS II) based on a
European/ North American multicenter study. JAMA 1993;270:2957– 63.
9. Hemington- Gorse SJ, Clover AJ, Macdonald C, et al. Comfort care in burns:the Burn Modied
Liverpool Care Pathway (BM- LCP). Burns 2011;37:981– 5.
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Chapter8
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Burns first aid
Importance of simple burns rst aid 60
Steps of burns rst aid 62
Initial management by medical personnel 64
Conclusion 66
Further reading 66
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CHAPTER8 Burns first aid
Importance ofsimple burns first aid
In the UK alone there are approximately 175,000 acute burn injuries seen
by emergency services every year. Despite these numbers, there is a great
variation in the way these injuries are managed prior to reaching hospital
both by those providing the initial rst aid and also pre- hospital medical and
paramedic services.
Advances in our understanding of the pathophysiology and natural history of burn injuries have highlighted the importance of early intervention
in minimizing later functional and cosmetic morbidity associated with these
injuries.
Dierences in beliefs and ethnic background have a large impact on the
way that burns are initially dealt with, as we know that only a minority of
patients presenting with burns are optimally managed before they reach
hospital.
Lack of education and conicting information about burns rst aid is believed to be a major factor in the common occurrence of burnt patients
presenting with a variety of domestic remedies (toothpaste, garlic, potato
peel, butter, milk) being applied to their burns as rst aid.
Judicious application of simple burns rst aid is the rst step for soft tissue
preservation, improvement of outcomes, and a decrease in the need for
operative management.
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IMPORTANCE OFSIMPLE BURNS FIRST AID
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