Background Orbital compartment syndrome (OCS) is a rare but devastating complication of over-resuscitation in burn patients that may lead to permanent visual loss. The purpose of this study was to (1) present a series of burn patients with OCS, and (2) survey practice patterns of monitoring intra-ocular pressure (IOP) during burn resuscitation. Methods Cases of OCS at two American Burn Association (ABA)-verified burn centers were retrospectively reviewed. Patients were included if they (a) required lateral canthotomy/cantholysis for elevated IOPs, or (b) developed blindness during admission unrelated to any other ocular pathology. Data was collected on demographics, burn characteristics, fluid administration, ophthalmologic findings and complications. An eight-item electronic survey was distributed by email through the ABA to all physician members. Results Twelve patients with OCS were identified, with a mean age of 47.8 ±12.4 years and TBSA of 63.7 ±18.6%. Mean fluid resuscitation at 24 hours was 4.9 ±1.6 mL/kg/%TBSA, or 0.29 ±0.06 L/kg. Eight patients underwent canthotomy/cantholysis for OCS, while four were later found to have visual loss. A total of 83 (14%) ABA physicians responded to the survey. IOP was routinely measured by 23% of respondents during acute burn resuscitation. Conclusions OCS appears to have developed despite a relatively low 24-hour mL/kg/% burn resuscitation volume, but with a relatively higher cumulative (L/kg) fluid volume. Our survey found that monitoring of IOP during burn resuscitation is not routinely performed by the majority of providers. Taken together, the present study suggests clinical guidelines to recognize this complication of over-resuscitation.
Introduction We report a case of a patient with a burn injury who developed a devastating necrotizing soft tissue infection (NSTI) early in the post-burn period. Methods An elderly male was admitted to an ABA verified burn centre after sustaining a 20% scald burn to his back and right upper extremity. He was found in the bathtub; a fall was suspected based on his history of Parkinson’s disease and a finding of bruising to his bilateral knees. Initially, his hospital course was uneventful apart from an elevated creatine kinase, which decreased with adequate resuscitation without signs or symptoms of compartment syndrome. Thirty-six hours following his admission, he developed rapid onset of progressively worsening renal function, respiratory requiring intubation, mechanical ventilation, and circulatory failure requiring vasopressor support. After ruling out other causes of shock and upon re-examination of his burns there were clinical signs of a rapidly advancing necrotizing soft tissue infection. He was taken urgently to the operating room for aggressive debridement of nonviable tissue. He underwent a right shoulder disarticulation and extensive debridement of the right chest, abdomen, and back. Intra-operative tissue samples and preoperative blood cultures were positive for Group A Streptococcus. The patient was predicted to require multiple operations and a prolonged hospital stay. Despite these interventions, his prognosis was poor. The family and the treatment team, in the context of the patient’s previous independent functioning, revised his goals of care on his first post-operative day. Life-sustaining treatment was withdrawn, and comfort care measures were implemented. The patient passed away two days later. Results We report a case of a patient with a burn injury who developed a devastating NSTI early in the post-burn period within 36–48 hours of presentation to a burn center. Soft-tissue infections in the immediate post-burn period are rare unless there is subsequent contamination. Burned tissue contains a large amount of necrotic tissue and protein-rich wound exudate, which provides a rich growth medium for bacteria. This, in addition to the immunosuppression secondary to the burn insult, favors the development of infection. NSTI in the context of thermal injury is a rare phenomenon and in the few reported cases in burn patients, necrotizing infections occurred closer to two weeks following the initial injury. Conclusions Necrotizing soft tissue infections are entities with a rapid and devastating course. The diagnosis is challenging, and occlusive dressings may contribute to a delay in diagnosis in burns. Acute hemodynamic compromise without any obvious cause should raise the suspicion for a necrotizing soft tissue infection and lead to early exposure of wounds in burn patients.
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