The Elderly Burn Patient John L. Hunt, MD, Gary F. Purdue, MD, Dallas.Texas
During a 16-year period, 5 4 7 patients who were older than 6 4 years of age with a mean total body surface area (TBSA) (third-degree burns) of 25% were treated. Etiologies were flame/flash in 81% of patients, scald in 11%, solids in 7%, and electrical/ chemical in 1%. Seventeen percent of patients had significant causal factors. An inhalation injury was present in 13% of patients, and the mortality in these patients was 100%. Burn excision was performed 2 3 9 times in 165 patients. The majority of excisions were for full-thickness burns. Excision did not improve overall survival in patients with thirddegree burns of 0% to 10%, but the length of stay (LOS) in excised and nonexcised survivors was improved ( 9 versus 21 days, respectively). The LOS and survival were not significantly different in patients with burns between 11% and 20%. Postburn complications occurred in 28% of patients. Overall mortality was 50% (mean age: 77 years; TBSA: 4 0 % ) . There were no survivors with over 47% TBSA burns. The leading cause of death was pulmonary sepsis. Most surviving patients returned to a satisfactory lifestyle after discharge.
he definition of elderly is generally accepted as age T 65 years and older. The number of elderly in the developed countries of the world will continue to increase well into the next century. By the year 2020, this population will increase by 16%. The mean life expectancy for women and men will be 82 and 74 years, respectively [I]. Approximately 6.7 million Americans will be older than 84 years by 2020. The incidence of hospitalized burns is reported to be between 25.5 and 37 per 100,000 population, with 41 per 100,000 admissions for patients older than 85 years [2]. Between 6% to 20% of burn unit admissions are of patients 60 years of age and older [3,4]. PATIENTS AND METHODS During a 16-year period, 547 patients aged 64 years and older were treated at the Parkland Memorial Hospital Burn Unit. This represented 11% of all adult burn admissions. Their mean age was 76 years, with a range of 65 to 99 years. Their mean total body surface area (TBSA) of the burn was 25% (range: 1% to 99%). The mean full-thickness burn was 13%. The ratio of men to women in elderly patients with burns was 1.2:1 compared with the 2.9:1 ratio seen in the burn patients who were less than 65 years of age. For all patients, mean time to admission was postburn day 2 (range: 0 to 40 days). There were 120 patients who were admitted 24 hours or more after the injury (mean: day 9; range: 2 to 40 days; median: 5 days). Etiologies of the burns were flame or flash (81%), scalds with liquid (11%), contact with hot solids (7%), electrical (1%), and chemical (1%). Seventeen percent of the injuries had associated causal factors. These included smoking (13%), intoxication (2%), physical abuse/assault (1%), suicide (1%), and seizure (0.5%). Significant chronic preburn morbidity included cardiac disease (24%), hypertension (20%), pulmonary (17%), neurologic (10%), diabetes (10%), ethanol abuse (9%), cancer (7%), psychiatric (5%), renal disease (3%), morbid obesity (3%), and liver disease (2%). Two percent had previously been hospitalized for severe burns.
RESULTS One hundred sixty patients (29%) were intubated during the course of their illness. One hundred seven of those patients (67%) required intubation during the initial 24 hours of hospitalization, and 89% were intubated either prior to their arrival or in the emergency room at Parkland Memorial Hospital. The majority were intubated either to prevent airway compromise due to edema seconFromthe ParklandMemorialHospital,The UniversityofTexasSouth- dary to a face or neck burn or because of a suspected westernMedicalCenterat Dallas,Dallas,Texas. inhalation injury. The mean TBSA and full-thickness Requests for reprints shouldbe addressedto John L. Hunt, MD, burn were 43% and 29%, respectively. Forty-eight paDepartment of Surgery, Universityof Texas SouthwesternMedical tients were intubated 24 hours after the first postburn day Center, 5323 Harry HinesBoulevard,Dallas,Texas75235-9031. Presentedat the 44th AnnualMeetingof the SouthwesternSurgi- (mean: day 11; range: 2 to 35 days). The indications cal Congress,Scottsdale,Arizona,April26-29, 1992. included bronchopneumonia, respiratory failure associ472
THE AMERICAN JOURNAL OF SURGERY VOLUME164 NOVEMBER1992
ELDERLY BURN PATIENT
ated with underlying sepsis, and chronic lung disease. The mortality for these intubated patients was 89%. Seventy patients (I 3%) were considered to have sustained a significant inhalation injury based on a combination of history, physical examination, laboratory data (carboxyhemoglobin greater than 15%), and bronchoscopy. Their mean TBSA and full-thickness burns were 45% and 28% respectively. All patients with significant inhalation injury died, 16 within 48 hours of injury. Either they were designated "do not resuscitate" (DNR), or they were resuscitation failures. Five other patients developed rapid and progressive pulmonary failure and died within 7 days. The other 49 died of pulmonary sepsis and/or multiple organ failure between the 8th and 77th postburn day. Tracheostomy was performed in 31 patients whose mean TBSA and full-thickness burn were 36% and 23%, respectively. Indications for traeheostomy included bronchopneumonia in 90% and respiratory failure secondary to either sepsis or failed extubation associated with chronic lung disease in the other 10%. Seven of these patients (23%) survived. Burn wound excision was performed 239 times (range: 1 to 8 per patient) in 165 patients, but excision was not attempted in any patients with a burn of more than 49%. Ninety-five percent of excisions were for fullthickness burns, and the remainder were for deep dermal hand burns. Table I compares patients with and without burn wound excision. The length of stay (LOS) and the mortality were not significantly different between the two groups in burns less than 21%. In excised versus nonexcised survivors, patients with burns of 0% to 10% had LOSs of 9 versus 21 days, respectively (p 0.05). In patients with burns between 21% and 30%, the overall mortalities were very different, and the LOSs in excised and nonexcised survivors were 48 and 36 days, respectively (p =
During a 16-year period, 5 4 7 patients who were older than 6 4 years of age with a mean total body surface area (TBSA) (third-degree burns) of 25% were treated. Etiologies were flame/flash in 81% of patients, scald in 11%, solids in 7%, and electrical/ chemical in 1%. Seventeen percent of patients had significant causal factors. An inhalation injury was present in 13% of patients, and the mortality in these patients was 100%. Burn excision was performed 2 3 9 times in 165 patients. The majority of excisions were for full-thickness burns. Excision did not improve overall survival in patients with thirddegree burns of 0% to 10%, but the length of stay (LOS) in excised and nonexcised survivors was improved ( 9 versus 21 days, respectively). The LOS and survival were not significantly different in patients with burns between 11% and 20%. Postburn complications occurred in 28% of patients. Overall mortality was 50% (mean age: 77 years; TBSA: 4 0 % ) . There were no survivors with over 47% TBSA burns. The leading cause of death was pulmonary sepsis. Most surviving patients returned to a satisfactory lifestyle after discharge.
he definition of elderly is generally accepted as age T 65 years and older. The number of elderly in the developed countries of the world will continue to increase well into the next century. By the year 2020, this population will increase by 16%. The mean life expectancy for women and men will be 82 and 74 years, respectively [I]. Approximately 6.7 million Americans will be older than 84 years by 2020. The incidence of hospitalized burns is reported to be between 25.5 and 37 per 100,000 population, with 41 per 100,000 admissions for patients older than 85 years [2]. Between 6% to 20% of burn unit admissions are of patients 60 years of age and older [3,4]. PATIENTS AND METHODS During a 16-year period, 547 patients aged 64 years and older were treated at the Parkland Memorial Hospital Burn Unit. This represented 11% of all adult burn admissions. Their mean age was 76 years, with a range of 65 to 99 years. Their mean total body surface area (TBSA) of the burn was 25% (range: 1% to 99%). The mean full-thickness burn was 13%. The ratio of men to women in elderly patients with burns was 1.2:1 compared with the 2.9:1 ratio seen in the burn patients who were less than 65 years of age. For all patients, mean time to admission was postburn day 2 (range: 0 to 40 days). There were 120 patients who were admitted 24 hours or more after the injury (mean: day 9; range: 2 to 40 days; median: 5 days). Etiologies of the burns were flame or flash (81%), scalds with liquid (11%), contact with hot solids (7%), electrical (1%), and chemical (1%). Seventeen percent of the injuries had associated causal factors. These included smoking (13%), intoxication (2%), physical abuse/assault (1%), suicide (1%), and seizure (0.5%). Significant chronic preburn morbidity included cardiac disease (24%), hypertension (20%), pulmonary (17%), neurologic (10%), diabetes (10%), ethanol abuse (9%), cancer (7%), psychiatric (5%), renal disease (3%), morbid obesity (3%), and liver disease (2%). Two percent had previously been hospitalized for severe burns.
RESULTS One hundred sixty patients (29%) were intubated during the course of their illness. One hundred seven of those patients (67%) required intubation during the initial 24 hours of hospitalization, and 89% were intubated either prior to their arrival or in the emergency room at Parkland Memorial Hospital. The majority were intubated either to prevent airway compromise due to edema seconFromthe ParklandMemorialHospital,The UniversityofTexasSouth- dary to a face or neck burn or because of a suspected westernMedicalCenterat Dallas,Dallas,Texas. inhalation injury. The mean TBSA and full-thickness Requests for reprints shouldbe addressedto John L. Hunt, MD, burn were 43% and 29%, respectively. Forty-eight paDepartment of Surgery, Universityof Texas SouthwesternMedical tients were intubated 24 hours after the first postburn day Center, 5323 Harry HinesBoulevard,Dallas,Texas75235-9031. Presentedat the 44th AnnualMeetingof the SouthwesternSurgi- (mean: day 11; range: 2 to 35 days). The indications cal Congress,Scottsdale,Arizona,April26-29, 1992. included bronchopneumonia, respiratory failure associ472
THE AMERICAN JOURNAL OF SURGERY VOLUME164 NOVEMBER1992
ELDERLY BURN PATIENT
ated with underlying sepsis, and chronic lung disease. The mortality for these intubated patients was 89%. Seventy patients (I 3%) were considered to have sustained a significant inhalation injury based on a combination of history, physical examination, laboratory data (carboxyhemoglobin greater than 15%), and bronchoscopy. Their mean TBSA and full-thickness burns were 45% and 28% respectively. All patients with significant inhalation injury died, 16 within 48 hours of injury. Either they were designated "do not resuscitate" (DNR), or they were resuscitation failures. Five other patients developed rapid and progressive pulmonary failure and died within 7 days. The other 49 died of pulmonary sepsis and/or multiple organ failure between the 8th and 77th postburn day. Tracheostomy was performed in 31 patients whose mean TBSA and full-thickness burn were 36% and 23%, respectively. Indications for traeheostomy included bronchopneumonia in 90% and respiratory failure secondary to either sepsis or failed extubation associated with chronic lung disease in the other 10%. Seven of these patients (23%) survived. Burn wound excision was performed 239 times (range: 1 to 8 per patient) in 165 patients, but excision was not attempted in any patients with a burn of more than 49%. Ninety-five percent of excisions were for fullthickness burns, and the remainder were for deep dermal hand burns. Table I compares patients with and without burn wound excision. The length of stay (LOS) and the mortality were not significantly different between the two groups in burns less than 21%. In excised versus nonexcised survivors, patients with burns of 0% to 10% had LOSs of 9 versus 21 days, respectively (p 0.05). In patients with burns between 21% and 30%, the overall mortalities were very different, and the LOSs in excised and nonexcised survivors were 48 and 36 days, respectively (p =
